Figure - available from: European Journal of Trauma and Emergency Surgery
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a Schematic sketch of the lateral ligaments contributing to ankle and subtalar joint stability. FCL fibulocalcaneal ligament, 1 interosseous talocalcaneal ligament (ITCL), 2 oblique talocalcaneal ligament (TCO = cervical ligament), 3 lateral talocalcaneal ligament (LTCL), 4 bifurcate ligament. bLeft insertion points of the three components of the inferior extensor retinaculum (IER). 1 Medial and intermediate, 2 lateral. Right removing the IER and the cervical ligament opens the view to the bilaminar bundle of the interosseous talocalcaneal ligament. c The view to the talocalcaneal joint from behind demonstrates how the IER blends with the ITCL and the TCO
Source publication
Purpose:
Subtalar joint instability may frequently be overlooked and erroneously be integrated under the diagnosis of ankle joint instability. It was the scope of this review to characterize the present state-of-art with regard to the adequate diagnosis and treatment.
Methods:
While the clinical picture is mostly inconclusive for subtalar joint...
Citations
... The interosseous talocalcaneal ligament contributes more to subtalar joint stability than the calcaneofibular ligament. 1,20,29 We suggest that dissection of this interosseous complex, especially the interosseous talocalcaneal ligament, which is involved in eversion and pronation, will improve the varus calcaneal alignment of the calcaneus relative to the talus. Furthermore, the subtalar joint has an anterior compartment (coxa pedis) consisting of the anterior and articular surfaces of the talonavicular joint and the anterior and middle calcaneal facets, and a posterior compartment comprising the concave posterior-inferior talar facet and the large convex posterior calcaneal facet. ...
Background
Recovering normal hindfoot alignment and correcting deformity of the ankle joint following total ankle arthroplasty (TAA) in osteoarthritis (OA) is essential for improving clinical outcomes and increasing long-term survival. We aim to evaluate hindfoot alignment following standard TAA compared to TAA with a total talar prosthesis (“combined TAA”) in varus-type OA patients.
Methods
This retrospective study was conducted between 2010 and 2022. We included 27 patients (30 feet) who underwent standard TAA and 19 patients (22 feet) who underwent combined TAA. Hindfoot alignment at the subtalar joint was measured by weightbearing subtalar radiographic view before and after surgery.
Results
In the standard TAA, the angle between the tibial shaft axis and the articular surface of the talar dome joint (TTS) changed from 75 to 87 degrees ( P < .01), the angle between the tibial axis and the surface on the middle facet (TMC) from 89 to 94 degrees ( P < .01), and the angle between the tibial axis and the surface on the posterior facet (TPC) from 80 to 84 degrees ( P < .01). The angle between the articular surface of the talar dome and the posterior facet of the calcaneus (SIA) decreased from 4.7 to −2.5 degrees ( P < .01). In the combined TAA, TTS angle changed from 77 to 88 degrees ( P < .01), TMC angle from 93 to 101 degrees ( P < .01), TPC angle from 84 to 90 degrees ( P < .05), and SIA from 6.6 to 2.1 degrees ( P < .01). Varus deviation to the subtalar joint (TMC, TPC) significantly improved postoperatively in both groups. However, TPC was smaller than TTS and SIA was negative in standard TAA, and TPC was larger than TTS and SIA was positive in combined TAA.
Conclusion
The amount of correction of the subtalar joint differed depending on the ligament dissection of the subtalar joint and shape of the talar component
Level of Evidence
Level III, retrospective cohort study.
... Because the CFL is recognized as an important stabilizer of both the talocrural and subtalar joint (Kjaersgaard-Andersen et al., 1987;Li et al., 2019), many authors recommend a low threshold to reconstruct the CFL in addition to the ATFL (Karlsson et al., 1997;Mittlmeier and Wichelhaus, 2015;Tourné and Mabit, 2017;Michels et al., 2018). The anatomical reconstruction of the CFL is a technically demanding procedure but recent publications offer helpful guidelines (Michels et al., 2016b;Matsui et al., 2017b;Lopes et al., 2018;Michels et al., 2020c;Michels et al., 2020d). ...
