Plane Alignment Research Articles

Correlation between Q angle and hip abductor muscle strength in patients with knee osteoarthritis

BackgroundThe Q angle has a major impact on the lower limb’s static alignment in the frontal plane; also, the lever-arm distance between the hip and knee joint centers also changes the hip abductor muscles’ ability to produce torque. An association between Q angle and hip muscle strength has been investigated in different population. However, the relationship between Q angle and hip abductor muscle strength in early knee osteoarthritis has not been investigated. Therefore, the objective of the study was to investigate the correlation between Q angle and hip abductor muscle strength in patients with initial stage of knee osteoarthritis (OA).Study designThis is a correlation study.MethodologyFifty-four involved OA knee among 32 patients (26 female and 6 male), with mean age of 49.38 ± 5.68 years, were included in the study. The Q angle was measured by universal goniometer, and the hip abductor muscle strength was measured by a hydraulic handheld dynamometer.ResultsSpearman’s correlation coefficient test showed that Q angle is significantly (weak negative) correlated (r = − 0.31; p < 0.05) with hip abductor muscle strength, in patients with knee osteoarthritis.ConclusionThere is a correlation between Q angle and hip abductor muscle strength in patients with knee OA. So, with the decrease in hip abductor, muscle strength may lead to increase in Q angle, which may be a factor responsible for early-stage degenerative changes in knee OA.

The distribution of Coronal Plane Alignment of the Knee (CPAK) phenotypes in the Malaysian population and their correlation with demographic variables

BackgroundOnly 80% of patients are satisfied with their outcomes post-TKA. Mounting attention has been paid to constitutional limb alignment and individualized alignment strategies in recent years. MacDessi et al. proposed the CPAK classification, which takes into account the patients’ arithmetic hip-knee-ankle axis (aHKA) and joint line obliquity (JLO). In this study, we aimed to establish local demographic data, compare them with published data, and assess their correlations with modifiable variables.MethodsA total of 500 end-stage osteoarthritic knees subjected to TKA were radiologically analyzed. The lateral distal femoral angle (LDFA) and medial proximal tibial angle (MPTA) were calculated from long limb radiographs before the aHKA and JLO were derived and a CPAK phenotype was assigned. Demographic data were harvested and analyzed for possible correlations.ResultsThere were 160 males (32%) and 340 females (68%), with a mean age of 66.42 years (range, 47–88). The mean MPTA was 85.8° (± 3.0)°, and the mean LDFA was 87.6° (± 2.4)°. The average aHKA was a varus of 1.8° (± 4.2)°, and the average JLO was 173.4° (± 3.45)°. The most common CPAK phenotype was Type 1 (43.4%). The Intraclass Correlation Coefficient demonstrated excellent reliability (> 0.9). No correlation existed between CPAK phenotypes and age, height, weight, or body mass index (BMI), but CPAK phenotype was significantly correlated with gender.ConclusionAn urban Malaysian population with osteoarthritic knees was found to be constitutionally varus, with the most common phenotype being varus aHKA with an apex-distal JLO. Constitutional alignment is not influenced by factors such as age, height, weight, or BMI.Level of EvidenceRetrospective Observational Study-III.

A retrospective comparison of Coronal Plane Alignment of the Knee

BackgroundUnicompartmental arthritic degeneration is treated by unicompartmental knee arthroplasties (UKA). The two current standards are mechanical alignment, where knee placement is perpendicular to the leg's mechanical axis and kinematic alignment, that consists of aligning the knee with the angles specific to the patient's innate bone structure. The purpose of this study was to compare knee alignment between mechanical and kinematic UKA. MethodsA retrospective study at Medstar Washington Hospital Center from 2015 to 2022 identified 156 cases of knee arthroplasties. Of these, 95 had mechanical alignments and 61 had kinematic alignments. Patients were evaluated post-surgically for Coronal Plane Alignment of the Knee (CPAK). Analysis of post-operative joint x-ray imaging was performed, and the mechanical medial proximal tibial angle (MPTA) and lateral distal femoral angle (LDFA) were measured. The arithmetic hip knee ankle angle (aHKA) and joint line obliquity (JLO) were calculated. ResultsThe CPAK results for mechanically aligned group demonstrated an average MPTA of 87.12 (±3), LDFA average of 86.04 (±3), aHKA average of 0.62 (±4) and JLO average of 172.57 (±4). The CPAK results for the kinematically aligned group demonstrated an average MPTA of 86.96 (±3), LDFA average of 84.67 (±3), aHKA average of 2.09 (±4), and JLO average of 171.1 (±4). A two-sample t-test on this data demonstrates statistically significant p-values of 0.004 for LDFA, 0.03 for aHKA, and 0.02 for JLO all below the 0.05 significance level. Both cohorts only contained CPAKs alignment types I and III. ConclusionThis study demonstrated that there is a statistically significant difference in knee alignment when comparing mechanically versus kinematically aligned knees which suggests that there is an advantage for patients that undergo kinematically aligned knee replacements.

