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Gao YH, Qi YM, Huang PH, Zhao XY, Qi X. Distribution of coronal plane alignment of the knee classification in Chinese osteoarthritic and healthy population: a retrospective cross-sectional observational study. Int J Surg 2024; 110:2583-2592. [PMID: 38349219 DOI: 10.1097/js9.0000000000001178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 01/29/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Few studies have reported the coronal constitutional alignment of the lower limbs in mainland China. This study aimed to analyse the distribution of the coronal plane alignment of the knee (CPAK) classification in the osteoarthritic (OA) and healthy Chinese populations. MATERIALS AND METHODS The CPAK distributions of 246 patients (477 knees) with OA and 107 healthy individuals (214 knees) were retrospectively examined using long-leg radiographs. Radiological measurements and CPAK classification of different Kellgren-Lawrence grades in patients with unilateral total knee arthroplasty (TKA) were compared. The clinical outcomes of patients with CPAK type I who underwent mechanical alignment or restricted kinematic alignment during TKA were examined. RESULTS The most common distributions in the OA and healthy groups were type I and type II, respectively. In patients who underwent unilateral TKA, the most common distribution of knees graded as Kellgren-Lawrence 3-4 was type I. However, the most common distributions of contralateral knees graded as Grade 0-2 were type I and II. For patients with CPAK type I, the mechanical alignment and restricted kinematic alignment groups did not differ significantly concerning postoperative clinical outcomes at 3 months. CONCLUSION The most common distributions in Chinese osteoarthritic and healthy populations were types I and II, respectively. In addition, OA progression may lead to changes in the CPAK classification.
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Affiliation(s)
- Yu-Hang Gao
- Department of Orthopaedic Surgery, Orthopaedic Center, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Yu-Meng Qi
- Departments of Biostatistics, Columbia University, New York, NY, USA
| | - Pei-Hong Huang
- Department of Orthopaedic Surgery, Orthopaedic Center, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Xing-Yu Zhao
- Department of Orthopaedic Surgery, Orthopaedic Center, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Xin Qi
- Department of Orthopaedic Surgery, Orthopaedic Center, The First Hospital of Jilin University, Changchun, Jilin, China
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Nedopil AJ, Rego E, Hernandez AM, Boone JM, Howell SM, Hull ML. Correcting for asymmetry of the proximal tibial epiphysis is warranted to determine postoperative alignment deviations in kinematic alignment from planned alignment of the tibial component on the native tibia. Clin Biomech (Bristol, Avon) 2024; 113:106215. [PMID: 38428263 DOI: 10.1016/j.clinbiomech.2024.106215] [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: 08/24/2023] [Revised: 02/19/2024] [Accepted: 02/20/2024] [Indexed: 03/03/2024]
Abstract
BACKGROUND In total knee arthroplasty, unrestricted kinematic alignment aims to restore pre-arthritic lower limb alignment and joint lines. Joint line orientations of the contralateral healthy proximal tibia might be used to evaluate accuracy of tibial component alignment post-operatively if asymmetry is minimal. Our objective was to evaluate left-to-right asymmetry of the proximal tibial epiphysis in posterior tibial slope and varus-valgus orientation as related to unrestricted kinematic alignment principles. METHODS High resolution CT images (0.5 mm slice thickness) were acquired from bilateral lower limbs of 11 skeletally mature subjects with no skeletal abnormalities. Images were segmented to generate 3D tibia models. Asymmetry was quantified by differences in orientations required to shape-match the proximal epiphysis of the mirror 3D tibia model to the proximal epiphysis of the contralateral 3D tibia model. FINDINGS Systematic and random differences (i.e. mean ± standard deviation) in tibial slope and varus-valgus orientation were - 0.8° ± 1.2° and - 0.2° ± 0.8°, respectively. Ninety five percent confidence intervals on the means included 0° indicating that systematic differences were minimal. INTERPRETATION Since random differences due to asymmetry are substantial in relation to random surgical deviations from pre-arthritic joint lines previously reported, post-operative computer tomograms of the contralateral healthy tibia should not be used to directly assess accuracy of tibial component alignment on a group level without correcting for differences in tibial slope and varus-valgus orientation due to asymmetry.
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Affiliation(s)
- Alexander J Nedopil
- Department of Orthopaedic Surgery, König-Ludwig-Haus, University of Würzburg, Brettreichstraße 11, 97074 Würzburg, Germany
| | - Ethan Rego
- Department of Biomedical Engineering, University of California at Davis, One Shields Avenue, Davis, CA 95616, USA.
| | - Andrew M Hernandez
- Department of Radiology, University of California at Davis Medical Center, Sacramento, CA 95817, USA.
| | - John M Boone
- Department of Radiology, University of California at Davis Medical Center, Sacramento, CA 95817, USA.
| | - Stephen M Howell
- Department of Orthopaedic Surgery, University of California at Davis Medical Center, Sacramento, CA 95817, USA
| | - Maury L Hull
- Department of Biomedical Engineering, University of California at Davis, One Shields Avenue, Davis, CA 95616, USA; Department of Mechanical Engineering, University of California at Davis, One Shields Avenue, Davis, CA 95616, USA; Department of Orthopaedic Surgery, University of California at Davis Medical Center, Sacramento, CA 95817, USA.
