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Radiographic Evaluation of the Normal Distal Tibiofibular Syndesmosis in Neutral to Dorsiflexion on Weight-Bearing
Korean J Sports Med 2021;39:1-9
Published online March 1, 2021;  https://doi.org/10.5763/kjsm.2021.39.1.1
© 2021 The Korean Society of Sports Medicine.

Seong Kee Shin1, Ki Chun Kim1, Se Yong Song1, Ki Won Young2, Kyung Tai Lee3

1Department of Orthopedic Surgery, Seoul Medical Center, Seoul, 2Department of Orthopedic Surgery, Nowon Eulji Medical Center, Eulji University, Seoul, 3K. T. Lee Orthopaedic Hospital, Seoul, Korea
Correspondence to: Ki Chun Kim
Department of Orthopedic Surgery, Seoul Medical Center, 156 Sinnae-ro, Jungnang-gu, Seoul 02053, Korea
Tel: +82-2-2276-7841, Fax: +82-2-539-1262, E-mail: 711000e@seoulmc.or.kr
*This research was supported by grants from the Seoul Medical Center, Research Institute in 2016 (16-C18).
Received October 26, 2020; Revised December 15, 2020; Accepted December 29, 2020.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
 Abstract
Purpose: Reliable landmarks of ankle syndesmosis change in various positions is important for managing ankle injury. The purpose of our study was to investigate and compare radiographic landmarks of normal ankle in various positions.
Methods: The study involved both ankle radiographs of 30 subjects (15 males, 15 females) without clinical or radiographic abnormality. Tibiofibular clear space (TFCS) and tibiofibular overlap (TFO) were measured on anteroposterior (AP) and mortise radiographs in non-standing (NS) and standing (S) neutral and dorsiflexion 10째 (DF10) and 20째 (DF20). The radiographic measurements were used to calculate means, standard deviations, and intra- and interobserver reliabilities, and compare TFCS and TFO in various positions and genders.
Results: On the AP view, the mean TFCS in NS, S, DF10, and DF20 positions were 4.00짹0.97, 4.00짹0.83, 4.35짹0.95, and 4.45짹0.89 mm and the mean TFO on the same positions were 6.58짹2.27, 4.27짹1.90, 3.44짹1.96, and 2.38짹1.91 mm. On the mortise view, the mean TFCS in NS, DF10, and DF20 positions were 3.62짹0.88, 4.08짹0.86, and 3.88짹0.97 mm and the mean TFO on the same positions were 3.57짹2.13, 2.31짹1.77, and 3.57짹2.14 mm. The reliabilities in all positions except TFCS on some positions were excellent. No measurement was significantly different between females and males except TFO in NS on mortise view (p=0.006) and DF10 on AP view (p=0.032).
Conclusion: Increase of TFCS and decrease of TFO on AP view reflects syndesmosis change from NS to DF20 on standing. Clinically, the effect of weight-bearing and reliability of TFO should be considered.
Keywords : Tibiofibular syndesmosis, Tibiofibular clear space, Tibiofibular overlap, Syndesmotic injuries, Ankle sprain
꽌 濡

議깃젅 넀긽 쓷엳 蹂 닔 엳뒗 洹쇨낏寃⑷퀎 쇅긽 以 븯굹濡 議깃젅 뿼醫뚯쓽 빟 5%뿉꽌 10%1,2, 議깃젅 怨⑥젅쓽 빟 23%뿉꽌 썝쐞 寃쎈퉬 寃고빀(syndesmosis)쓽 씠媛쒓 蹂댁씤떎3.

썝쐞 寃쎈퉬 寃고빀 쟾븯寃쎈퉬씤, 썑븯寃쎈퉬씤, 怨④컙寃쎈퉬씤 諛 怨④컙 留됱쑝濡 援ъ꽦릺硫, 吏二(strut) 뿭븷쓣 븯뒗 썝쐞 鍮꾧낏, 궡痢≪쓽 궪媛곸씤 븿猿 嫄곌낏쓽 쇅痢 쟾쐞瑜 젣븳븯硫댁꽌 議깃젅쓽 쉶쟾 븞젙꽦뿉 湲곗뿬븯뒗 寃 쇅뿉, 젣븳맂 踰붿쐞 궡뿉꽌 議깃렐 愿젅 寃⑹옄쓽 룺怨 源딆씠瑜 議곗젅븯뿬 6.4%–16%쓽 泥댁쨷 遺븯 븯以묒쓣 쟾떖븯뒗 鍮꾧낏쓽 룞쟻 뿭븷쓣 蹂댁“븳떎4-6. 嫄곌낏 긽遺쓽 쟾硫댁 썑硫대낫떎 빟 5–6 mm 뜑 꼻뼱꽌 議깅같 援닿끝 떆 鍮꾧낏 洹쇱쐞遺 썑쇅痢 씠룞 諛 쇅쉶쟾븯硫댁꽌 씤媛 湲댁옣릺뼱 愿젅씠 븞젙릺硫7, 議깆 援닿끝뿉꽌 議깅같 援닿끝 떆 怨쇨컙 嫄곕━媛 빟 1.5 mm 踰뚯뼱吏硫댁꽌8 泥댁쨷 遺븯媛 뜑빐吏硫 鍮꾧낏쓽 遺븯媛 利앷븯寃 맂떎4. 궗泥 뿰援ъ뿉 쓽븯硫 쟾븯寃쎈퉬씤 젅젣留뚯쑝濡 1–2.7룄쓽 쇅쉶쟾씠 利앷븳떎9,10. 씠긽쓽 뿰援 寃곌낵뱾濡쒕꽣 鍮꾩껜以 遺븯, 泥댁쨷 遺븯, 諛곌뎬 젙룄뿉 뵲씪 議깃젅뿉 媛빐吏뒗 遺븯 利앷뿉 뵲씪 寃쎈퉬怨 媛꾧꺽씠 踰뚯뼱吏 寃껋쑝濡 삁痢≫븷 닔 엳떎.

