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Ultrasound-Guided Ankle Lateral Ligament Stabilization

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DOI: 10.1007/s12178-019-09592-0

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Ultrasound-Guided Ankle Lateral
Ligament Stabilization

Soichi Hattori, Carlo Antonio

D. Alvarez, Stephen Canton, Macalus
V. Hogan & Kentaro Onishi

Current Reviews in Musculoskeletal

Medicine

e-ISSN 1935-9748

Curr Rev Musculoskelet Med

DOI 10.1007/s12178-019-09592-0

1 23
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 Author's personal copy
Current Reviews in Musculoskeletal Medicine
https://doi.org/10.1007/s12178-019-09592-0

MANAGEMENT OF ANKLE INSTABILITY (M HOGAN, SECTION EDITOR)

Ultrasound-Guided Ankle Lateral Ligament Stabilization

Soichi Hattori 1,2 & Carlo Antonio D. Alvarez 1 & Stephen Canton 3 & Macalus V. Hogan 3 & Kentaro Onishi 3,4

# Springer Science+Business Media, LLC, part of Springer Nature 2019

Abstract
Purpose of Review Ultrasound (US) is an increasingly popular imaging modality currently used both in clinics and operating
rooms. The purpose of this review is to appraise literature describing traditional lateral ankle stabilization techniques and discuss
potential advantages of US-guided ankle lateral ligament stabilization. In addition, albeit limited, we will describe our experi-
ences in perfecting this technique.
Recent Findings To date, the modified open Broström-Gould technique remains as the gold standard surgical treatment for
chronic ankle instability (CAI). In the past decade, modifications of this technique have been done, from a combination of
arthroscopic and open procedure to an all-inside arthroscopic technique with a goal of minimizing wound complications, better
outcomes, and earlier return to activity. Recently, the use of US as an adjunct to surgical procedures has gained popularity and
several novel techniques have been described. The use of US in lateral ankle stabilization could allow accurate placement of the
suture anchor at the anatomical attachment of the anterior talofibular ligament (ATFL) without iatrogenic damage to the
neurovascular structures such as anterolateral malleolar artery, superficial peroneal nerve, and sural nerve.
Summary In summary, the use of US in ankle lateral ligament stabilization is a promising new micro-invasive technique. The
theoretical advantages of US-guided ankle lateral ligament stabilization include direct visualization of desired anatomical land-
marks and structures which could increase accuracy, decrease iatrogenic neurovascular damage, minimize wound complications,
and improve outcomes.

Keywords Ultrasound . Ultrasound-guided surgery . Chronic ankle instability . Lateral ligament stabilization

Introduction ankle has three main structures: the anterior talofibular

ligament (ATFL), calcaneofibular ligament (CFL), and
Ankle sprains comprise 85% of all ankle injuries and are posterior talofibular ligament (PTFL) [1•, 2]. A recent
the most common injury accounting for 14–21% of all anatomic study by Vega et al. proposed the presence of
sports injury. The lateral ligament complex (LLC) of the the lateral fibulotalocalcaneal ligament complex which
connects ATFL and CFL as a stabilizing structure of the
This article is part of the Topical Collection on Management of Ankle lateral ankle [3••]. Tearing, stretching, and recurring
Instability sprains of these ligaments can result in chronic ankle in-
stability (CAI). The ATFL is involved in 90% of all lateral
* Soichi Hattori
sprains, whereas the CFL is involved in 50 to 75% of
[email protected]
these sprains and the PTFL less than 10%. Conservative
treatment with functional rehabilitation therapy remains as
1
Department of Sports Medicine, Kameda Medical Center, 929 the standard of care for acute ankle sprains [1•, 2].
Higashi-cho, Kamogawa City, Chiba Prefecture 2968602, Japan
Approximately 74% of acute ankle sprains result in per-
2
Department of Clinical Anatomy, Graduate School of Medical and sistent symptoms, 30% of which progress to CAI [4••].
Dental Sciences, Tokyo Medical and Dental University,
Tokyo, Japan CAI is defined as the perception of recurring “giving
3 way” of the ankle accompanied with a plethora of symp-
Department of Orthopedic Surgery, University of Pittsburgh School
of Medicine, Pittsburgh, PA 15213, USA toms including recurrent sprains, pain with activity, swell-
4 ing, difficulty walking on uneven ground, and avoidance
Department of Physical Medicine and Rehabilitation, University of
Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA of activities leading to persistent disability [1•, 2, 4••].
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Curr Rev Musculoskelet Med

Surgical intervention may be warranted when patients with use [19–23]. The evolution of US-guided surgical techniques
CAI fail to improve with conservative treatment. Many surgi- has been described, from procedures where US is utilized to
cal techniques to stabilize the LLC have been proposed. These guide a conventional needle to perform traditional surgical
procedures are categorized into non-anatomic and anatomic procedures percutaneously, to US-guided procedures wherein
repair or reconstruction. Early surgical techniques were non- special needles or devices are used to cut or release the target
anatomic reconstruction of the LLC proposed by Evans, structures. Several authors continue to describe novel US-
Chrisman-Snook, Watson-Jones, and Castaing [1•, 5–7•]. guided micro-invasive surgical techniques in the upper and
These techniques required peroneal tendons to be sacrificed lower extremities [24–33]. Although there are no English pub-
and used as grafts to restore ankle stability. However, the lications describing repair or reconstruction procedures that
results were suboptimal both from clinical and biomechanical have been completely converted to US-guided procedure,
standpoints, with recurrent instability due to altered ankle bio- some novel techniques have been reported such as US-
mechanics, persistent pain, and stiffness [5–7•]. Anatomic guided percutaneous mini-open repair of the Achilles tendon
open surgical technique was later developed by Broström, [34, 35•] and medial patellofemoral ligament (MPFL) [36].
wherein the native ATFL and CFL were imbricated together Recent systematic reviews have shown that US is a valu-
with ankle joint capsule [7•]. Gould later modified this proce- able diagnostic tool for detecting CAI, ATFL injuries in par-
dure by adding the inferior extensor retinaculum (IER) as part ticular [4••, 37, 38•]. However, to the best of our knowledge,
of the repair [8, 9]. The simplicity of the procedure and resto- previous studies regarding US-guided repair or reconstruction
ration of physiologic joint anatomy and kinematics offered techniques of the LLC of the ankle are limited. The purpose of
better outcomes and patient satisfaction compared to non- this review is to appraise literature describing traditional later-
anatomic techniques. Thus, the modified open Broström- al ankle stabilization techniques and discuss potential advan-
Gould technique remains the gold standard surgical treatment tages of US-guided ankle lateral ligament stabilization. In ad-
for CAI to date [1•, 6, 8, 9]. In recent years, arthroscopic ankle dition, albeit limited, we will describe our experiences in
evaluation has been routinely performed followed by open perfecting this technique.
procedures. Arthroscopic evaluation is performed in order to
address simultaneous intra-articular pathological entities such
as impingement lesions, ankle synovitis, intra-articular loose US-Guided Ankle Lateral Ligament
bodies, talar osteochondral lesions, and medial ankle tenosyn- Stabilization
ovitis [10–12]. Subsequently, physicians moved toward ar-
throscopic evaluation with mini-open repair of lateral liga- Theoretical Advantages
ments utilizing staples, suture anchors, thermal shrinkage,
and plication. Recently, completely arthroscopic or “all-in- A recent meta-analysis of arthroscopic and open repair of
side” techniques have been developed and the use of these ankle lateral ligament showed that overall complication rate
procedures has been rapidly increasing [11, 13, 14]. of arthroscopic repair of ankle lateral ligament was 10.3% and
Musculoskeletal ultrasound (MSK US) represents a cost open repair complication rate was 10.0%. With open repair,
effective, readily-available imaging modality that are both di- the nerve complication rate was 4.5% and the wound compli-
agnostic and interventional [15–18•]. Interventional US refers cation rate was 3.6%. Meanwhile, they were 5.2% and 0%
to the use of a real-time guidance in order to perform various with arthroscopic repair respectively. The other complications
procedures such as local injections, aspirations, or biopsies. In in arthroscopic repair included persistent pain, wound/scar
some places, US guidance is used in place of conventional pain, and deep venous thrombosis (DVT) [7•]. Most of the
operative procedures. To distinguish these from arthroscopic nerve complications involve the superficial peroneal nerve
procedures which are frequently referred to as “minimally (SPN) and its branches [7•]. A cadaveric study done by Pitts
invasive,” these US-guided surgical procedures are sometimes et al. suggested that sural nerve as well as SPN were the
referred to as micro-invasive surgery [15, 17]. Once one is anatomical structures at greatest risk during arthroscopic
familiar with regional anatomy, or sono-anatomy, micro- Bronström procedure [39]. With US guidance, both SPN
invasive surgical procedures appear to be as safe as their con- and sural nerve are made visible, and iatrogenic damage to
ventional alternates. In theory, a real-time visualization of vital these nerves could be avoided. The use of US to determine the
structures in the region affords added safety and accuracy course of the SPN was shown to be better than gross
compared to conventional surgery where visualization of visualization/palpation in a cadaver study [40•]. Also, we
these structures is not possible. In addition to being less inva- could possibly reduce wound complication rate with “micro-
sive, existing micro-invasive surgeries are generally per- invasive” nature of US-guided lateral ligament stabilization
formed faster due to the use of local anesthetic as opposed to with one 5-mm incision.
regional or general. Therefore, some micro-invasive surgeries Some authors pointed out that anchor insertion in arthro-
result in a faster recovery and a reduction of pain medication scopic procedures was often placed proximal to the
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Curr Rev Musculoskelet Med

