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Richter M, Zech S, Naef I, Duerr F, Schilke R. Automatic software-based 3D-angular measurement for weight-bearing CT (WBCT) is valid. Foot Ankle Surg 2024; 30:417-422. [PMID: 38448344 DOI: 10.1016/j.fas.2024.02.016] [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: 01/29/2024] [Revised: 02/17/2024] [Accepted: 02/28/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND The purpose of this study was to compare automatic software-based angular measurement (AM) with validated measurement by hand (MBH) regarding angle values and time spent for Weight-Bearing CT (WBCT) generated datasets. METHODS Five-hundred WBCT scans from different pathologies were included in the study. 1st - 2nd intermetatarsal angle, talo-1st metatarsal angle dorsoplantar and lateral, hindfoot angle, calcaneal pitch angle were measured and compared between MBH and AM. RESULTS The pathologies were ankle osteoarthritis/instability, n = 147 (29%); Haglund deformity/Achillodynia, n = 41 (8%); forefoot deformity, n = 108 (22%); Hallux rigidus, n = 37 (7%); flatfoot, n = 35 (7%); cavus foot, n = 10 (2%); osteoarthritis except ankle, n = 82 (16%). The angles did not differ between MBH and AM (each p > 0.36). The time spent for MBH / AM was 44.5 / 1 s on average per angle (p < .001). CONCLUSIONS AM provided angles which were not different from validated MBH and can be considered as a validated angle measurement method. The time spent was 97% lower for AM than for MBH. LEVELS OF EVIDENCE Level III.
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Affiliation(s)
- Martinus Richter
- Department for Foot and Ankle Surgery Rummelsberg and Nuremberg, Germany.
| | - Stefan Zech
- Department for Foot and Ankle Surgery Rummelsberg and Nuremberg, Germany
| | - Issam Naef
- Department for Foot and Ankle Surgery Rummelsberg and Nuremberg, Germany
| | - Fabian Duerr
- Department for Foot and Ankle Surgery Rummelsberg and Nuremberg, Germany
| | - Regina Schilke
- Department for Foot and Ankle Surgery Rummelsberg and Nuremberg, Germany
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Li J, Fang M, Van Oevelen A, Peiffer M, Audenaert E, Burssens A. Diagnostic applications and benefits of weightbearing CT in the foot and ankle: A systematic review of clinical studies. Foot Ankle Surg 2024; 30:7-20. [PMID: 37704542 DOI: 10.1016/j.fas.2023.09.001] [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: 05/28/2023] [Revised: 08/16/2023] [Accepted: 09/01/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Foot and ankle weightbearing CT (WBCT) imaging has emerged over the past decade. However, a systematic review of diagnostic applications has not been conducted so far. METHOD A systematic literature search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines after Prospective Register of Systematic Reviews (PROSPERO) registration. Studies analyzing diagnostic applications of WBCT were included. Main exclusion criteria were: cadaveric specimens and simulated WBCT. The Methodological Index for Non-Randomized Studies (MINORS) was used for quality assessment. RESULTS A total of 78 studies were eligible for review. Diagnostic applications were identified in following anatomical area's: ankle (n = 14); hindfoot (n = 41); midfoot (n = 4); forefoot (n = 19). Diagnostic applications that could not be used on weightbearing radiographs (WBRX) were reported in 56/78 studies. The mean MINORS was 9.8/24 (range: 8-12). CONCLUSION Diagnostic applications of WBCT were most frequent in the hindfoot, but other areas are on the rise. Post-processing of images was the main benefit compared to WBRX based on a moderate quality of the identified studies.
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Affiliation(s)
- Jing Li
- Department of Orthopaedics, Ghent University Hospital, Ghent, Belgium
| | - Mengze Fang
- Department of Orthopaedics, Ghent University Hospital, Ghent, Belgium
| | - Aline Van Oevelen
- Department of Orthopaedics, Ghent University Hospital, Ghent, Belgium
| | - Matthias Peiffer
- Department of Orthopaedics, Ghent University Hospital, Ghent, Belgium
| | | | - Arne Burssens
- Department of Orthopaedics, Ghent University Hospital, Ghent, Belgium.
