A New Paradigm in Foot and Ankle Outcomes?: Away From Radiographs and Toward Patient-Centered Outcomes.

Having reasonable outcome measures is essential to unbiased research. For years, provider-measured outcomes have been valued as they are more objective and convenient for investigators. However, with the popularity of patient-centered medical care delivery, patient-reported outcome measures are appropriately becoming more popular in foot and ankle research.

From jargon to clarity: Improving the readability of foot and ankle radiology reports with an artificial intelligence large language model.

BACKGROUND: The purpose of this study was to evaluate the efficacy of an Artificial Intelligence Large Language Model (AI-LLM) at improving the readability foot and ankle orthopedic radiology reports. METHODS: The radiology reports from 100 foot or ankle X-Rays, 100 computed tomography (CT) scans and 100 magnetic resonance imaging (MRI) scans were randomly sampled from the institution's database. The following prompt command was inserted into the AI-LLM: "Explain this radiology report to a patient in layman's terms in the second person: [Report Text]". The mean report length, Flesch reading ease score (FRES) and Flesch-Kincaid reading level (FKRL) were evaluated for both the original radiology report and the AI-LLM generated report. The accuracy of the information contained within the AI-LLM report was assessed via a 5-point Likert scale. Additionally, any "hallucinations" generated by the AI-LLM report were recorded. RESULTS: There was a statistically significant improvement in mean FRES scores in the AI-LLM generated X-Ray report (33.8 ± 6.8 to 72.7 ± 5.4), CT report (27.8 ± 4.6 to 67.5 ± 4.9) and MRI report (20.3 ± 7.2 to 66.9 ± 3.9), all p < 0.001. There was also a statistically significant improvement in mean FKRL scores in the AI-LLM generated X-Ray report (12.2 ± 1.1 to 8.5 ± 0.4), CT report (15.4 ± 2.0 to 8.4 ± 0.6) and MRI report (14.1 ± 1.6 to 8.5 ± 0.5), all p < 0.001. Superior FRES scores were observed in the AI-LLM generated X-Ray report compared to the AI-LLM generated CT report and MRI report, p < 0.001. The mean Likert score for the AI-LLM generated X-Ray report, CT report and MRI report was 4.0 ± 0.3, 3.9 ± 0.4, and 3.9 ± 0.4, respectively. The rate of hallucinations in the AI-LLM generated X-Ray report, CT report and MRI report was 4%, 7% and 6%, respectively. CONCLUSION: AI-LLM was an efficacious tool for improving the readability of foot and ankle radiological reports across multiple imaging modalities. Superior FRES scores together with superior Likert scores were observed in the X-Ray AI-LLM reports compared to the CT and MRI AI-LLM reports. This study demonstrates the potential use of AI-LLMs as a new patient-centric approach for enhancing patient understanding of their foot and ankle radiology reports. Jel Classifications: IV.

Diagnostic applications and benefits of weightbearing CT in the foot and ankle: A systematic review of clinical studies.

BACKGROUND: Foot and ankle weightbearing CT (WBCT) imaging has emerged over the past decade. However, a systematic review of diagnostic applications has not been conducted so far. METHOD: A systematic literature search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines after Prospective Register of Systematic Reviews (PROSPERO) registration. Studies analyzing diagnostic applications of WBCT were included. Main exclusion criteria were: cadaveric specimens and simulated WBCT. The Methodological Index for Non-Randomized Studies (MINORS) was used for quality assessment. RESULTS: A total of 78 studies were eligible for review. Diagnostic applications were identified in following anatomical area's: ankle (n = 14); hindfoot (n = 41); midfoot (n = 4); forefoot (n = 19). Diagnostic applications that could not be used on weightbearing radiographs (WBRX) were reported in 56/78 studies. The mean MINORS was 9.8/24 (range: 8-12). CONCLUSION: Diagnostic applications of WBCT were most frequent in the hindfoot, but other areas are on the rise. Post-processing of images was the main benefit compared to WBRX based on a moderate quality of the identified studies.

