Clinical Anatomy 21:619–626 (2008)

REVIEW

The Anatomy in Relation to Injury of the Lateral

Collateral Ligaments of the Ankle: A Current
Concepts Review
MICHEL P.J. VAN DEN BEKEROM,* ROELOF JAN OOSTRA,
PAU GOLANO ALVAREZ, AND C. NIEK VAN DIJK
Department of Orthopaedic Surgery, Academic Medical Centre, Amsterdam, the Netherlands

Injuries to the lateral ligament complex of the ankle are common problems in
acute care practice. We believe that a well-developed knowledge of the anat-
omy provides a foundation for understanding the basic mechanism of injury,
diagnosis, and treatment, especially surgical treatment, of lateral collateral
ankle ligament injury. To address this issue we performed this review with
regard to the anatomy of the lateral collateral ankle ligaments. Clin. Anat.
21:619–626, 2008. V 2008 Wiley-Liss, Inc.
C

Key words: ankle sprain; lateral collateral ankle ligaments; ankle anatomy;
current concepts review

INTRODUCTION acute ankle rupture with a sensitivity of 98% and a

Injuries to the lateral collateral ligaments of the
ankle are common problems in acute care practice.
Lateral ankle sprains account for 85% of all ankle
sprains (Ferran and Maffulli, 2006). The ankle sprain
is one of the most common injuries in athletes,
(Barker et al., 1997; Ferran and Maffulli, 2006) par-
ticularly in sports in which participants frequently
jump and land on one foot or are expected to make
sharp cutting maneuvers (for example, basketball,
soccer, football, and volleyball) (Garrick and Requa,
1989; Lindenfeld et al., 1994).
The most common mechanism of injury is supina-
tion and adduction (usually referred to as inversion)
of the plantar-flexed foot (Anderson, 1952). It is
known that the anterior talofibular ligament (ATFL)
is almost always the first or only ligament to sustain
injury (van Dijk, 1994). Broström (1966) found that
combined ruptures of the ATFL and the calcaneofibu-
lar ligament (CFL) occurred in 20% of cases and that
isolated rupture of the CFL was very rare. The poste-
rior talofibular ligament (PTFL) is usually not injured
unless there is a frank dislocation of the ankle. To-
gether, these ligaments, ATFL, CFL, and PTFL, form
the lateral collateral ligaments of the ankle
(Wiersma, 1998).
Delayed physical examination, 4 to 5 days after
trauma, has a high accuracy for detection of an
specificity of 84% (van Dijk, 1994; van Dijk
1996a,b). Inversion injuries of the ankle, if not
treated properly, may end up with late symptoms in
30–40% of the patients. (Bosien, 1955; Freeman,
1965; van Dijk, 1994; Verhagen, 1995; Pijnenburg,
2000) The treatment of inversion injuries is per-
formed by emergency and primary health care physi-
cians as well as by orthopaedic and trauma surgeons
(Kannus and Renstrom, 1991).
The most common diagnosis in ankle pathology is
distortion of the tibiotalar joint, but for a long time
there was no definite description given of the ana-
tomical structures meant when this diagnosis was
used. The literature mentioned primarily slight
Abbreviations used: ATFL, anterior talo fibular ligament; PTFL,
posterior talo fibular ligament; CFL, calcaneo fibular ligament;
TCL, talo calcaneal ligament; CFB, calcified fibrocartilage bone; E,
enthesis; CT, computer tomography.
*Correspondence to: Michel P.J. van den Bekerom, Department of
Orthopaedic Surgery, Academic Medical Centre, University of Am-
sterdam, P.O. Box 22660, Meibergdreef 15, 1105 AZ Amsterdam,
The Netherlands. E-mail: Bekerom@gmail.com
Received 17 January 2008; Revised 22 July 2008; Accepted 27
July 2008
Published online 4 September 2008 in Wiley InterScience
(www.interscience.wiley.com). DOI 10.1002/ca.20703

