Abstract
Background
The purpose of this study was to evaluate the effect of ankle plantarflexion and the axial location of measurement on quantitative syndesmosis assessment.
Methods
Twelve fresh–frozen cadaveric specimens were secured in three positions of ankle plantarflexion (0°, 15°, and 30°) using an ankle-spanning external fixator and underwent CT scans at each position. Syndesmotic measurements were obtained on axial images using three previously described methods (six measurements) at the level of the tibial plafond and 1 cm proximal to the plafond. Method 1 evaluated the distance between the most anterior and posterior aspects of the fibula and tibia. Method 2 measured medial–lateral diastasis of the anterior and posterior aspects of the fibula, and fibular anterior–posterior translation. Method 3 evaluated axial rotation of the fibula. All measurements were performed by two independent observers. Inter-rater reliability of each measurement was evaluated using intra-class coefficients. Repeated measures analysis of variance (RM-ANOVA) was performed to evaluate within-specimen differences in measurements obtained at varying ankle positions.
Results
The anterior incisura component of method 1 demonstrated poor-to-moderate inter-rater reliability across all ankle positions and at both measurement locations. Inter-rater reliability was highest for method 2, especially when measured 1 cm proximal to the plafond. Method 3 demonstrated moderate reliability 1 cm proximal to the plafond. After correcting for multiple comparisons, RM-ANOVA and pairwise analysis revealed that none of the measurements changed significantly with varying ankle position.
Conclusion
The inter-rater reliability of the most common method of syndesmotic evaluation (method 1) was found to be lower than in previous studies. The most reliable syndesmotic evaluation can be made by measuring diastasis and anteroposterior translation 1 cm proximal to the plafond (method 2). Ankle position from 0° to 30° of plantarflexion did not change the measurements obtained.
Level of evidence
IV.
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References
Tornetta P, Axelrad TW, Sibai TA et al (2012) Treatment of the Stress positive ligamentous SE4 ankle fracture. J Orthop Trauma. 26:659–661
Stark E, Tornetta P, Creevy WR (2007) Syndesmotic Instability in weber B Ankle fractures: a clinical evaluation. J Orthop Trauma. 21:643–646
Birnie MFN, van Schilt KLJ, Sanders FRK et al (2019) Anterior inferior tibiofibular ligament avulsion fractures in operatively treated ankle fractures: a retrospective analysis. Arch Orthop Trauma Surg. 139(6):787–793. https://doi.org/10.1007/s00402-019-03138-2
Little MM, Berkes MB, Schottel PC et al (2015) Anatomic Fixation of supination external rotation type IV Equivalent ankle fractures. J Orthop Trauma. 29:250–255
Miller AN, Carroll EA, Parker RJ et al (2010) Posterior malleolar stabilization of syndesmotic injuries is equivalent to screw fixation. Clin Orthop Relat Res. 468:1129–1135
Weening B, Bhandari M (2005) Predictors of Functional outcome following transsyndesmotic screw fixation of ankle fractures. J Orthop Trauma. 19:102–108
Andersen MR, Frihagen F, Hellund JC et al (2018) Randomized Trial comparing suture button with single syndesmotic screw for syndesmosis injury. J Bone Joint Surg Am. 100:2–12
Levack AE, Warner SJ, Gausden EB et al (2018) Comparing Functional outcomes after injury-specific fixation of posterior malleolar fractures and equivalent ligamentous injuries in rotational ankle fractures. J Orthop Trauma. 32:e123–e128
Gardner MJ, Demetrakopoulos D, Briggs SM et al (2006) Malreduction of the Tibiofibular syndesmosis in ankle fractures. Foot Ankle Int 27:788–792
Burns WC, Prakash K, Adelaar R et al (1993) Tibiotalar Joint dynamics: indications for the syndesmotic screws—A cadaver study. Foot Ankle. 14:153–158
Hunt KJ, Goeb Y, Behn AW et al (2015) Ankle Joint contact loads and displacement with progressive syndesmotic injury. Foot Ankle Int 36:1095–1103
Thordarson DB, Motamed S, Hedman T et al (1997) The Effect of fibular malreduction on contact pressures in an ankle fracture malunion model*. J Bone Joint Surg 79:1809–1815
Chissell HR, Jones J (1995) The influence of a diastasis screw on the outcome of Weber type-C ankle fractures. The Journal of Bone and Joint Surgery British volume. 77-B:435–438
