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Background: Tibiofibula fractures occur across all age groups, and postoperative complications are frequent. An accurate and rapid classification methodology for these fractures could significantly assist physicians. Clinically, tibiofibula fractures occur at various locations, and the fracture types are not evenly distributed. Methods: This paper presents a deep learning model for the interpretable multi-label classification of tibiofibula fractures in two-dimensional (2D) CT scan images, addressing the challenges posed by a limited sample size and an uneven distribution of fracture types. We retrospectively collected 2494 2D CT images from 168 patients with tibia or fibula fractures. The types of fractures identified in the CT scan images were classified according to the AO/OTA fracture classification. A deep learning model was developed to classify composite fractures in 2D CT images, providing visual interpretation for each identified class. The visual interpretation was given with the saliency maps constructed by the Grad-CAM++ method. The deep learning model was trained using data augmentation techniques to address class imbalance and the limited dataset size. Results: Our experiments demonstrated that the proposed model achieved a mean average precision (mAP) of 95.71%. Conclusions: The saliency map-based visual interpretation enables the verification of whether the model provides reliable decision-making for classification. [ABSTRACT FROM AUTHOR]

Category: Sports; Hindfoot Introduction/Purpose: Delays in diagnosis or treatment of acute Achilles tendon rupture are relatively frequent either due to the injury being misdiagnosed or the patient disregarding its severity. In the delayed presentation of Achilles tendon rupture, open repair is generally recommended for mobilization of the adherent and retracted tendons from the thickened paratenon layer repair although this introduces the risk of wound complications. Although a minimally invasive technique for acute Achilles tendon rupture has demonstrated lower infection rates, with functional results equivalent to those of open repair, their use in patients presenting in a delayed fashion has not been thoroughly investigated. The objective of this study is to compare the outcomes of percutaneous and open repair in cases of delayed presentation of acute Achilles tendon rupture. Methods: This was a retrospective study of prospectively collected data on consecutive patients who underwent either percutaneous or open repair for delayed presentation of Achilles tendon rupture and were followed up for at least one year. Delayed Achilles tendon rupture was defined as if patients underwent surgery 14 to 30 days after the injury and had received no treatment before surgery. The percutaneous repair was a modified Bunnell suture with an additional incision enough to permit mobilization of the tendon ends and core suture. An identical postoperative rehabilitation protocol was implemented in both groups: with below-knee cast in maximum plantarflexion, full weightbearing on the metatarsal heads was immediately allowed as tolerated. Postoperatively, the AT Resting Angle (ATRA), patient-reported functional outcomes using the AT Rupture Score (ATRS), and Calf circumference difference were evaluated. Postoperative complications, including re-rupture, wound infection, and sural nerve injury, were assessed. Results: There were no significant differences in demographic data between the percutaneous repair group (N =23) and the open repair group (N =23). The elapsed time from injury to surgical treatment and the gap between the proximal and distal stumps assessed on the MRI between the groups were similar. there were no statistically significant differences observed in ATRA (-2.9 ± 1.8 vs -2.1 ± 1.7, p = 0.687), ATRS (92.2 ± 2.5 vs 93.1 ± 2.6, p = 0.814), or calf circumference difference. Additionally, there were no cases of re-rupture in either group. A deep wound infection occurred in one patient in the open repair group. Symptoms related to sural nerve injury were observed in two patients in the percutaneous repair group, which resolved with conservative treatment. Conclusion: In cases of delayed presentation of Achilles tendon rupture, the percutaneous tendon repair technique is considered to yield comparable outcomes to the open tendon repair technique. [ABSTRACT FROM AUTHOR]

