Publications (20)26.99 Total impact
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Article: Chronic instability of the anterior tibiofibular syndesmosis of the ankle. Arthroscopic findings and results of anatomical reconstruction.
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ABSTRACT: The arthroscopic findings in patients with chronic anterior syndesmotic instability that need reconstructive surgery have never been described extensively. In 12 patients the clinical suspicion of chronic instability of the syndesmosis was confirmed during arthroscopy of the ankle. All findings during the arthroscopy were scored. Anatomical reconstruction of the anterior tibiofibular syndesmosis was performed in all patients. The AOFAS score was assessed to evaluate the result of the reconstruction. At an average of 43 months after the reconstruction all patients were seen for follow-up. The syndesmosis being easily accessible for the 3 mm transverse end of probe which could be rotated around its longitudinal axis in all cases during arthroscopy of the ankle joint, confirmed the diagnosis. Cartilage damage was seen in 8 ankles, of which in 7 patients the damage was situated at the medial side of the ankle joint. The intraarticular part of anterior tibiofibular ligament was visibly damaged in 5 patients. Synovitis was seen in all but one ankle joint. After surgical reconstruction the AOFAS score improved from an average of 72 pre-operatively to 92 post-operatively. To confirm the clinical suspicion, the final diagnosis of chronic instability of the anterior syndesmosis can be made during arthroscopy of the ankle. Cartilage damage to the medial side of the tibiotalar joint is often seen and might be the result of syndesmotic instability. Good results are achieved by anatomic reconstruction of the anterior syndesmosis, and all patients in this study would undergo the surgery again if necessary.BMC Musculoskeletal Disorders 09/2011; 12:212. · 1.58 Impact Factor -
Article: Pseudoarthrosis repair after failed metatarsophalangeal 1 arthrodesis.
Acta Orthopaedica 02/2011; 82(1):114-5. · 2.17 Impact Factor -
Article: Foot function after fusion of the first metatarsophalangeal joint.
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ABSTRACT: We measured with a validated score the operative outcome in patients without concomitant foot surgery who underwent fusion of the first metatarsophalangeal (MTP) joint for hallux rigidus (HR) and hallux valgus (HV). We also examined whether there is a correlation between foot function and hallux position to try to formulate an optimum fusion angle. Between 2002 and 2005, a consecutive series of 62 patients underwent crossed screw fusion of the first MTP joint (27 HR and 35 HV) without concomitant surgery of the same or contralateral foot or had previous surgery of the same foot. Foot function was measured by the Dutch Foot Function Index (FFI) pre- and postoperatively. Hallux valgus and dorsiflexion angles were measured on standing radiographs before operation and at followup. Postoperatively the median hallux valgus angle was 14 (range, -2 to 33) degrees and the median dorsiflexion angle was 23 (range, 7 to 45) degrees. The median FFI score improved from 38 (range, 0 to 80) to 8 (range, 0 to 59) (p < 0.001). The FFI score was not different between the HV and HR groups. There was no correlation between postoperative foot function, dorsiflexion angles and hallux valgus angles. Fusion of the first MTP joint in HR and HV results in improved function according to the validated FFI. There was no significant correlation between foot function and hallux position. This could be due to the fact that the desired position of the hallux was most often achieved.The Foot and Ankle Online Journal 08/2010; 31(8):670-5. · 1.22 Impact Factor -
Article: Surgical treatment of Achilles tendon ruptureExamination of strength of 3 types of suture techniques in a cadaver model
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ABSTRACT: Background The mechanical properties of present-day percutaneous repairs of Achilles tendon ruptures are not known. Material and methods Artificially-created ruptures in 24 human cadaveric Achilles tendons were repaired with an open Bunnell repair, a percutaneous calcaneal tunnel or a percutaneous bone-anchor repair. In the open technique no.1 PDS-II absorbable suture material was used, and in the percutaneous techniques either no.1 PDS-II or no.1 Panacryl absorbable suture material was used. The specimens were tested in a materials testing machine until failure occurred. Results The common mode of failure was suture breakage in non-anchor repairs, and anchor pullout in anchor repairs. The average strength of the repairs varied from 166 N (SD 60) to 211 N (SD 30), with no differences between the techniques (p = 0.5). Interpretation Taking costs into account, the percutaneous calcaneal tunnel technique and the open technique are the methods of choice.07/2009; 76(3):408-411. -
Article: Kinematics before and after reconstruction of the anterior syndesmosis of the ankleA prospective radiostereometric and clinical study in 5 patients
