Treatment of Intra-Articular Lesions After Posterior Inferior Tibiofibular Ligament Injury: A Case Series of Elite Rugby Players

Abstract

Background: Surgical intervention is not typically used to treat symptoms after mild tibiofibular ligament injuries without ankle dislocation or subluxation.

Purpose: To describe outcomes in patients arthroscopically treated for unique intra-articular lesions after sustaining syndesmosis injury of the ankle.

Study design: Case series; Level of evidence, 4.

Methods: A total of 11 elite male rugby players with a mean age of 21.0 years (range, 17-28 years) were referred to our hospital for prolonged posterior ankle pain after a high ankle sprain during rugby football. The patients were examined using standing view radiography, computed tomography (CT) and magnetic resonance imaging (MRI) to determine the extent of ligament damage. Posterior ankle arthroscopy was performed to examine intra-articular lesions. The patients were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle/hindfoot rating scale and sports activity score of the Self-Administered Foot Evaluation Questionnaire (SAFE-Q).

Results: The average reduced tibiofibular overlap on the standing mortise view was 1.2 mm (range, 0.5-2.0 mm) compared with the opposite ankles. Mason type 1 fracture was detected on CT in 6 patients, and ossification of the interosseous membrane was detected in 2 patients. A bone bruise in the posterior malleolus was observed on MRI in all but 1 patient. Intra-articular fragments located in the posterior ankle were observed and removed arthroscopically. Symptoms improved rapidly after arthroscopic treatment in all patients. All patients returned to rugby games at a median of 11 weeks postoperatively. The median AOFAS scores improved from 77 preoperatively to 100 postoperatively (P < .01), and the median SAFE-Q sports activity subscale score improved from 49.4 to 100 (P < .01).

Conclusion: All unique intra-articular lesions that developed in rugby football players after syndesmosis injury were able to be treated arthroscopically. Patients returned to playing rugby football without syndesmosis reduction. Posterior ankle arthroscopy was effective in patients with residual symptoms after syndesmosis injury.

Keywords: ankle; cartilage; ligament; posterior ankle impingement syndrome; rugby; syndesmosis injury.

Figure 1.

Examination results of a 28-year-old male rugby football player (patient 4). (A) Standing mortise radiographic view of the ankles. (B) Avulsion fracture of the posterior malleolus detected on axial view CT (arrow). (C) Lateral view STIR sequence MRI showing intramedullary edema of the posterior malleolus (large arrow) and lift of the posterior and distal periosteal membrane (small arrows). (D) A cartilaginous fragment (arrow) was observed in the posterior and lateral area of the ankle. CT, computed tomography; MRI, magnetic resonance imaging; STIR, short tau inversion recovery.

Figure 2.

Examination results of a 17-year-old male rugby player (patient 5). (A) Avulsion fracture (arrow) of the posterior malleolus and widening of the syndesmosis compared with contralateral ankle were detected on axial view CT. (B) Lateral view STIR sequence MRI showing intramedullary edema of the posterior malleolus (large arrow) and lifted posterior and distal periosteal membrane (small arrows). (C) Fragments (arrow) were impinged at the posterior and lateral area of the ankle. CT, computed tomography; MRI, magnetic resonance imaging; STIR, short tau inversion recovery.

Figure 3.

Examination results of a 21-year-old male rugby football player (patient 8). (A) Cartilaginous fragment observed at the posterior and lateral area of the ankle. (B) A chondral defect at the insertion of the PITFL is visible. (C) Histology of the fragment showing the structures of enthesis including collagen fibers, cartilage, and bone (hematoxylin and eosin staining; magnification, 40×). PITFL, posterior inferior tibiofibular ligament.

Figure 4.

Mechanism of cartilage detachment from the tibia without becoming free at the posterior inferior margin of the tibia to which the PITFL attaches. PITFL, posterior inferior tibiofibular ligament.