A 15-year-old girl who was hit by a bus was admitted to our hospital. Initial examination revealed extensive skin and soft tissue defects on the lateral side of her right ankle. The talus was visualized through the wound, and the ankle joint showed marked instability (Figure 1A). A comminuted fracture of the distal fibula was revealed by plain radiography and computed tomography (Figure 1B and C). Surgical debridement was performed under general anesthesia. The damaged skin area was resected, resulting in a 10x10-cm defect (Figure 2). A distal fibula bone fragment was resected. The upper one-third of the anterior talofibular ligament (ATFL) remained; however, the lower two-thirds of the ATFL and the calcaneofibular ligament (CFL) was shaven off and disappeared from the distal fibula, along with the lateral part of the capsule. The distal half of the inferior extensor retinaculum remained. The talocrural joint was lax during the stress test and anterior drawer stress test; there was no damage to the articular cartilage on either the tibial or the talar side. Both peroneus longus and brevis tendons were severely crushed with segmental tear, and were resected. Kirschner wires were inserted from the proximal tibia to the talus and calcaneus for temporary fixation (Figure 1D). The wound was covered with a VAC (V.A.C. GranuFoam; KCI, Lane Cove, New South Wales, Australia).
Thirteen days after the initial debridement, a second surgery was performed. Under general anesthesia, the patient was placed in the semilateral position and a thigh tourniquet (250 mmHg) was applied. The gracilis tendon and semitendinosus tendon were harvested using a tendon stripper. First, we reconstructed the ATFL and CFL using a semitendinosus graft.   Two parallel bone tunnels with a diameter of 3.5 mm were made at the footprints of the ATFL and CFL attachment sites of the distal fibula. The semitendinosus graft was passed through one bone tunnel in an anterior-to-posterior direction and through another tunnel in a posterior-to-anterior direction using a passing wire (Figure 3A and B). Another bone tunnel was made at the CFL footprint site in the calcaneus, and the distal end of the graft was inserted in the tunnel. Then, it was firmly fixed using a 4.75-mm interference screw (PEEK SwiveLock C; Arthrex Inc, Naples, FL). Additionally, a suture anchor (3.5 mm; Corkscrew FT; Arthrex Inc) was placed at the CFL footprint site of the calcaneus to reinforce the attachment site of the reconstructed CFL. Then, two perpendicular bone tunnels, merging in the talar neck, were made at the anterior border of the talar body. The proximal portion of the graft (ATFL) was passed through the tunnels, posteriorly to anteriorly, and then overlaid on itself (Figure 3B). With the ankle in 0 degrees of dorsiflexion and slight eversion, the proximal end of the graft was sutured on itself using nonabsorbable No. 2 FiberWire (Arthrex Inc.). After suturing the remnant of the ATFL on the graft, suture tape augmentation (InternalBrace; Arthrex Inc.) was performed. A 3.4-mm tunnel was made in the distal fibula, superior to the ATFL insertion, followed by 4.75 mm of tape. Another 3.4-mm tunnel was made in the talar neck, slightly distal to the graft tunnel. With the ankle in a neutral position, 3.5- and 4.75-mm suture anchors (PEEK SwiveLock; Arthrex Inc.) were loaded with suture tape (FiberTape; Arthrex Inc.) overlaying the reconstructed ATFL. To avoid overtensioning, a small hemostat was placed underneath the suture tape when inserting suture anchors. The inferior extensor retinaculum was then mobilized proximally and sutured onto the remaining fibular periosteum and ATFL with 3-0 Vicryl. Stability of the ankle was confirmed using anterior drawer and talar tilt tests. After reconstruction, the range of motion was maintained (dorsiflexion, 10 degrees; plantarflexion, 40 degrees).
Then, we reconstructed both the peroneus longus and brevis tendons. Two gracilis tendon grafts were prepared, and the proximal stumps of the peroneus tendons were sutured to the grafts with 3-0 Prolene using a Pulvertaft weave. While maintaining the foot in a neutral position, additional Pulvertaft weave suturing was performed between the distal stumps and grafts (Figure 4). The peroneal tendon sheath was repaired, and normal excursion of both peroneal tendons was confirmed. Finally, an 8x20-cm anterolateral thigh flap was harvested as a fasciocutaneous flap with subcutaneous perforators. The perforators were connected with anterior tibial vessels, and the wound was closed (Figure 5).
Postoperatively, the patient was fitted with a short leg splint. After 3 weeks, the splint was removed, and the ankle was completely free of immobilization, without any brace used. Physical therapy including proprioceptive training and active range of motion training was started. At 4 weeks, full weightbearing was permitted, and the patient returned to school. At final follow-up, two years after surgery, the patient returned to her preoperative level of work and sports activities, with no pain, no instability, and no loss of range of motion in her right ankle.