897214

research-article2020
FASXXX10.1177/1938640019897214Foot & Ankle SpecialistFoot & Ankle Specialist

vol. XX / no. X Foot & Ankle Specialist 1

〈 Review 〉
Anatomy of Ankle
Syndesmotic Ligaments Akilesh Anand Prakash, MBBS, MSpMed

A Systematic Review of Cadaveric

Studies
Abstract: Diagnosis and
management of isolated syndesmotic
injuries are controversial and
highly debated. Hence, the aim of
this study is to explore and gain the
current understanding pertaining
to detailed anatomy of syndesmotic
ligaments through a systematic
review of published cadaveric studies.
A systematic review was conducted
online for literature published in
clinical practice, as awareness of
anatomy is critical for assessment,
healing, and successful surgical
management.
Levels of Evidence: Level III:
Systematic review of anatomical
dissections
Keywords: syndesmotic ligaments;
systematic review; syndesmosis; blood
supply; anatomy
stable, unstable with latent diastasis, and
stable with frank diastasis.12 Furthermore,
syndesmotic ligament injuries have been
known to pose a diagnostic
challenge,14-18 particularly isolated
injuries and those without frank diastasis
on radiograph. They have been reported
to be associated with increased morbidity
and functional disability.5,7-10,19,20 The
recent resurgence of research involving
the syndesmotic ligaments and injuries

“
English using PubMed and Google
Scholar, as per PRISMA (Preferred

S . . . up-to-date anatomic
Reporting Items for Systematic yndesmotic
Reviews and Meta-Analyses) ligaments connect
guidelines, up to April 30, 2019. distal tibiofibular knowledge and understanding of the
Predefined eligibility criteria were joint firmly, imparting
applied, and the data thus compiled stability to the joint that syndesmotic ligament underpins a
was analyzed. Study quality was underpins the normal
assessed based on Quality Appraisal ankle joint motion and correct diagnosis and ensuing
1-5
for Cadaveric Studies (QUACS) functioning.
scale. A total of 12 studies reporting Syndesmotic ligament treatment.”
365 ankles were included in this has been shown to carry
review. Considerable inconsistency greater force than lateral
in the naming and description of and deltoid ligament during ambulation.6 has sparked debate and intrigue
syndesmotic ligaments was observed, Isolated syndesmotic ligament injuries regarding its potential role in ankle
with only 2 studies reporting the (SI) have been known to occur,7-12 kinematics, injury, and repair. In view of
vasculature of the ligaments. Hence though to a lesser extent compared with the current clinical scenario, up-to-date
further investigation of the anatomy lateral ankle sprain.13 Based on ligament anatomic knowledge and understanding
of the syndesmotic ligaments is involvement and radiological assessment of the syndesmotic ligament underpins a
recommended so as to better inform isolated SI has been categorized as correct diagnosis and ensuing treatment.

DOI: 10.1177/1938640019897214. From Department of Sports Medicine, Anamiivaa Clinic and Sports Medicine Centre, Coimbatore, Tamil Nadu, India. Address
https://doi.org/

