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Imaging Appearances of Lateral Ankle Ligament Reconstruction¹

¹ From the Department of Radiology, Pomona Valley Hospital and Medical Center, Pomona, Calif (A.J.C.); the Departments of Radiology (J.A.J., D.A.J., M.K.B.) and Orthopaedic Surgery (J.E.F.), University of Michigan Medical Center, 1500 E Medical Center Dr, TC-2910G, Ann Arbor, MI 48109-0329; and the Department of Radiology, Medical College of Virginia/Virginia Commonwealth University, Richmond, Virginia (C.W.H.). Received September 4, 2004; revision requested December 11 and received February 23, 2004; accepted March 8. Address correspondence to J.A.J. (e-mail: jjacobsn@umich.edu).

View larger version (70K): [in a new window]   Figure 1.  Drawing of the lateral ankle illustrates the normal anterior talofibular ligament (TFL) (straight arrow), calcaneofibular ligament (CFL) (curved arrow), and posterior TFL (arrowhead).

View larger version (59K): [in a new window]   Figure 2.  Drawing illustrates direct repair of the anterior talofibular (solid arrow) and calcaneofibular (open arrow) ligaments. The peroneus brevis tendon is shown in red and the peroneus longus tendon in yellow.

View larger version (52K): [in a new window]   Figure 3.  Drawing illustrates repair of the anterior TFL with retinaculum attachment to the fibula (arrow). As in Figure 2, the peroneus brevis tendon is shown in red and the peroneus longus tendon in yellow.

View larger version (137K): [in a new window]   Figure 4a.  Direct anterior TFL repair (Broström procedure) in a 34-year-old man. (a) Oblique radiograph of the ankle shows two suture anchors at the distal fibula (arrows) with no osseous tunnel. (b, c) Axial (b) and sagittal (c) T1-weighted MR images show artifact from suture anchors at the distal fibula in the region of the anterior TFL (arrows). The peroneal tendons are intact. (d) Longitudinal US image shows the normal anterior TFL with a compact fibrillar echotexture (arrowheads) and echogenic suture material (arrows). F = fibula, T = talus.

View larger version (168K): [in a new window]   Figure 4b.  Direct anterior TFL repair (Broström procedure) in a 34-year-old man. (a) Oblique radiograph of the ankle shows two suture anchors at the distal fibula (arrows) with no osseous tunnel. (b, c) Axial (b) and sagittal (c) T1-weighted MR images show artifact from suture anchors at the distal fibula in the region of the anterior TFL (arrows). The peroneal tendons are intact. (d) Longitudinal US image shows the normal anterior TFL with a compact fibrillar echotexture (arrowheads) and echogenic suture material (arrows). F = fibula, T = talus.

View larger version (138K): [in a new window]   Figure 4c.  Direct anterior TFL repair (Broström procedure) in a 34-year-old man. (a) Oblique radiograph of the ankle shows two suture anchors at the distal fibula (arrows) with no osseous tunnel. (b, c) Axial (b) and sagittal (c) T1-weighted MR images show artifact from suture anchors at the distal fibula in the region of the anterior TFL (arrows). The peroneal tendons are intact. (d) Longitudinal US image shows the normal anterior TFL with a compact fibrillar echotexture (arrowheads) and echogenic suture material (arrows). F = fibula, T = talus.

View larger version (141K): [in a new window]   Figure 4d.  Direct anterior TFL repair (Broström procedure) in a 34-year-old man. (a) Oblique radiograph of the ankle shows two suture anchors at the distal fibula (arrows) with no osseous tunnel. (b, c) Axial (b) and sagittal (c) T1-weighted MR images show artifact from suture anchors at the distal fibula in the region of the anterior TFL (arrows). The peroneal tendons are intact. (d) Longitudinal US image shows the normal anterior TFL with a compact fibrillar echotexture (arrowheads) and echogenic suture material (arrows). F = fibula, T = talus.

View larger version (39K): [in a new window]   Figure 5.  Drawing shows rerouting of the peroneus brevis tendon (red) through a fibular tunnel (dashed lines) with proximal reattachment (Evans procedure). The peroneus longus tendon is shown in yellow.

