Ligamentous Injuries About The Ankle and Subtalar Joints: Hans Zwipp, MD, PHD, Stefan Rammelt, MD, Rene Grass, MD

Clin Podiatr Med Surg
19 (2002) 195 – 229
Ligamentous injuries about the ankle

and subtalar joints
Hans Zwipp, MD, PhD, Stefan Rammelt, MD*,
René Grass, MD
Department of Trauma and Reconstructive Surgery,
Klinik und Poliklinik für Unfall- und Wiederherstellungschirurgie,
Universitätsklinikum ‘‘Carl Gustav Carus’’ der TU Dresden, Fetscherstrasse 74,
01307 Dresden, Germany
Distal tibiofibular syndesmosis

Syndesmotic sprains are estimated to occur in about 10% of all ankle sprains
[1] and are a common source of chronic ankle pain and arthritis in athletes,
especially if undiagnosed [2,3]. Because of a slightly oblique axis and the
irregular shape of the talus, which is not cylindrical, but broader ventrally and
laterally, the ankle joint is not a pure hinge joint [4,5]. Therefore a considerable
clearance takes place between the talus and the distal fibula, which is limited only
by the tibiofibular syndesmosis. The syndesmotic complex thus provides a
dynamic support to the ankle that is essential for normal performance [6,7]. It
was the British surgeon Bromfeild [8] who in 1773 brought attention to the
importance of a ligamentous junction between the distal tibia and fibula when he
stated that if the distal fibula were part of the tibia, then a malleolar fracture
would result after a few steps. The pathomechanical investigations of Maison-
neuve [9] shed light on the close connection between malleolar fractures and
ligamentous injuries. The high fibular fracture with rupture of the distal
tibiofibular syndesmosis and the interosseous membrane still bears his name.
Despite this long-standing awareness of the functional importance of the
syndesmotic complex, until today there has been no controlled clinical study
about the role of syndesmotic injuries in the wake of malleolar fractures [6].
* Corresponding author.
E-mail address: strammelt@hotmail.com (S. Rammelt).
0891-8422/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved.
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196 H. Zwipp et al / Clin Podiatr Med Surg 19 (2002) 195–229
Anatomy and biomechanics

The strong ligamentous junction between the tibia and fibula consists of three
parts. The proximal tibiofibular syndesmosis is formed by the Lig. capitis fibulae
anterior and posterior [10]. The aponeurotic interosseous membrane has little
mechanical strength. Of paramount importance is the distal tibiofibular ligament
complex, which consists of five separate portions:
1. The anterior tibiofibular ligament descends from the tubercúle de Tillaux-

Chaput (tubercle of Chaput) of the tibia to the anterior aspect of the distal
fibula. It has an average length of 16 mm, a breadth of 16 mm at the
tibial origin and of 13 mm at the fibular insertion, and has a stiffness of
5 kp/mm [11]. It consists mostly of two portions that are separated by a
gap of 1.6 mm. The anterior tibiofibular ligament is tensioned maximally
during plantarflexion.
2. The posterior tibiofibular ligament is the strongest part of the distal syn-
desmosis. It descends posterolaterally from the posterior tubercle of the
tibia. Like the anterior tibiofibular ligament, it has a stiffness of 5 kp/mm,
but the load to failure (120 kp in men, 70 kp in women) supersedes that
of the anterior tibiofibular ligament (95 kp in men, 60 kp in women). Its
average length is 20 mm, with a breadth of 18 mm at the tibial origin and
of 12 mm at the fibular insertion. The posterior tibiofibular ligament is
under maximum tension during dorsiflexion [12].
3. The transverse tibiofibular ligament lies distal to the posterior tibiofibular
ligament and has a fibrocartilagineous appearance. It runs almost
horizontally to the posterior tubercle of the fibula and is sometimes hard
to discriminate from the posterior tibiofibular ligament.
4. The interosseous tibiofibular ligament is neglected in many important
anatomical and surgical textbooks; it is nevertheless a mechanically
important rigid ligament [13], which also contains elastic fibers and
serves as buffer and stabilizer of the distal tibiofibular joint [7]. It lies in
the pivot of the ankle joint [14,15]. Synonyms include ‘‘syndesmotic
plate’’ and ‘‘Lig. malleoli lateralis intermedium’’ [13,15].
5. The distal portion of the interosseous membrane consists of aponeurotic
fibers that are recruited from the cranial origins of the anterior and pos-
terior tibiofibular ligaments.
With normal stance, almost no twisting and shearing forces act on the ankle
joint, and the pressures distributed through the joint surfaces are equal to the body
weight [12]. Therefore minimal tension is exerted on the tibiofibular ligaments
under static conditions [11]. Under normal conditions, 10 to 17 per cent of the
body weight is taken up by the distal fibula, an important mechanism that is
impaired by syndesmotic insufficiency [16]. The fibula then dislocates laterally
and posteriorly, resulting in an incongruent ankle joint [17].
H. Zwipp et al / Clin Podiatr Med Surg 19 (2002) 195–229 197
The pivot of the ankle joint runs from the tip of the lateral malleolus to the tip
of the medial malleolus and ascends eight degrees in the frontal plane and six
degrees in the transverse plain. The lateral slope of the talar dome is perpendic-
ular to the pivot, while the medial side is inclined by six degrees, which leads to
a pseudorotation of the talus during movement in the ankle mortise [4,5]. With
an experimental lesion of the anterior tibiofibular ligament, external rotation of
the talus occurs [17]. With an intact syndesmosis, the intermalleolar distance
increases with dorsiflexion of the talus by an average of 1.25 mm, while the
fibula rotates by two degrees externally [16]. The syndesmosis also allows
vertical and anteroposterior movement of the fibula [18]. The guidance of the
fibula in the fibular incisura of the tibia relies entirely on the syndesmotic
ligaments. Under a constant external rotation load of 5 Nm on the foot,
dissection of all syndesmotic ligaments increases tibiofibular diastasis by a mean
of 7.3 mm. With this pathologic rotation of the talus of about 10 degrees, the
fibula moves dorsally and only slightly laterally [13,17]. Given the reduction in
fibulotalar contact area, this condition should be considered a prearthrotic
deformity. In fact, among 64 patients who presented at our clinic for ankle
arthrodesis because of otherwise intractable arthritis after fracture-dislocations of
the ankle, 13 (20.3 per cent) had significant widening of the ankle mortise [6].
These data show that the role of the syndesmotic injury in ankle fractures needs
further clarification.
Mechanism of injury
Syndesmotic injury is produced by forced eversion (external rotation) of the
talus in the ankle mortise, with the foot in dorsiflexion, which puts the broader
anterior part of the talus into the ankle mortise [4,7,19,20]. With the foot in
supination, the anterior tibiofibular ligament is the first to rupture, followed by
the interosseous ligament. The posterior tibiofibular ligament is usually pre-
served and serves as a pivot for the distal fibula [19]. The isolated rupture of the
anterior tibiofibular ligament corresponds to a supination-external rotation stage I
injury to the ankle, according to the Lauge-Hansen classification of ankle frac-
tures [21].
However, isolated ruptures of the syndesmosis without a malleolar fracture are
rare. According to the Lauge-Hansen classification, most syndesmotic lesions
occur with pronation-external rotation stage IV injuries, which account for 8 to 11
per cent of malleolar fractures and are associated with the highest rate of post-
traumatic arthritis [7,13]. To a lesser degree, syndesmotic ruptures occur with
pronation-abduction and supination-external rotation injuries [21].
Diagnosis
Patients with acute or chronic syndesmotic injury present with pain in the
anterolateral aspect of the ankle joint, which is aggravated by forced dorsiflexion.
The anterolateral aspect of the ankle is tender to palpation. With passive external
rotation of the foot in neutral position against the fixed lower leg, pain over the
syndesmosis can be provoked (Frick’s test, [19]), which has proved to be a
sensitive test for syndesmotic injury [18]. Distal tibiofibular compression also
provokes pain. Standard radiographs of the ankle that include both the ‘‘true
anteroposterior’’ and ‘‘mortise view’’ rule out malleolar fractures. According to
Chaput [22], a useful tool in detecting syndesmotic injury is the evaluation of the
‘‘espace claire’’ (tibiofibular clear space), which is measured on both feet in the
true AP view (Fig. 1). Other radiographic landmarks include the tibiofibular
overlap and the medial clear space. An anteroposterior view of the lower leg is
done to exclude a high fibula fracture (Fig. 2), or Maisonneuve’s fracture. A
tibiofibular clear space of less than 6 mm, a tibiofibular overlap of 6 mm or more
(or 40% of fibular width) in the AP view, or greater than 1 mm in the mortise
view, are considered to be normal [23]. Syndesmotic insufficiency is finally
proved with stress radiographs (Fig. 3). The best way to diagnose isolated rupture
of the anterior tibiofibular ligament without tibiofibular instability is arthrography
within 48 hours of the injury [7,19].
Computed tomography (CT) scanning is the most accurate method of detect-
ing syndesmotic injuries, especially partial ruptures with tibiofibular diastasis of
Fig. 1. True anteroposterior view of the ankle. The tibiofibular clear space (AB), tibiofibular overlap
(BC), and medial clear space (EF) are measured for evaluation of the syndesmosis.
Fig. 2. Severe syndesmotic rupture with wedging of the talus. This kind of injury only rarely occurs
without fibular fracture.
2 mm or less. Care is taken to evaluate tibiofibular distance at exactly the same

