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Pratobevera A, Seil R, Menetrey J. Joint line and knee osteotomy. EFORT Open Rev 2024; 9:375-386. [PMID: 38726996 PMCID: PMC11099584 DOI: 10.1530/eor-24-0037] [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] [Indexed: 05/12/2024] Open
Abstract
This review explores the intricate relationship between knee osteotomy and frontal plane joint line orientation, emphasizing the dynamic nature of the joint line's influence on knee forces and kinematics. Consideration of coronal alignments, knee phenotypes, and associated angles (medial proximal tibial angle (MTPA), lateral distal femoral angle (LDFA), joint line convergence angle (JLCA)) becomes crucial in surgical planning to avoid joint line deformities. The double-level osteotomy is to be considered a valid option, especially for severe deformities; however, the target patient cannot be selected solely based on high predicted postoperative joint line obliquity (JLO) and MPTA.
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Affiliation(s)
- Andrea Pratobevera
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Romain Seil
- Department of Orthopaedic Surgery, Centre Hospitalier Luxembourg-Clinique d’Eich, Luxembourg, Luxembourg
- Luxembourg Institute of Research in Orthopaedics, Sports Medicine and Science (LIROMS), Luxembourg, Luxembourg
| | - Jacques Menetrey
- Centre de Medecine du Sport et de l’Exercice - Swiss Olympic Medical Center, Hirslanden Clinique La Colline, Geneva, Switzerland
- Orthopaedic Surgery Service, University Hospital of Geneva, Geneva, Switzerland
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Jun JB, Lee SS, Oh J, Lee DH. Knee Joint Line Obliquity With Adaptational Hip and Ankle Joint Orientation After Medial Open Wedge High Tibial Osteotomy. Am J Sports Med 2024; 52:1265-1273. [PMID: 38456270 DOI: 10.1177/03635465241230068] [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] [Indexed: 03/09/2024]
Abstract
BACKGROUND Time-dependent postoperative changes in knee joint line obliquity (KJLO) and subsequent adaptational changes in the hip and ankle joints have not been fully proven after medial open wedge high tibial osteotomy (MOWHTO). PURPOSE To investigate the serial postoperative changes in KJLO and subsequent adaptational changes in the hip and ankle joints over time after MOWHTO. STUDY DESIGN Case series, Level of evidence, 4. METHODS A total of 92 patients who underwent MOWHTO between April 2015 and December 2020 were evaluated. Radiographic parameters, including KJLO, ankle joint line obliquity (ALO), hip abduction angle (HAA), joint line convergence angle, weightbearing line ratio, and hip-knee-ankle angle, were analyzed in time sequence (preoperatively and 3, 6, 12, and 24 months postoperatively). Repeated-measures analysis of variance and post hoc analysis were used to demonstrate alterations and the statistical significance of KJLO and other related radiographic parameters over time. RESULTS The mean KJLO values were -1.9°, -2.1°, -2.7°, and -3.2° at 3, 6, 12, and 24 months postoperatively, respectively, indicating that there was consistent increase in valgus tilting of KJLO from 6 to 24 months (P < .001 for both 6-12 months and 12-24 months). ALO and HAA showed significant changes from 6 to 12 months (ALO, P < .001; HAA, P = .002), but not between 12 and 24 months (ALO: -3.0°, -2.7°, -1.9°, and -1.6°; HAA: -0.8°, -0.9°, -1.5°, and -1.8° at 3, 6, 12, and 24 months, respectively). The mean joint line convergence angle, weightbearing line ratio, and hip-knee-ankle angle did not change significantly from 3 months to 24 months postoperatively. CONCLUSION There was a consistent increase in valgus tilting of the postoperative KJLO from 6 to 24 months after MOWHTO. The adaptive ALO and HAA significantly changed between 6 and 12 months and were maintained until 24 months after MOWHTO. It is necessary to consider the adaptive change when hip or ankle surgery is planned within this period.
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Affiliation(s)
- June-Bum Jun
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sung-Sahn Lee
- Department of Orthopaedic Surgery, Ilsan Paik Hospital, Inje University School of Medicine, Goyangsi, Gyeonggido, Republic of Korea
| | - Juyong Oh
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dae-Hee Lee
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Wilhelm NJ, von Schacky CE, Lindner FJ, Feucht MJ, Ehmann Y, Pogorzelski J, Haddadin S, Neumann J, Hinterwimmer F, von Eisenhart-Rothe R, Jung M, Russe MF, Izadpanah K, Siebenlist S, Burgkart R, Rupp MC. Multicentric development and validation of a multi-scale and multi-task deep learning model for comprehensive lower extremity alignment analysis. Artif Intell Med 2024; 150:102843. [PMID: 38553152 DOI: 10.1016/j.artmed.2024.102843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 03/11/2024] [Accepted: 03/11/2024] [Indexed: 04/02/2024]
Abstract
Osteoarthritis of the knee, a widespread cause of knee disability, is commonly treated in orthopedics due to its rising prevalence. Lower extremity misalignment, pivotal in knee injury etiology and management, necessitates comprehensive mechanical alignment evaluation via frequently-requested weight-bearing long leg radiographs (LLR). Despite LLR's routine use, current analysis techniques are error-prone and time-consuming. To address this, we conducted a multicentric study to develop and validate a deep learning (DL) model for fully automated leg alignment assessment on anterior-posterior LLR, targeting enhanced reliability and efficiency. The DL model, developed using 594 patients' LLR and a 60%/10%/30% data split for training, validation, and testing, executed alignment analyses via a multi-step process, employing a detection network and nine specialized networks. It was designed to assess all vital anatomical and mechanical parameters for standard clinical leg deformity analysis and preoperative planning. Accuracy, reliability, and assessment duration were compared with three specialized orthopedic surgeons across two distinct institutional datasets (136 and 143 radiographs). The algorithm exhibited equivalent performance to the surgeons in terms of alignment accuracy (DL: 0.21 ± 0.18°to 1.06 ± 1.3°vs. OS: 0.21 ± 0.16°to 1.72 ± 1.96°), interrater reliability (ICC DL: 0.90 ± 0.05 to 1.0 ± 0.0 vs. ICC OS: 0.90 ± 0.03 to 1.0 ± 0.0), and clinically acceptable accuracy (DL: 53.9%-100% vs OS 30.8%-100%). Further, automated analysis significantly reduced analysis time compared to manual annotation (DL: 22 ± 0.6 s vs. OS; 101.7 ± 7 s, p ≤ 0.01). By demonstrating that our algorithm not only matches the precision of expert surgeons but also significantly outpaces them in both speed and consistency of measurements, our research underscores a pivotal advancement in harnessing AI to enhance clinical efficiency and decision-making in orthopaedics.
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Affiliation(s)
- Nikolas J Wilhelm
- Department of Orthopedics and Sports Orthopedics, Klinikum rechts der Isar, School of Medicine, Munich, Germany; Munich Institute of Robotics and Machine Intelligence, Department of Electrical and Computer Engineering, Technical University of Munich, Munich, Germany.
