Abstract
Background
Precise reduction of a syndesmosis after disruption is critical to improve patient physical function. Intraoperative lateral radiographs of the unaffected ankle are often used in clinical practice as a template for anatomic syndesmotic reduction because sagittal plane malreduction is common. However, there is little data to suggest fibular station, or the position of the fibula in the AP plane on the lateral radiograph, is symmetric side-to-side in patients.
Questions/purposes
(1) Is the position of the fibula in the AP plane (fibular station) on lateral ankle radiographs symmetric in an individual? (2) Do the measurements used to judge the position of the fibula on lateral radiographs have good inter- and intraobserver reliability?
Methods
Over the period from August 2016 to October 2018, we identified 478 patients who presented to an orthopaedic clinic with forefoot and midfoot complaints. Skeletally mature patients with acceptable bilateral lateral ankle radiographs, which are common radiographs obtained for new patients to clinic for any complaint, were included. Based on that, 52% (247 of 478 patients) were included with most (22%, 107 patients) excluded for poor lateral radiographs. The most common diagnosis in the patient cohort was midfoot OA (14%, 35 patients). The median (range) age of the included patients was 54 years (15 to 88), and 65% (159 of 247) of the patients were female. Fibular station, defined as the position of the fibula in the AP plane, and fibular length were measured using a digital ruler and goniometer on lateral radiographs. A paired t-test was used to determine if no difference in fibular station existed between the left and right ankles. With 247 paired-samples, with 80% power and an alpha level of 0.05, we could detect a difference between sides of 0.008 for the posterior ratio, 0.010 for the anterior ratio, and 0.012 for fibular length. Two readers, one fellowship-trained orthopaedic traumatologist and one PGY-4, measured 40 patients to determine the inter- and intraobserver reliability by intraclass correlation coefficient (ICC).
Results
The posterior fibular station (mean right 0.147 [σ = 0.056], left 0.145 [σ = 0.054], difference = 0.03 [95% CI 0 to 0.06]; p = 0.59), anterior fibular station (right 0.294 [σ = 0.062], left 0.299 [σ = 0.061], difference = 0.04 [95% CI 0 to 0.08]; p = 0.20), and fibular length (right 0.521 [σ = 0.080], left 0.522 [σ = 0.078], difference = 0.05 [95% CI 0.01 to 0.09]; p = 0.87) ratios did not differ with the numbers available between ankles. Inter- and intraobserver reliability were excellent for the posterior ratio (ICC = 0.928 and ICC = 0.985, respectively) and the anterior ratio (ICC = 0.922 and ICC = 0.929, respectively) and moderate-to-good for the fibular length ratio (ICC = 0.732 and ICC = 0.887, respectively).
Conclusion
The use of lateral radiographs of the contralateral uninjured ankle appears to be a valid template for determining the position of the fibula in the sagittal plane. However, further prospective studies are required to determine the efficacy of this method in reducing the syndesmosis over other methods that exists.
Level of Evidence
Level III, diagnostic study.
Introduction
Syndesmotic injuries are common, and they occur in association with many rotational ankle injuries [10]. Despite the frequency of these injuries, treatment strategies remain controversial, as is the treatment of the syndesmosis in unstable ankle fractures. Anatomic reduction of the syndesmosis when indicated during ankle fracture fixation surgery may increase patient-reported functional scores [7, 21, 22]. However, assessing the reduction of the syndesmosis is challenging and investigators have disagreed about how best to do it [7, 9, 20, 22]. Previous studies have assessed the ability to accurately reduce the syndesmosis using conventional radiography of the contralateral side, but these have used the AP and mortise views, without specific attention directed toward the lateral projection, which is more commonly used in clinical practice [1, 5, 6, 17]. Additional studies have investigated the reduction of the syndesmosis on CT scans. These studies have shown difficulty of reducing the syndesmosis and noted multiple planes of iatrogenic malreduction including rotational, translational, and over-compression [2, 8].
