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Koris J, Calder JDF, Dalmau-Pastor M, Fernandez MA, Ramasamy A. Deltoid ligament injuries: A review of the anatomy, diagnosis and treatments. Knee Surg Sports Traumatol Arthrosc 2024. [PMID: 38796726 DOI: 10.1002/ksa.12274] [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: 02/18/2024] [Revised: 04/28/2024] [Accepted: 05/07/2024] [Indexed: 05/28/2024]
Abstract
PURPOSE Ankle sprains remain the most common soft tissue injury presenting to Emergency Departments. Recently, there has been increased awareness and reporting of deltoid ligament injuries in association with injuries to the lateral ligament complex as well as with fibula fractures. This article reviews the currently available literature on the anatomy of the deltoid ligament, clinical and radiological diagnosis of injuries to the deltoid ligament and treatment recommendations. METHODS A literature review was conducted for keywords associated with deltoid ligament injuries. MEDLINE, PubMed and Embase databases were utilised for this search. Articles were included if involving an adult population, were English-language, were related to deltoid ligament injuries (with or without associated injuries) and reported on patho-anatomy, clinical or radiological diagnosis or treatment methods. RESULTS A total of 93 articles were assessed for relevance from the database search, and 47 were included after the removal of irrelevant articles and duplicates. Several studies reported on the clinical findings of deltoid ligament injury, as well as the radiographic analysis. Arthroscopy was considered the gold standard of diagnosis, with authors reporting on the potential benefit of performing arthroscopic repair or reconstruction at the same time. There were no studies that provided a system for the classification of deltoid ligament injury or larger studies of treatment pathways. Long-term studies of the incidence of instability in deltoid ligament injuries were not available. CONCLUSION There is limited evidence available regarding deltoid ligament injuries, particularly in terms of treatment options, either in isolation or with concomitant injuries. Long-term follow-up studies are needed to obtain more accurate data on the number of complications. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Jacob Koris
- Trauma & Orthopaedic Specialty Registrar, John Radcliffe Hospital, Oxford, UK
| | - James D F Calder
- Department of Bioengineering, Imperial College London, London, UK
- Fortius Clinic, London, UK
| | - Mikel Dalmau-Pastor
- Human Anatomy and Embryology Unit, Department of Pathology and Experimental Therapeutics, School of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
- MIFAS by GRECMIP (Minimally Invasive Foot and Ankle Society), Merignac, France
| | - Miguel A Fernandez
- Fortius Clinic, London, UK
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Arul Ramasamy
- Department of Bioengineering, Imperial College London, London, UK
- Academic Department of Military Trauma and Orthopaedics, Royal Centre for Defence Medicine, Edgbaston, Birmingham, UK
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Dalmau-Pastor M, Malagelada F, Guelfi M, Kerkhoffs G, Karlsson J, Calder J, Vega J. The deltoid ligament is constantly formed by four fascicles reaching the navicular, spring ligament complex, calcaneus and talus. Knee Surg Sports Traumatol Arthrosc 2024. [PMID: 38757967 DOI: 10.1002/ksa.12173] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 03/11/2024] [Accepted: 03/17/2024] [Indexed: 05/18/2024]
Abstract
PURPOSE The medial collateral ligament of the ankle, or deltoid ligament, can be injured in up to 40% of patients who sustain an ankle inversion sprain. Reporting injuries of the deltoid ligament is not easy due to confusion in the current anatomical descriptions, with up to 16 fascicles described, with variable frequencies. The purpose of this study was to clarify the anatomy of the deltoid ligament. METHODS Thirty-two fresh-frozen ankle specimens were used for this study. Careful dissection was undergone until full visualization of the deltoid ligament was achieved and measurements taken. RESULTS The deltoid ligament was found to have four constant fascicles in two layers. The superficial layer consists of the tibionavicular, tibiospring and tibiocalcaneal fascicles, while the deep layer consists of the tibiotalar fascicle. Measurements of these fascicles are given in detail. The tibiotalar fascicle and the anterior part of the tibionavicular fascicle were found to be intra-articular structures. CONCLUSION The deltoid ligament has a constant number of fascicles divided into a superficial and a deep layer. This clarification of the anatomy and terminology of the deltoid ligament and its fascicles will help clinical view, diagnosis and (interdoctor)communication and treatment. The ligamentous fibres of the deep layer, as well as the anterior fibres of the superficial layer (tibionavicular fascicle) are intra-articular, which could negatively impact its healing capacity, explaining chronicity of these types of injuries. LEVEL OF EVIDENCE Not applicable (cadaveric study).
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Affiliation(s)
- Miki Dalmau-Pastor
- Human Anatomy and Embryology Unit, Department of Pathology and Experimental Therapeutics, University of Barcelona, Barcelona, Spain
- MIFAS By GRECMIP (Minimally Invasive Foot and Ankle Society), Merignac, France
| | - Francesc Malagelada
- Foot and Ankle Unit, The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Matteo Guelfi
- Foot and Ankle Unit, Casa di Cura Villa Montallegro, Genoa, Italy
- Department of Orthopaedic Surgery "Gruppo Policlinico Di Monza", Clinica Salus, Alessandria, Italy
| | - Gino Kerkhoffs
- Department of Orthopedic Surgery and Sports Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Amsterdam, The Netherlands
- Amsterdam Collaboration for Health & Safety in Sports (ACHSS), International Olympic Committee (IOC) Research Center Amsterdam UMC, Amsterdam, The Netherlands
| | - Jon Karlsson
- Department of Orthopaedics, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Jordi Vega
- Human Anatomy and Embryology Unit, Department of Pathology and Experimental Therapeutics, University of Barcelona, Barcelona, Spain
- MIFAS By GRECMIP (Minimally Invasive Foot and Ankle Society), Merignac, France
- iMove Traumatology Tres Torres, Barcelona, Spain
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Pflüger P, Valderrabano V. Sprain of the Medial Ankle Ligament Complex. Foot Ankle Clin 2023; 28:355-367. [PMID: 37137629 DOI: 10.1016/j.fcl.2023.01.009] [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
Injuries of the medial ankle ligament complex (MALC; deltoid and spring ligament) are more common following ankle sprains than expected, especially in eversion-external rotation mechanisms. Often these injuries are associated with concomitant osteochondral lesions, syndesmotic lesions, or fractures of the ankle joint. The clinical assessment of the medial ankle instability together with a conventional radiological and MR imaging is the basis for the definition of the diagnosis and therefore the optimal treatment. This review aims to provide an overview as well as a basis to successfully manage MALC sprains.
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Affiliation(s)
- Patrick Pflüger
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Victor Valderrabano
- SWISS ORTHO CENTER, Swiss Medical Network, Schmerzklinik Basel, University of Basel, Hirschgässlein 15, Basel 4010, Switzerland.
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Puri A. Lateral ankle instability - repair/ reconstruct what's new. J Orthop Surg (Hong Kong) 2023; 31:10225536231182348. [PMID: 37449536 DOI: 10.1177/10225536231182348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/18/2023] Open
Abstract
Lateral ankle instability is a common condition which responds well to non-surgical management. However, the chronic symptomatic instability may require surgical intervention. The acceptable and practiced procedure is the Brostom Gould modification and it has a high patient satisfaction score. However, the current understanding and newer techniques for stabilising the lateral ligament complex has resulted in arthroscopic repairs, augmentation and tendon graft reconstructions. The literature does not provide an answer to the efficacy of these new techniques but there is some preliminary information favouring some of the latest procedures. It is now accepted practise to include ankle arthroscopy as a pre repair step. Augmentation of anatomical repair is also favoured in a select group of patients. This article provides an up to date account of the newer techniques for lateral ankle stabilisation.
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Affiliation(s)
- Arvind Puri
- Department of Orthopaedics, Cairns Hospital, Queensland, Australia
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5
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Zeni F, Cavazos DR, Bouffard JA, Vaidya R. Indications and Interpretation of Stress Radiographs in Supination External Rotation Ankle Fractures. Cureus 2023; 15:e38092. [PMID: 37252532 PMCID: PMC10209918 DOI: 10.7759/cureus.38092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2023] [Indexed: 05/31/2023] Open
Abstract
Introduction In supination external rotation (SER) ankle fractures with an intact medial malleolus, stability hinges upon the competence of the deltoid ligament. The purpose of this study is to define the indications and establish criteria for a positive stress radiograph. Methods This is a prospective study of 27 isolated SER lateral malleolar fractures with a reduced ankle mortise. Pain and swelling were noted about the medial ankle, followed by an ultrasound to evaluate the integrity of the deltoid ligament. Static and stress radiographs were performed on both the fractured and contralateral ankles. Results Fourteen patients were normal on ultrasound examination, eight had partial tears, and five had full-thickness tears. The difference in the level of pain to palpation postero-medially between the complete tear (7 +/- 1) and the partial tear (1.3 +/- 2.4) group was significant (p < .001). The negative predictive values for medial swelling and tenderness were 93% and 100%, respectively. Sensitivity and specificity for medial clear space on stress radiograph (fracture (fx)) > 5.0 mm were both 100% while a 2.5 mm or greater change to the contralateral side yielded a sensitivity of 100% and specificity of 95%. Conclusion The lack of significant medial pain, as well as swelling, implies the absence of a complete ligament tear and eliminates the need for stress examination. Conversely, the presence of medial signs of injury is suggestive, but not pathognomonic for a complete deltoid tear. Medial clear space (MCS) variability prompts to recommend a minimum of 2.5 mm on stress radiographs compared to the contralateral side as indirect evidence for a complete tear of the deltoid ligament.
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Affiliation(s)
| | - Daniel R Cavazos
- Orthopaedic Surgery, Wayne State University School of Medicine, Detroit, USA
- Orthopaedic Surgery, Detroit Medical Center, Detroit, USA
| | - José A Bouffard
- Orthopaedic Surgery, Wayne State University School of Medicine, Detroit, USA
| | - Rahul Vaidya
- Orthopaedic Surgery, Wayne State University School of Medicine, Detroit, USA
- Orthopaedic Surgery, Detroit Medical Center, Detroit, USA
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Yang X, Zeng J, Yang W, Dela Rosa RD, Jiang Z. A meta-analysis of deltoid ligament on ankle joint fracture combining deltoid ligament injury. Front Surg 2023; 10:976181. [PMID: 37051572 PMCID: PMC10083234 DOI: 10.3389/fsurg.2023.976181] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 02/16/2023] [Indexed: 03/29/2023] Open
Abstract
PurposeAnkle fracture combined with deltoid ligament (DL) injury results in decreased stability of ankle mortise, reduced contact surface between tibial and talus, increased local stress, and increased postoperative complications. The purpose of this meta-analysis was to evaluate the postoperative effects of repairing ligaments in ankle fractures with DL rupture.MethodsAccording to the steps of the Cochrane systematic review, the related literatures from PubMed, Embase and the Cochrane Library Databases were retrieved as of September 1, 2021, and all relevant randomized controlled trials and retrospective studies were collected. The evaluation indicators include medial clear space (MCS), visual analogue scale (VAS), American Orthopedic Foot and Ankle Society (AOFAS), complications rate. Meta-analysis was conducted by RevMan® 5.3 provided by the Cochrane collaboration.ResultsA total of 388 patients (195 patients in the ligament repair group and 193 patients in the non-repair group) were included in 7 clinical trials. Meta-analysis data showed there were no statistically significant differences between the ligament repair group and non-repair group in final follow-up VAS, final AOFAS and postoperative MCS (P = 0.50, P = 0.04, P = 0.14, P = 0.14, respectively). Final follow-up MCS and complications rate in ligament repair group were smaller than those in the non-repair group and were statistically significant (P < 0.00001, P = 0.006, respectively).ConclusionAlthough there was no difference in in final follow-up VAS, final follow-up AOFAS and postoperative MCS between experimental group and control group, It's statistically significant in final follow-up MCS and complications rate. Ligament repair could reduce the width of MCS, restore ankle stability, reduce the incidence of complications and lead to a better prognosis.
