Multi-fasciculated anterior talo-fibular ligament: reassessment of normal findings

MRI Assessment of Tendon Graft After Lateral Ankle Ligament Reconstruction: Does Ligamentization Exist?

BACKGROUND

No description exists in the literature about the normal evolution of tendon graft after a lateral ankle ligament (LAL) reconstruction.

PURPOSE

To assess the magnetic resonance imaging (MRI) characteristics and the evolution of the tendon graft during different moments in the follow-up after an endoscopic reconstruction of the LAL.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

This prospective study included 37 consecutive patients who underwent an endoscopic reconstruction of the LAL with an autograft using the gracilis tendon to treat chronic ankle instability (CAI) resistant to nonoperative treatment (CAI group) and 16 patients without ankle instability (control group). All patients in the CAI group underwent a postoperative assessment at 6, 12, and 24 months using the Karlsson score and MRI examination. Only patients with good and excellent results were included in the study. Graft assessment consisted of qualitative measurements and quantitative evaluations of the reconstructed anterior talofibular ligament (RATFL) and reconstructed calcaneofibular ligament (RCFL), including signal-to-noise quotient (SNQ) and contrast-to-noise quotient (CNQ) measurements in proton density-fat suppressed (PD-FS) and T1-weighted sequences. The analysis of variance test was used to compare the SNQ and the CNQ at different time points for each sequence.

RESULTS

The MRI signal at 6 months was increased compared with that of the control group. Next, a significant signal decrease from 6 to 24 months was noted on PD-FS and T1-weighted images. SNQ measurements on PD-FS weighted images for both the RATFL and the RCFL demonstrated a significantly higher signal (P < .01 and P = .01, respectively) at 6 months compared with that of the control group. Subsequently, the signal decreased from 6 to 24 months. Similarly, CNQ measurements on PD-FS weighted images for both the RATFL and the RCFL demonstrated a significantly higher signal (P < .01 and P < .01, respectively) at 6 months compared with that of the control group. Subsequently, the signal decreased from 6 to 24 months.

CONCLUSION

The present study demonstrated an evolution of the MRI characteristics, suggesting a process of graft maturation toward ligamentization. This is important for clinical practice, as it suggests an evolution in graft properties and supports the possibility of creating a viable ligament.

Individual fascicles of the ankle lateral ligaments and the lateral fibulotalocalcaneal ligament complex can be identified on 3D volumetric MRI

PURPOSE

Lateral ligament ankle sprains are common and the anatomy on imaging studies is vital for accurate diagnosis. The lateral fibulotalocalcaneal ligament (LFTCL) complex consists of the inferior fascicle of the anterior talofibular ligament (ATFL) which is connected by arciform fibres with the calcaneofibular ligament (CFL). The superior fascicle of ATFL is an independent structure that should be assessed individually. MRI evaluation of these distinct fascicles and the arciform fibres has not been described. The aim of this study is to identify the anatomical relationship of these components of the LFTCL complex in healthy individuals on MRI.

METHODS

Thirty ankles from healthy volunteers were imaged using 3D volumetric MRI. The ATFL fascicles and size were evaluated. Presence of arciform fibres connecting the inferior ATFL fascicle and CFL to form the LFTCL complex and anatomical relationship around the lateral ligament complex were assessed.

RESULTS

Both the superior and inferior ATFL fascicles were observed in 26 (86.7%) ankles. The superior ATFL fascicle was significantly larger in all specimens (39% longer and 80.7% wider). For the specimens with a single fascicle, this was similar in size to the superior fascicle observed in the other 26 specimens. These measurements were not affected by age or gender. Arciform fibres of the LFTCL complex were identified in 22 (84.6%) specimens with two ATFL fascicles and three (75%) ankles with a single ATFL fascicle. Connecting fibres from the ATFL to PTFL were observed in 19 (63.3%) ankles while connections between the CFL and PTFL were identified in 21 (70%) ankles. Five ankles had a perforating artery visualized in the intervening space between the superior and inferior ATFL fascicles (a branch of the lateral tarsal artery of the dorsalis pedis artery).

