Aims. We aimed to assess the reliability and validity of OpenPose, a posture estimation algorithm, for measurement of knee range of motion after total knee arthroplasty (TKA), in comparison to radiography and goniometry. Methods. In this prospective observational study, we analyzed 35 primary TKAs (24 patients) for knee osteoarthritis. We measured the knee angles in flexion and extension using OpenPose, radiography, and goniometry. We assessed the test-retest reliability of each method using intraclass correlation coefficient (1,1). We evaluated the ability to estimate other measurement values from the OpenPose value using linear regression analysis. We used intraclass correlation coefficients (2,1) and Bland–Altman analyses to evaluate the agreement and error between radiography and the other measurements. Results. OpenPose had excellent test-retest reliability (intraclass correlation coefficient (1,1) = 1.000). The R. 2. of all regression models indicated large correlations (0.747 to 0.927). In the flexion position, the intraclass correlation coefficients (2,1) of OpenPose indicated excellent agreement (0.953) with radiography. In the extension position, the intraclass correlation coefficients (2,1) indicated good agreement of OpenPose and radiography (0.815) and moderate agreement of goniometry with radiography (0.593). OpenPose had no systematic error in the flexion position, and a 2.3° fixed error in the extension position, compared to radiography. Conclusion. OpenPose is a reliable and valid tool for measuring flexion and extension positions after TKA. It has better accuracy than goniometry, especially in the extension position. Accurate measurement values can be obtained with low error, high reproducibility, and no contact, independent of the examiner’s skills. Cite this article: Bone Joint Res 2023;12(5):313–320

Abstract. Background. Post operative radiographs following total joint arthroplasty are requested as part of routine follow up in many institutions. These studies have a significant cost to the local departments, in terms of financial and clinic resources, however, previous research has suggested they may not alter the course of the patients treatment. The purpose of this study was to assess the significance of elective post operative radiographs on changes in management of patients who underwent total joint arthroplasty. Method. All patients who underwent total knee arthroplasty and total hip arthroplasty at a District General Hospital from 2019 to 2020 were included. Data was collected retrospectively from medical records and radiograph requests. Alterations to clinical management based on radiographic findings were reviewed in clinic letters. Results. A total of 227 Total joint arthroplasty were retrieved. With 111(49%) total hip arthroplasty and 116 (51%) total knee arthroplasty. 54 were excluded due to having no clinical follow up and 173 met inclusion criteria. 56 (32%) had their post operative elective radiograph, while 93 (53.8%) patients had none. There were no abnormalities detected from the elective radiographs and none of the patients returned to the theatre. 24 patients (13%) presented with symptoms and had non-elective radiographs, 16 (67%) did not have any interventions and 8 (4.6%) required intervention and were taken to theatre. Discussion: Not performing these radiographs saves time, cost, and prevents unnecessary radiation exposure. In our institution, a 2-view joint radiograph costs £29 and takes roughly 15 minutes. This does not include indirect costs of additional clinic time and patient waiting time. In the larger context, the cost associated with elective radiographs is significant and our data suggests that routine post-operative radiographs are not beneficial as part of standard post-operative protocol for asymptomatic patients. However, performing imaging remains beneficial for patients who re-present with symptoms. Conclusion. Routine elective post-operative joint radiographs did not detect any true abnormalities. Information from elective radiographs has no clinical significance and did not change management. Therefore, this study recommends that there is no rationale requesting elective post-operative joint radiographs. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Aims. Occult (clinical) injuries represent 15% of all scaphoid fractures, posing significant challenges to the clinician. MRI has been suggested as the gold standard for diagnosis, but remains expensive, time-consuming, and is in high demand. Conventional management with immobilization and serial radiography typically results in multiple follow-up attendances to clinic, radiation exposure, and delays return to work. Suboptimal management can result in significant disability and, frequently, litigation. Methods. We present a service evaluation report following the introduction of a quality-improvement themed, streamlined, clinical scaphoid pathway. Patients are offered a removable wrist splint with verbal and written instructions to remove it two weeks following injury, for self-assessment. The persistence of pain is the patient’s guide to ‘opt-in’ and to self-refer for a follow-up appointment with a senior emergency physician. On confirmation of ongoing signs of clinical scaphoid injury, an urgent outpatient ‘fast’-wrist protocol MRI scan is ordered, with instructions to maintain wrist immobilization. Patients with positive scan results are referred for specialist orthopaedic assessment via a virtual fracture clinic. Results. From February 2018 to January 2019, there were 442 patients diagnosed as clinical scaphoid fractures. 122 patients (28%) self-referred back to the emergency department at two weeks. Following clinical review, 53 patients were discharged; MRI was booked for 69 patients (16%). Overall, six patients (< 2% of total; 10% of those scanned) had positive scans for a scaphoid fracture. There were no known missed fractures, long-term non-unions or malunions resulting from this pathway. Costs were saved by avoiding face-to-face clinical review and MRI scanning. Conclusion. A patient-focused opt-in approach is safe and effective to managing the suspected occult (clinical) scaphoid fracture. Cite this article: Bone Jt Open 2024;5(2):117–122