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Affiliation(s)
- XiaoLing Yang
- Department of Nursing, Guizhou Nursing Vocational College, Guiyang, People's republic of China
- School of Nursing, Philippine Women's University, Manila, Philippines
| | - Jianshuang Zeng
- Department of Dermatology, Guizhou Provincal People's Hospital, Guiyang, People's republic of China
| | - Wei Yang
- Department of Neurosurgery, People's Hospital of Dechang County, Dechang, People's republic of China
| | - Ronnell D Dela Rosa
- School of Nursing, Philippine Women's University, Manila, Philippines
- College of Nursing and Midwifery, Bataan Peninsula State University, Balanga, Philippines
- Correspondence: Zhixia Jiang Ronnell D. Dela Rosa
| | - Zhixia Jiang
- Department of Nursing, Guizhou Nursing Vocational College, Guiyang, People's republic of China
- Correspondence: Zhixia Jiang Ronnell D. Dela Rosa
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Beltran LS, Zuluaga N, Verbitskiy A, Bencardino JT. Imaging of Acute Ankle and Foot Sprains. Radiol Clin North Am 2023; 61:319-344. [PMID: 36739148 DOI: 10.1016/j.rcl.2022.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Ankle and foot injuries are very common injuries in the general population, and more so in athletes. MR imaging is the optimal modality to evaluate for ligamentous injuries of the ankle and associated conditions after ankle sprain. In this article, the authors discuss the epidemiology, biomechanics, normal anatomy, and pathology of the ankle as well as injuries of the hindfoot and midfoot that are often associated with ankle injuries.
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Affiliation(s)
- Luis S Beltran
- Department of Radiology, Harvard Medical School, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
| | - Nicolas Zuluaga
- Department of Radiology, University of Pennsylvania Health System, 3737 Market Street, Philadelphia, PA 19104, USA
| | - Anna Verbitskiy
- Department of Radiology, NYU Grossman School of Medicine, New York, NY 10016, USA
| | - Jenny T Bencardino
- Department of Radiology, University of Pennsylvania Health System, 3737 Market Street, Philadelphia, PA 19104, USA
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8
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Gopinath R, Pigott M, Lindsey B, Finney FT, Holmes JR, Walton DM, Talusan PG. Medial Ankle Instability: Review of Anatomy, Evaluation, and Treatment. Foot Ankle Spec 2022; 15:573-578. [PMID: 36210762 DOI: 10.1177/1938640021992915] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The medial ankle ligamentous complex, which includes the deltoid, talocalcaneal, and calcaneonavicular ligaments, functions to provide stability to the medial ankle. Injuries to the deltoid ligament can lead to medial-sided ankle pain, subsequent instability, and posttraumatic osteoarthritis given the altered biomechanics of the ankle joint. After completing a thorough physical examination, imaging modalities such as stress radiographs and magnetic resonance imaging can be used to confirm the diagnosis. Acute injuries to the deltoid ligament should be managed conservatively with a short course of immobilization. For patients with continued pain and instability following a regimen of nonoperative management, surgical intervention can be considered. Primary repair using suture anchor fixation to the medial malleolus can be utilized if sufficient tissue remains. However, if reconstruction is necessitated, autograft or allograft can be utilized in several described techniques.Levels of Evidence: Therapeutic.
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Affiliation(s)
- Rohan Gopinath
- Department of Orthopaedics, University of Maryland, Baltimore, Maryland
| | - Matthew Pigott
- Department of Orthopaedics, University of Michigan, Ann Arbor, Michigan
| | - Benjamin Lindsey
- Department of Orthopaedics, University of Michigan, Ann Arbor, Michigan
| | - Fred T Finney
- Department of Orthopaedics, University of Michigan, Ann Arbor, Michigan
| | - James R Holmes
- Department of Orthopaedics, University of Michigan, Ann Arbor, Michigan
| | - David M Walton
- Department of Orthopaedics, University of Michigan, Ann Arbor, Michigan
| | - Paul G Talusan
- Department of Orthopaedics, University of Michigan, Ann Arbor, Michigan
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9
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Yoon YS, Cha JG, Lee YK. Prediction of anterior tibiotalar ligament injury: measurement of the angle between the deep posterior tibiotalar ligament and talus on MRI. Acta Radiol 2022; 64:1579-1588. [PMID: 36345217 DOI: 10.1177/02841851221135614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background Identification of anterior tibiotalar ligament (aTTL) injury is essential because it influences the surgeon's treatment option and patient prognosis. Purpose To assess the diagnostic accuracy of the angle measurement between the talus and posterior tibiotalar ligament (talus-pTTL) on magnetic resonance imaging (MRI) in patients with arthroscopically proven aTTL injuries. Material and Methods Ankle MRI scans of 67 patients who underwent arthroscopic examination were retrospectively reviewed. The talus-pTTL angle on axial T2-weighted MRI and the medial clear space (MCS) on mortise ankle radiograph were measured. Inter-observer agreement of the measurements was calculated. Also, sensitivity, specificity, and area under the receiver operating characteristic (ROC) curve (AUC) were the metrics of diagnostic accuracy. Results AUC was 0.90 for observer 1 with 78.6% sensitivity, 97.4% specificity, 88% accuracy, and 54.7° cutoff value for the talus-pTTL angle. AUC was 0.87 for observer 2 with 85.7% sensitivity, 84.6% specificity, 85.2% accuracy, and 53.7° cutoff value for the talus-pTTL angle. AUC was 0.86 with 82.1% sensitivity, 79.5% specificity, and 80.8% accuracy for observer 1 and 0.79 with 57.1% sensitivity, 92.3% specificity, and 74.7% accuracy for observer 2 for the MCS. Different MCS values and additional capabilities when complemented with the angle measurement showed an increase in diagnostic performances. Intra-observer reliability of MCS and talus-pTTL angle of the two radiologists was excellent. Inter-observer reliability of the two radiologists was excellent for both the talus-pTTL angle (0.95) and the MCS (0.85). Conclusion Measurement of the talus-pTTL angle showed good sensitivity, specificity, and accuracy for the evaluation of aTTL injury with excellent inter-observer reliability.
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Affiliation(s)
- Yu Sung Yoon
- Department of Radiology, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
| | - Jang Gyu Cha
- Department of Radiology, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
| | - Young Koo Lee
- Department of Orthopedic surgery, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
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Jin XY, Xiao WY, He T, Dong YQ, Zhang C. Fracture of the lateral process of the talus with associated deltoid ligament injury: a report of 2 cases. BMC Surg 2022; 22:356. [PMID: 36195942 PMCID: PMC9533565 DOI: 10.1186/s12893-022-01781-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 08/30/2022] [Indexed: 11/10/2022] Open
Abstract
Background Fractures of the lateral process of the talus (LTPF) are rare and only rarely are associated ligamentous injuries. The injury mechanism is commonly considered to be similar with ankle sprains, where excessive varus of the hindfoot leads to avulsion fractures of the lateral process of the talus. However, previous cadaveric studies have suggested that LTPF was more likely to be caused by eversion or external rotation force with dorsiflexion of the ankle. But no clinical evidence has been provided. Case presentation Two patients presented to the emergency department with ankle pain after ankle eversion or external rotation. Physical examination revealed tenderness and swelling on both medial and lateral sides of the ankles. Plain radiographs and computed tomography revealed LTPF and medial soft tissue swelling, and magnetic resonance imaging confirmed a discontinuity of the deltoid ligament in Case 1. Surgical exploration revealed rupture of the superficial layer of the deltoid ligaments with intact deep layer in both patients. Treatment included fixation of the lateral process of the talus with headless compression screws and repair of deltoid ligaments. Both patients achieved excellent clinical outcomes 1 year post injury. Conclusion There are many possibilities of the injury mechanism of LTPF. These two cases provided clinical evidence that eversion or external rotation force, in addition to inversion, was also an important mechanism of LTPF. Supplementary Information The online version contains supplementary material available at 10.1186/s12893-022-01781-y.
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Affiliation(s)
- Xiang-Yun Jin
- Department of Orthopedics, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200127, People's Republic of China
| | - Wei-Yuan Xiao
- Department of Orthopedics, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200127, People's Republic of China
| | - Tao He
- Department of Orthopedics, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200127, People's Republic of China
| | - Yu-Qi Dong
- Department of Orthopedics, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200127, People's Republic of China.
| | - Chao Zhang
- Department of Orthopedics, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200127, People's Republic of China.
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Early radiographic outcomes following deltoid ligament repair in bimalleolar equivalent ankle fractures. Foot Ankle Surg 2022; 28:720-725. [PMID: 34493449 DOI: 10.1016/j.fas.2021.08.007] [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: 04/21/2021] [Revised: 06/30/2021] [Accepted: 08/23/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Indications for deltoid ligament repair in bimalleolar equivalent ankle fractures are unclear. This study compared radiographic outcomes in bimalleolar equivalent ankle fractures undergoing open reduction internal fixation (ORIF) +/- deltoid ligament repair. METHODS A retrospective review of 1024 ankle fractures was performed. Bimalleolar equivalent injuries treated with ORIF +/- deltoid ligament repair were included. Radiographic assessment was performed preoperatively, and at three months postoperatively. RESULTS One hundred and forty-seven ankle fractures met inclusion criteria with 46 undergoing deltoid ligament repairs. There was a significant decrease in medial clear space (1.93 ± 0.65 mm vs. 2.26 ± 0.64 mm, p = 0.01), and tibiofibular clear space (3.89 ± 1.20 mm vs. 4.87 ± 1.37 mm, p = 0.0001) at 3 months postoperative in the deltoid repair group compared to the no repair group. When syndesmotic fixation was performed, there were no differences between groups. CONCLUSION Deltoid ligament repair in bimalleolar equivalent ankle fractures resulted in reduced medial clear space, and tibiofibular clear space in the early postoperative period. These differences were small and remained within established normal limits. LEVEL OF CLINICAL EVIDENCE Level III, retrospective cohort study.