Category: Bunion; Other Introduction/Purpose: Hallux valgus is known to be more prevalent and present with greater severity in the elderly population compared to the younger age group. However, surgical treatment of hallux valgus in the elderly carries a risk of suboptimal results owing to porotic bone quality and multiple comorbidities typical of this age group. Although the third-generation minimally invasive Chevron and Akin osteotomy (MICA) technique, which features minimal soft tissue disruption and rigid internal fixation, may be an attractive option for surgical treatment of hallux valgus in the elderly, its outcomes have not been thoroughly investigated. This study sought to compare the outcomes of third-generation MICA procedures in patients aged 65 and older with those in the cohort under 65 years of age. Methods: In this retrospective cohort study, 76 patients (79 feet) who underwent the third generation MICA procedure for hallux valgus and were followed up for at least 1 year were stratified into 2 groups: ≥65 years old (Group 1: 36 feet) and < 65 years old (Group 2: 40 feet). Radiographic assessments included HV angle (HVA), intermetatarsal angle (IMA) and distal metatarsal articular angle (DMAA). Clinical assessment included the American Orthopaedic Foot & Ankle Society (AOFAS) score, pain visual analog scale (VAS), and patient satisfaction rating. Postoperative complications, including recurrence of the deformity, reduction loss and reoperation, were assessed. Results: The average age at the time of surgery in group 1 was 70.9 ± 5.8 (range 65~90) years, and in group 2, 50.2 ± 2.8 (range 21~ 63), respectively. In the elderly group, Bone Mineral Density (BMD) was measured -2.9. The mean HVA, IMA and DMAA significantly improved at the final follow-up in both groups, respectively (all P <.001). Both preoperative and postoperative HVA were significantly greater in group 1 (both, P <.001), and the change of this parameter after surgery was also lower in group 1 than in group 2 (P <.001). There were significantly higher rates of reduction loss (16% vs 2.5%) and recurrence (11.1% vs 0.5%). However, clinical scores and patient satisfaction rates did not differ significantly. Conclusion: The present study demonstrates that chronological age, specifically categorized as 65 years or older, exhibits no substantial influence on the clinical outcomes following third-generation MICA surgery. Nevertheless, it is imperative to adequately apprise patients of the potential for reduction loss and recurrence, possibly due to age-associated bone fragility. [ABSTRACT FROM AUTHOR]

Category: Ankle Arthritis; Sports Introduction/Purpose: Repetitive ankle sprains can cause various intra-articular pathologies, and there is a relatively clear consensus on the relationship between chronic ankle instability and osteoarthritis. However, information on the natural course in patients with chronic ankle instability and treatment options for preventing degenerative changes remain limited. This study aimed to compare the intermediate-term prognoses between patients with surgical and non-surgical treatment. Methods: This study included 44 patients who underwent lateral stabilization procedure (anatomical ligament repair or reconstruction) and 62 patients with conservative treatment for chronic ankle instability conjunction with early-stage arthritis of Takakura grade 2. Daily living and sport activities were evaluated using the Foot and Ankle Ability Measure (FAAM). Progression of osteoarthritis was evaluated through periodic weight-bearing radiographs. Additionally, the correlation between clinical evaluation score and the presence of progressive osteoarthritis was analyzed. Results: The FAAM score significantly improved from a mean of 48.8 points preoperatively to 83.6 points at final follow-up (p <.001) in the surgical group, while it also improved in the non-surgical group from a mean of 65.9 points to 74.1 points (p = 0.188). There was no significant difference in daily living ability of the FAAM score between the two groups at final follow-up (88.6 vs 81.4 points, p = 0.385), but the surgical group showed better results than the non-surgical group in sports ability (79.4 vs. 67.3 points, p <.001). The incidence of progression of osteoarthritis grade was not significantly different between surgery group (15.9%) and non-surgical group (17.7%) (p = 0.861). Conclusion: Patients with early medial osteoarthritis accompanied by chronic lateral ankle instability who underwent surgical and non-surgical treatment showed similar intermediate-term clinical outcomes. However, in terms of sports activity ability, the surgical group showed superior results compared to the non-surgical group. The radiological prognosis based on the Takakura grade of degenerative arthritis also showed similar results in both groups. There was a significant difference in clinical evaluation scores between patients with and without progressive osteoarthritis. [ABSTRACT FROM AUTHOR]

