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Dawson M, Elson D, Claes S, Predescu V, Khakha R, Espejo-Reina A, Schröter S, van Heerwarden R, Menetrey J, Beaufils P, Seil R, Beker R, Mabrouk A, Ollivier M. Osteotomy around the painful degenerative varus knee has broader indications than conventionally described but must follow a strict planning process: ESSKA Formal Consensus Part I. Knee Surg Sports Traumatol Arthrosc 2024. [PMID: 38738832 DOI: 10.1002/ksa.12256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/21/2024] [Accepted: 04/26/2024] [Indexed: 05/14/2024]
Abstract
PURPOSE The European consensus was designed with the objective of combining science and expertise to produce recommendations that would educate and provide guidance in the treatment of the painful degenerative varus knee. Part I focused on indications and planning. METHODS Ninety-four orthopaedic surgeons from 24 European countries were involved in the consensus, which focused on the most common indications for osteotomy around the knee. The consensus was performed according to an established ESSKA methodology. The questions and recommendations made were initially designed by the consensus steering group. And 'best possible' answers were provided based upon the scientific evidence available and the experience of the experts. The statements produced were further evaluated by ratings and peer review groups before a final consensus was reached. RESULTS There is no reliable evidence to exclude patients based on age, gender or body weight. An individualised approach is advised; however, cessation of smoking is recommended. The same applies to lesser degrees of patellofemoral and lateral compartment arthritis, which may be accepted in certain situations. Good-quality limb alignment and knee radiographs are a mandatory requirement for planning of osteotomies, and Paley's angles and normal ranges are recommended when undertaking deformity analysis. Emphasis is placed upon the correct level at which correction of varus malalignment is performed, which may involve double-level osteotomy. This includes recognition of the importance of individual bone morphology and the maintenance of a physiologically appropriate joint line orientation. CONCLUSION The indications of knee osteotomies for painful degenerative varus knees are broad. Part I of the consensus highlights the versatility of the procedure to address multiple scenarios with bespoke planning for each case. Deformity analysis is mandatory for defining the bone morphology, the site of the deformity and planning the correct procedure. LEVEL OF EVIDENCE Level II, consensus.
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Affiliation(s)
- Matthew Dawson
- North Cumbria University Hospital NHS Trust, North Cumbria, UK
| | - David Elson
- Department of Orthopaedics, Queen Elizabeth Hospital, Gateshead, UK
| | - Steven Claes
- Department of Orthopedic Surgery, AZ Herentals Hospital, Herentals, Belgium
| | - Vlad Predescu
- Department of Orthopedics and Traumatology, St Pantelimon Clinical Hospital Bucharest, University of Medicine and Pharmacy 'Carol Davila', Bucharest, Romania
| | | | | | - Steffen Schröter
- Department of Traumatology and Reconstructive Surgery, BG Trauma Center, Tübingen, Germany
| | - Ronald van Heerwarden
- Centre for Deformity Correction and Joint Preserving Surgery, Kliniek ViaSana, Mill, The Netherlands
| | - Jacques Menetrey
- Orthopaedic Surgery Service, University Hospital of Geneva, Geneva, Switzerland
| | - Philippe Beaufils
- Department of Orthopaedics and Traumatology, Centre Hospitalier de Versailles, Le Chesnay, France
| | - Roman Seil
- Department of Orthopaedic Surgery, Centre Hospitalier Luxembourg-Clinique d'Eich, Luxembourg, Luxembourg
| | - Roland Beker
- Center of Orthopaedics and Traumatology, Medical School Brandenburg, University Hospital Brandenburg an der Havel, Brandenburg, Germany
| | - Ahmed Mabrouk
- Department of Trauma and Orthopaedics, Leeds Teaching Hospitals, Leeds, UK
| | - Matthieu Ollivier
- CNRS, ISM, Aix Marseille University, Marseille, France
- APHM, CNRS, ISM, Department of Orthopaedics and Traumatology, Sainte-Marguerite Hospital, Institute for Locomotion, Aix Marseille University, Marseille, France
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Yang J, Ren P, Xin P, Wang Y, Ma Y, Liu W, Wang Y, Wang Y, Zhang G. Automatic measurement of lower limb alignment in portable devices based on deep learning for knee osteoarthritis. J Orthop Surg Res 2024; 19:232. [PMID: 38594698 PMCID: PMC11005281 DOI: 10.1186/s13018-024-04658-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 03/02/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND For knee osteoarthritis patients, analyzing alignment of lower limbs is essential for therapy, which is currently measured from standing long-leg radiographs of anteroposterior X-ray (LLR) manually. To address the time wasting, poor reproducibility and inconvenience of use caused by existing methods, we present an automated measurement model in portable devices for assessing knee alignment from LLRs. METHOD We created a model and trained it with 837 conforming LLRs, and tested it using 204 LLRs without duplicates in a portable device. Both manual and model measurements were conducted independently, then we recorded knee alignment parameters such as Hip knee ankle angle (HKA), Joint line convergence angle (JCLA), Anatomical mechanical angle (AMA), mechanical Lateral distal femoral angle (mLDFA), mechanical Medial proximal tibial angle (mMPTA), and the time required. We evaluated the model's performance compared with manual results in various metrics. RESULT In both the validation and test sets, the average mean radial errors were 2.778 and 2.447 (P<0.05). The test results for native knee joints showed that 92.22%, 79.38%, 87.94%, 79.82%, and 80.16% of the joints reached angle deviation<1° for HKA, JCLA, AMA, mLDFA, and mMPTA. Additionally, for joints with prostheses, 90.14%, 93.66%, 86.62%, 83.80%, and 85.92% of the joints reached that. The Chi-square test did not reveal any significant differences between the manual and model measurements in subgroups (P>0.05). Furthermore, the Bland-Altman 95% limits of agreement were less than ± 2° for HKA, JCLA, AMA, and mLDFA, and slightly more than ± 2 degrees for mMPTA. CONCLUSION The automatic measurement tool can assess the alignment of lower limbs in portable devices for knee osteoarthritis patients. The results are reliable, reproducible, and time-saving.
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Affiliation(s)
- Jianfeng Yang
- Department of Orthopedics, the First Medical Center of Chinese PLA General Hospital, Beijing, China
- Senior Department of Orthopedics, the Fourth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Peng Ren
- Senior Department of Orthopedics, the Fourth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Peng Xin
- Department of Orthopedics, Chinese PLA Southern Theater Command General Hospital, Guangzhou, China
| | - Yiming Wang
- Department of Orthopedics, the First Medical Center of Chinese PLA General Hospital, Beijing, China
- Senior Department of Orthopedics, the Fourth Medical Center of Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese People's Liberation Army, Beijing, China
| | - Yonglei Ma
- Department of Anesthesiology, Guangzhou First People's Hospital, Guangzhou, China
| | - Wei Liu
- Damo Academy, Alibaba Group, Hangzhou, China
| | - Yu Wang
- Damo Academy, Alibaba Group, Hangzhou, China
| | - Yan Wang
- Department of Orthopedics, the First Medical Center of Chinese PLA General Hospital, Beijing, China.
- Senior Department of Orthopedics, the Fourth Medical Center of Chinese PLA General Hospital, Beijing, China.
- Department of Orthopedics, the First Medical Center, PLA General Hospital, Fuxing Road, Haidian District, Beijing, China.
| | - Guoqiang Zhang
- Department of Orthopedics, the First Medical Center of Chinese PLA General Hospital, Beijing, China.
