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Van Fraeyenhove B, Verhaegen JCF, Grammens J, Mestach G, Audenaert E, Van Haver A, Verdonk P. The quest for optimal femoral torsion angle measurements: a comparative advanced 3D study defining the femoral neck axis. J Exp Orthop 2023; 10:141. [PMID: 38108926 PMCID: PMC10728037 DOI: 10.1186/s40634-023-00679-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 10/19/2023] [Indexed: 12/19/2023] Open
Abstract
PURPOSE There is high variability in femoral torsion, measured on two-dimensional (2D) computed tomography (CT) scans. The aim of this study was to find a reliable three-dimensional (3D) femoral torsion measurement method, assess the influence of CAM deformity on femoral torsion measurement, and to promote awareness for the used measurement method. METHODS 3D models of 102 dry femur specimens were divided into a CAM and non-CAM group. Femoral torsion was measured by one 2D-CT method described by Murphy et al. (method 0) and five 3D methods. The 3D methods differed in strategies to define the femoral neck axis. Method 1 is based on an elliptical least-square fit at the middle of the femoral neck. Methods 2 and 3 defined the centre of mass of the entire femoral neck and of the most cylindrical part, respectively. Methods 4 and 5 were based on the intersection of the femoral neck with a 25% and 40% enlarged best fit sphere of the femoral head. RESULTS 3D methods resulted in higher femoral torsion measures than the 2D method; the mean torsion for method 0 was 8.12° ± 7.30°, compared to 9.93° ± 8.24° (p < 0.001), 13.21° ± 8.60° (p < 0.001), 8.21° ± 7.64° (p = 1.00), 9.53° ± 7.87° (p < 0.001) and 10.46° ± 7.83° (p < 0.001) for methods 1 to 5 respectively. In the presence of a CAM, torsion measured with method 4 is consistently smaller than measured with method 5. CONCLUSION 2D measurement might underestimate true femoral torsion and there is a difference up to 5°. There is a tendency for a higher mean torsion in hips with a CAM deformity. Methods 4 and 5 are the most robust techniques. However, method 4 might underestimate femoral torsion if a CAM deformity is present. Since method 5 is independent of a CAM deformity, it is the preferred technique to define expected values of torsion.
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Affiliation(s)
| | | | | | - Gino Mestach
- Universitair Ziekenhuis Antwerpen, Antwerp, Belgium
| | | | | | - Peter Verdonk
- Orthoca, Kielsevest 14, Antwerp, 2018, Belgium
- MoRe Institute, 2100, Antwerp, Belgium
- Department of Orthopaedic Surgery, Antwerp University, 2000, Antwerp, Belgium
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Hao K, Niu Y, Huo Z, Wang F. Distal femoral torsion is correlated with higher-grade trochlear dysplasia and shorter anterior condyles in patients with patellar dislocation and increased femoral torsion. Knee Surg Sports Traumatol Arthrosc 2023; 31:5664-5672. [PMID: 37878013 DOI: 10.1007/s00167-023-07628-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 10/09/2023] [Indexed: 10/26/2023]
Abstract
PURPOSE To describe the characteristics of femoral torsion in patients with different segmental torsion types and to evaluate the correlations between segmental torsion and the morphology of the femoral condyles and trochlea in patients with patellar dislocation and increased femoral torsion. METHODS Between January 2021 and March 2023, 69 patients were included and classified into two groups according to the femoral segment contributing the most to total torsion: 32 patients in Group A (femoral neck and shaft torsion) and 37 patients in Group B (distal torsion). Trochlear dysplasia was evaluated using Dejour's classification and sulcus angle. The morphology of the femoral condyles was evaluated using the lengths and ratios of the medial and lateral condyles. Correlations between femoral torsion and morphology were evaluated. RESULTS Total torsion was significantly correlated with femoral neck and shaft torsion (r = 0.882, P < 0.001) and distal torsion (r = 0.262, P = 0.030). Femoral neck and shaft torsion was significantly increased with increasing total torsion. The trochlear sulcus was flatter and more dysplastic, and the anterior condyles were shorter in Group B. Distal torsion was significantly correlated with the lengths of the medial and lateral anterior condyles (r = - 0.567, P < 0.001; r = -0.701, P < 0.001), sulcus angle (r = 0.611, P < 0.001) and Dejour trochlea type (r = 0.512, P = 0.001), while femoral neck and shaft torsion showed no correlations. CONCLUSION Femoral torsion is a complex of femoral neck and shaft torsion and distal torsion, especially femoral neck and shaft torsion. Distal torsion was significantly correlated with a flatter trochlear sulcus, higher-grade trochlear dysplasia, and shorter anterior condyles. The new findings highlighted the importance of the segmental evaluation of femoral torsion, which would facilitate understanding of the anatomical characteristics of femoral torsion in patients with patellar dislocation and increased femoral torsion and may lead to improvement in the surgical options regarding femoral torsion. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Kuo Hao
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050051, China
| | - Yingzhen Niu
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050051, China
| | - Zhenhui Huo
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050051, China
| | - Fei Wang
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050051, China.
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Iwasaka-Neder J, Bixby SD, Bedoya MA, Liu E, Jarrett DY, Agahigian D, Tsai A. Virtual 3D femur model to assess femoral version: comparison to the 2D axial slice approach. Pediatr Radiol 2023; 53:2411-2423. [PMID: 37740782 DOI: 10.1007/s00247-023-05758-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 08/22/2023] [Accepted: 08/23/2023] [Indexed: 09/25/2023]
Abstract
BACKGROUND Quantifying femoral version is crucial in diagnosing femoral version abnormalities and for accurate pre-surgical planning. There are numerous methods for measuring femoral version, however, reliability studies for most of these methods excluded children with hip deformities. OBJECTIVE To propose a method of measuring femoral version based on a virtual 3D femur model, and systematically compare its reliability to the widely used Murphy's 2D axial slice technique. MATERIALS AND METHODS We searched our imaging database to identify hip/femur CTs performed on children (<18 years old) with a clinical indication of femoral version measurement (September 2021-August 2022). Exclusion criteria were prior hip surgery, and inadequate image quality or field-of-view. Two blinded radiologists independently measured femoral version using the virtual 3D femur model and Murphy's 2D axial slice method. To assess intrareader variability, we randomly selected 20% of the study sample for re-measurements by the two radiologists >2 weeks later. We analyzed the reliability and correlation of these techniques via intraclass correlation coefficient (ICC), Bland-Altman analysis, and deformity subgroup analysis. RESULTS Our study sample consisted of 142 femurs from 71 patients (10.6±4.4 years, male=31). Intra- and inter-reader correlations for both techniques were excellent (ICC≥0.91). However, Bland-Altman analysis revealed that the standard deviation (SD) of the absolute difference between the two radiologists for the Murphy method (mean 13.7°) was larger than that of the 3D femur model technique (mean 4.8°), indicating higher reader variability. In femurs with hip flexion deformity, the SD of the absolute difference for the Murphy technique was 17°, compared to 6.5° for the 3D femur model technique. In femurs with apparent coxa valga deformity, the SD of the absolute difference for the Murphy technique was 10.4°, compared to 5.2° for the 3D femur model technique. CONCLUSION The 3D femur model technique is more reliable than the Murphy's 2D axial slice technique in measuring femoral version, especially in children with hip flexion and apparent coxa valga deformities.
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Affiliation(s)
- Jade Iwasaka-Neder
- Department of Radiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA.
| | - Sarah D Bixby
- Department of Radiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
| | - M Alejandra Bedoya
- Department of Radiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Enju Liu
- Department of Pediatrics, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Delma Y Jarrett
- Department of Radiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
- Department of Radiology, New York Presbyterian Hospital-Weill Cornell, 525 East 68th Street, New York, NY, 10065, USA
| | - Donna Agahigian
- Department of Radiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Andy Tsai
- Department of Radiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
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Noebauer-Huhmann IM, Koenig FRM, Chiari C, Schmaranzer F. [Femoroacetabular impingement in adolescents]. Radiologie (Heidelb) 2023; 63:749-757. [PMID: 37698653 PMCID: PMC10522737 DOI: 10.1007/s00117-023-01197-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/28/2023] [Indexed: 09/13/2023]
Abstract
Femoroacetabular impingement syndrome (FAIS) is caused by a repetitive mechanical conflict between the acetabulum and the proximal femur, occurring in flexion and internal rotation. In cam impingement, bony prominences of the femoral head-neck junction induce chondrolabral damage. The acetabular type of FAIS, termed pincer FAIS, may be either due to focal or global retroversion and/or acetabular overcoverage. Combinations of cam and pincer morphology are common. Pathological femoral torsion may aggravate or decrease the mechanical conflict in FAI but can also occur in isolation. Of note, a high percentage of adolescents with FAI-like shape changes remain asymptomatic. The diagnosis of FAIS is therefore made clinically, whereas imaging reveals the underlying morphology. X‑rays in two planes remain the primary imaging modality, the exact evaluation of the osseous deformities of the femur and chondrolabral damage is assessed by magnetic resonance imaging (MRI). Acetabular coverage and version are primarily assessed on radiographs. Evaluation of the entire circumference of the proximal femur warrants MRI which is further used in the assessment of chondrolabral lesions, and also bone marrow and adjacent soft tissue abnormalities. The MRI protocol should routinely include measurements of femoral torsion. Fluid-sensitive sequences should be acquired to rule out degenerative or inflammatory extra-articular changes.
