Non-invasive quantitative assessment of induced component displacement can safely and accurately diagnose tibial component loosening in patients: A prospective diagnostic study.

PURPOSE: Aseptic loosening often requires major, expensive and invasive revision surgery. Current diagnostic modalities merely show indirect signs of loosening. A recent proof of concept study proposed a non-invasive technique for the quantitative and visual assessment of implant movement as a diagnostic aid for tibial component loosening. The primary research question addressed is whether this novel diagnostic modality can safely and effectively aid the diagnosis of aseptic loosening. METHODS: This clinical study included patients suspected of aseptic total knee arthroplasty (TKA) loosening listed for revision surgery and asymptomatic patients. Safety was evaluated using a numerical rating scale (NRS) for discomfort and by registration of adverse events. Feasibility was assessed by recording the duration and ease of the procedure. Intra- and interrater reliability were evaluated. In symptomatic patients, diagnostic accuracy metrics were evaluated with intra-operative assessment as a reference test. RESULTS: In total, 34 symptomatic and 38 asymptomatic knees with a TKA were analysed. The median NRS for discomfort during loading was 6 (interquartile range [IQR]: 3.75-7.00) in symptomatic patients and 2 (IQR: 1.00-3.00) in asymptomatic patients. No adverse events were reported. The majority of users found the use of the loading device easy. The median time spent in the computed tomography room was 9 min (IQR: 8.00-11.00). Excellent to good intra- and interrater reliabilities were achieved. Diagnostic accuracy analysis resulted in a sensitivity of 0.91 (95% confidence interval [CI]: 0.72-0.97) and a specificity of 0.72 (95% CI: 0.43-0.90). CONCLUSIONS: The proposed diagnostic method is safe, feasible, reliable and accurate in aiding the diagnosis of aseptic tibial component loosening. LEVEL OF EVIDENCE: Level II.

Carpal Kinematics in Madelung Deformity.

PURPOSE: Various skeletal and soft tissue abnormalities have been identified in Madelung deformity and have been hypothesized to play a causal role in its progressive symptomatology; however, our pathological understanding of these changes remains limited. In this study, we biomechanically assessed the Madelung deformity wrist, using 4-dimensional computed tomography imaging. METHODS: Nine Madelung deformity wrists (5 patients; age, 24 ± 5 y) and 18 healthy wrists (9 volunteers; age, 28 ± 3 y) underwent 4-dimensional imaging during flexion-extension motion and radioulnar deviation. Carpal kinematics and radiocarpal joint parameters were quantified and compared. RESULTS: In Madelung deformity wrists, significantly decreased rotation was seen in the lunate (-4.6°) and the triquetrum (-4.8°) during flexion-extension motion. During radioulnar deviation, significant decreases were visible in lunate bone translation (-0.7 mm), triquetrum bone translation (-0.6 mm), and triquetrum bone rotation (-1.9°). Patients had significantly decreased articulating surface areas of the scaphoid (1.4 ± 0.2 cm2 versus 1.6 ± 0.2 cm2) and lunate (1.2 ± 0.4 cm2 versus 1.5 ± 0.3 cm2) fossa, and significantly increased radioscaphoid (1.3 ± 0.1 mm versus 1.2 ± 0.1 mm) and radiolunate (1.6 ± 0.2 mm versus 1.3 ± 0.3 mm) joint space thicknesses. CONCLUSIONS: There is a decreased mobility of the lunate and triquetrum bones in Madelung deformity. CLINICAL RELEVANCE: Four-dimensional imaging could be used in future studies that investigate the effect of surgical ligament release on carpal kinematics and subsequent wrist mobility.

The accuracy of 3D virtual bone models of the pelvis for morphological sex estimation.

