Maisonneuve fracture treated with short leg cast: A case report with 41-month follow-up.

RATIONALE: Maisonneuve fracture is a specific type of severe ankle injury. To our current knowledge, once a Maisonneuve fracture is diagnosed, the surgery is always recommended for fear of sequelae from inaccurate joint reconstruction. However, in this case, we treated a Maisonneuve fracture with a short leg cast, and the 41-month follow-up showed a favorable outcome with no post-traumatic osteoarthritis, chronic pain, and instability. Therefore, this case provides evidence for the feasibility of conservative treatment of Maisonneuve fracture. PATIENT CONCERNS: A female patient in her early twenties sprained her left ankle while running, suffering regional pain, swelling, and limited mobility. DIAGNOSES: We diagnosed a Maisonneuve fracture with superior fibular fracture and Volkmann tuberosity fracture, a slight separation of inferior tibiofibular syndesmosis (ITS). INTERVENTIONS: The patient rejected our surgical recommendations in favor of nonsurgical treatment, in addition to refusing immobilization of the knee. Consequently, we had to treat her with a short leg cast for 8 weeks and asked her to return for regular follow-up visits. OUTCOMES: At the final follow-up, the radiography showed complete healing of proximal fibula fracture. The patient reported no discernible subjective differences between her bilateral ankles. The range of motion of the left ankle was measured at 22° of dorsiflexion and 40° of plantarflexion. Functional assessments using Olerud-Molander ankle scale and American Orthopedic Foot and Ankle Society Ankle-Hindfoot scale both scored 100 points. Additionally, the radiographic assessment classified arthritis as stage 0 according to Morrey-Wiedeman classification. LESSONS: To avoid missing and misdiagnosing, the physical examination should always extend to 2 neighboring joints. Secondly, if a Maisonneuve fracture is suspected, further computed tomography scans, radiography, and magnetic resonance imaging can help to determine the stability of the ITS and the integrity of the lateral collateral ligaments before making therapeutic decisions. Finally, considering the lateral collateral ligaments may remain intact, we recommend stabilizing ITS by repairing the medial ligaments, which can be conducted arthroscopically and be more minimally invasive, providing an elastic fixation that aligns better with the biomechanics of the ITS which is characterized as a micro-mobile rather than fully fixed joint.

[Design and application of a device for radiographic projection of the tibio-astragalangeal mortise]. / Diseño y aplicación de dispositivo para proyección radiográfica de la mortaja tibio-astragalina.

INTRODUCTION: ligamentous injuries of the distal tibiofibular syndesmosis resulting in its opening are common occurrences in traumatology; however, their diagnosis poses a challenge for orthopedic surgeons. The tibioastragaloid mortise radiograph view is the most commonly used method for diagnosing this type of injury, but its reliability is compromised due to variations in ankle positioning during the study, which often depend on the operator. OBJECTIVE: to demonstrate that the designed device achieves a correct and consistent radiographic image of the distal tibiofibular syndesmosis in the mortise view. MATERIAL AND METHODS: we present a prospective, longitudinal, observational study. We designed a polypropylene device that maintains the ankle at 90 degrees of dorsiflexion and 15 degrees of internal rotation. The device was used to take mortise view radiographs of healthy ankles, and corresponding measurements were taken to assess the syndesmosis. RESULTS: we evaluated a total of 46 radiographs of healthy ankles, with a predominance of left ankles. The obtained measurements were as follows: anterior tibiofibular distance (ATFD) ranged from 3 to 6 mm, posterior tibiofibular distance (PTFD) ranged from 1 to 3 mm, tibiofibular clear space (TFCS) ranged from 2 to 3 mm, and a Merle D'Aubigne ratio of 2:1 was observed in all ankles. When comparing the measurements obtained with those established by Harper and Keller, no statistically significant difference was found (2 < 5). CONCLUSION: with the use of the designed device, we achieved a correct and consistent radiographic image of the mortise and the distal tibiofibular syndesmosis.