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Sava MP, Leica A, Amsler F, Leles S, Hirschmann MT. Only 26% of Native Knees Show an Identical Coronal Functional Knee Phenotype in the Contralateral Knee. J Pers Med 2024; 14:193. [PMID: 38392626 PMCID: PMC10890178 DOI: 10.3390/jpm14020193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 02/02/2024] [Accepted: 02/07/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND A comprehensive exploration evaluating left-to-right knee symmetry across all anatomical planes utilizing three-dimensional (3D) scans stands absent from the existing body of research. Therefore, the primary objectives of this investigation involved examining potential differences and resemblances in alignment and structure between left and right non-osteoarthritic (native) knees in various planes (coronal, sagittal, and axial) using three-dimensional single-photon emission computed tomography/computed tomography (SPECT/CT) images. METHODS A total of 282 native knees from 141 patients were retrospectively gathered from the hospital's records. Patients, aged between 16 and 45, who underwent Tc99m-methyl diphosphonate SPECT/CT scans for both knees, adhering to the Imperial Knee Protocol, were included. A statistical analysis was conducted, including 23 knee morphometric parameters, comparing left and right knees, and classifying them based on functional knee phenotypes across the coronal, sagittal, and axial planes. RESULTS Regarding the functional coronal knee phenotype, 26% of patients (n = 37) exhibited identical phenotypes in both knees (p < 0.001). Significant correlated similarities between the left and right knees were observed in the coronal plane (Pearson's r = 0.76, 0.68, 0.76, 0.76, p < 0.001) and in several morphometric measures in the sagittal plane (Pearson's r = 0.92, 0.72, 0.64, p < 0.001). Moderately correlated similarities were noted in the axial plane (Pearson's r = 0.43, 0.44, 0.43, p < 0.001). CONCLUSIONS Only 26% of native knees exhibit an identical coronal phenotype in their contralateral knee, whereas 67% have the adjacent coronal phenotype. Strongly correlated resemblances were established across various left and right knee morphometric parameters in the coronal, sagittal, and axial planes. These findings could enhance decisions in procedures like total knee arthroplasties or osteotomies, where alignment is key to outcomes, and reveal a potential for future artificial intelligence-driven models to improve our understanding and improve personalized treatment strategies for knee osteoarthritis.
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Affiliation(s)
- Manuel-Paul Sava
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), CH-4101 Bruderholz, Switzerland
- Department of Clinical Research, Research Group Michael T. Hirschmann, Regenerative Medicine & Biomechanics, University of Basel, CH-4001 Basel, Switzerland
| | - Alexandra Leica
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), CH-4101 Bruderholz, Switzerland
- Department of Clinical Research, Research Group Michael T. Hirschmann, Regenerative Medicine & Biomechanics, University of Basel, CH-4001 Basel, Switzerland
| | - Felix Amsler
- Amsler Consulting, Gundeldingerrain 111, CH-4059 Basel, Switzerland
| | - Sotirios Leles
- Iatriko Athinon Clinic, Distomou 5-7, 15125 Marousi Attica, Greece
| | - Michael T Hirschmann
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), CH-4101 Bruderholz, Switzerland
- Department of Clinical Research, Research Group Michael T. Hirschmann, Regenerative Medicine & Biomechanics, University of Basel, CH-4001 Basel, Switzerland
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Jiang X, Xie K, Chen H, Zhang K, Hu Y, Kan T, Sun L, Ai S, Zhu X, Zhang L, Yan M, Wang L. A Radiographic Analysis of Coronal Morphological Parameters of Lower Limbs in Chinese Non-knee Osteoarthritis Populations. Orthop Surg 2024; 16:452-461. [PMID: 38088238 PMCID: PMC10834221 DOI: 10.1111/os.13952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 10/22/2023] [Accepted: 10/24/2023] [Indexed: 02/03/2024] Open
Abstract
OBJECTIVES Analyzing the lower limb coronal morphological parameters in populations without knee osteoarthritis (KOA) holds significant value in predicting, diagnosing, and formulating surgical strategies for KOA. This study aimed to comprehensively analyze the variability in these parameters among Chinese non-KOA populations, employing a substantial sample size. METHODS A cross-sectional retrospective analysis was performed on the Chinese non-KOA populations (n = 407; 49.9% females). The study employed an in-house developed artificial intelligence software to meticulously assess the coronal morphological parameters of all 814 lower limbs. The parameters evaluated included the hip-knee-ankle angle (HKAA), weight-bearing line ratio (WBLR), joint line convergence angle (JLCA), mechanical lateral-proximal-femoral angle (mLPFA), mechanical lateral-distal-femoral angle (mLDFA), mechanical