scholarly journals Effect of a Controlled Ankle Motion Walking Boot on Syndesmotic Instability During Weightbearing: A Cadaveric Study

2019 ◽  
Vol 7 (8) ◽  
pp. 232596711986401 ◽  
Author(s):  
Stéphanie Lamer ◽  
Jonah Hébert-Davies ◽  
Vincent Dubé ◽  
Stéphane Leduc ◽  
Émilie Sandman ◽  
...  
Keyword(s):  
External Rotation ◽  
Axial Loading ◽  
Interosseous Ligament ◽  
Ankle Motion ◽  
Paired Samples ◽  
Tibiofibular Ligament ◽  
Custom Made ◽  
Anterior Inferior Tibiofibular Ligament ◽  
Careful Management

Background: Syndesmotic injuries can lead to long-term complications; hence, they require careful management. Conservative treatment is adequate when 1 syndesmotic ligament is injured, but surgery is often necessary to achieve articular congruity when 3 syndesmotic ligaments are ruptured. However, there is some controversy over the best treatment for 2-ligament injuries. Purpose: To evaluate the effect of a controlled ankle motion (CAM) walking boot on syndesmotic instability following iatrogenic isolated anterior inferior tibiofibular ligament (AiTFL) injury and combined AiTFL/interosseous ligament (IOL) injuries in a cadaveric simulated weightbearing model. Study Design: Controlled laboratory study. Methods: Ten cadaveric specimens were dissected to expose the tibial plateau and syndesmosis. The specimens were fitted to a custom-made device, and a reproducible axial load of 750 N was applied. Iatrogenic rupture of the syndesmotic ligaments (AiTFL + IOL) was done sequentially. Uninjured syndesmoses, isolated AiTFL rupture, and combined AiTFL/IOL rupture were compared with and without axial loading (AL) and CAM boot. The distal tibiofibular relationship was evaluated using a previously validated computed tomography scan measurement system. Wilcoxon tests for paired samples and nonparametric data were used. Results: The only difference noted in the distal tibiofibular relationship during AL was an increase in the external rotation of the fibula when using the CAM boot. This was observed with AiTFL rupture (8.40° vs 11.17°; P = .009) and combined AiTFL/IOL rupture (8.81° vs 11.97°; P = .005). Conclusion: AL did not cause a significant displacement between the tibia and fibula, even when 2 ligaments were ruptured. However, the CAM boot produced a significant external rotation with 1 or 2 injured ligaments. Clinical Relevance: Further studies are needed to assess the capacity of the CAM walking boot to prevent malreduction when external rotation forces are applied to the ankle. Moreover, special care should be taken during the fitting of the CAM boot to avoid overinflation of the cushions.

Arthroscopic Correlates of Subtle Syndesmotic Injury

2017 ◽  
Vol 38 (5) ◽  
pp. 502-506 ◽  
Author(s):  
Gregory P. Guyton ◽  
Kenneth DeFontes ◽  
Cameron R. Barr ◽  
Brent G. Parks ◽  
Lyn M. Camire
Keyword(s):  
External Rotation ◽  
Objective Measure ◽  
High Likelihood ◽  
Interosseous Ligament ◽  
Intact State ◽  
Spherical Probe ◽  
Tibiofibular Ligament ◽  
Tibiofibular Joint ◽  
Anterior Inferior Tibiofibular Ligament ◽  
Standardized Measurement

Background: Arthroscopic criteria for identifying syndesmotic disruption have been variable and subjective. We aimed to quantify syndesmotic disruption arthroscopically using a standardized measurement device. Methods: Ten cadaveric lower extremity specimens were tested in intact state and after serial sectioning of the syndesmotic structures (anterior inferior tibiofibular ligament [AiTFL], interosseous ligament [IOL], posterior inferior tibiofibular ligament [PiTFL], deltoid). Diagnostic ankle arthroscopy was performed after each sectioning. Manual external rotational stress was applied across the tibiofibular joint. Custom-manufactured spherical balls of increasing diameter mounted on the end of an arthroscopic probe were inserted into the tibiofibular space to determine the degree of diastasis of the tibiofibular joint under each condition. Results: A ball 3 mm in diameter reliably indicated a high likelihood of combined disruption of the AiTFL and IOL. Disruption of the AiTFL alone could not be reliably distinguished from the intact state. Conclusion: Use of a spherical probe placed into the tibiofibular space during manual external rotation of the ankle provided an objective measure of syndesmotic instability. Passage of a 2.5-mm probe indicated some disruption of the syndesmosis, but the test had poor negative predictive value. Passage of a 3.0-mm spherical probe indicated very high likelihood of disruption of both the AiTFL and the IOL. Clinical Relevance: The findings challenge the previously used but unsupported standard of a 2-mm diastasis of the tibiofibular articulation for diagnosis of subtle syndesmotic instability.

