Skip to main content

Endoscopic reconstruction of CFL and the ATFL with a gracilis graft: a cadaveric study

Knee Surgery, Sports Traumatology, Arthroscopy volume 24, pages 1007–1014 (2016)Cite this article

Abstract

Purpose

The purpose of this study was to evaluate a step-by-step approach to endoscopic reconstruction of the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL).

Methods

Fourteen lower extremity cadaveric specimens were used. Four standard portals were defined and used. A step-by-step approach using several anatomical landmarks was used to reconstruct the ATFL and CFL. The feasibility of visualising the anatomical landmarks and both ligaments and their footprints was assessed. Both ligaments were reconstructed using a gracilis graft fixed in bone tunnels. The lateral side of the ankle was completely exposed and dissected. The specimen was assessed for clinical stability of the reconstruction and damage to the surrounding anatomical structures. The distance between the centre of the tunnel and the anatomical insertions of the ligaments was measured. The distance between the portals and the nerves was measured.

Results

The step-by-step approach allowed a good visualisation of the entire course of the ATFL and CFL. An endoscopic reconstruction of both ligaments was performed, and good stability was obtained. The measurements revealed a good positioning of the reconstructed ligament insertions with a maximal error of 2 mm in most specimens. Anatomical dissection revealed no damage to the surrounding anatomical structures that were at risk. The average distance to the superficial peroneal nerve was 11.9 ± 5.3 mm (standard deviation), and the average distance to the sural nerve was 17.4 ± 3.2 mm (standard deviation). A safe zone was defined with regard to the surrounding nerves.

Conclusion

The described technique, which involves an anatomical endoscopic reconstruction of the ATFL and CFL, using a gracilis graft, is a viable option to treat lateral ankle instability. This technique is reproducible and safe with regard to the surrounding anatomical structures.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

43,34 €

Price includes VAT (Finland)
Tax calculation will be finalised during checkout.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9
Fig. 10

References

  1. Acevedo JI, Mangone PG (2011) Arthroscopic lateral ligament reconstruction. Tech Foot Ankle Surg 10:111–116

    Article  Google Scholar 

  2. Bahr R, Pena F, Shine J, Lew WD, Lindquist C, Tyrdal S, Engebretsen L (1997) Mechanics of the anterior drawer and talar tilt tests. A cadaveric study of lateral ligament injuries of the ankle. Acta Orthop Scand 68:435–441

    CAS  Article  PubMed  Google Scholar 

  3. Bahr R, Pena F, Shine J, Lew WD, Tyrdal S, Engebretsen L (1997) Biomechanics of ankle ligament reconstruction. An in vitro comparison of the Broström repair, Watson-Jones reconstruction, and a new anatomic reconstruction technique. Am J Sports Med 25:424–432

    CAS  Article  PubMed  Google Scholar 

  4. Broström L (1966) Sprained ankles. V. Treatment and prognosis in recent ligament ruptures. Acta Chir Scand 132:537–550

    PubMed  Google Scholar 

  5. Broström L (1966) Sprained ankles. VI Surgical treatment of “chronic” ligament ruptures. Acta Chir Scand 132:551–565

    PubMed  Google Scholar 

  6. Burks RT, Morgan J (1994) Anatomy of the lateral ankle ligaments. Am J Sports Med 22:72–77

    CAS  Article  PubMed  Google Scholar 

  7. Caprio A, Oliva F, Treia F, Maffuli N (2006) Reconstruction of the lateral ankle ligaments with allograft in patients with chronic ankle instability. Foot Ankle Clin 11:597–605

    Article  PubMed  Google Scholar 

  8. Clanton TO, Viens NA, Campbell KJ, LaPrade RF, Wijdicks CA (2013) Anterior talofibular ligament ruptures, part 2. Am J Sports Med 42:412–441

    Article  PubMed  Google Scholar 

  9. Corte-Real NM, Moreira RM (2009) Arthroscopic repair of chronic lateral ankle instability. Foot Ankle Int 30:213–217

    Article  PubMed  Google Scholar 

  10. Coughlin MJ, Schenck RC, Grebing BR, Treme G (2004) Comprehensive reconstruction of the lateral ankle for chronic instability using a free gracilis graft. Foot Ankle Int 25:231–241