| | - Claudio E von Schacky
- Department of Radiology, Klinikum rechts der Isar, School of Medicine, Munich, Germany
| | - Felix J Lindner
- Department of Orthopedic Sports Medicine , Klinikum rechts der Isar, School of Medicine, Munich, Germany
| | - Matthias J Feucht
- Department of Orthopedics and Trauma Surgery, Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany; Orthopedic Clinic Paulinenhilfe, Diakonie-Hospital, Stuttgart, Germany
| | - Yannick Ehmann
- Department of Orthopedic Sports Medicine , Klinikum rechts der Isar, School of Medicine, Munich, Germany
| | - Jonas Pogorzelski
- Department of Orthopedic Sports Medicine , Klinikum rechts der Isar, School of Medicine, Munich, Germany
| | - Sami Haddadin
- Munich Institute of Robotics and Machine Intelligence, Department of Electrical and Computer Engineering, Technical University of Munich, Munich, Germany
| | - Jan Neumann
- Department of Radiology, Klinikum rechts der Isar, School of Medicine, Munich, Germany
| | - Florian Hinterwimmer
- Department of Orthopedics and Sports Orthopedics, Klinikum rechts der Isar, School of Medicine, Munich, Germany
| | - Rüdiger von Eisenhart-Rothe
- Department of Orthopedics and Sports Orthopedics, Klinikum rechts der Isar, School of Medicine, Munich, Germany
| | - Matthias Jung
- Department of Radiology, Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Maximilian F Russe
- Department of Radiology, Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Kaywan Izadpanah
- Department of Radiology, Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Sebastian Siebenlist
- Department of Orthopedic Sports Medicine , Klinikum rechts der Isar, School of Medicine, Munich, Germany
| | - Rainer Burgkart
- Department of Orthopedics and Sports Orthopedics, Klinikum rechts der Isar, School of Medicine, Munich, Germany
| | - Marco-Christopher Rupp
- Department of Orthopedic Sports Medicine , Klinikum rechts der Isar, School of Medicine, Munich, Germany
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Ghanem D, Ghoul A, Assi A, Ghanem I. Towards a better understanding of knee angular deformities: discrepancies between clinical examination and 2D/3D assessments. Arch Orthop Trauma Surg 2024; 144:1005-1011. [PMID: 38070015 DOI: 10.1007/s00402-023-05153-w] [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: 04/11/2023] [Accepted: 11/20/2023] [Indexed: 02/28/2024]
Abstract
INTRODUCTION Discrepancy between the clinical examination and the 2D/3D radiographs is a common concern in patients with angular or rotational deformities of the lower limbs, as it may alter clinical judgment and subsequent treatment. The aim was to identify such discrepancies and assess determinants that may contribute to their existence. MATERIALS AND METHODS A retrospective chart review was conducted on 329 consecutive patients (658 lower limbs) who underwent physical examination and long-leg biplanar radiographs in our institution between 2013 and 2018 for limb length discrepancy or angular deformity of the knees (varus/valgus). Eleven parameters were measured on 2D and 3D images. 3D measurements were based on standing biplanar X-rays and their 3D reconstructions and were considered the gold standard. Contingency tables and multiple linear regression were used to assess discrepancies between the three modalities and their determinants respectively. RESULTS Significant mismatches were found between physical examination and 2D images (1% in varus and 1% in valgus), between physical examination and 3D assessment (1% in varus and 4.6% in valgus) as well as between 2 and 3D assessments (1.9% in varus and 7.6% in valgus). The significant determinants of the mismatch between 2 and 3D modalities were frontal pelvic obliquity, neck shaft angle, knee flexion, femoral torsion, and tibial mechanical angle. CONCLUSION In the presence of positional and/or morphological deformities, physical examination and 2D assessment of knee alignment could be biased due to axes projection errors. A better understanding of 3D alignment of the knee as part of the entire lower limb from pelvis to toes, may lead to a better diagnosis and subsequently a better treatment of knee angular deformities.
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Affiliation(s)
- Diane Ghanem
- Laboratory of Biomechanics and Medical Imaging, Faculty of Medicine, Saint-Joseph University of Beirut, Beirut, Lebanon.
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA.
| | - Ali Ghoul
- Laboratory of Biomechanics and Medical Imaging, Faculty of Medicine, Saint-Joseph University of Beirut, Beirut, Lebanon
- Hôtel-Dieu de France Hospital, Saint-Joseph University of Beirut, Beirut, Lebanon
| | - Ayman Assi
- Laboratory of Biomechanics and Medical Imaging, Faculty of Medicine, Saint-Joseph University of Beirut, Beirut, Lebanon
| | - Ismat Ghanem
- Laboratory of Biomechanics and Medical Imaging, Faculty of Medicine, Saint-Joseph University of Beirut, Beirut, Lebanon
- Hôtel-Dieu de France Hospital, Saint-Joseph University of Beirut, Beirut, Lebanon
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Tarassoli P, Warnock JM, Lim YP, Jagota I, Parker D. Large multiplanar changes to native alignment have no apparent impact on clinical outcomes following total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2024; 32:432-444. [PMID: 38294963 DOI: 10.1002/ksa.12044] [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: 09/14/2023] [Revised: 12/12/2023] [Accepted: 12/13/2023] [Indexed: 02/02/2024]
Abstract
PURPOSE This study sought to examine if achieved postoperative alignment when compared to the native anatomy would lead to a difference in Patient Reported Outcome Measures (PROMs), and whether the achieved alignment could be broadly categorised by an accepted alignment strategy. METHODS A retrospective cohort study of prospectively collected data on patients undergoing single primary or bilateral simultaneous total knee arthroplasty (TKA) was carried out. CT scans were used to determine the mean change ("delta values") between the pre and postoperative; hip-knee-ankle angle, lateral distal femoral angle, medial proximal tibial angle and femoral implant rotation. Femoral implant flexion and tibial implant slope were measured postoperatively. The primary outcome was the relationship of the variables to the change in KOOS pain subscale after one year. The secondary outcome was the number of knees which could be categorised postoperatively to an alignment strategy, and the mean PROMs in each cohort. RESULTS A total of 296 knees in 261 patients were available for analysis. With regards to the primary outcome, the delta values for each variable did not demonstrate any association with the change in knee injury and osteoarthritis outcome score (KOOS) pain score. Approximately 46% of knees could not be categorised to an alignment strategy based on postoperatively measured alignment, with no significant difference between each cohort with regards to the change in KOOS Pain score. CONCLUSION Achieved alignment does not consistently match accepted alignment strategies, and appears to confer no benefit to clinical outcomes when the native anatomy is most closely approximated, nor results in poorer outcomes in outliers. This study highlights the importance of routine three dimensional pre and postoperative imaging in clinical practice and for the valid analysis of outcomes in studies on alignment. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Payam Tarassoli
- Sydney Orthopaedic Research Institute, St Leonards, Australia
| | | | - Yoong Ping Lim
- Sydney Orthopaedic Research Institute, St Leonards, Australia
- The University of Sydney, Camperdown, Australia
- Charles Darwin University, Casuarina, Australia
| | - Ishaan Jagota
- 360 Med Care Pty Ltd, Pymble, Australia
- Flinders University, Adelaide, Australia
| | - David Parker
- Sydney Orthopaedic Research Institute, St Leonards, Australia
- The University of Sydney, Camperdown, Australia
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Strauch M, Kaufmann V, Graichen H. Tibia-first, gap-balanced patient-specific alignment technique achieves well-balanced gaps in 90% of cases by rebuilding bony anatomy within boundaries. Knee Surg Sports Traumatol Arthrosc 2024; 32:381-388. [PMID: 38270248 DOI: 10.1002/ksa.12056] [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: 11/19/2023] [Revised: 12/27/2023] [Accepted: 01/02/2024] [Indexed: 01/26/2024]
Abstract