- Senior Department of Orthopedics, the Fourth Medical Center of Chinese PLA General Hospital, Beijing, China.
- Department of Orthopedics, the First Medical Center, PLA General Hospital, Fuxing Road, Haidian District, Beijing, China.
- Department of Orthopedic Surgery, The First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, People's Republic of China.
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Glowalla C, Langer S, Lenze U, Lazic I, Hirschmann MT, Hinterwimmer F, von Eisenhart-Rothe R, Pohlig F. Postoperative full leg radiographs exhibit less residual coronal varus deformity compared to intraoperative measurements in robotic arm-assisted total knee arthroplasty with the MAKO™ system. Knee Surg Sports Traumatol Arthrosc 2023; 31:3912-3918. [PMID: 36964782 PMCID: PMC10435414 DOI: 10.1007/s00167-023-07386-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 03/09/2023] [Indexed: 03/26/2023]
Abstract
PURPOSE Robotic arm-assisted total knee arthroplasty (raTKA), currently a major trend in knee arthroplasty, aims to improve the accuracy of implant positioning and limb alignment. However, it is unclear whether and to what extent manual radiographic and navigation measurements with the MAKO™ system correlate. Nonetheless, a high agreement would be crucial to reliably achieve the desired limb alignment. METHODS Thirty-six consecutive patients with osteoarthritis and a slight-to-moderate varus deformity undergoing raTKA were prospectively included in this study. Prior to surgery and at follow-up, a full leg radiograph (FLR) under weight-bearing conditions was performed. In addition, a computed tomography (CT) scan was conducted for preoperative planning. The hip-knee-ankle angle (HKA), mechanical lateral distal femur angle (mLDFA), mechanical medial proximal tibial angle (mMPTA) and joint line convergence angle (JLCA) were measured in the preoperative and follow-up FLR as well as in the CT scout (without weight-bearing) by three independent raters. Furthermore, the HKA was intraoperatively assessed with the MAKO™ system before and after raTKA. RESULTS Significantly higher HKA values were identified for intraoperative deformity assessment using the MAKO system compared to the preoperative FLR and CT scouts (p = 0.006; p = 0.05). Intraoperative assessment of the HKA with final implants showed a mean residual varus deformity of 3.2° ± 1.9°, whereas a significantly lower residual varus deformity of 1.4° ± 1.9° was identified in the postoperative FLR (p < 0.001). The mMPTA was significantly higher in the preoperative FLR than in the CT scouts (p < 0.001). Intraoperatively, the mMPTA was adjusted to a mean of 87.5° ± 0.9° with final implants, while significantly higher values were measured in postoperative FLRs (p < 0.001). Concerning the mLDFA, no significant differences could be identified. CONCLUSION The clinical importance of this study lies in the finding that there is a difference between residual varus deformity measured intraoperatively with the MAKO™ system and those measured in postoperative FLRs. This has implications for preoperative planning as well as intraoperative fine-tuning of the implant position during raTKA to avoid overcorrection of knees with slight-to-moderate varus osteoarthritis. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Claudio Glowalla
- Department of Orthopaedic Surgery, Klinikum Rechts der Isar, Technical University Munich, Ismaninger-Strasse 22, 81675, Munich, Germany
- BG Unfallklinik Murnau, Professor-Kuentscher-Strasse 8, 82418, Murnau am Staffelsee, Germany
| | - Severin Langer
- Department of Orthopaedic Surgery, Klinikum Rechts der Isar, Technical University Munich, Ismaninger-Strasse 22, 81675, Munich, Germany
- BG Unfallklinik Murnau, Professor-Kuentscher-Strasse 8, 82418, Murnau am Staffelsee, Germany
| | - Ulrich Lenze
- Department of Orthopaedic Surgery, Klinikum Rechts der Isar, Technical University Munich, Ismaninger-Strasse 22, 81675, Munich, Germany
| | - Igor Lazic
- Department of Orthopaedic Surgery, Klinikum Rechts der Isar, Technical University Munich, Ismaninger-Strasse 22, 81675, Munich, Germany
| | - Michael T Hirschmann
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (BruderholzLiestalLaufen), 4101, Bruderholz, Switzerland
| | - Florian Hinterwimmer
- Department of Orthopaedic Surgery, Klinikum Rechts der Isar, Technical University Munich, Ismaninger-Strasse 22, 81675, Munich, Germany
| | - Rüdiger von Eisenhart-Rothe
- Department of Orthopaedic Surgery, Klinikum Rechts der Isar, Technical University Munich, Ismaninger-Strasse 22, 81675, Munich, Germany
| | - Florian Pohlig
- Department of Orthopaedic Surgery, Klinikum Rechts der Isar, Technical University Munich, Ismaninger-Strasse 22, 81675, Munich, Germany.
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Colyn W, Vanbecelaere L, Bruckers L, Scheys L, Bellemans J. The effect of weight-bearing positions on coronal lower limb alignment: A systematic review. Knee 2023; 43:51-61. [PMID: 37271072 DOI: 10.1016/j.knee.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 03/30/2023] [Accepted: 05/06/2023] [Indexed: 06/06/2023]
Abstract
BACKGROUND The coronal alignment of the lower limb is generally accepted as a major determinant of surgical outcome in total knee arthroplasty (TKA). To achieve the ideal post-operative alignment, surgeons need to be aware of the influence that weight-bearing positions have on the final knee alignment. Therefore, this review aims to define the effect of varying weight-bearing positions on the coronal alignment of the lower limb. We hypothesized that a coronal alignment deformity increases with loading. METHODS The PubMed, Medline and google scholar databases were searched systematically in June 2022. Only studies which compared coronal alignment with a standardized radiographic protocol in the single leg, double leg and supine positions were included. To obtain pooled estimates of the effect of different weight-bearing positions, random-effect analysis were fitted using SAS. RESULTS Compared to the supine position, double leg weight-bearing positions were found to be associated with a more pronounced varus deformity (mean difference in HKA is 1,76° (95% CI 1,32: 2,21), p < 0.0001)). The mean difference in HKA between double leg and single leg weight-bearing conditions was 1.43° (95% CI (-0,042;2,90), p = 0.0528). CONCLUSION The overall knee alignment was found to be influenced by the weight-bearing position. An average difference of 1.76° in HKA-angle was found between a double leg-stance and supine position, tending to increased varus in the former weight-bearing position. It is therefore possible that the deformity could increase by 1.76° if knee surgeons only follow a pre-op planning based on double-leg stance full length radiographs.
