• ankle
• ankle instability
• external torque
• syndesmosis
• syndesmotic instability

• Humans
• Ankle Joint/diagnostic imaging
• Torque
• Cross-Sectional Studies
• Joint Instability/diagnostic imaging
• Joint Instability/physiopathology
• Tomography, X-Ray Computed
• Adult
• Male
• Female
• Rotation
• Young Adult

• Humans
• Torque
• Reproducibility of Results
• Ankle Joint/diagnostic imaging
• Tomography, X-Ray Computed/methods
• Cadaver

• ankle injury
• syndesmotic injury
• syndesmotic reduction
• syndesmotic repair

• Male
• Humans
• Female
• Ankle Fractures/diagnostic imaging
• Ankle Fractures/surgery
• Retrospective Studies
• Ankle Joint/diagnostic imaging
• Ankle Joint/surgery
• Fracture Fixation, Internal/methods
• Bone Screws
• Ankle Injuries/diagnostic imaging
• Ankle Injuries/surgery
• Treatment Outcome

• Ankle syndesmotic injury
• Arthroscopy
• MRI
• Suture-button
• Syndesmotic screw fixation

• Humans
• Ankle Injuries/epidemiology
• Ankle Injuries/therapy
• Ankle Joint
• Bone Screws
• Fracture Fixation, Internal
• Germany/epidemiology

• Private Universität Witten/Herdecke gGmbH (3128)

• American Orthopaedic Foot and Ankle Society score
• screw trajectory
• syndesmosis
• tibiofibular vertical distance

To investigate the clinical effect of internal fixation of a Ni–Ti arched shape-memory connector in the treatment of distal tibiofibular syndesmosis ligament injury.

From January 2013 to January 2016, 108 cases of ankle fracture with distal tibiofibular syndesmosis ligament injury in our hospital were selected, and all of them were fixed with ASCs or screw fixation. The functional evaluation and efficacy evaluation were performed according to the Olerud Molander Ankle Score (Omas) and SF-36. At the same time, follow-ups recorded the incidence of postoperative complications: osteoarthritis, superficial infection, symptomatic hard and soft tissue irritation, early removal and poor reduction of internal fixation, and later loss of reduction.

In the ASC(Ni–Ti Arched shape-memory Connector) group, the incidence of symptomatic hardware, soft tissue or superficial infection decreased to 2.77%(from 13.8% or 11.1% in SCREW group). The early removal rate(2.77%) of internal fixation was also lower than that of the screw group. While the incidence of osteoarthritis is 13.8% in SCREW group, the incidence of osteoarthritis in the later follow-up was also as low as 1.38% in ASC group. Loss of fracture reduction due to removal of the fixation device for the distal tibiofibular syndesmosis ligament was not observed in the ASC group. With two postoperative scoring systems (OMAS and SF-36), patients in the ASC group significantly get higher score than that in SCREW group.

The design of the Ni–Ti arched shape-memory connector can be adapted to the irregular anatomical structure of the malleolus and the ability to continue to contract by body temperature. The use of ASCs in fixation of articular ligaments can preserve a slight range of motion, and the results suggest that ASCs can effectively reduce the incidence of fixation looseness, fracture, infection and other complications.

• Ankle
• Distal tibiofibular syndesmosis ligament
• Internal fixation
• Ni–Ti Arched shape-memory Connector

• Ankle
• Cartilage
• Football player
• Magnetic resonance imaging
• T2-mapping

A stable and precise articulation of the distal tibiofibular syndesmosis maintains the tibiofibular relationship, and it is essential for normal motion of the ankle joint. The disruption of this joint is frequently accompanied by rotational ankle fracture, such as pronation-external rotation, and rarely occurs without ankle fracture. The diagnosis is not simple, and ideal management of the various presentations of syndesmotic injury remains controversial to this day. Anatomical restoration and stabilization of the disrupted tibiofibular syndesmosis is essential to improve functional outcomes. In such an injury, including inadequately treated, misdiagnosed and correctly diagnosed cases, a chronic pattern characterized by persistent ankle pain, function disability and early osteoarthritis can result. This paper reviews anatomical and biomechanical characteristics of this syndesmosis, the mechanism of its acute injury associated to fractures, radiological and arthroscopic diagnosis and surgical treatment.

