Foot and Ankle Research and Innovation Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
Department of Orthopaedic Surgery, Asahikawa Medical University, Mitdorigaoka Higashi 2-1-1-1, Asahikawa, Hokkaido, 078-8510, Japan.
Knee Surg Sports Traumatol Arthrosc. 2022 Nov;30(11):3881-3887. doi: 10.1007/s00167-022-06985-6. Epub 2022 May 6.
This study aim was to detect the impact of lateral ankle ligaments injury on syndesmotic laxity when evaluated arthroscopically in a cadaveric model. The null hypothesis was that lateral ankle ligament injury does not affect the stability of syndesmosis.
Sixteen fresh-frozen above-knee amputated cadaveric specimens were divided into two groups of eight specimens that underwent arthroscopic evaluation of the distal tibiofibular joint. In both the groups, the assessment was first done with all syndesmotic and ankle ligaments intact. Thereafter, Group 1 underwent sequential transection of the three lateral ankle ligaments first to identify the effects of lateral ligament injury: (1) anterior talofibular ligament (ATFL), (2) calcaneofibular ligament (CFL), (3) posterior talofibular ligament (PTFL), then followed by the syndesmotic ligaments, (4) AITFL, (5) Interosseous ligament (IOL), and (6) PITFL. Group 2 underwent sequential transection of the (1) AITFL, (2) ATFL, (3) CFL, (4) IOL, (5) PTFL, and (6) PITFL, which represent the most commonly injured pattern in ankle sprain. In all scenarios, four loading conditions were considered under 100 N of direct force: (1) unstressed, (2) a lateral fibular hook test, (3) anterior to posterior (AP) fibular translation test, and (4) posterior to anterior (PA) fibular translation test. Distal tibiofibular coronal plane diastasis at the anterior and posterior third of syndesmosis, as well as AP and PA sagittal plane translation, were arthroscopically measured.
The distal tibiofibular joint remained stable after transection of all lateral ankle ligaments (ATFL, CFL, and PTFL) as well as the AITFL. However, after additional transection of the IOL, the syndesmosis became unstable in both the coronal and sagittal plane. Syndesmosis laxity in the coronal plane was also observed after transection of the ATFL, CFL, AITFL, and IOL. Subsequent transection of the PITFL precipitated syndesmosis laxity in the sagittal plane, as well.
The findings from the present study suggest that lateral ankle ligament injuries itself do not directly affect the stability of syndesmosis. However, if it combines with IOL injuries, even partial injuries cause syndesmotic laxity. As a clinical relevance, accurate diagnosis is the key for surgeons to determine syndesmosis fixation whether there is only AITFL injury or combined IOL injury in concomitant acute syndesmotic and lateral ligament injury.
本研究旨在通过尸体模型关节镜检查来检测外侧踝关节韧带损伤对下胫腓联合松弛度的影响。零假设是外侧踝关节韧带损伤不会影响下胫腓联合的稳定性。
将 16 个来自膝关节以上的冷冻尸体标本分为两组，每组 8 个标本进行关节镜下评估。在两组中，首先评估所有下胫腓联合和踝关节韧带完整的情况下的稳定性。然后，组 1 先依次切断外侧踝关节的三条韧带，以确定外侧韧带损伤的影响：（1）距腓前韧带（ATFL），（2）跟腓韧带（CFL），（3）距腓后韧带（PTFL），然后再切断下胫腓联合韧带，（4）胫腓前韧带（AITFL），（5）骨间韧带（IOL）和（6）后腓骨韧带（PITFL）。组 2 依次切断（1）AITFL、（2）ATFL、（3）CFL、（4）IOL、（5）PTFL 和（6）PITFL，这代表了踝关节扭伤中最常见的损伤模式。在所有情况下，在 100N 的直接力下考虑了四种加载情况：（1）无张力，（2）腓骨外侧钩试验，（3）前向后（AP）腓骨平移试验，（4）后向前（PA）腓骨平移试验。关节镜下测量下胫腓联合前 1/3 和后 1/3 的冠状面分离以及 AP 和 PA 矢状面平移。
切断所有外侧踝关节韧带（ATFL、CFL 和 PTFL）以及 AITFL 后，下胫腓关节仍然稳定。然而，在切断 IOL 后，冠状面和矢状面下胫腓联合均变得不稳定。在前、后距腓联合韧带切断后，冠状面下胫腓联合也出现了松弛。随后切断 PITFL 也会导致矢状面下胫腓联合松弛。
本研究结果表明，外侧踝关节韧带损伤本身不会直接影响下胫腓联合的稳定性。但是，如果与 IOL 损伤结合，即使是部分损伤也会导致下胫腓联合松弛。从临床相关性来看，准确的诊断是外科医生确定下胫腓联合固定的关键，无论是否有 AITFL 损伤或在急性下胫腓联合和外侧韧带损伤中同时伴有 IOL 损伤。
