Diagnostic Value of Weight-Bearing CT with Three-Dimensional Reconstruction in Chronic Ankle Instability: A Comparative Study with Conventional MRI

Diagnostic Value of Weight-Bearing CT with Three-Dimensional Reconstruction in Chronic Ankle Instability: A Comparative Study with Conventional MRI | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Diagnostic Value of Weight-Bearing CT with Three-Dimensional Reconstruction in Chronic Ankle Instability: A Comparative Study with Conventional MRI Han Fu, Yundi Tang, Yuyun You, XIA Zheng, Wei Song, Yonghui Xu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6845002/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 04 Feb, 2026 Read the published version in Archives of Orthopaedic and Trauma Surgery → Version 1 posted 10 You are reading this latest preprint version Abstract Objective This study aimed to assess the diagnostic value of weight-bearing computed tomography (WBCT) with three-dimensional reconstruction in detecting ligamentous injuries associated with chronic ankle instability (CAI) and to compare its efficacy with that of conventional magnetic resonance imaging (MRI). The goal was to assess the potential of WBCT as a more precise imaging modality to guide clinical decision-making. Methods Twenty patients with clinically suspected CAI, recruited between January 2024 and March 2025, underwent both WBCT (Planmed Verity; load equivalent to 100% body weight) and MRI (GE 1.5T; standard imaging protocols). Two senior musculoskeletal radiologists independently evaluated ligament integrity using a blinded protocol. Arthroscopic or intraoperative findings were used as the reference standard. Diagnostic parameters, including sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV), were calculated for each method. Interobserver agreement was quantified using the Kappa statistic. Results WBCT demonstrated significantly higher sensitivity for detecting anterior talofibular ligament (ATFL) injuries compared to MRI (90% vs. 70%, P < 0.05), particularly in cases with osseous abnormalities such as talar dome lesions and syndesmotic widening (P < 0.01). WBCT also yielded superior interobserver agreement (Kappa = 0.82) relative to MRI (Kappa = 0.68). Conclusion WBCT with [1]three-dimensional reconstruction offers enhanced diagnostic accuracy and reproducibility in assessing ATFL injuries, especially in the presence of functional instability or coexisting bony pathology. These findings support the use of WBCT as a complementary modality to MRI in the comprehensive evaluation of CAI. Chronic ankle instability anterior talofibular ligament Magnetic resonance imaging The emergence of weight-bearing computed tomography Figures Figure 1 Figure 2 Introduction Chronic ankle instability (CAI) is a common condition in sports medicine and orthopedics, affecting approximately 40% of individuals following an acute ankle sprain. The anterior talofibular ligament (ATFL) is the most frequently injured structure in such cases [1] . Magnetic resonance imaging (MRI), owing to its superior soft tissue contrast resolution, is widely regarded as the gold standard for non-invasive evaluation of ligamentous injuries [2] . However, conventional MRI is inherently limited by its static, non-weight-bearing nature, which may inadequately reflect the functional biomechanics of the ankle under physiological load. Consequently, its sensitivity in detecting subtle ligament laxity and associated osseous abnormalities may be suboptimal [3–4] . The emergence of weight-bearing computed tomography (WBCT) provides a novel imaging modality capable of dynamically assessing the ankle joint under load-bearing conditions. WBCT enables high-resolution, three-dimensional visualization of bony architecture and ligament attachment sites within a physiologically relevant context, thereby facilitating improved detection of ATFL injuries and concomitant osteochondral lesions [5–6] . Prior research has underscored WBCT's unique advantages in evaluating dynamic deformities, such as syndesmotic diastasis and abnormal talar tilt [7–8] . Nevertheless, head-to-head comparative studies between WBCT and MRI in diagnosing ATFL injuries remain scarce, and standardized imaging protocols for WBCT have yet to be firmly established [9] . Given these gaps, the present prospective study was designed to systematically compare the diagnostic efficacy of WBCT and MRI in the assessment of ATFL injuries, with arthroscopic evaluation serving as the diagnostic reference standard. By examining sensitivity, specificity, and interobserver agreement across modalities, this study aims to elucidate the clinical value of WBCT in diagnosing ligamentous injury associated with CAI. The findings are intended to support the development of optimized imaging strategies and the broader implementation of WBCT in sports medicine [10] . Materials and Methods 3.1 Study subjects 3.1.1 Inclusion criteria Patients were eligible if they met the diagnostic criteria for CAI as defined by the International Ankle Consortium (IAC), including a history of recurrent ankle sprains, subjective sensations of instability, and positive findings on physical examination. Eligible participants were aged between 18 and 50 years and scheduled for arthroscopic exploration or surgical treatment of ankle instability. 3.1.2 Exclusion criteria Exclusion criteria included a history of ankle surgery, systemic diseases such as rheumatoid arthritis or gout, or contraindications to MRI (e.g., pacemaker implantation or severe claustrophobia). Pregnant women were also excluded from the study. 3.1.3 General information” From January 2024 to March 2025, 20 patients were enrolled. The cohort comprised 12 males and 8 females, with a mean age of 32.5 ± 8.7 years (range: 18–50 years). Eleven patients had involvement of the left ankle, and nine had right-sided pathology. All participants provided written informed consent, and the study protocol was approved by the hospital's Ethics Committee. 3.2. Imaging protocols 3.2.1 WBCT WBCT examinations were conducted using the Planmed Verity scanner. Imaging parameters included a tube voltage of 120 kV and automatic tube current modulation. Images were acquired with a slice thickness of 0.6 mm and a reconstruction interval of 0.3 mm. During the scan, patients stood with full body weight on the affected limb, which was stabilized using elastic bandages to maintain alignment and to prevent motion artifacts or falls. Post-processing, including multiplanar reconstruction (MPR) and volume rendering (VR), was performed using a Neusoft PACS workstation to generate three-dimensional ankle reconstructions. 