    Article  PubMed  Google Scholar 

  11. Drakos M, Behrens S, Mulcahey M, Paller D, Hoffman E, DiGiovanni C (2013) Proximity of arthroscopic ankle stabilization procedures to surrounding structures: an anatomic study. Arthroscopy 29:1089–1094

    Article  PubMed  Google Scholar 

  12. Ferkel RD, Chams RN (2007) Chronic lateral instability: arthroscopic findings and long-term results. Foot Ankle Int 28:24–31

    Article  PubMed  Google Scholar 

  13. Giza E, Shin EC, Wong SE, Acevedo JI, Mangone PG, Olson K, Anderson MJ (2013) Arthroscopic suture anchor repair of the lateral ligament ankle complex: a cadaveric study. Am J Sports Med 41:2567–2572

    Article  PubMed  Google Scholar 

  14. Golanó P, Vega J, de Leeuw PA, Malagelada F, Manzanares MC, Götzens V, van Dijk CN (2010) Anatomy of the ankle ligaments: a pictorial essay. Knee Surg Sports Traumatol Arthrosc 18:557–569

    Article  PubMed  PubMed Central  Google Scholar 

  15. Gould N, Seligson D, Gassman J (1980) Early and late repair of lateral ligament of the ankle. Foot Ankle 1:94–99

    Article  Google Scholar 

  16. Guillo S, Archbold P, Perera A, Bauer T, Sonnery-Cottet B (2014) Arthroscopic anatomic reconstruction of the lateral ligaments of the ankle with gracilis autograft. Arthrosc Tech 22(3):e593–e598

    Article  Google Scholar 

  17. Guillo S, Bauer T, Lee JW, Takao M, Kong SW, Stone JW, Mangone PG, Molloy A, Perera A, Pearce CJ, Michels F, Tourné Y, Ghorbani A, Calder J (2013) Consensus in chronic ankle instability: aetiology, assessment, surgical indications and place for arhthroscopy. Orthop Traumatol Surg Res 99:411–419

    Article  Google Scholar 

  18. Guillo S, Cordier G, Sonnery-Cottet B, Bauer T (2014) Anatomical reconstruction of the anterior talofibular and calcaneofibular ligaments with an all-arthroscopic surgical technique. Orthop Traumatol Surg Res 100:S413–S417

    CAS  Article  PubMed  Google Scholar 

  19. Hinterman B, Boss A, Schäfer D (2002) Arthroscopic findings in patients with chronic ankle instability. Am J Sports Med 30:402–409

    Google Scholar 

  20. Hua Y (2010) Modified Broström procedure plus ankle arthroscopy may be effective for ankle instability. Arthroscopy 26:524–528

    Article  PubMed  Google Scholar 

  21. Jung HG, Kim TH, Park JY, Bae EJ (2012) Anatomic reconstruction of the anterior talofibular and calcaneofibular ligaments using a semitendinosus tendon allograft and interference screws. Knee Surg Sports Traumatol Arthrosc 20:1432–1437

    Article  PubMed  Google Scholar 

  22. Kim BS, Choi WJ, Kim YS, Lee JW (2010) The effect of an ossicle of the lateral malleolus on ligament reconstruction of chronic lateral ankle instability. Foot Ankle Int 31:191–196

    Article  PubMed  Google Scholar 

  23. Kim ES, Lee KT, Park JS, Lee YK (2011) Arthroscopic anterior talofibular ligament repair for chronic ankle instability with a suture anchor technique. Orthopedics 34(4). doi: 10.3928/01477447-201120228-03

  24. Komenda GA, Ferkel RD (1999) Arthroscopic findings associated with the unstable ankle. Foot Ankle Int 20:708–713

    CAS  Article  PubMed  Google Scholar 

  25. Lui TH (2007) Arthroscopic-assisted lateral ligamentous reconstruction in combined ankle and subtalar instability. Technical note. Arthroscopy 23:554.e1–554.e5

