Ankle Radiographs Research Articles

The Impact of Fibular Fixation Method on Pilon Fracture Healing.

Background: Pilon fractures are associated with high-energy injuries, and there is presently much debate as to optimal fixation strategies and timing of intervention. There is little evidence comparing the type of fibular fixation during pilon fracture fixation. The purpose of this study was to compare fibular fixation methods in complex pilon injuries as it relates to pilon union rates and development of post-traumatic arthritis. Methods: This was a retrospective review from an urban Level 1 trauma center from January 2009 to May 2019, including patients age ≥ 18 who sustained a pilon fracture with an associated fibula fracture. Patients were allocated into one of three groups based on fibular fracture treated with plating, intramedullary device, or no fixation. Radiographic analysis was performed postoperatively and at final follow up to evaluate for tibial or fibular nonunion, malunion, talocrural angle, and ankle Kellgren-Lawrence grade. Results: Of the 107 patients in this study, 42 underwent surgical fixation of their fibular fracture. There were no differences with respect to tibial or fibular union rates amongst the three groups. Furthermore, there were no differences in the presence of radiographic ankle arthritis at final follow up. However, Kellgren-Lawrence arthritis grading did appear to be a more severe grade in patients who did not undergo fibular fixation (p = 0.001). Conclusions: Fibular intramedullary fixation does not appear to influence tibial or fibular nonunion rates as compared to plating in complex pilon injuries.

Association of Complication Rates and Severe Obesity in Patients Undergoing Ankle Arthrodesis.

Tibiotalar arthrodesis (TTA) is a common operation for end-stage ankle arthritis. Elevated body mass index (BMI) is believed to contribute to complications following TTA. Previous studies involved national registries or small, underpowered cohorts. This study aimed to determine the effects of elevated BMI on nonunion and complication rates following TTA with a large cohort from a single academic institution. A retrospective study identified 514 patients (527 ankles) who underwent primary TTA from 2005-2017. Mean age was 60 years. Patients were stratified by BMI according to the World Health Organization classification. A reference group of 203 patients (208 ankles) included normal weight or mildly overweight patients (BMI 18.5 to <30). Ankle radiographs were evaluated to determine union or nonunion. Other outcomes included revision TTA, reoperations, subsequent adjacent joint arthrodesis, infection, and readmission. Data were analyzed using Pearson χ2 and odds ratios for categorical variables. Analysis of variance and Kaplan-Meier estimation assessed continuous variables and time-to-event outcomes, respectively. Mean follow-up was 34.3 months. Obesity class III patients had elevated risk of complications compared with normal weight patients including nonunion (odds ratio [OR] 3.96, P = .002), revision (OR 3.69, P = .03), superficial infection (OR 9.36, P = .002), and readmission (OR 10.90, P = .01). Superficial infection rates were elevated in class I (OR 6.36, P = .007) and readmissions in class II (OR 9.98, P = .01). No differences were found in reoperation (P = .448), symptomatic implant removal (P = .805), adjacent joint arthrodesis (P = .353), or deep infection (P = .507) rates. In this retrospective review after TTA, increased rates of nonunion, revision, superficial infection, and readmission were found in obesity class III patients, compared with the reference group of normal weight or mildly overweight patients. Superficial infection rates were likewise relatively elevated in class I and readmission rates in class II patients.

Valgus deformity of the distal tibia in children and adolescents with idiopathic flatfoot: Can it be predicted using 3D movement analysis?

BackgroundDistal tibial valgus deformity, though common in various medical conditions, has not been extensively studied in idiopathic flatfoot. It clinically presents as hindfoot valgus, mimicking flatfoot deformity, and requires X-rays for detection. Severity is quantified using resting calcaneal angle and standing tibio-calcaneal angles (STCA), but their prognostic value for identifying distal tibial valgus deformity remains unclear. The use of routine invasive radiographs in idiopathic flatfoot is controversial as instrumented non-invasive gait analysis gains popularity for investigative purposes. Research questionThis study aimed to determine the prevalence of distal tibial valgus deformity in children and adolescents with idiopathic flatfoot using radiography and to identify parameters assessed during standing or walking that predict this deformity. MethodsA retrospective study included outpatients aged 7–17 years with idiopathic flatfeet. Participants underwent clinical examination, foot and ankle X-rays, and instrumented 3-dimensional gait analysis. A lateral distal tibia angle (LDTA) < 86° indicated valgus deformity, with LDTA 86–92° considered normal. Two groups were analysed: ankle valgus (LDTA < 86°) and normal ankle (86–92°). STCA, ankle tilt, intermalleolar height difference (IMHD), and eight kinematic parameters were correlated with LDTA. ResultsThe study included 136 patients (mean age 11.5 years, SD=2.2). Sixty-three patients had ankle valgus (LDTA 83.8°, SD=1.7°), and 73 had normal ankles (LDTA 88.8°, SD=1.3°), showing a significant difference between groups (p < 0.001). STCA during standing was the best predictor, though it explained only 9 % of variance, limiting robust prediction. SignificanceThe prevalence of distal tibial valgus deformity was 42 % in idiopathic flatfoot cases, highlighting the necessity for routine ankle radiographs due to the inability to clinically suspect this deformity. Further studies should explore the biomechanical effects and their clinical implications for management.

