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Şahbat Y, Chou TFA, An JS, Gülağacı F, Ollivier M. CPAK classification detect the real knee joint apex position in less than half of the knees. Knee Surg Sports Traumatol Arthrosc 2024; 32:1548-1556. [PMID: 38613184 DOI: 10.1002/ksa.12175] [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: 01/17/2024] [Revised: 03/20/2024] [Accepted: 03/23/2024] [Indexed: 04/14/2024]
Abstract
PURPOSE Accurate assessment of the knee joint line is essential for surgeries involving the knee. The knee joint line obliquity (KJLO) is a radiological measurement that evaluates the position of the knee joint relative to the ground and is frequently used in preoperative planning and clinical follow-up. On the other hand, coronal plane alignment of the knee (CPAK) classifications assesses the joint line as the summation of the medial proximal tibial angle (MPTA) and mechanical lateral distal femoral angle (mLDFA). The purpose of this study is to determine the concordance of these two measurement techniques. METHODS This cross-sectional study evaluated the long-leg standing radiographs (LSRs) of 164 healthy knees. The extremity KJLO and CPAK classification JLO were measured twice by two observers at 8-week intervals. The knee joint line apex positions (proximal, neutral and distal) of the two measurement techniques are compared (concordance or discordant). The intraobserver and interobserver reliability were examined using the intraclass correlation coefficient (ICC). Possible causes of the discordant were evaluated with univariate and multivariate logistic regression analysis. RESULTS CPAK classification detected the KJLO apex position in 70 extremities (42.7%) only. Subgroups CPAK JLO detected 13.6% of the proximal apex, 20.4% of the neutral, and 90.7% of the distal apex (p < 0.01). Upon multivariate logistic regression analysis, the variable KJLO apex position (proximal, neutral vs. distal, odds ratio (OR) = 10.291, 95% confidence interval [CI] = 2.225-25.656, and (p < 0.01) was determined as a risk factor for discordant. CONCLUSION The CPAK JLO measurement technique can be misleading in defining the KJLO apex position and the concordance between them is less than 50%. It has a high tendency to misleadingly predict proximal and neutral apex positions, which can potentially have negative implications for assessing the joint line. LEVEL OF EVIDENCE Level I.
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Affiliation(s)
- Yavuz Şahbat
- Institute du Mouvement et de l'appareil locomoteur, Hôpital Sainte-Marguerite, Aix-Marseille Université, Marseille, France
- Erzurum Regional Training and Research Hospital, Department of Orthopaedics and Traumatology, Erzurum, Turkey
| | - Te-Feng Arthur Chou
- Institute du Mouvement et de l'appareil locomoteur, Hôpital Sainte-Marguerite, Aix-Marseille Université, Marseille, France
- Department of Orthopaedic Surgery, Medstar Union Memorial Hospital, Baltimore, Maryland, USA
| | - Jae-Sung An
- Institute du Mouvement et de l'appareil locomoteur, Hôpital Sainte-Marguerite, Aix-Marseille Université, Marseille, France
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Fırat Gülağacı
- Institute du Mouvement et de l'appareil locomoteur, Hôpital Sainte-Marguerite, Aix-Marseille Université, Marseille, France
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Trakya University, Edirne, Turkey
| | - Matthieu Ollivier
- Institute du Mouvement et de l'appareil locomoteur, Hôpital Sainte-Marguerite, Aix-Marseille Université, Marseille, France
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Hiranaka T, Fukai Y, Tanaka S, Okajima T, Ishida Y, Koide M, Fujishiro T, Okamoto K. Preoperative Arithmetic Hip-Knee-Ankle Angle as a Predictor of Postoperative Leg Alignment in Medial Oxford Unicompartmental Knee Arthroplasty. Cureus 2024; 16:e56046. [PMID: 38606266 PMCID: PMC11008927 DOI: 10.7759/cureus.56046] [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] [Accepted: 03/12/2024] [Indexed: 04/13/2024] Open
Abstract