anatomical ATFL attachment site of the fibula [41, 42••]. artery, which is often called the anterior lateral malleolar artery
Teramoto et al. showed in their cadaveric study that the dis- and provides vascular supply to the ATFL [47•, 48], is identi-
tance of markings made at the distal margin of the lateral fied with color doppler mode (Fig. 1c). The CFL is evaluated
malleolus under arthroscopy was 7–10 mm away from the in a prone position with the ankle maximally dorsiflexed. The
center of the ATFL attachment site [42••]. In our retrospective US probe is placed on the oblique coronal plane to visualize
analysis of 22 procedures of lateral ligament repair of the the long-axis view of the CFL for thickness, echogenicity, and
ankle, the distance of anchor placement from the anatomical continuity (Fig. 2) [49•]. In the CFL with normal tension, the
ATFL attachment site in the US-guided procedure was non- peroneal tendons are elevated toward the probe during
inferior to open procedures. With the fibular obscure tubercle dorsiflexion of the ankle [50]. US-guided lateral ligament sta-
(FOT) as a reference point, the mean distance between the bilization is considered if any pathologic finding is detected in
anchor and FOT was 6.0 ± 2.7 mm in open procedures, and ATFL and/or CFL by US (Fig. 3), and patients experience
7.4 ± 2.5 mm in the US-guided procedure respectively. The recurrent instability after intensive functional rehabilitation.
mean differences between the two techniques (open-US
guided) were − 1.5 mm (95% confidence interval 1.0 to −
3.9). The confidence interval was smaller than the non- Surgical Technique
inferiority margin (4 mm) [43••]. Thus, US-guided anchor
placement could be more anatomically accurate than the con- The patient is placed in a supine position with the affected leg
ventional arthroscopic Broström procedure. internally rotated. A bump is placed under the buttocks to keep
the leg internally rotated. A sterilized wedge surgical cushion
US Evaluation Protocol for Lateral Ligament Complex is placed under the calf as a counter during distraction when
(LLC) of the Ankle arthroscopic procedures for intra-articular lesions are per-
formed. Standard high frequency linear transducers (>
After acute ankle lateral ligament injury, the initial treatment is 12 MHz) or hockey stick probes are used. It is easier to per-
usually conservative, such as functional rehabilitation [1•, 2]. form this procedure with the hockey stick probe because of its
An incidence of 5 to 33% of patients experience pain and superior controllability and visualization of the ATFL and
instability after ankle sprain [44]. Surgical management is anterior lateral malleolar artery. In a case of severe mechanical
warranted in these situations. The investigators of CAI de- instability (namely, both ATFL and CFL are abnormal), how-
scribed two subgroups: mechanical instability and functional ever, standard linear transducers are employed to visualize the
instability. Mechanical instability is thought to result from sinus tarsi as well as the ATFL to place multiple sutures.
various anatomic changes that may exist in isolation or in
combination such as laxity caused by ligament tears. These 1. The tibiotalar joint is then infiltrated using 20 cc of epi-
changes are proposed to lead to insufficiencies that predispose nephrine or lidocaine with epinephrine while visualizing
the person to further episodes of instability. Functional insta- the long axis of the ATFL with out-of-plane technique
bility is proposed to result from functional insufficiencies such with 25G needle. The local infiltrates such as epinephrine
as impaired proprioceptive and neuromuscular control after and lidocaine allow us to improve the visualization of the
ankle sprain. Both mechanical and functional instabilities are ATFL with US by separating the ATFL from surrounding
difficult to distinguish as they often occur in combination tissues.
during the development of CAI [2, 45]. The former is evalu- 2. While visualizing the ATFL in a long-axis view, a large
ated with physical examinations and imaging modalities in- spinal needle with a curved tip such as the Micro
cluding US, and sometimes requires surgical stabilization. SutureLasso™ minor bend (Arthrex, Florida) is passed
The latter is managed with functional rehabilitation, which under the ATFL with out-of-plane technique (Fig. 4a, b),
addresses impaired proprioception and incoordination of dy- paying attention to the anterior lateral malleolar artery.
namic stabilizers of ankle. Once the needle tip becomes visible below the ATFL,
During the US evaluation of the mechanical instability of the probe is rotated 90° to scan the short-axis view of
the ATFL, the patient assumes a sitting position with the heel ATFL, and then the needle is advanced just proximal to
of the injured ankle hanging on the edge of examination bed peroneal tendons (Fig. 4c, d). By passing the needle below
[46•] or examiner’s knee. The ankle is maintained in the nat- ATFL and perpendicular to the long axis of the ATFL
urally plantarflexed (30 to 40°) position. The probe is placed under US guidance, we place sutures in the same manner
at the distal edge of the lateral malleolus almost in parallel as the arthroscopic all-inside ATFL repair technique
with the sole. In this position, a long-axis view of ATFL can [51••]. The needle position should be in close proximity
be visualized, and the weight of the lower limb can place the to the peroneal tendons, which enables us to pass sutures
ankle in the anterior drawer stress to evaluate mechanical in- into the lateral fibulotalocalcaneal ligament complex [3••]
stability (Fig. 1a–d) [46•]. The anterior branch of the peroneal to lift up elongated ATFL.
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Curr Rev Musculoskelet Med