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Affiliation(s)
- William Colyn
- Dept. of Orthopedic Surgery, AZ Turnhout, Turnhout, Belgium; UHasselt, Faculty of Medicine and Life Sciences, Diepenbeek, Belgium; Ziekenhuis Oost-Limburg, Dept. Future Health, Genk, Belgium.
| | - Lukas Vanbecelaere
- Dept. of Orthopedic Surgery, University Hospitals Leuven, Leuven, Belgium
| | | | - Lennart Scheys
- Dept. of Orthopedic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Johan Bellemans
- UHasselt, Faculty of Medicine and Life Sciences, Diepenbeek, Belgium; Dept. of Orthopedic Surgery, ZOL Genk, Genk, Belgium; GRIT Belgian Sports Clinic, Leuven, Belgium
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Brunner J, Jörgens M, Weigert M, Kümpel H, Fuermetz J. Veränderungen in der Ausrichtung des Beins durch Flexion und Rotation. ARTHROSKOPIE 2023. [DOI: 10.1007/s00142-023-00597-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
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Current clinical practice of knee osteotomy in the Netherlands. Knee 2023; 41:292-301. [PMID: 36801495 DOI: 10.1016/j.knee.2023.01.019] [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: 09/05/2022] [Revised: 12/16/2022] [Accepted: 01/26/2023] [Indexed: 02/23/2023]
Abstract
BACKGROUND Realignment osteotomies is gaining popularity amongst Dutch orthopaedic surgeons. Exact numbers and used standards in clinical practice concerning osteotomies are unknown due to the absence of a national registry. The aim of this study was to investigate the national statistics of performed osteotomies, utilized clinical workups, surgical techniques, and post-operative rehabilitation standards in the Netherlands. METHOD Dutch orthopaedic surgeons, all members of the Dutch Knee Society, received a web-based survey between January and March 2021. This electronic survey contained 36 questions, subdivided into: general surgeon-related information, number of performed osteotomies, inclusion of patients, clinical workup, surgical techniques, and post-operative management. RESULTS 86 orthopaedic surgeons filled in the questionnaire, of whom 60 perform realignment osteotomies around the knee. All the 60 responders (100%) perform high tibial osteotomies and 63.3% additionally perform distal femoral osteotomies, while 30% perform double level osteotomies. Discrepancies in surgical standards were reported regarding to inclusion criteria, clinical workup, surgical techniques, and post-operative strategies. CONCLUSIONS In conclusion, this study got more insight in knee osteotomy clinical practices as applied by Dutch orthopaedic surgeons. However, there are still important discrepancies which pleads for more standardization based on available evidence. A (inter)national knee osteotomy registry, and even more so, a (inter)national registry for joint preserving surgeries could be helpful to achieve more standardization and treatment insights. Such a registry could improve all aspects of osteotomies and its combinations with other joint-preserving interventions towards evidence for personalised treatments.
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Brunner J, Jörgens M, Weigert M, Kümpel H, Degen N, Fuermetz J. Significant changes in lower limb alignment due to flexion and rotation-a systematic 3D simulation of radiographic measurements. Knee Surg Sports Traumatol Arthrosc 2023; 31:1483-1490. [PMID: 36595052 PMCID: PMC10050026 DOI: 10.1007/s00167-022-07302-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 12/18/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Many radiographic lower limb alignment measurements are dependent on patients' position, which makes a standardised image acquisition of long-leg radiographs (LLRs) essential for valid measurements. The purpose of this study was to investigate the influence of rotation and flexion of the lower limb on common radiological alignment parameters using three-dimensional (3D) simulation. METHODS Joint angles and alignment parameters of 3D lower limb bone models (n = 60), generated from computed tomography (CT) scans, were assessed and projected into the coronal plane to mimic radiographic imaging. Bone models were subsequently rotated around the longitudinal mechanical axis up to 15° inward/outward and additionally flexed along the femoral intercondylar axis up to 30°. This resulted in 28 combinations of rotation and flexion for each leg. The results were statistically analysed on a descriptive level and using a linear mixed effects model. RESULTS A total of 1680 simulations were performed. Mechanical axis deviation (MAD) revealed a medial deviation with increasing internal rotation and a lateral deviation with increasing external rotation. This effect increased significantly (p < 0.05) with combined flexion up to 30° flexion (- 25.4 mm to 25.2 mm). With the knee extended, the mean deviation of hip-knee-ankle angle (HKA) was small over all rotational steps but increased toward more varus/valgus when combined with flexion (8.4° to - 8.5°). Rotation alone changed the medial proximal tibial angle (MPTA) and the mechanical lateral distal femoral angle (mLDFA) in opposite directions, and the effects increased significantly (p < 0.05) when flexion was present. CONCLUSIONS Axial rotation and flexion of the 3D lower limb has a huge impact on the projected two-dimensional alignment measurements in the coronal plane. The observed effects were small for isolated rotation or flexion, but became pronounced and clinically relevant when there was a combination of both. This must be considered when evaluating X-ray images. Extension deficits of the knee make LLR prone to error and this calls into question direct postoperative alignment controls. LEVEL OF EVIDENCE III (retrospective cohort study).
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Affiliation(s)
- Josef Brunner
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU, Marchioninistr. 15, 81377, Munich, Germany
| | - Maximilian Jörgens
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU, Marchioninistr. 15, 81377, Munich, Germany.
| | | | - Hannah Kümpel
- Statistical Consulting Unit StaBLab, LMU, Munich, Germany
| | - Nikolaus Degen
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU, Marchioninistr. 15, 81377, Munich, Germany
| | - Julian Fuermetz
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU, Marchioninistr. 15, 81377, Munich, Germany.,Department of Trauma Surgery, BG Unfallklinik Murnau, Murnau, Germany
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Moon HS, Kim SH, Kwak DK, Lee SH, Lee YH, Yoo JH. Factor affecting the discrepancy in the coronal alignment of the lower limb between the standing and supine radiographs. BMC Musculoskelet Disord 2022; 23:1136. [PMID: 36577972 PMCID: PMC9795742 DOI: 10.1186/s12891-022-06099-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 12/16/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Conflicting results have been reported regarding the factors that can predict the discrepancy in the coronal alignment of the lower limb between radiographs taken in the standing and supine positions. Therefore, this study aimed to investigate factors that can predict discrepancies in the coronal alignment of the lower limb between radiographs taken in the standing and supine positions. METHODS We retrospectively evaluated the medical records of patients who underwent full-length anteroposterior radiographs of the lower limb in both standing and supine positions between January 2019 and September 2021. The discrepancy in the coronal alignment of the lower limb between the standing and supine radiographs was defined as the absolute value of the difference in the hip-knee-ankle (HKA) angle between the two radiographs, which is presented as the ΔHKA angle. Correlation and regression analyses were performed to analyse the relationship among ΔHKA angle, demographic data, and several radiographic parameters. RESULTS In total, 147 limbs (94 patients) were included in this study. The mean ΔHKA angle was 1.3 ± 1.1° (range, 0-6.5°). The ΔHKA angle was significantly correlated with body mass index and several radiographic parameters, including the HKA angle, joint line convergence angle, and osteoarthritis grade. Subsequent multiple linear regression analysis was performed using the radiographic parameters measured on the supine radiographs with the two separate models from the two observers, which revealed that body mass index and advanced osteoarthritis (Kellgren-Lawrence grades 3 and 4) had a positive correlation with the ΔHKA angle. CONCLUSIONS Body mass index and advanced osteoarthritis affected the discrepancy in the coronal alignment of the lower limb between standing and supine radiographs. A discrepancy in the coronal alignment of the lower limb could be more prominent in patients with an increased body mass index and advanced osteoarthritis, corresponding to Kellgren-Lawrence grades 3 and 4.