Introduction This study aimed to evaluate whether the arithmetic hip-knee-ankle angle (aHKA) can be used to predict the postoperative HKA. Methods This study included 248 knees in 166 patients who underwent Oxford unicompartmental knee arthroplasty (UKA) between February 2021 and November 2022. Through preoperative and postoperative long-leg radiography, the medial proximal tibial angle (MPTA) and the lateral distal femoral angle (LDFA) were expressed as the deviation from the perpendicular line to the mechanical axes, and the mechanical HKA (mHKA) was defined as the angle between the femoral and tibial mechanical axes. Using the MPTA and LDFA, the arithmetic HKA (aHKA; MPTA + LDFA) and the joint line obliquity (JLO; MPTA - LDFA) were calculated, and the preoperative and postoperative values were compared. Results The preoperative aHKA and the postoperative mHKA values were similar (-0.38° ± 2.96°) and significantly smaller than the difference between the preoperative and postoperative mHKAs (4.58° ± 3.60°, P < 0.05). Meanwhile, the MPTA tended to be varus, and the LDFA tended to be valgus. Eventually, the JLO inclined more medially from -6.33° ± 3.42° preoperatively to -8.97° ± 3.92° postoperatively, representing a significant difference (P < 0.05). Conclusion The preoperative aHKA was similar to the postoperative mHKA. Therefore, it can be regarded as a predictor of postoperative leg alignment after Oxford UKA. Meanwhile, there was a medial incline of the joint line. Further investigation is required to evaluate the effect of such a joint line alteration.
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Affiliation(s)
- Takafumi Hiranaka
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, Takatsuki, JPN
| | - Yasuhiro Fukai
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, Takatsuki, JPN
| | - Sho Tanaka
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, Takatsuki, JPN
| | - Takahiro Okajima
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, Takatsuki, JPN
| | - Yuya Ishida
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, Takatsuki, JPN
| | - Motoki Koide
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, Takatsuki, JPN
| | - Takaaki Fujishiro
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, Takatsuki, JPN
| | - Koji Okamoto
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, Takatsuki, JPN
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Kim SE, Yun KR, Lee JM, Lee MC, Han HS. Preserving coronal knee alignment of the knee (CPAK) in unicompartmental knee arthroplasty correlates with superior patient-reported outcomes. Knee Surg Relat Res 2024; 36:1. [PMID: 38167246 PMCID: PMC10763258 DOI: 10.1186/s43019-023-00204-3] [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: 08/28/2023] [Accepted: 12/04/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND The optimal alignment target for unicompartmental knee arthroplasty (UKA) remains controversial, and literature suggests that its impact on patient-reported outcome measures (PROMs) varies. The purpose of this study was to identify the relationship between changes in the coronal plane alignment of the knee (CPAK) and PROMs in patients who underwent UKA. METHODS A retrospective analysis of 164 patients who underwent UKA was conducted. The types of CPAK types categorized into unchanged, minor (shift to an adjacent CPAK type, e.g., type I to II or type I to IV), and major changes (transitioning to a nearby diagonal CPAK type or two types across, such as type I to V or type I to III). PROMs were assessed preoperatively and 1 year postoperatively using the Hospital for Special Surgery (HSS) scores, Knee Society (KS) scores, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Forgotten Joint Scores (FJS). Comparison was performed between patients who experienced and who did not experience any changes in the CPAK. RESULTS Patients with preserved native CPAK alignment demonstrated significantly superior 1 year postoperative outcomes, with higher HSS, KS knee, and WOMAC pain scores (p = 0.042, p = 0.009, and p = 0.048, respectively). Meanwhile, the degree of change in CPAK did not significantly influence the PROMs, and patients who experienced minor and major changes in the CPAK showed comparable outcomes. CONCLUSION Preserving the native CPAK in UKA procedures is important for achieving favorable clinical outcomes at 1 year postoperative. The extent of change in the CPAK type exerted a limited impact on PROMs, thus emphasizing the importance of change in alignment itself.
