OBJECTIVES:To evaluate 1) whether portable ultrasonography can evaluate syndesmotic instability in the sagittal plane, and 2) how portable ultrasound measurements compare to arthroscopic evaluation. METHODS:Eight fresh, above-knee cadaveric specimens were used. The syndesmosis was evaluated with portable ultrasound and arthroscopy in the intact state, and thereafter with progressive sectioning of, 1) anterior-inferior tibiofibular ligament (AITFL), 2) interosseous ligament (IOL), and 3) posterior-inferior tibiofibular ligament (PITFL). Sagittal plane translation was simulated with 50N and 100N of anterior to posterior (A to P) and posterior to anterior (P to A) directed force using a bone hook. Separately, a 50N manual force was applied to the fibular tip and measured with portable ultrasound to simulate a fibular "shuck test" performed in the clinical setting. Agreement between portable ultrasound and arthroscopic measurements of fibular translation was assessed using BlandAltman analysis. RESULTS:When all three syndesmotic ligaments were transected, there was a statistically significant increase in fibular motion in the sagittal plane when evaluated using portable ultrasonography with application of 50N of manual pressure and when applying a 100N hook test when measuring total sagittal plane motion (p=<0.001 and p = 0.009). Arthroscopy demonstrated a statistically significant increased motion with a 100N hook test when measuring total sagittal plane motion (p < 0.001). Bland-Altman analysis between 50N manual portable ultrasound and 100N hook arthroscopy showed a mean difference of -0.24 with 95% limits of agreement ranging from -1.58 to 1.10. CONCLUSIONS:Portable ultrasound could detect increased fibular motion in the sagittal plane after progressive syndesmotic ligamentous injury and demonstrated acceptable agreement with arthroscopy. Portable ultrasound also offers several advantages over arthroscopy, including availability, non-invasiveness, low cost, and affording contralateral comparison. The promise of this technique suggests it should be further explored as a potential future standard for the diagnostic assessment of occult syndesmotic instability in the sagittal plane. LEVEL OF EVIDENCE:Not Applicable, diagnostic cadaver study.

Background Achilles tendon rupture (ATR) requires accurate diagnosis and timely intervention to reduce complications, disabilities, and costs. ATR gap influences treatment decisions, surgical or non-surgical. This study aimed to assess the correlation between ankle angle in knee flexion at 90 degrees and ATR gap size, exploring whether this method could reliably detect ATR and estimate the tendon gap. Methods In this prospective study, 47 patients with acute ATR underwent pre-operative assessment using portable handheld ultrasound. Measurements included the tendon gap at various foot positions and ankle angles in knee flexion. Baseline patient-reported outcome measures (PROMs) were also collected. Spearman's correlation was used to analyze relationships between gap size, angle measurements, and PROMs, while receiver operating characteristic (ROC) analysis identified an optimal ankle angle threshold. Results No significant correlation emerged between tendon gap size and angle values, nor between PROMs and angle or gap measurements. However, a significant difference in plantar flexion angles was found between injured and uninjured ankles, with a median of 99.4° for injured and 110.6° for healthy sides (p < 0.001). The optimal threshold of 104.75° achieved 83% sensitivity and 78% specificity in distinguishing ATR. Conclusion Ankle angle measurement may enhance ATR screening in settings without advanced imaging. The identified threshold could assist in clinical evaluation, though further research is needed to validate its use alongside portable handheld ultrasound as an accessible, cost-effective diagnostic tool.

BACKGROUND:Social determinants of health (SDOH) have been shown to impact postoperative outcomes for several orthopaedic injuries. Understanding the role of these factors in patients sustaining Lisfranc injury can help identify disparities and target interventions to optimize recovery. METHODS:We retrospectively evaluated the influence of SDOH in postoperative outcomes of patients with Lisfranc injury aged ≥ 18 years. Social Vulnerability Index (SVI) and Area Deprivation Index (ADI) were gathered using patient ZIP codes. Patient-Reported Outcome Measures (PROMs) were collected. RESULTS:Significant differences were found in postoperative physical health (p = 0.02) and function (p = 0.03) across different races, with white patients reporting better postoperative outcomes. Furthermore, private insurance was associated with better physical (p = 0.02) and mental health (p = 0.01). Lower socioeconomic status, minority status, poorer housing/transportation, higher social vulnerability, and higher area deprivation correlated with PROMs across physical, mental, and pain domains (all p < 0.05). CONCLUSION:This study found SDOH, including race, neighborhood factors, and socioeconomic status were associated with lower PROMs in patients with Lisfranc injury, highlighting the need for stakeholders to prioritize interventions aiming to address health disparities among patients with orthopaedic injuries. LEVEL OF EVIDENCE:III.

