Restricted accessResearch articleFirst published online 2022-5
Effects of the Ankle Flexion Angle During Anterior Talofibular Ligament Reconstruction on Ankle Kinematics,Laxity,and In Situ Forces of the Reconstructed Graft
This study aimed to evaluate the effects of the ankle flexion angle during anterior talofibular ligament (ATFL) reconstruction on ankle kinematics, laxity, and in situ force of a graft.
Methods:
Twelve cadaveric ankles were evaluated using a 6–degrees of freedom robotic system to apply passive plantar flexion and dorsiflexion motions and multidirectional loads. A repeated measures experiment was designed using the intact ATFL, transected ATFL, and reconstructed ATFL. During ATFL reconstruction (ATFLR), the graft was fixed at a neutral position (ATFLR 0 degrees), 15 degrees of plantar flexion (ATFLR PF15 degrees), and 30 degrees of plantar flexion (ATFLR PF30 degrees) with a constant initial tension of 10 N. The 3-dimensional path and reconstructed graft tension were simultaneously recorded, and the in situ force of the ATFL and reconstructed grafts were calculated using the principle of superposition.
Results:
The in situ forces of the reconstructed grafts in ATFLR 0 degrees and ATFLR PF 15 degrees were significantly higher than those of intact ankles. The ankle kinematics and laxity produced by ATFLR PF 30 degrees were not significantly different from those of intact ankles. The in situ force on the ATFL was 19.0 N at 30 degrees of plantar flexion. In situ forces of 41.0, 33.7, and 21.9 N were observed at 30 degrees of plantar flexion in ATFLR 0, 15, and 30 degrees, respectively.
Conclusion:
ATFL reconstruction with the peroneus longus (PL) tendon was performed with the graft at 30 degrees of plantar flexion resulted in ankle kinematics, laxity, and in situ forces similar to those of intact ankles. ATFL reconstructions performed with the graft fixed at 0 and 15 degrees of the plantar flexion resulted in higher in situ forces on the reconstructed graft.
Clinical Relevance:
Fixing the ATFL tendon graft at 30 degrees of plantar flexion results in an in situ force closest to that of an intact ankle and avoids the excessive tension on the reconstructed graft.
BahrRPenaFShineJLewWDEngebretsenL.Ligament force and joint motion in the intact ankle: a cadaveric study. Knee Surg Sports Traumatol Arthrosc. 1998;6(2):115-121. doi:10.1007/s001670050083.
2.
BeckerHPRosenbaumDZeithammelG, et al. Tenodesis versus carbon fiber repair of ankle ligaments: a clinical comparison. Clin Orthop Relat Res. 1996;325:194-202. doi:10.1097/00003086-199604000-00023.
3.
BrownCAHurwitDBehnAHuntKJ.Biomechanical comparison of an all-soft suture anchor with a modified Broström-Gould suture repair for lateral ligament reconstruction. Am J Sports Med. 2014;42(2):417-422. doi:10.1177/0363546513517873.
4.
BurksRTMorganJ.Anatomy of the lateral ankle ligaments. Am J Sports Med. 1994;22(1):72-77. doi:10.1177/036354659402200113.
5.
CaprioAOlivaFTreiaFMaffulliN. Reconstruction of the lateral ankle ligaments with allograft in patients with chronic ankle instability. Caprio. Foot Ankle Clin. 2006;11(3):597-605. doi:10.1007/s00064-011-0126-7.
6.
ClantonTOViensNACampbellKJLaPradeRFWijdicksCA.Anterior talofibular ligament ruptures, part 2. Am J Sports Med. 2013;42(2):412-416. doi:10.1177/0363546513509963.
7.
CliftonDRKoldenhovenRMHertelJOnateJADompierTPKerrZY.Epidemiological patterns of ankle sprains in youth, high school, and college football. Am J Sports Med. 2017;45(2):417-425. doi:10.1177/0363546516667914.
8.
CoughlinMJSchenckRCGrebingBRTremeG.Comprehensive reconstruction of the lateral ankle for chronic instability using a free gracilis graft. Foot Ankle Int. 2004;25(4):231-241. doi:10.1177/107110070402500407.
9.
DierckmanBDFerkelRD.Anatomic reconstruction with a semitendinosus allograft for chronic lateral ankle instability. Am J Sports Med. 2015;43(8):1941-1950. doi:10.1177/0363546515593942.
10.