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Affiliation(s)
- Hyun-Soo Moon
- grid.15444.300000 0004 0470 5454Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea ,grid.488421.30000000404154154Department of Orthopedic Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Republic of Korea
| | - Sung-Hwan Kim
- grid.15444.300000 0004 0470 5454Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea ,grid.15444.300000 0004 0470 5454Department of Orthopedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dae-Kyung Kwak
- grid.488421.30000000404154154Department of Orthopedic Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Republic of Korea
| | - Seung-Hun Lee
- grid.488421.30000000404154154Department of Orthopedic Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Republic of Korea
| | - Yung-Hong Lee
- grid.488421.30000000404154154Department of Orthopedic Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Republic of Korea
| | - Je-Hyun Yoo
- grid.15444.300000 0004 0470 5454Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea ,grid.488421.30000000404154154Department of Orthopedic Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Republic of Korea
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Automated Artificial Intelligence-Based Assessment of Lower Limb Alignment Validated on Weight-Bearing Pre- and Postoperative Full-Leg Radiographs. Diagnostics (Basel) 2022; 12:diagnostics12112679. [PMID: 36359520 PMCID: PMC9689840 DOI: 10.3390/diagnostics12112679] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 10/26/2022] [Accepted: 10/28/2022] [Indexed: 11/06/2022] Open
Abstract
The assessment of the knee alignment using standing weight-bearing full-leg radiographs (FLR) is a standardized method. Determining the load-bearing axis of the leg requires time-consuming manual measurements. The aim of this study is to develop and validate a novel algorithm based on artificial intelligence (AI) for the automated assessment of lower limb alignment. In the first stage, a customized mask-RCNN model was trained to automatically detect and segment anatomical structures and implants in FLR. In the second stage, four region-specific neural network models (adaptations of UNet) were trained to automatically place anatomical landmarks. In the final stage, this information was used to automatically determine five key lower limb alignment angles. For the validation dataset, weight-bearing, antero-posterior FLR were captured preoperatively and 3 months postoperatively. Preoperative images were measured by the operating orthopedic surgeon and an independent physician. Postoperative images were measured by the second rater only. The final validation dataset consisted of 95 preoperative and 105 postoperative FLR. The detection rate for the different angles ranged between 92.4% and 98.9%. Human vs. human inter-(ICCs: 0.85−0.99) and intra-rater (ICCs: 0.95−1.0) reliability analysis achieved significant agreement. The ICC-values of human vs. AI inter-rater reliability analysis ranged between 0.8 and 1.0 preoperatively and between 0.83 and 0.99 postoperatively (all p < 0.001). An independent and external validation of the proposed algorithm on pre- and postoperative FLR, with excellent reliability for human measurements, could be demonstrated. Hence, the algorithm might allow for the objective and time saving analysis of large datasets and support physicians in daily routine.
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Cheng L, Ren P, Zheng Q, Ni M, Geng L, Wang Y, Zhang G. Implication of Changes in the Imaging Measurements after Mechanically Aligned Total Knee Arthroplasty. Orthop Surg 2022; 14:3322-3329. [PMID: 36324288 PMCID: PMC9732610 DOI: 10.1111/os.13456] [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: 02/11/2022] [Revised: 07/02/2022] [Accepted: 07/25/2022] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE Imaging measurements allow assessment of the mechanical alignment before and after total knee arthroplasty (TKA). The changes in radiographic parameters in each period of time within 1 year after TKA has been poorly understood. The purpose of this study was to examine the timing and causes of imaging changes in lower extremity force lines after total knee arthroplasty with mechanical alignment. METHODS A total of 93 mechanically-aligned TKA were radiographically examined before, 3 days, 3 months, and 1 year after surgery. Radiographic parameters included hip-knee angle (HKA), lateral distal femoral angle (LDFA), medial proximal tibial angle (MPTA), knee joint line orientation (KJLO), ankle joint line orientation (AJLO), the knee joint line relative to ankle joint line angle (KJLTA) and midpoints of the ankle distance (MAD). Paired t-test were used to analyze the changes of these imaging parameters, By establishing a simple tibial model, the time points of changes in the imaging parameters after TKA was determined, with an attempt to understand the post-TKA changes in these imaging parameters. RESULTS Statistically significant differences were found between the preoperative data and the data measured 3 days after surgery in HKA, LDFA, MPTA, MAD, KJLTA, AJLO (P < 0.05) while KJLO exhibited no significant difference (P = 0.089). There existed significant differences between the data measured 3 days and the measurements taken 3 months after operation in HKA, MPTA, KJLTA, KJLO, AJLO (P < 0.05), whereas LDFA and MAD showed no significant difference (P > 0.05). Significant differences were revealed between the data measured 3 months and those collected 1 year after surgery in LDFA, MPTA, AJLO, KJLTA (P < 0.05) but HKA, KJLO, AJLO showed no significant differences (P > 0.05). The tibial model was made to look into the changes in postoperative imaging parameters. ΔMAD and postoperative AJLO were calculated to verify the model and hypothesis. CONCLUSIONS Postoperative changes in radiographic parameters and tibial models showed that the lower extremities were in an unnatural state within 1 year after TKA. The changes in the lower extremities force line were the results of the gradual adaptation of the lower extremities to TKA and the lateral swing of the extremities (3°) after surgery. Imaging data 1 year after surgery should be taken into account in the explanation of post-TKA changes in lower limb force lines.
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Affiliation(s)
- Long Cheng
- Medical School of Chinese People's Liberation Army General HospitalBeijingChina,Department of Orthopaedics, the First Medical CenterChinese People's Liberation Army General HospitalBeijingChina
| | - Peng Ren
- Department of Orthopaedics, the First Medical CenterChinese People's Liberation Army General HospitalBeijingChina
| | - Qingyuan Zheng
- Medical School of Chinese People's Liberation Army General HospitalBeijingChina,Department of Orthopaedics, the First Medical CenterChinese People's Liberation Army General HospitalBeijingChina
| | - Ming Ni
- Department of Orthopaedics, the First Medical CenterChinese People's Liberation Army General HospitalBeijingChina,Department of Orthopaedics, the Fourth Medical CenterChinese People's Liberation Army General HospitalBeijingChina
| | - Lei Geng
- Department of Orthopaedics, the First Medical CenterChinese People's Liberation Army General HospitalBeijingChina,Department of Orthopaedics, the Fourth Medical CenterChinese People's Liberation Army General HospitalBeijingChina
| | - Yi‐Ming Wang
- Medical School of Chinese People's Liberation Army General HospitalBeijingChina,Department of Orthopaedics, the First Medical CenterChinese People's Liberation Army General HospitalBeijingChina
| | - Guo‐Qiang Zhang
- Department of Orthopaedics, the First Medical CenterChinese People's Liberation Army General HospitalBeijingChina,Department of Orthopaedics, the Fourth Medical CenterChinese People's Liberation Army General HospitalBeijingChina
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11
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Barbotte F, Delord M, Pujol N. Coronal knee alignment measurements differ on long-standing radiographs vs. by navigation. Orthop Traumatol Surg Res 2022; 108:103112. [PMID: 34648999 DOI: 10.1016/j.otsr.2021.103112] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 02/19/2021] [Accepted: 03/08/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND The long-standing radiograph (LSR) is the reference tool for assessing knee alignment after total knee arthroplasty (TKA). However, its value is debatable, as many factors can influence measurement accuracy. Computer-assisted surgery (CAS) provides accurate measurements. Few studies have compared LSR and computer-assisted measurements of knee alignment. The objective of this study was to compare hip-knee-ankle (HKA) angle values obtained before and after TKA on LSRs to those obtained during CAS. HYPOTHESIS The HKA angle values measured on LSRs before and after surgery are identical to those measured during CAS. MATERIAL AND METHODS The HKA angles of 126 knees were measured on bipedal full-weight-bearing LSRs obtained before and 3 months after TKA. The results were compared to the values obtained during CAS. RESULTS Before surgery, the standard deviation was 2.672, with limits of agreement of {-5.391; + 5.082}. The intra-class coefficients were good for the overall measurements (0.9), good for detecting>10° varus (0.89), fair for<10° varus and valgus (0.66 and 0.71, respectively), poor for>10° valgus (0.43) and poor for normal alignment (0). Post-operatively, the standard deviation was 3.113, with limits of agreement of {-6.426; +5.776}. The intra-class coefficient was poor for the overall measurements (0.20), negative for normal alignment (-0.05) and<10° valgus (-0.05), and positive for<10° varus (0.017) and for>10° varus and valgus (0.33). CONCLUSION Before TKA, the LSR overestimates the deformity compared to CAS. After surgery, the two methods are not comparable. These findings underline the relevance of routinely obtaining LSRs and for using LSR results to estimate costs for healthcare insurance reimbursement purposes. LEVEL OF EVIDENCE IV, retrospective observational cohort study.