Purpose: Dorsal closing wedge calcaneal osteotomy (DCWCO) is purported to enhance both the biological and mechanical aspects of insertional Achilles tendinopathy (IAT) by altering its insertional anatomy. The biomechanical impacts of shifting the Achilles insertion, however, are not fully understood. This study aimed to analyze the effect of DCWCO on hindfoot alignment and gastrocnemius-soleus (G-S) power. Methods: Six weightbearing ankle CTs of patients diagnosed with IAT were segmented and standardized planes were used to conduct DCWCOs with six variations, resulting in a total of 42-foot models including the 6 preoperative original model. Two distinct representations of plantar osteotomy starting points were defined. One was 1 cm anterior to plantar calcaneal tubercle (posterior osteotomy) and the other was 2 cm anterior (anterior osteotomy). The osteotomies were extended to 1 cm anterior of posterosuperior calcaneal tuberosity with 6-, 10-, or 14-mm dorsal wedges. Pre-defined Achilles insertion points were used to create computational Achilles tendon models. Multiple automated measurements were performed to calculate the change in foot alignment and biomechanics. Results: Both anterior and posterior osteotomy locations resulted in decreased lateral talocalcaneal and calcaneal pitch angles, more substantially so with the anterior osteotomy (p = 0.028). Distance change between Achilles and Haglund was much greater with posterior osteotomy using 6- and 10-mm wedges as compared to the anterior alternative (p = 0.028). Anterior osteotomy caused a significant decrease in the B & ouml;hler angle (p < 0.001). The subtalar joint orientation was observed to change up to 3.8 degrees in anterior osteotomy and the decrease in G-S power was found to be a maximum of 2-3 %. Conclusion: A posteriorly placed starting point can provide more Achilles decompression while an anteriorly placed starting point can affect foot alignment more significantly. DCWCO can change the subtalar joint orientation predisposing the joint to increased loads. Decrease in G-S power was low and will presumably not have clinical impact. (c) 2024 European Foot and Ankle Society. Published by Elsevier Ltd. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

Background: Today women are more than 50% of medical school matriculants but remain underrepresented in orthopaedic surgery. Moreover, the rate of female orthopaedic subspecialty society membership and representation among meeting speakers is believed to be low. The objective of this study was to assess whether a gap exists in female representation among invited speakers at American Orthopaedic Foot & Ankle Society (AOFAS) national meetings relative to research productivity, as reflected by authorship in Foot and Ankle International (FAI). Methods: Programs for AOFAS national meetings and FAI articles between January 2012 and December 2022 were retrospectively analyzed. Sex was identified through personal acquaintance or online biographies. Presentations and articles were categorized as “technical” or “nontechnical,” where technical was defined as relating to preclinical or clinical practice. The chi-square test was used for comparisons ( P < 0.05). Results: One thousand twenty AOFAS talks and 2,230 FAI articles were analyzed. 11.08% of AOFAS invited speakers, 15.16% of FAI first authors, and 7.40% of FAI senior authors were women. In 2018 and 2019, women were more likely to give “nontechnical” AOFAS presentations ( P = 0.003). The average annual trend was +2.00% female AOFAS presenters and +0.31% FAI female first authors per year. FAI female senior authorship had an average annual decrease of −0.37%. Discussion: Women represented 15.16% of first authors in FAI between 2012 and 2022 and 11.08% of invited speakers at AOFAS meetings. Meanwhile, the percentage of women in AOFAS increased from 7.5% to 13%. Although female foot and ankle surgeons have been historically underrepresented in the field, they were proportionally represented in 2021 and 2022 among invited national conference presentations and first author research compared with society membership. There remains room to increase representation of deserving groups; however, the proportion of female AOFAS presenters demonstrates a positive trend. Level of Evidence: Level III

