Ankle X-rays Research Articles

Evaluation of treatment planning discrepancies: CT versus plain radiographic findings in patients with foot and ankle trauma

This study aimed to compare the findings of plain radiography and computed tomography (CT) of foot and ankle in patients submitted to the emergency department with high-energy foot and ankle trauma, to demonstrate if missing fractures on plain radiographs will significantly alter the treatment plan considered for each patient based on the findings of each imaging modality. We retrospectively observed standard radiological foot and ankle x-rays and CT scans in patients who presented to our center from April 2019 to June 2020 with a history of foot and ankle trauma with either loss of consciousness, a history of high-energy trauma, or clinical presentation disproportionate to plain radiographic findings. We investigated the number of fractures of each bone detected on plain radiographs and CT scans and the treatments based on each modality’s findings in patients admitted to our center. Sixty-five out of 163 (39.87%) included in our study had at least one missed fracture on plain radiography that was detected on CT. Thirty-one (19%) patients had normal radiography despite actually having fractures. In 38 (23.31%) patients CT changed the treatment plan decided by our surgeons (P < 0.001). The two imaging modalities had a moderate agreement for detecting foot and ankle fractures overall (κ = 0.432). The failure to detect fractures in patients with high-energy trauma can significantly impact treatment effectiveness. Integrating CT scans into the diagnostic process can lead to changes in treatment planning and ultimately improve patient outcomes.Level of clinical evidenceIV.

The Utility of Musculoskeletal Ultrasound in Diagnosing Uncommon Talocrural Synovitis in an Amateur Weightlifting Athlete

The use of musculoskeletal ultrasound to assess sports-related injuries has been increasing worldwide. This case report focuses on an unusual form of synovitis of the talocrural joint in a 33-year-old male amateur weightlifter who presented to our sports medicine clinic with acute non-traumatic left ankle pain lasting for 2 days. He reported a recent change in his squatting technique and had no significant medical history other than a recent viral upper respiratory illness. Weight-bearing ankle X-rays were inconclusive, however, ultrasound evaluation revealed effusion in the talocrural joint upon assessment of the ankle’s anterior joint capsule. Additionally, the ultrasound examination helped rule out other common soft tissue ankle pathologies that can affect athletes. The athlete's symptoms resolved by day 5 with conservative measures, including weight bearing as tolerated, nonsteroidal anti-inflammatory drugs, and lymphatic drainage techniques. This report demonstrates the utility of musculoskeletal ultrasound in diagnosing an uncommon cause of ankle pain in athletes.

MULTICENTRE RANDOMIZED CONTROLLED STUDY OF SUBTALAR ARTHRODESIS USING ALLOSTEM VERSUS AUTOLOGOUS BONE GRAFT

IntroductionAlloStem/Cellular Bone Allograft and autologous bone graft are accepted methods for managing hindfoot degenerative arthritis. The purpose was to evaluate outcomes of AlloStem and autograft in subtalar arthrodesis and compare overall fusion rates.MethodsThis study was conducted in IRB compliance. Patients between 18–80 years who qualified for a subtalar fusion were randomized 1:1 to AlloStem or autologous graft. The AOFAS hindfoot ankle scale, FFI-R and SF-12 were collected pre-operatively, 6 weeks, 3 &amp; 6 months, 1 and 2 year. Weight-bearing 3-view ankle X-rays were done at the same intervals. A CT scan was obtained at 6 months.Results140 patients were enrolled; 124 patients had surgery(60-AlloStem and 64-Control). Withdrawals included 14 voluntarily before surgery and 2 intra-operative failures. 19 were lost to follow-up. Mean age for AlloStem was 56.69(20.3–79.6) and Autograft was 54.60(20.74–80.07). 59 AlloStem patients completed their 6 month visit and 45 completed 2 years. AOFAS score improved: 40.02 at pre-op to 72.16(6 mo) to 79.51 at 1 year and 80.38 at 2 year. SF-12 improved 58.29 at pre-op to 65.67 at 6 month and 71.59 at 2 year. FFI-R improved 236.88 at pre-op to 203.53 at 6 month 149.93 at 2 year.60 Autograft patients completed their 6 month visit and 51 patients completed their 2 year. AOFAS score improved 42.89 at pre-op to 75.67 (6 mo) to 79.75 at 1 year and 78.62 at 2 year. Autograft SF-12 improved 60.55 at pre-op to 70.40 at 6 month and 75.26 at 2 year. Autograft FFI-R improved 217.16 at pre-op to 166.77 at 6 month and 145.43 at 2 year. AlloStem patients had a mean posterior fusion rate of 28.9% at 6 months whereas the Autograft had 46.3%(p=.049). Non-union rates were AlloStem(9/57)(15.7%) whereas Autograft was 3/60(5%).ConclusionAlloStem trended to be inferior to Autologous graft.