Prevalence of Ankle Charcot Neuroarthropathy Presenting in a Tertiary Care Center.

Charcot neuroarthropathy's (CN) anatomic classification was originally formulated by the Brodsky article and the Trepman et al modification, including midfoot (type 1), rearfoot (type 2), ankle (type 3a), calcaneus (type 3b), multiarticular (type 4), and forefoot (type 5). In these classic studies, ankle joint and multijoint CN are reported as 9% and 6% to 9%, respectively, but we believe ankle CN to be more common than that in a tertiary setting. We retrospectively reviewed patients presenting initially or as referral between 2004 and 2020. Initial presentation radiographs were reviewed and classified by 3 authors based on Brodsky's model with Trepman and colleagues' modification, and any discrepancies were reviewed by the fourth author. A total of 175 patients (205 feet) were assessed. This revealed 80 cases classified as type 1 (39.0%), 23 cases type 2 (11.2%), 17 cases type 3a (8.3%), 2 cases type 3b (1.0%), and 83 cases type 4 (40.5%). After subdividing type 4, total prevalence included 150 with type 1 anatomic location (73.2%), 103 type 2 (50.2%), 44 type 3a (21.5%), and still 2 type 3b (1.0%). This study revealed a similar prevalence of isolated ankle CN (8.5%) compared to the Trepman et al article (9%), however, in total, ankle CN (21.5%) occurred 2.4-times more than the original 9%. Our study also found there to be a higher prevalence of ankle CN in the setting of multiarticular CN, which has not been evaluated in past studies. The prevalence of multiarticular CN was found to be 4.5-fold greater than the Trepman article (6%-9%).

Anterior Tarsal Tunnel Syndrome: Entrapment of the Articular Branch of Deep Peroneal Nerve: A Case Report.

CASE: A 28-year-old male patient who injured his ankle 2 years ago presented with unilateral ankle pain, tingling, and numbness for 1 year. Clinically, tenderness and positive Tinel sign were localized on anterior aspect of ankle. On exploration, deep peroneal nerve and mainly its articular branch were encased in fibrotic tissue. Decompression of both nerves resulted in symptomatic relief after surgery. CONCLUSION: High index of suspicion, a thorough medical history, meticulous clinical examination, complete knowledge of nerve anatomy, proper radiological studies, and careful surgical decompression are all necessary for the diagnosis and management of such atypical cases.

Artificial intelligence in foot and ankle surgery: current concepts.

The twenty-first century has proven that data are the new gold. Artificial intelligence (AI) driven technologies might potentially change the clinical practice in all medical specialities, including orthopedic surgery. AI has a broad spectrum of subcomponents, including machine learning, which consists of a subdivision called deep learning. AI has the potential to increase healthcare delivery, improve indications and interventions, and minimize errors. In orthopedic surgery. AI supports the surgeon in the evaluation of radiological images, training of surgical residents, and excellent performance of machine-assisted surgery. The AI algorithms improve the administrative and management processes of hospitals and clinics, electronic healthcare databases, monitoring the outcomes, and safety controls. AI models are being developed in nearly all orthopedic subspecialties, including arthroscopy, arthroplasty, tumor, spinal and pediatric surgery. The present study discusses current applications, limitations, and future prospective of AI in foot and ankle surgery.

Ankle Joint Bone Density Distribution Correlates with Overall 3-Dimensional Foot and Ankle Alignment.

