Combining radiographic and CT measurements to rival MRI for the diagnosis of acute isolated syndesmotic injury.
Acute isolated syndesmotic injuries
Computed tomography
Diagnosis
Injuries
Radiography
Syndesmosis
Journal
Archives of orthopaedic and trauma surgery
ISSN: 1434-3916
Titre abrégé: Arch Orthop Trauma Surg
Pays: Germany
ID NLM: 9011043
Informations de publication
Date de publication:
Nov 2023
Nov 2023
Historique:
received:
16
03
2023
accepted:
04
07
2023
medline:
2
10
2023
pubmed:
21
7
2023
entrez:
21
7
2023
Statut:
ppublish
Résumé
Acute isolated syndesmotic injuries (AISIs) have a high potential to be misdiagnosed or underdiagnosed at initial presentation to the hospital. Although magnetic resonance imaging (MRI) is the gold standard in noninvasive diagnostics, it is not always available immediately and is much more expensive than other imaging modalities. This study identifies improvements in conventional radiography and computed tomography (CT) to diagnose AISI and aims to reduce the number of MRI scans needed to verify the diagnosis. A retrospective case match control study was conducted by searching our trauma database between 2008 and 2022. A study group of patients with AISI (n = 64) and a control group of patients without AISI (n = 76) were formed to generate an equal number of images from both groups (62 radiographs and 22 CT scans). A total of 16 parameters that quantify the distal tibiofibular relation in injured and uninjured ankles were analyzed. For statistical analysis, a two-sided t-test was applied to calculate significant differences (p < 0.05). In a further step, a receiver operating characteristic curve (ROC) was used to determine cut-off values for the most significant parameters. The most significant measurement (p < 0.001) on axial CT scans was the syndesmotic area (SA). The ROC curve revealed an area under the curve (AUC) of 0.94 (95% CI 0.86-1.0) and a cut-off value of 71.68 mm This study suggests that radiographic imaging could represent an equally accurate alternative to MRI. These methods might generate the correct diagnosis faster due to their availability and inexpensiveness. By applying our new cut-off values in a clinical setting, the number of underdiagnosed and untreated unstable syndesmotic injuries could be reduced. III, retrospective comparative study.
Sections du résumé
BACKGROUND
BACKGROUND
Acute isolated syndesmotic injuries (AISIs) have a high potential to be misdiagnosed or underdiagnosed at initial presentation to the hospital. Although magnetic resonance imaging (MRI) is the gold standard in noninvasive diagnostics, it is not always available immediately and is much more expensive than other imaging modalities. This study identifies improvements in conventional radiography and computed tomography (CT) to diagnose AISI and aims to reduce the number of MRI scans needed to verify the diagnosis.
METHODS
METHODS
A retrospective case match control study was conducted by searching our trauma database between 2008 and 2022. A study group of patients with AISI (n = 64) and a control group of patients without AISI (n = 76) were formed to generate an equal number of images from both groups (62 radiographs and 22 CT scans). A total of 16 parameters that quantify the distal tibiofibular relation in injured and uninjured ankles were analyzed. For statistical analysis, a two-sided t-test was applied to calculate significant differences (p < 0.05). In a further step, a receiver operating characteristic curve (ROC) was used to determine cut-off values for the most significant parameters.
RESULTS
RESULTS
The most significant measurement (p < 0.001) on axial CT scans was the syndesmotic area (SA). The ROC curve revealed an area under the curve (AUC) of 0.94 (95% CI 0.86-1.0) and a cut-off value of 71.68 mm
CONCLUSION
CONCLUSIONS
This study suggests that radiographic imaging could represent an equally accurate alternative to MRI. These methods might generate the correct diagnosis faster due to their availability and inexpensiveness. By applying our new cut-off values in a clinical setting, the number of underdiagnosed and untreated unstable syndesmotic injuries could be reduced.
LEVEL OF EVIDENCE
METHODS
III, retrospective comparative study.
Identifiants
pubmed: 37477661
doi: 10.1007/s00402-023-04985-w
pii: 10.1007/s00402-023-04985-w
doi:
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
6631-6639Informations de copyright
© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.