3.2.2 MRI MRI was performed using a 1.5T GE scanner. The scanning protocol included sagittal proton density fat-suppressed (PD-FS) sequences (TR: 3000 ms, TE: 30 ms), coronal T2-weighted images (TR: 3200 ms, TE: 80 ms), and axial short tau inversion recovery (STIR) sequences (TR: 4000 ms, TE: 60 ms). All scans were conducted with the patient in a supine position and the ankle placed in a neutral position. 3.3. Image analysis 3.3.1 Evaluation criteria The ATFL was evaluated using the Westin classification: Grade 0, normal; Grade I, thickened or abnormal signal; Grade II, partial tear; Grade III, complete rupture. Osseous abnormalities, including talar dome defects and syndesmotic widening (>2 mm), were also recorded. 3.3.2 Blinded interpretation Two senior radiologists with more musculoskeletal radiologist independently reviewed the images while blinded to clinical data and other imaging results. In cases of disagreement, a third senior radiologist provided the final consensus. 3.4. Reference standard Arthroscopic exploration, performed by two orthopedic surgeons using a double-blinded protocol, served as the diagnostic reference standard. Findings included the degree of ATFL injury and the presence of intra-articular abnormalities. 3.5. Statistical analysis Diagnostic sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for each imaging modality using 2×2 contingency tables, with arthroscopy as the reference standard. Interobserver agreement was assessed using the Cohen's Kappa coefficient. Inter-modality comparisons were conducted using the McNemar test. Statistical analysis was performed using SPSS version 26.0, and a p-value of <0.05 was considered statistically significant. Results 4.1. Diagnostic Performance and Patient Characteristics The final study cohort consisted of 20 patients diagnosed with CAI. Among them, 12 were male (60%) and 8 were female (40%), with a mean age of 32.5 ± 8.7 years. Eleven patients (55%) had left ankle involvement, while nine (45%) had right-sided lesions. All participants successfully completed both WBCT and MRI examinations and subsequently underwent diagnostic arthroscopy. Arthroscopic evaluation revealed the following distribution of ATFL injuries: 2 cases (10%) had normal ligaments (Grade 0), 3 (15%) showed thickening or abnormal signal without rupture (Grade I), 10 (50%) exhibited partial tears (Grade II), and 5 (25%) had complete ruptures (Grade III). Additionally, 7 patients (35%) had talar dome osteochondral lesions, and 4 (20%) exhibited syndesmotic widening (>2 mm). Using arthroscopy as the reference standard, the diagnostic performance of WBCT and MRI was compared (Table 1). Table 1: Diagnostic accuracy of WBCT and MRI Metric WBCT (%) MRI (%) |P Sensitivity 90.0 70.0 0.039* Specificity 85.7 85.7 1.000 PPV 94.7 87.5 0.317 NPV 75.0 66.7 0.683 MRI missed three Grade II partial tears confirmed by arthroscopy that were clearly visualized on WBCT (Figure 2)..WBCT generated one false positive (a Grade I lesion misclassified as Grade II) and two false negatives involving subtle thickening. MRI yielded two false positives and six false negatives, including four Grade II and two Grade I injuries. 4.2. Additional imaging findings WBCT outperformed MRI in identifying osseous abnormalities. Specifically, talar dome osteochondral lesions were detected in 7 cases (35%) on WBCT versus only 2 cases (10%) on MRI (P = 0.031). Syndesmotic widening was observed in 10 cases (50%) on WBCT and only 1 case (5%) on MRI (P = 0.0026). Additionally, WBCT identified three cases (15%) of anterior calcaneal process fractures that were not detected by MRI. 4.3. Interobserver agreement Interobserver agreement was significantly higher for WBCT than for MRI. The Kappa coefficient for WBCT was 0.82 [95% confidence interval (CI): 0.65–0.98], indicating excellent agreement, while MRI achieved a Kappa value of 0.68 (95% CI: 0.45–0.91), reflecting moderate agreement. Only two cases required adjudication in the WBCT group (Grade I vs. Grade II) compared to five in the MRI group, including three cases of Grade II vs. Grade III and two involving Grade 0 vs. Grade I. Discussion This prospective study demonstrates that WBCT with three-dimensional reconstruction achieves higher diagnostic sensitivity (90% vs. 70%) and interobserver agreement (Kappa = 0.82 vs. 0.68) than conventional MRI in detecting ATFL injuries in patients with CAI. These results were particularly evident in the identification of partial ligament tears (Grade II injuries) and associated osseous abnormalities frequently underdetected by MRI. These findings provide important evidence for optimizing imaging strategies in the clinical evaluation of CAI. Several factors likely contribute to WBCT's Technical advantages. First, WBCT accurately simulates the biomechanical environment of the ankle joint under physiological load, better reflecting actual ligament function. Our study found three Grade II ATFL injuries missed on MRI but detected via WBCT. This finding aligns with findings by Koo et al. [5] , who reported that non-weight-bearing MRI may miss up to 25% of functionally significant ligament damage. Second, WBCT's high spatial resolution (0.6 mm slice thickness) and 3D reconstruction capabilities provide unique advantages in detecting subtle osseous abnormalities. WBCT detected seven talar dome lesions compared to only two detected by MRI, consistent with detection rates of 35–40% reported by Chen et al. Third, multiplanar reformation (MPR) and volume rendering (VR) reconstruction techniques offer three-dimensional views, significantly improving diagnostic reproducibility. These capabilities likely contributed to WBCT's superior interobserver agreement (Kappa = 0.82) compared to MRI (Kappa = 0.68). Despite these advantages, WBCT has limitations. While excellent in diagnosing grade II and III ATFL injuries, WBCT remains less effective than MRI in detecting Grade I injuries (ligament thickening/signal abnormalities) due to relatively limited soft