INTRODUCCIÓN: las lesiones ligamentarias de la sindesmosis tibioperonea distal que ocasionan apertura de la misma son muy frecuentes en traumatología; sin embargo, su diagnóstico es un reto para el cirujano ortopedista. La radiografía de la mortaja tibioastragalina es el método más utilizado para el diagnóstico de este tipo de lesiones, pero es poco confiable ya que la posición del tobillo durante el estudio suele variar dependiendo del operador. OBJETIVO: demostrar que con el uso del dispositivo diseñado se logra una imagen radiográfica correcta y constante de la sindesmosis tibioperonea distal en la proyección de la mortaja. MATERIAL Y MÉTODOS: estudio prospectivo, longitudinal y observacional. Diseñamos un dispositivo de polipropileno que mantiene el tobillo a 90 grados de dorsiflexión y rotación interna de 15 grados. Aplicamos el dispositivo para tomar radiografías de la mortaja en tobillos sanos y les realizamos las mediciones correspondientes para valorar la sindesmosis. RESULTADOS: valoramos un total de 46 radiografías de tobillos sanos, con un predominio de tobillos izquierdos. Las mediciones conseguidas fueron las siguientes: espacio tibioperoneo (ETP) de 3 a 6 mm, la superposición tibioperonea (STP) de 1 a 3 mm, espacio astrágalo-tibial medial (EATM) de 2 a 3 mm y una relación de Merle D'Aubigne de 2:1 en todos los tobillos. Al comparar las mediciones obtenidas con las establecidas por Harper y Keller, no se encontró una diferencia estadísticamente significativa (2 < 5). CONCLUSIÓN: con el uso del dispositivo diseñado, obtuvimos una correcta y constante imagen radiográfica de la mortaja y la sindesmosis tibioperonea distal.

Rearfoot and Ankle Dislocations.

Subtalar dislocations, ankle dislocations, and total talar dislocations are high-energy injuries. As such, there may be associated osseous or soft tissue injuries that can be diagnosed with advanced imaging such as computed tomography (CT) or MRI. With closed injuries, closed reduction may require sedation or general anesthesia, flexion of the knee to release the tension of the gastrocnemius-soleus complex, distraction is applied, the deformity is accentuated, then the deformity is corrected. Open injuries are usually associated with a higher level of energy and a higher rate of infection. It is important to thoroughly irrigate and debride open dislocations both before and after reduction.

High Resolution MRI Confirms Torsional Injury as Mechanism for Combined Ankle and Common Fibular (Peroneal) Nerve Injuries.

Common fibular nerve (CFN) injury due to ankle fracture is an underreported complication. The authors have proposed that torsional injury to the ankle can be translated along the interosseous membrane (IOM), producing tension on the CFN at the fibular neck. A 23-year-old woman presented to our clinic for left foot drop. Three months prior, the patient sustained a fall with left ankle inversion injury while running. She was diagnosed with a minor ankle fracture and placed in an orthopaedic boot. Unfortunately, her swelling worsened and one week later the patient was diagnosed with foot drop, which was further corroborated with EMG studies showing severe CFN injury localizing to the fibular neck. Because of the lack of recovery, she underwent decompression of the CFN. She experienced immediate symptomatic relief. High resolution imaging in this case supports our previous mechanism for indirect trauma to the ankle resulting in CFN injury. (Journal of Surgical Orthopaedic Advances 33(1):053-055, 2024).

Management of Pediatric Supination-inversion Ankle Injuries Involving Distal Tibia and Intraepiphyseal Distal Fibula Fractures.

Pediatric ankle fractures are prevalent injuries that make up a notable portion of all periphyseal injuries. The Salter-Harris classification is the most popular classification about physeal and periepiphyseal injuries. Ogden expanded on this and described type 7 fractures which are completely intraepiphyseal and include propagation of the fracture from the articular surface through the epiphyseal cartilage and do not involve the physis. These injuries are common about the distal fibula in pediatric patients with supination-inversion type injuries. There are no specific guidelines or recommendations on treatment of these injuries in the literature. We present three cases of this injury pattern and describe our chosen management that leads each patient to full, painless ankle range of motion and return to all prior activities and sports without complication. Supination-inversion type pediatric ankle fractures are common injuries that all orthopaedic surgeons will encounter at some point throughout their practice or training. Recognizing fracture variants and understanding treatment options of pediatric ankle fractures are important for the orthopaedic community as a whole.

