Bone marrow edema at ligament insertion is an accurate MRI sign of deltoid ligament injury.

BACKGROUND: Magnetic resonance imaging (MRI) is effective in diagnosing deltoid ligament (DL) injury but its sensitivity in chronic cases is low. Additional diagnostic signs are required to reduce the risk of a false negative diagnosis. PURPOSE: To evaluate the added diagnostic value of bone marrow edema at the ligament insertion (BMELI) of DL to the MRI assessment of chronic DL injury. MATERIAL AND METHODS: One hundred patients who consecutively came to our institution between November 2018 and December 2021 and underwent arthroscopic surgery for chronic ankle instability (CAI) were enrolled in the present study. Preoperative MR images were retrospectively reviewed by two orthopedic surgeons to evaluate the sensitivity, specificity and interobserver reliability of three MRI signs in diagnosing chronic DL injury, namely, abnormal ligamentous morphological characteristics (ALMC), BMELI and medial clear space (MCS). RESULTS: Taking arthroscopy as the reference standard, there were 34 patients with and 66 without DL injury. ALMC had 64.71% (22/34; 46.47-79.70) sensitivity and 83.33% (55/66; 71.71-91.00) specificity, BMELI had 70.59% (24/34; 52.33-84.29) sensitivity and 95.45% (63/66; 86.44-98.82) specificity and MCS had 26.47% (9/34; 13.51-44.65) sensitivity and 92.42% (61/66; 82.50-97.18) specificity. Compared with ALMC, BMELI had similar efficacy in superficial cases (P = 0.06) and greater efficacy in deep cases (P = 0.04). All three signs showed good interobserver agreement (kappa values all above 0.7). CONCLUSION: BMELI can reliably indicate concomitant injury to the DL in CAI patients. Using BMELI as a sign of chronic DL injury when ALMC is unclear may reduce the risk of a false negative diagnosis.

Adult Tillaux-Chaput tubercle fracture of the ankle with rupture of the peroneus tertius muscle: a case report.

BACKGROUND: Tillaux-Chaput tubercle fractures occur in adolescents, which are often associated with the separation of the distal tibial growth plate. These types of fractures are rare in adults and even rarer when accompanied by a rupture of the peroneus tertius muscle. Given the limited number of reported cases, there is limited clinical awareness, resulting in missed diagnoses and delayed treatment, ultimately affecting ankle function. CASE PRESENTATION: We report a case of an adult patient who experienced a right ankle injury resulting in swelling and pain after a traffic accident. Initial examination failed to identify the rupture of the peroneus tertius muscle, but the patient was observed to have restricted dorsiflexion and eversion of the foot. Surgical exploration through an anterolateral incision confirmed the rupture and the muscle was then repaired. The patient received four weeks of cast immobilization and then engaged in progressive rehabilitation exercises. DISCUSSION AND CONCLUSION: This report shares the diagnostic and therapeutic experiences of an adult with a Tillaux-Chaput tubercle fracture associated with peroneus tertius muscle rupture to improve clinical recognition of such injuries, thus preventing misdiagnosis and treatment delays.

The distal tibiofibular joint effusion may be a reliable index for diagnosing the distal tibiofibular syndesmosis instability in ankle.

PURPOSE: To analyze the accuracy of MRI in diagnosis of distal tibiofibular syndesmosis instability (DTSI) and construct new diagnostic parameters. MATERIALS AND METHODS: This retrospective study evaluated 212 patients with history of ankle sprains and 3 T MRI and received a final diagnosis of distal tibiofibular syndesmosis instability by ankle arthroscopic surgery from October 2017 and December 2021. We compared the accuracy of syndesmotic injury, qualitative index of distal tibiofibular joint effusion (DTJE), and quantitative index of distal tibiofibular joint effusion (DTJE) in diagnosing distal tibiofibular syndesmosis instability. The criteria for syndesmotic injury were consistent with previous literature, and DTJE was grouped according to the pre-experimental results. RESULTS: A total of 212 patients (mean age, 35.64 ± 11.79, 74 female and 138 male) were included. Independent predictive MRI features included syndesmotic injury, qualitative index of distal tibiofibular joint effusion, and quantitative index of DTJE including the height, projected area of equal-point method, and projected area of incremental-value method. The quantitative index of DTJE showed a higher area under the receiver operating characteristic curve (0.805/0.803/0.804/0.811/0.817/0.805 > 0.8, P < 0.05; in comparison with all other method). The height measurement method was simpler and easier to operate, that could be gotten only by measuring the DTJE distance of a MRI independent layer, and the cut-off value of the effusion height was 8.00 mm and the Youden index (0.56) was the best. CONCLUSIONS: Our research translated a complicated string of MRI multi-dimensional spatial measurements into a simple measuring process, and established the significance of quantifying DTJE in the diagnosis of DTSI. We found that the 8-mm height of DTJE was a more specific indicator for DTSI and could serve as a novel MRI diagnostic cutoff in clinical practice.

