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European Journal of Trauma and Emergency Surgery

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01-08-2021 | Original Article

Diagnostic value of intraoperative tap test for acute deltoid ligament injury

Authors: Chun Bi, Dechao Kong, Jian Lin, Qiugen Wang, Kai Wu, Jianhua Huang

Published in: European Journal of Trauma and Emergency Surgery | Issue 4/2021

Abstract

Purpose

Deltoid ligament injuries appear with isolated or even no displacement of the lateral malleolus fracture which could easily lead to misdiagnosis, which frequently brings about ankle medial instability and talus shift that eventually lead to the occurrence of ankle osteoarthritis. This study is aimed to investigate the value of the tap test for assessing the integrity of the deltoid ligament intraoperatively.

Methods

Ninety-two patients with malleolar fractures and possible acute deltoid ligament injury treated in our hospital from March 2013 to May 2016 were enrolled in this prospective study. The gravity stress test and tap test were performed preoperatively by three physicians independently before and after fixation of the fibula. The sensitivity, specificity, positive and negative predictive values, and false-positive and false-negative rates of both tests were determined based on medial malleolus exploration for the integrity of the deltoid ligament. The inter-observer consistency was also analyzed.

Results

Forty seven (51.1%) versus fifty two (56.5%) of the 92 patients tested positive for deltoid ligament injury according to the preoperative gravity stress test or the subsequent tap test. Forty-eight cases (52.2%) were confirmed during surgery. The sensitivity of gravity stress test was lower than that of tap test (95.8% vs 100%), and specificity of gravity stress test was the same as tap test (97.7% vs 97.7%). Between gravity stress test and tap test, the positive and negative predictive values were 97.9% vs 92.3% and 95.6% vs 100%, and the false-positive and false-negative rates were 2.3% vs 9.09% and 4.2% vs 0%, respectively. Between the two tests results, the percentage of inter-observer agreement was > 90% (kappa coefficient > 0.80).

Conclusion

The tap test has the advantages of high sensitivity, simple operation, and less radiation exposure, suggesting that it is of high diagnostic value for assessing the integrity of the acute deltoid ligament.

Waterman BR, Belmont PJ Jr, Cameron KL, Svoboda SJ, Alitz CJ, Owens BD. Risk factors for syndesmotic and medial ankle sprain: role of sex, sport, and level of competition. Am J Sports Med. 2011;39(5):992–8. https://doi.org/10.1177/03635465103914620363546510391462.CrossRefPubMed

Savage-Elliott I, Murawski CD, Smyth NA, Golano P, Kennedy JG. The deltoid ligament: an in-depth review of anatomy, function, and treatment strategies. Knee Surg Sports Traumatol Arthrosc. 2013;21(6):1316–27. https://doi.org/10.1007/s00167-012-2159-3.CrossRefPubMed

Stufkens SA, van den Bekerom MP, Knupp M, Hintermann B, van Dijk CN. The diagnosis and treatment of deltoid ligament lesions in supination-external rotation ankle fractures: a review. Strat Trauma Limb Reconstr. 2012;7(2):73–85. https://doi.org/10.1007/s11751-012-0140-9.CrossRef

Schuberth JM, Collman DR, Rush SM, Ford LA. Deltoid ligament integrity in lateral malleolar fractures: a comparative analysis of arthroscopic and radiographic assessments. J Foot Ankle Surg. 2004;43(1):20–9. https://doi.org/10.1053/j.jfas.2003.11.005s1067251603004216.CrossRefPubMed

Michelson JD, Magid D, McHale K. Clinical utility of a stability-based ankle fracture classification system. J Orthop Trauma. 2007;21(5):307–15. https://doi.org/10.1097/bot.0b013e318059aea300005131-200705000-00004.CrossRefPubMed

Schock HJ, Pinzur M, Manion L, Stover M. The use of gravity or manual-stress radiographs in the assessment of supination-external rotation fractures of the ankle. J Bone Jt Surg Br. 2007;89(8):1055–9. https://doi.org/10.1302/0301-620x.89b8.19134.CrossRef

Michelson JD, Varner KE, Checcone M. Diagnosing deltoid injury in ankle fractures: the gravity stress view. Clin Orthop Relat Res. 2001;387:178–82.CrossRef

Jeong MS, Choi YS, Kim YJ, Kim JS, Young KW, Jung YY. Deltoid ligament in acute ankle injury: MR imaging analysis. Skelet Radiol. 2014;43(5):655–63. https://doi.org/10.1007/s00256-014-1842-5.CrossRef

Crim J, Longenecker LG. MRI and surgical findings in deltoid ligament tears. AJR Am J Roentgenol. 2015;204(1):W63–9. https://doi.org/10.2214/AJR.13.11702.CrossRefPubMed

10.

Henari S, Banks LN, Radovanovic I, Queally J, Morris S. Ultrasonography as a diagnostic tool in assessing deltoid ligament injury in supination external rotation fractures of the ankle. Orthopedics. 2011;34(10):e639–43. https://doi.org/10.3928/01477447-20110826-11.CrossRefPubMed

11.

