Anterior Tibiofibular Ligament Research Articles

Maisonneuve Fractures of the Ankle: A Critical Analysis Review.

Maisonneuve fractures (MFs), originally described as subcapital (high) fibular fractures with additional injury to the anterior and interosseous tibiofibular ligaments, display a variable injury pattern, ranging from stable to highly unstable fractures. The high incidence of associated fractures of the posterior malleolus, the medial malleolus, and the anterolateral distal tibia (the "anterior malleolus") as well as the variable position of the fibula in the fibular notch (FN) warrant preoperative examination via computed tomography (CT). The main goal of treatment is anatomic reduction of the distal fibula into the FN, which requires prior reduction of displaced posterior malleolar fractures, if present, to restore the integrity of the FN. Open reduction of the distal fibula into the FN and fixation with 2 transsyndesmotic screws or fixation with a screw(s) and suture-button implant, under direct vision, on the lateral aspect of the ankle joint and anterior tibiofibular alignment are preferred over closed reduction to avoid sagittal or rotational malpositioning, which is associated with an inferior outcome. Intra- or postoperative 3D CT visualization is essential for assessment of the accuracy of the reduction of the distal fibula into the FN.

Clinical outcomes of anterior tibiofibular ligament’s distal fascicle transfer versus ligament reconstruction with InternalBrace™ for chronic ankle instability patients

PurposeTreatment of chronic ankle instability (CAI) for ankle sprain patients remains a challenge. If initial treatments fail, surgical stabilization techniques including ligament reconstruction should be performed. Anterior tibiofibular ligament (ATiFL) distal fascicle transfer for CAI was recently introduced. The goal of the study is to assess the 1-year clinical effectiveness of ATiFL’s distal fascicle transfer versus ligament reconstruction with InternalBrace™ (Fa. Arthrex, Naples).MethodsBetween October 2019 and February 2021, 25 patients (14 males and 11 females) scheduled for ligament reconstruction treatment of CAI were enrolled after propensity score matching. Twelve underwent ligament reconstruction with InternalBrace™ (InternalBrace™ group) and thirteen underwent ATiFL’s distal fascicle transfer (ATiFL’s distal fascicle transfer group). We recorded the American Orthopedic Foot & Ankle Society (AOFAS) score, Visual Analogue Scale (VAS), anterior drawer test grade, patient satisfaction and complications. All results of this study were retrospectively analyzed.ResultsStatistically significant (p = 0.0251, independent-samples t test) differences in the AOFAS can be found between the ATiFL’s distal fascicle transfer group and the InternalBrace™ group. No substantial changes in the VAS (p = 0.1778, independent-samples t test), patient satisfaction (p = 0.1800, independent-samples t test) and anterior drawer test grade (p = 0.9600, independent-samples t test) were found between the two groups. There was one patient with superficial wound infection and one patient with sural nerve injury in the InternalBrace™ group and ATiFL’s distal fascicle transfer group, respectively.ConclusionThis is the first study that assessed a cohort of CAI patients and suggests that the ATiFL’s distal fascicle transfer operation has the potential to attain good-to-excellent clinical outcomes after 1-year recovery. The AOFAS scores were significantly higher for patients with ATiFL’s distal fascicle transfer, indicating that this technique may be considered a viable option for both patients and their surgeon, while long-term outcomes should be investigated in the future.

Pediatric versus adult magnetic resonance imaging patterns in acute high ankle sprains.

There is a paucity of literature describing MRI patterns of high ankle sprains in pediatric patients. Radiologists should understand MRI patterns of these injuries in both adults and children. To describe normal MRI appearance of pediatric syndesmotic ligaments and compare MRI patterns of high ankle sprains in children versus adults. We reviewed consecutive ankle MRIs performed over 3years and divided them into three cohorts: a normal pediatric (≤16years) cohort, and pediatric and adult cohorts with acute/subacute ankle syndesmosis injuries. Our retrospective review assessed interobserver agreement (Cohen kappa coefficient) and normal pediatric syndesmotic anatomy. We compared patterns of high ankle sprains (Fisher exact test) including ligament tears, periosteal stripping, avulsions and fractures. Of the 582 ankle MRIs, we included 25 in the normal pediatric cohort, 20 in the pediatric injury cohort and 23 in the adult injury cohort. The anterior and posterior tibiofibular ligaments all attached to cortex or cartilaginous precursor, while the interosseous ligament/membrane complex attached to the fibrous periosteum in 22/25 (88%) normal pediatric cases. Tibial periosteal stripping at the interosseous ligament/membrane complex attachment occurred in 7/20 (35%) pediatric and 1/23 (4%) adult injury cases (P=0.02). No other statistically significant differences were found. Interobserver agreement ranged from kappa=0.46 to kappa=0.82 (ligament tears), 0.38 to 0.45 (avulsions) and 0.69 to 0.77 (periosteal stripping). The normal interosseous ligament/membrane complex typically attaches to fibrous periosteum rather than bony cortex. Tibial periosteal stripping, usually without tibial fracture, is significantly more common among pediatric high ankle sprains. MRI patterns of high ankle sprains are otherwise not significantly different between children and adults.