떒닚 諛⑹궗꽑 寃궗踰뺤쑝濡 鍮꾩껜以 遺븯뿉꽌 議깃젅 떒닚 諛⑹궗꽑 궗吏 寃⑹옄긽뿉꽌 寃쎄낏 鍮꾧낏 媛꾧꺽(tibiofibular clear space, TFCS)씠 3–6 mm 씠븯, 寃쎄낏 鍮꾧낏 以묐났(tibiofibular overlap, TFO)씠 1 mm 씠긽, 쟾썑硫댁긽뿉꽌 TFO媛 6 mm 씠긽 삉뒗 鍮꾧낏 꼫鍮꾩쓽 42% 씠긽씤 寃쎌슦瑜 젙긽쑝濡 蹂댁븯떎11,12. Shah 벑13 젙긽씤쓽 泥댁쨷 遺븯 떆 쟾썑硫댁긽, 寃⑹옄긽뿉꽌 TFCS뒗 4.6±1.1 mm, 4.3±1.0 mm, TFO뒗 8.3±2.5 mm, 3.5±2.1 mm쑝硫, 寃⑹옄긽쓽 TFCS媛 醫뚯슦 李⑥씠媛 理쒖냼씤 젙솗븳 痢≪젙踰뺤씠씪怨 븯떎.

利, 썝쐞 寃쎈퉬 寃고빀 怨좎같쓽 븘슂꽦, 以묒슂꽦怨 떒닚 諛⑹궗꽑 궗吏꾩쓣 씠슜븳 룊媛쓽 렪쓽꽦, 떊냽꽦뿉 빐 遺遺 씪移섎맂 쓽寃ъ쓣 蹂댁씠吏留 젙긽怨 鍮꾩젙긽쓽 寃쎄퀎瑜 젙븯뒗 뜲 엳뼱 議깃젅 쐞移섏뿉 뵲瑜 깮뿭븰쟻 蹂솕, 泥댁쨷 遺븯 뿬遺14-16, 3李⑥썝쟻 援ъ“쓽 2李⑥썝쟻 떒닚 諛⑹궗꽑 쁺긽 遺꾩꽍뿉 湲곗씤븳 룊媛17 벑쑝濡 씤븳 삤李⑥뿉 븳 끉씠 怨꾩냽릺怨 엳떎.

썝쐞 寃쎈퉬 寃고빀쓽 룊媛뿉 엳뼱꽌 而댄벂꽣떒痢듭눋쁺(computed tomography, CT)쓣 넻빐 떒닚 諛⑹궗꽑 珥ъ쁺쓽 떒젏쓣 蹂댁셿븷 닔 엳쑝굹17,18, 떎젣 닔닠 솚寃쎌뿉꽌뒗 씠윴 뿬嫄댁쓣 媛뽰텛뒗 寃껋씠 뼱젮썙 C-arm쓣 씠슜븳 닾떆 쁺긽쑝濡 젙蹂 뿬遺瑜 룊媛븯뒗 寃쎌슦媛 뜑 鍮덈쾲븯怨, CT 쁺긽議곗감 썝쐞 씤 寃고빀 痢≪젙 쐞移섏쓽 꽦蹂꾩뿉 뵲瑜 李⑥씠媛 蹂닿퀬릺뿀떎19. 삉븳 異붿쟻 寃궗 떆 留ㅻ쾲 CT 珥ъ쁺쓣 븯湲 뼱젮슫 쁽떎쟻 뿬嫄닿낵 떒닚 諛⑹궗꽑 궗吏 寃궗쓽 렪쓽꽦 諛 二쇨린쟻 異붿쟻 愿李곗쓽 슜씠꽦쓣 怨좊젮븳떎硫 떒닚 諛⑹궗꽑 珥ъ쁺쓣 씠슜븯뿬 썝쐞 寃쎈퉬 寃고빀쓽 룊媛븯뒗 寃껋 뿬쟾엳 洹 쓽誘몄 媛移섍 엳떎.

삉븳, 떎젣 엫긽 吏꾨즺 솚寃쎌뿉꽌 닔긽 珥덇린 떖븳 넻利앹쑝濡 씤빐 닔긽 쟾怨 룞씪븳 젙룄쓽 쟾泥댁쨷 遺븯媛 遺덇븳 寃쎌슦媛 鍮덈쾲븯怨, 닔닠 솚寃쎌뿉꽌 留덉랬 븯뿉꽌뒗 鍮꾩껜以 遺븯 긽깭뿉꽌 룊媛媛 씠猷⑥뼱吏뒗 諛섎㈃ 넻利앹씠 샇쟾맂 썑뿉뒗 泥댁쨷 遺븯媛 媛뒫븯誘濡 엫긽쟻 긽솴뿉 뵲瑜 긽씠븳 깮뿭븰쟻 긽깭瑜 룊媛빐빞 븳떎.

꽌援ш텒쓽 뿰援ъ뿉 쓽븯硫 泥댁쨷 遺븯 떆 議깃젅쓽 蹂솕2,4,5,14,15,20, TFO, TFCS쓽 꽦蹂꾩뿉 뵲瑜 李⑥씠瑜 蹂닿퀬븯怨 엳쑝굹13,14,19,21, 援궡뿉꽌뒗 씠뿉 븳 뿰援ш 뾾떎.

蹂 뿰援щ뒗 泥レ㎏, 젙긽 議깃젅쓽 썝쐞 寃쎈퉬씤 媛꾧꺽쓽 泥댁쨷 遺븯 븯뿉 떒닚 諛⑹궗꽑 쟾썑硫댁긽, 寃⑹옄긽뿉꽌쓽 以묐┰ 쐞移, 泥댁쨷 遺븯 븯뿉 10룄 諛 20룄 議깅같 援닿끝븯쓣 븣 썝쐞 寃쎈퉬 寃고빀쓽 떒닚 諛⑹궗꽑븰쟻 젙긽 踰붿쐞瑜 젙븯怨, 泥댁쨷 遺븯 愿怨꾩뾾뒗 吏몴쓽 쑀臾대 븣怨좎옄 븯떎. 몮吏, 議깃젅쓽 泥댁쨷 遺븯 뿬遺 諛 議깅같 援닿끝뿉 뵲瑜 寃쎈퉬怨⑥쓽 깮뿭븰쟻 蹂솕뿉 뵲瑜 썝쐞 寃쎈퉬 寃고빀쓽 떒닚 諛⑹궗꽑 珥ъ쁺 긽 痢≪젙 吏몴씤 TFO, TFCS 痢≪젙媛믪쓽 蹂솕瑜 솗씤븯怨좎옄 븯떎. 뀑吏, 媛 痢≪젙 쐞移섏뿉꽌 꽦蹂꾩뿉 뵲瑜 쑀쓽븳 李⑥씠媛 엳뒗吏 븣븘蹂닿퀬옄 븯떎.

