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Kim H, Ryu SM, Keum JS, Oh SI, Kim KN, Shin YH, Jeon IH, Koh KH. Clinical validation of enhanced CT imaging for distal radius fractures through conditional Generative Adversarial Networks (cGAN). PLoS One 2024; 19:e0308346. [PMID: 39150966 PMCID: PMC11329132 DOI: 10.1371/journal.pone.0308346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 07/22/2024] [Indexed: 08/18/2024] Open
Abstract
BACKGROUND/PURPOSE Distal radius fractures (DRFs) account for approximately 18% of fractures in patients 65 years and older. While plain radiographs are standard, the value of high-resolution computed tomography (CT) for detailed imaging crucial for diagnosis, prognosis, and intervention planning, and increasingly recognized. High-definition 3D reconstructions from CT scans are vital for applications like 3D printing in orthopedics and for the utility of mobile C-arm CT in orthopedic diagnostics. However, concerns over radiation exposure and suboptimal image resolution from some devices necessitate the exploration of advanced computational techniques for refining CT imaging without compromising safety. Therefore, this study aims to utilize conditional Generative Adversarial Networks (cGAN) to improve the resolution of 3 mm CT images (CT enhancement). METHODS Following institutional review board approval, 3 mm-1 mm paired CT data from 11 patients with DRFs were collected. cGAN was used to improve the resolution of 3 mm CT images to match that of 1 mm images (CT enhancement). Two distinct methods were employed for training and generating CT images. In Method 1, a 3 mm CT raw image was used as input with the aim of generating a 1 mm CT raw image. Method 2 was designed to emphasize the difference value between the 3 mm and 1 mm images; using a 3 mm CT raw image as input, it produced the difference in image values between the 3 mm and 1 mm CT scans. Both quantitative metrics, such as peak signal-to-noise ratio (PSNR), mean squared error (MSE), and structural similarity index (SSIM), and qualitative assessments by two orthopedic surgeons were used to evaluate image quality by assessing the grade (1~4, which low number means high quality of resolution). RESULTS Quantitative evaluations showed that our proposed techniques, particularly emphasizing the difference value in Method 2, consistently outperformed traditional approaches in achieving higher image resolution. In qualitative evaluation by two clinicians, images from method 2 showed better quality of images (grade: method 1, 2.7; method 2, 2.2). And more choice was found in method 2 for similar image with 1 mm slice image (15 vs 7, p = 201). CONCLUSION In our study utilizing cGAN for enhancing CT imaging resolution, the authors found that the method, which focuses on the difference value between 3 mm and 1 mm images (Method 2), consistently outperformed.
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Affiliation(s)
- Hyojune Kim
- Department of Orthopedic Surgery, Hospital of Chung-Ang University of Medicine, Dongjak-gu, Seoul, Republic of Korea
| | - Seung Min Ryu
- Department of Orthopedic Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | | | | | | | - Young Ho Shin
- Department of Orthopedic Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - In-Ho Jeon
- Department of Orthopedic Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Kyoung Hwan Koh
- Department of Orthopedic Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
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Martino R, Carry P, Stickel J, Samara O, Lee S, Selberg C. Use of the flat panel detector fluoroscope reduces radiation exposure during periacetabular osteotomy. Sci Rep 2024; 14:9475. [PMID: 38658572 PMCID: PMC11043339 DOI: 10.1038/s41598-024-58314-1] [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: 08/28/2023] [Accepted: 03/27/2024] [Indexed: 04/26/2024] Open
Abstract
The Periacetabular Osteotomy is a technically demanding procedure that requires precise intraoperative evaluation of pelvic anatomy. Fluoroscopic images pose a radiation risk to operating room staff, scrubbed personnel, and the patient. Most commonly, a Standard Fluoroscope with an Image Intensifier is used. Our institution recently implemented the novel Fluoroscope with a Flat Panel Detector. The purpose of this study was to compare radiation dosage and accuracy between the two fluoroscopes. A retrospective review of a consecutive series of patients who underwent Periacetabular Osteotomy for symptomatic hip dysplasia was completed. The total radiation exposure dose (mGy) was recorded and compared for each case from the standard fluoroscope (n = 27) and the flat panel detector (n = 26) cohorts. Lateral center edge angle was measured and compared intraoperatively and at the six-week postoperative visit. A total of 53 patients (96% female) with a mean age and BMI of 17.84 (± 6.84) years and 22.66 (± 4.49) kg/m2 (standard fluoroscope) and 18.23 (± 4.21) years and 21.99 (± 4.00) kg/m2 (flat panel detector) were included. The standard fluoroscope averaged total radiation exposure to be 410.61(± 193.02) mGy, while the flat panel detector averaged 91.12 (± 49.64) mGy (p < 0.0001). The average difference (bias) between intraoperative and 6-week postoperative lateral center edge angle measurement was 0.36° (limits of agreement: - 3.19 to 2.47°) for the standard fluoroscope and 0.27° (limits of agreement: - 2.05 to 2.59°) for the flat panel detector cohort. Use of fluoroscopy with flat panel detector technology decreased the total radiation dose exposure intraoperatively and produced an equivalent assessment of intraoperative lateral center edge angle. Decreasing radiation exposure to young patients is imperative to reduce the risk of future comorbidities.