• Ankle
• Fracture
• Injury
• Distal tibiofibular joint
• Trauma
• Syndesmosis

Ankle fractures are among the most common injuries treated by orthopaedic traumatologists. These fractures range from stable, simple injuries to complex, multi-planar unstable ones. Osseo-ligamentous structures play a paramount role in maintaining the stability of the ankle joint. The deltoid ligament is among the most important ankle static stabilizers. Rupture of this ligament along with a lateral malleolar fracture is considered by many as an unstable type of injury and usually requires surgical treatment (bi-malleolar equivalent). Left untreated, it may lead to chronic pain, loss of function and secondary arthritis. Due to lack of high-quality evidence, there are no welldefined, well-accepted criteria for the diagnosis and treatment for treating this type of injury.

• bimalleolar equivalent
• deltoid ligament
• medial ligament complex
• trimalleolar fracture
• unstable ankle fracture

The necessity of the deep deltoid ligament repair in the treatment of supination-external rotation (SER) ankle stage IV fracture with deltoid ligament rupture is highly debated. We conducted this retrospective research aimed at exploring the curative effect of the deep deltoid ligament repair in treating SER fracture.

Sixty-three patients with closed SER stage IV fractures received open reduction and internal fixation (ORIF), using either deep deltoid ligament repair (the DDLR group, 31 patients) or nondeep deltoid ligament repair (the NDDLR group, 32 patients). The radiographic parameters examined include the talocrural angle (TA), fibular length (FL), tibiomedial malleolar angle (TMMA), medial clear space (MCS), and tibiofibular clear space (TFCS). The functional performance parameters examined in the study were visual analog scale (VAS) pain score, American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scales, and range of motion of bilateral ankles (RMBA). Complications, including bone nonunion, infection, and fragment displacement, were also recorded and compared.

Similar basic characteristics were found in both cohorts. All patients completed follow-up ranging from 12 to 22 months (mean time: 12.41 ± 4.21 months). The DDLR group had significantly reduced VAS score (p < 0.05), with markedly increased RMBA (p < 0.05) compared to the NDDLR group. The two cohorts showed similar follow-up performance at 3 months (p > 0.05), 6 months (p > 0.05), and 12 months (p > 0.05), in terms of parameters including TA, FL, TMMA, MCS, TCS, and AOFAS ankle-hindfoot scales.

Although similar radiographic performances were achieved in both cohorts, the DDLR group displayed enhanced functional outcome postsurgery, indicating that DDLR may be a better potential for the treatment of SER stage IV fracture with deltoid ligament rupture.

To quantitatively assess biochemical alterations in the cartilage of the subtalar and midtarsal joints in chronic lateral ankle instability (CLAI) patients with isolated anterior talofibular ligament (ATFL) injuries and combined calcaneofibular ligament (CFL) injuries using MRI T2 mapping.

This study was performed according to regulations of the Committee for Human Research at our institution, and written informed consent was obtained from all participants. Forty CLAI patients (26 with isolated ATFL injuries and 14 with combined ATFL and CFL injuries) and 25 healthy subjects were recruited for this study. All participants underwent MRI scans with T2 mapping. Patients were assessed with the American Orthopedic Foot and Ankle Society (AOFAS) rating system. The subtalar and midtarsal joints were segmented into 14 cartilage subregions. The T2 value of each subregion was measured from T2 mapping images. Data were analyzed with ANOVA, the Student's t test, and Pearson's correlation coefficient.

T2 values of most subregions of the subtalar joint and the calcaneal facet of the calcaneocuboid joint in CLAI patients with combined CFL injuries were higher than those in healthy controls (all p < 0.05). However, there were no significant differences in T2 values in subtalar and midtarsal joints between patients with isolated ATFL injuries and healthy controls (all p > 0.05). Moreover, T2 values of the medial talar subregions of the posterior subtalar joint in patients with combined CFL injuries showed negative correlations with the AOFAS scores (r = −0.687, p = 0.007; r = −0.609, p = 0.021, respectively).

CLAI with combined CFL injuries can lead to cartilage degeneration in subtalar and calcaneocuboid joints, while an isolated ATFL injury might not have a significant impact on the cartilage in these joints.

