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Buzzatti L, Keelson B, van der Voort JW, Segato L, Scheerlinck T, Héréus S, Van Gompel G, Vandemeulebroucke J, De Mey J, Buls N, Cattrysse E, Serrien B. Dynamic CT scanning of the knee: Combining weight bearing with real-time motion acquisition. Knee 2023; 44:130-141. [PMID: 37597475 DOI: 10.1016/j.knee.2023.07.014] [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: 07/27/2022] [Revised: 06/14/2023] [Accepted: 07/24/2023] [Indexed: 08/21/2023]
Abstract
BACKGROUND Imaging the lower limb during weight-bearing conditions is essential to acquire advanced functional joint information. The horizontal bed position of CT systems however hinders this process. The purpose of this study was to validate and test a device to simulate realistic knee weight-bearing motion in a horizontal position during dynamic CT acquisition and process the acquired images. METHODS "Orthostatic squats" was compared to "Horizontal squats" on a device with loads between 35% and 55% of the body weight (%BW) in 20 healthy volunteers. Intraclass Correlation Coefficient (ICC), and standard error of measurement (SEM), were computed as measures of the reliability of curve kinematic and surface EMG (sEMG) data. Afterwards, the device was tested during dynamic CT acquisitions on three healthy volunteers and three patients with patellofemoral pain syndrome. The respective images were processed to extract Tibial-Tuberosity Trochlear-Groove distance, Bisect Offset and Lateral Patellar Tilt metrics. RESULTS For sEMG, the highest average ICCs (SEM) of 0.80 (6.9), was found for the load corresponding to 42%BW. Kinematic analysis showed ICCs were the highest for loads of 42%BW during the eccentric phase (0.79-0.87) and from maximum flexion back to 20° (0.76). The device proved to be safe and reliable during the acquisition of dynamic CT images and the three metrics were computed, showing preliminary differences between healthy and pathological participants. CONCLUSIONS This device could simulate orthostatic squats in a horizontal position with good reliability. It also successfully provided dynamic CT scan images and kinematic parameters of healthy and pathological knees during weight-bearing movement.
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Affiliation(s)
- Luca Buzzatti
- Vrije Universiteit Brussel (VUB), Experimental Anatomy Research Group (EXAN), Laarbeeklaan 103, 1090 Brussels, Belgium; School of Allied Health, Anglia Ruskin University (ARU), Young Street, CB1 1PT Cambridge, UK.
| | - Benyameen Keelson
- Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Department of Radiology, Laarbeeklaan 101, 1090 Brussels, Belgium; Vrije Universiteit Brussel (VUB), Department of Electronics and Informatics (ETRO), Pleinlaan 2, 1050 Brussel, Belgium; imec, Kapeldreef 75, 3001 Leuven, Belgium
| | - Joris Willem van der Voort
- Vrije Universiteit Brussel (VUB), Experimental Anatomy Research Group (EXAN), Laarbeeklaan 103, 1090 Brussels, Belgium
| | - Lorenzo Segato
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Campus of Savona, Italy
| | - Thierry Scheerlinck
- Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Department of Orthopaedic Surgery and Traumatology, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Savanah Héréus
- Vrije Universiteit Brussel (VUB), Experimental Anatomy Research Group (EXAN), Laarbeeklaan 103, 1090 Brussels, Belgium
| | - Gert Van Gompel
- Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Department of Radiology, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Jef Vandemeulebroucke
- Vrije Universiteit Brussel (VUB), Department of Electronics and Informatics (ETRO), Pleinlaan 2, 1050 Brussel, Belgium; imec, Kapeldreef 75, 3001 Leuven, Belgium
| | - Johan De Mey
- Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Department of Radiology, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Nico Buls
- Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Department of Radiology, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Erik Cattrysse
- Vrije Universiteit Brussel (VUB), Experimental Anatomy Research Group (EXAN), Laarbeeklaan 103, 1090 Brussels, Belgium
| | - Ben Serrien
- Vrije Universiteit Brussel (VUB), Experimental Anatomy Research Group (EXAN), Laarbeeklaan 103, 1090 Brussels, Belgium
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Brunner J, Jörgens M, Weigert M, Kümpel H, Fuermetz J. Veränderungen in der Ausrichtung des Beins durch Flexion und Rotation. ARTHROSKOPIE 2023. [DOI: 10.1007/s00142-023-00597-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
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Brunner J, Jörgens M, Weigert M, Kümpel H, Degen N, Fuermetz J. Significant changes in lower limb alignment due to flexion and rotation-a systematic 3D simulation of radiographic measurements. Knee Surg Sports Traumatol Arthrosc 2023; 31:1483-1490. [PMID: 36595052 PMCID: PMC10050026 DOI: 10.1007/s00167-022-07302-x] [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: 10/18/2022] [Accepted: 12/18/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Many radiographic lower limb alignment measurements are dependent on patients' position, which makes a standardised image acquisition of long-leg radiographs (LLRs) essential for valid measurements. The purpose of this study was to investigate the influence of rotation and flexion of the lower limb on common radiological alignment parameters using three-dimensional (3D) simulation. METHODS Joint angles and alignment parameters of 3D lower limb bone models (n = 60), generated from computed tomography (CT) scans, were assessed and projected into the coronal plane to mimic radiographic imaging. Bone models were subsequently rotated around the longitudinal mechanical axis up to 15° inward/outward and additionally flexed along the femoral intercondylar axis up to 30°. This resulted in 28 combinations of rotation and flexion for each leg. The results were statistically analysed on a descriptive level and using a linear mixed effects model. RESULTS A total of 1680 simulations were performed. Mechanical axis deviation (MAD) revealed a medial deviation with increasing internal rotation and a lateral deviation with increasing external rotation. This effect increased significantly (p < 0.05) with combined flexion up to 30° flexion (- 25.4 mm to 25.2 mm). With the knee extended, the mean deviation of hip-knee-ankle angle (HKA) was small over all rotational steps but increased toward more varus/valgus when combined with flexion (8.4° to - 8.5°). Rotation alone changed the medial proximal tibial angle (MPTA) and the mechanical lateral distal femoral angle (mLDFA) in opposite directions, and the effects increased significantly (p < 0.05) when flexion was present. CONCLUSIONS Axial rotation and flexion of the 3D lower limb has a huge impact on the projected two-dimensional alignment measurements in the coronal plane. The observed effects were small for isolated rotation or flexion, but became pronounced and clinically relevant when there was a combination of both. This must be considered when evaluating X-ray images. Extension deficits of the knee make LLR prone to error and this calls into question direct postoperative alignment controls. LEVEL OF EVIDENCE III (retrospective cohort study).
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Affiliation(s)
- Josef Brunner
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU, Marchioninistr. 15, 81377, Munich, Germany
| | - Maximilian Jörgens
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU, Marchioninistr. 15, 81377, Munich, Germany.