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Affiliation(s)
- Iris-M Noebauer-Huhmann
- Universitätsklinik für Radiologie und Nuklearmedizin, Abteilung für Neuroradiologie und Muskuloskelettale Radiologie, Medizinische Universität Wien, Wien, Österreich.
| | - Felix R M Koenig
- Universitätsklinik für Radiologie und Nuklearmedizin, Abteilung für Neuroradiologie und Muskuloskelettale Radiologie, Medizinische Universität Wien, Wien, Österreich
| | - Catharina Chiari
- Universitätsklinik für Orthopädie und Unfallchirurgie, Klinische Abteilung für Orthopädie, Medizinische Universität Wien, Wien, Österreich
- Abteilung für Kinderorthopädie und Fußchirurgie, Orthopädisches Spital Speising, Wien, Österreich
| | - Florian Schmaranzer
- Universitätsklinik für Diagnostische‑, Interventionelle- und Pädiatrische Radiologie, Inselspital Bern, Universität Bern, Bern, Schweiz
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Flury A, Hoch A, Cirigliano G, Hodel S, Kühne N, Zimmermann SM, Vlachopoulos L, Fucentese SF. Excessive femoral torsion is not associated with patellofemoral pain or instability if TKA is functionally aligned and the patella denervated. Knee Surg Sports Traumatol Arthrosc 2023; 31:3665-3671. [PMID: 36114342 PMCID: PMC10435632 DOI: 10.1007/s00167-022-07162-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 09/05/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE Recent data suggest that individual morphologic factors should be respected to restore preoperative patellofemoral alignment and thus reduce the likelihood of anterior knee pain. The goal of this study was to investigate the effect of excessive femoral torsion (FT) on clinical outcome of TKA. METHODS Patients who underwent TKA and complete preoperative radiographic evaluation including a long-leg radiograph and CT scan were included. 51 patients showed increased FT of > 20° and were matched for age/sex to 51 controls (FT < 20°). Thirteen patients were lost to follow-up. Thirty-eight matched pairs were compared after a 2 year follow-up clinically (Kujala and patellofemoral score for TKA) and radiographically (FT, frontal leg axis, TT-TG, patellar thickness, patellar tilt, and lateral displacement of patella). Functional alignment of TKA was performed (hybrid-technique). All patellae were denervated but no patella was resurfaced. RESULTS There was no significant difference between clinical scores two years after surgery between patients with normal and excessive FT (n.s.). Kujala score was 64.3 ± 16.7 versus 64.8 ± 14.4 (n.s.), and patellofemoral score for TKA was 74.3 ± 21 versus 78.5 ± 20.7 (n.s.) for increased FT group and control group, respectively. There was no correlation between preoperative FT and clinical scores. Other radiographic parameters were similar between both groups. No correlations between clinical outcomes and preoperative/postoperative frontal leg axis or total leg axis correction were found (n.s.). CONCLUSION If the leg axis deformity is corrected to a roughly neutral alignment during cemented TKA, including patellar denervation, then excessive FT was not associated with patellofemoral pain or instability. LEVEL OF EVIDENCE Prospective comparative study, level II.
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Affiliation(s)
- Andreas Flury
- Orthopaedic Department, Balgrist University Hospital, University of Zurich, Forchstrasse 340, CH-8008, Zurich, Switzerland.
| | - Armando Hoch
- Orthopaedic Department, Balgrist University Hospital, University of Zurich, Forchstrasse 340, CH-8008, Zurich, Switzerland
| | - Gabriele Cirigliano
- Orthopaedic Department, Balgrist University Hospital, University of Zurich, Forchstrasse 340, CH-8008, Zurich, Switzerland
| | - Sandro Hodel
- Orthopaedic Department, Balgrist University Hospital, University of Zurich, Forchstrasse 340, CH-8008, Zurich, Switzerland
| | - Nathalie Kühne
- Orthopaedic Department, Balgrist University Hospital, University of Zurich, Forchstrasse 340, CH-8008, Zurich, Switzerland
| | - Stefan M Zimmermann
- Orthopaedic Department, Balgrist University Hospital, University of Zurich, Forchstrasse 340, CH-8008, Zurich, Switzerland
| | - Lazaros Vlachopoulos
- Orthopaedic Department, Balgrist University Hospital, University of Zurich, Forchstrasse 340, CH-8008, Zurich, Switzerland
| | - Sandro F Fucentese
- Orthopaedic Department, Balgrist University Hospital, University of Zurich, Forchstrasse 340, CH-8008, Zurich, Switzerland
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De Pieri E, Cip J, Brunner R, Weidensteiner C, Alexander N. The functional role of hip muscles during gait in patients with increased femoral anteversion. Gait Posture 2023; 100:179-187. [PMID: 36563590 DOI: 10.1016/j.gaitpost.2022.12.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 12/07/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Femoral anteversion affects the lever arm and moment-generating capacity of the hip abductors, while an increased hip internal rotation during walking was proposed to be a compensatory mechanism to restore the abductive lever arm. Children with isolated increased femoral anteversion, however, do not always present a deficit in the net hip abduction moment during gait, suggesting that a more comprehensive understanding of the effect of morphology and motion on muscle forces and moments is needed to aid clinical decision making. RESEARCH QUESTION Are muscle contributions to hip joint moments and muscle forces altered in patients with increased femoral anteversion and internally rotated gait pattern compared to a control group of typically developing children? And how would the functional role of the muscle be altered if the patients walked straight? METHODS This follow-up study compared patients with increased femoral anteversion (n = 42, 12.8 ± 1.9 years, femoral anteversion: 39.6 ± 6.9°) to controls (n = 9, 12.0 ± 3.0 years, femoral anteversion: 18.7 ± 4.1°). Muscle forces and moment contributions were calculated using personalized musculoskeletal models. Additionally, a hypothetical scenario, in which the gait of the controls was modelled with an anteverted femoral morphology, was used to understand what would happen if the patients walked straight. RESULTS Gluteus medius abductive contribution was lower in patients compared to controls, despite a comparable net abduction moment around the hip. Patients presented lower muscle forces. However, if modelled to walk straight, they would require higher forces as well as a larger co-contraction of both hip internal and external rotators in the transversal plane. SIGNIFICANCE This study suggests that patients with increased femoral anteversion walking with an internally rotated gait pattern present lower muscle forces, but when modelled to walk straight muscle forces increase. The current results provide important information to better understand this condition and improve treatment recommendations in these patients.
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Affiliation(s)
- Enrico De Pieri
- Laboratory for Movement Analysis, University of Basel Children's Hospital, Basel, Switzerland; Department of Biomedical Engineering, University of Basel, Basel, Switzerland
| | - Johannes Cip
- Department of Paediatric Orthopaedics, Children's Hospital of Eastern Switzerland, St. Gallen, Switzerland
| | - Reinald Brunner
- Laboratory for Movement Analysis, University of Basel Children's Hospital, Basel, Switzerland; Department of Biomedical Engineering, University of Basel, Basel, Switzerland; Department of Paediatric Orthopaedics, University of Basel Children's Hospital, Basel, Switzerland
| | - Claudia Weidensteiner
- Department of Biomedical Engineering, University of Basel, Basel, Switzerland; Division of Radiological Physics, Department of Radiology, University Hospital Basel, Basel, Switzerland
| | - Nathalie Alexander
- Laboratory for Motion Analysis, Department of Paediatric Orthopaedics, Children's Hospital of Eastern Switzerland, St. Gallen, Switzerland; Department of Orthopaedics and Traumatology, Cantonal Hospital St. Gallen, Switzerland.
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Ries AJ, Duffy EA, Schwartz MH, Novacheck TF, Chau MM. Interobserver reliability of biplanar radiography is unaffected by clinical factors relevant to individuals at risk of pathological lower limb torsion. Gait Posture 2023; 100:126-131. [PMID: 36521256 DOI: 10.1016/j.gaitpost.2022.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 11/08/2022] [Accepted: 12/07/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Assessments of lower limb torsion are ubiquitous in clinical gait analysis practice as pathologic lower limb rotational deformity may contribute to gait abnormalities, anterior knee pain, as well as other debilitating conditions. Understandably, the overall utility of any torsional assessment is dependent on the measurement method's intrinsic accuracy, precision, and robustness to clinical interference factors. Recently, biplanar radiography (BPR) measurements of torsion have been shown to be both accurate and precise, but the robustness of BPR to potential interference factors is unknown. RESEARCH QUESTION How robust are BPR lower limb torsional assessments to six potential interference factors: amount of torsion, skeletal maturity, radiograph quality, prior osteotomy, presence of implants, and observer training background and experience? METHODS In this retrospective cohort study, four observers of diverse backgrounds and experience generated digital 3D reconstructions of 44 lower limbs using BPR images obtained during standard of care visits (age range 7-35 years). From each reconstruction, four lower limb torsional parameters were computed: femoral torsion, femorotibial rotation, tibial torsion, and transmalleolar axis equivalent. The mean absolute deviation (MAD) of each torsional parameter - calculated across the four observers - was used as the measure of reliability and tested against all interference factors. RESULTS Results demonstrated that the average MAD was 2.1 degrees for femoral torsion, 3.0 degrees for transmalleolar axis equivalent, 3.8 degrees for femorotibial rotation, and 4.7 degrees for tibial torsion. None of the six potential interference factors were found to systematically influence BPR reliability across all four torsional parameters. Of the factors found to statistically influence one or more torsional parameter, none affected MAD values to a clinically meaningful extent. SIGNIFICANCE In addition to being accurate and precise, BPR appears to be robust to several clinical factors relevant to children and young adults with or at risk for pathological lower limb torsion.
