Chronic tibiofibular syndesmosis injury of ankle: evaluation with contrast-enhanced fat-suppressed 3D fast spoiled gradient-recalled acquisition in the steady state MR imaging

Proposed Classification of Syndesmotic Soft Tissue Impingement and Its Association With Lateral Talar Cartilage Lesions

BACKGROUND

Syndesmotic impingement syndrome has been described to explain persistent lateral or anterolateral ankle pain. This condition is thought to often result from a rotational ankle injury. This study aimed to identify the type of syndesmotic impingement tissue according to arthroscopic and histologic findings and to analyze its association with lateral talar cartilage lesions.

METHODS

This retrospective study included 107 ankles in 105 patients who underwent arthroscopic surgery for syndesmotic impingement syndrome from January 2017 to August 2019. Histologic findings of biopsied impingement tissue were obtained in 59 ankles (55.1%) and compared with gross findings on arthroscopy. Cartilage lesions were evaluated using the International Cartilage Repair Society grading system. Risk factors associated with lateral talar cartilage injury were evaluated using multivariate logistic regression analysis.

RESULTS

Based on the histologic results, the most common pathology was fibrosis (24 ankles [22.4%]), followed by fatty degeneration (23 ankles [21.5%]), synovial hyperplasia (8 ankles [7.5%]), and inflammatory synovium (4 ankles [3.7%]). Interclass correlation coefficient was 0.841 (P = .001) between histologic results and arthroscopic findings. Patients with fibrotic impingement tissue had on average a significantly longer duration of symptoms (12 vs 48 months, P = .021). A lateral talar dome cartilage lesion was detected in 25 ankles (23.4%). Fibrotic impingement tissue was the only factor significantly associated with lateral talar dome lesion on multivariate logistic regression analysis (odds ratio 10.04; 95% CI 1.84-54.9; P = .008).

CONCLUSION

Syndesmotic impingement with fibrotic tissue was often associated with cartilage lesions at the lateral talar dome. Patients with prolonged anterolateral or lateral ankle pain after a rotational ankle injury warrant careful assessment for possible syndesmotic impingement by fibrotic tissue and associated lateral talar cartilage injury.

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.

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.

The Role of Diffusion Weighted MR Imaging in the Diagnosis of Tendon Injuries of the Ankle and Foot

Background and objectives: Our aim is to determine the diagnostic performance and utility of Diffusion Weighted MR Imaging (DWI) against the routine Magnetic Resonance Imaging (MRI) for the evaluation of patients with tendon injuries of the ankle and foot. Materials and Method: After institutional review board approval and informed consent taken from all the patients, ankle and foot MR imaging and DWI-Apparent Diffusion Coefficient (ADC) mapping were performed on the 81 injured tendons of 50 patients. All tendon injuries were named as Rupture (R), Partial tear (PT), and Tenosynovitis (T). Diagnostic interpretation was based on the MRI-DWI and ADC mapping, verified by either open surgery, diagnostic arthroscopy, or conservative procedures-splint application. Statistical analysis of this research was assessed by Fischer’s exact test, variance analysis test between dependent groups, Receiver Operating Characteristics (ROC) curve, and Pearson chi square statistics. Results: MRI depicted all tendon injuries with 70% sensitivity and 100% specificity, and showed a significant statistical relationship to surgical and arthroscopic references with high agreement (p < 0.05, k: 0.609). DWI had 100% sensitivity and 83–90% specificity for the visualization of tendon injuries with certain agreement and a significant statistical relationship to the gold standard (p < 0.05, k: 0.890–0.899). For all those injured tendons, DWI had 100% sensitivity for the diagnosis of R, and 92–97% sensitivity corresponding to PT and T over routine ankle MR imaging. The specificity of DWI to MRI ranged from 75 to 44% for all the injured tendons. DWI had significant statistical superiority over MRI for the visualization of R, PT, and T of all tendons included in this research (p < 0.05). Conclusions: DWI is a good imaging modality for the visualization of ankles with tendon injuries, possibly further improving the sensitivity of the classical ankle and foot MRI, and supplying more beneficial and diagnostic information than routine MR imaging on the basis of R, PT, and T of tendons at the ankle and foot.

Non-enhanced multimodal magnetic resonance imaging in assessment of iliac vein obstruction with or without thrombosis

OBJECTIVE

To evaluate the diagnostic accuracy of a contrast-free multimodal magnetic resonance (MR) protocol (including M2DIPEAR, THRIVE, BTFE-SPAIR, and FLAIR sequences) in the detection of iliac vein obstruction with or without thrombosis.

