Abstract
Introduction
The current standard of care for measuring lower extremity length and angular discrepancies is using a full-length standing anteroposterior radiograph. However, there has been increasing interest to use biplanar linear EOS imaging as an alternative. This study aims to compare lower extremity length and implant measurements between biplanar linear and conventional radiographs.
Materials and methods
In this 5-year retrospective study, all patients who had a standing full-length anteroposterior and biplanar linear radiographs (EOS®) that include the lower extremities done within one year of each other were included. Patients who underwent surgery in between the imaging, underwent surgeries that could result in graduated length or angulated corrections and inadequate exposure of the lower extremity were excluded. Four radiographic segments were measured to assess lower limb alignment and length measurements. Height and width measurements of implants were performed for patients who had implants in both imaging.
Results
When comparing imaging and actual implant dimensions, biplanar linear radiographs were accurate in measuring actual implant height (median difference = − 0.14 cm, p = 0.66), and width (median difference = − 0.13 cm, p = 0.71). However, conventional radiographs were inaccurate in measuring actual implant height (median difference = 0.19 cm, p = 0.01) and width (median difference = 0.61 cm, p < 0.01). When comparing conventional and biplanar linear radiographs, there was statistically significant difference in all measurements. This includes anatomical femoral length (median difference = 3.53 cm, p < 0.01), mechanical femoral length (median difference = 3.89 cm, p < 0.01), anatomical tibial length (median difference = 2.34 cm, p < 0.01) and mechanical tibial length (median difference = 2.20 cm, p < 0.01).
Conclusion
First, there is a significant difference in the lower extremity length when comparing conventional and biplanar linear radiographs. Second, biplanar linear radiographs are found to be accurate while conventional radiographs are not as accurate in implant measurements of length and width in the lower extremity.
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Abbreviations
- MA:
-
Mechanical axis
- AFL:
-
Anatomical femoral length
- MFL:
-
Mechanical femoral length
- ATL:
-
Anatomical tibial length
- MTL:
-
Mechanical tibial length
- HTO:
-
High tibial osteotomy
References
Green WT, Anderson M (1955) The problem of unequal leg length. Pediatr Clin North Am. 2:1137–1155
Gross RH (1978) Leg length discrepancy: how much is too much? Orthopedics 1(4):307–310
Rush WA, Steiner HA (1946) A study of lower extremity length inequality. Am J Roentgenol Radium Ther 56(5):616–623
Song KM, Halliday SE, Little DG (1997) The effect of limb-length discrepancy on gait. J Bone Jt Surg Am 79(11):1690–1698
Reina-Bueno M, Lafuente-Sotillos G, Castillo-Lopez JM et al (2017) Radiographic assessment of lower-limb discrepancy. J Am Podiatr Med Assoc 107(5):393–398
Sabharwal S, Zhao C, McKeon JJ et al (2006) Computed radiographic measurement of limb-length discrepancy. Full-length standing anteroposterior radiograph compared with scanogram. J Bone Jt Surg Am. 88(10):2243–2251
Paley D (2002) Principles of deformity correction, 1st edn. Springer Verlag, Berlin Heidelberg
Jeon MR, Park HJ, Lee SY et al (2017) Radiation dose reduction in plain radiography of the full-length lower extremity and full spine. Br J Radiol 90(1080):20170483
Deschenes S, Charron G, Beaudoin G et al (2010) Diagnostic imaging of spinal deformities: reducing patients radiation dose with a new slot-scanning X-ray imager. Spine (Phila Pa 1976) 35(9):989–994
Dietrich TJ, Pfirrmann CW, Schwab A et al (2013) Comparison of radiation dose, workflow, patient comfort and financial break-even of standard digital radiography and a novel biplanar low-dose X-ray system for upright full-length lower limb and whole spine radiography. Skeletal Radiol 42(7):959–967
Chaibi Y, Cresson T, Aubert B et al (2012) Fast 3D reconstruction of the lower limb using a parametric model and statistical inferences and clinical measurements calculation from biplanar X-rays. Comput Methods Biomech Biomed Engin 15(5):457–466
Dubousset J, Charpak G, Dorion I et al (2005) A new 2D and 3D imaging approach to musculoskeletal physiology and pathology with low-dose radiation and the standing position: the EOS system. Bull Acad Natl Med. 189(2):287–297 (discussion 97-300)
Humbert L, De Guise JA, Aubert B et al (2009) 3D reconstruction of the spine from biplanar X-rays using parametric models based on transversal and longitudinal inferences. Med Eng Phys 31(6):681–687
