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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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Peiffer M, Dhont T, Cuigniez F, Tampere T, Ashkani-Esfahani S, D'Hooghe P, Audenaert E, Burssens A. Application of external torque enhances the detection of subtle syndesmotic ankle instability in a weight-bearing CT. Knee Surg Sports Traumatol Arthrosc 2023; 31:4886-4894. [PMID: 37572141 DOI: 10.1007/s00167-023-07536-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 07/28/2023] [Indexed: 08/14/2023]
Abstract
PURPOSE Acute syndesmotic ankle injuries continue to impose a diagnostic dilemma and it remains unclear whether weightbearing and/or external rotation should be added during the imaging process. Therefore, the aim of this study was to assess if combined weightbearing and external rotation increases the diagnostic sensitivity of syndesmotic ankle instability using weightbearing CT (WBCT) imaging, compared to isolated weightbearing. METHODS In this retrospective study, patients with an acute syndesmotic ankle injury were analysed using a WBCT (N = 21; Age = 31.6 ± 14.1 years old). Inclusion criteria were an MRI confirmed syndesmotic ligament injury imaged by a WBCT of the ankle during weightbearing and combined weightbearing-external rotation. Exclusion criteria consisted of fracture associated syndesmotic injuries. Three-dimensional (3D) models were generated from the CT slices. Tibiofibular displacement and talar rotation were quantified using automated 3D measurements (anterior tibiofibular distance (ATFD), Alpha angle, posterior Tibiofibular distance (PTFD) and Talar rotation (TR) angle in comparison to the contralateral non-injured ankle. RESULTS The difference in neutral-stressed Alpha angle and ATFD showed a significant difference between patients with a syndesmotic ankle lesion and contralateral control (P = 0.046 and P = 0.039, respectively). The difference in neutral-stressed PTFD and TR angle did not show a significant difference between patients with a syndesmotic ankle lesion and healthy ankles (n.s.). CONCLUSION Application of combined weightbearing-external rotation reveals an increased ATFD in patients with syndesmotic ligament injuries. This study provides the first insights based on 3D measurements to support the potential relevance of applying external rotation during WBCT imaging. In clinical practice, this could enhance the current diagnostic accuracy of subtle syndesmotic instability in a non-invasive manner. However, to what extent certain displacement patterns require operative treatment strategies has yet to be determined in future studies. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- M Peiffer
- Department of Orthopaedics and Traumatology, Ghent University Hospital, 9000, Ghent, OVL, Belgium.
- Department of Human Structure and Repair, Ghent University, Corneel Heymanslaan 10, 9000, Ghent, OVL, Belgium.
- Foot and Ankle Research and Innovation Laboratory (FARIL), Harvard Medical School-Massachusetts General Hospital, Boston, MA, USA.
| | - T Dhont
- Department of Orthopaedics and Traumatology, Ghent University Hospital, 9000, Ghent, OVL, Belgium
| | - F Cuigniez
- Department of Orthopaedics and Traumatology, Ghent University Hospital, 9000, Ghent, OVL, Belgium
| | - T Tampere
- Department of Orthopaedics and Traumatology, Ghent University Hospital, 9000, Ghent, OVL, Belgium
| | - S Ashkani-Esfahani
- Foot and Ankle Research and Innovation Laboratory (FARIL), Harvard Medical School-Massachusetts General Hospital, Boston, MA, USA
| | - P D'Hooghe
- Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar
| | - E Audenaert
- Department of Orthopaedics and Traumatology, Ghent University Hospital, 9000, Ghent, OVL, Belgium
- Department of Human Structure and Repair, Ghent University, Corneel Heymanslaan 10, 9000, Ghent, OVL, Belgium
- Department of Electromechanics, Op3Mech Research Group, University of Antwerp, 2020, Antwerp, Belgium
- Department of Trauma and Orthopedics, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - A Burssens
- Department of Orthopaedics and Traumatology, Ghent University Hospital, 9000, Ghent, OVL, Belgium
- Department of Human Structure and Repair, Ghent University, Corneel Heymanslaan 10, 9000, Ghent, OVL, Belgium
