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Ong SSL, Kwek EBK. Functional Syndesmotic Widening: A Case Report and Literature Review. Cureus 2024; 16:e63531. [PMID: 39086783 PMCID: PMC11288764 DOI: 10.7759/cureus.63531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2024] [Indexed: 08/02/2024] Open
Abstract
Injury to the distal tibiofibular syndesmosis can be a diagnostic challenge in the absence of advanced imaging. We report a case of a 21-year-old male patient who sustained an ankle injury and demonstrated radiological evidence of syndesmosis widening on plain radiographs. He underwent endobutton fixation which resulted in anterior subluxation of the talus and difficulty in ankle dorsiflexion. This is the first case report in the literature of a functional syndesmotic widening and the subsequent sequelae when subjected to a stabilisation procedure. The previously reported risk factors were inconsistent with our patient's demographics of a young, previously obese adult. We postulate that his childhood morbid obesity likely contributed to the functional widening of his ankle syndesmosis.
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Affiliation(s)
- Samuel Sing Li Ong
- Department of Orthopaedic Surgery, Sengkang General Hospital, Singapore, SGP
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Spindler FT, Böcker W, Polzer H, Baumbach SF. A 3-Ligament Syndesmotic Injury Is at Higher Risk for Malreduction Than a 2-Ligament Injury: A CT-Based Analysis. Foot Ankle Int 2024:10711007241238227. [PMID: 38817051 DOI: 10.1177/10711007241238227] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
BACKGROUND Syndesmotic malreduction is common and has been associated to an impaired outcome. Various risk factors for DTFJ malreduction have been postulated. The aims of this study were to assess the DTFJ malreduction rate based on (1) the severity of the syndesmotic injury, (2) the anatomy of the tibial incisura, and (3) the fixation device used in patients treated with suture-button systems. METHODS This retrospective, radiographic study included all adult patients who were treated for an acute, unilateral, and unstable syndesmotic injury with a suture-button system and postoperative bilateral CT imaging. Included were isolated syndesmotic injuries and fracture cases. The number of syndesmotic ligaments injured, that is, 2-ligament (AiTFL+IOL) and 3-ligament (AiTFL+IOL+PiTFL), was rated for each patient. The quality of DTFJ reduction, as well as the anatomy of the tibial incisura, was rated based on the postoperative, bilateral CT images and the intraoperative DTFJ reduction was recalculated based on the drilling-tunnel deviation. The possible influence on the DTFJ malreduction rate was assessed. RESULTS A total of 147 patients were included, and 94 and 53 patients had a 2- and 3-ligament syndesmotic injury, respectively. In addition, 113 patients were treated with a single-button system, 26 with a double suture-button system, and 8 with a hybrid fixation (suture-button + screw). Malreduction was significantly higher in 3-ligament compared with 2-ligament injuries, both intraoperatively (51% vs 27%; P = .003) and postoperatively (28% vs 11%; P = .006). The tibial anatomy had no significant influence on the malreduction rates. No significant differences were seen per the different fixation devices used independent of the number of ligaments injured. CONCLUSION This study did not find an influence of the incisura's anatomy on the DTFJ malreduction rate. However, we did find that 3-ligament syndesmotic injuries carried a higher risk of intra- and postoperative malreduction compared with 2-ligament injuries. LEVEL OF EVIDENCE Level III, retrospective radiologic study.
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Affiliation(s)
- Fabian Tobias Spindler
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
| | - Wolfgang Böcker
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
| | - Hans Polzer
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
| | - Sebastian Felix Baumbach
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
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Bhagat SK, Regmi A, Niraula BB, Sah SP, Kunwar BB, Yadav R, Maheshwari V, Meena PK. Computed tomography-based morphometric analysis of normal distal tibiofibular syndesmosis in the Indian population. Foot Ankle Surg 2024:S1268-7731(24)00120-6. [PMID: 38851941 DOI: 10.1016/j.fas.2024.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 03/13/2024] [Accepted: 05/28/2024] [Indexed: 06/10/2024]
Abstract
BACKGROUND In suspected Ankle Instability, the parameters that can be defined in the X-ray have their limitation owing to their variability in positioning and rotation of the tibiofibular joint. This inaccuracy further increases due to variability in morphometric parameters of distal tibiofibular syndesmosis among different populations based on race and sex. This research aims to study morphometry of normal distal tibiofibular syndesmosis based on computed tomography imaging in the Indian population. METHODS An Prospective observational study was performed from December 2020 to October 2022 on normal ankle CT scans of 100 Indian population using axial, sagittal, and coronal CT images. Anterior and posterior tibiofibular distance, Morphology of the incisura fibularis based on depth, Tibiofibular clear space (TFCS) and tibiofibular overlap (TFO), Transverse and longitudinal length of the fibula, and Relationship between the center of the talus and the center of a line joining the outer aspect of malleoli in the coronal plane were measured and analyzed by two different observers. RESULTS Out of the 100 participants, 77 (77 %) were male, and 23 (23 %) were female. The overall mean age of participants was 34.69 ± 9.7 years. The incisura fibularis was concave in 54 %, and shallow in 46 %. Anterior tibiofibular distance, Posterior tibiofibular distance, and Tibiofibular overlap were significantly different in comparison to the male with female populations (p-value < 0.05). CONCLUSION This study gives the indices that describe normal variations in the anatomical relationship between the fibula and fibular incisure in the Indian population, which will be helpful for improving the diagnostic accuracy of distal tibiofibular syndesmoses and providing optimal treatment in order to improve functional outcomes and reduce the risk of complications. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Saroj Kumar Bhagat
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India.
| | - Anil Regmi
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India.
| | - Bishwa Bandhu Niraula
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India.
| | - Saroj Prasad Sah
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India.
| | - Bom Bahadur Kunwar
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India.
| | - Robin Yadav
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India.
| | - Vikas Maheshwari
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India.
| | - Pradeep Kumar Meena
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India.
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Hamel C, Abdeen N, Avard B, Campbell S, Corser N, Ditkofsky N, Berger F, Murray N. Canadian Association of Radiologists Trauma Diagnostic Imaging Referral Guideline. Can Assoc Radiol J 2024; 75:279-286. [PMID: 37679336 DOI: 10.1177/08465371231182972] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023] Open
Abstract
The Canadian Association of Radiologists (CAR) Trauma Expert Panel consists of adult and pediatric emergency and trauma radiologists, emergency physicians, a family physician, a patient advisor, and an epidemiologist/guideline methodologist. After developing a list of 21 clinical/diagnostic scenarios, a systematic rapid scoping review was undertaken to identify systematically produced referral guidelines that provide recommendations for 1 or more of these clinical/diagnostic scenarios. Recommendations from 49 guidelines and contextualization criteria in the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) for guidelines framework were used to develop 50 recommendation statements across the 21 scenarios related to the evaluation of traumatic injuries. This guideline presents the methods of development and the recommendations for head, face, neck, spine, hip/pelvis, arms, legs, superficial soft tissue injury foreign body, chest, abdomen, and non-accidental trauma.
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Affiliation(s)
- Candyce Hamel
- Canadian Association of Radiologists, Ottawa, ON, Canada
| | - Nishard Abdeen
- Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Barb Avard
- North York General Hospital, Toronto, ON, Canada
| | - Samuel Campbell
- Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada
| | | | - Noah Ditkofsky
- St Michael's Hospital, Toronto, ON, Canada
- Michael Garon Hospital , Toronto, ON, Canada
| | - Ferco Berger
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
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Hashemi SA, Nosrati S, Shayan Z, Vosoughi AR. Morphological Variations and Normal Parameters of the Cross-Sectional Anatomy of the Tibiofibular Syndesmotic. Foot Ankle Spec 2024; 17:125-130. [PMID: 34724836 DOI: 10.1177/19386400211055274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The aim of this study was to determine morphological variations and normal parameters of the cross-sectional tibiofibular syndesmotic anatomy. METHODS Configurations of syndesmosis, anterior syndesmotic width (ASW), posterior syndesmotic width (PSW), and overlap distance, defined as the overlap of medial fibula with a drawn line from tip of anterior tubercle of incisura fibularis to the posterior tip, were measured on normal computed tomography (CT) scans of 110 cases. Results: Seventy seven male (70%) and 33 female (30%) (left: 50 and right: 60) were assessed. Mean age of the cases was 33 ± 13 (range: 15-80) years. Three different syndesmotic configurations were crescent (55.5%), rectangular (39.1 %), and semicircle (5.4 %). Overall, mean ASW, PSW, and overlap distance were 2.72, 3.98, and 1.02 mm, respectively. Upper limit of normal ASW in crescent, rectangular, and semicircle was 4.80, 4.85, and 3.89 mm, respectively. The maximum of PSW in crescent, rectangular, and semicircle was 6.25, 6.50, and 4.97 mm, respectively. There was not significant difference between syndesmotic configurations based on age (P = .69) and sex (P = .16). CONCLUSIONS During interpreting axial CT scan to diagnose syndesmotic injuries, the normal range of parameters according to the different configurations of the tibiofibular syndesmosis should be carefully considered. LEVEL OF EVIDENCE Level 4.
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Affiliation(s)
- Seyed Ali Hashemi
- Assistant Professor of Orthopedic Surgery, Bone and Joint Diseases Research Center, Department of Orthopedic Surgery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Soheil Nosrati
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Zahra Shayan
- Trauma Research Center, Department of Community Medicine, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Amir Reza Vosoughi
- Associate Professor of Orthopedic Surgery, Orthopedic Foot and Ankle Surgeon, Bone and Joint Diseases Research Center, Department of Orthopedic Surgery, Shiraz University of Medical Sciences, Shiraz, Iran
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Gomaa AR, Mason L. Chronic syndesmotic instability - Current evidence on management. J Clin Orthop Trauma 2024; 50:102382. [PMID: 38435397 PMCID: PMC10904910 DOI: 10.1016/j.jcot.2024.102382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 01/21/2024] [Accepted: 02/21/2024] [Indexed: 03/05/2024] Open
Abstract
This review article discusses the current evidence on the management of chronic syndesmotic instability. Conservative treatment has a limited role, and surgical intervention is most commonly reported as the mainstay of treatment, however the literature consists of small case series and descriptions of operative techniques, and thus the evidence base for any treatment is weak. Surgical options include arthroscopic debridement alone, static fixation with cortical screws, dynamic fixation with suture-button devices, and ligamentous repair or augmentation.
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Affiliation(s)
- Abdul-Rahman Gomaa
- Human Anatomy and Resource Centre, University of Liverpool, Liverpool, UK
- Liverpool Orthopaedic and Trauma Service, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Lyndon Mason
- Human Anatomy and Resource Centre, University of Liverpool, Liverpool, UK
- Liverpool Orthopaedic and Trauma Service, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
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Walinga AB, Dahmen J, Stornebrink T, Emanuel KS, Kerkhoffs GMMJ. Fifteen out of 16 elite athletes showed concomitant low-grade cartilage lesions of the ankle with unstable syndesmotic injuries: concerns from a prospective case series. BMJ Open Sport Exerc Med 2024; 10:e001879. [PMID: 38440746 PMCID: PMC10910472 DOI: 10.1136/bmjsem-2023-001879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2024] [Indexed: 03/06/2024] Open
Abstract
Objectives This study aimed to determine the incidence rate and characterise the location and severity of cartilage lesions in the ankle in elite athletes undergoing suture-button stabilisation for unstable distal syndesmotic injuries using needle arthroscopic examination. The feasibility and safety of ad hoc needle arthroscopy and its assisted interventions were also assessed. Methods This prospective case series included elite athletes undergoing surgical stabilisation between April 2021 and June 2023. Procedures involved suture button fixation and needle arthroscopy, conducted by a single ankle fellow-trained surgeon. Ankle cartilage lesions were graded using the Cheng and Ferkel classification and located using the nine-zone grid. The study followed the STROBE statement. Results This study included 16 elite athletes undergoing surgery for distal syndesmotic injuries, with 75% having acute and 25% chronic injuries. Cartilage lesions were prevalent (n=15/16, 94%), mainly at the talar dome (90%), and primarily scored as grade 1 (33%) or grade 2 (67%). Distal tibia cartilage damage occurred in 13% of cases. All patients were diagnosed with an instability of the syndesmosis confirmed through needle arthroscopy and were treated with a suture button (one or two buttons) fixation. Conclusion In 15/16 elite athletes with syndesmotic injuries, concomitant ankle cartilage lesions were identified through needle arthroscopy. In addition, most of the lesions were classified as grade 1 or 2, denoting superficial damage. Needle arthroscopic interventions proved feasible and safe for confirming syndesmotic instability and addressing intra-articular pathologies.
