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Mercan N, Yurteri A, Dere Y. Do lateral ankle ligaments contribute to syndesmotic stability: a finite element analysis study. Comput Methods Biomech Biomed Engin 2024; 27:1768-1780. [PMID: 37728074 DOI: 10.1080/10255842.2023.2258251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 08/30/2023] [Accepted: 09/07/2023] [Indexed: 09/21/2023]
Abstract
Whether the lateral ankle ligaments contribute to syndesmotic stability is still controversial and has been the subject of frequent research recently. In our study, we tried to elucidate this situation using the finite element analysis method. Intact model and thirteen different injury models were created to simulate injuries of the lateral ankle ligaments (ATFL, CFL, PTFL), injuries of the syndesmotic ligaments (AITFL, IOL, PITFL) and their combined injuries. The models were compared in terms of LFT, PFT and EFR. It was observed that 0.537 mm LFT, 0.626 mm PFT and 1.25° EFR occurred in the intact model (M#1), 0.539 mm LFT, 0.761 mm PFT and 2.31° EFR occurred in the isolated ATFL injury (M#2), 0.547 mm LFT, 0.791 mm PFT and 2.50° EFR occurred in the isolated AITFL injury (M#8). The LFT, PFT and EFR amounts were higher in the both M#2 and M#8 compared to the M#1. LFT, PFT and EFR amounts in M#2 and M#8 were found to be extremely close. In terms of LFT and PFT, when we compare models with (LFT: 0.650 mm, PFT: 1.104) and without (LFT: 0.457 mm, PFT: 1.150) IOL injury, it is seen that the amount of LFT increases and the amount of PFT decreases with IOL injury. We also observed that injuries to the CFL, PTFL and PITFL did not cause significant changes in fibular translations and PFT and EFR values show an almost linear correlation. Our results suggest that ATFL injury plays a crucial role in syndesmotic stability.
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Affiliation(s)
- Numan Mercan
- Department of Orthopaedic and Traumatology, Kahramanmaras Necip Fazıl City Hospital, Kahramanmaras, Turkey
| | - Ahmet Yurteri
- Department of Orthopaedic and Traumatology, Konya Sehir Hastanesi, Konya, Turkey
| | - Yunus Dere
- Department of Civil Engineering, Necmettin Erbakan University, Meram, Turkey
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Sugimoto K, Isomoto S, Ishida E, Miura K, Hyakuda Y, Ohta Y, Tanaka Y, Taniguchi A. Treatment of Intra-Articular Lesions After Posterior Inferior Tibiofibular Ligament Injury: A Case Series of Elite Rugby Players. Orthop J Sports Med 2023; 11:23259671231200934. [PMID: 37781642 PMCID: PMC10540585 DOI: 10.1177/23259671231200934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 05/19/2023] [Indexed: 10/03/2023] Open
Abstract
Background Surgical intervention is not typically used to treat symptoms after mild tibiofibular ligament injuries without ankle dislocation or subluxation. Purpose To describe outcomes in patients arthroscopically treated for unique intra-articular lesions after sustaining syndesmosis injury of the ankle. Study Design Case series; Level of evidence, 4. Methods A total of 11 elite male rugby players with a mean age of 21.0 years (range, 17-28 years) were referred to our hospital for prolonged posterior ankle pain after a high ankle sprain during rugby football. The patients were examined using standing view radiography, computed tomography (CT) and magnetic resonance imaging (MRI) to determine the extent of ligament damage. Posterior ankle arthroscopy was performed to examine intra-articular lesions. The patients were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle/hindfoot rating scale and sports activity score of the Self-Administered Foot Evaluation Questionnaire (SAFE-Q). Results The average reduced tibiofibular overlap on the standing mortise view was 1.2 mm (range, 0.5-2.0 mm) compared with the opposite ankles. Mason type 1 fracture was detected on CT in 6 patients, and ossification of the interosseous membrane was detected in 2 patients. A bone bruise in the posterior malleolus was observed on MRI in all but 1 patient. Intra-articular fragments located in the posterior ankle were observed and removed arthroscopically. Symptoms improved rapidly after arthroscopic treatment in all patients. All patients returned to rugby games at a median of 11 weeks postoperatively. The median AOFAS scores improved from 77 preoperatively to 100 postoperatively (P < .01), and the median SAFE-Q sports activity subscale score improved from 49.4 to 100 (P < .01). Conclusion All unique intra-articular lesions that developed in rugby football players after syndesmosis injury were able to be treated arthroscopically. Patients returned to playing rugby football without syndesmosis reduction. Posterior ankle arthroscopy was effective in patients with residual symptoms after syndesmosis injury.
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Affiliation(s)
- Kazuya Sugimoto
- Department of Orthopaedic Surgery, Nara Prefecture General Medical Center, Nara, Japan
| | - Shinji Isomoto
- Department of Orthopaedic Surgery, Nara Prefecture General Medical Center, Nara, Japan
| | - Eiwa Ishida
- Department of Pathology, Nara Prefecture General Medical Center, Nara, Japan
| | - Kimio Miura
- Department of Orthopaedic Surgery, Nara Prefecture General Medical Center, Nara, Japan
| | - Yoshinobu Hyakuda
- Department of Orthopaedic Surgery, Nara Prefecture General Medical Center, Nara, Japan
| | - Yuichi Ohta
- Department of Orthopaedic Surgery, Nara Prefecture General Medical Center, Nara, Japan
| | - Yasuhito Tanaka
- Department of Orthopaedic Surgery, School of Medicine, Nara Medical University, Kashihara, Japan
| | - Akira Taniguchi
- Department of Orthopaedic Surgery, School of Medicine, Nara Medical University, Kashihara, Japan
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Jungmann PM, Lange T, Wenning M, Baumann FA, Bamberg F, Jung M. Ankle Sprains in Athletes: Current Epidemiological, Clinical and Imaging Trends. Open Access J Sports Med 2023; 14:29-46. [PMID: 37252646 PMCID: PMC10216848 DOI: 10.2147/oajsm.s397634] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 05/06/2023] [Indexed: 05/31/2023] Open
Abstract
Purpose Ankle injuries are frequent sports injuries. Despite optimizing treatment strategies during recent years, the percentage of chronification following an ankle sprain remains high. The purpose of this review article is, to highlight current epidemiological, clinical and novel advanced cross-sectional imaging trends that may help to evaluate ankle sprain injuries. Methods Systematic PubMed literature research. Identification and review of studies (i) analyzing and describing ankle sprain and (ii) focusing on advanced cross-sectional imaging techniques at the ankle. Results The ankle is one of the most frequently injured body parts in sports. During the COVID-19 pandemic, there was a change in sporting behavior and sports injuries. Ankle sprains account for about 16-40% of the sports-related injuries. Novel cross-sectional imaging techniques, including Compressed Sensing MRI, 3D MRI, ankle MRI with traction or plantarflexion-supination, quantitative MRI, CT-like MRI, CT arthrography, weight-bearing cone beam CT, dual-energy CT, photon-counting CT, and projection-based metal artifact reduction CT may be introduced for detection and evaluation of specific pathologies after ankle injury. While simple ankle sprains are generally treated conservatively, unstable syndesmotic injuries may undergo stabilization using suture-button-fixation. Minced cartilage implantation is a novel cartilage repair technique for osteochondral defects at the ankle. Conclusion Applications and advantages of different cross-sectional imaging techniques at the ankle are highlighted. In a personalized approach, optimal imaging techniques may be chosen that best detect and delineate structural ankle injuries in athletes.
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Affiliation(s)
- Pia M Jungmann
- Department of Diagnostic and Interventional Radiology, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Radiology, Kantonsspital Graubünden, Chur, Switzerland
| | - Thomas Lange
- Department of Radiology, Medical Physics, Medical Center – University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Markus Wenning
- Department of Orthopedic and Trauma Surgery, Medical Center – University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Frédéric A Baumann
- Department of Vascular Medicine, Hospital of Schiers, Schiers, Switzerland
| | - Fabian Bamberg
- Department of Diagnostic and Interventional Radiology, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Matthias Jung
- Department of Diagnostic and Interventional Radiology, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Mercan N, Yıldırım A, Dere Y. Biomechanical Analysis of Tibiofibular Syndesmosis Injury Fixation Methods: A Finite Element Analysis. J Foot Ankle Surg 2022; 62:107-114. [PMID: 35732561 DOI: 10.1053/j.jfas.2022.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 05/09/2022] [Accepted: 05/11/2022] [Indexed: 02/03/2023]
Abstract
The optimal treatment strategy after syndesmotic injuries is still controversial. In our study, we aimed to evaluate ideal fixation method in syndesmotic injury by using finite element analysis method. A 3D SolidWorks model file was created by taking computed tomography (CT) images of the area from the right foot base to the knee joint level of a healthy adult male. The intact model, injury model, and 8 different fixation models were created that 3.5 mm screw and suture-button were used in. The models were compared in terms of lateral fibular translation, posterior fibular translation and external rotation of fibula compared to tibia and stress values occurred on screws and suture-buttons. In the hybrid-1 model, lateral fibular translation and external fibular rotation values were obtained as close to the intact model. Von Mises stresses occurred in the screw (435.7 MPa) and suture-button (424.7 MPa) that used in hybrid-1 model was more than single screw at 4 cm model (316.8 MPa) and single suture-button at 2 cm model (160.7 MPa). In the Hybrid-1 model, the screw compensates for posterior fibular translation and external fibular rotation, while the suture-button compensates for lateral fibular translation. Also, the effect of the distal suture-button preventing diastasis in case of proximal screw failure, it was concluded that the hybrid-1 model can be used as a good treatment alternative in the surgical treatment of distal tibiofibular syndesmotic injuries.
