Diagnostic accuracy of clinical tests for ankle syndesmosis injury

The Contralateral Ankle Joint Is a Reliable Reference for Testing Syndesmotic Stability Using Bilateral External Torque CT

BACKGROUND

Subtle chronic or latent instabilities are difficult to delineate with currently available diagnostic modalities and do not allow assessment of ligamentous functionality. The noninvasive bilateral external torque computed tomography (CT) was able to reliably detect syndesmotic lesions in a cadaveric study. The aim of the study was to test the external torque device in young, healthy subjects at 3 different torque levels and to demonstrate comparability with the contralateral side.

METHODS

Ten healthy subjects without history of injury or surgery to the ankle joint were enrolled in this cross-sectional study. Four CT scans were performed. During the scans, the lower legs and feet were placed in an external torque device with predefined external rotation torques of 0, 2.5, 5, and 7.5 Nm. Five different radiographic measures of syndesmotic stability were measured: anterior distance (AD), tibiofibular clear space (TCS), posterior distance (PD), external rotation (ER), and β angle.

RESULTS

With increasing external torque, slight increases in AD, ER, and β angle were observed, whereas TCS and PD decreased slightly. Large absolute differences were found between the healthy subjects for all measured parameters, regardless of the external torque applied. Differences from the contralateral side using the same external torque were minimal for all parameters, but smallest for AD with a maximum difference of 0.5 mm.

CONCLUSION

Using the healthy contralateral ankle joint is appropriate for assessing syndesmotic stability based on minimal intraindividual side differences using the external torque device. Side differences >0.5 mm in AD and >0.9 mm in PD may be considered abnormal and may indicate significant instability of the syndesmosis. However, future studies are needed to define definitive cutoff values for relevant side differences in acute and chronic syndesmotic instability to guide clinicians in their treatment decisions.

Prognostic Values of Clinical and Anthropometric Characteristics in Lateral Ankle Sprain Following Physiotherapy

Lateral ankle sprain (LAS) is a common injury in sports and daily activities. The present study aimed to determine the prognostic value of clinical and anthropometric parameters in predicting LAS recovery after physiotherapy. Twenty-seven patients with acute LAS were included in this cohort study. First, prognostic factors and anthropometric variables were assessed, along with the time elapsed since the injury, pain score on a visual analogue scale (VAS), navicular drop, ankle range of motion (ROM), and ambulation status. Second, patients received physiotherapy, and their recovery status was assessed using the foot and ankle outcome score (FAOS) questionnaire immediately (first evaluation) and one month after physiotherapy (second evaluation). Univariate regression analysis and stepwise regression were used to evaluate the association between prognostic factors and outcome predictability. The results of this paper have shown that ambulation status was significantly correlated with all FAOS subscales in both the first and second evaluations, except for the FAOS-symptoms (FAOS-Sx) and FAOS-quality of life (FAOS-QOL) subscales in the first evaluation. The eversion ROM was significantly correlated with the FAOS-Sx and FAOS-Sports and Recreational activities (FAOS-Sport/Rec) subscales in the first evaluation. Additionally, age, height, and VAS were significantly correlated with FAOS-activity of daily living (FAOS-ADL) in the first evaluation, so this means that ambulation status is a valuable predictor of treatment success immediately and one month after physiotherapy intervention and compared to other FAOS subscales, the FAOS-QOL subscale is a more reliable predictor of the effectiveness of physiotherapy.

[Current diagnostics and treatment of ankle sprains in German]

BACKGROUND

Ankle sprains are one of the most frequent injuries of the musculoskeletal system. The injury pattern determines the treatment and are crucial for the outcome. Nonoperative treatment is commonly recommended for isolated injuries of the lateral ligaments but no standard strategy exists in combined ankle ligament injuries. The goal of this national survey was to achieve an overview about the current diagnostic strategies and common treatment concepts in Germany.

MATERIAL AND METHODS

All members of the German Society for Orthopaedics and Trauma Surgery (DGOU) were invited to participate in an anonymous survey about the diagnostic and therapeutic approach in cases of ankle sprains. The online survey consisted of 20 questions. Besides questions about the speciality and scope of activities the participants were ask to depict their diagnostic and therapeutic strategy.

RESULTS

A total of 806 participants completed the survey. Most of them were orthopedic trauma surgeons and worked in a hospital. During the first presentation the anterior drawer test (89.5%) and the inversion/eversion test (81.6%) were most commonly used, 88.1% always make an X‑ray examination and 26.5% an ultrasonography examination. Isolated injuries of the anterior fibulotalar ligament (LFTA) were treated nonoperatively by 99.7% of the participants, 78.8% recommend full weight bearing in an orthesis, 78.8% treat the complete rupture of the lateral ligaments without operation whereas 30.1% stated that they would treat a combined lateral ligaments rupture with an injury of the syndesmosis nonoperatively.

DISCUSSION

Due to the heterogeneity of injury patterns after ankle sprain no consistent recommendations for diagnostics and treatment exist. The Ottawa ankle rules and ultrasonography were not often utilized despite of the good evidence. The isolated rupture of the LFTA is diagnosed and treated according to the national guidelines by most of the participants. In cases of combined injuries of the lateral and medial ankle ligaments the majority choose a nonoperative treatment strategy which is justified by the guidelines with a low level of evidence. Combined injuries of the syndesmosis and the lateral ankle ligaments were treated operatively, which also correlates with the recommendations in the literature. The standard care of ankle sprain in Germany is in accordance with the recommendations from the current literature.

Management of High Ankle Sprains Utilizing the Tightrope Surgical Procedure - A Novel Approach for a Rapid Return to Play

The distal tibiofibular joint is described as a syndesmosis. The syndesmosis is important to the structural integrity of the ankle joint by maintaining the proximity of the tibia, fibula, and talus. Syndesmotic or high ankle sprains, involving the syndesmotic ligaments, pose a significant rehabilitative challenge due to their intricate anatomy, prolonged recovery periods following injury, and high susceptibility to persistent disability. Traditional management strategies have often been conservative, marked by lengthy periods of immobilization and a gradual return to activity. Severe syndesmotic injuries with diastasis have been treated surgically with screw fixation which may require a second intervention to remove the hardware and carries an inherent risk of breaking the screw during rehabilitation. Another fixation technique, the Tightrope™, has gained popularity in treating ankle syndesmosis injuries. The TightRope™ involves inserting Fiberwire® through the tibia and fibula, which allows for stabilization of the ankle mortise and normal range of motion. The accelerated rehabilitation protocol promotes early weight-bearing and has been shown to expedite the return to sport. This emerging strategy has shown promise in reducing recovery time as it is now possible to return to sport in less than 2 months after a tightrope repair and accelerated rehabilitation, compared with 3-6 months post screw fixation. This clinical commentary delves into this novel approach, highlighting the procedure, rehabilitation protocols, and the implications for physical therapy practice.

Level of Evidence

V.

Bilateral External Torque CT Reliably Detects Syndesmotic Lesions in an Experimental Cadaveric Study

BACKGROUND

If tibiofibular syndesmotic injury is undetected, chronic instability may lead to persistent pain and osteoarthritis. So far, no reliable diagnostic method has been available. The primary objectives of this study were to determine whether defined lesions of the syndesmosis can be correlated with specific tibiofibular joint displacements caused by external rotational torque and to compare the performance of bilateral external torque computed tomography (BET-CT) and arthroscopy. Secondary objectives included an evaluation of the reliability of CT measurements and the suitability of the healthy contralateral ankle as a reference.

METHODS

Seven pairs of healthy, cadaveric lower legs were tested and assigned to 2 groups: (1) supination-external rotation (SER) and (2) pronation-external rotation (PER). In the intact state and after each surgical step, an ankle arthroscopy and 3 CT scans were performed. During the scans, the specimens were placed in an external torque device with 2.5, 5.0, and 7.5 Nm of torque applied.

RESULTS

The arthroscopic and CT parameters showed significant correlations in all pairwise comparisons. The receiver operating characteristic (ROC) curve analyses yielded the best prediction of syndesmotic instability with the anterior tibiofibular distance on CT, with a sensitivity of 84.1% and a specificity of 95.2% (area under the curve [AUC], 94.8%; 95% confidence interval [CI], 0.916 to 0.979; p < 0.0001) and with the middle tibiofibular distance on arthroscopy, with a sensitivity of 76.2% and specificity of 92.3% (AUC, 91.2%; 95% CI, 0.837 to 0.987; p < 0.0001). Higher torque amounts increased the rate of true-positive results.

CONCLUSIONS

BET-CT reliably detects experimental syndesmotic rotational instability, compared with the healthy side, with greater sensitivity and similar specificity compared with the arthroscopic lateral hook test. Translation of these experimental findings to clinical practice remains to be established.

LEVEL OF EVIDENCE

Diagnostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Standing on single foot-binding test yields satisfactory results as a novel method for the diagnosis of distal tibiofibular syndesmosis instability: a prospective, cross-sectional diagnostic-accuracy study

BACKGROUND

Non-invasive diagnosis of distal tibiofibular syndesmosis instability (DTSI) was a great challenge to clinicians. We designed a new method, the Standing on single foot-Binding test, and investigated the accuracy of the test in the diagnosis of distal tibiofibular syndesmosis instability in adults with a history of ankle injury.

