Weight-bearing Radiographs Research Articles

Weightbearing Computed Tomography Evaluation of Acute SER4a Ankle Fractures.

Supination external rotation (SER) fibula fractures with abnormal medial clear space (MCS) on stress radiographs that normalizes with weightbearing radiographs, termed SER4a ankle fractures, pose a challenge in treatment decision making. This study aims to quantify differences in joint contact area, tibiotalar rotation, and translation using weightbearing computed tomography (CT) scans in SER4a ankle fractures. Between November 2022 and September 2023, patients presenting with isolated Weber B fibula fractures were evaluated for inclusion. Adult patients presenting within 10 days of injury with an SER4a ankle fracture, and no history of ankle fractures or surgery, were included. Ten patients were enrolled and underwent bilateral ankle weightbearing CT scans. Disior Bonelogic Software was used to quantify joint contact area, tibiotalar rotation, and translation, with the uninjured ankle serving as the control. Ten patients (4 male, 6 female) with an average age of 51 years were included. The average MCS measured 2.5 mm (SD 0.36) on weightbearing and 5.7 mm (SD 0.67) on stress radiographs. The difference in joint contact area between injured and healthy joints was 12.2 mm2 (P = .085). Axial tibiotalar joint rotation averaged 6.6 degrees of increased external rotation on the injured extremity (P < .001). The mediolateral distance between the center of the tibial plafond and center of the talar dome was increased 1.0 mm in the injured extremity (P < .05). In this study evaluating 10 patients with acute SER4a ankle fractures, no difference in joint contact area was found between individuals' healthy and injured ankles. However, differences in external rotation and lateral translation of the talus were observed on the injured ankle. The clinical effects of these tibiotalar rotational and translational changes are unknown. This study provides insight regarding in vivo changes in 3-dimensional alignment of SER4a ankle fractures that may influence future management of these fractures.

Assessing the AIR classification reliability for estimating pronation of the first metatarsal

BackgroundHallux valgus (HV) is a multiplanar deformity and surgical treatment is often guided by two-dimensional radiographic parameters. This study assessed the reliability and accuracy of the AIR classification(The first metatarsal head’s lateral edge can be delineated as angular (type A), round (type R), or intermediate (type I) through visual inspection or circle measurements on weight-bearing radiographs.)commonly used in clinical settings to categorize the shape of the lateral edge of the first metatarsal head, against measurements from weight-bearing computed tomography (WBCT).MethodsThis retrospective study evaluated 18 patients, including 31 feet affected by HV. Two surgeons independently categorized the first metatarsal head’s lateral edge by both visual inspection and circle measurement. Additionally, two separate surgeons evaluated the α angle relative to the floor in WBCT scans. The reliability of the measurements was assessed using intraclass correlation coefficients (ICC) and weighted kappa statistics.ResultsWhile the first surgeon demonstrated perfect intra-observer reliability for both visual inspection and circular measurements (kappa values of 1.000 and 0.857, respectively), the second surgeon showed high and perfect reliability (kappa values of 0.759 and 1.000, respectively) for the same assessments. While the interobserver reliability for visual inspection was moderate (kappa values of 0.407 and 0.455, respectively), it was little to low for circular measurements (kappa values of 0.173 and 0.232, respectively). The interobserver reliability for the α angle assessment relative to the floor on WBCT scans was perfect (ICC = 0.968).ConclusionThe AIR classification may not provide a reliable estimate of first metatarsal pronation, so clinicians should be cautious and recognize these limitations in their diagnostic applications. Between the two AIR classifications, the visual inspection measurement seems to be more reliable according to kappa value. If allowed, it may be better to additionally include a 3D assessment method such as WBCT, in the preoperative evaluation.Level of evidenceIV, case series.

Stem subsidence in total hip arthroplasty: retrospective investigation of a short stem using a simple measurement approach

BackgroundUncemented total hip arthroplasty (THA) is a successful treatment for advanced hip joint diseases. More recently, short stems became increasingly popular, but stem subsidence remains a concern. This study investigates early short stem subsidence in a large patient cohort using a simple measurement approach for everyday practice.MethodsThis retrospective, single center, single implant design study included 1000 patients with primary THA. Subsidence was evaluated using standardized weight-bearing radiographs taken 3–5 days and 2–3 weeks postoperatively with full weight-bearing (FWB). A novel Subsidence Index (SID) was introduced to quantify stem subsidence in a simple and reproducible manner. The SID is calculated by averaging four distinct linear measurements between defined anatomical landmarks on the femur and the implant, captured on standard radiographs without additional software.ResultsOut of all analyzed patients 6% (60/1000) had subsidence of more than 3 mm. The mean subsidence was 1.3 mm (range, 0 to 16.25 mm).There were 0.6% (6) who underwent stem revision for symptomatic subsidence. Men and obese patients had greater subsidence. However, patient age, BMI, stems without lateral bone contact and other demographic factors were not associated with subsidence.ConclusionEarly subsidence is relatively frequent with this uncemented short stem, however revisions are rare. Patients with risk factors should be counseled regarding FWB and radiographic controls should be performed. The SID provides an easy, non-invasive and inexpensive tool for early subsidence assessment; however, its simplicity limits its accuracy. Further research is needed in comparison to more elaborate methods.