medial-proximal-tibial angle (mMPTA), and mechanical lateral-distal-tibial angle (mLDTA). Differences in these parameters were compared between left and right limbs, different genders, and different age groups (with 50 years as the cut-off point). RESULTS HKAA and JLCA exhibited left-right differences (left vs. right: 178.2° ± 3.0° vs. 178.6° ± 2.9° for HKAA, p = 0.001; and 1.8° ± 1.5° vs. 1.4° ± 1.6° for JLCA, p < 0.001); except for the mLPFA, all other parameters show gender-related differences (male vs. female: 177.9° ± 2.8° vs. 179.0° ± 3.0° for HKAA, p < 0.001; 1.5° ± 1.5° vs. 1.8° ± 1.7° for JLCA, p = 0.003; 87.1° ± 2.1° vs. 88.1° ± 2.1° for mMPTA, p < 0.001; 90.2° ± 4.0° vs. 91.1° ± 3.2° for mLDTA, p < 0.001; 38.7% ± 12.9% vs. 43.6% ± 14.1% for WBLR, p < 0.001; and 87.7° ± 2.3° vs. 87.4° ± 2.7° for mLDTA, p = 0.045); mLPFA increase with age (younger vs. older: 90.1° ± 7.2° vs. 93.4° ± 4.9° for mLPFA, p < 0.001), while no statistical difference exists for other parameters. CONCLUSIONS There were differences in lower limb coronal morphological parameters among Chinese non-KOA populations between left and right sides, different genders, and age.
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Affiliation(s)
- Xu Jiang
- Shanghai Frontiers Science Center of Degeneration and Regeneration in Skeletal System, Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic SurgeryShanghai Jiao Tong University of Medicine affiliated Ninth People's HospitalShanghaiChina
| | - Kai Xie
- Shanghai Frontiers Science Center of Degeneration and Regeneration in Skeletal System, Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic SurgeryShanghai Jiao Tong University of Medicine affiliated Ninth People's HospitalShanghaiChina
| | - Hongyu Chen
- Shanghai Frontiers Science Center of Degeneration and Regeneration in Skeletal System, Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic SurgeryShanghai Jiao Tong University of Medicine affiliated Ninth People's HospitalShanghaiChina
| | - Kai Zhang
- Shanghai Frontiers Science Center of Degeneration and Regeneration in Skeletal System, Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic SurgeryShanghai Jiao Tong University of Medicine affiliated Ninth People's HospitalShanghaiChina
| | - Yuqi Hu
- School of Biomedical EngineeringShanghai Jiao Tong UniversityShanghaiChina
| | - Tianyou Kan
- Shanghai Frontiers Science Center of Degeneration and Regeneration in Skeletal System, Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic SurgeryShanghai Jiao Tong University of Medicine affiliated Ninth People's HospitalShanghaiChina
| | - Lin Sun
- Shanghai Frontiers Science Center of Degeneration and Regeneration in Skeletal System, Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic SurgeryShanghai Jiao Tong University of Medicine affiliated Ninth People's HospitalShanghaiChina
| | - Songtao Ai
- Department of RadiologyShanghai Jiao Tong University of Medicine affiliated Ninth People's HospitalShanghaiChina
| | - Xianping Zhu
- Department of Orthopaedic SurgeryTaizhou Central HospitalTaizhouChina
| | - Lichi Zhang
- School of Biomedical EngineeringShanghai Jiao Tong UniversityShanghaiChina
| | - Mengning Yan
- Shanghai Frontiers Science Center of Degeneration and Regeneration in Skeletal System, Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic SurgeryShanghai Jiao Tong University of Medicine affiliated Ninth People's HospitalShanghaiChina
| | - Liao Wang
- Shanghai Frontiers Science Center of Degeneration and Regeneration in Skeletal System, Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic SurgeryShanghai Jiao Tong University of Medicine affiliated Ninth People's HospitalShanghaiChina
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Capella M, Sabatini L, Bosco F, Barberis L, Giustra F, Risitano S, Camazzola D, Massè A. A novel geometrical planning method to restore knee joint obliquity in double-level osteotomies. Arch Orthop Trauma Surg 2023; 143:6685-6693. [PMID: 37505270 PMCID: PMC10541832 DOI: 10.1007/s00402-023-04997-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 07/18/2023] [Indexed: 07/29/2023]
Abstract
PURPOSE Precise preoperative planning is mandatory when a double-level osteotomy (DLO) is required to correct a severe knee deformity. Literature does not report a validated planning method regarding DLO that could be performed directly on digital radiographs using simple measurement tools. This study aims to validate a novel DLO planning method called New Mikulicz-Joint Line (NM-JL) based on essential measurement tools, in which the correction angles are induced by the predicted post-operative joint line obliquity (JLO). METHODS Twenty-three patients who satisfied the inclusion criteria were enrolled. NM-JL planning method was performed using basic measurement tools to detect corrective angles and gaps. The correction was then simulated using a Virtual Segmentation Software method to obtain the osteotomy fragments. Both planning procedures were performed