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Abstract Current treatment strategy for managing Weber B ankle fractures is mainly governed by mortise congruency, malleolar alignment, deltoid ligament competence and fracture stability. While nonoperative treatment has yielded good functional outcomes in satisfactorily aligned stable injuries, a biomechanical rationale is not firmly established. Furthermore, current radiographic analysis is obscured by observer inaccuracy and beam rotation. This study aimed to utilize weightbearing CT and computational biomechanics to analyse 3D mortise displacement and contact mechanics in Weber-B ankle fractures and compare them with the uninjured contralateral side. 32 patients were included who sustained a Weber-B ankle fracture and underwent bilateral weightbearing CT imaging at injury. Segmentation into 3D models of bone was performed semi-automatically, and individualized cartilage layers were modeled based on a previously validated methodology. The 3D mortise congruency was evaluated by use of following parameters: alpha angle, fibular length, talocrural angle, medial gutter- and tibiofibular clear space- distance mapping. Contact mechanics were evaluated by the mean and maximum contact stress of the tibiotalar articulation. Statistical analysis revealed that there were no significant differences for all anatomical parameters. There was also no significant difference between the mean contact stress of the injured (2.10 ± 0.42 MPa) and uninjured side (2.10 ± 0.41 MPa), nor the maximum contact stress of the injured (7.67 ± 1.55 MPa) and uninjured (7.47 ± 1.67), respectively. Contact mechanics were unaffected in congruent Weber-B fractures. These findings support consideration of nonoperative management in such cases, given their presumably low risk for posttraumatic arthritic development in the long term. Level of Evidence: Level III; retrospective case-control study.

Background: Vision related quality of life (VRQOL) measures one's satisfaction with their visual ability to perform daily activities. Aging leads to vision impairment that can negatively affect VRQOL and physical, psychological, and social well-being. Objective: To assess vision-related quality of life (VR-QOL) and its determinants among elderly residents from rural blocks of Haryana, India. Method: This cross-sectional study was performed across 52 Indian villages. The vision-related quality of life scores was assessed using National Eye Institute Vision Function Questionnaire-25(VFQ-25). Social Connectedness, Geriatric Depression Scale, Mini-Mental Status Examination, and the Katz Index of Independence were collected using validated tools. Continuous data was represented as Mean (±SD) or median (IQR) depending upon their distribution. Categorical data as frequency (%). Bivariate analysis was done using Student t-test or Rank Sum test for continuous variables (for up to 2 groups) and One-Way ANOVA was run for continuous variables (for more than 2 groups). Chi-Sq. test or Fisher's for categorical variables and multivariable linear regression model was run to calculate the determinants of the VFQ composite score. Result: Amongst the 420 participants, 58 % were females and 74 % were illiterates. The mean VR-QOL was 42.30 ± 11.19 in the study population. The study found higher VR-QOL scores in General Health, Distance activities, and Near activities, while lower scores were observed in Mental health, Dependency, Social functioning, Ocular pain, General vision, and Role difficulties. Both the mean VR-QOL composite score and the VR-QOL domains of General Health, General Vision, Ocular Pain, Role Difficulties, Mental Health, and Dependence were all greater for women than for men. Among the reported morbidities 26 % had hearing loss, 23 % were hypertensives, 9 % were diabetics, 85 % were dependent, 60 % had depression, 14 % had moderate dementia, 10 % had lower tendency to connect, 8 % had low vision and 35 % had vertigo. VFQ scores were lower among males, non-Hindus, hypertensives and among person with history of vertigo and those living in dim light than their counterparts. Conclusion: The current study shows that VR-QOL is significantly lower in male, participants with history of vertigo, hypertension, diabetes and who live in dim light. There is a need to develop strategies to address these determinants through multidisciplinary approach including chronic disease management and environmental modification and promote healthy aging of elderly population.

Category: Trauma; Ankle Introduction/Purpose: Syndesmosis fixation, a common procedure, is vital for restoring ankle biomechanics, but malreduction occurs in up to 52% of cases, necessitating precise anatomic reduction. While AO guidelines recommend a 20-30 degree trajectory in the coronal plane, the proposed ideal syndesmotic alignment is the line connecting fibula and tibia centroids. Intraoperatively determining the ideal fixation angle is challenging due to non-patient-specific and surgeon-dependent angular direction decisions. This study explores the angle bisector method's potential in establishing a patient- and level-specific syndesmotic fixation angle in cadavers, aiming for reproducibility independent of the surgeon. Additionally, the research assesses the safety of this method concerning major neurovascular structures for potential surgical application. By addressing these aspects, the study contributes to enhancing the precision and reliability of syndesmotic fixation procedures. Methods: Fixations on cadaveric leg specimens were conducted utilizing the angle bisector method at two levels (2 cm and 3.5 cm proximal) parallel to the tibial plafond. Two surgeons employed an open lateral approach for the procedure. The angle bisector method involved using a drill (2.8 mm) and screw (3.5 mm) directed along the bisector of the angle formed between two percutaneously placed K-wires (1.8 mm) at the fixation level, tangent to the anterior and posterior aspects of the fibula and tibia (Figure 1a). Subsequently, CT images of the cadavers were obtained (Figure 1b). The angle between the true centroidal axis (determined by software) and the axis of the screw placed with the angle bisector method was measured. Furthermore, distances between entry points of the centroidal axis and the screw were measured. Distances in millimeters between the positioned K-wires and major neurovascular structures were measured on cadaver dissections. (Sponsored by AOFAS-grant) Results: The mean angle between the centroidal axis and the trajectory of the screw was 2.7 degrees (±2.2, range 0-9.2 degrees) at the 2 cm level and 1.8 degrees (±2.1, 0-7.8 degrees) at the 3.5 cm level. At the 2 cm level, the average distance between the fibular entry points of the centroidal axis and the screw was 1.7 mm (±1.2, range 0-3.2 mm), while at the 3.5 cm level, it was 1.2 mm (±1.3, range 0-2.5 mm). The results exhibited low inter-surgeon variability (ICC > 0.80). The distance between the placed K-wires and major neurovascular structures consistently exceeded 5 mm, ensuring the safety of the technique, as none of these structures incurred damage. Conclusion: Our findings demonstrate that the angle bisector method offers a precise trajectory for syndesmotic fixation, proving its safety and efficacy in surgical applications. It can provide a more precise and patient-specific anatomical trajectory for syndesmotic implant compared to the conventional freehand technique, without increasing fluoroscopy exposure.

