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The arthroscopic syndesmotic assessment tool can differentiate between stable and unstable ankle syndesmoses

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

Patients with stable isolated injuries of the ankle syndesmosis can be treated conservatively, while unstable injuries require surgical stabilisation. Although evaluating syndesmotic injuries using ankle arthroscopy is becoming more popular, differentiating between stable and unstable syndesmoses remains a topic of on-going debate in the current literature. The purpose of this study was to quantify the degree of displacement of the ankle syndesmosis using arthroscopic measurements. The hypothesis was that ankle arthroscopy by measuring multiplanar fibular motion can determine syndesmotic instability.

Methods

Arthroscopic assessment of the ankle syndesmosis was performed on 22 fresh above knee cadaveric specimens, first with all syndesmotic and ankle ligaments intact and subsequently with sequential sectioning of the anterior inferior tibiofibular ligament, the interosseous ligament, the posterior inferior tibiofibular ligament, and deltoid ligaments. In all scenarios, four loading conditions were considered under 100N of direct force: (1) unstressed, (2) a lateral hook test, (3) anterior to posterior (AP) translation test, and (4) posterior to anterior (PA) translation test. Anterior and posterior coronal plane tibiofibular translation, as well as AP and PA sagittal plane translation, were arthroscopically measured.

Results

As additional ligaments of the syndesmosis were transected, all arthroscopic multiplanar translation measurements increased (p values ranging from p < 0.001 to p = 0.007). The following equation of multiplanar fibular motion relative to the tibia measured in millimeters: 0.76*AP sagittal translation + 0.82*PA sagittal translation + 1.17*anterior third coronal plane translation—0.20*posterior third coronal plane translation, referred to as the Arthroscopic Syndesmotic Assessment tool, was generated from our data. According to our results, an Arthroscopic Syndesmotic Assessment value equal or greater than 3.1 mm indicated an unstable syndesmosis.

Conclusions

This tool provides a more reliable opportunity in determining the presence of syndesmotic instability and can help providers decide whether syndesmosis injuries should be treated conservatively or operatively stabilized. The long-term usefulness of the tool will rest on whether an unstable syndesmosis correlates with acute or chronic clinical symptoms.

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References

  1. Beumer A, Heijboer RP, Fontijne WP, Swierstra BA (2000) Late reconstruction of the anterior distal tibiofibular syndesmosis: good outcome in 9 patients. Acta Orthop Scand 71:519–521

    Article  CAS  PubMed  Google Scholar 

  2. Beumer A, Valstar ER, Garling EH, Niesing R, Ginai AZ, Ranstam J et al (2006) 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 77:531–540

    Article  PubMed  Google Scholar 

  3. Beumer A, Valstar ER, Garling EH, Niesing R, Heijboer RP, Ranstam J et al (2005) Kinematics before and after reconstruction of the anterior syndesmosis of the ankle: a prospective radiostereometric and clinical study in 5 patients. Acta Orthop 76:713–720

    Article  PubMed  Google Scholar 

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

    Article  Google Scholar 

  5. Brown KW, Morrison WB, Schweitzer ME, Parellada JA, Nothnagel H (2004) MRI findings associated with distal tibiofibular syndesmosis injury. AJR Am J Roentgenol 182:131–136

    Article  PubMed  Google Scholar 

  6. Calder JD, Bamford R, Petrie A, McCollum GA (2016) Stable versus unstable grade II high ankle sprains: a prospective study predicting the need for surgical stabilization and time to return to sports. Arthroscopy 32:634–642

    Article  PubMed  Google Scholar 

  7. Candal-Couto JJ, Burrow D, Bromage S, Briggs PJ (2004) Instability of the tibio-fibular syndesmosis: have we been pulling in the wrong direction? Injury 35:814–818

    Article  CAS  PubMed  Google Scholar 

  8. Chan KB, Lui TH (2016) Role of ankle arthroscopy in management of acute ankle fracture. Arthroscopy 32:2373–2380

    Article  PubMed  Google Scholar 

  9. Clanton TO, Ho CP, Williams BT, Surowiec RK, Gatlin CC, Haytmanek CT et al (2016) Magnetic resonance imaging characterization of individual ankle syndesmosis structures in asymptomatic and surgically treated cohorts. Knee Surg Sports Traumatol Arthrosc 24:2089–2102

    Article  PubMed  Google Scholar 

  10. Clanton TO, Paul P (2002) Syndesmosis injuries in athletes. Foot Ankle Clin 7:529–549

    Article  PubMed  Google Scholar 

  11. Colcuc C, Fischer S, Colcuc S, Busse D, Bliemel C, Neun O et al (2016) Treatment strategies for partial chronic instability of the distal syndesmosis: an arthroscopic grading scale and operative staging concept. Arch Orthop Trauma Surg 136:157–163