| | | | - Hannah Kümpel
- Statistical Consulting Unit StaBLab, LMU, Munich, Germany
| | - Nikolaus Degen
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU, Marchioninistr. 15, 81377, Munich, Germany
| | - Julian Fuermetz
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU, Marchioninistr. 15, 81377, Munich, Germany.,Department of Trauma Surgery, BG Unfallklinik Murnau, Murnau, Germany
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Ahrend MD, Baumgartner H, Ihle C, Histing T, Schröter S, Finger F. Influence of axial limb rotation on radiographic lower limb alignment: a systematic review. Arch Orthop Trauma Surg 2022; 142:3349-3366. [PMID: 34596760 PMCID: PMC9522705 DOI: 10.1007/s00402-021-04163-w] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 09/01/2021] [Indexed: 12/26/2022]
Abstract
INTRODUCTION The influence of limb malrotation on long-leg radiographs (LLR) is frequently discussed in literature. This systematic review aimed to describe the influence of limb rotation on alignment measurements alone and in combination with knee flexion, and determine its clinical impact. MATERIALS AND METHODS A literature search was conducted in June 2021 using the databases MEDLINE, Cochrane, Web of Science (Clarivate Analytics), and Embase. The search term ((radiograph OR X-ray) AND (position OR rotation) AND limb alignment) was used. Database query, record screening, and study inclusion and exclusion were performed by two reviewers independently. Experimental studies (using either specimens or synthetic bones) or clinical studies (prospective or retrospective using radiographs of patients) analyzing the influence of limb rotation on anatomic and mechanical limb alignment measurements were included. Characteristics and results of the included studies were summarized, simplified, and grouped for comparison to answer the research question. Studies were compared descriptively, and no meta-analysis was performed. RESULTS A total of 22 studies were included showing large heterogeneity, comprising studies with cadavers, patients, and synthetic bones. Most studies (7 out of 8) reported that external rotation (ER) causes less apparent valgus and leads to more varus and internal rotation (IR) causes more valgus and leads to less varus. However, there is no consensus on the extent of rotation influencing alignment measures. Studies reported about an average change of > 2° (n = 4) and < 2° (n = 4) hip-knee-ankle angle (HKA) between 15°IR and 15°ER. There is a consensus that the impact of rotation on mechanical alignment is higher if additional sagittal knee angulation, such as knee flexion, is present. All five studies analyzing the influence of rotation combined with knee flexion (5°-15°) showed an HKA change of > 2° between 15°IR and 15°ER. CONCLUSION Malrotation is frequently present on LLR, possibly influencing the measured alignment especially in knees with extension deficit. Surgeons must consider this when measuring and treating deformities (high tibial osteotomy or total knee arthroplasties), and analyzing surgical outcomes. Especially in patients with osteoarthritis with knee extension deficits or postoperative swelling, the effect of malrotation is significantly greater.
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Affiliation(s)
- Marc-Daniel Ahrend
- Department of Traumatology and Reconstructive Surgery, BG Trauma Center Tübingen, Eberhard-Karls University of Tübingen, Schnarrenberg-Str. 95, 72076 Tübingen, Germany
- AO Research Institute Davos, Davos, Switzerland
| | - Heiko Baumgartner
- Department of Traumatology and Reconstructive Surgery, BG Trauma Center Tübingen, Eberhard-Karls University of Tübingen, Schnarrenberg-Str. 95, 72076 Tübingen, Germany
| | - Christoph Ihle
- Department of Traumatology and Reconstructive Surgery, BG Trauma Center Tübingen, Eberhard-Karls University of Tübingen, Schnarrenberg-Str. 95, 72076 Tübingen, Germany
| | - Tina Histing
- Department of Traumatology and Reconstructive Surgery, BG Trauma Center Tübingen, Eberhard-Karls University of Tübingen, Schnarrenberg-Str. 95, 72076 Tübingen, Germany
| | - Steffen Schröter
- Department of Traumatology and Reconstructive Surgery, Diakonie Klinikum GmbH Jung-Stilling-Krankenhaus, Siegen, Germany
| | - Felix Finger
- Department of Traumatology and Reconstructive Surgery, BG Trauma Center Tübingen, Eberhard-Karls University of Tübingen, Schnarrenberg-Str. 95, 72076 Tübingen, Germany
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Choi HU, Kim DH, Lee SW, Choi BC, Bae KC. Comparison of Lower-Limb Alignment in Patients with Advanced Knee Osteoarthritis: EOS Biplanar Stereoradiography versus Conventional Scanography. Clin Orthop Surg 2022; 14:370-376. [PMID: 36061834 PMCID: PMC9393278 DOI: 10.4055/cios21050] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/20/2021] [Accepted: 05/27/2021] [Indexed: 11/24/2022] Open