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12
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Vacketta VG, Jones JM, Catanzariti AR. Radiographic Analysis and Clinical Efficacy of Hindfoot Arthrodesis With Versus Without Cotton Osteotomy in Stage III Adult Acquired Flatfoot Deformity. J Foot Ankle Surg 2022; 61:879-885. [PMID: 34987007 DOI: 10.1053/j.jfas.2021.12.012] [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] [Received: 07/14/2020] [Accepted: 12/06/2021] [Indexed: 02/03/2023]
Abstract
Forefoot varus develops as a result of longstanding adult-acquired flatfoot deformity (AAFD). This occurs with varying degrees of deformity and flexibility. Residual forefoot varus following hindfoot realignment in AAFD can lead to lateral column loading and a persistent pronatory moment in efforts to reestablish contact between the forefoot and the ground. The Cotton osteotomy may serve as a reasonable adjunct procedure to help avoid complications and poor outcomes associated with residual forefoot varus in patients undergoing hindfoot arthrodesis for stage III AAFD. The aim of this study was to compare the radiographic outcomes in patients undergoing isolated hindfoot arthrodesis to patients undergoing hindfoot arthrodesis with adjunctive cotton osteotomy. We retrospectively reviewed 47 patients matched based upon age, sex, and comorbidities who underwent hindfoot reconstruction for the treatment of stage III AAFD between 2015 and 2019. A retrospective radiographic review was performed on standard weightbearing radiographs including anterior-posterior and lateral views preoperatively, postoperatively at the initiation of full weightbearing, and at final follow-up. Statistical analysis utilizing paired t test to calculate p values where <.05 was statistically significant. At final follow-up, radiographic measurements showed statistically significant differences in CAA, calcaneal inclination, talo-calcaneal, and talar tilt (p value <.05). The Cotton osteotomy group showed a quicker return to presurgical activity level and a decreased incident of tibiotalar valgus. Our study suggests that the Cotton osteotomy can address residual forefoot varus and potentially prevent further progression of ankle valgus in AAFD when used in combination with hindfoot arthrodesis.
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Affiliation(s)
- Vincent G Vacketta
- Resident, Postgraduate Year 1, Division of Foot and Ankle Surgery, West Penn Hospital, Allegheny Health Network, Pittsburgh, PA
| | - Jacob M Jones
- Resident, Postgraduate Year 1, Division of Foot and Ankle Surgery, West Penn Hospital, Allegheny Health Network, Pittsburgh, PA
| | - Alan R Catanzariti
- Director of Residency Training, Division of Foot and Ankle Surgery, West Penn Hospital, Allegheny Health Network, Pittsburgh, PA.
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Xiao K, Xie W, An Y. Anatomic Repair of Deltoid Ligaments in Acute Injury With Suture Anchor Technique. Orthopedics 2022; 45:e168-e173. [PMID: 35201941 DOI: 10.3928/01477447-20220217-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Acute disruption of the deltoid ligament usually occurs in rotational ankle fracture. If left untreated, its instability may contribute to ankle arthritis. We have designed a suture technique to repair all deltoid ligament layers. It provides anatomic ligament-to-bone repair of the superficial and deep deltoid ligaments and anchor suture reinforcement. This technique may protect the horizontally oriented fibers of the deep deltoid ligaments and allow them to heal with sufficient rest while providing immediate stability of the construct. The superficial ligaments are then repaired with residual anchor sutures. [Orthopedics. 2022;45(3):e168-e173.].
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14
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Superficial Deltoid Ligament and Deep Deltoid Ligament Play Equally Important Roles in the Stability of Isolated Lateral Malleolus (OTA/AO 44-B1) Fractures: A Biomechanical Study. J Orthop Trauma 2022; 36:73-79. [PMID: 35061655 DOI: 10.1097/bot.0000000000002216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/15/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate the individual contributions to stability of the superficial and deep deltoid ligaments in the setting of SER IV ankle fractures. METHODS Nineteen total cadaveric specimens were used. SER IV injuries were created with the rupture of either the superficial (SER IV-S) (n = 9) or deep deltoid (SER IV-D) (n = 10). These were tested by applying an external rotation force (1 Nm, 2 Nm, 3 Nm, and 4 Nm). Changes in the position of the talus were recorded with a 3D motion tracker. Injury conditions were compared with a 4-step general linear model with repeated measures. Injury condition was also compared with the intact state and to each other using 2-tailed t tests. RESULTS The general linear model showed that increased loading had a significant effect with axial rotation (P = 0.02) and sagittal translation (P = 0.003). SER IV-S and SER IV-D showed significantly greater instability compared with the intact state in axial rotation (1 Nm, 2 Nm, and 3 Nm). SER IV-S and SER IV-D did not significantly differ from each other. CONCLUSIONS SER IV fracture patterns can be unstable with isolated injury to either the superficial or deep deltoid. This challenges the notion that deep deltoid rupture is necessary. Further clinical studies would help quantify the consequences of this instability.
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van der Merwe C, Shultz SP, Colborne GR, Fink PW. Foot Muscle Strengthening and Lower Limb Injury Prevention. RESEARCH QUARTERLY FOR EXERCISE AND SPORT 2021; 92:380-387. [PMID: 32633706 DOI: 10.1080/02701367.2020.1739605] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 03/02/2020] [Indexed: 06/11/2023]
Abstract
Background and objectives: The active and passive structures of the foot act in unison to not only be compliant enough to assist in ground reaction force attenuation but also resist deformation to provide a stable base of support. A foot that is unable to adjust to the imposed demands during high-intensity sporting activities may alter the moments and forces acting on the joints, increasing the risk of non-contact anterior cruciate ligament ruptures (ACLR) and lateral ankle sprains (LAS). Prophylactic strengthening programs are often used to reduce the risk of these injuries, but at present, very few prophylactic programs include foot-specific strengthening strategies. The aim of this theoretical review is to ascertain the prophylactic role strengthening muscles acting on the foot may have on ACLR and LAS injury risk. Methods: Literature relating to risk factors associated with ACLR and LAS injury and the anatomy and biomechanics of normal foot function was searched. In addition, ACLR and LAS injury prevention programs were also sought. A theoretical, narrative approach was followed to synthesize the information gathered from the articles. Results: The foot segments are governed by the congruity of the articulations and the activity of the foot muscles. As such, there is a coupling effect between shank, calcaneus, midfoot, and hallux movement which play a role in both ACLR and LAS injury risk. Conclusions: Strengthening the muscles acting on the foot may have a significant impact on ACLR and LAS injury risk.
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Abstract
The deltoid and spring ligaments are the primary restraints against pronation and valgus deformity of the foot, and in preserving the medial arch. The posterior tibial tendon has a secondary role in plantar arch maintenance, and its biomechanical stress increases considerably when other tissues fail. A thorough understanding of the anatomy and biomechanics of the deltoid-spring ligament is crucial for successful reconstruction of the tibiocalcanealnavicular ligament, hence, to restore ankle and medial peritalar stability. Although effective in correcting the deformity, tibionavicular tenodesis might be critical, as it blocks physiologic pronation of the hindfoot, which may result in dysfunction and pain.
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Affiliation(s)
- Beat Hintermann
- Center of Excellence for Foot and Ankle Surgery, Kantonsspital Baselland, Rheinstrasse 26, CH-4410 Liestal, Switzerland.
| | - Roxa Ruiz
- Center of Excellence for Foot and Ankle Surgery, Kantonsspital Baselland, Rheinstrasse 26, CH-4410 Liestal, Switzerland
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Abstract
The most common injury mechanism for ankle fractures with concomitant deltoid ligament injury is a supination external rotation type 4 trauma. In the acute setting, malalignment, ecchymosis, and profound edema of the affected ankle can be found. Clinical examination is a poor indicator for deltoid ligament injury. There is a lack of high-quality studies with suturing the deltoid as the primary question. The authors found 4 comparative studies that found it unnecessary to explore and to reconstruct the deltoid ligament and 4 comparative studies that find it unnecessary to explore and to reconstruct the deltoid ligament.
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Affiliation(s)
| | - Sjoerd A Stufkens
- Amsterdam University Medical Centers, Location AMC, Meibergdreef 9, Amsterdam 1105 AZ, The Netherlands.
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18
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Abstract
Foot and ankle instability can be seen both in acute and chronic settings, and isolating the diagnosis can be difficult. Imaging can contribute to the clinical presentation not only by identifying abnormal morphology of various supporting soft tissue structures but also by providing referring clinicians with a sense of how functionally incompetent those structures are by utilizing weight-bearing images and with comparison to the contralateral side. Loading the affected joint and visualizing changes in alignment provide clinicians with information regarding the severity of the abnormality and, therefore, how it should be managed.
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Affiliation(s)
- Carolyn M Sofka
- Department of Radiology and Imaging, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA.
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Deland JT, Ellis SJ, Day J, de Cesar Netto C, Hintermann B, Myerson MS, Sangeorzan BJ, Schon LC, Thordarson DB, Johnson JE. Indications for Deltoid and Spring Ligament Reconstruction in Progressive Collapsing Foot Deformity. Foot Ankle Int 2020; 41:1302-1306. [PMID: 32851857 DOI: 10.1177/1071100720950742] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
RECOMMENDATION There is evidence supporting medial soft tissue reconstruction, such as spring and deltoid ligament reconstructions, in the treatment of severe progressive collapsing foot deformity (PCFD). We recommend spring ligament reconstruction to be considered in addition to lateral column lengthening or subtalar fusion at the initial operation when those procedures have given at least 50% correction but inadequate correction of the severe flexible subluxation of the talonavicular and subtalar joints. We also recommend combined flatfoot reconstruction and deltoid reconstruction be considered as a joint sparing alternative in the presence of PCFD with valgus deformity of the ankle joint if there is 50% or more of the lateral joint space remaining. LEVEL OF EVIDENCE Level V, expert opinion.
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Affiliation(s)
| | | | | | - Cesar de Cesar Netto
- Department of Orthopaedics and Rehabilitation, University of Iowa, Iowa City, IA, USA
| | | | - Mark S Myerson
- Department of Orthopedic Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Lew C Schon
- Mercy Medical Center, Baltimore, MD, USA.,New York University Grossman School of Medicine, New York, NY, USA.,Johns Hopkins School of Medicine, Baltimore, MD, USA.,Georgetown School of Medicine, Washington, DC, USA
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Abstract
Despite the fact that ankle fractures are common injuries, not all patients obtain satisfactory results. Historically, the deltoid ligament injury and intra-articular pathology have not often been treated at the time of fracture stabilization. Recent literature has suggested that repair of the deltoid ligament may lead to better stability of the ankle mortise. Additionally, the use of arthroscopy in conjunction with fracture fixation may allow for better identification and treatment of intra-articular lesions and improve detection and reduction of subtle instability.
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Affiliation(s)
- Minton Truitt Cooper
- Department of Orthopaedic Surgery, University of Virginia, Box 800159, Charlottesvlle, VA 22908, USA.