Preoperative and Postoperative Imaging and Outcome Scores for Osteochondral Lesion Repair of the Ankle.

Cartilage lesions to the ankle joint are common and can result in pain and functional limitations. Surgical treatment aims to restore the damaged cartilage's integrity and quality. However, the current evidence for establishing best practices in ankle cartilage repair is characterized by limited quality and a low level of evidence. One of the contributing factors is the lack of standardized preoperative and postoperative assessment methods to evaluate treatment effectiveness and visualize repaired cartilage. This review article seeks to examine the importance of preoperative imaging, classification systems, patient-reported outcome measures, and radiological evaluation techniques for cartilage repair surgeries.

Risk Factors for Revision of External Fixation of Unstable Ankle Injuries.

INTRODUCTION: External fixation of unstable ankle injuries is commonly done by orthopaedic surgeons. An improper technique can negate the benefits of the procedure and necessitate revision. This study sought to determine the risk factors for revision of external fixation of unstable ankle injuries. METHODS: Retrospective cohort at a level I academic trauma center of 120 consecutive patients underwent external fixation of an unstable ankle injury. Exclusion criteria included external fixation for reason other than fracture, inadequate intraoperative imaging, skeletal immaturity, and follow-up less than 30 days. Primary outcome measurement was revision of external fixation within 30 days. RESULTS: Ninety-seven patients met inclusion criteria. Eighteen (18.6%) underwent revision within 30 days of whom 5 (28%, P < 0.001) had a poor reduction intraoperatively. No patients with a good reduction required revision. Revised patients had a significantly higher talar tilt (P < 0.001) and were more likely to lack a first metatarsal pin (P = 0.018). Multivariate analysis revealed talar tilt >0.5° (odds ratio, 22.62; 95% confidence interval, 6.52 to 50.63) as an independent risk factor for revision. DISCUSSION: For external fixation of unstable ankle injuries, poor reduction quality is a risk factor for need for revision surgery. Orthopaedic surgeons should be critical of their final intraoperative assessment to prevent revision.

Fibular morphology is not associated with incidence of peroneal tendon dislocation.

PURPOSE: The association of peroneal tendon dislocation with peroneal bone morphology and postoperative redislocation rates remains unknown. This study compared the fibula morphology in patients with peroneal tendon dislocation with that in a control population. METHODS: The study enrolled 48 patients who underwent surgery for peroneal tendon dislocation at our institution during between 2018 and 2023. Thirty-five patients with preoperative magnetic resonance imaging of the ankle were defined as Group D and 35 with magnetic resonance imaging of the ankle for other reasons and with similar background data were selected as the control group (Group C). The posterior tilting angle of the fibula, posterolateral angle and posterolateral edge angle were evaluated at the plafond level. The posterior tilting angle, posterolateral angle and retromalleolar bone shape according to the Rosenberg classification (flat, convex, concave) were evaluated at the midpoint between the plafond and the tip. RESULTS: At the plafond level, the posterior tilting, posterolateral and posterolateral edge angles were 57.7 ± 11.1°, 123.8 ± 12.3° and 90.8 ± 13.7°, respectively, in Group D and 64.1 ± 15.4°, 121.1 ± 12.3° and 88.7 ± 12.2°, respectively, in Group C, with no significant differences. No significant between-group differences existed in the posterior tilting and posterolateral angles at the midpoint level. Moreover, no significant differences existed in distribution of the bone geometry according to the Rosenberg classification. CONCLUSION: There were no differences in morphology between patients with peroneal tendon dislocation and controls. This study provides useful information on the indications for primary surgery and whether bony approach is useful for peroneal tendon dislocation. LEVEL OF EVIDENCE: Level IV.

Peroneal artery injury potential due to different syndesmosis screw placement options: a simulation study with lower extremity computed tomography angiography.

