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Tong J, Li H, Li H, Hua Y. Bone marrow edema at ligament insertion is an accurate MRI sign of deltoid ligament injury. Acta Radiol 2024; 65:91-98. [PMID: 37722764 DOI: 10.1177/02841851231197508] [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: 09/20/2023]
Abstract
BACKGROUND Magnetic resonance imaging (MRI) is effective in diagnosing deltoid ligament (DL) injury but its sensitivity in chronic cases is low. Additional diagnostic signs are required to reduce the risk of a false negative diagnosis. PURPOSE To evaluate the added diagnostic value of bone marrow edema at the ligament insertion (BMELI) of DL to the MRI assessment of chronic DL injury. MATERIAL AND METHODS One hundred patients who consecutively came to our institution between November 2018 and December 2021 and underwent arthroscopic surgery for chronic ankle instability (CAI) were enrolled in the present study. Preoperative MR images were retrospectively reviewed by two orthopedic surgeons to evaluate the sensitivity, specificity and interobserver reliability of three MRI signs in diagnosing chronic DL injury, namely, abnormal ligamentous morphological characteristics (ALMC), BMELI and medial clear space (MCS). RESULTS Taking arthroscopy as the reference standard, there were 34 patients with and 66 without DL injury. ALMC had 64.71% (22/34; 46.47-79.70) sensitivity and 83.33% (55/66; 71.71-91.00) specificity, BMELI had 70.59% (24/34; 52.33-84.29) sensitivity and 95.45% (63/66; 86.44-98.82) specificity and MCS had 26.47% (9/34; 13.51-44.65) sensitivity and 92.42% (61/66; 82.50-97.18) specificity. Compared with ALMC, BMELI had similar efficacy in superficial cases (P = 0.06) and greater efficacy in deep cases (P = 0.04). All three signs showed good interobserver agreement (kappa values all above 0.7). CONCLUSION BMELI can reliably indicate concomitant injury to the DL in CAI patients. Using BMELI as a sign of chronic DL injury when ALMC is unclear may reduce the risk of a false negative diagnosis.
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Affiliation(s)
- Jiahui Tong
- Department of Sports Medicine, Huashan Hospital, Shanghai, China
| | - Hong Li
- Department of Sports Medicine, Huashan Hospital, Shanghai, China
| | - Hongyun Li
- Department of Sports Medicine, Huashan Hospital, Shanghai, China
| | - Yinghui Hua
- Department of Sports Medicine, Huashan Hospital, Shanghai, China
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2
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Iyengar KP, Sharma GK, Botchu R. Accessory Tibionavicular Muscle: An Unusual Cause of Medial Ankle Pain. Indian J Radiol Imaging 2023; 33:555-559. [PMID: 37811165 PMCID: PMC10556311 DOI: 10.1055/s-0043-1769472] [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] [Indexed: 10/10/2023] Open
Abstract
Accessory or anomalous muscles around the ankle are not uncommon and are usually asymptomatic. They are traditionally encountered during imaging undertaken for evaluation of ankle pain. We reported the first case of a new accessory muscle in the anteromedial part of the ankle with associated partial thickness tear in an 18-year-old football player presenting as symptomatic pathology. In this article, we described the role of cross-sectional imaging in its diagnosis including successful management of the condition with ultrasound-guided platelet-rich plasma therapy and review-associated literature.
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Affiliation(s)
- Karthikeyan P. Iyengar
- Department of Orthopedics, Southport and Ormskirk NHS Trust, Southport, United Kingdom
- Department of Radiodiagnosis, Jaipur Institute of Pain and Sports Injuries, Jaipur, Rajasthan, India
| | - Gaurav Kant Sharma
- Department of Radiodiagnosis, Jaipur Institute of Pain and Sports Injuries, Jaipur, Rajasthan, India
| | - Rajesh Botchu
- Department of Muscoloskeletal Radiology, Royal Orthopedic Hospital, Birmingham, United Kingdom
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3
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Ahmad ZY, Rasiej MJ. Imaging of the Ankle Ligaments and Cartilage Injuries as an Aid to Ankle Preservation Surgery. Semin Ultrasound CT MR 2023; 44:319-331. [PMID: 37437970 DOI: 10.1053/j.sult.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
Ankle sprains are among the most common musculoskeletal injuries and can lead to ankle ligament and cartilage injuries. Imaging plays an important role in differentiating ligament injuries from other causes of ankle pain such as fractures, osteochondral lesions or tendon injuries that helps guide further management. Chronic untreated ankle ligamentous and cartilage injuries can further progress to ankle osteoarthritis, hence the need for timely diagnosis and treatment. Surgical treatment is often required in patients not responding to conservative treatment and ranges from repair and reconstruction procedures for ligament injuries to arthroscopic debridement and repair procedures for cartilage injuries. Cartilage defects and deficiency may be augmented depending on the extent of cartilage loss and associated subchondral changes on MRI. Awareness of operative techniques utilized is essential to interpret imaging findings in postoperative settings.
