Ten Tips for Addressing Ankle Instability

Tip #1. Use anterolateral and anteromedial drawer stress test(s) to the assess lateral and medial ankle, respectively. Do not use a traditional anterior drawer test, which depends on discerning as little as 2–3mm more motion on the injured versus uninjured side. Allow the foot to internally rotate (anterolateral stress), or externally rotate (anteromedial stress) around the other, possibly intact complex. This has been shown to give you twice as much talar subluxation versus the traditional anterior drawer¹; it’s hard to miss a 4 to 6mm difference between sides.
 
Tip #2. Watch for the unilateral flatfoot that corrects fully on single heel rise.  Progressive collapsing foot deformity is typically bilateral, and rarely corrects on single heel rise in middle-aged or older adults. A scenario involving a middle-aged male, acute medial “ankle sprain,” and a unilateral flatfoot is something we all may encounter. In my first encounter with this scenario, the patient was adamant about never having a flatfoot, having isolated pain medially, and having full correction on single heel rise with posterior tibial tendon strength within normal limits. This is not acute posterior tibial tendonitis in an adult with progressive collapsing foot deformity, the misdiagnosis I’ve seen it associated with a few times.
 
Tip #3. Utilize magnetic resonance imaging (MRI) (3.0 or 7.0 Tesla) and rely on a fellowship trained musculoskeletal trained radiologist for the interpretation. The deltoid and spring ligaments, are often overlooked. Call out your suspicion on the MRI order and communicate directly with radiology. 
 
Tip #4. Loosen the noninvasive distractor (if you use one) when assessing the syndesmosis under arthroscopy. Arthroscopy is the accepted gold standard for assessing the syndesmosis. However, longitudinal traction places tension on medial and lateral ligaments, which connect the foot to the leg, thus resulting in a reduction in the diastasis of the fibula and tibia during stress assessment. The easier solution—ditch the distractor. You don’t need it. 
 
Tip #5. Utilize augmentation. Anything that gives your repair additional stability and strength, while affording flexibility and motion, is to be desired. 
 
Tip #6. Directly reduce/realign your syndesmosis manually using the center-center technique to ensure fixation will be along the centroidal axis; not the arbitrary 20 to 30 degrees so commonly mis-cited in industry technique guides. Check the tib-fib congruence for step-off anteriorly, and visualize the cartilage on the anterolateral plafond. Fixation placement is flexible along the centroidal axis, with concurrent anterior inferior talofibular ligament (AITFL) repair as well. The AITFL repair is essential to rotary stability.
 
Tip #7. Anatomic lateral ankle stabilization (ATLAS) is my preferred method for lateral reconstruction. It’s a “better Brostrom” in the sense that it lifts the thin, attenuated tissues off the distal fibula like the traditional Brostrom-Gould, but it also utilizes an absorbable scaffold (multiple industry options) anchored in an orientation of a “V”; apex to the distal fibula and extending distally along the footprint of the anterior talofibular and calcaneofibular ligaments, respectively. The lateral tissues are then imbricated and advanced back to the distal fibula over the scaffold. I use anchors for the advancement in most cases. 
 
Tip #8. Consider an insurance policy on your medial ankle reconstructions, especially when/if isolated. My insurance policy is either a medial displacement calcaneal osteotomy (excluding the cavus foot), or a subtalar joint arthroereisis; this scenario is my only indication for an arthroereisis in an adult patient.  
 
Tip #9. When performing anatomic medial ankle reconstructions, specifically those configurations that involve passage through the navicular (with/without concurrent flexor digitorum longus [FDL] transfer), only pass 1 limb at a time. Nothing is more frustrating than ushing a Hewson, or other suture passage, to grab the whipped stitched ends of the graft, only to get caught up in the navicular. See the last tip below.
 
Tip #10. When performing anatomic medial ankle reconstructions as described above, utilize an empty Vicryl-loop stitch. First, pass the Hewson from top-down, through the navicular. Next, place the looped end of the suture through the Hewson along with the plantar limb of the graft, but the graft goes through the suture passer alone, not the empty loop. Pull the Hewson through the navicular for the transfer.  The plantar limb of the graft and FDL tendon (if transferred concurrently) are now dorsal. Finally, take the unpassed dorsal limb and place it through the empty Vicryl stitch (located dorsal to navicular); and pull the tails of the loop (located plantar to navicular) and secure. The result is transfer of the dorsal limp plantarly with ease. A 5–6mm tunnel through the navicular is most common for passage.
 
Reference

1. Miller AG, Myers SH, Parks BG, Guyton GP. Anterolateral drawer versus anterior drawer test for ankle instability: a biomechanical model. Foot Ankle Int. 2016 Apr;37(4):407-10. doi: 10.1177/1071100715620854. Epub 2015 Dec 9. PMID: 26660862.