It is currently unknown whether morphological sex estimation traits are accurately portrayed on virtual bone models, and this hampers the use of virtual bone models as an alternative source of contemporary skeletal reference data. This study determines whether commonly used morphological sex estimation traits can be accurately scored on virtual 3D pelvic bone elements. Twenty-seven intact cadavers from the body donation program of the Amsterdam UMC, University of Amsterdam, were CT scanned; this data was used to produce virtual bone models. Thereafter, the dry bones were obtained. Three traits by Klales (2012) and five traits from the Workshop of European Anthropologists (WEA) (1980) were scored on the virtual bone models and their dry skeletal counterparts. Intra- and inter-observer agreement and the agreement between the scores for each virtual bone model-dry bone pair were calculated using weighted Cohen's kappa (K). For all Klales (2012) traits, intra- and inter-observer agreement was substantial to almost perfect for the virtual- and dry bones (K = 0.62-0.90). The agreement in scores in the virtual-dry bone pairs ranged from moderate to almost perfect (K = 0.58-0.82). For the WEA (1980) traits, intra-observer agreement was substantial to almost perfect (K = 0.64-0.91), but results were less unambiguous for inter-observer agreement (K = 0.24-0.88). Comparison of the scores between the virtual bone models and the dry bones yielded kappa values of 0.42-0.87. On one hand, clinical CT data is a promising source for contemporary forensic anthropological reference data, but the interchangeability of forensic anthropological methods between virtual bone models and dry skeletal elements needs to be tested further.

Computerized fetal cardiotocography analysis in early preterm fetal growth restriction - a quantitative comparison of two applications.

Background We developed an open-source software for the computerized analysis of antenatal fetal cardiotocography (CTG) without limitation of duration of the registration, enabling batch processing and adaptation to any digital storage system. Methods STVcalc was developed based on literature about the FetalCare system (Huntleigh Healthcare Ltd, Cardiff, UK). For comparison with FetalCare, we selected the CTGs of all women who delivered in 2011 a small-for-gestational-age (SGA) fetus between 24 and 31 weeks by cesarean section (CS) for fetal distress, or had fetal death, before labor onset. Results In 471 CTGs from 39 women, the agreement was 99% for a short-term variation (STV) cut-off of 2.6 ms below 29 weeks and 3.0 ms thereafter, and 95% for 3.5 and 4.0 ms, respectively. In 18 (4%) cases, the proportional difference in STV between FetalCare and STVcalc was more than 10%. Conclusion As only slight differences were observed between the proposed feature-rich application and the FetalCare system, it can be considered valuable for clinical practice and research purposes.

Non-muscle myosin II drives vesicle loss during human reticulocyte maturation.

The process of maturation of reticulocytes into fully mature erythrocytes that occurs in the circulation is known to be characterized by a complex interplay between loss of cell surface area and volume, removal of remnant cell organelles and redundant proteins, and highly selective membrane and cytoskeletal remodeling. However, the mechanisms that underlie and drive these maturational processes in vivo are currently poorly understood and, at present, reticulocytes derived through in vitro culture fail to undergo the final transition to erythrocytes. Here, we used high-throughput proteomic methods to highlight differences between erythrocytes, cultured reticulocytes and endogenous reticulocytes. We identify a cytoskeletal protein, non-muscle myosin IIA (NMIIA) whose abundance and phosphorylation status differs between reticulocytes and erythrocytes and localized it in the proximity of autophagosomal vesicles. An ex vivo circulation system was developed to simulate the mechanical shear component of circulation and demonstrated that mechanical stimulus is necessary, but insufficient for reticulocyte maturation. Using this system in concurrence with non-muscle myosin II inhibition, we demonstrate the involvement of non-muscle myosin IIA in reticulocyte remodeling and propose a previously undescribed mechanism of shear stress-responsive vesicle clearance that is crucial for reticulocyte maturation.

The geometrical precision of virtual bone models derived from clinical computed tomography data for forensic anthropology.

Almost all European countries lack contemporary skeletal collections for the development and validation of forensic anthropological methods. Furthermore, legal, ethical and practical considerations hinder the development of skeletal collections. A virtual skeletal database derived from clinical computed tomography (CT) scans provides a potential solution. However, clinical CT scans are typically generated with varying settings. This study investigates the effects of image segmentation and varying imaging conditions on the precision of virtual modelled pelves. An adult human cadaver was scanned using varying imaging conditions, such as scanner type and standard patient scanning protocol, slice thickness and exposure level. The pelvis was segmented from the various CT images resulting in virtually modelled pelves. The precision of the virtual modelling was determined per polygon mesh point. The fraction of mesh points resulting in point-to-point distance variations of 2 mm or less (95% confidence interval (CI)) was reported. Colour mapping was used to visualise modelling variability. At almost all (>97%) locations across the pelvis, the point-to-point distance variation is less than 2 mm (CI = 95%). In >91% of the locations, the point-to-point distance variation was less than 1 mm (CI = 95%). This indicates that the geometric variability of the virtual pelvis as a result of segmentation and imaging conditions rarely exceeds the generally accepted linear error of 2 mm. Colour mapping shows that areas with large variability are predominantly joint surfaces. Therefore, results indicate that segmented bone elements from patient-derived CT scans are a sufficiently precise source for creating a virtual skeletal database.