INTRODUCTION: The aim of this study is to assess the risk of peroneal artery injury of hardware placement at the fixation of syndesmotic injuries. MATERIALS AND METHODS: The lower extremity computed tomography angiography was used to design the study. The syndesmosis screw placement range was simulated every 0.5 cm, from 0.5 to 5 cm proximal to the ankle joint. The screw axes were drawn as 20°, 30° or individual angle according to the femoral epicondylar axis. The proximity between the screw axis and the peroneal artery was measured in millimeters. Potential peroneal artery injury was noted if the distance between the peroneal artery to the axis of the simulated screw was within the outer shaft radius of the simulated screw. The Pearson chi-square test was used and a p-value < 0.05 was considered significant. RESULTS: The potential for injury to the peroneal artery increased as the syndesmosis screw level rose proximally from the ankle joint level or as the diameter of the syndesmosis screw increasds. In terms of syndesmosis screw trajection, the lowest risk of injury was observed with the syndesmosis screw angle of 20°. Simulations with a screw diameter of 3.5 mm exhibited the least potential for peroneal artery injury. CONCLUSION: Thanks to this radiological anatomy simulation study, we believe that we have increased the awareness of the peroneal artery potential in syndesmosis screw application. Each syndesmosis screw placement option may have different potential for injury to the peroneal artery. To decrease the peroneal artery injury potential, we recommend the followings. If individual syndesmosis screw angle trajection can be measured, place the screw 1.5 cm proximal to the ankle joint using a 3.5 mm screw shaft. If not, fix it with 30° trajection regardless of the screw diameter at the same level. If the most important issue is the peroneal artery circulation, use the screw level up to 1 cm proximal to the ankle joint regardless of the screw angle trajection and screw diameter.

Measuring External Rotation of the Fibula and Fibular Length in Bilateral Computed Tomography Scans: How Reliable Is This Method?

OBJECTIVES: During ankle fracture surgery, goals include accurate reduction and fixation of the fibula regarding rotation and fibular length. Bilateral postoperative computed tomography (CT) can be performed to assess fibular rotation using the talar dome angle, and fibular length. The aim of this study was to compare side-to-side differences of the fibular rotation and fibular length using bilateral CT scans of uninjured ankles. DESIGN: Retrospective. SETTING: Single center, Level I Academic Trauma Center. PATIENT SELECTION CRITERIA: Patients with bilateral CT scans of uninjured ankles. OUTCOME MEASURES AND COMPARISONS: External rotation using the Nault talar dome method and fibular length using the coronal method of Prior et al. The average, difference, and ratio (injured side/healthy side) and interobserver variability were calculated. RESULTS: There were 83 patients included (166 ankles, mean age 47 years, 77.1% male). A random set of 66 ankles (33 CT scans) were used to measure interobserver variability. The mean degrees of external rotation ranged from 6.6 to 7.7, mean difference ranged from 1.4 to 3.4 degrees, mean ratio ranged from 1.1 to 1.5, and interobserver variability ranged from 0.27 to 0.65. For fibular length, the mean ranged from 24.6 to 25.8 mm, mean difference in fibular length ranged from 0.5 to 2.1 mm, mean ratio ranged from 1.0 to 1.1 mm, and interobserver variability ranged from 0.45 to 0.73. CONCLUSIONS: Using bilateral ankle CT scans, mean differences in fibular rotation using the Nault talar dome method were 1.4-3.4 degrees. The distal fibular length had a mean difference between both sides of 0.5-2.1 mm. Although the intraclass correlation's were low, the interleg differences between patients were small, making them useful for clinical practice. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

MRI findings of peroneal tendon tears do not necessarily correlate to clinical findings in paediatric and adolescent patients.