Acute Lisfranc injury management.

Lisfranc injuries were previously described as fracture-dislocations of the tarsometatarsal joints. With advancements in modern imaging, subtle Lisfranc injuries are now more frequently recognized, revealing that their true incidence is much higher than previously thought. Injury patterns can vary widely in severity and anatomy. Early diagnosis and treatment are essential to achieve good outcomes. The original classification systems were anatomy-based, and limited as tools for guiding treatment. The current review, using the best available evidence, instead introduces a stability-based classification system, with weightbearing radiographs and CT serving as key diagnostic tools. Stable injuries generally have good outcomes with nonoperative management, most reliably treated with immobilization and non-weightbearing for six weeks. Displaced or comminuted injuries require surgical intervention, with open reduction and internal fixation (ORIF) being the most common approach, with a consensus towards bridge plating. While ORIF generally achieves satisfactory results, its effectiveness can vary, particularly in high-energy injuries. Primary arthrodesis remains niche for the treatment of acute injuries, but may offer benefits such as lower rates of post-traumatic arthritis and hardware removal. Novel fixation techniques, including suture button fixation, aim to provide flexible stabilization, which theoretically could improve midfoot biomechanics and reduce complications. Early findings suggest promising functional outcomes, but further studies are required to validate this method compared with established techniques. Future research should focus on refining stability-based classification systems, validation of weightbearing CT, improving rehabilitation protocols, and optimizing surgical techniques for various injury patterns to ultimately enhance patient outcomes.

Relationship Between the Relative Length of the Second Metatarsal and Occurrence of Metatarsalgia in Patients With Hallux Valgus.

Patients with hallux valgus (HV) may develop metatarsalgia, which is partly attributed to second metatarsal relative length (RL2M). However, no study has analyzed RL2Ms measured by various methods as predictors for metatarsalgia in HV patients. This study aimed to investigate the predictors for metatarsalgia in HV patients and calculate the cutoff values for metatarsalgia in preoperative planning for lesser metatarsal shortening osteotomy. In this retrospective cohort study, 103 female patients (131 feet) with HV were investigated for metatarsalgia (metatarsalgia-positive [MP] group: 55 feet; metatarsalgia-negative [MN] group: 76 feet). The HV angle (HVA) and intermetatarsal angles (IMAs) (1/2 and 1/5), lateral talo-first metatarsal angle, calcaneal pitch angle, first metatarsal-medial cuneiform angle, and first metatarsal lift (LIFT) were measured using weightbearing radiographs. RL2Ms were assessed using the 4 methods described by Morton and Nilsonne (method A), Coughlin (method B), Hardy and Clapham (method C), and Kumano (method D). RL2M (method D) was calculated as the ratio of this distance to the second metatarsal length. These measurements were compared between the groups. Multivariate logistic regression analysis was performed to determine the predictors of developing metatarsalgia. The cutoff values were calculated using receiver operating characteristic curve analysis. HVA, IMAs (1/2 and 1/5), LIFT, and RL2M (method D) were significantly higher in the MP group than in the MN group. In the multivariate analysis, HVA and RL2M (method D) were independent predictors for metatarsalgia. The cutoff values for HVA and the value and ratio of RL2M (method D) were 37.0 degrees, 13.1 mm, and 18.8%, respectively. HVA and RL2M measured by method D were independently associated with the occurrence of metatarsalgia in HV patients.

Enhanced diagnosis of pes planus and pes cavus using deep learning-based segmentation of weight-bearing lateral foot radiographs: a comparative observer study.

The online version contains supplementary material available at 10.1007/s13534-024-00439-3.

Erect weight-bearing pelvic radiographs are superior to supine radiographs for diagnosis of mixed type acetabular retroversion plus developmental dysplasia hip deformity

