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Ryan PM, Eakin JL, Goodrum JT. Subtle Syndesmotic Instability. J Am Acad Orthop Surg 2024; 32:719-727. [PMID: 38295390 DOI: 10.5435/jaaos-d-23-00707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Indexed: 02/02/2024] Open
Abstract
Latent or subtle syndesmotic instability is defined as an injury to the syndesmosis which is not apparent on static radiographs of the ankle. Syndesmotic injuries have also been referred to as high ankle sprains. Injury to the syndesmosis typically occurs with collision sports and often involves an external rotation force to the ankle. Diagnosis can be delayed because of negative initial imaging studies. Physical examination tests including the external rotation test, proximal squeeze test, and fibular shuck test can assist in the diagnosis. Advanced imaging modalities such as MRI and weight-bearing CT have been studied and can provide prognostic indications for management, although arthroscopic stress evaluation remains the benchmark for diagnosis. Both surgical and nonsurgical management techniques have been described, which can assist patients in returning to their preinjury level of function.
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Affiliation(s)
- Paul M Ryan
- From the Lake Tahoe Sports Medicine Fellowship, Department of Surgery, Barton Memorial Hospital, South Lake Tahoe, CA (Ryan, Eakin, Goodrum), University of Nevada, Reno School of Medicine, Reno, NV (Ryan), Uniformed Services University, Bethesda, MD (Ryan)
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Shaath MK, Williams WA, Kelly JJ, Garrett CH, Munro MW, Avilucea FR, Langford JR, Haidukewych GJ. Clinical and Radiographic Results After Treatment of Traumatic Syndesmotic Instability Using a Novel Screw-Suture Syndesmotic Fixation Device. J Orthop Trauma 2024; 38:e302-e306. [PMID: 39007667 DOI: 10.1097/bot.0000000000002824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/16/2024] [Indexed: 07/16/2024]
Abstract
OBJECTIVES The objective of this study was to report early outcomes of a novel screw-suture syndesmotic device compared with suture button fixation devices when treating traumatic syndesmotic instability. METHODS DESIGN Retrospective chart review. SETTING Single academic Level 1 Trauma Center. PATIENT SELECTION CRITERIA All adult patients who had syndesmotic fixation with the novel device [novel syndesmotic repair implant (NSRI) group] compared with a suture button device (SB group) between January 2018 and December 2022. OUTCOME MEASURES AND COMPARISONS Medial clear space and tibiofibular overlap measurements were compared immediately postoperatively and at the final follow-up. Patients were followed for a minimum of 1 year or skeletal healing. RESULTS Fifty-nine patients (25 female) with an average age of 47 years (range 19-78 years) were in the NSRI group compared with 52 patients (20 female) with an average age of 41 years (range 18-73 years) in the SB group. There were no significant differences when comparing body mass index, diabetes, or smoking status between groups (P > 0.05). There was no difference when comparing the postoperative and final medial clear space measurements in the NSRI group compared with the SB group (P = 0.86; 95% confidence interval, -0.32 to 0.27). There was no difference when comparing the postoperative and final tibiofibular overlap measurements in the NSRI group compared with the SB group (P = 0.79; 95% confidence interval, -0.072 to 0.09). There were 3 cases of implant removal in the NSRI group compared with 2 in the SB group (P = 0.77). There was 1 failure in the NSRI group and none in the SB group. The remaining patients were all fully ambulatory at the final follow-up (P = 0.35). CONCLUSIONS A novel screw-suture syndesmotic implant provides the fixation of a screw, and the flexibility of a suture had similar radiographic outcomes compared with suture button fixation devices in treating ankle syndesmotic instability. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- M Kareem Shaath
- Orlando Health Jewett Orthopedic Institute, Orlando, FL
- Florida State College of Medicine, Orlando, FL; and
- University of Central Florida College of Medicine, Orlando, FL
| | | | - John J Kelly
- Orlando Health Jewett Orthopedic Institute, Orlando, FL
| | | | - Mark W Munro
- Orlando Health Jewett Orthopedic Institute, Orlando, FL
- Florida State College of Medicine, Orlando, FL; and
- University of Central Florida College of Medicine, Orlando, FL
| | - Frank R Avilucea
- Orlando Health Jewett Orthopedic Institute, Orlando, FL
- Florida State College of Medicine, Orlando, FL; and
- University of Central Florida College of Medicine, Orlando, FL
| | - Joshua R Langford
- Orlando Health Jewett Orthopedic Institute, Orlando, FL
- Florida State College of Medicine, Orlando, FL; and
- University of Central Florida College of Medicine, Orlando, FL
| | - George J Haidukewych
- Orlando Health Jewett Orthopedic Institute, Orlando, FL
- Florida State College of Medicine, Orlando, FL; and
- University of Central Florida College of Medicine, Orlando, FL
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Kohler FC, Hallbauer J, Herrmann L, Ullrich BW, Biedermann U, Wildemann B, Hofmann GO, Ramm R, Lenz M, Marintschev I, Schenk P. Standardized analysis of syndesmosis stability in ankle trauma with an innovative syndesmosis-test-tool: a biomechanical study. Sci Rep 2024; 14:1659. [PMID: 38238396 PMCID: PMC10796637 DOI: 10.1038/s41598-024-51872-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 01/10/2024] [Indexed: 01/22/2024] Open
Abstract
When treating ankle fractures, the question of syndesmosis complex involvement often arises. So far, there is no standardized method to reliably detect syndesmosis injuries in the surgical treatment of ankle fractures. For this reason, an intraoperative syndesmosis-test-tool (STT) was developed and compared to the recommended and established hook-test (HT). Tests were performed on cadaveric lower legs (n = 20) and the diastasis was visualized by 3D camera. Tests were performed at 50, 80, and 100 N in native conditions and four instability levels. Instability was induced from anterior to posterior and the reverse on the opposite side. The impact on diastasis regarding the direction, the force level, the instability level, and the device used was checked using a general linear model for repeated measurement. The direction of the induced instability showed no influence on the diastasis during the stability tests. The diastasis measured with the STT increased from 0.5 to 3.0 mm depending on the instability, while the range was lower with the HT (1.1 to 2.3 mm). The results showed that the differentiation between the instability levels was statistically significantly better for the developed STT. The last level of maximum instability was significantly better differentiable with the STT compared to the HT. An average visualizable diastasis of more than 2 mm could only be achieved at maximum instability. In conclusion, the newly developed STT was superior to the commonly used HT to detect instability.
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Affiliation(s)
- Felix Christian Kohler
- Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University Jena, 07747, Jena, Germany.
| | - Jakob Hallbauer
- Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University Jena, 07747, Jena, Germany
| | - Lea Herrmann
- Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University Jena, 07747, Jena, Germany
| | - Bernhard Wilhelm Ullrich
- Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University Jena, 07747, Jena, Germany
- Department of Trauma and Reconstructive Surgery, BG Klinikum Bergmannstrost Halle gGmbH, 06112, Halle, Germany
| | - Uta Biedermann
- Institute of Anatomy I, Jena University Hospital, Friedrich Schiller University Jena, 07743, Jena, Germany
| | - Britt Wildemann
- Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University Jena, 07747, Jena, Germany
| | - Gunther Olaf Hofmann
- Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University Jena, 07747, Jena, Germany
| | - Roland Ramm
- Fraunhofer Institute for Applied Optics and Precision Engineering (IOF), Albert-Einstein-Str. 7, 07745, Jena, Germany
| | - Mark Lenz
- Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University Jena, 07747, Jena, Germany
| | - Ivan Marintschev
- Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University Jena, 07747, Jena, Germany
| | - Philipp Schenk
- Department of Science, Research and Education, BG Klinikum Bergmannstrost Halle gGmbH, 06112, Halle, Germany
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Junior MDSL, Ciardullo MB, Neto OC, Herrera YEG, Ochoa PGG, Silva JDS, Kojima KE. Protected immediate weight-bearing is safe after fixation of ankle fractures with syndesmosis injury fixed with position screw. A retrospective case-series study. Injury 2023; 54 Suppl 6:110745. [PMID: 38143122 DOI: 10.1016/j.injury.2023.04.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/15/2023] [Accepted: 04/14/2023] [Indexed: 12/26/2023]
Abstract
BACKGROUND About 10% of ankle fractures are located above the syndesmosis, which causes injury to the ligament structure of the syndesmosis. There is no consensus regarding when to allow weight-bearing on the operated limb of patients who suffered ankle fractures requiring intraoperative fixation. OBJECTIVE The aim of this study is the evaluation of radiographic parameters of syndesmosis reduction and fixation in patients with ankle fracture who underwent immediate protected weight-bearing (use of walking-boot and crutches). PATIENT AND METHODS Retrospective case series from January 2015 to December 2020. Evaluation of the tibiofibular clear space, tibiofibular overlap, and medial clear space in the preoperative x-ray, immediate postoperative, 3-, 6- and 12-month after syndesmosis fixation and rehabilitation with protected immediate weight-bearing with crutches and walking-boot. RESULTS Out of 137 ankle fractures 39 were included. There was no significant difference in the tibiofibular clear space between the immediate x-ray and after 12 months (4.5 mm ± 1.1 vs. 4.6 mm ± 1.8; p > 0.999). Tibiofibular overlap hasn't shown significant difference between immediate and 12-month x-ray (6.2 mm ± 2.6 vs. 6.6 mm ± 2.6; p > 0.999). Medial clear space also has shown no worsening from immediate to 12-month x-ray (3.1 mm ± 0.9 vs. 2.8 mm ± 0.9; p > 0.999). There were no fixation failure nor postoperative infection. CONCLUSION Immediate weight-bearing for patients with ankle fractures with syndesmosis injury and treated with intraoperative fixation with positioning screw proved to be safe with good maintenance of the reduction, no failures of the synthesis material observed and no reports of postoperative infection in the period. LEVEL 3 EVIDENCE: therapeutic retrospective case-series.
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Affiliation(s)
- Milton da Silva Linhares Junior
- Trauma Service, Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil.
| | - Marcos Broggi Ciardullo
- Trauma Service, Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil.
| | - Orlando Colavolpe Neto
- Trauma Service, Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil.
| | - Yasmín Estefanía González Herrera
- Trauma Service, Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil.
| | - Pablo Gabriel Garcia Ochoa
- Trauma Service, Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil.
| | - Jorge Dos Santos Silva
- Trauma Service, Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil.
| | - Kodi Edson Kojima
- Trauma Service, Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil.
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Cao S, Wang C, Chen Y, Zhang C, Huang J, Ma X, Wang X. Stress Tests for Deltoid Ligament and Syndesmosis Injury in Patients With Ankle Fracture: A Systemic Review With Meta-Analysis. J Orthop Trauma 2023; 37:e441-e446. [PMID: 37448133 DOI: 10.1097/bot.0000000000002651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/09/2023] [Indexed: 07/15/2023]
Abstract
OBJECTIVES To determine the diagnostic accuracy of various stress tests for deltoid ligament and syndesmosis injury in patients with ankle fracture. DATA SOURCES A systemic literature search was conducted in the MEDLINE, Embase, and Cochrane Library databases to identify studies published from January 1990 to August 2022. STUDY SELECTION Studies that evaluated external rotation or gravity stress tests or hook or tap tests for the diagnosis of deltoid ligament or syndesmosis injury were included. DATA EXTRACTION Authors, publication years, study design, index tests, reference standards, demographic features of participants, reliability, and the numbers of true-positive, true-negative, false-positive, and false-negative subjects were extracted from 14 included studies. Article quality was assessed through the revised Quality Assessment of Diagnostic Accuracy Studies tool. DATA SYNTHESIS The pooled sensitivity and specificity of each index test for each structure were calculated with a random-effects model using the extracted data of true-positive, true-negative, false-positive, and false-negative outcomes in all relevant studies. The overall diagnostic performance of the different index tests for different structures was determined with the estimation of the area under the curve using the summary receiver operating characteristics curve. CONCLUSIONS The gravity stress test and the tap test exhibited high sensitivity and specificity in diagnosing deltoid ligament injury. The hook test has relatively high accuracy in diagnosing syndesmosis injury. Further studies with large sample sizes are warranted to confirm the results of this review. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Shengxuan Cao
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China
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Hallbauer J, Schenk P, Herrmann L, Ullrich BW, Biedermann U, Wildemann B, Hofmann GO, Kohler FC. Objective Assessment of Syndesmosis Stability Using the Hook Test. J Clin Med 2023; 12:4580. [PMID: 37510697 PMCID: PMC10380604 DOI: 10.3390/jcm12144580] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 07/03/2023] [Accepted: 07/07/2023] [Indexed: 07/30/2023] Open
Abstract
The hook test is a widely used intraoperative method for assessing syndesmosis stability. However, there are no recommendations regarding the force required to perform this test. Furthermore, the reliability of the test is unclear. Ten experienced surgeons performed hook tests on a cadaver bone model. The applied forces were recorded in a blinded manner. In addition, standardized hook tests with defined forces (50, 80, and 100 N) were performed on 10 pairs of cadaver lower legs and the syndesmosis was sequentially destabilized. Diastasis of the syndesmosis was recorded using an optical 3D camera system. A median force of 81 N (Range: 50 N-145 N) was applied. A proportion of 82% of the tests showed a force < 100 N. The data showed good intraraterreliability and poor interraterreliability. In the standardized investigation of the hook test on the cadaver bone model, both the force and the instability of the syndesmosis had a significant influence on the syndesmosis diastasis. Nevertheless, even with maximum instability of the syndesmosis, diastasis > 2 mm could only be measured in 12 of the 19 evaluable specimens. The widely used hook test shows a high variability when performed in practice. Even in a standardized manner, the hook test cannot detect a relevant syndesmosis injury.
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Affiliation(s)
- Jakob Hallbauer
- Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University Jena, 07747 Jena, Germany
| | - Philipp Schenk
- Reseaserch Executive Department, BG Klinikum Bergmannstrost, 06112 Halle, Germany
- Department of Trauma and Reconstructive Surgery, BG Klinikum Bergmannstrost, 06112 Halle, Germany
| | - Lea Herrmann
- Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University Jena, 07747 Jena, Germany
| | - Bernhard Wilhelm Ullrich
- Department of Trauma and Reconstructive Surgery, BG Klinikum Bergmannstrost, 06112 Halle, Germany
| | - Uta Biedermann
- Institute of Anatomy I, Jena University Hospital, Friedrich Schiller University Jena, 07743 Jena, Germany
| | - Britt Wildemann
- Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University Jena, 07747 Jena, Germany
| | - Gunther Olaf Hofmann
- Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University Jena, 07747 Jena, Germany
- Department of Trauma and Reconstructive Surgery, BG Klinikum Bergmannstrost, 06112 Halle, Germany
| | - Felix Christian Kohler
- Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University Jena, 07747 Jena, Germany
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Arthroscopic assessment of syndesmotic instability: Are we pulling correctly in the coronal plane? Foot Ankle Surg 2023; 29:67-71. [PMID: 36202727 DOI: 10.1016/j.fas.2022.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 08/08/2022] [Accepted: 09/19/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND While the lateral hook test (LHT) has been widely used to arthroscopically evaluate syndesmotic instability in the coronal plane, it is unclear whether the angulation of the applied force has any impact on the degree of instability. We aimed to determine if changing the direction of the force applied while performing the LHT impacts the amount of coronal diastasis observed in subtle syndesmotic injuries. METHODS In 10 cadaveric specimens, arthroscopic evaluation of the syndesmotic joint was performed by measuring anterior and posterior-third coronal plane diastasis in the intact state, and repeated after sequential transection of the 1) anterior inferior tibiofibular ligament (AITFL), 2) interosseous ligament (IOL), and 3) posterior inferior tibiofibular ligament (PITFL). In all scenarios, LHT was performed under 100 N of laterally directed force. Additionally, LHT was also performed under: 1) anterior inclination of 15 degrees and 2) posterior inclination of 15 degrees in intact and AITFL+IOL deficient state. RESULTS Compared to the intact state, the syndesmosis became unstable after AITFL +IOL transection under laterally directed force with no angulation (p = 0.029 and 0.025 for anterior and posterior-third diastasis, respectively), which worsened with subsequent PITFL transection (p = <0.001). Moreover, there was no statistical difference in anterior and posterior-third coronal diastasis in both intact and AITFL+IOL deficient states under neutral, anterior, and posteriorly directed force (p-values ranging from 0.816 to 0.993 and 0.396-0.80, respectively). However, in AITFL+IOL transected state, posteriorly directed forces resulted in greater diastasis than neutral or anteriorly directed forces. CONCLUSIONS Angulation of the applied force ranging from 15 degrees anteriorly to 15 degrees posteriorly during intraoperative LHT has no effect on coronal plane measurements in patients with subtle syndesmotic instability. On the other hand, posteriorly directed forces result in more sizable diastasis, potentially increasing their sensitivity. CLINICAL RELEVANCE When arthroscopically evaluating subtle syndesmotic instability, clinicians should assess coronal diastasis with the hook angled 15 degrees posteriorly.