PURPOSE Patient-specific alignment (PSA) technique tries to achieve balanced gaps and simultaneously rebuild the individual bony phenotype. The hypothesis was: PSA technique achieves balanced knees in a high percentage with more anatomical resections than adjusted mechanical alignment (AMA). METHODS Three hundred sixty-seven patients underwent navigated total knee arthroplasty (TKA) with a tibia-first gap-balanced PSA technique. Resection boundaries for medial proximal tibia angle (MPTA) of 86-92°, mechanical lateral distal femoral angle (mLDFA) of 86-92°, and hip-knee-ankle angle (HKA) of 175-185° were defined. Preoperative and intraoperative parameters of HKA, MPTA, mLDFA, and gap widths were recorded. Depending on the coronal deformity, the patients were divided into three groups: varus HKA < 178°; straight 178-182° and valgus HKA > 182°. The stability was analysed by assessing the difference between medial and lateral extension and flexion gaps as well as between flexion and extension gaps. All PSA measurements were compared with data from a previously published AMA series. RESULTS PSA achieved balanced gaps in extension, flexion and between flexion/extension in over 90% of cases, being similar to AMA. In PSA, MPTA and mLDFA were restored within 1°, except in extreme varus (MPTA difference 2°) and valgus knees (mLDFA difference 3°). This was caused by the defined boundaries of the alignment technique. This individualised reconstruction led to significantly more anatomical resections of all tibia and femur resections. CONCLUSION A tibia-first, gap-balanced PSA technique achieves balanced joints in more than 90% of cases. By maintaining preoperative MPTA and mLDFA to a high extent, far more anatomical resections, compared to AMA were performed. Future studies need to be conducted to investigate whether those promising intraoperative results correlate with postoperative patient outcomes and whether patients outside the 5° corridor have higher failure rates. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Marco Strauch
- Department for Arthroplasty, Sports-Traumatology and General Orthopaedics, Asklepios Orthopaedic Hospital Lindenlohe, Schwandorf, Germany
| | - Verena Kaufmann
- Department for Arthroplasty, Sports-Traumatology and General Orthopaedics, Asklepios Orthopaedic Hospital Lindenlohe, Schwandorf, Germany
| | - Heiko Graichen
- Department for Arthroplasty, Sports-Traumatology and General Orthopaedics, Asklepios Orthopaedic Hospital Lindenlohe, Schwandorf, Germany
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Pflüger P, Hodel S, Zimmermann SM, Knechtle S, Vlachopoulos L, Fucentese SF. The coronal alignment differs between two-dimensional weight-bearing and three-dimensional nonweight bearing planning in total knee arthroplasty. J Exp Orthop 2024; 11:e12007. [PMID: 38455454 PMCID: PMC10885761 DOI: 10.1002/jeo2.12007] [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: 12/10/2023] [Accepted: 01/17/2024] [Indexed: 03/09/2024] Open
Abstract
Purpose The goal of this study is (1) to assess differences between two-dimensional (2D) weight-bearing (WB) and three-dimensional (3D) nonweight-bearing (NWB) planning in total knee arthroplasty (TKA) and (2) to identify factors that influence intermodal differences. Methods Retrospective single-centre analysis of patients planned for a TKA with patient-specific instruments (PSI). Preoperative WB long-leg radiographs and NWB computed tomography were analysed and following radiographic parameters included: hip-knee-ankle angle (HKA) (+varus/-valgus), joint line convergence angle (JLCA), femorotibial subluxation and bony defect classified according to Anderson. Preoperative range of motion was also considered as possible covariate. Demographic factors included age, sex, and body mass index. Results A total of 352 knees of 323 patients (66% females) with a mean age of 66 ± 9.7 years were analysed. The HKA differed significantly between 2D and 3D planning modalities; varus knees (n = 231): 9.9° ± 5.1° vs. 6.7° ± 4°, p < 0.001; valgus knees (n = 121): -8.2° ± 6° vs. -5.5° ± 4.4°, p < 0.001. In varus knees, HKA (β = 0.38; p < 0.0001) and JLCA (β = 0.14; p = 0.03) were associated with increasing difference between 2D/3D HKA. For valgus knees, HKA (β = -0.6; p < 0.0001), JLCA (β = -0.3; p = 0.0001) and lateral distal femoral angle (β = -0.28; p = 0.03) showed a significant influence on the mean absolute difference. Conclusion The coronal alignment in preoperative 3D model for PSI-TKA significantly differed from 2D WB state and the difference between modalities correlated with the extent of varus/valgus deformity. In the vast majority of cases, the 3D NWB approach significantly underestimated the preoperative deformity, which needs to be considered to achieve the planned correction when using PSI in TKA. Level of Evidence Level III.
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Affiliation(s)
- Patrick Pflüger
- Department of Orthopedics, Balgrist University HospitalUniversity of ZurichZurichSwitzerland
| | - Sandro Hodel
- Department of Orthopedics, Balgrist University HospitalUniversity of ZurichZurichSwitzerland
| | - Stefan M. Zimmermann
- Department of Orthopedics, Balgrist University HospitalUniversity of ZurichZurichSwitzerland
| | - Svenja Knechtle
- Department of Orthopedics, Balgrist University HospitalUniversity of ZurichZurichSwitzerland
| | - Lazaros Vlachopoulos
- Department of Orthopedics, Balgrist University HospitalUniversity of ZurichZurichSwitzerland
| | - Sandro F. Fucentese
- Department of Orthopedics, Balgrist University HospitalUniversity of ZurichZurichSwitzerland
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Hvidberg E, Antfang C, Gosheger G, Vogt B, Abood A, Møller-San Pedro A, Frommer A, Weyer-Elberich V, Møller-Madsen MK, Roedl R, Møller-Madsen B, Rölfing JD. Morphology of the knee after guided growth using tension-band devices: a retrospective multicenter study of 222 limbs and 285 implants. Acta Orthop 2023; 94:609-615. [PMID: 38153250 PMCID: PMC10755675 DOI: 10.2340/17453674.2023.34902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 11/08/2023] [Indexed: 12/29/2023] Open
Abstract
BACKGROUND AND PURPOSE Temporary hemiepiphysiodesis by tension-band devices is commonly applied to correct angular limb deformities in children. We aimed to evaluate knee joint morphology after guided growth using these devices. PATIENTS AND METHODS In a retrospective multicenter study we analyzed standardized anteroposterior long-leg radiographs of 222 limbs (285 implants) of patients treated by temporary hemiepiphysiodesis with either eight-Plates or FlexTacks for coronal angular deformities of the knee joint between 2013 and 2019. Femoral floor angle (FFA), femoral notch-intercondylar distance (FNID), and tibial roof angle (TRA) were measured pre- and postoperatively to assess the central knee joint morphology. Statistical exploratory analyses were performed using linear mixed models, t-tests, Wilcoxon signed-rank test, and Mann-Whitney U test. RESULTS 217 FlexTacks (femur 106, tibia 111) in 104 children and 68 eight-Plates (femur 61, tibia 7) in 35 children were identified. Median time period under growth guidance was 11 months (range 4-42). No statistically significant change in the FFA was detected (eight-Plate: P = 0.2; FlexTack: P = 0.3). A statistically significant difference of the FNID was found in the eight-Plate group (P = 0.02), but not in the FlexTack group (P = 0.3). While TRA increased in both groups, a statistical significance was observed only in the FlexTack group (P < 0.01). CONCLUSION We found minor but clinically irrelevant changes in knee morphology after the treatment.
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Affiliation(s)
- Emma Hvidberg
- Children's Orthopedics and Reconstruction, Aarhus University Hospital, Denmark; Danish Pediatric Orthopedic Research, Aarhus University Hospital, Denmark
| | - Carina Antfang
- Pediatric Orthopedics, Deformity Reconstruction and Foot Surgery, Muenster University Hospital, Germany
| | - Georg Gosheger
- Pediatric Orthopedics, Deformity Reconstruction and Foot Surgery, Muenster University Hospital, Germany
| | - Bjoern Vogt
- Pediatric Orthopedics, Deformity Reconstruction and Foot Surgery, Muenster University Hospital, Germany
| | - Ahmed Abood
- Children's Orthopedics and Reconstruction, Aarhus University Hospital, Denmark; Danish Pediatric Orthopedic Research, Aarhus University Hospital, Denmark
| | - Alexander Møller-San Pedro
- Children's Orthopedics and Reconstruction, Aarhus University Hospital, Denmark; Danish Pediatric Orthopedic Research, Aarhus University Hospital, Denmark
| | - Adrien Frommer
- Pediatric Orthopedics, Deformity Reconstruction and Foot Surgery, Muenster University Hospital, Germany
| | | | | | - Robert Roedl
- Pediatric Orthopedics, Deformity Reconstruction and Foot Surgery, Muenster University Hospital, Germany
| | - Bjarne Møller-Madsen
- Children's Orthopedics and Reconstruction, Aarhus University Hospital, Denmark; Danish Pediatric Orthopedic Research, Aarhus University Hospital, Denmark
| | - Jan Duedal Rölfing
- Children's Orthopedics and Reconstruction, Aarhus University Hospital, Denmark; Danish Pediatric Orthopedic Research, Aarhus University Hospital, Denmark; Pediatric Orthopedics, Deformity Reconstruction and Foot Surgery, Muenster University Hospital, Germany.