뿰援 諛⑸쾿

1. 뿰援щ긽

蹂 뿰援ъ 愿젴빐 꽌슱쓽猷뚯썝 쑄由ъ쐞썝쉶쓽 떖쓽瑜 꽌硫대룞쓽꽌 硫댁젣濡 넻怨쇳븯떎(No. 2016-042). 2016뀈 6썡 1씪遺꽣 12썡 31씪源뚯 씠쟾뿉 뼇痢 議깅 議깃젅 蹂묐젰씠 뾾뒗 젙긽씤 궓 媛곴컖 15紐(媛곴컖 30삁쓽 議깃젅)쓣 긽쑝濡 븯떎. 룊洹 굹씠뒗 35.5±9.6꽭(踰붿쐞, 20–57꽭)濡, 궓옄 32.5±9.8꽭(踰붿쐞, 20–57꽭), 뿬옄 38.5±8.6꽭(踰붿쐞, 23–50꽭)떎. 룊洹 떊옣 167.3±6.9 cm (踰붿쐞, 155–178 cm)濡 궓옄 173.2±3.3 cm (踰붿쐞, 167–178 cm), 뿬옄 161.5±3.6 cm (踰붿쐞, 155–168 cm)쑝硫, 룊洹 泥댁쨷 65.0±11.3 kg (踰붿쐞, 48–97 kg)濡 궓옄 72.5±9.6 kg (踰붿쐞, 57–97 kg), 뿬옄 57.5±7.1 kg (踰붿쐞, 48–75 kg)떎. 룊洹 泥댁쭏웾吏닔뒗 23.1±2.7 kg/m2 (踰붿쐞, 19.2–31 kg/m2)濡, 궓옄 24.1±2.8 kg/m2(踰붿쐞, 19.7–31 kg/m2), 뿬옄 22.1±2.2 kg/m2 (踰붿쐞, 19.2–27.6 kg/m2)떎. 鍮꾨쭔 25 kg/m2 씠긽쑝濡 젙쓽븯쑝硫22, 궓옄뒗 4紐(議깃젅 8삁)쑝濡 룊洹 泥댁쭏웾吏닔뒗 26.2±0.9 kg/m2 (踰붿쐞, 25.3–27.4 kg/m2), 뿬옄뒗 2紐(議깃젅 4삁) 26.3±1.4 kg/m2 (踰붿쐞, 25.1–27.6 kg/m2)씠뿀怨, 쟾泥대뒗 26.2±1.0 kg/m2 (踰붿쐞, 25.1–27.6 kg/m2)씠뿀떎.

2. 뿰援ъ꽕怨

몢 紐낆쓽 젙삎쇅怨 쓽궗媛 쟾썑諛⑹긽怨 寃⑹옄긽뿉 빐 2二쇱씪 씠긽쓽 媛꾧꺽쑝濡 2쉶 諛섎났 痢≪젙븯떎. TFCS뒗 愿젅硫 긽諛 1 cm뿉꽌 痢≪젙맂 寃쎄낏 긽쓽 鍮꾧낏 젅쓷(incisura fibularis)뿉꽌 鍮꾧낏 궡痢〓㈃源뚯 닔룊 嫄곕━씠硫, TFO뒗 鍮꾧낏 궡痢≪뿰뿉꽌 寃쎄낏 쟾諛 쇅痢≪뿰源뚯 닔룊 嫄곕━濡 痢≪젙븯떎(Fig. 1A and B).

Fig. 1. Measurements made on the anteroposterior view of the ankle at 1 cm above the plafond. (A) Measuring tibiofibular clear space and tibiofibular overlap on the anteroposterior view of standard radiograph in standing position, (B) its schematic drawing, and (C) cross-sectional schematic drawing matched with landmarks on panel B. L: lateral border of fibula, A: anterior tibial tubercle, M: medial border of fibula, P: posterior tibial tubercle, I: floor of incisura fibularis. All landmarks on panel C were added with superscript apostrophe to match landmarks on panel B.

뵒吏꽭 쁺긽쓣 쓽猷 쁺긽 옣 쟾넚떆뒪뀥(picture archiving and communication system)슜 쓽猷뚯쁺긽 봽濡쒓렇옩씤 M6 (6.0.6.1 version; INFINITT Healthcare, Seoul, Korea) 씠뿉 궡옣맂 냼봽듃썾뼱 룄援щ 씠슜븯뿬 嫄곕━瑜 痢≪젙븯떎. 뵒吏꽭 쁺긽 怨꾩륫쓽 젙솗꽦뿉 빐 1 mm 李⑥씠뒗 2 몴以렪李 궡 踰붿쐞濡 쑀쓽븯吏 븡떎뒗 Fowler Ilyas23쓽 蹂닿퀬뿉 洹쇨굅븯뿬 0.1 mm 떒쐞源뚯 痢≪젙븯쑝硫, 룞씪 遺쐞뿉 븳 몢 痢≪젙移섏쓽 李⑥씠媛 1 mm 씠긽씪 븣 쑀쓽븳 李⑥씠濡 媛꾩<븯떎. 닕젴맂 쁺긽 湲곗궗媛 醫뚯슦痢 議깃젅 媛곴컖뿉 빐 쟾썑硫댁긽 諛 寃⑹옄긽쓣 떒닚 諛⑹궗꽑 珥ъ쁺븯떎. 뒠釉뚯 븘由 궗씠쓽 嫄곕━뒗 1 m濡 븯떎.

以묐┰쐞 쟾썑硫댁긽 븰쐞 鍮꾩껜以 遺븯 긽깭뿉꽌 議깆媛 吏硫댁뿉 닔吏곸씠 릺룄濡 븳 썑 議곗궗꽑쓣 議깃젅쓽 以묒븰쓣 뼢빐 닔吏 엯궗븯뿬 珥ъ쁺븯怨, 寃⑹옄긽 15룄 궡쉶쟾븯뿬 룞씪븳 諛⑸쾿쑝濡 떎떆븯떎. 泥댁쨷 遺븯-以묐┰ 쐞移섏쓽 쟾썑硫댁긽 湲곕┰쐞뿉꽌 썑議깅瑜 븘由 移댁꽭듃(cassette)뿉 諛李⑹떆궓 썑 議곗궗꽑쓣 議깃젅쓽 以묒븰쓣 닔룊 엯궗븯뿬 珥ъ쁺븯떎. 10룄 諛 20룄 議깅같 援닿끝 긽깭쓽 泥댁쨷 遺븯 쟾썑硫댁긽 諛 寃⑹옄긽 씠 긽깭瑜 쑀吏븷 닔 엳뒗 諛쒗뙋 쐞뿉꽌 룞씪븳 諛⑸쾿쑝濡 珥ъ쁺븯떎(Fig. 2).

