Syndesmotic Ankle Research Articles

Return to Play after High Ankle Sprains in Athletes: A Systematic Review and Meta-Analysis

Category: Sports Introduction/Purpose: Syndesmotic ankle sprains, or high ankle sprains, are a challenging lower extremity injury, especially among high level athletes. The management of such injuries is still controversial, with a paucity of evidence on treatment protocols and unpredictability regarding the time lost to participate in sports following injury. Full recovery and return to play for syndesmotic injuries has been reported to require more than twice the time compared to standard, lateral ankle sprains The goal of this systematic review and meta-analysis was to provide orthopedic surgeons with the most updated evidence on high ankle sprains in athletes. Our primary objective was to report updated prevalence and time to return to play (RTP) after surgical or non-surgical management of syndesmotic injuries. Methods: A meta-analysis and systematic review of the literature was performed with adherence to the preferred reporting items for systematic reviews and meta analyses (PRISMA) guidelines. PubMed, Cochrane Library, and Google Scholar were queried in August 2021 for case series, cohorts, and randomized controlled trials that evaluated return to play time after ankle syndesmotic sprains. The primary outcome was the injury prevalence and time to RTP. Secondary outcomes were complications, functional outcomes, as well as recurrent injuries and reoperations after the initial management of an ankle syndesmotic sprain with no associated ankle fracture. To assess risk of bias, the Joanna Briggs institute critical appraisal tool was used for case series, the Newcastle Ottawa scale for comparetive studies and Rob2 for randomized clinical trials. Results: 18 articles were eligible for meta-analysis with a total of 1133 syndesmotic sprains. Four studies managed their patients with surgical intervention, nine articles reported non-surgical management, and three articles used both surgical and non-surgical methods. Two studies did not specify management method. The overall RTP was 99% (95% CI 0.96, 1.00), the overall mean RTP was 52.32 days (95% CI 39.01, 65.63). Pooled RTP for surgically treated patients was 70.94 days (95% CI 47.04, 94.85, while it was 39.33 days (95% CI 28.78, 49.88) for non-surgically treated cases. A low incidence of recurrence and complications were reported. Moreover platelet rich plasma injection was found to decrease the time needed to return to play in atheletes with high grade syndesmotic injuries. Conclusion: This systematic review and meta-analysis showed high rates of return to play after syndesmotic sprains in professional athletes regardless of surgical vs non-surgical treatment with surgically treated athletes needing more time to return to play compared to those treated non-surgically. Platelet rich plasma injections are safe and may improve time to RTP. Future comparative studies with larger sample size and subanalyis of grade of syndesmotic injury are required for better assessment of outcomes and complications.

Biomechanics comparison between endobutton fixation and syndesmotic screw fixation for syndesmotic injury ankle fracture; a finite element analysis and cadaveric validation study

IntroductionVarious syndesmotic fixation methods in ankle injury are recommended; however, a lack of biomechanical information persists regarding the stiffness of the fixation methods. The current study thus aimed to assess biomechanical cadaveric validation and perform a finite element analysis of syndesmotic fixation comparing endobutton vs. screw after syndesmotic injury with an ankle fracture. MethodFive pairs of ankles of fresh cadavers were used for the validity test for Anterior Inferior Tibiofibular Ligament (AITFL), Posterior Inferior Tibiofibular Ligament (PITFL), and Interosseous ligament biomechanics properties. Four finite element models (FEM) were created: an intact model, a fracture model with/without syndesmotic injury, an endobutton fixation model, and a syndesmotic screw fixation model. Each FEM was tested vis-à-vis external rotation force, anteroposterior translation force, and compression force until model failure. The primary outcomes were stiffness and force until failure. ResultThe respective anteroposterior translation force for the stiffness of the intact model, the screw fixation model, and the endobutton fixation was 8.14, 9.15, and 8.17 N/mm. The respective external rotation force for the stiffness of intact, screw fixation, and endobutton model was 0.927,0.949, and 0.940 Nm/degree. The respective stress under compression force in the intact, screw fixation, and endobutton model was 39.94,25.59, and 37.30 MPa. ConclusionBoth screw and endobutton fixation models provided more translation, compression, and rotation stability than normal syndesmosis, but the screw model provided greater translation and compression force stability than the endobutton model. There was no difference in rotational stability between the two models. We thus recommend the same rehabilitation protocol for both fixation methods; however, vigorous translation and compression should be avoided when using endobutton fixation.

