The Role of Calcaneofibular Ligament Injury in Ankle Instability: Implications for Surgical Management

Hunt, Kenneth J.; Pereira, Hélder; Kelley, Judas; Anderson, Nicholas; Fuld, Richard; Baldini, Todd; Kumparatana, Pam; D’Hooghe, Pieter

doi:10.1177/0363546518815160

Cited by 44 publications

(22 citation statements)

References 27 publications

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“…Previous studies have also evaluated the CFL’s effect on the talar tilt. 12,22 A cadaveric study by Hunt et al 12 revealed that sectioning of the CFL resulted in a significantly increased peak pressure and a decreased mean contact area in the tibiotalar joint as well as significantly more inversion of the talus and calcaneus with weight bearing. Our results are similar to those of Hunt et al, with increased laxity of the ankle, specifically in talar tilt, when the CFL was cut.…”

Section: Discussionmentioning

confidence: 99%

Evaluation of the Intact Anterior Talofibular and Calcaneofibular Ligaments, Injuries, and Repairs With and Without Augmentation: A Biomechanical Robotic Study

et al. 2021

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Background: Acute ankle sprains are common injuries. The anterior talofibular (ATFL) and calcaneofibular ligaments (CFL) are the most injured lateral structures. However, controversy exists on the optimal surgical treatment when the injury is both acute and severe or becomes chronic and unstable. Studies have evaluated the biomechanics of these ligaments, but no studies have robotically evaluated injury effects and surgical treatment of ATFL or ATFL and CFL injuries. Purpose: To quantitatively evaluate biomechanical effects of ATFL and CFL lesions, ATFL repair, ATFL and CFL repair, and augmentation of ATFL on ankle stability. Study Design: Controlled laboratory study. Methods: Ten nonpaired cadaveric ankles were tested using a 6 degrees of freedom robot. Each ankle underwent testing in the following states sequentially: (1) intact, (2) ATFL cut, (3) CFL cut, (4) ATFL repair + CFL cut, (5) ATFL repair + CFL repair, and (6) ATFL repair with augmentation with suture tape + CFL repair. Testing included 88 N anterior drawer and 5 N·m varus talar tilt tests at 0° and 30° of plantarflexion, and 88 N Cotton test at 0° of plantarflexion. Results: After all surgical treatments ankles still had increased laxity compared with intact state testing, except after augmented ATFL repair + CFL repair in anterior drawer testing at 30° of plantarflexion ( P = .393). Sectioning the CFL caused a significant increase in talar tilt compared with the ATFL cut state at 0° ( P < .001) and 30° of plantarflexion ( P < .001), but no increase in anterior drawer or Cotton tests. Conclusion: Complete native stability may not be attainable at time zero repair with the tested treatments. The option that best returned stability in anterior translation was augmented ATFL repair with nonaugmented CFL repair. The importance of the CFL as a primary ligamentous stabilizer for talar tilt was confirmed. Clinical Relevance: Evaluating lateral ankle stability and treatment with a 6 degrees of freedom robot should help delineate optimal treatment options. Findings in this study show that none of the repair methods at time zero restored kinematics to the intact state. Of the tested states, the augmented ATFL repair with CFL repair was the best option for controlling anterior translation at time zero. The importance of addressing the CFL to correct talar tilt instability was suggested as was the importance of a period of immobilization before beginning protected rehabilitation. The benefit of ATFL repair augmentation with suture tape is in limiting the postoperative motion in an anterior drawer motion to just 0.5 to 1 mm, but there was no significant improvement to talar tilt even with CFL repair, suggesting that further consideration should be given to CFL augmentation in future studies.

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Section: Discussionmentioning

confidence: 99%

Evaluation of the Intact Anterior Talofibular and Calcaneofibular Ligaments, Injuries, and Repairs With and Without Augmentation: A Biomechanical Robotic Study

et al. 2021

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“…34 Previous cadaveric studies have demonstrated that the resection of ATFL and CFL make the center of the force move medially toward the medial shoulder of the talus, which is the most common location of OLT. 8,10,19 It is reported that 48% of OLT patients develop OA after 11 years of follow-up. 5 In our study, there was no significant difference in the HU ratios between a talus with and one without chondral/osteochondral injuries.…”