Comparing Rates of Radiographic Baseplate Loosening Between Cement and Cementless INFINITY Total Ankle Prostheses.

Total ankle replacement is indicated for end-stage ankle osteoarthritis. Periprosthetic radiolucency, from separation between the bone and implant, is suggested to be indicative of potential prosthesis failure risk. Anchoring implants with cement may mitigate this. This study aimed to compare rates of periprosthetic radiolucency between patients with cement-affixed and cementless implants. A retrospective analysis was performed on 28 patients who underwent total ankle replacement with the INFINITY Total Ankle System (Wright Medical, Memphis, Tennessee) implant between January 2016 and May 2022. Anteroposterior, mortise, and lateral ankle X-rays were reviewed by 2 independent reviewers for tibiotalar angle, talar tilt, and periprosthetic radiolucency. The Wilcoxon rank-sum test and chi-square test were performed. The incidence of periprosthetic radiolucency at the most recent follow-up did not significantly differ between cement and cementless groups (57.1% in both groups, P = 1.0). Follow-up tibiotalar and talar tilt angles were not significantly different (P > .51 for all comparisons). Patients with cemented implants had a similar incidence of periprosthetic radiolucency compared with patients with cementless prostheses. Understanding of long-term clinical outcomes will help inform optimal operative approaches for ankle prostheses. Therapeutic, Level III, Retrospective cohort study.

Anthropometric evaluation of side, sex and age by radiological examination of the normal ankle joint among adult Egyptian population

PurposeSex and age estimation is important, particularly when information about the deceased is unavailable. There are limited radiological studies investigating side, sex and age differences in normal ankle morphometric parameters. The authors’ goal was to evaluate different ankle joint morphometric measurements and document variations among Egyptians.Design/methodology/approachA prospective study was conducted throughout 23 months on 203 (100 males and 103 females) adult Egyptians, aged between 20-69 years old, who were referred for a plain x-ray of bilateral normal ankle joints.FindingsAnkle parameters showed no statistical difference between both sides, except for tarsal width (TaW) which was significantly higher on right than left side (26.92 ± 2.66 vs 26.18 ± 2.65 mm). Males showed significantly higher morphometric values except for anteroposterior gap (APG) and talus height (TaH) which were significantly higher in females (2.29 ± 0.80 vs 1.80 ± 0.61 mm and 13.01 ± 1.68 vs 11.87 ± 1.91 mm, respectively). There was significant increase in tibial arc length, APG, distance of level of MTiTh from anterior limit of mortise, distance of level of MTiTh from vertex of mortise, sagittal distance between tibial and talar vertices and sagittal radius of trochlea tali arc in old age group compared to young one. A significant decrease in tibial width, malleolar width, TaW and TaH was noted in old age group compared to young one.Originality/valueAnkle joints of both sides are mostly symmetrical; however, there are significant differences in most morphometric values due to sex and age factors. These findings may be essential during side, sex and age determination.

The Center-Center Image Closely Approximates Other Methods for Syndesmosis Reduction Clamp Placement.

