and After imaging, all 10 specimens were deep frozen again, and nine were cut with a band saw into 2- to 3-mm-thick sections, two in each of the standard planes (axial, coronal, and sagittal) and three in the transverse oblique plane. 30 The function of the meniscofemoral ligament is to stabilize the lateral meniscus against the … We found that it was more difficult to evaluate the medial calcaneocuboid ligament (the lateral component of the bifurcate ligament) than the dorsolateral calcaneocuboid ligament. Cureus is on a mission to change the long-standing paradigm of medical publishing, where submitting research can be costly, complex and time-consuming. Terms of Use. 6 and 7) as might be seen with acute injuries of the anterior talofibular ligament . The authors wish to thank the individuals who donated their bodies for the advancement of medical education and research. The four ligaments connecting the calcaneus and cuboid are the medial calcaneocuboid ligament, a component of the bifurcate ligament; the dorsolateral calcaneocuboid ligament; the plantar calcaneocuboid ligament, or short plantar ligament; and the long plantar ligament [2–4]. Even so, we were able to identify the medial calcaneocuboid ligament in eight specimens, mostly in the coronal plane, and the dorsolateral calcaneocuboid ligament was seen in all specimens and also was best depicted in the coronal plane. It was visible in all planes, but was better depicted in the sagittal and coronal planes. ... medial collateral ligament complex, spring ligament, Chopart joint ligaments (bifurcate ligament, dorsal talonavicular ligament, lateral calcaneocuboid ligament, long and short plantar ligaments), Lisfranc ligaments, sinus tarsi ligaments. Intermetatarsal bursae are small fluid-filled sacs located between the metatarsal heads, cranial to the deep transverse intermetatarsal ligament (DTML). The calcaneocuboid part (Calcaneocuboid ligament) is fixed to the medial side of the cuboid and forms one of the principal bonds between the first and second … Reviewing with Cureus is easy, fast and hassle-free! Please note that Cureus is not responsible for any content or activities contained within our partner or affiliate websites. Interestingly, Barclay-Smith described two parts of the CNL: a short, inferior part and an upper, more superficial part. The data in these investigations are not uniform. The CNL was found in all the feet and the CCL was not present in 9.4% of the feet. Regarding the association between length of the CCL and sex, CCL length remained significant even after adjusting for the effect of foot length (p = 0.07), but the size of the effect was reduced, indicating that the longer CCL in males is partially attributable to their longer feet but the difference persists even when this factor is accounted for. The superomedial calcaneonavicular ligament was better seen in the coronal and sagittal planes. Sinus Tarsi. Both bands demonstrated dense regular connective tissue with interposed fibroblasts, characteristic of ligaments. We, therefore, endeavored to elucidate the morphological characteristics of the bifurcate ligament through a large-scale study involving … The black arrows delimit a thick band of collagen fibers. Furthermore, patients with injuries involving the calcaneocuboid joint require different treatment options than those with the more frequently occurring lateral ankle ligament injury [6]. All registered users are invited to contribute to the SIQ™ of any published article. with multiple different ultrasound systems and transducers •Ultrasound provides cost effective, quality imaging of … The BL also stabilizes the talocalcaneonavicular and midtarsal joints, and therefore, has been described as the keystone of the transverse tarsal joint [2] . The talocalcaneonavicular joint and the calcaneocuboid joint are separate joints, but together they represent the transverse tarsal, or mid tarsal, joint, which allows motion of the forefoot relative to the hindfoot [1, 8]. It was heterogeneous with fairly constant intermediate signal intensity. The dorsal ligamentous structures around the talocalcaneonavicular joint are longer and thicker than the corresponding calcaneocuboid ligaments [7]. Panel A, dorsoplantar radiograph without monofilament; Panel B, dorsoplantar radiograph with monofilament attached to the BL; Panel C, medial oblique radiograph without monofilament; Panel D, medial oblique radiograph with monofilament attached to the bifurcate ligament. Our BL fiber orientation classification system and angle measurements can pave the way for future biomechanical studies to investigate any relationships between fiber type, angle, and strength of the constituent bands. There was fat between its lateral border and the inferoplantar longitudinal calcaneonavicular ligament. Using embalmed Japanese cadavers, Edama et al. Bifurcate Ligament Tear treatment. In one foot, there was gross evidence of CNL ossification and in another the CCL was torn. The ligaments responsible for the stability of the calcaneocuboid joint are four, two dorsal and two plantar [4]. Magnified area of Figure 1 highlighting the bifurcate ligament. Ten ankle and foot specimens (four right and six left) transected approximately 8–10 cm proximal to the ankle joint were removed from 10 fresh cadavers (six men and four women; age at death, 64–89 years; mean age at death, 77.5 years) and were immediately deep frozen at –40°C (Forma BioFreezer, Forma Scientific). Histologic analysis was done on both bands to confirm that they were ligaments (Figure 3). CONCLUSION. 