Anatomy of the subtalar joint ligaments

NewsBot · Feb 21, 2022

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The different subtalar ligaments show significant differences in their mechanical properties
FrederickMichelsabcd et al
Foot and Ankle Surgery; 16 February 2022

Highlights
•The ACaL-ITCL is a rather stiff ligament with a relative high failure load. This supports the function of apposition of the calcaneus to the talus.
•The CL is a compliant ligament with a low failure load. The low failure load makes this ligament more vulnerable to injury.
•A gracilis tendon graft seems more appropriate to reconstruct a CL or CFL than a stiffer synthetic ligament.
•A partial rupture of the subtalar ligaments was the most common injury pattern after uniaxial loading to failure.
•Further research about injury patterns is needed as the surgical technique should be adapted accordingly.
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Background
Today, the relative contribution of each ligamentous structure in the stability of the subtalar joint is still unclear. The purpose of this study is to assess the material properties of the different ligamentous structures of the subtalar joint.

Methods
Eighteen paired fresh-frozen cadaveric feet were used to obtain bone–ligament–bone complexes of the calcaneofibular ligament (CFL), the cervical ligament (CL) and the anterior capsular ligament-interosseous talocalcaneal ligament complex (ACaL-ITCL). The samples were subjected to uniaxial testing to calculate their respective stiffness and failure load.

Results
The stiffness of ACaL-ITCL complex (mean: 150 ± 51 N/mm, 95% confidence interval (CI): 125.0–176.6 N/mm) was significantly higher than both CFL (mean: 55.8 ± 23.0 N/mm, CI: 43.8–67.7 N/mm) and CL (mean: 63.9 ± 38.0 N/mm, CI: 44.4–83.3 N/mm). The failure load of both the ACaL-ITCL complex (mean:382.5 ± 158 N, CI: 304.1–460.8 N) and the CFL (mean:320.4 ± 122.0 N, CI: 257.5–383.2 N) were significantly higher than that of the CL (mean:163.5 ± 58.0 N, CI: 131.3–195.7 N). The injury pattern demonstrated a partial rupture in all CFL and ACaL-ITCL specimens and in 60% of the CL specimens.

Conclusion
The CFL, CL and ACaL-ITCL show significant differences in their intrinsic mechanical properties. Both the CFL and CL are more compliant ligaments and seem to be involved in the development of subtalar instability. Based on the material properties, a gracilis tendon graft seems more appropriate than a synthetic ligament to reconstruct a CL or CFL. A partial rupture was the most commonly seen injury pattern in all ligaments. A fibular avulsion of the CFL was only rarely seen. The injury patterns need further investigation as they are important to optimize diagnosis and treatment.
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NewsBot · Feb 27, 2023

Relationship between Joint and Ligament Structures of the Subtalar Joint and Degeneration of the Subtalar Articular Facet
Ryoya Togashi et al
Int J Environ Res Public Health. 2023 Feb 9;20(4):3075

This study aimed to clarify the relationship between the joint and ligament structures of the subtalar joint and degeneration of the subtalar articular facet. We examined 50 feet from 25 Japanese cadavers. The number of articular facets, joint congruence, and intersecting angles were measured for the joint structure of the subtalar joint, and the footprint areas of the ligament attachments of the cervical ligament, interosseous talocalcaneal ligament (ITCL), and anterior capsular ligament were measured for the ligament structure. Additionally, subtalar joint facets were classified into Degeneration (+) and (-) groups according to degeneration of the talus and calcaneus. No significant relationship was identified between the joint structure of the subtalar joint and degeneration of the subtalar articular facet. In contrast, footprint area of the ITCL was significantly higher in the Degeneration (+) group than in the Degeneration (-) group for the subtalar joint facet. These results suggest that the joint structure of the subtalar joint may not affect degeneration of the subtalar articular facet. Degeneration of the subtalar articular facet may be related to the size of the ITCL.
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NewsBot · Mar 28, 2023

Role of the intrinsic subtalar ligaments in subtalar instability and consequences for clinical practice
Frederick Michels et al
Front Bioeng Biotechnol. 2023 Mar 10;11:1047134

Subtalar instability (STI) is a disabling complication after an acute lateral ankle sprain and remains a challenging problem. The pathophysiology is difficult to understand. Especially the relative contribution of the intrinsic subtalar ligaments in the stability of the subtalar joint is still controversial. Diagnosis is difficult because of the overlapping clinical signs with talocrural instability and the absence of a reliable diagnostic reference test. This often results in misdiagnosis and inappropriate treatment. Recent research offers new insights in the pathophysiology of subtalar instability and the importance of the intrinsic subtalar ligaments. Recent publications clarify the local anatomical and biomechanical characteristics of the subtalar ligaments. The cervical ligament and interosseous talocalcaneal ligament seem to play an important function in the normal kinematics and stability of the subtalar joint. In addition to the calcaneofibular ligament (CFL), these ligaments seem to have an important role in the pathomechanics of subtalar instability (STI). These new insights have an impact on the approach to STI in clinical practice. Diagnosis of STI can be performed be performed by a step-by-step approach to raise the suspicion to STI. This approach consists of clinical signs, abnormalities of the subtalar ligaments on MRI and intraoperative evaluation. Surgical treatment should address all the aspects of the instability and focus on a restoration of the normal anatomical and biomechanical properties. Besides a low threshold to reconstruct the CFL, a reconstruction of the subtalar ligaments should be considered in complex cases of instability. The purpose of this review is to provide a comprehensive update of the current literature focused on the contribution of the different ligaments in the stability of the subtalar joint. This review aims to introduce the more recent findings in the earlier hypotheses on normal kinesiology, pathophysiology and relation with talocrural instability. The consequences of this improved understanding of pathophysiology on patient identification, treatment and future research are described.
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NewsBot · May 18, 2023

Accuracy of radiographic techniques in detection of the calcaneofibular ligament calcaneal insertion for lateral ankle ligament complex surgery
S Ali Ghasemi et al
Surg Radiol Anat. 2023 May 17

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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NewsBot · Apr 26, 2024 at 3:31 AM

Anatomic Variations of the Calcaneofibular Ligament
Kacper Ruzik et al
Source

Background:
The lateral ankle joint comprises the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and posterior talofibular ligament (PTFL). The purpose of this study was to propose a classification of CFL morphology.
Methods:
The material comprised 120 paired lower limbs from human cadavers (30 male, 30 female), mean age 62.3 years. The morphology was carefully assessed, and morphometric measurements were performed.
Results:
A 4-part method for anatomic classification can be suggested based on our study. Type 1 (48.3%), the most common type, was characterized by a bandlike morphology. Type 2 (9.2%) was characterized by a Y-shaped band, and type 3 (21.7%) by a V-shaped band. Type 4 (20.8%) was characterized by the presence of 2 or 3 bands. Type 2 and 4 were divided into further subtypes based on origin footprint.
Conclusion:
The aim of our study was to describe variations of calcaneofibular ligament. Our proposed 4-part classification may be of value in clinical practice in future recognition of CFL injuries and in its repair or reconstruction.
Clinical Relevance:
The anatomy of the CFL plays an important role in stability of the ankle. Greater recognition of anatomical variation may help improve reconstructive options for patients with chronic lateral ankle instability.
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