Rotational Malalignment Research Articles

The Reliability of Measurements for Tibial Torsion: A Comparison of CT, MRI, Biplanar Radiography, and 3D Reconstructions With and Without Standardized Measurement Training

Background: Accurate and reliable assessment of tibial torsion is important for the identification and treatment of tibial rotation malalignment; however, the ideal rotational measurement modality and technique are controversial. This study compares rotational measurements between computed tomography (CT), magnetic resonance imaging (MRI), biplanar erect radiograph (BER) reconstructions, and three-dimensional (3D) reconstructed CT before and after standardized training of observers to evaluate the reliability of each assessment method.Methods: Eight adult cadaveric specimens underwent CT, MRI, and BER imaging. Tibial torsion was measured by three independent observers (one resident and two experienced orthopaedic surgeons) both before and after standardized measurement instruction. Reliability for inter-observer measurement was evaluated using the Intraclass Correlation Coefficient (ICC). Measurement values for CT, MRI, and BER reconstructions were compared to 3D CT reconstructions analyzed using custom software to align and measure tibial torsion (used as the reference standard).Results: Before training, there was poor inter-observer reliability for CT (ICC=0.492, p=0.014) and moderate interobserver reliability for MRI (ICC=0.633, p=0.002). There was no inter-method reliability between 3D CT and MRI for two of the three surgeons and moderate to good reliability between 3D CT and CT. After training, the interobserver reliability for CT improved to 0.536 and the inter-observer reliability for MRI improved to 0.701. The BER measurements (no observer involvement) had moderate reliability compared to the 3D CT reconstructions (ICC=0.69, p=0.026). Measurement error was 4 degrees for CT pre-training and 7 degrees post-training, and 7 degrees for MRI pre-training and 8 degrees post-training.Conclusions: A standardized training regimen for MRI measurements improved both inter-observer and intraobserver reliability. Inter-method reliability between CT, MRI, and BER compared to reference 3D CT reconstructions demonstrated that all imaging modalities are a valid means to measure tibial rotation but differ in reliability from moderate to good. When assessing tibial torsional deformities, it is important to consider these variations from true rotation and feel comfortable using them for pre-operative planning purposes.Level of Evidence: N/A for a cadaveric imaging study Key Concepts•A standardized training regimen for MRI measurements of tibial torsion significantly improved inter-observer and intra-observer reliability.•CT, MRI, and BER measurements are valid imaging modalities compared to 3D CT reference standards for measuring tibial rotation.•Established manual measurements of tibial torsion from MRI may be improved with adequate training.•Measurement error of up to 8 degrees can be seen from true tibial torsion during the imaging assessment.

Effect of Tibiofemoral Rotation Angle on Graft Failure After Anterior Cruciate Ligament Reconstruction

