Intraoperative Torque Test to Assess Syndesmosis Instability

Gosselin-Papadopoulos, Nayla; Hébert‐Davies, Jonah; Laflamme, G. Yves; Beauséjour, Marie; Ménard, Jérémie; Leduc, Sylvain; Nault, Marie-Lyne

doi:10.1177/1071100718816674

Cited by 10 publications

(8 citation statements)

References 20 publications

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“…One hypothesis for this discrepancy is that only complete tears were assessed in their study, whereas only 2 patients had a definitive complete AiTFL tear in ours. This hypothesis is supported by Fisher et al, 14 Gosselin-Papadopoulos et al, 35 and other studies, 33,34,36 which showed that partial AiTFL tears did not cause significant widening of the TFCS.…”

Section: Discussionsupporting

confidence: 57%

“…Even though partial AiTFL tear should be diagnosed and addressed with physical rehabilitation, it does not seem to be associated with instability, and complete tears are the most clinically significant. 33,34 When compared to other diagnostic modalities, such as physical evaluation or radiography, determining AiTFL integrity using US is more precise because it has a greater sensitivity and specificity. It is also simpler and faster than MRI and less invasive when compared with arthroscopy.…”

Section: Discussionmentioning

confidence: 99%

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Ultrasound Assessment of Ankle Syndesmotic Injuries in a Pediatric Population

Heitz,

Miron,

Beauséjour

et al. 2023

Clinical Journal of Sport Medicine

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Objective: To determine sensitivity and specificity for anterior-inferior tibiofibular ligament (AiTFL) integrity and tibiofibular clear-space (TFCS) cut-off points for dynamic evaluation using ultrasound (US) in a pediatric population. Design: Prospective cohort study. Setting: Tertiary care university-affiliated pediatric hospital patients between the ages of 12 and 18 sustaining acute ankle trauma with syndesmotic injury. Interventions: Participants were assigned to the syndesmotic injury protocol that included a standardized MRI and US. Main Outcome Measures: Anterior-inferior tibiofibular ligament integrity for static assessment and TFCS measurements for dynamic assessment on US. For dynamic assessment, the distance between the distal tibia and fibula was first measured in neutral position and then in external rotation for each ankle. The US results on AiTFL integrity were compared with MRI, considered as our gold standard. Optimal cut-off points of TFCS values were determined with receiver operating characteristics curve analysis. Results: Twenty-six participants were included. Mean age was 14.8 years (SD = 1.3 years). Sensitivity and specificity for AiTFL integrity were 79% and 100%, respectively (4 false negatives on partial tears). For dynamic assessment, the cut-off points for the differences in tibiofibular distance between the 2 ankles in 1) neutral position (TFCS N I-U) and 2) external rotation (TFCS ER I-U) were 0.2 mm (sensitivity = 83% and specificity = 80%) and 0.1 mm (sensitivity = 83% and specificity = 80%), respectively. Conclusions: Static US could be used in a triage context as a diagnostic tool for AiTFL integrity in a pediatric population as it shows good sensitivity and excellent specificity.

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Section: Discussionsupporting

confidence: 57%

Section: Discussionmentioning

confidence: 99%

Ultrasound Assessment of Ankle Syndesmotic Injuries in a Pediatric Population

Heitz,

Miron,

Beauséjour

et al. 2023

Clinical Journal of Sport Medicine

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“…This would explain why, when the PITFL is injured in Mason and Molloy type 1 injuries, internal rotation stress testing using live or arthroscopic screening identifies a quarter of isolated posterior syndesmotic disruptions. 9 Gosselin-Papadopoulos et al 7 also described a test where stressing the fibula posterolaterally under direct visualization showed the greatest degree of displacement when the PITFL was sectioned.…”