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Peiffer M, Van Den Borre I, Segers T, Ashkani-Esfahani S, Guss D, De Cesar Netto C, DiGiovanni CW, Victor J, Audenaert E, Burssens A. Implementing automated 3D measurements to quantify reference values and side-to-side differences in the ankle syndesmosis. Sci Rep 2023; 13:13774. [PMID: 37612321 PMCID: PMC10447572 DOI: 10.1038/s41598-023-40599-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 08/14/2023] [Indexed: 08/25/2023] Open
Abstract
Detection of syndesmotic ankle instability remains challenging in clinical practice due to the limitations of two-dimensional (2D) measurements. The transition to automated three-dimensional (3D) measurement techniques is on the verge of a breakthrough but normative and side-to-side comparative data are missing. Therefore, our study aim was two-fold: (1) to establish 3D anatomical reference values of the ankle syndesmosis based on automated measurements and (2) to determine to what extent the ankle syndesmosis is symmetric across all 3D measurements. Patients without syndesmotic pathology with a non-weight-bearing CT scan (NWBCT; N = 38; Age = 51.6 ± 17.43 years) and weight-bearing CT scan (WBCT; N = 43; Age = 48.9 ± 14.3 years) were retrospectively included. After training and validation of a neural network to automate the segmentation of 3D ankle models, an iterative closest point registration was performed to superimpose the left on the right ankle. Subsequently, 3D measurements were manually and automatically computed using a custom-made algorithm and side-to-side comparison of these landmarks allowed one to investigate symmetry. Intra-observer analysis showed excellent agreements for all manual measurements (ICC range 0.85-0.99) and good (i.e. < 2.7° for the angles and < 0.5 mm for the distances) accuracy was found between the automated and manual measurements. A mean Dice coefficient of 0.99 was found for the automated segmentation framework. The established mean, standard deviation and range were provided for each 3D measurement. From these data, reference values were derived to differ physiological from pathological syndesmotic alignment. Furthermore, side-to-side symmetry was revealed when comparing left to right measurements (P > 0.05). In clinical practice, our novel algorithm could surmount the current limitations of manual 2D measurements and distinguish patients with a syndesmotic ankle lesion from normal variance.
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Affiliation(s)
- Matthias Peiffer
- Resident Orthopaedic Surgery, Department of Orthopaedics and Traumatology, Ghent University Hospital, Corneel Heymanslaan 10, OVL, 9000, Gent, Belgium.
- Department of Human Structure and Repair, Ghent University, Corneel Heymanslaan 10, OVL, 9000, Ghent, Belgium.
- Foot and Ankle Research and Innovation Laboratory (FARIL), Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA.
| | - Ide Van Den Borre
- Department of Human Structure and Repair, Ghent University, Corneel Heymanslaan 10, OVL, 9000, Ghent, Belgium
| | - Tanguy Segers
- Resident Orthopaedic Surgery, Department of Orthopaedics and Traumatology, Ghent University Hospital, Corneel Heymanslaan 10, OVL, 9000, Gent, Belgium
| | - Soheil Ashkani-Esfahani
- Foot and Ankle Research and Innovation Laboratory (FARIL), Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Daniel Guss
- Foot and Ankle Research and Innovation Laboratory (FARIL), Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | | | - Christopher W DiGiovanni
- Foot and Ankle Research and Innovation Laboratory (FARIL), Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Jan Victor
- Department of Orthopaedics and Traumatology, Ghent University Hospital, Corneel Heymanslaan 10, OVL, 9000, Gent, Belgium
| | - Emmanuel Audenaert
- Department of Human Structure and Repair, Ghent University, Corneel Heymanslaan 10, OVL, 9000, Ghent, Belgium
- Department of Orthopaedics and Traumatology, Ghent University Hospital, Corneel Heymanslaan 10, OVL, 9000, Gent, Belgium
- Department of Trauma and Orthopedics, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK
- Department of Electromechanics, Op3Mech Research Group, University of Antwerp, 2020, Antwerp, Belgium
| | - Arne Burssens
- Department of Human Structure and Repair, Ghent University, Corneel Heymanslaan 10, OVL, 9000, Ghent, Belgium
- Department of Orthopaedics and Traumatology, Ghent University Hospital, Corneel Heymanslaan 10, OVL, 9000, Gent, Belgium
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