BACKGROUND:The talus plays a central role in understanding the pathophysiology and natural history of clubfoot deformity. The morphology, severity, natural history, and functional implications of talar dysplasia in patients with clubfoot are poorly understood. Flat-top talus is a common finding in patients with a history of clubfoot that can lead to limited ankle dorsiflexion and painful anterior ankle impingement. The aim of this review was to assess the morphological differences between clubfoot and non-clubfoot tali. METHODS:We performed a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE/PubMed, Embase, and Scopus for articles reporting on talar morphology in patients with clubfoot. Our primary outcomes collected were demographic data of included patients and variables describing talar morphology. RESULTS:The clubfoot talus is dysplastic in multiple dimensions. The prevalence of talar flattening appears to increase in early life and stabilizes during childhood. Differences in talar length and transverse talar neck angle between clubfoot and nonclubfoot tali virtually disappear by adolescence. The current literature suggests that differences in talar morphology in patients with clubfoot are both of an innate and an acquired nature. Despite the lack of longitudinal studies, some studies show a potential correlation between the presence or development of a flat-top talus and increased clubfoot severity. CONCLUSION:Talar dysplasia in patients with clubfoot, including flat-top talus, remains poorly understood, and further studies are necessary to inform treatment guidelines for flat-top talus. LEVEL OF EVIDENCE:Level IV. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND:Weightbearing computed tomography (WBCT) provides a dynamic evaluation through the comparison of the injured foot with the uninjured contralateral side under physiologic weight. This study aims to determine 3D WBCT Lisfranc variations among healthy individuals and determine WBCT measurement cutoff values to determine Lisfranc instability. METHODS:In this retrospective study, 222 adult patients with bilateral foot WBCT were included: 32 cases (with Lisfranc instability) and 190 controls (with no current or prior midfoot injuries). Lisfranc complex WBCT volume (mm3), axial area (mm2), and diastasis (mm) across the medial cuneiform (C1) and second metatarsal (M2) were measured for both groups. The percentage difference between the injured and uninjured sides for each measurement was calculated for each patient. Cutoff values were determined using area under the receiver operator curve (AUC). RESULTS:Demographic data had no association with the percentage difference of all 3 measurements. There were significant differences between cases and controls for all 3 WBCT measurements (P < .001). The cutoff values were found to be 20%, 26%, and 34%, for volume, area, and diastasis, respectively. Diastasis resulted in the greatest area under the curve (AUC = 0.905) and a corresponding sensitivity and specificity of 0.813 and 0.900, respectively. CONCLUSION:In our study, we found a median physiologic difference of up to 12% between contralateral feet of healthy individuals. In the Lisfranc cohort, the median percentage difference was ≥32% across measurements; receiver operating characteristic analysis identified diagnostic cutoffs of 20% (volume), 26% (area), and 34% (diastasis). Therefore, measurements in the intermediate zone between 12% and 32% may warrant further assessment to prevent misdiagnosis and further morbidity. Between volume, area, and diastasis, diastasis showed the highest diagnostic performance (AUC = 0.90) for isolated Lisfranc instability.

The aim of this article is to provide a narrative review on the diagnosis of syndesmotic instability. For diagnosing syndesmotic instability, clinical evaluation remains the mainstay in the diagnosis. When there is suspicion of syndesmosis injury based on the mechanism of injury and clinical examination, further diagnostic imaging studies need to be performed. To determine if there is injury to the (anterior) syndesmosis, static ultrasound or MRI are useful diagnostic tools. However, to determine the stability of the syndesmosis, a dynamic assessment technique should be used. Current potential options are dynamic ultrasound, weight-bearing CT scan, and Arthroscopy. Each assessment technique has important advantages and disadvantages that need to be considered before choosing the diagnostic techniques of choice. Conventional radiography should be performed to rule out a concomitant ankle fracture, but stress radiography is not a reliable assessment technique to adequately detect syndesmotic instability and should therefore not be used as such.Level of Evidence:Level V.