PURPOSE: Pathologic abnormality of the peroneal tendons are thought to be an under-appreciated source of vague ankle and hindfoot pain in paediatric patients, partly because they can be difficult to diagnose and differentiate from lateral ankle ligament injuries. While magnetic resonance imaging (MRI) is the primary imaging modality used to detect peroneal tendon pathology, previous studies in adults have found that positive MRIs demonstrate a positive predictive value (PPV) of associated clinical findings around 48%. There are no similar known published studies in the paediatric population. Our objective was to determine the positive predictive value of peroneal tendon pathology as diagnosed by MRI as related to positive clinical exam findings in the paediatric and adolescent population. METHODS: This IRB approved retrospective study was conducted at a tertiary children's hospital. Inclusion criteria included patients under 18 years from our tertiary care institution with (a) ankle MRI findings indicating pathology of the peroneus brevis/longus tendons confirmed by a board certified paediatric musculoskeletal radiologist and (b) formal review of the clinical examination by a fellowship trained paediatric orthopaedic surgeon. Patients with congenital deformities or previous surgical intervention of the lateral ankle were excluded. RESULTS: Forty-seven patients (with 48 MRIs) met inclusion criteria over a ten year period. The majority of the positive MRI scans (70%) demonstrated a peroneus brevis split tear. Of the patients with positive findings on MRI, 17 patients had an associated positive clinical exam. The positive predictive value of MRI for peroneal tendon tears with positive clinical findings was 35.41% (95% confidence interval = 31.1% to 41.6%). There were 31 patients with MRI positive findings with a negative clinical exam. CONCLUSION: Despite having a negative clinical exam, a high percentage of patients had positive MRI findings suggestive of peroneal tendon pathology which confirms findings of adult populations demonstrating a high rate of incidental finding of peroneal tendon pathology on MRI in paediatric patients.

Differences and relationships between weightbearing and non-weightbearing dorsiflexion range of motion in foot and ankle injuries.

BACKGROUND: This study aimed to: (1) identify assessment methods that can detect greater ankle dorsiflexion range of motion (DROM) limitation in the injured limb; (2) determine whether differences in weightbearing measurements exist even in the absence of DROM limitations in the injured limb according to non-weightbearing measurements; and (3) examine associations between DROM in the weightbearing and non-weightbearing positions and compare those between a patient group with foot and ankle injuries and a healthy group. METHODS: Eighty-two patients with foot and ankle injuries (e.g., fractures, ligament and tendon injuries) and 49 healthy individuals participated in this study. Non-weightbearing DROM was measured under two different conditions: prone position with knee extended and prone position with knee flexed. Weightbearing DROM was measured as the tibia inclination angle (weightbearing angle) and distance between the big toe and wall (weightbearing distance) at maximum dorsiflexion. The effects of side (injured, uninjured) and measurement method on DROM in the patient groups were assessed using two-way repeated-measures ANOVA and t-tests. Pearson correlations between measurements were assessed. In addition, we analyzed whether patients without non-weightbearing DROM limitation (≤ 3 degrees) showed limitations in weightbearing DROM using t-tests with Bonferroni correction. RESULTS: DROM in patient groups differed significantly between legs with all measurement methods (all: P < 0.001), with the largest effect size for weightbearing angle (d = 0.95). Patients without non-weightbearing DROM limitation (n = 37) displayed significantly smaller weightbearing angle and weightbearing distance on the injured side than on the uninjured side (P < 0.001 each), with large effect sizes (d = 0.97-1.06). Correlation coefficients between DROM in non-weightbearing and weightbearing positions were very weak (R = 0.17, P = 0.123) to moderate (R = 0.26-0.49, P < 0.05) for the patient group, and moderate to strong for the healthy group (R = 0.51-0.69, P < 0.05). CONCLUSIONS: DROM limitations due to foot and ankle injuries may be overlooked if measurements are only taken in the non-weightbearing position and should also be measured in the weightbearing position. Furthermore, DROM measurements in non-weightbearing and weightbearing positions may assess different characteristics, particularly in patient group. LEVEL OF EVIDENCE: Level IV, cross-sectional study.

Bilateral Os Trigonum Fracture Treated With Simultaneous Posterior Ankle Arthroscopy.

This is a case report of a 21-year-old female undergraduate student who sustained bilateral ankle injuries while jumping from a moving van wearing 3-inch high heel shoes. Upon initial presentation, her injury was treated conservatively as an acute bilateral ankle sprain for 6 weeks. However, the patient reported no improvement of pain and remained unable to self-ambulate. Bilateral MRI and CT scans of both ankles demonstrated bilateral os trigonum fractures. She underwent bilateral posterior ankle arthroscopic débridement of both os trigonum. At the postoperative 36-month follow-up, the patient reported notable improvement of all functional outcomes (36-item Short Form survey and Foot and Ankle Ability Measure), reported return to the same level of sports activities, and experienced no pain (visual analog scale) on either ankle. This is the first report in the literature of bilateral os trigonum fracture treated with simultaneous posterior ankle arthroscopic débridement.