level on the uninjured side. Generally, diastases of 2 mm and more are considered
to be pathological [17]. Apart from the tibiofibular diastasis, rotation of the distal
fibula can be assessed exactly [6].
Depending on the radiographic findings, Edwards and DeLee [24] classified
traumatic syndesmotic sprains into latent diastasis (seen on stress radiographs
only) and frank diastasis, which is obvious on plain radiographs. The latter is
further divided into Types I to IV:
Type I, lateral subluxation of the fibula

Type II, plastic deformation of the fibula
Type III, posterior rotary subluxation of the fibula (rare)
Type IV, wedging of the talus between the tibia and fibula without fracture (rare)
Apart from that, classification must discriminate acute, subacute, and chronic
sprains, as well as atraumatic disorders.
Treatment
Acute syndesmotic injury
Isolated ruptures of the anterior tiobiofibular ligament can be treated suc-
cessfully with conservative-functional treatment in an ankle orthosis for six
weeks [7]. Acute instability of the distal tibiofibular syndesmosis, either isolated
or in conjunction with malleolar fractures, is treated with a syndesmosis screw as
the ‘‘golden standard’’ [7,13,16,25,26]. The distal tibiofibular joint is freed from
avulsed ligamentous tissue or debris. After open reduction and internal fixation
of supination-external rotation fractures, stability of the syndesmotic complex is
tested with a hook under fluoroscopic control, as described by Heim [13]. Care
is taken to set the fibula properly into the tibial incisura; it may be secured for
Fig. 3. (A) Manual stress test for syndesmotic instability that is evidenced by fluoroscopy (B).
Fig. 3 (continued ).
that reason temporarily with a Kirschner-wire after fitting it properly into the
incisura [6]. The foot is brought into dorsiflexion to ensure a correct tibiofibular
distance [25]. A 3.5 mm cortical screw is positioned less than 4 cm above the
joint level in 30 from posterolateral to anteromedial, and penetrates three
cortices [13,27]. In order to avoid any lag effect, the screw is not overdrilled.
The ruptured anterior tibiofibular ligament is sutured separately, or reattached
if avulsed.
In pronation-external rotation fractures, the syndesmosis is generally injured.
When reviewing CT scans with respect to syndesmotic reduction, Pottorff and
Kaye found the syndesmosis to be usually under-reduced [28]. Since there is
frequently a higher degree of instability with rupture of all components of the
syndesmosis in pronation-external rotation injuries, we generally use a post-
operative CT after open reduction, internal fixation, and syndesmosis screw
placement, to ensure tibiofibular congruency and to allow early correction, if
necessary (Fig. 4). With Maisonneuve-type fractures, two parallel syndesmosis
screws are applied to achieve sufficient rotational stability [6,7,13]. Syndesmosis
screws are kept in place for six to eight weeks, and for this period the patient is
restricted to 15 kp partial weight bearing.
Chronic syndesmotic instability