Subtalar instability (STI) is a disabling complication after an acute lateral ankle sprain and remains a challenging problem. The pathophysiology is difficult to understand. Especially the relative contribution of the intrinsic subtalar ligaments in the stability of the subtalar joint is still controversial. Diagnosis is difficult because of the overlapping clinical signs with talocrural instability and the absence of a reliable diagnostic reference test. This often results in misdiagnosis and inappropriate treatment. Recent research offers new insights in the pathophysiology of subtalar instability and the importance of the intrinsic subtalar ligaments. Recent publications clarify the local anatomical and biomechanical characteristics of the subtalar ligaments. The cervical ligament and interosseous talocalcaneal ligament seem to play an important function in the normal kinematics and stability of the subtalar joint. In addition to the calcaneofibular ligament (CFL), these ligaments seem to have an important role in the pathomechanics of subtalar instability (STI). These new insights have an impact on the approach to STI in clinical practice. Diagnosis of STI can be performed be performed by a step-by-step approach to raise the suspicion to STI. This approach consists of clinical signs, abnormalities of the subtalar ligaments on MRI and intraoperative evaluation. Surgical treatment should address all the aspects of the instability and focus on a restoration of the normal anatomical and biomechanical properties. Besides a low threshold to reconstruct the CFL, a reconstruction of the subtalar ligaments should be considered in complex cases of instability. The purpose of this review is to provide a comprehensive update of the current literature focused on the contribution of the different ligaments in the stability of the subtalar joint. This review aims to introduce the more recent findings in the earlier hypotheses on normal kinesiology, pathophysiology and relation with talocrural instability. The consequences of this improved understanding of pathophysiology on patient identification, treatment and future research are described.
... Additionally, due to the lack of treatment, the probability of recurrent ankle sprain is increased resulting in chronic joint instability [5]. However, because of similar manifestations, it is difficult to diagnose whether ankle joint instability involves subtalar joint instability, so the incidence rate of ankle-subtalar joint complex instability is probably higher [6][7][8]. As instability occurs, the probability of joint degeneration increases, even affecting adjacent joints. ...
Background: Ankle-subtalar joint complex instability is not uncommonly presented in the clinic, but symptoms and signs similar to other conditions can easily lead to its misdiagnosis. Due to the lack of appropriate animal models, research on ankle-subtalar joint complex instability is limited. The aims of the present study were to establish an animal model of ankle-subtalar joint complex instability in mice and to explore its relationship with post-traumatic osteoarthritis (PTOA). Methods: Twenty-one male C57BL/6J mice were randomly divided into three groups: SHAM group (sham surgery group), transected cervical ligament + anterior talofibular ligament (CL+ATFL) group, and transected cervical ligament + deltoid ligament (CL+DL) group. Two weeks after surgery, all mice underwent cage running training. Balance beam and gait tests were used to evaluate the changes in self-movement in the mice after ankle-subtalar ligament injury. Micro-CT and histological staining were used to evaluate the progress of PTOA.
... 68 Although ankle instability is a well-known risk factor for ankle OA, 80 the field continues to search for adequate evidence on the difficult-to-diagnose subtalar joint instability. 5,38,54,55 The ankle and subtalar joints are in close proximity and share stabilizing ligaments. 55 A systematic literature review of 23 imaging studies, mostly using radiographs, found that current imaging options do not reliably predict subtalar joint instability. ...
... 5,38,54,55 The ankle and subtalar joints are in close proximity and share stabilizing ligaments. 55 A systematic literature review of 23 imaging studies, mostly using radiographs, found that current imaging options do not reliably predict subtalar joint instability. 42 Recently, WBCT with 3D image analysis has been used to investigate and quantify the interaction of loading and torque of the subtalar joint in vitro. ...