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Tarassoli P, Corban LE, Wood JA, Sergis A, Chen DB, MacDessi SJ. Long leg radiographs underestimate the degree of constitutional varus limb alignment and joint line obliquity in comparison with computed tomography: a radiographic study. Knee Surg Sports Traumatol Arthrosc 2023; 31:4755-4765. [PMID: 37490128 DOI: 10.1007/s00167-023-07505-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 07/05/2023] [Indexed: 07/26/2023]
Abstract
PURPOSE The purpose of this study was to understand if differences exist between computed tomography (CT) and long leg radiographs (LLR) when defining coronal plane alignment of the lower limb in total knee arthroplasty (TKA). It aimed to identify any such differences between the two imaging modalities by quantifying constitutional limb alignment (arithmetic hip-knee-ankle angle (aHKA), joint line obliquity (JLO) and Coronal Plane Alignment of the Knee (CPAK) type within the same population. METHODS A retrospective radiographic study compared pre-operative LLR and CT measurements in patients undergoing robotic-assisted TKA. The aHKA, JLO and CPAK types were calculated after measuring the medial proximal tibial angle (MPTA) and lateral distal femoral angle (LDFA). The primary outcomes were the mean differences in aHKA (MPTA-LDFA), JLO (MPTA + LDFA) and proportions of CPAK types between LLR and CT groups. The secondary outcomes were the differences in CT-derived MPTA values based on four different tibial sagittal landmarks. RESULTS After exclusions, 465 imaging sets were analysed in 394 patients. There was a statistically significant mean difference between LLR and CT, respectively, for both MPTA (87.5° vs. 86.2°; p < 0.01) and LDFA (88.7° vs. 87.3°; p < 0.01). There were also statistically significant differences for aHKA (- 0.2° vs. - 1.1°) and JLO (175.1° vs. 173.4°) for LLR and CT, respectively (both p < 0.01). CT increased the proportion of patients with CPAK Type I (constitutional varus aHKA, apex distal JLO) and CPAK Type II (neutral aHKA, apex distal JLO), and decreased numbers of CPAK Types III-VI. There were significant mean differences in the MPTA using varying sagittal landmarks. CONCLUSION Alignment determined by LLRs underestimates the magnitude of both constitutional varus alignment and joint line obliquity compared to CT, differences that notably increase the proportions of patients included in CPAK Types I and II. These distinctions are primarily due to underestimation of proximal tibial varus when measured on LLRs compared to CT, which more specifically defines articular weight-bearing points. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Payam Tarassoli
- Sydney Knee Specialists, Suite 201, Level 2, 131 Princes Hwy, Kogarah, NSW, 2217, Australia
| | - Luke E Corban
- Sydney Knee Specialists, Suite 201, Level 2, 131 Princes Hwy, Kogarah, NSW, 2217, Australia
| | - Jil A Wood
- Sydney Knee Specialists, Suite 201, Level 2, 131 Princes Hwy, Kogarah, NSW, 2217, Australia
| | - Andrew Sergis
- Stryker Australia, 8 Herbert St, St Leonards, NSW, 2065, Australia
| | - Darren B Chen
- Sydney Knee Specialists, Suite 201, Level 2, 131 Princes Hwy, Kogarah, NSW, 2217, Australia
- St George Private Hospital, 1 South St, Kogarah, NSW, 2217, Australia
| | - Samuel J MacDessi
- Sydney Knee Specialists, Suite 201, Level 2, 131 Princes Hwy, Kogarah, NSW, 2217, Australia.
- St George Private Hospital, 1 South St, Kogarah, NSW, 2217, Australia.
- School of Clinical Medicine, University of New South Wales, St George and Sutherland Campuses, Sydney, NSW, Australia.
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Huber S, Mitterer JA, Vallant SM, Simon S, Hanak-Hammerl F, Schwarz GM, Klasan A, Hofstaetter JG. Gender-specific distribution of knee morphology according to CPAK and functional phenotype classification: analysis of 8739 osteoarthritic knees prior to total knee arthroplasty using artificial intelligence. Knee Surg Sports Traumatol Arthrosc 2023; 31:4220-4230. [PMID: 37286901 DOI: 10.1007/s00167-023-07459-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 05/13/2023] [Indexed: 06/09/2023]
Abstract
PURPOSE Osteoarthritis of the knee is commonly associated with malalignment of the lower limb. Recent classifications, as the Coronal Plane Alignment of the Knee (CPAK) and Functional Phenotype classification, describe the bony knee morphology in addition to the overall limb alignment. Data on distribution of these classifications is not sufficient in large populations. The aim of this study was to analyse the preoperative knee morphology with regard to the aforementioned classifications in long leg radiographs prior to total knee arthroplasty surgery using Artificial Intelligence. METHODS The cohort comprised 8739 preoperative long leg radiographs of 7456 patients of all total knee arthroplasty surgeries between 2009 and 2021 from our institutional database. The automated measurements were performed with the validated Artificial Intelligence software LAMA (ImageBiopsy Lab, Vienna) and included standardized axes and angles [hip-knee-ankle angle (HKA), mechanical lateral distal femur angle (mLDFA), mechanical medial proximal tibia angle (mMPTA), mechanical axis deviation (MAD), anatomic mechanic axis deviation (AMA) and joint line convergence angle (JLCA)]. CPAK and functional phenotype classifications were performed and all measurements were analysed for gender, age, and body mass index (BMI) within these subgroups. RESULTS Varus alignment was more common in men (m: 2008, 68.5%; f: 2953, 50.8%) while neutral (m: 578, 19.7%; f: 1357, 23.4%) and valgus (m: 345, 11.8%; f: 1498, 25.8%) alignment was more common in women. The most common morphotypes according to CPAK classification were CPAK Type I (2454; 28.1%), Type II (2383; 27.3%), and Type III (1830; 20.9%). An apex proximal joint line (CPAK Type VII, VIII and IX) was only found in 1.3% of all cases (n = 121). In men, CPAK Type I (1136; 38.8%) and CPAK Type II (799; 27.3%) were the most common types and women were spread more equally between CPAK Type I (1318; 22.7%), Type II (1584; 27.3%) and Type III (1494; 25.7%) (p < 0.001). The most common combination of femur and tibia types was NEUmLDFA0°,NEUmMPTA0° (m: 514, 17.5%; f: 1004, 17.3%), but men showed femoral varus more often. Patients with a higher BMI showed a significantly lower age at surgery (R2 = 0.09, p < 0.001). There were significant differences between men and women for all radiographic parameters (p < 0.001). CONCLUSION Distribution in knee morphology with gender-specific differences highlights the wide range in osteoarthritic knees, characterized by CPAK and phenotype classification and may influence future surgical planning. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Stephanie Huber
- Michael Ogon Laboratory for Orthopedic Research, Orthopedic Hospital Vienna Speising, Speisinger Straße 109, 1130, Vienna, Austria
- Center for Anatomy and Cell Biology, Medical University Vienna Speising, Währinger Straße 13, 1090, Vienna, Austria
| | - Jennyfer A Mitterer
- Michael Ogon Laboratory for Orthopedic Research, Orthopedic Hospital Vienna Speising, Speisinger Straße 109, 1130, Vienna, Austria
| | - Sascha M Vallant
- Michael Ogon Laboratory for Orthopedic Research, Orthopedic Hospital Vienna Speising, Speisinger Straße 109, 1130, Vienna, Austria
| | - Sebastian Simon
- Michael Ogon Laboratory for Orthopedic Research, Orthopedic Hospital Vienna Speising, Speisinger Straße 109, 1130, Vienna, Austria
- 2nd Department, Orthopedic Hospital Vienna Speising, Speisinger Straße 109, 1130, Vienna, Austria
| | - Florian Hanak-Hammerl
- Michael Ogon Laboratory for Orthopedic Research, Orthopedic Hospital Vienna Speising, Speisinger Straße 109, 1130, Vienna, Austria
| | - Gilbert M Schwarz
- Michael Ogon Laboratory for Orthopedic Research, Orthopedic Hospital Vienna Speising, Speisinger Straße 109, 1130, Vienna, Austria
- Center for Anatomy and Cell Biology, Medical University Vienna Speising, Währinger Straße 13, 1090, Vienna, Austria
- Department of Orthopedics and Trauma-Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Antonio Klasan
- Department of Orthopedics and Trauma-Surgery, AUVA Trauma Hospital Graz, Göstinger Straße 26, 8020, Graz, Austria
- Johannes Kepler University Linz, Altenberger Strasse 69, 4040, Linz, Austria
| | - Jochen G Hofstaetter
- Michael Ogon Laboratory for Orthopedic Research, Orthopedic Hospital Vienna Speising, Speisinger Straße 109, 1130, Vienna, Austria.