Kinematic Analysis of Combined Suture-Button and Suture Anchor Augment Constructs for Ankle Syndesmosis Injuries

2020 ◽  
Vol 41 (4) ◽  
pp. 463-472
Author(s):  
Addison R. Wood ◽  
Seyed A. Arshad ◽  
Hannah Kim ◽  
Donald Stewart
Keyword(s):  
Degrees Of Freedom ◽  
Suture Anchor ◽  
Sagittal Plane ◽  
External Rotation ◽  
Simultaneous Recording ◽  
Ankle Injuries ◽  
Interosseous Ligament ◽  
Suture Button ◽  
Cortical Screw ◽  
Custom Made

Background: Syndesmosis injuries are common, with up to 25% of all ankle injuries being reported to involve an associated syndesmosis injury. These injuries are typically treated with cortical screw fixation or suture-button implants when indicated, but the addition of a suture anchor augment implant has yet to be evaluated. The purpose of this study was to evaluate the ability of a suture anchor augment to add sagittal plane translational and transverse plane rotational constraint to suture-button constructs with syndesmosis injuries. We hypothesized that the suture anchor augment oriented in parallel with the fibers of an injured anterior-inferior tibiofibular ligament (AITFL) in addition to a suture-button construct would achieve physiological motion and stability at the syndesmosis through increased rotational and translational constraint of the fibula. Methods: Eleven fresh-frozen cadaver ankles were stressed in external rotation using a custom-made ankle rig. Each ankle had simultaneous recording of ultrasound video, 6 degrees-of-freedom kinematics of the fibula and tibia, and torque as the ankle was stressed by an examiner. The ankles were tested in 6 different states: native uninjured; injured with interosseous ligament and AITFL sectioned; 1× suture button; 2× suture buttons, divergent; 1× suture anchor augment with 2× suture buttons, divergent; and 1× suture anchor augment with 1× suture buttons. Results: Only the suture anchor augment + 2× suture buttons and suture anchor augment + 1× suture-button constructs were found to be significantly different from the injured state ( P = .0003, P = .002) with mean external rotation of the fibula. Conclusion: Overall, the most important finding of this study was that the addition of a suture anchor augment to suture-button constructs provided a mechanism to increase external rotational constraint of the fibula. Clinical Relevance: This study provides a mechanistic understanding of how the combined suture-button and suture anchor augment construct provides an anatomically similar reconstruction of constraints found in the native ankle. However, none of the constructs examined in this study were able to fully restore physiologic motion.

scholarly journals Effect of CAM boot immobilization on weightbearing stability in syndesmotic injuries

2018 ◽  
Vol 3 (3) ◽  
pp. 2473011418S0030
Author(s):  
Stéphanie Lamer ◽  
Vincent Dube ◽  
Jonah Hebert-Davies ◽  
Leduc Stephane ◽  
Jeremie Menard ◽  
...  
Keyword(s):  
Internal Rotation ◽  
Weight Bearing ◽  
Axial Loading ◽  
Nonoperative Treatment ◽  
Ankle Injuries ◽  
Ligament Injury ◽  
Ankle Motion ◽  
Parametric Data ◽  
Custom Made ◽  
Significant Difference

