Syndesmosis and deltoid ligament injuries in the athlete

Needle arthroscopic-assisted repair of tibio-fibular syndesmosis acute injury: A case report

BACKGROUND

Acute injuries to the tibiofibular syndesmosis, often associated with high ankle sprains or malleolar fractures, require precise diagnosis and treatment to prevent long-term complications. This case report explores the use of needle arthroscopy as a minimally invasive technique for the repair of tibiofibular syndesmosis injuries.

CASE SUMMARY

We report on a 40-year-old male patient who presented with a trimalleolar fracture and ankle subluxation following a high ankle sprain. Due to significant swelling and poor soft tissue quality, initial management involved external stabilization. Subsequently, needle arthroscopy was employed to assess and treat the tibiofibular syndesmosis injury. The procedure, performed under spinal anesthesia and fluoroscopic control, included nanoscopic evaluation of the ankle joint and reduction of the syndesmosis using a suture button. Follow-up assessments showed significant improvement in pain levels, range of motion, and functional scores. At 26 weeks post-procedure, the patient achieved full range of motion and pain-free status. Needle arthroscopy offers a promising alternative for the management of acute tibiofibular syndesmosis injuries, combining diagnostic and therapeutic capabilities with minimal invasiveness.

CONCLUSION

This technique may enhance clinical outcomes and reduce recovery times, warranting further investigation and integration into clinical practice.

Transformer-Based Multilabel Deep Learning Model Is Efficient for Detecting Ankle Lateral and Medial Ligament Injuries on Magnetic Resonance Imaging and Improving Clinicians' Diagnostic Accuracy for Rotational Chronic Ankle Instability

PURPOSE

To develop a deep learning (DL) model that can simultaneously detect lateral and medial collateral ligament injuries of the ankle, aiding in the diagnosis of chronic ankle instability (CAI), and assess its impact on clinicians' diagnostic performance.

METHODS

DL models were developed and externally validated on retrospectively collected ankle magnetic resonance imaging (MRI) between April 2016 and March 2022 respectively at 3 centers. Included patients had confirmed diagnoses of CAI through arthroscopy, as well as individuals who had undergone MRI and physical examinations that ruled out ligament injuries. DL models were constructed based on a multilabel paradigm. A transformer-based multilabel DL model (AnkleNet) was developed and compared with 4 convolution neural network (CNN) models. Subsequently, a reader study was conducted to evaluate the impact of model assistance on clinicians when diagnosing challenging cases: identifying rotational CAI (RCAI). Diagnostic performance was assessed using area under the receiver operating characteristic curve (AUC).

RESULTS

Our transformer-based model achieved AUCs of 0.910 and 0.892 for detecting lateral and medial collateral ligament injury, respectively, both of which were significantly higher than those of CNN-based models (all P < .001). In terms of further CAI diagnosis, there was a macro-average AUC of 0.870 and a balanced accuracy of 0.805. The reader study indicated that incorporation with our model significantly enhanced the diagnostic accuracy of clinicians (P = .042), particularly junior clinicians, and led to a reduction in diagnostic variability. The code of the model can be accessed at https://github.com/ChiariRay/AnkleNet.

CONCLUSIONS

Our transformer-based model was able to detect lateral and medial collateral ligament injuries based on MRI and outperformed CNN-based models, demonstrating a promising performance in diagnosing CAI, especially patients with RCAI.

CLINICAL RELEVANCE

Developing such an algorithm can improve the diagnostic performance of clinicians, aiding in identifying patients who would benefit from arthroscopy, such as patients with RCAI.

[Treatment of acute ankle distortion in footballers : Are we doing it particularly right or particularly wrong?]

BACKGROUND

Despite the high incidence of ankle sprains, the ideal treatment is controversial and a significant percentage of patients who have suffered an ankle sprain never fully recover. Even professional athletes are affected by this post-traumatic complication. There is strong evidence that permanent impairment after an ankle injury is often due to an inadequate rehabilitation and training program and too early return to sport.

THERAPY AND REHABILITATION

Therefore, athletes should start a criteria-based rehabilitation after ankle sprain and gradually progress through the programmed activities, including e.g. cryotherapy, edema reduction, optimal load management, range of motion exercises to improve ankle dorsiflexion and digital guidance, stretching of the triceps surae with isometric exercises and strengthening of the peroneus muscles, balance and proprioception training, and bracing/taping. The fact that this is professional sport does not exempt it from consistent, stage-appropriate treatment and a cautious increase in load. However, there are a number of measures and tools that can be used in the intensive care of athletes to improve treatment and results.

Syndesmosis Injury Contributes a Large Negative Effect on Clinical Outcomes: A Systematic Review

INTRODUCTION

The literature largely addresses questions of diagnostic accuracy and therapeutic accuracy. However, the magnitude of the clinical impact of syndesmosis injury is commonly described in intuitive yet qualitative terms. This systematic review aimed to quantify the impact of syndesmosis injury.

METHODS

Published clinical outcomes data were used to compute an effect size reflecting the impact of syndesmosis injury. This was done within the clinical contexts of isolated syndesmosis injury and syndesmosis injury with concomitant ankle fracture. Clinical outcomes data included Olerud-Molander (OM) and American Orthopaedic Foot and Ankle Society (AOFAS) scores, visual analog scale for pain, and days missed from sport competition. Parametric data were compared with Student t tests. Effect size was computed using Cohen's d.

RESULTS

In ankle fracture patients, syndesmosis injury demonstrated a large effect size for OM (d = 0.96) and AOFAS (d = 0.83) scores. In athletic populations without concomitant ankle fracture, syndesmosis injury demonstrated a large effect size on days missed from competition (d = 2.32).

DISCUSSION

These findings confirm the magnitude of the negative impact of syndesmosis injury in athletic populations with isolated injury and in ankle fracture patients. In ankle fracture patients, this large negative effect remains despite surgery. Thus, syndesmosis repair may not fully mitigate the impact of the injury.

LEVELS OF EVIDENCE

Level III: Systematic review.

Arthroscopic repair of the tibiotalar fascicle of deltoid ligament is feasible through anterior ankle arthroscopy

PURPOSE

Although arthroscopic repair of the deltoid ligament is becoming a popular procedure, no studies have assessed which bundles of the deltoid ligament can be reached by anterior ankle arthroscopy. This study aimed to assess the feasibility of the arthroscopic repair of the deep layer of the deltoid ligament. In addition, it aimed to correlate which fascicle of the superficial layer of the deltoid ligament corresponds to the deep fascicle visualised by arthroscopy.

METHODS

Arthroscopy was performed in 12 fresh frozen ankles by two foot and ankle surgeons. With the arthroscope introduced through the anterolateral portal, the medial compartment and the deltoid ligament were explored in ankle dorsiflexion without distraction. Using a suture passer introduced percutaneously, the most posterior fibres of the deep deltoid ligament visualised by anterior arthroscopy were tagged. Then, the ankles were dissected to identify the deep and superficial bundles of the deltoid ligament tagged with a suture.

RESULTS

In all specimens (100%), the intermediate part of the tibiotalar fascicle, corresponding to the fibres originating from the anterior colliculus, was tagged with a suture. The posterior part of the tibiotalar fascicle was never tagged with a suture. In all specimens, the intermediate part of the tibiotalar fascicle grasped by the suture correlated with the tibiospring fascicle of the superficial layer.

CONCLUSIONS

The current study demonstrates the feasibility of the arthroscopic repair of the deep fascicle of the deltoid ligament. By performing anterior arthroscopy, it is possible to visualise and repair the intermediate part of the tibiotalar fascicle (deep layer of the deltoid ligament). These fibres correspond to the tibiospring fascicle of the superficial layer. The clinical relevance of the current study is that the arthroscopic repair of the deep layer of the deltoid ligament is feasible through anterior ankle arthroscopy.

