bluuebunny/crossref_metadata_2025 huggingface dataset:
AI-Based Foot X-Ray Reading in Real-World: Evaluating the Accuracy of Assistive Decisions for Diagnosing Foot & Ankle Disorders
Authors: Kim Yoon-Chung , Choi Youn-Ho
Published: December 2023

Category:

Midfoot/Forefoot; Hindfoot

Introduction/Purpose:

Evaluation of plain radiographs is of fundamental importance in the diagnosis and treatment planning of foot and ankle disorders. These assessments are essential, but can be difficult for the following reasons: First, many angles must be measured using various reference lines. Second, there may be inter-observer differences in the measurements. Consistent and standardized measurement methods are required to increase the efficiency and accuracy of radiographic readings. Several recent studies have reported good results using deep learning (DL) models for medical image analysis. It is expected that efficiency and accuracy can be increased through radiographic readings using DL. This study aims to develop a DL model that recognizes the bones of the foot and ankle in plain radiographs and automatically measures angles frequently used for diagnosis.

Methods:

The DL model was developed using two architectures: segmenting objects by locations (SOLO) for bone segmentation and Global Universal U-Net (GU2Net) for reference line detection. The angles measured were hallux valgus angle (HVA) and 1st- 2nd intermetatarsal angle (IMA) on anterior-posterior (AP) X-ray; calcaneal pitch angle (CPA) and lateral Meary's angle (LMA) on lateral X-ray. Only data obtained from external test set were used for statistical analysis to evaluate the model's performance. The test set used a total of 558 images collected from January 2022 to September 2022. Angles measured by the DL model were compared with angles measured manually by human researchers. The intraclass correlation coefficient (ICC) was used to evaluate the accuracy of angle measurements. The error between the angle measured by the DL model and the angle measured by human researchers was evaluated using root mean square error (RMSE) and mean absolute difference (MAE).

Results:

As shown in the attached table, the ICCs of HVA were 0.957 (right) and 0.933 (left). The ICCs of IMA were 0.881 (right) and 0.902 (left). The ICCs of LMA were 0.895 (right) and 0.937 (left). The ICCs of CPA were 0.918 (right) and 0.868 (left). All ICCs were greater than 0.8, indicating excellent correlations between angles measured with the DL model and angles measured manually (ground truth). For RMSE and MAE, the left IMA was the smallest (1.50 and 1.16, respectively), and the right LMA was the largest (4.50 and 2.47, respectively).

Conclusion:

The DL model in our study was able to perform various angle measurements in both AP and lateral X-rays with considerable accuracy. Through additional model training and development, it is expected that it will be useful for analyzing various foot and ankle disorders such as hallux valgus, flatfoot, pes cavus and other alignment deformities.
Automated AI Detection Tool for Ankle Fractures Using X-Rays and Smart Devices
Authors: Nassour Nour , Acitores Jose M. , Jang Caleb , Ranganathan Noopur , Wolf John , Kwon John , DiGiovanni Christopher W. , Ashkani-Esfahani Soheil
Published: December 2023

Category:

Ankle; Trauma

Introduction/Purpose:

The use of artificial intelligence (AI) is particularly salient to visually oriented medical professions, especially orthopedics. The most prominent use of AI in orthopedics comes in the form of medical imaging examinations. AI has a huge potential to help doctors make diagnoses by acting as a second pair of eyes. Some results suggested a very high level of agreement between AI models’ and the clinician’s assessments of radiographs. Furthermore, it was also suggested that the sensitivity and specificity of emergency medicine physicians for detecting some pathologies are significantly improved when aided by an AI tool. In view of these observations, our study aimed to create an AI-based ankle fracture detection tool that can be used on smart devices for X-ray interpretation.

Methods:

We examined 2,193 patients’ charts from 2 academic and 1 community hospital in Boston. We retrieved the anteroposterior (AP), oblique, and lateral ankle X-rays of each patient. Patients with ankle fractures and adults older than 18 years met our inclusion criteria. We excluded patients younger than 18 years old and those with any artifact, such as a cast, screws, or other artifacts in their X-rays. The study comprised 352 healthy controls and a total of 579 ankle fracture patients. Other than the digital images obtained from Electronic patient records (EPR), we used two different smart devices, a cellphone, and a tablet, to capture images from the monitor screen. Using Machine Learning models, we developed a fracture detection model using all three types of imaging and named it the “combination model”. We subsequently tested the combination model on digital X-rays, smart devices, and on both datasets together (Table 1).

Results:

We extracted the X-rays of a total of 931 patients in this study. Following the development and testing of our AI models, we noticed that all performed well with AUCs and accuracies above 0.85 and 0.86, respectively (Table1). The best performance was found when the combination model was tested on images taken from the camera of our smart devices, with an AUC of 0.88, a sensitivity of 0.86, and an accuracy of 0.89. This performance was closely followed by that of our model tested on a mix of both smart devices and original digital images with an AUC of 0.88, a sensitivity of 0.86, and an accuracy of 0.88.