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Affiliation(s)
- Zohaib Y Ahmad
- Department of Radiology, Division of Musculoskeletal Radiology, New York-Presbyterian Hospital-Columbia University Irving Medical Center, New York, NY.
| | - Michael J Rasiej
- Department of Radiology, Division of Musculoskeletal Radiology, New York-Presbyterian Hospital-Columbia University Irving Medical Center, New York, NY
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4
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Armstrong TM, Rowbotham E, Robinson P. Update on Ankle and Foot Impingement. Semin Musculoskelet Radiol 2023; 27:256-268. [PMID: 37230126 DOI: 10.1055/s-0043-1764387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Ankle impingement syndromes are a well-recognized cause of chronic ankle symptoms in both the elite athletic and general population. They comprise several distinct clinical entities with associated radiologic findings. Originally described in the 1950s, advances in magnetic resonance imaging (MRI) and ultrasonography have allowed musculoskeletal (MSK) radiologists to further their understanding of these syndromes and the range of imaging-associated features. Many subtypes of ankle impingement syndromes have been described, and precise terminology is critical to carefully separate these conditions and thus guide treatment options. These are divided broadly into intra-articular and extra-articular types, as well as location around the ankle. Although MSK radiologists should be aware of these conditions, the diagnosis remains largely clinical, with plain film or MRI used to confirm the diagnosis or assess a surgical/treatment target. The ankle impingement syndromes are a heterogeneous group of conditions, and care must be taken not to overcall findings. The clinical context remains paramount. Treatment considerations are patient symptoms, examination, and imaging findings, in addition to the patient's desired level of physical activity.
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Affiliation(s)
- T M Armstrong
- Royal Free Hospitals NHS Foundation Trust, London, United Kingdom
| | - Emily Rowbotham
- Musculoskeletal Radiology Department, Chapel Allerton Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
- NIHR Leeds Biomedical Research Centre, Leeds, United Kingdom
| | - Philip Robinson
- Musculoskeletal Radiology Department, Chapel Allerton Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
- NIHR Leeds Biomedical Research Centre, Leeds, United Kingdom
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5
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Pflüger P, Valderrabano V. Sprain of the Medial Ankle Ligament Complex. Foot Ankle Clin 2023; 28:355-367. [PMID: 37137629 DOI: 10.1016/j.fcl.2023.01.009] [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
Injuries of the medial ankle ligament complex (MALC; deltoid and spring ligament) are more common following ankle sprains than expected, especially in eversion-external rotation mechanisms. Often these injuries are associated with concomitant osteochondral lesions, syndesmotic lesions, or fractures of the ankle joint. The clinical assessment of the medial ankle instability together with a conventional radiological and MR imaging is the basis for the definition of the diagnosis and therefore the optimal treatment. This review aims to provide an overview as well as a basis to successfully manage MALC sprains.
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Affiliation(s)
- Patrick Pflüger
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Victor Valderrabano
- SWISS ORTHO CENTER, Swiss Medical Network, Schmerzklinik Basel, University of Basel, Hirschgässlein 15, Basel 4010, Switzerland.