correspondence to Akilesh Anand Prakash, MBBS, MSpMed, Department of Sports Medicine, Anamiivaa Clinic and Sports Medicine Centre, 5A, Sir C. V. Raman Road, R.
S. Puram, Coimbatore, Tamil Nadu 641002, India; e-mail: akilesh.dr@gmail.com.
For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav.
Copyright © 2020 The Author(s)
2 Foot & Ankle Specialist
Figure 1.
Study selection flowchart.
The aim of this study was to conduct a
systematic review of the literature to
define the anatomy and vascular supply
of the syndesmotic ligaments connecting
distal tibia and fibula. A clear-cut
understanding of syndesmotic ligaments
anatomy enables better and early
diagnosis of SI and hence in planning of
surgical management.
Materials and Methods
Computerized literature searches was
performed for articles published in
English using PubMed and Google
Scholar, from inception through April 30,
2019 using search items with key word
Syndesmo* and tibiofibular*. The study
design was developed according to the
Preferred Reporting Items for Systematic
Reviews and Meta-Analyses (PRISMA)
guidelines21 (Figure 1). The studies
published in English and those reporting
gross anatomy and vascular supply of
the syndesmotic ligament either
individually or as a whole were included.
Non-English language article without
English translation, noncadaveric studies,
biomechanical studies, radiographic
evaluations, conference papers, posters,
Mon XXXX
book chapters, and review articles were
excluded.
The QUACS scale (QUality Appraisal
for Cadaveric Studies)22 was used for
quality appraisal of the included
dissection/cadaveric studies. The QUACS
scale includes a 13-item checklist and
reported to be highly reliable exhibiting
strong construct validity.
Screening of all eligible publications
were carried out by a single author for
titles, abstracts, full text, and
bibliographies. Data were extracted from
the included studies that included
authors, year of publication, sample size,
vol. XX / no. X
mean age, specimen description,
measurement techniques, incidence,
morphometric measures of syndesmotic
ligaments, morphologic description of
the ligaments, ligament vasculature, and
any variations in syndesmotic ligament.
The studies included were
heterogeneous in nature owing to the
varied methodology involved, and hence
rendering performance of meta-analysis
inappropriate. Hence a narrative analysis
was applied. Data were summarized as
described in respective studies using
descriptive statistics, with means and
standard deviations for continuous
variables and frequencies and
percentages for categorical variables.
Results
The results are presented in Tables 1
to 5. Of the 13 studies1,5,23-33 identified,
only 12 were included in the current
review5,23-33—examining 265 ankles for
syndesmotic ligament anatomy and
another 100 ankles for vasculature.32,33
The study by Ray and Kriz1 was not
included due to inability to retrieve the
same.
Of the 12 studies, 4 studies were done
on fresh frozen23,26,28,31 specimens, while
5 were done on embalmed
specimens,25,27,29,30,33 While 1 study used
fresh cadaver (within 72 hours of
death),32 there was no information on
specimen preparation technique used in
2 studies.5,24 But for 1 study,23 all the
other studies took place well within the
past 2 decades.5,24-33
Though 5 studies reported the age of
the specimen, which ranged from 35 to
96 years25,27,28,31,33 and 5 studies
reported the gender distribution, which
consisted of 91 male ankles and 87
female ankles,25,27,28,30,31,33 none
included the effect of the same on
syndesmotic ligament.
Of the 12 studies, 2 studies were
limited to the distal fascicle of AITFL,23,24
and 2 studies exclusively dealt with the
vasculature of syndesmotic ligaments.32,33
The remaining 8 studies dealt with
anatomy of all the components of
syndesmotic ligaments.5,24-31 The
ligaments identified were anterior inferior
tibiofibular ligament (AITFL), distal
fascicle of AITFL, posterior inferior