Background Clinical outcomes after fixation of distal humerus intraarticular fractures are directly related to the quality of reduction. The use of three-dimensional (3D)-printed fracture models can benefit preoperative planning to ensure good reduction. This review aims to determine if surgery performed with 3D printing assistance are faster and result in fewer complications and improved clinical outcomes than conventional methods. We also outline the benefits and drawbacks of this novel technique in surgical management of distal humerus fractures. Methods A systematic literature search was carried out in various electronic databases. Search results were screened based on title and abstract. Data from eligible studies were extracted into spreadsheets. Meta-analysis was performed using appropriate computer software. Results Three randomized controlled trials with 144 cases were included in the final analysis. The 3D-printed group had significantly shorter mean operating time (mean difference, 16.25 minutes; 95% confidence interval [CI], 12.74–19.76 minutes; P

Category: Ankle; Trauma Introduction/Purpose: Chaput tubercle fractures, which are thought to represent tibial-sided avulsions of the anterior inferior tibiofibular ligament (AITFL), are prevalent in up to 30% of trimalleolar ankle fractures. The optimal treatment of small Chaput avulsions is debatable; direct fixation with suture anchor devices and indirect (syndesmotic) fixation are considered as viable options, with proponents on both sides. Moreover, recent literature highlights the potential anatomical alterations to the incisura tibialis resulting from malreduction of large Chaput fragments, furthering the case for direct fixation. Hence, we performed a CT- based three-dimensional fracture mapping study to identify the morphological characteristics of these fractures, and to determine whether they consistently involve the AITFL, tibial plafond and incisura tibialis. Methods: This study included adult patients who had an ankle fracture with a Chaput component; the scheme described by Rammelt et al. was used to classify these fractures. CT scans were obtained, and 3D models were generated. The models were superimposed over a statistical shape model of the right tibia which served as a template and fracture lines were marked. The footprints of proximal and main bands of the AITFL and Basset’s ligament were also marked on the template tibia. The tibial template along with the fracture lines was then imported into MATLAB, and an automated script was used to determine the fragment size (length, breadth, and height), fracture surface area, involvement of the tibial plafond, tibial incisura, and the anterior inferior tibiofibular ligament (AITFL) and Basset’s ligament. Fracture maps and heat maps were generated. Agglomerative cluster analysis using Ward’s linkage was used to identify discrete fracture categories. Results: 76 patients, 21 males and 55 females were included in this study. Cluster analysis identified two distinct groups of fractures, each with two unique subgroups. We present this as a modification of the existing classification system. The first group, corresponded to Rammelt Type 1 fractures (sub centimetric extra-articular avulsion fractures, n=47). Of these, 19% (n=9) did not involve the AITFL, which we termed as Type 1a, and 91% (n=48) involved the AITFL, which we termed as Type 1b. The second group consisted of large intra-articular fractures that corresponded to Rammelt Type 2 injuries. Of these 23% (n=6) involved only the incisura, which we termed as Type 2a; 77 % involved both the incisura and the tibial plafond and were termed as Type 2b. Conclusion: We propose a modification of the existing classification of Chaput fractures on the basis of quantitative fracture mapping. This study provides new insights into the morphological characteristics of Chaput fractures. 19% of small Chaput fractures do not involve the AITFL and may not require direct fixation. Conversely, all large-sized fragments involve the incisura and necessitate anatomical reduction to achieve accurate syndesmotic reduction. Our proposed modification can aid in surgical decision-making, particularly in choosing between direct and indirect syndesmotic fixation.

Category: Trauma; Hindfoot Introduction/Purpose: Malunion is a disabling complication of talar neck fractures and is prevalent in approximately 17% of cases. The impact of talar neck malunions (TNM) on foot biomechanics and functional outcomes is not well established. The available evidence is primarily derived from cadaveric studies which have demonstrated that TNMs result in reduced motion and significant alterations in contact characteristics of the subtalar joint. Owing to the paucity of literature on this subject, we conducted this study to evaluate the kinematic and pedobarographic changes and functional outcomes associated with TNMs. Methods: In this study, adult patients with talar neck malunions (TNM) without ankle arthrosis were prospectively enrolled over a 5-year period. The Rammelt and Zwipp classification was utilized to categorize the deformities. Demographic data and ankle and subtalar range of motion were assessed. Weight-bearing anteroposterior (AP), lateral, and long axial radiographs, as well as CT scans of both feet, were obtained. Dynamic pedobarography was performed to evaluate gait kinematics and plantar pressure distribution. Functional outcomes were evaluated using the Manchester Oxford Foot Questionnaire (MOxFQ), Visual Analog Score, and the EQ5D questionnaire. The t-test was utilized to compare the range of motion, pedobarographic and kinematic parameters between the normal and pathologic foot. Furthermore, correlation coefficients were calculated to determine the strength of the association between changes in talar neck geometry, plantar pressures, kinematics, and functional outcomes. Results: A total of 10 patients, 6 males, and 4 females, with a mean age of 32.4 years were enrolled. On the TNM side, significant increases were observed in step length and step time, while significant decreases were noted in the single limb support time and single limb support center of pressure line. Moreover, midfoot forces were significantly increased, whereas the forefoot and hindfoot forces were significantly decreased on the TNM side. A strong positive correlation was found between midfoot force and the talar torsion angle, and a moderate negative correlation was observed between hindfoot and midfoot forces and the inclination angle. A strong positive correlation was also noted between high midfoot pressures and VAS Scores, MOxFQ scores, and the EQ5D walking and usual activities domains. Conclusion: This study demonstrates that TNMs are associated with decreased single limb support time, increased step length and time, increased midfoot pressures, and decreased forefoot and hindfoot pressures. Additionally, an increase in talar neck torsion after TNM is linked with higher midfoot pressures, which can lead to higher levels of pain and poorer function. Our findings provide valuable insights into the altered foot biomechanics after TNMs, which can assist surgeons in offering optimal management strategies for these patients.