PurposeThis study focused on the mixed-type deformities of acetabular retroversion (AR) and developmental dysplasia hip deformity (DDH) and aimed to ascertain the changes in pelvic tilt from a supine to a standing position in these cases and identify potential underlying mechanisms. MethodsA retrospective study was conducted on cases with symptomatic DDH from January 1, 2019, to April 30, 2023. DDH was defined as LCEA < 20°. AR was diagnosed by using a crossover index threshold of 0.2 in standing pelvic X-ray. Two observers assessed the supine and weight-bearing pelvic radiographs, along with computed tomography (CT) scans. The evaluated parameters included pelvic tilt (sacrofemoral-pubic angle (SFP), symphysis to sacrococcygeal distance (PSSC), pubic symphysis to sacroiliac (PSSI)), acetabular retroversion (crossover index, posterior wall sign), acetabular coverage (lateral center-edge angle (LCEA), ischial spine sign (ISS)), and axial rotation of the hemipelvis (pelvic width index, obturator index, and ilio-ischial angle). Acetabular orientation and coverage was measured by CT through anterior sector angle (ASA), posterior sector angle (PSA) and acetabular anteversion (AA). Cases with acetabular retroversion plus DDH were defined as the mixed-type deformity. Comparative analyses between mixed-type deformities and DDH cases were performed along with subgroup and correlation analyses within mixed-type cases. Inter-observer and intra-observer reliabilities were assessed using intraclass correlation coefficients. ResultsA total of 85 were included. 26 cases (30.59%) had mixed-type deformity, where transition from the supine to standing position led to an increased posterior pelvic tilt (SFP (supine: 64.35±4.6°, standing: 74.75±4.16°, p<0.001), PSSC (supine: 6.37±2.47, standing: 2.08±1.32, p<0.001) and PSSI (supine: 9.47±1.66, standing: 6.33±1.08, p<0.001)). Compared to cases with DDH, CT examination revealed a significantly greater anterior acetabular coverage and less posterior superior coverage, with smaller posterior sector angle and greater anterior sector angle (ASA) (p<0.05) for cases with AR. The superior iliac wing angle (mixed type: 45.63±9.22°, isolated type: 50.70±8.77°, p=0.013), inferior iliac wing angle(mixed type: 60.77±8.24°, isolated type: 65.24±8.02°, p=0.013), and ischiopubic angle (IPA) (mixed type: 32.27±3.19°, isolated type: 36.71±5.38°, p<0.001) were significantly reduced in AR cases, suggesting external rotation of the hemipelvis. Subgroup analysis showed that cases with a higher crossover index had a significantly higher PSSC and a significantly lower IPA. ConclusionAR was observed in 31% of DDH cases and was associated with a notable posterior pelvic tilt during postural transitions. This tilt appeared to be a compensatory mechanism affecting the AR diagnosis. Key changes in the acetabular coverage, including increased anterior coverage and decreased superior posterior coverage, were also observed. Additionally, external rotation of the hemipelvis in mixed-type cases correlated strongly with the extent of AR and anterior acetabular coverage, suggesting that it may be a key contributor to the underlying mechanism of this mixed-type deformity. Level of evidenceIII, retrospective case series.

High-Energy Transsyndesmotic Ankle Fracture Dislocation-Does Deltoid Ligament Repair Influence the Progression of Posttraumatic Arthritis in Logsplitter Injuries?

To determine the effect of deltoid ligament repair on the development of posttraumatic arthritis in logsplitter ankle injuries. Retrospective cohort. Academic, Level I trauma center. Patients ≥18 years of age with logsplitter injuries (OTA/AO 44B, 44C) treated with open reduction internal fixation (ORIF) with or without deltoid ligament repair from January 2008 to October 2021. The rate of posttraumatic arthritis (PTOA) development at the final follow-up (minimum 6 months) after ORIF was evaluated using the Kellgren-Lawrence scale. The achievement of acceptable reduction indicated by articular reduction <2 mm, and a medial clear space ≤4 mm was assessed at 6 weeks postoperatively with weight-bearing radiographs. The effect of deltoid ligament repair on the development of PTOA was investigated. Fifty-nine patients aged 49.1 ± 17.2 years met inclusion criteria with a mean follow-up of 16.6 months (range = 6 to 96). Twenty-six of 59 patients (44%) had developed PTOA at the final follow-up. Acceptable reduction was achieved in 83.1% (49/59) of fractures. The acceptable reduction rate in fractures undergoing deltoid ligament repair was 100% versus 78% in those without deltoid ligament repair (13/13 vs. 36/46, P = 0.017). The rate of PTOA development was significantly lower in patients who underwent deltoid ligament repair (15%) than those who did not (52%), P = 0.026. Patients who underwent deltoid ligament repair had a significantly reduced rate of PTOA development leading to arthrodesis compared with those who did not (0% vs. 17%, P = 0.013). Logsplitter injuries resulted in a high rate of development of posttraumatic arthritis. An acceptable reduction is required to minimize the risk of development of PTOA and progression to arthrodesis. Deltoid ligament repair during ORIF may facilitate acceptable reduction and decrease the rate of PTOA and progression to arthrodesis in these injuries. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Integrating weightbearing CT findings into evaluation of conventional radiographs in progressive collapsing foot deformity