The optimal placement for a syndesmosis reduction clamp remains an open question. This study compared the center-center axis, which localizes clamp placement using only an internally rotated lateral ankle X-ray, with other common approaches, whose accuracy can only be confirmed using computed tomography (CT). Bone models of anatomically aligned (n = 6) and malreduced (n = 48) limbs were generated from CT scans of cadaveric specimens. Four axes for guiding clamp placement (center-center, centroid, B2, and trans-syndesmotic) were then analyzed, using digitally reconstructed radiographs derived from the bone models. Each axis' location was defined using angle-height pairs that describe axis orientation along the full anatomical region where syndesmosis fixation occurs. In anatomically aligned limbs, the center-center axis was located on average (±95% CI [confidence interval]), 0.64° (±0.50°) internal rotation, 1.03° (±0.73°) internal rotation, and 2.09° (±7.29°) external rotation from the centroid, B2, and trans-syndesmotic axes, respectively. Fibular displacement altered the magnitude of limb rotation needed to identify the center-center axis. The center-center technique is a valid method that closely approximates previously described methods for syndesmosis clamp placement without using CT, and the magnitude of C-arm rotation needed to transition from a talar dome lateral to a center-center view may be a potential method for assessing syndesmosis reduction. Level III: Retrospective comparative study.

Calcaneus metastasis: a rare presentation of poorly differentiated thyroid cancer.

A 60-year-old woman presented to our clinic with an acute onset 3 months history of right ankle pain. The patient had a history of poorly differentiated thyroid cancer, which was treated with total thyroidectomy, left lateral neck dissection levels II-V and central neck dissection levels VI-VII followed by postoperative I-131 radioactive iodine (131I) ablation therapy 3.7 GBq 6 months ago. The post-131I WBS showed residual iodine-avid thyroid tissue with no other iodine-avid disease or metastasis. SPECT/CT of the neck and chest showed nonavid bilateral pulmonary nodules, discrete nodal masses in mediastinum and nonavid bone lesions. FDG-PET CT scan showed FDG-avid mediastinal lymph nodes (LN), innumerable non-FDG-avid subcentimetric pulmonary nodules and few FDG-avid lytic lesions in the skeleton. X-ray and MRI of the right ankle showed a well-marginated lytic lesion in the posterior body of calcaneus and 5 × 6 cm soft tissue mass lesion, respectively. The histopathology of the calcaneus mass confirmed a positive immunostaining for thyroid origin which includes thyroglobulin and TTF-1 with PAX-8. Endobronchial mediastinal and bronchial LN biopsy confirmed thyroid cancer metastasis. Gene mutation showed HRAS and GNA13 with a high tumor mutational burden. We describe a rare case of poorly differentiated thyroid cancer in a patient who presented with right ankle pain; we confirmed the cause to be a calcaneus metastasis from the thyroid cancer, with calcaneus being an extremely rare site for bone metastases. Gene mutations points toward treatment with immune checkpoint inhibitors. Poorly differentiated thyroid carcinoma (PDTC) usually metastasizes to lung and bone but can rarely occur in the calcaneus. Patients with distant metastases have significantly worse long-term prognosis. Radiotherapy is effective in reducing the metastatic pains as well as reducing the size of the metastasis. PAX-8 staining can be used to differentiate thyroid carcinomas from lung adenocarcinomas. The importance of searching for gene mutations to decide the treatment of PDTC.

Measurement of the Medial Clear Space: An Intra-Observer Comparison of Various Measurement Methods

