[Ligamentous injuries of the ankle joint : Importance of radiological imaging procedures]. / Bandverletzungen des Sprunggelenks : Stellenwert radiologischer bildgebender Verfahren.

Injuries of the ankle joint show lesions of the lateral ligamentous apparatus with an incidence of 1 in 1000 cases. With a range of 0.3-0.7 in 1000 cases, injuries of the medial ligamentous apparatus occur more frequently than previously thought and are often overlooked. Correct imaging diagnostics of the ankle ligaments are mandatory for the prognosis and treatment planning. In cases of clinically strong suspicion of ligamentous injury or osteochondral lesions of the ankle joint, after primary radiographic evaluation magnetic resonance imaging (MRI) is primarily recommended for a more precise assessment. Additionally, the sensitivity for assessment of the ligaments with ultrasonography is good (91% vs. 97% with MRI) but its specificity is inferior compared to MRI (63% vs. 93% with MRI). Supination trauma is the most common ankle injury and attention should be paid to the anterior tibiofibular ligament and calcaneofibular ligament. In approximately 50%, injuries to the superficial layer of the medial collateral ligament complex are associated with lesions of the posterior tibiotalar ligament.

Apoptosis Occurs in the Anterior Talofibular Ligament of Patients With Chronic Lateral Ankle Instability: An In Vitro Study.

BACKGROUND: Chronic lateral ankle instability is treated operatively, whereas most acute ankle sprains associated with acute anterior talofibular ligament injury are usually treated nonoperatively. This treatment strategy is widely accepted and has been validated using a variety of clinical or radiological methods. We suspected that there may be biological differences between chronic and acutely injured ligaments, particularly with respect to apoptosis. Apoptosis is known to cause ligament degeneration. If it could be demonstrated that apoptosis occurs more in the anterior talofibular ligament tissues of patients with chronic lateral ankle instability compared with patients with acute anterior talofibular ligament injury, biological evidence could be supported. QUESTIONS/PURPOSES: We sought to (1) elucidate the difference in the extent of apoptosis between patients with chronic lateral ankle instability and those with acute anterior talofibular ligament injury. In addition, we asked: (2) What is the expression level of apoptotic enzymes such as caspases 3, 7, 8, and 9 and cytochrome c in each patient group? (3) Is there a correlation between apoptotic activities and the symptom duration period of chronic lateral ankle instability? METHODS: Between March 2019 and February 2021, 50 patients were prospectively enrolled in this study. Anterior talofibular ligament tissues were harvested from patients who were divided into two groups: the chronic lateral ankle instability group and the acute anterior talofibular ligament injury group. Patients with insufficient remaining ligaments were excluded from the chronic lateral ankle instability group, and cases in which the tissue was severely damaged or the quality of collected tissue was insufficient because of severe impingement into the fracture site were excluded from the acute anterior talofibular ligament injury group. Tissues were collected from 21 patients (11 males and 10 females) in the chronic lateral ankle instability group with a mean age of 37 ± 14 years and from 17 patients (6 males and 11 females) in the acute anterior talofibular ligament injury group with a mean age of 49 ± 17 years. To investigate our first purpose, apoptotic cells were counted using a TUNEL assay. To answer our second question, Western blotting for apoptotic enzymes such as caspases 3, 7, 8, and 9 and cytochrome c was performed to investigate apoptotic activity. Immunohistochemistry was also used to detect apoptotic enzymes. To answer our third question, the time elapsed after the first symptom related to chronic lateral ankle instability occurred and the expression level of each enzyme was investigated. RESULTS: More apoptotic cells were observed in the chronic lateral ankle instability group than in the acute anterior talofibular ligament injury group in the TUNEL assay. Western blotting revealed that the apoptotic activities of the chronic lateral ankle instability group were higher than those of the acute anterior talofibular ligament injury group: caspase 3 was 117 in the chronic lateral ankle instability group and 59 in the acute anterior talofibular ligament injury group (mean difference 58 [95% confidence interval (CI) 31 to 86]; p < 0.001), caspase 7 was 138 in the chronic lateral ankle instability group and 45 in the acute anterior talofibular ligament injury group (mean difference 93 [95% CI 58 to 128]; p < 0.001), caspase 8 was 126 in the chronic lateral ankle instability group and 68 in the acute anterior talofibular ligament injury group (mean difference 58 [95% CI 29 to 89]; p < 0.001), caspase 9 was 128 in the chronic lateral ankle instability group and 54 in the acute anterior talofibular ligament injury group (mean difference 74 [95% CI 44 to 104]; p < 0.001), and cytochrome c was 139 in the chronic lateral ankle instability group and 51 in the acute anterior talofibular ligament injury group (mean difference 88 [95% CI 46 to 129]; p < 0.001). Immunohistochemistry revealed higher expression of caspases 3, 7, 8, and 9 and cytochrome c in the chronic lateral ankle instability group compared with those in the acute anterior talofibular ligament injury group. Caspases 3, 7, and 9 showed no correlation with duration of chronic lateral ankle instability symptoms: the Pearson correlation coefficient was 0.22 [95% CI -0.25 to 0.69] for caspase 3 (p = 0.36), 0.29 [95% CI -0.16 to 0.74] for caspase 7 (p = 0.23), and 0.29 [95% CI -0.16 to 0.74] for caspase 9 (p = 0.23). CONCLUSION: In chronic lateral ankle instability, apoptotic activity in the anterior talofibular ligament was higher than in acute anterior talofibular ligament injury. CLINICAL RELEVANCE: Apoptosis occurs more in chronic injured ligaments than in acutely injured ligaments. Although urgent surgical repair is not required for acute anterior talofibular ligament injury, chronic lateral ankle instability may progress if the nonoperative treatment is not successful. Further research should focus not only on timing of apoptotic progression, but also on biological augmentation to reverse or prevent apoptosis within the anterior talofibular ligament.