Case report of a Tillaux Chaput fracture in an adult having Becker muscular dystrophy with fracture of medial and posterior malleloli

Tillaux fractures are the avulsion of the distal tibial physis caused by the stress placed on the anterior tibio-fibular ligament, which are very rare in case of an adult. Due to severe swelling and overlapping of bones they are often missed in an innocuous looking X ray. Our case includes a 40 year old presented with severe pain and swelling of the ankle joint following trauma on a background history of Becker’s muscular dystrophy .While, the patient had proximal muscle weakness in lower limbs due to the comorbidity, Investigations also revealed the tillaux fracture with fractures of posterior and medial malleolus, which roughly outlines the injury mechanism to be of Supination-external rotation type. The objective of this publication is to highlight this unusual injury, to avoid incorrect diagnosis and its management which focuses on different challenges in achieving absolute reduction with early rehabilitation of the patient keeping in view of the existing co-morbidity. Keywords: Ankle injury, Adult Tillaux fracture, Chaput fracture syndesmotic injury, Tibiofibular ligament, Becker muscular dystrophy.

Fixation of anterolateral distal tibial fractures: the anterior malleolus.

The anterior tibial rim with the anterolateral tibial tubercle provides attachment to the anterior tibiofibular syndesmosis. It may be considered an anterior or "fourth" malleolus. Fixation of adisplaced anterior tibial fragment in the treatment of malleolar fractures aims at providing abone-to-bone fixation of the anterior tibiofibular ligament and restoring the integrity of the tibial incisura. Displaced intra-articular fragments of the anterior tibia; fractures involving the tibial incisura; fractures with intercalary fragments; impaction of the anterior tibial plafond; syndesmotic avulsions producing instability or preventing reduction of the distal fibula into the tibial incisura. Critical local soft tissues preventing an anterolateral approach; missing consent to surgery by the patient; overall critical general condition preventing surgery to the extremities. Anterolateral approach over the tibial tubercle. Identification and mobilization of the anterior tibial fragment without dissecting the anterior syndesmosis. Reduction of the anterior tibial fragment with apointed reduction clamp. Fixation of extra-articular avulsion fractures (type1) with suture anchor. Screw fixation of larger fragments involving the joint surface and incisura (type2). Disimpaction, realignment of the joint surface, bone grafting as needed and plate fixation of impaction fractures of the anterolateral tibial plafond (type3). Mobilization with partial weight bearing (15-20 kg) in aspecial boot (ankle foot orthosis) or cast for 6-8weeks depending on the overall malleolar fracture pattern, bone quality and patient compliance. Few studies report the results of anterior tibial fractures in adults. Failure to fix displaced fragments frequently leads to nonunions. Overlooked Chaput fractures have been reported to result in malpositioning of the distal fibula in the tibial incisura leading to incongruity of the ankle mortise requiring revision surgery. Secondary avascular necrosis of the anterolateral tibial plafond may develop after joint impaction.

Biomechanics of the Distal Tibiofibular Syndesmosis: A Systematic Review of Cadaveric Studies.

Background:This investigation’s purpose was to perform a systematic review of the literature examining the biomechanics of the ligaments comprising the distal tibiofibular syndesmosis with specific attention to their resistance to translational and rotational forces. Although current syndesmosis repair techniques can achieve an anatomic reduction, they may not reapproximate native ankle biomechanics, resulting in loss of reduction, joint overconstraint, or lack of external rotation resistance. Armed with a contemporary understanding of individual ligament biomechanics, future operative strategies can target key stabilizing structure(s), translating to a repair better equipped to resist anatomic displacing forces.Study design:Systematic review.Methods:A systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines using a PRISMA checklist. Biomechanical studies testing cadaveric lower limb specimens in the intact and injured state measuring the distal tibiofibular syndesmosis resistance to translational and rotational forces were included in this review. Only studies that included numerical data were included in this review; studies that only reported figures and graphs were excluded.Results:Twelve studies met the inclusion and exclusion criteria. Two studies determined the mechanical properties of syndesmotic ligaments, finding superior strength and stiffness of the interosseous ligament (IOL), as compared to the anterior (AITFL) or posteroinferior tibiofibular ligament (PITFL). Four studies examined native ankle biomechanics establishing physiologic range of motion of the fibula relative to the tibia. Fibular range of motion was found to be up to 2.53 mm of posterior translation (Markolf et al), 1.00 mm lateral translation (Xenos et al), 3.6 degrees of external rotation (Burssens et al), and 1.4 degrees of internal rotation (Clanton et al). Four studies evaluated syndesmotic biomechanics under physiological loading and found that the AITFL, IOL, and PITFL provide the majority of resistance to external rotation, diastasis, and internal rotation, respectively. Two studies investigated the biomechanics of clinically and intraoperatively used tests for syndesmotic injuries and found increased sensitivity of sagittal plane posterior fibular translation, as opposed to coronal plane lateral fibular translation for unstable injuries.Conclusions:Study findings suggest that although the IOL is the strongest syndesmotic ligament, the AITFL has a dominant role stabilizing the distal tibiofibular syndesmosis to external rotation force. Because of these characteristics, operative repair of the AITFL along its native vector may provide a more biomechanically advantageous construct and should be investigated clinically. Additionally, evaluation of clinical stress tests revealed that the external rotation stress test is the most sensitive test to recognize an AITFL tear, and that a 3-ligament disruption is needed to cause diastasis greater than 2 mm.

