Dataset Information

The Diagnostic Accuracy of Radiographs and Magnetic Resonance Imaging in Predicting Deltoid Ligament Ruptures in Ankle Fractures.

ABSTRACT: Background:Operative indications for supination-external rotation (SER) ankle fractures depend on the integrity of the medial structures. Despite the importance of assessing deep deltoid ligament injuries, the accuracy of common diagnostic tests has not been established. Questions/Purposes:The objective of this study was to compare the ability of injury (non-stress) and stress radiographs and magnetic resonance imaging (MRI) to diagnose deep deltoid ligament ruptures in operative SER ankle fractures. Methods:Patients were included who underwent surgical fixation of SER ankle fractures and had appropriate injury and manual stress test radiographs, pre-operative ankle MRI, and intra-operative assessment of deep deltoid integrity by direct visualization. The medial clear space (MCS) was considered positive for all values over 5 mm on the injury or stress mortise radiographs. MRI analysis of the deep deltoid ligament injury was performed by blinded fellowship-trained musculoskeletal radiologists. Intra-operative direct visualization and assessment of the deltoid was performed using a direct medial ankle approach at the time of operative fracture fixation. Results:Using intra-operative visualization as the gold standard, MCS measurements and MRI had differing abilities to diagnose a deep deltoid rupture. In cases where the MCS was less than 5 mm on injury radiographs and stress tests were performed, MCS measurements were much less accurate than MRI in predicting deltoid ruptures (46% versus 79%, respectively) with a high false positive rate (80%). In contrast, an MCS measurement of greater than 5 mm on injury radiographs was a strong predictor of deep deltoid rupture (accuracy of 95%). Conclusion:Compared with direct visualization of the deltoid ligament intra-operatively, these data support proceeding with surgery when the MCS on injury radiographs is greater than 5 mm without any additional stress tests or advanced imaging. When the MCS is less than 5 mm, we recommend MRI analysis because of its increased accuracy and decreased false positive rate. Improving our ability to diagnose deltoid ruptures will contribute to more effective management of patients with SER ankle fractures.

SUBMITTER: Warner SJ

PROVIDER: S-EPMC6609669 | biostudies-literature | 2019 Jul

REPOSITORIES: biostudies-literature

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The Diagnostic Accuracy of Radiographs and Magnetic Resonance Imaging in Predicting Deltoid Ligament Ruptures in Ankle Fractures.

Warner Stephen J SJ Garner Matthew R MR Fabricant Peter D PD Schottel Patrick C PC Loftus Michael L ML Hentel Keith D KD Helfet David L DL Lorich Dean G DG

HSS journal : the musculoskeletal journal of Hospital for Special Surgery 20190104 2

<h4>Background</h4>Operative indications for supination-external rotation (SER) ankle fractures depend on the integrity of the medial structures. Despite the importance of assessing deep deltoid ligament injuries, the accuracy of common diagnostic tests has not been established.<h4>Questions/purposes</h4>The objective of this study was to compare the ability of injury (non-stress) and stress radiographs and magnetic resonance imaging (MRI) to diagnose deep deltoid ligament ruptures in operative ...[more]

PMID: 31327941

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Project description:BackgroundConventionally, transsyndesmotic fibula fractures with concomitant signs of deltoid ligament injury have been considered unstable and thus treated operatively. Recent studies have indicated that partial deltoid ligament rupture is common and may allow for nonoperative treatment of stress-unstable ankles if normal tibiotalar alignment is obtained in the weightbearing position. Biomechanical support for this principle is scarce. The purpose of this study was to evaluate the biomechanical effects of gradually increasing deltoid ligament injury in transsyndesmotic fibula fractures.MethodsFifteen cadaveric ankle specimens were tested using an industrial robot. All specimens were tested in 4 states: native, SER2, SER4a, and SER4b models. Ankle stability was measured in lateral translation, valgus, and internal and external rotation stress in 3 talocrural joint positions: 20 degrees plantarflexion, neutral, and 10 degrees dorsiflexion. Talar shift and talar valgus tilt in the talocrural joint was measured using fluoroscopy.ResultsIn most tests, SER2 and SER4a models resulted in a small instability increase compared to native joints and thus were deemed stable according to our predefined margins. However, SER4a models were unstable when tested in the plantarflexed position and for external rotation in all positions. In contrast, SER4b models had large-magnitude instability in all directions and all tested positions and were thus deemed unstable.ConclusionThis study demonstrated substantial increases in instability between the SER4a and SER4b states. This controlled cadaveric simulation suggests a significant ankle-stabilizing role of the deep posterior deltoid after oblique transsyndesmotic fibular fracture and transection of the superficial and anterior deep deltoid ligaments.Clinical relevanceThe study provides new insights into how the heterogenicity of deltoid ligament injuries can affect the natural stability of the ankle after Weber B fractures. These findings may be useful in developing more targeted and better treatment strategies.

