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Current Reviews in Musculoskeletal Medicine logoLink to Current Reviews in Musculoskeletal Medicine
. 2019 Nov 20;12(4):497–508. doi: 10.1007/s12178-019-09592-0

Ultrasound-Guided Ankle Lateral Ligament Stabilization

Soichi Hattori 1,2,✉, Carlo Antonio D Alvarez 1, Stephen Canton 3, Macalus V Hogan 3, Kentaro Onishi 3,4
PMCID: PMC6942111  PMID: 31749104

Abstract

Purpose of Review

Ultrasound (US) is an increasingly popular imaging modality currently used both in clinics and operating rooms. The purpose of this review is to appraise literature describing traditional lateral ankle stabilization techniques and discuss potential advantages of US-guided ankle lateral ligament stabilization. In addition, albeit limited, we will describe our experiences in perfecting this technique.

Recent Findings

To date, the modified open Broström-Gould technique remains as the gold standard surgical treatment for chronic ankle instability (CAI). In the past decade, modifications of this technique have been done, from a combination of arthroscopic and open procedure to an all-inside arthroscopic technique with a goal of minimizing wound complications, better outcomes, and earlier return to activity. Recently, the use of US as an adjunct to surgical procedures has gained popularity and several novel techniques have been described. The use of US in lateral ankle stabilization could allow accurate placement of the suture anchor at the anatomical attachment of the anterior talofibular ligament (ATFL) without iatrogenic damage to the neurovascular structures such as anterolateral malleolar artery, superficial peroneal nerve, and sural nerve.

Summary

In summary, the use of US in ankle lateral ligament stabilization is a promising new micro-invasive technique. The theoretical advantages of US-guided ankle lateral ligament stabilization include direct visualization of desired anatomical landmarks and structures which could increase accuracy, decrease iatrogenic neurovascular damage, minimize wound complications, and improve outcomes.

Keywords: Ultrasound, Ultrasound-guided surgery, Chronic ankle instability, Lateral ligament stabilization

Introduction

Ankle sprains comprise 85% of all ankle injuries and are the most common injury accounting for 14–21% of all sports injury. The lateral ligament complex (LLC) of the ankle has three main structures: the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and posterior talofibular ligament (PTFL) [1•, 2]. A recent anatomic study by Vega et al. proposed the presence of the lateral fibulotalocalcaneal ligament complex which connects ATFL and CFL as a stabilizing structure of the lateral ankle [3••]. Tearing, stretching, and recurring sprains of these ligaments can result in chronic ankle instability (CAI). The ATFL is involved in 90% of all lateral sprains, whereas the CFL is involved in 50 to 75% of these sprains and the PTFL less than 10%. Conservative treatment with functional rehabilitation therapy remains as the standard of care for acute ankle sprains [1•, 2]. Approximately 74% of acute ankle sprains result in persistent symptoms, 30% of which progress to CAI [4••]. CAI is defined as the perception of recurring “giving way” of the ankle accompanied with a plethora of symptoms including recurrent sprains, pain with activity, swelling, difficulty walking on uneven ground, and avoidance of activities leading to persistent disability [1•, 2, 4••].

Surgical intervention may be warranted when patients with CAI fail to improve with conservative treatment. Many surgical techniques to stabilize the LLC have been proposed. These procedures are categorized into non-anatomic and anatomic repair or reconstruction. Early surgical techniques were non-anatomic reconstruction of the LLC proposed by Evans, Chrisman-Snook, Watson-Jones, and Castaing [1•, 5–7•]. These techniques required peroneal tendons to be sacrificed and used as grafts to restore ankle stability. However, the results were suboptimal both from clinical and biomechanical standpoints, with recurrent instability due to altered ankle biomechanics, persistent pain, and stiffness [5–7•]. Anatomic open surgical technique was later developed by Broström, wherein the native ATFL and CFL were imbricated together with ankle joint capsule [7•]. Gould later modified this procedure by adding the inferior extensor retinaculum (IER) as part of the repair [8, 9]. The simplicity of the procedure and restoration of physiologic joint anatomy and kinematics offered better outcomes and patient satisfaction compared to non-anatomic techniques. Thus, the modified open Broström-Gould technique remains the gold standard surgical treatment for CAI to date [1•, 6, 8, 9]. In recent years, arthroscopic ankle evaluation has been routinely performed followed by open procedures. Arthroscopic evaluation is performed in order to address simultaneous intra-articular pathological entities such as impingement lesions, ankle synovitis, intra-articular loose bodies, talar osteochondral lesions, and medial ankle tenosynovitis [10–12]. Subsequently, physicians moved toward arthroscopic evaluation with mini-open repair of lateral ligaments utilizing staples, suture anchors, thermal shrinkage, and plication. Recently, completely arthroscopic or “all-inside” techniques have been developed and the use of these procedures has been rapidly increasing [11, 13, 14].