View larger version (155K): [in a new window]   Figure 6a.  Peroneus brevis tendon rerouting (Evans procedure) in a 55-year-old woman. (a, b) Oblique (a) and lateral (b) radiographs of the ankle show a fibular tunnel (arrows). (c-g) Axial (c-f) (c most caudal, f most cephalic) and sagittal (g) T1-weighted MR images show the peroneus brevis tendon (solid arrows) coursing through the fibular tunnel. Note the normal peroneus longus tendon (arrowheads) and suture artifact at the proximal peroneus brevis tendon reattachment site (open arrow in g).

View larger version (169K): [in a new window]   Figure 6b.  Peroneus brevis tendon rerouting (Evans procedure) in a 55-year-old woman. (a, b) Oblique (a) and lateral (b) radiographs of the ankle show a fibular tunnel (arrows). (c-g) Axial (c-f) (c most caudal, f most cephalic) and sagittal (g) T1-weighted MR images show the peroneus brevis tendon (solid arrows) coursing through the fibular tunnel. Note the normal peroneus longus tendon (arrowheads) and suture artifact at the proximal peroneus brevis tendon reattachment site (open arrow in g).

View larger version (118K): [in a new window]   Figure 6c.  Peroneus brevis tendon rerouting (Evans procedure) in a 55-year-old woman. (a, b) Oblique (a) and lateral (b) radiographs of the ankle show a fibular tunnel (arrows). (c-g) Axial (c-f) (c most caudal, f most cephalic) and sagittal (g) T1-weighted MR images show the peroneus brevis tendon (solid arrows) coursing through the fibular tunnel. Note the normal peroneus longus tendon (arrowheads) and suture artifact at the proximal peroneus brevis tendon reattachment site (open arrow in g).

View larger version (119K): [in a new window]   Figure 6d.  Peroneus brevis tendon rerouting (Evans procedure) in a 55-year-old woman. (a, b) Oblique (a) and lateral (b) radiographs of the ankle show a fibular tunnel (arrows). (c-g) Axial (c-f) (c most caudal, f most cephalic) and sagittal (g) T1-weighted MR images show the peroneus brevis tendon (solid arrows) coursing through the fibular tunnel. Note the normal peroneus longus tendon (arrowheads) and suture artifact at the proximal peroneus brevis tendon reattachment site (open arrow in g).

View larger version (115K): [in a new window]   Figure 6e.  Peroneus brevis tendon rerouting (Evans procedure) in a 55-year-old woman. (a, b) Oblique (a) and lateral (b) radiographs of the ankle show a fibular tunnel (arrows). (c-g) Axial (c-f) (c most caudal, f most cephalic) and sagittal (g) T1-weighted MR images show the peroneus brevis tendon (solid arrows) coursing through the fibular tunnel. Note the normal peroneus longus tendon (arrowheads) and suture artifact at the proximal peroneus brevis tendon reattachment site (open arrow in g).

View larger version (127K): [in a new window]   Figure 6f.  Peroneus brevis tendon rerouting (Evans procedure) in a 55-year-old woman. (a, b) Oblique (a) and lateral (b) radiographs of the ankle show a fibular tunnel (arrows). (c-g) Axial (c-f) (c most caudal, f most cephalic) and sagittal (g) T1-weighted MR images show the peroneus brevis tendon (solid arrows) coursing through the fibular tunnel. Note the normal peroneus longus tendon (arrowheads) and suture artifact at the proximal peroneus brevis tendon reattachment site (open arrow in g).

View larger version (171K): [in a new window]   Figure 6g.  Peroneus brevis tendon rerouting (Evans procedure) in a 55-year-old woman. (a, b) Oblique (a) and lateral (b) radiographs of the ankle show a fibular tunnel (arrows). (c-g) Axial (c-f) (c most caudal, f most cephalic) and sagittal (g) T1-weighted MR images show the peroneus brevis tendon (solid arrows) coursing through the fibular tunnel. Note the normal peroneus longus tendon (arrowheads) and suture artifact at the proximal peroneus brevis tendon reattachment site (open arrow in g).

View larger version (113K): [in a new window]   Figure 7.  Peroneus brevis tendon rerouting (Evans procedure) in a 42-year-old woman. Longitudinal US image of the fibular diaphysis (F) shows the peroneus brevis tendon (P) entering the proximal end of a fibular tunnel (arrows). (Left side of image is superior, right side is inferior, top is lateral.)

