Radiographic measurement of the distal tibiofibular syndesmosis has limited use

Radiographs of 20 plastinated human cadaveric lower legs were obtained in 12 positions of rotation to determine the optimal parameter for reliable assessment of syndesmotic and ankle integrity, and to assess the effect of positioning of the ankle on this parameter. Three observers measured eight parameters twice after four repetitions of ankle positioning. Intraclass correlation coefficients and reproducibility were assessed. Some tibiofibular overlap was present in all radiographs in any position of rotation. The medial clear space was smaller than or equal to the superior clear space in all radiographs. Intraclass correlation coefficients of the other parameters were too weak for reliable quantitative measurements, as was shown with a mixed model analysis of variance. This resulted from the inability to reproduce ankle positioning, even under optimal laboratory circumstances. This study shows that no optimal radiographic parameter exists to assess syndesmotic integrity. Tibiofibular overlap and medial and superior clear space are the most useful, because one-sided traumatic absence of tibiofibular overlap may be an indication of syndesmotic injury, and a medial clear space larger than a superior clear space is indicative of deltoid injury. Additional quantitative measurement of all syndesmotic parameters with repeated radiographs of the ankle cannot be done reliably and therefore are of little value.

Correlation between radiological assessment of acute ankle fractures and syndesmotic injury on MRI

OBJECTIVE

Owing to the shortcomings of clinical examination and radiographs, injury to the syndesmotic ligaments is often misdiagnosed. When there is no indication requiring that the fractured ankle be operated on, the syndesmosis is not tested intra-operatively, and rupture of this ligamentous complex may be missed. Subsequently the patient is not treated properly leading to chronic complaints such as instability, pain, and swelling. We evaluated three fracture classification methods and radiographic measurements with respect to syndesmotic injury.

MATERIALS AND METHODS

Prospectively the radiographs of 51 consecutive ankle fractures were classified according to Weber, AO-Müller, and Lauge-Hansen. Both the fracture type and additional measurements of the tibiofibular clear space (TFCS), tibiofibular overlap (TFO), medial clear space (MCS), and superior clear space (SCS) were used to assess syndesmotic injury. MRI, as standard of reference, was performed to evaluate the integrity of the distal tibiofibular syndesmosis. The sensitivity and specificity for detection of syndesmotic injury with radiography were compared to MRI.

RESULTS

The Weber and AO-Müller fracture classification system, in combination with additional measurements, detected syndesmotic injury with a sensitivity of 47% and a specificity of 100%, and Lauge-Hansen with both a sensitivity and a specificity of 92%. TFCS and TFO did not correlate with syndesmotic injury, and a widened MCS did not correlate with deltoid ligament injury.

CONCLUSION

Syndesmotic injury as predicted by the Lauge-Hansen fracture classification correlated well with MRI findings. With MRI the extent of syndesmotic injury and therefore fracture stage can be assessed more accurately compared to radiographs.

Acute syndesmotic instability in ankle fractures: A review

Ankle fractures are among the most common fracture types, and 10% of all ankle fractures lead to accessory syndesmotic injury. An injury that is challenging in every respect is syndesmotic instability. Since the range of diagnostic techniques and the therapeutic options is extensive, it still is a controversial subject, despite the abundance of literature. This review aimed to summarize the current knowledge on syndesmotic instability in ankle fractures and to formulate some recommendations for clinical practice. Chronic instability and the operative osseous treatment of ankle fractures are not part of this review.

Osteochondritis dissecans of the humeral capitellum: reliability of four classification systems using radiographs and computed tomography

BACKGROUND

The radiographic appearance of osteochondritis dissecans (OCD) of the humeral capitellum varies according to the stage of the lesion. It is important to evaluate the stage of OCD lesion carefully to guide treatment. We compared the interobserver reliability of currently used classification systems for OCD of the humeral capitellum to identify the most reliable classification system.

METHODS

Thirty-two musculoskeletal radiologists and orthopaedic surgeons specialized in elbow surgery from several countries evaluated anteroposterior and lateral radiographs and corresponding computed tomography (CT) scans of 22 patients to classify the stage of OCD of the humeral capitellum according to the classification systems developed by (1) Minami, (2) Berndt and Harty, (3) Ferkel and Sgaglione, and (4) Anderson on a Web-based study platform including a Digital Imaging and Communications in Medicine viewer. Magnetic resonance imaging was not evaluated as part of this study. We measured agreement among observers using the Siegel and Castellan multirater κ.

RESULTS

All OCD classification systems, except for Berndt and Harty, which had poor agreement among observers (κ = 0.20), had fair interobserver agreement: κ was 0.27 for the Minami, 0.23 for Anderson, and 0.22 for Ferkel and Sgaglione classifications. The Minami Classification was significantly more reliable than the other classifications (P < .001).

CONCLUSIONS

The Minami Classification was the most reliable for classifying different stages of OCD of the humeral capitellum. However, it is unclear whether radiographic evidence of OCD of the humeral capitellum, as categorized by the Minami Classification, guides treatment in clinical practice as a result of this fair agreement.