1 Department of Radiology, Universitair Ziekenhuis Brussel, Brussel, Belgium. The normal calcaneonavicular component of the bifurcate ligament … Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Therefore, the objective of this anatomico-radiological study was to investigate the morphology of the BL using a multifaceted approach, and classify the fiber characteristics of the CNL and CCL. Combating Diagnostic Delay of Endometriosis in Adolescents via Educational Awareness: A Systemati... 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In 60% of the specimens, as this ligament extended distally it divided into at least two bands that attached to the cuboid (the more lateral and deep fibers) and to the second to fourth metatarsal bases (the more medial and superficial fibers) (Fig. 2Department of Radiology, University of California, San Diego, VA San Diego Healthcare System, San Diego, CA. A p-value of less than 0.05 was considered to be statistically significant. This link will take you to a third party website that is not affiliated with Cureus, Inc. It was best seen in the axial and transverse oblique planes. PLAY. © Copyright 2019Kafka et al. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: This research was partially funded by a small research grant from the Corporate Advisory Board of the American Podiatric Medical Students’ Association. Bifurcate ligament . The bifurcate ligament is demonstrated in the center of the photograph. Sarrafian [2] refers to an inferior calcaneocuboid ligament that then divides into a long (superficial) plantar ligament and short (deep) plantar ligament, the latter of which is also known as the plantar calcaneocuboid ligament. In Panels B and D, note how the proximal stem of the bifurcate ligament attaches to the dorso-distal surface of the calcaneus. 1). There have been reports of isolated bilateral dislocations of the calcaneocuboid joints that required surgical repair [9-10]. Qualitative evaluation—MR images were assessed for visualization of the ligamentous structures in the tarsal joint complex and their signal intensity characteristics by consensus of two radiologists with 2 and 3 years' experience in musculo skeletal imaging. There were no significant relationships between the bifurcation angle and the mean length and mean overall width of the CNL or CCL (p > 0.1). Mean (standard deviation) thickness of the CNL and CCL was 3.23 (1.56) mm and 1.48 (0.71) mm, respectively. Unfortunately, involvement of the bifurcate ligament (BL) is often overlooked when assessing such injuries in clinical practice and identification of this ligament on magnetic resonance (MR) scans can be challenging. It was present in all specimens and was better seen in the coronal plane as a reinforcement of the calcaneocuboid capsule. In our sample, the dorsal ligaments—the medial and dorsolateral calcaneocuboid ligaments—were thin, whereas the plantar calcaneocuboid ligaments were larger, likely explaining why the medial and dorsolateral calcaneocuboid ligaments are more prone to injuries [4–7]. We were able to define three components of the spring ligament complex [10–12, 17]. One of the reasons for the infrequency of isolated mid tarsal injuries is the strong adjacent ligamentous structures that act as important static supporters of the arch of the foot. All specimens were allowed to thaw for at least 24 hours at room temperature before transverse tarsal joint complex arthrography and MRI. Data are presented as means (standard deviations, SDs), ranges, or percentages, whenever appropriate. These include the talocrural articular cartilage, bifurcate calcaneocuboid and talonavicular ligaments, subtalar ligaments, extensor digitorum brevis, sinus tarsi, Achilles tendon, tibiofibular syndesmosis, and avulsion or compression fractures. Both ligaments were predominantly cord-shaped or flat-shaped, and their constituent fibers were arranged in one of the following patterns: spiral, parallel, or fanned. Scholarly Impact Quotient™ (SIQ™) is our unique post-publication peer review rating process. Deltoid examination in relation to inversion injury . A probable reason for this is that the morphological characteristics of this structure have yet to be sufficiently elucidated. These videos will help lay the foundation of scanning skills for those who wish to extend their knowledge beyond just scanning the basic lateral ankle ligaments. In the coronal and sagittal MR arthrographic images, normal leakage of intraarticular contrast among the different portions of the spring ligament complex corresponding to the regions of fat was seen (Fig. The correlation between the two measured angles