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Oh CW, Park KH, Kim JW, Kim DH, Seo I, Lee JH, Kim JW, Yoon SH. Minimally Invasive Derotational Osteotomy of Long Bones: Smartphone Application Used to Improve the Accuracy of Correction. J Clin Med 2023; 12:jcm12041335. [PMID: 36835871 PMCID: PMC9965314 DOI: 10.3390/jcm12041335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 01/22/2023] [Accepted: 02/06/2023] [Indexed: 02/10/2023] Open
Abstract
Correction of rotational malalignments caused by fractures is essential as it may cause pain and gait disturbances. This study evaluated the intraoperative use of a smartphone application (SP app) to measure the extent of corrective rotation in patients treated using minimally invasive derotational osteotomy. Intraoperatively, two parallel 5 mm Schanz pins were placed above and below the fractured/injured site, and derotation was performed manually after percutaneous osteotomy. A protractor SP app was used intraoperatively to measure the angle between the two Schanz pins (angle-SP). Intramedullary nailing or minimally invasive plate osteosynthesis was performed after derotation, and computerized tomography (CT) scans were used to assess the angle of correction postoperatively (angle-CT). The accuracy of rotational correction was assessed by comparing angle-SP and angle-CT. The mean preoperative rotational difference observed was 22.1°, while the mean angle-SP and angle-CT were 21.6° and 21.3°, respectively. A significant positive correlation between angle-SP and angle-CT was observed, and 18 out of 19 patients exhibited complete healing within 17.7 weeks (1 patient exhibited nonunion). These findings suggest that using an SP app during minimally invasive derotational osteotomy can result in accurate correction of malrotation of long bones in a reproducible manner. Therefore, SP technology with integrated gyroscope function represents a suitable alternative for determination of the magnitude of rotational correction when performing corrective osteotomy.
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Affiliation(s)
- Chang-Wug Oh
- Department of Orthopedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu 41944, Republic of Korea
| | - Kyeong-Hyeon Park
- Department of Orthopedic Surgery, Severance Children’s Hospital, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
- Correspondence: ; Tel.: +82-53-420-5628
| | - Joon-Woo Kim
- Department of Orthopedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu 41944, Republic of Korea
| | - Dong-Hyun Kim
- Department of Orthopedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu 41944, Republic of Korea
| | - Il Seo
- Department of Orthopedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu 41944, Republic of Korea
| | - Jin-Han Lee
- Department of Orthopedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu 41944, Republic of Korea
| | - Ji-Wan Kim
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea
| | - Sung-Hyuk Yoon
- Department of Orthopedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu 41944, Republic of Korea
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Keppler AM, Küßner K, Schulze AL, Suero EM, Neuerburg C, Weigert M, Braun C, Böcker W, Kammerlander C, Zeckey C. Radiographic cortical thickness parameters as predictors of rotational alignment in proximal tibial shaft fractures: a cadaveric study. BMC Musculoskelet Disord 2021; 22:590. [PMID: 34174846 PMCID: PMC8236139 DOI: 10.1186/s12891-021-04452-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 06/10/2021] [Indexed: 11/10/2022] Open
Abstract
AIM The treatment of tibial fractures with an intramedullary nail is an established procedure. However, torsional control remains challenging using intraoperatively diagnostic tools. Radiographic tools such as the Cortical Step Sign (CSS) and the Diameter Difference Sign (DDS) may serve as tools for diagnosing a relevant malrotation. The aim of this study was to investigate the effect of torsional malalignment on CSS and DDS parameters and to construct a prognostic model to detect malalignment. METHODS A proximal tibial shaft fracture was set in human tibiae. Torsion was set stepwise from 0° to 30° in external and internal torsion. Images were obtained with a C-arm and transferred to a PC for measuring the medical cortical thickness (MCT), lateral cortical thickness (LCT), tibial diameter (TD) in AP and the anterior cortical thickness (ACT) as well as the posterior cortical thickness (PCT) and the transverse diameter (TD) of the proximal and the distal main fragment. RESULTS There were significant differences between the various degrees of torsion for each of the absolute values of the examined variables. The parameters with the highest correlation were TD, LCT and ACT. A model combining ACT, LCT, PCT and TD lateral was most suitable model in identifying torsional malalignment. The best prediction of clinically relevant torsional malalignment, namely 15°, was obtained with the TD and the ACT. CONCLUSION This study shows that the CSS and DDS are useful tools for the intraoperative detection of torsional malalignment in proximal tibial shaft fractures and should be used to prevent maltorsion.