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Affiliation(s)
- Rachael Martino
- Children's Hospital Colorado - Orthopedics Institute, 13123 E 16th Ave, Box 060, Aurora, CO, 80045, USA
| | - Patrick Carry
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jennifer Stickel
- Children's Hospital Colorado - Orthopedics Institute, 13123 E 16th Ave, Box 060, Aurora, CO, 80045, USA
| | - Omar Samara
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Sterling Lee
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Courtney Selberg
- Children's Hospital Colorado - Orthopedics Institute, 13123 E 16th Ave, Box 060, Aurora, CO, 80045, USA.
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
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Dornacher D, Lutz B, Sgroi M, Caffard T, Reichel H. Age and magnitude of acetabular correction impair bone healing after triple pelvic osteotomy. Arch Orthop Trauma Surg 2023; 143:6599-6607. [PMID: 37421516 PMCID: PMC10541840 DOI: 10.1007/s00402-023-04966-z] [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: 03/09/2023] [Accepted: 06/22/2023] [Indexed: 07/10/2023]
Abstract
INTRODUCTION The aim of this examination was to assess, which risk factors impair bone healing after triple pelvic osteotomy (TPO) in the treatment of symptomatic hip dysplasia. METHODS A consecutive series of 241 TPO was reviewed retrospectively. Of these, a set of five postoperative radiographs was available, performed in a standardized regimen in the first year after surgery. Two experienced observers had to agree on the existence of a non-union on the radiographs obtained 1 year after TPO. Both observers measured the lateral center edge angle (LCEA) and acetabular index (AI) on all radiographs. Besides patient-specific risk factors, the magnitudes of acetabular correction and the amounts of a detectable slight change in acetabular correction were assessed. Binary logistic regression analysis and chi-squared test were used to detect the impact of the risk factor on bone healing. RESULTS A total of 222 cases were left for further examination. In 19 of these, at least one osteotomy was not healed completely one year after surgery. Binary logistic regression showed a significant relationship between the risk factors "age" (p < 0.001; odds ratio (OR) 1.109 (95% CI 1.05-1.18)) as well as "magnitude of acetabular correction (LCEA)" (p = 0.01; OR 1.087 (95% CI 1.02-1.16)) and non-union. Pearson's chi-square test showed a relationship between the risk factor "wound healing disorder" and non-union (p < 0.001). LCEA and AI showed a slight increase from the first to the last follow-up (observer 1: 1.6° and 1.3°, resp.), but regression analysis for the risk factor "amount of postoperative change of acetabular correction (LCEA, AI)" did not show statistically significant values. CONCLUSION The age at surgery and the magnitude of acetabular correction negatively influenced the healing progress of the osteotomy sites. The amount of a slight postoperative change of LCEA and AI did not correlate with a non-union.
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Affiliation(s)
- Daniel Dornacher
- Department of Orthopedics, University of Ulm, Oberer Eselsberg 45, 89081 Ulm, Germany
| | - Bernd Lutz
- Department of Orthopedics, University of Ulm, Oberer Eselsberg 45, 89081 Ulm, Germany
| | - Mirco Sgroi
- Department of Orthopedics, University of Ulm, Oberer Eselsberg 45, 89081 Ulm, Germany
| | - Thomas Caffard
- Department of Orthopedics, University of Ulm, Oberer Eselsberg 45, 89081 Ulm, Germany
| | - Heiko Reichel
- Department of Orthopedics, University of Ulm, Oberer Eselsberg 45, 89081 Ulm, Germany
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Dornacher D, Kelsch M, Sgroi M, Reichel H, Lutz B. Screw fixation after tripe pelvic osteotomy is reliable: changes of acetabular correction are rare and do not correlate with risk factors. J Orthop Surg Res 2023; 18:709. [PMID: 37735695 PMCID: PMC10512489 DOI: 10.1186/s13018-023-04186-6] [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: 05/16/2023] [Accepted: 09/10/2023] [Indexed: 09/23/2023] Open
Abstract
PURPOSE The aim of this examination was to assess whether there is a change of acetabular correction after triple pelvic osteotomy (TPO) and if so, whether there is a correlation with patient-specific risk factors or with certain periods in the postoperative course. METHODS A consecutive series of 241 TPO was reviewed retrospectively. The close-meshed radiographic follow-up of the first 12 weeks comprised pelvic radiographs performed immediately after the procedure, 5 days, 6 and 12 weeks after TPO. Three observers measured the lateral center edge angle, acetabular index and the craniocaudal offset of the pubic osteotomy. Patient-specific risk factors (e. g. age, gender, body mass index, nicotine abuse) and certain periods in the postoperative course were correlated with a change of acetabular correction. RESULTS After application of the exclusion criteria, 225 hips were available for further examination. Intraclass correlation coefficient resulted in predominantly excellent agreement between the measurements of the three observers (0.74-0.91). In 27 cases (12%), the three observers agreed on a change of acetabular correction. In 18 cases (8%), there was a slight change, in 9 cases (4%), a relevant change. The latter entailed consequences in the postoperative aftercare. General equation estimation did not show any correlation between a change of acetabular correction and patient-specific risk factors or certain periods in the postoperative course (p = 0.79-0.99). CONCLUSION Every once treated hip should be followed-up with the same attention, irrespective of the apparent risk profile. There is no rationale to skip a radiographic follow-up in the first 12 weeks after TPO.