Estimating Scaphoid Lengths Using Anatomical Measurements in the Wrist.

PURPOSE: In reconstructive surgery of scaphoid nonunions with humpback deformity, some surgeons recommend restoration of the normal scaphoid length whereas others overexpand the normal length to ensure carpal realignment and prevent late collapse. To be able to define overexpansion and investigate which levels of overexpansion yield optimal clinical results, a precise method for estimating the original scaphoid length is required. The purpose of this anatomic study was to investigate the precision of estimating normal scaphoid lengths based on intact adjacent bone dimensions, compared with using the contralateral scaphoid length. METHODS: From bilateral computed tomographic scans of 28 healthy wrist pairs, 3-dimensional virtual bone models were created. The left and right scaphoid lengths were determined at the central axis. The capitate length at the central axis and the distal radius width served to derive an ipsilateral scaphoid length estimate. Estimation precision for individual cases was based on the 95% range (±1.96 × SD) of the observed differences between the actual and estimated lengths. RESULTS: On average, the capitate length was 10% smaller than the scaphoid length; the radius width was 9% larger. Consequently, we averaged the capitate length and radius width for ipsilateral estimations. The average difference between the scaphoid length and the latter ipsilateral estimate was 0.1 mm. The average contralateral scaphoid length difference was also 0.1 mm. Estimation precisions, however, were ±2.2 and ±1.4 mm, respectively. CONCLUSIONS: Scaphoid length estimation based on the contralateral scaphoid is more precise than the estimating scaphoid length using the ipsilateral radius and capitate. CLINICAL RELEVANCE: Scaphoid overexpansion can be ensured if the restored length is at least 1.4 mm longer than the contralateral length. This may be valuable information when establishing a target length for reconstruction and investigating the consequences of scaphoid overexpansion on clinical function, such as range of motion, which are currently unknown.

Validation of the contralateral side as reference for selecting radial head implant sizes.

PURPOSE: In arthroplasty of comminuted radial head fractures, the contralateral radial head diameter can be used as reference for implant selection. However, potential bilateral asymmetry may result in a mismatch of the implant with the native bone. Therefore, our purpose was to evaluate anatomical right-to-left differences of radial head diameters. We also compared conventional two-dimensional (2D) with three-dimensional (3D) measurements. METHODS: We used bilateral CT-scans from 25 intact proximal radius pairs of right-handed adult subjects to obtain 50 3D radial head models. After contralateral matching, diameters were calculated using a 3D-based method using an automated circle-fit in standardized cross-sections at the widest level midway through the radial head. The 3D-based diameters were compared to orthogonal line measurements in standard axial CT-slices. RESULTS: Three-dimensional analysis yielded a radial head diameter of 23.0 ± 1.7 mm. The dominant right side was significantly wider, with right-to-left differences of 0.2 ± 0.4 mm, with a maximum of 0.9 mm. The 2D-based diameter was 22.9 ± 1.7 mm, which was 0.1 ± 0.3 mm smaller compared to corresponding 3D-based diameter. CONCLUSIONS: In healthy radial heads, the diameter was biased to the dominant right side, but individual differences were not larger than 1 mm. Compared to implant designs, in which diameter increments are usually 2 mm, this right-bias is not clinically relevant, as it would not affect implant selection. Therefore, the contralateral side can be considered a suitable reference. In clinical practice, the surgeon could estimate this diameter using standard axial CT slices, since its difference with the 3D-based evaluation was also relatively small compared to implant sizing increments.

Quantifying scaphoid malalignment based upon height-to-length ratios obtained by 3-dimensional computed tomography.