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Richter M, Schilke R, Duerr F, Zech S, Andreas Meissner S, Naef I. Automatic software-based 3D-angular measurement for Weight-Bearing CT (WBCT) provides different angles than measurement by hand. Foot Ankle Surg 2022; 28:863-871. [PMID: 34876354 DOI: 10.1016/j.fas.2021.11.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/12/2021] [Accepted: 11/27/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Purpose of this study was to compare automatic software-based angular measurement (AM, Autometrics, Curvebeam, Warrington, PA, USA) with previously validated measurement by hand (MBH) regarding angle values and time spent for the investigator for Weight-Bearing CT (WBCT). METHODS Five-hundred bilateral WBCT scans (PedCAT, Curvebeam, Warrington, PA, USA) were included in the study. Five angles (1st - 2nd intermetatarsal angle, talo-metatarsal 1-angle (TMT) dorsoplantar and lateral projection, hindfoot angle, calcaneal pitch angle) were measured with MBH and AM on the foot/ankle (side with pathology). Angles and time spent of MBH and AM were compared (t-test, homoscedatic). RESULTS The specific pathologies were ankle osteoarthritis/instability, n = 147 (29%); Haglund deformity/Achillodynia, n = 41 (8%); forefoot deformity, n = 108 (22%); Hallux rigidus, n = 37 (7%); flatfoot, n = 35 (7%); cavus foot, n = 10 (2%); osteoarthritis except ankle, n = 82 (16%). The angles differed between MBH and AM (each p < 0.001) except the calcaneal pitch angle (p = 0.05). The time spent for MBH / AM was 44.5 ± 12 s / 1 ± 0 s on average per angle (p < 0.0011). CONCLUSIONS AM provided different angles as MBH and can currently not be considered as validated angle measurement method. The investigator time spent is 97% lower for AM (1 s per angle) than for MBH (44.5 s per angle). Cases with correct angles in combination with almost no time spent showed the real potential of AM. The AM system will have to become reliable (especially in diminishing positive and negative angle values as defined) and valid which has to be proven by planned studies in the future. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Martinus Richter
- Department for Foot and Ankle Surgery Rummelsberg and Nuremberg, Germany.
| | - Regina Schilke
- Department for Foot and Ankle Surgery Rummelsberg and Nuremberg, Germany
| | - Fabian Duerr
- Department for Foot and Ankle Surgery Rummelsberg and Nuremberg, Germany
| | - Stefan Zech
- Department for Foot and Ankle Surgery Rummelsberg and Nuremberg, Germany
| | | | - Issam Naef
- Department for Foot and Ankle Surgery Rummelsberg and Nuremberg, Germany
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Richter M, Duerr F, Schilke R, Zech S, Meissner SA, Naef I. Semi-automatic software-based 3D-angular measurement for Weight-Bearing CT (WBCT) in the foot provides different angles than measurement by hand. Foot Ankle Surg 2022; 28:919-927. [PMID: 35065853 DOI: 10.1016/j.fas.2022.01.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 12/28/2021] [Accepted: 01/06/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND The purpose of this study was to compare semi-automatic software-based angular measurement (SAM) with previously validated measurement by hand (MBH) regarding angle values and time spent for the investigator for Weight-Bearing CT (WBCT). METHODS In this retrospective comparative study, five-hundred bilateral WBCT scans (PedCAT, Curvebeam, Warrington, PA, USA) were included in the study. Five angles (1st - 2nd intermetatarsal angle (IM), talo-metatarsal 1-angle (TMT) dorsoplantar and lateral projection, hindfoot angle, calcaneal pitch angle) were measured with MBH and SAM (Bonelogic Ortho Foot and Ankle, Version 1.0.0-R, Disior Ltd, Helsinki, Finland) on the right/left foot/ankle. The angles and time spent of MBH and SAM were compared (t-test, homoscesdatic). RESULTS The angles differed between MBH and SAM (mean values MBH/SAM; IM, 9.1/13.0; TMT dorsoplantar, -3.4/8.2; TMT lateral. -6.4/-1.1; hindfoot angle, 4.6/21.6; calcaneal pitch angle, 20.5/20.1; each p < 0.001 except the calcaneal pitch angle, p = 0.35). The time spent for MBH / SAM was 44.5 ± 12 s / 12 ± 0 s on average per angle (p < 0.001). CONCLUSIONS SAM provided different angles as MBH (except calcaneal pitch angle) and can currently not be considered as validated angle measurement method (except calcaneal pitch angle). The investigator time spent is 73% lower for SAM (12 s per angle) than for MBH (44.5 s per angle). SAM might be an important step forward for 3D-angle measurement of WBCT when valid angles are provided.
