At the University of Iowa Health Care Ankle Arthritis Service, the diagnosis is made based on the patient's report, standing X-rays of the ankle, and other diagnostic tests. The exact location of the loss of cartilage sometimes requires advanced imaging techniques such as MRI or CT scans.

Specialists have developed a unique system using the injection of air and dye into the ankle to determine the exact location of the loss of the joint lining and see cartilage problems less than one millimeter in size with three dimensional pictures.

References

AJR Am J Roentgenol. 2000 Jun;174(6):1691-7.

Contribution of individual projections alone and in combination for radiographic detection of ankle fractures.

Brandser EA, Berbaum KS, Dorfman DD, Braksiek RJ, El-Khoury GY, Saltzman CL, Marsh JL, Clark WA.

Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City 52240, USA.

OBJECTIVE: We wanted to determine whether the standard three-view ankle radiographic series could be replaced by a two-view combination, and if so, which two-view combination (anteroposterior with lateral or mortise with lateral) would be superior.

MATERIALS AND METHODS: During a 12-month period, we retrospectively reviewed 556 consecutive ankle radiographic studies consisting of anteroposterior, mortise, and lateral views. One hundred twenty patients with at least one ankle fracture were paired with 140 healthy control subjects. Each image in the three-view examination was separated and sorted by view and studied independently; all images were reviewed by two skeletal radiologists and two orthopedic surgeons. Each radiograph was evaluated for fracture of the medial, lateral, and posterior malleoli and the foot using a five-point confidence rating. Performance of each view and modeled two- and three-view combinations of views was evaluated with modified receiver operating characteristic analysis.

RESULTS: The data provide little support for preferring either two-view combination (anteroposterior-lateral or mortise-lateral) for any type of fracture. The three-view combination does detect significantly more fractures than some two-view combinations in some locations, and there is a statistically significant cost in diagnostic accuracy for eliminating the anteroposterior or mortise view.

CONCLUSION: Reducing the ankle radiographic series from three to two views would result in a small but significant decrease in the detection of fractures of the ankle and foot. Both two-view combinations are equivalent for fracture detection.

Foot Ankle Int. 1995 Sep;16(9):572-6.

Comment in: Foot Ankle Int. 1996 Mar;17(3):189-90.

The hindfoot alignment view.

Saltzman CL, el-Khoury GY.

Department of Orthopaedic Surgery, University of Iowa, Iowa City 52242, USA.

A modification of Cobey's method for radiographically imaging the coronal plane alignment of the hindfoot is described. Using this view, we estimated the moment arm between the weightbearing axis of the leg and the contact point of the heel. Normative data on 57 asymptomatic adult subjects are presented. The weightbearing line of the tibia falls within 8 mm of the lowest calcaneal point in 80% of subjects and within 15 mm of the lowest calcaneal point in 95% of subjects. The technique for measuring coronal plane hindfoot alignment is reliable, with an interobserver correlation coefficient of 0.97. This radiographic technique should help in the evaluation of complex hindfoot malalignments.

Clin J Sport Med. 1999 Jan;9(1):40-5.

Is stress radiography necessary in the diagnosis of acute or chronic ankle instability?

Frost SC, Amendola A.

The Fowler/Kennedy Sport Medicine Clinic, The University of Western Ontario, London, Canada.

BACKGROUND: Clinicians often use the talar tilt (TT) and anterior drawer (AD) stress x-rays to diagnose acute or chronic mechanical ankle instability. However, the wide range of TT and AD values in normal and injured ankles makes interpretation of the test results difficult.

OBJECTIVE: To critically review the literature and determine the accuracy of stress radiography in the diagnosis of mechanical ankle instability.

DATA SOURCES: MEDLINE was searched for relevant articles published since 1966 using MEDLINE subject headings (MeSH) and textwords for English articles related to ankle injuries and radiography. Additional references were reviewed from the bibliographies of the retrieved articles. The total number of articles reviewed was 67. Of these, 8 studies met criteria for inclusion and were analyzed.

STUDY SELECTION: Only clinical studies that used surgical exploration as the gold standard for diagnosing lateral ligament rupture were evaluated for this study. Cadaver or laboratory studies were excluded.