• Cartilage
• Chronic lateral ankle instability
• Magnetic resonance imaging
• Midtarsal joint
• Subtalar joint

• ankle joint
• biomechanics
• syndesmosis

• Ankle
• Meta-analysis
• Screw
• Suture button
• Syndesmosis

• Ankle fracture
• Deltoid ligament
• Deltoid ligament reconstruction
• Deltoid ligament repair
• Medial collateral ligament ankle

The aim of this study was to characterize the microscopic structure and sensory nerve endings of the crural interosseous membrane (IM). 13 IMs from 7 cadavers were used to analyze the organization of the collagen fibers, IM’s thickness, distribution of elastic fibers and nerve elements. The IM is mainly a two-layer collagen fascicle structure with the collagen fibers of adjacent layers orientated along different directions, forming angles of 30.5 +/- 1.7° at proximal and 26.6 +/- 2.1° at distal part (P>0.05). The percentage of elastic fibers between the two layers and inside the collagen fascicle layer is 10.1 +/- 0.5% and 2.2 +/- 0.1% (P<0.001). The IM’s thickness at proximal, middle, and distal parts is 268.5 +/- 18.6μm; 293.2 +/- 12.5μm; 365.3 +/- 19.3 μm, respectively (Proximal vs Distal: P<0.001; Middle vs Distal: P<0.05). Nerve elements were present and located both inside and on the surface of the IM, whereas the mechanoreceptors are mainly located on the surface of the IM. Free nerve endings (33.3 +/- 5.0/cm²) and Ruffini corpuscles (3.4 +/- 0.6/cm²) were the predominant sensory elements, while Pacinian corpuscles (1.3 +/- 0.7/cm²) were rarely found. The type of mechanoreceptors found suggests that the IM may play a role in proprioception.

• crural interosseous membrane
• mechanoreceptor
• sensory nerve ending

• ankle
• diagnosis
• ligament
• syndesmosis injury

• biomechanics
• statistical analysis

Ankle sprains with distal tibiofibular syndesmosis injuries (DTSIs) require anatomic reduction and fixation to restore the normal biomechanics of the ankle joint. In the last decade, dynamic fixation (DF) for DTSIs using a suture-button device has gained popularity because of its advantages over static fixation (SF).

The present meta-analysis was conducted to compare clinical outcomes between DF and SF of DTSIs. PubMed, Cochrane Central Register of Controlled Trials, and Embase were systematically searched. Three randomized controlled studies and 7 cohort studies, with a total of 420 patients, were involved in this study. DTSIs patients treated with DF were assigned to the experimental group, and patients treated with SF were assigned to the control group. Outcomes were evaluated and analyzed by using review-manager software. Mean difference (MD) or risk ratio (RR) with 95% confidence interval (95% CI) was analyzed and calculated by utilizing the random effects models.

Analysis revealed no statistically significant differences between DF and SF in American Orthopedic Foot and Ankle Society Ankle-Hindfoot score (MD, 1.90; 95% CI, −0.23–4.03; p=0.08; I²=0%), Olerud-Molander score (MD, 1.92; 95% CI, −7.96–11.81; p=0.70; I²=55%), incidence of syndesmotic malreduction (RR, 0.19; 95% CI, 0.03–1.09; p=0.06; I²=0%), and overall postoperative complication rate (RR, 0.30; 95% CI, 0.09–0.99; p=0.05, I²=75%). The rate of second procedure was significantly lower compared with DF (RR, 0.17; 95% CI, 0.07–0.43; p=0.0002, I²=54%).

The dynamic fixation and static fixation methods are equal in clinical outcomes, with dynamic fixation needing fewer second interventions for DTSIs.

• ankle injury
• arthroscopy
• deltoid ligament
• instability
• syndesmosis

High ankle “syndesmosis” injuries are common in American football players relative to the general population. At the professional level, syndesmotic sprains represent a challenging and unique injury lacking a standardized rehabilitation protocol during conservative management.

PubMed, Biosis Preview, SPORTDiscus, PEDro, and EMBASE databases were searched using the terms syndesmotic injuries, American football, conservative management, and rehabilitation.

Clinical review.

Level 3.

When compared with lateral ankle sprains, syndesmosis injuries result in significantly prolonged recovery times and games lost. For stable syndesmotic injuries, conservative management features a brief period of immobilization and protected weightbearing followed by progressive strengthening exercises and running, and athletes can expect to return to competition in 2 to 6 weeks. Further research investigating the efficacy of dry needling and blood flow restriction therapy is necessary to evaluate the benefit of these techniques in the rehabilitation process.

Successful conservative management of stable syndesmotic injuries in professional American football athletes requires a thorough understanding of the anatomy, injury mechanisms, diagnosis, and rehabilitation strategies utilized in elite athletes.

