diagnostics

Article
The Valid Diagnostic Parameters in Bilateral CT Scan
to Predict Unstable Syndesmotic Injury with
Ankle Fracture
Si-Wook Lee 1 , Kyung-Jae Lee 1 , Chul Hyun Park 2 , Hyuk-Jun Kwon 1 and Beom-Soo Kim 1, *
1 Department of Orthopedic Surgery, Keimyung University Dongsan Hospital, Keimyung University School
of Medicine, Daegu 42601, Korea; [email protected] (S.-W.L.); [email protected] (K.-J.L.);
[email protected] (H.-J.K.)
2 Department of Orthopedic Surgery, Yeungnam University Medical Center, Hyeonchungno 170, Nam-gu,
Daegu 42415, Korea; [email protected]
* Correspondence: [email protected]; Tel.: +82-53-258-4771




Received: 31 August 2020; Accepted: 12 October 2020; Published: 13 October 2020


Abstract: The purpose of this study is to evaluate the reasonable parameters to predict unstable
syndesmotic injuries in ankle fractures. Seventy consecutive patients who underwent preoperative
bilateral computed tomography (CT) scans were enrolled. Group A consisted of 20 patients
intraoperatively diagnosed with syndesmotic injuries according to an intraoperative stress test and
group B consisted of 50 patients who had nosyndesmotic injuries. The tibiofibular overlap (TFO) and
tibiofibular clear space (TFCS) were measured using preoperative ankle radiographs. Measuring
the anterior fibular distance (AFD), posterior fibular distance (PFD), anterior translation distance
(AT), fibular diastasis (FD), anterior-posterior translation (APT), fibular length (FL), and surface area
of syndesmosis (SAS) 1.0 and 1.5 which 1.0 cm and 1.5 cm above the tibial plafond was done via
preoperative CT scan. The ratio of measurements (Injured/Intact) of the TFO, PFD, APD, and SAS
1.0 showed statistically significant differences. The researchers identified the SAS 1.0 as the most
reasonable parameter to predict transfixation using receiver-operating characteristic (ROC) curve
analysis. The SAS 1.0 is most valid parameter to predict syndesmotic injuries in this study and
these results show that performing a bilateral CT scan on an ankle fracture may provide substantial
information in measuring valid parameters.

Keywords: ankle fracture; syndesmotic injury; computed tomography; tibiofibular transfixation

1. Introduction
In unstable ankle fractures with syndesmotic injuries, an open reduction and internal fixation
of fracture site and stabilization of syndesmosis are required in an effort to minimize the risk of
posttraumatic arthritis [1]. Syndesmotic injuries in ankle fractures are challenging to treat in particular,
not to mention relatively common in fields that require intense physical activity [2–4]. Measuring
the tibiofibular clear space (TFCS) and the tibiofibular overlap (TFO) in a classic radiograph is the
standard evaluation method [5–7], but they show only one side of the ankle structure. In addition,
fractures around the tibia and the fibular can result in various clinical features that complicate classic
radiography diagnosis. An intraoperative stress test, such as an external rotation test or hook test [8,9],
can be used as more accurate dynamic test tool. However, this also has its limitations, as it requires
anesthesia, preventing preoperative information from being provided.
On the other hand, computed tomography (CT) scans have recently proven effective in diagnosing
fracture patterns and associated syndesmotic ankle injuries. CT scans provide a wealth of information
on fracture patterns by producing clear visualizations of bones and surrounding anatomic structures.