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Affiliation(s)
- Martinus Richter
- Department for Foot and Ankle Surgery Rummelsberg and Nuremberg, Germany.
| | - Fabian Duerr
- Department for Foot and Ankle Surgery Rummelsberg and Nuremberg, Germany
| | - Regina Schilke
- Department for Foot and Ankle Surgery Rummelsberg and Nuremberg, Germany
| | - Stefan Zech
- Department for Foot and Ankle Surgery Rummelsberg and Nuremberg, Germany
| | | | - Issam Naef
- Department for Foot and Ankle Surgery Rummelsberg and Nuremberg, Germany
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Abstract
The standard for diagnostic radiographic imaging in foot and ankle surgery was until 2012 radiographs with full weight-bearing without any useful alternative. Weight-bearing cone-beam computed tomography (WBCT) was introduced 2012 for foot and ankle use as a new technology that allows 3D imaging with full weight-bearing which should be not influenced by projection and/or foot orientation. The assessment of ankle osteoarthritis with WBCT including the description of healthy status, effect of alignment and7or (in)stability is extensively illustrated in this review article.
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Angular and linear measurements of adult flexible flatfoot via weight-bearing CT scans and 3D bone reconstruction tools. Sci Rep 2021; 11:16139. [PMID: 34373546 PMCID: PMC8352889 DOI: 10.1038/s41598-021-95708-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 07/28/2021] [Indexed: 12/14/2022] Open
Abstract
Acquired adult flatfoot is a frequent deformity which implies multiple, complex and combined 3D modifications of the foot skeletal structure. The difficult thorough evaluation of the degree of severity pre-op and the corresponding assessment post-op can now be overcome by cone-beam (CBCT) technology, which can provide access to the 3D skeletal structure in weight-bearing. This study aims to report flatfoot deformities originally in 3D and in weight-bearing, with measurements taken using two different bone segmentation techniques. 21 such patients, with indication for surgical corrections, underwent CBCT (Carestream, US) while standing on one leg. From these scans, 3D models of each bone of the foot were reconstructed by using two different state-of-the-art segmentation tools: a semi-automatic (Mimics Innovation Suite, Materialise, Belgium), and an automatic (Bonelogic Ortho Foot and Ankle, Disior, Finland). From both reconstructed models, Principal Component Analysis was used to define anatomical reference frames, and original foot and ankle angles and other parameters were calculated mostly based on the longitudinal axis of the bones, in anatomical plane projections and in 3D. Both bone model reconstructions revealed a considerable valgus of the calcareous, plantarflexion and internal rotation of the talus, and typical Meary’s angles in the lateral and transverse plane projections. The mean difference from these angles between semi-automatic and automatic segmentations was larger than 3.5 degrees for only 3 of the 32 measurements, and a large number of these differences were not statistically significant. CBCT and the present techniques for bone shape reconstruction finally provide a novel and valuable 3D assessment of complex foot deformities in weight-bearing, eliminating previous limitations associated to unloaded feet and bidimensional measures. Corresponding measurements on the bone models from the two segmentation tools compared well. Other more representative measurements can be defined in the future using CBCT and these techniques.
