Skip to main content

Advertisement

SpringerLink
Log in

The CFL fails before the ATFL immediately after combined ligament repair in a biomechanical cadaveric model

  • ANKLE
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

To assess the impact on ankle stability after repairing the ATFL alone compared to repairing both the ATFL and CFL in a biomechanical cadaver model.

Methods

Ten matched pairs of intact, fresh frozen human cadaver ankles (normal) were mounted to a test machine in 20.0° plantar flexion and 15.0° of internal rotation. Each ankle was loaded to body weight and then tested from 0.0° to 20.0° of inversion. The data recorded were torque at 20.0° and stiffness, peak pressure and contact area in the ankle joint using a Tekscan sensor, rotation of the talus and calcaneus, and translation of the calcaneus using a three-dimensional motion capture system. Ankles then underwent sectioning of the ATFL and CFL (injured), retested, then randomly assigned to ATFL-only Broström repair or combined ATFL and CFL repair. Testing was repeated after repair then loaded in inversion to failure (LTF).

Results

The stiffness of the ankle was not significantly increased compared to the injured condition by repairing the ATFL only (n.s.) or the ATFL/CFL (n.s.). The calcaneus had significantly more rotation than the injured condition in the ATFL-only repair (p = 0.037) but not in the ATFL/CFL repair (n.s.). The ATFL failed at 40.3% higher torque than the CFL, at 17.4 ± 7.0 N m and 12.4 ± 4.1 N m, respectively, and 62.0% more rotation, at 43.9 ± 5.6° and 27.1 ± 6.8°, respectively.

Conclusions

There was a greater increase in stiffness following combined ATFL/CFL repair compared to ATFL-only repair, although this did not reach statistical significance. The CFL fails before the ATFL, potentially indicating its vulnerability immediately following repair.

Level of evidence

III, case–control therapeutic study.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Attarian DE, McCrackin HJ, DeVito DP, McElhaney JH, Garrett WE Jr (1985) Biomechanical characteristics of human ankle ligaments. Foot Ankle 6:54–58

    Article  CAS  Google Scholar 

  2. Bahr R, Pena F, Shine J, Lew WD, Tyrdal S, Engebretsen L (1997) Biomechanics of ankle ligament reconstruction. An in vitro comparison of the Brostrom repair, Watson–Jones reconstruction, and a new anatomic reconstruction technique. Am J Sports Med 25:424–432

    Article  CAS  Google Scholar 

  3. Baker JM, Ouzounian TJ (2000) Complex ankle instability. Foot Ankle Clin 5:887–896

    CAS  PubMed  Google Scholar 

  4. Brown CA, Hurwit D, Behn A, Hunt KJ (2014) Biomechanical comparison of an all-soft suture anchor with a modified Brostrom–Gould suture repair for lateral ligament reconstruction. Am J Sports Med 42:417–422

    Article  Google Scholar 

  5. Chaudhry H, Simunovic N, Petrisor B (2015) Cochrane in CORR (R): surgical versus conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults (review). Clin Orthop Relat Res 473:17–22

    Article  Google Scholar 

  6. Chrisman OD, Snook GA (1969) Reconstruction of lateral ligament tears of the ankle. An experimental study and clinical evaluation of seven patients treated by a new modification of the Elmslie procedure. J Bone Jt Surg Am 51:904–912

    Article  CAS  Google Scholar 

  7. Colville MR (1998) Surgical treatment of the unstable ankle. J Am Acad Orthop Surg 6:368–377

    Article  CAS  Google Scholar 

  8. Dell RB, Holleran S, Ramakrishnan R (2002) Sample size determination. ILAR J 43:207–213

    Article  CAS  Google Scholar 

  9. DiGiovanni BF, Partal G, Baumhauer JF (2004) Acute ankle injury and chronic lateral instability in the athlete. Clin Sports Med 23(1–19):v

    Google Scholar 

  10. Doherty C, Bleakley C, Hertel J, Caulfield B, Ryan J, Delahunt E (2016) Recovery from first-time lateral ankle sprain and the predictors of chronic ankle instability: a prospective cohort analysis. Am J Sports Med 44(4):995–1003