C 2008
V Wiley-Liss, Inc.
620 van den Bekerom et al.
Fig. 1. Osteoarticular anatomical dissection of the
ligaments of the foot and ankle joint (Lateral view). (1)
Fibula and lateral malleolus. (2) Tibia. (3) Anterior tibio-
fibular ligament. (30 ). Distal fascicle of the anterior tibio-
fibular ligament. (4) Anterior talofibular ligament. (5)
Calcaneofibular ligament. (6) Lateral talocalcaneal liga-
ment. (7) Talocalcaneal interosseous ligament and sinus
damage of the surrounding tissue combined with iso-
lated ruptures of the ligamentous fibers and the
presence of haematoma (Kaufmann, 1922; Quigley,
1959). Different authors were sure that a lesion of
the perivascular network of nerve fibres caused the
clinical signs of the damage (Leriche and Arnulf,
1939; Casagrande et al., 1951). Dehne (1933) and
Buchner (1960) saw the partial rupture as the com-
mon lesion, whereas the complete lesion was stated
to be a very seldom injury. With the help of special-
ized means of diagnosis and operative treatment we
know that complete rupture of the fibular ligaments
is not a seldom and isolated injury (Leonard, 1949).
Although there is little scientific evidence, RICE
(Rest, Ice Compression, and Elevation) therapy is a
well-established treatment modality for acute lateral
ligament injuries in the first days after trauma. After
that, the goal of taping or bracing is to externally
stabilize the joint while protecting the ligamentous
structures without altering normal joint kinematics.
Early mobilization and functional treatment are
advocated as a preferable treatment strategy.
There is insufficient evidence available from
randomized controlled trials to determine the relative
effectiveness of surgical and conservative treatment
tarsi. (8) Cervical ligament. (9) Dorsolateral calcaneo-
cuboid ligament. (10) Dorsal talonavicular ligament.
(11) Calcaneonavicular fascicle of Chopart ligament.
(12) Dorsal cuneonavicular ligament. (13) Calcaneal
bursa. (14) Calcaneal tendon (cut). [Color figure can be
viewed in the online issue, which is available at www.
interscience.wiley.com.]
for acute injuries of the lateral ligament complex of
the ankle (Kerkhoffs et al., 2007). However, func-
tional treatment comprises a broad spectrum of
treatment strategies (brace, tape, lace-up brace)
and as of yet no optimal strategy has been identified
(Kerkhoffs et al., 2002).
Compared to other joints, the ligaments of the
ankle have not been studied in great detail. The
descriptions in book chapters and literature often
lack the precision of the orientation and attachment
points. We believe that a well-developed knowledge
of the anatomy provides a foundation for under-
standing the basic mechanism of injury, diagnosis,
and treatment (especially surgical treatment) of
ankle sprains. It is important to be aware of the
detailed anatomy of the lateral collateral ankle liga-
ments and the possibility of additional ligaments
because ligament substitutes should be placed at the
original anatomical lateral ankle ligament reconstruc-
tions (Larsen, 1990). There is considerable interest
in diagnostic modalities and the clinical outcome of
treatment protocols but there is relatively little litera-
ture concerning the anatomy of the lateral collateral
ligaments. To address this issue we performed this
review.

