Treatment results in severe lateral ligament injury of the ankle based on talar tilt angle

Category: Ankle, Sports, Trauma Introduction/Purpose: Acute ankle ligament injuries are usually treated non-operatively, even if the injury is severe. However, when chronic ankle instability is symptomatic, operative treatment is required. When planning local repair, the condition of the remaining ligament is important. We surgically treated acute severe lateral ligament injuries in 103 ankles and investigated the locations of the injuries in the anterior talofibular (ATF) and calcaneofibular (CF) ligaments, subdividing each into three parts. This paper should facilitate more precise planning of the surgical reconstruction procedure. Methods: From 2006 to 2014, 1,042 patients visited our outpatient clinic with a diagnosis of acute lateral ligament injury of the ankle. In total, 103 feet underwent surgical treatment and the locations of the ATF and CF ligament ruptures were investigated. The rupture location in the ATF ligament was subclassified as fibular side, body, or talar side, while for the CF ligament it was classified as fibular side, body, or calcaneal side. Results: The ATF ligament was ruptured on the fibular side in 38 feet (36.9%), body in 30 feet (29.1%), and talar side in 35 feet (34.0%). The CF ligament was ruptured on the fibular side in 15 feet (14.6%), body in 26 feet (25.2%), and calcaneal side in 62 feet (60.2%). Conclusion: Almost all surgical reports on lateral ligament reconstruction procedures (Brostrom et al.) describe ATF ligament repair and advancement on the fibular side, although only one-third of the ligaments were injured on the fibular side in our series. About two-thirds of the CF ligaments had damage to the calcaneal side structure of the entheses. When CF ligament repair is needed, surgeons should be aware of our finding that this ligament was ruptured at the fibular attachment in only 15% of cases, and on the calcaneal side in 60%. This knowledge should lead to better results of surgical reconstruction.

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The Broken “Ring of Fire”: A New Radiological Sign as Predictor of Syndesmosis Injury?

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967117695064 ◽

2017 ◽

Vol 5 (3) ◽

pp. 232596711769506 ◽

Cited By ~ 4

Author(s):

James Calder ◽

Adam Mitchell ◽

Adam Lomax ◽

Moez S. Ballal ◽

John Grice ◽

...

Keyword(s):

Ankle Joint ◽

Distal Tibia ◽

Interosseous Membrane ◽

Ligament Injury ◽

Lateral Ligament ◽

Ankle Sprains ◽

Radiological Sign ◽

Syndesmosis Injury ◽

Significant Difference ◽

Lateral Ligament Injury

Background: Subcircumferential periosteal edema above the ankle joint is frequently present on magnetic resonance imaging (MRI) with syndesmosis injuries but has not been previously reported. Fluid height within the interosseous membrane also has not previously been shown to be associated with syndesmosis injury severity. Purpose: To investigate whether a new sign on MRI and measurement of the length of fluid within the interosseous membrane above the ankle may be used to enable identification of a syndesmosis injury and allow differentiation from lateral ligament injury. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: Three groups of patients (those with an isolated syndesmosis injury [SI group], isolated lateral ligament injury [LLI group], and no injury [NI group]) who had an ankle MRI for another reason were identified from a patient notes database and the MRI scans retrieved. The scans were anonymized and independently assessed by 8 clinicians (surgeons and radiologists) who were blinded to the diagnosis. The maximum length of fluid above the ankle within the intraosseous membrane was measured for each patient. The presence or absence of distal anterior, lateral, and posterior tibial periosteal edema was recorded (broken “ring of fire”). Results: Measurement of the length of fluid above the ankle had excellent intraobserver reliability (intraclass correlation coefficient, 0.97; 95% CI, 0.93-0.99) but poor interobserver reliability. Fluid extended higher in both the LLI group ( P = .0043) and SI group ( P = .0058) than the NI group, but there was no significant difference between the LLI and SI groups ( P = .3735), indicating that this measurement cannot differentiate between the injuries. The presence of the broken “ring of fire” around the distal tibia was significantly more frequent in the SI group when compared with both LLI and NI groups ( P < .00001). The sensitivity of this sign is 49%, but when present, this sign has a 98% specificity for syndesmosis injury. Conclusion: The presence of tibial subcircumferential periosteal edema 4 to 6 cm above the ankle joint (the “ring of fire”) is highly suggestive of a syndesmosis injury. This new radiological sign can assist with early identification of such injuries. The measurement of height of fluid above the ankle within the interosseous membrane is variable and cannot differentiate severe ankle sprains from high ankle sprains involving the syndesmosis.

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