Advertisement

Torque application helps to diagnose incomplete syndesmotic injuries using weight-bearing computed tomography images

  • Nicola Krähenbühl
  • Travis L. Bailey
  • Angela P. Presson
  • Chelsea McCarty Allen
  • Heath B. Henninger
  • Charles L. Saltzman
  • Alexej BargEmail author
Scientific Article
  • 3 Downloads

Abstract

Objective

Accurate identification of distal tibio-fibular syndesmotic injuries is essential to limit potential deleterious post-traumatic effects. To date, conventional radiographs, computed tomography (CT), and magnetic resonance imaging (MRI) have shown limited utilization. This cadaver study evaluates the utility of weight-bearing CT scans on the assessment of incomplete and more complete syndesmotic injuries.

Materials and methods

Ten male cadavers (tibial plateau to toe-tip) were included. Weight-bearing CTs were taken under four test conditions, with and without torque on the tibia (corresponding to external rotation of the foot and ankle). First, intact ankles (native) underwent imaging. Second, the anterior–inferior tibio-fibular ligament (AITFL) was transected (condition 1). Then, the deltoid ligament (condition 2) was transected, followed by the interosseous membrane (IOM, condition 3). Finally, the posterior–inferior tibio-fibular ligament (PITFL) was transected (condition 4). The medial clear space (MCS), the tibio-fibular clear space (TFCS), and the tibio-fibular overlap (TFO) were assessed on digitally reconstructed radiographs (DRRs), and on axial CT images.

Results

The TFO differentiated isolated AITFL transection from native ankles when torque was applied. Also under torque conditions, the MCS was a useful predictor of an additional deltoid ligament transection, whereas the TFCS identified cadavers in which the PITFL was also transected.

Conclusion

Torque application helps to diagnose incomplete syndesmotic injuries when using weight-bearing CT. The TFO may be useful for identifying incomplete syndesmotic injuries, whereas the MCS and TFCS predict more complete injuries.

Keywords

Imaging Weight-bearing CT Syndesmotic injury Deltoid ligament injury 

Notes

Acknowledgements

The authors thank Nathan B Davidson, for planning the frame used to hold the specimens in the weight-bearing CT, and Maxwell W Weinberg, who helped to plan the experiments.

Source of funding

This work was supported by a grant from the American Orthopaedic Foot & Ankle Society with funding from the Orthopaedic Foot & Ankle Foundation. N Krähenbühl received a grant from the Swiss National Science Foundation (SNF; grant number P2BSP3_174979).

Compliance with ethical standards

Conflicts of interest

For the remaining authors, no conflicts of interest were declared.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

