Diagnostic Accuracy of Conventional Ankle CT Scan With External Rotation and Dorsiflexion in Patients With Acute Isolated Syndesmotic Instability

Abstract

Background:

Syndesmotic injury in an athletic population is associated with a prolonged ankle disability after an ankle sprain and often requires a longer recovery than a lateral collateral ligament injury. Although several imaging tests are available, diagnosing syndesmotic instability remains challenging.

Purpose:

To determine the diagnostic accuracy of conventional ankle computed tomography (CT) scans with the joint in external rotation and dorsiflexion and compare it with that of conventional ankle CT scans in a neutral position.

Study Design:

Cohort study (Diagnosis); Level of evidence, 2.

Methods:

Between September 2018 and April 2021, this prospective study consecutively included adults visiting the foot and ankle outpatient clinic with a positive orthopaedic examination for acute syndesmotic injury. Participants underwent 3 CT scan tests. First, ankles were scanned in a neutral position. Second, ankles were scanned with 45° of external rotation, dorsiflexion, and extended knees. Third, ankles were scanned with 45° of external rotation, dorsiflexion, and flexed knees. Three measurements, comprising rotation (measurement a ), lateral translation (measurement c ), and anteroposterior translation (measurement f ) of the fibula concerning the tibia, were used to diagnose syndesmotic instability in the 3 CT scans. Magnetic resonance imaging was used as a reference standard. The area under the curve (AUC) was used to compare the diagnostic accuracy, and Youden’s J index was calculated to determine the ideal cutoff point.

Results:

Images obtained in 68 participants (mean age, 36.5 years; range, 18-69 years) were analyzed, comprising 36 syndesmotic injuries and 32 lateral collateral ligament injuries. The best diagnostic accuracy occurred with the rotational measurement a , in which the second and third CT scans with stress maneuvers presented greater AUCs (0.97 and 0.99) than did the first CT scan in a neutral position (0.62). The ideal cutoff point for the stress maneuvers was 1.0 mm in the rotational measurement a and reached a sensitivity and specificity of 83% and 97% for the second CT scan with extended knees and 86% and 100% for the third CT scan with flexed knees, respectively. The ideal cutoff point for the first CT scan with a neutral position was 0.7 mm in the rotational measurement a , with a sensitivity of 25% and specificity of 97%.

Conclusion:

Conventional ankle CT with stress maneuvers has excellent performance for diagnosing subtle syndesmotic rotational instability, as it shows a greater AUC and enhanced sensitivity at the ideal cutoff point compared with ankle CT in the neutral position.