Magnetic resonance imaging and incidental findings of lateral ankle pathologic features with asymptomatic ankles

Multiaxial 3D MRI of the Ankle: Advanced High-Resolution Visualization of Ligaments, Tendons, and Articular Cartilage

MRI is a valuable tool for diagnosing a broad spectrum of acute and chronic ankle disorders, including ligament tears, tendinopathy, and osteochondral lesions. Traditional two-dimensional (2D) MRI provides a high image signal and contrast of anatomic structures for accurately characterizing articular cartilage, bone marrow, synovium, ligaments, tendons, and nerves. However, 2D MRI limitations are thick slices and fixed slice orientations. In clinical practice, 2D MRI is limited to 2 to 3 mm slice thickness, which can cause blurred contours of oblique structures due to volume averaging effects within the image slice. In addition, image plane orientations are fixated and cannot be changed after the scan, resulting in 2D MRI lacking multiplanar and multiaxial reformation abilities for individualized image plane orientations along oblique and curved anatomic structures, such as ankle ligaments and tendons. In contrast, three-dimensional (3D) MRI is a newer, clinically available MRI technique capable of acquiring high-resolution ankle MRI data sets with isotropic voxel size. The inherently high spatial resolution of 3D MRI permits up to five times thinner (0.5 mm) image slices. In addition, 3D MRI can be acquired image voxel with the same edge length in all three space dimensions (isotropism), permitting unrestricted multiplanar and multiaxial image reformation and postprocessing after the MRI scan. Clinical 3D MRI of the ankle with 0.5 to 0.7 mm isotropic voxel size resolves the smallest anatomic ankle structures and abnormalities of ligament and tendon fibers, osteochondral lesions, and nerves. After acquiring the images, operators can align image planes individually along any anatomic structure of interest, such as ligaments and tendons segments. In addition, curved multiplanar image reformations can unfold the entire course of multiaxially curved structures, such as perimalleolar tendons, into one image plane. We recommend adding 3D MRI pulse sequences to traditional 2D MRI protocols to visualize small and curved ankle structures to better advantage. This article provides an overview of the clinical application of 3D MRI of the ankle, compares diagnostic performances of 2D and 3D MRI for diagnosing ankle abnormalities, and illustrates clinical 3D ankle MRI applications.

Anatomic Features of Patients With Recurrent Peroneal Tendon Dislocation

BACKGROUND

There are several anatomic variations of the peroneal muscles and lateral malleolus of the ankle that may play an important role in the onset of peroneal tendon dislocation.

PURPOSE

To investigate the anatomic variations of the retromalleolar groove and peroneal muscles in patients with and without recurrent peroneal tendon dislocation using magnetic resonance imaging (MRI) and computed tomography (CT).

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

A total of 30 patients (30 ankles) with recurrent peroneal tendon dislocation who underwent both MRI and CT before surgery (PD group) and 30 age- and sex-matched patients (control [CN] group) who underwent MRI and CT were included in this study. The imaging was reviewed at the level of the tibial plafond (TP level) and at the center slice between the TP and the fibular tip (CS level). The appearance of a malleolar groove (convex, concave, or flat) and the posterior tilting angle of the fibula were assessed on CT images. The appearance of accessory peroneal muscles, height of the peroneus brevis muscle belly, and volume of the peroneal muscle and tendons were assessed on MRI scans.

RESULTS

There were no differences in the appearance of the malleolar groove, posterior tilting angle of the fibula, or accessory peroneal muscles at the TP and CS levels between the PD and CN groups. The peroneal muscle ratio was significantly higher in the PD group than in the CN group at the TP and CS levels (both P < .001). The height of the peroneus brevis muscle belly was significantly lower in the PD group than in the CN group (P = .001).

CONCLUSION

A low-lying muscle belly of the peroneus brevis and a larger muscle volume in the retromalleolar space were significantly associated with peroneal tendon dislocation. Retromalleolar bony morphology was not associated with peroneal tendon dislocation.

Incidental Finding of Plantar Plate Pathology on Routine Magnetic Resonance Imaging of the Foot and Ankle

BACKGROUND

We hypothesized that there would be a comparable and high incidence of an incidental torn plantar plate on routine magnetic resonance imaging (MRI) in asymptomatic patients.

