![]() ![]() After the ankle capsule is incised a “vest over pants” repair is performed (fig 10). Once the appropriate ankle capsular incision is made joint fluid is usually encountered. #Anterior talofibular ligament skin#Once the capsule is identified, an incision is made in the ankle capsule, in line with the skin incision (fig 9). A small tear can sometimes be visualized in the ankle capsule. One usually can see a thickening of the ankle capsule, representing the ATFL. The ankle capsule will be encountered with a white coloration. Blunt dissection is then performed with care not to damage the sural nerve. An oblique or curvilinear incision is made in the area of the sinus tarsi (fig 8). Meaning, that the calcaneo-fibular and posterior talo-fibular ligament is intact. Again, we are only speaking of primary repair of a partially or fully torn ATFL ligament only. Primary repair of the ATFL is relatively simple procedure. Moreover, the pseudo-bands margins are usually blurred and irregular. However, this pseudo-band is usually lax, and can be thicker in comparison to the normal ligament. This can be mistaken for an intact tear on MRI and US. described an anomaly where the torn ligament fills in with inhomogeneous scar and inflammatory tissue. The practitioner however, should be aware of a phenomenon known as pseudo-band formation. (2012) reported a sensitivity and specificity of 97.7 and 92.3 in determining ATFL tears from intact ligaments (fig 7A and 7B). With the right sonographic personnel, Hua et al. Ultrasound has long been in use for diagnosing soft tissue abnormalities and in aiding in invasive procedures. With the soaring cost to an individual for their deductible, a reliable, cost-effective modality for ATFL radiographic analysis is available. Park et al (2012) reported that MRI had a sensitivity and specificity of 75% and 86% for complete ATFL tears, and a sensitivity and specificity of 75% and 78% for partial tears. Magnetic resonance imaging (MRI) (fig 6) is a time tested method of determining soft tissue injuries. Non-invasive testing is an important part in determining whether a tear of the ATFL ligament exists. The one caveat is that because pain and edema are present, these stress tests may be inconclusive secondary to guarding. Additionally, an increase in 15-30 degrees the ATFL and CFL are torn, greater than 30 degrees ATFL, CFL and PTFL are most probably torn. When compared to the contralateral limb, 5-10 degree increase is indicative of an ATFL tear (fig 5C). As with the ADT, the tibia is stabilized and the ankle is inverted. The talar tilt test is performed with the patient sitting and the ankle plantar flexed 10-20 degrees (fig 5). Measurements of greater than 3mm when compared to the contralateral limb, on a lateral view, is considered to be pathologic (Fig 4C). As the tibia is stabilized, the foot is attempted to be moved forward. The anterior draw test is accomplished by plantar flexing the ankle 10 degrees stabilizing the anterior distal tibia with one hand and cupping the posterior calcaneus with the other (fig 4A). The two standard in office testing modalities are the anterior drawer test (ADT) and talar tilt test (TTT). In office testing of the ATFL ligament is relatively easy, however, one must be cautious with the results. ![]()
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