This second of a 2-part series of articles recounts the key points presented in a collaborative symposium sponsored jointly by the Arthritis Foundation and the American Orthopaedic Foot & Ankle Society with the intent to survey current treatment options for osteoarthritis (OA) of the foot and ankle. A meeting was held virtually on December 10, 2021. A group of experts were invited to present brief synopses of the current state of knowledge and research in this area. Topics were chosen by meeting organizers, who then identified and invited the expert speakers. Part 2 overviews the current treatment options, including orthotics, non–joint destructive procedures, as well as arthroscopies and arthroplasties in ankles and feet. Opportunities for future research are also discussed, such as developments in surgical options for ankle and the first metatarsophalangeal joint. The OA scientific community, including funding agencies, academia, industry, and regulatory agencies, must recognize the importance to patients of addressing the foot and ankle with improved basic, translational, and clinical research.
Level of Evidence
Level V, review article/expert opinion.
... As the CFL bridges both the tibiotalar and subtalar joint, a low threshold to reconstruct the CFL in addition to the ATFL is recommended. [10,[12][13][14] However, many studies suggest the subtalar ligaments having an important function in the stability of the subtalar joint. [15][16][17][18][19] Therefore, several studies described and recommended the reconstruction of the cervical ligament (CL) in complex cases of subtalar instability. ...
... [22] Only patients with a score < 20 were considered for surgical treatment. The mean preoperative CAIT score was 9.3 (range, [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17]. ...
Purpose
Diagnosis and treatment of subtalar instability (STI) remains complicated and challenging. The purpose of this study was to investigate the outcome of an anatomical reconstruction of the cervical ligament in patients with suspected chronic STI.
Methods
This prospective study assessed the results of a surgical reconstruction of the cervical ligament using a gracilis tendon graft in a group of 14 patients (16 feet). Diagnosis of STI was performed using a predefined algorithm including clinical signs, MRI and peroperative evaluation. All patients had symptoms of chronic hindfoot instability despite prolonged non-surgical treatment. At final follow-up the outcome was assessed using the Karlsson score, the Foot and Ankle Outcome Score and the American Orthopaedic Foot and Ankle Society score.
Results
After an average follow up of 22.6 months (range, 15-36), all patients reported significant improvement compared to their preoperative symptoms. The mean preoperative Karlsson score improved from 36.4 ±13.5 (median 37, range 10–55) to a mean postoperative Karlsson score was 89.6±8.5 (median 90, range 72-100) (P<0.0001). The cervical ligament reconstruction was combined with other procedures in 13 cases: calcaneofibular ligament (CFL) reconstruction (3), CFL and anterior talofibular ligament reconstruction (7), bifurcate ligament reconstruction (3).
Conclusion
Anatomical reconstruction of the cervical ligament is a valid technique to treat patients with STI. It is a safe procedure and produces good clinical results with minimal complications. This technique can be considered in more complex cases and can be combined with other procedures according to the specific location of the instability.
Level of evidence
Level III
... It has a triplane joint axis and allows for pronation and supination in conjunction with the midtarsal joint [1,2]. Subtalar joint osteoarthritis is often precipitated by articular talar and calcaneal fractures and causes pain and limited range of motion of the hindfoot complex [3,4]. Conservative treatments may be employed including NSAIDs, physical therapy, bracing, and steroid/ anesthetic injections [5]. ...
... Conservative treatments may be employed including NSAIDs, physical therapy, bracing, and steroid/ anesthetic injections [5]. Patients that fail conservative treatment often go on to have arthroscopic surgery [6] and or joint fusions [3,4]. ...
This case study evaluates the use of Extracorporeal Pulse Activation Therapy (EPAT) and Amniotic Extracellular Matrix Injection (AEMI) in a patient suffering unilateral post-traumatic subtalar joint (STJ) osteoarthritis. Following an injury he was not able to work or exercise secondary to subtalar joint pain. He had failed treatment with bracing, physical therapy, and PRP injections and was not interested in surgery. Following serial EPAT and AEMI the patient had a decrease in pain score (from 5/10 at rest, to 2/10 with activity and 0/10 at rest) and was able to return to work and activities. In conclusion, EPAT and AEMI are effective treatments for STJ arthritis, present a viable alternative to surgery, and should be explored for use in other degenerative conditions of the foot and ankle.