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21
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Salameh M, Alhammoud A, Alkhatib N, Attia AK, Mekhaimar MM, D'Hooghe P, Mahmoud K. Outcome of primary deltoid ligament repair in acute ankle fractures: a meta-analysis of comparative studies. INTERNATIONAL ORTHOPAEDICS 2020; 44:341-347. [PMID: 31776609 PMCID: PMC6968990 DOI: 10.1007/s00264-019-04416-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 09/13/2019] [Indexed: 01/08/2023]
Abstract
PURPOSE The indications of deltoid ligament repair in ankle injuries with widened medial clear space in the absence of medial malleolus fracture remain controversial. Many authors reported no difference in long-term functional outcomes, while others stated that persistent medial clear space widening and malreduction are higher when deltoid ligaments went without repair. This meta-analysis aims to report the current published evidence about the outcomes of deltoid ligament repair in ankle fractures. METHODS Several databases were searched through May 2018 for comparative studies. The primary outcome was the medial clear space correction, while secondary outcomes included maintenance of medial clear space reduction, pain scores, functional outcome, and total complications if any. Three comparative studies met the inclusion criteria for the meta-analysis. The analysis included a total of 192 patients, 81 in the deltoid ligament repair group and 111 in the non-repair group. RESULTS The medial clear space correction and maintenance of the said correction on final follow-up radiographs were superior in the deltoid ligament repair group. Although the pain scores were better in the repair group at the final follow-up, this did not result in a better functional outcome, with similar total complication rates. CONCLUSION In conclusion, those who had their deltoid ligament repaired had superior early and late radiological correction of the medial clear space, an indicator of the quality of ankle reduction with better pain scores. However, no differences in the functional outcome and complications rate were reported.
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Affiliation(s)
- Motasem Salameh
- Orthopedic Surgery Department, Hamad General Hospital, PO Box 3050, Doha, Qatar.
| | | | - Nedal Alkhatib
- Orthopedic Surgery Department, Hamad General Hospital, PO Box 3050, Doha, Qatar
| | - Ahmed K Attia
- Orthopedic Surgery Department, Hamad General Hospital, PO Box 3050, Doha, Qatar
| | - Mohamed M Mekhaimar
- Orthopedic Surgery Department, Hamad General Hospital, PO Box 3050, Doha, Qatar
| | - Pieter D'Hooghe
- Aspetar Orthopedic and Sports Medicine Hospital, Doha, Qatar
| | - Karim Mahmoud
- University of Pennsylvania Foot and Ankle Program, Philadelphia, PA, USA
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Vega J, Allmendinger J, Malagelada F, Guelfi M, Dalmau-Pastor M. Combined arthroscopic all-inside repair of lateral and medial ankle ligaments is an effective treatment for rotational ankle instability. Knee Surg Sports Traumatol Arthrosc 2020; 28:132-140. [PMID: 28983653 DOI: 10.1007/s00167-017-4736-y] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 09/28/2017] [Indexed: 11/27/2022]
Abstract
PURPOSE When the anterior fascicle of the deltoid ligament is injured in patients with chronic ankle instability, the diagnosis of rotational ankle instability is supported. The aim of this study was to report the results of an all-arthroscopic technique to concomitantly repair the lateral collateral and deltoid ligaments to treat patients with rotational ankle instability. METHODS Thirteen patients [12 men and 1 woman, median age 32 (15-54) years] with rotational ankle instability were treated by arthroscopic means after failing non-operative management. Median follow-up was 35 (18-42) months. Using a suture passer and knotless anchors, the ligaments were repaired with an arthroscopic all-inside technique. RESULTS During diagnostic arthroscopy, 12 patients showed an isolated anterior talofibular ligament (ATFL) injury, and in one patient, both the ATFL and calcaneofibular ligament were affected. Arthroscopic examination of the deltoid ligament demonstrated a tear affecting the anterior area of the ligament in all cases. The tear was described as an "open book" tear, because the ligament was separated from the medial malleolus when applying passive internal rotation of the tibio-talar joint. This gap was closed when the tibio-talar joint was in neutral rotation or externally rotated. All patients reported subjective improvement in their ankle instability after the arthroscopic all-inside ligaments repair. The median AOFAS score increased from 70 (44-77) preoperatively to 100 (77-100) at final follow-up. CONCLUSION Rotational ankle instability can be successfully treated by an arthroscopic all-inside repair of the lateral and medial ligaments of the ankle. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Jordi Vega
- Foot and Ankle Unit, Hospital Quirón Barcelona, Plaza Alfonso Comín 5, 08023, Barcelona, Spain.
- Laboratory of Arthroscopic and Surgical Anatomy, Department of Pathology and Experimental Therapeutics (Human Anatomy Unit), University of Barcelona, Barcelona, Spain.
| | | | - Francesc Malagelada
- Foot and Ankle Unit, Department of Trauma and Orthopaedic Surgery, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Matteo Guelfi
- Orthopaedic and Traumatology Unit, Department of Medicine and Science of Aging, University G. d'Annunzio, Chieti-Pescara, Chieti, Italy
| | - Miki Dalmau-Pastor
- Laboratory of Arthroscopic and Surgical Anatomy, Department of Pathology and Experimental Therapeutics (Human Anatomy Unit), University of Barcelona, Barcelona, Spain
- Faculty of Health Sciences at Manresa, University of Vic-Central University of Catalonia, Manresa, Barcelona, Spain
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Gibson PD, Ippolito JA, Hwang JS, Didesch J, Koury KL, Reilly MC, Adams M, Sirkin M. Physiologic widening of the medial clear space: What's normal? J Clin Orthop Trauma 2019; 10:S62-S64. [PMID: 31695262 PMCID: PMC6823741 DOI: 10.1016/j.jcot.2019.04.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 04/20/2019] [Accepted: 04/22/2019] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Literature has validated the use of stress radiographs for evaluation of ankle stability. However, to our knowledge no study has reported the amount of physiological widening that occurs with manual external rotation stress test in uninjured ankles. The purpose of this study was to assess the amount of medial clear space widening that occurs with a manual external rotation stress test in uninjured ankles. METHODS A cohort of adult patients undergoing operative fixation of unstable ankle fractures were prospectively enrolled to have their contralateral ankle undergo manual external rotation stress examination. Fluoroscopic images of the unaffected ankle were performed in the OR. A non-stressed mortise view and manual external rotation stress view were obtained with a standardized marker to correct for magnification differences. The images were de-identified, presented in a randomized order and reviewers who were blinded. Each reviewer measured the medial clear space. RESULTS Thirty fluoroscopic images on fifteen patients were obtained. The mean medial clear space on the non-stressed mortise view was 3.1 mm (SD-0.69; Range 1.9 to 4.2, 95% CI [2.75, 3.45]) versus a mean of 3.2 mm (SD-0.71; Range 2.0 to 4.7, 95% CI [2.94, 3.66]) in the stressed mortise view group. Inter-rater reliability was excellent between all observers for medial clear space (ICC-0.88; CI [0.78, 0.94]). CONCLUSIONS Our results support the previous literature and allow us to advocate for ankle fractures with >5 mm medial clear space after external rotational stress to be considered unstable. Additionally, ankles with a medial clear space between 4 and 5 mm, instability should be considered only if lateral shift is > 2 mm on stress examination. Our data shows that no physiologically healthy ankles widened beyond these established cut-offs before or after the manual external rotation stress.
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Affiliation(s)
| | - Joseph A. Ippolito
- Corresponding author. Department of Orthopaedics, Rutgers New Jersey Medical School, 140 Bergen Street, ACC Building, Suite D1610, Newark, NJ, 07103, USA.
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Biomechanical Analysis of Instability in Rotational Distal Fibula Fractures (OTA/AO 44-B1) With an Intact Deltoid Ligament. J Orthop Trauma 2019; 33:411-416. [PMID: 31335566 DOI: 10.1097/bot.0000000000001487] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To biomechanically analyze instability in supination external rotation (SER) II/III patterns. METHODS Nineteen cadaver legs were tested in a mechanical jig. One, 2, 3, and 4 Nm of external rotation were applied to intact ankles, SER II injuries, and SER III injuries. The talar position relative to the tibia was recorded using 3D motion tracking. Change from the unloaded state in each condition and the torque level was calculated. Results were analyzed using analysis of variance with post hoc paired t tests. RESULTS SER II showed statistically significant differences from the intact state with coronal translation (2, 3, and 4 Nm), sagittal translation (1 and 2 Nm), axial rotation (1, 2, 3, and 4 Nm), and coronal rotation (3 and 4 Nm). SER III showed statistically significant differences from the intact state with coronal translation (2, 3, and 4 Nm), sagittal translation (1, 2, and 3 Nm), axial rotation (1, 2, 3, and 4 Nm), and coronal rotation (3 and 4 Nm). SER II and SER III differed significantly from each other with coronal translation (1, 2, and 3 Nm), axial rotation (2, 3, and 4 Nm), and coronal rotation (1, 3, and 4 Nm). CONCLUSION Instability in SER injuries has only been described with coronal translation and suggests that deltoid rupture is necessary. Our data demonstrate instability in SER II/III in sagittal translation and axial rotation as well as subtle instability in coronal translation. The clinical impact is unclear, but better understanding of long-term sequelae of this instability is needed.
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25
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Inappropriate Questions Asked of Female Orthopaedic Surgery Applicants From 1971 to 2015: A Cross-sectional Study. J Am Acad Orthop Surg 2019; 27:519-526. [PMID: 30399030 DOI: 10.5435/jaaos-d-17-00868] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION The Civil Rights Act prohibits employers from making employment decisions based on sex, race, color, religion, or national origin. Questions regarding these topics during a residency interview are therefore prohibited. METHODS A questionnaire was sent to all female orthopaedic surgeons who had an e-mail address in the American Academy of Orthopaedic Surgeons directory. Participants were asked to describe what, if any, inappropriate questions they were asked during interviews. RESULTS Four hundred eighty-eight of 997 invited female orthopaedic surgeons completed the questionnaire (48.9%). Their residency interviews took place from 1971 to 2015. Overall, 61.7% of participants were asked an inappropriate question during an interview. This proportion neither increased nor decreased from 1971 to 2015 (P = 0.315). The most common themes of questions included "raising children during residency" (37.9%), "marital status" (32.4%), and "pregnancy during residency" (29.7%). Of those who were asked an inappropriate question, only 1.4% reported the inappropriate question to authorities. DISCUSSION The present study suggests that over half of female applicants have been asked inappropriate questions at orthopaedic surgery residency interviews, and that there has been no improvement in that percentage over nearly five decades. It is the responsibility those interviewing to be aware of this issue and to be in compliance with national guidelines. LEVEL OF EVIDENCE Level IV.
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Abstract
The last stage of a supination-external rotation ankle fracture involves either transverse fracture of the medial malleolus or rupture of the deltoid ligament. When the deltoid ligament ruptures, a "bimalleolar equivalent" ankle fracture occurs, and the surgeon is presented with several diagnostic and therapeutic challenges. In the native ankle, the deltoid ligament provides restraint to eversion and external rotation of the talus on the tibia. In bimalleolar equivalent ankle fractures, there is often gross medial instability even after fibular reduction. Retraction of the deltoid with subsequent healing in a nonanatomic position theoretically may cause instability, persistent medial gutter pain, and loss of function with risk of early arthritis. In mild cases, deltoid injury may not be obvious, and potential diagnostic techniques include preoperative and intraoperative stress radiography, MRI, and ultrasonography. The most common injury pattern is avulsion from the medial malleolus, and most current repair techniques involve direct repair of the capsular and deltoid injuries involving suture anchors in the medial malleolus and imbrication of the superficial and deep deltoid fibers. To date, there is limited evidence of superior clinical outcomes with the addition of deltoid repair compared with open reduction and internal fixation of the fibula alone.