Impact of chronic ankle instability on gait loading strategy in individuals with chronic ankle instability: a comparative study.

BACKGROUND: Lateral ankle sprains rank among the most prevalent musculoskeletal injuries, while chronic ankle instability (CAI) is its most common cascade. In addition to the conflicting results of the previous studies and their methodological flaws, the specific gait loading strategy is still not well studied. PURPOSE: The study aimed to investigate the fluctuations in gait loading strategy in people with chronic ankle instability compared to health control. METHODS: A total of 56 male subjects participated in this study and were allocated into two groups: (A) CAI group: 28 subjects with unilateral CAI (age 24.79 ± 2.64 and BMI 26.25 ± 3.50); and (B) control group: 28 subjects without a history of ankle sprains (age 24.57 ± 1.17 and BMI 26.46 ± 2.597). Stance time, weight acceptance time, and load distribution were measured to investigate gait loading strategy. RESULTS: The study findings revealed that the CAI group had a significant higher load over the lateral rearfoot. However, MANOVA indicates that there was no overall significant difference in gait loading strategy between the CAI and control groups. Furthermore, in terms of stance time, time of weight acceptance phase, load over medial foot, and load over lateral foot, CAI and healthy controls seemed to walk similarly. CONCLUSIONS: The findings revealed that individuals with CAI had the significant alteration in the lateral rearfoot loading, suggesting a potential compensatory mechanism to address instability during the weight acceptance phase. This could manifest a laterally deviated center of pressure and increased frontal plane inversion during the early stance phase. However, it is acknowledged that these alterations could be both the result and the origin of CAI. The study highlights the vulnerability of CAI during the early stance phase, emphasizing the need for gait reeducation as individuals return to walking as healthcare clinicians should focus on treatment modalities aimed at reducing rearfoot inversion in individuals with CAI.

A hypertrophic distal fascicle of the anterior tibiofibular ligament is associated with a high rate of osteochondral lesions of the talus.

PURPOSE: The purpose of this retrospective review was to determine the prevalence of osteochondral lesions (OCLs) of the lateral talar dome in patients with anterior ankle impingement with an associated hypertrophic distal fascicle of the anterior tibio-fibular ligament. METHODS: Retrospective chart review identified 40 patients who underwent anterior ankle arthroscopy for the management of anterior ankle impingement. Clinical outcomes assessed included pre- and postoperative foot and ankle outcome score (FAOS), visual analogue scale (VAS), complications, failures, secondary surgical procedures, return-to-work data and return-to-sport data. RESULTS: Thirty-two patients with a mean follow-up time of 29.3 ± 10.4 months were included. The hypertrophic distal fascicle of the anterior tibio-fibular ligament was hypertrophic in 29 patients (90.6%), with a mean thickness of 2.5 ± 0.4 mm on MRI. There were 22 OCLs of the lateral talar dome (75.9%) with an associated hypertrophic distal fascicle of the anterior tibio-fibular ligament visualized during arthroscopy. The international cartilage repair society gradings of the lesions included 3 (13.6%) grade I lesions, 15 (68.1%) grade II lesions, 3 (13.6%) grade III lesions, and 1 (4.6%) grade IV lesion. There was a statistically significant improvement in mean FAOS and VAS scores from preoperative to postoperative (p < 0.001). No cases of syndesmotic instability were observed following resection of hypertrophic distal fascicle of the anterior tibio-fibular ligament. CONCLUSION: This retrospective case series demonstrated that a hypertrophic distal fascicle of the anterior tibio-fibular ligament was associated with an OCL of the lateral talar dome identified during arthroscopic evaluation. In addition, preoperative MRI demonstrated poor sensitivity for the detection of these OCLs. Heightened awareness is warranted for potential lateral talar dome OCLs in patients presenting with anterolateral ankle impingement with a hypertrophic ATiFLdf identified on preoperative MRI in the absence of an associated OCLs. LEVEL OF EVIDENCE: Level IV, Retrospective case series.