Musculoskeletal ultrasound (MSK US) represents a cost effective, readily-available imaging modality that are both diagnostic and interventional [15–18•]. Interventional US refers to the use of a real-time guidance in order to perform various procedures such as local injections, aspirations, or biopsies. In some places, US guidance is used in place of conventional operative procedures. To distinguish these from arthroscopic procedures which are frequently referred to as “minimally invasive,” these US-guided surgical procedures are sometimes referred to as micro-invasive surgery [15, 17]. Once one is familiar with regional anatomy, or sono-anatomy, micro-invasive surgical procedures appear to be as safe as their conventional alternates. In theory, a real-time visualization of vital structures in the region affords added safety and accuracy compared to conventional surgery where visualization of these structures is not possible. In addition to being less invasive, existing micro-invasive surgeries are generally performed faster due to the use of local anesthetic as opposed to regional or general. Therefore, some micro-invasive surgeries result in a faster recovery and a reduction of pain medication use [19–23]. The evolution of US-guided surgical techniques has been described, from procedures where US is utilized to guide a conventional needle to perform traditional surgical procedures percutaneously, to US-guided procedures wherein special needles or devices are used to cut or release the target structures. Several authors continue to describe novel US-guided micro-invasive surgical techniques in the upper and lower extremities [24–33]. Although there are no English publications describing repair or reconstruction procedures that have been completely converted to US-guided procedure, some novel techniques have been reported such as US-guided percutaneous mini-open repair of the Achilles tendon [34, 35•] and medial patellofemoral ligament (MPFL) [36].

Recent systematic reviews have shown that US is a valuable diagnostic tool for detecting CAI, ATFL injuries in particular [4••, 37, 38•]. However, to the best of our knowledge, previous studies regarding US-guided repair or reconstruction techniques of the LLC of the ankle are limited. The purpose of this review is to appraise literature describing traditional lateral ankle stabilization techniques and discuss potential advantages of US-guided ankle lateral ligament stabilization. In addition, albeit limited, we will describe our experiences in perfecting this technique.

US-Guided Ankle Lateral Ligament Stabilization

Theoretical Advantages

A recent meta-analysis of arthroscopic and open repair of ankle lateral ligament showed that overall complication rate of arthroscopic repair of ankle lateral ligament was 10.3% and open repair complication rate was 10.0%. With open repair, the nerve complication rate was 4.5% and the wound complication rate was 3.6%. Meanwhile, they were 5.2% and 0% with arthroscopic repair respectively. The other complications in arthroscopic repair included persistent pain, wound/scar pain, and deep venous thrombosis (DVT) [7•]. Most of the nerve complications involve the superficial peroneal nerve (SPN) and its branches [7•]. A cadaveric study done by Pitts et al. suggested that sural nerve as well as SPN were the anatomical structures at greatest risk during arthroscopic Bronström procedure [39]. With US guidance, both SPN and sural nerve are made visible, and iatrogenic damage to these nerves could be avoided. The use of US to determine the course of the SPN was shown to be better than gross visualization/palpation in a cadaver study [40•]. Also, we could possibly reduce wound complication rate with “micro-invasive” nature of US-guided lateral ligament stabilization with one 5-mm incision.

