The Diagnostic Accuracy of Radiographs and Magnetic Resonance Imaging in Predicting Deltoid Ligament Ruptures in Ankle Fractures

Warner, Stephen J.; Garner, Matthew R.; Fabricant, Peter D.; Schottel, Patrick C.; Loftus, Michael L.; Hentel, Keith; Helfet, David L.; Lorich, Dean G.

doi:10.1007/s11420-018-09655-x

Cited by 24 publications

(18 citation statements)

References 54 publications

(67 reference statements)

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“…In contrast, Nortunen et al [33] would not recommend MRI for evaluating deltoid ligament integrity since only 54.1% of the patients who appeared to have a deltoid ligament rupture according to an MRI, actually had a rupture. Jeong et al [16] concluded that using MRI alone is inadequate to evaluate deltoid ligament ruptures, while the results of Warner et al [19] suggest that MRI is able to detect deltoid ligament rupture with sufficient certainty. However, the results of Warner et al [19] may be questioned since they only included surgically treated patients with SER-type ankle fractures, which may explain the high prevalence of deltoid ligament ruptures and, ultimately, influenced the sensitivity and specificity.…”

Section: Discussionmentioning

confidence: 99%

“…Jeong et al [16] concluded that using MRI alone is inadequate to evaluate deltoid ligament ruptures, while the results of Warner et al [19] suggest that MRI is able to detect deltoid ligament rupture with sufficient certainty. However, the results of Warner et al [19] may be questioned since they only included surgically treated patients with SER-type ankle fractures, which may explain the high prevalence of deltoid ligament ruptures and, ultimately, influenced the sensitivity and specificity. The discrepancy between these two studies could also be explained by the fact that both studies did not use the same reference test.…”

Section: Discussionmentioning

confidence: 99%

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Diagnostic tools to evaluate ankle instability caused by a deltoid ligament rupture in patients with supination-external rotation ankle fractures: A systematic review and meta-analysis

Krom

Kalmet

Jagtenberg

et al. 2022

Injury

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Supination-external rotation (SER) ankle fractures account for the majority of ankle fractures and can be divided into stable or unstable fractures, based on the state of the deltoid ligament. The objective of this review was to appraise the available literature concerning diagnostic tools to evaluate deltoid ligament integrity in patients with SER-type ankle fractures. Methods: A comprehensive literature search of Pubmed and Embase was performed up to December 2020. The outcome measures were sensitivity, specificity and positive and negative predictive value of the diagnostic tools. A meta-analysis was performed to obtain an overview of sensitivity, specificity and area under the curve (AUC). The methodological quality of the articles was evaluated using Quality Assessment of Diagnostic Accuracy Studies. Results: A total of 12 studies investigating tools for deltoid ligament rupture in patients with SER-type ankle fractures were included. The present study found sensitivity (and specificity) ranges of 0.20-0.90 (and 0.38-0.97) for clinical features, Magnetic Resonance Imaging (MRI) 0.57-0.85 (and 0.81-1.00), ultrasonography 1.00 (and 0.89-1.00), Malleolar Medial Fleck Sign (MMFS) 0.25 (and 0.99), conventional ankle mortise radiography 0.33-0.57 (and 0.60-0.94), gravity stress radiography 0.71-1.00 (and 0.72-0.88) and manual stress ankle radiography 0.65-1.0 0 (and 0.0 0-0.77). The largest AUC was found for ultrasonography, followed by MMFS, gravity stress radiography and MRI. Conclusion: Ultrasonography and gravity stress radiography seem the most accurate diagnostic tools to evaluate deltoid ligament integrity. To strengthen this conclusion, future research should use an identical reference test to ensure comparability of results. Nevertheless, present study is of high value to close the knowledge gap about which presently available diagnostic tool is to be preferred to evaluate deltoid ligament integrity in patients with SER-type ankle fractures.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Diagnostic tools to evaluate ankle instability caused by a deltoid ligament rupture in patients with supination-external rotation ankle fractures: A systematic review and meta-analysis

Krom

Kalmet

Jagtenberg

et al. 2022

Injury

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“…The present study provides details about the bony attachments of the different bands of DL, that could assist in the radiological diagnosis of DL injuries and advanced procedures related to its surgical repair and reconstruction. An MRI analysis, because of its increased accuracy, is a better diagnostic test for diagnosing deep deltoid rupture [31]. This study also offers a detailed approach for different band identification and isolation, using both gross observation and micro-dissection methods.…”

