Syndesmotic ankle sprains in athletes

Chronic syndesmotic instability - Current evidence on management

This review article discusses the current evidence on the management of chronic syndesmotic instability. Conservative treatment has a limited role, and surgical intervention is most commonly reported as the mainstay of treatment, however the literature consists of small case series and descriptions of operative techniques, and thus the evidence base for any treatment is weak. Surgical options include arthroscopic debridement alone, static fixation with cortical screws, dynamic fixation with suture-button devices, and ligamentous repair or augmentation.

The Clinical Outcomes of Syndesmotic Flexible Fixation for Syndesmotic Injury With Ankle Fracture

BACKGROUND

We evaluated whether the quality of syndesmotic reduction affects the short-term clinical outcomes of flexible fixation in patients with a rotational ankle fracture.

METHODS

This study included 59 patients (32 men and 27 women) who underwent syndesmotic flexible fixation. The degree of syndesmotic reduction was evaluated on computed tomography (CT) images acquired within 3 days after surgery. We measured the divergence between anterior and posterior incisura at 1 cm above the distal tibial articular joint, then evaluated the degree of fibular rotation relative to the tibia. At 1 year after surgery, an objective clinical evaluation was performed using the American Orthopaedic Foot & Ankle Society (AOFAS) score, the visual analog scale (VAS), and the Foot and Ankle Outcome Score (FAOS). Additionally, repeat arthroscopy was performed during routine implant removal at nearly 1 year postoperatively.

RESULTS

Among 59 patients who underwent syndesmotic flexible fixation, 56 patients had syndesmotic stability on repeat arthroscopy. At 1 year postoperation, AOFAS, VAS, and FAOS scores were, respectively, 90, 2.0, and 94 in the accurate reduction group (n = 24) and 90, 1.0, and 94.5 in the malreduction group (n = 35).

CONCLUSION

Reduction quality after syndesmotic injury with flexible fixation, as determined by early postoperative CT imaging, did not affect patient prognosis. In this cohort, syndesmotic reduction and flexible fixation may produce good clinical outcomes in patients with syndesmotic injury and ankle fracture.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Modified Stabilization Test to Diagnose Chronic Syndesmotic Injuries Based on Posture Control

BACKGROUND

To propose and validate a modified noninvasive method for the diagnosis of chronic syndesmotic injuries.

METHODS

This study included 16 patients with chronic ankle instability. Herein, we propose the Modified Stabilization Test, a new measurement for use in the diagnosis of chronic syndesmotic injury, as determined by wearing a 60-kPa pneumatic brace. The test combines the center of pressure and sensory organization test to measure postural control. For comparison, we also measured the tibiofibular clear space, tibiofibular overlap, and medial clear space using anteroposterior radiograph; a line marked horizontally above the tibial plaque using computed tomography (CT) to measure the syndesmotic gap and fibular rotation angle; and magnetic resonance imaging (MRI) scans to determine the presence of the λ sign. The distance of syndesmosis was confirmed in 16 individuals through arthroscopy, and the results of the examination were used to determine the diagnostic efficacy of each index.

RESULTS

Receiver operating characteristic curve analysis revealed that the optimal cut-off value, sensitivity, and specificity of the Modified Stabilization Test for the diagnosis of chronic syndesmotic injuries were 0.80, 100%, and 87.5%, respectively. The area under the curve (AUC) of the Modified Stabilization Test was 0.906 (95% CI 0.656, 0.993; P < .001), which was superior to imaging indices such as radiography, CT, and MRI (AUC = 0.516-0.891).

CONCLUSION

We developed the Modified Stabilization Test-a noninvasive diagnostic tool for the screening of chronic syndesmotic injuries. The test showed high sensitivity and specificity for the identification of chronic syndesmotic injuries and is helpful in the identification of chronic syndesmotic injuries.

LEVEL OF EVIDENCE

Level II, diagnostic-investigating a diagnostic test.

Treatment of Intra-Articular Lesions After Posterior Inferior Tibiofibular Ligament Injury: A Case Series of Elite Rugby Players

Background

Surgical intervention is not typically used to treat symptoms after mild tibiofibular ligament injuries without ankle dislocation or subluxation.

Purpose

To describe outcomes in patients arthroscopically treated for unique intra-articular lesions after sustaining syndesmosis injury of the ankle.

Study Design

Case series; Level of evidence, 4.

Methods

A total of 11 elite male rugby players with a mean age of 21.0 years (range, 17-28 years) were referred to our hospital for prolonged posterior ankle pain after a high ankle sprain during rugby football. The patients were examined using standing view radiography, computed tomography (CT) and magnetic resonance imaging (MRI) to determine the extent of ligament damage. Posterior ankle arthroscopy was performed to examine intra-articular lesions. The patients were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle/hindfoot rating scale and sports activity score of the Self-Administered Foot Evaluation Questionnaire (SAFE-Q).

Results

The average reduced tibiofibular overlap on the standing mortise view was 1.2 mm (range, 0.5-2.0 mm) compared with the opposite ankles. Mason type 1 fracture was detected on CT in 6 patients, and ossification of the interosseous membrane was detected in 2 patients. A bone bruise in the posterior malleolus was observed on MRI in all but 1 patient. Intra-articular fragments located in the posterior ankle were observed and removed arthroscopically. Symptoms improved rapidly after arthroscopic treatment in all patients. All patients returned to rugby games at a median of 11 weeks postoperatively. The median AOFAS scores improved from 77 preoperatively to 100 postoperatively (P < .01), and the median SAFE-Q sports activity subscale score improved from 49.4 to 100 (P < .01).

Conclusion

All unique intra-articular lesions that developed in rugby football players after syndesmosis injury were able to be treated arthroscopically. Patients returned to playing rugby football without syndesmosis reduction. Posterior ankle arthroscopy was effective in patients with residual symptoms after syndesmosis injury.

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.

Physical Examination of Ankle Sprain and Ankle Instability: Can We Really Divide It into Low and High Ankle Sprains?

Lateral ankle ligament sprains and syndesmotic injuries are two different entities. However, they may be combined under the same spectrum depending on the arch of violence during the injury. Currently, the clinical examination has a limited value in the differential diagnosis between an acute anterior talofibular ligament rupture and a syndesmotic high ankle sprain. However, its use is indispensable for raising a high index of suspicion for detecting these injuries. Based on the mechanism of injury, clinical examination plays an essential role in guiding further imaging and early diagnosis of low/high ankle instability.

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.

Ankle syndesmotic reconstruction in chronic ankle syndesmotic injury

Acute syndesmotic injury is a common problem treated with different surgical tools. If not managed appropriately, it can lead to chronic ankle syndesmotic insufficiency. Chronic syndesmotic insufficiency is challenging to diagnose, and the patient can suffer for a long time. There is no consensus in previous literature on the surgical treatment of chronic syndesmotic injury. We present a case of personnel who suffered from chronic syndesmotic injury treated by syndesmotic reconstruction 5 years after his ankle fracture dislocation and returned to his work. This case highlights the importance of a CT scan post-reduction of an acute syndesmotic injury to assess accurate reduction, especially in severe injuries with frank diastasis.

