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Iwata S, Yamaguchi S, Kimura S, Hattori S, Sasahara J, Akagi R, Amaha K, Atsuta T, Kanzaki N, Noguchi K, Okada H, Omodani T, Ohuchi H, Sato H, Takada S, Takahashi K, Yamada Y, Yasui T, Yokoe T, Fukushima S, Iida D, Ono Y, Kawasaki Y, Shiko Y, Sasho T, Ohtori S. Do standardization of the procedure reduce measurement variability of the sonographic anterior drawer test of the ankle? J Orthop Sci 2023:S0949-2658(23)00320-2. [PMID: 37996296 DOI: 10.1016/j.jos.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 11/04/2023] [Accepted: 11/09/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND In quantitative ankle stress sonography, different examiners use different techniques, which may cause measurement variability. This study aimed to clarify whether standardizing stress sonography techniques reduces variability in the quantitative measurement of anterior talofibular ligament length change. METHODS Fourteen examiners with a mean ultrasound experience of 8.7 years participated in this study. Each examiner performed stress ultrasonography of the ankle using their preferred method on one patient with an intact anterior talofibular ligament (Patient 1) and on two patients with chronic ankle instability (Patient 2 and 3). Changes in the ligament length between the resting and stressed positions were determined. A consensus meeting was then conducted to standardize the sonographic technique, which was used by the examiners during a repeat stress sonography on the same patients. The variance and measured values were compared between the preferred and standardized techniques using F-tests and paired t-tests, respectively. RESULTS At a consensus meeting, a sonographic technique in which the examiner pushed the lower leg posteriorly against the fixed foot was adopted as the standardized technique. In Patient 1, the change in the anterior talofibular ligament length was 0.4 (range, -2.3-1.3) mm and 0.6 (-0.6-1.7) mm using the preferred and standardized techniques, respectively, with no significant difference in the variance (P = 0.51) or the measured value (P = 0.52). The length changes in Patient 2 were 2.0 (0.3-4.4) mm and 1.7 (-0.9-3.8) mm using the preferred and standardized techniques, respectively. In Patient 3, the length changes were 1.4 (-2.7-7.1) mm and 0.7 (-2.0-2.3) mm. There were no significant differences between the techniques in either patient group. CONCLUSION Variability in the quantitative measurement of ankle stress sonography was not reduced despite the standardization of the technique among examiners. Hence, comparing the measured values between different examiners should be avoided.
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Affiliation(s)
- Shuhei Iwata
- Department of Orthopaedic Surgery, Graduate School of Medical and Pharmaceutical Sciences, Chiba University, Chiba, Japan
| | - Satoshi Yamaguchi
- Department of Orthopaedic Surgery, Graduate School of Medical and Pharmaceutical Sciences, Chiba University, Chiba, Japan; Graduate School of Global and Transdisciplinary Studies, Chiba University, Chiba, Japan.
| | - Seiji Kimura
- Department of Orthopaedic Surgery, Graduate School of Medical and Pharmaceutical Sciences, Chiba University, Chiba, Japan
| | - Soichi Hattori
- Department of Sports Medicine, Kameda Medical Center, Chiba, Japan
| | - Jun Sasahara
- Institute of Sports Science & Medicine, Teikyo University, Tokyo, Japan
| | - Ryuichiro Akagi
- Department of Orthopaedic Surgery, Oyumino Central Hospital, Chiba, Japan
| | - Kentaro Amaha
- Department of Orthopaedic Surgery, St. Luke's International Hospital, Tokyo, Japan
| | | | - Noriyuki Kanzaki
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Koji Noguchi
- Department of Orthopaedic Surgery, Japan Community Health Care Organization Kurume General Hospital, Fukuoka, Japan
| | | | | | - Hiroshi Ohuchi
- Department of Sports Medicine, Kameda Medical Center, Chiba, Japan
| | - Hiroyuki Sato
- Department of Sports Medicine, Kameda Medical Center, Chiba, Japan
| | - Satoshi Takada
- Department of Orthopaedic Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Kenji Takahashi
- Sports Medicine & Joint Center, Funabashi Orthopaedic Hospital, Chiba, Japan
| | - Yuichi Yamada
- Institute for Integrated Sports Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Tetsuro Yasui
- Department of Orthopaedic Surgery, Teikyo University Mizonokuchi Hospital, Kanagawa, Japan
| | - Takuji Yokoe
- Division of Orthopaedic Surgery, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Shun Fukushima
- Department of Orthopaedic Surgery, Graduate School of Medical and Pharmaceutical Sciences, Chiba University, Chiba, Japan
| | - Daisuke Iida
- Department of Orthopaedic Surgery, Graduate School of Medical and Pharmaceutical Sciences, Chiba University, Chiba, Japan
| | - Yoshimasa Ono
- Department of Orthopaedic Surgery, Numazu City Hospital, Shizuoka, Japan
| | - Yohei Kawasaki
- Biostatistics Section, Clinical Research Center, Chiba University Hospital, Chiba, Japan
| | - Yuki Shiko
- Biostatistics Section, Clinical Research Center, Chiba University Hospital, Chiba, Japan
| | - Takahisa Sasho
- Department of Orthopaedic Surgery, Graduate School of Medical and Pharmaceutical Sciences, Chiba University, Chiba, Japan; Center for Preventive Medical Sciences, Chiba University, Chiba, Japan
