Posterior Tibiotalar Ligament Research Articles

Effects of Fibular Plate Fixation on Ankle Stability in a Weber B Fracture Model With Partial Deltoid Ligament Sectioning.

Weber B fractures with concomitant deltoid ligament injury have traditionally been operated with open reduction and internal fixation of the fibular fracture. More recently, clinical studies have suggested that some fractures have concomitant partial deltoid ligament injury with the deep posterior tibiotalar ligament intact (SER4a), allowing for nonoperative treatment in this subgroup. This study explores whether plate fixation of the fibula improves ankle stability in an SER4a injury model. And if so, does it restore native ankle stability? Fifteen cadaver ankle specimens were tested in 3 states using an industrial robot: intact joint, SER4a models without plate fixation of the fibula, and SER4a models with plate fixation of the fibula. The robot measured ankle stability in lateral translation, valgus, and internal and external rotation in 3 talocrural joint positions: 10 degrees dorsiflexion, neutral, and 20 degrees plantar flexion. Furthermore, fluoroscopic mortise view radiographs were taken to measure isolated talar shift and talar tilt. The talar shift and tilt tests showed no differences between the SER4a injury model with and without fibular plate fixation at neutral ankle position with a mean difference of -0.16 mm (95% CI -0.33 to 0.01 mm, P = .071) for talar shift and -0.15 degrees (95% CI -0.01 to 0.30 degrees, P = .068) for talar tilt. However, plate fixation increased external rotation stability, with mean improvements ranging from -7.43 to -9.52 degrees (P < .001 for all comparisons), but did not restore intact ankle stability. For internal rotation, plate fixation resulted in minor differences. The results of this suggest that plate fixation of the fibular fracture primarily improves external rotation stability but does not substantially improve lateral translation, valgus, or internal rotation stability in SER4a injury models. In this robotic cadaver model, fibular plate fixation did not fully restore intact ankle stability after simulated SER4a injury. This study offers insights into the effects of fibular plate fixation on Weber B/SER4a injury models and may assist informed decisions when selecting treatments for these types of fractures.

Effect of Plate and Screw Fixation on Stability of Weber B/Supination-External Rotation Fractures with Partial Deltoid Ligament Injury (SER4a): Robotic-Based Joint Testing

Category: Trauma; Ankle Introduction/Purpose: Fibular fractures with signs of concomitant deltoid ligament injury have been operated on with plate and screw fixation of the fibula for decades. More recently, clinical studies have suggested that some fibular fractures have only partial deltoid ligament injury and that the deep posterior tibiotalar ligament may be intact (SER4a), allowing for nonoperative treatment. The purpose was to determine whether fibula fracture fixation using plate and screws improves stability and restores normal joint kinematics in such fractures. It was hypothesised that fixation of the fibula fracture does not add significantly to the stability of SER4a models or restore normal joint kinematics. Methods: Fifteen cadaveric foot and ankle specimens underwent biomechanical testing using a six-degrees-of-freedom force- movement robotic arm in three states: intact joint, SER4a model (anterior inferior tibiofibular ligament sectioned + oblique trans syndesmotic fibular osteotomy + superficial layer of deltoid ligament sectioned + deep anterior tibiotalar ligament sectioned) and SER4a model + plate and screw fixation of the fibula. Joint stability was measured in lateral translation, valgus, and talar internal- and external rotation in three talocrural joint positions: 20° plantarflexion, neutral, and 10° dorsiflexion. Fluoroscopy was used to measure isolated talar lateralisation and talar tilt. The foot was rigidly fixed to a custom pedestal, while the tibia was rigidly fixed to the robot arm through a load cell. Talar lateral translation at neutral ankle position was the primary outcome. Results: Fixation of the fibular fracture reduced lateral translation by 0.16 millimetres (P = .101) at neutral ankle position (See Figure 1). In general, the tests for lateral translation and valgus showed no differences between the SER4a models and the SER4a models with fibular fracture fixation. As for talar internal rotation, the fixation only slightly increased stability. But, when the talus was externally rotated, the fixation provided stability. Although the fixation improved stability during rotations, it did not fully restore the native ankle kinematics. Conclusion: The results suggest that plate and screw fixation of the fibular fracture does not significantly reduce instability or restore intact joint stability in SER4a models. These results support the nonoperative treatment of these fractures, as suggested by previous clinical studies.