CONCLUSION

Two distinct ATFL fascicles may be identified in the majority of ankles on MRI. Isolated injury to the superior fascicle identified on MRI may be useful when diagnosing patients presenting with symptoms of subtle instability without overt ankle laxity on clinical examination. The current study is the first to identify the arciform fibres of the LFTCL complex supporting isolated ATFL repair in the presence of intact LFTCL complex.

LEVEL OF EVIDENCE

Level III.

Anatomic Measurement and Variability Analysis of the Anterior Talofibular Ligament and Calcaneofibular Ligament of the Ankle

Background:

The anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) contribute greatly to the overall stability of the ankle joint; however, ATFL and combined ATFL-CFL sprains are common. Anatomic reconstruction of the lateral collateral ligament with grafts has been proposed for patients with poor tissue quality or inadequate local tissue. Anatomic reconstruction of the lateral ankle ligaments requires a good understanding of their anatomic location.

Purpose:

To describe the anatomy of the ATFL and CFL ligaments quantitatively and qualitatively and explore the relationship of some morphological parameters.

Study Design:

Descriptive laboratory study.

Methods:

A total of 66 adult ankle specimens were analyzed for ATFL band type, origin, length, width, thickness, and angle between the ATFL and CFL, and 73 adult ankle specimens were used for measuring the origin of the CFL. The coefficient of variation was used to describe and compare the respective variability of angle, length, width, and thickness. The origin of the ATFL was labeled as point A, and the leading edge of the CFL intersection with the articular surface of the calcaneus was considered point B.

Results:

The ATFL had a variable number of bands. A high degree of variability (coefficient of variation >0.2) was seen for most morphological measurements of the ATFL. In addition, the length of distance AB also varied. The CFL originated at the tip of the fibula in only 9% of specimens. It was found more commonly at the anterior border of the lateral malleolus (4.94 ± 1.70 mm from the tip). The angle between the ATFL and CFL was consistent at 100° to 105º.

Conclusion:

A fair amount of variability of ATFL length, width, and thickness were found in our study, with less variability in the ATFL-CFL angle. Most CFLs attached anterior to the tip of the fibula.

Clinical Relevance:

Providing relevant anatomic data of ATFL and CFL is important in ensuring proper surgical treatment of ankle joint injuries.

Number of fiber bundles in the fetal anterior talofibular ligament

PURPOSE

For the anterior talofibular ligament (ATFL), a three-fiber bundle has recently been suggested to be weaker than a single or double fiber bundle in terms of ankle plantarflexion and inversion braking function. However, the studies leading to those results all used elderly specimens. Whether the difference in fiber bundles is a congenital or an acquired morphology is important when considering methods to prevent ATFL damage. The purpose of this study was to classify the number of fiber bundles in the ATFL of fetuses.

METHODS

This study was conducted using 30 legs from 15 Japanese fetuses (mean weight, 1764.6 ± 616.9 g; mean crown-rump length, 283.5 ± 38.7 mm; 8 males, 7 females. The ATFL was then classified by the number of fiber bundles: Type I, one fiber bundle; Type II, two fiber bundles; and Type III, three fiber bundles.

RESULTS

Ligament type was Type I in 5 legs (16.7%), Type II in 21 legs (70%), and Type III in 4 legs (13.3%).

CONCLUSION

The present results suggest that the three fiber bundles of the structure of the ATFL may be an innate structure.