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The effect of partial deltoid ligament injuries on the external rotation stability: A cadaveric study. Foot Ankle Surg 2022; 28:1215-1219. [PMID: 35431116 DOI: 10.1016/j.fas.2022.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 03/18/2022] [Accepted: 03/31/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND The anterior and posterior part of the deltoid ligament have different functions during ankle flexion motion. Partial ligament injuries have been demonstrated in previous clinical reports. However, the efficacy of external rotation stress test in partial injured cases is unavailable till now. METHODS Thirty-two fresh cadaveric specimens were included and allocated into two destabilization groups. In the first group, the anterior portion of deltoid ligament (DL) and syndesmotic ligament were sequentially severed, while in the second group, the posterior portion of DL and syndesmotic ligament were sequentially severed. Mortise view radiographs were taken after each destabilization stage when the ankles were placed at plantarflexion and dorsiflexion positions and stressed in standard external rotation force. The medial clear space (MCS) and talar tilt (TT) angle were measured and compared among different destabilization stages. RESULTS When the ankles were placed at neutral position, the TT significantly increased in all destabilization stages. The MCS significantly increased after the partial deltoid ligament ruptures only with presence of syndesmotic ligament injuries. There was no significant difference of MCS at plantarflexion for all stages of destabilization if the anterior portion of DL is preserved. Similarly, no significant increase of MCS was detected at dorsiflexion if the posterior portion of DL and posterior inferior tibiofibular ligament are intact. CONCLUSION Partial DL rupture causes ankle rotational instability at different ankle joint positions, especially when combined with syndesmotic injuries. The neutral position is recommended for diagnosis of partial DL ruptures under external rotation stress.
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Cao MM, Zhang YW, Hu SY, Dai GC, Lu PP, Xie T, Wang C, Chen H, Rui YF. 3D Mapping of the Lateral Malleolus Fractures for Predicting Syndesmotic Injuries in Supination External Rotation Type Ankle Fractures. J Foot Ankle Surg 2022; 61:1197-1202. [PMID: 35183455 DOI: 10.1053/j.jfas.2022.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 01/15/2022] [Accepted: 01/18/2022] [Indexed: 02/03/2023]
Abstract
Supination external rotation (SER) type ankle fracture is the most common ankle fracture in the Lauge-Hansen classification and is often accompanied with syndesmotic injury. However, the mechanism of this injury is indistinct and a suggestive role can be given by preoperative imaging. This study was to preoperatively predict whether SER type ankle fractures are accompanied with syndesmotic injuries by the means of lateral malleolus fracture mapping. One hundred and forty-eight patients diagnosed with SER type ankle fractures were retrospectively enrolled in this study. The baseline data were collected and computed tomography data were reconstructed in 3-dimensional (3D) model. Patients were divided into stable and unstable groups according to intraoperative Cotton test and whether the inferior tibiofibular screw was placed. All fracture lines were superimposed on the ankle template to create a fracture map, and the data on the fracture map were further measured. Logistic regression was conducted to identify relevant factors and the cutoff values were given using receiver operating characteristic curves. Forty-one patients were enrolled in the unstable group and 107 patients were enrolled in the stable group. The lateral malleolus fracture lines of the unstable group were higher and steeper than that in the stable group on lateral and posterior views. The fracture height of the posterior cortex and peak height were the significant contributing factors, and the cut-off values of posterior cortex, peak height and inclination angle were 40.35 mm (sensitivity: 78%, specificity: 82%), 55.34 mm (sensitivity: 85%, specificity: 70%) and 55.6° (sensitivity: 66%, specificity: 86%), respectively. In general, when the fracture lines of the lateral malleolus were high and steep, it was usually indicative of a syndesmotic injury and can be predicted by the preoperative 3D reconstruction of fracture height of posterior cortex, peak height and inclination angle. If the cut-off values of these indicators are exceeded, the syndesmotic injuries may be presented and need to be verified in the intraoperative Cotton test to decide whether to insert an inferior tibiofibular screw.
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Affiliation(s)
- Mu-Min Cao
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, PR China; School of Medicine, Southeast University, Nanjing, Jiangsu, PR China; Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, PR China; Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, PR China
| | - Yuan-Wei Zhang
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, PR China; School of Medicine, Southeast University, Nanjing, Jiangsu, PR China; Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, PR China; Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, PR China
| | - Sheng-Ye Hu
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, PR China; School of Medicine, Southeast University, Nanjing, Jiangsu, PR China; Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, PR China; Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, PR China
| | - Guang-Chun Dai
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, PR China; School of Medicine, Southeast University, Nanjing, Jiangsu, PR China; Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, PR China; Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, PR China
| | - Pan-Pan Lu
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, PR China; School of Medicine, Southeast University, Nanjing, Jiangsu, PR China; Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, PR China; Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, PR China
| | - Tian Xie
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, PR China; School of Medicine, Southeast University, Nanjing, Jiangsu, PR China; Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, PR China; Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, PR China
| | - Chen Wang
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, PR China; School of Medicine, Southeast University, Nanjing, Jiangsu, PR China; Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, PR China; Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, PR China
| | - Hui Chen
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, PR China; School of Medicine, Southeast University, Nanjing, Jiangsu, PR China; Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, PR China; Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, PR China.
| | - Yun-Feng Rui
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, PR China; School of Medicine, Southeast University, Nanjing, Jiangsu, PR China; Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, PR China; Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, PR China.
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Isolated injuries to the lateral ankle ligaments have no direct effect on syndesmotic stability. Knee Surg Sports Traumatol Arthrosc 2022; 30:3881-3887. [PMID: 35523878 DOI: 10.1007/s00167-022-06985-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 04/11/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE This study aim was to detect the impact of lateral ankle ligaments injury on syndesmotic laxity when evaluated arthroscopically in a cadaveric model. The null hypothesis was that lateral ankle ligament injury does not affect the stability of syndesmosis. METHODS Sixteen fresh-frozen above-knee amputated cadaveric specimens were divided into two groups of eight specimens that underwent arthroscopic evaluation of the distal tibiofibular joint. In both the groups, the assessment was first done with all syndesmotic and ankle ligaments intact. Thereafter, Group 1 underwent sequential transection of the three lateral ankle ligaments first to identify the effects of lateral ligament injury: (1) anterior talofibular ligament (ATFL), (2) calcaneofibular ligament (CFL), (3) posterior talofibular ligament (PTFL), then followed by the syndesmotic ligaments, (4) AITFL, (5) Interosseous ligament (IOL), and (6) PITFL. Group 2 underwent sequential transection of the (1) AITFL, (2) ATFL, (3) CFL, (4) IOL, (5) PTFL, and (6) PITFL, which represent the most commonly injured pattern in ankle sprain. In all scenarios, four loading conditions were considered under 100 N of direct force: (1) unstressed, (2) a lateral fibular hook test, (3) anterior to posterior (AP) fibular translation test, and (4) posterior to anterior (PA) fibular translation test. Distal tibiofibular coronal plane diastasis at the anterior and posterior third of syndesmosis, as well as AP and PA sagittal plane translation, were arthroscopically measured. RESULTS The distal tibiofibular joint remained stable after transection of all lateral ankle ligaments (ATFL, CFL, and PTFL) as well as the AITFL. However, after additional transection of the IOL, the syndesmosis became unstable in both the coronal and sagittal plane. Syndesmosis laxity in the coronal plane was also observed after transection of the ATFL, CFL, AITFL, and IOL. Subsequent transection of the PITFL precipitated syndesmosis laxity in the sagittal plane, as well. CONCLUSIONS The findings from the present study suggest that lateral ankle ligament injuries itself do not directly affect the stability of syndesmosis. However, if it combines with IOL injuries, even partial injuries cause syndesmotic laxity. As a clinical relevance, accurate diagnosis is the key for surgeons to determine syndesmosis fixation whether there is only AITFL injury or combined IOL injury in concomitant acute syndesmotic and lateral ligament injury.
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11
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Spindler FT, Herterich V, Holzapfel BM, Böcker W, Polzer H, Baumbach SF. A systematic review and meta-analysis on the value of the external rotation stress test under fluoroscopy to detect syndesmotic injuries. EFORT Open Rev 2022; 7:671-679. [PMID: 36287127 PMCID: PMC9619390 DOI: 10.1530/eor-22-0037] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Purpose Methods Results Conclusion
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Affiliation(s)
- F T Spindler
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
| | - V Herterich
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
| | - B M Holzapfel
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
| | - W Böcker
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
| | - H Polzer
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany,Correspondence should be addressed to H Polzer;
| | - S F Baumbach
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
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12
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Hagemeijer NC, Lubberts B, Saengsin J, Bhimani R, Sato G, Waryasz GR, Kerkhoffs GMMJ, DiGiovanni CW, Guss D. Portable dynamic ultrasonography is a useful tool for the evaluation of suspected syndesmotic instability: a cadaveric study. Knee Surg Sports Traumatol Arthrosc 2022; 31:1986-1993. [PMID: 35881148 PMCID: PMC10089982 DOI: 10.1007/s00167-022-07058-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 06/20/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE Portable ultrasonography (P-US) is increasingly used to diagnose syndesmotic instability. The aim of this study was to evaluate syndesmotic instability by measuring the distal tibiofibular clear space (TFCS) in a cadaveric model using P-US with progressive stages of syndesmotic ligamentous transection under external rotation stress. METHODS Ten fresh lower leg cadaveric specimens amputated above the proximal tibiofibular joint were used. Using P-US, the TFCS was evaluated in the intact stage and after progressive sectioning of the (1) anterior-inferior tibiofibular ligament (AITFL), (2) interosseous ligament (IOL), and (3) posterior-inferior tibiofibular ligament (PITFL). The TFCS was measured in both the unstressed (0 Nm) state and with 4.5, 6.0, 7.5, and 9.0 Nm of external rotation stress using a bone hook placed on the first metatarsal bone at each stage of ligamentous transection stage using both P-US and fluoroscopy. RESULTS When assessed with P-US, partial syndesmotic injury encompassing the AITFL and IOL resulted in significant TFCS widening at 4.5 Nm of external rotation torque when compared to intact state with a TFCS-opening of 2.6 ± 2 mm, p = 0.01. In contrast, no significant differences in TFCS were detected using fluoroscopy. Only a moderate correlation was found between P-US and fluoroscopy. CONCLUSION P-US is a useful tool in diagnosing syndesmotic instability during external rotation stress examination. TFCS-opening increased as additional ligaments of the syndesmosis were transected, and application of 4.5 Nm torque was sufficient to detect a difference of 2.6 mm after the IOL cut.
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Affiliation(s)
- N C Hagemeijer
- Foot and Ankle Research and Innovation Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, USA. .,Department of Orthopaedic Surgery and Sports Medicine, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Zuidoost, 1105 AZ, Amsterdam, The Netherlands. .,Amsterdam Collaboration for Health and Safety in Sports (ACHSS), IOC Research Center, Amsterdam, the Netherlands. .,Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
| | - B Lubberts
- Foot and Ankle Research and Innovation Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, USA.,Amsterdam Collaboration for Health and Safety in Sports (ACHSS), IOC Research Center, Amsterdam, the Netherlands
| | - J Saengsin
- Foot and Ankle Research and Innovation Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, USA.,Department of Orthopaedic Surgery, Faculty of Medicine, Chiang Mai University, 110 Inthawarorot, Sri Phum subdistrict, Mueang Chiang Mai District, Chiang Mai 50200, Chiang Mai, Thailand.,Amsterdam Collaboration for Health and Safety in Sports (ACHSS), IOC Research Center, Amsterdam, the Netherlands
| | - R Bhimani
- Foot and Ankle Research and Innovation Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, USA.,Amsterdam Collaboration for Health and Safety in Sports (ACHSS), IOC Research Center, Amsterdam, the Netherlands
| | - G Sato
- Foot and Ankle Research and Innovation Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, USA.,Amsterdam Collaboration for Health and Safety in Sports (ACHSS), IOC Research Center, Amsterdam, the Netherlands
| | - G R Waryasz
- Foot and Ankle Research and Innovation Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, USA.,Foot and Ankle Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Yawkey Building, 55 Fruit St, Boston, MA, 02114, USA.,Amsterdam Collaboration for Health and Safety in Sports (ACHSS), IOC Research Center, Amsterdam, the Netherlands
| | - G M M J Kerkhoffs
- Department of Orthopaedic Surgery and Sports Medicine, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Zuidoost, 1105 AZ, Amsterdam, The Netherlands.,Newton-Wellesley Hospital, Harvard Medical School, Massachusetts General Hospital, 2014 Washington St, Newton, MA, 02462, USA.,Academic Center for Evidence Based Sports Medicine (ACES), Academic Medical Centre Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.,Amsterdam Collaboration for Health and Safety in Sports (ACHSS), IOC Research Center, Amsterdam, the Netherlands
| | - C W DiGiovanni
- Foot and Ankle Research and Innovation Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, USA.,Foot and Ankle Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Yawkey Building, 55 Fruit St, Boston, MA, 02114, USA.,Newton-Wellesley Hospital, Harvard Medical School, Massachusetts General Hospital, 2014 Washington St, Newton, MA, 02462, USA.,Amsterdam Collaboration for Health and Safety in Sports (ACHSS), IOC Research Center, Amsterdam, the Netherlands
| | - D Guss
- Foot and Ankle Research and Innovation Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, USA.,Foot and Ankle Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Yawkey Building, 55 Fruit St, Boston, MA, 02114, USA.,Newton-Wellesley Hospital, Harvard Medical School, Massachusetts General Hospital, 2014 Washington St, Newton, MA, 02462, USA.,Amsterdam Collaboration for Health and Safety in Sports (ACHSS), IOC Research Center, Amsterdam, the Netherlands
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13
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Ingall EM, Kaiser P, Ashkani-Esfahani S, Zhao J, Kwon JY. The Lateral Fibular Stress Test: High Variability of Force Applied by Orthopaedic Surgeons in a Biomechanical Model. FOOT & ANKLE ORTHOPAEDICS 2022; 7:24730114221106484. [PMID: 35770144 PMCID: PMC9234856 DOI: 10.1177/24730114221106484] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background: The lateral fibular stress test (LFST), also known as the hook or Cotton
test, is commonly performed to assess syndesmotic instability
intraoperatively. Several studies have used 100 N as the force applied when
performing the LFST to detect syndesmotic instability, though no
evidence-based requisite force has been described for the test. We
hypothesize that surgeons do not apply force uniformly or consistently when
performing the LFST and that substantial variation exists. Fundamentally,
this could lead to inconsistent diagnosis of syndesmotic instability as
surgeons may not be applying the force in a consistent manner. Methods: A biomechanical ankle model consisting of an industrial force gauge attached
through a SawBones model was fashioned. Orthopaedic attending surgeons and
trainees were asked to perform a series of LFSTs and to simulate the force
they typically apply intraoperatively. Basic demographic data were collected
on each participant. Results: Thirty-three surgeons participated in the study, including 18 trainees. The
median (IQR) force applied during the LFST was 96.42 (71.42-126.33), 87.49
(69.19-117.40), 99.99 (79.91-137.49), for the pooled group, attendings, and
trainees respectively. More than half (54.5%) of all trials were less than
100 N (57.8% of surgeons, 51.8% trainees). Intraobserver correlation was
excellent within the overall cohort (0.92, P < .001),
trainees (0.90, P < .001), and attendings (0.94,
P < .001), respectively. Interobserver reliability
was fair among the overall cohort (κ =0.28, P = .49), and
poor between the attendings (κ = 0.11, P = .69) and the
trainees (κ = 0.05, P = .82), respectively. Conclusion: Our study demonstrates that the amount of force applied by typical surgeons
when performing the LFST test is highly variable. Variable force application
when performing the LFST may lead to inconsistent detection of syndesmotic
instability, which may portend a poorer outcome. Clinical Relevance: In this study, we demonstrate the wide variability in the amount of force
used during a lateral fibular stress test. High variability of force
application when performing the LFST may lead to inconsistent diagnosis of
syndesmotic instability, which may portend a poorer outcome. Our findings
suggest the need for further investigation into the technical aspects of
syndesmotic testing that will permit more reproducible and valid
interrogation of the syndesmosis.
