Using machine learning in the prediction of symptomatic venous thromboembolism following ankle fracture.

BACKGROUND: Venous thromboembolism (VTE) is a major cause of morbidity and mortality in the trauma setting, and both prediction and prevention of VTE have long been a concern for healthcare providers in orthopedic surgery. The purpose of this study was to evaluate the use of novel statistical analysis and machine-learning in predicting the risk of VTE and the usefulness of prophylaxis following ankle fractures. METHODS: The medical profiles of 16,421 patients with ankle fractures were screened retrospectively for symptomatic VTE. In total, 238 patients sustaining either surgical or nonsurgical treatment for ankle fracture with subsequently confirmed VTE within 180 days following the injury were placed in the case group. Alternatively, 937 patients who sustained ankle fractures managed similarly but had no documented evidence of VTE were randomly chosen as the control group. Individuals from both the case and control populations were also divided into those who had received VTE prophylaxis and those who had not. Over 110 variables were included. Conventional statistics and machine learning methods were used for data analysis. RESULTS: Patients who had a motor vehicle accident, surgical treatment, increased hospital stay, and were on warfarin were shown to have a higher incidence of VTE, whereas patients who were on statins had a lower incidence of VTE. The highest Area Under the Receiver Operating Characteristic Curves (AUROC) showing the performance of our machine learning approach was 0.88 with 0.94 sensitivity and 0.36 specificity. The most balanced performance was seen in a model that was trained using selected variables with 0.86 AUROC, 0.75 sensitivity, and 0.85 specificity. CONCLUSION: By using machine learning, this study successfully pinpointed several predictive factors linked to the occurrence or absence of VTE in patients who experienced an ankle fracture. Training these algorithms using larger, more granular, and multicentric data will further increase their validity and reliability and should be considered the standard for the development of such algorithms. LEVEL OF EVIDENCE: Case-Control study - 3.

Effect of sequential burr passes on osteotomy magnitude and calcaneal morphology in minimally invasive Zadek osteotomy.

PURPOSE: This study aimed to evaluate the impact of each burr pass on degree of correction, gap size and calcaneal morphology in MIS Zadek osteotomy. METHODS: MIS Zadek osteotomy was performed on ten cadaveric specimens using a 3.1 mm Shannon burr. After each burr pass, the osteotomy gap was manually closed, and the subsequent burr passes were carried out with the foot held in dorsiflexion, which was repeated five times. Lateral X-rays were taken before and after each burr pass. Two independent reviewers measured the dorsal calcaneal length after each burr passage, as well as changes in several calcaneal parameters including X/Y ratio, Fowler Philip angle, and Böhler angle. RESULTS: The average decrease in dorsal calcaneal cortical length with each burr pass was as follows: 2.6 ± 0.9 mm at the 1st pass, 2.4 ± 1 mm at the 2nd pass, 2 ± 1 mm at the 3rd pass, 1.6 ± 1 mm at the 4th pass, and 1.4 ± 0.7 mm at the 5th pass. The Fowler Philip and Böhler angles consistently decreased while the X/Y ratio consistently increased following each consecutive burr pass. Interobserver reliability analysis demonstrated good agreement for all parameters. CONCLUSION: The results revealed the trends of length and anatomical changes in the calcaneus with each burr pass. On average, a dorsal wedge resection of 10 mm was achieved after 5 burr passes. This data can aid surgeons in determining the optimal number of burr passes required for a particular amount of resection, ensuring the attainment of the desired patient-specific surgical outcome.

Effect of sequential burr passes on minimally invasive akin and first metatarsal dorsiflexion osteotomies.