The double fascicular variations of the anterior talofibular ligament and the calcaneofibular ligament correlate with interconnections between lateral ankle structures revealed on magnetic resonance imaging

The anterior talofibular ligament and the calcaneofibular ligament are the most commonly injured ankle ligaments. This study aimed to investigate if the double fascicular anterior talofibular ligament and the calcaneofibular ligament are associated with the presence of interconnections between those two ligaments and connections with non-ligamentous structures. A retrospective re-evaluation of 198 magnetic resonance imaging examinations of the ankle joint was conducted. The correlation between the double fascicular anterior talofibular ligament and calcaneofibular ligament and connections with the superior peroneal retinaculum, the peroneal tendon sheath, the tibiofibular ligaments, and the inferior extensor retinaculum was studied. The relationships between the anterior talofibular ligament's and the calcaneofibular ligament's diameters with the presence of connections were investigated. Most of the connections were visible in a group of double fascicular ligaments. Most often, one was between the anterior talofibular ligament and calcaneofibular ligament (74.7%). Statistically significant differences between groups of single and double fascicular ligaments were visible in groups of connections between the anterior talofibular ligament and the peroneal tendon sheath (p < 0.001) as well as the calcaneofibular ligament and the posterior tibiofibular ligament (p < 0.05), superior peroneal retinaculum (p < 0.001), and peroneal tendon sheath (p < 0.001). Differences between the thickness of the anterior talofibular ligament and the calcaneofibular ligament (p < 0.001), the diameter of the fibular insertion of the anterior talofibular ligament (p < 0.001), the diameter of calcaneal attachment of the calcaneofibular ligament (p < 0.05), and tibiocalcaneal angle (p < 0.01) were statistically significant. The presence of the double fascicular anterior talofibular ligament and the calcaneofibular ligament fascicles correlate with connections to adjacent structures.

Morphological characteristics of the lateral ankle ligament complex

PURPOSE

The relevance of each ligament comprising the lateral ankle ligament complex, including the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and posterior talofibular ligament (PTFL), has not been sufficiently elucidated; therefore, we aimed to clarify the morphological characteristics and relevance of these ligaments.

METHODS

Total 152 legs from 152 Japanese cadavers were investigated. The lengths and widths of the ATFL, CFL, and PTFL were measured using a caliper. The ATFL was classified according to the number of fiber bundles (Types I, II, and III corresponded to one, two, and three fiber bundles, respectively), and the lengths and widths of the three ligaments were compared between the Type groups. In addition, the ratio of each ligament's length and width to the tibial length was calculated, and the correlation of the ratio of ligament length and width between the ATFL, CFL, and PTFL was examined about 34 legs.

RESULTS

The ATFL, CFL, and PTFL were found to connect at the anterior/inferior tip of the lateral malleolus each other. The Type II group of the ATFL was most common (54.6%) in our investigated specimens. However, there were no significant inter-group differences in the lengths and widths of the CFL and PTFL.

CONCLUSIONS

This study demonstrates that the lateral ankle ligaments may stabilize the ankle joint through interconnections.

Lower Signal Intensity of the Anterior Talofibular Ligament is Associated with a Higher Rate of Return to Sport After ATFL Repair for Chronic Lateral Ankle Instability

BACKGROUND

The treatment strategy for anterior talofibular ligament (ATFL) injury is usually determined by the ATFL remnant condition during surgery. Preoperative magnetic resonance imaging (MRI)-based signal intensity of the ATFL remnant, represented by the signal/noise ratio (SNR) value, can reveal the ATFL remnant condition. Thus far, there is a lack of evidence regarding the relationship between the ATFL remnant condition and functional outcomes.

PURPOSE/HYPOTHESIS

The purpose was to quantitatively evaluate whether the MRI-based ATFL ligament SNR value is related to functional outcomes after ATFL repair for ankles with chronic lateral ankle instability. The hypothesis was that a lower preoperative SNR is related to a better clinical outcome, particularly a higher rate of return to sport.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

First, a preliminary study was performed to measure the ATFL SNR in preoperative MRI, the results of which suggested that a preoperative SNR >10.4 was indicative of a poor ATFL condition. Then, a cohort study was retrospectively performed with consecutive patients who underwent open repair of ATFL injuries between January 2009 and August 2014. Accordingly, the patients were divided into 2 groups: high SNR (HSNR; ≥10.4) and low SNR (LSNR; <10.4). Functional outcomes based on the American Orthopaedic Foot and Ankle Society (AOFAS) score, Karlsson Ankle Functional Score (KAFS), and Tegner Activity Scale were then compared between the HSNR group and the LSNR group.

