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ComparisonoftheReliabilityofThreeMethodsfortheAssessmentoftheLowerLimbLength:
EOSwithNewMicro–DoseProtocolvs.Long–StandingRadiographvs.CTScanogram
BurakAbay,MehmetFa1hErol,Me1nKucukkayaIstanbulBilimUniversity
Dept.ofOrtopedicsandTraumatology,Istanbul,TURKEY
25thAnnualScien1ficMee1ngofLimbLengtheningandReconstruc1onSociety–Charleston,SC
22July2016
Disclosure• Nofinancialrela1onshipsintereststodisclose.
Introduction• Newinternalfixa1ondevices
(IMLengtheningnails,anatomicplates)• Acutecorrec1on&precisepreopera1veplanning• Needforaccurateradiologicalimagingmethods
ProblemsinacutecorrectionandinternalGixation
1)Preopera1veplanningismadebylongstandingroentgenogram• Correc1onisperformed
• Undergeneralanesthesia• Innon-weightbearingsupineposi1on• WiththeFluoroscopyimages
2)Decisiontoendthedistrac1onperiodofthelengtheningnails
Methodsusedformeasuringlowerlimblength
Clinicaltechniques
• TapeMeasure• Standingonblocks
ImagingMethods
• LongStandingroentgenogram
• Slitscanography• Orthoroentgenogram• Scanogram• ComputerizedTomography(CT)scanogram
• Ultrasound• MRIScanogram• Biplanardigitalroentgenogram
• EOS
Imagingmethodsfordeformityandlimblengtheningsurgery
• Longstandingroentgenogram• ComputerizedTomography(CT)scanogram• EOS• Slitscanography(supineposi1on)• Orthoroentgenogram• Scanogram• MRIScanogram
Studymethod
1. Inter-raterreliability:agreementbetween
thereaders
2. Intra-raterreliability:agreementinthe
reader.(test–retestorreproducibility)
3. MeanAbsoluteDifferences(MAD):
betweenthethreeimagingmodali1es
Materials
• 14lowerlimbsof7pa1ents(7men;meanage,31years;range,25-46years)• Threemethodsofradiologicalimagingmodali1es• EOS(micro-doseprotocol)• CTscanogram• Longstandingroentgenogram
Assessment• Lengthsofbones(lowerlimb,femur,1bia)
• Radiologictechnician• Orthopedicsurgeon• Seniorresident(2seperateoccasionsataminimumof4weeksapart)
• Sta1s1cs• Meanabsolutedifference(ANOVA)• Bland-Altmananalyses
(Agreementbetweenreadersandmodali1es)
EOStechnique
• Biplanarradiography• Scannerpladorm• Wholelowerlimb• Feetsamecoronalplane• Micro-doseprotocol
EOSwithmicrodoseprotocol
LongStandingroentgenogramtechnique
• Single-exposure• Standingfull-lengthteleroentgenogram• Patellasfacingforward• Beamtothekneejoint• Fullextension• 300cmdistancefromtube• 20mmradioopaquesphere
LongStandingroentgenogramtechnique
• Single-exposure• Standingfull-lengthteleroentgenogram• Patellasfacingforward• Beamtothekneejoint• Fullextension• 300cmdistancefromtube• 20mmradioopaquesphere
LongStandingroentgenogram
CTscanogramtechnique
• feetenteringthegantryfirst• patellasorientedanteriorly• asingleposteroanteriorscoutimage• Non-weightbearingposi1on
LengthmeasurementsandanalysisLongstandingroentgenogram CTScanogram EOS
PACS®CORELDRAWX7®
PACS®
DrorPaley,PrinciplesofDeformityCorrecRon
Results
• ThemeanabsolutedifferencesforthestandingroentgenogramandCTscanogramwereallsignificantlydifferentfromthatofEOS(p<0.05).
• 6,3mm/863,7mm(wholelowerlimb)=0,7%differencebetweenEOSandLongstandingroentgenogram
• Meanabsolutedifferencesamongthreemodali1es
ResultsInter-raterreliability
• Inter-raterreliability,quan1fiedwithIntraclassCorrela1onCoefficients,showedexcellent(>0.90)agreementforstandingroentgenogram,CTscanogramandEOSwithmicrodoseprotocol.
• LSR=EOS=CT
ResultsIntra-raterreliability
• Intra-raterreliability,quan1fiedwithIntraclassCorrela1onCoefficients,showedexcellent(>0.90)agreementforstandingroentgenogram,CTscanogramandEOSwithmicrodoseprotocol.
• LSR=EOS=CT
LongStandingroentgenogram
• Magnifica1onerrordependson
- Lengthofthelowerlimb- Thedistancetothetube- Divergenceofthebeam
300cm
Sabharwaletal,2008
• ComparisonofEOSwithCTscanogram• InterraterandintraraterreliabilitywereexcellentforbothtotallengthandintrabeaddistanceonbothEOSandCTscanogram
• (r>0.99andP<0.001)
• UsingPhantomlimb(withsawbones)• EOSwasthemostaccuratemodality• ThemeandifferencesonbothEOSsenngs
weresignificantlydifferentfromthoseonCTscanograms,notclinicallyimportant.
• Nocalibra1onmethodwasused.
EOSwithmicrodoseprotocol
Ar#factinslowmode
EOS–Slow EOS-microdose
16y,FSamepa1ent
23y,F
EOS=Biplanarradiography
LSR EOS
Idealmethod1. Accurate2. Excellentreliabilityandexcellentreproducibility3. Readilyavailableinthephysician’soffice4. Technicallyeasy5. Itscostandradia1ondosageshouldbelow
Conclusion• ThereliabilityoftheLSRissimilartoothertwomethodsifappropriatecalibra1onisdone.
• WiththecalibraRon1mm≈1mm• EOSmightbehelpfulduringtheendofthedistrac1onperiod• Single–exposureLSRwiththecalibra1onmightbegoodchoicefortheassessmentandpreopera1veplanningofthelowerlimbdeformi1es.
Thankyou