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Affiliation(s)
- Andrew J Ries
- Gillette Children's Specialty Healthcare, St. Paul, MN 55101, USA.
| | | | - Michael H Schwartz
- Gillette Children's Specialty Healthcare, St. Paul, MN 55101, USA; University of Minnesota, Department of Orthopaedic Surgery, Minneapolis, MN 55455, USA
| | - Tom F Novacheck
- Gillette Children's Specialty Healthcare, St. Paul, MN 55101, USA; University of Minnesota, Department of Orthopaedic Surgery, Minneapolis, MN 55455, USA
| | - Michael M Chau
- University of Minnesota, Department of Orthopaedic Surgery, Minneapolis, MN 55455, USA
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Meier MK, Schmaranzer F, Kaim T, Tannast M, Novais EN, Siebenrock KA, Steppacher SD, Lerch TD. Combined femoral and acetabular version is sex-related and differs between patients with hip dysplasia and acetabular retroversion. Eur J Radiol 2023; 158:110634. [PMID: 36462225 DOI: 10.1016/j.ejrad.2022.110634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 11/23/2022] [Accepted: 11/24/2022] [Indexed: 11/30/2022]
Abstract
AIMS Frequency of abnormal femoral and acetabular version (AV) and combinations are unclear in patients with developmental dysplasia of the hip (DDH). This study aimed to investigate femoral version (FV), the proportion of increased FV and femoral retroversion, and combined-version (CV, FV+AV) in DDH patients and acetabular-retroversion (AR). PATIENTS AND METHODS A retrospective IRB-approved observational study was performed with 78 symptomatic DDH patients (90 hips) and 65 patients with femoroacetabular-impingement (FAI) due to AR (77 hips, diagnosis on AP radiographs). CT/MRI-based measurement of FV (Murphy method) and central AV were compared. Frequency of increased FV(FV > 25°), severely increased FV (FV > 35°) and excessive FV (FV > 45°) and of decreased FV (FV < 10°) and CV (McKibbin-index/COTAV-index) was analysed. RESULTS Mean FV and CV was significantly (p < 0.001) increased of DDH patients (mean ± SD of 25 ± 11° and 47 ± 18°) compared to AR (16 ± 11° and 28 ± 13°). Mean FV of female DDH patients (27 ± 16°) and AR (19 ± 12°) was significantly (p < 0.001) increased compared to male DDH patients (18 ± 13°) and AR (13 ± 8°). Frequency of increased FV (>25°) was 47% and of severely increased FV (>35°) was 23% for DDH patients. Proportion of femoral retroversion (FV < 10°) was significantly (p < 0.001) higher in patients AR (31%) compared to DDH patients (17%). 18% of DDH patients had AV > 25° combined with FV > 25°. Of patients with AR, 12% had FV < 10° combined with AV < 10°. CONCLUSION Patients with DDH and AR have remarkable sex-related differences of FV and CV. Frequency of severely increased FV > 35° (23%) is considerable for patients with DDH, but 17% exhibited decreased FV, that could influence management. The different combinations underline the importance of patient-specific evaluation before open hip preservation surgery (periacetabular osteotomy and femoral derotation osteotomy) and hip-arthroscopy.
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Affiliation(s)
- Malin K Meier
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Florian Schmaranzer
- Department of Diagnostic, Interventional and Paediatric Radiology, University of Bern, Inselspital, Bern University Hospital, Bern, Switzerland.
| | - Tilman Kaim
- Department of Diagnostic, Interventional and Paediatric Radiology, University of Bern, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Moritz Tannast
- Department of Orthopaedic Surgery and Traumatology, Fribourg Cantonal Hospital, University of Fribourg, Fribourg, Switzerland.
| | - Eduardo N Novais
- Department of Pediatric Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Klaus A Siebenrock
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Simon D Steppacher
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Till D Lerch
- Department of Diagnostic, Interventional and Paediatric Radiology, University of Bern, Inselspital, Bern University Hospital, Bern, Switzerland.
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9
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Waelti S, Fischer T, Griessinger J, Cip J, Dietrich TJ, Ditchfield M, Allmendinger T, Messerli M, Markart S. Ultra-low-dose computed tomography for torsion measurements of the lower extremities in children and adolescents. Insights Imaging 2022; 13:118. [PMID: 35838922 PMCID: PMC9287501 DOI: 10.1186/s13244-022-01257-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 06/23/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Quantifying femoral and tibial torsion is crucial in the preoperative planning for derotation surgery in children and adolescents. The use of an ultra-low-dose computed tomography (CT) protocol might be possible for modern CT scanners and suitable for reliable torsion measurements even though the bones are not completely ossified. METHODS This is a retrospective review of 77 children/adolescents (mean age 12.7 years) who underwent a lower extremity CT for torsion measurements on a 64-slice scanner. A stepwise dose reduction (70%, 50%, 30% of the original dose) was simulated. Torsion measurements were performed on all image datasets, and image noise, interrater agreement and subjective image quality were evaluated. Effective radiation dose of each original scan was estimated. As proof of concept, 24 children were scanned with an ultra-low-dose protocol, adapted from the 30% dose simulation, and the intra-class correlation coefficient (ICC) was determined. Ethics approval and informed consent were given. RESULTS Torsion measurements at the simulated 30% dose level had equivalent interrater agreement compared to the 100% dose level (ICC ≥ 0.99 for all locations and dose levels). Image quality of almost all datasets was rated excellent, regardless of dose. The mean sum of the effective dose of the total torsion measurement was reduced by simulation from 0.460/0.490 mSv (boys/girls) at 100% dose to 0.138/0.147 mSv at 30%. The ICC of the proof-of-concept group was as good as that of the simulated 30% dose level. CONCLUSION Pediatric torsion measurements of the lower extremities can be performed using an ultra-low-dose protocol without compromising diagnostic confidence.
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Affiliation(s)
- Stephan Waelti
- Department of Radiology and Nuclear Medicine, Children's Hospital of Eastern Switzerland, Claudiusstrasse 6, 9006, St. Gallen, Switzerland. .,Department of Radiology and Nuclear Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland.
| | - Tim Fischer
- Department of Radiology and Nuclear Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Jennifer Griessinger
- Radiation Protection and Medical Physics, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Johannes Cip
- Department of Orthopedic Surgery, Children's Hospital of Eastern Switzerland, St. Gallen, Switzerland
| | - Tobias Johannes Dietrich
- Department of Radiology and Nuclear Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Michael Ditchfield
- Department of Diagnostic Imaging, Monash Children's Hospital, Clayton, Australia
| | - Thomas Allmendinger
- Diagnostic Imaging, Computed Tomography, Siemens Healthcare, Forchheim, Germany
| | - Michael Messerli
- Department of Nuclear Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Stefan Markart
- Department of Radiology and Nuclear Medicine, Children's Hospital of Eastern Switzerland, Claudiusstrasse 6, 9006, St. Gallen, Switzerland.,Department of Radiology and Nuclear Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
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Häller TV, Schenk P, Jud L, Hoch A, Götschi T, Zingg PO. Consistency of 3D femoral torsion measurement from MRI compared to CT gold standard. BMC Musculoskelet Disord 2021; 22:739. [PMID: 34454445 PMCID: PMC8403345 DOI: 10.1186/s12891-021-04633-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 08/16/2021] [Indexed: 01/17/2023] Open
Abstract
Background Several hip and knee pathologies are associated with aberrant femoral torsion. Diagnostic workup includes computed tomography (CT) and magnetic resonance imaging (MRI). For three-dimensional (3D) analysis of complex deformities it would be desirable to measure femoral torsion from MRI data to avoid ionizing radiation of CT in a young patient population. 3D measurement of femoral torsion from MRI has not yet been compared to measurements from CT images. We hypothesize that agreement will exist between MRI and CT 3D measurements of femoral torsion. Methods CT and MRI data from 29 hips of 15 patients with routine diagnostic workup for suspected femoroacetabular impingement (FAI) were used to generate 3D bone models. 3D measurement of femoral torsion was performed by two independent readers using the method of Kim et al. which is validated for CT. Inter-modalitiy and inter-reader intraclass correlation coefficients (ICC) were calculated. Results Between MRI and CT 3D measurements an ICC of 0.950 (0.898; 0.976) (reader 1) respectively 0.950 (0.897; 0.976) (Reader 2) was found. The ICC (95% CI) expressing the inter-reader reliability for both modalities was 0.945 (0.886; 0.973) for MRI and 0.957 (0.910; 0.979) for CT, respectively. Mean difference between CT and MRI measurement was 0.42° (MRI – CT, SD: 2.77°, p = 0.253). Conclusions There was consistency between 3D measurements of femoral torsion between computer rendered MRI images compared to measurements with the “gold standard” of CT images. ICC for inter-modality and inter-reader consistency indicate excellent reliability. Accurate, reliable and reproducible 3D measurement of femoral torsion is possible from MRI images.
