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Ghandour S, Taseh A, Sharma S, Peiffer M, Karaismailoglu B, Ashkani Esfahani S, Waryasz G, Guss D. Unveiling Syndesmotic Malreduction: A Proof-of-Concept towards Portable Ultrasound Detection. Arch Bone Jt Surg 2024; 12:198-203. [PMID: 38577516 PMCID: PMC10989729 DOI: 10.22038/abjs.2023.75672.3503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 12/16/2023] [Indexed: 04/06/2024]
Abstract
Objectives To evaluate the utility and diagnostic performance of portable handheld ultrasound for evaluating fibular rotation at the distal tibiofibular articulation after syndesmotic disruption. Methods Four above-the-knee cadaveric specimens were included. Syndesmotic disruption was precipitated by transecting the Anterior Inferior Tibiofibular Ligament, Interosseous Ligament, and Posterior Inferior Tibiofibular Ligament. Thereafter, a proximal fibular osteotomy was performed, and three conditions were modeled at the distal syndesmosis: 1) reduced, 2) 5 degree internal rotation malreduction, and 3) 5 degree external rotation malreduction. Two blinded observers performed separate ultrasonographic examinations for each condition at the level of both the anterior and posterior distal tibiofibular articular surfaces. Syndesmotic gap penetrance, defined as the ability of the P-US to generate signal between the distal fibula and tibia at the level of the incisura, was graded positive if the sonographic waves penetrated between the distal tibiofibular joint and negative if no penetrating waves were detected. The accuracy measures of the anterior and posterior gap penetrance were evaluated individually. Results Our preliminary results showed that posterior gap penetrance showed good performance when detecting either internal or external rotational malreduction of the fibula with very good specificity (87.5%) and PPV (90.0%). On the other hand, the anterior gap penetrance showed limited performance when detecting either form of rotational malreduction. Conclusion We introduced a novel sign, the "gap penetrance sign", best measured from the posterior ankle, which can accurately detect syndesmotic malreduction using P-US in a manner that does not require specific quantitative measurements and is readily accessible to early P-US users.
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Affiliation(s)
- Samir Ghandour
- Foot & Ankle Research and Innovation Lab (FARIL), Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Foot and Ankle Division, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Atta Taseh
- Foot & Ankle Research and Innovation Lab (FARIL), Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Foot and Ankle Division, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Siddhartha Sharma
- Foot & Ankle Research and Innovation Lab (FARIL), Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Foot and Ankle Division, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
- Department of Orthopedics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Matthias Peiffer
- Foot & Ankle Research and Innovation Lab (FARIL), Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Foot and Ankle Division, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
- Department of Orthopaedics and Traumatology, Ghent University Hospital, Ghent, Belgium
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| | - Bedri Karaismailoglu
- Foot & Ankle Research and Innovation Lab (FARIL), Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Foot and Ankle Division, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
- Istanbul University – Cerrahpasa, Cerrahpasa Medical Faculty, Department of Orthopaedics and Traumatology, Istanbul, Turkey
- CAST (Cerrahpasa Research, Simulation and Design Laboratory), Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Soheil Ashkani Esfahani
- Foot & Ankle Research and Innovation Lab (FARIL), Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Foot and Ankle Division, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Gregory Waryasz
- Foot & Ankle Research and Innovation Lab (FARIL), Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Foot and Ankle Division, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Daniel Guss
- Foot & Ankle Research and Innovation Lab (FARIL), Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Foot and Ankle Division, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
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Lee SH, Cho HG, Yang JH. Predisposing factors for chronic syndesmotic instability following syndesmotic fixation in ankle fracture: Minimum 5-year follow-up outcomes. Foot Ankle Surg 2021; 27:777-783. [PMID: 34583831 DOI: 10.1016/j.fas.2020.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 09/06/2020] [Accepted: 10/05/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND This study aimed to identify risk factors for chronic syndesmotic instability following syndesmotic fixation. METHODS We performed a retrospective review of consecutive patients who had sustained ankle fractures requiring syndesmotic fixation. Patients available for a minimum 5 years of follow-up were classified into 2 groups according to the presence of syndesmotic instability. Statistical binary logistic regression analyses were performed to investigate the significance of various risk factors. Functional outcomes were assessed using the FAOS. RESULTS In total, 166 patients who met the study inclusion criteria underwent analysis. The overall postoperative instability rate was 20.5%, which was significantly affected due to BMI (p = 0.018; OR 6.72), and concomitant posterior malleolar fracture (p = 0.032, OR 2.77). The mean scores in the syndesmotic instability (SI) group were significantly lower than those in the no syndesmotic instability (NSI) group (p = 0.021). CONCLUSIONS Obesity and concomitant posterior malleolar fracture were significant risk factors for postoperative syndesmotic instability.
