External Rotation Stress Test Research Articles

A systematic review of studies on the diagnostics and classification system used in surgically treated, acute, isolated, unstable syndesmotic injury: a plea for uniform definition of syndesmotic injuries.

To this day, diagnostic standards and uniform definition for acute, isolated syndesmotic injuries are missing. The aim of the current study was to conduct a systematic review of the classification systems and diagnostics currently applied and to propose a best evidence diagnostic approach. Medline (PubMed), Scopus, Cochrane Central Register of Controlled Trials, and Embase were searched from inception to June 5, 2022, for studies reporting the outcome of surgically treated acute, isolated syndesmotic injuries. First, all classifications used in the eligible studies were identified and illustrated according to the individual syndesmotic structures injured. Second, the indication for surgery and stabilization, based on the diagnostics applied and the time point assessed (pre- or intra-operatively), was analyzed, including the applied cutoff criteria. Ten out of 4190 studies, comprising 317 acute ligamentous syndesmotic injuries, met the inclusion criteria. Seven studies facilitated one of the three different classification systems (Calder, West Point, or Sikka classification). Eight studies based their indication for surgery on a combination of clinical and radiographic examinations and two on radiographs only. The most applied clinical tests were the external rotation stress test and squeeze test. The most common radiologic diagnostics were plain radiographs and MRI. Intraoperatively, instability was verified most commonly using arthroscopy. Current classifications and diagnostics for syndesmotic injuries are heterogeneous, often cannot be attributed to the ligaments injured. An evidence-based diagnostic algorithm based on noninvasive diagnostics and an anatomy-based classification for acute syndesmotic instability is presented.

Stress Tests for Deltoid Ligament and Syndesmosis Injury in Patients With Ankle Fracture: A Systemic Review With Meta-Analysis.

To determine the diagnostic accuracy of various stress tests for deltoid ligament and syndesmosis injury in patients with ankle fracture. A systemic literature search was conducted in the MEDLINE, Embase, and Cochrane Library databases to identify studies published from January 1990 to August 2022. Studies that evaluated external rotation or gravity stress tests or hook or tap tests for the diagnosis of deltoid ligament or syndesmosis injury were included. Authors, publication years, study design, index tests, reference standards, demographic features of participants, reliability, and the numbers of true-positive, true-negative, false-positive, and false-negative subjects were extracted from 14 included studies. Article quality was assessed through the revised Quality Assessment of Diagnostic Accuracy Studies tool. The pooled sensitivity and specificity of each index test for each structure were calculated with a random-effects model using the extracted data of true-positive, true-negative, false-positive, and false-negative outcomes in all relevant studies. The overall diagnostic performance of the different index tests for different structures was determined with the estimation of the area under the curve using the summary receiver operating characteristics curve. The gravity stress test and the tap test exhibited high sensitivity and specificity in diagnosing deltoid ligament injury. The hook test has relatively high accuracy in diagnosing syndesmosis injury. Further studies with large sample sizes are warranted to confirm the results of this review. Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Technical note: Intraoperative ultrasound measurement for evaluating the stability of the inferior tibiofibular joint in patients with ankle fractures

ObjectivesInjury to the tibiofibular syndesmosis is a common complication of ankle fractures. Currently, it is challenging to determine the stability of the tibiofibular joint caused by ankle fractures during surgery. This study aims to establish a standardized method for dynamically evaluating the stability of the inferior tibiofibular joint under intraoperative ultrasound and assess its utility in surgery, thereby assisting in determining the necessity for fixation of the inferior tibiofibular joint after fracture reduction and fixation. MethodsThe stability of the inferior tibiofibular joint was assessed using an intraoperative ultrasonic external rotation stress test, with a torque set at 7.2 N·m. The measured parameters included the width of the inferior tibiofibular space in neutral (N) and external rotation (E) positions, stretch ratio (E/N), and injured/healthy side stretch ratio (I/H). Patients with Weber B or C type ankle fractures were selected as participants. ResultsFor the case with Weber C fracture, the N measurement was 4.22 mm after fracture fixation, while E measured 5.77 mm and E/N ratio was 1.37, which were larger than those on the healthy side (N: 4.17, E: 4.50, E/N:1.08), with an I/H ratio of 1.27. Intraoperative X-ray revealed instability of the inferior tibiofibular joint. After inserting a tibiofibular screw, the N measurement was 4.20 mm, while the E measurement recorded 4.32 mm, resulting in an E/N ratio of 1.03 and an I/H ratio of 0.95, indicating improved joint stability. For the Weber B fracture case, the N measurement was 3.55 mm after fracture fixation, while E measured 3.98 mm and the E/N ratio was 1.12, slightly lower than those on the healthy side (N: 3.94, E: 4.47, E/N: 1.13), with an I/H ratio of 0.99. The intraoperative X-ray revealed stability of the inferior tibiofibular joint. Therefore, no further fixation was performed on it. ConclusionStandardized intraoperative ultrasound stress test allows for real-time, dynamic assessment of the stability of the inferior tibiofibular joint after ankle fracture reduction and fixation, which can help guide the fixation of the inferior tibiofibular joint, thereby reducing the risk of postoperative traumatic arthritis.