Could medial malleolus fracture be combined with deltoid ligament injury?: A rare case report.

RATIONALE: Medial malleolus injuries mainly comprise of fractures and deltoid ligament ruptures. Medial malleolus fractures, as a kind of common ankle fractures, could occur separately or be accompanied by lateral and posterior malleolus fractures. It is generally agreed that medial malleolus fracture and deltoid ligament rupture could not occur simultaneously. PATIENT CONCERNS: In our study, we report a case of 36 year-old man diagnosed with trimalleolar fracture accompanying ankle dislocation initially. The patient was admitted to our hospital due to traffic accident. DIAGNOSIS: The patient was diagnosed with trimalleolar fracture accompanying ankle dislocation initially. We missed the diagnosis of accompanied deltoid ligament due to the arthralgia of medial ankle and the widened medial articular space in X-ray after operation. INTERVENTION: As we missed the diagnosis of accompanied deltoid ligament, we only selected open reduction and internal fixation for trimalleolar fracture at first. After we realized the existence of deltoid ligament rupture, the patient refuse further diagnosis and treatment in our hospital. OUTCOMES: During the rehabilitation exercise, the patient had medial arthralgia in his right ankle. He complained it and refuse further diagnosis and treatment in our hospital. LESSONS: The newfound injury pattern, medial malleolus fracture accompanying deltoid ligament rupture, has not been reported in previous studies. The injury pattern needs further researches to explore the mechanism and it should be taken seriously in clinical practice.

Standing on single foot-binding test yields satisfactory results as a novel method for the diagnosis of distal tibiofibular syndesmosis instability: a prospective, cross-sectional diagnostic-accuracy study.

BACKGROUND: Non-invasive diagnosis of distal tibiofibular syndesmosis instability (DTSI) was a great challenge to clinicians. We designed a new method, the Standing on single foot-Binding test, and investigated the accuracy of the test in the diagnosis of distal tibiofibular syndesmosis instability in adults with a history of ankle injury. METHODS: 85 participants with ankle injury were subjected to the Standing on single foot-Binding test, MRI and palpation to detect the distal tibiofibular syndesmosis instability (DTSI) and the findings were compared with ankle arthroscopic results. Both participants and arthroscopist were blind to the predicted results of the clinical tests. Sensitivity, specificity, PPV, NPV, LR+, LR - and their 95% CIs were calculated for each of the clinical tests as well as for the positive clinical diagnosis. RESULTS: The Standing on single foot-Binding test (SOSF-B test) outperformed MRI and palpation, in terms of sensitivity (87.5%/84.38%), specificity (86.79%/86.79%), PPV (80%/79.41%), NPV (92%/91.2%), LR+ (6.625/6.39), LR- (0.14/0.18) and diagnostic accuracy (87.06/85.88), among others, in the diagnosis of distal tibiofibular syndesmosis instability (DTSI). The diagnostic performance of 20° SOSF-B test was virtually identical to that of 0° SOSF-B test. According to the prevalence (28.7%) of DTSI and LR of four tests, the post-test probability could be used in clinical practice for the prediction of DTSI. CONCLUSION: This prospective and double-blind diagnostic test showed that the SOSF-B test is clinically feasible for the diagnosis of distal tibiofibular syndesmosis instability (DTSI), and new diagnostic tools for rapid screening of distal tibiofibular syndesmosis instability (DTSI). LEVEL OF EVIDENCE: II.

Anterior talofibular ligament's superior fascicle as a cause of ankle microinstability can be routinely identified by ultrasound.