tissue contrast. As noted by Zhang et al., MRI remains indispensable for identifying early ligament degeneration. Additionally, radiation exposure from WBCT warrants consideration. Although modern WBCT systems use low-dose protocols (mean effective dose ~ 0.15), risk-benefit analysis remains important for younger patients. The findings of this study suggest specific clinical scenarios, in which WBCT offers diagnostic advantages: In patients with persistent clinical signs of ATFL injury, such as weight-bearing pain or recurrent ankle sprains, despite negative MRI results, WBCT should be considered as an adjunct imaging modality. When concurrent osseous abnormalities (such as talar dome injury) are suspected, WBCT is the preferred diagnostic method. Additionally, during preoperative planning, the three-dimensional imaging provided by WBCT facilitates more accurate localization of injuries, thereby offering critical insights into surgical planning. The present study is limited by a relatively small sample size, which may affect statistical robustness and generalizability. Further research with larger, multicenter cohorts is needed to validate these findings. In addition, this study did not assess the diagnostic impact of different weight-bearing levels, nor did it evaluate the correlation between imaging findings and long-term functional outcomes, both of which warrant further investigation. Conclusion WBCT with three-dimensional reconstruction shows superior diagnostic accuracy and interobserver agreement compared to conventional MRI for evaluating ATFL injuries in CAI. WBCT is particularly effective in identifying high-sensitivity ligament injuries and concurrent osseous abnormalities. We recommend WBCT as an important complementary examination to MRI, particularly when evaluating functional CAI and planning surgical interventions. Future large-scale studies are needed to establish standardized WBCT diagnostic criteria and clinical application guidelines. Abbreviations WBCT: weight-bearing computed tomography; CAI :chronic ankle instability ; MRI :magnetic resonance imaging ; ATFL ：anterior talofibular ligament PPV ：positive predictive value； NPV ：negative predictive value Declarations Author Contribution Author Yundi Tang、Yuyun You and Xia Zheng contributed to experimental design, data collection, and manuscript drafting.Author Wei Song participated in data analysis, interpretation, and critical revisions of the manuscript.Authors Yonghui Xu and Han Fureviewed and approved the final version of the manuscript. Funding : There were no funding sources for this study. References Vohra R, Singh A, Thorat B, Patel D. Instability of the distal tibiofibular syndesmosis. J Orthop Surg (Hong Kong). 2023;31(2):10225536231182349. doi:10.1177/10225536231182349 Anderson DD, Ledoux WR, Lenz AL, Wilken J, Easley ME, de Cesar Netto C. Ankle osteoarthritis: Toward new understanding and opportunities for prevention and intervention. J Orthop Res. 2024;42(12):2613-2622. doi:10.1002/jor.25973 Lintz F, Beaudet P, Richardi G, Brilhault J. Weight-bearing CT in foot and ankle pathology. Orthop Traumatol Surg Res. 2021;107(1S):102772. doi:10.1016/j.otsr.2020.102772 Segal NA, Anderson DD. Editorial commentary on Fritz et al. article entitled 'Three-dimensional analysis for quantification of knee joint space width with weight-bearing CT: comparison with non-weight-bearing CT and weight-bearing radiography'.Osteoarthritis Cartilage.2022;30(5):629-632. doi:10.1016/j.joca.2021.12.005 Turmezei TD, Malhotra K, MacKay JW, et al. 3-D joint space mapping at the ankle from weight-bearing CT: reproducibility, repeatability, and challenges for standardisation. Eur Radiol. 2023;33(11):8333-8342. doi:10.1007/s00330-023-09718-6 Elabd OM, Elabd AM, El-Azez MSA, Taha MM, Mohammed AH. Impact of chronic ankle instability on gait loading strategy in individuals with chronic ankle instability: a comparative study. J Neuroeng Rehabil. 2024;21(1):185. Published 2024 Oct 18. doi:10.1186/s12984-024-01478-8 Caubère A, Viricel C, Garcia-Jaldon F, et al. Assessment of chronic ankle instability: are functional scores relevant enough?. Orthop Traumatol Surg Res. Published online January 16, 2025. doi:10.1016/j.otsr.2025.104167 Du Y, Wang S, Yang F, Xu H, Cheng Y, Yu J. Effects of chronic ankle instability after grade I ankle sprain on the post-traumatic osteoarthritis. Arthritis Res Ther. 2024;26(1):168. Published 2024 Sep 28. doi:10.1186/s13075-024-03402-w Kawabata S, Ozone K, Minegishi Y, et al. Chronic Ankle Joint Instability Induces Ankle Sensorimotor Dysfunction: A Controlled Laboratory Study. 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J Athl Train. 2024;59(11):1089-1094. doi:10.4085/1062-6050-0582.23 Yoshimoto K, Noguchi M, Maruki H, Tominaga A, Ishibashi M, Okazaki K. Anterior talofibular ligament remnant quality is important for achieving a stable ankle after arthroscopic lateral ankle ligament repair. Knee Surg Sports Traumatol Arthrosc. 2023;31(6):2183-2191. doi:10.1007/s00167-022-07211-z Chen TX, Wu JY, Yang TJ, Chen G, Li Y, Zhang L. Development and validation of radiomics model for MRI-based identification of anterior talofibular ligament injuries. Sci Rep. 2025;15(1):15575. Published 2025 May 4. doi:10.1038/s41598-025-99813-z Yau WP, Chan YC. Evaluation of Graft Ligamentization by MRI After Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 2023;51(6):1466-1479. doi:10.1177/03635465231160790 Colò G, Bignotti B, Costa G, Signori A, Tagliafico AS. Ultrasound or MRI in the Evaluation of Anterior Talofibular Ligament (ATFL) Injuries: Systematic Review and Meta-Analysis. Diagnostics (Basel). 2023;13(14):2324. Published 2023 Jul 10. doi:10.3390/diagnostics13142324 Hu Y, Li Q, Li X, et al. Evaluation of Open Versus Arthroscopic Anterior Talofibular Ligament Reconstruction for Chronic Lateral Ankle Instability With Talar and Subtalar Cartilage MRI T2 Mapping: A 3-Year Prospective Study. Am J Sports Med. 2024;52(3):730-738. doi:10.1177/03635465231222931 Xie D, Murray J, Lartey R, et al. Multi-vendor multi-site quantitative MRI analysis of cartilage degeneration 10 Years after anterior cruciate ligament reconstruction: MOON-MRI protocol and preliminary results. Osteoarthritis Cartilage. 