Lateral Ankle Radiographs Research Articles

The Effect of Three-Component Total Ankle Replacement Malalignment on Clinical Outcome: Pain Relief and Functional Outcome in 317 Consecutive Patients

Total ankle replacement has become an increasingly popular treatment for patients with end-stage ankle osteoarthritis. The surgery is technically demanding and generally performed by only experienced foot and ankle surgeons. An important complication of total ankle replacement is malposition of the talar component. The biomechanical effect of malposition has been reported; however, the functional outcomes of patients with varying degrees of talar component malposition have not. The purpose of this study was to assess the influence of talar component malposition on postoperative pain relief and functional outcome. This retrospective cohort study included 317 total ankle replacements in 317 patients. The anteroposterior offset ratio was measured with use of lateral ankle radiographs made with the patient in a standing, weight-bearing position. Patients were classified into one of three groups: those with an anteroposterior offset ratio of 0 (127 ankles), those with a ratio of >0 (103 ankles), and those with a ratio of <0 (eighty-seven ankles). Postoperative pain relief was assessed with use of a visual analogue scale. Functional outcome was assessed with the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score and measurement of ankle range of motion. The mean duration of follow-up (and standard deviation) was 53.2 ± 18.4 months (range, twenty-four to ninety-eight months). The postoperative pain level in the group with an anteroposterior offset ratio of 0 was significantly lower than that for both the group with a ratio of >0 (p < 0.001) and the group with a ratio of <0 (p = 0.017). Also, the functional outcome, measured with use of the AOFAS hindfoot score, was significantly higher, and ankle motion was significantly greater, in the group with an anteroposterior offset ratio of 0 than in the group with a ratio of >0 (p = 0.003 and p < 0.001, respectively) and the group with a ratio of <0 (p = 0.007 and p = 0.080). The anteroposterior offset ratio may be a useful predictor of outcome in patients with total ankle replacement with regard to both pain and function. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Lateral Ankle Radiographs: Do We Really Understand What We Are Seeing?

To evaluate the validity of using lateral intraoperative fluoroscopic imaging to assess the reduction of the tibial plafond articular surface, two hypotheses were tested: 1) the distal tibial subchondral shadow on the lateral ankle radiograph is created equally by the medial, central, and lateral portions of the distal tibia; and (2) displacement of a 5-mm width osteochondral fragment is consistently recognizable on lateral fluoroscopic imaging. Six human fresh-frozen tibial plafond cadaveric specimens were sagitally sectioned in 5-mm increments after removal of the anterior soft tissue and stabilization of the position of the ankle through external fixation. To test the first hypothesis, a perfect lateral radiograph was taken after sectioning the specimens. The sagittal sections were then removed sequentially from medial to lateral. A perfect lateral radiograph was taken after each change. The sagittal sections were then removed beginning laterally and moving medially. A perfect lateral radiograph was taken after each change. The images were then compared with specific evaluation of the change in the subchondral shadow density. To test the second hypothesis, three malreductions were created by displacing a 5-mm osteochondral segment. After each malreduction, a perfect lateral radiograph was saved. These saved fluoroscopic images were placed in random order with lateral images of normal specimens. Four experienced ankle surgeons were then asked to determine whether the radiographs revealed displacement. Inter- and intraobserver reliability was then evaluated. First, the subchondral shadow of the distal tibia appears to be created by an equal confluence of the subchondral bone of the medial, central, and lateral aspects of the tibial plafond. Second, fellowship-trained observers experienced in pilon fracture treatment correctly identified malreduction only 45% of the time. Intraclass correlation coefficient revealed very poor interobserver reliability with an alpha reliability statistic of 0.183. Intraobserver reliability across all four observers yielded an alpha statistic of 0.474, indicating inconsistencies in observers' evaluation of identical images at separate viewings. It is difficult to discern rotational or translational displacement of a 5-mm osteochondral fragment on a perfect lateral fluoroscopic view of the ankle. Even with what appears to be a perfect lateral fluoroscopic view intraoperatively, displacement may still be present. When small osteochondral fragments are present, direct visualization of the articular surface is necessary to confidently establish that an anatomic reduction has been achieved.