Conclusion:

Our AI-based tool showed promising performance in the detection of ankle fractures using smart devices and images obtained from the monitor screen. We were able to reach an accuracy of diagnosis on smart device-captured images that were comparable with the original digital X-rays. The outcome of this study can be used to help providers who lack sufficient experience in detecting fractures. It can also be used for educational purposes for trainees in this field.
Complication Rates and Functional Outcomes after Total Ankle Arthroplasty in Patients with Rheumatoid Arthritis
Authors: Wixted Colleen M. , Kim Billy I. , Anastasio Albert T. , DeOrio James K. , Nunley James A. , Adams Samuel , Easley Mark
Published: December 2023

Category:

Ankle Arthritis; Other

Introduction/Purpose:

Utilization rates of total ankle arthroplasty (TAA) have greatly increased in recent years. For patients with rheumatoid arthritis (RA) undergoing TAA, conflicting data have been reported regarding risk of complications and patient reported outcome (PRO) improvement when compared to patients with osteoarthritis. The purpose of this study is to compare complication rates and PROs of patients with RA to patients with osteoarthritis and posttraumatic arthritis.

Methods:

This was a retrospective study of 1,071 primary TAA performed at a single institution between 2001 and 2020. Minimum follow-up was two years. Patients were stratified by indication for TAA (osteoarthritis, n=372; posttraumatic arthritis, n=642; RA, n=57). Patient demographics, intraoperative variables, postoperative complications, and PRO measures were compared between groups using univariable statistics. Multivariable Cox regression was performed to assess risk for implant failure. Mean follow-up was 5.6 years (SD: 3.1).

Results:

Compared to the osteoarthritis and posttraumatic arthritis groups, the RA cohort had the lowest mean age (p < 0.001), lowest percentage of males (p < 0.001), and highest ASA score (p < 0.001). Univariate analysis showed no statistically significant difference for infection rates among groups (p=1.0). The RA cohort had the highest rate of heterotopic ossification postoperatively (2/57, 3.5%, p< 0.001). Multivariable regression analysis showed no increased risk of implant failure for the RA cohort (p=0.23). For the SMFA, SF-36, AOFAS-hindfoot, FAOS-symptoms, and FAOS-ADL the RA group reported the worst scores at final follow-up (p < 0.001). However, the RA cohort demonstrated the largest improvements from preoperative to postoperative scores on the FADI, SF-36, and the symptoms and ADL subscales of the FAOS (p=0.04, 0.01, 0.03, 0.03).

Conclusion:

In the largest single institution study to date, patients with RA had the worst PRO scores compared to the osteoarthritis and posttraumatic arthritis groups. However, they experienced significantly higher improvements in functional outcomes from their preoperative baseline. Large patient samples with mid- to long-term follow up such as a presented in this series are imperative to fully understand the risk-benefit of TAA in various patient cohorts.
Effects of Ankle Arthrodesis vs Total Ankle Arthroplasty on Patient’s Shoe-Wear: What Fits Better?
Authors: Willegger Madeleine , Anderson Lindsay , Symes Michael , Younger Alastair , Wing Kevin , Penner Murray , Veljkovic Andrea
Published: December 2023

Category:

Ankle Arthritis; Ankle

Introduction/Purpose:

Currently there are two major surgical options for the treatment of end-stage ankle arthritis (ESAA), namely total ankle arthroplasty (TAA) and ankle arthrodesis (AA). Many patients inquire about what shoes they can expect to wear after surgery. Shoes should fit to the patient’s feet, help shielding pathological joints, be comfortable, but also fashionable, as they are part of personal style and fashion. The impact ESAA surgery has on choice of shoes and consecutively on quality of life, has not been studied. Potentially maintenance of ankle range of motion and improved gait mechanics with TAA could also improve the ability to comfortably wear different styles of shoes. The purpose of this study is to evaluate the effects of either AA and TAA on shoe-wear.

Methods:

This study is a retrospective analysis of a cohort of ESAA patients surgically treated with AA or TAA from the COFAS (Canadian Orthopaedic Foot and Ankle Society) database. Patient’s shoe wear comfort was obtained from the Musculoskeletal Outcomes Data Evaluation and Management Scale questionnaire, completed pre-operatively and post-operatively two and five years following surgery. The relationship between ankle-related quality of life and shoe-wear comfort, adjusting for patient factors was evaluated. A linear regression model adjusted for age, gender, BMI, smoking status, presence of inflammatory arthritis and baseline score was calculated. Additionally, differences within each pre-operative COFAS grades were analyzed.

Results:

104 patients after AA and 106 following TAR have been included. The mean pre-operative baseline score did not differ between the cohorts (39.36 for AA and 38.94 for TAA, respectively; p= 0.74). Comparing AA patients with TAA patient scores over a 5-year period, there was no difference in shoe-wear comfort after 2 years, but after 5 years scores significantly improved for TAA patients (p= 0.02). Subgroup analysis showed that COFAS 4 patients improved the most with significant changes already after 2 years (mean difference 5.4, p=0.05), which further improved after 5 years of follow-up (mean difference 10.7, p=0.001).

