Posterior Tibiofibular Ligament Research Articles

Anatomic Popliteus Tendon and Tibiofibular Joint Reconstructions

Background: The popliteus tendon is a primary stabilizer of external knee rotation and has been described as the “fifth ligament of the knee.” Injuries involving the posterolateral corner of the knee commonly involve the popliteus tendon; isolated injury to the popliteus tendon is relatively rare and usually involves a rotatory injury mechanism and symptoms of instability and pain. In this patient, there was a concomitant injury to the proximal tibiofibular joint. Indications: Popliteus tendon reconstruction is indicated for patients with abnormal external rotation on examination and symptoms of pain and instability. Proximal tibiofibular joint reconstruction is indicated for patients with instability of the tibiofibular joint. Technique Description: Preoperative examination under anesthesia is essential to determine the extent of external rotation and assess for additional posterolateral pathology. The popliteus tendon procedure begins with a meticulous common peroneal nerve neurolysis to minimize nerve irritation and decrease the risk of a postoperative foot drop. Semitendinosus and gracilis graft harvest is performed with at least 16 cm of graft length followed by tunnel reaming of the popliteus tendon femoral attachment and tibia tunnel identification and reaming. The femoral attachment of the popliteus tendon is secured, and the semitendinosus graft is anatomically oriented along the native path and passed from posterior to anterior through the femoral tunnel. The gracilis graft for anatomic proximal tibiofibular joint reconstruction requires an anterior to posterior tunnel through the fibular head. Finally, both grafts are secured in the tibial tunnel with the application of an anterior traction force. Results: A cadaveric study by LaPrade et al reported that an anatomic popliteus tendon reconstruction with a semitendinosus autograft significantly reduced external rotation laxity compared with the sectioned state. In addition, popliteus tendon reconstruction resulted in significantly decreased varus laxity, anterior tibial translation, and internal rotation. Discussion: This is a technique that effectively restores external rotation knee stability utilizing an anatomically oriented reconstruction of the popliteus tendon and tibiofibular joint. The popliteus tendon serves as a primary stabilizer to external rotation and facilitates static function of the knee. The proximal tibiofibular joint reconstruction restores the function of the posterior proximal tibiofibular joint ligaments. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Syndesmosis dislocation and ankle ligament stress in the posterior malleolus fracture fixated – “in vitro analysis”

PurposeThe objectives of this study were to compare syndesmosis dislocation and ankle ligament stress after the fixation of the posterior malleolus fracture (PMF) with four different techniques by Finite Element Analysis (FEM). MethodsFour internal fixation techniques used for fixation of PMF were assessed by FEM: posterior one-third tubular 3.5 mm buttress plate (PP) with one screw (PP 1 screw), PP with two screws (PP 2 screws), two cannulated 3.5 mm lag screws in the anteroposterior (AP) direction (AP lag screws), and two posteroanterior (PA) cannulated 3.5 mm lag screws (PA lag screws). PMF with 30% fragment size was simulated through computational processing reconstructed from computed tomography (CT). The simulated loads of 700 N and 1200 N were applied to the proximal tibial end. The FEM evaluated the syndesmosis dislocation (mm) and stress values of the posterior tibiofibular ligament (PTFL) (in Kpa) and deltoid ligament (in Kpa) in the four mentioned subgroups. ResultsWe found that with a load of 700 N, syndesmosis dislocation varied from 6.5 to 7.9 mm, being the lowest and greatest for PA lag screw and PP 1 screw, respectively. In all groups was observed a greater dislocation in the syndesmosis at 1200 N of load. We observed that the stress values on the PTFL were lower for AP lag screws and PP 2 screws with 700 N and 1200 N, respectively. For both loads, PP 1 screw presented the greatest stress. Regarding the stress in the deltoid ligament, the AP lag screws presented the lowest stress for 700 N and PP 1 screw for 1200 N. For all fixation techniques, the syndesmosis displacement and ligament stresses were higher when 1200 N were imposed. ConclusionThis study demonstrated that PMF fixed with lag screws presents greater stability in the distal tibiofibular syndesmosis and higher joint loadings promoted greater displacement and ligaments stress, regardless of the fixation technique. Besides, lower stress in the syndesmosis is accompanied by a greater load on the deltoid ligament.

