bluuebunny/crossref_metadata_2025_split huggingface dataset:
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.