Conclusion:

This study is the first study to elucidate patient experience after ankle arthrodesis and total ankle arthroplasty with regards to their shoe-wear. Patients undergoing TAR have better shoe-wear scores by five years post-operatively than those undergoing AA. Especially patients with a COFAS 4 grade, which represents a patient population with adjacent joint arthritis, show significant improvement already 2 years after surgery. This data is useful when counselling patients preoperatively, and further provides support for TAA over AA after appropriate patient selection.
Evaluating the Utility of Plain Radiograph and Computerised Tomography Scanning in Identifying Concomitant Foot Fractures in Patients with Unstable Lisfranc Injuries
Authors: Aamir Junaid , Caldwell Robyn , Karthikappallil Dileep , Elbannan Mamdouh M. , Tanaka Hiro , Mason Lyndon W.
Published: December 2023

Category:

Midfoot/Forefoot; Trauma

Introduction/Purpose:

Lisfranc fracture dislocations are uncommon injuries, which frequently require surgical intervention. Currently, there is varying evidence on the diagnostic utility of plain radiographs (XR) and CT in identifying Lisfranc injuries and concomitant fractures. Our aim was to identify the utility of XR as compared to CT, with the nul hypothesis that there was no difference in fracture identification.

Methods:

A retrospective assessment of patients who had sustained a Lisfranc injury between 2013 and 2022 across two trauma centres within the United Kingdom who underwent surgery. Pre-operative XR and CT images were reviewed independently by 2 reviewers to identify the presence of associated fractures.

Results:

A total of 175 patients were included. Our assessment identified that XR images significantly under-diagnosed all metatarsal and midfoot fractures. The largest discrepancies between XR and CT in their rates of detection were in fractures of the cuboid (5.7% vs 28%, p< 0.001), medial cuneiform (20% vs 51%, p=0.008), lateral cuneiform (4% vs 36%, p=0.113), second metatarsal (57% vs 82%, p< 0.001), third metatarsal (37% vs 61%, p< 0.001) and fourth metatarsal (26% vs 43%, p< 0.001). As compared to CT, the sensitivity of XR was low. The lowest sensitivity for identification however was lateral foot injuries, specifically fractures of the lateral cuneiform (sensitivity 7.94%, specificity 97.3%), cuboid (sensitivity 18.37%, specificity 99.21%), fourth (sensitivity 46.7%, specificity 89.80%) and fifth metatarsal (sensitivity 45.00%, specificity 96.10%).

Conclusion:

From our analysis, we can determine that XR significantly under-diagnoses associated injuries in patient sustaining an unstable Lisfranc injury, with lateral foot injuries being the worst identified. We advised the use of CT imaging in all cases for appropriate surgical planning.
Fixed Bearing in Primary Total Ankle Replacement Is Associated with Reduced Revision Rates
Authors: Stavrou Peter , Harries Dylan , Lorimer Michelle , Corfield Sophie
Published: December 2023

Category:

Ankle Arthritis; Ankle

Introduction/Purpose:

The revision rate for total ankle replacement (TAR) in Australia has decreased over the past 6-years, coinciding with an increased use in fixed bearing prostheses. This study aimed to determine if the use of fixed bearing prostheses or surface coating are associated with lower revision rates.

Methods:

Data from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) included primary cementless TAR procedures performed for any diagnosis from January 2015-December 2021. Procedures were grouped by insert mobility (fixed & mobile) and surface coating (HA & non HA). The time to first revision was summarised using Kaplan-Meier estimates of survivorship, with hazard ratios (HR) obtained from Cox proportional hazards models including age, gender, insert mobility and surface coating.

Results:

There were 1,865 primary cementless TAR procedures of which 1,467 (78.7%) were fixed bearing and 398 (21.3%) mobile bearing. HA coating was used in 422 (28.8%) of fixed bearing procedures and 336 (84.4%) of mobile bearings. The cumulative percent revision (CPR) at 6 years was 4.1% for fixed bearing and 9.8% for mobile bearing TAR procedures. When the effects of insert mobility and bearing surface were considered separately, fixed bearings had a significantly lower revision rate compared to mobile bearings (HR=0.48), but there was no significant difference between HA and non HA coatings (HR = 1.18). When analysed by insert mobility and surface coating, mobile bearing HA prostheses had a significantly higher revision rate than fixed bearing prostheses with either coating.

Conclusion:

Analysis of 1,865 primary cementless TAR procedures shows that fixed bearing prostheses have significantly lower rates of revision than mobile bearing prostheses even when adjusting for surface coating.
Identification and Analysis of the Ankle Microbiome Using Next-Generation DNA Sequencing: An Observational Analysis
Authors: Hoch Caroline , Allen John R. , Morningstar Joshua L. , Rodriguez-Materon Solangel , Gross Christopher E. , Scott Daniel
Published: December 2023

Category:

Ankle; Basic Sciences/Biologics

Introduction/Purpose:

Next-generation DNA sequencing (NGS) technologies have increased the sensitivity of bacterial cultures and has been used in other areas of orthopaedics to better understand the native microbiome of various joints. This study uses NGS to determine whether (1) a unique microbiome exists in human ankle tissues, (2) if components of the ankle microbiome impact patient outcomes, and (3) whether microbes found on the skin are a normal part of the ankle microbiome.

Methods:

A prospective study recruited 32 patients undergoing total ankle arthroplasty (TAA, n=23) or ankle arthrodesis via an anterior approach (n=9) during 2020-2021 with one of two fellowship-trained foot and ankle surgeons at an academic medical center. During the operation, the surgeon would swab five layers of the ankle for analysis at a CLIA-licensed molecular diagnostic laboratory: skin (n=32), retinaculum (n=31), tibialis anterior tendon (n=31), joint capsule (n=31), and distal tibia (n=32). Demographics, medical comorbidities, surgical indication, postoperative complications, and readmission and reoperation rates were collected from patient records.

