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This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Anatomy & Pathophysiology¶

Bony Anatomy¶

• The ankle mortise is formed by the tibial plafond, medial malleolus, and lateral malleolus [5].
• The ankle mortise articulates with the dome of the talar body [5].
• The talar dome is wider anteriorly and narrower posteriorly [5].
• The ankle mortise widens 1 to 1.5 mm during motion from plantar flexion to dorsiflexion [5].
• Medial and superior clear spaces appear wider with the foot in plantar flexion [5].
• A simplified model of the ankle joint has a horizontal axis from anteromedial to posterolateral [5].
• A simplified model of the ankle joint has a coronal axis from superomedial directed distally and laterally to the tip of the fibula [5].
• The distal fibula has a convex medial surface [5].
• The incisura fibularis is the concave surface of the distal lateral tibia [5].
• The fibula rotates approximately 2 degrees within the incisura during ankle motion and ambulation [5].
• Ankle dorsiflexion results in external rotation and proximal translation of the fibula [5].

Ligamentous Anatomy¶

• Lateral ankle ligaments function as restraints to varus and inversion forces at the ankle [5].
• The anterior talofibular ligament (ATFL) originates from the anteroinferior aspect of the lateral malleolus, 1 cm proximal to its tip [5].
• The anterior talofibular ligament extends to the lateral aspect of the talar neck [5].
• The calcaneofibular ligament (CFL) extends from the tip of the lateral malleolus to the lateral aspect of the calcaneus [5].
• The posterior talofibular ligament (PTFL) extends from the posterior lateral malleolus to the posterolateral talus [5].
• The ATFL is the weakest ankle ligament [5].
• The PTFL is the strongest ankle ligament [5].
• The distal tibiofibular joint and fibula provide stability against lateral talar translation [5].
• The deltoid ligament complex is the primary ankle stabilizer during stance [5].
• The deep deltoid ligament extends from the apex of the medial malleolus to the medial talar body [5].
• The deep deltoid ligament functions primarily to resist lateral talar translation and external rotation [5].
• The posterior deep deltoid is the most important component of the deep deltoid ligament [5].
• The superficial deltoid ligament extends from the distal medial malleolus to the navicular bone, sustentaculum tali of calcaneus, medial talus, and spring ligament [5].
• The superficial deltoid ligament functions primarily to resist valgus and eversion ankle forces [5].
• The deltoid ligament consists of superficial and deep layers, with at most six bands [11].
• Only three bands of the deltoid ligament are constant: the tibionavicular ligament, tibiospring ligament, and deep posterior tibiotalar ligament [11].
• The superficial layer of the deltoid ligament originates from the anterior malleolus and inserts into the navicular, neck of the talus, sustentaculum tali, and posteromedial talar tubercle [11].
• The tibiocalcaneal portion of the superficial deltoid ligament is the strongest component and resists eversion of the calcaneus [11].
• The deep portion of the deltoid ligament is the primary medial stabilizer of the ankle joint [11].
• The deep deltoid ligament is organized into two short, thick, discrete bands: the anterior and posterior deep tibiotalar ligaments [11].
• The anterior and posterior deep tibiotalar ligaments are intra-articular but extrasynovial [11].
• The deep posterior band comprises the largest band of the deltoid complex [11].
• The anterior deep tibiotalar ligament arises from the anterior malleolus and attaches to the medial aspect of the talus [11].
• The posterior deep tibiotalar ligament originates from the posterior malleolus and inserts on the medial body of the talus [11].
• The deltoid ligament has a rich vascular supply from three extraosseous sources: the medial tarsal artery, posterior tibial artery, and tibialis anterior artery [11].
• The deltoid ligament also has intraosseous vascular supply from either the talus or the medial malleolus [11].
• The deep deltoid ligament has the highest load to failure at 713.8 N ± 69.3 compared with the lateral collateral ligaments [11].
• The dominant mode of failure for the deep deltoid ligament is an intrasubstance rupture near its talar insertion [11].
• The failure of the superficial deltoid ligament is most commonly at its insertion on the anterior malleolus [11].