Section: Discussionmentioning

confidence: 99%

Bone Mineralization Changes in the Subchondral Bone of the Medial Gutter in Chronic Lateral Ankle Instability

et al. 2020

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Background: Chronic ankle instability (CAI) induces osteoarthritis (OA) by inflicting abnormal stresses on the medial gutter. It is important to detect early OA change and to explore factors likely to induce the OA. The purpose of this study was to evaluate subchondral bone change in the medial gutter of CAI using computed tomography (CT) scans. Methods: Thirty-five ankles with CAI (CAI group) and 35 ankles without CAI (control group) were included. The region of interest (ROI) in the subchondral bone of the medial gutter on CT axial images was set on the tibia and talus. The Hounsfield unit (HU) in ROIs was measured and corrected by the HU of the fibula in the same slice. HU ratios were compared between the CAI and control groups. In the CAI group, the relationship between the HU ratio and the talar tilt angle (TTA), OA change, and the anterior talofibular ligament (ATFL) remnant quality were analyzed. Results: The mean HU ratio in the CAI group was significantly higher than that in the control. In the CAI group, HU ratios in ≥10 degrees of TTA were significantly higher than those in <10 degrees. But there was no significant difference in the HU ratios with or without OA change in the medial gutter. A good-quality ATFL remnant showed a low HU ratio compared with that with poor quality. Conclusion: CAI patients exhibited subchondral bone change in the medial gutter, which suggests that the elimination of instability may help to prevent or decrease the development and/or progression of osteoarthritis. Level of Evidence: Level III, comparative series.

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“…In addition, a muscle strength deficit could be also closely related to the ligament injury pattern and concomitant injuries, which have rarely been studied. In terms of the ligament injury pattern, an isolated lesion of the anterior talofibular ligament (ATFL) occurs in approximately 65% of cases, while combined ruptures of the ATFL and calcaneofibular ligament (CFL) occur in approximately 20% [ 12 ]. The isolated ATFL injury or the combined both ligament injuries may affect the degree of lateral instability, resulting in different characteristics of muscle strength.…”

Section: Introductionmentioning

confidence: 99%

Characteristics and predictors of muscle strength deficit in mechanical ankle instability

Hou

Miao

et al. 2020

BMC Musculoskelet Disord

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Purpose Muscle strength training is a common strategy for treating chronic ankle instability (CAI), but the effectiveness decreases for mechanical ankle instability (MAI) patients with initial severe ligament injuries. The purpose of this study was to investigate the characteristics and the potential predictors of muscle strength deficit in MAI patients, with a view to proposing a more targeted muscle strength training strategy. Methods A total of 220 MAI patients with confirmed initial lateral ankle ligament rupture and a postinjury duration of more than 6 months were included. All patients underwent a Biodex isokinetic examination of the ankle joints of both the affected and unaffected sides. Then, the associations between the limb symmetry index (LSI) (mean peak torque of the injury side divided by that of the healthy side) and the patients’ sex, body mass index, postinjury duration, presence of intra-articular osteochondral lesions, presence of osteophytes and ligament injury pattern (i.e., isolated anterior talofibular ligament (ATFL) injury or combined with calcaneofibular ligament injury) were analysed. Results There was significantly weaker muscle strength on the affected side than on the unaffected side in all directions (p < 0.05). The LSI in plantar flexion was significantly lower than that in dorsiflexion at 60°/s (0.87 vs 0.98, p < 0.001). A lower LSI in eversion was significantly correlated with female sex (0.82 vs 0.94, p = 0.016) and isolated ATFL injury (0.86 vs 0.95, p = 0.012). No other factors were found to be associated with muscle strength deficits. Conclusion MAI patients showed significant muscle strength deficits on the affected side, especially in plantar flexion. There were greater strength deficits in eversion in females and individuals with an isolated ATFL injury. Thus, a muscle strength training programme for MAI patients was proposed that focused more on plantar flexion training and eversion training for females and those with an isolated ATFL injury.

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The Role of Calcaneofibular Ligament Injury in Ankle Instability: Implications for Surgical Management

Cited by 44 publications

References 27 publications

Evaluation of the Intact Anterior Talofibular and Calcaneofibular Ligaments, Injuries, and Repairs With and Without Augmentation: A Biomechanical Robotic Study

Evaluation of the Intact Anterior Talofibular and Calcaneofibular Ligaments, Injuries, and Repairs With and Without Augmentation: A Biomechanical Robotic Study

Bone Mineralization Changes in the Subchondral Bone of the Medial Gutter in Chronic Lateral Ankle Instability

Characteristics and predictors of muscle strength deficit in mechanical ankle instability

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