Fig. 1 Ultrasound (US) evaluation of the anterior talofibular ligament doppler mode (white arrow). In order to obtain clear vascular images, we
(ATFL) in left ankle. a The patient assumes a sitting position with the should avoid excessive compression of the artery or vein by the
heel of the injured ankle hanging over the examiner’s knee. The probe is transducer. d Under the anterior drawer stress by the weight of the
placed at the distal edge of the lateral malleolus almost in parallel with the lower limb and the examiner’s hand, the ATFL is stretched (white
sole. b A long-axis view of the ATFL is visualized (white arrowheads). c arrowheads) with a clear fibrillar pattern
The anterior lateral malleolar artery is identified next to vein with color

3. Also, the sural nerve can be avoided since it runs distal to no. 11 blade is made 45° to the long axis of the
the peroneal tendons. The wire of the Micro fibula and 1 cm distal-medial to the anatomical at-
SutureLasso™ is deployed after the needle tip penetrates tachment of the ATFL. Blunt dissection with a mos-
the subcutaneous tissue and skin. The second wire can quito forceps is carried down to the intra-articular
then be placed along with the long axis of ATFL under area between the fibula and talus (Fig. 5a, b). A
US guidance, again attempting not to damage the anterior suture anchor is placed at the anatomical attachment
lateral malleolar artery. of the ATFL after bringing the outer trocar to the
4. After confirming a bony landmark of the fibular attachment of the ATFL under US guidance (Fig.
attachment of the ATFL, a 5-mm skin incision with 5c–e).

Fig. 2 Ultrasound (US) evaluation of the calcaneofibular ligament (CFL) the ankle in maximum dorsiflexion, both fibula and calcaneal fibers of the
in right ankle. a The CFL is evaluated with the patient in prone position CFL can be visualized (white arrowheads). c With the ankle in
with the ankle in maximum dorsiflexion. The probe is placed anterior to plantarflexion, only the calcaneal fibers of the CFL are visible (white
the tip of the fibula toward calcaneal tuberosity. Anatomic studies have arrowheads). Peroneal tendons are also visible above the CFL
suggested that the calcaneal attachment of the CFL has variations. b With
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Fig. 3 Ultrasound (US) images of pathological anterior talofibular calcaneal footprint (yellow double arrow) is increased under anterior
ligament (ATFL) and calcaneofibular ligament (CFL) in chronic ankle drawer stress. c A long-axis view of hypoechoic and thick CFL (white
instability (CAI). a A long-axis view of hypoechoic ATFL (white arrowheads) is visualized. Only calcaneal fibers of the CFL
arrowheads) without clear fibrillar pattern is visualized. b Under below peroneal tendons (P) are assessed in plantarflexion. d Under
anterior drawer stress, no fibrillar pattern of elongated ATFL becomes maximum dorsiflexion, the fibular fibers of the CFL (white arrowheads)
apparent. The distance between intra-articular fibular footprint and become visible, yet no fibrillar pattern is apparent

5. The proximal and distal limbs of the wire are retrieved or without a knot pusher or the lasso loop stitch technique
subcutaneously with a grasper through the anchor inci- [52•] is performed for tensioning the LLC with the ankle
sion. After suture relay, a simple interrupted suture with in a neutral position.

Fig. 4 Ultrasound (US)-guided passing of the needle into the lateral 90° and a short axis of the ATFL (yellow arrowheads) is visualized. The
ligament complex of right ankle. a, b A large spinal needle with a needle is advanced below the ATFL just proximal to the peroneal tendons
curved tip (yellow arrow) such as the Micro SutureLasso™ minor bend (P). Theoretically, the needle tip could reach the lateral
(Arthrex, Florida) is introduced below the ATFL (white arrowheads) in a fibulotalocalcaneal ligament complex which connect ATFL and CFL
long-axis view with out-of-plane technique while paying attention to the fibers
location of anterior lateral malleolar artery. c, d The transduce is rotated
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Curr Rev Musculoskelet Med

Fig. 5 Sonographically guided fibular anchor placement. a, b The mosquito forceps is carried down to the intra-articular area between the
anatomical attachment of the ATFL (white arrowheads) with a unique fibula and talus. c After bringing the outer trochar to the anatomical
angular shape at fibula is confirmed. After a 5-mm skin incision with attachment of ATFL under US guidance, we fix it with a hammer. d A
no. 11 blade is made 45° to the long axis of the fibula and 1 cm distal- small hole is made via the outer trochar by a drill. e A suture anchor is
medial to the anatomical attachment of the ATFL. Blunt dissection with a placed at the anatomical attachment of the ATFL

6. Additional arthroscopic procedures are necessary in cases applying the tension to the LLC. The suture wires can
of anterior impingement due to osteophytes and soft tis- be visualized with arthroscopy 100% of the time, but the
sues, osteochondritis dissecans, and synovitis before suture anchors are rarely visible since it is difficult to

Fig. 6 Arthroscopic view of the wire and suture anchors in ultrasound anchor (yellow arrow) was visible under arthroscopy at the distal
(US)-guided lateral ligament stabilization. a The wire, which is placed margin of the fibula. b) A postoperative computed tomography (CT)
under US guidance, can be visualized over the ATFL under arthroscopy showed two anchors. The proximal anchor (yellow arrow) was visible
without fail. In contrast, a suture anchor is rarely visible under under arthroscopy. The distal anchor (black arrow), which was placed at
arthroscopy. In the current case, we placed two anchors under US the center of the anatomical attachment of the fibula under US guidance,
guidance: one at the anatomical footprint of the ATFL, the other placed was not visible under arthroscopy
proximally to the anatomical footprint. Only the proximally placed
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Curr Rev Musculoskelet Med