MATERIALS AND METHODS

From May 1st, 2015, to May 1st, 2016, a total of 73 patients (aged 51.33 ± 4.21 years) who received both digital subtraction angiography (DSA) and the multimodal MR imaging were included. The protocol of the multimodal MR included M2DIPEAR and BTFE-SPAIR for presenting iliac vein obstruction, and THRIVE and FLAIR for revealing the co-existed thrombosis. Three observers who were blinded to clinical and DSA results independently analyzed all multimodal MR datasets. Per-patient evaluations on presence or absence of iliac vein obstruction were performed to calculate the diagnostic performance of MR imaging (DSA regarded as gold reference) in terms of overall accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Capability to display the co-existing venous thrombus was also evaluated per-MR sequence using a 3-point scale system.

RESULTS

Iliac vein obstruction was depicted with DSA in 64 patients. In per-patient evaluation, the multimodal MR imaging yielded accuracy of 95.9% (70/73), sensitivity of 96.9% (62/64), specificity of 88.9% (8/9), positive predictive value of 98.4% (62/63), and negative predictive value of 80% (8/10), respectively. In the multimodal MR sequences, balanced turbo field echo-spectral attenuated inversion recovery (BTFE-SPAIR) sequence was superior to other sequences in depicting the iliac vein configuration, but fluid attenuated inversion recovery (FLAIR) and T1 high-resolution isovolumetric examination (THRIVE) seemed superior in detecting co-existing venous thrombosis.

CONCLUSIONS

M2DIPEAR and BTFE-SPAIR sequence can reveal iliac vein obstruction while THRIVE and FLAIR can detect the co-existed thrombosis. The proposed multimodal MR protocol can accurately depict the iliac vein obstruction and accurately detect the co-existing venous thrombosis comparable with that of DSA.

Arthroscopic characterization of syndesmotic instability in the coronal plane: Exactly what measurement matters?

BACKGROUND

Although ankle arthroscopy is increasingly used to diagnose syndesmotic instability, precisely where in the incisura one should measure potential changes in tibiofibular space or how much tibiofibular space is indicative of instability, however, remains unclear. The purpose of this study was to determine where within the incisura one should assess coronal plane syndesmotic instability and what degree of tibiofibular space correlates with instability in purely ligamentous syndesmotic injuries under condition of lateral hook stress test (LHT) assessment.

METHODS

Ankle arthroscopy was performed on 22 cadaveric specimens, first with intact ankle ligaments and then after sequential sectioning of the syndesmotic and deltoid ligaments. At each step, a 100N lateral hook test was applied through a lateral incision 5 cm proximal to the ankle joint and the coronal plane tibiofibular space in the stressed and unstressed states were measured at both anterior and posterior third of the distal tibiofibular joint, using calibrated probes ranging from 0.1 to 6.0 mm, in 0.1 mm of increments. The anterior and posterior points of measurements were defined as the junction between the anterior and middle third, and junction between posterior and middle third of the incisura, respectively.

RESULTS

Anterior third tibiofibular space measurements did not correlate significantly with the degree of syndesmotic instability after transection of the ligaments, neither before nor after applying LHT at all the three groups of different sequences of ligament transection (P range 0.085-0.237). In contrast, posterior third tibiofibular space measurements correlated significantly with the degree of syndesmotic instability after transection of the ligaments, both with and without applying stress in all the groups of different ligament transection (P range <0.001-0.015). Stressed tibiofibular space measurements of the posterior third showed higher sensitivity and specificity when compared to the stressed anterior third measurements. Using 2.7 mm as a cut off for posterior third stressed measurements has both sensitivity and specificity about 70 %.

CONCLUSION

Syndesmotic ligament injury results in coronal plane instability of the distal tibiofibular articulation that is readily identified arthroscopically with LHT when measured in the posterior third of the incisura.

CLINICAL RELEVANCE

When applying LHT, tibiofibular space measurement for coronal plane instability along the anterior third of the incisura is less sensitive for identifying syndesmotic instability and may miss this diagnosis especially when subtle.

Arthroscopic coronal plane syndesmotic instability has been over-diagnosed

PURPOSE

Ankle arthroscopy is widely used for diagnosis of syndesmotic instability, especially in subtle cases. To date, no published article has systematically reviewed the literature in aggregate to understand which instability values should be used intraoperatively. The primary aim was to systematically review the amount of tibiofibular displacement that correlates with syndesmotic instability after a high ankle sprain. A secondary aim is to assess the quality of such research.

METHODS

Systematic searches of EMBASE (Ovid) and MEDLINE via PubMed, CINAHL, Web of Science, and Google Scholar were used.

INCLUSION CRITERIA

studies that arthroscopically evaluated the fibular displacement at various stages of syndesmotic ligament injury. Two reviewers independently extracted data and assessed methodological quality using the Anatomical Quality Assessment (AQUA) Tool and methodological index for non-randomized studies (MINORS).

