Anat Cell Biol.  2023 Sep;56(3):334-341. 10.5115/acb.23.002.

Anatomical study of the bone morphology of the anterior talofibular ligament attachment

• Fujishiro H
• Nimura A
• Azumaya M
• Hattori S
• Hoshi O
• Akita K

• KMID: 2546461
• DOI: http://doi.org/10.5115/acb.23.002

Abstract

Anterior talofibular ligament (ATFL) injuries are the most common cause of ankle sprains. To ensure anatomically accurate surgery and ultrasound imaging of the ATFL, anatomical knowledge of the bony landmarks around the ATFL attachment to the distal fibula is required. The purpose of the present study was to anatomically investigate the ATFL attachment to the fibula with respect to bone morphology and attachment structures. First, we analyzed 36 feet using microcomputed tomography. After excluding 9 feet for deformities, the remaining 27 feet were used for chemically debrided bone analysis and macroscopic and histological observations. Ten feet of living specimens were observed using ultrasonography. We found that a bony ridge was present at the boundary between the attachments of the ATFL and calcaneofibular ligament (CFL) to the fibula. These two attachments could be distinguished based on a difference in fiber orientation. Histologically, the ATFL was attached to the anterodistal part of the fibula via fibrocartilage anterior to the bony ridge indicating the border with the CFL attachment. Using ultrasonography in living specimens, the bony ridge and hyperechoic fibrillar pattern of the ATFL could be visualized. We established that the bony ridge corresponded to the posterior margin of the ATFL attachment itself. The ridge was obvious, and the superior fibers of the ATFL have directly attached anteriorly to it. This bony ridge could become a valuable and easy-to-use landmark for ultrasound imaging of the ATFL attachment if combined with the identification of the fibrillar pattern of the ATFL.

Keyword

Lateral ligament; Ankle; Fibula; Ultrasonography; Anatomy

Figure

• 

  Fig. 1 The bony morphology of the fibula. Bone morphology of the distal fibula of the right ankle as shown by (A–C) micro computed tomography and (D–F) chemically debrided bone. (A) Micro-computed tomography image. (B) Region boxed in white in (A); dotted line: ridge between attachments of the anterior talofibular ligament (ATFL, dagger) and the calcaneofibular ligament (CFL, asterisk). (C) The border indicated in B, which is remarkable in the anterolateral view of the distal fibula. (D–F) The same specimen as in (A–C) after chemical debridement of soft tissues. ATFL, anterior talofibular ligament; CFL, calcaneofibular ligament; Prox, proximal; Ant, anterior; FOT, fibular obscure tubercle.

• 

  Fig. 2 Fibrous orientations of the ATFL and CFL in their fibular attachments. (A) After removal of the skin, subcutaneous tissues, muscles, synovial articular capsule, and tibia, the anterior talofibular and calcaneofibular ligaments (ATFL and CFL, respectively) in the lateral ankle can be seen. (B) After the removal of connecting fibers, the fibrous orientations of the ATFL and CFL are clearly seen. ATFL, anterior talofibular ligament; CFL, calcaneofibular ligament; Prox, proximal; Ant, anterior.

• 

  Fig. 3 Fibular attachments of the ATFL and CFL. Shown is the lateral aspect of the right ankle seen in . (A) After removal of the calcaneofibular ligament (CFL) fibers, demonstrating the CFL attachment (asterisk). (B) After removal of the anterior talofibular ligament (ATFL) seen in A, demonstrating the ATFL attachment (dagger) and the posterior talofibular ligament (PTFL) distal to the ATFL and CFL attachments. ATFL, anterior talofibular ligament; CFL, calcaneofibular ligament; Prox, proximal; Ant, anterior.

• 

  Fig. 4 Measurements of the ATFL attachment. Explanation of the data provided in Table 1. Dotted areas indicate the attachments of the anterior talofibular ligament (ATFL, dagger) and calcaneofibular ligament (CFL, asterisk). (a) The proximal-distal length, (b) the anteroposterior width, (c) the distance between the anterior tubercle of the fibula (section) and the proximal edge of the ATFL attachment, and (d) the distance between the ATFL attachment and the inferior tip of the fibula (double dagger). ATFL, anterior talofibular ligament; CFL, calcaneofibular ligament; Post, posterior; Dist, distal.