Talar Positional Fault in Persons With Chronic Ankle Instability

Wikstrom EA, Hubbard TJ. Talar positional fault in persons with chronic ankle instability. Objective To determine whether sagittal plane talar position differs between uninjured controls and individuals with chronic ankle instability (CAI) using lateral ankle radiographs. Design Single-blind case control. Setting University-based sports medicine research laboratory. Participants University students (N=48) volunteered to participate. Twenty-four uninjured controls (12 men, 12 women; mean ± SD, 21.8±2.6y; 170±10cm; 73±16kg), and 24 adults with CAI (12 men, 12 women; 21.7±2.8y; 175±13cm; 71±13kg) participated. Intervention A single nonweight-bearing lateral radiograph was taken of each ankle. Subjects were positioned side lying with the hip and knee in a neutral position in the transverse plane and the ankle joint in a neutral position (90° of dorsiflexion, 0° of inversion/eversion). Main Outcome Measure The sagittal plane talar position was calculated as the distance between the most anterior margin of the inferior tibia and the most anterior margin of the talar dome in millimeters for each radiograph. Results Talar position was significantly more anterior in the involved CAI limb (3.69±1.37mm) than the uninvolved CAI limb (2.98±1.61mm; P=.03). Additionally, an anterior talar position was significantly greater in the involved CAI limb than the matched control limb (2.65±1.24cm; P<.01). No differences were found between the uninvolved CAI limb and the matched control group limb ( P=.57) or between the limbs of the uninjured control group ( P=.75). Intratester reliability was found to be .90, while intertester reliability was .78. Conclusions An anterior talar positional fault is present in the involved limb of individuals with CAI relative to their uninvolved limb and compared with the matched limb of a control group. The talar position measurement technique has excellent intratester and intertester reliability.

Dynamic postural control but not mechanical stability differs among those with and without chronic ankle instability

The purpose of this investigation was to compare dynamic postural control and mechanical ankle stability among patients with and without chronic ankle instability (CAI) and controls. Seventy-two subjects were divided equally into three groups: uninjured controls, people with previous ankle injury but without CAI, and people with CAI. Subjects completed a single-leg hop-stabilization task, and then had an anterior drawer test and lateral ankle radiograph performed bilaterally. The dynamic postural stability index was calculated from the ground reaction forces of the single-leg hop-stabilization task. Ankle joint stiffness (N/m) was measured with an instrumented arthrometer during the anterior drawer test, and fibula position was assessed from the radiographic image. Patients with previous ankle injuries but without CAI demonstrated higher frontal plane dynamic postural stability scores than both the uninjured control and CAI groups (P<0.01). Patients with and without CAI had significantly higher sagittal plane dynamic postural stability scores (P<0.01) and increased ankle joint stiffness (P=0.045) relative to the control group. The increased frontal plane dynamic postural control may represent a component of a coping mechanism that limits recurrent sprains and the development of CAI. Mechanical stability alterations are speculated to result from the initial ankle trauma.

Surgical Management of Insertional Achilles Tendinopathy with Haglund's Deformity: A Preliminary Report

Purpose: We wanted to report on treatment outcomes in insertional Achilles tendinopathy patients with Haglund's deformity that were operated on using a central achilles tendon splitting approach. Materials and Methods: We enrolled six cases of insertional tendinopathy with concomitant Haglund's disease who underwent an operation between January, 2007 and November, 2008 and for whom follow-up duration for more than 1 year were available. The mean age was 41.5 (21-62) years; the mean follow-up period was 16.3 (12-24) months. Resection of retrocalcaneal bony prominences and inflamed bursa with debridement of degenerative tendons was done using central splitting approach in all cases. A lateral ankle radiograph was used to assess the amount of bony resection. Clinical and functional evaluations were done before and after the operation. Results: In all cases, retrocalcaneal bony prominences were completely resected. Clinical and functional outcomes were significantly improved. One case had a mild tingling distal to the operative lesion. There were no other complications. Conclusion: A central splitting approach is an efficient procedure that can provide sufficient exposure to remove pathologic lesions in patients with insertional Achilles tendinopathy accompanying Haglund's disease.