2022;30(12):1647-1657. doi:10.1016/j.joca.2022.08.006 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 04 Feb, 2026 Read the published version in Archives of Orthopaedic and Trauma Surgery → Version 1 posted Editorial decision: Revision requested 19 Aug, 2025 Reviews received at journal 04 Aug, 2025 Reviewers agreed at journal 23 Jul, 2025 Reviews received at journal 07 Jul, 2025 Reviewers agreed at journal 26 Jun, 2025 Reviewers agreed at journal 26 Jun, 2025 Reviewers invited by journal 26 Jun, 2025 Editor assigned by journal 13 Jun, 2025 Submission checks completed at journal 13 Jun, 2025 First submitted to journal 07 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6845002","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":478038845,"identity":"f44d77c6-f13e-42df-bf7b-19fa2001753e","order_by":0,"name":"Han Fu","email":"","orcid":"","institution":"Kunming Municipnl hospital Of traditional Chinese medicine","correspondingAuthor":false,"prefix":"","firstName":"Han","middleName":"","lastName":"Fu","suffix":""},{"id":478038846,"identity":"50c01a53-8907-451a-bcda-ad5b98b54520","order_by":1,"name":"Yundi Tang","email":"","orcid":"","institution":"Kunming Children's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yundi","middleName":"","lastName":"Tang","suffix":""},{"id":478038847,"identity":"67a41c8c-5a06-45f6-b494-452e62d9f969","order_by":2,"name":"Yuyun You","email":"","orcid":"","institution":"Kunming Municipnl hospital Of traditional Chinese medicine","correspondingAuthor":false,"prefix":"","firstName":"Yuyun","middleName":"","lastName":"You","suffix":""},{"id":478038848,"identity":"6ecf2cb8-3c01-44b2-80a2-0310ba7faae3","order_by":3,"name":"XIA Zheng","email":"","orcid":"","institution":"Kunming Municipnl hospital Of traditional Chinese medicine","correspondingAuthor":false,"prefix":"","firstName":"XIA","middleName":"","lastName":"Zheng","suffix":""},{"id":478038849,"identity":"188cc258-6544-4862-8b04-34cf62daacbe","order_by":4,"name":"Wei Song","email":"","orcid":"","institution":"Kunming Municipnl hospital Of traditional Chinese medicine","correspondingAuthor":false,"prefix":"","firstName":"Wei","middleName":"","lastName":"Song","suffix":""},{"id":478038850,"identity":"e08cb3ec-a8c0-4024-814c-c323aa4b2d37","order_by":5,"name":"Yonghui Xu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyElEQVRIiWNgGAWjYPCCAwxs7A1AkjQtPAdI1cIgkUCkWoMbOYaPC37dSeyTfP7wcEENgzy/GAHLJGfkGBvP7HuW2CadY3B4xjEGw5mzCVjHL5FjJs3bcxikheEwDxtDgsFtAlrY4Fokjz84zPOPCC1gW3h+ALVIMBgc5m0jQotkz7NiY96Gw8ZtPEC/8PZJEPaLwfHkjY95/hyWnd9+/PFnnm828vzSBLQwMHAYMDC2wXkShJSDAPsDBoY/xCgcBaNgFIyCEQsAsUtEEx1q7+kAAAAASUVORK5CYII=","orcid":"","institution":"Kunming Municipnl hospital Of traditional Chinese medicine","correspondingAuthor":true,"prefix":"","firstName":"Yonghui","middleName":"","lastName":"Xu","suffix":""}],"badges":[],"createdAt":"2025-06-08 01:38:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6845002/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6845002/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00402-026-06211-9","type":"published","date":"2026-02-04T15:57:40+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":85834848,"identity":"d55305a9-7bfd-4e0b-9db2-a50162ac3dab","added_by":"auto","created_at":"2025-07-02 08:13:29","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":179479,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eComparison of WBCT and MRI in detecting ATFL injuries.\u003c/strong\u003e\u003cbr\u003e\n (A)Weight-bearing CT demonstrates a complete rupture of the anterior talofibular ligament (ATFL, yellow arrow) and associated syndesmotic widening.\u003c/p\u003e\n\u003cp\u003e(B)Conventional MRI (axial STIR sequence) demonstrates a complete rupture of the anterior talofibular ligament (ATFL, blue arrow) and associated syndesmotic widening.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6845002/v1/5626a90a88228fdd8b3c699a.png"},{"id":85834858,"identity":"b2e8e140-7ae1-453b-a81b-31a545036a46","added_by":"auto","created_at":"2025-07-02 08:13:29","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":258900,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eComparison of WBCT and MRI in detecting ATFL injuries.\u003c/strong\u003e\u003cbr\u003e\n \u003cstrong\u003e(C)\u003c/strong\u003e Weight-bearing CT demonstrates a complete rupture of the anterior talofibular ligament (ATFL, white arrow) and associated syndesmotic widening.\u003cbr\u003e\n \u003cstrong\u003e(D)\u003c/strong\u003e Conventional MRI (axial STIR sequence) of the same patient shows partial discontinuity of the ATFL (red arrow), misclassified as a Grade II partial tear, while syndesmotic widening was not visualized.\u003cbr\u003e\n \u003cstrong\u003eAbbreviations\u003c/strong\u003e: ATFL, Anterior Talofibular Ligament; STIR, Short Tau Inversion Recovery.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6845002/v1/55ea7c5f5beb7a716cecef9f.png"},{"id":102234232,"identity":"feaf986f-a7b7-48d4-acb6-dec74491e210","added_by":"auto","created_at":"2026-02-09 16:08:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":852771,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6845002/v1/a4fb2d2a-819c-4fcb-848f-3476cf25c091.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Diagnostic Value of Weight-Bearing CT with Three-Dimensional Reconstruction in Chronic Ankle Instability: A Comparative Study with Conventional MRI","fulltext":[{"header":"Introduction","content":"\u003cp\u003eChronic ankle instability (CAI) is a common condition in sports medicine and orthopedics, affecting approximately 40% of individuals following an acute ankle sprain. The anterior talofibular ligament (ATFL) is the most frequently injured structure in such cases\u003csup\u003e\u0026nbsp;[1]\u003c/sup\u003e. Magnetic resonance imaging (MRI), owing to its superior soft tissue contrast resolution, is widely regarded as the gold standard for non-invasive evaluation of ligamentous injuries \u003csup\u003e[2]\u003c/sup\u003e. However, conventional MRI is inherently limited by its static, non-weight-bearing nature, which may inadequately reflect the functional biomechanics of the ankle under physiological load. Consequently, its sensitivity in detecting subtle ligament laxity and associated osseous abnormalities may be suboptimal\u003csup\u003e\u0026nbsp;[3–4]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eThe emergence of weight-bearing computed tomography (WBCT) provides a novel imaging modality capable of dynamically assessing the ankle joint under load-bearing conditions. WBCT enables high-resolution, three-dimensional visualization of bony architecture and ligament attachment sites within a physiologically relevant context, thereby facilitating improved detection of ATFL injuries and concomitant osteochondral lesions \u003csup\u003e[5–6]\u003c/sup\u003e. Prior research has underscored WBCT's unique advantages in evaluating dynamic deformities, such as syndesmotic diastasis and abnormal talar tilt \u003csup\u003e[7–8]\u003c/sup\u003e. Nevertheless, head-to-head comparative studies between WBCT and MRI in diagnosing ATFL injuries remain scarce, and standardized imaging protocols for WBCT have yet to be firmly established \u003csup\u003e[9] .