Introduction: Traditionally, partially threaded cancellous lag screws (PTCS) are used for most medial malleolar fractures but are often challenging to execute in elderly patients because of the high risk of postoperative complications. Limited literature explores whether hook-type locking compression plates (LCPs) reliably offer better outcomes than PTCS in elderly patients. We aimed to compare the midterm radiologic and clinical outcomes between hook-type LCP and PTCS for medial malleolar fractures in an elderly population. Methods: We included 258 patients, aged 65 years and above, treated with either a hook-type locking plate (hook LCP group: 121 patients) or PTCS (screw group: 137 patients), and with follow-ups of at least 36 months in this retrospective study. Radiographic assessments included the union rate and interval to fracture union. Clinical assessment included the postoperative complications and revision procedures. Results: Although a significantly higher rate of comminuted fractures was observed in the hook LCP group than in the screw group (p <.001), no significant difference in the union rate was observed between the two groups (hook LCP group: 93.4% vs. screw group: 89.8%, p =.151), and a significantly shorter interval to union was observed in the hook LCP group (10.2 ± 7.0 vs. 12.3 ± 6.7 weeks, p =.015). There was a trend toward a lower rate of complications, including revision procedures, in the hook LCP group than in the screw group (19.9% vs. 28.5%, p =.107 and 6.6% vs. 13.8%, p =.074). Conclusion: Hook-type LCP may be an alternative option for treating medial malleolar fractures with comminution in elderly patients. [ABSTRACT FROM AUTHOR]

Category: Sports; Ankle Introduction/Purpose: Even after a considerable period following the modified Broström procedure, it is not uncommon for individuals to fail to fully regain their pre-injury sports activity capabilities. Return to sports activity can be influenced by various factors beyond the patient's determination (hope for sports activity), including residual pain or swelling, inadequate mechanical stability, deficits in postural control abilities or proprioception, among others. This study aimed to investigate the factors influencing the return to sports activity after anatomical ligament repair for chronic ankle instability. Methods: We conducted a study involving 62 patients under the age of 35 who underwent the modified Broström procedure for chronic ankle instability and were followed up for over 3 years. Among them, 51 patients (82.3%) were able to return to their pre-injury level of sports activity (return group), while 11 patients (17.7%) experienced some or significant limitations (non-return group). Clinical outcomes were evaluated using the Foot and Ankle Outcome Score (FAOS) and the Foot and Ankle Ability Measure (FAAM). Mechanical stability was assessed through physical examination and stress radiography. peroneal strength was evaluated using Biodex isokinetic dynamometer to measure peak torque and total work during eversion movement. Postural control abilities were analyzed using the static and dynamic stability assessment modes of Biodex posturography. Results: There was a significant difference between the two groups in FAOS pain (94.7 points in return group vs 85.1 points in non-return group, p=0.004) and sports (91.2 points vs 78.8 points, p<.001) subscales. In FAAM assessment, there was a significant difference in the sports activity (90.5 points vs 77.4 points, p<.001). Recurrence of mechanical instability was confirmed in 2 patients (3.9%) in the return group and 4 patients (36.4%) in the non-return group. There were no significant differences between the groups in evertor peak torque and total work. Regarding posturography assessment, static postural control ability(overall stability index) did not show significant differences between the groups, but significant differences were observed in dynamic postural control ability (1.4 vs 2.3, p=0.002). Conclusion: It has been analyzed that residual pain, recurrence of mechanical instability, and inadequate recovery of dynamic postural control ability affect the return to pre-injury level of sports activity after the modified Broström procedure for chronic ankle instability. It is deemed necessary to develop effective treatment strategies considering these factors during the rehabilitation process aimed at returning to sports activity after surgery. [ABSTRACT FROM AUTHOR]

Featured Application: Using Deep Learning to Detect Ankle Fractures. Ankle fractures are common and, compared to other injuries, tend to be overlooked in the emergency department. We aim to develop a deep learning algorithm that can detect not only definite fractures but also obscure fractures. We collected the data of 1226 patients with suspected ankle fractures and performed both X-rays and CT scans. With anteroposterior (AP) and lateral ankle X-rays of 1040 patients with fractures and 186 normal patients, we developed a deep learning model. The training, validation, and test datasets were split in a 3/1/1 ratio. Data augmentation and under-sampling techniques were administered as part of the preprocessing. The Inception V3 model was utilized for the image classification. Performance of the model was validated using a confusion matrix and the area under the receiver operating characteristic curve (AUC-ROC). For the AP and lateral trials, the best accuracy and AUC values were 83%/0.91 in AP and 90%/0.95 in lateral. Additionally, the mean accuracy and AUC values were 83%/0.89 for the AP trials and 83%/0.9 for the lateral trials. The reliable dataset resulted in the CNN model providing higher accuracy than in past studies. [ABSTRACT FROM AUTHOR]