Diagnostics 2020, 10, 812; doi:10.3390/diagnostics10100812 www.mdpi.com/journal/diagnostics

Diagnostics 2020, 10, 812 2 of 10

Moreover, scanning contralateral ankle images at the same time also creates a perfect “template” of
a patient’s uninjured anatomy without expending too much time and effort [10–12]. In particular,
axial CT imaging is sensitive at detecting rotational mal-reductions [13].
There are many approaches to measuring, evaluating, and predicting syndesmotic injuries.
TFCS and TFO are relatively well-known measurements that can be acquired via plain radiography [5,14].
Predicting syndesmotic injuries requires the evaluation of specific parameters, namely: anterior fibular
distance (AFD), posterior fibular distance (PFD), anterior translation distance (AT), fibular diastasis
(FD), anterior-posterior translation (APT), and fibular length (FL) [15,16]. However, these parameters
still have limits and remain inconsistent in reliably predicting syndesmotic ankle injuries [17–19].
The differences in reported values are the result of methodological differences in research
designs, techniques used to produce the measurements, measurement errors, or differences among
patient populations.
Although the CT scan is considered a valid method for detecting syndesmotic injury, there has
been no substantial attempt to utilize the two-dimensional information given in CT scans. Therefore,
the objective of this study was two-fold: (1) to evaluate the current parameters in predicting unstable
syndesmotic injuries and (2) to validate the efficacy of the new parameters measured in bilateral CT
before comparing the injured side with the intact side.

2. Materials and Methods

The present study reviewed 103 consecutive patients with ankle fractures who took preoperative
bilateral CT scans and were operatively treated between 2008 and 2017. The researchers diagnosed
these patients through physical examinations, noting their medical histories, and detailed image
studies. Juveniles with incomplete growth arrest, ankle fractures with entire dislocations, a history
of previous syndesmotic injury, and bilateral ankle fractures were excluded from this study. Thus,
the remaining 70 patients (140 ankles) were enrolled in this retrospective study. The researchers were
able to obtain the approval of the institutional review board to identify cases for this retrospective
cohort study (Dongsan Hospital Institutional Review Board number: 2019-10-008; 11 October 2019).
The mean patient age at the time of injury was 39.5 years (range: 18–87 years). Meanwhile,
the mean duration between the time of injury and the time of surgery was 5.74 days (range: 1–48 days).
The patients were divided into two groups according to their intraoperative dynamic stress test results
to compare their clinical and radiologic outcomes before and after the operation. One group (group
A) consisted of 20 patients intraoperatively diagnosed with syndesmotic injuries throughout positive
stress test, resulting in tibiofibular transfixation. The other group (group B) consisted of 50 patients
whose intraoperative tests were negative and were consequently treated without transfixation.

2.1. Assessment of Syndesmotic Injury during Surgery

An unstable syndesmotic injury was confirmed under anesthesia with an external rotational stress
test or hook test after the reduction and fixation of the fibular fracture. Initially, the fibular fixation was
done with plate fixation, followed by fixation of the medial malleolar if there was a fracture. After the
lateral and medial malleolar fracture was fixed, the posterior malleolar fracture was not fixed if there
was no rotation or displacement, and if there was a posterior malleolar fracture containing more than
20% of the articular surface, fixation was performed. After fixation for these fractures was completed,
a stress test was performed to find syndesmotic injury that needed fixation.
During the external rotation stress test, the tibia was stabilized while the foot was neutrally
flexed and externally rotated under fluoroscopy. A positive external-rotation stress test, indicated by a
widened TFCS of more than 5 mm, suggested syndesmotic injury [7]. For the hook test, the surgeon
pulled the lateral malleolus with a bone hook while stabilizing the tibia. Lateral fibula movement
of more than 2 mm indicated a positive hook test [8]. After the fixation of the fracture, tests were
performed again under fluoroscopic visualization, to clarify the syndesmotic reduction (Figure 1).
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Figure
Figure 1. 1. Thirty-seven-year-oldmale
Thirty-seven-year-old male with
with left
left ankle
ankle fracture.
fracture. Preoperative
Preoperativeanterior-posterior
anterior-posterior (AP)
(AP)
and lateral radiographs (A). Bilateral axial computed tomography (CT) scan of intact
and lateral radiographs (A). Bilateral axial computed tomography (CT) scan of intact (B) and injured (B) and injured
ankle
ankle (C)(C)with
withsurface
surface area
area of
of syndesmosis
syndesmosis(SAS)(SAS) measured.
measured. The The
ratioratio
of hisofSAS
his(injured/intact) was
SAS (injured/intact)
1.65. Corresponding coronal section (D) at level of 1.0 cm (a) and 1.5 cm (b) above
was 1.65. Corresponding coronal section (D) at level of 1.0 cm (a) and 1.5 cm (b) above the tibial the tibial plafond.
Intraoperative
plafond. fluoroscopic
Intraoperative image (E)
fluoroscopic during
image (E) stress
during test demonstrates
stress possible possible
test demonstrates syndesmotic injury.
syndesmotic
Immediate postoperative AP and lateral radiographs with syndesmosis transfixation
injury. Immediate postoperative AP and lateral radiographs with syndesmosis transfixation included. included. (F)
Last follow up of AP and lateral radiographs (G) with implanted devices removed without diastasis
(F) Last follow up of AP and lateral radiographs (G) with implanted devices removed without diastasis
recurrence 11 months later.
recurrence 11 months later.

