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Peiffer M, Dhont T, Cuigniez F, Tampere T, Ashkani-Esfahani S, D'Hooghe P, Audenaert E, Burssens A. Application of external torque enhances the detection of subtle syndesmotic ankle instability in a weight-bearing CT. Knee Surg Sports Traumatol Arthrosc 2023; 31:4886-4894. [PMID: 37572141 DOI: 10.1007/s00167-023-07536-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 07/28/2023] [Indexed: 08/14/2023]
Abstract
PURPOSE Acute syndesmotic ankle injuries continue to impose a diagnostic dilemma and it remains unclear whether weightbearing and/or external rotation should be added during the imaging process. Therefore, the aim of this study was to assess if combined weightbearing and external rotation increases the diagnostic sensitivity of syndesmotic ankle instability using weightbearing CT (WBCT) imaging, compared to isolated weightbearing. METHODS In this retrospective study, patients with an acute syndesmotic ankle injury were analysed using a WBCT (N = 21; Age = 31.6 ± 14.1 years old). Inclusion criteria were an MRI confirmed syndesmotic ligament injury imaged by a WBCT of the ankle during weightbearing and combined weightbearing-external rotation. Exclusion criteria consisted of fracture associated syndesmotic injuries. Three-dimensional (3D) models were generated from the CT slices. Tibiofibular displacement and talar rotation were quantified using automated 3D measurements (anterior tibiofibular distance (ATFD), Alpha angle, posterior Tibiofibular distance (PTFD) and Talar rotation (TR) angle in comparison to the contralateral non-injured ankle. RESULTS The difference in neutral-stressed Alpha angle and ATFD showed a significant difference between patients with a syndesmotic ankle lesion and contralateral control (P = 0.046 and P = 0.039, respectively). The difference in neutral-stressed PTFD and TR angle did not show a significant difference between patients with a syndesmotic ankle lesion and healthy ankles (n.s.). CONCLUSION Application of combined weightbearing-external rotation reveals an increased ATFD in patients with syndesmotic ligament injuries. This study provides the first insights based on 3D measurements to support the potential relevance of applying external rotation during WBCT imaging. In clinical practice, this could enhance the current diagnostic accuracy of subtle syndesmotic instability in a non-invasive manner. However, to what extent certain displacement patterns require operative treatment strategies has yet to be determined in future studies. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- M Peiffer
- Department of Orthopaedics and Traumatology, Ghent University Hospital, 9000, Ghent, OVL, Belgium.
- Department of Human Structure and Repair, Ghent University, Corneel Heymanslaan 10, 9000, Ghent, OVL, Belgium.
- Foot and Ankle Research and Innovation Laboratory (FARIL), Harvard Medical School-Massachusetts General Hospital, Boston, MA, USA.
| | - T Dhont
- Department of Orthopaedics and Traumatology, Ghent University Hospital, 9000, Ghent, OVL, Belgium
| | - F Cuigniez
- Department of Orthopaedics and Traumatology, Ghent University Hospital, 9000, Ghent, OVL, Belgium
| | - T Tampere
- Department of Orthopaedics and Traumatology, Ghent University Hospital, 9000, Ghent, OVL, Belgium
| | - S Ashkani-Esfahani
- Foot and Ankle Research and Innovation Laboratory (FARIL), Harvard Medical School-Massachusetts General Hospital, Boston, MA, USA
| | - P D'Hooghe
- Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar
| | - E Audenaert
- Department of Orthopaedics and Traumatology, Ghent University Hospital, 9000, Ghent, OVL, Belgium
- Department of Human Structure and Repair, Ghent University, Corneel Heymanslaan 10, 9000, Ghent, OVL, Belgium
- Department of Electromechanics, Op3Mech Research Group, University of Antwerp, 2020, Antwerp, Belgium
- Department of Trauma and Orthopedics, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - A Burssens
- Department of Orthopaedics and Traumatology, Ghent University Hospital, 9000, Ghent, OVL, Belgium
- Department of Human Structure and Repair, Ghent University, Corneel Heymanslaan 10, 9000, Ghent, OVL, Belgium
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Evidence-Based Surgical Treatment Algorithm for Unstable Syndesmotic Injuries. J Clin Med 2022; 11:jcm11020331. [PMID: 35054025 PMCID: PMC8780481 DOI: 10.3390/jcm11020331] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 12/26/2021] [Accepted: 01/05/2022] [Indexed: 02/01/2023] Open
Abstract
Background: Surgical treatment of unstable syndesmotic injuries is not trivial, and there are no generally accepted treatment guidelines. The most common controversies regarding surgical treatment are related to screw fixation versus dynamic fixation, the use of reduction clamps, open versus closed reduction, and the role of the posterior malleolus and of the anterior inferior tibiofibular ligament (AITFL). Our aim was to draw important conclusions from the pertinent literature concerning surgical treatment of unstable syndesmotic injuries, to transform these conclusions into surgical principles supported by the literature, and finally to fuse these principles into an evidence-based surgical treatment algorithm. Methods: PubMed, Embase, Google Scholar, The Cochrane Database of Systematic Reviews, and the reference lists of systematic reviews of relevant studies dealing with the surgical treatment of unstable syndesmotic injuries were searched independently by two reviewers using specific terms and limits. Surgical principles supported by the literature were fused into an evidence-based surgical treatment algorithm. Results: A total of 171 articles were included for further considerations. Among them, 47 articles concerned syndesmotic screw fixation and 41 flexible dynamic fixations of the syndesmosis. Twenty-five studies compared screw fixation with dynamic fixations, and seven out of these comparisons were randomized controlled trials. Nineteen articles addressed the posterior malleolus, 14 the role of the AITFL, and eight the use of reduction clamps. Anatomic reduction is crucial to prevent posttraumatic osteoarthritis. Therefore, flexible dynamic stabilization techniques should be preferred whenever possible. An unstable AITFL should be repaired and augmented, as it represents an important stabilizer of external rotation of the distal fibula. Conclusions: The current literature provides sufficient arguments for the development of an evidence-based surgical treatment algorithm for unstable syndesmotic injuries.
