Stable and unstable grade II syndesmotic injuries require different treatment strategies and vary in functional outcomes: a systematic review

Lubberts, Bart; Dijk, Pim A. D. van; Donovan, Nathan; Dijk, C. Niek van; Calder, James

doi:10.1136/jisakos-2015-000026

Cited by 14 publications

(12 citation statements)

References 55 publications

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“…The potentially altered tibiotalar relationship, in turn, can increase joint contact pressures potentiating post-traumatic arthritis [ 31 , 41 , 53 ]. Appropriate diagnosis and surgical repair of syndesmotic instability is, therefore, crucial towards preserving ankle stability and maximizing long term functional outcomes [ 23 , 29 ].…”

Section: Introductionmentioning

confidence: 99%

Arthroscopic coronal plane syndesmotic instability has been over-diagnosed

Hagemeijer

Elghazy

Waryasz

et al. 2020

Knee Surg Sports Traumatol Arthrosc

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Purpose Ankle arthroscopy is widely used for diagnosis of syndesmotic instability, especially in subtle cases. To date, no published article has systematically reviewed the literature in aggregate to understand which instability values should be used intraoperatively. The primary aim was to systematically review the amount of tibiofibular displacement that correlates with syndesmotic instability after a high ankle sprain. A secondary aim is to assess the quality of such research. Methods Systematic searches of EMBASE (Ovid) and MEDLINE via PubMed, CINAHL, Web of Science, and Google Scholar were used. Inclusion criteria: studies that arthroscopically evaluated the fibular displacement at various stages of syndesmotic ligament injury. Two reviewers independently extracted data and assessed methodological quality using the Anatomical Quality Assessment (AQUA) Tool and methodological index for non-randomized studies (MINORS). Results Eight cadaveric studies and three clinical studies were included for review. All studies reported displacement in the coronal plane, four studies reported in the sagittal plane, and one reported findings in the rotational plane. Four cadaveric studies had a similar experimental set up and the weighted mean associated with instability in the coronal plane could be calculated and was 2.9 mm at the anterior portion of the distal tibiofibular joint and 3.4 mm at the posterior portion. Syndesmotic instability in the sagittal plane is less extensively studied, however available data from a cadaveric study suggests thresholds of 2.2 mm of posterior fibular translation when performing an anterior to posterior hook test and 2.6 mm of anterior fibular translation when performing a posterior to anterior hook test. Conclusions The results have concluded that the commonly used 2.0 mm threshold value of distal tibiofibular diastasis may lead to overtreatment of syndesmotic instability, and that using threshold values of 2.9 mm measured at the anterior portion of the incisura and 3.4 mm at the posterior portion may represent better cut off values. Given the ready availability of 3 mm probes among standard arthroscopic instrumentation, at the very least surgeons should use 3 mm in lieu of 2 mm probes intraoperatively. Level of evidence IV.

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Section: Introductionmentioning

confidence: 99%

Arthroscopic coronal plane syndesmotic instability has been over-diagnosed

Hagemeijer

Elghazy

Waryasz

et al. 2020

Knee Surg Sports Traumatol Arthrosc

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“…The current consensus recommends that individuals with grade 1 and 2A syndesmotic injuries be treated nonoperatively, whereas grade 2B and 3 injuries should be treated surgically. 48 Grade 2 has been considered the most challenging injury for decision-making between nonoperative and operative treatment as current evidence is weak 31 and standard imaging tests have limitations in adequately differentiating grade 2A stable from 2B unstable injuries. Our method shows clinical importance in grade 2 injuries.…”

Section: Discussionmentioning

confidence: 99%

Diagnostic Accuracy of Conventional Ankle CT Scan With External Rotation and Dorsiflexion in Patients With Acute Isolated Syndesmotic Instability

