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Hodel S, Arn-Roth T, Haug F, Carillo F, Vlachopoulos L, Fucentese SF, Fürnstahl P. The influence of the weight-bearing state on three-dimensional (3D) planning in lower extremity realignment - analysis of novel vs. state-of-the-art planning approaches. Arch Orthop Trauma Surg 2024; 144:1989-1996. [PMID: 38554205 PMCID: PMC11093806 DOI: 10.1007/s00402-024-05289-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 03/17/2024] [Indexed: 04/01/2024]
Abstract
BACKGROUND The use of 3D planning to guide corrective osteotomies of the lower extremity is increasing in clinical practice. The use of computer-tomography (CT) data acquired in supine position neglects the weight-bearing (WB) state and the gold standard in 3D planning involves the manual adaption of the surgical plan after considering the WB state in long-leg radiographs (LLR). However, this process is subjective and dependent on the surgeons experience. A more standardized and automated method could reduce variability and decrease costs. PURPOSE The aim of the study was (1) to compare three different three-dimensional (3D) planning modalities for medial open-wedge high tibial osteotomy (MOWHTO) and (2) to describe the current practice of adapting NWB CT data after considering the WB state in LLR. The purpose of this study is to validate a new, standardized approach to include the WB state into the 3D planning and to compare this method against the current gold standard of 3D planning. Our hypothesis is that the correction is comparable to the gold standard, but shows less variability due compared to the more subjective hybrid approach. METHODS Three surgical planning modalities were retrospectively analyzed in 43 legs scheduled for MOWHTO between 2015 and 2019. The planning modalities included: (1) 3D hybrid (3D non-weight-bearing (NWB) CT models after manual adaption of the opening angle considering the WB state in LLR, (2) 3D NWB (3D NWB CT models) and (3) 3D WB (2D/3D registration of 3D NWB CT models onto LLR to simulate the WB state). The pre- and postoperative hip-knee-ankle angle (HKA) and the planned opening angle (°) were assessed and differences among modalities reported. The relationship between the reported differences and BMI, preoperative HKA (LLR), medial meniscus extrusion, Outerbridge osteoarthritis grade and joint line convergence angle (JLCA) was analyzed. RESULTS The mean (std) planned opening angle of 3D hybrid did not differ between 3D hybrid and 3D WB (0.4 ± 2.1°) (n.s.) but was higher in 3D hybrid compared to 3D NWB (1.1° ± 1.1°) (p = 0.039). 3D WB demonstrated increased preoperative varus deformity compared to 3D NWB: 6.7 ± 3.8° vs. 5.6 ± 2.7° (p = 0.029). Patients with an increased varus deformity in 3D WB compared to 3D NWB (> 2 °) demonstrated more extensive varus alignment in LLR (p = 0.009) and a higher JLCA (p = 0.013). CONCLUSION Small intermodal differences between the current practice of the reported 3D hybrid planning modality and a 3D WB approach using a 2D/3D registration algorithm were reported. In contrast, neglecting the WB state underestimates preoperative varus deformity and results in a smaller planned opening angle. This leads to potential under correction in MOWHTO, especially in patients with extensive varus deformities or JLCA. CLINICAL RELEVANCE Incorporating the WB state in 3D planning modalities has the potential to increase accuracy and lead to a more consistent and reliable planning in MOWHTO. The inclusion of the WB state in automatized surgical planning algorithms has the potential to reduce costs and time in the future.
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Affiliation(s)
- Sandro Hodel
- Balgrist University Hospital, Department of Orthopedics, University of Zurich, Forchstrasse 340, Zurich, 8008, Switzerland.
| | - Tabitha Arn-Roth
- Balgrist University Hospital, Research in Orthopaedics Computer Science, University of Zurich, Balgrist Forchstrasse 340, Zurich, 8008, Switzerland
| | - Florian Haug
- Balgrist University Hospital, Department of Orthopedics, University of Zurich, Forchstrasse 340, Zurich, 8008, Switzerland
| | - Fabio Carillo
- Balgrist University Hospital, Research in Orthopaedics Computer Science, University of Zurich, Balgrist Forchstrasse 340, Zurich, 8008, Switzerland
| | - Lazaros Vlachopoulos
- Balgrist University Hospital, Department of Orthopedics, University of Zurich, Forchstrasse 340, Zurich, 8008, Switzerland
| | - Sandro F Fucentese
- Balgrist University Hospital, Department of Orthopedics, University of Zurich, Forchstrasse 340, Zurich, 8008, Switzerland
| | - Philipp Fürnstahl
- Balgrist University Hospital, Research in Orthopaedics Computer Science, University of Zurich, Balgrist Forchstrasse 340, Zurich, 8008, Switzerland
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Won SH, Eim SH, Shen QH, Kim KK, Won YY. Caliper-verified unrestricted kinematically aligned total knee arthroplasty in Asian patients showed efficacious mid- to long-term results regardless of postoperative alignment categories. Knee Surg Sports Traumatol Arthrosc 2024; 32:941-952. [PMID: 38461403 DOI: 10.1002/ksa.12117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 02/10/2024] [Accepted: 02/15/2024] [Indexed: 03/11/2024]
Abstract
PURPOSE There have been insufficient data regarding the long-term results of unrestricted kinematically aligned total knee arthroplasty (unKATKA) in Asian patients. We investigated mid- to long-term clinical and radiological follow-up data of Korean patients after caliper-verified unKATKA of minimum 7.4-10 years including categorised data of postoperative tibial component, limb and knee alignment. Additionally, we analysed the preoperative distribution and postoperative restoration of coronal plane alignment of knee (CPAK) phenotypes. METHODS This study is a retrospective analysis of 63 patients: 96 osteoarthritic underwent consecutive caliper-verified unKATKA between October 2013 and May 2016 by a single surgeon. Implant survivorship was investigated for revision for any reason. Each knee was categorised into an in-range or outlier group by three postoperative alignment parameters: tibial component, knee and limb alignment. Statistical analyses were done for any significant differences in clinical scores and implant survival rates between groups. Finally, all knees were classified into CPAK classification postoperatively and postoperatively. The CPAK restoration rate was calculated. RESULTS Among 85 knees in the clinically confirmed group, implant survival was 98.8%. There was one case of revision due to periprosthetic fracture. The percentage postoperatively aligned in the varus (valgus) outlier range was 100% (0%) for tibial component, 16.7% (24.8%) for the knee alignment and 51% (0%) for the limb alignment. All three categories did not affect implant survival or clinical scores. Eighty one out of 96 knees (84.4%) were restored to their CPAK phenotype postoperatively. CONCLUSION With the limitation of a case series having a small number of patients and gender deviation, our study suggests that caliper-verified unKATKA could be a good option regardless of geographical variation of constitutional alignment in patients with osteoarthritis (OA). LEVEL OF EVIDENCE Level IV, therapeutic study.