independently and later repeated by two orthopaedic surgeons to assess the inter and intra-observer reliability. RESULTS The intraclass correlation coefficient (ICC) regarding corrective angles and gaps showed a significant positive correlation between the values determined using the two procedures by both raters (p < 0.05). Pearson's correlation analysis revealed a significant correlation between the measured results of the two planning methods. (p < 0.05). Finally, the Bland-Altman analysis showed an excellent agreement (p < 0.05) for all measurements performed. CONCLUSIONS The NM-JL method showed high values of intra and inter-rater reliability. The procedure is built up starting from the predicted value of post-operative joint line obliquity, allowing to maintain this parameter fixed. Other advantages include the quickness, adaptability, and possibility to be performed on any Digital Imaging and Communication in Medicine (DICOM) viewer. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Marcello Capella
- Department of Orthopaedics and Traumatology, University of Turin, CTO, Via Zuretti 29, 10126, Turin, Italy
| | - Luigi Sabatini
- Department of Orthopaedics and Traumatology, University of Turin, CTO, Via Zuretti 29, 10126, Turin, Italy
| | - Francesco Bosco
- Department of Orthopaedics and Traumatology, University of Turin, CTO, Via Zuretti 29, 10126, Turin, Italy.
| | - Luca Barberis
- Department of Orthopaedics and Traumatology, University of Turin, CTO, Via Zuretti 29, 10126, Turin, Italy
| | - Fortunato Giustra
- Department of Orthopaedics and Traumatology, University of Turin, CTO, Via Zuretti 29, 10126, Turin, Italy
| | - Salvatore Risitano
- Department of Orthopaedics and Traumatology, University of Turin, CTO, Via Zuretti 29, 10126, Turin, Italy
| | - Daniele Camazzola
- Department of Orthopaedics and Traumatology, University of Turin, CTO, Via Zuretti 29, 10126, Turin, Italy
| | - Alessandro Massè
- Department of Orthopaedics and Traumatology, University of Turin, CTO, Via Zuretti 29, 10126, Turin, Italy
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Stine S, Joiner JD, Andersen D, Schweller E, Vaidya R. Transparency films: intraoperative templating to prevent limb deformity. OTA Int 2023; 6:e280. [PMID: 37601826 PMCID: PMC10438797 DOI: 10.1097/oi9.0000000000000280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 06/03/2023] [Indexed: 08/22/2023]
Abstract
Operative management of fractures and malunions can be challenging when restoring native anatomy is not straightforward. Comminuted fractures and managing deformity correction in the setting of osteolysis, callus, and even complete fracture healing must include careful planning. Preoperative planning has been popularized and taught as an integral part of a surgeon's skill set, with critical evaluation and assessment of the implemented plan being the final step in the process. We present a robust, reproducible, and cost-effective technique for intraoperative fracture fixation assessment with case examples, used routinely at our institution.
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Affiliation(s)
- Sasha Stine
- Wayne State University, Department of Orthopaedic Surgery, Detroit Medical Center, Detroit, MI
| | | | - Daniel Andersen
- Michigan State University College of Osteopathic Medicine, Lansing, MI
| | - Eric Schweller
- Michigan State University College of Osteopathic Medicine, Lansing, MI
| | - Rahul Vaidya
- Wayne State University, Department of Orthopaedic Surgery, Detroit Medical Center, Detroit, MI
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Winnock de Grave P, Luyckx T, Van Criekinge T, Müller JH, Ollivier B, Van Eecke E, LiArno S, Faizan A, Claeys K. Inverse kinematic alignment accommodates native coronal knee alignment better in comparison to adjusted mechanical alignment and restricted kinematic alignment. Knee Surg Sports Traumatol Arthrosc 2023; 31:3765-3774. [PMID: 36781450 DOI: 10.1007/s00167-023-07326-x] [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: 10/03/2022] [Accepted: 01/25/2023] [Indexed: 02/15/2023]
Abstract
PURPOSE The purpose was to determine the proportion of native non-arthritic knees that fit within the target zones of adjusted mechanical alignment (aMA), restricted kinematic alignment (rKA), and inverse kinematic alignment (iKA), and to estimate adjustments in native coronal alignment to bring outlier knees within the respective target zones. The hypothesis was that the target zone of iKA, compared to the target zones of aMA and rKA, accommodates a higher proportion of native non-arthritic knees. METHODS The study used measurements obtained from a computed tomography (CT) scan database (SOMA, Stryker) of 972 healthy knees (Caucasian, 586; Asian, 386). Hip knee ankle (HKA) angle, medial proximal tibial angle (MPTA) and lateral distal femoral angle (LDFA) were used to estimate the proportions of knees within the patient-specific alignment target zones; and to estimate theoretical adjustments