PURPOSE: To determine if 3-dimensional height-to-length (H/L) measurements including coronal plane assessment will improve malalignment detection of scaphoid fractures and to determine if more waist than proximal pole nonunions are malaligned. METHODS: Computed tomography scans of uninjured wrists (n = 74) were used to obtain 3-dimensional models of healthy scaphoids. These models were used to determine 95% normal ranges of the H/L ratio in standard sagittal and coronal planes in an automated fashion. Subsequently, the H/L ratios of fibrous nonunions (n = 26) were compared with these normal ranges and were classified as either aligned or malaligned. RESULTS: The mean normal H/L ratio in the sagittal plane was 0.61 (range, 0.54-0.69) and in the coronal plane 0.42 (range, 0.36-0.48). The mean H/L ratios of the nonunions differed from those of the healthy scaphoids in these planes: 0.65 and 0.48, respectively. Based on sagittal plane evaluation of all nonunions, 46% exceeded the normal H/L range versus 54% based on combining sagittal and coronal plane measurements. More waist nonunions (71%) than proximal pole nonunions (22%) exceed the normal H/L range. CONCLUSIONS: Evaluation of the H/L ratio in the coronal plane provided valuable additional information for the detection of scaphoid deformities. More malaligned cases were found for waist nonunions than for proximal pole nonunions. CLINICAL RELEVANCE: This method may be a helpful diagnostic tool to detect malalignment and to choose between in situ fixation or reconstruction.

A three-dimensional algorithm for precise measurement of human auricle parameters.

Measurement of auricle parameters for planning and post-operative evaluation presents substantial challenges due to the complex 3D structure of the human auricle. Traditional measurement methods rely on manual techniques, resulting in limited precision. This study introduces a novel automated surface-based three-dimensional measurement method for quantifying human auricle parameters. The method was applied to virtual auricles reconstructed from Computed Tomography (CT) scans of a cadaver head and subsequent measurement of important clinically relevant aesthetical auricular parameters (length, width, protrusion, position, auriculocephalic angle, and inclination angle). Reference measurements were done manually (using a caliper and using a 3D landmarking method) and measurement precision was compared to the automated method. The CT scans were performed using both a contemporary high-end and a low-end CT scanner. Scans were conducted at a standard scanning dose, and at half the dose. The automatic method demonstrated significantly higher precision in measuring auricle parameters compared to manual methods. Compared to traditional manual measurements, precision improved for auricle length (9×), width (5×), protrusion (5×), Auriculocephalic Angle (5-54×) and posteroanterior position (23×). Concerning parameters without comparison with a manual method, the precision level of supero-inferior position was 0.489 mm; and the precisions of the inclination angle measurements were 1.365 mm and 0.237 mm for the two automated methods investigated. Improved precision of measuring auricle parameters was associated with using the high-end scanner. A higher dose was only associated with a higher precision for the left auricle length. The findings of this study emphasize the advantage of automated surface-based auricle measurements, showcasing improved precision compared to traditional methods. This novel algorithm has the potential to enhance auricle reconstruction and other applications in plastic surgery, offering a promising avenue for future research and clinical application.

The biodistribution of triamcinolone acetonide injections in severe keloids: an exploratory three-dimensional fluorescent cryomicrotome study.

Intralesional corticosteroid injections are a first-line treatment for keloids; yet clinical treatment results are highly variable and often suboptimal. Variation in triamcinolone acetonide (TAC) biodistribution may be an important reason for the variable effects of TAC treatment in keloids. In this exploratory study we investigated the biodistribution of TAC in keloids and normal skin using different drug delivery techniques. Fluorescent-labeled TAC suspension was administered into keloids and normal skin with a hypodermic needle and an electronic pneumatic jet injector. TAC biodistribution was represented by the fluorescent TAC volume and 3D biodistribution shape of TAC, using a 3D-Fluorescence-Imaging Cryomicrotome System. Twenty-one keloid and nine normal skin samples were analyzed. With needle injections, the mean fluorescent TAC volumes were 990 µl ± 479 in keloids and 872 µl ± 227 in normal skin. With the jet injector, the mean fluorescent TAC volumes were 401 µl ± 252 in keloids and 249 µl ± 67 in normal skin. 3D biodistribution shapes of TAC were highly variable in keloids and normal skin. In conclusion, TAC biodistribution in keloids is highly variable for both needle and jet injection. This may partly explain the variable treatment effects of intralesional TAC in keloids. Future research is needed to confirm this preliminary finding and to optimize drug delivery in keloids.

Minimal but potentially clinically relevant anteroinferior position of the humeral head following traumatic anterior shoulder dislocations: A 3D-CT analysis.