• ankle
• football
• high ankle
• rehabilitation
• syndesmosis

• Ankle fractures
• Ligament injury
• Syndesmotic injuries

• ankle
• cone-beam computed tomography
• distal tibiofibular joint
• syndesmosis
• weight-bearing

The aim of this study was to design and validate a functional assessment scale for assisted gait with forearm crutches (Chamorro Assisted Gait Scale—CHAGS) and to assess its reliability in people with sprained ankles.

Thirty subjects who suffered from sprained ankle (anterior talofibular ligament first and second degree) were included in the study. A modified Delphi technique was used to obtain the content validity. The selected items were: pelvic and scapular girdle dissociation(1), deviation of Center of Gravity(2), crutch inclination(3), steps rhythm(4), symmetry of step length(5), cross support(6), simultaneous support of foot and crutch(7), forearm off(8), facing forward(9) and fluency(10). Two raters twice visualized the gait of the sample subjects which were recorded. The criterion-related validity was determined by correlation between CHAGS and Coding of eight criteria of qualitative gait analysis (Viel Coding). Internal consistency and inter and intra-rater reliability were also tested.

CHAGS obtained a high and negative correlation with Viel Coding. We obtained a good internal consistency and the intra-class correlation coefficients oscillated between 0.97 and 0.99, while the minimal detectable changes were acceptable.

CHAGS scale is a valid and reliable tool for assessing assisted gait with crutches in people with sprained ankles to perform partial relief of lower limbs.

• Adolescent
• Adult
• Ankle/pathology
• Ankle/physiopathology
• Ankle Injuries/pathology
• Ankle Injuries/physiopathology
• Ankle Injuries/rehabilitation
• Crutches
• Female
• Forearm
• Gait/physiology
• Humans
• Male
• Middle Aged
• Observer Variation
• Reproducibility of Results
• Research Design
• Video Recording
• Walking/physiology

• Telefonica Chair, University of Seville

Lateral ankle sprain (LAS) has often been considered an injury leading to localized joint impairments affecting the musculoskeletal system. Persistent chronic ankle instability and bilateral alterations in motor control after a first ankle sprain episode suggest that the origin of relapses might be a maladaptive reorganization of central motor commands. The objectives of this study were (1) to compare the quality of motor control through motor strategy variables of two groups (with and without LAS) from a military population (n = 10/group), (2) to evaluate the contribution of the lower limbs and the trunk to global body strategy and (3) to identify which global variable best estimates performance on the Star Excursion Balance Test (SEBT) for each group, reaching direction, and lower limb.

Personal and clinical characteristics of the participants of both groups were collected. Their functional ability was measured using questionnaires and they performed a series of functional tests including the SEBT. During this test, the maximal reach distance (MRD) and biomechanical data were collected to characterize whole body and segmental strategies using a 3D motion capture system.

At maximal lower limb reach, participants with LAS had a smaller variation in their vertical velocity in lowering-straightening and lowered the body centre of mass less for all injured limb conditions and some conditions with the uninjured lower limb. The global body centre of mass variables were significantly correlated to SEBT performance (MRD).

Modifications in global motor strategies were found in participants with LAS as well as a decreased performance on the SEBT for the injured and uninjured lower limbs. These results support the hypothesis that following LAS, there may be a maladaptive reorganization of the central motor commands. Level of evidence: 3b.

The online version of this article (doi:10.1186/1471-2474-15-436) contains supplementary material, which is available to authorized users.

• diastasis
• injuries
• management
• tibiofibular syndesmosis

• ankle
• football
• magnetic resonance imaging
• reliability
• syndesmosis

• Ankle injuries
• Lower extremity injuries
• Sporting injuries

• ankle rehabilitation
• distal tibiofibular sprain
• syndesmosis ankle sprain
• syndesmosis instability

Maisonneuve fractures result from a disruption of the medial ankle structures and a proximal fibular fracture. Patient complaints can be misleading and there is a significant rate of delayed diagnosed injuries. We present a case of bilateral Maisonneuve fractures after a fall due to a syncopal collapse. A precise clinical examination led to this rare diagnosis. The injuries were treated with syndesmotic screw fixation, removal of hardware followed after 6 weeks. The patient was asymptomatic at three-months follow up. Patients with bilateral injuries undergoing standard surgical treatment can gain full recovery, but high suspicion in clinical examination is needed to detect this uncommon bilateral injury.

• ankle injury.
• bilateral
• maisonneuve fracture