Method of Spatial Alignment of Focal Planes and Sample Positioning in the Pump–Probe Scheme

Method of Spatial Alignment of Focal Planes and Sample Positioning in the Pump–Probe Scheme

Comparison of Imaging Characteristics in Pediatric Patients With Trochlear Versus Medial Femoral Condyle Osteochondritis Dissecans.

Although osteochondritis dissecans (OCD) lesions are well-described in the femoral condyles and have been associated with varus limb alignment, there is limited data on OCD lesions in the trochlea. To compare the baseline imaging characteristics in pediatric patients with trochlear OCD with those with medial femoral condyle (MFC) OCD to understand whether measures of coronal plane alignment predispose to OCD development by anatomic location. Cross-sectional study; Level of evidence, 3. This study retrospectively reviewed all pediatric patients (age ≤18 years) diagnosed with isolated trochlear OCD at a tertiary-care medical center from January 2016 to May 2023; all included patients had weight-bearing hip-to-ankle alignment radiographs. Hip-knee-ankle angle (HKA), mechanical lateral distal femoral angle (mLDFA), medial proximal tibial angle (MPTA), mechanical axis deviation (MAD), Caton-Deschamps Index (CDI), patellar tilt, and sulcus angle were measured on initial/preoperative anteroposterior and lateral knee radiographs. Tibial tubercle-trochlear groove (TT-TG) distance and OCD lesion size were measured on initial/preoperative magnetic resonance imaging sequences. Patients were 1 to 2 matched based on age (±2 years) and sex to a cohort with isolated MFC OCD. A total of 18 extremities in 16 patients were included in the trochlear OCD cohort and matched to 36 extremities in the MFC OCD cohort. The mean age at the first clinical visit for all patients was 14.8 ± 1.5 years and did not differ significantly between the two groups (P = .40). The extremities with trochlear OCD had significantly less varus HKA (1°± 2° vs -1°± 2°; P = .004) and MAD (4 ± 8 vs -3 ± 8 mm; P = .004) compared with the MFC cohort as well as lower mLDFA (86°± 2° vs 88°± 2°; P = .004). There were no differences in MPTA, CDI, patellar tilt, sulcus angle, TT-TG distance, or OCD lesion size between groups. Pediatric patients with trochlear OCD had statistically less varus coronal plane alignment compared with age- and sex-matched patients with MFC OCD, with the latter exhibiting more significant varus based on the HKA and MAD.

Pre-arthritic coronal plane alignment predicted by the arithmetic hip-knee-ankle angle (aHKA) and the Flexion Extension Balancing Algorithm (FEBA) for Primary Total Knee Arthroplasty (TKA)

BackgroundGiven the relative rate of dissatisfaction following total knee arthroplasty (TKA) and the need to further improve outcomes for all patients, various surgical methods have been developed that aim to restore the pre-arthritic alignment of the knee and lower limb. Common to these methodologies is a need to determine the pre-arthritic alignment of the knee and limb, thus producing defined targets for surgery. The aim of this paper was to compare the predicted pre-arthritic constitutional alignment of knee and lower limb calculated by the Flexion Extension Balancing Algorithm (FEBA) and the arithmetic HKA (aHKA) methods. The aHKA has been proposed as a means of accurately estimating the constitutional alignment of a knee and lower limb. MethodsWe calculated the proposed pre-arthritic alignment of 78 knees immediately prior to TKA surgery based on calculations using both methods. The results produced by the FEBA planning system (fHKA) were compared to the coronal plane alignment proposed by the aHKA process. ResultsNo significant difference was demonstrated between the pre-arthritic alignments calculated by the two methods. The mean aHKA was −1.5° (SD 3.38°; range −7.9°–6.9°) and the mean fHKA was −1.1° (SD 2.96°; range −8.1°–7.5°). The mean angular difference between the methods was 0.4° ±1.94; p = 0.146. The two methods produced alignment measurements with a strong positive correlation r = 0.82 p < 0.0001; R2 = 0.674. ConclusionsThere is a high correlation between the proposed pre-arthritic knee alignments when comparing the FEBA and arithmetic HKA methods. The pre-arthritic alignment of the knee is difficult to know with certainty. The use of both calculation methods will deliver a potential target zone for TKA knee alignment that makes use of all residual anatomy.