RESULTS

Eight cadaveric studies and three clinical studies were included for review. All studies reported displacement in the coronal plane, four studies reported in the sagittal plane, and one reported findings in the rotational plane. Four cadaveric studies had a similar experimental set up and the weighted mean associated with instability in the coronal plane could be calculated and was 2.9 mm at the anterior portion of the distal tibiofibular joint and 3.4 mm at the posterior portion. Syndesmotic instability in the sagittal plane is less extensively studied, however available data from a cadaveric study suggests thresholds of 2.2 mm of posterior fibular translation when performing an anterior to posterior hook test and 2.6 mm of anterior fibular translation when performing a posterior to anterior hook test.

CONCLUSIONS

The results have concluded that the commonly used 2.0 mm threshold value of distal tibiofibular diastasis may lead to overtreatment of syndesmotic instability, and that using threshold values of 2.9 mm measured at the anterior portion of the incisura and 3.4 mm at the posterior portion may represent better cut off values. Given the ready availability of 3 mm probes among standard arthroscopic instrumentation, at the very least surgeons should use 3 mm in lieu of 2 mm probes intraoperatively.

LEVEL OF EVIDENCE

IV.

Evaluation of the anterior inferior tibiofibular and anterior talofibular ligaments using 2D oblique coronal imaging and 3D isotropic resolution T2-weighted fast spin-echo sequences at 3.0 T: Is there additional diagnostic value?

INTRODUCTION

To compare diagnostic performance of additional two-dimensional (2D) oblique coronal view and three-dimensional (3D) T2-weighted fast spin-echo(FSE) images for diagnosing injury of the anterior inferior tibiofibular (AiTFL) and anterior talofibular ligaments (ATFL).

METHODS

This study included 48 patients with ankle sprain who had undergone MRI using standard protocol and two additional sequences with 2D oblique coronal and 3D isotropic images, followed by arthroscopic surgery. Ligament injuries was subdivided by intact tendon, partial or complete tear. Retrospectively, two musculoskeletal radiologists respectively reviewed three image sets of MR including 2D axial image only (set 1), 2D axial and oblique coronal images (set 2), and 2D axial with 3D-isotropic images (set 3). Using arthroscopic findings as reference standard, diagnostic performances of both methods were analysed by the area under the curve (AUC).

RESULTS

Arthroscopy confirmed 13 AiTFL and 41 ATFL injuries. For AiTFL, when set 1 and set 3 were compared, AUC value was significantly higher for set 3 (P < 0.05). However, there was no significant difference between AUC values for set 2 and set 3 sequences by either reader for either type of tear (P > 0.05). For ATFL, both readers found there was no significant difference in AUC values between set 1 and set 3 and between set 2 and set 3.

CONCLUSION

Additional oblique coronal sequence demonstrated better diagnostic performance for AiTFL injury than conventional and isotropic imaging did. This sequence showed as much diagnostic accuracy as isotropic sequence for evaluation of ATFL injury.

MRI of the distal tibiofibular joint

The distal tibiofibular joint is a fibrous joint that plays a crucial role in the stability of the ankle joint. It is stabilized by three main ligaments: the anterior inferior tibiofibular ligament, the posterior inferior tibiofibular ligament, and the interosseous tibiofibular ligament, which are well delineated on magnetic resonance imaging. Pathology of the distal tibiofibular joint is mostly related to trauma and the longer-term complications of trauma, such as soft tissue impingement, heterotopic ossification, and synostosis. This review article outlines the MRI anatomy and pathology of this joint.

CT arthrography for demonstration of various articular injuries in post-sprained ankle pain

Background

Post-sprained ankles may sustain ligamentous tear, chondral defect, or osteochondral lesions (OCL). Being widely available and does not depend on high-end machine, the aim of this study was to assess the value of high resolution multi-detector CT arthrography (CTA) in detection of various ligamentous tears, chondral defects, and osteochondral lesions in case of sprain-related persistent ankle pain.

Results

There were 34 (68%) cases of ligamentous injury, most of which had single ligament affection whereas some cases demonstrated multi-ligamentous injury, and the total number of individual injured ligaments was 42 ligaments. There were 36 cases (72%) which had either chondral or osteochondral defects; the total number of OCL was 21 lesions and the total number of segmental cartilage defects was 20.

Conclusion

This study emphasized the diagnostic importance of multi-detector CTA in sprain-related ankle pain. In persistent post-sprained ankle pain, multi-detector CTA is a helpful imaging modality which could be utilized for detection of OCL, chondral defects, and various ligamentous tears.

Surgical outcome in chronic syndesmotic injury: A systematic literature review

BACKGROUND

Chronic injuries of the distal tibio-fibular syndesmosis often present with non-specific clinical and radiographic findings. If chronic instability to the distal tibio-fibular syndesmosis is verified, various reconstruction options are available. The purpose of this article is to give a systematic review of current surgical treatment options in patients with chronic syndesmotic injury.