Category: Ankle; Trauma Introduction/Purpose: The term ‘quadrimalleolar fracture’ (QMF) describes a trimalleolar (TM) ankle fracture with an associated Chaput or Wagstaffe fracture. Optimal fixation of these injuries not only allows for bone-to-bone healing but also facilitates syndesmotic reduction. However, this is a relatively new concept, and the literature on QMFs is limited to a few case series. Hence, we conducted this study to determine the epidemiology, patterns, and clinicoradiologic correlations of QMFs. The primary objective of this study was to describe the prevalence and patterns of QMFs. The secondary objective was to determine if certain clinical or radiological parameters were associated with different types and patterns of QMFs. Methods: A retrospective analysis of ankle fractures presenting to three tertiary referral hospitals was undertaken. Adult patients (≥18 years) presenting with an acute, traumatic TM ankle fracture over 3 years (July 2018 to July 2021) were included. Isolated medial and lateral malleolar fractures, bimalleolar ankle fractures, pediatric patients, pilon fractures, pathological fractures, and those with delayed presentation or (≥3 weeks of injury) were excluded. Clinical demographic variables were obtained from the patients’ medical records. AP, lateral, and mortise ankle radiographs, and CT scans, (axial, coronal, and sagittal sections along with 3D volume reconstructed models) whenever available, were evaluated in detail. Demographics and radiological parameters were compared between TM and QMF, as well as between different types of QMFs. Odds ratios with 95% confidence intervals were determined to test the strength of association. Results: A total of 876 adult patients with ankle fractures were included after the screening, of which 323 had a TM ankle fracture for which a CT scan had been performed. A total of 159 AITFL avulsions were identified, yielding a prevalence of 18.2% amongst all ankle fractures and 26.1% in ankle fractures where a CT scan had been performed. TMFs had the significantly highest proportion of CT-confirmed AITFL avulsions (44.4%) in comparison to unimalleolar (4.4%) and bimalleolar fractures (6.4%) (P < 0.0001). Age and osteoporosis were significant associations of QMFs. Avulsion of the medial malleolus, Weber B fibular fracture, and supination external rotation mechanism were significantly associated with Wagstaffe fractures. Size of the Chaput fracture was inversely related to that of the posterior malleolar fracture. Conclusion: Quadrimalleolar ankle fractures account for a significant proportion of ankle fractures. The strengths of this study include a large sample size, which was derived from three different hospitals, consecutive inclusion (or exclusion) of cases, strict adherence to the STROBE guidelines, and the fact that only CT-confirmed cases were used to determine clinic-radiological associations. Wagstaffe and Chaput fractures have distinct clinical and radiological correlations. However, further research is needed to determine the optimal fixation protocols for these injuries.

Category: Sports; Ankle Introduction/Purpose: Acute Achilles tendon ruptures (ATRs) can be treated surgically through either open repair or minimally invasive surgical techniques (MIS). While the relative complication rates between these techniques, including wound dehiscence, re-rupture, and sural nerve injury, have been debated, many studies demonstrate no significant difference between these two approaches. In this study, we conducted a Kaplan-Meier survival analysis to compare the incidence and timing of complications between open and MIS repair of acute ATRs and examine factors that may influence these rates. Methods: A retrospective study was conducted to evaluate the outcomes of patients (≥18 years) who underwent surgical intervention for acute ATR within a four-week period following injury, with a minimum follow-up of three months. Data on demographic variables, type of surgical procedure (MIS or open approach), and the occurrence and timing of postoperative complications were collected. Postoperative complications were classified as venous thromboembolism (VTE), re-rupture, surgical site infecti+D2on (SSI), wound dehiscence, and sural nerve injury.The Kaplan-Meier method was employed to compare the complication rates between the MIS and open repair groups. The log-rank test was used to test the equality of survivor functions. The Cox proportional hazards model was employed to determine predictors of complications. Results: In total, 417 patients were included in the final analysis. The MIS group had a higher proportion of patients with tobacco use. Fifty-two complications in 50 patients were recorded (Table 1). We found no significant difference in the complication rates between the MIS and open repair groups. However, Cox proportional hazards modeling revealed that body mass index (BMI) was a significant predictor of re-ruptures (HR 1.2, 95% CI = 1.05–1.4) and that surgical delay was found to be a significant predictor of wound dehiscence (HR 1.2, 95% CI =1.01–1.3) and sural nerve injury (HR 1.2, 95% CI =1.1–1.3). A surgical delay of more than 2 weeks was noted to have a positive likelihood ratio of 2.3 for wound dehiscence and 3.1 for sural nerve injury. Conclusion: The results of this study indicate that MIS and open repair techniques for acute ATRs demonstrate comparable complication rates. However, patients with elevated BMI exhibit an increased risk of re-rupture. Those with surgical delay beyond two weeks have an elevated likelihood of wound dehiscence and sural nerve injury, presumptively due to associated scaring and the requisite tissue manipulation. Surgeons and patients may consider these variables when formulating a surgical treatment plan.