Use of medialized trochanteric-entry intramedullary nail to improve alignment in proximal femur nonunions.

Proximal femur shaft nonunion is a challenging problem, often occurring after malreduction that results in postoperative malalignment and decreased healing potential. Correction of malalignment is critical to achieving osseous union. Here we present a novel technique for treating proximal femur nonunions with varus malalignment using an intramedullary nail inserted through a medialized trochanteric entry point. Patients who underwent a proximal femur shaft (subtrochanteric or proximal third shaft) nonunion operation at a single level 1 academic referral centre by two attending surgeons between 1/1/2014 and 1/1/2022 were identified. Radiographic imaging was reviewed to determine initial fracture classification and calculation of coronal plane alignment (CPA), which was measured on preoperative, immediate postoperative, and final follow-up radiographs. Postoperative complications, reoperations, infections, and osseous union were also collected. Twenty-one patients with a mean age of 49.9 years (66% male) were identified. Mean preoperative CPA was 125.6 degrees, immediate postoperative mean CPA was 132.6 degrees, and mean final follow-up CPA was 131.5 degrees. Mean change in CPA from immediate postoperative films to final follow-up was a decrease of 0.4 degrees. 17 patients had follow up for a minimum of 12 months or until osseous union, and all achieved union without any major complications. Exchange nailing with an antegrade trochanteric entry nail through a medialized trochanteric starting point is a safe and effective technique in the treatment of proximal femur nonunions. This technique results in improved postoperative alignment that is sustained throughout the postoperative course, and may lead to increased rates of osseous union.

Fixed-bearing medial unicompartmental knee arthroplasty restores pre-arthritic coronal alignment and achieves satisfactory functional outcomes: a retrospective study

PurposeThis study aimed to (1) analyze the Coronal Plane Alignment of the Knee (CPAK) classification in patients undergoing unicompartmental knee arthroplasty (UKA), (2) assess whether UKA can restore pre-arthritic coronal alignment by utilizing the arithmetic hip-knee-ankle angle (aHKA), and (3) evaluate the relationship between patient-reported outcome measures (PROMs) and postoperative alignment following UKA.MethodsWe retrospectively analyzed 152 consecutive patients who underwent fixed-bearing medial UKA. A radiological analysis was conducted using an EOS imaging system. Postoperative alignment was classified as neutral (varus ≤ 3°), mild varus (3° < varus ≤ 7°), or marked varus (varus > 7°) based on the mechanical hip-knee-ankle angle (mHKA). The aHKA was calculated and the CPAK classification was used to categorize knee phenotypes. The PROMs were obtained both before and after the surgery.ResultsA total of 152 knees from 113 patients were included with a mean two-year follow-up. The mean difference between the postoperative mHKA and the estimated aHKA was 0.80° (90% CI 0.35 to 1.24; P = 0.003). Postoperatively, 63 (41.45%) of the 152 knees were in neutral group, 54 (35.53%) mild varus, and 35 (23.03%) marked varus. The neutrally aligned cohort did not exhibit significantly higher scores in range of motion, VAS, HSS, WOMAC, or FJS-12 scores compared to the mild or marked varus cohort (P = 0.205, 0.118, 0.076, 0.140, and 0.788, respectively) during the short-term follow-up.ConclusionNon-robotically assisted, fixed-bearing medial UKA can restore pre-arthritic coronal alignment and achieve satisfactory PROMs. Fixed-bearing medial UKA aims to restore the pre-arthritic alignment rather than achieving neutral mechanical alignment.

Impact of Aging and Knee Osteoarthritis on Lower Limb Alignment and CPAK Classification: Gender Differences in a Japanese Cohort.