BACKGROUND: Minimally invasive surgical (MIS) osteotomies are increasing as a surgical option for treating midfoot and forefoot conditions. This study aimed to evaluate the impact of each burr pass on the degree of correction, gap size, and alignment in MIS Akin and first metatarsal dorsiflexion osteotomies (DFO). METHODS: MIS Akin and first metatarsal DFO were performed on ten cadaveric specimens. Fluoroscopic measurements included the metatarsal dorsiflexion angle (MDA), dorsal cortical length (MDCL), first phalangeal medial cortical length (PCML) and proximal to distal phalangeal articular angle (PDPAA). RESULTS: The average decrease in PCML with each burr pass was as follows: 1.53, 1.33, 1.27, 1.23 and 1.13 mm at the 1st to 5th pass, respectively. The MDCL sequentially decreased by 1.80, 1.59, 1.35, 0.75, and 0.60 mm. The MDA consistently decreased, and the PDPAA incrementally became more valgus oriented. CONCLUSION: On average, a first metatarsal dorsal wedge resection of 4.7 mm and first phalangeal medial wedge resection of 2.9 mm was achieved after 3 and 2 burr passes, respectively. This data may aid surgeons determine the optimal number of burr passes required to achieve the desired patient-specific surgical correction.

Normative contact mechanics of the ankle Joint: Quantitative assessment utilizing bilateral weightbearing CT.

Alterations in ankle's articular contact mechanics serve as one of the fundamental causes of significant pathology. Nevertheless, computationally intensive algorithms and lack of bilateral weightbearing imaging have rendered it difficult to investigate the normative articular contact stress and side-to-side differences. The aims of our study were two-fold: 1) to determine and quantify the presence of side-to-side contact differences in healthy ankles and 2) to establish normative ranges for articular ankle contact parameters. In this retrospective comparative study, 50 subjects with healthy ankles on bilateral weight-bearing CT were confirmed eligible. Segmentation into 3D bony models was performed semi-automatically, and individualized cartilage layers were modelled based on a previously validated methodology. Contact mechanics were evaluated by using the mean and maximum contact stress of the tibiotalar articulation. Absolute and percentage reference range values were determined for the side-to-side difference. Amongst a cohort of individuals devoid of ankle pathology, mean side-to-side variation in these measurements was < 12 %, while respective differences of > 17 % talar peak stress and > 31 % talar mean stress indicate abnormality. No significant differences were found between laterality in any of the evaluated contact parameters. Understanding these values may promote a more accurate assessment of ankle joint biomechanics when distinguishing acceptable versus pathological contact mechanics in clinical practice.

Disparity in sex in ankle fracture treatment.

BACKGROUND: Literature has shown implicit bias in the treatment between non-operative and surgical treatment in patients with certain types of ankle fractures, which comprise 7.6% of all adult fractures. An understanding of any bias across all ankle fracture management may prove to be critical for the understanding of potential correlations between treatment methods and outcomes of patients with ankle fractures. Therefore, this study aimed to determine whether there is a sex-based bias in the operative and non-operative treatment of all ankle fractures. METHODS: A retrospective study of 1175 adult patients with ankle fractures was conducted. Data extracted included sex, race, age, type of treatment (non-operative/operative), fracture type (displaced/non-displaced), fracture class, BMI, and length of hospital stay. Odds ratio (OR), Chi-squared, t-test, and Pearson's correlation tests were used with p < 0.05 considered significant. RESULTS: The study population consisted of 750 females (63.8%) and 425 males (36.2%). The study demonstrated a sex-based disparity in operative and non-operative treatment revealing that women are less likely than men to receive operative treatment for displaced ankle fractures (OR = 0.7, 95% CI: 0.5-0.9, p = 0.01). Of the 750 females, 417 (55.6%) underwent non-operative treatment, while 333 (44.4%) females had an operation. Of the 425 males, 204 (48%) had non-operative treatment, while 221 (52%) underwent operative treatment. The distribution of ankle fracture classes between both sexes was similar, suggesting fracture class did not influence the observed disparity. CONCLUSION: Our results suggest sex correlates with the treatment type for ankle fractures, with women more likely to receive non-operative treatment for displaced fractures. As post-treatment outcomes often reflect the chosen form of treatment, it is imperative to determine if a disparity in sex explicates differences in clinical outcomes.

Correlation Between Statin Use and Symptomatic Venous Thromboembolism Incidence in Patients With Ankle Fracture: A Machine Learning Approach.

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

Protective effect of Melissa officinalis against acetic acid-induced ulcerative colitis in rat models: an experimental study.