Few papers discuss surgical reconstruction for chronic instability after
syndesmosis ruptures. Ogilvie-Harris and Reed [2] performed arthroscopic
treatment for chronic syndesmotic injuries in 19 patients with an average of
two years of symptoms. Arthroscopic resection of the torn interosseous ligament
Fig. 5. Peroneus longus ligamentoplasty for chronic syndesmotic insufficiency [6]. A split peroneus
longus tendon is used to reconstruct all three major parts of the syndesmosis: the anterior,
interosseous, and posterior distal tibiofibular ligaments.
and chondroplasty relieved symptoms in all patients in the short term. This
method, however, does not restore syndesmotic stability. Tibiofibular fusion with
bone-grafting, as recommended by Outland [29] and Weber [26], produces a non-
physiological stiffness of the ankle mortise, preventing the fibula from its normal
movements and thus restricting talar movement. Consequently, this almost
inevitably leads to arthritis of the ankle [30]. Castaing et al [31] performed
reconstruction of the anterior and posterior tibiofibular ligaments with the
peroneus brevis tendon. We have modified this procedure in order to achieve a
three-point-fixation of the distal fibula, because experimental data have demon-
strated the importance of an intact interosseous tibiofibular ligament for ankle
stability [17,21,32]. Xenos et al [17] have shown that pathological tibiofibular
diastasis of more than 2 mm does not occur with dissection of the anterior
tibiofibular ligament alone, but only after additional dissection of the interosseous
tibiofibular ligament.
The modified ligamentoplasty uses the peroneus longus tendon as a split
graft. The split tendon is guided through one canal in the distal tibia parallel
to the fibular incisura, and two canals in the distal fibula lying at an angle of
45 degrees to each other, thus paralleling the normal anatomic conditions of
the syndesmotic complex. The free end of the tendon is then secured with a
3.5 mm cancellous screw with washer inserted obliquely to the tibial canal (Fig. 5).
A temporary cortical ‘‘syndesmosis’’ screw is placed for six weeks, as in acute
syndesmotic rupture [6]. Although biomechanical testing of this method is still
Fig. 4. (A) Underreduced fibula in a pronation-external rotation fracture of the ankle with a too short
plate and syndesmosis screws that are more than 4 cm above the joint level. (B) The CT shows the
widened tibiofibular clear space. (C) After correction the syndesmosis screw is in the ideal position.
(D) CT shows correct position of the fibula in the incisura of the tibia.
pending, the first results in a series of 10 patients are encouraging, with 9 out of 10
relieved of pain and chronic instability [33]. Mullins and Sallis reported on
successful treatment of recurrent ankle sprains in the subacute and chronic stage
with placement of a Johansen lag screw [34]. Recently, Harper [35] performed
delayed reduction and stabilization with a 6.5 mm cancellous screw engaging four
cortices for chronic syndesmotic instability. In a preliminary report, satisfactory
results were obtained in five of six cases.
Deltoid ligament
The strong deltoid ligament has a complex anatomy and consists of two
portions that are composed of different components. The superficial layer, which
is shaped like the Greek D gave the medial ligament complex its name. It
originates broadly at the anterior colliculus of the medial malleolus, and consists
of the broad tibiocalcaneal component, the smaller superficial tibiotalar compo-
nent, and the tibionavicular component. The deep layer of the deltoid ligament is
considerably stronger and hence of greater functional importance than the
superior layer. It consists of the anterior and posterior tibiotalar components.
The anterior tibiotalar ligament originates in the intercollicular groove of the
medial malleolus and inserts at the talar neck, while the posterior tibiotalar
ligament has its origin at the posterior colliculus of the distal tibia and inserts at
the posterior tubercle of the posterior process of the talus. The deltoid ligament
serves as a secondary restraint against anterior translation after rupture of the
lateral ankle ligaments; the deep deltoid acts as restraint against lateral translation
and valgus tilting [36]. After dissection of the tibiocalcaneal fibers of the
superficial deltoid, tibiotalar contact area decreased by 43% and peak pressure
increased up to 30% with a lateral movement of 4 mm [37].
Ruptures of the deltoid ligament generally occur in the sequence of fracture-
dislocations of the ankle joint. Isolated ruptures of the deltoid ligament are
exceedingly rare. They require considerable forces because of the high me-
chanical ligament strength. Lauge-Hansen described these ‘‘Ligamentous ankle
fractures’’ as stage I pronation-external rotation injuries in his systematic
classification of ankle injuries [38]. They may also be produced by forced
plantarflexion or dorsiflexion. Rasmussen [39] showed that forced abduction
leads to isolated rupture of the superficial deltoid, followed by disruption of the
deep deltoid. Patients may experience a pop on the medial side of the ankle after
landing from a jump. The medial malleolus is tender to palpation and a hematoma
quickly develops. One must search for associated injuries as syndesmotic sprains,
lateral ligament ruptures, or malleolar fractures. The differential diagnosis should
also include tendon dysfunctions.
While Broström [1] reported on isolated deltoid ruptures in 3 of 105 acute
ankle sprains in his classical study, Staples [40] regarded them as not likely. In
our 20 years of experience, we are aware of only one case that was verified with
varus stress radiographs and arthrography (Fig. 6). The ligament healed unevent-
Fig. 6. A rare case of medial ankle ligament rupture without ankle or Maisonneuve fracture as
evidenced by valgus stress radiographs (A) and tenography (B).
fully with conservative treatment of six weeks in an orthosis. Others propose

casting or a walking boot that prevents external rotation of the foot for six to eight
weeks. Surgery is rarely indicated for isolated deltoid ligament ruptures, while
treatment in cases of associated injuries to the ankle remains controversial.
Chronic medial ligament instability is extremely rare. The reconstructive proce-
dures for recurrent deltoid insufficiency described in the literature include direct
imbrication, anchoring suture, and the use of free flexor digitorum longus and
split posterior tibial tendon graft [41 –43].
Lateral ankle ligaments

Lateral ankle sprains are among the most common injuries, and are therefore
of great socio-economic importance. One estimate is that there is one such injury
per day in a population of 10,000 [44]. Apart from that, injuries to the lateral
ankle ligaments are the most common specific sports injuries, associated
especially with running and jumping. The estimated incidence is one-fifth of
all sports injuries, and up to 45% of injuries in basketball [45]. In 1877, in
cadaver experiments that are still valid today, Hönigschmied established the
sequence of rupture of the three lateral ankle ligaments [46]. With increased
understanding of the mechanism of injury, and new diagnostic tools like stress
radiographs, introduced by Moehring in 1916 [47], the era of surgical repair of
the lateral ankle ligaments began in the 1920s [48,49]. Elmslie [48] performed the
first reconstruction of a chronic fibular ligament tear with fascia lata in a young
tennis player in 1928. Almost 80 reconstructive procedures for chronic ankle
instability have been described since then [50]. Therapy of acute lateral ankle
ligament ruptures has made dramatic changes during recent years and, though
still debated, has shifted considerably from operative and immobilizing therapy to
conservative-functional treatment with early mobilization [51].
Anatomy
The lateral ankle ligamentous complex consist of three parts: the anterior
talofibular ligament (ATFL), the calcaneofibular ligament (CFL), and the pos-
terior talofibular ligament (PTFL). The three ligaments originate close to each
other at the distal fibula, like clover leaves, and are oriented in the three different
spatial directions [7]. The ATFL is the weakest of the lateral ankle ligaments, and
phylogenetically the youngest [52]. It originates at the anterior crest of the distal
fibula and runs to the lateral aspect of the talar head at an descending ankle of
about 15 degrees in neutral position of the ankle, with an average length of
20 mm [53]. The CFL originates at the fibular tip and inserts at the lateral wall
of the calcaneus. In neutral ankle position this ligament is relaxed and almost
S-shaped. It is under maximum tension with inversion and dorsiflexion of the
foot [50]. At about 30 mm it is the longest lateral ankle ligament. The PTFL is the
strongest of the lateral ankle ligaments, with an average diameter of 6.5 mm [53].
It originates at a small groove at the posterior aspect of the dorsomedial aspect of
the distal fibula, and runs almost horizontally to the lateral tubercle of the
posterior process of the talus. Over the whole length, small fibers radiate into the
posterolateral aspect of the talar dome and—in one third of cases—into the distal
tibia [50]. Several authors have demonstrated the importance of neuromuscular
proprioceptive reflex mechanisms, via mechanoceptors in the ankle ligaments