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Affiliation(s)
- Eitan M. Ingall
- Harvard Combined Orthopaedic Residency Program, Massachusetts General Hospital, Boston, MA, USA
| | - Philip Kaiser
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Soheil Ashkani-Esfahani
- Foot & Ankle Research and Innovation Laboratory (FARIL), Massachusetts General Hospital, Boston, MA, USA
| | - John Zhao
- Harvard Combined Orthopaedic Residency Program, Massachusetts General Hospital, Boston, MA, USA
| | - John Y. Kwon
- Department of Orthopaedic Surgery, Division of Foot and Ankle Surgery, Massachusetts General Hospital, Boston, MA, USA
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14
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Beak JS, Kim YT, Lee SH. Predisposing Factors for Posttraumatic Osteoarthritis After Malleolus Fracture Fixation in Patients Younger Than 50 Years. Foot Ankle Int 2022; 43:389-397. [PMID: 34677107 DOI: 10.1177/10711007211050039] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to identify the risk factors for posttraumatic osteoarthritis (OA) after surgery for ankle fractures in patients aged ≤50 years. METHODS We performed a retrospective review of consecutive patients who underwent surgery for ankle fractures and were followed up for a minimum period of 5 years. The patients were assigned to 2 groups according to the presence of advanced OA at the last follow-up. Binary logistic regression was used to model the correlation between risk factors and OA. Functional outcomes were assessed using the Foot and Ankle Outcome Score. RESULTS The data of 332 patients who met the inclusion criteria were included in the analysis. The overall rate of posttraumatic arthritis was 27.7% (nonarthritis group: 240 patients, arthritis group: 92 patients). The arthritic change was significantly affected by BMI (95% confidence interval [CI] 1.29-19.76; adjusted odds ratio [OR] ≥ 30, 6.56), fracture-dislocation injury (CI 1.66-11.57; adjusted OR, 4.06), posterior malleolus (PM) fracture (CI 1.92-12.73, adjusted OR > 25% of the articular surface, 5.72), and postoperative articular incongruence (CI 1.52-18.10; adjusted OR, 7.21). The mean scores of the arthritis group were lower than those in the nonarthritis group (P < .05). CONCLUSION Obesity, fracture-dislocation injury, concomitant large PM fracture, and articular incongruence were risk factors of posttraumatic OA after surgery for ankle fractures. Surgeons should be aware that accurate reduction is critical in patients with ankle fractures with associated large PM fractures, especially those with obesity or severe initial injuries such as fracture-dislocation. LEVEL OF EVIDENCE Level III, case control study.
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Affiliation(s)
- Jong Seok Beak
- Department of Orthopedic Surgery, School of Medicine, Wonkwang University Hospital, Iksan, Republic of Korea
| | - Yeong Tae Kim
- Department of Orthopedic Surgery, School of Medicine, Wonkwang University Hospital, Iksan, Republic of Korea
| | - Sung Hyun Lee
- Department of Orthopedic Surgery, School of Medicine, Wonkwang University Hospital, Iksan, Republic of Korea
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15
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Hennings R, Spiegl UJ, Fuchs C, Hepp P, Fakler JKM, Ahrberg AB. Does the orientation of syndesmosis fixative device affect the immediate reduction of the distal tibiofibular joint? Arch Orthop Trauma Surg 2022; 142:3213-3220. [PMID: 34363523 PMCID: PMC9522764 DOI: 10.1007/s00402-021-04073-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 07/13/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Incongruent stabilization of the distal tibiofibular joint (syndesmosis) results in poorer long-term outcome in malleolar fractures. The aim was to analyze whether the orientation of the syndesmotic stabilization would affect the immediate reduction imaged in computed tomography (CT). MATERIALS AND METHODS The syndesmotic congruity in 114 ankle fractures with stabilization of the syndesmosis were retrospectively analyzed in the post-operative bilateral CT scans. The incisura device angle (IDA) was defined and correlated with the side-to-side difference of Leporjärvi clear-space (ΔLCS), anterior tibiofibular distance (ΔantTFD) and Nault talar dome angle (ΔNTDA) regardless of the stabilization technique and separately for suture button system and syndesmotic screw. Asymmetric reduction was defined as ΔLCS > 2 mm and |ΔantTFD|> 2 mm. RESULTS Regardless of the stabilization technique, no correlation between the IDA and the ΔLCS (r = 0.069), the ΔantTFD (r = 0.019) nor the ΔNTDA (r = 0.177) could be observed. There were no differences between suture button system and syndesmotic screw. Asymmetrical reduction was detected in 46% of the cases, while sagittal asymmetry was most common. No association was found between the orientation of stabilization device and occurrence of asymmetrical reduction (p > 0.05). The results of suture button system and syndesmotic screw were comparable in this respect (p > 0.05). CONCLUSION Poor correlation between the orientation of the stabilization device and the immediate post-operative congruity of the syndesmosis could be shown. In contrast to current literature, this study did not show difference of suture button system over syndesmotic screw in this regard. Careful adjustment of the fibula in anteroposterior orientation should be given special attention.
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Affiliation(s)
- Robert Hennings
- Department of Orthopaedics, Traumatology and Plastic Surgery, University of Leipzig, Liebigstr. 20, 04103 Leipzig, Saxony Germany
| | - Ulrich J. Spiegl
- Department of Orthopaedics, Traumatology and Plastic Surgery, University of Leipzig, Liebigstr. 20, 04103 Leipzig, Saxony Germany
| | - Carolin Fuchs
- Department of Orthopaedics, Traumatology and Plastic Surgery, University of Leipzig, Liebigstr. 20, 04103 Leipzig, Saxony Germany
| | - Pierre Hepp
- Department of Orthopaedics, Traumatology and Plastic Surgery, University of Leipzig, Liebigstr. 20, 04103 Leipzig, Saxony Germany
| | - Johannes K. M. Fakler
- Department of Orthopaedics, Traumatology and Plastic Surgery, University of Leipzig, Liebigstr. 20, 04103 Leipzig, Saxony Germany
| | - Annette B. Ahrberg
- Department of Orthopaedics, Traumatology and Plastic Surgery, University of Leipzig, Liebigstr. 20, 04103 Leipzig, Saxony Germany
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16
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Diagnosis and Treatment of Syndesmotic Unstable Injuries: Where We Are Now and Where We Are Headed. J Am Acad Orthop Surg 2021; 29:985-997. [PMID: 34478409 DOI: 10.5435/jaaos-d-20-01350] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 07/24/2021] [Indexed: 02/01/2023] Open
Abstract
Up to 10% of ankle sprains are considered "high ankle" sprains with associated syndesmotic injury. Initial diagnosis of syndesmotic injury is based on physical examination, but further evaluation of the distal tibiofibular joint in the sagittal, coronal, and rotational planes is necessary to determine instability. Imaging modalities including weight-bearing CT and ultrasonography allow a physiologic and dynamic assessment of the syndesmosis. These modalities in turn provide the clinician useful information in two and three dimensions to identify and consequently treat syndesmotic instability, especially when subtle. Because there is notable variability in the shape of the incisura between individuals, contralateral comparison with the uninjured ankle as an optimal internal control is advised. Once syndesmotic instability is identified, surgical treatment is recommended. Several fixation methods have been described, but the foremost aspect is to achieve an anatomic reduction. Identifying any associated injuries and characteristics of the syndesmotic instability will lead to the appropriate treatment that restores the anatomy and stability of the distal tibiofibular joint.
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17
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Bejarano-Pineda L, Guss D, Waryasz G, DiGiovanni CW, Kwon JY. The Syndesmosis, Part I: Anatomy, Injury Mechanism, Classification, and Diagnosis. Orthop Clin North Am 2021; 52:403-415. [PMID: 34538351 DOI: 10.1016/j.ocl.2021.05.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Ankle fractures are common injuries to the lower extremity with approximately 20% sustaining a concomitant injury to the syndesmosis. Although the deltoid ligament is not formally included in the syndesmotic complex, it plays an important role in the mortise stability. Therefore, its integrity should be always evaluated when syndesmotic injury is suspected. Given the anatomic variability of the syndesmosis between individuals, bilateral ankle imaging is recommended, especially in cases of subtle instability. Diagnostic tests that allow dynamic assessment of the distal tibiofibular joint in the 3 planes are the most reliable in determining the presence of syndesmotic injury.
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Affiliation(s)
- Lorena Bejarano-Pineda
- Foot & Ankle Research and Innovation Laboratory - Harvard Medical School, Division of Foot and Ankle Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital - Newton-Wellesley Hospital, 40 2nd Avenue Building 52, Suite 1150, Waltham, MA 02451, USA; Foot & Ankle Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, 40 2nd Avenue Building 52, Suite 1150, Waltham, MA 02451, USA
| | - Daniel Guss
- Foot & Ankle Research and Innovation Laboratory - Harvard Medical School, Division of Foot and Ankle Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital - Newton-Wellesley Hospital, 40 2nd Avenue Building 52, Suite 1150, Waltham, MA 02451, USA; Foot & Ankle Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, 40 2nd Avenue Building 52, Suite 1150, Waltham, MA 02451, USA
| | - Gregory Waryasz
- Foot & Ankle Research and Innovation Laboratory - Harvard Medical School, Division of Foot and Ankle Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital - Newton-Wellesley Hospital, 40 2nd Avenue Building 52, Suite 1150, Waltham, MA 02451, USA; Foot & Ankle Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, 40 2nd Avenue Building 52, Suite 1150, Waltham, MA 02451, USA
| | - Christopher W DiGiovanni
- Foot & Ankle Research and Innovation Laboratory - Harvard Medical School, Division of Foot and Ankle Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital - Newton-Wellesley Hospital, 40 2nd Avenue Building 52, Suite 1150, Waltham, MA 02451, USA; Foot & Ankle Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, 40 2nd Avenue Building 52, Suite 1150, Waltham, MA 02451, USA
| | - John Y Kwon
- Foot & Ankle Research and Innovation Laboratory - Harvard Medical School, Division of Foot and Ankle Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital - Newton-Wellesley Hospital, 40 2nd Avenue Building 52, Suite 1150, Waltham, MA 02451, USA; Foot & Ankle Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, 40 2nd Avenue Building 52, Suite 1150, Waltham, MA 02451, USA.
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18
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Lee SH, Cho HG, Yang JH. Predisposing factors for chronic syndesmotic instability following syndesmotic fixation in ankle fracture: Minimum 5-year follow-up outcomes. Foot Ankle Surg 2021; 27:777-783. [PMID: 34583831 DOI: 10.1016/j.fas.2020.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 09/06/2020] [Accepted: 10/05/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND This study aimed to identify risk factors for chronic syndesmotic instability following syndesmotic fixation. METHODS We performed a retrospective review of consecutive patients who had sustained ankle fractures requiring syndesmotic fixation. Patients available for a minimum 5 years of follow-up were classified into 2 groups according to the presence of syndesmotic instability. Statistical binary logistic regression analyses were performed to investigate the significance of various risk factors. Functional outcomes were assessed using the FAOS. RESULTS In total, 166 patients who met the study inclusion criteria underwent analysis. The overall postoperative instability rate was 20.5%, which was significantly affected due to BMI (p = 0.018; OR 6.72), and concomitant posterior malleolar fracture (p = 0.032, OR 2.77). The mean scores in the syndesmotic instability (SI) group were significantly lower than those in the no syndesmotic instability (NSI) group (p = 0.021). CONCLUSIONS Obesity and concomitant posterior malleolar fracture were significant risk factors for postoperative syndesmotic instability.
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Affiliation(s)
- Sung Hyun Lee
- Department of Orthopedic Surgery, Wonkwang University Hospital, 895, Muwang-Ro, Iksan 54538, Republic of Korea.
| | - Hyung Gyu Cho
- Department of Orthopedic Surgery, Wonkwang University Hospital, 895, Muwang-Ro, Iksan 54538, Republic of Korea
| | - Je Heon Yang
- Department of Orthopedic Surgery, Wonkwang University Hospital, 895, Muwang-Ro, Iksan 54538, Republic of Korea
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The Impact of Suture Button Removal in Syndesmosis Fixation. J Clin Med 2021; 10:jcm10163726. [PMID: 34442022 PMCID: PMC8397003 DOI: 10.3390/jcm10163726] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Revised: 08/17/2021] [Accepted: 08/19/2021] [Indexed: 11/26/2022] Open
Abstract
The suture button (SB) device was introduced to negate the need for routine hardware removal in the treatment of syndesmosis injuries. However, a considerable SB removal rate has been reported, and the impact of removal is unknown. This study aimed to evaluate the radiographic and clinical outcomes after removal of SB for syndesmosis fixation. A total of 36 patients who underwent removal surgery after syndesmosis fixation using SB were identified. The mean postoperative time to removal was 12.2 months. On a plain radiograph, tibiofibular clear space (TFCS) was measured and compared at three follow-up time points. In patients with computed tomography (CT) imaging (n = 18), the anterior-to-posterior (A/P) ratio was measured to evaluate changes in quality of reduction. Additionally, clinical outcomes were assessed. There were no significant differences in TFCS between the three follow-up periods. None of the patients exhibited recurrent diastasis after SB removal. Although CT analysis demonstrated malreduction in six patients (33.3%), five of six patients had a subsequent spontaneous reduction of the syndesmosis. Clinically, all patients described the resolution of symptoms related to painful hardware at the final follow-up. Our results demonstrate that SB removal at one year following syndesmosis fixation leads to improved clinical symptoms without negatively impacting the quality of syndesmosis reduction.
