Post-traumatic heterotopic ossification of distal tibiofibular syndesmosis mimicking a surface osteosarcoma

Functional Characterization of Posttraumatic Heterotopic Ossification of Tibiofibular Syndesmosis with Dynamic Bone Scan and Single-Photon Emission Computed Tomography/Computed Tomography

A 53-year-old man was investigated for ongoing right ankle pain and lateral malleolus swelling following a traumatic inversion injury 12 weeks prior. The initial ankle radiograph was normal with no evidence of fracturing. The follow-up radiograph showed bridging ossification in the distal tibiofibular syndesmosis. As the pain did not subside, posttraumatic heterotopic ossification (HO) was suspected, and triple-phase dynamic bone imaging with technetium 99m-methylene diphosphonate was performed to guide further management. The bone scan revealed intense focal tracer activity centered on the HO of the tibiofibular syndesmosis, with no evidence of occult fracturing confirming HO as a pain generator.

Internal tibial torsion is related to syndesmosis injury in a large osteological collection

BACKGROUND

The long-term consequences of tibial torsion remain unclear. This study evaluated whether syndesmotic injuries are associated with tibial torsion.

METHODS

A collection of over 3000 cadaveric skeletons was screened for irregular bony prominence along the lateral distal tibia, consistent with previous syndesmosis injury. Tibial torsion was measured and compared to 1034 control cadaveric tibiae.

RESULTS

Mean torsion of 236 specimens with syndesmotic injury was 6.2±8.9 degrees, while that of control specimens was 7.9±8.8 degrees (P = 0.008). Multiple regression analysis showed a non-statistically significant trend toward internal torsion and syndesmotic injury (standardized beta=-0.051, P=0.059). Syndesmosis injury was present in 48/200 specimens (24.0%) with internal torsion and 31/199 specimens (15.6%) with external torsion (P=0.035).

CONCLUSION

This association between internal tibial torsion and syndesmotic injury suggests that internal tibial torsion might not be an entirely benign condition and merits further study.

MRI of the distal tibiofibular joint

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

Diagnosis and treatment of ankle syndesmosis injuries with associated interosseous membrane injury: a current concept review

BACKGROUND

Tibiofibular syndesmosis injury leads to ankle pain and dysfunction when ankle injuries are not treated properly. Despite several studies having been performed, many questions about diagnosis and treatment remain unanswered, especially in ankle syndesmosis injury with interosseous membrane injury. Therefore, the purpose of this study was to help guide best practice recommendations.

METHODS

This review explores the mechanism of injury, clinical features, diagnosis methods, and the treatment strategy for ankle syndesmosis injury with interosseous membrane injury to highlight the current evidence in terms of the controversies surrounding the management of these injuries.

RESULTS

Radiological and CT examination are an important basis for diagnosing ankle syndesmosis injury. Physical examination combined with MRI to determine the damage to the interosseous membrane is significant in guiding the treatment of ankle syndesmosis injury with interosseous membrane injury. In the past, inserting syndesmosis screws was the gold standard for treating ankle syndesmosis injury. However, there were increasingly more controversies regarding loss of reduction and broken nails, so elastic fixation has become more popular in recent years.

CONCLUSIONS

Anatomical reduction and effective fixation are the main aspects to be considered in the treatment of ankle syndesmosis injury with interosseous membrane injury and are the key to reducing postsurgery complications.

Heterotopic Ossification and Entrapment of the Tibial Nerve Within the Tarsal Tunnel: A Case Report

Heterotopic ossification has been reported to occur after musculoskeletal trauma (including orthopedic procedures). This has been known to cause nerve entrapment syndromes and persistent pain, limiting joint mobility. We present a case of a 19-year old female collegiate athlete who had previously undergone ankle arthroscopy and arthrotomy to remove 2 ossicles. At approximately 1 year postoperatively, the patient developed pain when planting and pivoting her foot. Imaging revealed a radiodense lesion at the posteromedial ankle consistent with heterotopic ossification and entrapment of the tibial nerve within the tarsal tunnel. The patient underwent surgical resection and postoperative indomethacin prophylaxis. At the 1-year follow-up visit, the patient remained asymptomatic, without evidence of recurrence of the heterotopic ossification. In our review of the published data, we found no previously reported cases of heterotopic ossification causing entrapment of the tibial nerve within the tarsal tunnel. In the present case report, we describe this rare case and the postulated etiologies and pathophysiology of this disease process. In addition, we discuss the clinical signs and symptoms and recommended imaging modalities and treatment.