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Affiliation(s)
- Numan Mercan
- Physician, Department of Orthopedics and Traumatology, Medical Faculty of Selcuk University, Konya, Turkey
| | - Ahmet Yıldırım
- Associate Professor, Department of Orthopedics and Traumatology, Medical Faculty of Selcuk University, Konya, Turkey.
| | - Yunus Dere
- Assistant Professor, Department of Civil Engineering, Necmettin Erbakan University, Konya, Turkey
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Yammine K, Jalloul M, Assi C. Distal tibiofibular syndesmosis: A meta-analysis of cadaveric studies. Morphologie 2022; 106:241-251. [PMID: 34801386 DOI: 10.1016/j.morpho.2021.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 10/24/2021] [Accepted: 10/25/2021] [Indexed: 06/13/2023]
Abstract
Though injuries to the distal tibiofibular (DTF) syndesmosis are commonly encountered in orthopedic and trauma settings, its anatomical structures have been poorly researched. The commonly overlooked DTF ligament injuries are known to cause chronic ankle pain, instability and post-traumatic osteoarthritis. Quantitative and morphological evidence synthesis has not been yet conducted. A meta-analysis was conducted to collect data from morphological studies to document more accurate details on the prevalence, size, and insertion sites of its components. The Checklist for Anatomical Reviews and Meta-Analyses (CARMA) was followed. Ten studies met the inclusion criteria with a total of 265 investigated ankles. The analysis demonstrated that the anterior and posterior tibiofibular ligaments along with the interosseous ligament were present in 100% of joints. The inferior transverse tibiofibular and the distal fascicle of the anterior tibiofibular ligament were the least prevalent with frequencies of 96% and 86.5%, respectively. The inferior transverse ligament was recorded as the longest ligament. The widest ligament was found to be the interosseous tibiofibular ligament at its fibular attachment. The thickest of the ligamentous components was the posterior tibiofibular ligament. While more cadaveric research is warranted, these results would help directing future biomechanical investigations and planning new research to further aid in diagnostic and therapeutic approaches to the injuries of the distal tibiofibular syndesmosis.
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Affiliation(s)
- K Yammine
- Department of Orthopedic Surgery, Lebanese American University Medical Center-Rizk Hospital, Lebanese American University School of Medicine, Beirut, Lebanon; The Foot Clinic, Lebanese American University Medical Center-Rizk Hospital, Lebanese American University School of Medicine, Beirut, Lebanon; Center for Evidence-Based Anatomy, Sport & Orthopedics Research, Beirut, Lebanon.
| | - M Jalloul
- Department of Orthopedic Surgery, Lebanese American University Medical Center-Rizk Hospital, Lebanese American University School of Medicine, Beirut, Lebanon
| | - C Assi
- Department of Orthopedic Surgery, Lebanese American University Medical Center-Rizk Hospital, Lebanese American University School of Medicine, Beirut, Lebanon; Center for Evidence-Based Anatomy, Sport & Orthopedics Research, Beirut, Lebanon
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Cao MM, Zhang YW, Hu SY, Rui YF. A systematic review of ankle fracture-dislocations: Recent update and future prospects. Front Surg 2022; 9:965814. [PMID: 36017521 PMCID: PMC9398172 DOI: 10.3389/fsurg.2022.965814] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 07/25/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Ankle fracture-dislocations are one of the most severe types of ankle injuries. Compared to the simple ankle fractures, ankle fracture-dislocations are usually more severely traumatized and can cause worse functional outcomes. The purpose of this study was to review the previous literatures to understand the anatomy, mechanisms, treatment, and functional outcomes associated with ankle fracture-dislocations. METHODS The available literatures from January 1985 to December 2021 in three main medical databases were searched and analyzed. The detailed information was extracted for each article, such as researchers, age, gender, groups, type of study, type of center research, level of evidence, significant findings, study aim, cause of injury, time from injury to surgery, type of fracture, direction of dislocation, follow-up, postoperative complications and functional evaluation scores. RESULTS A total of 15 studies (1,089 patients) met the inclusion criteria. Only one study was a prospective randomized trial. The top-ranked cause of injury was high-energy injury (21.3%). Moreover, the most frequent type of fracture in ankle dislocations was supination-external rotation (SER) ankle fracture (43.8%), while the most common directions of dislocation were lateral (50%) and posterior (38.9%). CONCLUSIONS Collectively, most ankle fracture-dislocations are caused by high-energy injuries and usually have poor functional outcomes. The mechanism of injury can be dissected by the ankle anatomy and Lauge-Hansen's classification. The treatment of ankle fracture-dislocations still requires more detailed and rational solutions due to the urgency of occurrence, the severity of injury, and the postoperative complications.
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Affiliation(s)
- Mu-Min Cao
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
- School of Medicine, Southeast University, Nanjing, Jiangsu, China
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Yuan-Wei Zhang
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
- School of Medicine, Southeast University, Nanjing, Jiangsu, China
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Sheng-Ye Hu
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
- School of Medicine, Southeast University, Nanjing, Jiangsu, China
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Yun-Feng Rui
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
- School of Medicine, Southeast University, Nanjing, Jiangsu, China
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
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Hagemeijer NC, Lubberts B, Saengsin J, Bhimani R, Sato G, Waryasz GR, Kerkhoffs GMMJ, DiGiovanni CW, Guss D. Portable dynamic ultrasonography is a useful tool for the evaluation of suspected syndesmotic instability: a cadaveric study. Knee Surg Sports Traumatol Arthrosc 2022; 31:1986-1993. [PMID: 35881148 PMCID: PMC10089982 DOI: 10.1007/s00167-022-07058-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 06/20/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE Portable ultrasonography (P-US) is increasingly used to diagnose syndesmotic instability. The aim of this study was to evaluate syndesmotic instability by measuring the distal tibiofibular clear space (TFCS) in a cadaveric model using P-US with progressive stages of syndesmotic ligamentous transection under external rotation stress. METHODS Ten fresh lower leg cadaveric specimens amputated above the proximal tibiofibular joint were used. Using P-US, the TFCS was evaluated in the intact stage and after progressive sectioning of the (1) anterior-inferior tibiofibular ligament (AITFL), (2) interosseous ligament (IOL), and (3) posterior-inferior tibiofibular ligament (PITFL). The TFCS was measured in both the unstressed (0 Nm) state and with 4.5, 6.0, 7.5, and 9.0 Nm of external rotation stress using a bone hook placed on the first metatarsal bone at each stage of ligamentous transection stage using both P-US and fluoroscopy. RESULTS When assessed with P-US, partial syndesmotic injury encompassing the AITFL and IOL resulted in significant TFCS widening at 4.5 Nm of external rotation torque when compared to intact state with a TFCS-opening of 2.6 ± 2 mm, p = 0.01. In contrast, no significant differences in TFCS were detected using fluoroscopy. Only a moderate correlation was found between P-US and fluoroscopy. CONCLUSION P-US is a useful tool in diagnosing syndesmotic instability during external rotation stress examination. TFCS-opening increased as additional ligaments of the syndesmosis were transected, and application of 4.5 Nm torque was sufficient to detect a difference of 2.6 mm after the IOL cut.