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Affiliation(s)
| | - Marc Delord
- Centre hospitalier de Versailles, Le Chesnay, France
| | - Nicolas Pujol
- Centre hospitalier de Versailles, Le Chesnay, France.
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The contralateral limb is no reliable reference to restore coronal alignment in TKA. Knee Surg Sports Traumatol Arthrosc 2022; 30:477-487. [PMID: 32696089 DOI: 10.1007/s00167-020-06152-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 07/10/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Implementation of morphometric reference data from the contralateral, unaffected lower limb is suggested when reconstructing the coronal plane alignment in TKA. Limited information, however, is available which confirms this left-to-right symmetry in coronal alignment based upon radiographs. The purpose of the study was, therefore, (1) to verify if a left-to-right symmetry is present and (2) to assess whether the contralateral lower limb would be a reliable reference for reconstructing the frontal plane alignment. METHODS Full-leg standing radiographs of 250 volunteers (male, 125; female,125) were reviewed for three alignment parameters (Hip-Knee-Ankle angle (HKA), Femoral Mechanical Angle (FMA) and Tibial Mechanical Angle (TMA)). Evaluation of assumed left-to-right symmetry was performed according to two coronal alignment classifications (HKA subdivisions (HKA) and limb, femoral and tibial phenotypes (HKA, FMA and TMA)). Inter- and within-subject variability was calculated, along with correlations coefficients (r) and coefficients of determination (r2). Reliability of the contralateral limb as a personalized reference to reconstruct the constitutional alignment was investigated by intervals, expanding by 1° increments (0.5° increment both to varus and valgus) around the right knee alignment parameters. Subsequently, it was verified whether or not the left knee parameters fell within this interval. RESULTS Symmetrical distribution in coronal alignment was found in 79% (HKA subdivision) and 59% (limb phenotype) of the cohort. Gender differences were present for the most common symmetric limb phenotypes (VARHKA3° (23.2%) in males and NEUHKA0° (38.4%) in females). Inter-subject variability was more prominent than the within-subject side differences for all parameters. Correlations analyses revealed mostly moderate correlations between the alignment measurements. Coefficients of determination showed overall weak left-to-right relationship, except for a moderate predictability for HKA (r2 = 0.538, p < 0.001) and FMA (r2 = 0.618, p < 0.001) in females. FMA and TMA marked weak predictive values for contralateral HKA. Only 60% of left knees were referenced within a 3° interval around the right knee. CONCLUSION No strict left-to-right symmetry was observed in coronal alignment measurements. There is insufficient left-to-right agreement to consider the concept of the contralateral unaffected limb as an idealized reference for frontal plane alignment reconstruction based upon full-leg standing radiographs. LEVEL OF EVIDENCE I.
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Graef F, Hommel H, Falk R, Tsitsilonis S, Zahn RK, Perka C. Correction of severe valgus osteoarthritis by total knee arthroplasty is associated with increased postoperative ankle symptoms. Knee Surg Sports Traumatol Arthrosc 2022; 30:527-535. [PMID: 32839848 PMCID: PMC8866357 DOI: 10.1007/s00167-020-06246-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 08/14/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE The aim of this study was to assess the mid-term clinical outcome of the ankle joint after total knee arthroplasty (TKA) in high-grade valgus osteoarthritis. METHODS In this case-control study, n = 36 patients with a preoperative mechanical tibiofemoral angle (mTFA) ≥ 15° who underwent TKA between December 2002 and December 2012 were included. The control group (mTFA < 15°) of n = 60 patients was created using case matching. Radiological [mechanical tibiofemoral angle (mTFA) and ankle joint orientation to the ground (G-AJLO)] and clinical parameters [Foot Function Index (FFI), Knee Society Score, Forgotten Joint Score, and Range of Motion (ROM)] were analysed. The mean follow-up time was 59 months (IQR [56, 62]). RESULTS The degree of correcting the mTFA by TKA significantly correlated with the postoperative FFI (R = 0.95, p < 0.05), although the knee and ankle joint lines were corrected to neutral orientations. A cut-off value of 16.5° [AUC 0.912 (0.85-0.975 95% CI), sensitivity = 0.8, specificity = 0.895] was calculated, above which the odds ratio (OR) for developing ankle symptoms increased vastly [OR 34.0 (9.10-127.02 95% CI)]. ROM restrictions of the subtalar joint displayed a strong significant correlation with the FFI (R = 0.74, p < 0.05), demonstrating that decreased ROM of the subtalar joint was associated with aggravated outcomes of the ankle joint. CONCLUSIONS In this study, higher degrees of leg axis correction in TKA were associated with increased postoperative ankle symptoms. When TKA is performed in excessive valgus knee osteoarthritis, surgeons should be aware that this might trigger the onset or progression of ankle symptoms, particularly in cases of a stiff subtalar joint. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Frank Graef
- Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany.
| | - Hagen Hommel
- Department of Orthopedics, Märkisch-Oderland Hospital, Brandenburg Medical School Theodor Fontane, Wriezen, Germany
| | - Roman Falk
- Department of Orthopedics, Märkisch-Oderland Hospital, Brandenburg Medical School Theodor Fontane, Wriezen, Germany
| | - Serafeim Tsitsilonis
- Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Robert Karl Zahn
- Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Carsten Perka
- Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
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Tomo Y, Edamura K, Yamazaki A, Tanegashima K, Seki M, Asano K, Tinga S, Hayashi K. Evaluation of Hindlimb Deformity and Posture in Dogs with Grade 2 Medial Patellar Luxation during Awake Computed Tomography Imaging while Standing. Vet Comp Orthop Traumatol 2021; 35:143-151. [PMID: 34933377 PMCID: PMC9236725 DOI: 10.1055/s-0041-1740607] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The aim of this study was to determine the degree of bone deformities and hindlimb postural abnormalities in a standing position in awake Toy poodles with and without grade 2 medial patellar luxation (MPL) using high speed 320-row computed tomography (CT). METHODS The limbs with grade 2 MPL (MPL-G2 group) and without any orthopaedic disorders (control group) were imaged in a standing position, without sedation or anaesthesia, using CT. In MPL-G2 group, images were obtained when the patella was luxated (G2-L group) and reduced (non-luxation, G2-NL group). Bone morphologies of the femur and tibia were quantified three-dimensionally. Hindlimb standing posture was evaluated by measuring femoral rotation and abduction angles, tibial rotation angle, metatarsal rotation angle, foot rotation angle, angle between the femoral anatomical axis and the mechanical axis of hindlimb and stifle joint line convergence angle. RESULTS There were no significant differences in bone morphologic parameters between the MPL-G2 group (5 limbs) and the control group (6 limbs). In the G2-NL group, there were no significant hindlimb postural abnormalities. In contrast, in the G2-L group, significant hindlimb postural abnormalities including external rotation of femur, internal rotation of tibia and foot, external rotation of tarsal joint, large stifle joint convergence angle, genu varum and toe-in standing were observed. CONCLUSION Dogs with grade 2 MPL have no bone deformities but show abnormal standing posture when the patella is luxated.