• 

  Fig. 5 Histological analyses of the ATFL attachment by Masson trichrome stain. Sections are parallel to the fibrous orientation of the ATFL. (A) White lines show the orientations and locations of sections. (B) Shown is the proximal part of the ATFL. (C) Magnified view of the region boxed in black in (B); black arrow: the bony ridge at the posterior edge of the ATFL. (D) The distal part of the ATFL. (E) Magnified view of the region boxed in black in (D). The white arrow indicates the bony ridge dividing the attachments of the ATFL and calcaneofibular ligaments (CFL, black arrowheads). ATFL, anterior talofibular ligament; CFL, calcaneofibular ligament; Prox, proximal; Ant, anterior; Lat, lateral.

• 

  Fig. 6 Ultrasonographic imaging of ATFL in living specimens. (A) Gray boxes show the locations of ultrasonographic images (B, C), and (D). Dotted areas indicate the attachments of the anterior talofibular ligament (ATFL, dagger) and calcaneofibular ligament (CFL, asterisk). (B) The short axis view at the level of the anterior tubercle (AT, section mark). The anterior tibiofibular ligament (AiTFL) was identified anterior to the AT. (C) The short axis view at the level of the posterior margin (dot) of the attachment of the anterior talofibular ligament (ATFL, white arrowheads) (D). The view at the level parallel to the ATFL fibers. ATFL, anterior talofibular ligament; Post, posterior; Dist, distal.

Reference

References

1. Taser F, Shafiq Q, Ebraheim NA. 2006; Anatomy of lateral ankle ligaments and their relationship to bony landmarks. Surg Radiol Anat. 28:391–7. DOI: 10.1007/s00276-006-0112-1. PMID: 16642279.

2. Beynnon BD, Renström PA, Haugh L, Uh BS, Barker H. 2006; A prospective, randomized clinical investigation of the treatment of first-time ankle sprains. Am J Sports Med. 34:1401–12. DOI: 10.1177/0363546506288676. PMID: 16801691.

3. Khawaji B, Soames R. 2015; The anterior talofibular ligament: a detailed morphological study. Foot (Edinb). 25:141–7. DOI: 10.1016/j.foot.2015.05.004. PMID: 26205996.

4. Edama M, Kageyama I, Kikumoto T, Nakamura M, Ito W, Nakamura E, Hirabayashi R, Takabayashi T, Inai T, Onishi H. 2018; Morphological features of the anterior talofibular ligament by the number of fiber bundles. Ann Anat. 216:69–74. DOI: 10.1016/j.aanat.2017.11.001. PMID: 29196235.

5. Kakegawa A, Mori Y, Tsuchiya A, Sumitomo N, Fukushima N, Moriizumi T. 2019; Independent attachment of lateral ankle ligaments: anterior talofibular and calcaneofibular ligaments - a cadaveric study. J Foot Ankle Surg. 58:717–22. DOI: 10.1053/j.jfas.2018.12.009. PMID: 31130481.

6. Dong Y, Qian Y, Liu L, Zhang X, Cai C. 2021; Anatomical study on the reconstruction of the anterior talofibular ligament. J Foot Ankle Surg. 60:908–11. DOI: 10.1053/j.jfas.2021.03.004. PMID: 33814310.

7. Inchai C, Vaseenon T, Mahakkanukrauh P. 2020; The comprehensive review of the neurovascular supply of the ankle joint: clinical implications. Anat Cell Biol. 53:126–31. DOI: 10.5115/acb.20.037. PMID: 32647079. PMCID: PMC7343567.

8. Song B, Li C, Chen N, Chen Z, Zhang Y, Zhou Y, Li W. 2017; All-arthroscopic anatomical reconstruction of anterior talofibular ligament using semitendinosus autografts. Int Orthop. 41:975–82. DOI: 10.1007/s00264-017-3410-9. PMID: 28233114.

9. Lee DW, Park IK, Kim MJ, Kim WJ, Kwon MS, Kang SJ, Kim JG, Yi Y. 2019; Three-dimensional computed tomography tunnel assessment of allograft anatomic reconstruction in chronic ankle instability: 33 cases. Orthop Traumatol Surg Res. 105:145–52. DOI: 10.1016/j.otsr.2018.10.008. PMID: 30502025.

10. Hattori S, Alvarez CAD, Canton S, Hogan MV, Onishi K. 2019; Ultrasound-guided ankle lateral ligament stabilization. Curr Rev Musculoskelet Med. 12:497–508. DOI: 10.1007/s12178-019-09592-0. PMID: 31749104. PMCID: PMC6942111.