Category: Ankle; Trauma Introduction/Purpose: The Medial Clear Space (MCS) is an anatomic space between the lateral cortex of the medial malleolus and the medial cortex of the talus. Measurement of the MCS is helpful in differentiating which ankle fractures are amenable to non- operative treatment, and which may require fixation. The MCS is often evaluated on radiographic views of the ankle, and several different methods of measuring the MCS have been described in the literature. There is little information on intra-observer reliability of MCS measurement, nor validation of the various medial clear space measurement techniques. As such, the aim of this study was to better understand intra-observer reliability of MCS via several of the most popularly described techniques. Methods: Patients with matched ankle X-rays and CT scans - either weight bearing or non-weight bearing imaging pairs - were identified via electronic medical record database review of a Level-1, academic medical system after IRB approval. Measurement of the MCS on CT scan was used as the gold standard against which radiographic measurements were compared given its superior osseous definition. Four independent reviewers measured the medial clear space on 20 weight bearing, and 20 non-weight bearing x-rays via the five most commonly described methods: 5mm inferior to the talar dome (MCS #1), half way down the medial articular surface of the talus (MCS #2), obliquely at the supero-medial corner of the talus (MCS #3), and at the level of the talar dome (MCS #4). Intraclass Correlation Coefficients (ICC) were then calculated for each of the four MCS measurements methods after compilation of all independent reviewer data. Results: The ICC varied between each of the four MCS measurement techniques. For measurements 5mm below the talar dome (MCS #1) the ICC was 0.041. Measured halfway down the medial talar articular surface, the ICC was 0.466. The superior oblique MCS measurement ICC was 0.725, and the MCS measured at the level of the talar dome had an ICC of 0.419. MCS measurement 5mm below the talar dome had poor intra-observer reliability, while measurement halfway down the medial articular surface and at the level of the talar dome had fair intra-observer correlation. Overall, measurement of the MCS at the superomedial talar dome had good intra-observer reliability, ranking as the most favorable measurement method. Conclusion: The commonality of ankle fractures demands accurate radiographic interpretation for the determination of need for surgical intervention. The medial clear space measurement is the most common metric used to determine the need for surgery. There is no consensus regarding the optimal method, nor reliability of the various MCS measurement techniques. The results of this study suggest that measurement of the medial clear space at the superomedial corner of the talar dome has the highest intra- observer reliability.

Automated AI Detection Tool for Ankle Fractures Using X-Rays and Smart Devices

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.

3D Printed Titanium Wedges for Distraction Arthrodesis of the Subtalar Joint

Category: Hindfoot Introduction/Purpose: Distraction arthrodesis of the subtalar joint is performed to restore height and correct deformity in the case of subtalar joint arthrosis, malalignment of the rear foot, calcaneal fracture, or other pathologies. Historically, autograft or allograft bone blocks were used to restore natural alignment and improve hindfoot function. Although successful use has been reported, complications associated with donor site morbidity and size limitation for autograft, as well as additional complications including nonunion, graft collapse, and loss of alignment are common. Recently, innovative advancements have enabled the use of 3D printed porous titanium implants for use, improving the union rates and reduced risk of subsidence and graft collapse. Methods: 6 patients with subtalar collapse and anterior ankle impingement were indicated for distraction subtalar arthrodesis. Surgery was performed with a lateral approach for the distraction arthrodesis using an off the shelf 3D printed subtalar wedge and a nitinol pseudoelastic fusion rod for stabilization and fixation. Patients were followed 6 months post op for fusion and alignment. Fusion was confirmed at 3 months with CT scans and alignment was monitored with weightbearing ankle X-rays. Results: 3D wedge incorporation and sustained correction of height and alignment was maintained over time at the subtalar joint. There were no nonunions, 2 patients reports skin healing issues due to tension on the skin with wound closure. These healed with local wound care. Improvement in preoperative to postoperative tibiotalar sagittal plane alignment was observed in all patients. Conclusion: The use of a 3D printed titanium wedge for distraction Arthrodesis of the subtalar joint is a safe procedure and useful procedure in short-term follow-up. This procedure does provide improvement in the patients alignment and fusion occurs with in 3 months of surgery.

Grading Fractures on Foot and Ankle X-rays and MRI Scans in the Active Charcot Foot in Diabetes: How Strong Is the Agreement Between Modalities?

To compare X-ray and MRI as diagnostic tests of active Charcot neuro-osteoarthropathy (CNO) in diabetes. X-rays and MRI scans of 48 participants were rated for severity of fracture (0 = no fracture, 1 = fracture, 2 = collapse/fragmentation), and for absence/presence of bone marrow edema (BME) on MRI and absence/presence of bone injury on X-ray. The agreement between modalities was assessed with tests for symmetry, marginal homogeneity, and κ-coefficients. X-ray underscored MRI in grading fractures in the metatarsals (P = 0.05) and tarsals (P < 0.001) and reported as normal 79% of the bones with BME. The agreement between X-ray and MRI for grading severity of fracture was moderate to substantial (κ = 0.53; P < 0.001) and for detecting bone injury, slight to fair (κ = 0.17; P < 0.001). The significant underperformance of X-ray in the assessment of the hot, swollen foot in diabetes should be considered when confirming or refuting the diagnosis of active CNO.