Malalignment is often postulated as the main reason for the high failure rate of total ankle replacements (TARs). Only a few studies have been performed to correlate radiographic TAR malalignment to the clinical outcome, but no consistent trends between TAR alignment parameters and the clinical outcome were found. No standard TAR alignment measurement method is present, so reliable comparison between studies is difficult. Standardizing TAR alignment measurements and increasing measurable parameters on radiographs in the clinic might lead to a better insight into the correlation between malalignment and the clinical outcome. This study aims to develop and validate a tool to semi-automatic measure TAR alignment, and to improve alignment measurement on radiographs in the clinic. A tool to semi-automatically measure TAR alignment on anteroposterior and lateral radiographs was developed and used by two observers to measure TAR alignment parameters of ten patients. The Intraclass Coefficient (ICC) was calculated and accuracy was compared to the manual measurement method commonly used in the clinic. The tool showed an accuracy of 76% compared to 71% for the method used during follow-up in the clinic. ICC values were 0.94 (p<0.01) and higher for both inter-and intra-observer reliability. The tool presents an accurate, consistent, and reliable method to measure TAR alignment parameters. Three-dimensional alignment parameters are obtained from two-dimensional radiographs, and as the tool can be applied to any TAR design, it offers a valuable addition in the clinic and for research purposes

Knee joint distraction (KJD) has been associated with clinical and structural improvement and synovial fluid (SF) marker changes. However, structural changes have not yet been shown satisfactorily in regular care, since radiographic acquisition was not fully standardized. AI-based modules have shown great potential to reduce reading time, increase inter-reader agreement and therefore function as a tool for treatment outcome assessment. The objective was to analyse structural changes after KJD in patients using this AI-based measurement method, and relate these changes to clinical outcome and SF markers. 20 knee OA patients (<65 years old) were included in this study. KJD treatment was performed using an external fixation device, providing 5 mm distraction for 6 weeks. SF was aspirated before, during and immediately after treatment. Weight-bearing antero-posterior knee radiographs and WOMAC questionnaires were collected before and ~one year after treatment. Radiographs were analysed with the Knee Osteoarthritis Labelling Assistant (KOALA, IB Lab GmbH, Vienna, Austria), and 10 pre-defined biomarker levels in SF were measured by immunoassay. Radiographic one-year changes were analysed and linear regression was used to calculate associations between changes in standardized joint space width (JSW) and WOMAC, and changes in JSW and SF markers. After treatment, radiographs showed an improvement in Kellgren-Lawrence grade in 7 of 16 patients that could be evaluated; 3 showed a worsening. Joint space narrowing scores and continuous JSW measures improved especially medially. A greater improvement in JSW was significantly associated with a greater improvement in WOMAC pain (β=0.64;p=0.020). A greater increase in MCP1 (β=0.67;p=0.033) and lower increase in TGFβ1 (β=-0.787;p=0.007) were associated with JSW improvement. Despite the small number of patients, also in regular care KJD treatment shows joint repair as measured automatically on radiographs, significantly associated with certain SF marker change and even with clinical outcome