METHODS

85 participants with ankle injury were subjected to the Standing on single foot-Binding test, MRI and palpation to detect the distal tibiofibular syndesmosis instability (DTSI) and the findings were compared with ankle arthroscopic results. Both participants and arthroscopist were blind to the predicted results of the clinical tests. Sensitivity, specificity, PPV, NPV, LR+, LR - and their 95% CIs were calculated for each of the clinical tests as well as for the positive clinical diagnosis.

RESULTS

The Standing on single foot-Binding test (SOSF-B test) outperformed MRI and palpation, in terms of sensitivity (87.5%/84.38%), specificity (86.79%/86.79%), PPV (80%/79.41%), NPV (92%/91.2%), LR+ (6.625/6.39), LR- (0.14/0.18) and diagnostic accuracy (87.06/85.88), among others, in the diagnosis of distal tibiofibular syndesmosis instability (DTSI). The diagnostic performance of 20° SOSF-B test was virtually identical to that of 0° SOSF-B test. According to the prevalence (28.7%) of DTSI and LR of four tests, the post-test probability could be used in clinical practice for the prediction of DTSI.

CONCLUSION

This prospective and double-blind diagnostic test showed that the SOSF-B test is clinically feasible for the diagnosis of distal tibiofibular syndesmosis instability (DTSI), and new diagnostic tools for rapid screening of distal tibiofibular syndesmosis instability (DTSI).

LEVEL OF EVIDENCE

II.

Prevalence, diagnosis and management of musculoskeletal disorders in elite athletes: A mini-review

Musculoskeletal injuries in elite sports are ones of the most impact issue because their remarkable impact on performance caused by drastic absence of training and competition and a progressive deterioration in physical health, emotional and social athletes' dimensions. Also, the prevalence of epidemiologic research found an incidence of musculoskeletal disorders vary within sports and in elite athletes which is even higher as a consequence of higher demand physical performance. This way, the loss of physical performance due to an sport injury impacts not only the individual economic sphere of the professional but also that ofsports entities, reaching, according to some studies, a loss estimated in the range of 74.7 million pounds. Thus, the purpose of this article is to review and to provide an overview of the most common musculoskeletal injuries in elite sports precipitating factors, clinical presentation, evidence-based diagnostic evaluation, and treatment recommendations with a view to preventing medical conditions or musculoskeletal injuries that may alter performance and general health in the elite athletes.

Advances in Diagnosis and Management of Lateral Ankle Instability: A Review of Current Literature

Lateral ankle sprains and instability are an increasingly identified pain point for patients, accounting for 20 to 25% of musculoskeletal injuries. Lateral ankle injuries are especially concerning given the propensity for patients to develop chronic lateral ankle instability and for the high risk of reinjury on an unstable ankle. With the complex articulation of the tibiofibular syndesmosis, subtalar, and talocrural joints, pinpointing ankle dysfunction remains difficult. Multiple reviews have evaluated management and diagnosis of lateral ankle instability, but with newer treatment options available, a more comprehensive assessment of the current literature was conducted. Although multiple surgical options exist, many nonsurgical functional options have also been developed for patients that may help patients prevent the development of chronic lateral ankle instability. In recent times, many new options have come up, including in-office needle arthroscopy and continual advancements in diagnosis and our understanding of this difficult topic. Multiple reviews have evaluated the management and diagnosis of lateral ankle instability, but with newer treatment options available, a more comprehensive assessment of the current literature was conducted. Given this, this review will help to highlight new diagnostic and nonsurgical therapeutic options for the management of lateral ankle instability.

The Role of Ultrasound in the Management of Ankle Sprains and a Clinically Relevant Geisinger Ankle Sprain Sports Ultrasound Protocol

ABSTRACT

Ankle sprains are the most common lower extremity injury in physically active individuals. These injuries are classified as lateral, medial, and/or syndesmotic. Treatment may include functional rehabilitation, bracing, weight-bearing restriction, medications, injections, and surgery. While most sprains heal rapidly, permanent disability and pain may arise. Diagnostic ultrasound has been demonstrated to be accurate in diagnosing ligamentous injuries, but it is often excluded from management algorithms that rely on physical examination alone to diagnose significant injuries. This article proposes a comprehensive, evidence-based diagnostic ankle ultrasound protocol to implement in conjunction with thorough history and physical examination. We also review the current literature to describe where this protocol most improves diagnostic accuracy compared with physical examination alone.

High-Ankle Sprain and Syndesmotic Instability: How Far Have We Come with Diagnosis and Treatment?

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.

Shoe-Integrated Sensor System for Diagnosis of the Concomitant Syndesmotic Injury in Chronic Lateral Ankle Instability: A Prospective Double-Blind Diagnostic Test

Chronic lateral ankle instability (CLAI) is commonly secondary to prior lateral ankle ligament injury, and the concomitant latent syndesmosis injury would prolong recovery time and increase the risk of substantial traumatic arthritis. However, differentiating syndesmotic injury from isolated lateral ankle ligament injury in CLAI cases is difficult by conventional physical and radiological examinations. To improve the accuracy of syndesmotic injury diagnosis, a shoe-integrated sensor system (SISS) is proposed. This system measures plantar pressure during walking to detect the presence of syndesmotic injury. The study included 27 participants who had ankle sprains and underwent an examination. Plantar pressure in eight regions of interest was measured for both limbs, and syndesmotic injuries were examined using arthroscopy. The width of the syndesmosis was measured to evaluate its severity. The characteristics of plantar pressure were compared between patients with normal and injured syndesmosis. The results indicated that peak plantar pressure ratios with logistic regression predicted value > 0.51 accurately distinguished concomitant syndesmotic injury during walking, with high sensitivity (80%) and specificity (75%). The post-test probability of having a syndesmotic injury was positively 80% and negatively 25%. These findings demonstrate the effectiveness of cost-effective wearable sensors in objectively diagnosing concomitant syndesmotic injuries in cases of CLAI.

Treatment of lateral ankle instability patient-specific remnant approach

Lateral ankle instability is one of the most common problems seen in the orthopaedic setting. Proper diagnosis is essential in order to provide the ideal treatment for these patients. All patients are subjected to nonoperative management in the form of functional rehabilitation. For those, however, who did not respond well to therapy, surgical treatment is then recommended. There are several surgical techniques available which have been meticulously studied and discussed in previous articles. The focus of this paper is on the author's perspective on choosing the surgical technique based on the quality of the anterior talofibular ligament and calcaneofibular ligament remnants. All patients are subjected to a diagnostic arthroscopy, where the remnant is assessed. The procedure then of doing an all-arthroscopic, open Modified Brostrom or anatomic reconstruction is then chosen based on this initial assessment.

Instability of the distal tibiofibular syndesmosis

The distal tibiofibular syndesmosis (DTFS) is more frequently injured than previously thought. Early diagnosis and appropriate treatment is essential to avoid long term complications like chronic instability, early osteoarthritis and residual pain. Management of these injuries require a complete understanding of the anatomy of DTFS, and the role played by the ligaments stabilizing the DTFS and ankle. High index of suspicion, appreciating the areas of focal tenderness and utilizing the provocative maneuvers help in early diagnosis. In pure ligamentous injuries radiographs with stress of weight bearing help to detect subtle instability. If these images are inconclusive, then further imaging with MRI, CT scan, stress examination under anesthesia, and arthroscopic examination facilitate diagnosis. An injury to syndesmosis frequently accompanies rotational fractures and all ankle fractures need to be stressed intra-operatively under fluoroscopy after fixation of the osseous components to detect syndesmotic instability. Non-operative treatment is appropriate for stable injuries. Unstable injuries should be treated operatively. Anatomic reduction of the syndesmosis is critical, and currently both trans-syndesmotic screws and suture button fixation are commonly used for syndesmotic stabilization. Chronic syndesmotic instability (CSI) requires debridement of syndesmosis, restoration of ankle mortise with or without syndesmotic stabilization. Arthrodesis of ankle is used a last resort in the presence of significant ankle arthritis. This article reviews anatomy and biomechanics of the syndesmosis, the mechanism of pure ligamentous injury and injury associated with ankle fractures, clinical, radiological and arthroscopic diagnosis and surgical treatment.

Instabilität des oberen Sprunggelenks

Die symptomatische Bandinstabilität des oberen Sprunggelenks (OSG) ist eine häufige Pathologie und bedarf bei gescheiterter konservativer Therapie oft einer operativen Stabilisierung. Neben Anamnese und subjektiver Wahrnehmung des Patienten liefern klinische Untersuchung, funktionelle Diagnostik, Bildgebung und je nach Bedarf die Arthroskopie des Sprunggelenks wichtige Informationen. Meistens benötigt es eine Kombination mehrerer Untersuchungsmethoden, um die Diagnose einer behandlungsbedürftigen OSG-Instabilität zu stellen. Neben der Beurteilung der Stabilität ist ebenfalls die Feststellung von Zusatzpathologien wichtig. Dies beinhaltet auch das Erkennen einer pathologischen Rückfußachse, was essenziell für die weitere Behandlung sein kann. Die operative Therapie kann mittels Arthroskopie oder offener Operation mit weitgehend erfreulichen klinischen Resultaten durchgeführt werden.