Assessment of articular cartilage of ankle joint in stable and unstable unilateral weber type-B/SER-type ankle fractures shortly after trauma using T2 relaxation time.

Early detection of post-traumatic cartilage damage in the ankle joint in magnetic resonance images can be difficult due to disturbances to structures usually appearing over time. To study the articular cartilage of unilateral Weber type-B/SER-type ankle fractures shortly post-trauma using T2 relaxation time. Fifty one fractured ankles were gathered from consecutively screened patients, compiled initially for RCT studies, and treated at Oulu University Hospital and classified as stable (n = 28) and unstable fractures (n = 23) based on external-rotation stress test: medial clear space of ≥5mm was interpreted as unstable. A control group of healthy young individuals (n = 19) was also gathered. All ankles were imaged on average 9 (range: 1 to 25) days after injury on a 3.0T MRI unit for T2 relaxation time assessment, and the cartilage was divided into sub-regions for comparison. Control group displayed significantly higher T2 values in tibial cartilage compared to stable (six out of nine regions, p-values = .003-.043) and unstable (six out of nine regions, p-values = .001-.037) ankle fractures. No differences were detected in talar cartilage. Also, no differences were observed between stable and unstable fractures in tibial or talar cartilage. Lower T2 relaxation times of tibial cartilage in fractured ankles suggest intact extra cellular matrix (ECM) of the cartilage. Severity of the ankle fracture, measured by ankle stability, does not seem to increase ECM degradation immediately after trauma.

Syndesmosis Instability

The syndesmosis is one of important stabilizer of the ankle joint and consists of a complex ligamentous structure: the anterior inferior tibiofibular ligament; the interosseous ligament; the posterior inferior tibiofibular and the transverse ligaments. The posterior syndesmosis plays the most important role providing 40–45% of the resistance to diastasis, while the AITFL provides around 35%. Major injuries of two of the syndesmosis components represent a loss of more than 50% of resistance to diastasis and may result in instability. Syndesmosis injury or a high ankle sprain, is a frequent athletic trauma accounting for 1% to 18% of all ankle sprains, 17 to 84% of all sport injuries, and 10% of all ankle fractures. Most of the mechanism injury is external rotation injury. A radiographic study suggested that about 20.3% of ankle sprains were combined with a syndesmosis injury. Without proper treatment, the chronic syndesmosis injury remains symptomatic for more than 6 months after the initial trauma, with persistent pain, functional disability, and early-stage ankle arthritis. Normally, syndesmosis widens 1 mm during normal gait. Widening of syndesmosis more than 1 mm can reduce tibiotalar contact surface about 42%. The degenerative changes can occur if the lateral talar shift more than 2 mm. Clinical tests for syndesmosis injuries are external rotation stress test, Cotton test, dorsiflexion-compression test, squeeze test, crossed-leg test, fibular translation and AITFL palpation. Standard radiographs are part of ankle trauma evaluation, especially for fracture exclusion, applying the Ottawa criteria. Computerized tomography (CT) scan is a useful tool to assess tibiofibular diastasis, fibular rotation and joint asymmetry, but shows low sensitivity. MRI is showing very high sensitivity and specificity in identification of syndesmotic injuries. For stable lesion can be treated with conservative means, including non weight bearing or protected weight bearing with a cast or walking boot and a rehabilitation protocol. An unstable lesion requires a surgical procedure to avoid long-term disability and chronic instability. Ankle arthroscopy remains essential for diagnosis and treatment. With accessory tools that measure the syndesmosis gap (e.g. 3.5 mm shaver canula or a metallic tools). Passage of a 3 mm spherical probe during external rotation indicates very high likelihood of rupture of both the AITFL and the IOL. Also, concomitant intra-articular pathologies (osteochondral lesions, other ligamentous rupture or loose bodies) can be presented, with 19% needs to be addressed, reinforcing the role of arthroscopy not only for diagnosis but also for treatment. It is also an excellent tool to evaluate anatomic reduction and residual diastasis.

