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Function of Ankle Ligaments for Subtalar and Talocrural Joint Stability

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Function of Ankle Ligaments for Subtalar and Talocrural Joint Stability Li et al. Journal of Foot and Ankle Research (2019) 12:16 https://doi.org/10.1186/s13047-019-0330-5 RESEARCH Open Access Function of ankle ligaments for subtalar and talocrural joint stability during an inversion movement – an in vitro study Lu Li1* , Albert Gollhofer1, Heinz Lohrer1,2,3, Nadja Dorn-Lange4, Guiseppe Bonsignore4 and Dominic Gehring1 Abstract Background: The lateral ankle ligament complex consisting of the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL) and the posterior talofibular ligament (PTFL) is known to provide stability against ankle joint inversion. As injuries of the ankle joint have been reported at a wide range of plantarflexion/dorsiflexion angles, the aim of the present study was to evaluate the stabilizing function of these ligaments depending on the sagittal plane positioning of the ankle joint. Methods: Eight fresh-frozen specimens were tested on a custom-built ankle deflection tester allowing the application of inversion torques in various plantarflexion/dorsiflexion positions. A motion capture system recorded kinematic data from the talus, calcaneus and fibula with bone-pin markers during inversion movements at 10° of dorsiflexion, at neutral position and at plantarflexion 10°. ATFL, CFL and PTFL were separately but sequentially sectioned in order to assess the contribution of the individual ligament with regard to ankle joint stability. Results: Joint- and position-specific modulations could be observed when the ligaments were cut. Cutting the ATFL did not lead to any observable alterations in ankle inversion angle at a given torque. But subsequently cutting the CFL increased the inversion angle of the talocrural joint in the 10° plantarflexed position, and significantly increased the inversion angle of the subtalar joint in the 10° dorsiflexed position. Sectioning of the PTFL led to minor increases of inversion angles in both joints. Conclusions: The CFL is the primary ligamentous stabilizer of the ankle joint against a forced inversion. Its functioning depends greatly on the plantar−/dorsiflexion position of the ankle joint complex, as it provides the stability of the talocrural joint primarily during plantarflexion and the stability of the subtalar joint primarily during dorsiflexion. Keywords: Lateral ankle ligament complex, Ankle stability, Ankle inversion restriction, Biomechanics Introduction sprain can impair the function of the ankle joint com- Epidemiological data indicate that ankle injuries repre- plex in the long term, which is referred to as chronic sent the most frequent type of sport-related injuries [1]. ankle instability [5]. There exists overwhelming evidence that most of the From an anatomical perspective, the lateral ankle liga- ankle injuries affect the ligaments [2] and that approxi- ment complex consists of the anterior talofibular liga- mately 85% of those injuries are lateral ankle sprains [3]. ment (ATFL), the calcaneofibular ligament (CFL) and The aetiology for injuries of the lateral ankle joint typic- the posterior talofibular ligament (PTFL). Epidemiologic ally comprises excessive inversion, often combined with surveys indicate that the ATFL is the ligament that is in- a pronounced plantarflexion and internal rotation of the jured in 85% of all ankle sprain ligament injuries, while ankle joint complex [4]. It has been shown that an initial the CFL is involved in 35% and the PTFL in 12% [6]. In trying to identify why the individual ligaments are affected during an ankle sprain with different rates, their functional * Correspondence: [email protected] 1Department of Sport and Sport Science, University of Freiburg, roles and their mechanical properties must be taken into Schwarzwaldstraße 175, 79117 Freiburg, Germany consideration. Most of the current information about the Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Li et al. Journal of Foot and Ankle Research (2019) 12:16 Page 2 of 8 functioning of the ankle ligament originates from in-vitro investigations focused on either the stability of the talo- studies, where custom-made devices were developed to crural joint or on the stability of the subtalar joint alone study the biomechanics of the ankle joint while analysing [7, 15, 17, 18, 21]. Integrative investigations analyzing the differential functional importance of the ligaments. the function of the ligaments on both joints of the ankle Researchers typically applied inversion-eversion stimuli joint complex, and possible interactions, are missing. Fi- and/or plantarflexion-dorsiflexion in predefined positions nally, in many of the studies, the researchers have tried of the ankle joint. The biomechanical function is then to slowly rotate the ankle joint to explore