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An oblique fibular tunnel is recommended when reconstructing the ATFL and CFL

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

A bone tunnel is often used during the reconstruction of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL). The purpose of this study is to compare proposed directions for drilling this fibular tunnel and to assess potential tunnel length, using a 5-mm-diameter tunnel and surrounding bone.

Methods

Anonymous DICOM data from spiral CT-scan images of the ankle were obtained from 12 Caucasian patients: 6 females and 6 males. Virtual tunnels were generated in a 3D bone model with angles of 30°, 45°, 60° and 90° in relation to the fibular long axis. Several measurements were performed: distance from entrance to perforation of opposing cortex, shortening of the tunnel, distance from tunnel centre to bone surface.

Results

A tunnel in a perpendicular direction resulted in an average possible tunnel length of 16.8 (± 2.7) mm in the female group and 20.3 (± 3.4) mm in the male group. A tunnel directed at 30° offered the longest length: 30.9 (± 2.5) mm in the female group and 34.4 (± 2.9) mm in the male group. The use of a 5-mm-diameter tunnel in a perpendicular direction caused important shortening of the tunnel at the entrance in some cases. The perpendicular tunnel was very near to the digital fossa while the most obliquely directed tunnels avoided this region.

Conclusion

An oblique tunnel allows for a longer tunnel and avoids the region of the digital fossa, thereby retaining more surrounding bone. In addition, absolute values of tunnel length are given, which can be useful when considering the use of certain implants. We recommend drilling an oblique fibular tunnel when reconstructing the ATFL and CFL.

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References

  1. Caprio A, Oliva F, Treia F, Maffulli N (2006) Reconstruction of the lateral ankle ligaments with allograft in patients with chronic ankle instability. Foot Ankle Clin 11:597–605

    Article  Google Scholar 

  2. 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:e98. https://doi.org/10.2106/JBJS.M.00798

    Article  PubMed  Google Scholar 

  3. Clanton TO, Viens NA, Campbell KJ, Laprade RF, Wijdicks CA (2014) Anterior talofibular ligament ruptures, part 2: biomechanical comparison of anterior talofibular ligament reconstruction using semitendinosus allografts with the intact ligament. Am J Sports Med 42:412–416

    Article  Google Scholar 

  4. Golano P, Vega J, de Leeuw P, Malagelada F, Manzanares MC, Götzens V, van Dijk CN (2010) Anatomy of the ankle ligaments: a pictorial essay. Knee Surg Sports Traumatol Arthrosc 18:557–569

    Article  Google Scholar 

  5. 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. Arthrosc Tech 22(3):e593–e598

    Article  Google Scholar 

  6. Guillo S, Bauer T, Lee JW, Takao M, Kong SW, Stone JW, Mangone PG, Molloy A, Perera A, Pearce CJ, Michels F, Tourné Y, Ghorbani A, Calder J (2013) Consensus in chronic ankle instability: aetiology, assessment, surgical indications and place for arthroscopy. Orthop Traumatol Surg Res 99:411–419

    Article  Google Scholar 

  7. 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–S417

    Article  CAS  Google Scholar 

  8. Higashiyama R, Aikawa J, Iwase D, Takamori Y, Watanabe E, Takaso M (2019) Anatomical arthroscopic anterior talofibular ligament and calcaneofibular ligament reconstruction using an autogenic hamstring tendon: safe creation of anatomical fibular tunnel. Arthrosc Tech 8(3):e215–e222

    Article  Google Scholar 

  9. Jeys L, Korrosis S, Stewart T, Harris NJ (2004) Bone anchors or interference screws? A biomechanical evaluation for autograft ankle stabilization. Am J Sports Med 32(7):1651–1659

    Article  Google Scholar 

  10. Koo TK, Li MY (2016) A guideline of selecting and reporting intraclass correlation coefficients for reliability research. J Chiropr Med 15:155–163

    Article  Google Scholar 

  11. Krähenbühl N, Weinberg MW, Davidson NP, Mills MK, Hintermann B, Saltzman CL, Barg A (2018) Currently used imaging options cannot accurately predict subtalar joint instability. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-018-5232-8

    Article  PubMed  Google Scholar 

  12. Kuo CC, Lu HL, Leardini A, Lu TW, Kuo MY, Hsu HC (2014) Three-dimensional computer graphics-based ankle morphometry with computerized tomography for total ankle replacement design and positioning. Clin Anat 27:659–668

    Article  Google Scholar 

  13. Li H, Hua Y, Li H, Chen S (2018) Anatomical reconstruction produced similarly favorable outcomes as repair procedures for the treatment of chronic lateral ankle instability at long-term follow-up. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-5176-z

    Article  PubMed  Google Scholar 

  14. Matsui K, Oliva XM, Takao M, Pereira BS, Gomes TM, Lozano JM, ESSKA AFAS Ankle Instability Group, Glazebrook M (2017) Bony landmarks available for minimally invasive lateral ankle stabilization surgery: a cadaveric anatomical study. Knee Surg Sports Traumatol Arthrosc 25(6):1916–1924