Fig. 2. Osteoarticular anatomical dissection of the
ligaments of the foot and ankle joint (Lateral view). (1)
Lateral malleolus (tip). (2) Tibia. (3) Anterior tibiofibular
ligament. (30 ) Distal fascicle of the anterior tibiofibular
ligament. (4) Anterior talofibular ligament. (5) Calcaneo-
fibular ligament. (6) Lateral talocalcaneal ligament. (7)
Talocalcaneal interosseous ligament and sinus tarsi. (8)
Cervical ligament. (9) Dorsolateral calcaneocuboid
ligament. (10) Calcaneonavicular fascicle of Chopart
ligament. [Color figure can be viewed in the online issue,
which is available at www.interscience.wiley.com.]
Anatomy of the Lateral Ligaments of the
Talocrural Joint
The ligaments of the ankle can be divided in three
groups: the lateral group, the medial group, and the
ligaments of the syndesmosis (Figs. 1–4). The bony
stabilization of the talus by the tibia and the fibula is
reinforced by strong ligamentous structures that
make supplementary muscular attachment useless.
This review is restricted to the lateral group or lateral
collateral ligaments of the ankle; this group consists
of three ligaments: the ATFL, the CFL, and the PTFL.
ATFL
The ATFL plays an important role in limiting ante-
rior displacement of the talus and plantar flexion of
Lateral Collateral Ligaments of the Ankle 621
the ankle. The ATFL is the weakest of the three lateral
ankle ligaments, having the least elastic transforma-
tion properties (Sauer et al., 1978). The ATFL is a
flat, quadrilateral ligament that is incorporated in the
joint capsule and passes from the distal area of the
anterior margin of the lateral malleolus to the body of
the talus just in front of the cartilaginous margin of its
lateral articular surface. The ligament is approxi-
mately 6–10 mm in width, 15–20 mm in length, and
2 mm in thickness (Broström, 1964; Lang et al.,
1972, Prins, 1978, Ludolph and Hierholzer, 1986).
The ATFL is directed an average of 44.88 medially
from the fibula toward the talus in the coronal plane
(Burks, 1994), it made mean angle of 258 with hori-
zontal plane (Taser et al., 2006), and a mean angle of
478 with saggital plane (Taser et al., 2006).
The average area of attachment is 8.2 mm in the
saggital dimension and 5.4 mm in coronal dimension
Fig. 3. Osteoarticular anatomical dissection of the
ligaments of the foot and ankle joint (Anterior view). (1)
Lateral malleolus. (2) Tibia. (3) Anterior tibiofibular liga-
ment. (30 ) Distal fascicle of the anterior tibiofibular liga-
ment. (4) Interosseous membrana. (5) Anterior talofibu-
lar ligament. (5) Calcaneofibular ligament. (6) Anterior
articular surface of the talus. (7) Medial malleolus. (8)
Medial collateral ligament. (9) Dorsal talonavicular liga-
ment. [Color figure can be viewed in the online issue,
which is available at www.interscience.wiley.com.]
622 van den Bekerom et al.
Fig. 4. Posterior view of anatomical dissection of
the ankle ligaments. Posterior intermalleolar ligament
and bundles indicated with arrows. (1) Fibula. (2) Su-
perficial component of the posterior tibiofibular liga-
ment. (3) Transverse ligament or deep component of
the posterior tibiofibular ligament. (4) Lateral talar pro-
(Burks, 1994). The center is an average 10.1 mm
proximal to the tip of the fibula as measured along the
axis of the fibula (Burks, 1994). It thus encroaches
slightly on the entrance of the tarsal tunnel so that the
ligament ‘‘braces’’ the talus and makes a marked turn
around the antero-lateral corner of its lateral articular
surface (Kumai et al., 2002).
The insertion on the talus begins directly distal to
the articular surface and the center is an average
18.1 mm proximal to the subtalar joint (Burks,
1994). This measurement is to the center of what is
believed to be the main ATFL, not the inferior addi-
tional ligament seen in some patients. A distinct infe-
rior band was an inconsistent finding in the study of
Burks and Morgan (1994). When present, it had an
average length of 20 mm and an average width of
4.6 mm. When the foot is in the anatomical position,
the ATFL runs approximately horizontal, but when it
is plantarflexed, the ligament is nearly parallel to the
long axis of the leg. It is only in the latter position
that the ligament comes under strain and is vulnera-
ble to injury, particularly when the foot is inverted
(Broström, 1966; Colville et al., 1990; Kannus and
cess. (5) Calcaneofibular ligament. (6) Posterior talofib-
ular ligament. (7) Posterior intermalleolar ligament. (8)
Flexor hallucis longus tendon. (9) Flexor digitorum lon-
gus tendon. (10) Tibialis posterior tendon. [Color figure
can be viewed in the online issue, which is available at
www.interscience.wiley.com.]
Renstrom, 1991; Marder, 1995). In dorsiflexion, the
ATFL is directed slightly upward (Sarrafian, 1993).
The majority of the ATFL consists of typical dense
fibrous connective tissue with fibroblasts lying
between the bundles of collagen fibers (Kumai et al.,
2002). Occasional blood vessels are present in the
endotenon and epitenon and a highly vascular syno-
vial membrane lined its deep surface (Lang et al.,
1972; Kumai et al., 2002; Sobotta et al., 2006).
At both entheses 4 zones of tissue can be identi-
fied: (1) pure dense fibrous connective tissue, (2)
uncalcified fibrocartilage, (3) calcified fibrocartilage,
and (4) bone (Kumai et al., 2002). The subchondral
plate is thicker at the talar than at the fibular end of
the ligament and this is reflected in a significant dif-
ference between the mean percentages of calcified
tissue: marrow (CT/marrow) at the two ends of the
ligament in favour of the talar end. Kumai et al.
(2002) suggest that the lower CT/marrow ratio at
the fibular attachment site and the thinner subchon-
dral plate make it reasonable to conclude that the
bone is weaker here than at the talar entheses of the
ATFL. There is no reason to suspect that the two