Dextrose Prolotherapy for Muscle, Tendon and Ligament Injury or Pathology: A Systematic Review

Background: Prolotherapy with dextrose has recently gained attention as a potential treatment for muscle, ligament or tendon pathology/injury.
 Questions/Purpose: This review aimed to: 1) evaluate the main outcome of dextrose prolotherapy treatment for muscle, ligament or tendon pathology/injury; 2) determine the concentrations of dextrose and protocol of injection; and 3) assess complications or adverse effects after dextrose prolotherapy.
 Methods: Four electronic databases were searched for related published articles. Articles that met the following criteria were included in this review: 1) articles on peer-reviewed level 1 to 4 studies; 2) articles published in English; 3) articles on dextrose prolotherapy study for tendon or ligament or muscle injury/pathology; and 5) articles that describe dose of dextrose. Published articles that met this inclusion criteria were included in this systematic review.
 Results: Twenty four studies fulfilled inclusion criteria,consisting of seventeen clinical studies, four animal studies and three invitro studies. Eleven studies reported there were improvement of functional outcome after dextrose prolotherapy. Three Studies reported improvement of patient satisfaction after dextroprolotherapy in supraspinatus tear, Achilles tendinopathy. And patellar tendinopathy, meniscus tear and anterior tibiofibular ligament tear. Three studies reported there are increasing of neovascularization in Achilles tendinopathy and patellar tendinopathy in animal studies, increasing of inflammatory response in animal studies and in vitro studies and increasing of cell proliferation and collagen production. Nine studies (52%) use dextrose 25% concentration. A few adverse effects were reported and minor effect, such as discomfort Minor soreness, extreme pain, skin burns 2nd grade, hypotension, Deep Vein Thrombosis (DVT) ( patient has history DVT).
 Conclusions: Dextrose Prolotherapy is a potentially effective treatment for patients with muscle, tendon or ligament tear or pathology. Efficacy in long term follow-up, as single therapy or first-line therapy cannot be determined from the current literature.

Deep deltoid ligament injury is related to rotational instability of the ankle joint: a biomechanical study.

In the athletic population, the prevalence of isolated syndesmotic lesions is high. To detect potential instability of the ankle is crucial to define those lesions in need of surgical management. The aim was to define how the extent of tibio-fibular syndesmotic ligament injury influences the overall stability of the ankle joint in a cadaver model. Twenty fresh-frozen through knee cadaveric leg specimens were subjected to different simulated syndesmotic ligament lesions. In Group 1 (n = 10), the order of ligament sectioning was: anterior tibio-fibular ligament (ATFL), superficial deltoid ligament (SDL), deep deltoid ligament (DDL), posterior tibio-fibular ligament (PTFL), and progressive sectioning at 10, 50 and 100mm of the distal interosseous membrane (IOM). In Group 2 (n = 10), the sequence was: ATFL, PITFL, 10 and then 50mm of the distal IOM, SDL, DDL, and 100mm of the distal IOM. Diastasis of 4mm in the coronal or sagittal plane and external rotation of the ankle greater than 20° were considered indicative of instability. Both coronal and sagittal diastasis exceeded 4mm with injury patterns characterized by IOM lesions extending beyond 5cm. External rotation of the ankle exceeded 20° with injury patterns characterized by a DDL lesion. Coronal and sagittal plane diastases of the tibio-fibular syndesmosis are particularly affected by sequential lesions involving the IOM, whereas increased external rotation of the ankle most depends on DDL. The identification of the specific syndesmotic and deltoid ligament injuries is crucial to understanding which lesions need operative management. The knowledge of which pattern of tibio-fibular syndesmotic ligament injury influences the ankle joint stability is crucial in defining which lesions need for surgical management.

