The additional value of an oblique image plane for MRI of the anterior and posterior distal tibiofibular syndesmosis
The optimal MRI scan planes of collateral ligaments of the ankle have been described extensively, with the exception of the syndesmotic ligaments. We assessed the optimal scan plane for depicting the distal tibiofibular syndesmosis.
Materials and Methods
In order to determine the optimal oblique caudal-cranial and lateral-medial MRI scan plane, two fresh frozen cadaveric ankles were used. The angle of the scan plane that demonstrated the anterior and posterior distal tibiofibular ligament uninterrupted in their full length was determined. In a prospective study this oblique scan plane was then used in addition to the axial and coronal planes, for MRI scans of both ankles in 21 healthy volunteers. Two observers independently evaluated the anterior tibiofibular ligament (ATIFL) and posterior tibiofibular ligament (PTIFL) regarding the continuity of the individual fascicles, thickness and wavy contour of the ligaments in both the axial and the oblique plane. Kappa was calculated to determine the interobserver agreement. McNemar’s test was used to statistically quantify the significance of the two scan planes.
In the axial plane the ATIFL was in 31% (13/42) partly and in 69% (29/42) completely discontinuous; in the oblique plane the ATIFL was continuous in 88% (37/42) and partly discontinuous in 12% (5/42). Compared with the axial plane, the oblique plane demonstrated significantly less discontinuity (p < 0.001), but not significantly less thickening (p = 1.00) or less wavy contour (p = 0.06) of the ATIFL. In the axial scan plane the PTIFL was continuous in 76% (32/42), partially discontinuous in 19% (8/42) and completely discontinuous in 5% (2/42); in the oblique plane the PTIFL was continuous in 100% (42/42). Compared with the axial plane, the oblique plane demonstrated significantly less discontinuity (p = 0.002), but not significantly less thickening (p = 1.00) or less wavy contour (p = 0.50) of the PTIFL. The interobserver agreement score and kappa (κ) regarding the continuity for the ATIFL in the axial and oblique planes was 91% (κ = 0.79) and 91% (κ = 0.55) respectively; for the PTIFL it was 86% (κ = 0.65) and 100% (κ = not defined).
The ATIFL and PTIFL are routinuely scanned in the orthogonal planes. The advantage of MRI scanning in an oblique image plane of about 45 degrees permits a better evaluation of the ligaments compared with the axial plane, particularly a better interpretation of ligament continuity, thickening and wavy contour. This may lead to a reduction in false-positive results, especially regarding partial or complete ligament ruptures. This can be of considerable aid in therapeutic management.
- Cedell CA. Ankle lesions. Acta Orthop Scand. 1975;46(3):425–45.
- Hopkinson WJ, St Pierre P, Ryan JB, Wheeler JH. Syndesmosis sprains of the ankle. Foot Ankle. 1990;10(6):325–30.
- Brostroem L. Sprained ankles. I. Anatomic lesions in recent sprains. Acta Chir Scand. 1964;128:483–95.
- 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.
- Beumer A, Heijboer RP, Fontijne WP, Swierstra BA. Late reconstruction of the anterior distal tibiofibular syndesmosis: good outcome in 9 patients. Acta Orthop Scand. 2000;71(5):519–21. CrossRef
- Beumer A, Valstar ER, Garling EH, Niesing R, Ginai AZ, Ranstam J, et al. Effects of ligament sectioning on the kinematics of the distal tibiofibular syndesmosis: a radiostereometric study of 10 cadaveric specimens based on presumed trauma mechanisms with suggestions for treatment. Acta Orthop. 2006;77(3):531–40. CrossRef
- Kelikian H, Kelikian AS. Disorders of the ankle. Philadelphia: Saunders; 1985.
- Cedell CA. Supination-outward rotation injuries of the ankle. A clinical and roentgenological study with special reference to the operative treatment. Acta Orthop Scand 1967;(Suppl 110):3+.