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Affiliation(s)
- Alex B Walinga
- Department of Orthopedic Surgery and Sports Medicine, Amsterdam Movement Sciences, Amsterdam UMC Locatie AMC, Amsterdam, Netherlands
- Amsterdam Collaboration on Health & Safety in Sports, International Olympic Committee (IOC) Research Center Amsterdam UMC, Amsterdam, Netherlands
- Academic Center for Evidence based Sports Medicine (ACES), Amsterdam UMC Locatie AMC, Amsterdam, Netherlands
| | - Jari Dahmen
- Department of Orthopedic Surgery and Sports Medicine, Amsterdam Movement Sciences, Amsterdam UMC Locatie AMC, Amsterdam, Netherlands
- Amsterdam Collaboration on Health & Safety in Sports, International Olympic Committee (IOC) Research Center Amsterdam UMC, Amsterdam, Netherlands
- Academic Center for Evidence based Sports Medicine (ACES), Amsterdam UMC Locatie AMC, Amsterdam, Netherlands
| | - Tobias Stornebrink
- Department of Orthopedic Surgery and Sports Medicine, Amsterdam Movement Sciences, Amsterdam UMC Locatie AMC, Amsterdam, Netherlands
- Amsterdam Collaboration on Health & Safety in Sports, International Olympic Committee (IOC) Research Center Amsterdam UMC, Amsterdam, Netherlands
- Academic Center for Evidence based Sports Medicine (ACES), Amsterdam UMC Locatie AMC, Amsterdam, Netherlands
| | - Kaj S Emanuel
- Department of Orthopedic Surgery and Sports Medicine, Amsterdam Movement Sciences, Amsterdam UMC Locatie AMC, Amsterdam, Netherlands
- Amsterdam Collaboration on Health & Safety in Sports, International Olympic Committee (IOC) Research Center Amsterdam UMC, Amsterdam, Netherlands
- Academic Center for Evidence based Sports Medicine (ACES), Amsterdam UMC Locatie AMC, Amsterdam, Netherlands
| | - Gino M M J Kerkhoffs
- Department of Orthopedic Surgery and Sports Medicine, Amsterdam Movement Sciences, Amsterdam UMC Locatie AMC, Amsterdam, Netherlands
- Amsterdam Collaboration on Health & Safety in Sports, International Olympic Committee (IOC) Research Center Amsterdam UMC, Amsterdam, Netherlands
- Academic Center for Evidence based Sports Medicine (ACES), Amsterdam UMC Locatie AMC, Amsterdam, Netherlands
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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: 0] [Impact Index Per Article: 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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Sugimoto K, Isomoto S, Ishida E, Miura K, Hyakuda Y, Ohta Y, Tanaka Y, Taniguchi A. Treatment of Intra-Articular Lesions After Posterior Inferior Tibiofibular Ligament Injury: A Case Series of Elite Rugby Players. Orthop J Sports Med 2023; 11:23259671231200934. [PMID: 37781642 PMCID: PMC10540585 DOI: 10.1177/23259671231200934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 05/19/2023] [Indexed: 10/03/2023] Open
Abstract
Background Surgical intervention is not typically used to treat symptoms after mild tibiofibular ligament injuries without ankle dislocation or subluxation. Purpose To describe outcomes in patients arthroscopically treated for unique intra-articular lesions after sustaining syndesmosis injury of the ankle. Study Design Case series; Level of evidence, 4. Methods A total of 11 elite male rugby players with a mean age of 21.0 years (range, 17-28 years) were referred to our hospital for prolonged posterior ankle pain after a high ankle sprain during rugby football. The patients were examined using standing view radiography, computed tomography (CT) and magnetic resonance imaging (MRI) to determine the extent of ligament damage. Posterior ankle arthroscopy was performed to examine intra-articular lesions. The patients were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle/hindfoot rating scale and sports activity score of the Self-Administered Foot Evaluation Questionnaire (SAFE-Q). Results The average reduced tibiofibular overlap on the standing mortise view was 1.2 mm (range, 0.5-2.0 mm) compared with the opposite ankles. Mason type 1 fracture was detected on CT in 6 patients, and ossification of the interosseous membrane was detected in 2 patients. A bone bruise in the posterior malleolus was observed on MRI in all but 1 patient. Intra-articular fragments located in the posterior ankle were observed and removed arthroscopically. Symptoms improved rapidly after arthroscopic treatment in all patients. All patients returned to rugby games at a median of 11 weeks postoperatively. The median AOFAS scores improved from 77 preoperatively to 100 postoperatively (P < .01), and the median SAFE-Q sports activity subscale score improved from 49.4 to 100 (P < .01). Conclusion All unique intra-articular lesions that developed in rugby football players after syndesmosis injury were able to be treated arthroscopically. Patients returned to playing rugby football without syndesmosis reduction. Posterior ankle arthroscopy was effective in patients with residual symptoms after syndesmosis injury.
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Affiliation(s)
- Kazuya Sugimoto
- Department of Orthopaedic Surgery, Nara Prefecture General Medical Center, Nara, Japan
| | - Shinji Isomoto
- Department of Orthopaedic Surgery, Nara Prefecture General Medical Center, Nara, Japan
| | - Eiwa Ishida
- Department of Pathology, Nara Prefecture General Medical Center, Nara, Japan
| | - Kimio Miura
- Department of Orthopaedic Surgery, Nara Prefecture General Medical Center, Nara, Japan
| | - Yoshinobu Hyakuda
- Department of Orthopaedic Surgery, Nara Prefecture General Medical Center, Nara, Japan
| | - Yuichi Ohta
- Department of Orthopaedic Surgery, Nara Prefecture General Medical Center, Nara, Japan
| | - Yasuhito Tanaka
- Department of Orthopaedic Surgery, School of Medicine, Nara Medical University, Kashihara, Japan
| | - Akira Taniguchi
- Department of Orthopaedic Surgery, School of Medicine, Nara Medical University, Kashihara, Japan
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Lei Q, Chen P, He X, Xu Z, He W. Preoperative CT parameters to predict tibiofibular syndesmosis injury associated with ankle fracture: a propensity score-matched analysis. Eur J Trauma Emerg Surg 2023; 49:1883-1890. [PMID: 37072565 DOI: 10.1007/s00068-023-02256-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 02/24/2023] [Indexed: 04/20/2023]
Abstract
BACKGROUND Untreated ankle fractures with concomitant tibiofibular syndesmosis injury often lead to postoperative pain and early traumatic arthritis. CT has advantages in the preoperative diagnosis of combined ankle injuries. However, a few studies have investigated the best preoperative CT parameters to predict tibiofibular syndesmosis injuries associated with ankle fractures. This study aimed to identify and evaluate the optimal preoperative CT parameters for predicting tibiofibular syndesmosis injuries associated with ankle fractures. METHODS We retrospectively analyzed 129 patients who underwent preoperative CT of an ankle fracture treated between January 2016 and April 2022 at a tertiary A hospital. All patients underwent open reduction and internal fixation and intraoperative stability testing. Based on the Cotton test, the patients were divided into the stable group (n = 83, 64.3%) and unstable group (n = 46, 35.7%). After 1:1 propensity score matching, the general conditions, anterior tibiofibular distance (TFD), posterior TFD, maximum TFD, tibiofibular syndesmosis area, sagittal fracture angle, Angle-A, and Angle-B were compared between the stable and unstable groups. RESULTS The propensity score-matched cohort comprised 82 patients. There were no significant differences between the stable and unstable groups in sex, age, affected side, operation interval, injury mechanism, Lauge-Hansen classification, sagittal fracture angle, and Angle-A (all P > 0.05). Compared with the stable group, the unstable group had a significantly greater aTFD, pTFD, maxTFD, and area (all P < 0.05). PTFD, maxTFD, and area were positively correlated with joint instability. Angle-B was smaller in the unstable group (57.13°) than the stable group (65.56°). ROC analysis showed that Area (AUC 0.711) and maxTFD (AUC 0.707) had the highest diagnostic efficacy. CONCLUSION MaxTFD and Area were the best predictive parameters; a larger Area was associated with a higher likelihood of instability of the tibiofibular syndesmosis after ankle fracture fixation.
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Affiliation(s)
- Qinliang Lei
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, 350001, Fujian, China
| | - Pinhua Chen
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, 350001, Fujian, China
- Department of Emergency Trauma Surgery, Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, 350001, Fujian, China
- Fujian Trauma Medicine Center, Fuzhou, 350001, Fujian, China
- Fujian Key Laboratory of Emergency Medicine, Fuzhou, 350001, Fujian, China
| | - Xueyi He
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, 350001, Fujian, China
- Department of Emergency Trauma Surgery, Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, 350001, Fujian, China
- Fujian Trauma Medicine Center, Fuzhou, 350001, Fujian, China
- Fujian Key Laboratory of Emergency Medicine, Fuzhou, 350001, Fujian, China
| | - Zhixian Xu
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, 350001, Fujian, China.
- Department of Emergency Trauma Surgery, Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, 350001, Fujian, China.
- Fujian Trauma Medicine Center, Fuzhou, 350001, Fujian, China.
- Fujian Key Laboratory of Emergency Medicine, Fuzhou, 350001, Fujian, China.
| | - Wubing He
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, 350001, Fujian, China.
- Department of Emergency Trauma Surgery, Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, 350001, Fujian, China.
- Fujian Trauma Medicine Center, Fuzhou, 350001, Fujian, China.
- Fujian Key Laboratory of Emergency Medicine, Fuzhou, 350001, Fujian, China.
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de Cesar Netto C, Valderrabano V, Mansur NSB. Multidirectional Chronic Ankle Instability: What Is It? Foot Ankle Clin 2023; 28:405-426. [PMID: 37137631 DOI: 10.1016/j.fcl.2023.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
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.
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Affiliation(s)
- Cesar de Cesar Netto
- University of Iowa, Carver College of Medicine, 200 Hawkins Drive, John PappaJohn Pavillion (JPP), Room 01066, Lower Level, Iowa City, IA 52242, USA; Duke University Medical Center, USA.
| | - Victor Valderrabano
- Swiss Ortho Center & University of Basel, Schmerzklinik Basel, Swiss Medical Network, Hirschgässlein 15, 4010 Basel, Switzerland
| | - Nacime Salomão Barbachan Mansur
- University of Iowa, Carver College of Medicine, 200 Hawkins Drive, John PappaJohn Pavillion (JPP), Room 01066, Lower Level, Iowa City, IA 52242, USA; Escola Paulista de Medicina - Universidade Federal de São Paulo, 740 Botucatu Street, Sao Paulo, SP, Brazil 04023-062
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12
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Barbachan Mansur NS, Godoy-Santos AL, Schepers T. High-Ankle Sprain and Syndesmotic Instability: How Far Have We Come with Diagnosis and Treatment? Foot Ankle Clin 2023; 28:369-403. [PMID: 37137630 DOI: 10.1016/j.fcl.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Probably one of the most controversial subjects in the orthopedic field is the distal tibiofibular articulation. Even though its most primary knowledge can be a matter of enormous debate, it is in the diagnosis and treatment most of the disagreements reign. Distinguishing between injury and instability remains challenging as well as an optimal clinical decision regarding surgical intervention. The last years presented technology and that was able to bring body to an already well-developed scientifical rationale. In this review article, we aim to demonstrate the current data behind syndesmotic instability in the ligament scenario, whereas using few fracture concepts.
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Affiliation(s)
- Nacime Salomao Barbachan Mansur
- Escola Paulista de Medicina - Universidade Federal de São Paulo, Brazil; University of Iowa, Carver College of Medicine, USA.
| | | | - Tim Schepers
- Trauma Unit, Department of Surgery, Amsterdam UMC Location J1A-214 Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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13
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Park EH, de Cesar Netto C, Fritz J. MRI in Acute Ankle Sprains: Should We Be More Aggressive with Indications? Foot Ankle Clin 2023; 28:231-264. [PMID: 37137621 DOI: 10.1016/j.fcl.2023.01.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Acute ankle sprains are common sports injuries. MRI is the most accurate test for assessing the integrity and severity of ligament injuries in acute ankle sprains. However, MRI may not detect syndesmotic and hindfoot instability, and many ankle sprains are treated conservatively, questioning the value of MRI. In our practice, MRI adds value in confirming the absence or presence of ankle sprain-associated hindfoot and midfoot injuries, especially when clinical examinations are challenging, radiographs are inconclusive, and subtle instability is suspected. This article reviews and illustrates the MRI appearances of the spectrum of ankle sprains and associated hindfoot and midfoot injuries.
