Acute clinical evaluation for the diagnosis of lateral ankle ligament injuries is useful: A comparison between the acute and delayed settings.

PURPOSE: To determine the diagnostic value of seven injury history variables, nine clinical tests (including the combination thereof) and overall clinical suspicion for complete discontinuity of the lateral ankle ligaments in the acute (0-2 days post-injury) and delayed setting (5-8 days post-injury). METHODS: All acute ankle injuries in adult athletes (≥18 years) presenting up to 2 days post-injury were assessed for eligibility. Athletes were excluded if imaging studies demonstrated a frank fracture or 3 T MRI could not be acquired within 10 days post-injury. Using standardized history variables and clinical tests, acute clinical evaluation was performed within 2 days post-injury. Delayed clinical evaluation was performed 5-8 days post-injury. Overall, clinical suspicion was recorded after clinical evaluation. MRI was used as the reference standard. RESULTS: Between February 2018 and February 2020, a total of 117 acute ankle injuries were screened for eligibility, of which 43 were included in this study. Complete discontinuity of lateral ankle ligaments was observed in 23 (53%) acute ankle injuries. In the acute setting, lateral swelling had 100% (95% confidence interval [CI]: 82-100) sensitivity, haematoma had 85% (95% CI: 61-96) specificity and the anterior drawer test had 100% (95% CI: 77-100) specificity. In the delayed setting, sensitivity for the presence of haematoma improved from 43% (95% CI: 24-65) to 91% (95% CI: 70-98; p < 0.01) and the sensitivity of the anterior drawer test improved from 21% (95% CI: 7-46) to 61% (95% CI: 39-80; p = 0.02). Clinical suspicion had a positive likelihood ratio (LR) of 4.35 (95% CI: 0.55-34.17) in the acute setting and a positive LR of 6.09 (95% CI: 1.57-23.60) in the delayed setting. CONCLUSIONS: In the acute setting, clinical evaluation can exclude complete discontinuity (e.g., absent lateral swelling) and identify athletes with a high probability of complete discontinuity (e.g., positive anterior drawer test) of the lateral ankle ligaments. In the delayed setting, the sensitivity of common clinical findings increases resulting in an improved diagnostic accuracy. In clinical practice, this study underlines the importance of meticulous clinical evaluation in the acute setting. LEVEL OF EVIDENCE: Level III.

Acute clinical evaluation for syndesmosis injury has high diagnostic value.

PURPOSE: To determine the diagnostic value of injury history, physical examination, six syndesmosis tests and overall clinical suspicion for syndesmosis injury. METHODS: All athletes (> 18 yrs) with an acute ankle injury presenting within 7 days post-injury were assessed for eligibility. Acute ankle injuries were excluded if imaging studies demonstrated a frank fracture or 3 T MRI could not be acquired within 10 days post-injury. Standardized injury history was recorded, and physical examination was performed by an Orthopaedic Surgeon or Sports Medicine Physician. Overall clinical suspicion was documented prior to MRI. Multivariate logistic regression was used to determine the association between independent predictors and syndesmosis injury. RESULTS: Between September 2016 and July 2019, a total of 150 acute ankle injuries were included. The median time from injury to acute clinical evaluation was 2 days (IQR 2). Prior to clinical evaluation, the median patient reported Visual Analog Scale for pain was 8/10 (IQR 2). Syndesmosis injury was present in 26 acute ankle injuries. An eversion mechanism of injury had a positive LR 3.47 (CI 95% 1.55-7.77). The squeeze tests had a positive LR of 2.20 (CI 95% 1.29-3.77) and a negative LR of 0.68 (CI 95% 0.48-0.98). Overall clinical suspicion had a sensitivity of 73% (CI 95% 52-88) and negative predictive value of 89% (CI 95% 78-95). Multivariate regression analyses demonstrated significant association for eversion mechanism of injury (OR 4.99; CI 95% 1.56-16.01) and a positive squeeze test (OR 3.25; CI 95% 1.24-8.51). CONCLUSIONS: In an acute clinical setting with patients reporting high levels of ankle pain, a negative overall clinical suspicion reduces the probability of syndesmosis injury. Eversion mechanism of injury and a positive squeeze test are associated with higher odds of syndesmosis injury. LEVEL OF EVIDENCE: Level III.