of MPTA, LDFA and soft tissue balance (HKA) to bring outlier knees within target zones. Theoretical adjustments to bring outlier knees within the alignment target zones of aMA, rKA and iKA were calculated by subtracting the native coronal alignment angles (MPTAnative, LDFAnative and HKAnative) from angles on the nearest target zone border (MPTAtarget, LDFAtarget and HKAtarget). RESULTS Patients were aged 59.8 ± 15.8 years with a BMI of 25.0 ± 4.4 kg/m2. The HKA angles were between 168° and 186°, MPTA between 78° and 98° and LDFA between 79° and 93°. Of the 972 knees, 81 (8%) were in the aMA target zone, 530 (55%) were in the rKA target zone, and 721 (74%) were in the iKA target zone. Adjustments of MPTA, LDFA and HKA angle to bring outlier knees within the target zones, were, respectively, 90, 91 and 28% for aMA, 45, 28 and 25% for rKA, and 25, 23 and 7% for iKA. CONCLUSIONS There is considerable variability in native knee coronal alignment that corresponds to different proportions of the restricted patient-specific alignment target zones for TKA. Although extension of the MPTA and LDFA target zones with rKA accommodate native knee alignment better than aMA, up to 25% would require adjustment of native HKA angle. By also extending the HKA angle target zone into varus, iKA accommodates a greater proportion (93%) of native limb alignment. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Philip Winnock de Grave
- Department Orthopaedic Surgery, AZ Delta Roeselare, Brugsesteenweg 90, 8800, Roeselare, Belgium.
- Department Rehabilitation Sciences, KU Leuven, Spoorwegstraat 12, 8200, Brugge, Belgium.
| | - Thomas Luyckx
- Department Orthopaedic Surgery, AZ Delta Roeselare, Brugsesteenweg 90, 8800, Roeselare, Belgium
- Department Orthopaedic Surgery, UZ Leuven, Herestraat 49, 3000, Louvain, Belgium
| | - Tamaya Van Criekinge
- Department Orthopaedic Surgery, AZ Delta Roeselare, Brugsesteenweg 90, 8800, Roeselare, Belgium
- Department Rehabilitation Sciences, KU Leuven, Spoorwegstraat 12, 8200, Brugge, Belgium
| | | | - Britt Ollivier
- Department Orthopaedic Surgery, AZ Delta Roeselare, Brugsesteenweg 90, 8800, Roeselare, Belgium
- Department Orthopaedic Surgery, UZ Leuven, Herestraat 49, 3000, Louvain, Belgium
| | - Eduard Van Eecke
- Department Orthopaedic Surgery, AZ Delta Roeselare, Brugsesteenweg 90, 8800, Roeselare, Belgium
- Department Orthopaedic Surgery, UZ Leuven, Herestraat 49, 3000, Louvain, Belgium
| | - Sally LiArno
- Stryker, 325 Corporate Drive, Mahwah, NJ, 07621, USA
| | - Ahmad Faizan
- Stryker, 325 Corporate Drive, Mahwah, NJ, 07621, USA
| | - Kurt Claeys
- Department Rehabilitation Sciences, KU Leuven, Spoorwegstraat 12, 8200, Brugge, Belgium
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Nedopil AJ, Hernandez AM, Boone JM, Howell SM, Hull ML. Correcting for distal femoral asymmetry is necessary to determine postoperative alignment deviations from planned alignment of the femoral component. Knee 2023; 42:193-199. [PMID: 37054496 DOI: 10.1016/j.knee.2023.01.013] [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: 02/23/2022] [Revised: 08/07/2022] [Accepted: 01/26/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND One method for assessing the accuracy of manual, patient-specific, navigational, and robotic-assisted total knee arthroplasty (TKA) instrumentation is to use a post-operative computer tomogram and determine the deviation of the femoral component alignment relative to the planned alignment in the native (i.e. healthy) contralateral distal femoral epiphysis. However, side-to-side asymmetry might introduce errors which inflate alignment deviations. This study quantified asymmetry in the distal femoral epiphysis. METHODS High resolution CT images (0.5 mm slice thickness) were acquired from bilateral lower limb specimens of 13 skeletally mature subjects with no skeletal abnormalities. Images were segmented to generate 3D femur models. Asymmetry was quantified by differences in positions and orientations required to shape-match the distal epiphysis of the mirror 3D femur model to the distal epiphysis of the contralateral 3D femur model. RESULTS Asymmetry was due to random rather than systematic differences. Random differences (i.e. standard deviations) in proximal-distal (P-D) and anterior-posterior (A-P) positions were 1.1 mm and in varus-valgus (V-V) and internal-external (I-E) orientations were 0.9° and 1.3°, respectively. These represented substantial relative errors of up to 50 % in previously reported overall alignment deviations. CONCLUSIONS Although small in an absolute sense, asymmetry of the distal femur epiphysis introduced substantial relative errors when assessing accuracy of femoral component alignment in TKA. When post-operative computer tomograms are used to assess the accuracy of manual, patient specific, navigational, and robotic-assisted TKA instrumentation, the overall deviation should be corrected for asymmetry to better indicate the accuracy of the surgical technique.
