Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 25, Issue 6, pp 1892–1902 | Cite as

Anatomy of anterior talofibular ligament and calcaneofibular ligament for minimally invasive surgery: a systematic review

  • Kentaro MatsuiEmail author
  • Masato Takao
  • Yuki Tochigi
  • Satoru Ozeki
  • Mark Glazebrook



To gain a better understanding of the precise anatomy of the lateral ligaments of the ankle through a systematic review of published cadaveric studies in order to improve anatomical minimally invasive surgery (MIS) for treatment of chronic ankle instability (CAI).


A systematic review of the literature was performed using the PubMed, EMBASE, Cochrane databases and Web of Science on June 2015 with the two search concepts: “lateral ligament of the ankle” and “anatomy”. Anatomical studies that reported gross anatomy of the anterior talar fibular ligament (ATFL) and calcaneal fibular ligament (CFL) in English were included to assess the morphology and origins and insertions of the ligaments. All records found in the literature search were screened by title and abstract. Potentially relevant articles were selected for full-text review. Each of the identified articles was reviewed and included in qualitative synthesis. The following data were abstracted from the included articles: authors, date of publication, sample size, mean age, the length and the width of the each ligament, number of bundle of the ATFL and the location and the footprint of the origins and insertions for the ATFL and CFL.


Sixteen studies were identified indicating the length of the ATFL and CFL was 12–24.8 and 18.5–35.8 mm, respectively, while the width was 5–11.1 and 4.6–7.6 mm, respectively. Fibular origins of the ATFL and CFL were located on the anterior border of distal fibula at a distance of 10–13.8 and 5.3–8.5 mm proximal to the tip of the fibula, respectively. The talar insertion of the ATFL was located 14.2–18.1 mm to the subtalar joint or 11.3–14.8 mm to the anterolateral corner of the talar body. The calcaneal insertion of the CFL was located 12.1–13 mm to the subtalar joint or 13.2–27.1 mm to the peroneal tubercle on the lateral wall of calcaneus.


Systematic review of the literature of the research for the ATFL and CFL has identified the morphology of the ligaments and their location of origins and insertions. This is the best available data about the ATFL and CFL which will facilitate more precise anatomical MIS for treatment of CAI.

Level of evidence

Systematic review, Level IV.


Anatomy Lateral ligament of the ankle Minimally invasive surgery Systematic review 



Anterior talofibular ligament


Calcaneofibular ligament


Posterior talofibular ligament


Chronic ankle instability


Minimally invasive surgeries


Not applicable



The Biomet sports medicine department provided the use of the cadaver laboratory and pictures. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this review. No sources of funding were received to assist in this review. The authors have no conflicts of interest that are directly relevant to this review.

Authors’ contributions

K.M. has made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data and has been involved in drafting the manuscript or revising it critically for important intellectual content. M.T., Y.T. and S.O. agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. M.G. has given final approval of the version to be published. All authors read and approved the final manuscript.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no competing interests.