The Tibiofibular Line: A Reliable Method of Syndesmosis Assessment in Certain Fibula Morphologies

Background The tibiofibular line (TFL) technique was initially proposed to assess syndesmosis reduction. Clinical utility was limited by low observer reliability when applied to all fibulas. This study aimed to refine this technique by describing TFL's applicability to various fibula morphologies. Methods Three observers reviewed 52 ankle CT scans. Observer consistencies for TFL measurement, anterolateral fibula contact length, and fibula morphology were assessed using intraclass correlation (ICC) and Fleiss' Kappa. Results TFL measurement and fibula contact length intra-observer and inter-observer consistencies were excellent (minimum ICC, 0.87). Fibula shape categorization intra-observer consistency was substantial to almost perfect (Fleiss' Kappa, 0.73 to 0.97). Six to 10 mm of fibula contact length corresponded to excellent TFL distance consistency (ICC, 0.80 to 0.98). Conclusion The TFL technique appears best for patients with 6 mm to 10 mm of straight anterolateral fibula. Sixty-one percent (61%) of fibulas featured this morphology, indicating most patients may be amenable to this technique.

Acute Syndesmosis Injuries

Ankle syndesmosis injuries include isolated ligamentous rupture, as well as fractures with ligamentous injury. These injuries can significantly affect athletes in all sports, and lead to prolonged recovery and return to sport. Adequate evaluation and diagnosis of these injuries are imperative for treatment and return to play. Many can be treated nonoperatively, but operative treatment is indicated in fractures with syndesmosis disruption and ligamentous injuries with instability. Anatomic reduction and fixation of these injuries will allow functional rehab and return to sport.

Presurgical Perspective and Postsurgical Evaluation of Instability and Microinstability Secondary to Ankle Ligaments Injury

Injuries of the ankle ligaments complexes are very common, and ∼ 20 to 40% of patients can develop chronic ankle instability (CAI). Current concepts in CAI allow a better understanding of the ankle biomechanics needed to repair it. The surgical treatment of CAI has evolved in the last decade, and ankle arthroscopy has become an essential tool in the treatment of instability with promising results. We review the different surgical techniques to treat CAI, both those frequently used and the new approaches, as well as the normal postsurgical appearance of ankle ligaments repair and the most common complications.

Isolated injuries to the lateral ankle ligaments have no direct effect on syndesmotic stability

PURPOSE

This study aim was to detect the impact of lateral ankle ligaments injury on syndesmotic laxity when evaluated arthroscopically in a cadaveric model. The null hypothesis was that lateral ankle ligament injury does not affect the stability of syndesmosis.

METHODS

Sixteen fresh-frozen above-knee amputated cadaveric specimens were divided into two groups of eight specimens that underwent arthroscopic evaluation of the distal tibiofibular joint. In both the groups, the assessment was first done with all syndesmotic and ankle ligaments intact. Thereafter, Group 1 underwent sequential transection of the three lateral ankle ligaments first to identify the effects of lateral ligament injury: (1) anterior talofibular ligament (ATFL), (2) calcaneofibular ligament (CFL), (3) posterior talofibular ligament (PTFL), then followed by the syndesmotic ligaments, (4) AITFL, (5) Interosseous ligament (IOL), and (6) PITFL. Group 2 underwent sequential transection of the (1) AITFL, (2) ATFL, (3) CFL, (4) IOL, (5) PTFL, and (6) PITFL, which represent the most commonly injured pattern in ankle sprain. In all scenarios, four loading conditions were considered under 100 N of direct force: (1) unstressed, (2) a lateral fibular hook test, (3) anterior to posterior (AP) fibular translation test, and (4) posterior to anterior (PA) fibular translation test. Distal tibiofibular coronal plane diastasis at the anterior and posterior third of syndesmosis, as well as AP and PA sagittal plane translation, were arthroscopically measured.

RESULTS

The distal tibiofibular joint remained stable after transection of all lateral ankle ligaments (ATFL, CFL, and PTFL) as well as the AITFL. However, after additional transection of the IOL, the syndesmosis became unstable in both the coronal and sagittal plane. Syndesmosis laxity in the coronal plane was also observed after transection of the ATFL, CFL, AITFL, and IOL. Subsequent transection of the PITFL precipitated syndesmosis laxity in the sagittal plane, as well.

CONCLUSIONS

The findings from the present study suggest that lateral ankle ligament injuries itself do not directly affect the stability of syndesmosis. However, if it combines with IOL injuries, even partial injuries cause syndesmotic laxity. As a clinical relevance, accurate diagnosis is the key for surgeons to determine syndesmosis fixation whether there is only AITFL injury or combined IOL injury in concomitant acute syndesmotic and lateral ligament injury.

Detection of fibular rotational changes in cone beam CT: experimental study in a specimen model

Background

In syndesmotic injuries, incorrect reduction leads to early arthrosis of the ankle joint. Being able to analyze the reduction result is therefore crucial for obtaining an anatomical reduction. Several studies that assess fibular rotation in the incisura have already been published. The aim of the study was to validate measurement methods that use cone beam computed tomography imaging to detect rotational malpositions of the fibula in a standardized specimen model.

Methods

An artificial Maisonneuve injury was created on 16 pairs of fresh-frozen lower legs. Using a stable instrument, rotational malpositions of 5, 10, and 15° internal and external rotation were generated. For each malposition of the fibula, a cone beam computed tomography scan was performed. Subsequently, the malpositions were measured and statistically evaluated with t-tests using two measuring methods: angle (γ) at 10 mm proximal to the tibial joint line and the angle (δ) at 6 mm distal to the talar joint line.

Results

Rotational malpositions of ≥ 10° could be reliably displayed in the 3D images using the measuring method with angle δ. For angle γ significant results could only be displayed for an external rotation malposition of 15°.

Conclusions

Clinically relevant rotational malpositions of the fibula in comparison with an uninjured contralateral side can be reliably detected using intraoperative 3D imaging with a C-arm cone beam computed tomography. This may allow surgeons to achieve better reduction of fibular malpositions in the incisura tibiofibularis.

Maisonneuve Fractures of the Ankle: A Critical Analysis Review

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Maisonneuve fractures (MFs), originally described as subcapital (high) fibular fractures with additional injury to the anterior and interosseous tibiofibular ligaments, display a variable injury pattern, ranging from stable to highly unstable fractures.

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The high incidence of associated fractures of the posterior malleolus, the medial malleolus, and the anterolateral distal tibia (the "anterior malleolus") as well as the variable position of the fibula in the fibular notch (FN) warrant preoperative examination via computed tomography (CT).

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The main goal of treatment is anatomic reduction of the distal fibula into the FN, which requires prior reduction of displaced posterior malleolar fractures, if present, to restore the integrity of the FN.

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Open reduction of the distal fibula into the FN and fixation with 2 transsyndesmotic screws or fixation with a screw(s) and suture-button implant, under direct vision, on the lateral aspect of the ankle joint and anterior tibiofibular alignment are preferred over closed reduction to avoid sagittal or rotational malpositioning, which is associated with an inferior outcome.

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Intra- or postoperative 3D CT visualization is essential for assessment of the accuracy of the reduction of the distal fibula into the FN.

