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Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 24, Issue 7, pp 2089–2102 | Cite as

Magnetic resonance imaging characterization of individual ankle syndesmosis structures in asymptomatic and surgically treated cohorts

  • Thomas O. Clanton
  • Charles P. HoEmail author
  • Brady T. Williams
  • Rachel K. Surowiec
  • Coley C. Gatlin
  • C. Thomas Haytmanek
  • Robert F. LaPrade
Ankle

Abstract

Purpose

Historically, syndesmosis injuries have been underdiagnosed. The purpose of this study was to characterize the 3.0-T MRI presentations of the distal tibiofibular syndesmosis and its individual structures in both asymptomatic and injured cohorts.

Methods

Ten age-matched asymptomatic volunteers were imaged to characterize the asymptomatic syndesmotic anatomy. A series of 21 consecutive patients with a pre-operative 3.0-T ankle MRI and subsequent arthroscopic evaluation for suspected syndesmotic injury were reviewed and analysed. Prospectively collected pre-operative MRI findings were correlated with arthroscopy to assess diagnostic accuracy [sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV)].

Results

Pathology diagnosed on pre-operative MRI correlated strongly with arthroscopic findings. Syndesmotic ligament disruption was prospectively diagnosed on MRI with excellent sensitivity, specificity, PPV, NPV, and accuracy: anterior inferior tibiofibular ligament (87.5, 100, 100, 71.4, 90.5 %); posterior inferior tibiofibular ligament (N/A, 95.2, 0.0, 100, 95.2 %); and interosseous tibiofibular ligament (66.7, 86.7, 66.7, 86.7, 81.0 %).

Conclusions

Pre-operative 3.0-T MRI demonstrated excellent accuracy in the diagnosis of syndesmotic ligament tears and allowed for the visualization of relevant individual syndesmosis structures. Using a standard clinical ankle MRI protocol at 3.0-T, associated ligament injuries could be readily identified. Clinical implementation of optimal high-field MRI sequences in a standard clinical ankle MRI exam can aid in the diagnosis of syndesmotic injuries, augment pre-operative planning, and facilitate anatomic repair by providing additional details regarding the integrity of individual syndesmotic structures not discernible through physical examination and radiographic assessments.

Level of evidence

II.

Keywords

Syndesmosis ligament tears Anatomy Magnetic resonance imaging (MRI) Arthroscopy Diagnostics (sensitivity, specificity, NPV, PPV) 

