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de Cesar Netto C, Valderrabano V, Mansur NSB. Multidirectional Chronic Ankle Instability: What Is It? Foot Ankle Clin 2023; 28:405-426. [PMID: 37137631 DOI: 10.1016/j.fcl.2023.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Not all ankle sprains are the same and not all ankles behave the same way after an injury. Although we do not know the mechanisms behind an injury producing an unstable joint, we do know ankle sprains are highly underestimated. While some of the presumed lateral ligament lesions might eventually heal and produce minor symptoms, a substantial number of patients will not have the same outcome. The presence of associated injuries, such as additional medial chronic ankle instability, chronic syndesmotic instability, has been long discussed as a possible reason behind this. To explain multidirectional chronic ankle instability, this article aims to present the literature surrounding the condition and its importance nowadays.
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Affiliation(s)
- Cesar de Cesar Netto
- University of Iowa, Carver College of Medicine, 200 Hawkins Drive, John PappaJohn Pavillion (JPP), Room 01066, Lower Level, Iowa City, IA 52242, USA; Duke University Medical Center, USA.
| | - Victor Valderrabano
- Swiss Ortho Center & University of Basel, Schmerzklinik Basel, Swiss Medical Network, Hirschgässlein 15, 4010 Basel, Switzerland
| | - Nacime Salomão Barbachan Mansur
- University of Iowa, Carver College of Medicine, 200 Hawkins Drive, John PappaJohn Pavillion (JPP), Room 01066, Lower Level, Iowa City, IA 52242, USA; Escola Paulista de Medicina - Universidade Federal de São Paulo, 740 Botucatu Street, Sao Paulo, SP, Brazil 04023-062
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Barbachan Mansur NS, Godoy-Santos AL, Schepers T. High-Ankle Sprain and Syndesmotic Instability: How Far Have We Come with Diagnosis and Treatment? Foot Ankle Clin 2023; 28:369-403. [PMID: 37137630 DOI: 10.1016/j.fcl.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
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.
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Affiliation(s)
- Nacime Salomao Barbachan Mansur
- Escola Paulista de Medicina - Universidade Federal de São Paulo, Brazil; University of Iowa, Carver College of Medicine, USA.
| | | | - Tim Schepers
- Trauma Unit, Department of Surgery, Amsterdam UMC Location J1A-214 Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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Marín Fermín T, Symeonidis PD. Physical Examination of Ankle Sprain and Ankle Instability: Can We Really Divide It into Low and High Ankle Sprains? Foot Ankle Clin 2023; 28:217-229. [PMID: 37137620 DOI: 10.1016/j.fcl.2022.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
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.
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Affiliation(s)
- Theodorakys Marín Fermín
- Aspetar Orthopaedic and Sports Medicine Hospital, Inside Aspire Zone, Sports City Street, Al Buwairda St, 29222, Doha, Qatar.
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Jungmann PM, Lange T, Wenning M, Baumann FA, Bamberg F, Jung M. Ankle Sprains in Athletes: Current Epidemiological, Clinical and Imaging Trends. Open Access J Sports Med 2023; 14:29-46. [PMID: 37252646 PMCID: PMC10216848 DOI: 10.2147/oajsm.s397634] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 05/06/2023] [Indexed: 05/31/2023] Open
Abstract
Purpose Ankle injuries are frequent sports injuries. Despite optimizing treatment strategies during recent years, the percentage of chronification following an ankle sprain remains high. The purpose of this review article is, to highlight current epidemiological, clinical and novel advanced cross-sectional imaging trends that may help to evaluate ankle sprain injuries. Methods Systematic PubMed literature research. Identification and review of studies (i) analyzing and describing ankle sprain and (ii) focusing on advanced cross-sectional imaging techniques at the ankle. Results The ankle is one of the most frequently injured body parts in sports. During the COVID-19 pandemic, there was a change in sporting behavior and sports injuries. Ankle sprains account for about 16-40% of the sports-related injuries. Novel cross-sectional imaging techniques, including Compressed Sensing MRI, 3D MRI, ankle MRI with traction or plantarflexion-supination, quantitative MRI, CT-like MRI, CT arthrography, weight-bearing cone beam CT, dual-energy CT, photon-counting CT, and projection-based metal artifact reduction CT may be introduced for detection and evaluation of specific pathologies after ankle injury. While simple ankle sprains are generally treated conservatively, unstable syndesmotic injuries may undergo stabilization using suture-button-fixation. Minced cartilage implantation is a novel cartilage repair technique for osteochondral defects at the ankle. Conclusion Applications and advantages of different cross-sectional imaging techniques at the ankle are highlighted. In a personalized approach, optimal imaging techniques may be chosen that best detect and delineate structural ankle injuries in athletes.