BACKGROUND:Chronic Achilles tendon ruptures (CATRs) present significant challenges because of delayed diagnosis and more complicated salvage treatments that can result in unfavorable outcomes and increased rates of adverse events. Various reconstructive surgical options have been described, each with its own unique advantages and disadvantages. Comprehensive comparison of these techniques, however, is lacking. This meta-analysis aimed to compare clinical outcomes following 3 of the most commonly used salvage techniques including flexor hallucis longus (FHL) transfer, hamstring transfer, and gastric-soleal turndown flap. METHODS:This systematic review adhered to PRISMA guidelines and included studies registered on PROSPERO. Searches were conducted across multiple databases, and eligibility criteria encompassed studies reporting on clinical scores and complications following surgical treatment of CATRs with FHL transfer, hamstring tendon transfer, or turndown flaps. Data extraction, quality assessment, and statistical analyses were performed following standardized protocols. RESULTS:Among 1910 identified studies, 25 met inclusion criteria with 11 focusing on FHL transfer, 9 on hamstring tendon transfer, and 6 on turndown flap management. A meta-analysis revealed variations in patient demographics, surgical techniques, and rehabilitation protocols across the 3 intervention groups. Although the mean improvement in American Orthopaedic Foot & Ankle Society scores was comparable (38.9 for turndown flap, 31.8 for FHL transfer, and 26.0 for hamstring transfer), complication rates differed significantly. The turndown flap group exhibited the highest overall complication rate, particularly because of wound-related complications, with a wound complication rate of 12.5%, compared with 5.7% for FHL transfer and 3.5% for hamstring transfer. CONCLUSION:This study underscores the challenge of evidence-based decision making in the surgical management of CATRs. Despite apparently similar functional outcomes, the choice of open surgical technique affects complication rates. Turndown flaps, although effective in restoring musculotendinous continuity, carry higher risks of wound complications compared with the other techniques evaluated.

Background Recent deep learning (DL) techniques have demonstrated multiple breakthroughs in improving the detection of musculoskeletal pathologies through clinical imaging. Weightbearing CT (WBCT) has been shown to improve diagnostic accuracy in Lisfranc instability, particularly when it is subtle. The aim of the present study was to investigate the impact of applying DL algorithms on WBCT images for the diagnosis of isolated Lisfranc instability. Methods The WBCT scans of 280 patients were evaluated (140 cases who had isolated Lisfranc instability, 140 controls without any foot injuries). The entire data set in each group was divided into the training set, validation set, and test set with an 80:10:10 split ratio, in a random manner. Three DL models were developed: (1) a 3D convolutional neural network (3D-CNN); (2) a CNN with long short-term memory (LSTM); and (3) a differential CNN-LSTM. After training, the models' performance was assessed by means of sensitivity, specificity, accuracy, F1-score, and the area under the receiver operating characteristic (ROC) curve. Results The case group included 41% males, and the control group 43%. Mean age and BMI were 35.7 and 26.6, respectively, in the case group, and 32.6 and 27.1 in controls. No significant baseline differences were found. Model 1 had an F1-score of 0.72, while Models 2 and 3 demonstrated substantially higher F1-scores of 0.92 and 0.99, respectively. Conclusion This study developed a DL model for 3D WBCT-based Lisfranc injury detection with excellent accuracy. The findings suggest that DL integration has the potential to improve diagnostic accuracy. Further research should focus on larger datasets and external validation.

Destabilizing injuries to the deltoid ligament have relied on radiographic stress examination for diagnosis, with a focus on medial clear space widening. Increasingly, Portable ultrasound has also been used in the clinical setting, allowing dynamic and non-invasive evaluation at the point of care. The aim of this study was to determine whether portable ultrasound can detect medial sided instability associated with supination-external rotation type ankle injuries during the gravity stress, weightbearing, and external rotation stress. Ten fresh-frozen cadaveric ankles were used in this study. Assessment of medial clear space distances with portable ultrasound was first performed with all structures intact, and later with sequential transection of the anterior inferior tibiofibular ligament (Stage I), Weber B fibular fracture (Stage II), posterior inferior tibiofibular ligament (Stage III), superficial deltoid ligament (Stage IVa), and the deep deltoid ligament (Stage IVb). In all scenarios, four loading conditions were considered; (1) a gravity stress test with the ankle positioned in a neutral position; (2) a gravity stress test with the ankle positioned in a plantarflexed position; (3) an external rotation stress test; and (4) simulated weightbearing condition. Among all four loading conditions, all medial clear space values increased as the supination-external rotation ankle injury stage progressed (Spearman’s rank correlation ranged from 0.43 to 0.90, P <.001). The medial clear space values measured with the portable ultrasound during; (1) gravity stress test in neutral ankle position, (2) gravity stress test in plantarflexed ankle position, (3) weightbearing, and (4) external rotation stress test were significantly increased between intact stage vs. stage IVb (P =.036), as well as between stage III vs. IVb (P ranged from 0.015 to 0.047). Portable ultrasonography is a feasible tool for diagnosing medial ankle instability in supination-external rotation ankle injury. The medial clear space measurements assessed with portable ultrasound during the gravity stress test, weightbearing, and the external rotation stress test well correlated with the supination-external rotation ankle injury staging. Besides, the portable ultrasound method can differentiate the supination-external rotation ankle injury stage IVb from the intact stage, as well as differentiating the supination-external rotation ankle fracture without deltoid ligament injury (III) from the supination-external rotation stage with complete deltoid ligament injury (IVb).