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.

Potential Roles of Inflammation on Post-Traumatic Osteoarthritis of the Ankle.

Post-traumatic osteoarthritis of the ankle (PTOA) is frequently observed following a debilitating consequence of intra-articular ankle fractures. Numerous risk factors contribute to the pathogenesis of PTOA, including articular incongruity, joint malalignment, and concomitant soft tissue damage. Despite attempts to restore joint anatomy and manage soft tissues to avoid long-term complications after intra-articular ankle fractures, the incidence of PTOA remains markedly elevated. Inflammatory processes triggered by intra-articular ankle fractures have emerged as potential instigators that expedite the progression of PTOA. Injury to the articular cartilage and subchondral bone may lead to the release of inflammatory mediators, which can contribute to cartilage degradation and bone resorption. This study provides a narrative review on the current knowledge concerning the association between inflammation and the development of PTOA following intra-articular ankle fractures. We also discuss novel therapeutic agents that target inflammatory pathways to impede the progression of post-traumatic osteoarthritis after intra-articular ankle fractures. These medication and interventions were summarized within this review article.

Relationship between pain and intra-articular pathology in patients with chronic lateral ankle instability.

PURPOSE: Repeated ankle sprains can lead to chronic lateral ankle instability (CLAI). It is unclear whether CLAI causes pain unless complicated by intra-articular lesions. This study aimed to analyze the characteristics of pain and the relationship between pain and intra-articular pathology in patients with CLAI. MATERIALS AND METHODS: Fifty-three ankles in 46 patients with CLAI who had undergone surgery were retrospectively reviewed. The self-administered foot evaluation questionnaire (SAFE-Q) was given to patients the day before surgery. Intra-articular lesions were assessed using arthroscopy and magnetic resonance imaging (MRI). In addition, the Hounsfield Unit (HU) on computed tomography (CT) of the medial gutter was measured. The relationship between pain and intra-articular findings was also analyzed. RESULTS: The pain and pain-related scores in the SAFE-Q were significantly correlated with synovitis in 96.3% (rs = - 0.532). HU ratios in the tibia and talus were also significantly correlated with pain (rs = - 0.603, - 0.534, respectively). The arthroscopic synovitis score and HU ratios in patients with high pain scores were significantly higher than those in patients with low pain scores. Forty ankles (75.5%) had synovitis and articular cartilage injuries were observed in 22 ankles (41.5%). Patients with fluid collection or bone marrow lesions (BML) scored significantly lower in pain than those without, but there was no significant difference between patients with and without cartilage injury. Multiple regression analysis revealed that a high synovitis score and HU ratio of the talus were significantly associated with high pain. CONCLUSIONS: Intra-articular lesions such as synovitis and BML were associated with pain in patients with CLAI. Osteosclerotic changes in the medial gutter also induced ankle pain, indicating that osteoarthritic changes had already begun. Therefore, lateral ankle ligament injuries after ankle sprain should be appropriately treated to avoid secondary degenerative changes.

Postoperative Stability in Displaced Ankle Fractures With Concomitant Ligamentous Injuries.

Ankle instability, which can be attributed to either the deltoid or lateral ligamentous complex, may be both a cause and a consequence of ankle fractures. This study aimed to assess postoperative ankle instability in patients with displaced ankle fractures. A total of 54 patients with displaced ankle fractures were included. Malleolar fractures were surgically reduced and fixated, and if necessary, the syndesmosis was stabilized. Concomitant deltoid injuries were left unrepaired. Ankle stress radiographs were taken approximately 25.4 months after surgery, with a standard deviation of 20.5 months. Radiographic measurements included the tibiotalar tilt angle (TT) on varus stress view, anterior translation of the talus (AT) on the anterior drawer view, and the medial clear space (MC) and tibiotalar tilt angle on the valgus stress view. These measurements were compared between the injured and the noninjured contralateral ankle for all patients as well as in a subgroup of 19 patients with concomitant deltoid and syndesmosis injuries. There were no significant differences in Varus TT (p = .675, p = .394), AT (p = .516, p = .967), Valgus MC (p = .190, p = 0.498), and Valgus TT (p = .173, p = .442) between the injured and noninjured ankles in the whole group of patients as well as in the subgroup of patients with concomitant deltoid and syndesmosis injuries. Patients with displaced ankle fractures exhibited radiographically stable ankles postoperatively. Syndesmosis fixation without deltoid ligament repair is a viable treatment option for achieving ankle stability postoperatively in fractures with both ligament injuries.