Background: Inflammation and oxidative activities within the gut play major roles in the pathogenesis of ulcerative colitis (UC). We aimed to determine the effect of Melissa officinalis, an antioxidant and anti-inflammatory agent, on the colon histological characteristics in acetic acid (AA)-induced UC in rat models. Methods: Thirty-six male rats with AA-induced colitis were divided into 5 groups: no treatment (AA); daily treatment with 300 mg/kg Melissa officinalis orally (MO) and rectally (MR); and 100 mg/kg mesalamine orally (AO) and rectally (AR). Macroscopic and histopathological evaluation of the colon, along with a biochemical laboratory evaluation, were performed 10 days after UC induction. Results: All treatment groups demonstrated lower macroscopic grading scores compared to the AA group. After treatment with MO, 42.9% of cases demonstrated no macroscopic changes, while 14.3% demonstrated only mucosal erythema. In the MR group 28.6% of rats had no changes in their mucosal lining and 28.6% had only mucosal erythema. Following histopathological evaluation, the AO group had lower scores regarding the severity of ulcer, inflammation, destruction, crypt abscess, and disorganization compared to the MO group. (P=0.02) The MR group demonstrated lower microscopic scores compared to the MO group, and also lower macroscopic scores compared to the AR group, although not significantly (P>0.05). Conclusions: Both oral and topical administration of Melissa officinalis have satisfactory healing properties compared to mesalamine, with topical route having better results. Therefore, further studies are needed to establish the benefit of Melissa officinalis administration (both orally and topically) within a UC treatment protocol.

Outcomes and complications of Traumatic ear lobe repair techniques: A systematic review.

BACKGROUND: Traumatic earlobe is a frequently encountered problem in our practice. Numerous techniques have been published in the past decades including case reports, retrospective reviews, and prospective studies. However, to date, no study has investigated the overall complications or satisfaction rates associated with the wide spectrum of techniques. OBJECTIVES: This review aims to assess the outcomes of the various earlobe repair techniques and to provide a simplified classification system. METHODS: This systematic review was performed in accordance with the PRISMA guidelines. PubMed database was queried in search of clinical studies describing surgical and non-surgical techniques, which reported techniques, indications, and outcomes. RESULTS: Twenty-six studies, published from 1973 through 2019, were included. Six main technique categories were identified: These were straight-line closure (type 1, n = 82), Z-plasty (type 2, n = 165), flaps (type 3, n = 66), L-specular plasty (type 4, n = 35), double-curve specular plasty (type 5, n = 15), and non-surgical techniques (type 6, n = 38). Z-plasty (type 2) had the highest post-operative infection rate of 11.5%. CONCLUSIONS: While all the techniques are generally simple and efficient, they should be chosen based on both surgeon and patient preference. Complication rates and morbidity are relatively low.

A rare case of an anatomical variation of bilateral long head of the biceps brachii tendons identified within the substance of bifid subscapularis tendons.

The long head of the biceps tendon is stabilized in the intertubercular groove by several anatomical structures. Dislocation or identification of the biceps tendon into or within the subscapularis tendon is very rarely mentioned in the literature. This is the first reported case of bilateral identification of the long head of the biceps tendons within the lateral subscapularis tendon. This report presents the case of a 51-year-old male patient who presented for bilateral shoulder pain. After failure of conservative treatment, MRIs were done which identified bilateral biceps tendons within the subscapularis tendons, with a concomitant supraspinatus tear on the right side. He underwent right shoulder arthroscopic biceps tenotomy, with supraspinatus repair. The symptoms of the left shoulder diminished as a result of the continuation of conservative treatment. The long head of the biceps tendon normally travels through the intertubercular groove and is stabilized by soft tissue and bony structures. Medial dislocation of the tendon is affected by the medial wall angle and by the integrity of the soft tissue stabilizers; most importantly the coracohumeral ligament in the proximal part of the groove. Dislocation of the biceps tendon into the substance of the subscapularis has been rarely mentioned in the literature; and as far as we know, bilateral occurrence without any identifiable subscapularis tears has never been previously mentioned. The bilateral occurrence with the absence of subscapularis lesions indicates that this is a congenital anomaly.