BACKGROUND:Midsubstance Achilles tendon repair is a common procedure, yet the factors influencing its cost have been underexamined and often imprecisely understood. Using time-driven activity-based costing (TDABC), we examined variation in total cost, compared patient-, surgeon-, and surgery-specific characteristics between high- and non-high-cost repairs, and assessed factors associated with total cost to identify specific cost drivers that might reduce expenses without compromising clinical outcomes. METHODS:Patients undergoing midsubstance Achilles tendon rupture repair between January 3, 2022 and December 28, 2023 at 2 academic medical centers and their affiliated community hospitals and ambulatory surgical centers were identified. Exclusion criteria included revision procedures and those with concurrent procedures besides fasciotomy. TDABC methodology was used to determine total cost across 3 clinical phases: preoperative, intraoperative, and postoperative. Cost was normalized per institution requirements. Bivariate analysis was performed across all characteristics between high-cost (top decile) procedures and all others. Spearman correlation between operative time and total cost was assessed. Multivariable linear regression was used to identify key cost drivers. RESULTS:Among 341 primary midsubstance Achilles rupture repairs performed by 8 surgeons, the most expensive procedure was 6 times costlier than the least expensive one. Eighty-five percent of the cost, on average, was incurred intraoperatively. A "good" correlation was found between operative time and total cost (P < .05). When accounting for covariates, increasing time between rupture and repair was associated with higher cost (P < .05). Surgical location, surgical approach, and repair suture were also associated with total cost (P < .05). CONCLUSION:Substantial variability in the cost of primary midsubstance Achilles rupture repair is driven by factors including timing of surgical repair, intraoperative surgeon-specific characteristics (ie, surgical approach and suture choice), and surgical location. Further standardization of treatment approach and decreasing time to the operating room could lower cost variability and improve the value of care for patients with midsubstance Achilles tendon rupture undergoing surgery.

Category: Ankle; Sports Introduction/Purpose: Syndesmotic injuries may be associated with subsequent instability, even following operative fixation of etiologic fractures. The development of advanced imaging techniques like weightbearing computed tomography (WBCT) has enabled clinicians to identify subtle syndesmotic instability under physiologic conditions that would otherwise go undetected using conventional CT scans. Moreover, the normal reference ranges for the syndesmotic interval distance, area at 1 cm above the plafond, and volume 5 cm above the plafond have been established. These measurements, however, may be cumbersome and time-consuming to perform. This validation study aims to develop and evaluate the reliability of an automated algorithm that automatically segments WBCTs of the ankle and performs dimensional measurements. Methods: Five bilateral WBCT scans of individuals with operatively confirmed syndesmotic instability were included (10 ankles). An independent observer manually performed the anterior tibiofibular distance (ATFD) at 1 cm above the plafond, posterior talofibular distance (PTFD) at 1 cm above the plafond, the syndesmotic area (SA) at 1 cm above the plafond using 2D ROI, and the syndesmotic volume (SV) at 5 cm above the plafond using 3D ROI. Visage software was used to perform the measurements manually. The same WBCT scans were fed into the automated algorithm to perform the same measurements. The time required to perform the manual and automated measurements was recorded for comparison. The intraclass correlation coefficient (ICC) was measured for repeated automated measurements to evaluate the automation's consistency Results: The manual measurements required 19 (+/-4) minutes on average to perform for each case compared to 9 (+/-1) minutes for the automated measurements (P< 0.05). The ICC between the repeated automated measurements for each case was 0.99. Conclusion: Our automated syndesmosis dimension measurement tool can efficiently perform the ATFD, PTFD, SA, and SV measurements as reliably as an expert clinician would with significantly less time. Incorporating such a tool into existing healthcare software infrastructure, particularly in foot and ankle clinics, may expand the accessibility of this tool and provide immediate data for clinicians to support their decision-making in real time.