Diagnostic Accuracy of Conventional Ankle CT Scan With External Rotation and Dorsiflexion in Patients With Acute Isolated Syndesmotic Instability

BACKGROUND

Syndesmotic injury in an athletic population is associated with a prolonged ankle disability after an ankle sprain and often requires a longer recovery than a lateral collateral ligament injury. Although several imaging tests are available, diagnosing syndesmotic instability remains challenging.

PURPOSE

To determine the diagnostic accuracy of conventional ankle computed tomography (CT) scans with the joint in external rotation and dorsiflexion and compare it with that of conventional ankle CT scans in a neutral position.

STUDY DESIGN

Cohort study (Diagnosis); Level of evidence, 2.

METHODS

Between September 2018 and April 2021, this prospective study consecutively included adults visiting the foot and ankle outpatient clinic with a positive orthopaedic examination for acute syndesmotic injury. Participants underwent 3 CT scan tests. First, ankles were scanned in a neutral position. Second, ankles were scanned with 45° of external rotation, dorsiflexion, and extended knees. Third, ankles were scanned with 45° of external rotation, dorsiflexion, and flexed knees. Three measurements, comprising rotation (measurement a), lateral translation (measurement c), and anteroposterior translation (measurement f) of the fibula concerning the tibia, were used to diagnose syndesmotic instability in the 3 CT scans. Magnetic resonance imaging was used as a reference standard. The area under the curve (AUC) was used to compare the diagnostic accuracy, and Youden's J index was calculated to determine the ideal cutoff point.

RESULTS

Images obtained in 68 participants (mean age, 36.5 years; range, 18-69 years) were analyzed, comprising 36 syndesmotic injuries and 32 lateral collateral ligament injuries. The best diagnostic accuracy occurred with the rotational measurement a, in which the second and third CT scans with stress maneuvers presented greater AUCs (0.97 and 0.99) than did the first CT scan in a neutral position (0.62). The ideal cutoff point for the stress maneuvers was 1.0 mm in the rotational measurement a and reached a sensitivity and specificity of 83% and 97% for the second CT scan with extended knees and 86% and 100% for the third CT scan with flexed knees, respectively. The ideal cutoff point for the first CT scan with a neutral position was 0.7 mm in the rotational measurement a, with a sensitivity of 25% and specificity of 97%.

CONCLUSION

Conventional ankle CT with stress maneuvers has excellent performance for diagnosing subtle syndesmotic rotational instability, as it shows a greater AUC and enhanced sensitivity at the ideal cutoff point compared with ankle CT in the neutral position.

Impairment-based assessments for patients with lateral ankle sprain: A systematic review of measurement properties

STUDY DESIGN

Systematic review.

BACKGROUND AND OBJECTIVE

The International Ankle Consortium developed a core outcome set for the assessment of impairments in patients with lateral ankle sprain (LAS) without consideration of measurement properties (MP). Therefore, the aim of this study is to investigate MPs of assessments for the evaluation of individuals with a history of LAS.

METHODS

This systematic review of measurement properties follows PRISMA and COSMIN guidelines. Databases Pubmed, CINAHL, Embase, Web of Science, Cochrane Library and SPORTDiscus were searched for eligible studies (last search: July 2022). Studies on MP of specific tests and patient-reported outcome measurements (PROMs) in patients with acute and history of LAS (>4 weeks post injury) were deemed eligible.

RESULTS

Ten studies of acute LAS and 39 studies of history of LAS patients with a total of 3313 participants met the inclusion criteria. Anterior Drawer Test (ADT) in supine position five days post injury and Reverse Anterolateral Drawer Test are recommended in acute settings in single studies. In the history of LAS patients, Cumberland Ankle Instability Tool (CAIT) (4 studies) as a PROM, Multiple Hop (3 studies) and Star Excursion Balance Tests (SEBT) (3 studies) for dynamic postural balance testing showed good MPs. No studies investigated pain, physical activity level and gait. Only single studies reported on swelling, range of motion, strength, arthrokinematics, and static postural balance. Limited data existed on responsiveness of the tests in both subgroups.

CONCLUSION

There was good evidence to support the use of CAIT as PROM, Multiple Hop, and SEBT for dynamic postural balance testing. Insufficient evidence exists in relation to test responsiveness, especially in the acute situation. Future research should assess MPs of assessments of other impairments associated with LAS.

Diagnostic Value of DECT-Based Collagen Mapping for Assessing the Distal Tibiofibular Syndesmosis in Patients with Acute Trauma

Background: Injury to the distal tibiofibular syndesmosis (DTFS) is common in patients with trauma to the ankle, but diagnostic accuracy of conventional X-ray and CT is insufficient. A novel dual energy CT (DECT) post-processing algorithm enables color-coded mapping of collagenous structures, which can be utilized to assess the integrity of the DTFS. Methods: Patients were included in this retrospective study if they underwent third-generation dual-source DECT followed by 3T-MRI or ankle joint surgery within 14 days between January 2016 and December 2021. Three radiologists blinded to all patient data independently evaluated grayscale images and, after 8 weeks, grayscale and collagen mapping images for the presence of ligamentous injury or avulsion fractures of the DTFS. MRI and surgery provided the reference standard. Diagnostic accuracy parameters were calculated for all ratings, and a comparison of ROC curve analysis was performed to evaluate the incremental diagnostic value of color-coded images over grayscale images. Results: A total of 49 patients (median age 49 years; 32 males) were evaluated. Application of collagen mapping significantly increased sensitivity (25/30 [83%] vs. 20/30 [67%]), specificity (110/118 [93%] vs. 70/118 [60%]), positive predictive value (25/33 [76%] vs. 20/67 [30%]), negative predictive value (110/115 [96%] vs. 70/80 [88%]), and accuracy (134/147 [91%] vs. 90/147 [61%]) for the detection of injury to the DTFS (all parameters, p < 0.001). Collagen mapping achieved higher diagnostic confidence, image quality, and noise scores compared to grayscale CT (all parameters, p < 0.001). Conclusions: Collagen mapping yields substantially higher diagnostic accuracy and confidence for assessing the integrity of the distal tibiofibular syndesmosis compared to grayscale CT in patients with acute trauma. The application of this algorithm can accelerate the adequate diagnosis and treatment of DTFS injury in clinical routine.

Reliability and validity of physical examination tests for the assessment of ankle instability

INTRODUCTION

Clinicians rely on certain physical examination tests to diagnose and potentially grade ankle sprains and ankle instability. Diagnostic error and inaccurate prognosis may have important repercussions for clinical decision-making and patient outcomes. Therefore, it is important to recognize the diagnostic value of orthopaedic tests through understanding the reliability and validity of these tests.

OBJECTIVE

To systematically review and report evidence on the reliability and validity of orthopaedic tests for the diagnosis of ankle sprains and instability.

METHODS

PubMed, CINAHL, Scopus, and Cochrane databases were searched from inception to December 2021. In addition, the reference list of included studies, located systematic reviews, and orthopaedic textbooks were searched. All articles reporting reliability or validity of physical examination or orthopaedic tests to diagnose ankle instability or sprains were included. Methodological quality of the reliability and the validity studies was assessed with The Quality Appraisal for Reliability studies checklist and the Quality Assessment of Diagnostic Accuracy Studies-2 respectively. We identified the number of times the orthopaedic test was investigated and the validity and/or reliability of each test.

RESULTS

Overall, sixteen studies were included. Three studies assessed reliability, eight assessed validity, and five evaluated both. Overall, fifteen tests were evaluated, none demonstrated robust reliability and validity scores. The anterolateral talar palpation test reported the highest diagnostic accuracy. Further, the anterior drawer test, the anterolateral talar palpation, the reverse anterior lateral drawer test, and palpation of the anterior talofibular ligament reported the highest sensitivity. The highest specificity was attributed to the anterior drawer test, the anterolateral drawer test, the reverse anterior lateral drawer test, tenderness on palpation of the proximal fibular, and the squeeze test.

CONCLUSION

Overall, the diagnostic accuracy, reliability, and validity of physical examination tests for the assessment of ankle instability were limited. Physical examination tests should not be used in isolation, but rather in combination with the clinical history to diagnose an ankle sprain. Preliminary evidence suggests that the overall validity of physical examination for the ankle may be better if conducted five days after the injury rather than within 48 h of injury.

