The predictive value of MRI in the syndesmotic instability of ankle fracture
Although many types of ankle fracture can be combined with syndesmosis injury, preoperative imaging studies rarely reveal instability of the syndesmosis. This study assessed the use of magnetic resonance imaging (MRI) for syndesmotic instability in patients with unstable ankle fracture.
A total of 74 patients who were treated for Lauge-Hansen supination external rotation/Weber B type fracture or pronation external rotation/Weber C type fracture and who underwent MRI for preoperative assessment were enrolled. The MRI findings of the syndesmotic ligament and the results of an intraoperative stress test were evaluated.
Twenty-six patients had a positive result on the intraoperative stress test for syndesmotic instability. The MRI findings of the syndesmotic ligaments revealed that complete tear of the posterior inferior tibiofibular ligament (PITFL) was the most reliable predictor of syndesmotic instability (sensitivity, 74%; specificity, 78%; positive predictive value, 54%). Interobserver agreement for the intraoperative stress test and MRI assessment was excellent, except for the MRI findings of the interosseous ligament (62% agreement; kappa, 0.3).
Complete tear of the PITFL on MRI has additional diagnostic value for syndesmotic instability in ankle fracture. However, because the sensitivity might not be sufficient to justify the costs associated with MRI, cost-effectiveness should be considered.
KeywordsAnkle fracture Intraoperative stress test Magnetic resonance imaging Syndesmotic instability
Y. H. Park: Designed the study, lead investigator, and first author.
M. A. Yoon: Study implementation, data analysis and interpretation, review of the manuscript.
W. S. Choi: Study implementation, data analysis and interpretation.
G. W. Choi: Study implementation, data analysis and interpretation.
S. J. Hong: Designed the study, study implementation, data analysis and interpretation.
H. J. Kim: Designed the study, Corresponding author, Primary surgeon, approval of the final manuscript.
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the contents of this study.
Compliance with ethical standards
Conflict of interest
The authors have no conflicts of interest to declare.
- 3.Lindsjo U. Operative treatment of ankle fracture-dislocations. A follow-up study of 306/321 consecutive cases. Clin Orthop Relat Res. 1985;199:28–38.Google Scholar
- 7.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.CrossRefPubMedGoogle Scholar
- 14.Hahn DM, Colton CL. Malleolar fracture. In: Ruedi TP, Murphy WL, editors. AO principles of fracture management Vol2. New York: Thieme; 2000. p. 559–81.Google Scholar
- 23.Cotton F. Dislocations and joint fractures. Philadelphia: WB Saunders; 1910.Google Scholar
- 25.Solomon L, Warwick DJ, Nayagam S. Apley’s system of orthopaedics and fractures. 8th ed. London: Arnold; 2001.Google Scholar