الفهرس 
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Abstract
The present study was aimed to evaluate the diagnostic value of high-resolution CT arthrography in characterization of chondral and osteochondral injuries in sprained ankle. In addition, it was aimed to assess the efficacy of CT arthrography and skeletal ultrasonography in evaluation of different ligamentous injuries in sprain-related ankle pain.
This analytical observational study was conducted in the department of Diagnostic Radiology, Faculty of Medicine, Minia University, during the period from June 2017 through May 2019 after being ethically approved by the local Medical Ethics Committee. Fifty patients, suffered from sprain-related ankle pain, were referred from orthopedic clinics, in our hospital, to be recruited in the study. Inclusion criteria for patients were based on: 1- chronic post-sprain ankle pain lasting more than three months either continuously or intermittently. 2- Subacute sprain-related persistent ankle pain of more than 2 weeks duration despite adequate treatment protocol. 3- Recurrent ankle sprain more than three episodes, currently presented with severe acute sprain of less than two weeks duration. Exclusion criteria for patients were: 1- Overlying or surrounding soft tissue infection. 2- Pregnancy (first trimester). 3- History of allergy to iodinated contrast medium. 4- Bleeding disorders and anticoagulant therapy.
All recruited patients were submitted to:- 1- Thorough medical history taking with analysis of symptoms, severity and number of episodes of ankle sprain as well as the mechanism of injury. 2- Targeted Ultrasonography of the injured ankle assessing different ankle ligaments using Xario-200 Toshiba machine (Japan) with multi-frequency linear array transducer (selected frequency 12 MHz). 3- Ultrasonographic guided intra-articular contrast medium injection. 4- CT arthrography using multi-detector row CT machine (bright speed 16; GE health care-America: Milwaukee, USA) in order to acquire isotropic pixels and perfect multiplanar reformations. 5- Surgical repair was done when indicated.
Results ultrasonography and CTA were recorded and tabulated and statistically analyzed using SPSS-16. Descriptive statistics were done for all data. Comparison between ATFL thickness in intact and partially injured cases was done. Correlation analysis between pathologic ankle changes and the type of presenting pain was done with assessment of Spearman correlation coefficient (r).
The study revealed that 34 (68%) patients had ligamentous injury on CT arthrography, 28 of them had single ligament affection (20 patients had isolated ATFL injury and 8 patients had isolated DD injury), the remaining 6 patients demonstrated multi-ligamentous injury (2 patients had 3 ligamentous affection, whereas 4 patients had 2 ligamentous affection). The total number of individual injured ligaments was 42 ligaments. ATFL were observed 1n 26 cases ( 8 complete and 18 partial tears). CFL tear were observed in 3 patients. SD in 2 patients while DDL observed in 11 patients.
The ATFL thickness was measured on axial CT arthrographic images, in 18 patients demonstrating partial tear (2.07 ±0.54), and in 24 patients demonstrating intact ligament (2.08 ± 0.88) with non-significant p value = 0.7. In the same manner, CFL thickness was measured in all patients except in case of ligament tear (1.93±0.46), as such measurement was non-applicable. The syndesmotic recess length in coronal plane was measured in all patients (13.66 ±3.9).
There were 36 patients (72%) who had either chondral or osteochondral defects; 18 patients had osteochondral lesions and another 18 patients had chondral injury with intact subchondral bone plate. Among 18 patients of osteochondral lesions, there were 3 patients had osteochondral lesions at both medial and lateral aspects of talar dome, with total number of osteochondral lesions was 21 lesions. the large and medium sized lesions were the most common OCLs in the study; all medial talar OCLs were large or medium sized, whereas lateral talar lesions were medium sized. Only the tibial OCLs were equally divided between the small and medium size.
The most common location of OCLs was on posteromedial aspect of the talar dome, whereas the tibial plafond harbored four OCLs, all of which were found on its postero-lateral aspect. No co-existing talar and tibial OCLs were detected. There were 18 patients who had cartilage defect with intact subchondral bone plate, 11 of them had partial thickness defect whereas seven patients have full-thickness chondral loss. There were 2 patients had both tibial and talar cartilage defect with total number of segmental cartilage defects was 20. Most of chondral loss in the study were small (<5mm).
There were some pathologic features detected on CT arthrography other than ligamentous tear and chondral/OCL, as synovial thickening seen in 21 patinets, intraarticular bodies in one case. One patient had lateral malleolus fissure and the other had anterior calcaneus and opposing cuboid fissure fractures and all of these features were co-incident with either ligamentous tear or with OCL/chondral defect except one patient demonstrated synovitis without any other pathologic changes.
There were only 3 patients addressed normal on both CTA and ultrasonography without any detectable pathology.
During CT arthrographic study, communication with some anatomic structures outside the ankle joint were observed, the most common location was the FHL tendon sheath in 17 patients then the subtalar joint in 10 patients, all opacified subtalar joints were normal. Passage of contrast to peroneal tendon sheath occurred in three patients indicating CFL tear while passage of contrast to tibialis posterior tendon sheath occurred in two patients indicating superficial deltoid ligament tear. Among the seventeen patients demonstrated opacified FHL tendon sheath, there were nine patients associated with other abnormalities observed.
Among all patients in the study, ultrasonography demonstrated 37 ligamentous affections. There were 21 patients had ATFL tear; complete tear was addressed when complete fiber disruption or when its fibers are not seen at all. Beside ligamentous injury detection, ankle effusion and synovial thickening were frequently observed on ultrasonography.
There were only 3 patients addressed as normal on both CTA and ultrasonography without any detectable pathology.
Among different pathologies detected in the study, there was significant reasonable positive correlation only between the presence of OCL or chondral defects and chronic pain presentation( r = 0.41), and recurrent sprain ( r = 0.43).
Minor complications were observed in the study ; vaso-vagal attack, it occurred in 4 patients when contrast injection was done while the patient in sitting position while anterior ankle swelling occurred in 5 patients due to mixed intra- and extra- articular contrast injection. No major complications were observed .
There were 18 patients suffered mainly from lateral ankle ligamentous injuries underwent surgical management. The indication for surgical management was persistent ankle instability. Pain itself was not an indication for surgical treatment except when coexisting ankle instability.
The chosen method for surgery was the standard anatomic repair technique; open modified Brostrom procedure including augmentation when needed. The augmentation was done using a split peroneus previs tendon (Evans’), or the inferior extensor retinaculum (Gould’s).
For concurrent superficial deltoid ligament tear, targeted anatomic ligament-to-bone repair was done.
When considering the operative data as a reference standard method, both CT arthrography and ultrasonography showed variable sensitivities, specificities and accuracies in detecting lateral ankle ligament tear. The test of significance concerning the medial ligaments was not applicable.