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Affiliation(s)
- Pia M Jungmann
- Department of Diagnostic and Interventional Radiology, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Radiology, Kantonsspital Graubünden, Chur, Switzerland
| | - Thomas Lange
- Department of Radiology, Medical Physics, Medical Center – University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Markus Wenning
- Department of Orthopedic and Trauma Surgery, Medical Center – University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Frédéric A Baumann
- Department of Vascular Medicine, Hospital of Schiers, Schiers, Switzerland
| | - Fabian Bamberg
- Department of Diagnostic and Interventional Radiology, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Matthias Jung
- Department of Diagnostic and Interventional Radiology, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Gan TJ, Li YX, Chen Y, Liu X, Zhang H. Open reduction and internal fixation for posterior pilon fracture: Transfibular approach versus posterior approach. Injury 2023; 54:751-760. [PMID: 36404163 DOI: 10.1016/j.injury.2022.11.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 11/01/2022] [Accepted: 11/08/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND For posterior pilon fractures, the posterior approach (PA) is widely used but has its limitations. The transfibular approach (TFA) has been adopted to treat posterior malleolar fractures for the advantage of direct visual confirmation of the reduction status intraoperatively, yet the report of its application on posterior pilon fractures is rare. This study aims to compare TFA with PA in terms of their corresponding reduction quality. METHODS Clinical data of 85 posterior pilon fracture patients treated via PA (n = 62) or TFA (n = 23) were retrospectively reviewed. Radiographic and clinical assessments, including articular step-off or gap, syndesmosis reduction quality, signs of ankle arthritis, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, visual analogue scale (VAS), ankle stability, and the active range of motion (ROM) of the ankle, were all evaluated by two readers independently. RESULTS The total incidence of step-off or gap ≥ 1 mm was significantly higher in the PA group (35.5%) than in the TFA group (8.7%, p = 0.015). In all the patients, step-off ≥ 1 mm was identified as an independent risk factor for the development of arthritis and a lower AOFAS score (p < 0.001). No significant difference was found in ROM and complication incidence between the two groups. Ankle instability was found in neither group during the follow-up. CONCLUSION TFA could offer a way to intraoperatively evaluate the reduction status with direct visual confirmation and, thereby, might improve the results of reduction for posterior pilon fractures. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Ting-Jiang Gan
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province 610041, China
| | - Ya-Xing Li
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province 610041, China; Disaster Medicine Center, Sichuan University, Chengdu, Sichuan Province 610041, China
| | - Yu Chen
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province 610041, China
| | - Xi Liu
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province 610041, China
| | - Hui Zhang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province 610041, China; Disaster Medicine Center, Sichuan University, Chengdu, Sichuan Province 610041, China.
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Mercan N, Yıldırım A, Dere Y. Biomechanical Analysis of Tibiofibular Syndesmosis Injury Fixation Methods: A Finite Element Analysis. J Foot Ankle Surg 2022; 62:107-114. [PMID: 35732561 DOI: 10.1053/j.jfas.2022.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 05/09/2022] [Accepted: 05/11/2022] [Indexed: 02/03/2023]
Abstract
The optimal treatment strategy after syndesmotic injuries is still controversial. In our study, we aimed to evaluate ideal fixation method in syndesmotic injury by using finite element analysis method. A 3D SolidWorks model file was created by taking computed tomography (CT) images of the area from the right foot base to the knee joint level of a healthy adult male. The intact model, injury model, and 8 different fixation models were created that 3.5 mm screw and suture-button were used in. The models were compared in terms of lateral fibular translation, posterior fibular translation and external rotation of fibula compared to tibia and stress values occurred on screws and suture-buttons. In the hybrid-1 model, lateral fibular translation and external fibular rotation values were obtained as close to the intact model. Von Mises stresses occurred in the screw (435.7 MPa) and suture-button (424.7 MPa) that used in hybrid-1 model was more than single screw at 4 cm model (316.8 MPa) and single suture-button at 2 cm model (160.7 MPa). In the Hybrid-1 model, the screw compensates for posterior fibular translation and external fibular rotation, while the suture-button compensates for lateral fibular translation. Also, the effect of the distal suture-button preventing diastasis in case of proximal screw failure, it was concluded that the hybrid-1 model can be used as a good treatment alternative in the surgical treatment of distal tibiofibular syndesmotic injuries.