Category: Ankle; Trauma Introduction/Purpose: Syndesmosis injury can be of a varying magnitude; little information exists about the influence of degree of initial syndesmotic injury/instability on functional outcomes in ankle fractures, nor is there any correlation of this with follow up radiological parameters. Aims and Objectives: To identify and define morphological patterns of syndesmotic injury in ankle fractures according to a zone based evaluation, and correlate initial degree of instability with mid-term functional and radiological outcomes using validated scores Design: Retrospective cohort study, to review a prospective question. Methods: 40 complex ankle fractures out of 120 ankle fractures in our ankle registry met the inclusion criteria ie significant documented syndesmosis involvement needing stabilization, with all initial clinical and radiological records available. The patients were followed up between January 2020 to July 2021. Injury characteristics, fracture morphology of posterior malleolus, medial malleolus and fibula were noted and classified by validated classification systems based on x-rays and CT scan. The syndesmosis was analyzed on axial CT scan; it was divided into 3 zones, A,B,C from anterior to posterior, and degree of displacement and morphology was noted. Immediate post-operative radiographs were evaluated for fracture and syndesmosis reduction. The patients were evaluated at final follow up with both ankle specific scores (Olerud Molander score, Ankle-Hindfoot scale, Manchester-Oxford Foot questionnaire) and quality of life score (SF-12). Ankle Osteoarthritis grade was used to evaluate radiological outcomes. Results: Mean follow-up was 19 months. 22(55%) patients had syndesmotic widening on plain radiographs; however in pre- operative CT scan evaluation 40(100%) patients had syndesmotic injury based on the Zone evaluation of the syndesmosis. 22 patients had Zone A injury (widening, AITFL, Chaput, Wagstaff). 22 patients had widening of Zone B. Zone C was involved in 30 patients (PM fracture,PITFL involvement). At final follow up; the mean OMAS was 83.38±16.35, mean Ankle-Hindfoot scale= 88±9.98, mean Mox-FQ score=27.15±13.35 & mean SF-12 were (MCS=56.59±8.24, PCS=51.18±8.48). There was no significant difference in outcome scores based on fracture types, Posterior malleolus morphology, or based on zones of syndesmosis injury. Syndesmosis malreduction contributed to significantly poorer outcomes (SF-12, OMAS, MoxFQ) Conclusion: Despite a zonal classification of syndesmotic injury on CT and more clarity of injury patterns, we could not corelate the site and extent of syndesmotic injury with final functional and radiological outcomes. The one factor that has significant influence is initial accurate reduction of both the malleolar fractures and syndesmosis injury. In this the CT based axial classification may play a role.

Category: Hindfoot; Ankle Introduction/Purpose: The medial displacement calcaneal osteotomy is used to correct hindfoot valgus in adult-acquired flatfoot disease(AAFD). This is done by means of an oblique cut, which is then translated medially. The chevron variant of the MDCO has gained popularity in recent times. This osteotomy involves a V-cut, with the apex of the V placed anteriorly. This is thought to be inherently more stable than the conventional MDCO owing to its geometrical design and higher contact area, especially with higher magnitudes of translation of the osteotomized fragment. However, it is technically more demanding, and many surgeons may not be familiar with the technique. Moreover, there is no literature comparing the stability of the chevron and oblique MDCO. Hence, we conducted this study to address this knowledge gap. Methods: Computed Tomography (CT) scan of the foot of a patient diagnosed with Johnson stage 2 AAFD was segmented and converted into a 3D computational model. Subsequently, oblique and chevron (160o V-angle) calcaneal osteotomies were performed virtually. For each variant, the osteotomized fragment was translated medially by 8-, 10- and 12-mm and then fixed virtually with two 6.5 mm screws. The six models were imported into a Finite Element Software (ANSYS v19) and subjected to 500 N axial loading through the tibia to simulate a single-leg stance. The von Mises stresses at the osteotomy interfaces and the screws, and the total displacement of the posterior fragment was recorded for each model. Results: The compiled simulation results are presented in Table 1. For both osteotomies, the overall stresses at the osteotomy contact site and the screws increased incrementally with increasing medial translation. Similarly, sagittal plane displacement of the anterior fragment was noted to follow a similar trend. Across all translation levels, the stresses were recorded to be lower for chevron MDCO when compared to the oblique variants. Relative fragment displacement was also noted to be lower for the chevron MDCO. Conclusion: The chevron osteotomy results in lower contact stresses and osteotomy fragment displacement and may prove to be a more stable alternative to the oblique MDCO. However, these results need to be replicated in a larger cohort of patients, as well as in cadaveric studies to determine if surgeons can permit early weight-bearing with the chevron MDCO.