and the peroneal muscles, for functional ankle stability [54 – 56].
Mechanism of injury
The classical mechanism of injury to the lateral ankle ligaments is forced
adduction, supination, and internal rotation of the foot (when tipping off an edge
or jumping on uneven ground, for example), making it an everyday injury and the
most common sports injury [45]. In our own experience with 1307 patients’
injuries, accidents during sports (soccer, volleyball, basketball) make up about
50% of the total, about 34% occur during housework, and less than 14% are work-
related accidents [50]. Predisposing factors are unsuitable footwear (especially
higher heels), general ligamentous laxity, calcaneus varus, muscular exhaustion
(mostly of the peroneal muscles), and neurologic deficits, including peroneal palsy
or proprioceptive deficit after previous trauma [50]. The pathomechanism of acute
ankle instability was described exactly by Dehne as early as 1933 [57]. With
rupture of the ATFL or the CFL, the talus dislocates in all three directions:
1. A varus tilt in the frontal plane

2. An anterior dislocation in the sagittal plane (‘‘anterior drawer’’)
3. An internal rotation in the horizontal plane
The result is a three-dimensional instability. Although already defined in other

words by Dehne [57], the term ‘‘acute antero-lateral rotary instability (ALRI) of
the ankle’’ was not used by analogy to multiplanar knee instability until the
middle 1980s. The ATFL, as the weakest ligament, is the first to rupture, and
when explored surgically, is completely torn in three quarters of all cases. The
CFL is ruptured in about 60% of cases and elongated (insufficient), in another
25% of cases [50]. The most stable PTFL is torn in less than 5% of cases, and
according to our experience, upon surgical exposure is most seldom completely
ruptured. This rupture would result in the extremely rare total submalleolar
dislocation of the foot (Luxatio pedis cum talo), which has an estimated incidence
of 0.2% [50]. A chip fracture of the talar dome is seen in 2.4% of cases [50]. In a
series of ankle arthroscopies in 30 patients with lateral ligament rupture, fresh
injury to the cartilage, especially at the medial malleolus and correspondent
surface of the talar dome, was seen in two-thirds of cases, and loose pieces of
articular cartilage were seen in 20% [58].
Diagnosis
Patients mostly recall the accident as a ‘‘twisting injury’’ to their ankle, with
an audible ‘‘click.’’ Weight bearing is possible, but often avoided because of pain.
In most instances of acute ligament rupture, a massive perimalleolar subcuta-
neous hematoma is visible. Pain is localized at or below the fibular tip at the
ligamentous insertions. Also, the course of the ATFL and CFL is tender to
palpation. The degree of ankle instability can be assessed clinically in a reliable

and standardized fashion by testing the anterior drawer and talar tilt. Van Dijk and
collaborators [59] found an 84% specificity and 96% sensitivity of physical
examination delayed four to seven days compared to physical examination within
48 hours of the injury with a 33% specificity and 71% sensitivity.
Standard radiographs of the ankle exclude severe arthritis, and osteochondral or
avulsion fractures. If the clinical diagnosis is equivocal, anteroposterior and lateral
stress radiographs are carried out. The anterior drawer and talar tilt are measured
with a force of 15 kp (Fig. 7). In rare cases of doubt, especially with recurrent
minor sprains, the uninjured side may serve as a control. In patients with chronic
instability, subluxation of the ankle during normal stance may be seen in
anteroposterior weight-bearing films of both ankles. Under standardized condi-
tions, a talar tilt of more than seven degrees (or more than five degrees difference
from the uninjured side) and anterior drawer of more than 7 mm (or more than
5 mm difference from the uninjured side) are diagnostic for ankle instability [50].
Furthermore, one has to discriminate between acute and chronic instability, as
well as second-stage injuries. A second-stage injury is defined as an acute rupture
in a scar resulting from a previous ligament rupture. This condition typically
presents as an acute rupture with radiographic evidence of a previous injury
(usually subfibular calcifications, but also ossifications within the deltoid
ligament) or a reliable history given by the patient.
Treatment
Acute ankle instability
Most authors today prefer non-operative treatment for first-time acute injuries
to the lateral ankle ligaments. Our own prospective randomized study showed no
Fig. 7. Measurements for talar tilt and anterior drawer in stress radiographs for acute rupture of the
lateral ankle ligaments.
objective or subjective differences in outcome after operative or non-operative

treatment, either with cast immobilization or orthosis over a period of five years
[51,60]. 78 percent of the patients met the criteria of total ankle stability in stress
radiographs (less than five degrees of talar tilt, less than 5 mm of anterior drawer).
While there had been slightly higher percentages of total radiographic stability in
the operative groups after three months, there were no detectable statistical
differences after one, two, and five years, regardless of the extent of the previous
injury (one- or two-ligament rupture). In our preference the indication for surgery
is limited to the following findings:
Rupture of medial and lateral ankle ligaments (Luxatio pedis cum talo, Fig. 8)
Talar tilt of more than 30 (Luxatio pedis supinatoria)
Osteochondral fracture of the talus
Massive hematoma requiring immediate decompression
Altogether these indications characterize about 1 to 5% of cases with acute

rupture of the lateral ankle ligaments [51].
Fig. 8. (A) Luxatio pedis cum talo (total submalleolar dislocation) after rupture of all lateral and
medial ankle ligaments. (B) Immediate reduction and reconstruction of the ligaments is indicated; the
ankle is protected in an external fixator.
For conservative-functional treatment, the affected leg is immobilized in a