METHODS

We included adult patients undergoing a foot MRI from 2019 to 2020. Based on the documented reason for MRI, patients were divided into symptomatic and asymptomatic. A separate musculoskeletal radiologist re-evaluated MRI images. Findings were categorized as "torn vs intact." We also used the anatomical grading system (AGS).

RESULTS

We reviewed 218 records, including 165 asymptomatic and 53 symptomatic patients. The chance of finding a plantar plate (PP) tear on MRI of symptomatic patients was 28% (21% in PP2, 5.7% in PP3, 5.7% in PP4, and 2% in PP5), while PP tear in asymptomatic patients was only apparent in 2% of MRIs (1.5% in PP2, 0 in PP3, 0 in PP4, and 0.6% in PP5). Cohen's kappa coefficient was 0.92, showing excellent agreement between the radiologists. Odds calculation revealed that the chance of finding a torn PP in an asymptomatic patient is 2.5%. In comparison, the chance of finding an intact PP in a symptomatic patient is 72%, showing 2.5 times more likely to find an intact PP than a torn PP in symptomatic individuals.

CONCLUSION

Interestingly, there was a low rate of abnormal PP appearance on MRI in both symptomatic and asymptomatic patients, which suggests that the chance of finding a false-positive PP tear in an asymptomatic patient is minimal and probably negligible.

LEVEL OF EVIDENCE

Level IV diagnostic.

3D MRI of the Ankle: A Concise State-of-the-Art Review

Magnetic resonance imaging (MRI) is a powerful imaging modality for visualizing a wide range of ankle disorders that affect ligaments, tendons, and articular cartilage. Standard two-dimensional (2D) fast spin-echo (FSE) and turbo spin-echo (TSE) pulse sequences offer high signal-to-noise and contrast-to-noise ratios, but slice thickness limitations create partial volume effects. Modern three-dimensional (3D) FSE/TSE pulse sequences with isotropic voxel dimensions can achieve higher spatial resolution and similar contrast resolutions in ≤ 5 minutes of acquisition time. Advanced acceleration schemes have reduced the blurring effects of 3D FSE/TSE pulse sequences by affording shorter echo train lengths. The ability for thin-slice partitions and multiplanar reformation capabilities eliminate relevant partial volume effects and render modern 3D FSE/TSE pulse sequences excellently suited for MRI visualization of several oblique and curved structures around the ankle. Clinical efficiency gains can be achieved by replacing two or three 2D FSE/TSE sequences within an ankle protocol with a single isotropic 3D FSE/TSE pulse sequence. In this article, we review technical pulse sequence properties for 3D MRI of the ankle, discuss practical considerations for clinical implementation and achieving the highest image quality, compare diagnostic performance metrics of 2D and 3D MRI for major ankle structures, and illustrate a broad spectrum of ankle abnormalities.

Unintended consequences: quantifying the benefits, iatrogenic harms and downstream cascade costs of musculoskeletal MRI in UK primary care

OBJECTIVES

The largest proportion of general practitioner (GP) magnetic resonance imaging (MRI) is musculoskeletal (MSK), with consistent annual growth. With limited supporting evidence and potential harms from early imaging overuse, we evaluated practice to improve pathways and patient safety.

METHODS

Cohort evaluation of routinely collected diagnostic and general practice data across a UK metropolitan primary care population. We reviewed patient characteristics, results and healthcare utilisation.

