scholarly journals Invisible Injuries in Ankle Fractures

2017 ◽  
Vol 2 (3) ◽  
pp. 2473011417S0001
Author(s):  
Robin Blom ◽  
Markus Knupp ◽  
Beat Hintermann ◽  
Sjoerd Stufkens
Keyword(s):  
Ankle Instability ◽  
External Rotation ◽  
Plantar Flexion ◽  
Axial Loading ◽  
Ankle Fractures ◽  
Deltoid Ligament ◽  
Neutral Position ◽  
Need For Treatment ◽  
Ligament Rupture ◽  
Fresh Frozen

Category: Ankle, Trauma, Biomechanical Introduction/Purpose: Ankle fractures are often associated with ligamentous injuries of the distal tibiofibular syndesmosis, the deltoid ligament and are predictive of ankle instability, early joint degeneration and long-term ankle dysfunction. Detection of ligamentous injuries and the need for treatment remain subject of ongoing debate. In the classic article of Boden it was made clear that injuries of the syndesmotic ligaments were of no importance in the absence of a deltoid ligament rupture. Even in the presence of a deltoid ligament rupture, the interosseous membrane withstood lateralization of the fibula in fractures up to 4.5 mm above the ankle joint. Generally, syndesmotic ligamentous injuries are treated operatively by temporary fixation performed with positioning screws. But do syndesmotic injuries need to be treated operatively at all? Methods: The purpose of this biomechanical cadaveric study was to investigate the relative movements of the tibia and fibula, under normal physiological conditions and after sequential sectioning of the syndesmotic ligaments. Ten fresh-frozen below-knee human cadaveric specimens were tested under normal physiological loading conditions. Axial loads of 50 Newton (N) and 700 N were provided in an intact state and after sequential sectioning of the following ligaments: anterior-inferior tibiofibular (AITFL), posterior-inferior tibiofibular (PITFL), interosseous (IOL), and whole deltoid (DL). In each condition the specimens were tested in neutral position, 10 degrees of dorsiflexion, 30 degrees of plantar flexion, 10 degrees of inversion, 5 degrees of eversion, and externally rotated up to 10 Nm torque. Finally, after sectioning of the deltoid ligament, we triangulated Boden’s classic findings with modern instruments. We hypothesized that only after sectioning of the deltoid ligament; the lateralization of the talus will push the fibula away from the tibia. Results: During dorsiflexion and external rotation the ankle syndesmosis widened, and the fibula externally rotated after sequential sectioning of the syndesmotic ligaments. After the AITFL was sectioned the fibula starts rotating externally. However, the external rotation of the fibula significantly reduced when the external rotation torque was combined with axial loading up to 700 N as compared to the external rotation torque alone. The most relative moments between the tibia and fibula were observed after the deltoid ligament was sectioned. Conclusion: Significant increases in movements of the fibula relative to the tibia occur when an external rotation torque is provided. However, axial pressure seemed to limit external rotation because of the bony congruence of the tibiotalar surface. The AITFL is necessary to prevent the fibula to rotate externally when the foot is rotating externally. The deltoid ligament is the main stabilizer of the ankle mortise.

scholarly journals Syndesmotic Behavior after Sequential Sectioning: Simulation of Ligamentous Ankle Injuries in Vitro

2019 ◽  
Vol 4 (4) ◽  
pp. 2473011419S0001
Author(s):  
Robin P. Blom ◽  
Kaj S. Emanuel ◽  
Markus Knupp ◽  
Inger N. Sierevelt ◽  
Gino M.M.J. Kerkhoffs ◽  
...  
Keyword(s):  
External Rotation ◽  
Lower Limbs ◽  
Ankle Injuries ◽  
Deltoid Ligament ◽  
Active Motion ◽  
Need For Treatment ◽  
Ligament Rupture ◽  
Fresh Frozen ◽  
Rotation Stress