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Affiliation(s)
- N C Hagemeijer
- Foot and Ankle Research and Innovation Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, USA. .,Department of Orthopaedic Surgery and Sports Medicine, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Zuidoost, 1105 AZ, Amsterdam, The Netherlands. .,Amsterdam Collaboration for Health and Safety in Sports (ACHSS), IOC Research Center, Amsterdam, the Netherlands. .,Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
| | - B Lubberts
- Foot and Ankle Research and Innovation Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, USA.,Amsterdam Collaboration for Health and Safety in Sports (ACHSS), IOC Research Center, Amsterdam, the Netherlands
| | - J Saengsin
- Foot and Ankle Research and Innovation Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, USA.,Department of Orthopaedic Surgery, Faculty of Medicine, Chiang Mai University, 110 Inthawarorot, Sri Phum subdistrict, Mueang Chiang Mai District, Chiang Mai 50200, Chiang Mai, Thailand.,Amsterdam Collaboration for Health and Safety in Sports (ACHSS), IOC Research Center, Amsterdam, the Netherlands
| | - R Bhimani
- Foot and Ankle Research and Innovation Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, USA.,Amsterdam Collaboration for Health and Safety in Sports (ACHSS), IOC Research Center, Amsterdam, the Netherlands
| | - G Sato
- Foot and Ankle Research and Innovation Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, USA.,Amsterdam Collaboration for Health and Safety in Sports (ACHSS), IOC Research Center, Amsterdam, the Netherlands
| | - G R Waryasz
- Foot and Ankle Research and Innovation Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, USA.,Foot and Ankle Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Yawkey Building, 55 Fruit St, Boston, MA, 02114, USA.,Amsterdam Collaboration for Health and Safety in Sports (ACHSS), IOC Research Center, Amsterdam, the Netherlands
| | - G M M J Kerkhoffs
- Department of Orthopaedic Surgery and Sports Medicine, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Zuidoost, 1105 AZ, Amsterdam, The Netherlands.,Newton-Wellesley Hospital, Harvard Medical School, Massachusetts General Hospital, 2014 Washington St, Newton, MA, 02462, USA.,Academic Center for Evidence Based Sports Medicine (ACES), Academic Medical Centre Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.,Amsterdam Collaboration for Health and Safety in Sports (ACHSS), IOC Research Center, Amsterdam, the Netherlands
| | - C W DiGiovanni
- Foot and Ankle Research and Innovation Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, USA.,Foot and Ankle Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Yawkey Building, 55 Fruit St, Boston, MA, 02114, USA.,Newton-Wellesley Hospital, Harvard Medical School, Massachusetts General Hospital, 2014 Washington St, Newton, MA, 02462, USA.,Amsterdam Collaboration for Health and Safety in Sports (ACHSS), IOC Research Center, Amsterdam, the Netherlands
| | - D Guss
- Foot and Ankle Research and Innovation Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, USA.,Foot and Ankle Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Yawkey Building, 55 Fruit St, Boston, MA, 02114, USA.,Newton-Wellesley Hospital, Harvard Medical School, Massachusetts General Hospital, 2014 Washington St, Newton, MA, 02462, USA.,Amsterdam Collaboration for Health and Safety in Sports (ACHSS), IOC Research Center, Amsterdam, the Netherlands
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8
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Kang L, Helms E, Broadhead M. Bilateral ankle syndesmosis injury: a rare case report. Orthop Rev (Pavia) 2022. [DOI: 10.52965/001c.35494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
This report describes a case of bilateral acute ankle syndesmosis injuries in a 15-year-old male basketball player. The patient had a background of previous inversion injuries but no symptoms of chronic pain or instability. The case report illustrates the importance of clinical suspicion when evaluating acute syndesmosis injuries in conjunction with radiographic assessments in primary care. This is the first reported case of such injury in bilateral limbs.
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Rammelt S, Bartoníček J, Kroker L. Pathoanatomy of the Anterolateral Tibial Fragment in Ankle Fractures. J Bone Joint Surg Am 2022; 104:353-363. [PMID: 35122687 DOI: 10.2106/jbjs.21.00167] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The anterior distal tibial tubercle provides attachment to the anterior tibiofibular syndesmosis. It may be considered a fourth, or anterior, malleolus (AM). Fractures of the AM may extend into the tibial incisura and tibial plafond. The purpose of this study was to analyze the pathoanatomy of AM fractures and associated ankle injuries. METHODS One hundred and forty patients (median age, 61.0 years) with a total of 140 acute malleolar fractures (OTA/AO 44) involving the anterolateral distal tibial rim were analyzed with computed tomography (CT) imaging. All components of the malleolar fractures were analyzed and classified. Fracture patterns were compared with those of all patients with malleolar fractures treated during the same 9-year period. Patients with fractures of the tibial pilon (OTA/AO 43) and patients <18 years of age were excluded. RESULTS Of the 140 AM fractures, 52.9% were classified as type 1 (extra-articular avulsion); 35.7%, type 2 (incisura and plafond involvement); and 11.4%, type 3 (impaction of the anterolateral plafond). The fibula was fractured in 87.1%; the medial malleolus, in 66.4%; and the posterior malleolus, in 68.6%. An isolated AM fracture was seen in 4.3%. The size of the AM fractures correlated negatively with that of the posterior malleolar fractures. The proportion of pronation-abduction fractures increased and the proportion of supination-external rotation fractures decreased as the type of AM fracture increased. A fracture involving the AM occurred in 12.6% of all ankle fractures and occurred significantly more frequently in pronation-type injuries and elderly patients. No supination-adduction fractures with AM involvement were seen. The intraclass correlation coefficient for the proposed classification of the AM fractures was 0.961 (95% confidence interval [CI] = 0.933 to 0.980) for interobserver agreement and 0.941 (95% CI = 0.867 to 0.974) for intraobserver agreement. CONCLUSIONS Knowledge of the 3D pathoanatomy of AM fractures and associated malleolar fractures may help with surgical decision-making and planning. CT imaging should be employed generously in the diagnosis of complex ankle fractures, in particular with pronation-type injuries. CLINICAL RELEVANCE Depending on the individual 3D fracture pattern, fixation of displaced anterolateral distal tibial fragments potentially contributes to the restoration of joint congruity, tibiofibular alignment, and syndesmotic stability in complex malleolar fractures.
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Affiliation(s)
- Stefan Rammelt
- Center of Orthopaedics, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Jan Bartoníček
- Orthopaedic Department of First Faculty of Medicine, Charles University and Central Military Hospital, Prague, Czech Republic
| | - Livia Kroker
- Center of Orthopaedics, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus, Dresden, Germany
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10
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Gilbertson JA, Sweet MC, Weistroffer JK, Jastifer JR. Articular Cartilage of the Syndesmosis: Avoiding Iatrogenic Cartilage Injury During Syndesmotic Fixation. Foot Ankle Int 2022; 43:186-192. [PMID: 34493113 DOI: 10.1177/10711007211041325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The optimal surgical management of syndesmosis injuries consists of internal fixation between the distal fibula and tibia. Much of the available data on this joint details the anatomy of the syndesmotic ligaments. Little is published evaluating the distribution of articular cartilage of the syndesmosis, which is of importance to minimize the risk of iatrogenic damage during surgical treatment. The purpose of this study is to describe the articular cartilage of the syndesmosis. METHODS Twenty cadaveric ankles were dissected to identify the cartilage of the syndesmosis. Digital images of the articular cartilage were taken and measured using calibrated digital imaging software. RESULTS On the tibial side, distinct articular cartilage extending above the plafond was identified in 19/20 (95%) specimens. The tibial cartilage extended a mean of 6 ± 3 (range, 2-13) mm above the plafond. On the fibular side, 6/20 (30%) specimens demonstrated cartilage proximal to the talar facet, which extended a mean of 24 ± 4 (range, 20-31) mm above the tip of the fibula. The superior extent of the syndesmotic recess was a mean of 10 ± 3 (range, 5-17) mm in height. In all specimens, the syndesmosis cartilage did not extend more than 13 mm proximal to the tibial plafond and the syndesmotic recess did not extend more than 17 mm proximal to the tibial plafond. CONCLUSION Syndesmosis fixation placed more than 13 mm proximal to the tibial plafond would have safely avoided the articular cartilage in all specimens and the synovial-lined syndesmotic recess in most. CLINICAL RELEVANCE This study details the articular anatomy of the distal tibiofibular joint and provides measurements that can guide implant placement during syndesmotic fixation to minimize the risk of iatrogenic cartilage damage.
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Affiliation(s)
- Jeffrey A Gilbertson
- Department of Orthopaedic Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
| | - Matthew C Sweet
- Department of Orthopaedic Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
| | - Joseph K Weistroffer
- Department of Orthopaedic Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
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Surgical Anatomy for Fibular Free Flap Focusing on the Inferior Tibiofibular Syndesmotic System: A Cadaveric Study and Case Series of 3-Dimensional Prefabricate Cutting Guided Fibular Free Flap. J Craniofac Surg 2021; 33:951-955. [DOI: 10.1097/scs.0000000000008323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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12
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Pflüger P, Braun KF, Mair O, Kirchhoff C, Biberthaler P, Crönlein M. Current management of trimalleolar ankle fractures. EFORT Open Rev 2021; 6:692-703. [PMID: 34532077 PMCID: PMC8419795 DOI: 10.1302/2058-5241.6.200138] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
A trimalleolar ankle fracture is considered unstable and treatment is generally performed operatively. Computed tomography is important for the operative planning by providing an elaborated view of the posterior malleolus. Trimalleolar ankle fractures have a rising incidence in the last decade with up to 40 per 100,000 people per year. With a growing number of elderly patients, trimalleolar ankle injuries will become more relevant in the form of fragility fractures, posing a particular challenge for trauma surgeons. In patients with osteoporotic trimalleolar ankle fractures and relevant concomitant conditions, further evidence is awaited to specify indications for open reduction and internal fixation or primary transfixation of the ankle joint. In younger, more demanding patients, arthroscopic-assisted surgery might improve the outcome, but future research is required to identify patients who will benefit from assisted surgical care. This review considers current scientific findings regarding all three malleoli to understand the complexity of trimalleolar ankle injuries and provide the reader with an overview of treatment strategies and research, as well as future perspectives. Cite this article: EFORT Open Rev 2021;6:692-703. DOI: 10.1302/2058-5241.6.200138
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Affiliation(s)
- Patrick Pflüger
- Department of Trauma Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Karl-Friedrich Braun
- Department of Trauma Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany.,Department of Traumatology and Reconstructive Surgery including Department of Orthopedic Surgery, Charite Universitätsmedizin Berlin, Berlin, Germany
| | - Olivia Mair
- Department of Trauma Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Chlodwig Kirchhoff
- Department of Trauma Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Peter Biberthaler
- Department of Trauma Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Moritz Crönlein
- Department of Trauma Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
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Grewal US, Southgate C, Dhinsa BS. Sub-Acute Syndesmotic Injury: A Review and Proposed Treatment Algorithm. Cureus 2021; 13:e16670. [PMID: 34462694 PMCID: PMC8390008 DOI: 10.7759/cureus.16670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2021] [Indexed: 11/05/2022] Open
Abstract
Sub-acute syndesmotic injuries are classified as from six weeks to six months from the initial injury date and can be considered a distinct group of patients; however, they are often mistreated and progress to chronic injuries with significant sequelae. The authors performed a comprehensive literature search on the MEDLINE database. The search yielded 165 studies up to January 2021, after the application of inclusion/exclusion criteria. This yielded 10 studies with a total of 156 relevant patients for review. We found that a delay in diagnosis is common and has a negative impact on outcomes. If a sub-acute syndesmotic injury is suspected and plain radiographs are inconclusive, magnetic resonance imaging is indicated if there is still an index of suspicion. Surgical intervention should aim to restore normal length and rotational alignment of the fibula whilst also addressing the need to debride tissues within the joint and syndesmosis. Syndesmosis must then be adequately reduced and stabilised with syndesmotic screw fixation, and augmentation with tendon/ligament reconstruction should be considered. All studies showed an average improvement in functional outcome measures post-operatively. The only study to compare sub-acute and chronic patients' functional outcomes post-operatively showed significant improvement in the sub-acute cohort; highlighting the importance of early intervention. We suggest a treatment algorithm that may help with the diagnosis and management of these injuries. We believe this will help all healthcare professionals to standardise care. Further research is required to assess sub-acute injury outcomes with tendon/ligamentous augmented reconstruction, as no level 1 or 2 studies currently exist.