References

  1. 1.
    Bartonicek J (2003) Anatomy of the tibiofibular syndesmosis and its clinical relevance. Surg Radiol Anat 25(5–6):379–386CrossRefPubMedGoogle Scholar
  2. 2.
    Bauer JS, Banerjee S, Henning TD, Krug R, Majumdar S, Link TM (2007) Fast high-spatial-resolution MRI of the ankle with parallel imaging using GRAPPA at 3 T. AJR Am J Roentgenol 189(1):240–245CrossRefPubMedGoogle Scholar
  3. 3.
    Beumer A, Swierstra BA, Mulder PG (2002) Clinical diagnosis of syndesmotic instability evaluation of stress tests behind the curtains. Acta Orthop Scand 73(6):667–669PubMedGoogle Scholar
  4. 4.
    Beumer A, Valstar ER, Garling EH, van Leeuwen WJ, Sikma W, Niesing R, Ranstam J, Swierstra BA (2003) External rotation stress imaging in syndesmotic injuries of the ankle: comparison of lateral radiography and radiostereometry in a cadaveric model. Acta Orthop Scand 74(2):201–205CrossRefPubMedGoogle Scholar
  5. 5.
    Beumer A, van Hemert WL, Niesing R, Entius CA, Ginai AZ, Mulder PG, Swierstra BA (2004) Radiographic measurement of the distal tibiofibular syndesmosis has limited use. Clin Orthop Relat Res 423:227–234CrossRefPubMedGoogle Scholar
  6. 6.
    Brown KW, Morrison WB, Schweitzer ME, Parellada JA, Nothnagel H (2004) MRI findings associated with distal tibiofibular syndesmosis injury. AJR Am J Roentgenol 182(1):131–136CrossRefPubMedGoogle Scholar
  7. 7.
    Cedell CA (1975) Ankle lesions. Acta Orthop Scand 46(3):425–445PubMedGoogle Scholar
  8. 8.
    César de César PC, Avila EM, de Abreu MR (2011) Comparison of magnetic resonance imaging to physical examination for syndesmotic injury after lateral ankle sprain. Foot Ankle Int 32(12):1110–1114CrossRefGoogle Scholar
  9. 9.
    Ebraheim NA, Taser F, Shafiq Q, Yeasting RA (2006) Anatomical evaluation and clinical importance of the tibiofibular syndesmosis ligaments. Surg Radiol Anat 28(2):142–149CrossRefPubMedGoogle Scholar
  10. 10.
    Fritschy D (1989) An unusual ankle injury in top skiers. Am J Sports Med 17(2):282–285CrossRefPubMedGoogle Scholar
  11. 11.
    Gerber JP, Williams GN, Scoville CR, Arciero RA, Taylor DC (1998) Persistent disability associated with ankle sprains: a prospective examination of an athletic population. Foot Ankle Int 19(10):653–660CrossRefPubMedGoogle Scholar
  12. 12.
    Griffith JF, Lau DT, Yeung DK, Wong MW (2012) High-resolution MR imaging of talar osteochondral lesions with new classification. Skeletal Radiol 41(4):387–399CrossRefPubMedGoogle Scholar
  13. 13.
    Han SH, Lee JW, Kim S, Suh JS, Choi YR (2007) Chronic tibiofibular syndesmosis injury: the diagnostic efficiency of magnetic resonance imaging and comparative analysis of operative treatment. Foot Ankle Int 28(3):336–342CrossRefPubMedGoogle Scholar
  14. 14.
    Harper MC, Keller TS (1989) A radiographic evaluation of the tibiofibular syndesmosis. Foot Ankle 10(3):156–160CrossRefPubMedGoogle Scholar
  15. 15.
    Hermans JJ, Beumer A, de Jong TA, Kleinrensink GJ (2010) Anatomy of the distal tibiofibular syndesmosis in adults: a pictorial essay with multimodality approach. J Anat 217(6):633–645CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Hermans JJ, Beumer A, Hop WC, Moonen AF, Ginai AZ (2012) Tibiofibular syndesmosis in acute ankle fractures—additional value of an oblique MR image plane. Skelet Radiol 41(2):193–202CrossRefGoogle Scholar
  17. 17.