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6
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Cerezal A, Ocampo R, Llopis E, Cerezal L. Ankle Instability Update. Semin Musculoskelet Radiol 2023; 27:231-244. [PMID: 37230124 DOI: 10.1055/s-0043-1767767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Sprains are the most frequent injuries of the ankle, especially in sports. Up to 85% of cases affect the lateral ligament complex. Multi-ligament injuries with associated lesions of the external complex, deltoid, syndesmosis, and sinus tarsi ligaments are also common. Most ankle sprains respond to conservative treatment. However, up to 20 to 30% of patients can develop chronic ankle pain and instability.New concepts have been recently developed, based on arthroscopic advances, such as microinstability and rotatory ankle instability. These entities could be precursors of mechanical ankle instability and at the origin of frequently associated ankle injuries, such as peroneus tendon lesions, impingement syndromes, or osteochondral lesions.Imaging methods, especially magnetic resonance (MR) imaging and MR arthrography, are key in precisely diagnosing ligament lesions and associated injuries, facilitating an adequate therapeutic approach.
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Affiliation(s)
- Alvaro Cerezal
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario La Paz, Madrid, Spain
| | - Ronald Ocampo
- Department of Radiology, Hospital de Trauma del Instituto Nacional de Seguros, San Jose, Costa Rica
| | - Eva Llopis
- Department of Radiology, Hospital IMSKE, Hospital de la Ribera, Valencia, Spain
| | - Luis Cerezal
- Department of Radiology, Diagnóstico Médico Cantabria (DMC), Santander, Spain
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7
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Iyengar KP, Gregory K, Beale D, Prem H, Gavvala S, Botchu R. Isolated, periosteal stripping injuries of the Flexor Retinaculum: Case series of 3 patients with clinico-radiological review. J Clin Orthop Trauma 2023; 36:102082. [PMID: 36465495 PMCID: PMC9712989 DOI: 10.1016/j.jcot.2022.102082] [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: 04/11/2022] [Revised: 10/03/2022] [Accepted: 11/23/2022] [Indexed: 11/25/2022] Open
Abstract
Isolated periosteal avulsion injuries of the flexor retinaculum on the medial side of the ankle are rare and may mimic osseous injuries or deltoid ligament tears. We describe a case series of 3 individuals with isolated, stripping injuries of the tibial attachment of the flexor retinaculum without underlying fracture or deltoid ligament disruption. A new classification system of flexor retinaculum periosteal stripping injuries of the ankle is proposed with clinico-radiological features.
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Affiliation(s)
| | - K.M. Gregory
- Department of Sport and Exercise Medicine, University Hospitals of Birmingham, Birmingham and University Hospitals of Leicester, UK
| | | | - H. Prem
- Department of Foot and Ankle Surgery, Royal Orthopedic Hospital, Birmingham, UK
| | - S.N. Gavvala
- Department of Radiology, Kurnool Medical College, Kurnool, India
| | - R. Botchu
- Heath Lodge Clinic, Knowle, UK
- Department of Musculoskeletal Radiology, Royal Orthopedic Hospital, Birmingham, UK
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8
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Yoon YS, Cha JG, Lee YK. Prediction of anterior tibiotalar ligament injury: measurement of the angle between the deep posterior tibiotalar ligament and talus on MRI. Acta Radiol 2022; 64:1579-1588. [PMID: 36345217 DOI: 10.1177/02841851221135614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background Identification of anterior tibiotalar ligament (aTTL) injury is essential because it influences the surgeon's treatment option and patient prognosis. Purpose To assess the diagnostic accuracy of the angle measurement between the talus and posterior tibiotalar ligament (talus-pTTL) on magnetic resonance imaging (MRI) in patients with arthroscopically proven aTTL injuries. Material and Methods Ankle MRI scans of 67 patients who underwent arthroscopic examination were retrospectively reviewed. The talus-pTTL angle on axial T2-weighted MRI and the medial clear space (MCS) on mortise ankle radiograph were measured. Inter-observer agreement of the measurements was calculated. Also, sensitivity, specificity, and area under the receiver operating characteristic (ROC) curve (AUC) were the metrics of diagnostic accuracy. Results AUC was 0.90 for observer 1 with 78.6% sensitivity, 97.4% specificity, 88% accuracy, and 54.7° cutoff value for the talus-pTTL angle. AUC was 0.87 for observer 2 with 85.7% sensitivity, 84.6% specificity, 85.2% accuracy, and 53.7° cutoff value for the talus-pTTL angle. AUC was 0.86 with 82.1% sensitivity, 79.5% specificity, and 80.8% accuracy for observer 1 and 0.79 with 57.1% sensitivity, 92.3% specificity, and 74.7% accuracy for observer 2 for the MCS. Different MCS values and additional capabilities when complemented with the angle measurement showed an increase in diagnostic performances. Intra-observer reliability of MCS and talus-pTTL angle of the two radiologists was excellent. Inter-observer reliability of the two radiologists was excellent for both the talus-pTTL angle (0.95) and the MCS (0.85). Conclusion Measurement of the talus-pTTL angle showed good sensitivity, specificity, and accuracy for the evaluation of aTTL injury with excellent inter-observer reliability.