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20
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Rogero RG, Illical EM, Corr DO, Raikin SM, Krieg JC, Tsai J. Management of Ankle Fractures With Syndesmotic Disruption: A Survey of Orthopaedic Surgeons. Cureus 2021; 13:e16391. [PMID: 34408944 PMCID: PMC8363056 DOI: 10.7759/cureus.16391] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction: With no current “gold standard” fixation strategy for syndesmotic injuries and differences in preferred preoperative and intraoperative diagnostic techniques and criteria, methods of reduction, fixation constructs, and postoperative management, the goals of this study were to determine how orthopaedic surgeons currently manage ankle fractures with concomitant syndesmotic disruption, as well as to identify surgeon demographics predictive of syndesmotic management techniques. Methods: This study was conducted as a web-based survey of foot and ankle fellowship-trained surgeons, Orthopaedic Trauma Association (OTA) members, and Canadian Orthopaedic Association (COA) members. The survey, sent and completed via the HIPAA-compliant Research Electronic Data Capture (REDCap) system, consisted of 18 questions: 6 surgeon demographic questions and 12 specific syndesmotic management questions regarding perioperative protocols and syndesmotic fixation construct techniques. Results: One hundred and ten orthopaedic surgeons completed our survey. Years of practice and type of fellowship were found to be the variables that influenced perioperative syndesmotic management strategies the most, while a number of fractures operated on per year, country of practice, and practice setting also influenced management decisions. Additionally, 59% (65/110) surgeons indicated that the way they have managed syndesmotic injuries has changed at some point in their career, while 33% (36/110) specified that they could foresee themselves changing their management of these injuries in the future. Conclusions: There was significant variability among responders in preoperative and intraoperative assessment technique, fixation construct, screw removal protocol, and postoperative weightbearing protocol. This study raises awareness of differences in and factors predictive of management strategies and should be used for further discussion when determining a potential gold standard for the management of these complex injuries.
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Affiliation(s)
- Ryan G Rogero
- Orthopaedic Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, USA.,Orthopaedic Surgery, Rothman Orthopaedic Institute, Philadelphia, USA
| | | | - Daniel O Corr
- Foot and Ankle Surgery, Rothman Orthopaedic Institute, Philadelphia, USA
| | - Steven M Raikin
- Orthopaedic Surgery, Rothman Orthopaedic Institute, Philadelphia, USA
| | - James C Krieg
- Orthopaedic Surgery, Rothman Orthopaedic Institute, Philadelphia, USA
| | - Justin Tsai
- Orthopaedic Surgery, Rothman Orthopaedic Institute, New York, USA
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21
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Arthroscopic characterization of syndesmotic instability in the coronal plane: Exactly what measurement matters? Injury 2021; 52:1964-1970. [PMID: 33883076 DOI: 10.1016/j.injury.2021.04.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 03/20/2021] [Accepted: 04/05/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Although ankle arthroscopy is increasingly used to diagnose syndesmotic instability, precisely where in the incisura one should measure potential changes in tibiofibular space or how much tibiofibular space is indicative of instability, however, remains unclear. The purpose of this study was to determine where within the incisura one should assess coronal plane syndesmotic instability and what degree of tibiofibular space correlates with instability in purely ligamentous syndesmotic injuries under condition of lateral hook stress test (LHT) assessment. METHODS Ankle arthroscopy was performed on 22 cadaveric specimens, first with intact ankle ligaments and then after sequential sectioning of the syndesmotic and deltoid ligaments. At each step, a 100N lateral hook test was applied through a lateral incision 5 cm proximal to the ankle joint and the coronal plane tibiofibular space in the stressed and unstressed states were measured at both anterior and posterior third of the distal tibiofibular joint, using calibrated probes ranging from 0.1 to 6.0 mm, in 0.1 mm of increments. The anterior and posterior points of measurements were defined as the junction between the anterior and middle third, and junction between posterior and middle third of the incisura, respectively. RESULTS Anterior third tibiofibular space measurements did not correlate significantly with the degree of syndesmotic instability after transection of the ligaments, neither before nor after applying LHT at all the three groups of different sequences of ligament transection (P range 0.085-0.237). In contrast, posterior third tibiofibular space measurements correlated significantly with the degree of syndesmotic instability after transection of the ligaments, both with and without applying stress in all the groups of different ligament transection (P range <0.001-0.015). Stressed tibiofibular space measurements of the posterior third showed higher sensitivity and specificity when compared to the stressed anterior third measurements. Using 2.7 mm as a cut off for posterior third stressed measurements has both sensitivity and specificity about 70 %. CONCLUSION Syndesmotic ligament injury results in coronal plane instability of the distal tibiofibular articulation that is readily identified arthroscopically with LHT when measured in the posterior third of the incisura. CLINICAL RELEVANCE When applying LHT, tibiofibular space measurement for coronal plane instability along the anterior third of the incisura is less sensitive for identifying syndesmotic instability and may miss this diagnosis especially when subtle.
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22
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Comparison between cotton test and tap test for the assessment of coronal syndesmotic instability: A cadaveric study. Injury 2021; 52 Suppl 3:S84-S88. [PMID: 34088466 DOI: 10.1016/j.injury.2021.02.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 02/06/2021] [Accepted: 02/09/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION In surgically treated rotational malleolar fractures, residual syndesmotic instability is typically assessed following fixation with the widely used intraoperative Cotton test. However, due to its dynamic nature, there are inconsistencies of the magnitude and direction of the distraction force when attempting to pull the fibula away from the tibia using a bone hook. The novel Tap test advances a cortical tap through a drilled hole in the fibula with a stable, unidirectional distraction force applied to the tibia. The objective of this cadaveric study was to compare the Cotton and Tap tests as diagnostic tools for coronal plane syndesmotic instability. METHODS Tibiofibular Clear Space (TFCS) of 10 cadaveric specimens was measured for: intact, non-stressed; intact, stressed; injured, non-stressed; and injured, stressed (Tap and Cotton tests). In injured conditions, the syndesmotic ligamentous complex was sectioned using an anterolateral longitudinal approach. Perfect fluoroscopic Mortise images were acquired for all conditions. Two independent and blinded Orthopaedic Foot and Ankle Surgeons measured TFCS 1 cm proximal to the ankle joint line. Intra and interobserver reliabilities were assessed by Intraclass Correlation Coefficient. Syndesmotic TFCS values for all conditions were compared by paired Wilcoxon. Diagnostic performance of the Cotton and Tap tests was assessed using a relative increase of TFCS > 2 mm when comparing intact stressed and injured stressed conditions. P-values <0.05 were considered significant. RESULTS The intraclass correlation coefficient for intraobserver and interobserver reliability was respectively 0.96 and 0.79. TFCS measurements were similar in intact non-stressed, intact stressed (both Cotton and Tap tests) and injured non-stressed conditions, with mean values and 95% Confidence Intervals of: intact non-stressed, 3.5 mm; intact stressed, 3.6 mm (Cotton test) and 4.0 mm (Tap test); injured non-stressed, 3.8 mm. The Cotton test and Tap test had, respectively, 73.3% and 70% sensitivity, 100% and 90% specificity, 86.7% and 80% diagnostic accuracy. CONCLUSIONS Our cadaveric study compared the Cotton and Tap tests for detection of coronal plane syndesmotic instability. Both tests demonstrated similar increases in the TFCS measurements in stressed injured conditions when compared to intact non-stressed and stressed conditions, as well as injured non-stressed conditions.
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23
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Connors JC, Grossman JP, Zulauf EE, Coyer MA. Syndesmotic Ligament Allograft Reconstruction for Treatment of Chronic Diastasis. J Foot Ankle Surg 2021; 59:835-840. [PMID: 32111408 DOI: 10.1053/j.jfas.2020.01.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Accepted: 01/12/2020] [Indexed: 02/03/2023]
Abstract
Chronic diastasis after a syndesmotic injury can lead to ankle joint instability and loss of joint congruence. Failure to restore the fibula into the proper anatomic position within the incisura increases the focal stress on the talus and can accelerate degenerative joint destruction. In the case of failed syndesmotic repair, fixation options are limited. If promptly diagnosed, the syndesmosis may be amenable to open debridement and subsequent fixation with 2 interosseous screws. If latent diastasis is found, however, syndesmotic fusion by bone block arthrodesis is recommended. We present a syndesmotic allograft repair technique for surgical reconstruction of chronic unstable syndesmotic ruptures.
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Affiliation(s)
- James C Connors
- Assistant Professor, Division of Foot/Ankle Surgery and Biomechanics, Kent State University College of Podiatric Medicine, Independence, OH.
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24
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Bhimani R, Lubberts B, Sornsakrin P, Massri-Pugin J, Waryasz G, DiGiovanni CW, Guss D. Do Coronal or Sagittal Plane Measurements Have the Highest Accuracy to Arthroscopically Diagnose Syndesmotic Instability? Foot Ankle Int 2021; 42:805-809. [PMID: 33890514 DOI: 10.1177/10711007211004151] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND To compare the accuracy of arthroscopic sagittal versus coronal plane distal tibiofibular motion toward diagnosing syndesmotic instability. METHODS Arthroscopic assessment of the syndesmosis was performed on 21 above-knee cadaveric specimens, first with all ligaments intact and subsequently with sequential transection of the anterior inferior tibiofibular ligament, the interosseous ligament, the posterior inferior tibiofibular ligament, and the deltoid ligament. A lateral hook test, an anterior-to-posterior (AP) translation test, and a posterior-to-anterior (PA) translation test were performed under 100 N of applied force. Anterior and posterior third coronal plane diastasis and AP and PA sagittal plane fibular translations were measured relative to the static tibia. RESULTS Receiver operating characteristic (ROC) curve analysis revealed that the area under the curve (AUC) was higher for the combined AP and PA sagittal measurements (AUC, 0.91; accuracy, 83.5%; sensitivity, 78%; specificity, 89%) than the coronal plane measurements (anterior third: AUC, 0.65; accuracy, 60.5%; sensitivity, 63%; specificity, 59%; posterior third: AUC, 0.73; accuracy, 68.5%; sensitivity, 80%; specificity, 57%) (P < .001), underscoring the higher accuracy of sagittal plane measurements. CONCLUSION Arthroscopic measurement of sagittal plane fibular translation is more accurate than coronal plane diastasis for evaluating syndesmotic instability. CLINICAL RELEVANCE Clinicians should focus on distal tibiofibular motion in the sagittal plane when arthroscopically evaluating suspected syndesmotic instability. LEVEL OF EVIDENCE Biomechanical cadaveric study.
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Affiliation(s)
- Rohan Bhimani
- Foot & Ankle Research and Innovation Laboratory, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Bart Lubberts
- Foot & Ankle Research and Innovation Laboratory, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Pongpanot Sornsakrin
- Foot & Ankle Research and Innovation Laboratory, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Jafet Massri-Pugin
- Foot & Ankle Research and Innovation Laboratory, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA.,Department of Orthopaedic Surgery, School of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Gregory Waryasz
- Foot & Ankle Research and Innovation Laboratory, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA.,Department of Orthopaedic Surgery, School of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile.,Foot & Ankle Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Christopher W DiGiovanni
- Foot & Ankle Research and Innovation Laboratory, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA.,Department of Orthopaedic Surgery, School of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile.,Foot & Ankle Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Daniel Guss
- Foot & Ankle Research and Innovation Laboratory, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA.,Department of Orthopaedic Surgery, School of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile.,Foot & Ankle Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA.,Newton-Wellesley Hospital, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
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25
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Kyriacou H, Mostafa AMHAM, Davies BM, Khan WS. Principles and guidelines in the management of ankle fractures in adults. J Perioper Pract 2021; 31:427-434. [PMID: 33826430 PMCID: PMC8575982 DOI: 10.1177/1750458920969029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Ankle fractures are common injuries that have many physical and psychosocial complications. As a result, it is important to be aware of how these patients present and are managed perioperatively. Detailed guidelines from NICE and the British Orthopaedic Association have been produced on this topic, including recent developments such as the decision to weight-bear early after surgery and the use of virtual fracture clinics. This article provides an overview of the key perioperative factors that need to be considered in cases of ankle fracture and the relevant clinical guidelines.
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Affiliation(s)
- Harry Kyriacou
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | | | - Benjamin M Davies
- Department of Trauma & Orthopaedics, Addenbrooke's Hospital, Cambridge, UK
| | - Wasim S Khan
- Department of Trauma & Orthopaedics, Addenbrooke's Hospital, Cambridge, UK
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26
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Spennacchio P, Seil R, Gathen M, Cucchi D. Diagnosing instability of ligamentous syndesmotic injuries: A biomechanical perspective. Clin Biomech (Bristol, Avon) 2021; 84:105312. [PMID: 33756400 DOI: 10.1016/j.clinbiomech.2021.105312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 02/26/2021] [Accepted: 03/02/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND High ankle sprains are insidious injuries associated with a long recovery period, functional impairment and long-term sequelae if mistreated. This systematic review investigates the biomechanical knowledge on the kinematic consequences of sequential syndesmotic ligamentous injuries, aiming to furnish an updated and objective contribution for the critical appraisal and further elaboration of current diagnostic algorithms for high ankle sprains. METHODS A systematic review was performed to identify human biomechanical studies evaluating the stabilizing role of the syndesmotic ligaments. Special attention was paid to identify the smallest lesion within the progressive simulated injuries able to provoke statistically significant changes of the syndesmotic kinematic on the specimen, the mechanical solicitation that provoked it, and the measurement methodology. FINDINGS Fourteen studies were included. In eight articles already an isolated injury to the anterior inferior tibiofibular ligament provoked significant changes of the syndesmotic kinematic, which was always depicted under an external rotation torque. In three articles an isolated deltoid ligament injury provoked significant changes of the syndesmotic kinematic. Four articles described a direct measure of the bony movements, whereas seven collected data through conventional radiography or CT-scan imaging and three via a 3D motion analysis tracking system. INTERPRETATION An isolated lesion of the anterior inferior tibiofibular ligament can provoke significant kinematic modifications in ex vivo syndesmotic models and may be responsible of subtle patterns of dynamic instability, regardless of further syndesmotic ligamentous injuries. The data observed support efforts to define reliable CT imaging parameters to improve non-invasive diagnostic of subtle forms of syndesmotic instability.
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Affiliation(s)
- Pietro Spennacchio
- Department of Orthopaedic Surgery, Centre Hospitalier de Luxembourg-Clinique d'Eich, Luxembourg, Luxembourg.
| | - Romain Seil
- Department of Orthopaedic Surgery, Centre Hospitalier de Luxembourg-Clinique d'Eich, Luxembourg, Luxembourg; Sports Medicine Research Laboratory, Luxembourg Institute of Health, Luxembourg, Luxembourg.
| | - Martin Gathen
- Department of Orthopaedics and Trauma Surgery, Universitätsklinikum Bonn, Venusberg-Campus 1, 53127 Bonn, Germany.
| | - Davide Cucchi
- Department of Orthopaedics and Trauma Surgery, Universitätsklinikum Bonn, Venusberg-Campus 1, 53127 Bonn, Germany.