BACKGROUND: Altered stress distribution in the lower limb may impact bone mineral density (BMD) in the ankle bones. The purpose of the present study was to evaluate the spatial distribution of BMD with use of weight-bearing cone-beam computed tomography (WBCT). Our hypothesis was that BMD distribution would be even in normal hindfeet, increased medially in varus hindfeet, and increased laterally in valgus hindfeet. METHODS: In this study, 27 normally aligned hindfeet were retrospectively compared with 27 valgus and 27 varus-aligned hindfeet. Age (p = 0.967), body mass index (p = 0.669), sex (p = 0.820), and side (p = 0.708) were similar in the 3 groups. Hindfoot alignment was quantified on the basis of WBCT data sets with use of multiple measurements. BMD was calculated with use of the mean Hounsfield unit (HU) value as a surrogate. The HU medial-to-lateral ratio (HUR), calculated from tibial and talar medial and lateral half-volumes, was the primary outcome of the study. RESULTS: The 3 groups significantly differed (p < 0.001) in terms of tibial HUR (median, 0.91 [interquartile range (IQR), 0.75 to 0.98] in valgus hindfeet, 1 [IQR, 0.94 to 1.05] in normal hindfeet, and 1.04 [IQR, 0.99 to 1.1] in varus hindfeet) and talar HUR (0.74 [IQR, 0.50 to 0.80] in valgus hindfeet, 0.82 [IQR, 0.76 to 0.87] in normal hindfeet, and 0.92 [IQR, 0.86 to 1.05] in varus hindfeet). Linear regression showed that all hindfoot measurements significantly correlated with tibial and talar HUR (p < 0.001 for all). The mean HU values for normally-aligned hindfeet were 495.2 ± 110 (medial tibia), 495.6 ± 108.1 (lateral tibia), 368.9 ± 80.3 (medial talus), 448.2 ± 90.6 (lateral talus), and 686.7 ± 120.4 (fibula). The mean HU value for each compartment was not significantly different across groups. CONCLUSIONS: Hindfoot alignment and medial-to-lateral BMD distribution were correlated. In varus hindfeet, an increased HU medial-to-lateral ratio was consistent with a greater medial bone density in the tibia and talus as compared with the lateral parts of these bones. In valgus hindfeet, a decreased ratio suggested greater bone density in the lateral as compared with the medial parts of both the tibia and the talus. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Osteomyelitis and Septic Arthritis of the Foot and Ankle: Imaging Update.

Radiography is considered the first-line screening exam for clinically suspected osteomyelitis. However, additional evaluation is generally needed. MRI is the definitive diagnostic exam with high sensitivity and specificity combined with excellent anatomic definition. Gadolinium contrast can be useful to detect areas of devitalization before surgery. Bone marrow edema on fluid-sensitive images and low signal intensity on T1-weighted images in the presence of secondary MRI findings, including ulcer, sinus tract, and cellulitis with or without abscess are typical findings of osteomyelitis. If MRI is contraindicated, three phase bone scan can be used. Early diagnosis and treatment is essential.

MRI of Pediatric Foot and Ankle Conditions.

The increase in competitive sports practice among children and lack of ionizing radiation have resulted in a higher demand for MRI examinations. MRI of the children skeleton has some particularities that can lead orthopedists, pediatricians, and radiologists to diagnostic errors. The foot and ankle have several bones with abundant radiolucent and high signal intensity cartilage in several ossification centers, apophysis and physis, that can make this interpretation even harder. The present revision aims to show, how to differentiate between normal developmental findings and anatomic variants from pathologic conditions, whether mechanical, inflammatory, infectious, or neoplastic.

Osteochondral Lesions of the Ankle and Foot.

Osteochondral lesions (OCLs) in the ankle are more common than OCLs of the foot, but both share a similar imaging appearance. Knowledge of the various imaging modalities, as well as available surgical techniques, is important for radiologists. We discuss radiographs, ultrasonography, computed tomography, single-photon emission computed tomography/computed tomography, and magnetic resonance imaging to evaluate OCLs. In addition, various surgical techniques used to treat OCLs-debridement, retrograde drilling, microfracture, micronized cartilage-augmented microfracture, autografts, and allografts-are described with an emphasis on postoperative appearance following these techniques.

Current Concepts of Foot and Ankle Angioleiomyoma.

Angioleiomyoma is a benign tumor, which arises from the smooth muscle. It comprises approximately 4.4% of all benign soft tissues' neoplasms and they are commonly located at the lower extremities. They are most frequently found in middle-aged women. Angioleiomyoma is usually presented as a painful solitary lesion in the subcutaneous tissue. Due to the lack of evidence in the literature, the aim of this current concepts review was to provide foot and ankle surgeons the most updated and useful information for diagnosis and management of foot or ankle's angioleiomyoma. The possible diagnosis of angioleiomyoma is rarely thought of before surgery. X-ray, US, MRI, aspiration, scintigraphy, CT and EMG make part of the diagnostic tools available and angioleiomyoma's main characteristics in each of the exams are detailed. Angioleiomyoma cannot be neglected as consequence of delay or mistreatment increases morbidity and the potential risk to malignant transformation.