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Affiliation(s)
- Yuma Tomo
- Laboratory of Veterinary Surgery, Department of Veterinary Medicine, College of Bioresource and Sciences, Nihon University, Fujisawa, Kanagawa, Japan
| | - Kazuya Edamura
- Laboratory of Veterinary Surgery, Department of Veterinary Medicine, College of Bioresource and Sciences, Nihon University, Fujisawa, Kanagawa, Japan
| | - Atsushi Yamazaki
- Laboratory of Veterinary Surgery, Department of Veterinary Medicine, College of Bioresource and Sciences, Nihon University, Fujisawa, Kanagawa, Japan
| | - Koji Tanegashima
- Laboratory of Veterinary Surgery, Department of Veterinary Medicine, College of Bioresource and Sciences, Nihon University, Fujisawa, Kanagawa, Japan
| | - Mamiko Seki
- Laboratory of Veterinary Surgery, Department of Veterinary Medicine, College of Bioresource and Sciences, Nihon University, Fujisawa, Kanagawa, Japan
| | - Kazushi Asano
- Laboratory of Veterinary Surgery, Department of Veterinary Medicine, College of Bioresource and Sciences, Nihon University, Fujisawa, Kanagawa, Japan
| | - Selena Tinga
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, United States
| | - Kei Hayashi
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, United States
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Evaluation of the reliability of lower extremity alignment measurements using EOS imaging system while standing in an even weight-bearing posture. Sci Rep 2021; 11:22039. [PMID: 34764394 PMCID: PMC8585885 DOI: 10.1038/s41598-021-01646-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 10/15/2021] [Indexed: 11/08/2022] Open
Abstract
This study aimed to analyze the reproducibility and reliability of the alignment parameters measured using the EOS image system in both limbs while standing with an even weight-bearing posture. Overall, 104 lower extremities in 52 patients were analyzed retrospectively. The patients stood with an even load over both lower extremities then rotated 15° in both directions. Two EOS images were acquired and 104 pairs of lower extremities were compared according to the position of the indexed lower extremities. Then, the inter-observer reliability of the EOS system and the inter-modality reliability between EOS and computed tomography (CT) were evaluated. Femoro-tibial rotation (FTR) and tibial torsion demonstrated a significant difference between the anterior and posterior positions of the indexed lower extremity. In the inter-observer reliability analysis, all values except for FTR and tibial torsion demonstrated good or very good reliability. In the anterior position, FTR demonstrated moderate, and tibial torsion demonstrated poor reliability. In the posterior position, both FTR and tibial torsion demonstrated poor reliability. In the reliability analysis between the three-dimensional (3D) EOS model and 3D CT images, all measurements of the femur demonstrated very good reliability, but measurements of the tibia did not. For the coronal and sagittal alignment parameters measured by the EOS 3D system with rotated standing posture, except for the measurement including tibial torsion., there were no significant difference for either position of the indexed extremities with high agreement between the observers as well as with the CT 3D model.
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Andreisek G. Advances in Daily Musculoskeletal Imaging: Automated Analysis of Classic Radiographs. Radiol Artif Intell 2021; 3:e200300. [PMID: 33939771 PMCID: PMC8043358 DOI: 10.1148/ryai.2021200300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/04/2021] [Accepted: 01/07/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Gustav Andreisek
- From the Institute of Radiology, Cantonal Hospital Münsterlingen, Spital Thurgau, Münsterlingen, Spitalcampus 1, 8596 Munsterlingen, Switzerland; and University of Zurich, Zürich, Switzerland
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Tuecking LR, Ettinger M, Nebel D, Welke B, Schwarze M, Windhagen H, Savov P. 3D-surface scan based validated new measurement technique of femoral joint line reconstruction in total knee arthroplasty. J Exp Orthop 2021; 8:16. [PMID: 33634333 PMCID: PMC7907296 DOI: 10.1186/s40634-021-00330-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 01/20/2021] [Indexed: 01/16/2023] Open
Abstract
Purpose This study aimed to validate a new joint line measurement technique in total knee arthroplasty for separated assessment of the medial and lateral femoral joint line alteration with 3D-surface scan technology. Separate assessment of the medial and lateral joint line alteration may improve TKA alignment assessment regarding to joint line restoration in kinematic alignment and use of robotic-assisted TKA surgery. Methods The medial and lateral joint line difference after TKA implantation on an artificial bone model was analyzed and compared with a 3D-scan and full femoral radiographs pre- and postoperatively. Radiographic analysis included the perpendicular distance between the most distal point of the medial and lateral condyle and the reproduced preoperative lateral distal femoral angle (LDFA). For evaluation of validity and reliability, radiographs were captured initially with true anteroposterior view and subsequently with combined flexion and rotation malpositioning. Reliability of the introduced measurement technique in between three observers was tested with intraclass correlation coefficient (ICC). Results Radiographic measurement showed a mean difference of 0.9 mm on the medial side and 0.6 mm on the lateral side when compared to the 3D-surface scan measurement. The reliability of measurement accuracy was ≤ 1 mm in x-rays with < 10° flexion error regardless to malrotation in these images. The ICC test showed very good reliability for the medial joint line evaluation and good reliability for lateral joint line evaluation (ICC 0.92, ICC 0.86 respectively). Conclusion The new introduced joint line measurement method showed a sufficient reliability, accuracy and precision. It provides separated information about medial and lateral joint line alteration in TKA surgery in absolute values. Level of evidence V - Experimental Study
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Affiliation(s)
- Lars-Rene Tuecking
- Department of Orthopaedic Surgery, Medical School Hannover, Anna-von-Borries-Str. 1-7, 30625, Hannover, Germany
| | - Max Ettinger
- Department of Orthopaedic Surgery, Medical School Hannover, Anna-von-Borries-Str. 1-7, 30625, Hannover, Germany
| | - Dennis Nebel
- Laboratory for Biomechanics and Biomaterials, Medical School Hannover, Anna-von-Borries-Str. 1-7, 30625, Hannover, Germany
| | - Bastian Welke
- Laboratory for Biomechanics and Biomaterials, Medical School Hannover, Anna-von-Borries-Str. 1-7, 30625, Hannover, Germany
| | - Michael Schwarze
- Laboratory for Biomechanics and Biomaterials, Medical School Hannover, Anna-von-Borries-Str. 1-7, 30625, Hannover, Germany
| | - Henning Windhagen
- Department of Orthopaedic Surgery, Medical School Hannover, Anna-von-Borries-Str. 1-7, 30625, Hannover, Germany
| | - Peter Savov
- Department of Orthopaedic Surgery, Medical School Hannover, Anna-von-Borries-Str. 1-7, 30625, Hannover, Germany.