An 11-year-old Boy with Ankle Trauma

An 11-year-old Boy with Ankle Trauma

The calcaneal angles in the Turkish population

The purpose of this study was to determine the calcaneal angles on radiograms of individuals without a calcaneal fracture. We retrospectively analyzed a total of 308 digital records of lateral ankle or foot radiographs taken from 268 patients (106 males, 162 females; mean age 42 years; range 18-79 years) without a calcaneal fracture. On these radiographs, the reference lines were drawn with the use of an angle measurement software with a sensitivity of 1/100 mm and the Böhler (BA) and Gissane (GA) angles were measured. The distribution characteristics of the angles with respect to age, gender, and side of the body were analyzed and compared with those of previous studies. The mean BA was 33.8 + or - 4.8 degrees (range 20 degrees to 46 degrees) and the mean GA was 115.0 + or - 6.5 degrees (range 100 degrees to 133 degrees). There were no significant differences for both angles with respect to measurements obtained from the right and left sides (for BA, p=0.198; for GA, p=0.601) and from both sexes (for BA, p=0.177; for GA, p=0.412). The highest (35.2 degrees) and lowest (32.3 degrees) means of BA were seen in the age brackets of 41-50 and 61-83 years, respectively. The corresponding age brackets for GA were 21-30 and 51-60 years with 115.7 degrees and 114.4 degrees , respectively. There were no significant differences between the age groups for both angles (for BA, p=0.086; for GA, p=0.955). Of note, the mean BA was significantly higher than those reported in previous studies. There was no correlation between BA and GA (r=0.018; p=0.76), nor between the calcaneal angles and age (for BA, r=-0.092; p=0.11 and for GA, r=-0.070; p=0.22). The calcaneal angles show considerable variations in diverse ethnic groups and populations in terms of normal range, age, gender, and side. The ranges herein reported (20-46 degrees for BA, 100-133 degrees for GA) can be used as reference values for the Turkish population.

Reliability of Classification of Fractures of the Tibial Plafond According to a Rank-Order Method

Many orthopedic classification systems, including those for tibial plafond fractures, are either unvalidated or have demonstrated problems with interobserver reliability. Classification of tibial plafond fractures according to a rank-order method has shown excellent interobserver reliability with several observers. The purpose of this study is to determine the reliability of a rank order classification of plafond fractures with a large number of observers. A radiographic review study was completed by 69 orthopedists of varying training levels. Observers ranked 10 fractures of the tibial plafond based on anteroposterior and lateral ankle radiographs. Fractures were ranked in increasing severity from 1 to 10. No instructions were given regarding determination of severity. Agreement between rankings was analyzed by the intraclass correlation coefficient (ICC). Rankings were performed by viewing prints at the annual Orthopaedic Trauma Association meeting and through the Orthopaedic Trauma Association website using digital images. The overall ICC was 0.62. There was no difference in the ICC between traumatologists and general orthopedists (p > 0.5). Eleven observers commented that the radiographs did not represent the full spectrum of injury severity. The interobserver reliability of the rank-order classification in this study was fair to good, which is better than previously reported for plafond fracture classification systems. It remains to identify and validate a series of tibial plafond fractures that represent a full spectrum of injury and can be ranked with excellent interobserver reliability. A series of cases such as this may then serve a measurement standard for severity of bony injury against which individual cases may be reliably compared.

Relation between hallux valgus deformity and lumbar and lower extremity biomechanics.

Hallux valgus (HV) is a static subluxation of the first metatarsophalangeal joint with lateral deviation of the great toe and medial deviation of the first metatarsal. Our aim was to evaluate the interference of HV deformity with changes in lumbar lordosis and some foot deformities. Twenty HV patients and 20 healthy subjects were selected for the study. Hallux valgus angle, metatarsus primus varus (MPV), metatarsus omnis varus (MOV), first intermetatarsal (1.IMT), second metatarsal (2. MT) and hallux interphalangeal (HIP) angles were estimated from the anteroposterior foot X-rays. Lumbosacral (LSA) and sacrohorizontal angles (SHA) were measured from lateral lumbar x-rays and pes planus was detected from lateral and anteroposterior ankle and foot radiographs. There was a significant difference between HV angle mean values of two groups. MPV, MOV, 1.IMT, 2. MT and HIP angles did not show significant difference between groups. HV angle was found to be correlated with MPV. HIP angle was found to be correlated with LSA and SHA, indicating a relation with lordosis. HV and pes planus were correlated with each other. HV also showed weak correlation with hyperlordosis. Transmission of variations in body mechanics through pelvis and lower extremity plays an important role for certain foot deformities. Some factors affecting HV development are correctable; early diagnosis and treatment of MPV and pes planus, suggesting healthy rather than fashionable footwear and preventing obesity may lower HV incidence.