visualize the center of anatomical footprint of the ATFL References

under arthroscopy guidance [42••] (Fig. 6).
Papers of particular interest, published recently, have been
highlighted as:
• Of importance
•• Of major importance
Rehabilitation
1.• Porter D, Kamman K. Chronic lateral ankle instability: open
Despite micro-invasive nature of this procedure, rehabilitation surgical management. Foot and Ankle Clin N Am. 2018;23:
539–54 Anatomic ligament repair/reconstruction with pa-
program is similar to that of conventional arthroscopic and
tient satisfaction rates more than 90%, the most popular-
open stabilization since the time period required for biological ized technique, the modified Brostrom is routinely consid-
healing process would be the same. It consists of three phases: ered the first-line treatment of CLAI. We prefer the open
phase 1 (0–4 weeks) focuses on restoring full range of motion approach with the use of bone tunnels with an absorbable
suture (BT) rather than suture anchors (SAs). A recent level
with a brace after weaning off crutches and splint in 2 weeks;
II prospective cohort study comparing BT and SA tech-
phase 2 (4–8 weeks) focuses on restoring strength and propri- niques in 81 patients undergoing the modified Brostrom
oception in the brace; phase 3 (8–12 weeks) focuses on procedure demonstrated similar outcomes.34 The mean
implementing a sport-specific functional progression pro- Karlsson scores, American Orthopedic Foot and Ankle
gram, starting with jogging and ending up with return to sport Society scores, anterior talar translation, and talar tilt im-
proved significantly with both procedures after interven-
or work-related activity by the end of phase 3 [1•]. tion. There were no significant differences between the two
cohorts, yet there was a clear trend in preoperative scores
favoring the SA group over the BT group, suggesting the
Limitations BT patients had more attenuated ligaments preoperatively.
Associated pathology (defined as synovitis, OCL of talus,
anterior bony impingement, loose body, and ossicles at the
US-guided procedures are operator-dependent; thus, the phy- lateral malleolus) occurred in 53% of BT patients and 63%
sicians should be skilled in handling and operating US ma- of SA patients. SA displacement, breakage, and pullout
chines. Also, US view is limited to superficial structures of the have all been reported in the literature35; but these compli-
cations that are unique to the SA technique were not inves-
ankle; therefore, if additional intra-articular pathologic is pres- tigated in this study. Indeed, one disadvantage of SAs is the
ent, they cannot be appreciated or treated using US only. unique complications that are inherent to its use. For these
reasons, as well as the cost of SA and the ease of using BT,
we advocate the use of bone tunnels for our open approach
BLAR. In overview, the BLAR operative technique begins
with diagnostic arthroscopy using anterolateral and
Conclusions anteromedial portals (and other auxiliary portals as need-
ed) and after appropriately evaluating for and treating
Ultrasound is a useful adjunct to traditional surgical pro- intra-articular pathology, finishes with an open modified
Brostrom ligament reconstruction using bone tunnels.
cedures for CAI. With US guidance, direct visualization Arthroscopy time should be minimized to limit soft tissue
of desired ankle anatomical landmarks and structures edema and induration.
could increase accuracy, thus reducing surgical time, de- 2. Hong C, Tan KJ. Concepts of ankle instability: a review. OA Sports
creasing the incidence of iatrogenic damage to Medicine. 2014;2(1):3.
3.•• Vega J, Malagelada F, MCM C, Dalmau-Pastor M. The lateral
neurovascular and other soft tissue structures, minimizing fibulotalocalcaneal ligament complex: an ankle stabilizing iso-
wound complications, and improving outcomes. Despite metric structure. Knee Surg Sports Traumatol Arthrosc. 2018.
the steep learning curve, fundamental knowledge in the https://doi.org/10.1007/s00167-018-5188-8 The purpose of
use of US equipment and knowledge of the anatomy of this study was to describe in detail the components of the
lateral collateral ligament complex—ATFL and CFL—and
lateral ankle make ultrasound-guided ankle lateral liga- determine its anatomical relationships. Methods An ana-
ment stabilization reproducible. tomical study was performed in 32 fresh-frozen below-the-
knee ankle specimens. A plane-per-plane anatomical dissec-
Compliance with Ethical Standards tion was performed. Overdissecting the area just distal to
the inferior ATFL fascicle was avoided to not alter the orig-
inal morphology of the ligaments and the connecting fibers
Conflict of Interest Soichi Hattori, M.D., Carlo Antonio Alvarez, M.D.,
between them. The characteristics of the ATFL and CFL, as
Stephen Canton, M.D., Kentaro Onishi, D.O., and Macalus V. Hogan,
well as any connecting fibers between them were recorded.
M.D. declare that they have no conflict of interest.
Measures were obtained in plantar and dorsal flexion, and
by two different observers. Results. the ATFL was observed
Human and Animal Rights and Informed Consent This article does not as a two-fascicle ligament in all the specimens. The superior
contain any studies with human or animal subjects performed by any of ATFL fascicle was observed intra-articular in the ankle, in
the authors. contrast to the inferior fascicle. The mean distance
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Curr Rev Musculoskelet Med