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Affiliation(s)
- Daniel Dornacher
- Department of Orthopedics, University of Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany.
| | - Maximilian Kelsch
- Department of Orthopedics, University of Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany
| | - Mirco Sgroi
- Department of Orthopedics, University of Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany
| | - Heiko Reichel
- Department of Orthopedics, University of Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany
| | - Bernd Lutz
- Department of Orthopedics, University of Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany
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Anderson LA, Erickson JA, Kapron CR, Blackburn BE, Peters CL. John Charnley Award: A Quantitative Fluoroscopic Tool Improves Acetabular Fragment Positioning in Periacetabular Osteotomy. J Arthroplasty 2023:S0883-5403(23)00280-2. [PMID: 36966888 DOI: 10.1016/j.arth.2023.03.052] [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: 11/21/2022] [Revised: 03/16/2023] [Accepted: 03/19/2023] [Indexed: 04/16/2023] Open
Abstract
BACKGROUND Radiographic assessment of acetabular fragment positioning during periacetabular osteotomy (PAO) has been linked to hip survivorship. Intraoperative plain radiographs are time and resource intensive, while fluoroscopy can introduce image distortion affecting measurement accuracy. Our purpose was to determine whether intraoperative fluoroscopy-based measurements with a distortion correcting fluoroscopic tool improved PAO measurement targets. METHODS We retrospectively reviewed 570 PAOs; 136 PAOs utilized a distortion correcting fluoroscopic tool, and 434 PAOs performed with routine fluoroscopy, prior to this technology. Lateral center-edge angle (LCEA), acetabular index (AI), posterior wall sign (PWS), and anterior center-edge angle (ACEA) were measured on preoperative standing radiographs, intraoperative fluoroscopic images, and postoperative standing radiographs. Defined target zones of correction were AI: 0-10°, ACEA: 25-40°, LCEA: 25-40°, PWS: negative. Postoperative correction in zones and patient-reported outcomes were compared using chi-square tests and paired t-tests, respectively. RESULTS The average difference between postcorrection fluoroscopic measurements and 6-week postoperative radiographs was 0.21° for LCEA, 0.01° for ACEA, and -0.07° for AI (all P < .01). The PWS agreement was 92%. The percentages of hips meeting target goals overall improved with the new fluoroscopic tool: 74%-92% for LCEA (P < .01), 72%-85% for ACEA (P < .01), and 69 versus 74% for AI (P = .25), though there was no improvement in PWS (85 versus 85%, P = .92). All patient-reported outcomes except PROMIS Mental Health were significantly improved at most recent follow-up. CONCLUSIONS Our study demonstrated improved PAO measurements and target goals with the use of a distortion correcting quantitative fluoroscopic real-time measuring device. This value-additive tool gives reliable quantitative measurements of correction without interfering with surgical workflow.
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Affiliation(s)
- Lucas A Anderson
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Jill A Erickson
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Claire R Kapron
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Brenna E Blackburn
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
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3D Reconstruction of Wrist Bones from C-Arm Fluoroscopy Using Planar Markers. Diagnostics (Basel) 2023; 13:diagnostics13020330. [PMID: 36673139 PMCID: PMC9858297 DOI: 10.3390/diagnostics13020330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 01/01/2023] [Accepted: 01/13/2023] [Indexed: 01/18/2023] Open
Abstract
In orthopedic surgeries, such as osteotomy and osteosynthesis, an intraoperative 3D reconstruction of the bone would enable surgeons to quickly assess the fracture reduction procedure with preoperative planning. Scanners equipped with such functionality are often more expensive than a conventional C-arm fluoroscopy device. Moreover, a C-arm fluoroscopy device is commonly available in many orthopedic facilities. Based on the widespread use of such equipment, this paper proposes a method to reconstruct the 3D structure of bone with a conventional C-arm fluoroscopy device. We focus on wrist bones as the target of reconstruction in this research as this will facilitate a flexible imaging scheme. Planar markers are attached to the target object and are tracked in the fluoroscopic image for C-arm pose estimation. The initial calibration of the device is conducted using a checkerboard pattern. In general, reconstruction algorithms are sensitive to geometric calibration errors. To assess the practicality of the method for reconstruction, a simulation study demonstrating the effect of checkerboard thickness and spherical marker size on reconstruction quality was conducted.