Ligamentous injuries of the ankle joint : Importance of radiological imaging procedures

Injuries of the ankle joint show lesions of the lateral ligamentous apparatus with an incidence of 1 in 1000cases. With arange of 0.3-0.7 in 1000 cases, injuries of the medial ligamentous apparatus occur more frequently than previously thought and are often overlooked. Correct imaging diagnostics of the ankle ligaments are mandatory for the prognosis and treatment planning. In cases of clinically strong suspicion of ligamentous injury or osteochondral lesions of the ankle joint, after primary radiographic evaluation magnetic resonance imaging (MRI) is primarily recommended for a more precise assessment. Additionally, the sensitivity for assessment of the ligaments with ultrasonography is good (91% vs. 97% with MRI) but its specificity is inferior compared to MRI (63% vs. 93% with MRI). Supination trauma is the most common ankle injury and attention should be paid to the anterior tibiofibular ligament and calcaneofibular ligament. In approximately 50%, injuries to the superficial layer of the medial collateral ligament complex are associated with lesions of the posterior tibiotalar ligament.

Ligamentous injuries of the ankle joint : Importance of radiological imaging procedures

Injuries of the ankle joint show lesions of the lateral ligamentous apparatus with an incidence of 1 in 1000cases. With arange of 0.3-0.7 in 1000 cases, injuries of the medial ligamentous apparatus occur more frequently than previously thought and are often overlooked. Correct imaging diagnostics of the ankle ligaments are mandatory for the prognosis and treatment planning. In cases of clinically strong suspicion of ligamentous injury or osteochondral lesions of the ankle joint, after primary radiographic evaluation magnetic resonance imaging (MRI) is primarily recommended for a more precise assessment. Additionally, the sensitivity for assessment of the ligaments with ultrasonography is good (91% vs. 97% with MRI) but its specificity is inferior compared to MRI (63% vs. 93% with MRI). Supination trauma is the most common ankle injury and attention should be paid to the anterior tibiofibular ligament and calcaneofibular ligament. In approximately 50%, injuries to the superficial layer of the medial collateral ligament complex are associated with lesions of the posterior tibiotalar ligament.

Prediction of anterior tibiotalar ligament injury: measurement of the angle between the deep posterior tibiotalar ligament and talus on MRI.

Identification of anterior tibiotalar ligament (aTTL) injury is essential because it influences the surgeon's treatment option and patient prognosis. To assess the diagnostic accuracy of the angle measurement between the talus and posterior tibiotalar ligament (talus-pTTL) on magnetic resonance imaging (MRI) in patients with arthroscopically proven aTTL injuries. Ankle MRI scans of 67 patients who underwent arthroscopic examination were retrospectively reviewed. The talus-pTTL angle on axial T2-weighted MRI and the medial clear space (MCS) on mortise ankle radiograph were measured. Inter-observer agreement of the measurements was calculated. Also, sensitivity, specificity, and area under the receiver operating characteristic (ROC) curve (AUC) were the metrics of diagnostic accuracy. AUC was 0.90 for observer 1 with 78.6% sensitivity, 97.4% specificity, 88% accuracy, and 54.7° cutoff value for the talus-pTTL angle. AUC was 0.87 for observer 2 with 85.7% sensitivity, 84.6% specificity, 85.2% accuracy, and 53.7° cutoff value for the talus-pTTL angle. AUC was 0.86 with 82.1% sensitivity, 79.5% specificity, and 80.8% accuracy for observer 1 and 0.79 with 57.1% sensitivity, 92.3% specificity, and 74.7% accuracy for observer 2 for the MCS. Different MCS values and additional capabilities when complemented with the angle measurement showed an increase in diagnostic performances. Intra-observer reliability of MCS and talus-pTTL angle of the two radiologists was excellent. Inter-observer reliability of the two radiologists was excellent for both the talus-pTTL angle (0.95) and the MCS (0.85). Measurement of the talus-pTTL angle showed good sensitivity, specificity, and accuracy for the evaluation of aTTL injury with excellent inter-observer reliability.

