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Torque application helps to diagnose incomplete syndesmotic injuries using weight-bearing computed tomography images

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Abstract

Objective

Accurate identification of distal tibio-fibular syndesmotic injuries is essential to limit potential deleterious post-traumatic effects. To date, conventional radiographs, computed tomography (CT), and magnetic resonance imaging (MRI) have shown limited utilization. This cadaver study evaluates the utility of weight-bearing CT scans on the assessment of incomplete and more complete syndesmotic injuries.

Materials and methods

Ten male cadavers (tibial plateau to toe-tip) were included. Weight-bearing CTs were taken under four test conditions, with and without torque on the tibia (corresponding to external rotation of the foot and ankle). First, intact ankles (native) underwent imaging. Second, the anterior–inferior tibio-fibular ligament (AITFL) was transected (condition 1). Then, the deltoid ligament (condition 2) was transected, followed by the interosseous membrane (IOM, condition 3). Finally, the posterior–inferior tibio-fibular ligament (PITFL) was transected (condition 4). The medial clear space (MCS), the tibio-fibular clear space (TFCS), and the tibio-fibular overlap (TFO) were assessed on digitally reconstructed radiographs (DRRs), and on axial CT images.

Results

The TFO differentiated isolated AITFL transection from native ankles when torque was applied. Also under torque conditions, the MCS was a useful predictor of an additional deltoid ligament transection, whereas the TFCS identified cadavers in which the PITFL was also transected.

Conclusion

Torque application helps to diagnose incomplete syndesmotic injuries when using weight-bearing CT. The TFO may be useful for identifying incomplete syndesmotic injuries, whereas the MCS and TFCS predict more complete injuries.

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Acknowledgements

The authors thank Nathan B Davidson, for planning the frame used to hold the specimens in the weight-bearing CT, and Maxwell W Weinberg, who helped to plan the experiments.

Funding

This work was supported by a grant from the American Orthopaedic Foot & Ankle Society with funding from the Orthopaedic Foot & Ankle Foundation. N Krähenbühl received a grant from the Swiss National Science Foundation (SNF; grant number P2BSP3_174979).

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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, Travis L. Bailey, Charles L. Saltzman & Alexej Barg

  2. Division of Epidemiology, Department of Internal Medicine, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84108, USA

    Angela P. Presson & Chelsea McCarty Allen

  3. Orthopaedic Research Laboratory, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA

    Heath B. Henninger

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  1. Nicola Krähenbühl
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Correspondence to Alexej Barg.

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For the remaining authors, no conflicts of interest were declared.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

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Investigation performed at the University of Utah, Salt Lake City, Utah, USA

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Krähenbühl, N., Bailey, T.L., Presson, A.P. et al. Torque application helps to diagnose incomplete syndesmotic injuries using weight-bearing computed tomography images. Skeletal Radiol 48, 1367–1376 (2019). https://doi.org/10.1007/s00256-019-3155-1

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