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Kellam PJ, Dekeyser GJ, Haller JM, Rothberg DL, Higgins TF, Marchand LS. Predicting Syndesmotic Injury in OTA/AO 44-B2.1 (Danis-Weber B) Fractures. J Orthop Trauma 2021; 35:473-478. [PMID: 33395177 DOI: 10.1097/bot.0000000000002052] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/22/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To establish if preoperative radiographs could predict the rate of syndesmotic injury. SETTING Level 1 trauma center. DESIGN Retrospective cohort study. PATIENTS/PARTICIPANTS There were 548 OTA/AO 44-B2.1 fractures that were reviewed, and 287 patients were included in the study. MAIN OUTCOME MEASUREMENTS Ankle radiographs were used to determine the zone of distal extent of the proximal fracture fragment. Syndesmotic injury was defined as positive intraoperative stress examination that required syndesmotic fixation. RESULTS There were 191 zone 1 (ending below the plafond) injuries, 57 zone 2 (ending between the physeal scar and the plafond) injuries, and 39 zone 3 (ending above the physeal scar) injuries. Of these, 17% (33 patients) of zone 1, 42% (24) of zone 2, and 74% (29) of zone 3 fractures had syndesmotic injuries. The relative risk of syndesmotic injury of zone 1 compared with zone 2 was 2.4 (P < 0.001), zone 1 to zone 3 was 4.3 (P < 0.001), and zone 2 to zone 3 was 1.8 (P = 0.002). The interobserver and intraobserver reliability was excellent (κ = 0.86, 0.94). CONCLUSION OTA/AO 44-B2.1 fractures have a varying rate of syndesmotic injury. Weber B fractures that end between the level of the plafond and the physeal scar (zone 2) are 2.4 times more likely to have a syndesmotic injury compared with those that end below the plafond (zone 1). This is magnified in those injuries ending above the scar (zone 3). This simple classification of OTA/AO 44-B2.1 fractures is predictive of syndesmotic injury and may aid in preoperative counseling and planning. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Patrick J Kellam
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT
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Fisher A, Bond A, Philpott MDG, Jayatilaka MLT, Lambert LA, Fisher L, Weigelt L, Myatt D, Molloy A, Mason L. The anatomy of the anterior inferior tibiofibular ligament and its relationship with the Wagstaffe fracture. Foot Ankle Surg 2021; 27:291-295. [PMID: 33446454 DOI: 10.1016/j.fas.2021.01.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 12/28/2020] [Accepted: 01/04/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Our aim in this study was to identify the fibular footprint of the Anterior Inferior Tibiofibular Ligament (AITFL) and its relation to Wagstaffe fracture fragment size. METHODS We examined 25 cadaveric lower limbs which were carefully dissected to identify the lateral ankle ligaments. The AITFL anatomy was compared to 40 Wagstaffe fractures identified from our ankle fracture database. RESULTS The AITFL origin was from the anterior fibular tubercle with an average length of 21.61 mm (95% CI 20.22, 22.99). The average distance of the distal aspect of the AITFL footprint to the distal fibula margin was 11.60 mm (95% CI 10.49, 12.71). In the ankle fractures analyzed, the average length of the Wagstaffe fragment was 17.88 mm (95% CI 16.21, 19.54). The average distance from the distal tip of the fibula to the Wagstaffe fracture fragment was 21.40 mm (95% CI 19.78, 23.01). In total there were 22 syndesmosis injuries. There was no statistical difference in Wagstaffe fragment size between stable and unstable groups. CONCLUSION The AITFL fibular origin was both larger and more distal than the Wagstaffe fracture fragments seen in our institution. Therefore, this suggests that a ligamentous failure will also have to occur to result in syndesmotic instability. The size of fracture fragment also did not confer to syndesmotic instability on testing. Level of Evidence - 3.
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Affiliation(s)
| | | | | | | | | | - Lauren Fisher
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | | | - Darren Myatt
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Andrew Molloy
- University of Liverpool, Liverpool, UK; Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Lyndon Mason
- University of Liverpool, Liverpool, UK; Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.
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Ferkel RD, Kwong C, Farac R, Pinto M, Fahimi N, Rahhal S, Marumoto J. Arthroscopic Posterior Ankle Ligament Anatomy. FOOT & ANKLE ORTHOPAEDICS 2021; 6:24730114211000624. [PMID: 35097439 PMCID: PMC8564934 DOI: 10.1177/24730114211000624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The purpose of this article is to document the normal arthroscopic appearance of the posterior ankle capsular and ligamentous structures, and variations in their anatomical relationships. METHODS 102 ankle arthroscopy videotapes were evaluated retrospectively for the configuration of the posterior capsuloligamentous structures. Based on these observations, the variations in the appearance and position of the posterior tibiofibular ligament (PTFL) and transverse (tibiofibular) ligament (TTFL) were documented. In addition, differences in the appearance of the flexor hallucis longus (FHL) were also noted. RESULTS All patients had evidence of both a PTFL and TTFL, which formed a labrum or meniscus-like addition to the posterior distal tibia. No patients demonstrated disruption of the PTFL; 3 had tears of the TTFL. We noted 4 distinct patterns of the PTFL and the TTFL. Thirty-four patients (33%) had a gap of ≥2 mm between the 2 ligamentous structures. Thirty-three (32.4%) had a gap <2 mm between the PTFL and TTFL. Twenty-six (25.5%) had a confluence of the 2 ligaments without a gap. Nine (9%) demonstrated a sizable gap between the 2 ligaments, and the TTFL appeared as a "cord-like" structure. CONCLUSION To our knowledge, this is the first article to describe the variations in the arthroscopic normal posterior capsuloligamentous structures and FHL of the ankle. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
| | - Cory Kwong
- Southern California Orthopedic Institute, Van Nuys, CA, USA
| | | | - Mark Pinto
- Chelsea Orthopedic Specialists, Chelsea, MI, USA
| | - Nader Fahimi
- Elite Orthopaedics & Sports Medicine, Clifton, NJ, USA
| | - Scott Rahhal
- Advanced Orthopedics of Oklahoma, Tulsa, OK, USA
| | - Jay Marumoto
- Orthopedic Associates of Hawaii, Honolulu, HI, USA
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Fixation of anterolateral distal tibial fractures: the anterior malleolus. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2021; 33:125-138. [PMID: 33751133 DOI: 10.1007/s00064-021-00703-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 09/12/2020] [Accepted: 10/14/2020] [Indexed: 12/30/2022]
Abstract
OBJECTIVE The anterior tibial rim with the anterolateral tibial tubercle provides attachment to the anterior tibiofibular syndesmosis. It may be considered an anterior or "fourth" malleolus. Fixation of a displaced anterior tibial fragment in the treatment of malleolar fractures aims at providing a bone-to-bone fixation of the anterior tibiofibular ligament and restoring the integrity of the tibial incisura. INDICATIONS Displaced intra-articular fragments of the anterior tibia; fractures involving the tibial incisura; fractures with intercalary fragments; impaction of the anterior tibial plafond; syndesmotic avulsions producing instability or preventing reduction of the distal fibula into the tibial incisura. CONTRAINDICATIONS Critical local soft tissues preventing an anterolateral approach; missing consent to surgery by the patient; overall critical general condition preventing surgery to the extremities. SURGICAL TECHNIQUE Anterolateral approach over the tibial tubercle. Identification and mobilization of the anterior tibial fragment without dissecting the anterior syndesmosis. Reduction of the anterior tibial fragment with a pointed reduction clamp. Fixation of extra-articular avulsion fractures (type 1) with suture anchor. Screw fixation of larger fragments involving the joint surface and incisura (type 2). Disimpaction, realignment of the joint surface, bone grafting as needed and plate fixation of impaction fractures of the anterolateral tibial plafond (type 3). POSTOPERATIVE MANAGEMENT Mobilization with partial weight bearing (15-20 kg) in a special boot (ankle foot orthosis) or cast for 6-8 weeks depending on the overall malleolar fracture pattern, bone quality and patient compliance. RESULTS Few studies report the results of anterior tibial fractures in adults. Failure to fix displaced fragments frequently leads to nonunions. Overlooked Chaput fractures have been reported to result in malpositioning of the distal fibula in the tibial incisura leading to incongruity of the ankle mortise requiring revision surgery. Secondary avascular necrosis of the anterolateral tibial plafond may develop after joint impaction.