Limited intrarater and interrater reliability of acute ligamentous ankle injuries on 3 T MRI.

OBJECTIVES: To determine the diagnostic reliability of the Schneck grading system for acute ligamentous injuries of (1) the three major ligamentous ankle complexes, (2) the individual ankle ligaments and (3) the Sikka classification for syndesmosis injury. METHODS: All acute ankle injuries in adult athletes (≥18 years), presenting to the outpatient department of a specialised Orthopaedic and Sports Medicine Hospital, within 7 days postinjury were screened for inclusion. Ankle injuries were excluded if imaging demonstrated a frank ankle fracture or if the 3 T MRI study could not be acquired within 10 days postinjury. Two radiologists graded the three major ligamentous complexes (lateral ankle complex, deltoid complex and syndesmosis complex) and their comprising individual ligaments according the four-grade Schneck grading system. Syndesmotic injuries were classified according the four-grade Sikka classification for consequent injury of the individual syndesmosis ligaments and the deltoid complex. Agreement and kappa (K) statistics were calculated to determine intrarater and interrater reliability. RESULTS: Between September 2016 and September 2018, a total of 92 MR scans were obtained (87 patients). Interrater and intrarater reliability of the Schneck grading system was moderate to substantial for the lateral ankle complex (K=0.47-0.76), fair to almost perfect for the syndesmosis complex (K=0.37-0.89) and fair to moderate for the deltoid complex (K=0.14-0.51). For the individual ligaments, kappa values ranged from moderate to substantial for the anterior talofibular ligament (ATFL) (K=0.55-0.73), fair to substantial for the calcaneofibular ligament (K=0.31-0.62) and fair to almost perfect for the anteroinferior tibiofibular ligament (AITFL) (K=0.36-0.89). Diagnostic reliability of the Sikka classification ranged from moderate to almost perfect (K=0.51-0.95). CONCLUSIONS: Grading of the three major ligamentous complexes and of the individual ankle ligaments according the Schneck grading system resulted in limited diagnostic reliability. When dichotomised for the presence of complete discontinuity, the interrater reliability of the Schneck grading system improved to substantial and almost perfect for the ATFL and AITFL, respectively. Classification of syndesmosis injury according the Sikka classification resulted in moderate interrater reliability.

Diagnostic value of ultrasonography in acute lateral and syndesmotic ligamentous ankle injuries.

OBJECTIVES: To determine the diagnostic value of ultrasonography for complete discontinuity of the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL) and the anterior inferior tibiofibular ligament (AITFL). METHODS: All acute ankle injuries in adult athletes (> 18 years old) presenting to the outpatient department of a specialised Orthopaedic and Sports Medicine Hospital within 7 days post-injury were assessed for eligibility. Using ultrasonography, one musculoskeletal radiologist assessed the ATFL, CFL and AITFL for complete discontinuity. Dynamic ultrasound measurements of the tibiofibular distance (mm) in both ankles (injured and contralateral) were acquired in the neutral position (N), during maximal external rotation (Max ER), and maximal internal rotation (Max IR). MR imaging was used as a reference standard. RESULTS: Between October 2017 and July 2019, 92 acute ankle injuries were included. Ultrasound diagnosed complete discontinuity of the ATFL with 87% (CI 74-95%) sensitivity and 69% (CI 53-82%) specificity. Discontinuity of the CFL was diagnosed with 29% (CI 10-56%) sensitivity and 92% (CI 83-97%) specificity. Ultrasound diagnosed discontinuity of the AITFL with 100% (CI 74-100%) sensitivity and 100% (CI 95-100%) specificity. Of the dynamic measurements, the side-to-side difference in external rotation had the highest diagnostic value for complete discontinuity of the AITFL (sensitivity 82%, specificity 86%; cut-off 0.93 mm). CONCLUSIONS: Ultrasound has a good to excellent diagnostic value for complete discontinuity of the ATFL and AITFL. Therefore, ultrasound can be used to screen for injury of the ATFL and AITFL. Compared with ultrasound, dynamic ultrasound has inferior diagnostic value for complete discontinuity of the AITFL. KEY POINTS: • Ultrasound has a good to excellent diagnostic value for complete discontinuity of the anterior talofibular ligament (ATFL) and anterior inferior tibiofibular ligament (AITFL). • Ultrasound can be used to screen for injury of the ATFL and AITFL. • Compared with ultrasound, dynamic ultrasound has inferior diagnostic value for complete discontinuity of the AITFL.