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Weight-bearing CT in foot and ankle pathology. Orthop Traumatol Surg Res 2021; 107:102772. [PMID: 33321232 DOI: 10.1016/j.otsr.2020.102772] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 03/10/2020] [Accepted: 03/13/2020] [Indexed: 02/09/2023]
Abstract
Cone-beam scanners (CBCT) enable CT to be performed under weight-bearing - notably for the foot and ankle. The technology is not new: it has been used since 1996 in dental surgery, where it has come to replace panoramic X-ray. What is new is placing the scanner on the ground, so as to have 3D weight-bearing images, initially of the foot and ankle, and later for the knee and pelvis. This saves time, radiation and money. It is now increasingly used, but is unfortunately limited by not having specific national health insurance cover in France, and by the psychological reticence that goes with any technological breakthrough. A review of the topic is indispensable, as it is essential to become properly acquainted with this technique. To this end, we shall be addressing 5 questions. What biases does conventional radiography incur? Projecting a volume onto a plane incurs deformation, precluding true measurement. Conventional CT is therefore often associated with an increased dose of radiation. What is the impact of CBCT on radiation dose, costs and the care pathway? The conical beam turns around the limb (under weight-bearing if so desired) in less than a minute, making the radiation dose no greater than in standard X-ray. What does the literature have to say about CBCT, and what are the indications? CBCT is indicated in all foot and ankle pathologies, and indications now extend to the upper limb and the knee, and will soon include the pelvis. How are angles measured on this 3D technique? The recently developed concept of 3D biometry uses dedicated software to identify anatomic landmarks and automatically segment the bones, thereby enabling every kind of measurement. What further developments are to be expected? CBCT may become indispensable to lower-limb surgical planning. Artificial Intelligence will reveal novel diagnostic, prognostic and therapeutic solutions. LEVEL OF EVIDENCE: V; expert opinion.
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Godoy-Santos AL, Bernasconi A, Bordalo-Rodrigues M, Lintz F, Lôbo CFT, de Cesar Netto C. Weight-bearing cone-beam computed tomography in the foot and ankle specialty: where we are and where we are going - an update. Radiol Bras 2021; 54:177-184. [PMID: 34108765 PMCID: PMC8177673 DOI: 10.1590/0100-3984.2020.0048] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 07/17/2020] [Indexed: 12/24/2022] Open
Abstract
Cone-beam computed tomography (CBCT) has been applied in dentistry and medicine for nearly two decades. Its application in the foot and ankle specialty has grown exponentially in recent years. Weight-bearing CBCT allows clinicians to obtain weight-bearing images that can be viewed in all three planes and to construct three-dimensional models, similar to those constructed from traditional CT scans, as well as exposing patients to less radiation than do traditional CT scans. This technology has revolutionized diagnoses, improving the understanding of various lesions and surgical planning in the foot and ankle specialty. Ongoing studies of the use of weight-bearing CBCT in foot and ankle surgery are focused on fully automated and semi-automated three-dimensional measurements, as well as bone segmentation, mapping of the distances/orientation of the joints, and the production of customized implants. The aims of this review article are to show the evolution of this emerging tool in the foot and ankle specialty, to update those in related specialties on its use in current clinical practice, and to indicate where the research community is heading.
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Affiliation(s)
- Alexandre Leme Godoy-Santos
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP), São Paulo, SP, Brazil., Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.,Correspondence: Dr. Alexandre Leme Godoy-Santos. Laboratório Professor Manlio Mario Marco Napoli - HC-FMUSP. Rua Doutor Ovídio Pires de Campos, 333, Cerqueira César. São Paulo, SP, Brazil, 05403-010.
