Skip to main content

Advertisement

SpringerLink
Log in

Combining radiographic and CT measurements to rival MRI for the diagnosis of acute isolated syndesmotic injury

  • Trauma Surgery
  • Published:
Archives of Orthopaedic and Trauma Surgery Aims and scope Submit manuscript

Abstract

Background

Acute isolated syndesmotic injuries (AISIs) have a high potential to be misdiagnosed or underdiagnosed at initial presentation to the hospital. Although magnetic resonance imaging (MRI) is the gold standard in noninvasive diagnostics, it is not always available immediately and is much more expensive than other imaging modalities. This study identifies improvements in conventional radiography and computed tomography (CT) to diagnose AISI and aims to reduce the number of MRI scans needed to verify the diagnosis.

Methods

A retrospective case match control study was conducted by searching our trauma database between 2008 and 2022. A study group of patients with AISI (n = 64) and a control group of patients without AISI (n = 76) were formed to generate an equal number of images from both groups (62 radiographs and 22 CT scans). A total of 16 parameters that quantify the distal tibiofibular relation in injured and uninjured ankles were analyzed. For statistical analysis, a two-sided t-test was applied to calculate significant differences (p < 0.05). In a further step, a receiver operating characteristic curve (ROC) was used to determine cut-off values for the most significant parameters.

Results

The most significant measurement (p < 0.001) on axial CT scans was the syndesmotic area (SA). The ROC curve revealed an area under the curve (AUC) of 0.94 (95% CI 0.86–1.0) and a cut-off value of 71.68 mm2 that shows a sensitivity and specificity of 95.5% and 81.8%, respectively.

Conclusion

This study suggests that radiographic imaging could represent an equally accurate alternative to MRI. These methods might generate the correct diagnosis faster due to their availability and inexpensiveness. By applying our new cut-off values in a clinical setting, the number of underdiagnosed and untreated unstable syndesmotic injuries could be reduced.

Level of evidence

III, retrospective comparative study

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6

Similar content being viewed by others

Data availability

The authors confirm that the data supporting the findings of this study are available within the article.

References

  1. Abdelaziz ME, Hagemeijer N, Guss D, El-Hawary A, El-Mowafi H, DiGiovanni CW (2019) Evaluation of syndesmosis reduction on CT scan. Foot Ankle Int 40(9):1087–1093

    Article  PubMed  Google Scholar 

  2. Ahn TK, Choi SM, Kim JY, Lee WC (2017) Isolated Syndesmosis Diastasis: Computed Tomography Scan Assessment With Arthroscopic Correlation. Arthroscopy 33(4):828–834

    Article  PubMed  Google Scholar 

  3. Beumer A, van Hemert WL, Niesing R et al (2004) Radiographic measurement of the distal tibiofibular syndesmosis has limited use. Clin Orthop Relat Res 423:227–234

    Article  Google Scholar 

  4. Boytim MJ, Fischer DA, Neumann L (1991) Syndesmotic ankle sprains. Am J Sports Med 19(3):294–298

    Article  CAS  PubMed  Google Scholar 

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

    Article  PubMed  PubMed Central  Google Scholar 

  6. Del Rio A, Bewsher SM, Roshan-Zamir S et al (2020) Weightbearing cone-beam computed tomography of acute ankle syndesmosis injuries. J Foot Ankle Surg 59(2):258–263

    Article  PubMed  Google Scholar 

  7. Dikos GD, Heisler J, Choplin RH, Weber TG (2012) Normal tibiofibular relationships at the syndesmosis on axial CT imaging. J Orthop Trauma 26(7):433–438

    Article  PubMed  Google Scholar 

  8. Elgafy H, Semaan HB, Blessinger B, Wassef A, Ebraheim NA (2010) Computed tomography of normal distal tibiofibular syndesmosis. Skeletal Radiol 39(6):559–564

    Article  PubMed  Google Scholar 

  9. Futamura K, Baba T, Mogami A et al (2017) Malreduction of syndesmosis injury associated with malleolar ankle fracture can be avoided using Weber’s three indexes in the mortise view. Injury 48(4):954–959

    Article  PubMed  Google Scholar 

  10. Gardner MJ, Demetrakopoulos D, Briggs SM, Helfet DL, Lorich DG (2006) Malreduction of the tibiofibular syndesmosis in ankle fractures. Foot Ankle Int 27(10):788–792

    Article  PubMed  Google Scholar 

  11. Ginde AA, Foianini A, Renner DM, Valley M, Camargo CA Jr (2008) Availability and quality of computed tomography and magnetic resonance imaging equipment in U.S. emergency departments. Acad Emerg Med 15(8):780–783

    Article  PubMed  Google Scholar 

  12. Hagemeijer NC, Chang SH, Abdelaziz ME et al (2019) Range of normal and abnormal syndesmotic measurements using weightbearing CT. Foot Ankle Int 40(12):1430–1437

    Article  PubMed  Google Scholar 

  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):336–342

    Article  PubMed  Google Scholar 

  14. Hermans JJ, Wentink N, Beumer A et al (2012) Correlation between radiological assessment of acute ankle fractures and syndesmotic injury on MRI. Skeletal Radiol 41(7):787–801

    Article  CAS  PubMed  Google Scholar 

  15. 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 from 2004–2005 to 2008–2009. Clin J Sport Med 23(4):278–282