LEVEL OF EVIDENCE

Not applicable.

Stress Tests for Deltoid Ligament and Syndesmosis Injury in Patients With Ankle Fracture: A Systemic Review With Meta-Analysis

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.

The Clinical Outcomes of Syndesmotic Flexible Fixation for Syndesmotic Injury With Ankle Fracture

BACKGROUND

We evaluated whether the quality of syndesmotic reduction affects the short-term clinical outcomes of flexible fixation in patients with a rotational ankle fracture.

METHODS

This study included 59 patients (32 men and 27 women) who underwent syndesmotic flexible fixation. The degree of syndesmotic reduction was evaluated on computed tomography (CT) images acquired within 3 days after surgery. We measured the divergence between anterior and posterior incisura at 1 cm above the distal tibial articular joint, then evaluated the degree of fibular rotation relative to the tibia. At 1 year after surgery, an objective clinical evaluation was performed using the American Orthopaedic Foot & Ankle Society (AOFAS) score, the visual analog scale (VAS), and the Foot and Ankle Outcome Score (FAOS). Additionally, repeat arthroscopy was performed during routine implant removal at nearly 1 year postoperatively.

RESULTS

Among 59 patients who underwent syndesmotic flexible fixation, 56 patients had syndesmotic stability on repeat arthroscopy. At 1 year postoperation, AOFAS, VAS, and FAOS scores were, respectively, 90, 2.0, and 94 in the accurate reduction group (n = 24) and 90, 1.0, and 94.5 in the malreduction group (n = 35).

CONCLUSION

Reduction quality after syndesmotic injury with flexible fixation, as determined by early postoperative CT imaging, did not affect patient prognosis. In this cohort, syndesmotic reduction and flexible fixation may produce good clinical outcomes in patients with syndesmotic injury and ankle fracture.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

The Biomechanical Role of the Deltoid Ligament on Ankle Stability: Injury, Repair, and Augmentation

BACKGROUND

Deltoid ligament injuries occur in isolation as well as with ankle fractures and other ligament injuries. Both operative treatment and nonoperative treatment are used, but debate on optimal treatment continues. Likewise, the best method of surgical repair of the deltoid ligament remains unclear.

PURPOSE

To determine the biomechanical role of native anterior and posterior components of the deltoid ligament in ankle stability and to determine the efficacy of simple suture versus augmented repair.

STUDY DESIGN

Controlled laboratory study.

METHODS

Ten cadaveric ankles (mean age, 51 years; age range, 34-64 years; all male specimens) were mounted on a 6 degrees of freedom robotic arm. Each specimen underwent biomechanical testing in 8 states: (1) intact, (2) anterior deltoid cut, (3) anterior repair, (4) tibiocalcaneal augmentation, (5) deep anterior tibiotalar augmentation, (6) posterior deltoid cut, (7) posterior repair, and (8) complete deltoid cut. Testing consisted of anterior drawer, eversion, and external rotation (ER), each performed at neutral and 25° of plantarflexion. A 1-factor, random-intercepts, linear mixed-effect model was created, and all pairwise comparisons were made between testing states.

RESULTS

Cutting the anterior deltoid introduced ER (+2.1°; P = .009) and eversion laxity (+6.2° of eversion; P < .001) at 25 degrees of plantarflexion. Anterior deltoid repair restored native ER but not eversion. Tibiocalcaneal augmentation reduced eversion laxity, but tibiotalar augmentation provided no additional benefit. The posterior deltoid tear showed no increase in laxity. Complete tear introduced significant anterior translation, ER, and eversion laxity (+7.6 mm of anterior translation, +13.8° ER and +33.6° of eversion; P < .001).

CONCLUSION

A complete deltoid tear caused severe instability of the ankle joint. Augmented anterior repair was sufficient to stabilize the complete tear, and no additional benefit was provided by posterior repair. For isolated anterior tear, repair with tibiocalcaneal augmentation was the optimal treatment.

CLINICAL RELEVANCE

Deltoid repair with augmentation may reduce or avoid the need for prolonged postoperative immobilization and encourage accelerated rehabilitation, preventing stiffness and promoting earlier return to preinjury activity.

Incidence of Injuries Associated With Anterior Talofibular Ligament Injury Based on the Reporting of Magnetic Resonance Imaging

Introduction This paper aims to report the incidence of ligamentous, tendon, and other structural injuries associated with an anterior talofibular ligament (ATFL) injury based on magnetic resonance imaging (MRI) findings. Methods The reports of all patients who underwent surgical treatment for ATFL injury between 2021 and 2022 at Changi General Hospital and had preoperative MRI ankle scans performed were analyzed in this retrospective study. Patients who had a preoperative MRI ankle scan performed with specific reporting of the ATFL, calcaneofibular ligament (CFL), deltoid ligaments, peroneal tendons, and the presence of an osteochondral defect (OCD) were included in this study. Patients who underwent surgery but did not have a preoperative MRI ankle scan done or had ankle fractures or systemic conditions affecting the same ankle were excluded. Results Eighty-six patients were included in this study, of which 59 were males and 27 were females. About 73.3% (63 of 86) of patients had sustained injuries in association with ATFL injury, and 58.1% (50 of 86) of patients suffered an associated injury to the calcaneofibular ligament (CFL). There were injuries to the superficial and deep deltoid ligaments in 29.1% (25 of 86) and 44.2% (38 of 86) of patients, respectively. The peroneal tendons were also injured in 17.4% (15 of 86) of patients. Lastly, there were also associated OCDs found in 19.8% (17 of 86) of patients. Conclusion There is a high incidence of injuries associated with an ATFL injury. The CFL and deltoid ligament complex are the most commonly injured structures in association with the ATFL. One in five patients will also have an associated OCD. The ATFL tends to be the only structure that is commonly addressed during surgery. Repair of the ATFL only may thus lead to poorer outcomes and persistent pain, if the underlying cause is due to the other concurrent injuries. Clinical evaluation of the other structures should thus be thoroughly performed to allow the addressing of any concurrent injuries in the same surgical setting to achieve better outcomes.

Republication of "High-Speed Video Analysis of Syndesmosis Injuries in Soccer-Can It Predict Injury Mechanism and Return to Play? A Pilot Study"

Background

Ankle syndesmosis injuries in professional soccer may lead to an unpredictable and prolonged recovery. This injury has been investigated in anatomical and radiologic studies but the precise mechanism leading to syndesmosis injury is not well understood and remains debated. The 2 goals of this study were to (1) evaluate the relationship between the mechanism of syndesmosis injury as determined by high-speed video analysis and the injured structures identified by clinical and radiologic examination and to (2) investigate the relationship between mechanism of injury and time of return to play.

Methods

This pilot study prospectively reviewed high-speed video analysis of 12 professional soccer players who sustained syndesmosis injuries. The mechanism of injury was compared with the clinical and MRI evaluation and the time taken to return to play.

Results

Higher-grade syndesmosis injuries occurred during ankle external rotation with dorsiflexion. Supination-inversion injuries with a standard lateral ankle sprain (rupture of the anterior talofibular ligament) may extend proximally, causing a lower-grade syndesmosis injury. These may present with signs of a high ankle sprain but have a quicker return to sport than those following a dorsiflexion-external rotation injury (mean 26 days vs 91 days).

Conclusions

Video analysis confirmed that at least 2 mechanisms may result in injury to the ankle syndesmosis. Those "simple" ankle sprains with signs of syndesmosis injury had a quicker return to play. This new finding may be used by club medical teams during their initial assessment and help predict the expected time away from soccer in players with suspected high ankle sprains.

Level of Evidence

Level IV, retrospective cohort study.

Multidirectional Chronic Ankle Instability: What Is It?