BackgroundProgressive collapsing foot deformity (PCFD) remains challenging to treat. Surgical planning depends on the amount and complexity of the deformity, which requires accurate differentiation through precise imaging. Weightbearing CT (WBCT) imaging has enhanced the three-dimensional (3D) assessment of PCFD. However, it remains unclear how PCFD findings on WBCT are related to the evaluation of conventional weightbearing radiographs. Therefore, we aimed to (1) compare specific X-ray measurements to corresponding WBCT measurements; (2) evaluate the reliability of X-ray measurements of interest; and (3) investigate whether X-ray measurements can infer osseous impingement in the subtalar joint region identified through WBCT. MethodsTwo clinically established measurements were assessed on standardized weightbearing radiographs (manually) as well as on the WBCT datasets (auto-generated): (1) talo-calcaneal overlap (TCO, mm) and (2) talo-navicular coverage (TNC, °). In addition to the measurements, osseous impingement in the subtalar joint region was assessed on WBCT using three criteria, compared both inter- and intra-rater: (1) joint obliteration; (2) cyst formation; and (3) signs of secondary instability. Two of the criteria needed to be fulfilled to confirm subtalar impingement. ResultsWhile no significant difference between X-ray and WBCT measurements was evident for TCO, significant differences were found for TNC. Inter- and intra-observer reliability was with an intraclass correlation coefficient > 0.9 excellent for both measurements on X-rays. The mean bias of measurement (between X-ray and WBCT) was 0.2 mm for TCO and −22 degrees for TNC. Cohen’s Kappa for inter- and intra-rater reliability to assess patients for subtalar instability was > 0.9. The probability to infer subtalar impingement was ≥ 0.85 if TCO was > 15 mm or TNC was > 25 degrees on X-ray. ConclusionThe examined imaging parameters are reliably assessable through conventional radiographs (TCO/TNC) or WBCT (osseous subtalar impingement). In situations where WBCT is unavailable, X-ray-assessed TCO and TNC can serve as predictors for osseous sinus tarsi impingement. This finding plays a pivotal role in evaluating PCFD patients, aiding in the surgical decision-making process between joint-preserving interventions (e.g., osteotomies) and joint-sacrificing procedures (e.g., realignment fusion). Level of EvidenceLevel IV, observational study

Grading of Knee Osteoarthritis Based on Kellgren-Lawrence Classification and Finding an Association Between Radiographic Features and Pain: A Cross-Sectional Study at a Tertiary Health Care Hospital.

Introduction: Osteoarthritis leads to painful joints, disability, restriction of ambulation, and reduces the person's ability to perform activities of daily living. Pain is one of the major symptoms of osteoarthritis. Some patients presented with severe pain while some with severe deformity. Method: Patients presenting with complaints of knee pain were screened. Written consent was taken from the patient. Radiographic data was collected and these patients were also shownthe visual analogue scale (VAS) and asked to rate their pain. Further, the weight-bearing radiographs of both kneesofpatients in anteroposterior, lateral, and skyline views were also taken. The radiographs were evaluated using the Kellgren-Lawrence classification to determine the grade of osteoarthritis. Results: For this study, radiographs of 116 patients (48 males (42%), 68 females (58%)) with knee OA who were eligible were included. The prevalence of the disease was highestamong patients inthe age group 51-60 years. The prevalence of bilateral knee osteoarthritis was observed in 98 patients (86.2%) and that of unilateral in 16 patients (13.8%). The prevalence of associated pain was comparatively higher in females than in males. Conclusion: This study found there is no significant correlation between VAS pain score and the severity of radiological grading. Hence treatment should be tailored according to symptoms and not just the X-ray findings.

Radiographic Measurements of Pes Planovalgus Do Not Predict Clinical Outcomes in Tarsal Coalition Excision.

Many patients who undergo tarsal coalition excision have persistent postoperative pain. Most studies have utilized cat scan (CT) scan parameters of pes planovalgus and heel valgus but have found this to be an inconsistent predictor of outcomes. Plain radiographic parameters have been less utilized in trying to predict outcomes after coalition excision. Radiographic talonavicular coverage angle correlates with pain in patients with flexible pes planovalgus (PPV) but has not been studied in tarsal coalition population. Furthermore, foot alignment is not understood to change after simple coalition excision. The purpose of this study was to compare plain radiographic parameters, including talonavicular coverage angle, with pain after tarsal coalition excision, as well as compare preoperative and postoperative weight-bearing radiographs. Seventy-seven feet that underwent excision of the tarsal coalition had clinical outcomes and radiographic data collected >1 year postoperatively. Measures of PPV on preoperative and postoperative weight-bearing radiographs and CT scans were evaluated. Patients were an average of 13 years old at excision. Of the total, 65% had calcaneonavicular (CN) coalitions, whereas the remainder had talocalcaneal coalitions. All patients had significant postoperative improvement in clinical outcomes but 34% (13/38) had continued pain at the most recent follow-up, more so in talocalcaneal than CN coalitions (55% vs 26%, P < 0.001). The subset with CN coalitions had more severe preoperative PPV but greater postoperative PPV improvement. Except for a weak correlation between radiographic weight-bearing (anterior-posterior) talus-first metatarsal angle and pain with activity (r = -0.54), there were no other correlations between preoperative radiographic parameters and clinical outcomes. Heel valgus on CT did not correlate with radiographic measurements of PPV or pain. We did not find a correlation of radiographic PPV with persistent pain after tarsal coalition excision. We did find improvement in radiographic PPV in CN coalitions after treatment with simple excision. Heel valgus on CT was not a useful metric for evaluating PPV in the setting of a tarsal coalition. Level III-prognostic study.

