The Diagnostic Challenge of Ankle Injuries in the Emergency Department

An ankle injury is a very common musculoskeletal problem that can be easily misdiagnosed. About 15% to 20% of these injuries result in fractures, whereas the rest can range from a simple sprain to more complicated injuries, including tears to ligaments and the interosseous membrane. Ankle injuries that are not properly assessed may result in a lifetime of joint instability, pain, and problems with ambulation.     

A comparison of double single suture-button fixation,suture-button fixation,and screw fixation for ankle syndesmosis injury: A retrospective cohort study

Different methods have been used throughout the years for syndesmotic injury but there is no consensus on the ideal treatment. Some methods are expensive and some have more complications. The aim of this study is to compare single suture endobutton with double suture endobutton and screw fixation for syndesmotic injury.Sixty nine patients with syndesmotic injury with fibular fractures whom were treated with a single interosseous suture endobutton system (ZipTight^TM, Zimmer Biomet), a double interosseous suture endobutton system (ZipTight^TM, Zimmer Biomet) and 1 syndesmotic screw (TST, Istanbul, Turkey) were included in this study. Functional and radiological results from patient records between 2015 and 2018 were retrospectively evaluated.Twenty patients were treated with the double interosseous suture endobutton, 23 were treated with the single interosseous suture endobutton, and 26 were treated with traditional AO screw fixation. Three patients from the screw fixation group (11.5%) required revision surgery (P < .05). All the radiologic and clinical outcomes were statistical similar in all 3 groups.Our findings showed that the interosseous suture endobutton system is at least as safe as the screw fixation technique for treatment of syndesmosis joint injuries and can be used as an alternative to the screw method. The interosseous suture endobutton system eliminates the need for a second surgery to remove the hardware, which minimizes the probability of re-diastasis. Since our results showed no statistical difference between single and double interosseous suture endobutton systems, the less costly single endobutton system may be the better alternative.     

2种内固定方式治疗下胫腓联合损伤的临床对照研究

目的比较采用下胫腓联合弹性钩钢板及4.0 mm AO皮质钉内固定治疗下胫腓联合损伤的疗效。方法回顾性分析自2010-09—2012-12采用下胫腓联合弹性钩钢板（弹性钩钢板组,32例）及4.0 mm AO皮质钉（AO皮质钉组,43例）内固定治疗的下胫腓联合损伤75例。比较2组手术时间、术中出血量、住院时间及末次随访时AOFAS评分。结果75例均获得随访6~14个月,平均8.3个月。弹性钩钢板组未出现断钉及下胫腓联合再次分离;AO皮质钉组3例在术后10~12周发现螺钉断裂,1例下胫腓联合再次分离。2组手术时间、术中出血量、住院时间差异无统计学意义（P〉0.05）;末次随访时弹性钩钢板组AOFAS评分优良率高于AO皮质钉组,差异有统计学意义（P〈0.05）。结论对于下胫腓联合损伤,采用下胫腓联合弹性钩钢板内固定疗效明显优于4.0 mm AO皮质钉内固定。     

下胫腓联合损伤韧带重建的生物力学研究

目的比较下胫腓联合损伤采用腓骨长肌腱在不同方向上进行重建的生物力学特性,为临床韧带重建提供科学依据。方法采用新鲜成人尸体踝标本6具,运用生物力学实验方法和压敏片技术,测量不同韧带重建方式的内外踝的应变、位移、胫距间负重面积、接触应力。结果在下胫腓前韧带及骨间韧带之间方向上斜向重建下胫腓在内外踝应变、位移、负重面积、接触压力方面均优于其他重建方式,具有显著性差异（P〈0．05）。结论在下胫腓前韧带及骨间韧带之间方向上斜向重建下胫腓,既有利于增强生物力学性能,又有利于改善踝关节的稳定性,对临床上指导下胫腓联合损伤韧带重建方案有理论指导意义。     

Bassett韧带的解剖学研究及其临床意义

目的　通过对Bassett韧带的精细解剖,明确其解剖特点,探讨其功能及临床意义。 方法　取10例成人完整踝关节标本,观察韧带的起止点,走行,毗邻关系,并对相应解剖参数进行精细测量(包括它们的长度、宽度和厚度)。 结果　8例踝关节标本存在Bassett韧带,起自胫骨远端前侧止于腓骨外踝前侧,形状呈四方形,走行与下胫腓前韧带平行,长17.86~18.56 mm,宽3.22~3.89 mm,厚0.67~1.47 mm。 结论　Bassett韧带是一正常韧带组织结构,通过模拟此韧带损伤机制可探讨其造成踝关节前外侧胫距撞击综合征机制。     