et al. 2023

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Background: Syndesmotic injury in an athletic population is associated with a prolonged ankle disability after an ankle sprain and often requires a longer recovery than a lateral collateral ligament injury. Although several imaging tests are available, diagnosing syndesmotic instability remains challenging. Purpose: To determine the diagnostic accuracy of conventional ankle computed tomography (CT) scans with the joint in external rotation and dorsiflexion and compare it with that of conventional ankle CT scans in a neutral position. Study Design: Cohort study (Diagnosis); Level of evidence, 2. Methods: Between September 2018 and April 2021, this prospective study consecutively included adults visiting the foot and ankle outpatient clinic with a positive orthopaedic examination for acute syndesmotic injury. Participants underwent 3 CT scan tests. First, ankles were scanned in a neutral position. Second, ankles were scanned with 45° of external rotation, dorsiflexion, and extended knees. Third, ankles were scanned with 45° of external rotation, dorsiflexion, and flexed knees. Three measurements, comprising rotation (measurement a), lateral translation (measurement c), and anteroposterior translation (measurement f) of the fibula concerning the tibia, were used to diagnose syndesmotic instability in the 3 CT scans. Magnetic resonance imaging was used as a reference standard. The area under the curve (AUC) was used to compare the diagnostic accuracy, and Youden’s J index was calculated to determine the ideal cutoff point. Results: Images obtained in 68 participants (mean age, 36.5 years; range, 18-69 years) were analyzed, comprising 36 syndesmotic injuries and 32 lateral collateral ligament injuries. The best diagnostic accuracy occurred with the rotational measurement a, in which the second and third CT scans with stress maneuvers presented greater AUCs (0.97 and 0.99) than did the first CT scan in a neutral position (0.62). The ideal cutoff point for the stress maneuvers was 1.0 mm in the rotational measurement a and reached a sensitivity and specificity of 83% and 97% for the second CT scan with extended knees and 86% and 100% for the third CT scan with flexed knees, respectively. The ideal cutoff point for the first CT scan with a neutral position was 0.7 mm in the rotational measurement a, with a sensitivity of 25% and specificity of 97%. Conclusion: Conventional ankle CT with stress maneuvers has excellent performance for diagnosing subtle syndesmotic rotational instability, as it shows a greater AUC and enhanced sensitivity at the ideal cutoff point compared with ankle CT in the neutral position.

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“…In general, patients without diastasis or joint dynamic instability can be treated nonoperatively. Lubberts et al 12 systematically reviewed the previous study and suggested stable grade 2 syndesmosis injury could be treated nonoperatively. Nussbaum et al 18 treated 60 patients with stable syndesmosis injury nonoperatively and achieved an overall good result.…”

Section: Discussionmentioning

confidence: 99%

APKASS Consensus Statement on Chronic Syndesmosis Injury, Part 1: Clinical Manifestation, Radiologic Examination, Diagnosis Criteria, Classification, and Nonoperative Treatment

Chen

Gui²,

Kurokawa

et al. 2021

Orthopaedic Journal of Sports Medicine

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Background: Clinical manifestation, radiologic examination, diagnostic criteria, classification, and nonoperative treatment strategies regarding chronic syndesmosis injury remain unclear. Purpose: An international group of experts representing the fields of sports injuries in the foot and ankle area were invited to collaboratively advance toward consensus opinions based on the best available evidence regarding chronic syndesmosis injuries. All were members of the Asia-Pacific Knee, Arthroscopy and Sports Medicine Society (APKASS). Study Design: Consensus statement. Methods: From November to December 2020, a total of 111 international experts on sports medicine or ankle surgery participated in a 2-stage Delphi process that included an anonymous online survey and an online meeting. A total of 13 items with 38 statements were drafted by 13 core authors. Of these, 4 items with 15 clinical questions and statements were related to the clinical manifestation, radiologic examination, diagnostic criteria, classification, and nonoperative treatment strategies for chronic syndesmosis injury and are presented here. Each statement was individually presented and discussed, followed by a general vote. The strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; unanimous, 100%. Results: Of the 15 questions and statements, 5 reached unanimous support and 10 achieved strong consensus. Conclusion: This APKASS consensus statement, developed by international experts in the field, will assist surgeons and physical therapists with diagnosis, classification, and nonoperative treatment strategies for chronic syndesmosis injury.

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Stable and unstable grade II syndesmotic injuries require different treatment strategies and vary in functional outcomes: a systematic review

Cited by 14 publications

References 55 publications

Arthroscopic coronal plane syndesmotic instability has been over-diagnosed

Arthroscopic coronal plane syndesmotic instability has been over-diagnosed

Diagnostic Accuracy of Conventional Ankle CT Scan With External Rotation and Dorsiflexion in Patients With Acute Isolated Syndesmotic Instability

APKASS Consensus Statement on Chronic Syndesmosis Injury, Part 1: Clinical Manifestation, Radiologic Examination, Diagnosis Criteria, Classification, and Nonoperative Treatment

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