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Affiliation(s)
- Eun Hae Park
- Division of Musculoskeletal Radiology, Department of Radiology, NYU Grossman School of Medicine, 660 1St Ave, 3rd Floor, New York, NY 10016, USA; Department of Radiology, Jeonbuk National University Medical School, Jeonju, Republic of Korea
| | - Cesar de Cesar Netto
- Department of Orthopaedics and Rehabilitation, University of Iowa, 200 Hawkins Dr, Iowa City, IA 52242, USA
| | - Jan Fritz
- Division of Musculoskeletal Radiology, Department of Radiology, NYU Grossman School of Medicine, 660 1St Ave, 3rd Floor, New York, NY 10016, USA.
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Abstract
The distal tibiofibular syndesmosis (DTFS) is more frequently injured than previously thought. Early diagnosis and appropriate treatment is essential to avoid long term complications like chronic instability, early osteoarthritis and residual pain. Management of these injuries require a complete understanding of the anatomy of DTFS, and the role played by the ligaments stabilizing the DTFS and ankle. High index of suspicion, appreciating the areas of focal tenderness and utilizing the provocative maneuvers help in early diagnosis. In pure ligamentous injuries radiographs with stress of weight bearing help to detect subtle instability. If these images are inconclusive, then further imaging with MRI, CT scan, stress examination under anesthesia, and arthroscopic examination facilitate diagnosis. An injury to syndesmosis frequently accompanies rotational fractures and all ankle fractures need to be stressed intra-operatively under fluoroscopy after fixation of the osseous components to detect syndesmotic instability. Non-operative treatment is appropriate for stable injuries. Unstable injuries should be treated operatively. Anatomic reduction of the syndesmosis is critical, and currently both trans-syndesmotic screws and suture button fixation are commonly used for syndesmotic stabilization. Chronic syndesmotic instability (CSI) requires debridement of syndesmosis, restoration of ankle mortise with or without syndesmotic stabilization. Arthrodesis of ankle is used a last resort in the presence of significant ankle arthritis. This article reviews anatomy and biomechanics of the syndesmosis, the mechanism of pure ligamentous injury and injury associated with ankle fractures, clinical, radiological and arthroscopic diagnosis and surgical treatment.
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Affiliation(s)
- Rajeev Vohra
- Department of Foot & Ankle Surgery, Amandeep Hospital, Amritsar, India
| | - Avtar Singh
- Department of Foot & Ankle Surgery, Amandeep Hospital, Amritsar, India
| | - Babaji Thorat
- Department of Foot & Ankle Surgery, Amandeep Hospital, Amritsar, India
| | - Dharmesh Patel
- Department of Foot & Ankle Surgery, Amandeep Hospital, Amritsar, India
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15
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Baumbach SF, Böcker W, Polzer H. Frakturen des Sprunggelenkes. ARTHROSKOPIE 2023. [DOI: 10.1007/s00142-023-00595-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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16
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Rodrigues JC, do Amaral E Castro A, Rosemberg LA, de Cesar Netto C, Godoy-Santos AL. Diagnostic Accuracy of Conventional Ankle CT Scan With External Rotation and Dorsiflexion in Patients With Acute Isolated Syndesmotic Instability. Am J Sports Med 2023; 51:985-996. [PMID: 36790178 DOI: 10.1177/03635465231153144] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
BACKGROUND Syndesmotic injury in an athletic population is associated with a prolonged ankle disability after an ankle sprain and often requires a longer recovery than a lateral collateral ligament injury. Although several imaging tests are available, diagnosing syndesmotic instability remains challenging. PURPOSE To determine the diagnostic accuracy of conventional ankle computed tomography (CT) scans with the joint in external rotation and dorsiflexion and compare it with that of conventional ankle CT scans in a neutral position. STUDY DESIGN Cohort study (Diagnosis); Level of evidence, 2. METHODS Between September 2018 and April 2021, this prospective study consecutively included adults visiting the foot and ankle outpatient clinic with a positive orthopaedic examination for acute syndesmotic injury. Participants underwent 3 CT scan tests. First, ankles were scanned in a neutral position. Second, ankles were scanned with 45° of external rotation, dorsiflexion, and extended knees. Third, ankles were scanned with 45° of external rotation, dorsiflexion, and flexed knees. Three measurements, comprising rotation (measurement a), lateral translation (measurement c), and anteroposterior translation (measurement f) of the fibula concerning the tibia, were used to diagnose syndesmotic instability in the 3 CT scans. Magnetic resonance imaging was used as a reference standard. The area under the curve (AUC) was used to compare the diagnostic accuracy, and Youden's J index was calculated to determine the ideal cutoff point. RESULTS Images obtained in 68 participants (mean age, 36.5 years; range, 18-69 years) were analyzed, comprising 36 syndesmotic injuries and 32 lateral collateral ligament injuries. The best diagnostic accuracy occurred with the rotational measurement a, in which the second and third CT scans with stress maneuvers presented greater AUCs (0.97 and 0.99) than did the first CT scan in a neutral position (0.62). The ideal cutoff point for the stress maneuvers was 1.0 mm in the rotational measurement a and reached a sensitivity and specificity of 83% and 97% for the second CT scan with extended knees and 86% and 100% for the third CT scan with flexed knees, respectively. The ideal cutoff point for the first CT scan with a neutral position was 0.7 mm in the rotational measurement a, with a sensitivity of 25% and specificity of 97%. CONCLUSION Conventional ankle CT with stress maneuvers has excellent performance for diagnosing subtle syndesmotic rotational instability, as it shows a greater AUC and enhanced sensitivity at the ideal cutoff point compared with ankle CT in the neutral position.
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Affiliation(s)
- João Carlos Rodrigues
- Department of Imaging Diagnostic, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Musculoskeletal Radiology, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Adham do Amaral E Castro
- Department of Imaging Diagnostic, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Department of Radiology and Diagnostic Imaging, Escola Paulista de Medicina, Universidade Federal de São Paulo UNIFESP, São Paulo, Brazil
| | - Laercio Alberto Rosemberg
- Department of Imaging Diagnostic, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Musculoskeletal Radiology, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Cesar de Cesar Netto
- Department of Orthopaedic and Rehabilitation, University of Iowa, Carver College of Medicine, Iowa City, Iowa, USA
| | - Alexandre Leme Godoy-Santos
- Lab. Prof. Mario Manlio Marco Napoli, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
- Locomotor Program, Hospital Israelita Albert Einstein, São Paulo, Brazil
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17
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Doyle MD, Ligas CJ, Vora NS. Acute Syndesmosis Injuries. Clin Podiatr Med Surg 2023; 40:23-37. [PMID: 36368846 DOI: 10.1016/j.cpm.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Ankle syndesmosis injuries include isolated ligamentous rupture, as well as fractures with ligamentous injury. These injuries can significantly affect athletes in all sports, and lead to prolonged recovery and return to sport. Adequate evaluation and diagnosis of these injuries are imperative for treatment and return to play. Many can be treated nonoperatively, but operative treatment is indicated in fractures with syndesmosis disruption and ligamentous injuries with instability. Anatomic reduction and fixation of these injuries will allow functional rehab and return to sport.
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Affiliation(s)
- Matthew D Doyle
- Silicon Valley Reconstructive Foot and Ankle Fellowship, Palo Alto Medical Foundation, 701 East El Camino Real, Mountain View, CA 94040, USA.
| | - Chandler J Ligas
- Silicon Valley Reconstructive Foot and Ankle Fellowship, Palo Alto Medical Foundation, 701 East El Camino Real, Mountain View, CA 94040, USA
| | - Nishit S Vora
- Saint Mary's Medical Center, 450 Stanyan Street, San Francisco, CA 94117, USA
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18
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Peiffer M, Burssens A, De Mits S, Heintz T, Van Waeyenberge M, Buedts K, Victor J, Audenaert E. Statistical shape model-based tibiofibular assessment of syndesmotic ankle lesions using weight-bearing CT. J Orthop Res 2022; 40:2873-2884. [PMID: 35249244 DOI: 10.1002/jor.25318] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 02/03/2022] [Accepted: 03/01/2022] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Matthias Peiffer
- Department of Orthopaedics and Traumatology, Ghent University Hospital, Ghent, Belgium.,Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| | - Arne Burssens
- Department of Orthopaedics and Traumatology, Ghent University Hospital, Ghent, Belgium.,Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| | - Sophie De Mits
- Department of Reumatology, Ghent University Hospital, Ghent, Belgium.,Department of Podiatry, Artevelde University of Applied Sciences, Ghent, Belgium
| | - Thibault Heintz
- Department of Orthopaedics, Ghent University Hospital, Ghent, Belgium
| | | | - Kris Buedts
- Department of Orthopaedics, ZNA Middelheim, Antwerpen, Belgium
| | - Jan Victor
- Department of Orthopaedics and Traumatology, Ghent University Hospital, Ghent, Belgium
| | - Emmanuel Audenaert
- Department of Orthopaedics and Traumatology, Ghent University Hospital, Ghent, Belgium.,Department of Human Structure and Repair, Ghent University, Ghent, Belgium.,Department of Trauma and Orthopedics, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,Department of Electromechanics, Op3Mech Research Group, University of Antwerp, Antwerp, Belgium
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19
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Presurgical Perspective and Postsurgical Evaluation of Instability and Microinstability Secondary to Ankle Ligaments Injury. Semin Musculoskelet Radiol 2022; 26:644-655. [PMID: 36791734 DOI: 10.1055/s-0042-1760245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Injuries of the ankle ligaments complexes are very common, and ∼ 20 to 40% of patients can develop chronic ankle instability (CAI). Current concepts in CAI allow a better understanding of the ankle biomechanics needed to repair it. The surgical treatment of CAI has evolved in the last decade, and ankle arthroscopy has become an essential tool in the treatment of instability with promising results. We review the different surgical techniques to treat CAI, both those frequently used and the new approaches, as well as the normal postsurgical appearance of ankle ligaments repair and the most common complications.
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20
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Baumbach SF, Hamberger MA, Polzer H, Schepers T. Letter to the Editor: Can Weightbearing Cone-beam CT Reliably Differentiate Between Stable and Unstable Syndesmotic Ankle Injuries? A Systematic Review and Meta-analysis. Clin Orthop Relat Res 2022; 480:2465-2467. [PMID: 36190511 PMCID: PMC10538888 DOI: 10.1097/corr.0000000000002442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 09/12/2022] [Indexed: 11/22/2022]
Affiliation(s)
| | | | - Hans Polzer
- Department of Trauma Surgery, Ludwig Maximilian University Hospital, Munich, Germany
| | - Tim Schepers
- Trauma Unit, Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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21
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Rougereau G, Langlais T, Vigan M, Hardy A, Vialle R, Marty-Diloy T, Cambon-Binder A. Ankle syndesmosis biomechanical evaluation by shear-waves elastography in healthy young adults: Assessment of the reliability and accuracy of the measurements and definition of a corridor of normality. Foot Ankle Surg 2022; 28:1279-1285. [PMID: 35717494 DOI: 10.1016/j.fas.2022.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 05/22/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Aims of this study were: 1/ to evaluate the shear wave speed (SWS) properties of the anteroinferior tibiofibular ligament (AITFL) and the distal interosseous membrane (DIOM) in neutral, dorsal flexion and plantar flexion positions in a cohort of healthy adult volunteers; 2/ to assess the reliability and reproducibility of these measurements. METHODS Both ankles were analyzed by shear wave elastography (SWE) in 20 healthy patients (10 females/10 males) standing on a hinge support with their ankles in neutral, 20° dorsal flexion and 30° plantar flexion positions. Stiffness of AITFL and DIOM was evaluated by SWS measurement. RESULTS The SWS of AITFL and DIOM were minimal in the plantar flexion position (4.28 m/s [2.65-5.11] and 3.35 m/s [1.69-4.55], respectively). It increased significantly for both ligaments in neutral position (4.69 m/s [3.53-5.71] and 3.81 m/s [1.91-4.74], respectively; p < 0.0001), and reached their maximum values in dorsal flexion (6.58 m/s [5.23-8.34] and 4.79 m/s [3.07-6.19], respectively; p < 0.0001). There was no correlation between each ligament regardless the positions. SWS of AITFL was independent of demographic characteristics analyzed. SWS of DIOM was negatively correlated with height in dorsal flexion (ρ = -0.35; p = 0.03) and in plantar flexion (ρ = -0.37; p = 0.02). Female gender was associated with increased DIOM SWS in neutral (p = 0.005), dorsal flexion (p = 0.003), and plantar flexion (p = 0.001) positions. Moreover, foot morphology (foot arch, hind foot frontal deviation) did not impact AITFL nor DIOM SWS. Inter- and intra-observer measurements were all good or excellent. CONCLUSION The AITFL and DIOM, stabilizers of the distal tibiofibular syndesmosis, increase in stiffness while dorsal flexion increases. This study describes a reliable and reproducible protocol to assess their stiffness by SWE, and defines a corridor of normality.