was very strong (p < 0.001). Its insufficiency is associated with the development of a flatfoot deformity together with dysfunction of the tibialis posterior tendon [17, 18]. There were 26 right feet and 27 left feet (total of 53 feet). However, in every specimen, there was an area of contact between both structures, which probably represents the “gliding layer” described in the literature [11, 21, 22], an area of connective tissue. Read our Reviewer Guide for more info. We were able to visualize the lateral calcaneonavicular ligament in all imaging planes and in every specimen (Fig. The strongest and thickest ligamentous structures of the transverse tarsal joint, as confirmed in our study, are on the plantar side [8]—specifically, the inferior calcaneocuboid ligaments (the long and short plantar ligaments) and inferior calcaneonavicular ligament (the spring ligament). 13A, 13B, 13C, 13D and 14A, 14B, 14C). 12A, 12B). Ultrasound Examination Technique Table 8.1 is a checklist for ankle, calf, and forefoot ultrasound examination. We think this is the most useful anatomy picture that you … The dorsal calcaneocuboid ligament attaches to the anterolateral calcaneus (lateral to the bifurcate ligament) and to the dorsolateral cuboid. It attached to the navicular beak on the plantar and lateral aspects of the navicular bone (Figs. Keywords: anatomy, calcaneocuboid joint, midfoot ligaments, MRI, musculoskeletal imaging, sports medicine, talocalcaneonavicular joint. The medioplantar oblique calcaneonavicular ligament was more clearly visualized on removal of the talus and the fibrocartilage that covered the spring ligament complex (Fig. Lend a hand to your fellow Cureus authors and volunteer for our peer review panel. (Authors cannot rate their own articles.). 13A, 13B, 13C, 13D and 15A, 15B). 1). a The calcaneocuboid ligament was absent in five feet (n=48). Unfortunately, the authors did not correlate their data with diagnostic images [11]. Readers also measured the dimensions (length, width, and thickness) of the different components of the spring ligament complex, bifurcate ligament, and plantar calcaneocuboid ligaments. doi:10.7759/cureus.3847. There are few anatomical studies on the morphometric characteristics of the BL and even fewer biomechanical studies. Each compartment was filled with approximately 5–7 mL of a contrast solution consisting of 1 mL of gadopentate dimeglumine (Magnevist, Bayer HealthCare) diluted in 250 mL of saline solution, 0.5 mL of iohexol, and 0.5 mL of a mixture of gelatin. "Never doubt that a small group of thoughtful, committed citizens can change the world. [10] as the third ligament, was seen in all specimens and was best depicted in the axial and transverse oblique planes. Anatomy. We were able to consistently delineate the superomedial calcaneonavicular ligament from the tibiospring ligament on coronal MR images because of their different thicknesses. Scholary Impact Quotient™ (SIQ™) is our unique post-publication peer review rating process. In all specimens, a deeper band that reinforced the calcaneocuboid joint capsule was identified with a distinct attachment to the calcaneus and showed a more oblique orientation (Fig. The bifurcate ligament was located deep under the extensor hallucis brevis and extensor digitorum brevis muscles in all specimens. 3A, 3B, 3C, 3D). It had a V configuration, with the medial component being the lateral calcaneonavicular ligament and the lateral component, the medial calcaneocuboid ligament (Fig. The mean angle between the CNL and CCL has been reported to be 30o [8]. The objective of our study was to clarify the detailed anatomy of the transverse tarsal joint ligamentous complex and evaluate the diagnostic capability of MRI in the assessment of the tarsal joint complex with detailed anatomic correlation in cadavers. This corresponded to the site of pain and was reported as probable bifurcate ligament injury. Measurements of the length, width, thickness, and shape of the CNL and CCL were taken using a digital caliper. The bifurcate ligament is a Y shaped ligament with two components, the calcaneocuboid and calcaneonavicular ligaments . This study was funded by a research grant from the Corporate Advisory Board of the American Podiatric Medical Students’ Association. These frequencies are similar to a recent Japanese study. (Images courtesy of Douglas N. Mintz, MD, FACR, Hospital for Special Surgery, NY). The medial calcaneocuboid ligament was not always traceable, and even when it was visible, it was faint and very small. The bifurcate ligament (BL) of the foot, also called Chopart ligament, is a strong Y-shaped structure that stabilizes the calcaneocuboid joint . Regardless of its precise anatomic features, the spring ligament has two important functions: It supports the head of the talus, thus providing stability to the talocalcaneonavicular joint, and it acts as a static supporter of the medial longitudinal arch [1]. The ligament is anatomically found on the dorsal surface of the calcaneocuboid joint and has a main proximal stem that attaches to the calcaneal sulcus, which then divides distally to attach to the navicular and dorsomedial aspect of the cuboid [1,3-5]. Additionally, a sagittal magnetic resonance (MR) scan from the left foot of a 30-year-old man was included to show how the BL looks on MR imaging. It was better evaluated in the coronal and sagittal planes. Published: January 08, 2019. On average, the CNLs were longer (p < 0.05, paired t test) and thicker (p < 0.05, Wilcoxon signed-rank test) than the CCLs. Some investigators believe that this complex is formed by two major components: the superomedial calcaneonavicular ligament and the inferoplantar longitudinal calcaneonavicular ligament [9]. 