Concomitant Factors Associated With Tillaux-Chaput Fractures in Adults: A Case-Control Study.

Tillaux-Chaput fractures (TCFs) consist of fractures of the anterolateral distal tibia. They rarely occur in isolation in adults. When TCFs are missed, there is a risk of chronic pain, instability, and ankle osteoarthritis. This study aimed to identify which factors are related to the presence of TCFs in ankle injuries. A retrospective review of 1134 ankle fractures evaluated between 2013 and 2023 at a level 1 trauma center was performed. Inclusion criteria were patients aged ≥18 years, ankle radiographs and computed tomographic (CT) scan evaluation, and the presence of a TCF confirmed by CT scan. Exclusion criteria were prior ankle surgery, pilon, or distal tibial fractures. A musculoskeletal radiologist and a foot and ankle-trained orthopaedic surgeon classified the TCFs into type 1, an extraarticular avulsion; type 2, a fracture involving the incisura fibularis; and type 3, a fracture with impaction of the anterolateral tibial plafond. A matching control group of ankle fractures without TCF was created with a 1:2 ratio. The following variables were collected: sex, age (<50 vs >50 years), ankle dislocation or subluxation, Weber classification, Maisonneuve fracture, type of medial and posterior malleolar fracture, Lauge-Hansen classification, malleoli involved, and osteochondral lesion of the talus. Multivariate logistic regression was performed to detect which variables had an association with the TCF and their subtypes. P value <.05 was considered significant. A total of 481 ankle fractures had radiographs and CT scans available for evaluation, of which 83 (17.3%) had a TCF. Of these, 44.6% were type 1, 44.6% type 2, and 9.6% type 3. The mean age was 52.2 years; 66.3% were women. Six patients (7.2%) had an isolated TCF. Fifty-eight (69.9%), 50 (60.2%), and 62 (74.7%) ankles had involvement of the lateral, medial, and posterior malleolus, respectively. Age ≥50 years (OR 2.73, 95% CI 1.45-5.14) and pronation external rotation injuries (OR 2.94, 95% CI 1.43-6.06) had a significant association with TCF. Moreover, ankle dislocation or subluxation (OR 3.16, 95% CI 1.11-8.96) and the absence of posterior malleolar fracture (OR 5.97, 95% CI 1.65-21.6) were significantly associated with TCF type 2 and 3. In this study, age ≥50 years and pronation external rotation injuries were the unique independent risk factors for TCF. Furthermore, ankle dislocation or subluxation and the absence of posterior malleolar fractures increased the odds of having a more severe TCF. This study provides insights into the factors associated with TCF and its subtypes during adulthood.

Radiographic outcomes of flexible and rigid fixation techniques of syndesmotic injuries across various body mass indices: A retrospective analysis

In the setting of ankle trauma, surgical management of syndesmosis injury involves screw fixation and suture button technique. The efficacy of flexible (suture button) versus rigid (screw) fixation in the management of syndesmotic injury has been investigated extensively in current literature. There is sparse data comparing these two techniques across different body mass indices (BMI). In this study, two fellowship-trained foot and ankle surgeons at urban level-1 trauma centers reviewed blinded post-operative ankle radiographs of BMI-stratified patients undergoing syndesmotic fixation. A total of 79 patients were included for analysis based on inclusion and exclusion criteria. There were 42 patients in the screw fixation group and 37 patients in the suture button group. The average follow-up period was 5.5 months. No significant difference was found in the average radiographic measurements when comparing the two fixation types, regardless of BMI parameters. This was consistent when analyzing individual fixation types stratified by BMI, as well as when comparing BMI groups stratified by fixation type. Additionally, the distribution of body mass index was even across both fixation types. Our study demonstrates that both fixation groups achieved comparable anatomic ankle reduction regardless of body mass index. The authors suggest expanding the indication of suture button fixation to include the higher body mass index patients.