Fig. 2. Footholds for 10° and 20° ankle dorsiflexion. Left foothold is for 10° and right one for 20° in each image. (A) View from above. Blue footprints mean neutral position and green mean 15° internal rotation. (B) Sideview.

3. 넻怨 遺꾩꽍

몴蹂 겕湲곕뒗 愿李곗옄 1쓽 泥 踰덉㎏ 痢≪젙移섏쨷 궓 媛 10媛쒖쓽 議깃젅쓣 몴蹂몄쑝濡 異붿텧븯뿬 媛 蹂닔뿉 빐 궛젙븯떎. 0.80쓽 寃젙젰쑝濡 0.1쓽 쑀쓽닔以(alpha level)쓣 留뚯”떆궎湲 쐞빐 痢≪젙 쐞移섏뿉 뵲씪 11–60媛쒓 븘슂븯떎.

媛 痢≪젙 쐞移섏뿉 빐 룊洹, 몴以렪李, 踰붿쐞, 90% 떊猶곌뎄媛꾩쓣 怨꾩궛븯쑝硫, 넻긽쟻쑝濡 씤슜릺뒗 젙긽 踰붿쐞뿉꽌 踰쀬뼱궃 TFCS뒗 6 mm 씠긽, TFO뒗 1 mm 씠븯쓽 遺꾩쑉쓣 援ы븯떎. 媛쒓컻쓽 愿李곗옄媛 2二쇱씪 씠긽쓽 媛꾧꺽쑝濡 2쉶 諛섎났 痢≪젙븳 媛믪뿉 빐 愿李곗옄 궡 떊猶곕룄뒗 湲됰궡긽愿怨꾩닔(intraclass correlation coefficient, ICC)瑜 씠슜븯뿬 遺꾩꽍븯떎. 愿李곗옄 媛 떊猶곕룄뒗 媛 愿李곗옄쓽 몢 怨꾩륫移섏쓽 룊洹좎쓣 씠슜븯떎. 湲됰궡 긽愿 怨꾩닔뒗 遺덈웾(≤0.4), 뼇샇(>0.40, ≤0.60), 醫뗭쓬(>0.60, ≤0.75), 留ㅼ슦 醫뗭쓬(>0.75, ≤1.00) 4援곗쑝濡 援щ텇븯떎24.

쟾썑諛⑹긽뿉꽌뒗 鍮꾩껜以 遺븯 以묐┰쐞, 泥댁쨷 遺븯 以묐┰쐞, 泥댁쨷 遺븯 10룄 諛곌뎬, 泥댁쨷 遺븯 20룄 諛곌뎬쓽 4媛 痢≪젙 쐞移섎줈 援щ텇븯怨, 寃⑹옄긽뿉꽌뒗 鍮꾩껜以 遺븯 以묐┰쐞, 泥댁쨷 遺븯 10룄 諛곌뎬, 泥댁쨷 遺븯 20룄 諛곌뎬쓽 3媛 痢≪젙 쐞移섎줈 援щ텇 썑 媛곴컖 TFCS, TFO瑜 痢≪젙븯떎. 愿李곗옄 1쓽 泥 踰덉㎏ 痢≪젙移섎 씠슜븯뿬 媛 痢≪젙 쐞移섏뿉꽌 遺꾩궛遺꾩꽍, 쉶洹遺꾩꽍쓣 떆뻾븯怨 넻怨꾩쟻 쑀쓽 닔以 0.05 씠븯濡 꽕젙븯떎. 꽦蹂꾩뿉 뵲瑜 李⑥씠뒗 t-寃젙踰뺤쓣 궗슜븯뿬 遺꾩꽍븯떎.

寃 怨

1. 썝쐞 寃쎈퉬 寃고빀 痢≪젙移 諛 꽦蹂꾩뿉 뵲瑜 李⑥씠(愿李곗옄 1쓽 泥 踰덉㎏ 痢≪젙移 궗슜)

쟾썑諛⑹긽뿉꽌뒗 鍮꾩껜以 遺븯 以묐┰쐞, 泥댁쨷 遺븯 以묐┰쐞, 泥댁쨷 遺븯 10룄 諛곌뎬, 泥댁쨷 遺븯 20룄 諛곌뎬 쐞移섏뿉꽌 TFCS뒗 媛곴컖 4.0±0.97, 4.00±0.83, 4.35±0.95, 4.45±0.89 mm쑝硫, TFO뒗 媛곴컖 6.58±2.27, 4.27±1.90, 3.44±1.96, 2.38±1.91 mm떎. 寃⑹옄긽뿉꽌뒗 鍮꾩껜以 遺븯 以묐┰쐞, 泥댁쨷 遺븯 10룄 諛곌뎬, 泥댁쨷 遺븯 20룄 諛곌뎬 쐞移섏뿉꽌 TFCS뒗 媛곴컖 3.62±0.88, 4.08±0.86, 3.88± 0.97 mm쑝硫, TFO뒗 媛곴컖 3.57±2.13, 2.31±1.77, 3.57±2.14 mm떎. 媛 痢≪젙 쐞移섏뿉꽌 꽦蹂, 쟾泥댁뿉 븳 TFCS, TFO쓽 룊洹, 理쒕–理쒖냼媛믪쓽 踰붿쐞, 몴以렪李, 90% 떊猶곌뎄媛꾩쓽 겕湲곗 TFCS쓽 寃쎌슦 6 mm 씠긽쓽 諛깅텇쐞닔, TFO쓽 寃쎌슦 1 mm 씠븯쓽 諛깅텇쐞닔뒗 Table 1怨 媛숇떎. 鍮꾩껜以 遺븯 寃⑹옄긽 TFO 諛 泥댁쨷 遺븯 쟾썑諛⑹긽 諛곌뎬 10룄 TFO뿉꽌 궓옄媛 뿬옄蹂대떎 쑀쓽븯寃 넂寃 굹궗쑝硫(p=0.006, p=0.032), 洹 쇅쓽 痢≪젙 쐞移섏뿉꽌뒗 쑀쓽븳 李⑥씠媛 뾾뿀떎.