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Affiliation(s)
- Alexander M Keppler
- Department of General, Trauma and Reconstructive Surgery, University Hospital LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Konstantin Küßner
- Department of General, Trauma and Reconstructive Surgery, University Hospital LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Anna-Lena Schulze
- Department of General, Trauma and Reconstructive Surgery, University Hospital LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Eduardo M Suero
- Department of General, Trauma and Reconstructive Surgery, University Hospital LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Carl Neuerburg
- Department of General, Trauma and Reconstructive Surgery, University Hospital LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Maximilian Weigert
- Statistical Consulting Unit, StabLab, Department of Statistics, LMU Munich, Munich, Germany
| | - Christian Braun
- Institute of Legal and Forensic Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Wolfgang Böcker
- Department of General, Trauma and Reconstructive Surgery, University Hospital LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Christian Kammerlander
- Department of General, Trauma and Reconstructive Surgery, University Hospital LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Christian Zeckey
- Department of General, Trauma and Reconstructive Surgery, University Hospital LMU Munich, Marchioninistraße 15, 81377, Munich, Germany. .,Departement of Trauma and Orthopedic Surgery, RoMed Hospital, Pettenkoferstr.10, 83022, Rosenheim, Germany.
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Keppler AM, Küssner K, Suero EM, Kronseder V, Böcker W, Kammerlander C, Zeckey C, Neuerburg C. Intraoperative torsion control using the cortical step sign and diameter difference in tibial mid-shaft fractures. Eur J Trauma Emerg Surg 2021; 48:3659-3667. [PMID: 33388784 DOI: 10.1007/s00068-020-01566-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 11/21/2020] [Indexed: 11/25/2022]
Abstract
AIM Intramedullar nailing of tibial mid-shaft fractures is a common surgical treatment. Fracture reduction, however, remains challenging and maltorsion is a common discrepancy which aggravates functional impairment of gait and stability. The use of radiographic tools such as the cortical step sign (CSS) and the diameter difference sign (DDS) could improve fracture reduction. Therefore, the validity of the CSS and DDS was analyzed to facilitate detection of maltorsion in tibial mid-shaft fractures. METHODS Tibial mid-shaft fractures were induced in human cadaveric tibiae according to the AO classification type A3. Torsional discrepancies from 0° to 30° in-/external direction were enforced after intramedullary nailing. Fluoroscopic-guided fracture reduction was assessed in two planes via analysis of the medical cortical thickness (MCT), lateral cortical thickness (LCT), tibial diameter (TD), anterior cortical thickness (ACT), posterior cortical thickness (PCT) and the transverse diameter (TD) of the proximal and distal fracture fragment. RESULTS The TD, LCT and ACT have shown a highly significant correlation to predict tibial maltorsion. While a model combining ACT, LCT, PCT and TD lateral was most suitable model to identify tibial maltorsion, a torsional discrepancy of 15°was most reliably detected with use of the TD and ACT. CONCLUSION The present study has shown, that maltorsion can be reliably assessed by the CSS and DDS during fluoroscopy. Thus, torsional discrepancies in tibial mid-shaft fractures can be most reliably assessed in the lateral plane by analysis of the LCT and TD.