Validation of patient-specific flatfoot models on finite element analysis

Adult-acquired flatfoot causes various deformities. If a patient-specific foot model can be created using the finite element method, it can be used to study the appropriate surgical technique for each patient. Nine patient-specific flatfoot models were created, and loading simulations were performed. To validate the models, the patients’ weight-bearing radiographs were compared with the parameters of the models. The CCC values ranged from 0.917 to 0.993 , all exceeding the moderate threshold according to the McBride criteria. Our model reproduces the biomechanics of a patient’s foot under loading conditions, which may be useful for investigating patient-specific surgical procedures.

The Impact of Anterior Pelvic Tilt on Return to Duty/Return to Run in Active Duty Personnel After Hip Arthroscopy for Femoroacetabular Impingement.

Annually, 300,000 soldiers are rendered medically nondeployable because of musculoskeletal injuries (MSKIs). Of this population, nearly 10,000 (3.3%) involve injuries to the hip. Factors related to these injuries impose significant healthcare, financial, and readiness burdens on the Army system, degrading overall mission readiness. The purpose of this retrospective study was to assess for correlation between increased anterior pelvic tilt and a lower likelihood for return to duty/return to run (RTD/RTR) in active duty personnel who underwent hip arthroscopy for femoroacetabular impingement (FAI), thus identifying increased anterior pelvic tilt as a potential prognostic indicator for RTD/RTR. Ninety-two active duty U.S. Army service members aged 18 years or older who underwent hip arthroscopy for FAI at the William Beaumont Army Medical Center from September 1, 2014, to September 1, 2019, were included. Utilizing a retrospective review of existing data, the amount of anterior pelvic tilt, as estimated on a presurgical weight-bearing anterior-posterior pelvis radiograph using the distance from the pubic symphysis to the transischial line, was measured and compared to postoperative RTD/RTR statuses, assessing for correlation. The overall RTD rate was 39.1% with a 22.8% RTR rate. Only 6.5% (6/92) of subjects returned to full, unrestricted duty and running. Logistic regression analyses showed that individuals with increased anterior pelvic tilt (≥7°) were 2.6 times less likely to RTD and 2.9 times less likely to RTR compared to those with minimal or no anterior pelvic tilt (<7°) (respectively, odds ratio (OR) 2.619; 95% CI, 1.107-6.195; P = .029 and OR 2.897; 95% CI, 1.041-8.059; P = .042). Results support the study teams' hypothesis that increased anterior pelvic tilt is associated with a lower odds of RTD/RTR. Statistical analysis confirmed the correlation between an increased amount of anterior pelvic tilt and a lower odds of RTD and RTR after hip arthroscopy for FAI in active duty U.S. Army personnel. This information can be used in patient counseling to better inform shared decision-making, provide more thorough informed consent, and help determine the optimal timing for surgical intervention, thus contributing to better stewardship of medical resources and decreasing the ever-growing financial healthcare burden. These findings will spur future research to consider the causes and optimal treatment of anterior pelvic tilt, positively impacting the culture of Army medicine by focusing on preventive and targeted treatments in order to preserve and grow the force.

Talocalcaneonavicular Realignment: The Foundation for Comprehensive Reconstruction of Severe, Resistant Neurologic Cavovarus, and Equinocavovarus Foot Deformities in Children and Adolescents.

The progression of neurologic cavovarus (NCV) and equinocavovarus (NECV) foot deformities during growth can eventually lead to non-reducible severe talonavicular (TN) and subtalar (ST) joint rotational malalignments. This study aimed to describe a technique to correct severe, resistant inversion deformity of the ST joint complex as the foundational procedure in comprehensive reconstruction of multi-segmental NCV and NECV deformities in pediatric patients and to analyze mid-term radiologic, functional, and satisfaction outcomes. This prospective study included children with severe NCV and NECV foot deformities who underwent TCNR between 2019 and 2022, with a minimum follow-up of 2 years. Talocalcaneal angle, talus-1 metatarsal angles, and TN coverage angle were measured in preoperative and postoperative weight-bearing foot radiographs. The foot and ankle disability index, foot function index, and Maryland foot score evaluated functionality. Qualitative questions assessed perceived improvement, satisfaction, and expectations of patients/caregivers. Descriptive, comparative pre-post, subgroup, correlation, and satisfaction analysis were performed. Twenty-six patients (36 feet: 16 unilateral and 10 bilateral) were included; 50% were female, median age was 12.1 years (IQR, 3.21) and median follow-up was 32.9 months (IQR, 18.7). Fifty-four percent had cerebral palsy, and 23% had charcot-marie-tooth disease; 84.6% were ambulatory. Significant improvements were found in radiologic parameters and functional outcomes (P<0.01), with no relevant differences between unilateral or bilateral procedures, pathology, functional level, or ambulatory capacity (P>0.05). Correlations between radiologic parameters or functional scales with age were generally low. Most reported significant functional improvements, outcomes exceeding expectations, and high satisfaction; they would recommend the surgery and undergo the procedure again. There were 3 minor complications: hypersensitivity, partial recurrence, and undercorrection. The TCNR technique enables realignment of severe, resistant inversion deformity of the ST joint complex in NCV and NECV foot deformities. When combined with procedures to correct the other foot deformities and muscle imbalances, functional outcomes are enhanced, high patient/caregiver satisfaction is achieved, and low complication rates are possible. This approach represents an important modification and extension of an already described technique, the deep plantar-medial release. Level III, therapeutic prospective cohort study.