The C sign.

The talocalcaneal C sign can be seen in patients with subtalar coalition on lateral ankle radiographs. The anatomic-pathologic basis for a talocalcaneal C sign on lateral ankle radiographs is the bony bridge that extends from the talar dome to the sustentaculum tali, in combination with a prominent inferior outline of the sustentaculum tali (Figure). The talocalcaneal C sign can also be seen in the absence of synostosis of the posterior subtalar joint in patients with a subtalar syndesmosis or synchondrosis, which lies in a plane that is not parallel with the x-ray beam. A posterior interruption of the talocalcaneal C sign occurs in patients with radiolucent syndesmosis or synchondrosis of the medial part of the posterior subtalar joint that is parallel with the x-ray beam, or in patients with coalition of the middle subtalar joint without involvement of the posterior subtalar joint. The C sign may frequently be posteriorly interrupted in the absence of synostosis of the posterior facet; therefore, the sign has lower specificity. Subtalar coalition is frequently accompanied by a dysplastic sustentaculum tali, which may not cast a well-defined lower interface to contribute to the inferior aspect of the C (1). DISCUSSION

Relationship of ankle joint involvement with subtalar destruction in patients with rheumatoid arthritis.A 20-year follow-up study

Aims. In the present study we evaluated radiographically involvement of the ankle joint and its relationship to destruction of the subtalar joint in rheumatoid arthritis (RA). Methods. An inception cohort of 103 patients with seropositive RA was followed over a period of 20 years. Follow-up examinations were conducted after onset, 1, 3, 8, 15, and 20 years from entry. A total of 83 patients attended the 15-year and 68 patients the 20-year follow-up. Radiographic evaluation was performed using a lateral weight-bearing ankle radiograph. A simplified grading was applied for the talocrural joint, in which the ankles (patients) were divided into three groups: no changes, minor changes and major changes. In the end-point analysis the last radiograph was assigned. Subtalar destruction was recorded (Larsen grade ≥ 2). Severity of RA in different groups was evaluated using the Larsen score of 0–100 of hands and feet. Difference between patient groups was evaluated using Cuzick’s test. Results. At the endpoint major changes of the ankles were detected in seven patients (7%) only, minor changes were observed in 17 patients (16%). The first minor involvement of the ankle was observed at the three-year follow-up in two patients. First major changes were detected at the 15-year follow-up in three ankles of two patients. Subtalar pathology preceded that of TC joint in all ankles with major changes. In 17 patients with minor changes, simultaneous subtalar pathology was observed in all but two ankles, while preceding subtalar involvement was radiographically manifest in 13 of 21 ankles. The means of Larsen scores of 0–100 were in the three ankle grading groups 40, 54 and 63, respectively. Cuzick’s test for the trend was highly significant ( P < 0.001). No reconstructive surgery was performed on the ankle joint during the follow-up, whereas the subtalar joint complex was fused cumulatively in 12 patients. Conclusions. The ankle joint is involved in a late stage of RA and is usually affected only in the patients with severe disease. Subtalar pathology precedes the changes in the talocrural joint almost regularly.

The C sign: more specific for flatfoot deformity than subtalar coalition.

To assess the sensitivity and specificity of the C sign, a C-shaped line created by the outline of the talar dome and the inferior margin of the sustentaculum tali on lateral ankle radiographs, for patients with both flatfoot deformity and specifically talocalcaneal (TC) coalition. All patients in this retrospective study were under 35 years of age and had a lateral ankle radiograph and follow-up CT scan for a non-traumatic indication. Forty-eight cases over the past 5 years fulfilled these criteria. Two masked musculoskeletal radiologists determined the presence or absence of the C sign for each lateral radiograph by consensus. Each CT study was then assessed by a third musculoskeletal radiologist for the presence of tarsal coalition. Observations were correlated with clinical history regarding presence or absence of flatfoot deformity. Ten cases of TC coalition were diagnosed, four of which demonstrated a C sign (40%). Eight cases with a C sign were encountered, four of which had TC coalition (50%) and four did not. All patients with a positive C sign had a flatfoot clinically (100%), while only eight of 24 flatfooted patients had a C sign (33%). The C sign is specific, but not sensitive, for flatfoot deformity, and is neither sensitive nor specific for subtalar coalition.