\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eGiven these gaps, the present prospective study was designed to systematically compare the diagnostic efficacy of WBCT and MRI in the assessment of ATFL injuries, with arthroscopic evaluation serving as the diagnostic reference standard. By examining sensitivity, specificity, and interobserver agreement across modalities, this study aims to elucidate the clinical value of WBCT in diagnosing ligamentous injury associated with CAI. The findings are intended to support the development of optimized imaging strategies and the broader implementation of WBCT in sports medicine \u003csup\u003e[10]\u003c/sup\u003e.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e3.1 Study subjects\u003c/p\u003e\n\u003cp\u003e3.1.1 Inclusion criteria\u003c/p\u003e\n\u003cp\u003ePatients were eligible if they met the diagnostic criteria for CAI as defined by the International Ankle Consortium (IAC), including a history of recurrent ankle sprains, subjective sensations of instability, and positive findings on physical examination. Eligible participants were aged between 18 and 50 years and scheduled for arthroscopic exploration or surgical treatment of ankle instability.\u003c/p\u003e\n\u003cp\u003e3.1.2 Exclusion criteria\u003c/p\u003e\n\u003cp\u003eExclusion criteria included a history of ankle surgery, systemic diseases such as rheumatoid arthritis or gout, or contraindications to MRI (e.g., pacemaker implantation or severe claustrophobia). Pregnant women were also excluded from the study.\u003c/p\u003e\n\u003cp\u003e3.1.3 General information”\u003c/p\u003e\n\u003cp\u003eFrom January 2024 to March 2025, 20 patients were enrolled. The cohort comprised 12 males and 8 females, with a mean age of 32.5 ± 8.7 years (range: 18–50 years). Eleven patients had involvement of the left ankle, and nine had right-sided pathology. All participants provided written informed consent, and the study protocol was approved by the hospital's Ethics Committee.\u003c/p\u003e\n\u003cp\u003e3.2. Imaging protocols\u003c/p\u003e\n\u003cp\u003e3.2.1 WBCT\u003c/p\u003e\n\u003cp\u003eWBCT examinations were conducted using the Planmed Verity scanner. Imaging parameters included a tube voltage of 120 kV and automatic tube current modulation. Images were acquired with a slice thickness of 0.6 mm and a reconstruction interval of 0.3 mm. During the scan, patients stood with full body weight on the affected limb, which was stabilized using elastic bandages to maintain alignment and to prevent motion artifacts or falls. Post-processing, including multiplanar reconstruction (MPR) and volume rendering (VR), was performed using a Neusoft PACS workstation to generate three-dimensional ankle reconstructions.\u003c/p\u003e\n\u003cp\u003e3.2.2 MRI\u003c/p\u003e\n\u003cp\u003eMRI was performed using a 1.5T GE scanner. The scanning protocol included sagittal proton density fat-suppressed (PD-FS) sequences (TR: 3000 ms, TE: 30 ms), coronal T2-weighted images (TR: 3200 ms, TE: 80 ms), and axial short tau inversion recovery (STIR) sequences (TR: 4000 ms, TE: 60 ms). All scans were conducted with the patient in a supine position and the ankle placed in a neutral position.\u003c/p\u003e\n\u003cp\u003e3.3. Image analysis\u003c/p\u003e\n\u003cp\u003e3.3.1 Evaluation criteria\u003c/p\u003e\n\u003cp\u003eThe ATFL was evaluated using the Westin classification: Grade 0, normal; Grade I, thickened or abnormal signal; Grade II, partial tear; Grade III, complete rupture. Osseous abnormalities, including talar dome defects and syndesmotic widening (\u0026gt;2 mm), were also recorded.\u003c/p\u003e\n\u003cp\u003e3.3.2 Blinded interpretation\u003c/p\u003e\n\u003cp\u003eTwo senior radiologists with more musculoskeletal radiologist independently reviewed the images while blinded to clinical data and other imaging results. In cases of disagreement, a third senior radiologist provided the final consensus.\u003c/p\u003e\n\u003cp\u003e3.4. Reference standard\u003c/p\u003e\n\u003cp\u003eArthroscopic exploration, performed by two orthopedic surgeons using a double-blinded protocol, served as the diagnostic reference standard. Findings included the degree of ATFL injury and the presence of intra-articular abnormalities.\u003c/p\u003e\n\u003cp\u003e3.5. Statistical analysis\u003c/p\u003e\n\u003cp\u003eDiagnostic sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for each imaging modality using 2×2 contingency tables, with arthroscopy as the reference standard. Interobserver agreement was assessed using the Cohen's Kappa coefficient. Inter-modality comparisons were conducted using the McNemar test. Statistical analysis was performed using SPSS version 26.0, and a p-value of \u0026lt;0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e4.1. Diagnostic Performance and Patient Characteristics\u003c/p\u003e\n\u003cp\u003eThe final study cohort consisted of 20 patients diagnosed with CAI. Among them, 12 were male (60%) and 8 were female (40%), with a mean age of 32.5 \u0026plusmn; 8.7 years. Eleven patients (55%) had left ankle involvement, while nine (45%) had right-sided lesions. All participants successfully completed both WBCT and MRI examinations and subsequently underwent diagnostic arthroscopy.\u003c/p\u003e\n\u003cp\u003eArthroscopic evaluation revealed the following distribution of ATFL injuries: 2 cases (10%) had normal ligaments (Grade 0), 3 (15%) showed thickening or abnormal signal without rupture (Grade I), 10 (50%) exhibited partial tears (Grade II), and 5 (25%) had complete ruptures (Grade III). Additionally, 7 patients (35%) had talar dome osteochondral lesions, and 4 (20%) exhibited syndesmotic widening (\u0026gt;2 mm).