Tibiofibular syndesmosis in acute ankle fractures: additional value of an oblique MR image plane

Objective: To evaluate the additional value of a 45° oblique MRI scan plane for assessing the anterior and posterior distal tibiofibular syndesmotic ligaments in patients with an acute ankle fracture. Materials and methods: Prospectively, data were collected for 44 consecutive patients with an acute ankle fracture who underwent a radiograph (AP, lateral, and mortise view) as well as an MRI in both the standard three orthogonal planes and in an additional 45° oblique plane. The fractures on the radiographs were classified according to Lauge-Hansen (LH). The anterior (ATIFL) and posterior (PTIFL) distal tibiofibular ligaments, as well as the presence of a bony avulsion in both the axial and oblique planes was evaluated on MRI. MRI findings regarding syndesmotic injury in the axial and oblique planes were compared to syndesmotic injury predicted by LH. Kappa and the agreement score were calculated to determine the interobserver agreement. The Wilcoxon signed rank test and McNemar's test were used to compare the two scan planes. Results: The interobserver agreement (κ) and agreement score [AS (%)] regarding injury of the ATIFL and PTIFL and the presence of a fibular or tibial avulsion fracture were good to excellent in both the axial and oblique image planes (κ 0.61-0.92, AS 84-95%). For both ligaments the oblique image plane indicated significantly less injury than the axial plane (p < 0.001). There was no significant difference in detection of an avulsion fracture in the axial or oblique plane, neither anteriorly (p = 0.50) nor posteriorly (p = 1.00). With syndesmotic injury as predicted by LH as comparison, the specificity in the oblique MR plane increased for both anterior (to 86% from 7%) and posterior (to 86% from 48%) syndesmotic injury when compared to the axial plane. Conclusion: Our results show the additional value of an 45° oblique MR image plane for detection of injury of the anterior and posterior distal tibiofibular syndesmoses in acute ankle fractures. Findings of syndesmotic injury in the oblique MRI plane were closer to the diagnosis as assumed by the Lauge-Hansen classification than in the axial plane. With more accurate information, the surgeon can better decide when to stabilize syndesmotic injury in acute ankle fractures.

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