RESULTS

Of 306 MSK-MRIs requested by 107 clinicians across 29 practices, only 4.9% (95% CI ±2.4%) appeared clearly indicated and only 16.0% (95% CI ±4.1%) received appropriate prior therapy. 37.0% (95% CI ±5.5%) documented patient imaging request. Most had chronic symptoms and half had psychosocial flags. Mental health was addressed in only 11.8% (95% CI ±6.3%) of chronic sufferers with psychiatric illness, suggesting a solely pathoanatomical approach to MSK care. Only 7.8% (95% CI ±3.0%) of all patients were appropriately managed without additional referral. 1.3% (95% CI ±1.3%) of scans revealed diagnoses leading to change in treatment (therapeutic yield). Most imaged patients received pathoanatomical explanations to their symptoms, often based on expected age or activity-related changes. Only 16.7% (95% CI ±4.2%) of results appeared correctly interpreted by GPs, with spurious overperception of surgical targets in 65.4% (95% CI ±5.3%) who suffered 'low-value' (ineffective, harmful or wasteful) post-MRI referral cascades due to misdiagnosis and overdiagnosis. Typically, 20%-30% of GP specialist referrals convert to a procedure, whereas MRI-triggered referrals showed near-zero conversion rate. Imaged patients experienced considerable delay to appropriate care. Cascade costs exceeded direct-MRI costs and GP-MSK-MRI potentially more than doubles expenditure compared with physiotherapist-led assessment services, for little-to-no added therapeutic yield, unjustifiable by cost-consequence or cost-utility analysis.

CONCLUSION

Unfettered GP-MSK-MRI use has reached unaccceptable indication creep and disutility. Considerable avoidable harm occurs through ubiquitous misinterpretation and salient low-value referral cascades for two-thirds of imaged patients, for almost no change in treatment. Any marginally earlier procedural intervention for a tiny fraction of patients is eclipsed by negative consequences for the vast majority. Only 1-2 patients need to be scanned for one to suffer mismanagement. Direct-access imaging is neither clinically, nor cost-effective and deimplementation could be considered in this setting. GP-MSK-MRI fuels unnecessary healthcare utilisation, generating nocebic patient beliefs and expectations, whilst appropriate care is delayed and a high burden of psychosocial barriers to recovery appear neglected.

Fluid distribution in ankle tendon sheaths in healthy volunteers: MRI findings

PURPOSE

To assess normal distribution of fluid in the tendon sheaths of the ankle.

METHODS

21 healthy volunteers were evaluated. Bilateral ankle MRI was performed on a 3T unit with PD-weighted images with fat saturation. The images were interpreted by two radiologists separately, and the short-axis dimension of fluid amount was measured. Bland-Altman plots and correlation plots were used to assess consistency between readers.

RESULTS

There were 13 men and 8 women. The mean age was 24.7 years. Fluid in the retromalleolar part of the peroneus longus was seen in three ankles of three volunteers and in the inframalleolar part in three ankles of three volunteers. Fluid in the retromalleolar part of the peroneus brevis was seen in four ankles of three volunteers and in the inframalleolar part in three ankles of two volunteers. Fluid in the retromalleolar part of the tibialis posterior was seen in 37 ankles of 20 volunteers and in the inframalleolar part in 38 ankles of 21 volunteers Fluid in the retromalleolar part of the flexor digitorum was seen in 14 ankles of eight volunteers and in the inframalleolar part in 11 ankles of eight volunteers Fluid in the retromalleolar part of the flexor hallucis longus was seen in 23 ankles of 16 volunteers and in the inframalleolar part in 17 ankles of 11 volunteers.

CONCLUSION

Fluid is common in the retro- and inframalleolar parts of the medial tendons. Fluid is virtually absent in the peroneal tendons and anterior tendon sheaths in normal volunteers.

Anatomical variations related to pathological conditions of the peroneal tendon: evaluation of ankle MRI with a 3D SPACE sequence in symptomatic patients

OBJECTIVE

To evaluate anatomical variations in the lateral ankle and their relationships with pathological conditions of the peroneal tendon on magnetic resonance imaging (MRI) in symptomatic patients.

MATERIALS AND METHODS

Sixty-nine ankles MRIs of 60 adult patients with symptomatic ankles were included. The presence and sizes of peroneal tubercle and retrotrochlear eminence (RTE), the prevalence of peroneus quartus (PQ), os peroneum, and boomerang-shaped peroneus brevis (PB) tendon, the shape of the retromalleolar fibular groove (RMFG), and the location of the PB muscle-tendon junction were evaluated. The relationships of these variations with peroneal tendinopathies were assessed. The correlations between pathological peroneal conditions on MRI and clinical findings were evaluated.