\u003c/p\u003e\n\u003cp\u003eUsing arthroscopy as the reference standard, the diagnostic performance of WBCT and MRI was compared (Table 1).\u003c/p\u003e\n\u003cp\u003eTable 1: Diagnostic accuracy of WBCT and MRI\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003eMetric\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003eWBCT (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003eMRI (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003e|P\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003eSensitivity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003e90.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003e70.0\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003e0.039*\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003eSpecificity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003e85.7 \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003e\u0026nbsp;85.7\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003e1.000\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003ePPV \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003e\u0026nbsp;94.7 \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003e\u0026nbsp;87.5 \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003e\u0026nbsp;0.317\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003eNPV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003e75.0 \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003e66.7\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25%;\"\u003e\n \u003cp\u003e0.683\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eMRI missed three Grade II partial tears confirmed by arthroscopy that were clearly visualized on WBCT (Figure 2)..WBCT generated one false positive (a Grade I lesion misclassified as Grade II) and two false negatives involving subtle thickening. MRI yielded two false positives and six false negatives, including four Grade II and two Grade I injuries.\u003c/p\u003e\n\u003cp\u003e4.2. Additional imaging findings\u003c/p\u003e\n\u003cp\u003eWBCT outperformed MRI in identifying osseous abnormalities. Specifically, talar dome osteochondral lesions were detected in 7 cases (35%) on WBCT versus only 2 cases (10%) on MRI (P = 0.031). Syndesmotic widening was observed in 10 cases (50%) on WBCT and only 1 case (5%) on MRI (P = 0.0026). Additionally, WBCT identified three cases (15%) of anterior calcaneal process fractures that were not detected by MRI.\u003c/p\u003e\n\u003cp\u003e4.3. Interobserver agreement\u003c/p\u003e\n\u003cp\u003eInterobserver agreement was significantly higher for WBCT than for MRI. The Kappa coefficient for WBCT was 0.82 [95% confidence interval (CI): 0.65\u0026ndash;0.98], indicating excellent agreement, while MRI achieved a Kappa value of 0.68 (95% CI: 0.45\u0026ndash;0.91), reflecting moderate agreement. Only two cases required adjudication in the WBCT group (Grade I \u003cem\u003evs.\u003c/em\u003e Grade II) compared to five in the MRI group, including three cases of Grade II \u003cem\u003evs.\u003c/em\u003e Grade III and two involving Grade 0 \u003cem\u003evs.\u003c/em\u003e Grade I.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis prospective study demonstrates that WBCT with three-dimensional reconstruction achieves higher diagnostic sensitivity (90% \u003cem\u003evs.\u003c/em\u003e 70%) and interobserver agreement (Kappa\u0026thinsp;=\u0026thinsp;0.82 \u003cem\u003evs.\u003c/em\u003e 0.68) than conventional MRI in detecting ATFL injuries in patients with CAI. These results were particularly evident in the identification of partial ligament tears (Grade II injuries) and associated osseous abnormalities frequently underdetected by MRI. These findings provide important evidence for optimizing imaging strategies in the clinical evaluation of CAI.\u003c/p\u003e \u003cp\u003eSeveral factors likely contribute to WBCT's Technical advantages. First, WBCT accurately simulates the biomechanical environment of the ankle joint under physiological load, better reflecting actual ligament function. Our study found three Grade II ATFL injuries missed on MRI but detected \u003cem\u003evia\u003c/em\u003e WBCT. This finding aligns with findings by Koo et al. \u003csup\u003e[5]\u003c/sup\u003e, who reported that non-weight-bearing MRI may miss up to 25% of functionally significant ligament damage. Second, WBCT's high spatial resolution (0.6 mm slice thickness) and 3D reconstruction capabilities provide unique advantages in detecting subtle osseous abnormalities. WBCT detected seven talar dome lesions compared to only two detected by MRI, consistent with detection rates of 35\u0026ndash;40% reported by Chen et al. Third, multiplanar reformation (MPR) and volume rendering (VR) reconstruction techniques offer three-dimensional views, significantly improving diagnostic reproducibility. These capabilities likely contributed to WBCT's superior interobserver agreement (Kappa\u0026thinsp;=\u0026thinsp;0.82) compared to MRI (Kappa\u0026thinsp;=\u0026thinsp;0.68).\u003c/p\u003e \u003cp\u003eDespite these advantages, WBCT has limitations. While excellent in diagnosing grade II and III ATFL injuries, WBCT remains less effective than MRI in detecting Grade I injuries (ligament thickening/signal abnormalities) due to relatively limited soft tissue contrast. As noted by Zhang et al., MRI remains indispensable for identifying early ligament degeneration. Additionally, radiation exposure from WBCT warrants consideration. Although modern WBCT systems use low-dose protocols (mean effective dose\u0026thinsp;~\u0026thinsp;0.15), risk-benefit analysis remains important for younger patients.\u003c/p\u003e \u003cp\u003eThe findings of this study suggest specific clinical scenarios, in which WBCT offers diagnostic advantages: In patients with persistent clinical signs of ATFL injury, such as weight-bearing pain or recurrent ankle sprains, despite negative MRI results, WBCT should be considered as an adjunct imaging modality. When concurrent osseous abnormalities (such as talar dome injury) are suspected, WBCT is the preferred diagnostic method. Additionally, during preoperative planning, the three-dimensional imaging provided by WBCT facilitates more accurate localization of injuries, thereby offering critical insights into surgical planning.