A new method for tibial torsion measurement by computerized tomography

Madadi, Firooz; Maleki, Arash; Shamie, Arya Nick; Washington, Eleby R.; Yazdanshenas, Hamed

doi:10.1016/j.jor.2015.09.001

Cited by 19 publications

(19 citation statements)

References 28 publications

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“…The literature on tibial torsion mainly pertains to the pediatric population and describes normal external tibial torsion to be around 30 degrees 1,7,13,20 ; however, it has been described to be as high as 82 degrees in normal patients. 13 Excessive external tibial torsion may contribute to an external foot progression angle and has been associated with progressive equinoplanovalgus foot segmental malalignment, hallux valgus, and midfoot degenerative arthritis in adults, 4,6 and following tibial malunion, an increased risk of ankle arthritis has been shown.…”

Section: Discussionmentioning

confidence: 99%

Role of Rotation in Total Ankle Replacement

2019

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Background: The importance of total ankle replacement (TAR) implant orientation in the axial plane is poorly understood with major variation in surgical technique of implants on the market. Our aim was to better understand the axial rotational profile of patients undergoing TAR. Methods: In 157 standardized computed tomography (CT) scans of patients with end-stage ankle arthritis planning to undergo primary TAR surgery, we measured the relationship between the knee posterior condylar axis, the tibial tuberosity, the transmalleolar axis (TMA), and the tibiotalar angle. The foot position was measured in relation to the TMA with the foot plantigrade. The variation between the medial gutter line and the line bisecting both gutters was assessed. Results: The mean external tibial torsion was 34.5 ± 10.3 degrees (11.8-62 degrees). When plantigrade, the mean foot position relative to the TMA was 21 ± 10.6 degrees (0.7-38.4 degrees) internally rotated. As external tibial torsion increased, the foot position became more internally rotated relative to the TMA (Pearson correlation, 0.6; P < .0001). As the tibiotalar angle became more valgus, the foot became more externally rotated relative to the TMA (Pearson correlation, −0.4; P < .01). The mean difference between the medial gutter line and a line bisecting both gutters was 4.9 ± 2.8 degrees (1.7-9.4 degrees). More than 51% of patients had a difference greater than 5 degrees. The mean angle between the medial gutter line and a line perpendicular to the TMA was 7.5 ± 2.6 degrees (2.8-13.7 degrees). Conclusion: There was a large variation in rotational profile of patients undergoing TAR, particularly between the medial gutter line and the TMA. Surgeon designers and implant manufacturers should develop consistent methods to guide surgeons toward judging the appropriate axial rotation of their implant on an individual basis. We recommend careful clinical assessment and preoperative CT scans to enable the correct rotation to be determined. Level of Evidence: Level IIc, outcomes research.

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Section: Discussionmentioning

confidence: 99%

Role of Rotation in Total Ankle Replacement

2019

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“…Our method meets this requirement since a volumetric model is used for the calculation and it is therefore closer to the anatomic reality than points selected by the examiner. The fact that the method works with or without consideration of the fibula is convenient, since the position of the fibula is variable [ 24 ]. However, since the fibula is a relevant stabilizer for the ankle joint and makes a relevant contribution to the ankles kinematic function, we think it should be included in the analysis.…”

Section: Discussionmentioning

confidence: 99%

“…On the one hand, the determination of the proximal axis for 2D measurements, the highly variable posterior shape of the proximal epiphysis and metaphysis is a challenge for routine measurements. On the other hand, the distal axis, as defined by most standard methods, is directly dependent on the highly variable position of the fibula [ 24 ]. Various attempts have been undertaken to assess 2D measurements of tibial torsion, but the variabilities between some of these methods remain substantial [ 23 – 28 ].…”

Section: Introductionmentioning

confidence: 99%

Tibial torsion analysis in computed tomography: development and validation of a real 3D measurement technique

et al. 2021

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Purpose Pathological tibial torsion is known to negatively influence the functionality of the lower extremity, and therefore, its assessment might play an important role. While 3D imaging is used for many examinations of the musculoskeletal system, for the determination of tibial torsion no 3D measurement technique has been available so far. We developed a 3D measurement method and assess its interobserver reliability as well as its correlation with standard 2D measurement methods. Methods CT scans of 82 tibiae in 79 patients with a mean age of 41 years were included. A novel 3D measurement technique was developed and applied. Measurements were compared with two frequently used 2D measurement methods. ICC (intraclass correlation coefficient) for the new technique was determined and compared to the 2D measurement method. Furthermore, differences between left and right legs as well as between males and females were assessed. Results The ICC for the 2D methods was 0.917 and 0.938, respectively. For the 3D measurements, ICCs were calculated to be 0.954 and 0.950. Agreement between 2 and 3D methods was moderate to good with ICCs between 0.715 and 0.795. Torsion values for left and right legs did not differ significantly in 2D and in 3D (26.2 vs 28.5° and 27.2 vs. 25.9°). The same is true for the differences between male and female in 2D and 3D (26.2 vs. 29.6° and 25.0 vs. 31.2°). Conclusion The newly developed 3D measurement technique shows a high intraclass agreement and offers an applicable opportunity to assess the tibial torsion three-dimensionally.