The Use of Diastasis to Determine Lisfranc Instability

Category: Midfoot/Forefoot; Trauma Introduction/Purpose: Lisfranc injuries have a reported incidence of 1 in 55,000 people. However, given the subtle displacement present in some of these injuries, up to one third are missed on initial diagnosis. Weightbearing imaging is the gold standard for evaluation and diagnosis of the Lisfranc complex, and diastasis between the medial cuneiform and second metatarsal (C1-M2) is the most commonly discussed parameter. However, no explicit consensus on precisely where within the Lisfranc complex to measure the diastasis has been established. Therefore, the aim of this study was to determine what specific diastasis measurement is most sensitive in diagnosing Lisfranc instability using weightbearing radiographs and computed tomography (WBCT). Methods: A total of 159 adult patients with bilateral foot WBCTs were included: 44 with confirmed Lisfranc instability and 115 controls. A subset had unilateral weightbearing X-rays (38 and 83 patients, respectively). Lisfranc instability was confirmed intraoperatively or by physical exam. Exclusion criteria were: prior midfoot surgery, Charcot arthropathy, severe midfoot arthropathy, cuneiform fractures, and significantly displaced 1st-3rd metatarsal base fractures. In the axial plane, C1-M2 diastasis was measured on weightbearing radiograph and WBCT. In the coronal plane, diastasis was measured at different levels between C1-M2 (dorsal, interosseus, plantar, planter apex) and C1-M3 (plantar apex) on WBCT. For WBCT measurements, percent difference between feet was calculated. Case and control measurements were compared with Mann-Whitney U tests (p &lt; 0.05). Diagnostic cutoffs were determined using receiver operator curves (ROC) and minimum distance to the corner. Sensitivity, specificity, negative and positive predictive values, and area under the curve were calculated for each cutoff value. Results: A significant portion of the subjects were female (Lisfranc instability: 60% and controls: 61%). Average age was 39±17 years and 44±17 years for the Lisfranc instability and control groups, respectively. Mann-Whitney U testing revealed a significant difference between groups for all measurements except plantar C1-M2 (p=0.13), C1-M2 plantar apex (p=0.69) and C1-M3 plantar apex (p=0.07). Figure 1 summarizes the diagnostic cutoff values and the associated efficacy measures. Axial WBCT diastasis was the most effective diagnostic measure, followed by dorsal coronal WBCT diastasis. Using a percent difference cutoff of 34%, axial WBCT diastasis (AUC=0.90) demonstrated outstanding diagnostic capability. Dorsal coronal WBCT diastasis with a percent difference cutoff of 46% (AUC=0.80) demonstrated excellent capability. The remaining measurements provided less reliable diagnostic capability, including diastasis on radiograph (AUC=0.77). Conclusion: Axial WBCT diastasis and dorsal coronal WBCT diastasis both effectively diagnose Lisfranc instability on WBCT, with axial WBCT diastasis demonstrating outstanding diagnostic capability. The traditional method of C1-M2 diastasis on weightbearing radiograph is not as effective as either of these WBCT measurements and only provides adequate diagnostic capability. Our results emphasize the value of diastasis measurements using bilateral WBCT imaging to diagnose Lisfranc instability. These results also suggest that diastasis measurements should be performed in the axial plane and on the dorsal aspect of the Lisfranc complex.

Changes in the Subtalar Joint Alignment after Supramalleolar Osteotomy for Varus Ankle Arthritis

Category: Ankle; Hindfoot Introduction/Purpose: The subtalar joint may compensate for tibio-talar deformity, but what would happen to the joint after the deformity was corrected is not well known. Supramalleolar osteotomy (SMOT) is an effective procedure for the treatment of varus deformity of ankle arthritis. The objective of this study was to investigate the subtalar joint alignment pre and postoperatively following SMOT, and the factors which influenced the alignment of the subtalar joint. Methods: Thirty-one patients with varus ankle arthritis (Takakura stage 2, 3a and 3b) who were treated using SMOT were retrospectively reviewed. The subtalar and ankle joint alignment was measured on weightbearing radiograph and weightbearing computerized tomography (WBCT). Results: The foot ankle offset (FAO), tibial articular surface angle (TAS), tibio-talar surface angle (TTS), subtalar vertical angle (SVA) and subtalar inclination angle (SIA) were significantly corrected (P&lt;0.05). There were 19 cases with the subtalar joints shifted medially after surgery (ΔSIA=-4.27±3.23°), and the other 12 cases with the subtalar joints moved to the lateral side (ΔSIA=2.79±1.68°). The shift of subtalar joint (ΔSIA) showed an inverse correlation with the preoperative FAO (P&lt;0.001, r=-0.621). Conclusion: The shift of subtalar joint after SMOT could maintain the neutral position of the hindfoot and showed a negative correlation with the preoperative FAO. The ΔSIA was greater in the severer preoperative hindfoot deformity. Figure 1 The varus deformation of the ankle joint was corrected by the supramalleolar osteotomy, and the increased SIA after surgery resulted in the stenosis of the lateral joint space. (A and C, preoperative; B and D, postoperative, the pre and postoperatively SIA were 3 degrees and 10 degrees; the pre and postoperatively FAO were -5.77% and -1.89%). Abbreviations: TAS, tibia articular surface angle; SIA, subtalar inclination ankle; FAO, foot ankle offset.