Not all ankle sprains are the same and not all ankles behave the same way after an injury. Although we do not know the mechanisms behind an injury producing an unstable joint, we do know ankle sprains are highly underestimated. While some of the presumed lateral ligament lesions might eventually heal and produce minor symptoms, a substantial number of patients will not have the same outcome. The presence of associated injuries, such as additional medial chronic ankle instability, chronic syndesmotic instability, has been long discussed as a possible reason behind this. To explain multidirectional chronic ankle instability, this article aims to present the literature surrounding the condition and its importance nowadays.

Sprain of the Medial Ankle Ligament Complex

Injuries of the medial ankle ligament complex (MALC; deltoid and spring ligament) are more common following ankle sprains than expected, especially in eversion-external rotation mechanisms. Often these injuries are associated with concomitant osteochondral lesions, syndesmotic lesions, or fractures of the ankle joint. The clinical assessment of the medial ankle instability together with a conventional radiological and MR imaging is the basis for the definition of the diagnosis and therefore the optimal treatment. This review aims to provide an overview as well as a basis to successfully manage MALC sprains.

Comparison of the diagnostic value of measurements of transverse syndesmotic interval and 'lambda sign' in distinguishing latent syndesmotic diastasis in chronic lateral ankle instability: a cross-sectional study of 188 cases

INTRODUCTION

Chronic lateral ankle instability (CLAI) could accompany with latent syndesmotic diastasis (LSD), which is difficult to distinguish before surgery. Tibiofibular interval width and extravasation of joint fluid ('lambda sign') on MRI are widely used in the diagnosis of syndesmotic injury, but the reliability of these methods in distinguishing the associated LSD in CLAI was rarely studied. Our objective was to compare the diagnostic value of the measurement of the transverse tibiofibular interval and 'lambda sign' on MRI in distinguishing LSD in CLAI and to investigate the radiological predictor that best matched the intraoperatively measured syndesmotic width.

METHODS

138 CLAI patients undergoing arthroscopy in our institute from March 2017 to June 2020 were enrolled (CLAI group). Anterior space width (ASW) and posterior space width (PSW) at 10 mm layer above tibial articular and fluid height above tibial articular surface (FH) were measured on preoperative MRI. The same parameters were measured on MRI of 50 healthy volunteers as control group. At arthroscopy, syndesmotic width was measured and the patients were divided into arthroscopic widening (AW) and arthroscopic normal (AN) subgroup taking 2 mm as critical value. The CLAI group was compared with the control group to explore the interval changes related to CLAI. The AW and AN subgroups were compared to explore the potential diagnostic indicators and reference values for the LSD.

RESULTS

All parameters showed significant difference between CLAI group and control group (p < 0.05), but only PSW (p = 0.004) showed significant difference between AW and AN subgroups other than FH (p = 0.461). Only PSW was involved in formula of multiple-factor analysis (p = 0.005; OR, 1.819; 95%CI, 1.196-2.767). ROC analysis showed critical value of PSW was 3.8 mm (sensitivity, 66%; specificity, 66%; accuracy, 66.7%), while accuracy of lambda sign was 41.3%.

CONCLUSIONS

Transverse tibiofibular interval measurements were more reliable than the 'lambda sign' in distinguishing associated LSD in CLAI patients. The PSW ≥ 3.8 mm could be a predictor of syndesmotic diastasis.

Statistical shape model-based tibiofibular assessment of syndesmotic ankle lesions using weight-bearing CT

Forced external rotation is hypothesized as the key mechanism of syndesmotic ankle injuries, inducing a three-dimensional deviation from the normal distal tibiofibular joint (DTFJ) alignment. However, current diagnostic imaging modalities are impeded by a two-dimensional assessment, without considering ligamentous stabilizers. Therefore, our aim is threefold: (1) to construct an articulated statistical shape model of the normal DTFJ with the inclusion of ligamentous morphometry, (2) to investigate the effect of weight-bearing on the DTFJ alignment, and (3) to detect differences in predicted syndesmotic ligament length of patients with syndesmotic lesions with respect to normative data. Training data comprised non-weight-bearing CT scans from asymptomatic controls (N = 76), weight-bearing CT scans from patients with syndesmotic ankle injury (N = 13), and their weight-bearing healthy contralateral side (N = 13). Path and length of the syndesmotic ligaments were predicted using a discrete element model, wrapped around bony contours. Statistical shape model evaluation was based on accuracy, generalization, and compactness. The predicted ligament length in patients with syndesmotic lesions was compared with healthy controls. With respect to the first aim, our presented skeletal shape model described the training data with an accuracy of 0.23 ± 0.028 mm. Mean prediction accuracy of ligament insertions was 0.53 ± 0.12 mm. In accordance with the second aim, our results showed an increased tibiofibular diastasis in healthy ankles after weight-bearing. Concerning our third aim, a statistically significant difference in anterior syndesmotic ligament length was found between ankles with syndesmotic lesions and healthy controls (p = 0.017). There was a significant correlation between the presence of syndesmotic injury and the positional alignment between the distal tibia and fibula (r = 0.873, p < 0,001). Clinical Significance: Statistical shape modeling combined with patient-specific ligament wrapping techniques can facilitate the diagnostic workup of syndesmosic ankle lesions under weight-bearing conditions. In doing so, an increased anterior tibiofibular distance was detected, corresponding to an "anterior open-book injury" of the ankle syndesmosis as a result of anterior inferior tibiofibular ligament elongation/rupture.

Augmented stress weightbearing CT for evaluation of subtle tibiofibular syndesmotic injuries in the elite athlete

OBJECTIVE

We aim to present a novel imaging technique utilizing weight-bearing CT with syndesmotic stress to identify subtle, unstable syndesmotic injuries. We illustrate this with a case presentation of such an injury in an elite athlete that ultimately required operative fixation.

MATERIALS AND METHODS

In order to perform an augmented stress weightbearing CT, the patient is in the standing position, feet facing forward, and with weight distributed equally. The patient is then coached to internally rotate the shin and knee. This places an external rotational moment on the TFS due to the planted foot and ankle. The augmented stress images undergo 3D reconstruction and post-processing to render coronal and sagittal images. These are subsequently compared to standard, conventional weightbearing CT images performed without the external rotation stress.

RESULTS

We illustrate this technique by presenting a case in which a 21-year-old collegiate athlete sustained a Grade II syndesmotic injury, diagnosed by MRI and clinical exam without evidence of instability by standard weightbearing CT or weightbearing radiographs. After undergoing the augmented stress weightbearing CT, the instability was noted. This prompted subsequent operative fixation and ultimately return to sport.

CONCLUSION

We propose this technique for diagnosing unrecognized, subtle dynamically unstable syndesmosis injuries where clinical suspicion persists despite negative imaging, particularly in the elite athlete.

Acute clinical evaluation for syndesmosis injury has high diagnostic value

PURPOSE

To determine the diagnostic value of injury history, physical examination, six syndesmosis tests and overall clinical suspicion for syndesmosis injury.

METHODS

All athletes (> 18 yrs) with an acute ankle injury presenting within 7 days post-injury were assessed for eligibility. Acute ankle injuries were excluded if imaging studies demonstrated a frank fracture or 3 T MRI could not be acquired within 10 days post-injury. Standardized injury history was recorded, and physical examination was performed by an Orthopaedic Surgeon or Sports Medicine Physician. Overall clinical suspicion was documented prior to MRI. Multivariate logistic regression was used to determine the association between independent predictors and syndesmosis injury.

