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Weight-Bearing CT May Improve Diagnoses in Hallux Valgus Patients

Hallux Valgus

A recent analysis of studies titled Imaging of Hallux Valgus by James Welck and Naji Al-Khudairi has shown that newer, three-dimensional imaging techniques including weight-bearing computer tomography (WBCT) may permit a more thorough understanding of the hallux valgus (HV) deformity and provide greater information to foot and ankle surgeons prior to corrective surgery.

Traditional two-dimensional AP, lateral, and oblique radiographs are the current standard for imaging HV deformity. Two-dimensional radiographic images can be used to measure several radiographic angles which are commonly used to quantify the extent of HV deformity. However, recent research shows that some of these angle measures show low levels of reliability and accuracy. Coughlin et. al. found that measures of the hallux valgus angle and the intermetatarsal angle assessed using 2-D imaging had high intraobserver and interobserver reliability. In contrast, the distal metatarsal articular angle was measured to 5° or less in only 58.9% of cases, and measurement of metatarsophalangeal joint congruency led to a wide variation in cases identified. The primary reason that two-dimensional imaging techniques may fail to be reliable is that HV is a triplanar deformity with rotational aspects that two-dimensional images cannot account for.

Fortunately, research shows three-dimensional HV imaging techniques have promise. Conventional CT imaging is not weight-bearing, but weight-bearing cone beam CT provides better insight into HV. This means that many patients imaged through traditional CT may not have been diagnosed correctly.

  • Welck and colleagues have found WBCT to better display the sesamoids, which are difficult to represent accurately using traditional AP radiographs.
  • Collan and colleagues demonstrated the importance that CT is weight-bearing by finding that there were significant differences in HVAs and IMAs between HV and control groups only when patients were in a weight-bearing stance.

Two other research groups found that WBCT provided insight into the effects of joint hypermobility in HV patients which would not typically be measurable using two-dimensional imaging techniques.

To learn more about how three-dimensional imaging techniques like WBCT can benefit your foot and ankle practice, visit http://www.curvebeam.com/products/pedcat/. CurveBeam’s PedCAT systems are at the cutting edge of WBCT innovation and can help provide your patients with the best HV care that current science has to offer.

i-FAB Awarded to Hindfoot Misalignment Research Study

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Hindfoot malalignment is a major cause of pathology in the foot and ankle and impacts the biomechanics of these areas of the body. Standard 2D radiograph measurements are plagued by anatomical and operator bias due to inaccuracies with 2D plane projections. Weight Bearing Computed Tomography (WBCT) and semi-automated 3D measurements of the hindfoot have shown promise for increased accuracy. They do have a critical shortcoming, however; they cannot offer information related to surface-to-surface interactions throughout various parts of the ankle and foot.

Sorin Siegler, Maui Jepsen, and Francois Lintz recently completed a study with the goal of addressing these inadequacies and finding solutions. They applied a 3D biometric tool based on distance mapping, which describes this interaction to WBCT data to characterize the effect of hindfoot valgus and varus deformities. 30 bilateral data sets were obtained, and the images were then processed to create 3D models of the foot and ankle structures. 3D CAD software calculated surface-to-surface interactions at various joints and created color-coded distance maps. The team then compared the images from the deformed feet to those of the normal feet.

With respect to hindfoot valgus, they discovered the antero-medial side of the talus is closer to the medial malleolus as this bone moves into slight external rotation and plantarflexion. The calcaneus is externally rotated relative to the talus, resulting in surface approximations on the lateral side of the posterior articular facet and an impingement of the sinus tarsi. In addition, a strong approximation on the superior side of the calcaneocuboid joint and the lateral side of the talonavicular joint occurs at the Chopart joint. At the cunei-navicular joint, there is a significant approximation of the lateral cuneiform to the navicular. At the metatarsal-cuneiform joints is a strong approximation at the 2nd and 3rd metatarsals joint surfaces.

In hindfoot varus, it was evident that the medial and lateral sides of the talus are closer to their respective malleoli, and anteromedial side of the talar dome approximates the tibial plafond, as the talus moves into inversion and slight dorsiflexion. The calcaneus is internally rotated and inverted relative to the talus, resulting in surface approximations on the medial side of the calcaneus bridging the gap between the posterior and middle articular facet and at the lateral side of the posterior articular facet of the calcaneus. The cuboid is displaced inferior to the navicular resulting in contact on the lateral facet of the calcaneocuboid joint. Also, a strong approximation at the talo-navicular joint can be observed on the medial side. At the cunei-navicular joint, the lateral cuneiform surface is displaced away from the navicular surface compared to normal.