Introduction. Knee arthroplasty (KA), encompassing Total Knee Replacement (TKR) and Unicompartmental Knee Replacement (UKR), is one of the most common orthopedic procedures, aimed at alleviating severe knee arthritis. Postoperative KA management, especially radiographic imaging, remains a substantial financial burden and lacks standardised protocols for its clinical utility during follow-up. Method. In this retrospective multicentre cohort study, data were analysed from January 2014 to March 2020 for adult patients undergoing primary KA at Imperial NHS Trust. Patients were followed over a five-year period. Four machine learning models were developed to evaluate if post-operative X-ray frequency can predict revision surgery. The best-performing model was used to assess the risk of revision surgery associated with different number of X-rays. Result. The study assessed 289 knees with a 2.4% revision rate. The revision group had more X-rays on average than the primary group. The best performing model was Logistic Regression (LR), which indicated that each additional X-ray raised the revision risk by 52% (p<0.001). Notably, having four or more X-rays was linked to a three-fold increase in risk of revision (OR=3.02; p<0.001). Our results align with the literature that immediate post-operative X-rays have limited utility, making the 2nd post-operative X-ray of highest importance in understanding the patient's trajectory. These insights can enhance management by improving risk stratification for patients at higher revision surgery risk. Despite LR being the best-performing model, it is limited by the dataset's significant class imbalance. Conclusion. X-ray frequency can independently predict revision surgery. This study provides insights that can guide surgeons in evidence-based post-operative decision-making. To use those findings and influence post-operative management, future studies should build on this predictive model by incorporating a more robust dataset, surgical indications, and X-ray findings. This will allow early identification of high-risk patients, allowing for personalised post-operative recommendations

Introduction. Routine radiographs in the follow-up of circular frames is commonplace, however the effect on clinical decision making is unclear. Previous work locally has suggested that >95% of radiographs, particularly at early time points, do not affect clinical management. This study was conducted to assess the impact of a transition to early remote follow-up on circular frame patients with limited radiographic assessment. Materials and Methods. Patients were identified from a prospective limb reconstruction database. Data were collected including the number of clinic appointments, type of clinic appointment, number of radiographs performed, and impact this had on clinical management. This was compared to our previous cohort of 85 patients undergoing standard follow-up. Results. Fourteen patients were eligible for inclusion (mean age 45, range 26–75). Circular frames were indicated for trauma (12), or limb reconstruction (2). Following introduction of remote follow-up, the mean number of face-to-face appointments reduced from 6.1 to 1.7 to the point of frame removal. Conversion from telephone follow-up to face-to-face follow-up was required in just one case where hardware failure occurred. The number of radiographs during treatment was reduced from a mean of 22 to 11 (range 4–20). Conclusions. Remote follow-up of circular frame patients was associated with significantly fewer radiographs and face-to-face appointments, without significantly increasing complications. We believe this is a safe and effective method of follow-up, optimising resource use in line with the NHS long term plan. Data collection is ongoing, and a larger cohort would be available for presentation

Polyethylene wear represents a significant risk factor for the long-term success of knee arthroplasty [1]. This work aimed to develop and in vivo validate an automated algorithm for accurate and precise AI based wear measurement in knee arthroplasty using clinical AP radiographs for scientifically meaningful multi-centre studies. Twenty postoperative radiographs (knee joint AP in standing position) after knee arthroplasty were analysed using the novel algorithm. A convolutional neural network-based segmentation is used to localize the implant components on the X-Ray, and a 2D-3D registration of the CAD implant models precisely calculates the three-dimensional position and orientation of the implants in the joint at the time of acquisition. From this, the minimal distance between the involved implant components is determined, and its postoperative change over time enables the determination of wear in the radiographs. The measured minimum inlay height of 335 unloaded inlays excluding the weight-induced deformation, served as ground truth for validation and was compared to the algorithmically calculated component distances from 20 radiographs. With an average weight of 94 kg in the studied TKA patient cohort, it was determined that an average inlay height of 6.160 mm is expected in the patient. Based on the radiographs, the algorithm calculated a minimum component distance of 6.158 mm (SD = 81 µm), which deviated by 2 µm in comparison to the expected inlay height. An automated method was presented that allows accurate and precise determination of the inlay height and subsequently the wear in knee arthroplasty based on a clinical radiograph and the CAD models. Precision and accuracy are comparable to the current gold standard RSA [2], but without relying on special radiographic setups. The developed method can therefore be used to objectively investigate novel implant materials with meaningful clinical cohorts, thus improving the quality of patient care