Section: Discussionmentioning

confidence: 99%

Defining the Components of the Deltoid Ligament (DL): A Cadaveric Study

Ismail¹,

Saffar²,

Motawei³

et al. 2022

Cureus

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Background: The deltoid ligament (DL) is a strong triangle-shaped ligament with a complex fascicular arrangement. Understanding the morphological and/or functional typing of the DL structure is hindered by a paucity of clear, quantitative, and reproducible data and is further complicated by inconsistent terminology use. The aim of this work was to describe different components of the DL using strict identification criteria.Methods: Thirty embalmed cadaveric ankles of both sides were dissected on all sides and studied by using gross examination, micro-dissection, and light microscopy by tracing the fascicular pattern of each under 6X magnification.Results: Six ligamentous bands were identified. The tibiotalocalcaneal ligament (TTC) and the superficial posterior tibiotalar ligament (sPTT) were two superficial variants and the anterior tibiotalar ligament (ATT), the anterior tibiotalonavicular ligament (ATTN), the intermediate tibiotalar ligament (ITT), and the deep posterior tibiotalar ligament (dPTT) were four deep variants. The TTC was identified in all 30 embalmed cadaveric specimens. Five additional ligamentous bands (ITT, sPTT, dPTT, ATT, and ATTN) were variable findings in the current cohort.Conclusion: This study presents six ligamentous bands as a regular finding and five additional ligamentous bands as variable findings in the dissected specimen. This data could assist in the radiological diagnosis of DL injuries and advanced procedures related to its surgical repair and reconstruction.

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“…However, recent studies using magnetic resonance imaging and intraoperative assessment to evaluate deep deltoid ligaments have suggested that MSV may overestimate the incidence of deltoid incompetence. 2,24 Further, Park et al 18 demonstrated that ankle position at the time of stress examination can influence the appearance of the MCS, suggesting that the test is subject to user error.…”

Section: Discussionmentioning

confidence: 99%

Effect of Muscle Activation on the Gravity Stress View in Unstable Weber B Ankle Fractures

et al. 2020

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Background: In the setting of apparently isolated distal fibula fractures, the gravity stress view (GSV) is a validated method to determine mortise stability. There is currently no published data evaluating whether dynamic muscle activation can reduce an unstable mortise. If patients with instability can overcome gravity, resultant images could yield false-negative results. The goal of this investigation was to determine if patient effort can influence medial clear space (MCS) measurements in proven unstable bimalleolar-equivalent ankle fractures. Methods: Patients presenting with Weber B fibula fractures were assessed for mortise stability using the GSV. If the GSV demonstrated instability based on MCS widening >4 mm, 3 additional views were performed: GSV with an assistant maintaining the ankle in a neutral position; GSV with the patient actively dorsiflexing to neutral; and GSV with the patient actively dorsiflexing and supinating the foot. Twenty-four consecutive patients met inclusion criteria, with a mean age of 48.7 (range, 22-85) years. Fifteen patients (62.5%) were female and 9 (37.5%) were male. The laterality was evenly divided. Results: The mean MCS was 5.8 ± 2.0 6.0 ± 2.6, and 6.2 ± 2.7 mm for the manual assist, active dorsiflexion, and active supination radiograph measurement groups, respectively ( P = .434). Only 5 of 24 subjects had any measurable decrease in their MCS with active supination, with a maximum change of 1.2 mm. The remainder of the patients had an increase in MCS ranging from 0.1 to 4.0 mm. Conclusion: There was no significant difference between measurement states indicating that muscle activation is unlikely to yield a false-negative result on GSV. Mortise instability, secondary to deep deltoid injury in the presence of gravity stress, is unlikely to be actively overcome by dynamic stabilizers, supporting the validity and specificity of the GSV. Level of Evidence: Level III, prospective study.

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The Diagnostic Accuracy of Radiographs and Magnetic Resonance Imaging in Predicting Deltoid Ligament Ruptures in Ankle Fractures

Cited by 24 publications

References 54 publications

Diagnostic tools to evaluate ankle instability caused by a deltoid ligament rupture in patients with supination-external rotation ankle fractures: A systematic review and meta-analysis

Diagnostic tools to evaluate ankle instability caused by a deltoid ligament rupture in patients with supination-external rotation ankle fractures: A systematic review and meta-analysis

Defining the Components of the Deltoid Ligament (DL): A Cadaveric Study

Effect of Muscle Activation on the Gravity Stress View in Unstable Weber B Ankle Fractures

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