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Affiliation(s)
- Thomas Vincent Häller
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland.
| | - Pascal Schenk
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Lukas Jud
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Armando Hoch
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Tobias Götschi
- Computer Assisted Research and Development Group, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Patrick Oliver Zingg
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
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11
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Goronzy J, Franken L, Hartmann A, Thielemann F, Blum S, Günther KP, Nowotny J, Postler A. Acetabular- and femoral orientation after periacetabular osteotomy as a predictor for outcome and osteoarthritis. BMC Musculoskelet Disord 2020; 21:846. [PMID: 33357245 PMCID: PMC7764525 DOI: 10.1186/s12891-020-03878-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 12/14/2020] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Periacetabular osteotomy is a successful treatment for hip dysplasia. The results are influenced, however, by optimal positioning of the acetabular fragment, femoral head morphology and maybe even femoral version as well as combined anteversion have an impact. In order to obtain better insight on fragment placement, postoperative acetabular orientation and femoral morphology were evaluated in a midterm follow-up in regard to functional outcome and osteoarthritis progression. METHODS A follow-up examination with 49 prospectively documented patients (66 hips) after periacetabular osteotomy (PAO) was performed after 62.2 ± 18.6 months. Mean age of patients undergoing surgery was 26.7 ± 9.6 years, 40 (82%) of these patients were female. All patients were evaluated with an a.p. pelvic x-ray and an isotropic MRI in order to assess acetabular version, femoral head cover, alpha angle, femoral torsion and combined anteversion. The acetabular version was measured at the femoral head center as well as 0.5 cm below and 0.5 and 1 cm above the femoral head center and in addition seven modified acetabular sector angles were determined. Femoral torsion was assessed in an oblique view of the femoral neck. The combined acetabular and femoral version was calculated as well. To evaluate the clinical outcome the pre- and postoperative WOMAC score as well as postoperative Oxford Hip Score and Global Treatment Outcome were analyzed. RESULTS After PAO acetabular version at the femoral head center (31.4 ± 9.6°) was increased, the anterior cover at the 15 o'clock position (34.7 ± 15.4°) was reduced and both correlated significantly with progression of osteoarthritis, although not with the functional outcome. Combined acetabular and femoral torsion had no influence on the progression of osteoarthritis or outcome scores. CONCLUSION Long-term results after PAO are dependent on good positioning of the acetabular fragment in all 3 planes. Next to a good lateral coverage a balanced horizontal alignment without iatrogenic pincer impingement due to acetabular retroversion, or insufficient coverage of the anterior femoral head is important.
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Affiliation(s)
- Jens Goronzy
- University Center of Orthopedics and Traumatology, University Medicine Carl Gustav Carus Dresden, TU Dresden, Dresden, Germany
| | - Lea Franken
- University Center of Orthopedics and Traumatology, University Medicine Carl Gustav Carus Dresden, TU Dresden, Dresden, Germany
| | - Albrecht Hartmann
- University Center of Orthopedics and Traumatology, University Medicine Carl Gustav Carus Dresden, TU Dresden, Dresden, Germany
| | - Falk Thielemann
- University Center of Orthopedics and Traumatology, University Medicine Carl Gustav Carus Dresden, TU Dresden, Dresden, Germany
| | - Sophia Blum
- Department of Radiology, University Medicine Carl Gustav Carus Dresden, TU Dresden, Dresden, Germany
| | - Klaus-Peter Günther
- University Center of Orthopedics and Traumatology, University Medicine Carl Gustav Carus Dresden, TU Dresden, Dresden, Germany
| | - Jörg Nowotny
- University Center of Orthopedics and Traumatology, University Medicine Carl Gustav Carus Dresden, TU Dresden, Dresden, Germany
| | - Anne Postler
- University Center of Orthopedics and Traumatology, University Medicine Carl Gustav Carus Dresden, TU Dresden, Dresden, Germany
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12
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Lerch TD, Liechti EF, Todorski IAS, Schmaranzer F, Steppacher SD, Siebenrock KA, Tannast M, Klenke FM. Prevalence of combined abnormalities of tibial and femoral torsion in patients with symptomatic hip dysplasia and femoroacetabular impingement. Bone Joint J 2020; 102-B:1636-1645. [PMID: 33249913 DOI: 10.1302/0301-620x.102b12.bjj-2020-0460.r1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
AIMS The prevalence of combined abnormalities of femoral torsion (FT) and tibial torsion (TT) is unknown in patients with femoroacetabular impingement (FAI) and hip dysplasia. This study aimed to determine the prevalence of combined abnormalities of FT and TT, and which subgroups are associated with combined abnormalities of FT and TT. METHODS We retrospectively evaluated symptomatic patients with FAI or hip dysplasia with CT scans performed between September 2011 and September 2016. A total of 261 hips (174 patients) had a measurement of FT and TT. Their mean age was 31 years (SD 9), and 63% were female (165 hips). Patients were compared to an asymptomatic control group (48 hips, 27 patients) who had CT scans including femur and tibia available for analysis, which had been acquired for nonorthopaedic reasons. Comparisons were conducted using analysis of variance with Bonferroni correction. RESULTS In the overall study group, abnormal FT was present in 62% (163 hips). Abnormal TT was present in 42% (109 hips). Normal FT combined with normal TT was present in 21% (55 hips). The most frequent abnormal combination was increased FT combined with normal TT of 32% (84 hips). In the hip dysplasia group, 21% (11 hips) had increased FT combined with increased TT. The prevalence of abnormal FT varied significantly among the subgroups (p < 0.001). We found a significantly higher mean FT for hip dysplasia (31°; SD 15)° and valgus hips (42° (SD 12°)) compared with the control group (22° (SD 8°)). We found a significantly higher mean TT for hips with cam-type-FAI (34° (SD 6°)) and hip dysplasia (35° (SD 9°)) compared with the control group (28° (SD 8°)) (p < 0.001). CONCLUSION Patients with FAI had a high prevalence of combined abnormalities of FT and TT. For hip dysplasia, we found a significantly higher mean FT and TT, while 21% of patients (11 hips) had combined increased TT and increased FT (combined torsional malalignment). This is important when planning hip preserving surgery such as periacetabular osteomy and femoral derotation osteotomy. Cite this article: Bone Joint J 2020;102-B(12):1636-1645.
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Affiliation(s)
- Till D Lerch
- Department of Orthopaedic Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,University Institute of Diagnostic, Interventional and Paediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Emanuel F Liechti
- Department of Orthopaedic Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Inga A S Todorski
- Department of Orthopaedic Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,University Institute of Diagnostic, Interventional and Paediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Florian Schmaranzer
- Department of Orthopaedic Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,University Institute of Diagnostic, Interventional and Paediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Simon D Steppacher
- Department of Orthopaedic Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Klaus A Siebenrock
- Department of Orthopaedic Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Moritz Tannast
- Department of Orthopaedic Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Department of Orthopaedic Surgery and Traumatology, Fribourg Cantonal Hospital, University of Fribourg, Fribourg, Switzerland
| | - Frank M Klenke
- Department of Orthopaedic Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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13
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Riad J, Finnbogason T, Broström E. Anatomical and dynamic rotational alignment in spastic unilateral cerebral palsy. Gait Posture 2020; 81:153-158. [PMID: 32738739 DOI: 10.1016/j.gaitpost.2020.07.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 06/30/2020] [Accepted: 07/07/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Even in mild unilateral cerebral palsy increased internal hip rotation can be noted on physical- and gait examination. The influence of spasticity on femoral growth in the transverse plane is not clear. These deviations and asymmetry in movement pattern may negatively affect efficiency of gait and cause psychological concerns about appearance. RESEARCH QUESTION Is increased internal hip rotation on the involved side in mild unilateral CP common and is there compensatory external pelvic rotation to keep foot progression symmetrical? METHODS This prospective study included 45 individuals with unilateral cerebral palsy, mean age 17.7 (13.0-24.0) years. All were Gross Motor Function Classification Level I. Physical examination, three-dimensional gait analysis and magnetic resonance imaging for assessment of rotational alignment was performed. RESULTS On physical examination internal hip rotation was mean 50.6 (SD 10.4) degrees on the involved side and 44.3 (SD 10.3) on the non-involved side, p = 0.001. In gait analysis calculating the whole gait cycle, internal hip rotation was mean 2.3 (6.2) degrees on the involved side, and on the non-involved side external 1.8 (7.6) degrees, p = 0.004. Increased external pelvic rotation was noted on the involved side, mean 2.0 (4.3) degrees with corresponding internal rotation on the non-involved side, mean 3.6 (4.4), p = 0.001. There was no difference in foot progression, p = 0.067, with mean 5.1 (8.6) and 3.9 (6.4) external respectively. Magnetic resonance imaging revealed femoral torsion on the involved side mean 17.3 (11.3) degrees compared to 11.4 (10.8) on the non-involved side, p = 0.001. SIGNIFICANCE Transverse plane asymmetry in the femur was noted in mild unilateral cerebral palsy. Increased anatomical and dynamic internal rotation was compensated for by external pelvic rotation. Rotational malalignment may contribute to gait deviations in this mild group and should be part of the overall assessment.