Maisonneuve骨折中下胫腓联合损伤的诊疗进展

Maisonneuve骨折(Maisonneuve fracture,MEF)是外旋力作用于旋前位的足,依次导致内踝骨折或三角韧带损伤、下胫腓联合损伤、胫腓骨骨间膜损伤、高位腓骨骨折伴或不伴有后踝骨折的一类特殊骨折[1]。研究表明,除MEF的下胫腓联合损伤外,其余踝关节骨折下胫腓联合损伤通过保守治疗可以获得与手术治疗相当的结果,不建议手术治疗[2]。     

Diagnostic imaging of ankle syndesmosis injuries: A general review

Literature on the various techniques for imaging injuries to the ankle syndesmosis to determine the most appropriate imaging modality for diagnosing syndesmosis ligament disruption and instability was reviewed using the following data sources: Pubmed, Google scholar, SportsDiscus, E‐journals and PLOSone. Search terms used were: syndesmosis paired with injury, imaging, radiology, X‐ray, stress X‐ray, arthrography, ultrasound, nuclear medicine scan, CT scan, MRI and arthroscopy. Articles were selected by reading abstracts and the full article if indicated. Further articles were derived from the references of the primary articles. Plain x‐rays of the ankle will detect approximately half on AP view to two‐thirds on mortise view of syndesmosis injuries. Syndesmosis injuries frequently occur in association with tibial or fibular fractures. Intra‐operative stress radiography failed to detect approximately half of instabilities confirmed at arthroscopy. The current benchmark imaging techniques to diagnose syndesmosis injury and diastasis are arthroscopy and high‐power (3T) MRI. Ultrasound is a promising, developing, cost‐effective imaging technique which is yet to reach its full diagnostic potential. CT and nuclear medicine scans have limited roles. MRI (3T) scanning in the plane of the syndesmotic ligaments is the investigation of choice to detect ankle syndesmosis injuries. In the presence of associated injuries requiring surgery, arthroscopic viewing with stress examination is the diagnostic benchmark when available.     

Correlation and comparison of syndesmosis dimension on CT and MRI

IntroductionVarious methods using CT scan have been described to diagnose distal tibiofibular syndesmotic injuries. However, CT scan does not take into account the amount of cartilage within the distal tibiofibular joint and could therefore lead to false positive results. We present the first study correlating the findings of the distal tibiofibular syndesmosis on CT and MRI scans.MethodsCT and MRI scan of consecutive patients over a period of 18 months, and of a time lapsed less than 12 months between the two imaging modalities, were reviewed. Measurements of the distal tibiofibular syndesmosis were taken according to a previously published study at the level of the distal tibial physeal scar.ResultsTwenty-six ankles from 25 patients were included in this study for analysis. Significant difference between CT and MRI assessments in the overall distal tibiofibular dimensions and in the posterior distal tibiofibular distance for those ankles with evidence of osteoarthritis was found. Interclass correlation coefficients suggest that such methodology was reproducible and reliable.ConclusionWhen the widening found on a CT scan is minor or the diagnosis is equivocal, a contralateral comparative CT or an ipsilateral MRI scan is recommended to prevent misdiagnosis.Level of evidenceLevel IV.     

Fractures of the foot and ankle

Fractures of the foot and ankle are common in all age groups. Soft tissue swelling, smoking and co-morbidities such as diabetes mellitus and peripheral vascular disease should be considered when forming the management plan.Careful attention to neurovascular status and the soft tissue envelope of the foot and ankle is essential to the management of these injuries especially where crush injuries have occurred. Open fractures should be treated urgently with a combined approach with the plastic surgeons.A good understanding of surgical anatomy is key to managing these fractures. Good intra-articular involvement and ligamentous stability are crucial in predicting long-term prognosis.The core principles of management are: to maintain the soft tissue envelope (minimize disruption); to obtain appropriate alignment; restoration of joint surfaces; and rehabilitation to obtain optimum function.