measured between superior ATFL fascicle insertions in- 6. Cao Y, Hong Y, et al. Surgical management of chronic lateral ankle
creases in plantar flexion (median 19.2 mm in plantar flex- instability: a metanalysis. J Orthop Surg Res. 2018;13:159.
ion, and 12.6 mm in dorsal flexion, p<0.001), while the same 7.• Brown A, Shimozono Y, et al. Arthroscopic versus open repair of
measures observed in the inferior ATFL fascicle does not lateral ankle ligament for chronic lateral ankle instability: a meta-
vary (median 10.6 mm in plantar flexion, and 10.6 mm in analysis. Knee Surg Sports Traumatol Arthrosc. 2018. https://doi.
dorsal flexion, n.s.). The inferior ATFL fascicle was ob- org/10.1007/s00167-018-5100-6. The purpose of this meta-
served with a common fibular origin with the CFL. The analysis was to analyze the current comparative studies of ar-
CFL distance between insertions does not vary with ankle throscopic and open techniques for lateral ankle ligament re-
movement (median 20.1 mm in plantar flexion, and 19. pair to treat chronic lateral ankle instability. Methods. A sys-
9 mm in dorsal flexion, n.s.). The inferior ATFL fascicle tematic search of MEDLINE, EMBASE and Cochrane Library
and the CFL were connected by arciform fibers, that were databases was performed during February 2018. Included
observed as an intrinsic reinforcement of the subtalar joint studies were evaluated with regard to level of evidence and
capsule. Conclusion The superior fascicle of the ATFL is a quality of evidence using the Modified Coleman Methodology
distinct anatomical structure, whereas the inferior ATFL Score. Total number of patients, patient age, follow-up time,
fascicle and the CFL share some features being both isomet- gender ratio, surgical technique, surgical complications, com-
ric ligaments, having a common fibular insertion, and being plication rate, recurrent instability or revision rate, clinical out-
connected by arciform fibers, and forming a functional and come measures and percentage of patients who returned to
anatomical entity, that has been named the lateral sport at previous level were also evaluated. Statistical analysis
fibulotalocalcaneal ligament (LFTCL) complex. The clinical was performed using RevMan, and a p value of < 0.05 was
relevance of this study is that the superior fascicle of the considered to be statistically significant. Results. Four
ATFL is anatomical and functionally a distinct structure comparative studies for a total of 207 ankles were included.
from the inferior ATFL fascicle. The superior ATFL fascicle There was a significant difference in favor of arthroscopic
is an intra-articular ligament, that will most probably not repair with regard to AOFAS score, and there was no
be able to heal after a rupture, and a microinstability of the significant difference with regard to Karlsson score. There
ankle is developed. However, when the LFTCLis injured, was a statistically significant difference in AOFAS score in
classical ankle instability resulted. In addition, because of favor of the arthroscopic repair (MD; 1.41, 95% CI 0.29-2.52,
the presence of LFTCL complex, excellent results are ob- I 2 = 0%, p < 0.05). There was no statistically significant
served when an isolated repair of the ATFL is performed difference in Karlsson score (MD; 0.00, 95% CI − 3.51 to 3.
even when an injury of both the ATFL and CFL exists. 51, I 2 = 0%, n.s.). There was no statistically significant
4.•• Radwan A, Bakowski J, Dew S, Greenwald B, Hyde E, Webber difference in total, nerve, or wound complications.
N. Effectiveness of ultrasonography in diagnosing chronic lat- Conclusion. The current meta-analysis found that short-term
eral ankle instability: a systematic review. Int J Sports Phys AOFAS functional outcome scores were significantly improved
Ther. 2016;11:164–74 The purpose of this systematic review with arthroscopic lateral ankle repair compared to open repair.
was to investigate the effectiveness of ultrasonography in There was no significant difference between arthroscopic and
diagnosing CAI, in comparison with other diagnostic tools. open repair with regards to Karlsson functional outcome score,
Methods: articles published between the years 2000–2015, total complication rate, or the nerve and wound complication
and articles that were peer reviewed and published in the subsets with the included studies with at least 12 months of
English language. Databases searched: CINAHL, PubMed, follow-up. However, the current evidence is still limited, and
Medline, Medline Plus, Science Direct, OVID, Cochrane, further prospective trials with longer follow-up are needed.
and EBSCO. Titles and abstracts of the 1,420 articles were Level of evidence. III.
screened for the inclusion criteria by two independent 8. Porter M, Shadbolt B, Ye X, Stuart R. Ankle lateral ligament aug-
raters, with discrepancies solved by a third rater. The mod- mentation versus the modified Bronstrom-Gould procedure, a 5-
ified 14-point Quality Assessment of Diagnostic Accuracy year randomized controlled trial. Am J Sports Med. 2019:1–8.
Studies (QUADAS) scale was used to assess methodological 9. Maffulli N, Buono A, et al. Isolated anterior talofibular ligament
quality of included articles. Results: Six high quality articles Bronstrom repair for chronic lateral ankle instability. A 9-year fol-
were included in this systematic review, as indicated by high low-up. Am J Sports Med. 2013;41:–4.
scores on the QUADAS scale, ranging from 10 to 13. 10. Guillo S, Takao M, et al. Arthroscopic anatomical reconstruction of
Sensitivity of US ranged from: 84.6–100%, specificity of the lateral ankle ligaments. Knee Surg Sports Traumatol Arthrosc.
US ranged from: 90.9–100% and accuracy ranged from: 2015, 2016. https://doi.org/10.1007/s00167-015-3789-z.
87–90.9%. The results of the included studies suggest that 11. Acevedo J, Mangone P. Ankle instability and arthroscopic lateral
US is able to accurately differentiate between the grades of ligament repair. Foot and Ankle Clin N Am. 2015;20:50–69.
ankle sprains and between a lax ligament, torn ligament,
12. Almohrej O, Al-Kenani NS. Chronic ankle instability: current per-
thick ligament, absorbed ligament and a non-union avulsion
spectives. Avicena J Med. 2016;6:103–8.
fracture. These findings indicate that US is a reliable meth-
od for diagnosing CAI, and that US is able to classify the 13. Cottom J, Rigby R. The “all inside” arthroscopic Broström proce-
degree of instability. Conclusion: Researchers found that dure: a prospective study of 40 consecutive patients. Foot Ankle
US is effective, reliable, and accurate in the diagnosis of Surg. 2013;52:568–74.
CAI. Clinical Implications: US would allow for earlier di- 14. Cottom J, Rigby R. A comparison of the “all inside” arthroscopic
agnosis, which could increase the quality of care as well as Broström procedure with the traditional open Modified Broström-
decrease the number of outpatient visits. This could lead to Gould technique: a review of 62 patients. Foot Ankle Surg. 2017.
improvement in treatment plans, goals and rehabilitation https://doi.org/10.1016/j.fas.2017.07.64.
outcomes. level of Evidence: 1a. 15. Baloch N, Hasan O, Jessar M, Hattori S, Yamada S. “Sports
5. Guelfi M, Zamparetti M, et al. Open and arthroscopic lateral Ultrasound”, advantages, indications and limitations in upper and
ligament repair for treatment of chronic ankle instability: a sys- lower limbs musculoskeletal disorders. Review article. Int J Surg.
tematic review. Foot Ankle Surg. 2016;24:11–8. 2018;54:333–40.
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16. Lento P, Primack S. Advances and utility of diagnostic ultrasound 31. Seng C, Mohan C, et al. Ultrasonic percutaneous tenotomy for
in musculoskeletal medicine. Curr Rev Musculosket Med. 2008;1: recalcitrant lateral elbow tendinopathy: sustainability and sono-
24–31. graphic progression at 3 years. Am J Sports Med. 2015;44(2):
17. Del Cura J, Corta R. Ultrasound guided interventional procedures in 504–9.
the musculoskeletal system. Radiologia. 2010;52(6):525–33. 32. Lungu E, Grondin P, et al. Ultrasound-guided tendon fenestration
18.• Beard N, Gousse R. Current ultrasound application in the foot and versus open-release surgery for the treatment of chronic lateral
ankle. Orthop Clin N Am. 2018;49:109–21 Ultrasound has been epicondylitis of the elbow: protocol for a prospective, randomized,
used in the foot and ankle for nearly 2 decades and is being used single blinded study. BMJ Open. 2018;8:e021373.
with increasing frequency and indication. Utilization in diagno- 33. Battista C, Dorweiler M, et al. Ultrasonic percutaneous tenotomy of
sis demonstrates unique advantages that are complementary to common extensor tendons for recalcitrant lateral epicondylitis. Tech
other imaging modalities. High-resolution ultrasound is the mo- Hand Upper Extrem Surg. 2017;22:15–8.
dality of choice for needle placement, including joint injection. 34. Giannetti S, Patricola A, Stancati A, Santucci A. Intraoperative
Increasing collaboration between foot and ankle surgery and ultrasound assistance for percutaneous repair of the Achilles tendon
skilled ultrasonographers is leading to innovation in minimally rupture. Orthopedics. 2014;37(12):820–4.
invasive treatment of common diagnoses. Ultrasonic augmen- 35.• Chavez J, Hattori S, et al. The use of ultrasonography during
tation of surgery. Ultrasound has the potential to augment minimally invasive Achilles tendon repair to avoid sural nerve
many aspects of traditional foot and ankle surgery. Perhaps injury. J Med Ultrason. 2019. https://doi.org/10.1007/s10396-
most helpful is the ability to use ultrasound preoperatively or 019-00951-5 Four patients with Achilles tendon ruptures
intraoperatively to identify soft tissue and bony structures over underwent minimally invasive repair in our institution by
and above traditional palpation or landmark-guided tech- the same surgeon. With the patients positioned prone under
niques. Assistance in endoscopy is documented not just in help- general endotracheal anesthesia, a 3-cm transverse incision
ing with port placement but also with offering another means of was made about 1 cm proximal to the rupture site. A
visualization. Published cases and series include arthroscopy of Percutaneous Achilles Repair System (PARS; Arthrex®,
the hallux and several techniques at the plantar fascia. Florida, USA) jig was slid within the paratenon. With a
Augmentation of traditional surgery techniques and tools, al- sterile sleeve covering the transducer (12 MHz), a mobile
though promising, is not yet well established and requires a ultrasound machine (VenueTM50, GE Healthcare, Tokyo,
team of highly skilled interventional ultrasonographers and or- Japan) was used to avoid the neurovascular bundle each
thopedic surgeons to effectively apply. time a needle passed through the lateral side of the tendon.
19. Lapeque P, Andrei A, et al. US-guided percutaneous release of the The sutures were all retrieved as the jig was pulled out
trigger finger using a 21-gauge needle: a prospective study of 60 andthe tendon ends were approximated with the foot in
cases. Radiology. 2016;280(2):483–99. plantarflexion. The procedure was well tolerated by all pa-
20. Petrover D, Richette P. Treatment of carpal tunnel syndrome: from tients, with no complaints pointing to sural nerve injury