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Affiliation(s)
- Jacques Riad
- Dept of Orthopedics, Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Dept of Orthopedics Skaraborgs Hospital, Skövde, Sweden; Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.
| | - Thröstur Finnbogason
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.
| | - Eva Broström
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.
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14
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Yang G, Dai Y, Dong C, Kang H, Niu J, Lin W, Wang F. Distal femoral morphological dysplasia is correlated with increased femoral torsion in patients with trochlear dysplasia and patellar instability. Bone Joint J 2020; 102-B:868-873. [PMID: 32600137 DOI: 10.1302/0301-620x.102b7.bjj-2019-1331.r1] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
AIMS The purpose of this study was to explore the correlation between femoral torsion and morphology of the distal femoral condyle in patients with trochlear dysplasia and lateral patellar instability. METHODS A total of 90 patients (64 female, 26 male; mean age 22.1 years (SD 7.2)) with lateral patellar dislocation and trochlear dysplasia who were awaiting surgical treatment between January 2015 and June 2019 were retrospectively analyzed. All patients underwent CT scans of the lower limb to assess the femoral torsion and morphology of the distal femur. The femoral torsion at various levels was assessed using the a) femoral anteversion angle (FAA), b) proximal and distal anteversion angle, c) angle of the proximal femoral axis-anatomical epicondylar axis (PFA-AEA), and d) angle of the AEA-posterior condylar line (AEA-PCL). Representative measurements of distal condylar length were taken and parameters using the ratios of the bianterior condyle, biposterior condyle, bicondyle, anterolateral condyle, and anteromedial condyle were calculated and correlated with reference to the AEA, using the Pearson Correlation coefficient. RESULTS The femoral torsion had a strong correlation with distal condylar morphology. The FAA was significantly correlated with the ratio of the bianterior condyle (r = 0.355; p = 0.009), the AEA-PCL angle (r = 0.340; p = 0.001) and the ratio of the anterolateral condyle and lateral condyle (ALC-LC) (r = 0.309; p = 0.014). The PFA-AEA angle was also significantly correlated with the ratio of the bianterior condyle (r = 0.319; p = 0.008), the AEA-PCL angle (r = 0.231; p = 0.031), and the ratio of ALC-LC (r = 0.261; p = 0.034). In addition, the bianterior condyle ratio showed a significant correlation with the biposterior condyle ratio (r = -0.324; p = 0.027) and the AEA-PCL angle (r = 0.342; p = 0.021). CONCLUSION Increased femoral torsion correlated with a prominent anterolateral condyle and a shorter posterolateral condyle compared with the medial condyle. The deformities of the anterior and posterior condyles are combined deformities rather than being isolated and individual deformities in patients with trochlear dysplasia and patella instability. Cite this article: Bone Joint J 2020;102-B(7):868-873.
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Affiliation(s)
- Guangmin Yang
- Department of Joint Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Yike Dai
- Department of Joint Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Conglei Dong
- Department of Joint Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Huijun Kang
- Department of Joint Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Jinghui Niu
- Department of Joint Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Wei Lin
- Department of Joint Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Fei Wang
- Department of Joint Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
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15
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Lerch TD, Schmaranzer F, Hanke MS, Leibold C, Steppacher SD, Siebenrock KA, Tannast M. [Torsional deformities of the femur in patients with femoroacetabular impingement : Dynamic 3D impingement simulation can be helpful for the planning of surgical hip dislocation and hip arthroscopy]. Orthopade 2020; 49:471-481. [PMID: 31853580 DOI: 10.1007/s00132-019-03847-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Torsional deformities of the femur include femoral retrotorsion and increased femoral torsion, which are possible causes for hip pain and osteoarthritis. For patients with femoroacetabular impingement (FAI), torsional deformities of the femur represent an additional cause of FAI in addition to cam and pincer-type FAI. OBJECTIVES The aim of this article is to provide an overview of measurement techniques and normal values of femoral torsion. The clinical presentation, possible combinations and surgical therapy of patients with torsional deformities of the femur will be discussed. METHODS For measurement of femoral torsion, CT or MRI represent the method of choice. The various definitions should be taken into account, because they can lead to differing values and misdiagnosis. This is the case especially for patients with high femoral torsion. Dynamic 3D impingement simulation using 3D-CT can help to differentiate between intra und extra-articular FAI. RESULTS AND DISCUSSION Femoral retrotorsion (< 5°) can lead to anterior intra- and extraarticular (subspine) FAI, between the anterior iliac inferior spine (AIIS) and the proximal femur. Increased femoral torsion (> 35°) can lead to posterior intra- and extra-articular ischiofemoral FAI, between the lesser/greater trochanter and the ischial tuberosity. During clinical examination, a patient with femoral retrotorsion exhibits loss of internal rotation and a positive anterior impingement test. Hips with increased femoral torsion show high internal rotation if examined in prone position and have a positive FABER and posterior impingement test. During surgical therapy for patients with torsional deformities, intra and extra-articular causes for FAI in addition to cam and pincer-deformities should be considered. In addition to hip arthroscopy and surgical hip dislocation, also femoral rotational or derotational osteotomies should be evaluated during surgical planning of these patients.
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Affiliation(s)
- Till D Lerch
- Universitätsklinik für orthopädische Chirurgie und Traumatologie, Inselspital, Universität Bern, Freiburgstraße, 3010, Bern, Schweiz.
| | - Florian Schmaranzer
- Universitätsklinik für orthopädische Chirurgie und Traumatologie, Inselspital, Universität Bern, Freiburgstraße, 3010, Bern, Schweiz.,Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie, Inselspital, Universität Bern, Bern, Schweiz
| | - Markus S Hanke
- Universitätsklinik für orthopädische Chirurgie und Traumatologie, Inselspital, Universität Bern, Freiburgstraße, 3010, Bern, Schweiz
| | - Christiane Leibold
- Universitätsklinik für orthopädische Chirurgie und Traumatologie, Inselspital, Universität Bern, Freiburgstraße, 3010, Bern, Schweiz
| | - Simon D Steppacher
- Universitätsklinik für orthopädische Chirurgie und Traumatologie, Inselspital, Universität Bern, Freiburgstraße, 3010, Bern, Schweiz
| | - Klaus A Siebenrock
- Universitätsklinik für orthopädische Chirurgie und Traumatologie, Inselspital, Universität Bern, Freiburgstraße, 3010, Bern, Schweiz
| | - Moritz Tannast
- Universitätsklinik für orthopädische Chirurgie und Traumatologie, Inselspital, Universität Bern, Freiburgstraße, 3010, Bern, Schweiz.,Klinik für Orthopädische Chirurgie und Traumatologie, HFR Freiburg - Kantonsspital, Universität Freiburg, Chemin des Pensionnats 2-6, 1708, Freiburg, Schweiz
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16
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de Pina Cabral F, Figueiredo F, Todorski I, Toledo de Araujo LC, Locks R, Aguiar DP. Femoral torsion evaluation by computed tomography in a young Brazilian population with hip pain and femoroacetabular impingement. J Orthop 2020; 18:32-35. [PMID: 32189880 DOI: 10.1016/j.jor.2019.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 10/19/2019] [Indexed: 01/17/2023] Open
Abstract
Introduction The aim of the study was to evaluate femoral torsion (FT) by computed tomography (CT) in young patients with hip pain and femoroacetabular impingement (FAI) in a Brazilian population. After the diagnosis of impingement, the complete analysis from the hip biomechanics and morphology has become essential. Methods Forty-one patients from 18 to 45 years presenting hip pain without arthrosis (Tönnis<2) were evaluated by CT scan from February 2017 to February 2018. All patients presented hip pain for at least 3 months and FAI. They have followed the same radiographic protocol and modified Harris Hip Score (mHHS) evaluation. Statistical analyses by software R version 3.4.4. with significance p < 0,05. Results After exclusion criterias, twenty-six patients (9 bilateral) were included, mostly man (73%). The average age was 35 years for both genders. BMI was 19 kg/m2 for women and 24 kg/m2 for men and the mean modified Harris Hip Score was 67 points. We have found femoral torsion changes in 11 hips with pain (31%) and high variability (60%). The mean FT was 14,5°, ranging from 0 to 39°. Patients with hip pain, CAM impingement and altered FT had no correlation when compared to controls (without pain) (p = 0.234), neither Mixed impingement (p = 0.314). Patients with Pincer impingement and painful hips had higher FT (16,63°) than controls (11,77°) (p = 0.045). Conclusion: The presence of torsional alterations in almost 1/3 of the patients with FAI and the high variability reveal the importance of measuring FT at this disease.