The well-described methods of syndesmotic reduction include using measurements on the AP and mortise views, including medial clear space widening, tibia-fibula overlap, and tibia-fibula clear space [16]. However, numerous studies have shown that there is a high rate of syndesmotic malreduction when using just these criteria [5, 6, 14]. Intraoperative CT scans have been shown to decrease the rate of malreduction by using measurements of the anterior, middle and posterior border of the fibula to the tibia [8], but that finding is not universal [5]. Furthermore, the use of intraoperative CT scans are not always available, can be cost-prohibitive, and carry the risk of increased radiation exposure. Most importantly, studies have demonstrated that the most common reason for malreduction of the syndesmosis is translation in the sagittal plane [2, 3, 15]. A different method for reduction using the position of the fibula in relation to the tibia, or fibular station, on lateral radiographs of the contralateral uninjured ankle as a template was described by Summers et al. [20] in 2013. Although only a small series of 18 patients, the authors showed an anatomic reduction rate of 94% confirmed by intraoperative CT scan. This premise relies on fibular station being a reproducible measurement; however, there can be variability in fibular station between patients (Fig. 1). Despite this, there is a paucity of data confirming the side-to-side symmetry or reproducibility of the fibular station in uninjured ankles.
Fig. 1.
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We therefore asked: (1) Is the position of the fibula in the AP (fibular station) on lateral ankle radiographs symmetric in an individual? (2) Do the measurements used to judge the position of the fibula on lateral radiographs have good inter- and intraobserver reliability?
Patients and Methods
After institutional review board approval, this retrospective study was performed at a Level I trauma center. All skeletally mature patients with bilateral foot radiographs that included lateral plain radiographs of the ankle were identified in the electronic medical record by using a billing code identifier. Patient records were reviewed to collect demographic data, chief complaint (reason for evaluation), and lower-extremity surgical history.
Inclusion Criteria
Patients were included in the study if they were skeletally mature and were evaluated for complaints of the forefoot. Furthermore, each patient had to have acceptable bilateral lateral radiographs of the ankle.
Exclusion Criteria
Patients were excluded from the study if they were skeletally immature; did not have an acceptable lateral radiograph of both ankles; had a history of ankle or hindfoot surgery, moderate or severe ankle osteoarthritis, Charcot arthropathy, congenital osseous abnormalities of the tibia or talus; or were determined to have ankle disease at their clinic visit.
Patient Population
Over the period from August 2016 to October 2018, we identified 478 patients who presented to a university orthopaedic clinic with fore- and midfoot complaints and who had bilateral lateral ankle radiographs. It is common for new patients within this institution with any foot complaint to obtain “new patient series” radiographs. The “new patient series” contains bilateral APs of the ankle, laterals of the ankle including the entire foot, and APs and obliques of the foot. Twenty-two percent (107 patients) were excluded because they had unacceptable lateral radiographs of the ankle, 8% (40) were excluded for previous trauma, 8% (38) were excluded because they had moderate-to-severe ankle osteoarthritis, 5% (26) patients were excluded because they had a previous fusion procedure, 3% (12) were excluded because they had skeletal immaturity, 1% (4) were excluded because they underwent Charcot arthropathy, and 1% (4) were excluded for congenital abnormalities of the ankle (Fig. 2). After exclusion, 247 patients were included in this review. The median (range) age of the included patients was 54 years (15 to 88). Sixty-four percent (159 of 247) of the patients were female. The most common diagnoses in the patient cohort were: 14% (35) midfoot OA, 14% (34) tendinitis, 12% (31) plantar fasciitis, 10% (24) hallux rigiditis, 10% (24) hallux valgus, 10% (24) flatfoot deformity, 30% (75) other (such as, 7% (18) metatarsalgia, 6% (15) peripheral neuropathy, 4% (10) mid- or forefoot fractures, 4% (9) cavovarus foot deformity, 4% (9) hammertoe, 6% (14) combination of bunionette, ganglion cyst, gout, and toe amputation. The use of patients with only midfoot or forefoot complaints reduces the possibility of fibular abnormalities in the cohort. Furthermore, without exposing patients to unnecessary radiation, this is the most appropriate means of obtaining a cohort of patients with lateral radiographs of the ankle.