View larger version (43K): [in a new window]   Figure 8.  Drawing illustrates the peroneus brevis tendon loop (Lee procedure). Note the rerouting of the tendon (red) through a fibular tunnel (dashed lines) with distal reattachment. The peroneus longus tendon is shown in yellow.

View larger version (119K): [in a new window]   Figure 9a.  Peroneus brevis tendon loop (Lee procedure) in a 22-year-old woman. Sequential axial T1-weighted MR images (b obtained inferior to a) show one segment of the peroneus brevis tendon loop lateral to the fibula (arrow in a) and another segment coursing through a fibular tunnel (arrowhead in a) above the level of the tendon anastomosis (arrow in b).

View larger version (119K): [in a new window]   Figure 9b.  Peroneus brevis tendon loop (Lee procedure) in a 22-year-old woman. Sequential axial T1-weighted MR images (b obtained inferior to a) show one segment of the peroneus brevis tendon loop lateral to the fibula (arrow in a) and another segment coursing through a fibular tunnel (arrowhead in a) above the level of the tendon anastomosis (arrow in b).

View larger version (145K): [in a new window]   Figure 10a.  Peroneus brevis tendon loop (Lee procedure) in a 47-year-old man. (a) Oblique radiograph of the ankle shows a distal fibular tunnel (arrows). (b) Axial computed tomographic scan of the ankle obtained after air-contrast arthrography shows one segment of the peroneus brevis tendon loop lateral to the fibula (arrow) and another segment coursing through the fibular tunnel (arrowhead) (cf Fig 9). (c) Longitudinal US image shows a segment of the distal peroneus brevis tendon (arrows) entering the fibular tunnel. F = fibula, PL = adjacent normal peroneus longus tendon. (Left side of image is proximal.) (d, e) Transverse US images show one segment of the peroneus brevis tendon loop (arrow in d) lateral to the fibula (F), another segment entering the fibular tunnel (arrowhead), and a distal tendon anastomosis with echogenic suture material (arrow in e).

View larger version (167K): [in a new window]   Figure 10b.  Peroneus brevis tendon loop (Lee procedure) in a 47-year-old man. (a) Oblique radiograph of the ankle shows a distal fibular tunnel (arrows). (b) Axial computed tomographic scan of the ankle obtained after air-contrast arthrography shows one segment of the peroneus brevis tendon loop lateral to the fibula (arrow) and another segment coursing through the fibular tunnel (arrowhead) (cf Fig 9). (c) Longitudinal US image shows a segment of the distal peroneus brevis tendon (arrows) entering the fibular tunnel. F = fibula, PL = adjacent normal peroneus longus tendon. (Left side of image is proximal.) (d, e) Transverse US images show one segment of the peroneus brevis tendon loop (arrow in d) lateral to the fibula (F), another segment entering the fibular tunnel (arrowhead), and a distal tendon anastomosis with echogenic suture material (arrow in e).

View larger version (137K): [in a new window]   Figure 10c.  Peroneus brevis tendon loop (Lee procedure) in a 47-year-old man. (a) Oblique radiograph of the ankle shows a distal fibular tunnel (arrows). (b) Axial computed tomographic scan of the ankle obtained after air-contrast arthrography shows one segment of the peroneus brevis tendon loop lateral to the fibula (arrow) and another segment coursing through the fibular tunnel (arrowhead) (cf Fig 9). (c) Longitudinal US image shows a segment of the distal peroneus brevis tendon (arrows) entering the fibular tunnel. F = fibula, PL = adjacent normal peroneus longus tendon. (Left side of image is proximal.) (d, e) Transverse US images show one segment of the peroneus brevis tendon loop (arrow in d) lateral to the fibula (F), another segment entering the fibular tunnel (arrowhead), and a distal tendon anastomosis with echogenic suture material (arrow in e).

View larger version (123K): [in a new window]   Figure 10d.  Peroneus brevis tendon loop (Lee procedure) in a 47-year-old man. (a) Oblique radiograph of the ankle shows a distal fibular tunnel (arrows). (b) Axial computed tomographic scan of the ankle obtained after air-contrast arthrography shows one segment of the peroneus brevis tendon loop lateral to the fibula (arrow) and another segment coursing through the fibular tunnel (arrowhead) (cf Fig 9). (c) Longitudinal US image shows a segment of the distal peroneus brevis tendon (arrows) entering the fibular tunnel. F = fibula, PL = adjacent normal peroneus longus tendon. (Left side of image is proximal.) (d, e) Transverse US images show one segment of the peroneus brevis tendon loop (arrow in d) lateral to the fibula (F), another segment entering the fibular tunnel (arrowhead), and a distal tendon anastomosis with echogenic suture material (arrow in e).