Background: Coronal and sagittal malalignment of the knee are well-recognized risk factors for failure after anterior cruciate ligament (ACL) reconstruction (ACLR). However, the effect of axial malalignment on graft survival after ACLR is yet to be determined. Purpose: To evaluate whether increased tibiofemoral rotational malalignment, namely, tibiofemoral rotation angle (TFA) and tibial tubercle–trochlear groove (TT-TG) distance, is associated with graft failure after ACLR. Study Design: Cohort study; Level of evidence, 3. Methods: In this retrospective matched control study of a single center’s database, 151 patients who underwent revision ACLR because of graft failure (ACLR failure group, defined as symptomatic patients with anterior knee instability and an ACL graft tear appreciated on magnetic resonance imaging [MRI] and confirmed during arthroscopic surgery) were compared with a matched control group of 151 patients who underwent primary ACLR with no evidence of failure after ≥2-year follow-up (intact ACLR group). Patients were matched by sex, age, and meniscal injury during primary ACLR. Axial malalignment was assessed on preoperative MRI through the TFA and the TT-TG distance. Sagittal alignment was measured through the posterior tibial slope on MRI. The optimal TFA cutoff associated with graft failure was identified by a receiver operating characteristic curve. The Kaplan-Meier curve with log-rank analysis was performed to evaluate the influence of the TFA on ACLR longevity. Results: The mean age was 25.7 ± 10.4 years for the ACLR failure group and 25.9 ± 10.0 years for the intact ACLR group. Among all the included patients, 174 (57.6%) were male. In the ACLR failure group, the mean TFA was 5.8°± 4.5° (range, −5° to 16°), while it was 3.0°± 3.3° (range, −3° to 15°) in the intact ACLR group (P < .001). Neither the TT-TG distance nor the posterior tibial slope presented statistical differences between the groups. The receiver operating characteristic curve suggested an optimal TFA cutoff of 4.5° for graft failure (area under the curve = 0.71; P < .001; sensitivity, 68.2%; specificity, 75.5%). Considering this a threshold, patients who had a TFA ≥4.5° had 6.6 times higher odds of graft failure compared with patients with a TFA <4.5° (P < .001). Survival analysis demonstrated a 5-year survival rate of 81% in patients with a TFA <4.5°, while it was 44% in those with a TFA ≥4.5° (P < .001). Conclusion: An increased TFA was associated with increased odds of ACLR failure when the TFA was ≥4.5°. Measuring the TFA in patients with ACL tears undergoing reconstruction may inform the surgeon about additional factors that may require consideration before ACLR for a successful outcome.

Poster 316: Increased tibiofemoral rotation angle is associated with graft failure after anterior cruciate ligament reconstruction

Objectives: Coronal and sagittal malalignment of the knee are well-recognized risk factors for failure after anterior cruciate ligament reconstruction (ACLR). However, the effect of axial malalignment on ACLR graft survival is yet to be determined. This study aimed to evaluate whether increased tibiofemoral rotational malalignment, namely tibiofemoral rotation angle (TFA) and tibial tubercle-trochlear groove (TT-TG) distance, is associated with ACLR graft failure. Methods: In this matched-control study, 151 patients who underwent revision ACLR due to graft failure (failure ACLR group) were compared to a matched-control group of 151 patients who underwent primary ACLR with no evidence of failure after at least 2-years follow-up (intact ACLR group). Patients were matched by sex, age, and meniscal injury during primary ACLR. Axial malalignment was assessed on preoperative magnetic resonance imaging (MRI) through the TFA and the TT-TG distance. Sagittal alignment was measured through posterior tibial slope (PTS) on MRI. Optimal TFA cutoff associated with graft failure was identified by a receiver operating characteristic (ROC) curve. Kaplan-Meier curve with log-rank analysis was performed to evaluate the influence of TFA on ACLR longevity. Results: In the failure ACLR group, mean TFA was 5.8 ± 4.5 (range, -5 to 16) degrees while this mean was 3.0 ± 3.3 (range, -3 to 15) degrees in the intact ACLR group (p&lt;0.001). Neither TT-TG distance nor PTS presented statistical differences between the groups. ROC curve suggested an optimal TFA cutoff of 4.5 degrees for ACLR graft failure. Considering this as a threshold, patients who presented TFA ≥ 4.5 degrees had 6.6-times higher likelihood of graft failure compared to patients with TFA &lt; 4.5 degrees (p&lt;0.001). Survival analysis demonstrated a 5-years survival of 81% in patients with TFA &lt; 4.5 degrees, while it was 44% when TFA ≥ 4.5 degrees (p&lt;0.001). Conclusions: Increased TFA was associated with increased odds of ACLR failure when the TFA was ≥ 4.5 degrees. Measuring the TFA in patients with ACL tears undergoing reconstruction may inform the surgeon about additional factors that may require consideration prior to ACL reconstruction for a successful outcome.

Using a Traction Table for Fracture Reduction during Minimally Invasive Plate Osteosynthesis (MIPO) of Distal Femoral Fractures Provides Anatomical Alignment.