    Article  PubMed  Google Scholar 

  16. Kotwal R, Rath N, Paringe V, Hemmadi S, Thomas R, Lyons K (2016) Targeted computerised tomography scanning of the ankle syndesmosis with low dose radiation exposure. Skeletal Radiol 45(3):333–338

    Article  PubMed  Google Scholar 

  17. Krähenbühl N, Weinberg MW, Davidson NP et al (2018) Imaging in syndesmotic injury: a systematic literature review. Skeletal Radiol 47(5):631–648

    Article  PubMed  Google Scholar 

  18. Malhotra G, Cameron J, Toolan BC (2014) Diagnosing chronic diastasis of the syndesmosis: a novel measurement using computed tomography. Foot Ankle Int 35(5):483–488

    Article  PubMed  Google Scholar 

  19. Malhotra K, Welck M, Cullen N, Singh D, Goldberg AJ (2019) The effects of weight bearing on the distal tibiofibular syndesmosis: a study comparing weight bearing-CT with conventional CT. Foot Ankle Surg 25(4):511–516

    Article  PubMed  Google Scholar 

  20. Nault ML, Hébert-Davies J, Laflamme GY, Leduc S (2013) CT scan assessment of the syndesmosis: a new reproducible method. J Orthop Trauma 27(11):638–641

    Article  PubMed  Google Scholar 

  21. Oae K, Takao M, Naito K et al (2003) Injury of the tibiofibular syndesmosis: value of MR imaging for diagnosis. Radiology 227(1):155–161

    Article  PubMed  Google Scholar 

  22. Patel S, Malhotra K, Cullen NP, Singh D, Goldberg AJ, Welck MJ (2019) Defining reference values for the normal tibiofibular syndesmosis in adults using weight-bearing CT. Bone Jt J 101-b(3):348–352

    Article  CAS  Google Scholar 

  23. Ryan LP, Hills MC, Chang J, Wilson CD (2014) The lambda sign: a new radiographic indicator of latent syndesmosis instability. Foot Ankle Int 35(9):903–908

    Article  PubMed  Google Scholar 

  24. Schoennagel BP, Karul M, Avanesov M et al (2014) Isolated syndesmotic injury in acute ankle trauma: comparison of plain film radiography with 3T MRI. Eur J Radiol 83(10):1856–1861

    Article  CAS  PubMed  Google Scholar 

  25. Scranton PE Jr, McMaster JG, Kelly E (1976) Dynamic fibular function: a new concept. Clin Orthop Relat Res 118:76–81

    Google Scholar 

  26. Shakoor D, Osgood GM, Brehler M et al (2019) Cone-beam CT measurements of distal tibio-fibular syndesmosis in asymptomatic uninjured ankles: does weight-bearing matter? Skeletal Radiol 48(4):583–594

    Article  PubMed  Google Scholar 

  27. Souleiman F, Heilemann M, Hennings R et al (2022) Effect of weightbearing and foot positioning on 3D distal tibiofibular joint parameters. Sci Rep 12(1):9357

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  28. 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 Jt Surg Br 85(3):324–329

    Article  CAS  Google Scholar 

  29. van den Bekerom MP (2011) Diagnosing syndesmotic instability in ankle fractures. World J Orthop 2(7):51–56

    Article  PubMed  PubMed Central  Google Scholar 

  30. van den Bekerom MP, de Leeuw PA, van Dijk CN (2009) Delayed operative treatment of syndesmotic instability. Current concepts review Injury 40(11):1137–1142

    PubMed  Google Scholar 

  31. Yeung TW, Chan CY, Chan WC, Yeung YN, Yuen MK (2015) Can pre-operative axial CT imaging predict syndesmosis instability in patients sustaining ankle fractures? Seven years’ experience in a tertiary trauma center. Skeletal Radiol 44(6):823–829

    Article  PubMed  Google Scholar 

  32. Zamzami MM, Zamzam MM (2009) Chronic isolated distal tibiofibular syndesmotic disruption: diagnosis and management. Foot Ankle Surg 15(1):14–19

    Article  PubMed  Google Scholar 

Download references

Funding

None.

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, Center for Musculoskeletal Surgery, Charité Berlin, University Hospital, Berlin, Germany

    Alexander M. H. Kunde, Michael Dahne, Arne Kienzle & Henrik C. Bäcker

  2. Jacksonville Orthopaedic Institute, 1325 San Marco Blvd., Jacksonville, FL, 32207, USA

    J. Turner Vosseller

Authors
  1. Alexander M. H. Kunde
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. J. Turner Vosseller
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Michael Dahne
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Arne Kienzle
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Henrik C. Bäcker
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

HCB, AK, and MD designed the study. HCB, AK, AK, and MD performed the research. HCB, AK, and JTV provided help and advice on the search and interpretation. AK analyzed the data. HCB, AK, AK, MD, and JTV were involved in writing the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Henrik C. Bäcker.

Ethics declarations

Conflict of interest

The authors declare that they do not have any conflict of interest.

Ethical approval

The Charite Berlin University hospital ethical committee approved the study EA1/283/21.

Informed consent

As this study is of retrospective design, no informed consent was required.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kunde, A.M.H., Vosseller, J.T., Dahne, M. et al. Combining radiographic and CT measurements to rival MRI for the diagnosis of acute isolated syndesmotic injury. Arch Orthop Trauma Surg 143, 6631–6639 (2023). https://doi.org/10.1007/s00402-023-04985-w

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00402-023-04985-w

Keywords

Search

Navigation