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Affiliation(s)
- Seok-Hyung Won
- Department of Orthopedic Surgery, Ajou University Medical Center, Suwon, South Korea
| | - Seong-Hyuk Eim
- Department of Orthopedic Surgery, Ajou University Medical Center, Suwon, South Korea
| | - Quan-Hu Shen
- Department of Orthopedic Surgery, The Affiliated Suqian First People's Hospital of Nanjing Medical University, Suqian, China
| | - Kwang-Kyoun Kim
- Department of Orthopedic Surgery, Konyang University Hospital, Daejeon, South Korea
| | - Ye-Yeon Won
- Department of Orthopedic Surgery, Ajou University Medical Center, Suwon, South Korea
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Tarassoli P, Warnock JM, Lim YP, Jagota I, Parker D. Large multiplanar changes to native alignment have no apparent impact on clinical outcomes following total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2024; 32:432-444. [PMID: 38294963 DOI: 10.1002/ksa.12044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 12/12/2023] [Accepted: 12/13/2023] [Indexed: 02/02/2024]
Abstract
PURPOSE This study sought to examine if achieved postoperative alignment when compared to the native anatomy would lead to a difference in Patient Reported Outcome Measures (PROMs), and whether the achieved alignment could be broadly categorised by an accepted alignment strategy. METHODS A retrospective cohort study of prospectively collected data on patients undergoing single primary or bilateral simultaneous total knee arthroplasty (TKA) was carried out. CT scans were used to determine the mean change ("delta values") between the pre and postoperative; hip-knee-ankle angle, lateral distal femoral angle, medial proximal tibial angle and femoral implant rotation. Femoral implant flexion and tibial implant slope were measured postoperatively. The primary outcome was the relationship of the variables to the change in KOOS pain subscale after one year. The secondary outcome was the number of knees which could be categorised postoperatively to an alignment strategy, and the mean PROMs in each cohort. RESULTS A total of 296 knees in 261 patients were available for analysis. With regards to the primary outcome, the delta values for each variable did not demonstrate any association with the change in knee injury and osteoarthritis outcome score (KOOS) pain score. Approximately 46% of knees could not be categorised to an alignment strategy based on postoperatively measured alignment, with no significant difference between each cohort with regards to the change in KOOS Pain score. CONCLUSION Achieved alignment does not consistently match accepted alignment strategies, and appears to confer no benefit to clinical outcomes when the native anatomy is most closely approximated, nor results in poorer outcomes in outliers. This study highlights the importance of routine three dimensional pre and postoperative imaging in clinical practice and for the valid analysis of outcomes in studies on alignment. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Payam Tarassoli
- Sydney Orthopaedic Research Institute, St Leonards, Australia
| | | | - Yoong Ping Lim
- Sydney Orthopaedic Research Institute, St Leonards, Australia
- The University of Sydney, Camperdown, Australia
- Charles Darwin University, Casuarina, Australia
| | - Ishaan Jagota
- 360 Med Care Pty Ltd, Pymble, Australia
- Flinders University, Adelaide, Australia
| | - David Parker
- Sydney Orthopaedic Research Institute, St Leonards, Australia
- The University of Sydney, Camperdown, Australia
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Pflüger P, Hodel S, Zimmermann SM, Knechtle S, Vlachopoulos L, Fucentese SF. The coronal alignment differs between two-dimensional weight-bearing and three-dimensional nonweight bearing planning in total knee arthroplasty. J Exp Orthop 2024; 11:e12007. [PMID: 38455454 PMCID: PMC10885761 DOI: 10.1002/jeo2.12007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 01/17/2024] [Indexed: 03/09/2024] Open
Abstract
Purpose The goal of this study is (1) to assess differences between two-dimensional (2D) weight-bearing (WB) and three-dimensional (3D) nonweight-bearing (NWB) planning in total knee arthroplasty (TKA) and (2) to identify factors that influence intermodal differences. Methods Retrospective single-centre analysis of patients planned for a TKA with patient-specific instruments (PSI). Preoperative WB long-leg radiographs and NWB computed tomography were analysed and following radiographic parameters included: hip-knee-ankle angle (HKA) (+varus/-valgus), joint line convergence angle (JLCA), femorotibial subluxation and bony defect classified according to Anderson. Preoperative range of motion was also considered as possible covariate. Demographic factors included age, sex, and body mass index. Results A total of 352 knees of 323 patients (66% females) with a mean age of 66 ± 9.7 years were analysed. The HKA differed significantly between 2D and 3D planning modalities; varus knees (n = 231): 9.9° ± 5.1° vs. 6.7° ± 4°, p < 0.001; valgus knees (n = 121): -8.2° ± 6° vs. -5.5° ± 4.4°, p < 0.001. In varus knees, HKA (β = 0.38; p < 0.0001) and JLCA (β = 0.14; p = 0.03) were associated with increasing difference between 2D/3D HKA. For valgus knees, HKA (β = -0.6; p < 0.0001), JLCA (β = -0.3; p = 0.0001) and lateral distal femoral angle (β = -0.28; p = 0.03) showed a significant influence on the mean absolute difference. Conclusion The coronal alignment in preoperative 3D model for PSI-TKA significantly differed from 2D WB state and the difference between modalities correlated with the extent of varus/valgus deformity. In the vast majority of cases, the 3D NWB approach significantly underestimated the preoperative deformity, which needs to be considered to achieve the planned correction when using PSI in TKA. Level of Evidence Level III.