External validation of an artificial intelligence multi-label deep learning model capable of ankle fracture classification

BackgroundAdvances in medical imaging have made it possible to classify ankle fractures using Artificial Intelligence (AI). Recent studies have demonstrated good internal validity for machine learning algorithms using the AO/OTA 2018 classification. This study aimed to externally validate one such model for ankle fracture classification and ways to improve external validity.MethodsIn this retrospective observation study, we trained a deep-learning neural network (7,500 ankle studies) to classify traumatic malleolar fractures according to the AO/OTA classification. Our internal validation dataset (IVD) contained 409 studies collected from Danderyd Hospital in Stockholm, Sweden, between 2002 and 2016. The external validation dataset (EVD) contained 399 studies collected from Flinders Medical Centre, Adelaide, Australia, between 2016 and 2020. Our primary outcome measures were the area under the receiver operating characteristic (AUC) and the area under the precision-recall curve (AUPR) for fracture classification of AO/OTA malleolar (44) fractures. Secondary outcomes were performance on other fractures visible on ankle radiographs and inter-observer reliability of reviewers.ResultsCompared to the weighted mean AUC (wAUC) 0.86 (95%CI 0.82–0.89) for fracture detection in the EVD, the network attained wAUC 0.95 (95%CI 0.94–0.97) for the IVD. The area under the precision-recall curve (AUPR) was 0.93 vs. 0.96. The wAUC for individual outcomes (type 44A-C, group 44A1-C3, and subgroup 44A1.1-C3.3) was 0.82 for the EVD and 0.93 for the IVD. The weighted mean AUPR (wAUPR) was 0.59 vs 0.63. Throughout, the performance was superior to that of a random classifier for the EVD.ConclusionAlthough the two datasets had considerable differences, the model transferred well to the EVD and the alternative clinical scenario it represents. The direct clinical implications of this study are that algorithms developed elsewhere need local validation and that discrepancies can be rectified using targeted training. In a wider sense, we believe this opens up possibilities for building advanced treatment recommendations based on exact fracture types that are more objective than current clinical decisions, often influenced by who is present during rounds.

Comparison of X-ray and Computed Tomography Scan in the Diagnosis and Classification of Tillaux-Chaput Fractures in Adults

Category: Trauma; Ankle Introduction/Purpose: Anterolateral distal tibial fractures, also known as Tillaux-Chaput fractures (TCF), have slowly gained attention, considering the risk of chronic pain and osteoarthritis if not appropriately managed. This study aimed to compare the diagnostic accuracy of ankle radiographs in diagnosing and classifying TCF with computed tomography (CT) scans in the adult population. Methods: A retrospective review of ankle fractures evaluated at a single institution between 2013-2023 was performed. Inclusion criteria were patients aged &gt;18 years and evaluation with ankle radiographs and CT scan. Exclusion criteria were distal tibial/pilon fractures,or prior ankle surgery. A matching 1:2 was performed on patients with and without TCF. A radiologist evaluated the TCF under CT scan and classified the fractures according to Rammelt’s classification: type 1,extraarticular avulsion; type 2,fracture with involvement of the incisura; type 3, fracture with impaction of the anterolateral plafond. His answers were used as a comparison parameter. Three foot and ankle surgeons assessed the radiographs and described if the TCF was present (yes/no). If present, they classified the TCF by subtype. The sensitivity(Sn), specificity(Sp), positive predictive value(PPV), and negative predictive value(NPV) of the radiographs for detecting TCF were calculated. Fleiss's Kappa coefficient measured the interobserver agreement for each subtype. P-values &lt; 0.05 were considered significant. Results: 1134 acute ankle fractures were initially evaluated, of which 481 met the eligibility criteria. The prevalence of TCF was 17.3% (83/481), with 37 (44.6%) type 1, 37 (44.6%) type 2, and 9 (10.8%) type 3. Using radiographs, the overall Sn, Sp, PPV, and NPV for the diagnosis of TCF were 50.2% (95% CI 45.8-54.6), 69.9% (95% CI 65.9-73.9), 62.5% (95% CI 58.3-66.8%), and 58.4% (95% CI 54.1-62.7), respectively. There was disagreement between surgeons using X-rays and the radiologist under CT scan for all subtypes (type 1: κ -0.54, type 2: -0.31, type 3: -0.27, p&lt; 0.001). Under CT scan, the global interobserver agreement was moderate for the TCF classification (κ 0.62) and its subtypes. Conclusion: This study demonstrated that ankle radiographs have low diagnostic accuracy for TCF in adults. Therefore, a CT scan should be routinely used when a TCF is suspected.

