Intraoperative chertsey test, is it a reliable alternative to computed tomography scan for diagnosing syndesmotic injuries of the ankle?

Document Type : Original Article

Authors

1 Department of Anesthesiology, Imam Hossein Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran

2 Department of Orthopedic Surgery and Traumatology, Imam Hossein Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran

Abstract

Background: The present study aims to evaluate the diagnostic exactitude of the intraoperative Chertsey test in tibiofibular syndesmotic injuries in patients with malleolar fractures, in comparison with a computed tomography (CT) scan. Materials and Methods: In this study, patients with malleolar fractures operated between 2018 and 2020 were examined. Thirty-nine patients were enrolled in the study. A three-dimensional preoperative CT scan was obtained. The opposite unfractured ankle was also scanned and considered as the control group. The Chertsey test was performed during the operation to assess the syndesmosis injury. Then, patients were partitioned into two distinct groups, considering the condition of their ankle, namely the Chertsey positive (unstable syndesmosis) group and the Chertsey negative (stable syndesmosis) group. Results: The outcomes of the present survey illustrated that the Chertsey test was positive in 16 patients (41.03%) and negative in 23 patients (59.07%). The median of all CT scan parameters (anterior tibiofibular distances (TFD), middle TFD, posterior TFD, and maximal TFD and volume) before surgery in the group of patients with a positive Chertsey test was significantly higher, measured against the unfractured control group (P < 0.001 for all parameters). Furthermore, a comparison of CT scan parameters and syndesmosis space volume before surgery between the two groups of patients with positive and negative Chertsey test results showed that the measurement of parameters in Chertsey-positive patients was significantly higher than the Chertsey-negative patients (P < 0.001). Conclusion: Chertsey test could be used to diagnose syndesmosis injuries in patients with malleolar fractures due to its high importance in the outcome of patients.

Keywords

1.
Bäcker HC, Vosseller JT. Fibula fracture: Plate versus nail fixation. Clin Orthop Surg 2020;12:529-34.  Back to cited text no. 1
    
2.
Ray R, Koohnejad N, Clement ND, Keenan GF. Ankle fractures with syndesmotic stabilisation are associated with a high rate of secondary osteoarthritis. Foot Ankle Surg 2019;25:180-5.  Back to cited text no. 2
    
3.
El-Rosasy M, Ali T. Realignment-lengthening osteotomy for malunited distal fibular fracture. Int Orthop 2013;37:1285-90.  Back to cited text no. 3
    
4.
van Vlijmen N, Denk K, van Kampen A, Jaarsma RL. Long-term results after ankle syndesmosis injuries. Orthopedics 2015;38:e1001-6.  Back to cited text no. 4
    
5.
Pfirrmann CW, Notzli HP, Dora C, Hodler J, Zanetti M. Abductor tendons and muscles assessed at MR imaging after total hip arthroplasty in asymptomatic and symptomatic patients. Radiology 2005;235:969-76.  Back to cited text no. 5
    
6.
Yeung TW, Chan CY, Chan WC, Yeung YN, Yuen MK. Can pre-operative axial CT imaging predict syndesmosis instability in patients sustaining ankle fractures? Seven years' experience in a tertiary trauma center. Skeletal Radiol 2015;44:823-9.  Back to cited text no. 6
    
7.
Lee SW, Lee KJ, Park CH, Kwon HJ, Kim BS. The valid diagnostic parameters in bilateral CT scan to predict unstable syndesmotic injury with ankle fracture. Diagnostics (Basel) 2020;10:812.  Back to cited text no. 7
    
8.
Chun DI, Cho JH, Min TH, Park SY, Kim KH, Kim JH, et al. Diagnostic accuracy of radiologic methods for ankle syndesmosis injury: A systematic review and meta-analysis. J Clin Med 2019;8:968.  Back to cited text no. 8
    
9.
Donohoe S, Alluri RK, Hill JR, Fleming M, Tan E, Marecek G. Impact of computed tomography on operative planning for ankle fractures involving the posterior malleolus. foot Ankle Int 2017;38:1337-42.  Back to cited text no. 9
    
10.
Black EM, Antoci V, Lee JT, Weaver MJ, Johnson AH, Susarla SM, et al. Role of preoperative computed tomography scans in operative planning for malleolar ankle fractures. Foot Ankle Int 2013;34:697-704.  Back to cited text no. 10
    