DATA EXTRACTION AND SYNTHESIS: In reviewing the literature, pertinent strengths of the different study designs were emphasized. From these data, particular attention was paid to the diagnostic accuracy of each study in comparing TT and AD stress x-rays to surgical confirmation of lateral ligament rupture.

MAIN RESULTS: A total of eight prospective clinical series satisfied the inclusion criteria. Seven of the eight assessed acute ankle instability as the outcome and one assessed chronic ankle instability. Of the seven studies that focused on acute ankle injuries, only one concluded significant benefit in using stress views to diagnose lateral ligament rupture. Three of the seven reported a positive relationship between stress radiography and surgical findings, although all six studies concluded that TT and AD stress x-rays are not reliable enough to make the diagnosis. The authors who assessed chronic ankle instability stated that TT and AD stress views combined were not useful in defining ankle instability.

CONCLUSION: The published data regarding TT and AD stress x-rays are too variable to determine accepted normal values compared with injured values. There are insufficient data for comparison of the use of mechanical versus manual techniques, or use of local anesthetic to facilitate the stress test. Because the treatment evolution of all acute ankle sprains is toward functional nonoperative treatment and because treatment does not depend on the degree of ankle instability on stress views, the TT and AD stress x-rays have no clinical relevance in the acute situation. In cases of chronic instability, the large variability in TT and AD values in both injured and noninjured ankles precludes their routine use.

Radiol Clin North Am. 1997 May;35(3):655-70.

Challenging fractures of the foot and ankle.

Prokuski LJ, Saltzman CL.

Department of Orthopaedic Surgery, University of Iowa Hospitals and Clinics, Iowa City, USA.

The foot and ankle is one of the most imaged parts of the body. Although most plain radiographs reveal no bony injury, subtle fractures can be overlooked. Because it is important to detect these fractures at the time of injury, a review of the most commonly missed foot and ankle fractures is presented.

Instr Course Lect. 1999;48:233-41.

Ankle osteoarthritis: distinctive characteristics.

Buckwalter JA, Saltzman CL.

Department of Orthopaedic Surgery, University of Iowa, Iowa City, USA.

Foot Ankle Int. 1998 Jul;19(7):466-71.

Ankle osteoarthritis scale.

Domsic RT, Saltzman CL.

Department of Orthopaedic Surgery, University of Iowa Hospital, Iowa City 52242, USA.

Although there is a wide array of outcome tools for assessing patients with symptomatic ankle arthritis, no disease-specific instrument for ankle arthritis has been shown to be reliable and valid. The purpose of this study was to develop a simple, reliable, and validated outcome measure for the clinical assessment of ankle osteoarthritis. We modified the Foot Function Index, a visual analog-based scale used to assess rheumatoid foot problems, to measure patient symptoms and functional limitations stemming from osteoarthritis of the ankle joint. Test-retest reliability and criterion and construct validity were determined for the overall Ankle Osteoarthritis Scale and its two subscales (pain and disability). Overall reliability (r=0.97; 95% confidence interval [CI], 0.94-0.99), pain subscale reliability (r=0.95; 95% CI, 0.90-0.98), and disability subscale reliability (r=0.94; 95% CI, 0.88-0.97) were excellent. Criterion validity testing of the instrument with the WOMAC (a disease-specific scale for osteoarthritis) and the SF-36 (a general health survey) showed a high degree of concordance for related subscales. Construct validity using a physical measure of ankle function demonstrated sensitivity of the instrument to the degree of joint dysfunction. Normative data were obtained from 562 individuals who were not patients (264 men and 298 women). The responses were analyzed for trends in gender, body mass index, presence of arthritis, history of fracture in relation to the response levels, and age. A small but statistically significant main effect for gender was found, with women consistently reporting higher pain, disability, and total index scores. Body mass index and arthritis were also found to correlate with response answers across the subscale and total index scores; however, these factors only accounted for 12% of the variation. The Ankle Osteoarthritis Scale is a reliable and valid self-assessment instrument that specifically measures patient symptoms and disabilities related to ankle arthritis.

J Bone Joint Surg Am. 2003 Feb;85-A(2):287-95.

Tibial plafond fractures. How do these ankles function over time?

Marsh JL, Weigel DP, Dirschl DR.