tibiofibular ligament (PITFL), inferior
transverse tibiofibular ligament (ITTFL),
and interosseous tibiofibular ligament
(IOL).
All (100%) the studies reported results
using a clear structure and including
figures, illustrations, or tables5,24-33 based
on QUACS scale. While only 8% of the
studies reported the dissecting
researcher’s education28 and involvement
of more than one researcher in making
the observations.31 Twenty-five percent
of studies used appropriate statistical
tests.24,28,31 Basic information about the
sample25,27,28,31,33 and condition of the
examined specimens25,28,31,32 were
reported only in 42% and 33% of the
studies, respectively.
AITFL
Eight studies reported AITFL5,25-31 with
varying use of terminologies that
included anterior inferior tibiofibular
ligament24,26,28,31 or anterior tibiofibular
ligament.5,25,27,29,30 AITFL was reported to
be trapezoid25,27,28,31 or quadrilateral in
shape5 and made of 3 bands separated
by 2-mm wide gaps.25,28,31 It was
reported to be obliquely oriented (25° to
50° to horizontal line), running
distolaterally.25-28,30,31 Posteriorly, it
formed an angle of 55° to 70° with the
sagittal plane.27,30 The proximal bands
were shorter than the distal bands,25,27-31
while the middle fibers were the widest
and thickest.25,27,30,31 Proximal fibers were
occasionally found to be divided into 2
stronger fascicles,25,30 while the middle
parts where occasionally found to have 3
or 4 smaller parts divided by narrow
gaps.25,30 The tibial insertion was wider
than the fibular insertion.5,25-28,31 The
inferior margin of the distal band was
found to be overlaid by the angle
between the anterior ridge of the tibia
coming into contact with the lateral ridge
of the trochlea of the talus.25,27,30
Distal Fascicle of AITFL
Incidence of distal fascicle of AITFL
ranged from 90%23,26,27 to 100%.28 The
terminologies used to identify the
Foot & Ankle Specialist 3
ligament were distal fascicle of anterior
inferior tibiofibular ligament,23,24,27,28
accessory anterior inferior tibiofibular
ligament,26 or Bassett ligament.28 It was
observed to be parallelogram shaped,
running obliquely, distal, and parallel to
AITFL.23,24,26 The ligament per se has
been considered as accessory or separate
part by one author,26 while others
considered it to be the distal part of
AITFL.23-25,27,28 It was reported to be intra-
articular not covered by synovial
tissue,23,26 and to cross superolateral
margin of ankle joint.26,28 The fibers
having more distal insertion were shown
to be in apparent contact with talar ridge
even in neutral position of the ankle.24
PITFL
Eight studies that reported PITFL5,25-31
labeled the ligament as posterior inferior
tibiofibular ligament,26,28,31 or posterior
tibiofibular ligament.5,25,27,29,30 PITFL was
reported to be strong, compact,25,30,31
trapezoid,28 or quadrilateral in shape,25
running obliquely and distally in
inferolateral direction31 but slightly more
horizontally than AITFL.25,27 It was easily
identified in fresh frozen specimens.31 It
was reported to be made of superficial
and deep components.28,30 Proximally, it
ran in continuity with interosseous
membrane, rendering it difficult to
differentiate between proximal margin
and IOL.25 It formed a 20° to 40°angle
with the horizontal plane and a 60° to
85° angle with the sagittal plane.27
ITTFL
Seven studies that reported ITTFL25-31
used the terminologies inferior transverse
ligament25,26,27,30,31 or inferior and
transverse tibiofibular ligament.28,29 ITTFL
is considered to be the deepest part of
PITFL by some authors,25,28,30 while
others reported it to be an independent
structure.26,27,29,31 Of those reporting the
incidence of ITTFL, it was reported in
70% to 100% specimens.28,31 It formed an
angle of 15° to 25° with the
horizontal27,30 and 78° to 92° with
sagittal.27 It appeared to serve as a
labrum to tibia for the lateral ridge of
talar trochlea and to fill the
4 Foot & Ankle Specialist Mon XXXX

