1
|
Ruiz-Tarrazo X, Escalona-Marfil C, Pla-Campas G, Coda A. Validity and reliability of ultrasonographic assessment of femoral and tibial torsion in children and adolescents: a systematic review. Eur J Pediatr 2024; 183:3159-3171. [PMID: 38831134 PMCID: PMC11263233 DOI: 10.1007/s00431-024-05619-y] [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: 03/22/2024] [Revised: 05/04/2024] [Accepted: 05/17/2024] [Indexed: 06/05/2024]
Abstract
Torsional disorders of the lower limb are common in childhood, and they are one of the primary reasons parents seek consultation with healthcare providers. While clinical manoeuvres can assess femoral and tibial torsion, their reliability is medium to low. Various imaging-based techniques, including computed tomography, magnetic resonance imaging, fluoroscopy, biplanar radiology and ultrasonography, have been used to evaluate torsional alterations of the lower extremity. Among these, ultrasound assessment offers certain advantages: it is a low-cost, non-irradiating technique, which allows the follow-up of children's torsional development. However, to the best of the authors' knowledge, its validity and reliability have not been summarised in a systematic review. This study aims to analyse the validity and reliability of ultrasonography in determining femoral and tibial torsion in children and adolescents. A search from Medline (via PubMed), Web of Science, Scopus and CINAHL databases were performed from inception to 16 March 2023. No restrictions were placed on the publication year or language. The methodological quality of all eligible studies was independently reviewed by two authors using QUADAS and STARD checklists. Overall, 1546 articles were identified through the searches; 30 were considered eligible for full-text screening; and 8 studies were finally included in this review. The included studies were conducted in Germany, Norway and the UK. Among them, 7 studies analysed the validity of ultrasonography compared with other imaging techniques such as computed tomography, magnetic resonance imaging and biplanar X-ray, and 4 studies assessed intra- and inter-observer reliability. All the studies assessed femoral torsion, but only one of them also included tibial torsion. Conclusion: Ultrasound is a good alternative for routine evaluation and follow-up of femoral torsional alterations in children and adolescents due to its safety, accessibility and immediate results in the clinical examination room. Although ultrasound has good accuracy and reliability for routine evaluations, there is controversy about whether it is sufficient for surgical planning. In cases where greater accuracy is required, magnetic resonance imaging and biplanar radiography are the preferred imaging techniques. What is Known: • Several imaging-based techniques have been described for the assessment of torsional alterations of the lower extremity. • Computed tomography, magnetic resonance imaging, biplanar radiology and ultrasonography are the most used and studied methods. What is New: • Ultrasonography represents a good alternative for the assessment of femoral and tibial torsional alterations in children and adolescents, given its safety, accessibility and immediacy of results in the consultation room. • Its accuracy and reliability are good but not sufficient for surgical planning, in which case MRI and biplanar X-ray will be the preferred choices.
Collapse
Affiliation(s)
- Xavier Ruiz-Tarrazo
- Faculty of Health Sciences at Manresa, University of Vic - Central University of Catalonia (UVic-UCC), Av. Universitària, 4-6, 08242, Manresa, Spain.
| | - Carles Escalona-Marfil
- Faculty of Health Sciences at Manresa, University of Vic - Central University of Catalonia (UVic-UCC), Av. Universitària, 4-6, 08242, Manresa, Spain
- University of Girona, Girona, Spain
| | - Gil Pla-Campas
- Faculty of Education, Translation, Sport and Psychology at Vic, University of Vic - Central University of Catalonia (UVic-UCC), C/ Sagrada Família 7, 080500, Vic, Spain
| | - Andrea Coda
- Podiatry, School of Health Sciences, College of Health, Medicine and Wellbeing - The University of Newcastle, Newcastle, Australia
- Equity in Health and Wellbeing Research Program, Hunter Medical Research Institute (HMRI), New Lambton Heights, New South Wales, Australia
| |
Collapse
|
2
|
Iwasaka-Neder J, Bixby SD, Bedoya MA, Liu E, Jarrett DY, Agahigian D, Tsai A. Virtual 3D femur model to assess femoral version: comparison to the 2D axial slice approach. Pediatr Radiol 2023; 53:2411-2423. [PMID: 37740782 DOI: 10.1007/s00247-023-05758-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 08/22/2023] [Accepted: 08/23/2023] [Indexed: 09/25/2023]
Abstract
BACKGROUND Quantifying femoral version is crucial in diagnosing femoral version abnormalities and for accurate pre-surgical planning. There are numerous methods for measuring femoral version, however, reliability studies for most of these methods excluded children with hip deformities. OBJECTIVE To propose a method of measuring femoral version based on a virtual 3D femur model, and systematically compare its reliability to the widely used Murphy's 2D axial slice technique. MATERIALS AND METHODS We searched our imaging database to identify hip/femur CTs performed on children (<18 years old) with a clinical indication of femoral version measurement (September 2021-August 2022). Exclusion criteria were prior hip surgery, and inadequate image quality or field-of-view. Two blinded radiologists independently measured femoral version using the virtual 3D femur model and Murphy's 2D axial slice method. To assess intrareader variability, we randomly selected 20% of the study sample for re-measurements by the two radiologists >2 weeks later. We analyzed the reliability and correlation of these techniques via intraclass correlation coefficient (ICC), Bland-Altman analysis, and deformity subgroup analysis. RESULTS Our study sample consisted of 142 femurs from 71 patients (10.6±4.4 years, male=31). Intra- and inter-reader correlations for both techniques were excellent (ICC≥0.91). However, Bland-Altman analysis revealed that the standard deviation (SD) of the absolute difference between the two radiologists for the Murphy method (mean 13.7°) was larger than that of the 3D femur model technique (mean 4.8°), indicating higher reader variability. In femurs with hip flexion deformity, the SD of the absolute difference for the Murphy technique was 17°, compared to 6.5° for the 3D femur model technique. In femurs with apparent coxa valga deformity, the SD of the absolute difference for the Murphy technique was 10.4°, compared to 5.2° for the 3D femur model technique. CONCLUSION The 3D femur model technique is more reliable than the Murphy's 2D axial slice technique in measuring femoral version, especially in children with hip flexion and apparent coxa valga deformities.