1, 6 In two specimens, two separate calcaneal attachments were seen. We measured the length and width of 53 embalmed feet from 33 adult cadavers (24 females and nine males) with a mean (range) age at death of 76 (42-94) years (Table 1). The calcaneonavicular ligament was 20.8 ± 2.9 mm long, 4.9 ± 1.2 mm wide, and 3.8 ± 1.1 mm thick. Two intraarticular injections were performed with a 22-gauge needle through the dorsal skin at the level of the calcaneocuboid and talocalcaneonavicular articulations under fluoroscopic guidance. The bifurcated ligament ( internal calcaneocuboid, interosseous ligament or bifurcate ligament) is a strong band, attached behind to the deep hollow on the upper surface of the calcaneus and dividing in front in a Y-shaped manner into a calcaneocuboid and a calcaneonavicular part. European Journal of Radiology. Peer review concluded: January 05, 2019 13A, 13B, 13C, 13D). It had low signal intensity and was best visualized in the sagittal plane (Fig. Intermetatarsal bursae are small fluid-filled sacs located between the metatarsal heads, cranial to the deep transverse intermetatarsal ligament (DTML). The CNL is usually more cord shaped, and the comparative morphologies of both ligaments can be observed in Figures 1-2. For ligament width, we measured overall, proximal, middle and distal widths because of the striking morphologic changes that were observed as the ligaments coursed distally to attach to their respective bones. SIQ™ assesses article importance and quality by embracing the collective intelligence of the Cureus community-at-large. The medial calcaneocuboid ligament is the lateral band of the bifurcate ligament. Ligaments stabilizing the Chopart joint include the dorsal talonavicular ligament, bifurcate ligament, dorsal calcaneocuboid ligament, short and long plantar ligaments, and spring ligament (3,4). One of the feet was dissected by an orthopedic surgeon to compare the gross anatomy with the imaging findings. Injuries of the spring ligament complex are typically seen in patients with acquired flatfoot deformity in association with tibialis posterior tendon dysfunction [14, 15]. The bifurcate ligament (BL) of the foot, also called Chopart ligament, is a strong Y-shaped structure that stabilizes the calcaneocuboid joint [1]. Indeed, it is the only thing that ever has.". We aim to become the reddit home of radiologists, radiographers, technologists, sonographers and lay-users … FMA. Grade III ankle sprain with disruption of the anterior talofibular ligament Each email address must be separated by a comma. The dorsolateral calcaneocuboid ligament was a broad, flat, and thin ligament that arose at the superior and lateral aspects of the calcaneus, lateral to the medial calcaneocuboid ligament, and extended anteromedially to the dorsal surface of the cuboid (Fig. Significant data exist for the personal, environmental, and occupational risk factors for carpal tunnel syndrome. Where are common talar injuries? Kelikian reported the mean width of the CNL at its proximal attachment to be 10 mm and we found the mean (SD) proximal width to be 9.70 (3.01) mm. Anatomynote.com found Bifurcate Ligament Anatomy from plenty of anatomical pictures on the internet. 3Orthopaedic Department, Hospital Geral de Santo ... complex, bifurcate ligament, and plantar calcaneocuboid ligaments. : Walter WR, Hirschmann A, Tafur M, Rosenberg ZS. There are published reports of avulsion fractures at the anterior process of the calcaneus at the site of origin of the BL [19-20]. 16A, 16B). This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 3.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. To analyze the associations between ligament length, thickness, and width with variables such as the patients' age at death and sex, we calculated Pearson's correlation coefficients. The talocalcaneonavicular joint comprises the rounded head of the talus; concave posterior surface of the navicular, anterior articular surface of the calcaneus; and upper surface of the plantar calcaneonavicular ligament, or spring ligament [1, 2, 8]. OBJECTIVE. 5A, 5B, 5C). The CCLs tended to be wider distally and tapered compared to the CNLs. