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The Distal Tibiofibular Ankle
Syndesmosis: A Qualitative and
Quantitative Anatomical
Investigation
Brady T. Williams, BS; Annette B. Ahrberg, MD; Mary T
Goldsmith, MSc; Kevin J. Campbell, MD; Lauren Shirley;
Coen A. Wijdicks, Ph.D; Robert F. LaPrade, MD, Ph.D;
Thomas O. Clanton, MD
The Distal Tibiofibular Ankle Syndesmosis: A
Qualitative and Quantitative Anatomical Investigation
Thomas O. Clanton, MD
My disclosure is in the Final AOFAS Mobile App.
I have potential conflicts with this presentation due to
consultancy for Arthrex Inc. and Stryker.
The Steadman Philippon Research Institute is a 501(c)(3) non-profit institution supported
financially by private donations and corporate support from the following entities: Smith &
Nephew, Arthrex, Inc., Siemens Medical Solutions USA, Inc., ConMed Linvatec, Össur
Americas, Synthes, Ceterix Orthopaedics, Inc., AANA, University of Oslo, The Steadman
Clinic, Vail Valley Medical Center
Background
• Syndesmosis sprains can contribute to
chronic pain and instability, and often
require operative treatment
• Currently, the literature lacks sufficient
objective data detailing the complex
anatomy and localized osseous landmarks
essential for current surgical techniques1,4
Purpose
• To qualitatively and quantitatively analyze the
anatomy of the three syndesmotic ligaments,
including the anterior inferior tibiofibular ligament
(AITFL), posterior inferior tibiofibular ligament
(PITFL), and the interosseous tibiofibular
ligament (ITFL) with respect to surgically
relevant bony landmarks
Methods • Sixteen ankle specimens were dissected to identify
the anterior inferior tibiofibular ligament (AITFL),
posterior inferior tibiofibular ligament (PITFL),
interosseous tibiofibular ligament (ITFL), and bony
anatomy
• Ligament lengths, footprints, and orientations were
measured in reference to bony landmarks using an
anatomically based coordinate system and a three
dimensional coordinate measuring device and
reported as means with 95% confidence intervals2-3,5
Anterior Inferior Tibiofibular Ligament
• Present in all specimens
• Minimum and median of 3
bands
• Attached along the distolateral
margin of the anterolateral
tibial tubercle – Tibial footprint: 33.2 [30.3, 36.1] mm2
• Attached on the anterior
border of the fibula. – Fibular footprint: 34.2 [30.2, 38.1] mm2
Anterolateral Tibial (Tillaux-Chaput) Tubercle
Inferior Tip Lateral Malleolus
6.5 mm
30.5 mm
Posterior Inferior Tibiofibular Ligament
• Present in all specimens – Both superficial and deep constituents
• Superficial Fibers – Attached along inferior margin of the
posterolateral tibial tubercle and
posterior fibular border
8.3 mm
7.9 mm
11.1 mm
15.4 mm
Posterior Fibular Fossa
Posterolateral Tubercle
Proximal Prominence
Distal Prominence
7.8 mm
– Tibial footprint: 84.5 [76.8, 92.3] mm2
– Fibular fooprint: 108.1 [96.0, 120.1] mm2
• Deep fibers
– Attached inferior and medial to superfical fibers along the
tibial plafond and immediately proximal to the posteror
fibular fossa
– Tibial footprint: 52.2 [44.8, 59.6] mm2
Fibular footprint: 53.9 [47.3, 60.6] mm2
Interosseous Tibiofibular Ligament
• Present in all
specimens
• Fibrous expansion of the
distal interosseous
membrane
– Pyramidal ligamentous
network of fibers
– Originated 49.4 mm proximal
to the central aspect of the
tibial plafond
– Terminated 9.3 mm proximal
to the central aspect of the
tibial plafond
49.4 mm
9.3 mm
34.5 mm
Inferior Tip Lateral Malleolus
Synovial Recess/Articular Cartilage
• A synovial-lined joint
space was found in all
specimens – Border superiorly by the distal
border of the ITFL
• Articular Cartilage
– All specimens had an area of tibial
cartilage along the lateral aspect
of the plafond
– In 14/16 (87.5%) of specimens,
there were corresponding direct
articulating facets of tibial and
fibular cartilage along the anterior
tibiofibular joint
Anterolateral Corner Tibial Plafond
5.2 mm 3.6 mm
Inferior Tip Lateral Malleolus
30.9 mm
Conclusions
• Syndesmotic ligaments were uniform in their
locations and sites of attachment
• Qualitative and quantitative anatomy of the
syndesmosis ligaments and clinically relevant
structures was reproducibly defined with
respect to surgically relevant bony
prominences
Clinical Relevance
• Anatomic attachment sites and distances to
bony prominences can help optimize current
surgical fixation techniques, improve anatomic
restoration, and reduce the risk of iatrogenic
injury from malreduction or misplaced implants.
• Quantitative data also provides the consistency
required for the development of novel anatomic
reconstructions.
References
1. Bartonicek J. Anatomy of the tibiofibular syndesmosis and its clinical relevance. Surg Radiol Anat.
2003;25:379-386. PMID: 14504816
2. Campbell KJ, Michalski MP, Wilson KJ, Goldsmith MT, Wijdicks CA, LaPrade RF, Clanton TO. The
ligament anatomy of the deltoid complex of the ankle: a qualitative and quantitative anatomical
study. J Bone Joint Surg Am. 2014;96(8):e62. PMID: 24740670
3. Clanton TO, Campbell KJ, Wilson KJ, Michalski MP, Goldsmith MT, Wijdicks CA, LaPrade RF.
Qualitative and quantitative anatomic investigation of the lateral ankle ligaments for surgical
reconstruction procedures. J Bone Joint Surg Am. 2014;96(12):e98. [Epub ahead of print] PMID:
24951749
4. Ebraheim NA, Taser F, Shafiq Q, Yeasting RA. Anatomical evaluation and clinical importance of the
tibiofibular syndesmosis ligaments. Surg Radiol Anat. 2006;28(2):142-149. PMID: 16463081
5. Wu G, Siegler S, Allard P, Kirtley C, Leardini A, Rosenbaum D, Whittle M, D’Lima DD, Cristofolini L,
Witte H, Schmid O, Stokes I, Standardization and Terminology Committee of the International
Society of Biomechanics. ISB recommendation on definitions of joint coordinate system of various
joints for the reporting of human joint motion – part I: ankle, hip, and spine. International Society of
Biomechanics, J Biomech. 2002;35(4):543. PMID: 11934426
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