Fig. 2.
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Imaging
Plain radiographs were obtained by experienced radiologic technicians working at the university orthopaedic center. Bilateral AP, oblique, and lateral radiographs of the foot and ankle were obtained for each patient. Acceptable lateral radiographs of the ankle were defined as weightbearing radiographs with overlap of the medial and lateral talar dome. Initial images were screened for inclusion by two reviewers (PJK, LSM), and any disagreement regarding the quality of the radiograph was settled by a third reviewer (TLB). Only lateral radiographs were used for measurements.
Measurements
Measurements were taken using Spectra PACS software with freewheel zoom capability to allow appropriate resolution and accuracy for the measurements. A virtual ruler was used on magnified digital images and rounded to the nearest 0.1 mm on a university-licensed imaging system (IntelliSpace PACS Enterprise, Phillips; Foster City, CA, USA). All measurements were made by four independent readers (LSM, PJK, TLB, GD). The level of training of these readers were as follows: one fellowship-trained orthopaedic traumatologist, one PGY-5 orthopaedic resident, and two PGY-4 orthopaedic residents.
Three measurements were made on the lateral-view radiographs (Fig. 3). First, we made a line marking out the plafond width, which was defined as a line from the most-anterior portion of the plafond to the most-posterior portion of the plafond (all subsequent measurements were made either parallel or perpendicular to this line). Second, we measured the tibial width, which was measured as the distance from the anterior tibial cortex to the posterior tibial cortex at the level just superior to the proximal most aspect of the tibial articular surface on the lateral radiograph (parallel to the plafond width line). Third, we measured the anterior fibular station, which was measured as the distance from the anterior tibial cortex to the anterior fibular cortex along the same plane as the tibial width line. Fourth, we measured the posterior fibular station, which was measured as the distance from the posterior tibial cortex to the posterior fibular cortex along the same plane as the tibial width line. Finally, we measured the fibular length, which was measured as the distance from the most-distal point of the fibula to the plafond width line (perpendicular to the plafond width).
Fig. 3.
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Because films were taken without a calibration marker, the radiographic images were unable to be sized appropriately, thus ratios were then made to normalize the data. Ratio measurements included the anterior fibular station, posterior fibular station, and fibular length normalized to the tibial width measurement.
Statistical Analysis
Imaging measurement ratios were compared between the left and right ankles. Descriptive statistics for demographic variables are reported as means with the SD or median with quartiles, depending on the distribution of continuous variables. Variables of interest for each ankle were found to be normally distributed and were compared using a two-tailed paired t-test. Correlation was assessed using Pearson’s correlation coefficient. Forty patients’ radiographs were measured by two reviewers (LSM, PJK) to determine interobserver and intraobserver reliability. One reviewer was a fellowship-trained orthopaedic traumatologist, and one reviewer was a PGY-4 resident. To determine intraobserver reliability, all 40 images were re-reviewed with a 4-week washout period in between measurements. The first measurements were blinded to the reviewer at the time of the second measurement. Inter- and intraobserver reliability were determined using the intraclass correlation coefficient (ICC), where 0 to 0.5 represents poor agreement, 0.51 to 0.75 represents fair agreement, 0.76 to 0.9 represents good agreement, and 0.9 to 1 represents excellent agreement.
A post-hoc power analysis was performed to determine the amount of change between ankles that could be determined with a paired sample size of 247 at a power of 80% and a significant level of 0.05. For the posterior fibular station, a change of 0.008 could be determined. For the anterior fibular station, a change of 0.010 could be detected. And finally, for fibular length, a change of 0.012 could be found. The clinically important difference was set at 0.1, or a 10% difference between sides.