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Affiliation(s)
- Alexander J Nedopil
- Department of Orthopaedic Surgery, König-Ludwig-Haus, University of Würzburg, Brettreichstraße 11, 97074 Würzburg, Germany.
| | - Andrew M Hernandez
- Department of Radiology, University of California at Davis, 4860 Y Street, Suite 3100, Sacramento, CA 95817, USA
| | - John M Boone
- Department of Radiology, University of California at Davis, 4860 Y Street, Suite 3100, Sacramento, CA 95817, USA
| | - Stephen M Howell
- Department of Biomedical Engineering, University of California at Davis, 451 E. Health Sciences Drive, Room 2303, Davis, CA 95616, United States.
| | - Maury L Hull
- Department of Biomedical Engineering, University of California at Davis, 451 E. Health Sciences Drive, Room 2303, Davis, CA 95616, United States; Department of Mechanical Engineering, University of California at Davis, One Shields Avenue, Davis, CA 95616 USA; Department of Orthopaedic Surgery, University of California at Davis Medical Center, Sacramento, CA 95817 USA.
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Patients with varus knee osteoarthritis undergoing high tibial osteotomy exhibit more femoral varus but similar tibial morphology compared to non-arthritic varus knees. Knee Surg Sports Traumatol Arthrosc 2022; 30:680-687. [PMID: 33423093 DOI: 10.1007/s00167-020-06426-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 12/23/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE The aim of this study was to compare alignment parameters between patients undergoing high tibial osteotomy (HTO) for knee osteoarthritis (OA) and non-arthritic controls. METHODS Pre-operative computed tomography images from 194 patients undergoing HTO for medial knee OA and 118 non-arthritic controls were utilized. All patients had varus knee alignment (mean age: 57 ± 11 years; 45% female). The hip-knee-ankle (HKA) angle, mechanical lateral distal femoral angle (mLDFA), medial proximal tibial angle (MPTA) and non-weight-bearing joint line convergence angle (nwJLCA) were compared between "control group" and "HTO group". Femoral and tibial phenotypes were also assessed and compared between groups. Variables found on univariate analysis to be different between the groups were entered into a binary logistic regression model. RESULTS The mean age was lower (Δ = 4 ± 6 years, p = 0.024), body mass index (BMI) was higher (Δ = 1.1 ± 2.8 kg/m2, p = 0.032) and there were more females (Δ = 14%, p = 0.020) in the HTO group. The HTO group had more overall varus (7° ± 4.7° vs 4.8° ± 1.3°, p < 0.001). There was a significant difference in the mean mLDFA between the two groups with the HTO group having more femoral varus (88.7 ± 3.2° vs 87.3 ± 1.8°, p < 0.001). MPTA was similar between the groups (p = 0.881). Age was found to be a strong determinant for femoral varus (p = 0.03). CONCLUSION Patients undergoing HTO for medial knee OA have more femoral varus compared to non-arthritic controls while tibial morphology was similar. This will be an important consideration in pre-operating planning for realignment osteotomy in patients presenting with medial knee OA and warrants further investigation. LEVEL OF EVIDENCE III, retrospective comparative study.
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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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Dagneaux L, Bin Abd Razak HR, Laumonerie P, Faizhan A, LiArno S, Wellings P, Ollivier M, Jacquet C. Bony asymmetry in patellofemoral morphology and risk factors of instability are mostly clinically negligible. Knee Surg Sports Traumatol Arthrosc 2021; 29:3793-3799. [PMID: 33452575 DOI: 10.1007/s00167-020-06413-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 12/10/2020] [Indexed: 01/17/2023]
Abstract
PURPOSE Previous investigations suggested that femoral side-to-side differences were located in the upper femur anatomy. However, little is known about the asymmetry between distal femur and patella. The degree of bony asymmetry in the patellofemoral joint was evaluated using pairs of CT-scans with emphasis on morphometric measurements and risk factors relevant to patellofemoral disorders. METHODS Patellofemoral morphometric parameters and anatomical risk factors were analyzed from 345 pairs of CT scans to evaluate side-to-side differences for each patient. All measurements were automatized using previously published algorithm-calculated bone landmarks. We analyzed asymmetry based on absolute differences (AD) and percentage asymmetry (AS%). Significant asymmetry was defined as AS% > 10%. RESULTS Patellar height was found to be highly symmetric (mean AD 0.1 for both Insall-Salvatti and Caton-Deschamps methods, AS% 8% and 9%, respectively). Patellar and femoral morphometric parameters were found highly symmetric, except for the trochlear groove depth. Substantial asymmetry was reported in two patellofemoral risk factors: the lateral trochlear inclination (mean AD 2°, AS% 16%) and the tibial tuberosity-trochlear groove distance (1 mm, 116%). Patellar and femoral morphometric asymmetries were independent of demographics, including age, gender, height, weight and ethnicity. CONCLUSION Patellar height was found to be highly symmetric and is, therefore, a reasonable index for contralateral templating. While very few patellofemoral morphometric parameters and anatomical risk factors were asymmetric, the mean differences were clinically negligible and independent of demographics. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Louis Dagneaux
- Department of Orthopaedic Surgery, Lapeyronie University Hospital, Montpellier University, 371 Av du Doyen Gaston Giraud, 34295, Montpellier Cedex 5, France.