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ABSTRACT: Background We have previously shown that patients with instability of the anterior syndesmosis benefit from an anatomical reconstruction. It is not known whether this is because of restored kinematics. Methods In a prospective study of 5 patients, we assessed clinical findings and tibiofibular kinematics, evaluated by radiostereometry, before and after reconstruction of a chronic syndesmotic injury. Results We found no statistically significant differences in tibiofibular kinematics before and after reconstruction. The kinematics of the fibula relative to the tibia during external rotation stress differed from that known in asymptomatic volunteers, but the differences were not typical enough to differentiate between patients and healthy subjects. Clinical examination and ankle scores, however, showed that all patients benefited from reconstruction of the anterior syndesmosis. Interpretation Radiostereometry is not an adequate technique to diagnose chronic syndesmotic instability or to demonstrate restoration of the kinematics of the ankle as a cause of the beneficial effect of anatomical reconstruction of the syndesmosis.07/2009; 76(5):713-720. -
Article: Suture-button versus screw fixation in a syndesmosis rupture model: a biomechanical comparison.
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ABSTRACT: Flexible suture-button devices are used to stabilize the distal tibiofibular joint after syndesmotic rupture, but little is known about how they affect fibular motion during cyclic physiological loading. This study examined how much fibular motion occurs during cyclic loading of ankles repaired with suture-buttons or screws relative to one with intact ligaments. Ten pairs of cadaveric legs with intact ligaments were tested in axial compression (750 N), external rotational torque (7.5 Nm), and a combination thereof. Fibular rotation and translation in the sagittal and frontal planes were measured with linear variable displacement transducers. Then we sectioned the anterior tibiofibular, posterior tibiofibular, deltoid, and interosseous ligaments. Ankles were repaired with suture-buttons or a 3.5-mm screw through four-cortices. The ankles were tested for 10,000 cycles using the same loading protocol. Surviving ankles were brought to failure by increasing external rotation (1 degree/sec). Data from the linear variable differential transducers were used to calculate fibular motion at 100, 1,000, 5,000, and 10,000 cycles. There was no significant difference in the effect of the suture-button or screw for translation in the sagittal or coronal plane or for rotation about the fibular axis. The screw repair had a significantly greater (p = 0.02) failure torque (median, 26.5 Nm; inner quartile range, 25.7 to 35.2 Nm) than did the suture-button repair (median, 23.6 Nm; inner quartile range, 16.5 to 25.6 Nm). The fibular motion that occurs during cyclic loading appears to be similar for the suture-button and syndesmotic screw. Motion in both constructs was similar, but neither restored native ankle motion. It appears the suture-button behaves similarly to the syndesmotic screw in the syndesmotic rupture injury model tested. Clinical trials are needed to determine how the device performs in vivo.The Foot and Ankle Online Journal 05/2009; 30(4):346-52. · 1.22 Impact Factor -
Article: Revision arthrodesis of the ankle: posterior inlay bone grafting in 11 patients.
Acta Orthopaedica 05/2009; 80(2):256-8. · 2.17 Impact Factor -
Article: Percutaneous Achilles tendon lengthening: a cadaver-based study of failure of the triple hemisection technique.
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ABSTRACT: Modern descriptions of the percutaneous triple hemisection technique for Achilles tendon lengthening do not take into account the axial twist in the ligament. We were concerned that technical failures of the lengthening technique might occur more often than has been reported, and analyzed the results of the triple hemisection technique in cadaveric tendons in quantitative and qualitative terms, focusing on insufficient or complete tenotomies. We performed a percutaneous triple hemisection of the Achilles tendon in 20 legs from adult cadavers, and measured the increase in ankle dorsiflexion in degrees, the length of the cuts in mm, and the depth of the cuts as a percentage of the total diameter of the tendon. Failure of the hemisection was defined as a sliding gap of <or=2 mm and/or a cut depth of <or=25% or <75%. 21 of the 60 hemisections failed. These failures occurred in 12 of the 20 legs, and included 1 complete tendon rupture and 3 near-ruptures with only a few connecting fibers left. Our findings support our hypothesis that technical failures in the triple hemisection procedure occur more often than acknowledged. Despite the scarce but good clinical results described in children, we suggest performing this technique as an open procedure, especially in cases where the boundaries of the tendon are less easily palpable (adults, obese children), and to use the largest possible distance between the hemisections.Acta Orthopaedica 01/2008; 78(6):808-12. · 2.17 Impact Factor -
Article: Biomechanical comparison of the interosseous tibiofibular ligament and the anterior tibiofibular ligament.