Category: Trauma Introduction/Purpose: Ankle injuries are one of the most frequent traumas of the lower limb. They typically involve the lower lateral ligaments of the ankle, but the syndesmosis is also affected in up to 18% of cases. The degree of instability of syndesmotic joint depends on which ligaments are affected. Adequate management of syndesmotic injuries is crucial to avoid long term complications. The primary goal of our study was to evaluate the effect of simulated weightbearing on syndesmotic instability resulting from isolated AiTFL injury and from combined AiTFL/IOL injuries. The secondary goal was to evaluate the effect of a controlled ankle motion walking boot on syndesmosis stability following injury. We hypothesized that the CAM boot would prevent significant instability even in two ligaments injuries. Methods: Ten cadaveric specimens were dissected to expose the syndesmosis to create progressive iatrogenic syndesmosis ruptures. Uninjured syndesmoses were compared to isolated AiTFL and combined AiTFL/IOL ruptures. The specimens were fitted in a custom-made device to allow stabilization of the leg and apply a reproducible axial load (AL) of 750 N, equivalent to the weight of a 168-pound person. For each specimen and injury pattern, CT-scan images were obtained with and without AL, and with a CAM boot under AL. Distal tibio-fibular relationship was evaluated in three planes using a previously validated measurement system developed on CT. Wilcoxon tests for paired samples and non-parametric data were done to compare the different conditions. Results: For our first objective, when comparing ankles with isolated AiTFL to combined AiTFL/IOL rupture with and without AL, the only significant difference was an increase in internal rotation between the incisura and a line drawn in the axis of the fibula. Even with minimal statistical differences, it appears that axial loading does not impact syndesmotic stability apart from a slight increase in internal rotation with a single or two-ligament injury. As for our second end point, with the CAM orthopedic boot, no significant widening of the syndesmosis happened when either one or both ligaments were sectioned, in an axial loading state. We therefore confirmed our hypothesis that even with two syndesmotic ligament injuries, axial loading in a CAM boot does not affect distal tibio-fibular anatomy. Conclusion: This study reveals that weight bearing without rotational force does not affect the stability of the syndesmosis. Incomplete syndesmotic injuries can likely be treated with nonoperative treatment in a CAM boot and weight bearing as tolerated. Further clinical studies are needed to confirm these findings.

scholarly journals Diagnostic value of ultrasonography in acute lateral and syndesmotic ligamentous ankle injuries

2020 ◽  
Author(s):  
Thomas P. A. Baltes ◽  
Javier Arnáiz ◽  
Liesel Geertsema ◽  
Celeste Geertsema ◽  
Pieter D’Hooghe ◽  
...  
Keyword(s):  
External Rotation ◽  
Diagnostic Value ◽  
Ankle Injuries ◽  
Anterior Talofibular Ligament ◽  
Neutral Position ◽  
Post Injury ◽  
Calcaneofibular Ligament ◽  
Tibiofibular Ligament ◽  
Anterior Inferior Tibiofibular Ligament ◽  
Dynamic Ultrasound

Abstract Objectives To determine the diagnostic value of ultrasonography for complete discontinuity of the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL) and the anterior inferior tibiofibular ligament (AITFL). Methods All acute ankle injuries in adult athletes (> 18 years old) presenting to the outpatient department of a specialised Orthopaedic and Sports Medicine Hospital within 7 days post-injury were assessed for eligibility. Using ultrasonography, one musculoskeletal radiologist assessed the ATFL, CFL and AITFL for complete discontinuity. Dynamic ultrasound measurements of the tibiofibular distance (mm) in both ankles (injured and contralateral) were acquired in the neutral position (N), during maximal external rotation (Max ER), and maximal internal rotation (Max IR). MR imaging was used as a reference standard. Results Between October 2017 and July 2019, 92 acute ankle injuries were included. Ultrasound diagnosed complete discontinuity of the ATFL with 87% (CI 74–95%) sensitivity and 69% (CI 53–82%) specificity. Discontinuity of the CFL was diagnosed with 29% (CI 10–56%) sensitivity and 92% (CI 83–97%) specificity. Ultrasound diagnosed discontinuity of the AITFL with 100% (CI 74–100%) sensitivity and 100% (CI 95–100%) specificity. Of the dynamic measurements, the side-to-side difference in external rotation had the highest diagnostic value for complete discontinuity of the AITFL (sensitivity 82%, specificity 86%; cut-off 0.93 mm). Conclusions Ultrasound has a good to excellent diagnostic value for complete discontinuity of the ATFL and AITFL. Therefore, ultrasound can be used to screen for injury of the ATFL and AITFL. Compared with ultrasound, dynamic ultrasound has inferior diagnostic value for complete discontinuity of the AITFL. Key Points • Ultrasound has a good to excellent diagnostic value for complete discontinuity of the anterior talofibular ligament (ATFL) and anterior inferior tibiofibular ligament (AITFL). • Ultrasound can be used to screen for injury of the ATFL and AITFL. • Compared with ultrasound, dynamic ultrasound has inferior diagnostic value for complete discontinuity of the AITFL.