Triplane ankle fracture patterns in paediatric patients.

Triplane ankle fractures are complex injuries typically occurring in children aged between 12 and 15 years. Classic teaching that closure of the physis dictates the overall fracture pattern, based on studies in the 1960s, has not been challenged. The aim of this paper is to analyze whether these injuries correlate with the advancing closure of the physis with age. A fracture mapping study was performed in 83 paediatric patients with a triplane ankle fracture treated in three trauma centres between January 2010 and June 2020. Patients aged younger than 18 years who had CT scans available were included. An independent Paediatric Orthopaedic Trauma Surgeon assessed all CT scans and classified the injuries as n-part triplane fractures. Qualitative analysis of the fracture pattern was performed using the modified Cole fracture mapping technique. The maps were assessed for both patterns and correlation with the closing of the physis until consensus was reached by a panel of six surgeons. Fracture map grouped by age demonstrates that, regardless of age (even at the extremes of the spectrum), the fracture lines consolidate in a characteristic Y-pattern, and no shift with closure of the physis was observed. A second fracture map with two years added to female age also did not show a shift. The fracture map, grouped by both age and sex, shows a Y-pattern in all different groups. The fracture lines appear to occur between the anterior and posterior inferior tibiofibular ligaments, and the medially fused physis or deltoid ligament. This fracture mapping study reveals that triplane ankle fractures have a characteristic Y-pattern, and acknowledges the weakness created by the physis, however it also challenges classic teaching that the specific fracture pattern at the level of the joint of these injuries relies on advancing closure of the physis with age. Instead, this study observes the importance of ligament attachment in the fracture patterns of these injuries.

A prospective observational study of functional outcome of fracture distal end of Tibia, treated with minimally invasive plating osteosynthesis (Mippo) technic

Background: Distal tibia fractures including Tibia pilon fractures present a challenge as to their best method of management due to subcutaneous location of larger portion of tibia, paucity of soft tissue coverage and precarious blood supply to the distal leg. The involvement of the ankle joint and the vulnerability of the surrounding soft tissues further complicate these already complex injuries. Numerous classifications have been proposed for these fractures, however AO-OTA alphanumeric classifications the most comprehensive as well as the most commonly quoted classification. The lower end of the tibia including its medial and the lateral malleoli of the fibula form a socket (mortise) into which the body of the talus articulates, and along with capsule and ligament thus form the ankle joint. Any disruption of length, axis or rotation of the fibula or the tibia can result in an incongruent ankle joint. The lateral aspect of the distal tibia forms a triangular notch where the fibula articulates. The interosseous membrane and the anterior and posterior tibiofibular ligaments bind these bones together.Aim: To evaluate the efficiency of internal fixation for the fractures of distal tibia by using minimally invasive plating osteosynthesis [Mippo] technique. To assess the functional outcome of Mippo technique with locking compression plate and dynamic compression plate.Methods: A prospective observational study of patients above the age of 20 years with distal tibia fracture admitted in King George hospital, Visakhapatnam. Study duration 9 months.Results: There were 72 patients in the study including 50 males (69.4%) and 22 females (30.6%) of mean age 46 years. The commonest cause of injury was RTA with High energy trauma with total of 31 patients (43.06%) followed by Low energy RTA with total of 28 patients (38.89%) and the rest 28 of the patients with Low energy fall (18.06%) respectively. All fractures united at an average of 15 weeks (range 12 to 20 weeks). As regards pain, 48 patients (66.66%) were pain-free, 18 patients (25%) had only occasional pain.Conclusion: It is well accepted that the final outcome of distal tibial fractures including pilon fractures with this MIPPO technique, a single stage operative procedure. It is obvious that these are not directly influenced by this technique MIPPO, single-stage operative procedure, contributing to a favorable outcome.