A Preliminary Study to Assess the Relevance of Shear-Wave Elastography in Characterizing Biomechanical Changes in the Deltoid Ligament Complex in Relation to Ankle Position.

The purpose of this study was (1) to evaluate the biomechanical properties of the different bundles of the deltoid ligament in various ankle positions in a cohort of healthy adult volunteers; (2) describe the impact of demographic and hindfoot morphology characteristics on their stiffness; (3) to assess the reliability and reproducibility of these measurements. Deltoid ligament complex of both ankles were assessed by shear-wave elastography (SWE) in 20 healthy patients resting on hinge support. The propagation shear-wave speed (SWS) in ligaments was measured, which is related to the tissue's elastic modulus. The following ligaments were analyzed in a neutral position and then in varus, valgus, dorsal, and plantar flexions: tibionavicular ligament (TNL), tibiocalcaneal ligament (TCL), the superficial posterior tibiotalar ligament (SPTL), the anterior tibiotalar ligament (ATTL), and the deep posterior tibiotalar ligament (DPTTL). The mean SWS increased between neutral and 20 degrees valgus position for TCL (4.08 ± 0.78 m/s vs 5.56 ± 0.62 m/s, respectively; P < .0001) and for DPTTL (2.58 ± 0.52 m/s vs 3.59 ± 0.87 m/s, respectively; P < .0001). The mean SWS increased between neutral and 30 degrees plantarflexion for ATTL (2.11 ± 0.44 m/s vs 3.1 ± 0.5 m/s, respectively; P < .0001) and TNL (2.96 ± 0.66 m/s vs 4.99 ± 0.69 m/s, respectively; P < .0001). The mean SWS increased between neutral and 20 degrees dorsal flexion for SPTL (4.2 ± 1 m/s vs 5.45 ± 0.65 m/s, respectively; P < .0001).Women had less DPTTL SWS than men in the neutral position (2.37 ± 0.35 m/s vs 2.71 ± 0.49 m/s, respectively; P = .007). Other demographics had no impact on the SWS value of other ligaments. All inter- and intraobserver agreements were good to excellent. This study presents a reliable and reproducible SWE measurement protocol to describe the physiological function of all bundles of the medial collateral ligament in healthy adults. This examination technique can be available to orthopaedic surgeons, allowing reliable and reproducible monitoring of the SWS of the various ligaments constituting the medial collateral plane. The biomechanical values described in this study may give insight into in what position medial ankle ligament reconstruction should be tensioned.

The Anatomy and Function of the Individual Bands of the Deltoid Ligament-and Implications for Stability Assessment of SER Ankle Fractures.

Background:Deltoid ligament injury occurs often with supination-external rotation (SER) ankle trauma. SER fibula fractures with concomitant deltoid ligament injury are considered unstable—requiring operative fixation. Recent studies have questioned this general practice with emphasis on better defining the medial side ankle ligamentous injury. The function of the individual bands of the deltoid ligament, and the interplay between them, are not fully understood. We undertook this study to develop a better understanding of these complex ligamentous structures and ultimately aid assessment and treatment choice of SER ankle fractures with concomitant deltoid ligament injuries.Methods:Ten fresh-frozen cadaveric foot and ankle specimens were studied. We identified the various ligament bands and did a functional analysis by assessment of ligament length and tension at predefined angles of ankle dorsi-plantarflexion combined with valgus/varus and rotation. The results were determined by manual evaluation with calipers and goniometers, manual stress, and direct visualization.Results:We recorded primarily 5 different bands of the deltoid ligament: the tibionavicular (TNL; 10/10) tibiospring (TSL; 9/10), tibiocalcaneal (TCL; 10/10), deep anterior tibiotalar (dATTL; 9/10), and deep posterior tibiotalar (dPTTL; 10/10) ligaments. The tibiospring ligament was tense in plantarflexion, while the tibiocalcaneal and deep posterior tibiotalar ligaments were tense in dorsiflexion. The superficial layer ligaments and the deep anterior tibiotalar ligament length and tension were largely affected by changes in varus/valgus and rotation. The deep posterior tibiotalar ligament length and tension was altered predominantly by changes in dorsi-plantarflexion; varus/valgus positioning had a minor effect on this band.Conclusions:We confirmed the finding of previous studies that dorsi-plantarflexion affects the tensile engagement of the separate ligament bands differently. Likewise, combined movements with varus/valgus and rotation seem to affect the separate ligament bands differently. Our results suggest that the TNL, TSL, and dATTL are at risk of injury, whereas the TCL and particularly the dPTTL are protected in the event of an SER-type ankle fracture mechanism of injury.Level of EvidenceLevel V, cadaveric study.