- 2nd Department, Orthopedic Hospital Vienna Speising, Speisinger Straße 109, 1130, Vienna, Austria.
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Jörgens M, Brunner J, Weigert M, Bormann M, Böhm E, Böcker W, Paulus AC, Ehrl D, Fürmetz J. Linear correlation between patellar positioning and rotation of the lower limb in radiographic imaging: a 3D simulation study. Knee Surg Sports Traumatol Arthrosc 2023; 31:4292-4298. [PMID: 37329367 PMCID: PMC10471691 DOI: 10.1007/s00167-023-07466-0] [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: 02/28/2023] [Accepted: 05/20/2023] [Indexed: 06/19/2023]
Abstract
PURPOSE The purpose of this study was to quantify changes in rotation of the lower limb between image pairs based on patellar position. Additionally, we investigated the differences in alignment between centralized patellar and orthograde-positioned condyles. METHODS Three-dimensional models of 30 paired legs were aligned in neutral position with condyles orthogonal to the sagittal axis and then rotated internally and externally in 1° increments up to 15°. For each rotation, the deviation of the patella and the subsequent changes in alignment parameters were calculated and plotted using a linear regression model. Differences between neutral position and patellar centralization were analysed qualitatively. RESULTS A linear relationship between lower limb rotation and patellar position can be postulated. The regression model (R2 = 0.99) calculated a change of the patellar position of - 0.9 mm per degree rotation and alignment parameters showed small changes due to rotation. The physiological lateralization of the patella at neutral position was on average - 8.3 mm (SD: ± 5.4 mm). From neutral position, internal rotation that led to a centralized patella was on average - 9.8° (SD: ± 5.2°). CONCLUSION The approximately linear dependence of the patellar position on rotation allows an inverse estimation of the rotation during image acquisition and its influence on the alignment parameters. As there is still no absolute consensus about lower limb positioning during image acquisition, data about the impact of a centralized patella compared to an orthograde condyle positioning on alignment parameters was provided. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Maximilian Jörgens
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU, Munich, Germany.
| | - Josef Brunner
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU, Munich, Germany
| | | | - Markus Bormann
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU, Munich, Germany
| | - Elisabeth Böhm
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU, Munich, Germany
| | - Wolfang Böcker
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU, Munich, Germany
| | - Alexander C Paulus
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU, Munich, Germany
| | - Denis Ehrl
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU, Munich, Germany
| | - Julian Fürmetz
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU, Munich, Germany
- Department of Trauma Surgery, BG Unfallklinikum Murnau, Murnau, Germany
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Schröter S, Konrads C, Maiotti M, Mederake M, Fischer C, Ahrend M, Schüll D. In closed wedge distal femur osteotomies for correction of valgus malalignment overcorrection of mLDFA should be avoided. Knee Surg Sports Traumatol Arthrosc 2023; 31:3992-3999. [PMID: 37149824 DOI: 10.1007/s00167-023-07449-1] [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: 03/01/2023] [Accepted: 04/25/2023] [Indexed: 05/08/2023]
Abstract
PURPOSE The purpose of the study was to investigate the influence of the mLDFA (mechanical lateral distal femur angle) as a parameter in varus realignment osteotomies for valgus deformities of the knee. We hypothesized that joint line obliquity with mLDFA > 90° after distal femur osteotomy (DFO) is associated with inferior clinical outcome. METHODS In a retrospective study, a total of 52 patients with isolated femoral valgus deformities were included in the study. The mean postoperative follow-up was 70.5 (SD 33.3) months (standard deviation SD±33.3). In all patients, a distal femur osteotomy was performed. A clinical examination and survey of questionnaires was conducted with the HSS (Hospital for Special Surgery), LG (Lysholm-Gilquist), and KOOS (Knee Injury and Osteoarthritis Outcome Score) scores. Several radiological parameters were assessed on long-standing x-rays: mechanical tibio-femoral angle (mTFA), mLDFA, mechanical medial proximal tibia angle (mMPTA), joint-line convergence angle (JLCA). The t test was used for normally distributed data. The Mann-Whitney U test was performed in non-normally distributed data. RESULTS The mLDFA was 84.9° (SD±2.3) preop and changed to 91.9° (SD±3, 22.9) postop. The mTFA (mechanical tibio-femoral angle) was 5.2° (SD±2.9°) preop and - 1.8° (SD±2.9) postop demonstrating a difference of 6.7°. For analysis, the data was divided into two groups based on postop mLDFA. Group 1: mLDFA ≤ 90°; Group 2: > 90°. Postoperatively, a mean mLDFA of 88.6° (SD±1.4°) was measured in group 1 and 93.9° (SD±2.1) in group 2. The change in mLDFA was 4.7° (SD±1.6) in group 1 and 8.4° (SD±2.8) in group 2. Preoperatively, the mTFA was 4.8° (SD±1.9) in group 1 and 5.5° (SD±3.3) in group 2. Postoperatively, the mTFA decreased in group 1 by 4.8° (SD±2.3) to - 0.1° (SD±2.1). In group 2, the mTFA decreased by 8.2° (SD±3.8) to - 2.8° (SD±2.9). Regarding the HSS, group 1 showed a 10.4 points better score than group 2 (p<0.01). Also, regarding the Lysholm, a significant difference of 16.9 points was found (p<0.01). CONCLUSION Correction of valgus knees using closed wedge DFO leads to good clinical results. A postoperative mLDFA of 85-90° results in superior clinical outcome compared to mLDFA > 90°. Joint-line obliquity should be avoided using double level osteotomy, if needed. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Steffen Schröter
- Department of Orthopaedics and Traumatology, Diakonie Klinikum GmbH Jung-Stilling, Siegen, Germany.