Category: Ankle, Trauma, Distal Tibiofibular Joint Introduction/Purpose: Ankle fractures are often associated with ligamentous injuries of the distal tibiofibular syndesmosis and the deltoid ligament. These injuries may predispose to instability, early joint degeneration and long-term ankle dysfunction. In the classic article of Boden it was made clear that injuries of the syndesmotic ligaments were of no importance in absence of a deltoid ligament rupture. Even in the presence of a deltoid ligament rupture, the interosseous membrane withstood lateralization of the talus in fixated fibula fractures up to 4.5 mm above the ankle joint. However, detection of ligamentous injuries and the need for treatment remain subject of ongoing debate. Syndesmotic injuries are often treated operatively by temporary fixation performed with positioning screws. But do isolated syndesmotic injuries need to be treated operatively at all? Methods: Ten fresh-frozen, exarticulated through the knee, human cadaveric lower limbs were tested under axial compressive loads of 50 and 700 N, simulating non-weightbearing and weightbearing conditions. All specimens were tested with different foot positions (plantigrade, dorsiflexion, inversion, eversion, and 10 Nm external rotational torque) during sequential sectioning of the syndesmotic ligaments and the deltoid ligament. We triangulated Boden’s classic findings with an active motion capture system (0.1 mm accuracy) to track the translations and rotations of the fibula relative to the tibia. Results: Isolated sectioning of the AITFL resulted in an increase of external fibula rotation up to 8.9 degrees (doubling the physiological 4.0 degrees) with an external rotation stress of 10 Nm in non-weightbearing conditions. However, weightbearing appeared somewhat protective, reducing the external rotation to 7.9 degrees. Sectioning of all syndesmotic ligaments with an intact deltoid ligament resulted in a syndesmotic widening of 0.9 mm in weightbearing conditions with a plantigrade foot. Dorsiflexion of the foot resulted in a significant increase of syndesmotic widening for all conditions of the syndesmotic ligaments. Sectioning of the deltoid ligament resulted in a significant increase of all fibula translations in all foot positions during weightbearing conditions. Conclusion: The results of our study have implications for common ligamentous ankle injuries and their treatment. In isolated syndesmotic injuries with a plantigrade foot, weightbearing seemed protective and limiting syndesmotic widening probably due to the saddle shape of the tibiotalar surface. Conservative treatment in a cast seems justifiable. External rotation stress causes the “open-book-phenomenon” in isolated AITFL injuries, especially in non-weightbearing conditions. Protection with cast or surgery is necessary. The deltoid ligament prevents lateralization of the talus but allows increased syndesmotic widening and external rotation of the fibula in dorsiflexion and external rotation stress due to the shape of the talus.

scholarly journals Does Foot Position and Local of Measurement Influence on Ankle Medial Clear Space?

2017 ◽  
Vol 2 (3) ◽  
pp. 2473011417S0000
Author(s):  
Tiago Baumfeld ◽  
Daniel Baumfeld ◽  
João Cangussú ◽  
Benjamim Macedo ◽  
Thiago Silva ◽  
...  
Keyword(s):  
Gold Standard ◽  
External Rotation ◽  
Plantar Flexion ◽  
Deltoid Ligament ◽  
Anatomical Site ◽  
Neutral Position ◽  
Foot And Ankle ◽  
Clear Space ◽  
Foot Position ◽  
Rotation Stress