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Affiliation(s)
- Grégoire Rougereau
- Sorbonne University, Department of Pediatric Orthopedic Surgery, Armand Trousseau Hospital, APHP, 75571 Paris, France; Sorbonne University, Department of Adult Orthopedic Surgery, Pitié-Salpêtrière Hospital, APHP, 75571 Paris, France.
| | - Tristan Langlais
- Sorbonne University, Department of Pediatric Orthopedic Surgery, Armand Trousseau Hospital, APHP, 75571 Paris, France; Toulouse University, Department of Pediatric Orthopedic Surgery, Children's Hospital, Purpan, Toulouse, France
| | - Marie Vigan
- Sorbonne University, Department of Pediatric Orthopedic Surgery, Armand Trousseau Hospital, APHP, 75571 Paris, France; Department of Adult Orthopedic surgery, Hospital Ambroise Paré, APHP, 92100 Boulogne-Billancourt, France
| | - Alexandre Hardy
- Clinique du sport, Department of Orthopedic Surgery, 75005 Paris, France
| | - Raphaël Vialle
- Sorbonne University, Department of Pediatric Orthopedic Surgery, Armand Trousseau Hospital, APHP, 75571 Paris, France; The MAMUTH Hospital University Department for Innovative Therapies in Musculoskeletal Disease Sorbonne University, Paris, France
| | - Thibault Marty-Diloy
- Sorbonne University, Department of Pediatric Orthopedic Surgery, Armand Trousseau Hospital, APHP, 75571 Paris, France
| | - Adeline Cambon-Binder
- Sorbonne University, Department of Adult Orthopedic Surgery, Saint Antoine Hospital, APHP, 75571 Paris, France
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Spindler FT, Herterich V, Holzapfel BM, Böcker W, Polzer H, Baumbach SF. A systematic review and meta-analysis on the value of the external rotation stress test under fluoroscopy to detect syndesmotic injuries. EFORT Open Rev 2022; 7:671-679. [PMID: 36287127 PMCID: PMC9619390 DOI: 10.1530/eor-22-0037] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Purpose Methods Results Conclusion
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Affiliation(s)
- F T Spindler
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
| | - V Herterich
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
| | - B M Holzapfel
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
| | - W Böcker
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
| | - H Polzer
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany,Correspondence should be addressed to H Polzer;
| | - S F Baumbach
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
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23
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Kandemir V, Akar MS, Yiğit Ş, Durgut F, Atiç R, Özkul E. Can American Orthopaedic Foot and Ankle Society (AOFAS) score prevent unnecessary MRI in isolated ankle ligament injuries? J Orthop Surg (Hong Kong) 2022; 30:10225536221131374. [PMID: 36192368 DOI: 10.1177/10225536221131374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION AND OBJECTIVE Ankle injuries are the most common musculoskeletal injuries. Its incidence is also high among sports injuries. Direct X-ray, ultrasound and MRI can be requested after the history and physical examination in the patient who presents with ankle ligament injury. Some classifications are used for requesting direct X-ray after ankle injury. Since clear limits are not specified in the literature for MRI, the rate of unnecessary MRI examinations is high. We argue that the decision can be made according to the AOFAS score to be checked before MR is requested, and thus unnecessary MR requests can be reduced. MATERIAL AND METHOD Ankle MRI images of patients who underwent ankle MRI due to ankle trauma between January 2018 and December 2020 were scanned. 328 patients who met the criteria were included in the study. Patients with AOFAS scores in their outpatient clinic records were identified. AOFAS scores of patients with at least one ligament injury and those with normal MR images were statistically compared. Sensitivity and specificity were determined for the AOFAS score using ROC analysis. RESULTS Patients with ligament damage as a result of MRI examination were 21.3% (n=70), and patients without any ligament damage were 78.7% (n=258). There was a statistically significant difference in terms of AOFAS between the group with ligament damage and the group without ligament damage (p< 0.05). In the ROC analysis, the AOFAS threshold value for MR request was determined as 80.5 (84.3% sensitivity and 72.3% specificity). Based on the determined threshold value, 73 patients who had unnecessary MRI would have been eliminated, thus reducing the number of MRIs by 42.6%. CONCLUSION The AOFAS scores of patients with ligament damage were statistically significantly lower than those of patients without ligament pathology. Unnecessary MRI can be significantly prevented by using the AOFAS score in ankle traumas without bone fractures.
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Affiliation(s)
- Veysel Kandemir
- Department of Orthopaedic Surgery, Tatvan State Hospital, Bitlis, Turkey
| | - Mehmet Sait Akar
- Department of Orthopaedic Surgery, 37507Dicle University, Faculty of Medicine, Diyarbakır, Turkey
| | - Şeyhmus Yiğit
- Department of Orthopaedic Surgery, 37507Dicle University, Faculty of Medicine, Diyarbakır, Turkey
| | - Fatih Durgut
- Department of Orthopaedic Surgery, 37507Dicle University, Faculty of Medicine, Diyarbakır, Turkey
| | - Ramazan Atiç
- Department of Orthopaedic Surgery, 37507Dicle University, Faculty of Medicine, Diyarbakır, Turkey
| | - Emin Özkul
- Department of Orthopaedic Surgery, 37507Dicle University, Faculty of Medicine, Diyarbakır, Turkey
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24
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Cao MM, Zhang YW, Hu SY, Rui YF. A systematic review of ankle fracture-dislocations: Recent update and future prospects. Front Surg 2022; 9:965814. [PMID: 36017521 PMCID: PMC9398172 DOI: 10.3389/fsurg.2022.965814] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 07/25/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundAnkle fracture-dislocations are one of the most severe types of ankle injuries. Compared to the simple ankle fractures, ankle fracture-dislocations are usually more severely traumatized and can cause worse functional outcomes. The purpose of this study was to review the previous literatures to understand the anatomy, mechanisms, treatment, and functional outcomes associated with ankle fracture-dislocations.MethodsThe available literatures from January 1985 to December 2021 in three main medical databases were searched and analyzed. The detailed information was extracted for each article, such as researchers, age, gender, groups, type of study, type of center research, level of evidence, significant findings, study aim, cause of injury, time from injury to surgery, type of fracture, direction of dislocation, follow-up, postoperative complications and functional evaluation scores.ResultsA total of 15 studies (1,089 patients) met the inclusion criteria. Only one study was a prospective randomized trial. The top-ranked cause of injury was high-energy injury (21.3%). Moreover, the most frequent type of fracture in ankle dislocations was supination-external rotation (SER) ankle fracture (43.8%), while the most common directions of dislocation were lateral (50%) and posterior (38.9%).ConclusionsCollectively, most ankle fracture-dislocations are caused by high-energy injuries and usually have poor functional outcomes. The mechanism of injury can be dissected by the ankle anatomy and Lauge-Hansen's classification. The treatment of ankle fracture-dislocations still requires more detailed and rational solutions due to the urgency of occurrence, the severity of injury, and the postoperative complications.
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Affiliation(s)
- Mu-Min Cao
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
- School of Medicine, Southeast University, Nanjing, Jiangsu, China
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Yuan-Wei Zhang
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
- School of Medicine, Southeast University, Nanjing, Jiangsu, China
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Sheng-Ye Hu
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
- School of Medicine, Southeast University, Nanjing, Jiangsu, China
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Yun-Feng Rui
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
- School of Medicine, Southeast University, Nanjing, Jiangsu, China
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
- Correspondence: Yun-Feng Rui
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Rougereau G, Marty-Diloy T, Vigan M, Donadieu K, Hardy A, Vialle R, Langlais T. A Preliminary Study to Assess the Relevance of Shear-Wave Elastography in Characterizing Biomechanical Changes in the Deltoid Ligament Complex in Relation to Ankle Position. Foot Ankle Int 2022; 43:840-849. [PMID: 35373593 DOI: 10.1177/10711007221079829] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was (1) to evaluate the biomechanical properties of the different bundles of the deltoid ligament in various ankle positions in a cohort of healthy adult volunteers; (2) describe the impact of demographic and hindfoot morphology characteristics on their stiffness; (3) to assess the reliability and reproducibility of these measurements. METHODS Deltoid ligament complex of both ankles were assessed by shear-wave elastography (SWE) in 20 healthy patients resting on hinge support. The propagation shear-wave speed (SWS) in ligaments was measured, which is related to the tissue's elastic modulus. The following ligaments were analyzed in a neutral position and then in varus, valgus, dorsal, and plantar flexions: tibionavicular ligament (TNL), tibiocalcaneal ligament (TCL), the superficial posterior tibiotalar ligament (SPTL), the anterior tibiotalar ligament (ATTL), and the deep posterior tibiotalar ligament (DPTTL). RESULTS The mean SWS increased between neutral and 20 degrees valgus position for TCL (4.08 ± 0.78 m/s vs 5.56 ± 0.62 m/s, respectively; P < .0001) and for DPTTL (2.58 ± 0.52 m/s vs 3.59 ± 0.87 m/s, respectively; P < .0001). The mean SWS increased between neutral and 30 degrees plantarflexion for ATTL (2.11 ± 0.44 m/s vs 3.1 ± 0.5 m/s, respectively; P < .0001) and TNL (2.96 ± 0.66 m/s vs 4.99 ± 0.69 m/s, respectively; P < .0001). The mean SWS increased between neutral and 20 degrees dorsal flexion for SPTL (4.2 ± 1 m/s vs 5.45 ± 0.65 m/s, respectively; P < .0001).Women had less DPTTL SWS than men in the neutral position (2.37 ± 0.35 m/s vs 2.71 ± 0.49 m/s, respectively; P = .007). Other demographics had no impact on the SWS value of other ligaments. All inter- and intraobserver agreements were good to excellent. CONCLUSION This study presents a reliable and reproducible SWE measurement protocol to describe the physiological function of all bundles of the medial collateral ligament in healthy adults. CLINICAL RELEVANCE This examination technique can be available to orthopaedic surgeons, allowing reliable and reproducible monitoring of the SWS of the various ligaments constituting the medial collateral plane. The biomechanical values described in this study may give insight into in what position medial ankle ligament reconstruction should be tensioned.
