Lateral Ankle Sprain Anatomy Can the Bifurcate Ligament be Consistently Identified with Ultrasound on Cadavers. Lyman Wood, 1 st Year Medical Student

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1 Lateral Ankle Sprain Anatomy Can the Bifurcate Ligament be Consistently Identified with Ultrasound on Cadavers Lyman Wood, 1 st Year Medical Student

2 Overview Objective Bifurcate ligament anatomy Understanding lateral ankle injury Methods & Materials Results and clinical significance Conclusion

3 Objective Investigate whether the bifurcate ligament could be identified using ultrasound on cadavers as a training exercise for anatomy education, clinical training, and assessment

4 Introduction The bifurcate ligament (BFL) is under appreciated regarding lateral ankle injuries Similar orientation to the anterior talofibular ligament (ATFL) The BFL supports the joints between the calcaneous, cuboid and naviculus bones

5 Understanding Lateral Ankle Sprians Typical Mechanism Plantar flexion Inversion High Recurrence A survey of 380 athletes revealed 73.5% of 563 ankle sprains had been previously injured Variable Recovery Time Average non-surgical complete rehabilitation days

6 Methods Literature Search current imaging text and online journals Dissection 58 cadavers to identify BFL 55 (n=110 sides; 55R:55L) Carolina solution 3 (n=6; 3R:3L) Freedom Art solution

7 Methods Evaluate Structural Relationships Digital caliper measurements between: Apex distal fibula (ADF), 5 th metatarsal tuberosity (5MT) ADF, Proximal aspect of BFL ligament (PBFL)

8 Methods Surface Anatomy Template - developed using palpable bony landmarks for proper probe placement Ultrasound 31 donor cadaver patients (n=61 30R:31L) utilizing surface anatomy template

9 Materials Ultrasound systems used Sonosite M-Turbo Classic probe Fukuda-Denshi AG760 machines - SonicEye finger probe Sonosite M-Turbo Fukuda-Denshi AG760

Results Literature Search Revealed no studies of ultrasound (US) identification of BFL on cadavers Study of 19 patients revealed 95% positive I.D.

10 Results Literature Search Revealed no studies of ultrasound (US) identification of BFL on cadavers Study of 19 patients revealed 95% positive I.D. by US of ATFL damage (confirmation by Arthroscopy) Dissection & Measurements Ratio ADF-PBFL:ADF-5MT = 1/3 from ADF ADF 5MT 60.22mm ± 0.43 ADF PBFL 42.18mm ± /3 2/3

11 Results Surface Anatomy Template Revealed 76.27% positive BFL I.D. with 1 st probe placement Ultrasound Probe Placement Accuracy Modified 2 nd attempt revealed 92.86% positive I.D. with slight transducer adjustment Accuracy of 61 US probe placements utilizing surface anatomy template and palpable landmarks

12 Results Caveric tissue In vivo

13 Results Caveric tissue In Vivo

14 Conclusion & Discussion The bifurcate ligament can be positively identified using ultrasound on cadavers Utilizing the surface anatomy template provides accurate and efficient I.D. with multiple different ultrasound systems and transducers Ultrasound provides cost effective, quality imaging of affected anatomy regarding lateral ankle injuries Accurate identification of ALL injured structures can reduce recurrence, recovery time, and improve overall patient care

15 Acknowledgements Bryan Beall 4 th Year Medical Student Brion Benninger, MD MSc

16 References Anagnostopoulos, D., Bali, N., Alo, K., & McKenzie, J. (2014). (iii) Arthroscopy of the foot and ankle. Orthopaedics and Trauma, 28(1), Anderson, S. J. (2002). Acute ankle sprains. Physician and sportsmedicine, 30(12). Ansede, G., Lee, J. C., & Healy, J. C. (2010). Musculoskeletal sonography of the normal foot. Skeletal radiology, 39(3), Clanton, T. O., & Porter, D. A. (1997). Primary care of foot and ankle injuries in the athlete. Clinics in sports medicine, 16(3), Croy, T., Saliba, S., Saliba, E., Anderson, M. W., & Hertel, J. (2012). Differences in lateral ankle laxity measured via stress ultrasonography in individuals with chronic ankle instability, ankle sprain copers, and healthy individuals. Journal of orthopaedic & sports physical therapy, 42(7), Fallat, L., Grimm, D. J., & Saracco, J. A. (1998). Sprained ankle syndrome: prevalence and analysis of 639 acute injuries. The journal of foot and ankle surgery, 37(4), Golanó, P., Vega, J., De Leeuw, P. A., Malagelada, F., Manzanares, M. C., Götzens, V., & Van Dijk, C. N. (2010). Anatomy of the ankle ligaments: a pictorial essay. Knee Surgery, Sports Traumatology, Arthroscopy, 18(5), Hertel, J. (2002). Functional anatomy, pathomechanics, and pathophysiology of lateral ankle instability. Journal of athletic training, 37(4), 364. Hodge, J. C. (1999). Anterior process fracture or calcaneus secundarius: a case report. The Journal of emergency medicine, 17(2), Hua, Y., Yang, Y., Chen, S., & Cai, Y. (2012). Ultrasound examination for the diagnosis of chronic anterior talofibular ligament injury. Acta Radiologica, 51(10), Hubbard, T. J., & Hicks-Little, C. A. (2008). Ankle ligament healing after an acute ankle sprain: an evidence-based approach. Journal of athletic training, 43(5), 523. Mei-Dan, O., Kots, E., barchilon, v., Massarwe, S., Nyska, M., & Mann, g. (2009). A dynamic ultrasound examination for the diagnosis of ankle syndesmotic injury in professional athletes a preliminary study. The American journal of sports medicine, 37(5), Oae, K., Takao, M., Uchio, Y., & Ochi, M. (2010). Evaluation of anterior talofibular ligament injury with stress radiography, ultrasonography and MR imaging. Skeletal Radiology, 39(1), Robbins, M. I., Wilson, M. G., & Sella, E. J. (1999). MR imaging of anterosuperior calcaneal fractures. AJR. American journal of roentgenology, 172(2), Seybold, J. D., J. R., & Myerson, M. S. (2014) Hindfoot fusions in the flatfood deformity: when and what techniques to use in late stage II and stage III deformities. techniques in foot & ankel surgery, 13(1), Yeung, M. S., Chan, K. M., So, C. H., & Yuan, W. Y. (1994). An epidemiological survey on ankle sprain. British journal of sports medicine, 28(2), Weiss, D. B., Jacobson, J. A., & Karunakar, M. A. (2005). The use of ultrasound in evaluating orthopaedic trauma patients. Journal of the American Academy of Orthopaedic Surgeons, 13(8),

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