Department of Orthopaedic Surgery, University of Iowa Hospitals and Clinics, College of Medicine, Iowa City 52242, USA. j-marsh@uiowa.edu

BACKGROUND: The intermediate outcome of fractures of the tibial plafond treated with current techniques has not been reported, to our knowledge. The purpose of this study, performed at a minimum of five years after injury, was to determine the effect of these fractures on ankle function, pain, and general health status and to determine which factors predict favorable and unfavorable outcomes.

METHODS: Fifty-six ankles (fifty-two patients) with a tibial plafond fracture were treated with a uniform technique consisting of application of a monolateral hinged transarticular external fixator coupled with screw fixation of the articular surface. Thirty-one patients with thirty-five involved ankles returned between five and twelve years after the injury for a physical examination, assessment of ankle pain and function with the Iowa Ankle Score and Ankle Osteoarthritis Scale, assessment of general health status with the Short Form-36 (SF-36), and radiographic examination of the ankle.

RESULTS: Arthrodesis had been performed on five of the forty ankles for which the outcome was known at a minimum of five years after the injury. Other than removal of prominent screws (two patients), no other surgical procedure had been performed on any patient. The average Iowa Ankle Score was 78 points (range, 28 to 96 points). The scores on the SF-36 and Ankle Osteoarthritis Scale demonstrated a long-term negative effect of the injury on general health and on ankle pain and function when compared with those parameters in age-matched controls. The degree of osteoarthrosis was grade 0 in three ankles, grade 1 in six, grade 2 in twenty, and grade 3 in six. The majority of patients had some limitation with regard to recreational activities, with an inability to run being the most common complaint (twenty-seven of the thirty-one patients). Fourteen patients changed jobs because of the ankle injury. Fifteen ankles were rated by the patient as excellent; ten, as good; seven, as fair; and one, as poor. Nine patients with previously recorded ankle scores had better scores after the longer follow-up interval. The patients perceived that their condition had improved for an average of 2.4 years after the injury.

CONCLUSIONS: Although tibial plafond fractures have an intermediate-term negative effect on ankle function and pain and on general health, few patients require secondary reconstructive procedures and symptoms tend to decrease for a long time after healing.

Foot Ankle Int. 1999 Jan;20(1):44-9.

Comment in:

• Foot Ankle Int. 1999 Aug;20(8):539.

Rank order analysis of tibial plafond fractures: does injury or reduction predict outcome?

DeCoster TA, Willis MC, Marsh JL, Williams TM, Nepola JV, Dirschl DR, Hurwitz SR.

University of New Mexico Medical Center, Department of Orthopedics, Albuquerque 87131-5296, USA.

We investigated the effects of severity of initial injury pattern and the quality of the articular reduction on outcome of displaced intra-articular distal tibial fractures, using a series of 25 patients who were treated with articulated external fixation and limited internal fixation, which provided a spectrum of reduction quality. Outcome was assessed by clinical ankle scores and radiographic arthrosis. The results demonstrate the rank order method to be a reliable means of stratifying severity of injury and quality of reduction. Neither injury nor reduction correlated with clinical ankle score. Reduction had a significant correlation with radiographic arthrosis. We conclude that the rank order method is useful in stratification of fracture patients, and that factors other than injury pattern and quality of articular reduction are important in determining outcome of patients with this severe articular injury.

J Orthop Trauma. 1995;9(5):371-6.

Major open injuries of the talus.

Marsh JL, Saltzman CL, Iverson M, Shapiro DS.

Department of Orthopaedics, University of Iowa Hospitals and Clinics, Iowa City 52242, USA.

Seventeen patients with 18 open talar fracture-dislocations or total dislocations of the talus were reviewed to determine the functional outcome and incidence of infection. Seven of 18 feet (38%) developed infection. Infection was associated with extrusion of the talar body through the open wound (p < 0.025). Final follow-up was achieved in 13 of 17 patients (14 of 18 feet) at an average of 7 years and 4 months after injury. According to the Boston Children's Hospital ankle grading system, the overall results were considered excellent in one, good in five, fair in two, and failures in six feet. The data suggest a greater proportion of failures in the infected group compared with the non-infected group (p = 0.05).