METHODS

Three major medical databases were searched from inception through December 12, 2017: PubMed, ScienceDirect, and SpringerLink. Studies were included if they were original research studies which assessed the outcome of patients treated surgically for chronic syndesmotic instability. Only studies written in English were considered. The following data were extracted from each study: number of patients and ankles included, average patients' age, gender, study design, preoperative examination, time between the initial injury and the operation, postoperative follow-up time, operative technique, complication rates, and clinical outcome. The modified Coleman Score was used to assess the methodologic quality of the included studies.

RESULTS

Seventeen (17) studies were included. All studies were retrospective or prospective case series. Each study was performed at a single center. In general, good functional outcomes and low complication rates were reported. The American Orthopaedic Foot and Ankle (AOFAS) score was most frequently used outcome tool to measure postoperative outcomes. The quality of the included studies was overall satisfactory.

CONCLUSIONS

A few studies have reported on the operative outcomes after treating chronic syndesmotic instability. Several different techniques were used to treat this problem. The quality of current studies is overall satisfactory but could be improved with larger patient numbers and prospective analysis. Recognition of this clinical entity as an identifiable and treatable cause of ankle pain requires vigilant clinical investigation.

LEVEL OF EVIDENCE

Level IV; Systematic Review of Level IV Studies.

Diagnostic Accuracy of Radiologic Methods for Ankle Syndesmosis Injury: A Systematic Review and Meta-Analysis

: Misdiagnosis and inadequate treatment of syndesmosis could result in significant long-term morbidity including pain, instability, and degenerative changes of the ankle joint. The objective of this systematic review and meta-analysis was to determine whether radiologic tests accurately and reliably diagnose ankle syndesmosis injury. Medline, Embase, and Cochrane were searched. The database search resulted in 258 full text articles that we assessed for eligibility, we used eight studies that met all the inclusion criteria. In subgroup meta-analysis, the sensitivity analysis showed significant differences only in the MRI (Magnetic Resonance Imaging), and specificity was not statistically significant. In diagnostic meta-analysis, the pooled sensitivity and specificity were 0.528 and 0.984 for X-rays, 0.669 and 0.87&nbsp;for CT (Computed Tomography), and 0.929 and 0.865 for MRI, all respectively. For sensitivity, MRI showed significantly sensitivity as higher than the other methods, and we detected no significance for specificity. Syndesmosis injuries differed significantly in the accuracy of radiological methods according to the presence of accompanied ankle fractures. In patients with fractures, simple radiography has good specificity, and CT and MRI have high sensitivity and specificity irrespective of fracture; in particular, MRI has similar accuracy to gold standard arthroscopic findings.

Imaging in syndesmotic injury: a systematic literature review

OBJECTIVES

To give a systematic overview of current diagnostic imaging options for assessment of the distal tibio-fibular syndesmosis.

MATERIALS AND METHODS

A systematic literature search across the following sources was performed: PubMed, ScienceDirect, Google Scholar, and SpringerLink. Forty-two articles were included and subdivided into three groups: group one consists of studies using conventional radiographs (22 articles), group two includes studies using computed tomography (CT) scans (15 articles), and group three comprises studies using magnet resonance imaging (MRI, 9 articles).The following data were extracted: imaging modality, measurement method, number of participants and ankles included, average age of participants, sensitivity, specificity, and accuracy of the measurement technique. The Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool was used to assess the methodological quality.

RESULTS

The three most common techniques used for assessment of the syndesmosis in conventional radiographs are the tibio-fibular clear space (TFCS), the tibio-fibular overlap (TFO), and the medial clear space (MCS). Regarding CT scans, the tibio-fibular width (axial images) was most commonly used. Most of the MRI studies used direct assessment of syndesmotic integrity. Overall, the included studies show low probability of bias and are applicable in daily practice.

CONCLUSIONS

Conventional radiographs cannot predict syndesmotic injuries reliably. CT scans outperform plain radiographs in detecting syndesmotic mal-reduction. Additionally, the syndesmotic interval can be assessed in greater detail by CT. MRI measurements achieve a sensitivity and specificity of nearly 100%; however, correlating MRI findings with patients' complaints is difficult, and utility with subtle syndesmotic instability needs further investigation. Overall, the methodological quality of these studies was satisfactory.

Distal Tibiofibular Syndesmosis: Anatomy, Biomechanics, Injury and Management

A stable and precise articulation of the distal tibiofibular syndesmosis is essential for normal motion of the ankle joint. Injury to the syndesmosis occurs through rupture or bony avulsion of the syndesmotic ligament complex. External rotation of the talus has been identified as the major mechanism of syndesmotic injury. None of the syndesmotic stress tests was sensitive or specific; therefore the diagnosis of syndesmotic injury should not be made based on the medical history and physical examination alone. With the improvement in ankle arthroscopic technique, it can be used as a diagnostic and therapeutic tool in the management of distal tibiofibular syndesmosis injury.

