Needle-Arthroscopic Ankle Lateral Ligament Repair Using a Knotless Suture Anchor

CATEGORY: Arthroscopy; Ankle; Arthroscopy; Sports INTRODUCTION/PURPOSE: Arthroscopic techniques have been increasingly used to repair the anterior talofibular ligament (ATFL) for lateral ankle instability, however there are still concerns on complications, such as nerve injury, iatrogenic cartilage damage and wound scar. Additionally, standard suture anchors can cause prominent knots. Recently, a novel needle-arthroscopic system (NanoScope(TM)) has been introduced, with a 1.9-mm diameter arthroscope and semirigid frame, which can reduce conventional arthroscopic-related complications by minimizing the skin incisions and provide excellent visualization without ankle distraction due to its small and semirigid features. The purpose of this surgical technical note is to describe a new, very minimally invasive surgical technique for the ATFL repair using this needle-arthroscopy with a knotless suture anchor, which has the potential to reduce both conventional arthroscopic-related and knot-related complications. METHODS: We have developed a novel surgical treatment of the ATFL repair for lateral ankle instability in a cadaveric model. The arthroscopic system (NanoScope(TM), Arthrex, Naples, FL) is used during the procedures. The handpiece tube is 9.5-cm long, semi-rigid and has a 1.9-mm outer diameter. The scope's direction of view is 0°, with a 120° field of view. The patient is placed in a supine position and no distraction is applied to the ankle joint. Standard anteromedial and anterolateral portals are first used. An accessory anterolateral (AAL) portal is then created around 1.5 cm anterior to the tip of the fibula, of which the portal position is determined under the visualization through the anterolateral portal. RESULTS: Almost all of the talar and tibial surfaces are reachable without distraction, due to its small and semirigid features. There is no difficulty problem obtaining proper visualization of the ATFL and the surrounding structures during the whole procedures, due to a wide 120°-field of view. The major steps of the procedure are (1) suture anchor insertion into the distal fibula through the AAL portal using a Knotless SutureTak Anchor (Arthrex), (2) penetration of suture string into the ATFL remnant using a Micro SutureLasso(TM) (Arthrex), (3) capture of the ATFL remnant using a suture-relay technique, (4) reattachment of the ATFL remnant by pulling out the passing wire without knot-tying, in the dorsiflexed ankle position (Figure). All skin-incisions are tiny and require only paper skin closures. This method requires neither blunt dissection of subcutaneous tissue to pass the suture nor knot-tying to reattach the ATFL. CONCLUSION: Our technique is a simple, feasible, and very minimally invasive anatomic repair of the ATFL for lateral ankle instability using a 1.9-mm diameter needle-arthroscopy with a knotless suture anchor. However, the long-term clinical results need to be evaluated in future studies.