RESULTS

Between September 2016 and July 2019, a total of 150 acute ankle injuries were included. The median time from injury to acute clinical evaluation was 2 days (IQR 2). Prior to clinical evaluation, the median patient reported Visual Analog Scale for pain was 8/10 (IQR 2). Syndesmosis injury was present in 26 acute ankle injuries. An eversion mechanism of injury had a positive LR 3.47 (CI 95% 1.55-7.77). The squeeze tests had a positive LR of 2.20 (CI 95% 1.29-3.77) and a negative LR of 0.68 (CI 95% 0.48-0.98). Overall clinical suspicion had a sensitivity of 73% (CI 95% 52-88) and negative predictive value of 89% (CI 95% 78-95). Multivariate regression analyses demonstrated significant association for eversion mechanism of injury (OR 4.99; CI 95% 1.56-16.01) and a positive squeeze test (OR 3.25; CI 95% 1.24-8.51).

CONCLUSIONS

In an acute clinical setting with patients reporting high levels of ankle pain, a negative overall clinical suspicion reduces the probability of syndesmosis injury. Eversion mechanism of injury and a positive squeeze test are associated with higher odds of syndesmosis injury.

LEVEL OF EVIDENCE

Level III.

Treatment and outcome of a patient with low-energy 'Logsplitter' injury

The low-energy ‘Logsplitter’ fracture, caused by a sprain or fall, is characterized by an intact or slightly separated inferior tibiofibular joint. Compared with the high-energy ‘Logsplitter’ fracture, this atypical subtype is rarely seen and is easily missed. Here, the case of a 33-year-old male patient with a fractured right ankle as a result of a sprain during walking is reported. The patient initially received routine surgical treatment comprising internal fixation of the fibular, medial and posterior malleoli. Unexpectedly, post-surgery imaging examinations revealed that the medial clear space of the right ankle had widened to 6 mm, due to incomplete reduction of the lateral malleolus, shortening and rotation of the fibula, and an unreduced avulsion fracture block of the anterior malleolus. A revision surgery was then performed to anatomically reduce and fix the lateral malleolus, as well as the anterior malleolus avulsion fracture. During 5 months following surgery, the patient achieved good fracture union and functional restoration of the right ankle. For this rare injury, the present case demonstrates that complete restoration of the fracture is required to achieve good clinical efficacy.

Deltoid ligament (DL) repair produced better results than DL nonrepair for the treatment for rotational ankle instability

PURPOSE

To compare the clinical and magnetic resonance imaging (MRI) results after arthroscopic deltoid ligament (DL) repair versus DL nonrepair in patients with rotational ankle instability.

METHODS

All patients with rotational ankle instability were enrolled in this retrospective cohort study. Clinical evaluation was performed by the American Orthopedic Foot and Ankle Society (AOFAS) score, Karlsson Ankle Functional Score (KAFS), and Tegner activity score preoperatively and at a minimum follow-up of 2 years. MRI at follow-up was performed to evaluate the DL morphology.

RESULTS

A total of 50 patients were enrolled in this study. Among them, 24 patients received DL repair (the repair group), whereas 26 patients did not (the nonrepair group). No significant difference was found in the AOFAS score (98 ± 4 vs. 97 ± 4; n.s.), KAFS (94 ± 7 vs. 93 ± 9; n.s.), or Tegner activity score (5 ± 2 vs. 5 ± 1; n.s.) between the repair group and the nonrepair group at the final follow-up. However, the repair group had a significantly shorter return-to-sport time than the nonrepair group (4.6 ± 1.6 mo vs. 6.0 ± 2.5 mo; p = 0.03). Comparison of the postoperative deltoid ligament showed that the repair group had a lower signal intensity than the nonrepair group.

CONCLUSION

Arthroscopic treatment of rotational ankle instability revealed good to excellent clinical results. However, patients who underwent DL repair had a significantly earlier return to sports as well as a lower signal intensity of DL than those who did not undergo DL repair.

LEVEL OF EVIDENCE

Level III.

Anatomic Repair of Deltoid Ligaments in Acute Injury With Suture Anchor Technique

Acute disruption of the deltoid ligament usually occurs in rotational ankle fracture. If left untreated, its instability may contribute to ankle arthritis. We have designed a suture technique to repair all deltoid ligament layers. It provides anatomic ligament-to-bone repair of the superficial and deep deltoid ligaments and anchor suture reinforcement. This technique may protect the horizontally oriented fibers of the deep deltoid ligaments and allow them to heal with sufficient rest while providing immediate stability of the construct. The superficial ligaments are then repaired with residual anchor sutures. [Orthopedics. 2022;45(3):e168-e173.].

Arthroscopic Quantitative Measurement of Medial Clear Space for Deltoid Injury of the Ankle: A Cadaveric Comparative Study With Stress Radiography

BACKGROUND

The deltoid ligament (DL) is an important stabilizer of the ankle. DL injury of varying severity can occur alone or with syndesmotic injury and fibular fracture. Limited diagnostic tools are available to assess DL injury quantitatively.

PURPOSE

To establish an arthroscopic quantitative assessment of DL injury and to compare its performance with that of external rotation stress (ERS) and gravity stress (GS) radiography.

STUDY DESIGN

Controlled laboratory study.

METHODS

In total, 24 cadaveric lower extremities were divided into 4 groups: group 1 consisted of intact DL, group 2 of superficial DL disruption, group 3 of deep DL disruption, and group 4 of complete DL (superficial and deep) disruption. All specimens underwent sequential sectioning of syndesmotic ligaments, and medial clear space (MCS) was measured with ankle arthroscopy, ERS radiography, and GS radiography at different stages of syndesmotic sectioning.

RESULTS

For noninjured deltoid (group 1) and injured deltoid (groups 2-4), area under the receiver operating characteristic curve (AUC) of measurement of MCS was 0.939 for arthroscopy, 0.932 for ERS radiography, and 0.874 for GS radiography, with a significant difference between arthroscopy and GS radiography (P = .014). For incomplete deltoid injury (groups 1-3) and complete deltoid injury (group 4), the AUC of MCS was 0.811 for arthroscopy, 0.656 for ERS radiography, and 0.721 for GS radiography, with a significant difference between arthroscopy and ERS radiography (P < .001) and between arthroscopy and GS radiography (P = .035). For all stages of syndesmotic sectioning, cutoff values of arthroscopic MCS with intact fibula were ≤2.5 mm for intact DL, between 2.5 and 3.5 mm for partial DL injury (superficial or deep), and ≥3.5 mm for complete DL injury. Arthroscopy was unable to detect a difference between superficial deltoid injury (group 2) and deep deltoid injury (group 3) in partial DL injury, with a measured MCS between 2.5 and 3.5 mm. The intraclass correlation coefficient of interrater reliability was 0.975 for arthroscopy, 0.917 for ERS radiography, and 0.811 for GS radiography.

CONCLUSION

Arthroscopic MCS measurement can differentiate intact DL, partial DL injury, and complete DL injury. Compared with ERS and GS radiography, arthroscopic MCS measurement has greater accuracy with excellent interrater reliability.

CLINICAL RELEVANCE

For patients with suspected DL injury, arthroscopic MCS is useful for determining deltoid lesion severity based on defined cutoff values for consideration in preoperative planning to improve surgical outcomes.

3-T MRI of the Ankle Tendons and Ligaments

Ankle sprain is the most common injury in athletic populations. Ligament and tendon pathologies of the ankle are common, ranging from traumatic injuries to degeneration leading to chronic pain and acquired foot deformities. MRI is the imaging modality of choice to evaluate tendon and ligament pathology of the ankle, specifically derangements of tendons and ligaments. 3-T MRI offers improved imaging characteristics relative to 1.5-T MRI, allowing for better delineation of anatomic detail and pathology. This article provides a review of the anatomy and common pathologies of the ankle ligaments and tendons using high-resolution 3-T MRI.

Functional outcomes of unstable ankle fractures with and without syndesmotic fixation in the adolescent population

PURPOSE

The purpose of this study was to compare functional outcomes of adolescents with and without ankle syndesmotic injuries and identify predictors of functional outcome after operative ankle fractures.