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Rammelt S, Bartoníček J, Neumann AP, Kroker L. [Fractures of the anterolateral tibial rim : The fourth malleolus]. Unfallchirurg 2021; 124:212-221. [PMID: 33580301 DOI: 10.1007/s00113-021-00959-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2021] [Indexed: 01/28/2023]
Abstract
The anterolateral tibial rim with the anterior tibial tubercle (Tubercule de Tillaux-Chaput) serves as an insertion site of the anterior inferior tibiofibular ligament (AITFL). It can also be termed the anterior malleolus or fourth malleolus. Fractures of the anterolateral tibial rim typically result from an external rotation or abduction mechanism of the talus within the ankle mortise. They are frequently overlooked in plain radiographs. Computed tomography (CT) is needed for an exact visualization of the fracture anatomy and treatment planning. A total of three main types can be differentiated: (1) extra-articular avulsion fracture of the AITFL, (2) fracture of the anterolateral distal tibia with involvement of the joint and tibial incisura and (3) impaction fracture of the anterolateral tibial plafond. Surgical fixation of displaced anterolateral distal tibial fractures aims at bone-to-bone stabilization of the anterior syndesmosis, restoration of the tibial incisura for the distal fibula and joint surface. Displaced extra-articular avulsion fractures (type 1) are fixed with a suture anchor or transosseal suture. Larger fragments involving the tibial incisura and plafond (type 2) are mostly fixed with screws. Impression fractures of the anterolateral tibial plafond (type 3) necessitate elevation with restoration of the joint surface, bone grafting of the impaction zone as needed and anterior buttress plating. Only a few studies have reported the treatment results of anterolateral tibial rim fractures in adults. Conservative treatment of dislocated fragments reportedly leads to non-union and malposition of the distal fibula with incongruence of the ankle mortise requiring revision. Impaction fractures (type 3) can lead to secondary avascular necrosis of the anterolateral tibial plafond.
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Affiliation(s)
- Stefan Rammelt
- UniversitätsCentrum für Orthopädie, Plastische und Unfallchirurgie, Universitätsklinikum Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland.
| | - Jan Bartoníček
- 1. Medizinische Fakultät der Karls-Universität und Militärkrankenhaus Prag, Prag, Tschechien
| | - Annika Pauline Neumann
- UniversitätsCentrum für Orthopädie, Plastische und Unfallchirurgie, Universitätsklinikum Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland
| | - Livia Kroker
- UniversitätsCentrum für Orthopädie, Plastische und Unfallchirurgie, Universitätsklinikum Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland
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19
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Abstract
"Chronic syndesmotic injury covers a broad range of symptoms and pathologies. Anterolateral ankle impingement without instability is treated by arthroscopic debridement. Subacute, unstable, syndesmotic injuries are treated by arthroscopic or open debridement followed by secondary stabilization using suture button device or permanent screw placement. Chronic syndesmotic instability is treated by a near-anatomic ligamentoplasty supplemented by screw fixation. In case of poor bone stock, failed ligament reconstruction, or comorbidities, tibiofibular fusion with bone grafting is preferred. Malleolar malunions and particularly anterior or posterior syndesmotic avulsions must be corrected in order to achieve a stable and congruent ankle mortise."
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Affiliation(s)
- Stefan Rammelt
- University Center for Orthopaedics, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at the TU Dresden, Fetscherstrasse 74, Dresden 01307, Germany.
| | - Andrzej Boszczyk
- Department of Traumatology and Orthopaedics, Centre of Postgraduate Medical Education, Adam Gruca Clinical Hospital, Konarskiego Str. 13, Otwock 05-400, Poland
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20
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Huang H, Yang Y. [Research progress in diagnosis and treatment of distal tibiofibular syndesmosis injury]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2020; 34:1346-1351. [PMID: 33063503 DOI: 10.7507/1002-1892.201911090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To review the research progress in the diagnosis and treatment of distal tibiofibular syndesmosis injury. Methods The recent literature about distal tibiofibular syndesmosis injury was reviewed and analyzed. Results Distal tibiofibular syndesmosis injury is commonly seen in ankle joint injury, the anatomical complexities make diagnosis and treatment difficult. Preoperative physical examination, radiologic evaluation, and intraoperative stress-testing are important for the diagnosis. Aggressive treatment is also recommended for these injuries to prevent long-term chronic instability. Internal fixation is the main treatment, including metal screw, degradable screw, elastic fixation, and hybrid techniques. Metal screw fixation is still the current mainstream, but elastic fixation represented by Suture-button is more in line with the physiological characteristics of ankle joint, and the rate of secondary operation is low while the clinical outcome is satisfactory. The application prospect of elastic fixation is worthy of expectation. Conclusion It's crucial for patient with ankle fracture to repair the distal tibiofibular syndesmosis injury. How to diagnose the injury more accurately and simply, how to increase the success rate of reduction, and how to reduce the complications of surgery are still worthy for further exploration.
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Affiliation(s)
- Hui Huang
- Department of Orthopaedics, Tongji Hospital, Tongji University, Shanghai, 200065, P.R.China
| | - Yunfeng Yang
- Department of Orthopaedics, Tongji Hospital, Tongji University, Shanghai, 200065, P.R.China
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Fujimoto S, Teramoto A, Anzai K, Murahashi Y, Okada Y, Kamiya T, Watanabe K, Fujimiya M, Yamashita T. Tibial Plafond Attachment of the Posterior-Inferior Tibiofibular Ligament: A Cadaveric Study. FOOT & ANKLE ORTHOPAEDICS 2020; 5:2473011420945689. [PMID: 35097406 PMCID: PMC8702662 DOI: 10.1177/2473011420945689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Some recent studies have reported the role of the posterior malleolus as an attachment of the posterior-inferior tibiofibular ligament (PITFL) and suggested that even a small fragment should be fixed. However, there are few anatomic studies of the tibial plafond attachment of the PITFL. Methods: Seven Thiel-embalmed ankles were obtained. The margin of the distal tibial joint surface and the attachments of the superficial fiber of the PITFL (sPITFL) and the deep fiber (dPITFL) were identified. In the frontal view, the percentages of the attachments of the sPITFL and dPITFL of the mediolateral dimension of the posterior tibial plafond were measured. In the lateral view, the line that started from the proximal margin of the attachment of the sPITFL and parallel to the tibial axis was drawn, and the distance between that line and the posterior edge of the joint surface was measured (AP distance of the sPITFL). Then, the percentage of the AP distance of the sPITFL of the joint surface in the anteroposterior dimension of the tibial plafond was measured. Results: In the frontal view, the mediolateral distance of the attachment of the sPITFL was 5.0 mm, and that of the dPITFL was 19.5 mm. The percentage of the attachment of the sPITFL on the tibial plafond was 20.6%, and that of the dPITFL was 78.2%. In the lateral view, the average AP distance of the sPITFL was 0.5 mm, and the percentage in the anteroposterior dimension of the tibial plafond was 1.7%. Conclusion: The PITFL was attached to less than 10% of the anteroposterior dimension of the tibial plafond in most ankles. Conversely, the PITFL attached widely in the mediolateral dimension. Clinical Relevance: This study suggests that the size of the posterior malleolar fragment in the mediolateral dimension could help estimate how much of the PITFL attaches to the fragment which may have implications for ankle stability.