Síndrome del impacto posterior del tobillo secundario a proceso de Stieda / Posterior Ankle Impingement secondary to a Stieda process

Introducción: El síndrome de impacto posterior es una condición que resulta de la compresión de tejidos blandos entre la cara posterior del astrágalo y el área posteroinferior de la tibia durante el movimiento de flexión plantar del tobillo y provoca inflamación de los tejidos blandos circundantes. Objetivo: Presentar un caso de síndrome de impacto posterior secundario a proceso de Stieda. Presentación de caso: Se presenta el caso de un varón de 53 años, cocinero de profesión que se quejaba de dolor en la región posterior del tobillo derecho, que se exacerbaba con la flexión plantar del tobillo sin traumatismo previo. Se descartaron lesiones de tipo tendinosas y ligamentosas al examen físico, por lo que se indica radiografía convencional. A través de la radiografía de tobillo se define proceso de Stieda el cual justifica la clínica. Por esto no se realizaron otros estudios. Conclusiones: La radiografía convencional en el contexto clínico de un síndrome de impacto posterior del tobillo permite establecer el diagnóstico sin requerir estudios de imagen de mayor complejidad(AU)

Introduction: The posterior impingement syndrome is a condition resulted of compressed posterior soft tissues, between the posterior talus and the calcaneus. Classically, this is seen at activities that cause extreme plantar flexion. Objective: To describe a posterior Ankle Impingement case secondary to a Stieda process. Case report: We report a 53 years old male, cook profession, with a chronic pain history within the posterior ankle, previous trauma was denied. At clinical examination tendon and ligament injuries were not found. Initial evaluation with conventional radiography showed the presence of a Stieda's process as cause of clinical manifestations. No further imaging studies were required. Conclusion: Conventional radiograph allows to clarify diagnosis in the posterior impingement syndrome(AU)

Ankle microinstability: arthroscopic findings reveal four types of lesion to the anterior talofibular ligament's superior fascicle.

PURPOSE: ATFL's superior fascicle injury has been considered to be the underlying cause in cases of ankle microinstability. As its clinical diagnosis can be difficult, arthroscopic examination may be the only objective diagnostic tool. The purpose of this study was to determine what types of injuries to the ATFL's superior fascicle are associated with ankle microinstability, and to provide the reader with an arthroscopic classification of the types of microinstability affecting the ankle. METHODS: Ankle arthroscopy video records obtained during a four-year period from 232 patients with the diagnosis of ankle microinstability were reviewed. The characteristics of the ATFL's superior fascicle injury were identified, described and recorded along with any concomitant intra-articular pathology. RESULTS: Four different injury patterns were consistently seen affecting the ATFL's superior fascicle. These ranged from ligament attenuation associated with loss of tension (type I), through to partial detachment (type II) or total detachment (type III) from the fibula. Finally, a total or partial resorption of the ATFL's superior fascicle (type IV) was also observed. There was a statistically significant association between the type of injury identified and the rate of intra-articular pathology observed arthroscopically. Equally, the higher the type in the classification, the higher the rate of loose bodies, lateral talar OCD, deltoid "open book" tears, and anterior soft-tissue formation. CONCLUSION: Different types of ATFL's superior fascicle injury can be observed in patients with ankle microinstability, ranging from ligament attenuation associated with a loss of tension (8.2%) to different degrees of partial (69.1%) and total (16.8%) ligament detachment from the fibula, or ligament remnant resorption (5.9%). As the type of injury progresses along with the proposed classification, the rate of intra-articular injuries also increases. The clinical relevance of this study is that a morphological ATFL's superior fascicle tear is recognized in patients with the diagnosis of ankle microinstability. LEVEL OF EVIDENCE: IV.