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Schock J, Truhn D, Abrar DB, Merhof D, Conrad S, Post M, Mittelstrass F, Kuhl C, Nebelung S. Automated Analysis of Alignment in Long-Leg Radiographs by Using a Fully Automated Support System Based on Artificial Intelligence. Radiol Artif Intell 2020; 3:e200198. [PMID: 33937861 DOI: 10.1148/ryai.2020200198] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 11/20/2020] [Accepted: 12/10/2020] [Indexed: 11/11/2022]
Abstract
Purpose To develop and validate a deep learning-based method for automatic quantitative analysis of lower-extremity alignment. Materials and Methods In this retrospective study, bilateral long-leg radiographs (LLRs) from 255 patients that were obtained between January and September of 2018 were included. For training data (n = 109), a U-Net convolutional neural network was trained to segment the femur and tibia versus manual segmentation. For validation data (n = 40), model parameters were optimized. Following identification of anatomic landmarks, anatomic and mechanical axes were identified and used to quantify alignment through the hip-knee-ankle angle (HKAA) and femoral anatomic-mechanical angle (AMA). For testing data (n = 106), algorithm-based angle measurements were compared with reference measurements by two radiologists. Angles and time for 30 random radiographs were compared by using repeated-measures analysis of variance and one-way analysis of variance, whereas correlations were quantified by using Pearson r and intraclass correlation coefficients. Results Bilateral LLRs of 255 patients (mean age, 26 years ± 23 [standard deviation]; range, 0-88 years; 157 male patients) were included. Mean Sørensen-Dice coefficients for segmentation were 0.97 ± 0.09 for the femur and 0.96 ± 0.11 for the tibia. Mean HKAAs and AMAs as measured by the readers and the algorithm ranged from 0.05° to 0.11° (P = .5) and from 4.82° to 5.43° (P < .001). Interreader correlation coefficients ranged from 0.918 to 0.995 (r range, P < .001), and agreement was almost perfect (intraclass correlation coefficient range, 0.87-0.99). Automatic analysis was faster than the two radiologists' manual measurements (3 vs 36 vs 35 seconds, P < .001). Conclusion Fully automated analysis of LLRs yielded accurate results across a wide range of clinical and pathologic indications and is fast enough to enhance and accelerate clinical workflows.Supplemental material is available for this article.© RSNA, 2020See also commentary by Andreisek in this issue.
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Affiliation(s)
- Justus Schock
- Department of Diagnostic and Interventional Radiology, University Hospital Düsseldorf, Düsseldorf, Germany (J.S., D.B.A., S.N.); Institute of Computer Vision and Imaging, RWTH University Aachen, Pauwelsstrasse 30, 52072 Aachen, Germany (J.S., D.M.); Department of Diagnostic and Interventional Radiology, University Hospital Aachen, Aachen, Germany (D.T., M.P., F.M., C.K., S.N.); and Faculty of Mathematics and Natural Sciences, Institute of Informatics, Heinrich Heine University Düsseldorf, Düsseldorf, Germany (S.C.)
| | - Daniel Truhn
- Department of Diagnostic and Interventional Radiology, University Hospital Düsseldorf, Düsseldorf, Germany (J.S., D.B.A., S.N.); Institute of Computer Vision and Imaging, RWTH University Aachen, Pauwelsstrasse 30, 52072 Aachen, Germany (J.S., D.M.); Department of Diagnostic and Interventional Radiology, University Hospital Aachen, Aachen, Germany (D.T., M.P., F.M., C.K., S.N.); and Faculty of Mathematics and Natural Sciences, Institute of Informatics, Heinrich Heine University Düsseldorf, Düsseldorf, Germany (S.C.)
| | - Daniel B Abrar
- Department of Diagnostic and Interventional Radiology, University Hospital Düsseldorf, Düsseldorf, Germany (J.S., D.B.A., S.N.); Institute of Computer Vision and Imaging, RWTH University Aachen, Pauwelsstrasse 30, 52072 Aachen, Germany (J.S., D.M.); Department of Diagnostic and Interventional Radiology, University Hospital Aachen, Aachen, Germany (D.T., M.P., F.M., C.K., S.N.); and Faculty of Mathematics and Natural Sciences, Institute of Informatics, Heinrich Heine University Düsseldorf, Düsseldorf, Germany (S.C.)
| | - Dorit Merhof
- Department of Diagnostic and Interventional Radiology, University Hospital Düsseldorf, Düsseldorf, Germany (J.S., D.B.A., S.N.); Institute of Computer Vision and Imaging, RWTH University Aachen, Pauwelsstrasse 30, 52072 Aachen, Germany (J.S., D.M.); Department of Diagnostic and Interventional Radiology, University Hospital Aachen, Aachen, Germany (D.T., M.P., F.M., C.K., S.N.); and Faculty of Mathematics and Natural Sciences, Institute of Informatics, Heinrich Heine University Düsseldorf, Düsseldorf, Germany (S.C.)
| | - Stefan Conrad
- Department of Diagnostic and Interventional Radiology, University Hospital Düsseldorf, Düsseldorf, Germany (J.S., D.B.A., S.N.); Institute of Computer Vision and Imaging, RWTH University Aachen, Pauwelsstrasse 30, 52072 Aachen, Germany (J.S., D.M.); Department of Diagnostic and Interventional Radiology, University Hospital Aachen, Aachen, Germany (D.T., M.P., F.M., C.K., S.N.); and Faculty of Mathematics and Natural Sciences, Institute of Informatics, Heinrich Heine University Düsseldorf, Düsseldorf, Germany (S.C.)
| | - Manuel Post
- Department of Diagnostic and Interventional Radiology, University Hospital Düsseldorf, Düsseldorf, Germany (J.S., D.B.A., S.N.); Institute of Computer Vision and Imaging, RWTH University Aachen, Pauwelsstrasse 30, 52072 Aachen, Germany (J.S., D.M.); Department of Diagnostic and Interventional Radiology, University Hospital Aachen, Aachen, Germany (D.T., M.P., F.M., C.K., S.N.); and Faculty of Mathematics and Natural Sciences, Institute of Informatics, Heinrich Heine University Düsseldorf, Düsseldorf, Germany (S.C.)
| | - Felix Mittelstrass
- Department of Diagnostic and Interventional Radiology, University Hospital Düsseldorf, Düsseldorf, Germany (J.S., D.B.A., S.N.); Institute of Computer Vision and Imaging, RWTH University Aachen, Pauwelsstrasse 30, 52072 Aachen, Germany (J.S., D.M.); Department of Diagnostic and Interventional Radiology, University Hospital Aachen, Aachen, Germany (D.T., M.P., F.M., C.K., S.N.); and Faculty of Mathematics and Natural Sciences, Institute of Informatics, Heinrich Heine University Düsseldorf, Düsseldorf, Germany (S.C.)
| | - Christiane Kuhl
- Department of Diagnostic and Interventional Radiology, University Hospital Düsseldorf, Düsseldorf, Germany (J.S., D.B.A., S.N.); Institute of Computer Vision and Imaging, RWTH University Aachen, Pauwelsstrasse 30, 52072 Aachen, Germany (J.S., D.M.); Department of Diagnostic and Interventional Radiology, University Hospital Aachen, Aachen, Germany (D.T., M.P., F.M., C.K., S.N.); and Faculty of Mathematics and Natural Sciences, Institute of Informatics, Heinrich Heine University Düsseldorf, Düsseldorf, Germany (S.C.)
| | - Sven Nebelung
- Department of Diagnostic and Interventional Radiology, University Hospital Düsseldorf, Düsseldorf, Germany (J.S., D.B.A., S.N.); Institute of Computer Vision and Imaging, RWTH University Aachen, Pauwelsstrasse 30, 52072 Aachen, Germany (J.S., D.M.); Department of Diagnostic and Interventional Radiology, University Hospital Aachen, Aachen, Germany (D.T., M.P., F.M., C.K., S.N.); and Faculty of Mathematics and Natural Sciences, Institute of Informatics, Heinrich Heine University Düsseldorf, Düsseldorf, Germany (S.C.)
