Bilateral Low-Dose Computed Tomography Assessment for Post-Operative Rotational Malalignment After Intramedullary Nailing for Tibial Shaft Fractures: Reliability of a Practical Imaging Technique

Bleeker, Nils Jan; Cain, Megan; Rego, Mariana; Saarig, Aimane; Chan, Andrew G.; Sierevelt, Inger N.; Doornberg, Job N.; Jaarsma, Ruurd L.

doi:10.1016/j.injury.2018.07.031

Cited by 18 publications

(38 citation statements)

References 30 publications

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“… 8 – 10 Moreover, radiographs were used to measure alignment, whereas CT-scans are superior in detecting malalignment. 13 , 38 , 39 The included studies in this review did not report on rotational malalignment based on CT-measurements. Low-dose CT-based data on rotational malalignment after SP-nailing is lacking and may be of added value to the ongoing debate on SP- or IP-nailing of tibial fractures as incidences up to 35% were reported after the IP-approach.…”

Section: Discussionmentioning

confidence: 99%

“…Low-dose CT-based data on rotational malalignment after SP-nailing is lacking and may be of added value to the ongoing debate on SP- or IP-nailing of tibial fractures as incidences up to 35% were reported after the IP-approach. 38 , 39 …”

Section: Discussionmentioning

confidence: 99%

“…Angular deformities are defined as a deformity of ≥5 degrees in the coronal or sagittal plane 8 , 36 , 37 and rotational malalignment is defined as a rotation of ≥10 degrees in comparison to the unaffected side. 38 , 39 Nonunion includes no signs of cortical healing after 6 months. Subsequent surgeries include screw(s) removal, implant removal, and revision for complications.…”

Section: Methodsmentioning

confidence: 99%

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Difference in Pain, Complication Rates, and Clinical Outcomes After Suprapatellar Versus Infrapatellar Nailing for Tibia Fractures? A Systematic Review of 1447 Patients

Bleeker

Reininga

Wall

et al. 2021

Journal of Orthopaedic Trauma

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

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Difference in Pain, Complication Rates, and Clinical Outcomes After Suprapatellar Versus Infrapatellar Nailing for Tibia Fractures? A Systematic Review of 1447 Patients

Bleeker

Reininga

Wall

et al. 2021

Journal of Orthopaedic Trauma

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“…A discrepancy of more than 10° is defined according to most authors as malrotation [2][3][4][5][9][10][11]. Currently, computed tomography is accepted as gold standard procedure for determining tibial torsion [2,9,[12][13][14][15][16].…”

Section: Introductionmentioning

confidence: 99%

Clinical assessment of tibial torsion differences. Do we always need a computed tomography?

Hawi

Kaireit

Krettek

et al. 2022

Eur J Trauma Emerg Surg

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Background Tibial torsional malalignment presents a well-known complication of intramedullary nailing for tibial shaft fractures. Purpose Objective of this study was to investigate the ability to clinically assess tibial torsion differences. Computed Tomography (CT) was used here as the gold standard. Further, intra- and inter-observer reliability of the clinical examination, and radiological measurements were calculated. Methods Fifty-one patients with torsion-difference CTs, obtained for various reasons, were asked to kneel on an examination couch with free hanging feet. All patients are positioned with 90° flexed knee and neutral ankle. A picture of the lower extremities was obtained from the back of the patient. Two blinded orthopedic surgeons were asked to look at the pictures and measure the tibial torsion with a digital goniometer, based on the axis of the femur in relation to the second ray of the foot. To determine the intra-observer variation, the torsional angles were calculated again after 4 weeks. To be able to compare values, two blinded radiologists calculated torsional differences based on computed tomography. Results All patients were able to be positioned for clinical assessment (n = 51). Clinical assessment of torsional difference revealed 4.55° ± 6.85 for the first, respectively, 4.55° ± 7.41 for the second investigator. The second measurement of the first investigator revealed a value of 4.57° ± 6.9. There was a good intra-observer agreement for clinical assessment (ICC 0.993, p < 0.001). Also, the inter-observer agreement showed a good inter-observer agreement (ICC 0.949, p < 0.001). Evaluation of radiological inter-observer assessment could also show a good inter-observer agreement (ICC 0.922, p < 0.001). The clinical method showed a good correlation to the CT method (0.839, p < 0.001). Additionally, the Bland–Altman plot was used to compare graphically both measurement techniques, which proved the agreement. Conclusion In summary, computed tomography-assisted measurement of tibial torsion and clinical assessment correlated significantly good. In addition to that, clinical measurement has a good intra- and inter-observer reliability. Clinical examination is a reliable and cost-effective tool to detect mal-torsion and should be part of the repertoire of every surgeon.

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“…Intraoperative tools for torsion control are limited and often not reproducible [ 15 ]. The gold standard for torsion control is a postoperative CT, which does not allow for intraoperative decision-making or corrections, therefore promoting additional revision procedures [ 16 ].…”

Section: Introductionmentioning

confidence: 99%

Radiographic cortical thickness parameters as predictors of rotational alignment in proximal tibial shaft fractures: a cadaveric study

Keppler

Küssner

et al. 2021

BMC Musculoskelet Disord

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Aim The treatment of tibial fractures with an intramedullary nail is an established procedure. However, torsional control remains challenging using intraoperatively diagnostic tools. Radiographic tools such as the Cortical Step Sign (CSS) and the Diameter Difference Sign (DDS) may serve as tools for diagnosing a relevant malrotation. The aim of this study was to investigate the effect of torsional malalignment on CSS and DDS parameters and to construct a prognostic model to detect malalignment. Methods A proximal tibial shaft fracture was set in human tibiae. Torsion was set stepwise from 0° to 30° in external and internal torsion. Images were obtained with a C-arm and transferred to a PC for measuring the medical cortical thickness (MCT), lateral cortical thickness (LCT), tibial diameter (TD) in AP and the anterior cortical thickness (ACT) as well as the posterior cortical thickness (PCT) and the transverse diameter (TD) of the proximal and the distal main fragment. Results There were significant differences between the various degrees of torsion for each of the absolute values of the examined variables. The parameters with the highest correlation were TD, LCT and ACT. A model combining ACT, LCT, PCT and TD lateral was most suitable model in identifying torsional malalignment. The best prediction of clinically relevant torsional malalignment, namely 15°, was obtained with the TD and the ACT. Conclusion This study shows that the CSS and DDS are useful tools for the intraoperative detection of torsional malalignment in proximal tibial shaft fractures and should be used to prevent maltorsion.

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Bilateral Low-Dose Computed Tomography Assessment for Post-Operative Rotational Malalignment After Intramedullary Nailing for Tibial Shaft Fractures: Reliability of a Practical Imaging Technique

Cited by 18 publications

References 30 publications

Difference in Pain, Complication Rates, and Clinical Outcomes After Suprapatellar Versus Infrapatellar Nailing for Tibia Fractures? A Systematic Review of 1447 Patients

Difference in Pain, Complication Rates, and Clinical Outcomes After Suprapatellar Versus Infrapatellar Nailing for Tibia Fractures? A Systematic Review of 1447 Patients

Clinical assessment of tibial torsion differences. Do we always need a computed tomography?

Radiographic cortical thickness parameters as predictors of rotational alignment in proximal tibial shaft fractures: a cadaveric study

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