Randomized controlled trial of multidisciplinary rehabilitation therapy using mobile applications in cases of ankle fractures.

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Abstract

Conflict of interest statement: We confirm that we have read the journal’s position on ethical issues involved in publication and affirm that this report is consistent with those guidelines. The ankle is the most overloaded hinge joint with a joint surface of 6 sq.cm. and one of the joints suffering the most injuries. The Maisonneuve fracture is a spiral fracture of the proximal third of the fibula associated with a tear of the distal tibiofibular syndesmosis and the interosseous membrane.¹ According Goost H. ankle fractures are initially evaluated by physical examination and then by x-ray. They can be classified according to either the AO Foundation (Association for the Study of Internal Fixation) or the Weber classification. Dislocated fractures need emergency treatment with immediate reduction; this is crucial for the prevention of hypoperfusion and nerve damage. Weber A fractures can usually be treated conservatively, while Weber B and C fractures are usually treated with surgery. An evaluation of the stability of the syndesmosis is important for anatomical reconstruction of the joint.² Ankle fractures often affect people in their active years and it reflects on their physical and social status. The ankle joint bears a great weight and is also the structural morphological unit that plays an active part in maintaining the static-dynamic balance of the body. Ankle fractures can be classified as single malleolar, bimalleolar, and trimalleolar if the posterior part of the tibial plafond is involved. Careful attention must be paid to all single malleolar fractures because ligament instability is frequently associated with the contralateral side. Ankle fractures are common, with an incidence of up to 174 cases per 100 000 adults per year. Their correct classification and treatment are of decisive importance for clinical outcome.² In a study of Kannus et al about prediction of the number and incidence of low-trauma ankle fractures in Finnish persons ≥60 years of age rose substantially: the total number of fractures increased from 369 in 1970 to 1545 in 2000, a 319% increase, and the crude incidence increased from 57 to 150, a 163% increase. The age-adjusted incidence of these fractures also rose in both women (from 66 in 1970 to 174 in 2000, a 164% increase) and men (from 38 in 1970 to 114 in 2000, a 200% increase). The regression model indicates that, if this trend continues, there will be about three times more low-trauma ankle fractures in Finland in the year 2030 than there was in 2000.³ In children ankle fractures occur in about 1 per 1000 per year., Ankle fractures have a bimodal age distribution with peaks in younger males and older females.⁶ There has been three-fold increase in the incidence amongst elderly females over the past three decades.⁷ In addition, amongst multiply injured patients foot injuries are prognostically important: those who survive their injuries are far more impaired functionally if they have a foot injury in addition to multisystem trauma., Ankle fractures result in significant morbidity in adults, with prognosis worsening with increasing age.¹⁰ They usually result from indirect traumas. In recent years, surgical treatment has been increasingly applied in ankle fractures. The research of the Swiss group on osteosynthesis and the works of Weber have contributed to this. The Danis-Weber classification for ankle fractures is simple and is the most useful for primary care management. This classification scheme is based on the level of the fracture in relationship to the joint mortise of the distal fibula., Calcaneal fractures are complex injuries that historically had a poor prognosis, resulting in substantial disability.¹³ Multidisciplinary rehabilitation therapy is one of the main parts in the recover process in cases of fractures of the shank bones. Due to the accompanying muscular atrophy of the quadriceps of the thigh, the process of rehabilitation has to commence as early as possible. During the early postoperative period (3-7 days), mild exercises, segmental massage of the lower limb, and physiotherapeutic procedures can be performed. In the late postoperative period (24-30 days), is recommended balance and coordination exercises, muscle-strengthening exercises, cycle ergometer, and hydrotherapy. There is a wide range of kinesitherapeutic techniques that can be performed during this stage. The physiotherapeutic interventions are the key elements of the multidisciplinary management of musculoskeletal conditions and diseases. The application of preformed physical factors is mandatory in disorders and diseases of the locomotor system. The means to choose from in this type of fracture include: electrical muscle stimulation with low-frequency current or medium frequency current. Transcutaneous electrical stimulation of low- and medium-frequency currents is commonly used in pain management. Interferential current (IFC) therapy, a medium frequency alternating current therapy that reportedly reduces skin impedance, can reach deeper tissues.