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Affiliation(s)
- Sung Hyun Lee
- Department of Orthopedic Surgery, Wonkwang University Hospital, 895, Muwang-Ro, Iksan 54538, Republic of Korea.
| | - Hyung Gyu Cho
- Department of Orthopedic Surgery, Wonkwang University Hospital, 895, Muwang-Ro, Iksan 54538, Republic of Korea
| | - Je Heon Yang
- Department of Orthopedic Surgery, Wonkwang University Hospital, 895, Muwang-Ro, Iksan 54538, Republic of Korea
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Abstract
Syndesmotic injuries in the setting of ankle fracture are critically important to diagnosis and treat to restore an anatomic tibiotalar relationship. Physical examination and clinical suspicion remain critically important for diagnosis. Ultrasound examination and weight-bearing computed tomography scans are evolving to help diagnosis more subtle injuries. Although flexible syndesmotic fixation may decrease malreduction rates, the benefits over rigid fixation is the subject of ongoing study. Anatomic reduction remains critical regardless of fixation choice. Routine removal of rigid syndesmotic hardware does not seem to offer substantial clinical improvement in pain or range of motion; however, broken hardware may cause irritation.
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Affiliation(s)
- Philip B Kaiser
- Department of Orthopaedic Surgery, Foot and Ankle Service, Harvard Medical School, Massachusetts General Hospital and Newton-Wellesley Hospital, Boston, MA, USA; Foot & Ankle Research and Innovation Laboratory - Harvard Medical School, Division of Foot and Ankle Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital - Newton-Wellesley Hospital, Boston, MA, USA.
| | - Lorena Bejarano-Pineda
- Department of Orthopaedic Surgery, Foot and Ankle Service, Harvard Medical School, Massachusetts General Hospital and Newton-Wellesley Hospital, Boston, MA, USA; Foot & Ankle Research and Innovation Laboratory - Harvard Medical School, Division of Foot and Ankle Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital - Newton-Wellesley Hospital, Boston, MA, USA
| | - John Y Kwon
- Department of Orthopaedic Surgery, Foot and Ankle Service, Harvard Medical School, Massachusetts General Hospital and Newton-Wellesley Hospital, Boston, MA, USA; Foot & Ankle Research and Innovation Laboratory - Harvard Medical School, Division of Foot and Ankle Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital - Newton-Wellesley Hospital, Boston, MA, USA
| | - Christopher W DiGiovanni
- Department of Orthopaedic Surgery, Foot and Ankle Service, Harvard Medical School, Massachusetts General Hospital and Newton-Wellesley Hospital, Boston, MA, USA; Foot & Ankle Research and Innovation Laboratory - Harvard Medical School, Division of Foot and Ankle Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital - Newton-Wellesley Hospital, Boston, MA, USA
| | - Daniel Guss
- Department of Orthopaedic Surgery, Foot and Ankle Service, Harvard Medical School, Massachusetts General Hospital and Newton-Wellesley Hospital, Boston, MA, USA; Foot & Ankle Research and Innovation Laboratory - Harvard Medical School, Division of Foot and Ankle Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital - Newton-Wellesley Hospital, Boston, MA, USA
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Vivtcharenko VY, Giarola I, Salgado F, Li S, Wajnsztejn A, Giordano V, de Cesar Netto C, Godoy-Santos AL. Comparison between cotton test and tap test for the assessment of coronal syndesmotic instability: A cadaveric study. Injury 2021; 52 Suppl 3:S84-8. [PMID: 34088466 DOI: 10.1016/j.injury.2021.02.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 02/06/2021] [Accepted: 02/09/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION In surgically treated rotational malleolar fractures, residual syndesmotic instability is typically assessed following fixation with the widely used intraoperative Cotton test. However, due to its dynamic nature, there are inconsistencies of the magnitude and direction of the distraction force when attempting to pull the fibula away from the tibia using a bone hook. The novel Tap test advances a cortical tap through a drilled hole in the fibula with a stable, unidirectional distraction force applied to the tibia. The objective of this cadaveric study was to compare the Cotton and Tap