APKASS Consensus Statement on Chronic Syndesmosis Injury, Part 1: Clinical Manifestation, Radiologic Examination, Diagnosis Criteria, Classification, and Nonoperative Treatment

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 distal tibiofibular joint effusion may be a reliable index for diagnosing the distal tibiofibular syndesmosis instability in ankle

PURPOSE

To analyze the accuracy of MRI in diagnosis of distal tibiofibular syndesmosis instability (DTSI) and construct new diagnostic parameters.

MATERIALS AND METHODS

This retrospective study evaluated 212 patients with history of ankle sprains and 3 T MRI and received a final diagnosis of distal tibiofibular syndesmosis instability by ankle arthroscopic surgery from October 2017 and December 2021. We compared the accuracy of syndesmotic injury, qualitative index of distal tibiofibular joint effusion (DTJE), and quantitative index of distal tibiofibular joint effusion (DTJE) in diagnosing distal tibiofibular syndesmosis instability. The criteria for syndesmotic injury were consistent with previous literature, and DTJE was grouped according to the pre-experimental results.

RESULTS

A total of 212 patients (mean age, 35.64 ± 11.79, 74 female and 138 male) were included. Independent predictive MRI features included syndesmotic injury, qualitative index of distal tibiofibular joint effusion, and quantitative index of DTJE including the height, projected area of equal-point method, and projected area of incremental-value method. The quantitative index of DTJE showed a higher area under the receiver operating characteristic curve (0.805/0.803/0.804/0.811/0.817/0.805 > 0.8, P < 0.05; in comparison with all other method). The height measurement method was simpler and easier to operate, that could be gotten only by measuring the DTJE distance of a MRI independent layer, and the cut-off value of the effusion height was 8.00 mm and the Youden index (0.56) was the best.

CONCLUSIONS

Our research translated a complicated string of MRI multi-dimensional spatial measurements into a simple measuring process, and established the significance of quantifying DTJE in the diagnosis of DTSI. We found that the 8-mm height of DTJE was a more specific indicator for DTSI and could serve as a novel MRI diagnostic cutoff in clinical practice.

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.

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.

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.

Prevalence of ankle instability in performers of Chinese classical dance: a cross-sectional study of 105 Chinese dancers

Objectives

Foot and ankle injuries are commonly seen in dancers, yet limited studies exist on the injury prevalence of performers of Chinese classical dance. This study aims to determine and assess the prevalence of chronic ankle instability (CAI) in Chinese dancers and correlate the impact of CAI with foot function.

Methods

This is a cross-sectional study of 105 Chinese dancers. CAI was assessed using the Cumberland Ankle Instability Tool and foot function via the Foot and Ankle Outcome Score (FAOS). Both self-reported assessment tools were distributed online between January and February 2021. Subjects were divided into CAI and healthy groups to observe any correlations in demographics, training hours and foot function.

Results

CAI was seen in 28% of Chinese dancers, with most being unilateral instability. The number of training hours, level of expertise, occupation, gender and age showed no statistical significance with CAI. The FAOS showed that subjects with CAI had significantly greater pain and poorer quality of life.

Discussion and conclusion

CAI is a problem affecting 28% of performers of Chinese dance. Future research should investigate the ankle biomechanics in Chinese dance and specific risk factors for CAI to formulate strategies to prevent ankle injuries in Chinese dancers.