In chronic lateral ankle instability, primary ligament repair is not always possible because of poor quality of the local tissues. A free autologous or allograft tendon graft or synthetic grafts are suitable alternative. We describe middle term results of arthroscopic reconstruction of the anterior talofibular ligament (ATFL) using a free autologous ipsilateral gracilis graft in patients with chronic ankle instability.

Eleven patients with chronic lateral ankle instability with imaging evidence of isolated ATFL tear underwent arthroscopic reconstruction of the ATFL using a free ipsilateral gracilis graft. Functional and subjective assessment were performed after an average of 24 months following the index procedure.

At 24 months, all patients showed objective improvements. One patient reported transient dysaesthesiae on the dorsolateral aspect of the foot and heel.

Arthroscopic isolated reconstruction of the ATFL with a free ipsilateral gracilis grafts is safe, allowing restoration of joint stability and low surgical morbidity.

Case series.

Posterior ankle impingement syndrome (PAIS) is a common injury in athletes engaging in repetitive plantarflexion, particularly ballet dancers and soccer players. Despite the increase in popularity of the posterior two-portal hindfoot approach, concerns with the technique remain, including; the technical difficulty, relatively steep learning curve, and difficulty performing simultaneous anterior ankle arthroscopy. The purpose of the current literature review is to provide comprehensive knowledge about PAIS, and to describe a systematic four-stage approach of the posterior two-portal arthroscopy. The etiology, clinical presentation, diagnostic strategies are first introduced followed by options in conservative and surgical management. A detailed systematic approach to posterior hindfoot arthroscopy is then described. This technique allows for systematic review of the anatomic structures and treatment of the bony and/or soft tissue lesions in four regions of interest in the hindfoot (superolateral, superomedial, inferomedial, and inferolateral). The review then discusses biological adjuncts and postoperative rehabilitation and ends with a discussion on the most recent clinical outcomes after posterior hindfoot arthroscopy for PAIS. Although clinical evidence suggests high success rates following posterior hindfoot arthroscopy in the short- and mid-term it may be limited in the pathology that can be addressed due to the technical skills required, but the systematic four-stage approach of the posterior two-portal arthroscopy may improve upon this problem.

Posterior and anterior arthroscopy of the ankle and hindfoot may have to be undertaken at the same surgical sitting. Standard arthroscopic practice does not allow to approach both compartments without changing the position of the patient. In the supine position, most intra-articular structures of posterior portion of the ankle joint can be accessed from anterior portals with judicious traction, but visualization of posterior extra-articular compartment and hindfoot are not possible. To avoid repositioning of the patient, we have developed a procedure that allows access to the posterior compartment of the ankle with the patient supine. We describe a 2 posteromedial ankle portals procedure, which allows to reach both the posterior side of the ankle joint and the hindfoot extra-articular compartments keeping the patient supine throughout the procedure. After treatment of anterior compartment disorders using standard anterior portals, 2 posteromedial entry portals permit to visualize and treat pathologies of the posterior ankle and of the hindfoot, without prolonging surgery.

To determine the technical feasibility and preliminary clinical efficacy of performing simultaneous arthroscopic management in cases with combined posterior and anterior ankle pathologies utilizing previously described standard arthroscopic procedures within a single surgical sitting.

Nineteen consecutive patients with combined anterior and posterior ankle pathologies were included in the current study, after at least 6 months of failed conservative managements. Combined standard posterior and anterior ankle arthroscopy was performed in all patients within the same surgical session; first with the patient in the prone position, then with the patient turned onto the supine position to perform the anterior procedure.

All patients were available for the follow-up; the median follow-up period was 33 months (range 22-61 months). No persistent neurological deficits or infections were recorded. The American Orthopedic Foot and Ankle Society Ankle and Hind foot Scale score significantly improved from 70.2 ± 15.2 points preoperatively to reach 93.0 ± 5.4 points at 1 year post-operatively (p < 0.001). Sixteen patients (84.2 %) returned to their previous activity levels.

Combined arthroscopic management of concurrent posterior and anterior ankle pathologies within the same surgical session is initially clinically encouraging; it allows for an earlier return to activities of daily living without a significantly added morbidity.

Case series, Level IV.