Results:

Of the 157 swabs sent for NGS, 19 (12.1%) indicated 27 bacteria were present (positive), while the remaining 138 (87.9%) had no bacteria present (negative). The most common organisms were Cutibacterium acnes, present in 11 ankles (34.4%), and Staphylococcus epidermidis, present in 3 ankles (9.4%). The most bacteria were found in the retinaculum (29.6%). No PROM nor follow-up duration was associated with the presence of bacteria, or the number of bacteria or affected layers. Similarly, complication (positive=18.2%, negative=23.8%; p=1.000), nonunion (positive=0.0%, negative=28.6%; p=1.000), infection (positive=0.0%, negative=4.8%; p=1.000), 90-day readmission (positive=0.0%, negative=4.8%; p=1.000), and reoperation (positive=0.0%, negative=4.8%; p=1.000) rates did not differ if a subject’s NGS profile was positive or negative.

Conclusion:

This study found that C. acnes and S. epidermidis were most commonly found in the ankle microbiome, with C. acnes being present in 34% of ankles. There was no difference in complication rates between patient with and without positive bacterial cultures following TAA or ankle arthrodesis.
Immediate Unprotected Weightbearing After Open Reduction Internal Fixation of Ankle Fractures: A Prospective Trial
Authors: Le Vu (Brian) , Viskontas Darius , Lohre Ryan , Yan James R. , Stone Trevor , Perey Bertrand , Moola Farhad O. , Boyer Dory , Lemke Mike M. , Apostle Kelly L.
Published: December 2023

Category:

Trauma; Ankle

Introduction/Purpose:

Ankle fractures are among the most common orthopaedic injuries treated surgically, with indications well- established. However, post-operative care protocols remain controversial and vary widely between surgeons. This prospective controlled trial compared functional outcomes of the local institutional standard (control group) of nonweightbearing (NWB) for two weeks in a short leg splint followed by weightbearing as-tolerated (WBAT) in a boot with range of motion (ROM), versus immediate unprotected weightbearing (IMWB).

Methods:

40 consecutive patients undergoing ankle fracture open reduction internal fixation (ORIF) at a single level-1 trauma center meeting inclusion and exclusion criteria were enrolled into the control group, and the next 40 consecutive patients were enrolled in the IMWB group. The study sample size was powered to detect a statistically significant difference in the Olerud- Molander score (OMAS), the primary study outcome. Secondary outcome measures included the Euroquol-5D (EQ5D) self reported patient score and Work Productivity and Activity Impairment: Specific Health Problem (WPAI:SHP) scores, ankle ROM, wound complications, time to return to work, radiograph measurements and loss of fracture reduction. Patients underwent ankle ORIF with surgical technique and implant choice left to the surgeon’s discretion. Postoperative follow-ups were done at 2, 6, and 12 weeks.

Results:

Demographics of the two groups were similar except for the control group having 4 patients with type II diabetes and the IMWB group having none. There was no statistically significant difference in OMAS at any time point. There were also no statistically significant differences in the EQ5D or WPAI:SHP scores, ROM, time to return to work, or radiographic measurements at any time point. The IMWB group had 5 superficial wound complications versus 1 in the control group. There were 2 cases of loss of reduction in the IMWB group versus none in the control group. Both loss of reductions were determined to not be related to the post operative protocol.

Conclusion:

Immediate unprotected weightbearing after ORIF of ankle fractures results in equivocal functional outcomes compared with 2 weeks of NWB followed by protected weightbearing and ROM over the first 3 postoperative months. An increased number of wound healing complications was seen in the IMWB group which requires further investigation.
Mid- to Long-Term Outcomes of the STAR Total Ankle Replacement
Authors: Anastasio Albert T. , Poehlein Emily , Easley Mark , Nunley James A.
Published: December 2023

Category:

Ankle Arthritis; Ankle

Introduction/Purpose:

The Scandinavian Total Ankle Replacement (STAR) is a widely used ankle prosthesis, but mid- to long-term follow up remains limited. In thirteen different studies involving 939 STAR total ankle prostheses, the average duration of follow- up for recipients was 3.9 years. Thus, we sought to evaluate the STAR at the mid- to long-term interval with regards to survivorship, complications, and patient reported outcomes (PROs) in one of the largest series with the longest-term follow up to date.

Methods:

All patients managed with a primary STAR prosthesis at our institution from March 2002 through January 2017 were included in the analysis. Demographic characteristics including gender, race, age, diabetes status, body mass index (BMI), smoking status, American Society of Anesthesiologist (ASA) score, and surgery time were summarized. The cumulative incidence of implant failure was at 5 years and the last recorded time to event (8 years) were reported with 95% confidence intervals (CI). Paired t- tests were used to compare pre-operative and 5 year post-operative (±1 year) for PROs including Visual Analog Scale (VAS), Short Musculoskeletal Function Assessment (SMFA), Short-form-36 (SF-36), and American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot subscales. Additionally, intra- and post-operative complications were recorded. All statistical analysis were conducted in SAS 9.4 (Cary, NC). Statistical significance was assessed at α = 0.05.