    Article  Google Scholar 

  11. Doherty C, Delahunt E, Caulfield B, Hertel J, Ryan J, Bleakley C (2014) The incidence and prevalence of ankle sprain injury: a systematic review and meta-analysis of prospective epidemiological studies. Sports Med 44(1):123–140

    Article  Google Scholar 

  12. Drakos M, Behrens SB, Mulcahey MK, Paller D, Hoffman E, DiGiovanni CW (2013) Proximity of arthroscopic ankle stabilization procedures to surrounding structures: an anatomic study. Arthroscopy 29(6):1089–1094

    Article  Google Scholar 

  13. Ferran NA, Maffulli N (2006) Epidemiology of sprains of the lateral ankle ligament complex. Foot Ankle Clin 11:659–662

    Article  Google Scholar 

  14. Fong DT, Ha SC, Mok KM, Chan CW, Chan KM (2012) Kinematics analysis of ankle inversion ligamentous sprain injuries in sports: five cases from televised tennis competitions. Am J Sports Med 40:2627–2632

    Article  Google Scholar 

  15. Giza E, Shin EC, Wong SE, Acevedo JI, Mangone PG, Olson K, Anderson MJ (2013) Arthroscopic suture anchor repair of the lateral ligament ankle complex: a cadaveric study. Am J Sports Med 41:2567–2572

    Article  Google Scholar 

  16. Kjaersgaard-Andersen P, Wethelund JO, Nielsen S (1987) Lateral talocalcaneal instability following section of the calcaneofibular ligament: a kinesiologic study. Foot Ankle 7:355–361

    Article  CAS  Google Scholar 

  17. Kovaleski JE, Heitman RJ, Gurchiek LR, Hollis JM, Liu W, Pearsall AWt (2014) Joint stability characteristics of the ankle complex after lateral ligamentous injury, part I: a laboratory comparison using arthrometric measurement. J Athl Train 49:192–197

    Article  Google Scholar 

  18. Lee KT, Lee JI, Sung KS, Kim JY, Kim ES, Lee SH, Wang JH (2008) Biomechanical evaluation against calcaneofibular ligament repair in the Brostrom procedure: a cadaveric study. Knee Surg Sports Traumatol Arthrosc 16:781–786

    Article  Google Scholar 

  19. Li HY, Hua YH, Wu ZY, Chen B, Chen SY (2013) Strength of suture anchor versus transosseous tunnel in anatomic reconstruction of the ankle lateral ligaments: a biomechanical study. Arthroscopy 29:1817–1825

    Article  Google Scholar 

  20. Michels F, Pereira H, Calder J, Matricali G, Glazebrook M, Guillo S, Karlsson J, Acevedo J, Batista J, Bauer T, Carreira D, Choi W, Corte-Real N, Ghorbani A, Giza E, Hunt K, Kong SW, Lee JW, Molloy A, Mangone P, Matsui K, Nery C, Ozeki S, Pearce C, Perera A, Pijnenburg B, Raduan F, Stone J, Takao M, Tourne Y, Vega J (2018) Searching for consensus in the approach to patients with chronic lateral ankle instability: ask the expert. Knee Surg Sports Traumatol Arthrosc 26(7):2095–2102

    Article  Google Scholar 

  21. Miklovic TM, Donovan L, Protzuk OA, Kang MS, Feger MA (2018) Acute lateral ankle sprain to chronic ankle instability: a pathway of dysfunction. Phys Sportsmed 46:116–122

    Article  Google Scholar 

  22. Miller CA, Bosco JA 3rd (2001) Lateral ankle and subtalar instability. Bull Hosp Jt Dis 60:143–149

    PubMed  Google Scholar 

  23. Okuda R, Kinoshita M, Morikawa J, Jotoku T, Abe M (1999) Reconstruction for chronic lateral ankle instability using the palmaris longus tendon: is reconstruction of the calcaneofibular ligament necessary? Foot Ankle Int 20:714–720