Fracture reduction and fixation of distal femur fractures are technically demanding. Postoperative malalignment is still commonly reported after minimally invasive plate osteosynthesis (MIPO). We evaluated the postoperative alignment after MIPO using a traction table with a dedicated femoral support. The study included 32 patients aged 65 years or older with distal femur fractures of all AO/OTA types 32 (c) and 33 (except 33 B3 and C3) and peri-implant fractures with stable implants. Internal fixation was achieved with MIPO using a bridge-plating construct. Bilateral computed tomography (CT) scans of the entire femur were performed postoperatively, and measurements of the uninjured contralateral side defined anatomical alignment. Due to incomplete CT scans or excessively distorted femoral anatomy, seven patients were excluded from analyses. Fracture reduction and fixation on the traction table provided excellent postoperative alignment. Only one of the 25 patients had a rotational malalignment of more than 15° (18°). The surgical setup for MIPO of distal femur fractures on a traction table with a dedicated femoral support facilitated reduction and fixation, resulting in a low rate of postoperative malalignment, despite a high rate of peri-implant fractures, and could be recommended for surgical treatment of distal femur fractures.

Combination of exchange nailing augmented with plate and allograft in treating femoral shaft nonunion after intramedullary nailing – Our experience

Risk factors for femoral nonunion after intramedullary nailing are open fracture, delay in weight bearing, and tobacco use. The treatment of nonunion with a statically locked intramedullary nail in place is either bone grafting in situ, dynamization of the nail by locking screw removal, or exchange nailing. We combined exchange nailing augmented with plate and bone grafting to study its usefulness in treating femur shaft nonunions after nailing.We did a retrospective study. Cases were collected between Aug 2020-June 2022. 15 patients were collected. They had underwent intramedullary nailing for femur fracture. Infection was ruled out. Mean period for presentation of nonunion - 20 months after primary surgery. Initially old nail was removed. Then we freshened the ends of the nonunion till the ends bleed. Then we passed a nail, did distal interlocking and then added a plate. We used a muller device to compress the nonunion, added a bone graft &amp; then finally locked proximally. All 15 of the patients achieved postoperative bony union uneventfully at a mean time of 22.1 weeks (range, 12–40 weeks). The mean operative time was 105 minutes (range, 60–150 minutes), and the mean blood loss was 340 ml (range, 150–700 ml). All of the patients could walk bearing full weight without pain within 3 months. There were no significant complications such as broken hardware, implant back-out, axial or rotational malalignment, or deep infections. Exchange nailing with plate and graft augmentation is a good option in treating femur shaft nonunions after open reduction and internal fixation with intramedullary nailing. We used exchange nailing augmented with plate and bone graft and found it to lead to union in 100% cases.

Malunion of the distal radius: 3Dplanning and performance of intra- and extra-articular corrective osteotomy

Restoration of the original anatomy with reduction of both current symptoms and risk of posttraumatic osteoarthritis. Symptomatic intra- or extra-articular malunion due to limitation of movement and/or painful function, intra-articular step of > 1 mm, instability of the distal radioulnar joint. Minimal deformity. Pre-existing osteoarthritis Knirk and JupiterII or higher. Simpler surgical alternative, e.g., ulna shortening osteotomy. Smoking or advanced age are not contraindications. Preoperative assessment and performance of abilateral computed tomography (CT). Three-dimensional (3D) malposition analysis and calculation of the correction. Planning of the corrective osteotomy on the 3D model and creation of patient-specific drilling and sawing guides. Performing the 3D-guided osteotomy. Early functional unloaded mobilization with the splint for 8weeks until consolidation control with CT. Significant reduction of the step to < 1 mm (p ≤ 0.05) can be achieved with intra-articular corrections. In extra-articular corrective osteotomies, amean residual rotational malalignment error of2.0° (± 2.2°) and atranslational malalignment error of 0.6 mm (± 0.2 mm) is achieved. Single-cut osteotomies in the shaft region can be performed to within afew degrees for rotation (e.g., pronation/supination4.9°) and for translation (e.g., proximal/distal, 0.8 mm). After surgery, amean residual 3D angle of5.8° (SD3.6°) was measured. Furthermore, surgical time for 3D-assisted surgery is significantly reduced compared to the conventional technique (140 ± 37 vs 108 ± 26 min; p < 0.05). Thus, the progression of osteoarthritis can be reduced in the medium term and improved mobility and grip strength are achieved. The clinical outcome parameters based on patient-rated wrist evaluation (PRWE) and the disabilities of the arm, shoulder and hand (DASH) scores are roughly comparable.