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Graef F, Falk R, Tsitsilonis S, Perka C, Zahn RK, Hommel H. Correction of excessive intraarticular varus deformities in total knee arthroplasty is associated with deteriorated postoperative ankle function. Knee Surg Sports Traumatol Arthrosc 2020; 28:3758-3765. [PMID: 31776626 DOI: 10.1007/s00167-019-05812-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 11/19/2019] [Indexed: 11/27/2022]
Abstract
PURPOSE The aim of this study was to demonstrate, whether the degree of limb alignment correction in varus knee osteoarthritis correlated with an increase in ankle symptoms and to define a cut-off value concerning the degree of correction above which to expect ankle problems. METHODS Ninety-nine consecutive patients with preoperative intraarticular varus knee deformities who underwent total knee arthroplasty were retrospectively analyzed. Patients were examined clinically (Knee Society Score, Forgotten Joint Score, Foot Function Index, Range of Motion of the knee and ankle joint, pain scales) as well as radiologically. The mean follow-up time was 57 months. RESULTS The degree of operative limb alignment correction strongly correlated with the Foot Function Index (R = 0.91, p < 0.05). Given this, higher degrees of knee malalignment corrections were associated with worse postoperative outcomes in the knee and ankle joint-despite postoperative improved joint line orientations. Subsequently, a cut-off value for arthritic varus deformities (14.5°) could be calculated, above which the prevalence of ankle symptoms increased manifold [OR = 15.6 (3.2-77.2 95% CI p < 0.05)]. Furthermore, ROM restrictions in the subtalar joint were associated with a worse outcome in the ankle joint. CONCLUSIONS When correcting excessive intraarticular varus knee osteoarthritis, surgeons have to be aware of possible postoperative ankle symptoms and should consider ankle deformities or decreased subtalar ROM before operative procedures. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Frank Graef
- Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany.
- Berlin Institute of Health, Anna-Louisa-Karsch-Straße 2, 10178, Berlin, Germany.
| | - R Falk
- Department of Orthopaedics, Märkisch-Oderland Hospital, Brandenburg Medical School Theodor Fontane, Wriezen, Germany
| | - S Tsitsilonis
- Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - C Perka
- Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - R K Zahn
- Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - H Hommel
- Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Department of Orthopaedics, Märkisch-Oderland Hospital, Brandenburg Medical School Theodor Fontane, Wriezen, Germany
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Rotation or flexion alters mechanical leg axis measurements comparably in patients with different coronal alignment. Knee Surg Sports Traumatol Arthrosc 2020; 28:3128-3134. [PMID: 31705148 DOI: 10.1007/s00167-019-05779-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 10/28/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE Flexion and rotation of the knee joint are supposed to alter the measurement of the mechanical leg axis on long leg radiographs. However, in patients with varus or valgus alignment it has not been systematically analyzed so far. The hypothesis is that measurement of the mechanical leg axis is more influenced by flexion and rotation in presence of varus or valgus alignment compared to patients with a straight coronal alignment. METHODS 3D surface models of the lower extremities of seven individuals with varying degrees of coronal alignment were created based on CT data. The coronal alignment of the seven individuals captured the range between 9° varus and 9° valgus with equal steps of 3°. Combinations of internal and external rotations of 10°, 20°, and 30° with flexion of 5°, 10°, 15°, 20°, and 30° were simulated. The mechanical leg axis was measured for each combination as the antero-posterior (ap)-projected hip-knee-ankle (HKA-) angle. RESULTS 294 simulations with all combinations of rotation and flexion were performed. Ranges of deviation of HKA never showed a critical deviation of more than 3° from median values. Deviations from baseline appeared normally distributed for all flexion and rotation combinations (p < 0.05) and the probability for a deviation from the mean mechanical leg axis of more than 3° was less than 0.03 for all combinations. Comparability of the models, therefore, could be assumed. CONCLUSION Deviations in HKA-angle measurements, caused by rotation or flexion, does not vary relevantly through the range of coronal alignment of 9° varus to 9° valgus. As a clinical relevance, deviations in HKA-angle measurements can be considered as comparable in patients with different coronal alignment. LEVEL OF EVIDENCE III.
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Moon HS, Choi CH, Jung M, Lee DY, Kim JH, Kim SH. The effect of knee joint rotation in the sagittal and axial plane on the measurement accuracy of coronal alignment of the lower limb. BMC Musculoskelet Disord 2020; 21:470. [PMID: 32680484 PMCID: PMC7368736 DOI: 10.1186/s12891-020-03487-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 07/07/2020] [Indexed: 11/10/2022] Open
Abstract
Background Although the measurement of coronal alignment of the lower limb on conventional full-length weight-bearing anteroposterior (FLWAP) radiographs was reported to be influenced by the knee joint rotation, no comparative analysis was performed considering the effects of knee joint rotation on the sagittal and axial planes simultaneously using the three-dimensional images while taking into account the actual weight-bearing conditions. The aim of this study was to investigate the effect of knee joint rotation on the measurement accuracy of coronal alignment of the lower limb on the FLWAP radiograph. Methods Radiographic images of 90 consecutive patients (180 lower limbs) who took both the FLWAP radiograph and the EOS image were retrospectively reviewed. The relationship among delta values of mechanical tibiofemoral angle (mTFA) between the FLWAP radiographs and the EOS images (ΔmTFA), knee flexion/extension angle (sagittal plane rotation) on the EOS images, and patellar rotation (axial plane rotation) on the FLWAP radiographs were analyzed. Further, subgroup analysis according to each direction of knee joint rotation was performed. Results There was a significant correlation between ΔmTFA and sagittal plane rotation (r = 0.368, P < 0.001), whereas axial plane rotation was not correlated. In the analysis according to the direction, statistically significant correlation was observed only in the knee flexion group (r = 0.399, P < 0.001). The regression analysis showed a significant linear relationship between ΔmTFA and sagittal plane rotation (r2 = 0.136, P < 0.001). Additional subgroup analysis in patients with the patellar rotation greater than 3% showed a similar result of a linear relationship between ΔmTFA and sagittal plane rotation (r2 = 0.257, P < 0.001), whereas no statistically significant relationship was found in patients with the patellar rotation less than 3%. Conclusion The measurement accuracy of coronal alignment of the lower limb on the FLWAP radiographs would be influenced by knee flexion, specifically when there is any subtle rotation of the knee joint in the axial plane. A strict patellar forward position without axial plane rotation of the knee could provide accurate results of the measurement even if there is a fixed flexion contracture of the knee.
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Affiliation(s)
- Hyun-Soo Moon
- Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.,Department of Orthopedic Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Republic of Korea
| | - Chong-Hyuk Choi
- Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.,Department of Orthopedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Min Jung
- Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.,Department of Orthopedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dae-Young Lee
- Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.,Department of Orthopedic Surgery, Saegil Hospital, Seoul, Republic of Korea
| | - Jung-Hwan Kim
- Department of Orthopedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung-Hwan Kim
- Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea. .,Department of Orthopedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
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