METHODS

A retrospective review was conducted on operative adolescent ankle fractures treated between 2009 and 2019 with a minimum of one-year follow-up (mean 4.35 years). Patients who underwent syndesmotic fixation (SF) (n = 48) were compared with operative ankle fractures without syndesmotic injury (n = 63). Functional outcomes were assessed using standardized questionnaires, specifically the Foot and Ankle Ability Measure (FAAM) and Single Assessment Numerical Evaluation.

RESULTS

There were no differences in patient-reported outcomes, rates of return to sport or complications between groups with and without SF. The SF group had a longer tourniquet time (p = 0.04), duration of non-weight-bearing (p = 0.01), more Weber C fibula fractures (p < 0.001), fewer medial malleolus fractures (p = 0.03) and more frequently underwent implant removal (p < 0.0001). Male sex, lower body mass index (BMI) and longer duration of follow-up were significant predictors of a higher FAAM sports score using multivariable linear regression. SF was not a predictor of functional outcome.

CONCLUSION

This study demonstrated that patients that undergo surgical fixation of syndesmotic injuries have equivalent functional outcomes compared to operative ankle fractures without intraoperative evidence of syndesmotic injury. We also identified that male sex, lower BMI and longer duration of follow-up are predictors of a good functional outcome.

LEVEL OF EVIDENCE

III.

Functional outcome of fusion versus ligament reconstruction in patients with a syndesmosis injury: A narrative review

Injury to distal tibiofibular syndesmosis is commonly associated with ankle fractures. The surgical treatment especially in isolated chronic syndesmosis instability is still debated. This article has reviewed literature identified from PubMed, EMBASE and Cochrane from year 2000 onwards and compared the functional outcomes between syndesmosis fusion and ligament reconstruction based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Eighteen studies were included. All the included papers described a good-to-excellent post-operative functional outcome without major complications. No significant difference between the two surgical interventions could be concluded. Further studies of better quality shall be conducted in the future.

Ankle and syndesmosis instability: consensus and controversies

Ankle sprains are mainly benign lesions, but if not well addressed can evolve into permanent disability. A non-treated lateral, syndesmotic or medial ankle instability can evolve into ankle osteoarthritis. For this reason, diagnosis and treatment of these entities is of extreme importance.In general, acute instabilities undergo conservative treatment, while chronic instabilities are better addressed with surgical treatment. It is important to identify which acute instabilities are better treated with early surgical treatment.Syndesmosis injuries are frequently overlooked and represent a cause for persistent pain in ankle sprains. Unstable syndesmotic lesions are always managed by surgery.Non-treated deltoid ligament ruptures can evolve into a progressive valgus deformity of the hindfoot, due to its links with the spring ligament complex. This concept would give new importance to the diagnosis and treatment of acute medial ligament lesions.Multi-ligament lesions are usually unstable and are better treated with early surgery. A high suspicion rate is required, especially for combined syndesmotic and medial lesions or lateral and medial lesions.Ankle arthroscopy is a powerful tool for both diagnostic and treatment purposes. It is becoming mandatory in the management of ankle instabilities and multiple arthroscopic lateral/syndesmotic/medial repair techniques are emerging. Cite this article: EFORT Open Rev 2021;6:420-431. DOI: 10.1302/2058-5241.6.210017.

Deltoid Rupture in Ankle Fractures: To Repair or Not to Repair?

The most common injury mechanism for ankle fractures with concomitant deltoid ligament injury is a supination external rotation type 4 trauma. In the acute setting, malalignment, ecchymosis, and profound edema of the affected ankle can be found. Clinical examination is a poor indicator for deltoid ligament injury. There is a lack of high-quality studies with suturing the deltoid as the primary question. The authors found 4 comparative studies that found it unnecessary to explore and to reconstruct the deltoid ligament and 4 comparative studies that find it unnecessary to explore and to reconstruct the deltoid ligament.

Maisonneuve injury with no fibula fracture: A case report

BACKGROUND

Ankle syndesmosis injury is difficult to diagnose accurately at the initial visit. Missed diagnosis or improper treatment can lead to chronic complications. Complete syndesmosis injury with a concomitant rupture of the interosseous membrane (IOM) is more unstable and severe. The relationship between this type of injury and Maisonneuve injury, in which the syndesmosis is also injured, has not been discussed in the literature previously.

CASE SUMMARY

A 16-year-old patient sustained left medial malleolar fracture, and the associated inferior tibiofibular syndesmotic instability was overlooked. After open reduction and internal fixation of the medial malleolar fracture, inferior tibiofibular syndesmosis diastasis with IOM rupture was detected by auxiliary imaging. Secondary surgical intervention was performed to reduce anatomically and fix with two trans-syndesmosis screws. Twelve weeks later, the screws were removed. At the 6-mo follow-up, the patient gained full range of motion of the ankle.

CONCLUSION

Complete syndesmosis injury with IOM rupture should be considered Maisonneuve-type injury. Open reduction and internal fixation could obtain good outcomes.

Deep deltoid ligament injury is related to rotational instability of the ankle joint: a biomechanical study

PURPOSE

In the athletic population, the prevalence of isolated syndesmotic lesions is high. To detect potential instability of the ankle is crucial to define those lesions in need of surgical management. The aim was to define how the extent of tibio-fibular syndesmotic ligament injury influences the overall stability of the ankle joint in a cadaver model.

METHODS

Twenty fresh-frozen through knee cadaveric leg specimens were subjected to different simulated syndesmotic ligament lesions. In Group 1 (n = 10), the order of ligament sectioning was: anterior tibio-fibular ligament (ATFL), superficial deltoid ligament (SDL), deep deltoid ligament (DDL), posterior tibio-fibular ligament (PTFL), and progressive sectioning at 10, 50 and 100 mm of the distal interosseous membrane (IOM). In Group 2 (n = 10), the sequence was: ATFL, PITFL, 10 and then 50 mm of the distal IOM, SDL, DDL, and 100 mm of the distal IOM. Diastasis of 4 mm in the coronal or sagittal plane and external rotation of the ankle greater than 20° were considered indicative of instability.

RESULTS

Both coronal and sagittal diastasis exceeded 4 mm with injury patterns characterized by IOM lesions extending beyond 5 cm. External rotation of the ankle exceeded 20° with injury patterns characterized by a DDL lesion.

CONCLUSION

Coronal and sagittal plane diastases of the tibio-fibular syndesmosis are particularly affected by sequential lesions involving the IOM, whereas increased external rotation of the ankle most depends on DDL. The identification of the specific syndesmotic and deltoid ligament injuries is crucial to understanding which lesions need operative management. The knowledge of which pattern of tibio-fibular syndesmotic ligament injury influences the ankle joint stability is crucial in defining which lesions need for surgical management.

Ankle injuries in athletes: A review of the literature

Ankle injuries are commonplace in the athletic population, with lateral ligament sprains accounting for the majority of them. The medial ligament complex, the distal tibiofibular syndesmosis as well as any of the bones that constitute the ankle joint can also be injured. Typical mechanisms of injury include inversion-plantarflexion and external rotation on a supinated, dorsiflexed or pronated foot. Lesions of the ankle present with similar symptoms of pain, swelling and tenderness. Therefore, a thorough history and physical examination must be obtained to make the correct diagnosis. This is especially critical for athletes as certain injuries can lead to termination of their career if not treated accurately on time. Imaging may be useful in some cases to confirm or rule out differential diagnoses. Most injuries can be managed conservatively using the Protection, Rest, Ice, Compression and Elevation protocol followed by a comprehensive rehabilitation programme. Surgery is reserved for grade III ligament tears that are refractory to initial non-operative treatment and displaced fractures that are unlikely to unite without surgical intervention. The objective of this review is to discuss the common ankle injuries encountered in the athletic population and the approaches to their diagnosis and management.

Diagnosing instability of ligamentous syndesmotic injuries: A biomechanical perspective

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.