RESULTS

Ultimately, 70 patients were available for the final follow-up: 37 in the HSNR group and 33 in the LSNR group. No significant difference was detected between the HSNR group and the LSNR group in terms of the AOFAS score, KAFS, or Tegner Activity Scale (P > .05 for all) preoperatively. At the final follow-up, the mean ± SD AOFAS score in the LSNR group (92 ± 6) was higher than that in the HSNR group (87 ± 12), although no significant difference was detected postoperatively (P = .16). The mean KAFS in the LSNR group (94 ± 7) was significantly higher than that in the HSNR group (88 ± 11) postoperatively (P = .03). At follow-up, the mean Tegner score in the LSNR group (6; range, 3-7) was significantly higher than that in the HSNR group (5; range, 1-8) postoperatively (P = .03). Patients in the LSNR group had a significantly higher percentage of sports participation than those in the HSNR group (91% vs 65%, P = .02) postoperatively.

CONCLUSION

A lower signal intensity in the ATFL ligament based on preoperative MRI is associated with a better clinical outcome, particularly a higher rate of return to sport.

Relationships between differences in the number of fiber bundles of the anterior talofibular ligament and differences in the angle of the calcaneofibular ligament and their effects on ankle-braking function

PURPOSE

The aim was to clarify the relationships between differences in the number of fiber bundles of the anterior talofibular ligament (ATFL) and differences in the angle of the calcaneofibular ligament (CFL) with respect to the long axis of the fibula and their effects on ankle braking function.

METHODS

The study sample included 110 Japanese cadavers. ATFLs were categorized as: Type I with one fiber bundle; Type II with two fiber bundles with incomplete separation and complete separation; and Type III with three fiber bundles. The CFLs were categorized according to the angles of the CFLs with respect to the long axis of the fibula and the number of fiber bundles. Six categories were established: CFL10° (angle of the CFL with respect to the long axis of the fibula from 10° to 19°); CFL20° (range 20°-29°); CFL30° (range 30°-39°); CFL40° (range 40°-49°); CFL50° (range 50°-59°); and CFL2 (CFLs with two crossing fiber bundles).

RESULTS

ATFL was Type I in 34 legs (31%), Type II in 66 legs (60%), and Type III in 10 legs (9%). Five CFL categories were identified: CFL10° in 4 feet (3.7%); CFL20° in 23 feet (20.9%); CFL30° in 34 feet (30.9%); CFL40° in 33 feet (30%); CFL50° in 15 feet (13.6%); and CFL2 in one foot (0.9%). Type III contained mainly CFL40° and CFL50° (7 of 10 feet).

CONCLUSIONS

ATFL and CFL appear to cooperate in the ankle joint braking function.

Morphological features of the anterior talofibular ligament by the number of fiber bundles

The aims of this study have been to clarify differences in morphological features based on the number of fiber bundles in the anterior talofibular ligament (ATFL), and to investigate the relationship between the ATFL and the calcaneofibular ligament (CFL). This study used 81 legs from 43 cadavers. The ATFL was classified according to differences in the number of fiber bundles as: Type I, with one fiber bundle; Type II-a, with two fiber bundles that were incompletely separated; Type II-b, with two fiber bundles that were completely separated; and Type III, with three fiber bundles. The morphological features measured were fiber bundle length, fiber bundle width, and fiber bundle angle. For the relationship between the ATFL and CFL, the positional relationship and attachment sites of the two ligaments were examined. Type I was present in 33%, Type II-a in 17%, Type II-b in 40%, and Type III in 10%. The morphological features of superior fiber bundles and inferior fiber bundles were significantly different within each type. Among types, there were significant differences in the morphological features of Type II-a and Type III inferior fiber bundles. In the relationship between the ATFL and CFL, there was a connection between the ATFL and CFL in all specimens. Various types were present in the positional relationship and attachment sites of the two ligaments. The results of this study suggest that, among different ligament types with two or three fiber bundles, the control function of the ankle may differ within each type and among types.

