The Archives of Bone and Joint Surgery

The Archives of Bone and Joint Surgery

Does Sectioning and Then Repairing of the Calcaneofibular Ligament at Subtalar Approach Lead to Residual Lateral Ankle Instability?

Document Type : RESEARCH PAPER

Authors
Ali Yüce 1
Abdulhamit Mısır 2
Bülent Karslıoğlu 1
MUSTAFA YERLİ 3
Mustafa Yerli 1
Yunus Imren 1
1 Department of Orthopedic and Traumatology, Prof. Dr. Cemil Taşçıoğlu City Hospital, Istanbul, Turkey
2 Department of Orthopedic and Traumatology, Medicana International Istanbul Hospital, Istanbul, Turkey
3 Department of Orthopedic and Traumatology, Prof. Dr. Cemil Taşcıoğlu City Hospital, Istanbul, TURKEY
10.22038/abjs.2021.54080.2702
Abstract
Background: The calcaneofibular ligament is cut to increase vision in surgical field in minimally invasive surgery 
of displaced intraarticular calcaneus fractures with subtalar incision. We aimed to investigate whether this causes 
talar tilt instability in ankle stress radiographs due to the calcaneofibular ligament deficiency in postoperative period.
Methods: The files of 38 patients who were operated with the diagnosis of displaced calcaneus fracture between 2013 
and 2018 were examined retrospectively. All the cases underwent with subtalar approach and the calcaneofibular 
ligament was repaired after the operation. The age, sex, injury mechanism, follow-up length, type of fracture by 
the Sanders classification, preoperative and postoperative Bohler’s and Gissane’s angle measurements, talar tilt 
measurements of intact and fractured side, postoperative calcaneal length, calcaneal height and calcaneal width of 
the cases were recorded. The obtained data were evaluated statistically. 
Results: 31 (81.6%) of the cases were men, seven (18.4%) were women. The average age was 31.92±7.95 years. 
The average follow-up time was 15.82±3.33 months. The preoperative Bohler’s angle was 14.16±3.67 degree, while 
the postoperative Bohler’s angle was 31.53±4.60 degree (P<0.05). The average talar tilt was 0.96±0.87 degrees on 
the intact side and 1.19±1.12 degrees on the fractured side (P:0.001). Although the talar tilt values were statistically 
higher on the fractured side than the intact side, no radiological instability finding was found in any case. The average 
postoperative Gissane’s angles were 126.45±6.69 degrees. The calcaneal length (P:0.665), calcaneal width (P:0.212) 
and calcaneal height (P:0.341) were statistically similar between the postoperative fractured foot and intact foot.
Conclusion: Sectioning of the calcaneofibular ligament in the surgical treatment with subtalar approach does 
not cause lateral ankle instability in stress radiographs but may cause laxity. Possible postoperative lateral ankle 
injuries can be prevented by ankle proprioception exercises.
Level of evidence: III
Keywords
Ankle instability
Calcaneal fracture
Calcaneofibular ligament
Sinus tarsi approach
Subtalar approach
  1. Dhillon MS, Bali K, Prabhakar S. Controversies in calcaneus fracture management: a systematic review of the literature. Musculoskelet Surg.2011; 95(3):171-81.
  2. Abdelgaid SM. Closed reduction and percutaneous cannulated screws fixation of displaced intra-articular calcaneus fractures. J Foot Ankle Surg. 2012;18(3):164–79.
  3. Fan B, Zhou X, Wei Z, Ren Y, Lin W, Hao Y, et al. Cannulated screw fixation and plate fixation for displaced intraarticular calcaneus fracture: A meta-analysis of randomized controlled trials. Int J Surg. 2016;34:64-72.
  4. Kikuchi C, Charlton TP, Thordarson DB. Limited Sinus Tarsi Approach for Intra-articular Calcaneus Fractures. Foot Ankle Int. 2013;34(12):1689-94.
  5. Kumar VS, Marimuthu K, Subramani S, Sharma V, Bera J, Kotwal P. Prospective randomized trial comparing open reduction and internal fixation with minimally invasive reduction and percutaneous fixation in managing displaced intra-articular calcaneal fractures. Int Orthop. 2014;38(12):2505-12.