A New Method for Reduction and Stabilization of the Distal Tibiofibular Syndesmosis

Category:Ankle; TraumaIntroduction/Purpose:Fixation strategies for distal tibiofibular syndesmotic injuries are associated with risk of malreduction. We describe a new method of reduction and fixation of the syndesmosis with two suture buttons placed through a single sagittal tunnel through the fibula and across the tibia at the attachment sites of the anterior and posterior-inferior tibiofibular ligaments.Methods:Eighteen frozen cadaveric lower leg specimens were divided in two groups of nine and subjected to syndesmotic injury followed by reduction and fixation. Nine were repaired with the new method and 9 with the conventional method. Post-reduction CT images were obtained and compared to pre-injury CT images to assess quality of reduction. Specimens were then tested on an MTS machine and loaded between +\\-5Nm at 0.5Hz of internal and external rotation for 500 cycles. Cyclic loading was paused at 0, 100, and 500 cycles to assess torsional resistance, fibular rotation, and fibular translation with the foot first internally rotated 10 degrees and then externally rotated 15 degrees. Peak torque and translation of the fibula was measured.Results:A statistically significant difference was detected between groups, with the new method of fixation showing less lateral translation of the fibula. Data that did not reach statistical significance showed a trend towards decreased post reduction translation in the sagittal plane and improved rotational alignment with the new method. Decreased fibular rotation that reached statistical significance was noted in the new technique with internal rotation at 0, 100 and 500 cycles and during external rotation at 100 and 500 cycles. No differences were noted for torsional resistance or fibular translation between groups.Conclusion:The new method of syndesmotic fixation facilitated reduction of the syndesmosis that resulted in improved alignment, and better rotational stability compared with the conventional technique. This may be a reliable alternative to current methods of syndesmosis reduction and fixation.

Posterior to anterior malleolar extended lateral approach to the ankle (PAMELA): a cadaveric anatomic study.

The posterolateral approach is used in most cases of surgical treatment of ankle fractures involving the posterior and lateral malleoli. However, this approach does not allow access to the anterolateral structures of the ankle, which represent important landmarks to allow an anatomical reduction in case of complex ankle fracture. Our objective is to propose a novel surgical approach for optimal management of injuries including both a fracture of the posterior malleolus and a complex lesion of the lateral and/or anterolateral portions of the ankle. Cadaveric dissection, including a vascular study, was performed on eight specimens. Assessment included density of the vascular supply around the lateral malleolus, identification of the structures at risk, quality of exposure of the bony structures, and convenience of hardware fixation. The cutaneous flap benefits from a rich interconnected arterial supply. Structures at risk, including the superficial peroneal and sural nerves, the lesser saphenous vein, and the peroneal artery are easily identified and protected. The interval between the peroneal tendons and the flexor hallucis longus muscle provides optimal access to the posterior malleolus. The lateral malleolus is exposed by retracting the peroneal tendons medially. An anterolateral arthrotomy, respecting the anterior talofibular and tibiofibular ligaments, offers a sharp view on the talo-tibio-fibular junction. Hardware placement can be done with optimal access to any exposed surfaces. The PAMELA opens a new perspective in the optimal management of complex fractures of the ankle. The approach allows optimal exposure to address fractures of the posterior malleolus, of the lateral malleolus, and of the anterolateral portion of the ankle through a single incision. Application in clinical practice is the subject of a future study in our institution.

A Revised Surgical Strategy for the Distal Tibiofibular Interosseous Osteochondroma

Osteochondroma is one of the most common benign bone tumor; however, the surgical treatment still remains a challenge for those that occur at the distal tibiofibular interosseous location. Previously, the transfibular approach has been successfully described, but the potential damage of the syndesmosis would give rise to the instability of the ankle joint and thus may result in the unfavorable long-term outcome. Here, a revised strategy which can protect the syndesmotic complex is introduced. From 2010 to 2017, eleven patients with the distal tibiofibular interosseous osteochondroma who underwent the revised surgery were collected. The distal fibular osteotomy and posterior tibial osteotomy were performed to keep the inferior syndesmosis intact for better stability of the ankle joint. Both the anterior tibiofibular ligaments (AITFL) and posterior tibiofibular ligaments (PITFL) have been preserved successfully, and thus, the stability of the ankle joint has been maintained due to our strategy. The VAS and AOFAS scores were utilized to assess the clinical outcome and function. Postoperatively, all the patients were pain-free and were able to wear the appropriate shoes at the last follow-up. Preoperative and postoperative AOFAS scores were 93.63 ± 6.91 and 47.27 ± 5.27 (P < 0.05), respectively. Moreover, the average VAS score was 1.73 ± 0.27 (compared with preoperative as 7.45 ± 2.15, P < 0.05), demonstrating obvious improvement after the operation. To our best knowledge, this is the first time to perform the resection of the distal tibial interosseous osteochondroma involving the fibula without interrupting the inferior syndesmotic complex especially the AITFL and PITFL. We believe that this strategy may pave a new way for optimized clinical outcome for these patients with distal tibiofibular interosseous osteochondroma. This clinical trial study is registered with number ChiCTR1900024690.