... Effective imaging techniques have yet to be identified. Stress radiographs are generally used but their reliability is still disputed [2,10,11]. Clinical diagnosis may depend on several parameters including MRI for the assessment of the morphology of ligamentous structure and associated lesions underlying the disorder [11]. ...
... Quantitatively, the IOLV dimension was significantly smaller in width in the group with IOLV tears than in intact IOLV group. Because subtalar disorders are less known, the structures in the tarsal sinus may be overlooked [10]. It may be attributed to limited consensus about the definition of anatomic structures and the interpretation of their biomechanical relevance in tarsal sinus [16]. ...
Background
Interosseous ligament vertical segment (IOLV) and calcaneofibular ligament (CFL) have been reported to be important in stabilizing the subtalar joint. Unlike CFL, there is not much information regarding the comparison of MRI results with surgical evaluation of IOLV and the comparison between 2D and 3D MRI on IOLV evaluation. The feasibility of MRI in IOLV evaluation has yet to be reported. The purpose of this study was to evaluate the validity and reliability of MRI in IOLV tear detection via correlation with arthroscopic results. We also compared the diagnostic performance of 2D and 3D MR images.
Methods
In this retrospective study, 52 patients who underwent subtalar arthroscopy after ankle MRI were enrolled. Arthroscopic results confirmed IOLV tear in 25 cases and intact IOLV in 27 cases. Two radiologists independently evaluated the IOLV tears using only conventional 2D images, followed by isotropic 3D images, and comparison with arthroscopic results.
Results
Only the 2D sequences interpreted by two readers showed a sensitivity of 64.0–96.0%, a specificity of 29.6–44.4%, a positive predictive value of 51.6–56.4%, and a negative predictive value of 57.1–88.9%. Addition of isotropic 3D sequences changed the sensitivity to 60.0–80.0%, specificity to 63.0–77.8%, positive predictive value to 64.3–76.9%, and negative predictive value to 66.7–80.8%. The overall diagnostic performance of isotropic 3D sequences (AUC values: 0.679–0.816) was higher than that of 2D sequences (AUC values: 0.568–0.647). Inter-observer and intra-observer agreement between the two readers was moderate-to-good for both 2D and 3D sequences. The diagnostic accuracy in 19 patients with tarsal sinus fat obliteration tended to increase from 26.3–42.1% to 57.9–73.7% with isotropic 3D sequences compared with 2D sequences.
Conclusions
Isotropic 3D MRI was feasible for the assessment of IOLV tear prior to subtalar arthroscopy. Additional 3D sequences showed higher diagnostic accuracy compared with conventional 2D sequences in IOLV evaluation. Isotropic 3D sequences may be more valuable in detecting IOLV tear in case of tarsal sinus fat obliteration.
... Additionally, due to the lack of treatment, the probability of recurrent ankle sprain is increased resulting in chronic joint instability [5]. However, because of similar manifestations, it is difficult to diagnose whether ankle joint instability involves subtalar joint instability, so the incidence rate of ankle-subtalar joint complex instability is probably higher [6][7][8]. As instability occurs, the probability of joint degeneration increases, even affecting adjacent joints. ...
Background
Ankle-subtalar joint complex instability is not uncommonly presented in the clinic, but symptoms and signs similar to other conditions can easily lead to its misdiagnosis. Due to the lack of appropriate animal models, research on ankle-subtalar joint complex instability is limited. The aims of the present study were to establish an animal model of ankle-subtalar joint complex instability in mice and to explore its relationship with post-traumatic osteoarthritis (PTOA).
Methods
Twenty-one male C57BL/6J mice were randomly divided into three groups: SHAM group (sham surgery group), transected cervical ligament + anterior talofibular ligament (CL+ATFL) group, and transected cervical ligament + deltoid ligament (CL+DL) group. Two weeks after surgery, all mice underwent cage running training. Balance beam and gait tests were used to evaluate the changes in self-movement in the mice after ankle-subtalar ligament injury. Micro-CT and histological staining were used to evaluate the progress of PTOA.