Category: Ankle; Trauma Introduction/Purpose: Approximately 10-15% of posterior malleolar fractures (PMFs) are "small shell," extra-articular fragments. Current classification systems present difficulties to perform a uniform typification of PMFs and contain no consensus on whether they should be fixed. Anatomical studies have identified two distinct components of the posterior inferior tibiofibular ligament (PITFL); the superficial band is thought to be more important than its deep counterpart in imparting syndesmotic stability. However, the involvement of one or both bands of the PITFL by small shell PMFs has not been evaluated so far. Hence, we conducted this study to perform 3D mapping of small shell PMFs and to determine whether surgeons should fix these routinely. Methods: Ankle fracture patients with a ‘small shell’ PMF (Haraguchi 3/Mason 1/Bartoníček 1 or 2) were included. Demographics, radiological features, treatment, and outcomes were recorded. 3D models of the fractured tibiae were generated from CT scans and superimposed on a statistical shape model of the right tibia, which served as a template. Fracture lines along with footprints of superficial and deep PITFL were marked on the template. 3D fracture heat maps were generated. Size of the fracture fragments and involvement of the superficial and deep PITFL footprints were quantified using a custom MATLAB script (Figure 1). Sparing of the footprint was defined as an overlap of < 1% between the fracture line and the footprint areas. Odds ratios (OR) with 95% confidence intervals (CI) were determined to determine which variables correlated with sparing of the PITFL footprint; P-values of < 0.05 were considered significant. Results: Thirty-nine patients were included. The superficial PITFL footprint was spared in 15 (38%), deep PITFL in 10 (26%), and both in 4 cases (10%). Males and Weber C fractures had a higher likelihood of sparing the superficial and deep PITFL footprints, respectively (P = 0.04). Supination external rotation (SER) patterns were less likely to demonstrate syndesmotic widening if either PITFL footprint was spared. Direct fixation of the PMF was done in 1 case; syndesmotic fixation in 25 cases and in 14 cases, no syndesmotic fixation was done. Of these, 11 were SER injuries where stability was achieved after fixation of medial and lateral malleoli. In 1 SER and pronation external rotation (PER) injury case, the syndesmosis was stable after fixation of a large Chaput fragment. Conclusion: This study demonstrated that 48% of small shell PMFs spare either the superficial or deep footprint of the PITFL; in 10% both PITFL footprints were spared. Hence, 58 % of small-shell PMFs may not benefit from direct fixation. Additionally, SER injuries with small shell PMFs that spare either PITFL footprint may not demonstrate radiographic instability and may not need direct or indirect fixation after addressing other components of the ankle fracture. However, given the fact that syndesmotic stability is not dictated by the PITFL alone, it remains prudent to stress the syndesmosis per-operatively to determine if syndesmotic fixation is needed.

Category: Hindfoot; Sports Introduction/Purpose: Posterior heel pain at the Achilles tendon insertion is a prevalent and debilitating condition that is not yet fully understood. It results from a combination of bony and soft tissue abnormalities, including insertional Achilles tendinopathy, retrocalcaneal bursitis, and posterosuperior bony prominence. While the most commonly used surgical technique for treatment is debridement and reattachment of the tendon, dorsal closing wedge calcaneal osteotomy (DCWCO) has recently gained popularity. In this meta-analysis, we aimed to analyze the published literature related to both surgical techniques and compare their outcomes. Our hypothesis was that DCWCO can provide similar clinical outcomes with a lower complication rate. Methods: We conducted a literature search in Medline, Embase, and Scopus databases. Clinical studies reporting at least one of the clinical outcomes among AOFAS score and complications, with an open technique and sufficient data to extract and pool, were included. The extraction was made by two users using the Covidence platform. Studies with less than 10 patients or less than 12 months follow-up were excluded. Initial search yielded 329 papers, and after excluding duplicates and irrelevant studies, 43 papers were left. After a full-text review of these 43 papers, we found 15 papers eligible for meta-analysis. We used the Modified Coleman Methodology to assess the quality of papers. Results: Out of the 15 articles, seven included reattachment patients, while eight included DCWCO patients. 171 feet underwent reattachment, while 239 feet underwent DCWCO. The average follow-up of patients was significantly higher in the DCWCO group (42.2 months) than reattachment group (23.2 months). The average AOFAS score improvement was similar between the groups. The total complication numbers were 30 (16.6%) in the reattachment group and 28 (9.2%) in the DCWCO group, but the difference did not reach significance since the confidence intervals were overlapping. However, wound complications were significantly more common in Reattachment group (10.1%) compared to DCWCO (2.5%). The number of revision surgeries and neurological complications (sural neuritis, hypersensitivity, etc.) were similar between the groups. The average AOFAS score improvement was similar between the groups. Conclusion: Both techniques yielded comparable clinical outcomes. The overall complication rate was similar, but DCWCO exhibited a lower wound complication rate than reattachment. Therefore, the study results imply that DCWCO can provide similar clinical outcomes with fewer wound complications. However, further well-designed studies are necessary to reach a definitive conclusion on this matter and compare both techniques in the same study setting.

Category: Hindfoot; Sports Introduction/Purpose: The use of a dorsal closing wedge calcaneal osteotomy (DCWCO) in the treatment of insertional Achilles tendinopathy (IAT) has recently gained popularity. The anatomical changes imposed by the osteotomy are believed to improve both the biological and mechanical processes involved in IAT. However, the impact of shortening the Achilles leverage arm after DCWCO and the full impact of DCWCO on foot anatomy and function is not well understood. This study aimed to examine the effects of DCWCO on the 3D alignment and biomechanics of the foot and ankle in IAT patients through simulated models of DCWCO. The hypothesis was that DCWCO would significantly impact foot alignment and decrease gastrocsoleus lever arm. Methods: Six weightbearing ankle CTs of patients with IAT were identified from the clinical database. Bone segmentation was performed and DCWCOs were conducted in standardized planes with six variations, resulting in a total of 36 foot models. Two plantar osteotomy starting points were defined as 1-cm anterior (posterior osteotomy) and 2-cm anterior (anterior osteotomy) to the most plantar point of calcaneus. The osteotomies were extended to dorsal surface at 1-cm anterior to posterosuperior calcaneus with 6, 10, or 14-mm wedges anteriorly. After the osteotomies, the posterior part of the calcaneus was rotated around the plantar starting point until proper bone contact was achieved. Achilles reconstruction was also performed using pre-defined Achilles insertion points. All models were then transferred to a MATLAB-based algorithm for automated measurements. These measurements included talocalcaneal, calcaneal pitch, Böhler, and Achilles tendon sagittal angles, Achilles moment arm, Achilles- posterosuperior calcaneus distance, and difference in soleus-Achilles length. Results: Anteriorly placed osteotomy caused more significant decrease in the Böhler angle (p < 0.001). Evaluation of the posteriorly placed osteotomy separately showed no significant decrease in the Böhler angle for patients with more than 30- degrees of preoperative Böhler angle (p=0.26). However, patients with a preoperative Böhler angle less than 30-degrees showed a significant decrease, approaching values close to 5-degrees (p=0.004). Gastrocsoleus moment arm decrease was found to be 2-3% by using force/moment equation. The change in the distance between Achilles tendon and the posterosuperior calcaneus was similar between anterior and posterior osteotomies, with less than 3-mm in a 6-mm wedge and more than 5-mm in a 10-mm wedge osteotomy. The calculations showed that ankle dorsiflexion can increase by one degree for each mm of resection. Conclusion: An anteriorly placed starting point for a DCWCO can negatively affect foot alignment and offer limited benefits for Achilles decompression. If the preoperative Böhler angle is less than 30, a DCWCO can significantly decrease the Böhler angle, potentially putting the subtalar joint at risk for arthritis by increasing the load as reported by some finite element studies. The maximum decrease in gastrocsoleus power is less than 3%, which may be clinically insignificant. A posterior starting point with 10- mm wedge can be adequate to move Haglund around 5-mm anteriorly and can move Achilles insertion 10-mm superiorly to decrease tension.