Objective: Radiologic parameters are important factors for planning the treatment for thoracolumbar fracture. However, we noted that measurements of the degree of kyphosis by lateral decubitus plain radiography were greater than supine CT. The cause of this discrepancy is unclear.Methods: We retrospectively reviewed the plain radiographs and CT scans of 90 patients with thoracolumbar fractures (fracture group). We measured the segmental sagittal angle (SSA) on lateral decubitus plain radiographs and in the median sagittal plane on CT scans obtained in the supine position. The method agreement (plain radiography versus CT) was determined by utilizing Bland-Altman plots. For the purpose of comparison, the same analyses were performed in a group of age and sex-matched controls (normal group). After establishing the method disagreement in the fracture group, the factors that contributed to the difference in the SSA between plain radiography and CT, as well as their threshold values, were determined.Results: On Bland-Altman plots for the fracture group, the mean difference was 4.53° [95% confidence interval (CI) - 4.87° to 13.93°]. For the normal group, the mean difference was - 0.64° (95% CI - 5.87° to 4.58°). On univariate analysis, male sex, thoracolumbar level, and SSA(X) were significant factors associated with ∆SSA (P = 0.03, 0.002, and 0.000, respectively). Multivariable regression analysis showed that SSA(X) was the only significant factor. Receiver operating characteristic curve analysis indicated that the optimal threshold of SSA(X) was 17° with a sensitivity of 78% and a specificity of 75% (area under curve: 0.752).Conclusions: The mean SSA determined on lateral decubitus plain radiographs indicated significantly more kyphosis than that determined on CT images obtained in supine position. When the SSA on plain radiography is more than 17°, there might be a significant discrepancy between the two imaging modalities. This discrepancy seems to be mainly attributable to the difference in patient positioning (lateral decubitus position for plain radiography versus supine position for CT imaging). [ABSTRACT FROM AUTHOR]

Category: Sports; Ankle Introduction/Purpose: Because modified Broström procedure for chronic ankle instability provides a restoration of mechanical stability by reinforcing attenuated host tissue, poor quality of remnant ligamentous tissue can be considered as a prognostic factor for anatomic ligament repair surgery. The aim of this study was to evaluate the intermediate-term clinical outcomes after anatomic lateral ligaments repair augmented with suture-tape for chronic ankle instability with poor quality of ligament remnants. Methods: Thirty-six patients with the insufficient lateral ligament remnants confirmed by preoperative magnetic resonance image and intraoperative inspection were followed for more than 3 years after the augmented Broström repair. The clinical evaluation consisted of the Foot and Ankle Outcome Score(FAOS), Foot and Ankle Ability Measure(FAAM). Measurements on stress radiographs were performed to evaluate the changes of mechanical instability. To identify the changes of functional ankle instability, postural control ability was evaluated using single leg stance test with eyes closed. Results: FAOS and FAAM scores had significantly improved from preoperative average 56.3 and 51.8 points to 90.2 and 88.5 points at final follow-up, respectively (p <.001). Talar tilt angle and anterior talar translation had significantly improved from preoperative average 16.3° and 13.2 mm to 3.5° and 4.3 mm at final follow-up, respectively (p <.001). Balance retention time had significantly improved from preoperative average 3.8 seconds to 6.6 seconds at final follow-up (p <.001). Complications included two wound problems (one with superficial infection and one with marginal necrosis) and one superficial peroneal nerve injury with temporary paresthesia. Although 8 patients sustained an ankle sprain after operation, only 1 patient(2.8%) showed a recurrence of subjective and mechanical instability. Conclusion: Modified Broström procedure augmented with suture-tape appears to be an effective alternative for chronic ankle instability with poor quality of ligament remnants. Through the suture-tape augmentation and the direct repair of attenuated ligaments, this combined procedure can provide reliable stability and advantages of the anatomic ligament repair. [ABSTRACT FROM AUTHOR]