Syndesmotic Disruption with Distal Fibular Fracture Among the Football Players of Manipur: A Case Series

Football is one of the most popular sports in Manipur. Ankle joint is frequently injured in contact sports like football. Syndesmotic ankle sprains are less common than typical ankle sprain; but are associated more often with significant morbidity and need for surgical treatment. It leads to prolonged loss of sports activities. Fracture of fibula is commonly associated with syndesmotic disruption. Here we present three cases of syndesmotic disruption with distal fibular fracture in football players presented to Sports Medicine OPD RIMS. They have presented with pain and swelling around the ankle joint following twisting injuries. Diagnosis was made from X-ray findings correlated with clinical examinations. All are treated surgically by open reduction and internal fixation with syndesmotic screw fixation, but one case without syndesmotic screw fixation. The patients followed an early functional rehabilitation program followed by sports specific exercises. They have returned to their previous sports activity within 6 months. Keywords: Football, Syndesmotic ankle sprains, Distal fibula Fracture

CORR Insights®: Can Weightbearing Cone-beam CT Reliably Differentiate Between Stable and Unstable Syndesmotic Ankle Injuries? A Systematic Review and Meta-Analysis.

CORR Insights®: Can Weightbearing Cone-beam CT Reliably Differentiate Between Stable and Unstable Syndesmotic Ankle Injuries? A Systematic Review and Meta-Analysis.

Return to Play After Isolated Syndesmotic Ligamentous Injury in Athletes: A Systematic Review and Meta-analysis.

Background:Syndesmotic ankle sprains are common and challenging injuries for athletes. The management of such injuries is controversial, with a paucity of evidence on treatment protocols with unpredictability regarding the time lost to participate in sports following injury. The present study seeks to review and report the return to play (RTP) time and examine the outcomes and complications of ankle syndesmotic sprains in the athletic population.Methods:PubMed, Cochrane Library, and Google Scholar were queried in August 2021 for case series, cohorts, and randomized controlled trials that evaluated return to play time after ankle syndesmotic sprains. The primary outcomes were the rate and time to return to play after syndesmotic ankle sprains for both surgical and nonsurgical treatment. Secondary outcomes included short-term complications and recurrence.Results:Eighteen articles were eligible for meta-analysis with a total of 1133 syndesmotic sprains. The overall RTP was 99% (95% CI 0.96, 1.00), the overall mean RTP was 52.32 days (95% CI 39.01, 65.63). Pooled RTP for surgically treated patients was 70.94 days (95% CI 47.04, 94.85), whereas it was 39.33 days (95% CI 28.78, 49.88) for nonsurgically treated cases. A low incidence of recurrence and complications were reported.Conclusion:This article reports a high rate of RTP after syndesmotic sprains. Grade of injury and surgical vs conservative management can affect the time to RTP in high-level athletes.Level of Evidence: Level IV, systematic review and meta-analysis.

Statistical shape model-based tibiofibular assessment of syndesmotic ankle lesions using weight-bearing CT.

Forced external rotation is hypothesized as the key mechanism of syndesmotic ankle injuries, inducing a three-dimensional deviation from the normal distal tibiofibular joint (DTFJ) alignment. However, current diagnostic imaging modalities are impeded by a two-dimensional assessment, without considering ligamentous stabilizers. Therefore, our aim is threefold: (1) to construct an articulated statistical shape model of the normal DTFJ with the inclusion of ligamentous morphometry, (2) to investigate the effect of weight-bearing on the DTFJ alignment, and (3) to detect differences in predicted syndesmotic ligament length of patients with syndesmotic lesions with respect to normative data. Training data comprised non-weight-bearing CT scans from asymptomatic controls (N = 76), weight-bearing CT scans from patients with syndesmotic ankle injury (N = 13), and their weight-bearing healthy contralateral side (N = 13). Path and length of the syndesmotic ligaments were predicted using a discrete element model, wrapped around bony contours. Statistical shape model evaluation was based on accuracy, generalization, and compactness. The predicted ligament length in patients with syndesmotic lesions was compared with healthy controls. With respect to the first aim, our presented skeletal shape model described the training data with an accuracy of 0.23 ± 0.028 mm. Mean prediction accuracy of ligament insertions was 0.53 ± 0.12 mm. In accordance with the second aim, our results showed an increased tibiofibular diastasis in healthy ankles after weight-bearing. Concerning our third aim, a statistically significant difference in anterior syndesmotic ligament length was found between ankles with syndesmotic lesions and healthy controls (p = 0.017). There was a significant correlation between the presence of syndesmotic injury and the positional alignment between the distal tibia and fibula (r = 0.873, p < 0,001). Clinical Significance: Statistical shape modeling combined with patient-specific ligament wrapping techniques can facilitate the diagnostic workup of syndesmosic ankle lesions under weight-bearing conditions. In doing so, an increased anterior tibiofibular distance was detected, corresponding to an "anterior open-book injury" of the ankle syndesmosis as a result of anterior inferior tibiofibular ligament elongation/rupture.