Defining the Components of the Deltoid Ligament (DL): A Cadaveric Study

Background: The deltoid ligament (DL) is a strong triangle-shaped ligament with a complex fascicular arrangement. Understanding the morphological and/or functional typing of the DL structure is hindered by a paucity of clear, quantitative, and reproducible data and is further complicated by inconsistent terminology use. The aim of this work was to describe different components of the DL using strict identification criteria.Methods: Thirty embalmed cadaveric ankles of both sides were dissected on all sides and studied by using gross examination, micro-dissection, and light microscopy by tracing the fascicular pattern of each under 6X magnification.Results: Six ligamentous bands were identified. The tibiotalocalcaneal ligament (TTC) and the superficial posterior tibiotalar ligament (sPTT) were two superficial variants and the anterior tibiotalar ligament (ATT), the anterior tibiotalonavicular ligament (ATTN), the intermediate tibiotalar ligament (ITT), and the deep posterior tibiotalar ligament (dPTT) were four deep variants. The TTC was identified in all 30 embalmed cadaveric specimens. Five additional ligamentous bands (ITT, sPTT, dPTT, ATT, and ATTN) were variable findings in the current cohort.Conclusion: This study presents six ligamentous bands as a regular finding and five additional ligamentous bands as variable findings in the dissected specimen. This data could assist in the radiological diagnosis of DL injuries and advanced procedures related to its surgical repair and reconstruction.

Length change pattern of the ankle deltoid ligament during physiological ankle motion

BackgroundLength change pattern of the ankle deltoid ligament during physiological ankle motion is still confused currently and had not been studied in vivo. MethodsThe deltoid ligaments from 7 cadaveric specimens were dissected. Lengths of each band during 30° plantarflexion to 20° dorsiflexion were measured. A dual fluoroscopy imaging system was utilized to capture the images of hindfoot joint of 7 healthy subjects during the stance phase of walking. 3D bone models were reconstructed from CT images. Lengths of each band were calculated after model-image registration utilizing a solid modeling software. Percentage of length variation and poses when the bands were in maximum extension were documented among each band. ResultsThe anterior border of tibiocalcaneal ligament (TCL) had only 1.7% length variation in vitro and 5.7% length variation in vivo. The tibionavicular ligament, tibiospring ligament, and deep anterior tibiotalar ligament were in maximum extension at 30° plantarflexion, however, superficial posterior tibiotalar ligament, deep posterior tibiotalar ligament, and the posterior border of TCL were in maximum extension at 20° dorsiflexion. The tibionavicular ligament, tibiospring ligament, and deep anterior tibiotalar ligament were in maximum extension during foot flat. The TCL was in maximum extension during midstance. The superficial posterior tibiotalar ligament and deep posterior tibiotalar ligament were in maximum extension during heel off and toe off. ConclusionThe length of TCL did not change during ankle dorsiflexion and plantarflexion. The bands anterior to and posterior to the TCL showed different length change pattern during physiological ankle dorsiflexion and plantarflexion.

Analysis of the main soft tissue stress associated with flexible flatfoot deformity: a finite element study.