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Affiliation(s)
- Yu Sung Yoon
- Department of Radiology, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
| | - Jang Gyu Cha
- Department of Radiology, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
| | - Young Koo Lee
- Department of Orthopedic surgery, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
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9
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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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10
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Abstract
Ankle impingement presents with painful and limited range of motion with dorsiflexion or plantar flexion, originating from pathological contact between bone and/or soft-tissue structures. Diagnosis is made primarily through clinical examination with adjunct radiographs and magnetic resonance imaging, with care taken to rule out a plethora of similarly presenting pathologies. Arthroscopic surgical approaches bring satisfactory short, mid, and long-term outcomes, with the current body of evidence dominated by Level-IV studies. Minimally invasive techniques offer improvements in time to return to play and complication rates relative to open approaches. Recent advances in the arthroscopic management of ankle impingement include long-term outcome studies, novel prognostic classification systems, and strategies for concomitant lesion management.
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11
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Ikuta Y, Nakasa T, Sumii J, Nekomoto A, Adachi N. Quantitative Analysis of Deltoid Ligament Degradation in Patients With Chronic Ankle Instability Using Computed Tomographic Images. Foot Ankle Int 2021; 42:952-958. [PMID: 33703931 DOI: 10.1177/1071100721997070] [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] [Indexed: 02/01/2023]
Abstract
BACKGROUND Rotational ankle instability (RAI) is associated with the faster onset of severe ankle osteoarthritis via dysfunction of the anterior talofibular ligament, calcaneofibular ligament, and deltoid ligament. No specific clinical examination is available for RAI, and diagnostic imaging has limitations in evaluating ligament degradation. This study investigated the deltoid ligament degeneration using Hounsfield unit (HU) values on computed tomography (CT) images. METHODS Patients were enrolled in this retrospective analysis if they had undergone magnetic resonance imaging (MRI) and CT scans of the ankle. The chronic ankle instability (CAI) group comprised 20 ankles with CAI (9 men, 11 women; mean age, 28.7 years) and the control group comprised 28 ankles (16 men, 12 women, mean age, 41.3 years). The average HU values of the deep posterior tibiotalar ligament (dPTL) that constitutes the deltoid ligament were measured on coronal CT images, and MRI results were used as a reference. All patients were subdivided based on the MRI findings of dPTL injury such as fascicular disruption, irregularity, and the loss of striation. RESULTS A strong negative correlation was identified between age and HU values for all patients (Spearman ρ = -0.63; P < .001). The mean HU values of the dPTL for participants aged <60 years were 81.0 HU for the control group (21 ankles) and 69.5 HU for the CAI group (P = .0075). No significant differences in the HU values were observed for the dPTL among the MRI subgroups. CONCLUSION In addition to the conventional imaging examination such as stress radiographs and MRI, HU measurements of CT images could be useful for quantitatively and noninvasively evaluating degenerative changes in the deltoid ligament for CAI patients to assist the diagnosis of RAI. LEVEL OF EVIDENCE Level III. case-control study.
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Affiliation(s)
- Yasunari Ikuta
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.,Sports Medical Center, Hiroshima University Hospital, Hiroshima, Japan
| | - Tomoyuki Nakasa
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.,Medical Center for Translational and Clinical Research, Hiroshima University Hospital, Hiroshima, Japan
| | - Junichi Sumii
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Akinori Nekomoto
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Nobuo Adachi
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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12
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Abstract
Undiagnosed medial ankle instability can be a prerequisite for pathogenic progression in the foot, particularly for adult acquired flatfoot deformity. With the complex anatomy in this region, and the limitations of each individual investigational method, accurately identifying peritalar instability remains a serious challenge to clinicians. Performing a thorough clinical examination aided by evaluation with advanced imaging can improve the threshold of detection for this condition and allow early proper treatment to prevent further manifestations of the instability.