A Prospective Randomized Study Comparing Functional Outcome in Distal Fibula Fractures between Conventional AO Semitubular Plating and Minimal Invasive Intramedullary "Photodynamic Bone Stabilisation"

(1) Background: As age in western populations is rising, so too are fractures, e.g., of the distal fibula. The aim of this study was to find out whether a novel, minimally invasive intramedullary osteosynthesis technique for the treatment of distal fibula fractures in elderly patients results in not only a reduction of postoperative complications, but also a shorter hospitalization time, an improved clinical outcome, and preserved autonomy in geriatric trauma patients. (2) Methods: In this prospective study, the results following surgical treatment for distal fibula fractures in geriatric patients after using DePuy Synthes^® one-third semitubular plate (Group I) or a minimally invasive intramedullary photodynamic Bone StabilizationSystem (IlluminOss^®) (Group II) were compared at 6 weeks, 12 weeks, 6 months, and 1 year after initial treatment. (3) Results: Significant improvement regarding clinical outcome was shown in Group II 6 and 12 weeks after surgery. (4) Conclusions: Our study results demonstrate that the use of this new intramedullary stabilization system in combination with an immediate postoperative weight bearing seems to be a safe and stable treatment option for ankle fractures in geriatric patients, especially in the early stages of recovery.

Ankle syndesmosis biomechanical evaluation by shear-waves elastography in healthy young adults: Assessment of the reliability and accuracy of the measurements and definition of a corridor of normality

BACKGROUND

Aims of this study were: 1/ to evaluate the shear wave speed (SWS) properties of the anteroinferior tibiofibular ligament (AITFL) and the distal interosseous membrane (DIOM) in neutral, dorsal flexion and plantar flexion positions in a cohort of healthy adult volunteers; 2/ to assess the reliability and reproducibility of these measurements.

METHODS

Both ankles were analyzed by shear wave elastography (SWE) in 20 healthy patients (10 females/10 males) standing on a hinge support with their ankles in neutral, 20° dorsal flexion and 30° plantar flexion positions. Stiffness of AITFL and DIOM was evaluated by SWS measurement.

RESULTS

The SWS of AITFL and DIOM were minimal in the plantar flexion position (4.28 m/s [2.65-5.11] and 3.35 m/s [1.69-4.55], respectively). It increased significantly for both ligaments in neutral position (4.69 m/s [3.53-5.71] and 3.81 m/s [1.91-4.74], respectively; p < 0.0001), and reached their maximum values in dorsal flexion (6.58 m/s [5.23-8.34] and 4.79 m/s [3.07-6.19], respectively; p < 0.0001). There was no correlation between each ligament regardless the positions. SWS of AITFL was independent of demographic characteristics analyzed. SWS of DIOM was negatively correlated with height in dorsal flexion (ρ = -0.35; p = 0.03) and in plantar flexion (ρ = -0.37; p = 0.02). Female gender was associated with increased DIOM SWS in neutral (p = 0.005), dorsal flexion (p = 0.003), and plantar flexion (p = 0.001) positions. Moreover, foot morphology (foot arch, hind foot frontal deviation) did not impact AITFL nor DIOM SWS. Inter- and intra-observer measurements were all good or excellent.

CONCLUSION

The AITFL and DIOM, stabilizers of the distal tibiofibular syndesmosis, increase in stiffness while dorsal flexion increases. This study describes a reliable and reproducible protocol to assess their stiffness by SWE, and defines a corridor of normality.

Acute clinical evaluation for syndesmosis injury has high diagnostic value

PURPOSE

To determine the diagnostic value of injury history, physical examination, six syndesmosis tests and overall clinical suspicion for syndesmosis injury.

METHODS

All athletes (> 18 yrs) with an acute ankle injury presenting within 7 days post-injury were assessed for eligibility. Acute ankle injuries were excluded if imaging studies demonstrated a frank fracture or 3 T MRI could not be acquired within 10 days post-injury. Standardized injury history was recorded, and physical examination was performed by an Orthopaedic Surgeon or Sports Medicine Physician. Overall clinical suspicion was documented prior to MRI. Multivariate logistic regression was used to determine the association between independent predictors and syndesmosis injury.

RESULTS

Between September 2016 and July 2019, a total of 150 acute ankle injuries were included. The median time from injury to acute clinical evaluation was 2 days (IQR 2). Prior to clinical evaluation, the median patient reported Visual Analog Scale for pain was 8/10 (IQR 2). Syndesmosis injury was present in 26 acute ankle injuries. An eversion mechanism of injury had a positive LR 3.47 (CI 95% 1.55-7.77). The squeeze tests had a positive LR of 2.20 (CI 95% 1.29-3.77) and a negative LR of 0.68 (CI 95% 0.48-0.98). Overall clinical suspicion had a sensitivity of 73% (CI 95% 52-88) and negative predictive value of 89% (CI 95% 78-95). Multivariate regression analyses demonstrated significant association for eversion mechanism of injury (OR 4.99; CI 95% 1.56-16.01) and a positive squeeze test (OR 3.25; CI 95% 1.24-8.51).

CONCLUSIONS

In an acute clinical setting with patients reporting high levels of ankle pain, a negative overall clinical suspicion reduces the probability of syndesmosis injury. Eversion mechanism of injury and a positive squeeze test are associated with higher odds of syndesmosis injury.

LEVEL OF EVIDENCE

Level III.

Anterior Inferior Tibiofibular Ligament Suture Tape Augmentation for Isolated Syndesmotic Injuries

BACKGROUND

The best operative construct and technique for treatment of isolated syndesmotic injuries is highly debated. The purpose of this study was to determine whether the addition of anterior inferior tibiofibular ligament (AITFL) suture repair or suture tape (ST) augmentation provides any biomechanical advantage to the operative repair of an isolated syndesmotic injury.

METHODS

Twelve lower leg specimens underwent biomechanical testing in 6 states: (1) intact, (2) AITFL suture repair, (3) AITFL suture repair + transsyndesmotic suture button (SB), (4) AITFL suture repair + ST augmentation + SB, (5) AITFL suture repair + ST augmentation, and (6) complete syndesmotic injury. The ankle joint was subjected to 6 cycles of 5 Nm internal and external rotation torque under a constant axial load. The spatial relationship between the tibia, fibula, and talus was continuously recorded with a 5-camera motion capture system.

RESULTS

AITFL suture repair and AITFL suture repair + ST augmentation showed no statistically significant change in fibula kinematics compared to the intact state. Compared to native, AITFL suture repair + SB showed increased fibular external rotation (+2.32 degrees, P < .001), and decreased tibiofibular gap (overtightening) (-0.72 mm, P = .007). AITFL suture repair + ST augmentation + SB also showed increased fibular external rotation (+1.46 degrees, P = .013). Sagittal plane motion of the fibula was not significantly different between any states. None of the repairs restored intact state talus rotation; however, the repairs that used ST augmentation reduced the talus external rotation laxity compared to the complete syndesmotic injury.

CONCLUSION

AITFL suture repair and AITFL ST augmentation best restored the rotational kinematics and stability of the fibula and ankle joint in an isolated syndesmotic injury model.

CLINICAL RELEVANCE

AITFL suture repair with or without ST augmentation may be a good operative addition or alternative to SB fixation for isolated syndesmotic disruptions.

Analysis of the uninjured tibiofibular syndesmosis using conventional CT-imaging and axial force in different foot positions

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.

The Australian ankle syndesmosis injury survey

BACKGROUND & OBJECTIVE

The ankle syndesmosis is frequently disrupted in ankle injuries, with higher incidence in concomitant ankle fractures. There is debate regarding the most appropriate surgical management of these injuries, with the development of suture-button devices challenging the conventional approach of surgical stabilisation with syndesmotic screws. The primary aim of this study was to assess current practice variation at a national level, enabling a comparison with reported practice around the world. The secondary aims were to assess practice variation between operative indications and inconsistencies between surgeon device usage and personal preference should they be injured themselves.

METHODS

A 20-item survey detailing surgical experience, diagnosis, surgical management preference and a series of case studies was conducted. The survey was endorsed and promoted by the Australian Orthopaedic Association (AOA).

RESULTS

125 responses were received during the three-month study period. The most commonly used method to stabilise a syndesmotic injury by Australian orthopaedic surgeons was two 3.5 mm screws (26.4%), closely followed by one suture-button (23.2%). Overall, 44% of surgeons employ a dynamic stabilisation method and 54.4% a static stabilisation method. Half of surgeons recommend routine removal of syndesmosis screws, and surgeons tend to use two devices for high Weber C fractures. One third of surgeons who most commonly use screws in their practice would actually prefer a suture-button for management of their own syndesmosis injury.

CONCLUSION

Significant variability remains in the management of syndesmosis injuries. This survey of Australian orthopaedic surgeons reveals higher suture-button device use when compared to other countries.

Syndesmotic instability can be assessed by measuring the distance between the tibia and the fibula using an ultrasound without stress: a cadaver study

Background

Ultrasound examinations for syndesmosis injury might be useful for the quantitative evaluation of syndesmotic instability. The purpose of this study was to evaluate the efficacy of ultrasound assessment by measuring the tibiofibular distance of syndesmosis injuries in various ligament-injured models and stress load conditions.