    Article  CAS  PubMed  Google Scholar 

  12. Feller R, Borenstein T, Fantry AJ, Kellum RB, Machan JT, Nickisch F et al (2017) Arthroscopic quantification of syndesmotic instability in a cadaveric model. Arthroscopy 33:436–444

    Article  PubMed  Google Scholar 

  13. Fisher RA (1936) The use of multiple measurements in taxonomic problems. Ann Eugen 7:179–188

    Article  Google Scholar 

  14. Flik K, Lyman S, Marx RG (2005) American collegiate men’s ice hockey: an analysis of injuries. Am J Sports Med 33:183–187

    Article  PubMed  Google Scholar 

  15. Forgy EW (1965) Cluster analysis of multivariate data: efficiency versus interpretability of classifications. Biometrics 21:768–769

    Google Scholar 

  16. Fritschy D (1989) An unusual ankle injury in top skiers. Am J Sports Med 17:282–285

    Article  CAS  PubMed  Google Scholar 

  17. 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 19:653–660

    Article  CAS  PubMed  Google Scholar 

  18. Guyton GP, DeFontes K 3rd, Barr CR, Parks BG, Camire LM (2017) Arthroscopic correlates of subtle syndesmotic injury. Foot Ankle Int 38:502–506

    Article  PubMed  Google Scholar 

  19. Han SH, Lee JW, Kim S, Suh J-S, Choi YR (2007) Chronic tibiofibular syndesmosis injury: the diagnostic efficiency of magnetic resonance imaging and comparative analysis of operative treatment. Foot Ankle Int 28:336–342

    Article  PubMed  Google Scholar 

  20. Haraguchi N, Armiger RS (2009) A new interpretation of the mechanism of ankle fracture. J Bone Joint Surg Am 91:821–829

    Article  PubMed  Google Scholar 

  21. Hepple S, Guha A (2013) The role of ankle arthroscopy in acute ankle injuries of the athlete. Foot Ankle Clin 18:185–194

    Article  PubMed  Google Scholar 

  22. Hermans JJ, Wentink N, Beumer A, Hop WCJ, Heijboer MP, Moonen AFCM et al (2012) Correlation between radiological assessment of acute ankle fractures and syndesmotic injury on MRI. Skeletal Radiol 41:787–801

    Article  CAS  PubMed  Google Scholar 

  23. Hopkinson WJ, St Pierre P, Ryan JB, Wheeler JH (1990) Syndesmosis sprains of the ankle. Foot Ankle 10:325–330

    Article  CAS  PubMed  Google Scholar 

  24. Huber T, Schmoelz W, Bolderl A (2012) Motion of the fibula relative to the tibia and its alterations with syndesmosis screws: a cadaver study. Foot Ankle Surg 18:203–209

    Article  PubMed  Google Scholar 

  25. 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 to 2005 to 2008–2009. Clin J Sport Med 23:278–282

    Article  PubMed  Google Scholar 

  26. Jain N, Murray D, Kemp S, Calder JD (2018) High-speed video analysis of syndesmosis injuries in soccer—can it predict injury mechanism and return to play? A pilot study. Foot Ankle Orthop 3:1–5

    Article  Google Scholar 

  27. Jiang KN, Schulz BM, Tsui YL, Gardner TR, Greisberg JK (2014) Comparison of radiographic stress tests for syndesmotic instability of supination-external rotation ankle fractures: a cadaveric study. J Orthop Trauma 28:123–127

    Article  Google Scholar 

  28. Kaplan LD, Jost PW, Honkamp N, Norwig J, West R, Bradley JP (2011) Incidence and variance of foot and ankle injuries in elite college football players. Am J Orthop (Belle Mead NJ) 40:40–44

    Google Scholar 

  29. Krahenbuhl N, Weinberg MW, Davidson NP, Mills MK, Hintermann B, Saltzman CL et al (2018) Imaging in syndesmotic injury: a systematic literature review. Skelet Radiol 47:631–648

    Article  Google Scholar 

  30. Lambert Z, Durand R (1975) Some precautions in using canonical analysis. J Mark Res 12:468–475

    Article  Google Scholar 

  31. LaMothe JM, Baxter JR, Murphy C, Gilbert S, DeSandis B, Drakos MC (2016) Three-dimensional analysis of fibular motion after fixation of syndesmotic injuries with a screw or suture-button construct. Foot Ankle Int 37:1350–1356