Discrepancies in Pedobarography between Affected and Unaffected Sides in Patients with Plantar Fasciitis

Category: Other; Basic Sciences/Biologics Introduction/Purpose: Plantar fasciitis is one of the most common causes of chronic heel pain. Typically, conservative treatment involves stretching exercises and the use of orthosis such as heel cups. To prescribe the appropriate orthosis, a fundamental understanding of plantar pressure distribution is essential. We evaluated the plantar pressure distribution of patients with unilateral plantar fasciitis by comparing it with contralateral unaffected sides. Methods: We prospectively recruited 20 participants who were diagnosed with unilateral plantar fasciitis and had been complaining of heel pain for at least 6 months. The emed® system was used to measure the plantar pressure of both feet during gait. We measured the pedobarographic parameters, such as contact area, maximum force, peak pressure, force time integrals, and pressure time integrals. The analysis was performed using a 4-mask configuration (hindfoot, midfoot, forefoot, and toes). In addition, we measured radiographic parameters that could potentially affect plantar pressure in simple foot and ankle radiographs. Results: Both sides showed no significant difference in radiographic parameters. The affected side showed significantly higher contact area (28.9±10.3 vs. 26.3±8.2, p=0.007), maximum force (27.3±12.9 vs. 24.4±11.9, p=0.048), and force time integrals (0.6±0.3 vs. 0.5±0.2, p=0.044) in the midfoot. However, the unaffected side demonstrated significantly higher maximum force (67.5±11.4 vs. 60.1±8.4, p=0.030) and force time integrals (1.4±0.2 vs. 1.2±0.2, p=0.038) in the hindfoot. Conclusion: The increase in the contact area and maximum force in the midfoot on the side with plantar fasciitis can be interpreted as a result of weight transfer from the hindfoot to the midfoot due to heel pain. It can be suggested that Achilles tendon and plantar fascia stretching exercise is necessary to prevent weight transfer from the original hindfoot to the midfoot or forefoot. Moreover, the findings of this study could be helpful in prescribing appropriate orthosis for patients effectively.

Associated Injuries in Ankle Fractures Involving the Tillaux-Chaput Fragment in Adults

Category: Trauma; Ankle Introduction/Purpose: Tillaux-Chaput fractures (TCF) consist of fractures of the anterolateral distal tibia. They are considered a rare entity during adulthood and can occur in isolation or be associated with other injuries around the ankle. When the TCF is ignored, there is a risk of complications such as chronic pain, instability, and post-traumatic ankle osteoarthritis. Although prior studies have correlated some factors with the presence of TCF, to our knowledge, no studies have evaluated which variables are independently associated with the presence of TCF in a multivariate regression analysis. This study aimed to identify which factors are related to the presence of TCF in ankle injuries. Methods: A retrospective review of ankle fractures evaluated in the emergency or outpatient department between 2013-2023 at a single trauma center was performed. Inclusion criteria were age≥18 years, ankle radiographs and CT scan evaluation, and the presence of TCF confirmed by CT scan. Exclusion criteria were pilon/distal tibial fractures, or prior ankle surgery. A radiologist classified the TCF into: type 1,extraarticular avulsion; type 2,fracture with involvement of the incisura; and type 3, fracture with impaction of the anterolateral plafond. A matching 1:2 was performed among ankle fractures with and without TCF. The following variables were collected: sex, age(&lt; 50 vs &gt;50 years), dislocation, Weber classification, Maisonneuve fracture, type of medial malleolar fracture(Herscovici classification), type of posterior malleolar fracture (Bartonicek/Rammelt classification), Lauge-Hansen classification, type of malleolus involved, and acute osteochondral lesion of the talus. Logistic regression was performed to detect which variables had association with the TCF and their subtypes.P-value&lt; 0.05 was considered significant. Results: 1134 ankle fractures were evaluated, of which 481 fulfilled the eligibility criteria. Eighty-three (17.3%) ankle fractures had a TCF, of which 37(44.6%) were type I, 37(44.6%) type 2, and 9(9.6%) type 3. In patients with TCF, the mean age was 52.2(19.7) years, and 55(66.3%) were women. Six(7.2%) patients had an isolated TCF. Fifty-six(67.5%), 50(60.2%), and 62 (74.7%) ankles had involvement of the lateral, medial, and posterior malleolus, respectively. Eight (9.6%) ankles had a Maisonneuve fracture. In the multivariate-regression analysis, the patients aged&gt;50 years (OR=2.73,95%CI 1.45-5.14) and Lauge-Hansen/pronation external rotation injuries (OR=2.94,95%CI 1.43-6.06) had a significant association with the TCF. When analyzing for subtypes, the ankle dislocation (OR=3.16,95%CI 1.11-8.96), and the absence of posterior malleolar fracture (OR=5.97,95%CI 1.65-21.6) were associated with TCF type 2 and 3. Conclusion: Patients aged &gt;50 years and pronation external rotation injuries were the unique independent variables associated with the existence of a TCF in this study. Furthermore, ankle dislocation and the indemnity of the posterior malleolus increased the chance of having a more severe TCF by 3.2 and 6.0 times, respectively. This study provides novel insights into the factors associated with TCF and its subtypes during adulthood, allowing for a higher degree of suspicion during the ankle fracture evaluation.

