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The calcaneofibular ligament has distinct anatomic morphological variants: an anatomical cadaveric study

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

The purpose of this study was to investigate if the calcaneofibular ligament (CFL) presents morphologic variants and measure the morphometrics of the ligament and its footprints

Methods

An anatomical study of 47 fresh-frozen below-the-knee ankle specimens was performed. Lateral ankle structures were dissected to expose the CFL. Overdissection was avoided to not modify the native morphology. The morphology (number and orientation of CFL bundles) and measurements of CFL insertions were recorded with ankle secured in neutral position.

Results

Four distinct morphological-oriented shapes of the CFL were observed. These included single bundle, Y-shape double bundle, V-shape double bundle, and associated with the lateral talocalcaneal ligament. The most frequent CFL morphology observed was the single bundle and the Y-shape double bundle, present in 21 (44.7%) and 13 (27.7%) ankles. The V-shape double bundle and the CFL double bundle associated with the lateral talocalcaneal ligaments were less common, appearing only in eight (17.0%) and five (10.6%) ankles. The CFL length was higher in single bundle and Y-shaped double bundle CFL variants, about 30 mm each. Footprint morphometrics were heterogenous amongst the different CFL variants.

Conclusion

The CFL presents four distinct morphological-oriented shapes. The double bundle, V-shaped and Y-shaped CFL variants are uncommon and poorly reported in the literature. Their relation to the lateral talocalcaneal ligament and the inferior fascicle of the anterior talofibular ligament requires further research. The CFL morphology provides detailed knowledge of CFL anatomy that can improve diagnostic procedures. Furthermore, this information can fine-tune graft selection and sizing and allow a more precise anatomic placement during surgical reconstruction.

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References

  1. Acevedo JI, Mangone P (2015) Arthroscopic brostrom technique. Foot Ankle Int 36:465–473

    PubMed  Google Scholar 

  2. Acevedo JI, Mangone PG (2011) Arthroscopic lateral ankle ligament reconstruction. Tech Foot Ankle Surg 10:111–116

    Google Scholar 

  3. Andersen TE, Floerenes TW, Arnason A, Bahr R (2004) Video analysis of the mechanisms for ankle injuries in football. Am J Sports Med 32:69–79

    Google Scholar 

  4. Bahr R, Bahr I (1997) Incidence of acute volleyball injuries: a prospective cohort study of injury mechanisms and risk factors. Scand J Med Sci Sports 7:166–171

    CAS  PubMed  Google Scholar 

  5. Baumhauer JF, O'Brien T (2002) Surgical considerations in the treatment of ankle instability. J Athl Train 37:458–462

    PubMed  PubMed Central  Google Scholar 

  6. Brostroem L (1964) Sprained ankles. I. Anatomic lesions in recent sprains. Acta Chir Scand 128:483–495

    CAS  PubMed  Google Scholar 

  7. Brostrom L (1966) Sprained ankles. V. Treatment and prognosis in recent ligament ruptures. Acta Chir Scand 132:537–550

    CAS  PubMed  Google Scholar 

  8. Burks RT, Morgan J (1994) Anatomy of the lateral ankle ligaments. Am J Sports Med 22:72–77

    CAS  PubMed  Google Scholar 

  9. 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 15:55–74

    Google Scholar 

  10. Choisne J, Hoch MC, Bawab S, Alexander I, Ringleb SI (2013) The effects of a semi-rigid ankle brace on a simulated isolated subtalar joint instability. J Orthop Res 31:1869–1875

    PubMed  Google Scholar 

  11. Clanton TO, Campbell KJ, Wilson KJ, Michalski MP, Goldsmith MT, Wijdicks CA et al (2014) Qualitative and quantitative anatomic investigation of the lateral ankle ligaments for surgical reconstruction procedures. J Bone Jt Surg Am 96:e98

    Google Scholar 

  12. Colville MR, Marder RA, Boyle JJ, Zarins B (1990) Strain measurement in lateral ankle ligaments. Am J Sports Med 18:196–200

    CAS  PubMed  Google Scholar 

  13. Cooke MW, Marsh JL, Clark M, Nakash R, Jarvis RM, Hutton JL et al (2009) Treatment of severe ankle sprain: a pragmatic randomised controlled trial comparing the clinical effectiveness and cost-effectiveness of three types of mechanical ankle support with tubular bandage. The CAST trial. Health Technol Assess 13:1–121

    Google Scholar 

  14. Cottom JM, Rigby RB (2013) The “all inside” arthroscopic Broström procedure: a prospective study of 40 consecutive patients. J Foot Ankle Surg 52:568–574