2. 愿李곗옄 궡 諛 愿李곗옄 媛 ICC

愿李곗옄 1뿉꽌 쟾썑硫댁긽 以묐┰쐞 鍮꾩껜以 遺븯뿉꽌 TFCS 醫뗭쓬(ICCs, 0.717), 愿李곗옄 媛꾩뿉꽌 쟾썑硫댁긽 諛곌뎬 20룄뿉꽌 TFCS 醫뗭쓬(ICCs, 0.724), 愿李곗옄 媛꾩뿉꽌 寃⑹옄긽 TFCS뿉꽌 諛곌뎬 10룄뿉꽌 뼇샇(ICCs, 0.469), 諛곌뎬 20룄뿉꽌 醫뗭쓬(ICCs, 0.678)쓣 蹂댁떎. 洹 씠쇅쓽 紐⑤뱺 痢≪젙 쐞移, 愿李곗옄 1 諛 2, 愿李곗옄 媛 ICC뒗 留ㅼ슦 醫뗭쓬씠뿀떎(Table 2).

Table 2 . Intraobserver and interobserver agreement

VariableAnteroposteriorMortise


Non-standing positionStanding positionDF10DF20Non-standing positionDF10DF20
Observer 1
TFCS
ICC0.717a)0.9020.8370.9010.8300.9110.801
95% CI0.528−0.8300.836−0.9420.727−0.9030.835−0.9410.716−0.8980.852−0.9470.666−0.881
TFO
ICC0.9920.9850.9630.9420.9750.830.807
95% CI0.986−0.9950.975−0.9910.938−0.9780.903−0.9650.958−0.9850.716−0.8980.671−0.886
Observer 2
TFCS
ICC0.9900.9800.9980.9970.9670.9980.999
95% CI0.975−0.990.966−0.9880.996−0.9990.995−0.9980.944−0.9800.996−0.9990.998−0.999
TFO
ICC0.9970.9960.9990.9990.9930.9990.999
95% CI0.995−0.9990.993−0.9980.999−1.0000.999−1.0000.988−0.9960.999−1.0000.999−1.000
Interobserver
TFCS
ICC0.8760.8290.8000.724a)0.8390.469a)0.678a)
95% CI0.793−0.9260.713−0.8980.665−0.8800.538−0.8350.730−0.9040.112−0.6830.460−0.807
TFO
ICC0.9860.9010.8730.9220.9400.8960.827
95% CI0.976−0.9920.834−0.9410.788−0.9240.870−0.9530.899−0.9640.827−0.9380.711−0.897

DF10: 10° ankle dorsiflexion in standing position, DF20: 20° ankle dorsiflexion in standing position, TFCS: tibiofibular clear space, TFO: tibiofibular overlap, ICC: intraclass correlation coefficient, 95% CI: 95% confidence interval.

a)Fair or good results.



3. 쟾썑硫댁긽, 寃⑹옄긽 TFCS 諛 TFO쓽 鍮꾩껜以 諛 泥댁쨷 遺븯 떆 媛 痢≪젙 쐞移섏뿉꽌쓽 鍮꾧탳

쟾썑硫댁긽뿉꽌 TFCS뒗 鍮꾩껜以 遺븯 泥댁쨷 遺븯 諛곌뎬 10룄(p=0.007) 諛 20룄(p<0.001) 쑀쓽븳 李⑥씠瑜 蹂댁떎. 泥댁쨷 遺븯 以묐┰쐞뒗 泥댁쨷 遺븯 諛곌뎬 10룄(p=0.006) 諛 20룄(p<0.001) 쑀쓽븳 李⑥씠瑜 蹂댁떎. 鍮꾩껜以 遺븯 泥댁쨷 遺븯 以묐┰쐞(p>0.999), 泥댁쨷 遺븯 諛곌뎬 10룄 20룄(p=0.774)뒗 쑀쓽븳 李⑥씠瑜 蹂댁씠吏 븡븯떎. 寃⑹옄긽뿉꽌 TFCS뒗 鍮꾩껜以 遺븯 泥댁쨷 遺븯 諛곌뎬 10룄(p=0.001)뿉꽌 쑀쓽븳 李⑥씠瑜 蹂댁떎. 洹 쇅쓽 쐞移섏뿉꽌뒗 쑀쓽븳 李⑥씠瑜 蹂댁씠吏 븡븯떎.

쟾썑硫댁긽뿉꽌 TFO뒗 鍮꾩껜以 遺븯, 泥댁쨷 遺븯 諛곌뎬 10룄 諛 20룄쓽 紐⑤뱺 쐞移섏뿉꽌 꽌濡 쑀쓽븳 李⑥씠瑜 蹂댁떎. 寃⑹옄긽뿉꽌 TFO뒗 鍮꾩껜以 遺븯 泥댁쨷 遺븯 諛곌뎬 10룄(p<0.001)뿉꽌 쑀쓽븳 李⑥씠瑜 蹂댁떎. 泥댁쨷 遺븯 諛곌뎬 10룄(p=0.006)뒗 泥댁쨷 遺븯 諛곌뎬 20룄(p<0.001) 쑀쓽븳 李⑥씠瑜 蹂댁떎. 洹 쇅쓽 쐞移섏뿉꽌뒗 쑀쓽븳 李⑥씠瑜 蹂댁씠吏 븡븯떎(Table 3).