Are we overestimating internal rotation gait by conventional modelling?

BackgroundThe determination of the knee joint axis (KJA) via specific calibration movements has become a promising alternative to the conventional approach to determine this axis based on regression equations or directly via marker placement on bony landmarks of the knee. Since the orientation of the KJA may differ between methods, it has direct influence on hip rotation and may therefore influence clinical decision making in context of transverse plane gait deviations.Research question: Does a functional KJA calibration lead to clinically relevant differences in hip rotation estimates during gait compared to the conventional method? Methods95 subjects (age: 19.9 years; BMI: 21.1 kg/m2), including 71 patients with potential rotation malalignment, were prospectively examined and underwent 3D gait analysis. For the conventional approach the KJA was determined by applying a knee alignment device, for the functional approach subjects were asked to perform two different calibration movements. Each procedure was performed twice. Mean hip rotation in stance (mHipRotSt) was determined following the conventional and the functional KJA calibration. ResultsDeming regression analysis for the comparison of conventional and functionally measured hip rotation revealed a systematic and substantial difference between methods (slope: 0.63; intercept: 0.31°). Measurement repetition with the knee alignment device revealed typical errors around 5°, whereas the functional methods lead to profoundly smaller errors around 1-2° with slightly inferior results for SQUAT compared to FLEX. However, when compared to conventional frontal plane video-taping, the conventional method seemed to reflect the more consistent results. SignificanceThe systematic linear discrepancy in mHipRotSt obtained by a functional approach as compared to the conventional approach appears critical since patients with severe internal or external rotation gait may be misjudged in function when receiving corrective procedures such as femoral derotation osteotomy.

A PROSPECTIVE RANDOMISED CLINICAL TRIAL TO EVALUATE THE EFFECT OF FIBULAR PLATING IN TWO STAGED TREATMENT OF TIBIAL PLAFOND FRACTURES

Introduction: A single blinded randomized clinical trial of distal plafond fractures , who were treated with primary external xation with and without bular plating followed by distal tibial plating .Sincere efforts were made to analyze and compare the results of bular xation and staged protocol in tibial plafond fractures. A prospective study was Materials and Methods: conducted for 40 cases of tibial plafond fractures who were aged between 18yrs - 65yrs and presented within 2 weeks of injury. Randomization was done to allocate 20 patients each into two treatment models – a)External xation with bular plating , b)External xation without bular plating. Second stage distal tibial lock plating was done in all cases and follow up was carried out. Results: Statistically signicant differences were found in case of operating time, duration of hospital stay in favour of external xation without bula plating group, but these may not be clinically signicant. Delay in second stage tibial plating was more in bular plating group. Fibula plating reduces rotational malalignment more signicantly than coronal and saggital plane malalignment. There is no signicant early union , malunion or nonunion on comparing both groups. Both the procedures gave equally good functional results. We recommend two stage protoc Conclusion: ol for management of plafond fracture to decrease complication rate and bular xation is not always necessary in those cases with undisplaced lateral column. Displaced bular fractures which destabilize the ankle mortise should always be picked up for bular plating.