The evaluation of the distance between the popliteus tendon and the lateral collateral ligament footprint and the implant in Total knee Arthroplasty using a 3-dimensional template.

BACKGROUND: The popliteus tendon (PT) or lateral collateral ligament (LCL) stabilizes the postero-lateral aspects of the knees. When surgeons perform total knee arthroplasty (TKA), PT and LCL iatrogenic injuries are a risk because the femoral attachments are relatively close to the femoral bone resection area. The purpose of this study was to evaluate the distance between the PT or LCL footprint and the TKA implant using a 3D template system and to evaluate any significant differences according to the implant model. METHODS: Eighteen non-paired formalin fixed cadaveric lower limbs were used (average age: 80.3). Whole length lower limbs were resected from the pelvis. All the surrounding soft tissue except the PT, knee ligaments and meniscus were removed from the limb. Careful dissection of the PT and LCL was performed, and the femoral footprints were detected. Each footprint periphery was marked with a 1.5 mm K-wire. Computed tomography (CT) scanning of the whole lower limb was then performed. The CT data was analyzed with a 3D template system. This simulation models for TKA were the Journey II BCS and the Persona PS. The area of each footprint, and the length between the most distal and posterior point of the lateral femoral condyle and the edge of each footprint were measured. Matching the implant model to the CT image of the femur, the shortest length between each footprint and the bone resection area were calculated. RESULTS: PT and LCL footprint were detected in all knees. The area of the PT and LCL footprints was 38.7 ± 17.7 mm2 and 58.0 ± 24.6 mm2, respectively. The length between the most distal and posterior point of the lateral femoral condyle and the edge of the PT footprint was 10.3 ± 2.4 mm and 14.2 ± 2.8 mm, respectively. The length between most distal and most posterior point of the lateral femoral condyle and the edge of the LCL footprint was 16.3 ± 2.3 mm and 15.5 ± 3.3 mm, respectively. Under TKA simulation, the shortest length between the PT footprint and the femoral bone resection area for the Journey II BCS and the Persona PS was 4.3 ± 2.5 mm and 3.2 ± 2.9 mm, respectively. The shortest length between the LCL footprint and the femoral bone resection area for the Journey II BCS and the Persona PS was 7.2 ± 2.3 mm and 5.6 ± 2.1 mm, respectively. The PT attachment was damaged by the bone resection of the Journey II BCS and the Persona PS TKA in 3 and 9 knees, respectively. CONCLUSION: The PT and LCL femoral attachments existed close to the femoral bone resection area of the TKA. To prevent postero-lateral instability in TKA, careful attention is needed to avoid damage to the PT and LCL during surgical procedures.

The correlation between clinical and ultrasound evaluation of anterior talofibular ligament and calcaneofibular ligament tears in athletes.

BACKGROUND: The objectives of this study were to find correlation between the clinical and ultrasound grading in anterior talofibular ligament and calcaneofibular ligament tear, and to determine the sensitivity and specificity of the two stability tests among the athletes. Subsequently, we would like to propose a new grading criterion for an ultrasound examination. METHODS: Two blinded assessors examined thirty-five patients with a history of recent lateral ankle sprain. The first assessor performed physical examination on the injured ankle by using the anterior drawer test and talar tilt test, and the second assessor performed dynamic and static ultrasound assessment for anterior talofibular ligament and calcaneofibular ligament. The clinical laxity grading and sonographic extent of ligamentous injury was graded into a three-point scale. RESULTS: There was a moderate positive correlation between clinical test and ultrasound grading of anterior talofibular ligament and calcaneofibular ligament with Spearman's correlation coefficient values of 0.58 and 0.66 respectively. Clinical grading of anterior drawer test had 59.1% sensitivity (95% CI: 0.36-0.79) while ultrasound grading had 100.0% specificity (95% CI: 0.75-1.00), with positive likelihood ratio of 0.77 and negative likelihood ratio of 0.44 in detecting a complete (grade 3) anterior talofibular ligament tear (P<0.05). Meanwhile, the clinical grading of talar tilt test had 54.5% sensitivity (95% CI: 0.23-0.83) and ultrasound grading had 100.0% specificity (95% CI: 0.85-1.00), with positive likelihood ratio of 1.0 and negative likelihood ratio of 0.45 in detecting a complete grade 3 calcaneofibular ligament tear (P<0.05). CONCLUSIONS: The dynamic ultrasound is recommended to determine the actual degree of disruption of the ligament especially when clinical grading under-grades the degree of tear. Grade 2 tears can vary from 10% tear to 90% tear causing the clinical correlation to become less strong. We recommend a new classification for ultrasound grading of grade 2 tears, which could result in a stronger correlation between clinical and ultrasound grading.