Results:

247 patients with a unilateral STAR procedure were included in this analysis. Demographics are listed in Table 1. The average number of years of follow-up was 5.71 ± 4.07 years. The cumulative incidence of implant failure at 5 years was 7.7% (95% CI 4.3%-12.5%). The last failure event occurred at 8 years post-implant. The cumulative incidence of implant failure at 8 years was 11.1% (95% CI 6.3%-17.3%) (Table 2, Figure 1). The most common post-operative complications were impingement (N = 39, 15.8%), ankle pain (N = 22, 8.9%), and implant failure (N = 16, 6.5%) (Table 3). With regards to PROs, patients significantly improved between baseline and 5-year follow up in all measures (all p< 0.001; Table 4).

Conclusion:

At mid- to long-term follow up, patients receiving the STAR prosthesis experienced a significant and durable improvement in PROs across multiple functional indices. Complication and failure rates were lower than those reported in previous series evaluating the STAR, with an observed survivorship of 88.9% at 8-year follow up.
Operative Treatment of Jones Fractures (OTA Type 87,5.2A) is not Associated with Earlier Clinical or Radiographic Healing
Authors: Kingery Matthew T. , Kadiyala Manasa , Walls Raymond J. , Ganta Abhishek , Konda Sanjit , Leucht Philipp , Rivero Steven , Egol Kenneth A.
Published: December 2023

Category:

Midfoot/Forefoot; Trauma

Introduction/Purpose:

The purpose of this study was to compare the time to radiographic and clinical healing between patients with metadiaphyseal metatarsal fractures (True Jones) treated operatively and those treated nonoperatively.

Methods:

This was a retrospective cohort study of patients presenting to a single large, urban, academic hospital center with Jones fractures between December 2012 and April 2022. Jones fractures were defined as 5th metatarsal base fractures occurring in the proximal metadiaphyseal region, just distal to the articulation of the 4th and 5th metatarsals on the oblique radiographic view (Zone 3). Information regarding patient demographics, injury mechanism, clinical presentation, management, and time to healing was collected. A fracture was defined as clinically healed when the patient had returned to their baseline ambulatory status without pain and there was an absence of tenderness to palpation on physical examination. Radiographic healing was defined as the presence of complete osseous consolidation. A total of 2,466 patients presented with 5th metatarsal fractures during the study period.

Results:

Among all 5th metatarsal fractures, 170 patients (6.9%) were classified as “true Jones” fractures. The mean age of patients presenting with Jones fractures was 46.1 +/- 18.6 years, and 65.8% were female. 19.9% were treated operatively (92.9% with screw fixation and 7.1% with ORIF), and 80.1% were treated nonoperatively. 95.9% of patients with Jones fractures went on to heal with no difference in time to radiographic healing (p = 0.296) or clinical healing between both groups (p = 0.228). Furthermore, there was no difference between groups with respect to the proportion of patients who developed delayed radiographic union with incomplete osseous healing at 6 months post-injury (9.3% in the nonoperative group versus 10.7% in the operative group, p = 0.098).

Conclusion:

Contrary to popular opinion, operative treatment of true Jones fractures was not associated with faster or more reliable radiographic union or time to clinical healing compared to patients treated nonoperatively. The overall rate of nonunion in true Jones fractures was found to be lower than previously described, and there was no evidence of any difference in nonunion rate with operative treatment compared to nonoperative management.
Outcomes of Arthroscopic Anterior Talofibular Ligament Repair with and without Inferior Extensor Retinaculum Augmentation for Chronic Ankle Instability: A Prospective Randomized Study
Authors: Lee Sung Hyun , Jo Yang Hun
Published: December 2023

Category:

Sports; Arthroscopy

Introduction/Purpose:

Although Modified Broström Technique is still gold standard procedure for chronic ankle instability (CAI), the effect of inferior extensor retinaculum (IER) augmentation remains unclear. Recently, as several arthroscopic surgical techniques for CAI have been introduced, the issue on additional IER augmentation has been controversial in the arthroscopic field as well. The purpose of this study was to compare the clinical and radiological outcomes between all-inside arthroscopic anterior talofibular ligament (ATFL) repair with and without IER augmentation.

Methods:

We prospectively randomized 59 patients who underwent arthroscopic surgery for CAI into 2 groups: arthroscopic ATFL repair with IER augmentation (group W, 29 patients) and without IER augmentation (group WO, 30 patients). The pain visual analog scale, American Orthopaedic Foot & Ankle Society score, Foot and Ankle Outcome Score, and the Karlsson Ankle Function Score were measured as subjective outcomes, and posturographic analysis was performed using a Tetrax device as an objective outcome. Radiologic outcome evaluations were performed preoperatively and at 2 years postoperatively using stress radiographs and axial view magnetic resonance imaging.

Results:

All clinical scores, objective posturography, and stress radiographs improved significantly at 2 years postoperatively in both groups (all, p< 0.05), with no significant differences between the groups with respect to the preoperative and postoperative values (all, p>0.05). In addition, we identified 3 retear (5.1%) based on postoperative MRI evaluation (3.4% [1/29] in group W and 6.7% [2/30] in group WO). However, there was no significant differences between 2 groups (p>0.05). One patient in group WO had neuralgia of the superficial peroneal nerve; 2 patients in group W had knot irritation causing mild discomfort.