below-the-knee plaster cast for three to five days, depending on the initial
swelling. An ankle orthosis limiting hindfoot motion is applied after the swelling
has subsided, and is worn night and day until five weeks after the injury. During
this time, strengthening exercises of the peroneus muscles are carried out. Ten
units of proprioceptive training are then added to the protocol (Fig. 9) [7].
The surgical repair of ruptured ankle ligaments can be achieved by either
direct suture for intraligamentous ruptures, transosseous anchoring suture, or
refixation with a small screw for ligament avulsions [7]. Surgical exploration
begins with the PTFL, because this ligament is accessible only by tilting the
talus, and then the ATFL and CFL are sutured (Fig. 10). When exploring the
CFL, care has to be taken not to damage the sural nerve, and to gently mobilize
the peroneal tendons when they are periostally avulsed from the calcaneus. A cast
is applied until wound healing, then functional after treatment is carried out as
described above.
Since the mid 1980s, a number of prospective randomized trials have not
demonstrated any significant differences in functional outcome after non-opera-
tive treatment versus operative treatment of acute rupture of the collateral fibular
ankle ligaments [60 – 67]. In 1991, Kannus and Renström, reviewed 12 pro-
spective studies and concluded that there are no differences in outcome after
Fig. 9. Proprioceptive training after healed acute rupture of the lateral ankle ligaments. This treatment
is also useful in cases of chronic instability.
Fig. 10. Surgical repair for acute rupture of all three lateral ankle ligaments: the PTFL (FTP) is
repaired first with transosseous suture. After that, the ATFL (FTA) and CFL (FC) are repaired by direct
suture (a), anchoring suture (b), or a combination of both depending on the type of rupture.
either surgical repair, cast alone, or early controlled mobilization [68]. However,
the results were compared directly in only one of the cited studies [66]. A
previous injury to the ankle was a criterion for exclusion in three more studies
[67,69,70], as in our own study [60]. Recently, two more prospective-randomized
trials have added to the evidence that non-operative treatment with early
mobilization does not produce results inferior to treatment with surgical repair
and immobilization [63,65]. The relatively small numbers of randomized patients
and short follow-up periods are major limitations to most studies. We are aware
of three reports on five-year-results after functional treatment of acute lateral
ligament rupture [51,67,71]. All of them showed no significant differences
between operative and conservative treatment when early and late results were
compared. Only one report [72] showed better results after operative treatment in
a clinical study of 345 patients treated either by operation or immobilization for
three weeks, which is presumably too short a period for proper ligament healing.
The paper gave no information on rearfoot position (pronation or neutral) in the
cast. In addition, approximately one third of the patients had previous supination
injuries, so that preexisting chronic instability could not be excluded in the
randomized patients. A recent meta-analysis including seven randomized, con-
trolled trials comparing operative and non-operative treatment for acute lateral
ankle rupture noted a significant difference in favor of operative treatment with
respect to giving way, while no differences were found for pain [73]. However,
outcome variables were restricted to these two subjective criteria. It was not
possible to include such important objective outcome measurements as recurrent
instability, range of motion, objective instability, or arthritis, because they were
(according to the authors) used or clearly defined in only a limited number of
studies. In the same meta-analysis, in ten trials comparing cast with functional
treatment, the latter lead to a significant reduction of pain.
The mean complication rate after surgical repair is about 10%. Complications
include wound healing disturbance, sensory deficits, nerve affections, deep
venous thrombosis, suppurating infection, and even one case of Sudeck’s atrophy
and lung embolism [62,73]. Another important aspect when comparing different
treatment methods is the estimated cost. Conservative-functional treatment results
in a considerably reduced time off work (less than half that with operative
treatment) and the complete dispensability of hospitalization. Given the high
incidence of these injuries, non-operative treatment has an immense additional
socioeconomic benefit [51,65]. In professional athletes and highly active patients,
treatment tends more towards surgical repair, although there is no clear evidence
for a better outcome in these patients.
There is consensus in the literature that any form of treatment should be
supplemented with early mobilization in an ankle orthosis. That provides not only
a considerable increase in patient comfort and hygiene, but also allows physical
therapy to avoid loss of calf muscle activity, which makes anticoagulation with
low molecular weight heparin injections unnecessary. This results in better
muscular and coordinate performance after three months of follow-up in the
non-operative group treated with orthosis and early mobilization than in the
group treated with plaster immobilization [60]. A multitude of ankle orthoses
exist; care has to be taken to assure that pronation and supination movements of
the ankle are completely restricted. We prefer the Caligamed (MHH, Bauerfeind,
Kempen, Germany) orthosis, which also restricts dorsiflexion and plantarflexion
at the ankle level. An additional lateral heel lift brings the foot in slight pronation.
In a cadaver study, this orthosis had the greatest passive stabilizing effect on the
ankle [74]. Although some studies [64] attribute only a ‘‘memorizing effect’’ to
the orthoses, a stable protection of the ankle is desirable, since a disruption of
proprioceptive pathways always has to be suspected after rupture of the lateral
ankle ligaments [54 –56]. For the same reason, peroneus muscle and proprio-
ceptive reflex training is advocated immediately after healing of ruptured ankle
ligaments (see Fig. 9) independently of previous treatment [7].
Chronic ankle instability

Recurrent sprains and neglected acute tears of the lateral ankle ligaments may
result in chronic ankle instability. About 50% respond to physical therapy and
proprioceptive training [75]. Chronic ankle instability frequently results in ankle
arthritis and chronic synovitis, due to repetitive injury to the cartilage [76].
Symptomatic patients complain about pain and swelling after varying degrees of
loading, a subjective giving way feeling, and sometimes reduced range of mo-
tion in the ankle and subtalar joints [77]. About 80 procedures and modifications
for reconstruction of the lateral ankle ligaments have been described in the
literature, while only a few have gained broader acceptance [50]. In general,
reconstruction of the insufficient ligaments can be achieved either by tenodesis
or anatomical reconstruction.
Tenodeses use the peroneus brevis or longus tendons, or parts of them. The
first description of such procedures was given by Nilsonne in 1932 [78], followed
by Watson-Jones [79], and Evans [80]. The tenodeses described by the latter
reports are still—with some modifications—the most frequently used for ankle
ligament reconstruction. The Watson-Jones tenodesis uses the whole peroneus
brevis tendon and reconstructs the AFTL, while the new CFL lies almost
perpendicular to the original direction of the ligament. The Evans tenodesis
leads the whole peroneus brevis tendon from distally through the lateral
malleolus, and acts along the resultant of the ATFL and CFL. This method has
been modified by using a split peroneus brevis graft to preserve some muscle
function [81]. Another frequently used tenodesis is the Chrisman Snook [82]
procedure, which reconstructs both the ATFL and CFL in its original direction,
using a split peroneus brevis tendon. Since all these tenodeses are non-anatomical
procedures, several limitations have been reported. All of them have been shown
to decrease inversion of the foot, most notably with the Chrisman-Snook and
Evans procedures [83]. Also, in clinical and cadaver studies, all tenodeses failed
to correct the instability of the talocrural joint, especially the Evans procedure,
where there is no direct attachment of the talus [75,83,84]. However, in most
clinical series, good to excellent short-term results are reported in 80% to 90% of
cases, although they tend to deteriorate with time [44,75,85,86]. Some degree of
osteoarthritis is seen in a high percentage of cases, but does not correlate with
residual instability [85,86]. Therefore, these findings may be explained by
cartilage damage at the time of injury, or recurrent sprains prior to ligament
reconstruction. Other researchers state that the altered joint kinematics are re-
sponsible for accelerated joint degeneration [83].
Anatomic replacement of the ankle ligaments using periosteum, fascia lata,
cutis, tendon grafts, lyophilized dura, and carbon-fiber implants has been
described [50,87]. Because all of these procedures require either tissue preserva-
tion or a second incision for harvesting, or carry the risk of foreign-body reaction,
anatomical reconstruction using local tissue has become more popular recently
[50,83,87]. These procedures include a periosteal flap (Fig. 11) or direct suture
with shortening and reinsertion of the torn ligaments—the modified Broström
procedure [4,88,89]. Clinical studies show good to excellent results in transection
and reefing of the ATFL and CFL [74] and in over 80 percent of periosteal flap
procedures [87,90]. Comparison between the studies is difficult, because various
scoring systems are used by different authors. One small study (10 patients in
each group) comparing periosteal flap with modified Evans tenodesis did not
show significant differences in outcome after one year [83].
We prefer direct reconstruction of insufficiently healed ligaments with dystop
insertions or elongation, attempted with transosseous reinsertion of the ligaments
(see Fig. 11C). A symptomatic ‘‘Os subfibulare,’’ a pseudarthrotic bony avulsion,