A systematic review and meta-analysis on the value of the external rotation stress test under fluoroscopy to detect syndesmotic injuries.

The aim was to conduct a systematic literature review and meta-anaylsis to analyze the diagnostic accuracy of the external rotation stress test (ERST) for syndesmotic injuries. The systematic review was conducted according to the PRISMA-P guidelines (Prospero ID: CRD42021282457). Four common databases were searched from inception to September 29, 2021. Eligible were any studies facilitating the ERST under fluoroscopy in a defined state of syndesmotic instability. Syndesmotic ligament-specific rupture must have been proven by MRI, arthroscopy, or controlled dissection (cadaver study). Two reviewers independently conducted each step of the systematic literature review. The risk of bias was assessed by the Quality Appraisal for Cadaveric Studies Score scale. The data analysis was performed qualitatively and quantitatively. Eight studies were eligible for a qualitative analysis, and six studies were eligible for a quantitative analysis. All studies included were cadaver studies. The qualitative analysis comprised 94 specimens and revealed considerable heterogeneity. Six studies allowed for a quantitative analysis of the tibiofibular clear space (TFCS) and five studies for the medial clear space (MCS) during the ERST. The quantitative analysis of the TFCS revealed no significant differences between intact and any stage of syndesmotic injury. The MCS was able to differentiate between intact and 2-ligament- (Z = 2.04, P = 0.02), 3-ligament- (Z = 3.2, P = 0.001), and 3-ligament + deltoid ruptures (Z = 3.35, P < 0.001). The ERST is the only noninvasive test to assess syndesmotic instability and can be conducted bilaterally. The uninjured contralateral side can serve as a baseline reference. Based on the conducted quantitative analysis, the MCS seems to be able to differentiate between stable (intact/1-ligament) and unstable (2-ligament/3-ligament) lesions.

Current status of the management of isolated syndesmotic injuries in Germany

IntroductionAlthough non-fracture-related syndesmotic injuries of the ankle are relatively rare, they may lead to poor clinical outcome if initially undiagnosed or managed improperly. Despite a variety of literature regarding possibilities for treatment of isolated syndesmotic injuries, little is known about effective applications of different therapeutic methods in day-to-day work. The aim of this study was to assess the current status of the treatment of isolated syndesmotic injuries in Germany.Materials and methodsAn online-questionnaire, capturing the routine diagnostic workup including clinical examination, radiologic assessment and treatment strategies, was sent to all members of the German Society of Orthopedic Surgery and Traumatology (DGOU) and Association of Arthroscopic and Joint Surgery (AGA). Statistical analysis was performed using Microsoft excel and SPSS.ResultsEach question of the questionnaire was on average answered by 431 ± 113 respondents. External rotation stress test (66%), squeeze test (61%) and forced dorsiflexion test (40%) were most commonly used for the clinical examination. In the diagnostic workup, most clinicians relied on MRI (83%) and conventional X-ray analysis (anterior–posterior 58%, lateral 41%, mortise view 38%). Only 15% of the respondents stated that there is a role for arthroscopic evaluation for the assessment of isolated syndesmotic injuries. Most frequently used fixation techniques included syndesmotic screw fixation (80%, 42% one syndesmotic screw, 38% two syndesmotic screws), followed by suture-button devices in 13%. Syndesmotic screw fixation was mainly performed tricortically (78%). While 50% of the respondents stated that syndesmotic screw fixation and suture-button devices are equivalent in the treatment of isolated syndesmotic injuries with respect to clinical outcome, 36% answered that syndesmotic screw fixation is superior compared to suture-button devices.ConclusionsWhile arthroscopy and suture-button devices do not appear to be widely used, syndesmotic screw fixation after diagnostic work-up by MRI seems to be the common treatment algorithm for non-fracture-related syndesmotic injuries in Germany.