Arthroscopic Anatomy of the Ankle Joint

There are a number of variations in the intra-articular anatomy of the ankle which should not be considered pathological under all circumstances. The anteromedial corner of the tibial plafond (between the anterior edge of the tibial plafond and the medial malleolus) can have a notch, void of cartilage and bone. This area can appear degenerative arthroscopically; it is actually a normal variant of the articular surface. The anterior inferior tibiofibular ligament (AITF) can possess a lower, accessory band which can impinge on the anterolateral edge of the talar dome. In some cases it can cause irritation along this area of the talus laterally. If it is creating local irritation it can be removed since it does not provide any additional stabilization to the syndesmosis. There is a beveled region at the anterior leading edge of the lateral and dorsal surfaces of the talus laterally. This triangular region is void of cartilage and subchondral bone. The lack of talar structure in this region allows the lower portion of the AITF ligament to move over the talus during end range dorsiflexion of the ankle, preventing impingement. The variation in talar anatomy for this area should not be considered pathological.

Magnetic resonance imaging characterization of individual ankle syndesmosis structures in asymptomatic and surgically treated cohorts

PURPOSE

Historically, syndesmosis injuries have been underdiagnosed. The purpose of this study was to characterize the 3.0-T MRI presentations of the distal tibiofibular syndesmosis and its individual structures in both asymptomatic and injured cohorts.

METHODS

Ten age-matched asymptomatic volunteers were imaged to characterize the asymptomatic syndesmotic anatomy. A series of 21 consecutive patients with a pre-operative 3.0-T ankle MRI and subsequent arthroscopic evaluation for suspected syndesmotic injury were reviewed and analysed. Prospectively collected pre-operative MRI findings were correlated with arthroscopy to assess diagnostic accuracy [sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV)].

RESULTS

Pathology diagnosed on pre-operative MRI correlated strongly with arthroscopic findings. Syndesmotic ligament disruption was prospectively diagnosed on MRI with excellent sensitivity, specificity, PPV, NPV, and accuracy: anterior inferior tibiofibular ligament (87.5, 100, 100, 71.4, 90.5 %); posterior inferior tibiofibular ligament (N/A, 95.2, 0.0, 100, 95.2 %); and interosseous tibiofibular ligament (66.7, 86.7, 66.7, 86.7, 81.0 %).

CONCLUSIONS

Pre-operative 3.0-T MRI demonstrated excellent accuracy in the diagnosis of syndesmotic ligament tears and allowed for the visualization of relevant individual syndesmosis structures. Using a standard clinical ankle MRI protocol at 3.0-T, associated ligament injuries could be readily identified. Clinical implementation of optimal high-field MRI sequences in a standard clinical ankle MRI exam can aid in the diagnosis of syndesmotic injuries, augment pre-operative planning, and facilitate anatomic repair by providing additional details regarding the integrity of individual syndesmotic structures not discernible through physical examination and radiographic assessments.

LEVEL OF EVIDENCE

II.

Classification and diagnosis of acute isolated syndesmotic injuries: ESSKA-AFAS consensus and guidelines

PURPOSE

The aim of the present study was to perform a systematic review of the current classification systems, and the clinical and radiological tests for the acute isolated syndesmotic injuries to identify the best method of classification and diagnosis allowing the surgeon to choose the appropriate management.

METHODS

A systematic review of the literature according to the PRISMA guidelines has been performed. A comprehensive search using various combinations of the keywords "classification", "grading system", "ankle injury", "ligament", "syndesmotic injury", "internal fixation", "acute", "synostosis", "ligamentoplasties", "clinical", "radiological" over the years 1962-2015 was performed. The following databases were searched: MEDLINE, Google Scholar, EMBASE and Ovid.

RESULTS

The literature search resulted in 345 references for classification systems and 308 references for diagnosis methods, of which 283 and 295 were rejected due to off-topic abstract and/or failure to fulfil the inclusion criteria. After reading the remaining full-text articles, we included 27 articles describing classification systems and 13 articles describing diagnostic tests for acute isolated syndesmotic injuries.

CONCLUSIONS

The ESSKA-AFAS consensus panel recommends distinguishing acute isolated syndesmotic injury as stable or unstable. Stable injuries should be treated non-operatively with a short-leg cast or brace, while unstable injuries should be managed operatively. The recommended clinical tests include: tenderness on palpation over the anterior tibiofibular ligament, the fibular translation test and the Cotton test. Radiographic imaging must include an AP view and a mortise view of the syndesmosis to check the tibiofibular clear space, medial clear space overlap, tibial width and fibular width.

LEVEL OF EVIDENCE

IV.

What's new in the use of MRI in the orthopaedic trauma patient?