Ultrasound’s limitations in investigating dynamic ligamentous ankle anatomy

The distal tibiofibular joint, or tibiofibular syndesmosis, is supported by the anterior and posterior inferior tibiofibular ligaments, tibiofibular interosseous membrane and ligament, and inferior transverse ligament. As a component of the ankle complex, the tibiofibular syndesmosis exhibits little mobility, with the fibula translating not only laterally (Harris 1991), but also posteriorly, with external rotation (Malhotra et al. 2019), during ankle dorsiflexion to accommodate the foot’s internal rotation and talar wedging. The mobility of the tibiofibular syndesmosis is relevant in both clinical and evolutionary contexts; disruption of the syndesmosis results in a high ankle sprain, one of the most recalcitrant orthopedic injuries (Gerber et al. 1998), and flexibility of the syndesmosis is thought to be critical to arboreal resource acquisition via tree climbing (Venkataraman, Kraft, and Dominy 2013). While Mei‐Dan et al. (2009) argued dynamic ultrasound investigation of the anterior inferior tibiofibular ligament could be used to diagnose distal tibiofibular syndesmotic injury after analyzing 47 professional athletes, to our knowledge no studies have sought to quantify basic normal variation of the tibiofibular interosseous ligament in non‐professional athletes (i.e., most people). We hypothesized the length of the tibiofibular interosseous ligament measured via ultrasound would be greater during closed‐packed dorsiflexion than closed‐packed standing in adults lacking a prior history of an ankle injury. Data were collected after obtaining informed consent from a mixed‐sex and mixed‐ancestry population of young adults (n = 78), via ultrasounding the distal tibiofibular joint during standing with the knee in closed‐packed position, measuring the tibiofibular interosseous ligament within the tibiofibular clear space, then measuring the same structure within the tibiofibular clear space during squatting with the ankle in closed‐packed position. We found approximately 25% of subjects’ tibiofibular interosseous ligaments decreased in length as measured by ultrasound – which we attribute to registration error inherent to the non‐reproducibility of consistent ultrasound probe placement throughout the ankle’s range of movement. These results cast doubt on the utility of ultrasound in investigating dynamic ligamentous ankle anatomy, consistent with the findings of Prakash (2018), and likely a consequence of the fibula’s complex pattern of motion relative to the tibia during ankle movement.Support or Funding InformationThis work was supported by the Arkansas College of Osteopathic Medicine.

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

To compare diagnostic performance of additional two-dimensional (2D) oblique coronal view and three-dimensional (3D) T2-weighted fast spin-echo(FSE) images for diagnosing injury of the anterior inferior tibiofibular (AiTFL) and anterior talofibular ligaments (ATFL). This study included 48 patients with ankle sprain who had undergone MRI using standard protocol and two additional sequences with 2D oblique coronal and 3D isotropic images, followed by arthroscopic surgery. Ligament injuries was subdivided by intact tendon, partial or complete tear. Retrospectively, two musculoskeletal radiologists respectively reviewed three image sets of MR including 2D axial image only (set 1), 2D axial and oblique coronal images (set 2), and 2D axial with 3D-isotropic images (set 3). Using arthroscopic findings as reference standard, diagnostic performances of both methods were analysed by the area under the curve (AUC). Arthroscopy confirmed 13 AiTFL and 41 ATFL injuries. For AiTFL, when set 1 and set 3 were compared, AUC value was significantly higher for set 3 (P<0.05). However, there was no significant difference between AUC values for set 2 and set 3 sequences by either reader for either type of tear (P>0.05). For ATFL, both readers found there was no significant difference in AUC values between set 1 and set 3 and between set 2 and set 3. Additional oblique coronal sequence demonstrated better diagnostic performance for AiTFL injury than conventional and isotropic imaging did. This sequence showed as much diagnostic accuracy as isotropic sequence for evaluation of ATFL injury.