Suture Anchor Augmentation for Acute Unstable Isolated Ankle Syndesmosis Disruption in Athletes

2021 ◽  
pp. 107110072110151
Author(s):  
Jin Su Kim ◽  
Hyuck Soo Shin
Keyword(s):  
Suture Anchor ◽  
External Rotation ◽  
Activity Level ◽  
Return To Play ◽  
Level Of Evidence ◽  
Chronic Instability ◽  
Sports Activity ◽  
Tibiofibular Ligament ◽  
Anterior Inferior Tibiofibular Ligament

Background: Isolated ankle syndesmosis disruption (without fibula fracture) causes acute pain and may cause chronic instability and pain. The aim of the present study was to evaluate the outcomes after anterior inferior tibiofibular ligament (AITFL) anatomical fixation using anchor sutures for unstable isolated syndesmosis disruption without fibular fractures. Methods: This study assessed 22 athletes who were diagnosed with unstable isolated syndesmosis disruption with a positive external rotation test, had more than 2-mm diastasis on ultrasound, and had complete AITFL rupture on magnetic resonance imaging between 2004 and 2020. Eighteen patients (82%) were elite-level athletes, and the remaining 4 were recreational athletes. Twelve patients (55%) were injured by an external rotation force. The athletes underwent open anatomical suture anchor fixation between the AITFL attachment sites, the fibula and tibia. The mechanism of injury, return-to-play time, and Foot and Ankle Outcome Score (FAOS) were evaluated. Results: All athletes returned to previous play except 1 retired elite athlete. Twenty-two athletes returned to jogging, team training, and official game play at an average of 62, 89, and 102 days, respectively. The final average follow-up FAOS symptom, pain, daily activity, sports activity, and quality of life scores were 98, 97, 100, 99, and 97, respectively. Two athletes were reinjured, and 1 required reoperation in the follow-up period. Conclusion: Athletes with isolated syndesmosis disruption had a high likelihood to return to their previous activity level after suture anchor augmentation. Level of Evidence: Level IV.

scholarly journals New “Freer test” for assessment of syndesmotic diastasis -Cadaveric study

2018 ◽  
Vol 3 (3) ◽  
pp. 2473011418S0029
Author(s):  
Jinsu Kim ◽  
Young-uk Park ◽  
Kyung-tai Lee ◽  
Kiwon Young ◽  
Sang Lee
Keyword(s):  
Diagnostic Value ◽  
Type B ◽  
Interosseous Ligament ◽  
Firm Structure ◽  
Tibiofibular Ligament ◽  
Fibular Fracture ◽  
Probe Test ◽  
Anterior Inferior Tibiofibular Ligament ◽  
Weber Type ◽  
Fibular Fixation

