Validation of anterior ankle soft tissue dynamics and shear modulus for anterior ankle impingement syndrome after ankle fracture surgery

Abstract

Anterior ankle impingement syndrome (AAIS) has been reported to account for a high percentage of complications following ankle fracture surgery. The soft tissue etiology of AAIS is thought to be thickening and inflammation of the anterior ankle soft tissues intervening anteriorly at the tibiotalar joint, causing pain and functional limitation during dorsiflexion. However, the effects of anterior ankle soft tissue dynamics and stiffness on AAIS have yet to be clarified. This study aimed to determine the relationship between AAIS and the anterior ankle soft tissue thickness change ratio and shear modulus using ultrasonography (US). The participants were 20 patients with ankle joint fractures (AO classification A, B) who had undergone open reduction and internal fixation and 20 healthy adults. The evaluation periods were 3 months and 6 months postoperatively. US was used to delineate the tibialis anterior tendon, extensor hallucis longus tendon, and the extensor digitorum longus tendon over the talus and tibia on a long-axis image. Anterior ankle soft tissue thickness was measured as the shortest distance from the most convex part of the talus to the tendon directly above it. The Anterior ankle soft tissue thickness change ratio was determined by dividing the value at 0° dorsiflexion by the value at 10° plantarflexion. The same images as for the anterior soft tissue thickness measurement were drawn for the shear modulus measurement, and the average shear modulus (kPa) was calculated using shear-wave elastography. There was no significant difference in the thickness change ratio between the postoperative and healthy groups. Compared with the healthy group, the shear modulus was significantly higher at 3 and 6 months in the postoperative group (p < 0.01). The shear elastic modulus at 6-month postoperative group was significantly lower than at 3-month postoperative group (p < 0.01). Anterior ankle joint soft tissue stiffness may increase after surgery for an ankle fracture.

Keywords: Ankle fracture; Anterior ankle impingement syndrome; Anterior ankle soft tissue; Shear-wave elastography; Ultrasonography.

Figure 1

Flow chart detailing the study protocol. ORIF open reduction and internal fixation, BMI body mass index, AO arbeitsgemeinschaft osteosynthesefragen.

Figure 2

Anterior ankle soft tissue thickness measurement. (A) Measurement of the TA tendon at 10° plantarflexion, (B) measurement of the EHL tendon at 10° plantarflexion, (C) measurement of the EDL tendon at 10° plantarflexion, (D) Measurement of the TA tendon at 0° dorsiflexion, (E) measurement of the EHL tendon at 0° dorsiflexion, (F) measurement of the EDL tendon at 0° dorsiflexion. 1: TA tendon, 2: EHL tendon, 3: EDL tendon, 4: Tibia, (5) Talus.

Figure 3

Shear modulus measurement of anterior ankle soft tissue. (A) Measurement of the TA tendon at 10° plantarflexion, (B) measurement of the EHL tendon at 10° plantarflexion, (C) measurement of the EDL tendon at 10° plantarflexion, (D) measurement of the TA tendon at 0° dorsiflexion, (E) measurement of the EHL tendon at 0° dorsiflexion, (F) Measurement of the EDL tendon at 0° dorsiflexion. 1: TA tendon, 2: EHL tendon, 3: EDL tendon, 4: Tibia, 5: Talus.

Figure 4

Protocol for measurements on ultrasound. TA Tibialis anterior, EHL extensor hallucis longus, EDL extensor digitorum longus, US anterior ankle soft tissue thickness and shear modulus measured using ultrasound imaging system, respectively. Measurements of each limb position and each tendon were taken randomly.