Reliability of distal tibio-fibular syndesmotic instability measurements using weightbearing and non-weightbearing cone-beam CT

Osgood, Greg; Shakoor, Delaram; Orapin, Jakrapong; Qin, Jianzhong; Khodarahmi, Iman; Thawait, Gaurav K.; Ficke, James R.; Schon, Lew C.; Demehri, Shadpour

doi:10.1016/j.fas.2018.10.003

Cited by 31 publications

(29 citation statements)

References 39 publications

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“…A 10-Nm internal rotation was exerted on the tibia (corresponding to external rotation of the foot), to investigate the incremental effect of torque on tibiofibular displacement (0 kg + 10 Nm and 85 kg + 10 Nm, respectively), as current imaging techniques in clinical practice assess the ankle syndesmosis both during nonweightbearing (0 kg) and weightbearing (85 kg) conditions. 36,49 A torque of 10 Nm was implemented based on previous literature demonstrating its applicability for in vivo testing for patients with symptomatic hindfoot instability. 33 Furthermore, the 10-Nm torque was in the range of previous cadaveric studies ranging from 2.0 to 20 Nm.…”

Section: Methodsmentioning

confidence: 99%

Comparison of External Torque to Axial Loading in Detecting 3-Dimensional Displacement of Syndesmotic Ankle Injuries

et al. 2020

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Background: Current imaging techniques try to quantify 3-dimensional displacement of syndesmotic ankle injuries using 2-dimensional measurements, which may obscure an exact diagnosis. Therefore, our aim was to determine 3-dimensional displacement of syndesmotic ankle injuries under load and torque using a weightbearing computed tomography (WBCT) and to assess the relation with previously established 2-dimensional measurements. Methods: Seven paired cadaver specimens were mounted into a radiolucent frame. WBCT scans were obtained to generate 3-dimensional models after different patterns of axial load (0 kg, 85 kg) combined with external torque (0, 10 Nm). Sequential imaging was repeated in ankles containing intact syndesmotic ligaments, sectioning of the anterior inferior tibiofibular ligament (AITFL; condition 1A), deltoid ligament (DL; condition 1B), combined AITFL+DL (condition 2), and AITFl+DL+interosseous membrane (condition 3). Reference anatomical landmarks were established relative to the intact position of the fibula to quantify displacement. A subsequent correlation analysis was performed between the obtained 2- and 3-dimensional measurements. Results: Axial load increased lateral translation (mean = −0.9 mm, 95% confidence interval [CI]: 1.3, –0.1) significantly in condition 2 relative to the intact ankle ( P < .05) but did not demonstrate other significant displacements. External torque increased displacement significantly in all directions ( P < .05), except for dorsal translation of the fibula ( P > .05). The highest displacement could be detected when external torque was applied in condition 3 and consisted of posterior translation (mean = −3.1 mm; 95% CI: –4.8, –2.7) and external rotation (mean = −4.7 degrees; 95% CI: –5.6, –2.9). Pearson correlation coefficients between the 2-dimensional and 3-dimensional measurements were moderate and ranged from 0.31 to 0.56 ( P < .05). Conclusion: External torque demonstrated superiority over axial load in detecting syndesmotic ankle instability. Axial load increased lateral translation; however, differences were submillimeter in magnitude until torque was applied. A moderate correlation was found with previously established 2-dimensional measurements. Clinical Relevance: In clinical practice these findings substantiate application of external torque in current imaging modalities to improve detection of syndesmotic ankle injuries.

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Section: Methodsmentioning

confidence: 99%

Comparison of External Torque to Axial Loading in Detecting 3-Dimensional Displacement of Syndesmotic Ankle Injuries

et al. 2020

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“…The literature on weight-bearing CBCT is mainly related to the investigation of pes planus, or flatfoot ( 28 ) ; ankle fractures and syndesmosis injuries ( 29 , 30 ) ; subtalar joint instability ( 31 , 32 ) ; hypermobility of the first ray with hallux valgus ( 33 ) ; hallux rigidus ( 34 ) ; and patellar instability and tibiofemoral arthritis ( 35 , 36 ) .…”

Section: Indications For Weight-bearing Cbctmentioning

confidence: 99%

“…Some authors have shown that traditional 2D measurements can be used with greater precision in 3D imaging, especially in conjunction with new parameters and measurements ( 28 - 38 ) . To improve accuracy, there are three recommended ways to measure angles and distances in weight-bearing CBCT data sets: in the DRR mode ( 44 , 45 ) ; in a single plane ( 28 - 30 ) ; and in the total volume in 3D ( 46 ) .…”