11. Hunt KJ, Griffith R. 2020; Open Brostrom for lateral ligament stabilization. Curr Rev Musculoskelet Med. 13:788–96. DOI: 10.1007/s12178-020-09679-z. PMID: 33159666. PMCID: PMC7661567.

12. Gautschi M, Bachmann E, Shirota C, Götschi T, Renner N, Wirth SH. 2020; Biomechanics of ankle ligament reconstruction: a cadaveric study to compare stability of reconstruction techniques using 1 or 2 fibular tunnels. Orthop J Sports Med. 8:2325967120959284. DOI: 10.1177/2325967120959284. PMID: 33150191. PMCID: PMC7585988.

13. Hattori S, Onishi K, Yano Y, Kato Y, Ohuchi H, Hogan MV, Kumai T. 2020; Sonographically guided anchor placement in anterior talofibular ligament repair is anatomic and accurate. Orthop J Sports Med. 8:2325967120967322. DOI: 10.1177/2325967120967322. PMID: 33354581. PMCID: PMC7734515.

14. Park JH, Kwon HW, Kim D, Park KR, Lee M, Choi YJ, Cho J. 2021; The location of the fibular tunnel for anatomically accurate reconstruction of the lateral ankle ligament: a cadaveric study. Biomed Res Int. 2021:5575524. DOI: 10.1155/2021/5575524. PMID: 33791364. PMCID: PMC7997753.

15. Brasseur JL, Luzzati A, Lazennec JY, Guérin-Surville H, Roger B, Grenier P. 1994; Ultrasono-anatomy of the ankle ligaments. Surg Radiol Anat. 16:87–91. DOI: 10.1007/BF01627927. PMID: 8047974.

16. De Maeseneer M, Marcelis S, Jager T, Shahabpour M, Van Roy P, Weaver J, Jacobson JA. 2009; Sonography of the normal ankle: a target approach using skeletal reference points. AJR Am J Roentgenol. 192:487–95. DOI: 10.2214/AJR.08.1316. PMID: 19155415.

17. Sisson L, Croy T, Saliba S, Hertel J. 2011; Comparison of ankle arthrometry to stress ultrasound imaging in the assessment of ankle laxity in healthy adults. Int J Sports Phys Ther. 6:297–305. PMID: 22163091. PMCID: PMC3230157.

18. Croy T, Koppenhaver S, Saliba S, Hertel J. 2013; Anterior talocrural joint laxity: diagnostic accuracy of the anterior drawer test of the ankle. J Orthop Sports Phys Ther. 43:911–9. DOI: 10.2519/jospt.2013.4679. PMID: 24175608.

19. Cho JH, Lee DH, Song HK, Bang JY, Lee KT, Park YU. 2016; Value of stress ultrasound for the diagnosis of chronic ankle instability compared to manual anterior drawer test, stress radiography, magnetic resonance imaging, and arthroscopy. Knee Surg Sports Traumatol Arthrosc. 24:1022–8. DOI: 10.1007/s00167-015-3828-9. PMID: 26515772.

20. Kemmochi M, Sasaki S, Fujisaki K, Oguri Y, Kotani A, Ichimura S. 2016; A new classification of anterior talofibular ligament injuries based on ultrasonography findings. J Orthop Sci. 21:770–8. DOI: 10.1016/j.jos.2016.06.011. PMID: 27444555.

21. Yildizgoren MT, Velioglu O, Demetgul O, Turhanoglu AD. 2017; Assessment of the anterior talofibular ligament thickness in patients with chronic stroke: an ultrasonographic study. J Med Ultrasound. 25:145–9. DOI: 10.1016/j.jmu.2017.03.001. PMID: 30065479. PMCID: PMC6029297. PMID: 4e7c2ce4ae464f1187e258419f07b59c.

22. Mizrahi DJ, Nazarian LN, Parker L. 2018; Evaluation of the anterior talofibular ligament via stress sonography in asymptomatic and symptomatic populations. J Ultrasound Med. 37:1957–63. DOI: 10.1002/jum.14542. PMID: 29363788.