RESULTS

Peroneal tubercle (mean size, 3.2 mm) and RTE (mean size, 4.5 mm) were identified in 58 (84%) and 69 (100%) ankles respectively. PQ muscle, os peroneum, and boomerang-shaped PB tendon were found in 9 (13%), 7 (10%), and 24 (34.8%) ankles respectively. The RMFG was concave, flat, convex, and irregular in 14 (20.3%), 40 (58%), 13 (18.8%), and 2 (2.9%) ankles respectively. Sixteen (23.2%) patients had low-lying PB muscle belly. Only boomerang-shaped PB tendons showed a significant relationship with peroneal tendinopathies. MRI and clinical findings had a poor correlation in pathological peroneal conditions and both had low sensitivity in diagnosis.

CONCLUSION

Lateral ankle anatomical variations are common and cannot be attributed to pathological conditions of the peroneal tendon, except for boomerang-shaped PB tendons. Both clinical and MRI findings have low sensitivity in the diagnosis of peroneal tendinopathies, which are often incidental findings on MRI.

Diagnostic Value of Early Magnetic Resonance Imaging After Acute Lateral Ankle Injury

We report a retrospective study of 171 consecutive patients with a lateral ankle sprain. All the patients with direct or blunt force trauma were excluded. Within 21 days of injury, 115 (67.25%) patients had undergone magnetic resonance imaging to evaluate for more serious or significant injuries. The average patient age was 44.09 years. Of the 115 patients, 75 (65.23%) had findings noted to be "significant." MRI can serve as a valuable and underused tool in the evaluation of acute lateral ankle injuries. The underuse of MRI might explain the high degree of variability in patients recovering from a lateral ankle sprain.

ACR Appropriateness Criteria® Chronic Ankle Pain

Chronic ankle pain is a common clinical problem whose cause is often elucidated by imaging. The ACR Appropriateness Criteria for chronic ankle pain define best practices of image ordering. Clinical scenarios are followed by the imaging choices and their appropriateness. The information is in ordered tables with an accompanying narrative explanation to guide physicians to order the right test. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Emerging Concepts in Treating Cartilage, Osteochondral Defects, and Osteoarthritis of the Knee and Ankle

The management and treatment of cartilage lesions, osteochondral defects, and osteoarthritis remain a challenge in orthopedics. Moreover, these entities have different behaviors in different joints, such as the knee and the ankle, which have inherent differences in function, biology, and biomechanics. There has been a huge development on the conservative treatment (new technologies including orthobiologics) as well as on the surgical approach. Some surgical development upraises from technical improvements including advanced arthroscopic techniques but also from increased knowledge arriving from basic science research and tissue engineering and regenerative medicine approaches. This work addresses the state of the art concerning basic science comparing the knee and ankle as well as current options for treatment. Furthermore, the most promising research developments promising new options for the future are discussed.

Spectrum of intracranial incidental findings on pediatric brain magnetic resonance imaging: What clinician should know?

Intracranial incidental findings on magnetic resonance imaging (MRI) of the brain continue to generate interest in healthy control, research, and clinical subjects. However, in clinical practice, the discovery of incidental findings acts as a “distractor”. This review is based on existing heterogeneous reports, their clinical implications, and how the results of incidental findings influence clinical management. This draws attention to the followings: (1) the prevalence of clinically significant incidental findings is low; (2) there is a lack of a systematic approach to classification; and discusses (3) how to deal with the detected incidental findings based a proposed common clinical profile. Individualized neurological care requires an active discussion regarding the need for neuroimaging. Clinical significance of incidental findings should be decided based on lesion’s neuroradiologic characteristics in the given clinical context. Available evidence suggests that the outcome of an incidentally found “serious lesion in children” is excellent. Future studies of intracranial incidental findings on pediatric brain MRI should be focused on a homogeneous population. The study should address this clinical knowledge based review powered by the statistical analyses.

Calf injuries in professional football: Treat the patient or the scan? - A case study

OBJECTIVE

To describe a case of a professional football player with significant imaging findings despite a rather innocuous clinical presentation with gradual onset of calf pain and who was able to continue training and playing with minor medical intervention. To discuss some of the limitations of existing muscle injury grading systems and their potential to cover the full range of injury presentations for calf injuries.