A better understanding of soft tissue stress and its role in supporting the medial longitudinal arch in flexible flatfoot could help to guide the clinical treatment. In this study, a 3-Dimensional finite element (FE) foot model was reconstructed to measure the stress of the soft tissue, and its variation in different scenarios related to flexible flatfoot. All bones, cartilages, ligaments and related tendons around the ankle, and fat pad were included in the finite element model. The equivalent stress on the articular surface of the joints in the medial longitudinal arch and the maximum principal stress of the ligaments around the ankle were obtained. The results show that the plantar fascia (PF) is the main tissue in maintaining the medial longitudinal arch. The equivalent stress of all the joints in the medial longitudinal arch increases when the PF attenuation and the talonavicular joint increases, while other joints decreases when all the three tissue attenuation. Moreover, the maximum principal stress variation of calcaneofibular ligament is largest when the PF attenuation and the tibionavicular ligament and posterior tibiotalar ligament are largest when the posterior tibial tendon (PTT) attenuation. The maximum principal stress variation of tibionavicular ligament and posterior tibiotalar ligament are even larger when all the three tissue attenuation. These findings support that the PF is the main factor in maintaining the medial longitudinal arch. The medial longitudinal arch collapse mainly affects the talonavicular joint and the calcaneofibular ligament, the tibionavicular ligament and the posterior tibiotalar ligament. This approach could help to improve the understanding of adult-acquired flatfoot deformity (AAFD).

Quantitative Analysis of Deltoid Ligament Degradation in Patients With Chronic Ankle Instability Using Computed Tomographic Images.

Rotational ankle instability (RAI) is associated with the faster onset of severe ankle osteoarthritis via dysfunction of the anterior talofibular ligament, calcaneofibular ligament, and deltoid ligament. No specific clinical examination is available for RAI, and diagnostic imaging has limitations in evaluating ligament degradation. This study investigated the deltoid ligament degeneration using Hounsfield unit (HU) values on computed tomography (CT) images. Patients were enrolled in this retrospective analysis if they had undergone magnetic resonance imaging (MRI) and CT scans of the ankle. The chronic ankle instability (CAI) group comprised 20 ankles with CAI (9 men, 11 women; mean age, 28.7 years) and the control group comprised 28 ankles (16 men, 12 women, mean age, 41.3 years). The average HU values of the deep posterior tibiotalar ligament (dPTL) that constitutes the deltoid ligament were measured on coronal CT images, and MRI results were used as a reference. All patients were subdivided based on the MRI findings of dPTL injury such as fascicular disruption, irregularity, and the loss of striation. A strong negative correlation was identified between age and HU values for all patients (Spearman ρ = -0.63; P < .001). The mean HU values of the dPTL for participants aged <60 years were 81.0 HU for the control group (21 ankles) and 69.5 HU for the CAI group (P = .0075). No significant differences in the HU values were observed for the dPTL among the MRI subgroups. In addition to the conventional imaging examination such as stress radiographs and MRI, HU measurements of CT images could be useful for quantitatively and noninvasively evaluating degenerative changes in the deltoid ligament for CAI patients to assist the diagnosis of RAI. Level III. case-control study.

Quantitative Analysis of the Deltoid Ligament Degradation in Chronic Ankle Instability Patients using the CT Value

Category:Ankle; OtherIntroduction/Purpose:Chronic lateral ankle instability (CLAI) that is developed after multiple lateral ankle ligament injury lead to ankle osteoarthritis. Although isolated deltoid ligament injury is rare compared to lateral ankle ligament injury, deltoid ligament tear, especially deep posterior tibiotalar ligament (PTT) can be observed arthroscopically in CLAI patients. Unphysiological loading of the ankle joint with CLAI might cause degradation of the deltoid ligament. This study aimed to investigate image findings of the deltoid ligament using computed tomography (CT) value for quantitative analysis of degenerative ligament changes in CLAI patients.Methods:Among the enrolled patients who underwent ankle magnetic resonance imaging (MRI) and CT scans of the ankle, this retrospective analysis included 24 ankles without ankle osteoarthritis, osteochondral lesion of the talus (OLT), flatfoot and ankle fractures (14 males and 10 females; mean age, 42.8 years) as a control group, and 14 CLAI ankles without OLT (7 males and 7 females; mean age, 31.1 years) as CLAI group. The CT scans were performed using a 64-slice multidetector row CT. Deep PTT was detected on coronal T2-weighted MR images. Both the coronal MR and CT images were matched for analysis, then average CT values were measured using the region of interest that was applied to the detected area of deep PTT on the CT images.Spearman’s correlation coefficient was used to evaluate the correlation between age and CT value in the control group.Results:The strong negative correlation was identified between age and CT value in the control group (Spearman ρ= -0.88; p< 0.001). The CT value of the deep PTT are degraded with aging. Mean CT value of deep PTT in participants under 60 years old were 79.9 HU (95% CI, 75.1-84.8) in the control group (18 ankles), and 66.5 HU (95% CI, 58.6-74.5) in the CLAI group (14 ankles) (Welch’s t test; p = 0.005).Conclusion:MRI techniques and protocols recently have been developed, however, some limitations remain such as a quantitative evaluation of the ligament. Our findings suggest that the CLAI can lead to degradation of the deltoid ligament via an overloading of medial ankle structures. Additionally, CT values should be useful for quantitatively evaluating ligament status including degenerative changes.