2.2.2.2. Clinical
Clinical andand RadiologicalAssessment
Radiological Assessment

AnAn imaging
imaging study
study including
including ankle
ankle anteroposterior
anteroposterior radiograph
radiograph andand CT scan
CT scan was was performing
performing before
before the surgery. All parameters were measured as the ratio of the intact side
the surgery. All parameters were measured as the ratio of the intact side and the injured side, not and the injured side,the
not the measured
measured indexThis
index values. values.
wasThis was possible
possible becausebecause bilateral
bilateral radiographs
radiographs and bilateral
and bilateral CT wereCT were
taken
taken for this study, and this was done after obtaining patient consent. CT scans were acquired using
for this study, and this was done after obtaining patient consent. CT scans were acquired using a
a Siemens SOMATOM Sensation 64-slice CT scanner (Siemens, Erlangen, Germany) and a standard
Siemens SOMATOM Sensation 64-slice CT scanner (Siemens, Erlangen, Germany) and a standard
ankle coil with 1 mm sliced cuts. The TFCS and TFO were measured from the radiograph using a
ankle coil with 1 mm sliced cuts. The TFCS and TFO were measured from the radiograph using a PACS
PACS viewer (INFINITT PACS; Infinitt Healthcare, Seoul, South Korea), while the AFD, PFD, AT,
viewer (INFINITT PACS; Infinitt Healthcare, Seoul, South Korea), while the AFD, PFD, AT, FD, APT,
FD, APT, and FL [15,16,19] were measured in preoperative bilateral CT scans, 1.0 cm above the tibial
and FL [15,16,19] were measured in preoperative bilateral CT scans, 1.0 cm above the tibial plafond.
plafond.
TheThestudy
studyalso
alsoutilized
utilizeda anew
newparameter
parameter to to evaluate syndesmoticinjuries.
evaluate syndesmotic injuries.The
Thesurface
surface area
area of of
syndesmosis (SAS) was measured 1.0 cm and 1.5 cm above the tibial plafond.
syndesmosis (SAS) was measured 1.0 cm and 1.5 cm above the tibial plafond. From here, the From here, the researchers
named them SAS
researchers 1.0 them
named and SASSAS1.5, respectively.
1.0 and The methodThe
SAS 1.5, respectively. for method
measurements of SAS 1.0 of
for measurements and SAS
SAS 1.01.5
was established by a consultative meeting made up of specialist in ankle joint trauma
and SAS 1.5 was established by a consultative meeting made up of specialist in ankle joint trauma (SWL, CHP, BSK).
The inferior border of the tibial plafond was first identified on the axial section
(SWL, CHP, BSK). The inferior border of the tibial plafond was first identified on the axial section and cross-referenced
with
andthecross-referenced
coronal section withwith the
scout imaging
coronal using
section CT scout
with scan. Each parameter
imaging using CT (SAS 1.0Each
scan. and SAS 1.5) was
parameter
measured
(SAS 1.0inand the SAS
axial1.5)
section
was of CT scan,in
measured which corresponds
the axial section ofwith
CTthe coronal
scan, whichsection 1.0 cm with
corresponds and 1.5
thecm
coronal section 1.0 cm and 1.5 cm above tibial plafond. (Figure 2). If there is a fracture
above the tibial plafond (Figure 2). If there is a fracture line in the area to be measured at fibular site,
the line in the
area
that areato was
be measured
includedatasfibular site,
fracture that area was included as fracture diastasis.
diastasis.
Diagnostics 2020, 10, 812 4 of 10
Diagnostics 2020, 10, x FOR PEER REVIEW 4 of 10