FujieHLivesayGAFujitaMWooSLY. Forces and moments in six-DOF at the human knee joint: Mathematical description for control. J Biomech. 1996;29(12):1577-1585. doi:10.1016/S0021-9290(96)80009-1.
11.
FujieHLivesayGAWooSLKashiwaguchiSBlomstromG.The use of a universal force-moment sensor to determine in-situ forces in ligaments: a new methodology. J Biomech Eng. 1995;117(1):1-7. doi:10.1115/1.2792266.
12.
FujieHSekitoTOritaA.A novel robotic system for joint biomechanical tests: application to the human knee joint. J Biomech Eng. 2004;126(1):54. doi:10.1115/1.1644567.
13.
GerberJPWilliamsGNScovilleCRArcieroRATaylorDC.Persistent disability associated with ankle sprains: a prospective examination of an athletic population. Foot Ankle Int. 1998;19(10):653-660. doi:10.1177/107110079801901002.
14.
GizaEWhitlowSRWilliamsBT, et al. Biomechanical analysis of an arthroscopic Broström ankle ligament repair and a suture anchor-augmented repair. Foot Ankle Int. 2015;36(7):836-841. doi:10.1177/1071100715576539.
15.
GolanóPVegaJde LeeuwPAJ, et al. Anatomy of the ankle ligaments: a pictorial essay. Knee Surg Sports Traumatol Arthrosc. 2016;24(4):944-956. doi:10.1007/s00167-016-4059-4.
16.
HagioTYoshimuraIKanazawaKMinokawaSYamamotoT.Morphology of anterior talofibular ligament after arthroscopic lateral ankle ligament repair. Foot Ankle Int. 2020;41(8):993-1001. doi:10.1177/1071100720920610
17.
HigashiyamaRAikawaJIwaseDTakamoriYWatanabeETakasoM.Anatomical arthroscopic anterior talofibular ligament and calcaneofibular ligament reconstruction using an autogenic hamstring tendon: safe creation of anatomical fibular tunnel. Arthrosc Tech. 2019;8(3):e215-e222. doi:10.1016/j.eats.2018.10.016.
18.
HuaYChenSJinYZhangBLiYLiH.Anatomical reconstruction of the lateral ligaments of the ankle with semitendinosus allograft. Int Orthop. 2012;36(10):2027-2031. doi:10.1007/s00264-012-1577-7.
19.
JungHGKimTHParkJYBaeEJ.Anatomic reconstruction of the anterior talofibular and calcaneofibular ligaments using a semitendinosus tendon allograft and interference screws. Knee Surg Sports Traumatol Arthrosc. 2012;20(8):1432-1437. doi:10.1007/s00167-011-1666-y.
20.
KarlssonJBergstenTLansingerOPetersonL.Reconstruction of the lateral ligaments of the ankle for chronic lateral instability. J Bone Joint Surg Am. 1988;70(4):581-588.
21.
KarlssonJErikssonBIBergstenTRudholmOSwärdL.Comparison of two anatomic reconstructions for chronic lateral instability of the ankle joint. Am J Sports Med. 1997;25(1):48-53. doi:10.1177/036354659702500109.
22.
KatsuragiRYasudaKTsujiroJKeiraMKanedaK.The effect of nonphysiologically high initial tension on the mechanical properties of in situ frozen anterior cruciate ligament in a canine model. Am J Sports Med. 2000;28(1):47-56.
23.
KawaguchiYKondoEKitamuraNKaiSInoueMYasudaK.Comparisons of femoral tunnel enlargement in 169 patients between single-bundle and anatomic double-bundle anterior cruciate ligament reconstructions with hamstring tendon grafts. Knee Surg Sports Traumatol Arthrosc. 2011;19(8):1249-1257. doi:10.1007/s00167-011-1455-7.
24.
KimHNJeonJYDongQ, et al. Lateral ankle ligament reconstruction using the anterior half of the peroneus longus tendon. Knee Surg Sports Traumatol Arthrosc. 2015;23(6):1877-1885. doi:10.1007/s00167-014-3072-8.
25.
KirwanGWPhtyMBourkeMG, et al. Initial graft tension and the effect on postoperative patient reconstruction. Arthroscopy. 2013;29(5):934-941. doi:10.1016/j.arthro.2013.01.021.
26.
KobayashiTYamakawaSWatanabeK, et al. The in situ force in the calcaneofibular ligament and the contribution of this ligament to ankle joint stability. Clin Biomech. 2016;40:8-13. doi:10.1016/j.clinbiomech.2016.10.009.
27.