Table 1.
Tibial and Fibular Insertion of Syndesmotic Ligaments.

Tibial Insertion Fibular Insertion

AITFL
 AITFL •  A nterior (anterolateral) tibial tubercle •  A nteromedial (longitudinal tubercle,
(Tillaux-Chaput),25,27,28,30 distal tibia 5 mm Wagstaff) aspect of fibular
above articular surface26 malleolus25-28,30
  Proximal band •  A bove the anterior tubercle of tibia •  A bove the anterior tubercle of fibular (Le
(Chaput’s tubercle)25,30 Fort’s tubercle)25,30
  Middle/Primary band •  Anterior tubercle of tibia25,27,30 •  Anterior tubercle of fibula25,27,30
  Lower band •  B
 elow the anterior tubercle of tibia •  B
 elow the anterior tubercle of fibular
(Chaput’s tubercle)25,30 (Le Fort’s tubercle)25,30 close above the
anterior talofibular ligament insertion27
Distal fascicle of AITFL
  Distal fascicle of AITFL •  Anterolateral corner of distal tibia23,24,26,28 •  A nteromedial aspect of the lateral
malleolus (approximating the fibular
insertion of the anterior talofibular
ligament)23,24,26
PITFL
 PITFL •  P osterior tubercle of tibia •  N
 egligible posterior tubercle of the
(Volkmann),25,28,31, posterior edge of fibula medial to the sulcus of the lateral
fibular notch of tibia27,30 malleolus,25,31 rough malleolar fossa
behind triangular articular facet of lateral
malleolus,27 blend medially across the
posterior tibial cortical surface28
  Proximal fibers •  Posterior margin of the lateral malleolus30 •  Posterior tubercle of tibia30
  Distal fibers •  Posterior margin of tibia30 •  Lateral malleolar fossa30
ITTFL
 ITTFL •  P osterior tibial margin,25 posterior border •  P roximal end of lateral malleolar
of tibial articular surface,26 posteroinferior fossa,26,27,30 inferomedial aspect of distal
corner of fibular notch on distal tibia,27,30 fibula31
posteromedial aspect of ankle mortise at
angle of plafond31
IOL
 IOL •  D
 istal end of the IOM between the ATFL •  1 cm proximal to the articular surface of
and PTFL.26 Most distal fibers attach to the distal tibia,26,27,30 attach broadly on
tibia at ATT level,27,30 proximal to tibia fibula (shaped like number 7)5
between 2 and 5 cm above joint5

Abbreviations: AITFL, anterior inferior tibiofibular ligament; PITFL, posterior inferior tibiofibular ligament; ITTFL, inferior transverse tibiofibular ligament; IOL,
interosseous tibiofibular ligament; ATFL, anterior tibiofibular ligament; PTFL, posterior tibiofibular ligament; IOM, interosseus membrane; ATT, anterior tibial
tubercle.
vol. XX / no. X Foot & Ankle Specialist 5

Table 2.
Footprints of Syndesmotic Ligaments: Tibial and Fibular.

AITFL
 Tibial •• 1.25 cm above edge of ankle5
•• 5 mm in average above the articular surface,26 8.35 (2.05)a mm from inferior tibial articular surface29
•• 9.3 mm superior and medial to the anterolateral corner of the tibial plafond28
•• 5.04 (1.32)a mm from fibular notch29
•• 22.7 [16.7-22.4]b mm from distal articular cartilage of tibia31
 Fibular •• 0.75 cm below edge of ankle5
•• 30.5 mm superior and anterior to the inferior tip of the lateral malleolus28
•• 25.45 (5.84)a mm from tip of lateral malleolus29
•• 3.12 (1.01)a mm from malleolar articular surface29
•• 3.4 [1.9-5]b mm from distal articular cartilage of tibia31
Distal fascicle of AITFL
 Tibial •• 10.3 [5-13]b mm from joint level24
•• 5.8 (5.2-6.5)b mm superior to the anterolateral corner of the tibial plafond28
 Fibular •• 25.5 (23.3-27.7)b mm superior to the inferior tip of the lateral malleolus28
PITFL
 Tibial •• 8.0 (7.5-8.4)b mm proximal and medial to posterolateral corner of the tibial plafond28
•• 6.98 (2.89)a mm from inferior tibial articular surface29
•• 6.43 (2.56)a from fibular notch29
•• 15.2 [11.6-17.9]b mm proximal to distal articular cartilage of tibia31
 Fibular •• 26.3 (24.5-28.1)b mm superior and posterior to inferior tip of the lateral malleolus28
•• 22.78 (3.67)a mm from inferior tibial articular surface29
•• 3.64 (2.03)a from fibular notch29
ITTFL
 Tibial •• 8.0 (7.1-8.8)b mm distal, medial, and slightly anterior to the center of the superficial attachment along
tibial plafond28
 Fibular •• 7.8 (6.8-8.9)b mm anterior and distal to the superficial attachment, immediately proximal to the
posterior fibular fossa28
IOL
 Tibial •• between 2 and 5 cm above joint5,25
•• 32.43 [22.35-43.7]b mm proximal to mortise (fibular notch)27
•• 49.4 (45.4-53.3)b mm proximal to the centre of the tibial plafond on tibia28
•• 70.4 (66.7-74.1)b mm proximal to the inferior tip of the lateral malleolus on the fibula28
•• 31.8 [21.9-49.9]b mm above superior border of distal tibiofibular articular cartilage31
 Fibular •• Variable (from just above to 2 cm above fibular synovial reflection or joint line)5
•• 1 to 1.5 cm above the plafond25, or 9.3 (8.3-10.2)b mm proximal to tibial plafond along the superior
border of the synovial recess28
•• 8.1 [5.15-14.3]b mm proximal to mortise at same level as ATT27
•• 34.5 (32.4-36.6)b mm superior to the inferior tip of the lateral malleolus28
•• 9.2 [5.8-13.1]b mm proximal to ankle mortise abutting the synovial plica31