The effect of partial deltoid ligament injuries on the external rotation stability: A cadaveric study

BackgroundThe anterior and posterior part of the deltoid ligament have different functions during ankle flexion motion. Partial ligament injuries have been demonstrated in previous clinical reports. However, the efficacy of external rotation stress test in partial injured cases is unavailable till now. MethodsThirty-two fresh cadaveric specimens were included and allocated into two destabilization groups. In the first group, the anterior portion of deltoid ligament (DL) and syndesmotic ligament were sequentially severed, while in the second group, the posterior portion of DL and syndesmotic ligament were sequentially severed. Mortise view radiographs were taken after each destabilization stage when the ankles were placed at plantarflexion and dorsiflexion positions and stressed in standard external rotation force. The medial clear space (MCS) and talar tilt (TT) angle were measured and compared among different destabilization stages. ResultsWhen the ankles were placed at neutral position, the TT significantly increased in all destabilization stages. The MCS significantly increased after the partial deltoid ligament ruptures only with presence of syndesmotic ligament injuries. There was no significant difference of MCS at plantarflexion for all stages of destabilization if the anterior portion of DL is preserved. Similarly, no significant increase of MCS was detected at dorsiflexion if the posterior portion of DL and posterior inferior tibiofibular ligament are intact. ConclusionPartial DL rupture causes ankle rotational instability at different ankle joint positions, especially when combined with syndesmotic injuries. The neutral position is recommended for diagnosis of partial DL ruptures under external rotation stress.

Diagnosing Medial Ankle Instability with Gravity Stress, Weight-Bearing, and External Rotation Stress Ultrasonography: A Cadaveric Study

Category:Ankle; TraumaIntroduction/Purpose:Destabilizing injuries to the deltoid ligament have historically relied on radiographic stress examination for diagnosis, with a focus on medial clear space (MCS) widening. Increasingly, Portable ultrasound (P-US) has increasingly been used in the clinical setting, allowing dynamic and non-invasive evaluation at the point of care. This study aims to determine whether the P-US assisted MCS evaluation during the gravity stress (GST), weight-bearing, and external rotation stress test can detect medial side instability in supination-external rotation (SER) type ankle injuries with sequential disruption of the anterior inferior tibiofibular ligament (AITFL) (stage I), the fibula (Weber B fracture) (stage II), the posterior inferior tibiofibular ligament (PITFL) (stage III), the superficial deltoid ligament (stage IVa) and the deep deltoid ligament (stage IVb).Methods:Ten fresh-frozen cadaveric specimens were used. Medial ankle instability was assessed by the P-US. The assessment was performed with all structures intact and later with sequential transection of the AITFL, Weber-B fibular fracture, the PITFL, the superficial and deep deltoid ligament. In all scenarios, three loading conditions were considered, including the GST, the external rotation stress test (45N), and the simulated weight-bearing (750N). The P-US measurement of the MCS was assessed at the anteromedial aspect and inferomedial aspect of the ankle joint. Three different MCS distances were measured, as demonstrated in Figure 1. To investigate the correlation between the P-US measurements and the staging of SER ankle injuries, a Spearman rank correlation was used. To detect a difference in MCS distances between each injured stage and the intact stage for each stress test, a Wilcoxon signed-rank test was used. P-values were adjusted for multiple comparisons using the Holm- Bonferroni method.Results:MCS values measured with the P-US increased as the SER ankle injury stage progressed. The Spearman's rank correlation coefficient ranged from 0.43 to 0.90 (p-values <0.001), which represent moderate to strong positive correlations between the ultrasonographic MCS measurements, and the sequentially created supination-external rotation ankle injury model. All MCS values measured with the P-US during; 1) the GST in neutral ankle position, 2) the GST in plantarflexed ankle position, 3) weight-bearing, and 4) the external rotation stress test, were significantly different between intact stage vs. stage IVb (p ranged from 0.02-0.03). When compared between SER ankle injury stage IVa vs. IVb, the P-US MCS values measured in SER stage IVb were significantly larger (p ranged from 0.005-0.03). Inter-rater (0.97; 95% confidence interval: 0.96-0.98) and intra-rater reliability (0.95; 95% confidence interval: 0.94-0.96) for the P-US MCS measurements were all substantial.Conclusion:Portable ultrasonography is a feasible tool for diagnosing medial ankle instability in SER ankle injury. The MCS measurements assessed with P-US during the GST, weight-bearing, and the external rotation stress test well correlated with the SER ankle injury staging. Besides, the P-US method is capable of differentiating the SER ankle injury stage IVb from the intact stage, as well as differentiating the stable SER ankle injury stage from the unstable stage. Therefore, the P-US can be a valuable diagnostic tool at the point of care due to its ability to dynamically evaluate suspect medial ankle instability in SER type injury.

