scholarly journals Can Subtle Syndesmotic Injury Be Assessed Using Weightbearing CT Scans?

2018 ◽  
Vol 3 (3) ◽  
pp. 2473011418S0006
Author(s):  
Nicola Krähenbühl ◽  
Maxwell Weinberg ◽  
Travis Bailey ◽  
Nathan Davidson ◽  
Heath Henninger ◽  
...  
Keyword(s):  
External Rotation ◽  
Paired Comparison ◽  
Anterior Part ◽  
Weight Bearing ◽  
Ct Scans ◽  
Deltoid Ligament ◽  
Medial Malleolus ◽  
X Rays ◽  
Syndesmotic Injury ◽  
Significant Difference

Category: Sports Introduction/Purpose: Between 1-18% of all ankle sprains and 23% of all ankle fractures involve injury to the distal tibio-fibular syndesmosis. Syndesmotic injuries can create a substantial diagnostic and therapeutic challenge for orthopaedic surgeons. While acute injuries can be assessed using conventional radiographs, subtle syndesmotic injuries may be misdiagnosed using X-rays. Misdiagnoses may result in chronic ankle instability, pain and post-traumatic osteoarthritis of the tibio-talar joint. Recently, weight-bearing computed tomography (CT) scans gained popularity with foot and ankle surgeons. This method is advantageous in that the distal tibio-fibular syndesmosis can be assessed in greater detail and under weight-bearing conditions. However, there are no studies investigating weight-bearing CT scans for assessment of subtle syndesmotic injury. Methods: Five pairs of cadavers (tibia plateau to toe-tip, mean 61 years, range 52-70 years) were scanned with weight-bearing CT (170 lb) including external rotational torque (10 Nm). The following conditions were tested: First, intact ankles (Native) were tested. Second, one specimen from each pair underwent AITFL resection, while the contralateral underwent deltoid resection (Condition 1). Third, the remaining intact deltoid ligament or AITFL was resected in each ankle (Condition 2). Finally, the interosseous membrane (IOM) was resected in all ankles (Condition 3). Using coronal CT images, the width between the anterior tibia and fibula (A), distance between the anterior tibial incisura and anterior fibula (F), the tibio-fibular overlap (TFO), and the angle between the medial malleolus and the longitudinal axis of the fibula were assessed (a). Statistical analysis was performed using paired (comparison within groups) and unpaired (comparison between groups) t-test where p=0.05 was considered significant. Results: Regarding measurement A, a significant difference (p=0.046) was observed between Condition 2 and 3 vs. Native, independent of which ligament was dissected first. Measurement F was significantly different between Condition 2 and 3 vs. Native (p=0.011) if the AITFL was dissected first, but only reached significance for Condition 3 vs. Native if the deltoid ligament was dissected first (p=0.007). The TFO and a were significant in Conditions 1, 2, and 3 vs. Native if the deltoid ligament was dissected first (p=0.050). When the AITFL was dissected first, significance was reached for the same conditions (p=0.046) with the exception of the TFO for Condition 2 vs. Native. No differences were found when comparing the conditions of the AITFL with the same conditions of the deltoid group. Conclusion: With weight-bearing CT scans and applied external rotation torque, the TFO and angle between the tibia and fibula (a) may be used to assess subtle syndesmotic injury to either the AITFL or the deltoid ligament. When both ligaments (AITFL and deltoid) were injured, the tibio-fibular width (A) and distance between the anterior part of the tibia and fibula (F) could also be used for assessment. Weight-bearing CT scans cannot be used to distinguish between injuries to the AITFL or deltoid ligament. Further studies are needed to assess weight-bearing CT scans in the clinical setting.