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Affiliation(s)
- Sung Eun Kim
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, 101 Daehak-Ro, Jongno-Gu, Seoul, 110-744, Republic of Korea
| | - Kuk-Ro Yun
- Department of Orthopaedic Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Jae Min Lee
- Department of Orthopaedic Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Myung Chul Lee
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, 101 Daehak-Ro, Jongno-Gu, Seoul, 110-744, Republic of Korea
- Department of Orthopaedic Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Hyuk-Soo Han
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, 101 Daehak-Ro, Jongno-Gu, Seoul, 110-744, Republic of Korea.
- Department of Orthopaedic Surgery, Seoul National University Hospital, Seoul, South Korea.
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Automated Artificial Intelligence-Based Assessment of Lower Limb Alignment Validated on Weight-Bearing Pre- and Postoperative Full-Leg Radiographs. Diagnostics (Basel) 2022; 12:diagnostics12112679. [PMID: 36359520 PMCID: PMC9689840 DOI: 10.3390/diagnostics12112679] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 10/26/2022] [Accepted: 10/28/2022] [Indexed: 11/06/2022] Open
Abstract
The assessment of the knee alignment using standing weight-bearing full-leg radiographs (FLR) is a standardized method. Determining the load-bearing axis of the leg requires time-consuming manual measurements. The aim of this study is to develop and validate a novel algorithm based on artificial intelligence (AI) for the automated assessment of lower limb alignment. In the first stage, a customized mask-RCNN model was trained to automatically detect and segment anatomical structures and implants in FLR. In the second stage, four region-specific neural network models (adaptations of UNet) were trained to automatically place anatomical landmarks. In the final stage, this information was used to automatically determine five key lower limb alignment angles. For the validation dataset, weight-bearing, antero-posterior FLR were captured preoperatively and 3 months postoperatively. Preoperative images were measured by the operating orthopedic surgeon and an independent physician. Postoperative images were measured by the second rater only. The final validation dataset consisted of 95 preoperative and 105 postoperative FLR. The detection rate for the different angles ranged between 92.4% and 98.9%. Human vs. human inter-(ICCs: 0.85−0.99) and intra-rater (ICCs: 0.95−1.0) reliability analysis achieved significant agreement. The ICC-values of human vs. AI inter-rater reliability analysis ranged between 0.8 and 1.0 preoperatively and between 0.83 and 0.99 postoperatively (all p < 0.001). An independent and external validation of the proposed algorithm on pre- and postoperative FLR, with excellent reliability for human measurements, could be demonstrated. Hence, the algorithm might allow for the objective and time saving analysis of large datasets and support physicians in daily routine.
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Patellar height after unicompartmental knee arthroplasty: comparison between fixed and mobile bearing. Arch Orthop Trauma Surg 2022; 142:3449-3460. [PMID: 34669039 DOI: 10.1007/s00402-021-04183-6] [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: 05/31/2021] [Accepted: 09/13/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE The purpose of this study was to determine the changes in patellar heights by comparing standardised pre- and post-operative radiographs in a consecutive series of patients undergoing unicompartmental knee arthroplasty (UKA) with two different approaches and implant designs [fixed bearing (FB) vs mobile bearing (MB)] and to correlate the patellar heights with clinical outcomes. METHODS One hundred and seventy-two UKA patients were prospectively enrolled in the study. 75 patients underwent a minimally invasive FB medial UKA (referred to hereinafter as the 'FB group'); 97 patients were treated with a minimally invasive MB medial UKA. The pre-operative and mid-term (1-year) post-operative patellar heights and clinical scores of these groups of patients were compared using the Insall-Salvati (IS) and Caton-Deschamps (CD) indices and the Oxford Knee Score (OKS). RESULTS No differences were found between the two groups either with regard to the pre-operative data (p > 0.05) or between pre- and post-operative radiographic scores at the time of each follow-up (p > 0.05). Both the groups reported a significant clinical improvement (p<0.05) as did all the sub-groups (p < 0.05). In the MB group, a higher CD index in females was found at the final follow-up stage (p = 0.043) and a higher pre-operative CD index was found in patients with BMI ≥ 28 (p = 0.040). A statistically negative correlation was found between the pre-operative OKS and pre-operative IS index (rho=- 0.165; p=0.031). CONCLUSIONS Both FB and MB arthroplastys with different surgical approaches did not change the patellar height regardless of the age, gender and BMI at short-medium-term follow-up. The post-operative patellar height seems not to be correlated with the clinical outcomes. A higher pre-operative IS index was correlated with knee pain and function. LEVEL OF EVIDENCE Level II-prospective comparative study. STUDY REGISTRATION Researchregistry6433- www.researchregistry.com .
