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Optimal fibular tunnel direction for anterior talofibular ligament reconstruction: 45 degrees outperforms 30 and 60 degrees

  • ANKLE
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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

There is currently no consensus on the optimal drilling direction of the fibular bone tunnel for anterior talofibular ligament (ATFL) reconstruction, and few studies have investigated the potential injury to the peroneus longus and brevis tendons and the possibility of fibular fractures during the drilling process. The aim of this study was to assess the potential risk of drilling the tunnel from different directions and determine the most appropriate tunnel direction. The hypothesis was that drilling the tunnel in the 45-degree direction would be the safest and most suitable for the fibular tunnel.

Methods

Forty-eight fibular tunnels were drilled on fresh ankle specimens using a K-wire guide and a 5.0 mm hollow drill. Three tunnel orientations were created, parallel to the sagittal plane of the long axis of the fibula and angled 30°, 45°, and 60° to the coronal plane. The length of the fibular tunnel and the distances from the outlet of the K-wire to the peroneus longus and brevis tendons were measured. The occurrence of a fibula fracture was also observed.

Results

The lengths of the bone tunnels in the three groups were 32.9 ± 6.1 mm (30°), 27.2 ± 4.4 mm (45°) and 23.6 ± 4.0 mm (60°). The length of the tunnel drilled at 30° was the longest when compared with that of the tunnels drilled at 45° and 60° (all p values < 0.05). The distances from the outlet of the K-wire to the peroneus longus tendon were 3.0 ± 3.8 mm (30°), 3.8 ± 3.2 mm (45°) and 5.3 ± 1.8 mm (60°), and the distances to the peroneus brevis tendon were 4.2 ± 4.0 mm (30°), 6.1 ± 3.8 mm (45°), 7.9 ± 3.5 mm (60°). In terms of protecting the peroneus longus and brevis tendons, drilling in the 60° direction was better than drilling in the 30° and 45° directions (all p values < 0.05). The risk of injury to the peroneal longus and brevis tendons was 62.5% (30°), 31.3% (45°), and 0% (60°). Although no fibular fractures were observed in any of the three directions, drilling the bone tunnel in the 60° direction disrupted the lateral cortex of the fibula.

Conclusion

This study shows that drilling the tunnel in the 45° direction is less likely to cause injury to the peroneus longus and brevis tendons, while ensuring that the tunnel has a sufficient length and avoiding fracturing the distal fibula. Drilling a fibular bone tunnel in a 45° direction is safer and recommended for ATFL reconstruction.

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Acknowledgements

Thank all participants of this study for their active participation and cooperation in this study.

Funding

This study was supported by Sun Yat-sen Clinical Research Cultivating Program (SYS-Q-202005) and Natural Science Foundation of Guangdong Province (2020A1515011322, 2022A1515010215).

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Authors and Affiliations

  1. Department of Orthopedics, Sun Yat-Sen Memorial Hospital, No. 107 on Yanjiang Road West, Guangzhou, 510120, Guangdong, China

    Cheng-Xiao Liu, Zheng-Zheng Zhang, Jing-Song Wang, Xing-Hao Deng, Yun-Feng Zhou, Wei-Ping Li & Bin Song

  2. Sun Yat-Sen University, Guangzhou, Guangdong, China

    Xi-Yuan Luo, Tian-Yu Liu, Yu-Fan Ma & Da-Zheng Xu

  3. Department of Orthopedics, Eighth Affiliated Hospital of Sun Yat-Sen University, Shenzhen, Guangdong, China

    Peng Wang

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  1. Cheng-Xiao Liu
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Contributions

C-XL and Z-ZZ equally contributed to this study. C-XL and Z-ZZ put forward the conceptions of the work, conducted the experiments, and drafted the manuscript. BS, W-PL and PW made detailed designs of the work and revised the manuscript. J-SW assisted with revising the manuscript. Y-FZ and D-ZX assisted in the conduct of experiments. Y-FM, X-YL, T-YL and X-HD assisted with collecting experimental data and analysed data. All authors read and approved the final manuscript.

Corresponding authors

Correspondence to Peng Wang or Bin Song.

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Conflict of interest

The authors have no relevant financial or non-financial interests to disclose.

Ethical approval

This is a cadaveric study. All experimental protocols are approved by the ethics committee of our hospital (No. SYSEC-KY-KS-2021-276). For this type of study, formal consent is not required.

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Liu, CX., Zhang, ZZ., Wang, JS. et al. Optimal fibular tunnel direction for anterior talofibular ligament reconstruction: 45 degrees outperforms 30 and 60 degrees. Knee Surg Sports Traumatol Arthrosc 31, 4546–4550 (2023). https://doi.org/10.1007/s00167-023-07452-6

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