    PubMed  Google Scholar 

  15. De Boer AS, Schepers T, Panneman MJ, Van Beeck EF, Van Lieshout EM (2014) Health care consumption and costs due to foot and ankle injuries in the Netherlands, 1986–2010. BMC Musculoskelet Disord 15:128

    PubMed  PubMed Central  Google Scholar 

  16. 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 44:123–140

    PubMed  Google Scholar 

  17. Doring S, Provyn S, Marcelis S, Shahabpour M, Boulet C, de Mey J et al (2018) Ankle and midfoot ligaments: ultrasound with anatomical correlation: a review. Eur J Radiol 107:216–226

    PubMed  Google Scholar 

  18. Espinosa N, Smerek J, Kadakia AR, Myerson MS (2006) Operative management of ankle instability: reconstruction with open and percutaneous methods. Foot Ankle Clin 11:547–565

    PubMed  Google Scholar 

  19. Fong DT-P, Hong Y, Chan L-K, Yung PS-H, Chan K-M (2007) A systematic review on ankle injury and ankle sprain in sports. Sports Med 37:73–94

    PubMed  Google Scholar 

  20. Golanó P, Vega J, De Leeuw PA, Malagelada F, Manzanares MC, Götzens V et al (2010) Anatomy of the ankle ligaments: a pictorial essay. Knee Surg Sports Traumatol Arthrosc 18:557–569

    PubMed  PubMed Central  Google Scholar 

  21. Gould N (1987) Repair of lateral ligament of ankle. Foot Ankle 8:55–58

    CAS  PubMed  Google Scholar 

  22. Gould N, Seligson D, Gassman J (1980) Early and late repair of lateral ligament of the ankle. Foot Ankle 1:84–89

    CAS  PubMed  Google Scholar 

  23. Hamilton WG, Thompson FM, Snow SW (1993) The modified Brostrom procedure for lateral ankle instability. Foot Ankle 14:1–7

    CAS  PubMed  Google Scholar 

  24. Hollis JM, Blasier RD, Flahiff CM (1995) Simulated lateral ankle ligamentous injury. Change in ankle stability. Am J Sports Med 23:672–677

    CAS  PubMed  Google Scholar 

  25. Hootman JM, Dick R, Agel J (2007) Epidemiology of collegiate injuries for 15 sports: summary and recommendations for injury prevention initiatives. J Athl Train 42:311–319

    PubMed  PubMed Central  Google Scholar 

  26. Jung H-G, Shin M-H, Park J-T, Eom J-S, Lee D-O, Lee S-H (2015) Anatomical reconstruction of lateral ankle ligaments using free tendon allografts and biotenodesis screws. Foot Ankle Int 36:1064–1071

    PubMed  Google Scholar 

  27. Jung HG, Kim TH (2012) Subtalar instability reconstruction with an allograft: technical note. Foot Ankle Int 33:682–685

    PubMed  Google Scholar 

  28. Karlsson J, Bergsten T, Lansinger O, Peterson L (1988) Reconstruction of the lateral ligaments of the ankle for chronic lateral instability. J Bone Jt Surg Am 70:581–588

    CAS  Google Scholar 

  29. Kennedy JG, Smyth NA, Fansa AM, Murawski CD (2012) Anatomic lateral ligament reconstruction in the ankle: a hybrid technique in the athletic population. Am J Sports Med 40:2309–2317

    PubMed  Google Scholar 

  30. 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 35:1082–1086

    PubMed  Google Scholar 

  31. 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

    PubMed  PubMed Central  Google Scholar 

  32. Maffulli N, Del Buono A, Maffulli GD, Oliva F, Testa V, Capasso G et al (2013) Isolated anterior talofibular ligament Brostrom repair for chronic lateral ankle instability: 9-year follow-up. Am J Sports Med 41:858–864

    PubMed  Google Scholar 

  33. Martin LP, Wayne JS, Owen JR, Smith RT, Martin SN, Adelaar RS (2002) Elongation behavior of calcaneofibular and cervical ligaments in a closed kinetic chain: pathomechanics of lateral hindfoot instability. Foot Ankle Int 23:515–520

    PubMed  Google Scholar 

  34. Matsui K, Oliva XM, Takao M, Pereira BS, Gomes TM, Lozano JM et al (2017) Bony landmarks available for minimally invasive lateral ankle stabilization surgery: a cadaveric anatomical study. Knee Surg Sports Traumatol Arthrosc 25:1916–1924