Validity and Reliability of Hindi version of Foot and Ankle Disability Index in patients with chronic recurrent lateral ankle sprain.

BACKGROUND: Lateral Ankle Sprain (LAS) is a recurrent musculoskeletal injury commonly noticed in primary care, podiatry, orthopaedics, and physical therapy centers. The Foot and Ankle Disability Index (FADI) is a self-reported and region-specific tool with no previous literature available on the translation of the FADI scale into Hindi language. AIM: The study aims to translate and evaluate each translated domain of FADI to see its cross-cultural adaptation, content validity and reliability for patients with chronic recurrent LAS. STUDY DESIGN: A Cross-Sectional Study. METHODS: The scale was translated from the reference language to the target language, Hindi, using the instructions provided in the literature. Delphi survey was conducted for content validation followed by recruitment of 51 participants with a history of long lasting repetitive lateral sprain of ankle to evaluate test-retest reliability of Hindi version of FADI. RESULT: The S-CVI/Ave and S-CVI/UA came out to be 0.988 and 0.884, respectively and I-CVI for all items of Hindi version of FADI were more than 0.90. The ICC (Intra-class Correlation Coefficient) and internal consistency was evaluated, which came out to 0.961 and 0.980, respectively for Hindi version of FADI. CONCLUSION: Hindi version of FADI is a valid and reliable scale that has been translated and adapted to be implemented among Indian population suffering from long lasting repetitive LAS.

Effect of simultaneous bilateral surgery or simultaneous arthroscopic ankle lateral ligament repair in hindfoot endoscopic surgery for posterior ankle impingement syndrome in athletes.

BACKGROUND: Posterior ankle impingement syndrome (PAIS) is sometimes complicated by bilateral cases and lateral ankle ligament injuries. Reports on bilateral surgery for PAIS and simultaneous surgery for lateral ankle ligament injury are scarce in the literature. METHODS: We present a 2-year follow-up of 76 athletic patients who underwent endoscopic hindfoot surgery for PAIS. Patients were divided into those who underwent unilateral or simultaneous bilateral surgery and PAIS surgery alone or simultaneous bilateral PAIS surgery without arthroscopic ankle lateral ligament repair. RESULTS: All patients returned to full athletic activities postoperatively. There was no difference in all subscales of the SAFE-Q score between groups except for mean days after surgery for full return to athletic activities. CONCLUSION: Simultaneous bilateral surgery and simultaneous arthroscopic lateral ankle ligament repair had no negative effect on subjective clinical evaluation 2 years after surgery in hindfoot endoscopic surgery for PAIS. LEVEL OF EVIDENCE: III, retrospective case-control study.

Modified classifications and surgical decision-making process for chronic anterior talofibular ligament injuries based on the correlation of imaging studies and arthroscopic findings.

PURPOSE: Surgical treatment of chronic ankle instability (CAI) typically includes ligament repair or reconstruction. Using preoperative ultrasonography or magnetic resonance imaging (MRI) to choose an appropriate arthroscopic procedure is still difficult. The aim of this study was to evaluate the correlation of imaging studies with arthroscopic findings and support the arthroscopic surgical decision-making process. METHODS: One hundred twelve patients with chronic anterior talofibular ligament (ATFL) injuries were treated using the arthroscopic surgical decision-making process from November 2018 to August 2020. Preoperative imaging assessments using dynamic ultrasonography, MRI, and combined methods were applied to categorize the ATFL remnants into three quality grades ("good," "fair," and "poor"). Arthroscopic findings were classified into 6 major types (7 subtypes) and used to select an appropriate surgical procedure. Correlations between imaging studies, arthroscopic findings, and surgical methods were evaluated. Diagnostic parameters, clinical outcomes, and complications were also assessed. RESULTS: There was a significant interobserver agreement in the evaluation of dynamic ultrasonography (0.954, P < 0.001), MRI (0.958, P < 0.001), and arthroscopy diagnosis (0.978, P < 0.001). There was a significant correlation between the modified imaging classifications, arthroscopic diagnostic types, and surgical procedures. The mean follow-up period was 33.58 ± 8.85 months. Significant improvements were documented in postoperative ankle functions when assessed with Karlson-Peterson scores and Cumberland Ankle Instability Tool scores. The risk of complications is also very low. CONCLUSION: The modified classifications and surgical decision-making process based on dynamic ultrasonography, MRI, and arthroscopic findings, as proposed in this study, might help in selecting an appropriate arthroscopic surgical procedure for chronic ATFL injuries.