DESIGN

Case report.

SETTING

A professional football player was assessed by physical examination, clinical testing and imaging (MRI) after a gradual onset of a calf injury. After returning to training and competition, a follow-up of his symptoms was performed with regular ultrasound imaging assessments.

PARTICIPANT

A professional football player (35 years, 1.90 m, 88 kg) male, African, striker, playing in the Professional Arabian Gulf League.

CONCLUSION

The discordance between the clinical presentation and the imaging findings resulted in a challenging situation regarding the decision of whether to allow the player to train and compete. In addition, existing muscle injury grading systems do not seem to cover the full range of injuries seen in clinical practice.

Peroneal Tendon Abnormalities on Routine Magnetic Resonance Imaging of the Foot and Ankle

BACKGROUND

Abnormalities of the peroneal tendons can frequently be identified on routine MRI of the foot and ankle. Previous studies in the orthopedic literature have discussed the prevalence of abnormal MRI findings in asymptomatic patients, most notably with regards to the spine and shoulder. The purpose of this study was to determine the prevalence of abnormal findings of the peroneal tendons on MRI in asymptomatic individuals.

METHODS

We retrospectively reviewed all foot and ankle MRIs from 2 independent time periods that were either performed or reviewed at our institution. Studies were excluded if performed on patients with documented inversion injuries, ankle sprains, or lateral ankle trauma. A total of 294 (of 617) MRIs were eligible for inclusion in this study. A single attending musculoskeletal radiologist reviewed each MRI. Pathologies of the peroneal tendons included tendinosis, tenosynovitis, acute tears, chronic tears, and tendon splits. Additionally, the primary pathology encountered on each MRI was noted. The mean age of the MRIs included in this study was 46.8 years (range 9-82) with 155 females and 139 males.

RESULTS

The most commonly occurring primary pathology was Achilles tendinosis/tears (86), followed by posterior tibial tendon dysfunction (43). With regards to the peroneal tendons, 103 of the 294 (35%) MRIs demonstrated some pathology.

CONCLUSION

The results of this study demonstrated that a sizeable percentage of asymptomatic individuals could have peroneal tendon pathology on MRI of the foot and ankle. This study can have important clinical implications for when patients present with concerning MRI findings that do not correlate clinically. Physicians providing musculoskeletal care can counsel and reassure patients who present with peroneal pathology on MRI but an absence of clinical findings.

LEVEL OF EVIDENCE

Level IV, case series.

Activity Level and Function After Lateral Ankle Ligament Repair Versus Reconstruction

BACKGROUND

Few studies have compared outcomes of Broström-Gould repair and allograft reconstruction.

HYPOTHESIS/PURPOSE

The purpose of this study was to compare outcomes and revision rates after Broström-Gould lateral ankle ligament repair versus anatomic allograft reconstruction in patients with lateral ankle instability. The hypothesis was that patients who underwent lateral ankle ligament repair would have outcomes and revision rates similar to those of patients who underwent anatomic allograft reconstruction.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

All patients who underwent surgical repair or reconstruction of the anterior talofibular ligament and/or the calcaneofibular ligament by a single surgeon between September 2009 and February 2013 were included in this study. Patients completed a subjective questionnaire at minimum 2 years after ankle surgery. Outcomes measures included the Foot and Ankle Disability Index (FADI), American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score, Lysholm score, Western Ontario and McMaster Universities Arthritis Index (WOMAC), Short Form-12 Physical Component Summary (PCS) and Mental Component Summary (MCS) scores, Tegner activity scale, and patient satisfaction with outcome. Detailed surgical data and intraoperative findings were documented at the time of surgery. All data were collected prospectively and reviewed retrospectively.