Methods

Five normal ankles from Thiel-embalmed cadavers were used. Ultrasound assessment was performed by placing a probe in parallel with the ligament running just above the anterior inferior tibiofibular ligament (AITFL). The distance between the anterior border of the tibia and the fibula was measured in the intact condition. Next, Bassett’s ligament was cut arthroscopically to reduce damage to soft tissues as much as possible and measurement was performed in the same way. After that, the AITFL, interosseous membrane (IOM), deltoid ligament, and posterior inferior tibiofibular ligament (PITFL) were macroscopically cut and measured in that order. Ankle positions were without stress (natural plantar flexion without applying stress to the ankle joint), dorsiflexion stress, inversion stress, and external rotation stress. All stress to the ankle joint was carried out manually to the maximum extent.

Results

As with the without-stress condition, significant increases in tibiofibular distances after AITFL dissection were seen compared with the intact state under all stress conditions (intact: 4.9 ± 1.0 mm without stress, 5.6 ± 1.2 mm with dorsiflexion, 5.9 ± 1.0 mm with inversion, and 6.7 ± 1.3 mm with external rotation; AITFL dissection: 6.7 ± 1.5 mm without stress, 7.3 ± 1.2 mm with dorsiflexion, 7.5 ± 1.4 mm with inversion, and 8.7 ± 1.6 mm with external rotation). AITFL dissection with external rotation stress significantly increased the tibiofibular distance compared to without stress.

Conclusion

Changes in tibiofibular distance with the severity of syndesmosis injury were measured by ultrasound using cadavers. No significant change was seen with Bassett’s ligament injury, but tibiofibular distance increased significantly with injuries of equal to or greater severity than AITFL injury. Results were similar not only for external rotation stress, but also for dorsiflexion stress and inversion stress, and even in unloaded states, significant tibiofibular widening was confirmed with injuries of equal to or greater severity than AITFL injury.

Utility of WBCT to Diagnose Syndesmotic Instability in Patients With Weber B Lateral Malleolar Fractures

BACKGROUND

Diagnosing syndesmotic instability accompanying Weber B ankle fractures can be challenging. This study aimed to evaluate the ability of weight-bearing computed tomography (WBCT) to diagnose syndesmotic instability using one-dimensional, two-dimensional, and three-dimensional measurements among patients with unilateral Weber B lateral malleolar fractures with symmetric medial clear space (MCS) on initial radiographs and yet demonstrated operatively confirmed syndesmotic instability.

METHODS

The treatment group included 23 patients with unilateral surgically confirmed syndesmotic instability accompanying Weber B ankle fractures who underwent preoperative bilateral foot and ankle WBCT. The control group included 18 unilateral Weber B ankle fracture patients without syndesmotic instability who underwent bilateral WBCT. Measurements on WBCT images included the following: (1) syndesmotic area, (2) anterior, middle, and posterior distal tibiofibular distance, (3) fibular rotation, (4) distance from fibular tip to plafond, (5) fibular fracture displacement, and (6) MCS distance. In addition, the following volumetric measurements were calculated: (1) syndesmotic joint volume from the tibial plafond extending to 3 and 5 cm proximally, (2) MCS volume, and (3) lateral clear space volume. Area under the receiver operating characteristic curve analysis and Delong test were used, and optimal cutoff values to distinguish between stable and unstable syndesmosis were determined using Youden J statistic.

RESULTS

Among patients with unilateral syndesmotic instability and Weber B ankle fractures, all WBCT measurements were significantly greater than uninjured side, except MCS distance, syndesmotic area, and anterior and posterior tibiofibular distances (P values <0.001 to 0.004). Moreover, syndesmosis volume spanning from the tibial plafond to 5 cm proximally had the largest area under the curve of 0.96 (sensitivity = 90%; specificity = 95%), followed by syndesmosis volume up to 3 cm proximally (area under the curve = 0.91; sensitivity = 90%; specificity = 90%). Except for MCS volume and distal fibular tip to tibial plafond distance, the control group showed no side-to-side difference in any parameter.

CONCLUSION

Syndesmotic joint volume measurements seem to be best suited to diagnose syndesmotic instability among patients with Weber B ankle fractures, compared with other two-dimensional and three-dimensional WBCT measurements.

LEVEL OF EVIDENCE

Level III, comparative diagnostic study.

Diagnosis and Treatment of Syndesmotic Unstable Injuries: Where We Are Now and Where We Are Headed

Up to 10% of ankle sprains are considered "high ankle" sprains with associated syndesmotic injury. Initial diagnosis of syndesmotic injury is based on physical examination, but further evaluation of the distal tibiofibular joint in the sagittal, coronal, and rotational planes is necessary to determine instability. Imaging modalities including weight-bearing CT and ultrasonography allow a physiologic and dynamic assessment of the syndesmosis. These modalities in turn provide the clinician useful information in two and three dimensions to identify and consequently treat syndesmotic instability, especially when subtle. Because there is notable variability in the shape of the incisura between individuals, contralateral comparison with the uninjured ankle as an optimal internal control is advised. Once syndesmotic instability is identified, surgical treatment is recommended. Several fixation methods have been described, but the foremost aspect is to achieve an anatomic reduction. Identifying any associated injuries and characteristics of the syndesmotic instability will lead to the appropriate treatment that restores the anatomy and stability of the distal tibiofibular joint.

Sub-Acute Syndesmotic Injury: A Review and Proposed Treatment Algorithm

Sub-acute syndesmotic injuries are classified as from six weeks to six months from the initial injury date and can be considered a distinct group of patients; however, they are often mistreated and progress to chronic injuries with significant sequelae. The authors performed a comprehensive literature search on the MEDLINE database. The search yielded 165 studies up to January 2021, after the application of inclusion/exclusion criteria. This yielded 10 studies with a total of 156 relevant patients for review. We found that a delay in diagnosis is common and has a negative impact on outcomes. If a sub-acute syndesmotic injury is suspected and plain radiographs are inconclusive, magnetic resonance imaging is indicated if there is still an index of suspicion. Surgical intervention should aim to restore normal length and rotational alignment of the fibula whilst also addressing the need to debride tissues within the joint and syndesmosis. Syndesmosis must then be adequately reduced and stabilised with syndesmotic screw fixation, and augmentation with tendon/ligament reconstruction should be considered. All studies showed an average improvement in functional outcome measures post-operatively. The only study to compare sub-acute and chronic patients' functional outcomes post-operatively showed significant improvement in the sub-acute cohort; highlighting the importance of early intervention. We suggest a treatment algorithm that may help with the diagnosis and management of these injuries. We believe this will help all healthcare professionals to standardise care. Further research is required to assess sub-acute injury outcomes with tendon/ligamentous augmented reconstruction, as no level 1 or 2 studies currently exist.

Diagnostic accuracy of clinical tests assessing ligamentous injury of the ankle syndesmosis: A systematic review with meta-analysis

OBJECTIVE

To summarise and evaluate research on the diagnostic accuracy of clinical tests for ligamentous injury of the ankle syndesmosis.

METHODS

CINAHL, Embase, and MEDLINE were searched from inception to February 12, 2021. Studies comparing clinical examination to arthroscopy, magnetic resonance imaging, or ultrasound were considered eligible. Meta-analysis was based on random effect modelling and limited to studies fulfilling all QUADAS-2 criteria. Sensitivity (SN), specificity (SP) and likelihood ratios determined diagnostic accuracy, all with 95% confidence intervals (CI).

RESULTS

Six studies were included (512 participants; 13 clinical tests; 29% median prevalence). No individual test was associated with both high sensitivity and high specificity. Tests with the highest sensitivity were: palpation [SN 92% (95%CI 79-98)] and dorsiflexion lunge [SN 75% (95% CI 64-84%); n = 2 studies]. Tests with the highest specificity were: squeeze test [SP 85% (95% CI 81-89%); n = 4 studies] and external rotation [SP 78% (95% CI 73-82%); n = 4 studies].

CONCLUSIONS

Clinical examination should involve initial clustering of tests with high sensitivity (palpation; dorsiflexion lunge), followed by a test with high specificity (squeeze). However, as these tests cannot definitively stratify syndesmotic injuries into stable vs unstable, decisions on optimal management (conservative vs surgery) require additional imaging or arthroscopy.

Diagnostic value of ultrasonography in acute lateral and syndesmotic ligamentous ankle injuries

Objectives

To determine the diagnostic value of ultrasonography for complete discontinuity of the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL) and the anterior inferior tibiofibular ligament (AITFL).

Methods

All acute ankle injuries in adult athletes (> 18 years old) presenting to the outpatient department of a specialised Orthopaedic and Sports Medicine Hospital within 7 days post-injury were assessed for eligibility. Using ultrasonography, one musculoskeletal radiologist assessed the ATFL, CFL and AITFL for complete discontinuity. Dynamic ultrasound measurements of the tibiofibular distance (mm) in both ankles (injured and contralateral) were acquired in the neutral position (N), during maximal external rotation (Max ER), and maximal internal rotation (Max IR). MR imaging was used as a reference standard.