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Affiliation(s)
- Shutaro Fujimoto
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Atsushi Teramoto
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Ken Anzai
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Yasutaka Murahashi
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Yohei Okada
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Tomoaki Kamiya
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Kota Watanabe
- Second Division of Physical Therapy, Sapporo Medical University School of Health Sciences, Sapporo, Hokkaido, Japan
| | - Mineko Fujimiya
- Department of Anatomy, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Toshihiko Yamashita
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
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Burssens A, Krähenbühl N, Weinberg MM, Lenz AL, Saltzman CL, Barg A. Comparison of External Torque to Axial Loading in Detecting 3-Dimensional Displacement of Syndesmotic Ankle Injuries. Foot Ankle Int 2020; 41:1256-1268. [PMID: 32672067 DOI: 10.1177/1071100720936596] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Current imaging techniques try to quantify 3-dimensional displacement of syndesmotic ankle injuries using 2-dimensional measurements, which may obscure an exact diagnosis. Therefore, our aim was to determine 3-dimensional displacement of syndesmotic ankle injuries under load and torque using a weightbearing computed tomography (WBCT) and to assess the relation with previously established 2-dimensional measurements. METHODS Seven paired cadaver specimens were mounted into a radiolucent frame. WBCT scans were obtained to generate 3-dimensional models after different patterns of axial load (0 kg, 85 kg) combined with external torque (0, 10 Nm). Sequential imaging was repeated in ankles containing intact syndesmotic ligaments, sectioning of the anterior inferior tibiofibular ligament (AITFL; condition 1A), deltoid ligament (DL; condition 1B), combined AITFL+DL (condition 2), and AITFl+DL+interosseous membrane (condition 3). Reference anatomical landmarks were established relative to the intact position of the fibula to quantify displacement. A subsequent correlation analysis was performed between the obtained 2- and 3-dimensional measurements. RESULTS Axial load increased lateral translation (mean = -0.9 mm, 95% confidence interval [CI]: 1.3, -0.1) significantly in condition 2 relative to the intact ankle (P < .05) but did not demonstrate other significant displacements. External torque increased displacement significantly in all directions (P < .05), except for dorsal translation of the fibula (P > .05). The highest displacement could be detected when external torque was applied in condition 3 and consisted of posterior translation (mean = -3.1 mm; 95% CI: -4.8, -2.7) and external rotation (mean = -4.7 degrees; 95% CI: -5.6, -2.9). Pearson correlation coefficients between the 2-dimensional and 3-dimensional measurements were moderate and ranged from 0.31 to 0.56 (P < .05). CONCLUSION External torque demonstrated superiority over axial load in detecting syndesmotic ankle instability. Axial load increased lateral translation; however, differences were submillimeter in magnitude until torque was applied. A moderate correlation was found with previously established 2-dimensional measurements. CLINICAL RELEVANCE In clinical practice these findings substantiate application of external torque in current imaging modalities to improve detection of syndesmotic ankle injuries.
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Affiliation(s)
- Arne Burssens
- Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA
| | - Nicola Krähenbühl
- Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA
| | | | - Amy L Lenz
- Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA
| | | | - Alexej Barg
- Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA.,Deartment of Orthopaedics, Trauma and Reconstructive Surgery, University of Hamburg, Hamburg, Germany
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Abstract
Diagnosis and management of isolated syndesmotic injuries are controversial and highly debated. Hence, the aim of this study is to explore and gain the current understanding pertaining to detailed anatomy of syndesmotic ligaments through a systematic review of published cadaveric studies. A systematic review was conducted online for literature published in English using PubMed and Google Scholar, as per PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, up to April 30, 2019. Predefined eligibility criteria were applied, and the data thus compiled was analyzed. Study quality was assessed based on Quality Appraisal for Cadaveric Studies (QUACS) scale. A total of 12 studies reporting 365 ankles were included in this review. Considerable inconsistency in the naming and description of syndesmotic ligaments was observed, with only 2 studies reporting the vasculature of the ligaments. Hence further investigation of the anatomy of the syndesmotic ligaments is recommended so as to better inform clinical practice, as awareness of anatomy is critical for assessment, healing, and successful surgical management.Levels of Evidence: Level III: Systematic review of anatomical dissections.
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Affiliation(s)
- Akilesh Anand Prakash
- Department of Sports Medicine, Anamiivaa Clinic and Sports Medicine Centre, Coimbatore, Tamil Nadu, India
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24
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Littlechild J, Mayne A, Harrold F, Chami G. A cadaveric study investigating the role of the anterior inferior tibio-fibular ligament and the posterior inferior tibio-fibular ligament in ankle fracture syndesmosis stability. Foot Ankle Surg 2020; 26:547-550. [PMID: 31345649 DOI: 10.1016/j.fas.2019.06.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 05/28/2019] [Accepted: 06/25/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND This cadaveric study aimed to investigate the role AITFL and PITFL have on preventing talar shift in ankle fractures, as well as investigating the role of AITFL reconstruction in preventing talar shift. METHODS Twelve lower limb cadavers were used. Talar shift was measured following: Step 1- no ligaments cut; Step 2- entire deltoid ligament division; Step 3- group A (5 specimens) PITFL cut whilst group B (7 specimens) AITFL cut; Step 4- group A had AITFL divided whilst group B had PITFL cut. Reconstruction of the AITFL was performed using part of the superior extensor retinaculum as a local flap. Measurement of talar shift was then repeated. RESULTS With no ligaments divided, mean talar shift was 0.8mm for group A and 0.7mm for group B. When the deltoid ligament was divided, mean talar shift for group A was 4.8mm compared to 4.7mm in group B (P=1.00). The mean shift in group A after PITFL division was 6.0mm, increasing the talar shift by an average of 1.2mm. In group B after AITFL division mean talar shift was 8.3mm (P=0.06), increasing talar shift by an average of 3.6mm. After division of the second tibiofibular ligament, mean talar shift in group A measured 10.0mm and in group B was 10.9mm (P=0.29). Three times more talar shift occurred after the AIFTL was divided compared to the PITFL (P=0.06). CONCLUSION Consequently, repairing the PITFL in isolation (for example by fixation of a posterior malleolus avulsion fracture) may not adequately prevent talar shift; we feel consideration should also be given to reconstruction of the AITFL to augment the syndesmosis fixation, which may provide a stronger restoration of ankle stability. LEVEL OF CLINICAL EVIDENCE 5.
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Affiliation(s)
| | | | | | - George Chami
- St Bernards Hospital, Harbour View Road, Gibraltar.
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Abstract
Optimal healing for fractures requires anatomic reduction and stable fixation. This optimizes not only bone healing, but optimal function within the limb including joint functioning. Proper ligamentous healing is also crucial for optimal functioning. In patients with injuries around the ankle involving distal tibiofibular syndesmotic injuries of the ankle, malreduction of the syndesmosis is a potential consequence that can lead to chronic pain and functional limitations. This article discusses proper ways of evaluating reduction of the syndesmosis and surgical revision for the chronic injury.
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Krähenbühl N, Bailey TL, Weinberg MW, Davidson NP, Hintermann B, Presson AP, Allen CM, Henninger HB, Saltzman CL, Barg A. Is load application necessary when using computed tomography scans to diagnose syndesmotic injuries? A cadaver study. Foot Ankle Surg 2020; 26:198-204. [PMID: 30853391 DOI: 10.1016/j.fas.2019.02.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 01/27/2019] [Accepted: 02/09/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Injuries to the distal tibio-fibular ligaments are common. While pronounced injuries can be reliably diagnosed using conventional radiographs, assessment of subtle syndesmotic injuries is challenging. This cadaver study determines the impact of loading on the assessment of incomplete and more complete syndesmotic injuries when using weightbearing computed tomography (CT) scans. METHODS Fourteen paired male cadavers (tibial plateau to toe-tip) were included. A radiolucent frame held specimens in a plantigrade position while both non-weightbearing and weightbearing computed tomography (CT) scans were taken. The following conditions were tested: First, intact ankles (Native) were scanned. Second, one specimen from each pair underwent anterior inferior tibio-fibular ligament (AITFL) transection (Condition 1A), while the contralateral underwent deltoid transection (Condition 1B). Third, the remaining intact deltoid or AITFL was transected from each specimen (Condition 2). Finally, the distal tibiofibular interosseous membrane (IOM) was transected in all ankles (Condition 3). Eight different measurements were performed to assess the integrity of the distal tibio-fibular syndesmosis on axial CT scans. RESULTS Load application had no impact on most measurements. While incomplete syndesmotic injuries could not be identified, cadavers with more complete injuries differentiated from native ankles when assessed using axial CT images. No significant difference was evident between discrete AITFL or deltoid ligament transection. CONCLUSIONS In a cadaver model, load application had no effect on the assessment of the distal tibio-fibular syndesmosis in incomplete and more complete syndesmotic injuries. Only more complete injuries of the distal tibio-fibular syndesmosis could be identified using axial CT images.
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Affiliation(s)
- Nicola Krähenbühl
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, USA
| | - Travis L Bailey
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT 84132, USA
| | - Maxwell W Weinberg
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, USA
| | - Nathan P Davidson
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, USA
| | - Beat Hintermann
- Department of Orthopaedics, Kantonsspital Baselland, Rheinstrasse 26, 4410, Liestal, Switzerland
| | - Angela P Presson
- Division of Epidemiology, Department of Internal Medicine, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Chelsea McCarty Allen
- Division of Epidemiology, Department of Internal Medicine, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Heath B Henninger
- Orthopaedic Research Laboratory, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, USA
| | - Charles L Saltzman
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, USA
| | - Alexej Barg
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, USA.