  6. Femino JE, MD, Vaseenon T, Levin DA, Yian EH. Modification of the Sinus Tarsi Approach for Open Reduction and Plate Fixation of Intra-articular Calcaneus Fractures: The limits of proximal extension based upon the vascular Anatomy of the lateral calcaneal artery. Iowa Orthop J. 2010;30:161-7.
  7. Zhou H-C, Yu T, Ren H-Y, Li B, Chen K, Zhao Y-G, et al. Clinical Comparison of Extensile Lateral Approach and Sinus Tarsi Approach Combined with Medial Distraction Technique for Intra-Articular Calcaneal Fractures. Orthop Surg. 2017;9(1):77-85.
  8. Park C, Lee DY. Surgical Treatment of Sanders Type 2 Calcaneal Fractures Using a Sinus Tarsi Approach. Indian J Orthop. 2017;51(4):461-7.
  9. Yıldız S, Yalçın B. The anterior talofibular and calcaneofibular ligaments: an anatomic study. Surg Radiol Anat. 2013;35(6):511-6.
  10. Kjaersgaard-Andersen P, Wethelund J, Helmlg P, Nielsen S. Effect of the calcaneofibular ligament on hindfoot rotation in amputation specimens. Acta Orthop Scand. 1987;58(2):135-8.
  11. Chan KW, Ding BC, Mroczek KJ. Acute and chronic lateral ankle instability in the athlete. Bull NYU Hosp Jt Dis. 2011;69(1):17-26.
  12. Beighton P, Horan F. Orthopaedic aspects of the Ehlers-Danlos syndrome. J Bone Joint Surg Br. 1969;51(3):444-53.
  13. Hashimoto T, Inokuchi S, Kokubo T. Clinical study of chronic lateral ankle instability: injured ligaments compared with stress X-ray examination. J Orthop Sci. 2009;14(6):699-703.
  14. Wang C-S, Tzeng Y-H, Lin C-C, Huang C-K, Chang M-C, Chiang C-C. Radiographic Evaluation of Ankle Joint Stability After Calcaneofibular Ligament Elevation During Open Reduction and Internal Fixation of Calcaneus Fracture. Foot Ankle Int.2016; 37(9):944-9.
  15. Dowling LB, Giakoumis M, Ryan JD. Narrowing the Normal Range for Lateral Ankle Ligament Stability with Stress Radiography. J Foot Ankle Surg. 2014;53(3):269-73.
  16. Rubin G, Witten M. The talar-tilt angle and the fibular collateral ligaments: a method for the determination of talar tilt. J Bone Joint Surg Am. 1960;42(2):311-26.
  17. Galloway MT, Lalley AL, Shearn JT. The role of mechanical loading in tendon development, maintenance, injury, and repair. J Bone Joint Surg Am. 2013 Sep 4;95(17):1620-8.
  18. Weiss JA, Woo SLY, Ohland KJ, Horibe S, Newton PO. Evaluation of a new injury model to study medial collateral ligament healing: Primary repair versus nonoperative treatment. J Orthop Res. 1991;9(4):516-28.
  19. Woo S L-Y, Vogrin TM, MS, Abramowitch SD. Healing and Repair of Ligament Injuries in the Knee. J Am Acad Orthop Surg. 2000;8(6):364-72.
  20. Hertel J. Functional Anatomy, Pathomechanics, and Pathophysiology of Lateral Ankle Instability. J Athl Train. 2002;37(4):364-75.
  21. Lee KM, Chung CY, Kwon S-S, Chung MK, Won SH, Lee SY, et al. Relationship between stress ankle radiographs and injured ligaments on MRI. Skeletal Radiol. 2013;42(11):1537-42.
  22. Heilman AE, Braly WG, Bishop JO, Noble PC, Tullos HS. An Anatomic Study Of Subtalar Instability. Foot Ankle. 1990;10(4):224-8.
  23. Okuda R, Kinoshita M, Morikawa J, Jotoku T, Abe M. Reconstruction for Chronic Lateral Ankle Instability Using the Palmaris Longus Tendon: Is Reconstruction of the Calcaneofibular Ligament Necessary? Foot Ankle Int. 1999;20(11):714-20.
  24. Golanó P,  Vega J, de Leeuw PA, Malagelada F, Manzanares MC, Götzens V, et al. Anatomy of the ankle ligaments: a pictorial essay. Knee Surg Sports Traumatol Arthrosc. 2010;18(5):557-69.
  25. Zwipp H, Rammelt S, Grass R. Ligamentous injuries about the ankle and subtalar joints. Clin Podiatr Med Surg. 2002;19(2):195-229.
  26. Fujii T, Luo Z-P, Kitaoka HB, An K-N. The manual stress test may not be sufficient to differentiate ankle ligament injuries. Clin Biomech. 2000;15(8):619-23.
The Archives of Bone and Joint Surgery
Volume 10, Issue 4
April 2022
Pages 347-352

  • Receive Date 11 December 2020
  • Revise Date 24 August 2021
  • Accept Date 26 August 2021