Return to play after surgery for isolated unstable syndesmotic ankle injuries (West Point grade IIB and III) in 110 male professional football players: a retrospective cohort study.

OBJECTIVES: To evaluate time to return to play following surgical stabilisation of isolated unstable syndesmosis injuries in a cohort of professional male football players. METHODS: All professional football players undergoing surgery for isolated unstable syndesmosis injury (West Point grade ≥IIB) at a specialised Orthopaedic and Sports Medicine Hospital were followed up until return to play (minimum ≥6 months). Players with a stable syndesmosis, injuries older than 6 weeks, concomitant medial or lateral malleolar fracture or previous ankle surgery were excluded. During rehabilitation, time required to return to sports-specific rehabilitation, team training and first match play, were recorded. RESULTS: Between January 2012 and December 2017, a total of 110 male professional football players were included. The mean time required to begin on field rehabilitation was 37±12 days, while the mean time to return to team training was 72±28 days. The first official match was played on average 103±28 days postoperatively. Multivariable analysis revealed that the severity of injury, the concomitant presence of talar cartilage injury and the age of the player were significantly associated (p<0.00001) with time to return to on field rehabilitation, team training and match play. CONCLUSION: In this cohort of professional football players, surgical stabilisation of isolated unstable syndesmosis injuries (West Point grade ≥IIB) allowed for relatively quick return to play. High grade injury (West Point grade III), concomitant cartilage injury and greater age were associated with longer return to play times. LEVEL OF EVIDENCE: Longitudinal observational cohort study (level II).

Endoscopic Treatment of Mid-Portion Achilles Tendinopathy: A Retrospective Case Series of Patient Satisfaction and Functional Outcome at a 2- to 8-Year Follow-up.

PURPOSE: To evaluate the results of endoscopic treatment in patients affected by mid-portion Achilles tendinopathy, by release of the paratenon combined with a resection of the plantaris tendon, regarding patient satisfaction, functional outcome, and pain scores. METHODS: This retrospective study evaluated patients endoscopically treated for mid-portion Achilles tendinopathy between 2000 and 2013. Patient satisfaction, functional outcome, pain scores, and health-related quality of life were measured by the use of a numeric rating scale, the Foot and Ankle Outcome Score, the Victorian Institute of Sport assessment for the Achilles tendon, the numeric rating scale for pain during running and during sports, and the EuroQol 5D (EQ-5D-3L) standardized questionnaire. Additional questions were asked on the effectiveness of the treatment and sport participation. RESULTS: The response rate was 76.3% (45 of 59). Thirty-five (78%) patients were treated unilaterally and 10 (22%) patients were treated bilaterally. For the unilaterally treated patients, the median time to follow-up was 67 months (interquartile range [IQR] 48-99 months), and for the bilaterally treated patients, it was 89.5 months (IQR 37.5-161.75 months). The median satisfaction score for treatment results was 9 out of 10 (IQR 7-10) and 9.5 (IQR 7-10), respectively. The median Foot and Ankle Outcome Score subscales were scored 75 to 99 and 75 to 97, the median Victorian Institute of Sport assessment for the Achilles tendon scored 81 (IQR 47-90) and 97 (IQR 87-100), and the median numeric rating scale pain scores during both running and sports were 1 (IQR 0-6.5) for the unilaterally treated patients and 0 (IQR 0-4.5) and 0 (IQR 0-1) for the bilaterally treated patients, respectively. The median EQ-5D were 0.81 (IQR 0.71-1) and 1 (IQR 0.64-1), respectively. One reoperation for recurrence of symptoms was necessary. CONCLUSIONS: This study shows high patient satisfaction and good functional outcomes in patients affected by mid-portion Achilles tendinopathy who were endoscopically treated by means of release of the paratenon in combination with transection of the plantaris tendon. LEVEL OF EVIDENCE: Level IV, retrospective case series (therapeutic).

