Foot & Ankle International - June 2017 - 625

Jung et al

625

Figure 6. Scarred ATFL of right ankle, which was interpreted
as attenuated and wavy on preoperative MRI, was observed in
the operative field. The asterisk indicates the fibular tip that is
the origin of the ATFL.
Figure 5. Receiver operating characteristic curve for
predicting ligament thickness using the talar tilt angle in
varus stress view (grey line: ATFL thickness, dotted line: CFL
thickness). Absent or attenuated remnant of ligament (ATFL
or CFL) was predicted by about 10 degrees of talar tilt angle
on varus stress view.

is, 89% for the ATFL and 41% for the CFL.16 In most CLAI
cases, the healing process may reconnect the 2 ends of the
ligament. Although the chronic injury state did not show
any MRI findings distinguishable from acute injury in this
series, the proportion of some appearances was different
from the acute findings. In fact, concerning the detailed
findings, we were unable to compare our outcomes to those
of previous studies because no previous studies reported the
incidence of each chronic tear finding.16
Correlation analyses revealed that anterior translation
had no relationship with any ligamentous factors, which
was consistent with previous research.18 Talar tilt angle
alone was reported to be insufficient to predict ATFL or
CFL thickness on varus stress radiographs in a previous
study.12 However, we found that both ATFL and CFL thickness correlated with the talar tilt angle on the varus stress
view. The talar tilt angle decreased as the ATFL and CFL
became thicker. Additionally, a recent study suggested that
age, gender, and ATFL injury significantly affected the talar
tilt angle on the varus stress view.18 Should the talar tilt
angle on the varus stress imaging be related to the thickness
of the lateral ligaments, stress radiography may be used as a
screening test for the state of the lateral ligaments, which
might aid surgeons in determining the operative method,
that is, reconstruction using auto/allograft or simple ligament repair.
In several studies, when the ATFL has a highly irregular
appearance on arthroscopic evaluation, the histology of the
ligament fibers reveals scar tissue without type I collagen.8,25

Therefore, when the ATFL shows a severely irregular pattern, ligament reconstruction with allografts has been
favored by some surgeons over direct repair approaches,
such as the modified Brostrom procedure. MRI findings are
sometimes better than operative findings from the perspective of a detailed description, that is, signal intensity or wavy
pattern, because of combined soft tissue adhesions or scar
tissue in an operative field (Figure 6). Thus, further studies
correlating the morphologic findings of lateral ankle ligaments on MRI with mechanical properties or operative outcomes are warranted.
Our study has some limitations. First, other factors such
as the posterior talofibular ligament or effusion were not
considered. However, the posterior talofibular ligament is
usually the least damaged structure in most CLAI cases,
and effusion is not frequently observed in chronic ankle
instability patients. Second, this study included MRI images
from other clinics that were obtained using different techniques and did not quantify interobserver reliability, which
might have altered the accuracy or consistency of the
described MRI findings.
In conclusion, attenuated and thickened states were the 2
most commonly observed ATFL and CFL MRI morphologies in CLAI patients. The most common combined pattern
was the attenuated ATFL and attenuated CFL. ATFL and
CFL thickness correlated with the talar tilt angle on the
varus stress view.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.

Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article: This



Table of Contents for the Digital Edition of Foot & Ankle International - June 2017

Contents
Foot & Ankle International - June 2017 - Intro
Foot & Ankle International - June 2017 - Cover1
Foot & Ankle International - June 2017 - Cover2
Foot & Ankle International - June 2017 - i
Foot & Ankle International - June 2017 - ii
Foot & Ankle International - June 2017 - Contents
Foot & Ankle International - June 2017 - iv
Foot & Ankle International - June 2017 - v
Foot & Ankle International - June 2017 - vi
Foot & Ankle International - June 2017 - vii
Foot & Ankle International - June 2017 - viii
Foot & Ankle International - June 2017 - 1A
Foot & Ankle International - June 2017 - 1B
Foot & Ankle International - June 2017 - ix
Foot & Ankle International - June 2017 - x
Foot & Ankle International - June 2017 - xi
Foot & Ankle International - June 2017 - xii
Foot & Ankle International - June 2017 - 2A
Foot & Ankle International - June 2017 - 2B
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Foot & Ankle International - June 2017 - xv
Foot & Ankle International - June 2017 - xvi
Foot & Ankle International - June 2017 - 3A
Foot & Ankle International - June 2017 - 3B
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Foot & Ankle International - June 2017 - CT1
Foot & Ankle International - June 2017 - CT2
Foot & Ankle International - June 2017 - 4A
Foot & Ankle International - June 2017 - 4B
Foot & Ankle International - June 2017 - Cover3
Foot & Ankle International - June 2017 - Cover4
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