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Warner SJ, Garner MR, Fabricant PD, Schottel PC, Loftus ML, Hentel KD, Helfet DL, Lorich DG. The Diagnostic Accuracy of Radiographs and Magnetic Resonance Imaging in Predicting Deltoid Ligament Ruptures in Ankle Fractures. HSS J 2019; 15:115-121. [PMID: 31327941 PMCID: PMC6609669 DOI: 10.1007/s11420-018-09655-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 11/19/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Operative indications for supination-external rotation (SER) ankle fractures depend on the integrity of the medial structures. Despite the importance of assessing deep deltoid ligament injuries, the accuracy of common diagnostic tests has not been established. QUESTIONS/PURPOSES The objective of this study was to compare the ability of injury (non-stress) and stress radiographs and magnetic resonance imaging (MRI) to diagnose deep deltoid ligament ruptures in operative SER ankle fractures. METHODS Patients were included who underwent surgical fixation of SER ankle fractures and had appropriate injury and manual stress test radiographs, pre-operative ankle MRI, and intra-operative assessment of deep deltoid integrity by direct visualization. The medial clear space (MCS) was considered positive for all values over 5 mm on the injury or stress mortise radiographs. MRI analysis of the deep deltoid ligament injury was performed by blinded fellowship-trained musculoskeletal radiologists. Intra-operative direct visualization and assessment of the deltoid was performed using a direct medial ankle approach at the time of operative fracture fixation. RESULTS Using intra-operative visualization as the gold standard, MCS measurements and MRI had differing abilities to diagnose a deep deltoid rupture. In cases where the MCS was less than 5 mm on injury radiographs and stress tests were performed, MCS measurements were much less accurate than MRI in predicting deltoid ruptures (46% versus 79%, respectively) with a high false positive rate (80%). In contrast, an MCS measurement of greater than 5 mm on injury radiographs was a strong predictor of deep deltoid rupture (accuracy of 95%). CONCLUSION Compared with direct visualization of the deltoid ligament intra-operatively, these data support proceeding with surgery when the MCS on injury radiographs is greater than 5 mm without any additional stress tests or advanced imaging. When the MCS is less than 5 mm, we recommend MRI analysis because of its increased accuracy and decreased false positive rate. Improving our ability to diagnose deltoid ruptures will contribute to more effective management of patients with SER ankle fractures.
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Affiliation(s)
- Stephen J. Warner
- University of Texas Health Science Center at Houston, 6400 Fannin Street, Suite 1700, Houston, TX 70030 USA
| | | | | | | | - Michael L. Loftus
- Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY USA
| | - Keith D. Hentel
- Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY USA
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Medina McKeon JM, Hoch MC. The Ankle-Joint Complex: A Kinesiologic Approach to Lateral Ankle Sprains. J Athl Train 2019; 54:589-602. [PMID: 31184957 DOI: 10.4085/1062-6050-472-17] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Copious research exists regarding ankle instability, yet lateral ankle sprains (LASs) persist in being among the most common recurrent musculoskeletal injuries. Key anatomical structures of the ankle include a triform articulating structure that includes the inferior tibiofibular, talocrural, and subtalar joints. Functionally, force absorption and propulsion through the ankle complex are necessary for any task that occurs in weight bearing. For optimal ankle performance and avoidance of injury, an intricate balance between stability and mobility is necessary to ensure that appropriate force transfer occurs during sports and activities of daily living. Consideration for the many structures that may be directly or indirectly involved in LASs will likely translate into advancements in clinical care. In this clinical review, we present the structure, function, and relevant pathologic states of the ankle complex to stimulate a better understanding of the prevention, evaluation, and treatment of LASs.
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Affiliation(s)
| | - Matthew C Hoch
- Sports Medicine Research Institute, University of Kentucky, Lexington
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29
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Butler BA, Hempen EC, Barbosa M, Muriuki M, Havey RM, Nicolay RW, Kadakia AR. Deltoid ligament repair reduces and stabilizes the talus in unstable ankle fractures. J Orthop 2019; 17:87-90. [PMID: 31879481 DOI: 10.1016/j.jor.2019.06.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 04/03/2019] [Accepted: 06/02/2019] [Indexed: 11/18/2022] Open
Abstract
Introduction Treatment of supination external rotation type IV (SER-IV) ankle injuries has focused on reduction and fixation of the fibula and syndesmosis (ORIF), not repair of the deltoid ligament. Methods Twenty-one ankles were analyzed with a motion capture system. Uninjured ankles were stressed and compared to ankles with SER-IV injuries, then with ORIF, and finally ORIF and deltoid repair. Results After deltoid ligament repair, talar coronal and axial rotation normalized to the uninjured state and were significantly reduced compared to ORIF alone. Discussion Deltoid ligament repair after an SER-IV ankle injury can help directly reduce and stabilize the tibiotalar joint.
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Affiliation(s)
- Bennet A Butler
- Northwestern Memorial Hospital Department of Orthopaedic Surgery, 676 N. Saint Clair, Suite 1350, Chicago, IL, 60611, USA
| | - Eric C Hempen
- Northwestern Memorial Hospital Department of Orthopaedic Surgery, 676 N. Saint Clair, Suite 1350, Chicago, IL, 60611, USA
| | - Mauricio Barbosa
- Northwestern Memorial Hospital Department of Orthopaedic Surgery, 676 N. Saint Clair, Suite 1350, Chicago, IL, 60611, USA
| | - Muturi Muriuki
- Musculoskeletal Biomechanics Laboratory, Edward Hines, Jr VA Hospital, 5000 5th Ave, Hines, IL, 60141, USA
| | - Robert M Havey
- Musculoskeletal Biomechanics Laboratory, Edward Hines, Jr VA Hospital, 5000 5th Ave, Hines, IL, 60141, USA
| | - Richard W Nicolay
- Northwestern Memorial Hospital Department of Orthopaedic Surgery, 676 N. Saint Clair, Suite 1350, Chicago, IL, 60611, USA
| | - Anish R Kadakia
- Northwestern Memorial Hospital Department of Orthopaedic Surgery, 676 N. Saint Clair, Suite 1350, Chicago, IL, 60611, USA
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Xu C, Li MQ, Wang C, Liu H. Nonanatomic versus anatomic techniques in spring ligament reconstruction: biomechanical assessment via a finite element model. J Orthop Surg Res 2019; 14:114. [PMID: 31036018 PMCID: PMC6489249 DOI: 10.1186/s13018-019-1154-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 04/12/2019] [Indexed: 11/12/2022] Open
Abstract
Background Several approaches to spring ligament reconstruction have been reported. However, a comparative study of nonanatomic and anatomic techniques with respect to biomechanical responses, such as kinematics and contact characteristics, has not been previously performed via a finite element analysis. The purpose of this study was to evaluate the biomechanical results of such spring ligament reconstructions via a finite element analysis. Methods A three-dimensional finite element model of the foot was developed and validated, and four reconstruction methods were simulated. The talonavicular dorsiflexion and abduction, hindfoot valgus, and contact characteristics in the Chopart joints were quantified in each model. Results Nonanatomic reconstructions corrected the talonavicular and hindfoot deformities to a greater extent than the anatomic reconstructions. The anatomic techniques also corrected the abduction and dorsiflexion deformities, although they presented insufficient power to correct for hindfoot valgus. None of the procedures restored the contact characteristics of the talonavicular and calcaneocuboid joints to those of a normal condition. Conclusion Nonanatomic reconstruction of the spring ligament complex provided the greatest correction for midfoot and hindfoot misalignments in flatfoot. Severe deformities with large amounts of midfoot pronation and hindfoot valgus may be better treated with nonanatomic reconstruction methods. The spring ligament reconstruction method may mitigate the need for nonanatomic bony procedures associated with complications and allows for the preservation of the triple joint complex.
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Affiliation(s)
- Can Xu
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Ming Qing Li
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Chenggong Wang
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Hua Liu
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, 410008, China.