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“…In the presence of an abnormal or displaced fibula (eg, distal fibular fracture) or disruption of the normal relationship between fibula and tibia (eg, rupture of syndesmosis, creating a diastasis), referencing tibial torsion in relation to the fibula will be inaccurate. 26 Investigators have also defined axes formed by connecting the center of a circle fitted to the distal tibia and the midpoint of a line across the fibular notch of the tibia 39 , 47 and the perpendicular axis to the line connecting the distal fibular notch of the tibia. 26 Generation of the cloud points described above demonstrated clearly and consistently that the distal tibial slice medially represented a partial ellipse.…”

Section: Methodsmentioning

confidence: 99%

“… 26 Investigators have also defined axes formed by connecting the center of a circle fitted to the distal tibia and the midpoint of a line across the fibular notch of the tibia 39 , 47 and the perpendicular axis to the line connecting the distal fibular notch of the tibia. 26 Generation of the cloud points described above demonstrated clearly and consistently that the distal tibial slice medially represented a partial ellipse. However, laterally in the region where the fibula rests against the tibia, the shape of the region of bone contact between the fibula and tibia was highly variable ( Figure 5 ) in our study of 56 CT and 12 MRI scans.…”

Section: Methodsmentioning

confidence: 99%

A Validated, Automated, 3-Dimensional Method to Reliably Measure Tibial Torsion

et al. 2021

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Background: Tibial torsion is a twist in the tibia measured as an angle between a proximal axis line and a distal axis line. Abnormal torsion has been associated with a variety of painful clinical syndromes of the lower limb. Measurements of normal tibial torsion reported by different authors vary by 100% (ranging from 20° to 42°), making it impossible to determine normal and pathological levels. Purpose: To address the problem of unreliable measurements, this study was conducted to define an automated, validated computer method to calculate tibial torsion. Reliability was compared with current clinical methods. The difference between measurements of torsion generated from computed tomography (CT) and magnetic resonance imaging (MRI) scans of the same bone, and between males and females, was assessed. Study Design: Controlled laboratory study. Methods: Previous methods of analyzing tibial torsion were reviewed, and limitations were identified. An automated measurement method to address these limitations was defined. A total of 56 cadaveric and patient tibiae (mean ± SD age, 37 ± 15 years; range, 17-71 years; 28 female) underwent CT scanning, and 3 blinded assessors made torsion measurements by applying 2 current clinical methods and the automated method defined in the present article. Intraclass correlation coefficient (ICC) values were calculated. Further, 12 cadaveric tibiae were scanned by MRI, stripped of tissue, and measured using a structured light (SL) scanner. Differences between torsion values obtained from CT, SL, and MRI scans, and between males and females, were compared using t tests. SPSS was used for all statistical analysis. Results: When the automated method was used, the tibiae had a mean external torsion of 29°± 11° (range, 9°-65). Automated torsion assessment had excellent reliability (ICC, 1), whereas current methods had good reliability (ICC, 0.78-0.81). No significant difference was found between the torsion values calculated from SL and CT ( P = .802), SL and MRI ( P = .708), or MRI and CT scans ( P = .826). Conclusion: The use of software to automatically perform measurements ensures consistency, time efficiency, validity, and accuracy not possible with manual measurements, which are dependent on assessor experience. Clinical Relevance: We recommend that this method be adopted in clinical practice to establish databases of normal and pathological tibial torsion reference values and ultimately guide management of related conditions.

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A new method for tibial torsion measurement by computerized tomography

Abstract: We proposed a reliable method, independent of the fibular midpoint, in assessment of tibial torsion by CT.

Cited by 19 publications

References 28 publications

Role of Rotation in Total Ankle Replacement

Role of Rotation in Total Ankle Replacement

Tibial torsion analysis in computed tomography: development and validation of a real 3D measurement technique

A Validated, Automated, 3-Dimensional Method to Reliably Measure Tibial Torsion

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