The influence of ankle positioning on the radiography of the distal tibial tubercles

Three embalmed human lower legs, with the anterior and posterior tubercles of the distal tibia marked with needles, were radiographed in four positions of rotation to describe the projection and the configuration of the distal tibial tubercles and the tibiofibular syndesmosis, since the distal tibial tubercles are often described incorrectly in the literature. The anterior and posterior tubercles have distinct features that can be recognized in different positions of rotation. The anterior tubercle has an angular shape with its maximum dimension approximately 1 cm above the joint line. The posterior tubercle is a rounded structure in continuity with the posterior lip of the tibia, projecting caudally from the anterior tubercle superimposed on the talus. It was shown that the tibiofibular clear space (TFCS) and the tibiofibular overlap (TFO) differ considerably with rotation and that neither the TFCS nor the TFO depicts a constant syndesmotic interval. Both change considerably with varying rotational projections. To achieve uniformity it is recommended that the TFCS be measured as the distance between the medial border of the fibula and the floor of the incisura, and the TFO as the distance between medial border of the fibula and the anterior tubercle, both on the anteroposterior radiograph.

The straight line graph in limb length inequality. A new design based on 182 Dutch children

Moseley's Straight Line Graph (M-SLG), which is based on growth data obtained in the 1940s and 1950s, is helpful for the timing of physiodesis. We investigated whether current growth data could improve this graph. We estimated growth curves based on recent data on 182 Dutch children, collected between 1979 and 1994, using repeated measure analysis of variance. In both boys and girls, the mean femur and tibia length had increased, when compared to the data collected by Anderson et al. (1964). Based on our growth data, a new straight line graph (Rotterdam Straight Line Graph; R-SLG) was created. Its value was assessed by comparing the difference between the predicted length of the short (i.e., not operated) limb at maturity with the final limb length. In a group of 34 children who underwent physiodesis up to 10 years ago, the R-SLG gave better prediction of limb length at maturity than the M-SLG did in 22 of 34 cases and equal results were obtained in 5 cases. We conclude that our updated SLG can improve the prediction of final limb length and thus also the timing of physiodesis.

Agreement between physical therapists and radiologists of stratifying patients with shoulder pain into new treatment related categories using ultrasound; an exploratory study

STUDY DESIGN

A systematic overview of the literature and an agreement study.

OBJECTIVES

The aim of this study is to explore the inter-professional agreement of diagnostic musculoskeletal ultrasound (DMUS) between physical therapists (PT) and radiologists, using a new classification strategy based upon the therapeutic consequences in patients with shoulder pain.

BACKGROUND

DMUS is frequently used by PTs, although the agreement regarding traditional diagnostic labels between PTs and radiologists is only fair. Nevertheless, DMUS could be useful when used as a stratifying-tool.

METHODS

First, a systematic overview of current evidence was performed to assess which traditional diagnostic labels could be recoded into new treatment related categories (referral to secondary care, corticosteroid injections, physical therapy, watchful waiting). Next, kappa values were calculated for these categories between PTs and radiologists.

RESULTS

Only three categories were extracted, as none of the traditional diagnostic labels were classified into the 'corticosteroid injection' category. Overall, we found moderate agreement to stratify patients into treatment related categories and substantial agreement for the category 'referral to secondary care'. Both categories 'watchful waiting' and 'indication for physical therapy' showed moderate agreement between the two professions.

CONCLUSION

Our results indicate that the agreement between radiologists and PTs is moderate to substantial when labelling is based on treatment consequences. DMUS might be able to help the PT to guide treatment, especially for the category 'referral to secondary care' as this showed the highest agreement. However, as this is just an explorative study, more research is needed, to validate and assess the consequences of this stratification classification for clinical care.

Cubital tunnel release with Wide Awake Local Anaesthesia No Tourniquet (WALANT) technique in an outpatient setting is safe and effective

Ulnar nerve release is often performed under general anaesthesia. Wide Awake Local Anaesthesia No Tourniquet (WALANT) is a new anaesthetic method increasingly used by hand surgeons in an outpatient setting. It has advantages such as the possibility to shift surgical interventions out of the regular surgical theatre settings into an outpatient clinical setting, no risk of complications or side effects resulting from regional and general anesthesia and decreased costs. The use of WALANT has not been investigated extensively in elbow surgery. This study aims to evaluate clinical outcomes after ulnar nerve release under WALANT 27 patients with ulnar nerve release for cubital tunnel syndrome were included. The primary outcome was the presence of (remaining) symptoms after ulnar nerve release. Data was extracted from medical records. 13 out of 27 patients had (mild) remaining symptoms after ulnar nerve release, and 1 complication (superficial wound infection) was seen. Ulnar nerve release under WALANT is safe and effective in patients with primary ulnar nerve entrapment that have failed conservative therapy.