Minimally Invasive Derotational Osteotomy of Long Bones: Smartphone Application Used to Improve the Accuracy of Correction

Correction of rotational malalignments caused by fractures is essential as it may cause pain and gait disturbances. This study evaluated the intraoperative use of a smartphone application (SP app) to measure the extent of corrective rotation in patients treated using minimally invasive derotational osteotomy. Intraoperatively, two parallel 5 mm Schanz pins were placed above and below the fractured/injured site, and derotation was performed manually after percutaneous osteotomy. A protractor SP app was used intraoperatively to measure the angle between the two Schanz pins (angle-SP). Intramedullary nailing or minimally invasive plate osteosynthesis was performed after derotation, and computerized tomography (CT) scans were used to assess the angle of correction postoperatively (angle-CT). The accuracy of rotational correction was assessed by comparing angle-SP and angle-CT. The mean preoperative rotational difference observed was 22.1°, while the mean angle-SP and angle-CT were 21.6° and 21.3°, respectively. A significant positive correlation between angle-SP and angle-CT was observed, and 18 out of 19 patients exhibited complete healing within 17.7 weeks (1 patient exhibited nonunion). These findings suggest that using an SP app during minimally invasive derotational osteotomy can result in accurate correction of malrotation of long bones in a reproducible manner. Therefore, SP technology with integrated gyroscope function represents a suitable alternative for determination of the magnitude of rotational correction when performing corrective osteotomy.

Investigation on the site of coronal deformities in Hallux valgus

Hallux valgus (HV) is a common foot deformity that is more prevalent in females, characterised by abnormal adduction of the first metatarsal (MT) and valgus deviation of the phalanx on the transverse plane. Increasing evidence indicates that HV is more than a 2D deformity but a 3D one with rotational malalignment. Pronation deformity is seen during clinical examination for HV patients, but the exact origin of this rotational deformity is still unknown. Some attribute it to first tarsometatarsal (TMT) joint rotation, while others attribute it to intra-metatarsal bony torsion. In addition, the correlation between the rotational and transverse plane deformity is inconclusive. Identifying the origin of the rotational deformity will help surgeons choose the optimal surgical procedure while also enhancing our understanding of the pathophysiology of HV. This study aims to (1) develop an objective method for measuring the first MT torsion and first TMT joint rotation; (2) investigate the exact location of the coronal deformity in HV; (3) investigate the relationship between the severity of deformity on the transverse and coronal planes as well as the correlation between deformity severity and foot function/symptoms in HV. Age-matched females with and without HV were recruited at the Foot and Ankle Clinic of the Department of Orthopaedics and Traumatology. Computed tomography was conducted for all subjects with additional weight-bearing dorsal-plantar X-ray examination for HV subjects. Demographic information of all subjects was recorded, with symptoms and functions related to HV evaluated. The intra-class correlation was used to explore the relationship between deformities on different planes and the deformity severity and functional outcomes, respectively. An Independent t-test was used to compare joint rotation and bone torsion degrees. TMT joint rotation is significantly correlated with foot function. HV patients had more TMT joint rotation but not MT torsion compared to normal controls. No relationship was found between the coronal rotation and the 1,2-intermetatarsal angle (IMA) or Hallux valgus angle (HVA) on the transverse plane. Our results indicate that coronal deformities in HV may originate from TMT joint rotation. In addition, the severity of the TMT joint coronal rotation correlates with worse foot function; thus, multi-plane assessment and examination will be necessary for more precise surgical correction.

Rotational Guided Growth: A Preliminary Study of Its Use in Children.

Torsional malalignment of the legs is common in children, and those that do not remodel may benefit from surgical correction. Traditionally, this is corrected with an open osteotomy. Guided growth is the gold standard for minimally invasive angular correction and has been investigated for use in torsional deformities. This study presents our preliminary results of rotationally guided growth in the femur and tibia using a novel technique of peripheral flexible tethers. A total of 8 bones in 5 patients were treated with flexible tethers consisting of separated halves of a hinge plate (Orthopediatrics Pega Medical, Montreal, QC, Canada), which were fixed to the epiphysis and metaphysis at 45° angles to the physis and connected with Fibertape (Arthrex, Naples, FL, USA). The implants are placed medially and laterally in the opposite 45° inclination, determined by the desired direction of rotation. Additionally, the average treatment time was 12 months. All patients corrected the rotational malalignment by clinical evaluation. The average rotational change was 30° in the femurs and 9.5° in the tibias. Further, the average follow-up was 18 months, with no recurrence of the rotational deformity. There was no change in longitudinal growth in the patients who underwent bilateral treatment. Rotational guided growth with flexible tether devices is a novel technique that successfully corrects torsional malalignment without invasive osteotomy surgery.

