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Accuracy of radiographic techniques in detection of the calcaneofibular ligament calcaneal insertion for lateral ankle ligament complex surgery

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Abstract

Background

Grade III ankle sprains that fail conservative treatment can require surgical management. Anatomic procedures have been shown to properly restore joint mechanics, and precise localization of insertion sites of the lateral ankle complex ligaments can be determined through radiographic techniques. Ideally, radiographic techniques that are easily reproducible intraoperatively will lead to a consistently well-placed CFL reconstruction in lateral ankle ligament surgery.

Purpose

To determine the most accurate method to locate the calcaneofibular ligament (CFL) insertion radiographically.

Methods

MRIs of 25 ankles were utilized to identify the “true” insertion of the CFL. Distances between the true insertion and three bony landmarks were measured. Three proposed methods (Best, Lopes, and Taser) for determining the CFL insertion were applied to lateral ankle radiographs. X and Y coordinate distances were measured from the insertion found on each proposed method to the three bony landmarks: the most superior point of the postero-superior surface of the calcaneus, the posterior most aspect of the sinus tarsi, and the distal tip of the fibula. X and Y distances were compared to the true insertion found on MRI. All measurements were made using a picture archiving and communication system. The average, standard deviation, minimum, and maximum were obtained. Statistical analysis was performed using repeated measures ANOVA, and a post hoc analysis was performed with the Bonferroni test.

Results

The Best and Taser techniques were found to be closest to the true CFL insertion when combining X and Y distances. For distance in the X direction, there was no significant difference between techniques (P = 0.264). For distance in the Y direction, there was a significant difference between techniques (P = 0.015). For distance in the combined XY direction, there was a significant difference between techniques (P = 0.001). The CFL insertion as determined by the Best method was significantly closer to the true insertion compared to the Lopes method in the Y (P = 0.042) and XY (P = 0.004) directions. The CFL insertion as determined by the Taser method was significantly closer to the true insertion compared to the Lopes method in the XY direction (P = 0.017). There was no significant difference between the Best and Taser methods.

Conclusion

If the Best and Taser techniques can be readily used in the operating room, they would likely prove the most reliable for finding the true CFL insertion.

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Availability of data and materials

Data that support the findings of this study are available from the corresponding author upon request.

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Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sector.

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Authors and Affiliations

  1. Department of Orthopaedic Surgery, Albert Einstein Healthcare Network, Philadelphia, PA, USA

    S. Ali Ghasemi, Gene Shaffer & James Raphael

  2. Naval Medical Center Portsmouth, Portsmouth, VA, USA

    Benjamin C. Murray

  3. Royal Oak Beaumont Department of Orthopaedic Surgery, Royal Oak, MI, USA

    Matthew Lipphardt, Clark Yin, Zachary Vaupel & Paul Fortin

Authors
  1. S. Ali Ghasemi
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  2. Benjamin C. Murray
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  3. Matthew Lipphardt
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  4. Clark Yin
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  5. Gene Shaffer
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  6. James Raphael
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  7. Zachary Vaupel
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  8. Paul Fortin
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Contributions

SAG: Protocol/project development, manuscript writing/editing. BCM: Manuscript writing/editing, data management. ML: Protocol/project development, data collection, data analysis. CY: Protocol/project development, data collection, data analysis. GS: Protocol/project development. JR: Protocol/project development. ZV: Protocol/project development. P Fortin: Protocol/project development.

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Correspondence to S. Ali Ghasemi.

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We declare no conflict of interests.

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The study protocol was approved by the Royal Oak Beaumont Institutional Review Board.

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Ghasemi, S.A., Murray, B.C., Lipphardt, M. et al. Accuracy of radiographic techniques in detection of the calcaneofibular ligament calcaneal insertion for lateral ankle ligament complex surgery. Surg Radiol Anat 45, 917–922 (2023). https://doi.org/10.1007/s00276-023-03162-3

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