Naqvi GA, Cunningham P, Lynch B et al (2012) Fixation of Ankle syndesmotic injuries: comparison of tightrope fixation and syndesmotic screw fixation for accuracy of syndesmotic reduction. Am J Sports Med. 40:2828–2835
Sagi HC, Shah AR, Sanders RW (2012) The Functional consequence of syndesmotic joint malreduction at a minimum 2-Year follow-up. J Orthop Trauma. 26:439–443
Egol KA, Pahk B, Walsh M et al (2010) Outcome after Unstable ankle fracture: effect of syndesmotic stabilization. J Orthop Trauma. 24:7–11
Bauer M, Jonsson K, Nilsson B (1985) 33 follow-up of ankle fractures. Acta Orthop Scand. 56:103–106
Tunturi T, Kemppainen K, Pätiälä H et al (1983) Importance of Anatomical reduction for subjective recovery after ankle fracture. Acta Orthop Scand. 54:641–647
Kennedy JG, Soffe KE, Vedova PD et al (2000) Evaluation of the Syndesmotic screw in low weber C Ankle fractures. J Orthop Trauma. 14:359–366
Wikeroy AK, Hoiness PR, Andreassen GS et al (2010) No difference in functional and radiographic results 8.4 years after quadricortical compared with tricortical syndesmosis fixation in ankle fractures. J Orthop Trauma. 24:17–23
Harper MC (1993) An Anatomic and radiographic investigation of the tibiofibular clear space. Foot Ankle. 14:455–458
Elgafy H, Semaan HB, Blessinger B et al (2010) Computed tomography of normal distal tibiofibular syndesmosis. Skeletal Radiol. 39:559–564
Marmor M, Hansen E, Han HK et al (2011) Limitations of Standard fluoroscopy in detecting rotational malreduction of the syndesmosis in an Ankle fracture model. Foot Ankle Int 32:616–622
Ebraheim NA, Lu J, Yang H et al (1997) Radiographic and CT evaluation of Tibiofibular Syndesmotic Diastasis: a cadaver study. Foot Ankle Int 18:693–698
Taser F, Shafiq Q, Ebraheim NA (2006) Three-dimensional volume rendering of tibiofibular joint space and quantitative analysis of change in volume due to tibiofibular syndesmosis diastases. Skeletal Radiol. 35:935–941
Mukhopadhyay S, Metcalfe A, Guha AR et al (2011) Malreduction of syndesmosis—are we considering the anatomical variation? Injury 42:1073–1076
Shah AS, Kadakia AR, Tan GJ et al (2012) Radiographic Evaluation of the normal distal tibiofibular syndesmosis. Foot Ankle Int 33:870–876
Davidovitch RI, Weil Y, Karia R et al (2013) Intraoperative syndesmotic reduction: three-dimensional versus standard fluoroscopic imaging. J Bone Joint Surg 95:1838–1843
Warner SJ, Fabricant PD, Garner MR et al (2015) The Measurement and clinical importance of syndesmotic reduction after operative fixation of rotational ankle fractures: The Journal of Bone and Joint Surgery-American Volume. 97:1935–1944
Anand Prakash A (2018) Syndesmotic stability: is there a radiological normal?—A systematic review. Foot Ankle Surg 24(3):174–184
Amin A, Janney C, Sheu C, Jupiter DC, Panchbhavi VK (2018) Weight-bearing radiographic analysis of the tibiofibular syndesmosis. Foot Ankle Spec. https://doi.org/10.1177/1938640018766631
Nault M, Leduc S (2013) CT Scan Assessment of the syndesmosis: a new reproducible method. J Orthop Trauma. 27:4
Lepojarvi S, Pakarinen H, Savola O et al (2016) Rotational Dynamics of the normal distal tibiofibular joint with weight-bearing computed tomography. Foot Ankle Int 37:627–635
Dikos GD, Heisler J, Choplin RH et al (2012) Normal Tibiofibular relationships at the syndesmosis on axial CT imaging: J Orthop Trauma. 26:433–438
Koo TK, Li MY (2015) A Guideline of Selecting and reporting intraclass correlation coefficients for reliability research. Journal of Chiropractic Medicine. 15:155–163
Norkus SA, Floyd RT (2001) The anatomy and mechanisms of syndesmotic ankle sprains. J Athl Train. 36:68–73
Funding
This publication was supported by National Institute of Arthritis and Musculoskeletal and Skin Diseases of the National Institutes of Health (NIH) under award number T32 AR007281. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
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Dean G. Lorich: Deceased December 10, 2017
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Levack, A.E., Dvorzhinskiy, A., Gausden, E.B. et al. Sagittal ankle position does not affect axial CT measurements of the syndesmosis in a cadaveric model. Arch Orthop Trauma Surg 140, 25–31 (2020). https://doi.org/10.1007/s00402-019-03209-4
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DOI: https://doi.org/10.1007/s00402-019-03209-4