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: Trauma; Hindfoot Introduction/Purpose: Malunions of the talar neck significantly alter the foot biomechanics and predispose patients to arthrosis and poor functional outcomes. Recent interest has focused on the surgical correction of these deformities, with corrective talar neck osteotomy emerging as a safe and effective treatment for malunions without ankle arthrosis. While a talus malunion is traditionally thought to cause a varus deformity due to the shortening of the medial talar neck, the pathoanatomy of these deformities remains unclear and sparsely reported in the literature. Therefore, this study aimed to investigate the three- dimensional changes in morphometric parameters of the talar neck after malunion and to determine how these changes affect the architecture of the foot. Methods: Adult patients with a talar neck malunion without ankle arthrosis (Rammelt and Zwipp Type 1-3) were prospectively included. Weight-bearing (WB) AP, Lateral and long axial radiographs, and CT scans of both feet were obtained. 3D models of both tali were generated. The malunion side was mirrored and superimposed on the normal side, and distance maps were generated to identify pathoanatomic changes. Deviation of the talar neck in the axial plane (declination angle [DA]), sagittal plane (inclination angle [IA]), coronal plane (torsion angle [TA]) as well as the medial and lateral neck lengths (MNL and LNL) were measured on the 3D talus models using a semi-automated GEOGEBRA script. AP and Lateral Meary’s angle and the hindfoot moment arm (HMA) was determined on WB radiographs. The t-test was used to compare the talar neck parameters, and correlation coefficients were used to determine the association between talar neck parameters and foot radiographic parameters. Results: 10 patients, 6 males, and 4 females, with a mean age of 32.4 years were included. There were 4 cases of Rammelt and Zwipp Type 1 deformity, and 6 cases of Type 3 deformity. Axial plane changes included varus deviation of the talar neck in 8 cases and valgus deviation in 2. Sagittal plane changes included dorsiflexion of the talar neck in 4, neutral alignment in 3 cases, and plantarflexion in 3 cases. The TA was increased in all cases. TA and MNL had a moderate positive correlation with AP Meary’s angle and, and a moderate negative correlation with Lateral Meary’s Angle. DA and MNL had a moderate positive correlation with the HMA. Conclusion: Talar neck malunions are complex three-dimensional deformities resulting in the common varus and dorsiflexion variants, as well as less common valgus and plantarflexion variants. Despite the variation in malunion types, all cases are characterized by an increased TA. Furthermore, the combination of increased TA and DA and decreased MNL leads to forefoot adduction and hindfoot varus. Due to the intricate and diverse three-dimensional nature of these deformities, surgeons must conduct a comprehensive evaluation of the pathoanatomy before planning surgical correction.

Category: Ankle; Other Introduction/Purpose: Anatomical reduction of the distal syndesmosis can be challenging. There is ongoing debate and variability in the methods used for evaluating the accuracy of reduction, including radiography, intra-operative CT, arthroscopy, and direct visualization. Tornetta et al. have described a method called ‘the articular surface method’ that evaluates the relationship between the articular cartilage of the distal anteromedial fibula and the anterolateral tibia as being significantly more accurate for detecting malreduction. However, it entails an additional surgical incision over the distal aspect of the ankle. The aim of this study was to find a non-invasive method using ultrasound to assess the accuracy of reduction in syndesmotic injuries. Methods: A cadaveric syndesmotic instability model was created by dissecting the PITFL, IOL, and AITFL through a small posterior incision. The fibula was fixed in incremental degrees of rotational malreduction to achieve a malreduction of 3, 5, and 7 mm. A blinded observer assessed the syndesmosis using a portable ultrasound device. The probe was placed in its short axis at the level of the ankle joint then moved proximally until both the anteromedial fibular and anterolateral tibial articular surfaces were visualized simultaneously in one view. In a reduced syndesmosis, the distal articular surfaces of the tibia and fibula overlap. This relationship is altered in a malreduced syndesmosis, which allows ultrasonographic waves to ‘penetrate’ through the malreduced articular surfaces and be readily detected. This sign was graded positive if an acoustic signal penetrated between the distal articular surfaces of the tibia and fibula, and negative if no acoustic signal was detected. Results: The gap penetrance sign was positive in all 3 instances of malreduced syndesmoses, and negative in an anatomically reduced syndesmosis. Figure 1 illustrates the outcomes in a reduced syndesmosis and malreduced syndesmosis, respectively. Conclusion: We introduced a novel sign that can be used as a surrogate of the ‘articular surface method’ to detect syndesmotic malreduction. It is accurate, can obviate the need for a separate surgical incision for direct visualization, permits rapid point-of- care evaluation in the operating room, and minimizes radiation exposure

We performed bibliometric analysis of the research papers published on clinical cervical spondylotic myelopathy (CSM) in the last 50 years. We extracted bibliometric data from Scopus and PubMed from 1970 to 2020 pertaining to clinical studies of CSM. The predominant journals, top cited articles, authors, and countries were identified using performance analysis. Science mapping was also performed to reveal the emerging trends, and conceptual and social structures of the authors and countries. Bibliometrix R-package was deployed for the study. The total numbers of clinical studies available in PubMed and Scopus were 1,302 and 3,470, respectively. The most cited article was published by Hilibrand AS, as observed in Scopus. Regarding the conceptual structure of the research, two main research themes were identified, one involving symptomatology, scientific-scale-based objective evaluation of symptoms, and surgical removal of the offending culprit, while the other was based on patho-etiology, relevant diagnostic modalities, and the surgery commonly performed for CSM. In terms of emerging trends, in recent times there is an increasing trend of scale-based objective evaluations, along with investigations of advanced nonoperative management. The United States is the most productive country, whereas Canada tops the list for inter-country collaboration. The trend of research showed a shift toward noninvasive procedures.