Haglund's Disease: A Case Report

Haglund's disease is a relatively under-appreciated pathology, linked to calcaneo-achilles impingement. The etiology is not well known, and may be confused with other causes of talalgia. We report the case of a 55-year-old patient presenting with painful ankle oedema. The diagnosis was evoked on a standard weight-bearing X-ray of the left ankle and on ultrasound, and confirmed by an MRI of the ankle, showing a fissure with signal abnormality of the achilles tendon in relation to the oedema associated with preachilean bursitis. Treatment, initially medical, resulted in surgical resection of the posterosuperior angle of the calcaneus with good clinical outcome.

Reinsertion of the Achilles Tendon with Bony Anchor in Insertional Achilles Tendinitis with Haglund’s Deformity

Haglund’s deformity is a common cause of hindfoot pain in adults and functional disability. Conservative treatment is effective often. Surgery is required only in intractable cases. Many surgical treatments in a Haglund deformity have been described. After resect and debridement, an anchor suture may use to reattach Achille’s tendon. This study aims to show the place of the suture anchor to improve the reinsertion of the Achilles tendon in an insertional Achilles tendinitis and Haglund’s deformity. We report a 54-year-old male complains of 2 years of chronic right heel pain while strength training. A focused exam of the left ankle showed a bump on the posterior heel with inflammation to the anterior and posterior Achilles tendon. A lateral X-ray and CT scan of the left ankle showed a bone spur and intratendinous calcification of the Achilles tendon with the Philip – Fowler angle at 87°. The Bohler’s ankle was at 27°. After the failure of at least 6 months of conservative treatment, surgical management was indicated. It has consisted of a midline incision. Bursectomy and, resection of the posterosuperior tuberosity of the calcaneus was performed. Then, debridement of necrotic tissue and calcifications in the tendon and any posterior osteophytes were carried out. The tendon had been reinserted at its central part with single-row anchor. The lower leg was immobilized in 20° plantar flexion, this was switched to a walking boot with adjustable plantar flexion. Partial support was allowed at the 6th postoperative week. Full rehabilitation was prescribed after the removal of the cast. At 2-year follow-up, the patient is very satisfied and had no pain when standing on the toes of the operated leg. Dorsiflexion was symmetric. The effective return to full-sport activities was at 6 months at the same level.

Onset of an Active Charcot Foot in a Person with Longstanding Type 1 Diabetes and Normal Vibration Perception Threshold-A Case Report.

Charcot neuro-osteoarthropathy (CNO), or Charcot foot, is a disabling complication of diabetes, which is poorly understood and frequently overlooked. We describe an atypical presentation of an active Charcot foot in a woman with a long-standing type 1 diabetes who did not exhibit loss of protective sensation (sensate to a 10-gram monofilament) or loss of vibration sensation. These standard measures of large nerve fibre function ruled out "classical" neuropathy. However, additional testing showed reduced sweat gland function most likely related to degeneration of c-fibres (small fibre neuropathy). This case raises the awareness that in addition to the "textbook" description, in diabetes, Charcot foot can develop in individuals with "minimal" or "no signs" of clinical neuropathy. The onset of active Charcot foot should be suspected in every person with diabetes and history of trauma even when foot and ankle x-rays are normal. Offloading should be initiated until the diagnosis is proven otherwise.