Radiographs Over-Estimates Joint Space Narrowing in Hallux Rigidus in Comparison to Weight-Bearing Computed Tomography

Category: Other; Bunion Introduction/Purpose: Twenty years ago, Coughlin and Shurnas proposed a clinical and radiographic classification grading scale for hallux rigidus (HR). Radiographic grading was based on weight-bearing anteroposterior and lateral conventional radiographs. Radiographic metrices include joint space width, a narrowing percentage of the dorsal joint space, and sesamoidal changes such as enlargement, irregularities, and sclerosis. Dorsal osteophytes were the main findings in all grades. The aim of this study was to compare hallux rigidus radiographic findings between conventional and weight-bearing computed tomography (WBCT). We hypothesized that radiographs overestimate joint space narrowing due to bone overlap and osteophytes. Methods: In this IRB approved study, all patients who had weight-bearing radiographs and WBCT for HR were included. Patients with previous hallux surgeries or associated severe hallux valgus were excluded. The first metatarsophalangeal joint (1st MTPJ) was measured using the summation method. (figure1) Dorsal osteophytes were measured. We measured the percentage of narrowing of the dorsal articular surface on a weight-bearing lateral/sagittal view. We evaluated the proximal phalanx (P1), first metatarsal (M1), and sesamoids (SS) for cysts. (Figure 1) All measurements were performed by two fellowship-trained orthopaedic foot and ankle surgeons. A comparison between groups was performed using the t-test or the Mann-Whitney U test according to data normality. Inter-rater reliability was evaluated using inter class correlation coefficient. Significant differences were established for p-values under 0.05. Results: The study included 21 patients; 13 were males. The average age was 55.9 ± 12.5 and the BMI was 28.9 ± 6.5. The joint space width was significantly larger on WBCT (1.9mm ± 0.44) vs. (0.92mm ± 0.53) (P &lt; 0.001). WBCT showed less narrowing of the dorsal articular surface (46.59% ± 18.8%) vs. (22.78% ± 8.71). There was no difference in the size of dorsal spurs (4.57 mm ± 1.49) vs. (4.39 mm ± 1.56) (P = 0.684). WBCT detected loose bodies in nine patients, while radiographs detected them only in six patients. Sesamoid changes were appreciated on the WBCT image of all patients. Conclusion: Radiographic parameters of the Coughlin classification of hallux rigidus are better evaluated with WBCT. WBCT showed less narrowing of the dorsal joint space as it’s not affected by the overlap of other bones. Dorsal spurs may give the false impression of joint space narrowing on radiographs. Dedicated radiographic sesamoid views (not routinely ordered) are required to study sesamoid changes. The detection of less joint space affection could potentially lead to more joint sparing surgeries.

Clinical and Radiological Outcomes of Flexible Flatfoot Correction with Calcaneal Osteotomy

Category: Midfoot/Forefoot; Hindfoot Introduction/Purpose: Various surgical procedures have been used to correct flexible flatfoot deformity; however, the most effective procedure for this deformity remains controversial. This study was performed to evaluate the radiographic and clinical effectiveness of double calcaneal osteotomy (medial displacement calcaneal osteotomy with lateral column lengthening) to correct flexible flatfoot deformities. Methods: Thirty-one patients who had 44 symptomatic flexible flatfeet and underwent double calcaneal osteotomy were examined retrospectively with a mean follow-up of 50 months. Visual analog scale, foot and ankle activity measure, and other clinical data were obtained from medical records. Various radiographic variables for assessing flatfoot and osteoarthritic change in tarsal joints were analyzed from weightbearing radiographs. Results: Results revealed that clinical scores and radiographic variables were significantly improved postoperatively. The mean values of medial sliding and lateral lengthening were 7.6 and 8.7 mm, respectively. No osteoarthritic changes were observed. Conclusion: Double calcaneal osteotomy could be used to correct flatfoot deformities effectively and sustainably and provide symptomatic relief and patient satisfaction.