In unstable shoulders, excessive anteroinferior position of the humeral head relative to the glenoid can lead to a dislocation. Measuring humeral head position could therefore be valuable in quantifying shoulder laxity. The aim of this study was to measure (1) position of the humeral head relative to the glenoid and (2) joint space thickness during passive motion in unstable shoulders caused by traumatic anterior dislocations and in contralateral uninjured shoulders. A prospective cross-sectional CT-study was performed in patients with unilateral anterior shoulder instability. Patients underwent CT scanning of both injured and uninjured side in supine position (0° abduction and 0° external rotation) and in 60°, 90°, and 120° of abduction with 90° of external rotation without an external load. Subsequently, 3D virtual models were created of the humerus and the scapula to create a glenoid coordinate system to identify poster-anterior, inferior-superior, and lateral-medial position of the humeral head relative to the glenoid. Joint space thickness was defined as the average distance between the subchondral bone surfaces of the humeral head and glenoid. Fifteen consecutive patients were included. In supine position, the humeral head was positioned more anteriorly (p = 0.004), inferiorly (p = 0.019), and laterally (p = 0.021) in the injured compared to the uninjured shoulder. No differences were observed in any of the other positions. A joint-space thickness map, showing the bone-to-bone distances, identified the Hill-Sachs lesion footprint on the glenoid surface in external rotation and abduction, but no differences on average joint space thickness were observed in any position.

Madelung Deformity: Radioscapholunate Arthrodesis With a Neo-DRUJ.

BACKGROUND: Madelung deformity is a rare wrist anomaly that causes considerable pain while restricting function. In this study, we describe a radioscapholunate (RSL) arthrodesis with a neo-distal radioulnar joint (DRUJ) in Madelung deformity patients with an abnormal sigmoid notch and compare results to patients after a reverse wedge osteotomy. METHODS: Six wrists underwent RSL arthrodesis with a neo-DRUJ in a two-phase approach: (1) modified RSL arthrodesis with triquetrectomy; and (2) distal scaphoidectomy. Seven wrists underwent a reverse wedge osteotomy procedure. RESULTS: There were no differences found in postoperative pain, grip strength, or range of motion (ROM), apart from extension, which was decreased after RSL arthrodesis with a neo-DRUJ. Quality of life and Michigan Hand Outcomes Questionnaire scores were similar. CONCLUSIONS: Although clinical outcome parameters are not different among the two groups, the RSL arthrodesis with construction of a neo-DRUJ could prove a valid treatment option for a subset of patients with a severely affected sigmoid notch.

Kinematic analysis of forearm rotation using four-dimensional computed tomography.

This study aimed to quantify forearm kinematics with a focus on the forearm rotation axis. Ten healthy volunteers were included in the study. One three-dimensional computed tomographic scan and two four-dimensional computed tomographic scans were done in all the arms to capture forearm joint motion. After image processing, the rotation axis and the movement of the radius with respect to various axes were quantified. The rotation axis was calculated using finite helical axis analysis and a circle fitting approach. The mean error of the rotation axis found through circle fitting was 0.2 mm (SD 0.1) distally and 0.1 mm (SD 0.1) proximally, indicating an improvement in precision over the finite helical axis approach. The translations of the radius along the ulnar axis and the forearm rotation axis were 2.6 (SD 0.8) and 0.6 mm (SD 0.9), respectively. The rotation of the radius around the radial axis was 7.2°. The techniques presented provide a detailed description of forearm kinematics.

Performance of the Aptis Distal Radioulnar Joint Implant: A Clinical Case Series Including Four-Dimensional Computed Tomography Kinematic Analysis.

High complication rates and surgical revision rates following Aptis implant placement have been reported in the literature. This study evaluates the performance of the Aptis implant of twelve patients using four-dimensional kinematic analysis. The (mean) follow-up was 58 months. Wrist motion, grip strength, and kinematic analysis of both arms were used to investigate possible causes of the reported complications. In nine cases (75%), the proximal to distal translation of the distal radius along the ulnar axis in the affected forearm was too little or absent. Significant correlations were found between postoperative extension and translation of the distal radius along the ulnar axis and between the radial deviation and combined error. The four-dimensional kinematic analysis suggests that the current design of the implant could lead to limited restoration of the position of the forearm rotation axis and the translation of the radius along the ulnar axis.

Promising results of an non-invasive measurement of knee implant loosening using a loading device, CT-scans and 3D image analysis.

