Anatomy of the Ankle and Subtalar Joint Ligaments

Reconstruction of the interosseous talocalcaneal ligament using allograft for subtalar joint stabilization is effective

“…Though the trend is towards anatomic reconstruction of the damaged structures and use of arthroscopically assisted techniques, most studies are limited to retrospective case series with a limited number of patients and variable follow-up, without any biomechanical rationale supporting the proposed techniques [ 11 , 14 , 21 ]. Several authors proposed anatomic reconstruction of the inter-talocalcaneal ligament, considered by many the most potent ligament and main stabiliser of the subtalar joint [ 6 , 15 , 18 , 21 , 34 , 40 ]. The surgical technique described has many advantages compared to other techniques, such as (1) anatomic tunnel placement under direct arthroscopic visualisation, without the need of fluoroscopy; (2) the creation of a talar half tunnel avoids the complications associated with drilling a complete tunnel, such as talar neck fracture and injury to the anterior tendinous and neurovascular structures; (3) cortical fixation on the anterior talar surface allows for a more stable fixation and reduces the need for immobilisation; (4) the use of allograft avoids donor site morbidity and (5) simplicity of this technique allows for a relatively brief learning curve and a short duration of surgery, of particular interest in cases of combined tibiotalar and subtalar instability that also require reconstruction of the lateral ankle ligaments.…”

“…The ITCL was then anatomically reconstructed with a bifascicular technique using the harvested extensor hallucis longus graft, with a complete calcaneal tunnel and a talar half tunnel, and fixed using the dynamic ACL TightRope ® system (Arthrex, Naples, FL, USA) at the talar end and a 6.25 mm biotenodesis screw (Arthrex, Naples, FL, USA) at the calcaneal end, with the subtalar joint in slight eversion and dorsiflexion (Fig. 3) [6]. Angular stability was assessed again after reconstruction and the angular movements were recorded. 6.…”

“…An arthrometer specifically designed to measure angular displacements in all three anatomic planes (axial, coronal, sagittal) [ 6 ] was used. A sensor to the calcaneus (Fig.…”

“…Its stability resides in the configuration of the anterior and posterior subtalar joint surfaces as well as several ligamentous structures (Fig. 1 ) [ 6 , 25 , 27 ]: the inferior extensor retinaculum (IER), the calcaneo-fibular ligament (CFL), the cervical ligament (CL) and finally the inter-talocalcaneal ligament (ITCL), which comprises an anterior and a posterior fascicle that rotate over each other regulating subtalar motion—similar to the cruciate ligaments of the knee [ 5 , 6 , 8 , 10 , 18 , 19 , 25 , 39 , 40 ].

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