Aims

Posterior malleolar (PM) fractures are commonly associated with ankle fractures, pilon fractures, and to a lesser extent tibial shaft fractures. The tibialis posterior (TP) tendon entrapment is a rare complication associated with PM fractures. If undiagnosed, TP entrapment is associated with complications, ranging from reduced range of ankle movement to instability and pes planus deformities, which require further surgeries including radical treatments such as arthrodesis.

The February 2015 Trauma Roundup³⁶⁰ looks at: Evaluating the syndesmosis in ankle fractures; Calcaneal fracture management an ongoing problem; Angular stable locking in low tibial fractures did not improve results; Open fractures: do the seconds really count?; Long-term outcomes of tibial fractures; Targeted performance improvements in pelvic fractures

Summary. The ankle X-ray has moderate diagnostic power to identify syndesmotic instability, showing large sensitivity ranges between observers. Classification systems and radiographic measurements showed moderate to high interobserver agreement, with extended classifications performing worse. Introduction. There is no consensus regarding the diagnosis and treatment of ankle fractures with respect to syndesmotic injury. The diagnosis of syndesmotic injury is currently based on intraoperative findings. Surgical indication is mainly made by ankle X-ray assessment, by several classification systems and radiographic measurements. Misdiagnosis of the injury results in suboptimal treatment, which may lead to chronic complaints, like instability and osteoarthritis. This study investigates the diagnostic power and interobserver agreement of three classification methods and radiographic measures, currently used to assess X-ankles and to identify syndesmotic injury. Patients and Methods. Twenty patients (43.2 ± 15.3yrs) with an ankle fracture, indicated for surgery, were prospectively included. All patients received a preoperative ankle X-ray, which was assessed by several observers: two orthopaedic surgeons, one trauma surgeon and two radiologists. The ankle X-ray was assessed on syndesmotic injury/stability and presence of fractures (fibula, medial/tertius malleolus). Three classification systems were used: Weber, AO-Müller (short-version n=3 options; extended-version n=27 options), Lauge-Hansen (short-version n=5 options; extended-version n=17 options) and two radiographic measurements were done: tibiofibular overlap (TFO) and ratio medial clearspace/superior clear space (MCS/SCS). All observers were instructed about the assessments before the measurements. During surgery, a proper intraoperative description of the syndesmosis was noted. Agreement (%), Intraclass Correlation Coefficients (ICC) and Kappa were calculated to determine interobserver agreement. Kappa statistic was interpreted according to Landis and Koch. To test the diagnostic power of ankle X-rays to identify syndesmotic instability, sensitivity and specificity were calculated with intraoperative findings serving as golden standard. Results. Six of 20 ankles showed syndesmotic instability intraoperatively. An overall sensitivity of 43% (specificity: 78) was found for X-rays in identifying syndesmotic instability, showing a wide range in sensitivity between observers (17–83%), with radiologists performing better (range 50–83%) than surgeons (range: 17–33%). Overall, substantial to perfect interobserver agreement (range 70–100%) was found for all short classification systems, showing an average kappa ≥0.60. The agreement reduced for more extended classification systems. E.g. observer agreement for the AO-Muller classification with 3, 9 and 27 options was respectively 85% (kappa 0.66), 68% (kappa 0.57) and 55% (kappa 0.51). One observer deviated slightly from others in all classification assessments. Removing this observer resulted in excellent agreement for all classification systems (>90%). Radiographic measurements showed moderate to high interobserver agreement, with TFO performing best (avg. ICC 0.88). Discussion/Conclusion. In ankle fractures, a preoperative X-ray has low sensitivity in detecting syndesmotic instability, showing large sensitivity ranges between observers. Further study is needed to investigate the contribution of classification systems in determining the best treatment method for syndesmotic injury. Ankle X-ray assessment using the three classification systems and radiographic measures was consistent among observers. Disagreement between observers can be attributed to intrinsic differences among the systems (e.g. stepwise classification vs. single assessment). No preference for one specific classification was found, as all showed comparable interobserver agreement. However classification systems with few options are recommended, as the observer agreement reduced with more extending classifications

Introduction. Post-traumatic arthritis is the commonest cause of arthritis of the ankle. Development of arthritis is dependent on the restoration of pre-injury anatomy. To assess the effect of grade of lead surgeon on the accuracy of surgical reduction, we performed a retrospective radiographic analysis of all ankle fractures undergoing open reduction and internal fixation, in a single institution. Method. All patients treated by surgical intervention in an 11 month period (January to November 2011) were included, with the grade of lead surgeon performing the operation recorded.105 patients, 48 males and 53 females, were included with a mean age of 41 years (range: 17–89). Standard antero-posterior (AP) and mortise views were analysed for tibiofibular overlap, ankle clear space and talocrural angle and compared to standardised values from the literature. Lead surgeon grade was stratified as either, trauma consultant, senior registrar (years 4+) or junior registrar (years 1–3). Results. Radiographic reduction within accepted margins was achieved in 78% of ankles on the AP radiograph and 81% on the mortise view. Trauma consultants achieved the highest rate of anatomical reduction, followed by senior registrars, with junior registrars achieving the lowest rate; the rates of anatomical reduction on the mortise view were 83.3%, 79.2% and 75%, respectively. However, senior registrars performed the majority of cases (70%). Conclusion. Radiographic reduction in this institute is comparable to that in the literature. The majority of cases are performed by senior trainees who are able to restore to anatomical reduction radiographically. Junior registrars achieved the lowest rate of anatomical reduction, which may reflect their level of experience and a greater need for supervision in the early years of specialty training