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

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

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

Finite Element Analysis of Fixed Medial Malleolar Fractures

2013 ◽  
Author(s):  
Ruchi D. Chande ◽  
John R. Owen ◽  
Robert S. Adelaar ◽  
Jennifer S. Wayne
Keyword(s):  
Finite Element Analysis ◽  
Finite Element ◽  
Mechanical Performance ◽  
External Rotation ◽  
Weight Bearing ◽  
High Stress ◽  
Ankle Injuries ◽  
Deltoid Ligament ◽  
Medial Malleolus ◽  
Element Analysis

The ankle joint, comprised of the distal ends of the tibia and fibula as well as talus, is key in permitting movement of the foot and restricting excessive motion during weight-bearing activities. Medial ankle injury occurs as a result of pronation-abduction or pronation-external rotation loading scenarios in which avulsion of the medial malleolus or rupture of the deltoid ligament can result if the force is sufficient [1]. If left untreated, the joint may experience more severe conditions like osteoarthritis [2]. To avoid such consequences, medial ankle injuries — specifically bony injuries — are treated with open reduction and internal fixation via the use of plates, screws, wires, or some combination thereof [1, 3–4]. In this investigation, the mechanical performance of two such devices was compared by creating a 3-dimensional model of an earlier cadaveric study [5], validating the model against the cadaveric data via finite element analysis (FEA), and comparing regions of high stress to regions of experimental failure.

Weightbearing Radiography and MRI Findings in Ankle Fractures

2020 ◽  
pp. 193864002092157
Author(s):  
Henrik C. Bäcker ◽  
J. Turner Vosseller ◽  
Harald Bonel ◽  
Jennifer Cullmann-Bastian ◽  
Fabian Krause ◽  
...  
Keyword(s):  
Structural Integrity ◽  
External Rotation ◽  
Stress Test ◽  
Ankle Fractures ◽  
Deltoid Ligament ◽  
Medial Malleolus ◽  
Mri Findings ◽  
Partial Tear ◽  
Complete Rupture ◽  
Significant Difference

Background. Static weightbearing radiography can be used to assess stability in ankle fractures by measuring lateral talar shift (medial clear space; MCS). However, the correlation of a stable ankle joint under weightbearing load and the structural integrity of the deltoid ligament has not been shown. In this study, we assessed deltoid ligament integrity on magnetic resonance imaging (MRI) and correlated that with weightbearing and gravity stress test radiography. Methods. Thirty-four patients with supination external rotation II-IV (SER) fractures underwent MRI, weightbearing radiography, and gravity stress test. On MRI, the deep anterior and posterior tibiotalar deltoid, tibionavicular and tibiocalcaneal ligaments, as well as the syndesmosis were assessed as intact, partial rupture, or complete rupture. The MCS was measured as the distance between the lateral border of the medial malleolus and the medial border of the talus at the level of the talar dome on the mortise view. Results. Twenty-three patients suffered a deep anterior tibiotalar ligament rupture (16 partial; 7 complete) and 2 a deep posterior tibiotalar ligament tear (1 partial; 1 complete). For MCS on weightbearing radiography, no statistically significant differences were identified between any of the individual groups. With gravity stress radiography, only a complete tear of the tibiocalcaneal ligament showed a significantly higher MCS than a partial tear or intact tibiocalcaneal ligament ( P < .005). No other ligament disruption showed a significant difference between the complete rupture versus intact or partial tear. Conclusion. Weightbearing radiography does not show much variation in terms of MCS even with ligamentous disruption and fibula fracture. The talus often centers itself underneath the tibia with weightbearing radiography. Levels of Evidence: Level III: Retrospective cohort study

Labyrinthectomy decreases bone mineral density in the femoral metaphysis in rats

2004 ◽  
Vol 14 (5) ◽  
pp. 361-365
Author(s):  
Régis Levasseur ◽  
Jean Pierre Sabatier ◽  
Olivier Etard ◽  
Pierre Denise ◽  
Annie Reber
Keyword(s):  
Bone Mineral Density ◽  
Bone Mineral ◽  
Weight Bearing ◽  
Whole Body ◽  
X Rays ◽  
Mineral Density ◽  
Femoral Metaphysis ◽  
Significant Difference ◽  
Distal Femoral Metaphysis ◽  
Vestibular Influence

To determine whether the vestibular system could influence bone remodeling in rats, we measured bone mineral density with dual energy X-rays absorptiometry before and 30 days after bilateral labyrinthectomy. Comparatively to intact control rats, labyrinthectomized animals showed a reduced bone mineral density in distal femoral metaphysis (p = 0.007): the variations between D0 and D30 were +3.0% for controls and -13.9% for labyrinthectomized rats. No significant difference between the 2 groups was observed in the whole body mineral density. These results suggest that the peripheral vestibular apparatus is a modulator of bone mass and more specifically in weight bearing bone. We discuss possible mechanisms of this vestibular influence probably mediated by the sympathetic nervous system.