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Affiliation(s)
- Fernando de Pina Cabral
- Department of Orthopaedics, SOS Cardio Hospital, Rodovia SC 401, 121 Itacorubi, Florianópolis, SC, Brazil
| | - Felipe Figueiredo
- Department of Reserch, National Institute of Traumatology and Orthopaedics Jamil Haddad, Av. Brasil, 500 Caju, Rio de Janeiro, RJ, Brazil
| | - Inga Todorski
- Department of Radiology, Inselspital, Freiburgstrasse 18, 3010, Bern, Switzerland
| | - Lucio C Toledo de Araujo
- Department of Orthopaedics, Regional Hospital of São José Dr Homero de Miranda Gomes, R. Adolfo Donato da Silva S/n Praia Comprida, São José, SC, Brazil
| | - Renato Locks
- Department of Orthopaedics, Regional Hospital of São José Dr Homero de Miranda Gomes, R. Adolfo Donato da Silva S/n Praia Comprida, São José, SC, Brazil
| | - Diego Pinheiro Aguiar
- Department of Reserch, National Institute of Traumatology and Orthopaedics Jamil Haddad, Av. Brasil, 500 Caju, Rio de Janeiro, RJ, Brazil
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17
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Imhoff FB, Funke V, Muench LN, Sauter A, Englmaier M, Woertler K, Imhoff AB, Feucht MJ. The complexity of bony malalignment in patellofemoral disorders: femoral and tibial torsion, trochlear dysplasia, TT-TG distance, and frontal mechanical axis correlate with each other. Knee Surg Sports Traumatol Arthrosc 2020; 28:897-904. [PMID: 31127313 DOI: 10.1007/s00167-019-05542-y] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 05/14/2019] [Indexed: 01/26/2023]
Abstract
PURPOSE Several anatomic risk factors associated with patellofemoral disorders have been described. The purpose of this study was to analyze the relationship between bony parameters commonly used to analyze and define patellofemoral malalignment. METHODS Patients with patellofemoral disorders presenting between 2016 and 2018 who underwent a standardized radiographic workup including conventional radiographs, weight bearing full-leg radiographs, magnetic resonance imaging (MRI) of the knee, and torsional analysis using hip-knee-ankle MRI were initially included. Patients with a history of lower extremity fracture and a history of surgical procedures affecting bony alignment or partial/total arthroplasty were subsequently excluded. Radiographs and MRI of all included patients were analyzed by four independent observers. Parameters of interest were: femoral torsion, tibial torsion, trochlear dysplasia, tibial tuberosity-trochlear groove (TT-TG) distance, and frontal mechanical axis. All parameters were compared between patients with low grade and high grade trochlear dysplasia as well as between female and male patients. Correlation of continuous variables was assessed with the Pearson correlation coefficient. A binary logistic regression model was used for the calculation of odds ratio between different parameters. Interclass correlation coefficients (ICC) were calculated to determine the interobserver reproducibility. RESULTS A total of 151 patients could be included for detailed analysis. Group comparison revealed that patients with high grade trochlear dysplasia showed significantly higher values for femoral torsion (low grade: 9.8° ± 11.0°, high grade: 16.8° ± 11.5°; p < 0.001) and significantly higher values for TT-TG distance (low grade: 19.0 mm ± 5.0 mm, high grade: 21.9 mm ± 5.4 mm; p = 0.002). No significant difference was found for age, tibial torsion, and frontal mechanical axis. With regard to gender, female patients had higher values for femoral torsion (female: 15.6° ± 11.3°, male: 11.0° ± 12.7°; p = 0.044). The correlation analysis found significant correlation between femoral torsion and tibial torsion (r = 0.244, p = 0.003), femoral torsion and TT-TG distance (r = 0.328, p < 0.001), femoral torsion and frontal mechanical axis (r = 0.291, p < 0.001), and tibial torsion and TT-TG distance (r = 0.182, p = 0.026). CONCLUSION Bony malalignment in patients with patellofemoral disorder is a complex problem given the significant correlation between femoral and tibial torsion, trochlear dysplasia, TT-TG distance, and frontal mechanical axis. Advanced imaging to analyze rotational and frontal plane alignment is recommended in patients with trochlear dysplasia and/or increased TT-TG on standard radiographs and knee MRI. Understanding of the bony pathology in patellofemoral disorders is key to improve the therapeutic and surgical decision. LEVEL OF EVIDENCE III, retrospective cohort study.
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18
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Lerch TD, Eichelberger P, Baur H, Schmaranzer F, Liechti EF, Schwab JM, Siebenrock KA, Tannast M. Prevalence and diagnostic accuracy of in-toeing and out-toeing of the foot for patients with abnormal femoral torsion and femoroacetabular impingement: implications for hip arthroscopy and femoral derotation osteotomy. Bone Joint J 2019; 101-B:1218-1229. [PMID: 31564157 DOI: 10.1302/0301-620x.101b10.bjj-2019-0248.r1] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Abnormal femoral torsion (FT) is increasingly recognized as an additional cause for femoroacetabular impingement (FAI). It is unknown if in-toeing of the foot is a specific diagnostic sign for increased FT in patients with symptomatic FAI. The aims of this study were to determine: 1) the prevalence and diagnostic accuracy of in-toeing to detect increased FT; 2) if foot progression angle (FPA) and tibial torsion (TT) are different among patients with abnormal FT; and 3) if FPA correlates with FT. PATIENTS AND METHODS A retrospective, institutional review board (IRB)-approved, controlled study of 85 symptomatic patients (148 hips) with FAI or hip dysplasia was performed in the gait laboratory. All patients had a measurement of FT (pelvic CT scan), TT (CT scan), and FPA (optical motion capture system). We allocated all patients to three groups with decreased FT (< 10°, 37 hips), increased FT (> 25°, 61 hips), and normal FT (10° to 25°, 50 hips). Cluster analysis was performed. RESULTS We found a specificity of 99%, positive predictive value (PPV) of 93%, and sensitivity of 23% for in-toeing (FPA < 0°) to detect increased FT > 25°. Most of the hips with normal or decreased FT had no in-toeing (false-positive rate of 1%). Patients with increased FT had significantly (p < 0.001) more in-toeing than patients with decreased FT. The majority of the patients (77%) with increased FT walk with a normal foot position. The correlation between FPA and FT was significant (r = 0.404, p < 0.001). Five cluster groups were identified. CONCLUSION In-toeing has a high specificity and high PPV to detect increased FT, but increased FT can be missed because of the low sensitivity and high false-negative rate. These results can be used for diagnosis of abnormal FT in patients with FAI or hip dysplasia undergoing hip arthroscopy or femoral derotation osteotomy. However, most of the patients with increased FT walk with a normal foot position. This can lead to underestimation or misdiagnosis of abnormal FT. We recommend measuring FT with CT/MRI scans in all patients with FAI. Cite this article: Bone Joint J 2019;101-B:1218-1229.
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Affiliation(s)
- Till D Lerch
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Patric Eichelberger
- Bern University of Applied Sciences Health, Physiotherapy, Bern, Switzerland
| | - Heiner Baur
- Bern University of Applied Sciences Health, Physiotherapy, Bern, Switzerland
| | - Florian Schmaranzer
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Emanuel F Liechti
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Joe M Schwab
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Klaus A Siebenrock
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Moritz Tannast
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Department of Orthopaedic Surgery and Traumatology, Fribourg Cantonal Hospital, University of Fribourg, Fribourg, Switzerland
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Vanhove F, Noppe N, Fragomen AT, Hoekstra H, Vanderschueren G, Metsemakers WJ. Standardization of torsional CT measurements of the lower limbs with threshold values for corrective osteotomy. Arch Orthop Trauma Surg 2019; 139:795-805. [PMID: 30737593 DOI: 10.1007/s00402-019-03139-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Re-establishing anatomic rotational alignment of shaft fractures of the lower extremities remains challenging. Clinical evaluation in combination with radiological measurements is important in pre- and post-surgical assessment. Based on computed tomography (CT), a range of reference values for femoral torsion (FT) and tibial torsion (TT) have historically been reported, which require standardization to optimize the significant intra- and inter-observer variability. The aims of this study were (re-)evaluation of the reference FT and TT angles, determination of the normal intra-individual side-to-side torsional differences to aid the surgical decision-making process for reoperation, and development of a novel 3D measurement method for FT. MATERIALS AND METHODS In this retrospective study, we included 55 patients, without any known torsional deformities of the lower extremities. Two radiologists, independently, measured the rotational profile of the femora using the Hernandez and Weiner CT methods for FT, and the tibiae using the bimalleolar method for TT. The intra-individual side-to-side difference in paired femora and paired tibiae was determined. A 3D technique for FT assessment using InSpace® was designed. RESULTS FT and TT demographic values were lower than previously reported, with mean FT values of 5.1°-8.8° and mean TT values of 25.5°-27.7°. Maximal side-to-side differences were 12°-13° for FT and 12° for TT. The Weiner method for FT was less variable than the Hernandez method. The new 3D method was equivocal to the conventional CT measurements. CONCLUSION The results from this study showed that the maximal side-to-side tolerance in asymptomatic normal adult lower extremities is 12°-13° for FT and 12° for TT, which could be a useful threshold for surgeons as indication for revision surgery (e.g., derotational osteotomy). We developed a new 3D CT method for FT measurement which is similar to 2D and could be used in the future for virtual 3D planning.
