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Imaging in syndesmotic injury: a systematic literature review

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Abstract

Objectives

To give a systematic overview of current diagnostic imaging options for assessment of the distal tibio-fibular syndesmosis.

Materials and methods

A systematic literature search across the following sources was performed: PubMed, ScienceDirect, Google Scholar, and SpringerLink. Forty-two articles were included and subdivided into three groups: group one consists of studies using conventional radiographs (22 articles), group two includes studies using computed tomography (CT) scans (15 articles), and group three comprises studies using magnet resonance imaging (MRI, 9 articles).The following data were extracted: imaging modality, measurement method, number of participants and ankles included, average age of participants, sensitivity, specificity, and accuracy of the measurement technique. The Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool was used to assess the methodological quality.

Results

The three most common techniques used for assessment of the syndesmosis in conventional radiographs are the tibio-fibular clear space (TFCS), the tibio-fibular overlap (TFO), and the medial clear space (MCS). Regarding CT scans, the tibio-fibular width (axial images) was most commonly used. Most of the MRI studies used direct assessment of syndesmotic integrity. Overall, the included studies show low probability of bias and are applicable in daily practice.

Conclusions

Conventional radiographs cannot predict syndesmotic injuries reliably. CT scans outperform plain radiographs in detecting syndesmotic mal-reduction. Additionally, the syndesmotic interval can be assessed in greater detail by CT. MRI measurements achieve a sensitivity and specificity of nearly 100%; however, correlating MRI findings with patients’ complaints is difficult, and utility with subtle syndesmotic instability needs further investigation. Overall, the methodological quality of these studies was satisfactory.

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References

  1. van den Bekerom MP. Diagnosing syndesmotic instability in ankle fractures. World J Orthop. 2011;2(7):51–6.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Sman AD, Hiller CE, Rae K, Linklater J, Black DA, Nicholson LL, et al. Diagnostic accuracy of clinical tests for ankle syndesmosis injury. Br J Sports Med. 2015;49(5):323–9.

    Article  PubMed  Google Scholar 

  3. Hopkinson WJ, St Pierre P, Ryan JB, Wheeler JH. Syndesmosis sprains of the ankle. Foot Ankle. 1990;10(6):325–30.

    Article  CAS  PubMed  Google Scholar 

  4. Ryan PM, Rodriguez RM. Outcomes and return to activity after operative repair of chronic latent syndesmotic instability. Foot Ankle Int. 2016;37(2):192–7.

    Article  PubMed  Google Scholar 

  5. Rammelt S, Obruba P. An update on the evaluation and treatment of syndesmotic injuries. Eur J Trauma Emerg Surg. 2015;41(6):601–14.

    Article  CAS  PubMed  Google Scholar 

  6. Gerber JP, Williams GN, Scoville CR, Arciero RA, Taylor DC. Persistent disability associated with ankle sprains: a prospective examination of an athletic population. Foot Ankle Int. 1998;19(10):653–60.

    Article  CAS  PubMed  Google Scholar 

  7. Zalavras C, Thordarson D. Ankle syndesmotic injury. J Am Acad Orthop Surg. 2007;15(6):330–9.

    Article  PubMed  Google Scholar 

  8. Miyamoto W, Takao M. Management of chronic disruption of the distal tibiofibular syndesmosis. World J Orthop. 2011;2(1):1–6.

    Article  PubMed  PubMed Central  Google Scholar 

  9. van Dijk CN, Longo UG, Loppini M, Florio P, Maltese L, Ciuffreda M, et al. Classification and diagnosis of acute isolated syndesmotic injuries: ESSKA-AFAS consensus and guidelines. Knee Surg Sports Traumatol Arthrosc. 2016;24(4):1200–16.

    Article  PubMed  Google Scholar 

  10. 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.

    Article  PubMed  Google Scholar 

  11. Schuberth JM, Jennings MM, Lau AC. Arthroscopy-assisted repair of latent syndesmotic instability of the ankle. Arthroscopy. 2008;24(8):868–74.

    Article  PubMed  Google Scholar 

  12. Kim JH, Gwak HC, Lee CR, Choo HJ, Kim JG, Kim DY. A comparison of screw fixation and suture-button fixation in a syndesmosis injury in an ankle fracture. J Foot Ankle Surg. 2016;55(5):985–90.

    Article  PubMed  Google Scholar 

  13. Hunt KJ, Goeb Y, Behn AW, Criswell B, Chou L. Ankle joint contact loads and displacement with progressive syndesmotic injury. Foot Ankle Int. 2015;36(9):1095–103.

    Article  PubMed  Google Scholar 

  14. Ramsey PL, Hamilton W. Changes in tibiotalar area of contact caused by lateral talar shift. J Bone Joint Surg Am. 1976;58(3):356–7.