| | | | - Marcelo Bordalo-Rodrigues
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP), São Paulo, SP, Brazil
| | | | - Carlos Felipe Teixeira Lôbo
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP), São Paulo, SP, Brazil
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A cone beam CT based 3D-assessment of bony forefoot geometry after modified Lapidus arthrodesis. Foot Ankle Surg 2020; 26:883-889. [PMID: 31843521 DOI: 10.1016/j.fas.2019.11.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 10/26/2019] [Accepted: 11/17/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Modified Lapidus arthrodesis (MLA) is a well-established treatment modality for hallux valgus deformities (HVD) associated with instability of the first ray. Although the three-dimensional (3D) nature of HVD has long been recognized, diagnostics still focus on plain radiographs. The objective of this study was to validate 3D Cone Beam CT (CBCT) in the perioperative assessment of HVD with focus on the alignment of the forefoot. METHODS In a prospective clinical study, MLA was performed on 30 patients (25 females, 5 males; mean age: 63.2 years). Pre- and postoperatively standard radiographs and CBCT with full weight-bearing were acquired. For the CBCT based assessment, reproducible criteria have been defined, measured, and correlated with established radiological indicators. RESULTS Evaluation of standard radiographic parameters (hallux-valgus angle [HVA], intermetatarsal angle 1-2 [IMA 1-2], distal metatarsal articular angle [DMAA], tibial sesamoid position [TSP]) showed significant improvement postoperatively. Comparison of measurements obtained from plain radiographs and CBCT were significantly correlated between both measuring techniques, indicating high reliability. Pronation of the first metatarsal and the sesamoids were significantly reduced by the procedure. Due to this repositioning effect, the second metatarsal head was elevated by 3.1mm, and the lateral sesamoid was lowered by 3.8mm. However, there was no correlation between the amount of pronation and conventional radiographic measures. CONCLUSIONS Compared to plain radiographs, CBCT allows a more detailed view of the forefoot alignment in the coronal plain after MLA. MLA was able to recenter the sesamoids under der first metatarsal head and conversely led to elevation of the second metatarsal head.
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Richter M, Lintz F, de Cesar Netto C, Barg A, Burssens A. Results of more than 11,000 scans with weightbearing CT - Impact on costs, radiation exposure, and procedure time. Foot Ankle Surg 2020; 26:518-522. [PMID: 31239196 DOI: 10.1016/j.fas.2019.05.019] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 05/29/2019] [Accepted: 05/31/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Weightbearing CT (WBCT) has been proven to more precisely measure bone position than conventional weightbearing radiographic series (R) and conventional CT (CT). The purpose of this study was to assess the benefit of using WBCT instead of R and/or CT as the standard imaging modality, evaluating image acquisition time, radiation dose, and cost-effectiveness. METHODS All patients who obtained a WBCT as part of standard of care from July 1, 2013 until March 15, 2019 were included in the study. Image acquisition time (T), radiation dose (RD) per patient, and cost-effectiveness were analyzed and compared between the time period using WBCT (yearly average) and the parameters from 2012, i.e. before the availability of WBCT (RCT group). RESULTS 11,009 WBCT scans were obtained from 4987 patients (4,987 scans (45%) before treatment; 6,022 scans (55%) at follow-up). On a yearly average, 1,957 WBCTs (bilateral scans) and an additional 10.6 CTs (bilateral feet and ankles) were obtained (WBCT group). In 2012, 1,850 Rs (bilateral feet, dorsoplantar and lateral, metatarsal head skyline view) and 254 CTs were obtained from 885 patients (RCT group). The mean yearly RD was 4.3/4.8uSv for the WBCT/RCT groups (mean difference of .5uSv; a decrease of 10% for the WBCT group; p<.01). Yearly mean T was 114/493h in total (3.3/16.0min per patient) for WBCT/RCT groups (mean difference of 379h; a 77% decrease for the WBCT group; p<.01). Yearly cost-effectiveness was a mean profit of 43,959/-723 Euros for WBCT/RCT groups. CONCLUSIONS 11,009 WBCT scans from 4,987 patients over a period of 5.6 years at a foot and ankle department resulted in 10% decreased RD, 77% decreased T, and increased financial profit (51 Euros per patient) for the institution.
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Affiliation(s)
- Martinus Richter
- International Weight-Bearing CT Society, Gent, Belgium; Department for Foot and Ankle Surgery Rummelsberg and Nuremberg, Germany.
| | - Francois Lintz
- International Weight-Bearing CT Society, Gent, Belgium; Clinique de l'Union, Foot and Ankle Surgery Centre, Toulouse, France
| | - Cesar de Cesar Netto
- International Weight-Bearing CT Society, Gent, Belgium; Department of Orthopedics and Rehabilitation, Carver College of Medicine, University of Iowa, Iowa City, USA
| | - Alexej Barg
- International Weight-Bearing CT Society, Gent, Belgium; Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA
| | - Arne Burssens
- International Weight-Bearing CT Society, Gent, Belgium; Department of Orthopaedics and Traumatology, University Hospital of Ghent, Gent, Belgium
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Abstract
Hallux valgus (HV) represents a progressive 3-dimensional deformity that includes bone malalignment, hypermobility of the first ray, and imbalanced soft-tissue structures of the midfoot and forefoot. Conventional radiographs provide sectorized and limited information of the deformity in different planes. The literature evidence supporting the use of cone beam weightbearing computed tomography in the assessment of HV has been growing. It demonstrates important advances that include the ability to reliably perform traditional measurements such as HV angle and intermetatarsal angle in the 3-dimensional setting.