Biomechanics & Motion¶

• The primary functions of the foot and ankle are to provide weight-bearing support and forward ambulation [5].
• The ankle is responsible for most sagittal plane motion of the foot and ankle [5].
• Ankle plantar flexion ranges from 23 to 48 degrees [5].
• Ankle dorsiflexion ranges from 10 to 23 degrees [5].
• The ankle contributes to inversion, eversion, and rotation [5].

Neurovascular Anatomy¶

• The superficial peroneal nerve penetrates the deep fascia and lies subcutaneously 8 to 10 cm proximal to the tip of the lateral malleolus [9].
• The anterior tibial artery can be palpated beneath the superior extensor retinaculum 4 to 5 cm proximal to the distal articular surface of the tibia [9].
• The deep peroneal nerve accompanies the anterior tibial artery and lies between the tendons of the anterior tibial and extensor digitorum longus [9].
• The deep peroneal nerve lies just lateral to the anterior tibial artery [9].
• The saphenous nerve is located just medial or posterior to the saphenous vein in a slightly deeper plane 3 to 5 cm proximal to the tip of the medial malleolus [9].

Pathophysiology of Injury¶

• More than 75% of ankle ligament injuries involve the lateral ligament complex, particularly the ATFL and CFL [12].
• Medial ligament injuries are usually seen in association with a fracture or joint injury [12].
• In an ATFL sprain, tenderness is maximal just distal and slightly anterior to the lateral malleolus [12].
• The deltoid ligament primarily prohibits eversion and abduction [11].
• The deep deltoid ligament resists external rotation when the foot is dorsiflexed [11].
• The deep deltoid ligament is responsible for the greatest restraint against lateral translation [11].
• Valgus tilting of the talus within the mortise requires complete rupture of both the superficial and deep deltoid ligaments [11].
• Isolated rupture of the deltoid ligament without lateral ligamentous or fibular injury is rare [11].
• Syndesmotic injury, lateral ligamentous injury, and fibular fractures are common associations with deltoid injury [11].
• The criteria for diagnosis of medial instability include a feeling of giving way, medial ankle joint pain, and a correctable valgus or pronation deformity [11].
• Medial instability is reinforced by excess motion in external rotation, eversion, valgus, and/or posterior translation [11].
• With complete deltoid injury, a valgus AP stress radiograph shows talar tilt and/or lateral translation of the talus [11].
• Most incomplete deltoid injuries are normal on standard radiographic imaging [11].
• MRI is the imaging modality of choice for defining injury to the deltoid ligaments and associated structures [11].
• Ankle arthroscopy allows direct assessment of the deltoid ligament with lateral stress applied to the talus [11].

Investigations¶

Osteochondral Lesions¶

• Osteochondral lesions of the ankle are seen in up to 70% of ankle sprains and 75% of ankle fractures [15, 16].
• The most common location for osteochondral lesions is the medial talar dome [15, 16].
• Modern data indicate that the most common location for medial talar dome lesions is central, contradicting historical beliefs that the posterior location was more common [15, 16].
• Medial talar dome lesions are larger and deeper than lateral lesions [15, 16].
• Lateral talar dome lesions are less common than medial lesions [15, 16].
• Lateral talar dome lesions are more often unstable, displaced, or symptomatic than medial lesions [15, 16].
• Lateral talar dome lesions are often refractory to conservative measures [15, 16].
• Physical examination for osteochondral lesions demonstrates deep pain over the ankle joint line [15, 16].
• Palpation often does not reproduce the symptoms described by patients with osteochondral lesions [15, 16].
• Ankle effusion is common in patients with osteochondral lesions [15, 16].
• AP, mortise, and lateral weight-bearing ankle x-rays may not demonstrate subtle osteochondral lesions [15, 16].
• CT scan is helpful for determining the integrity of subchondral bone and identifying cysts in osteochondral lesions [15, 16].
• MRI is sensitive for all osteochondral lesions [15, 16].
• The edema pattern on MRI frequently overestimates the severity of osteochondral injury [15, 16].
• Linear fluid signal deep to subchondral bone on MRI indicates an unstable osteochondral injury [15, 16].
• MRI has a sensitivity of 92% for predicting stable versus unstable osteochondral lesions [15, 16].