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Affiliation(s)
- Alexander M Keppler
- Department for General, Trauma and Reconstructive Surgery, University Hospital LMU Munich, Munich, Germany
| | - Konstantin Küssner
- Department for General, Trauma and Reconstructive Surgery, University Hospital LMU Munich, Munich, Germany
| | - Eduardo M Suero
- Department for General, Trauma and Reconstructive Surgery, University Hospital LMU Munich, Munich, Germany
| | - Veronika Kronseder
- StaBLab, Department of Statistics, Statistical Consulting Unit, LMU Munich, Munich, Germany
| | - Wolfgang Böcker
- Department for General, Trauma and Reconstructive Surgery, University Hospital LMU Munich, Munich, Germany
| | - Christian Kammerlander
- Department for General, Trauma and Reconstructive Surgery, University Hospital LMU Munich, Munich, Germany
| | - Christian Zeckey
- Department for General, Trauma and Reconstructive Surgery, University Hospital LMU Munich, Munich, Germany.
- Department for Trauma and Orthopedic Surgery, RoMed Klinikum Rosenheim, Pettenkoferstr. 10, 83022, Rosenheim, Germany.
| | - C Neuerburg
- Department for General, Trauma and Reconstructive Surgery, University Hospital LMU Munich, Munich, Germany
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Degen N, Suero E, Bogusch M, Neuerburg C, Manz KM, Becker CA, Befrui N, Kammerlander C, Böcker W, Zeckey C. Intraoperative use of cortical step sign and diameter difference sign: Accuracy, inter-rater agreement and influence of surgical experience in subtrochanteric transverse fractures. Orthop Traumatol Surg Res 2020; 106:639-644. [PMID: 32280057 DOI: 10.1016/j.otsr.2020.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 01/25/2020] [Accepted: 01/31/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND The cortical step sign (CSS) and diameter difference sign (DDS) are radiographic tools for torsional alignment control in intramedullary nailing. They have been found to be highly relevant in objective radiographic measurements, but for intraoperative visual identification they lack sufficient evidence yet. The aim of this experimental study was to evaluate their (1) accuracy, (2) inter-rater agreement, (3) predictors of correct identification for clinically relevant maltorsion (CRM: ≥15°), and (4) positive and negative predictive values. HYPOTHESIS Sensitivity and specificity of CSS and DDS in visual identification of CRM are comparable to those in objective measurement. MATERIAL AND METHODS Six observers of three different levels of surgical experience evaluated 50 a.p. and 50 lateral views of subtrochanteric fractures of cadaveric specimens with internal/external maltorsion from 0° to 30° to assess for CSS, DDS, and CRM. (1) Sensitivity and specificity were evaluated. Percentage agreement and Cohen's Kappa were used to evaluate accuracy as agreement with measured/true values and (2) inter-rater agreement. To determine (3) significant predictors of correct identification of the CSS, DDS, and CRM, a mixed-effects logistic model was constructed, and (4) predictive values were calculated. RESULTS (1) Sensitivities of CSS and DDS for CRM (0.99±0.03 and 0.88±0.06) were close to those in objective measurement (1.00 and 0.90). So were specificities (0.25±0.08 and 0.47±0.17 vs. 0.32 and 0.47). Agreement percentage for CSS was high (90-94%, kappa 0.40-0.69), for DDS and CRM it was slightly lower (74-82%, kappa 0.34-0.57 and 62-76%, kappa 0.26-0.49). (2) Inter-rater agreement also showed the highest values for CSS (88-96%, kappa 0.51-0.73) with slightly lower values for DDS (74-84%, kappa 0.36-0.63) and CRM (62-84%, kappa 0.21-0.68). (3) Training level and the magnitude of maltorsion were found the most relevant predictors of a correct identification of CSS/DDS/CRM. (4) DDS showed a higher positive predictive value (73.1%), CSS a higher negative predictive value (93.5%). DISCUSSION We found visual identification of CSS and DDS to be almost as accurate as objective measurement in the detection of CRM. Estimation of maltorsion is not sufficiently reliable, but a negative CSS excludes a CRM with high probability. Both signs should be applied by experienced surgeons. LEVEL OF EVIDENCE Level III, experimental setting, non-randomised experimental trial.