Establishment of a finite element model of supination-external rotation ankle joint injury and its mechanical analysis

By establishing a three-dimensional finite element model of ankle injury arising from supination and external rotation, the stress characteristics of the posterior malleolar surface can be obtained, and analysis of the corresponding stress on the lateral ankle can be conducted. Thin-layer computed tomography images of normal ankle joint in the supination and external rotation nonweight-bearing states was selected, to construct a three-dimensional data model of each ankle joint. A load was applied to examine different ankle joint stress values and pressure distributions on the surface of the posterior ankle joint. A 600 N vertical compressive and 10 Nm internal rotation load was applied in Stage III (removing the anterior tibiofibular ligament and the posterior tibiofibular ligament) of SER (supination-external rotation). When the lateral malleolar was intact, the maximum stress (132.7 MPa) was located at the point of attachment of the posterior tibiofibular ligament to the fibula, and the maximum pressure of the posterior malleolar surface was lower than 4.505 MPa. When a lateral malleolar fracture was present, the maximum stress (82.72 MPa) was located on the fibular fracture surface, and the maximum pressure of the posterior malleolar surface was 8.022 MPa. This study shows that reconstruction of the lateral malleolus in supination-external rotation ankle injuries significantly affects the stress distribution at the posterior malleolar joint surface. Through this reconstruction, the pressure distribution of the posterior malleolar joint surface can be significantly reduced.

Repair of distal fibular and lateral malleolus defects with individualized 3D-printed titanium alloy prosthesis: The first case report from China.

Introduction and importanceThis case report describes the reconstruction of the traumatic distal fibular and lateral malleolus defects with a novel method of using individualized 3D printed titanium prosthesis for the first time.Case presentationA 63-year-old male farmer was hospitalized in emergency because of open injury and distal fibular and lateral malleolus defects in the left leg caused by a car accident. 3 months after debridement and latissimus dorsi muscle flap transplantation and skin graft operation, the patient re-hospitalized because of distal fibular and lateral malleolus defect and local pain. We examined the bilateral ankle joint with three-dimensional CT, obtained data about the missing left distal fibular and lateral malleolus through the mirror principle. The corresponding titanium alloy prosthesis then was designed and printed using a 3D metal printer. The patient had no obvious contraindication for surgery, so the prosthesis was surgically implanted. The patient was followed up for 2 years. There was no discomfort at the surgical site. The function of the operated ankle was satisfied by the patient, the AOFAS (American Orthopaedic Foot & Ankle Society) score was 85 (Kitaoka et al., 1994 [1]).Clinical discussionIndividualized 3D printed titanium alloy prosthesis consistent with the anatomical structure of lost distal fibula and lateral malleolus. The proximal end of the prosthesis was designed with four nail holes to install screws to fix the fibula together with it. The lower tibiofibular and talofibular joint surfaces of the prosthesis were designed smoothly. In order to improve the stability of the lower tibiofibular joint, anchors were placed at the attachment of the anterior and posterior tibiofibular ligaments to reconstruct these ligaments.ConclusionThe structure and function of the reconstructed distal fibular and the lateral malleous were close to normal. Individualized 3D printed prosthesis might have considerable advantages over traditional treatment methods. The individualized 3D printed titanium alloy prosthesis provides a new method for the repair and reconstruction of similar bone defects. The use of 3D printed prosthesis for surgical repair needs to be further examined in the future through long-term follow-up studies and in more cases.

The prevalence of posterior inferior tibiofibular ligament and inferior tibiofibular transverse ligament injuries in syndesmosis-injured ankles evaluated by oblique axial magnetic resonance imaging: a retrospective study

BackgroundTransverse ligament and posterior inferior tibiofibular ligament injuries have not been investigated till date because these are difficult to evaluate using standard magnetic resonance imaging. This study aimed to investigate the prevalence of transverse ligament and posterior inferior tibiofibular ligament injuries in syndesmosis-injured ankles using oblique axial magnetic resonance imaging.MethodsThe patients who were diagnosed with syndesmosis injury using magnetic resonance imaging (MRI) within 7 days of the trauma were included. Patients with concomitant fractures were excluded. A total of 34 patients (1 woman and 33 men) with an average age of 22 years (range, 14–64 years) were included. The anterior inferior tibiofibular, interosseous, transverse, and posterior inferior tibiofibular ligaments were classified as intact, partial tear, or complete tear using usual axial and oblique axial MRIs.ResultsThere were 8 (23.5%) ankles with an intact, 21 (61.8%) ankles with a partially torn, and 5 (14.7%) ankles with a complete tear of transverse ligament. There were 20 (58.8%) ankles with an intact, 12 (35.3%) ankles with a partially torn, and 2 (5.9%) ankles with a complete tear of posterior inferior tibiofibular ligament. Overall, 50% of the transverse ligament injuries occurred without posterior inferior tibiofibular ligament involvement.ConclusionsThe oblique axial magnetic resonance imaging scan revealed that the prevalence of transverse ligament and posterior inferior tibiofibular ligament injuries in syndesmosis-injured ankles were 76.5 and 41.2%, respectively.