\u003c/p\u003e \u003cp\u003eThe present study is limited by a relatively small sample size, which may affect statistical robustness and generalizability. Further research with larger, multicenter cohorts is needed to validate these findings. In addition, this study did not assess the diagnostic impact of different weight-bearing levels, nor did it evaluate the correlation between imaging findings and long-term functional outcomes, both of which warrant further investigation.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWBCT with three-dimensional reconstruction shows superior diagnostic accuracy and interobserver agreement compared to conventional MRI for evaluating ATFL injuries in CAI. WBCT is particularly effective in identifying high-sensitivity ligament injuries and concurrent osseous abnormalities. We recommend WBCT as an important complementary examination to MRI, particularly when evaluating functional CAI and planning surgical interventions. Future large-scale studies are needed to establish standardized WBCT diagnostic criteria and clinical application guidelines.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eWBCT:\u003c/strong\u003eweight-bearing computed tomography;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCAI\u003c/strong\u003e:chronic ankle instability ;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMRI\u003c/strong\u003e:magnetic resonance imaging ;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eATFL\u003c/strong\u003e：anterior talofibular ligament\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePPV\u003c/strong\u003e：positive predictive value；\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNPV\u003c/strong\u003e：negative predictive value\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAuthor Yundi Tang、Yuyun You and Xia Zheng contributed to experimental design, data collection, and manuscript drafting.Author Wei Song participated in data analysis, interpretation, and critical revisions of the manuscript.Authors Yonghui Xu and Han Fureviewed and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003eThere were no funding sources for this study.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eVohra R, Singh A, Thorat B, Patel D. Instability of the distal tibiofibular syndesmosis. J Orthop Surg (Hong Kong). 2023;31(2):10225536231182349. doi:10.1177/10225536231182349\u003c/li\u003e\n \u003cli\u003eAnderson DD, Ledoux WR, Lenz AL, Wilken J, Easley ME, de Cesar Netto C. Ankle osteoarthritis: Toward new understanding and opportunities for prevention and intervention. J Orthop Res. 2024;42(12):2613-2622. doi:10.1002/jor.25973\u003c/li\u003e\n \u003cli\u003eLintz F, Beaudet P, Richardi G, Brilhault J. Weight-bearing CT in foot and ankle pathology. Orthop Traumatol Surg Res. 2021;107(1S):102772. doi:10.1016/j.otsr.2020.102772\u003c/li\u003e\n \u003cli\u003eSegal NA, Anderson DD. Editorial commentary on Fritz et al. article entitled \u0026apos;Three-dimensional analysis for quantification of knee joint space width with weight-bearing CT: comparison with non-weight-bearing CT and weight-bearing radiography\u0026apos;.Osteoarthritis Cartilage.2022;30(5):629-632. doi:10.1016/j.joca.2021.12.005\u003c/li\u003e\n \u003cli\u003eTurmezei TD, Malhotra K, MacKay JW, et al. 3-D joint space mapping at the ankle from weight-bearing CT: reproducibility, repeatability, and challenges for standardisation. Eur Radiol. 2023;33(11):8333-8342. doi:10.1007/s00330-023-09718-6\u003c/li\u003e\n \u003cli\u003eElabd OM, Elabd AM, El-Azez MSA, Taha MM, Mohammed AH. Impact of chronic ankle instability on gait loading strategy in individuals with chronic ankle instability: a comparative study. J Neuroeng Rehabil. 2024;21(1):185. Published 2024 Oct 18. doi:10.1186/s12984-024-01478-8\u003c/li\u003e\n \u003cli\u003eCaub\u0026egrave;re A, Viricel C, Garcia-Jaldon F, et al. Assessment of chronic ankle instability: are functional scores relevant enough?. Orthop Traumatol Surg Res. Published online January 16, 2025. doi:10.1016/j.otsr.2025.104167\u003c/li\u003e\n \u003cli\u003eDu Y, Wang S, Yang F, Xu H, Cheng Y, Yu J. Effects of chronic ankle instability after grade I ankle sprain on the post-traumatic osteoarthritis. Arthritis Res Ther. 2024;26(1):168. Published 2024 Sep 28. doi:10.1186/s13075-024-03402-w\u003c/li\u003e\n \u003cli\u003eKawabata S, Ozone K, Minegishi Y, et al. Chronic Ankle Joint Instability Induces Ankle Sensorimotor Dysfunction: A Controlled Laboratory Study. Am J Sports Med. 2024;52(3):739-749. doi:10.1177/03635465231217490\u003c/li\u003e\n \u003cli\u003eDonovan L, Linens SW, Hubbard-Turner T, Simon J, Gribble PA, Thomas AC. Participant demographics and research questions from 10-years of chronic ankle instability studies: A scoping review. J Sci Med Sport. Published online March 14, 2025. doi:10.1016/j.jsams.2025.03.003\u003c/li\u003e\n \u003cli\u003eYang X, Lv Z, Sun Z, et al. Plantar Pressure Analysis and the Ankle Instability Index: Quantifying \u0026quot;Giving Away\u0026quot; in Functional Ankle Instability. Foot Ankle Int. 2025;46(4):435-442. doi:10.1177/10711007251318739\u003c/li\u003e\n \u003cli\u003eCao S, Chen Y, Zhu Y, et al. Concomitant osteochondral lesion of the talus affects in vivo ankle kinetics in patients with chronic ankle instability. Bone Joint Res. 2024;13(12):716-724. Published 2024 Dec 4. doi:10.1302/2046-3758.1312.BJR-2023-0217.R2\u003c/li\u003e\n \u003cli\u003eKobayashi T, Koshino Y, Takahashi K, et al. Influence of Anterior Talofibular Ligament Injury and Ankle Anterior Displacement on Symptoms in Individuals With Chronic Ankle Instability. J Athl Train. 2024;59(11):1089-1094. doi:10.4085/1062-6050-0582.23\u003c/li\u003e\n \u003cli\u003eYoshimoto K, Noguchi M, Maruki H, Tominaga A, Ishibashi M, Okazaki K. Anterior talofibular ligament remnant quality is important for achieving a stable ankle after arthroscopic lateral ankle ligament repair. Knee Surg Sports Traumatol Arthrosc. 