ultrasonography to ultrasound guided carpal tunnel release. Joint such as sensory disturbance and pain throughout their re-
Bone Spine. 2018;85:545–52. spective follow up periods. The incision sites all healed well
21. Ohuchi H, Hattori S, et al. Ultrasound-assisted endoscopic carpal without any wound complications such as dehiscence or lo-
tunnel release. Arthroscopy Techniques. 2016;5(3):e483–7. cal infection. Minimally invasive Achilles tendon repair con-
22. Dekimpe C, Adreani O, et al. Ultrasound-guided percutaneous re- tinues to be accompanied by a risk of iatrogenic sural nerve
lease of the carpal tunnel: comparison of the learning curves of a injury despite the employment of measures to consciously
senior versus junior operator. a cadaveric study. Skelet Radiol. protect the sural nerve during repair. Some authors have
2019. https://doi.org/10.1007/s00256-019-03207-y. recommended exposure and visualization of the sural nerve
23. Bouillis J, Lallouet S, Ropars M. Echography-guided pinning for during repair to minimize injury by being able to avoid it
prevention of iatrogenic injuries to the radial nerve during fixation with a certain degree of confidence. Others have advocated
of extra-articular distal radius fracture: an anatomical study. J Wrist performing the procedure just under local anesthesia to fa-
Surg. 2017;6:336–9. cilitate a wide-awake surgery so that the patient can gener-
24. Shroeder A. Utilization of ultrasound in the treatment of athletes for ate feedback if any neural disturbance was felt during punc-
beginners. In: Goto H, editor. Medical View; 2019. ture or infiltration. We have shown that ultrasonography
25. Quinones P, Hattori S, Ohuchi H, Kato Y. Ultrasound guided mus- can be used in order to have indirect but real-time visuali-
cle hematoma evacuation. Arthroscopy Techniques. 2019. https:// zation during minimally invasive Achilles tendon repair.
doi.org/10.1016/j.eats.2019.03.007. This can be achieved with the patient comfortable under
26. Ahn K, Jhun H, Choi K, Lee YS. Ultrasound-guided interventional general or spinal anesthesia, without having to ask feedback
release of rotator interval and posterior capsule for adhesive regarding neural disturbances throughout the surgery. This
capsulitis of the shoulder using a specially designed needle. Pain also avoids additional incisions and soft tissue trauma just
Physician. 2011;14:531–7. to directly visualize the sural nerve in order to avoid it.
Under ultrasound guidance, it was ensured that the needle
27. Peck E, Jelsing E, Onishi K. Advanced ultrasound guided interven-
was always deep to sural nerve each time it passed through
tions for tendinopathy. Phys Med Rehabil Clin N Am. 2016;27:
the lateral side of the Achilles tendon. With these encourag-
733–48.
ing results, we highly recommend this method to avoid iat-
28. Zhang J, Fukushima Y, Onishi K. The application of ultrasound
rogenic sural nerve injury during minimally invasive repair
imaging in tendinopathy. Med Res Clin Case Rep. 2018;2(1):
of the Achilles tendon.
141–8.
36. Hirahara A, Andersen W. Ultrasound-guided percutaneous repair of
29. Balius R, Bong D, Ardèvol J, Pedret C, Codina D, Dalmau A.
medial patellofemoral ligament: surgical technique and outcomes.
Ultrasound guided fasciotomy for anterior chronic exertional com-
Am J Orthop. 2017;46(3):152–7.
partment syndrome of the leg. J Ultrasound Med. 2016;35:823–9.
37. Chen Y, Cai Y, Wang Y. Value of ultrasonography for detecting
30. Ohuchi H, Ichikawa K, et al. Ultrasound-assisted endoscopic partial
chronic injury of the lateral ligaments compared with ultraso-
plantar fascia release. 2013. Arthroscopy Techniques.2(3):e227–
nography findings. Br J Radiol. 2014;87:20130406.
e230.
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38.• Cao S, Wang C, Xi M, Xu W, Huang J, Zhang C. Imaging placement of the anterolateral arthroscopic portal to the
diagnosis for chronic lateral ankle injury: a systematic review ankle.
with meta-analysis. J Orthop Surg Res. 2018;13:159 This sys- 41. Thes A, Klouche S, et al. Assessment of the feasibility of ar-
temic review will explore the effectiveness of different imag- throscopic visualization of the lateral ligament of the ankle: a
ing techniques in diagnosing chronic lateral ankle ligament cadaveric study. Knee Surg Sports Traumatol Arthrosc.
injury. Methods: Relative studies were retrieved after 2016;24:985–90.
searching 3 databases (MEDLINE, EMBASE, and 42.•• Teramoto A, Shoji H, et al. The distal margin of the lateral
Cochrane Central Register of Controlled Trails). Eligible malleolu s v isible un der an kle art hrosco py fro m th e
studies were summarized. Data were extracted to calculate anteromedial portal, is separate from the ATFL attachment site
pooled sensitivity and specificity of magnetic resonance im- of the fibula: a cadaver study. J Orthop Surg Res. 2018;23:5655
aging (MRI), ultrasonography (US), stress radiography, The purpose of this study was to evaluate the relationship
and arthrography. Results: Fifteen studies met our inclu- between the lateral malleolus view under ankle arthroscopy
sion and exclusion criteria. A total of 695 participants were and the anterior talofibular ligament (ATFL) attachment
included. The pooled sensitivities in diagnosing chronic site. Methods: Seven normal ankles from Thiel-embalmed
ATFL injury were 0.83 [0.78, 0.87] for MRI, 0.99 [0.96, cadavers were investigated. Ankle arthroscopy was per-
1.00] for US, and 0.81 [0.68, 0.90] for stress radiography. formed using a 2.7-mm-diameter, 30-degree, oblique-
The pooled specificities in diagnosing chronic ATFL injury viewing endoscope. An antero-medial portal (AM), a medial
were 0.79 [0.69, 0.87] for MRI, 0.91 [0.82, 0.97] for US, and midline portal (MML), and an antero-central portal (AC)
0.92 [0.79, 0.98] for stress radiography. The pooled sensitiv- were created in order, and the ankle arthroscope was
ities in diagnosing chronic CFL injury were 0.56 [0.46, 0.66] inserted. The lateral malleolus was visualized as distally as
for MRI, 0.94 [0.85, 0.98] for US, and 0.90 [0.73, 0.98] for possible, and the site that appeared to be the distal margin
arthrography. The pooled specificities in diagnosing chronic was marked with a 1.5-mm-diameter K-wire. Visualization
CFL injury were 0.88 [0.82, 0.93] for MRI, 0.91 [0.80, 0.97] with arthroscopy was carried out from all portals to mark
for US, and 0.90 [0.77, 0.97] for arthrography. Conclusion: the distal margin, and the ankle was subsequently exposed
This systematic review with meta-analysis investigated the to directly measure the distance from the center of the
accuracy of imaging for the diagnosis of chronic lateral an- ATFL attachment site at the fibula to each marking.
kle ligament injury. Ultrasound manifested high diagnostic Results: The distances from the ATFL attachment site to
accuracy in diagnosing chronic lateral ankle ligament inju- the markings made under arthroscopy from the AM,
ry. Clinicians should be aware of the limitations of MRI in MML, and AC portals were 10.4 ± 2.6 mm, 7.4 ± 1.9 mm,
detecting chronic CFL injuries. and 7.3 ± 1.9 mm, respectively. Compared to markings
39. Pitts C, Haley M, et al. Anatomic structures at risk in the arthro- made from the MML or AC portal, the marking made from
scopic Bronstrom - Gould procedure:a cadaver study. Foot Ankle the AM portal was significantly further away from the
Surg. 2019. https://doi.org/10.1016/j.fas.2019.04.008. ATFL attachment site. Conclusions: A typical ankle ar-
40.• Poggio D, Claret G, et al. Correlation between visual inspection throscopy portal may not allow complete visualization of
and ultrasonography to identify the distal branches of superfi- the tip of the lateral malleolus, indicating that it may not
cial peroneal nerves: a cadaveric study. Foot Ankle Surg. be feasible to thoroughly observe the ATFL attachment site.
2016;55:492–5 The anatomy of the superficial peroneal It is necessary to perform arthroscopic surgeries with the
nerve (SPN) and, more precisely, of the distal branches of understanding that the distal margin of the lateral
the SPN at the ankle has attracted interest owing to the malleolus that appears under ankle arthroscopy is
possibility of injury when performing ankle arthroscopy. 7e10 mm proximal to the ATFL attachment site.
The anterolateral portal is one of the most commonly used 43.•• Hattori S, Kumai T, Ohuchi H. Ultrasound-guided repair of
portals in ankle arthroscopy, and the intermediate dorsal anterior talofibular ligament: anatomical accuracy of anchor
cutaneous nerve can easily be injured during portal place- placement. Non-inferiority. Abstract. 2019. The 31st Annual
ment. The purpose of the present study was to assess wheth- Meeting of the Japanese Society of Orthopedic Ultrasonics.
er visual inspection and palpation of the cutaneous nerves at The purpose of this study was to evaluate the accuracy of
the ankle differed from examination with ultrasonography anchor placement in ultrasound-guided anterior talofibular
and whether the 2 examination techniques correlated with ligament repair (USG ATFLR). Method: We included those
the anatomic location of the SPN, which was verified by underwent open ATFLR and those with USG ATFLR. The
cadaver dissection. First, visual examination and palpation distance between the distal anchor and the fibular obscure
was performed to identify the SPN, after which 12 cadaver tubercle (FOT) in 3DCT was measured. We considered that
legs from separate specimens were examined with ultraso- the distance of USG ATFLR would be non-inferior to open
nography to mark the course of the SPN. We then measured ATFLR within 5 mm. Result: We had 11 cases of open
the distance between the nerve as identified with gross ATFLR and 10 USG ATFLR. The mean distance between
visualization/palpation and ultrasound examination, and anchor and FOT was 6.0 ± 2.7 mm in open ATFLR and 7.4
compared these with the precise location determined by an- ± 2.5 mm in USG ATFLR respectively. The mean differ-
atomic dissection. The use of ultrasonography to determine ences of two techniques were − 1.5 mm (95% confidence
the course of the SPN was good or excellent in 11 of the 12 interval 1.0 to − 3.9). The CI was smaller than the non-
legs (91.7%) studied. In contrast, gross visualization/ inferiority margin (5 mm). Conclusion: Anchor placement
palpation was good or excellent in 4 legs (33.3%). under USG ATFLR can be anatomically accurate.
Excellent agreement was observed between the ultrasound 44. Kannus P, Renström P. Treatment for acute tears of the lateral lig-
markings and the anatomic dissection results. However, the aments of the ankle. Operation, cast, or early controlled mobiliza-
visual examination poorly identified the course and the an- tion. J Bone Joint Surg Am. 1991;73(2):305–12.
atomic variations of the nerve branches evidenced in the
45. Guillo S, Bauer T, Lee JW, Takao M, Kong SW, Stone JW, et al.
anatomic dissection. From these findings in cadaver speci-
Consensus in chronic ankle instability: aetiology, assessment, sur-
mens, ultrasound identification of the SPN and its branches
gical indications and place for arthroscopy. Orthop Traumatol Surg
is likely preferable to gross visualization/palpation before
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Curr Rev Musculoskelet Med