23. Kristen KH, Seilern Und Aspang J, Wiedemann J, Hartenbach F, Platzgummer H. 2019; Reliability of ultrasonography measurement of the anterior talofibular ligament (ATFL) length in healthy subjects (in vivo), based on examiner experience and patient positioning. J Exp Orthop. 6:30. DOI: 10.1186/s40634-019-0199-z. PMID: 31267337. PMCID: PMC6606687. PMID: f260008ad7454a1ea9ba48b20831113c.

24. Park S, Kim T, Lee M, Park Y. 2020; Absence of ATFL remnant does not affect the clinical outcomes of the modified Broström operation for chronic ankle instability. Knee Surg Sports Traumatol Arthrosc. 28:213–20. DOI: 10.1007/s00167-019-05464-9. PMID: 30887064.

25. Li Q, Tu Y, Chen J, Shan J, Yung PS, Ling SK, Hua Y. 2020; Reverse anterolateral drawer test is more sensitive and accurate for diagnosing chronic anterior talofibular ligament injury. Knee Surg Sports Traumatol Arthrosc. 28:55–62. DOI: 10.1007/s00167-019-05705-x. PMID: 31559464.

26. Baltes TPA, Arnáiz J, Geertsema L, Geertsema C, D'Hooghe P, Kerkhoffs GMMJ, Tol JL. 2021; Diagnostic value of ultrasonography in acute lateral and syndesmotic ligamentous ankle injuries. Eur Radiol. 31:2610–20. DOI: 10.1007/s00330-020-07305-7. PMID: 33026501. PMCID: PMC7979658.

27. Song JH, Kang C, Kim NS, Yi JW, Lee GS, Jang MG, Kim TH. 2021; Evaluation of the uninjured anterior talofibular ligament by ultrasound for assessing generalized joint hypermobility. Foot Ankle Surg. 27:256–62. DOI: 10.1016/j.fas.2020.10.014. PMID: 33189546.

28. Kakegawa A, Fukushima N, Sumitomo N, Nagira A, Ichinose Y, Moriizumi T. 2022; Relationship between inferior fascicle of anterior talofibular ligament and articular capsule in lateral ankle ligament complex. Surg Radiol Anat. 44:253–9. DOI: 10.1007/s00276-021-02851-1. PMID: 34738180.

29. Yokoe T, Tajima T, Kawagoe S, Yamaguchi N, Morita Y, Chosa E. 2022; Does the contralateral healthy ankle of patient with ipsilateral mechanical lateral ankle laxity show greater lateral ankle laxity? Evaluation of the anterior talofibular ligament by stress ultrasonography. BMC Musculoskelet Disord. 23:887. DOI: 10.1186/s12891-022-05838-0. PMID: 36180864. PMCID: PMC9524134. PMID: 01b7fe967230437ea434ba021b44bc82.

30. Özgül B, Starbuck C, Polat MG, Abdeen R, Nester C. 2023; Inter and intra-examiner reliability of musculoskeletal ultrasound scanning of anterior talofibular ligament and ankle muscles. J Ultrasound. 26:137–46. DOI: 10.1007/s40477-022-00699-8. PMID: 36048331.

31. Clanton TO, Campbell KJ, Wilson KJ, Michalski MP, Goldsmith MT, Wijdicks CA, LaPrade RF. 2014; Qualitative and quantitative anatomic investigation of the lateral ankle ligaments for surgical reconstruction procedures. J Bone Joint Surg Am. 96:e98. DOI: 10.2106/JBJS.M.00798. PMID: 24951749.

32. Haytmanek CT, Williams BT, James EW, Campbell KJ, Wijdicks CA, LaPrade RF, Clanton TO. 2015; Radiographic identification of the primary lateral ankle structures. Am J Sports Med. 43:79–87. DOI: 10.1177/0363546514553778. PMID: 25325559.

33. Wenny R, Duscher D, Meytap E, Weninger P, Hirtler L. 2015; Dimensions and attachments of the ankle ligaments: evaluation for ligament reconstruction. Anat Sci Int. 90:161–71. DOI: 10.1007/s12565-014-0238-x. PMID: 24797869.

34. Thès A, Klouche S, Ferrand M, Hardy P, Bauer T. 2016; Assessment of the feasibility of arthroscopic visualization of the lateral ligament of the ankle: a cadaveric study. Knee Surg Sports Traumatol Arthrosc. 24:985–90. DOI: 10.1007/s00167-015-3804-4. PMID: 26410094.