Results
Compared with the SHAM group, balance and gait were affected in the ligament transection group. Twelve weeks after surgery, the time required to cross the balance beam in the CL+ATFL group was 35.1% longer and the mice slipped 3.6-fold more often than before surgery, and the mean step length on the right side was 7.2% smaller than that in the SHAM group. The time required to cross the balance beam in the CL+DL group was 32.1% longer and the mice slipped 3-fold more often than prior to surgery, and the average step length on the right side was 5.6% smaller than that in the SHAM group. CT images indicated that 28.6% of the mice in the CL+DL group displayed dislocation of the talus. Tissue staining suggested that articular cartilage degeneration occurred in mice with ligament transection 12 weeks after surgery.
Conclusions
Transected mice in the CL+ATFL and CL+DL groups displayed mechanical instability of the ankle-subtalar joint complex, and some mice in the CL+DL group also suffered from talus dislocation due to ligament injury leading to loss of stability of the bone structure. In addition, as time progressed, the articular cartilage displayed degenerative changes, which affected the ability of animals to move normally.
... [1][2][3] Insufficiency and chronic tear of these ligaments, primarily of the interosseous talocalcaneal (InOL) and cervical (CvL) ligaments, predispose the subtalar joint to chronic instability, with subsequent anterior shift, medialization, and varus tilt of the calcaneus. [4][5][6] It is well known that 10 to 25% of people with chronic lateral ankle instability exhibit coexisting instability at the STj level. 7 Distinction between ankle joint and STj instability is not straightforward because of overlapping symptoms and ...
Ligament injuries around the subtalar, talocalcaneonavicular, and calcaneocuboid joints are often underestimated on clinical and imaging findings during investigation of patients with ankle and foot injuries. Because a delayed diagnosis of midtarsal ligament tears may lead to chronic pain and functional disability, an in-depth knowledge of the complex regional anatomy and of the appropriate ultrasound scanning technique is a prerequisite for evaluating these structures and avoiding misdiagnoses. The objective of this article is twofold: to describe the relevant anatomy and biomechanics related to the ligaments that stabilize the subtalar, talocalcaneonavicular, and calcaneocuboid joints, and to illustrate reasoned landmark-based scanning techniques to provide a systematic examination of these ligaments and thus make ultrasound an effective tool for assessment of patients with suspected subtalar or midtarsal sprain.
... Given that the incidence of ankle sprains in the United States has been reported as high as 30,000 per day, it would stand to reason that STJ sprains are a common injury (2,3). Of patients that fail an appropriate course of nonoperative treatment for lateral ankle sprain, Mittlmeier and Wichelhaus (4) reported that 25% may owe their poor recovery to chronic STJ instability. Because of similar injury mechanisms and similar clinical symptoms between ankle and STJ instability, and given that there is no currently accepted standard for isolated STJ instability assessment, STJ instability is often misdiagnosed or left undiagnosed. ...
New surgical strategies to treat symptomatic subtalar joint (STJ) instability are evolving. We modified a previously described reconstruction strategy and then refined our new surgical technique through simulated surgery and subsequent cadaver dissections. Our purpose was to show that a tunnel intended to facilitate STJ stabilization surgery could safely be drilled across the footprints of the interosseous talocalcaneal ligament (ITCL). A percutaneous fluoroscopically guided tunnel for the purpose of ITCL reconstruction was created in 10 cadaveric below-knee specimens. Accuracy of the tunnel with relation to the anatomic boundaries of the ITCL attachment sites as well as damage to relevant structures at risk were recorded. Two sets of 5 surgeries were performed to assess for improvement in technique. Mean distances from the tunnel to the ITCL on the calcaneus improved between groups 1 and 2: 4.04 and 1.80 mm, respectively (p = .04). Mean distances from the tunnel to the ITCL on the talus improved between groups 1 and 2: 6.2 and 1.8 mm, respectively (p = .08). With information obtained from this study, an osseous tunnel can be safely placed within 2 mm of the ITCL footprints.