A Comparison of Portable Ultrasonography and the Fluoroscopy for Evaluating Medial Ankle Instability: A Cadaveric Study

Category:Ankle; TraumaIntroduction/Purpose:Diagnosis of destabilizing deltoid ligament injuries remains challenging and is best identified with dynamic imaging techniques. This study aims to assess and compare medial clear space (MCS) distances in various stages of sequentially created supination external rotation (SER) ankle injury model using portable ultrasound (P-US) and fluoroscopy. We hypothesize that there is a strong correlation between the P-US and fluoroscopic measurements for the assessment of medial ankle instability in SER type ankle injury during the gravity stress test (GST), weight-bearing, or external rotation stress test.Methods:Ten cadaveric specimens were used for assessing medial ankle instability. The assessment was performed with all structures intact, and later with sequential transection of the anterior inferior tibiofibular ligament (Stage I), fibular (Weber-B fracture) (Stage II), posterior inferior tibiofibular ligament (Stage III), superficial deltoid ligament (Stage IVa), and deep deltoid ligament (Stage IVb). In all scenarios, the GST, external rotation stress test(45N), and Simulated weight-bearing condition(750N) were performed. The P-US measurement of the MCS was assessed at the anteromedial and inferomedial aspect of the ankle joint. Three different MCS distances were measured, as demonstrated in Figure 1. The fluoroscopic MCS measurements were assessed on a true mortise ankle view achieved during each loading condition. Spearman rank correlation was used to investigate the relationship between the P-US and fluoroscopic measurements. The inter- and intra-observer agreement was assessed using the intraclass correlation coefficient (ICC) through a two-way mixed-effects model with absolute agreement.Results:The P-US and fluoroscopic assessed medial ankle instability values during the GST, weight-bearing, and the external rotation stress test increased as the SER ankle injury stage progressed. The P-US values measured during all stress tests demonstrated a moderate to strong positive correlation with those measured with the fluoroscopy (Spearman's rank correlation ranged from 0.61-0.93, p-values <0.001). Inter-rater (P-US: 0.97, 95%CI: 0.96-0.98) and intra-rater reliability (P-US, 0.95, 95%CI: 0.94-0.96) for the P-US measurements were all substantial.Conclusion:The use of dynamic P-US to measure the MCS appears to be a reliable and repeatable technique. The P-US MCS measurement values measured in the SER ankle injury model during the GST, weight-bearing and the external rotation stress test are well correlated with those values measured with fluoroscopy. Therefore, the dynamic P-US with stress examination of the ankle has the potential to quantify medial ankle instability in a radiation-free, non-invasive, low cost, and point of care setting.

Dynamic Portable Ultrasound Cutoff Values for Diagnosing Medial Ankle Instability in Supination External Rotation Ankle Injury: A Cadaveric Study

Category:Ankle; TraumaIntroduction/Purpose:In the setting of an isolated lateral malleolar fracture, stability is predicated by whether the deep deltoid ligament is intact. Portable ultrasound (P-US) has also been used in the clinical setting, allowing dynamic and non-invasive evaluation at the point of care. This study aimed to determine the cutoff values, as well as its sensitivity and specificity for diagnosing supination external rotation (SER) ankle injury stage IVb (with complete deltoid ligament rupture) using the P-US.Methods:Ten fresh-frozen cadaveric specimens were used. Medial ankle instability was assessed by the P-US. The assessment was performed with all structures intact and later with sequential transection of the AITFL, Weber-B fibular fracture, the PITFL, the superficial and deep deltoid ligament. In all scenarios, three loading conditions were considered, including the GST, the external rotation stress test (45N), and the simulated weight-bearing (750N). The P-US measurement of the MCS was assessed at the anteromedial aspect and inferomedial aspect of the ankle joint. The P-US measurement of the MCS was assessed by placing the ultrasound probe perpendicularly to the medial gutter at the anteromedial aspect and inferomedial aspect of the ankle joint. Three different MCS distances were measured, as demonstrated in Figure 1. To determine the sensitivity and specificity of the diagnosis of SER injury type IV using the P-US, a receiver operating characteristic (ROC) curve analysis was performed.Results:The MCS optimal cutoff point to distinguish SER ankle injury stage IVb from other injury stages ranged from 10.4 to 13.8 during the GST, 4.2 to 7.9mm during the weight-bearing stress, and 10.6-17.9mm during the external rotation stress test (Table 1). All P-US cutoff values provided acceptable sensitivity (60-100%), specificity (84-100%), and the area under ROC curve (0.8-1.0) for diagnosing SER ankle injury stage IVb.Conclusion:MCS cutoff points assessed with the P-US under the GST, weight-bearing, and the external rotation stress test demonstrate high sensitivity and specificity for detecting SER ankle injury stage IVb. The cutoff values vary depending on which loading condition is being used. Additional clinical studies are necessary in the in vivo setting to better understand the implications of these test conditions.

