2015 ISAKOS Biennial Congress ePoster #111

Arthroscopic Anterior Talofibular Ligament Reconstruction and Arthroscopy-Assisted Calcaneofibular Ligament Reconstruction Using an Autogenous Hamstring Tendon

Reiji Higashiyama, MD, PhD, Sagamihara, Kanagawa JAPAN
Jun Aikawa, MD, Sagamihara, Kanagawa JAPAN
Dai Iwase, MD, Sagamihara-Shi JAPAN
Atsushi Minatani, MD, Sagamihara, Kanagawa JAPAN
Hiroyuki Sekiguchi, MD, Sagamihara JAPAN
Shotaro Takano, MD, Sagamihara JAPAN
Shintaro Shoji, MD, Sagamihara JAPAN
Hiroyuki Watanabe, PhD, Sagamihara JAPAN
Tomonori Kenmoku, MD, PhD, Sagamihara, Kanagawa JAPAN
Kensuke Fukushima, MD, Sagamihara, Kanagawa JAPAN
Eiichiro Watanabe, Chiba City JAPAN
Masashi Takaso, MD, Sagamihara JAPAN

Department of Orthopaedic Surgery, Kitasato University School of Medicine, Sagamihara, Kanagawa, JAPAN

FDA Status Cleared

Summary: We report good clinical results of the arthroscopic anterior talofibular ligament reconstruction and arthroscopy-assisted calcaneofibular ligament reconstruction using an autogenous hamstring tendon, which are cosmetic advantage, less postoperative pain and good stability.




The anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) are the structure frequently involved in ankle sprains. The Broström-Gould technique, which repairs the ruptured ATFL, is the most popular reconstruction procedure. However, postoperative results may be poor when the ATFL scar is insufficiently strong, and a ligament reconstruction method using a free tendon is thought to provide a better prognosis in such cases. We report clinical results of arthroscopic ATFL reconstruction and arthroscopy-assisted calcaneofibular ligament (CFL) using a free autogenous hamstring tendon.


The number of subjects was ten patients (eleven feet), one of whom was performed with both feet. They were four male and six female. Mean age was 33.6. Causes of the chronic lateral instability were nine of ATFL rupture and two of avulsion fracture of the distal tip of fibula where ATFL attached. The arthroscopic ATFL reconstruction was performed in all patients and the arthroscopy-assisted CFL reconstruction was added in two patients who were diagnosed with severe both ATFL and CFL instability.
Anterior ankle arthroscopy was performed using two conventional portals. A gracilis tendon was used in nine patients and a semitendinosus muscle tendon was used in one patient. The hamstring tendon was folded in half for ATFL reconstruction or in reversed-Y-shaped for both ATFL and CFL reconstruction. 6 mm-diameter bone tunnels were drilled at the fibula, talus and calcaneus. Tunnels of the talus and the fibula were drilled through the accessory lateral portal. Calcaneus tunnel was drilled through the lateral small incision which located just posteriorly from the peroneal tendon. The tendon was passed through the tunnels with the aid of a guide pin and fixed with 5-mm-diameter interference screws (TJ screw, Meira Co.). CFL portion of the new ligament was passed under peroneal tendons from accessory lateral portal to the calcaneus bone tunnel by relaying a looped string.
Postoperatively, range of motion exercise was initiated 2 days later. Progressive weight bearing with an ankle brace was allowed after 1 week. Patients were permitted to resume sports activities 3 months after surgery. The clinical results were evaluated using the Japanese Society for Surgery of the Foot Ankle-Hindfoot scale (JSSF) score and by measuring the talar tilt angle (TTA) and the anterior displacement of the talus (ADT) using stress radiography.


In one patient with posterior ankle impingement syndrome, hindfoot endoscopy via the van Dijk technique was performed just before ATFL reconstruction.
The mean ADT improved from 9.3 mm preoperatively to 5.7 mm postoperatively, the mean TTA from 14° to 4.2°, and the mean JSSF score from 60.5 points to 95 points. The mean length of follow-up was 17.7 months. Little postoperative scar pain was reported. Two patients experienced transient slight numbness of the dorsum of the foot along the superficial peroneal nerve. Tinel’s sign was elicited over the anterolateral portal scar in one and the accessory lateral portal in the other.


This is the first report of arthroscopic ATFL reconstruction and arthroscopy-assisted CFL reconstruction using a hamstring tendon. This procedure has not only cosmetic but also functional advantages, producing less postoperative pain and an earlier return to activities of daily life. This new procedure is a good alternative for patients with chronic lateral ankle instability.