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Affiliation(s)
- Patrick Pflüger
- Department of Orthopedics, Balgrist University HospitalUniversity of ZurichZurichSwitzerland
| | - Sandro Hodel
- Department of Orthopedics, Balgrist University HospitalUniversity of ZurichZurichSwitzerland
| | - Stefan M. Zimmermann
- Department of Orthopedics, Balgrist University HospitalUniversity of ZurichZurichSwitzerland
| | - Svenja Knechtle
- Department of Orthopedics, Balgrist University HospitalUniversity of ZurichZurichSwitzerland
| | - Lazaros Vlachopoulos
- Department of Orthopedics, Balgrist University HospitalUniversity of ZurichZurichSwitzerland
| | - Sandro F. Fucentese
- Department of Orthopedics, Balgrist University HospitalUniversity of ZurichZurichSwitzerland
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Tarassoli P, Corban LE, Wood JA, Sergis A, Chen DB, MacDessi SJ. Long leg radiographs underestimate the degree of constitutional varus limb alignment and joint line obliquity in comparison with computed tomography: a radiographic study. Knee Surg Sports Traumatol Arthrosc 2023; 31:4755-4765. [PMID: 37490128 DOI: 10.1007/s00167-023-07505-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 07/05/2023] [Indexed: 07/26/2023]
Abstract
PURPOSE The purpose of this study was to understand if differences exist between computed tomography (CT) and long leg radiographs (LLR) when defining coronal plane alignment of the lower limb in total knee arthroplasty (TKA). It aimed to identify any such differences between the two imaging modalities by quantifying constitutional limb alignment (arithmetic hip-knee-ankle angle (aHKA), joint line obliquity (JLO) and Coronal Plane Alignment of the Knee (CPAK) type within the same population. METHODS A retrospective radiographic study compared pre-operative LLR and CT measurements in patients undergoing robotic-assisted TKA. The aHKA, JLO and CPAK types were calculated after measuring the medial proximal tibial angle (MPTA) and lateral distal femoral angle (LDFA). The primary outcomes were the mean differences in aHKA (MPTA-LDFA), JLO (MPTA + LDFA) and proportions of CPAK types between LLR and CT groups. The secondary outcomes were the differences in CT-derived MPTA values based on four different tibial sagittal landmarks. RESULTS After exclusions, 465 imaging sets were analysed in 394 patients. There was a statistically significant mean difference between LLR and CT, respectively, for both MPTA (87.5° vs. 86.2°; p < 0.01) and LDFA (88.7° vs. 87.3°; p < 0.01). There were also statistically significant differences for aHKA (- 0.2° vs. - 1.1°) and JLO (175.1° vs. 173.4°) for LLR and CT, respectively (both p < 0.01). CT increased the proportion of patients with CPAK Type I (constitutional varus aHKA, apex distal JLO) and CPAK Type II (neutral aHKA, apex distal JLO), and decreased numbers of CPAK Types III-VI. There were significant mean differences in the MPTA using varying sagittal landmarks. CONCLUSION Alignment determined by LLRs underestimates the magnitude of both constitutional varus alignment and joint line obliquity compared to CT, differences that notably increase the proportions of patients included in CPAK Types I and II. These distinctions are primarily due to underestimation of proximal tibial varus when measured on LLRs compared to CT, which more specifically defines articular weight-bearing points. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Payam Tarassoli
- Sydney Knee Specialists, Suite 201, Level 2, 131 Princes Hwy, Kogarah, NSW, 2217, Australia
| | - Luke E Corban
- Sydney Knee Specialists, Suite 201, Level 2, 131 Princes Hwy, Kogarah, NSW, 2217, Australia
| | - Jil A Wood
- Sydney Knee Specialists, Suite 201, Level 2, 131 Princes Hwy, Kogarah, NSW, 2217, Australia
| | - Andrew Sergis
- Stryker Australia, 8 Herbert St, St Leonards, NSW, 2065, Australia
| | - Darren B Chen
- Sydney Knee Specialists, Suite 201, Level 2, 131 Princes Hwy, Kogarah, NSW, 2217, Australia
- St George Private Hospital, 1 South St, Kogarah, NSW, 2217, Australia
| | - Samuel J MacDessi
- Sydney Knee Specialists, Suite 201, Level 2, 131 Princes Hwy, Kogarah, NSW, 2217, Australia.
- St George Private Hospital, 1 South St, Kogarah, NSW, 2217, Australia.
- School of Clinical Medicine, University of New South Wales, St George and Sutherland Campuses, Sydney, NSW, Australia.
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Walker EA, Fox MG, Blankenbaker DG, French CN, Frick MA, Hanna TN, Jawetz ST, Onks C, Said N, Stensby JD, Beaman FD. ACR Appropriateness Criteria® Imaging After Total Knee Arthroplasty: 2023 Update. J Am Coll Radiol 2023; 20:S433-S454. [PMID: 38040463 DOI: 10.1016/j.jacr.2023.08.014] [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: 08/15/2023] [Accepted: 08/22/2023] [Indexed: 12/03/2023]
Abstract
Total knee arthroplasty is the most commonly performed joint replacement procedure in the United States. This manuscript will discuss the recommended imaging modalities for six clinical variants; 1. follow-up of symptomatic or asymptomatic patients with a total knee arthroplasty. Initial imaging, 2. Suspected infection after total knee arthroplasty. Additional imaging following radiographs, 3. Pain after total knee arthroplasty. Infection excluded. Suspect aseptic loosening or osteolysis or instability. Additional imaging following radiographs, 4. Pain after total knee arthroplasty. Suspect periprosthetic or hardware fracture. Additional imaging following radiographs, 5. Pain after total knee arthroplasty. Measuring component rotation. Additional imaging following radiographs, and 6. Pain after total knee arthroplasty. Suspect periprosthetic soft-tissue abnormality unrelated to infection, including quadriceps or patellar tendinopathy. Additional imaging following radiographs. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
- Eric A Walker
- Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania; Uniformed Services University of the Health Sciences, Bethesda, Maryland.
| | | | - Donna G Blankenbaker
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Cristy N French
- Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | | | - Tarek N Hanna
- Emory University, Atlanta, Georgia; Committee on Emergency Radiology-GSER
| | | | - Cayce Onks
- Penn State Health, Hershey, Pennsylvania, Primary care physician
| | - Nicholas Said
- Duke University Medical Center, Durham, North Carolina
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Aunan E, Alhaug E, Schuller SG, Rundfloen JE. 3-dimensional computer tomography is more accurate than traditional long-leg radiographs in the planning and evaluation of coronal alignment in total knee arthroplasty: a prospective study on 121 knees. Acta Orthop 2023; 94:530-536. [PMID: 37882334 PMCID: PMC10601491 DOI: 10.2340/17453674.2023.19695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 08/23/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND AND PURPOSE Accurate measuring tools are essential in preoperative planning and for the study of the association between postoperative alignment and clinical outcome in total knee arthroplasty (TKA). We aimed to describe a simple method to measure preoperative hip-knee-femoral shaft (HKFS) angle and postoperative coronal alignment in TKA with the use of standard 3D CT and to compare preoperative HKFS angles and postoperative coronal alignment measured with the 3D CT technique and with standing long-leg hip-knee-ankle (HKA) radiographs. PATIENTS AND METHODS HKA radiographs and 3D CT were taken preoperatively and 3 months after the operation in 121 knees. The interrater reliability for the 3D CT method was calculated with intra-class correlation coefficient (ICC). The preoperative HKFS angles and the postoperative deformity measured with the 2 methods were compared and illustrated on Bland-Altman plots, frequency tables, and by Cohen's kappa coefficients (k). RESULTS The 3D CT method was feasible in all knees and the ICC was excellent. Mean (SD, range) difference in HKFS angle measured on HKA radiographs and on 3D CT was -0.3° (0.9°, -4.1° to 2.4°). Mean (SD, range) difference in postoperative deformity was 0.1° (1.6°, -5° to 6°). The 95% limits of agreement were 1.4° and -2° for HKFS and ±3° for postoperative alignment. The agreement in outlier (≥ 3°) identification was moderate with a k (95% confidence interval) of 0.48 (0.32-0.64). CONCLUSION 3-dimensional computer tomography was feasible and was shown to be more accurate than traditional long-leg radiographs.