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Ferlic PW, Runer A, Seeber C, Thöni M, Seitlinger G, Liebensteiner MC. Segmental torsion assessment is a reliable method for in-depth analysis of femoral alignment in Computer Tomography. Int Orthop 2017; 42:1227-1231. [PMID: 28808753 DOI: 10.1007/s00264-017-3598-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 07/31/2017] [Indexed: 11/30/2022]
Abstract
PURPOSE De-rotational osteotomies are indicated in patients with pathologic femoral torsion. However, there is disagreement whether an osteotomy should be performed proximally or distally. Conventionally only the total torsion is measured, which does not allow differentiation between a torsional deformity located in the proximal or distal metaphysis or the diaphysis. The aim of this study is to validate a new multi-level measurement protocol for evaluation of the magnitude of torsion of the respective femoral segments in CT. PATIENTS AND METHODS The torsional profile of 30 femora was evaluated in CT scans. For separate measurements of the torsion of the metaphysis and the diaphysis, four axes where determined: one through the femoral neck, a second determined by the midpoint of the femoral shaft and the lesser trochanter, a third determined by a tangent dorsal to the popliteal surface, and a fourth axis posterior to the condyles. The total femoral torsion was measured between the first and the fourth axis, proximal torsion between the first and the second, mid torsion between the second and the third, and distal torsion between the third and the fourth axis. Four investigators performed all measurements independently and intra-class correlation coefficients (ICC) were calculated to evaluate intra- and inter-rater reliability. RESULTS Average total femoral torsion was 22.6 ± 8.7°, proximal torsion 47.7 ± 10.6°, mid torsion -33.4 ± 9.9°, and distal torsion 8.3 ± 3.2°. Intra-rater ICC ranged between 0.504 and 0.957 and inter-rater ICC between 0.643 and 0.992. The majority of the ICC were graded as "almost perfect" and some as "substantial" agreement. CONCLUSION Evaluation of the segmental torsion of the femur allows in-depth analysis of femoral alignment. High reliability was shown for this measuring method in computed tomography, which can be deployed when studying interdependencies between joint pathologies and torsional deformities or when planning the site for an osteotomy. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Peter Wilhelm Ferlic
- Department of Orthopaedic Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
| | - Armin Runer
- Department of Orthopaedic Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Christopher Seeber
- Department of Orthopaedic Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Maria Thöni
- Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Gerd Seitlinger
- General Hospital Oberndorf, Teaching Hospital of Paracelsus Medical University Salzburg, Oberndorf, Austria
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21
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Rosskopf AB, Agten CA, Ramseier LE, Pfirrmann CWA, Buck FM. Femoral torsion assessment with MRI in children: Should we use the bony or cartilaginous contours? Eur J Radiol 2017. [PMID: 28624013 DOI: 10.1016/j.ejrad.2017.04.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To assess whether the use of cartilaginous contours at the femoral condyles instead of bony contours significantly changes femoral torsion measurements in children. MATERIALS AND METHODS Femoral torsion was measured in 32 girls (mean age 10.1 years±2.3 standard deviation) and 42 boys (10.9 years±2.5) on axial magnetic resonance (MR) images by two independent readers (R1,R2). The femoral condyle angle was measured using each the cartilaginous and bony contours of the distal femur. Cartilage thickness at femoral condyles was assessed. Intraclass-correlation-coefficient (ICC) and Pearson's correlation were used for statistical analysis. RESULTS Mean difference between cartilaginous and bony femoral torsion in girls was -1.1°±1.75 (range, -5.4° to 3.1°) for R1 and -1.64°±1.67 (-6.3° to 2.1°) for R2, in boys -1.5°±1.87 (-8.4° to 1.1°) for R1 and -2.28°±1.48 (-4.3° to 9.7°) for R2. Weak-to-moderate correlations between difference of cartilaginous-versus-bony measurements and cartilage thickness (r=-0.15 to -0.55, P<0.001-0.46) or age (r=-0.33 to 0.46, P<0.001-0.006) were found for both genders. Intermethod-ICC for cartilaginous versus bony femoral torsion measurements was 0.99/0.99 for R1/R2 in girls, and 0.99/0.98 in boys. CONCLUSION There is only a small difference when measuring femoral torsion through cartilaginous versus bony contours, and no major difference in this between boys and girls.
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Affiliation(s)
- Andrea B Rosskopf
- Radiology, Orthopedic University Hospital Balgrist, Forchstrasse 340, CH-8008 Zurich, Switzerland; University of Zurich, Faculty of Medicine, Zurich, Switzerland.
| | - Christoph A Agten
- Radiology, Orthopedic University Hospital Balgrist, Forchstrasse 340, CH-8008 Zurich, Switzerland; University of Zurich, Faculty of Medicine, Zurich, Switzerland.
| | - Leonhard E Ramseier
- University of Zurich, Faculty of Medicine, Zurich, Switzerland; Department of Orthopedic Surgery, Balgrist Orthopedic University Hospital, Zurich, Switzerland.
| | - Christian W A Pfirrmann
- Radiology, Orthopedic University Hospital Balgrist, Forchstrasse 340, CH-8008 Zurich, Switzerland; University of Zurich, Faculty of Medicine, Zurich, Switzerland.
| | - Florian M Buck
- Radiology, Orthopedic University Hospital Balgrist, Forchstrasse 340, CH-8008 Zurich, Switzerland; University of Zurich, Faculty of Medicine, Zurich, Switzerland.
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22
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Rosskopf AB, Buck FM, Pfirrmann CWA, Ramseier LE. Femoral and tibial torsion measurements in children and adolescents: comparison of MRI and 3D models based on low-dose biplanar radiographs. Skeletal Radiol 2017; 46:469-476. [PMID: 28154901 DOI: 10.1007/s00256-017-2569-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 12/31/2016] [Accepted: 01/05/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The aim of our study was to evaluate the reliability and interchangeability of femoral (FT) and tibial torsion (TT) measurements in children using magnetic resonance (MR) imaging compared to measurements on 3D models based on biplanar radiographs (BPR). MATERIALS AND METHODS FT and TT were measured in 60 children (mean age 10.1 years; range 6.2-16.2 years; 28 female) using axial MR images by two readers. MR measurements were compared to measurements based on BPR-3D models by two separate independent readers. Interreader and intermethod agreements were calculated using descriptive statistics, the intraclass correlation coefficient (ICC), and Bland-Altman analysis. RESULTS FT/TT was -8.4°-54.1°/0°-45.9° on MR images and -13°-63°/4°-52° for measurements on BPR-3D models. The median of difference between the two methods was -0.18° (range -13.6°-19.1°) for FT and -0.20° (range -18.4°-9.5°) for TT, respectively. Interreader agreement (ICC) of FT/TT measurements was 0.98/0.96 on MR images and 0.98/0.94 on BPR 3D models. Intermethod agreement (ICC) for MR measurements was 0.95 [95% confidence interval (CI), 0.93-0.96] for FT and of 0.86 (CI, 0.24-0.95) for TT. Mean interreader differences at MR were 3.1° (0.0°-8.0°) for FT and 3.2° (0.1°-9.5°) for TT. On Bland-Altman plots all measurements were within the 95% limit of agreement (-10.8°; 11.5° for FT; -14.6°; 4.2°) for TT-except for five measurements of FT and six measurements of TT. CONCLUSION FT measurements on MR images are comparable to measurements using BPR-3D models. TT measurements differ between the two modalities, but the discrepancy is comparable to measurement variations between CT and BPR.