Category: Sports Introduction/Purpose: Syndesmotic stability is usually assessed arthroscopically by an arthroscopic probe insertion between the anterolateral tibio-fibular recess. This probe test can predict the syndesmotic instability, however, is difficult to determine syndesmotic fixation. The syndesmosis has dynamic motion and fairly firm structure, 2 mm thin probe cannot make syndesmotic dynamic diastasis. We proposed a new “Freer test” for diagnosis of syndesmosis injury which performed to insert a 2 mm diameter freer elevator between tibio-fibular lateral gutter while keeping the ankle at the plantigrade. The purpose of the present study was to evaluate the diagnostic value of freer test for anterior inferior tibiofibular ligament (AITFL) complete tear, interosseous ligament (IOL) tear and Weber type B fibular fracture. Methods: Ten fresh ankle cadaveric specimens were used. Operative procedures progressed as below; firstly, exposed antero-lateral ankle joint with direct lateral longitudinal incision, incised AITFL, incised IOL, performed Weber type B osteotomy at fibular, fixed the osteomized fibular with 8-hole locking plate and fixed the AITFL with suture anchors. In each procedure, freer tests with ankle dorsiflexion (DF, plantigrade) and plantarflexion (PF) were performed with freer elevator linked 3 kgf compression gauge. A negative test was defined as the freer did not insert with a more than 3 kgf. A positive test was defined lesser than 3 kgf, and measured the force at the insertion. Results: All freer test was negative with DF before procedures. Six ankles with PF were positive with average 1.5 kgf. All freer test positive has shown after AITFL cutting in DF, PF(mean 1.76 kgf, 1.19 kgf). After IOL cutting, all freer tests were positive in DF, PF(mean 1.46, 0.79 kgf). After fibular osteotomy, all freer tests were positive in DF, PF (mean 0.83,0.18 kgf). After fibular fixation with plate, all freer tests were positive in DF, PF (mean 1.26, 0.97 kgf). After syndesmotic fixation with anchors, 8 freer tests were positive in DF. 2 negative in PF, 4 negative in PF and 6 positive in PF. 2 positive in DF had partial breakage on anchor footprint due to weak bone. Conclusion: The “freer test” is useful diagnostic tool which test positive means AITFL rupture.

Do Coronal or Sagittal Plane Measurements Have the Highest Accuracy to Arthroscopically Diagnose Syndesmotic Instability?

2021 ◽  
pp. 107110072110041
Author(s):  
Rohan Bhimani ◽  
Bart Lubberts ◽  
Pongpanot Sornsakrin ◽  
Jafet Massri-Pugin ◽  
Gregory Waryasz ◽  
...  
Keyword(s):  
Operating Characteristic ◽  
Sagittal Plane ◽  
Area Under The Curve ◽  
Coronal Plane ◽  
Deltoid Ligament ◽  
Roc Curve Analysis ◽  
Level Of Evidence ◽  
Interosseous Ligament ◽  
Tibiofibular Ligament ◽  
Anterior Inferior Tibiofibular Ligament

Background: To compare the accuracy of arthroscopic sagittal versus coronal plane distal tibiofibular motion toward diagnosing syndesmotic instability. Methods: Arthroscopic assessment of the syndesmosis was performed on 21 above-knee cadaveric specimens, first with all ligaments intact and subsequently with sequential transection of the anterior inferior tibiofibular ligament, the interosseous ligament, the posterior inferior tibiofibular ligament, and the deltoid ligament. A lateral hook test, an anterior-to-posterior (AP) translation test, and a posterior-to-anterior (PA) translation test were performed under 100 N of applied force. Anterior and posterior third coronal plane diastasis and AP and PA sagittal plane fibular translations were measured relative to the static tibia. Results: Receiver operating characteristic (ROC) curve analysis revealed that the area under the curve (AUC) was higher for the combined AP and PA sagittal measurements (AUC, 0.91; accuracy, 83.5%; sensitivity, 78%; specificity, 89%) than the coronal plane measurements (anterior third: AUC, 0.65; accuracy, 60.5%; sensitivity, 63%; specificity, 59%; posterior third: AUC, 0.73; accuracy, 68.5%; sensitivity, 80%; specificity, 57%) ( P < .001), underscoring the higher accuracy of sagittal plane measurements. Conclusion: Arthroscopic measurement of sagittal plane fibular translation is more accurate than coronal plane diastasis for evaluating syndesmotic instability. Clinical Relevance: Clinicians should focus on distal tibiofibular motion in the sagittal plane when arthroscopically evaluating suspected syndesmotic instability. Level of Evidence: Biomechanical cadaveric study.