Battaglia PJ, Craig K, Kettner NW. Ultrasonography in the assessment of lateral ankle ligament injury, instability, and anterior ankle impingement: a diagnostic case report. J Chiropr Med. 2015;14(4):265–9. https://doi.org/10.1016/j.jcm.2015.05.004.CrossRefPubMedPubMedCentral

12.

Chun KY, Choi YS, Lee SH, Kim JS, Young KW, Jeong MS, et al. Deltoid ligament and tibiofibular syndesmosis injury in chronic lateral ankle instability: magnetic resonance imaging evaluation at 3T and comparison with arthroscopy. Korean J Radiol. 2015;16(5):1096–103. https://doi.org/10.3348/kjr.2015.16.5.1096.CrossRefPubMedPubMedCentral

13.

Rajagopalan S, Upadhyay V, Taylor HP, Sangar A. New intra-operative technique for testing the distal tibiofibular syndesmosis. Ann R Coll Surg Engl. 2010;92(3):258. https://doi.org/10.1308/rcsann.2010.92.3.258.CrossRefPubMedPubMedCentral

14.

Fleiss JL. Statistical methods for rates and proportions. 2nd edn. New York: Wiley; 1981.

15.

Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33(1):159–74.CrossRef

16.

Bluman EM. Deltoid ligament injuries in ankle fractures: should I leave it or fix it? Foot Ankle Int. 2012;33(3):236–8. https://doi.org/10.3113/FAI.2012.0236.CrossRefPubMed

17.

Stromsoe K, Hoqevold HE, Skjeldal S, Alho A. The repair of a ruptured deltoid ligament is not necessary in ankle fractures. J Bone Jt Surg Br. 1995;77(6):920–1.CrossRef

18.

Yu GR, Zhang MZ, Aiyer A, Tang X, Xie M, Zeng LR, et al. Repair of the acute deltoid ligament complex rupture associated with ankle fractures: a multicenter clinical study. J Foot Ankle Surg. 2015;54(2):198–202. https://doi.org/10.1053/j.jfas.2014.12.013s1067-2516(14)00641-3.CrossRefPubMed

19.

Hintermann B, Knupp M, Pagenstert GI. Deltoid ligament injuries: diagnosis and management. Foot Ankle Clin. 2006;11(3):625–37. https://doi.org/10.1016/j.fcl.2006.08.001(S1083-7515(06)00071-4 [pii]).CrossRefPubMed

20.

Lee TH, Jang KS, Choi GW, Jeong CD, Hong SJ, Yoon MA, et al. The contribution of anterior deltoid ligament to ankle stability in isolated lateral malleolar fractures. Injury. 2016;47(7):1581–5. https://doi.org/10.1016/j.injury.2016.03.017.CrossRefPubMed

21.

Lui TH. Endoscopic repair of the superficial deltoid ligament and spring ligament. Arthrosc Tech. 2016;5(3):e621–5. https://doi.org/10.1016/j.eats.2016.02.004.CrossRefPubMedPubMedCentral

22.

Won HJ, Koh IJ, Won HS. Morphological variations of the deltoid ligament of the medial ankle. Clin Anat. 2016. https://doi.org/10.1002/ca.22793.CrossRefPubMed

23.

Boden SD, Labropoulos PA, McCowin P, Lestini WF, Hurwitz SR. Mechanical considerations for the syndesmosis screw. A cadaver study. J Bone Jt Surg Am. 1989;71(10):1548–55.CrossRef

24.

Wang C, Ma X, Wang X, Huang JZ, Zhang C, Chen L, et al. The effect of lateral malleolar malrotational deformity on ankle stability-a study of 3D CT reconstruction. Chin J Orthop. 2013;33(10):1058–64. https://doi.org/10.3760/cma.j.issn.0253-2352.2013.10.014.CrossRef

25.

DeAngelis NA, Eskander MS, French BG. Does medial tenderness predict deep deltoid ligament incompetence in supination-external rotation type ankle fractures? J Orthop Trauma. 2007;21(4):244–7. https://doi.org/10.1097/BOT.0b013e3180413835.CrossRefPubMed

Title: Diagnostic value of intraoperative tap test for acute deltoid ligament injury
Authors: Chun Bi
Dechao Kong
Jian Lin
Qiugen Wang
Kai Wu
Jianhua Huang
Publication date: 01-08-2021
Publisher: Springer Berlin Heidelberg
Published in: European Journal of Trauma and Emergency Surgery / Issue 4/2021
Print ISSN: 1863-9933
Electronic ISSN: 1863-9941
DOI: https://doi.org/10.1007/s00068-019-01243-w

At a glance: The STEP trials

Springer Medicine

Diagnostic value of intraoperative tap test for acute deltoid ligament injury

Abstract

Purpose

Methods

Results

Conclusion

At a glance: The STEP trials

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusion

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