Can Weightbearing Cone-beam CT Reliably Differentiate Between Stable and Unstable Syndesmotic Ankle Injuries? A Systematic Review and Meta-analysis.

Ankle injuries are common presentations to the emergency department and may lead to syndesmotic instability. These have a high socioeconomic burden due to prolonged rehabilitation, chronic pain, and posttraumatic arthritis. Early diagnosis is essential to minimize these complications, and the assessment of instability in the clinical setting is often limited by pain and clinician experience. Cross-sectional imaging of the distal syndesmosis accurately evaluates the syndesmosis through abnormal bony relationships, which in the presence of instability, worsens during physiological loading. Cone-beam CT (CBCT) has gained popularity in the diagnosis of these injuries because it enables syndesmotic assessment under weightbearing conditions, it mitigates the high radiation dose, and it is time-efficient. The purposes of this systematic review were: (1) to establish normal values for weightbearing CBCT of the syndesmosis in uninjured ankles and ascertain interobserver reliability and (2) to identify the impact of weightbearing on the syndesmosis in patients with occult ankle injuries and assess the effect of patient demographics on these metrics. This systematic review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and registered in PROSPERO (ID CRD42021248623). MEDLINE, PubMed, Embase, and Emcare databases were searched for studies assessing for syndesmotic instability, of which 307 studies were screened and 11 studies with 559 ankles in 408 uninjured patients and 151 patients with syndesmotic instability were included. All patients 18 years of age or older presenting with unilateral ankle injuries who underwent weightbearing CBCT for the diagnosis of an occult fracture or syndesmotic instability compared with the uninjured contralateral side were included. A control group of uninjured ankles was identified during weightbearing CBCT performed for other indications such as forefoot or midfoot injuries. Methodological assessment of the studies was performed using the Risk of Bias In Non-randomized Studies (ROBINS-1) tool and most included studies had a low risk of bias. Thus, a random-effects restricted maximum likelihood ratio model was used. In the uninjured ankle, the mean area of the tibiofibular syndesmosis was 112.5 ± 7.1 mm 2 , which increased to 157.5 ± 9.6 mm 2 after injury when compared with uninjured ankles with a standardized mean difference of 29.5 (95% confidence interval 19.5 to 39.5; p < 0.01), and an excellent interobserver agreement (κ = 1.0 [95% CI 0.9 to 1.0]). However, syndesmosis volume decreased with age (β = -0.76; p = 0.04), and therefore, has a negative association with increasing age. Our study has shown that the syndesmotic area is the most reliable parameter in the assessment of syndesmotic injuries because it increases in the presence of instability during weightbearing status. It is a composite measurement that could potentially allow clinicians to use weightbearing CBCT as an adjunct when there is a clinical suspicion of syndesmotic instability. Thus, weightbearing CBCT has the potential of being diagnostic of syndesmotic instability and should be evaluated against current radiological modalities to evaluate its accuracy. Level IV, prognostic study.