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Affiliation(s)
- Numan Mercan
- Physician, Department of Orthopedics and Traumatology, Medical Faculty of Selcuk University, Konya, Turkey
| | - Ahmet Yıldırım
- Associate Professor, Department of Orthopedics and Traumatology, Medical Faculty of Selcuk University, Konya, Turkey.
| | - Yunus Dere
- Assistant Professor, Department of Civil Engineering, Necmettin Erbakan University, Konya, Turkey
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Comparison of Several Combinations of Suture Tape Reinforcement and Suture Button Constructs for Fixation of Unstable Syndesmosis. J Am Acad Orthop Surg 2022; 30:e769-e778. [PMID: 35171859 DOI: 10.5435/jaaos-d-21-00508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 11/08/2021] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION The purpose of this study was to arthroscopically evaluate syndesmotic stability after fixation with several combinations of suture buttons (SBs) and suture tape reinforcement in a completely unstable cadaver model. METHODS Fifteen cadaver above-knee specimens underwent sequential ligament transection and fixation to create six experimental models: (1) intact model, (2) after complete disruption of the syndesmotic ligaments, and after repair with either suture tape reinforcement (3), suture tape reinforcement with a single SB (4), suture tape reinforcement with two diverging SBs (5), or two diverging SBs alone (6). Instability measurements included anterior and posterior tibiofibular spaces measured arthroscopically under 100 N coronal stress, tibiofibular anteroposterior and posteroanterior translation in sagittal plane measured arthroscopically under sagittal stress of 100 N, and anterior tibiofibular space measured directly with a caliper under external rotation torque of 7.5 N·m. Instability measurements taken after each fixation method were compared with the uninjured model and with the complete unstable model using the Wilcoxon signed-rank test. RESULTS Fixation using a combination of one SB and singular suture tape reinforcement augmentation provided stability similar to the intact stage (coronal anterior space 1.24 versus 1.15, P = 0.887; coronal posterior space 1.63 versus 1.64, P = 0.8421; anteroposterior translation 0.91 versus 0.46, P = 0.003; posteroanterior translation 0.51 versus 0.57, P = 0.051; external rotation anterior tibiofibular space 1.08 versus 0.55, P = 0.069). Moreover, adding a second SB led to further gains in fixation stability. DISCUSSION This study suggests that although a destabilizing syndesmotic injury that includes the anterior inferior tibiofibular ligament, interosseous ligament, and posterior inferior tibiofibular ligament is not adequately stabilized by either one or two SBs, the addition of a suture tape reinforcement to even one SB restores syndesmotic stability to the preinjury level.
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Altmeppen JN, Colcuc C, Balser C, Gramlich Y, Klug A, Neun O, Manegold S, Hoffmann R, Fischer S. A 10-Year Follow-Up of Ankle Syndesmotic Injuries: Prospective Comparison of Knotless Suture-Button Fixation and Syndesmotic Screw Fixation. J Clin Med 2022; 11:jcm11092524. [PMID: 35566650 PMCID: PMC9105986 DOI: 10.3390/jcm11092524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 04/24/2022] [Accepted: 04/28/2022] [Indexed: 12/16/2022] Open
Abstract
Background: Acute syndesmosis injury (ASI) is an indication for surgical stabilization if instability is confirmed. In recent years, fixation using the knotless suture-button (SB) device has become increasingly established as an alternative to set screw fixation (SF). This study directly compared the clinical long-term results after prospective randomized inclusion. Materials and Methods: Between 2011 and 2012, 62 patients with ASI were enrolled in a prospective, randomized, and monocentric study. Forty-one patients were available for a 10-year follow-up ((31 males and 10 females), including 21 treated with SB (mean age 44.4 years), and 20 with SF (mean age 47.2 years)). In addition to comparing the demographic data and syndesmosis injury etiology, follow-up assessed the Olerud−Molander Ankle Score (OMAS) and FADI-Score (Foot and Ankle Disability Index Score) with subscales for activities of daily living (ADL) and sports activity. Results: The mean OMAS was 95.98 points (SB: 98.81, SF: 93.00), the mean FADI ADL was 97.58 points (SB: 99.22, SF: 95.86), and the mean FADI Sport was 94.14 points (SB: 97.03, SF: 91.10). None of the measurements differed significantly between the groups (p > 0.05). No clinical suspicion of chronic instability remained in any of the patients, regardless of treatment. Conclusions: The short-term results showed that athletes in particular benefit from SB fixation due to their significantly faster return to sports activities. However, the available long-term results confirm a very good outcome in the clinical scores for both approaches. Chronic syndesmotic insufficiency was not suspected in any of the patients. Level of evidence: I, randomized controlled trial.