Nonoperative Management of High Ankle Sprains: A Case Series With ≥18-Year Follow-up

Background: High ankle sprains are common athletic injuries and can be associated with long-term sequelae. Regardless of operative or nonoperative treatment, there is a paucity of data in the literature about the long-term outcomes of high ankle sprains. Hypothesis: Nonoperative treatment of high ankle sprains utilizing a standardized protocol will result in good long-term outcomes. Study Design: Case series; Level of evidence, 4. Methods: Patients who experienced a high ankle sprain without radiographic diastasis of the syndesmosis were identified from a previous study database and contacted for long-term follow-up. All patients were high school or National Collegiate Athletic Association Division IA athletes at initial injury and were treated nonoperatively with the same standardized protocol. Patients completed a questionnaire that included documentation of any interim ankle injuries, 2 different patient-reported outcome scores, and ankle radiographs to conduct Kellgren-Lawrence scoring for ankle osteoarthritis. Results: In total, 76 cases in 74 patients were identified in the database. A total of 40 patients were successfully contacted, and 31 patients (24 collegiate and 7 high school athletes) with 33 high ankle sprains completed the survey (31/40; 77.5%). The mean age at follow-up was 45 years (range, 34-50 years), with a mean time from injury to follow-up of 25 years. Overall, 93.5% (n = 29) of the respondents were male, and 42% (n = 13) of the respondents reported an ipsilateral ankle injury since their initial injury, with 16% (n = 5) having ankle or Achilles surgery. The mean Patient-Reported Outcomes Measurement Information System-10 score was 53.4 (SD, 8.3; range, 37.4-67.7), PROMIS median (IQR), 54.1 (39.9, 68.3), and the mean Self-reported Foot and Ankle Score score was 42.7 (SD, 5.86). Follow-up ankle radiographs were obtained in 11 (35%) of the respondents; 27% had Kellgren-Lawrence grade >2 osteoarthritis, and 36% had signs of heterotopic ossification on imaging. The mean tibiofibular clear space was 4.5 mm, and the mean tibiofibular overlap was 7.15 mm, with 27% of patients demonstrating some tibiotalar narrowing. Conclusion: At long-term follow-up, nonoperative management of high ankle sprains without diastasis on imaging was associated with acceptable patient-reported functional outcomes and low rates of subsequent ankle injuries. There was a high incidence of arthritis, but most cases were not clinically significant. This case series shows the natural history of nonoperatively treated high ankle sprains and may serve as a comparison for different management techniques in the future.

Magnetic Resonance Imaging Has Utility in Clinical Decision-Making for Children and Adolescents With Symptomatic Subfibular Ossicles.

We performed a retrospective study of pediatric patients with lateral ankle pain, recurrent sprains, and radiographs showing SOs who had undergone an MRI as part of their diagnostic work-up.We identified 22 patients from the senior author's registry of pediatric patients with lateral ankle injuries. Eleven were girls, and 11 were boys, ages ranging from five to 19 years.Eleven involved the left ankle; 11 involved the right. Positive MRIs showed a high-intensity signal between the SO and the distal fibular epiphysis; negative MRIs had a low-intensity signal. The main outcome measure was operative versus non-operative treatment. Sixteen of the 22 patients had positive MRIs, and six had negative MRIs. Twelve of the 16 patients with positive MRIs had undergone an operation. All six patients with negative MRIs responded to nonoperative management. MRI has utility in clinical decision-making for symptomatic patients with SOs.Patients with negative MRI sequences responded to nonoperative management.Most patients with positive MRI sequences will require surgery to alleviate their symptoms and return to full activities. IV.

Male National Basketball Association G-League and Collegiate Basketball Athletes Have a High Prevalence of Radiographic Ankle Abnormalities

