Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

Keynote webinar | Spotlight on medication adherence

LIVE: Thursday 27th June 2024, 18:00-19:30 (CEST)
Join our expert panel to discover why you need to understand the drivers of non-adherence in your patients, and how you can optimize medication adherence in your clinics to drastically improve patient outcomes.
ADVANCED SEARCH
Log in
Top
European Journal of Orthopaedic Surgery & Traumatology

22-04-2024 | Computed Tomography | Original Article

The role of computed tomography with external rotation and dorsiflexion in decision making for acute isolated non-displaced posterior malleolar fractures Bartoníček and Rammelt type II: a prospective study

Authors: Alexandre Leme Godoy-Santos, Joao Carlos Rodrigues, Durval Barros-Santos, Cesar de Cesar Netto, Nacime Salomao Barbachan Mansur, Kepler Alencar Mendes de Carvalho, Vincenzo Giordano, Stefan Rammelt

Published in: European Journal of Orthopaedic Surgery & Traumatology

Login to get access

Abstract

Purpose

Our objective was to evaluate the syndesmotic and fracture instability using conventional ankle computed tomography (CT) with stress maneuvers.

Methods

A consecutive sample of 123 individuals with an ankle sprain was assessed for eligibility. In total, 33 patients met the inclusion criteria. All patients underwent a magnetic resonance imaging (MRI) and CT scan with stress maneuvers (CTSM). The patterns of ligament tears f were classified using West Point grades I, IIA, IIB, III. Mann–Whitney test was used to test the differences in the numerical variables between injured and uninjured syndesmoses. The Spearman correlation tested the strength of the association between the tibial joint surface involved in posterior malleolus fracture and syndesmotic instability.

Results

In MRI, two patterns of syndesmotic ligament injury predominated. A completely torn anterior inferior tibiofibular (AITFL) and interosseous tibiofibular ligaments (ITFL) and a completely torn AITFL were combined with a partially torn ITFL. In the neutral phase CTSM and during the stress phase the median difference of the narrowest tibiofibular distance between injured and uninjured syndesmoses was 0.2 mm (P = 0.057) and 2.3 mm (P < 0.0001), respectively. There was no association between the percentage of involvement of the posterior tibial joint surface in the posterior malleolar fracture and syndesmotic instability as measured with CTSM.