tests as diagnostic tools for coronal plane syndesmotic instability. METHODS Tibiofibular Clear Space (TFCS) of 10 cadaveric specimens was measured for: intact, non-stressed; intact, stressed; injured, non-stressed; and injured, stressed (Tap and Cotton tests). In injured conditions, the syndesmotic ligamentous complex was sectioned using an anterolateral longitudinal approach. Perfect fluoroscopic Mortise images were acquired for all conditions. Two independent and blinded Orthopaedic Foot and Ankle Surgeons measured TFCS 1 cm proximal to the ankle joint line. Intra and interobserver reliabilities were assessed by Intraclass Correlation Coefficient. Syndesmotic TFCS values for all conditions were compared by paired Wilcoxon. Diagnostic performance of the Cotton and Tap tests was assessed using a relative increase of TFCS > 2 mm when comparing intact stressed and injured stressed conditions. P-values <0.05 were considered significant. RESULTS The intraclass correlation coefficient for intraobserver and interobserver reliability was respectively 0.96 and 0.79. TFCS measurements were similar in intact non-stressed, intact stressed (both Cotton and Tap tests) and injured non-stressed conditions, with mean values and 95% Confidence Intervals of: intact non-stressed, 3.5 mm; intact stressed, 3.6 mm (Cotton test) and 4.0 mm (Tap test); injured non-stressed, 3.8 mm. The Cotton test and Tap test had, respectively, 73.3% and 70% sensitivity, 100% and 90% specificity, 86.7% and 80% diagnostic accuracy. CONCLUSIONS Our cadaveric study compared the Cotton and Tap tests for detection of coronal plane syndesmotic instability. Both tests demonstrated similar increases in the TFCS measurements in stressed injured conditions when compared to intact non-stressed and stressed conditions, as well as injured non-stressed conditions.
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de Cesar Netto C, Pinto M, Roberts L, Lee SR, Roney AR, Naranje S, Godoy-Santos AL, Shah A. Intraoperative tap test for coronal syndesmotic instability: A cadaveric study. Injury 2018; 49:1758-1762. [PMID: 30115447 DOI: 10.1016/j.injury.2018.08.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 06/09/2018] [Accepted: 08/06/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Precise diagnosis of distal tibiofibular syndesmotic injury is challenging, and a gold standard diagnostic test has still not been established. Tibiofibular clear space identified on radiographic imaging is considered the most reliable indicator of the injury. The Cotton test is the most widely used intraoperative technique to evaluate the syndesmotic integrity although it has its limitations. We advocate for a novel intra operative test using a 3.5 mm blunt cortical tap. METHODS Tibiofibular clear space was assessed in nine cadaveric specimens using three sequential fluoroscopic images. The first image was taken prior to the application of the tap test (intact, non-stressed). Then, a 2.5 mm hole was drilled distally on the lateral fibula, and a 3.5 mm cortical tap was then threaded in the hole. The tap test involved gradually advancing the blunt tip against the lateral tibia, providing a tibiofibular separation force (intact, stressed). This same stress was then applied after all syndesmotic ligaments were released (injured, stressed). Measurements were compared by one-way ANOVA and paired Student's t-test. Intra and inter-observer agreements were evaluated by intraclass correlation coefficient (ICC). P-values <.05 were considered significant. RESULTS We found excellent intra-observer (0.97) and inter-observer (0.98) agreement following the imaging assessment. Significant differences were found in the paired comparison between the groups (p < .05). When using an absolute value for TFCS >6 mm as diagnostic for coronal syndesmotic instability, the tap test demonstrated a 96.3% sensitivity and specificity, a 96.3% PPV and NPV and a 96.3% accuracy in diagnosing coronal syndesmotic instability. CONCLUSIONS Our cadaveric study demonstrated that this novel coronal syndesmotic instability test using a 3.5 mm blunt cortical tap is a simple, accurate and reliable technique able to demonstrate significant differences in the tibiofibular clear space when injury was present. It could represent a more controlled and stable alternative to the most used Cotton test.