Some authors pointed out that anchor insertion in arthroscopic procedures was often placed proximal to the anatomical ATFL attachment site of the fibula [41, 42••]. Teramoto et al. showed in their cadaveric study that the distance of markings made at the distal margin of the lateral malleolus under arthroscopy was 7–10 mm away from the center of the ATFL attachment site [42••]. In our retrospective analysis of 22 procedures of lateral ligament repair of the ankle, the distance of anchor placement from the anatomical ATFL attachment site in the US-guided procedure was non-inferior to open procedures. With the fibular obscure tubercle (FOT) as a reference point, the mean distance between the anchor and FOT was 6.0 ± 2.7 mm in open procedures, and 7.4 ± 2.5 mm in the US-guided procedure respectively. The mean differences between the two techniques (open-US guided) were − 1.5 mm (95% confidence interval 1.0 to − 3.9). The confidence interval was smaller than the non-inferiority margin (4 mm) [43••]. Thus, US-guided anchor placement could be more anatomically accurate than the conventional arthroscopic Broström procedure.

US Evaluation Protocol for Lateral Ligament Complex (LLC) of the Ankle

After acute ankle lateral ligament injury, the initial treatment is usually conservative, such as functional rehabilitation [1•, 2]. An incidence of 5 to 33% of patients experience pain and instability after ankle sprain [44]. Surgical management is warranted in these situations. The investigators of CAI described two subgroups: mechanical instability and functional instability. Mechanical instability is thought to result from various anatomic changes that may exist in isolation or in combination such as laxity caused by ligament tears. These changes are proposed to lead to insufficiencies that predispose the person to further episodes of instability. Functional instability is proposed to result from functional insufficiencies such as impaired proprioceptive and neuromuscular control after ankle sprain. Both mechanical and functional instabilities are difficult to distinguish as they often occur in combination during the development of CAI [2, 45]. The former is evaluated with physical examinations and imaging modalities including US, and sometimes requires surgical stabilization. The latter is managed with functional rehabilitation, which addresses impaired proprioception and incoordination of dynamic stabilizers of ankle.

During the US evaluation of the mechanical instability of the ATFL, the patient assumes a sitting position with the heel of the injured ankle hanging on the edge of examination bed [46•] or examiner’s knee. The ankle is maintained in the naturally plantarflexed (30 to 40°) position. The probe is placed at the distal edge of the lateral malleolus almost in parallel with the sole. In this position, a long-axis view of ATFL can be visualized, and the weight of the lower limb can place the ankle in the anterior drawer stress to evaluate mechanical instability (Fig. 1a–d) [46•]. The anterior branch of the peroneal artery, which is often called the anterior lateral malleolar artery and provides vascular supply to the ATFL [47•, 48], is identified with color doppler mode (Fig. 1c). The CFL is evaluated in a prone position with the ankle maximally dorsiflexed. The US probe is placed on the oblique coronal plane to visualize the long-axis view of the CFL for thickness, echogenicity, and continuity (Fig. 2) [49•]. In the CFL with normal tension, the peroneal tendons are elevated toward the probe during dorsiflexion of the ankle [50]. US-guided lateral ligament stabilization is considered if any pathologic finding is detected in ATFL and/or CFL by US (Fig. 3), and patients experience recurrent instability after intensive functional rehabilitation.

Fig. 1.

Fig. 1

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Ultrasound (US) evaluation of the anterior talofibular ligament (ATFL) in left ankle. a The patient assumes a sitting position with the heel of the injured ankle hanging over the examiner’s knee. The probe is placed at the distal edge of the lateral malleolus almost in parallel with the sole. b A long-axis view of the ATFL is visualized (white arrowheads). c The anterior lateral malleolar artery is identified next to vein with color doppler mode (white arrow). In order to obtain clear vascular images, we should avoid excessive compression of the artery or vein by the transducer. d Under the anterior drawer stress by the weight of the lower limb and the examiner’s hand, the ATFL is stretched (white arrowheads) with a clear fibrillar pattern

Fig. 2.