It was concluded that WBCT can provide accurate classification of these foot and ankle deformities. Distance mapping allowed the team to characterize the specific surface-to-surface interactions at the joints and distinguish more readily between the hindfoot deformities. This information can be valuable in understanding certain pathologies associated with hindfoot varus and valgus deformities. In addition, the color-coded distance maps provided an effective method for assessing the effect of hindfoot deformities on articular joint surface interaction in the foot and ankle. The maps also enhance diagnostics, with future applications in evaluating therapy efforts to restore normal alignment.

Not only was this study highly successful in its future applications to diagnosing and treating these deformities, it also was the recipient of the distinguished i-FAB award. The mission of i-FAB, or International Foot and Ankle Biometrics Community, is to improve our understanding of foot and ankle mechanics as it applies to health, disease, and the design, development and evaluation of foot and ankle surgery, and interventions such as footwear and insoles/orthotics.

Learn about CurveBeam’s ongoing commitment to advancing foot and ankle care here.

Studies Point to Many Benefits of Weightbearing CT Scanning Technology

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For patients whose lives are impacted by medical technology breakthroughs, there is a significant improvement in the quality of care their doctors are then able to provide. This is especially true when it comes to cone beam computed tomography (CT) scanning. In the last decade, the innovations made in this field have allowed for true weightbearing CT scans to be taken.

In order to present a picture of the difference weightbearing CT scanning has made on foot and ankle patients, authors from the University of Utah, as well as a team of international researchers, presented a series of studies showing the benefits of the new technology. In their article, Weightbearing Computed Topography of the Foot and Ankle: Emerging Technology Topical Review, Drs. Alexej Barg and Charles Saltzman show that true weightbearing CT scans are far more effective than their simulated counterparts.

The article covered 8 studies performed between 2013 and 2017, each of which covered alignment analysis within the foot. While previous attempts to replicate weightbearing environments involved rigging up weights to affect the foot while the patient was lying down, modern technology is allowing doctors to observe the interactions within the foot in actual weightbearing scenarios with the patient standing and even walking. Regardless of whether the studies focused on talar anatomy, hindfoot alignment, valgus deformities or flat-footedness, the studies all had a similar theme. The cone beam weightbearing CT scan offered a more complete view of the relationships in the foot than what was attainable with traditional radiography.

Perhaps most importantly, the overview of the literature available pointed to several key benefits offered by this scanning technology. Not only does it allow for scans to be taken while the patient is standing, but there is increased spatial resolution and faster imaging times due to cone beam scanning. Plus, the side benefits of having lower radiation than traditional CT scans coupled with modest costs can help alleviate many patient concerns. The authors also advocate for utilizing the images provided through weightbearing CT scanning to establish standardized forefoot, midfoot and hindfoot alignment positions using anatomical landmarks, which could greatly enhance both diagnoses and care plan development for the patient.

Leading the charge in this innovative technology is CurveBeam. With a line of cone beam scanning devices like the InReach, LineUP and their standard PedCAT, CurveBeam allows clinics to offer weight bearing CT scanning to their patients to improve their quality of care. To learn more about the possibilities offered by devices like the PedCAT, or to see their products for yourself, visit http://www.curvebeam.com/products/pedcat/ today!

Weight Bearing CT Finds Important Displacement in Patients with Hallux Valgus

It’s difficult to understand how much a bunion can affect your life until you experience it. Known by the medical term hallux valgus, this deformity is painful and can be extremely disruptive. While the traditional solution has been to perform a fusion of two key bones in what is known as the Lapidus Procedure, a team of researchers believes this overlooks a secondary displacement that can cause lasting postoperative problems.

In their study, Comparison of Intercuneiform I-2 Joint Mobility Between Hallux Valgus and Normal Feet Using Weightbearing Computed Tomography and 3-Dimensional Analysis, Dr. Tadashi Kimura and fellow researchers looked at an understudied joint to find out if there is more that can be done in the treatment of hallux valgus. They looked at the feet of 11 women with the condition, as well as the feet of 11 healthy women, and found a significant difference in the displacement of the I-2 joint between the two groups.

To conduct their study, the team used CT scanning with simulated weightbearing effects on the foot to see the mobility of the joint. The images portrayed enough difference in the two groups to suggest that hallux valgus does affect the I-2 joint. Previously, a Lapidus Procedure had been used to fuse the first metatarsal with the medial cuneiform, but an additional operation may be needed to fuse the I-2 joint, a process known also as arthrodesis, in order to relieve the patient’s symptoms.

While this might not be the case for all patients with hallux valgus, it can be significant for those who experience hypermobility of this joint. To determine that this is the case, utilizing true weightbearing CT scanning technology may be critical. This study used CT scans that simulated a weightbearing environment with the intention of replicating the effects, but the authors state that the displacement may be even more severe once true weightbearing interaction is observed.