General Imaging and Diagnosis¶

• Advanced imaging is often helpful in the diagnosis of foot and ankle injuries when combined with a thorough clinical examination [18].
• MRI is used for the evaluation of tibiofibular syndesmotic ligaments [3].
• MRI is used for the evaluation of posterior tibial tendon dysfunction [3].
• MRI is used for the evaluation of anterolateral soft tissue impingement of the ankle [3, 20].
• MRI is used for the evaluation of osteochondral lesions of the talus [3].
• MRI is used for the diagnosis of ligamentous and chondral pathology in the ankle [3].
• MRI and stress radiography are used in the evaluation of chronic lateral ankle instability [3].
• MRI is used in the pre-operative evaluation of the anterior talofibular ligament in chronic ankle instability [3].
• MRI is used for the diagnosis of ruptures of the tibialis posterior tendon [3].
• MRI is used for the imaging evaluation of traumatic ligamentous injuries of the ankle and foot [3].
• MRI is used for the diagnosis of plantar plate injury [3].
• MRI findings are associated with symptoms in patients with chronic ankle sprain [3].
• MRI is used for the evaluation of chronic Achilles tendon ruptures [3].
• MRI is used for the evaluation of peroneal tendon abnormalities [17].
• MR imaging is used for the evaluation of entrapment neuropathies of the lower extremity, including the ankle and foot [21].
• Ultrasonography is used for the examination of the deltoid ligament in bimalleolar equivalent fractures [19].
• Point-of-care ultrasonography is used in the diagnosis and management of superficial peroneal nerve entrapment [21].
• MRI lacks additional diagnostic value for stability assessment of the ankle mortise in supination-external rotation-type ankle fractures [19].
• Preoperative computed tomography scans are used in operative planning for malleolar ankle fractures [19].
• Axial CT imaging is used to evaluate normal tibiofibular relationships at the syndesmosis [19].
• Radiographic evaluation of the normal distal tibiofibular syndesmosis is a standard diagnostic consideration [19].
• Fluoroscopy is used to assess if the syndesmosis is reduced [19].
• The ankle fracture spur sign is pathognomonic for a variant ankle fracture [19].
• Evaluation of posterior malleolar fractures and the posterior pilon variant is performed in operatively treated ankle fractures [19].
• Stability criteria for nonoperative ankle fracture management are established via radiographic assessment [19].
• Gravity stress radiographs are used to assess deltoid ligament integrity and medial clear space measurements [4].
• Radiographic identification of primary lateral ankle structures is possible [4].
• Comparison of magnetic resonance imaging to physical examination is performed for syndesmotic injury after lateral ankle sprain [4].