Weightbearing Radiography and MRI Findings in Ankle Fractures

Background. Static weightbearing radiography can be used to assess stability in ankle fractures by measuring lateral talar shift (medial clear space; MCS). However, the correlation of a stable ankle joint under weightbearing load and the structural integrity of the deltoid ligament has not been shown. In this study, we assessed deltoid ligament integrity on magnetic resonance imaging (MRI) and correlated that with weightbearing and gravity stress test radiography. Methods. Thirty-four patients with supination external rotation II-IV (SER) fractures underwent MRI, weightbearing radiography, and gravity stress test. On MRI, the deep anterior and posterior tibiotalar deltoid, tibionavicular and tibiocalcaneal ligaments, as well as the syndesmosis were assessed as intact, partial rupture, or complete rupture. The MCS was measured as the distance between the lateral border of the medial malleolus and the medial border of the talus at the level of the talar dome on the mortise view. Results. Twenty-three patients suffered a deep anterior tibiotalar ligament rupture (16 partial; 7 complete) and 2 a deep posterior tibiotalar ligament tear (1 partial; 1 complete). For MCS on weightbearing radiography, no statistically significant differences were identified between any of the individual groups. With gravity stress radiography, only a complete tear of the tibiocalcaneal ligament showed a significantly higher MCS than a partial tear or intact tibiocalcaneal ligament (P < .005). No other ligament disruption showed a significant difference between the complete rupture versus intact or partial tear. Conclusion. Weightbearing radiography does not show much variation in terms of MCS even with ligamentous disruption and fibula fracture. The talus often centers itself underneath the tibia with weightbearing radiography.Levels of Evidence: Level III: Retrospective cohort study.

The Syndesmosis, Part I: Anatomy, Injury Mechanism, Classification, and Diagnosis

Ankle fractures are common injuries to the lower extremity with approximately 20% sustaining a concomitant injury to the syndesmosis. Although the deltoid ligament is not formally included in the syndesmotic complex, it plays an important role in the mortise stability. Therefore, its integrity should be always evaluated when syndesmotic injury is suspected. Given the anatomic variability of the syndesmosis between individuals, bilateral ankle imaging is recommended, especially in cases of subtle instability. Diagnostic tests that allow dynamic assessment of the distal tibiofibular joint in the 3 planes are the most reliable in determining the presence of syndesmotic injury.

Short-Term Effect of Manual Therapy &amp; Taping on Subacute Ankle Sprains with Potential Syndesmotic Sprain: A Case Series

STUDY DESIGN

Case Series.

BACKGROUND

Syndesmotic ankle sprains can occur in up to 17% of ankle trauma and can lead to long-term disability. This study describes the management of seven patients with subacute, high-grade ankle sprains with concerns of concurrent syndesmotic strain utilizing manual therapy and rigid sports taping.

METHODS

Seven active duty military members with clinically diagnosed, high-grade ankle sprains and concern for syndesmotic sprain participated in this case series. All patients received multi-modal treatment consisting of manual therapy, rigid sports taping, progressive exercises, and proprioceptive training. Decrease in Numeric Pain Rating Scale (NPRS) following manual therapy and taping treatment, number of sessions before discharge, and the Global Rating of Change (GROC) at discharge were retrospectively reviewed.

RESULTS

All patients demonstrated an immediate decrease in NPRS following treatment on average of 5 points (range, 3-8 points) with a functional asterisk sign. The improvement in pain and function was maintained until the next treatment session with a mean GROC score of +3. The mean time until recovery was 5.4 weeks (range, 1-8 weeks).

DISCUSSION

A multimodal approach for patients diagnosed clinically with high-grade ankle sprains and concern for syndesmotic sprain was useful to immediately reduce pain and improve function, and improvements were maintained throughout the duration of care. This study is the first to assess a combination of manual therapy and rigid sports taping for the treatment of suspected syndesmotic ankle sprains, and more stringent research is needed to validate the findings.

LEVEL OF EVIDENCE

Therapy, 4.

Suture Anchor Augmentation for Acute Unstable Isolated Ankle Syndesmosis Disruption in Athletes

BACKGROUND

Isolated ankle syndesmosis disruption (without fibula fracture) causes acute pain and may cause chronic instability and pain. The aim of the present study was to evaluate the outcomes after anterior inferior tibiofibular ligament (AITFL) anatomical fixation using anchor sutures for unstable isolated syndesmosis disruption without fibular fractures.

METHODS

This study assessed 22 athletes who were diagnosed with unstable isolated syndesmosis disruption with a positive external rotation test, had more than 2-mm diastasis on ultrasound, and had complete AITFL rupture on magnetic resonance imaging between 2004 and 2020. Eighteen patients (82%) were elite-level athletes, and the remaining 4 were recreational athletes. Twelve patients (55%) were injured by an external rotation force. The athletes underwent open anatomical suture anchor fixation between the AITFL attachment sites, the fibula and tibia. The mechanism of injury, return-to-play time, and Foot and Ankle Outcome Score (FAOS) were evaluated.

RESULTS

All athletes returned to previous play except 1 retired elite athlete. Twenty-two athletes returned to jogging, team training, and official game play at an average of 62, 89, and 102 days, respectively. The final average follow-up FAOS symptom, pain, daily activity, sports activity, and quality of life scores were 98, 97, 100, 99, and 97, respectively. Two athletes were reinjured, and 1 required reoperation in the follow-up period.

CONCLUSION

Athletes with isolated syndesmosis disruption had a high likelihood to return to their previous activity level after suture anchor augmentation.

LEVEL OF EVIDENCE

Level IV, case series.

Functional outcomes of unstable ankle fractures with and without syndesmotic fixation in the adolescent population

PURPOSE

The purpose of this study was to compare functional outcomes of adolescents with and without ankle syndesmotic injuries and identify predictors of functional outcome after operative ankle fractures.

METHODS

A retrospective review was conducted on operative adolescent ankle fractures treated between 2009 and 2019 with a minimum of one-year follow-up (mean 4.35 years). Patients who underwent syndesmotic fixation (SF) (n = 48) were compared with operative ankle fractures without syndesmotic injury (n = 63). Functional outcomes were assessed using standardized questionnaires, specifically the Foot and Ankle Ability Measure (FAAM) and Single Assessment Numerical Evaluation.

RESULTS

There were no differences in patient-reported outcomes, rates of return to sport or complications between groups with and without SF. The SF group had a longer tourniquet time (p = 0.04), duration of non-weight-bearing (p = 0.01), more Weber C fibula fractures (p < 0.001), fewer medial malleolus fractures (p = 0.03) and more frequently underwent implant removal (p < 0.0001). Male sex, lower body mass index (BMI) and longer duration of follow-up were significant predictors of a higher FAAM sports score using multivariable linear regression. SF was not a predictor of functional outcome.

CONCLUSION

This study demonstrated that patients that undergo surgical fixation of syndesmotic injuries have equivalent functional outcomes compared to operative ankle fractures without intraoperative evidence of syndesmotic injury. We also identified that male sex, lower BMI and longer duration of follow-up are predictors of a good functional outcome.

LEVEL OF EVIDENCE

III.