Anatomical Augmentation Using Suture Tape for Acute Syndesmotic Injury in Maisonneuve Fracture: A Case Report.

Ankle syndesmosis is crucial to the integrity of the ankle joint and weight-bearing; an injury to this structure can lead to significant disability. The treatment methods for distal syndesmosis injuries are controversial. The representative treatment methods include transsyndesmotic screw fixation and suture-button fixation, and good results with suture tape augmentation have recently been reported. However, an augmentation using suture tape is only possible when the posterior inferior tibiofibular ligament (PITFL) is intact. This study describes the case of an unstable syndesmosis injury, accompanied by anterior inferior tibiofibular ligament (AITFL) and PITFL injuries, which were treated successfully using suture tape. A 39-year-old male patient sustained right ankle damage while skateboarding. His leg and ankle radiographs revealed a widening of the medial clear space, a posterior malleolus fracture, a reduced "syndesmosis overlap" compared with the contralateral side, and a proximal fibula fracture. The magnetic resonance imaging revealed ruptured deltoid ligaments, accompanied by AITFL, PITFL, and interosseous ligament injuries. A diagnosis of a Maisonneuve fracture with an unstable syndesmotic injury was made. The patient underwent an open syndesmotic joint reduction, along with an AITFL and PITFL augmentation. This anatomical reduction was confirmed using intraoperative arthroscopy and postoperative computed tomography (CT). An axial CT that was performed at the 6-month follow-up exam revealed a similar alignment of the syndesmosis between the injured and uninjured sides. There were no surgical complications and the patient did not complain of discomfort in his daily life. At the 12-month follow-up exam, a good clinical outcome was confirmed. As a treatment for unstable syndesmosis injury, ligament augmentation using suture tape shows satisfactory clinical outcomes and can be considered as a useful and reliable method for anatomical restoration and rapid rehabilitation.

Association between joint effusions and concomitant structural injuries (tendinitis and structural injury) on MRI in ankle trauma without fracture.

BACKGROUND: The evaluation of correlations among joint effusion, ligament injuries, tenosynovitis and osteochondral lesion of talus (OLT) in the ankle joint is important for developing a treatment plan and predicting prognosis. PURPOSE: To evaluate correlations among tibiotalar (anterior) and talocalcaneal (posterior) joint effusion, tenosynovitis of major flexor tendons, ligaments, and OLT in a group of patients with ankle trauma. MATERIAL AND METHODS: This retrospective study included 101 patients with ankle trauma who underwent magnetic resonance imaging. Two radiologists assessed the presence and amount of effusion in the tibiotalar and talocalcaneal joints from grade 0 to 2, according to the amount of capsular distension. Concomitant structural injuries were assessed in the tibialis posterior (TP), flexor digitorum longus, flexor hallucis longus, and peroneus tendons, and the anterior talofibular ligament, calcaneofibular ligament, anteroinferior tibiofibular ligament, posteroinferior tibiofibular ligament, and OLT. RESULTS: The proportion of anterior and posterior joint effusion according to grade was 67.3% for anterior joint effusion grade 0, 22.8% for grade 1, and 9.9% for grade 2; for posterior joint effusion, grade 0 was 74.2%, grade 1 was 22.8%, and grade 2 was 3.0%. We found statistically significant correlations between posterior joint effusion and tenosynovitis of TP (P < 0.05) and between posterior joint effusion and OLT (P < 0.05). CONCLUSION: Posterior joint effusion is correlated with TP injury and OLT; however, tendon injuries have no correlation with other structural injuries of the ankle joint in a general population with ankle trauma.