29 Ankle Syndesmotic Injury: Tightrope vs Screw Fixation, a Clinical Academic Survey

Abstract Aim Unstable syndesmotic ankle injury requires surgical management in the form of screw or tightrope fixation. However, the superiority of one technique over the other remains debatable. Our Study aims to identify the fixation of choice in unstable ankle syndesmotic injury based on the surgeon’s level of experience. Methods A survey was undertaken to analyse the management of ankle syndesmotic injuries AO 44c in a 35-year-old patient. Surgeons attending an orthopaedic course were invited to participate in a survey categorised into groups: junior surgeons, middle grades and experienced. X-ray was shown to the 100 participants and treatment options were asked. Results 100 surgeons from 20 nations took part in the event. Juniors made up 39%, registrars 38% and experienced surgeons were 29%. 93% chose screw fixation, out of which 66% favoured a single screw over two screws. 3–4 cortices were virtually evenly divided in choice, with 54 % preferring three and 46% preferring four cortices. Only 22% of the time did they utilise a washer with screws. 52% of the surgeons allowed weight-bearing 4 to 6 weeks after surgery. 34% preferred to remove the screw at 1–2 months and 29% at 2–3 months post-operatively. Conclusions Data show that majority of junior level doctors manage their patients according to AO principles. The majority prefer one 3.5mm screw positioned between 2–4 cm above the ankle joint, with three cortices being somewhat preferred. Despite the lack of data to support one procedure, the majority of people remove their screws within 1 to 3 months.

Anterior-Inferior Tibiofibular Ligament Suture-Tape Augmentation for Isolated Syndesmotic Injuries

Category:Sports; AnkleIntroduction/Purpose:Aggressive surgical treatment of isolated syndesmotic injuries has recently gained some traction in the media and sports world. New developments in syndesmotic fixation aim to restore native syndesmotic stability and ankle motion with a goal of returning athletes to sport quickly. However, the best surgical technique is debated. Dynamic repair with a suture- button (SB) can provide an accurate reduction of the syndesmotic space but may alter the rotational kinematics of the fibula. Previous studies have suggested that repair or reconstruction of the anterior-inferior tibiofibular ligament (AITFL) may restore the dynamics of the syndesmosis better than other devices. The purpose of this study was to biomechanically compare SB fixation and augmented repair of the AITLF using suture and suture-tape (ST) in isolated syndesmotic injuries.Methods:Twelve unpaired lower leg specimens underwent biomechanical testing in 6 states: 1) intact, 2) AITFL suture repair alone, 3) AITFL suture repair + ST augmentation, 4) AITFL suture repair + ST augmentation + SB fixation, 5) AITFL suture repair + SB fixation, and 6) complete syndesmotic injury. The testing consisted of subjecting the ankle joint to 6 cycles of 5 Nm internal and external rotation torque under a constant 750 N axial compression load in a dynamic tensile testing machine. A lower level of torque was chosen than in previous studies in order to replicate physiologic motion of everyday activities instead of injury level forces. The spatial relationship between the tibia and fibula and tibia and talus was continuously recorded using a 5-camera motion capture system.Results:AITLF suture repair and suture repair + ST augmentation repair constructs showed no statistically significant change in fibula kinematics during testing compared to the intact state. The suture repair + SB construct showed increased external rotation of the fibula (p<0.001, mean 2.32 degrees) and medial translation (mean 0.72 mm, p= 0.007) or overtightening compared to the intact state. The suture repair + SB + ST augmentation state also showed increased external rotation of the fibula compared to the intact state (p<0.001). Sagittal plane motion of the fibula was not significantly different in the repair states compared to the intact state. None of the repair states restored talus rotation back to the intact state; however, the repairs that utilized suture tape reduced the talus external rotation laxity compared to the complete syndesmotic injury.Conclusion:For isolated syndesmotic injuries without significant fibular displacement, augmentation of the AITFL with suture- tape best restored the rotational profile of the fibula and ankle joint. Suture-button constructs had a tendency to over-tighten and externally rotate the fibula when compared to the intact state. Suture-tape AITFL augmentation may be a good surgical option and alternative to suture-button fixation for isolated syndesmotic disruptions. Further clinical trials are needed to determine the role for suture-tape augmentation of the AITLF in syndesmotic injuries.

Short-Term Effect of Manual Therapy & Taping on Subacute Ankle Sprains with Potential Syndesmotic Sprain: A Case Series

ABSTRACT Study Design Case Series Background Syndesmotic ankle sprains can occur in up to 17% of ankle trauma and can lead to long-term disability. This study describes the management of seven patients with subacute, high-grade ankle sprains with concerns of concurrent syndesmotic strain utilizing manual therapy and rigid sports taping. Methods Seven active duty military members with clinically diagnosed, high-grade ankle sprains and concern for syndesmotic sprain participated in this case series. All patients received multi-modal treatment consisting of manual therapy, rigid sports taping, progressive exercises, and proprioceptive training. Decrease in Numeric Pain Rating Scale (NPRS) following manual therapy and taping treatment, number of sessions before discharge, and the Global Rating of Change (GROC) at discharge were retrospectively reviewed. Results All patients demonstrated an immediate decrease in NPRS following treatment on average of 5 points (range, 3–8 points) with a functional asterisk sign. The improvement in pain and function was maintained until the next treatment session with a mean GROC score of +3. The mean time until recovery was 5.4 weeks (range, 1–8 weeks). Discussion A multimodal approach for patients diagnosed clinically with high-grade ankle sprains and concern for syndesmotic sprain was useful to immediately reduce pain and improve function, and improvements were maintained throughout the duration of care. This study is the first to assess a combination of manual therapy and rigid sports taping for the treatment of suspected syndesmotic ankle sprains, and more stringent research is needed to validate the findings. Level of Evidence Therapy, 4