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Souleiman F, Heilemann M, Hennings R, Hennings M, Klengel A, Hepp P, Osterhoff G, Ahrberg AB. A standardized approach for exact CT-based three-dimensional position analysis in the distal tibiofibular joint. BMC Med Imaging 2021; 21:41. [PMID: 33676399 PMCID: PMC7937306 DOI: 10.1186/s12880-021-00570-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 02/18/2021] [Indexed: 02/07/2023] Open
Abstract
Background Assessment of tibiofibular reduction presents an intra- and postoperative challenge. Numerous two-dimensional measurement methods have been described, most of them highly dependent on leg orientation and rater. Aim of the present work was to develop a standardized and orientation-independent 3D based method for the assessment of syndesmotic joint position. Methods In a retrospective single center study, 3D models of bilateral ankle joints, either after unilateral syndesmosis stabilization (operative group) or with no injury (native group) were superimposed (best fit matching) and aligned uniformly. Based on center of gravity calculations three orientation- and rater-independent parameters were determined: tibiofibular clears space (CS), vertical offset between both fibulae, and translation angle of the fibulae about tibia axis. Results Bilateral CT datasets of 57 native and 47 postoperative patients were analyzed. In the native group mean CS was 2.7 (SD, 0.8; range, 0.7–4.9) mm, mean CS side difference was 0.62 (SD, 0.45) mm and mean translation angle was 1.6 (SD, 1.4) degrees regarding absolute values. The operative group was found to show a significantly higher CS side difference of 0.88 (SD, 0.75) mm compared to native group (P = .046). Compared to the healthy contralateral side, operated fibulae showed mean proximal displacement of 0.56 (SD, 1.67) mm (P = .025), dorsal displacement of 1.5 (SD 4.1) degrees (P = .017). Conclusion By using 3D best fit matching, orientation- and rater-dependent errors can be minimized. Large interindividual and small intraindividual differences of uninjured couples support previous recommendations for bilateral imaging. Trial registration: AZ 131/18-ek; AZ 361/19-ek Level of evidence Level III.
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Affiliation(s)
- Firas Souleiman
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany.
| | - Martin Heilemann
- ZESBO - Centre for Research On Musculoskeletal Systems, University of Leipzig, Leipzig, Germany
| | - Robert Hennings
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Mareike Hennings
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Alexis Klengel
- Department of Radiology, University Hospital Leipzig, Leipzig, Germany
| | - Pierre Hepp
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Georg Osterhoff
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Annette B Ahrberg
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
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Yang TC, Tzeng YH, Wang CS, Lin CC, Chang MC, Chiang CC. Untreated small posterior fragment of ankle fracture with early removal of syndesmotic screw is associated with recurrent syndesmotic instability. Injury 2021; 52:638-643. [PMID: 33051073 DOI: 10.1016/j.injury.2020.10.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 09/08/2020] [Accepted: 10/06/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION This retrospective study aimed to report outcomes of fixation of bi-malleolar or tri-malleolar fractures combined with syndesmotic injury with or without posterior malleolar fracture (PMF), and to ascertain whether syndesmotic screw removal at 6 to 8 weeks or 3 months postoperatively is more beneficial. METHODS We retrospectively reviewed patients who received open reduction and internal fixation for bi-malleolar (without PMF) or tri-malleolar ankle fracture (with PMF) with syndesmotic injury between January 2013 and December 2017 with at least 24 months of postoperative follow-up. All patients suffered syndesmotic instabilities and were treated using a syndesmotic screw without PMF fixation. Patients with bi-malleolar fracture with syndesmotic screw removal at 6 to 8 weeks postoperatively were included in Group I, tri-malleolar fracture with syndesmotic screw removal at 6 to 8 weeks in Group II, and tri-malleolar fracture with syndesmotic screw removal at 3 months in Group III. Demographic data, clinical and radiographic outcomes were analyzed. RESULTS A total of 113 patients were included (Group I, n=47; Group II, n=43; Group III, n=23). Average size of PMF was 14% in patients with tri-malleolar fractures (Groups II and III). No significant difference in ankle functional outcome among groups was observed. The recurrence rate of syndesmotic instability was 10.6% in Group I, 20.9% in Group II, and 8.7% in Group III. Although the difference in recurrence rates of syndesmotic instability among three groups was not statistically significant (P=0.264), Group II showed more interval change in tibiofibular clear space between initial postoperative radiographs and last follow-up radiographs (P=0.028) compared to the other two groups. Fracture union was achieved in all patients without screw breakage. CONCLUSION We suggest that the better timing for syndesmotic screw removal is 3 months, instead of 6 to 8 weeks postoperatively, to reduce the risk of recurrence of syndesmotic instability for tri-malleolar fracture without posterior fragment fixation. LEVEL OF EVIDENCE Level III- Case-control study.
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Affiliation(s)
- Tzu-Cheng Yang
- Division of Orthopaedic Trauma; Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, 201, Sec.2, Shih-Pai Rd. Taipei 112, Taiwan; Department of Orthopaedics, School of Medicine, National Yang-Ming University.
| | - Yun-Hsuan Tzeng
- Division of Medical Imaging for Health Management, Cheng-Hsin General Hospital; Department of Radiology, School of Medicine, National Yang-Ming University.
| | - Chien-Shun Wang
- Division of Orthopaedic Trauma; Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, 201, Sec.2, Shih-Pai Rd. Taipei 112, Taiwan; Department of Orthopaedics, School of Medicine, National Yang-Ming University.
| | - Chun-Cheng Lin
- Division of Orthopaedic Trauma; Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, 201, Sec.2, Shih-Pai Rd. Taipei 112, Taiwan; Department of Orthopaedics, School of Medicine, National Yang-Ming University.
| | - Ming-Chau Chang
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, 201, Sec.2, Shih-Pai Rd. Taipei 112, Taiwan; Department of Orthopaedics, School of Medicine, National Yang-Ming University.
| | - Chao-Ching Chiang
- Division of Orthopaedic Trauma; Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, 201, Sec.2, Shih-Pai Rd. Taipei 112, Taiwan; Department of Orthopaedics, School of Medicine, National Yang-Ming University.
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Cornu O, Manon J, Tribak K, Putineanu D. Traumatic injuries of the distal tibiofibular syndesmosis. Orthop Traumatol Surg Res 2021; 107:102778. [PMID: 33333279 DOI: 10.1016/j.otsr.2020.102778] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 05/15/2020] [Indexed: 02/03/2023]
Abstract
The distal tibiofibular syndesmosis (DTFS) is frequently injured during ankle trauma. The sequelae can be significant, including chronic instability, early osteoarthritis and residual pain. The aim of this study is to summarize the current state knowledge about these injuries by answering four questions. They frequently occur in the context of an ankle sprain (20-40% of cases) or during various types of ankle fractures (20-100% of cases). They cannot be ruled out based solely on fracture type and must be investigated when a fibular or posterior malleolar fracture is present. Clinical examination and imaging are essential but do not provide a definitive diagnosis. Ultrasonography, CT scan and MRI have high sensitivity, but their static nature does not allow a treatment strategy to be defined. Dynamic radiographs must be taken, either with load or during a procedure. If instability is detected, stabilization is the general rule. In fracture cases, reduction is achieved by restoring the length and rotation of the distal fibular fragment, preferably during an open procedure. In sprain cases, reduction is not a problem unless there is ligament interposition. Tibiofibular fixation is done 1.5 to 3cm from the talocrural joint, while ensuring the reduction is perfect. The main complication-non-healing of the syndesmosis-is attributed to poor initial reduction. This or functional discomfort during weight bearing will require removal of the fixation hardware. In most cases, this allows functional recovery and correction of the inadequate reduction. Persistence of instability will require ligament reconstruction or fusion of the syndesmosis. Chronic instability can lead to ankle osteoarthritis. LEVEL OF EVIDENCE: V, expert opinion.
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Affiliation(s)
- Olivier Cornu
- Service de chirurgie orthopédique et traumatologie, cliniques universitaires Saint-Luc UCL, université catholique de Louvain, Brussels, Belgium.
| | - Julie Manon
- Service de chirurgie orthopédique et traumatologie, cliniques universitaires Saint-Luc UCL, université catholique de Louvain, Brussels, Belgium
| | - Karim Tribak
- Service de chirurgie orthopédique et traumatologie, cliniques universitaires Saint-Luc UCL, université catholique de Louvain, Brussels, Belgium
| | - Dan Putineanu
- Service de chirurgie orthopédique et traumatologie, cliniques universitaires Saint-Luc UCL, université catholique de Louvain, Brussels, Belgium
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30
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Hagemeijer NC, Elghazy MA, Waryasz G, Guss D, DiGiovanni CW, Kerkhoffs GMMJ. Arthroscopic coronal plane syndesmotic instability has been over-diagnosed. Knee Surg Sports Traumatol Arthrosc 2021; 29:310-323. [PMID: 32451623 PMCID: PMC7862212 DOI: 10.1007/s00167-020-06067-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 05/14/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE Ankle arthroscopy is widely used for diagnosis of syndesmotic instability, especially in subtle cases. To date, no published article has systematically reviewed the literature in aggregate to understand which instability values should be used intraoperatively. The primary aim was to systematically review the amount of tibiofibular displacement that correlates with syndesmotic instability after a high ankle sprain. A secondary aim is to assess the quality of such research. METHODS Systematic searches of EMBASE (Ovid) and MEDLINE via PubMed, CINAHL, Web of Science, and Google Scholar were used. INCLUSION CRITERIA studies that arthroscopically evaluated the fibular displacement at various stages of syndesmotic ligament injury. Two reviewers independently extracted data and assessed methodological quality using the Anatomical Quality Assessment (AQUA) Tool and methodological index for non-randomized studies (MINORS). RESULTS Eight cadaveric studies and three clinical studies were included for review. All studies reported displacement in the coronal plane, four studies reported in the sagittal plane, and one reported findings in the rotational plane. Four cadaveric studies had a similar experimental set up and the weighted mean associated with instability in the coronal plane could be calculated and was 2.9 mm at the anterior portion of the distal tibiofibular joint and 3.4 mm at the posterior portion. Syndesmotic instability in the sagittal plane is less extensively studied, however available data from a cadaveric study suggests thresholds of 2.2 mm of posterior fibular translation when performing an anterior to posterior hook test and 2.6 mm of anterior fibular translation when performing a posterior to anterior hook test. CONCLUSIONS The results have concluded that the commonly used 2.0 mm threshold value of distal tibiofibular diastasis may lead to overtreatment of syndesmotic instability, and that using threshold values of 2.9 mm measured at the anterior portion of the incisura and 3.4 mm at the posterior portion may represent better cut off values. Given the ready availability of 3 mm probes among standard arthroscopic instrumentation, at the very least surgeons should use 3 mm in lieu of 2 mm probes intraoperatively. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Noortje C Hagemeijer
- Foot and Ankle Research and Innovation Lab, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA.
- Department of Orthopaedic Surgery, Amsterdam University Medical Center, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam Zuidoost, The Netherlands.
- Academic Center for Evidence Based Sports Medicine (ACES), Amsterdam, The Netherlands.
- Amsterdam Collaboration for Health and Safety in Sports (ACHSS), AMC/VUMC IOC Research Center, Amsterdam, The Netherlands.
| | - Mohamed Abdelaziz Elghazy
- Foot and Ankle Research and Innovation Lab, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
- Mansoura Faculty of Medicine, Mansoura University Hospital, Mansoura, Egypt
| | - Gregory Waryasz
- Foot and Ankle Research and Innovation Lab, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
- Foot and Ankle Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, USA
| | - Daniel Guss
- Foot and Ankle Research and Innovation Lab, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
- Foot and Ankle Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, USA
- Massachusetts General Hospital, Newton-Wellesley Hospital, Harvard Medical School, Boston, USA
| | - Christopher W DiGiovanni
- Foot and Ankle Research and Innovation Lab, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
- Foot and Ankle Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, USA
- Massachusetts General Hospital, Newton-Wellesley Hospital, Harvard Medical School, Boston, USA
| | - Gino M M J Kerkhoffs
- Department of Orthopaedic Surgery, Amsterdam University Medical Center, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam Zuidoost, The Netherlands
- Academic Center for Evidence Based Sports Medicine (ACES), Amsterdam, The Netherlands
- Amsterdam Collaboration for Health and Safety in Sports (ACHSS), AMC/VUMC IOC Research Center, Amsterdam, The Netherlands
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Stenquist D, Velasco BT, Cronin PK, Briceño J, Miller CP, Riedel MD, Kwon JY. Syndesmotic Fixation Utilizing a Novel Screw: A Retrospective Case Series Reporting Early Clinical and Radiographic Outcomes. Foot Ankle Spec 2020; 13:397-403. [PMID: 31353946 DOI: 10.1177/1938640019866322] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background. Syndesmotic disruption occurs in 20% of ankle fractures and requires anatomical reduction and stabilization to maximize outcomes. Although screw breakage is often asymptomatic, the breakage location can be unpredictable and result in painful bony erosion. The purpose of this investigation is to report early clinical and radiographic outcomes of patients who underwent syndesmotic fixation using a novel metal screw designed with a controlled break point. Methods. We performed a retrospective review of all patients who underwent syndesmotic fixation utilizing the R3lease Tissue Stabilization System (Paragon 28, Denver, CO) over a 12-month period. Demographic and screw-specific data were obtained. Postoperative radiographs were reviewed, and radiographic parameters were measured. Screw loosening or breakage was documented. Results. 18 patients (24 screws) met inclusion criteria. The mean follow-up was 11.7 months (range = 6.0-14.7 months). 5/24 screws (21%) fractured at the break point. No screw fractured at another location, nor did any fracture prior to resumption of weight bearing; 19 screws did not fracture, with 8/19 intact screws (42.1%) demonstrating loosening. There was no evidence of syndesmotic diastasis or mortise malalignment on final follow-up. No screws required removal during the study period. Conclusion. This study provides the first clinical data on a novel screw introduced specifically for syndesmotic fixation. At short-term follow up, there were no complications and the R3lease screw provided adequate fixation to allow healing and prevent diastasis. Although initial results are favorable, longer-term follow-up with data on cost comparisons and rates of hardware removal are needed to determine cost-effectiveness relative to similar implants.Level of Evidence: Level IV: Retrospective case series.