Lee KM, Chung CY, Park MS et al (2010) Reliability and validity of radiographic measurements in hindfoot varus and valgus. J Bone Jt Surg Am 92(13):2319–2327
McGraw KO, Wong SP (1996) Forming inferences about some intraclass correlation coefficients. Psychol Methods 1(1):30–46
Melhem E, Assi A, El Rachkidi R, Ghanem I (2016) EOS((R)) biplanar X-ray imaging: concept, developments, benefits, and limitations. J Child Orthop 10(1):1–14
Escott BG, Ravi B, Weathermon AC et al (2013) EOS low-dose radiography: a reliable and accurate upright assessment of lower-limb lengths. J Bone Jt Surg Am 95(23):e1831–e1837
Wybier M, Bossard P (2013) Musculoskeletal imaging in progress: the EOS imaging system. Jt Bone Spine 80(3):238–243
Illes T, Tunyogi-Csapo M, Somoskeoy S (2011) Breakthrough in three-dimensional scoliosis diagnosis: significance of horizontal plane view and vertebra vectors. Eur Spine J 20(1):135–143
Chiron P, Demoulin L, Wytrykowski K et al (2017) Radiation dose and magnification in pelvic X-ray: EOS imaging system versus plain radiographs. Orthop Traumatol Surg Res 103(8):1155–1159
Damet J, Fournier P, Monnin P et al (2014) Occupational and patient exposure as well as image quality for full spine examinations with the EOS imaging system. Med Phys 41(6):063901
Kalifa G, Charpak Y, Maccia C et al (1998) Evaluation of a new low-dose digital x-ray device: first dosimetric and clinical results in children. Pediatr Radiol 28(7):557–561
Bittersohl B, Freitas J, Zaps D et al (2013) EOS imaging of the human pelvis: reliability, validity, and controlled comparison with radiography. J Bone Jt Surg Am 95(9):e58
Guenoun B, El Hajj F, Biau D et al (2015) Reliability of a new method for evaluating femoral stem positioning after total hip arthroplasty based on stereoradiographic 3D reconstruction. J Arthroplasty 30(1):141–144
Journe A, Sadaka J, Belicourt C, Sautet A (2012) New method for measuring acetabular component positioning with EOS imaging: feasibility study on dry bone. Int Orthop 36(11):2205–2209
Lazennec JY, Rousseau MA, Rangel A et al (2011) Pelvis and total hip arthroplasty acetabular component orientations in sitting and standing positions: measurements reproductibility with EOS imaging system versus conventional radiographies. Orthop Traumatol Surg Res 97(4):373–380
Clave A, Fazilleau F, Cheval D et al (2015) Comparison of the reliability of leg length and offset data generated by three hip replacement CAOS systems using EOS imaging. Orthop Traumatol Surg Res 101(6):647–653
Clave A, Maurer DG, Nagra NS et al (2018) Reproducibility of length measurements of the lower limb by using EOS. Musculoskelet Surg 102(2):165–171
Gheno R, Nectoux E, Herbaux B et al (2012) Three-dimensional measurements of the lower extremity in children and adolescents using a low-dose biplanar X-ray device. Eur Radiol 22(4):765–771
Krug KB, Weber C, Schwabe H et al (2014) Comparison of image quality using a X-ray stereotactical whole-body system and a direct flat-panel X-ray device in examinations of the pelvis and knee. Rofo 186(1):67–76
Hau M, Menon D, Chan R, Chung K, Chau W, Ho K (2020) Two-dimensional/three-dimensional EOSTM imaging is reliable and comparable to traditional X-ray imaging assessment of knee osteoarthritis aiding surgical management. Knee 27(3):970–979
Wise KL, Kelly BJ, Agel J, Marette S, Macalena JA (2020) Reliability of EOS compared to conventional radiographs for evaluation of lower extremity deformity in adult patients. Skeletal Radiol 49(9):1423–1430. https://doi.org/10.1007/s00256-020-03425-9
Guggenberger R, Pfirrmann CW, Koch PP, Buck FM (2014) Assessment of lower limb length and alignment by biplanar linear radiography: comparison with supine CT and upright full-length radiography. AJR Am J Roentgenol 202(2):W161–W167. https://doi.org/10.2214/AJR.13.10782
Brouwer RW, Jakma TS, Bierma-Zeinstra SM et al (2003) The whole leg radiograph: standing versus supine for determining axial alignment. Acta Orthop Scand 74(5):565–568
Sabharwal S, Zhao C (2008) Assessment of lower limb alignment: supine fluoroscopy compared with a standing full-length radiograph. J Bone Jt Surg Am 90(1):43–51
Specogna AV, Birmingham TB, Hunt MA et al (2007) Radiographic measures of knee alignment in patients with varus gonarthrosis: effect of weightbearing status and associations with dynamic joint load. Am J Sports Med 35(1):65–70
Winer BJ, Brown DR, Michels KM (1971) Statistical principles in experimental design. McGraw-Hill Humanities/Social Sciences/Languages, Michigan