A Novel Operative Approach to the Treatment of Posterior Malleolus Fractures

Background: Posterior malleolar fractures are a common subtype of ankle fractures. The management of these fractures remains controversial, though there has been a move toward more operative management in recent years. The operative approach most commonly used to treat these fractures is posterolateral. This method has several drawbacks including the amount of retraction required on already traumatized skin, the risk of damaging the posterior interosseous tibio-fibular ligament, and the difficulty visualizing both the distal fibular and posterior malleolar fractures. We describe a novel operative approach for visualizing and treating these fractures and report on our results. Method: This was a retrospective review of prospectively collected data. Data from 2 orthopedic trauma units where this technique is used was analyzed. Demographic and radiographic data was recorded, and a chart review was conducted to identify any noted complications. Results: On analysis of medical records, 50 patients were identified who had been operated on using this technique. When classified using the Bartonicek classification, 46% were type II, 36% were type III and 18% were type IV. Analysis of final x-rays showed that there was no incidence of implant failure or loss of reduction in this cohort. There were 2 complications recorded: 1 early wound dehiscence and 1 late infection giving an overall complication rate of 4%. Discussion: The technique described in this paper is a novel approach, which we feel offers several benefits. We demonstrated that this technique is safe with an incidence of early complications lower than figures commonly quoted for standard care of this cohort of patients. Level of Evidence: Level IV—case series

Comparison of Suture-Button Fixation with Suture-Tape Augmentation and Trans-Syndesmotic Screw Fixation for Syndemosis Injury: A Biomechanical Study

Category:Ankle; Basic Sciences/BiologicsIntroduction/Purpose:The treatment of syndesmotic injuries with ankle fractures is controversial. The purpose of this study was to compare the biomechanical properties of suture-button fixation with suture-tape augmentation with those of screw fixation.Methods:Ten matched pairs of human cadaver specimens were subjected to suture-button fixation with suture-tape augmentation or screw fixation. Each specimen underwent initial intact physiologic loading, consisting of 10 cycles of axial loading with peak of 750N, 10 cycles of external torsional loading with peak of 7.5Nm, and 10 cycles of combined axial and external torsional loading with peak of 750N and 7.5Nm at 0.05 Hz. Injuries of the anterior inferior tibiofibular ligament, tibiofibular interosseous membrane, posterior tibiofibular ligament and medial malleolar fracture were applied to each specimen. Postfixation cyclic loading consisted of 50 cycles of combinedaxial and external rotation loading with peak torques of 750 N and 7.5 Nm at a rate of 0.05 Hz. After postfixation loading, each specimen underwent failure loading by external rotation at 0.25 degrees/second. Failure torque and failure angle were measured.Results:Mean failure torques were 15.99 +- 8.88 Nm in the suture-button fixation with suture-tape augmentation and 17.10 +- 10.38 Nm in the screw group. There was no significant difference in average failure torque between two groups (p-value = 0.669)Average failure angle in screw-fixation group (39.37 +- 10.19 deg) was significantly lower than average failure angle suture- button fixation with suture-tape augmentation (56.64 +- 9.64 deg) (p-value = 0.001).Average rotational stiffness in screw-fixation group (0.53 +- 0.24 Nm/deg) was significantly higher than average rotational stiffness in suture-button fixation with suture-tape augmentation group (0.35 +- 0.19 Nm/deg) (p-value = 0.033).Conclusion:Suture-button fixation with suture-tape augmentation for ankle syndesmotic injury provides similar torsional strength to that of screw fixation and has lower stiffness than screw fixation. Therefore, Suture-button fixation with suture-tape augmentation can be considered as an alternative treatment option for syndesmosis injury.