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ABSTRACT: The mechanical importance of the interosseous tibiofibular ligament of the ankle is unclear. The purpose of the current study was to compare the stiffness and strength of the interosseous tibiofibular ligament to that of the anterior tibiofibular ligament. Twelve pairs of ankles were obtained from the Maryland State Anatomy Board. All soft tissue was removed except for the interosseous tibiofibular ligament in one ankle of each pair and the anterior tibiofibular ligament in the contralateral ankle. The assignment of which ligament would be excised in the right or left ankle of each pair was random. The specimens were potted as bone-ligament-bone preparations and mounted in a servohydraulic testing machine so that the ligament's long axis was coincident with the actuator. Specimens were elongated at 0.5 mm/s until rupture. Failure load and failure site were recorded, and stiffness was calculated. Stiffness and failure loads were compared with a paired t-test. Significance was set at p < 0.05. The interosseous ligament was significantly stiffer (234 +/- 122 N/mm) than the anterior tibiofibular ligament (162 +/- 64 N/mm). The mean failure load of the interosseous tibiofibular ligament (822 +/- 298 N) was significantly greater than that of the anterior tibiofibular ligament (625 +/- 255 N). The interosseous tibiofibular ligament is stiffer and stronger than the anterior tibiofibular ligament. CLINICAL RELEVANCE. The current study suggests that the interosseous ligament plays an important role in the stability of the ankle, and its status should be part of the diagnostic evaluation in syndesmotic instability.The Foot and Ankle Online Journal 05/2007; 28(5):602-4. · 1.22 Impact Factor -
Article: Sonography after total hip replacement: reproducibility and normal values in 47 clinically uncomplicated cases.
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ABSTRACT: Interpretation of sonographic data is difficult when hematoma after total hip replacement is suspected, as there are no normative data. We describe the normal sonographic image, focusing on the amount and location of postoperative fluid collections after a clinically uncomplicated, primary total hip replacement by the posterior approach. Inter- and intraobserver reproducibility is also considered. We performed sonography of the hip in 47 patients between the second and the fifth postoperative day. Bone-to-capsule distance and deep and superficial extraarticular fluid collections were measured. Intraclass correlation coefficients were calculated. The normal values of bone-to-capsule distance and amount of extraarticular fluid after total hip replacement were established from the upper bound of the 95% confidence interval. The upper bound for bone-capsule distance was 6 mm, for deep fluid collections 21 mm, and for superficial fluid collections 28 mm. In this clinically normal patient group, 4 patients had an extreme value (< 3 SD) for bone-to-capsule distance. For the deep and superficial fluid collections, no extremes were found. No correlation was found between bone-to-capsule distance and whether or not there was extraarticular fluid. Intraclass correlation coefficients were 0.98 for bone-to-capsule distance and 0.99 for fluid collection measurements. Sonography is a reproducible method for the evaluation of fluid collections after total hip replacement. The values measured can be helpful in decision making when there is clinical suspicion of postoperative hematoma after hip replacement by the posterior approach.Acta Orthopaedica 02/2007; 78(1):81-5. · 2.17 Impact Factor -
Article: Effects of ligament sectioning on the kinematics of the distal tibiofibular syndesmosis: a radiostereometric study of 10 cadaveric specimens based on presumed trauma mechanisms with suggestions for treatment.