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Kikuchi S, Tajima G, Sugawara A, Yan J, Maruyama M, Oikawa S, Saigo T, Oikawa R, Doita M. Characteristic features of the insertions of the distal tibiofibular ligaments on three-dimensional computed tomography- cadaveric study. J Exp Orthop 2020; 7:3. [PMID: 31974931 PMCID: PMC6977791 DOI: 10.1186/s40634-020-0220-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 01/10/2020] [Indexed: 01/15/2023] Open
Abstract
Purpose The purpose of this study was to clarify the insertion sites of the anterior inferior tibiofibular ligament (AITFL) and posterior inferior tibiofibular ligament (PITFL) and related osseous landmarks on three-dimensional computed tomography images. Methods Twenty-nine non-paired, formalin-fixed human cadaveric ankles were evaluated. The tibial and fibular insertion sites of the AITFL and PITFL were identified. The morphology and location of the insertion sites and their positional relationships with osseous structures were analyzed on three-dimensional computed tomography images. Results The AITFL had a trapezoidal shape, with fibers that ran obliquely lateral from a wider insertion at the lateral distal tibia to the medial distal fibula. The PITFL had a similar shape to the AITFL; however, it ran more horizontally, with fibers running in the same direction. In the tibia, the anterior capsular ridge and the Chaput’s and Volkmann’s tubercles were useful osseous landmarks for the insertion sites. In the fibula, the centers of the insertion sites of the AITFL and PITFL were located on the edges of the distal anterior and posterior fibula, which were useful osseous landmarks. The mean distances between the center points of the tibial and fibular insertion sites of the AITFL and PITFL were 10.1 ± 2.4 mm and 11.7 ± 2.6 mm, respectively. Conclusions The relationships between the characteristic features of the distal tibia and fibula and the insertions of the AITFL and PITFL were consistent. The present findings improve the understanding of the anatomy of the insertions of the distal tibiofibular syndesmotic joint.
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Affiliation(s)
- Sho Kikuchi
- Department of Orthopedic Surgery, Iwate Medical University, Uchimaru, 19-1, Morioka, Iwate, Japan.
| | - Goro Tajima
- Department of Orthopedic Surgery, Iwate Medical University, Uchimaru, 19-1, Morioka, Iwate, Japan
| | - Atsushi Sugawara
- Department of Orthopedic Surgery, Iwate Medical University, Uchimaru, 19-1, Morioka, Iwate, Japan
| | - Jun Yan
- Department of Anatomy, Iwate Medical University, Uchimaru,19-1, Morioka, Japan
| | - Moritaka Maruyama
- Department of Orthopedic Surgery, Iwate Medical University, Uchimaru, 19-1, Morioka, Iwate, Japan
| | - Shinya Oikawa
- Department of Orthopedic Surgery, Iwate Medical University, Uchimaru, 19-1, Morioka, Iwate, Japan
| | - Takaaki Saigo
- Department of Orthopedic Surgery, Iwate Medical University, Uchimaru, 19-1, Morioka, Iwate, Japan
| | - Ryunosuke Oikawa
- Department of Orthopedic Surgery, Iwate Medical University, Uchimaru, 19-1, Morioka, Iwate, Japan
| | - Minoru Doita
- Department of Orthopedic Surgery, Iwate Medical University, Uchimaru, 19-1, Morioka, Iwate, Japan
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Bergman C, Morin M, Lawson K. Anatomy, Classification, and Management of Ankle Fractures Involving the Posterior Malleolar Fragment: A Literature Review. FOOT & ANKLE ORTHOPAEDICS 2019; 4:2473011419887724. [PMID: 35097350 PMCID: PMC8697079 DOI: 10.1177/2473011419887724] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The posterior malleolar fragment is frequently involved in rotational ankle fractures, but diagnosis and definitive management remains controversial. Ankle fractures with a posterior malleolar component that are not identified and treated in a timely manner may contribute significantly to future comorbidities, including continued pain, instability, and the development of arthritis. This article highlights the anatomic features of posterior malleolar ankle fractures, the classification schemes used, and discusses the various nonsurgical and surgical methods currently used.
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Affiliation(s)
| | - Matthew Morin
- Department of Orthopedic Surgery, Banner University Medical Center, AZ, USA
| | - Kevin Lawson
- Department of Orthopedic Surgery, Banner University Medical Center, AZ, USA
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Tourné Y, Molinier F, Andrieu M, Porta J, Barbier G. Diagnosis and treatment of tibiofibular syndesmosis lesions. Orthop Traumatol Surg Res 2019; 105:S275-S286. [PMID: 31594732 DOI: 10.1016/j.otsr.2019.09.014] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 09/10/2019] [Indexed: 02/06/2023]
Abstract
The tibiofibular syndesmosis is a fibrous joint essential for ankle stability, whence the classical comparison with a mortise. Syndesmosis lesions are quite frequent in ankle trauma. This is a key element in ankle stability and lesions may cause pain or instability and, in the longer term, osteoarthritis. The lesions are often overlooked due to diagnostic difficulties, but collision sport with strong contact is the main culprit. Diagnosis, whether in the acute or the chronic phase, is founded on an association of clinical and paraclinical signs. Cross-sectional imaging such as MRI is fundamental to confirming clinical suspicion. Absence of tibiofibular diastasis no longer rules out the diagnosis. Stress CT and the introduction of weight-bearing CT are promising future diagnostic tools. Exhaustive osteo-ligamentous ankle assessment is necessary, as syndesmosis lesions may be just one component in more complex rotational instability. Therapeutically, arthroscopy and new fixation techniques, such as suture buttons, are opening up new perspectives, especially for chronic lesions (>6months). The present anatomic, epidemiological, diagnostic and therapeutic review does not preclude further clinical studies of rotational ankle instability with its strong risk of osteoarthritis.
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Affiliation(s)
- Yves Tourné
- Institut Grenoblois de Chirurgie du Pied, Centre Ostéoarticulaire des Cèdres, 5, Rue des Tropiques, 38130 Echirolles, France.
| | - François Molinier
- Capio Clinique des Cèdres, Château D'Alliez, 31700 Cornebarrieu, France
| | - Michael Andrieu
- Clinique Pont De Chaume, 330, avenue Marcel Unal, 82000 Montauban, France
| | - Julieta Porta
- Institut Grenoblois de Chirurgie du Pied, Centre Ostéoarticulaire des Cèdres, 5, Rue des Tropiques, 38130 Echirolles, France
| | - Geoffroy Barbier
- HFR Fribourg-Hôpital Cantonal, Chemin des Pensionnats 2-6, 1752, Villars-sur-Glâne, Switzerland
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Abstract
OBJECTIVES To compare the quality of syndesmotic reduction obtained using the incisura versus the ankle articular surface as the visual cue. Secondarily, we evaluated the difference in the anterior to posterior depth of the fibula to the tibia at the joint level and the fibula to the incisura 1 cm above the joint. METHODS Seven surgeons reduced disrupted syndesmoses of 10 cadaveric ankles using either the anterolateral articular surface of the distal tibia to the anteromedial fibular articular surface or the location of the fibula within the incisura as a visual reference. Malreductions in translation were measured in millimeter from the anatomical position of the fibula. The anterior to posterior distances of the tibia and fibula were also measured at both levels to determine the differences in their depths. RESULTS The translational reduction was within 2 mm in 93% (0.7 ± 0.7 mm) of reductions using the articular surface as a reference compared with 80% (1.2 ± 1.0 mm) using the incisura as a reference (P = 0.0001). All surgeons' reductions were better using the joint articular surface as the visual reference. The difference in the fibular and the tibial depth was smaller at the level of the articular surface versus the incisura (2.1 mm vs. 5.9 mm; P = 0.0002). CONCLUSIONS The articular surface is a significantly more accurate visual landmark for translational reduction of the syndesmosis. This is potentially explained by the larger differences in the fibula and tibial depth at the incisura versus the articular surface.
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Lamer S, Hébert-Davies J, Dubé V, Leduc S, Sandman É, Ménard J, Nault ML. Effect of a Controlled Ankle Motion Walking Boot on Syndesmotic Instability During Weightbearing: A Cadaveric Study. Orthop J Sports Med 2019; 7:2325967119864018. [PMID: 31457067 PMCID: PMC6702776 DOI: 10.1177/2325967119864018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
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.