Category: Ankle, Sports, Trauma Introduction/Purpose: The ankle Medial Clear Space (MCS) is frequently used in foot and ankle surgery for determining the competence of the deltoid ligament in Weber B ankle fractures. A widened MCS indicates deltoid ligament incompetence, requiring surgery to prevent lateral talar shift. Controversy still exists regarding Medial Clear Space (MCS) normal and abnormal values, and its possible variation in previously uncontrolled biases. Sex, height, foot position, and type of radiograph were all described as possible influencing factors. The objective of this study was to access how much different degrees of plantar flexion, all performed with and without stress, influence on MCS width. Methods: We submitted 30 volunteers to six different anteroposterior non-weight bearing digital radiographs of the ankle in the following positions: neutral, neutral with external rotation stress, physiologic plantar flexion (FPF), physiologic plantar flexion with external rotation stress, maximum plantar flexion (MPF) and maximum plantar flexion with external rotation stress. The medial clear space MCS oblique (MCSo) and perpendicular (MCSp) were measured in all images by an experienced foot and ankle surgeon. Results: The data analysis showed with statically significance that the position of the foot does influence in the value of both MCSp and MCSo (p<0,05), regardless of three exceptions. MCSo does not change statistically between FPF with stress and MPF with stress. On the other hand, MCSp did not change in two situations: between FPF and Neutral with stress and between MPF and FPF with stress. It is noteworthy that MCSo, on average, was 15% wider than MCSp in all positions tested. It is also noticeable that, from the neutral position, plantar flexing the ankle has a great impact on MCS than external rotation stress, increasing MCSp by 25% and 22% respectively. MCSo follows the same pattern, with 21% and 17% respectively. Conclusion: This study is unique on showing that many different ways of positioning the foot and making stress radiographs do result in completely different MCS values, and that these values differ depending on the anatomical site they are measured. All these data indicates that we need to establish a gold standard for measuring MCS, taking into account patient sex, height, local of measurement of MCS, position of the foot and type of radiograph (AP or Mortise). This study was not able to address all variables that influence directly on MCS and therefore did not intended to establish this new gold standard.

scholarly journals Repair of the Deltoid Ligament Complex Rupture Associated with Ankle Fractures

2017 ◽  
Vol 2 (3) ◽  
pp. 2473011417S0004
Author(s):  
Mingzhu Zhang
Keyword(s):  
Ankle Instability ◽  
Outcome Measurement ◽  
Ankle Fractures ◽  
Deltoid Ligament ◽  
Ligament Rupture ◽  
Sf 36 ◽  
The Mean ◽  
Mean Time ◽  
Center Study

Category: Ankle Introduction/Purpose: It is controversial for operative repair of deltoid ligament in acute ankle fractures. To investigate the indication for surgical interference and the clinical outcome about repair whole deltoid ligament rupture associating with ankle fractures. Methods: We performed multiple-center study in 4 clinical centers in 4 cities of China. From January 2006 to December 2011, of 1533 ankle fractures operated, 131 deltoid ligament rupture were identified and repaired operatively. They were 74 males and 57 females with a mean age of 37.2 years (range, 15-83 years). Clinical examination, radiographs, AOFAS ankle-hindfoot scores and visual analogue scale were used for outcome measurement. Results: All incision healed primarily. 106 patients were followed up for 12 to 72 months, with the mean follow-up of 27 months.The mean time of fracture union was 14.5 weeks (range, 9-16 weeks). The mean AOFAS ankle-hindfoot score at last follow-up was 91.4 points (range, 83-100 points). The mean score of VAS was 1.2 points (range, 0-6 points). The mean score of SF-36 was 91.2 points (range, 80-96 points). There was no ankle instability and post-trauma osteoarthritis. Conclusion: This multiple-center study demonstrated that deltoid ligament repair can benefit patients with unstable ankle after fracture fixation. A reasonable clinical evaluation and surgical repair could be done, choosing an appropriate repair technique according to the site of deltoid ligament rupture.

scholarly journals Repair of the acute deltoid ligament complex rupture associated with ankle fractures

2018 ◽  
Vol 3 (3) ◽  
pp. 2473011418S0053
Author(s):  
Ming-Zhu Zhang ◽  
Guang-rong Yu
Keyword(s):  
Ankle Instability ◽  
Outcome Measurement ◽  
Ankle Fractures ◽  
Deltoid Ligament ◽  
Ligament Rupture ◽  
Sf 36 ◽  
The Mean ◽  
Mean Time ◽  
Center Study