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Affiliation(s)
- Derek Stenquist
- Harvard Combinated Orthopaedic Surgery Residency Program, Massachusetts General Hospital, Boston, Massachusetts (DS, PKC).,Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (BTV, CPM, MDR, JYK).,Department of Orthopaedic Surgery, Pontificia Universidad de Chile, Santiago, Chile (JB)
| | - Brian T Velasco
- Harvard Combinated Orthopaedic Surgery Residency Program, Massachusetts General Hospital, Boston, Massachusetts (DS, PKC).,Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (BTV, CPM, MDR, JYK).,Department of Orthopaedic Surgery, Pontificia Universidad de Chile, Santiago, Chile (JB)
| | - Patrick K Cronin
- Harvard Combinated Orthopaedic Surgery Residency Program, Massachusetts General Hospital, Boston, Massachusetts (DS, PKC).,Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (BTV, CPM, MDR, JYK).,Department of Orthopaedic Surgery, Pontificia Universidad de Chile, Santiago, Chile (JB)
| | - Jorge Briceño
- Harvard Combinated Orthopaedic Surgery Residency Program, Massachusetts General Hospital, Boston, Massachusetts (DS, PKC).,Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (BTV, CPM, MDR, JYK).,Department of Orthopaedic Surgery, Pontificia Universidad de Chile, Santiago, Chile (JB)
| | - Christopher P Miller
- Harvard Combinated Orthopaedic Surgery Residency Program, Massachusetts General Hospital, Boston, Massachusetts (DS, PKC).,Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (BTV, CPM, MDR, JYK).,Department of Orthopaedic Surgery, Pontificia Universidad de Chile, Santiago, Chile (JB)
| | - Matthew D Riedel
- Harvard Combinated Orthopaedic Surgery Residency Program, Massachusetts General Hospital, Boston, Massachusetts (DS, PKC).,Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (BTV, CPM, MDR, JYK).,Department of Orthopaedic Surgery, Pontificia Universidad de Chile, Santiago, Chile (JB)
| | - John Y Kwon
- Harvard Combinated Orthopaedic Surgery Residency Program, Massachusetts General Hospital, Boston, Massachusetts (DS, PKC).,Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (BTV, CPM, MDR, JYK).,Department of Orthopaedic Surgery, Pontificia Universidad de Chile, Santiago, Chile (JB)
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Direct visualization of the syndesmosis for evaluation of syndesmotic disruption: A cadaveric study. OTA Int 2020; 1:e006. [PMID: 33937644 PMCID: PMC7953467 DOI: 10.1097/oi9.0000000000000006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 03/15/2018] [Accepted: 05/01/2018] [Indexed: 01/12/2023]
Abstract
Objectives: Radiologic criteria for syndesmosis instability evaluation remain controversial and direct visualization (DV) of the distal tibiofibular articulation is an alternative diagnostic method worthy of further investigation. We speculate that DV is a more accurate way to evaluate syndesmosis instability than fluoroscopy. The purpose of this study is to determine whether syndesmosis instability can accurately be recognized through DV and if this new intraoperative diagnostic method is more sensitive than fluoroscopy in detecting syndesmosis instability. Methods: Ten cadaveric ankles were tested using a sequential iatrogenic syndesmosis injury model. Specimens were tested incrementally with the lateral stress test (LST) and the external rotation stress test (ERT). The resulting instability was measured directly and fluoroscopically with a true mortise view by using medial clear space (MCS) and tibiofibular clear space (TFCS). Results: DV detected a 2-ligaments injury at a mean diastasis of 3.02 mm (P = 0.0077) and 3.19 mm (P = 0.0077) with the LST and ERT, respectively. Fluoroscopically, TFCS showed a significant diastasis only with a complete syndesmosis rupture while MCS did not show any significant differences. Conclusions: DV of the syndesmosis in a cadaver injury model appears to be more sensitive than fluoroscopy in identifying injury, especially incomplete syndesmotic disruption.
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Validation of a new method for evaluation of syndesmotic injuries of the ankle. INTERNATIONAL ORTHOPAEDICS 2020; 44:2095-2100. [PMID: 32440814 DOI: 10.1007/s00264-020-04631-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 05/12/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE To define a new parameter in CT that could make imaging of the contralateral ankle dispensable evaluating the position of the fibula after syndesmotic injury. METHODS Thirty bilateral CTs of 30 patients were included. Five parameters were defined in axial CT for the injured (_inju) and uninjured (_unin) ankle. Reproducibility was examined for inter-observer and intra-observer reliability. Comparisons for all parameters were performed between the CT scans of both ankles. RESULTS All measurements had a high agreement for the inter-observer and intra-observer correlation coefficients. A large interindividual variance could be found between all parameters. If the difference of the anterior tibiofibular distance antTFD_unin and antTFD_inju was less than 2 mm, there was a strong significant pairwise correlation between all parameters between both sides. CONCLUSION Bilateral CT is still to be recommended, as it is the only way to exactly assess anterior posterior reduction of the fibula.
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Lubberts B, Massri-Pugin J, Guss D, Wolf JC, Bhimani R, Waryasz GR, DiGiovanni CW. Arthroscopic Assessment of Syndesmotic Instability in the Sagittal Plane in a Cadaveric Model. Foot Ankle Int 2020; 41:237-243. [PMID: 31592680 DOI: 10.1177/1071100719879673] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Syndesmotic instability is multidirectional, occurring in the coronal, sagittal, and rotational planes. Despite the multitude of studies examining such instability in the coronal plane, other studies have highlighted that syndesmotic instability may instead be more evident in the sagittal plane. The aim of this study was to arthroscopically assess the degree of syndesmotic ligamentous injury necessary to precipitate fibular translation in the sagittal plane. METHODS Twenty-one above-knee cadaveric specimens underwent arthroscopic evaluation of the syndesmosis, first with all syndesmotic and ankle ligaments intact and subsequently with sequential sectioning of the anterior inferior tibiofibular ligament (AITFL), the interosseous ligament (IOL), the posterior inferior tibiofibular ligament (PITFL), and deltoid ligament (DL). In all scenarios, an anterior to posterior (AP) and a posterior to anterior (PA) fibular translation test were performed under a 100-N applied force. AP and PA sagittal plane translation of the distal fibula relative to the fixed tibial incisura was arthroscopically measured. RESULTS Compared with the intact ligamentous state, there was no difference in sagittal fibular translation when only 1 or 2 ligaments were transected. After transection of all the syndesmotic ligaments (AITFL, IOL, and PITFL) or after partial transection of the syndesmotic ligaments (AITFL, IOL) alongside the DL, fibular translation in the sagittal plane significantly increased as compared with the intact state (P values ranging from .041 to <.001). The optimal cutoff point to distinguish stable from unstable injuries was equal to 2 mm of fibular translation for the total sum of AP and PA translation (sensitivity 77.5%; specificity 88.9%). CONCLUSION Syndesmotic instability appears in the sagittal plane after injury to all 3 syndesmotic ligaments or after partial syndesmotic injury with concomitant deltoid ligament injury in this cadaveric model. The optimal cutoff point to arthroscopically distinguish stable from unstable injuries was 2 mm of total fibular translation. CLINICAL RELEVANCE These data can help surgeons arthroscopically distinguish between stable syndesmotic injuries and unstable ones that require syndesmotic stabilization.
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Affiliation(s)
- Bart Lubberts
- Foot and Ankle Research and Innovation Lab, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jafet Massri-Pugin
- Foot and Ankle Research and Innovation Lab, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Department of Orthopaedic Surgery, School of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Daniel Guss
- Foot and Ankle Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Newton-Wellesley Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Rohan Bhimani
- Foot and Ankle Research and Innovation Lab, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Gregory R Waryasz
- Massachusetts General Hospital, Newton-Wellesley Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher W DiGiovanni
- Massachusetts General Hospital, Newton-Wellesley Hospital, Harvard Medical School, Boston, MA, USA
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35
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McHale S, Williams M, Ball T. Retrospective cohort study of operatively treated ankle fractures involving the posterior malleolus. Foot Ankle Surg 2020; 26:138-145. [PMID: 30709682 DOI: 10.1016/j.fas.2019.01.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 11/20/2018] [Accepted: 01/02/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Direct fixation of the posterior malleolus through a posterolateral approach is increasing in popularity. However, data is limited, and no studies have stratified results by posterior malleolus size. METHODS A retrospective cohort study of patients with posterior malleolus (PM) fractures undergoing internal fixation over an 18-month period was conducted. Radiographic and patient reported outcomes measures (PROMs) were assessed. 75 patients were included, and 31 returned Manchester-Oxford Foot and Ankle (MOXFQ), EQ-5D-3 L, 5-point Likert satisfaction questionnaires. Mean age was 56.2 years, 68% were female, mean ASA was 1.72, 6.7% were diabetic, and average surgical time was 75.7 min (±40.9). RESULTS Overall, the MOXFQ summary score was 26.9 (±25.8), with the pain domain showing the most severe score 32.4 (±24.0). The EQ-5D VAS index was 0.75 (±0.24). Larger PM size was associated with more anatomical reduction (58.8%, n = 20 of <10% vs. 90.9%, n = 10 of >30%) and larger sized fragments were more likely to be fixed posteriorly. Best PROMs were observed in PM fragments <10%, and the worst in fragments 10-20%. A tendency towards more secondary surgery was observed with posterior subluxation 21.9% (n = 7) vs. 7.0% (n = 3) (p = 0.06). CONCLUSIONS Patients with fragments >10% have an intra-articular injury. We recommend direct anatomic reduction and rigid internal fixation. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Stephen McHale
- Department of Trauma and Orthopaedics, Torbay and South Devon NHS Foundation Trust, Torbay Hospital, Torquay, TQ2 7AA, UK.
| | - Mark Williams
- Department of Trauma and Orthopaedics, Torbay and South Devon NHS Foundation Trust, Torbay Hospital, Torquay, TQ2 7AA, UK
| | - Thomas Ball
- Department of Trauma and Orthopaedics, Torbay and South Devon NHS Foundation Trust, Torbay Hospital, Torquay, TQ2 7AA, UK
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36
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Kamin K, Notov D, Kleber C, Al-Sadi O, Rammelt S. [Treatment of ankle fractures: operative techniques : Standards, tips and pitfalls]. Unfallchirurg 2020; 123:57-67. [PMID: 31925455 DOI: 10.1007/s00113-019-00754-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Konrad Kamin
- UniversitätsCentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Carl Gustav Carus, 01307, Dresden, Deutschland.
| | - Dmitri Notov
- UniversitätsCentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Carl Gustav Carus, 01307, Dresden, Deutschland
| | - Christian Kleber
- UniversitätsCentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Carl Gustav Carus, 01307, Dresden, Deutschland
| | - Onays Al-Sadi
- UniversitätsCentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Carl Gustav Carus, 01307, Dresden, Deutschland
| | - Stefan Rammelt
- UniversitätsCentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Carl Gustav Carus, 01307, Dresden, Deutschland
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37
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Lubberts B, Guss D, Vopat BG, Johnson AH, van Dijk CN, Lee H, DiGiovanni CW. The arthroscopic syndesmotic assessment tool can differentiate between stable and unstable ankle syndesmoses. Knee Surg Sports Traumatol Arthrosc 2020; 28:193-201. [PMID: 30367196 DOI: 10.1007/s00167-018-5229-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 10/17/2018] [Indexed: 12/13/2022]
Abstract
PURPOSE Patients with stable isolated injuries of the ankle syndesmosis can be treated conservatively, while unstable injuries require surgical stabilisation. Although evaluating syndesmotic injuries using ankle arthroscopy is becoming more popular, differentiating between stable and unstable syndesmoses remains a topic of on-going debate in the current literature. The purpose of this study was to quantify the degree of displacement of the ankle syndesmosis using arthroscopic measurements. The hypothesis was that ankle arthroscopy by measuring multiplanar fibular motion can determine syndesmotic instability. METHODS Arthroscopic assessment of the ankle syndesmosis was performed on 22 fresh above knee cadaveric specimens, first with all syndesmotic and ankle ligaments intact and subsequently with sequential sectioning of the anterior inferior tibiofibular ligament, the interosseous ligament, the posterior inferior tibiofibular ligament, and deltoid ligaments. In all scenarios, four loading conditions were considered under 100N of direct force: (1) unstressed, (2) a lateral hook test, (3) anterior to posterior (AP) translation test, and (4) posterior to anterior (PA) translation test. Anterior and posterior coronal plane tibiofibular translation, as well as AP and PA sagittal plane translation, were arthroscopically measured. RESULTS As additional ligaments of the syndesmosis were transected, all arthroscopic multiplanar translation measurements increased (p values ranging from p < 0.001 to p = 0.007). The following equation of multiplanar fibular motion relative to the tibia measured in millimeters: 0.76*AP sagittal translation + 0.82*PA sagittal translation + 1.17*anterior third coronal plane translation-0.20*posterior third coronal plane translation, referred to as the Arthroscopic Syndesmotic Assessment tool, was generated from our data. According to our results, an Arthroscopic Syndesmotic Assessment value equal or greater than 3.1 mm indicated an unstable syndesmosis. CONCLUSIONS This tool provides a more reliable opportunity in determining the presence of syndesmotic instability and can help providers decide whether syndesmosis injuries should be treated conservatively or operatively stabilized. The long-term usefulness of the tool will rest on whether an unstable syndesmosis correlates with acute or chronic clinical symptoms.
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Affiliation(s)
- Bart Lubberts
- Foot and Ankle Research and Innovation Lab, Massachusetts General Hospital, Newton-Wellesley Hospital, Harvard Medical School, Boston, USA.
| | - Daniel Guss
- Division of Foot & Ankle Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital, Newton-Wellesley Hospital, Harvard Medical School, Boston, USA
| | - Bryan G Vopat
- Department of Orthopaedic Surgery, Kansas Medical Center, Kansas City, USA
| | - Anne H Johnson
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, USA
| | - C Niek van Dijk
- Department of Orthopaedic Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | - Hang Lee
- Biostatistics Center, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Christopher W DiGiovanni
- Division of Foot & Ankle Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital, Newton-Wellesley Hospital, Harvard Medical School, Boston, USA
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Bae KJ, Kang SB, Kim J, Lee J, Go TW. Reduction and fixation of anterior inferior tibiofibular ligament avulsion fracture without syndesmotic screw fixation in rotational ankle fracture. J Int Med Res 2019; 48:300060519882550. [PMID: 31885342 PMCID: PMC7607056 DOI: 10.1177/0300060519882550] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Objective We aimed to present the radiographic and functional outcomes of anatomical reduction and fixation of anterior inferior tibiofibular ligament (AITFL) avulsion fracture without syndesmotic screw fixation in rotational ankle fracture. Methods We retrospectively reviewed 66 consecutive patients with displaced malleolar fracture combined with AITFL avulsion fracture. We performed reduction and fixation for the AITFL avulsion fracture when syndesmotic instability was present after malleolar fracture fixation. A syndesmotic screw was inserted only when residual syndesmotic instability was present even after AITFL avulsion fracture fixation. The radiographic parameters were compared with those of the contralateral uninjured ankles. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores were assessed 1 year postoperatively. Results Fifty-four patients showed syndesmotic instability after malleolar fracture fixation and underwent reduction and fixation for AITFL avulsion fracture. Among them, 45 (83.3%) patients achieved syndesmotic stability, while 9 (16.7%) patients with residual syndesmotic instability needed additional syndesmotic screw fixation. The postoperative radiographic parameters were not significantly different from those of the uninjured ankles. The mean AOFAS score was 94. Conclusion Reduction and fixation of AITFL avulsion fracture obviated the need for syndesmotic screw fixation in more than 80% of patients with AITFL avulsion fracture and syndesmotic instability.