Prevalence of Os Trigonum on CT Imaging.

BACKGROUND: The os trigonum is known as one of the main causes of posterior ankle impingement. In the literature, a wide variation of occurrence has been reported. METHODS: All foot and/or ankle computed tomography (CT) scans made between January 2012 and December 2013 were reviewed. CT images were assessed, blinded for patient characteristics, for the presence of an os trigonum, size of the os trigonum, and type of os trigonum. In addition, the shape of the lateral tubercle of the posterior talar process was assessed. RESULTS: A total of 628 patients (1256 ankles) were included. In 32.5% of the patients of the cohort, an os trigonum was present. In 14.3% of these patients, it was present bilaterally. In a subgroup of patients without posterior ankle impingement the prevalence was 30.3%. Of the nonaffected ankles, an os trigonum was present in 23.7%. Patients with posterior ankle impingement were more likely to have an os trigonum (adjusted odds ratio [OR], 1.86). Afro-Caribbean/Surinamese/Central African origin was associated with a lower rate of occurrence of os trigonum (adjusted OR 0.43). In the ankles without an os trigonum, an enlarged lateral tubercle of the posterior talar process was found in 34.9% and 36.5% of the ankles. CONCLUSION: This study showed that os trigonum is a common accessory bone. With a prevalence of 30.3% in a population of patients with CT imaging of both ankles and 23.7% of the nonaffected ankles, the os trigonum is more common than previously reported. Patients with posterior ankle impingement complaints had a higher prevalence of an os trigonum. In one-third of the patients without an os trigonum, there was an enlarged lateral tubercle of the posterior talar process. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

What is the hardware removal rate after anteroinferior plating of the clavicle? A retrospective cohort study.

BACKGROUND: Plate position in the operative treatment of displaced midshaft clavicle fractures or nonunions is most often on the superior side. However, superior clavicular plating often results in complaints of plate prominence and local soft tissue irritation, necessitating hardware removal. We have used anteroinferior placement of the plate in the hope of increasing biomechanical stability and fixation and also of lowering complaints of plate prominence and soft tissue irritation. In this report, we set out to study the percentage of hardware removal in our group of patients treated with anteroinferior plating of the clavicle after long-term follow-up. METHODS: In this retrospective review, we evaluated all patients who were surgically treated with anteroinferior plating for midshaft clavicle fracture, delayed union, or nonunion by the senior author between February 2003 and July 2015. Patients required a minimum age of 16 years at time of surgery and a follow-up of >12 months. Patients with malunion, plating on the superior aspect, or double plating were excluded. RESULTS: The medical records of 53 patients (54 fractures) were reviewed after a mean follow-up duration of 6.4 years (range, 1.1-13.1). The mean age at follow-up was 47.8 years (range, 20.4-80.7). All fractures and nonunions healed. In only 3 cases (5.6%), hardware removal was requested by the patient because of plate prominence. CONCLUSIONS: Anteroinferior plating of midshaft clavicle fractures, delayed unions, and nonunions resulted in low hardware removal rates in our cohort.