Quantitative magnetic resonance imaging (MRI) analysis of anterior talofibular ligament in lateral chronic ankle instability ankles pre- and postoperatively

BACKGROUND

The aim of this study was to quantitatively evaluate and characterize the dimension and signal intensity of anterior talofibular ligament (ATFL) using 3.0 T MRI in the mechanical ankle instability group pre- and postoperatively.

METHODS

A total of 97 participants were recruited retrospectively in this study, including 56 with mechanical chronic ankle instability (CAI group) and 41 without ankle instability (Control group). All the subjects accepted MRI preoperatively. Among the 56 CAI patients, 25 patients, who accepted modified Broström repair of ATFL, underwent a MRI scan at follow-up. The ATFL dimension (length and width) and signal/noise ratio (SNR) were measured based on MRI images. The results of the MRI studies were then compared between groups.

RESULTS

The CAI group had a significantly higher ATFL length (p = 0.03) or ATFL width (p < 0.001) compared with the control group. The mean SNR value of the CAI group was significantly higher than that of the control group (p = 0.006). Furthermore, the mean SNR value of the ATFL after repair surgery (8.4 ± 2.4) was significantly lower than that of the ATFL before surgery (11.2 ± 3.4) (p < 0.001). However, no significant change of ATFL length or ATFL width were observed after repair surgery.

CONCLUSIONS

CAI ankles had a higher ATFL length or width as well as higher signal intensity compared with stable ankles. After repair surgery, the mean SNR value of the ATFL decreased, indicating the relaxed ATFL becomes tight postoperatively.

Anatomy of the ankle ligaments: a pictorial essay

Understanding the anatomy of the ankle ligaments is important for correct diagnosis and treatment. Ankle ligament injury is the most frequent cause of acute ankle pain. Chronic ankle pain often finds its cause in laxity of one of the ankle ligaments. In this pictorial essay, the ligaments around the ankle are grouped, depending on their anatomic orientation, and each of the ankle ligaments is discussed in detail.

Reliability and Validity of Magnetic Resonance Imaging for the Evaluation of the Anterior Talofibular Ligament in Patients Undergoing Ankle Arthroscopy

PURPOSE

To analyze the reliability and validity of magnetic resonance imaging (MRI) for the detection of anterior talofibular ligament (ATFL) injuries in chronic lateral ankle instability by comparing its findings with arthroscopic findings.

METHODS

This diagnostic study enrolled patients who underwent MRI followed by subsequent arthroscopy for their various ankle disorders between April 2012 and February 2013. Two radiologists independently assessed the ATFL on MRI, and the results of their MRI assessments were then compared with the arthroscopic findings, which were used as the standard of reference.

RESULTS

On arthroscopy, 55 ATFL injuries were identified in 79 patients. The interobserver reliability of detecting ATFL injuries with MRI was excellent (intraclass correlation coefficient, 0.915). MRI, as interpreted by readers A and B, showed a sensitivity of 83.6% and 76.4%, respectively; specificity of 91.7% and 83.3%, respectively; negative predictive value of 71.0% and 60.6%, respectively; positive predictive value of 95.8% and 91.3%, respectively; and accuracy of 86.1% and 78.5%, respectively. According to the location of the ATFL injury, the sensitivity of MRI for readers A and B was 72.7% and 63.6%, respectively, at the fibular attachment site; 80.0% and 66.7%, respectively, at the talar attachment site; and 100% at the midsubstance and multiple sites. All false-negative diagnoses of ATFL injuries were observed at the fibular or talar attachment site (9 cases for reader A and 13 cases for reader B).