Treatment¶

Complications and Revision¶

• Revision of failed total ankle arthroplasty can be performed as a hindfoot fusion [1].
• Infection in total ankle arthroplasty requires specific diagnostic and treatment protocols [1].
• Patient-related risk factors for periprosthetic joint infection have been analyzed in a cohort of 6977 total ankle arthroplasties [1].
• Risk factors for symptomatic deep-vein thrombosis exist in patients after total ankle replacement who received routine chemical thromboprophylaxis [1].
• Perioperative outcomes of total ankle arthroplasty differ when performed at an orthopaedic specialty hospital versus an academic teaching hospital [1].
• Salvage of failed total ankle arthroplasty can be achieved with fusion using structural allograft and internal fixation [1].
• Bone lysis of the AES total ankle replacement is subject to clinical evaluation and radiographic assessment [1].
• Heterotopic ossification can occur after total ankle arthroplasty [1].
• Risks associated with total ankle arthroplasty have been evaluated in the literature [1].
• Short-term complications are associated with procedures performed through separate incisions during total ankle replacement [1].
• The ankle arthritis score is associated with the need for revision surgery [1].
• Patient risk factors do not impact 90-day readmission and emergency department visitation after total ankle arthroplasty [1].
• Supramalleolar osteotomy is a treatment for tibial component malposition in total ankle replacement [1].
• Hindfoot arthritis progression and arthrodesis risk occur after total ankle replacement [1].
• Arthroscopic debridement is a management option after total ankle arthroplasty [1].
• Failures of total ankle replacement can be managed with the Agility total ankle arthroplasty [1].
• Blood transfusion during total ankle arthroplasty is associated with increased in-hospital complications and cost [1].
• A three-grade classification of complications has been assessed for total ankle replacement [1].
• Soft tissue reconstruction is performed after total ankle arthroplasty [1].
• Operative wound complications occur following total ankle arthroplasty [1].
• Bone grafting of bone cysts is an outcome management strategy after total ankle arthroplasty [1].
• Secondary arthrodesis is performed after total ankle arthroplasty [1].
• Short-term perioperative complications and mortality occur after total ankle arthroplasty in the United States [1].
• The incidence of symptomatic thromboembolic events is low after total ankle arthroplasty without routine use of chemoprophylaxis [1].
• Evaluation and management strategies exist for the painful total ankle arthroplasty [1].
• Anterior heterotopic ossification at the talar neck can occur after total ankle arthroplasty [1].
• Salvage arthrodesis is performed for failed total ankle replacement [1].
• Platelet-rich plasma has been evaluated for its efficacy in incision healing after total ankle replacement using the Agility system [1].
• Computed tomography has been evaluated for its added information on radiographic analysis in detecting periprosthetic osteolysis after total ankle arthroplasty [1].
• The impact of complications in total ankle replacement and ankle arthrodesis has been analyzed with a validated outcome measurement [1].
• Revision rates after total ankle arthroplasty have been reported in sample-based clinical studies and national registries [1].
• Acute hematogenous periprosthetic joint infection in total ankle arthroplasty can be treated with irrigation, debridement, and polyethylene exchange [1].
• Cigarette use is associated with complication rates and outcomes following total ankle arthroplasty [1].
• Heterotopic ossification occurs after primary total ankle arthroplasty [1].
• Delayed onset medial malleolar pain following total ankle arthroplasty has a defined etiology and treatment [1].
• Periprosthetic fractures occur in total ankle replacement [1].

General Outcomes and Trends¶

• Postoperative range of motion trends have been documented following total ankle arthroplasty [2].
• Total ankle arthroplasty outcomes have been compared for post-traumatic and primary osteoarthritis [2].
• Total ankle arthroplasty has been reported in France [2].
• Results of total ankle arthroplasty have been published [2].
• The success of current ankle replacements has been evaluated in a systematic review of the literature [2].
• The 10-year survival of total ankle arthroplasties was reported on 780 cases from the Swedish ankle register [2].
• Outcomes after total ankle arthroplasty have been reported from worldwide arthroplasty registers [2].
• Trends in total ankle arthroplasty and revisions have been analyzed in the Medicare database [2].
• Inconsistency in the reporting of adverse events in total ankle arthroplasty has been identified in a systematic review [2].
• Trends in the use of total ankle replacement and ankle arthrodesis have been analyzed in the United States Medicare population [2].
• Changes in pain, function, and gait mechanics two years following total ankle arthroplasty performed with two modern fixed-bearing prostheses have been documented [2].
• Trends in treatment of advanced ankle arthropathy by total ankle replacement or ankle fusion have been analyzed [2].
• The utilization of total ankle replacement in the United States has been assessed [2].
• Total ankle replacement was studied in a population-based study of 515 cases from the Finnish arthroplasty registry [2].
• Practice patterns in total ankle replacement and ankle fusion in the United States have been compared [2].
• Patient and practice trends in total ankle replacement and ankle arthrodesis in the United States from 2007 to 2013 have been analyzed [2].
• The evolution of the technology and future applications of total ankle replacement have been discussed [2].

