title: Endoscopic reconstruction of CFL and the ATFL with a gracilis graft: a cadaveric study.
abstract: OBJECTIVE
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Orthopaedic Department, AZ Groeninge Kortrijk, Burg Vercruysselaan 5, 8500, Kortrijk, Belgium. frederick_michels@hotmail.com.
authors.forename: Frederick
authors.initials: F
authors.lastname: Michels
authors.affiliation: Orthopaedic Department, Mérignac Sport Clinic, 2, Rue Georges Negrevergne, 33700, Mérignac, France.
authors.forename: Guillaume
authors.initials: G
authors.lastname: Cordier
authors.affiliation: Orthopaedic Department, AZ Groeninge Kortrijk, Burg Vercruysselaan 5, 8500, Kortrijk, Belgium.
authors.forename: Arne
authors.initials: A
authors.lastname: Burssens
authors.affiliation: Department Development and Regeneration, Faculty of Medicine, Kulak, Catholic University Leuven, Etienne Sabbelaan 53, 8500, Kortrijk, Belgium.
authors.forename: Evie
authors.initials: E
authors.lastname: Vereecke
authors.affiliation: Orthopaedic Department, Mérignac Sport Clinic, 2, Rue Georges Negrevergne, 33700, Mérignac, France.
authors.forename: Stéphane
authors.initials: S
authors.lastname: Guillo
mesh_terms: D016512:Ankle Injuries / Q000601:surgery*; D000843:Ankle Joint / Q000601:surgery*; D002102:Cadaver; D004724:Endoscopy; D006801:Humans; D007593:Joint Instability / Q000601:surgery*; D017844:Lateral Ligament, Ankle / Q000293:injuries / Q000601:surgery*; D019651:Plastic Surgery Procedures; D013710:Tendons / Q000637:transplantation*; D019737:Transplants / Q000601:surgery
keywords: Allograft; Ankle instability; Anterior talofibular ligament; Autograft; Calcaneofibular ligament; Endoscopic reconstruction; Gracilis tendon; Tendoscopy