Treatment of Acute Ankle Syndesmotic Injury by Syndesmotics Screw Fixation

Background: The distal tibiofibular syndesmosis is a connection between tibia and fibula that consists of the anterior tibiofibular ligament, the posterior tibiofibular ligament, the transverse ligament and the interosseous ligament. Syndesmotic ligament injuries are most often seen in combination with ankle fractures, but can occur in isolation as well. The term ‘isolated syndesmotic injury’ is used for the syndesmotic rupture without ankle fracture, although concomitant other injuries may be present. These isolated injuries, which are often accompanied by deltoid ligament injuries. Objective: To evaluate the efficiency of use of syndesmotic screw fixation in treatment of acute ankle syndesmotic injury. Patients and Methods: This Prospective study included twenty adult patients with recent ankle syndesmotic injury who were treated by syndesmotic screw at Al-Azhar university hospital and mansheyat El-bakry hospital, Cairo, Egypt. Those twenty patients prospectively followed up for 12 months with average of 9 months. The clinical outcomes were calculated according AOFAS score. Results: Those 20 patients prospectively followed up for an average of 9 months. Preoperative mean value for medial clear space (MCS) was 11.8±3.9 mm, tibiofibular clear space (TFCS) was 9.2±1.6 mm and tibiofibular overlap (TFO) was 2.2±4.7 mm. while the follow up mean MCS was 3.3±0.4 mm, TFCS was 3.2±0.4 mm and TFO was measured as 11.9±1.2 mm The mean AOFAS score was 97.0±3.8 (range 90–100). Conclusion: Reduction of the syndesmosis is essential for improving functional outcomes and avoiding posttraumatic osteoarthritis. It is important to intraoperatively stress all surgically treated ankle fractures to evaluate latent syndesmotic injury.

Maisonneuve fracture.

Maisonneuve fracture (MF) is agenerally known entity in ankle trauma. However, details about this type of injury can be found only rarely in the literature. For these reasons we have decided to perform astudy on MF epidemiology and pathoanatomy. The group comprised 70 patients (47 men, 23 women), with the mean age of 48 years, who sustained an ankle fracture-dislocation involving the proximal quarter of the fibula. Ankle radiographs in three views and lower leg radiographs in two views were performed in all patients. Atotal of 59 patients underwent CT examination in three views, including 3D CT reconstruction in 49 of these patients. MRI was performed in 4 patients. Operative treatment was used in 67 patients; open reduction of the distal fibula into the fibular notch was opted for in 54 of them. The highest MF incidence rate was recorded in the 5th decade in the whole group and in men, while in women the peak incidence was in the 6th decade. After the age of 50, the share of women significantly increased. In 64 cases, the fibular fracture was subcapital, and in 6 cases it involved the fibular head. In 24% of the patients, the fibular fracture was seen only in the lateral radiograph of the lower leg. Widening of the tibiofibular clear space was shown by radiographs in 40 cases. Posterior dislocation of the fibula (Bosworth fracture) and tibiofibular diastasis were recorded in 2 cases each. An injury to the anterior and posterior tibiofibular ligaments was found in all 54 patients with open reduction of the distal fibula. Afracture of the medial malleolus was identified in 27 cases (39%) and acomplete lesion of the deltoid ligament in 36 cases (51%); in 7 cases (10%) the medial structures were intact. Afracture of the posterior malleolus occurred in 54 (77%) patients. Osteochondral fracture of the talar dome was diagnosed in 2 patients and compression of the articular surface of the distal tibia in the region of the fibular notch in 1 patient. Maisonneuve fracture includes awide range of injuries both to bone and ligamentous structures of the ankle. Therefore, CT examination is an indispensable part of assessment of this type of fracture.

Extremity CT and ultrasound in the assessment of ankle injuries: occult fractures and ligament injuries.

To assess the rates of fractures and ligament injuries in patients with an acute ankle injury and a normal radiographic examination, and to consider the most appropriate examination protocol. Patients with an acute ankle injury who presented to the John Radcliffe Hospital Emergency Department with a normal radiographic examination were eligible for the study. They were invited to receive a cone beam CT and ultrasound examination at a local radiology department within 5 days of their ankle injury. Of the 100 patients recruited to the study, 19 patients were found to have major fractures and 42 patients had small avulsion fractures. Additionally, 42 patients had ankle effusions and there were a large number of soft tissue injuries. There were 83 acute injuries of the anterior talofibular ligament, 19 of the anterior tibiofibular ligaments, 26 of the calcaneofibular ligament, 39 of the deltoid ligament complex, 21 of the talonavicular ligament, 14 of the spring ligament and 3 of the calcaneocuboid ligament. Conventional radiographic examination misses significant fractures of the foot and ankle and the presence of an ankle effusion does not relate to the severity of injury. Ultrasound is a useful imaging technique that can supplement clinical practice, but it is unlikely to replace current protocols alone. Cone beam CT is an appropriate alternative to plain radiography, being more sensitive in detecting fractures and delivering a similar dose of radiation. However, neither CT or ultrasound examination can detect all avulsion fractures. Simple anterior process fractures of the calcaneus are associated with talonavicular ligament injuries and the medial ligaments are injured in almost 50% of cases when there is a lateral ligament injury. Fractures in the foot and ankle are detected more precisely with cone beam CT compared to radiographs. Cone beam CT delivers similar doses of to conventional radiographs which is around 10% of that resulting from conventional CT. Ultrasound examination is an effective assessment tool to detect ligamentous injuries. The absence of an ankle effusion does not exclude a major fracture.