    Article  CAS  PubMed  Google Scholar 

  15. Bartonicek J. Anatomy of the tibiofibular syndesmosis and its clinical relevance. Surg Radiol Anat. 2003;25(5–6):379–86.

    Article  PubMed  Google Scholar 

  16. Sora MC, Strobl B, Staykov D, Forster-Streffleur S. Evaluation of the ankle syndesmosis: a plastination slices study. Clin Anat. 2004;17(6):513–7.

    Article  PubMed  Google Scholar 

  17. Ebraheim NA, Taser F, Shafiq Q, Yeasting RA. Anatomical evaluation and clinical importance of the tibiofibular syndesmosis ligaments. Surg Radiol Anat. 2006;28(2):142–9.

    Article  PubMed  Google Scholar 

  18. Magan A, Golano P, Maffulli N, Khanduja V. Evaluation and management of injuries of the tibiofibular syndesmosis. Br Med Bull. 2014;111(1):101–15.

    Article  PubMed  Google Scholar 

  19. Lilyquist M, Shaw A, Latz K, Bogener J, Wentz B. Cadaveric analysis of the distal tibiofibular syndesmosis. Foot Ankle Int. 2016;37(8):882–90.

    Article  PubMed  Google Scholar 

  20. Hermans JJ, Beumer A, de Jong TA, Kleinrensink GJ. Anatomy of the distal tibiofibular syndesmosis in adults: a pictorial essay with a multimodality approach. J Anat. 2010;217(6):633–45.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Williams BT, Ahrberg AB, Goldsmith MT, Campbell KJ, Shirley L, Wijdicks CA, et al. Ankle syndesmosis: a qualitative and quantitative anatomic analysis. Am J Sports Med. 2015;43(1):88–97.

    Article  PubMed  Google Scholar 

  22. Mengiardi B, Pfirrmann CW, Vienne P, Hodler J, Zanetti M. Medial collateral ligament complex of the ankle: MR appearance in asymptomatic subjects. Radiology. 2007;242(3):817–24.

    Article  PubMed  Google Scholar 

  23. Boss AP, Hintermann B. Anatomical study of the medial ankle ligament complex. Foot Ankle Int. 2002;23(6):547–53.

    Article  PubMed  Google Scholar 

  24. Knupp M, Lang TH, Zwicky L, Lotscher P, Hintermann B. Chronic ankle instability (medial and lateral). Clin Sports Med. 2015;34(4):679–88.

    Article  PubMed  Google Scholar 

  25. Hintermann B, Golano P. The anatomy and function of the deltoid ligament. Tech Foot Ankle. 2014;13:67–72.

    Article  Google Scholar 

  26. Milner CE, Soames RW. The medial collateral ligaments of the human ankle joint: anatomical variations. Foot Ankle Int. 1998;19(5):289–92.

    Article  CAS  PubMed  Google Scholar 

  27. 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.

    Article  Google Scholar 

  28. Takao M, Ochi M, Naito K, Iwata A, Kawasaki K, Tobita M, et al. Arthroscopic diagnosis of tibiofibular syndesmosis disruption. Arthroscopy. 2001;17(8):836–43.

    Article  CAS  PubMed  Google Scholar 

  29. 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.

    Article  Google Scholar 

  30. Jeong MS, Choi YS, Kim YJ, Kim JS, Young KW, Jung YY. Deltoid ligament in acute ankle injury: MR imaging analysis. Skelet Radiol. 2014;43(5):655–63.

    Article  Google Scholar 

  31. 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.

    Article  PubMed  Google Scholar 

  32. Whiting PF, Rutjes AW, Westwood ME, Mallett S, Deeks JJ, Reitsma JB, et al. QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med. 2011;155(8):529–36.

    Article  PubMed  Google Scholar 

  33. 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.

    Article  CAS  Google Scholar 

  34. 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.

    Article  CAS  PubMed  Google Scholar 

  35. 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.

    Article  PubMed  Google Scholar 

  36. Takao M, Ochi M, Oae K, Naito K, Uchio Y. Diagnosis of a tear of the tibiofibular syndesmosis: the role of arthroscopy of the ankle. J Bone Joint Surg. 2003;85(3):324–9.

    Article  CAS  Google Scholar 

  37. 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.

    Article  CAS  PubMed  Google Scholar 

  38. Harper MC, Keller TS. A radiographic evaluation of the tibiofibular syndesmosis. Foot Ankle. 1989;10(3):156–60.

    Article  CAS  PubMed  Google Scholar 

  39. Xenos JS, Hopkinson WJ, Mulligan ME, Olson EJ, Popovic NA. The tibiofibular syndesmosis: evaluation of the ligamentous structures, methods of fixation, and radiographic assessment. J Bone Joint Surg Am. 1995;77(6):847–56.