References

  1. 1.
    Krahenbuhl N, Weinberg MW, Davidson NP, Mills MK, Hintermann B, Saltzman CL, et al. Imaging in syndesmotic injury: a systematic literature review. Skeletal Radiol. 2018;47(5):631–48.CrossRefGoogle Scholar
  2. 2.
    Rammelt S, Obruba P. An update on the evaluation and treatment of syndesmotic injuries. Eur J Trauma Emerg Surg. 2015;41(6):601–14.CrossRefGoogle Scholar
  3. 3.
    Nussbaum ED, Hosea TM, Sieler SD, Incremona BR, Kessler DE. Prospective evaluation of syndesmotic ankle sprains without diastasis. Am J Sports Med. 2001;29(1):31–5.CrossRefGoogle Scholar
  4. 4.
    Krahenbuhl N, Weinberg MW, Hintermann B, Haller JM, Saltzman CL, Barg A. Surgical outcome in chronic syndesmotic injury: a systematic literature review. Foot Ankle Surg. 2018.  https://doi.org/10.1016/j.fas.2018.08.008.CrossRefPubMedGoogle Scholar
  5. 5.
    Waterman BR, Belmont PJ Jr, Cameron KL, Svoboda SJ, Alitz CJ, Owens BD. Risk factors for syndesmotic and medial ankle sprain: role of sex, sport, and level of competition. Am J Sports Med. 2011;39(5):992–8.CrossRefGoogle Scholar
  6. 6.
    Pakarinen H, Flinkkila T, Ohtonen P, Hyvonen P, Lakovaara M, Leppilahti J, et al. Intraoperative assessment of the stability of the distal tibiofibular joint in supination-external rotation injuries of the ankle: sensitivity, specificity, and reliability of two clinical tests. J Bone Joint Surg Am. 2011;93(22):2057–61.CrossRefGoogle Scholar
  7. 7.
    Roemer FW, Jomaah N, Niu J, Almusa E, Roger B, D'Hooghe P, et al. Ligamentous injuries and the risk of associated tissue damage in acute ankle sprains in athletes: a cross-sectional MRI study. Am J Sports Med. 2014;42(7):1549–57.CrossRefGoogle Scholar
  8. 8.
    Hermans JJ, Wentink N, Beumer A, Hop WC, Heijboer MP, Moonen AF, et al. Correlation between radiological assessment of acute ankle fractures and syndesmotic injury on MRI. Skeletal Radiol. 2012;41(7):787–801.CrossRefGoogle Scholar
  9. 9.
    Schoennagel BP, Karul M, Avanesov M, Bannas P, Gold G, Grossterlinden LG, et al. Isolated syndesmotic injury in acute ankle trauma: comparison of plain film radiography with 3T MRI. Eur J Radiol. 2014;83(10):1856–61.CrossRefGoogle Scholar
  10. 10.
    Golano P, Vega J, de Leeuw PA, Malagelada F, Manzanares MC, Gotzens V, et al. Anatomy of the ankle ligaments: a pictorial essay. Knee Surg Sports Traumatol Arthrosc. 2010;18(5):557–69.CrossRefGoogle Scholar
  11. 11.
    Jeong MS, Choi YS, Kim YJ, Kim JS, Young KW, Jung YY. Deltoid ligament in acute ankle injury: MR imaging analysis. Skeletal Radiol. 2014;43(5):655–63.CrossRefGoogle Scholar
  12. 12.
    Clanton TO, Williams BT, Backus JD, Dornan GJ, Liechti DJ, Whitlow SR, et al. Biomechanical analysis of the individual ligament contributions to syndesmotic stability. Foot Ankle Int. 2017;38(1):66–75.CrossRefGoogle Scholar
  13. 13.
    Tuominen EK, Kankare J, Koskinen SK, Mattila KT. Weight-bearing CT imaging of the lower extremity. AJR Am J Roentgenol. 2013;200(1):146–8.CrossRefGoogle Scholar
  14. 14.
    Mozzo P, Procacci C, Tacconi A, Martini PT, Andreis IA. A new volumetric CT machine for dental imaging based on the cone-beam technique: preliminary results. Eur Radiol. 1998;8(9):1558–64.CrossRefGoogle Scholar
  15. 15.
    Barg A, Bailey T, Richter M, de Cesar Netto C, Lintz F, Burssens A, et al. Weightbearing computed tomography of the foot and ankle: emerging technology topical review. Foot Ankle Int. 2018;39(3):376–86.CrossRefGoogle Scholar
  16. 16.
    Barg A, Amendola RL, Henninger HB, Kapron AL, Saltzman CL, Anderson AE. Influence of ankle position and radiographic projection angle on measurement of supramalleolar alignment on the anteroposterior and hindfoot alignment views. Foot Ankle Int. 2015;36(11):1352–61.CrossRefGoogle Scholar
