Modified Anterior Drawer Test for Subtalar Joint Instability

NewsBot · Jun 27, 2018

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The Modified Anterior Drawer Test (MADT): A New Clinical Test for
Assessing Subtalar Instability a Cadaveric and Clinical Assessment
Pasapula C et al
Clin Res Foot Ankle 2018, 6:2

Background: Chronic lateral ankle instability describes multiple pathologies affecting the tibiotalar or
talocalcaneal articulations of the foot. One quarter of cases are caused by isolated or concomitant subtalar
instability. The standard anterior drawer test (ADT) is used in routine clinical practice to assess abnormal movement
at the tibiotalar joint. However, a positive test does not discriminate whether excessive translation is at the tibiotalar
or subtalar joint. We suggest a modification to the standard ADT which separates the ankle joint translation by
manually immobilising the tibiotalar joint in order isolate anterior translation at the subtalar joint. In the presence of a
positive ADT, the modified anterior drawer test (MADT) would help discriminate if the pathological translation is at
the tibiotalar or the subtalar joint or both.
Methods: Our clinical study was an observational analysis of a cohort of 12 patients who had presented to an
outpatient foot clinic in the east of England. In addition, a cadaveric study was used to assess subtalar anterior
translation.
Results: In 50% of patients who had a clinically positive ADT, the MADT was negative which correlated 100%
with Stress Broden radiographic views. Cadaveric analysis was done to show an increase in anterior translation with
sequential sectioning of supporting ligaments. We demonstrated an absolute reduction in anterior translation in
subtalar instability with the additional posterior force (MADT).
Conclusion: The clinical and cadaveric data supports the use of the MADT as a valuable adjunct in the diagnosis
and exclusion of subtalar instability as a cause of symptoms in addition to stress radiography.
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NewsBot · Feb 23, 2019

Does subtalar instability really exist? A Systematic Review
StefanClockaertsabJanVan Der BauwhedeaFilipStockmansacGiovanniMatricalidefFrederickMichelsa
Foot and Ankle Surgery; 18 February 2019

Highlights
•Complaints of instability are related to subtalar ligaments injuries and an abnormal increased movement of the subtalar joint.
•Acute lesions of the subtalar ligaments are related to chronic complaints of instability.
•The STS is related to lesions of the subtalar ligaments but without signs of increased subtalar motion.
•There is insufficient evidence to use Brodén stress radiographs, however, anterior drawer-supination radiographs can be considered.
•The findings in this study could not indicate the one responsible ligament but suggest a multiple ligament involvement causing different degrees of STI.
•Clinical diagnosis should rely on several parameters including MRI.
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Background
Subtalar joint instability (STI) is considered as a potential source of chronic lateral hindfoot instability. However, clinical diagnosis of STI is still challenging. This systematic review was conducted to assess the consistency of the clinical entity “subtalar instability”, to investigate the reliability of available diagnostic tools and to provide a critical overview of related studies.

Methods
A systematic review of the Medline, Web of Sciences and EMBASE databases was performed for studies reporting on tests to investigate subtalar instability or lesions of the subtalar ligaments. To investigate the relation with chronic STI, studies focusing on sinus tarsi syndrome (STS) or acute lesions of the subtalar ligaments were also included in the search strategy and were assessed separately.

Results
This review identified 25 studies focusing on different topics: chronic STI (16), acute lesions of the subtalar ligaments (5) and STS (4). Twelve studies, assessing STI, demonstrated the existence of a subgroup with instability complaints related to abnormal increased subtalar motion (7) or abnormalities of the subtalar ligaments (6). We found insufficient evidence for measuring subtalar tilting using stress radiographs. MRI was able to assess abnormalities of the ligaments and stress-MRI detected abnormal increased motion.

Conclusion
Complaints of instability can be related to subtalar ligaments injuries and an abnormally increased movement of the subtalar joint. Stress radiographs should be interpreted with caution and should not have the status of a reference test. Clinical diagnosis should rely on several parameters including MRI.
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NewsBot · Jun 20, 2022

Reconstruction of the cervical ligament in patients with chronic subtalar instability
FrederickMichelsa et al
Foot and Ankle Surgery; 18 June 2022

Highlights
•Anatomical reconstruction of the cervical ligament is a valid technique to treat patients with STI.
•Anatomical cervical ligament reconstruction can be performed as an isolated procedure of in combination with other procedures according to the specific location of the instability.
•The technique can be considered in more complex cases such as patients with generalised hyperlaxity, revisions, severe long-standing instability, isolated subtalar instability and obesity.
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Purpose
Diagnosis and treatment of subtalar instability (STI) remains complicated and challenging. The purpose of this study was to investigate the outcome of an anatomical reconstruction of the cervical ligament in patients with suspected chronic STI.

