Skeletal Radiology

, Volume 47, Issue 4, pp 533–540 | Cite as

The predictive value of MRI in the syndesmotic instability of ankle fracture

  • Young Hwan Park
  • Min A. Yoon
  • Won Seok Choi
  • Gi Won Choi
  • Suk Joo Hong
  • Hak Jun Kim
Scientific Article
  • 153 Downloads

Abstract

Objective

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.

Methods

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.

Results

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).

Conclusions

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.

Keywords

Ankle fracture Intraoperative stress test Magnetic resonance imaging Syndesmotic instability 

Notes

Author contributions

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.

References

  1. 1.
    Ebraheim NA, Mekhail AO, Gargasz SS. Ankle fractures involving the fibula proximal to the distal tibiofibular syndesmosis. Foot Ankle Int. 1997;18(8):513–21.CrossRefPubMedGoogle Scholar
  2. 2.
    Leeds HC, Ehrlich MG. Instability of the distal tibiofibular syndesmosis after bimalleolar and trimalleolar ankle fractures. J Bone Joint Surg Am. 1984;66(4):490–503.CrossRefPubMedGoogle Scholar
  3. 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
  4. 4.
    Pettrone FA, Gail M, Pee D, Fitzpatrick T, Van Herpe LB. Quantitative criteria for prediction of the results after displaced fracture of the ankle. J Bone Joint Surg Am. 1983;65(5):667–77.CrossRefPubMedGoogle Scholar
  5. 5.
    Jenkinson RJ, Sanders DW, Macleod MD, Domonkos A, Lydestadt J. Intraoperative diagnosis of syndesmosis injuries in external rotation ankle fractures. J Orthop Trauma. 2005;19(9):604–9.CrossRefPubMedGoogle Scholar
  6. 6.
    Nielson JH, Sallis JG, Potter HG, Helfet DL, Lorich DG. Correlation of interosseous membrane tears to the level of the fibular fracture. J Orthop Trauma. 2004;18(2):68–74.CrossRefPubMedGoogle Scholar
  7. 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
  8. 8.
    Amendola A. Controversies in diagnosis and management of syndesmosis injuries of the ankle. Foot Ankle. 1992;13(1):44–50.CrossRefPubMedGoogle Scholar
  9. 9.
    Weening B, Bhandari M. Predictors of functional outcome following transsyndesmotic screw fixation of ankle fractures. J Orthop Trauma. 2005;19(2):102–8.CrossRefPubMedGoogle Scholar
  10. 10.
    Ebraheim NA, Elgafy H, Padanilam T. Syndesmotic disruption in low fibular fractures associated with deltoid ligament injury. Clin Orthop Relat Res. 2003;409:260–7.CrossRefGoogle Scholar
  11. 11.
    Miller SD. Controversies in ankle fracture treatment. Indications for fixation of stable Weber type B fractures and indications for syndesmosis stabilization. Foot Ankle Clin. 2000;5(4):841–51. viPubMedGoogle Scholar
  12. 12.
    Kaye RA. Stabilization of ankle syndesmosis injuries with a syndesmosis screw. Foot Ankle. 1989;9(6):290–3.CrossRefPubMedGoogle Scholar
  13. 13.
    Beumer A, van Hemert WL, Niesing R, Entius CA, Ginai AZ, Mulder PG, et al. Radiographic measurement of the distal tibiofibular syndesmosis has limited use. Clin Orthop Relat Res. 2004;423:227–34.CrossRefGoogle Scholar
  14. 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
  15. 15.
    McBryde A, Chiasson B, Wilhelm A, Donovan F, Ray T, Bacilla P. Syndesmotic screw placement: a biomechanical analysis. Foot Ankle Int. 1997;18(5):262–6.CrossRefPubMedGoogle Scholar
  16. 16.
    Gardner MJ, Demetrakopoulos D, Briggs SM, Helfet DL, Lorich DG. Malreduction of the tibiofibular syndesmosis in ankle fractures. Foot Ankle Int. 2006;27(10):788–92.CrossRefPubMedGoogle Scholar
  17. 17.
    Brown KW, Morrison WB, Schweitzer ME, Parellada JA, Nothnagel H. MRI findings associated with distal tibiofibular syndesmosis injury. AJR Am J Roentgenol. 2004;182(1):131–6.CrossRefPubMedGoogle Scholar
  18. 18.
    Hermans JJ, Ginai AZ, Wentink N, Hop WC, Beumer A. The additional value of an oblique image plane for MRI of the anterior and posterior distal tibiofibular syndesmosis. Skelet Radiol. 2011;40(1):75–83.CrossRefGoogle Scholar
  19. 19.