Conclusion:

Arthroscopic ATFL repair represent good postoperative functional and radiologic outcomes, regardless IER augmentation. Additional IER augmentation after arthroscopic ATFL repair is not promise better clinical outcomes.
Outpatient Total Ankle Arthroplasty (TAA) as a Safe and Lower Cost Alternative to Inpatient TAA
Authors: Wolfe Isabel , Conti Matthew S. , Demetracopoulos Constantine , Ellis Scott J.
Published: December 2023

Category:

Ankle; Other

Introduction/Purpose:

Joint replacement procedures have traditionally been performed in an inpatient setting to minimize complication rates. While the Centers for Medicare and Medicaid Services (CMS) have made provisions for outpatient total hip and knee arthroplasty, Medicare patients undergoing total ankle arthroplasty (TAA), until recently, required inpatient admission. There is growing evidence that TAA can safely be performed as an outpatient procedure, with the benefit of decreased healthcare expenses and improved patient satisfaction. Studies have largely investigated direct costs associated with TAA. The purpose of our study was to compare payer costs and complication rates between inpatient and outpatient TAA using a large publicly available for-fee database.

Methods:

The PearlDiver Database was queried to identify TAA-associated claims for all payer types from January 2010 to April 2021. The claims were identified by the following ICD and CPT codes and analyzed based on service location: CPT-27700, CPT- 27702, ICD-9-P-8156, ICD-10-P-0SRF07Z, ICD-10-P-0SRF0JZ, ICD-10-P-0SRF0KZ, ICD-10-P-0SRG07Z, ICD-10-P-0SRG0JZ, ICD-10-P-0SRG07Z. Baseline comparisons of age, Charleston Comorbidity Index (CCI), geographic region, and payer type were performed. Total reimbursement amount for all associated claims was summed and divided by the number of patients assigned to those claims for the average amount paid per patient. Total cost over a 90-day period was calculated by summing the cost of all claims assigned to patients who underwent TAA within this time frame. The data were analyzed for postoperative infections and readmissions within 90 days as well as failure of TAA defined as conversion to ankle arthrodesis, revision ankle arthroplasty, and/or infection requiring postoperative irrigation and debridement.

Results:

A total of 7,520 patients who underwent outpatient TAA and 10,772 patients who underwent inpatient TAA were identified. The average age was 54.3 years for outpatients and 63.9 years for inpatients (p

Conclusion:

In patients undergoing TAA, both average paid per patient and total cost within 90 days were significantly lower in the outpatient setting. Patients who underwent TAA in the outpatient setting as compared to the inpatient setting were younger, with a lower comorbidity index and a different distribution by geographic region and payer type. Complication rates including postoperative infections, readmissions, and arthroplasty failures were significantly lower in the outpatient setting, perhaps due to differences in baseline patient characteristics. These data suggest that outpatient TAA is a safe and lower cost alternative to inpatient TAA.
Diagnostic Accuracy of Conventional Ankle CT Scan With External Rotation and Dorsiflexion in Patients With Acute Isolated Syndesmotic Instability
Authors: Rodrigues Joao Carlos , do Amaral e Castro Adham , Rosemberg Laercio Alberto , de Cesar Netto Cesar , Godoy-Santos Alexandre Leme
Published: December 2023

Category:

Ankle; Sports

Introduction/Purpose:

Syndesmotic injury in an athletic population is associated with a prolonged ankle disability after an ankle sprain and often requires a longer recovery than a lateral collateral ligament injury. Although several imaging tests are available, diagnosing syndesmotic instability remains challenging. The main objective was to determine the diagnostic accuracy of conventional ankle computed tomography (CT) scans with the joint in external rotation and dorsiflexion and compare it with that of conventional ankle CT scans in a neutral position.

Methods:

Between September 2018 and April 2021, this prospective study consecutively included adults visiting the foot and ankle outpatient clinic with a positive orthopedic examination for acute syndesmotic injury. Participants underwent 3 CT scan tests. First, ankles were scanned in a neutral position. Second, ankles were scanned with 45° of external rotation, dorsiflexion, and extended knees. Third, ankles were scanned with 45° of external rotation, dorsiflexion, and flexed knees. Three measurements, comprising rotation (measurement a), lateral translation (measurement c), and anteroposterior translation (measurement f) of the fibula concerning the tibia, were used to diagnose syndesmotic instability in the 3 CT scans. Magnetic resonance imaging was used as a reference standard. The area under the curve (AUC) was used to compare the diagnostic accuracy, and Youden’s J index was calculated to determine the ideal cutoff point.

Results:

Images obtained in 68 participants (mean age, 36.5 years; range, 18-69 years) were analyzed, comprising 36 syndesmotic injuries and 32 lateral collateral ligament injuries. The best diagnostic accuracy occurred with the rotational measurement a, in which the second and third CT scans with stress maneuvers presented greater AUCs (0.97 and 0.99) than the first CT scan in a neutral position (0.62). The ideal cutoff point for the stress maneuvers was 1.0 mm in the rotational measurement and reached a sensitivity and specificity of 83% and 97% for the second CT scan with extended knees and 86% and 100% for the third CT scan with flexed knees, respectively.