Factors that Increase Elbow Stress in the Throwing Athlete: a Systematic Review of Biomechanical and Motion Analysis Studies of Baseball Pitching and Throwing.

Elbow pain poses a unique challenge in the throwing athlete. Due to the high levels of elbow stress during the throwing motion, elbow injuries are common in throwers of all ages. There are several postulated factors believed to contribute increased stress to the throwing elbow. A detailed review of the published biomechanical studies evaluating the stresses experienced by the throwing elbow is needed. Here, we review these biomechanical studies to extrapolate the contributing factors that increase stress, the modifications that may reduce such stress, and the post-injury rehabilitation that optimizes outcomes and reduces recurrence. The biomechanical forces on the elbow have been further investigated delineated in recent work. Rotational malalignment of the shoulder, including both GIRD and decreased adduction, increases torque experienced by the elbow during pitching motions. Exact interactions between lower extremity, lumbopelvic or trunk rotation, and elbow forces during throwing remain uncertain with mixed results in recent literature. Pitch types may influence elbow stresses although delivery mechanism and distance thrown do not. Several biomechanical factors influence the stresses imparted on the throwing elbow. Throwing volume, proper throwing mechanics, and appropriate rehabilitation are likely to be to be the most influential on mitigating unnecessary stresses imparted to the elbow in the throwing athlete. A proper understanding of these factors may reduce the occurrence of these injuries in this population. Moreover, an understanding of proper rehabilitation following injury may ensure optimized results and reduce recurrence.

The Salford technique of correction of rotational malalignment in lower limbs

Derotational osteotomies of lower limb are widely used to correct rotational deformity and the ability to translate pre-operative plan to accurate intra-operative correction remains challenging in these situations. Salford technique uses pre-operative CT scan, limb length radiographs and PACS tools to calculate a correction distance that can be marked on the surface of bone at the osteotomy site intra-operatively to obtain accurate correction. The calculation is based on the two dimensional geometrical formulae of a circle. We present this case report of a patient who underwent derotational osteotomies of femur and ipsilateral tibia along with Medial patellofemoral ligament reconstruction using this technique. Salford technique is simple, reproducible and cost effective in allowing surgeons to accurately correct rotational deformity of lower limbs without the need for specialist equipment.

Correction of post-traumatic lower-limb discrepancy with Precice intramedullary lengthening nails: a review of 34 adults with an average follow-up of 2 years.

Background and purposeWe report results and complications of gradual bone lengthening for post-traumatic lower-limb length discrepancy (LLD) with Precice intramedullary lengthening nails in 34 adults.Patients and methodsInclusion criteria were lowerlimb lengthening using the Precice nail, posttraumatic etiology, age older than 18 years, and minimum follow-up of 12 months after implantation. 34 patients met the inclusion criteria. Radiological and clinical outcome data were collected.ResultsPrecice lengthening was performed in the femur in 28 patients (21 antegrade, 7 retrograde) and in the tibia in 6. Mean patient age at time of surgery was 32 years (18–72). Mean preoperative LLD was 31 mm (20–71). Acute correction of axial or rotational malalignment was performed in 11 segments. At final follow-up (mean 2 years [1.1–3.6]), 33 of 34 nails had been removed. All lengthening sites were healed, and all patients mobilized with full weight-bearing. 14 adverse events occurred in 11 patients and were categorized as problems (n = 5), obstacles (n = 3), and complications (n = 6). Unplanned surgery was necessary in 7 patients, 3 of whom did not complete treatment with Precice.InterpretationCorrection of posttraumatic LLD with or without axial malalignment using Precice intramedullary lengthening nails is associated with a low number of complications and good functional outcome. However, one-fifth of patients in this series needed further unplanned surgery for revision of obstacles or complications.