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Peng J, Xiao F, Zhu J, Shen C, Li Y, Han X, Cui Y, Chen X. What is the agreement between intraoperative fluoroscopy and postoperative radiographs in Bernese periacetabular osteotomy? BMC Musculoskelet Disord 2022; 23:1139. [PMID: 36581915 PMCID: PMC9801538 DOI: 10.1186/s12891-022-06054-6] [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: 05/10/2022] [Accepted: 12/05/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND It is important to reorient the acetabular fragment into an optimal position and version to ensure a good long-term outcome after Bernese periacetabular osteotomy (PAO). Unfortunately, the intraoperative balance between overcorrection and undercorrection remains challenging for the surgeon. The purpose of this study was to answer two questions: (1) Does the femoral head coverage measured on intraoperative fluoroscopy agree with that measured on postoperative radiography? (2) What is the reliability of intraoperative fluoroscopy in identifying hip center correction in PAO? METHODS A total of 173 patients (173 hips) who underwent PAO for developmental dysplasia of the hip (DDH) at our center from July 01, 2020, to December 31, 2020, were retrospectively reviewed. Imaging data from 111 patients (female/male, 98/13; right/left, 72/39; mean age, 28.93 years) were included in this study. The analysis included measurement of the lateral center-edge angle (LCEA), acetabular index (AI), anterior wall index (AWI), posterior wall index (PWI), extrusion index (EI), and medial offset distance (MO). These measurements were acquired from intraoperative fluoroscopic images and postoperative radiographs and compared by paired t test using SPSS (version 24.0). Significance was determined at a p value of < 0.05. Bland-Altman analysis, conducted using GraphPad Software (version 9), was used to quantify the agreement between intraoperative fluoroscopic images and postoperative radiographs. RESULTS The means (standard deviations, SDs) of the LCEA, AI, AWI, PWI, EI, and MO obtained on intraoperative fluoroscopy were 32.86° (5.73°), 0.66° (5.55), 0.29 (0.10), 0.75 (0.17), 11.15% (6.50%), and 8.49 mm (3.68 mm), respectively. On postoperative radiography, the corresponding values were 32.91° (6.31°), 1.63° (5.22°), 0.29 (0.15), 0.85 (0.14), 11.27% (7.36%), and 9.60 mm (3.79 mm). The differences in the LCEA, AWI, and EI acquired from intraoperative fluoroscopic images and postoperative radiographs were not significant (p = 0.90, 0.95, and 0.83, respectively), but those in the AI, PWI, and MO were significant (p < 0.05). The mean biases (95% limits of agreement) of the LCEA, AI, AWI, PWI, EI, and MO were - 0.04 (- 6.85), - 0.97 (- 7.78), 0 (- 0.30), - 0.11 (- 0.36), - 0.12 (- 11.92), and - 1.11 (- 5.51), respectively. CONCLUSION The LCEA, EI, and AWI can be used to reliably predict postoperative femoral head coverage at the level of 2D graphics. Acetabular inclination can be cautiously assessed using AI on intraoperative fluoroscopy. In the absence of intraoperative 3D image evaluation, the AWI and PWI demonstrate acceptable agreement between fluoroscopy and radiography in assessing the acetabular version. Although the MO shows slight bias, it can be helpful in properly positioning the acetabulum during PAO.
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Affiliation(s)
- Jianping Peng
- grid.412987.10000 0004 0630 1330Department of Orthopaedics, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Building 8, No. 1665, Kongjiang Road, Shanghai, 200092 China
| | - Fei Xiao
- grid.412987.10000 0004 0630 1330Department of Orthopaedics, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Building 8, No. 1665, Kongjiang Road, Shanghai, 200092 China
| | - Junfeng Zhu
- grid.412987.10000 0004 0630 1330Department of Orthopaedics, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Building 8, No. 1665, Kongjiang Road, Shanghai, 200092 China
| | - Chao Shen
- grid.412987.10000 0004 0630 1330Department of Orthopaedics, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Building 8, No. 1665, Kongjiang Road, Shanghai, 200092 China
| | - Yang Li
- grid.412987.10000 0004 0630 1330Department of Orthopaedics, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Building 8, No. 1665, Kongjiang Road, Shanghai, 200092 China
| | - Xiuguo Han
- grid.412987.10000 0004 0630 1330Department of Orthopaedics, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Building 8, No. 1665, Kongjiang Road, Shanghai, 200092 China
| | - Yimin Cui
- grid.412987.10000 0004 0630 1330Department of Orthopaedics, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Building 8, No. 1665, Kongjiang Road, Shanghai, 200092 China
| | - Xiaodong Chen
- grid.412987.10000 0004 0630 1330Department of Orthopaedics, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Building 8, No. 1665, Kongjiang Road, Shanghai, 200092 China
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Top 100 cited studies in periacetabular osteotomy for acetabular dysplasia: do lower levels of evidence guide clinical practice? J Pediatr Orthop B 2022; 31:560-564. [PMID: 35357359 DOI: 10.1097/bpb.0000000000000974] [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: 11/26/2022]
Abstract
As no prior study has examined the citations profile of key articles related to periacetabular osteotomy (PAO), our analysis utilized the Web of Science database to (1) identify the most-cited clinical studies relating to PAO in the management of acetabular dysplasia and (2) assess any trends over time with respect to the quality of literature. The top 100 highest-cited studies related to PAO had a mean of 49 citations (range, 6-666 per study). With respect to the level of evidence, most studies had level IV evidence (58%); 1% level I, 16% level II, 28% level III and 2% level V. Most studies were retrospective ( n = 86); there were 14 prospective studies (including one randomized study). The most common study designs were case series ( n = 58) and cohort ( n = 16), followed by matched-cohort ( n = 13) and case-control ( n = 6). The mean ± SD Newcastle-Ottawa Scale score was 6.48 ± 1.31. A total of 59 and 41 of the included articles were classified as high risk and high quality, respectively. No studies were classified as very high risk. As a whole, our analysis demonstrated that currently available PAO literature is still of low quality and of low level of evidence. While PAO has been well-documented as a durable procedure for addressing acetabular dysplasia, future research must focus on higher quality, randomized and prospective data to answer key clinical or technique-related topics.