Figure 2. The surface

surface area of syndesmosis, which was measured as a new parameter between four
anatomic landmark
landmarkpoints
pointson
onthe
theaxial
axialCTCT image;
image; thethe points
points thatthat
linklink
the the anterior
anterior colliculus
colliculus of theoftibia
the
tibiathe
(A), (A),most
the most anterior
anterior aspectaspect
of theoffibular
the fibular (B),posterior
(B), the the posterior colliculus
colliculus of theoftibia
the (C),
tibiaand
(C),the
and the
most
most posterior
posterior aspectaspect
of theof the fibular
fibular (D). (D).

2.3. Statistical
2.3. Statistical Analysis
Analysis
The researchers
The researchersused a Mann-Whitney
used a Mann-Whitney test totest
compare the ratio of
to compare preoperative
the and postoperative
ratio of preoperative and
parameters
postoperative between groupsbetween
parameters A and B.groups
Such a A comparison
and B. Such canaconfirm whether
comparison canthe parameters
confirm in both
whether the
groups show any statistical difference. Next, the researchers performed a Shapiro-Wilk
parameters in both groups show any statistical difference. Next, the researchers performed a Shapiro- test to test the
assumption of normal distribution and the homogeneity of variances. The researchers
Wilk test to test the assumption of normal distribution and the homogeneity of variances. The then performed
a receiver-operating
researchers characteristic
then performed curve (ROC) analysis
a receiver-operating to verify the
characteristic ideal(ROC)
curve parameter [20]. to
analysis Furthermore,
verify the
for evaluating the sensitivity and specificity, the researchers investigated with linear
ideal parameter [20]. Furthermore, for evaluating the sensitivity and specificity, the researchers regression analysis
using support vector machine between parameters. Statistical significance was
investigated with linear regression analysis using support vector machine between parameters. set at a p-value of <0.05.
Statistical analyses
Statistical were
significance performed
was using SPSS
set at a p-value of < software 21.0 (SPSS
0.05. Statistical Inc., were
analyses Chicago, IL, USA).
performed using SPSS
software 21.0 (SPSS Inc., Chicago, IL, USA).
3. Results
3. Results
The mean age of patients mean age was 51.0 years (range: 18–78 years), with 41 males and
29 females. The affected limbs were 26 left-side ankles and 44 right-side ankles. All these cases were
The mean age of patients mean age was 51.0 years (range: 18–78 years), with 41 males and 29
found to have four main causes: slip-and-fall injuries (43 cases), compression injuries from heavy
females. The affected limbs were 26 left-side ankles and 44 right-side ankles. All these cases were
objects (five cases), traffic accidents (18 cases), and falling from a height (four cases). There were
found to have four main causes: slip-and-fall injuries (43 cases), compression injuries from heavy
no statistically significant differences between groups A and B in terms of age, sex, affected side,
objects (five cases), traffic accidents (18 cases), and falling from a height (four cases). There were no
and body mass index (BMI) (Table 1). However, in these two groups, the fracture patterns, using the
statistically significant differences between groups A and B in terms of age, sex, affected side, and
Lauge-Hansen classification system, is significantly different (Table 1).
body mass index (BMI) (Table 1). However, in these two groups, the fracture patterns, using the
Since patients in group B were treated without transfixation, the study put a particular focus on
Lauge-Hansen classification system, is significantly different (Table 1).
group A, where patients were treated with transfixation. In group A, seven out of 20 patients (35%)
Since patients in group B were treated without transfixation, the study put a particular focus on
were treated with two transfixation materials. Two of them were with a suture-button device, while the
group A, where patients were treated with transfixation. In group A, seven out of 20 patients (35%)
remaining five were with cortical screws. Post-operation, six patients (30%) required the transfixation
were treated with two transfixation materials. Two of them were with a suture-button device, while
of three cortices on tibia and fibula, while the remaining 14 patients (70%) with cortical screws and a
the remaining five were with cortical screws. Post-operation, six patients (30%) required the
suture-button device required transfixing four cortices.
transfixation of three cortices on tibia and fibula, while the remaining 14 patients (70%) with cortical
Statistically significant differences were found between the ratio (injured/intact) of TFO (p = 0.001),
screws and a suture-button device required transfixing four cortices.
PFD (p = 0.047), APT (p = 0.044), and FD (p = 0.003) between both groups. SAS 1.0 (p = 0.002) was also
Statistically significant differences were found between the ratio (injured/intact) of TFO (p =
significant, whereas SAS 1.5 (p = 0.125) was confirmed as not statistically valid (Table 2). Within these
0.001), PFD (p = 0.047), APT (p = 0.044), and FD (p = 0.003) between both groups. SAS 1.0 (p = 0.002)
proven parameters, the researchers performed a ROC curve analysis. The result showed that the
was also significant, whereas SAS 1.5 (p = 0.125) was confirmed as not statistically valid (Table 2).
Within these proven parameters, the researchers performed a ROC curve analysis. The result showed
that the ratio of SAS was the most reasonable, having the highest sensitivity and specificity among
Diagnostics 2020, 10, x FOR PEER REVIEW 5 of 10
Diagnostics 2020, 10, 812 5 of 10