RESULTS

A total of 86 patients were included in this study: 45 men and 41 women (mean age, 38 years; range, 19-68 years) with a mean body mass index of 26.5 (range, 17.5-47.1). There were 61 (71%) patients in the repair cohort and 25 (29%) in the reconstruction cohort. There was no significant difference in age or sex between cohorts. Seventy-six (88%) patients had minimum 2-year follow-up (mean follow-up, 3.0 years; range, 2.0-5.3 years). There was no significant difference in FADI (87 vs 91; P = .553), AOFAS (77 vs 82; P = .372), Lysholm score (83 vs 87; P = .110), Tegner activity scale (6 vs 4; P = .271), patient satisfaction (9 vs 10; P = .058), WOMAC (8 vs 5; P = .264), or Short Form-12 PCS (51.3 vs 54.6; P = .169) or MCS (54.8 vs 51.5; P = .239) score between the repair cohort and the reconstruction cohort, respectively. No patient in either cohort underwent revision lateral ligament surgery.

CONCLUSION

When compared with lateral ankle repair, anatomic allograft reconstruction produced similarly favorable outcomes, including high patient satisfaction, high function and activity levels, and no revision surgeries in either cohort.

The accessory peroneal (fibular) muscles: peroneus quartus and peroneus digiti quinti. A systematic review and meta-analysis

The denomination of "accessory peroneal muscle" (APM) refers usually to two muscles: the peroneus quartus (PQua) and the peroneus digit quinti (PQui) which were believed to be variants of a same muscle. Their morphology and prevalence show high variation in relevant literature mainly owing to the diverse terminology used to describe this muscle group. The aim of this meta-analysis is to generate more accurate description and frequency of those muscles. A total of 46 studies (3,928 legs/ankles) met the inclusion criteria. The aggregate results were: (a) a true APM prevalence of 16 % with 10.2 % for PQua vs. 34.3 % for PQui; (b) a crude prevalence of 16.6 % for PQua vs. 21.5 % for PQui; (c) a bilateral prevalence of 1.73 % for PQua vs. 12.5 % for PQui; (d) the PQua was significantly more prevalent in Indian populations compared to all other ancestries, and the PQui is significantly more prevalent in Europeans and Americans compared to Japanese and Korean populations; (e) though a tendency for higher frequency was found in males and on the right specimens, no significance was found for gender and side; for (f) the "surgical" occurrence of PQua in studies dealing with peroneal tendon surgery was 5.5 % where peroneal tendon pathology seems to be not associated with the presence of an APM; (g) the MRI prevalence of APM was 10.6 %; (h) APMs took origin from peroneus brevis in 60 %, from the distal fibula in 36 % and from other structures in 4 %; (i) APMs took insertion on retrotroclear eminence of the calcaneum in 53.4 %, on peroneal trochlea in 6.6 %, merged with a peroneal tendon in 9.3 %, and inserted on the extensor apparatus of the 5th toe in 18.4 %. Despite the acknowledged limitation owing to the varied terminology used to describe this accessory muscle group, the significant differences found between the aggregate frequency estimates of each muscle do not support the hypothesis that both muscles are variants of a same structure.

An examination of anatomic variants and incidental peroneal tendon pathologic features: a comprehensive MRI review of asymptomatic lateral ankles

Intraoperatively, foot and ankle surgeons will encounter peroneal pathologic features in patients with asymptomatic lateral ankles. The purpose of the present study was to review the ankle magnetic resonance imaging (MRI) scans of patients without a history of ankle trauma or lateral ankle pain to determine which anatomic variants correlate with peroneal tendon pathologic features and noted pathophysiology. A total of 500 MRI scans were screened, 108 (41.90 ± 20.42) of which met the inclusion criteria. The peroneus brevis tendon was intact in 104 MRI scans (96.30%), and the peroneus longus tendon was intact in 108 (100.00%). The results of the present study have confirmed statistically significant correlations between the presence of an os perineum and tendinopathy of the peroneus longus [rs(106) = 0.27], undulating peroneal grooves and the severity of peroneal brevis tears [rs(106) = 0.32], a boomerang-shaped peroneus brevis tendon and increasing tendinopathy of the peroneal tendons [brevis (rs(106) = 0.37; longus rs(106) = 0.33], and low-lying muscle bellies and chronic injuries of the superior peroneal retinaculum (rϕ = 0.19). However, the present study did not find evidence to support the presumed correlations between peroneal tendon pathologic findings and hypertrophied peroneal tubercles, low-lying muscle bellies, or the peroneus quartus muscle. Adding to the published data, the present study found a statistically significant correlation between undulating peroneal grooves and an increasing prevalence of osteophytes within the peroneal groove [rs(106) = 0.32]. MRI findings of anatomic variants or peroneal pathologic features might be useful for injury prevention; however, we advise caution from using the findings alone to advocate surgical intervention. To definitively assess causation, prospective, long-term cohort studies are warranted.

