Radiographic Landmarks of the Lateral Ankle Structures for Ligament Reconstruction

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1 Radiographic Landmarks of the Lateral Ankle Structures for Ligament Reconstruction C. Thomas Haytmanek, MD; Brady T. Williams, BS; Evan W. James, BS; Kevin J. Campbell, MD; Coen A. Wijdicks, Ph.D; Robert F. LaPrade, MD, Ph.D; Thomas O. Clanton, MD

2 Radiographic Landmarks of the Lateral Ankle Structures for Ligament Reconstruction C. Thomas Haytmanek My disclosure is in the Final AOFAS Mobile App. I have no potential conflicts with this presentation. The Steadman Philippon Research Institute is a 501(c)(3) non-profit institution supported financially by private donations and corporate support from the following entities: Smith & Nephew, Arthrex, Inc., Siemens Medical Solutions USA, Inc., ConMed Linvatec, Össur Americas, Synthes, Ceterix Orthopaedics, Inc., AANA, University of Oslo, The Steadman Clinic, Vail Valley Medical Center

3 Background Lateral ankle ligament injuries rank among the most frequently observed athletic injuries 2,4,7 Up to 20% of patients experience chronic instability that may require surgical intervention to restore lateral ankle stability 5-6 Current lack of objective quantitative data detailing the ligament attachment sites on standard radiographic views

4 Purpose To quantitatively describe the anatomic attachment sites of the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and posterior talofibular ligament (PTFL) on standard radiographic views with respect to reproducible osseous landmarks to assist with intraoperative and postoperative assessment of lateral ankle ligament repairs and reconstructions

Methods Twelve, non-paired, fresh frozen foot and ankle cadaveric specimens Ligament footprints were marked with 2 mm stainless steel spheres embedded in cortical bone 3,8-10 prior to obtaining

5 Methods Twelve, non-paired, fresh frozen foot and ankle cadaveric specimens Ligament footprints were marked with 2 mm stainless steel spheres embedded in cortical bone 3,8-10 prior to obtaining standard mortise and lateral radiographs A modified anatomical illustration from Clanton et al 1 of the lateral ankle. A graphical representation of the anterior talofibular ligament (ATFL) origin (1) and insertion (2) and calcaneofibular ligament origin (3) and insertion (4) that have been marked with 2 mm stainless steel spheres. A subset of selected anatomical osseous landmarks used for radiographic reference measurements are also indicated (arrows): a, distal point talar neck; b, proximal point talar neck; c, anterior fibular tubercle; d, apex lateral talar process; e, inferior tip of the lateral malleolus; f, posterior point peroneal tubercle; posterior point of the calcaneus

6 Methods Measurements were performed twice by two blinded raters independently to calculate mean distances and assess reliability via intraclass correlation coefficients Measurements were reported with respect to established radiographic reference frames

each individual ligament ATFL, Anterior Talofibular Ligament; CFL, Calcaneofibular Ligament; PTFL,

7 Results Radiographic measurements demonstrated excellent reproducibility between raters and across trials Excellent agreement for mortise and lateral views Excellent agreement for measurements of each individual ligament ATFL, Anterior Talofibular Ligament; CFL, Calcaneofibular Ligament; PTFL, Posterior Talofibular Ligament; ICC, Intraclass correlation coefficient; LB, lower bound; UB, upper bound

8 Anterior Talofibular Ligament Lateral view: (ATFL) 8.4 ± 1.8 mm from inferior tip of the lateral malleolus 13.8 ± 2.0 mm from the apex of the lateral talar process Mortise View: 4.9 ± 1.4 mm proximal to the inferior tip of the lateral malleolus 9.0 ± 2.1 mm from the apex of the lateral talar process 18.9 ± 3.1 inferior to the superior lateral corner of the talar dome

9 Calcaneofibular Ligament (CFL) Lateral view: 5.0 ± 1.4 mm from inferior tip of the lateral malleolus 18.5 ± 4.6 mm from the posterior point of the peroneal tubercle Mortise View: 2.9 ± 1.4 mm proximal to the inferior tip of the lateral malleolus 18.0 ± 5.1 mm from the apex of the lateral talar process

10 Posterior Talofibular Ligament Lateral view: 7.9 ± 2.5 mm from inferior tip of the lateral malleolus 6.8 ± 3.2 mm from the posterolateral talar tubercle Mortise View: 6.1 ± 1.0 mm proximal to the inferior tip of the lateral malleolus 15.2 ± 2.1 mm from the apex of the lateral talar process

11 Conclusions/Clinical Relevance Radiographic parameters quantitatively describing the anatomy of the lateral ankle ligaments were defined with excellent reproducibility and agreement between reviewers Quantitative radiographic data will assist in preoperative planning, improve intraoperative localization, and provide objective measures for postoperative assessment of anatomic repairs and reconstructions

12 References 1. Clanton TO, Campbell KJ, Wilson KJ, Michalski MP, Goldsmith MT, Wijdicks CA, LaPrade RF. Qualitative and quantitative anatomic investigation of the lateral ankle ligaments for surgical reconstruction procedures. J Bone Joint Surg Am. 2014;96(12):e98. [Epub ahead of print] PMID: Garrick JG. The frequency of injury, mechanism of injury, and epidemiology of ankle sprains. Am J Sports Med. 1977;5(6): PMID: Johansson AM, Anderson CJ, Wijdicks CA, Engebretsen L, LaPrade RF. Radiographic landmarks for tunnel positioning in posterior cruciate ligament reconstructions. Am J Sports Med. 2013;41(1): PMID: Junge A, Engebretsen L, Mountjoy ML, Alonso JM, Renstrom PA, Aubry MJ, Dvorak J. 325 Sports injuries during the summer Olympic games Am J Sports Med ;37(11): PMID: Konradsen L, Bech L, Ehrenbjerg M, Nickelsen T. Seven years follow-up after ankle inversion trauma. Scand J Med Sci Sports. 2002;12(3): PMID: Neuschwander TB, Indresano AA, Hughes TH, Smith BW. Footprint of the lateral ligament complex of the ankle. Foot Ankle Int. 2013;34(4): PMID: Petersen W, Rembitzki IV, Keppenburg AG, Ellerman A, Liebau C, Bruggermann GP, Beset R. Treatment of acute ankle ligament injuries: a systematic review. Arch Orthop Trauma Surg. 2013;133(8): PMID: Pietrini SD, LaPrade RF, Griffith CJ, Wijdicks CA, Ziegler CG. Radiographic identification of the primary posterolateral knee structures. Am J Sports Med. 2009;37(3): PMID: Pietrini SD, Ziegler CG, Anderson CJ, Wijdicks CA, Westerhaus BD, Johansen S, Engebretsen L, LaPrade RF. Radiographic landmarks for tunnel positioning in double-bundle ACL reconstructions. Knee Surg Sports Traumatol Arthrosc. 2011;19(5): PMID: Wijdicks CA, Griffith CJ, LaPrade RF, Johansen S, Sunderland A, Arendt EA, Engebretsen L. Radiographic identification of the primary medial knee structures. J Bone Joint Surg Am. 2009;91(3): PMID:

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