Abstract:Background
Ultrasound examinations for syndesmosis injury might be useful for the quantitative evaluation of syndesmotic instability. The purpose of this study was to evaluate the efficacy of ultrasound assessment by measuring the tibiofibular distance of syndesmosis injuries in various ligament-injured models and stress load conditions.
Methods
Five normal ankles from Thiel-embalmed cadavers were used. Ultrasound assessment was performed by placin… Show more
“…The TFCS-opening values detected in this study using P-US are similar to those found by Xenos et al and Shoji et al, who also evaluated the tibioibular diastasis after sequential transection of the syndesmosis [36,43]. The study by Xenos et al evaluated TFCS-opening under an external rotation torque of 5 Nm but using a Storz calliper instead of ultrasound and detected a tibioibular opening of 1.3 (AITFL), 3.5, (IOL), and 6.3 mm after the PITFL cut as opposed to the unloaded, intact stage [43].…”
Section: Discussionsupporting
confidence: 90%
“…The study by Xenos et al evaluated TFCS-opening under an external rotation torque of 5 Nm but using a Storz calliper instead of ultrasound and detected a tibiofibular opening of 1.3 (AITFL), 3.5, (IOL), and 6.3 mm after the PITFL cut as opposed to the unloaded, intact stage [ 43 ]. Thereby, shoji et al already found a significant widening of the tibiofibular distance after the AITFL cut with external rotation stress using ultrasound [ 36 ]. The correlation between ultrasound studies and direct measurement techniques highlight the opportunity to evaluate the syndesmosis noninvasively at the point of care.…”
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.
“…The TFCS-opening values detected in this study using P-US are similar to those found by Xenos et al and Shoji et al, who also evaluated the tibioibular diastasis after sequential transection of the syndesmosis [36,43]. The study by Xenos et al evaluated TFCS-opening under an external rotation torque of 5 Nm but using a Storz calliper instead of ultrasound and detected a tibioibular opening of 1.3 (AITFL), 3.5, (IOL), and 6.3 mm after the PITFL cut as opposed to the unloaded, intact stage [43].…”
Section: Discussionsupporting
confidence: 90%
“…The study by Xenos et al evaluated TFCS-opening under an external rotation torque of 5 Nm but using a Storz calliper instead of ultrasound and detected a tibiofibular opening of 1.3 (AITFL), 3.5, (IOL), and 6.3 mm after the PITFL cut as opposed to the unloaded, intact stage [ 43 ]. Thereby, shoji et al already found a significant widening of the tibiofibular distance after the AITFL cut with external rotation stress using ultrasound [ 36 ]. The correlation between ultrasound studies and direct measurement techniques highlight the opportunity to evaluate the syndesmosis noninvasively at the point of care.…”
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.
“…With an external rotation stress applied, the tibiofibular distance increased by 2.0 mm after sectioning the AITFL alone ( P = 0.015). 22 While the results are promising, US has not been directly compared with other modalities or with arthroscopic evaluation.…”
Latent or subtle syndesmotic instability is defined as an injury to the syndesmosis which is not apparent on static radiographs of the ankle. Syndesmotic injuries have also been referred to as high ankle sprains. Injury to the syndesmosis typically occurs with collision sports and often involves an external rotation force to the ankle. Diagnosis can be delayed because of negative initial imaging studies. Physical examination tests including the external rotation test, proximal squeeze test, and fibular shuck test can assist in the diagnosis. Advanced imaging modalities such as MRI and weight-bearing CT have been studied and can provide prognostic indications for management, although arthroscopic stress evaluation remains the benchmark for diagnosis. Both surgical and nonsurgical management techniques have been described, which can assist patients in returning to their preinjury level of function.
“…85 Ultrasound is another modality recommended for diagnosing syndesmotic instability as it can be easily performed in outpatient and bedside settings, is minimally invasive and allows the possibility of dynamic evaluation without radiation exposure. 86 Although dynamic ultrasonographic examination showed a 100% sensitivity and specificity, 87 unfortunately it has the drawback that it cannot detect associated injuries and is investigator-dependent. 22 Figure 4.On the magnetic resonance coronal image, the lambda sign is marked by the red arrow.Figure 5.Magnetic resonance axial image showing the ring of fire sign (marked by red arrow).…”
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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