the individual studied by dissecting a specific ligament and estimating its ligament’s contribution to ankle joint stability in inver- contribution to stabilizing the ankle joint [7–11]. sion simulations. For example, investigating the contri- Increased knowledge about the function of the specific bution of the CFL, Kobayashi applied an inversion ligaments revealed that the ATFL seems to be the most motion that was limited to up to 1°/s [10]; other studies affected ligament [12, 13], because its functional role is do not even mention the deflection velocity [7, 8, 11]. to restrict both plantarflexion and inversion movements This may be problematic because it is known that liga- [14] and because the maximal tension until failure is ment stiffness is related to the speed of its elongation quite low [8]. Moreover it has been shown that a certain [23] and that typically the ligaments are loaded at high inversion torque, applied at the fixed foot, increases the angular velocities during ankle sprains [13]. posterior tibial displacement by a factor of 2 when the Therefore, the major purpose of the present study was ATFL is dissected [15]. In addition to the ATFL, the to evaluate the biomechanics of the talocrural and subta- CFL seems to resist ankle inversion, as cutting this liga- lar joints when the ligaments of the lateral ankle joint ment led to an increased range of inversion [9]. Applying complex are sequentially resected. Specifically, we aimed an inversion loading following a dissection of both ATFL to assess how the sagittal positions would influence the and CFL respectively increased the range of motion and relative contributions of the individual ligaments to joint decreased the end-range stiffness when compared with stability during dynamic inversion. the intact and solely ATFL-sectioned ankles [16]. Fur- thermore, evidence exists showing that a dissection of Methods the CFL causes significant range of motion changes re- Specimens garding all three planes in the subtalar joint [10]. Thus, Fourteen fresh-frozen human anatomic lower limb spec- it seems that the CFL plays a key role in the lateral imens, amputated above the knee joints, were selected stabilization of both the ankle and the subtalar joint. for the experiments. Already during the experiments, it The functional properties of the PTFL were analysed by became evident that fixation of bone-screws was loos- Ozeki and Kitaoka, who concluded that the PTFL is an ened during dynamic movements in six specimens. Fi- important stabilizer especially when the ankle was in a nally, eight cadavers could be included in the study (age: dorsiflexed postion [17]. Previous research has also 84.0 ± 5.6 years; donors were two men and two women). shown that the strain of the PTFL increases in dorsiflex- Before preparation and measurement, the specimens ion (DF) and plantarflexion (PF), but is only minimally were kept at room temperature for 24 h in order to en- affected by ankle inversion [18]. In summary, the PTFL sure conditional physical properties. An experienced seems to play a supplementary role in lateral ankle sta- anatomist inspected the ankles by manual examination bility, especially when the ATFL and CFL are intact [19]. for normal function and confirmed that there was no Although it is possible to draw important conclusions sign of pathological limitations on any of the cadaver about the ligament function from the above mentioned legs. Thereafter, all ankles were exposed layer by layer in-vitro studies, specific methodological restrictions have creating a skin and soft tissue window (5 × 5 cm) distal to be considered. First, some of the papers selectively fo- to the lateral malleolus and ankle. The integrity of the cused on only one specific ligament of the ankle and its anterior and posterior talofibular ligaments (ATFL and defined functional role [9, 14, 15, 18, 19] while others in- PTFL) and the calcaneofibular ligament (CFL) was veri- vestigated multiple ligaments but considered only cor- fied by visual inspection. During the entire measure- onal movements [7, 16]. Secondly, most of the studies ments the specimen were regularly irrigated with saline, tested the lateral ankle ligament complex with a distinct preventing them from drying-out. The procedures were torque but only either in sagittal or in coronal plane [7, in accordance with the Declaration of Helsinki and ap- 10, 15, 18, 20, 21]. Yet, investigations of the injury mech- proved by the local ethics committee (#10006/18). anism have revealed that ankle sprains can occur at a wide range of plantarflexion/dorsiflexion angles [4, 22]. Experimental equipment setup It therefore appears important to evaluate the functional A custom-built ankle deflection tester (ADT) allowed properties of the involved ligaments under different application of inversion torques in various plantarflex- plantarflexion/dorsiflexion positions.
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