Category: Trauma Introduction/Purpose: It is controversial for operative repair of deltoid ligament in acute ankle fractures. To investigate the indication for surgical interference and the clinical outcome about repair whole deltoid ligament rupture associating with ankle fractures. Methods: We performed multiple-center study in 4 clinical centers in 4 cities of China. From January 2006 to December 2011, of 1533 ankle fractures operated, 131 deltoid ligament rupture were identified and repaired operatively. They were 74 males and 57 females with a mean age of 37.2 years (range, 15-83 years). Clinical examination, radiographs, AOFAS ankle-hindfoot scores and visual analogue scale were used for outcome measurement. Results: All incision healed primarily. 106 patients were followed up for 12 to 72 months with the mean follow-up of 27 months. The mean time of fracture union was 14.5 weeks (range, 9-16 weeks). The mean AOFAS ankle-hindfoot score at last follow-up was 91.4 points (range, 83-100 points). The mean score of VAS was 1.2 points (range, 0-6 points). The mean score of SF-36 was 91.2 points (range, 80-96 points). There was no ankle instability and post-trauma osteoarthritis. Conclusion: This multiple-center study demonstrated that deltoid ligament repair can benefit patients with unstable ankle after fracture fixation. A reasonable clinical evaluation and surgical repair could be done, choosing an appropriate repair technique according to the site of deltoid ligament rupture.

Ankle Joint Pressure in Supination–External Rotation Injuries: A Biomechanical Study in an Unrestrained Cadaver Model

2020 ◽  
pp. 193864002095018
Author(s):  
Andreas C. Fösel ◽  
Angela Seidel ◽  
Marc C. Attinger ◽  
Ivan Zderic ◽  
Boyko Gueorguiev ◽  
...  
Keyword(s):  
Ankle Joint ◽  
Contact Area ◽  
Peak Pressure ◽  
External Rotation ◽  
Axial Loading ◽  
Biomechanical Study ◽  
Deltoid Ligament ◽  
Neutral Position ◽  
Joint Reaction Forces ◽  
Supination External Rotation

Background Previous biomechanical studies simulating supination–external rotation (SER) IV injuries revealed different alterations in contact area and peak pressure. We investigated joint reaction forces and radiographic parameters in an unrestrained, more physiological setup. Methods Twelve lower leg specimens were destabilized stepwise by osteotomy of the fibula (SER II) and transection of the superficial (SER IVa) and the deep deltoid ligament (SER IVb) according to the Lauge-Hansen classification. Sensors in the ankle joint recorded tibio-talar pressure changes with axial loading at 700 N in neutral position, 10° of dorsiflexion, and 20° of plantarflexion. Radiographs were taken for each step. Results Three of 12 specimen collapsed during SER IVb. In the neutral position, the peak pressure and contact area changed insignificantly from 2.6 ± 0.5 mPa (baseline) to 3.0 ± 1.4 mPa (SER IVb) ( P = .35) and from 810 ± 42 mm2 to 735 ± 27 mm2 ( P = .08), respectively. The corresponding medial clear space (MCS) increased significantly from 2.5 ± 0.4 mm (baseline) to 3.9 ± 1.1 mm (SER IVb) ( P = .028). The position of the ankle joint had a decisive effect on contact area ( P = .00), center of force ( P = .00) and MCS ( P = .01). Conclusion Simulated SER IVb injuries demonstrated radiological, but no biomechanical changes. This should be considered for surgical decision making based on MCS width on weightbearing radiographs. Levels of Evidence: Not applicable. Biomechanical study

scholarly journals Stress vs. Non-Stress Radiographs in Subtle Syndesmotic Injuries

