Abstract
Purpose
Lateral ligament ankle sprains are common and the anatomy on imaging studies is vital for accurate diagnosis. The lateral fibulotalocalcaneal ligament (LFTCL) complex consists of the inferior fascicle of the anterior talofibular ligament (ATFL) which is connected by arciform fibres with the calcaneofibular ligament (CFL). The superior fascicle of ATFL is an independent structure that should be assessed individually. MRI evaluation of these distinct fascicles and the arciform fibres has not been described. The aim of this study is to identify the anatomical relationship of these components of the LFTCL complex in healthy individuals on MRI.
Methods
Thirty ankles from healthy volunteers were imaged using 3D volumetric MRI. The ATFL fascicles and size were evaluated. Presence of arciform fibres connecting the inferior ATFL fascicle and CFL to form the LFTCL complex and anatomical relationship around the lateral ligament complex were assessed.
Results
Both the superior and inferior ATFL fascicles were observed in 26 (86.7%) ankles. The superior ATFL fascicle was significantly larger in all specimens (39% longer and 80.7% wider). For the specimens with a single fascicle, this was similar in size to the superior fascicle observed in the other 26 specimens. These measurements were not affected by age or gender. Arciform fibres of the LFTCL complex were identified in 22 (84.6%) specimens with two ATFL fascicles and three (75%) ankles with a single ATFL fascicle. Connecting fibres from the ATFL to PTFL were observed in 19 (63.3%) ankles while connections between the CFL and PTFL were identified in 21 (70%) ankles. Five ankles had a perforating artery visualized in the intervening space between the superior and inferior ATFL fascicles (a branch of the lateral tarsal artery of the dorsalis pedis artery).
Conclusion
Two distinct ATFL fascicles may be identified in the majority of ankles on MRI. Isolated injury to the superior fascicle identified on MRI may be useful when diagnosing patients presenting with symptoms of subtle instability without overt ankle laxity on clinical examination. The current study is the first to identify the arciform fibres of the LFTCL complex supporting isolated ATFL repair in the presence of intact LFTCL complex.
Level of evidence
Level III.
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References
Broström L (1964) Sprained ankles. I. Anatomic lesions in recent sprains. Acta Chir Scand 128:483–495
Choo HJ, Lee SJ, Kim DW, Jeong HW, Gwak H (2014) Multibanded anterior talofibular ligaments in normal ankles and sprained ankles using 3D isotropic proton density-weighted fast spin-echo MRI sequence. AJR Am J Roentgenol 202(1):W87-94
Cordier G, Nunes GA, Vega J, Roure F, Dalmau-Pastor M (2021) Connecting fibers between ATFL’s inferior fascicle and CFL transmit tension between both ligaments. Knee Surg Sports Traumatol Arthrosc 29(8):2511–2516
Dalmau-Pastor M, Malagelada F, Calder J, Manzanares MC, Vega J (2020) The lateral ankle ligaments are interconnected: the medial connecting fibres between the anterior talofibular, calcaneofibular and posterior talofibular ligaments. Knee Surg Sports Traumatol Arthrosc 28(1):34–39
Delfaut EM, Demondion X, Boutry N, Cotten H, Mestdagh H, Cotten A (2003) Multi-fasciculated anterior talo-fibular ligament: reassessment of normal findings. Eur Radiol 13(8):1836–1842
Garrick JG (1977) The frequency of injury, mechanism of injury, and epidemiology of ankle sprains. Am J Sports Med 5(6):241–242
Golanó P, Vega J, de Leeuw PA, Malagelada F, Manzanares MC, Götzens V, van Dijk CN (2016) Anatomy of the ankle ligaments: a pictorial essay. Knee Surg Sports Traumatol Arthrosc 24(4):944–956
Gosselin MM, Haynes JA, McCormick JJ, Johnson JE, Klein SE (2019) The arterial anatomy of the lateral ligament complex of the ankle: a cadaveric study. Am J Sports Med 47(1):138–143
Lee KT, Park YU, Kim JS, Kim JB, Kim KC, Kang SK (2011) Long-term results after modified Brostrom procedure without calcaneofibular ligament reconstruction. Foot Ankle Int 32(2):153–157