    PubMed  Google Scholar 

  35. Matsui K, Takao M, Miyamoto W, Innami K, Matsushita T (2014) Arthroscopic Broström repair with Gould augmentation via an accessory anterolateral port for lateral instability of the ankle. Arch Orthop Trauma Surg 134:1461–1467

    PubMed  Google Scholar 

  36. 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 25:1892–1902

    PubMed  Google Scholar 

  37. Nery C, Raduan F, Del Buono A, Asaumi ID, Cohen M, Maffulli N (2011) Arthroscopic-assisted Broström-Gould for chronic ankle instability: a long-term follow-up. Am J Sports Med 39:2381–2388

    PubMed  Google Scholar 

  38. Neuschwander TB, Indresano AA, Hughes TH, Smith BW (2013) Footprint of the lateral ligament complex of the ankle. Foot Ankle Int 34:582–586

    PubMed  Google Scholar 

  39. Noailles T, Lopes R, Padiolleau G, Gouin F, Brilhault J (2018) Non-anatomical or direct anatomical repair of chronic lateral instability of the ankle: a systematic review of the literature after at least 10 years of follow-up. Foot Ankle Surg 24:80–85

    PubMed  Google Scholar 

  40. Nuno MC-R, Moreira RM (2009) Arthroscopic repair of chronic lateral ankle instability. Foot Ankle Int 30:213–217

    Google Scholar 

  41. Ozeki S, Yasuda K, Kaneda K, Yamakoshi K, Yamanoi T (2002) Simultaneous strain measurement with determination of a zero strain reference for the medial and lateral ligaments of the ankle. Foot Ankle Int 23:825–832

    PubMed  Google Scholar 

  42. Panagiotakis E, Mok KM, Fong DT, Bull AMJ (2017) Biomechanical analysis of ankle ligamentous sprain injury cases from televised basketball games: understanding when, how and why ligament failure occurs. J Sci Med Sport 20:1057–1061

    PubMed  Google Scholar 

  43. Ringleb SI, Udupa JK, Siegler S, Imhauser CW, Hirsch BE, Liu J et al (2005) The effect of ankle ligament damage and surgical reconstructions on the mechanics of the ankle and subtalar joints revealed by three-dimensional stress MRI. J Orthop Res 23:743–749

    CAS  PubMed  Google Scholar 

  44. Sammarco VJ (2001) Complications of lateral ankle ligament reconstruction. Clin Orthop Relat Res 391:123–132

    Google Scholar 

  45. Shah S, Thomas AC, Noone JM, Blanchette CM, Wikstrom EA (2016) Incidence and cost of ankle sprains in United States emergency departments. Sports Health 8:547–552

    PubMed  PubMed Central  Google Scholar 

  46. Simpson JD, Stewart EM, Mosby AM, Macias DM, Chander H, Knight AC (2018) Lower extremity kinematics during ankle inversion perturbations: a novel experimental protocol that simulates an unexpected lateral ankle sprain mechanism. J Sport Rehabil 28:593–600

    Google Scholar 

  47. Sindel M, Demir S, Yildirim A, Yaşar U (1998) Anatomy of the lateral ankle ligaments. Turk J Med Sci 28:53–56

    Google Scholar 

  48. Skazalski C, Kruczynski J, Bahr MA, Bere T, Whiteley R, Bahr R (2018) Landing-related ankle injuries do not occur in plantarflexion as once thought: a systematic video analysis of ankle injuries in world-class volleyball. Br J Sports Med 52:74–82

    PubMed  Google Scholar 

  49. Strudwick K, McPhee M, Bell A, Martin-Khan M, Russell T (2018) Best practice management of common ankle and foot injuries in the emergency department (part 2 of the musculoskeletal injuries rapid review series). Emerg Med Australas 30:152–180

    PubMed  Google Scholar 

  50. Takao M, Matsui K, Stone JW, Glazebrook MA, Kennedy JG, Guillo S et al (2016) Arthroscopic anterior talofibular ligament repair for lateral instability of the ankle. Knee Surg Sports Traumatol Arthrosc 24:1003–1006

    PubMed  Google Scholar 

  51. 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

    PubMed  Google Scholar 

  52. Taser F, Shafiq Q, Ebraheim NA (2006) Anatomy of lateral ankle ligaments and their relationship to bony landmarks. Surg Radiol Anat 28:391–397

    PubMed  Google Scholar 

  53. Trouilloud P, Dia A, Grammont P, Gelle MC, Autissier JM (1988) Variations in the calcaneo-fibular ligament (lig. calcaneofibulare). Application to the kinematics of the ankle. Bull Assoc Anat (Nancy) 72:31–35