Cherian JJ, Kapadia BH, Banerjee S et al (2014) Mechanical, anatomical, and kinematic axis in TKA: concepts and practical applications. Curr Rev Musculoskelet Med 7(2):89–95
Khattak MJ, Umer M, Davis ET et al (2010) Lower-limb alignment and posterior tibial slope in Parkistanis: a radiographic study. J Orthopaed Surg 18(1):22–25
Domholdt E (2005) Statistical analysis of relationship. In: Domholdt E (ed) Rehabilitation research: principles and applications. Elseviers Saunders, St Louis, pp 351–363
Cohen J (1988) Statistical power analysis for the behavioral sciences. Routledge Academic, New York
Kim SB, Heo YM, Hwang CM et al (2018) Reliability of the EOS imaging system for assessment of the spinal and pelvic alignment in the sagittal plane. Clin Orthop Surg 10(4):500–507
Green WT, Wyatt GM, Anderson M (1946) Orthoroentgenography as a method of measuring the bones of the lower extremities. J Bone Jt Surg Am 28:60–65
Horsfield D, Jones SN (1986) Assessment of inequality in length of the lower limb. Radiography 52(605):223–227
Moseley CF (2000) Leg length discrepancy, Lippincott Williams & Wilkins, Philadelphia
Sabharwal S, Kumar A (2008) Methods for assessing leg length discrepancy. Clin Orthop Relat Res 466(12):2910–2922
Machen MS, Stevens PM (2005) Should full-length standing anteroposterior radiographs replace the scanogram for measurement of limb length discrepancy? J Pediatr Orthop B 14(1):30–37
Ribeiro CH, Mod MSB, Isch D, Baier C, Maderbacher G, Severino NR, Cataneo DC (2020) A novel device for greater precision and safety in open-wedge high tibial osteotomy: cadaveric study. Arch Orthop Trauma Surg 140(2):203–208. https://doi.org/10.1007/s00402-019-03300-w (Epub 2019 Nov 9 PMID: 31707483)
Tsuji M, Akamatsu Y, Kobayashi H, Mitsugi N, Inaba Y, Saito T (2020) Joint line convergence angle predicts outliers of coronal alignment in navigated open-wedge high tibial osteotomy. Arch Orthop Trauma Surg 140(6):707–715. https://doi.org/10.1007/s00402-019-03245-0 (Epub 2019 Aug 30 PMID: 31468134)
Vanhove F, Noppe N, Fragomen AT, Hoekstra H, Vanderschueren G, Metsemakers WJ (2019) Standardization of torsional CT measurements of the lower limbs with threshold values for corrective osteotomy. Arch Orthop Trauma Surg 139(6):795–805. https://doi.org/10.1007/s00402-019-03139-1 (Epub 2019 Feb 8 PMID: 30737593)
Ji W, Luo C, Zhan Y, Xie X, He Q, Zhang B (2019) A residual intra-articular varus after medial opening wedge high tibial osteotomy (HTO) for varus osteoarthritis of the knee. Arch Orthop Trauma Surg 139(6):743–750. https://doi.org/10.1007/s00402-018-03104-4 (Epub 2019 Jan 23 PMID: 30673869)
Schröter S, Nakayama H, Yoshiya S, Stöckle U, Ateschrang A, Gruhn J (2019) Development of the double level osteotomy in severe varus osteoarthritis showed good outcome by preventing oblique joint line. Arch Orthop Trauma Surg 139(4):519–527. https://doi.org/10.1007/s00402-018-3068-9 (Epub 2018 Nov 10 PMID: 30413943)
Kim MK, Lee SH, Kim ES et al (2011) The impact of sagittal balance on clinical results after posterior interbody fusion for patients with degenerative spondylolisthesis: a pilot study. BMC Musculoskelet Disord 12:69
Takemoto M, Boissiere L, Vital JM et al (2017) Are sagittal spinopelvic radiographic parameters significantly associated with quality of life of adult spinal deformity patients? Multivariate linear regression analyses for pre-operative and short-term post-operative health-related quality of life. Eur Spine J 26(8):2176–2186
Ilharreborde B, Ferrero E, Alison M, Mazda K (2016) EOS microdose protocol for the radiological follow-up of adolescent idiopathic scoliosis. Eur Spine J 25(2):526–531
Hey HWD, Chan CX, Wong YM et al (2018) The effectiveness of full-body EOS compared with conventional chest X-ray in preoperative evaluation of the chest for patients undergoing spine operations: a preliminary study. Spine 43(21):1502–1511
Mahboub-Ahari A, Hajebrahimi S, Yusefi M, Velayati A (2016) EOS imaging versus current radiography: a health technology assessment study. Med J Islam Repub Iran 30:331
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Chua Chen Xi Kasia and Tan Si Heng Sharon are co-authors
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Chua, C.X.K., Tan, S.H.S., Lim, A.K.S. et al. Accuracy of biplanar linear radiography versus conventional radiographs when used for lower limb and implant measurements. Arch Orthop Trauma Surg 142, 735–745 (2022). https://doi.org/10.1007/s00402-020-03700-3
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DOI: https://doi.org/10.1007/s00402-020-03700-3