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Affiliation(s)
- Nikolaus Degen
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Marchioninistr, 15, 81377 Munich, Germany.
| | - Eduardo Suero
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Marchioninistr, 15, 81377 Munich, Germany
| | - Miriam Bogusch
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Marchioninistr, 15, 81377 Munich, Germany
| | - Carl Neuerburg
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Marchioninistr, 15, 81377 Munich, Germany
| | - Kirsi Marjaana Manz
- Institute for Medical Information Processing, Biometry and Epidemiology (IBE), LMU Munich, Munich, Germany
| | - Christopher A Becker
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Marchioninistr, 15, 81377 Munich, Germany
| | - Nima Befrui
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Marchioninistr, 15, 81377 Munich, Germany
| | - Christian Kammerlander
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Marchioninistr, 15, 81377 Munich, Germany
| | - Wolfgang Böcker
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Marchioninistr, 15, 81377 Munich, Germany
| | - Christian Zeckey
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Marchioninistr, 15, 81377 Munich, Germany
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Turgut A, Koca A, Uzakgider M, Hancıoğlu S, Erkuş S, Kalenderer Ö. Quantitative assessment of changes in lesser trochanter shapes in relation to femoral rotations. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2020; 54:149-154. [PMID: 32254030 DOI: 10.5152/j.aott.2020.02.126] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate changes in lesser trochanter shapes in relation to femoral rotations and to develop a reference value for the determination of clinically relevant malrotation of the femur. METHODS Patients who underwent computed tomography angiography between January 2009 and July 2018 were identified based on a review of their institutional medical records. Thereafter, three-dimensional (3D) images of the whole femur for a total of 860 patients were obtained from their tomographic sections. The distance between the lateral outer cortex of the femur and the most medial point of the lesser trochanter with the femur in neutral rotation was measured and set as the reference value. Then, the same distance was measured at 5°, 10°, 15°, and 20° of femoral internal rotation and at 5°, 10°, 15°, 20°, and 25° of femoral external rotation. To avoid magnification errors, the reference values were divided by each measured value at these different rotation angles and then multiplied by 100. RESULTS The mean distances between the lateral cortex and the most medial point of the lesser trochanter at 5°, 10°, 15°, and 20° of femoral internal rotation were 97%, 93%, 90%, and 88%, respectively, of those measured with the femur in neutral rotation. The same distances at 5°, 10°, 15°, 20°, and 25° of femoral external rotation were 102%, 104%, 106%, 107%, and 108%, respectively, of those measured with the femur in neutral rotation. There was no statistically significant difference between the measured distances in males and females (p>0.05). However, significant differences were observed among each measured distance at different angles of femoral rotation (p<0.01). CONCLUSION The surgeon should be aware of the possible femoral malrotation if the distance between the lateral cortex of the femur and the most medial point of the lesser trochanter on the operated side is more than 106% or less than 90% of that measured with the femur in neutral rotation on the healthy side. LEVEL OF EVIDENCE Level IV, Diagnostic study.
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Affiliation(s)
- Ali Turgut
- Department of Orthopaedics and Traumatology, Tepecik Training and Research Hospital, İzmir, Turkey
| | - Anıl Koca
- Department of Orthopaedics and Traumatology, Tepecik Training and Research Hospital, İzmir, Turkey
| | - Melikşah Uzakgider
- Department of Orthopaedics and Traumatology, Tepecik Training and Research Hospital, İzmir, Turkey
| | - Sertan Hancıoğlu
- Department of Orthopaedics and Traumatology, Tepecik Training and Research Hospital, İzmir, Turkey
| | - Serkan Erkuş
- Department of Orthopaedics and Traumatology, Tepecik Training and Research Hospital, İzmir, Turkey
| | - Önder Kalenderer
- Department of Orthopaedics and Traumatology, Tepecik Training and Research Hospital, İzmir, Turkey
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