Objective: This study investigates the impact of age and knee osteoarthritis (OA) on the coronal plane alignment of the lower extremity in Japanese males and females, utilizing the Coronal Plane Alignment of the Knee (CPAK) classification system. Methods: A cross-sectional analysis was conducted with 150 male and 150 female patients. Participants were divided into three groups according to age and OA progression. The mechanical lateral distal femoral angle (mLDFA) and mechanical medial proximal tibial angle (mMPTA) were measured using standard digital long-leg radiographs. Arithmetic hip-knee-ankle angle (aHKA) and joint line obliquity (JLO) were calculated, and the CPAK classification was performed to verify the distribution among the three groups. Results: The results showed increased varus alignment of the mean mLDFA correlated with OA in both genders and with aging in males. The mean mMPTA did not change in males but shifted toward varus in females with both aging and OA. Both genders demonstrated a constitutional varus alignment with the progression of osteoarthritis (males: 1.3 ± 2.4° to -3.5 ± 3.7°, p < 0.001; females: -1.2 ± 3.2° to -3.6 ± 2.9°, p < 0.001). However, this trend with aging was observed only in females (0.0 ± 2.5° to -1.2 ± 3.2°, p = 0.018). JLO maintained its apex distal position with aging and OA progression in all subjects. The study further revealed a notable transition from CPAK Type II to Type I with OA progression in both genders, additionally influenced by aging in females. Conclusions: Aging affects coronal alignment and CPAK classification differently across genders. With OA progression, there was a shift toward smaller aHKA, while JLO remained unchanged. Compared to other races, young Japanese people exhibit similar CPAK distributions, but distinct differences appear in OA-affected individuals, highlighting potential racial variations in CPAK classifications.

Unicompartmental Knee Arthroplasty: What is the optimal alignment correction to achieve success? The role of kinematic alignment

Unicompartmental knee arthroplasty (UKA) is in many ways the ultimate kinematic operation, as the express aim is to resurface the diseased side of the joint and restore pre-arthritic alignment and balance while maintaining integrity of both cruciate ligaments. An increasing body of knowledge relates the outcomes of UKA to pre-arthritic anatomy rather than an arbitrarily defined neutral. The Coronal Plane Alignment of the Knee (CPAK) classification provides a validated technique for calculating pre-arthritic limb alignment (the arithmetic hip-knee-ankle angle (aHKA)) and joint line obliquity (JLO) and will enable a greater understanding of the interactions between pre-arthritic anatomy, choice of prosthetic position and outcomes. When pre-arthritic alignment is not taken into consideration a post-operative limb alignment of mild to moderate varus for medial UKA and moderate valgus for lateral UKA appears to produce the best outcomes. When pre-arthritic anatomy is taken into account, superior results have been reported with restoration of pre-arthritic limb alignment and joint line obliquity. Restriction boundaries have yet to be clearly defined for tibial component coronal and hip-knee-ankle (HKA) angles when applying this new paradigm, but existing evidence would suggest a 6° varus limit for the tibial coronal angle may be a reasonable starting point. Lateral UKA has inherent differences in terms of tibial component positioning and ligament balance targets. Mobile bearing UKA demands a three-dimensional understanding of the effect of implant position on bearing stability. Modification of technique is necessary to produce anatomic tibia component angles with equipment designed for mechanical alignment. Robotic technology allows accurate understanding of pre-arthritic anatomy, precise reproduction of patient specific virtual planning, equally precise manipulation of soft tissue balance, and future research using these platforms is likely to further clarify in terms of ideal patient-specific component and limb alignment targets.

Windswept deformity of the knee: prevalence and predictive factors in osteoarthritic and healthy populations.

This study examined windswept deformity (WSD) of the knee, comparing prevalence and contributing factors in healthy and osteoarthritic (OA) cohorts. A case-control radiological study was undertaken comparing 500 healthy knees (250 adults) with a consecutive sample of 710 OA knees (355 adults) undergoing bilateral total knee arthroplasty. The mechanical hip-knee-ankle angle (mHKA), medial proximal tibial angle (MPTA), and lateral distal femoral angle (LDFA) were determined for each knee, and the arithmetic hip-knee-ankle angle (aHKA), joint line obliquity, and Coronal Plane Alignment of the Knee (CPAK) types were calculated. WSD was defined as a varus mHKA of < -2° in one limb and a valgus mHKA of > 2° in the contralateral limb. The primary outcome was the proportional difference in WSD prevalence between healthy and OA groups. Secondary outcomes were the proportional difference in WSD prevalence between constitutional varus and valgus CPAK types, and to explore associations between predefined variables and WSD within the OA group. WSD was more prevalent in the OA group compared to the healthy group (7.9% vs 0.4%; p < 0.001, relative risk (RR) 19.8). There was a significant difference in means and variance between the mHKA of the healthy and OA groups (mean -1.3° (SD 2.3°) vs mean -3.8°(SD 6.6°) respectively; p < 0.001). No significant differences existed in MPTA and LDFA between the groups, with a minimal difference in aHKA (mean -0.9° healthy vs -0.5° OA; p < 0.001). Backwards logistic regression identified meniscectomy, rheumatoid arthritis, and osteotomy as predictors of WSD (odds ratio (OR) 4.1 (95% CI 1.7 to 10.0), p = 0.002; OR 11.9 (95% CI 1.3 to 89.3); p = 0.016; OR 41.6 (95% CI 5.4 to 432.9), p ≤ 0.001, respectively). This study found a 20-fold greater prevalence of WSD in OA populations. The development of WSD is associated with meniscectomy, rheumatoid arthritis, and osteotomy. These findings support WSD being mostly an acquired condition following skeletal maturity.