Maffulli N, Del Buono A, Maffulli GD, Oliva F, Testa V, Capasso G, Denaro V (2013) Isolated anterior talofibular ligament Broström repair for chronic lateral ankle instability: 9-year follow-up. Am J Sports Med 41(4):858–864
Murray MM, Spindler KP, Ballard P, Welch TP, Zurakowski D, Nanney LB (2007) Enhanced histologic repair in a central wound in the anterior cruciate ligament with a collagen-platelet-rich plasma scaffold. J Orthop Res 25(8):1007–1017
Nakasa T, Ikuta Y, Sumii J, Nekomoto A, Kawabata S, Adachi N (2022) MRI appearance of the lateral fibulotalocalcaneal ligament complex injury in the patients with chronic lateral ankle instability. Foot Ankle Surg 28(7):968–974
Szaro P, Ghali Gataa K, Polaczek M, Ciszek B (2020) The double fascicular variations of the anterior talofibular ligament and the calcaneofibular ligament correlate with interconnections between lateral ankle structures revealed on magnetic resonance imaging. Sci Rep 10(1):20801
van den Bekerom MP, Kerkhoffs GM, McCollum GA, Calder JD, van Dijk CN (2013) Management of acute lateral ankle ligament injury in the athlete. Knee Surg Sports Traumatol Arthrosc 21(6):1390–1395
Vavken P, Murray MM (2011) The potential for primary repair of the ACL. Sports Med Arthrosc Rev 19(1):44–49
Vega J, Dalmau-Pastor M, Malagelada F, Fargues-Polo B, Peña F (2017) Ankle arthroscopy: an update. J Bone Joint Surg Am 99(16):1395–1407
Vega J, Malagelada F, Dalmau-Pastor M (2021) Ankle microinstability: arthroscopic findings reveal four types of lesion to the anterior talofibular ligament’s superior fascicle. Knee Surg Sports Traumatol Arthrosc 29(4):1294–1303
Vega J, Malagelada F, Manzanares Céspedes MC, Dalmau-Pastor M (2020) The lateral fibulotalocalcaneal ligament complex: an ankle stabilizing isometric structure. Knee Surg Sports Traumatol Arthrosc 28(1):8–17
Vega J, Peña F, Golanó P (2016) Minor or occult ankle instability as a cause of anterolateral pain after ankle sprain. Knee Surg Sports Traumatol Arthrosc 24(4):1116–1123
Waterman BR, Belmont PJ Jr, Cameron KL, Deberardino TM, Owens BD (2010) Epidemiology of ankle sprain at the United States Military Academy. Am J Sports Med 38(4):797–803
Woods C, Hawkins R, Hulse M, Hodson A (2003) The Football Association Medical Research Programme: an audit of injuries in professional football: an analysis of ankle sprains. Br J Sports Med 37(3):233–238
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All authors contributed to the study conception and design. AT, MK and MJ: prepared the study protocol and performed the ethical review process. Material preparation, data collection and analysis were performed by CCH, JCL, AWM, MD-P and JC. The first draft of the manuscript was written by CCH and all authors commented on previous versions of the manuscript. JC: supervised and reviewed the final manuscript. All authors read and approved the final manuscript.
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All authors do not have any conflict of interest except for James Calder who received remuneration for speaking in educational programme by Arthrex unrelated to this study.
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Institutional approval to undertake this study was provided by the West Midlands—Coventry & Warwickshire Research Ethics Committee (Reference: 19/WM/0383).
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Informed consent was obtained for all volunteers prior to the scan.
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Hong, C.C., Lee, J.C., Tsuchida, A. et al. Individual fascicles of the ankle lateral ligaments and the lateral fibulotalocalcaneal ligament complex can be identified on 3D volumetric MRI. Knee Surg Sports Traumatol Arthrosc 31, 2192–2198 (2023). https://doi.org/10.1007/s00167-022-07275-x
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DOI: https://doi.org/10.1007/s00167-022-07275-x