| | - Seiji Ohtori
- Department of Orthopaedic Surgery, Graduate School of Medical and Pharmaceutical Sciences, Chiba University, Chiba, Japan
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Wenning M, Gehring D, Lange T, Fuerst-Meroth D, Streicher P, Schmal H, Gollhofer A. Clinical evaluation of manual stress testing, stress ultrasound and 3D stress MRI in chronic mechanical ankle instability. BMC Musculoskelet Disord 2021; 22:198. [PMID: 33596891 PMCID: PMC7890850 DOI: 10.1186/s12891-021-03998-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 01/15/2021] [Indexed: 12/26/2022] Open
Abstract
Background Chronic ankle instability (CAI) arises from the two etiological factors of functional (FAI) and mechanical ankle instability (MAI). To distinguish the contributions of the two etiologies, it is necessary to quantitively assess functional and mechanical deficits. Validated and reproducible assessment of mechanical instability remains a challenge in current research and practice. Physical examination, stress sonography and a novel 3D stress MRI have been used, while stress radiography has been called into question and arthrometry is limited to research purposes. The interaction of these primarily mechanical measurements with the functional and subjective components of CAI are subject to debate. The aim of this study was the evaluation of the clinical and biomechanical preferences of the three different methods in the diagnosis of MAI. Methods In this cross-sectional diagnostic study, we compared three different diagnostic approaches to mechanical ankle instability: (1) manual stress testing (anterior drawer test [ADT] and talar tilt test [TTT]), (2) stress sonography and (3) 3D stress MRI (3SAM) The latter includes quantification of 3D cartilage contact area (CCA) in plantarflexion-supination compared to neutral-null position. We applied these measurements to a cohort of patients suffering from chronic mechanical ankle instability (n = 25) to a matched cohort of healthy controls (n = 25). Perceived instability was assessed using the Cumberland Ankle Instability Tool (CAIT) and Forgotten Joint Score (FJS). Functional deficits were measured using postural sway and the y-Balance test. Results Significant differences between the two groups (single-factor “group” ANOVA, p < 0.05) were found in all of the mechanical assessments with strong effect sizes. Spearman’s correlations were strong for CAIT and manual stress testing (TTT rho = − 0.83, ADT rho = − 0.81), 3D stress MRI (rho = − 0.53) and stress sonography (TTT rho = − 0.48, ADT rho = − 0.44). Furthermore, the correlation between manual stress testing and CCA in the fibulotalar articulation (CCAFT) was strong (rho = 0.54) and the correlations to stress sonography were moderate (ADT rho = 0.47 and TTT rho = 0.43). The calculation of cutoff values revealed a distance of > 5.4 mm increase in ligament length during stress sonography (sensitivity 0.92, specificity 0.6) and > 43% loss of articulating surface in the fibulotalar joint (CCAFT in supination-plantarflexion using 3SAM, sensitivity 0.71, specificity 0.8) as potential cutoff values for diagnosing MAI. Conclusions Manual stress testing showed to be a valuable method of identifying mechanical ankle instability. However, due to is subjective character it may overvalue patient-reported instability as a factor which explains the high correlation to the CAIT-score, but this may also reduce its value in diagnosing the isolated mechanical quality of the joint. Thus, there is a persisting need for objective and reproducible alternatives focusing on MAI. According to our results, 3D stress MRI and stress sonography represent valuable alternatives and may be used to quantitively assess mechanical ankle instability in research and practice. Trial registration German Registry of Clinical Trials # DRKS00016356, registered on 05/11/2019.
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Affiliation(s)
- Markus Wenning
- Department of Sport and Sport Science, University of Freiburg, Schwarzwaldstrasse 175, 79117, Freiburg, Germany. .,Department of Orthopedic and Trauma Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Hugstetter Str. 55, 79106, Freiburg, Germany.
| | - Dominic Gehring
- Department of Sport and Sport Science, University of Freiburg, Schwarzwaldstrasse 175, 79117, Freiburg, Germany
| | - Thomas Lange
- Department of Radiology, Medical Physics, Medical Center - University of Freiburg, Faculty of Medicine, Kilianstrasse 5, 79106, Freiburg, Germany
| | - David Fuerst-Meroth
- Department of Orthopedic and Trauma Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Paul Streicher
- Department of Sport and Sport Science, University of Freiburg, Schwarzwaldstrasse 175, 79117, Freiburg, Germany
| | - Hagen Schmal
- Department of Orthopedic and Trauma Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Hugstetter Str. 55, 79106, Freiburg, Germany.,University Hospital Odense, Department of Orthopaedic Surgery, Sdr. Boulevard 29, 5000, Odense C, Denmark
| | - Albert Gollhofer
- Department of Sport and Sport Science, University of Freiburg, Schwarzwaldstrasse 175, 79117, Freiburg, Germany
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