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12
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Three-dimensional kinematic change of hindfoot during full weightbearing in standing: an analysis using upright computed tomography and 3D-3D surface registration. J Orthop Surg Res 2019; 14:355. [PMID: 31711523 PMCID: PMC6849314 DOI: 10.1186/s13018-019-1443-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 10/31/2019] [Indexed: 02/06/2023] Open
Abstract
Background Weightbearing of the hindfoot affects positional changes of the ankle joint and subtalar joint (ankle-joint complex [AJC]). However, it is difficult to assess the kinematic changes in the hindfoot in a natural full weightbearing condition using conventional CT or cone beam computed tomography (CT) due to limitations of acquiring foot images under a physiological weightbearing condition using those imaging modalities. Analysis of AJC kinematics using fluoroscopy and 2D-3D registration technique requires data on the number of steps and amount of time to build and match the bones. This study aimed to analyze the effect of full weightbearing on hindfoot motion when standing using upright CT and 3D-3D surface registration. Methods Forty-eight AJCs of 24 asymptomatic volunteers (13 women, 11 men) were examined under no weightbearing, 50% weightbearing, and single leg full weightbearing conditions while standing. The CT images were acquired from the distal femur to the whole foot using a 320-row upright CT scanner. The condition of each weightbearing stance was measured using a pressure mat. Bone-to-bone rotations of the talus relative to the tibia and calcaneus relative to the talus were evaluated using the surface registration technique. Image quality of the CT and intra- and interobserver reliabilities of the rotation angle were also evaluated. Results All CT images were excellent or good quality and the intra- and interobserver correlation coefficients for the angle were 0.996 and 0.995, respectively. The motion of the ankle joint and subtalar joint under 50% and 100% weightbearing were as follows (in degrees); the talus plantarflexed (5.1 ± 4.5 and 6.8 ± 4.8), inverted (1.3 ± 1.4 and 2.0 ± 1.6), and internally rotated (2.4 ± 4.2 and 4.3 ± 4.6) relative to the tibia, and the calcaneus dorsiflexed (2.8 ± 1.4 and 3.8 ± 1.7), everted (5.3 ± 2.6 and 8.0 ± 3.6), and externally rotated (3.0 ± 2.0 and 4.1 ± 2.4) relative to the talus, respectively. Conclusions The effect of weightbearing was clearly identified using an upright CT and the 3D-3D registration technique. Three-dimensional kinematics under static full weightbearing were opposite between the ankle and subtalar joints on their respective axes.
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Brehler M, Islam A, Vogelsang L, Yang D, Sehnert W, Shakoor D, Demehri S, Siewerdsen JH, Zbijewski W. Coupled Active Shape Models for Automated Segmentation and Landmark Localization in High-Resolution CT of the Foot and Ankle. PROCEEDINGS OF SPIE--THE INTERNATIONAL SOCIETY FOR OPTICAL ENGINEERING 2019; 10953. [PMID: 31337927 DOI: 10.1117/12.2515022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Purpose We develop an Active Shape Model (ASM) framework for automated bone segmentation and anatomical landmark localization in weight-bearing Cone-Beam CT (CBCT). To achieve a robust shape model fit in narrow joint spaces of the foot (0.5 - 1 mm), a new approach for incorporating proximity constraints in ASM (coupled ASM, cASM) is proposed. Methods In cASM, shape models of multiple adjacent foot bones are jointly fit to the CBCT volume. This coupling enables checking for proximity between the evolving shapes to avoid situations where a conventional single-bone ASM might erroneously fit to articular surfaces of neighbouring bones. We used 21 extremity CBCT scans of the weight-bearing foot to compare segmentation and landmark localization accuracy of ASM and cASM in leave-one-out validation. Each scan was used as a test image once; shape models of calcaneus, talus, navicular, and cuboid were built from manual surface segmentations of the remaining 20 scans. The models were augmented with seven anatomical landmarks