Collapse
Affiliation(s)
- Jade Iwasaka-Neder
- Department of Radiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA.
| | - Sarah D Bixby
- Department of Radiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
| | - M Alejandra Bedoya
- Department of Radiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Enju Liu
- Department of Pediatrics, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Delma Y Jarrett
- Department of Radiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
- Department of Radiology, New York Presbyterian Hospital-Weill Cornell, 525 East 68th Street, New York, NY, 10065, USA
| | - Donna Agahigian
- Department of Radiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Andy Tsai
- Department of Radiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
| |
Collapse
|
3
|
Bernstein M, Bunge T, Rosinski K, Kfuri M, Crist B, Knapp A, Vaidya R. Online Instruction to Measure Axial Alignment with the Bonesetter App. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58081079. [PMID: 36013547 PMCID: PMC9415140 DOI: 10.3390/medicina58081079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 08/04/2022] [Accepted: 08/08/2022] [Indexed: 11/16/2022]
Abstract
Background and objectives: Alignment of the lower extremity is important when treating congenital deformities, fractures, and joint replacement. During the COVID-19 pandemic, AO North America offered an online course on deformity measurement and planning. The Bonesetter app is a deformity planning tool that is freely available online. The purpose of this study was to see how effective an online course was in teaching axial alignment measurement and to assess that skill using an online digital planning tool, the Bonesetter app. Materials and Methods: An online module on axial alignment was provided during the AONA osteotomy course as well as a tutorial on how to use an online digital planning tool (Bonesetter app). The tools within the Bonesetter app allow users to draw digital lines directly on the CT images and measure the exact angle between two planes. Participants in this study were directed to perform these measurements in four different cases that tested different variations of deformity. Results: The measurements were completed correctly in case 1 = 56%, case 2 = 61%, case 3 = 84%, and case 4 = 76%. The standard deviation of angular digital measurements between individuals was ±4.26 degrees. Measuring the angle directly vs. drawing angles to a horizontal line had smaller standard deviations per case (p < 0.005) and less incidents outside 1 standard deviation for each measurement. Errors in adding and subtracting were the most common errors, particularly in relation to femoral anteversion or retroversion. Conclusions: The online course successfully instructed a group of orthopedic surgeons to measure alignment and malalignment of lower limb axial deformities. The Bonesetter app helped participants to learn this skill and identify errors in measurement. The inability to differentiate between anteversion and retroversion of the femur is a common source of error when it occurs and should be a focus of instruction.