Optimizing Return to Play for Common and Controversial Foot and Ankle Sports Injuries

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Surgical decision-making should consider factors to help optimize return to play for athletes with foot and ankle injuries, including injuries to the syndesmosis, the Achilles tendon, the fifth metatarsal, and the Lisfranc complex. Understanding influential factors on return to play may help orthopaedic surgeons counsel athletes and coaches on expectations for a timeline to return to play and performance metrics.

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Outcomes after rigid and flexible fixation for syndesmotic injuries are generally favorable. Some data support an earlier return to sport and higher functional scores with flexible fixation, in addition to lower rates of reoperation and a decreased incidence of malreduction, particularly with deltoid repair, if indicated.

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Minimally invasive techniques for Achilles tendon repair have been shown to have a decreased risk of wound complications. Athletes undergoing Achilles repair should expect to miss a full season of play to recover.

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Athletes with fifth metatarsal fractures have better return-to-play outcomes with surgical management and can expect a high return-to-play rate within approximately 3 months of surgery.

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Percutaneous treatment of Lisfranc injuries may expedite return to play relative to open procedures.

Limited intrarater and interrater reliability of acute ligamentous ankle injuries on 3 T MRI

OBJECTIVES

To determine the diagnostic reliability of the Schneck grading system for acute ligamentous injuries of (1) the three major ligamentous ankle complexes, (2) the individual ankle ligaments and (3) the Sikka classification for syndesmosis injury.

METHODS

All acute ankle injuries in adult athletes (≥18 years), presenting to the outpatient department of a specialised Orthopaedic and Sports Medicine Hospital, within 7 days postinjury were screened for inclusion. Ankle injuries were excluded if imaging demonstrated a frank ankle fracture or if the 3 T MRI study could not be acquired within 10 days postinjury. Two radiologists graded the three major ligamentous complexes (lateral ankle complex, deltoid complex and syndesmosis complex) and their comprising individual ligaments according the four-grade Schneck grading system. Syndesmotic injuries were classified according the four-grade Sikka classification for consequent injury of the individual syndesmosis ligaments and the deltoid complex. Agreement and kappa (K) statistics were calculated to determine intrarater and interrater reliability.

RESULTS

Between September 2016 and September 2018, a total of 92 MR scans were obtained (87 patients). Interrater and intrarater reliability of the Schneck grading system was moderate to substantial for the lateral ankle complex (K=0.47-0.76), fair to almost perfect for the syndesmosis complex (K=0.37-0.89) and fair to moderate for the deltoid complex (K=0.14-0.51). For the individual ligaments, kappa values ranged from moderate to substantial for the anterior talofibular ligament (ATFL) (K=0.55-0.73), fair to substantial for the calcaneofibular ligament (K=0.31-0.62) and fair to almost perfect for the anteroinferior tibiofibular ligament (AITFL) (K=0.36-0.89). Diagnostic reliability of the Sikka classification ranged from moderate to almost perfect (K=0.51-0.95).

CONCLUSIONS

Grading of the three major ligamentous complexes and of the individual ankle ligaments according the Schneck grading system resulted in limited diagnostic reliability. When dichotomised for the presence of complete discontinuity, the interrater reliability of the Schneck grading system improved to substantial and almost perfect for the ATFL and AITFL, respectively. Classification of syndesmosis injury according the Sikka classification resulted in moderate interrater reliability.

Diagnosing syndesmotic instability with dynamic ultrasound - establishing the natural variations in normal motion

BACKGROUND

Syndesmotic instability, when subtle, is challenging to diagnose and often requires visualization of the syndesmosis during applied stress. The primary aim was to assess normal distal tibiofibular motion in the sagittal plane using dynamic ultrasound under stress conditions. The secondary aim was to evaluate the reliability of dynamic stress ultrasonography.

METHODS

Twenty-eight participants without history of ankle injury were included. Sagittal fibular translation was generated by applying a manual force to the fibula from anterior to posterior and from posterior to anterior. Distance between the ultrasound probe and the fibula was taken at two predefined points: 1) no force applied and, 2) during maximum force application. Each participant was scanned twice by two independent examiners, and each scan was analysed by two independent examiners. Three participants were scanned a second time by the same examiner who analysed these films twice to assess for intraobserver agreement. Means of exam 1 versus exam 2 were compared using a mixed linear model. Agreement among observers was calculated using intraclass correlation coefficients (ICC) interpreted as 0.4, poor; 0.4 〈 ICC < 0.59, acceptable; 0.6 < ICC < 0.74, good; ICC 〉 0.74, excellent.

RESULTS

Fifty-six ankles were included in the study, including 16 (57%) males and 12 (42%) females. Average anterior to posterior fibular sagittal translation was 0.89 ± 0.6 mm and posterior to anterior fibular sagittal translation was 0.49 ± 1.1 mm. Anterior to posterior translation means of exam 1 versus exam 2 showed no significant differences, means of 0.81 mm [0.7-0.9] versus 0.77 mm [0.7-1.0], and posterior to anterior means [95% CI] of 0.42 mm [0.3-0.5] versus 0.44 mm [0.2-0.6] (p-values 0.416 and 0.758, respectively). Excellent Inter- and intraobserver agreement was found for all measurements taken.

CONCLUSION

Dynamic ultrasound allows one to effectively and readily evaluate sagittal translation of the distal tibiofibular joint. It is able to afford bilateral comparisons, which becomes critical as the amount of syndesmotic instability approaches greater degrees of subtlety.

Mechanisms of acute ankle syndesmosis ligament injuries in professional male rugby union players: a systematic visual video analysis

BACKGROUND

The mechanisms of acute ankle syndesmosis ligament injuries in professional rugby union are not well understood.

AIM

To describe the mechanisms of acute ankle syndesmosis ligament injuries in male professional rugby union players using systematic visual video analysis.

METHODS

All time-loss acute ankle syndesmosis ligament injuries identified via retrospective analysis of the Leinster Rugby injury surveillance database across the 2013/2014 to 2017/2018 seasons were considered as potentially eligible for inclusion. Three Chartered Physiotherapists (analysts) independently assessed all videos with a final consensus meeting convened to describe the injury mechanisms. One of the analysts developed a qualitative description of each injury mechanism.

RESULTS

Thirteen acute ankle syndesmosis injuries were included in this study. The most common biomechanical presentation of the injured limb was characterised by hip flexion, knee flexion, knee valgus, ankle dorsiflexion, pronation and external rotation of the foot. Six of the included injuries (46%) were the result of an external load application to the injured limb (ie, direct contact injuries). In the other seven instances (54%), the injury was the result of a collapse of the injured player's body mass over the injured ankle joint, while tackling or being tackled, without direct contact to the injured limb (ie, indirect contact injuries).

CONCLUSION

Injuries incurred while tackling were exclusively the result of suboptimal tackle mechanics. A majority of injuries incurred while being tackled involved a posterior tackle, which often resulted in a posterior collapse of the injured player's centre of mass over a fixed externally rotated foot.

Diagnostic value of ultrasonography in acute lateral and syndesmotic ligamentous ankle injuries

Objectives

To determine the diagnostic value of ultrasonography for complete discontinuity of the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL) and the anterior inferior tibiofibular ligament (AITFL).

Methods

All acute ankle injuries in adult athletes (> 18 years old) presenting to the outpatient department of a specialised Orthopaedic and Sports Medicine Hospital within 7 days post-injury were assessed for eligibility. Using ultrasonography, one musculoskeletal radiologist assessed the ATFL, CFL and AITFL for complete discontinuity. Dynamic ultrasound measurements of the tibiofibular distance (mm) in both ankles (injured and contralateral) were acquired in the neutral position (N), during maximal external rotation (Max ER), and maximal internal rotation (Max IR). MR imaging was used as a reference standard.