APKASS Consensus Statement on Chronic Syndesmosis Injury, Part 3: Fusion Techniques, Comorbidity Treatments, Postoperative Rehabilitation, and Return-to-Sport Indications

Background:

Questions regarding surgical fusion techniques, postoperative treatment, and indications for return to sport after chronic syndesmosis injury or its comorbidities remain unanswered.

Purpose:

An international group of experts representing the field of injuries in the foot and ankle area was invited to collaboratively advance toward consensus opinions based on the best available evidence regarding chronic syndesmosis injury. All were members of the Asia-Pacific Knee, Arthroscopy and Sports Medicine Society (APKASS).

Study Design:

Consensus statement.

Methods:

From November to December 2020, a total of 111 international experts on sports medicine or ankle surgery participated in a 2-stage Delphi process that included an anonymous online survey and an online meeting. A total of 13 items with 38 statements were drafted by 13 core authors. Of these, 4 items with 6 clinical questions and statements were related to surgical fusion techniques, comorbidity treatments, postoperative rehabilitation, and return-to-sports indications and are presented here. Each statement was individually presented and discussed, followed by a general vote. The strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; and unanimous, 100%.

Results:

Of the 6 questions and statements, 5 achieved unanimous support and 1 reached strong consensus.

Conclusion:

This APKASS consensus statement, developed by international experts in the field, will assist surgeons and physical therapists with surgical and postoperative treatment strategies for chronic syndesmosis injury.

Acute syndesmotic injuries in ankle fractures: From diagnosis to treatment and current concepts

A stable and precise articulation of the distal tibiofibular syndesmosis maintains the tibiofibular relationship, and it is essential for normal motion of the ankle joint. The disruption of this joint is frequently accompanied by rotational ankle fracture, such as pronation-external rotation, and rarely occurs without ankle fracture. The diagnosis is not simple, and ideal management of the various presentations of syndesmotic injury remains controversial to this day. Anatomical restoration and stabilization of the disrupted tibiofibular syndesmosis is essential to improve functional outcomes. In such an injury, including inadequately treated, misdiagnosed and correctly diagnosed cases, a chronic pattern characterized by persistent ankle pain, function disability and early osteoarthritis can result. This paper reviews anatomical and biomechanical characteristics of this syndesmosis, the mechanism of its acute injury associated to fractures, radiological and arthroscopic diagnosis and surgical treatment.

Persistent Pain After Operative Treatment for Chronic Lateral Ankle Instability

A high frequency of associated injuries is seen in patients with chronic lateral ankle instability. Comorbidities include intraarticular pathologies (osteochondral lesion, soft tissue or bony impingement syndrome, loose body, synovitis, etc.), peroneal tendon pathologies, neural injuries, and other extraarticular pathologies. Surgeons should have a high index of suspicion for these associated pathologies before operative intervention, correlate with clinical findings, and plan the treatment. Despite the restoration of ankle stability following ligament repair or reconstruction surgery, postoperative residual pain, which can negatively affect clinical outcomes and patient satisfaction, is highly prevalent (13–35%). The aim of this review was to discuss the causes of persistent pain after operative treatment for chronic lateral ankle instability.

Chronic Syndesmotic Injuries: Arthrodesis versus Reconstruction

"Chronic syndesmotic injury covers a broad range of symptoms and pathologies. Anterolateral ankle impingement without instability is treated by arthroscopic debridement. Subacute, unstable, syndesmotic injuries are treated by arthroscopic or open debridement followed by secondary stabilization using suture button device or permanent screw placement. Chronic syndesmotic instability is treated by a near-anatomic ligamentoplasty supplemented by screw fixation. In case of poor bone stock, failed ligament reconstruction, or comorbidities, tibiofibular fusion with bone grafting is preferred. Malleolar malunions and particularly anterior or posterior syndesmotic avulsions must be corrected in order to achieve a stable and congruent ankle mortise."

Effect of Novel Remodeled Bicycle Pedal Training on Balance Performance in Athletes With Functional Ankle Instability

Context

Appropriate training without risk of injury is a critical concern for athletes. Remodeled bicycle pedal training with multi-directional challenges may be effective in improving the balance performance of athletes with functional ankle instability (FAI).

Objective

To evaluate the effects of 6-week modified bicycle pedal training on the balance ability and proprioception of athletes with FAI.

Design

Randomized controlled trial.

Setting

University motion analysis laboratory.

Participants

Fourteen healthy athletes (healthy group) and twenty-six athletes with FAI and an age of 18 to 30 years old. The participants with FAI were randomly distributed to two groups, designated as the training group (AI-T group) and non-training group (AI-NT group), respectively. The athletes in the AI-T group received 6-week remodeled bicycle pedal training, while those in the AI-NT group received no intervention at all.

Intervention

A 6-week training using modified bicycle pedal capable of moving freely during loading cycle vs no intervention.

Main Outcome Measures

The passive ankle joint position sense (JPS) in four angles and the center of pressure (COP) parameters were analyzed during single-leg standing with and without vision, respectively.

Results

A 6-week remodeled pedal training: (1) significantly improved the passive JPS of ankle in all directions (P < 0.05); (2) reduced the excursion of the COP in the medial-lateral (ML) direction (p < 0.05), the velocity of the COP in the ML direction (p < 0.05), and the RMS of the COP in the ML direction (P < 0.05) during single-leg standing both with and without vision.

Conclusion

The remodeled bicycle pedal training improved the passive JPS and reduced the postural sway in single-leg standing both with and without vision. Therefore, remodeled bicycle pedal training can be considered for inclusion in rehabilitation programs for athletes with FAI to restore the proprioception and balance ability.

Diagnosing syndesmotic instability with dynamic ultrasound - establishing the natural variations in normal motion

BACKGROUND

Syndesmotic instability, when subtle, is challenging to diagnose and often requires visualization of the syndesmosis during applied stress. The primary aim was to assess normal distal tibiofibular motion in the sagittal plane using dynamic ultrasound under stress conditions. The secondary aim was to evaluate the reliability of dynamic stress ultrasonography.

METHODS

Twenty-eight participants without history of ankle injury were included. Sagittal fibular translation was generated by applying a manual force to the fibula from anterior to posterior and from posterior to anterior. Distance between the ultrasound probe and the fibula was taken at two predefined points: 1) no force applied and, 2) during maximum force application. Each participant was scanned twice by two independent examiners, and each scan was analysed by two independent examiners. Three participants were scanned a second time by the same examiner who analysed these films twice to assess for intraobserver agreement. Means of exam 1 versus exam 2 were compared using a mixed linear model. Agreement among observers was calculated using intraclass correlation coefficients (ICC) interpreted as 0.4, poor; 0.4 〈 ICC < 0.59, acceptable; 0.6 < ICC < 0.74, good; ICC 〉 0.74, excellent.

RESULTS

Fifty-six ankles were included in the study, including 16 (57%) males and 12 (42%) females. Average anterior to posterior fibular sagittal translation was 0.89 ± 0.6 mm and posterior to anterior fibular sagittal translation was 0.49 ± 1.1 mm. Anterior to posterior translation means of exam 1 versus exam 2 showed no significant differences, means of 0.81 mm [0.7-0.9] versus 0.77 mm [0.7-1.0], and posterior to anterior means [95% CI] of 0.42 mm [0.3-0.5] versus 0.44 mm [0.2-0.6] (p-values 0.416 and 0.758, respectively). Excellent Inter- and intraobserver agreement was found for all measurements taken.