2018 ◽  
Vol 3 (3) ◽  
pp. 2473011418S0029
Author(s):  
Nicola Krähenbühl ◽  
Travis Bailey ◽  
Nathan Davidson ◽  
Heath Henninger ◽  
Charles Saltzman ◽  
...  
Keyword(s):  
Ankle Instability ◽  
External Rotation ◽  
Paired Comparison ◽  
Weight Bearing ◽  
Deltoid Ligament ◽  
Ankle Sprains ◽  
X Rays ◽  
Syndesmotic Injury ◽  
Stress Radiographs ◽  
Clear Space

Category: Sports Introduction/Purpose: Between 1-18% of all ankle sprains and 23% of all ankle fractures involve injury to the distal tibio-fibular syndesmosis. Syndesmotic injuries can create a substantial diagnostic and therapeutic challenge for orthopaedic surgeons. While acute injuries can be assessed using conventional radiographs, subtle syndesmotic injuries may be misdiagnosed using X-rays. Misdiagnoses may result in chronic ankle instability, pain and post-traumatic osteoarthritis of the tibio-talar joint. The purpose of this study was to investigate whether syndesmotic injury was more easily diagnosed with stress vs. non-stress radiographs.radiographs.sed with stress vs. non-stress radiographs. Methods: Five pairs of cadavers (tibia plateau to toe-tip, mean 61 years, range 52-70 years) were scanned with weight-bearing CT (170 lb, w/ and w/o 10 Nm static external rotation torque). Digitally reconstructed radiographs (DRRs), which are comparable to conventional radiographs, were reconstructed from the 3D CT data. The following conditions were tested: First, intact ankles (Native) were tested. Second, one specimen from each pair underwent AITFL resection, while the contralateral underwent deltoid resection (Condition 1). Third, the remaining intact deltoid ligament or AITFL was resected in each ankle (Condition 2). Finally, the interosseous membrane (IOM) was resected in all ankles (Condition 3). Condition 3 was defined as acute syndesmotic injury. Using antero-posterior (AP) views, the tibio-fibular clear space (TFCS), tibiofibular overlap (TFO) and medial clear space (MCS) were assessed. Statistical analysis was performed using paired (comparison within groups) and unpaired (comparison between groups) t-test where p=0.05 was considered significant. Results: Regarding the TFCS, Native vs. Condition 3 in 10 Nm stress radiographs was significantly different in the deltoid group (p=0.021). Using TFO in stress and non-stressed radiographs, Native vs. Condition 2 and 3 was significantly different for the deltoid group (p=0.043), and Native vs. Condition 3 in the syndesmotic group (p=0.027). Regarding the MCS in non-stress radiographs, Native vs. Condition 3 was significantly different in the deltoid group (p=0.007), while in stress views, Native vs. Condition 2 was significant different in the syndesmotic (p=0.026) and Native vs. Condition 3 in the deltoid group (p=0.030). No differences were found comparing the conditions of the AITFL with the same conditions of the deltoid group. Conclusion: The TFCS cannot be used to assess subtle or acute syndesmotic injuries in stress and non-stress radiographs. The TFO can be used to assess a combined injury to the AITFL and deltoid ligament in stress and non-stress radiographs. The MCS can be used to assess acute syndesmotic injuries in stress and non-stress radiographs. Radiographs (stress or non-stress) cannot be used to distinguish between injuries to the AITFL or deltoid ligament. Therefore, stress and non-stress radiographs are not useful in assessment of subtle syndesmotic injuries. Stress-radiographs are not superior compared to non-stress radiographs in assessment of acute syndesmotic injuries.