Results

Between October 2017 and July 2019, 92 acute ankle injuries were included. Ultrasound diagnosed complete discontinuity of the ATFL with 87% (CI 74–95%) sensitivity and 69% (CI 53–82%) specificity. Discontinuity of the CFL was diagnosed with 29% (CI 10–56%) sensitivity and 92% (CI 83–97%) specificity. Ultrasound diagnosed discontinuity of the AITFL with 100% (CI 74–100%) sensitivity and 100% (CI 95–100%) specificity. Of the dynamic measurements, the side-to-side difference in external rotation had the highest diagnostic value for complete discontinuity of the AITFL (sensitivity 82%, specificity 86%; cut-off 0.93 mm).

Conclusions

Ultrasound has a good to excellent diagnostic value for complete discontinuity of the ATFL and AITFL. Therefore, ultrasound can be used to screen for injury of the ATFL and AITFL. Compared with ultrasound, dynamic ultrasound has inferior diagnostic value for complete discontinuity of the AITFL.

Key Points

• Ultrasound has a good to excellent diagnostic value for complete discontinuity of the anterior talofibular ligament (ATFL) and anterior inferior tibiofibular ligament (AITFL).

• Ultrasound can be used to screen for injury of the ATFL and AITFL.

• Compared with ultrasound, dynamic ultrasound has inferior diagnostic value for complete discontinuity of the AITFL.

Electronic supplementary material

The online version of this article (10.1007/s00330-020-07305-7) contains supplementary material, which is available to authorized users.

Delayed stabilisation of dynamically unstable syndesmotic injuries results in worse functional outcomes

PURPOSE

Patients with primarily ligamentous injuries of the distal tibiofibular joint comprise up to 12% of all ankle sprains. Patients frequently present late after a syndesmosis injury and delayed treatment potentially leads to pain, prolonged disability and arthritis in the long term. This study aimed to assess clinical outcomes in patients who required syndesmosis fixation in the presence of arthroscopically proven instability, the hypothesis being that a delay to treatment would be associated with worse function.

METHOD

A retrospective cohort study was performed of patients with dynamic instability requiring fixation between the years of 2010-2016. The procedures were performed by two foot and ankle fellowship trained orthopaedic surgeons, over three hospital sites. Patients were classified into three groups based on the time since injury to surgery, acute syndesmotic injury (< 6 weeks), sub-acute (6 weeks-6 months) and chronic syndesmotic injury (> 6 months). Functional scores were retrospectively collected using the Foot and Ankle Outcome Score (FAOS).

RESULTS

Compared to patients with acute injuries, those with chronic injuries had significantly lower FAOS subscales (p < 0.001), with the greatest difference in quality of life (- 20.7, 95% CI - 31.6 to - 9.8, p = 0.012). There was a mean follow-up of 4.3 years. Although the average FAOS subscales in those with sub-acute injuries were lower than in those with acute injuries, the difference was not statistically significant.

CONCLUSION

The results of this study suggest that delayed surgical stabilisation (> 6 months) is associated with significantly worse clinical function, and thus timely identification and early referral of those patients with potentially unstable syndesmotic injuries is recommended.

LEVEL OF EVIDENCE

Level III.

Anatomy of Ankle Syndesmotic Ligaments: A Systematic Review of Cadaveric Studies

Diagnosis and management of isolated syndesmotic injuries are controversial and highly debated. Hence, the aim of this study is to explore and gain the current understanding pertaining to detailed anatomy of syndesmotic ligaments through a systematic review of published cadaveric studies. A systematic review was conducted online for literature published in English using PubMed and Google Scholar, as per PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, up to April 30, 2019. Predefined eligibility criteria were applied, and the data thus compiled was analyzed. Study quality was assessed based on Quality Appraisal for Cadaveric Studies (QUACS) scale. A total of 12 studies reporting 365 ankles were included in this review. Considerable inconsistency in the naming and description of syndesmotic ligaments was observed, with only 2 studies reporting the vasculature of the ligaments. Hence further investigation of the anatomy of the syndesmotic ligaments is recommended so as to better inform clinical practice, as awareness of anatomy is critical for assessment, healing, and successful surgical management.Levels of Evidence: Level III: Systematic review of anatomical dissections.

Syndesmotic Overload in 3-Component Total Ankle Replacement

BACKGROUND

Mobile-bearing total ankle replacement (TAR) potentially enables motion at the tibial implant-polyethylene insert (PI) interface. Such additional freedom of movement may overload periarticular ligaments and subsequently result in coronal translation of the talus. The aim of this study was to assess whether syndesmotic overload affects clinical and radiographic outcomes following mobile-bearing TAR and whether tibiofibular fusion is an effective treatment option.

METHODS

Thirty-one patients who underwent revision surgery for syndesmotic overload after mobile-bearing TAR were retrospectively analyzed. Clinical and radiographic outcomes were assessed before and after index TAR, preoperatively to revision surgery, and at the last follow-up after revision surgery. Computed tomography scans were also analyzed.

RESULTS

Ankles with lateral talar translation prior to revision surgery were about 10 times more likely to have valgus tibial implant position (P = .003). A wide tibiofibular distance at the level of the syndesmosis after index TAR was associated with an increased hindfoot moment arm at revision surgery (P = .025). Decrease of PI height at revision surgery and a PI fracture were evident in 10 (32%) and 4 (13%) cases, respectively. Talar cyst formation at revision surgery was evident in 12 (39%) cases. Tibiofibular fusion was effective in restoring function of the replaced ankle and providing pain relief.

CONCLUSION

Syndesmotic overload impaired clinical and radiographic outcomes after mobile-bearing TAR. Proper implant positioning and additional realignment procedures may prevent overload of periarticular soft tissue structures after mobile-bearing TAR.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Assessing mechanical ankle instability via functional 3D stress-MRI - A pilot study

BACKGROUND

Quantitative measurement of the mechanical deficit in chronic ankle instability (CAI) is difficult. Therefore, the distinction between functional (FAI) and mechanical ankle instability (MAI) as well as the evaluation of surgical techniques is difficult. This pilot study uses a novel method of functional 3-dimensional stress ankle-MRI to test its applicability for assessing mechanical ankle instability.

METHODS

We used a custom-built ankle arthrometer that allows a stepless positioning of the foot and an axial in situ loading with up to 500 N combined with a 3-dimensional MRI protocol. We assessed four parameters (3D cartilage contact area (CCA) fibulotalar, tibiotalar horizontal and vertical and intermalleolar distance) under six different conditions (neutral-null, plantarflexion-supination and dorsiflexion-pronation each with and without loading) in n = 10 individuals (7 suffering from MAI and 3 healthy controls).

FINDINGS

The MAI group showed a substantially increased reduction of lateral osseous constraint compared to healthy controls when the foot was positioned in plantarflexion-supination (CCA fibulotalar 69% vs. 30% in controls). The reduction of the weight bearing surface in plantarflexion-supination was also more pronounced (CCA tibiotalar horizontal -49% in MAI vs. -28% in controls).

INTERPRETATION

This novel technique is valuable for assessing mechanical ankle instability in the target population and has a potential clinical benefit for assessing the mechanical deficit of individual patients. Further studies are needed to provide evidence for a possible prognostic value of this novel technique.

Diagnostic capability of dynamic ultrasound evaluation of supination-external rotation ankle injuries: a cadaveric study

BACKGROUND

Ankle syndesmosis injuries are common and range in severity from subclinical to grossly unstable. Definitive diagnosis of these injuries can be made with plain film radiographs, but are often missed when severity or image quality is low. Computed tomography (CT) and magnetic resonance imaging (MRI) can provide definitive diagnosis, but are costly and introduce the patient to radiation when CT is used. Ultrasonography may circumvent many of these disadvantages by being inexpensive, efficient, and able to detect injuries without radiation exposure. The purpose of this study was to evaluate the ability of ultrasonography to detect early stage supination-external rotation (SER) ankle syndesmosis injuries with a dynamic external rotational stress test.

METHODS

Nine, all male, fresh frozen specimens were secured to an ankle rig and stress tested to 10 Nm of external rotational torque with ultrasonography at the tibiofibular clear space. The ankles were subjected to syndesmosis ligament sectioning and repeat stress measurements of the tibiofibular clear space at peak torque. Stress tests and measurements were repeated three times and averaged and analyzed using a repeated one-way analysis of variance (ANOVA). There were six ankle injury states examined including: Intact State, 75% of AITFL Cut, 100% of AITFL Cut, Fibula FX - Cut 8 cm proximal, 75% PITFL Cut, and 100% PITFL Cut.

RESULTS

Dynamic external rotation stress evaluation using ultrasonography was able to detect a significant difference between the uninjured ankle with a tibiofibular clear space of 4.5 mm and the stage 1 complete injured ankle with a clear space of 6.0 mm (P < .02). Additionally, this method was able to detect significant differences between the uninjured ankle and the stage 2-4 injury states.

CONCLUSION

Dynamic external rotational stress evaluation using ultrasonography was able to detect stage 1 Lauge-Hansen SER injuries with statistical significance and corroborates criteria for diagnosing a syndesmosis injury at ≥6.0 mm of tibiofibular clear space widening.