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.

Cadaveric Analysis of Exposure of the Talar Articular Surface Through the Posteromedial Approach

The purpose of this cadaveric study is to assess the talar articular surface visible through a modified posterior medial approach to the ankle joint for talar osteochondral defects. Ten fresh frozen cadaveric specimens were included. The talar surface area was outlined utilizing a marker. The talus was removed to measure the medial to lateral length and posterior to anterior length using a flexible ruler. A skin incision was made posterior to the medial malleolus. The incision was deepened through the flexor retinaculum. Dissection was carried between the posterior tibial and flexor digitorum longus tendons through the posterior tibial tendon sheath in order to access the posteromedial ankle joint. The posterior tibiofibular ligament should remain intact. A Hintermann distractor was then inserted to distract the ankle joint. The average articular cartilage visible from medial to lateral was 1.90 (68.6%) centimeters, while from posterior to anterior was 2.00 (43.6%) centimeters. Medial malleolar osteotomy is often required to visualize posteromedial talar osteochondral defects that are difficult to visualize with standard anterior ankle arthroscopy. Our study suggests that the modified posteromedial approach between the posterior tibial and flexor digitorum longus tendons and utilizing a Hintermann distractor allows for visualization of common posterior and central-medial lesions. When considering the anatomic 9-zone grid scheme proposed by Raikin etal, zone 4, 7, and 8 lesions can be assessed with this approach. A clinical study should be undertaken to evaluate the morbidity of this approach.

Open reduction and internal fixation of posterior malleolus fractures

Stabilization of the syndesmotic complex by open reduction and internal fixation (ORIF) of the posterior malleolus, restoration of the tibial articular surface, stability of the ankle, posterior tibiofibular ligament and the incisura tibiae, reduction of the fibula into the incisura tibiae by ligamentotaxis. Unstable ankle fractures (OTA/AO type 44-B3, C1.3, C2.3, C3.3) with involvement of the posterior malleolus (typeII-IV according to Bartoníček and Rammelt). Critical general condition, circulatory disorders, severe soft tissue swelling (if necessary, first external fixator), percutaneous treatment the better alternative. Positioning in unstable lateral position, dorsolateral approach dorsally of the peroneal tendons, incision of the superficial and deep fascia, retraction of the flexor hallucis longus tendon medially, visualization of the posterior malleolus, reduction and fixation. To treat the lateral malleolus fracture, preparation of afull-thickness flap above the peroneal tendons on the fibula, treatment according to AO principles. For the treatment of the medial malleolus positioning in supine position without changing the sterile covers, medial approach for the medial malleolus, wound closure. Sixweeks partial weight bearing (20 kg), early functional exercise, exercise of the flexor hallucis longus muscle; transition to full weight bearing after clinical and radiological follow-up after 6weeks RESULTS: Few clinical results on open ORIF of the posterior malleolus have been published. However, most studies found that ORIF resulted in better reconstruction of the distal articular surface and the tibial incisura, better reduction of the fibula into the tibial incisura, stabilization of the distal tibiofibular joint and better clinical results, regardless of fragment size, when compared to closed reduction or untreated fragments.