DOES CHANGE IN CORONAL PLANE ALIGNMENT OF THE KNEE CLASSIFICATION FOLLOWING TOTAL KNEE ARTHROPLASTY INFLUENCE PATIENT-REPORTED OUTCOMES AND SURVIVORSHIP? A REVIEW OF 1,062 CASES WITH TEN YEARS’ FOLLOW-UP

Restoration of native Coronal Plane Alignment of the Knee (CPAK) phenotype is a strategy suggested to achieve better satisfaction. The aim of this study was to investigate the influence of changes in CPAK classification on patient-reported outcome measures (PROMs) and survivorship in a large cohort of manual mechanically aligned (MA) cemented TKAs.A retrospective analysis of 1062 consecutive cemented TKAs using MA philosophy at a single institution. Pre- and post-operative hip-knee-ankle radiographs were classified using the CPAK classification. Oxford Knee Score (OKS) and patient satisfaction (4-point-Likert scale) were collected prospectively. Implant survival data was obtained from our national arthroplasty database. We compared the outcomes of patients who maintained or changed their CPAK classification following TKA. Satisfaction was analysed using chi-square test, and OKS was analysed using Mann-Whitney test.Pre-operatively, most patients were CPAK type-I (38.8%). 85.5% of patients changed their CPAK type post-operatively, with CPAK type-V observed in 41.2% of these. Significantly better satisfaction (p=0.033) and OKS (p=0.021) were observed at one-year follow-up in patients who changed CPAK type, although the difference was below OKS minimally important clinical difference. There was no difference in satisfaction (p=0.73) and OKS (p=0.26) at one year between CPAK-V and non-V classifications. Post-operative CPAK type had no correlation with satisfaction and OKS. 12 TKAs (1.1%) were revised within 10 years (3 septic).In this large cohort of MA-TKA, excellent survivorship was observed at 10 years, with no demonstrable difference in outcome related to the final CPAK phenotype or change in phenotype.

The Distribution of Coronal Plane Alignment of the Knee Classification in a Sample of Spanish Southeast Osteoarthritic Population: A Retrospective Cross-Sectional Observational Study.

Background and Objectives: The Coronal Plane Alignment of the Knee (CPAK) classification is a pragmatic distribution of nine phenotypes for coronal knee alignment that can be used on healthy and arthritic knees. Our study aimed to describe the CPAK distributions in a Spanish southeast osteoarthritic population and compare them to other populations' published alignment distributions. Method and Materials: Full-leg standing X-rays of the lower limb from 528 cases originating from the so-called Vega Alta del Segura (southeast of the Iberian Peninsula) were retrospectively analysed. We measured the mechanical hip-knee-ankle, lateral distal femoral, and medial proximal tibial angles. We calculated the arithmetic hip-knee-ankle angle and the joint line obliquity to classify each case according to the criteria of the CPAK classification. Results: Based on the aHKA result, 59.1% of the cases were varus (less than -2°), 32.7% were neutral (0° ± 2°), and 8.2% were valgus (greater than +2°). Based on the JLO result, 56.7% of the cases had a distal apex (less than 177°), 39.9% had a neutral apex (180° ± 3°), and 3.4% had a proximal apex (greater than 183°). The most common CPAK distribution in our Spanish southeast osteoarthritic population was type I (30.7%), followed by type IV (25.9%), type II (21%), type V (11.2%), type III (5%), type VI (2.8%), type VII (2.4%), type VIII (0.6%), and type IX (0.4%). Conclusions: We described the distribution according to the CPAK classification in a sample of the osteoarthritic population from southeastern Spain. In our sample, more than 75% of the patients were classified as type I, II, and IV.