Correlating Arthroscopic and Radiographic Findings of Deep Deltoid Ligament Injuries in Rotational Ankle Fractures

2020 ◽  
pp. 107110072096279
Author(s):  
D’Ann Arthur ◽  
Casey Pyle ◽  
Stephen J. Shymon ◽  
David Lee ◽  
Thomas Harris
Keyword(s):  
External Rotation ◽  
Open Reduction Internal Fixation ◽  
Ankle Fractures ◽  
Ligament Injury ◽  
Deltoid Ligament ◽  
Posterior Tibial Tendon ◽  
Level Of Evidence ◽  
Radiographic Findings ◽  
Type Iv ◽  
Retrospective Comparative Study

Background: The deep deltoid ligament (DDL) is a key stabilizer to the medial ankle and ankle mortise and can be disrupted in ligamentous supination external rotation type IV (LSER4) ankle fractures. The purpose of this study was to define the medial clear space (MCS) measurement on injury mortise radiographs that corresponds with complete DDL injury. Methods: A retrospective record review at a level 1 hospital was performed identifying patients with LSER4 ankle fractures who underwent arthroscopy and open reduction internal fixation. Chart reviews provided arthroscopic images and operative reports. Complete DDL injury was defined as arthroscopic visualization of the posterior tibial tendon (PTT). Inability to completely visualize the PTT was defined as a partial DDL injury. MCS was measured on injury mortise radiographs. Eighteen subjects met inclusion criteria. Results: Twelve subjects had complete and 6 subjects had partial DDL injury based on arthroscopic findings. Patients with complete DDL injury and those with partial DDL injury had injury radiograph MCS ranging from 5.5 to 29.9 mm and 4.0 to 5.0 mm, respectively. All patients with MCS ≥5.5 mm on injury radiographs had complete DDL injury and all patients with MCS ≤5.0 mm on injury radiographs had partial DDL injury. Conclusion: Complete DDL injury was found on injury ankle mortise radiographs as MCS widening of ≥5.5 mm, which correlated with arthroscopic visualization of the PTT. Using this cutoff, surgeons can surmise the presence of a complete deltoid ligament injury, allowing for improved preoperative planning. Level of Evidence: Level III, retrospective comparative study.

scholarly journals Evaluation of Joint Position Recognition Measurement Variables Associated With Chronic Ankle Instability: A Meta-Analysis

2012 ◽  
Vol 47 (4) ◽  
pp. 444-456 ◽  
Author(s):  
Jennifer M. Medina McKeon ◽  
Patrick O. McKeon
Keyword(s):  
Ankle Instability ◽  
Meta Analysis ◽  
Plantar Flexion ◽  
Absolute Error ◽  
Chronic Ankle Instability ◽  
Effect Sizes ◽  
Control Group ◽  
Neutral Position ◽  
Joint Position ◽  
Standard Deviations

Objective To identify the most precise and consistent variables using joint repositioning for identifying joint position recognition (JPR) deficits in individuals with chronic ankle instability (CAI). Data Sources We conducted a computerized search of the relevant scientific literature from January 1, 1965, to July 31, 2010, using PubMed Central, CINAHL, MEDLINE, SPORTDiscus, and Web of Science. We also conducted hand searches of all retrieved studies to identify relevant citations. Included studies were written in English, involved human participants, and were published in peer-reviewed journals. Study Selection Studies were included in the analysis if the authors (1) had examined JPR deficits in patients with CAI using active or passive repositioning techniques, (2) had made comparisons with a group or contralateral limb without CAI, and (3) had provided means and standard deviations for the calculation of effect sizes. Data Extraction Studies were selected and coded independently and assessed for quality by the investigators. We evaluated 6 JPR variables: (1) study comparisons, (2) starting foot position, (3) repositioning method, (4) testing range of motion, (5) testing velocity, and (6) data-reduction method. The independent variable was group (CAI, control group or side without CAI). The dependent variable was errors committed during joint repositioning. Means and standard deviations for errors committed were extracted from each included study. Data Synthesis Effect sizes and 95% confidence intervals were calculated to make comparisons across studies. Separate meta-analyses were calculated to determine the most precise and consistent method within each variable. Between-groups comparisons that involved active repositioning starting from a neutral position and moving into plantar flexion or inversion at a rate of less than 5°/s as measured by the mean absolute error committed appeared to be the most sensitive and precise variables for detecting JPR deficits in people with CAI.

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