Magnetic resonance imaging of the ankle: Pathology of the lateral and posterior compartments.

Magnetic resonance imaging (MRI) is the gold standard for imaging the tendons and the ligaments of the ankle. MRI combines excellent tissue contrast and accurate anatomic delineation of joint structures. In the first article of this series, we discussed a compartmental approach to the interpretation of ankle pathology focusing on the anterior and medial compartments. This article will complete the MR review of the ankle, with a focus on the lateral and posterior compartments of the ankle.

Magnetic resonance imaging of the ankle: Pathology of the anterior and medial compartments.

Magnetic resonance imaging (MRI) is the gold standard for imaging the tendons and the ligaments of the ankle. MRI combines excellent tissue contrast and accurate anatomic delineation of joint structures. In this pictorial essay, the first of two parts, we delineate the ankle into anatomic compartments and use this as a template for describing pathology in each compartment.

A 3-DOF electromotor-driven external fixator for foot and ankle deformity correction based on X-ray digital measurement.

BACKGROUND: The use of external fixators to treat foot and ankle deformities remains a challenge in orthopedic surgery due to their diversity. We hope to improve the automation and accuracy of the correction process. METHODS: A three-degree-of-freedom (3-DOF) electromotor-driven external fixator for uniplanar foot and ankle deformities was proposed. Computer-assisted correction software was developed to help surgeons use digital technology to measure the required parameters from patients' X-ray radiographs. The correction trajectory and the prescriptions were generated in the software based on the proposed correction strategy. RESULTS: Two clinical cases were simulated to verify the correction ability of the developed external fixator. The results showed that the angular and displacement deformities were well corrected. CONCLUSIONS: The developed external fixator can accurately and automatically correct foot and ankle deformities with the help of computer-assisted correction software, which significantly reduces the burden on surgeons and patients.

Hindfoot alignment assessment by the foot-ankle offset: a diagnostic study.

INTRODUCTION: Foot-ankle offset (FAO) is a three-dimensional (3D) biometric measurement of hindfoot alignment (HA) measured on images from weight-bearing computed tomography (WBCT). Our aim was to investigate its distribution in a large cohort of patients, hypothesizing that threshold FAO values in valgus or varus could be identified as markers for increased risk of associated pathologies. MATERIALS AND METHODS: Prospective, monocentric, level II study including 125 subjects (250 feet) undergoing bilateral WBCT [58.4% female; mean age, 54 years (18-84)]. Patients were clinically assessed and pathologies were classified according to anatomic location (valgus- or varus associated). HA was measured using FAO on 3D datasets and tibio-calcaneal angles (TCA) on two-dimensional Saltzman-El-Khoury views. Threshold FAO values and area under the receiver operating characteristics curve (AUC) were calculated for predicting increased risk of medial or lateral pathologies. RESULTS: Mean FAO was 1.65% ± 4.72 and mean TCA was 4.15° ± 7.67. Clinically, 167 feet were normal, 33 varus and 50 valgus with FAO values of 1.71% ± 3.16, - 4.96% ± 5.30 and 5.79% ± 3.77, respectively. Mean FAO was 0.99% ± 3.26 for non-pathological feet, - 2.53% ± 5.05 for lateral and 6.81% ± 2.70 for medial pathologies. Threshold FAO values of - 1.64% (51.4% sensitivity, 85.1% specificity, AUC = 0.72) and 2.71% (95% sensitivity, 82.8% specificity, AUC = 0.93) best predicted the risk of lateral and medial pathology, respectively. CONCLUSION: Patients with FAO between - 1.64% and 2.71% had the least risk of degenerative foot and ankle pathology. This interval could be considered a target for patients undergoing realignment procedures. CLINICAL RELEVANCE: A "safe zone" for Foot Ankle Offset was described between - 1.64% and 2.71%, for which the risk of foot and ankle pathologies is lower. LEVEL OF EVIDENCE: II-Diagnostic study.