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ABSTRACT: Syndesmotic injuries of the ankle without fractures can result from external rotation, abduction and dorsiflexion injuries. Kinematic studies of these trauma mechanisms have not been performed. We attempted to describe the kinematics of the tibiofibular joint in cadaveric specimens using radiostereometry after sequential ligament sectioning, and resulting from different trauma mechanisms and axial loading, in order to put forward treatment guidelines for the different types of syndesmotic injuries. We assessed the kinematics of the distal tibiofibular joint in fresh-frozen cadaveric specimens using radiostereometry in the intact situation, and after alternating and sequential sectioning of the distal tibiofibular and anterior deltoid ligaments. To assess which of the known trauma mechanisms would create the largest displacements at the syndesmosis, the ankle was brought into the following positions under an axial load that was comparable to body weight (750 N): neutral, dorsiflexion, external rotation, abduction, and a combination of external rotation and abduction. In the neutral position, the largest displacements of the fibula consisted of external rotation and posterior translation. Loading of the ankle with 750 N did not apparently increase or decrease the displacements of the fibula, but gave a larger variety of displacements. In every position, sectioning of a ligament resulted in some fibular displacement. Sectioning of the anterior tibiofibular ligament (ATiFL) invariably resulted in external rotation of the fibula. Additional sectioning of the anterior part of the deltoid ligament (AD) gave a larger variety of displacements. In general, sectioning of the posterior tibiofibular ligament (PTiFL) gave the smallest displacements. Combined sectioning of the ATiFL and the PTiFL resulted in a larger variety of displacements in the neutral position. Sectioning of the AD together with the ATiFL and PTiFL resulted in tibiofibular displacements in the neutral situation exceeding the maximum values found in the intact situation, the most important being fibular external rotation. Sectioning of the ATiFL results in mechanical instability of the syndesmosis. Of all trauma mechanisms, external rotation of the ankle resulted in the largest and most consistent displacements of the fibula relative to the tibia found at the syndesmosis. Based on our findings and the current literature, we recommend that patients with isolated PTiFL or AD injuries should be treated functionally when no other injuries are present. Patients with acute complete ATiFL ruptures, or combined ATiFL and AD ruptures should be treated with immobilization in a plaster. Patients with combined ruptures of the ATiFL, AD and PTiFL need to be treated with a syndesmotic screw.Acta Orthopaedica 07/2006; 77(3):531-40. · 2.17 Impact Factor -
Article: Prediction of torsional failure in 22 cadaver femora with and without simulated subtrochanteric metastatic defects: a CT scan-based finite element analysis.
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ABSTRACT: In metastatic bone disease, prophylactic fixation of impending long bone fracture is preferred over surgical treatment of a manifest fracture. There are no reliable guidelines for prediction of pathological fracture risk, however. We aimed to determine whether finite element (FE) models constructed from quantitative CT scans could be used for predicting pathological fracture load and location in a cadaver model of metastatic bone disease. Subject-specific FE models were constructed from quantitative CT scans of 11 pairs of human femora. To simulate a metastatic defect, a transcortical hole was made in the subtrochanteric region in one femur of each pair. All femora were experimentally loaded in torsion until fracture. FE simulations of the experimental set-up were performed and torsional stiffness and strain energy density (SED) distribution were determined. In 15 of the 22 cases, locations of maximal SED fitted with the actual fracture locations. The calculated torsional stiffness of the entire femur combined with a criterion based on the local SED distribution in the FE model predicted 82% of the variance of the experimental torsional failure load. In the future, CT scan-based FE analysis may provide a useful tool for identification of impending pathological fractures requiring prophylactic stabilization.Acta Orthopaedica 07/2006; 77(3):474-81. · 2.17 Impact Factor -
Article: Kinematics before and after reconstruction of the anterior syndesmosis of the ankle: A prospective radiostereometric and clinical study in 5 patients.
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ABSTRACT: We have previously shown that patients with instability of the anterior syndesmosis benefit from an anatomical reconstruction. It is not known whether this is because of restored kinematics. In a prospective study of 5 patients, we assessed clinical findings and tibiofibular kinematics, evaluated by radiostereometry, before and after reconstruction of a chronic syndesmotic injury. We found no statistically significant differences in tibiofibular kinematics before and after reconstruction. The kinematics of the fibula relative to the tibia during external rotation stress differed from that known in asymptomatic volunteers, but the differences were not typical enough to differentiate between patients and healthy subjects. Clinical examination and ankle scores, however, showed that all patients benefited from reconstruction of the anterior syndesmosis. Radiostereometry is not an adequate technique to diagnose chronic syndesmotic instability or to demonstrate restoration of the kinematics of the ankle as a cause of the beneficial effect of anatomical reconstruction of the syndesmosis.Acta Orthopaedica 11/2005; 76(5):713-20. · 2.17 Impact Factor -
Article: Surgical treatment of achilles tendon rupture: examination of strength of 3 types of suture techniques in a cadaver model.