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Affiliation(s)
- Andrea B Rosskopf
- Radiology, University Hospital Balgrist, Forchstrasse 340, CH-8008, Zurich, Switzerland. .,University of Zurich, Faculty of Medicine, Zurich, Switzerland.
| | - Florian M Buck
- Radiology, University Hospital Balgrist, Forchstrasse 340, CH-8008, Zurich, Switzerland.,University of Zurich, Faculty of Medicine, Zurich, Switzerland
| | - Christian W A Pfirrmann
- Radiology, University Hospital Balgrist, Forchstrasse 340, CH-8008, Zurich, Switzerland.,University of Zurich, Faculty of Medicine, Zurich, Switzerland
| | - Leonhard E Ramseier
- University of Zurich, Faculty of Medicine, Zurich, Switzerland.,Department of Orthopedic Surgery, University Hospital Balgrist, Zurich, Switzerland
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Knafo J, Thelen T, Verdier D, Creppy L, Tournier C, Fabre T. Reproducibility of low-dose stereography measurements of femoral torsion after IM nailing of femoral shaft fractures and in intact femurs. Orthop Traumatol Surg Res 2016; 102:595-9. [PMID: 27364964 DOI: 10.1016/j.otsr.2016.03.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Revised: 03/16/2016] [Accepted: 03/21/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Rotational malunion is a complication of intramedullary (IM) nailing for femur fractures. Symptoms can appear with 15° or more of axial deformity. None of the currently available measurement methods have a satisfactory reliability/irradiation ratio. The purpose of this study was to study the reproducibility of measuring femoral torsion with an EOS(®) low-dose stereography (LDX) system. HYPOTHESIS LDX is a reproducible method for measuring post-traumatic femoral torsion. MATERIAL AND METHODS The intra- and inter-observer reproducibility was studied in 45 patients who had a femoral fracture treated by IM nailing. Both the injured and contralateral healthy femurs were modelled. Bland-Altman plots were used to analyze the measurements made by three different observers (two orthopedic surgeons and one radiologist). For a given comparison, the interval between the upper limit of agreement (ULA) and lower limit of agreement (LLA) had to be within [-5°; 5°] for the examination to qualify as reproducible. Measurements were made by three observers (A, B, C) on the injured and healthy femur. RESULTS With the fractured femurs (n=39), the intra-observer [LLA; ULA] interval was [-16.295; 12.977]; it was [-18.475; 16.744] for the A-B pairing, [-13.316; 13.532] for the B-C pairing and [-17.839; 19.355] for the A-C pairing. With the healthy femurs (n=37), the intra-observer [LLA; ULA] interval was [-7.909; 7.88]; it was [-11.924; 11.639] for the A-B pairing, [-12.654; 11.93] for the B-C pairing and [-11; 12.009] for the A-C pairing. DISCUSSION The [LLA; ULA] intervals were greater than the [-5; +5] interval in all cases. LDX reproducibility is not sufficient for measuring femoral torsion after fracture or in healthy femurs. Observer experience, cohort size and the perfectible image quality are likely sources of bias. Conversely, the use of Bland-Altman plots and the multidisciplinary training of observers are major strengths of this study. Reproducibility will likely improve as the software is developed further and the image acquisition improves.
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Affiliation(s)
- J Knafo
- CHU Pellegrin, place Amélie-Raba-Léon, 33000 Bordeaux, France.
| | - T Thelen
- CHU Pellegrin, place Amélie-Raba-Léon, 33000 Bordeaux, France
| | - D Verdier
- CHU Pellegrin, place Amélie-Raba-Léon, 33000 Bordeaux, France
| | - L Creppy
- CHU Pellegrin, place Amélie-Raba-Léon, 33000 Bordeaux, France
| | - C Tournier
- CHU Pellegrin, place Amélie-Raba-Léon, 33000 Bordeaux, France
| | - T Fabre
- CHU Pellegrin, place Amélie-Raba-Léon, 33000 Bordeaux, France
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Passmore E, Pandy MG, Graham HK, Sangeux M. Measuring Femoral Torsion In Vivo Using Freehand 3-D Ultrasound Imaging. Ultrasound Med Biol 2016; 42:619-623. [PMID: 26639301 DOI: 10.1016/j.ultrasmedbio.2015.10.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 10/16/2015] [Accepted: 10/18/2015] [Indexed: 06/05/2023]
Abstract
Despite variation in bone geometry, muscle and joint function is often investigated using generic musculoskeletal models. Patient-specific bone geometry can be obtained from computerised tomography, which involves ionising radiation, or magnetic resonance imaging (MRI), which is costly and time consuming. Freehand 3-D ultrasound provides an alternative to obtain bony geometry. The purpose of this study was to determine the accuracy and repeatability of 3-D ultrasound in measuring femoral torsion. Measurements of femoral torsion were performed on 10 healthy adults using MRI and 3-D ultrasound. Measurements of femoral torsion from 3-D ultrasound were, on average, smaller than those from MRI (mean difference = 1.8°; 95% confidence interval: -3.9°, 7.5°). MRI and 3-D ultrasound had Bland and Altman repeatability coefficients of 3.1° and 3.7°, respectively. Accurate measurements of femoral torsion were obtained with 3-D ultrasound offering the potential to acquire patient-specific bone geometry for musculoskeletal modelling. Three-dimensional ultrasound is non-invasive and relatively inexpensive and can be integrated into gait analysis.
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Affiliation(s)
- Elyse Passmore
- Hugh Williamson Gait Analysis Laboratory, Royal Children's Hospital, Melbourne, Australia; Murdoch Childrens Research Institute, Melbourne, Australia; Department of Mechanical Engineering, University of Melbourne, Melbourne, Australia.
| | - Marcus G Pandy
- Department of Mechanical Engineering, University of Melbourne, Melbourne, Australia
| | - H Kerr Graham
- Hugh Williamson Gait Analysis Laboratory, Royal Children's Hospital, Melbourne, Australia; Murdoch Childrens Research Institute, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Morgan Sangeux
- Hugh Williamson Gait Analysis Laboratory, Royal Children's Hospital, Melbourne, Australia; Murdoch Childrens Research Institute, Melbourne, Australia; Department of Mechanical Engineering, University of Melbourne, Melbourne, Australia
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Rosskopf AB, Pfirrmann CW, Buck FM. Assessment of two-dimensional (2D) and three-dimensional (3D) lower limb measurements in adults: Comparison of micro-dose and low-dose biplanar radiographs. Eur Radiol 2016; 26:3054-62. [PMID: 26738507 DOI: 10.1007/s00330-015-4166-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 12/09/2015] [Accepted: 12/11/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To evaluate reliability of 2D and 3D lower limb measurements in adults using micro-dose compared to low-dose biplanar radiographs(BPR). MATERIALS AND METHODS One hundred patients (mean 54.9 years) were examined twice using micro-dose and low-dose BPR. Length and mechanical axis of lower limbs were measured on the antero-posterior(ap) micro-dose and low-dose images by two independent readers. Femoral and tibial torsions of 50 patients were measured by two independent readers using reconstructed 3D-models based on the micro-dose and low-dose BPR. Intermethod and interreader agreements were calculated using descriptive statistics, intraclass-correlation-coefficient(ICC), and Bland-Altman analysis. RESULTS Mean interreader-differences on micro-dose were 0.3 cm(range 0-1.0)/ 0.7°(0-2.9) for limb length/axis and 0.4 cm (0-1.0)/0.8°(0-3.3) on low-dose BPR. Mean intermethod-difference was 0.04 cm ± 0.2/0.04° ± 0.6 for limb length/axis. Interreader-ICC for limb length/axis was 0.999/0.991 on micro-dose and 0.999/0.987 on low-dose BPR. Interreader-ICC for micro-dose was 0.879/0.826 for femoral/ tibial torsion, for low-dose BPR was 0.924/0.909. Mean interreader-differences on micro-dose/low-dose BPR were 3°(0-13°)/2°(0°-12°) for femoral and 4°(0-18°)/3°(0°-10°) for tibial torsion. Mean intermethod-difference was -0.1° ± 5.0/-0.4° ± 2.9 for femoral/tibial torsion. Mean dose-area-product was significantly lower (9.9 times;p < 0.001) for micro-dose BPR. CONCLUSION 2D-and 3D-measurements of lower limbs based on micro-dose BPR are reliable and provide a 10-times lower radiation dose. KEY POINTS • Lower limb length and mechanical axis can be reliably measured with micro-dose. • Femoral and tibial torsion can be reliably assessed with micro-dose. • Micro-dose allows a huge reduction of radiation exposure.
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Folinais D, Thelen P, Delin C, Radier C, Catonne Y, Lazennec JY. Measuring femoral and rotational alignment: EOS system versus computed tomography. Orthop Traumatol Surg Res 2013; 99:509-16. [PMID: 23877073 DOI: 10.1016/j.otsr.2012.12.023] [Citation(s) in RCA: 110] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Revised: 11/23/2012] [Accepted: 12/17/2012] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Computed tomography (CT) is currently the reference standard for measuring femoral and tibial rotational alignment. The EOS System is a new biplanar low-dose radiographic device that allows 3-dimensional lower-limb modelling with automated measurements of femoral and tibial rotational alignment (torsion). HYPOTHESIS Femoral and tibial torsion measurements provided by the EOS System are equivalent to those obtained using CT. MATERIALS AND METHODS In a retrospective analysis of 43 lower limbs in 30 patients, three senior radiologists measured femoral and tibial torsion on both CT and EOS images. Agreement between CT and EOS values was assessed by computing Pearson's correlation coefficient and interobserver reproducibility by computing the intraclass correlation coefficient (ICC). RESULTS Femoral torsion was 13.4° by EOS vs. 13.7° by CT (P=0.5) and tibial torsion was 30.8° by EOS vs. 30.3° by CT (P=0.4). Strong associations were found between EOS and CT values for both femoral torsion (P=0.93) and tibial torsion (P=0.89). With EOS, the ICC was 0.93 for femoral torsion and 0.86 for tibial torsion; corresponding values with CT were 0.90 and 0.92. DISCUSSION The EOS system is a valid alternative to CT for lower-limb torsion measurement. EOS imaging allows a comprehensive evaluation in all three planes while substantially decreasing patient radiation exposure. LEVEL OF EVIDENCE Level III, case-control.
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Affiliation(s)
- D Folinais
- RIM Maussins-Nollet, 114, rue Nollet, 75017 Paris, France.
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