Gender, BMI, and Age-Related Variations in Lower Limb Alignment Parameters and CPAK Phenotypes in Chinese Patients with Knee Osteoarthritis.

Research on the distribution of and the variation in coronal plane alignment of the knee (CPAK) in the Chinese osteoarthritis population is limited. We aimed to establish the CPAK classification based on the characteristics of lower limb alignment in the Chinese osteoarthritis population. We also investigated variations in lower limb alignment parameters and CPAK phenotypes based on gender, body mass index (BMI), and age. A retrospective study was conducted on a total of 944 knees diagnosed with osteoarthritis in 479 patients from January 2017 to December 2023. A scatterplot was used to describe the distribution of the CPAK classification, and the differences in lower limb alignment parameters and the CPAK classification were compared across genders (male, female), ages (middle-aged/<65 years, elderly/≥65 years), and BMI categories (normal/<25 kg/m2, overweight and obese/≥25 kg/m2) using the chi-squared test or Fisher's exact test. The average arithmetic hip-knee-ankle angle and joint line obliquity (JLO) were -3.03° ± 5.69° and 174.45° ± 4.29°, respectively. There was a higher prevalence of constitutional varus alignment in males and the overweight or obese group, while constitutional valgus alignment was more common in females and the normal BMI group (p < 0.05). Additionally, females had a greater apex distal JLO than males (p < 0.05). There were no statistically significant differences in lower limb alignment parameters among different age groups (p > 0.05). Although there were variations in alignment parameters across different genders and BMI categories in the knee osteoarthritis population, the predominant CPAK classifications were type I (38.03%), followed by type II (20.02%) and type IV (17.06%). The most common CPAK types were I, II, and IV, and they were not influenced by gender, BMI, or age, indicating that the CPAK classification can reliably reflect constitutional alignment. A better understanding of native alignment variability can aid in providing patient-specific recommendations when considering orthopedic alignment strategies.

A Restriction Boundary-Based Coronal Plane Alignment of the Knee (CPAK) Classification for Restricted Kinematic Alignment Total Knee Arthroplasty.

Background Coronal plane alignment of the knee (CPAK) classification was proposed as a means of understanding the knee phenotype in leg alignment and joint line obliquity (JLO). However, when it is adapted to restricted kinematic alignment total knee arthroplasty (rKA-TKA), the boundaries of CPAK and those of rKA-TKA phenotype are different. We therefore reappraise the boundary between the CPAK classification and restriction protocol and propose a restriction boundary-based CPAK (Rb-CPAK). Methods Between May 2020 and March 2022, 143 knees in 95 patients underwent rKA at our institution and were included in this study. In Rb-CPAK, we set the following ranges: 6° varus to 3° valgus for arithmetic hip-knee-ankle angle (aHKA), 0° to 6° varus for the medial proximal tibial angle (MPTA), 0° to 5° valgus for the lateral distal femoral angle (LDFA), and 169° to 180° for JLO. The pre- and postoperative alignments were classified using the original CPAK and Rb-CPAK. Results There were significant differences in pre- and postoperative distributions between original CPAK and Rb-CPAK (p < 0.0001). Postoperative Rb-CPAK primarily led to neutral aHKA (116 of 143 knees), and decreased MPTA varus (pre: 83.9 ± 3.4, post: 87.0 ± 2.3, p < 0.0001) and stable LDFA values (pre: 88.7 ± 3.1, post: 88.5 ± 2.7, p = 0.4) were observed. Among cases with neutral JLO, 78 knees required MPTA or LDFA corrections. Postoperatively, 67 (64%) out of 119 knees categorized as neutral JLO fell within MPTA and LDFA ranges. Conclusion The Rb-CPAK modification more effectively outlined knees that required restriction, and the restriction was properly performed compared with the original CPAK. However, JLO does not effectively indicate if a knee requires restriction or not, and thus individual evaluation of LDFA and MPTA might be necessary.

Variability of three-dimensional knee morphology cannot be effectively assessed using a coronal plane knee alignment classification in total knee arthroplasty patients.