    Hermans JJ, Ginai AZ, Wentink N, Hop WC, Beumer A (2011) The additional value of an oblique image plane for MRI of the anterior and posterior distal tibiofibular syndesmosis. Skelet Radiol 40(1):75–83CrossRefGoogle Scholar
  18. 18.
    Hermans JJ, Wentink N, Beumer A, Hop WC, Heijiboer MP, Moonen AF, Ginai AZ (2012) Correlation between radiological assessment of acute ankle fractures and syndesmotic injury on MRI. Skelet Radiol 41(7):787–801CrossRefGoogle Scholar
  19. 19.
    Hopkinson WJ, Pierre PS, Ryan JB, Wheeler JH (1990) Syndesmosis sprains of the ankle. Foot Ankle 10(6):325–330CrossRefPubMedGoogle Scholar
  20. 20.
    Hunt KJ (2013) Syndesmosis injuries. Curr Rev Musculoskelet Med 6(4):304–312CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Hunt KJ, George E, Harris AH, Dragoo JL (2013) Epidemiology of syndesmosis injuries in intercollegiate football: incidence and risk factors from National Collegiate Athletic Association injury surveillance system data 2004–2005 to 2008–2009. Clin J Sport Med 23(4):278–282CrossRefPubMedGoogle Scholar
  22. 22.
    Kim S, Huh YM, Song HT, Lee SA, Lee JW, Lee JE, Chung IH, Suh JS (2007) Chronic tibiofibular syndesmosis injury of the ankle: evaluation with contrast-enhanced fat-suppressed 3D fast spoiled gradient-recalled acquisition in the steady state MR imaging. Radiology 242(1):225–235CrossRefPubMedGoogle Scholar
  23. 23.
    Lui TH, Ip K, Chow HT (2005) Comparison of radiologic and arthroscopic diagnoses of distal tibiofibular syndesmosis disruption in acute ankle fracture. Arthroscopy 21(11):1370PubMedGoogle Scholar
  24. 24.
    McCollum GA, van den Bekerom MP, Kerkhoffs GM, Calder JD, van Dijk CN (2013) Syndesmosis and deltoid ligament injuries in the athlete. Knee Surg Sports Traumatol Arthrosc 21(6):1328–1337CrossRefPubMedGoogle Scholar
  25. 25.
    Muhle C, Frank LR, Rand T, Ahn JM, Yeh LR, Trudell D, Haghighi P, Resnick D (1998) Tibiofibular syndesmosis: high resolution MRI using a local gradient coil. J Comput Assist Tomogr 22(6):938–944CrossRefPubMedGoogle Scholar
  26. 26.
    Nielson JH, Gardner MJ, Peterson MG, Sallis JG, Potter HG, Helfet DL, Lorich DG (2005) Radiographic measurements do not predict syndesmotic injury in ankle fractures: an MRI study. Clin Orthop Relat Res 436:216–221CrossRefPubMedGoogle Scholar
  27. 27.
    Oae K, Takao M, Naito K, Uchio Y, Kono T, Ishida J, Ochi M (2003) Injury of the tibiofibular syndesmosis: value of MR imaging for diagnosis. Radiology 227(1):155–161CrossRefPubMedGoogle Scholar
  28. 28.
    Ogilvie-Harris DJ, Reed SC, Hedman TP (1994) Disruption of the ankle syndesmosis: biomechanical study of the ligamentous restraints. Arthroscopy 10(5):558–560CrossRefPubMedGoogle Scholar
  29. 29.
    Pneumaticos SG, Noble PC, Chatziioannou SN, Trevino SG (2002) The effects of rotation on radiographic evaluation of the tibiofibular syndesmosis. Foot Ankle Int 23(2):107–111PubMedGoogle Scholar
  30. 30.
    Rammelt S, Zwipp H, Grass R (2008) Injuries to the distal tibiofibular syndesmosis: an evidence-based approach to acute and chronic lesions. Foot Ankle Clin 13(4):611–633CrossRefPubMedGoogle Scholar
  31. 31.
    Ramsey PL, Hamilton W (1976) Changes in tibiotalar area of contact caused by lateral talar shift. J Bone Joint Surg Am 58(3):356–357PubMedGoogle Scholar
  32. 32.
    Rasmussen O (1985) Stability of the ankle joint. Analysis of the function and traumatology of the ankle ligaments. Acta Orthop Scan Suppl 211:1–75CrossRefGoogle Scholar
  33. 33.