Ankle and syndesmosis instability: consensus and controversies.

Ankle sprains are mainly benign lesions, but if not well addressed can evolve into permanent disability. A non-treated lateral, syndesmotic or medial ankle instability can evolve into ankle osteoarthritis. For this reason, diagnosis and treatment of these entities is of extreme importance.In general, acute instabilities undergo conservative treatment, while chronic instabilities are better addressed with surgical treatment. It is important to identify which acute instabilities are better treated with early surgical treatment.Syndesmosis injuries are frequently overlooked and represent a cause for persistent pain in ankle sprains. Unstable syndesmotic lesions are always managed by surgery.Non-treated deltoid ligament ruptures can evolve into a progressive valgus deformity of the hindfoot, due to its links with the spring ligament complex. This concept would give new importance to the diagnosis and treatment of acute medial ligament lesions.Multi-ligament lesions are usually unstable and are better treated with early surgery. A high suspicion rate is required, especially for combined syndesmotic and medial lesions or lateral and medial lesions.Ankle arthroscopy is a powerful tool for both diagnostic and treatment purposes. It is becoming mandatory in the management of ankle instabilities and multiple arthroscopic lateral/syndesmotic/medial repair techniques are emerging.Cite this article: EFORT Open Rev 2021;6:420-431. DOI: 10.1302/2058-5241.6.210017

785 Ankle Fractures Management in Stoke Mandeville Hospital

Abstract Introduction Ankle fractures treatment aims to restore joint stability and alignment to achieve full functional recovery. Current quality of care in Stoke Mandeville Hospital was compared to the gold-standard management approach as described in BOAST-12 guidelines. Method This closed loop audit looked at closed malleolar and syndesmotic ankle injuries in skeletally mature patients under Trauma and Orthopaedics. In the first audit cycle, 16 patients were included over a one-month period and 53 cases, with similar management, were identified over a three-month period for the second audit cycle. Results The initial audit cycle revealed that the main aspects of management that required improvement were the timing of reduction and splinting, as well as the documentation of neurovascular status post-reduction. We discussed our findings at the clinical governance meeting and interventional posters were distributed around the hospital. Documentation of the timing of reduction and splinting significantly increased from 6% to 85% post-interventions, and neurovascular examination post-reduction improved from 17% to 43%. All other quality assessment criteria recorded more than 90% documentation rates after implementation of changes. Conclusions Quality of care significantly improved post-interventions, which indicates that BOAST-12 gold-standard is achievable. The introduction of a proforma was suggested to further facilitate appropriate documentation.

Functional outcome of surgical management of ankle fractures with syndesmotic injury

Background: Ankle fractures with Syndesmotic injury are common in Orthopaedic practice. Ankle fractures are the second most common significant lower extremity fractures. Syndesmotic ankle injuries disrupt normal joint functioning, hence need meticulous diagnosis and surgical management to prevent crippling disabilities. Objective: To evaluate the functional outcome of surgically managed ankle fractures with Syndesmotic injury using AOFAS score. Materials and Methods: In this study, 40 patients diagnosed as ankle fractures with Syndesmotic injury, underwent Syndesmotic screw fixation using 3.5mm cortical screws in addition to anatomical fixation of medial and lateral malleolus. Functional outcome was analyzed at 6 months using AOFAS score. Results: In this study, 42.5% (17 patients) of patients had excellent outcome, 45% (18 patients) patients had good outcome, 7.5% (3 patients) had fair outcome, while 5% (2 patients) had poor outcome. 2 patients developed superficial wound infection, treated with IV antibiotics. One patient developed non union and one patient with ankle stiffness. Conclusion: For all cases of Ankle fractures with Syndesmotic injury, open reduction and internal fixation of ankle fracture with Syndesmotic screw fixation helped to achieve good union of fractures and pain free, stable ankle joint.