Objectives

Overlap between the distal tibia and fibula has always been quoted to be positive. If the value is not positive then an injury to the syndesmosis is thought to exist. Our null hypothesis is that it is a normal variant in the adult population.

Introduction: Diagnosis of syndesmotic injuries is primarily based upon the assessment of ankle radiographs. Earlier studies examining normal radiographs are limited by small sample size and methodological issues. Materials and Methods: One thousand four hundred and fifteen consecutive patients with ankle radiographs were reviewed. 1023 patients were excluded as a result of a history of ankle/hindfoot pain, trauma, or surgery; or radiographic evidence of ankle/hindfoot pathology. 392 patients (218 females, 174 males) with normal ankle radiographs were included. 83 of 392 patients had bilateral normal radiographs. All radiographs were reviewed independently by a fellowship-trained foot and ankle surgeon and a fellowship-trained musculoskeletal radiologist. Tibiofibular overlap and tibiofibular clear space were measured on anteroposterior (AP) and mortise radiographs. These four measurements were analyzed. Results: Mean AP overlap was 8.3 mm (±2.5). Mean mortise overlap was 3.5 mm (±2.1), 7.7% patients had < 1 mm overlap and 4.9% of patients had < 0 mm overlap. Mean AP clear space was 4.6 mm (±1.1), 7.1% patients had > 6 mm clear space. Mean mortise clear space was 4.3 mm (±1.0), 4.3% patients had > 6 mm clear space. All measurements were significantly different between females and males (p < 0.001). Mortise clear space is the most accurate measure when obtaining contralateral radiographs. Intraobserver and interobserver reliabilities of all measurements were high (intra-class correlation coefficient range 0.820–0.983). Discussion and Conclusion: Our data unequivocally demonstrates that basing treatment of syndesmotic injuries on previously reported radiographic criteria can lead to unnecessary operative intervention or failure to treat. Lack of overlap on the mortise view can represent a normal variant, which has not been definitively reported in prior investigations. Our data forms the basis for new radiographic criteria to evaluate syndesmotic disruption

The management of injury to the distal tibiofibular syndesmosis remains controversial in the treatment of ankle fractures. Operative fixation usually involves the insertion of a metallic diastasis screw. There are a variety of options for the position and characterisation of the screw, the type of cortical fixation, and whether the screw should be removed prior to weight-bearing. This paper reviews the relevant anatomy, the clinical and radiological diagnosis and the mechanism of trauma and alternative methods of treatment for injuries to the syndesmosis.

Aims: We aimed to evaluate diagnostic contribution of MRI-Arthrography in syndesmosis disruption at ankle fractures. Methods: 18 patient who had Denis Weber type B-C fractures and are suspected to have syndesmotic diastasis considering tibiofibular clear space and tibiofibular overlap measurments in conventional radiographs are assesed with MRI followed by MRI-Arthrography. Because joint fluid was already seen in tibiofibular space in 3 patients at MRI, MRI-Arthrography was performed for the remaining 15 patients. If there was a changes between the results obtained from MRI and the results obtained after MRI-arthrography was tested istatistically. Convantional radiographs, MRIs and MRI-Arthrographies were analysed by 2 independent observers and interobserver concordance was assesed. Following intraoperative observation and asssesment syndesmotic diastasis was treated considering radiographic and MRI-arthrographic results. Results: In 15 cases who were regarded to have syndesmotic diastasis according to conventional radiographies, 8 (53.3%) diastasis were confirmed with only MRI and 12 (80%) diastasis were confirmed with MRI arthrography. Following intraoperative assesment 13 (86.6%) cases were regarded to have diastasis and surgical intervention was performed for diastasis repair. In 2 (13.3%) cases surgical intervention for diastasis repair was not performed. If there was a change in decission after MRI and after MRI-arthrography is analysed with chi-square test between related groups. There were statistically significiant difference (p< 0.05) in these means. There is interobserver concordance in conventional radiographic, MRI-arthrographic assesments and in assesments for ATIF and PTIF seperately inMRI.(p< 0.001). Conclusion: These results suggest that conventional radiography and MRI is not sufficient in assesing syndesmosis and MRI-arthrography is important for diagnosis