View larger version (124K): [in a new window]   Figure 10e.  Peroneus brevis tendon loop (Lee procedure) in a 47-year-old man. (a) Oblique radiograph of the ankle shows a distal fibular tunnel (arrows). (b) Axial computed tomographic scan of the ankle obtained after air-contrast arthrography shows one segment of the peroneus brevis tendon loop lateral to the fibula (arrow) and another segment coursing through the fibular tunnel (arrowhead) (cf Fig 9). (c) Longitudinal US image shows a segment of the distal peroneus brevis tendon (arrows) entering the fibular tunnel. F = fibula, PL = adjacent normal peroneus longus tendon. (Left side of image is proximal.) (d, e) Transverse US images show one segment of the peroneus brevis tendon loop (arrow in d) lateral to the fibula (F), another segment entering the fibular tunnel (arrowhead), and a distal tendon anastomosis with echogenic suture material (arrow in e).

View larger version (43K): [in a new window]   Figure 11.  Drawing illustrates rerouting of the peroneus brevis tendon (red) through fibular (dashed lines) and talar tunnels with distal reattachment (Watson-Jones procedure). The peroneus longus tendon is shown in yellow.

View larger version (45K): [in a new window]   Figure 12.  Drawing illustrates peroneal tendon split and rerouting (Chrisman-Snook procedure). A portion of the split peroneus brevis tendon is seen coursing through a fibular tunnel and is secured to the talus and calcaneus with periosteal flaps before reattachment to the distal portion of the tendon. The peroneus longus tendon is shown in yellow.

View larger version (162K): [in a new window]   Figure 13a.  Peroneus brevis split and rerouting (Chrisman-Snook procedure) in a 19-year-old woman. (a, b) Anteroposterior (a) and oblique (b) radiographs of the ankle show a fibular tunnel (arrows). (c) Longitudinal US image shows a portion of the split peroneus brevis tendon (solid arrow) entering the anterior end of the fibular tunnel (open arrow). F = fibula. (Left side of image is proximal.) (d) Longitudinal US image shows a segment of the peroneus brevis tendon (solid arrow) between the posterior aspect of the fibular tunnel (open arrow) and the calcaneal periosteal flap (arrowheads). C = calcaneus, CFL = calcaneofibular ligament, PB = spared half of the peroneus brevis tendon, PL = peroneus longus tendon. (Left side of image is superior.) (e) Longitudinal US image shows the peroneus brevis tendon (arrows) exiting the periosteal calcaneal tunnel (arrowheads). C = calcaneus. (Left side of image is posterior.) (f) Transverse US image of the split segment of the peroneus brevis tendon shows a distal tendon anastomosis (arrows).

View larger version (122K): [in a new window]   Figure 13b.  Peroneus brevis split and rerouting (Chrisman-Snook procedure) in a 19-year-old woman. (a, b) Anteroposterior (a) and oblique (b) radiographs of the ankle show a fibular tunnel (arrows). (c) Longitudinal US image shows a portion of the split peroneus brevis tendon (solid arrow) entering the anterior end of the fibular tunnel (open arrow). F = fibula. (Left side of image is proximal.) (d) Longitudinal US image shows a segment of the peroneus brevis tendon (solid arrow) between the posterior aspect of the fibular tunnel (open arrow) and the calcaneal periosteal flap (arrowheads). C = calcaneus, CFL = calcaneofibular ligament, PB = spared half of the peroneus brevis tendon, PL = peroneus longus tendon. (Left side of image is superior.) (e) Longitudinal US image shows the peroneus brevis tendon (arrows) exiting the periosteal calcaneal tunnel (arrowheads). C = calcaneus. (Left side of image is posterior.) (f) Transverse US image of the split segment of the peroneus brevis tendon shows a distal tendon anastomosis (arrows).