MRI has been established as an essential tool for accurate diagnosis in patients with musculoskeletal trauma. Its major advantages include excellent soft tissue contrast, high spatial resolution and lack of ionizing radiation. Although plain radiographs remain the basic tool for diagnosis and treatment planning in bone fractures assisted by CT in pelvic, spine and large joints injuries, there are specific circumstances that require MRI. For instance, tendinous, ligamentous, intraarticular structures such as the cartilage and menisci, and intramedullary injury are seen mostly with MRI. Volumetric 3D techniques are now commercially available and provide higher spatial resolution which improves anatomic detail, allows multiplanar reformations and reduces the acquisition time. Newer applications on quantitative rather than morphologic imaging, such as relaxometry and diffusion tensor imaging, may be of paramount importance in treatment planning in the near future. Software improvements reduce metal induced artefacts, allowing thus imaging of the postoperative patient with metallic implants. A tendency towards a structured reporting pattern and standardised medical communication needs to be further explored for the benefit of orthopaedic surgeons, radiologists and patients.

Syndesmosis injuries

Traumatic injuries to the distal tibiofibular syndesmosis commonly result from high-energy ankle injuries. They can occur as isolated ligamentous injuries and can be associated with ankle fractures. Syndesmotic injuries can create a diagnostic and therapeutic challenge for musculoskeletal physicians. Recent literature has added considerably to the body of knowledge pertaining to injury mechanics and treatment outcomes, but there remain a number of controversies regarding diagnostic tests, implants, techniques, and postoperative protocols. Use of the novel suture button device has increased in recent years and shows some promise in clinical and cadaveric studies. This article contains a review of syndesmosis injuries, including anatomy and biomechanics, diagnosis, classification, and treatment options.

National Athletic Trainers' Association position statement: conservative management and prevention of ankle sprains in athletes

OBJECTIVE

To present recommendations for athletic trainers and other allied health care professionals in the conservative management and prevention of ankle sprains in athletes.

BACKGROUND

Because ankle sprains are a common and often disabling injury in athletes, athletic trainers and other sports health care professionals must be able to implement the most current and evidence-supported treatment strategies to ensure safe and rapid return to play. Equally important is initiating preventive measures to mitigate both first-time sprains and the chance of reinjury. Therefore, considerations for appropriate preventive measures (including taping and bracing), initial assessment, both short- and long-term management strategies, return-to-play guidelines, and recommendations for syndesmotic ankle sprains and chronic ankle instability are presented.

RECOMMENDATIONS

The recommendations included in this position statement are intended to provide athletic trainers and other sports health care professionals with guidelines and criteria to deliver the best health care possible for the prevention and management of ankle sprains. An endorsement as to best practice is made whenever evidence supporting the recommendation is available.

An evaluation of a superfast MRI sequence in the diagnosis of suspected acute appendicitis

BACKGROUND

A lack of typical symptoms in acute appendicitis may delay the appropriate therapy. We hypothesized that a superfast MRI sequence with fat suppression could assist in the diagnosis of acute appendicitis.

OBJECTIVE

To evaluate the sensitivity and specificity of MRI in the diagnosis of suspected acute appendicitis especially in the early stages and before surgery.

METHODS

Subject images were acquired with a 1.5-T clinical MRI scanner (Achieva Nova Dual, Philips, Netherlands) with a four-element phased array abdominal coil with a SENSE factor of 1.8. A total of 41 cases with suspected acute appendicitis were recruited. SENSE-BTFE-SPIR sequence, sensitivity encoding (SENSE) with balanced turbo field echo (BTFE) and spectral presaturation and inversion recovery (SPIR), was adopted in this study.

RESULTS

The sensitivity and specificity were 91.7% and 100%, respectively, in the diagnosis of acute appendicitis by SENSE-BTFE-SPIR in this series. Cases with simple acute appendicitis showed a higher T2 signal in the appendiceal wall, with local fluid surrounding appendix. Cases with purulent appendicitis showed an increased T2 signal within the cavity of the appendix, along with appendiceal wall thickening, or increased T2 signals around effusions in cases with gangrenous appendicitis. A periappendiceal abscess showed a localized, high-signal fluid collection that may have had extensive effects on the adjacent bowel loops, into which the entire appendix may disappear.

CONCLUSIONS

The fast SENSE-BTFE-SPIR sequence is capable of demonstrating the location and position of the appendix, the presence of acute appendicitis and its complications, and the clinical stages.