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Intraoperative Fluoroscopy Allows the Reliable Assessment of Deformity Correction during Periacetabular Osteotomy. J Clin Med 2022; 11:jcm11164817. [PMID: 36013054 PMCID: PMC9410010 DOI: 10.3390/jcm11164817] [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: 07/05/2022] [Revised: 08/10/2022] [Accepted: 08/16/2022] [Indexed: 11/17/2022] Open
Abstract
We aimed to determine the accuracy and reliability of measures characterizing anterior, lateral, and posterior acetabular coverage on intraoperative fluoroscopic images compared to postoperative radiographs when performing periacetabular osteotomies (PAOs). A study involving 100 PAOs was initiated applying a standardized intraoperative imaging protocol. Coverage was determined by the lateral center edge angle (LCEA), the Tönnis angle (TA), and the anterior and posterior wall index (AWI, PWI). An intraclass correlation coefficient (ICC) model was used to assess interrater (ICC (3,2)) and intrarater (ICC (2,1)) reliability. The ICC (2,2) between analyses obtained from intraoperative fluoroscopy and postoperative radiographs and the corresponding 95% confidence interval (CI) were determined and complemented by Bland–Altman analysis, the mean difference, and 95% limits of agreement (LOA). The ICCs were 0.849 for the LCEA (95% CI 0.783–0.896), 0.897 for the TA (95% CI 0.851–0.930), 0.864 for the AWI (95% CI 0.804–0.907), and 0.804 for the PWI (0.722–0.864). The assessed interrater reliability was excellent except for the AWI, which was graded good (ICC = 0.857, 95% CI 0.794–0.902). Interrater agreement was generally good and fair for the AWI (ICC = 0.715, 95% CI 0.603–0.780). For each postoperative radiograph, interrater reliability was good with ICCs ranging from 0.813 (TA) to 0.881 (PWI). Intrarater reliability was good for all measurements and excellent for the preoperative TA (ICC = 0.993, 95% CI 0.984–0.997) and PWI (ICC = 0.954, 95% CI 0.919–0.97). In summary, we confirm the validity and reliability of intraoperative fluoroscopy as an alternative imaging modality to radiography to evaluate acetabular fragment orientation during PAO. We affirm the LCEA and TA as precise measures for lateral head coverage, and show the suitability of the AWI and PWI to steadily assess acetabular version.
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Park JW, Shin CH, Choi BS, Cho YJ, Yoo WJ, Choi IH, Cho TJ. Effect of Leg Length Discrepancy on Lateral Center-edge Angle Measurement. J Pediatr Orthop 2022; 42:e295-e300. [PMID: 35051955 DOI: 10.1097/bpo.0000000000002034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND In patients with leg length discrepancy (LLD) and consequent pelvic obliquity, either the longitudinal axis of the pelvis or a line perpendicular to the ground may be used as the longitudinal reference line for measuring the lateral center-edge angle (LCEA). We aimed to (1) systematically inspect which longitudinal reference line has been used for measuring the LCEA in previous studies; (2) evaluate the frequency of change in the radiographical classification of acetabular overcoverage or undercoverage per the longitudinal reference line; and (3) validate the trigonometric method, predicting the change in the LCEA according to the LLD. METHODS Studies investigating the LCEA published between January 1976 and July 2019 in the MEDLINE database were categorized according to the longitudinal reference line used. Further, in a retrospective analysis of 238 patients surgically treated for LLD, the LCEA was first measured on standing pelvic radiographs using the longitudinal axis of the pelvis (pLCEA) and measured again using a line perpendicular to the ground (gLCEA). Femoral head coverage was categorized as undercoverage, normal, or overcoverage based on the pLCEA and gLCEA. The theoretically calculated difference between the pLCEA and gLCEA (dLCEA) as determined using a trigonometric method was compared with the dLCEA measured on radiographs. RESULTS Of 229 previous studies, 188 did not specify the longitudinal reference line. The number of patients who were diagnosed with acetabular overcoverage using the pLCEA and gLCEA was one and fourteen, respectively (P<0.001). The number of patients who were diagnosed with acetabular undercoverage using the pLCEA and gLCEA was one and zero, respectively (P=1.000). There was no difference (P=0.433) between the theoretically calculated (9±5 degrees) and measured (9±5 degrees) dLCEAs. CONCLUSIONS The definition of the longitudinal reference line should be clarified when measuring the LCEA. The trigonometric method can accurately predict the change in the LCEA according to LLD in concentric hips without proximal femoral and pelvic deformities. LEVEL OF EVIDENCE Level IV-diagnostic study.
