Intraoperative tap test for coronal syndesmotic instability: A cadaveric study |
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| Affiliation: | 1. Hospital for Special Surgery, Department of Foot and Ankle Orthopedics, 535 East 70thStreet, New York, NY, 10021, United States;2. University of Alabama at Birmingham (UAB), Department of Orthopedics, Birmingham, AL, United States;3. University of Sao Paulo (USP), Department of Orthopedics, Sao Paulo, SP, Brazil;1. Department of Orthopaedic Surgery, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Republic of Korea;2. Department of Orthopaedic Surgery, Pusan National University Hospital, Busan, Republic of Korea;1. Department of Occupational Therapy and Physiotherapy, Aalborg University Hospital, Aalborg, Denmark;2. Department of Orthopaedic Surgery, Aalborg University Hospital, Aalborg, Denmark;1. Southmead Hospital, Bristol, UK;2. University Hospital Coventry and Warwickshire, Coventry, UK;3. Oxford University Hospitals, Oxford, UK;4. Sheffield Northern General Hospital, Sheffield, UK;5. University of the West of England, Bristol, UK;1. Department of Trauma, Hand and Reconstructive Surgery, Johann Wolfgang Goethe-University, Frankfurt/Main, Germany;2. Institute for Cardiovascular Physiology, Goethe-University, Germany;1. Department of Orthopedics, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China;2. Department of General Surgery, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, Nanjing Medical University Affiliated Cancer Hospital, Nanjing, China;3. School of Pharmacy, Curtin University, Bentley, Australia |
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| Abstract: | IntroductionPrecise diagnosis of distal tibiofibular syndesmotic injury is challenging, and a gold standard diagnostic test has still not been established. Tibiofibular clear space identified on radiographic imaging is considered the most reliable indicator of the injury. The Cotton test is the most widely used intraoperative technique to evaluate the syndesmotic integrity although it has its limitations. We advocate for a novel intra operative test using a 3.5 mm blunt cortical tap.MethodsTibiofibular clear space was assessed in nine cadaveric specimens using three sequential fluoroscopic images. The first image was taken prior to the application of the tap test (intact, non-stressed). Then, a 2.5 mm hole was drilled distally on the lateral fibula, and a 3.5 mm cortical tap was then threaded in the hole. The tap test involved gradually advancing the blunt tip against the lateral tibia, providing a tibiofibular separation force (intact, stressed). This same stress was then applied after all syndesmotic ligaments were released (injured, stressed). Measurements were compared by one-way ANOVA and paired Student’s t-test. Intra and inter-observer agreements were evaluated by intraclass correlation coefficient (ICC). P-values <.05 were considered significant.ResultsWe found excellent intra-observer (0.97) and inter-observer (0.98) agreement following the imaging assessment. Significant differences were found in the paired comparison between the groups (p < .05). When using an absolute value for TFCS >6 mm as diagnostic for coronal syndesmotic instability, the tap test demonstrated a 96.3% sensitivity and specificity, a 96.3% PPV and NPV and a 96.3% accuracy in diagnosing coronal syndesmotic instability.ConclusionsOur cadaveric study demonstrated that this novel coronal syndesmotic instability test using a 3.5 mm blunt cortical tap is a simple, accurate and reliable technique able to demonstrate significant differences in the tibiofibular clear space when injury was present. It could represent a more controlled and stable alternative to the most used Cotton test. |
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| Keywords: | Ankle fracture Syndesmotic injury Syndesmotic instability Cotton test Malleolar fracture |
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