Strain Distribution in the Anterior Inferior Tibiofibular Ligament, Posterior Inferior Tibiofibular Ligament, and Interosseous Membrane Using Digital Image Correlation

2018 ◽  
Vol 39 (5) ◽  
pp. 618-628 ◽  
Author(s):  
Daorong Xu ◽  
Yibei Wang ◽  
Chunyu Jiang ◽  
Maoqing Fu ◽  
Shiqi Li ◽  
...  
Keyword(s):  
Digital Image Correlation ◽  
Digital Image ◽  
External Rotation ◽  
Image Correlation ◽  
Tibial Insertion ◽  
Tibiofibular Ligament ◽  
Anterior Inferior Tibiofibular Ligament ◽  
Augmentation Techniques ◽  
The Mean ◽  
Mean Strain

Background: Ligament repair and augmentation techniques can stabilize syndesmosis injuries. However, little is known about the mechanical behavior of syndesmotic ligaments. The aim of this study was to analyze full-field strain, strain trend under foot rotation, and subregional strain differences of the anterior inferior tibiofibular ligament (AITFL), posterior inferior tibiofibular ligament (PITFL), and interosseous membrane (IOM). Methods: Eleven fresh-frozen lower limbs were dissected to expose the AITFL, PITFL, and IOM. The foot underwent rotation from 0° to 25° internal and 35° external, with 3 ankle positions (neutral, 15° dorsiflexion, and 25° plantarflexion) and a vertical load of 430 N. Ligament strain was recorded using digital image correlation. Results: The mean strain on the AITFL with 35° external rotation was greater in the proximal portion compared with distal portion in the neutral position ( P = .009) and dorsiflexion ( P = .003). The mean strain in the tibial insertion and midsubstance near tibial insertion were greater when compared with other regions ( P = .018 and P = .009). The subregions of mean strain in the PITFL and IOM groups were not significantly different. The strain trend of AITFL, PITFL, and IOM showed common transformation, just when the foot was externally rotated. Conclusion: The findings of this study show that a significantly high strain was observed on the proximal part and the midsubstance near the Chaput tubercle of the AITFL when the ankle was externally rotated. All 3 ligaments resisted the torque in the syndesmosis by external rotation of the foot. Clinical Relevance: This study allows for better understanding of the mechanical behavior of the syndesmosis ligaments, which could influence the repair technique and AITFL augmentation techniques

scholarly journals Portable Dynamic Ultrasonography Versus Fluoroscopy for the Evaluation of Syndesmotic Instability: A Cadaveric Study

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0004
Author(s):  
Noortje Hagemeijer ◽  
Bart Lubberts ◽  
Jirawat Saengsin ◽  
Rohan Bhimani ◽  
Go Sato ◽  
...  
Keyword(s):  
External Rotation ◽  
Intraclass Correlation ◽  
Diagnostic Technique ◽  
P Value ◽  
Proximal Tibiofibular Joint ◽  
Diagnostic Modality ◽  
Interosseous Ligament ◽  
Cadaveric Specimen ◽  
Tibiofibular Ligament ◽  
The Us

Category: Ankle; Trauma Introduction/Purpose: Syndesmotic instability, when subtle, is challenging to diagnose and often requires visualization of the syndesmosis during applied stress. The purpose of this study was to determine the association between tibiofibular clear space (TFCS) values measured with 1) a portable ultrasound (US) device and 2) fluoroscopy during applied external roation stress for the evaluation of syndesmotic instability. Methods: Eight fresh lower leg cadaveric specimen amputated above the proximal tibiofibular joint were used in this study. Portable US device (Butterfly iQ, Butterfly Network Inc) images and fluoroscopic images taken by a mini C-arm were used to evaluate the ankle syndesmosis in the intact stage, and after sequentially sectioning of the anterior-inferior tibiofibular ligament (AITFL), interosseous ligament (IOL), and posterior-inferior tibiofibular ligament (PITFL) at 7.5Nm torque. A Pearson’s correlation was performed to investigate the correlation between the TFCS among the two modalities. A paired t-test was used to compare TFCS values measured with US or fluoroscopy. Three cadavers were measured by two independent observers to assess reliability of the measurements for each diagnostic modality and analyzed using intraclass correlation coefficients (ICC). P-values of < 0.05 were considered significant. Results: The mean TFCS (+- SD mm) values measured with the US and fluoroscopy are presented in Table 1. TFCS values obtained with the US and fluoroscopy correlated (rho 0.60). Between the imaging modalities similar TFCS values were found in the intact state (difference 0.81+-1.0, p-value 0.061). Compared with fluoroscopy, the TFCS values measured using US increased significantly after sequential transection of the AITFL (0.039), IOL (p=0.004) and PITFL (p<0.001). The ICC for measuring the TFCS with US was 0.86 and 0.84 with fluoroscopy indicating excellent agreement. Conclusion: During application of an external rotation force to the ankle, US and fluoroscopic TFCS measurements among different stages of syndesmotic ligamentous injury correlate. However, compared with fluoroscopy, a portable US ultrasound device seems to be a more sensitive diagnostic technique to evaluate subtle syndesmotic instability. [Table: see text]