Results

Between October 2017 and July 2019, 92 acute ankle injuries were included. Ultrasound diagnosed complete discontinuity of the ATFL with 87% (CI 74–95%) sensitivity and 69% (CI 53–82%) specificity. Discontinuity of the CFL was diagnosed with 29% (CI 10–56%) sensitivity and 92% (CI 83–97%) specificity. Ultrasound diagnosed discontinuity of the AITFL with 100% (CI 74–100%) sensitivity and 100% (CI 95–100%) specificity. Of the dynamic measurements, the side-to-side difference in external rotation had the highest diagnostic value for complete discontinuity of the AITFL (sensitivity 82%, specificity 86%; cut-off 0.93 mm).

Conclusions

Ultrasound has a good to excellent diagnostic value for complete discontinuity of the ATFL and AITFL. Therefore, ultrasound can be used to screen for injury of the ATFL and AITFL. Compared with ultrasound, dynamic ultrasound has inferior diagnostic value for complete discontinuity of the AITFL.

Key Points

• Ultrasound has a good to excellent diagnostic value for complete discontinuity of the anterior talofibular ligament (ATFL) and anterior inferior tibiofibular ligament (AITFL).

• Ultrasound can be used to screen for injury of the ATFL and AITFL.

• Compared with ultrasound, dynamic ultrasound has inferior diagnostic value for complete discontinuity of the AITFL.

Electronic supplementary material

The online version of this article (10.1007/s00330-020-07305-7) contains supplementary material, which is available to authorized users.

Sports Imaging of Team Handball Injuries

Team handball is a fast high-scoring indoor contact sport with > 20 million registered players who are organized in > 150 federations worldwide. The combination of complex and unique biomechanics of handball throwing, permitted body tackles and blocks, and illegal fouls contribute to team handball ranging among the four athletic sports that carry the highest risks of injury. The categories include a broad range of acute and overuse injuries that most commonly occur in the shoulder, knee, and ankle. In concert with sports medicine, physicians, surgeons, physical therapists, and radiologists consult in the care of handball players through the appropriate use and expert interpretations of radiography, ultrasonography, CT, and MRI studies to facilitate diagnosis, characterization, and healing of a broad spectrum of acute, complex, concomitant, chronic, and overuse injuries. This article is based on published data and the author team's cumulative experience in playing and caring for handball players in Denmark, Sweden, Norway, Germany, Switzerland, and Spain. The article reviews and illustrates the spectrum of common handball injuries and highlights the contributions of sports imaging for diagnosis and management.

MRI of the distal tibiofibular joint

The distal tibiofibular joint is a fibrous joint that plays a crucial role in the stability of the ankle joint. It is stabilized by three main ligaments: the anterior inferior tibiofibular ligament, the posterior inferior tibiofibular ligament, and the interosseous tibiofibular ligament, which are well delineated on magnetic resonance imaging. Pathology of the distal tibiofibular joint is mostly related to trauma and the longer-term complications of trauma, such as soft tissue impingement, heterotopic ossification, and synostosis. This review article outlines the MRI anatomy and pathology of this joint.

Chronic deltoid ligament insufficiency repair with Internal Brace™ augmentation

BACKGROUND

Patients with chronic deltoid ligament insufficiency (CDLI) present a challenging situation. Although numerous procedures have been described, optimal treatment is still a matter of debate. While the treatment armamentarium ranges from simple ligament repair to complex reconstructions with or without realignment osteotomies, direct repair augmented with an Internal Brace™ device appears to be an attractive intermediate option. We investigated functional outcomes and complications in patients with CDLI operated on using Internal Brace™ augmentation.

METHODS

A prospective study was conducted. Patients were included if they presented medial ankle pain and/or giving way, exhibited asymmetric flexible hindfoot valgus, failed conservative treatment, and had a positive MRI evaluated by an independent radiologist. Patients with stage IV flatfoot deformity, neuropathy and/or inflammatory arthritis were excluded. CDLI was confirmed intraoperatively with the arthroscopic drive-through sign. Patients were evaluated preoperatively and postoperatively using FAAM, SF-36 and grade of satisfaction. Paired t-tests were used to assess FAAM and SF-36 scores variation.

RESULTS

Thirteen patients met inclusion criteria. No patient was lost to follow-up, with a mean follow-up time of 13.5 months (range 6-21). Preoperative FAAM and SF-36 scores improved from 58.7 to 75.3 and from 60.2 to 84.4 postoperatively, respectively (p<.01). Two implant failures were observed, with no apparent compromise of construct stability. No patient was re-operated.

CONCLUSIONS

Our results suggest that deltoid ligament repair with Internal Brace™ augmentation in patients with CDLI is a reliable option with good functional outcomes and high satisfaction grade in short term follow-up.

LEVEL OF EVIDENCE

Level IV.

Advances in the Surgical Management of Ankle Fractures

Ankle fractures are one of the most common injuries treated by orthopedic surgeons worldwide. However, operative indications, techniques, and reported outcomes following operative fixation vary widely in the literature. This evidence-based review focuses on recent advances in the operative management of ankle fractures including arthroscopic-assisted surgery, deltoid ligament complex repair, expanded indications for posterior malleolus fixation, fibula intramedullary nailing, and dynamic syndesmosis repair.

LEVEL OF EVIDENCE

Level V, expert opinion.

Ankle Sprains: Evaluation, Rehabilitation, and Prevention

Ankle sprains affect athletic populations at high rates. Athletes who suffer an ankle sprain frequently go on to develop persistent symptoms, resulting in significant resources spent toward treatment, rehabilitation, and prevention. A thorough clinical evaluation is necessary to ensure an accurate diagnosis and appropriate treatment prescription. This narrative review aims to present an approach to evaluation of high and low ankle sprains for athletes of all levels. The authors review the current evidence for ankle sprain treatment and rehabilitation. Strategies for prevention of recurrent sprains and return to play considerations also are discussed.

Syndesmotic Ligaments of the Ankle: Anatomy, Multimodality Imaging, and Patterns of Injury

Injuries to the syndesmotic ligaments of the ankle or "high ankle sprains" are common in acute ankle trauma but can be difficult to diagnose both clinically and on imaging. Missed injuries to the syndesmosis can lead to chronic ankle instability, which can cause persistent pain and lead to early osteoarthritis. This review will illustrate the anatomy of the syndesmotic ligamentous complex, describe radiographic, CT, and MR imaging of the syndesmosis, demonstrate typical mechanisms of injuries and associated fracture patterns, and provide an overview of important management considerations.

MRI for high ankle sprains with an unstable syndesmosis: posterior malleolus bone oedema is common and time to scan matters

PURPOSE

Early clinical examination combined with MRI allows accurate diagnosis of syndesmosis instability after a high ankle sprain. However, patients often present late. The aims of the current study were to describe MRI characteristics associated with syndesmosis instability and to test the hypothesis that MRI patterns would differ according to time from injury.

METHODS

Over a 5-year period, 164 consecutive patients who had arthroscopically proven syndesmosis instability requiring fixation were retrospectively studied. Patients with distal fibula fractures were not included. Injuries were classified as acute in 108 patients (< 6 weeks), intermediate in 32 (6-12 weeks) and chronic in 24 patients (> 12 weeks).

RESULTS

Posterior malleolus bone oedema was noted in 65 (60.2%), and posterior malleolus fracture in 17 (15.7%) of acute patients, respectively, which did not significantly differ over time. According to MRI, reported rates of posterior syndesmosis disruption significantly differed over time, observed in 101 (93.5%), 28 (87.5%) and 13 (54.2%) of acute, intermediate and chronic patients, respectively (p < 0.001). Apparent rates of PITFL injury significantly reduced with time (p < 0.001).

