STAR Drill for Ankle Ligament Reconstruction
Modified Bostrom Repair
The modified Bostrom repair, pulling up the anterior talofibular ligament onto the newly prepared fibula bed, is greatly facilitated by the use of the STAR Drill.
The sutures can be placed into the anterior talofibular ligament capsule using a Kessler type suture. The STAR Drill is used to drill from the posterior to anterior just behind the posterolateral border of the fibular avoiding the peroneal tendons.
The hole exists in the bed of the anterior talofibular ligament and then a further hole is drilled in the same fashion to exit adjacent to the bed in the anterior talofibular ligament footprint, with the tunnels divergent towards the posterior aspect of the fibula. The sutures can then be tied over the bone bridge posteriorly where they are less prominent.
Modified Bostrom Repair Requiring New Tissue
A modified technique when the anterior talofibular ligament has completely resorbed and new tissue needs to be introduced as follows:
The surgeon extends the wound proximally along the line of the fibula to find the peroneus longus tendon. A strip of approximately 40% of the cross sectional area of this tendon is harvested. A 60mm piece can easily be obtained.
A footprint of the anterior talofibular ligament onto the talus is identified. This area is freshened up and an anchor will be used. The area where the anchor is going to enter is deepened into a slight pit. The anchor is threaded with a second suture, the 2.4mm drill hole is made, and the anchor is tapped in.
The free tendon graft is taken and tied over the anchor in a ratio of two-thirds to one-third, the longer tail being inferior. The second suture can then be passed partially through the tendon graft to reinforce this if necessary, or passed again over the top to give a double purchase.
The two tails are now attached to the fibula into the footprint of the anterior talofibular ligament.
This is simply achieved by taking the STAR Drill and drilling from posteriorly to anteriorly producing two holes exiting in the footprint. The STAR Drill is left as it exists each of the holes and the true free ends of a suture are pulled through these holes as a lasso.
The tendon grafts are passed through the two eyes of the lasso, the longer inferiorly, the shorter superiorly. The double sutures are then tied together over the posterior aspect of the fibula as the tendon graft is tightened with haemostats on each end, thereby snaring it and pulling it in to the holes and locking it tightly. The knot itself is tied into one of the holes to reduce its bulk posteriorly.
The anterior talofibular ligament has now been reconstructed.
The residual inferior arm is now taken down and used to reinforce the calcaneofibular portion of the lateral ligament complex and this can be done either by suturing it back into the bed of the original ligament or otherwise a further suture anchor can be used distally. The ends of the lassoed tendon graft are sutured to the periosteum with braided sutures.
The capsule of the ankle joint and extensor retinaculum are then closed in standard fashion as for Bostrom repair.
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