Abbreviations: AITFL, anterior inferior tibiofibular ligament; PITFL, posterior inferior tibiofibular ligament; ITTFL, inferior transverse tibiofibular ligament;
IOL, interosseous tibiofibular ligament; ATT, anterior tibial tubercle.
a
Mean (SD).
b
Mean [Range].
6 Foot & Ankle Specialist Mon XXXX

Table 3.
Morphometrics (in mm) of Syndesmotic Ligaments: AITFL, PITFL, and IOL.

Study

Bartonicek Ebraheim et al Wenny et al Williams et al Nikolopoulos et al

(2003)25 (2006)27 Lilyquist et al (2016)31 (2015)29 (2015)28 (2004)26
Syndesmotic
Ligament Mean (SD) Range

AITFL

Length 10 — — — — 12-20

  Proximal 6 8.89 (2.9) 4.9 (1.2) to 6 (1.7) 8.35 (2.31) 5.5 —

 Middle 12 15.46 (4.22) 7.2 (1.7) to 10.6 (2.2) — 7.8 —

 Distal 17 20.57 (5.36) 11.1 (2.4) to 13.6 (2.3) 11.03 (4.12) 13.1 —

Width — — — — — 9-22 (TI), 7-12 (FI)

  Proximal 4 4.92 (1.21) 5.6 (2.1) (TI), 7.1 (2.4) (FI) 9.47 (2.27) — —

 Middle 10 8.28 (2.2) 11,9 (2.5) (TI), 9.8 (2.6) (FI) — — —

 Distal 4 3.76 (0.52) 5 (1.4) (TI), 5.7 (1.1) (FI) 9.24 (1.73) — —

Thickness 5 — — — — 1.5-3

  Proximal 3 1.76 (0.26) — — — —

 Middle 4 2.62 (0.53) — — — —

 Distal 2 2.15 (0.7) — — — —

PITFL

Length — — — — — 14-24

  Proximal margin 13 9.71 (6.91) 6.6 (0.9) 10.09 (2) 11.6 —

  Distal margin 24 21.83 (7.52) 17.7 (3.4) 12.18 (2.1) 12.7 —

Width 18 17.44 (3.54) — — — 14-28

 Tibial — — 16.1 (2.3) 11.32 (3.25) — 18-28

 Fibular — — 17.3 (3.6) 8.94 (2.48) — 14-22

Thickness 6 — — — — 2-4

  Tibial insertion — 6.38 (1.91) — — — —

  Fibular insertion — 9.67 (1.74) — — — —

IOL

Length 20-30 — — — — 3-6

  Proximal — 6.64 (1.28) — — 7.2 —

 Distal — 10.39 (3.05) — — 6.3 —

Width — — — — — 2-4

 Tibial — 17.72 (1.02) 22.5 (7.5) — — —

 Fibular — 21.22 (1.73) 23.1 (5.6) — — —

Thickness — 4.75 (1.05) — — — 2-4

Abbreviations: AITFL, anterior inferior tibiofibular ligament; PITFL, posterior inferior tibiofibular ligament; IOL, interosseous tibiofibular ligament; TI, tibial insertion; FI, fibular
insertion.
vol. XX / no. X Foot & Ankle Specialist 7