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Affiliation(s)
- Kee Jeong Bae
- Department of Orthopaedic Surgery, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Seung-Baik Kang
- Department of Orthopaedic Surgery, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Jihyeung Kim
- Department of Orthopaedic Surgery, Seoul National University Hospital, Seoul, Korea
| | - Jaewoo Lee
- Department of Orthopaedic Surgery, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Tae Won Go
- Department of Orthopaedic Surgery, Seoul National University Hospital, Seoul, Korea
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Abstract
OBJECTIVES We hypothesize that a single syndesmotic view, capturing both sagittal and coronal tibiofibular displacement, will be more sensitive than a mortise view to detect syndesmotic instability. METHODS Ten fresh frozen human lower limbs were used to test the new syndesmotic view with simulated syndesmosis injury. The anteroinferior tibiofibular ligament, interosseous membrane, and posteroinferior tibiofibular ligament were sectioned sequentially. At each stage, the syndesmosis was tested using the external rotation stress (ERS) test and lateral stress test (LST). For each stress condition, a true mortise view and the new syndesmotic view were performed. Medial clear space and tibiofibular clear space (TFCS) were measured on a mortise view, and TFCS was measured on a syndesmotic view (TFCS-s). Wilcoxon signed-rank tests were used to compare measurements. RESULTS Syndesmotic view enabled instability detection with a 2-ligament dissection at a mean increase in TFCS-s of 2.37 mm (P = 0.021) and 1.98 mm (P = 0.011), using the ERS and LST, respectively. TFCS on the mortise view was significantly different only with a complete injury. Medial clear space did not vary significantly with injury increments. Sensitivity was 66% and 61% using ERS and LST, respectively, for the TFCS-s, compared with 27% and 33%, respectively, for the TFCS. Specificity was similar for TFCS and TFCS-s. CONCLUSIONS This study was able to demonstrate that the syndesmotic view is more sensitive than the mortise view in detecting syndesmotic instability in a cadaveric model. It is particularly helpful to uncover instability secondary to an incomplete syndesmosis injury requiring fixation.
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40
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Chun DI, Kim J, Kim YS, Cho JH, Won SH, Park SY, Yi Y. Relationship between fracture morphology of lateral malleolus and syndesmotic stability after supination-external rotation type ankle fractures. Injury 2019; 50:1382-1387. [PMID: 31174871 DOI: 10.1016/j.injury.2019.05.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 04/24/2019] [Accepted: 05/21/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Syndesmotic injury with supination-external rotation (SER)-type ankle fractures are well known for the serious damages to the osseous and soft tissue envelope. However, the Lauge-Hansen classification system does not provide sufficient information related to syndesmotic injury. In this study, we aimed to investigate factors for preoperative detection of syndesmotic injury according to fracture patterns in SER III and IV ankle fractures by using radiography and computed tomography (CT). METHODS All operative SER III and IV ankle fractures treated by a single surgeon from 2009 to 2015 were enrolled in a retrospective database. Based on computed tomographic evidence and intra-operative Cotton test, stable and unstable groups of the ankle factures were divided. RESULTS A total of 52 patients with SER III, 75 patients with SER IV, and 27 patients with SER IV equivalent ankle fractures were identified, with 106 in the unstable syndesmosis group (68.8%) and 48 patients in the stable syndesmosis group (31.2%). Medial space widening and fragment angle of the fibular posterior cortex were significant predictors. The cutoff values of these factors were 4.4 mm and 32.8 degrees, respectively. CONCLUSIONS CT was superior to simple radiography in predicting syndesmotic injury at the preoperative period in SER-type III and IV. Medial space widening and fragment angle of the fibular posterior cortex, as predictive factors, showed significant correlations. In particular, sharper fragment angle of the posterior cortex indicated higher probability of instability that remained after fracture fixation.
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Affiliation(s)
- Dong-Il Chun
- Department of Orthopedic Surgery, Soonchunhyang University Seoul Hospital, 657-52 Hannam-dong Yong-San Gu, Seoul, Republic of Korea.
| | - Jahyung Kim
- Department of Orthopedic Surgery, Soonchunhyang University Seoul Hospital, 657-52 Hannam-dong Yong-San Gu, Seoul, Republic of Korea.
| | - Yoon Seok Kim
- Department of Orthopedic Surgery, Seoul Paik Hospital, Inje University, 85, 2-ga, Jeo-dong, Jung-gu, Seoul, 100-032, Republic of Korea.
| | - Jae-Ho Cho
- Department of Orthopedic Surgery, Chuncheon Sacred Heart Hospital, Hallym University, College of Medicine, 77, SakJu-Ro, Gyo-dong, Chun-Cheon, 24262, Republic of Korea.
| | - Sung-Hun Won
- Department of Orthopedic Surgery, Soonchunhyang University Seoul Hospital, 657-52 Hannam-dong Yong-San Gu, Seoul, Republic of Korea.
| | - Su-Yeon Park
- Department of biostatistics, Soonchunhyang University Hospital, College of medicine, 657-52 Hannam-dong Yong-San Gu, Seoul, Republic of Korea.
| | - Young Yi
- Department of Orthopedic Surgery, Seoul Paik Hospital, Inje University, 85, 2-ga, Jeo-dong, Jung-gu, Seoul, 100-032, Republic of Korea.
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Krähenbühl N, Bailey TL, Weinberg MW, Davidson NP, Hintermann B, Presson AP, Allen CM, Henninger HB, Saltzman CL, Barg A. Impact of Torque on Assessment of Syndesmotic Injuries Using Weightbearing Computed Tomography Scans. Foot Ankle Int 2019; 40:710-719. [PMID: 30762447 DOI: 10.1177/1071100719829720] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The diagnosis of subtle injuries to the distal tibiofibular syndesmosis remains elusive. Conventional radiographs miss a large subset of injuries that present without frank diastasis. This study evaluated the impact of torque application on the assessment of syndesmotic injuries when using weightbearing computed tomography (CT) scans. METHODS Seven pairs of male cadavers (tibia plateau to toe-tip) were included. CT scans with axial load application (85 kg) and with (10 Nm) or without torque to the tibia (corresponding to external rotation of the foot and ankle) were taken during 4 test conditions. First, intact ankles (native) were scanned. Second, 1 specimen from each pair underwent anterior inferior tibiofibular ligament (AITFL) transection (condition 1A), while the contralateral underwent deltoid transection (condition 1B). Third, the lesions were reversed on the same specimens and the remaining intact deltoid or AITFL was transected (condition 2). Finally, the distal tibiofibular interosseous membrane (IOM) was transected in all ankles (condition 3). Measurements were performed to assess the integrity of the distal tibiofibular syndesmosis on digitally reconstructed radiographs (DRRs) and on axial CT scans. RESULTS Torque impacted DRR and axial CT scan measurements in almost all conditions. The ability to diagnose syndesmotic injuries using axial CT measurements improved when torque was applied. No significant syndesmotic morphological change was observed with or without torque for either isolated AITFL or deltoid ligament transection. DISCUSSION Torque application had a notable impact on two-dimensional (2-D) measurements used to diagnose syndesmotic injuries for both DRRs and axial CT scans. Because weightbearing conditions allow for standardized positioning of the foot while radiographs or CT scans are taken, the combination of axial load and torque application may be desirable. CLINICAL RELEVANCE Application of torque to the tibia impacts 2-D measurements and may be useful when diagnosing syndesmotic injuries by DRRs or axial CT images.
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Affiliation(s)
- Nicola Krähenbühl
- 1 Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA
| | - Travis L Bailey
- 1 Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA
| | - Maxwell W Weinberg
- 1 Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA
| | - Nathan P Davidson
- 1 Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA
| | - Beat Hintermann
- 2 Department of Orthopaedics, Kantonsspital Baselland, Liestal, Switzerland
| | - Angela P Presson
- 3 Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Chelsea McCarty Allen
- 3 Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Heath B Henninger
- 4 Orthopaedic Research Laboratory, University of Utah, Salt Lake City, UT, USA
| | - Charles L Saltzman
- 1 Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA
| | - Alexej Barg
- 1 Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA
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Lamer S, Hébert-Davies J, Leduc S, Nault ML. Epidemiology of syndesmotic fixations in a pediatric center: A 12-year retrospective review. Medicine (Baltimore) 2019; 98:e16061. [PMID: 31192967 PMCID: PMC6587479 DOI: 10.1097/md.0000000000016061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 05/14/2019] [Accepted: 05/17/2019] [Indexed: 12/26/2022] Open
Abstract
Syndesmosis injuries need to be accurately diagnosed and managed to avoid chronic pain, early arthritis, and instability. To this end, the present study aimed to analyze the epidemiology of syndesmotic injuries in a pediatric ankle fracture cohort and identify patient and surgery-related characteristics.A retrospective review of all the ankle fractures during a 12-year period at a single pediatric referral center was conducted. Inclusion criteria were: a fractured ankle that underwent a surgical fixation, at least 1 radiograph available for review before fixation, available information regarding surgery, including operative report and fluoroscopic images, and younger than 18 years at the time of surgery. Demographic information, trauma, radiographs, surgical details, clinical examination, follow up, outcomes, and physeal status (skeletally immature, transitional, or mature) were recorded. Finally, patients were divided in 2 groups: with or without syndesmotic fixation. Statistical analysis included descriptive statistics, Mann-Whitney test for nonparametric data to compare continuous parameters, and χ test for categorical parameters.A total of 128 patients were included with a mean age of 14.1 years. There were 80 boys and 48 girls. There were 51 skeletally immature patients, 23 with transitional fractures, and 54 that were skeletally mature. The main finding of this study is that only 11 patients from the mature group underwent syndesmotic fixation. There were no cases of syndesmotic fixation in the skeletally immature and transitional groups.This is the first retrospective study to focus specifically on syndesmotic injuries in a pediatric population who underwent ankle fracture fixation. Only 11 skeletally mature patients underwent syndesmotic fixation out of 128 patients in this cohort. This result raises the question of whether there are accurate diagnostic tools to evaluate syndesmosis in children.
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Affiliation(s)
- Stéphanie Lamer
- CHU Sainte-Justine, 7905- 3175 Chemin de la Côte Ste-Catherine
- Department of Surgery, Université de MontréalEdouard-Montpetit
| | - Jonah Hébert-Davies
- Department of Surgery, Université de MontréalEdouard-Montpetit
- Hôpital du Sacré-Cœur de Montréal, Montreal, Quebec, Canada
| | - Stéphane Leduc
- Department of Surgery, Université de MontréalEdouard-Montpetit
- Hôpital du Sacré-Cœur de Montréal, Montreal, Quebec, Canada
| | - Marie-Lyne Nault
- CHU Sainte-Justine, 7905- 3175 Chemin de la Côte Ste-Catherine
- Department of Surgery, Université de MontréalEdouard-Montpetit
- Hôpital du Sacré-Cœur de Montréal, Montreal, Quebec, Canada
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43
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Kohake MBJ, Wiebking U, O'Loughlin PF, Krettek C, Gaulke R. Mid- to Long-term Outcomes After Weber B-type Ankle Fractures With and Without Syndesmotic Rupture. In Vivo 2019; 33:255-261. [PMID: 30587633 DOI: 10.21873/invivo.11469] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 11/08/2018] [Accepted: 11/09/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND/AIM The aim of the present study was to assess the impact of syndesmotic screw fixation on overall clinical outcomes following Weber B-type ankle fractures. MATERIALS AND METHODS A total of 21 patients with syndesmotic rupture requiring screw fixation were compared to 40 patients with an intact syndesmosis. Olerud-Molander-Ankle-Score, American Orthopedic Foot & Ankle Society ankle hindfoot score, and the Short Form Health Survey-36 were recorded. Weight-bearing plain radiographs were performed to rate post traumatic osteoarthrosis according to the Kellgren-Lawrence score. Pain levels were evaluated with a visual analog scale. RESULTS A total of 61 patients with a mean follow-up of 6.6 years (range=2-12 years) satisfied the inclusion criteria. Pain level, clinical outcome scores, and radiographs did not reveal significant differences between the groups. Ankle joints with syndesmotic rupture showed a significant restriction in dorsiflexion compared to those with an intact syndesmosis (15 vs. 20°, p=0.028). CONCLUSION Syndesmotic rupture does not affect clinical and radiological outcome parameters following Weber B-type ankle fractures, but does lead to a significant restriction in dorsiflexion of the ankle joint.
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Affiliation(s)
- Michael B J Kohake
- Section Upper Extremity, Foot- and Rheuma Surgery, Trauma Department, Medical School Hanover (MHH), Hanover, Germany.,Trauma Department, Medical School Hanover (MHH), Hanover, Germany
| | - Ulrich Wiebking
- Section Upper Extremity, Foot- and Rheuma Surgery, Trauma Department, Medical School Hanover (MHH), Hanover, Germany.,Trauma Department, Medical School Hanover (MHH), Hanover, Germany
| | | | | | - Ralph Gaulke
- Section Upper Extremity, Foot- and Rheuma Surgery, Trauma Department, Medical School Hanover (MHH), Hanover, Germany .,Trauma Department, Medical School Hanover (MHH), Hanover, Germany
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Gosselin-Papadopoulos N, Hébert-Davies J, Laflamme GY, Beauséjour M, Ménard J, Leduc S, Nault ML. Intraoperative Torque Test to Assess Syndesmosis Instability. Foot Ankle Int 2019; 40:408-413. [PMID: 30596281 DOI: 10.1177/1071100718816674] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND: In this cadaveric study, a new "torque test" (TT) stressing the fibula posterolaterally under direct visualization was compared with the classical external rotation stress test (ERT) and lateral stress test (LST). METHODS: The anteroinferior tibiofibular ligament (AiTFL), the interosseous membrane (IOM), and the posteroinferior tibiofibular ligament (PiTFL) were sectioned sequentially on 10 fresh-frozen human ankles. At each stage of dissection, instability was assessed using the LST, ERT, and TT under direct visualization. Anatomical tibiofibular diastasis measurements were taken directly on cadavers and compared using the Wilcoxon signed rank test. RESULTS: All 3 tests showed statistically significant motion in the syndesmosis when at least 2 ligaments were sectioned. The mean increase across diastasis with a 2-ligament section was 3.0 mm ( P = .005), 3.2 mm ( P = .005), and 4.8 mm ( P = .005) for the LST, ERT, and TT, respectively. The largest mean increase in diastasis was obtained with a complete injury using the TT and was 6.2 mm ( P = .008). With the TT, a 3.5-mm tibiofibular diastasis was 90% sensitive and 100% specific when 2 or more syndesmotic ligaments were sectioned. CONCLUSION: The TT was a more sensitive and specific tool for detecting syndesmosis instability than classic LST and ERT. CLINICAL RELEVANCE: Stressing the fibula in a posterolateral direction created a larger distal tibiofibular diastasis, which would be easier to detect in the intraoperative setting. The TT was more sensitive and specific to detecting a 2-ligament syndesmotic injury than the classic test and required less force to perform.