    Article  CAS  Google Scholar 

  24. Panjabi MM, Krag M, Summers D, Videman T (1985) Biomechanical time-tolerance of fresh cadaveric human spine specimens. J Orthop Res 3:292–300

    Article  CAS  Google Scholar 

  25. van Putte-Katier N, van Ochten JM, van Middelkoop M, Bierma-Zeinstra SM, Oei EH (2015) Magnetic resonance imaging abnormalities after lateral ankle trauma in injured and contralateral ankles. Eur J Radiol 84(12):2586–2592

    Article  Google Scholar 

  26. van Rijn RM, van Os AG, Bernsen RM, Luijsterburg PA, Koes BW, Bierma-Zeinstra SM (2008) What is the clinical course of acute ankle sprains? a systematic literature review. Am J Med 121(4):324–331

    Article  Google Scholar 

  27. Vega J, Golanó P, Pellegrino A, Rabat E, Peña F (2013) All-inside arthroscopic lateral collateral ligament repair for ankle instability with a knotless suture anchor technique. Foot Ankle Int 34(12):1701–1709

    Article  Google Scholar 

  28. Woo SL, Orlando CA, Camp JF, Akeson WH (1986) Effects of postmortem storage by freezing on ligament tensile behavior. J Biomech 19:399–404

    Article  CAS  Google Scholar 

  29. Yildiz S, Yalcin B (2013) The anterior talofibular and calcaneofibular ligaments: an anatomic study. Surg Radiol Anat 35:511–516

    Article  Google Scholar 

Download references

Acknowledgements

The authors would like to thank Patrick Carry, MS, for his guidance regarding statistical analyses. He has no conflicts of interest regarding the authorship or publication of this contribution.

Funding

This study was funded by a research Grant from ISAKOS. Implants were donated by Zimmer-Biomet.

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, Aspetar Orthopaedic and Sports Medicine Hospital, Aspire Zone, Doha, Qatar

    Pieter D’Hooghe

  2. Orthopedic Department Póvoa de Varzim, Vila do Conde Hospital Centre, Vila do Conde, Portugal

    Helder Pereira

  3. Ripoll y De Prado Sports Clinic FIFA Medical Centre of Excellence, Murcia, Madrid, Spain

    Helder Pereira

  4. ICVS/3 Bs-Associated Laboratory, Minho University, Braga, Portugal

    Helder Pereira

  5. Bioengineering Laboratory, Department of Orthopaedic Surgery, University of Colorado School of Medicine, Aurora, CO, USA

    Judas Kelley, Nicholas Anderson, Richard Fuld, Pam Kumparatana, Todd Baldini & Kenneth J. Hunt

Authors
  1. Pieter D’Hooghe
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Helder Pereira
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Judas Kelley
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Nicholas Anderson
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Richard Fuld
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Pam Kumparatana
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Todd Baldini
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Kenneth J. Hunt
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Kenneth J. Hunt.

Ethics declarations

Conflict of interest

Kenneth J. Hunt, MD, is a consultant for Panther Orthopedics. He has received institutional research funding from Acumed, Zimmer-Biomet, and Smith & Nephew. He has not personally received financial compensation from any of these entities. Todd Baldini, MSc, has received funds for research from Acumed and donation of supplies from Smith & Nephew. Pieter D’Hooghe, Helder Pereira, Pam Kumparatana, Judas Kelley, Nicholas Anderson, and Richard Fuld declare that they have no conflict of interest.

Ethical approval

Our Institutional Review Board does not consider laboratory studies for ethical approval. No patients were involved in this cadaveric study.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

D’Hooghe, P., Pereira, H., Kelley, J. et al. The CFL fails before the ATFL immediately after combined ligament repair in a biomechanical cadaveric model. Knee Surg Sports Traumatol Arthrosc 28, 253–261 (2020). https://doi.org/10.1007/s00167-019-05626-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-019-05626-9

Keywords

Search

Navigation