scholarly journals A Novel and Safe Fibular Osteotomy for Total Ankle Replacement through Lateral Transfibular Approach

2019 ◽  
Vol 4 (4) ◽  
pp. 2473011419S0042
Author(s):  
Federico G. Usuelli ◽  
Jonathan RM Kaplan ◽  
Camilla Maccario ◽  
Luigi Manzi ◽  
Cristian Indino
Keyword(s):  
Short Form ◽  
Weight Bearing ◽  
Hardware Removal ◽  
Composite Score ◽  
Wound Complications ◽  
X Rays ◽  
Fibular Osteotomy ◽  
Significant Difference ◽  
Primary Lateral ◽  
Reconstruction Group

Category: Ankle Arthritis Introduction/Purpose: The lateral transfibular total ankle arthroplasty (TAA) has been reported on with good short term outcomes. One key downside to the lateral TAA is the rate of symptomatic hardware and wound issues requiring hardware removal seen with the short oblique fibular osteotomy. Therefore, we report on a comparative cohort study of lateral TAA using the traditional short oblique fibular osteotomy to a long oblique fibular osteotomy, termed Foot and Ankle Reconstruction Group Osteotomy (FARG). Methods: Retrospective identification of primary lateral transfibular TAA performed by a single surgeon from May 2013 to October 2016 with minimum 2 years follow-up. Clinical assessment included patient demographics, wound complications, need for hardware removal, visual analogue scale, American Orthopaedic Foot & Ankle Society score, Short Form-12 Mental Composite Score, and Short Form-12 Physical Composite Score. Radiographic assessment included weight bearing x-rays to assess tibiotalar alignment, implant alignment, and fibular osteotomy healing. Results: A total of 159 primary lateral TAA were identified. The short oblique fibular osteotomy was used in 50 cases and the FARG osteotomy in 109 cases. Implant survival was 100% and there were no fibular osteotomy nonunions in both groups. There was improvement in all clinical parameters in both groups with no significant difference between groups in any of these parameters. The radiographic measures showed excellent alignment at all time points in both groups with no significant difference between groups. There was a significant difference between groups in the rate of wound dehiscence and rate of hardware removal for any reason with the FARG osteotomy having a lower rate of both compared to the short oblique fibular osteotomy. Conclusion: Modification of the traditional fibular osteotomy to the long oblique Foot & Ankle Reconstruction Group fibular osteotomy has excellent 2-year survival with good clinical and radiographic outcomes yet provides decreased rates of wound complications and decreased rates of symptomatic fibular hardware compared to the traditional short oblique fibular osteotomy.

Impact of Torque on Assessment of Syndesmotic Injuries Using Weightbearing Computed Tomography Scans

2019 ◽  
Vol 40 (6) ◽  
pp. 710-719 ◽  
Author(s):  
Nicola Krähenbühl ◽  
Travis L. Bailey ◽  
Maxwell W. Weinberg ◽  
Nathan P. Davidson ◽  
Beat Hintermann ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Axial Load ◽  
External Rotation ◽  
Ct Scans ◽  
Deltoid Ligament ◽  
Tibiofibular Syndesmosis ◽  
Tibiofibular Ligament ◽  
Distal Tibiofibular Syndesmosis ◽  
Axial Ct ◽  
The Impact

Background: The diagnosis of subtle injuries to the distal tibiofibular syndesmosis remains elusive. Conventional radiographs miss a large subset of injuries that present without frank diastasis. This study evaluated the impact of torque application on the assessment of syndesmotic injuries when using weightbearing computed tomography (CT) scans. Methods: Seven pairs of male cadavers (tibia plateau to toe-tip) were included. CT scans with axial load application (85 kg) and with (10 Nm) or without torque to the tibia (corresponding to external rotation of the foot and ankle) were taken during 4 test conditions. First, intact ankles (native) were scanned. Second, 1 specimen from each pair underwent anterior inferior tibiofibular ligament (AITFL) transection (condition 1A), while the contralateral underwent deltoid transection (condition 1B). Third, the lesions were reversed on the same specimens and the remaining intact deltoid or AITFL was transected (condition 2). Finally, the distal tibiofibular interosseous membrane (IOM) was transected in all ankles (condition 3). Measurements were performed to assess the integrity of the distal tibiofibular syndesmosis on digitally reconstructed radiographs (DRRs) and on axial CT scans. Results: Torque impacted DRR and axial CT scan measurements in almost all conditions. The ability to diagnose syndesmotic injuries using axial CT measurements improved when torque was applied. No significant syndesmotic morphological change was observed with or without torque for either isolated AITFL or deltoid ligament transection. Discussion: Torque application had a notable impact on two-dimensional (2-D) measurements used to diagnose syndesmotic injuries for both DRRs and axial CT scans. Because weightbearing conditions allow for standardized positioning of the foot while radiographs or CT scans are taken, the combination of axial load and torque application may be desirable. Clinical Relevance: Application of torque to the tibia impacts 2-D measurements and may be useful when diagnosing syndesmotic injuries by DRRs or axial CT images.