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Affiliation(s)
| | - Jonah Hébert-Davies
- 1 Hôpital du Sacré-Cœur de Montréal, Montreal, QC, Canada.,2 Department of Surgery, Université de Montréal, Montreal, QC, Canada
| | - G Yves Laflamme
- 1 Hôpital du Sacré-Cœur de Montréal, Montreal, QC, Canada.,2 Department of Surgery, Université de Montréal, Montreal, QC, Canada
| | - Marie Beauséjour
- 2 Department of Surgery, Université de Montréal, Montreal, QC, Canada.,3 CHU Ste-Justine, Montréal, QC, Canada
| | - Jérémie Ménard
- 1 Hôpital du Sacré-Cœur de Montréal, Montreal, QC, Canada
| | - Stéphane Leduc
- 1 Hôpital du Sacré-Cœur de Montréal, Montreal, QC, Canada.,2 Department of Surgery, Université de Montréal, Montreal, QC, Canada
| | - Marie-Lyne Nault
- 1 Hôpital du Sacré-Cœur de Montréal, Montreal, QC, Canada.,2 Department of Surgery, Université de Montréal, Montreal, QC, Canada.,3 CHU Ste-Justine, Montréal, QC, Canada
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Wu Y, He QF, Lai LP, Li X, Zhou JL. Functional Outcome of Pronation-External Rotation-Weber C Ankle Fractures with Supracollicular Medial Malleolar Fracture Treated with or without Syndesmotic Screws: A Retrospective Comparative Cohort Study. Chin Med J (Engl) 2019; 131:2551-2557. [PMID: 30381588 PMCID: PMC6213829 DOI: 10.4103/0366-6999.244112] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Background: In treatment of ankle fracture, intraoperative stress tests are used to assess the syndesmotic injury and instability. However, the optimized timing of the strees test should be applied whether in pre- or post-bony fixation during operation is seldom be reported in previous studies. The different strategies on stress test timing would exhibit opposite results within a type of pronation-external rotation (PER) fractures with supracollicular medial malleolar (SMM) fractures. This study was designed to assess the 3-year functional outcomes of the special PER fractures with or without a syndesmotic transfixation based on the results of two different intraoperative stress test strategies. Methods: This retrospective cohort study included 61 PER injury-Weber C ankle fractures combined with SMM fractures who were treated in Beijing Jishuitan Hospital between 2013 and 2014 and followed up for 3 years. Stress test was performed twice intraoperatively. A positive intraoperative stress test before bony fixation and a negative intraoperative stress test after bony fixation were found in these included patients. Twenty-nine patients (Group 1) were treated without a supplemental syndesmotic screw fixation, according to the negative intraoperative stress test after bony fixation, while 32 patients (Group 2) were treated with an additional syndesmotic screw fixation based on the positive intraoperative stress test before bony fixation. The American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale and Visual Analog Scale (VAS) for pain scores were the main measurements of outcome. The statistical index of demographic data, fracture morphologic data, time interval of follow-up, AOFAS and VAS were recorded and assessed by SPSS 21.0 software through Fisher exact tests and one-way analysis of variance. The associations between the main outcomes and influential factors were evaluated by linear regression models. Results: We observed no difference in the distribution of age, sex, presence of associated posterior malleolus (PM), fracture dislocation, and fixation of associated PM between two treatment groups. With the numbers available, no statistically significant association could be detected with regard to the AOFAS (Group 1 vs. Group 2, 96.72 ± 6.20 vs. 94.63 ± 8.26, F = 1.24, P = 0.27) and VAS (Group 1 vs. Group 2, 1.47 ± 2.14 vs. 0.72 ± 1.49, F = 2.44, P = 0.12) in association with two strategies. Conclusions: The present study indicates no difference to the use of the syndesmotic screw in terms of the functional outcome between syndesmosis transfixation and no-fixation patients among PER-Weber C ankle fracture patients with SMM fracture after 3-year follow-up. More attention should be paid to pre- and post-bony-fixation intraoperative stress tests and the morphology of medial malleoli fractures in ankle fractures.
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Affiliation(s)
- Yong Wu
- Department of Orthopaedics, Chaoyang Hospital, Third Clinical Medical School of Capital Medical University, Bejing 100020; Department of Trauma Orthopaedics, Jishuitan Hospital, Forth Clinical Medical School of Peking University, Beijing 100035, China
| | - Qi-Fei He
- Department of Trauma Orthopaedics, Jishuitan Hospital, Forth Clinical Medical School of Peking University, Beijing 100035, China
| | - Liang-Peng Lai
- Department of Trauma Orthopaedics, Jishuitan Hospital, Forth Clinical Medical School of Peking University, Beijing 100035, China
| | - Xia Li
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, Bejing 100191, China
| | - Jun-Lin Zhou
- Department of Orthopaedics, Chaoyang Hospital, Third Clinical Medical School of Capital Medical University, Bejing 100020, China
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Naguib SL, Meyr AJ. Reliability, Surgeon Preferences, and Eye-Tracking Assessment of the Stress Examination of the Ankle Syndesmosis. J Foot Ankle Surg 2019; 57:1148-1153. [PMID: 30253965 DOI: 10.1053/j.jfas.2018.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Indexed: 02/03/2023]
Abstract
The diagnosis and stabilization of ankle syndesmotic injuries after acute injury remains an area of controversy in the foot and ankle surgical literature, seemingly without universal consensus. The primary objective of this investigation was to determine the frequency of agreement and reliability of the stress examination of the ankle syndesmosis. Secondary objectives were to determine surgeon preferences and protocols with respect to the ankle syndesmosis and to use gaze recognition software to perform an eye-tracking assessment during performance of stress examinations. Twelve foot and ankle surgeons, 12 residents, and 12 students were shown 5 intraoperative fluoroscopic still images and videos of the stress examination of the ankle syndesmosis. They were asked to evaluate the result as being "positive" or "negative" for syndesmotic stability. The overall reliability of the interpretation of the stress examination of the ankle syndesmosis was a kappa of 0.123 (surgeons 0.087; residents 0.019; students 0.237), indicating "slight" agreement. Survey results indicated wide variability in the perioperative preferences and protocols of surgeons dealing with the evaluation and treatment of the ankle syndesmosis. Eye-tracking results also demonstrated variability in the anatomic structures of interest focused on during performance of this testing. The results of this investigation provide evidence of reliability well below what would be expected of a gold standard test during stress examination of the ankle syndesmosis. These results indicate that future scientific endeavors are required to standardize the performance and interpretation of this testing.
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Affiliation(s)
- Sara L Naguib
- Resident, Temple University Hospital Podiatric Surgical Residency Program, Philadelphia, PA
| | - Andrew J Meyr
- Clinical Associate Professor, Department of Podiatric Surgery, Temple University School of Podiatric Medicine, Philadelphia, PA.
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47
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Lee SY, Moon SY, Park MS, Jo BC, Jeong H, Lee KM. Syndesmosis Fixation in Unstable Ankle Fractures Using a Partially Threaded 5.0-mm Cannulated Screw. J Foot Ankle Surg 2018; 57:721-725. [PMID: 29705234 DOI: 10.1053/j.jfas.2017.12.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Indexed: 02/03/2023]
Abstract
The present study evaluated the radiographic outcomes of syndesmosis injuries treated with a partially threaded 5.0-mm cannulated screw. The present study included 58 consecutive patients with syndesmosis injuries concurrent with ankle fractures who had undergone operative fixation with a partially threaded 5.0-mm cannulated screw to repair the syndesmosis injury. Radiographic indexes, including the medial clear space, tibiofibular overlap, tibiofibular clear space, and fibular position on the lateral radiograph, were measured on the preoperative, immediate postoperative, and final follow-up radiographs. The measurements were compared between the injured and intact ankles. All preoperative radiographic indexes, including the medial clear space (p < .001), tibiofibular overlap (p < .001), tibiofibular clear space (p < .001), and fibular position on the lateral radiograph (p = .026), were significantly different between the injured and intact ankles. The medial clear space of the injured ankle was significantly wider than that of the intact ankle preoperatively (p < .001) and had become significantly narrower immediately postoperatively (p < .001). Finally, the medial clear space was not significantly different between the injured and intact ankles at the final follow-up examination (p = .522). No screw breakage or repeat fractures were observed. A 5.0-mm partially threaded cannulated screw effectively restored and maintained the normal relationship between the tibia and fibula within the ankle mortise with a low risk of complications. This appears to be an effective alternative technique to treat syndesmosis injuries concurrent with ankle fractures.
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Affiliation(s)
- Seung Yeol Lee
- Clinical Associate Professor, Department of Orthopaedic Surgery, Ewha Womans University Mokdong Hospital, Seoul, Republic of Korea
| | - Sang Young Moon
- Orthopedist, Seocho Gangnam Yeok Orthopedic Clinic, Seoul, Republic of Korea
| | - Moon Seok Park
- Clinical Professor, Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Kyungki, Republic of Korea
| | - Byung Chae Jo
- Orthopedist, Department of Orthopaedic Surgery, Seoul Jaeil Hospital, Kyungki, Republic of Korea
| | - Hyunseok Jeong
- Orthopedist, Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Kyungki, Republic of Korea
| | - Kyoung Min Lee
- Clinical Associate Professor, Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Kyungki, Republic of Korea.
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Alshalawi S, Galhoum AE, Alrashidi Y, Wiewiorski M, Herrera M, Barg A, Valderrabano V. Medial Ankle Instability: The Deltoid Dilemma. Foot Ankle Clin 2018; 23:639-657. [PMID: 30414658 DOI: 10.1016/j.fcl.2018.07.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Diagnosis and treatment of medial ankle instability (MAI) are still controversial and poorly discussed in literature. The purpose of this review is to highlight different clinical presentations of MAI and develop a guide for its management. The deltoid ligament complex is injured more commonly than expected, because deltoid ligament injuries may either be isolated or occur in combination with other lesions, such as lateral ankle ligament injury, posterior tibial tendon insufficiency, osteochondral lesion, and others. The presence of a pes planovalgus deformity in a patient without posterior tibial tendon insufficiency may indicate MAI.
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Affiliation(s)
- Saud Alshalawi
- Prince Sultan Military Medical City, PO Box 13225-6604, Riyadh 12233, Saudi Arabia
| | - Ahmed E Galhoum
- Department of Orthopedic, Nasser Institute for Research and Treatment, Nile Corniche Street, Cairo 1351, Egypt
| | - Yousef Alrashidi
- Orthopaedic Department, College of Medicine, Taibah University, PO Box 30001, Medina 42353, Saudi Arabia
| | - Martin Wiewiorski
- Head Foot and Ankle Unit, Orthopaedic and Trauma Department, Kantonsspital Winterthur, Winterthur 8401, Switzerland
| | - Mario Herrera
- Head Foot and Ankle Unit, Orthopaedic Department, University of La Laguna, Tenerife 38200, Spain
| | - Alexej Barg
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, USA
| | - Victor Valderrabano
- Orthopaedic Department, Swiss Ortho Center, Swiss Medical Network, Schmerzklinik Basel, Hirschgässlein 15, Basel 4010, Switzerland.
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de Cesar Netto C, Pinto M, Roberts L, Lee SR, Roney AR, Naranje S, Godoy-Santos AL, Shah A. Intraoperative tap test for coronal syndesmotic instability: A cadaveric study. Injury 2018; 49:1758-1762. [PMID: 30115447 DOI: 10.1016/j.injury.2018.08.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 06/09/2018] [Accepted: 08/06/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Precise diagnosis of distal tibiofibular syndesmotic injury is challenging, and a gold standard diagnostic test has still not been established. Tibiofibular clear space identified on radiographic imaging is considered the most reliable indicator of the injury. The Cotton test is the most widely used intraoperative technique to evaluate the syndesmotic integrity although it has its limitations. We advocate for a novel intra operative test using a 3.5 mm blunt cortical tap. METHODS Tibiofibular clear space was assessed in nine cadaveric specimens using three sequential fluoroscopic images. The first image was taken prior to the application of the tap test (intact, non-stressed). Then, a 2.5 mm hole was drilled distally on the lateral fibula, and a 3.5 mm cortical tap was then threaded in the hole. The tap test involved gradually advancing the blunt tip against the lateral tibia, providing a tibiofibular separation force (intact, stressed). This same stress was then applied after all syndesmotic ligaments were released (injured, stressed). Measurements were compared by one-way ANOVA and paired Student's t-test. Intra and inter-observer agreements were evaluated by intraclass correlation coefficient (ICC). P-values <.05 were considered significant. RESULTS We found excellent intra-observer (0.97) and inter-observer (0.98) agreement following the imaging assessment. Significant differences were found in the paired comparison between the groups (p < .05). When using an absolute value for TFCS >6 mm as diagnostic for coronal syndesmotic instability, the tap test demonstrated a 96.3% sensitivity and specificity, a 96.3% PPV and NPV and a 96.3% accuracy in diagnosing coronal syndesmotic instability. CONCLUSIONS Our cadaveric study demonstrated that this novel coronal syndesmotic instability test using a 3.5 mm blunt cortical tap is a simple, accurate and reliable technique able to demonstrate significant differences in the tibiofibular clear space when injury was present. It could represent a more controlled and stable alternative to the most used Cotton test.
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Affiliation(s)
- Cesar de Cesar Netto
- Hospital for Special Surgery, Department of Foot and Ankle Orthopedics, 535 East 70thStreet, New York, NY, 10021, United States; University of Alabama at Birmingham (UAB), Department of Orthopedics, Birmingham, AL, United States.
| | - Martim Pinto
- University of Alabama at Birmingham (UAB), Department of Orthopedics, Birmingham, AL, United States
| | - Lauren Roberts
- Hospital for Special Surgery, Department of Foot and Ankle Orthopedics, 535 East 70thStreet, New York, NY, 10021, United States
| | - Sung Ro Lee
- University of Alabama at Birmingham (UAB), Department of Orthopedics, Birmingham, AL, United States
| | - Andrew R Roney
- Hospital for Special Surgery, Department of Foot and Ankle Orthopedics, 535 East 70thStreet, New York, NY, 10021, United States
| | - Sameer Naranje
- University of Alabama at Birmingham (UAB), Department of Orthopedics, Birmingham, AL, United States
| | | | - Ashish Shah
- University of Alabama at Birmingham (UAB), Department of Orthopedics, Birmingham, AL, United States
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Krähenbühl N, Weinberg MW, Davidson NP, Mills MK, Hintermann B, Saltzman CL, Barg A. Imaging in syndesmotic injury: a systematic literature review. Skeletal Radiol 2018; 47:631-648. [PMID: 29188345 DOI: 10.1007/s00256-017-2823-2] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 10/29/2017] [Accepted: 11/07/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To give a systematic overview of current diagnostic imaging options for assessment of the distal tibio-fibular syndesmosis. MATERIALS AND METHODS A systematic literature search across the following sources was performed: PubMed, ScienceDirect, Google Scholar, and SpringerLink. Forty-two articles were included and subdivided into three groups: group one consists of studies using conventional radiographs (22 articles), group two includes studies using computed tomography (CT) scans (15 articles), and group three comprises studies using magnet resonance imaging (MRI, 9 articles).The following data were extracted: imaging modality, measurement method, number of participants and ankles included, average age of participants, sensitivity, specificity, and accuracy of the measurement technique. The Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool was used to assess the methodological quality. RESULTS The three most common techniques used for assessment of the syndesmosis in conventional radiographs are the tibio-fibular clear space (TFCS), the tibio-fibular overlap (TFO), and the medial clear space (MCS). Regarding CT scans, the tibio-fibular width (axial images) was most commonly used. Most of the MRI studies used direct assessment of syndesmotic integrity. Overall, the included studies show low probability of bias and are applicable in daily practice. CONCLUSIONS Conventional radiographs cannot predict syndesmotic injuries reliably. CT scans outperform plain radiographs in detecting syndesmotic mal-reduction. Additionally, the syndesmotic interval can be assessed in greater detail by CT. MRI measurements achieve a sensitivity and specificity of nearly 100%; however, correlating MRI findings with patients' complaints is difficult, and utility with subtle syndesmotic instability needs further investigation. Overall, the methodological quality of these studies was satisfactory.
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Affiliation(s)
- Nicola Krähenbühl
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Maxwell W Weinberg
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Nathan P Davidson
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Megan K Mills
- Department of Radiology and Imaging Sciences, University of Utah, 30 N. 1900 E. No. 1A071, Salt Lake City, UT, 84132, USA
| | - Beat Hintermann
- Department of Orthopaedics, Kantonsspital Baselland, Rheinstrasse 26, 4410, Liestal, Switzerland
| | - Charles L Saltzman
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Alexej Barg
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA.
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