The clinical characteristics and outcomes of Maisonneuve fractures

Objective To investigate the clinical characteristics and outcomes of Maisonneuve fractures. Methods Data of 21 cases of Maisonneuve fractures from February 2015 to December 2017 were retrospectively analyzed. There were 16 males and 5 females with an average age of 38.8 years (range, 21 to 61 years). The fractures occurred on the left side in 11 patients and on the right side in 10 patients. The causes of injuries were traffic accident in 4 patients, sprain injury in 9 patients and falling injury from height in 8 patients. There were 16 cases of medial malleolar fractures and 5 cases of ruptures of deltoid ligament (4 entirely and 1 partial). There were 17 cases of fractures of the posterior malleolus, among which there were 5 of typeⅠ, 8 of typeⅡ and 4 of type Ⅲ according to the Bartonicek classification of posterior malleolus. There were 4 cases without fracture of posterior malleolus including 1 complete disruption of posterior inferior tibiofibular ligament. Four cases were overlooked of Maisonneuve fracture at the first time. The interval between injury and operation was 2-12 days (mean, 4.9 days). Results Stabilization of proximal fibular fractures were achieved with plate in 3 cases. There were 16 cases of medial malleolar fractures, and the fixation were achieved with cannulated screws in 13 cases and with anti-glide plates in 3 cases. The entirely rupture of deltoid ligament was repaired in 4 cases with suture anchors, the partial rupture of deltoid ligament was not repaired. There were 17 cases of posterior malleolar fractures, 12 cases treated with open reduction and internal fixation including cannulated screws in 9 cases and anti-glide plates in 3 cases. Stabilization of syndesmosis was achieved with syndesmotic plate in 1 case; the medial and posterior malleolar fractures were stabilized and anterior inferior tibiofibular ligament was repaired with suture anchor in 1 case; the other 19 cases were stabilized with syndesmotic screws, 2 screws in 11 cases and 1 screw in 8. Twenty-one patients were followed up for 13-48 months with an average of 25.6 months. The time of bony union was from 3 to 6 months with an average time of 4.9 months after operation. All patients received anatomical reduction without postoperative complications such as incision infection, reduction lose, breakage of screw and posttraumatic arthritis. In 13 cases, the syndesmotic screw was removed at the mean time of 15.38 weeks postoperative (range, 13-25 weeks). At the latest follow up, AOFAS score was from 84 to 100, with excellent in 13 cases, good in 8 cases, and the excellent and good rate was 100% (21/21). Baird-Jackson score was from 83 to 100, with excellent in 11 cases, good in 8 and fair in 2, and the excellent and good rate was 90.48%(19/21). Conclusion The diagnosis of proximal fibular fracture of Maisonneuve fracture is easily missed. The complete rupture of deep deltoid ligament and displaced obviously of posterior malleolar fracture should be reduction and stabilization. The accuracy of reduction of the syndesmosis is of great concern. The outcome of operation is satisfied. Key words: Ankle joint; Fibula; Fractures, bone; Ligaments

Diagnostic performance of ankle ultrasound for diagnosing anterior talofibular and calcaneofibular ligament injuries: a meta-analysis.

Background Ankle ultrasound imaging could be an option with higher priority due to its lack of radiation, and cost- and time-effectiveness. However, previous studies regarding anterior tibiofibular ligament and calcaneofibular ligament injuries have shown varied results. Purpose To evaluate the diagnostic performance of ankle ultrasound for anterior tibiofibular ligament and calcaneofibular ligament injuries. Material and Methods PubMed and EMBASE databases were searched for diagnostic accuracy studies that used ultrasound for diagnosing anterior tibiofibular ligament and calcaneofibular ligament injuries. Bivariate and hierarchical summary receiver operating characteristic modeling were used to evaluate diagnostic performance. Subgroup analysis was performed using studies according to severity of the injury (complete and partial anterior tibiofibular ligament tear). We performed meta-regression analyses for heterogeneity exploration. Results Ten articles involving a total of 380 patients were included. For anterior tibiofibular ligament injury, the summary sensitivity, summary specificity, and area under the hierarchical summary receiver operating characteristic curve (AUC) were 0.99, 0.92, and 0.99, respectively. For calcaneofibular ligament injury, the summary sensitivity, summary specificity, and AUC were 0.95, 0.99, and 0.95, respectively. In subgroup analysis, for complete anterior tibiofibular ligament tear, the summary sensitivity, summary specificity, and AUC were 0.96, 0.82, and 0.96, respectively. For partial anterior tibiofibular ligament tear, the summary sensitivity, summary specificity, and AUC were 0.90, 0.82, and 0.93, respectively. Among the various potential covariates, proportion of anterior tibiofibular ligament tear, ultrasound interpreter, and reference standard were associated with specificity heterogeneity. Conclusion Ankle ultrasound demonstrates high diagnostic performance in the diagnosis of anterior tibiofibular ligament and calcaneofibular ligament injuries. We recommend ultrasound performed by a musculoskeletal radiologist as a first-line diagnostic tool to diagnose anterior tibiofibular ligament and calcaneofibular ligament injuries.