    Shah AS, Kadakia AR, Tan GJ, Karadsheh MS, Wolter TD, Sabb B (2012) Radiographic evaluation of the normal distal tibiofibular syndesmosis. Foot Ankle Int 33(10):870–876CrossRefPubMedGoogle Scholar
  34. 34.
    Sikka RS, Fetzer GB, Sugarman E, Wright RW, Fritts H, Boyd JL, Fischer DA (2012) Correlating MRI findings with disability in syndesmotic sprains of NFL players. Foot Ankle Int 33(5):371–378CrossRefPubMedGoogle Scholar
  35. 35.
    Sman AD, Hiller CE, Rae L, Linklater J, Black DA, Nicholoson LL, Burns J, Refshauge KM (2013) Diagnostic accuracy of clinical tests for ankle syndesmosis injury. Br J Sports Med. doi: 10.1136/bjsports-2013-092787 Google Scholar
  36. 36.
    Sman AD, Hiller CE, Rae K, Linklater J, Black DA, Refschuage KM (2014) Prognosis of ankle syndesmosis injury. Med Sci Sports Exerc 46(4):671–677CrossRefPubMedGoogle Scholar
  37. 37.
    Sman AD, Hiller CE, Refshauge KM (2013) Diagnostic accuracy of clinical tests for diagnosis of ankle syndesmosis injury: a systematic review. Br J Sports Med 47(10):620–628CrossRefPubMedGoogle Scholar
  38. 38.
    Stoffel K, Wysocki D, Baddour E, Nicholls R, Yates P (2009) Comparison of two intraoperative assessment methods for injuries to the ankle syndesmosis. A cadaveric study. J Bone Joint Surg Am 91(11):2646–2652CrossRefPubMedGoogle Scholar
  39. 39.
    Takao M, Ochi M, Naito K, Iwata A, Kawasaki K, Tobita M, Mivamoto W, Oae K (2001) Arthroscopic diagnosis of tibiofibular syndesmosis disruption. Arthroscopy 17(8):836–843CrossRefPubMedGoogle Scholar
  40. 40.
    Takao M, Ochi M, Oae K, Naito K, Uchio Y (2003) Diagnosis of a tear of the tibiofibular syndesmosis. The role of arthroscopy of the ankle. J Bone Joint Surg Br 85(3):324–329CrossRefPubMedGoogle Scholar
  41. 41.
    Van den Bekerom MP (2011) Diagnosing syndesmotic instability in ankle fractures. World J Orthop 2(7):51–56CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Vincelette P, Laurin CA, Lévesque HP (1972) The footballer’s ankle and foot. Can Med Assoc J 107(9):872–874PubMedPubMedCentralGoogle Scholar
  43. 43.
    Vogl TJ, Hochmuth K, Diebold T, Lubrich J, Hofmann R, Stöckle U, Söllner O, Bisson S, Südkamp N, Maeurer J, Haas N, Felix R (1997) Magnetic resonance imaging in the diagnosis of acute injured distal tibiofibular syndesmosis. Invest Radiol 32(7):401–409CrossRefPubMedGoogle Scholar
  44. 44.
    Xenos JS, Hopkinson WJ, Mulligan ME, Olson EJ, Popovic NA (1995) The tibiofibular syndesmosis. Evaluation of the ligamentous structures, methods of fixation, and radiographic assessment. J Bone Joint Surg Am 77(6):847–856PubMedGoogle Scholar
  45. 45.
    Williams GN, Jones MH, Amendola A (2007) Syndesmotic ankle sprains in athletes. Am J Sports Med 35(7):1197–1207CrossRefPubMedGoogle Scholar
  46. 46.
    Zindrick MR, Hopkins DE, Knight GW (1985) The effects of lateral talar shift upon the biomechanics of the ankle joint. Orthop Trans 9:332–333Google Scholar

Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2014

Authors and Affiliations

  • Thomas O. Clanton
    • 1
    • 2
  • Charles P. Ho
    • 1
    • 2
    Email author
  • Brady T. Williams
    • 1
  • Rachel K. Surowiec
    • 1
  • Coley C. Gatlin
    • 1
    • 2
  • C. Thomas Haytmanek
    • 1
    • 2
  • Robert F. LaPrade
    • 1
    • 2
  1. 1.Departments of BioMedical Engineering and Imaging ResearchSteadman Philippon Research InstituteVailUSA
  2. 2.The Steadman ClinicVailUSA

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