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Affiliation(s)
- Grégoire Rougereau
- Department of Pediatric Orthopedic surgery, Armand Trousseau Hospital, APHP, Sorbonne University, Paris, France
- Department of Adult Orthopedic surgery, Pitié-Salpêtrière Hospital, APHP, Sorbonne University, Paris, France
| | - Thibault Marty-Diloy
- Department of Pediatric Orthopedic surgery, Armand Trousseau Hospital, APHP, Sorbonne University, Paris, France
| | - Marie Vigan
- Department of Pediatric Orthopedic surgery, Armand Trousseau Hospital, APHP, Sorbonne University, Paris, France
- Unité de Recherche Clinique Hôpitaux Universitaires Paris Ile-de-France Ouest, APHP, Boulogne-Billancourt, France
| | - Kalinka Donadieu
- Department of Pediatric Orthopedic surgery, Armand Trousseau Hospital, APHP, Sorbonne University, Paris, France
| | - Alexandre Hardy
- Clinique du sport, Department of Orthopedic surgery, Paris, France
| | - Raphaël Vialle
- Department of Pediatric Orthopedic surgery, Armand Trousseau Hospital, APHP, Sorbonne University, Paris, France
- Department for Innovative Therapies in Musculoskeletal Disease, The MAMUTH Hospital, Sorbonne University, Paris
| | - Tristan Langlais
- Department of Pediatric Orthopedic surgery, Armand Trousseau Hospital, APHP, Sorbonne University, Paris, France
- Department of Pediatric Orthopedic surgery, Children's hospital, Purpan, Toulouse University, Toulouse, France
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Yamamoto N, Iwamoto K, Tomita Y, Iwamoto Y, Kiyono M, Yoshimura M, Noda T, Kawasaki K, Ozaki T. Pre-and postoperative factors associated with functional outcomes in patients with posterior malleolar fractures. Injury 2022; 53:2297-2303. [PMID: 35260245 DOI: 10.1016/j.injury.2022.02.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 02/19/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Recent studies on posterior malleolar fractures mainly focus on the reduction quality and fixation of the posterior fragment since it contributes to ankle stability and articular congruency. However, the association of pre-and postoperative factors considering the whole ankle joint in postoperative functional outcomes remains unclear. Therefore, this study aimed to examine the association between pre-and postoperative variables for postoperative functional outcomes in patients with posterior malleolar fragments (classified as Haraguchi type I or II) and considered the association between reduction and fixation for small posterior malleolar fragments of less than 25% of the intra-articular surface. METHODS This multicenter retrospective cohort study included 110 adult patients who underwent internal fixation for ankle fractures with posterior malleolar fragments. The primary outcome was the American Orthopaedic Foot and Ankle Society (AOFAS) score 12-months postoperatively. As pre-and postoperative variables, the preoperative demographic data, radiographic findings, operative method, postoperative radiographic findings, and complications were evaluated. In addition, univariable and multivariable logistic regression analyses were conducted to examine the association between pre-and postoperative variables and AOFAS scores. RESULTS Twenty-four (21.8%) cases had postoperative complications. Univariate analysis showed that age was significantly according to AOFAS score-stratified groups in patients with Haraguchi type II fractures. Multivariable logistic regression analysis using bootstrapping in the Haraguchi type II group showed that postoperative complications were significantly associated with low AOFAS scores, indicating poor functionality. In both fracture types, postoperative complications had the highest odds ratio among the explanatory variables. In patients with small posterior malleolar fragments, fragment reduction, fixation, and ankle stability were not associated with AOFAS scores. CONCLUSIONS Our results suggest that postoperative complications were associated with AOFAS scores at postoperative 12 months in patients with ankle fractures with posterior malleolar fragments. In patients with small posterior malleolar fragments, reduction and fixation were not associated with AOFAS scores. Therefore, clinical decisions for posterior fragment fixation should be made based on the possible risk of complications related to the surgical procedures in addition to the posterior malleolar fragment size.
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Affiliation(s)
- Norio Yamamoto
- Department of Orthopedic Surgery, Kagawa Prefectural Central Hospital, 1-2-1, Asahi-machi, Takamatsu, Kagawa 760-8557, Japan; Scientific Research Works Peer Support Group (SRWS-PSG), Osaka, Japan.
| | - Kohei Iwamoto
- Department of Emergency Medical Center, Kagawa Prefectural Central Hospital, Kagawa, Japan
| | - Yosuke Tomita
- Department of Physical Therapy, Faculty of Health Care, Takasaki University of Health and Welfare, Gunma, Japan
| | - Yuki Iwamoto
- Department of Orthopedic Surgery, Okayama Saiseikai General Hospital, Okayama, Japan
| | - Masahiro Kiyono
- Department of Orthopedic Surgery, Mitoyo General Hospital, Kagawa, Japan
| | | | - Tomoyuki Noda
- Department of Orthopaedic Surgery and Traumatology, Kawasaki Medical School General Medical Center, Okayama, Japan
| | - Keisuke Kawasaki
- Department of Orthopedic Surgery, Kagawa Prefectural Central Hospital, 1-2-1, Asahi-machi, Takamatsu, Kagawa 760-8557, Japan
| | - Toshifumi Ozaki
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
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Shiwaku K, Teramoto A, Iba K, Otsubo H, Kamiya T, Shoji H, Watanabe K, Yamashita T. The prevalence of posterior inferior tibiofibular ligament and inferior tibiofibular transverse ligament injuries in syndesmosis-injured ankles evaluated by oblique axial magnetic resonance imaging: a retrospective study. BMC Musculoskelet Disord 2022; 23:264. [PMID: 35303842 PMCID: PMC8932331 DOI: 10.1186/s12891-022-05220-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 03/11/2022] [Indexed: 11/16/2022] Open
Abstract
Background Transverse ligament and posterior inferior tibiofibular ligament injuries have not been investigated till date because these are difficult to evaluate using standard magnetic resonance imaging. This study aimed to investigate the prevalence of transverse ligament and posterior inferior tibiofibular ligament injuries in syndesmosis-injured ankles using oblique axial magnetic resonance imaging. Methods The patients who were diagnosed with syndesmosis injury using magnetic resonance imaging (MRI) within 7 days of the trauma were included. Patients with concomitant fractures were excluded. A total of 34 patients (1 woman and 33 men) with an average age of 22 years (range, 14–64 years) were included. The anterior inferior tibiofibular, interosseous, transverse, and posterior inferior tibiofibular ligaments were classified as intact, partial tear, or complete tear using usual axial and oblique axial MRIs. Results There were 8 (23.5%) ankles with an intact, 21 (61.8%) ankles with a partially torn, and 5 (14.7%) ankles with a complete tear of transverse ligament. There were 20 (58.8%) ankles with an intact, 12 (35.3%) ankles with a partially torn, and 2 (5.9%) ankles with a complete tear of posterior inferior tibiofibular ligament. Overall, 50% of the transverse ligament injuries occurred without posterior inferior tibiofibular ligament involvement. Conclusions The oblique axial magnetic resonance imaging scan revealed that the prevalence of transverse ligament and posterior inferior tibiofibular ligament injuries in syndesmosis-injured ankles were 76.5 and 41.2%, respectively. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-022-05220-0.
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Affiliation(s)
- Kousuke Shiwaku
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Atsushi Teramoto
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan.
| | - Kousuke Iba
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
| | | | - Tomoaki Kamiya
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Hiroaki Shoji
- Department of Orthopaedic Surgery, Sunagawa City Medical Center, Sunagawa, Japan
| | - Kota Watanabe
- Second Division of Physical Therapy, Sapporo Medical University School of Health Sciences, Sapporo, Hokkaido, Japan
| | - Toshihiko Yamashita
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
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Harris NJ, Nicholson G, Pountos I. Anatomical reconstruction of the anterior inferior tibiofibular ligament in elite athletes using InternalBrace suture tape. Bone Joint J 2022; 104-B:68-75. [PMID: 34969286 DOI: 10.1302/0301-620x.104b1.bjj-2021-0542.r2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
AIMS The ideal management of acute syndesmotic injuries in elite athletes is controversial. Among several treatment methods used to stabilize the syndesmosis and facilitate healing of the ligaments, the use of suture tape (InternalBrace) has previously been described. The purpose of this study was to analyze the functional outcome, including American Orthopaedic Foot & Ankle Society (AOFAS) scores, knee-to-wall measurements, and the time to return to play in days, of unstable syndesmotic injuries treated with the use of the InternalBrace in elite athletes. METHODS Data on a consecutive group of elite athletes who underwent isolated reconstruction of the anterior inferior tibiofibular ligament using the InternalBrace were collected prospectively. Our patient group consisted of 19 elite male athletes with a mean age of 24.5 years (17 to 52). Isolated injuries were seen in 12 patients while associated injuries were found in seven patients (fibular fracture, medial malleolus fracture, anterior talofibular ligament rupture, and posterior malleolus fracture). All patients had a minimum follow-up period of 17 months (mean 27 months (17 to 35)). RESULTS All patients returned to their pre-injury level of sports activities. One patient developed a delayed union of the medial malleolus. The mean return to play was 62 days (49 to 84) for isolated injuries, while the patients with concomitant injuries returned to play in a mean of 104 days (56 to 196). The AOFAS score returned to 100 postoperatively in all patients. Knee-to-wall measurements were the same as the contralateral side in 18 patients, while one patient lacked 2 cm compared to the contralateral side. CONCLUSION This study suggests the use of the InternalBrace in the management of unstable syndesmotic injuries offers an alternative method of stabilization, with good short-term results, including early return to sports in elite athletes. Cite this article: Bone Joint J 2022;104-B(1):68-75.
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Affiliation(s)
- Nick J Harris
- Spire Leeds Hospital, Leeds, UK.,Carnegie School of Sport, Leeds Becket University, Leeds, UK
| | | | - Ippokratis Pountos
- Academic Department of Trauma and Orthopaedics, University of Leeds, Leeds, UK.,Chapel Allerton Hospital, Leeds Teaching Hospitals, Leeds, UK
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Diagnosis and Treatment of Syndesmotic Unstable Injuries: Where We Are Now and Where We Are Headed. J Am Acad Orthop Surg 2021; 29:985-997. [PMID: 34478409 DOI: 10.5435/jaaos-d-20-01350] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 07/24/2021] [Indexed: 02/01/2023] Open
Abstract
Up to 10% of ankle sprains are considered "high ankle" sprains with associated syndesmotic injury. Initial diagnosis of syndesmotic injury is based on physical examination, but further evaluation of the distal tibiofibular joint in the sagittal, coronal, and rotational planes is necessary to determine instability. Imaging modalities including weight-bearing CT and ultrasonography allow a physiologic and dynamic assessment of the syndesmosis. These modalities in turn provide the clinician useful information in two and three dimensions to identify and consequently treat syndesmotic instability, especially when subtle. Because there is notable variability in the shape of the incisura between individuals, contralateral comparison with the uninjured ankle as an optimal internal control is advised. Once syndesmotic instability is identified, surgical treatment is recommended. Several fixation methods have been described, but the foremost aspect is to achieve an anatomic reduction. Identifying any associated injuries and characteristics of the syndesmotic instability will lead to the appropriate treatment that restores the anatomy and stability of the distal tibiofibular joint.
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Marasco D, Russo J, Izzo A, Vallefuoco S, Coppola F, Patel S, Smeraglia F, Balato G, Mariconda M, Bernasconi A. Static versus dynamic fixation of distal tibiofibular syndesmosis: a systematic review of overlapping meta-analyses. Knee Surg Sports Traumatol Arthrosc 2021; 29:3534-3542. [PMID: 34455448 DOI: 10.1007/s00167-021-06721-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 08/24/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Multiple Level I meta-analyses were conducted comparing traditional static vs. more recently introduced dynamic strategies of fixation for injuries of the distal tibiofibular syndesmosis (TFS). The aim of this review was to assess their robustness and methodological quality, providing support in the choice of a treatment strategy in case of TFS injury using the highest level of evidence. METHODS In this systematic review, conducted in accordance with the PRISMA guidelines, meta-analyses/systematic reviews comparing static and dynamic fixation methods after acute TFS injury were identified. The robustness of studies was evaluated using the fragility index (FI) for meta-analysis and the fragility quotient (FQ). The risk of bias was evaluated using the Assessment of Multiple Systematic Reviews (AMSTAR) instrument. Finally, the Jadad was applied to select the study which provided the highest quality of evidence to develop recommendations for the fixation strategy of these lesions. RESULTS Out of 1.302 records, four Level I meta-analyses were included in this study. Analyzing the statistically significant dichotomous outcomes, the median FI was 3.5 (IQR, 2 to 5.5; range, 1 to 9), while the median FQ was 1.9% (IQR, 1 to 3.5; range 0.35 to 4.4). In total, 37% had an FI of 2 or less and 75% of outcomes had a FI of 4 or less. According to the AMSTAR score and Jadad algorithm, the largest meta-analysis was selected as the highest evidence provided so far. CONCLUSION The meta-analyses with statistically significant dichotomous outcomes comparing dynamic and static fixation for treating injuries of the distal tibiofibular syndesmosis are fragile, with a change in less than four patients or less than 2% of the study population sufficient to reverse a significant outcome to nonsignificant. LEVEL OF EVIDENCE Level I.
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Affiliation(s)
- Domenico Marasco
- Department of Public Health, Trauma and Orthopaedics, University Federico II of Naples, Via Pansini 5, 80131, Naples, Italy
| | - Jacopo Russo
- Department of Public Health, Trauma and Orthopaedics, University Federico II of Naples, Via Pansini 5, 80131, Naples, Italy
| | - Antonio Izzo
- Department of Public Health, Trauma and Orthopaedics, University Federico II of Naples, Via Pansini 5, 80131, Naples, Italy
| | - Salvatore Vallefuoco
- Department of Public Health, Trauma and Orthopaedics, University Federico II of Naples, Via Pansini 5, 80131, Naples, Italy
| | - Francesco Coppola
- Department of Public Health, Trauma and Orthopaedics, University Federico II of Naples, Via Pansini 5, 80131, Naples, Italy
| | - Shelain Patel
- Foot and Ankle Unit, Royal National Orthopaedic Hospital, Stanmore, UK
| | - Francesco Smeraglia
- Department of Public Health, Trauma and Orthopaedics, University Federico II of Naples, Via Pansini 5, 80131, Naples, Italy
| | - Giovanni Balato
- Department of Public Health, Trauma and Orthopaedics, University Federico II of Naples, Via Pansini 5, 80131, Naples, Italy
| | - Massimo Mariconda
- Department of Public Health, Trauma and Orthopaedics, University Federico II of Naples, Via Pansini 5, 80131, Naples, Italy
| | - Alessio Bernasconi
- Department of Public Health, Trauma and Orthopaedics, University Federico II of Naples, Via Pansini 5, 80131, Naples, Italy.