2023;31(6):2183-2191. doi:10.1007/s00167-022-07211-z\u003c/li\u003e\n \u003cli\u003eChen TX, Wu JY, Yang TJ, Chen G, Li Y, Zhang L. Development and validation of radiomics model for MRI-based identification of anterior talofibular ligament injuries. Sci Rep. 2025;15(1):15575. Published 2025 May 4. doi:10.1038/s41598-025-99813-z\u003c/li\u003e\n \u003cli\u003eYau WP, Chan YC. Evaluation of Graft Ligamentization by MRI After Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 2023;51(6):1466-1479. doi:10.1177/03635465231160790\u003c/li\u003e\n \u003cli\u003eCol\u0026ograve; G, Bignotti B, Costa G, Signori A, Tagliafico AS. Ultrasound or MRI in the Evaluation of Anterior Talofibular Ligament (ATFL) Injuries: Systematic Review and Meta-Analysis. Diagnostics (Basel). 2023;13(14):2324. Published 2023 Jul 10. doi:10.3390/diagnostics13142324\u003c/li\u003e\n \u003cli\u003eHu Y, Li Q, Li X, et al. Evaluation of Open Versus Arthroscopic Anterior Talofibular Ligament Reconstruction for Chronic Lateral Ankle Instability With Talar and Subtalar Cartilage MRI T2 Mapping: A 3-Year Prospective Study. Am J Sports Med. 2024;52(3):730-738. doi:10.1177/03635465231222931\u003c/li\u003e\n \u003cli\u003eXie D, Murray J, Lartey R, et al. Multi-vendor multi-site quantitative MRI analysis of cartilage degeneration 10 Years after anterior cruciate ligament reconstruction: MOON-MRI protocol and preliminary results. Osteoarthritis Cartilage. 2022;30(12):1647-1657. doi:10.1016/j.joca.2022.08.006\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"archives-of-orthopaedic-and-trauma-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aots","sideBox":"Learn more about [Archives of Orthopaedic and Trauma Surgery](http://link.springer.com/journal/402)","snPcode":"402","submissionUrl":"https://submission.springernature.com/new-submission/402/3","title":"Archives of Orthopaedic and Trauma Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Chronic ankle instability, anterior talofibular ligament, Magnetic resonance imaging, The emergence of weight-bearing computed tomography ","lastPublishedDoi":"10.21203/rs.3.rs-6845002/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6845002/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003eThis study aimed to assess the diagnostic value of weight-bearing computed tomography (WBCT) with three-dimensional reconstruction in detecting ligamentous injuries associated with chronic ankle instability (CAI) and to compare its efficacy with that of conventional magnetic resonance imaging (MRI). The goal was to assess the potential of WBCT as a more precise imaging modality to guide clinical decision-making.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003eTwenty patients with clinically suspected CAI, recruited between January 2024 and March 2025, underwent both WBCT (Planmed Verity; load equivalent to 100% body weight) and MRI (GE 1.5T; standard imaging protocols). Two senior musculoskeletal radiologists independently evaluated ligament integrity using a blinded protocol. Arthroscopic or intraoperative findings were used as the reference standard. Diagnostic parameters, including sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV), were calculated for each method. Interobserver agreement was quantified using the Kappa statistic.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e WBCT demonstrated significantly higher sensitivity for detecting anterior talofibular ligament (ATFL) injuries compared to MRI (90%\u003cem\u003e vs. \u003c/em\u003e70%, P \u0026lt; 0.05), particularly in cases with osseous abnormalities such as talar dome lesions and syndesmotic widening (P \u0026lt; 0.01). WBCT also yielded superior interobserver agreement (Kappa = 0.82) relative to MRI (Kappa = 0.68).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion \u003c/strong\u003eWBCT with [1]three-dimensional reconstruction offers enhanced diagnostic accuracy and reproducibility in assessing ATFL injuries, especially in the presence of functional instability or coexisting bony pathology. These findings support the use of WBCT as a complementary modality to MRI in the comprehensive evaluation of CAI.\u003c/p\u003e","manuscriptTitle":"Diagnostic Value of Weight-Bearing CT with Three-Dimensional Reconstruction in Chronic Ankle Instability: A Comparative Study with Conventional MRI","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-02 08:13:24","doi":"10.21203/rs.3.rs-6845002/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-19T18:20:13+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-04T21:00:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"135503842503313714243389901936363189076","date":"2025-07-23T21:21:00+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-07T16:14:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"20097413696047669466244559753536088963","date":"2025-06-26T20:14:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"185207844349226399842212215516508422403","date":"2025-06-26T15:55:05+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-26T15:48:27+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-14T01:13:03+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-14T01:12:32+00:00","index":"","fulltext":""},{"type":"submitted","content":"Archives of Orthopaedic and Trauma Surgery","date":"2025-06-08T01:33:49+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"archives-of-orthopaedic-and-trauma-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aots","sideBox":"Learn more about [Archives of Orthopaedic and Trauma Surgery](http://link.springer.com/journal/402)","snPcode":"402","submissionUrl":"https://submission.springernature.com/new-submission/402/3","title":"Archives of Orthopaedic and Trauma Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"2032bda2-dbc4-4276-a651-e2517f041bd1","owner":[],"postedDate":"July 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-09T16:05:37+00:00","versionOfRecord":{"articleIdentity":"rs-6845002","link":"https://doi.org/10.1007/s00402-026-06211-9","journal":{"identity":"archives-of-orthopaedic-and-trauma-surgery","isVorOnly":false,"title":"Archives of Orthopaedic and Trauma Surgery"},"publishedOn":"2026-02-04 15:57:40","publishedOnDateReadable":"February 4th, 2026"},"versionCreatedAt":"2025-07-02 08:13:24","video":"","vorDoi":"10.1007/s00402-026-06211-9","vorDoiUrl":"https://doi.org/10.1007/s00402-026-06211-9","workflowStages":[]},"version":"v1","identity":"rs-6845002","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6845002","identity":"rs-6845002","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}