Category: Midfoot/Forefoot; Trauma Introduction/Purpose: The diagnosis of fractures can be challenging in specific medical settings due to limited expertise or time. While deep learning has shown promising results, its use is confined to the quality of images and the hassle of importing images to the models. This study aims to develop a model to detect fifth metatarsal fractures based on cell phone photos of radiographs directly taken from a regular screen. Methods: retrospective case-control study was conducted including patients aged > 18 years with fifth metatarsal fractures (n=1240) (Fx), and healthy controls (n=1224) (NoF). Three view radiographs (anterior, posterior, and lateral) were obtained from the Electronic Health Record (EHR) in PNG format. To generate a mixed-quality dataset, Android and iOS smartphones (SP) were used to create two separate datasets for each Fx and NoF group. Two separate deep learning models on each EHR, SP, and combined datasets were developed using Inception V3 architecture (Figure 1.). The models were also tested on a separate SP dataset (SP-test) that was not included in the development process. Area Under the Receiver Operating Characteristics Curve (AUC) along with other performance metrics were calculated and reported. Continuous data were presented as median (interquartile range), and a p-value of < 0.05 was considered to be significant. Results: Baseline analysis revealed differences between the groups with a median age of 56 years (36-68) for the Fx group, and 62 years (51-72) for the NoF group (p < 0.001). Similarly, the racial composition of the groups was also different (Fx: 84.8% white; NoF: 92.2% white; p < 0.001). Initially, the SP model showed the best performance (Youden Index (YI): 0.92, AUC: 0.99) followed by the EHR (YI: 0.74, AUC: 0.96), and combined (YI: 0.52, AUC: 0.97) models. When tested on the SP-test dataset the EHR model’s performance dropped markedly showing a YI of 0.33, an AUC of 0.78, and a sensitivity of 0.49 (Table 1.). However, the SP and combined models continued to perform optimally (YI: 0.94, AUC: 0.99; YI: 0.78, AUC: 0.98, respectively). Conclusion: This study highlights the crucial role of image quality in developing deep learning models for detecting fifth metatarsal fractures. Our findings demonstrate a markedly reduced performance of the EHR model in identifying fractures within lower-quality images. This emphasizes the need for training algorithms on images of varying quality to create more generalizable models capable of operating effectively across diverse settings.

BACKGROUND:Identifying factors that correlate with the incidence of venous thromboembolism (VTE) has the potential to improve VTE prevention and positively influence decision-making regarding prophylaxis. In this study, we aimed to investigate the correlation between statin consumption and the incidence of VTE in patients who sustained an ankle fracture. METHODS:In this retrospective, case-controlled study, cases were those who developed VTE and controls were those who had no VTE, and the ratio was 1:4. Patients' demographics, history of hyperlipidemia, and reported statins use were obtained. A random forest classifier (RFC) model was used to predict whether statin consumers were at risk of VTE after ankle fracture regardless of VTE prophylaxis administration based on statin consumption, body mass index (BMI), age, and biological sex. RESULTS:Of the 1175 patients with ankle fractures, 238 had confirmed VTE (case group), and 937 had no symptomatic VTE (control group; ratio 1:4). Fifty (21%) cases and 407 (43%) controls were on a statin. Statin users had a significantly lower incidence of VTE after ankle fracture, odds ratio (OR) = 0.35, 95% CI: 0.25, 0.49, P < .001. Our model showed an area under the receiving operator curve (AUROC) of 78%, a sensitivity of 73%, and a specificity of 83% in predicting the risk of VTE. The importance of the predictors of VTE, other than the use of statins (model importance = 0.1), were age (model importance of 0.72), BMI (model importance of 0.24), and biological sex (model importance of 0.02). CONCLUSION:Statins were significantly associated with a lower rate of VTE in our population of patients who sustained an ankle fracture. LEVELS OF EVIDENCE:3.

