Skeletal Radiology

, Volume 47, Issue 4, pp 483–490 | Cite as

Radiographic markers for measuring tibial rotation based on CT-reconstructed radiographs: an accuracy and feasibility study

  • David Hakimian
  • Amal Khoury
  • Rami Mosheiff
  • Meir Liebergall
  • Yoram A. Weil
Scientific Article
  • 60 Downloads

Abstract

Objectives

Malreduction in the axial plane (malrotation) following tibial fracture surgery is often undiagnosed. A few clinical and radiographic methods have been proposed for measuring tibial rotation intraoperatively, yet have failed to match the accuracy of computed tomography (CT). The aim of this study was to develop radiographic tools for future intraoperative assessment of the tibial shaft rotation profile.

Methods

The setting was a laboratory computerized analysis. Twenty lower limb CT scans were used to construct a three-dimensional (3D) model using AMIRA© software. A virtual 3D cylinder was implanted in the posterior condylar line and in the transmalleolar axis. The 3D models were used to simulate four standard knee and ankle plain radiographs. On each radiograph, four landmarks were depicted by two observers and their relation with the cylinder was measured and analyzed for accuracy and reproducibility. A cadaveric lower leg was implanted with two Kirschner wires. A CT scan was performed in addition to 2D fluoroscopy. The simulated radiographs and the fluoroscopy were compared for accuracy.

Results

Measurement of the landmarks showed reliability in most of the knee anteroposterior and ankle mortise radiographs (coefficients of variation < 0.01 and = 0.01) respectively. Cadaveric measurement of the landmarks using real fluoroscopy and simulated radiographs were similar.

Conclusions

To date, no reliable and common methods have been reported for the evaluation of tibial axial rotation. We propose a model in which simple radiographic landmarks can be used to calculate a 3D coordinate system that accurately assesses the axial rotation angle of the tibial shaft.

Keywords

Tibial torsion Tibial fractures Malrotation 

Notes

Compliance with ethical standards

Conflicts of interest statement

The corresponding authors state on behalf of all other authors that none of the authors has a potential conflict of interests, received any grants or fees concerning any part of this study.

Ethical approval

The authors have used only anonymous radiographic data without disclosures of any patients’ data. The ethical board of the institution had waived the need for formal IRB approval or patients’ consent to conduct this study.