| | - Christian Konrads
- Department of Orthopaedics and Traumatology, Helios Hanseatic Hospital Stralsund, Stralsund, Germany
- Medical Faculty, University of Tübingen, Tübingen, Germany
| | - Marco Maiotti
- Shoulder Unit Villa Stuart Clinic (Rome) Orthopedics, Rome, Italy
| | - Moritz Mederake
- Department of Trauma and Reconstructive Surgery, BG Klinik, University of Tübingen, Tübingen, Germany
| | - Cornelius Fischer
- Department of Trauma and Reconstructive Surgery, BG Klinik, University of Tübingen, Tübingen, Germany
| | - Marc Ahrend
- Department of Trauma and Reconstructive Surgery, BG Klinik, University of Tübingen, Tübingen, Germany
| | - Daniel Schüll
- Department of Orthopaedic Surgery, University of Tübingen, Tübingen, Germany
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Affiliation(s)
- Anirejuoritse Bafor
- Department of Orthopedic Surgery, Nationwide Children's Hospital, Columbus, Ohio
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Gieroba TJ, Marasco S, Babazadeh S, Di Bella C, van Bavel D. Arithmetic hip knee angle measurement on long leg radiograph versus computed tomography-inter-observer and intra-observer reliability. ARTHROPLASTY 2023; 5:35. [PMID: 37528475 PMCID: PMC10394810 DOI: 10.1186/s42836-023-00193-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 05/03/2023] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND Pre-operative alignment is important for knee procedures including total knee arthroplasty (TKA), especially when considering alternative alignments. The arithmetic Hip Knee Angle (aHKA) is a measure of coronal alignment calculated using the medial proximal tibial (MPTA) and lateral distal femoral angles (LDFA). Traditionally, aHKA is measured on long leg radiographs (LLR). This study assesses the reproducibility of aHKA measurement on LLR and robotic-assisted TKA planning CT. METHODS Sixty-eight TKA patients with pre-operative LLR and planning CTs were included. Three observers measured the LDFA, MPTA and aHKA three times on each modality and intra-observer and inter-observer reliability was calculated. Statistical analysis was undertaken with Pearson's r and the Bland-Altman test. RESULTS Mean intra-observer coefficient of repeatability (COR) for LLR vs. CT: MPTA 3.50° vs. 1.73°, LDFA 2.93° vs. 2.00° and aHKA 2.88° vs. 2.57° for CT. Inter-observer COR for LLR vs. CT: MPTA 2.74° vs. 1.28°, LDFA 2.31° vs. 1.92°, aHKA 3.56° vs. 2.00°. Mean intra-observer Pearson's r for MPTA was 0.93 for LLR and 0.94 for CT, LDFA 0.90 for LLR and 0.91 for CT and aHKA 0.92 for LLR and 0.94 for CT. Inter-observer Pearson's r for LLR compared to CT: MPTA 0.93 vs. 0.97, LDFA 0.91 vs. 0.90, aHKA 0.91 and 0.95. CONCLUSION When compared to LLR, CT measurements of MPTA, LDFA and aHKA are more reproducible and have a good correlation with LLR measurement. CT overcomes difficulties with positioning, rotation, habitus and contractures when assessing coronal plane alignment and may obviate the need for LLRs.
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Affiliation(s)
- Tom Jan Gieroba
- Department of Orthopaedics, St Vincent's Hospital Melbourne, Fitzroy, VIC, 3065, Australia.
- Discipline of Orthopaedics and Trauma, Adelaide University, Adelaide, SA, 5005, Australia.
- College of Medicine and Public Health, Flinders University, Bedford Park, SA, 5042, Australia.
- Sportsmed, Stepney, SA, 5069, Australia.
| | - Sofia Marasco
- Department of Orthopaedics, St Vincent's Hospital Melbourne, Fitzroy, VIC, 3065, Australia
| | - Sina Babazadeh
- Department of Orthopaedics, St Vincent's Hospital Melbourne, Fitzroy, VIC, 3065, Australia
- Australian Orthopaedic Research Group, Kew East, VIC, 3102, Australia
- Department of Surgery, The University of Melbourne, Parkville, VIC, 3010, Australia
| | - Claudia Di Bella
- Department of Orthopaedics, St Vincent's Hospital Melbourne, Fitzroy, VIC, 3065, Australia
- Department of Surgery, The University of Melbourne, Parkville, VIC, 3010, Australia
- Aikenhead Centre for Medical Discovery (ACMD), St Vincent's Hospital Melbourne, Fitzroy, VIC, 3065, Australia
| | - Dirk van Bavel
- Department of Orthopaedics, St Vincent's Hospital Melbourne, Fitzroy, VIC, 3065, Australia
- Department of Surgery, Epworth Healthcare, Richmond, VIC, 3121, Australia
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Colyn W, Cleymans A, Bruckers L, Truijen J, Smeets K, Bellemans J. The pre-diseased coronal alignment can be predicted from conventional radiographs taken of the varus arthritic knee. Arch Orthop Trauma Surg 2023; 143:4425-4436. [PMID: 36494462 DOI: 10.1007/s00402-022-04709-6] [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: 10/09/2022] [Accepted: 11/19/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The concept of restoring the constitutional, pre-diseased alignment has gained lots of interest among knee surgeons. Previous attempts to use the contralateral limb to bridge the gap between the arthritic and the constitutional alignment were unsuccessful. We investigated the usability of a mathematical formula to predict the constitutional (pre-diseased) coronal alignment once arthritis has occurred. It is our hypothesis that by using the KL grade, CPAK classification and four radiographic measurements of the arthritic knee, the pre-diseased coronal alignment could be predicted. MATERIAL AND METHODS Hundred arthritic patients with consecutive X-rays were used to determine a mathematical formula. Five alignment parameters were determined on full-length X-rays: HKA angle, mechanical lateral distal femoral angle (mLDFA), medial proximal tibial angle (MPTA), joint line convergence angle (JLCA) and the tibial joint line angle (TJLA). A refinement of the algorithm was implemented based on a reference cohort, consisted of 250 young adults aged between 20 and 27 years. Moreover, all knees were subdivided based on their CPAK-phenotype and the Kellgren-Lawrence scale (KL scale). An independent arthritic cohort of 289 patients scheduled for primary total knee arthroplasty was included to verify the accuracy of the predicted HKAs (HKAPRED). RESULTS In CPAK type 1, the HKAPRED was 3.86° varus (STD 1.39) and the HKAYHA was 4.0° varus. In CPAK type 2, the HKAPRED was 1.68° varus (STD 1.95) compared to a HKAYHA of 1.34° (STD 0.81). The average constitutional HKA is not different in both CPAK 1 (p = 0.61) and CPAK 2 (p = 0.25), and the difference in the mean is estimated to be equal to - 0.14 (95CI - 0.68 to 0.40) in CPAK 1 and 0.35 (95CI - 0.06 to 0.75) in CPAK 2. CONCLUSION Using the KL grade, CPAK classification and four radiographic measurements of the arthritic knee, the pre-diseased coronal alignment can be predicted in 80% of the varus knees with an accuracy of ≤ 0.5°. The predicted HKA (HKAPRED) can be very useful in the current and future clinical practice.
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Affiliation(s)
- William Colyn
- Department of Orthopedic Surgery, AZ Turnhout, Steenweg Op Merksplas 44, 2300, Turnhout, Belgium.
- Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium.
- Limburg Clinical Research Center, ZOL Genk, Genk, Belgium.