PURPOSE: Chronic pain can affect up to 40% of patients after ankle inversion sprains. The current hypothesis to explain this high percentage of chronic pain is a partial/total rupture of anterior talofibular ligament (ATFL) superior fascicle, a structure that has recently been described as intra-articular and as having a different function than ATFL's inferior fascicle. This has created the need for diagnosing ATFL superior and inferior fascicles independently. Therefore, the objective of this study is to investigate if the ATFL's superior fascicle can be visualized on ultrasound, and to describe its ultrasonographic appearance. METHODS: Twenty fresh-frozen ankle specimens were used in this 4-phases study. First, the specimens were scanned on US to identify what was believed to be ATFL's superior fascicle. Second, ATFL's superior fascicle was sutured under direct arthroscopic vision. Next, the specimens were scanned on US to obtain an image of the sutured structure. Finally, the specimens were dissected to confirm that the suture was indeed placed on ATFL's superior fascicle. RESULTS: On the 20 specimens studied, full correlation was obtained between US, arthroscopic suture and specimen dissection. ATFL's superior fascicle US appearance is provided. CONCLUSION: ATFL's superior fascicle can be visualized on US, which will allow to undergo diagnosis of isolated injuries to that fascicle, a common finding in ankle microinstability. The results of this study will facilitate the diagnosis of partial or complete rupture of ATFL's superior fascicle, likely increasing the amount of ankle microinstability diagnosis, impacting clinical management of ankle sprain consequences.

Variability in sonographic anterior drawer test measurements of the ankle: Experienced versus beginner examiners.

BACKGROUND: This study aimed to clarify the variability in the measurements of stress sonography of the ankle and determine the effects of examiner experience on the measurements. METHODS: Twenty examiners (10 experienced and 10 beginners) were included in the study. Each examiner performed stress ultrasonography on a patient with a chronic anterior talofibular ligament injury and a patient with an intact ligament using the reverse anterior drawer method. Changes in ligament length before versus after stress were determined. The same 20 examiners performed ultrasonography on two other patients with an injured or intact ATFL using the anterior drawer method. The length change values and variance were compared between the groups using t-tests and F-tests. RESULTS: Using the reverse anterior drawer method, the change in the anterior talofibular ligament length was 3.3 mm (range, 2.2-4.8 mm) in the experienced group and 2.7 mm (0.0-4.1 mm) in the beginner group for the ligament injured patient. The length changes for the patient with intact anterior talofibular ligament were 0.5 mm (0.1-0.9 mm) and 0.4 mm (-0.1-1.5 mm) in the experienced and beginner groups, respectively. There were no significant intergroup differences in measurement amount (P = 0.37) or variance (P = 0.72). Similarly, using the anterior drawer method, no significant differences between the groups were found in measurement amount or variance. CONCLUSION: The quantitative evaluation of stress sonography of the ankle was variable regardless of examiner experience or stress method, particularly in patients with an anterior talofibular ligament injury. The amount of variability appeared to be unacceptably large for clinical application. Our study results highlight the need for technical standardization.

Morphology of Fibular Incisura is a Deciding Factor Between Posterior Malleolus Avulsion Fracture or Syndesmotic Ligament Injury in Ankle Fractures.

The bone anatomy of tibiofibular syndesmosis has been a topic of interest. Fibular incisura morphology has been analyzed on cadaver specimens, plain radiographs, or CT images. The aim of this study is to examine the effects of fibula incisura features and fibula morphology in ankle injuries, especially involving posterior malleolus and posteroinferior tibiofibular ligament injuries. From 2017 through 2022, A total of 59 patients with isolated lateral malleolar fracture, Mason-Malloy type 1 posterior malleolar fracture, syndesmosis injury in those without posterior malleolar fracture, supination external rotation type 3 injuries according to Lauge-Hansen classification, and preoperative bilateral ankle computed tomography images were included in the study. Fibula morphologies and syndesmosis measurements were made from preoperative computed tomography images using axial CT images from 1 cm proximal to the tibial plafond. The diagnosis of posterior malleolar fractures was made using the CT classification system of Mason and Malloy, and the diagnosis of syndesmosis injury was made with a cotton test during surgery. Age, gender, fractured side, incisura type, incisor depth, width, anterior and posterior facet lengths, incisor version (antevert-retrovert), the angle between the anterior and posterior facets, and fibula type were recorded. There was a statistically significant difference between the groups in posterior facet length and incisura width. Morphological features of fibular incisura may be the determinant of PITFL injury or PMA injury in fibular fractures caused by an external rotation mechanism.