Semi-automated 3-dimensional analysis of the normal foot and ankle using weight bearing CT - A report of normal values and bony relationships.

BACKGROUND: Foot and ankle deformities have translational and rotational components in multiple planes, at multiple levels. Semi-automatic segmentation is a relatively new technology, which when used with weight-bearing CT (WBCT), can build an accurate model of the foot and calculate the orientation and relationships of bones under physiological load. However, few papers report reference values using these techniques. We report normative values for key bony relationships based on semi-automated analysis of WBCT. METHODS: This was a single-centre, retrospective analysis of 100 feet without deformity from 55 adult patients undergoing WBCT as part of routine clinical activity (mean age 40.5 ± 17.3 years). Imaging was analysed using Bonelogic 2.1 (DISIOR, Finland). Semi-automatic segmentation was used to compute the various bony axes in 3-dimensional space. Selected coronal, axial and sagittal plane relationships were then calculated for bones of the hindfoot, midfoot and forefoot. RESULTS: Data is presented on axial and sagittal plane relationships between the metatarsals in the forefoot, and the metatarsals and cuneiforms in the midfoot. In the hindfoot, the calcaneal pitch, talar-first-metatarsal angles, talonavicular coverage angles and Saltzman angles are reported. Coronal plane axes and their relationships are reported at multiple levels from hindfoot to forefoot. Results are presented as mean values with standard deviations and 95% confidence intervals. CONCLUSIONS: We present an observational analysis of the normal values from non-deformed feet. We highlight the major relationships in the axial, sagittal and coronal planes as obtained by semi-automated analysis of WBCT. This data may serve as a reference for future research. LEVEL OF EVIDENCE: Basic science study.

A rare case of an intra-articular true lipoma of the ankle.

BACKGROUND: Most of the foot and ankle soft tissue tumors are benign. Although lipomas are the most common soft tissue tumors, intra-articular lipomas are an extremely rare entity. The majority of described cases of intra-articular lipomas occur in the knee joint. In particular, an intra-articular true lipoma of the ankle has not been reported. CASE PRESENTATION: We report the case of a 45-year-old woman who presented with a progressively growing ankle mass over 5 years, which started to restrict the range of motion. It was not preceded by any trauma or sports activity. On examination, a non-tender firm mass was evident on the lateral aspect of the right ankle joint with no signs of inflammation. It was non-compressible, non-mobile, and did not transilluminate. The clinical diagnosis was probable for a soft tissue ganglion. A radiograph revealed a soft tissue opacity over the anterolateral aspect of the tibiotalar joint. Magnetic resonance imaging (MRI) demonstrated a well-defined, multilobulated, encapsulated lesion located at the lateral aspect of the tibiotalar joint; with intra- and extra-articular components and an analogous signal intensity to fat. The patient underwent surgical excision of the tumor, and the histopathological examination showed mature adipose tissue representing an intra-articular lipoma. At the follow-up visit, the patient had complete resolution of symptoms and no active complaints. CONCLUSION: An intra-articular true lipoma of the ankle is an extremely rare tumor. MRI is an invaluable diagnostic tool to make a reliable diagnosis of intra-articular masses.

Postoperative MRI of the Ankle and Foot.

Many surgical procedures and operations are used to treat ankle and foot disorders. Radiography is the first-line imaging for postoperative surveillance and evaluation of pain and dysfunction. Computed tomography scans and MR imaging are used for further evaluation. MR imaging is the most accurate test for soft tissues assessments. MR imaging protocol adjustments include basic and advanced metal artifact reduction. We chose a surgical approach to select the common types of procedures and discuss the normal and abnormal postoperative MR imaging appearances, highlighting potential complications. This article reviews commonly used surgical techniques and their normal and abnormal MR imaging appearances.