Fig. 2

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Ultrasound (US) evaluation of the calcaneofibular ligament (CFL) in right ankle. a The CFL is evaluated with the patient in prone position with the ankle in maximum dorsiflexion. The probe is placed anterior to the tip of the fibula toward calcaneal tuberosity. Anatomic studies have suggested that the calcaneal attachment of the CFL has variations. b With the ankle in maximum dorsiflexion, both fibula and calcaneal fibers of the CFL can be visualized (white arrowheads). c With the ankle in plantarflexion, only the calcaneal fibers of the CFL are visible (white arrowheads). Peroneal tendons are also visible above the CFL

Fig. 3.

Fig. 3

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Ultrasound (US) images of pathological anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) in chronic ankle instability (CAI). a A long-axis view of hypoechoic ATFL (white arrowheads) without clear fibrillar pattern is visualized. b Under anterior drawer stress, no fibrillar pattern of elongated ATFL becomes apparent. The distance between intra-articular fibular footprint and calcaneal footprint (yellow double arrow) is increased under anterior drawer stress. c A long-axis view of hypoechoic and thick CFL (white arrowheads) is visualized. Only calcaneal fibers of the CFL below peroneal tendons (P) are assessed in plantarflexion. d Under maximum dorsiflexion, the fibular fibers of the CFL (white arrowheads) become visible, yet no fibrillar pattern is apparent

Surgical Technique

The patient is placed in a supine position with the affected leg internally rotated. A bump is placed under the buttocks to keep the leg internally rotated. A sterilized wedge surgical cushion is placed under the calf as a counter during distraction when arthroscopic procedures for intra-articular lesions are performed. Standard high frequency linear transducers (> 12 MHz) or hockey stick probes are used. It is easier to perform this procedure with the hockey stick probe because of its superior controllability and visualization of the ATFL and anterior lateral malleolar artery. In a case of severe mechanical instability (namely, both ATFL and CFL are abnormal), however, standard linear transducers are employed to visualize the sinus tarsi as well as the ATFL to place multiple sutures.

  1. The tibiotalar joint is then infiltrated using 20 cc of epinephrine or lidocaine with epinephrine while visualizing the long axis of the ATFL with out-of-plane technique with 25G needle. The local infiltrates such as epinephrine and lidocaine allow us to improve the visualization of the ATFL with US by separating the ATFL from surrounding tissues.

  2. While visualizing the ATFL in a long-axis view, a large spinal needle with a curved tip such as the Micro SutureLasso™ minor bend (Arthrex, Florida) is passed under the ATFL with out-of-plane technique (Fig. 4a, b), paying attention to the anterior lateral malleolar artery. Once the needle tip becomes visible below the ATFL, the probe is rotated 90° to scan the short-axis view of ATFL, and then the needle is advanced just proximal to peroneal tendons (Fig. 4c, d). By passing the needle below ATFL and perpendicular to the long axis of the ATFL under US guidance, we place sutures in the same manner as the arthroscopic all-inside ATFL repair technique [51••]. The needle position should be in close proximity to the peroneal tendons, which enables us to pass sutures into the lateral fibulotalocalcaneal ligament complex [3••] to lift up elongated ATFL.

  3. Also, the sural nerve can be avoided since it runs distal to the peroneal tendons. The wire of the Micro SutureLasso™ is deployed after the needle tip penetrates the subcutaneous tissue and skin. The second wire can then be placed along with the long axis of ATFL under US guidance, again attempting not to damage the anterior lateral malleolar artery.

  4. After confirming a bony landmark of the fibular attachment of the ATFL, a 5-mm skin incision with no. 11 blade is made 45° to the long axis of the fibula and 1 cm distal-medial to the anatomical attachment of the ATFL. Blunt dissection with a mosquito forceps is carried down to the intra-articular area between the fibula and talus (Fig. 5a, b). A suture anchor is placed at the anatomical attachment of the ATFL after bringing the outer trocar to the attachment of the ATFL under US guidance (Fig. 5c–e).

  5. The proximal and distal limbs of the wire are retrieved subcutaneously with a grasper through the anchor incision. After suture relay, a simple interrupted suture with or without a knot pusher or the lasso loop stitch technique [52•] is performed for tensioning the LLC with the ankle in a neutral position.