the other parameters of radiograph and CT (95% confidence interval = 0.598–0.869) (Figure 3) (Table
3). Its cut-off value is 1.56. In group A, 13 patients (65%) showed SAS 1.0 ratios higher than 1.56. In
ratio of SAS was the most reasonable, having the highest sensitivity and specificity among the other
group B, six patients (12%) showed SAS 1.0 ratios higher than 1.56. In addition, TFO was the highest
parameters of radiograph and CT (95% confidence interval = 0.598–0.869) (Figure 3) (Table 3). Its cut-off
for the positive prediction value, and PFD and FD were the highest for the negative prediction value
value is 1.56. In group A, 13 patients (65%) showed SAS 1.0 ratios higher than 1.56. In group B,
(Table 4). SAS 1.0 was 52% and 84% in positive prediction value and negative value, respectively, and
six patients (12%) showed SAS 1.0 ratios higher than 1.56. In addition, TFO was the highest for the
statistically, the diagnostic significance of SAS 1.0 was similar compared to the four parameters (TFO,
positive prediction value, and PFD and FD were the highest for the negative prediction value (Table 4).
PFD, APT, and FD).
SAS 1.0 was 52% and 84% in positive prediction value and negative value, respectively, and statistically,
the diagnostic significance of SAS 1.0 was similar compared to the four parameters (TFO, PFD, APT,
Table 1. Patient demographics.
and FD).
Group A * Group B **
Table 1. Patient demographics. p-Value
(n = 20) (n = 50)
Sex (male:female) 14:06 Group 3:23
Group A * B **
0.156
Mean age (year) 46.4 52.9 p-Value
0.116
(n = 20) (n = 50)
Side of injury (Right:Left)
Sex (male:female) 14:06 11:9 3:2333:17 0.775
0.156
BodyMeanmassageindex
(year) (kg/m )
2
46.4 24.05 52.924.83 0.662
0.116
Duration since
Side trauma
of injury till operation (days) 11:9 7.57
(Right:Left) 33:175.02 0.788
0.775
Body mass index (kg/m 2) 24.05 24.83 0.662
Mechanism of injury 0.064
Duration since trauma till operation (days) 7.57 5.02 0.788
Traffic accident 8 10
Mechanism of injury 0.064
Slip-and-fall
Traffic accident 8 7 10 36
Fall from a height
Slip-and-fall 7 3 36 1
Fall Compression
from a height 3 2 1 3
Lauge-Hansen Compression
Classification of fracture 2 3 <0.001
Lauge-Hansen Classification of fracture <0.001
Supination adduction 0 4
Supination adduction 0 4
Supination external
Supination external rotationrotation 1 1 42 42
Pronation
Pronation abduction
abduction 1 1 2 2
Pronation
Pronation external
external rotation
rotation 18 18 2 2
**Group
GroupA,A, patients
patients whowho had suspected
had suspected syndesmotic
syndesmotic injury
injury under under intraoperative
intraoperative stress B,
stress test; ** Group test; ** Group
patients who
were suspected not to have syndesmotic injury under intraoperative stress test.
B, patients who were suspected not to have syndesmotic injury under intraoperative stress test.