- Riede UN, Schenk RK, Willenegger H. Joint mechanical studies on post-traumatic arthrosas in the ankle joint. I. The intra-articular model fracture. Langenbecks Arch Chir. 1971;328(3):258–71. CrossRef
- 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.
- 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.
- 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.
- Brage ME, Bennett CR, Whitehurst JB, Getty PJ, Toledano A. Observer reliability in ankle radiographic measurements. Foot Ankle Int. 1997;18(6):324–9.
- Wrazidlo W, Karl EL, Koch K. Arthrographic diagnosis of rupture of the anterior syndesmosis of the upper ankle joint. Rofo. 1988;148(5):492–7.
- Karl EL, Wrazidlo W. Fresh rupture of the syndesmosis of the proximal ankle joint. Clinical significance and arthrographic diagnosis. Unfallchirurg. 1987;90(2):92–6.
- Sanders HW. Ankle arthrography and ankle distortion. Radiol Clin (Basel). 1977;46(1):1–10.
- Milz P, Milz S, Steinborn M, Mittlmeier T, Putz R, Reiser M. Lateral ankle ligaments and tibiofibular syndesmosis. 13-MHz high-frequency sonography and MRI compared in 20 patients. Acta Orthop Scand. 1998;69(1):51–5. CrossRef
- Ebraheim NA, Lu J, Yang H, Mekhail AO, Yeasting RA. Radiographic and CT evaluation of tibiofibular syndesmotic diastasis: a cadaver study. Foot Ankle Int. 1997;18(11):693–8.
- 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.
- 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 Jt Surg. 2003;85(3):324–9. CrossRef
- Muhle C, Frank LR, Rand T, Ahn JM, Yeh LR, Trudell D, et al. Tibiofibular syndesmosis: high-resolution MRI using a local gradient coil. J Comput Assist Tomogr. 1998;22(6):938–44. CrossRef
- 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. CrossRef
- Schneck CD, Mesgarzadeh M, Bonakdarpour A, Ross GJ. MR imaging of the most commonly injured ankle ligaments. I. Normal anatomy. Radiology. 1992;184(2):499–506.
- Bartonicek J. Anatomy of the tibiofibular syndesmosis and its clinical relevance. Surg Radiol Anat. 2003;25(5–6):379–86. CrossRef
- 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. CrossRef
- 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. CrossRef
- Beumer A. Chronic instability of the anterior syndesmosis of the ankle. Acta Orthop. 2007;78(327):4–36. CrossRef
- Grass R, Herzmann K, Biewener A, Zwipp H. Injuries of the inferior tibiofibular syndesmosis. Unfallchirurg. 2000;103(7):520–32. CrossRef
- Kapanji I. Funktionelle Anatomie der Gelenke. Gerlingen: Enke; 1985.
- Ebraheim NA, Taser F, Shafiq Q, Yeasting RA. Anatomical evaluation and clinical importance of the tibiofibular syndesmosis ligaments. Surg Radiol Anat. 2006;28(2):142–49. CrossRef
- Bassett III FH, Gates III HS, Billys JB, Morris HB, Nikolaou PK. Talar impingement by the anteroinferior tibiofibular ligament. A cause of chronic pain in the ankle after inversion sprain. J Bone Jt Surg Am. 1990;72(1):55–9.
- Subhas N, Vinson EN, Cothran RL, Santangelo JR, Nunley Jr JA, Helms CA. MRI appearance of surgically proven abnormal accessory anterior-inferior tibiofibular ligament (Bassett's ligament). Skeletal Radiol. 2008;37(1):27–33. CrossRef
- Feinstein AR, Cicchetti DV. High agreement but low kappa. I. The problems of two paradoxes. J Clin Epidemiol. 1990;43(6):543–49. CrossRef
- The additional value of an oblique image plane for MRI of the anterior and posterior distal tibiofibular syndesmosis
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- 1. Department of Radiology, Erasmus University Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
- 2. Department of Epidemiology and Biostatistics, Erasmus University Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
- 3. Department of Orthopaedics, Upper Limb Unit, Amphia Ziekenhuis, PO Box 90158, 4800 RK, Breda, The Netherlands