Does the contralateral healthy ankle of patient with ipsilateral mechanical lateral ankle laxity show greater lateral ankle laxity? Evaluation of the anterior talofibular ligament by stress ultrasonography.

BACKGROUND: A number of studies have evaluated risk factors for lateral ankle sprain (LAS) or chronic lateral ankle instability (CLAI). However, the definitive risk factors for LAS or CLAI remain controversial. The purpose of this study was to evaluate whether the contralateral healthy ankles of subjects with ipsilateral mechanical lateral ankle laxity (group I) show greater lateral ankle laxity in comparison to the healthy ankles of bilateral healthy controls (group B). METHODS: From March 2020, anterior talofibular ligament (ATFL) lengths of young adult volunteers were cross-sectionally measured in non-stress and stress positions using a previously reported stress ultrasonography (US) procedure. The ATFL ratio (the ratio of stress ATFL/non-stress ATFL length) was calculated as an indicator of lateral ankle laxity. The manual anterior drawer test (ADT) was also performed. The US findings of healthy ankles from groups I and B were compared. RESULTS: A total of 154 subjects in group B (mean age, 24.5 ± 2.8 years; male/female, 84/70) and 40 subjects in group I (mean age, 24.4 ± 2.3 years; male/female, 26/14) were included in the study. There was no significant difference in the ADT between the groups. There were no significant differences in the non-stress ATFL length (19.4 ± 1.8 vs. 19.3 ± 1.9, p = 0.84), stress ATFL length (20.8 ± 1.8 vs. 20.9 ± 1.9, p = 0.66), length change (1.5 ± 0.6 vs. 1.6 ± 0.6, p = 0.12) and ATFL ratio (1.08 ± 0.03 vs. 1.08 ± 0.03, p = 0.13) between the groups. CONCLUSION: No significant difference was detected between the contralateral healthy ankles of subjects with ipsilateral mechanical lateral ankle laxity and those of bilateral healthy controls.

Traumatic rupture of the midportion of the interosseous membrane: a rare cause of acute lower leg pain in two soccer players kicked in the anterior shin.

The interosseous membrane (IOM) of the leg is a component of the tibiofibular syndesmosis that serves an important role in stabilization, as well as transferring forces to the fibula during weight-bearing. We present two separate cases of acute traumatic rupture of the midportion of the interosseous membrane in high school soccer players with blunt trauma to the anterior shin with MRI and ultrasound confirmation.

Bone marrow edema of the medioplantar talar head is associated with severe ligamentous injury in ankle sprain.

PURPOSE: To investigate the predictive value of talar head edema (THE) in acute ankle sprain for the presence of concomitant ligament injuries. METHODS: This retrospective study was approved by the ethics committee and informed consent was obtained. One hundred patients (mean age: 37 years ± 14 [standard deviation], range 13-77 years) with MRI of the ankle after acute trauma were included. The cohort in this matched-pair study consisted of 50 patients with THE (group 1) and 50 patients without THE (group 2). Two readers independently evaluated presence and size of bone marrow edema of the talus head and injuries of the lateral, medial, talonavicular, and spring ligament complex. Statistics included intraclass correlation coefficient (ICC) and Kappa statistics as well as parametric and non-parametric tests. RESULTS: On average, patients with THE demonstrated significantly more ligament injuries in comparison to patients without THE (3.7 vs. 1.3, p ≤ 0.01). Also, in patients with THE, the number of injured ligaments was significantly higher at the lateral (p = 0.03), medial (p ≤ 0.01), and talonavicular (p ≤ 0.01) compartment in comparison to patients without THE. The most frequently injured ligaments in patients with THE were the anterior talofibular ligament (60%) and the anterior tibiotalar ligament (42%). There was no significant correlation between edema size and the number of injured ligaments or compartments (p = 0.5). CONCLUSION: THE is associated with more extensive ligamentous ankle injury, in particular to the medial and lateral collateral ligament complex, and therefore indicative of severe ankle trauma.

Development of a nomogram to predict surgical site infection after closed comminuted calcaneal fracture.