| | - Hamid Rahmatullah Bin Abd Razak
- SingHealth Duke-NUS Musculoskeletal Sciences Academic Clinical Programme, 20 College Road, Academia Level 4, Singapore, 169865, Singapore
| | - Pierre Laumonerie
- Department of Orthopedic Surgery, Hôpital Pierre-Paul Riquet, Place du Docteur Baylac, 31059, Toulouse, France
| | | | | | | | - Matthieu Ollivier
- Department of Orthopedics and Traumatology, St. Marguerite Hospital, Aix Marseille University, APHM, CNRS, ISM, Institute of Movement and Locomotion, 270 Boulevard Sainte Marguerite, BP 29, 13274, Marseille, France
| | - Christophe Jacquet
- Department of Orthopedics and Traumatology, St. Marguerite Hospital, Aix Marseille University, APHM, CNRS, ISM, Institute of Movement and Locomotion, 270 Boulevard Sainte Marguerite, BP 29, 13274, Marseille, France
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Bakhshayesh P, Ihediwa U, Sandher S, Vris A, Heidari N, Enocson A. A novel technique to assess rotational deformities in lower extremities using CT-based motion analysis. Sci Rep 2021; 11:21123. [PMID: 34702869 PMCID: PMC8548303 DOI: 10.1038/s41598-021-00532-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 10/07/2021] [Indexed: 11/17/2022] Open
Abstract
Rotational deformities following intramedullary (IM) nailing of tibia has a reported incidence of as high as 20%. Common techniques to measure deformities following IM nailing of tibia are either based on clinical assessment, plain X-rays or Computed Tomography (CT) comparing the treated leg with the uninjured contralateral side. All these techniques are based on examiners manual calculation inherently subject to bias. Following our previous rigorous motion analysis and symmetry studies on hemi pelvises, femurs and orthopaedic implants, we aimed to introduce a novel fully digital technique to measure rotational deformities in the lower legs. Following formal institutional approval from the Imperial College, CT images of 10 pairs of human lower legs were retrieved. Images were anonymized and uploaded to a research server. Three dimensional CT images of the lower legs were bilaterally reconstructed. CT-based motion analysis (CTMA) was used and the mirrored images of the left side were merged with the right side proximally as stationary and distally as moving objects. Discrepancies in translation and rotation were automatically calculated. Our study population had a mean age of 54 ± 20 years. There were six males and four females. We observed a greater variation in translation (mm) of Centre of Mass (COM) in sagittal plane (95% CI − 2.959–.292) which was also presented as rotational difference alongside the antero-posterior direction or Y axis (95% CI .370–1.035). In other word the right lower legs in our study were more likely to be in varus compared to the left side. However, there were no statistically significant differences in coronal or axial planes. Using our proposed fully digital technique we found that lower legs of the human adults were symmetrical in axial and coronal plane. We found sagittal plane differences which need further addressing in future using bigger sample size. Our novel recommended technique is fully digital and commercially available. This new technique can be useful in clinical practice addressing rotational deformities following orthopaedic surgical intervention. This new technique can substitute the previously introduced techniques.
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Affiliation(s)
- Peyman Bakhshayesh
- Karolinska Institutet Karolinska University Hospital, Stockholm, Sweden. .,Royal London Hospital, Barts Healthcare NHS Trust, London, UK.