Weightbearing Radiography and MRI Findings in Ankle Fractures.

Background. Static weightbearing radiography can be used to assess stability in ankle fractures by measuring lateral talar shift (medial clear space; MCS). However, the correlation of a stable ankle joint under weightbearing load and the structural integrity of the deltoid ligament has not been shown. In this study, we assessed deltoid ligament integrity on magnetic resonance imaging (MRI) and correlated that with weightbearing and gravity stress test radiography. Methods. Thirty-four patients with supination external rotation II-IV (SER) fractures underwent MRI, weightbearing radiography, and gravity stress test. On MRI, the deep anterior and posterior tibiotalar deltoid, tibionavicular and tibiocalcaneal ligaments, as well as the syndesmosis were assessed as intact, partial rupture, or complete rupture. The MCS was measured as the distance between the lateral border of the medial malleolus and the medial border of the talus at the level of the talar dome on the mortise view. Results. Twenty-three patients suffered a deep anterior tibiotalar ligament rupture (16 partial; 7 complete) and 2 a deep posterior tibiotalar ligament tear (1 partial; 1 complete). For MCS on weightbearing radiography, no statistically significant differences were identified between any of the individual groups. With gravity stress radiography, only a complete tear of the tibiocalcaneal ligament showed a significantly higher MCS than a partial tear or intact tibiocalcaneal ligament (P < .005). No other ligament disruption showed a significant difference between the complete rupture versus intact or partial tear. Conclusion. Weightbearing radiography does not show much variation in terms of MCS even with ligamentous disruption and fibula fracture. The talus often centers itself underneath the tibia with weightbearing radiography.Levels of Evidence: Level III: Retrospective cohort study.

Strain pattern of each ligamentous band of the superficial deltoid ligament: a cadaver study

BackgroundThere are few reports on the detailed biomechanics of the deltoid ligament, and no studies have measured the biomechanics of each ligamentous band because of the difficulty in inserting sensors into the narrow ligaments. This study aimed to measure the strain pattern of the deltoid ligament bands directly using a Miniaturization Ligament Performance Probe (MLPP) system.MethodsThe MLPP was sutured into the ligamentous bands of the deltoid ligament in 6 fresh-frozen lower extremity cadaveric specimens. The strain was measured using a round metal disk (clock) fixed on the plantar aspect of the foot. The ankle was manually moved from 15° dorsiflexion to 30° plantar flexion, and a 1.2-N-m force was applied to the ankle and subtalar joint complex. Then the clock was rotated every 30° to measure the strain of each ligamentous band at each endpoint.ResultsThe tibionavicular ligament (TNL) began to tense at 10° plantar flexion, and the tension becomes stronger as the angle increased; the TNL worked most effectively in plantar flex-abduction. The tibiospring ligament (TSL) began to tense gradually at 15° plantar flexion, and the tension became stronger as the angle increased. The TSL worked most effectively in abduction. The tibiocalcaneal ligament (TCL) began to tense gradually at 0° dorsiflexion, and the tension became stronger as the angle increased. The TCL worked most effectively in pronation (dorsiflexion-abduction). The superficial posterior tibiotalar ligament (SPTTL) began to tense gradually at 0° dorsiflexion, and the tension became stronger as the angle increased, with the SPTTL working most effectively in dorsiflexion.ConclusionOur results show the biomechanical function of the superficial deltoid ligament and may contribute to determining which ligament is damaged during assessment in the clinical setting.