  6. Additional arthroscopic procedures are necessary in cases of anterior impingement due to osteophytes and soft tissues, osteochondritis dissecans, and synovitis before applying the tension to the LLC. The suture wires can be visualized with arthroscopy 100% of the time, but the suture anchors are rarely visible since it is difficult to visualize the center of anatomical footprint of the ATFL under arthroscopy guidance [42••] (Fig. 6).

Fig. 4.

Fig. 4

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Ultrasound (US)-guided passing of the needle into the lateral ligament complex of right ankle. a, b A large spinal needle with a curved tip (yellow arrow) such as the Micro SutureLasso™ minor bend (Arthrex, Florida) is introduced below the ATFL (white arrowheads) in a long-axis view with out-of-plane technique while paying attention to the location of anterior lateral malleolar artery. c, d The transduce is rotated 90° and a short axis of the ATFL (yellow arrowheads) is visualized. The needle is advanced below the ATFL just proximal to the peroneal tendons (P). Theoretically, the needle tip could reach the lateral fibulotalocalcaneal ligament complex which connect ATFL and CFL fibers

Fig. 5.

Fig. 5

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Sonographically guided fibular anchor placement. a, b The anatomical attachment of the ATFL (white arrowheads) with a unique angular shape at fibula is confirmed. After a 5-mm skin incision with no. 11 blade is made 45° to the long axis of the fibula and 1 cm distal-medial to the anatomical attachment of the ATFL. Blunt dissection with a mosquito forceps is carried down to the intra-articular area between the fibula and talus. c After bringing the outer trochar to the anatomical attachment of ATFL under US guidance, we fix it with a hammer. d A small hole is made via the outer trochar by a drill. e A suture anchor is placed at the anatomical attachment of the ATFL

Fig. 6.

Fig. 6

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Arthroscopic view of the wire and suture anchors in ultrasound (US)-guided lateral ligament stabilization. a The wire, which is placed under US guidance, can be visualized over the ATFL under arthroscopy without fail. In contrast, a suture anchor is rarely visible under arthroscopy. In the current case, we placed two anchors under US guidance: one at the anatomical footprint of the ATFL, the other placed proximally to the anatomical footprint. Only the proximally placed anchor (yellow arrow) was visible under arthroscopy at the distal margin of the fibula. b) A postoperative computed tomography (CT) showed two anchors. The proximal anchor (yellow arrow) was visible under arthroscopy. The distal anchor (black arrow), which was placed at the center of the anatomical attachment of the fibula under US guidance, was not visible under arthroscopy

Rehabilitation

Despite micro-invasive nature of this procedure, rehabilitation program is similar to that of conventional arthroscopic and open stabilization since the time period required for biological healing process would be the same. It consists of three phases: phase 1 (0–4 weeks) focuses on restoring full range of motion with a brace after weaning off crutches and splint in 2 weeks; phase 2 (4–8 weeks) focuses on restoring strength and proprioception in the brace; phase 3 (8–12 weeks) focuses on implementing a sport-specific functional progression program, starting with jogging and ending up with return to sport or work-related activity by the end of phase 3 [1•].

Limitations

US-guided procedures are operator-dependent; thus, the physicians should be skilled in handling and operating US machines. Also, US view is limited to superficial structures of the ankle; therefore, if additional intra-articular pathologic is present, they cannot be appreciated or treated using US only.

Conclusions

Ultrasound is a useful adjunct to traditional surgical procedures for CAI. With US guidance, direct visualization of desired ankle anatomical landmarks and structures could increase accuracy, thus reducing surgical time, decreasing the incidence of iatrogenic damage to neurovascular and other soft tissue structures, minimizing wound complications, and improving outcomes. Despite the steep learning curve, fundamental knowledge in the use of US equipment and knowledge of the anatomy of lateral ankle make ultrasound-guided ankle lateral ligament stabilization reproducible.

Compliance with Ethical Standards

Conflict of Interest

Soichi Hattori, M.D., Carlo Antonio Alvarez, M.D., Stephen Canton, M.D., Kentaro Onishi, D.O., and Macalus V. Hogan, M.D. declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Footnotes

This article is part of the Topical Collection on Management of Ankle Instability

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

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