Table 3 . Results of the two-way analysis of variance in various position

VariableGroup 1Group 2Mean difference(group 1–group 2)Standard errorp-value95% CI
Tibiofibular clear space
APNSS0.00330.106060.999−0.2717 to 0.2784
DF10−0.34650.106060.007*−0.6216 to −0.0714
DF20−0.44800.10606<0.001*−0.7231 to −0.1729
SDF10−0.34980.106060.006*−0.6249 to −0.0748
DF20−0.45130.10606<0.001*−0.7264 to −0.1763
DF10DF20−0.10150.106060.774−0.3766 to 0.1736
MortiseNSDF10−0.45620.127720.001*−0.7593 to −0.1530
DF20−0.25430.127720.119−0.5575 to 0.0488
DF10DF200.20180.127720.258−0.1013 to 0.5050
Tibiofibular overlap
APNSS2.31230.21320<0.001*1.7594 to 2.8653
DF103.14370.21320<0.001*2.5907 to 3.6966
DF204.20480.21320<0.001*3.6519 to 4.7578
SDF100.83130.213200.001*0.2784 to 1.3843
DF201.89250.21320<0.001*1.3395 to 2.4455
DF10DF201.06120.21320<0.001*0.5082 to 1.6141
MortiseNSDF101.26230.31847<0.001*0.5064 to 2.0183
DF200.00480.318470.999−0.7511 to 0.7608
DF10DF20−1.25750.31847<0.001*−2.0134 to −0.5016

95% CI: 95% confidence interval, AP: anteroposterior, NS: non-standing position, S: standing position, DF10: 10° ankle dorsiflexion in standing position, DF20: 20° ankle dorsiflexion in standing position.

*p<0.05, statistically significant.



쟾썑硫댁긽뿉꽌 TFCS뒗 鍮꾩껜以 遺븯, 泥댁쨷 遺븯 以묐┰쐞媛 쑀쓽븳 李⑥씠媛 뾾뿀쑝誘濡 以묐┰쐞뿉꽌 諛곌뎬 10룄, 20룄뿉 빐 異붽濡 쉶洹 遺꾩꽍쓣 떆뻾븯떎(Fig. 3E). 以묐┰쐞뿉꽌 諛곌뎬濡 吏꾪뻾븷 븣 利앷 냼寃ъ쓣 蹂댁쑝硫 諛곌뎬 젙룄媛 吏꾪뻾븷닔濡 利앷꽭뒗 셿留뚰븯怨 꽕紐낅젰 4.5%떎. 쟾썑硫댁긽뿉꽌 TFO뒗 鍮꾩껜以 遺븯뿉꽌 泥댁쨷 遺븯 以묐┰쐞, 諛곌뎬濡 蹂솕븷 븣 媛먯냼븯쑝硫 諛곌뎬 젙룄媛 吏꾪뻾븷닔濡 媛먯냼꽭뒗 셿留뚰븯怨 꽕紐낅젰 36.8%떎. 寃⑹옄긽뿉꽌 TFCS뒗 鍮꾩껜以 遺븯 以묐┰쐞뿉꽌 諛곌뎬 10룄濡 쐞移섎 蹂솕븷 븣 利앷, 諛곌뎬 10룄뿉꽌 諛곌뎬 20룄濡 蹂솕븷 븣 媛먯냼븯쑝硫 꽕紐낅젰 4.1%떎. 寃⑹옄긽뿉꽌 TFO뒗 鍮꾩껜以 遺븯 以묐┰쐞뿉꽌 諛곌뎬 10룄濡 쐞移섎 蹂솕븷 븣 媛먯냼, 諛곌뎬 10룄뿉꽌 諛곌뎬 20룄濡 蹂솕븷 븣 利앷븯쑝硫 꽕紐낅젰 8.1%떎(Fig. 3).

Fig. 3. Regression analysis of various ankle position: neutral in non-standing (NS) and standing (S) and dorsiflexion 10째 (DF10) and 20째 (DF20) in standing position of standard radiograph. (A) Tibiofibular clear space (TFCS) on the anteroposterior (AP) view. Coefficient of determination (linear)=0.042. (B) Tibiofibular overlap (TFO) on the AP view. Coefficient of determination (quadratic)=0.368. (C) TFCS on the mortise view. Coefficient of determination (quadratic)=0.041. (D) TFO on the mortise view. Coefficient of determination (quadratic)=0.081. (E) TFCS on the AP view excluding NS position. Coefficient of determination (quadratic)=0.045.
怨 李

썝쐞 寃쎈퉬 媛꾧꺽 議깃젅쓽 븞젙꽦뿉 以묒슂븳 뿭븷쓣 븳떎. 留롮 끉씠 엳쑝굹 뿬윭 吏몴뱾쓽 痢≪젙媛믪쓣 넻빐 젙긽怨 鍮꾩젙긽쓣 援щ퀎븯怨 吏꾨떒怨 移섎즺뿉 쟻슜븯怨좎옄 븯뒗 끂젰씠 엳뼱솕떎. 뿬윭 吏몴뱾 以 TFCS, TFO媛 몴쟻씠吏留 젙긽怨 鍮꾩젙긽쓽 寃쎄퀎瑜 젙븯湲 뼱졄怨13,25,26, 臾명뿄뿉 뵲씪 젙긽 踰붿쐞뿉룄 李⑥씠媛 議댁옱븳떎13,21,27. 젙긽 踰붿쐞瑜 젣떆븳 臾명뿄議곗감 泥댁쨷 遺븯 뿬遺媛 긽씠븯硫13,19,26,27, 떖吏뼱 遺덈챸솗븳 寃쎌슦룄 엳떎12,21. 鍮꾩껜以 遺븯 湲곗 湲됱꽦 넀긽 諛 닔닠 솚寃쎌뿉꽌 룊媛븷 븣뒗 쑀슜븯굹 泥댁쨷 遺븯 긽깭뿉꽌 쟻슜븯젮硫 떒닚 諛⑹궗꽑븰쟻 痢≪젙 吏몴뱾씠 鍮꾩껜以 遺븯 泥댁쨷 遺븯뿉꽌 룞씪븯떎뒗 洹쇨굅媛 엳뼱빞 븳떎.