CONCLUSION

Dynamic ultrasound allows one to effectively and readily evaluate sagittal translation of the distal tibiofibular joint. It is able to afford bilateral comparisons, which becomes critical as the amount of syndesmotic instability approaches greater degrees of subtlety.

Hybrid Fixation Restores Tibiofibular Kinematics for Early Weightbearing After Syndesmotic Injury

Background:

Disruption of the anterior inferior tibiofibular ligament (AITFL), posterior inferior tibiofibular ligament (PITFL), and interosseous membrane (IOM) is a predictive measure of residual symptoms after an ankle injury. Controversy remains regarding the ideal fixation technique for early return to sport, which requires restoration of tibiofibular kinematics with early weightbearing.

Purpose:

To quantify tibiofibular kinematics after syndesmotic fixation with different tricortical screw and suture button constructs during simulated weightbearing.

Study Design:

Controlled laboratory study.

Methods:

A 6 degrees of freedom robotic testing system was used to test 9 fresh-frozen human cadaveric specimens (mean age, 65.1 ± 17.3 years). A 200-N compressive load was applied to the ankle, while a 5-N·m external rotation and a 5-N·m inversion moment were applied independently to the ankle at 0° of flexion, 15° and 30° of plantarflexion, and 10° of dorsiflexion. Fibular medial-lateral translation, anterior-posterior translation, and internal-external rotation relative to the tibia were tracked by use of an optical tracking system in the following states: (1) intact ankle; (2) AITFL, PITFL, and IOM transected ankle; (3) single-screw fixation; (4) double-screw fixation; (5) hybrid fixation; (6) single suture button fixation; and (7) divergent suture button fixation. Repeated-measures analysis of variance with Bonferroni correction was performed for statistical analysis.

Results:

In response to the external rotation moment and axial compression, single tricortical screw fixation resulted in significantly higher lateral translation of the fibula compared with that of the intact ankle at 10° of dorsiflexion (P < .05). Suture button fixation resulted in significantly higher posterior translation of the fibula at 0° of flexion and 10° of dorsiflexion, whereas divergent suture button fixation resulted in higher posterior translation at only 0° of flexion (P < .05). In response to the inversion moment and axial compression, single tricortical screw and hybrid fixation significantly decreased lateral translation in plantarflexion, whereas double tricortical screw fixation and hybrid fixation significantly decreased external rotation of the fibula compared with that of the intact ankle at 15° of plantarflexion (P < .05).

Conclusion:

Based on the data in this study, hybrid fixation with 1 suture button and 1 tricortical screw may most appropriately restore tibiofibular kinematics for early weightbearing. However, overconstraint of motion during inversion may occur, which has unknown clinical significance.

Clinical Relevance:

Surgeons may consider this data when deciding on the best algorithm for syndesmosis repair and postoperative rehabilitation.

Physical Examination of the Ankle: A Review of the Original Orthopedic Special Test Description and Scientific Validity of Common Tests for Ankle Examination

OBJECTIVES

To review the literature, identify and describe commonly used special tests for diagnosing injury to the ligaments of the ankle complex, present the distinguishing characteristics and limitations of each test, and discuss the current evidence for the clinical use of each test.

DATA SOURCES

Multiple PubMed (1920-2018) and CINAHL (1920-2018) searches were conducted and various musculoskeletal examination textbooks were reviewed to examine common orthopedic tests used to assess the ankle. The articles were reviewed for additional references and the search continued until the original description was found when possible.

STUDY SELECTION

All articles discussing the performance of the test or its validity (ie, sensitivity and specificity) were reviewed and summarized.

DATA EXTRACTION

Articles were reviewed for additional references and the search continued until the original description was found when possible.

DATA SYNTHESIS

The literature was reviewed, commonly used special tests for diagnosing ankle injuries were identified and described, distinguishing characteristics and limitations of each test were presented, and the current evidence for the clinical use of each test was discussed.

CONCLUSIONS

A complete physical examination is critical in the diagnosis of ankle injuries. The combination of available information such as mechanism of injury, all signs and symptoms, and changes in gait, is key to a conclusive and correct diagnosis. Clinicians should be aware of the severely limited evidence supporting the use of many commonly used special tests. Applying evidence from the literature will improve diagnostic accuracy. Further research is needed to understand the performance ability of special tests, both individually and when grouped as part of a test battery.

Patterns and Implications of Early Syndesmotic Screw Failure in Rotational Ankle Fractures

BACKGROUND

The purpose of this study was to identify characteristic patterns of syndesmotic screw (SS) failure, and any effects on clinical outcome.

METHODS

A retrospective study was performed using a consecutive series of patients treated with open reduction and internal fixation with trans-syndesmotic screws for unstable ankle fractures with syndesmotic injury between 2015 and 2017. Patient demographics, fracture characteristics and classification, rates and patterns of trans-syndesmotic screw breakage, and backout were analyzed. Functional outcome was assessed using passive range of motion (ROM) and Maryland Foot Score (MFS).

RESULTS

A total of 113 patients (67%) had intact screws and 56 patients (33%) demonstrated either screw breakage or backout. Patients with SS failure were younger (P = .002) and predominantly male (P = .045). Fracture classification and energy level of injury were not associated with screw failure. Nine screws (11%) demonstrated backout (2 also broke) and 56 other screws broke. There was no association between the number of screws or cortices of purchase and screw failure. There was a trend toward a higher proportion of screw removal (20%) in this failed SS group compared with the intact SS group (12%) (P = .25), but with similar ankle ROM and MFS (P > .07).

CONCLUSION

Syndesmotic screw breakage was common in younger, male patients. Despite similarities in ankle range of motion and clinical outcome scores to patients with intact screws, there was a trend towards more frequent screw removal. This information can be used to counsel patients pre- and postoperatively regarding the potential for screw failure and subsequent implant removal.

LEVEL OF EVIDENCE

Level III, retrospective case-control study.

Acute and Chronic Syndesmotic Instability: Role of Surgical Stabilization

Acute and chronic syndesmotic injuries significantly impact athletic function and activities of daily living. Patient history, examination, and judicious use of imaging modalities aid diagnosis. Surgical management should be used when frank diastasis, instability, and/or chronic pain and disability ensue. Screw and suture-button fixation remain the mainstay of treatment of acute injuries, but novel syndesmotic reconstruction techniques hold promise for treatment of acute and chronic injuries, especially for athletes. This article focuses on anatomy, mechanisms of injury, diagnosis, and surgical reduction and stabilization of acute and chronic syndesmotic instability. Fixation methods with a focus on considerations for athletes are discussed.

Ankle Injuries in the Pediatric Emergency Department

Ankle injuries are a common reason for presentation to the pediatric emergency department. An understanding of the anatomy of the ankle joint, the mechanism of injury, and a thorough history and physical examination can help narrow the differential diagnosis. This article will discuss the management of common ankle injuries, including ankle sprains, dislocations, and pediatric fractures, including transitional triplane and Tillaux fractures. A brief review of the literature regarding radiographic evaluation of the ankle and various ankle rules is also discussed.