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ABSTRACT: The mechanical properties of present-day percutaneous repairs of Achilles tendon ruptures are not known. Artificially-created ruptures in 24 human cadaveric Achilles tendons were repaired with an open Bunnell repair, a percutaneous calcaneal tunnel or a percutaneous bone-anchor repair. In the open technique no.1 PDS-II absorbable suture material was used, and in the percutaneous techniques either no.1 PDS-II or no.1 Panacryl absorbable suture material was used. The specimens were tested in a materials testing machine until failure occurred. The common mode of failure was suture breakage in non-anchor repairs, and anchor pullout in anchor repairs. The average strength of the repairs varied from 166 N (SD 60) to 211 N (SD 30), with no differences between the techniques (p = 0.5). Taking costs into account, the percutaneous calcaneal tunnel technique and the open technique are the methods of choice.Acta Orthopaedica 07/2005; 76(3):408-11. · 2.17 Impact Factor -
Article: Screw fixation of the syndesmosis: a cadaver model comparing stainless steel and titanium screws and three and four cortical fixation.
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ABSTRACT: We assessed syndesmotic set screw strength and fixation capacity during cyclical testing in a cadaver model simulating protected weight bearing. Sixteen fresh frozen legs with artificial syndesmotic injuries and a syndesmotic set screw made of stainless steel or titanium, inserted through three or four cortices, were axially loaded with 800 N for 225,000 cycles in a materials testing machine. The 225,000 cycles equals the number of paces taken by a person walking in a below knee plaster during 9 weeks. Syndesmotic fixation failure was defined as: bone fracture, screw fatigue failure, screw pullout, and/or excessive syndesmotic widening. None of the 14 out of 16 successfully tested legs or screws failed. No difference was found in fixation of the syndesmosis when stainless steel screws were compared to titanium screws through three or four cortices. Mean lateral displacement found after testing was 1.05 mm (S.D. = 0.42). This increase in tibiofibular width exceeds values described in literature for the intact syndesmosis loaded with body weight. Based on this laboratory study it is concluded that the syndesmotic set screw cannot prevent excessive syndesmotic widening when loaded with a load comparable with body weight. Therefore, we advise that patients with a syndesmotic set screw in situ should not bear weight.Injury 02/2005; 36(1):60-4. · 1.98 Impact Factor -
Article: Kinematics of the distal tibiofibular syndesmosis: radiostereometry in 11 normal ankles.
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ABSTRACT: In 11 healthy volunteers, the normal kinematics of the tibiofibular syndesmosis of the ankle during weight bearing and external rotation stress were compared to a nonweight-bearing neutral position by radiostereometry. We found very small rotations and displacements in this "normal" group, which indicated that the fibula is closely attached to the tibia, thereby preventing larger movements at the level of the ankle. We found no common kinematic pattern during weight bearing in the neutral position. Application of a 75 Nm external rotation moment on the foot caused external rotation of the fibula between 2 and 5 degrees, medial translation between 0 and 2.5 mm and posterior displacement between 1.0 and 3.1 mm. These data can be used as normal reference values for studies of patients with suspected syndesmotic injuries.Acta Orthopaedica Scandinavica 07/2003; 74(3):337-43. -
Article: A biomechanical evaluation of the tibiofibular and tibiotalar ligaments of the ankle.