entheses of the ATFL would be differentially affected
by bone mineral loss and trabecular thinning that
occurs with age. However, it is the comparative
values at either end of the ligament that is more im-
portant to explain the greater frequency of avulsion
fractures at the fibular end.
In the study of Kumai et al. (2002), the degree of
irregularity of the interface between the zones of cal-
cified fibrocartilage and bone (CFB) at each attach-
ment site was assessed by expressing the length of
this interface relative to that of the enthesis (E) itself
(CFB/E ratio). This led to greater CFB/E ratio at the
fibular end. Explanation for this is that the compres-
sive force exerted on the ATFL by the talus in a plan-
tarflexed and inverted foot means that stress is dis-
sipated away from the talar enthesis in a manner
that can not occur at the fibular insertion (Kumai
et al., 2002). The regular alignment of trabeculae
seen at the fibular enthesis suggests that the load
transfer may be more directional than at the talar
enthesis. This may reflect the presence of a region of
increased metachromasia or sesamoid fibrocartilage
where the deep surface of the ligament presses
against the talar articular cartilage (Kumai et al.,
2002). It is the proteoglycans in this region that
must enable the ligament to withstand intermittent
compression during foot movements (Benjamin
et al., 1995; Benjamin and Ralphs 1995, 1998).
This increased surface area at the fibular end pro-
tects against shear stress (Schneider, 1956) and
promotes anchorage of the ligament to the bone
(Milz et al., 2002). Gao and Messner (1996) sug-
gested that the shape and interface length of the
CFB junction at the ligament insertions is determined
by the tensile loads to which a ligament is subjected
around the puberty. The immunohistochemical sur-
vey performed by Kumai et al. (2002) showed that
Type I, III, and VI collagens, together with dermatan
and keratan sulphate, are present in all regions of
the ligament. However, Type VI collagen is largely
pericellular in the fibrocartilages. Type II collagen
and chondroitin 4 sulphate are especially present at
both entheses in the sesamoid cartilage. Versican is
present throughout the ligament but aggrecan is
most pronounced in the enthesis fibrocartilages and
near the surface of the sesamoid cartilage.
The sesamoid fibrocartilage of the ATFL is charac-
terized by its content of Type II collagen and aggre-
can. These molecules are typical of articular carti-
lage, a tissue known for its compression tolerance
properties. The presence of a sesamoid fibrocartilage
near the talar end reduces the change in insertional
angle that occurs at the talar enthesis during foot
movements. When the ATFL comes under strain in a
plantarflexed and inverted foot, it becomes increas-
ingly bent around the talar articular cartilage,
instead of accommodating the movement directly at
the insertion site. Kumai et al. (2002) provide with
these data an answer to the paradox between the
clinical and biomechanical studies of distal fibular
avulsion fractures. In clinical setting there is a higher
incidence of avulsion fractures at the fibular end of
the ATFL (Broström, 1964, 1966). However, biome-
chanical studies suggest the opposite, with the talar
Lateral Collateral Ligaments of the Ankle 623
end of the ATFL being more vulnerable to avulsion
fractures (St Pierre et al., 1983; Attarian, 1985). St
Pierre et al. (1983) studied the tensile strength to
destruction in 36 ligaments. Eighteen ligaments
failed by bone avulsion from the talus, the other 18
had a midsubstance failure of the ligament.
Many textbooks describe the existence of a single
ATFL. Anatomically as well as functionally, a superior
and an inferior part of the ligament may be distin-
guished. The existence of two unconnected fiber
bundles is confirmed by many authors (Pernkopf,
1964; Rouvière, 1967; Ludolph et al., 1984;
Schmidt, 1984; Burks, 1994). This interval allows
the penetration of vascular branches of the anterior
fibular artery (Sarrafian, 1993). In plantar flexion,
the lower part of the ligament remains relaxed while
the upper part becomes taut. In dorsiflexion, the
upper part remains relaxed and the lower part
becomes tight. When an upper and a lower part of
the ligament can be distinguished the width of the
ATFL was less than when the additional ligament was
not present (Burks, 1994). In many specimens these
two ligaments are united with arciform fibers at their
malleolar origin with the anterior tibiofibular and
CFL, proximal and distal, respectively (Sarrafian,
1993). Milner and Soames (1997) studied 26 ankles