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Lee SH, Cho HG, Yang JH. Predisposing factors for chronic syndesmotic instability following syndesmotic fixation in ankle fracture: Minimum 5-year follow-up outcomes. Foot Ankle Surg 2021; 27:777-783. [PMID: 34583831 DOI: 10.1016/j.fas.2020.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 09/06/2020] [Accepted: 10/05/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND This study aimed to identify risk factors for chronic syndesmotic instability following syndesmotic fixation. METHODS We performed a retrospective review of consecutive patients who had sustained ankle fractures requiring syndesmotic fixation. Patients available for a minimum 5 years of follow-up were classified into 2 groups according to the presence of syndesmotic instability. Statistical binary logistic regression analyses were performed to investigate the significance of various risk factors. Functional outcomes were assessed using the FAOS. RESULTS In total, 166 patients who met the study inclusion criteria underwent analysis. The overall postoperative instability rate was 20.5%, which was significantly affected due to BMI (p = 0.018; OR 6.72), and concomitant posterior malleolar fracture (p = 0.032, OR 2.77). The mean scores in the syndesmotic instability (SI) group were significantly lower than those in the no syndesmotic instability (NSI) group (p = 0.021). CONCLUSIONS Obesity and concomitant posterior malleolar fracture were significant risk factors for postoperative syndesmotic instability.
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Affiliation(s)
- Sung Hyun Lee
- Department of Orthopedic Surgery, Wonkwang University Hospital, 895, Muwang-Ro, Iksan 54538, Republic of Korea.
| | - Hyung Gyu Cho
- Department of Orthopedic Surgery, Wonkwang University Hospital, 895, Muwang-Ro, Iksan 54538, Republic of Korea
| | - Je Heon Yang
- Department of Orthopedic Surgery, Wonkwang University Hospital, 895, Muwang-Ro, Iksan 54538, Republic of Korea
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Bejarano-Pineda L, Guss D, Waryasz G, DiGiovanni CW, Kwon JY. The Syndesmosis, Part I: Anatomy, Injury Mechanism, Classification, and Diagnosis. Orthop Clin North Am 2021; 52:403-415. [PMID: 34538351 DOI: 10.1016/j.ocl.2021.05.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Ankle fractures are common injuries to the lower extremity with approximately 20% sustaining a concomitant injury to the syndesmosis. Although the deltoid ligament is not formally included in the syndesmotic complex, it plays an important role in the mortise stability. Therefore, its integrity should be always evaluated when syndesmotic injury is suspected. Given the anatomic variability of the syndesmosis between individuals, bilateral ankle imaging is recommended, especially in cases of subtle instability. Diagnostic tests that allow dynamic assessment of the distal tibiofibular joint in the 3 planes are the most reliable in determining the presence of syndesmotic injury.
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Affiliation(s)
- Lorena Bejarano-Pineda
- Foot & Ankle Research and Innovation Laboratory - Harvard Medical School, Division of Foot and Ankle Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital - Newton-Wellesley Hospital, 40 2nd Avenue Building 52, Suite 1150, Waltham, MA 02451, USA; Foot & Ankle Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, 40 2nd Avenue Building 52, Suite 1150, Waltham, MA 02451, USA
| | - Daniel Guss
- Foot & Ankle Research and Innovation Laboratory - Harvard Medical School, Division of Foot and Ankle Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital - Newton-Wellesley Hospital, 40 2nd Avenue Building 52, Suite 1150, Waltham, MA 02451, USA; Foot & Ankle Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, 40 2nd Avenue Building 52, Suite 1150, Waltham, MA 02451, USA
| | - Gregory Waryasz
- Foot & Ankle Research and Innovation Laboratory - Harvard Medical School, Division of Foot and Ankle Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital - Newton-Wellesley Hospital, 40 2nd Avenue Building 52, Suite 1150, Waltham, MA 02451, USA; Foot & Ankle Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, 40 2nd Avenue Building 52, Suite 1150, Waltham, MA 02451, USA
| | - Christopher W DiGiovanni
- Foot & Ankle Research and Innovation Laboratory - Harvard Medical School, Division of Foot and Ankle Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital - Newton-Wellesley Hospital, 40 2nd Avenue Building 52, Suite 1150, Waltham, MA 02451, USA; Foot & Ankle Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, 40 2nd Avenue Building 52, Suite 1150, Waltham, MA 02451, USA
| | - John Y Kwon
- Foot & Ankle Research and Innovation Laboratory - Harvard Medical School, Division of Foot and Ankle Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital - Newton-Wellesley Hospital, 40 2nd Avenue Building 52, Suite 1150, Waltham, MA 02451, USA; Foot & Ankle Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, 40 2nd Avenue Building 52, Suite 1150, Waltham, MA 02451, USA.
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Gil JA, Kosinski LR, Shah KN, Katarincic JA, Kakar S. Distal Radioulnar Joint Instability: Assessment of Three Intraoperative Radiographic Stress Tests. Hand (N Y) 2021; 16:674-678. [PMID: 31631704 PMCID: PMC8461195 DOI: 10.1177/1558944719875487] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: The purpose of this study is to describe three radiographic stress tests that could be used to examine for distal radioulnar joint (DRUJ) instability intraoperatively, and to determine their ability to detect DRUJ instability after sequentially sectioning the DRUJ. Methods: Eleven fresh frozen cadaveric upper extremities (mean age 52.6 ± 14.9 years) were obtained. We sequentially sectioned the DRUJ. After each component of the DRUJ was sectioned, we performed three radiographic stress tests-squeeze test, ulnar pull in coronal plane, and simulated DRUJ ballotment test. Results: The squeeze test detected a significant increase in diastasis relative to the intact DRUJ after sectioning of the foveal insertion of the triangular fibrocartilage complex (TFCC; 1.0 mm) and the distal oblique bundle (DOB; 1.2 mm). The ulnar pull test in the coronal plane detected a significant increase in diastasis relative to the intact DRUJ after sectioning of the dorsal and volar radioulnar ligaments (2 mm), the foveal insertion of the TFCC (2.6 mm), and the DOB (4.4 mm). The simulated DRUJ ballotment test detected a significant increase in dorsal translation of the ulna relative to the intact DRUJ with sectioning of the foveal insertion of the TFCC (4.9 mm) and the DOB (5.6 mm). Conclusion: The squeeze test and simulated DRUJ ballotment test detect a significant increase in diastasis after the foveal attachment of the TFCC was sectioned. The ulnar pull test in the coronal plane was the most sensitive test for detecting a significant increase in diastasis relative to the intact DRUJ.
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Affiliation(s)
- Joseph A. Gil
- Brown University, Providence, RI, USA,Joseph A. Gil, Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, 593 Eddy Street, Providence, RI 02906, USA.
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Grewal US, Southgate C, Dhinsa BS. Sub-Acute Syndesmotic Injury: A Review and Proposed Treatment Algorithm. Cureus 2021; 13:e16670. [PMID: 34462694 PMCID: PMC8390008 DOI: 10.7759/cureus.16670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2021] [Indexed: 11/05/2022] Open
Abstract
Sub-acute syndesmotic injuries are classified as from six weeks to six months from the initial injury date and can be considered a distinct group of patients; however, they are often mistreated and progress to chronic injuries with significant sequelae. The authors performed a comprehensive literature search on the MEDLINE database. The search yielded 165 studies up to January 2021, after the application of inclusion/exclusion criteria. This yielded 10 studies with a total of 156 relevant patients for review. We found that a delay in diagnosis is common and has a negative impact on outcomes. If a sub-acute syndesmotic injury is suspected and plain radiographs are inconclusive, magnetic resonance imaging is indicated if there is still an index of suspicion. Surgical intervention should aim to restore normal length and rotational alignment of the fibula whilst also addressing the need to debride tissues within the joint and syndesmosis. Syndesmosis must then be adequately reduced and stabilised with syndesmotic screw fixation, and augmentation with tendon/ligament reconstruction should be considered. All studies showed an average improvement in functional outcome measures post-operatively. The only study to compare sub-acute and chronic patients' functional outcomes post-operatively showed significant improvement in the sub-acute cohort; highlighting the importance of early intervention. We suggest a treatment algorithm that may help with the diagnosis and management of these injuries. We believe this will help all healthcare professionals to standardise care. Further research is required to assess sub-acute injury outcomes with tendon/ligamentous augmented reconstruction, as no level 1 or 2 studies currently exist.
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Wei XK, Jing GW, Shu Y, Tong J, Wang JH. Self-made wire-rope button plate: A novel option for the treatment of distal tibiofibular syndesmosis separation. J Orthop Surg (Hong Kong) 2021; 29:2309499020975215. [PMID: 33557688 DOI: 10.1177/2309499020975215] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE To compare the clinical effect of the self-made wire-rope button plate and cortical screw in the treatment of the distal tibiofibular syndesmosis separation. METHODS Total 26 patients with distal tibiofibular syndesmosis separation were treated with internal fixation with a self-made wire-rope button plate and cortical screw. They were divided into a self-made wire-rope button plate group and cortical screw group. self-made wire-rope button plate group: 12 cases of inferior tibiofibular syndesmosis were reconstructed by self-made wire-rope button plate. Cortical screw group: 14 cases of inferior tibiofibular syndesmosis were reconstructed by cortical screw. The follow-up data of 2, 6, 12 weeks and 6 and 12 months after operation were collected. RESULTS There was no significant difference in operative time, the amount of intraoperative bleeding and postoperative complications between the two groups (P > 0.05). Comparison of postoperative complications: There was no loosening and rupturing of internal fixation in the self-made wire-rope button plate group. In the cortical screw group, the rupture of screws was found in 1 case, which occurred in the 10th weeks after the operation, and the broken screws were removed after 1 year with other internal fixations. Within 12 weeks of reoperation to remove the internal fixation rate: There was a significant difference in the rate of reoperation to remove the internal fixation within 12 weeks (p < 0.05). At the last follow-up, the AOFAS score of the ankle joint were 94 ± 4.79 in the self-made wire-rope button plate group and 92.8 ± 6.73 in the cortical screw group. There was no significant difference (P > 0. 05). CONCLUSION The self-made wire-rope button plate and cortical screw can effectively treat the separation of the tibiofibular syndesmosis. It provides a new choice for the treatment of inferior tibiofibular syndesmosis.
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Affiliation(s)
- Xiang-Ke Wei
- Department of Orthopedics, The First People'S Hospital of Yibin City, Yibin, Sichuan, China
| | - Guang-Wu Jing
- Department of Orthopedics, Affiliated Hospital of Jianghan University, Wuhan, Hubei, China
| | - Yang Shu
- Department of Orthopedics, Affiliated Hospital of Jianghan University, Wuhan, Hubei, China
| | - Jie Tong
- Department of Orthopedics, Affiliated Hospital of Jianghan University, Wuhan, Hubei, China
| | - Jin-Hua Wang
- Department of Orthopedics, Affiliated Hospital of Jianghan University, Wuhan, Hubei, China
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Abstract
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.