Category: Trauma; Ankle Introduction/Purpose: Weber-B ankle fractures represent an increasingly common injury world-wide, and the decision for operative fixation often hinges on the stability and congruency of the ankle. While tibiotalar displacement is typically evaluated using the medial clear space on plain radiographs, this method remains prone to inaccuracy because of x-ray beam rotation and manual measurement errors. Furthermore, the influence of these fractures on the mechanical environment of the ankle remains unknown. The recent advent of weightbearing cone-beam CT (WBCT) overcomes these drawbacks by imaging during bipedal stance, allowing a 3D anatomical and mechanical analysis. Therefore, the aim of this study was to analyze the 3D mortise displacement and contact mechanics in weber B ankle fractures by use of WBCT in comparison to their healthy contralateral side. Methods: In this retrospective study, our ankle trauma database was searched for Weber-B ankle fractures imaged by bilateral WBCT imaging between 2015 and 2022. Exclusion criteria consisted of metal or motion artifacts, presence of ankle osteoarthritis, and an age less than 18 years or more than 75 years. Segmentation into 3D models of bone was performed semi-automatically, while personalized cartilage layers were modeled based on a previously validated methodology. Bilateral ankle models were imported in custom-made Matlab® script for an automated anatomical and mechanical analysis. 3D mortise congruency was evaluated by use of following parameters: fibular length, talocrural angle, distance mapping of the medial gutter and tibiofibular clear space distance mapping. Contact mechanics were evaluated by the mean and maximum contact stress of the tibia and talus, as well as the contact area (Figure 1). A student’s T-test was performed to investigate the difference between the fractured and healthy side. Results: Thirty-two patients, with mean age 38.50 years (SD = 15.81 ) and weight 79.12 kg (SD = 16,24), were confirmed eligible for analysis. Statistical analysis revealed that there were no significant differences for all anatomical parameters (P > 0.05). The mean contact stress of the fractured and healthy side was 2.10 (SD = 0.42) MPa and 2.10 (SD = 0,41) MPa, respectively, whereas the maximum stress was 7.67 MPa (SD = 1.55) and 7,47 MPa (SD = 1,67), respectively. No statistical significant differences were found between all mechanical parameters (P > 0.05). Conclusion: This study demonstrates that contact mechanics are not affected in Weber-B fractures with a congruent mortise. Therefore, non-operative treatment could be considered, as there will theoretically be no increased risk for the patients to develop posttraumatic osteoarthritis in the long term. In clinical practice, WBCT could prove useful to determine the 3D anatomical and mechanical environment of ankle fractures and guide patients towards (non-) operative treatment. However, further studies should focus on the minimal clinical important difference/rehabilitation factors associated with mortise malalignment based on concomitant contact stress increase, which would warrant and identify which cases need surgical reduction.

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.

Category: Sports; Hindfoot Introduction/Purpose: While patient comorbidities are known to affect surgical complication rates after Achilles tendon rupture (ATR) repair, the correlation between social determinants of health (SDH) and postoperative complication rates is poorly understood. Two validated indices representative of SDH include the Area Deprivation Index (ADI), which ranks neighborhoods by social disadvantage, and the Social Vulnerability Index (SVI), which uses 16 US census variables to identify communities at risk before or after natural disasters. In this study, we aim to determine whether there is any correlation between patient demographics, SDH, and postoperative complication rates following surgical treatment of ATR. Methods: A retrospective chart review identified 521 patients who underwent surgical repair of an acute ATR between 2015 and 2021. Inclusion criteria included age ≥ 18 years, a minimum 30 day follow up, and patients who underwent acute repair within 28 days of ATR. Collected variables included patient demographics, time to surgery (TTS), injury characteristics, and postoperative complications sub-categorized into venous thromboembolism (VTE), re-rupture, surgical site infection (SSI), wound dehiscence, and sural nerve injury. SDH variables included age, race, smoking status, insurance status, level of education, and employment status. The ADI and SVI measurements of patient deprivation or vulnerability were also extracted from the data. A univariate regression test was performed to determine the correlation between each complication and each SDH indicator. Variables that showed significance (p < 0.05) were then included in a multivariate regression to determine the correlation coefficients and significance. Results: Sixty-eight complications occurred in 59 patients (11.3%). Multivariate regression showed higher ADI was associated with VTE occurrence (OR = 0.39, 95% CI: 0.16 –0.91, p = 0.03). Female patients and open surgical approach correlated with decreased VTE occurrence (OR = 0.24, 95% CI: 0.09 – 0.66, p< 0.01), (OR = 0.15, 95% CI: 0.04 – 0.55, p< 0.01), respectively. Higher BMI was associated with VTE (OR = 1.62, 95% CI: 1.05 – 2.51, p=0.03) and re-rupture (OR = 3.86, 95% CI: 1.51 – 9.08, p< 0.01). Women experienced decreased wound dehiscence rates (OR = 0.25, 95% CI: 0.09 – 0.69, p< 0.01) and SSI (OR = 0.31, 95% CI: 0.11 – 0.93, p=0.04) compared to men. TTS correlated with sural nerve injuries (OR=2.09, 95% CI: 1.32 – 3.31, p< 0.01). Conclusion: This study found that SDH, such as ADI, impacts complication rates after ATR repair, though the nature of this relationship remains unclear. Patient demographic and anthropometric factors such as gender and BMI also have an impact. Future studies should include a larger, more diverse sample population to better understand the impact of these factors on surgical outcomes.