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Quan Y, Lu H, Xu H, Liu Y, Xie W, Zhang B, Zhang D, Jiang B. The Distribution of Posterior Malleolus Fracture Lines. Foot Ankle Int 2021; 42:959-966. [PMID: 33745344 DOI: 10.1177/1071100721996700] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The morphology and classification of posterior malleolus (PM) fractures remain controversial. An increasing number of studies have found that merely focusing on the fragment size does not lead to a satisfactory prognosis. This study aimed to demonstrate the fracture line and comminution zones of PM fractures using computed tomography (CT), in order to provide insights into the injury mechanism of PM fractures. METHODS We retrospectively reviewed the data of 95 patients with PM fractures between 2013 and 2018 at a level 1 trauma center. The CT data of the PM of the patients were reconstructed using software. Images of all patients were superimposed together, and drawn as a heat map of the fragments and line distributions of PM fractures. RESULTS Our study included 66 type I, 19 type II, and 10 type III PM fractures according to the classification of Haraguchi. In the single-fragment fracture group, the fracture lines were mainly concentrated in the posterolateral tibial tubercle area (Volkmann's tubercle) and a larger tubercle area involving the tibialis posterior groove. In the multifragment fracture group, there were 10 (43.5%) patients with a 2-fragment pattern and 13 (56.5%) patients with a compressive-fragment pattern. CONCLUSION According to the fracture map and previous studies on the syndesmosis, our study provides a different understanding of the pathomechanisms of ankle injuries compared with previous classifications of PM fractures. LEVEL OF EVIDENCE Level III, retrospective study.
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Affiliation(s)
- Yuan Quan
- Orthopaedic and Traumatology, Peking University People's Hospital, Beijing, China.,Key Laboratory of Trauma and Neural Regeneration (Peking University), Ministry of Education, Beijing, China
| | - Hao Lu
- Orthopaedic and Traumatology, Peking University People's Hospital, Beijing, China
| | - Hailin Xu
- Orthopaedic and Traumatology, Peking University People's Hospital, Beijing, China
| | - Yijun Liu
- Orthopaedic and Traumatology, Peking University People's Hospital, Beijing, China
| | - Wenyong Xie
- Orthopaedic and Traumatology, Peking University People's Hospital, Beijing, China
| | - Boyu Zhang
- Orthopaedic and Traumatology, Peking University People's Hospital, Beijing, China
| | - Dianying Zhang
- Orthopaedic and Traumatology, Peking University People's Hospital, Beijing, China
| | - Baoguo Jiang
- Orthopaedic and Traumatology, Peking University People's Hospital, Beijing, China
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Fujimoto S, Teramoto A, Anzai K, Murahashi Y, Okada Y, Kamiya T, Watanabe K, Fujimiya M, Yamashita T. Tibial Plafond Attachment of the Posterior-Inferior Tibiofibular Ligament: A Cadaveric Study. FOOT & ANKLE ORTHOPAEDICS 2020; 5:2473011420945689. [PMID: 35097406 PMCID: PMC8702662 DOI: 10.1177/2473011420945689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Some recent studies have reported the role of the posterior malleolus as an attachment of the posterior-inferior tibiofibular ligament (PITFL) and suggested that even a small fragment should be fixed. However, there are few anatomic studies of the tibial plafond attachment of the PITFL. Methods: Seven Thiel-embalmed ankles were obtained. The margin of the distal tibial joint surface and the attachments of the superficial fiber of the PITFL (sPITFL) and the deep fiber (dPITFL) were identified. In the frontal view, the percentages of the attachments of the sPITFL and dPITFL of the mediolateral dimension of the posterior tibial plafond were measured. In the lateral view, the line that started from the proximal margin of the attachment of the sPITFL and parallel to the tibial axis was drawn, and the distance between that line and the posterior edge of the joint surface was measured (AP distance of the sPITFL). Then, the percentage of the AP distance of the sPITFL of the joint surface in the anteroposterior dimension of the tibial plafond was measured. Results: In the frontal view, the mediolateral distance of the attachment of the sPITFL was 5.0 mm, and that of the dPITFL was 19.5 mm. The percentage of the attachment of the sPITFL on the tibial plafond was 20.6%, and that of the dPITFL was 78.2%. In the lateral view, the average AP distance of the sPITFL was 0.5 mm, and the percentage in the anteroposterior dimension of the tibial plafond was 1.7%. Conclusion: The PITFL was attached to less than 10% of the anteroposterior dimension of the tibial plafond in most ankles. Conversely, the PITFL attached widely in the mediolateral dimension. Clinical Relevance: This study suggests that the size of the posterior malleolar fragment in the mediolateral dimension could help estimate how much of the PITFL attaches to the fragment which may have implications for ankle stability.
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Affiliation(s)
- Shutaro Fujimoto
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Atsushi Teramoto
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Ken Anzai
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Yasutaka Murahashi
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Yohei Okada
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Tomoaki Kamiya
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Kota Watanabe
- Second Division of Physical Therapy, Sapporo Medical University School of Health Sciences, Sapporo, Hokkaido, Japan
| | - Mineko Fujimiya
- Department of Anatomy, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Toshihiko Yamashita
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
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