Table 4.
Morphometrics (in mm) of Syndesmotic Ligaments (ITTFL) and Distal Fascicle of AITFL.

Study Unit Length Width Thickness

Distal fascicle of AITFL
  Bassett et al (1990)23 Range 18-24 4-6 1-2
  Akseki et al (2002)24 Mean (SD) 16.1 (2.94) 4.2 (1) —
  Nikolopoulous et al (2004)26 Range 17-22 3-5 (TI), 2-5 (FI) 1-2
ITTFL
  Nikolopoulous et al (2004)26 Range 22-35 3-6 2-5
  Ebraheim et al (2006)27 Mean (SD) 36.6 (9.51) 4.2 (0.74) 2.12 (0.67)
  Mroz et al (2015)30 Mean (SD) 36.6 (9.4) — —
31
  Lilyquist et al (2016) Mean (SD) 33.9 (5.7) — —

Abbreviations: AITFL, anterior inferior tibiofibular ligament; ITTFL, inferior transverse tibiofibular ligament; TI, tibial insertion; FI, fibular insertion.

Table 5.
Mean Area Distribution of Syndesmotic Ligaments.

AITFL PITFL
Study Unit AITFL Distal Superficial Deep IOL
Tibial attachment  
  Williams et al (2015)28 mm2 33.2 13.3 84.5 52.2 490
  Wenny et al (2015)29 cm2 1.9 — 1.24 —
Fibular attachment
  Williams et al (2015)28 mm2 34.2 16.4 108.1 53.9 408.4
  Wenny et al (2015)29 cm2 1.86 — 1.2 —

Abbreviations: AITFL, anterior inferior tibiofibular ligament; PITFL, posterior inferior tibiofibular ligament; IOL, interosseous tibiofibular ligament.