    Article  Google Scholar 

  15. Matsui K, Takao M, Tochigi Y, Ozeki S, Glazebrook M (2017) Anatomy of anterior talofibular ligament and calcaneofibular ligament for minimally invasive surgery: a systematic review. Knee Surg Sports Traumatol Arthrosc 25(6):1892–1902

    Article  Google Scholar 

  16. Michels F, Clockaerts S, Van Der Bauwhede J, Stockmans F, Matricali G (2019) Does subtalar instability really exist? A systematic review. Foot Ankle Surg. https://doi.org/10.1016/j.fas.2019.02.001

    Article  PubMed  Google Scholar 

  17. Michels F, Cordier G, Burssens A, Vereecke E, Guillo S (2016) Endoscopic reconstruction of CFL and the ATFL with a gracilis graft: a cadaveric study. Knee Surg Sports Traumatol Arthrosc 24(4):1007–1014

    Article  Google Scholar 

  18. Michels F, Cordier G, Guillo S, Stockmans F, ESKKA-AFAS Ankle Instability Group (2016) endoscopic ankle lateral ligament graft anatomic reconstruction. Foot Ankle Clin 21:665–680

    Article  Google Scholar 

  19. Michels F, Guillo S, Vanrietvelde F, Brugman E, Ankle Instability Group, Stockmans F (2016) How to drill the talar tunnel in ATFL reconstruction? Knee Surg Sports Traumatol Arthrosc 24(4):991–997

    Article  Google Scholar 

  20. Michels F, Pereira H, Calder J, Matricali G, Glazebrook M, Guillo S, Karlsson J, ESSKA-AFAS Ankle Instability Group (2018) Searching for consensus in the approach to patients with chronic lateral ankle instability: ask the expert. Knee Surg Sports Traumatol Arthrosc 26:2095–2102

    Article  Google Scholar 

  21. Neuschwander T, Indressano A, Hughes T, Smith B (2013) Footprint of the lateral ligament complex of the ankle. Foot Ankle Int 34:582–586

    Article  Google Scholar 

  22. Takao M, Oae K, Uchio Y, Ochi M, Yamamoto H (2005) Anatomical reconstruction of the lateral ligaments of the ankle with a gracilis autograft: a new technique using an interference fit anchoring system. Am J Sports Med 33:814–823

    Article  Google Scholar 

  23. Vuurberg G, Pereira H, Blankevoort L, van Dijk CN (2018) Anatomic stabilization techniques provide superior results in terms of functional outcome in patients suffering from chronic ankle instability compared to non-anatomic techniques. Knee Surg Sports Traumatol Arthrosc 26(7):2183–2195

    Article  CAS  Google Scholar 

  24. Wang B, Xu XY (2013) Minimally invasive reconstruction of lateral ligaments of the ankle using semitendinosus autograft. Foot Ankle Int 34:711–715

    Article  CAS  Google Scholar 

  25. Weiler A, Hoffmann RF, Siepe CJ, Kolbeck SF, Südkamp NP (2000) The influence of screw geometry on hamstring tendon interference fit fixation. Am J Sports Med 28(3):356–359

    Article  CAS  Google Scholar 

  26. 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 33:99–104

    Article  Google Scholar 

Download references

Funding

No funding was received by any of the authors related to this study.

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Authors and Affiliations

  1. Orthopaedic Department, AZ Groeninge, President Kennedylaan 4, 8500, Kortrijk, Belgium

    Frederick Michels & Filip Stockmans

  2. Department of Development and Regeneration, KU Leuven, Leuven, Belgium

    Giovanni Matricali

  3. Department of Orthopaedics, Foot and Ankle Unit, University Hospitals Leuven, KU Leuven, Leuven, Belgium

    Giovanni Matricali

  4. Institute of Orthopaedic Research and Training, KU Leuven, Leuven, Belgium

    Giovanni Matricali

  5. Orthopaedic Department, Mérignac Sports Clinic, 2, Rue Georges Negrevergne, 33700, Mérignac, France

    Stephane Guillo

  6. Radiology Department, AZ Groeninge Kortrijk, President Kennedylaan 4, 8500, Kortrijk, Belgium

    Frederik Vanrietvelde

  7. Department of Public Health and Primary Care, Catholic University Leuven, Kortrijk, Belgium

    Hans Pottel

  8. Department of Development and Regeneration, Faculty of Medicine, University of Leuven Campus Kortrijk, Etienne Sabbelaan 53, 8500, Kortrijk, Belgium

    Filip Stockmans

Authors
  1. Frederick Michels
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  2. Giovanni Matricali
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  3. Stephane Guillo
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  4. Frederik Vanrietvelde
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  6. Filip Stockmans
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Corresponding author

Correspondence to Frederick Michels.

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The authors declare that they have no conflict of interest.

Ethical approval

The present study was approved by the Ethics Committee of X (BUN B396201835645).

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Michels, F., Matricali, G., Guillo, S. et al. An oblique fibular tunnel is recommended when reconstructing the ATFL and CFL. Knee Surg Sports Traumatol Arthrosc 28, 124–131 (2020). https://doi.org/10.1007/s00167-019-05583-3

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  • DOI: https://doi.org/10.1007/s00167-019-05583-3

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