  1. 1.
    Acevedo JI, Mangone PG (2011) Arthroscopic lateral ankle ligament reconstruction. Tech Foot Ankle Surg 10:111–116CrossRefGoogle Scholar
  2. 2.
    Acevedo JI, Mangone P (2015) Arthroscopic Broström technique. Foot Ankle Int 36:465–473CrossRefPubMedGoogle Scholar
  3. 3.
    Broström L (1966) Sprained ankles. V. Treatment and prognosis in recent ligament ruptures. Acta Chir Scand 132:537–550PubMedGoogle Scholar
  4. 4.
    Burks RT, Morgan J (1994) Anatomy of the lateral ankle ligaments. Am J Sports Med 22:72–77CrossRefPubMedGoogle Scholar
  5. 5.
    Buzzi R, Todescan G, Brenner E, Segoni F, Inderster A, Aglietti P (1993) Reconstruction of the lateral ligaments of the ankle: an anatomic study with evaluation of isometry. J Sports Traumatol Relat Res 15:55–74Google Scholar
  6. 6.
    Clanton TO, Campbell KJ, Wilson KJ, Michalski MP, Goldsmith MT, Wijdicks CA, LaPrade RF (2014) Qualitative and quantitative anatomic investigation of the lateral ankle ligaments for surgical reconstruction procedures. J Bone Joint Surg Am 96:e98CrossRefPubMedGoogle Scholar
  7. 7.
    Corte-Real NM, Moreira RM (2009) Arthroscopic repair of chronic lateral ankle instability. Foot Ankle Int 30:213–217CrossRefPubMedGoogle Scholar
  8. 8.
    Cottom JM, Rigby RB (2013) The “all inside” arthroscopic brostrom procedure: a prospective study of 40 Consecutive Patients. J Foot Ankle Surg 52:568–574CrossRefPubMedGoogle Scholar
  9. 9.
    Espinosa N, Smerek J, Kadakia AR, Myerson MS (2006) Operative management of ankle instability: reconstruction with open and percutaneous methods. Foot Ankle Clin 11:547–565CrossRefPubMedGoogle Scholar
  10. 10.
    Golano P, Vega J, de Leeuw PAJ, Malagelada F, Cristina Manzanares M, Gotzens V, van Dijk CN (2010) Anatomy of the ankle ligaments: a pictorial essay. Knee Surg Sports Traumatol Arthrosc 18:557–569CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Guillo S, Archbold P, Perera A, Bauer T, Sonnery-Cottet B (2014) arthroscopic anatomic reconstruction of the lateral ligaments of the ankle with gracilis autograft. Arthroscopy Tech 3:e593–e598CrossRefGoogle Scholar
  12. 12.
    Guillo S, Cordier G, Sonnery-Cottet B, Bauer T (2014) Anatomical reconstruction of the anterior talofibular and calcaneofibular ligaments with an all-arthroscopic surgical technique. Orthop Traumatol Surg Res 100:S413–S417CrossRefPubMedGoogle Scholar
  13. 13.
    Guillo S, Bauer T, Lee JW, Takao M, Kong SW, Stone JW, Mangone PG, Molloy A, Perera A, Pearce CJ, Michels F, Tourne Y, Ghorbani A, Calder J (2013) Consensus in chronic ankle instability: aetiology, assessment, surgical indications and place for arthroscopy. Orthop Traumatol Surg Res 99:S411–S419CrossRefPubMedGoogle Scholar
  14. 14.
    Kashuk KB, Carbonell JA, Blum JA (1997) Arthroscopic stabilization of the ankle. Clin Podiatr Med Surg 14:459–478PubMedGoogle Scholar
  15. 15.
    Kashuk KB, Landsman AS, Werd MB, Hanft JR, Roberts M (1994) Arthroscopic lateral ankle stabilization. Clin Podiatr Med Surg 11:407–423PubMedGoogle Scholar
  16. 16.
    Kelikian A, Sarrafian S (2011) Sarrafian’s anatomy of the foot and ankle: descriptive, topographic, functional. Lippincott, Williams & Wilkins, Wolters Kluwer, Philadelphia, pp 40–119, 163–222Google Scholar
  17. 17.
    Kim ES, Lee KT, Park JS, Lee YK (2011) Arthroscopic anterior talofibular ligament repair for chronic ankle instability with a suture anchor technique. Orthopedics 34(4):2011. doi: 10.3928/01477447-0228-03 Google Scholar
  18. 18.
    Kim HN, Dong Q, Hong DY, Yoon YH, Park YW (2014) Percutaneous lateral ankle ligament reconstruction using a split peroneus longus tendon free graft: technical tip. Foot Ankle Int 35:1082–1086CrossRefPubMedGoogle Scholar
  19. 19.
    Laidlaw PP (1904) The varieties of the os calcis. J Anat Physiol 38:133–143PubMedPubMedCentralGoogle Scholar
  20. 20.
    Lui TH (2007) Arthroscopic-assisted lateral ligamentous reconstruction in combined ankle and subtalar instability. Arthrosc J Arthrosc Relat Surg 23:554.e1–554.e5CrossRefGoogle Scholar
  21. 21.
    Matsui K, Takao M, Miyamoto W, Innami K, Matsushita T (2014) Arthroscopic Brostrom repair with Gould augmentation via an accessory anterolateral port for lateral instability of the ankle. Arch Orthop Trauma Surg 134:1461–1467CrossRefPubMedGoogle Scholar
  22. 22.
    Milner CE, Soames RW (1998) Anatomy of the collateral ligaments of the human ankle joint. Foot Ankle Int 19:757–760CrossRefPubMedGoogle Scholar
  23. 23.