Introduction and Objective. Up to 30% of thoracolumbar (TL) fractures are missed in the emergency room. Failure to identify these fractures can result in neurological injuries up to 51% of the casesthis article aimed to clarify the incidence and risk factors of traumatic fractures in China. The China National Fracture Study (CNFS. Obtaining sagittal and anteroposterior radiographs of the TL spine are the first diagnostic step when suspecting a traumatic injury. In most cases, CT and/or MRI are needed to confirm the diagnosis. These are time and resource consuming. Thus, reliably detecting vertebral fractures in simple radiographic projections would have a significant impact. We aim to develop and validate a deep learning tool capable of detecting TL fractures on lateral radiographs of the spine. The clinical implementation of this tool is anticipated to reduce the rate of missed vertebral fractures in emergency rooms. Materials and Methods. We collected sagittal radiographs, CT and MRI scans of the TL spine of 362 patients exhibiting traumatic vertebral fractures. Cases were excluded when CT and/or MRI where not available. The reference standard was set by an expert group of three spine surgeons who conjointly annotated (fracture/no-fracture and AO Classification) the sagittal radiographs of 171 cases. CT and/or MRI were used confirm the presence and type of the fracture in all cases. 302 cropped vertebral images were labelled “fracture” and 328 “no fracture”. After augmentation, this dataset was then used to train, validate, and test deep learning classifiers based on the ResNet18 and VGG16 architectures. To ensure that the model's prediction was based on the correct identification of the fracture zone, an Activation Map analysis was conducted. Results. Vertebras T12 to L2 were the most frequently involved, accounting for 48% of the fractures. Accuracies of 88% and 84% were obtained with ResNet18 and VGG16 respectively. The sensitivity was 89% with both architectures but ResNet18 had a significantly higher specificity (88%) compared to VGG16 (79%). The fracture zone used was precisely identified in 81% of the heatmaps. Conclusions. Our AI model can accurately identify anomalies suggestive of TL vertebral fractures in sagittal radiographs precisely identifying the fracture zone within the vertebral body

Objectives. The radiographic union score for tibial (RUST) fractures was developed by Whelan et al to assess the healing of tibial fractures following intramedullary nailing. In the current study, the repeatability and reliability of the RUST score was evaluated in an independent centre (a) using the original description, (b) after further interpretation of the description of the score, and (c) with the immediate post-operative radiograph available for comparison. Methods. A total of 15 radiographs of tibial shaft fractures treated by intramedullary nailing (IM) were scored by three observers using the RUST system. Following discussion on how the criteria of the RUST system should be implemented, 45 sets (i.e. AP and lateral) of radiographs of IM nailed tibial fractures were scored by five observers. Finally, these 45 sets of radiographs were rescored with the baseline post-operative radiograph available for comparison. Results. The initial intraclass correlation (ICC) on the first 15 sets of radiographs was 0.67 (95% CI 0.63 to 0.71). However, the original description was being interpreted in different ways. After agreeing on the interpretation, the ICC on the second cohort improved to 0.75. The ICC improved even further to 0.79, when the baseline post-operative radiographs were available for comparison. Conclusion. This study demonstrates that the RUST scoring system is a reliable and repeatable outcome measure for assessing tibial fracture healing. Further improvement in the reliability of the scoring system can be obtained if the radiographs are compared with the baseline post-operative radiographs. Cite this article: Mr J.M. Leow. The radiographic union scale in tibial (RUST) fractures: Reliability of the outcome measure at an independent centre. Bone Joint Res 2016;5:116–121. DOI: 10.1302/2046-3758.54.2000628

Aims

To determine whether side-bending films in scoliosis are assessed for adequacy in clinical practice; and to introduce a novel method for doing so.