KripsRvan DijkCHalasiP, et al. Long-term outcome of anatomical reconstruction versus tenodesis for the treatment of chronic anterolateral instability of the ankle joint: a multicenter study. Foot Ankle Int. 2001;22(5):415-421. doi:10.1177/107110070102200510.
LiHHuaYLiHChenS.Anatomical reconstruction produced similarly favorable outcomes as repair procedures for the treatment of chronic lateral ankle instability at long-term follow-up. Knee Surg Sports Traumatol Arthrosc. 2018;28(10):3324-3329. doi:10.1007/s00167-018-5176-z.
30.
MaeTShinoKNakataKToritsukaYOtsuboHFujieH.Optimization of graft fixation at the time of anterior cruciate ligament reconstruction: Part I: effect of initial tension. Am J Sports Med. 2008;36(6):1087-1093. doi:10.1177/0363546508314433.
31.
MaeTShinoKNakataKToritsukaYOtsuboHFujieH.Optimization of graft fixation at the time of anterior cruciate ligament reconstruction: Part II: effect of knee flexion angle. Am J Sports Med. 2008;36(6):1094-1100. doi:10.1177/0363546508317412.
32.
MalliaropoulosNNtessalenMPapacostasELongoUGMaffulliN.Reinjury after acute Lateral ankle sprains in elite track and field athletes. Am J Sports Med. 2009;37(9):1755-1761. doi:10.1177/0363546509338107.
33.
MauntelTCWikstromEARoosKGDjokoADompierTPKerrZY.The epidemiology of high ankle sprains in National Collegiate Athletic Association sports. Am J Sports Med. 2017;45(9):2156-2163. doi:10.1177/0363546517701428.
34.
MesserTMCumminsCAAhnJKelikianAS.Outcome of the modified Broström procedure for chronic lateral ankle instability using suture anchors. Foot Ankle Int. 2000;21(12):996-1003. doi:10.1177/107110070002101203.
35.
MichelsFCordierGBurssensAVereeckeEGuilloS.Endoscopic reconstruction of CFL and the ATFL with a gracilis graft: a cadaveric study. Knee Surg Sports Traumatol Arthrosc. 2016;24(4):1007-1014. doi:10.1007/s00167-015-3779-1.
36.
NaeemRLahiriA.Modified Camitz opponensplasty for severe thenar wasting secondary to carpal tunnel syndrome: case series. J Hand Surg Am. 2013;38(4):795-798. doi:10.1016/j.jhsa.2013.01.027.
37.
NeuschwanderTBIndresanoAAHughesTHSmithBW.Footprint of the lateral ligament complex of the ankle. Foot Ankle Int. 2013;34(4):582-586. doi:10.1177/1071100712466851.
38.
NicholasSD’AmatoMMullaneyMTylerTKolstadKMcHughM.A prospectively randomized double-blind study on the effect of initial graft tension on knee stability after anterior cruciate ligament reconstruction. Am J Sports Med. 2004;32(8):1881-1886.
39.
NiggBMSkarvanGFrankCBYeadonMR.Elongation and forces of ankle ligaments in a physiological range of motion. Foot Ankle. 1990;11(1):30-40. doi:10.1177/107110079001100107.
40.
O’LoughlinPFMurawskiCDEganCKennedyJG.Ankle instability in sports. Phys Sportsmed. 2009;37(2):93-103. doi:10.3810/psm.2009.06.1715.
41.
OzekiSKitaokaHUchiyamaELuoZPKaufmanKAnKN.Ankle ligament tensile forces at the end points of passive circumferential rotating motion of the ankle and subtalar joint complex. Foot Ankle Int. 2006;27(11):965-969. doi:10.1177/107110070602701117.
42.
PatersonRCohenBTaylorDBourneABlackJ.Reconstruction of the lateral ligaments of the ankle using semi-tendinosis graft. Foot Ankle Int. 2000;21(5):413-419. doi:10.1177/107110070002100510.
43.
PriskVRImhauserCWO’LoughlinPFKennedyJG.Lateral ligament repair and reconstruction restore neither contact mechanics of the ankle joint nor motion patterns of the hindfoot. J Bone Joint Surg Am. 2010;92(14):2375-2386. doi:10.2106/JBJS.I.00869.
44.
RenstromPWertzMIncavoS, et al. Strain in the lateral ligaments of the ankle. Foot Ankle. 1988;9(2):59-63. doi:10.1177/107110078800900201.
45.