11.
Mak MF, Stern R, Assal M. Repair of syndesmosis injury in ankle fractures: Current state of the art. EFORT Open Rev 2018;3:24-9.  Back to cited text no. 11
    
12.
Porter DA, Jaggers RR, Barnes AF, Rund AM. Optimal management of ankle syndesmosis injuries. Open Access J Sports Med 2014;5:173-82.  Back to cited text no. 12
    
13.
Boyd RP, Nawaz SZ, Khaleel A. A new assessment for syndesmosis injury – The 'Chertsey test'. Injury 2016;47:1293-6.  Back to cited text no. 13
    
14.
Clanton TO, Williams BT, Backus JD, Dornan GJ, Liechti DJ, Whitlow SR, et al. Biomechanical analysis of the individual ligament contributions to syndesmotic stability. Foot Ankle Int 2017;38:66-75.  Back to cited text no. 14
    
15.
Vopat ML, Vopat BG, Lubberts B, DiGiovanni CW. Current trends in the diagnosis and management of syndesmotic injury. Curr Rev Musculoskelet Med 2017;10:94-103.  Back to cited text no. 15
    
16.
Taser F, Shafiq Q, Ebraheim NA. Three-dimensional volume rendering of tibiofibular joint space and quantitative analysis of change in volume due to tibiofibular syndesmosis diastases. Skeletal Radiol 2006;35:935-41.  Back to cited text no. 16
    
17.
Summers HD, Sinclair MK, Stover MD. A reliable method for intraoperative evaluation of syndesmotic reduction. J Orthop Trauma 2013;27:196-200.  Back to cited text no. 17
    
18.
Abbasian M, Biglari F, Sadighi M, Ebrahimpour A. Reliability of postoperative radiographies in ankle fractures. Arch Bone Jt Surg 2020;8:598-604.  Back to cited text no. 18
    
19.
Maradit Kremers H, Larson DR, Crowson CS, Kremers WK, Washington RE, Steiner CA, et al. Prevalence of total hip and knee replacement in the United States. J Bone Joint Surg Am 2015;97:1386-97.  Back to cited text no. 19
    
20.
Dikos GD, Heisler J, Choplin RH, Weber TG. Normal tibiofibular relationships at the syndesmosis on axial CT imaging. J Orthop Trauma 2012;26:433-8.  Back to cited text no. 20
    
21.
Kocadal O, Yucel M, Pepe M, Aksahin E, Aktekin CN. Evaluation of reduction accuracy of suture-button and screw fixation techniques for syndesmotic injuries. Foot Ankle Int 2016;37:1317-25.  Back to cited text no. 21
    
22.
Ebraheim NA, Lu J, Yang H, Mekhail AO, Yeasting RA. Radiographic and CT evaluation of tibiofibular syndesmotic diastasis: A cadaver study. Foot Ankle Int 1997;18:693-8.  Back to cited text no. 22
    
23.
Amouzadeh Omrani F, Kazemian G, Salimi S. Evaluation of syndesmosis reduction after removal syndesmosis screw in ankle fracture with syndesmosis injury. Adv Biomed Res 2019;8:50.  Back to cited text no. 23
[PUBMED]  [Full text]  
24.
Prior CP, Widnall JC, Rehman AK, Weller DM, Wood EV. A simplified, validated protocol for measuring fibular reduction on ankle CT. Foot Ankle Surg 2017;23:53-6.  Back to cited text no. 24
    
25.
Davidovitch RI, Weil Y, Karia R, Forman J, Looze C, Liebergall M, et al. Intraoperative syndesmotic reduction: three-dimensional versus standard fluoroscopic imaging. J Bone Joint Surg Am 2013;95:1838-43.  Back to cited text no. 25
    
26.
Nielson JH, Gardner MJ, Peterson MG, Sallis JG, Potter HG, Helfet DL, et al. Radiographic measurements do not predict syndesmotic injury in ankle fractures: An MRI study. Clin Orthop Relat Res 2005;436:216-21.  Back to cited text no. 26
    
27.
Pepe M, Kocadal O, Gunes Z, Calisal E, Ceritoglu K, Aktekin CN. A radiographic dye method for intraoperative evaluation of syndesmotic injuries. Foot Ankle Int 2017;38:1380-6.  Back to cited text no. 27