Absence of ATFL remnant does not affect the clinical outcomes of the modified broström operation for chronic ankle instability.

PURPOSE: The modified Broström operation for chronic ankle instability has demonstrated good clinical results. Absence of ligamentous tissue is a risk factor for recurrence of ankle instability after surgery. This study evaluated the effect of quality of ligament tissue (anterior talofibular ligament, ATFL) on prognosis, in a cohort of patients with chronic ankle instability after the modified Broström operation. METHODS: This was a retrospective case series. Overall, 60 patients underwent the modified Broström operation for chronic ankle instability (mean follow-up, 30.1 [range, 24-47] months). Presence of ATFL remnant was assessed on ultrasound, magnetic resonance imaging, and arthroscopy in all patients. Foot and ankle outcome score (FAOS) was used to evaluate functional outcomes. Clinical outcomes were compared by the condition of the ligament remnant. Association with other risk factors was evaluated using multiple linear regression analysis. RESULTS: ATFL was visible in 51/60 cases on ultrasound. Thirty, 22, and eight patients had thin or absent; normal thickness; and thick ATFL on magnetic resonance imaging, respectively. ATFL was visible in 15 patients on arthroscopy and nonvisible or not clear in 45. No significant differences occurred in FAOS with the presence of ATFL remnant on ultrasound, arthroscopy, and the grade of ATFL thickness on magnetic resonance imaging. No correlation was found between FAOS and the thickness of ATFL. CONCLUSION: The results suggest that the modified Broström operation for patients with chronic ankle instability was good, regardless of the presence or absence of ATFL remnant. LEVEL OF EVIDENCE: III, Retrospective cohort study.

Reliability and validity of different ankle MRI scanning planes for the anterior talofibular ligament injury diagnosis: a cadaveric study.

BACKGROUND: The objective of the current study is to compare reliability, accuracy, sensitivity, and specificity in magnetic resonance imaging (MRI) evaluation of anterior talofibular ligament (ATFL) among the routine axial scanning plane, oblique axial-coronal scanning plane, and oblique axial-sagittal scanning plane. METHODS: Twenty cadaveric feet were studied. ATFL was exposed before scanning. Routine axial, oblique axial-coronal, and oblique axial-sagittal MRI scanning of 20 ATFL-intact cadaveric feet were acquired utilizing a 1.5-T MRI unit. The scans were repeated on the 20 cadaveric feet after the ATFL was artificially injured. In total, 120 sets of MR images were obtained and were randomly numbered. Three independent observers who were blinded to the experiment evaluated the images. Interobserver agreement, sensitivity, specificity, and accuracy were calculated and compared between different scanning planes utilizing the McNemar test. RESULTS: The interobserver agreement was fair to good (kappa, 0.55 to 0.65) in the routine axial plane, fair to good (kappa, 0.557 to 0.75) in the oblique axial-sagittal plane, and excellent (kappa, 0.85 to 0.95) in the oblique axial-coronal plane. The accuracy was significantly higher when utilizing oblique axial-coronal MRI scanning than routine axial MRI scanning (reader 1: p = .018; reader 2: p = .005). CONCLUSIONS: The diagnostic accuracy of oblique axial-coronal plane MRI was higher than the routine axial plane concerning ATFL injury, and the interobserver agreement was excellent. The oblique axial-coronal plane could be added to the MRI scanning protocol during clinical practices to improve the diagnostic accuracy of ATFL injury.

Accuracy of internet images of ligamentous knee injuries.

