2015 ISAKOS Biennial Congress ePoster #121

The Anatomical Reconstruction of Lateral Ankle Ligaments Using Double Bundle Gracilis Tendon

Satoru Ozeki, MD, PhD, Koshigaya, Saitama JAPAN
Masato Ogawa, MD, Koshigaya, Saitama JAPAN
Yuki Tochigi, PhD, Iowa City, IA UNITED STATES

Dept. of Orthop. Surg.Dokkyo Medical Univ. Koshigaya Hospital, Koshigaya, JAPAN

FDA Status Cleared

Summary: A simplified graft fixation method using a modified suture anchor was developed for the anatomical reconstruction methods with double bundle Gracilis tendon for the lateral ankle ligament.s.



We devised


to reconstruct the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) in anatomical placement. Because the origins of these two ligaments are anatomically close to each other, our surgical procedure involved reconstructing the two ligaments from one hole on the anterior side of the lateral malleolus. To simplify fixation of the graft to the ATFL and CFL insertion sites, we used a omega- loop anchor modified from one used in rotator cuff repair. The aim of this study was to introduce our methods and to report the clinical results.

Materials And Methods

From 2008 to 2013, 34 ankles in 30 patients were treated. Ten patients were male, and twenty patients were female. The average age at surgery was 33.6 years old. The average follow up period was 2.5years. The Japanese Society for Surgery of Foot (JSSF) scoring system was used to evaluate the ankle function. X-ray evaluation of instability was assessed using a Telos device with 150N of force on the ankle joint inversion stress test and anterior withdrawal test.
Surgical Technique
The gracilis tendon was harvested using an open tendon stripper. Two double bundle substitutes were made from the tendon and then connected with polyester mesh. An oblique 4cm straight incision was made to identify the ATFL and CFL origin and insertion sites. From the anterior side of the lateral malleolus, two bone tunnels 5.5 mm in diameter sharing one entrance were made for the ATFL and CFL graft fixation. At the insertion site of the ATFL in the talus and of the CFL in the calcaneus, a drill hole 5.5 mm in diameter and 15mm in depth was made for each substitute. An omega- loop anchor was inserted into the center of the bottom of each hole and connected to one end of the substitute. The polyester mesh connected to the other end of the substitute for ATFL reconstruction was lead into the horizontal bone tunnel of the lateral malleolus, and that for CFL reconstruction was lead into the vertical tunnel. These two substitutes were crossed at the entrance of the two bone tunnels on the anterior aspect of the lateral malleolus. Both polyester mesh leaders were fastened on the lateral malleolus using 5 mm width double staples while applying sufficient tension. Full weight bearing with an Aircast brace was allowed the next day after surgery.


The JSSF Score improved from 61.9±7.6 (mean ± S.D.) to 97.4±4.8. The element with the most improved score was ankle stability. No patient experienced residual apprehension or restriction of the ankle and the subtalar joint. The most common remaining symptom was joint pain after sports or hard work. The average talar tilt improved from 13.8 ± 4.6 to 4.7 ± 2.3 degrees, and the anterior drawer improved from 75.4 ±13.1% to 60.8 ± 5.8 %.


Anatomical graft placements are especially important and the omega- loop graft fixation provided sufficient stability.