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Affiliation(s)
- Nuno Corte-Real
- Department of Orthopaedics, Hospital de Cascais Dr. José de Almeida, Portugal
| | - João Caetano
- Department of Orthopaedics, Hospital de Cascais Dr. José de Almeida, Portugal
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Jiao C, Gui J, Kurokawa H, Tanaka Y, Yung P, Han SH, Angthong C, Song Y, Hua Y, Li H, Shi Z, Li Q, Ling SKK. APKASS Consensus Statement on Chronic Syndesmosis Injury, Part 1: Clinical Manifestation, Radiologic Examination, Diagnosis Criteria, Classification, and Nonoperative Treatment. Orthop J Sports Med 2021; 9:23259671211021057. [PMID: 34222547 PMCID: PMC8221687 DOI: 10.1177/23259671211021057] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 04/20/2021] [Indexed: 02/05/2023] Open
Abstract
Background Clinical manifestation, radiologic examination, diagnostic criteria, classification, and nonoperative treatment strategies regarding chronic syndesmosis injury remain unclear. Purpose An international group of experts representing the fields of sports injuries in the foot and ankle area were invited to collaboratively advance toward consensus opinions based on the best available evidence regarding chronic syndesmosis injuries. All were members of the Asia-Pacific Knee, Arthroscopy and Sports Medicine Society (APKASS). Study Design Consensus statement. Methods From November to December 2020, a total of 111 international experts on sports medicine or ankle surgery participated in a 2-stage Delphi process that included an anonymous online survey and an online meeting. A total of 13 items with 38 statements were drafted by 13 core authors. Of these, 4 items with 15 clinical questions and statements were related to the clinical manifestation, radiologic examination, diagnostic criteria, classification, and nonoperative treatment strategies for chronic syndesmosis injury and are presented here. Each statement was individually presented and discussed, followed by a general vote. The strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; unanimous, 100%. Results Of the 15 questions and statements, 5 reached unanimous support and 10 achieved strong consensus. Conclusion This APKASS consensus statement, developed by international experts in the field, will assist surgeons and physical therapists with diagnosis, classification, and nonoperative treatment strategies for chronic syndesmosis injury.
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Affiliation(s)
- Chen Jiao
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Jianchao Gui
- Department of Sports Medicine, Nanjing First Hospital, Nanjing, China
| | - Hiroaki Kurokawa
- Department of Orthopedic Surgery, Nara Medical University, Nara, Japan
| | - Yasuhito Tanaka
- Department of Orthopedic Surgery, Nara Medical University, Nara, Japan
| | - Patrick Yung
- Department of Orthopaedics and Traumatology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Seung Hwan Han
- Department of Orthopaedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Chayanin Angthong
- Division of Digital and Innovative Medicine, Faculty of Medicine, King Mongkut's Institute of Technology Ladkrabang, Bangkok, Thailand
| | - Yujie Song
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Yinghui Hua
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Hongyun Li
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Zhongmin Shi
- Department of Orthopedic Surgery, Shanghai Sixth People's Hospital, Jiaotong University, Shanghai, China
| | - Qi Li
- Department of Orthopedic Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Samuel K K Ling
- Department of Orthopaedics and Traumatology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
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Longo UG, Loppini M, Fumo C, Lanotte A, Trovato U, Risi Ambrogioni L, Candela V, Forriol F, DiGiovanni CW, Denaro V. Deep deltoid ligament injury is related to rotational instability of the ankle joint: a biomechanical study. Knee Surg Sports Traumatol Arthrosc 2021; 29:1577-1583. [PMID: 33044605 DOI: 10.1007/s00167-020-06308-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 09/28/2020] [Indexed: 12/26/2022]
Abstract
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.
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Affiliation(s)
- Umile Giuseppe Longo
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo 200, 00128, Rome, Trigoria, Italy.
| | - Mattia Loppini
- Humanitas University, Via Alessandro Manzoni 113, 20089, Milan, Rozzano, Italy
- Humanitas Clinical and Research Center, Via Alessandro Manzoni 56, 20089, Milan, Rozzano, Italy
| | - Caterina Fumo
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo 200, 00128, Rome, Trigoria, Italy
| | - Angela Lanotte
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo 200, 00128, Rome, Trigoria, Italy
| | - Ugo Trovato
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo 200, 00128, Rome, Trigoria, Italy
| | - Laura Risi Ambrogioni
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo 200, 00128, Rome, Trigoria, Italy
| | - Vincenzo Candela
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo 200, 00128, Rome, Trigoria, Italy
| | - Francisco Forriol
- Orthopaedic Surgery Department, University Foundation San Pablo CEU, Madrid, Spain
| | - Christopher W DiGiovanni
- Department of Orthopaedic Surgery, Massachusetts General Hospital and Newton Wellesley Hospital, Boston, Massachusetts, US
| | - Vincenzo Denaro
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo 200, 00128, Rome, Trigoria, Italy
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Spennacchio P, Seil R, Gathen M, Cucchi D. Diagnosing instability of ligamentous syndesmotic injuries: A biomechanical perspective. Clin Biomech (Bristol, Avon) 2021; 84:105312. [PMID: 33756400 DOI: 10.1016/j.clinbiomech.2021.105312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 02/26/2021] [Accepted: 03/02/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND High ankle sprains are insidious injuries associated with a long recovery period, functional impairment and long-term sequelae if mistreated. This systematic review investigates the biomechanical knowledge on the kinematic consequences of sequential syndesmotic ligamentous injuries, aiming to furnish an updated and objective contribution for the critical appraisal and further elaboration of current diagnostic algorithms for high ankle sprains. METHODS A systematic review was performed to identify human biomechanical studies evaluating the stabilizing role of the syndesmotic ligaments. Special attention was paid to identify the smallest lesion within the progressive simulated injuries able to provoke statistically significant changes of the syndesmotic kinematic on the specimen, the mechanical solicitation that provoked it, and the measurement methodology. FINDINGS Fourteen studies were included. In eight articles already an isolated injury to the anterior inferior tibiofibular ligament provoked significant changes of the syndesmotic kinematic, which was always depicted under an external rotation torque. In three articles an isolated deltoid ligament injury provoked significant changes of the syndesmotic kinematic. Four articles described a direct measure of the bony movements, whereas seven collected data through conventional radiography or CT-scan imaging and three via a 3D motion analysis tracking system. INTERPRETATION An isolated lesion of the anterior inferior tibiofibular ligament can provoke significant kinematic modifications in ex vivo syndesmotic models and may be responsible of subtle patterns of dynamic instability, regardless of further syndesmotic ligamentous injuries. The data observed support efforts to define reliable CT imaging parameters to improve non-invasive diagnostic of subtle forms of syndesmotic instability.
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Affiliation(s)
- Pietro Spennacchio
- Department of Orthopaedic Surgery, Centre Hospitalier de Luxembourg-Clinique d'Eich, Luxembourg, Luxembourg.
| | - Romain Seil
- Department of Orthopaedic Surgery, Centre Hospitalier de Luxembourg-Clinique d'Eich, Luxembourg, Luxembourg; Sports Medicine Research Laboratory, Luxembourg Institute of Health, Luxembourg, Luxembourg.
| | - Martin Gathen
- Department of Orthopaedics and Trauma Surgery, Universitätsklinikum Bonn, Venusberg-Campus 1, 53127 Bonn, Germany.
| | - Davide Cucchi
- Department of Orthopaedics and Trauma Surgery, Universitätsklinikum Bonn, Venusberg-Campus 1, 53127 Bonn, Germany.
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Netterström-Wedin F, Bleakley C. Diagnostic accuracy of clinical tests assessing ligamentous injury of the ankle syndesmosis: A systematic review with meta-analysis. Phys Ther Sport 2021; 49:214-226. [PMID: 33774464 DOI: 10.1016/j.ptsp.2021.03.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 03/09/2021] [Accepted: 03/11/2021] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To summarise and evaluate research on the diagnostic accuracy of clinical tests for ligamentous injury of the ankle syndesmosis. METHODS CINAHL, Embase, and MEDLINE were searched from inception to February 12, 2021. Studies comparing clinical examination to arthroscopy, magnetic resonance imaging, or ultrasound were considered eligible. Meta-analysis was based on random effect modelling and limited to studies fulfilling all QUADAS-2 criteria. Sensitivity (SN), specificity (SP) and likelihood ratios determined diagnostic accuracy, all with 95% confidence intervals (CI). RESULTS Six studies were included (512 participants; 13 clinical tests; 29% median prevalence). No individual test was associated with both high sensitivity and high specificity. Tests with the highest sensitivity were: palpation [SN 92% (95%CI 79-98)] and dorsiflexion lunge [SN 75% (95% CI 64-84%); n = 2 studies]. Tests with the highest specificity were: squeeze test [SP 85% (95% CI 81-89%); n = 4 studies] and external rotation [SP 78% (95% CI 73-82%); n = 4 studies]. CONCLUSIONS Clinical examination should involve initial clustering of tests with high sensitivity (palpation; dorsiflexion lunge), followed by a test with high specificity (squeeze). However, as these tests cannot definitively stratify syndesmotic injuries into stable vs unstable, decisions on optimal management (conservative vs surgery) require additional imaging or arthroscopy.
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Affiliation(s)
| | - C Bleakley
- School of Health Sciences, Faculty of Life and Health Sciences, Ulster University, Jordanstown Campus, BT370QB, United Kingdom.
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Rellensmann K, Baumbach SF, Polzer H. [28/f-Ankle sprains: not always are the lateral ligaments injured : Preparation for the medical specialist examination: part 64]. Unfallchirurg 2021; 124:179-183. [PMID: 33620519 DOI: 10.1007/s00113-021-00961-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Kathrin Rellensmann
- Klinik für Allgemeine, Unfall- und Wiederherstellungschirurgie, Klinikum der Universität München, LMU München, Nussbaumstr. 20, 80336, München, Deutschland
| | - Sebastian F Baumbach
- Klinik für Allgemeine, Unfall- und Wiederherstellungschirurgie, Klinikum der Universität München, LMU München, Nussbaumstr. 20, 80336, München, Deutschland
| | - Hans Polzer
- Klinik für Allgemeine, Unfall- und Wiederherstellungschirurgie, Klinikum der Universität München, LMU München, Nussbaumstr. 20, 80336, München, Deutschland.
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Reconstruction of Chronic Injured Distal Tibiofibular Syndesmosis with Autogenous Tendon Graft: A Systematic Review. BIOMED RESEARCH INTERNATIONAL 2021; 2021:3182745. [PMID: 33604371 PMCID: PMC7870304 DOI: 10.1155/2021/3182745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 01/05/2021] [Accepted: 01/20/2021] [Indexed: 11/17/2022]
Abstract
Background Chronic injuries of the distal tibiofibular syndesmosis are common in patients who fail to receive adequate diagnosis and timely treatment. Reconstruction of the distal tibiofibular syndesmosis with an autogenous tendon graft in these patients is effective, although relatively rarely reported. Purpose To investigate clinical outcomes of syndesmosis reconstruction with an autogenous tendon graft for chronic injuries of the distal tibiofibular syndesmosis by reviewing the current literature. Methods An English literature search was conducted in the MEDLINE, CENTRAL, and Cochrane databases to identify published studies up to October 2017. Preset inclusion and exclusion criteria were applied to identify all eligible articles. Results Five studies (all with level IV evidence) that included a total of 51 patients who underwent reconstruction with an autogenous tendon graft were identified. It was reported that the symptoms were relieved postoperatively, including obviously improved functional outcomes and restoration of motions and exercise capacity. The mean American Orthopedic Foot and Ankle Society scale score of 16 patients was 53 preoperatively and 89 postoperatively. The visual analogue scale score of 14 patients decreased from 82.4 preoperatively to 12.6 postoperatively. A total of 5 (9.8%) complication cases were reported. Conclusion Reconstruction of the distal tibiofibular syndesmosis with an autogenous tendon for chronic syndesmosis injury showed a good therapeutic effect in terms of both subjective symptoms and objective evaluation scores. The interosseous ligament could be an appropriate reconstruction target in the treatment of chronic syndesmosis injury.