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Affiliation(s)
- Stéphanie Lamer
- Hôpital du Sacré-Cœur de Montréal, Montréal, Quebec, Canada
- Department of Surgery, Université de Montréal, Montréal, Quebec, Canada
| | | | - Vincent Dubé
- Hôpital du Sacré-Cœur de Montréal, Montréal, Quebec, Canada
- Department of Surgery, Université de Montréal, Montréal, Quebec, Canada
| | - Stéphane Leduc
- Hôpital du Sacré-Cœur de Montréal, Montréal, Quebec, Canada
- Department of Surgery, Université de Montréal, Montréal, Quebec, Canada
| | - Émilie Sandman
- Hôpital du Sacré-Cœur de Montréal, Montréal, Quebec, Canada
- Department of Surgery, Université de Montréal, Montréal, Quebec, Canada
| | - Jérémie Ménard
- Hôpital du Sacré-Cœur de Montréal, Montréal, Quebec, Canada
| | - Marie-Lyne Nault
- Hôpital du Sacré-Cœur de Montréal, Montréal, Quebec, Canada
- Department of Surgery, Université de Montréal, Montréal, Quebec, Canada
- Harborview Medical Center, Seattle, Washington, USA
- Marie-Lyne Nault, MD, PhD, CHU Ste-Justine, 7905- 3175 chemin de la Côte Ste-Catherine, Montréal, QC H3T1C5, Canada ()
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Hagen JE, Rausch S, Simons P, Richards RG, Lenz M, Knobe M, Gueorguiev B, Klos K. Computed Tomography Analysis for Quantification of Displacement of the Distal Fibula in Different Foot Positions With Weightbearing and Sequentially Increased Instability: An Anatomic Cadaveric Study on Syndesmosis. J Foot Ankle Surg 2019; 58:734-738. [PMID: 31256900 DOI: 10.1053/j.jfas.2018.12.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Indexed: 02/03/2023]
Abstract
Syndesmotic injuries are quite common, but accurate diagnosis and treatment can be difficult, in part because of individual anatomic variation and complex movements of the fibula in the incisura. The current cadaveric study was designed to investigate changes in the position of the fibula in the incisura during simulated weightbearing in different foot positions and with sequential sectioning of syndesmotic and deltoid ligaments. Sixteen paired, fresh-frozen cadaveric limbs were embedded in polymethylmethacrylate mid-calf and placed in a weightbearing simulation frame. Computed tomography scans were obtained while the legs were in a simulated foot-flat position (75 N) and single-leg stance (700 N) in 5 foot positions: neutral, 15° external rotation, 15° internal rotation, 20° dorsiflexion, and 20° plantar flexion. The anterior-inferior tibiofibular ligament, posterior tibiofibular ligament complex, deltoid, and interosseous membranes were sectioned sequentially and rescanned. Measurements of fibular diastasis, rotation, anterior-posterior and medial-lateral translation, and fibular shortening were performed. The most destructive state resulted in the largest displacement at the syndesmosis. The degree of subluxation in all ligament states was dependent on the foot position. External rotation created statistically significant displacement at all levels of injury. There were no significant differences between sides of the same donor. Our data demonstrate the importance of foot position in reduction at the syndesmosis under weightbearing. The current ex vivo model could be used to evaluate other aspects of this injury or the value of reconstructive techniques in the future.
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Affiliation(s)
- Jennifer E Hagen
- Surgeon, AO Research Institute Davos, Davos, Switzerland; Assistant Professor, Department of Orthopedics and Rehabilitation, University of Florida, Gainesville, FL
| | - Sascha Rausch
- Surgeon, Department of Trauma, Hand and Reconstructive Surgery, University Hospital Jena, Jena, Germany.
| | - Paul Simons
- Surgeon, Department of Foot and Ankle Surgery, Catholic Clinic Mainz, Mainz, Germany
| | | | - Mark Lenz
- Surgeon, Private Docent, Department of Trauma, Hand and Reconstructive Surgery, University Hospital Jena, Jena, Germany
| | - Matthias Knobe
- Surgeon, Professor, Department of Orthopedic Trauma, University of Aachen Medical Center, Aachen, Germany
| | | | - Kajetan Klos
- Surgeon, Department of Foot and Ankle Surgery, Catholic Clinic Mainz, Mainz, Germany; Department of Trauma, Hand and Reconstructive Surgery, University Hospital Jena, Jena, Germany
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Abstract
Poor clinical results are seen with syndesmotic injuries in the setting of ankle sprains and ankle fractures. The goal of syndesmosis repair is to restore the normal anatomic relationship of the distal tibiofibular joint and prevent ankle arthritis. Indications for surgical intervention for isolated syndesmotic injuries include frank syndesmosis diastasis, medial clear space widening on plain radiographs, significant radiographic syndesmosis diastasis during stress examination, or subtle syndesmotic diastasis detected by arthroscopic evaluation. Complications after syndesmosis repair include symptomatic hardware, malreduction, and arthritis. Anatomic reduction of the syndesmosis leads to better outcomes following surgery.
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Affiliation(s)
- Craig C Akoh
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health Madison, 600 Highland Avenue, Room 6220, Madison, WI 53705-2281, USA.
| | - Phinit Phisitkul
- Tri-State Specialists, LLP, 2730 Pierce Street, Suite 300, Sioux City, IA 51104, USA
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Krähenbühl N, Weinberg MW, Davidson NP, Mills MK, Hintermann B, Saltzman CL, Barg A. Imaging in syndesmotic injury: a systematic literature review. Skeletal Radiol 2018; 47:631-648. [PMID: 29188345 DOI: 10.1007/s00256-017-2823-2] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 10/29/2017] [Accepted: 11/07/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To give a systematic overview of current diagnostic imaging options for assessment of the distal tibio-fibular syndesmosis. MATERIALS AND METHODS A systematic literature search across the following sources was performed: PubMed, ScienceDirect, Google Scholar, and SpringerLink. Forty-two articles were included and subdivided into three groups: group one consists of studies using conventional radiographs (22 articles), group two includes studies using computed tomography (CT) scans (15 articles), and group three comprises studies using magnet resonance imaging (MRI, 9 articles).The following data were extracted: imaging modality, measurement method, number of participants and ankles included, average age of participants, sensitivity, specificity, and accuracy of the measurement technique. The Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool was used to assess the methodological quality. RESULTS The three most common techniques used for assessment of the syndesmosis in conventional radiographs are the tibio-fibular clear space (TFCS), the tibio-fibular overlap (TFO), and the medial clear space (MCS). Regarding CT scans, the tibio-fibular width (axial images) was most commonly used. Most of the MRI studies used direct assessment of syndesmotic integrity. Overall, the included studies show low probability of bias and are applicable in daily practice. CONCLUSIONS Conventional radiographs cannot predict syndesmotic injuries reliably. CT scans outperform plain radiographs in detecting syndesmotic mal-reduction. Additionally, the syndesmotic interval can be assessed in greater detail by CT. MRI measurements achieve a sensitivity and specificity of nearly 100%; however, correlating MRI findings with patients' complaints is difficult, and utility with subtle syndesmotic instability needs further investigation. Overall, the methodological quality of these studies was satisfactory.
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Affiliation(s)
- Nicola Krähenbühl
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Maxwell W Weinberg
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Nathan P Davidson
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Megan K Mills
- Department of Radiology and Imaging Sciences, University of Utah, 30 N. 1900 E. No. 1A071, Salt Lake City, UT, 84132, USA
| | - Beat Hintermann
- Department of Orthopaedics, Kantonsspital Baselland, Rheinstrasse 26, 4410, Liestal, Switzerland
| | - Charles L Saltzman
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Alexej Barg
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA.
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Anatomic Fixation of Posterior Malleolus Fractures as an Alternative to Transsyndesmotic Fixation. Tech Orthop 2017. [DOI: 10.1097/bto.0000000000000221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Lilyquist M, Shaw A, Latz K, Bogener J, Wentz B. Response to "Letter Regarding: Cadaveric Analysis of the Distal Tibiofibular Syndesmosis". Foot Ankle Int 2017; 38:346. [PMID: 28238278 DOI: 10.1177/1071100717690428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Vopat ML, Vopat BG, Lubberts B, DiGiovanni CW. Current trends in the diagnosis and management of syndesmotic injury. Curr Rev Musculoskelet Med 2017; 10:94-103. [PMID: 28101828 DOI: 10.1007/s12178-017-9389-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Ideal management of the various presentations of syndesmotic injury remains controversial to this day. High quality evidentiary science on this topic is rare, and numerous existing studies continue to contradict one another. The primary reasons for these discrepancies are that previous studies have failed to (1) properly distinguish between isolated (non-fractured) and non-isolated injuries, (2) accurately define stable from unstable injuries, and (3) sufficiently differentiate between acute and chronic injuries. The purpose of this review is to summarize today's body of literature regarding diagnosis and management of syndesmotic injury and discuss current trends and important future directions to optimize care of this very heterogeneous population.
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Affiliation(s)
- Matthew L Vopat
- Department of Orthopaedics, University of Kansas School of Medicine-Wichita, Via Christi Health, 929 N. St. Francis, Room 4076, Wichita, KS, 67214, USA.
| | - Bryan G Vopat
- University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS, 66160, USA
| | - Bart Lubberts
- Massachusetts General Hospital/ Harvard University, 55 Fruit St, Boston, MA, 02114, USA
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Schnetzke M, Vetter SY, Beisemann N, Swartman B, Grützner PA, Franke J. Management of syndesmotic injuries: What is the evidence? World J Orthop 2016; 7:718-725. [PMID: 27900268 PMCID: PMC5112340 DOI: 10.5312/wjo.v7.i11.718] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 08/26/2016] [Accepted: 09/08/2016] [Indexed: 02/06/2023] Open
Abstract
Ankle fractures are accompanied by a syndesmotic injury in about 10% of operatively treated ankle fractures. Usually, the total rupture of the syndesmotic ligaments with an external rotation force is associated with a Weber type B or C fracture or a Maisonneuve fracture. The clinical assessment should consist of a comprehensive history including mechanism of injury followed by a specific physical examination. Radiographs, and if in doubt magnetic resonance imaging, are needed to ascertain the syndesmotic injury. In the case of operative treatment the method of fixation, the height and number of screws and the need for hardware removal are still under discussion. Furthermore, intraoperative assessment of the accuracy of reduction of the fibula in the incisura using fluoroscopy is difficult. A possible solution might be the assessment with intraoperative three-dimensional imaging. The aim of this article is to provide a current concepts review of the clinical presentation, diagnosis and treatment of syndesmotic injuries.
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