| | - A Cleymans
- Department of Orthopedic Surgery, AZ Turnhout, Steenweg Op Merksplas 44, 2300, Turnhout, Belgium
- Department of Orthopedic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - L Bruckers
- I-BioStat, University Hasselt, Hasselt, Belgium
| | - J Truijen
- Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
- Department of Orthopedic Surgery, ZOL Genk, Genk, Belgium
| | - K Smeets
- Department of Orthopedic Surgery, AZ Vesalius, Tongeren, Belgium
- Faculty of Rehabilitation Science, Hasselt University, Diepenbeek, Belgium
- GRIT Belgian Sports Clinic, Leuven, Belgium
| | - J Bellemans
- Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
- Department of Orthopedic Surgery, ZOL Genk, Genk, Belgium
- GRIT Belgian Sports Clinic, Leuven, Belgium
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Jiang X, Hu X, Wang L. Author Reply to "Regarding 'Pre-surgery Hip-Knee-Ankle Angle and Weightbearing Line Percentage Are Nearly Perfectly Correlated to the Miniaci Angle When Planning Open-Wedge High Tibial Osteotomies'". Arthroscopy 2023; 39:1370-1372. [PMID: 37147067 DOI: 10.1016/j.arthro.2023.02.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 02/15/2023] [Indexed: 05/07/2023]
Affiliation(s)
- Xu Jiang
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Department of Orthopaedic Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Xumin Hu
- Department of Orthopaedic Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Liao Wang
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Kuiper RJA, Seevinck PR, Viergever MA, Weinans H, Sakkers RJB. Automatic Assessment of Lower-Limb Alignment from Computed Tomography. J Bone Joint Surg Am 2023; 105:700-712. [PMID: 36947661 DOI: 10.2106/jbjs.22.00890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
BACKGROUND Preoperative planning of lower-limb realignment surgical procedures necessitates the quantification of alignment parameters by using landmarks placed on medical scans. Conventionally, alignment measurements are performed on 2-dimensional (2D) standing radiographs. To enable fast and accurate 3-dimensional (3D) planning of orthopaedic surgery, automatic calculation of the lower-limb alignment from 3D bone models is required. The goal of this study was to develop, validate, and apply a method that automatically quantifies the parameters defining lower-limb alignment from computed tomographic (CT) scans. METHODS CT scans of the lower extremities of 50 subjects were both manually and automatically segmented. Thirty-two manual landmarks were positioned twice on the bone segmentations to assess intraobserver reliability in a subset of 20 subjects. The landmarks were also positioned automatically using a shape-fitting algorithm. The landmarks were then used to calculate 25 angles describing the lower-limb alignment for all 50 subjects. RESULTS The mean absolute difference (and standard deviation) between repeat measurements using the manual method was 2.01 ± 1.64 mm for the landmark positions and 1.05° ± 1.48° for the landmark angles, whereas the mean absolute difference between the manual and fully automatic methods was 2.17 ± 1.37 mm for the landmark positions and 1.10° ± 1.16° for the landmark angles. The manual method required approximately 60 minutes of manual interaction, compared with 12 minutes of computation time for the fully automatic method. The intraclass correlation coefficient showed good to excellent reliability between the manual and automatic assessments for 23 of 25 angles, and the same was true for the intraobserver reliability in the manual method. The mean for the 50 subjects was within the expected range for 18 of the 25 automatically calculated angles. CONCLUSIONS We developed a method that automatically calculated a comprehensive range of 25 measurements that defined lower-limb alignment in considerably less time, and with differences relative to the manual method that were comparable to the differences between repeated manual assessments. This method could thus be used as an efficient alternative to manual assessment of alignment. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Ruurd J A Kuiper
- Department of Orthopaedics, University Medical Center Utrecht, Utrecht, the Netherlands
- Image Sciences Institute, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Peter R Seevinck
- Image Sciences Institute, University Medical Center Utrecht, Utrecht, the Netherlands
- MRIguidance B.V., Utrecht, the Netherlands
| | - Max A Viergever
- Image Sciences Institute, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Harrie Weinans
- Department of Orthopaedics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Ralph J B Sakkers
- Department of Orthopaedics, University Medical Center Utrecht, Utrecht, the Netherlands
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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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Functional gait analysis reveals insufficient hindfoot compensation for varus and valgus osteoarthritis of the knee. INTERNATIONAL ORTHOPAEDICS 2023; 47:1233-1242. [PMID: 36840777 PMCID: PMC10079753 DOI: 10.1007/s00264-023-05738-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 02/16/2023] [Indexed: 02/26/2023]
Abstract
PURPOSE The hindfoot is believed to compensate varus and valgus deformities of the knee by eversion and inversion movements. But these mechanisms were merely found in static radiologic measurements. The aim of this study was, therefore, to assess dynamic foot posture during gait using pressure-sensitive wireless insoles in patients with osteoarthritis of the knee and frontal knee deformities. METHODS Patients with osteoarthritis of the knee were prospectively included in this study. Patients were clinically and radiologically (mechanical tibiofemoral angle (mTFA), hindfoot alignment view angle (HAVA), and talar tilt (TT)) exa mined. Gait line analysis was conducted using pressure-sensitive digital shoe insoles. RESULTS Eighty-two patients (varus n = 52, valgus n = 30) were included in this prospective clinical study. Radiologically, the mTFA significantly correlated with the HAVA (cor = -0.72, p < 0.001) and with the TT (Pearson's cor = 0.32, p < 0.006). Gait analysis revealed that the gait lines in varus knee osteoarthritis were lateralized, despite the hindfoot valgus. In valgus knee osteoarthritis, gait lines were medialized, although the hindfoot compensated by varization. CONCLUSIONS Functional dynamic gait analysis could demonstrate that the hindfoot is not able to sufficiently compensate for frontal malalignments of the knee joint, contrary to static radiologic findings. This led to a narrowing of the joint space of the ankle medially in varus and laterally in valgus knee osteoarthritis.
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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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21
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Jiang X, Zhang D, Li B, Yan M, Hu X, Wang L, Gao L. Pre-surgery HKA angle and WBL percentage are nearly perfectly correlated to the Miniaci angle when planning open wedge high tibial osteotomies. Arthroscopy 2022; 39:1222-1231.e1. [PMID: 36368520 DOI: 10.1016/j.arthro.2022.11.007] [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: 04/15/2022] [Revised: 07/11/2022] [Accepted: 11/05/2022] [Indexed: 11/11/2022]
Abstract
PURPOSE To investigate the conversion formulas between the Miniaci angle, pre-surgery parameters, and changes in pre-surgery parameters in open-wedge high tibial osteotomy (OWHTO), including hip-knee-ankle (HKA) angle, weight-bearing line (WBL) percentage, mechanical medial proximal tibial angle (mMPTA), ΔHKA angle, ΔWBL percentage, ΔmMPTA, and other parameters. METHODS From January 2012 to December 2019, 247 lower limbs of 144 patients with medial unicompartmental knee osteoarthritis combined with proximal tibia vara were enrolled. Inclusion criteria were adults, medial unicompartmental knee osteoarthritis, Kellgren-Lawrence classification grade ≤ Ⅲ, mMPTA ≤85° and mechanical lateral distal femoral angle (mLDFA) is normal (85°-90°), and patella facing anterior in the bipedal standing position. Exclusion criteria were history of fracture, trauma, or orthopaedic surgery; developmental dysplasia of the hip or femoral head necrosis; femoral bowing deformity; deformity of the tibial shaft; and leg length discrepancy. Using standing whole-leg radiographs (WLRs), an OWHTO simulation was performed to determine the Miniaci angle by delivering the WBL to the Fujisawa point. The relationship of the Miniaci angle, the pre-surgery parameters, and the changes in pre-surgery parameters were analysed by spearman's correlation and linear regression analyses. The relationship between the post-surgery HKA angle and pre-surgery parameters was analysed by multiple linear regression model. RESULTS The Miniaci angle showed a near perfect correlation with the pre-surgery HKA angle (y=-1.05x+192.10, r2=0.99), pre-surgery WBL percentage (y=-0.25x+15.14, r2=0.97), ΔHKA angle (y=1.04x-0.03, r2=1.00), ΔWBL percentage (y=0.25x-0.52, r2=0.97), and ΔmMPTA (y=1.04x-0.03, r2=1.00). The ΔHKA angle showed nearly perfect correlation with the ΔmMPTA (y=1.00x, r2=1.00), and ΔWBL percentage (y=0.24x-0.47, r2=0.97). CONCLUSIONS The pre-surgery HKA angle, pre-surgery WBL percentage, ΔHKA angle, ΔWBL, and ΔmMPTA percentage are nearly perfectly correlated to the Miniaci angle, while the ΔmMPTA and ΔWBL percentage are nearly perfectly correlated to the ΔHKA angle. CLINICAL RELEVANCE With the conversion formulas determined in the current study, surgeons can calculate the Miniaci angle based on the pre-surgery parameters without the assistance of digital software for complex surgical simulation. The Miniaci angle is closely related to the gap of the medial opening wedge. Based on the Miniaci angle and the depth of the osteotomy, surgeons can calculate the gap required prior to surgery using trigonometric functions and then simply measure the gap during surgery.