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. (see history), Cite this article as: It consists of two components, which form a Y-shape: MRI of the Extensor Tendons of the Wrist. (January 08, 2019) Anatomico-radiological Study of the Bifurcate Ligament of the Foot with Clinical Significance. Gross anatomy. The rarity of isolated BL rupture is attributed to its high mechanical stability and strength, and possibly to its relationship with the surrounding rigid tarsal framework [8]. In this study, we used dissection in conjunction with diagnostic images (radiographs and MR scan) to better investigate the morphology and arrangement of the constituent bands of the BL. Two prior MRI studies have reported abnormalities of the bifurcate ligament in association with anterior process fractures with conflicting results. Mechanical instability of the calcaneocuboid joint with possible avulsion fracture of the anterior process of the calcaneus due to forcible inversion and plantar flexion of the foot necessitates morphometric analysis of the BL. Volume 107, October 2018, Pages 216-226. Review. The short plantar ligament appeared striated and had two consistent bands, one deep and one superficial. The bifurcate ligament arises from the anterior process of the calcaneus (distal to the origin of the extensor digitorum brevis). Some authors have suggested that the BL has a mechanical coupling relationship with the talonavicular joint [3]. We found that 90.6% of feet had both the CNL and CCL, 9.4% had the CNL and no CCL, and none (0%) had the CCL and no CNL. The bifurcate ligament was considered injured if it was thickened with hyperintense signal edema (Figs. Damage to the BL may be unrecognized by clinicians in patients with inversion injuries of the feet [6-7]. The angle between both ligaments was then recorded and is 36o in this foot. In several previous studies, investigators have described the anatomy of the spring ligament complex [2, 9–13]. These injuries predominantly affect young and active persons and are of significant economic importance [4, 6]. The lengths of the short and long plantar ligaments were measured in the sagittal plane. Anything above 5 should be considered above average. The bifurcate ligament is a strong Y-shaped structure stabilizing the … MATERIALS AND METHODS. The calcaneocuboid ligament originates from the rostrum of the calcaneus and is directed towards the cuboid. Bifurcate ligament: This ligament connects the anterior process of the calcaneus to both the cuboid and navicular bones (indicated by green triangle in the image above) Inversion stress of the foot will result in stretch of this ligament or avulsion fracture of the anterior process. It could be seen in all the planes but was better visualized in the axial and sagittal planes. anatomy, ankle sprain, bifurcate ligament, calcaneocuboid ligament, calcaneonavicular ligament, foot, foot joints, orthopedic surgery, podiatry, radiology, Rene M. Kafka, Ian L. Aveytua, Paul J. Choi, Anthony C. DiLandro, R. Shane Tubbs, Marios Loukas, Douglas N. Mintz, Ritwik Baidya, Sushil Kumar, Santosh K. Sangari, Estomih P. Mtui, Anthony V. D'Antoni, Published: Bifurcate Ligament. The wide variety of configurations and the morphology of these ligaments probably explain the different terms used in the literature [3]. RESULTS. Privacy Policy The bifurcate ligament extends from the calcaneus to the navicular and cuboid bones at the lateral aspect of the mid-foot. Ten fresh cadaveric feet were studied with high-spatial-resolution MRI before and after intraarticular injection of a gadopentetate dimeglumine solution. In this illustration, the talus has been removed so that the origin of both bands can be appreciated relative to the sinus tarsi. The BL has been described as a Y-shaped structure [1]. Inferoplantar longitudinal calcaneonavicular ligament—The inferoplantar longitudinal calcaneonavicular ligament was a rectangular ligament that arose between the middle and anterior facets of the calcaneus. An article’s SIQ™ will appear alongside the article after being rated twice and is recalculated with each additional rating. Meticulous dissection of each foot was performed to expose the BL. More recently, Taniguchi and coworkers [10] reported a third component lying beneath the cartilaginous surface of the complex that is known as the medioplantar oblique calcaneonavicular ligament; this finding has been further supported by other dissection and MRI studies [11, 12]. 10A, 10B). Finally, the inferoplantar longitudinal calcaneonavicular ligament was completely separated from the medioplantar oblique calcaneonavicular ligament by fatty tissue. The bifurcate ligament, also designated the “ligament of Chopart,” is formed by two ligaments: the medial calcaneocuboid ligament and lateral calcaneonavicular ligament [1, 2] (Fig. January 08, 2019 MR images were evaluated by two readers, with an emphasis on the visibility of ligamentous structures and their appearance and signal intensity. Indeed, these injuries are a cause of symptoms after an inversion injury of the foot, and the resulting clinical manifestations may mimic a lateral ankle ligament injury, which is more common [1, 4–7]. The CNL was usually cord shaped (36 of 53 feet) and the CCL usually flat shaped (40 of 48 feet). Its parent muscle arises from the upper two-thirds of the lateral aspect of the tibia.
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