Examining the Relationship Between Pathologies of the Peroneal, Achilles, and Posterior Tibial Tendons: An MRI Review in an Asymptomatic Lateral Ankle Population

The hindfoot and ankle are dynamic structures to which the interplay of tendinous pathologies is scarcely understood. Five hundred consecutive ankle magnetic resonance imaging examinations, obtained between December 27, 2011 and April 9, 2013, were reviewed. Patients without a history of hindfoot or ankle trauma or lateral ankle pain were included. The 108 MRIs that met the inclusion and exclusion criteria were then re-evaluated by 2 musculoskeletal radiologists. Of these, 55.56% demonstrated pathology of the Achilles tendon (AT), 44.44% demonstrated pathology of the posterior tibial tendon (PTT), 35.19% demonstrated pathology of the peroneus brevis (PB), and 37.96% demonstrated pathology of the peroneus longus (PL). In our asymptomatic patient population, 16 (14.81%) patients demonstrated concomitant pathology of the AT, PTT, and peroneal tendons. There were positive, moderate correlations between graded pathology of the AT and the PTT, r_s(106) = 0.32, P = .001; the AT and PB, r_s(106) = 0.38, P = 0.001; and the AT and PL, r_s(106) = 0.46, P = .001. However, there were no statistically significant correlations between pathology of the PTT and PB, r_s(106) = 0.17, P = .08, or the PTT and PL, r_s(106) = 0.14, P = .15. These findings suggest an intimate relationship between the AT, PTT, and the peroneal tendons. These individual anatomic structures may have underappreciated functional relationships that could lead to future investigations.

LEVEL OF CLINICAL EVIDENCE

Level IV.

Examining the relation of osteochondral lesions of the talus to ligamentous and lateral ankle tendinous pathologic features: a comprehensive MRI review in an asymptomatic lateral ankle population

Given the frequency and burden of ankle sprains, the pathologic features identified on magnetic resonance imaging (MRI) scans are widely known in the symptomatic population. Ankle MRI pathologic features in the asymptomatic population, however, are poorly understood. Such examinations are rarely undertaken unless an ankle has been injured or is painful. We report the systematic MRI findings from the reports of 108 consecutive asymptomatic lateral ankles (104 patients). Our purpose was to (1) report the prevalence of osteochondral lesions of the talus (OLTs) and pathologic features of the medial and lateral ligaments, peroneal tendons, and superior peroneal retinaculum (SPR); (2) correlate the presence of OLTs with the pathologic features of the medial and lateral ligaments, peroneal tendons, and SPR; and (3) correlate ligamentous discontinuity with the peroneal pathologic features, OLTs, and SPR pathologic features. A total of 16 OLTs (14.81%) were present (13 medial and 3 lateral). Of the 16 patients with OLTs, 8 (50.00%) had concomitant peroneal pathologic findings. Healthy medial and lateral ligaments were noted in 41 patients (37.96%), and ligamentous discontinuity was grade I in 25 (23.15%), II in 32 (29.63%), III in 5 (4.63%), and grade IV in 5 patients (4.63%). A weak positive correlation was found between attenuation or tears of the superficial deltoid and medial OLTs (phi coefficient = 0.23, p = .0191) and a moderate positive correlation between tears of the posterior talofibular ligament and lateral OLTs (phi coefficient = 0.30, p = .0017). Additionally, a moderate positive correlation between ligamentous discontinuity and tendinopathy of the peroneus brevis was noted [Spearman's coefficient(106) = 0.29, p = .0024]. These findings add to the evidence of concomitant pathologic features in the asymptomatic population. To definitively assess causation and evaluate the clinical evolution of radiologic findings, future, prospective, longitudinal cohort studies are necessary.