遺곷멸텒쓽 蹂닿퀬뿉 쓽븯硫 鍮꾩껜以 遺븯 쟾썑硫댁긽21, 泥댁쨷 遺븯 쟾썑硫 諛 寃⑹옄긽13,14,16 TFCS, TFO뿉 엳뼱꽌 꽦蹂꾩뿉 뵲瑜 쑀쓽븳 李⑥씠瑜 蹂닿퀬븯굹, 蹂 뿰援ъ뿉꽌뒗 鍮꾩껜以 遺븯 寃⑹옄긽 TFO, 泥댁쨷 遺븯 쟾썑諛⑹긽 諛곌뎬 10룄 TFO 씠쇅뿉꽌 꽦蹂꾩뿉 뵲瑜 쑀쓽븳 李⑥씠瑜 蹂 닔 뾾뿀떎. 援궡 뿰援28뿉꽌 궓꽦쓽 鍮꾩껜以 쟾썑諛⑹긽 TFCS뒗 3.74±1.06 mm, TFO뒗 8.82±1.93 mm怨 蹂 뿰援ъ뿉꽌뒗 TFCS 4.02±0.9 mm, TFO 7.5±2.3 mm濡, 遺곷멸텒뿉꽌 蹂닿퀬맂21 궓꽦쓽 룊洹 TFCS 4.6 mm, TFO 9.6 mm 쑀궗븳 냼寃ъ씠뿀떎. 洹몃윭굹, 蹂 뿰援ъ쓽 泥댁쨷 遺븯 쟾썑諛⑹긽 TFO뒗 궓옄 4.67±2.16 mm, 뿬옄 3.87±1.54 mm濡 遺곷멸텒쓽 궓옄 룊洹 9.3 mm 씠긽, 뿬옄 7.4 mm 씠긽13,14怨 빟 2諛곗쓽 李⑥씠媛 궗떎. 遺곷멸텒怨 鍮꾧탳븯뿬 씪遺 쐞移섏쓽 痢≪젙媛믪쓣 젣쇅븯怨 援궡쓽 TFCS, TFO뒗 꽦蹂 媛 李⑥씠瑜 諛쒓껄븷 닔 뾾뿀쑝硫, 泥댁쨷 遺븯 쟾썑諛⑹긽 TFO媛 遺곷멸텒쓽 2諛곗씤 젏 씤醫 媛 李⑥씠濡 蹂댁씤떎.

떊猶곕룄 寃궗뿉꽌 떎瑜 뿰援ъ쓽 寃곌낵13,26 媛숈씠 蹂 뿰援ъ뿉꽌룄 TFO媛 TFCS 벑븯嫄곕굹 슦썡븳 떊猶곕룄瑜 蹂댁떎. 떒닚 諛⑹궗꽑 궗吏 긽 鍮꾧낏쓽 궡痢 寃쎄퀎뿉꽌 鍮꾧낏 젅쓷源뚯 TFCS쓽 痢≪젙떆 寃쎄낏쓽 썑쇅痢 寃곗젅씠 몢뱶윭吏 寃쎌슦 鍮꾧낏 젅쓷쓽 寃쎄퀎媛 遺덈챸솗빐졇 TFO蹂대떎 떊猶곕룄媛 궙 寃껋쑝濡 異붿젙맂떎(Fig. 1B and C)25. 뵲씪꽌, 떊猶곕룄쓽 痢〓㈃뿉꽌뒗 TFCS蹂대떎 TFO瑜 湲곗쑝濡 썝쐞 寃쎈퉬 媛꾧꺽쓣 룊媛븯뒗 寃껋씠 쟻젅븷 寃껋씠떎.

뿬윭 臾명뿄뿉꽌 泥댁쨷 遺븯뿉 뵲瑜 썝쐞 寃쎈퉬 寃고빀쓽 깮뿭븰쟻 蹂솕4,29瑜 蹂닿퀬븯怨 엳떎. 議깆 援닿끝 긽깭뿉꽌 嫄곌낏 긽遺쓽 醫곸 썑諛⑹씠 議깃젅 寃⑹옄 궡뿉 쐞移섑븯硫댁꽌 쉶쟾 슫룞씠 媛뒫빐吏꾨떎. 以묐┰쐞, 諛곌뎬濡 吏꾪뻾븯硫댁꽌 嫄곌낏 긽遺쓽 꼻 쟾諛⑹씠 議깃젅 寃⑹옄 궡뿉 쐞移섑븯怨 泥댁쨷 遺븯媛 릺硫댁꽌 썝쐞 寃쎈퉬 寃고빀씠 湲댁옣 긽깭媛 맂떎. 泥댁쨷 遺븯 CT瑜 씠슜븳 뿰援 寃곌낵뿉 쓽븯硫, 寃쎄낏쓽 쟾쇅痢 삉뒗 썑쇅痢≪뿉꽌 씤젒븳 鍮꾧낏 궡痢 寃쎄퀎源뚯쓽 嫄곕━뒗 泥댁쨷 遺븯뿉 쓽븳 쑀쓽븳 李⑥씠媛 뾾吏留 鍮꾧낏 젅쓷쓽 以묎컙뿉꽌 씤젒븳 鍮꾧낏 궡痢 寃쎄퀎源뚯쓽 嫄곕━ 諛 鍮꾧낏쓽 쇅쉶쟾쓽 쑀쓽븳 利앷媛 愿李곕맂떎25. 씠뒗 議깃젅 以묐┰ 쐞移섏뿉꽌 泥댁쨷 遺븯留뚯쑝濡 썝쐞 寃쎈퉬 媛꾧꺽쓽 씠媛 諛 鍮꾧낏쓽 쇅쉶쟾쓣 넻빐 TFCS媛 媛먯냼, TFO媛 利앷븿쓣 떆궗븳떎. 泥댁쨷 遺븯 諛곌뎬씠 룞떆뿉 씠猷⑥뼱吏 븣 嫄곌낏 긽遺 쟾諛⑹씠 議깃젅 쟾諛⑹뿉꽌 썝쇅 寃쎈퉬 씤 寃고빀쓽 湲댁옣쓣 뜑슧 쑀諛쒗븯誘濡 썝쐞 寃쎈퉬 媛꾧꺽쓽 씠媛쒖 鍮꾧낏쓽 쇅쉶쟾뿉 븳 遺븯뒗 利앷븷 寃껋쑝濡 삁긽맂떎. 蹂 뿰援 寃곌낵뿉 쓽븯硫 以묐┰ 쐞移섏뿉꽌 泥댁쨷 遺븯 뿬遺뿉 뵲瑜 떒닚 諛⑹궗꽑 쟾썑諛⑹긽 TFCS쓽 쑀쓽븳 利앷뒗 솗씤븷 닔 뾾뿀쑝굹 TFO뿉꽌 쑀쓽븳 媛먯냼瑜 솗씤븷 닔 엳뿀떎. 泥댁쨷 遺븯 쟾썑諛⑹긽뿉꽌 以묐┰쐞 諛곌뎬 10룄, 20룄瑜 鍮꾧탳븷 븣 TFCS, TFO쓽 쑀쓽븳 蹂솕媛 엳뿀怨(Table 3), 쉶洹 遺꾩꽍 긽 TFCS뒗 利앷븯怨 TFO뒗 媛먯냼븯떎뒗 젏뿉꽌(Fig. 3), 議깃젅 諛곌뎬 떆쓽 깮뿭븰쟻 蹂솕뒗 諛곌뎬씠 吏꾪뻾맆닔濡 뜑 遺꾨챸빐吏꾨떎. 泥댁쨷 遺븯 以묐┰쐞뿉꽌 諛곌뎬 10룄 궗씠쓽 蹂솕媛 諛곌뎬 10룄뿉꽌 20룄 궗씠濡 蹂솕븷닔濡 TFCS 利앷遺꾧낵 TFO쓽 媛먯냼遺꾩씠 媛먯냼븯뒗 寃껋 議깃젅쓽 諛곌뎬 젙룄媛 깮由ы븰쟻 踰붿쐞 궡뿉꽌 긽븳移섏뿉 씠瑜쇱닔濡 썝쐞 寃쎈퉬 寃고빀쓽 씠媛쒖쓽 蹂솕웾씠 媛먯냼븯뒗 寃껋쓣 쓽誘명븳떎. 洹몃윭굹, 寃⑹옄긽 諛곌뎬 10룄뿉꽌 20룄 궗씠濡 蹂솕븷닔濡 TFCS媛 媛먯냼븯怨 TFO媛 利앷븯뒗 寃껋 蹂 뿰援 寃곌낵濡쒕뒗 븣 닔 뾾떎. 洹몃윭誘濡 泥댁쨷 遺븯 긽깭뿉꽌 議깃젅 諛곌뎬쓣 利앷떆궎硫댁꽌 CT 珥ъ쁺 諛 쟾썑硫댁긽怨 寃⑹옄긽쓽 떒닚 諛⑹궗꽑 룞떆 珥ъ쁺 벑쓣 넻븳 鍮꾧탳 뿰援ш 븘슂븷 寃껋쑝濡 깮媛곷맂떎.

