Diagnostic Accuracy of Clinical Tests Assessing Ligamentous Injury of the Talocrural and Subtalar Joints: A Systematic Review With Meta-Analysis

Context: Ankle sprains are the most common acute musculoskeletal injury. Clinical tests represent the first opportunity to assess the sprain’s severity, but no systematic review has compared these tests to contemporary reference standards. Objective: To determine the diagnostic accuracy of clinical tests assessing the talocrural and subtalar joint ligaments after ankle sprain. Data Sources: CINAHL, EMBASE, MEDLINE, hand-searching, and PubMed-related article searches (inception to November 18, 2020). Study Selection: Eligible diagnostic studies compared clinical examination (palpation, joint laxity) against imaging or surgery. Studies at a high risk of bias or with high concerns regarding applicability on Quality Assessment of Diagnostic Accuracy Studies-2 were excluded from the meta-analysis. Study Design: Systematic review and meta-analysis. Level of Evidence: Level 3a. Data Extraction: True-positive, false-negative, false-positive, and true-negative findings were extracted to calculate sensitivity, specificity, and likelihood ratios. If ordinal data were reported, these were extracted to calculate Cohen’s kappa. Results: A total of 14 studies met the inclusion criteria (6302 observations; 9 clinical tests). No test had both sensitivity and specificity exceeding 90%. Palpation of the anterior talofibular ligament is highly sensitive (sensitivity 95%-100%; specificity 0%-32%; min-max; n = 6) but less so for the calcaneofibular ligament (sensitivity 49%-100%; specificity 26%-79%; min-max; n = 6). Pooled data from 6 studies (885 observations) found a low sensitivity (54%; 95% CI 35%-71%) but high specificity (87%; 95% CI 63%-96%) for the anterior drawer test. Conclusion: The anterior talofibular ligament is best assessed using a cluster of palpation (rule out), and anterior drawer testing (rule in). The talar tilt test can rule in injury to the calcaneofibular ligament, but a sensitive clinical test for the ligament is lacking. It is unclear if ligamentous injury grading can be done beyond the binary (injured vs uninjured), and clinical tests of the subtalar joint ligaments are not well researched. The generalizability of our findings is limited by insufficient reporting on blinding and poor study quality. Registration: Prospero ID: CRD42020187848. Data Availability: Data are available in a public, open access repository on publication, including our RevMan file and the CSV file used for meta-analysis: http://doi.org/10.5f281/zenodo.4917138

Occipitocervical fusion of traumatic atlanto-occipital dissociation in a patient with autofused cervical facet joints: illustrative case

BACKGROUND Patients who survive traumatic atlanto-occipital dissociation (AOD) may present with normal neurological examinations and near-normal-appearing diagnostic images, such as cervical radiographs and computed tomography (CT) scans. OBSERVATIONS The authors described a neurologically intact 64-year-old female patient with a degenerative autofusion of her right C4–5 facet joints who presented to their center after a motor vehicle collision. Prevertebral soft tissue swelling and craniocervical subarachnoid hemorrhage prompted awareness and consideration for traumatic AOD. An abnormal occipital condyle–C1 interval (4.67 mm) on CT and craniocervical junction ligamentous injury on magnetic resonance imaging (MRI) confirmed the diagnosis of AOD. Her autofused right C4–5 facet joints were incorporated into the occipitocervical fusion construct. LESSONS Traumatic AOD can be easily overlooked in patients with a normal neurological examination and no associated upper cervical spine fractures. A high index of suspicion is needed when evaluating CT scans because normal values for craniocervical parameters are significantly different from the accepted ranges of normal on radiographs in the adult population. MRI of the cervical spine is helpful to evaluate for atlanto-occipital ligamentous injury and confirm the diagnosis. Occipitocervical fusion construct may need to be extended to incorporate spinal levels with degenerative autofusion to prevent adjacent level degeneration.