Surgical outcome in chronic syndesmotic injury: A systematic literature review

BACKGROUND

Chronic injuries of the distal tibio-fibular syndesmosis often present with non-specific clinical and radiographic findings. If chronic instability to the distal tibio-fibular syndesmosis is verified, various reconstruction options are available. The purpose of this article is to give a systematic review of current surgical treatment options in patients with chronic syndesmotic injury.

METHODS

Three major medical databases were searched from inception through December 12, 2017: PubMed, ScienceDirect, and SpringerLink. Studies were included if they were original research studies which assessed the outcome of patients treated surgically for chronic syndesmotic instability. Only studies written in English were considered. The following data were extracted from each study: number of patients and ankles included, average patients' age, gender, study design, preoperative examination, time between the initial injury and the operation, postoperative follow-up time, operative technique, complication rates, and clinical outcome. The modified Coleman Score was used to assess the methodologic quality of the included studies.

RESULTS

Seventeen (17) studies were included. All studies were retrospective or prospective case series. Each study was performed at a single center. In general, good functional outcomes and low complication rates were reported. The American Orthopaedic Foot and Ankle (AOFAS) score was most frequently used outcome tool to measure postoperative outcomes. The quality of the included studies was overall satisfactory.

CONCLUSIONS

A few studies have reported on the operative outcomes after treating chronic syndesmotic instability. Several different techniques were used to treat this problem. The quality of current studies is overall satisfactory but could be improved with larger patient numbers and prospective analysis. Recognition of this clinical entity as an identifiable and treatable cause of ankle pain requires vigilant clinical investigation.

LEVEL OF EVIDENCE

Level IV; Systematic Review of Level IV Studies.

MRI for high ankle sprains with an unstable syndesmosis: posterior malleolus bone oedema is common and time to scan matters

PURPOSE

Early clinical examination combined with MRI allows accurate diagnosis of syndesmosis instability after a high ankle sprain. However, patients often present late. The aims of the current study were to describe MRI characteristics associated with syndesmosis instability and to test the hypothesis that MRI patterns would differ according to time from injury.

METHODS

Over a 5-year period, 164 consecutive patients who had arthroscopically proven syndesmosis instability requiring fixation were retrospectively studied. Patients with distal fibula fractures were not included. Injuries were classified as acute in 108 patients (< 6 weeks), intermediate in 32 (6-12 weeks) and chronic in 24 patients (> 12 weeks).

RESULTS

Posterior malleolus bone oedema was noted in 65 (60.2%), and posterior malleolus fracture in 17 (15.7%) of acute patients, respectively, which did not significantly differ over time. According to MRI, reported rates of posterior syndesmosis disruption significantly differed over time, observed in 101 (93.5%), 28 (87.5%) and 13 (54.2%) of acute, intermediate and chronic patients, respectively (p < 0.001). Apparent rates of PITFL injury significantly reduced with time (p < 0.001).

CONCLUSIONS

MRI detected a posterior syndesmosis injury in 93.5% of patients acutely but became less reliable with time. The clinical relevance of this study is that posterior malleolus bone oedema may be the only marker of a complete syndesmosis injury and can help clinically identify those injuries which require arthroscopic assessment for instability. If suspicious of a high ankle sprain, we advocate early MRI assessment to help determine stable versus unstable injuries as MRI becomes less reliable after 12 weeks.

LEVEL OF EVIDENCE

III.

Return to play after surgery for isolated unstable syndesmotic ankle injuries (West Point grade IIB and III) in 110 male professional football players: a retrospective cohort study

Objectives

To evaluate time to return to play following surgical stabilisation of isolated unstable syndesmosis injuries in a cohort of professional male football players.

Methods

All professional football players undergoing surgery for isolated unstable syndesmosis injury (West Point grade ≥IIB) at a specialised Orthopaedic and Sports Medicine Hospital were followed up until return to play (minimum ≥6 months). Players with a stable syndesmosis, injuries older than 6 weeks, concomitant medial or lateral malleolar fracture or previous ankle surgery were excluded. During rehabilitation, time required to return to sports-specific rehabilitation, team training and first match play, were recorded.

Results

Between January 2012 and December 2017, a total of 110 male professional football players were included. The mean time required to begin on field rehabilitation was 37±12 days, while the mean time to return to team training was 72±28 days. The first official match was played on average 103±28 days postoperatively. Multivariable analysis revealed that the severity of injury, the concomitant presence of talar cartilage injury and the age of the player were significantly associated (p<0.00001) with time to return to on field rehabilitation, team training and match play.

Conclusion

In this cohort of professional football players, surgical stabilisation of isolated unstable syndesmosis injuries (West Point grade ≥IIB) allowed for relatively quick return to play. High grade injury (West Point grade III), concomitant cartilage injury and greater age were associated with longer return to play times.

Level of evidence

Longitudinal observational cohort study (level II).

Anatomic Ligament Repairs of Syndesmotic Injuries

Poor clinical results are seen with syndesmotic injuries in the setting of ankle sprains and ankle fractures. The goal of syndesmosis repair is to restore the normal anatomic relationship of the distal tibiofibular joint and prevent ankle arthritis. Indications for surgical intervention for isolated syndesmotic injuries include frank syndesmosis diastasis, medial clear space widening on plain radiographs, significant radiographic syndesmosis diastasis during stress examination, or subtle syndesmotic diastasis detected by arthroscopic evaluation. Complications after syndesmosis repair include symptomatic hardware, malreduction, and arthritis. Anatomic reduction of the syndesmosis leads to better outcomes following surgery.

MANAGEMENT OF ACUTE GRADE II LATERAL ANKLE SPRAINS WITH AN EMPHASIS ON LIGAMENT PROTECTION: A DESCRIPTIVE CASE SERIES

Background and Purpose

Lateral ankle sprain the most common injury in physically active populations. Individuals who sustain an acute lateral ankle sprain may not receive timely formal rehabilitation and are at an increased risk to have subsequent sprains which can lead to chronic pain and instability. Attention to essential factors for ligament protection and healing while preserving ankle movement, may result in a more stable yet mobile ankle offering improved outcomes. The purpose of this case series was to describe the methods and observe the outcomes associated with a comprehensive strategy for managing acute first episode grade II lateral ankle sprains.

Study design

Prospective case series.

Case Descriptions and Interventions

Ten patients (mean age 26.7 years, range 16-51 years, mean 2.3 days from injury) with acute grade II lateral ankle sprain were treated with an approach to protect the injured ligament, prevent impairments to movement, restore strength and proprioception, and progress to full function. Patient outcomes were assessed at four, eight and 12 weeks. Follow-up interviews at six and 12 months assessed injury recurrence.

Outcomes

Patients were treated for an average of eight sessions over a mean of seven weeks. Rapid change in self-reported function, ankle ROM, and pain were observed in the first four weeks of care. Clinically meaningful improvements in function and ankle ROM were also noted at eight weeks and maintained at 12-week follow-ups. All patients returned to desired physical activity with only a single re-sprain event within one year after injury.

Conclusion

The results of this prospective case series suggest that a treatment approach designed to protect the injured ligament, maintain and restore normal ankle motion, and provide a tailored functional pathway to return to run and sport demonstrated resolution of symptoms and improvement in reported functional outcomes in a group of patients following grade II acute primary ankle sprain.

Level of Evidence

Level IV, Case Series.

Tibiofibular syndesmosis in asymptomatic ankles: initial kinematic analysis using four-dimensional CT

AIM

To evaluate the reliability of ankle syndesmotic measurements and their changes during active motion using four-dimensional computed tomography (4DCT) examination in asymptomatic ankles.

MATERIALS AND METHODS

4DCT was performed on both ankles of patients with signs and symptoms of unilateral ankle instability. Ankles from the asymptomatic side of 10 consecutive patients were included in this analysis. Five ankle syndesmotic measurements were adopted from the available literature and performed by two fellowship-trained foot and ankle surgeons: (1) syndesmotic anterior distance (SAD); (2) syndesmotic posterior distance (SPD); (3) syndesmotic translation (ST); (4) syndesmotic tibiofibular angle (STFA); and (5) ankle tibiofibular angle (ATFA). A Monte Carlo simulation was also performed to obtain exact p-values with 99% confidence intervals.

RESULTS

Excellent interobserver reliability was observed among the two readers for four out of five measurements (intra-class correlation coefficients [ICC]: 0.767-0.995, p<0.001-0.020). The ICC values for SAD were not statistically significant (ICC=0.548 and 0.569 for dorsi and plantarflexion respectively, p=0.1). Among the five measurements, only ST measurements had significant changes during active motion (median [interquartile range] for change: -0.70 mm [-1.6-0.10]; p=0.012). Of the above measurements, only the ST measurements demonstrated a negative linear association with the tibiocalcaneal angle during active motion (beta=-2.5, p=0.04).

CONCLUSIONS

Reliable quantitative kinematic assessment of ankle syndesmosis can be performed using 4DCT examination. Syndesmotic measurements remain unchanged during ankle motion except for the syndesmotic translation, which tends to decrease during plantar flexion.