| | - Ugwunna Ihediwa
- Royal London Hospital, Barts Healthcare NHS Trust, London, UK
| | - Sukha Sandher
- Royal London Hospital, Barts Healthcare NHS Trust, London, UK
| | - Alexandros Vris
- Royal London Hospital, Barts Healthcare NHS Trust, London, UK
| | - Nima Heidari
- Royal London Hospital, Barts Healthcare NHS Trust, London, UK
| | - Anders Enocson
- Karolinska Institutet Karolinska University Hospital, Stockholm, Sweden
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Micicoi G, Jacquet C, Sharma A, LiArno S, Faizan A, Kley K, Parratte S, Ollivier M. Neutral alignment resulting from tibial vara and opposite femoral valgus is the main morphologic pattern in healthy middle-aged patients: an exploration of a 3D-CT database. Knee Surg Sports Traumatol Arthrosc 2021; 29:849-858. [PMID: 32372282 DOI: 10.1007/s00167-020-06030-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 04/21/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Given the goal of achieving optimal correction and alignment after knee arthroplasty or high tibial osteotomy, literature focusing on the inter-individual variability of the native knee, tibia and femur with regards to the coronal or sagittal alignment is lacking. The aim of this study was to analyse normal angular values in the healthy middle-aged population and determine differences of angular values according to inter-individual features. The first hypothesis was that common morphological patterns may be identified in the healthy middle-aged non-osteoarthritic population. The second hypothesis was that high inter-individual variability exists with regards to gender, ethnicity and alignment phenotype. METHODS A CT scan-based modelling and analysis system was used to examine the lower limb of 758 normal healthy patients (390 men, 368 women; mean age 58.5 ± 16.4 years) with available data concerning angular values and retrieved from the SOMA database. The hip-knee-ankle angle (HKA), lateral distal femoral angle (LDFA), medial proximal tibial angle (MPTA), posterior distal femoral angle (PDFA), posterior proximal tibial angle (PPTA) and non weight-bearing joint line convergence angle (nwJLCA) were then measured for each patient. Results were analysed for the entire cohort and based on gender, ethnicity and phenotype. RESULTS The mean HKA was 179.4° ± 2.6°, LDFA: 85.8° ± 2.0°, MPTA: 85.6° ± 2.4°, PDFA: 85.2° ± 1.5°, PPTA: 83.8° ± 2.9° and nwJLCA: 1.09° ± 0.9°. Gender was associated with higher LDFA and lower HKA for men. Ethnicity was associated with greater proximal tibial vara and distal femoral valgus for Asian patients. Patients with an overall global varus alignment had more tibia vara and less femoral valgus than patients with an overall valgus alignment. CONCLUSION Even if significant differences were found based on subgroup analysis (gender, ethnicity or phenotype), this study demonstrated that neutral alignment is the main morphological pattern in the healthy middle-aged population. This neutrality is the result from tibia vara compensated by an ipsilateral femoral valgus. LEVEL OF CLINICAL EVIDENCE III, retrospective cohort study.
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Affiliation(s)
- Grégoire Micicoi
- iULS-University Institute for Locomotion and Sports, Pasteur 2 Hospital, University Côte d'Azur, Nice, France.,Aix Marseille Univ, APHM, CNRS, ISM, Sainte-Marguerite Hospital, Institute for Locomotion, Department of Orthopedics and Traumatology, Marseille, France.,Department of Orthopedics and Traumatology, Institute of Movement and Locomotion, St. Marguerite Hospital, 270 Boulevard Sainte Marguerite, BP 29, 13274, Marseille, France
| | - Christophe Jacquet
- Aix Marseille Univ, APHM, CNRS, ISM, Sainte-Marguerite Hospital, Institute for Locomotion, Department of Orthopedics and Traumatology, Marseille, France.,Department of Orthopedics and Traumatology, Institute of Movement and Locomotion, St. Marguerite Hospital, 270 Boulevard Sainte Marguerite, BP 29, 13274, Marseille, France
| | - Akash Sharma
- Aix Marseille Univ, APHM, CNRS, ISM, Sainte-Marguerite Hospital, Institute for Locomotion, Department of Orthopedics and Traumatology, Marseille, France.,Department of Orthopedics and Traumatology, Institute of Movement and Locomotion, St. Marguerite Hospital, 270 Boulevard Sainte Marguerite, BP 29, 13274, Marseille, France
| | | | | | - Kristian Kley
- Aix Marseille Univ, APHM, CNRS, ISM, Sainte-Marguerite Hospital, Institute for Locomotion, Department of Orthopedics and Traumatology, Marseille, France.,The London clinic, 20 Devonshire Pl, Marylebone, London, W1G 6BW, UK
| | - Sébastien Parratte
- Aix Marseille Univ, APHM, CNRS, ISM, Sainte-Marguerite Hospital, Institute for Locomotion, Department of Orthopedics and Traumatology, Marseille, France.,Department of Orthopedics and Traumatology, Institute of Movement and Locomotion, St. Marguerite Hospital, 270 Boulevard Sainte Marguerite, BP 29, 13274, Marseille, France.,Adult Reconstructive Surgery, International Knee and Joint Centre, Abu Dhabi, United Arab Emirates
| | - Matthieu Ollivier
- Aix Marseille Univ, APHM, CNRS, ISM, Sainte-Marguerite Hospital, Institute for Locomotion, Department of Orthopedics and Traumatology, Marseille, France. .,Department of Orthopedics and Traumatology, Institute of Movement and Locomotion, St. Marguerite Hospital, 270 Boulevard Sainte Marguerite, BP 29, 13274, Marseille, France.
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