scholarly journals Is Load Application Necessary When Using CT Scans to Diagnose Syndesmotic Injuries? A Cadaver Study

2019 ◽  
Vol 4 (4) ◽  
pp. 2473011419S0001
Author(s):  
Alexej Barg ◽  
Maxwell W. Weinberg ◽  
Nathan P. Davidson ◽  
Beat Hintermann ◽  
Charles L. Saltzman ◽  
...  
Keyword(s):  
Weight Bearing ◽  
Cadaver Study ◽  
Observer Agreement ◽  
Load Application ◽  
Ct Scans ◽  
Deltoid Ligament ◽  
3 Dimensional ◽  
Detailed Assessment ◽  
Axial Ct ◽  
Weightbearing Ct

Category: Ankle, Trauma, Imaging Introduction/Purpose: Injury to the distal tibio-fibular syndesmosis is common and appears in up to 20% of patients with an ankle sprain or ankle fracture. While pronounced injuries can be reliably diagnosed using conventional radiographs, assessment of subtle syndesmotic injuries is challenging. With the introduction of weightbearing CT (WBCT) scans, detailed assessment of foot and ankle disorders under load bearing conditions became possible. The purpose of this cadaver study was to assess the influence of weight on assessment of incomplete and more complete syndesmotic injuries using two-dimensional (2D) measurements on axial CT images. We hypothesized that weight would significantly impact assessment of both incomplete and more complete injuries to the distal tibio-fibular syndesmosis. 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 CT scans were taken. Four 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 (Condition 2). Finally, the distal tibio-fibular interosseous membrane (IOM) was transected in all ankles (Condition 3). For each condition, non-weightbearing, half-bodyweight (42.5 kg), and full-bodyweight (85 kg) CT scans were taken. Six measurements were performed to assess the integrity of the distal tibio-fibular syndesmosis on axial CT scans 1 cm above the ankle joint (Figure 1A/ B) and two measurements at the level of the talar surface (Figure 1C). Inter- and intra- observer agreement were additionally calculated. Results: Inter- and intra-observer agreement differed between measurements. Excellent agreement was evident for the tibio- fibular clear space (TFCS) and tibio-fibular overlap (TFO) with an intra-observer agreement of 0.79 and 0.94, respectively. Poor agreement was evident for Angle 1 (inter-observer, 0.39). Agreement of the other measurements (inter- and intra-observer) was either rated as fair or good and ranged from 0.44 to 0.71. Weightbearing had no significant influence on measurements. Only more complete injuries (Condition 3) differed from native ankles when using either the anterior tibio-fibular distance (ATFD) or TFO. For these two measurements, no significant differences were observed within each condition between non-, half-, and full- weightbearing. Also, no significant differences were evident between single AITFL and deltoid ligament transection for the ATFD and TFO. Conclusion: Load application does not impact the ability of WBCT scans to diagnose incomplete and also more complete syndesmotic injuries in a cadaver model. The utility of current 2D measurements on axial WBCT scans for diagnosing incomplete syndesmotic injuries is questionable. Nevertheless, the ability to reliably position the foot during imaging is an advantage of WBCT technology over other imaging options. Further investigations using more precise measurement options (e.g. 3-dimensional [3D] measurements) are necessary to better understand the potential role of weight bearing to diagnose syndesmotic injuries with CT scan imaging technology.

scholarly journals BIMALLEOLAR ANKLE FRACTURE: A SIMPLE FRACTURE?