Multiclass datasets expand neural network utility: an example on ankle radiographs

PurposeArtificial intelligence in computer vision has been increasingly adapted in clinical application since the implementation of neural networks, potentially providing incremental information beyond the mere detection of pathology. As its algorithmic approach propagates input variation, neural networks could be used to identify and evaluate relevant image features. In this study, we introduce a basic dataset structure and demonstrate a pertaining use case.MethodsA multidimensional classification of ankle x-rays (n = 1493) rating a variety of features including fracture certainty was used to confirm its usability for separating input variations. We trained a customized neural network on the task of fracture detection using a state-of-the-art preprocessing and training protocol. By grouping the radiographs into subsets according to their image features, the influence of selected features on model performance was evaluated via selective training.ResultsThe models trained on our dataset outperformed most comparable models of current literature with an ROC AUC of 0.943. Excluding ankle x-rays with signs of surgery improved fracture classification performance (AUC 0.955), while limiting the training set to only healthy ankles with and without fracture had no consistent effect.ConclusionUsing multiclass datasets and comparing model performance, we were able to demonstrate signs of surgery as a confounding factor, which, following elimination, improved our model. Also eliminating pathologies other than fracture in contrast had no effect on model performance, suggesting a beneficial influence of feature variability for robust model training. Thus, multiclass datasets allow for evaluation of distinct image features, deepening our understanding of pathology imaging.

Decision to Preserving Ankle Joint Function in Neglected Neck Talus Fracture with Type 2 Diabetic Mellitus Patient : A Case Report

Talus fractures are rare injuries to the hindfoot that still challenging in treatment. The anastomotic ring is likely to be damaged in neck talus fractures, which disrupt the blood flow and cause significant problems affecting fracture healing. Poor fracture healing and an increased risk of surgical complications were also associated with complex diabetes mellitus. We follow the progress of the illness from a 47 year old female complaint pain on her left ankle after falling down 6 months before outpatient. Physical examination shows swelling and varus deformed on affected ankle. Ankle x-ray and CT scan were done. Patient diagnosed as neglected close fracture left neck talus Hawkins type IV with type 2 diabetes mellitus. Then patient undergo an ankle arthroscopy to evaluate ankle joint and preserving ankle joint procedure by subtalar arthrodesis and iliac bone graft. This procedure achieved an excellent result in preserve ankle aligment, stability and soft tissue management. After 2 weeks wound heals without signs of infection and 3 weeks of followup VAS score mention from 0 to 1, with good compliance of the patient. Arthroscopy is safe procedure obtaining anatomical joint surface and reduce tissue damage. While arthrodesis enhance blood supply to encourage bone union, though loss of its ankle motion also has significant effect on ambulation.

Percent Weightbearing in Foot and Ankle X-rays

Category: Other; Ankle; Hindfoot; Midfoot/Forefoot Introduction/Purpose: Weightbearing x-rays remain standard of care in diagnosing and evaluating foot and ankle injuries and are crucial for clinicians to evaluate foot alignment and ligamentous injuries. Failure for patients to place adequate body weight on x-ray may produce a radiograph that inaccurately demonstrates foot alignment and injury. The objective of the study was to evaluate the percentage of body weight a patient puts on his/her foot during weight bearing x-ray. Methods: Study participants (n= 278) included patients requiring a clinically indicated x-ray. They were asked to place body weight on foot/ankle during x-ray. The radiograph categories included: lateral foot, AP ankle, oblique ankle and lateral ankle. The scale was concealed from patients and wrapped in a pad and placed on platform as to avoid any bias. The scale measured the weight each patient placed on their foot during each radiograph. The scale was connected to Bluetooth and data was recorded on computer during imaging. The percent of body weight placed on x-ray was calculated using weight during radiograph and weight measured in clinic. Results: Acute injury was defined as pain/injury of duration less than or equal to 3 months with chronic being pain greater than 3 months. Percent bodyweight data in both acute and chronic groups is as follows. Lateral foot acute: mean= 47.39%, max=84.94%, median=46.90%, min= 6.25%; lateral foot chronic: mean=54.80%, max =99.87%, median=54.44%, min=11.56%. AP ankle acute: mean= 56.74%, max=99.51%, median=56.36%, min=6.63%; AP ankle chronic: mean=58.90%, max=97.90%, median=58.42%, min=11.58%. Oblique ankle acute: mean=57.68%, max=98.32%, median=57.40%, min =6.27%; oblique ankle chronic: mean=58.91%, max=96.15%, median=58.46%, min=17.17%. Lateral ankle acute: mean= 50.42%, max=97.92%, median=50.41%, min=11.52%; lateral ankle chronic: mean= 50.03%, max=82.12%, median=50.32%, min=14.10%. Please see attached graphs. Conclusion: Preliminary data suggests patients are not placing full body weight during weightbearing x-ray (lateral foot, AP ankle, oblique ankle, lateral ankle). In lateral foot x-rays, patients with acute injuries place less weight during x-ray as compared with patients of chronic conditions (p=0.02). In the categories of AP ankle, oblique ankle and lateral ankle x-rays, the difference in means between acute/chronic was not statistically significant. We plan to further analyze the data to determine how injury type and time since injury changes the percent body weight placed on foot during x-ray as this may affect how patients are diagnosed via radiographs.FIG