Res. 2013;99(8 Suppl):S411–9. https://doi.org/10.1016/j.otsr.2013. 48. Kelikian A. Sarrafian’s anatomy of the foot and ankle: descriptive,
10.009. topographical, functional. 3rd ed: Lippincott Williams & Wilkins;
46.• Kenmochi M, Sasaki S, Fujisaki K, Yusuke O, Kotani A, Ichimura 2011. p. 344.
S. A new classification of anterior talofibular ligament injuries 49.• Hattori S, Nimura A, Koyoma M, Tsutsumi M, Amaha K, Ohuchi
based on ultrasonography findings. J Orthop Surg Res. 2016;21: H, et al. Dorsiflexion is more feasible than plantar flexion in ultra-
770e–78 This study aimed to assess the treatment outcomes of sound evaluation of the calcaneofibular ligament: a combination
lateral ankle ligament injuries using a new classification for study of ultrasound and cadaver. Knee Surg Sports Traumatol
ATFL injuries based on US findings. Methods: A total of 140 Arthrosc. 2019. https://doi.org/10.1007/s00167-019-05630-z
acute lateral ankle ligament injuries in 132 patients (46 men, 86 Purpose Ultrasound (US) is a valuable tool for the evaluation
women) treated non-operatively were evaluated retrospectively. of chronic lateral instability of the ankle; however, the feasibil-
The average age of the patients was 17.8 years (range, 7– ity of US for calcaneofibular ligament (CFL) assessment re-
57 years). Patients with a complaint of lateral ankle injury were mains unknown. This study aimed to depict and compare
examined using US, and the anterior talofibular ligament dam- CFL on US in various ankle positions to determine the optimal
age was classified into 5 types depending on the type of the method for evaluating CFL with US and to interpret US find-
injury. The treat ment method was selected based on the ultra- ings using cadaveric specimens. Methods The US study includ-
sonographic classification, and the clinical results were assessed ed 43 ankles of 25 healthy individuals. The CFL was scanned
by original evaluation and compared between treatment with US in 20° plantar flexion, neutral position, 20°
methods and classification types. Results: A Good or dorsiflexion, and maximum dorsiflexion. The distances be-
Excellent treatment result was obtained in 133 out of 140 inju- tween fibula and CFL were compared. The cadaveric study
ries (95.0%). Significant differences were observed in the dis- included macroscopic qualitative observation of the dynamic
tribution of treatment methods by injury type (P < 0.001), and change of CFL in 7 ankles and quantitative observation of the
the distribution of outcomes was significantly different from the directions of CFL and footprints in 17 ankles. Results In the US
uniform distribution (P < 0.001). Our findings demonstrate that study, the mean distance (mm) between fibula and CFL was 7.3
the ultrasonographic classification proposed in this study can ± 1.3 in 20° plantar flexion, 6.7 ± 1.6 in neutral position, 4.3 ± 2.
be used to determine the appropriate treatment resulting in 5 in 20° dorsiflexion and 3.1 ± 2.1 in maximum dorsiflexion.
good outcomes for all types of anterior talofibular ligament The more dorsiflexed the ankle was, the shorter the distance
damage. Conclusion: Visualization of injured ligaments using between fibula and CFL was (Jonckheere’s trend test p < 0.
US may introduce a novel approach of rating and treating lig- 001). In the cadaveric study, the CFL fibers were aligned
ament injuries. parallel between the mid-substance and the fibular attachment
47.• Gosselin M, Haynes J, et al. The arterial anatomy of the lateral in maximum dorsiflexion, whilst CFL was reflected and rotated
ligament complex of the ankle: a cadaveric study. Am J Sports in plantar flexion. Conclusions The whole length of the CFL,
Med. 2018:1–6. https://doi.org/10.1177/0363546518808060 including its fibular attachment, is more likely to be visualized
The purpose of this study was to define the vascular with US in dorsiflexion than in plantar flexion due to the direc-
anatomy of the lateral ligament complex of the ankle. tion of the CFL at the fibular attachment, which is parallel with
Methods: Thirty pairs of cadaveric specimens (60 total the mid-substance in maximum dorsiflexion. Level of evidence
legs) were amputated below the knee. India ink, followed IV.
by Ward blue latex, was injected into the peroneal, 50. Peetrons P, Creuter V, Bacq C. Sonography of ankle ligaments. J
anterior tibial, and posterior tibial arteries to identify the Clin Ultrasound. 2004;32:491–9.
vascular supply of the lateral ligaments of the ankle. 51.•• Vega J, Guelfi M, Malagelada F, Pena F, Dalmau-Pastor M.
Chemical debridement was performed with 8.0% sodium Arthroscopic all-inside anterior talofibular ligament repair through
hypochlorite to remove the soft tissues, leaving casts of the a three-portal and no-ankle-distraction technique. JBJS Essent Surg
vascular anatomy intact. The vascular supply to the lateral Tech. 2018;8(3):e25. https://doi.org/10.2106/JBJS.ST.18.00026
ligament complex was then evaluated and recorded. Arthroscopic treatment of ankle instability is an emerging
Results: The vascular supply to the lateral ankle ligaments field attracting increased interest among surgeons. The
was characterized in 56 specimens: 52 (92.9%) had arterial arthroscopic all-inside ATFL repair allows the surgeon to ex-
supply with an origin from the perforating anterior branch plore the ankle joint, treat concomitant pathology when en-
of the peroneal artery; 51 (91.1%), from the posterior countered, and reattach the injured ATFL to its fibular ana-
branch of the peroneal artery; 29 (51.8%), from the tomical location. The aim of this article is to describe the ar-
lateral tarsal branch of the dorsalis pedis; and 12 (21.4%), throscopic all-inside ATFL repair through a 3-portal no-ankle-
from the posterior tibial artery. The anterior branch of the distraction technique. Description: after patient positioning,
peroneal artery was the dominant vascular supply in 39 anteromedial and anterolateral portals are created. An acces-
specimens (69.6%). Conclusion: There are 4 separate sory anterolateral portal is created just anterior to the fibula
sources of extraosseous blood supply to the lateral and about 1 cm proximal to the tip of the lateral malleolus. The
ligaments of the ankle. In all specimens, the anterior arthroscope is introduced through the anteromedial portal,
talofibular ligament was supplied by the anterior branch and the instruments are introduced through the anterolateral
of the peroneal artery and/or the lateral tarsal artery of portal. Recognition of the ligament and evaluation of the liga-
the dorsalis pedis, while the posterior talofibular ligament ment tear with a probe are required. The footprint for the
was supplied by the posterior branch of the peroneal artery fibular attachment of the ATFL is debrided. The ligament is
and/or the posterior tibial artery. The calcaneofibular liga- penetrated with a suture passer. A nitinol loop is pushed and
ment received variable contributions from the anterior and then is pulled out through the accessory portal. The nitinol wire
posterior branches of the peroneal artery, with few speci- is replaced by a double high-resistance suture.The limbs of the
mens receiving a contribution from the lateral tarsal or pos- suture located in the accessory portal are passed through the
terior tibial arteries. Clinical Relevance: Understanding the anterolateral portal. Next, one or both limbs of the suture are
vascular anatomy of the lateral ligament complex is benefi- passed through the loop suture. Pulling of the suture limbs
cial when considering surgical management and may pro- introduces the loop into the joint and the ligament is grasped
vide insight into factors that lead to chronic instability. by the suture. The tunnel for the anchor is drilled. The knotless
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Curr Rev Musculoskelet Med