CONCLUSIONS

MRI detected a posterior syndesmosis injury in 93.5% of patients acutely but became less reliable with time. The clinical relevance of this study is that posterior malleolus bone oedema may be the only marker of a complete syndesmosis injury and can help clinically identify those injuries which require arthroscopic assessment for instability. If suspicious of a high ankle sprain, we advocate early MRI assessment to help determine stable versus unstable injuries as MRI becomes less reliable after 12 weeks.

LEVEL OF EVIDENCE

III.

Effect of a Dynamic Fixation Construct on Syndesmosis Reduction: A Cadaveric Study

OBJECTIVES

To explore what effect a dynamic fixation construct would have on the final reduction of the syndesmosis.

METHODS

Syndesmotic ligaments were sectioned in 10 cadaveric specimens. The syndesmosis was intentionally malreduced with a clamp, and the distance from the anterior edge of the fibula to the anterior incisura of the tibia was measured to quantify the sagittal syndesmotic displacement (SSD). A 3.5-mm quadricortical screw was then placed, the clamp was removed, and the SSD measured. The clamp was then replaced, and a suture-button construct (Knotless Tightrope; Arthrex Inc, Naples, FL) was then placed through the bone tunnel, the clamp was again removed, and the SSD was measured.

RESULTS

In all cases, the fibula reduced to within 1 mm of its native anatomical position with the dynamic construct. The static screw construct, however, maintained an identical SSD measurement as the clamped malreduction. The dynamic suture-button construct reliably improved the SSD (P < 0.0001).

CONCLUSIONS

Our study demonstrates that dynamic fixation constructs can help restore anatomical alignment in the case of syndesmotic malreduction. The size difference between the suture diameter and drill hole effectively allows the fibula to be pulled and seated into the tibial incisura fibularis. These findings should not be viewed as a justification to ignore the syndesmotic reduction; however, they do validate an important benefit of dynamic fixation that has been found in the recent clinical literature.

LEVEL OF EVIDENCE

Therapeutic Level III.

Return to play after surgery for isolated unstable syndesmotic ankle injuries (West Point grade IIB and III) in 110 male professional football players: a retrospective cohort study

Objectives

To evaluate time to return to play following surgical stabilisation of isolated unstable syndesmosis injuries in a cohort of professional male football players.

Methods

All professional football players undergoing surgery for isolated unstable syndesmosis injury (West Point grade ≥IIB) at a specialised Orthopaedic and Sports Medicine Hospital were followed up until return to play (minimum ≥6 months). Players with a stable syndesmosis, injuries older than 6 weeks, concomitant medial or lateral malleolar fracture or previous ankle surgery were excluded. During rehabilitation, time required to return to sports-specific rehabilitation, team training and first match play, were recorded.

Results

Between January 2012 and December 2017, a total of 110 male professional football players were included. The mean time required to begin on field rehabilitation was 37±12 days, while the mean time to return to team training was 72±28 days. The first official match was played on average 103±28 days postoperatively. Multivariable analysis revealed that the severity of injury, the concomitant presence of talar cartilage injury and the age of the player were significantly associated (p<0.00001) with time to return to on field rehabilitation, team training and match play.

Conclusion

In this cohort of professional football players, surgical stabilisation of isolated unstable syndesmosis injuries (West Point grade ≥IIB) allowed for relatively quick return to play. High grade injury (West Point grade III), concomitant cartilage injury and greater age were associated with longer return to play times.

Level of evidence

Longitudinal observational cohort study (level II).

Effect of a Controlled Ankle Motion Walking Boot on Syndesmotic Instability During Weightbearing: A Cadaveric Study

Background:

Syndesmotic injuries can lead to long-term complications; hence, they require careful management. Conservative treatment is adequate when 1 syndesmotic ligament is injured, but surgery is often necessary to achieve articular congruity when 3 syndesmotic ligaments are ruptured. However, there is some controversy over the best treatment for 2-ligament injuries.

Purpose:

To evaluate the effect of a controlled ankle motion (CAM) walking boot on syndesmotic instability following iatrogenic isolated anterior inferior tibiofibular ligament (AiTFL) injury and combined AiTFL/interosseous ligament (IOL) injuries in a cadaveric simulated weightbearing model.

Study Design:

Controlled laboratory study.

Methods:

Ten cadaveric specimens were dissected to expose the tibial plateau and syndesmosis. The specimens were fitted to a custom-made device, and a reproducible axial load of 750 N was applied. Iatrogenic rupture of the syndesmotic ligaments (AiTFL + IOL) was done sequentially. Uninjured syndesmoses, isolated AiTFL rupture, and combined AiTFL/IOL rupture were compared with and without axial loading (AL) and CAM boot. The distal tibiofibular relationship was evaluated using a previously validated computed tomography scan measurement system. Wilcoxon tests for paired samples and nonparametric data were used.

Results:

The only difference noted in the distal tibiofibular relationship during AL was an increase in the external rotation of the fibula when using the CAM boot. This was observed with AiTFL rupture (8.40° vs 11.17°; P = .009) and combined AiTFL/IOL rupture (8.81° vs 11.97°; P = .005).

Conclusion:

AL did not cause a significant displacement between the tibia and fibula, even when 2 ligaments were ruptured. However, the CAM boot produced a significant external rotation with 1 or 2 injured ligaments.

Clinical Relevance:

Further studies are needed to assess the capacity of the CAM walking boot to prevent malreduction when external rotation forces are applied to the ankle. Moreover, special care should be taken during the fitting of the CAM boot to avoid overinflation of the cushions.

Efficacy and Prognosis of 3D Printing Technology in Treatment of High-Energy Trans-Syndesmotic Ankle Fracture Dislocation - "Log-Splitter" Injury

Background

This study aimed to retrospectively assess the feasibility and efficacy of three-dimensional (3D) printing technology in the treatment of high-energy trans-syndesmotic ankle fracture dislocation – “log-splitter” injury – and to evaluate the efficacy and prognosis.

Material/Methods

We included 29 patients (17 males and 12 females; mean age, 44.0±13.2 years) with log-splitter injury from June 2011 to December 2016, divided into a routine group (n=13) and a 3D printing group (n=16) according to the surgical method used. Operation time, intraoperative blood loss, fluoroscopy times, fracture union time, functional outcomes based on AOFAS (American Orthopedic Foot and Ankle Society) score, and postoperative complications were observed and recorded.

Results

Compared with the routine treatment group, 3D printing technology had better safety and efficacy for the treatment of log-splitter injury and the advantages of shorter operation time, less intraoperative blood loss, fewer fluoroscopies needed, and higher rate of good functional outcome (P<0.001, P<0.001, P<0.001, and P=0.017, respectively). However, no significant difference was noted in the rate of anatomical reduction, mean AOFAS score at the last follow-up (mean time, 19.9±2.8 months), or postoperative complications between the 2 groups (P=0.370, P=0.156, and P=0.485, respectively).

Conclusions

Surgery assisted by 3D printing technology to treat log-splitter injury is feasible and effective, and may be a good optional approach to formulate a reasonable personalized surgical plan and to optimize the outcomes.

Deltoid ligament repair reduces and stabilizes the talus in unstable ankle fractures

Introduction

Treatment of supination external rotation type IV (SER-IV) ankle injuries has focused on reduction and fixation of the fibula and syndesmosis (ORIF), not repair of the deltoid ligament.

Methods

Twenty-one ankles were analyzed with a motion capture system. Uninjured ankles were stressed and compared to ankles with SER-IV injuries, then with ORIF, and finally ORIF and deltoid repair.

Results

After deltoid ligament repair, talar coronal and axial rotation normalized to the uninjured state and were significantly reduced compared to ORIF alone.

Discussion

Deltoid ligament repair after an SER-IV ankle injury can help directly reduce and stabilize the tibiotalar joint.

Epidemiology of syndesmotic fixations in a pediatric center: A 12-year retrospective review

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.