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ABSTRACT: The purpose of this ex vivo biomechanical study was to determine the strength and stiffness of the anterior and posterior syndesmotic tibiofibular ligaments and the posterior tibiotalar component of the deltoid ligament. Injuries to these ligaments are a prevalent clinical problem, yet little is known about their mechanical behavior. Ten fresh-frozen cadaver lower extremities (average age at death, 72 +/- 8 years) were harvested. The anterior and posterior tibiofibular ligaments and the posterior tibiotalar component of the deltoid were isolated and prepared as bone-ligament-bone complexes for tensile testing to determine strength, stiffness, and mode of failure. The posterior tibiofibular ligament exhibited greater strength, but not significantly so (p < .05), than the anterior tibiofibular ligament and the posterior tibiotalar component of the deltoid ligament. There were no significant differences in stiffness between the three ligaments tested. The dominant mode of failure for the anterior tibiofibular ligament was ligament substance rupture, primarily near its fibular insertion, whereas the failure modes of the posterior tibiofibular ligament were evenly split between substance ruptures and fibular avulsions. The posterior tibiotalar component of the deltoid ligament ruptured most often near the talar insertion. The tibiofibular ligaments showed greater strength than the lateral collateral and deltoid ligaments, as mentioned in literature. The greater strength of the tibiofibular ligaments relative to the lateral collateral and deltoid ligaments suggests that these ligaments play an important role in ankle constraint.The Foot and Ankle Online Journal 05/2003; 24(5):426-9. · 1.22 Impact Factor -
Article: External rotation stress imaging in syndesmotic injuries of the ankle: comparison of lateral radiography and radiostereometry in a cadaveric model.
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ABSTRACT: We compared the value of 7.5 Nm external rotation stress in diagnosing tibiofibular syndesmotic injuries of the ankle on lateral radiographs with radiostereometric analysis (RSA) in 10 cadaveric legs. After sectioning 2 ligaments, RSA showed an increase in posterior translation and external rotation of the fibula. This increase in posterior translation was smaller than the posterior displacement of the fibula on the lateral radiograph, and RSA showed mainly an increase in external rotation of the fibula that can not be measured on conventional radiographs. We conclude that instability of the syndesmosis in cadaveric ankles can be detected with 7.5 Nm external rotation stress RSA, but that external rotation stress lateral radiography is unreliable.Acta Orthopaedica Scandinavica 05/2003; 74(2):201-5. -
Article: A biomechanical evaluation of clinical stress tests for syndesmotic ankle instability.
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ABSTRACT: Displacement transducers were placed across the anterior and posterior tibiofibular ligaments of 17 fresh cadaver (78.4 +/- 6.7 years old at death) lower extremities. Displacements induced by various clinical tests (squeeze, fibula translation, Cotton, external rotation, and anterior drawer) were measured with the ankle ligaments intact and after sequential sectioning of the anterior tibiofibular ligament, anterior deltoid ligament, and posterior tibiofibular ligament. None of the syndesmotic stress tests could distinguish which ligaments were sectioned. Furthermore, the small displacements measured during the stress tests (with the exception of the external rotation test) suggest it is unlikely that the displacement induced in injured syndesmoses can be clinically differentiated from normal syndesmoses. Therefore, pain, rather than increased displacement, should be considered the outcome measure of these tests.The Foot and Ankle Online Journal 05/2003; 24(4):358-63. · 1.22 Impact Factor -
Article: Clinical diagnosis of syndesmotic ankle instability: evaluation of stress tests behind the curtains.
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ABSTRACT: We studied the feasibility of clinical tests in the diagnosis of syndesmotic injury of the ankle. 9 investigators examined 12 persons twice, including 2 patients with an arthroscopically-confirmed syndesmotic injury. They sat behind a curtain that exposed only the lower legs. We found a statistically significant relation between the final arthroscopic diagnosis and the squeeze, fibula translation, Cotton, and external rotation tests as well as for limited dorsal flexion. None of the syndesmotic tests was uniformly positive in chronic syndesmotic injury. The external rotation test had the fewest false-positive results, the fibula translation test the most. The external rotation test had the smallest inter-observer variance. The physical diagnosis was missed in one fifth of all examinations. When in accordance with medical history and physical examination, positive stress tests should raise a high index of suspicion of syndesmotic instability. The final diagnosis of such instability, however, should be made by additional diagnostic imaging and/or arthroscopy.Acta Orthopaedica Scandinavica 01/2003; 73(6):667-9.
Top co-authors
Top Journals
Institutions
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2006–2011
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Sint Maartenskliniek
Nijmegen, Provincie Gelderland, Netherlands
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2005–2009
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Erasmus Universiteit Rotterdam
- Department of Orthopaedics
Rotterdam, South Holland, Netherlands
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2007–2008
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Johns Hopkins University
- Department of Orthopaedic Surgery
Baltimore, MD, USA
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2003
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University of Maryland, Baltimore
Baltimore, MD, USA
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