  17. 17.
    Krahenbuhl N, Siegler L, Deforth M, Zwicky L, Hintermann B, Knupp M. Subtalar joint alignment in ankle osteoarthritis. Foot Ankle Surg. 2017.  https://doi.org/10.1016/j.fas.2017.10.004.
  18. 18.
    Krahenbuhl N, Tschuck M, Bolliger L, Hintermann B, Knupp M. Orientation of the subtalar joint: measurement and reliability using weightbearing CT scans. Foot Ankle Int. 2016;37(1):109–14.CrossRefGoogle Scholar
  19. 19.
    Takao M, Ochi M, Naito K, Iwata A, Uchio Y, Oae K, et al. Computed tomographic evaluation of the position of the leg for mortise radiographs. Foot Ankle Int. 2001;22(10):828–31.CrossRefGoogle Scholar
  20. 20.
    Lepojarvi S, Niinimaki J, Pakarinen H, Koskela L, Leskela HV. Rotational dynamics of the talus in a normal tibiotalar joint as shown by weight-bearing computed tomography. J Bone Joint Surg Am. 2016;98(7):568–75.CrossRefGoogle Scholar
  21. 21.
    Shah AS, Kadakia AR, Tan GJ, Karadsheh MS, Wolter TD, Sabb B. Radiographic evaluation of the normal distal tibiofibular syndesmosis. Foot Ankle Int. 2012;33(10):870–6.CrossRefGoogle Scholar
  22. 22.
    Grass R, Rammelt S, Biewener A, Zwipp H. Peroneus longus ligamentoplasty for chronic instability of the distal tibiofibular syndesmosis. Foot Ankle Int. 2003;24(5):392–7.CrossRefGoogle Scholar
  23. 23.
    Dikos GD, Heisler J, Choplin RH, Weber TG. Normal tibiofibular relationships at the syndesmosis on axial CT imaging. J Orthop Trauma. 2012;26(7):433–8.CrossRefGoogle Scholar
  24. 24.
    Yeung TW, Chan CY, Chan WC, Yeung YN, Yuen MK. Can pre-operative axial CT imaging predict syndesmosis instability in patients sustaining ankle fractures? Seven years’ experience in a tertiary trauma center. Skeletal Radiol. 2015;44(6):823–9.CrossRefGoogle Scholar
  25. 25.
    Brage ME, Bennett CR, Whitehurst JB, Getty PJ, Toledano A. Observer reliability in ankle radiographic measurements. Foot Ankle Int. 1997;18(6):324–9.CrossRefGoogle Scholar
  26. 26.
    Shakoor D, Osgood GM, Brehler M, Zbijewski WB, de Cesar Netto C, Shafiq B, et al. Cone-beam CT measurements of distal tibio-fibular syndesmosis in asymptomatic uninjured ankles: does weight-bearing matter? Skeletal Radiol. 2018.  https://doi.org/10.1007/s00256-018-3074-6.CrossRefPubMedGoogle Scholar
  27. 27.
    Lepojarvi S, Niinimaki J, Pakarinen H, Leskela HV. Rotational dynamics of the normal distal tibiofibular joint with weight-bearing computed tomography. Foot Ankle Int. 2016;37(6):627–35.CrossRefGoogle Scholar
  28. 28.
    Pneumaticos SG, Noble PC, Chatziioannou SN, Trevino SG. The effects of rotation on radiographic evaluation of the tibiofibular syndesmosis. Foot Ankle Int. 2002;23(2):107–11.CrossRefGoogle Scholar
  29. 29.
    Nault ML, Marien M, Hebert-Davies J, Laflamme GY, Pelsser V, Rouleau DM, et al. MRI quantification of the impact of ankle position on syndesmosis anatomy. Foot Ankle Int. 2017;38(2):215–9.CrossRefGoogle Scholar
  30. 30.
    Feller R, Borenstein T, Fantry AJ, Kellum RB, Machan JT, Nickisch F, et al. Arthroscopic quantification of Syndesmotic instability in a cadaveric model. Arthroscopy. 2017;33(2):436–44.CrossRefGoogle Scholar

Copyright information

© ISS 2019

Authors and Affiliations

  • Nicola Krähenbühl
    • 1
  • Travis L. Bailey
    • 1
  • Angela P. Presson
    • 2
  • Chelsea McCarty Allen
    • 2
  • Heath B. Henninger
    • 3
  • Charles L. Saltzman
    • 1
  • Alexej Barg
    • 1
    Email author
  1. 1.Department of OrthopaedicsUniversity of UtahSalt Lake CityUSA
  2. 2.Division of Epidemiology, Department of Internal MedicineUniversity of UtahSalt Lake CityUSA
  3. 3.Orthopaedic Research LaboratoryUniversity of UtahSalt Lake CityUSA

Personalised recommendations