PurposeThe purposes of this study were to characterize radiographic foot/ankle bony abnormalities in elite-level, asymptomatic male basketball athletes, and to investigate the association between anthropometric (age, height, weight) or sport-specific characteristics (total exposures, player position, pregame ankle taping) and the prevalence of abnormal radiographic findings in asymptomatic basketball athletes MethodsElite-level basketball players who underwent routine, pre-season static radiographic imaging, including antero-posterior, lateral, and mortise views of the ankle were included. Radiographs were collected from asymptomatic athletes participating in pre-season history and physical with negative anterior drawer/talar tilt test. Radiographs were evaluated by a musculoskeletal radiologist and board-certified orthopedic surgeon; kappa statistics were used to evaluate agreement. ResultsFifty-four basketball players (34 collegiate, 20 professional; mean age 21.5 years) were included, totaling 5,148 player exposures from 2017-2019. 106 ankles presented with radiographic findings (98.15%). The most prevalent radiographic finding was pes planus (47.22%), followed by degenerative joint disease (DJD) (33.33%), talonavicular sclerosis (28.70%), prominent stieda process (25.93%), os trigonum (20.93%), os subfibulare (11.11%), pes cavus (5.56%), subtalar coalition (2.78%), and cavovarus (0.93%). Height ≥ 80” was significantly associated with talonavicular sclerosis and Kellgren-Lawrence 1 changes. ConclusionsThis study demonstrated a strong association between height and talonavicular sclerosis and DJD, as well as a relatively high prevalence of pes planus and DJD in asymptomatic collegiate and professional basketball players.

Prognostic factors and the value of radiographic osteoarthritis for persistent complaints after referral for ankle radiography

BackgroundAnkle symptoms are a common reason to consult the general practitioner and often persist for years. In a population referred for ankle radiography, the prevalence of radiographic osteoarthritis (OA) is substantial, but its additional predictive value for persistent symptoms is unknown. Therefore, we examined the prognosis of symptoms 2–3 years after referral for ankle radiography, assessed clinical prognostic factors, and the additional predictive value of radiographic OA for persistent ankle complaints. MethodsWe included 893 adults referred for ankle radiography and studied the following candidate prognostic factors at baseline: age, sex, body mass index (BMI), referral for chronic complaints (>3 months), pain during activity (NRS-11) and presence of stiffness and functional loss as predominant symptom. X-rays were scored for radiographic OA. After 2–3 years participants were invited for a follow-up questionnaire including persistence of ankle complaints. To assess prognostic factors for persistent complaints, uni- and multivariable logistic regression were used. ResultsOf the 194 responders at follow-up, ankle complaints persisted in 71(36.6 %). BMI (OR 1.08; 95 % CI 1.01–1.15), stiffness as predominant symptom (OR 1.69; 95 % CI 0.89–3.21), and chronic complaints (OR 2.84; 95 % CI 1.45–5.57) were in the initial model for persistent complaints (AUC=0.69). After adding radiographic OA (OR 2.36; 95 % CI 1.01–5.50), the AUC of the final model became 0.70. ConclusionAnkle complaints persist in a considerable proportion of patients 2–3 years after referral for ankle radiography. BMI, chronic complaints and radiographic OA are prognostic factors for persistent complaints, but the additional predictive value of radiographic OA on top of clinical factors is negligible.

Ossification of the posterior longitudinal ligament is linked to heterotopic ossification of the ankle/foot tendons.

Systemic osteogenesis has been speculated to be involved in the pathogenesis of ossification of the posterior longitudinal ligament (OPLL). Our purpose was to compare the radiologic prevalence and severity of heterotopic ossification in foot tendons of Japanese patients with OPLL and to determine their association with systemic heterotopic ossification. Clinical and radiographic data of 114 patients with OPLL were collected from 2020 to 2022. Control data were extracted from a medical database of 362 patients with ankle radiographs. Achilles and plantar tendon ossification were classified as grades 0-4, and the presence of osteophytes at five sites in the foot/ankle joint was assessed by radiography. Factors associated with the presence and severity of each ossification were evaluated by multivariable logistic regression and linear regression analysis. The prevalence of Achilles and plantar tendon ossification (grade ≥ 2) was 4.0-5.5 times higher in patients with OPLL (40-56%) than in the controls (10-11%). The presence of Achilles tendon ossification was associated with OPLL, age, and coexisting plantar tendon ossification, and was most strongly associated with OPLL (standardized regression coefficient, 0.79; 95% confidence interval, 1.34-2.38). The severity of Achilles and plantar tendon ossification was associated with the severity of ossification of the entire spinal ligament. The strong association of foot tendon ossification with OPLL suggests that patients with OPLL have a systemic osteogenesis background. These findings will provide a basis for exploring new treatment strategies for OPLL, including control of metabolic abnormalities.

Using the Equatorial Talar Line as a Radiographic Predictor of Sanders Type 3 and 4 Calcaneus Fractures and Lateral Wall Blowout.