Severity of rotational malalignment impacts on the hip rotation angle calculated using conventional and functional knee calibration

Severity of rotational malalignment impacts on the hip rotation angle calculated using conventional and functional knee calibration

Transversal Malalignment and Proximal Involvement Play a Relevant Role in Unilateral Cerebral Palsy Regardless the Subtype.

Classification of gait disorders in cerebral palsy (CP) remains challenging. The Winters, Gage, and Hicks (WGH) is a commonly used classification system for unilateral CP regarding the gait patterns (lower limb kinematics) solely in the sagittal plane. Due to the high number of unclassified patients, this classification system might fail to depict all gait disorders accurately. As the information on trunk/pelvic movements, frontal and transverse planes, and kinetics are disregarded in WGH, 3D instrumented gait analysis (IGA) for further characterization is necessary. The objective of this study was a detailed analysis of patients with unilateral CP using IGA taking all planes/degrees of freedom into account including pelvic and trunk movements. A total of 89 individuals with unilateral CP matched the inclusion criteria and were classified by WGH. Subtype-specific differences were analyzed. The most remarkable findings, in addition to the established WGH subtype-specific deviations, were pelvic obliquity and pelvic retraction in all WGH types. Furthermore, the unclassified individuals showed altered hip rotation moments and pelvic retraction almost throughout the whole gait cycle. Transversal malalignment and proximal involvement are relevant in all individuals with unilateral CP. Further studies should focus on WGH type-specific rotational malalignment assessment (static vs. dynamic, femoral vs. tibial) including therapeutic effects and potential subtype-specific compensation mechanisms and/or tertiary deviations of the sound limb.

Failure modes in malrotated total knee replacement.

Achieving normal rotational alignment of both components in total knee arthroplasty (TKA) is essential for improved knee survivorship and function. However, malrotation is a known complication resulting in higher revision rates. Understanding malrotation of the components and its concomitant clinical and functional outcomes are important for early diagnosis and management. The purpose of this study was to evaluate the effect of malrotation on clinical outcomes and failure modes in both single and combined rotational malalignment. From our hospital database of 364 revisions, a cohort of 76 knees with patellar maltracking, stiffness, reduced range of motion and early aseptic failure were reviewed and investigated for component malrotation using computed tomography following Berger protocol. CT findings confirmed component malrotation in 70 of these patients. Investigations included (1) measurement of femoral component malrotation using surgical transepicondylar axis, (2) measurement of tibial component malrotation using anteroposterior axis and (3) measurement of combined component rotational errors. The correlation of CT analysis and clinical outcomes after primary TKA revealed association of patellar maltracking with femoral internal rotation, pain and instability with tibial internal rotation and knee stiffness in patients with combined component malrotation as the commonest mode of presentation. Our study showed that patients with isolated femoral, tibial and combined malrotation presented at a mean period of 3.4 ± 1.34, 1.7 ± 0.8 and 2.3 ± 0.69years, respectively, after the index surgery. Post-revision, the mean Knee Society Score and Oxford Knee Score improved from 29.1 to 78.7, and 10.5 to 32.8, respectively, and the mean range of motion improved from 74.9 ± 24.8 to 97.1 ± 12.7 degrees at a mean follow-up of 42months. Early detection of malrotation in TKA and its management with revision of both components can lead to better clinical and functional outcomes. III.