Complications¶

• Revision of failed total ankle arthroplasty to a hindfoot fusion is a documented salvage procedure [1].
• Perioperative outcomes for total ankle arthroplasty differ when performed at an orthopaedic specialty hospital versus an academic teaching hospital [1].
• Salvage of failed total ankle arthroplasty can be performed with fusion using structural allograft and internal fixation [1].
• Heterotopic ossification is a recognized complication after total ankle arthroplasty [1].
• The risks associated with total ankle arthroplasty have been specifically evaluated [1].
• Supramalleolar osteotomy is used to treat tibial component malposition in total ankle replacement [1].
• A three-grade classification of complications in total ankle replacement has been assessed [1].
• Anterior heterotopic ossification at the talar neck occurs after total ankle arthroplasty [1].
• Computed tomography has been evaluated for its ability to add information on radiographic analysis in detecting periprosthetic osteolysis after total ankle arthroplasty [1].
• The impact of complications in total ankle replacement and ankle arthrodesis has been analyzed using a validated outcome measurement [1].
• Inconsistency exists in the reporting of adverse events in total ankle arthroplasty [2].

References¶

[1] Campbell S Operative Orthopaedics 4 Volume Set. Reported Outcomes of Ankle Arthroplasty Compared With Ankle Arthrodesis > COMPLICATIONS AND REVISION.

[2] Campbell S Operative Orthopaedics 4 Volume Set. Reported Outcomes of Ankle Arthroplasty Compared With Ankle Arthrodesis > REFERENCES.

[3] Campbell S Operative Orthopaedics 4 Volume Set. REFERENCES > FOOT AND ANKLE.

[4] Campbell S Operative Orthopaedics 4 Volume Set. REPAIR OF ACUTE RUPTURE OF LATERAL LIGAMENTS > ACUTE ANKLE LIGAMENT INJURIES, CHRONIC ANKLE INSTABILITY.

[5] Miller S Review Of Orthopaedics. SECTION 16 PATELLAR TRACKING IN TOTAL KNEE ARTHROPLASTY > BIOMECHANICS OF THE FOOT AND ANKLE.

[9] Campbell S Operative Orthopaedics 4 Volume Set. MULTIPLE Z-PLASTY RELEASE OF A CONGENITAL RING > ANKLE BLOCK.

[11] Orthopaedic Knowledge Update Sports Medicine 6. Ankle and Foot Injuries and Other Disorders > Ankle Sprains > Medial Ankle Injury.

[12] Apley And Solomon S Concise System Of Orthopaedics And Trauma. INJURIES OF THE ANKLE.

[15] Miller S Review Of Orthopaedics. SECTION 16 PATELLAR TRACKING IN TOTAL KNEE ARTHROPLASTY > OSTEOCHONDRAL LESIONS.

[16] Miller S Review Of Orthopaedics. OSTEOCHONDRAL LESIONS.

[17] Campbell S Operative Orthopaedics 4 Volume Set. MULTIPLE Z-PLASTY RELEASE OF A CONGENITAL RING > PERONEAL TENDONS.

[18] Orthopaedic Knowledge Update Sports Medicine 6. Ankle and Foot Injuries and Other Disorders > Summary.

[19] Orthopaedic Knowledge Update Trauma. Ankle Fractures > Annotated References.

[20] Campbell S Operative Orthopaedics 4 Volume Set. ARTHROSCOPIC EXAMINATION AND DEBRIDEMENT OF THE ANKLE JOINT > IMPINGEMENT.

[21] Campbell S Operative Orthopaedics 4 Volume Set. COMBINED HAMMER TOE AND MALLET TOE DEFORMITY WITH ASSOCIATED DOUBLE CORNS > REFERENCES > TARSAL TUNNEL SYNDROME.