Conclusion:

Conventional ankle CT with stress maneuvers has excellent performance for diagnosing subtle syndesmotic rotational instability, as it shows a greater AUC and enhanced sensitivity at the ideal cutoff point compared with ankle CT in the neutral position.
The Effect of Diabetes Mellitus on Total Ankle Arthroplasty Outcomes
Authors: Helbing Jordan A. , Farley Benjamin , Gu Alex , Siram Gautam , Stein Benjamin , Chodos Marc David
Published: December 2023

Category:

Ankle Arthritis; Ankle

Introduction/Purpose:

The utility of total ankle arthroplasty (TAA) for management of end-stage ankle arthritis continues to increase. Postoperative infection after TAA is a devastating complication leading to additional surgeries, hospitalizations, long term antibiotics, arthrodesis, and sometimes amputation. Diabetes has been shown to be associated with postoperative infections following other orthopedic procedures. While the majority of literature demonstrates an association between diabetes and post- operative complications following TAA, other studies have demonstrated no such association. The goal of this study was to determine if diabetes influences the outcomes following TAA.

Methods:

An insurance database was utilized to identify patients undergoing TAA for end-stage ankle arthritis with a concurrent diagnosis of diabetes based on CPT, ICD-9, and ICD-10 diagnosis and procedure codes from 2010 to 2021. The postoperative outcomes of all cause revision, periprosthetic joint infection, periprosthetic joint infection with revision, and aseptic revision were compared between diabetic and nondiabetic patients with a minimum 2-year follow up using Kaplan-Meier and Cox proportional hazards analyses. Patient demographics, comorbidities, and Charlson Comorbidity Index was queried and analyzed via univariate and multivariate analysis, along with 90-day postoperative outcomes.

Results:

The study population included 8,317 patients who underwent TAA, 345 of which had a concurrent diagnosis of diabetes, with a minimum of 2-year follow up from 2010 to 2021. After multivariate Cox proportional hazards analysis, the 5-year cumulative incidence of PJI was 7.3% in diabetic patients compared to 3.9% in nondiabetic patients, with a 95% increased risk of revision (HR 1.95, 95% CI: 1.15-3.30, P=0.01). Diabetic patients also demonstrated a 5-year cumulative incidence of septic revision rate of 1.4% compared to 0.4% in nondiabetic patients, with a 363% increased risk (HR 4.63, 95% CI: 1.22-17.52, P=0.02). After controlling for differences in demographics and comorbidities through multivariate analysis, diabetes was independently associated with an increased risk for stroke (OR 10.12, P=0.007).

Conclusion:

The incidence of post-operative complications, including increased risk of 5-year risk of periprosthetic joint infection and septic revision was higher among diabetic patients compared to nondiabetic patients.
The Role of Computed Tomography with External Rotation and Dorsiflexion in Decision Making for Acute Isolated Posterior Malleolar Fractures Bartoníček and Rammelt Type II: A Cross-Sectional Study
Authors: Godoy-Santos Alexandre Leme , Rodrigues Joao Carlos , de Cesar Netto Cesar , Carvalho Kepler A.M. , Mansur Nacime Salomao Barbachan , Sposeto Rafael Barban , Giordano Vincenzo
Published: December 2023

Category:

Ankle; Sports

Introduction/Purpose:

A ligament-centered analysis is currently incorporated in the assessment of joint stability in malleolar fractures. Although several imaging tests are available, in the setting of acute isolated non-displaced posterior malleolar fractures Bartoníček/Rammelt types II and IV diagnosing syndesmotic instability remains challenging. The objective of this multi-center cross- sectional study was to evaluate the syndesmotic and fracture instability using conventional ankle CT with external rotation and dorsiflexion in the setting of acute, isolated non-displaced Bartoníček and Rammelt type II posterior malleolar fractures.

Methods:

Between March 2018 and September 2022, a consecutive sample of 123 individuals with an ankle sprain were assessed for eligibility. In total, 33 participants met the inclusion criteria. All participants underwent a CT scan (CTSM), comprising a first phase with the ankles in a neutral position, then a stress phase with the ankles in external rotation and dorsiflexion and semiflexed knees. Investigators used the patterns of ligament tear found at MRI and instability at CTSM to classify all participants into West Point grades I, IIA, IIB, or III. Mann-Whitney test was used to test the differences in the numerical variables between injured and uninjured syndesmoses. The Spearman correlation tested the strength of the association between the tibial joint surface involved in posterior malleolus fracture and syndesmotic instability.

Results:

In MRI reading parameters two patterns of syndesmotic ligament injury predominated. A completely torn AITF and IO ligaments and a completely torn AITF was combined with a partially torn IO. Regarding the deep layer of the deltoid ligament, participants were classified as normal, strained and partially torn. In CT scan reading parameters in the neutral phase, the median difference of 0.2 mm in d measurements between injured and uninjured syndesmoses was not statistically significant (P = 0.057). During the stress phase, the injured and uninjured syndesmoses had distinct behavior, and the 2.3 mm median difference for d measurement was statistically significant (P < 0.0001).

Conclusion:

The conventional computed tomography with external rotation and dorsiflexion represent a reproducible and accurate diagnostic option for the detection of syndesmosis instability and fracture instability in acute isolated posterior malleolar fractures Bartonícek and Rammelt type II.
Total Ankle Arthroplasty is Associated with Decreased Risk of Postoperative Total Knee Arthroplasty Compared to Ankle Arthrodesis
Authors: Coden Gloria , Brzezinski Andrzej , Hofmann Kurt
Published: December 2023

Category:

Ankle Arthritis

Introduction/Purpose:

There is a known association between ankle arthritis and ipsilateral knee arthritis. However, it is unknown if the increased range of motion and improved gait mechanics provided by total ankle arthroplasty (TAA) may delay the progression of knee arthritis compared to ankle arthrodesis (AA). We hypothesized that patients treated with TAA would have a lower incidence and longer time to total knee arthroplasty (TKA) compared to AA.