Redefining anterior ankle arthroscopic anatomy: medial and lateral ankle collateral ligaments are visible through dorsiflexion and non-distraction anterior ankle arthroscopy.

A thorough understanding of the arthroscopic anatomy is important to recognise pathological conditions. Although some ankle ligaments have been described as intra-articular structures, no studies have assessed the full visibility of these structures. The purpose of this study was to assess arthroscopic visibility of medial and lateral ankle collateral ligaments. Arthroscopy was performed in 20 fresh frozen ankles. The arthroscope was introduced through the anteromedial portal and the anterior compartment was explored in ankle dorsiflexion without distraction. Intra-articular structures were tagged using a suture-passer introduced percutaneously and they were listed in a table according to the surgeon's identification. After the arthroscopic procedure, the ankles were dissected to identify the suture-tagged structures. According to the suture-tagged structures, 100% correlation was found between arthroscopy and dissection. In the anterior compartment, the superior fascicle of the anterior talofibular ligament, the distal fascicle of the anterior tibiofibular ligament and the anterior tibiotalar ligament on the medial side were observed. The deep fascicle of the posterior tibiofibular ligament and the intermalleolar ligament were tagged at the posterior compartment. Ankle dorsiflexion and non-distraction arthroscopic technique allows full visualisation of the medial and lateral ankle collateral ligaments: the superior fascicle of the anterior talofibular ligament, the distal fascicle of the anterior tibiofibular ligament and the anterior tibiotalar ligament. When using distraction, posterior structures as the deep fascicle of the posterior tibiofibular ligament and the intermalleolar ligament can be observed with anterior arthroscopy.

Differentiation of anteroposterior pelvic compression type I and II injuries and severity evaluation

Objective To investigate the reliability of using the pubic symphysis diastasis of 25 mm and anterior separation distance of sacroiliac joint to differentiate anteroposterior compression (APC) type I and II injuries as well as assess the injury severity. Methods A total of 11 (seven males and four females) fresh cadaver specimens with 22 hemipelvis were collected. The pelvic APC injury test models including fixed hemipelvis (restricted group) and unfixed hemipelvis (non-restricted group) were established, with 11 hemipelvis in each group according to the random number table method. Meanwhile the specimens were divided into male group (14 hemipelvis) and female group (eight hemipelvis), simulating APC type injury external rotation hemipelvis. The public symophysis interval and anterior interval of sacroiliac joint of the original pelvis, the pubic symphysis diastasis and anterior diastasis of sacroiliac joint after anterior tibiofibular ligament failure, as well as the affected pelvis ligament and sacral ligament injury were recorded and compared between the restricted and non-restricted groups, male and female groups. Results There were no significant differences in the public symphysis interval of the original pelvis and anterior interval of sacroiliac joint between the restricted group and the non-restricted group (P>0.05). The pubic symphysis interval of the original pelvis was [(5.13±0.61)mm] in male group and (4.03±0.84)mm] in female group (P 0.05). In terms of anterior interval of sacroiliac joint, there was significant difference between male and female groups (P 0.05). In the restricted group, sacrotuberous ligament injuries were found in four patients, and sacrospinous ligament injuries in five, whhile there were no obvious sacrospinous ligament and sacrotuberous ligament injuries in non-restricted group. There were 10 specimens with the pubic symphysis diastasis ≥23.36 mm and 10 specimens with the diastasis distance of anterior sacroiliac joint ≥9.82 mm (46%), and there were 15 specimens with at least the pubic symphysis interval ≥23.36 mm or the anterior interval of sacroiliac joint ≥9.82 mm (68%). Conclusions The public symphysis interval ≥ 23.36 mm or anterior interval of sacroiliac joint ≥ 9.82 mm can distinguish anteroposterior compression I from II injuries, and the combination of the two criteria can be beneficial to assessment of pelvic injury severity. Key words: Pelvis; Ligaments; Injury classification