References

  1. 1.
    Güven M, Akman B, Ünay K. A new radiographic measurement method for evaluation of tibial torsion: a pilot study in adults. Clin Orthop Relat Res. 2009;467(7):1807–12.CrossRefPubMedGoogle Scholar
  2. 2.
    Turner MS, Smillie IS. The effect of tibial torsion of the pathology of the knee. J Bone Joint Surg Br. 1981;63-B(3):396–8.PubMedGoogle Scholar
  3. 3.
    Lee SH, Chung CY, Park MS, Choi IH, Cho TJ. Tibial torsion in cerebral palsy: validity and reliability of measurement. Clin Orthop Relat Res. 2009;467(8):2098–104.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Puloski S, Romano C, Buckley R, Powell J. Rotational malalignment of the tibia following reamed intramedullary nail fixation. J Orthop Trauma. 2004;18(7):397–402.CrossRefPubMedGoogle Scholar
  5. 5.
    Eckhoff DG. Effect of limb malrotation on malalignment and osteoarthritis. Orthop Clin North Am. 1994;25(3):405–14.PubMedGoogle Scholar
  6. 6.
    Krettek C, Schandelmaier P, Tscherne H. Nonreamed interlocking nailing of closed tibial fractures with severe soft tissue injury. Clin Orthop Relat Res. 1995;315:34–47.Google Scholar
  7. 7.
    Shin SY, Yoon CH, Lee ES, Oh MK, Kim AR, Park JM, et al. The availability of radiological measurement of tibial torsion: three-dimensional computed tomography reconstruction. Ann Rehabil Med. 2011;35(5):673–9.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Clementz BG, Magnusson A. Fluoroscopic measurement of tibial torsion in adults. A comparison of three methods. Arch Orthop Trauma Surg. 1989;108(3):150–3.CrossRefPubMedGoogle Scholar
  9. 9.
    Jakob RP, Haertel M, Stüssi E. Tibial torsion calculated by computerised tomography and compared to other methods of measurement. J Bone Joint Surg Br. 1980;62-B(2):238–42.PubMedGoogle Scholar
  10. 10.
    Kahler DM. Navigated long-bone fracture reduction. J Bone Joint Surg Am. 2009;91(Suppl 1):102–7.CrossRefPubMedGoogle Scholar
  11. 11.
    Mosheiff R, Weil Y, Peleg E, Liebergall M. Computerised navigation for closed reduction during femoral intramedullary nailing. Injury. 2005;36:866–70.CrossRefPubMedGoogle Scholar
  12. 12.
    Ballinger PW. Merrill’s atlas of radiographic positions and radiologic procedures. 7th ed. St. Louis: Mosby Year Book; 1991. p. 220–50.Google Scholar
  13. 13.
    Deza MM, Deza E. Encyclopedia of distances. Berlin Heidelberg: Springer; 2009. p. 94.CrossRefGoogle Scholar
  14. 14.
    Lipschutz S, Lipson M. Linear algebra (Schaum’s Outlines) 4th ed. New York: McGraw Hill; 2009. p. 4.Google Scholar
  15. 15.
    Le Damany P. La torsion du tibia, normale, pathologique expérimentale (abstr). J Anat Physiol. 1909;45:598–615.Google Scholar
  16. 16.
    Prasad CV, Khalid M, McCarthy P, OSullivan ME. CT assessment of torsion following locked intramedullary nailing of tibial fractures. Injury. 1999;30(7):467–70.CrossRefPubMedGoogle Scholar
  17. 17.
    Hutter CG Jr, Scott W. Tibial torsion. J Bone Joint Surg Am. 1949;31A(3):511–8.CrossRefPubMedGoogle Scholar
  18. 18.
    Staheli LT, Engel GM. Tibial torsion: a method of assessment and a survey of normal children. Clin Orthop Relat Res. 1972;86:183–6.CrossRefPubMedGoogle Scholar
  19. 19.
    Hazlewood ME, Simmons AN, Johnson WT, Richardson AM, van der Linden ML, Hillman SJ, et al. The footprint method to assess transmalleolar axis. Gait Posture. 2007;25(4):597–603.CrossRefPubMedGoogle Scholar
  20. 20.
    Jend HH, Heller M, Dallek M, Schoettle H. Measurement of tibial torsion by computer tomography. Acta Radiol Diagn. 1981;22(3A):271–6.CrossRefGoogle Scholar
  21. 21.
    Wang G, Zheng G, Gruetzner PA, Mueller-Alsbach U, von Recum J, Staubli A, Nolte LP. A fluoroscopy-based surgical navigation system for high tibial osteotomy. Tech Health Care. 2005;13(6):469–83.Google Scholar
  22. 22.
    Weil YA, Greenberg A, Khoury A, Mosheiff R, Liebergall M. Computerized navigation for length and rotation control in femoral fractures: a preliminary clinical study. J Orthop Trauma. 2014;28(2):e27–33.  https://doi.org/10.1097/BOT.0b0131829aaefb.CrossRefPubMedGoogle Scholar
  23. 23.
    Weil YA, Gardner MJ, Helfet DL, Pearle A. Computer navigation allows for accurate reduction of femoral fractures. Clin Orthop Relat Res. 2007;460:185–91.PubMedGoogle Scholar

Copyright information

© ISS 2017

Authors and Affiliations

  • David Hakimian
    • 1
  • Amal Khoury
    • 1
  • Rami Mosheiff
    • 1
  • Meir Liebergall
    • 1
  • Yoram A. Weil
    • 1
  1. 1.Department of OrthopaedicsHadassah Hebrew University HospitalJerusalemIsrael

Personalised recommendations