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DeSilva J, McNutt E, Benoit J, Zipfel B. One small step: A review of Plio‐Pleistocene hominin foot evolution. AMERICAN JOURNAL OF PHYSICAL ANTHROPOLOGY 2018; 168 Suppl 67:63-140. [DOI: 10.1002/ajpa.23750] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 10/01/2018] [Accepted: 10/05/2018] [Indexed: 01/03/2023]
Affiliation(s)
- Jeremy DeSilva
- Department of AnthropologyDartmouth College Hanover New Hampshire
- Evolutionary Studies Institute and School of GeosciencesUniversity of the Witwatersrand Johannesburg South Africa
| | - Ellison McNutt
- Department of AnthropologyDartmouth College Hanover New Hampshire
| | - Julien Benoit
- Evolutionary Studies Institute and School of GeosciencesUniversity of the Witwatersrand Johannesburg South Africa
| | - Bernhard Zipfel
- Evolutionary Studies Institute and School of GeosciencesUniversity of the Witwatersrand Johannesburg South Africa
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Jeong BO, Kim TY, Baek JH, Song SH, Park JS. Assessment of Ankle Mortise Instability After Isolated Supination-External Rotation Lateral Malleolar Fractures. J Bone Joint Surg Am 2018; 100:1557-1562. [PMID: 30234620 DOI: 10.2106/jbjs.17.00993] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The diagnosis of clinically important instability following isolated supination-external rotation (SER) distal fibular fractures is a challenge. The purpose of this study was to investigate the accuracy of clinical findings including medial tenderness, swelling, and ecchymosis, combined with the gravity stress test and magnetic resonance imaging (MRI), in the assessment of ankle mortise stability in association with isolated SER-type lateral malleolar fractures. The external rotation (ER) stress test was used as the reference with which the methods of assessment were compared. METHODS Thirty-seven patients were enrolled prospectively. Using the ER stress test as a reference, we evaluated the sensitivity, specificity, likelihood ratio (LR), and post-test probability of instability when using clinical examination, the gravity stress test, and MRI for diagnosing ankle mortise instability after an isolated SER lateral malleolar fracture. RESULTS The positive LR for clinical findings ranged from 1.45 to 2.54, and the negative LR ranged from 0.25 to 0.70, shifting the pre-test probability to a rarely important degree. In contrast, the positive LR for the gravity stress test was 5.71 with a 95% confidence interval (CI) of 1.52 to 21.48, a moderate shift from the pre-test probability, and the negative LR was 0.33 (95% CI = 0.16 to 0.66), indicating a small shift. In cases with a deep deltoid ligament disruption identified on MRI, the positive LR was 3.05 (95% CI = 1.03 to 9.02) and the negative LR was 0.53 (95% CI = 0.31 to 0.91), demonstrating a small but sometimes important shift. CONCLUSIONS The gravity stress test is a reliable method for diagnosing ankle mortise instability in patients with an isolated SER lateral malleolar fracture. Nevertheless, this test alone would not qualify as a replacement for the ER stress test. However, when the gravity stress test result is consistent with the clinical or MRI findings, its diagnostic value is almost equivalent to that of the ER stress test. LEVEL OF EVIDENCE Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Bi O Jeong
- Departments of Orthopaedic Surgery (B.O.J., T.Y.K., J.H.B., and S.H.S.) and Radiology (J.S.P.), College of Medicine, Kyung Hee University, Seoul, South Korea
| | - Tae Yong Kim
- Departments of Orthopaedic Surgery (B.O.J., T.Y.K., J.H.B., and S.H.S.) and Radiology (J.S.P.), College of Medicine, Kyung Hee University, Seoul, South Korea
| | - Jong Hun Baek
- Departments of Orthopaedic Surgery (B.O.J., T.Y.K., J.H.B., and S.H.S.) and Radiology (J.S.P.), College of Medicine, Kyung Hee University, Seoul, South Korea
| | - Seung Hyun Song
- Departments of Orthopaedic Surgery (B.O.J., T.Y.K., J.H.B., and S.H.S.) and Radiology (J.S.P.), College of Medicine, Kyung Hee University, Seoul, South Korea
| | - Ji Seon Park
- Departments of Orthopaedic Surgery (B.O.J., T.Y.K., J.H.B., and S.H.S.) and Radiology (J.S.P.), College of Medicine, Kyung Hee University, Seoul, South Korea
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Nwosu K, Schneiderman BA, Shymon SJ, Harris T. A Medial Malleolar "Fleck Sign" May Predict Ankle Instability in Ligamentous Supination External Rotation Ankle Fractures. Foot Ankle Spec 2018; 11:246-251. [PMID: 28877594 DOI: 10.1177/1938640017729494] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Ankle joint stability dictates treatment in ligamentous supination external rotation ankle injuries (LSERAI). Investigation of the medial structures that support the ankle mortise is critical, and a small avulsion fracture, or "fleck", of the medial malleolus is occasionally encountered. This study aimed to assess the utility of this medial malleolus fleck sign (MMFS) in diagnosing instability requiring surgery in LSERAI. METHODS This retrospective observational study examined 166 LSERAI at a single level I trauma center. A standardized diagnostic and treatment protocol for ankle fractures was followed. LSERAI at presentation were reported as having a normal, dynamically wide, or statically wide medial clear space. Patient demographics, MMFS characteristics, and the use of operative management were recorded. RESULTS MMFS incidence in the cohort was 16 (10%) of 166 and was present in 25% of patients with unstable LSERAI. Fifteen (94%) of 16 patients with a MMFS were deemed to have an unstable LSERAI (P < .005). MMFS had a 25% sensitivity and 99% specificity in diagnosing an unstable LSERAI. For the subgroup of patients without a statically wide medial clear space, MMFS had a 50% sensitivity and 99% specificity in determining instability. CONCLUSION A MMFS may be indicative of an unstable LSERAI. With previous MRI studies demonstrating complete deltoid disruption in unstable LSERAI, we deduce the MMFS may be associated with extensive deltoid incompetence. The MMFS may help to diagnose a complete deltoid injury in LSERAI with a normal medial clear space, which could influence treatment and reduce patient morbidity, radiation exposure, and healthcare costs. LEVELS OF EVIDENCE Level III: Retrospective Cohort Study.
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Affiliation(s)
- Kenneth Nwosu
- Los Angeles County Harbor-UCLA Medical Center, Torrance, California
| | | | | | - Thomas Harris
- Los Angeles County Harbor-UCLA Medical Center, Torrance, California
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Abstract
Deltoid ligament reconstruction allows for joint preservation of the ankle in the setting of patients a triple arthrodesis due to a flat foot deformity. Although the increased forces that may occur in the ankle joint after a triple arthrodesis cannot be eliminated, reconstruction of the ligament will delay and may prevent the onset arthritis, allowing the patient to maintain mobility of the ankle joint. The anatomy, surgery, and risks and benefits are discussed.
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Affiliation(s)
- Ezekiel Oburu
- Department of Orthopaedics, University of Nairobi, PO Box 2206, Nairobi, Kenya.
| | - Mark S Myerson
- Institute of Foot and Ankle Reconstruction, 301 St. Paul Place, Baltimore, MD 21202, USA
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Vega J, Dalmau-Pastor M, Malagelada F, Fargues-Polo B, Peña F. Ankle Arthroscopy: An Update. J Bone Joint Surg Am 2017; 99:1395-1407. [PMID: 28816902 DOI: 10.2106/jbjs.16.00046] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Jordi Vega
- 1Foot and Ankle Unit, Hospital Quirón Barcelona, Barcelona, Spain 2Human Anatomy and Embriology Unit, Department of Pathology and Experimental Therapeutics, University of Barcelona, Barcelona, Spain 3Manresa Health Science School, University of Vic-Central University of Catalonia, Barcelona, Spain 4Foot and Ankle Unit, Department of Orthopaedic Surgery, Heatherwood and Wexham Park Hospitals, Frimley Health NHS Trust, Ascot, Berkshire, United Kingdom 5Foot and Ankle Unit, Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota
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Serial Radiographs Do Not Change the Clinical Course of Nonoperative Stable OTA/AO 44-B1 Ankle Fractures. J Orthop Trauma 2017; 31:264-269. [PMID: 28430746 DOI: 10.1097/bot.0000000000000785] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To assess radiographic markers of ankle stability in stable OTA/AO 44-B1 ankle fractures. DESIGN Retrospective review. SETTING Academic Level-I trauma hospital. PATIENTS One hundred thirty-four patients with stable OTA/AO 44-B1 (Danis-Weber B, Supination-External Rotation-II) ankle fractures. INTERVENTION Analysis of mortise view radiographs at the time of initial evaluation and final follow-up. VARIABLES MEASURED (1) medial clear space; (2) Mueller-Nose Distance. MAIN OUTCOME MEASURE Change in radiographic measurements resulting in conversion to operative intervention. RESULTS Patients followed up an average of 2.6 visits in our clinics (SD 1.06). Patients received an average of 11.2 individual radiographic images to evaluate their injury (SD 3.9, maximum 29). No patients progressed to surgery in this cohort. Mean medial clear space at the time of injury was 3.4 mm (SD 0.8) and was 3.3 mm (SD 0.7) at the time of final follow-up (P = 0.1). Mean Mueller-Nose measurement at the time of injury was 3.5 mm (SD 1.0) and was 3.5 mm (SD 0.8) at the time of final follow-up (P = 0.47). CONCLUSIONS No patients with stable OTA/AO 44-B1 fractures proceeded to surgery for loss of tibiotalar reduction or any other cause. Radiographic relationships were conserved during the follow-up, and serial radiographs may not be needed when managing these patients. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Nortunen S, Leskelä HV, Haapasalo H, Flinkkilä T, Ohtonen P, Pakarinen H. Dynamic Stress Testing Is Unnecessary for Unimalleolar Supination-External Rotation Ankle Fractures with Minimal Fracture Displacement on Lateral Radiographs. J Bone Joint Surg Am 2017; 99:482-487. [PMID: 28291180 DOI: 10.2106/jbjs.16.00450] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND This study aimed to identify factors from standard radiographs that contributed to the stability of the ankle mortise in patients with isolated supination-external rotation fractures of the lateral malleolus (OTA/AO 44-B). METHODS Non-stress radiographs of the mortise and lateral views, without medial clear space widening or incongruity, were prospectively collected for 286 consecutive patients (mean age, 45 years [range, 16 to 85 years]), including 144 female patients (mean age, 50 years [range, 17 to 85 years]) and 142 male patients (mean age, 40 years [range, 16 to 84 years]) from 2 trauma centers. The radiographs were analyzed for fracture morphology by 2 orthopaedic surgeons, who were blinded to each other's measurements and to the results of external rotation stress radiographs (the reference for stability). Factors significantly associated with ankle mortise stability were tested in multiple logistic regression. Receiver operating characteristic analyses were performed for continuous variables to determine optimal thresholds. A sensitivity of >90% was used as the criterion for an optimal threshold. RESULTS According to external rotation stress radiographs, 217 patients (75.9%) had a stable injury, defined as that with a medial clear space of <5 mm. Independent factors that predicted stable ankle mortise were female sex (odds ratio [OR], 2.5 [95% confidence interval (CI), 1.4 to 4.6]), a posterior diastasis of <2 mm (corresponding with a sensitivity of 0.94 and specificity of 0.39) on lateral radiographs (OR, 10.8 [95% CI, 3.7 to 31.5]), and only 2 fracture fragments (OR, 7.3 [95% CI, 2.1 to 26.3]). When the posterior diastasis was <2 mm and only 2 fracture fragments were present, the probability of a stable ankle mortise was 0.98 for 48 female patients (16.8%) and 0.94 for 37 male patients (12.9%). CONCLUSIONS Patients with noncomminuted lateral malleolar fractures (85 patients [29.7%]) could be diagnosed with a stable ankle mortise without further stress testing, when the fracture line widths were <2 mm on lateral radiographs. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Simo Nortunen
- 1Department of Surgery, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland 2Division of Orthopedics and Traumatology, Department of Trauma, Musculoskeletal Surgery and Rehabilitation, Tampere University Hospital, Tampere, Finland
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Won HJ, Koh IJ, Won HS. Morphological variations of the deltoid ligament of the medial ankle. Clin Anat 2016; 29:1059-1065. [PMID: 27618430 DOI: 10.1002/ca.22793] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 09/08/2016] [Indexed: 02/06/2023]
Abstract
Morphological variations of the deltoid ligament were investigated in this study, with the aim of classifying the different types on the basis of their components. Sixty ankles from 39 cadavers were dissected. The origin and insertion sites of the deltoid ligament were identified, and its length, width, and thickness were measured. The deltoid ligament was divided into two layers, superficial and deep, which respectively comprised four components (tibionavicular, tibiospring, tibiocalcaneal, and superficial posterior tibiotalar ligaments) and two components (anterior tibiotalar and deep posterior tibiotalar ligaments). The tibiospring and tibiocalcaneal ligaments were found in 100% of the specimens, while the prevalence rates of other components lay within the range 63.3-96.7%. The tibionavicular and deep posterior tibiotalar ligaments were the thinnest and thickest, respectively, while the other ligaments had similar thicknesses. The deltoid ligament was classified into types I-IV according to the combinations of these components: all components were present in type I (48.3%), the tibionavicular ligament was absent in type II (36.7%), only the superficial posterior tibiotalar ligament was absent in type III (6.7%), and only the anterior tibiotalar ligament was absent in type IV (8.3%). In conclusion, these results improve knowledge of the morphological and morphometric characteristics of the deltoid ligament and thus provide helpful information for surgical procedures in this region. Clin. Anat. 29:1059-1065, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Hyung-Jin Won
- Department of Anatomy, Yonsei University College of Medicine, Seoul, Korea
| | - In Jun Koh
- Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic Univesity of Korea, Seoul, Korea
| | - Hyung-Sun Won
- Department of Anatomy, Catholic Institute for Applied Anatomy, College of Medicine, The Catholic University of Korea, Seoul, Korea.