General Medicine - Weightlifting

HISTORY: A 49yo M, h/o prediabetes and hyperlipidemia, presented with R medial ankle pain and unilateral RLE swelling x5 days. Had acute onset of R medial ankle pain without a specific injury following a leg workout. Seen in urgent care and diagnosed with a deltoid ligament sprain; prescribed RICE, NSAIDs, crutches, and a CAM boot. The pain did not abate and the swelling progressed from the R ankle to the entire lower leg distal to the knee. Denied chest pain, dyspnea, history of malignancy, recent travel, and history of crystalline disease. Meds: None. Allergies: None. SH: Desk job, nonsmoker. PHYSICAL EXAMINATION: Obese male with normal vital signs. Normal cardiovascular, pulmonary, and neurologic exam. RLE notable for antalgic gait, 2+ pitting edema to the knee, no erythema, 2+ DP pulse, 2+ PT pulse. R ankle with full painless AROM; 5/5 strength in dorsiflexion, plantarflexion, inversion, eversion, toe flexion; intact distal sensation; non-focal tenderness to palpation over the posteromedial ankle; negative external rotation stress test, negative anterior drawer, negative talar tilt, and negative pronation talar tilt. DIFFERENTIAL DIAGNOSIS: 1. DVT 2. Gout 3. Deltoid Ligament Sprain 4. Osteoarthritis flare 5. Posterior tibialis tendinopathy TEST AND RESULTS: Imaging - Right ankle radiographs negative. BLE Venous Duplex Vascular Ultrasound negative. RLE MRI w/o Contrast showed diffuse circumferential subcutaneous edema about the lower leg, ankle, and foot with a small focus of bone marrow edema and periostitis at the posteromedial distal tibial cortex. Minimal posterior tibialis tendinopathy. No overlying ulceration or abscess. Labs - WBC 6.3 x 103 / uL. Creatinine 1.3 mg/dL. CRP 2.0 mg/L. ESR 6 mm/h. Uric Acid: 8.1 mg/dL FINAL WORKING DIAGNOSIS: Acute gout flare plus mild posterior tibialis tendinopathy TREATMENT AND OUTCOMES: 1. NSAIDs 2. Leg Elevation 3. Weight bearing as tolerated 4. Dietary modification 5. Pain free with markedly reduced RLE swelling at one-month follow-up. Returned to exercise. Did not start urate-lowering therapy.

Anteromedial Rotatory Laxity: What is it, When to Address, and How?

Recent biomechanical studies have clarified the role of the medial soft tissue stabilizers in restraining anteromedial rotatory instability (AMRI) of the knee: the superficial medial collateral ligament has been shown to be an important passive restraint to AMRI, with a relevant contribution of the deep medial collateral ligament (dMCL) near full extension. Clinically, concomitant injury of the anterior cruciate ligament (ACL) and dMCL or both dMCL and superficial medial collateral ligament, may lead to AMRI. Anterior drawer in external rotation, external rotation and valgus stress test are used to assess AMRI, although a feasible classification system has not yet been established. In cases of an acute ACL and high-grade MCL injury, it is still a matter of the debate whether both ligaments need to be addressed immediately or if a primary conservative treatment of the MCL should be followed by an ACL reconstruction. If not addressed adequately, chronic AMRI may arise and an increased rate of recurrent ACL insufficiency has to be assumed. In the setting of chronic AMRI, a combined ACL and MCL reconstruction with autologous tendon grafts should be considered. Nevertheless, indication for primary repair or reconstruction of the medial soft tissue stabilizers with autologous tendon grafts remains controversial and a lack of data exists regarding the potential of current treatment options for restoring AMRI.