BACKGROUND: The internet is an easily accessible resource for both providers and patients. Despite this, the internet is not peer reviewed, leaving searches subject to inaccuracies, especially with regards to medical information. The purpose of this study was to review internet images of anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL), and lateral collateral ligament (LCL) tears using two popular search engines: Google and Bing. METHODS: A search query was performed on both Google and Bing for the following terms: 'ACL tear', 'PCL tear', 'MCL tear' and 'LCL tear'. The first 100 images of each individual search were analyzed by three independent orthopedists. RESULTS: The inter-rater reliability was very good for PCL tear on Bing (Cronbach's alpha = 0.89) and excellent (Cronbach's alpha > 0.9) for the remainder of the search queries. When comparing Google to Bing, the only significant difference occurred in the ACL group, with Bing returning a significantly greater number of correct images 60%, 95% CI: 53.2 - 66.7%) compared to Google (45% correct, 95% CI: 38.1-51.8%), p = 0.034. With regards to the other ligaments Bing was more accurate than Google for PCL (39% versus 38%), and LCL (32% to 30%). Both sites were 48% accurate for MCL tear. CONCLUSION: Ultimately, our study revealed that physicians should take an active role in making high quality, easy to understand medical resources and anatomic diagrams available to their patients to avoid confusion and enhance understanding when querying the internet for additional information regarding their condition.

A chronic sinus tract infection developing after suture anchoring of the ankle: A case report.

RATIONALE: Suture anchors are increasingly used to fix soft tissue to bone. Favorable outcomes of the modified Brostrom operation (MBO) using suture anchors have been reported. However, to the best of our knowledge, few complications of suture anchors used in ankle surgery have been described. Here, we present a rare case of successful treatment of a chronic sinus tract infection developing after the MBO using a suture anchor. PATIENT CONCERNS: A healthy 18-year-old high school student presented with a chronic ulcerative wound in his right ankle 1 year after anterior talofibular and calcaneofibular ligament repair using a suture anchor at a local clinic. Clinical examination revealed a 1.5 × 2-cm-sized ulcerative wound, accompanied by a red-black discharge, on the anterior border of the right lateral malleolus. The wound could be approximated to the joint capsule level using a forceps. DIAGNOSIS: A simple standing anteroposterior radiograph of the right ankle revealed mild, lateral soft-tissue swelling. Magnetic resonance imaging showed that a sinus tract running from the wound to the talar body crossed the anterior joint capsule, and bone marrow edema surrounding the talus. INTERVENTIONS: We removed the sinus tract and the infected suture anchor. We rendered the wound zigzag-shaped and then performed simple suturing and applied a short leg cast. OUTCOMES: The wound healed completely by 4 weeks after surgery. The patient reported no complication or recurrence of infection at the 1-year follow-up. LESSONS: To obtain wound healing, the chronic sinus tract must be removed. If the suture anchor is the cause of infection, it should be removed.

Reliability and validity of preoperative MRI for surgical decision making in chronic lateral ankle instability.

PURPOSE: To evaluate the value of analyzing the anterior talofibular ligament (ATFL) on preoperative MRI as a decision-making tool to determine the surgical technique in patients undergoing surgery for chronic lateral ankle instability. METHODS: A retrospective study of prospective data was performed. All patients who underwent surgery between 2013 and 2016 for arthroscopic stabilization of the ankle were included. The ATFL was evaluated on preoperative MRI including axial T2-weighted images by two readers who were blinded to arthroscopic results. The arthroscopic evaluation, which was considered to be the reference examination, was performed by one senior surgeon. The main judgment criteria were two features of the ATFL: (1) absent or thin (< 1 mm thick) and (2) detached or thickened (> 3.2 mm in diameter) with or without a high intensity intraligamentous signal. Inter- and intraobserver reproducibility was evaluated by the kappa coefficient (k), and parameters of the diagnostic accuracy of preoperative MRI were analyzed. RESULTS: Twenty-two patients were included, 15 men/7 women mean age 30.3 ± 9.5 years. Fourteen patients (63.6%) underwent arthroscopic repair of the ATFL (Broström-Gould technique) and 8 patients (36.4%) an arthroscopic anatomical reconstruction of the ATFL. Intraobserver reproducibility of MRI findings was substantial (k = 0.68) and interobserver reproducibility moderate (k = 0.55) to nearly perfect (k = 0.87). Agreement between MRI and arthroscopic findings was substantial (k = 0.70). Diagnostic parameters of preoperative MRI were good for both observers: Se = 85.7-87.5%, Sp = 86.7-92.9%, PPV = 75-87.5%, NPV = 92.9%, and classification of patients was good = 86.4-90.9%. CONCLUSION: Preoperative MRI of the ATFL is a reliable and valid decisional tool to choose the surgical technique for stabilization of chronic lateral ankle instability. LEVEL OF EVIDENCE: Level II; Diagnostic study-development of diagnostic criteria on the basis of consecutive patients.

Talonavicular ligament: prevalence of injury in ankle sprains, histological analysis and hypothesis of its biomechanical function.