    Article  CAS  PubMed  Google Scholar 

  40. Brage ME, Bennett CR, Whitehurst JB, Getty PJ, Toledano A. Observer reliability in ankle radiographic measurements. Foot Ankle Int. 1997;18(6):324–9.

    Article  CAS  PubMed  Google Scholar 

  41. 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.

    Article  PubMed  Google Scholar 

  42. DeAngelis JP, Anderson R, DeAngelis NA. Understanding the superior clear space in the adult ankle. Foot Ankle Int. 2007;28(4):490–3.

    Article  PubMed  Google Scholar 

  43. Marmor M, Hansen E, Han HK, Buckley J, Matityahu A. Limitations of standard fluoroscopy in detecting rotational malreduction of the syndesmosis in an ankle fracture model. Foot Ankle Int. 2011;32(6):616–22.

    Article  PubMed  Google Scholar 

  44. 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.

    Article  PubMed  Google Scholar 

  45. Grenier S, Benoit B, Rouleau DM, Leduc S, Laflamme GY, Liew A. APTF: anteroposterior tibiofibular ratio, a new reliable measure to assess syndesmotic reduction. J Orthop Trauma. 2013;27(4):207–11.

    Article  PubMed  Google Scholar 

  46. Choi Y, Kwon SS, Chung CY, Park MS, Lee SY, Lee KM. Preoperative radiographic and CT findings predicting syndesmotic injuries in supination-external rotation-type ankle fractures. J Bone Joint Surg Am. 2014;96(14):1161–7.

    Article  PubMed  Google Scholar 

  47. Chen Y, Qiang M, Zhang K, Li H, Dai H. A reliable radiographic measurement for evaluation of normal distal tibiofibular syndesmosis: a multi-detector computed tomography study in adults. J Foot Ankle Res. 2015;8:32.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Peterson KS, Chapman WD, Hyer CF, Berlet GC. Maintenance of reduction with suture button fixation devices for ankle syndesmosis repair. Foot Ankle Int. 2015;36(6):679–84.

    Article  PubMed  Google Scholar 

  49. 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.

    Article  PubMed  Google Scholar 

  50. 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. Skelet Radiol. 2015;44(6):823–9.

    Article  Google Scholar 

  51. Tang CW, Roidis N, Vaishnav S, Patel A, Thordarson DB. Position of the distal fibular fragment in pronation and supination ankle fractures: a CT evaluation. Foot Ankle Int. 2003;24(7):561–6.

    Article  PubMed  Google Scholar 

  52. Elgafy H, Semaan HB, Blessinger B, Wassef A, Ebraheim NA. Computed tomography of normal distal tibiofibular syndesmosis. Skelet Radiol. 2010;39(6):559–64.

    Article  Google Scholar 

  53. Mukhopadhyay S, Metcalfe A, Guha AR, Mohanty K, Hemmadi S, Lyons K, et al. Malreduction of syndesmosis: are we considering the anatomical variation? Injury. 2011;42(10):1073–6.

    Article  CAS  PubMed  Google Scholar 

  54. 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.

    Article  PubMed  Google Scholar 

  55. Knops SP, Kohn MA, Hansen EN, Matityahu A, Marmor M. Rotational malreduction of the syndesmosis: reliability and accuracy of computed tomography measurement methods. Foot Ankle Int. 2013;34(10):1403–10.

    Article  PubMed  Google Scholar 

  56. Nault ML, Hebert-Davies J, Laflamme GY, Leduc S. CT scan assessment of the syndesmosis: a new reproducible method. J Orthop Trauma. 2013;27(11):638–41.

    Article  PubMed  Google Scholar 

  57. Lepojarvi S, Pakarinen H, Savola O, Haapea M, Sequeiros RB, Niinimaki J. Posterior translation of the fibula may indicate malreduction: CT study of normal variation in uninjured ankles. J Orthop Trauma. 2014;28(4):205–9.

    Article  PubMed  Google Scholar 

  58. Malhotra G, Cameron J, Toolan BC. Diagnosing chronic diastasis of the syndesmosis: a novel measurement using computed tomography. Foot Ankle Int. 2014;35(5):483–8.

    Article  PubMed  Google Scholar 

  59. Mendelsohn ES, Hoshino CM, Harris TG, Zinar DM. CT characterizing the anatomy of uninjured ankle syndesmosis. Orthopedics. 2014;37(2):e157–60.

    Article  PubMed  Google Scholar 

  60. Kotwal R, Rath N, Paringe V, Hemmadi S, Thomas R, Lyons K. Targeted computerised tomography scanning of the ankle syndesmosis with low dose radiation exposure. Skelet Radiol. 2016;45(3):333–8.