Section: Discussionmentioning

confidence: 99%

Anatomy of the Insertion of the Posterior Inferior Tibiofibular Ligament and the Posterior Malleolar Fracture

et al. 2019

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Background: Our aim in this study was to identify the extent of the posterior inferior tibiofibular ligament (PITFL) insertion on the posterior tibia and its relation to intra-articular posterior malleolar fractures. Methods: Careful dissection was undertaken on 10 cadaveric lower limbs to identify the ligamentous structures on the posterior aspect of the ankle. The ligamentous anatomy was further compared with our ankle fracture database, specifically posterior malleolar fracture patterns, demonstrating a rotational pilon etiology (Mason and Molloy type 2A and B). Computed tomography imaging was used to measure the dimensions of the fracture fragments. Results: The superficial PITFL was found to have a transverse component and an oblique component. The average size of the tibial insertion was 54.9 mm (95% CI, 51.8, 58.0) from joint line and 47.1 mm (95% CI, 43.0, 51.2) transverse. From our database of ankle fractures involving the posterior malleolus, 80 Mason and Molloy type 2 fractures were identified for analysis. Of these, 33 were type 2A and 47 were type 2B. The posterolateral fragments had an average size of 26.3 mm (95% CI, 25.0, 27.7) height and 22.1 mm (95% CI, 21.1, 23.1) width. The posteromedial fragments had an average size of 22.0 (95% CI, 18.9, 25.1) height and 19.8 (95% CI, 17.5, 22.0) width. Conclusion: The superficial PITFL insertion on the tibia is broad. In comparison with the average size of the posterior malleolar fragments, the PITFL insertion is significantly larger. Therefore, for a posterior malleolar fracture to cause posterior syndesmotic instability, a ligamentous injury must also occur. Clinical Relevance: Posterior syndesmotic instability results from injury to the PITFL. It has been widely reported that a posterior malleolar fracture will also give rise to posterior syndesmotic instability due to the insertion of the deep PITFL on the posterior tibia. On the contrary, in this paper, we have shown that the superficial PITFL insertion on the tibia is very large, much greater than the average size of the posterior malleolar fragments. Therefore, for a posterior malleolar fracture to cause posterior syndesmotic instability, a ligamentous injury will also have to occur.

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“…113 The Torque test is another described method to assess syndesmotic instability, and it involves stressing the fibula in a posterolateral direction and assessing instability under direct visualization of the syndesmosis. 114 For assessing sagittal plane instability lateral relationships of the tibia and fibula are found to be more sensitive. 115 Therefore antero-posterior rocking of the fibula with a clamp can be used to appreciate sagittal plane instability.…”

Section: Operative Treatmentmentioning

confidence: 99%

Instability of the distal tibiofibular syndesmosis

Vohra¹,

Singh²,

Thorat³

et al. 2023

J Orthop Surg (Hong Kong)

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The distal tibiofibular syndesmosis (DTFS) is more frequently injured than previously thought. Early diagnosis and appropriate treatment is essential to avoid long term complications like chronic instability, early osteoarthritis and residual pain. Management of these injuries require a complete understanding of the anatomy of DTFS, and the role played by the ligaments stabilizing the DTFS and ankle. High index of suspicion, appreciating the areas of focal tenderness and utilizing the provocative maneuvers help in early diagnosis. In pure ligamentous injuries radiographs with stress of weight bearing help to detect subtle instability. If these images are inconclusive, then further imaging with MRI, CT scan, stress examination under anesthesia, and arthroscopic examination facilitate diagnosis. An injury to syndesmosis frequently accompanies rotational fractures and all ankle fractures need to be stressed intra-operatively under fluoroscopy after fixation of the osseous components to detect syndesmotic instability. Non-operative treatment is appropriate for stable injuries. Unstable injuries should be treated operatively. Anatomic reduction of the syndesmosis is critical, and currently both trans-syndesmotic screws and suture button fixation are commonly used for syndesmotic stabilization. Chronic syndesmotic instability (CSI) requires debridement of syndesmosis, restoration of ankle mortise with or without syndesmotic stabilization. Arthrodesis of ankle is used a last resort in the presence of significant ankle arthritis. This article reviews anatomy and biomechanics of the syndesmosis, the mechanism of pure ligamentous injury and injury associated with ankle fractures, clinical, radiological and arthroscopic diagnosis and surgical treatment.

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Intraoperative Torque Test to Assess Syndesmosis Instability

Cited by 10 publications

References 20 publications

Ultrasound Assessment of Ankle Syndesmotic Injuries in a Pediatric Population

Ultrasound Assessment of Ankle Syndesmotic Injuries in a Pediatric Population

Anatomy of the Insertion of the Posterior Inferior Tibiofibular Ligament and the Posterior Malleolar Fracture

Instability of the distal tibiofibular syndesmosis

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