anchor is loaded with the suture, and the anchor and suture are inferior extensor retinaculum. There is also concern that
introduced with the ankle in dorsiflexion and valgus. when using the inferior extensor retinaculum, this is not
Postoperatively, the ankle is immobilized with a removable strictly an anatomical repair since its calcaneal attachment
walking boot for 4 weeks. Once use of the walking boot is is different to that of the calcaneofibular ligament. If a lig-
discontinued, physical therapy is started. Rationale: The de- ament repair is completed firmly, it is unnecessary to add
scribed technique has the advantage of being done with a min- argumentation with inferior extensor retinaculum. The au-
imally invasive approach and providing an anatomical repair thors describe a simplified technique, repair of the lateral
of the ligament. Concomitant intra-articular pathology can be ligament alone using a lasso-loop stitch, which avoids addi-
addressed during the procedure through the same arthroscopic tionally tighten the inferior extensor retinaculum. In this
approaches. Early rehabilitation and the lack of intra-articular paper, it is described an arthroscopic anterior talofibular
knots areadditional benefits of the technique. ligament repair using lasso-loop stitch alone for lateral in-
52.• Takao M, Matsui K, et al. Arthroscopic anterior talofibular lig- stability of the ankle that is likely safe for patients and min-
ament repair for lateral instability of the ankle. Knee Surg imal invasive. Level of evidence Therapeutic study, Level V.
Sports Traumatol Arthrosc. 2016;24:1003–6 Although several
arthroscopic procedures for lateral ligament instability of Publisher’s note Springer Nature remains neutral with regard to jurisdic-
the ankle have been reported recently, it is difficult to aug- tional claims in published maps and institutional affiliations.
ment the reconstruction by arthroscopically tightening the

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