Web based surveys have gained importance in last 20 years due to ease of internet access. It has proven to be a boon in terms of minimized contacts and still be able to churn out statistically valid results and on the other hand, it has faced a lot of criticism due to lack of repeatability and other scientific validity pillars. To increase the validity of such studies, a central database should be maintained and the questionnaires should be short and to the point and should take into considerations the diversity in culture and languages.

Background: Assessment of mortise stability is paramount in determining appropriate management of ankle fractures. Although instability is readily apparent in bimalleolar or trimalleolar ankle fractures, determination of instability in the isolated Weber B fibula fracture often requires further investigation. Prior authors have demonstrated poor predictive value of physical examination findings such as tenderness, ecchymosis, and swelling with instability. The goal of this study is to test the validity of a new clinical examination maneuver, the lateral drawer test, against the gravity stress view (GSV) in a cohort of patients with Weber B fibula fractures. Secondary goals included assessing pain tolerability of the lateral drawer test, as well as testing interobserver reliability. Methods: Sixty-two patients presenting with isolated fibula fractures were prospectively identified by an orthopaedic nurse practitioner or resident. Three nonweightbearing radiographic views of the ankle as well as a GSV were obtained. Radiographs were not visualized before conducting the lateral drawer test. Two foot and ankle fellowship–trained orthopaedic surgeons performed and graded the lateral drawer test. Radiographs were then examined and medial clear space (MCS) was measured. Visual analog scale (VAS) pain scores were obtained before and after testing. The results of the lateral drawer test were compared with radiographic measurements of MCS on GSV. A cadaveric experiment was devised to assess interobserver reliability of the lateral drawer test. Results: Thirty (48%) of 62 consecutively enrolled patients demonstrated radiographic instability with widening of the MCS ≥5 mm on GSV. When correlated with MCS measurement, the lateral drawer test demonstrated a sensitivity of 83%, specificity of 97%, positive predictive value (PPV) of 96%, and negative predictive value (NPV) of 86%. There was a strong correlation between the lateral drawer test grade and amount of MCS widening (Spearman correlation ρ = 0.82, P < .005). Patients tolerated the maneuver well with an average increase of 0.7 on the VAS pain scale. Testing of 2 observers utilizing the cadaveric model demonstrated a Cohen’s Kappa coefficient of 0.7 indicating moderate interobserver agreement. Conclusion: The lateral drawer test demonstrates high sensitivity, specificity, PPV, and NPV with moderate interobserver reliability compared with the MCS on GSV in patients presenting with Weber B fibula fractures. Although further external validation is required, the lateral drawer test may offer an adjunct tool via physical examination to help determine mortise stability. Level of Evidence: Level II, Prospective Cohort Study.

Septic arthritis of the ankle can result in short- and long-term disabilities and fatal complications if not addressed promptly. Urgent arthroscopic or open joint lavage is the standard of care in cases with septic arthritis. However, this may be delayed in older patients with comorbidities and immunocompromised individuals, for achieving preoperative optimization. To counter such situations, we present a simple and effective bedside joint lavage technique that relies on continuous irrigation and suction and can therefore prevent unwarranted delays in the operative management of these cases.

Introduction: Older adults continue to receive potentially inappropriate medications necessitating the need for medication optimization, by deprescribing. To ensure a holistic approach to deprescribing, it is essential to understand the perception of older adults towards deprescribing. This study aimed to assess the attitude of older ambulatory patients towards deprescribing and to identify factors predicting their willingness to deprescribe. Methods: A cross-sectional survey was conducted in central Nepal between March and September 2019 among 385 older ambulatory care patients (aged ⩾65 years) who were taking at least one regular medicine. The perception of patients towards deprescribing was assessed using the revised Patients’ Attitudes Towards Deprescribing (rPATD) questionnaire via a face-to-face interview method. Descriptive statistics were performed to describe patients’ characteristics and their attitudes towards deprescribing. A multivariate logistic regression analysis was used to determine predictors of the willingness of older ambulatory patients towards deprescribing. Results: The median [interquartile range (IQR)] age of patients was 72 (8) years. Nearly three in five patients (64.9%) had hypertension, with 11.2% having polypharmacy. More than half of the patients (57.4%) would be willing to stop one or more of their regular medicines if their doctor said it was possible to do so. Regression analysis showed that age [odds ratio (OR) 0.946; 95% CI 0.913, 0.981; p = 0.003] and concerns about stopping medicine score (OR 0.541; 95% CI 0.334, 0.876; p = 0.013) were predictors of the willingness of the older patients towards deprescribing. Conclusion: One in two older ambulatory care patients in Nepal would be willing to have one or more of their medicines deprescribed. The factors predicting their willingness to deprescribe are their age and concerns about stopping medicines. Clinicians should consider discussing the possibility of deprescribing with older patients for the prevention of potential medication-related harms. Plain Language Summary What do older Nepalese patients think about withdrawal or dose reduction of an inappropriate medication? Introduction: Research suggests that older adults (aged ⩾65 years) continue to receive medications that have the potential for harm rather than a benefit. This necessitates the need for withdrawal or dose reduction of such inappropriate medications, the process known as deprescribing. Understanding what older patients think about this process could be a stepping-stone to the general approach for its implementation. Data on deprescribing is lacking from Nepal. Therefore, we designed a survey to explore the attitude of older patients towards deprescribing and factors that could predict their willingness to deprescribe. Methods: This study was conducted between March to September 2019 among 385 older patients who were taking at least one regular medicine and were visiting selected hospitals of Nepal for outpatient services. We performed a face-to-face interview to assess the attitude of patients towards deprescribing using a validated tool called revised Patients’ Attitudes Towards Deprescribing (rPATD) questionnaire that quantified the response through scoring. The data were subjected to statistical analysis to determine the attitudes of Nepalese older patients towards deprescribing and to develop a model to predict their willingness to deprescribe. Results: The average age of the participant was 72 years with 65% having hypertension and 11% using more than five medications. Our data suggested that one in two older Nepalese patients would be willing to stop one or more of their regular medications if their doctors said it was possible to do so. Their willingness to deprescribe could be predicted from their age and concerns about stopping medications. Conclusion: Clinicians should consider discussing the possibility of deprescribing with older patients for the prevention of potential medication-related harms.