OBJECTIVE: To assess the prevalence of injury of the talonavicular ligament (TNL) in ankle sprains, its anatomy and the stability of the talonavicular joint (TNJ) before and after dividing the TNL in a cadaver. METHODS: During a prospective study of 100 patients to assess the outcome of ankle injuries, we noted high incidence of TNL injuries; we will discuss here the TNL findings. Each patient had undergone ultrasound and cone beam CT examination of the ankle. Six TNLs were dissected off fresh-frozen cadaveric feet for histological analysis. In further six cadaveric feet, the stability of the TNJ was assessed by mechanical stress before and after division of the TNL; movement at the joint was assessed by measuring the distance between the talus and navicular bone [talonavicular distance (TD)] using ultrasound. The TD was measured on ten randomly selected ultrasound images by three independent observers and repeated twice by a single observer to determine the inter- and intraobserver reliability. RESULTS: 21% of the patients had an injury to the TNL. Histological examination demonstrated a dense connective tissue composed of bundles of collagen in parallel arrangement along the ligament length. The interobserver and intraobserver reliability of the TD showed almost perfect agreement. Displacement at the TNJ after stress with the TNL intact measured 0.18 ± 0.08 cm and 0.29 ± 0.07 cm (p < 0.005) when divided. CONCLUSION: The TNL is surprisingly commonly injured in ankle sprains. Its anatomy and histology suggest a role in tensile force transmission during the windlass mechanism in gait. Advances in knowledge: Injury to the TNL is common and has not been described. Its anatomy suggests resistance to tensile forces and its injury allows excessive movement at the TNJ.

Intra-articular pathologies associated with chronic ankle instability.

Chronic ankle instability causes intra-articular lesions, which may lead to secondary degenerative changes. The aim of this study was to evaluate the usefulness of the ankle arthroscopy for the evaluation and treatment of intra-articular pathologies associated with chronic ankle instability. Between January 2013 and March 2016, 25 anterior ankle arthroscopies with modi ed anatomic Broström-Duquennoy-Tourne lateral ankle ligaments reconstructions were performed. In arthroscopy all patients (100%) had some intra-articular pathologies: 75% synovitis or so tissue scarring, 19% - deep chondral defect, 56% - superficial chondral lesion, 52% - osteophytes, 24% - bony or avulsion fragments, 20% - loose bodies. All intra-articular pathologies were treated during procedure. In conclusion, it is recommended to perform anterior ankle arthroscopy in addition to lateral ankle ligament reconstruction to diagnose and treat intra-articular lesions.

Three-dimensional isotropic T2-weighted fast spin-echo (VISTA) ankle MRI versus two-dimensional fast spin-echo T2-weighted sequences for the evaluation of anterior talofibular ligament injury.

AIM: To compare the performance of axial images of the ankle joint on three-dimensional (3D) volume isotropic turbo spin echo acquisition (VISTA) with that of two-dimensional (2D) fast spin echo (FSE) T2-weighted images for the diagnosis of anterior talofibular ligament (ATFL) injury. MATERIALS AND METHODS: This retrospective study included 101 patients who underwent both 2D FSE T2-weighted and 3D VISTA magnetic resonance imaging (MRI) of the ankle. The signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) of both sequences were measured. The anatomical identification score and diagnostic performances of both sequences were evaluated by two radiologists. The diagnostic performances of 3D VISTA and 2D FSE images were analysed in terms of sensitivity, specificity, and accuracy for diagnosing ATFL injury. Surgically or clinically confirmed diagnoses were used as reference standards. RESULTS: The margin sharpness scores on 3D VISTA were significantly inferior to those of 2D FSE (p<0.001). Other scores (entire length, entire width) were not significantly different between the two imaging methods. The SNRs and CNRs of 3D VISTA were significantly higher than those of 2D FSE (p<0.001). When diagnoses were classified as normal and abnormal, the specificity of the 3D VISTA images for the diagnosis of ATFL injury was 95.7%, significantly superior to 2D FSE (84.3-85.7%). There were no significant differences between 3D VISTA and 2D FSE images in sensitivity or accuracy for diagnosis (p=0.227-1.000), with the exception of accuracy by reader 1 (p=0.039). CONCLUSION: 3D VISTA imaging has a diagnostic performance comparable to that of 2D FSE for the diagnosis of ATFL injury, although 3D VISTA is inferior to 2D FSE for the evaluation of margin sharpness. Replacing axial and coronal images with 3D VISTA can save imaging time without negatively impacting the diagnostic ability for ATFL injury.