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Affiliation(s)
- Cesar de Cesar Netto
- Hospital for Special Surgery, Department of Foot and Ankle Orthopedics, 535 East 70thStreet, New York, NY, 10021, United States; University of Alabama at Birmingham (UAB), Department of Orthopedics, Birmingham, AL, United States.
| | - Martim Pinto
- University of Alabama at Birmingham (UAB), Department of Orthopedics, Birmingham, AL, United States
| | - Lauren Roberts
- Hospital for Special Surgery, Department of Foot and Ankle Orthopedics, 535 East 70thStreet, New York, NY, 10021, United States
| | - Sung Ro Lee
- University of Alabama at Birmingham (UAB), Department of Orthopedics, Birmingham, AL, United States
| | - Andrew R Roney
- Hospital for Special Surgery, Department of Foot and Ankle Orthopedics, 535 East 70thStreet, New York, NY, 10021, United States
| | - Sameer Naranje
- University of Alabama at Birmingham (UAB), Department of Orthopedics, Birmingham, AL, United States
| | | | - Ashish Shah
- University of Alabama at Birmingham (UAB), Department of Orthopedics, Birmingham, AL, United States
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Park YH, Yoon MA, Choi WS, Choi GW, Hong SJ, Kim HJ. The predictive value of MRI in the syndesmotic instability of ankle fracture. Skeletal Radiol 2018; 47:533-540. [PMID: 29196821 DOI: 10.1007/s00256-017-2821-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 10/23/2017] [Accepted: 11/07/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Although many types of ankle fracture can be combined with syndesmosis injury, preoperative imaging studies rarely reveal instability of the syndesmosis. This study assessed the use of magnetic resonance imaging (MRI) for syndesmotic instability in patients with unstable ankle fracture. METHODS A total of 74 patients who were treated for Lauge-Hansen supination external rotation/Weber B type fracture or pronation external rotation/Weber C type fracture and who underwent MRI for preoperative assessment were enrolled. The MRI findings of the syndesmotic ligament and the results of an intraoperative stress test were evaluated. RESULTS Twenty-six patients had a positive result on the intraoperative stress test for syndesmotic instability. The MRI findings of the syndesmotic ligaments revealed that complete tear of the posterior inferior tibiofibular ligament (PITFL) was the most reliable predictor of syndesmotic instability (sensitivity, 74%; specificity, 78%; positive predictive value, 54%). Interobserver agreement for the intraoperative stress test and MRI assessment was excellent, except for the MRI findings of the interosseous ligament (62% agreement; kappa, 0.3). CONCLUSIONS Complete tear of the PITFL on MRI has additional diagnostic value for syndesmotic instability in ankle fracture. However, because the sensitivity might not be sufficient to justify the costs associated with MRI, cost-effectiveness should be considered.
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Affiliation(s)
- Young Hwan Park
- Department of Orthopedic Surgery, Korea University Guro Hospital, 148 Gurodong-ro, Guro-gu, Seoul, 08308, South Korea
| | - Min A Yoon
- Department of Radiology, Korea University Guro Hospital, 148 Gurodong-ro, Guro-gu, Seoul, 08308, South Korea
| | - Won Seok Choi
- Department of Orthopedic Surgery, Korea University Guro Hospital, 148 Gurodong-ro, Guro-gu, Seoul, 08308, South Korea
| | - Gi Won Choi
- Department of Orthopedic Surgery, Korea University Ansan Hospital, 123 Jeokgeum-ro, Danwon-gu, Ansan, 15355, South Korea
| | - Suk Joo Hong
- Department of Radiology, Korea University Guro Hospital, 148 Gurodong-ro, Guro-gu, Seoul, 08308, South Korea
| | - Hak Jun Kim
- Department of Orthopedic Surgery, Korea University Guro Hospital, 148 Gurodong-ro, Guro-gu, Seoul, 08308, South Korea.
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Abstract
The ankle represents the most commonly injured weightbearing joint in the human body. They are typically the result of low-energy, rotational injury mechanisms. However, ankle fractures represent a spectrum of injury patterns from simple to very complex, with varying incidence of posttraumatic arthritis. Stable injury patterns can be treated nonoperatively; unstable injury patterns are typically treated operatively given that they could lead to severe arthritis if not properly addressed.
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Affiliation(s)
- Cristián A Ortiz
- Orthopaedic Department, Clínica Alemana de Santiago, Universidad del Desarrollo, Vitacura 5957, Santiago, Chile 7650568.
| | - Pablo Wagner
- Orthopaedic Department, Clínica Alemana de Santiago, Universidad del Desarrollo, Vitacura 5957, Santiago, Chile 7650568
| | - Emilio Wagner
- Orthopaedic Department, Clínica Alemana de Santiago, Universidad del Desarrollo, Vitacura 5957, Santiago, Chile 7650568
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