Type 2 diabetes mellitus (T2DM) adversely affects the normal functioning, intrinsic material properties, and structural integrity of many tissues, including bone. It is well known that the clinical utility of areal bone mineral density (aBMD) is limited to assess bone strength in individuals with T2DM. Therefore, there is a need to explore new diagnostic techniques that can better assist and improve the accuracy of assessment of bone tissue quality. The present study investigated the link between bone and fingernail material/compositional properties in type 2 diabetes mellitus (T2DM). For that, femoral head and fingernail samples were obtained from twenty-five adult female patients (with/without T2DM) with fragility femoral neck fractures undergoing hemi/total hip arthroplasty. Cylindrical cores of trabecular bone were subjected to micro-CT, and lower bone volume fraction was observed in the diabetic group than the non-diabetic group due to fewer and thinner trabeculae in individuals with T2DM. The material and compositional properties of bone/fingernail were estimated using nanoindentation and Fourier Transform Infrared Spectroscopy, respectively. Both bone/fingernails in T2DM had lower reduced modulus (Er), hardness (H), lower Amide I and Amide II area ratio (protein content), higher sugar-to-matrix ratio, and relatively high carboxymethyl-lysine (CML) content compared with non-diabetic patients. Sugar-to-matrix ratio and relative CML content were strongly and positively correlated with HbA1c for both bone/fingernail. There was a positive correlation between bone and fingernail glycation content. Our findings provide evidence that the degradation pattern of bone and fingernail properties go hand-in-hand in individuals with T2DM. Hence, the fingernail compositional/material properties might serve as a non-invasive surrogate marker of bone quality in T2DM; however, further large-scale studies need to be undertaken.

Aneurysmal bone cyst (ABC) of the talus is an extremely rare lesion; less than 20 cases have been reported in PubMed till 2012. We report a primary ABC of the talus in a 20-year-old male that was managed by extended intralesional curettage with phenol as an adjuvant and autologous cancellous iliac crest bone grafting. The patient had excellent functional outcome and there was no recurrence at 2 years of follow-up.

Intracellular delivery of biomolecules, such as proteins and siRNAs, into primary immune cells, especially resting lymphocytes, is a challenge. Here we describe the design and testing of microfluidic intracellular delivery systems that cause temporary membrane disruption by rapid mechanical deformation of human and mouse immune cells. Dextran, antibody and siRNA delivery performance is measured in multiple immune cell types and the approach's potential to engineer cell function is demonstrated in HIV infection studies.

Nipun Kalsotra, Manjeet Singh, Siddhartha Sharma, Dara SinghDepartment of Orthopaedics, Government Medical College Jammu, Jammu and Kashmir State, IndiaAbstract: Epidermoid cysts of the finger phalanx are rare pseudotumors. They are benign lesions with a satisfactory outcome after excision. It is important to differentiate this benign lesion, which can be easily treated by curettage, from other benign and malignant lesions of the bone with a similar clinical presentation, and which may require amputation. We describe a case of an epidermoid cyst in the distal phalanx of the ring finger. It was treated successfully and the patient had excellent functional results at one-year follow-up.Keywords: finger phalanx, epidermoid cyst, lytic bone lesion

Purpose. To evaluate the outcome of single screw-rod anterior instrumentation for thoracolumbar burst fractures with incomplete neurological deficit. Methods. 16 men and 5 women aged 22 to 55 (mean, 34) years underwent single screw-rod anterior instrumentation for thoracolumbar burst fractures with incomplete neurological deficit. The vertebrae involved were T10 (n=2), T11 (n=2), T12 (n=7), L1 (n=8), and L2 (n=2). No patient had disruption of the posterior ligament complex. Postoperatively, a thoracolumbar sacral orthosis was used until solid fusion. Outcome measures included neurological recovery, degree of kyphosis, complications, and pain and functional status of the patients. Results. The mean follow-up duration was 36 (range, 13–50) months. All patients recovered neurologically by at least one grade. Of the 21 patients, 6 improved from grade B to grade C (n=4) or grade D (n=2), 13 from grade C to grade D, and 2 from grade D to grade E. The mean degree of kyphosis improved from 23°±5° to 7°±3°. Seven patients had complications including ipsilateral basal atelectasis (n=3), urinary tract infection (n=1), haematuria (n=1), postoperative ileus (n=1), and superficial wound infection (n=1). None had iatrogenic visceral or vascular injury, pseudoarthrosis or hardware-related complications. Only one patient had severe back pain persistently. Conclusion. Single screw-rod anterior instrumentation supplemented with an orthosis can be an alternative for double screw-rod anterior instrumentation for thoracolumbar burst fractures in patients with smaller vertebral bodies.