The posterior fibulotalocalcaneal ligament complex: a forgotten ligament

PurposeThe purpose of the present anatomical study was to define the exact morphology of the posterior fibulotalocalcaneal ligament complex (PFTCLC), both for a better orientation and understanding of the anatomy, especially during hindfoot endoscopy.MethodsTwenty-three fresh frozen specimens were dissected in order to clarify the morphology of the PFTCLC.ResultsIn all specimens, the ligament originated from the posteromedial border of the lateral malleolus between the posterior tibiofibular ligament (superior border) and the calcaneofibular ligament (CFL), (inferior border). This origin functions as the floor for the peroneal tendon sheath. The origin of the PFTCLC can be subdivided into two parts, a superior and inferior part. The superior part forms an aponeurosis with the superior peroneal retinaculum and the lateral septum of the Achilles tendon. From this structure, two independent laminae can be identified. The inferior part of the origin has no role in the aponeurosis and ligamentous fibres run obliquely to insert in the lateral surface of the calcaneus, in the same orientation as the CFL, but slightly more posterior, which was a consistent finding in all examined specimens. The PFTCLC is maximally tensed with ankle dorsiflexion and is located within the fascia of the deep posterior compartment of the leg.ConclusionsThe PFTCLC is part of the normal anatomy of the hindfoot and therefore should be routinely recognized and partly released to achieve access to the posterior ankle anatomical pathology, relevant for hindfoot endoscopy. The origin of the ligament complex forms the floor for the peroneal tendon sheath. The superior part of the origin plays a role in the formation of an aponeurosis with the superior peroneal retinaculum and the lateral septum of the Achilles tendon.

Arthroscopic Posterior Ankle Ligament Anatomy.

Background:The purpose of this article is to document the normal arthroscopic appearance of the posterior ankle capsular and ligamentous structures, and variations in their anatomical relationships.Methods:102 ankle arthroscopy videotapes were evaluated retrospectively for the configuration of the posterior capsuloligamentous structures. Based on these observations, the variations in the appearance and position of the posterior tibiofibular ligament (PTFL) and transverse (tibiofibular) ligament (TTFL) were documented. In addition, differences in the appearance of the flexor hallucis longus (FHL) were also noted.Results:All patients had evidence of both a PTFL and TTFL, which formed a labrum or meniscus-like addition to the posterior distal tibia. No patients demonstrated disruption of the PTFL; 3 had tears of the TTFL. We noted 4 distinct patterns of the PTFL and the TTFL. Thirty-four patients (33%) had a gap of ≥2 mm between the 2 ligamentous structures. Thirty-three (32.4%) had a gap <2 mm between the PTFL and TTFL. Twenty-six (25.5%) had a confluence of the 2 ligaments without a gap. Nine (9%) demonstrated a sizable gap between the 2 ligaments, and the TTFL appeared as a “cord-like” structure.Conclusion:To our knowledge, this is the first article to describe the variations in the arthroscopic normal posterior capsuloligamentous structures and FHL of the ankle.Level of Evidence:Level IV, case series.

The double fascicular variations of the anterior talofibular ligament and the calcaneofibular ligament correlate with interconnections between lateral ankle structures revealed on magnetic resonance imaging

The anterior talofibular ligament and the calcaneofibular ligament are the most commonly injured ankle ligaments. This study aimed to investigate if the double fascicular anterior talofibular ligament and the calcaneofibular ligament are associated with the presence of interconnections between those two ligaments and connections with non-ligamentous structures. A retrospective re-evaluation of 198 magnetic resonance imaging examinations of the ankle joint was conducted. The correlation between the double fascicular anterior talofibular ligament and calcaneofibular ligament and connections with the superior peroneal retinaculum, the peroneal tendon sheath, the tibiofibular ligaments, and the inferior extensor retinaculum was studied. The relationships between the anterior talofibular ligament’s and the calcaneofibular ligament’s diameters with the presence of connections were investigated. Most of the connections were visible in a group of double fascicular ligaments. Most often, one was between the anterior talofibular ligament and calcaneofibular ligament (74.7%). Statistically significant differences between groups of single and double fascicular ligaments were visible in groups of connections between the anterior talofibular ligament and the peroneal tendon sheath (p < 0.001) as well as the calcaneofibular ligament and the posterior tibiofibular ligament (p < 0.05), superior peroneal retinaculum (p < 0.001), and peroneal tendon sheath (p < 0.001). Differences between the thickness of the anterior talofibular ligament and the calcaneofibular ligament (p < 0.001), the diameter of the fibular insertion of the anterior talofibular ligament (p < 0.001), the diameter of calcaneal attachment of the calcaneofibular ligament (p < 0.05), and tibiocalcaneal angle (p < 0.01) were statistically significant. The presence of the double fascicular anterior talofibular ligament and the calcaneofibular ligament fascicles correlate with connections to adjacent structures.

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 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.

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.

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.

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.