Reliability, Surgeon Preferences, and Eye-Tracking Assessment of the Stress Examination of the Ankle Syndesmosis

The diagnosis and stabilization of ankle syndesmotic injuries after acute injury remains an area of controversy in the foot and ankle surgical literature, seemingly without universal consensus. The primary objective of this investigation was to determine the frequency of agreement and reliability of the stress examination of the ankle syndesmosis. Secondary objectives were to determine surgeon preferences and protocols with respect to the ankle syndesmosis and to use gaze recognition software to perform an eye-tracking assessment during performance of stress examinations. Twelve foot and ankle surgeons, 12 residents, and 12 students were shown 5 intraoperative fluoroscopic still images and videos of the stress examination of the ankle syndesmosis. They were asked to evaluate the result as being "positive" or "negative" for syndesmotic stability. The overall reliability of the interpretation of the stress examination of the ankle syndesmosis was a kappa of 0.123 (surgeons 0.087; residents 0.019; students 0.237), indicating "slight" agreement. Survey results indicated wide variability in the perioperative preferences and protocols of surgeons dealing with the evaluation and treatment of the ankle syndesmosis. Eye-tracking results also demonstrated variability in the anatomic structures of interest focused on during performance of this testing. The results of this investigation provide evidence of reliability well below what would be expected of a gold standard test during stress examination of the ankle syndesmosis. These results indicate that future scientific endeavors are required to standardize the performance and interpretation of this testing.

Clinical assessment of acute lateral ankle sprain injuries (ROAST): 2019 consensus statement and recommendations of the International Ankle Consortium

Lateral ankle sprain injury is the most common musculoskeletal injury incurred by individuals who participate in sports and recreational physical activities. Following initial injury, a high proportion of individuals develop long-term injury-associated symptoms and chronic ankle instability. The development of chronic ankle instability is consequent on the interaction of mechanical and sensorimotor insufficiencies/impairments that manifest following acute lateral ankle sprain injury. To reduce the propensity for developing chronic ankle instability, clinical assessments should evaluate whether patients in the acute phase following lateral ankle sprain injury exhibit any mechanical and/or sensorimotor impairments. This modified Delphi study was undertaken under the auspices of the executive committee of the International Ankle Consortium. The primary aim was to develop recommendations, based on expert (n=14) consensus, for structured clinical assessment of acute lateral ankle sprain injuries. After two modified Delphi rounds, consensus was achieved on the clinical assessment of acute lateral ankle sprain injuries. Consensus was reached on a minimum standard clinical diagnostic assessment. Key components of this clinical diagnostic assessment include: establishing the mechanism of injury, as well as the assessment of ankle joint bones and ligaments. Through consensus, the expert panel also developed the International Ankle Consortium Rehabilitation-Oriented ASsessmenT (ROAST). The International Ankle Consortium ROAST will help clinicians identify mechanical and/or sensorimotor impairments that are associated with chronic ankle instability. This consensus statement from the International Ankle Consortium aims to be a key resource for clinicians who regularly assess individuals with acute lateral ankle sprain injuries.

Imaging in syndesmotic injury: a systematic literature review

OBJECTIVES

To give a systematic overview of current diagnostic imaging options for assessment of the distal tibio-fibular syndesmosis.

MATERIALS AND METHODS

A systematic literature search across the following sources was performed: PubMed, ScienceDirect, Google Scholar, and SpringerLink. Forty-two articles were included and subdivided into three groups: group one consists of studies using conventional radiographs (22 articles), group two includes studies using computed tomography (CT) scans (15 articles), and group three comprises studies using magnet resonance imaging (MRI, 9 articles).The following data were extracted: imaging modality, measurement method, number of participants and ankles included, average age of participants, sensitivity, specificity, and accuracy of the measurement technique. The Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool was used to assess the methodological quality.

RESULTS

The three most common techniques used for assessment of the syndesmosis in conventional radiographs are the tibio-fibular clear space (TFCS), the tibio-fibular overlap (TFO), and the medial clear space (MCS). Regarding CT scans, the tibio-fibular width (axial images) was most commonly used. Most of the MRI studies used direct assessment of syndesmotic integrity. Overall, the included studies show low probability of bias and are applicable in daily practice.

CONCLUSIONS

Conventional radiographs cannot predict syndesmotic injuries reliably. CT scans outperform plain radiographs in detecting syndesmotic mal-reduction. Additionally, the syndesmotic interval can be assessed in greater detail by CT. MRI measurements achieve a sensitivity and specificity of nearly 100%; however, correlating MRI findings with patients' complaints is difficult, and utility with subtle syndesmotic instability needs further investigation. Overall, the methodological quality of these studies was satisfactory.

Ankle syndesmosis repair and rehabilitation in professional rugby league players: a case series report

Background/aim

The distal tibiofibular joint is described as a syndesmosis. Traditionally, severe syndesmotic injuries with diastasis have been treated surgically with screw fixation. This case series details an ankle syndesmosis tightrope repair and an accelerated rehabilitation protocol that reduces the amount of time to return to professional rugby league in the UK. The aim of this study was to describe players’ journey from injury, through diagnosis to surgery, rehabilitation and return to participation, detailing time scales and methods used at each stage to highlight the change in current practice.

Methods

Players were identified via a single orthopaedic surgeon in the UK who specialises in ankle syndesmosis repair. Between January 2010 and September 2015, adult men playing full-time professional rugby league in the UK Super League with ankle syndesmosis injuries were identified.

Results

Eighteen players from six different clubs were included. The most common mechanism of injury was forced dorsiflexion/eversion. The average return to participation was 64 days (SD 17.2, range 38–108). This compares favourably to reports of between 120 and 180 days following screw fixation.

Conclusion

Ankle syndesmosis tightrope repair and an accelerated rehabilitation protocol is as safe as traditional methods. The accelerated rehabilitation protocol promotes early weight-bearing and has shown to expedite the return to sport for professional Rugby League players. It is possible to return to sport 2 months after a tightrope repair and accelerated rehabilitation, compared with 3–6 months post screw fixation. This is extremely encouraging for the professional sporting population.

Current trends in the diagnosis and management of syndesmotic injury

Ideal management of the various presentations of syndesmotic injury remains controversial to this day. High quality evidentiary science on this topic is rare, and numerous existing studies continue to contradict one another. The primary reasons for these discrepancies are that previous studies have failed to (1) properly distinguish between isolated (non-fractured) and non-isolated injuries, (2) accurately define stable from unstable injuries, and (3) sufficiently differentiate between acute and chronic injuries. The purpose of this review is to summarize today's body of literature regarding diagnosis and management of syndesmotic injury and discuss current trends and important future directions to optimize care of this very heterogeneous population.

Biomechanical Analysis of the Individual Ligament Contributions to Syndesmotic Stability

BACKGROUND

Biomechanical data and contributions to ankle joint stability have been previously reported for the individual distal tibiofibular ligaments. These results have not yet been validated based on recent anatomic descriptions or using current biomechanical testing devices.

METHODS

Eight matched-pair, lower leg specimens were tested using a dynamic, biaxial testing machine. The proximal tibiofibular joint and the medial and lateral ankle ligaments were left intact. After fixation, specimens were preconditioned and then biomechanically tested following sequential cutting of the tibiofibular ligaments to assess the individual ligamentous contributions to syndesmotic stability. Matched paired specimens were randomly divided into 1 of 2 cutting sequences: (1) anterior-to-posterior: intact, anterior inferior tibiofibular ligament (AITFL), interosseous tibiofibular ligament (ITFL), deep posterior inferior tibiofibular ligament (PITFL), superficial PITFL, and complete interosseous membrane; (2) posterior-to-anterior: intact, superficial PITFL, deep PITFL, ITFL, AITFL, and complete interosseous membrane. While under a 750-N axial compressive load, the foot was rotated to 15 degrees of external rotation and 10 degrees of internal rotation for each sectioned state. Torque (Nm), rotational position (degrees), and 3-dimensional data were recorded continuously throughout testing.

RESULTS

Testing of the intact ankle syndesmosis under simulated physiologic conditions revealed 4.3 degrees of fibular rotation in the axial plane and 3.3 mm of fibular translation in the sagittal plane. Significant increases in fibular sagittal translation and axial rotation were observed after syndesmotic injury, particularly after sectioning of the AITFL and superficial PITFL. Sequential sectioning of the syndesmotic ligaments resulted in significant reductions in resistance to both internal and external rotation. Isolated injuries to the AITFL resulted in the most substantial reduction of resistance to external rotation (average of 24%). However, resistance to internal rotation was not significantly diminished until the majority of the syndesmotic structures had been sectioned.

CONCLUSION

The ligaments of the syndesmosis provide significant contributions to rotary stability of the distal tibiofibular joint within the physiologic range of motion.

CLINICAL RELEVANCE

This study defined normal motion of the syndesmosis and the biomechanical consequences of injury. The degree of instability was increased with each additional injured structure; however, isolated injuries to the AITFL alone may lead to significant external rotary instability.