CONCLUSIONS

This study showed that MRI has excellent interobserver reliability (intraclass correlation coefficient, 0.915) for detecting ATFL injuries in patients in whom there is a clinical suspicion of chronic lateral ankle instability. The sensitivity and positive predictive value of MRI in the diagnosis of ATFL injuries were very high, whereas the sensitivity and negative predictive value of MRI were relatively low. According to the location of the ATFL injury, the sensitivities of MRI for the detection of ATFL injuries at the fibular or talar attachment site were lower than those at the midsubstance or multiple sites. In addition, all false-negative diagnoses of ATFL injuries were observed at the fibular or talar attachment site.

LEVEL OF EVIDENCE

Level III, diagnostic study of nonconsecutive patients (without consistently applied reference gold standard).

All-inside arthroscopic lateral collateral ligament repair for ankle instability with a knotless suture anchor technique

BACKGROUND

Recently, arthroscopic-assisted techniques have been described to treat lateral ankle instability with excellent results. However, complications including neuritis of the superficial peroneal or sural nerve, and pain or discomfort due to a prominent anchor or suture knot have been reported. The aim of this study was to describe a novel technique, the "all-inside arthroscopic lateral collateral ankle ligament repair," and its results for treating patients with ankle instability.

METHODS

Sixteen patients (10 men and 6 women, mean age 29.3 years, 17-46) with lateral ankle instability were treated with an arthroscopic procedure. Using a suture passer and a knotless anchor, the ligaments were repaired with an all-inside technique. The right ankle was affected in 10 cases. Mean follow-up was 22.3 (12-35) months.

RESULTS

On arthroscopic examination, 13 patients had an isolated anterior talofibular ligament (ATFL) injury, and in 3 patients, both the ATFL and calcaneofibular ligament (CFL) were affected. All-inside arthroscopic anatomic repair of the lateral collateral ligament complex was performed in all cases. All patients reported subjective improvement of their ankle instability. The mean AOFAS score increased from 67 preoperatively to 97 at final follow-up. No major complications were reported.

CONCLUSION

The all-inside arthroscopic ligament repair was a safe, reliable, and reproducible technique that both provided an anatomic repair of the lateral collateral ligament complex and restored ankle stability while preserving all the advantages of an arthroscopic technique.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Anatomy of the ankle ligaments: a pictorial essay

Understanding the anatomy of the ankle ligaments is important for correct diagnosis and treatment. Ankle ligament injury is the most frequent cause of acute ankle pain. Chronic ankle pain often finds its cause in laxity of one of the ankle ligaments. In this pictorial essay, the ligaments around the ankle are grouped, depending on their anatomic orientation, and each of the ankle ligaments is discussed in detail.

Imaging evaluation of chronic ankle and hindfoot pain in athletes

Acute ankle and hindfoot injuries are common in athletes and typically are treated conservatively. Persistent pain that has not responded to appropriate conservative treatment and prevents the patient from returning to play is more problematic for the athlete and the treating sports clinician. Making a specific clinical and imaging diagnosis in these patients can be quite challenging. This article discusses the imaging evaluation of chronic ankle and hindfoot pain related to osseous and soft-tissue injuries in athletes. MR imaging is the preferred imaging modality in most of the presented cases.

Arthroscopic and magnetic resonance image appearance and reconstruction of the anterior talofibular ligament in cases of apparent functional ankle instability

BACKGROUND

Many patients report feeling functional ankle instability, despite having no clinically demonstrable lateral instability.

HYPOTHESIS

Some patients who experience functional instability of the ankle have substantial abnormalities of the anterior talofibular ligament despite having apparently normal lateral laxity in clinical examination.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Fourteen patients who had functional ankle instability after sprain, despite having no clinically demonstrable lateral instability, were included in this study. All subjects underwent standard stress radiography, magnetic resonance imaging, and ankle arthroscopy. These patients were treated with anatomical reconstruction of the anterior talofibular ligament.

