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Comparison of Two Intraoperative Assessment Methods for Injuries to the Ankle SyndesmosisA Cadaveric Study
Karl Stoffel, MD, PhD, FRACS1; David Wysocki, MBBS1; Edward Baddour, MBBS1; Rochelle Nicholls, BAppSci, MSc, PhD1; Piers Yates, MBBS(Hons), BSc(Hons), MRCS, FRCS(Tr&Orth)1
1 Department of Orthopaedic Surgery, Level 6, B Block, Fremantle Hospital, Fremantle, Western Australia, Australia 6160. E-mail address for K. Stoffel: nkstoffel@hotmail.com
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
Investigation performed at the Department of Orthopaedic Surgery, Fremantle Hospital, Fremantle; and the Fremantle Orthopaedic Unit, The University of Western Australia, Crawley, Western Australia, Australia

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2009 Nov 01;91(11):2646-2652. doi: 10.2106/JBJS.G.01537
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Background: Intraoperative stress testing is required for the detection of syndesmosis instability following an ankle fracture. The present study compared two stress tests for the detection of syndesmotic injury.

Methods: A true mortise radiograph of the ankle was made for fourteen cadaver joints. Specimens were randomized into two groups to simulate ligament and syndesmosis injury on the basis of the Danis-Weber classification system. In the first group, the anterior inferior tibiofibular ligament was divided first (Weber Br), followed sequentially by division of the interosseous membrane (Weber C) and the deltoid ligament. In the second group, the deltoid ligament was divided first, followed by the anterior inferior tibiofibular ligament. Radiographs were made at each stage with use of two methods of stressing the ankle mortise: (1) external rotation of the foot with an external moment of 7.5 Nm, and (2) application of a lateral force of 100 N. Tibiofibular overlap, tibiofibular clear space, and medial clear space were measured.

Results: Lateral stress produced a significantly greater increase in the tibiofibular clear space than did the external rotation test for Weber C injuries and Weber C plus deltoid ligament injuries. A greater increase in the tibiofibular clear space was noted during the lateral stress test when both the deltoid and the anterior inferior tibiofibular ligament had been sectioned (p < 0.05). The external rotation stress test produced a significant increase in the medial clear space in the presence of isolated anterior inferior tibiofibular ligament and deltoid ligament injuries (p < 0.05).

Conclusions: For the detection of syndesmotic instability at the site of ankle fractures on stress radiographs, the lateral stress test appeared to be superior to the external rotation stress test in this cadaver model.

Clinical Relevance: The present study gives insight into the types of ligament damage that will produce a positive result on stress radiographs with use of two common intraoperative stress tests. Establishment of clinical correlation with the results of this cadaver model is necessary in order to develop operative guidelines.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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