Optimal reproduction of the native three-dimensional (3D) alignment in total knee arthroplasty (TKA) influences outcomes; however, much of the modern TKA alignment research, such as the coronal plane alignment of the knee (CPAK), focuses only on coronal alignment. Tibial, femoral and tibiofemoral measurements on the axial and sagittal planes were evaluated for their relationship to the arithmetic hip-knee-ankle angle (aHKA) and joint-line obliquity (JLO). These 3D anatomical measurements are also evaluated across CPAK groups. A retrospective analysis of the 360 Med Care computed tomography (CT) database was performed. Patient CT scans were segmented and landmarked. Linear regression analysis compared 12 axial and sagittal plane measurements (representing tibial, femoral and tibiofemoral rotation, tibial slope and femoral flexion) with both aHKA and JLO. Nonparametric tests assessed these anatomical measurements across the different CPAK groups, while Cohen's delta (d) determined the effect size. With a sample size of 7450 osteoarthritic knees, significant but weak relationships (r < 0.30) were observed between all 12 anatomical measurements and both aHKA and JLO. Tibiofemoral rotations between Insall's axis and both the posterior condylar and the surgical transepicondylar axes demonstrated large effect sizes (d > 0.80). However, trivial to small effect sizes (d < 0.50) were broadly observed across the 12 axial and sagittal measurements, underscoring their limited clinical significance. While useful for describing coronal knee anatomy, CPAK phenotypes fail to differentiate tibial, femoral and tibiofemoral rotation, tibial slope or femoral flexion-crucial aspects of 3D surgical planning. Therefore, more comprehensive knee phenotyping solutions are required to guide individualised TKA alignment strategies. Level II.

Pre- and postoperative Coronal Plane Alignment of the Knee classification and its impact on clinical outcomes in total knee arthroplasty.

The Coronal Plane Alignment of the Knee (CPAK) classification has been developed to predict individual variations in inherent knee alignment. The impact of preoperative and postoperative CPAK classification phenotype on the postoperative clinical outcomes of total knee arthroplasty (TKA) remains elusive. This study aimed to examine the effect of postoperative CPAK classification phenotypes (I to IX), and their pre- to postoperative changes on patient-reported outcome measures (PROMs). A questionnaire was administered to 340 patients (422 knees) who underwent primary TKA for osteoarthritis (OA) between September 2013 and June 2019. A total of 231 patients (284 knees) responded. The -Knee Society Score 2011 (KSS 2011), Knee injury and Osteoarthritis Outcome Score-12 (KOOS-12), and Forgotten Joint Score-12 (FJS-12) were used to assess clinical outcomes. Using preoperative and postoperative anteroposterior full-leg radiographs, the arithmetic hip-knee-ankle angle (aHKA) and joint line obliquity (JLO) were calculated and classified based on the CPAK classification. To investigate the impact on PROMs, multivariable regression analyses using stepwise selection were conducted, considering factors such as age at surgery, time since surgery, BMI, sex, implant use, postoperative aHKA classification, JLO classification, and changes in aHKA and JLO classifications from preoperative to postoperative. The preoperative and postoperative CPAK classifications were predominantly phenotype I (155 knees; 55%) and phenotype V (73 knees; 26%), respectively. The change in the preoperative to postoperative aHKA classification was a significant negative predictive factor for KOOS-12 and FJS-12, while postoperative apex proximal JLO was a significant negative predictive factor for KSS 2011 and KOOS-12. In primary TKA for OA, preoperative and postoperative CPAK phenotypes were associated with PROMs. Alteration in varus/valgus alignment from preoperative to postoperative was recognized as a negative predictive factor for both KOOS-12 and FJS-12. Moreover, the postoperative apex proximal JLO was identified as a negative factor for KSS 2011 and KOOS-12. Determining the target alignment for each preoperative phenotype with reproducibility could improve PROMs.