Acute Fractures and Dislocations of the Ankle and Foot in Children

Distinct biologic and mechanical attributes of the pediatric skeleton translate into fracture patterns, complications, and treatment dilemmas that differ from those of adults. In children, increasing participation in competitive sports activities has led to an increased incidence of acute injuries that affect the foot and ankle. These injuries represent approximately 13% of all pediatric osseous injuries. Important posttraumatic complications include premature physeal arrest, three-dimensional deformities and consequent articular incongruity, compartment syndrome, and infection. The authors describe normal developmental phenomena and injury mechanisms of the ankle and foot and associated imaging findings; mimics and complications of acute fractures; and dislocations that affect the pediatric ankle and foot. Treatment strategies, whether conservative or surgical, are aimed at restoring articular congruency and functional alignment and, for pediatric patients specifically, protecting the physis. The different types of ankle and foot fractures are described, and the American College of Radiology guidelines used to determine appropriate imaging recommendations for patients who meet the Ottawa ankle and foot rules are discussed. The systems used to classify clinically important fractures, including the Salter-Harris, Dias-Tachdjian, Rapariz, and Hawkins systems, are described, with illustrations that reinforce key concepts. These classification systems aid in diagnosis and treatment planning, facilitate communication, and help standardize documentation and research. This information is intended to supplement radiologists' understanding of developmental phenomena, anatomic variants, fracture patterns, and associated complications that affect the pediatric foot and ankle. In addition, the role of imaging in ensuring appropriate treatment, follow-up, and patient and parent counseling is highlighted. The online slide presentation from the RSNA Annual Meeting is available for this article. ^©RSNA, 2020.

Sagittal instability with inversion is important to evaluate after syndesmosis injury and repair: a cadaveric robotic study

PURPOSE

Disruption of the syndesmosis, the anterior-inferior tibiofibular ligament (AITFL), the posterior-inferior tibiofibular ligament (PITFL), and the interosseous membrane (IOM), leads to residual symptoms after an ankle injury. The objective of this study was to quantify tibiofibular joint motion with isolated AITFL- and complete syndesmotic injury and with syndesmotic screw vs. suture button repair compared to the intact ankle.

METHODS

Nine fresh-frozen human cadaveric specimens (mean age 60 yrs.; range 38-73 yrs.) were tested using a six degree-of-freedom robotic testing system and three-dimensional tibiofibular motion was quantified using an optical tracking system. A 5 Nm inversion moment was applied to the ankle at 0°, 15°, and 30° plantarflexion, and 10° dorsiflexion. Outcome measures included fibular medial-lateral translation, anterior-posterior translation, and external rotation in each ankle state: 1) intact ankle, 2) AITFL transected (isolated AITFL injury), 3) AITFL, PITFL, and IOM transected (complete injury), 4) tricortical screw fixation, and 5) suture button repair.

RESULTS

Both isolated AITFL and complete injury caused significant increases in fibular posterior translation at 15° and 30° plantarflexion compared to the intact ankle (p < 0.05). Tricortical screw fixation restored the intact ankle tibiofibular kinematics in all planes. Suture button repair resulted in 3.7 mm, 3.8 mm, and 2.9 mm more posterior translation of the fibula compared to the intact ankle at 30° and 15° plantarflexion and 0° flexion, respectively (p < 0.05).

CONCLUSION

Ankle instability is similar after both isolated AITFL and complete syndesmosis injury and persists after suture button fixation in the sagittal plane in response an inversion stress. Sagittal instability with ankle inversion should be considered when treating patients with isolated AITFL syndesmosis injuries and after suture button fixation.

LEVEL OF EVIDENCE

Controlled laboratory study, Level V.

Diagnosis and treatment of tibiofibular syndesmosis lesions

The tibiofibular syndesmosis is a fibrous joint essential for ankle stability, whence the classical comparison with a mortise. Syndesmosis lesions are quite frequent in ankle trauma. This is a key element in ankle stability and lesions may cause pain or instability and, in the longer term, osteoarthritis. The lesions are often overlooked due to diagnostic difficulties, but collision sport with strong contact is the main culprit. Diagnosis, whether in the acute or the chronic phase, is founded on an association of clinical and paraclinical signs. Cross-sectional imaging such as MRI is fundamental to confirming clinical suspicion. Absence of tibiofibular diastasis no longer rules out the diagnosis. Stress CT and the introduction of weight-bearing CT are promising future diagnostic tools. Exhaustive osteo-ligamentous ankle assessment is necessary, as syndesmosis lesions may be just one component in more complex rotational instability. Therapeutically, arthroscopy and new fixation techniques, such as suture buttons, are opening up new perspectives, especially for chronic lesions (>6months). The present anatomic, epidemiological, diagnostic and therapeutic review does not preclude further clinical studies of rotational ankle instability with its strong risk of osteoarthritis.

Comparison of three different reduction methods of the ankle mortise in unstable syndesmotic injuries

In order to achieve a clinically satisfying result and to prevent posttraumatic osteoarthritis in the treatment of unstable syndesmotic injuries, anatomically correct reduction is crucial. The objective of the study was to investigate three different reduction methods of the ankle mortise in unstable syndesmotic injuries. In a specimen model with 38 uninjured fresh-frozen lower legs, a complete syndesmotic dissection was performed. The ankle mortise was reduced with either a collinear reduction clamp, a conventional reduction forceps or manually with crossing K-wires. The reduction clamps and the K-wires were placed in a 0°-angle to the leg axis. The clamps were positioned on the posterolateral ridge of the fibula 20 mm proximal to the ankle joint line. A cone beam computed tomography was performed after dissection and after each reduction. Tibio-fibular distances and angles were determined. Despite significant differences in terms of overcompression (0.09–0.33 mm; p = 0.000–0.063) and the slight external rotation (0.29–0.47°; p = 0.014–0.07), the results show a satisfying reduction of the ankle mortise. There were no considerable differences between the reduction methods. It can therefore be concluded that the ankle mortise can be reduced with any of the methods used, but that the positioning and the contact pressure must be considered.

Effect of a Controlled Ankle Motion Walking Boot on Syndesmotic Instability During Weightbearing: A Cadaveric Study

Background:

Syndesmotic injuries can lead to long-term complications; hence, they require careful management. Conservative treatment is adequate when 1 syndesmotic ligament is injured, but surgery is often necessary to achieve articular congruity when 3 syndesmotic ligaments are ruptured. However, there is some controversy over the best treatment for 2-ligament injuries.

Purpose:

To evaluate the effect of a controlled ankle motion (CAM) walking boot on syndesmotic instability following iatrogenic isolated anterior inferior tibiofibular ligament (AiTFL) injury and combined AiTFL/interosseous ligament (IOL) injuries in a cadaveric simulated weightbearing model.

Study Design:

Controlled laboratory study.

