Magnetic Resonance Accuracy in the Diagnosis of Anterior Talo-Fibular Ligament Acute Injury: A Systematic Review and Meta-Analysis

Background: The studies about injury to the anterior talo-fibular ligament (ATFL) are focused mainly on chronic symptoms and chronic instability, and the literature about the accuracy of magnetic resonance imaging (MRI) in acute injuries is quite lacking. Methods: This systematic review with meta-analysis analyzes the diagnostic accuracy of MRI on acute ATFL injury. Relative studies were retrieved after searching three databases (MEDLINE, SCOPUS, and Cochrane Central Register of Controlled Trails). Eligible studies were summarized. The quality of the included articles was assessed using the revised Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. Data were extracted to calculate pooled sensitivity and specificity of MRI. Results: Seven studies met our inclusion and exclusion criteria. For MRI, the pooled sensitivities and specificity in diagnosing acute ATFL injury were respectively 1.0 (95% CI: 0.58–1) and 0.9 (95% CI: 0.79–0.96). Pooled LR+ and LR− were respectively 10.4 (95% CI: 4.6–23) and 0 (95% CI: 0–0.82). Conclusion: This systematic review with meta-analysis investigated the accuracy of imaging for the diagnosis of acute ATFL injury. Our results demonstrated that MRI shows high diagnostic accuracy in the diagnosis of acute ATFL lesions. These results suggest that routine MRI in the case of suspected ATFL acute injury may be clinically useful, although this is not done in clinical practice due probably to high cost.

Elbow Instability

The stability of the elbow is based on a combination of primary (static) and secondary stabilizers (dynamic). In varus stress, the bony structures and the lateral ulnar collateral ligament (LUCL) are the primary stabilizers, and in valgus stress, the ulnar collateral ligament (UCL) is the primary stabilizer. The flexor and extensor tendons crossing the elbow joint act as secondary stabilizers. Elbow instability is commonly divided into acute traumatic and chronic instability. Instability of the elbow is a continuum, with complete dislocation as its most severe form.Posterolateral rotatory instability is the most common elbow instability and can be detected at imaging both in the acute as well as the chronic phase. Imaging of suspected elbow instability starts with radiographs. Depending on the type of injury suspected, it is followed by magnetic resonance imaging (MRI) or computed tomography evaluation for depiction of a range of soft tissue and osseous injures. The most common soft tissue injuries are tears of the LUCL and the radial collateral ligament; the most common osseous injuries are an osseous LUCL avulsion, a fracture of the coronoid process, and a radial head fracture.Valgus instability is the second most common instability and mostly detected in the chronic phase, with valgus extension overload the dominant pattern of injury. The anterior part of the UCL is insufficient in valgus extension overload due to repetitive medial tension seen in many overhead throwing sports, with UCL damage readily seen at MRI.

Distal Radioulnar Joint Instability and Associated Injuries: A Literature Review

The distal radioulnar joint (DRUJ) allows supination and pronation of the distal forearm and wrist, an integral motion in everyday human activity. DRUJ injury and chronic instability can be a significant source of morbidity in patients’ lives. Although often linked with distal radius fractures, DRUJ injury may occur in a variety of other upper extremity injuries, as well as an isolated pathology. Diagnosis of this injury requires the clinician to have a high index of suspicion and low threshold for clinical testing and further imaging of the DRUJ. The purpose of this article is to provide a review on DRUJ anatomy and biomechanics, to discuss common diagnostic and treatment modalities, and to identify common injuries associated with DRUJ instability.

Case Study: Trans-styloid, Trans-scaphoid, Trans-triquetral, and Perilunate Dislocation

Introduction: Perilunate dislocations are rare high-energy injuries, and the diagnosis is not infrequently missed at initial presentation. The combination of fractures resulting in a trans-styloid, trans-scaphoid, and trans-triquetral perilunate fracture dislocation is extremely rare. Early recognition and diagnosis of these injuries is prudent to restore patient function and prevent morbidity. This injury pattern may progress through several distinct phases often involving the greater or lesser arc. The injury begins with traumatic disruption of the scapholunate joint, followed by an ordered progression of injury to the capitolunate, lunotriquetral, and radiolunate joints. When the radiolunate joint is disrupted, the lunate often dislocates volar transposing into the carpal tunnel, associated with median nerve compression. These injuries have the potential to cause lifelong disability of the wrist. Early treatment may prevent or lessen the chance of median neuropathy, post-traumatic wrist arthrosis, chronic instability, and fracture nonunion. Non-operative treatment is not indicated and is associated with poor functional outcomes and recurrent dislocation. Open reduction and internal fixation (ORIF) with ligamentous repair after emergent closed reduction and splinting is indicated for acute injuries (<8 weeks after injury). Case Report: We report a case of a 48-year-old right hand dominant male with a trans-styloid, trans-scaphoid, trans-triquetral, and perilunate dislocation after mechanical fall from height. He was evaluated in the ER and provisionally treated with closed reduction and splinting. ORIF of scaphoid, radial styloid, and triquetrum was performed, with ligamentous repair of the scapholunate joint and carpal tunnel decompression. Conclusion: The combination of fractures/injuries in this case has been very rarely been published in case reports to date. It is necessary to recognize these wrist injuries. Great detail should be given to physical and radiog

