title: Anatomic validation of the lateral malleolus as a cutaneous marker for the distal insertion of the calcaneofibular ligament.
abstract: OBJECTIVE
  An anatomic study was performed to confirm whether the lateral malleolus could serve as a simple and reproducible anatomic reference for the distal insertion of the calcaneofibular ligament (CFL).
  
  
  METHODS
  Dissection was performed after placement of a Kirschner wire to simulate the calcaneal tunnel for the distal insertion of the CFL. The skin was penetrated 1 cm distal and posterior to the tip of the lateral malleolus. The main information recorded was the distance from the Kirschner wire to the centre of the distal insertion of the CFL. Other elements were noted (characteristics of the CFL, distance between the distal insertion of the CFL-peroneal tubercle, nerve or tendon injuries).
  
  
  RESULTS
  Thirty ankles were dissected. The mean distance from the Kirschner wire to the centre of the distal insertion of the CFL was 2.4 ± 1.8 mm. Only one case of peroneal injury was noted. The sural nerve was usually located a mean 1.8 ± 1.1 mm from the Kirschner wire. The posterior tibial vascular pedicle was a mean 27.8 ± 3.5 mm from the point of exit of the Kirschner wire.
  
  
  CONCLUSIONS
  Using the lateral malleolus as the cutaneous reference for the distal insertion of the CFL seems to be more reliable than the pure arthroscopic technique. This study describes a percutaneous technique to obtain a calcaneal tunnel for distal insertion of the CFL. The sural nerve is at the greatest risk of injury with this technique and requires careful subcutaneous incision to prevent injury. This new percutaneous technique is less invasive than a purely arthroscopic technique and more accurately identifies the location of the tunnel. It can be used to do calcaneal tunnel in clinical practice during anatomic ligament reconstruction for chronic ankle instability.
authors: Department of Orthopaedic Surgery, Breteche Clinic, 3 rue de la Béraudière, 44000, Nantes, France. ronnybask@yahoo.fr.
authors: R
authors: http://orcid.org/0000-0002-4666-3518
authors: R
authors: Lopes
authors: Department of Orthopaedic Surgery, Centre hospitalier Universitaire de Nantes, Hotel Dieu Hospital, 1 place Alexis Ricordeau, 44000, Nantes, France.
authors: T
authors: T
authors: Noailles
authors: Department of Orthopaedic Surgery, Centre hospitalier Universitaire de Nantes, Hotel Dieu Hospital, 1 place Alexis Ricordeau, 44000, Nantes, France.
authors: K
authors: K
authors: Brulefert
authors: Department of Orthopaedic Surgery, Centre hospitalier Universitaire de Nantes, Hotel Dieu Hospital, 1 place Alexis Ricordeau, 44000, Nantes, France.
authors: L
authors: L
authors: Geffroy
authors: Department of Orthopaedic Surgery, Centre hospitalier Universitaire de Nantes, Hotel Dieu Hospital, 1 place Alexis Ricordeau, 44000, Nantes, France.
authors: C
authors: C
authors: Decante
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D059925:Anatomic Landmarks; D000843:Ankle Joint / Q000000981:diagnostic imaging / Q000601:surgery*; D002102:Cadaver; D002111:Calcaneus / Q000000981:diagnostic imaging / Q000601:surgery*; D005260:Female; D006801:Humans; D007593:Joint Instability / Q000175:diagnosis / Q000601:surgery*; D017844:Lateral Ligament, Ankle / Q000000981:diagnostic imaging / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D019651:Plastic Surgery Procedures / Q000379:methods*; D013708:Tendon Injuries / Q000175:diagnosis / Q000601:surgery*
keywords: Anatomic reference; Anatomy of the ankle; Calcaneofibular ligament; Ligament reconstruction