BackgroundIntra-articular injections are commonly used to manage joint pathologies, including osteoarthritis. While conventional ultrasound (US) guidance has generally improved intra-articular injection accuracy, forefoot and midfoot joint interventions are still often performed without imaging guidance. This pilot study aims to evaluate the efficacy of office-based, portable ultrasound (P-US) guided intra-articular injections for forefoot and midfoot joint pain caused by various degenerative pathologies.MethodsA retrospective analysis was conducted on a series of consecutive patients who underwent P-US guided intra-articular injections following a chief complaint of forefoot or midfoot joint pain. Patients reported their pain levels using the Visual Analog Scale (VAS) pre-injection and at 3 months follow-up. The procedure was performed by an experienced foot and ankle surgeon using a linear array transducer for guidance, and a 25-gauge needle was used to inject a combination of 2 cc 1% lidocaine and 12 cc of Kenalog (40 mg/ml). Complications and pain scores were analyzed using a paired t-test and p < 0.05 was considered significant.ResultsWe included 16 patients, 31% male and 69% female with a mean age (±SD) of 61.31 (±12.04) years. None of the patients experienced immediate complications following the intervention. The mean pre-injection VAS score was significantly reduced from 5.21 (±2.04) to a mean of 0.50 (±1.32) at 3 months follow-up (P < 0.001). Thirteen patients reported complete resolution of pain at the 3-month follow-up. No adverse events were reported throughout the duration of the study.ConclusionThis pilot study suggests P-US-guided intra-articular injections offer a safe and effective method for managing forefoot and midfoot joint pain caused by various arthritic pathologies. Further research is warranted to establish the long-term efficacy and comparative effectiveness of P-US-guided injections in larger patient cohorts as compared to non-image guided injections.

Background: Weight-bearing CT (WBCT) 3D volumetric measurement has shown promising accuracy for the diagnosis of syndesmotic instability. However, these measurements are rather complex and timeconsuming, rendering them a clinically unfavorable option. We hypothesized that automatized measurements would be more accurate and time-efficient than manual ones. Methods: Thirty cases of intraoperatively confirmed syndesmotic instability along with thirty individuals with no injuries to the ankle joint were recruited as cases and controls, retrospectively. Two observers conducted the manual volumetric measurements two times, at a one-week interval. An automated algorithm for 3D WBCT measurements was developed to conduct the measurements on the axial images. The time spent on each method was recorded. Mann-Whitney U test was used to compare the values between human raters and computers. Inter- and intra-class reliability were calculated. Results: The intra-class correlation coefficient was found to be "excellent" for the automated measurements (0.97) and "good" for the observers (0.75). Similarly, the Cronbach's alpha was shown to be higher for the computer (0.88) than the observers (0.60 and 0.62). The mean time spent on the measurements was different between human raters and the computer-assisted method (p < 0.001). Conclusion: Automated volumetric assessment of syndesmosis seems to be a faster and more reliable option than the manual one. We suggest future larger-scale prospective studies conducted under actual clinical circumstances for more definitive conclusions. Level of evidence: Retrospective case-control study - Level 3 (c) 2024 Published by Elsevier Ltd on behalf of European Foot and Ankle Society.