Relation entre arthrite de cheville et destruction sous-astragalienne au cours de la polyarthrite rhumatoïde. Une étude prospective de 20 ans

Objectives. In the present study we evaluated radiographically involvement of the ankle joint and its relationship with destruction of subtalar joint in rheumatoid arthritis (RA). Patients and methods. An inception cohort of 103 patients with seropositive RA was followed over a period of 20 years. Follow-up examinations were conducted after onset 1, 3, 8, 15, and 20 years from entry. A total of 83 patients attended the 15-year and 68 patients the 20-year follow-up. Radiographic evaluation was performed using a lateral weight-bearing ankle radiograph. A simplified grading was applied for the talocrural joint, in which the ankles (patients) were divided into 3 groups: no changes, minor changes and major changes. In the end point analysis the last radiograph was assigned. Subtalar destruction was recorded (Larsen grade ≥ 2). Severity of RA in different groups was evaluated using the Larsen score of 0 – 100 of hands and feet. Difference between patient groups was evaluated using Cuzicks test. Results. At the end point major changes of the ankles were detected in 7 patients (7%) only, minor changes were observed in 17 patients (16%). The first minor involvement of the ankle was observed at the 3-year follow-up in 2 patients. Fist major changes were detected at the 15-year follow-up in 3 ankles of 2 patients. Subtalar pathology preceded that of TC-joint in all ankles with major changes. In 17 patients with minor changes, simultaneous subtalar pathology was observed in all but 2 ankles, while preceding subtalar involvement was radiographically manifest in 13 of 21 ankles. The means of Larsen scores of 0–100 were in the three ankle grading groups 40, 54 and 63, respectively. Cuzicks test for the trend was highly significant (p < 0.001). No reconstructive surgery was performed on the ankle joint during the follow-up, whereas the subtalar joint complex was fused cumulatively in 12 patients. Conclusion. Ankle joint is involved in a late stage of RA and it usually is affected only in the patients with severe disease. Subtalar pathology precedes the changes in talocrural joint almost regularly.

Anterior bony ankle impingement

Anterior bony ankle impingement results from osteophyte formation on the anterior edge of the distal tibia and/or neck of the talus, secondary to direct trauma during extreme or repetitive ankle dorsiflexion. It is common in ballet dancers, gymnasts, soccer players, football players, runners, and high jumpers. Typically, patients will complain of painful limitation of dorsiflexion, catching, and swelling in the ankle. These symptoms can be debilitating and considerably limit their athletic performance. The suspected diagnosis is confirmed with a plain lateral ankle radiograph that shows the anterior osteophytes. Initial treatment includes rest, an internal or external heel lift, rubber-sole wedge shoes, nonsteroidal anti-inflammatory drugs, physical therapy, and intra-articular steroid injections. If nonoperative treatment fails, removal of the anterior osteophytes by open or arthroscopic technique offers symptomatic relief of pain in most patients.

Radiographic appearance of the normal distal tibiofibular syndesmosis in children.

In adults, a tibiofibular clear space (i.e., distance from the incisura fibularis to the medial fibula) of > or = 6 mm or a loss of tibiofibular overlap has been reported to correlate with injury to the distal tibiofibular syndesmosis. We reviewed anteroposterior (AP), lateral, and mortise ankle radiographs from 106 children (50 boys, 56 girls) aged 1-15 years in an attempt to assess whether these criteria are applicable to children. The incisura was detectable at a mean age of 8.2 years for girls and 11.2 years for boys. The range of tibiofibular clear space among the 48 children with a detectable incisura was 2-8 mm; seven (23%) of these 48 children had a clear space of > or = 6 mm in one or more views. The mean age at which the tibiofibular overlap began to appear on the AP view was 5 years for both genders, whereas on the mortise view, it was 10 years for girls and 16 years for boys. The criteria used to evaluate the integrity of the distal tibiofibular syndesmosis in adults do not apply to children in this normal study population.