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Affiliation(s)
- Yantarat Sripanich
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, USA; Department of Orthopaedics, Phramongkutklao Hospital and College of Medicine, 315 Rajavithi Road, Tung Phayathai, Ratchathewi, Bangkok 10400, Thailand
| | - Alexej Barg
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, USA; Department of Orthopaedics, Trauma and Reconstructive Surgery, University of Hamburg, Martinistr. 52, Hamburg 20246, Germany.
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13
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Abstract
Chronic deltoid instability (CDI), or medial ankle instability, can happen following traumas of the foot and ankle, predominantly rotational injuries. CDI is frequently underdiagnosed or misdiagnosed. Long-term residual instability can lead to ankle posttraumatic arthritis. Adequate assessment of patients with suspected CDI is paramount. Conservative treatment can be tried for stable or mildly unstable cases, but surgical treatment is usually needed for the more severely unstable patients, or when conservative measures fail. Few reconstruction techniques have been proposed in the setting of posttraumatic CDI. This article describes our preferred technique for reconstruction of the deep components of the deltoid ligament.
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Affiliation(s)
- Cesar de Cesar Netto
- Foot and Ankle Services, Department of Orthopedics and Rehabilitation, University of Iowa, Carver College of Medicine, John Pappajohn Pavilion (JPP), Room 01066, Lower Level, 200 Hawkins Drive, Iowa City, IA 52242, USA.
| | - John E Femino
- Foot and Ankle Services, Department of Orthopedics and Rehabilitation, University of Iowa, Carver College of Medicine, John Pappajohn Pavilion (JPP), Room 01066, Lower Level, 200 Hawkins Drive, Iowa City, IA 52242, USA
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14
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Abstract
Whereas tenderness, ecchymosis, and swelling over the deltoid ligament have relatively poor sensitivity, resulting valgus and pronation deformity that is seen to disappear when the patient is asked to activate the posterior tibial muscle or to go in tiptoe position is the hallmark for the presence of medial ankle instability. A pain on palpation at anteromedial edge of the ankle confirms the diagnosis. Various stress tests permit to confirm and specify the injury pattern. A pseudo hallux rigidus is the consequence of a hyperactivity of flexor hallucis longus muscle to protect the foot against the valgus and pronation deformity.
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Affiliation(s)
- Roxa Ruiz
- Center of Excellence for Foot and Ankle Surgery, Kantonsspital Baselland, Rheinstrasse 26, CH-4410 Liestal, Switzerland.
| | - Beat Hintermann
- Center of Excellence for Foot and Ankle Surgery, Kantonsspital Baselland, Rheinstrasse 26, CH-4410 Liestal, Switzerland
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15
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Abstract
Although far less common than lateral ankle injuries, medial ankle sprains have been reported to result in significantly greater time lost and long-term disability when not diagnosed and treated accurately. Adequate diagnosis is paramount and the most important aspect is to determine whether the lesion is stable or unstable. Evidence confronting surgical versus conservative treatment in acute deltoid ligament lesions is largely anchored in the setting of ankle fractures. Ultimately treatment decisions rely on the clinical and imaging appraisal of each individual patient. This article discusses the isolated acute deltoid ligament impairment.
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Affiliation(s)
- Gastón Slullitel
- Foot and Ankle Surgery Department, J Slullitel Institute of Orthopaedics, San Luis 2534, Rosario, Santa Fe 2000, Argentina.
| | - Juan Pablo Calvi
- Foot and Ankle Surgery Department, J Slullitel Institute of Orthopaedics, San Luis 2534, Rosario, Santa Fe 2000, Argentina. https://twitter.com/pieijs
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16
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Advanced Ankle and Foot Sonoanatomy: Imaging Beyond the Basics. Diagnostics (Basel) 2020; 10:diagnostics10030160. [PMID: 32183398 PMCID: PMC7151198 DOI: 10.3390/diagnostics10030160] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 03/12/2020] [Accepted: 03/12/2020] [Indexed: 12/16/2022] Open
Abstract
Ankle/foot pain is a common complaint encountered in clinical practice. Currently, due to the complex anatomy, the diagnosis and management of the underlying musculoskeletal disorders are extremely challenging. Nowadays, high-resolution ultrasound has emerged as the first-line tool to evaluate musculoskeletal disorders. There have been several existing protocols describing the fundamental sonoanatomy of ankle/foot joints. However, there are certain anatomic structures (e.g., Lisfranc ligament complex or Baxter nerve) which are also clinically important. As they are rarely elaborated in the available literature, a comprehensive review is necessary. In this regard, the present article aims to brief the regional anatomy, illustrate the scanning techniques, and emphasize the clinical relevance of the ankle/foot region.