REVOLUTIONIZING ONCOLOGY IMAGING: A PARADIGM SHIFT THROUGH STANDARDIZED MRI PROTOCOLS: VOLUME 2

Introduction: Oncology imaging is always developing, thus rapid and precise diagnosis are essential for cancer therapy. Recognizing the importance of Magnetic Resonance Imaging, our Mahamana Pandit Madan Mohan Malaviya Cancer Centre is standardizing MRI protocols to improve inspection and interpretation. This project aims to standardize, eliminate variance, and speed up patient care choices. Methods: Our standardized MRI procedures summarize scan parameters, sequences, modes, matrix and other data by body part. A 3 Tesla MRI machine was used to study how scanner differences affect parameters. Detailing appropriate pathological visualization sequences allowed diagnostic versatility. Localiser or scanogram was emphasized for exact scan plane alignment, ensuring uniform pictures for smooth comparisons. Results:Specific procedures were established for certain anatomical locations, with a focus on precise patient placement. Optimizing the localizer setup and selecting the appropriate coil can enhance the quality of images and increase diagnostic accuracy. Discussion: The conversation emphasizes the crucial need of standardizing MRI methods to ensure prompt and precise cancer diagnosis. The benefits of using this technology, such as maintaining consistency, saving time, and improving picture quality, help speed up the diagnostic process and lead to better outcomes for patients. Conclusion: Standardizing MRI procedures is a major step toward efficient and patient-centered cancer imaging, addressing varied oncological issues and improving consistency, time efficiency, and picture quality. Staff training and cooperation put our institution at the forefront of technology advances to improve cancer patient outcomes. We aim to enhance cancer care and treatment via cooperation, improvement, and a patient-centric approach.

A rare case of total hip replacement in an 11-year-old female: rehabilitation goals and challenges - a case report

This case report describes a unique pediatric patient, the first and youngest in India, who underwent total hip replacement (THR) for right ankylosed hip. Patient presented with preoperative musculoskeletal deformities, posing challenges for postoperative rehabilitation. This 11-year-old female presented with non-traumatic insidious right hip pain, limping, right hip flexion and abduction deformity. Patient was diagnosed with idiopathic chondrolysis of the hip through exclusion and clinico-radiological findings. Patient underwent surgery for ceramic-on-ceramic THR. Fusion of triradiate cartilage and epiphysis and Risser’s skeletal maturity staging were confirmed. Postoperative examination revealed right hip flexion and abduction deformity resulting in pelvic obliquity, which led to limb length discrepancy and functional scoliosis. There was increased anterior pelvic tilt, altering the gait pattern. Adhering to THR restrictions, rehabilitation strategies were tailored to restore normal pelvic orientation and address deformities through manual stretching of right hip abductor, tensor fascia latae, iliopsoas and rectus femoris. A left-sided shoe raise was also given. Lumbar segmental muscle activation, pelvic floor muscle training and gait training were crucial parts of the rehabilitation protocol. At ten-week, prodigious outcomes were achieved in the form of complete pain relief, complete correction of abduction and flexion deformity, normal pelvic alignment in the frontal plane and independent, stable full weight-bearing ambulation after two years of disabling ordeal suffering. However, minimal compensation of the anterior pelvic tilt persisted. Rehabilitation of this challenging patient with multiple deformities achieved excellent outcomes at ten-week post-rehabilitation. Thus, a tailored meticulous rehabilitation program can significantly improve quality of life.

The L1 spino-pelvic (L1SP) angle: a simplified approach for the assessment of the PI-LL mismatch in hip surgery

Introduction: Pelvic incidence - lumbar lordosis (PI-LL) mismatch is often considered when assessing spinopelvic alignment in the sagittal plane. The mismatch is conventionally obtained by measuring 2 separate angles on lateral spinopelvic radiographs. This study describes a simplified approach for assessing spinopelvic mobility and measuring the PI-LL mismatch through the evaluation of the L1-spinopelvis angle (L1SP). Methods: 96 standing lateral radiographs were obtained from consecutive patients presenting for total hip arthroplasty between November 2020 and July 2021. 3 operators were recruited to annotate landmarks on digital radiographs. Correlation analysis and error analysis were applied. Measurement reproducibility was assessed using intraclass correlation coefficient (ICC). Results: The correlation coefficients of the 3 variables were respectively 0.87 for PI, 0.94 for LL, and 0.96 for L1SP. The normalised root mean square error between the 2 measurement sets was 9.96% for PI, 5.97% for LL, and 4.41% for L1SP. The absolute error was 3.49° ± 4.63° for PI, 3.23° ± 3.78° for LL, 2.68° ± 3.19° for PI-LL conventional, and 2.35° ± 2.88° for PI-LL via L1SP, respectively. In terms of reproducibility, measurement of L1SP outperformed that of PI and LL (ICC = 0.97 versus 0.83 and 0.93, respectively). Conclusion: The simplified L1SP method, through the measurement of a single angle, produced similar measurements to the conventional PI-LL method. The measurement repeatability between operators was improved using the L1SP method. From a clinical practice perspective, both methods are equivalent. The new method is readily reproducible using commercially available PACS software during preoperative templating.