    CAS  Google Scholar 

  54. 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 34:1701–1709

    PubMed  Google Scholar 

  55. Vega J, Malagelada F, Céspedes M-CM, Dalmau-Pastor M (2018) The lateral fibulotalocalcaneal ligament complex: an ankle stabilizing isometric structure. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-018-5188-8

    Article  PubMed  Google Scholar 

  56. 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 26:2183–2195

    CAS  PubMed  Google Scholar 

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

    CAS  PubMed  Google Scholar 

  58. Waterman BR, Owens BD, Davey S, Zacchilli MA, Belmont PJ Jr (2010) The epidemiology of ankle sprains in the United States. J Bone Jt Surg Am 92:2279–2284

    Google Scholar 

  59. Weindel S, Schmidt R, Rammelt S, Claes L, Campe AV, Rein S (2010) Subtalar instability: a biomechanical cadaver study. Arch Orthop Trauma Surg 130:313–319

    CAS  PubMed  Google Scholar 

  60. 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 90:161–171

    PubMed  Google Scholar 

  61. Wiersma P, Griffioen F (1992) Variations of three lateral ligaments of the ankle. A descriptive anatomical study. Foot (Edinb) 2:218–224

    Google Scholar 

  62. 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 35:1015–1021

    PubMed  Google Scholar 

  63. Yasui Y, Murawski CD, Wollstein A, Kennedy JG (2017) Reoperation rates following ankle ligament procedures performed with and without concomitant arthroscopic procedures. Knee Surg Sports Traumatol Arthrosc 25:1908–1915

    PubMed  Google Scholar 

  64. Yasui Y, Murawski CD, Wollstein A, Takao M, Kennedy JG (2016) Operative treatment of lateral ankle instability. JBJS Rev 4:01874474-201605000-00006

    Google Scholar 

  65. Yoon DY, Moon SG, Jung HG, Kim NR (2018) Differences between subtalar instability and lateral ankle instability focusing on subtalar ligaments based on three dimensional isotropic magnetic resonance imaging. J Comput Assist Tomogr 42:566–573

    PubMed  Google Scholar 

  66. 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

    PubMed  Google Scholar 

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Funding

The authors declare that there was no funding of this study.

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Authors and Affiliations

  1. Hospital Privado de Braga, Lugar da Igreja Nogueira, Braga, Portugal

    Bruno S. Pereira

  2. Clínica Do Dragão, Espregueira-Mendes Sports Center, FIFA Medical Centre of Excellence, Porto, Portugal

    Bruno S. Pereira, C. Niek van Dijk, Renato Andrade & João Espregueira-Mendes

  3. Facultad de Medicina, University of Barcelona, Casanova, 143, 08036, Barcelona, Spain

    Bruno S. Pereira, Ricardo P. Casaroli-Marano & Xavier Martin Oliva

  4. Dom Henrique Research Centre, Porto, Portugal

    Bruno S. Pereira, Renato Andrade & João Espregueira-Mendes

  5. Department Orthopedic Surgery, Academic Medical Center (AMC), Amsterdam, The Netherlands

    C. Niek van Dijk

  6. FIFA Medical Centre of Excellence Ripoll De Prado and Van Dijk Sport Clinic, Madrid, Spain

    C. Niek van Dijk

  7. Faculty of Sports, University of Porto, Porto, Portugal

    Renato Andrade

  8. ICVS/3Bs, PT Government Associate Laboratory, Braga/Guimarães, Portugal

    João Espregueira-Mendes

  9. School of Medicine, Minho University, Braga, Portugal

    João Espregueira-Mendes

  10. Orthopedic Surgery Department, Clínica Ntra. Sra. Del Remei, Carrer de l’Escorial, 148, 08024, Barcelona, Spain

    Xavier Martin Oliva

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  1. Bruno S. Pereira
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Contributions

All the authors contributed substantially to conception and design, or acquisition of data, or analysis and interpretation of data; drafted the article or revised it critically for important intellectual content; provided the final approval of the version to be published; and agreed to act as guarantor of the work (ensuring that questions related to any part of the work are appropriately investigated and resolved).

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Correspondence to Bruno S. Pereira.

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Pereira, B.S., van Dijk, C.N., Andrade, R. et al. The calcaneofibular ligament has distinct anatomic morphological variants: an anatomical cadaveric study. Knee Surg Sports Traumatol Arthrosc 28, 40–47 (2020). https://doi.org/10.1007/s00167-019-05797-5

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