To assess the equatorial talar line (ETL) as a sensitive radiographic parameter to predict Sanders type III and IV fractures and the presence of lateral wall blowout. Reliability of the ETL was assessed using the intraclass correlation coefficient (ICC) and receiver operating curve (ROC) to predict sensitivity. Using lateral ankle radiographs, raters determined whether the calcaneal tuberosity was "above" (predicting Sanders type I or II) or "below" (predicting Sanders type III or IV and lateral wall blowout). In determining the "above" or "below" location of the ETL, the calculated ICC was 1.0 for each session. As a predictor of Sanders fracture classification type, the calculated ICC was 0.93 for the first session and 0.89 for the second session for an overall ICC of 0.91. As a predictor of Sanders fracture type, ROC analysis yielded an overall sensitivity of 0.82. As a predictor of lateral wall blowout, ROC analysis yielded an overall sensitivity of 0.81. The ETL is a reproducible radiographic parameter that can be reliably used to crudely predict between Sanders type I or II (ETL is "above") and Sanders type III or IV (ETL is "below") calcaneus fractures as well as the presence of lateral wall blowout.

Impact of Subtalar Distraction Arthrodesis on Ankle Joint: Radiological Insights from Modified Grice-Green Procedure.

Subtalar distraction arthrodesis (SDA) is a surgical procedure designed to treat hindfoot deformities associated with isolated subtalar joint arthritis. In 1996, Fitzgibbons was the first to observe that, in some cases, hindfoot fusion appeared to be associated with the development of tibiotalar valgus tilt. Since then, few studies have addressed this issue. Given that hindfoot fusion can be performed using various techniques, this study investigated the potential tibiotalar joint frontal or sagittal modifications resulting from the modified Grice-Green technique. All the consecutive patients who underwent the modified Grice-Green procedure were included. The patient records were reviewed to extract demographic data. Weight-bearing foot and ankle radiographs were assessed to measure the talar tilt angle and the tibiotalar ratio on the same picture archiving and communication system by three independent observers. A total of 69 patients met the criteria for inclusion. The mean talar tilt showed no substantial changes, since the increase from 1.46 ± 1.62 preoperatively to 1.93 ± 2.19 at a minimum of 8 months postoperatively was not statistically significant (p = 0.47). The average preoperative tibiotalar ratio significantly increased from 33.4 ± 4.4% to 35 ± 4% postoperatively (p = 0.007), although remaining within the normal range, indicating a possible realignment of the posterior facet of the subtalar joint. In conclusion, this study highlights the effectiveness of the modified Grice-Green procedure in achieving a favorable realignment without impacting the ankle joint, particularly regarding tibiotalar valgus tilt.

Effectiveness of implementation strategies for increasing clinicians' use of five validated imaging decision rules for musculoskeletal injuries: a systematic review.

Strategies to enhance clinicians' adherence to validated imaging decision rules and increase the appropriateness of imaging remain unclear. To evaluate the effectiveness of various implementation strategies for increasing clinicians' use of five validated imaging decision rules (Ottawa Ankle Rules, Ottawa Knee Rule, Canadian C-Spine Rule, National Emergency X-Radiography Utilization Study and Canadian Computed Tomography Head Rule). Systematic review. The inclusion criteria were experimental, quasi-experimental study designs comprising randomised controlled trials (RCTs), non-randomised controlled trials, and single-arm trials (i.e. prospective observational studies) of implementation interventions in any care setting. The search encompassed electronic databases up to March 11, 2024, including MEDLINE (via Ovid), CINAHL (via EBSCO), EMBASE (via Ovid), Cochrane CENTRAL, Web of Science, and Scopus. Two reviewers assessed the risk of bias of studies independently using the Cochrane Effective Practice and Organization of Care Group (EPOC) risk of bias tool. The primary outcome was clinicians' use of decision rules. Secondary outcomes included imaging use (indicated, non-indicated and overall) and knowledge of the rules. We included 22 studies (5-RCTs, 1-non-RCT and 16-single-arm trials), conducted in emergency care settings in six countries (USA, Canada, UK, Australia, Ireland and France). One RCT suggested that reminders may be effective at increasing clinicians' use of Ottawa Ankle Rules but may also increase the use of ankle radiography. Two RCTs that combined multiple intervention strategies showed mixed results for ankle imaging and head CT use. One combining educational meetings and materials on Ottawa Ankle Rules reduced ankle injury imaging among ED physicians, while another, with similar efforts plus clinical practice guidelines and reminders for the Canadian CT Head Rule, increased CT imaging for head injuries. For knowledge, one RCT suggested that distributing guidelines had a limited short-term impact but improved clinicians' long-term knowledge of the Ottawa Ankle Rules. Interventions such as pop-up reminders, educational meetings, and posters may improve adherence to the Ottawa Ankle Rules, Ottawa Knee Rule, and Canadian CT Head Rule. Reminders may reduce non-indicated imaging for knee and ankle injuries. The uncertain quality of evidence indicates the need for well-conducted RCTs to establish effectiveness of implementation strategies.