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Ballal MS, Pearce CJ, Calder JDF. Management of sports injuries of the foot and ankle. Bone Joint J 2016; 98-B:874-83. [DOI: 10.1302/0301-620x.98b7.36588] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 12/02/2015] [Indexed: 12/14/2022]
Abstract
Sporting injuries around the ankle vary from simple sprains that will resolve spontaneously within a few days to severe injuries which may never fully recover and may threaten the career of a professional athlete. Some of these injuries can be easily overlooked altogether or misdiagnosed with potentially devastating effects on future performance. In this review article, we cover some of the common and important sporting injuries involving the ankle including updates on their management and outcomes. Cite this article: Bone Joint J 2016;98-B:874–83.
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Affiliation(s)
- M. S. Ballal
- Fortius Clinic, 17
Fitzhardinge Street, London, W1H
6EQ, UK
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40
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Abstract
The ankle represents the most commonly injured weightbearing joint in the human body. They are typically the result of low-energy, rotational injury mechanisms. However, ankle fractures represent a spectrum of injury patterns from simple to very complex, with varying incidence of posttraumatic arthritis. Stable injury patterns can be treated nonoperatively; unstable injury patterns are typically treated operatively given that they could lead to severe arthritis if not properly addressed.
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Affiliation(s)
- Cristián A Ortiz
- Orthopaedic Department, Clínica Alemana de Santiago, Universidad del Desarrollo, Vitacura 5957, Santiago, Chile 7650568.
| | - Pablo Wagner
- Orthopaedic Department, Clínica Alemana de Santiago, Universidad del Desarrollo, Vitacura 5957, Santiago, Chile 7650568
| | - Emilio Wagner
- Orthopaedic Department, Clínica Alemana de Santiago, Universidad del Desarrollo, Vitacura 5957, Santiago, Chile 7650568
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Choi SM, Cho BK, Park KJ. Percutaneous Deltoid Ligament Augmentation Using Suture Tape for Medial Ankle Instability. J Foot Ankle Surg 2016; 55:1307-1311. [PMID: 26872524 DOI: 10.1053/j.jfas.2015.12.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Indexed: 02/03/2023]
Abstract
Compared with lateral ankle instability, medial ankle instability has many fewer treatment strategies and fewer reconstructive options available. The best method for deltoid ligament reconstruction remains unclear. Percutaneous deltoid ligament augmentation using suture tape represents a novel alternative technique for chronic medial ankle instability.
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Affiliation(s)
- Seung-Myung Choi
- Department of Orthopaedic Surgery, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Byung-Ki Cho
- Department of Orthopaedic Surgery, Chungbuk National University College of Medicine, Cheongju, Korea.
| | - Kyoung-Jin Park
- Department of Orthopaedic Surgery, Chungbuk National University College of Medicine, Cheongju, Korea
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Nortunen S, Flinkkilä T, Lantto I, Kortekangas T, Niinimäki J, Ohtonen P, Pakarinen H. Diagnostic accuracy of the gravity stress test and clinical signs in cases of isolated supination–external rotation-type lateral malleolar fractures. Bone Joint J 2015. [DOI: 10.1302/0301-620x.97b8.35062] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We prospectively assessed the diagnostic accuracy of the gravity stress test and clinical findings to evaluate the stability of the ankle mortise in patients with supination–external rotation-type fractures of the lateral malleolus without widening of the medial clear space. The cohort included 79 patients with a mean age of 44 years (16 to 82). Two surgeons assessed medial tenderness, swelling and ecchymosis and performed the external rotation (ER) stress test (a reference standard). A diagnostic radiographer performed the gravity stress test. For the gravity stress test, the positive likelihood ratio (LR) was 5.80 with a 95% confidence interval (CI) of 2.75 to 12.27, and the negative LR was 0.15 (95% CI 0.07 to 0.35), suggesting a moderate change from the pre-test probability. Medial tenderness, both alone and in combination with swelling and/or ecchymosis, indicated a small change (positive LR, 2.74 to 3.25; negative LR, 0.38 to 0.47), whereas swelling and ecchymosis indicated only minimal changes (positive LR, 1.41 to 1.65; negative LR, 0.38 to 0.47). In conclusion, when gravity stress test results are in agreement with clinical findings, the result is likely to predict stability of the ankle mortise with an accuracy equivalent to ER stress test results. When clinical examination suggests a medial-side injury, however, the gravity stress test may give a false negative result. Cite this article: Bone Joint J 2015; 97-B:1126–31.
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Affiliation(s)
- S. Nortunen
- Oulu University Hospital, PL
21, FI 90029 OYS, Oulu, Finland
| | - T. Flinkkilä
- Oulu University Hospital, PL
21, FI 90029 OYS, Oulu, Finland
| | - I. Lantto
- Oulu University Hospital, PL
21, FI 90029 OYS, Oulu, Finland
| | - T. Kortekangas
- Oulu University Hospital, PL
21, FI 90029 OYS, Oulu, Finland
| | - J. Niinimäki
- Oulu University Hospital, PL
21, FI 90029 OYS, Oulu, Finland
| | - P. Ohtonen
- Oulu University Hospital, PL
21, FI 90029 OYS, Oulu, Finland
| | - H. Pakarinen
- Oulu University Hospital, PL
21, FI 90029 OYS, Oulu, Finland
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Yu GR, Zhang MZ, Aiyer A, Tang X, Xie M, Zeng LR, Zhao YG, Li B, Yang YF. Repair of the acute deltoid ligament complex rupture associated with ankle fractures: a multicenter clinical study. J Foot Ankle Surg 2015; 54:198-202. [PMID: 25618804 DOI: 10.1053/j.jfas.2014.12.013] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2014] [Indexed: 02/03/2023]
Abstract
Controversy exists concerning the need for operative repair of the deltoid ligament during management of acute ankle fractures. The purpose of our report was to identify the indications for surgical intervention for deltoid ligament injury in the setting of ankle fractures. Furthermore, we aimed to elucidate the clinical outcomes after deltoid ligament repair in this setting. This was a multicenter study, involving 4 clinical institutions. From January 2006 to December 2011, 1533 ankle fractures underwent surgical intervention. Of this group, 131 deltoid ligament ruptures (8.55%) were identified and repaired operatively. Of the 131 patients, 74 were male (56.5%) and 57 were female (43.5%), with a mean age of 33.2 (range 16 to 63) years. The outcome measures included the clinical examination findings, radiographic findings, American Orthopaedic Foot and Ankle Society ankle-hindfoot scores, visual analog scale (VAS) scores, and Medical Outcomes Study Short Form 36-item questionnaire scores. All incisions healed primarily. A total of 106 patients were followed up for a minimum of 12 (range 12 to 72) months, with an average follow-up period of 27 months. The mean interval to fracture union was 14.5 (range 9 to 16) weeks. The mean American Orthopaedic Foot and Ankle Society ankle-hindfoot score at the latest follow-up visit was 91.4 (range 83 to 100) points. The mean visual analog scale score was 1.2 (range 0 to 6) points. The mean Short Form-36 score was 91.2 (range 80 to 96) points. Compared with the preoperative scores, all the 3 outcome measures had improved significantly postoperatively (p < .05). The postoperative stress radiographs did not reveal any ankle instability. None had evidence of post-traumatic arthritis of the ankle from the clinical examination and radiographs. A reasonable clinical evaluation and surgical repair was executed, with an appropriate repair technique chosen according to the site of deltoid ligament rupture. The results of the present multicenter study have shown that deltoid ligament rupture can be repaired in patients with an unstable medial ankle after fracture fixation and prevent ankle stabilization-related complications.
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Affiliation(s)
- Guang-rong Yu
- Orthopedist, Department of Orthopaedics, Tongji Hospital, Tongji University School of Medicine, Shanghai, China.
| | - Ming-zhu Zhang
- Orthopedist, Department of Orthopaedics, Tongji Hospital, Tongji University School of Medicine, Shanghai, China.
| | - Amiethab Aiyer
- Orthopedist, Institute for Foot and Ankle Reconstruction at Mercy, Baltimore, MD
| | - Xin Tang
- Orthopedist, Department of Orthopaedics, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Ming Xie
- Orthopedist, Department of Orthopaedics, Pu Ai Hospital of Huazhong Technology and Science University, Wuhan, China
| | - Lin-ru Zeng
- Orthopedist, Department of Orthopaedics, Hangzhou Xiaoshan Hospital, Hangzhou, China
| | - You-guang Zhao
- Orthopedist, Department of Orthopaedics, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Bing Li
- Orthopedist, Department of Orthopaedics, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yun-feng Yang
- Orthopedist, Department of Orthopaedics, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
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Nortunen S, Lepojärvi S, Savola O, Niinimäki J, Ohtonen P, Flinkkilä T, Lantto I, Kortekangas T, Pakarinen H. Stability assessment of the ankle mortise in supination-external rotation-type ankle fractures: lack of additional diagnostic value of MRI. J Bone Joint Surg Am 2014; 96:1855-62. [PMID: 25410502 DOI: 10.2106/jbjs.m.01533] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND This prospective diagnostic study assessed the utility of MRI (magnetic resonance imaging) findings for the deep aspect of the deltoid ligament in evaluating the stability of the ankle mortise in patients who have an SER (supination-external rotation)-type lateral malleolar fracture with no widening of the medial clear space. METHODS Sixty-one patients with a unilateral lateral malleolar fracture resulting from an SER mechanism were enrolled. Two surgeons assessed the stability of the ankle mortise with use of an external-rotation stress test. The anterior and posterior parts of the deep deltoid ligament were investigated with 3.0-T MRI and were graded (as normal, edematous, partial tear, or complete tear) by two musculoskeletal radiologists. The medial clear space was measured and compared with the MRI findings for the deep deltoid ligament in stable and unstable injuries. Interobserver reliability was calculated for both external-rotation stress testing and MRI assessment. RESULTS Thirty-three patients had a medial clear space of ≥ 5 mm in the external-rotation stress test. According to MRI, all of these patients had an injury involving the deep deltoid ligament (an edematous ligament in five, a partial tear in twenty-six, and a total tear in two). Twenty-eight patients had a medial clear space of <5 mm, and MRI indicated a deep deltoid ligament injury in all of these patients as well (an edematous ligament in nine and a partial tear in nineteen). The medial clear space increased according to the severity of the deep deltoid ligament injury as indicated by MRI (p < 0.001). The interobserver agreement of the external-rotation stress test was excellent (94% agreement; kappa = 0.87), whereas the interobserver reliability of the MRI assessments by the two musculoskeletal radiologists was fair to moderate (72% agreement for the posterior part of the deep deltoid ligament and 56% for the anterior part; kappa = 0.46 and 0.22, respectively). CONCLUSIONS On the basis of the study results, we do not recommend the use of MRI when choosing between operative and nonoperative treatment of an SER-type ankle fracture.