2017 ◽  
Vol 25 (1) ◽  
pp. 48-51 ◽  
Author(s):  
JUNJI MILLER FUKUYAMA ◽  
ROBINSON ESTEVES SANTOS PIRES ◽  
PEDRO JOSÉ LABRONICI ◽  
JOSÉ OCTÁVIO SOARES HUNGRIA ◽  
RODRIGO LOPES DECUSATI
Keyword(s):  
Ankle Fracture ◽  
Fragment Size ◽  
External Rotation ◽  
Ankle Fractures ◽  
Ligament Injury ◽  
Deltoid Ligament ◽  
Medial Malleolus ◽  
Level Of Evidence ◽  
Deltoid Ligament Injury ◽  
Supination External Rotation

ABSTRACT Objective: To evaluate the frequency of deltoid ligament injury in bimalleolar supination-external rotation type fractures and whether there is a correlation between the size of the fractured medial malleolus and deltoid ligament injury . Methods: Twenty six consecutive patients underwent magnetic resonance exams after clinical and radiographic diagnosis of bimalleolar supination-external rotation type ankle fractures . Results: Thirteen patients (50%) presented deltoid ligament injury associated to bimalleolar ankle fracture. Partial injury was present in seven (26.9%) patients and total injury in six (23.1%). Regarding medial fragment size, the average was 2.88 cm in the absence of deltoid ligament injury. Partial injuries presented 1.93 cm and total 2.1 cm on average . Conclusion: Deltoid ligament injury was present in 50% of bimalleolar ankle fractures. Smaller medial malleolus fragments, especially concerning the anterior colliculus, presented greater association with partial deltoid ligament injuries. Level of Evidence IV, Cross Sectional Study.

scholarly journals Kinematics after Syndesmotic Injury: Assessing the Magnitude of Talus and Fibula Rotation and Displacement

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0011
Author(s):  
Jonathan Bartolomei ◽  
Mark W. Bowers ◽  
Kenneth J. Hunt
Keyword(s):  
Repeated Measures ◽  
External Rotation ◽  
Deltoid Ligament ◽  
Ankle Sprains ◽  
Syndesmotic Injury ◽  
Suture Button ◽  
Clear Space ◽  
Lateral Translation ◽  
Radiographic Measurements

Category: Ankle; Sports; Other Introduction/Purpose: High ankle sprains, or injuries to the distal tibiofibular syndesmosis, are predictive of long-term ankle dysfunction. Our objectives were to evaluate ankle mortise stability, radiographically, and kinematically, using a cadaveric model with a simulated syndesmotic injury. We also measured the ability of a suture-button system to restore natural joint motion. Methods: Eight cadaveric specimens underwent serial sectioning of the anterior-inferior tibiofibular (AITFL), interosseous (IOL), posterior-inferior tibiofibular (PITFL), and deltoid ligaments. Specimens underwent external rotation and lateral translation testing after ligament release to obtain kinematic data (using a validated infrared LED motion capture system) and radiographic measurements. We then repeated external rotation and lateral translation testing after implementing a suture-button system. Repeated measures ANOVA with a Bonferroni/Dunn post-hoc test calculated the interspecimen comparisons. Results: Sectioning of each ligament, beginning with the AITFL, significantly increased talar external rotation. After releasing the AITFL and IOL, fibular external rotation increased significantly. Posterior displacement of the fibula began following the release of AITFL. Significant radiographic widening of the medial clear space and the syndesmosis occurred only after the release of the deltoid ligament. Syndesmotic and medial clear space widening was not significantly different from the intact state under lateral translation until after the release of the deltoid ligament. Placement of the suture-button system successfully reduced the medial clear space but was unable to restore the native stability of the ankle joint. Conclusion: This project addresses rotational and kinematic changes in the ankle after syndesmotic injury by quantifying the effect of ligamentous disruption on the tibiotalar articulation. The change in joint kinematics may explain why patients with moderate-to-severe syndesmosis injuries take longer to heal and develop long-term dysfunction. Significant talar rotation and posterior fibular displacement occur during external rotation, even with moderate syndesmosis injury, and before the disruption of the deltoid ligament. Stress radiography does not appear to be a reliable indicator of mild or moderate syndesmosis injuries.

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