used for common measurements of foot alignment. The landmarks were identified in the original CBCT volumes and mapped onto mean bone shape surfaces. ASM and cASM were run for 100 iterations, and the number of principal shape components was increased every 10 iterations. Automated landmark localization was achieved by applying known point correspondences between landmark vertices on the mean shape and vertices of the final active shape segmentation of the test image. Results Root Mean Squared (RMS) error of bone surface segmentation improved from 3.6 mm with conventional ASM to 2.7 mm with cASM. Furthermore, cASM achieved convergence (no change in RMS error with iteration) after ~40 iterations of shape fitting, compared to ~60 iterations for ASM. Distance error in landmark localization was 25% to 55% lower (depending on the landmark) with cASM than with ASM. The importance of using a coupled model is underscored by the finding that cASM detected and corrected collisions between evolving shapes in 50% to 80% (depending on the bone) of shape model fits. Conclusion The proposed cASM framework improves accuracy of shape model fits, especially in complexes of tightly interlocking, articulated joints. The approach enables automated anatomical analysis in volumetric imaging of the foot and ankle, where narrow joint spaces challenge conventional shape models.
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Affiliation(s)
- M Brehler
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD USA
| | - A Islam
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD USA
| | | | - D Yang
- Carestream Health, Rochester, NY USA
| | - W Sehnert
- Carestream Health, Rochester, NY USA
| | - D Shakoor
- Department of Radiology, Johns Hopkins University, Baltimore, MD USA
| | - S Demehri
- Department of Radiology, Johns Hopkins University, Baltimore, MD USA
| | - J H Siewerdsen
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD USA.,Department of Radiology, Johns Hopkins University, Baltimore, MD USA
| | - W Zbijewski
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD USA
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Kang DH, Kang C, Hwang DS, Song JH, Song SH. The value of axial loading three dimensional (3D) CT as a substitute for full weightbearing (standing) 3D CT: Comparison of reproducibility according to degree of load. Foot Ankle Surg 2019; 25:215-220. [PMID: 29409280 DOI: 10.1016/j.fas.2017.10.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 10/23/2017] [Accepted: 10/25/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Full weightbearing (WB) three dimensional computed tomography (3D CT) is an excellent imaging tool. However, due to its high cost, it is only used in a few hospitals. We evaluated the usefulness and cost-effectiveness of axial loading (AL) 3D CT by comparing bony alignments with standing radiographs, and assessed reproducibility according to the degree of AL. METHODS Eighty patients (156 feet), who underwent standing radiographs and 3D CT with an AL device from January 2016 to May 2017, were investigated. According to the degree of AL (AL force×100/body weight), the patients were randomly assigned to three groups: Group A (30-50%; n=21, 40 feet), Group B (50-70%; n=32, 63 feet), and Group C (70-100%; n=27, 53 feet). The following angles were measured three times by two orthopedists: hallux valgus (HVA), 1st-2nd intermetatarsal (IMA1-2), and talo-navicular coverage (TNCA), calcaneal pitch (CPA), talo-1st metatarsal (T1MA), and talo-calcaneal angle (TCA). Agreements between the two imaging methods were analyzed and compared according to the degree of axial loading in each group. RESULTS Intra- and interobserver reliability was excellent (>0.75). In Group A (30-50% AL), all of the angles except HVA and IMA1-2 differed (p<.05). In Group B (50-70%), TNCA (p=.023), T1MA (p=.017), and TCA (p=.035) differed. In Group C (70-100%), none of the angles differed between the two imaging methods (p>.05). Higher agreement between the two imaging methods was realized when 70% or more(>70%) AL was applied. CONCLUSIONS AL 3D CT with >70% axial load has full WB effects and can be substituted for expensive full WB 3D CT.