Associations between MRI findings and symptoms in patients with chronic ankle sprain

Magnetic resonance imaging (MRI) provides an accurate method of observing and diagnosing injuries of the ligament complex of the ankle. However, the association between ankle symptoms and MRI findings has been unclear. The purpose of the present study was to evaluate the relationship between ankle pain and MRI findings. This prospective study included 40 patients with ankle pain after inversion injury and 10 healthy volunteers. Correlations among the ankle symptoms (tenderness on the anterior talofibular ligament, pain during varus stress in a neutral and plantarflexed ankle), and MRI findings were analyzed. A complete tear of the anterior talofibular ligament correlated with ankle pain during varus stress in the neutral position (r = 0.365, p = .031) and tenderness at the anterior talofibular ligament (r = 0.362, p = .032). The results of our study suggest that a complete tear of the anterior talofibular ligament will correlate with lateral ankle pain.

Comparative study of peroneal tenosynovitis as the complication of intraarticular calcaneal fracture in surgically and non-surgically treated patients

Background

Calcaneus has the most fracture prevalence among tarsal bones. About 3/4 of calcaneal fractures are intra-articular fractures with displacement. The majority of calcaneal fractures occur in 21 - 35 year old young men, and that are mostly active people, these fractures cause complete disability for 15 months. Moreover, inappropriate treatment leads to lots of social and economical damages.

Objectives

In this study we compared the incidence and the severity of peroneal tenosynovitis as a complication of non-operative and operative treatment of intra-articular calcaneal fractures. In this study, some other complications of this fracture were also analyzed and the prevalence of the complication was higher in non-operated patients.

Patients and Methods

A total of 140 patients with intra-articular calcaneal fracture were analyzed prospectively. These patients were divided into 2 groups: operated group and non-operated group.

Results

In non-operated group (56 patients), 22 patients were complicated by peroneal tenosynovitis. In operated group (84 patients), 8 patients had the same complication. Statistical analysis revealed that the prevalence, and the severity of this complication in the mentioned groups had a meaningful difference. The results in operated group were much better than the non-operated one.

Conclusions

Although some of the orthopedic surgeons are not interested to manage these fractures surgically and most of them treat these cases conservatively (casting, etc.), in most displaced intra-articular calcaneal fractures, surgical treatment is the method of choice. Moreover, in non-surgical treatment the prevalence of these complications among the patients is more and as a result, inevitable social, occupational and familial damages occur.

Pseudotear of the peroneus longus tendon on MRI, secondary to a fibrocartilaginous node

OBJECTIVE

The purpose of this study was to identify the presence of a fibrocartilaginous node within the distal peroneus longus tendon (PLT) just proximal to the cubital tunnel and correlate this with MRI signal characteristics of the distal PLT, which could result in a pseudotear appearance on MRI. We correlated imaging characteristics with pathologic specimens.

MATERIALS AND METHODS

Institutional review board approval was obtained. Retrospectively, 91 ankle MRIs utilizing a standard ankle protocol were reviewed by two musculoskeletal radiologists. Four cadaver ankles were imaged using a standard ankle MRI protocol and reviewed by the same radiologists. All the MRIs were examined for signal changes in the PLT. The cadaver ankles then underwent PLT dissection by an orthopaedic surgeon, and a pathologic review was undertaken by a pathologist with orthopaedic specialization, who looked for an os peroneum or proposed fibrocartilaginous node relating to the signal change found on the MRIs.

RESULTS

In the 91 ankle MRI studies, the PLT demonstrated normal low and increased signals. On the fat-saturated T2-weighted sequence, 76 (83.5%) ankles demonstrated low signal and 15 (16.5%) demonstrated increased signal. Of the cadaver ankle MRIs, all four demonstrated increased signal within the PLT; three contained a fibrocartilaginous node and one contained an os peroneum in that same region.

CONCLUSIONS

The MRI signal of the PLT can change with the presence of a fibrocartilaginous node, which may be due to the molecular and chemical content of the fibrocartilage. This node increases the MRI signal in the distal PLT and gives the appearance of a pseudotear.