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Application of external torque enhances the detection of subtle syndesmotic ankle instability in a weight-bearing CT

  • ANKLE
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

Acute syndesmotic ankle injuries continue to impose a diagnostic dilemma and it remains unclear whether weightbearing and/or external rotation should be added during the imaging process. Therefore, the aim of this study was to assess if combined weightbearing and external rotation increases the diagnostic sensitivity of syndesmotic ankle instability using weightbearing CT (WBCT) imaging, compared to isolated weightbearing.

Methods

In this retrospective study, patients with an acute syndesmotic ankle injury were analysed using a WBCT (N = 21; Age = 31.6 ± 14.1 years old). Inclusion criteria were an MRI confirmed syndesmotic ligament injury imaged by a WBCT of the ankle during weightbearing and combined weightbearing-external rotation. Exclusion criteria consisted of fracture associated syndesmotic injuries. Three-dimensional (3D) models were generated from the CT slices. Tibiofibular displacement and talar rotation were quantified using automated 3D measurements (anterior tibiofibular distance (ATFD), Alpha angle, posterior Tibiofibular distance (PTFD) and Talar rotation (TR) angle in comparison to the contralateral non-injured ankle.

Results

The difference in neutral-stressed Alpha angle and ATFD showed a significant difference between patients with a syndesmotic ankle lesion and contralateral control (P = 0.046 and P = 0.039, respectively). The difference in neutral-stressed PTFD and TR angle did not show a significant difference between patients with a syndesmotic ankle lesion and healthy ankles (n.s.).

Conclusion

Application of combined weightbearing-external rotation reveals an increased ATFD in patients with syndesmotic ligament injuries. This study provides the first insights based on 3D measurements to support the potential relevance of applying external rotation during WBCT imaging. In clinical practice, this could enhance the current diagnostic accuracy of subtle syndesmotic instability in a non-invasive manner. However, to what extent certain displacement patterns require operative treatment strategies has yet to be determined in future studies.

Level of evidence

Level III.

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Data availability

The data that support the findings of this study are available upon reasonable request to the corresponding author M. Peiffer (email: matthias.peiffer@ugent.be). The dataset includes clinical CT scans, which contain sensitive patient information and cannot be shared due to privacy and ethical considerations. However, all measurement results derived from the analysis of these CT scans, as presented in the manuscript, can be accessed and provided upon request.

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Funding

Matthias Peiffer was financially supported by PhD grant (1120220N) from the Research Foundation Flanders (FWO). Emmanuel Audenaert was financially supported by a senior clinical research fellowship (1842619N) from the Research Foundation Flanders. All authors declared no conflict of interest.

Author information

Author notes

  1. E. Audenaert and A. Burssens have contributed equally to this manuscript as last authors.

Authors and Affiliations

  1. Department of Orthopaedics and Traumatology, Ghent University Hospital, 9000, Ghent, OVL, Belgium

    M. Peiffer, T. Dhont, F. Cuigniez, T. Tampere, E. Audenaert & A. Burssens

  2. Department of Human Structure and Repair, Ghent University, Corneel Heymanslaan 10, 9000, Ghent, OVL, Belgium

    M. Peiffer, E. Audenaert & A. Burssens

  3. Foot and Ankle Research and Innovation Laboratory (FARIL), Harvard Medical School-Massachusetts General Hospital, Boston, MA, USA

    M. Peiffer & S. Ashkani-Esfahani

  4. Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar

    P. D’Hooghe

  5. Department of Electromechanics, Op3Mech Research Group, University of Antwerp, 2020, Antwerp, Belgium

    E. Audenaert

  6. Department of Trauma and Orthopedics, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK

    E. Audenaert

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Contributions

All authors contributed equally to this article. MP designed, coordinated and co-drafted the final manuscript. TD performed the data analysis and reviewed the final manuscript. FC performed the data collection and reviewed the final manuscript. TT helped with data collection and reviewed the manuscript. SAE co-managed the data interpretation and reviewed the final manuscript. PD co-designed the research hypothesis reviewed the final manuscript. EA supervised drafting of the manuscript. AB designed, coordinated and co-drafted the final manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to M. Peiffer.

Ethics declarations

Conflict of interest

Matthias Peiffer, MD, has nothing to disclose; Thibaut Dhont, BSc, has nothing to disclose; Francis Cuigniez, MD, has nothing to disclose; Thomas Tampere, MD, has nothing to disclose; S. Ashkani-Esfahani, MD, has nothing to disclose; Pieter D’Hooghe, MD, PhD, has nothing to disclose; Emmanuel Audenaert, MD, PhD, has nothing to disclose; Arne Burssens, MD, PhD, has nothing to disclose.

Ethical approval

IRB:EC 2019/0887 (Institutional Review Board of University Hospital Ghent).

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Peiffer, M., Dhont, T., Cuigniez, F. et al. Application of external torque enhances the detection of subtle syndesmotic ankle instability in a weight-bearing CT. Knee Surg Sports Traumatol Arthrosc 31, 4886–4894 (2023). https://doi.org/10.1007/s00167-023-07536-3

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