Conclusion

The conventional computed tomography with external rotation and dorsiflexion represents a reproducible and accurate diagnostic option for detecting syndesmosis instability and fracture instability in acute isolated non-displaced posterior malleolar fractures Bartoníček and Rammelt type II.
Level of Evidence: Prospective study among consecutive patients (Diagnosis); Level of evidence, 2.
Literature
1.
Rammelt S, Bartoníček J, Kroker L, Neumann AP (2021) Surgical fixation of quadrimalleolar fractures of the ankle. J Orthop Trauma 35(6):e216–e222CrossRefPubMed
2.
Nicolai C, Bierry G, Faruch-Bilfeld M, Sans N, Willaume T (2022) The concept of ring of injuries: evaluation in ankle trauma. Skeletal Radiol 51(10):2027–2037CrossRefPubMed
3.
Bartoníček J, Rammelt S, Kostlivý K, Vaněček V, Klika D, Trešl I (2015) Anatomy and classification of the posterior tibial fragment in ankle fractures. Arch Orthop Trauma Surg 135(4):505–516CrossRefPubMed
4.
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):620–628CrossRefPubMed
5.
Rammelt S, Bartoníček J, Kroker L (2022) Pathoanatomy of the anterolateral tibial fragment in ankle fractures. J Bone Joint Surg Am 104(4):353–363CrossRefPubMed
6.
Rammelt S, Bartoníček J, Schepers T, Kroker L (2021) Fixation of anterolateral distal tibial fractures: the anterior malleolus. Operat Orthop Traumatol 33(2):125–138CrossRef
7.
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):653–660CrossRefPubMed
8.
Nortunen S, Flinkkilä T, Lantto I, Kortekangas T, Niinimäki J, Ohtonen P, Pakarinen H (2015) Diagnostic accuracy of the gravity stress test and clinical signs in cases of isolated supination-external rotation-type lateral malleolar fractures. Bone Joint J 97B(8):1126–1131CrossRef
9.
Seidel A, Krause F, Weber M (2017) Weightbearing vs gravity stress radiographs for stability evaluation of supination-external rotation fractures of the ankle. Foot Ankle Int 38(7):736–744CrossRefPubMed
10.
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 Rel Res 423:227–234CrossRef
11.
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 tibio-fibular syndesmosis. Invest Radiol 32(7):401–409CrossRefPubMed
12.
Rodrigues JC, do Amaral e Castro A, Rosemberg LA, de Cesar Netto C, Godoy-Santos AL (2023) Diagnostic accuracy of conventional ankle CT scan with external rotation and dorsiflexion in patients with acute isolated syndesmotic instability. Am J Sports Med 51(4):985-996
13.
Ahn TK, Choi SM, Kim JY, Lee WC (2017) Isolated syndesmosis diastasis: computed tomography scan assessment with arthroscopic correlation. Arthroscopy 33(4):828–834CrossRefPubMed
14.
Rammelt S, Boszczyk A (2023) Ligament ruptures in ankle fractures - was Lauge-Hansen right? Foot Ankle Clin 28(2):445–461CrossRefPubMed
15.
Bhimani R, Ashkani-Esfahani S, Lubberts B, Kaiser P, Kerkhoffs GMMJ, Waryasz G, DiGiovanni CW, Guss D (2022) Utility of WBCT to diagnose syndesmotic instability in patients with Weber B lateral malleolar fractures. J Am Acad Orthop Surg 30(3):e423–e433CrossRefPubMed
16.
Raheman FJ, Rojoa DM, Hallet C, Yaghmour KM, Jeyaparam S, Ahluwalia RS, Mangwani J (2022) Can weightbearing cone-beam CT reliably differentiate between stable and unstable syndesmotic ankle injuries? A systematic review and meta-analysis. Clin Orthop Relat Res 480(8):1547–1562CrossRefPubMedPubMedCentral
17.
Del Rio A, Bewsher SM, Roshan-Zamir S, Tate J, Eden M, Gotmaker R, Wang O, Bedi HS, Rotstein AH (2020) Weightbearing cone-beam computed tomography of acute ankle syndesmosis injuries. J Foot Ankle Surg 59(2):258–263CrossRefPubMed
18.
Hagemeijer NC, Chang SH, Abdelaziz ME, Casey JC, Waryasz GR, Guss D, DiGiovanni CW (2019) Range of normal and abnormal syndesmotic measurements using weightbearing CT. Foot Ankle Int 40(12):1430–1437CrossRefPubMed
19.
Ashkani Esfahani S, Bhimani R, Lubberts B, Kerkhoffs GM, Waryasz G, DiGiovanni CW, Guss D (2022) Volume measurements on weightbearing computed tomography can detect subtle syndesmotic instability. J Orthop Res 40(2):460–467CrossRefPubMed
20.
Femino JE, Vaseenon T, Phisitkul P, Tochigi Y, Anderson DD, Amendola A (2013) Varus external rotation stress test for radiographic detection of deep deltoid ligament disruption with and without syndesmotic disruption: a cadaveric study. Foot Ankle Int 34(2):251–260CrossRefPubMed
21.
22.
Wiegerinck JJI, Stufkens SA (2021) Deltoid rupture in ankle fractures: to repair or not to repair? Foot Ankle Clin 26(2):361–371CrossRefPubMed
23.
Stockwell E, Thomas P, Grossman L, Lyden E, Mormino M, Siebler J, Putnam S (2024) Successful outcomes with nonoperative treatment and immediate weightbearing despite stress-positive radiographs in isolated distal fibula (OTA/AO 44B) fractures. J Orthop Trauma 38(1):e20–e27CrossRefPubMed
24.
Fitzpatrick E, Goetz JE, Sittapairoj T, Hosuru Siddappa V, Femino JE, Phisitkul P (2018) Effect of posterior malleolus fracture on syndesmotic reduction: a cadaveric study. J Bone Joint Surg Am 100(3):243–248CrossRefPubMed
25.
Giordano V, Babinski MA, Freitas A, Pires RE, Souza FS, Faria LPG, Labronici PJ, Godoy-Santos A (2023) Biomechanical efficacy of three methods for the fixation of posterior malleolar fractures: a three-dimensional finite element study. Diagnostics (Basel) 13(23):3520CrossRefPubMed
Metadata
Title
The role of computed tomography with external rotation and dorsiflexion in decision making for acute isolated non-displaced posterior malleolar fractures Bartoníček and Rammelt type II: a prospective study
Authors
Alexandre Leme Godoy-Santos
Joao Carlos Rodrigues
Durval Barros-Santos
Cesar de Cesar Netto
Nacime Salomao Barbachan Mansur
Kepler Alencar Mendes de Carvalho
Vincenzo Giordano
Stefan Rammelt
Publication date
22-04-2024
Publisher
Springer Paris
Published in
European Journal of Orthopaedic Surgery & Traumatology
Print ISSN: 1633-8065
Electronic ISSN: 1432-1068
DOI
https://doi.org/10.1007/s00590-024-03952-4