BACKGROUND: Compared with open comminuted calcaneal fractures, less emphasis is placed on postoperative surgical site infection (SSI) of closed comminuted calcaneal fractures. This study aimed to identify the risk factors associated with SSI and build a nomogram model to visualize the risk factors for postoperative SSI. METHODS: We retrospectively collected patients with closed comminuted calcaneal fractures from the Second Affiliated Hospital of Wenzhou Medical University database from 2017 to 2020. Risk factors were identified by logistics regression analysis, and the predictive value of risk factors was evaluated by ROC (receiver operating characteristic curve). Besides, the final risk factors were incorporated into R4.1.2 software to establish a visual nomogram prediction model. RESULTS: The high-fall injury, operative time, prealbumin, aspartate aminotransferase (AST), and cystatin-C were independent predictors of SSI in calcaneal fracture patients, with OR values of 5.565 (95%CI 2.220-13.951), 1.044 (95%CI 1.023-1.064), 0.988 (95%CI 0.980-0.995), 1.035 (95%CI 1.004-1.067) and 0.010 (95%CI 0.001-0.185) (Ps < 0.05). Furthermore, ROC curve analysis showed that the AUC values of high-fall injury, operation time, prealbumin, AST, cystatin-C, and their composite indicator for predicting SSI were 0.680 (95%CI 0.593-0.766), 0.756 (95%CI 0.672-939), 0.331 (95%CI 0.243-0.419), 0.605 (95%CI 0.512-0.698), 0.319 (95%CI 0.226-0.413) and 0.860 (95%CI 0.794-0.926), respectively (Ps < 0.05). Moreover, the accuracy of the nomogram to predict SSI risk was 0.860. CONCLUSIONS: Our study findings suggest that clinicians should pay more attention to the preoperative prealbumin, AST, cystatin C, high-fall injury, and operative time for patients with closed comminuting calcaneal fractures to avoid the occurrence of postoperative SSI. Furthermore, our established nomogram to assess the risk of SSI in calcaneal fracture patients yielded good accuracy and can assist clinicians in taking appropriate measures to prevent SSI.

Fracture of the lateral process of the talus with associated deltoid ligament injury: a report of 2 cases.

BACKGROUND: Fractures of the lateral process of the talus (LTPF) are rare and only rarely are associated ligamentous injuries. The injury mechanism is commonly considered to be similar with ankle sprains, where excessive varus of the hindfoot leads to avulsion fractures of the lateral process of the talus. However, previous cadaveric studies have suggested that LTPF was more likely to be caused by eversion or external rotation force with dorsiflexion of the ankle. But no clinical evidence has been provided. CASE PRESENTATION: Two patients presented to the emergency department with ankle pain after ankle eversion or external rotation. Physical examination revealed tenderness and swelling on both medial and lateral sides of the ankles. Plain radiographs and computed tomography revealed LTPF and medial soft tissue swelling, and magnetic resonance imaging confirmed a discontinuity of the deltoid ligament in Case 1. Surgical exploration revealed rupture of the superficial layer of the deltoid ligaments with intact deep layer in both patients. Treatment included fixation of the lateral process of the talus with headless compression screws and repair of deltoid ligaments. Both patients achieved excellent clinical outcomes 1 year post injury. CONCLUSION: There are many possibilities of the injury mechanism of LTPF. These two cases provided clinical evidence that eversion or external rotation force, in addition to inversion, was also an important mechanism of LTPF.

[Diagnostics and Therapy of Ankle Instability]. / Sprunggelenksinstabilität.

Diagnostics and Therapy of Ankle Instability Abstract. Ankle sprains are among the most common musculoskeletal injuries and therefore often treated in the emergency department or in the general practitioner's office. In the majority of cases, the lateral ligamentous complex is affected. If treated correctly, ligamentous ankle injuries have a good prognosis and in about 80% of cases full recovery can be achieved. Risk factors for the development of chronic ankle instability are an inappropriate treatment of the ankle sprain, injury of the deltoid ligament, hyperlaxity and rearfoot deformities (e.g., cavovarus foot). Diagnostics after an ankle sprain include a medical history, focused physical examination, and appropriate imaging. Concomitant injuries such as fractures, osteochondral defects or tendon injuries should be excluded. Ankle sprains are usually treated conservatively, involving bracing or immobilization - depending on the severity of ligament damage - followed by functional rehabilitation. Patients with chronic ankle instability refractory to conservative treatment, should be considered for surgical interventions.