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Affiliation(s)
- Jung-Wee Park
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Bundang-gu, Seongnam
| | - Chang Ho Shin
- Division of Paediatric Orthopaedics, Seoul National University College of Medicine, Seoul National University Children's Hospital, Jongno-gu, Seoul, Republic of Korea
| | - Byung Sun Choi
- Division of Paediatric Orthopaedics, Seoul National University College of Medicine, Seoul National University Children's Hospital, Jongno-gu, Seoul, Republic of Korea
| | - Yoon Joo Cho
- Division of Paediatric Orthopaedics, Seoul National University College of Medicine, Seoul National University Children's Hospital, Jongno-gu, Seoul, Republic of Korea
| | - Won Joon Yoo
- Division of Paediatric Orthopaedics, Seoul National University College of Medicine, Seoul National University Children's Hospital, Jongno-gu, Seoul, Republic of Korea
| | - In Ho Choi
- Division of Paediatric Orthopaedics, Seoul National University College of Medicine, Seoul National University Children's Hospital, Jongno-gu, Seoul, Republic of Korea
| | - Tae-Joon Cho
- Division of Paediatric Orthopaedics, Seoul National University College of Medicine, Seoul National University Children's Hospital, Jongno-gu, Seoul, Republic of Korea
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Dittmer Flemig AJ, Essilfie A, Schneider B, Robustelli S, Sink EL. The use of image analysis software increases the accuracy of the periacetabular osteotomy fragment placement. J Hip Preserv Surg 2021; 8:325-330. [PMID: 35505798 PMCID: PMC9052410 DOI: 10.1093/jhps/hnab085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 11/04/2021] [Accepted: 11/18/2021] [Indexed: 11/14/2022] Open
Abstract
The purpose of this study was to report on the use of image analysis technology to enhance accuracy of intra-operative imaging and evaluation of periacetabular osteotomy (PAO) correction. This was a retrospective study reporting on the first 25 cases of PAO performed with the use of an image analysis tool. This technology was used intra-operatively to assess the position of the supine coronal image in comparison to pre-operative standing images using a ratio of pelvic tilt (PT). Intra-operative PT, Tönnis angle, lateral center–edge angle (LCEA) and anterior wall index were compared to post-operative images. Post-operative radiographic parameters in the study group were compared with a control group of PAO cases performed prior to the implementation of the new software. The image analysis software was able to obtain intra-operative supine imaging that was equivalent to pre-operative standing imaging. When comparing the PAOs performed with the use of the software versus those without, the study group trended toward being more likely within the surgeon’s defined target range of radiographic values, which was statistically significant for LCEA. This tool can be used to assure the surgeon that the intra-operative image being used for surgical decision-making is representative of the functional radiograph. PAOs performed with the use of this technology showed enhanced accuracy of surgical correction for the parameters within our defined target ranges. This may increase the ability of the surgeon to place the acetabular fragment more precisely within his or her goal parameters for acetabular reorientation correction.
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Affiliation(s)
- Alison J Dittmer Flemig
- Department of Orthopedic Surgery, Gillette Children’s Specialty Healthcare, 200 University Avenue East, St. Paul, MN 55101, USA
| | - Anthony Essilfie
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Brandon Schneider
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Stacy Robustelli
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Ernest L Sink
- Department of Hip Preservation, Hospital for Special Surgery, 535 East 70th Street, NY, NY 10021, USA
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Wylie JD, McClincy MP, Stieler EK, Millis MB, Kim YJ, Peters CL, Novais EN. What factors affect fluoroscopy use during Bernese periacetabular osteotomy for acetabular dysplasia? J Hip Preserv Surg 2019; 6:259-264. [PMID: 31798928 PMCID: PMC6874767 DOI: 10.1093/jhps/hnz035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 07/21/2019] [Accepted: 08/13/2019] [Indexed: 11/15/2022] Open
Abstract
Periacetabular osteotomy (PAO) is the treatment of choice for acetabular dysplasia in the skeletally mature. Little is known about factors affecting fluoroscopy use in PAO. Therefore, we strived to determine patient and surgery factors are associated with the amount of fluoroscopy time and radiation dose during PAO. We performed a retrospective review of 378 patients who underwent PAO between January 2012 and August 2017. The mean age was 21.7 years and 326 (86%) were females. A total of 85 patients underwent concomitant arthroscopy and 60 underwent open arthrotomy. We recorded fluoroscopy time in minutes and radiation dose area product (DAP) in mGy·m2. Multivariate general linear modeling identified independent predictors of fluoroscopy time and radiation dose. Mean fluoroscopy time was 1.21 minutes and mean fluoroscopy DAP was 0.71 mGy·m2. Multivariate predictors of increased fluoroscopy time were male gender (P = 0.001), surgeon (P < 0.001) and whether an arthroscopy was performed (P < 0.001). Multivariate predictors of increased fluoroscopy DAP were increased body mass index (BMI) (P = 0.001), surgeon (P < 0.001) and whether an arthroscopy was performed (P < 0.001). Patients undergoing hip arthroscopy concomitant to PAO are at higher risk of longer fluoroscopy time and higher radiation dose. Other factors affecting fluoroscopy time included male gender and surgeon, while radiation dose was further affected by surgeon and BMI. Our findings can facilitate discussion about the risk of radiation exposure during PAO.