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Itou J, Kuwashima U, Itoh M, Okazaki K. Perioperative varus alignment does not affect short-term patient-reported outcome measures following mobile-bearing unicompartmental knee arthroplasty. J Orthop Surg Res 2022; 17:98. [PMID: 35168658 PMCID: PMC8848965 DOI: 10.1186/s13018-022-02999-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 02/04/2022] [Indexed: 11/25/2022] Open
Abstract
Background Although favorable long-term survival of Oxford unicompartmental knee arthroplasty (UKA) has been reported regardless of postoperative varus alignment, the effect of degree of varus alignment on patient-reported outcome measures (PROMs) remains unclear. Furthermore, the Forgotten Joint Score-12 (FJS-12), which has a low ceiling effect, may be useful for such assessment. The objective of this study was to evaluate short-term clinical outcomes after Oxford UKA in knees with a greater degree of preoperative varus alignment focusing on use of the FJS-12. Methods This retrospective study involved 66 knees that had undergone primary Oxford UKA. Based on the hip-knee-ankle angle, the knees were divided into two alignment groups: severe varus group (≥ 185° varus alignment) and a mild varus group (< 185° varus alignment). PROMs, including the FJS-12, Knee Injury and Osteoarthritis Outcome Score, and Knee Society Score, were obtained pre- and postoperatively for assessment of clinical outcomes. In addition, the ceiling effect of the FJS-12 was evaluated. Results All PROMs showed significant improvement after surgery. However, there were no statistically significant differences between the severe varus group and the mild varus group. Moreover, no ceiling effect was found for the FJS-12 in this study. Conclusion Short-term results were good for Oxford UKA in knees with a greater degree of varus alignment and were not significantly different from those in knees with mild varus alignment.
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Affiliation(s)
- Junya Itou
- Department of Orthopaedic Surgery, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Umito Kuwashima
- Department of Orthopaedic Surgery, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Masafumi Itoh
- Department of Orthopaedic Surgery, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Ken Okazaki
- Department of Orthopaedic Surgery, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan.
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Nishida R, Hiranaka T. Response to Letter to the Editor "Nishida et al.: Impact of joint line orientation on clinical outcomes in bilateral Oxford mobile-bearing unicompartmental knee arthroplasty". Knee 2021; 31:195-197. [PMID: 33867251 DOI: 10.1016/j.knee.2021.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Ryota Nishida
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, Japan
| | - Takafumi Hiranaka
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, Japan.
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Rivière C. Letter to the Editor "Nishida et al.: Impact of joint line orientation on clinical outcomes in bilateral Oxford mobile-bearing unicompartmental knee arthroplasty". Knee 2021; 31:192-194. [PMID: 33875346 DOI: 10.1016/j.knee.2021.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 03/26/2021] [Indexed: 02/02/2023]
Affiliation(s)
- Charles Rivière
- Clinique du Sport, 04 Rue Nègrevergne, 33700 Mérignac, France; MSK Lab - Imperial College London, Sir Michael Uren Hub, London W12 0BZ, United Kingdom.
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Ricciardi B. Editorial. Knee 2021; 28:A1-A2. [PMID: 33706913 DOI: 10.1016/j.knee.2021.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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