35. Karahan N, Kaya M, Yılmaz B, Kurdal DP, Keskinoz EN, Çiçek EED. 2020; Hamstring autograft and anatomical footprint evaluation for anterior talofibular ligament reconstruction: cadaveric study. J Orthop Surg (Hong Kong). 28:2309499020974830. DOI: 10.1177/2309499020974830. PMID: 33272074. PMID: c4218af349cb44d5b0fc4281fa8b4d41.

36. Buzzi R, Todescan G, Brenner E, Segoni F, Inderster A, Aglietti P. 1993; Reconstruction of the lateral ligaments of the ankle: an anatomic study with evaluation of isometry. J Sports Traumatol Relat Res. 15:55–74.

37. Matsui K, Oliva XM, Takao M, Pereira BS, Gomes TM, Lozano JM, Glazebrook M. ESSKA AFAS Ankle Instability Group. 2017; Bony landmarks available for minimally invasive lateral ankle stabilization surgery: a cadaveric anatomical study. Knee Surg Sports Traumatol Arthrosc. 25:1916–24. DOI: 10.1007/s00167-016-4218-7. PMID: 27351549.

38. Wolff J. 1892. The law of Bone Remodelling. Hirschwald;German. DOI: 10.1007/978-3-642-71031-5.

39. Tano A, Nimura A, Tsutsumi M, Yamaguchi R, Okawa A, Akita K. 2021; Anatomical study of the interosseous ligament of the tibiofibular syndesmosis: an analysis of osseous morphology and attaching interposing structures. J Bone Joint Surg Am. 103:905–12. DOI: 10.2106/JBJS.20.01545. PMID: 33983148.

40. Tsutsumi M, Nimura A, Utsunomiya H, Kudo S, Akita K. 2021; Spatial distribution of loose connective tissues on the anterior hip joint capsule: a combination of cadaveric and in-vivo study. Sci Rep. 11:22813. DOI: 10.1038/s41598-021-02381-1. PMID: 34819610. PMCID: PMC8613189. PMID: 279b7b0e016c45c1a842fbf35abdd072.

41. Nakasa T, Ikuta Y, Ota Y, Kanemitsu M, Sumii J, Nekomoto A, Adachi N. 2021; Safe angles of ATFL and CFL anchor insertion into anatomical attachment of fibula in a lateral ankle ligament repair. J Orthop Sci. 26:156–61. DOI: 10.1016/j.jos.2020.02.011. PMID: 32201028.

42. Hattori S, Nimura A, Koyama M, Tsutsumi M, Amaha K, Ohuchi H, Akita K. 2020; Dorsiflexion is more feasible than plantar flexion in ultrasound evaluation of the calcaneofibular ligament: a combination study of ultrasound and cadaver. Knee Surg Sports Traumatol Arthrosc. 28:262–9. DOI: 10.1007/s00167-019-05630-z. PMID: 31327035.

43. Szaro P, Ghali Gataa K, Polaczek M, Ciszek B. 2020; The double fascicular variations of the anterior talofibular ligament and the calcaneofibular ligament correlate with interconnections between lateral ankle structures revealed on magnetic resonance imaging. Sci Rep. 10:20801. DOI: 10.1038/s41598-020-77856-8. PMID: 33247207. PMCID: PMC7695848.

44. Higashiyama R, Sekiguchi H, Takata K, Endo T, Takamori Y, Takaso M. 2020; Arthroscopic Reconstruction of the anterior tibiotalar ligament using a free tendon graft. Arthrosc Tech. 9:e541–7. DOI: 10.1016/j.eats.2020.01.003. PMID: 32368476. PMCID: PMC7189568.

45. Kobayashi T, Suzuki D, Kondo Y, Tokita R, Katayose M, Matsumura H, Fujimiya M. 2020; Morphological characteristics of the lateral ankle ligament complex. Surg Radiol Anat. 42:1153–9. DOI: 10.1007/s00276-020-02461-3. PMID: 32227271.

46. Hattori S, Onishi K, Chan CK, Yamakawa S, Yano Y, Winkler PW, Hogan MV, Debski RE. 2022; Ultrasound-guided anterior talofibular ligament repair with augmentation can restore ankle kinematics: a cadaveric biomechanical study. Orthop J Sports Med. 10:23259671221111397. DOI: 10.1177/23259671221111397. PMID: 35958291. PMCID: PMC9358583.