Evaluation of ankle ligaments with CT: A feasibility study

PurposeThis study aims to systematically investigate if normal ankle ligaments can be assessed with CT imaging, using MRI as reference standard. Methods35 patients (mean age: 47 ± 15 years; female n = 19) with combined CT and MRI exams and without MR-morphologic signs of ankle ligamental injury were retrospectively identified. 3 readers independently evaluated the syndesmotic, the lateral and medial ankle ligaments in terms of visibility on a 4-point Likert scale (0–3 points) in multiplanar MDCT images in standard bone kernel reconstructions. In consensus CT-based ligament density and thickness were measured and the appearance was rated for each ligament. Results were compared and validated with corresponding MRI images. ResultsAlmost all ankle ligaments identified in MRI images could be adequately depicted in standard multiplanar bone kernel CT images with a mean visual score of 2.7/3 (± 0.2). Difficulties in CT morphological delineation of ankle ligaments occurred in cases of filiform TNL and TCL and in cases of concurrent soft tissue edema. Interreader agreement for the CT-assessment of ankle ligaments was excellent, with Fleiss Kappa values >0.8. Mean density of evaluated medial and lateral ankle ligaments was 68 ± 2.9 HU, with substantially inter- and intraindividual variations. Thickness measurements and assessment of appearance of ankle ligaments showed a good concordance between CT and MRI. ConclusionsAssessment of normal ankle ligaments via standard CT in bone kernel reconstructions is feasible, with some restrictions concerning the medial collateral ligaments and in the presence of soft tissue edema.

Morphometric analysis of the incisura fibularis in patients with unstable high ankle sprains.

The role of the syndesmotic ankle ligaments as extrinsic stabilizers of the distal tibiofibular joint (DTFJ) has been studied extensively in patients with high ankle sprains (HAS). However, research concerning the fibular incisura as intrinsic stabilizer of the DTFJ has been obscured by a two-dimensional assessment of a three-dimensional structure. Therefore, we aimed to compare the morphometry of the incisura fibularis between patients with HAS and a control group using three-dimensional radiographic techniques. Fifteen patients with a mean age of 44years (SD = 15.2) diagnosed with an unstable HAS and twenty-five control subjects with a mean age of 47.4years (SD = 6.5) were analyzed in this retrospective comparative study. The obtained CT images were converted to three-dimensional models, and the following radiographic parameters of the incisura fibularis were determined using three-dimensional measurements: incisura width, incisura depth, incisura height, incisura angle, incisura width-depth ratio, and incisura-tibia ratio. The mean incisura depth (M = 4.7mm, SD = 1.1mm), incisura height (M = 36.1mm, SD = 5.3mm), and incisura angle of the control group (M = 137.2°, SD = 7.9°) differed significantly from patients with a HAS (resp., M = 3.8mm, SD = 1.1mm; M = 31.9mm, SD = 3.2mm; M = 143.2°, SD = 8.3°) (P <0.05). The incisura width, incisura width-depth ratio, and incisura-tibia ratio demonstrated no significant difference (P >0.05). Our three-dimensional comparative analysis has detected a shallower and shorter fibular incisura in patients with HAS. This distinct morphology could have repercussion on the intrinsic or osseous stability of the DTFJ. Future prospective radiographic assessment could determine to what extend the fibular incisura morphology contributes to syndesmotic ankle injuries caused by high ankle sprains.

Bilateral Comparison of the Three-dimensional Configuration in the Normal Ankle Syndesmosis: A non-Weightbearing and Weightbearing CT-analysis