Statistical results with a p value < 0.05 were considered significant. All statistical analyses were performed using JMP version 12 (SAS Inc, Cary, NC, USA).
Results
We found no important within-patient side-to-side differences in fibular station. Using the tibial width as the normalizing measurement, we found there was no difference between the left and right posterior fibular station (mean right 0.147 [σ = 0.056], left 0.145 [σ = 0.054], difference = 0.03 [95% CI 0 to 0.06]; p = 0.59), anterior fibular station (right 0.294 [σ = 0.062], left 0.299 [σ = 0.061], difference = 0.04 [95% CI 0 to 0.08]; p = 0.20) or fibular length measurements (right 0.521 [σ = 0.080], left 0.522 [σ = 0.078], difference = 0.05 [95% CI 0.01 to 0.09]; p = 0.87) (Table 1). The correlation had a Pearson’s correlation coefficient of 0.654 for the posterior fibular station, 0.593 for the anterior fibular station, and 0.669 for the fibular length (all p < 0.001) (Fig. 4).
Table 1.
Fibular station ratios normalized using tibial width
Fibular station ratio | Right (σ) | Left (σ) | Difference (95% confidence interval) | p value |
Posterior fibular ratio meana | 0.147 (0.056) | 0.145 (0.054) | 0.03 (0 to 0.06) | 0.59 |
Anterior fibular ratio meanb | 0.294 (0.062) | 0.299 (0.061) | 0.04 (0 to 0.08) | 0.20 |
Fibular length meanc | 0.521 (0.080) | 0.522 (0.078) | 0.05 (0.01 to 0.09) | 0.87 |
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a
The posterior fibular ratio is the distance from the posterior tibial cortex to the posterior fibular cortex along the same plane as the tibial width line.
b
The anterior fibular ratio is the distance from the anterior tibial cortex to the anterior fibular cortex along the same plane as the tibial width line.
c
The fibular length is the distance from the most-distal point of the fibula to the plafond width line (perpendicular to the plafond width line).
Fig. 4.
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We found that fibular position could be reliably and reproducibly measured, with excellent inter- and intraobserver reliability. Interobserver reliability was excellent for the posterior fibular station (ICC = 0.928) and anterior fibular station (ICC = 0.922) and fair for fibular length (ICC = 0.732). Intraobserver reliability was excellent for the posterior fibular station (ICC = 0.985) and anterior fibular station (ICC = 0.929) and good for fibular length (ICC = 0.887) (Table 2).
Table 2.
Interobserver and intraobserver reliability for radiographic measurements
Fibular station ratio | Interobserver | Intraobserver |
Posterior fibular station | 0.928 | 0.985 |
Anterior fibular station | 0.922 | 0.929 |
Fibular length | 0.732 | 0.887 |
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Two observers, one fellowship-trained orthopaedic traumatologist and one PGY-4 orthopaedic resident, reviewed 40 images to determine inter- and intraobserver reliability using intraclass correlation coefficient (ICC); 0 to 0.5 represents poor agreement, 0.51 to 0.75 represents fair agreement, 0.76 to 0.9 represents good agreement, and 0.9 to 1 represents excellent agreement.
Discussion
The importance of syndesmotic reduction in ankle fractures has been shown in the evidence [2, 9, 12, 22]. However, there has been much debate about how to accurately reduce a syndesmosis [1, 3-6, 9, 10, 17-20]. One method that has not been widely described, but is commonly used, is using the position of the fibula on a lateral radiograph of the contralateral ankle to judge reduction of a syndesmosis [13, 20, 23]. However, the symmetry of the fibular station in the bilateral ankles has yet to be fully explored, questioning the validity of this method. This study showed that the position the fibula sits in relation to the tibia on a lateral ankle radiograph is no different side-to-side within a single patient. Furthermore, the reproducibility of the measurements assessing the fibular station were good to excellent between clinicians. As such, the use of the contralateral uninjured ankle as a template is a valid model to aid in syndesmotic reduction.