is reinserted and anchored with transosseous suture or a cancallous screw, de-
pending on the size of the fragment. If direct reconstruction of one ligament (ATFL
or CFL) cannot be achieved, a doubled periosteal flap is created from the fibula
(see Fig. 11A and B). If both ligaments cannot be reconstructed, an anatomic
Fig. 11. The author’s’ preferred method for reconstruction of chronic lateral ligament instability.
Double-periosteal flap for ATFL (A) and CFL (B). (C)Transosseous anchoring suture for elongated
CFL. (D) Anatomic reconstruction for ATFL and CFL with split peroneus brevis ligamentoplasty.
peroneus brevis ligamentoplasty (see Fig. 11D) or modified Evans tenodesis is

carried out [91].
Subtalar instability
The complex anatomy of the subtalar joint makes detection and assessment of
injuries to the ligaments around this joint difficult. Subtalar sprains occur
frequently in the wake of lateral ankle sprains, and have to be discriminated from
them. Recurrent sprains may lead to chronic subtalar instability, with persistent
pain and the development of subtalar arthritis. Ligamentous injuries to the subtalar
joint may be classified, in analogy to the ankle joint, as acute or chronic antero-
lateral rotary instability [92]. The most severe ligamentous injuries are complete
subtalar dislocations that involve dislocation of both the subtalar and talonavicular
joints, and have an estimated incidence of 1% of all dislocations [41].
Anatomy
The most important ligament for subtalar stability is the strong talocalcaneal
interosseous ligament, which lies in the sinus tarsi and tarsal canal (Fig. 12). The
initial description of the different ligament structures in this region was provided by
Wood Jones in 1944 [93]; later reports showed a substantial variability of the
components of the IOL. Schmidt [94], who gave one of the most detailed descrip-
tions of the complex anatomy of the ligaments in the sinus tarsi and tarsal canal,
discriminates five separate ligaments apart from the IOL: the lateral, intermediate
and medial roots of the short (inferior) extensor retinacle, the oblique talocalcaneal
ligament (also referred to as cervical ligament, because it connects the talar neck
with the calcaneal neck), and the ligament of the tarsal canal [94]. He stated that
four of the five parts limit excessive supination and inversion because they lie pivot
of the subtalar joint, while only the medial root of the inferior extensor retinacle
limits pronation and eversion (external rotation). The fibular (lateral) talocalcaneal
ligament is an inconstant ligament that has not been termed uniformly and runs
parallel to and below the calcaneofibular ligament [95]. The posterior talocalcaneal
ligament is even more inconstant and, if present, a capsule reinforcement. The
important calcaneofibular ligament (CFL) provides lateral stability both to the
ankle and subtalar joints. The bifurcate ligament stabilizes both the anterior portion
of the subtalar joint (the talocalcaneonavicular joint) and the midtarsal (Chopart’s)
joint. The common origin of both the calcaneonavicular and calcaneocuboidal parts
of the bifurcate ligament lies on the dorsal aspect of the anterior process of the
calcaneus. According to Schmidt and Grünwald [53] the calcaneonavicular part is
stronger (average diameter of 3 mm) and longer (average length of 15 mm) than the
calcaneocuboidal part (2 mm in diameter and 9 mm in length). The anterior subtalar
joint is further stabilized by the dorsal talonavicular ligaments (mainly capsule
reinforcements), the plantar calcaneonavicular (‘‘Spring’’) ligament, and the
medial calcaneonavicular ligament (Volkmann’s ‘‘neglected’’) ligament [96].
Fig. 12. Anatomy of the ligaments of the subtalar joint.