Category:AnkleIntroduction/Purpose:Syndesmotic ankle injuries can be present in up to one-fifth of all ankle trauma and may lead to syndesmotic instability or posttraumatic ankle osteoarthirtis on the long term. It remains challenging to distinguish syndesmotic ankle injuries from other types of ankle trauma. Currently, diagnosis is based on plain radiographs by comparing 2D measurements of the injured to the non-injured side. However, it is unclear to what extent the 3D configuration of the normal ankle syndesmosis is symmetrical during non- or weightbearing conditions. Therefore, our aim was two-fold (1) to establish reference values based on three-dimensional side-to-side comparison of the normal ankle syndesmosis imaged by a non-weightbearing (NWBCT) and weightbearing CT (WBCT) (2) to compare measurements obtained from a NWBCT with those of a WBCT.Methods:In this retrospective comparative cohort study, patients with a NWBCT (N=38; Mean age=51+-17.4 years) and WBCT (N=43; Mean age=48+-14.3 years) were analyzed. Inclusion criteria were a bilateral NWBCT or WBCT of the foot and ankle between January 2016 and December 2018. Exclusion criteria consisted of hindfoot pathology and an age <18 years or >75 years. CT images were segmented to obtain 3D models. Computer Aided Design (CAD) operations were used to mirror the left ankle and superimpose it over the right ankle (Fig. 1A). The apex of the lateral malleolus (AML), anterior tubercle (ATF) and posterior tubercle (PTF) were determined. The difference in the coordinates attached to these anatomical landmarks of the left distal fibula in the ankle syndesmosis with respect to the right were used to establish reference values within two standard deviations. The Mann-Whitney U-test was used to compare measurements from a NWBCT with a WBCT.Results:Reference values within two standard deviations are given for each 3D measurement derived from a NWBCT and WBCT-scan (Fig 1B). The highest difference in translation was detected in the anterior-posterior direction (Mean APNWBCT= 0.161mm; 2SD=3.212/ Mean APWBCT= -0.082mm; 2SD=2.374). The highest difference in rotation was detected in the external- internal direction (Mean EINWBCT= -0.484°; 2SD=8.720/ Mean EIWBCT= -0,326°; 2SD=5.370). None of these differences were statistically significant in the normal ankle syndesmosis when obtained from a NWBCT scan compared to a WBCT scan (P>0.05).Conclusion:This study provides reference values of the three-dimensional configuration in the normal ankle syndesmosis based on side-to-side comparison. It did not demonstrate significant differences in the normal ankle syndesmosis between NWBT and WBCT scans. These novel 3D data contribute relevantly to previously established bilateral 2D radiographic reference values. In clinical practice, they will aid in distinguishing if a patient with a syndesmotic ankle lesion differs from normal variance in syndesmotic ankle symmetry.

Diagnosing the Impact of the Syndesmotic Injury on Lateral Ankle Stability using Dynamic Ultrasound

Category:Ankle; Basic Sciences/Biologics; Sports; TraumaIntroduction/Purpose:There is a high prevalence of coexisting lateral ankle ligament injuries and syndesmotic ligamentous injuries. However, it is unclear whether syndesmotic ligaments directly contribute toward the stability of the lateral ankle.Dynamic ultrasonography (US) is an imaging modality increasingly used for the care of orthopaedic foot and ankle patients because it allows dynamic evaluation of structures at the point of care with little risk to the patient and at low-cost. The aim of this study is to assess the effect of syndesmotic injury as well as combined syndesmotic and lateral ankle injury on the stability of the lateral ankle.Methods:Sixteen fresh frozen above-knee amputated cadaveric specimens, divided into two groups, underwent ultrasound evaluation for lateral ankle stability. In both the groups, the assessment was first done with all ligaments intact and later with sequential transection of anterior inferior tibiofibular ligament (AITFL), interosseous ligament (IOL), posterior inferior tibiofibular ligament (PITFL), anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL) and posterior talofibular ligament (PTFL). In all scenarios, two loading conditions were considered: (1) Anterior drawer test: 50N and 80N and (2) Lateral clear space (LCS): 1.7Nm torque. The talar translation and LCS to the fixed tibial plafond were measured using Image J. Wilcoxon rank-sum test was used to compare the findings of each ligamentous transection state to the intact state. A p-value <0.05 was considered statistically significant.Results:In group 1 after transection of the all syndesmotic ligament and ATFL, an increase in the anterior drawer and lateral clear space values were found as compared to the intact state. Similarly, in group 2 the anterior drawer and lateral clear space values significantly increased after transection of the AITFL and ATFL as compared to the intact state (p-values = 0.01).Conclusion:Ultrasound can be used to evaluate the impact of the syndesmotic injury on lateral ankle stability while performing dynamic stress maneuvers. Lateral ankle instability appears after injury to all syndesmotic ligaments and ATFL, or after one syndesmotic ligament rupture (AITFL) with a concomitant anterior talofibular ligament rupture (ATFL). These findings suggest that surgeons should lower their threshold for stabilizing the syndesmosis if there is a concomitant lateral ankle ligament injury.