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Affiliation(s)
- Eirik Aunan
- Department of Orthopaedic Surgery, Sykehuset Innlandet Hospital Trust, Lillehammer.
| | - Eivind Alhaug
- Department of Radiology, Sykehuset Innlandet Hospital Trust, Lillehammer, Norway
| | - Siri G Schuller
- Department of Radiology, Sykehuset Innlandet Hospital Trust, Lillehammer, Norway
| | - Jan E Rundfloen
- Department of Radiology, Sykehuset Innlandet Hospital Trust, Lillehammer, Norway
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Colyn W, Vanbecelaere L, Bruckers L, Scheys L, Bellemans J. The effect of weight-bearing positions on coronal lower limb alignment: A systematic review. Knee 2023; 43:51-61. [PMID: 37271072 DOI: 10.1016/j.knee.2023.05.004] [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: 06/25/2022] [Revised: 03/30/2023] [Accepted: 05/06/2023] [Indexed: 06/06/2023]
Abstract
BACKGROUND The coronal alignment of the lower limb is generally accepted as a major determinant of surgical outcome in total knee arthroplasty (TKA). To achieve the ideal post-operative alignment, surgeons need to be aware of the influence that weight-bearing positions have on the final knee alignment. Therefore, this review aims to define the effect of varying weight-bearing positions on the coronal alignment of the lower limb. We hypothesized that a coronal alignment deformity increases with loading. METHODS The PubMed, Medline and google scholar databases were searched systematically in June 2022. Only studies which compared coronal alignment with a standardized radiographic protocol in the single leg, double leg and supine positions were included. To obtain pooled estimates of the effect of different weight-bearing positions, random-effect analysis were fitted using SAS. RESULTS Compared to the supine position, double leg weight-bearing positions were found to be associated with a more pronounced varus deformity (mean difference in HKA is 1,76° (95% CI 1,32: 2,21), p < 0.0001)). The mean difference in HKA between double leg and single leg weight-bearing conditions was 1.43° (95% CI (-0,042;2,90), p = 0.0528). CONCLUSION The overall knee alignment was found to be influenced by the weight-bearing position. An average difference of 1.76° in HKA-angle was found between a double leg-stance and supine position, tending to increased varus in the former weight-bearing position. It is therefore possible that the deformity could increase by 1.76° if knee surgeons only follow a pre-op planning based on double-leg stance full length radiographs.
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Affiliation(s)
- William Colyn
- Dept. of Orthopedic Surgery, AZ Turnhout, Turnhout, Belgium; UHasselt, Faculty of Medicine and Life Sciences, Diepenbeek, Belgium; Ziekenhuis Oost-Limburg, Dept. Future Health, Genk, Belgium.
| | - Lukas Vanbecelaere
- Dept. of Orthopedic Surgery, University Hospitals Leuven, Leuven, Belgium
| | | | - Lennart Scheys
- Dept. of Orthopedic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Johan Bellemans
- UHasselt, Faculty of Medicine and Life Sciences, Diepenbeek, Belgium; Dept. of Orthopedic Surgery, ZOL Genk, Genk, Belgium; GRIT Belgian Sports Clinic, Leuven, Belgium
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Corbett J, Tai J, Salmon L, Roe J. Comparison of CT and EOS in assessing coronal lower limb alignment when planning total knee arthroplasty. Knee 2023; 42:400-408. [PMID: 37182443 DOI: 10.1016/j.knee.2023.04.010] [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: 02/08/2023] [Revised: 03/22/2023] [Accepted: 04/11/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND As surgical technologies and alignment strategies develop, accuracy of lower limb alignment assessment gains increasing importance. The current gold standard remains long leg (4ft) radiographs. Other measures include computed tomography (CT) and EOS scans. This study aimed to compare CT and EOS long leg views to determine the reliability of assessment of hip-knee-angle (HKA) in arthritic knees. MATERIALS AND METHODS A retrospective study of 96 knees in patients undergoing total knee arthroplasty (TKA) was performed comparing HKA alignment data from EOS and CT. Coronal HKA and sagittal flexion angle were assessed by two independent observers. Inter-observer correlation was calculated. RESULTS The coronal alignment on EOS was strongly positively correlated to coronal alignment on CT (r = 0.927, p = 0.001). 12 knees (13 %) exceeded CT vs EOS difference of 3°. Inter-rater reliability was excellent (intra-class coefficients >0.9). The mean difference between CT and EOS was significantly greater for patients with fixed flexion >10° (0.68) vs <10° (-0.2) p = 0.004. Mean difference in HKA did not differ between those 0-10° varus and >10° varus (p = 0.273). Valgus HKA had a higher mean difference (1.9°) compared to varus knees (-0.4°) (p = 0.001). CONCLUSION CT and EOS showed excellent inter-rater reliability and correlated well. Increased sagittal plane deformity does effect coronal HKA assessment. Extreme varus did not affect the mean difference significantly, while valgus did. For the majority of patients either CT or EOS will give a reliable assessment of HKA but beware those with significant valgus or sagittal deformity where both modalities may be necessary to plan TKA.
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Affiliation(s)
- James Corbett
- North Sydney Orthopaedic Research Group, Australia; North Sydney Orthopaedic & Sports Medicine Centre, Australia
| | - Jeffrey Tai
- North Sydney Orthopaedic Research Group, Australia; School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney, Australia
| | - Lucy Salmon
- North Sydney Orthopaedic Research Group, Australia; North Sydney Orthopaedic & Sports Medicine Centre, Australia; School of Medicine, University of Notre Dame, Sydney, Australia
| | - Justin Roe
- North Sydney Orthopaedic Research Group, Australia; North Sydney Orthopaedic & Sports Medicine Centre, Australia; School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney, Australia.
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León-Muñoz VJ, Moya-Angeler J, López-López M, Lisón-Almagro AJ, Martínez-Martínez F, Santonja-Medina F. Integration of Square Fiducial Markers in Patient-Specific Instrumentation and Their Applicability in Knee Surgery. J Pers Med 2023; 13:jpm13050727. [PMID: 37240897 DOI: 10.3390/jpm13050727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 04/23/2023] [Accepted: 04/23/2023] [Indexed: 05/28/2023] Open
Abstract
Computer technologies play a crucial role in orthopaedic surgery and are essential in personalising different treatments. Recent advances allow the usage of augmented reality (AR) for many orthopaedic procedures, which include different types of knee surgery. AR assigns the interaction between virtual environments and the physical world, allowing both to intermingle (AR superimposes information on real objects in real-time) through an optical device and allows personalising different processes for each patient. This article aims to describe the integration of fiducial markers in planning knee surgeries and to perform a narrative description of the latest publications on AR applications in knee surgery. Augmented reality-assisted knee surgery is an emerging set of techniques that can increase accuracy, efficiency, and safety and decrease the radiation exposure (in some surgical procedures, such as osteotomies) of other conventional methods. Initial clinical experience with AR projection based on ArUco-type artificial marker sensors has shown promising results and received positive operator feedback. Once initial clinical safety and efficacy have been demonstrated, the continued experience should be studied to validate this technology and generate further innovation in this rapidly evolving field.