    Article  PubMed  Google Scholar 

  32. Lloyd SP (1982) Least squares quantization in PCM. IEEE Trans Inf Theory 28:129–137

    Article  Google Scholar 

  33. Lubberts B, Guss D, Vopat BG, Wolf JC, Moon DK, DiGiovanni CW (2017) The effect of ankle distraction on arthroscopic evaluation of syndesmotic instability: a cadaveric study. Clin Biomech (Bristol Avon) 50:16–20

    Article  Google Scholar 

  34. Lubberts B, van Dijk PAD, Calder JD, DiGiovanni CW (2016) There is no best surgical treatment for chronic isolated syndesmotic instability: a systematic review. J ISAKOS 1:250–256

    Article  Google Scholar 

  35. Lubberts B, van Dijk PAD, Donovan N, van Dijk CN, Calder JD (2016) Time to return to sports after management of stable and unstable grade II syndesmotic injuries: a systematic review. J ISAKOS 1:192–197

    Article  Google Scholar 

  36. Lucas DE, Watson BC, Simpson GA, Berlet GC, Hyer CF (2016) Arthroscopic evaluation of syndesmotic instability and malreduction. Foot Ankle Spec 9:500–505

    Article  PubMed  Google Scholar 

  37. Lui TH, Ip K, Chow HT (2005) Comparison of radiologic and arthroscopic diagnoses of distal tibiofibular syndesmosis disruption in acute ankle fracture. Arthroscopy 21:1370

    PubMed  Google Scholar 

  38. Mak MF, Gartner L, Pearce CJ (2013) Management of syndesmosis injuries in the elite athlete. Foot Ankle Clin 18:195–214

    Article  PubMed  Google Scholar 

  39. Massri-Pugin J, Lubberts B, Vopat BG, Guss D, Hosseini A, DiGiovanni CW (2017) Effect of sequential sectioning of ligaments on syndesmotic instability in the coronal plane evaluated arthroscopically. Foot Ankle Int 38:1387–1393

    Article  PubMed  Google Scholar 

  40. Massri-Pugin J, Lubberts B, Vopat BG, Wolf JC, DiGiovanni CW, Guss D (2018) Role of the deltoid ligament in syndesmotic instability. Foot Ankle Int 39:598–603

    Article  PubMed  Google Scholar 

  41. Nielson JH, Gardner MJ, Peterson MG, Sallis JG, Potter HG, Helfet DL et al (2005) Radiographic measurements do not predict syndesmotic injury in ankle fractures: an MRI study. Clin Orthop Relat Res 216–221

  42. Nussbaum ED, Hosea TM, Sieler SD, Incremona BR, Kessler DE (2001) Prospective evaluation of syndesmotic ankle sprains without diastasis. Am J Sports Med 29:31–35

    Article  CAS  PubMed  Google Scholar 

  43. Oae K, Takao M, Naito K, Uchio Y, Kono T, Ishida J et al (2003) Injury of the tibiofibular syndesmosis: value of MR imaging for diagnosis. Radiology 227:155–161

    Article  PubMed  Google Scholar 

  44. Ogilvie-Harris DJ, Gilbart MK, Chorney K (1997) Chronic pain following ankle sprains in athletes: the role of arthroscopic surgery. Arthroscopy 13:564–574

    Article  CAS  PubMed  Google Scholar 

  45. Ogilvie-Harris DJ, Reed SC (1994) Disruption of the ankle syndesmosis: diagnosis and treatment by arthroscopic surgery. Arthroscopy 10:561–568

    Article  CAS  PubMed  Google Scholar 

  46. Pneumaticos SG, Noble PC, Chatziioannou SN, Trevino SG (2002) The effects of rotation on radiographic evaluation of the tibiofibular syndesmosis. Foot Ankle Int 23:107–111

    Article  PubMed  Google Scholar 

  47. Ramsey PL, Hamilton W (1976) Changes in tibiotalar area of contact caused by lateral talar shift. J Bone Joint Surg Am 58:356–357

    Article  CAS  PubMed  Google Scholar 

  48. Rasmussen O (1985) Stability of the ankle joint. Analysis of the function and traumatology of the ankle ligaments. Acta Orthop Scand Suppl 211:1–75

    Article  CAS  PubMed  Google Scholar 

  49. Ryan PM, Rodriguez RM (2016) Outcomes and return to activity after operative repair of chronic latent syndesmotic instability. Foot Ankle Int 37:192–197

    Article  PubMed  Google Scholar 

  50. Shah AS, Kadakia AR, Tan GJ, Karadsheh MS, Wolter TD, Sabb B (2012) Radiographic evaluation of the normal distal tibiofibular syndesmosis. Foot Ankle Int 33:870–876