Experimental pilot study after surgery on a food supplement for athletes to protect articular knee cartilage. A functional and biochemical study

This double-blind experimental study evaluates the efficacy of chondroprotective supplementation (Carticure Plus®, 5000 mg Collagen – Bioactive Peptides, 1500 mg Glucosamine Hydrochloride, 1200 mg Chondroitin Sulfate, 1.1 mg Copper, 80 mg Vitamin C, 2 mg Manganese) in patients with meniscal and ligament pathology who have required arthroscopic surgery. 12 patients with ligamentous injury and 12 patients with meniscopathy were selected, who underwent the measurement of different inflammatory markers using ELISA, collagen 2A and hyaluronic acid, in addition to evaluating pain as well as functionality and quality of life through VAS (Visual Analogue Scale), WOMAC (Western Ontario McMaster Universities Osteoarthritis Index) and KOOS (Knee Injury and Osteoarthritis Outcome Score). Statistically significant differences of clinical improvement were observed in favor of Carticure Plus®, with an improvement in the functional capacity of the WOMAC scale, 76% Carticure Plus® vs 53% placebo, for all patients and with a clear improvement in the first month in meniscal injury, in improvement of the activities of daily life (KOOS), Carticure Plus® 31% vs placebo -1%, sports activity, (Carticure Plus® 41% vs placebo 13,2%) and sports and recreational activities (KOOS) (Carticure Plus® 128% vs Placebo 10,4%). On the other hand, in ligamentous injury an improvement in quality of life (KOOS) Carticure Plus® 75% vs Placebo -8,8% and pain (KOOS) Carticure Plus® 49,6% vs Placebo 0,3% was observed in the first month compared to the baseline. In the patient group, pain (KOOS) Carticure Plus® 31,4% vs Placebo 1,3% and activities of daily living (KOOS) Carticure Plus® 43,9% vs Placebo 27,1% in the third month from baseline, are associated with an improvement due to Carticure Plus® when compared to the placebo group. Despite the small sample size, it is remarkable the fact that statistically significant differences have been found, the efficacy of Carticure Plus® could be assumed.

A Very Rare Fracture: Isolated Fresh Lunate Fracture

Lunate fractures are rare and usually occur together with other fractures, dislocations, or ligament disruptions. We want to report an acute fresh isolated lunate fracture without additional ligamentous injury fixated with early surgical intervention. A 23-year-old right-hand-dominated male patient was admitted to our hospital after falling from 1.5-meter ladder over right hand’s palmar face. Standard radiographs diagnosed a displaced lunate fracture. In the intraoperative evaluation, it was observed that there was only lunate dislocation, and there was no ligament lesion or other carpal bone pathology. Fracture was fixed with a headless cannulated screw. Radiographs showed bony union at 6-week follow-up. There was no evidence for Kienböck’s disease 6 months after surgery. Case report regarding fresh isolated lunate fracture that results in clinical success with early intervention without developing avascular necrosis as in our report is extremely rare. In conclusion, satisfying results can be obtained in these patients with careful surgical intervention.

Magnetic resonance imaging for the evaluation of ligamentous injury associated with pelvic anterior–posterior compression fracture

Background Pelvic anterior–posterior compression (APC) fracture is typically associated with pelvic ligament damage. We used magnetic resonance imaging (MRI) to evaluate ligamentous injury associated with pelvic APC fracture. Methods Thirty healthy adults and 26 patients with pelvic APC fractures were enrolled in this study. All healthy adults underwent a series of MRI scans. Pelvic ligament visualization was scored [0 (poor) to 3 (excellent)] to identify the best scanning method. Then, MRI examination of patients with pelvic APC fracture was performed using this method. Results For healthy adults, oblique axial and axial scans provided the best visualization of the anterior sacroiliac ligament [ASL; good and excellent scores in 100% (30/30) and 96.7% (29/30) of cases, respectively; both P < 0.05 vs. coronal scans], followed by coronal scans [73.3% (22/30)]; sagittal scans provided poor visualization of this ligament (0%). Oblique sagittal scans provided the best visualization of the sacrotuberous ligament (SBL) and sacrospinous ligament [SPL; good and excellent scores in 90% (27/30) and 67.7% (20/30) of cases, respectively]. In patients with type I APC fracture, all three ligaments were intact without injury; in those with type III fracture, all three ligaments had ruptured. All type II APC fractures were associated with ASL rupture; the other two ligaments were injured simultaneously in 8 (42.1%) cases and two ligaments were uninjured simultaneously in 7 (36.8%) of these cases. Four patients had pubic symphysis separation > 30 mm, with no SBL or SPL injury; two patients had about 25 mm separation with SPL injury. Conclusion Healthy and injured pelvic ligaments can be evaluated using MRI; oblique axial and axial scanning are best for ASL visualization, and oblique sagittal scanning are best for SPL and SBL visualization. Pubic symphysis separation > 25 mm is not necessarily associated with SPL or SBL injury.