Mechanism of injury
In contrast to the ligamentous injuries to the ankle joint that have been
investigated and discussed extensively in the literature, little was written until the
1980s on the pathomechanism and specific diagnosis of subtalar instability. In
1962, Rubin and Witten [97] were the first to suggest the clinical importance of
subtalar instability, and they also proposed a stress tomogram for evaluation and
diagnosis. In 1963, Hellpap described the continuation of supination forces from
the lateral ankle ligaments, through the posterior subtalar and calcaneocuboid
joints, to the base of the fifth metatarsal. He termed this the ‘‘Supination fracture
line’’ [98] and brought attention to avulsion fractures of the bifurcate and lateral
calcaneocuboid ligaments. The main cause of subtalar sprains is excessive
supination to the dorsiflexed ankle, such as in jumping or tipping off an edge.
Because the mechanism is the same as in ankle sprains, and these injuries
frequently occur together, the symptoms of ankle sprain can superimpose and
detract from additional or isolated subtalar sprain. In their clinical study, Chris-
man and Snook [82] found subtalar instability intraoperatively in three of seven
cases that were treated by tendon transfer for chronic ankle instability. Since the
calcaneus describes a screw-like, three-dimensional motion against the talus, a
rotary instability results with dissection of the ligaments [4]. As cadaver studies
have shown, the dissection of the talocalcaneal interosseous ligament results in
ventral translation and internal rotation of the calcaneus, while additional
dissection of the calcaneofibular, bifurcate, and talonavicular ligaments leads to
a considerable gaping of the subtalar joint in stress radiographs [92]. Thus the
subtalar instability is a combination of ventral translation, medial shift, and varus
tilt of the calcaneus, which by analogy to the ankle can be described as antero-
lateral rotary instability [7,92].
Diagnosis
Subtalar instability without dislocation is difficult to detect with clinical
examination alone. It is especially difficult to discriminate from acute or chronic
instability of the ankle. In our experience, a valid method is the exertion of varus
stress on the dorsiflexed foot, which fixes the broad anterior portion of the talar
trochlea within the ankle mortise. Only in this manner can an increased rotation of
the calcaneus in relation to the talus be discriminated from pure talar tilt in the ankle
joint. Instability in the anterior portion of the subtalar joint (talocalcaneonavicular
joint) is tested with varus stress with the hindfoot fixed manually. The midtarsal
(Chopart) joint is assessed with abduction/adduction stress. With clinical suspicion
stress radiographs of the subtalar joint are done (Fig. 13A and B). Subtalar
instability is defined radiographically with a talocalcaneal angle of more than five
degrees, talocalcaneal tilt of more than 10 degrees, and medial shift of the calcaneus
with respect to the talus of more than 5 mm, as compared to the uninjured side with
the leg rotated 30 internally and the tube tilted 30 caudally [92]. At the level of the
Chopart joint, calcaneocuboidal instability is diagnosed with calcaneocuboid tilt of
more than five degrees in the dorsoplantar view with the tube tilted 30 caudally
(see Fig. 13C). Furthermore, varus position of the hindfoot, which leads to
supination of the foot, is excluded with axial weight-bearing radiographs of both
calcanei (Saltzman view). Instability at the level of the talocalcaneonavicular or
Chopart joint is assessed with abduction/adduction stress radiographs [7]. Further
diagnostic measures include stress tomography [99] and MR arthrography, which
has a high sensibility [100]. If hindfoot instability cannot be verified clinically and
radiographically, the differential diagnosis must include functional instability,
meniscoid lesion, sinus tarsi syndrome, osteochondrosis dissecans tali, nerve
entrapment (superficial peroneal nerve), and neuropathic disorders.
Patients with chronic instability of the subtalar joint report repeated inversion
mechanism sprains during normal walking, but especially during running. The
patients state that they feel insecure while walking on uneven surfaces and have
to look at the ground constantly. Pain is frequently reported over the sinus tarsi
and is difficult to discriminate from the above-named conditions.
Treatment
Fresh isolated subtalar instability can be treated functionally-conservatively,
and rarely warrants surgical intervention [7,101]. Initially, a below-the-knee
plaster cast is applied for three to five days depending on the degree of swelling.
After that, an ankle orthosis is applied for another five weeks. Physical therapy
includes proprioceptive training.
Few recommendations exist for recurrent subtalar instability. Patients with
symptomatic chronic instability may benefit from a course of physical therapy
that includes taping, peroneal strengthening, proprioceptive training, and Achilles
tendon stretching, but in most cases they require surgical stabilization. Chrisman
and Snook [82] have inaugurated a Peroneus brevis tenodesis for combined
ankle/subtalar instability that is a modification of the Elmslie tenodesis for ankle
instability [48], which used a strip of fascia lata through drill holes in the lateral
malleolus, talus, and calcaneus. The Crisman/Snook procedure has been modified
by Vidal et al [102] for isolated anterior subtalar instablity, to reconstruct the
function of the elongated or torn talocalcaneal interosseous ligament in all three
directions (Fig. 14). A split peroneus brevis tendon is directed through the distal
fibula and the posterior aspect of the calcaneal tuberosity near the insertion of the
calcaneofibular ligament, and sutured to itself near the insertion at the base of
the fifth metatarsal [7]. If an anterior drawer can be provoked intra-operatively,
the tendon is guided through an additional channel at the talar head, as with the
Watson-Jones tenodesis for ankle instability [78]. Some authors described the use
of the plantaris tendon as a tendon graft, in order not to sacrifice the peroneus
brevis tendon. In a review by Brunner and Gaechter [103], this procedure com-
pared favorably with peroneal tendon transfers. However, the plantaris tendon is
absent in about 10% of the population and may be small, fragile, and difficult to
locate. Kato [104] has proposed additional reconstruction of the talocalcaneal
interosseous ligament with a tendon graft that runs from the superomedial aspect
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H. Zwipp et al / Clin Podiatr Med Surg 19 (2002) 195–229
Fig. 13. Stress radiograph of the subtalar joint (anteroposterior view with the leg 30 degrees rotated internally and the radiograph tube tilted 30 degrees
craniocaudally). (A) A load of 15 kp is applied to the subtalar joint with a standard Telos device. (B) A horizontal talocalcaneal angle of more than five
degrees, a medial shift of the calcaneus of more than five millimeters, and a talocalcaneal tilt measured tangentially of more than 10 degrees are
diagnostic for subtalar instability. The left x-ray shows a stable subtalar joint; the right x-ray an instable subtalar joint secondary to an injury to the
talocalcaneal interosseous ligament. (C) Stability of the calcaneocuboid joint is tested with abduction and adduction stress radiographs. Note the
instability of the calcaneocuboid joint with abduction stress.
of the talus towards the plantar lateral aspect of the calcaneus. However, there are
no controlled studies on anatomic repair of the interosseous ligament, although
anatomical studies suggest that they may be associated with considerably less
restriction at the ankle and subtalar joints [105].
Treatment of modified Elmslie tenodesis consists of a weight-bearing, below-
the-knee plaster cast for six weeks, which may be changed to a special walking
boot in the reliable patient after 10 days. After six weeks of strengthening
exercises and proprioceptive feedback, training of the peroneus group should be
added to the protocol [7]. Clinical results of the modified Elmslie procedure for
chronic subtalar instability have not been reported by many authors. The reported
results of about 100 cases, including our previous material, are good to excellent
in about 90% [7,102,104,106 – 108].
Isolated calcaneocuboidal instability is extremely rare, and may be treated

with ligamentoplasty. Arthrodesis of the calcaneoucuboid joint is advocated only
with degenerative arthritis [108]. It is important to remember, however, that
instability at the ankle and subtalar joint after repetitive supination trauma may be
associated with calcaneocuboid instability along the ‘‘Supination fracture line
[97].’’ These cases of combined instability at two or even three levels (either CC/
subtalar or CC/subtalar/ankle) require a modified Elmslie tenodesis, as described
above [7,108]. Other rare ligamentous injuries about the subtalar joint include
avulsions of the bifurcate ligament at the anterior calcaneal process, and isolated
ruptures of Volkmann’s neglected ligament. While both conditions can be treated
with good results non-operatively with casting of six weeks, the main point is not
to overlook them, beause bifurcate ligament avulsions may lead to non-union at
the anterior calcaneal process, and untreated ruptures of the mediodorsal
calcaneonavicular (Volkmann’s) ligament may lead to post-traumatic planovalgus
foot, similiar to ruptures of the tibialis posterior tendon [7].
Subtalar dislocations (Luxatio pedis sub talo)