Can Bassett's ligament be removed?

PURPOSE: To investigate the functional characteristics of Bassett's ligament in the ankle, focusing on mechanoreceptors and potential problems following resection of Bassett's ligament. METHODS: Bassett's ligament, the anterior talofibular ligament (ATFL), and synovium were obtained from 20 ankles of 10 fresh-frozen cadavers. Histologically, mechanoreceptors were identified and classified as Ruffini (type I), Vater-Pacini (type II), Golgi-Mazzoni (type III) corpuscles, and free nerve endings (type IV). Differences in receptor densities were compared. RESULTS: Type I clusters were observed with three to six ramifications; type II mechanoreceptors were encapsulated in clusters of two to four with ovoid or cylindrical shape; type III were amorphous, long and wide, and fusiform- or spindle-shaped; and type IV were long and fine without a defined shape. Differences in the densities of the mechanoreceptors inside three soft tissues (Bassett's ligament, ATFL, and synovium) were not significant. CONCLUSION: There were no significant differences in the densities of the four types of mechanoreceptors among the soft tissues studied. In Bassett's ligament, type I mechanoreceptors were present at significantly higher densities than the other receptors.

[ADVANCES IN ANATOMICAL REPAIR OF CHRONIC LATERAL ANKLE INSTABILITY].

OBJECTIVE: To summarize the current status and progress of the treatment of chronic lateral ankle instability (CLAI). METHODS: The literature about the anatomical repair of CLAI at home and abroad was reviewed and summarized. RESULTS: Broström and its modified operations are the most common surgical treatment of CLAI. The operations showed satisfactory clinical outcomes in the short-, medium-, and long-term follow-up and low complication rate. Suture anchor technique and arthroscopic techniques are gradually used in Broström and its modified operations with satisfactory short-term effectiveness, but long-term effectiveness needs further observation because of the limitation of the short clinical application time. CONCLUSIONS: Broström and its modified operations are effective, convenient, and safe to treat CLAI. Based on the researches of biomechanics and dynamic anatomy, the more personalized design of the rehabilitation program is the further research direction.

The anterior talofibular ligament: A detailed morphological study.

The anterior talofibular ligament (ATFL) is commonly injured and may result in ankle instability. Good results from ATFL reconstruction have been reported; however complications and movement restrictions have also been observed. ATFL differences have been reported; however details of its precise bony attachment are lacking. This study provides a detailed morphology of the ATFL with respect to surgical and clinical applications. ATFL morphology, number of bands and the exact insertion points were studied in 50 formaldehyde embalmed feet. ATFL length was measured in different joint positions to assess its functional role: ATFL length varied from 18.81 mm in dorsiflexion to 21.06 mm in plantarflexion: mid-length width and thickness were 4.97 mm and 1.01 mm respectively. The bony attachment lengths were also measured: mean proximal and distal bony attachment lengths were 4.68 mm and 3.1mm respectively, while 13.04 mm had no bony attachment. One (22.9%), two (56.3%) and three (20.8%) band morphologies were observed originating 10.37 mm anterosuperior to the lateral malleolar tip and inserting 3.92 mm anterior to the anterior lateral malleolar line (ALML). Detailed morphology of the ATFL may help in restoring injured ATFL function by appropriate ligament reconstruction, as well as aid the understanding of the mechanism of ligament injury.

[The Value of Ultrasonography Compared with Magnetic Resonance Imaging in the Diagnosis of Deltoid Ligament Injuries--Is there a Difference?]. / Vergleich der Sonografie und der Magnetresonanztomografie zur Diagnostik von Rupturen des Lig. deltoideum--gibt es einen Unterschied?