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Affiliation(s)
- James D Wylie
- The Orthopedic Specialty Hospital, Intermountain Healthcare, Fashion Blvd #120, Murray, UT, USA
| | - Michael P McClincy
- Children's Hospital of Pittsburgh, Department of Orthopaedic Surgery, 4401 Penn Ave, Pittsburgh, PA, USA
| | - Evan K Stieler
- Boston Children's Hospital, Department of Orthopaedic Surgery, 300 Longwood Ave, Boston, MA, USA
| | - Michael B Millis
- Boston Children's Hospital, Department of Orthopaedic Surgery, 300 Longwood Ave, Boston, MA, USA
| | - Young-Jo Kim
- Boston Children's Hospital, Department of Orthopaedic Surgery, 300 Longwood Ave, Boston, MA, USA
| | - Christopher L Peters
- University of Utah, Department of Orthopaedic Surgery, 590 Wakara Way, Salt Lake City, UT, USA
| | - Eduardo N Novais
- Boston Children's Hospital, Department of Orthopaedic Surgery, 300 Longwood Ave, Boston, MA, USA
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What Is the Reliability and Accuracy of Intraoperative Fluoroscopy in Evaluating Anterior, Lateral, and Posterior Coverage During Periacetabular Osteotomy? Clin Orthop Relat Res 2019; 477:1138-1144. [PMID: 30676406 PMCID: PMC6494329 DOI: 10.1097/corr.0000000000000616] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Periacetabular osteotomy (PAO) is an established treatment for acetabular dysplasia in the skeletally mature individual. Fluoroscopy is used intraoperatively for osteotomy completion and to judge fragment correction. However, a comprehensive study validating fluoroscopy to judge anterior, lateral, and posterior coverage in PAO has not been reported. QUESTIONS/PURPOSES (1) Are radiographic and fluoroscopic measures of anterior, lateral, and posterior acetabular coverage reliable? (2) Do fluoroscopic measures of fragment correction accurately measure anterior, lateral, and posterior coverage when compared with postoperative radiographs? METHODS We performed a retrospective study of patients undergoing PAO with a primary diagnosis of acetabular dysplasia. Between 2012 and 2014 two surgeons performed 287 PAOs with fluoroscopy. To be included in this retrospective study, patients had to be younger than 35 years old, have a primary diagnosis of dysplasia (not retroversion, Perthes, or skeletal dysplasia), have adequate radiographic and fluoroscopic imaging, be a primary PAO (not revision), and in the case of bilateral patients, only the first hip operated on in the study period was included. Based on these criteria, 46% of the PAOs performed were included here (133 of 287). A total of 109 (82%) of the patients were females (109 of 133), and the mean age of the patients represented was 24 years (SD, 7 years). Pre- and postoperative standing radiographs as well as intraoperative fluoroscopic images were reviewed and lateral center-edge angle (LCEA), Tönnis angle (TA), anterior center-edge angle (ACEA), anterior wall index (AWI), and posterior wall index (PWI) were measured. Two fellowship-trained hip preservation surgeons completed all measurements with one reader performing a randomized sample of 49 repeat measurements 4 weeks after the initial reading for purposes of calculating intraobserver reliability. Intra- and interrater reliability was assessed using an intraclass correlation coefficient (ICC) model. Agreement between intraoperative fluoroscopic and postoperative radiographic measures was determined by estimating the ICC with 95% confidence intervals and by Bland-Altman analysis. RESULTS Intrarater reliability was excellent (ICC > 0.75) for all measures and good for postoperative AWI (ICC = 0.72; 95% confidence interval [CI], 0.48-0.85). Interrater reliability was excellent (ICC > 0.75) for all measures except intraoperative TA (ICC = 0.72; 95% CI, 0.48-0.84). Accuracy of fluoroscopy was good (0.60 < ICC < 0.75) for LCEA (ICC = 0.73; 95% CI, 0.55-0.83), TA (ICC = 0.66; 95% CI, 0.41-0.79), AWI (ICC = 0.63; 95% CI, 0.48-0.74), and PWI (ICC = 0.72; 95% CI, 0.35-0.85) and excellent (ICC > 0.75) for ACEA (ICC = 0.80; 95% CI, 0.71-0.86). Bland-Altman analysis for systematic bias in the comparison between intraoperative fluoroscopy and postoperative radiography found the effect of such bias to be negligible (mean difference: LCEA 2°, TA 2°, ACEA 1°, AWI 0.02, PWI 0.11). CONCLUSIONS Fluoroscopy is accurate in measuring correction in PAO. However, surgeons should take care not to undercorrect the posterior wall. Based on our study, intraoperative fluoroscopy may be used as an alternative to an intraoperative AP pelvis radiograph to judge final acetabular fragment correction with an experienced surgeon. However, more studies are needed including a properly powered direct comparative study of intraoperative fluoroscopy and intraoperative radiographs. Moreover, the impact of radiographic correction achieved during surgery should be studied to determine the implications for patient-reported outcomes and long-term survival of the hip. LEVEL OF EVIDENCE Level IV, diagnostic study.