Figure 3.
Figure 3. Receiver-operating
Receiver-operating characteristic
characteristic(ROC)
(ROC)curve
curveanalysis.
analysis.The
Theresult
resultshowed that
showed thethe
that ratio of
ratio
SAS
of 1.01.0
SAS was
wasthe
themost
mostreasonable,
reasonable,having
havingthethehighest
highest sensitivity
sensitivity and
and specificity among the
the other
other
parametersof
parameters ofradiograph
radiographand
andCTCT(95%
(95%CICI== 0.598–0.869).
0.598–0.869).
Diagnostics 2020, 10, 812 6 of 10

Table 2. The ratio of measurements of ankle with syndesmotic injury and intact ankle.

Radiologic Reference Line Group Mean Ratio (Injured/Intact) SD p-Value

A* 0.57 0.27
TFO 0.001
B ** 0.87 0.39
A 1.51 0.87
TFCS 0.131
B 1.14 0.53
A 1.32 0.47
AFD 0.11
B 1.15 0.51
A 1.25 0.52
PFD 0.047
B 1.04 0.29
A 1.22 0.44
AT 0.178
B 1.13 0.61
A 1.78 0.99
FD 0.003
B 1.12 0.38
A 1.16 0.27
APT 0.044
B 1.01 0.18
A 1.01 0.11
Fibular length 0.104
B 1.09 0.2
A 1.98 0.98
SAS 1.0 0.002
B 1.41 0.33
A 1.47 0.58
SAS 1.5 0.125
B 1.37 0.22
* Group A, patients who had suspected syndesmotic injury under intraoperative stress test; ** Group B, patients
who were suspected not to have syndesmotic injury under intraoperative stress test; SD, standard deviation; TFO,
tibiofibular overlap; TFCS, tibiofibular clear space; AFD, anterior fibular distance; PFD, posterior fibular distance;
AT, anterior translation distance; FD, fibular diastasis; APT, anterior-posterior translation; SAS 1.0, surface area of
syndesmosis that was 1.0 cm above the tibial plafond; SAS 1.5, surface area of syndesmosis that was 1.5 cm above
the tibial plafond.

Table 3. The receiver-operating characteristic curve analysis of the ratio of parameters (injured/intact).

Approximate 95% CI
Radiologic Parameter Area Standard Error Significance Probability
Lower Limit Upper Limit
TFO 0.245 0.068 0.001 0.112 0.378
PFD 0.653 0.071 0.047 0.513 0.793
APT 0.655 0.078 0.044 0.501 0.809
FD 0.732 0.067 0.003 0.600 0.863
SAS 1.0 0.734 0.069 0.002 0.598 0.869
TFO: tibiofibular overlap; PFD: posterior fibular distance; APT: anterior-posterior translation; FD fibular diastasis:
SAS 1.0; surface area of syndesmosis that was 1.0 cm above the tibial plafond.