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Affiliation(s)
- Jan Niklas Altmeppen
- Department for Trauma and Orthopaedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, 60389 Frankfurt, Germany; (J.N.A.); (C.B.); (Y.G.); (A.K.); (R.H.)
| | - Christian Colcuc
- Department of Trauma and Orthopaedic Surgery, Evangelical Hospital Bethel Bielefeld, 33611 Bielefeld, Germany;
| | - Christian Balser
- Department for Trauma and Orthopaedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, 60389 Frankfurt, Germany; (J.N.A.); (C.B.); (Y.G.); (A.K.); (R.H.)
| | - Yves Gramlich
- Department for Trauma and Orthopaedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, 60389 Frankfurt, Germany; (J.N.A.); (C.B.); (Y.G.); (A.K.); (R.H.)
| | - Alexander Klug
- Department for Trauma and Orthopaedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, 60389 Frankfurt, Germany; (J.N.A.); (C.B.); (Y.G.); (A.K.); (R.H.)
| | - Oliver Neun
- Department of Foot and Ankle Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, 60389 Frankfurt, Germany; (O.N.); (S.M.)
| | - Sebastian Manegold
- Department of Foot and Ankle Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, 60389 Frankfurt, Germany; (O.N.); (S.M.)
| | - Reinhard Hoffmann
- Department for Trauma and Orthopaedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, 60389 Frankfurt, Germany; (J.N.A.); (C.B.); (Y.G.); (A.K.); (R.H.)
| | - Sebastian Fischer
- Department of Foot and Ankle Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, 60389 Frankfurt, Germany; (O.N.); (S.M.)
- Correspondence: ; Tel.: +49-(0)-69-475-0
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Ingall EM, Kaiser P, Ashkani-Esfahani S, Zhao J, Kwon JY. The Lateral Fibular Stress Test: High Variability of Force Applied by Orthopaedic Surgeons in a Biomechanical Model. FOOT & ANKLE ORTHOPAEDICS 2022; 7:24730114221106484. [PMID: 35770144 PMCID: PMC9234856 DOI: 10.1177/24730114221106484] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background: The lateral fibular stress test (LFST), also known as the hook or Cotton
test, is commonly performed to assess syndesmotic instability
intraoperatively. Several studies have used 100 N as the force applied when
performing the LFST to detect syndesmotic instability, though no
evidence-based requisite force has been described for the test. We
hypothesize that surgeons do not apply force uniformly or consistently when
performing the LFST and that substantial variation exists. Fundamentally,
this could lead to inconsistent diagnosis of syndesmotic instability as
surgeons may not be applying the force in a consistent manner. Methods: A biomechanical ankle model consisting of an industrial force gauge attached
through a SawBones model was fashioned. Orthopaedic attending surgeons and
trainees were asked to perform a series of LFSTs and to simulate the force
they typically apply intraoperatively. Basic demographic data were collected
on each participant. Results: Thirty-three surgeons participated in the study, including 18 trainees. The
median (IQR) force applied during the LFST was 96.42 (71.42-126.33), 87.49
(69.19-117.40), 99.99 (79.91-137.49), for the pooled group, attendings, and
trainees respectively. More than half (54.5%) of all trials were less than
100 N (57.8% of surgeons, 51.8% trainees). Intraobserver correlation was
excellent within the overall cohort (0.92, P < .001),
trainees (0.90, P < .001), and attendings (0.94,
P < .001), respectively. Interobserver reliability
was fair among the overall cohort (κ =0.28, P = .49), and
poor between the attendings (κ = 0.11, P = .69) and the
trainees (κ = 0.05, P = .82), respectively. Conclusion: Our study demonstrates that the amount of force applied by typical surgeons
when performing the LFST test is highly variable. Variable force application
when performing the LFST may lead to inconsistent detection of syndesmotic
instability, which may portend a poorer outcome. Clinical Relevance: In this study, we demonstrate the wide variability in the amount of force
used during a lateral fibular stress test. High variability of force
application when performing the LFST may lead to inconsistent diagnosis of
syndesmotic instability, which may portend a poorer outcome. Our findings
suggest the need for further investigation into the technical aspects of
syndesmotic testing that will permit more reproducible and valid
interrogation of the syndesmosis.
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Affiliation(s)
- Eitan M. Ingall
- Harvard Combined Orthopaedic Residency Program, Massachusetts General Hospital, Boston, MA, USA
| | - Philip Kaiser
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Soheil Ashkani-Esfahani
- Foot & Ankle Research and Innovation Laboratory (FARIL), Massachusetts General Hospital, Boston, MA, USA
| | - John Zhao
- Harvard Combined Orthopaedic Residency Program, Massachusetts General Hospital, Boston, MA, USA
| | - John Y. Kwon
- Department of Orthopaedic Surgery, Division of Foot and Ankle Surgery, Massachusetts General Hospital, Boston, MA, USA
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