Dynamic Evaluation Of The Effect Of Syndesmotic Injury On Lateral Ankle Stability Using Fluoroscopy

Category:Ankle; Sports; TraumaIntroduction/Purpose:There is a high incidence of concomitance between lateral ankle ligament injuries and syndesmotic ligamentous injuries. However, it is unclear whether syndesmotic ligaments directly contribute toward the stability of the lateral ankle. Stress radiographs are an accepted technique to assess the degree of lateral ankle instability by providing a static view of the ankle when subjected to the anterior drawer (AD) and talar tilt (TT) tests. The aim of this study is to assess the effect of syndesmotic injury as well as combined syndesmotic and lateral ankle injury on the stability of the lateral ankle.Methods:Sixteen fresh frozen above-knee amputated cadaveric specimens, divided into two groups, underwent fluoroscopic evaluation for lateral ankle stability. In both the groups, the assessment was first done with all ligaments intact and later with sequential transection of anterior inferior tibiofibular ligament (AITFL), interosseous ligament (IOL), posterior inferior tibiofibular ligament (PITFL), anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL) and posterior talofibular ligament (PTFL). In all scenarios, two loading conditions were considered: (1) Anterior drawer test: 50N and 80N and (2) Talar tilt and Lateral clear space (LCS): 1.7Nm torque. The talar translation, talar tilt, and LCS were measured using Image J. Wilcoxon rank-sum test was used to compare the findings of each ligamentous transection state to the intact state. A p-value <0.05 was considered statistically significant.Results:In group 1 after transection of the AITFL and IOL, an increase in the anterior drawer, talar tilt, and lateral clear space values was found as compared to the intact state. Similarly, in group 2 the anterior drawer, talar tilt, and lateral clear space values significantly increased after transection of the AITFL and ATFL as compared to the intact state (p-values = 0.001).Conclusion:Lateral ankle instability appears after injury to two syndesmotic ligaments (AITFL and IOL), or after one syndesmotic ligament rupture (AITFL) with a concomitant anterior talofibular ligament rupture (ATFL). These findings suggest that surgeons should lower their threshold for stabilizing the syndesmosis if there is a concomitant lateral ankle ligament injury.

Return to play after surgery for isolated unstable syndesmotic ankle injuries (West Point grade IIB and III) in 110 male professional football players: a retrospective cohort study

ObjectivesTo evaluate time to return to play following surgical stabilisation of isolated unstable syndesmosis injuries in a cohort of professional male football players.MethodsAll professional football players undergoing surgery for isolated...

Classification and treatment of lateral malleolar fractures - a single-center analysis of 439 ankle fractures using the Swedish Fracture Register

BackgroundThe decision regarding which trans syndesmotic ankle fractures to treat surgically and which to treat non-surgically is a matter of debate. The aim of this study was to describe the epidemiology of ankle fractures treated at Sahlgrenska University Hospital (SU) during a 2-year period and analyze the current diagnostic process, classification and choice of treatment for lateral malleolar fractures at the level of the syndesmosis.MethodsObservational data regarding all ankle fractures treated at SU between 1 April 2012 and 31 March 2014 was collected from the Swedish Fracture Register. For identified AO/OTA44-B1 fractures, medical records and radiographs were reviewed and analyzed.ResultsThe study included 1332 ankle fractures. 838 (63%) were B-fractures and 512 (38%) of these were B1 fractures. 439 of the patients with B1 fractures were included in the detailed study and of these 309 (70%) were treated non-surgically and 130 patients (30%) surgically. According to the preoperative physical examination described in the medical records, medial tenderness was found in 73 (24%) of the non-surgically treated patients. Among the surgically treated patients 18% (n = 24) were found to have no medial tenderness. For the non-surgically treated patients with medial tenderness, the treatment plan was changed to surgical treatment after the 1-week radiographic follow-up in 1 patient (1%) and 1 patient (1%) was treated surgically after 3 months due to non-union.ConclusionsThe current study demonstrates the difficulty involved in distinguishing whether or not a trans-syndesmotic lateral malleolar fracture has an associated medial ligament injury or not. As this distinguishes if the fracture is stable or not it affects the choice of subsequent treatment. The results of the study also indicate a lack of consensus on how to classify and treat lateral malleolar fractures at the level of the syndesmosis. The study further suggests that there is no need to check non-surgically treated stable fractures with follow-up radiographic examination at 1 week.