from four male and nine female cadavers of Euro-
pean Caucasian origin. In 38% he found a single
form of the ATFL, in 50% a bifurcate form and in
12% he observed a trifurcate form. All trifurcate
ATFL were observed unilateral and in females. The
overall width of the ATFL did not appear to vary
greatly irrespective of the number of bands present,
suggesting that the variations observed do not mod-
ify the ligament’s function.
Separated ossicles of the lateral malleolus, the
condition also known as os subfibulare, usually are
found in 1% of the human population (Powell,
1961). Os subfibulare is sometimes cause of ankle
pain or associated with instability in which case it is
called symptomatic os subfibulare (Berg, 1991).
There are two theories regarding the origin of os
subfibulare. The first theory is that the ossicles are
caused by an avulsion fracture of the ATFL or the ta-
lus (Ogden and Lee, 1990; Berg, 1991; Hasegawa et
al., 1996) and the second theory is that the ossicles
occur as a result of an accessory ossification (Grif-
fiths and Menelaus, 1987; Kono et al., 2002).
CFL
In cross section the ligament is a strong cord-like
or flat oval ligament and measures approximately di-
ameter of 4–8 mm (Prins, 1978), length of about 20
mm (Broström, 1964; Prins, 1978; Sarrafian, 1993;
Milner and Soames, 1998), and the width of 4–5.5
mm (Sarrafian, 1993; Burks, 1994; Milner and
Soames, 1998).
With the foot in plantigrade position, the CFL
forms an angle of 478 (range 678–308) with the fibula
(Burks, 1994). Ruth (1961) observed 55 ankles dur-
ing surgery and provides the following data with
regard to the angle formed by the long axis of the
CFL and the long axis of the fibula (108–458:
74.66%; 08: 18.66%; 808–908: 4%; fan shaped:
624 van den Bekerom et al.
2.66%). It made a mean angle of 408 (range 308–
588) with horizontal plane, and mean angle of 518
(range 328–608) with saggital plane (Taser et al.,
2006). The angle between CFL and ATFL was
approximately 1328 (Taser et al., 2006).
The valgus or varus position considerably affects
the direction of and the angle formed by the CFL
with the fibula. This angle is increased with valgus of
the heel and decreased with varus position and is
also variable with the position of the ankle joint
(Ruth, 1961).
The CFL crosses the posterior subtalar joint and is
separated from it by the lateral talocalcaneal liga-
ment (TCL). The interval between the two ligaments
is filled with adipose tissue (Sarrafian, 1993). Trouil-
loud et al. (1988) studied the variable relationship of
the CFL and the lateral TCL in 26 ankles. In 35% of
the cases, the CFL is reinforced by a lateral TCL,
attached by the former but diverging proximally or
distally. In 23% of the cases, a lateral TCL exists
anteriorly and independent of the CFL. In 42% of the
cases, the lateral TCL is absent and is replaced by an
anterior TCL. In these cases the CFL acquires more
functional significance in providing stability to the
subtalar joint.
The CFL rises from the distal part of the anterior
margin of the lateral malleolus, just below the origin
of the inferior band of the ATFL (Sarrafian, 1993),
centered 8.5 mm from the distal tip (Burks, 1994).
The insertion averages 8.2 mm in the saggital direc-
tion and 6.2 mm in the coronal direction. The origin
does not extend to the tip of the lateral malleolus,
which is left free (Sarrafian, 1993). Near the origin,
arciform fibers may unite the CFL and the inferior
band of the ATFL. In some cases, the CFL attaches
predominantly to the ATFL (Ludolph et al., 1984).
The CFL runs obliquely downwards and backwards
to be attached to the lateral surface of the calca-
neus. The bony landmarks on the calcaneus for
attachment of the CFL are vague; therefore, many
physicians do not know the precise anatomic points
where this should be attached. The CFL inserts on a
small tubercle, located on the posterior aspect of the
lateral calcaneal surface, postero-superior to the
processus trochlearis of the peronei muscles (Sarra-
fian, 1993). The calcaneal insertion begins an aver-
age 13-mm distal to the subtalar joint with its proxi-
mal edge on a line nearly perpendicular to the joint
(Burks, 1994). Laidlaw, in a study of 750 calcanei,
gives the following location of the calcaneal insertion
of the ligament: 64.5% typical location, 25.5% ante-
rior location, 5.5% posterior location, and 4.5%
downward location (Laidlaw, 1904). The variable
insertions result in variable obliquity of the ligament
relative to the long axis of the fibula (Laidlaw, 1904).
It should be noted that the CFL runs deep to the per-
oneal tendon sheaths and that the calcaneal attach-