Radiographic Appearance of the Normal Distal Tibiofibular Syndesmosis in Children

In adults, a tibiofibular clear space (i.e., distance from the incisura fibularis to the medial fibula) of ≥6 mm or a loss of tibiofibular overlap has been reported to correlate with injury to the distal tibiofibular syndesmosis. We reviewed anteroposterior (AP), lateral, and mortise ankle radiographs from 106 children (50 boys, 56 girls) aged 1-15 years in an attempt to assess whether these criteria are applicable to children. The incisura was detectable at a mean age of 8.2 years for girls and 11.2 years for boys. The range of tibiofibular clear space among the 48 children with a detectable incisura was 2-8 mm; seven (23%) of these 48 children had a clear space of ≥6 mm in one or more views. The mean age at which the tibiofibular overlap began to appear on the AP view was 5 years for both genders, whereas on the mortise view, it was 10 years for girls and 16 years for boys. The criteria used to evaluate the integrity of the distal tibiofibular syndesmosis in adults do not apply to children in this normal study population.

Improving the detection of radiographically occult ankle fractures: Positive predictive value of an ankle joint effusion

Objective: To assess the value of an ankle effusion on plain radiographs as a predictor of radiographically occult fracture after acute ankle trauma. Patients: Consecutive patients with acute ankle trauma and radiographic evidence of an ankle joint effusion. Patients were excluded if ankle trauma was sustained more than 48 h previously or if a fracture was visible on initial photographs Methods: All subjects ( n = 26) underwent computed tomography (CT) of the ankle in sagittal and coronal planes. Ankle effusion size was measured from initial lateral ankle radiographs. Results: Twelve patients (46%) had radiographically occult fractures identified with CT. Fracture sites included: posterior or lateral malleoli ( n = 4), calcaneus ( n = 1), or talus ( n = 7). Ankle effusion size was 11.2 mm in the group without fracture and 17.1 mm in the group with fracture ( P < 0.0001). The positive predictive value of an effusion 15 mm or greater was 83%. CT detected significant soft-tissue injuries in four (15%) patients including peroneal retinaculum tear ( n = 1), anterior talofibular ligament avulsion ( n = 1), and tears of the peroneus longus ( n = 1) and tibialis posterior ( n = 1) tendons. Conclusions: The presence of a large ankle effusion of radiographs after acute ankle trauma suggests an underlying fracture. An ankle effusion of ≥15 mm is a reasonable threshold to prompt additional imaging. Computed tomography provides good visualization of subtle bone injuries and may detect clinically imported soft-tissue injuries.

Bilateral accessory soleus: a report on four patients with partial fasciectomy.

Four young adults (average age 24 years) presented with complaints of posterior ankle pain after running. Bilateral accessory soleus muscles were diagnosed using magnetic resonance imaging or CT scan. Symptoms were present an average of 3 years before diagnosis. Two patients had previous surgery (ankle arthroscopy, tarsal tunnel release, and leg compartment release) before diagnosis and treatment. Obliteration of Kager's triangle (posterior ankle fat pad) was present on six out of eight lateral ankle radiographs. Posteromedial prominence was present on four out of eight ankles. Operative exploration confirmed the presence of five muscles and fasciectomy was performed. Follow-up (17 to 29 months) showed good relief of symptoms in all patients and return to long-distance running for three patients. Dissection of 47 preserved cadavers revealed three accessory soleus muscles in the 94 extremities (two muscles were bilateral in one cadaver).

A modification of the standard lateral ankle radiograph.

A modification of the standard lateral ankle radiograph.

The pre-Achilles fat pad: An aid to early diagnosis of local or systemic disease

The normal pre-Achilles fat pad seen on the lateral radiograph of the ankle is a triangular lucency with sharp, gently curving borders. Changes in the sharpness or contour of the fat pad margins may be associated with local or systemic disease. Alteration of the fat pad often precedes recognizable bone or joint abnormalities. Careful scrutiny of the pre-Achilles fat pad on the lateral ankle radiograph should help in early detection of ankle or systemic disease.