Aims

Leg length discrepancy (LLD) is a common pre- and postoperative issue in total hip arthroplasty (THA) patients. The conventional technique for measuring LLD has historically been on a non-weightbearing anteroposterior pelvic radiograph; however, this does not capture many potential sources of LLD. The aim of this study was to determine if long-limb EOS radiology can provide a more reproducible and holistic measurement of LLD.

Over the last few years low dose digital radiography (DR) has all but replaced traditional chemical image processing. This appears to have created a paradigm shift in the suitability of intraoperative radiographic guidance for total hip arthroplasty. It is the purpose of this publication to describe our preferred technique and assess its reliability in achieving the desired parameters of a successful total hip arthroplasty. A consecutive prospective evaluation of 150 primary total hip arthroplasties employing intraoperative digital radiography was carried out. An anteroposterior pelvic radiograph with the patient in the lateral decubitus position was obtained for all hips. The orientation of the intraoperative film was matched to that of the preoperative pelvic radiograph. The image was taken after placement of the acetabular component and best estimate of femoral trial size, position, and head and neck length. The DR system produced an image within 6 seconds of exposure. This trial radiograph was then used to make adjustments. Given that the cassette does not have to be moved for image processing, a precise anteroposterior film was obtained by simply adjusting the operating table. Two to three minutes were allotted for each radiograph. Corrections to stem size, cup position, screw length and position, limb length, and offset were made based on this intraoperative radiograph. The final intraoperative image was then compared to a postoperative standard radiograph in supine position at 2 weeks after total hip arthroplasty to verify the accuracy of intraoperative digital radiography. Abduction angle, limb length, offset, and canal fit and fill were assessed for confirmation of the validity of the intraoperative imaging technique. Acetabular abduction angle was determined with a mean of 43 degrees (range, 35 to 48 degrees). The intraoperative measurement was within 3 degrees of the postoperative measurement in all cases. Adjustment of acetabular cup orientation was performed 10% of the time based on the intraoperative radiograph. Apposition was within 2 mm 100% of the time. Re-seating of the cup was carried out in one hip only. Femoral component was neutral in 92% and between 3 and 5 degrees of varus in 8%. Femoral component was upsized 55% of the time. Intraoperatively measured limb length discrepancy and offset were within 3 mm of the postoperative measurement in all hips. Intraoperative digital imaging is a reliable tool for achieving the desired radiographic results in THA. The technique is efficient and affordable. The high rate of success in this series suggests that this technology should contribute to a paradigm shift in the standard of care in total hip arthroplasty

Introduction

Accurate assessment of alignment in pre-operative and post-operative knee radiographs is important for planning and evaluating knee replacement surgery. Existing methods predominantly rely on manual measurements using long-leg radiographs, which are time-consuming to perform and are prone to reliability errors. In this study, we propose a machine-learning-based approach to automatically measure anatomical varus/valgus alignment in pre-operative and post-operative standard AP knee radiographs.

Evaluation of patient specific spinopelvic mobility requires the detection of bony landmarks in lateral functional radiographs. Current manual landmarking methods are inefficient, and subjective. This study proposes a deep learning model to automate landmark detection and derivation of spinopelvic measurements (SPM).

A deep learning model was developed using an international multicenter imaging database of 26,109 landmarked preoperative, and postoperative, lateral functional radiographs (HREC: Bellberry: 2020-08-764-A-2). Three functional positions were analysed: 1) standing, 2) contralateral step-up and 3) flexed seated. Landmarks were manually captured and independently verified by qualified engineers during pre-operative planning with additional assistance of 3D computed tomography derived landmarks. Pelvic tilt (PT), sacral slope (SS), and lumbar lordotic angle (LLA) were derived from the predicted landmark coordinates. Interobserver variability was explored in a pilot study, consisting of 9 qualified engineers, annotating three functional images, while blinded to additional 3D information. The dataset was subdivided into 70:20:10 for training, validation, and testing.