Références
Abdelaziz ME, Hagemeijer N, Guss D, El-Hawary A, El-Mowafi H, DiGiovanni CW (2019) Evaluation of syndesmosis reduction on CT scan. Foot Ankle Int 40(9):1087–1093
doi: 10.1177/1071100719849850
pubmed: 31161809
Ahn TK, Choi SM, Kim JY, Lee WC (2017) Isolated Syndesmosis Diastasis: Computed Tomography Scan Assessment With Arthroscopic Correlation. Arthroscopy 33(4):828–834
doi: 10.1016/j.arthro.2017.01.009
pubmed: 28237080
Beumer A, van Hemert WL, Niesing R et al (2004) Radiographic measurement of the distal tibiofibular syndesmosis has limited use. Clin Orthop Relat Res 423:227–234
doi: 10.1097/01.blo.0000129152.81015.ad
Boytim MJ, Fischer DA, Neumann L (1991) Syndesmotic ankle sprains. Am J Sports Med 19(3):294–298
doi: 10.1177/036354659101900315
pubmed: 1907807
Chen Y, Qiang M, Zhang K, Li H, Dai H (2015) A reliable radiographic measurement for evaluation of normal distal tibiofibular syndesmosis: a multi-detector computed tomography study in adults. J Foot Ankle Res 8:32
doi: 10.1186/s13047-015-0093-6
pubmed: 26213578
pmcid: 4514948
Del Rio A, Bewsher SM, Roshan-Zamir S et al (2020) Weightbearing cone-beam computed tomography of acute ankle syndesmosis injuries. J Foot Ankle Surg 59(2):258–263
doi: 10.1053/j.jfas.2019.02.005
pubmed: 32130987
Dikos GD, Heisler J, Choplin RH, Weber TG (2012) Normal tibiofibular relationships at the syndesmosis on axial CT imaging. J Orthop Trauma 26(7):433–438
doi: 10.1097/BOT.0b013e3182535f30
pubmed: 22495526
Elgafy H, Semaan HB, Blessinger B, Wassef A, Ebraheim NA (2010) Computed tomography of normal distal tibiofibular syndesmosis. Skeletal Radiol 39(6):559–564
doi: 10.1007/s00256-009-0809-4
pubmed: 19830423
Futamura K, Baba T, Mogami A et al (2017) Malreduction of syndesmosis injury associated with malleolar ankle fracture can be avoided using Weber’s three indexes in the mortise view. Injury 48(4):954–959
doi: 10.1016/j.injury.2017.02.004
pubmed: 28219637
Gardner MJ, Demetrakopoulos D, Briggs SM, Helfet DL, Lorich DG (2006) Malreduction of the tibiofibular syndesmosis in ankle fractures. Foot Ankle Int 27(10):788–792
doi: 10.1177/107110070602701005
pubmed: 17054878
Ginde AA, Foianini A, Renner DM, Valley M, Camargo CA Jr (2008) Availability and quality of computed tomography and magnetic resonance imaging equipment in U.S. emergency departments. Acad Emerg Med 15(8):780–783
doi: 10.1111/j.1553-2712.2008.00192.x
pubmed: 18783491
Hagemeijer NC, Chang SH, Abdelaziz ME et al (2019) Range of normal and abnormal syndesmotic measurements using weightbearing CT. Foot Ankle Int 40(12):1430–1437
doi: 10.1177/1071100719866831
pubmed: 31442094
Han SH, Lee JW, Kim S, Suh JS, Choi YR (2007) Chronic tibiofibular syndesmosis injury: the diagnostic efficiency of magnetic resonance imaging and comparative analysis of operative treatment. Foot Ankle Int 28(3):336–342
doi: 10.3113/FAI.2007.0336
pubmed: 17371657
Hermans JJ, Wentink N, Beumer A et al (2012) Correlation between radiological assessment of acute ankle fractures and syndesmotic injury on MRI. Skeletal Radiol 41(7):787–801
doi: 10.1007/s00256-011-1284-2
pubmed: 22012479
Hunt KJ, George E, Harris AH, Dragoo JL (2013) Epidemiology of syndesmosis injuries in intercollegiate football: incidence and risk factors from National Collegiate Athletic Association injury surveillance system data from 2004–2005 to 2008–2009. Clin J Sport Med 23(4):278–282
doi: 10.1097/JSM.0b013e31827ee829
pubmed: 23339895