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Pellegrini MJ, Torres N, Cuchacovich NR, Huertas P, Muñoz G, Carcuro GM. Chronic deltoid ligament insufficiency repair with Internal Brace™ augmentation. Foot Ankle Surg 2019; 25:812-818. [PMID: 30478015 DOI: 10.1016/j.fas.2018.10.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 10/08/2018] [Accepted: 10/16/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND Patients with chronic deltoid ligament insufficiency (CDLI) present a challenging situation. Although numerous procedures have been described, optimal treatment is still a matter of debate. While the treatment armamentarium ranges from simple ligament repair to complex reconstructions with or without realignment osteotomies, direct repair augmented with an Internal Brace™ device appears to be an attractive intermediate option. We investigated functional outcomes and complications in patients with CDLI operated on using Internal Brace™ augmentation. METHODS A prospective study was conducted. Patients were included if they presented medial ankle pain and/or giving way, exhibited asymmetric flexible hindfoot valgus, failed conservative treatment, and had a positive MRI evaluated by an independent radiologist. Patients with stage IV flatfoot deformity, neuropathy and/or inflammatory arthritis were excluded. CDLI was confirmed intraoperatively with the arthroscopic drive-through sign. Patients were evaluated preoperatively and postoperatively using FAAM, SF-36 and grade of satisfaction. Paired t-tests were used to assess FAAM and SF-36 scores variation. RESULTS Thirteen patients met inclusion criteria. No patient was lost to follow-up, with a mean follow-up time of 13.5 months (range 6-21). Preoperative FAAM and SF-36 scores improved from 58.7 to 75.3 and from 60.2 to 84.4 postoperatively, respectively (p<.01). Two implant failures were observed, with no apparent compromise of construct stability. No patient was re-operated. CONCLUSIONS Our results suggest that deltoid ligament repair with Internal Brace™ augmentation in patients with CDLI is a reliable option with good functional outcomes and high satisfaction grade in short term follow-up. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- M J Pellegrini
- Department of Orthopaedic Surgery, Hospital Clinico Universidad de Chile, Clinica Universidad de Los Andes, Santos Dumont 999, Independencia, Santiago, 7640275, Chile.
| | - N Torres
- Department of Orthopaedic Surgery, Hospital Clinico Universidad de Chile, Clinica Universidad de Los Andes, Santos Dumont 999, Independencia, Santiago, 7640275, Chile.
| | - N R Cuchacovich
- Department of Orthopaedic Surgery, Hospital Clinico Universidad de Chile, Clinica Universidad de Los Andes, Santos Dumont 999, Independencia, Santiago, 7640275, Chile.
| | - P Huertas
- Medical Education Department, Senior Clinical Specialist Foot and Ankle, Naples, FL, USA.
| | - G Muñoz
- Department of Orthopaedic Surgery, Clinica Las Condes, Lo Fontecilla 441, Las Condes, Santiago, 7591046, Chile.
| | - G M Carcuro
- Department of Orthopaedic Surgery, Hospital Clinico Universidad de Chile, Clinica Universidad de Los Andes, Santos Dumont 999, Independencia, Santiago, 7640275, Chile.