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Davila-Parrilla AD, Wylie J, O'Donnell C, Maranho DA, Carry P, Novais EN. Reliability of and Correlation Between Measurements of Acetabular Morphology. Orthopedics 2018; 41:e629-e635. [PMID: 30011052 DOI: 10.3928/01477447-20180711-01] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Accepted: 04/02/2018] [Indexed: 02/03/2023]
Abstract
The authors sought to determine the intra- and interrater reliability of contemporary measures of acetabular morphology among a group of hip surgeons and to determine the correlations between measures of acetabular morphology. On 2 separate occasions, 3 hip surgeons independently performed blinded evaluations of anteroposterior pelvic radiographs of 40 patients. The lateral center-edge angle, medial center-edge angle, acetabular arc, extrusion index, acetabular index, Sharp's angle, posterior wall sign, crossover sign, femoro-epiphyseal acetabular roof index, acetabular wall indexes, and delta angle were assessed. A linear mixed model was used for variance estimation, and kappa and intra-class correlation coefficients were assessed for reliability. Pearson correlation coefficients were calculated for all possible pairs of radiographic measures. The acetabular index had the greatest interrater agreement (0.90; 95% confidence interval [CI], 0.84-0.93), whereas the lateral center-edge angle had the higher intrarater agreement (0.96; 95% CI, 0.92-0.98). The acetabular arc angle had the lowest interrater agreement (0.44; 95% CI, 0.29-0.57), and the Sharp's angle had the lowest intrarater agreement (0.66; 95% CI, 0.41-0.84). The posterior wall sign had an interrater agreement of 0.35 (95% CI, 0.11-0.54) and an intrarater agreement of 0.68 (95% CI, 0.49-0.86). The crossover sign had an interrater agreement of 0.66 (95% CI, 0.43-0.84) and an intrarater agreement of 0.85 (95% CI, 0.52-0.89). The acetabular index, lateral center-edge angle, and extrusion index presented with high coefficients of correlation. In addition, acetabular anteversion correlated with severity of dysplasia. Commonly used parameters such as the acetabular index, lateral center-edge angle, and extrusion index are reliable radiographic parameters to assess acetabular morphology. However, correlation between measures suggests that they may be redundant in quantifying acetabular morphology. [Orthopedics. 2018; 41(5):e629-e635.].
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Pascual-Garrido C, Harris MD, Clohisy JC. Innovations in Joint Preservation Procedures for the Dysplastic Hip "The Periacetabular Osteotomy". J Arthroplasty 2017; 32:S32-S37. [PMID: 28318866 DOI: 10.1016/j.arth.2017.02.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 02/05/2017] [Indexed: 02/01/2023] Open
Abstract
The Bernese periacetabular osteotomy is an effective treatment for symptomatic developmental dysplasia in the prearthritic young adult hip. Refinements in the periacetabular osteotomy technique and perioperative management have markedly improved the clinical outcomes and recovery in these patients. We will review the clinical presentation of acetabular dysplasia, indications for surgery, perioperative management, and contemporary refinements in technique including refined acetabular reduction, adjunctive hip arthroscopy, femoral head-neck osteochondroplasty, femoral procedures, and rapid recovery protocols. In well-selected patients, this reconstructive osteotomy should be considered safe and effective in alleviating pain and improving hip function in patients with symptomatic acetabular dysplasia.
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Affiliation(s)
- Cecilia Pascual-Garrido
- Adult Reconstruction and Adolescent and Young Adult Hip Service, Department of Orthopaedic Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Michael D Harris
- Program in Physical Therapy, Washington University School of Medicine, St Louis, Missouri; Department of Orthopaedic Surgery, Washington University School of Medicine, St Louis, Missouri
| | - John C Clohisy
- Adult Reconstruction and Adolescent and Young Adult Hip Service, Department of Orthopaedic Surgery, Washington University School of Medicine, St Louis, Missouri
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