SakakibaraYTeramotoATakagiT, et al. Effect of initial graft tension during anterior talofibular ligament reconstruction on ankle kinematics, laxity, and in situ forces of the reconstructed graft. Am J Sports Med. 2020;48(4):916-922. doi:10.1177/0363546520902725.
46.
SakakibaraYTeramotoATakagiT, et al. Effect of initial graft tension during calcaneofibular ligament reconstruction on ankle kinematics and laxity. Am J Sports Med. 2018;46(12):2935-2941. doi:10.1177/0363546518790254.
47.
SchmidtRCordierEBertschC, et al. Reconstruction of the lateral ligaments: do the anatomical procedures restore physiologic ankle kinematics?Foot Ankle Int. 2004;25(1):31-36. doi:10.1177/107110070402500107.
48.
ShojiHTeramotoASuzukiD, et al. Suture-button fixation and anterior inferior tibiofibular ligament augmentation with suture-tape for syndesmosis injury: a biomechanical cadaveric study. Clin Biomech. 2018;60:121-126. doi:10.1016/j.clinbiomech.2018.10.014.
49.
SugimotoKTakakuraYKumaiTIwaiMTanakaY.Reconstruction of the lateral ankle ligaments with bone-patellar tendon graft in patients with chronic ankle instability. A preliminary report. Am J Sports Med. 2002;30(3):340-346. doi:10.1177/03635465020300030701.
50.
TachibanaYMaeTShinoK, et al. Morphological changes in femoral tunnels after anatomic anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2015;23(12):3591-3600. doi:10.1007/s00167-014-3252-6.
51.
TakaoMKomatsuFNaitoKUchioYOchiM.Reconstruction of lateral ligament with arthroscopic drilling for treatment of early-stage osteoarthritis in unstable ankles. Arthroscopy. 2006;22(10):1119-1125. doi:10.1016/j.arthro.2006.06.012.
52.
TakaoMOaeKUchioYOchiMYamamotoH.Anatomical reconstruction of the lateral ligaments of the ankle with a gracilis autograft: a new technique using an interference fit anchoring system. Am J Sports Med. 2005;33(6):814-823. doi:10.1177/0363546504272688.
53.
VerhagenRAWde KeizerGvan DijkCN.Long-term follow-up of inversion trauma of the ankle. Arch Orthop Trauma Surg. 1995;114(2):92-96. doi:10.1007/BF00422833.
54.
WangBXuXY.Minimally invasive reconstruction of lateral ligaments of the ankle using semitendinosus autograft. Foot Ankle Int. 2013;34(5):711-715. doi:10.1177/1071100713478916.
55.
WatanabeKKitaokaHBBerglundLJZhaoKDKaufmanKRAnKN.The role of ankle ligaments and articular geometry in stabilizing the ankle. Clin Biomech. 2012;27(2):189-195. doi:10.1016/j.clinbiomech.2011.08.015.
56.
WatermanBROwensBDDaveySZacchilliMABelmontPJ.The epidemiology of ankle sprains in the United States. J Bone Joint Surg Am. 2010;92(13):2279-2284. doi:10.2106/JBJS.I.01537.
57.
WilleggerMBencaEHirtlerL, et al. Biomechanical stability of tape augmentation for anterior talofibular ligament (ATFL) repair compared to the native ATFL. Knee Surg Sports Traumatol Arthrosc. 2016;24(4):1015-1021. doi:10.1007/s00167-016-4048-7.
58.
WuGSieglerSAllardP, et al. ISB recommendation on definitions of joint coordinate system of various joints for the reporting of human joint motion—part I: ankle, hip, and spine. J Biomech. 2002;35(4):543-548. doi:10.1016/S0021-9290(01)00222-6.
59.
YamaguchiSSashoTKatoHKuroyanagiYBanksSA.Ankle and subtalar kinematics during dorsiflexion-plantarflexion activities. Foot Ankle Int. 2009;30(4):361-366. doi:10.3113/FAI.2009.0361.
60.
YoshiyaSAndrishJTManleyMTBauerTW.Graft tension in anterior cruciate ligament reconstruction. An in vivo study in dogs. Am J Sports Med. 1987;15(5):3674269. doi:10.1177/036354658701500506.
61.
ZongJCMaRWangH, et al. The effect of graft pretensioning on bone tunnel diameter and bone formation after anterior cruciate ligament reconstruction in a rat model: evaluation with micro-computed tomography. Am J Sports Med. 2017;45(6):1349-1358. doi:10.1177/0363546516686967.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