Isolated syndesmosis ankle injury

Isolated syndesmosis injuries often go unrecognized and are diagnosed as lateral ankle sprains; however, they are more disabling than lateral ankle sprains. The reported incidence of isolated syndesmosis injuries in acute ankle sprains ranges between 1% and 16%. When ankle disability lasts for more than 2 months after an ankle sprain, the incidence increases to 23.6%. Diagnostic workup may include stress radiographs, magnetic resonance imaging, or diagnostic arthroscopy. A simple stress test radiograph may reveal an unstable grade III syndesmosis sprain that may go unrecognized on plain anteroposterior and mortise or lateral radiographs of the ankle. The duration of symptoms in isolated syndesmosis injury is longer and more severe, often leading to chronic symptoms or ankle instability requiring operative stabilization.This article describes the clinical presentation, injury classification, and operative stabilization techniques of isolated syndesmosis injuries. The authors performed their preferred operative stabilization technique for isolated syndesmosis injury-arthroscopic debridement of the ankle with syndesmotic stabilization with a syndesmotic screw-in 4 patients. All patients were evaluated 1 year postoperatively with subjective and objective assessment scales. Three of 4 patients showed good improvement of general subjective ankle symptoms and subjective ankle instability rating and a high Sports Ankle Rating System score after 1 year.

Tibiofibular syndesmosis in acute ankle fractures: additional value of an oblique MR image plane

OBJECTIVE

To evaluate the additional value of a 45° oblique MRI scan plane for assessing the anterior and posterior distal tibiofibular syndesmotic ligaments in patients with an acute ankle fracture.

MATERIALS AND METHODS

Prospectively, data were collected for 44 consecutive patients with an acute ankle fracture who underwent a radiograph (AP, lateral, and mortise view) as well as an MRI in both the standard three orthogonal planes and in an additional 45° oblique plane. The fractures on the radiographs were classified according to Lauge-Hansen (LH). The anterior (ATIFL) and posterior (PTIFL) distal tibiofibular ligaments, as well as the presence of a bony avulsion in both the axial and oblique planes was evaluated on MRI. MRI findings regarding syndesmotic injury in the axial and oblique planes were compared to syndesmotic injury predicted by LH. Kappa and the agreement score were calculated to determine the interobserver agreement. The Wilcoxon signed rank test and McNemar's test were used to compare the two scan planes.

RESULTS

The interobserver agreement (κ) and agreement score [AS (%)] regarding injury of the ATIFL and PTIFL and the presence of a fibular or tibial avulsion fracture were good to excellent in both the axial and oblique image planes (κ 0.61-0.92, AS 84-95%). For both ligaments the oblique image plane indicated significantly less injury than the axial plane (p < 0.001). There was no significant difference in detection of an avulsion fracture in the axial or oblique plane, neither anteriorly (p = 0.50) nor posteriorly (p = 1.00). With syndesmotic injury as predicted by LH as comparison, the specificity in the oblique MR plane increased for both anterior (to 86% from 7%) and posterior (to 86% from 48%) syndesmotic injury when compared to the axial plane.

CONCLUSION

Our results show the additional value of an 45° oblique MR image plane for detection of injury of the anterior and posterior distal tibiofibular syndesmoses in acute ankle fractures. Findings of syndesmotic injury in the oblique MRI plane were closer to the diagnosis as assumed by the Lauge-Hansen classification than in the axial plane. With more accurate information, the surgeon can better decide when to stabilize syndesmotic injury in acute ankle fractures.

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.

Review of common and unusual causes of lateral ankle pain

Lateral ankle pain is a common clinical presentation having several important causes, including lateral ligament injury, peroneal tendon injury, sinus tarsi syndrome, and nerve entrapments. However, other causes should be kept in mind in patients with unusual patterns of pain or intractable symptoms. We present a review of common and some unusual causes of lateral ankle pain including a review of post-operative imaging findings following surgery for lateral ankle ligament and peroneal tendon injuries.

Anatomy of the distal tibiofibular syndesmosis in adults: a pictorial essay with a multimodality approach

A syndesmosis is defined as a fibrous joint in which two adjacent bones are linked by a strong membrane or ligaments.This definition also applies for the distal tibiofibular syndesmosis, which is a syndesmotic joint formed by two bones and four ligaments. The distal tibia and fibula form the osseous part of the syndesmosis and are linked by the distal anterior tibiofibular ligament, the distal posterior tibiofibular ligament, the transverse ligament and the interosseous ligament. Although the syndesmosis is a joint, in the literature the term syndesmotic injury is used to describe injury of the syndesmotic ligaments. In an estimated 1–11% of all ankle sprains, injury of the distal tibiofibular syndesmosis occurs. Forty percent of patients still have complaints of ankle instability 6 months after an ankle sprain. This could be due to widening of the ankle mortise as a result of increased length of the syndesmotic ligaments after acute ankle sprain. As widening of the ankle mortise by 1 mm decreases the contact area of the tibiotalar joint by 42%, this could lead to instability and hence early osteoarthritis of the tibiotalar joint. In fractures of the ankle, syndesmotic injury occurs in about 50% of type Weber B and in all of type Weber C fractures. However,in discussing syndesmotic injury, it seems the exact proximal and distal boundaries of the distal tibiofibular syndesmosis are not well defined. There is no clear statement in the Ashhurst and Bromer etiological, the Lauge-Hansen genetic or the Danis-Weber topographical fracture classification about the exact extent of the syndesmosis. This joint is also not clearly defined in anatomical textbooks, such as Lanz and Wachsmuth. Kelikian and Kelikian postulate that the distal tibiofibular joint begins at the level of origin of the tibiofibular ligaments from the tibia and ends where these ligaments insert into the fibular malleolus. As the syndesmosis of the ankle plays an important role in the stability of the talocrural joint, understanding of the exact anatomy of both the osseous and ligamentous structures is essential in interpreting plain radiographs, CT and MR images, in ankle arthroscopy and in therapeutic management. With this pictorial essay we try to fill the hiatus in anatomic knowledge and provide a detailed anatomic description of the syndesmotic bones with the incisura fibularis, the syndesmotic recess, synovial fold and tibiofibular contact zone and the four syndesmotic ligaments. Each section describes a separate syndesmotic structure, followed by its clinical relevance and discussion of remaining questions.