    Article  Google Scholar 

  26. Nery C, Raduan F, Del Buono A, Asaumi ID, Cohen M, Maffulli N (2011) Arthroscopic-assisted Broström-Gould for chronic ankle instability: a long-term follow-up. Am J Sports Med 39:2381–2388

    Article  PubMed  Google Scholar 

  27. Neuschwander TB, Indresano AA, Hughes TH, Smith BW (2013) Footprint of the lateral ligament complex of the ankle. Foot Ankle Int 34:582–586

    Article  PubMed  Google Scholar 

  28. Paterson R, Cohen B, Taylor MD, Borune A, Black J (2000) Reconstruction of the lateral ligaments of the ankle using semi-tendinosis graft. Foot Ankle Int 21:413–419

    CAS  PubMed  Google Scholar 

  29. Takao M, Innami K, Matsushita T, Uchio Y, Ochi M (2008) Arthroscopic and magnetic resonance image appearance and reconstruction of the anterior talofibular ligament in cases of apparent functional ankle instability. Am J Sports Med 36:1542–1547

    Article  PubMed  Google Scholar 

  30. Takao M, Matsui K, Stone JW, Glazebrook MA, Kennedy JG, Guillo S, Calder JD, Karlsson J, Ankle Instability Group (2015) Arthroscopic anterior talofibular ligament repair for lateral instability of the ankle. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-015-3638-0

    Google Scholar 

  31. Takao M, Oae K, Uchio Y, Ochi M, Yamamoto H (2005) Anatomical reconstruction of the lateral ligaments of the ankle with a gracilis autograft: a new technique using an interference fit anchoring system. Am J Sports Med 33:814–823

    Article  PubMed  Google Scholar 

  32. Vega J, Golano P, Pellegrino A, Rabat E, Pena F (2013) All-inside arthroscopic lateral collateral ligament repair for ankle instability with a knotless suture anchor technique. Foot Ankle Int 34:1701–1709

    Article  PubMed  Google Scholar 

  33. Wang B, Xu XY (2013) Minimally invasive reconstruction of lateral ligaments of the ankle using semitendinosus autograft. Foot Ankle Int 34:711–715

    CAS  Article  PubMed  Google Scholar 

  34. Ziai P, Benca E, von Skrbensky G, Graf A, Wenzel F, Basad E, Windhager R, Buchhorn T (2013) The role of the peroneal tendons in passive stabilisation of the ankle joint: an in vitro study. Knee Surg Sports Traumatol Arthrosc 21:1404–1408

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

We thank Prof. Dr. Gert-Jan Kleinrensink and his Surgical Skills Lab Erasmus MC for support in this study.

Author information

Affiliations

  1. Orthopaedic Department, AZ Groeninge Kortrijk, Burg Vercruysselaan 5, 8500, Kortrijk, Belgium

    Frederick Michels & Arne Burssens

  2. Orthopaedic Department, Mérignac Sport Clinic, 2, Rue Georges Negrevergne, 33700, Mérignac, France

    Guillaume Cordier & Stéphane Guillo

  3. Department Development and Regeneration, Faculty of Medicine, Kulak, Catholic University Leuven, Etienne Sabbelaan 53, 8500, Kortrijk, Belgium

    Evie Vereecke

Authors
  1. Frederick Michels
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Guillaume Cordier
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Arne Burssens
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Evie Vereecke
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Stéphane Guillo
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Frederick Michels.

Ethics declarations

Conflict of interest

The Biomet Sports Medicine Department provided the use of the cadaver laboratory. Biomet also paid for the drawings. Some of the authors (FM, GC, SG) are consultants for Biomet for training and education. The authors did not personally receive grants or outside funding in support of their research of preparation of this manuscript.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Michels, F., Cordier, G., Burssens, A. et al. Endoscopic reconstruction of CFL and the ATFL with a gracilis graft: a cadaveric study. Knee Surg Sports Traumatol Arthrosc 24, 1007–1014 (2016). https://doi.org/10.1007/s00167-015-3779-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-015-3779-1

Keywords

  • Ankle instability
  • Anterior talofibular ligament
  • Calcaneofibular ligament
  • Endoscopic reconstruction
  • Tendoscopy
  • Gracilis tendon
  • Autograft
  • Allograft