씠 뿰援ъ뿉뒗 紐 媛吏 젣븳젏씠 엳떎. 泥レ㎏, 鍮꾩껜以 遺븯 긽 以묐┰쐞 쐞移섎뒗 닕젴맂 쁺긽 湲곗궗媛 쐞移섎 젙븯뜑씪룄 寃궗 긽옄쓽 닚쓳뿉 쓽議댄븯뿬 珥ъ쁺릺뿀湲 븣臾몄뿉 怨좎젙맂 湲곌뎄瑜 궗슜븳 寃쎌슦蹂대떎 씪愿꽦 쑀吏媛 뼥뼱吏 媛뒫꽦씠 엳떎. 몮吏, 泥댁쨷 遺븯 寃⑹옄긽 珥ъ쁺씠 씠猷⑥뼱吏吏 븡븘 寃⑹옄긽 鍮꾩껜以 遺븯쓽 鍮꾧탳瑜 븷 닔 뾾뿀쑝硫, 泥댁쨷 遺븯 떆쓽 TFO뿉 븳 蹂 뿰援ъ 湲곗〈 꽌援ш텒 뿰援 寃곌낵쓽 李⑥씠쓽 썝씤쑝濡 씤醫낆쟻 李⑥씠瑜 怨좊젮븷 닔 엳吏留, 궎, 紐몃Т寃, 泥댁쭏웾吏닔, 굹씠 벑怨 媛숈 샎 蹂닔쓽 쁺뼢 뿭떆 怨좊젮븳 젙긽 踰붿쐞瑜 젣떆븯吏 紐삵뻽떎. 뵲씪꽌, 蹂 뿰援ъ쓽 痢≪젙 寃곌낵瑜 떎젣 엫긽 쁽옣뿉 쟻슜븷 븣뒗 젅쟻 젙긽 踰붿쐞濡 씤吏븯湲곕낫떎 嫄댁륫怨 鍮꾧탳븯怨30, 떎瑜 샎 蹂닔 벑쓣 李멸퀬븯뿬 議깃젅쓽 泥댁쨷 遺븯, 諛곌뎬怨 媛숈 깮뿭븰쟻 蹂솕媛 떒닚 諛⑹궗꽑븰쟻 吏몴濡쒖꽌 뼱뼸寃 몴쁽릺뒗吏뿉 珥덉젏쓣 몢뼱빞 븷 寃껋씠떎.

寃곕줎쟻쑝濡, 젙긽씤쓽 썝쐞 寃쎈퉬 泥댁쨷 遺븯 쟾썑諛⑹긽 TFCS쓽 利앷 TFO쓽 媛먯냼뒗 泥댁쨷 遺븯 븯뿉꽌 議깅같 援닿끝 떆 썝쐞 寃쎈퉬 씤 寃고빀씠 踰뚯뼱吏뒗 議깃젅쓽 깮뿭븰쟻 蹂솕瑜 諛섏쁺븯뒗 寃껋쑝濡 蹂댁씤떎. 떎젣 엫긽 쁽옣뿉 쟻슜븷 븣 泥댁쨷 遺븯뿉 뵲瑜 痢≪젙媛믪쓽 李⑥씠瑜 怨좊젮븯뿬빞 븯硫, 떊猶곕룄 痢〓㈃뿉꽌 TFO瑜 以묒슂븯寃 뿬寃⑥빞 븷 寃껋쑝濡 깮媛곷맂떎. 꽦蹂꾩뿉 뵲瑜 蹂솕뒗 遺곷멸텒 뿰援 寃곌낵 씪移섑븯吏 븡쑝誘濡 븳援씤뿉 留욌뒗 湲곗쓣 쟻슜빐빞 븷 寃껋쑝濡 蹂댁씤떎. 蹂 뿰援 寃곌낵뿉꽌 굹궃 떒닚 諛⑹궗꽑 궗吏 긽 議깃젅쓽 깮由ы븰쟻 踰붿쐞 궡쓽 諛곌뎬뿉 뵲瑜 TFCS, TFO쓽 利앷컧쓣 넻빐 異뷀썑 議깃젅 씤 넀긽 룊媛뿉 솢슜븷 닔 엳쑝由щ씪 湲곕븳떎.

Conflict of Interest

No potential conflict of interest relevant to this article was reported.

Author Contributions

Conceptualization: KWY, KTL. Data curation: SYS. Funding acquisition: KCK. Writing뱋riginal draft: KCK. Writing뱑eview & editing: SKS.

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