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Intra and Inter-rater Reliability between Ultrasound Imaging and Caliper Measures to determine Spring Ligament Dimensions in Cadavers. Sci Rep 2019; 9:14808. [PMID: 31616040 PMCID: PMC6794374 DOI: 10.1038/s41598-019-51384-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 09/30/2019] [Indexed: 12/14/2022] Open
Abstract
The purpose was to evaluate intra and inter-rater reliability, repeatability and absolute accuracy between ultrasound imaging (US) and caliper measures to determine Spring ligament (SL) dimensions in cadavers. SLs were identified from 62 human feet from formaldehyde-embalmed cadavers. Intra and inter-observer reliability, repeatability and absolute accuracy of SL width, thickness and length between US and caliper measurements were determined at intra and inter-session by intraclass correlation coefficients, Pearson´s correlation coefficients, Student t tests, standard errors of measurement, minimum detectable changes, values of normality, 95% limits of agreement, and Bland-Altman plots. Excellent inter-session and inter-rater reliability, adequate absolute accuracy, almost perfect agreement and strong correlations were shown for caliper, US and their comparison for all SL dimensions. US measurements presented higher absolute accuracy than caliper measures for SL length and thickness dimensions, while caliper displayed greater absolute accuracy for SL width dimensions. Good repeatability (P > 0.05) was shown for all SL dimensions by US, caliper and their comparison, except for SL width dimension measured with US (P = 0.019). Both US and caliper could be recommended for all SL dimensions evaluation due to their excellent reliability and absolute accuracy in cadavers, although width dimensions should be considered with caution due to US repeatability differences.
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Ankle medial flexor retinaculum avulsion fracture. Radiol Case Rep 2019; 14:1144-1147. [PMID: 31360277 PMCID: PMC6639679 DOI: 10.1016/j.radcr.2019.06.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 06/19/2019] [Accepted: 06/30/2019] [Indexed: 11/20/2022] Open
Abstract
Medial flexor retinaculum injuries are not uncommon, but medial flexor retinaculum periosteal avulsion injuries are rare. This patient sustained a medial flexor retinaculum tear readily characterized at computed tomography by an associated proximal retinacular avulsion fracture from the posteromedial tibia. Medial flexor retinaculum injury is often also associated with superficial deltoid pathology and/or medial malleolar fracture. An additional significant complication of medial flexor retinaculum tear is anterior dislocation of the tibialis posterior tendon, which heralds a tibialis posterior fibro-osseous tunnel injury.
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Sridharan SS, Dodd A. Diagnosis and Management of Deltoid Ligament Insufficiency. FOOT & ANKLE ORTHOPAEDICS 2019; 4:2473011419860073. [PMID: 35097332 PMCID: PMC8500389 DOI: 10.1177/2473011419860073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background: Surgical management of patients with acute and chronic ankle instability (CAI) has historically focused on the lateral ligament complex. Recent studies in CAI patients have shown that magnetic resonance imaging (MRI) and arthroscopy demonstrate concomitant injury to the deltoid ligament complex We performed a systematic review to determine if consistent clinical, diagnostic imaging, or arthroscopic findings of deltoid ligament injury in the setting of CAI have been described. In addition, we sought to determine if treatment options and/or clinical outcomes have been described. Methods: A systematic review was conducted using the PubMed, MEDLINE, and Embase databases. Articles were included if they had a majority of patients 18 years of age or older, focused on deltoid ligament injury in ankle instability, and reported diagnostic and/or treatment methods. Articles were excluded if the study focused on the deltoid ligament in the acute fracture setting. All included articles were assessed for diagnostic criteria, treatments, and patient outcomes. Results: Our search yielded 157 articles, of which a total of 13 were included in our study. Arthroscopy was described as the gold standard to diagnose and evaluate the severity of deltoid ligament injury, however, little objective data on the arthroscopic diagnosis of deltoid ligament insufficiency was reported. MRI was the imaging modality of choice to evaluate deltoid ligament injury and had a high sensitivity and specificity when compared with arthroscopy. No standard MRI diagnostic criteria for deltoid ligament injury were identified in the literature. Specific treatment techniques and long-term outcomes were not well described in the manuscripts included in this review. Conclusion: There is limited knowledge on deltoid ligament insufficiency in the setting of chronic ankle instability. Criteria for characterizing deltoid ligament damage with diagnostic imaging appear to be evolving, but there is no standard classification. Only 1 author has described a method to evaluate deltoid ligament competency on arthroscopic examination. There are currently no objective data to guide treatment decisions. Level of Evidence: Level III.