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Affiliation(s)
- Vicente J León-Muñoz
- Department of Orthopaedic Surgery and Traumatology, Hospital General Universitario Reina Sofía, 30003 Murcia, Spain
- Instituto de Cirugía Avanzada de la Rodilla (ICAR), 30005 Murcia, Spain
| | - Joaquín Moya-Angeler
- Department of Orthopaedic Surgery and Traumatology, Hospital General Universitario Reina Sofía, 30003 Murcia, Spain
- Instituto de Cirugía Avanzada de la Rodilla (ICAR), 30005 Murcia, Spain
| | - Mirian López-López
- Subdirección General de Tecnologías de la Información, Servicio Murciano de Salud, 30100 Murcia, Spain
| | - Alonso J Lisón-Almagro
- Department of Orthopaedic Surgery and Traumatology, Hospital General Universitario Reina Sofía, 30003 Murcia, Spain
| | - Francisco Martínez-Martínez
- Department of Orthopaedic Surgery and Traumatology, Hospital Clínico Universitario Virgen de la Arrixaca, 30120 Murcia, Spain
| | - Fernando Santonja-Medina
- Department of Orthopaedic Surgery and Traumatology, Hospital Clínico Universitario Virgen de la Arrixaca, 30120 Murcia, Spain
- Department of Surgery, Pediatrics and Obstetrics & Gynecology, Faculty of Medicine, University of Murcia, 30120 Murcia, Spain
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11
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Ogawa H, Nakamura Y, Sengoku M, Shimokawa T, Sohmiya K, Ohnishi K, Matsumoto K, Akiyama H. Medial proximal tibial angle at the posterior tibial plateau represents the pre-arthritic constitutional medial proximal tibial angle in anterior cruciate ligament-intact, advanced osteoarthritis of the knee. Knee Surg Sports Traumatol Arthrosc 2022; 30:2941-2947. [PMID: 35088097 DOI: 10.1007/s00167-022-06890-y] [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: 10/28/2021] [Accepted: 01/08/2022] [Indexed: 10/19/2022]
Abstract
PURPOSE In kinematically aligned total knee arthroplasty (TKA), it is necessary to infer the pre-arthritic constitutional medial proximal tibial angle (MPTA) in advanced osteoarthritis (OA) of the knee with bone loss. The aim of this study was to investigate whether MPTA at the posterior tibial plateau represents the pre-arthritic constitutional MPTA in anterior cruciate ligament (ACL)-intact, advanced OA knees. It was hypothesized that MPTA at the posterior tibial plateau represents the pre-arthritic constitutional MPTA of ACL-intact, advanced knee OA. METHODS One hundred varus, anterior cruciate ligament (ACL)-intact, advanced OA knees were analysed. The hip-knee-ankle (HKA) angle and MPTA were assessed on computed radiography (CR) and MPTAs at the anterior, middle, and posterior part of the tibial plateau were assessed on computed tomography (CT) images. The association between these parameters was also analysed. RESULTS CR images showed an HKA angle of 172.4 ± 4.1° and MPTA of 84.3 ± 2.5°. CT images showed different MPTAs in the three regions, ranging from 83.9 ± 2.4° to 85.9 ± 2.8°. The middle MPTA was the lowest at 83.9 ± 2.4°. HKA angle correlated with the middle MPTA (r = 0.3355, 95% confidence interval [CI] 0.1489-0.4991, p = 0.0006) and ΔMPTA (Middle-Posterior) (r = 0.5128, 95% CI 0.3518-0.6443, p < 0.0001). CONCLUSION The MPTA at the posterior tibial plateau represents the pre-arthritic constitutional MPTA in ACL-intact, advanced OA knees. LEVEL OF EVIDENCE III, retrospective cohort study.
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Affiliation(s)
- Hiroyasu Ogawa
- Department of Orthopaedic Surgery, Ogaki Tokushukai Hospital, Hayashi-machi 6-85-1, Ogaki, Gifu, 503-0015, Japan. .,Department of Orthopaedic Surgery, Gifu University Graduate School of Medicine, Yanagido 1-1, Gifu, 501-1194, Japan.
| | - Yutaka Nakamura
- Department of Orthopaedic Surgery, Ogaki Tokushukai Hospital, Hayashi-machi 6-85-1, Ogaki, Gifu, 503-0015, Japan
| | - Masaya Sengoku
- Department of Orthopaedic Surgery, Ogaki Tokushukai Hospital, Hayashi-machi 6-85-1, Ogaki, Gifu, 503-0015, Japan
| | - Tetsuya Shimokawa
- Department of Orthopaedic Surgery, Ogaki Tokushukai Hospital, Hayashi-machi 6-85-1, Ogaki, Gifu, 503-0015, Japan
| | - Kazuki Sohmiya
- Department of Orthopaedic Surgery, Ogaki Tokushukai Hospital, Hayashi-machi 6-85-1, Ogaki, Gifu, 503-0015, Japan
| | - Kazuichiro Ohnishi
- Department of Orthopaedic Surgery, Ogaki Tokushukai Hospital, Hayashi-machi 6-85-1, Ogaki, Gifu, 503-0015, Japan
| | - Kazu Matsumoto
- Department of Orthopaedic Surgery, Gifu University Graduate School of Medicine, Yanagido 1-1, Gifu, 501-1194, Japan
| | - Haruhiko Akiyama
- Department of Orthopaedic Surgery, Gifu University Graduate School of Medicine, Yanagido 1-1, Gifu, 501-1194, Japan
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12
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León-Muñoz VJ, Parrinello A, Galloni G, Lisón-Almagro AJ, López-López M, Martínez-Martínez F, Santonja-Medina F. Reliability of the posterior condylar offset. J Orthop Res 2022; 40:1794-1800. [PMID: 34717014 DOI: 10.1002/jor.25205] [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: 07/24/2021] [Accepted: 10/19/2021] [Indexed: 02/04/2023]
Abstract
The posterior condylar offset (PCO) has been proposed as a determinant of a postoperative range of motion after total knee arthroplasty, although there is no consensus. This study aimed to demonstrate the error introduced by forcing the femoral rotation to overlap both condyles for the "true" lateral X-ray projection for the PCO measurement. We hypothesize that the angular discrepancy between the posterior femoral cortical reference plane and the posterior condylar axis plane due to rotation invalidates the acquisition of reliable measurements on X-rays. We have measured the PCO in 50 "true" lateral X-rays and compared it with the medial and lateral condyles PCO's assessed on a computed tomography-scan-based three-dimensional (3D) model of each knee. PCO based on the 3D imaging differed significantly between the medial (25.8 ± 3.67 mm) and lateral (16.59 ± 2.92 mm) condyle. Three-dimensional PCO values differ significantly from those determined in the radiographic studies. Also, the mean values of the medial and lateral condyle PCO measurements differed significantly (p < 0.001) with all PCO measurements on radiographs. We have identified a difference between the posterior cortical plane and the posterior condylar axis projections, both on the axial plane with a mean value of 11.23° ± 3.64°. Our data show an interplane discrepancy angle between the posterior femoral diaphyseal cortical and the posterior condylar axis plane (due to the femur's necessary rotation to overlap both condyles) may invalidate the 2D X-ray PCO assessment as a reliable measurement.
