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Ankle sprains are frequent injuries among athletes and the general population, making them one of the most prevalent sports-related injuries. While most lateral ankle ligament injuries typically respond well to conservative treatment, a significant portion evolves into chronic lateral ankle instability, which may require surgical intervention. Recently, new anatomical insights regarding the lateral ankle ligaments have emerged, enhancing the advancement of innovative diagnostic and treatment approaches. The objective of this article was to discuss the latest trends in lateral ankle instability. Level of evidence V; Expert opinion.

Category: Basic Sciences/Biologics; Ankle Introduction/Purpose: The lateral ligament complex of the ankle has been extensively studied. Recently an anatomical study described a connection between anterior talofibular ligament inferior fascicle (ATFLif) and calcaneofibular ligament (CFL). The applicability and the mechanical role of these connections have not yet been studied and need to be clarified. The purpose of this study is to evaluate the connection between ATFLif and CFL through a dynamic measurement analysis. Methods: An anatomical study was performed in 13 fresh-frozen below-the-knee ankle specimens. Each specimen was dissected in a protocolized manner until the lateral ligaments were exposed. A complete injury to both ATFL's fascicles was created in the proximal third of the ligament. A displacement transducer specifically design was inserted in the CFL and in the lateral part of the calcaneus to test its lengthening. A traction of 1 kg weight (9.8 N) was applied to ATFLif while the transducer measured the lengthening that this force created in the CFL. Results: A total of 13 ankle specimens were carefully dissected. One specimen with signals of a prior traumatic injury of the ATFLif was excluded. A total of 12 specimens were included, 7 females and 5 males with an average age of 74 years (52-88 years). The right ankle was dissected in 6 specimens. ATFL was identified as a two-fascicled ligament in all cases. The fibers connecting the ATFLif and CFL were observed in all specimens. The displacement transducer showed lengthening in the CFL in all measurements with a median of 0.59 mm (SD 0.34). Conclusion: Connecting fibers between ATFLif and CFL are robust enough to transmit tension from one structure to the other.In the case of associated proximal lesions of the ATFLif and CFL, ligaments repair with a single suture may be considered. This can be applied in surgical procedures in patients with lateral ankle instability.

Category: Basic Sciences/Biologics; Ankle Introduction/Purpose: Recently an anatomical study described a medial connection between the anterior talofibular ligament inferior fascicle (ATFLif), calcaneofibular ligament (CFL) and posterior talofibular ligament (PTFL). Therefore, there is no research evaluating the lateral ligaments and their relationships through a three-dimensional view achieved by a digital marking of their foot prints. The authors hypothesize that a three-dimensional analysis made only by an accurately digital analysis can clarify the lateral collateral ligaments (LCL) connections and their foot prints relations. This work aims to carry out an anatomical study in cadaveric pieces in which the lateral ankle ligaments were dissected and evaluated by a tridimensional scanner that allows a digitally and three-dimensional assessment of their foot prints and connections. Methods: An anatomical study was performed in 11 fresh-frozen ankle specimens. Each ankle was dissected to achieve the amputation of the calcaneus, talus and fibula, keeping the inserts of the footprints of LCL. After that, each bone piece with the insertion remnants of the LCL was submitted to an evaluation by a scanner machine. Surface scans for these bones were collected using a structured light scanner. Each bone piece was set on a 3D automatic turntable to capture a 360° scan and was scanned in two orientations, with 6 scans per orientation. Finally, all the scans were aligned and final fused models were created using the HP DAVID software package and exported to a wavefront 3D object file. The 3D models were imported into Geomagic Studio to calculate surface area of the LCL foot prints. Results: A total of 11 units of each, talus, fibula and calcaneus were dissected from 11 ankles specimens. The ATFL was identified as a two-fascicled ligament and the fibers connecting fibers between the ATFLif and CFL was present in all specimens. In two talus there was only one insertion of the ATFL. After scanning the bones, the authors observed that the foot prints of ATFLif, CFL and PTFL were contiguous at medial side of the fibula, with an average of the surface area of 486,7 mm 2 . The foot print of the CFL on the calcaneus was located at the junction of a vertical line tangent to the highest point of the posterior subtalar with a horizontal line extending from the sinus tarsi in all specimens. Conclusion: This study demonstrated by a 3D analysis that the LCL of the ankle share the same foot print at medial side on the fibula and are all connected since the foot prints of the ATFL inf, CFL and PTFL were contiguous. In the case of associated proximal lesions of the ATFLif and CFL, ligaments repair with a single suture may be considered. This can be applied in surgical procedures in patients with lateral ankle instability.fig

Endoscopy for the posterior region of the ankle through two portals is becoming more widespread for the treatment of a large number of conditions which used to be treated with open surgery years ago. The tendon of the flexor hallucis longus (FHL) travels along an osteofibrous tunnel between the posterolateral and posteromedial tubercles of the talus. Chronic inflammation of this tendon may lead to painful stenosing tenosynovitis. The aim of this report is to describe two cases depicting an accessory tendon which is an anatomical variation of the flexor hallucis longus in patients with posterior friction syndrome due to posterior ankle impingement and associated with a posteromedial osteochondral lesion of the talus. The anatomical variation (FDAL) described was a finding during an endoscopy of the posterior region of the ankle, and we have spared it by sectioning the superior flexor retinaculum only. The accessory flexor digitorum longus is an anatomical variation and should be taken into account when performing an arthroscopy of the posterior region of the ankle. We recommend this treatment on this type of injury although we admit this does not make a definite conclusion.