Section: Indications For Weight-bearing Cbctmentioning

confidence: 99%

Weight-bearing cone-beam computed tomography in the foot and ankle specialty: where we are and where we are going - an update

et al. 2021

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Cone-beam computed tomography (CBCT) has been applied in dentistry and medicine for nearly two decades. Its application in the foot and ankle specialty has grown exponentially in recent years. Weight-bearing CBCT allows clinicians to obtain weight-bearing images that can be viewed in all three planes and to construct three-dimensional models, similar to those constructed from traditional CT scans, as well as exposing patients to less radiation than do traditional CT scans. This technology has revolutionized diagnoses, improving the understanding of various lesions and surgical planning in the foot and ankle specialty. Ongoing studies of the use of weight-bearing CBCT in foot and ankle surgery are focused on fully automated and semi-automated three-dimensional measurements, as well as bone segmentation, mapping of the distances/orientation of the joints, and the production of customized implants. The aims of this review article are to show the evolution of this emerging tool in the foot and ankle specialty, to update those in related specialties on its use in current clinical practice, and to indicate where the research community is heading.

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confidence: 99%

“…For the syndesmosis, weightbearing CT scan (WBCT) has the specific additional advantage of dynamic evaluation as shown by significant lateral fibular translation and fibular external rotation relative to the incisura during weightbearing vs nonweightbearing imaging. 16,20,22,25 Several studies have advocated the use of bilateral ankle CT imaging to determine the accuracy of syndesmotic reduction postoperatively in the axial plane. 7,14 These recommendations resulted in part because of the substantial variation in the anatomic relationship of the normal syndesmosis as demonstrated in a recent systematic review of its normal radiological measurements.…”

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confidence: 99%

Evaluation of Syndesmosis Reduction on CT Scan

et al. 2019

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Background: Computed tomography (CT) imaging has traditionally been considered the gold standard for evaluation of syndesmostic reduction, but there is no uniformly accepted method to assess reduction. The aim of this study was to evaluate the intra- and interobserver reliability of published measurement techniques for evaluation of syndesmotic reduction on weightbearing CT scan (WBCT) in hopes of determining which method is best. Methods: Medical records were reviewed to identify patients who underwent operative stabilization of unilateral syndesmotic injuries. Exclusion criteria included patients younger than 18 years, ipsilateral fractures extending to the tibial plafond, any contralateral ankle fracture or syndesmotic injury, and body mass index greater than 40 kg/m2. Twenty eligible patients underwent WBCT evaluation of both ankles at an average of 3 years after syndesmotic fixation. The anatomic accuracy of syndesmotic reduction was evaluated by 2 observers using axial CT images at a level 1 cm proximal to the tibial plafond using 9 previously published radiological measurement techniques. Inter- and intraobserver reliability were assessed for each evaluation method. Results: The syndesmotic area calculation showed the highest interobserver reliability (0.96), the highest intraobserver reliability for observer 2 (0.97), and the second highest intraobserver reliability for observer 1 (0.92). Fibular rotation had the second highest interobserver reliability in our results (0.84), with intraobserver reliability of 0.91 and 0.8 for first and second observers, respectively. The intraobserver reliability of the side-by-side method was 0.49 and 0.24 for the first and second observers, respectively, and the interobserver reliability was 0.26. Conclusion: Qualitatively assessing syndesmotic reduction via side-by-side comparison with the uninjured ankle had the least intra- and interobserver reliability and should not be relied on to determine syndesmotic reduction quality. In contradistinction, syndesmotic area calculation demonstrated the highest reliability when evaluating syndesmotic reduction, followed by fibular rotation. Given that syndesmotic area measurement techniques are not readily available on standard image viewers, technologically updating image viewers to allow such calculation would make this approach more accessible in clinical practice. Level of Evidence: Level IV, case series.

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Reliability of distal tibio-fibular syndesmotic instability measurements using weightbearing and non-weightbearing cone-beam CT

Cited by 31 publications

References 39 publications

Comparison of External Torque to Axial Loading in Detecting 3-Dimensional Displacement of Syndesmotic Ankle Injuries

Comparison of External Torque to Axial Loading in Detecting 3-Dimensional Displacement of Syndesmotic Ankle Injuries

Weight-bearing cone-beam computed tomography in the foot and ankle specialty: where we are and where we are going - an update

Evaluation of Syndesmosis Reduction on CT Scan

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