The model produced a mean absolute error (MAE), for PT, SS, and LLA of 1.7°±3.1°, 3.4°±3.8°, 4.9°±4.5°, respectively. PT MAE values were dependent on functional position: standing 1.2°±1.3°, step 1.7°±4.0°, and seated 2.4°±3.3°, p< 0.001. The mean model prediction time was 0.7 seconds per image. The interobserver 95% confidence interval (CI) for engineer measured PT, SS and LLA (1.9°, 1.9°, 3.1°, respectively) was comparable to the MAE values generated by the model.

The model MAE reported comparable performance to the gold standard when blinded to additional 3D information. LLA prediction produced the lowest SPM accuracy potentially due to error propagation from the SS and L1 landmarks. Reduced PT accuracy in step and seated functional positions may be attributed to an increased occlusion of the pubic-symphysis landmark. Our model shows excellent performance when compared against the current gold standard manual annotation process.

Aims

Treatment of Weber B ankle fractures that are stable on weightbearing radiographs but unstable on concomitant stress tests (classified SER4a) is controversial. Recent studies indicate that these fractures should be treated nonoperatively, but no studies have compared alternative nonoperative options. This study aims to evaluate patient-reported outcomes and the safety of fracture treatment using functional orthosis versus cast immobilization.

Aims

Radiological residual acetabular dysplasia (RAD) has been reported in up to 30% of children who had successful brace treatment of infant developmental dysplasia of the hip (DDH). Predicting those who will resolve and those who may need corrective surgery is important to optimize follow-up protocols. In this study we have aimed to identify the prevalence and predictors of RAD at two years and five years post-bracing.

Aims

In the Netherlands, general practitioners (GPs) can request radiographs. After a radiologically diagnosed fracture, patients are immediately referred to the emergency department (ED). Since 2020, the Máxima Medical Centre has implemented a new care pathway for minor trauma patients, referring them immediately to the traumatology outpatient clinic (OC) instead of the ED. We investigated whether this altered care pathway leads to a reduction in healthcare consumption and concomitant costs.

Aims

To assess the incidence of radiological lateral osteoarthritis (OA) at 15 years after medial unicompartmental knee arthroplasty (UKA) and assess the relationship of lateral OA with symptoms and patient characteristics.

When performing scarf osteotomies some surgeons use intraoperative radiography and others do not. Our experience is that when using intraoperative radiography we often change the osteotomy position to improve the correction of the hallux valgus angle and sesamoid position. We report the results of a single surgeon series of 62 consecutive patients who underwent a scarf osteotomy for hallux valgus. The first 31 patients underwent surgery without the use of intraoperative radiographs and the subsequent 31 patients underwent surgery with the use of intraoperative radiographs, this reflects a change in the surgeons practice. Hallux valgus angle, intermetatarsal angle, distal metatarsal articular angle and sesamoid position using the Hardy Clapham grading system were recorded. All patients had measurements recorded from weight baring radiographs taken pre operatively as well as at 6 and 12 weeks post operatively. Intraoperative measurements were also recorded for all patients in the intraoperative radiography group. The mean hallux valgus angle preoperatively was 28.5° in the control group and 30.5° in the intraoperative radiography group. The mean hallux valgus angle in the control group at 6 weeks was 12.4° and at 12 weeks was 12.6°. The mean hallux valgus angle in the intraoperative radiography group at 6 weeks was 10.5° and at 12 weeks was 9.8°. The median sesamoid position pre operatively was 4 for both groups. At 6 and 12 weeks the sesamoid position improved by a median of 1 position in the control group and 2 positions in the intraoperative radiography group (p<0.05). We recommend that surgeons who do not routinely use intraoperative radiography undertake a trial of this. We have found that the use of intraoperative radiography improves the correction of hallux valgus angle and sesamoid position. These have been shown to increase patient satisfaction and reduce recurrence