posteromedial aspect of lateral
malleolus.25,27,31 It was reported to be
easily identifiable in fresh frozen
specimens.26,28,31
IOL
Seven studies that reported IOL5,25-28,30,31
used the terminologies interosseous
tibiofibular ligament25,27,28,30,31 or
interosseous ligament.5,26 IOL was
reported to be a strong, pyramid-shaped
network5,25,28 that appears triangular on
sagittal section with apex passing
through interosseous membrane.25,31 It
was obliquely oriented running
laterodistally from tibia to fibula,5,25-28,30,31
as a distal continuation of interosseous
membrane25,26,28,30 with wider fibular
insertion.27,31 Anteriorly, a small gap
divided it from the AITFL,25 while the
posterior surface continuously passed
into PITFL.25,27 Very few fascicles ran
transversely or in reverse direction on
the dorsal aspect.25,27,28,30 Perforating
branch of peroneal artery has been
found to run in posteroanterior direction
through the upper part of IOL.25,30
Vascular Anatomy
Though studies have reported several
branches of fibular artery passing
through AITFL30 and IOL,25,30 only 2
studies were identified that studied and
8 Foot & Ankle Specialist
reported the vascular supply to
syndesmotic ligaments in detail.32,33 The
anterior vascularity exhibited 3 patterns
of supply involving anterior branches of
fibular artery, lateral anterior malleolar
arterial branch of anterior tibial artery
(LAMA), and anterior tibial artery, while
the posterior vascularity exhibited 2
patterns involving posterior branch of
fibular artery and posterior tibial
artery.32,33 A total of 52%33 to 63%32 of
anterior vasculature was reported to be
through anterior branch of fibular artery
with occasional anastomoses with LAMA,
while 63%32 to 96%33 of posterior
vasculature was through posterior branch
of fibular artery. The rest of the anterior
vasculature was either through LAMA or
multiple branches of fibular artery
supplemented by anterior tibial artery
branches,32,33 while that of posterior
vasculature was through branches of
posterior tibial artery.32,33 The mean
vascular density across anterior
vasculature was reported to be very low
(4.4%).33 The peroneal artery branches
were shown to be passing through
interosseous membrane, 3 cm proximal
to ankle joint before supplying anterior
syndesmosis.32
Of the specimens available for
side-to-side comparison, 55% of anterior
and 61% of posterior circulation were
consistent between legs,32 while the
remaining specimens exhibited side-to-
side variations involving the extent of
blood supply by peroneal artery, anterior
tibial artery and posterior tibial artery
individually or in combination.32
Discussion
The distal tibiofibular joint is
strengthened by presence of various
ligaments that form the syndesmotic
ligament complex imparting the needed
integrity and stability. The present review
confirms the presence of 3 major
ligaments AITFL, PITFL, and IOL,5,25-31
with the exception of distal fascicle of
AITFL and ITTFL. The presence of ITTFL
as a separate entity was reported in 4
studies,26,27,29,31 while 3 studies described
it as the deepest component of
PITFL.25,28,30 Similarly, only 1 study
considered distal fascicle of AITFL to be
an separate entity, an accessory
ligament,26 while the remaining studies
considered it to be part of AITFL.23-25,27,28
Though the terminologies used to
designate the ligaments in the review
varied, it was in accordance with the
variation noted across anatomical
textbooks.34,35 For better clinical
acceptability and to differentiate the
ligament from its proximal counterpart,
the following terminology is preferred
and recommended - anterior inferior
tibiofibular ligament, posterior inferior
tibiofibular ligament, interosseous
tibiofibular ligament, and inferior
transverse tibiofibular ligament.
The footprint area of IOL was found to
be largest followed by that of PITFL and
then AITFL.28 Though this is in proportion
to the relative strength and stiffness values
of the individual ligaments as seen across
various biomechanical studies,28,36,37 it did
not correspond to the individual ligament
contribution to overall syndesmotic
stability.38,39
Lateral collateral ligament prevented
talar tilt, while intact deltoid ligament
prevented lateral talar shift, but neither
prevented diastasis, which has been
shown to occur only after injury to AITFL
and IOL.5 This is significant as even
1-mm diastasis substantially increases
tibiotalar contact stress and hence
predispose to early arthrosis.40
The anterior syndesmotic ligaments are
more commonly injured in syndesmotic
injuries.5,41,42 The tibial insertion of AITFL
was wider than the fibular
insertion,5,25-28,31 which may probably
explain the rupture to primarily occur
near its fibular insertion.36 AITFL has
been reported to be the primary check
for talar external rotation and fibular
stability,5,27,39 while PITFL has been
shown to be least important for fibular
stability5,38 and to inhibit internal rotatory
forces.27
A distal fascicle of AITFL has been
shown to occur in majority (21% to
100%) of specimens as a normal variant
in the current review,23-25,27,28, but for 1