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

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.

New classification of osteochondral lesions of the talus in adults

Osteochondral lesions (OCL) of the ankle in adults are frequent lesions that mainly affect the cartilage and the subchondral bone, are relatively common, and have varied etiologies. However, in 50% of patients, these lesions may occur concomitantly with chronic instability of the ankle associated with lower limb deformities, acute sprains of the ankle, or fractures. We propose a classification into four types of lesions (traumatic, non-traumatic, with lateral instability of the ankle, and with mechanical axis defects), focusing not only on the diagnosis and treatment of OCL but also on associated injuries, such as instability and/or supramalleolar and hindfoot deformities. Level of Evidence V; Therapeutic Studies; Expert Opinion.

Chronic Anterior Pelvic Instability

Introduction: Chronic anterior pelvic instability means pathologic movement of the symphysis pubis with axial load. It is not a common pathology and its diagnosis is often delayed and difficult increasing the disability of affected patients. The pain is localized in the suprapubic area or groins, increasing with physical activity, direct palpation or compression. Main known causes are pregnancy, delivery, trauma, fractures, intense physical activity, infection, or previous surgeries. Treatment algorithms have not been standardized. Initially, it is managed with an orthosis, physical activity modification, medication, and rehabilitation. Surgical treatment with symphyseal arthrodesis is the last option. The literature on symphyseal plating for chronic instability found is sparse. Case Report: We report the case of a 33-year-old female presenting lower abdominal pain after her third delivery. Several months after, magnetic resonance imaging and scintigraphy suggested chronic symphysitis. Single leg stance pelvic X-rays indicated chronic anterior pelvic instability. Pain-relievers, physical rehabilitation, and local corticosteroid injection were noneffective; surgery was indicated, performing a double plate symphyseal arthrodesis with iliac bone graft. Conclusion: Pelvic instability should be ruled out when persistent abdominal or lower back pain are present. Thorough physical examination and specific provocative maneuvers need to be assessed. In our presented case, symphyseal arthrodesis was performed without complications. After a two-year follow-up, the patient has recovered her previous functional status and bone scintigraphy is negative. Radiologic controls rule out loosening or material breaking as a complication. We hope this case report may give a clue in surgical options management. Keywords: Arthrodesis, pelvic instability, symphysis.

Ankle Ligament Reconstruction - Return to Sport after Injury (ALR-RSI): a valid scale to quantify psychological readiness to return to sports after ankle ligament reconstruction

Objectives: Chronic instability is the main complication of ankle sprains and requires surgical intervention if non-surgical treatment fails. The aim of this study was to validate a tool to quantify psychological readiness to return to sports after ankle ligament reconstruction. Methods: The form was designed like the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale, and the term "anterior cruciate" was replaced by "ankle". The Ankle Ligament Reconstruction - Return to Sport after Injury Scale (ALR-RSI) was completed by patients who had undergone ankle ligament reconstruction and who practiced a sport. The scale was then validated according to the COSMIN international methodology. The AOFAS and Karlsson scores were used as reference questionnaires. Results: 57 patients (59 ankles) were included, 27 of whom were women. The ALR-RSI scale was highly correlated with the Karlsson score (r=0.79 [0.66-0.87]) and the AOFAS score (r=0.8 [0.66-0.87]). A highly significant difference was noted on the ALR-RSI scale between the subgroup of 50 patients who returned to sports and the 7 who did not: 68.8 (56.5-86.5) versus 45.0 (31.3-55.8), respectively, p = 0.02. The internal consistency of the scale was high (α = 0.96). Reproducibility of the test-retest was excellent (ρ = 0.92, 95% CI [0.86-0.96]). Conclusion: The ALR-RSI is a valid, reproducible scale with which to identify patients who are ready to resume the same sport after ankle ligament reconstruction. This scale can help to identify athletes who will have difficulty returning to sports.