Arthroscopic all-inside ATiFL’s distal fascicle transfer for ATFL’s superior fascicle reconstruction or biological augmentation of lateral ligament repair

  • Jordi Vega
  • Daniel Poggio
  • Nasser Heyrani
  • Francesc Malagelada
  • Matteo Guelfi
  • Aida Sarcon
  • Miki Dalmau-Pastor



Tendon grafts are often utilized for reconstruction of the lateral ligaments unamenable to primary repair. However, tendon and ligaments have different biological roles. The anterior tibiofibular ligament’s (ATiFL) distal fascicle may be resected without compromising the stability of the ankle joint. The aim of this study is to describe an all-arthroscopic and intra-articular surgical technique of ATiFL’s distal fascicle transfer for the treatment of chronic ankle instability.


Five unpaired cadaver ankles underwent arthroscopic ATiFL’s distal fascicle transfer using a non-absorbable suture and a knotless anchor. Injured or absent ATiFL’s distal fascicle were excluded from the study. Following arthroscopy, the ankles were dissected and evaluated for entrapment of nearby adjacent anatomical structures. The ligament transfer was also assessed. The distance between the anterolateral (AL) portals and the superficial peroneal nerve (SPN) was measured and the shortest distance was reported.


All specimens revealed successful transfer of the tibial origin of the ATiFL’s distal fascicle onto the talar insertion of anterior talofibular ligament’s (ATFL) superior fascicle. The fibular origin of the ATiFL’s distal fascicle remained intact. There were no specimens with SPN or extensor tendon entrapment. The median distance between the proximal AL portal and SPN was 3.8 mm. The median distance between the distal AL portal and SPN was 3.9 mm.


An all-arthroscopic approach to an ATiFL’s distal fascicle transfer is a reliable method to reconstruct the ATFL’s superior fascicle. Transfer of ATiFL’s distal fascicle avoids the need for tendon harvest or allograft. The lack of injury to nearby adjacent structures suggests that it is a safe procedure. The clinical relevance of the study is that ATiFL’s distal fascicle can be arthroscopically transferred to be used as a biological reinforcement of the ATFL repair, or as an ATFL reconstruction.


Ankle instability Ankle ligament Treatment Arthroscopy Anatomy 



No external funding was used.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

The study was approved by the University of Barcelona with IRB number: 00003099.


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Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2019

Authors and Affiliations

  • Jordi Vega
    • 1
    • 2
    • 3
  • Daniel Poggio
    • 4
  • Nasser Heyrani
    • 5
  • Francesc Malagelada
    • 6
  • Matteo Guelfi
    • 7
    • 8
  • Aida Sarcon
    • 5
  • Miki Dalmau-Pastor
    • 1
    • 3
    • 9
  1. 1.Laboratory of Arthroscopic and Surgical Anatomy, Department of Pathology and Experimental Therapeutics (Human Anatomy Unit)University of BarcelonaBarcelonaSpain
  2. 2.Foot and Ankle UnitiMove Tres Torres and Hospital QuirónBarcelonaSpain
  3. 3.Groupe de Recherche et d’Etude en Chirurgie Mini-Invasive du Pied (GRECMIP)MerignacFrance
  4. 4.Orthopaedic and Trauma Surgery, Foot and Ankle UnitHospital Clinic BarcelonaBarcelonaSpain
  5. 5.Department of Orthopaedic SurgeryUniversity of California, DavisSacramentoUSA
  6. 6.Foot and Ankle Unit, Department of Trauma and Orthopaedic SurgeryRoyal London Hospital, Barts Health NHS TrustLondonUK
  7. 7.Foot and Ankle UnitClinica MontallegroGenoaItaly
  8. 8.Human Anatomy and Embryology Unit, Department of Morphological SciencesUniversitat Autònoma de BarcelonaBarcelonaSpain
  9. 9.Vilamèdic, Santa Coloma de GramanetBarcelonaSpain

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