    Milner CE, Soames RW (1997) Anatomical variations of the anterior talofibular ligament of the human ankle joint. J Anat 191(Pt 3):457–458CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 6:e1000097CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Nery C, Raduan F, Del Buono A, Asaumi ID, Cohen M, Maffulli N (2011) Arthroscopic-assisted Brostrom-Gould for chronic ankle instability: a long-term follow-up. Am J Sports Med 39:2381–2388CrossRefPubMedGoogle Scholar
  26. 26.
    Neuschwander TB, Indresano AA, Hughes TH, Smith BW (2013) Footprint of the lateral ligament complex of the ankle. Foot Ankle Int 34:582–586CrossRefPubMedGoogle Scholar
  27. 27.
    Panchbhavi VK (2011) Minimally invasive allograft lateral ankle ligament reconstruction. Tech Foot Ankle Surg 10:117–121CrossRefGoogle Scholar
  28. 28.
    Raheem OA, O’Brien M (2011) Anatomical review of the lateral collateral ligaments of the ankle: a cadaveric study. Anat Sci Int 86:189–193CrossRefPubMedGoogle Scholar
  29. 29.
    Ruth C (1961) The Surgical Treatment of Injuries of the fibular collateral ligaments of the ankle. J Bone Joint Surg Am 43:229–239CrossRefGoogle Scholar
  30. 30.
    Siegler S, Block J, Schneck CD (1988) The mechanical characteristics of the collateral ligaments of the human ankle joint. Foot Ankle 8:234–242CrossRefPubMedGoogle Scholar
  31. 31.
    Sindel M (1998) Anatomy of the lateral ankle ligaments. Turk J Med Sci 28:53–56Google Scholar
  32. 32.
    Takao M, Matsui K, Stone JW, Glazebrook MA, Kennedy JG, Guillo S, Calder JD, Karlsson J, Ankle Instability Group (2016) Arthroscopic anterior talofibular ligament repair for lateral instability of the ankle. Knee Surg Sports Traumatol Arthrosc 24:1003–1006CrossRefPubMedGoogle Scholar
  33. 33.
    Taser F, Shafiq Q, Ebraheim NA (2006) Anatomy of lateral ankle ligaments and their relationship to bony landmarks. Surg Radiol Anat 28:391–397CrossRefPubMedGoogle Scholar
  34. 34.
    Ugurlu M, Bozkurt M, Demirkale I, Comert A, Acar HI, Tekdemir I (2010) Anatomy of the lateral complex of the ankle joint in relation to peroneal tendons, distal fibula and talus: a cadaveric study. Eklem Hastalik Cerrahisi 21:153–158PubMedGoogle Scholar
  35. 35.
    van den Bekerom MP, Kerkhoffs GM, McCollum GA, Calder JD, van Dijk CN (2013) Management of acute lateral ankle ligament injury in the athlete. Knee Surg Sports Traumatol Arthrosc 21:1390–1395CrossRefPubMedGoogle Scholar
  36. 36.
    Vega J, Golano P, Pellegrino A, Rabat E, Pena F (2013) All-inside arthroscopic lateral collateral ligament repair for ankle instability with a knotless suture anchor technique. Foot Ankle Int 34:1701–1709CrossRefPubMedGoogle Scholar
  37. 37.
    Wang B, Xu X- (2013) Minimally invasive reconstruction of lateral ligaments of the ankle using semitendinosus autograft. Foot Ankle Int 34:711–715CrossRefPubMedGoogle Scholar
  38. 38.
    Wenny R, Duscher D, Meytap E, Weninger P, Hirtler L (2015) Dimensions and attachments of the ankle ligaments: evaluation for ligament reconstruction. Anat Sci Int 90:161–171CrossRefPubMedGoogle Scholar
  39. 39.
    Wiersma PH (1992) Variations of three lateral ligaments of the ankle. A descriptive anatomical study. The Foot 2:218–224CrossRefGoogle Scholar
  40. 40.
    Xu X, Hu M, Liu J, Zhu Y, Wang B (2014) Minimally invasive reconstruction of the lateral ankle ligaments using semitendinosus autograft or tendon allograft. Foot Ankle Int 35:1015–1021CrossRefPubMedGoogle Scholar
  41. 41.
    Yildiz S, Yalcin B (2013) The anterior talofibular and calcaneofibular ligaments: an anatomic study. Surg Radiol Anat 35:511–516CrossRefPubMedGoogle Scholar
  42. 42.
    Youn H, Kim YS, Lee J, Choi WJ, Lee JW (2012) Percutaneous lateral ligament reconstruction with allograft for chronic lateral ankle instability. Foot Ankle Int 33:99–104CrossRefPubMedGoogle Scholar

Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2016

Authors and Affiliations

  • Kentaro Matsui
    • 1
    • 2
    Email author
  • Masato Takao
    • 3
  • Yuki Tochigi
    • 4
  • Satoru Ozeki
    • 4
  • Mark Glazebrook
    • 5
  1. 1.Queen Elizabeth II Health Sciences Center Halifax InfirmaryDalhousie UniversityHalifaxCanada
  2. 2.Department of Orthopaedic SurgeryTeikyo UniversityItabashiJapan
  3. 3.Department of Orthopaedic Surgery, Department of Sport and Medical ScienceTeikyo Institute of Sports Science and MedicineItabashiJapan
  4. 4.Department of Orthopaedic SurgeryDokkyo Medical University Koshigaya HospitalKoshigayaJapan
  5. 5.Queen Elizabeth II Health Sciences Center Halifax Infirmary (Suite 4867)Dalhousie UniversityHalifaxCanada

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