ment of the CFL is normally visible just posterior to
the tendons and their sheaths (Burks, 1994). These
tendons may leave an imprint on the CFL (Sarrafian,
1993). Only *10 mm of the ligament remains
uncovered by the crossing peronei (Sarrafian, 1993).
In contrast to the ATFL, this ligament is not part
of the fibrous capsule but is separated from it. It is
intimately associated with the peroneal tendon
sheath. It bridges the talocrural as well as the subta-
lar joint. The axis of rotation of the talocrural joint
runs approximately through, or just below, the tip of
the fibula. Insertion of the CFL as well as the ATFL at
its axis of rotation point (distal fibula tip) therefore
allows flexion and extension movements in the taloc-
rural joint. The connecting bundles that cross over
from the ATFL to the CFL provide an even lower
attachment point possibly to obtain this center of
rotation position. These bundles were noted to vary
in configuration, from a distinct rectangular structure
spanning the subtalar joint to a fan-shaped ligament
contiguous with the CFL inferiorly and broadening to
insert along the entire inferior portion of the ATFL
(Burks, 1994). When separately identifiable, these
bundles average 26.5 mm in length and 4.4 mm in
width (Burks, 1994). These bundles are known as
the lateral TCL (Prins, 1978), or the talocalcaneal
fibular ligament (Timmermans, 1981).
PTFL
The PTFL is a very strong ligament and passes
almost horizontally from a groove at the medial face
posterior to articular surface of the lateral malleolus
to the lateral and posterior aspects of the talus. This
ligament is intracapsular but extrasynovial. The liga-
ment is trapezoidal in contour and measures *30
mm in posterior length, 5 mm in width at the fibular
origin, and 5–8 mm in thickness (Sarrafian, 1993;
Milner and Soames, 1998). The measurement of the
free length of the PTFL is difficult because it has
attachments along almost the entire nonarticular
portion lateral face of the body of the talus (Burks,
1994). In plantar flexion and the neutral position the
ligament is relaxed, whereas in dorsiflexion the liga-
ment is tensed.
The fibular attachment is centered an average
9.7-mm proximal to the distal tip in the malleolar
fossa (Burks, 1994). The fibular origin is covered by
the superior peroneal retinaculum (Sarrafian, 1993).
The PTFL has a long attachment on the posterior
portion of the talus measuring 24.1 mm by 6 mm
(Burks, 1994). This attachment nearly involves the
entire nonarticular portion of the posterior talus to
the groove for the flexor hallucis longus tendon
(Burks, 1994). The medial segment is crossed by the
tendon of the flexor hallucis longus (Sarrafian,
1993). It is not an isolated area of insertion on the
posterolateral talus as represented in many articles
(Burks, 1994). The short transverse and intermedi-
ary fibers insert along the lateral surface of the talus
in a groove along the postero-inferior border of the
lateral malleolar articular surface up to its mid seg-
ment (Sarrafian, 1993). The long fibers are directed
postero-medially and insert on the posterior aspect
of the talus. The antero-posterior diameter averaged
10.1 mm and the proximal distal averaged 6.9 mm.
The width of this ligament varies markedly with foot
position (Sarrafian, 1993).
CONCLUSION
This review attempts to relate the anatomy of the
lateral collateral ankle ligaments to the sprained

ankle injury observed clinically. We believe that this
review of the anatomical characteristics of the lateral
collateral ankle ligament complex provides a founda-
tion for understanding the basic mechanism of injury
and for rationalizing the appropriate surgical inter-
ventions. Although we believe that this review con-
tributes to a more accurate placement of the liga-
ments, we realize that the original anatomic sites in
lateral ligament reconstruction are not always easily
identifiable at the time of reconstruction. The routine
histology and anatomy observations of the several
studies have necessarily been restricted to tissue
obtained from elderly dissecting room cadavers. This
means that degenerative changes in the ligaments
and alterations in bone mineral density are likely to
be more common than in younger active people. This
needs a careful interpretation to common practice.
ACKNOWLEDGMENTS
No benefits in any form have been received or will
be received from a commercial party related directly
or indirectly to the subject of this review. No sources
of funding were received to assist in this review. The
authors have no conflicts of interest that are directly
relevant to this review.
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