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Affiliation(s)
- Dong Hun Kang
- Department of Orthopedic Surgery, Chungnam National University School of Medicine, Daejeon, Republic of Korea
| | - Chan Kang
- Department of Orthopedic Surgery, Chungnam National University School of Medicine, Daejeon, Republic of Korea.
| | - Deuk Soo Hwang
- Department of Orthopedic Surgery, Chungnam National University School of Medicine, Daejeon, Republic of Korea
| | - Jae Hwang Song
- Department of Orthopedic Surgery, Chungnam National University School of Medicine, Daejeon, Republic of Korea
| | - Seok Hwan Song
- Department of Orthopedic Surgery, Chungnam National University School of Medicine, Daejeon, Republic of Korea
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Abstract
The 3D anatomical complexity of the foot and ankle and the importance of weight-bearing in diagnosis have required the combination of conventional radiographs and medical CT. Conventional plain radiographs (XR) have demonstrated substantial limitations such as perspective, rotational and fan distortion, as well as poor reproducibility of radiographic installations. Conventional CT produces high levels of radiation exposure and does not offer weight-bearing capabilities. The literature investigating biometrics based on 2D XR has inherent limitations due to the technology itself and thereby can focus only on whether measurements are reproducible, when the real question is whether the radiographs are. Low dose weight-bearing cone beam CT (WBCT) combines 3D and weight-bearing as well as ‘built in’ reliability validated through industry-standardized processes during production and clinical use (quality assurance testing). Research is accumulating to validate measurements based on traditional 2D techniques, and new 3D biometrics are being described and tested. Time- and cost-efficient use in medical imaging will require the use of automatic measurements. Merging WBCT and clinical data will offer new perspectives in terms of research with the help of modern data analysis techniques.
Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170066
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Affiliation(s)
- François Lintz
- Centre de Chirurgie de la Cheville et du Pied, Clinique de l'Union, France
| | - Cesar de Cesar Netto
- Foot and Ankle Surgery Department, Hospital for Special Surgery, New York City, USA
| | - Alexeij Barg
- Foot and Ankle Surgery Department, University of Utah, USA
| | - Arne Burssens
- Foot and Ankle Surgery Department, University of Ghent, Belgium
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Richter M, Lintz F, Zech S, Meissner SA. Combination of PedCAT Weightbearing CT With Pedography Assessment of the Relationship Between Anatomy-Based Foot Center and Force/Pressure-Based Center of Gravity. Foot Ankle Int 2018; 39:361-368. [PMID: 29251513 DOI: 10.1177/1071100717744206] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND A customized pedography sensor (Pliance; Novel, Munich, Germany) was inserted into a pedCAT (Curvebeam, Warrington, PA). The aim of this study was to analyze the relative position of the anatomical foot center (FC) and the pedographic center of gravity (COG). The hypothesis was that FC should be a good predictor of mediolateral position of COG but not longitudinal since hindfoot anatomy allows free anteroposterior movement but limited mediolateral movement. METHODS In 90 patients (180 feet), a pedCAT scan with simultaneous pedography with full weightbearing in a standing position was performed. The morphology-based definition of the FC was performed with the pedCAT data following the Torque Ankle Lever Arm System (TALAS) algorithm. The force/pressure-based COG was defined with the pedography data using a software-based algorithm. The distance between FC and COG and the direction of a potential shift (distal-proximal, mediolateral) was measured and analyzed. COG motion during data acquisition was recorded and analyzed. Mean age of patients was 53.8 (range, 17-84) years, and 57 (63%) were female. RESULTS The distance between FC and COG was 28.7 mm on average (range, 0-60). FC was distal to COG in 175 feet (97%; mean, 27.5 mm; range, -15 to 60) and lateral in 112 feet (62%; mean, 2.0 mm; range, -18 to 20). CONCLUSIONS There was a constant and major distal longitudinal shift of COG relative to FC and an inconstant minor mediolateral shift. CLINICAL RELEVANCE The data might be taken into consideration for planning and follow-up in foot and ankle surgery.
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Affiliation(s)
- Martinus Richter
- 1 Department for Foot and Ankle Surgery Rummelsberg and Nuremberg, Germany
| | - Francois Lintz
- 2 Clinique de l'Union, Foot and Ankle Surgery Centre, Toulouse, France
| | - Stefan Zech
- 1 Department for Foot and Ankle Surgery Rummelsberg and Nuremberg, Germany
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