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Affiliation(s)
- Sarup S. Sridharan
- Cumming School of Medicine, Department of Orthopedic Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Andrew Dodd
- Cumming School of Medicine, Department of Orthopedic Surgery, University of Calgary, Calgary, Alberta, Canada
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21
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Abstract
The crucial role of the spring ligament complex within the pathologic process that leads to flatfoot deformity has evolved recently. There has been improvement in the anatomic knowledge of the spring ligament and understanding of its complex relationship to the deltoid complex and outstanding advances in biomechanics concepts related to the spring ligament. Optimization of flatfoot treatment strategies are focused on a renewed interest in the spring ligament and medial soft tissue reconstruction in concert with bony correction to obtain an adequate reduction of the talonavicular deformity and restoration of the medial longitudinal arch.
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Affiliation(s)
- Gonzalo F Bastias
- Department of Orthopedic Surgery, Clinica Las Condes, Estoril 450, Las Condes, Santiago 7591047, Chile; Foot and Ankle Unit, Complejo Hospitalario San José, San José 1196, Santiago 8380419, Chile; Department of Orthopedic Surgery, Universidad de Chile, 1027 Independencia, Santiago 8380453, Chile.
| | - Miki Dalmau-Pastor
- Human Anatomy and Embryology Unit, Experimental Pathologies and Therapeutics Department, Universitat de Barcelona, Feixa Larga s/n, 08907, Hospitalet de Llobregat, Barcelona 08907, Spain; Health Sciences Faculty of Manresa, Universitat de Vic-Central de Catalunya, Sagrada Família, 7. 08500 Vic, Barcelona, Spain; Groupe de Recherche et d'Etude en Chirurgie Mini-Invasive du Pied, 2 Rue Georges Negrevergne, Merignac 33700, France
| | - Claudia Astudillo
- Department of Radiology, Clinica Las Condes, Estoril 450, Las Condes, Santiago 7591047, Chile
| | - Manuel J Pellegrini
- Department of Orthopedic Surgery, Universidad de Chile, 1027 Independencia, Santiago 8380453, Chile; Department of Orthopedic Surgery, Hospital Clinico Universidad de Chile, Santos Dumont 999, Independencia, Santiago 8380456, Chile; Clinica Universidad de los Andes, Plaza 2501, Santiago 7620157, Chile
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Alshalawi S, Galhoum AE, Alrashidi Y, Wiewiorski M, Herrera M, Barg A, Valderrabano V. Medial Ankle Instability: The Deltoid Dilemma. Foot Ankle Clin 2018; 23:639-657. [PMID: 30414658 DOI: 10.1016/j.fcl.2018.07.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Diagnosis and treatment of medial ankle instability (MAI) are still controversial and poorly discussed in literature. The purpose of this review is to highlight different clinical presentations of MAI and develop a guide for its management. The deltoid ligament complex is injured more commonly than expected, because deltoid ligament injuries may either be isolated or occur in combination with other lesions, such as lateral ankle ligament injury, posterior tibial tendon insufficiency, osteochondral lesion, and others. The presence of a pes planovalgus deformity in a patient without posterior tibial tendon insufficiency may indicate MAI.
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Affiliation(s)
- Saud Alshalawi
- Prince Sultan Military Medical City, PO Box 13225-6604, Riyadh 12233, Saudi Arabia
| | - Ahmed E Galhoum
- Department of Orthopedic, Nasser Institute for Research and Treatment, Nile Corniche Street, Cairo 1351, Egypt
| | - Yousef Alrashidi
- Orthopaedic Department, College of Medicine, Taibah University, PO Box 30001, Medina 42353, Saudi Arabia
| | - Martin Wiewiorski
- Head Foot and Ankle Unit, Orthopaedic and Trauma Department, Kantonsspital Winterthur, Winterthur 8401, Switzerland
| | - Mario Herrera
- Head Foot and Ankle Unit, Orthopaedic Department, University of La Laguna, Tenerife 38200, Spain
| | - Alexej Barg
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, USA
| | - Victor Valderrabano
- Orthopaedic Department, Swiss Ortho Center, Swiss Medical Network, Schmerzklinik Basel, Hirschgässlein 15, Basel 4010, Switzerland.
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LiMarzi GM, Khan O, Shah Y, Yablon CM. Imaging Manifestations of Ankle Impingement Syndromes. Radiol Clin North Am 2018; 56:893-916. [DOI: 10.1016/j.rcl.2018.06.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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