Kotwal R, Rath N, Paringe V, Hemmadi S, Thomas R, Lyons K (2016) Targeted computerised tomography scanning of the ankle syndesmosis with low dose radiation exposure. Skeletal Radiol 45(3):333–338
doi: 10.1007/s00256-015-2267-5
pubmed: 26490677
Krähenbühl N, Weinberg MW, Davidson NP et al (2018) Imaging in syndesmotic injury: a systematic literature review. Skeletal Radiol 47(5):631–648
doi: 10.1007/s00256-017-2823-2
pubmed: 29188345
Malhotra G, Cameron J, Toolan BC (2014) Diagnosing chronic diastasis of the syndesmosis: a novel measurement using computed tomography. Foot Ankle Int 35(5):483–488
doi: 10.1177/1071100714523273
pubmed: 24505045
Malhotra K, Welck M, Cullen N, Singh D, Goldberg AJ (2019) The effects of weight bearing on the distal tibiofibular syndesmosis: a study comparing weight bearing-CT with conventional CT. Foot Ankle Surg 25(4):511–516
doi: 10.1016/j.fas.2018.03.006
pubmed: 30321955
Nault ML, Hébert-Davies J, Laflamme GY, Leduc S (2013) CT scan assessment of the syndesmosis: a new reproducible method. J Orthop Trauma 27(11):638–641
doi: 10.1097/BOT.0b013e318284785a
pubmed: 23287760
Oae K, Takao M, Naito K et al (2003) Injury of the tibiofibular syndesmosis: value of MR imaging for diagnosis. Radiology 227(1):155–161
doi: 10.1148/radiol.2271011865
pubmed: 12616009
Patel S, Malhotra K, Cullen NP, Singh D, Goldberg AJ, Welck MJ (2019) Defining reference values for the normal tibiofibular syndesmosis in adults using weight-bearing CT. Bone Jt J 101-b(3):348–352
doi: 10.1302/0301-620X.101B3.BJJ-2018-0829.R1
Ryan LP, Hills MC, Chang J, Wilson CD (2014) The lambda sign: a new radiographic indicator of latent syndesmosis instability. Foot Ankle Int 35(9):903–908
doi: 10.1177/1071100714543646
pubmed: 25037708
Schoennagel BP, Karul M, Avanesov M et al (2014) Isolated syndesmotic injury in acute ankle trauma: comparison of plain film radiography with 3T MRI. Eur J Radiol 83(10):1856–1861
doi: 10.1016/j.ejrad.2014.06.034
pubmed: 25043987
Scranton PE Jr, McMaster JG, Kelly E (1976) Dynamic fibular function: a new concept. Clin Orthop Relat Res 118:76–81
Shakoor D, Osgood GM, Brehler M et al (2019) Cone-beam CT measurements of distal tibio-fibular syndesmosis in asymptomatic uninjured ankles: does weight-bearing matter? Skeletal Radiol 48(4):583–594
doi: 10.1007/s00256-018-3074-6
pubmed: 30242446
Souleiman F, Heilemann M, Hennings R et al (2022) Effect of weightbearing and foot positioning on 3D distal tibiofibular joint parameters. Sci Rep 12(1):9357
doi: 10.1038/s41598-022-12963-2
pubmed: 35672426
pmcid: 9174190
Takao M, Ochi M, Oae K, Naito K, Uchio Y (2003) Diagnosis of a tear of the tibiofibular syndesmosis. The role of arthroscopy of the ankle. J Bone Jt Surg Br 85(3):324–329
doi: 10.1302/0301-620X.85B3.13174
van den Bekerom MP (2011) Diagnosing syndesmotic instability in ankle fractures. World J Orthop 2(7):51–56
doi: 10.5312/wjo.v2.i7.51
pubmed: 22474636
pmcid: 3302043
van den Bekerom MP, de Leeuw PA, van Dijk CN (2009) Delayed operative treatment of syndesmotic instability. Current concepts review Injury 40(11):1137–1142
pubmed: 19524232
Yeung TW, Chan CY, Chan WC, Yeung YN, Yuen MK (2015) Can pre-operative axial CT imaging predict syndesmosis instability in patients sustaining ankle fractures? Seven years’ experience in a tertiary trauma center. Skeletal Radiol 44(6):823–829
doi: 10.1007/s00256-015-2107-7
pubmed: 25672945
Zamzami MM, Zamzam MM (2009) Chronic isolated distal tibiofibular syndesmotic disruption: diagnosis and management. Foot Ankle Surg 15(1):14–19
doi: 10.1016/j.fas.2008.04.002
pubmed: 19218059