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Affiliation(s)
- Simo Nortunen
- Division of Orthopedic and Trauma Surgery, Department of Surgery (S.N., T.F., I.L., T.K., and H.P), Department of Diagnostic Radiology (S.L. and J.N.), and Department of Anesthesiology and Surgery (P.O.), Oulu University Hospital, PL 21, Kajaanintie 50, FI 90029 OYS, Oulu, Finland. E-mail address for S. Nortunen: . E-mail address for S. Lepojärvi: . E-mail address for J. Niinimäki: . E-mail address: . E-mail address for T. Flinkkilä: . E-mail address for I. Lantto: . E-mail address for T. Kortekangas: . E-mail address for H. Pakarinen:
| | - Sannamari Lepojärvi
- Division of Orthopedic and Trauma Surgery, Department of Surgery (S.N., T.F., I.L., T.K., and H.P), Department of Diagnostic Radiology (S.L. and J.N.), and Department of Anesthesiology and Surgery (P.O.), Oulu University Hospital, PL 21, Kajaanintie 50, FI 90029 OYS, Oulu, Finland. E-mail address for S. Nortunen: . E-mail address for S. Lepojärvi: . E-mail address for J. Niinimäki: . E-mail address: . E-mail address for T. Flinkkilä: . E-mail address for I. Lantto: . E-mail address for T. Kortekangas: . E-mail address for H. Pakarinen:
| | - Olli Savola
- Omasairaala, Helsinki, Puutarhurinkuja 2, FI 00300 Helsinki, Finland. E-mail address:
| | - Jaakko Niinimäki
- Division of Orthopedic and Trauma Surgery, Department of Surgery (S.N., T.F., I.L., T.K., and H.P), Department of Diagnostic Radiology (S.L. and J.N.), and Department of Anesthesiology and Surgery (P.O.), Oulu University Hospital, PL 21, Kajaanintie 50, FI 90029 OYS, Oulu, Finland. E-mail address for S. Nortunen: . E-mail address for S. Lepojärvi: . E-mail address for J. Niinimäki: . E-mail address: . E-mail address for T. Flinkkilä: . E-mail address for I. Lantto: . E-mail address for T. Kortekangas: . E-mail address for H. Pakarinen:
| | - Pasi Ohtonen
- Division of Orthopedic and Trauma Surgery, Department of Surgery (S.N., T.F., I.L., T.K., and H.P), Department of Diagnostic Radiology (S.L. and J.N.), and Department of Anesthesiology and Surgery (P.O.), Oulu University Hospital, PL 21, Kajaanintie 50, FI 90029 OYS, Oulu, Finland. E-mail address for S. Nortunen: . E-mail address for S. Lepojärvi: . E-mail address for J. Niinimäki: . E-mail address: . E-mail address for T. Flinkkilä: . E-mail address for I. Lantto: . E-mail address for T. Kortekangas: . E-mail address for H. Pakarinen:
| | - Tapio Flinkkilä
- Division of Orthopedic and Trauma Surgery, Department of Surgery (S.N., T.F., I.L., T.K., and H.P), Department of Diagnostic Radiology (S.L. and J.N.), and Department of Anesthesiology and Surgery (P.O.), Oulu University Hospital, PL 21, Kajaanintie 50, FI 90029 OYS, Oulu, Finland. E-mail address for S. Nortunen: . E-mail address for S. Lepojärvi: . E-mail address for J. Niinimäki: . E-mail address: . E-mail address for T. Flinkkilä: . E-mail address for I. Lantto: . E-mail address for T. Kortekangas: . E-mail address for H. Pakarinen:
| | - Iikka Lantto
- Division of Orthopedic and Trauma Surgery, Department of Surgery (S.N., T.F., I.L., T.K., and H.P), Department of Diagnostic Radiology (S.L. and J.N.), and Department of Anesthesiology and Surgery (P.O.), Oulu University Hospital, PL 21, Kajaanintie 50, FI 90029 OYS, Oulu, Finland. E-mail address for S. Nortunen: . E-mail address for S. Lepojärvi: . E-mail address for J. Niinimäki: . E-mail address: . E-mail address for T. Flinkkilä: . E-mail address for I. Lantto: . E-mail address for T. Kortekangas: . E-mail address for H. Pakarinen:
| | - Tero Kortekangas
- Division of Orthopedic and Trauma Surgery, Department of Surgery (S.N., T.F., I.L., T.K., and H.P), Department of Diagnostic Radiology (S.L. and J.N.), and Department of Anesthesiology and Surgery (P.O.), Oulu University Hospital, PL 21, Kajaanintie 50, FI 90029 OYS, Oulu, Finland. E-mail address for S. Nortunen: . E-mail address for S. Lepojärvi: . E-mail address for J. Niinimäki: . E-mail address: . E-mail address for T. Flinkkilä: . E-mail address for I. Lantto: . E-mail address for T. Kortekangas: . E-mail address for H. Pakarinen:
| | - Harri Pakarinen
- Division of Orthopedic and Trauma Surgery, Department of Surgery (S.N., T.F., I.L., T.K., and H.P), Department of Diagnostic Radiology (S.L. and J.N.), and Department of Anesthesiology and Surgery (P.O.), Oulu University Hospital, PL 21, Kajaanintie 50, FI 90029 OYS, Oulu, Finland. E-mail address for S. Nortunen: . E-mail address for S. Lepojärvi: . E-mail address for J. Niinimäki: . E-mail address: . E-mail address for T. Flinkkilä: . E-mail address for I. Lantto: . E-mail address for T. Kortekangas: . E-mail address for H. Pakarinen:
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Peterson KS, Hyer CF. Surgical decision making for stage IV adult acquired flatfoot disorder. Clin Podiatr Med Surg 2014; 31:445-54. [PMID: 24980933 DOI: 10.1016/j.cpm.2014.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Adult acquired flatfoot deformity is a debilitating musculoskeletal condition affecting the lower extremity. Posterior tibial tendon dysfunction (PTTD) is the primary etiology for the development of a flatfoot deformity in an adult. PTTD is classified into 4 stages (with stage IV subdivided into stage IV-A and IV-B). This classification is described in detail in this article.
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Affiliation(s)
- Kyle S Peterson
- Advanced Foot and Ankle Surgical Fellowship, Orthopedic Foot and Ankle Center, 300 Polaris Parkway, Suite 2000, Westerville, OH 43082, USA.
| | - Christopher F Hyer
- Advanced Foot and Ankle Surgical Fellowship, Orthopedic Foot and Ankle Center, 300 Polaris Parkway, Suite 2000, Westerville, OH 43082, USA
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Abbas A. Open reduction and internal fixation of high fibular fractures in ankle injuries: Is it necessary? - A review of the literature. J Orthop 2014; 10:1-4. [PMID: 24403739 DOI: 10.1016/j.jor.2013.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2012] [Indexed: 01/26/2023] Open
Affiliation(s)
- Ammar Abbas
- Trauma and Orthopaedic Registrar, Department of Orthopaedic, Sligo General Hospital, Sligo, Ireland
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Won HJ, Won HS, Oh CS, Han SH, Chung IH, Suh JS, Lee WC. Posterior tibiotalar ligament: An anatomic study correlated with MRI. Clin Anat 2013; 27:798-803. [DOI: 10.1002/ca.22302] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Revised: 07/03/2013] [Accepted: 07/05/2013] [Indexed: 01/08/2023]
Affiliation(s)
- Hyung-Jin Won
- Department of Anatomy; Samsung Biomedical Research Institute; Sungkyunkwan University School of Medicine; Suwon Korea
| | - Hyung-Sun Won
- Catholic Institute for Applied Anatomy, Department of Anatomy; College of Medicine, The Catholic University of Korea; Seoul Korea
| | - Chang-Seok Oh
- Department of Anatomy; Samsung Biomedical Research Institute; Sungkyunkwan University School of Medicine; Suwon Korea
| | - Seung-Ho Han
- Department of Anatomy, College of Medicine; Chung-Ang University; Seoul Korea
| | - In-Hyuk Chung
- Catholic Institute for Applied Anatomy, Department of Anatomy; College of Medicine, The Catholic University of Korea; Seoul Korea
| | - Jin-Suck Suh
- Department of Diagnostic Radiology; Yonsei University College of Medicine; Seoul Korea
| | - Woo-Chun Lee
- Department of Orthopaedic Surgery; Seoul Paik Hospital, Inje University; Seoul Korea
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Ribbans WJ, Garde A. Tibialis posterior tendon and deltoid and spring ligament injuries in the elite athlete. Foot Ankle Clin 2013; 18:255-91. [PMID: 23707177 DOI: 10.1016/j.fcl.2013.02.006] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The tibialis posterior tendon and the spring and deltoid ligament complexes combine to provide dynamic and passive stabilization on the medial side of the ankle and hindfoot. Some of the injuries will involve acute injury to previous healthy structures, but many will develop insidiously. The clinician must be aware of new treatment strategies and the level of accompanying scientific evidence regarding injuries sustained by athletes in these areas, while acknowledging that more traditional management applied to nonathletic patients is still likely to be appropriate in the setting of treatment for elite athletes.
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Affiliation(s)
- William John Ribbans
- The University of Northampton, School of Health, Park Campus, Northampton NN2 7AL, UK.
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McCollum GA, van den Bekerom MPJ, Kerkhoffs GMMJ, Calder JDF, van Dijk CN. Syndesmosis and deltoid ligament injuries in the athlete. Knee Surg Sports Traumatol Arthrosc 2013; 21:1328-37. [PMID: 23052109 DOI: 10.1007/s00167-012-2205-1] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Accepted: 09/03/2012] [Indexed: 12/25/2022]
Abstract
PURPOSE Injury to the syndesmosis and deltoid ligament is less common than lateral ligament trauma but can lead to significant time away from sport and prolonged rehabilitation. This literature review will discuss both syndesmotic and deltoid ligament injuries without fracture in the professional athlete. METHODS A narrative review was performed using PUBMED, OVID, MEDLINE and EMBASE using the key words syndesmosis, injury, deltoid, ankle ligaments, and athlete. Articles related to the topic were included and reviewed. RESULTS The incidence of syndesmotic injury ranges from 1 to 18 % of ankle sprains. This may be underreported and is an often missed injury as clinical examination is generally not specific. Both MRI and ultrasonography have high sensitivities and specificities in diagnosing injury. Arthroscopy may confirm the diagnosis, and associated intra-articular pathology can be treated at the same time as surgical stabilization. Significant deltoid ligament injury in isolation is rare, there is usually associated trauma. Major disruption of both deep and superficial parts can lead to ankle dysfunction. Repair of the ligament following ankle fracture is not necessary, but there is little literature to guide the management of deltoid ruptures in isolation or in association with syndesmotic and lateral ligament injuries in the professional athlete. CONCLUSION Management of syndesmotic injury is determined by the grade and associated injury around the ankle. Grade I injuries are treated non-surgically in a boot with a period of non-weight bearing. Treatment of Grade II and III injuries is controversial with little literature to guide management. Athletes may return to training and play sooner if the syndesmosis is surgically stabilized. For deltoid ligament injury, grade I and II sprains should be treated non-operatively. Unstable grade III injuries with associated injury to the lateral ligaments or the syndesmosis may benefit from operative repair.
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Affiliation(s)
- Graham A McCollum
- Chelsea and Westminister Hospital, 369 Fulham Road, London, SW10 9NH, UK.
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