Collapse
Affiliation(s)
- Mitchell Bernstein
- Department of Orthopedic Surgery, McGill University, Montreal, QC H3A 0G4, Canada
| | - Tatiana Bunge
- Department of Orthopedic Surgery, Detroit Medical Center, Detroit, MI 48124, USA
| | - Kadence Rosinski
- Department of Orthopedic Surgery, Detroit Medical Center, Detroit, MI 48124, USA
| | - Mauricio Kfuri
- Department of Orthopedic Surgery, University of Missouri, Columbia, MO 65211, USA
| | - Brett Crist
- Department of Orthopedic Surgery, University of Missouri, Columbia, MO 65211, USA
| | - Andrew Knapp
- Department of Orthopedic Surgery, Detroit Medical Center, Detroit, MI 48124, USA
| | - Rahul Vaidya
- Department of Orthopedic Surgery, Detroit Medical Center, Detroit, MI 48124, USA
- Correspondence:
| |
Collapse
|
4
|
Morphological Parameters of the Hip Joint and Its Relation to Gender, Joint Side and Age-A CT-Based Study. Diagnostics (Basel) 2022; 12:diagnostics12081774. [PMID: 35892485 PMCID: PMC9332566 DOI: 10.3390/diagnostics12081774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 07/19/2022] [Accepted: 07/21/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Physiological reference values for morphological parameters of the hip (MPH) are of clinical importance for the treatment of painful, degenerated or fractured hip joints, as well as to detect morphological deformities, which could result in early osteoarthritis of the hip. Currently, sufficient data for MPH are lacking. Therefore, it remains unclear if age-dependent alterations in adult hip morphology are physiological and if there are side- and gender-dependent differences. The aim of the study was to analyze MPH according to gender, side and age in a large-scaled cohort by CT scans. Methods: A total of 1576 hip joints from 788 patients (female: 257, male: 531; mean age: 58.3 years (±18.9; 18−92 years)) were analyzed by CT. For all hips, acetabular anteversion (AcetAV); lateral centrum edge angle (LCE); acetabular index (AI); femoral neck version (FNV); centrum-collum-diaphyseal angle (CCD); and anterior alpha angle (AαA) were measured. Results: The mean values in this cohort were: AcetAV 20.5° (±6.9); LCE 40.8° (±8.8); AI 0.3° (±5.3); FNV 11.0° (±9.8); CCD 129.9° (±7.4); and AαA 41.2° (±7.7). There was a detectable side-specific difference for AcetAV (p = 0.001); LCE (p < 0.001); CCD (p < 0.001); and AαA (p < 0.001). All the analyzed parameters showed a significant gender-specific difference, except for AI (p = 0.37). There was a significant correlation between age and AcetAV (r = 0.17; p < 0.001); LCE (r = 0.39; p < 0.001); AI (r = −0.25; p < 0.001); CCD (r = −0.15; p < 0.001); and AαA (r = 0.09; p < 0.001), except FNV (p = 0.79). Conclusions: There are side-, gender- and age-specific alterations in hip morphology, which have to be considered in treating hip joint pathologies.
Collapse
|
5
|
Takeuchi S, Sugimoto K, Goto H, Tsuchiya A, Takenaga T, Takaba K, Saito M, Futamura H, Murakami H, Yoshida M. Characteristics of Femoral Torsion Angles and Relationships Between Femoral Torsion Angles and Hip Rotational Motion Variables in Adult Baseball Players. Orthop J Sports Med 2020; 8:2325967120966319. [PMID: 33415173 PMCID: PMC7750773 DOI: 10.1177/2325967120966319] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 06/08/2020] [Indexed: 11/23/2022] Open
Abstract
Background: Abnormalities in hip rotational motion (HRM) are risk factors for throwing
injuries. To evaluate hip rotational motion, it is necessary to assess the
torsion angle. However, no studies have investigated the femoral torsion
angle (FTA) in baseball players. Purpose: To investigate differences in hip FTA of adult baseball players through use
of ultrasonography to evaluate the relationship between the FTA and HRM. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 149 elite male baseball players (mean age, 20.0 ± 1.8 years; 64
pitchers, 85 position players) were enrolled in this study. Ultrasonographic
assessment of FTA was performed based on the tilting angles of the anterior
surface of the femoral neck and condylar axis. The hip internal rotation
(HIR) and hip external rotation (HER) were assessed at 0° and 90° of
flexion. Data related to FTA and HRM were compared between hips and between
pitchers and position players. Results: No significant difference was observed in the FTAs between hips for any
player (lead hip, 20.5° ± 9.2°; trail hip, 19.6° ± 9.8°; P
= .276). No significant difference was observed in FTAs of both hips between
pitchers and position players (lead hip, 20.1° ± 9.4° and 20.9° ± 9.0°,
respectively, P = .957; trail hip, 19.5° ± 9.8° and 19.7° ±
9.8°, P = .999). In terms of HER in 90° of hip flexion in
both hips, significant differences were observed in HRM variables between
pitchers and position players (lead hip, 33.0° ± 8.9° and 37.5° ± 9.8°,
respectively, P = .024; trail hip, 35.6° ± 9.6° and 40.4° ±
10.2°, P = .035). Linear regression analysis revealed a
significant agreement between the FTA and HIR at both 0° (R
= 0.298, P < .001) and 90° of hip flexion
(R = 0.279, P < .001). Conclusion: Our findings indicated that FTAs were not different between the hips of elite
baseball players. Abnormalities of the HRM are not caused by differences in
the FTA but rather involve soft tissue tightness around the hip area or
other bony morphologic factors in the hip joint.
Collapse
Affiliation(s)
- Satoshi Takeuchi
- Department of Orthopaedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | | | - Hideyuki Goto
- Department of Orthopaedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan.,Department of Sports and Fitness, Faculty of Wellness, Shigakkan University, Obu, Japan
| | - Atsushi Tsuchiya
- Arthroscopy & Sports Medicine Center, Meitetsu Hospital, Nagoya, Japan
| | - Tetsuya Takenaga
- Department of Orthopaedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Keishi Takaba
- Department of Orthopaedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | | | | | - Hideki Murakami
- Department of Orthopaedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Masahito Yoshida
- Department of Orthopaedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| |
Collapse
|