study, which reported it to be a separate
anatomical structure.26 Though the distal
fascicle of AITFL has no role in
Mon XXXX
stability,24,26 it has been reported to be a
cause for impingement,23,26,43 particularly
after any alteration in ankle mechanics
following lateral ligament complex
injury,23,24 or even in stable ankle with no
history of ankle sprain.44 Furthermore, as
seen in the current review, more distal
fibular insertion of the ligament may
predispose it to impingement and hence
injury.43
The IOL was central in location thinner
in the middle and thicker at insertions
with stronger bony attachments,26-28,31
giving it a spring like laxity.28 This may
be significant, as 50% or more stretch has
been shown to be required for IOL to
reach its peak load carrying capacity.45
Furthermore, IOL had an oblique course,
which may in turn facilitate distal
tibiofibular rotational and translational
motion.27,46
There exists a controversy with regard
to whether PITFL and ITTFL are 1 unit or
2 different anatomic structures.25-31 Some
reported it to be the deepest part of
PITFL,25,28,30 while others differed.26,27,29,31
This may be due to the fact that it may
be difficult to differentiate either in the
specimen due to presence of negligible
gap.27 The ITTFL has been shown to
serve as posterior labrum and to fill the
posteromedial aspect of lateral
malleolus,25,27,31 which may thereby
increase the joint stability.38,47
Furthermore, hypertrophy of the
ligament may cause posterior
impingement and ankle pain.48
In the 2 studies exploring the
syndesmotic ligament vasculature,32,33 the
anterior vasculature was predominantly
through anterior branch of fibular artery
with occasional anastomoses with LAMA,
while the posterior vasculature was
through posterior branch of fibular
artery.32,33 The anterior arterial supply
penetrates the interosseous membrane 3
cm proximal to ankle joint,25,30,32 thereby
predisposing it to injury, which may
further possibly cause delayed healing.32
On the other hand, the posterior arterial
supply does not penetrate the ligament
and hence may be less susceptible to
injury.32
The quality of studies included in the
review lacked uniformity and varied
vol. XX / no. X
considerably based on the QUACS
scale.22 Though all the studies presented
the results thoroughly and precisely,5,23-33
only 1 study reported the involvement of
2 or more persons in recording the
observations.31 Use of statistical analysis
in very few studies24,28,31 may be
explained to be due to the descriptive
nature of the studies exploring ligament
morphology in the current review and
the limited number of specimens. Very
few studies reported the age and gender
of the specimens25,27,28,31,33 and also
provided the specimens status (healthy
or injured, embalmed or fresh
frozen),25,28,31,32 which adds up to the
limitation of the current review.
The present review is limited in being
executed by a single reviewer, sample size,
and nature of data, thereby rendering
application of data analysis inappropriate.
Moreover, the lack of age and gender data
of the specimens examined across studies
in the current review also added to the
limitation.5,23,24,26,29,30,32 And of those
reporting age, they exclusively involved
elderly population.25,27,28,31 This is of
significance as various radiological and
biomechanical studies have shown
tibiofibular syndesmosis to be influenced
by age18,49 and gender.18,49 Furthermore,
variability observed in the current review
may be attributable to the varied
measurement tool used ranging from
calipers24,25,27,29 to 3-dimensional
techniques,28,31 varied measurement
techniques,29 and varied approaches in
dissection. Finally, use of different
landmarks for footprints like tibial articular
surface29 and superior border of the distal
tibial articular cartilage,31 rendered
between study comparisons difficult.
Conclusion
Anatomy forms the very basis of both
accurate diagnosis and best possible
surgical management in musculoskeletal
practice. Clearly, interest in syndesmotic
morphology has been on the rise with
92% of publications in the past 2 decades.
Syndesmotic ligament is an essential pillar
for distal tibiofibular joint integrity and
stability. Though anatomically, the
syndesmotic ligament has been debated
to be 3- to 5-ligament complex, this
review provided a comprehensive
description and analysis of the available
evidence. Further studies will be
necessary to build precise anatomic
understanding and strong evidence
regarding the clinical utility of this
information enabling accurate assessment
of isolated syndesmotic injuries and
injuries without frank diastasis.
Declaration of
Conflicting Interests
The author declared no potential conflicts
of interest with respect to the research,
authorship, and/or publication of this
article.
Funding
The author received no financial support
for the research, authorship, and/or
publication of this article.
Ethical Approval
Not applicable.
Informed Consent
Not applicable.
Trial Registration
Not applicable.
ORCID iD
Akilesh Anand Prakash https://orcid.
org/0000-0001-9944-2607
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