Syndesmosis fixation in supination-external rotation ankle fractures. Long-Term results of a prospective randomised study

BackroundThe clinical relevance and treatment of syndesmosis injury in supination-external rotation (SER) ankle fractures are controversial. MethodsAfter malleolar fixation 24 SER 4 ankle fracture patients with unstable syndesmosis in external rotation stress test were randomised to syndesmosis transfixation with a screw (13 patients) or no fixation (11 patients). Mean follow-up time was 9.7 years (range, 8.9–11.0). The primary outcome measure was the Olerud-Molander Ankle Outcome Score (OMAS). Secondary outcome measures included ankle mortise congruity and degenerative osteoarthritis, 100-mm visual analogue scale for function and pain, RAND 36-Item Health Survey, and range of motion. ResultsMean OMAS in the syndesmosis transfixation group was 87.3 (SD 15.5) and in the no-syndesmosis-fixation group 89.0 (SD 16.0) (difference between means 1.8, 95% CI −10.4–14.0, P = 0.76). There were no differences between the two groups in secondary outcome measures. ConclusionWith the numbers available, SER 4 ankle fractures with unstable syndesmosis can be treated with malleolar fixation only, with good to excellent long-term functional outcome.

The value of radiologic diagnostics in evaluating deltoid integrity in isolated type B ankle fractures: a systematic review of the literature.

Excluding deep deltoid ligament (DDL) rupture in isolated type B ankle fractures is crucial in the decision-making process for surgical or conservative treatment. There is no consensus about the most accurate radiologic diagnostic test to determine medial injury. The aim of this study is to systematically review the literature concerning radiologic diagnostics that evaluate medial injury in adult patients with isolated type B ankle fractures. The electronic databases PubMed, Embase, Web of Science, COCHRANE Library, and Emcare were searched to identify studies published from January 1990 to December 2020 concerning sensitivity and specificity of diagnostic tests that evaluate medial injury in patients with an isolated type B ankle fracture. For inclusion, comparison to a reference test was required to provide results in terms of sensitivity, specificity, and preferably positive predictive value and negative predictive value RESULTS: This review included 8 studies. Ultrasound showed the highest sensitivity of 100% and a specificity between 90 and 100% for detecting DDL rupture. Gravity stress radiographs showed a sensitivity of 71-100% and a specificity between 88 and 92%. The mortise, external rotation stress test, and MRI had lower sensitivity and specificity values, between 65 and 88%. The most accurate and available methods for diagnosing deltoid integrity seem to be the ultrasound and the GS radiograph. Further research is needed to confirm the results of this review.

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.

Is there any change in surgeon's attitude to the management of ankle fractures accompanying syndesmotic injury? A nationwide survey.

Objectives This study aims to investigate the attitudes of orthopedic surgeons to the management of ankle fractures accompanied by syndesmotic injury with a nationwide survey.Patients and methods In the first step of this descriptive study, an electronic survey was prepared in Google drive and a survey link was sent to the Turk-Ortopedi e-mail group between 09 and 19 January 2019. The orthopedic surgeons and residents were requested to complete the questionnaire. A total of 320 orthopedic surgeons (77%) and residents (23%) participated in the survey. The responses were analyzed statistically. To evaluate the changing attitudes, our results were compared with the surgeon survey studies key worded “syndesmotic injury” in PubMed.Results The majority of the participants stated that they used the hook test, external rotation stress test, and fluoroscopy together (47.2%) for the diagnosis of syndesmotic injury during the operation. Of the participants, the majority (93%) reported to use metallic syndesmotic screws, and 59% reported to remove the syndesmotic screw routinely. Young surgeons with five to 10 years of experience preferred intraoperative diagnosis methods compared to surgeons with more than 20 years of experience. Foot and ankle surgeons and sports surgeons reported to allow weight bearing before removal of the screw much more than other unspecified branches.ConclusionThe preferences of the surgeon vary in syndesmotic injuries and there is still no consensus regarding diagnosis and rehabilitation. Compared to the past decade, fewer surgeons prefer to remove the screws today.

Dynamic and Stabilometric Analysis After Syndesmosis Injuries.

Distal tibiofibular syndesmosis contributes to dynamic stability of the ankle joint and thereby affects gait cycle. The purpose of this study was to evaluate the grade of syndesmosis injury on plantar pressure distribution and dynamic parameters of the foot. Grade of syndesmosis injury was determined by preoperative plain radiographic evaluation, intraoperative hook test, or external rotation stress test under fluoroscopic examination, and two groups were created: group 1, patients with grade III syndesmosis injury (n = 17); and group 2, patients with grade II syndesmosis injury (n = 10). At the last visit, radiologic and clinical assessment using the Foot and Ankle Outcome Score was performed. Dynamic and stabilometric analysis was carried out at least 1 year after surgery. The mean age of the patients was 48.9 years (range, 17-80 years), and the mean follow-up was 16 months (range, 12-24 months). No statistically significant difference was noted between two groups regarding Foot and Ankle Outcome Score. The comparison of stabilometric and dynamic analysis revealed no significant difference between grade II and grade III injuries (P > .05). However, comparison of the data of patients with grade III syndesmosis injury between injured and healthy feet showed a significant difference for dynamic maximum and mean pressures (P = .035 and P = .49, respectively). Syndesmosis injury does not affect stance phase but affects the gait cycle by generating increased pressures on the uninjured foot and decreased pressures on the injured foot. With the help of pedobarography, processing suitable orthopedic insoles for the injured foot and interceptive measures for overloading of the normal foot may prevent later consequences of ankle trauma.