BACKGROUND: Ruptures of the deltoid ligament can lead to ankle instability which may cause arthrosis. Aim of this comparative clinical trial was to assess the value of ultrasonography (US) compared to magnetic resonance imaging (MRI) in the diagnosis of medial collateral (deltoid) ligament ruptures associated with Weber type B and C fractures. PATIENTS AND METHODS: All four components of the deltoid ligament of the ankles of 28 patients with Weber type B and 14 patients with Weber type C fractures were preoperatively evaluated by US and MRI for partial or complete ruptures. RESULTS: Deltoid ligament injuries were detected in 10 of 28 patients (35.7 %) with Weber type B and in 12 of 14 patients (85.7 %) with Weber type C fractures with MRI. US reliably identified all 17 patients with complete rupture of the deltoid ligament (sensitivity 100 %, specifity 92 %). However only half of the 6 patients who sustained a partial rupture were correctly identified (sensitivity 50 %, specifity 97.2 %). 26 of 30 ruptures (sensitivity 86.6 %, specifity 96.3 %) and 13 of 27 partial ruptures (sensitivity 48.1 %, specifity 97.8 %) of the four components of the deltoid ligament were correctly identified with US. CONCLUSION: US is a reliable procedure for detection of clinically relevant ruptures and uninjured components of the deltoid ligament after distal fibula fractures. However US is not suitable to reliably identify partial ruptures. The treatment decision for operation or conservative treatment of ankle fractures is based on the stability of the ankle. Patients with lateral malleolar fractures and intact medial malleolus but rupture of the deltoid ligament often show a spontaneous reduction of the talus in X-ray images and may therefore be falsely classified as stable (unrecognised medial instability). However, unstable malleolar fractures should be treated with open reduction and internal fixation in order to improve outcome. Hence US is able to influence therapeutic decisions by detecting medial ankle instability, which cannot be detected clinically or radiologically.

Reliability and Validity of Magnetic Resonance Imaging for the Evaluation of the Anterior Talofibular Ligament in Patients Undergoing Ankle Arthroscopy.

PURPOSE: To analyze the reliability and validity of magnetic resonance imaging (MRI) for the detection of anterior talofibular ligament (ATFL) injuries in chronic lateral ankle instability by comparing its findings with arthroscopic findings. METHODS: This diagnostic study enrolled patients who underwent MRI followed by subsequent arthroscopy for their various ankle disorders between April 2012 and February 2013. Two radiologists independently assessed the ATFL on MRI, and the results of their MRI assessments were then compared with the arthroscopic findings, which were used as the standard of reference. RESULTS: On arthroscopy, 55 ATFL injuries were identified in 79 patients. The interobserver reliability of detecting ATFL injuries with MRI was excellent (intraclass correlation coefficient, 0.915). MRI, as interpreted by readers A and B, showed a sensitivity of 83.6% and 76.4%, respectively; specificity of 91.7% and 83.3%, respectively; negative predictive value of 71.0% and 60.6%, respectively; positive predictive value of 95.8% and 91.3%, respectively; and accuracy of 86.1% and 78.5%, respectively. According to the location of the ATFL injury, the sensitivity of MRI for readers A and B was 72.7% and 63.6%, respectively, at the fibular attachment site; 80.0% and 66.7%, respectively, at the talar attachment site; and 100% at the midsubstance and multiple sites. All false-negative diagnoses of ATFL injuries were observed at the fibular or talar attachment site (9 cases for reader A and 13 cases for reader B). CONCLUSIONS: This study showed that MRI has excellent interobserver reliability (intraclass correlation coefficient, 0.915) for detecting ATFL injuries in patients in whom there is a clinical suspicion of chronic lateral ankle instability. The sensitivity and positive predictive value of MRI in the diagnosis of ATFL injuries were very high, whereas the sensitivity and negative predictive value of MRI were relatively low. According to the location of the ATFL injury, the sensitivities of MRI for the detection of ATFL injuries at the fibular or talar attachment site were lower than those at the midsubstance or multiple sites. In addition, all false-negative diagnoses of ATFL injuries were observed at the fibular or talar attachment site. LEVEL OF EVIDENCE: Level III, diagnostic study of nonconsecutive patients (without consistently applied reference gold standard).

Usefulness of the oblique coronal plane in ankle MRI of the calcaneofibular ligament.

AIM: To evaluate the usefulness and diagnostic accuracy of oblique coronal MRI of the calcaneofibular ligament (CFL) view for diagnosis of CFL injury. MATERIAL AND METHODS: This retrospective study included 91 patients who were suspected to have CFL injury who underwent CFL view imaging. Anatomical identification of the CFL on orthogonal MRI sequences and CFL views was evaluated. Two radiologists evaluated the CFL based on an entire length view, an entire width view, and margin sharpness using a four-point scale. Diagnostic accuracy using orthogonal and CFL views was evaluated by calculating sensitivity, specificity, and accuracy. Arthroscopic or clinical findings were used as the reference standard. RESULTS: Both readers found identification of lesions using the entire length, entire width, and sharp margin from CFL view images to be superior to that based on orthogonal images. The sensitivity and accuracy of diagnosing CFL injury were significantly higher when using the CFL view compared to the orthogonal view, although specificity was not significantly different between the CFL view and orthogonal view images. CONCLUSIONS: CFL view imaging enables better anatomical evaluation and improved sensitivity and accuracy of diagnosis of CFL injury. CFL view images should therefore be used to evaluate potential CFL injuries.