The tibiocalcaneal bundle of the deltoid ligament – Prevalence and variations

IntroductionA precise understanding of the anatomy of the multiple bundles of the deltoid ankle ligament might have clinical impact. The most relevant deltoid anatomical series report a variable frequency of the tibiocalcaneal ligament, possibly the most important bundle to be reconstructed in medial ankle insufficiency. Our purpose was to access the deltoid's tibiocalcaneal ligament morphology in a large anatomical study as well as to perform a historical literature review on the reasons for its variable prevalence. Materials and methodsForty-three ankle specimen were dissected to describe the prevalence of superficial and deep deltoid bundles, with special attention to the tibiocalcaneal ligament and its variants. ResultsAll ankles had distinct deep and superficial bundles. In all 43 ankles the tibionavicular and tibiospring ligaments were clearly identified. The superficial posterior tibiotalar ligament was identified in 38 ankles (88%). The deep anterior tibiotalar bundle was identified in 35 ankles (81%). The deep posterior tibiotalar bundle was identified in all ankles. The tibiocalcaneal ligament was identified in 33 ankles (77%). In ten ankles there wasn’t a direct bundle between the tibia and the sustentaculum tali. In all of these, however, we found some fibers spanning the gap between the tibiospring ligament and the sustentaculum tali. ConclusionThe tibiocalcaneal ligament is present in most specimens. In those in which we could not identify a direct bundle between the tibia and the calcareous we found a variant of the tibiospring ligament that connects to the sustentaculum tali.

Pseudo-tear appearance of the posterior tibiotalar ligament on fluid-sensitive sequences.

This study aimed at studying the MR imaging appearance of the tibiotalar ligament in asymptomatic volunteers. Fourty-two ankles were imaged on a 3T MR system using proton density weighted images with fat saturation (TR, 2969ms; TE 30ms; NA, 2; slice thickness, 2.5mm). Subjects with acute ankle conditions or history of previous trauma were not included in the study group. Images were obtained in the three orthogonal planes. The posterior tibiotalar ligament was assessed on coronal imaging, by consensus of two radiologists. The signal intensity was recorded as isointense, hypointense, or hyperintense relative to muscle. The morphology of the ligament was classified as homogenous or striated. Descriptive statistics were obtained. There were 8 men and 14 women with a mean age of 24.7years (range 19-43years). The ligaments were classified as hyperintense in 30/42 (70%) of ankles and isointense in 9/42 (21%) of ankles. A striated appearance was seen in 34/42 (80%) of ankles. The posterior deep deltoid ligament is commonly hyperintense. It is usually striated although it can be homogeneously hyperintense. This appearance simulates a tear.

The Morphology and Prevalence of the Deltoid Complex Ligament of the Ankle.

Systematic review of level III studies: prospective studies.

Morphological variations of the deltoid ligament of the medial ankle.

Morphological variations of the deltoid ligament were investigated in this study, with the aim of classifying the different types on the basis of their components. Sixty ankles from 39 cadavers were dissected. The origin and insertion sites of the deltoid ligament were identified, and its length, width, and thickness were measured. The deltoid ligament was divided into two layers, superficial and deep, which respectively comprised four components (tibionavicular, tibiospring, tibiocalcaneal, and superficial posterior tibiotalar ligaments) and two components (anterior tibiotalar and deep posterior tibiotalar ligaments). The tibiospring and tibiocalcaneal ligaments were found in 100% of the specimens, while the prevalence rates of other components lay within the range 63.3-96.7%. The tibionavicular and deep posterior tibiotalar ligaments were the thinnest and thickest, respectively, while the other ligaments had similar thicknesses. The deltoid ligament was classified into types I-IV according to the combinations of these components: all components were present in type I (48.3%), the tibionavicular ligament was absent in type II (36.7%), only the superficial posterior tibiotalar ligament was absent in type III (6.7%), and only the anterior tibiotalar ligament was absent in type IV (8.3%). In conclusion, these results improve knowledge of the morphological and morphometric characteristics of the deltoid ligament and thus provide helpful information for surgical procedures in this region. Clin. Anat. 29:1059-1065, 2016. © 2016 Wiley Periodicals, Inc.