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Affiliation(s)
- Vicente J León-Muñoz
- Department of Orthopedic Surgery and Traumatology, Hospital General Universitario Reina Sofía, Murcia, Spain
| | - Andrea Parrinello
- Product Management Department, Medacta International SA, Castel San Pietro, Switzerland
| | - Gianluca Galloni
- Patient Matched Technology Department, Medacta International SA, Castel San Pietro, Switzerland
| | - Alonso J Lisón-Almagro
- Department of Orthopedic Surgery and Traumatology, Hospital General Universitario Reina Sofía, Murcia, Spain
| | - Mirian López-López
- Subdirección General de Tecnologías de la Información, Servicio Murciano de Salud, Murcia, Spain
| | - Francisco Martínez-Martínez
- Department of Orthopedic Surgery and Traumatology, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain.,Department of Surgery, Pediatrics and Obstetrics and Gynecology, Faculty of Medicine, University of Murcia, Murcia, Spain
| | - Fernando Santonja-Medina
- Department of Orthopedic Surgery and Traumatology, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain.,Department of Surgery, Pediatrics and Obstetrics and Gynecology, Faculty of Medicine, University of Murcia, Murcia, Spain
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13
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León-Muñoz VJ, López-López M, Santonja-Medina F. Patient-specific instrumentation makes sense in total knee arthroplasty. Expert Rev Med Devices 2022; 19:489-497. [PMID: 35903900 DOI: 10.1080/17434440.2022.2108320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Patient-specific instrumentation (PSI) for total knee arthroplasty (TKA) surgery was initially developed to increase accuracy. The potential PSI benefits have expanded in the last decade, and other advantages have been published. However, different authors are critical of PSI and argue that the advantages are not such and do not compensate for the extra cost. This article aims to describe the recently published advantages and disadvantages of PSI. AREAS COVERED Narrative description of the latest publications related to PSI in accuracy, clinical and functional outcomes, operative time, efficiency, and other benefits. EXPERT COMMENTARY We have published high accuracy of the system, with a not clinically relevant loss of accuracy, significantly higher precision with PSI than with conventional instruments, and a high percentage of cases in the optimal range and similar to that obtained with computer-assisted navigation, greater imprecision for tibial slope, a significant blood loss reduction, and time consumption, an acceptable and non-significant increase in the cost per procedure and no difference in complications during hospital admission and at 90 days. We think that PSI will not follow the Scott Parabola and that it will continue to be a valuable type of device in some instances of TKA surgery.
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Affiliation(s)
- Vicente J León-Muñoz
- Department of Orthopedic Surgery and Traumatology. Hospital General Universitario Reina Sofía. Murcia (Spain)
| | - Mirian López-López
- Subdirección General de Tecnologías de la Información. Servicio Murciano de Salud. Murcia (Spain)
| | - Fernando Santonja-Medina
- Department of Orthopedic Surgery and Traumatology. Hospital Clínico Universitario Virgen de la Arrixaca. Murcia (Spain).,Department of Surgery, Pediatrics and Obstetrics & Gynecology, Faculty of Medicine, University of Murcia. Murcia (Spain)
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14
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Fury MS, Paschos NK, Fabricant PD, Anderson CN, Busch MT, Chambers HG, Christino MA, Cordasco FA, Edmonds EW, Ganley TJ, Green DW, Heyworth BE, Lawrence JTR, Matava MJ, Micheli LJ, Milewski MD, Nepple JJ, Parikh SN, Pennock AT, Perkins CA, Saluan PM, Shea KG, Wall EJ, Willimon SC, Kocher MS. Assessment of Skeletal Maturity and Postoperative Growth Disturbance After Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients: A Systematic Review. Am J Sports Med 2022; 50:1430-1441. [PMID: 33984243 DOI: 10.1177/03635465211008656] [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] [Indexed: 01/31/2023]
Abstract
BACKGROUND Growth disturbance is an uncommon but potentially serious complication after anterior cruciate ligament (ACL) reconstruction in skeletally immature patients. PURPOSE To describe how the pediatric ACL literature has assessed preoperative skeletal maturity and the amount of growth remaining and to comprehensively review the incidence, reporting, and monitoring of postoperative growth disturbance. STUDY DESIGN Systematic review; Level of evidence, 4. METHODS This review included studies reporting original research of clinical outcomes of skeletally immature patients after ACL reconstruction. Patient characteristics, surgical techniques, preoperative assessments of skeletal maturity or growth remaining, and postoperative assessments of growth disturbances were extracted. RESULTS A total of 100 studies met inclusion criteria. All studies reported chronological age, and 28 studies (28%) assessed skeletal age. A total of 44 studies (44%) used Tanner staging, and 12 studies (12%) obtained standing hip-to-ankle radiographs preoperatively. In total, 42 patients (2.1%) demonstrated a leg length discrepancy (LLD) >10 mm postoperatively, including 9 patients (0.5%) with LLD >20 mm; furthermore, 11 patients (0.6%) with LLD underwent growth modulation. Shortening was the most common deformity overall, but overgrowth was reported more frequently in patients who had undergone all-epiphyseal techniques. Most LLDs involved the femur (83%). A total of 26 patients (1.3%) demonstrated a postoperative angular deformity ≥5°, and 9 of these patients underwent growth modulation. The most common deformities were femoral valgus (41%), tibial recurvatum (33%), and tibial varus (22%). Although standing hip-to-ankle radiographs were the most common radiographic assessment of growth disturbance, most studies inadequately reported the clinical and radiographic methods of assessment for growth disturbance. Additionally, only 35% of studies explicitly followed patients to skeletal maturity. CONCLUSION This systematic review described significant variability in the reporting and monitoring of growth-related complications after ACL reconstruction in skeletally immature patients. The incidence of LLD and angular deformity appeared to be low, but the quality of research was not comprehensive enough for accurate assessment. REGISTRATION CRD42019136059 (PROSPERO).