Table 4. The sensitivity, specificity, and positive and negative predictive values of ratio of parameters.

Radiologic Parameter Sensitivity Specificity Positive Predictive Value (%) Negative Predictive Value (%)
TFO 0.920 0.500 71 82
PFD 0.800 0.600 44 88
APT 0.650 0.580 38 81
FD 0.850 0.460 39 88
SAS 1.0 0.650 0.820 52 84
TFO: tibiofibular overlap; PFD: posterior fibular distance; APT: anterior-posterior translation; FD fibular diastasis:
SAS 1.0; surface area of syndesmosis that was 1.0 cm above the tibial plafond.
Diagnostics 2020, 10, 812 7 of 10

4. Discussion
The purpose of this study is to evaluate the classical radiographic parameters and newly established
parameters to predict syndesmotic injuries in unstable ankle fractures using bilateral radiograph
and CT scan. The results of this study revealed that TFO, PFD, APT, and SAS 1.0 were significantly
reasonable parameters in judging syndesmotic injury. Among these parameters, SAS 1.0 is the most
reliable reference for predicting syndesmotic injuries, and if the SAS 1.0 is 1.56 times larger than
that of the intact side, there is a high possibility of syndesmotic injury. These results can predict
syndesmotic stabilization prior to surgical treatment of ankle fractures and provide information on the
fracture mechanism.
There are some limitations to this study. First, the surgeon who performed the diagnostic physical
examination (either an external rotational stress test or a hook test) was aware of previous patient
information (radiograph and CT scans), including clinical data and radiological examinations. Second,
these parameters were measured only once. However, at the time of measurement, two ankle specialists
and two orthopedic surgeons performed measurements through a common consensus, thus, bias has
not influenced the results. Third, this study was retrospective in design, with a relatively small number
of patients in subgroups. This study also focused on diagnoses and methods for assessing syndesmotic
injuries, not clinical outcomes. A study with a more extended replication period, that correlates the
result with the clinical and the functional outcome possible, would provide surgeons with better
suggestions in deciding transfixation in syndesmotic injuries.
Despite these limitations, the present study’s findings are valuable because it included consecutive
patients treated by a single surgeon at a single institution that had consistent results. In addition,
studying the results of other known parameters to test and compare their validity before introducing a
new valid parameter is advantageous. Furthermore, since this study was measured as a ratio through
comparison with the intact side, it has the advantage of being able to obtain accurate predictions
regardless of race.
The present study also sought a parameter that is more appropriate for Asian patients. There have
been several studies that have reported the absolute value of the difference between the posterior and
anterior tibiofibular distance in Western patients [10,21]. One study by Gardner et al. [10] stated a
criterion of 2 mm for syndesmosis malreduction. Another study by Elgafy et al. [21] reported average
values of 2 mm and 4 mm for the absolute distance between the tibia and fibula (anterior and posterior).
However, these values do not directly apply to an Asian population. Consequently, Nault et al. [22]
reported that these criteria were possibly overestimated and unreliable. Therefore, the present study’s
goal was to develop a more versatile diagnostic parameter that not only includes Asian patients but
also allows it to be measured and calculated with a bilateral CT scan without any additional equipment.
Syndesmotic injuries in ankle fractures that were initially observed through simple radiographs
were believed to provide fair information for diagnosis [6]. The results of our study confirm that TFO
is a prominent parameter for diagnosing syndesmotic injuries. However, some syndesmotic injuries
in ankle fractures are occasionally concealed or overlooked in classic radiographs [23]. Specifically,
tibia and fibula displacement in the anterior-posterior (AP) direction is not sufficiently observable in a
radiograph’s AP view [17]. In such cases, CT scans can be an alternative diagnostic tool for presenting
morphologic information and providing measured quantitative data to predict a syndesmotic ankle
injury [14,24,25].
Although acquiring quantitative measurements from CT scans may vary with inspectors, it can
show more insightful spatial anatomic information compared with classic radiographs. As ankle
fractures can result in various disintegration patterns of anatomical structures, classic radiographs
may be insufficient in providing a comprehensive understanding of the structure. These advantages
leverage the CT scan as a valuable method for ankle fracture diagnosis, screening, and follow-up [10,17].
The question of which diagnostic parameter is the most accurate remains controversial [15,19].
Several studies have adopted different tools for optimal diagnosis because of the highly distinct
variations in measurements and discrepancies between image and intraoperative inspections of
Diagnostics 2020, 10, 812 8 of 10