¹⁴ The mechanism of impact of the various physical factors (electrical therapy, ultra sound, radiation, mineral water, mechanical influence, etc.) is complex and complicated. A significant clinical effect can be expected only when the effect of these factors is well known and used competently and expertly. The rehabilitation therapy of ankle fractures is complex: physical therapy interventions, electrical therapy, cryotherapy, cryomassage, medicinal massage, drainage massage and selective massage, kinesitherapy and mechanical therapy, depending on the stage and the functional deficiencies The prompt and purposeful administration of the means and methods of kinesitherapy is of vital importance for the recuperation of patients who have suffered a trauma of the ankle joint. The aim of this study is to follow up on the restoration of the locomotion in lower extremities among patients with ankle fractures. 3. Eur J Trauma Emerg Surg. 2023 Apr;49(2):1057-1069. doi: 10.1007/s00068-022-02136-1. Epub 2022 Nov 14. Development and external validation of automated detection, classification, and localization of ankle fractures: inside the black box of a convolutional neural network (CNN). Prijs J(1)(2)(3), Liao Z(4), To MS(5)(6), Verjans J(4), Jutte PC(7), Stirler V(7), Olczak J(8), Gordon M(8), Guss D(9)(10), DiGiovanni CW(9)(10), Jaarsma RL(11), IJpma FFA(7), Doornberg JN(7)(11)(5); Machine Learning Consortium. Collaborators: Aksakal K, Barvelink B, Beuker B, Bultra AE, Oliviera LEC, Colaris J, de Klerk H, Duckworth A, Ten Duis K, Fennema E, Harbers J, Hendrickx R, Heng M, Hoeksema S, Hogervorst M, Jadav B, Jiang J, Karhade A, Kerkhoffs G, Kuipers J, Laane C, Langerhuizen D, Lubberts B, Mallee W, Mhmud H, El Moumni M, Nieboer P, Nijhuis KO, van Ooijen P, Oosterhoff J, Rawat J, Ring D, Schilstra S, Schwab J, Sprague S, Stufkens S, Tijdens E, van der Bekerom M, van der Vet P, de Vries JP, Wendt K, Wijffels M, Worsley D. Author information: (1)Department of Orthopaedic Surgery, Groningen University Medical Centre, Groningen, The Netherlands. jasperprijs@icloud.com. (2)Department of Surgery, Groningen University Medical Centre, Groningen, The Netherlands. jasperprijs@icloud.com. (3)Department of Orthopaedic & Trauma Surgery, Flinders Medical Centre, Flinders University, Adelaide, Australia. jasperprijs@icloud.com. (4)Australian Institute for Machine Learning, Adelaide, Australia. (5)College of Medicine and Public Health, Flinders University, Adelaide, Australia. (6)Department of Neurosurgery, Flinders Medical Center, Adelaide, Australia. (7)Department of Orthopaedic Surgery, Groningen University Medical Centre, Groningen, The Netherlands. (8)Institute of Clinical Sciences, Danderyd University Hospital, Karolinska Institute, Solna, Sweden. (9)Massachusetts General Hospital, Boston, USA. (10)Harvard Medical School, Boston, USA. (11)Department of Orthopaedic & Trauma Surgery, Flinders Medical Centre, Flinders University, Adelaide, Australia. PURPOSE: Convolutional neural networks (CNNs) are increasingly being developed for automated fracture detection in orthopaedic trauma surgery. Studies to date, however, are limited to providing classification based on the entire image-and only produce heatmaps for approximate fracture localization instead of delineating exact fracture morphology. Therefore, we aimed to answer (1) what is the performance of a CNN that detects, classifies, localizes, and segments an ankle fracture, and (2) would this be externally valid? METHODS: The training set included 326 isolated fibula fractures and 423 non-fracture radiographs. The Detectron2 implementation of the Mask R-CNN was trained with labelled and annotated radiographs. The internal validation (or 'test set') and external validation sets consisted of 300 and 334 radiographs, respectively. Consensus agreement between three experienced fellowship-trained trauma surgeons was defined as the ground truth label. Diagnostic accuracy and area under the receiver operator characteristic curve (AUC) were used to assess classification performance. The Intersection over Union (IoU) was used to quantify accuracy of the segmentation predictions by the CNN, where a value of 0.5 is generally considered an adequate segmentation. RESULTS: The final CNN was able to classify fibula fractures according to four classes (Danis-Weber A, B, C and No Fracture) with AUC values ranging from 0.93 to 0.99. Diagnostic accuracy was 89% on the test set with average sensitivity of 89% and specificity of 96%. External validity was 89-90% accurate on a set of radiographs from a different hospital. Accuracies/AUCs observed were 100/0.99 for the 'No Fracture' class, 92/0.99 for 'Weber B', 88/0.93 for 'Weber C', and 76/0.97 for 'Weber A'. For the fracture bounding box prediction by the CNN, a mean IoU of 0.65 (SD ± 0.16) was observed. The fracture segmentation predictions by the CNN resulted in a mean IoU of 0.47 (SD ± 0.17). CONCLUSIONS: This study presents a look into the 'black box' of CNNs and represents the first automated delineation (segmentation) of fracture lines on (ankle) radiographs. The AUC values presented in this paper indicate good discriminatory capability of the CNN and substantiate further study of CNNs in detecting and classifying ankle fractures. LEVEL OF EVIDENCE: II, Diagnostic imaging study. © 2022. The Author(s). DOI: 10.1007/s00068-022-02136-1 PMCID: PMC10175446