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Affiliation(s)
- Matthew S Fury
- Harvard Combined Orthopaedic Residency Program, Boston, Massachusetts, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Nikolaos K Paschos
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Peter D Fabricant
- Division of Pediatric Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
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- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Christian N Anderson
- Tennessee Orthopaedic Alliance, Nashville, Tennessee, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Michael T Busch
- Children's Healthcare of Atlanta, Children's Orthopaedics of Atlanta, Atlanta, Georgia, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Henry G Chambers
- Pediatric Orthopedics & Scoliosis Center, Rady Children's Hospital, San Diego, California, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Melissa A Christino
- Boston Children's Hospital, Division of Sports Medicine, Department of Orthopaedics, Harvard Medical School, Boston, Massachusetts, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Frank A Cordasco
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Eric W Edmonds
- Pediatric Orthopedics & Scoliosis Center, Rady Children's Hospital, San Diego, California, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Theodore J Ganley
- Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Daniel W Green
- Division of Pediatric Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Benton E Heyworth
- Boston Children's Hospital, Division of Sports Medicine, Department of Orthopaedics, Harvard Medical School, Boston, Massachusetts, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - J Todd R Lawrence
- Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Matthew J Matava
- Department of Orthopaedic Surgery, Washington University School of Medicine, St Louis, Missouri, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lyle J Micheli
- Boston Children's Hospital, Division of Sports Medicine, Department of Orthopaedics, Harvard Medical School, Boston, Massachusetts, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Matthew D Milewski
- Boston Children's Hospital, Division of Sports Medicine, Department of Orthopaedics, Harvard Medical School, Boston, Massachusetts, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Jeffrey J Nepple
- Department of Orthopaedic Surgery, Washington University School of Medicine, St Louis, Missouri, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Shital N Parikh
- Division of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Andrew T Pennock
- Pediatric Orthopedics & Scoliosis Center, Rady Children's Hospital, San Diego, California, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Crystal A Perkins
- Children's Healthcare of Atlanta, Children's Orthopaedics of Atlanta, Atlanta, Georgia, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Paul M Saluan
- Cleveland Clinic Orthopaedic and Rheumatologic Institute, Garfield Heights, Ohio, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kevin G Shea
- Department of Orthopedic Surgery, Stanford University, Stanford, California, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Eric J Wall
- Division of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Samuel C Willimon
- Children's Healthcare of Atlanta, Children's Orthopaedics of Atlanta, Atlanta, Georgia, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Mininder S Kocher
- Boston Children's Hospital, Division of Sports Medicine, Department of Orthopaedics, Harvard Medical School, Boston, Massachusetts, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
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15
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Sun X, Yang B, Xiao S, Yan Y, Liu Z, Yuan L, Wang X, Sun B, Yao J, Fan Y. Effect of limb rotation on radiographic alignment measurement in mal-aligned knees. Biomed Eng Online 2021; 20:119. [PMID: 34838009 PMCID: PMC8626971 DOI: 10.1186/s12938-021-00956-7] [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: 08/27/2021] [Accepted: 11/10/2021] [Indexed: 11/16/2022] Open
Abstract
Purpose Long-leg-radiography (LLR) is commonly used for the measurement of lower limb alignment. However, limb rotations during radiography may interfere with the alignment measurement. This study examines the effect of limb rotation on the accuracy of measurements based on the mechanical and anatomical axes of the femur and tibia, with variations in knee flexion and coronal deformity. Methods Forty-five lower limbs of 30 patients were scanned with CT. Virtual LLRs simulating five rotational positions (neutral, ± 10\documentclass[12pt]{minimal}
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\begin{document}$$^{\circ }$$\end{document}∘ internal rotation) were generated from the CT images. Changes in the hip–knee–ankle angle (HKA) and the femorotibial angle (FTA) were measured on each image with respect to neutral values. These changes were related to knee flexion and coronal deformity under both weight- and non-weight-bearing conditions. Results The measurement errors of the HKA and FTA derived from limb rotation were up to 4.84 ± 0.66\documentclass[12pt]{minimal}
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\begin{document}$$^{\circ }$$\end{document}∘, respectively, and were correlated with knee flexion (p < 0.001) and severe coronal deformity (p < 0.001). Compared with the non-weight-bearing position, the coronal deformity measured in the weight-bearing condition was 2.62\documentclass[12pt]{minimal}
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\begin{document}$$^{\circ }$$\end{document}∘ greater, the correlation coefficients between the coronal deformity and the deviation ranges of HKA and FTA were also greater. Conclusions Flexion and severe coronal deformity have a significant influence on the measurement error of lower limb alignment. Errors can be amplified in the weight-bearing condition compared with the non-weight-bearing condition. When using HKA and FTA to represent the mechanical axis and the anatomical axis on LLR, limb rotation impacts the anatomic axis more than the mechanical axis in patients with severe deformities. Considering LLR as the gold standard image modality, attention should be paid to the measurement of knee alignment. Especially for the possible errors derived from weight-bearing long-leg radiographs of patients with severe knee deformities. Supplementary Information The online version contains supplementary material available at 10.1186/s12938-021-00956-7.
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Affiliation(s)
- Xiaoshu Sun
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, People's Republic of China
| | - Bin Yang
- Orthopedics Department, Peking University International Hospital, Life Park 1, Zhongguancun Life Science Park, Changping District, Beijing, People's Republic of China
| | - Shengzhao Xiao
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, People's Republic of China
| | - Yichen Yan
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, People's Republic of China
| | - Zifan Liu
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, People's Republic of China
| | - Liang Yuan
- Orthopedics Department, Peking University International Hospital, Life Park 1, Zhongguancun Life Science Park, Changping District, Beijing, People's Republic of China
| | - Xiaohua Wang
- Orthopedics Department, Peking University International Hospital, Life Park 1, Zhongguancun Life Science Park, Changping District, Beijing, People's Republic of China
| | - Bin Sun
- Orthopedics Department, Peking University International Hospital, Life Park 1, Zhongguancun Life Science Park, Changping District, Beijing, People's Republic of China
| | - Jie Yao
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, People's Republic of China.
| | - Yubo Fan
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, People's Republic of China. .,School of Medical Science and Engineering, Beihang University, No.37 Xueyuan Road, Haidian District, Beijing, 100083, People's Republic of China.
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16
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Coronal and axial alignment relationship in Caucasian patients with osteoarthritis of the knee. Sci Rep 2021; 11:7836. [PMID: 33837279 PMCID: PMC8035173 DOI: 10.1038/s41598-021-87483-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 03/30/2021] [Indexed: 01/26/2023] Open
Abstract
Individualized pre-operative assessment of the patterns of the lower extremity anatomy and deformities in patients undergoing total knee arthroplasty seems essential for a successful surgery. In the present study, we investigated the relationship among the coronal alignment and the rotational profile of the lower extremities in the Caucasian population with end-stage knee osteoarthritis. We conducted a prospective study of 385 knees that underwent a pre-operative three-dimensional computed tomography-based model. The lower extremity alignment was determined (mechanical tibiofemoral or hip-knee-ankle angle, supplementary angle of the femoral lateral distal angle, and proximal medial tibial angle). For each case, the femoral distal rotation (condylar twist angle), the femoral proximal version, and the tibial torsion were determined. As the coronal alignment changed from varus to valgus, the femoral external rotation increased (r = 0.217; p < 0.0005). As the coronal alignment changed from varus to valgus, the external tibial torsion increased (r = 0.248; p < 0.0005). No correlation was found between the global coronal alignment and the femoral version. The present study demonstrates a linear relationship between the coronal alignment and the rotational geometry of the distal femur. This correlation also occurs with the tibial torsion. Perhaps outcomes of total knee arthroplasty surgery might be improved by addressing these deformities as well.