    Article  Google Scholar 

  61. Kocadal O, Yucel M, Pepe M, Aksahin E, Aktekin CN. Evaluation of reduction accuracy of suture-button and screw fixation techniques for syndesmotic injuries. Foot Ankle Int. 2016;37(12):1317–25.

    Article  PubMed  Google Scholar 

  62. Nault ML, Gascon L, Hebert-Davies J, Leduc S, Laflamme GY, Kramer D. Modification of distal tibiofibular relationship after a mild syndesmotic injury. Foot Ankle Spec. 2017a;10(2):133–8.

    Article  PubMed  Google Scholar 

  63. Nault ML, Hebert-Davies J, Yen YM, Shore B, Jarrett DY, Kramer DE. Variation of syndesmosis anatomy with growth. J Pediatr Orthop. 2016;36(4):e41–4.

    Article  PubMed  Google Scholar 

  64. 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. 2017b;38(2):215–9.

    Article  PubMed  Google Scholar 

  65. Chun KY, Choi YS, Lee SH, Kim JS, Young KW, Jeong MS, et al. Deltoid ligament and tibiofibular syndesmosis injury in chronic lateral ankle instability: magnetic resonance imaging evaluation at 3T and comparison with arthroscopy. Korean J Radiol. 2015;16(5):1096–103.

    Article  PubMed  PubMed Central  Google Scholar 

  66. Han SH, Lee JW, Kim S, Suh JS, Choi YR. Chronic tibiofibular syndesmosis injury: the diagnostic efficiency of magnetic resonance imaging and comparative analysis of operative treatment. Foot Ankle Int. 2007;28(3):336–42.

    Article  PubMed  Google Scholar 

  67. Kim S, Huh YM, Song HT, Lee SA, Lee JW, Lee JE, et al. Chronic tibiofibular syndesmosis injury of ankle: evaluation with contrast-enhanced fat-suppressed 3D fast spoiled gradient-recalled acquisition in the steady state MR imaging. Radiology. 2007;242(1):225–35.

    Article  PubMed  Google Scholar 

  68. Warner SJ, Garner MR, Schottel PC, Hinds RM, Loftus ML, Lorich DG. Analysis of PITFL injuries in rotationally unstable ankle fractures. Foot Ankle Int. 2015;36(4):377–82.

    Article  PubMed  Google Scholar 

  69. 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.

    Article  CAS  PubMed  Google Scholar 

  70. Chaput V. Les fractures malleolaires du cou-de-pieds et les accidents du travaill. Paris: Masson & Cie; 1907.

    Google Scholar 

  71. 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.

    Article  PubMed  Google Scholar 

  72. Stoffel K, Wysocki D, Baddour E, Nicholls R, Yates P. Comparison of two intraoperative assessment methods for injuries to the ankle syndesmosis: cadaveric study. J Bone Joint Surg Am. 2009;91(11):2646–52.

    Article  PubMed  Google Scholar 

  73. 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.

    Article  PubMed  Google Scholar 

  74. Cherney SM, Spraggs-Hughes AG, McAndrew CM, Ricci WM, Gardner MJ. Incisura morphology as a risk factor for syndesmotic malreduction. Foot Ankle Int. 2016;37(7):748–54.

    Article  PubMed  Google Scholar 

  75. Vasarhelyi A, Lubitz J, Gierer P, Gradl G, Rosler K, Hopfenmuller W, et al. Detection of fibular torsional deformities after surgery for ankle fractures with a novel CT method. Foot Ankle Int. 2006;27(12):1115–21.

    Article  PubMed  Google Scholar 

  76. Lucas DE, Watson BC, Simpson GA, Berlet GC, Hyer CF. Arthroscopic evaluation of syndesmotic instability and malreduction. Foot Ankle Spec. 2016.

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Authors and Affiliations

  1. Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA

    Nicola Krähenbühl, Maxwell W. Weinberg, Nathan P. Davidson, Charles L. Saltzman & Alexej Barg

  2. Department of Radiology and Imaging Sciences, University of Utah, 30 N. 1900 E. No. 1A071, Salt Lake City, UT, 84132, USA

    Megan K. Mills

  3. Department of Orthopaedics, Kantonsspital Baselland, Rheinstrasse 26, 4410, Liestal, Switzerland

    Beat Hintermann

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  1. Nicola Krähenbühl
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  2. Maxwell W. Weinberg
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Correspondence to Alexej Barg.

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Nicola Krahenbuhl is supported by a grant from the Swiss National Science Foundation (SNF; grant number P2BSP3_174979).

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Investigation performed at the Department of Orthopaedics and Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah, USA

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Krähenbühl, N., Weinberg, M.W., Davidson, N.P. et al. Imaging in syndesmotic injury: a systematic literature review. Skeletal Radiol 47, 631–648 (2018). https://doi.org/10.1007/s00256-017-2823-2

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