Methods:

Ten cadaveric specimens were dissected to expose the tibial plateau and syndesmosis. The specimens were fitted to a custom-made device, and a reproducible axial load of 750 N was applied. Iatrogenic rupture of the syndesmotic ligaments (AiTFL + IOL) was done sequentially. Uninjured syndesmoses, isolated AiTFL rupture, and combined AiTFL/IOL rupture were compared with and without axial loading (AL) and CAM boot. The distal tibiofibular relationship was evaluated using a previously validated computed tomography scan measurement system. Wilcoxon tests for paired samples and nonparametric data were used.

Results:

The only difference noted in the distal tibiofibular relationship during AL was an increase in the external rotation of the fibula when using the CAM boot. This was observed with AiTFL rupture (8.40° vs 11.17°; P = .009) and combined AiTFL/IOL rupture (8.81° vs 11.97°; P = .005).

Conclusion:

AL did not cause a significant displacement between the tibia and fibula, even when 2 ligaments were ruptured. However, the CAM boot produced a significant external rotation with 1 or 2 injured ligaments.

Clinical Relevance:

Further studies are needed to assess the capacity of the CAM walking boot to prevent malreduction when external rotation forces are applied to the ankle. Moreover, special care should be taken during the fitting of the CAM boot to avoid overinflation of the cushions.

Epidemiology of Foot and Ankle Injuries in National Collegiate Athletic Association Men's and Women's Ice Hockey

Background:

Ice hockey is a high-speed contact sport in which athletes are prone to many different injuries. While past studies have examined overall injury rates in ice hockey, foot and ankle injuries among collegiate ice hockey players have yet to be analyzed.

Purpose/Hypothesis:

The purpose of this study was to elucidate the epidemiology of foot and ankle injuries among collegiate ice hockey players utilizing data from the National Collegiate Athletic Association (NCAA) Injury Surveillance Program. We hypothesized that male ice hockey players would sustain more injuries compared with female ice hockey players and that the injuries sustained would be more severe.

Study Design:

Descriptive epidemiology study.

Methods:

Data on all foot and ankle injuries sustained during the academic years 2004 through 2014 were obtained from the NCAA Injury Surveillance Program. Injury rates, rate ratios (RRs), and injury proportion ratios were reported with 95% CIs.

Results:

Over the study period, the overall rate of foot and ankle injuries for men was higher than that for women (413 vs 103 injuries, respectively; RR, 4.01 [95% CI, 3.23-4.97]). Injury rates were highest during the regular season for both men (358 injuries; RR, 64.78 [95% CI, 58.07-71.49]) and women (89 injuries; RR, 38.37 [95% CI, 30.40-46.35]) compared with the preseason or postseason. The most common injury in men was a foot and/or toe contusion (22.5%), while women most commonly sustained a low ankle sprain (31.1%). For men, foot and/or toe contusions accounted for the most non–time loss (≤24 hours ) and moderate time-loss (2-13 days) injuries, while high ankle sprains accounted for the most severe time-loss (≥14 days) injuries. For women, foot and/or toe contusions accounted for the most non–time loss injuries, low ankle sprains accounted for the most moderate time-loss injuries, and high ankle sprains accounted for the most severe time-loss injuries.

Conclusion:

Foot and ankle injuries were frequent among collegiate ice hockey players during the period studied. For men, contusions were the most commonly diagnosed injury, although high ankle sprains resulted in the most significant time lost. For women, low ankle sprains were the most common and resulted in the most moderate time lost. These findings may direct future injury prevention and guide improvements in ice skate design.

Epidemiology of syndesmotic fixations in a pediatric center: A 12-year retrospective review

Syndesmosis injuries need to be accurately diagnosed and managed to avoid chronic pain, early arthritis, and instability. To this end, the present study aimed to analyze the epidemiology of syndesmotic injuries in a pediatric ankle fracture cohort and identify patient and surgery-related characteristics.A retrospective review of all the ankle fractures during a 12-year period at a single pediatric referral center was conducted. Inclusion criteria were: a fractured ankle that underwent a surgical fixation, at least 1 radiograph available for review before fixation, available information regarding surgery, including operative report and fluoroscopic images, and younger than 18 years at the time of surgery. Demographic information, trauma, radiographs, surgical details, clinical examination, follow up, outcomes, and physeal status (skeletally immature, transitional, or mature) were recorded. Finally, patients were divided in 2 groups: with or without syndesmotic fixation. Statistical analysis included descriptive statistics, Mann-Whitney test for nonparametric data to compare continuous parameters, and χ test for categorical parameters.A total of 128 patients were included with a mean age of 14.1 years. There were 80 boys and 48 girls. There were 51 skeletally immature patients, 23 with transitional fractures, and 54 that were skeletally mature. The main finding of this study is that only 11 patients from the mature group underwent syndesmotic fixation. There were no cases of syndesmotic fixation in the skeletally immature and transitional groups.This is the first retrospective study to focus specifically on syndesmotic injuries in a pediatric population who underwent ankle fracture fixation. Only 11 skeletally mature patients underwent syndesmotic fixation out of 128 patients in this cohort. This result raises the question of whether there are accurate diagnostic tools to evaluate syndesmosis in children.

Propagation of Syndesmotic Injuries During Forced External Rotation in Flexed Cadaveric Ankles

Background

Forced external rotation of the foot is a mechanism of ankle injuries. Clinical observations include combinations of ligament and osseous injuries, with unclear links between causation and injury patterns. By observing the propagation sequence of ankle injuries during controlled experiments, insight necessary to understand risk factors and potential mitigation measures may be gained.

Hypothesis

Ankle flexion will alter the propagation sequence of ankle injuries during forced external rotation of the foot.

Study Design

Controlled laboratory study.

Methods

Matched-pair lower limbs from 9 male cadaveric specimens (mean age, 47.0 ± 11.3 years; mean height, 178.1 ± 5.9 cm; mean weight, 94.4 ± 30.9 kg) were disarticulated at the knee. Specimens were mounted in a test device with the proximal tibia fixed, the fibula unconstrained, and foot translation permitted. After adjusting the initial ankle position (neutral, n = 9; dorsiflexed, n = 4; plantar flexed, n = 4) and applying a compressive preload to the tibia, external rotation was applied by rotating the tibia internally while either lubricated anteromedial and posterolateral plates or calcaneal fixation constrained foot rotation. The timing of osteoligamentous injuries was determined from acoustic sensors, strain gauges, force/moment readings, and 3-dimensional bony kinematics. Posttest necropsies were performed to document injury patterns.

Results

A syndesmotic injury was observed in 5 of 9 (56%) specimens tested in a neutral initial posture, in 100% of the dorsiflexed specimens, and in none of the plantar flexed specimens. Superficial deltoid injuries were observed in all test modes.

Conclusion

Plantar flexion decreased and dorsiflexion increased the incidence of syndesmotic injuries compared with neutral matched-pair ankles. Injury propagation was not identical in all ankles that sustained a syndesmotic injury, but a characteristic sequence initiated with injuries to the medial ligaments, particularly the superficial deltoid, followed by the propagation of injuries to either the syndesmotic or lateral ligaments (depending on ankle flexion), and finally to the interosseous membrane or the fibula.