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17
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Three-dimensional preoperative planning in the weight-bearing state: validation and clinical evaluation. Insights Imaging 2021; 12:44. [PMID: 33825985 PMCID: PMC8026795 DOI: 10.1186/s13244-021-00994-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 03/24/2021] [Indexed: 12/03/2022] Open
Abstract
Objectives 3D preoperative planning of lower limb osteotomies has become increasingly important in light of modern surgical technologies. However, 3D models are usually reconstructed from Computed Tomography data acquired in a non-weight-bearing posture and thus neglecting the positional variations introduced by weight-bearing. We developed a registration and planning pipeline that allows for 3D preoperative planning and subsequent 3D assessment of anatomical deformities in weight-bearing conditions. Methods An intensity-based algorithm was used to register CT scans with long-leg standing radiographs and subsequently transform patient-specific 3D models into a weight-bearing state. 3D measurement methods for the mechanical axis as well as the joint line convergence angle were developed. The pipeline was validated using a leg phantom. Furthermore, we evaluated our methods clinically by applying it to the radiological data from 59 patients. Results The registration accuracy was evaluated in 3D and showed a maximum translational and rotational error of 1.1 mm (mediolateral direction) and 1.2° (superior-inferior axis). Clinical evaluation proved feasibility on real patient data and resulted in significant differences for 3D measurements when the effects of weight-bearing were considered. Mean differences were 2.1 ± 1.7° and 2.0 ± 1.6° for the mechanical axis and the joint line convergence angle, respectively. 37.3 and 40.7% of the patients had differences of 2° or more in the mechanical axis or joint line convergence angle between weight-bearing and non-weight-bearing states. Conclusions Our presented approach provides a clinically feasible approach to preoperatively fuse 2D weight-bearing and 3D non-weight-bearing data in order to optimize the surgical correction.
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18
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León-Muñoz VJ, Parrinello A, Manca S, Galloni G, López-López M, Martínez-Martínez F, Santonja-Medina F. Patient-Specific Instrumentation Accuracy Evaluated with 3D Virtual Models. J Clin Med 2021; 10:jcm10071439. [PMID: 33916110 PMCID: PMC8036812 DOI: 10.3390/jcm10071439] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 03/20/2021] [Accepted: 03/24/2021] [Indexed: 12/25/2022] Open
Abstract
There have been remarkable advances in knee replacement surgery over the last few decades. One of the concerns continues to be the accuracy in achieving the desired alignment. Patient-specific instrumentation (PSI) was developed to increase component placement accuracy, but the available evidence is not conclusive. Our study aimed to determine a PSI system’s three-dimensional accuracy on 3D virtual models obtained by post-operative computed tomography. We compared the angular placement values of 35 total knee arthroplasties (TKAs) operated within a year obtained with the planned ones, and we analyzed the possible relationships between alignment and patient-reported outcomes. The mean (SD) discrepancies measured by two experienced engineers to the planned values observed were 1.64° (1.3°) for the hip–knee–ankle angle, 1.45° (1.06°) for the supplementary angle of the femoral lateral distal angle, 1.44° (0.97°) for the proximal medial tibial angle, 2.28° (1.78°) for tibial slope, 0.64° (1.09°) for femoral sagittal flexion, and 1.42° (1.06°) for femoral rotation. Neither variables related to post-operative alignment nor the proportion of change between pre-and post-operative alignment influenced the patient-reported outcomes. The evaluated PSI system’s three-dimensional alignment analysis showed a statistically significant difference between the angular values planned and those obtained. However, we did not find a relevant effect size, and this slight discrepancy did not impact the clinical outcome.
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Affiliation(s)
- Vicente J. León-Muñoz
- Department of Orthopaedic Surgery and Traumatology, Hospital Clínico Universitario Virgen de la Arrixaca, Ctra. Madrid-Cartagena, s/n, 30120 Murcia, Spain; (F.M.-M.); (F.S.-M.)
- Correspondence:
| | - Andrea Parrinello
- Product Management Department, Medacta International SA, Strada Regina, 6874 Castel San Pietro, Switzerland;
| | - Silvio Manca
- Patient Matched Technology Department, Medacta International SA, Strada Regina, 6874 Castel San Pietro, Switzerland; (S.M.); (G.G.)
| | - Gianluca Galloni
- Patient Matched Technology Department, Medacta International SA, Strada Regina, 6874 Castel San Pietro, Switzerland; (S.M.); (G.G.)
| | - Mirian López-López
- Subdirección General de Tecnologías de la Información, Servicio Murciano de Salud, Avenida Central, 7, Edificio Habitamia, Espinardo, 30100 Murcia, Spain;
| | - Francisco Martínez-Martínez
- Department of Orthopaedic Surgery and Traumatology, Hospital Clínico Universitario Virgen de la Arrixaca, Ctra. Madrid-Cartagena, s/n, 30120 Murcia, Spain; (F.M.-M.); (F.S.-M.)
- Department of Surgery, Pediatrics and Obstetrics & Gynecology, Faculty of Medicine, University of Murcia, 30100 Murcia, Spain
| | - Fernando Santonja-Medina
- Department of Orthopaedic Surgery and Traumatology, Hospital Clínico Universitario Virgen de la Arrixaca, Ctra. Madrid-Cartagena, s/n, 30120 Murcia, Spain; (F.M.-M.); (F.S.-M.)
- Department of Surgery, Pediatrics and Obstetrics & Gynecology, Faculty of Medicine, University of Murcia, 30100 Murcia, Spain
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LÔBO CARLOSFELIPETEIXEIRA, BORDALO-RODRIGUES MARCELO, Godoy-Santos AL, Gobbi RG, Cesar Netto CD, Burssens A, Lintz F, Barg A. WEIGHT-BEARING CONE BEAM CT SCANS AND ITS USES IN ANKLE, FOOT, AND KNEE: AN UPDATE ARTICLE. ACTA ORTOPEDICA BRASILEIRA 2021; 29:105-110. [PMID: 34248411 PMCID: PMC8244836 DOI: 10.1590/1413-785220212902236939] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 08/20/2020] [Indexed: 11/22/2022]
Abstract
Imaging plays a key role in the preoperative diagnosis, surgical planning, and postsurgical assessment of the foot, ankle, and knee pathologies. Interpreting diagnostic imaging accurately is crucial for the clinical practice of orthopedic surgeons. Although among the most used imaging modalities, radiographic assessments are amenable to errors for various technical reasons and superposition of bones. Computed tomography (CT) is a conventional imaging procedure that provides high-resolution images, but fails in considering a truly weight-bearing (WB) condition. In an attempt to overcome this limitation, WB cone beam CT technology has being successfully employed in the clinical practice for the past decade. Besides economically viable and safe, the WB cone beam CT considers WB conditions and provides high-quality scans, thus allowing an equitable and correct interpretation. This review aims to address extensive description and discussion on WBCT, including imaging quality; costs; time consumption; and its applicability in common foot, ankle, and knee, conditions. With this technology increasing popularity, and considering the extensive literature on medical research, radiologists and orthopedic surgeons need to understand its potential applications and use it optimally. Level of Evidence III, Systematic review of level III studies.
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