    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. Skelet Radiol. 2012;41(7):787–801.CrossRefGoogle Scholar
  20. 20.
    Grossterlinden LG, Hartel M, Yamamura J, Schoennagel B, Burger N, Krause M, et al. Isolated syndesmotic injuries in acute ankle sprains: diagnostic significance of clinical examination and MRI. Knee Surg Sports Traumatol Arthrosc. 2016;24(4):1180–6.CrossRefPubMedGoogle Scholar
  21. 21.
    Nielson JH, Gardner MJ, Peterson MG, Sallis JG, Potter HG, Helfet DL, et al. Radiographic measurements do not predict syndesmotic injury in ankle fractures: an MRI study. Clin Orthop Relat Res. 2005;436:216–21.CrossRefGoogle Scholar
  22. 22.
    Vogl TJ, Hochmuth K, Diebold T, Lubrich J, Hofmann R, Stockle U, et al. Magnetic resonance imaging in the diagnosis of acute injured distal tibiofibular syndesmosis. Investig Radiol. 1997;32(7):401–9.CrossRefGoogle Scholar
  23. 23.
    Cotton F. Dislocations and joint fractures. Philadelphia: WB Saunders; 1910.Google Scholar
  24. 24.
    van den Bekerom MP, Haverkamp D, Kerkhoffs GM, van Dijk CN. Syndesmotic stabilization in pronation external rotation ankle fractures. Clin Orthop Relat Res. 2010;468(4):991–5.CrossRefPubMedGoogle Scholar
  25. 25.
    Solomon L, Warwick DJ, Nayagam S. Apley’s system of orthopaedics and fractures. 8th ed. London: Arnold; 2001.Google Scholar
  26. 26.
    Nortunen S, Lepojarvi S, Savola O, Niinimaki J, Ohtonen P, Flinkkila T, et al. Stability assessment of the ankle mortise in supination-external rotation-type ankle fractures: lack of additional diagnostic value of MRI. J Bone Joint Surg Am. 2014;96(22):1855–62.CrossRefPubMedGoogle Scholar
  27. 27.
    Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33(1):159–74.CrossRefPubMedGoogle Scholar
  28. 28.
    Sarsam IM, Hughes SP. The role of the anterior tibio-fibular ligament in talar rotation: an anatomical study. Injury. 1988;19(2):62–4.CrossRefPubMedGoogle Scholar
  29. 29.
    Ogilvie-Harris DJ, Reed SC, Hedman TP. Disruption of the ankle syndesmosis: biomechanical study of the ligamentous restraints. Arthroscopy. 1994;10(5):558–60.CrossRefPubMedGoogle Scholar
  30. 30.
    Oae K, Takao M, Naito K, Uchio Y, Kono T, Ishida J, et al. Injury of the tibiofibular syndesmosis: value of MR imaging for diagnosis. Radiology. 2003;227(1):155–61.CrossRefPubMedGoogle Scholar
  31. 31.
    Ogilvie-Harris DJ, Reed SC. Disruption of the ankle syndesmosis: diagnosis and treatment by arthroscopic surgery. Arthroscopy. 1994;10(5):561–8.CrossRefPubMedGoogle Scholar
  32. 32.
    Close JR. Some applications of the functional anatomy of the ankle joint. J Bone Joint Surg Am. 1956;38-A(4):761–81.CrossRefPubMedGoogle Scholar
  33. 33.
    McCullough CJ, Burge PD. Rotatory stability of the load-bearing ankle. An experimental study. J Bone Joint Surg Br. 1980;62-B(4):460–4.PubMedGoogle Scholar
  34. 34.
    Gardner MJ, Brodsky A, Briggs SM, Nielson JH, Lorich DG. Fixation of posterior malleolar fractures provides greater syndesmotic stability. Clin Orthop Relat Res. 2006;447:165–71.CrossRefPubMedGoogle Scholar
  35. 35.
    Miller AN, Carroll EA, Parker RJ, Helfet DL, Lorich DG. Posterior malleolar stabilization of syndesmotic injuries is equivalent to screw fixation. Clin Orthop Relat Res. 2010;468(4):1129–35.CrossRefPubMedGoogle Scholar
  36. 36.
    Stoffel K, Wysocki D, Baddour E, Nicholls R, Yates P. Comparison of two intraoperative assessment methods for injuries to the ankle syndesmosis. A cadaveric study. J Bone Joint Surg Am. 2009;91(11):2646–52.CrossRefPubMedGoogle Scholar

Copyright information

© ISS 2017

Authors and Affiliations

  • Young Hwan Park
    • 1
  • Min A. Yoon
    • 2
  • Won Seok Choi
    • 1
  • Gi Won Choi
    • 3
  • Suk Joo Hong
    • 2
  • Hak Jun Kim
    • 1
  1. 1.Department of Orthopedic SurgeryKorea University Guro HospitalSeoulSouth Korea
  2. 2.Department of RadiologyKorea University Guro HospitalSeoulSouth Korea
  3. 3.Department of Orthopedic SurgeryKorea University Ansan HospitalAnsanSouth Korea

Personalised recommendations