This study had several limitations. First, this study evaluated a subset of patients who were seen for complaints that warranted foot radiographs, including a lateral view of the ankle. It is commonplace in foot and ankle clinics to obtain what is referred to as a “new patient series”, which includes bilateral lateral radiographs of the foot including the ankle, for new patients being seen for either foot or ankle complaints. None of the patients included were seen for ankle issues and our variety of diagnoses confirm this fact. And, without exposing patients to unnecessary radiation, this is felt to be the best surrogate cohort available. Second, we retrospectively collected data on these patients. Given the number of patients excluded for poor lateral radiographs, we maintained a high standard for technique. Despite this, we still had enough patients to power the study to detect a small difference side-to-side, which we did not find. Additionally, the patient population was diverse, including a wide age range and a good mixture of genders. Lastly, although we support the use of lateral imaging as a template for syndesmotic reduction, the risk of malreduction is not completely avoided with this technique. The risk of over-compression or residual widening of the syndesmosis is still very much possible if only the lateral radiograph is used to judge reduction. Thus, the use of the mortise view in combination with the lateral view of the ankle is imperative to confirm anatomic reduction.
We found that the fibular position or station on lateral radiographs was consistently comparable between contralateral ankles in a given patient. Only one prior study has compared the position of the fibula on lateral radiographs between bilateral ankles. Grenier et al. [11] examined the AP tibiofibular ratio in 30 patients and they found that these measurements were not different side-to-side. Although this was a different ratio, they studied the same concept and their findings were consistent with this study. Furthermore, Summers et al. [20] reduced the syndesmosis intraoperatively by matching the distance from the posterior cortex of the fibula to the posterior cortex of the tip of the posterior malleolus on lateral radiographs. With the use of intraoperative CT images, they found that 17 of 18 ankles were accurately reduced. Both these investigations have small sample sizes but started the conversation as to the utility of this concept. This current study confirmed these findings on a larger scale with adequate power.
We found that the fibular position could be reliably and reproducibly measured, with excellent inter- and intraobserver reliability. The importance of this finding is imperative to the ability of the clinician to use this test as a template for reduction. Specifically, we found that the most reliable measurement for judging the fibular station on lateral radiographs was the distance from the posterior fibular cortex to the posterior tibial cortex. This measurement had the highest correlation between the right and left ankles, with the highest interrater reliability measurement. However, with a posterior malleolus fracture, this distance becomes impracticable for comparison because hardware or fracture displacement may obscure this measurement. The distance from the anterior fibular cortex to the anterior tibial cortex was also reliable and was well-correlated between the right and left ankles. Other studies have examined the reliability and reproducibility of radiographic measurements of the ankle [1, 11, 23]. Both, Grenier et al.[11] and Xenos et al. [23] found that measurements on the lateral ankle radiograph have high intra- and interobserver reliability. This finding is, again, consistent with the findings of our study. These studies included 30 paired patients and 25 cadaveric specimens, respectively, to determine these measurements. Although our study’s findings are in line with this, at 247 patients included, this is a large cohort to confirm that these measurements are in fact reliable and reproducible.
In conclusion, we found that the relationship of the fibula in reference to the tibia on the lateral radiograph of the ankle was no different side-to-side within patients. Additionally, the measurements used to determine the symmetry of the fibula can be made reliably and reproducibly. The increasing use of the lateral radiographic of the uninjured ankle for templating syndesmotic reduction required validation that the syndesmosis is symmetric side-to-side. This has been shown on both a small and large scale; further research should focus on prospectively evaluating the success of anatomically reducing the syndesmosis using this technique versus other techniques. Furthermore, evaluation regarding the use of this technique to improve functional results and decrease the rates of posttraumatic osteoarthritis is needed.
Acknowledgments
We thank Brook Martin PhD, for his help with power calculations of the study.
Footnotes
Each author certifies that neither he, nor any member of his immediate family, has funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.
Clinical Orthopaedics and Related Research® neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use.
Each author certifies that his institution approved the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research.
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