scholarly journals Portable Dynamic Ultrasonography is a Useful Tool for the Evaluation of Suspect Syndesmotic Instability: A Cadaveric Study

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0024
Author(s):  
Noortje Hagemeijer ◽  
Rohan Bhimani ◽  
Jirawat Saengsin ◽  
Bart Lubberts ◽  
Gregory R. Waryasz ◽  
...  
Keyword(s):  
Repeated Measures ◽  
External Rotation ◽  
P Value ◽  
Proximal Tibiofibular Joint ◽  
Interosseous Ligament ◽  
Portable Ultrasound ◽  
Cadaveric Specimen ◽  
Ultrasound Device ◽  
Tibiofibular Ligament ◽  
Significant Difference

Category: Ankle; Sports; Trauma Introduction/Purpose: To evaluate syndesmotic instability by measuring the tibiofibular clear space (TFCS) opening using a portable ultrasound device. In addition, we assessed the optimal amount of external rotation torque required to detect syndesmotic instability. Methods: Eight fresh lower leg cadaveric specimen amputated above the proximal tibiofibular joint were used. Using a portable ultrasound device (Butterfly iQ, Butterfly Network Inc) the ankle syndesmosis was evaluated in the intact stage, and after sequentially sectioning of the anterior-inferior tibiofibular ligament (AITFL), interosseous ligament (IOL), and posterior-inferior tibiofibular ligament (PITFL)(Figure 1). In each ligamentous sectioning stage TFCS in millimeter (mm) was measured with ultrasound while consecutively 0N, 45N, 60N, 75N, and 90N external rotation directed torque was applied to the ankle. To evaluate which amount of torque would be sufficient to detect syndesmotic instability the delta increase of TFCS opening at different states of torque compared to the unstressed state was calculated. One-way repeated measures ANOVA was used to detect whether an increase in delta-TFCS opening could be detected between the intact state and consecutive syndesmotic ligament transection stages. Correction for multiple comparisons was performed using the Bonferroni-Holm correction. Results: Under all torque-loading conditions TFCS (mean+-SDmm) opening increased as additional syndesmosis ligaments were transected (p-values<0.001). With all ligaments intact an increase of TFCS opening was detected during torque increment, ranging from 4.50+-1.2mm at 0N to 5.7+-1.00mm at 90N. After AITFL transection this amount increased from 5.2+-1.4mm at 0N to 6.5+-1.8mm at 90N. After AITFL+IOL transaction from 6.2+-1.3mm at 0N to 10.6+-6.2mm increase at 90N, and after AITFL+IOL+PITFL transection the TFCS opening increased from 6.8+-1.2mm at 0N to 11.1+-2.8mm at 90N. Significant difference from intact was seen after transection of the IOL, already from the unstressed (0N) state on (difference 3.0+-1.4mm, p-value 0.036). Additionally, the AITF+IOL could also be differentiated from AITFL transection stage at 45N with a difference in TFCS opening of 2.06+-1.2mm (p-value 0.006). Conclusion: Portable dynamic ultrasonography is a useful tool to evaluate suspect syndesmotic instability. TFCS opening increased as additional ligaments of the syndesmosis were transected and application of 45N torque seems to be sufficient to detect syndesmotic instability.

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