Project description:BackgroundAnkle traumas are common presenting injuries to emergency departments in Australia and worldwide. The Ottawa Ankle Rules (OAR) are a clinical decision tool to exclude ankle fractures, thereby precluding the need for radiographic imaging in patients with acute ankle injury. Previous studies support the OAR as an accurate means of excluding ankle and midfoot fractures, but have included a paediatric population, report both the ankle and mid-foot, or are greater than 5 years old. This systematic review and meta-analysis aimed to update and assess the existing evidence of the diagnostic accuracy of the Ottawa Ankle Rule (OAR) acute ankle injuries in adults.MethodsA systematic search and screen of was performed for relevant articles dated 1992 to 2020. Prospective and retrospective studies documenting OAR outcomes by physicians to assess ankle injuries were included. Critical appraisal of included studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. Outcomes related to psychometric data were pooled using random effects or fixed effects modelling to calculate diagnostic performance of the OAR. Between-study heterogeneity was assessed using the Higgins I2 test, with Spearman's correlation test for threshold effect.ResultsFrom 254 unique studies identified in the screening process, 15 were included, involving 8560 patients from 13 countries. Sensitivity, specificity, negative likelihood ratio, positive likelihood ratio and diagnostic odds ratio were 0.91 (95% CI, 0.89 to 0.92), 0.25 (95% CI, 0.24 to 0.26), 1.47 (95% CI, 1.11 to 1.93), 0.15 (95% CI, 0.72 to 0.29) and 10.95 (95% CI, 5.14 to 23.35) respectively, with high between-study heterogeneity observed (sensitivity: I2 = 94.3%, p < 0.01; specificity: I2 = 99.2%, p < 0.01). Most studies presented with low risk of bias and concern regarding applicability following assessment against QUADAS-2 criteria.ConclusionsApplication of the OAR is highly sensitive and can correctly predict the likelihood of ankle fractures when present, however, lower specificity rates increase the likelihood of false positives. Overall, the use of the OAR tool is supported as a cost-effective method of reducing unnecessary radiographic referral, that should improve efficiency, lower medical costs and reduce waiting times.

Project description:BackgroundSurgical management of patients with acute and chronic ankle instability (CAI) has historically focused on the lateral ligament complex. Recent studies in CAI patients have shown that magnetic resonance imaging (MRI) and arthroscopy demonstrate concomitant injury to the deltoid ligament complex We performed a systematic review to determine if consistent clinical, diagnostic imaging, or arthroscopic findings of deltoid ligament injury in the setting of CAI have been described. In addition, we sought to determine if treatment options and/or clinical outcomes have been described.MethodsA systematic review was conducted using the PubMed, MEDLINE, and Embase databases. Articles were included if they had a majority of patients 18 years of age or older, focused on deltoid ligament injury in ankle instability, and reported diagnostic and/or treatment methods. Articles were excluded if the study focused on the deltoid ligament in the acute fracture setting. All included articles were assessed for diagnostic criteria, treatments, and patient outcomes.ResultsOur search yielded 157 articles, of which a total of 13 were included in our study. Arthroscopy was described as the gold standard to diagnose and evaluate the severity of deltoid ligament injury, however, little objective data on the arthroscopic diagnosis of deltoid ligament insufficiency was reported. MRI was the imaging modality of choice to evaluate deltoid ligament injury and had a high sensitivity and specificity when compared with arthroscopy. No standard MRI diagnostic criteria for deltoid ligament injury were identified in the literature. Specific treatment techniques and long-term outcomes were not well described in the manuscripts included in this review.ConclusionThere is limited knowledge on deltoid ligament insufficiency in the setting of chronic ankle instability. Criteria for characterizing deltoid ligament damage with diagnostic imaging appear to be evolving, but there is no standard classification. Only 1 author has described a method to evaluate deltoid ligament competency on arthroscopic examination. There are currently no objective data to guide treatment decisions.Level of evidenceLevel III.

Dataset Information

The Diagnostic Accuracy of Radiographs and Magnetic Resonance Imaging in Predicting Deltoid Ligament Ruptures in Ankle Fractures.

Publications

The Diagnostic Accuracy of Radiographs and Magnetic Resonance Imaging in Predicting Deltoid Ligament Ruptures in Ankle Fractures.

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