Abstract
Background Accurate measurement of the lower limb alignment is one of the most crucial factors in advanced knee osteoarthritis patients scheduled for surgery. Recently, EOS biplanar stereoradiography with three-dimensional reconstruction was developed. The purpose of this study was to compare radiographic parameters between conventional scanography and EOS in patients with advanced knee osteoarthritis who need surgical treatment. Methods A total of 52 consecutive patients (104 knees) with bilateral knee osteoarthritis of advanced stage (Kellgren-Lawrence [KL] grade 3 or 4) were retrospectively reviewed. We measured the hip-knee-ankle angle (HKA) on conventional scanograms. In EOS, we measured HKA, hip-knee-shaft angle, mechanical lateral distal femoral angle, and mechanical medial proximal tibial angle. To evaluate sagittal and axial plane alignment, knee flexion angle (KFA), and knee joint rotation (KJR) were also measured. Results Ninety knees were KL grade 4, and 14 knees were grade 3. The average HKA was 10.14° ± 6.16° on conventional scanograms and 11.26° ± 6.21° in EOS. HKA was greater in EOS than on conventional scanograms, and the difference (1.12°; range, −1.07° to 3.22°) was statistically significant (p < 0.001). Significant correlations were observed on the difference in HKA and mechanical medial proximal tibial angle (r = –0.198, p = 0.044), KFA (r = 0.193, p = 0.049), and KJR (r = 0.290, p = 0.003). In multivariable linear regression analysis, the difference in HKA had significant relationship with KFA (β = 0.286, p = 0.003) and KJR (β = 0.363, p < 0.001). Conclusions HKA measured on conventional scanograms and in EOS differed significantly and the difference had a significant correlations with KFA, KJR, and medial proximal tibial angle. Surgeons can consider these results before orthopedic surgery in patients who have advanced knee osteoarthritis.
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Affiliation(s)
- Hyeong-Uk Choi
- Department of Orthopaedic Surgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
| | - Du-Han Kim
- Department of Orthopaedic Surgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
| | - Si-Wook Lee
- Department of Orthopaedic Surgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
| | - Byung-Chan Choi
- Department of Orthopaedic Surgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
| | - Ki-Cheor Bae
- Department of Orthopaedic Surgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
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Tsukeoka T, Tsuneizumi Y. False malalignment after computer-navigated total knee arthroplasty. Knee 2021; 30:100-105. [PMID: 33887620 DOI: 10.1016/j.knee.2021.03.018] [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: 07/21/2020] [Revised: 02/17/2021] [Accepted: 03/24/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Although computer navigation has improved component alignment in total knee arthroplasty (TKA), radiographic outliers are reported with a wide range in literature even using this technique. We hypothesized that the postoperative malalignment after computer-navigated TKA was partially derived from the inherent problems with two-dimensional (2D) measurement such as inaccuracies in measurement due to the knee position during the radiographic examination and the direction of the X-ray beam. We therefore conducted this study to determine how often knees with malalignment on 2D imaging were truly mal-aligned on three-dimensional (3D) reconstructed imaging. METHODS Sixty-two computer-navigated primary TKAs performed in 47 patients were included in this study. In all cases, a weight-bearing long-leg radiograph was obtained after TKA. 3D measurements were performed for outliers 2° or more in coronal alignment of the femoral or tibial component. RESULTS For the 18 femoral mal-aligned components on 2D imaging, eight (44.4%) were not truly mal-aligned on 3D imaging (P = 0.0014). For the eight tibial mal-aligned components on 2D imaging, all knees (100%) were not truly mal-aligned on 3D imaging (P < 0.0001). CONCLUSIONS A considerable number of the false malalignments were included on 2D measurement. Postoperative component alignment in the computer-navigated TKA might be much better than previously reported.
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Affiliation(s)
- Tadashi Tsukeoka
- Department of Orthopaedic Surgery, Chiba Rehabilitation Center, Chiba, Japan.
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