Clinical Relevance

Superficial deltoid injuries may occur in any case of hyper-external rotation of the foot. A syndesmotic ankle injury is often concomitant with a superficial deltoid injury; however, based on the research detailed herein, a deep deltoid injury is then concomitant with a syndesmotic injury or offloads the syndesmosis altogether. A syndesmotic ankle injury more often occurs when external rotation is applied to a neutral or dorsiflexed ankle. Plantar flexion may shift the injury to other ankle ligaments, specifically lateral ligaments.

Strain Distribution in the Anterior Inferior Tibiofibular Ligament, Posterior Inferior Tibiofibular Ligament, and Interosseous Membrane Using Digital Image Correlation

BACKGROUND

Ligament repair and augmentation techniques can stabilize syndesmosis injuries. However, little is known about the mechanical behavior of syndesmotic ligaments. The aim of this study was to analyze full-field strain, strain trend under foot rotation, and subregional strain differences of the anterior inferior tibiofibular ligament (AITFL), posterior inferior tibiofibular ligament (PITFL), and interosseous membrane (IOM).

METHODS

Eleven fresh-frozen lower limbs were dissected to expose the AITFL, PITFL, and IOM. The foot underwent rotation from 0° to 25° internal and 35° external, with 3 ankle positions (neutral, 15° dorsiflexion, and 25° plantarflexion) and a vertical load of 430 N. Ligament strain was recorded using digital image correlation.

RESULTS

The mean strain on the AITFL with 35° external rotation was greater in the proximal portion compared with distal portion in the neutral position ( P = .009) and dorsiflexion ( P = .003). The mean strain in the tibial insertion and midsubstance near tibial insertion were greater when compared with other regions ( P = .018 and P = .009). The subregions of mean strain in the PITFL and IOM groups were not significantly different. The strain trend of AITFL, PITFL, and IOM showed common transformation, just when the foot was externally rotated.

CONCLUSION

The findings of this study show that a significantly high strain was observed on the proximal part and the midsubstance near the Chaput tubercle of the AITFL when the ankle was externally rotated. All 3 ligaments resisted the torque in the syndesmosis by external rotation of the foot.

CLINICAL RELEVANCE

This study allows for better understanding of the mechanical behavior of the syndesmosis ligaments, which could influence the repair technique and AITFL augmentation techniques.

Effects of visual feedback balance training on the balance and ankle instability in adult men with functional ankle instability

[Purpose] This study examined the effects of visual feedback balance training on the balance and ankle instability in adult men with functional ankle instability. [Subjects and Methods] Twenty eight adults with functional ankle instability, divided randomly into an experimental group, which performed visual feedback balance training for 20 minutes and ankle joint exercises for 10 minutes, and a control group, which performed ankle joint exercise for 30 minutes. Exercises were completed three times a week for 8 weeks. Bio rescue was used for balance ability. It measured limit of stability at one minute. For ankle instability was measured using Cumberland ankle instability tool (CAIT). This measure was performed before and after the experiments in each group. [Results] The experimental group had significant increase in the Limit of Stability and CAIT score. The control group had significant increase in CAIT score. While the Limit of Stability increased without significance. [Conclusion] In conclusion, visual feedback balance training can be recommended as a treatment method for patients with functional ankle instability.

Epidemiology and return to play following isolated syndesmotic injuries of the ankle: a prospective cohort study of 3677 male professional footballers in the UEFA Elite Club Injury Study

Aim

To determine the epidemiology of isolated syndesmotic injuries in professional football players.

Methods

Data from 15 consecutive seasons of European professional football between 2001 and 2016 contributed to the dataset of this study. Match play and training data from a total of 3677 players from 61 teams across 17 countries have been included. Team medical staff recorded player exposure and time loss injuries. Injury incidence was defined as the number of injuries per 1000 player-hours. Injury burden was defined as number of days absence per 1000 player-hours. Seasonal trends for isolated syndesmotic injury incidence, isolated syndesmotic injury proportion of ankle ligament injuries and isolated syndesmotic injury burden were analysed via linear regression.

Results

The isolated syndesmotic injury incidence was 0.05 injuries per 1000 hours of exposure (95% CI 0.04 to 0.06) or one injury per team every three seasons. The injury incidence during match play was 13 times higher compared with during training, 0.21 (95% CI 0.16 to 0.26) and 0.02 (95% CI 0.01 to 0.02), respectively. Out of the 1320 ankle ligament injuries registered during the 15 seasons, 94 (7%) were diagnosed as isolated syndesmotic injuries. An annual increase in injury incidence was observed (R2=0.495, b=0.003, 95% CI 0.001 to 0.004, P=0.003). However, no significant annual change of injury burden was observed (R2=0.033, b=0.032, 95% CI −0.073 to 0.138, P=0.520). Seventy-four per cent of the injuries were contact related, and the mean (±SD) absence following an isolated syndesmotic injury was 39 (±28) days.

Conclusions

The incidence of isolated syndesmotic injuries in elite professional European football annually increased between 2001 and 2016.

The Epidemiology of High Ankle Sprains in National Collegiate Athletic Association Sports

BACKGROUND

Ankle sprains are among the most common injuries experienced by collegiate athletes. The type of ankle sprain is rarely differentiated in epidemiological studies. This differentiation is necessary, as each ankle sprain type has a unique injury mechanism and recovery period. High ankle sprains commonly result in long recovery periods. Thus, a further examination of the epidemiology of high ankle sprains is warranted.

PURPOSE

To describe the epidemiology of high ankle sprains in National Collegiate Athletic Association (NCAA) sports during the 2009/2010-2014/2015 academic years.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

NCAA Injury Surveillance Program high ankle sprain data and athlete-exposures (AEs) from 25 sports were evaluated. Certified athletic trainers recorded sport-related injury, event, and AE data during team-sanctioned events. High ankle sprain injury rates per 10,000 AEs were calculated. Percentage distributions were calculated for the amount of time lost from sport and percentage of recurrent injuries. Injury rate ratios (RRs) and 95% CIs compared injury rates by event type, participation restriction time, and sex. 95% CIs not containing 1.00 were considered statistically significant.

RESULTS

The overall high ankle sprain injury rate was 1.00 per 10,000 AEs. Overall, 56.7% of high ankle sprain injuries occurred during competitions, and 9.8% of high ankle sprain injuries were recurrent. Men's football (2.42/10,000 AEs), wrestling (2.11/10,000 AEs), and ice hockey (1.19/10,000 AEs) had the highest high ankle sprain injury rates. In sex-comparable sports, men had higher injury rates (RR, 1.77; 95% CI, 1.28-2.44). Player contact was the most common injury mechanism (60.4%), and 69.0% of injuries resulted in ≥1 day of participation restriction, with 47.1% resulting in ≥7 days of participation restriction and 15.8% resulting in >21 days of participation restriction.

CONCLUSION

High ankle sprains resulted in significant participation restriction time from sport participation. The majority of high ankle sprain injuries resulted from player contact and were observed in contact/collision sports. The large proportion of high ankle sprains resulting from player contact, specifically in male contact sports, is worthy of further investigation.

CLINICAL RELEVANCE

The enhanced understanding of the epidemiology of high ankle sprains provided in our study will aid clinicians in developing targeted injury prevention strategies to mitigate the negative consequences of these injuries.