syndesmotic injuries. In addition, the parameters suggested in prior studies were based on Western
patients, whose physiques differ from most Asians [10,14–17]. Therefore, we utilized bilateral imaging to
compare and minimize the differences between populations and individuals. Preoperatively diagnosing
a syndesmotic injury in an ankle fracture provides various advantages to medical professionals in
predicting an operation’s overall outcome, enabling advanced preparation. In this study, we found TFO,
PFD, FD, APT, and SAS 1.0 as parameters with the highest potential in such preoperative diagnosis,
regardless of differences among individuals.
The introduction of SAS 1.0 was a trial to utilize the two-dimensional image information in
evaluating ankle fractures with syndesmotic injuries. We speculated that a two-dimensional surface
area would stand out with better spatial comprehension of anatomic structures between the tibia
and the fibula. The SAS 1.0 was measured 1.0 cm above the tibial plafond, which represents the
deepest part of the incisura fibulae, similar to previous studies that utilized axial CT scans [9,12–14].
When more than one transfixation between tibia and fibula is performed, the area 15 mm above it
is commonly transfixed [9,25]. Therefore, by analyzing the level of measurement, the SAS 1.5 was
measured 1.5 cm above the tibial plafond and resulted in no better validity than the SAS measured
1.0 cm above the tibial plafond. This study confirmed that the SAS 1.0 ratio could be a useful diagnostic
tool for syndesmotic injuries.
Although SAS 1.0 showed the most statistical validity among all radiological parameters,
only 13 patients out of 20 in group A had a SAS 1.0 ratio higher than the cut off value of 1.56.
The SAS 1.0 ratio of six out of 50 patients from group B was also higher than 1.56, but transfixation
was still not performed. These results demonstrate a fair number of syndesmotic injuries concealed
by radiological diagnosis. Therefore, these injuries require an intraoperative stress test to confirm.
Although numerous trials were using preoperative radiologic imaging, which allows surgeons to
predict syndesmotic injuries, the present study indicates that an intraoperative stress test has better
potential. Future studies with larger cohorts, valid parameters, and different measurement levels,
and studies that include volumetric measurements in a three-dimensional context, may provide
more information.

5. Conclusions
The results of this study showed that TFO, PFD, APT, and SAS 1.0 were significantly reasonable
parameters in judging syndesmotic injury. In particular, this study demonstrated that performing
preoperative bilateral CT scans and measuring the SAS 1.0 to compare with the uninjured side are
useful and reliable diagnostic methods for predicting syndesmotic injuries in ankle fractures.

Author Contributions: Conceptualization, S.-W.L.; Methodology, S.-W.L.; Software, H.-J.K.; Validation, C.H.P.,
B.-S.K., and S.-W.L.; Formal analysis, K.-J.L.; Investigation, H.-J.K.; Resources, H.-J.K.; Data curation, K.-J.L. and
B.-S.K.; Writing—original draft preparation, C.H.P. and B.-S.K.; Writing—review and editing, S.-W.L.; Visualization,
H.-J.K.; Supervision, S.-W.L. and C.H.P.; Project administration, B.-S.K. All authors have read and agreed to the
published version of the manuscript.
Funding: This work was supported by an Institute of Information & communications Technology Planning &
Evaluation (IITP) grant funded by the Korean government (MSIT) (No.2019-0-01682, Development of custom
artificial ankle joint fusion SW technology based on ceramic 3D printing).
Conflicts of Interest: The authors declare no conflict of interest.

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