RANDOMIZED PROSPECTIVE TRIAL COMPARING THE SALTO TALARIS FIXED-BEARING AND SALTO MOBILE-BEARING TOTAL ANKLE ARTHROPLASTY

IntroductionComparative studies examining Fixed-Bearing (FB) and Mobile-Bearing (MB) Total Ankle Replacement (TAR) designs have demonstrated similar results and successful long-term outcomes for both. To date there has been no study directly comparing FB and MB designs of the same prosthesis. We present the first prospective randomised trial comparing patient satisfaction, functional outcomes and radiographic results of the Salto Talaris Fixed-Bearing and the Salto Mobile-Bearing Total Ankle Replacement in the treatment of end-stage ankle arthritis.MethodsA total of 108 adult patients with end-stage ankle arthritis were enrolled in the study between November 2014 and October 2021 with similar demographic comparison. Prospective patient-reported outcomes and standardised weightbearing ankle radiographs were performed preoperatively, at 6 weeks, 6 months and 12 months post-operatively, followed by yearly intervals. All surgeries were performed by a single non-design orthopaedic foot and ankle specialist with experience in over 200 Salto and Salto Talaris TAR prior to the study. Radiographs were examined independently by two clinicians. Complete patient data and radiographs were available for 103 patients with an average follow up of 2 years.ResultsBoth groups demonstrated statistically significant improvement from preoperative evaluation to most recent follow up with no statistically significant difference between the two groups in all outcome measures. Radiographic incidence of subchondral cyst formation was 8.9% and 38.2% for FB and MB, respectively. Talar subsidence occurred in 2.2% and 5.5% of FB and MB, respectively.DiscussionOur study demonstrates a higher than previously reported rate of cyst formation in the MB TAR and comparatively higher talar subsidence in the MB TAR vs FB however this did not correlate with clinical outcome measures which were favourable for both groups.ConclusionFixed-Bearing and Mobile-Bearing Total Ankle Replacement demonstrate comparable favourable

The radiographic breadth of the talus bone for forensic and clinical use

BACKGROUND: The accurate identification of unknown human remains plays a critical role in natural disaster scenarios and medico-legal cases in forensic anthropology and forensic medicine. This study aimed to determine normal reference values for the breadth of the talus bone using ankle radiographs from a Teaching Hospital in Delta State, Nigeria. MATERIAL AND METHODS: This cross-sectional study retrospectively reviewed 107 digital ankle radiographs from patients aged 20 to 60 years (60 males and 47 females). Ethical clearance was obtained before accessing the digital images archived in a radiological unit of a Hospital in Delta State, Nigeria. The talus breadth was measured using digital calipers and the Statistical Package for Social Sciences (SPSS) was used to compare the means based on gender and age. The association of variables was done using the Pearson’s correlation test. Statistical significance was considered at P &lt; 5%. RESULTS: The mean talus breadth was significantly larger in males (41.76 mm) than in females (38.59 mm). However, the means had no significant association with age. The right talus breadth had a strong positive correlation with the left talus breadth. CONCLUSION: The findings are useful to orthopedic surgeons managing ankle pathologies. In addition, the study reveals the potential use of the talar breadth in sex determination when other methods are inconclusive.

Torsional Deformity Significantly Impacts Lateral Ankle Radiographic Imaging Parameters.

Background Optimal lateral ankle imaging is important for the diagnosis and treatment of multiple ankle conditions. The effects of limb deformity on lateral ankle imaging are not well described and are clarified in this osteological study. Materials and methods We utilized an osteological collection and imaged all specimens after the first positioning of the talus in the lateral position and positioning the tibia and fibula to match. We then measured the relative positions of the tibia and fibula and their widths to calculate standard ratios. All measurements were evaluated for reliability using intra-class correlation coefficients. Multiple regression analysis determined how patient characteristics, tibial torsion, and medial proximal tibial angle affected various lateral ankle imaging ratios. Results The intra-class correlation coefficient was excellent for all measurements. In the multiple regression analysis, all five imaging ratios had at least one statistically significant outcome. The anterior tibiofibular interval (ATFI)-tibial width (TW) ratio (ATFI:TW) had only one association with sex and had the lowest standard deviation. All other parameters had variation with tibial torsion and/or medial proximal tibia angle (MPTA). The mean ATFI was 1.06 ± 0.21 cm and 1.19 ± 0.23 cm for females and males, respectively. Conclusions Patient sex and tibial torsion impacted the fidelity of lateral imaging parameters. ATFI:TW may pose the greatest utility given its minimal association with deformity parameters and low standard deviation.