BACKGROUND: After total knee arthroplasty up to 13% requires revision surgery to address loosening. No current diagnostic modalities have a sensitivity or specificity higher than 70-80% to detect loosening, leading to 20-30% of patients undergoing unnecessary, risky and expensive revision surgery. A reliable imaging modality is required to diagnose loosening. This study presents a new and non-invasive method and evaluates its reproducibility and reliability in a cadaveric study. METHODS: Ten cadaveric specimens were implanted with a loosely fitted tibial components and CT scanned under load towards valgus and varus using a loading device. Advanced three-dimensional imaging software was used to quantify displacement. Subsequently, the implants were fixed to the bone and scanned to determine the differences between the fixed and the loose state. Reproducibility errors were quantified using a frozen specimen in which displacement was absent. FINDINGS: Reproducibility errors, expressed as mean target registration error, screw-axis rotation and maximum total point motion were 0.073 mm (SD 0.033), 0.129 degrees (SD 0.039) and 0.116 mm (SD 0.031), respectively. In the loose condition, all displacements and rotation changes were larger than the reported reproducibility errors. Comparing the mean target registration error, screw axis rotation and maximum total point motion in the loose condition to the fixed condition resulted in mean differences of 0.463 mm (SD 0.279; p = 0.001), 1.769 degrees (SD 0.868; p < 0.001) and 1.339 mm (SD 0.712; p < 0.001), respectively. INTERPRETATION: The results of this cadaveric study show that this non-invasive method is reproducible and reliable for detection of displacement differences between fixed and loose tibial components.

Difference in orientation of the talar articular facets between healthy ankle joints and ankle joints with chronic instability.

Since both the talocrural and subtalar joints can be involved in chronic ankle instability, the present study assessed the talar morphology as this bone is the key player between both joint levels. The 3D orientation and curvature of the superior and the posteroinferior facet between subjects with chronic ankle instability and healthy controls were compared. Hereto, the talus was segmented in the computed tomography images of a control group and a chronic ankle instability group, after which they were reconstructed to 3D surface models. A cylinder was fitted to the subchondral articulating surfaces. The axis of a cylinder represented the facet orientation, which was expressed by an inclination and deviation angle in a coordinate system based on the cylinder of the superior talar facet and the geometric principal axes of the subject's talus. The curvature of the surface was expressed as the radius of the cylinder. The results demonstrated no significant differences in the radius or deviation angle. However, the inclination angle of the posteroinferior talar facet was significantly more plantarly orientated (by 3.5°) in the chronic instability group (14.7 ± 3.1°) compared to the control group (11.2 ± 4.9°) (p < 0.05). In the coronal plane this corresponds to a valgus orientation of the posteroinferior talar facet relative to the talar dome. In conclusion, a more plantarly and valgus orientated posteroinferior talar facet may be associated to chronic ankle instability.

Translation of 3D Anatomy to 2D Radiographic Angle Measurements in the Ankle Joint: Validity and Reliability.

Background: The objective consisted of 2 elements, primarily to define 2 bone geometry variations of the ankle that may be of prognostic value on ankle instability and secondly to translate these bone variations from a 3D model to a simple 2D radiographic measurement for clinical use. Methods: The 3D tibial and talar shape differences derived from earlier studies were translated to two 2D radiographic parameters: the medial malleolar height angle (MMHA) and talar convexity angle (TCA) respectively to ensure clinical use. To assess validity, the MMHA and TCA were measured on 3D polygons derived from lower leg computed tomographic (CT) scans and 2D digitally reconstructed radiographs (DRRs) of these polygons. To assess reliability, the MMHA and TCA were measured on standard radiographs by 2 observers calculating the intraclass correlation coefficient (ICC). Results: The 3D angle measurements on the polygons showed substantial to excellent agreement with the 2D measurements on DRR for both the MMHA (ICC 0.84-0.93) and TCA (ICC 0.88-0.96). The interobserver reliability was moderate with an ICC of 0.58 and an ICC of 0.64 for both the MMHA and TCA, respectively. The intraobserver reliability was excellent with an ICC of 0.96 and 0.97 for the MMHA and the TCA, respectively. Conclusion: Two newly defined radiographic parameters (MMHA and TCA) are valid and can be assessed with excellent intraobserver reliability on standard radiographs. The interobserver reliability was moderate and indicates training is required to ensure uniformity in measurement technique. The current method may be used to translate more variations in bone shape prior to implementation in clinical practice. Level of Evidence: Level III, cohort study.