Posterior Malleolus Fracture Displacement Is Associated with Rotational Ankle Fracture Stability in Patients Without Medial Malleolar Fractures.

The optimal method for the determination of ankle stability remains controversial in rotational ankle fractures without medial bony injury. The purposes of this study were to (1) evaluate whether posterior malleolar (PM) fracture displacement is associated with deltoid ligament injury in supination-external rotation (SER) ankle fractures and (2) compare the diagnostic accuracy of PM displacement and magnetic resonance imaging (MRI) evaluation of the deep deltoid ligament in identifying fractures with deltoid ligament incompetence. Patients with rotational bimalleolar injuries containing lateral malleolar and PM fractures without bony medial injury were included. After operative lateral and PM fixation, an external rotation stress test was performed to evaluate deltoid ligament stability. Operative dictations were reviewed to confirm injury pattern, stability on stress test, and visual inspection of the deltoid ligament. Maximum PM displacement was assessed on lateral X-ray. Pre-operative MRI of the ankle was performed following closed reduction and splinting. The final cohort consisted of 13 trimalleolar equivalent fractures (torn deltoid ligament) and 20 bimalleolar fractures (medial malleolus and deltoid ligament intact). Average PM displacement was significantly higher for SER trimalleolar equivalent patterns when measured on lateral X-ray. The sensitivity of detecting trimalleolar equivalent fracture was higher on all reported X-ray findings than the sensitivity obtained by the reported MRI findings of deltoid ligament injury. PM displacement on X-ray is a useful adjuvant along with external rotation stress radiography and MRI evaluation of deep deltoid integrity to distinguish between stable and unstable fracture patterns and thus helps facilitate treatment decisions.

3D Talar Kinematics During External Rotation Stress Testing in Hindfoot Varus and Valgus Using a Model of Syndesmotic and Deep Deltoid Instability.

External rotation stress (ERS) identifies ankle instability after fibular reduction of rotational ankle injuries. Combined hindfoot and ankle motions and an inconsistent starting position could mask differing degrees of instability resulting from syndesmotic and/or deltoid ligament disruption. The goal of this work was to use full 3D talar kinematics to evaluate the effects of hindfoot orientation and foot starting position during ERS on the ability to detect instability caused by ligament disruptions. Six cadaveric ankles with metallic fiducial markers were CT scanned in neutral and 3 stress positions: varus hindfoot internal rotation stress (IRS-var), valgus hindfoot ERS (ERS-val), and varus hindfoot ERS (ERS-var). Scans were obtained in stress positions after transecting the deep deltoid ligament (tDDL) and then the syndesmotic ligaments (tDDL+Syn). Talar rotations and translations were computed in the axial, coronal, and sagittal planes in each stress position. Changes in a fixed center of rotation (CoR) relative to the intact sequence were calculated. Axial plane rotation beginning from IRS-var increased significantly for each level of ligamentous instability (P < .05 for all conditions) (10.9 degrees, intact; 14.1 degrees, tDDL; 22.7 degrees, tDDL+Syn during ERS-val; and 16.4 degrees, intact; 23.1 degrees, tDDL; 29.9 degrees, tDDL+Syn during ERS-var). With ERS-val, the talar CoR moved medially (3.6-5.4 mm) and posteriorly (0.5-5.2 mm); ERS-var moved anterior/laterally or posterior/medially depending on the specific ligamentous instability. With tDDL+Syn the ankle became grossly unstable and there were no clear trends in sagittal/coronal rotation or translation. An ERS test from internal to external rotation consistently differentiates between normal, tDDL, and tDDL+Syn. Talar CoR moved outside the mortise with ligamentous instability. Significant residual deep deltoid instability is likely underrecognized with current practice. The most discriminatory test for detecting such instability in our laboratory was an ERS test performed by internally rotating the foot to a hard, bony endpoint, positioning the hindfoot in varus, and then performing the entire external rotation maneuver while maintaining the varus hindfoot position.