231 Tillaux Fracture in a 40-Year-Old Man: A Rare Case Report

Abstract Tillaux fracture is an intra-articular Salter-Harris III fracture affecting the anterolateral aspect of the distal tibia. It is commonly seen in children and adolescents but rare for adults. As Tillaux fracture can be unstable, misdiagnosis may result in delayed surgical treatment and development of complications such as post-traumatic arthritis and persistent syndesmotic instability. A case of adult Tillaux fracture is reported, involving a 40-year-old gentleman who sustained a low energy injury. He presented to local hospital after being assaulted by a stranger. He tripped over a low fence and sprained his left ankle in external rotation. On examination, he was not able to weight bear. There were swelling and focal tenderness at the triangular concavity of distal fibula. Ankle X-Ray was reported as normal. It required CT scan for diagnosis after reviewed by orthopaedics team at fracture clinic. The patient was subsequently treated with lag screw fixation and recovered after 6 weeks post-operatively. This case highlights the importance of a systematic method to interpret ankle X-Ray. It is essential to observe the tibio-fibular overlap and any change in the outline of bony cortex of the fibular notch. CT scan has a high sensitivity in delineating fracture pattern hence it should be performed when there is difficulty to confirm the diagnosis solely based on X-Ray. In conclusion, Tillaux fracture should be suspected when patients present with external rotation injury. There should be low threshold to perform CT scan when there is any uncertainty with the ankle X-Ray interpretation.

Are SER-II Ankle Fractures Anatomic? Computed Tomography Demonstrates Mortise Malalignment in the Setting of Apparently Normal Radiographs.

Ankle fracture treatment is predicated on minimal displacement, leading to abnormal joint contact area. The purpose of this investigation is to determine whether computed tomography (CT) detects subtle mortise malalignment undetectable by x-ray in supination-external rotation-II (SER-II) injuries. A total of 24 patients with SER-II injuries, as demonstrated by negative gravity stress radiography, were included. Medial clear space (MCS) measurements were performed on bilateral ankle x-rays (injured and contralateral, uninjured side) at several time points as well as bilateral non-weight-bearing CT performed once clinical and radiographic healing was demonstrated (mean = 66 days post injury, range = 61-105 days). Statistical analyses examined differences in measurements between both sides. Final x-rays demonstrated no differences between normal and injured ankle MCS (P = .441). However, CT coronal/axial MCS measurements were different (P < .05). CT coronal MCS measured wider by a mean difference of 0.67 mm (P < .001). There is a high incidence of subtle mortise malalignment in SER-II ankle fractures, as demonstrated by CT, which is undetectable when assessed by plain radiographs. Although clinical outcomes are yet unknown, there are important implications of the finding of confirmed, subtle mortise malalignment in SER-II injuries and the limitations of x-ray to detect it. Level III.

Un'adolescente con uno strano e persistente gonfiore alle caviglie

A fourteen-year-old girl presented with a history of intermittent bilateral swelling in her ankles associated with moderate but progressively worsening pain that lasted for two years. The patient had been previously investigated and ankle X-rays, US and MRI, echocardiogram, blood and urine tests were negative. Physical examination highlighted bilateral non-pitting oedema. A scintigraphy was performed. The present paper discusses different diagnostic hypotheses and treatment options.