Intraoperative fluoroscopic protocol to avoid rotational malalignment after nailing of tibia shaft fractures: introduction of the ‘C-Arm Rotational View (CARV)’

PurposeRotational malalignment (≥ 10°) is a frequent pitfall of intramedullary-nailing of tibial shaft fractures. This study aimed to develop an intraoperative fluoroscopy protocol, coined ‘C-Arm Rotational View (CARV)’, to significantly reduce the risk for rotational malalignment and to test its clinical feasibility.MethodsA cadaver and clinical feasibility study was conducted to develop the CARV-technique, that included a standardized intraoperative fluoroscopy sequence of predefined landmarks on the uninjured and injured leg in which the rotation of the C-arm was used to verify for rotational alignment. A mid-shaft tibia fracture was simulated in a cadaver and an unlocked intramedullary-nail was inserted. Random degrees of rotational malalignment were applied using a hand-held goniometer via reference wires at the fracture site. Ten surgeons, blinded for the applied rotation, performed rotational corrections according to (1) current clinical practice after single-leg and dual-leg draping, and (2) according to the CARV-protocol. The primary outcome measure was the accuracy of the corrections relative to neutral tibial alignment. The CARV-protocol was tested in a small clinical cohort.ResultsIn total, 180 rotational corrections were performed by 10 surgeons. Correction according to clinical practice using single-leg and dual-leg draping resulted in a median difference of, respectively, 10.0° (IQR 5.0°) and 10.0° (IQR 5.0°) relative to neutral alignment. Single-leg and dual-leg draping resulted in malalignment (≥10°) in, respectively, 67% and 58% of the corrections. Standardized correction using the CARV resulted in a median difference of 5.0° (IQR 5.0°) relative to neutral alignment, with only 12% categorized as malalignment (≥10°). The incidence of rotational malalignment after application of the CARV decreased from 67% and 58% to 12% (p = <0.001). Both consultants and residents successfully applied the CARV-protocol. Finally, three clinical patients with a tibial shaft fracture were treated according to the CARV-protocol, resulting all in acceptable alignment (<10°) based on postoperative CT-measurements.ConclusionThis study introduces an easy-to-use and clinically feasible standardized intraoperative fluoroscopy protocol coined ‘C-arm rotational view (CARV)’ to minimize the risk for rotational malalignment following intramedullary-nailing of tibial shaft fractures.

The Effects of Lower Extremity Rotational Malalignment on Pediatric Patient-reported Outcomes Measurement and Information System (PROMIS) Scores.

Background:There is sparse literature demonstrating the relationship between lower limb pediatric idiopathic rotational malalignment (IRM) and patient-reported outcomes measurement information system (PROMIS) scores. Our goal is to determine and quantify the amount that IRM deformities, as measured with the 3D gait analysis, affect childrens’ pain interference, mobility, and peer relationship PROMIS domains. Secondary outcomes include investigating the potential relationships between IRM and various subgroups (Pediatric Outcomes Data Collection Instrument (PODCI), gender, Body Mass Index (BMI), femur Versus tibia). We also examine whether the PROMIS domains correlate with PODCI in this population.Methods:This study was a retrospective cohort, single institution, and consecutively recruited cases series. We identified 47 children over a 3-year period who were evaluated at the motion analysis center at our tertiary care hospital, with increased torsion of the femur or tibia. After exclusions, 25 children with IRM, documented PROMIS data and gait analysis were considered.Results:Femoral malrotation had a significant relationship with female gender (P=0.001) and increased BMI (P<0.001). Femoral malrotation had a correlation with PROMIS pain interference (P=0.016), whereas tibial rotation did not achieve significance (P=0.084). In the ANOVA regression analysis, there was a strong prediction of the PROMIS mobility domain when both malrotation and pain interference were present (P=0.007). There were Pearson Correlations of PROMIS and PODCI domains for Mobility Versus Sports (P=0.007) and Pain Interference Versus Comfort/Pain (P=0.004), respectively.Conclusion:The evident relationship between lower limb rotational malalignment and PROMIS scores signifies the likelihood for gait and pain disturbance. This in turn could show us that children are likely to be more debilitated and thus may benefit from timely correction. We aim to conduct this as a multicentre trial to confirm our findings.Level of Evidence:Level IV.

Evaluation of Rotational Malalignment after Intramedullary Nailing of the Femur

Evaluation of Rotational Malalignment after Intramedullary Nailing of the Femur