# Development of a deep learning algorithm for radiographic detection of syndesmotic instability in ankle fractures with intraoperative validation

## TL;DR

A deep learning algorithm was developed to detect syndesmotic instability in ankle fractures using radiographs, validated against intraoperative results.

## Contribution

The novel contribution is a deep learning model trained on an intraoperative gold standard for detecting syndesmotic instability in ankle fractures.

## Key findings

- The algorithm achieved 91% sensitivity in AO44 classification of ankle fractures.
- Syndesmotic instability was detected with 84% sensitivity and 80% specificity.
- GSCAM visualizations provided consistent and interpretable results for the model's decisions.

## Abstract

Identifying syndesmotic instability in ankle fractures using conventional radiographs is still a major challenge. In this study we trained a convolutional neural network (CNN) to classify the fracture utilizing the AO-classification (AO-44 A/B/C) and to simultaneously detect syndesmosis instability in the conventional radiograph by leveraging the intraoperative stress testing as the gold standard. In this retrospective exploratory study we identified 700 patients with rotational ankle fractures at a university hospital from 2019 to 2024, from whom 1588 digital radiographs were extracted to train, validate, and test a CNN. Radiographs were classified based on the therapy-decisive gold standard of the intraoperative hook-test and the preoperatively determined AO-classification from the surgical report. To perform internal validation and quality control, the algorithm results were visualized using Guided Score Class activation maps (GSCAM).The AO44-classification sensitivity over all subclasses was 91%. Furthermore, the syndesmosis instability could be identified with a sensitivity of 0.84 (95% confidence interval (CI) 0.78, 0.92) and specificity 0.8 (95% CI 0.67, 0.9). Consistent visualization results were obtained from the GSCAMs. The integration of an explainable deep-learning algorithm, trained on an intraoperative gold standard showed a 0.84 sensitivity for syndesmotic stability testing. Thus, providing clinically interpretable outputs, suggesting potential for enhanced preoperative decision-making in complex ankle trauma.

The online version contains supplementary material available at 10.1038/s41598-025-14604-w.