View larger version (143K): [in a new window]   Figure 13c.  Peroneus brevis split and rerouting (Chrisman-Snook procedure) in a 19-year-old woman. (a, b) Anteroposterior (a) and oblique (b) radiographs of the ankle show a fibular tunnel (arrows). (c) Longitudinal US image shows a portion of the split peroneus brevis tendon (solid arrow) entering the anterior end of the fibular tunnel (open arrow). F = fibula. (Left side of image is proximal.) (d) Longitudinal US image shows a segment of the peroneus brevis tendon (solid arrow) between the posterior aspect of the fibular tunnel (open arrow) and the calcaneal periosteal flap (arrowheads). C = calcaneus, CFL = calcaneofibular ligament, PB = spared half of the peroneus brevis tendon, PL = peroneus longus tendon. (Left side of image is superior.) (e) Longitudinal US image shows the peroneus brevis tendon (arrows) exiting the periosteal calcaneal tunnel (arrowheads). C = calcaneus. (Left side of image is posterior.) (f) Transverse US image of the split segment of the peroneus brevis tendon shows a distal tendon anastomosis (arrows).

View larger version (163K): [in a new window]   Figure 13d.  Peroneus brevis split and rerouting (Chrisman-Snook procedure) in a 19-year-old woman. (a, b) Anteroposterior (a) and oblique (b) radiographs of the ankle show a fibular tunnel (arrows). (c) Longitudinal US image shows a portion of the split peroneus brevis tendon (solid arrow) entering the anterior end of the fibular tunnel (open arrow). F = fibula. (Left side of image is proximal.) (d) Longitudinal US image shows a segment of the peroneus brevis tendon (solid arrow) between the posterior aspect of the fibular tunnel (open arrow) and the calcaneal periosteal flap (arrowheads). C = calcaneus, CFL = calcaneofibular ligament, PB = spared half of the peroneus brevis tendon, PL = peroneus longus tendon. (Left side of image is superior.) (e) Longitudinal US image shows the peroneus brevis tendon (arrows) exiting the periosteal calcaneal tunnel (arrowheads). C = calcaneus. (Left side of image is posterior.) (f) Transverse US image of the split segment of the peroneus brevis tendon shows a distal tendon anastomosis (arrows).

View larger version (132K): [in a new window]   Figure 13e.  Peroneus brevis split and rerouting (Chrisman-Snook procedure) in a 19-year-old woman. (a, b) Anteroposterior (a) and oblique (b) radiographs of the ankle show a fibular tunnel (arrows). (c) Longitudinal US image shows a portion of the split peroneus brevis tendon (solid arrow) entering the anterior end of the fibular tunnel (open arrow). F = fibula. (Left side of image is proximal.) (d) Longitudinal US image shows a segment of the peroneus brevis tendon (solid arrow) between the posterior aspect of the fibular tunnel (open arrow) and the calcaneal periosteal flap (arrowheads). C = calcaneus, CFL = calcaneofibular ligament, PB = spared half of the peroneus brevis tendon, PL = peroneus longus tendon. (Left side of image is superior.) (e) Longitudinal US image shows the peroneus brevis tendon (arrows) exiting the periosteal calcaneal tunnel (arrowheads). C = calcaneus. (Left side of image is posterior.) (f) Transverse US image of the split segment of the peroneus brevis tendon shows a distal tendon anastomosis (arrows).

View larger version (150K): [in a new window]   Figure 13f.  Peroneus brevis split and rerouting (Chrisman-Snook procedure) in a 19-year-old woman. (a, b) Anteroposterior (a) and oblique (b) radiographs of the ankle show a fibular tunnel (arrows). (c) Longitudinal US image shows a portion of the split peroneus brevis tendon (solid arrow) entering the anterior end of the fibular tunnel (open arrow). F = fibula. (Left side of image is proximal.) (d) Longitudinal US image shows a segment of the peroneus brevis tendon (solid arrow) between the posterior aspect of the fibular tunnel (open arrow) and the calcaneal periosteal flap (arrowheads). C = calcaneus, CFL = calcaneofibular ligament, PB = spared half of the peroneus brevis tendon, PL = peroneus longus tendon. (Left side of image is superior.) (e) Longitudinal US image shows the peroneus brevis tendon (arrows) exiting the periosteal calcaneal tunnel (arrowheads). C = calcaneus. (Left side of image is posterior.) (f) Transverse US image of the split segment of the peroneus brevis tendon shows a distal tendon anastomosis (arrows).