The most severe ligamentous injuries to the subtalar joint are subtalar
dislocations. They were first described by Broca in 1853 [109] as ‘‘Luxations
sous-astragaliennes.’’ He discriminated medial, lateral, and posterior dislocations,
the latter being exceedingly rare. Henke later added an anterior type, which has
not been reproduced since then. Buckingham showed that, after dissection of the
talocalcaneal interosseous ligament with subtalar dislocation, the deep portion of
the deltoid ligament and the CFL rupture [110]. Medial subtalar dislocations
(Fig. 15) are thought to be produced by forced adduction of the foot in
plantarflexion and supination of the ankle and subtalar joint. The sustentaculum
tali serves as a lever for medial dislocation. The lateral talonavicular ligaments
are the first to rupture, followed by the interosseous ligament that ruptures from
medial to lateral. [7]. In contrast, lateral subtalar dislocation is produced by forced
abduction with the foot in dorsiflexion and pronation. In addition to the
talonavicular and interosseous ligaments, the deltoid ligament is frequently
ruptured in these conditions. As our cadaver studies have shown, the ‘‘anterior’’
subtalar dislocation appears radiographically like the medial dislocation and the
‘‘posterior’’ subtalar dislocation resembles the lateral type, so we believe that
there are only two types of subtalar dislocation: anteromedial and posterolateral
[7]. In an analysis of 4521 dislocations at Böhler’s clinic, Leitner [111] found 42
cases of subtalar dislocations (36 medial, 6 lateral) and was the first to state that
interposed ligaments and tendons may warrant open reduction. We have seen 24
cases (21 medial, 3 lateral) in 20 years, among them five open dislocations and
two cases of arterial damage [7].
Fig. 14. (A) Modification of the Elmslie tenodesis for chronic isolated subtalar instability and (B)
combined ankle/subtalar instability.
224
H. Zwipp et al / Clin Podiatr Med Surg 19 (2002) 195–229
Fig. 15. (A) Anteromedial subtalar disolcation. (B) This condition can be treated with closed reduction in most cases and has a favourable
prognosis with early reduction.
In general, subtalar dislocations can be reduced in a closed manner under

general anesthesia and proper relaxation (Fig. 14). For medial dislocations, the
knee is bent 90 degreees, and the foot is plantarflexed and pulled distally, then
dorsiflexed and pronated. For lateral dislocations, an assistant holds the heel and
forefoot, while the surgeon holds the calf and manipulates the talus with one hand
while pressing the patients calcaneus to his knee. Frequently, the tibialis posterior
or flexor digitorum longus tendon is interposed, so that open reduction via an
anterolateral (or alternatively, Ollier’s) approach becomes necessary [7]. The
surgeon must be alert for fractures of the posterior process of the talus or the
sustentaculum tali. In most cases, immobilization in a cast for six weeks is
sufficient; K-wire transfixation is reserved for marked instability after initial
reduction. Prognosis after immediate reduction is good after these injuries;
chronic ligamentous instability after subtalar dislocations is rare.
Total talar dislocation (Luxatio talis totalis)

The complete disruption of the talar ligaments is undoubtedly the most severe
ligamentous injury to the foot. Broca called this ‘‘talar enucleation.’’ These injuries
require a considerable force and are regularly associated with severe soft tissue
damage that leads to rapid blistering, ischemia, and even full-thickness skin
necrosis. Detenbeck and Kelly [112] published nine cases of this entity, among
them seven open injuries. They saw seven cases of septic talar necrosis, one re-
quiring fusion, and one even amputation. In contrast, Pestessy et al [113] reported
four cases treated successfully. We have seen four cases over a 20-year period, with
only one requiring arthrodesis after immediate open reduction and transfixation [7].
Reduction is carried out via an extended dorso-median approach, which is also
used for dermatofasciotomy, if a compartment syndrome is seen. If reduction is not
possible, additional incisions are carried out medially and laterally. Open wounds
sometimes warrant changes of this approach. After successful reduction the talus is
transfixed by K-wires for six weeks, and additional tibiotarsal transfixation with an
external fixator for protection of the soft tissues for three weeks. If the wound
cannot be closed without tension, skin substitutes are used temporarily. Prognosis
mainly depends on the amount of initial soft tissue damage and rapid reduction.
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Ligamentous Injuries About The Ankle and Subtalar Joints: Hans Zwipp, MD, PHD, Stefan Rammelt, MD, Rene Grass, MD

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Ligamentous Injuries About The Ankle and Subtalar Joints: Hans Zwipp, MD, PHD, Stefan Rammelt, MD, Rene Grass, MD

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Clin Podiatr Med Surg

19 (2002) 195 – 229

Ligamentous injuries about the ankle

Distal tibiofibular syndesmosis

Anatomy and biomechanics

1. The anterior tibiofibular ligament descends from the tubercúle de Tillaux-

2 mm or less. Care is taken to evaluate tibiofibular distance at exactly the same

Type I, lateral subluxation of the fibula

Chronic syndesmotic instability

fully with conservative treatment of six weeks in an orthosis. Others propose

Lateral ankle ligaments

proprioceptive reflex mechanisms, via mechanoceptors in the ankle ligaments

1. A varus tilt in the frontal plane

The result is a three-dimensional instability. Although already defined in other

palpation. The degree of ankle instability can be assessed clinically in a reliable

objective or subjective differences in outcome after operative or non-operative

Altogether these indications characterize about 1 to 5% of cases with acute

For conservative-functional treatment, the affected leg is immobilized in a

Chronic ankle instability

(see Fig. 11C). A symptomatic ‘‘Os subfibulare,’’ a pseudarthrotic bony avulsion,

peroneus brevis ligamentoplasty (see Fig. 11D) or modified Evans tenodesis is

Fig. 12. Anatomy of the ligaments of the subtalar joint.

Isolated calcaneocuboidal instability is extremely rare, and may be treated

Subtalar dislocations (Luxatio pedis sub talo)

In general, subtalar dislocations can be reduced in a closed manner under

Total talar dislocation (Luxatio talis totalis)

ßenbandrupturen am oberen Sprunggelenk mit oder ohne Schiene? Eine prospektiv-random-

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