RESULTS

Arthroscopic assessment revealed 3 cases with no ligamentous structure with scar tissue, 9 cases with partial ligament tears and scar tissue on the disrupted anterior talofibular ligament fiber, and 2 cases of abnormal course of the ligament at the fibular or talar attachment. Magnetic resonance imaging revealed the following: 5 cases of discontinuity of the anterior talofibular ligament, 2 cases of narrowing of the anterior talofibular ligament, 4 cases of high-intensity lesion in the anterior talofibular ligament, and 3 normal cases. The mean American Orthopaedic Foot and Ankle Society Ankle Hindfoot scale score was 66.2 +/- 3.2 points at preoperation and 92.3 +/- 4.4 points 2 years after surgery.

CONCLUSION

All patients in this study with functional ankle instability, despite their having no demonstrable abnormal lateral laxity, had morphologic ligamentous abnormality on arthroscopic assessment.

Magnetresonanztomographie des Sprunggelenkes

The ankle represents an anatomically complex region with a broad spectrum of pathologies. Magnetic resonance imaging (MRI) of the ankle offers detailed, high-resolution imaging of the bones, the ligaments and the surrounding soft tissue structures and therefore has a major role in the diagnostic evaluation of traumatic sequelae, infectious diseases or ankle pain of unknown origin. MRI is especially valuable in the detection of radiographically occult stress reactions or osteomyelitis because it can visualize bone marrow edema earlier than any other imaging method. MRI is superior to any other imaging method for visualizing the tendons and ligaments of the foot and is an important basis for further treatment planning.

Ankle anatomy for the arthroscopist. Part II: Role of the ankle ligaments in soft tissue impingement

The biomechanical anatomy of the ankle ligaments continues to be a subject of interest because detailed knowledge of these structures is essential for proper diagnosis and treatment of the injuries affecting them. Lesions to the ankle ligaments are one of the most common sports injuries and the origin of soft tissue impingement syndrome. Together with the ligaments of the tibiofibular syndesmosis, two large ligamentous complexes are the main static stabilizers of the ankle joint: the lateral collateral ligament and the medial collateral (or deltoid) ligament. This article provides an anatomic description of the various ligaments of the ankle joint, with particular emphasis on specific anatomic details that are often omitted or little known and that have considerable clinical interest because of their involvement in soft tissue syndrome.

Arthroscopic assessment for intra-articular disorders in residual ankle disability after sprain

BACKGROUND

After ankle sprain, there can be many causes of disability, the origins of which cannot be determined using standard diagnostic tools.

HYPOTHESIS

Ankle arthroscopy is a useful tool in identifying intra-articular disorders of the talocrural joint in cases of residual ankle disability after sprain.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 2.

METHODS

The authors gathered the independent diagnostic results of physical examination, standard mortise and lateral radiography, stress radiography of the talocrural joint, and magnetic resonance imaging for 72 patients with residual ankle disability lasting more than 2 months after injury (mean, 7 months after injury). They performed arthroscopic procedures and compared the double-blind results.

RESULTS

In all cases, the arthroscopic results matched those of other means of diagnosis. In 14 cases, the arthroscopic approach exceeded the capabilities of the other methods. Including duplications, 39 patients (54.2%) had anterior talofibular ligament injuries, 17 patients (23.6%) had distal tibiofibular ligament injuries, 29 patients (40.3%) had osteochondral lesions, 13 patients (18%) had symptomatic os subfibulare, 3 patients (4.2%) had anterior impingement exostosis, and 3 patients (4.2%) had impingement due to abnormally fibrous bands. There were only 2 cases in which the cause of symptoms could not be detected by ankle arthroscopy, compared with 16 cases in which the cause of disability could not be detected using standard methods. In 3 cases (17.6%) of distal tibiofibular ligament injuries, 8 cases (27.6%) of osteochondral lesions, and all 3 cases (100%) of impingement of an abnormal fibrous band, ankle arthroscopy was the only method capable of diagnosing the cause of residual ankle pain after a sprain.

CONCLUSION

The present results suggest that arthroscopy can be used to diagnose the cause of residual pain after an ankle sprain in most cases that are otherwise undiagnosable by clinical examination and imaging study.