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Affiliation(s)
- Xu Jiang
- Department of Orthopaedic Surgery, Sun Yat -Sen Memorial Hospital, Sun Yat -Sen University, Guangzhou 510120, China; Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, China
| | - Di Zhang
- Department of Orthopaedic Surgery, Sun Yat -Sen Memorial Hospital, Sun Yat -Sen University, Guangzhou 510120, China
| | - Bo Li
- Department of Orthopaedic Surgery, Sun Yat -Sen Memorial Hospital, Sun Yat -Sen University, Guangzhou 510120, China
| | - Mengning Yan
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, China.
| | - Xumin Hu
- Department of Orthopaedic Surgery, Sun Yat -Sen Memorial Hospital, Sun Yat -Sen University, Guangzhou 510120, China.
| | - Liao Wang
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, China.
| | - Liangbin Gao
- Department of Orthopaedic Surgery, Sun Yat -Sen Memorial Hospital, Sun Yat -Sen University, Guangzhou 510120, China.
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22
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Preoperative joint line convergence angle correction is a key factor in optimising accuracy in varus knee correction osteotomy. Knee Surg Sports Traumatol Arthrosc 2022; 31:1583-1592. [PMID: 35994079 PMCID: PMC10049955 DOI: 10.1007/s00167-022-07092-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 07/24/2022] [Indexed: 10/15/2022]
Abstract
PURPOSE This study aimed to identify and prevent preoperative factors that can be influenced in preoperative planning to reduce postoperative malcorrections. METHODS The method used in this study was a retrospective two-centre analysis of 78 pre and postoperative fully weight-bearing radiographs of patients who underwent valgus osteotomy correction due to symptomatic medial compartment osteoarthritis. A computer software (TraumaCad®) was used to aim for an intersection point of the mechanical tibiofemoral axis (mTFA) with the tibia plateau at 55-60% (medial = 0%, lateral = 100%). Postoperative divergence ± 5% of this point was defined as over- and undercorrection. Preoperative joint geometry factors were correlated with postoperative malcorrection. Planning was conducted using the established method described by Miniaci (Group A) and with additional correction of the joint line convergence angle (JLCA) using the formula JLCA-2/2 (Group B). Additionally, in a small clinical case series, planning was conducted with JLCA correction. Statistical analysis was performed using (multiple) linear regression analysis and analysis of variance (ANOVA) with p < 0.05 considered significant. RESULTS In 78 analysed cases, postoperative malcorrection was detected in 37.2% (5.1% undercorrection, 32.1% overcorrection). Linear regression analysis revealed preoperative body mass index (BMI, p = 0.04), JLCA (p = 0.0001), and osteotomy level divergence (p = 0.0005) as factors correlated with overcorrection. In a multiple regression analysis, JLCA and osteotomy level divergence remained significant factors. Preoperative JLCA correction reduced the planned osteotomy gap (A 9.7 ± 2.8 mm vs B 8.3 ± 2.4 mm; p > 0.05) and postoperative medial proximal tibial angle (MPTA: A 94.3 ± 2.1° vs B 92.3 ± 1.5°; p < .05) in patients with preoperative JLCA ≥ 4°. The results were validated using a virtual postoperative correction of cases with overcorrection. A case series (n = 8) with a preoperative JLCA > 4 revealed a postoperative accuracy using the JLCA correction of 3.4 ± 1.9%. CONCLUSION Preoperative JLCA ≥ 4° and tibial osteotomy level divergence were identified as risk factors for postoperative overcorrection. Preoperative JLCA correction using the formula JLCA-2/2 is proposed to better control ideal postoperative correction and reduce MPTA. The intraoperatively realised osteotomy level should be precisely in accordance with preoperative planning. LEVEL OF EVIDENCE III, cross-sectional study.
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23
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Laven IEWG, Schröder FF, de Graaff F, Rompen JC, Hoogeslag RAG, van Houten AH. Accuracy, inter- and intrarater reliability, and user-experience of high tibial osteotomy angle measurements for preoperative planning: manual planning PACS versus semi-automatic software programs. J Exp Orthop 2022; 9:44. [PMID: 35581416 PMCID: PMC9114281 DOI: 10.1186/s40634-022-00475-x] [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: 02/14/2022] [Accepted: 04/05/2022] [Indexed: 11/16/2022] Open
Abstract
Purpose To compare the accuracy, inter- and intrarater reliability, and user-experience of manual and semi-automatic preoperative leg-alignment measurement planning software for high tibial osteotomy (HTO). Methods Thirty patients (31 lower limbs) who underwent a medial opening wedge HTO between 2017 and 2019 were retrospectively included. The mechanical lateral distal femur angle (mLDFA), mechanical medial proximal tibial angle (mMPTA), and planned correction angle were measured on preoperative long-leg full weight-bearing radiographs utilising PACS Jivex Review® v5.2 manual and TraumaCad® v2.4 semi-automatic planning software. Independent measurements were performed by four raters. Two raters repeated the measurements. Accuracy in the standard error of measurement (SEM), inter- and intrarater reliability, and user-experience were analysed. Additionally, measurements errors of more than 3° were remeasured and reanalysed. Results The SEMs of all measured varus malalignment angles and planned correction angle were within 0.8° of accuracy for both software programs. Measurements utilising the manual software demonstrated moderate interrater intraclass correlation coefficient (ICC)-values for the mLDFA and mMPTA, and an excellent interrater ICC-value for the correction angle (0.810, 0.779, and 0.981, respectively). Measurements utilising the semi-automatic software indicated excellent interrater ICC-values for the mLDFA, mMPTA, and correction angle (0.980, 0.909, and 0.989, respectively). The intrarater reliability varied substantially per angle, presenting excellent intrarater agreements by both raters (ICC > 0.900) for the correction angle in each software program as well as poor-to-excellent ICC-values for the mLDFA (0.282–0.951 and 0.316–0.926) and mMPTA (0.893–0.934 and 0.594–0.941) in both the manual planning and semi-automatic software. Regarding user-experience, semi-automatic software was preferred by two raters, while the other two raters had no distinctive preference. After remeasurement of five outliers, excellent interrater ICC-values were found for the mLDFA (0.913) and mMPTA (0.957). Conclusions Semi-automatic software outperforms the manual software when user-experience and outliers are considered. However, both software programs provide similar performance after remeasurement of the human-related erroneous outliers. For clinical practice, both programs can be utilised for HTO planning. Level of evidence Diagnostic study, Level III. Supplementary Information The online version contains supplementary material available at 10.1186/s40634-022-00475-x.
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Affiliation(s)
- Iris E W G Laven
- Centre for Orthopaedic Surgery and Sports Medicine, OCON, Hengelo, 7550 AM, The Netherlands.,Techmed Centre, Faculty of Science and Technology (S&T), University of Twente, Enschede, 7522 NB, The Netherlands
| | - Femke F Schröder
- Centre for Orthopaedic Surgery and Sports Medicine, OCON, Hengelo, 7550 AM, The Netherlands.,Techmed Centre, Faculty of Science and Technology (S&T), University of Twente, Enschede, 7522 NB, The Netherlands
| | - Feike de Graaff
- Centre for Orthopaedic Surgery and Sports Medicine, OCON, Hengelo, 7550 AM, The Netherlands.
| | - J Christiaan Rompen
- Centre for Orthopaedic Surgery and Sports Medicine, OCON, Hengelo, 7550 AM, The Netherlands
| | - Roy A G Hoogeslag
- Centre for Orthopaedic Surgery and Sports Medicine, OCON, Hengelo, 7550 AM, The Netherlands
| | - Albert H van Houten
- Centre for Orthopaedic Surgery and Sports Medicine, OCON, Hengelo, 7550 AM, The Netherlands
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