The Use of AI For Hallux Valgus Assessment via Mobile Phone-Based 3D Camera Scan

Category: Bunion; Other Introduction/Purpose: Hallux valgus (HV) is a prevalent forefoot deformity that leads to pain, stiffness, and difficulties with footwear. Conventional diagnosis of HV relies on clinical and radiographic examination, which can be cumbersome and expose patients to ionizing radiation. The emergence of 3D scanning technologies, such as structured light, integrated into smartphones, presents a novel approach to early detection and diagnosis of HV, potentially allowing for earlier intervention and subsequent reduction in the progression of the deformity. Methods: This prospective non-randomized clinical trial recruited patients from the foot and ankle clinic, identifying cases and controls based on the presence or lack of clinically diagnosed HV. Patients older than 18 years of age and able to consent were included. The 3D scanning of the foot utilized structured light technology integrated into smartphones, with an algorithm developing a surrogate angle for HV detection. This angle was correlated with conventional radiographic measurements, including hallux valgus angle (HVA) and intermetatarsal angle (IMA) from weightbearing radiographs. A cluster analysis assessed the algorithm’s capacity to identify deformity severity according to radiographic severity grading. The algorithm's accuracy and performance were assessed using the area under the receiver operating characteristic curve, precision-recall Curves, and the leave-one-out cross-validation method. Results: 120 patients were enrolled in this trial. Out of 240 feet examined, HV was present in 29.1% of cases. The algorithm's surrogate angle showed a robust correlation with the clinical hallux valgus angle (HVA), with a correlation coefficient of 0.91 and a specificity of 0.882. Notably, the surrogate angle's correlation with the intermetatarsal angle (IMA) was also significant, albeit lower (r = 0.65). The area under the ROC curve (AUC) was 0.947, and the precision-recall AUC scores for positive and negative classes were 0.89 and 0.92, respectively. These metrics confirmed the algorithm's potential as a reliable diagnostic tool for detecting HV and determining its severity through non-invasive, commonly available smartphone technology. Conclusion: This study validates the accuracy of a smartphone-based 3D scanning algorithm in detecting and grading HV deformity, providing a low-cost, accessible decision-support tool for physicians and patients. This approach could improve early detection, reduce the need for clinical visits, and potentially expand to remote monitoring of HV and other pathologies, aligning with the growing trend of telemedicine and personalized healthcare.

Outcomes of Deltoid Ligament Repair in Surgically Treated Weber C Fibula Fractures with Deltoid Ligament Injury. A Retrospective Comparative Radiographic and Functional Outcomes Study

Category: Ankle; Trauma Introduction/Purpose: The indications of deltoid ligament repair in ankle injuries with widened medial clear space in the absence of medial malleolus fracture remain controversial. Many authors reported no difference in long-term functional outcomes, while others reported persistent medial clear space widening and higher malreduction when deltoid ligaments went without repair. This malreduction can lead to chronic ankle instability and pain. Talar shift as little as 1mm is reported to lead to a 49% increase in ankle joint pressure, a detrimental factor for developing post-traumatic ankle arthritis. The purpose of this study was to compare deltoid ligament repair to no repair in a homogenous group of surgically treated isolated Weber C fibula fractures exclusively. Methods: A retrospective chart review of prospectively collected data was carried out to identify consecutive surgically treated Weber C lateral malleolus fractures and syndesmosis stabilization with associated deltoid ligament injury between February 2013-December 2023. Associated posterior/medial malleolus fractures other than avulsions, Weber A/B fractures, fibula fixation constructs besides plate and screws, Charcot neuropathy, pes planovalgus with incompetent deltoid ligament, and revisions were excluded. Those meeting inclusion criteria were split into two groups: deltoid ligament suture repair vs. no repair. Collected data included demographics, smoking and diabetes status, surgical procedure and patient reported outcome measures (PROMs).. Primary outcomes were oblique medial clear space (MCS) and valgus talar tilt angle (TTA) on weightbearing radiographs. All radiographs were independently reviewed by a fellowship trained foot and ankle orthopedic surgeon. Secondary outcomes were fracture union, complications, reoperations, and PROMs: Foot and Ankle Ability Measure (FAAM), Veterans-Rand 12 (VR12) General Health Survey, visual analog pain scale (VAS). Results: Seventy-nine fractures were included; 49 underwent deltoid ligament repair while 30 did not. The mean follow-up was 18.5 months. There was a statistically significant post-op improvement in most study outcomes within the groups. The valgus TTA in the repair vs no repair groups were 0.1±0.9 vs. 1.2±2.1 degrees, respectively (p=0.007). The MCS in the repair vs. no repair groups was 3.5±0.6 vs. 3.9±1.4mm, respectively (p=0.107). There were no statistically significant differences between deltoid repair and no repair groups in post-operative VR12 MCS (p=0.194), VR12 PCS (p=0.077), VAS (p=0.231), FAAM ADL (p=0.109), FAAM sport (p=0.314), or patient satisfaction (p=0.33). The union rate was 100% in the repair vs. 96% in the no repair groups (p=0.163). There were no complications related to repairing the deltoid ligament. Conclusion: Deltoid ligament repair led to a superior ankle coronal alignment in comparison to no repair. There were no complications or revisions related to the medial approach and repairing the deltoid ligament. While there were trends toward better functional outcomes with deltoid ligament repair, this did not reach statistical significance. Long term studies may be required before recommending deltoid ligament repair as the gold standard in isolated Weber C fractures. Meanwhile, we recommend valgus stressing the ankle at the end of the procedure and decide whether deltoid repair is needed on individual basis. Outcomes of deltoid repair group vs no deltoid repair group.