Methods
This prospective study assessed the results of a surgical reconstruction of the cervical ligament using a gracilis tendon graft in a group of 14 patients (16 feet). Diagnosis of STI was performed using a predefined algorithm including clinical signs, MRI and peroperative evaluation. All patients had symptoms of chronic hindfoot instability despite prolonged non-surgical treatment. At final follow-up the outcome was assessed using the Karlsson score, the Foot and Ankle Outcome Score and the American Orthopaedic Foot and Ankle Society score.

Results
After an average follow up of 22.6 months (range, 15-36), all patients reported significant improvement compared to their preoperative symptoms. The mean preoperative Karlsson score improved from 36.4 ±13.5 (median 37, range 10–55) to a mean postoperative Karlsson score was 89.6±8.5 (median 90, range 72-100) (P<0.0001). The cervical ligament reconstruction was combined with other procedures in 13 cases: calcaneofibular ligament (CFL) reconstruction (3), CFL and anterior talofibular ligament reconstruction (7), bifurcate ligament reconstruction (3).

Conclusion
Anatomical reconstruction of the cervical ligament is a valid technique to treat patients with STI. It is a safe procedure and produces good clinical results with minimal complications. This technique can be considered in more complex cases and can be combined with other procedures according to the specific location of the instability.
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NewsBot · Feb 28, 2023

High reproducibility of a novel supported anterior drawer test for diagnosing ankle instability
Yasutaka Murahashi, Atsushi Teramoto, Katsunori Takahashi, Yohei Okada, Shinichiro Okimura, Rui Imamura, Makoto Kawai, Kota Watanabe & Toshihiko Yamashita
BMC Musculoskeletal Disorders volume 24, Article number: 148 (2023)

Background
The manual traditional anterior drawer test (ADT) is essential for deciding the treatment for chronic ankle instability, but it has been shown to have a comparatively low reproducibility and accuracy, especially in less experienced hands. To clarify the inter-examiner reproducibility, we compared the actual distance of anterior translation between junior and senior examiners in ADT. We also evaluated the diagnostic abilities of traditional ADT, and a novel modified ADT (supported ADT).

Methods
Thirty ankles were included in this study, and ankle instability was defined using stress radiography. All subjects underwent two methods of manual ADT by junior and senior examiners, and ankle instability was judged in a blinded fashion. The anterior drawer distance was calculated from the lengthening measured using a capacitance-type sensor device.

Results
The degree of anterior translation determined by the junior examiner was significantly lower than that determined by the senior examiner when traditional ADT was performed (3.3 vs. 4.5 mm, P = 0.016), but there was no significant difference in anterior translation between the two examiners when supported ADT was performed (4.6 vs. 4.1 mm, P = 0.168). The inter-examiner reliability of supported ADT was higher than that of traditional ADT. For the junior examiner, the diagnostic accuracy of supported ADT was higher than that of traditional ADT (sensitivity, 0.40 vs. 0.80; specificity, 0.75 vs. 0.80).

Conclusion
Supported ADT may have the advantage of being a simple manual test of ankle instability with less error between examiners.
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NewsBot · Jan 13, 2024

Do standardization of the procedure reduce measurement variability of the sonographic anterior drawer test of the ankle?
Shuhei Iwata et al
J Orthop Sci. 2023 Nov 22:S0949-2658(23)00320-2

Background: In quantitative ankle stress sonography, different examiners use different techniques, which may cause measurement variability. This study aimed to clarify whether standardizing stress sonography techniques reduces variability in the quantitative measurement of anterior talofibular ligament length change.

Methods: Fourteen examiners with a mean ultrasound experience of 8.7 years participated in this study. Each examiner performed stress ultrasonography of the ankle using their preferred method on one patient with an intact anterior talofibular ligament (Patient 1) and on two patients with chronic ankle instability (Patient 2 and 3). Changes in the ligament length between the resting and stressed positions were determined. A consensus meeting was then conducted to standardize the sonographic technique, which was used by the examiners during a repeat stress sonography on the same patients. The variance and measured values were compared between the preferred and standardized techniques using F-tests and paired t-tests, respectively.

Results: At a consensus meeting, a sonographic technique in which the examiner pushed the lower leg posteriorly against the fixed foot was adopted as the standardized technique. In Patient 1, the change in the anterior talofibular ligament length was 0.4 (range, -2.3-1.3) mm and 0.6 (-0.6-1.7) mm using the preferred and standardized techniques, respectively, with no significant difference in the variance (P = 0.51) or the measured value (P = 0.52). The length changes in Patient 2 were 2.0 (0.3-4.4) mm and 1.7 (-0.9-3.8) mm using the preferred and standardized techniques, respectively. In Patient 3, the length changes were 1.4 (-2.7-7.1) mm and 0.7 (-2.0-2.3) mm. There were no significant differences between the techniques in either patient group.

Conclusion: Variability in the quantitative measurement of ankle stress sonography was not reduced despite the standardization of the technique among examiners. Hence, comparing the measured values between different examiners should be avoide
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