    Article  PubMed  Google Scholar 

  51. Shrout PE (1998) Measurement reliability and agreement in psychiatry. Stat Methods Med Res 7:301–317

    Article  CAS  PubMed  Google Scholar 

  52. Stevens J (1986) Applied multivariate statistics for the social sciences. L Erlbaum Associates 375

  53. 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 91:2646–2652

    Article  PubMed  Google Scholar 

  54. Takao M, Ochi M, Naito K, Iwata A, Kawasaki K, Tobita M et al (2001) Arthroscopic diagnosis of tibiofibular syndesmosis disruption. Arthroscopy 17:836–843

    Article  CAS  PubMed  Google Scholar 

  55. 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 85:324–329

    Article  CAS  PubMed  Google Scholar 

  56. Turky M, Menon KV, Saeed K (2018) Arthroscopic grading of injuries of the inferior tibiofibular syndesmosis. J Foot Ankle Surg 18:1067–2516

    Google Scholar 

  57. van Dijk CN, Longo UG, Loppini M, Florio P, Maltese L, Ciuffreda M et al (2016) Conservative and surgical management of acute isolated syndesmotic injuries: ESSKA-AFAS consensus and guidelines. Knee Surg Sports Traumatol Arthrosc 24:1217–1227

    Article  PubMed  Google Scholar 

  58. Vopat ML, Vopat BG, Lubberts B, DiGiovanni CW (2017) Current trends in the diagnosis and management of syndesmotic injury. Curr Rev Musculoskelet Med 10:94–103

    Article  PubMed  PubMed Central  Google Scholar 

  59. Wagener ML, Beumer A, Swierstra BA (2011) Chronic instability of the anterior tibiofibular syndesmosis of the ankle. Arthroscopic findings and results of anatomical reconstruction. BMC Musculoskelet Disord 12:212–212

    Article  PubMed  PubMed Central  Google Scholar 

  60. Watson BC, Lucas DE, Simpson GA, Berlet GC, Hyer CF (2015) Arthroscopic evaluation of syndesmotic instability in a cadaveric model. Foot Ankle Int 36:1362–1368

    Article  PubMed  Google Scholar 

  61. Wright RW, Barile RJ, Surprenant DA, Matava MJ (2004) Ankle syndesmosis sprains in national hockey league players. Am J Sports Med 32:1941–1945

    Article  PubMed  Google Scholar 

  62. 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 77:847–856

    Article  CAS  PubMed  Google Scholar 

  63. Yu M, Zhang Y, Su Y, Wang F, Zhao D (2018) An anthropometric study of distal tibiofibular syndesmosis (DTS) in a Chinese population. J Orthop Surg Res 13:95

    Article  PubMed  PubMed Central  Google Scholar 

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Funding

This research has been sponsored by an internal merit-based institutional research fund.

Author information

Authors and Affiliations

  1. Foot and Ankle Research and Innovation Lab, Massachusetts General Hospital, Newton-Wellesley Hospital, Harvard Medical School, Boston, USA

    Bart Lubberts

  2. Division of Foot & Ankle Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital, Newton-Wellesley Hospital, Harvard Medical School, Boston, USA

    Daniel Guss & Christopher W. DiGiovanni

  3. Department of Orthopaedic Surgery, Kansas Medical Center, Kansas City, USA

    Bryan G. Vopat

  4. Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, USA

    Anne H. Johnson

  5. Department of Orthopaedic Surgery, Academic Medical Center, Amsterdam, the Netherlands

    C. Niek van Dijk

  6. Biostatistics Center, Massachusetts General Hospital, Harvard Medical School, Boston, USA

    Hang Lee

Authors
  1. Bart Lubberts
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  2. Daniel Guss
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  3. Bryan G. Vopat
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  4. Anne H. Johnson
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  5. C. Niek van Dijk
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  6. Hang Lee
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  7. Christopher W. DiGiovanni
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Contributions

All authors were responsible for the conception and design of the study. BL, DG, and BV have been involved in the data collection. BL and HL conducted the analyses, which were planned and checked with CND and CWD. All authors contributed to the interpretation of the findings. BL and DG wrote the first draft of the paper, which was critically revised by BV, AJ, CND and CWD. The final manuscript has been approved by all authors.

Corresponding author

Correspondence to Bart Lubberts.

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Conflict of interest

There were no relationships/conditions/circumstances that present a potential conflict of interest.

Ethical approval

This study was approved by the Partners Human Research Committee under ID number: 2016P001295.

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Lubberts, B., Guss, D., Vopat, B.G. et al. The arthroscopic syndesmotic assessment tool can differentiate between stable and unstable ankle syndesmoses. Knee Surg Sports Traumatol Arthrosc 28, 193–201 (2020). https://doi.org/10.1007/s00167-018-5229-3

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