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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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Heitz PH, Miron MC, Beauséjour M, Hupin M, DiLiddo L, Jourdain N, Nault ML. Ultrasound Assessment of Ankle Syndesmotic Injuries in a Pediatric Population. Clin J Sport Med 2024; 34:83-90. [PMID: 37882722 DOI: 10.1097/jsm.0000000000001193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 09/05/2023] [Indexed: 10/27/2023]
Abstract
OBJECTIVE To determine sensitivity and specificity for anterior-inferior tibiofibular ligament (AiTFL) integrity and tibiofibular clear-space (TFCS) cut-off points for dynamic evaluation using ultrasound (US) in a pediatric population. DESIGN Prospective cohort study. SETTING Tertiary care university-affiliated pediatric hospital patients between the ages of 12 and 18 sustaining acute ankle trauma with syndesmotic injury. INTERVENTIONS Participants were assigned to the syndesmotic injury protocol that included a standardized MRI and US. MAIN OUTCOME MEASURES Anterior-inferior tibiofibular ligament integrity for static assessment and TFCS measurements for dynamic assessment on US. For dynamic assessment, the distance between the distal tibia and fibula was first measured in neutral position and then in external rotation for each ankle. The US results on AiTFL integrity were compared with MRI, considered as our gold standard. Optimal cut-off points of TFCS values were determined with receiver operating characteristics curve analysis. RESULTS Twenty-six participants were included. Mean age was 14.8 years (SD = 1.3 years). Sensitivity and specificity for AiTFL integrity were 79% and 100%, respectively (4 false negatives on partial tears). For dynamic assessment, the cut-off points for the differences in tibiofibular distance between the 2 ankles in 1) neutral position (TFCS N I-U ) and 2) external rotation (TFCS ER I-U ) were 0.2 mm (sensitivity = 83% and specificity = 80%) and 0.1 mm (sensitivity = 83% and specificity = 80%), respectively. CONCLUSIONS Static US could be used in a triage context as a diagnostic tool for AiTFL integrity in a pediatric population as it shows good sensitivity and excellent specificity.
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Affiliation(s)
- Pierre-Henri Heitz
- Department of Surgery, CHU Sainte-Justine, Montréal, QC, Canada
- Department of Surgery, Université de Montréal, Edouard-Montpetit, Montréal, QC, Canada
| | - Marie-Claude Miron
- Department of Radiology, CHU Sainte-Justine, Montréal, QC, Canada
- Department of Radiology, Université de Montréal, Edouard-Montpetit, Montréal, QC, Canada
| | - Marie Beauséjour
- Department of Surgery, CHU Sainte-Justine, Montréal, QC, Canada
- Department of Surgery, Université de Sherbrooke, Université de Sherbrooke-Campus Longueuil, Longueuil, QC, Canada
| | - Mathilde Hupin
- Department of Surgery, CHU Sainte-Justine, Montréal, QC, Canada
- Department of Surgery, Université de Montréal, Edouard-Montpetit, Montréal, QC, Canada
| | - Lydia DiLiddo
- Department of Pediatrics, CHU Sainte-Justine, Montréal, QC, Canada
- Department of Pediatrics, Université de Montréal, Edouard-Montpetit, Montréal, QC, Canada
| | | | - Marie-Lyne Nault
- Department of Surgery, CHU Sainte-Justine, Montréal, QC, Canada
- Department of Surgery, Université de Montréal, Edouard-Montpetit, Montréal, QC, Canada
- Department of Surgery, Hôpital du Sacré-Coeur de Montréal, Montreal, QC, Canada
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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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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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Chans-Veres J, Vallejo-Márquez M, Galhoum AE, Tejero S. Analysis of the uninjured tibiofibular syndesmosis using conventional CT-imaging and axial force in different foot positions. Foot Ankle Surg 2022; 28:650-656. [PMID: 34376323 DOI: 10.1016/j.fas.2021.07.014] [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: 05/17/2021] [Revised: 06/17/2021] [Accepted: 07/23/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Syndesmosis measurments and indices have been controversial and showed interindividual variability. The purpose of this study was to analyze, by conventional axial computed tomography images and a simulated load device, the uninjured tibiofibular syndesmosis under axial force and forced foot positions. METHODS A total of 15 healthy patients (30 ankles) were studied using adjustable simulated load device (ASLD). This device allowed to perform bilateral ankle CT scans in two forced foot and ankle positions (30° of plantar flexion, 15° of inversion, 20° of internal rotation and 15° of dorsal flexion, 15° of eversion, 30° of external rotation). Axial load was applied simultaneously in a controlled manner (70% body weight). Measurements on the axial image of computed tomography were: syndesmotic area (SA), fibular rotation (FR), position of the fibula in the sagittal plane (FPS), depth of the incisura (ID) and direct anterior difference (ADD), direct middle difference (MDD) and direct posterior difference (PDD). RESULTS In patients without injury to the tibiofibular syndesmosis, the application of axial load and forced foot and ankle positions showed statistically significant differences on the distal tibiofibular measurements between the stressed and the relaxed position, it also showed interindividual variability : SA (median = 4.12 [IQR = 2.42, 6.63]) (p < 0.001), ADD (0.67 [0.14, 0.67]) (p < 0.001), MDD(0.45, [0.05, 0.9]) (p < 0.001), PDD (0.73 [-0.05, 0.73]) (p < 0.002). However, it did not detect statistically significant differences when the tibiofibular differences between the stressed and the relaxed position in one ankle were compared with the contralateral side: SA (-0.14, SD = 4.33 [95% CI = -2.53, 2.26]), ADD (-0.42, 1.08 [-1.02, 0.18]), MDD (0.29, 0.54 [-0.01, 0.59]), PDD (-0.1, 1.42 [-0.89, 0.68]). Interobserver reliability showed an Intraclass correlation coefficient of 0.990 [95% CI = 0.972, 0.997]. CONCLUSIONS Wide interindividual variability was observed in all syndesmotic measurements, but no statistically significant differences were found when comparing one ankle to the contralateral side. Measuring syndesmosis alignment parameters, may only be of value, if those are compared to the contralateral ankle.
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Affiliation(s)
| | | | | | - Sergio Tejero
- Foot Ankle Unit University Hospital Virgen del Rocío, Seville, Spain; University of Seville, Spain.
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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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