Methods:

We retrospectively reviewed a matched cohort of 5726 AA and 5726 TAA performed between 1/1/2007 and 12/31/2021 using a commercial claims database. Patients with a history of preoperative ipsilateral or unknown laterality TKA were excluded. Records were reviewed for demographics, comorbidities, diagnosis, documented history of an ankle deformity, and postoperative ipsilateral or unknown laterality TKA. Mahalanobis nearest neighbor matching was performed based on age, gender, year of surgery, geographical region, and diagnosis was used to determine the cohorts from 13,679 AAs and 5726 TAAs. Mean follow-up was 2.2 years. Univariate and multivariate analyses were performed to assess for risk factors. Significance was set at p< 0.05.

Results:

Patients who underwent TAA were older (p < 0.001), female (p < 0.001), had earlier ankle surgery (p < 0.001), and increased ankle deformity (p < 0.001) than AA, but rates of rheumatoid arthritis (p=0.54) and posttraumatic arthritis (p=0.53) compared to osteoarthritis were similar. Patients who underwent AA were 2.77 times more likely to undergo a postoperative TKA compared to TAA (p < 0.001). However, for those who underwent a TKA, patients with an AA (mean=3.48 years) tended to wait longer before proceeding with TKA than patients who underwent TAA (mean=2.62 years, p< 0.001). Risk factors for undergoing postoperative TKA included having AA (p < 0.001), earlier year of ankle surgery (p < 0.001), older age (p < 0.001), lack of ankle deformity (p < 0.005), lack of obesity (p < 0.047), and posttraumatic arthritis (p < 0.001), while gender (p=0.55) and rheumatoid arthritis (p=0.75) were not.

Conclusion:

Our results showed that there is a significantly higher incidence of patients undergoing TKA after AA compared to TAA (p < 0.001). Therefore, we recommend that surgeons consider TAA over AA, especially in young, active patients with minimal knee arthritis as a strategy to help delay the progression of knee arthritis. Patients who underwent AA tended to have a longer time interval to TKA (p < 0.001), which may be related to the longer expected recovery from an AA compared to TAA. With improved rehabilitation protocols for TAA, patients may recover faster so that they can proceed with their ipsilateral TKA earlier.
Clinical and Radiographic Outcomes of Revision Total Ankle Arthroplasty using a Revision Ankle System
Authors: Ray Justin J. , Graham George Dillon , Irwin Todd A. , Jones Carroll , Cohen Bruce , Davis Hodges
Published: December 2023

Category:

Ankle Arthritis; Ankle

Introduction/Purpose:

With the growing popularity of total ankle arthroplasty (TAA), revision surgeries are inevitable and expected to significantly increase over the next decade. Revision TAA remains a significant challenge with high complication rates. No previous study has reported on outcomes following revision TAA using an implant designed specifically for revisions. Theoretical benefits of a revision-specific ankle system include tibial and talar fixation/stability, restoration of joint height, coverage of bone loss/defects, and maximal talar coverage. The purpose of this study was to investigate radiographic and clinical outcomes at a minimum of 2 years following revision TAA using a revision-specific ankle system.

Methods:

Patients who underwent a revision TAA using a revision-specific ankle system (Invision, Stryker, Kalamazoo, MI) between January 2016 and December 2020 were eligible to be included in this study. Patients with less than 2-year follow-up and unwilling to return to clinic were excluded. Overall, 25 patients met inclusion criteria. Indications for revision TAA (Table 1) included talar loosening (n = 6), tibial loosening (n = 7), talar subsidence (n = 6), re-implant after infection (n = 4), instability (n = 3), periprosthetic fracture (n = 2), and severe osteolysis (n = 2). Medians and interquartile ranges (IQRs) were reported since the data was not normally distributed. Clinical and radiographic outcomes, complications, reoperations, and implant survival was recorded.

Results:

Implant survival was noted in 80% of patients (20/25) at a median of 3.8 years following revision TAA. Index revision was most commonly performed for implant loosening (tibia 28%, talus 24%), talar subsidence (24%), or re-implant after infection (16%). Foot and Ankle Ability Measure (FAAM) Activities of Daily Living and Sports scores were 53.9 (IQR 46.4, 71.4) and 37.5 (IQR 21.9, 46.9), respectively at final follow-up. There was evidence of talar loosening in 3 patients (12%) and talar subsidence in 5 patients (20%) on final radiographs. Reoperation rate at final follow-up was 48%, most commonly for talar loosening/subsidence (n= 2), tibial loosening (n = 3), septic TAA (n = 1), medial/lateral gutter impingement (n = 2), and instability (n = 2).

Conclusion:

At a minimum follow-up of 2 years, 80% of patients retained their metal revision TAA, but reoperation rates were high with 48% of patients requiring an additional procedure most commonly for implant loosening, talar subsidence, gutter impingement, or instability. Revision TAA using a revision-specific ankle system is a viable option for patients with a failed TAA. Physicians and patients should be aware that revision TAA remains a significant challenge with a high risk of complication and reoperation rates.