Medial Collateral Ligament Complex of the Ankle: MR Imaging Anatomy and Findings in Medial Instability.

Ankle ligament injuries are among the most common injuries in sports and recreational activities. Injuries of the medial collateral ligament or deltoid ligament complex account for ∼ 15% of ligamentous ankle trauma. They are usually associated with injuries of the lateral collateral ligaments and the tibiofibular syndesmosis, as well as malleolar fractures. The deltoid ligament complex consists of a superficial and a deep layer. The three main components of the superficial layer are the tibionavicular, tibiospring, and tibiocalcaneal ligaments. The deep layer is composed of the anterior and posterior tibiotalar ligaments; the latter is the strongest ligament of the whole complex. In approximately half of patients, injuries of the superficial layer are associated with a lesion of the posterior tibiotalar ligament (pTTL), whereas in contradistinction most injuries to the pTTL are associated with lesions of the superficial layer. The most common location of injuries to the superficial layer is at the tibial periosteal attachment with partial discontinuity, delamination, or a complete tear with or without lesions of the flexor retinaculum. Lesions of the pTTL are often midsubstance. In chronic lesions a distorted and thickened superficial layer at the tibial insertion with periosteal reaction and bony spurs is usually visible. The scarred pTTL shows loss of normal striation. In chronic stages of pTTL lesions, volume loss is typically seen. Associated periosteal spurs and intraligamentous ossicles are common. In late stages, tibiotalar valgus with osteoarthritic changes of the ankle will develop.

Radiographic Identification of the Deltoid Ligament Complex of the Medial Ankle

Background: An injury to the deltoid ligament complex of the ankle can require surgical intervention in cases of chronic instability. There is an absence of data describing medial ankle ligament anatomy on standard radiographic views. Purpose: To quantitatively describe the anatomic origins and insertions of the individual ligamentous bands of the superficial and deep deltoid on standard lateral and mortise radiographic views with reference to osseous landmarks and anatomic axes. Study Design: Descriptive laboratory study. Methods: Twelve nonpaired, fresh-frozen cadaveric foot and ankle specimens were utilized. Specimens were dissected free of all overlying soft tissue to identify individual ligamentous bands of the superficial and deep deltoid ligaments and to isolate their distinct origins and insertions. Footprint centers were identified on standard lateral and mortise radiographs by 2-mm stainless steel spheres embedded at the level of the cortical bone. Distances to osseous landmarks were measured independently by 2 blinded reviewers to calculate mean distances and evaluate reliability and repeatability measures using intraclass correlation coefficients. Results: Varying subsets of the 4 superficial deltoid bands including the tibionavicular (12/12), tibiospring (12/12), tibiocalcaneal (9/12), and superficial posterior tibiotalar (9/12) ligaments were found across specimens. On the lateral view, the tibionavicular ligament was the most anterior and attached 7.6 ± 1.9 mm superior and anterior to the inferior tip of the medial malleolus. The tibiospring ligament attached 12.1 ± 2.2 mm superior and anterior to the inferior tip of the medial malleolus and attached to the spring ligament, which coursed from its origin 12.3 ± 1.6 mm anterior and slightly inferior to the posterior point of the sustentaculum tali to its insertion on the navicular tuberosity. The tibiocalcaneal ligament and superficial posterior tibiotalar ligament were found posteriorly in the majority of specimens. Two constituents of the deep deltoid, including the deep anterior tibiotalar (11/12) and deep posterior tibiotalar (12/12) ligaments, were found in the majority of specimens. The deep posterior was larger and coursed from the tibia, 8.1 ± 2.2 mm posterior and superior to the inferior tip of the medial malleolus, to its attachment on the talus, 15.5 ± 2.4 mm superior and anterior to the posterior inferior point of the talus on the lateral view. Conclusion: Quantitative radiographic relationships describing the anatomic origins and insertions of the individual superficial and deep deltoid constituents were defined with excellent reliability and reproducibility. Clinical Relevance: Radiographic parameters will augment current anatomic data by assisting with preoperative planning, intraoperative guidance, and postoperative assessment. These radiographic guidelines will facilitate the development of novel anatomic reconstructions and allow surgeons to plan the locations of reconstruction tunnels.