The additional value of an oblique image plane for MRI of the anterior and posterior distal tibiofibular syndesmosis

OBJECTIVE

The optimal MRI scan planes of collateral ligaments of the ankle have been described extensively, with the exception of the syndesmotic ligaments. We assessed the optimal scan plane for depicting the distal tibiofibular syndesmosis.

MATERIALS AND METHODS

In order to determine the optimal oblique caudal-cranial and lateral-medial MRI scan plane, two fresh frozen cadaveric ankles were used. The angle of the scan plane that demonstrated the anterior and posterior distal tibiofibular ligament uninterrupted in their full length was determined. In a prospective study this oblique scan plane was then used in addition to the axial and coronal planes, for MRI scans of both ankles in 21 healthy volunteers. Two observers independently evaluated the anterior tibiofibular ligament (ATIFL) and posterior tibiofibular ligament (PTIFL) regarding the continuity of the individual fascicles, thickness and wavy contour of the ligaments in both the axial and the oblique plane. Kappa was calculated to determine the interobserver agreement. McNemar's test was used to statistically quantify the significance of the two scan planes.

RESULTS

In the axial plane the ATIFL was in 31% (13/42) partly and in 69% (29/42) completely discontinuous; in the oblique plane the ATIFL was continuous in 88% (37/42) and partly discontinuous in 12% (5/42). Compared with the axial plane, the oblique plane demonstrated significantly less discontinuity (p<0.001), but not significantly less thickening (p=1.00) or less wavy contour (p=0.06) of the ATIFL. In the axial scan plane the PTIFL was continuous in 76% (32/42), partially discontinuous in 19% (8/42) and completely discontinuous in 5% (2/42); in the oblique plane the PTIFL was continuous in 100% (42/42). Compared with the axial plane, the oblique plane demonstrated significantly less discontinuity (p=0.002), but not significantly less thickening (p=1.00) or less wavy contour (p=0.50) of the PTIFL. The interobserver agreement score and kappa (κ) regarding the continuity for the ATIFL in the axial and oblique planes was 91% (κ=0.79) and 91% (κ=0.55) respectively; for the PTIFL it was 86% (κ=0.65) and 100% (κ = not defined).

CONCLUSION

The ATIFL and PTIFL are routinuely scanned in the orthogonal planes. The advantage of MRI scanning in an oblique image plane of about 45 degrees permits a better evaluation of the ligaments compared with the axial plane, particularly a better interpretation of ligament continuity, thickening and wavy contour. This may lead to a reduction in false-positive results, especially regarding partial or complete ligament ruptures. This can be of considerable aid in therapeutic management.

[Fractures of the upper ankle]

Upper ankle injuries are the most common reason for presentation in emergency departments. The initial treatment is often left in the hands of young clinical professionals. While the mechanism of injury might appear banal, insufficient diagnosis and treatment can lead to long periods of disability and functional impairment of the joint. Therefore, it is the aim of this work to provide a thorough understanding of the anatomy, biomechanics, mechanism of injury, diagnostic and operative procedures of ankle joint fractures.

Founder's lecture of the ISS 2006: borderlands of normal and early pathological findings in MRI of the foot and ankle

The purpose of this article is to highlight the anatomical variants, technical pitfalls, and the prevalence of abnormal conditions in the asymptomatic population in magnetic resonance imaging of the foot and ankle. Special attention is drawn to the complex anatomy of the deltoid ligament (the superficial tibionavicular ligament, tibiospring ligament, the tibiocalcaneal ligament, and the deep anterior and posterior tibiotalar ligaments) and the posterior tibial tendon insertion including the magic angle artifact and the high prevalence of asymptomatic findings such as "hypertrophied" peroneal tubercle (abnormal only when larger than 5 mm), peroneus quartus (prevalence 17%), and cysts (vascular remnants) just inferior to the angle of Gissane.