Category: Ankle Arthritis; Ankle Introduction/Purpose: Because nonunion is known to be a relatively common complication following ankle arthrodesis, various fixation techniques have been introduced to enhance the stability and to improve fusion rate. With the use of anterior plate supplementation, postoperative wound problems have been frequently reported despite better fusion rate. This study was performed to determine the effects of tibialis anterior(TA) tenotomy on wound complications and functional outcomes after anterior fusion plating for severe ankle arthritis. Methods: Forty-six patients who underwent ankle arthrodesis using anterior fusion plate were followed for more than 3 years. TA tenotomy was performed prior to wound closure in all patients. As a control group, thirty-eight patients who underwent arthrodesis without TA tenotomy were analysed. Clinical outcomes were evaluated with Ankle Osteoarthritis Scale(AOS) and Foot and Ankle Ability Measure(FAAM). Wound complication rate, time to fusion, fusion rate, time to pain relief below 3 points in visual analog scale were evaluated. Results: Mean AOS and FAAM scores significantly improved to 32.6 and 69.4 points at final followup, respectively. As compared to control group (33.8 and 67.7 points), there were no significant differences in clinical outcomes. As postoperative wound complications, there were 1 case of wound dehiscence and 1 case of superficial wound infection. TA tenotomy group showed lower wound complication rate (4.3%) than control group (21.1%). While there were no significant differences in fusion rate, time to fusion, and time to pain relief between both groups, control group needed higher rate of implant removal. Conclusion: Ankle arthrodesis using anterior fusion plate in conjuction with TA tenotomy appears to be an effective surgical option for end-stage ankle arthritis, with higher fusion rate and less wound complication rate. Although there was no specific functional deficit related to a loss of the TA tendon, further studies are needed to determine the long-term effects of the TA tenotomy in patients with a fused ankle. [ABSTRACT FROM AUTHOR]

Category: Midfoot/Forefoot; Midfoot/Forefoot Introduction/Purpose: The surgical treatment of severe hallux valgus (HV) deformity is challenging due to the difficulty in achieving sufficient reduction and the increased risk of complications such as recurrence, delayed or non-union. Minimally invasive surgery (MIS) has been increasingly used to treat HV deformity, with the third-generation minimally invasive Chevron and Akin osteotomies (MICA) technique being widely accepted. This retrospective cohort study aimed to compare the radiographic and clinical outcomes between the distal and proximal MICA techniques for severe hallux valgus deformity. It was hypothesized that the proximal MICA technique would provide better radiographic results due to the stronger deformity correction achieved by the proximal metatarsal osteotomy. Methods: Seventy-four feet with severe HV (defined as HVA [≥40 degrees] and/or IMA [≥20 degrees]) treated with distal MICA (40 feet) or proximal MICA (34 feet) were included in this study after at least one year of follow-up. Clinical assessment included the American Orthopaedic Foot & Ankle Society (AOFAS) score, pain visual analog scale (VAS), patient satisfaction rating, and complications. Radiographic assessments included HV angle (HVA), intermetatarsal angle (IMA), and distal metatarsal articular angle (DMAA). Results: There were no differences in the mean AOFAS score, pain VAS score, and patient satisfaction rate at the final follow-up between the two groups (all p >.05). The mean postoperative HVA, IMA, and DMAA significantly improved at the final follow-up in both groups (all p <.001). There was no significant difference in the improvement of radiographic values after surgery between the two groups (all p > 0.05). Although not statistically significant, there was a trend toward a higher recurrence and delayed or nonunion rate in the distal MICA group (7.5% vs. 2.9%, P =.218 and 10% vs. 2.9%, P =.072). Conclusion: Both types of minimally invasive techniques resulted in satisfactory outcomes in terms of significant improvement in clinical values, large deformity correction, and reasonable complication rates. However, the proximal MICA technique appears to provide more stable maintenance of deformity correction than the distal technique. [ABSTRACT FROM AUTHOR]