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Rellensmann K, Behzadi C, Usseglio J, Vosseller JT, Böcker W, Polzer H, Baumbach SF. Acute, isolated and unstable syndesmotic injuries are frequently associated with intra-articular pathologies. Knee Surg Sports Traumatol Arthrosc 2021; 29:1516-1522. [PMID: 32728787 PMCID: PMC8038950 DOI: 10.1007/s00167-020-06141-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 07/02/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE Although simultaneous arthroscopy for the surgical treatment of acute isolated, unstable syndesmotic injuries has been recommended, little knowledge is present about the actual frequency of intra-articular pathologies for this injury. The aim of this study was to investigate the frequency and severity of intra-articular pathologies detected during arthroscopy and their subsequent treatment in acute isolated, unstable syndesmotic injuries. METHODS A retrospective chart review of patients treated by arthroscopic-assisted stabilization for acute isolated, syndesmotic instability was performed. The primary outcome parameter was the frequency of intra-articular pathologies. Secondary outcome parameters were the type of syndesmotic lesion (ligamentous/bony), severity of chondral lesions, MRI findings, treatment details, complications and the identification of factors associated with intra-articular pathologies. RESULTS Twenty-seven patients, 19% female, with a mean age of 37 ± 12 years met the inclusion criteria. 70% suffered isolated ligamentous injuries, the remaining suffered avulsion fractures of the syndesmosis. Chondral lesions occurred in 48% (ICRS grade II: 33%; ICRS grade IV 15%) and intra-articular loose bodies in 11% of patients. Overall, arthroscopy revealed intra-articular pathologies necessitating further treatment in 19% of patients. Neither the type of syndesmotic injury (bony vs. ligamentous; ns) nor the degree of ligamentous instability (West Point IIB vs. III; ns) had a significant influence on the occurrence of chondral lesions. One complication (SSI) occurred. Pre-operative MRI revealed a sensitivity/specificity of 100/79% for chondral lesions and 50/93% for loose bodies. CONCLUSION Intra-articular pathologies in acute isolated, unstable syndesmotic injuries occur in up to 50% of patients, 19% necessitated additional treatment. Simultaneous arthroscopy, independent of the pre-operative MRI findings, appears reasonable in highly active patients. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Kathrin Rellensmann
- grid.5252.00000 0004 1936 973XDepartment of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Nussbaumstraße 20, 80336 Munich, Germany
| | - Cyrus Behzadi
- Radiologie München, Dienerstraße 12, 80331 Munich, Germany
| | - John Usseglio
- grid.21729.3f0000000419368729Long Health Sciences Library, Columbia University Irving Medical Center, New York, USA
| | - James Turner Vosseller
- grid.239585.00000 0001 2285 2675Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY USA
| | - Wolfgang Böcker
- grid.5252.00000 0004 1936 973XDepartment of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Nussbaumstraße 20, 80336 Munich, Germany
| | - Hans Polzer
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Nussbaumstraße 20, 80336, Munich, Germany. .,Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY, USA.
| | - Sebastian Felix Baumbach
- grid.5252.00000 0004 1936 973XDepartment of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Nussbaumstraße 20, 80336 Munich, Germany
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Evaluation of ankle ligaments with CT: A feasibility study. Eur J Radiol 2020; 134:109446. [PMID: 33310554 DOI: 10.1016/j.ejrad.2020.109446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 10/25/2020] [Accepted: 11/24/2020] [Indexed: 11/20/2022]
Abstract
PURPOSE This study aims to systematically investigate if normal ankle ligaments can be assessed with CT imaging, using MRI as reference standard. METHODS 35 patients (mean age: 47 ± 15 years; female n = 19) with combined CT and MRI exams and without MR-morphologic signs of ankle ligamental injury were retrospectively identified. 3 readers independently evaluated the syndesmotic, the lateral and medial ankle ligaments in terms of visibility on a 4-point Likert scale (0-3 points) in multiplanar MDCT images in standard bone kernel reconstructions. In consensus CT-based ligament density and thickness were measured and the appearance was rated for each ligament. Results were compared and validated with corresponding MRI images. RESULTS Almost all ankle ligaments identified in MRI images could be adequately depicted in standard multiplanar bone kernel CT images with a mean visual score of 2.7/3 (± 0.2). Difficulties in CT morphological delineation of ankle ligaments occurred in cases of filiform TNL and TCL and in cases of concurrent soft tissue edema. Interreader agreement for the CT-assessment of ankle ligaments was excellent, with Fleiss Kappa values >0.8. Mean density of evaluated medial and lateral ankle ligaments was 68 ± 2.9 HU, with substantially inter- and intraindividual variations. Thickness measurements and assessment of appearance of ankle ligaments showed a good concordance between CT and MRI. CONCLUSIONS Assessment of normal ankle ligaments via standard CT in bone kernel reconstructions is feasible, with some restrictions concerning the medial collateral ligaments and in the presence of soft tissue edema.
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45
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Kent S, Yeo G, Marsland D, Randell M, Forster B, Lutz M, Okano S. Delayed stabilisation of dynamically unstable syndesmotic injuries results in worse functional outcomes. Knee Surg Sports Traumatol Arthrosc 2020; 28:3347-3353. [PMID: 32246172 DOI: 10.1007/s00167-020-05962-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 03/23/2020] [Indexed: 12/13/2022]
Abstract
PURPOSE Patients with primarily ligamentous injuries of the distal tibiofibular joint comprise up to 12% of all ankle sprains. Patients frequently present late after a syndesmosis injury and delayed treatment potentially leads to pain, prolonged disability and arthritis in the long term. This study aimed to assess clinical outcomes in patients who required syndesmosis fixation in the presence of arthroscopically proven instability, the hypothesis being that a delay to treatment would be associated with worse function. METHOD A retrospective cohort study was performed of patients with dynamic instability requiring fixation between the years of 2010-2016. The procedures were performed by two foot and ankle fellowship trained orthopaedic surgeons, over three hospital sites. Patients were classified into three groups based on the time since injury to surgery, acute syndesmotic injury (< 6 weeks), sub-acute (6 weeks-6 months) and chronic syndesmotic injury (> 6 months). Functional scores were retrospectively collected using the Foot and Ankle Outcome Score (FAOS). RESULTS Compared to patients with acute injuries, those with chronic injuries had significantly lower FAOS subscales (p < 0.001), with the greatest difference in quality of life (- 20.7, 95% CI - 31.6 to - 9.8, p = 0.012). There was a mean follow-up of 4.3 years. Although the average FAOS subscales in those with sub-acute injuries were lower than in those with acute injuries, the difference was not statistically significant. CONCLUSION The results of this study suggest that delayed surgical stabilisation (> 6 months) is associated with significantly worse clinical function, and thus timely identification and early referral of those patients with potentially unstable syndesmotic injuries is recommended. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Steven Kent
- Mater Hospital, Brisbane, QLD, Australia. .,Department of Orthopaedic Surgery, Mater Adults Hospital, Raymond Terrace, South Brisbane, QLD, 4101, Australia.
| | - Gerald Yeo
- Prince Charles Hospital, Brisbane, QLD, Australia
| | | | | | | | | | - Satomi Okano
- Statistics Unit, QIMR Berghofer Medical Research Institute, Herston, QLD, Australia
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Fritz B, Parkar AP, Cerezal L, Storgaard M, Boesen M, Åström G, Fritz J. Sports Imaging of Team Handball Injuries. Semin Musculoskelet Radiol 2020; 24:227-245. [PMID: 32987422 DOI: 10.1055/s-0040-1710064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
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.
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Affiliation(s)
- Benjamin Fritz
- Department of Radiology, Balgrist University Hospital, Zurich, and Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Anagha P Parkar
- Department of Radiology, Haraldsplass Deaconess Hospital, Bergen, Norway.,Department of Clinical Medicine, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway
| | - Luis Cerezal
- Department of Radiology, Diagnostico Médico Cantabria, Santander, Spain
| | - Morten Storgaard
- Institute of Sports Medicine Copenhagen, Copenhagen Area, Denmark
| | - Mikael Boesen
- Department of Radiology Copenhagen university hospital, Bispebjerg and Frederiksberg, Copenhagen NV, Denmark.,Parker Institute, Copenhagen University Hospital Bispebjerg and Frederiksberg, Frederiksberg, Denmark
| | - Gunnar Åström
- Department of Immunology, Genetics and Pathology (Oncology) and department of Surgical Sciences (Radiology), Uppsala University, Uppsala, Sweden
| | - Jan Fritz
- Department of Radiology, New York University Grossman School of Medicine, New York University, New York, New York
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Rodrigues JC, Santos ALG, Prado MP, Alloza JFM, Masagão RA, Rosemberg LA, Barros DDCS, Castro ADAE, Demange MK, Lenza M, Ferretti M. Comparative CT with stress manoeuvres for diagnosing distal isolated tibiofibular syndesmotic injury in acute ankle sprain: a protocol for an accuracy- test prospective study. BMJ Open 2020; 10:e037239. [PMID: 32883728 PMCID: PMC7473658 DOI: 10.1136/bmjopen-2020-037239] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Although several imaging options are available for diagnosing syndesmotic injury, a fundamental question that guides treatment remains unanswered. Syndesmotic instability is still challenging to diagnose correctly, and syndesmotic disruption and true syndesmotic instability should be differentiated. Currently, imaging tests quickly diagnose severe syndesmotic instability but have difficulty in diagnosing mild and moderate cases. This study aims to investigate which strategy among an existing CT index test and two new add-on CT index tests with stress manoeuvres more accurately diagnoses syndesmotic instability. The secondary objective is to investigate the participants' disability outcomes by applying the Foot and Ankle Ability Measure questionnaire. METHODS AND ANALYSES This study of a diagnostic accuracy test will consecutively select individuals older than 18 years with a clinical diagnosis of a suspected acute syndesmotic injury. Three strategies of the CT index test (one in the neutral position and two with stress) will examine the accuracy using MRI as the reference standard. The external rotation and dorsiflexion of the ankle will guide the stress manoeuvres. A comparison of measurements between the injured syndesmosis and the uninjured contralateral side of the same individual will investigate the syndesmotic instability, by evaluating the rotational and translational relationships between the fibula and tibia. Sensitivity, specificity, area under the receiver operating characteristic curve and likelihood analyses will compare the diagnostic accuracies of the strategies. ETHICS AND DISSEMINATION The Internal Review Board and the Einstein Ethics Committee approved this study (registered number 62100016.5.0000.0071). All participants will receive an oral description of the study's aim, and the choice to participate will be free and voluntary. Participants will be enrolled after they sign the written informed consent form, including the terms of confidentiality. The results will be presented at national and international conferences and published in peer-reviewed journals and social media. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT04095598; preresults).
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Affiliation(s)
- João Carlos Rodrigues
- Radiologia, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
- Radiologia, Universidade de São Paulo Hospital das Clínicas, Sao Paulo, Brazil
| | - Alexandre Leme Godoy Santos
- Programa Locomotor, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
- Ortopedia, Universidade de São Paulo Hospital das Clínicas, Sao Paulo, Brazil
| | | | | | | | - Laercio Alberto Rosemberg
- Radiologia, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
- Radiologia, Universidade de São Paulo Hospital das Clínicas, Sao Paulo, Brazil
| | | | | | - Marco Kawamura Demange
- Programa Locomotor, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
- Ortopedia, Universidade de São Paulo Hospital das Clínicas, Sao Paulo, Brazil
| | - Mario Lenza
- Programa Locomotor, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Mario Ferretti
- Programa Locomotor, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
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Abstract
Acute and chronic syndesmotic injuries significantly impact athletic function and activities of daily living. Patient history, examination, and judicious use of imaging modalities aid diagnosis. Surgical management should be used when frank diastasis, instability, and/or chronic pain and disability ensue. Screw and suture-button fixation remain the mainstay of treatment of acute injuries, but novel syndesmotic reconstruction techniques hold promise for treatment of acute and chronic injuries, especially for athletes. This article focuses on anatomy, mechanisms of injury, diagnosis, and surgical reduction and stabilization of acute and chronic syndesmotic instability. Fixation methods with a focus on considerations for athletes are discussed.
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Abstract
Diagnosis and management of isolated syndesmotic injuries are controversial and highly debated. Hence, the aim of this study is to explore and gain the current understanding pertaining to detailed anatomy of syndesmotic ligaments through a systematic review of published cadaveric studies. A systematic review was conducted online for literature published in English using PubMed and Google Scholar, as per PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, up to April 30, 2019. Predefined eligibility criteria were applied, and the data thus compiled was analyzed. Study quality was assessed based on Quality Appraisal for Cadaveric Studies (QUACS) scale. A total of 12 studies reporting 365 ankles were included in this review. Considerable inconsistency in the naming and description of syndesmotic ligaments was observed, with only 2 studies reporting the vasculature of the ligaments. Hence further investigation of the anatomy of the syndesmotic ligaments is recommended so as to better inform clinical practice, as awareness of anatomy is critical for assessment, healing, and successful surgical management.Levels of Evidence: Level III: Systematic review of anatomical dissections.
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Affiliation(s)
- Akilesh Anand Prakash
- Department of Sports Medicine, Anamiivaa Clinic and Sports Medicine Centre, Coimbatore, Tamil Nadu, India
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50
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Abstract
Ankle injuries are a common reason for presentation to the pediatric emergency department. An understanding of the anatomy of the ankle joint, the mechanism of injury, and a thorough history and physical examination can help narrow the differential diagnosis. This article will discuss the management of common ankle injuries, including ankle sprains, dislocations, and pediatric fractures, including transitional triplane and Tillaux fractures. A brief review of the literature regarding radiographic evaluation of the ankle and various ankle rules is also discussed.
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