An industry leader in weight bearing, 3D scanning technology, CurveBeam’s innovations give doctors the ability to develop comprehensive treatment plans that address this entire issue. The authors of the study write that simple radiography would be unable to capture the displacement of the I-2 joint and traditional CT scanning is unable to account for the shifts caused once the full weight of a patient’s body is placed on the foot. Hallux valgus treatment can greatly improve the quality of life for a patient, and it is important to ensure that the treatment provided eliminates the problem. The PedCAT can give doctors the ability to do exactly that. To learn more about CurveBeam and the pedCAT, click here.

CurveBeam Throws A Curve at Conventional CT Scans for Orthopedic Practices

Often used for orthopedic and podiatric use when plain x-rays do not provide the visualization needed, a CBCT (Cone Beam Computed Tomography) scan is a quick, pain-free, noninvasive radiology diagnostic imaging test used to accurately generate comprehensive images of bones. These images can then be reformatted into three-dimensional images which can be easily shared through PACS. Quicker than the spiral motion of a typical CT scan, CBCT imaging exposes patients to less radiation than traditional CT scanners.

Watch the below video to learn Dr. Josef Zoldos, MD, DDS, one of the founders of the Arizona Center for Hand Surgery, explain how CurveBeam CBCT aids their doctors in detecting inflammatory conditions, tumors, and evaluating other abnormalities of the hand, wrist, and elbow, improving overall diagnoses, treatment plans, and patient engagement in their facility.

Health Canada Approves CurveBeam’s InReach Cone Beam CT

March 26, 2018 – Warrington, Penn. – CurveBeam announced the InReach cone beam CT system for orthopedics has been approved by Health Canada regulatory authority for sale in Canada.

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The InReach is primarily designed for the hand, wrist &elbow; & lower extremities in non-weight bearing position. The InReach is an ultra-compact CT scanner that provides high-contrast 3D datasets of bony anatomy, which could potentially replace radiographs as a first line of diagnosis.

The InReach is ideal for the point-of-care, imaging centers, and hospital orthopedic departments because of its small footprint, its self-shielded design, and standard power requirements.

“The InReach will revolutionize the speed and accuracy of assessment of upper extremity conditions that specialists have traditionally found challenging to diagnose with plain X-Ray, such as scaphoid fractures,” said CurveBeam President & CEO, Arun Singh. “The InReach continues the company’s mission to elevate advanced diagnostic imaging capabilities to enhance orthopedic care.”

The InReach is designed with patient comfort in mind. Patients’ hand, wrist or elbow is positioned in a height-adjustable bore while in standing or sitting position. The unit can also accommodate non-weight bearing, lower limb imaging. Scan times are less than 30 seconds.

The InReach device is supplemented by CubeVue, CurveBeam’s custom visualization software.  CubeVue gives orthopedic specialists to multi-planar slice navigation tools and vivid 3D renderings of the anatomy previously not easily accessible to specialists. CubeVue’s Insta-X feature provides Digitally Reconstructed Radiographs, potentially eliminating the need for radiographic exams altogether.

The InReach is the second extremity CT imaging system CurveBeam has introduced to Canada. CurveBeam’s pedCAT system permits weight bearing CT imaging of the feet and ankles.

The InReach system was cleared by the US FDA for sale in the United States in 2017.

CurveBeam is the leader in Weight-Bearing extremity CT imaging, starting with the introduction of its pioneer product, the pedCAT, in 2012. The pedCAT is the only CT system that allows for bilateral, true weight-bearing imaging of the lower extremities. Since 2012, the pedCAT has been integrated into leading foot & ankle orthopedic and podiatric practices around the world.

CurveBeam is currently developing its next generation multi-extremity device, the LineUP, which will provide bilateral Weight-Bearing images of the knees in addition to feet, as well as hand, wrist & elbow.

Weight-Bearing CT Can Help Doctors Zoom in on the Problem

Sometimes the simplest solution to a difficult challenge is a change of perspective. That’s exactly what Dr. Selene Parekh and his colleagues at the North Carolina Orthopaedic Clinic have learned after using the CurveBeam pedCAT. In his talk titled “Standing CT: Zooming in on the Problem,” Dr. Parekh outlines how his experiences at the clinic and as a professor of orthopaedic surgery at Duke University have demonstrated the importance of weight-bearing computed tomography (WBCT) scans.

All too often, clinics rely solely on x-rays for initial diagnosis. If CT scans are used, the patient is usually lying horizontally, with weight and pressure completely removed from the area in question. As a result, the treatment plans or pre-operation strategies are developed from incomplete information. With WBCT scanners, doctors can accurately view the interaction of elements in the patient’s lower extremities, allowing them to better diagnose the issue.

To illustrate this point, Dr. Parekh outlines several of his own real-world cases, one of which occurred within the last week. A 35-year-old woman visited the clinic complaining of medial ankle pain. While an initial x-ray revealed a minor increased talar tilt, a review of the patient’s history prompted her doctors to look again with the weight-bearing pedCAT. The test revealed the presence of osteochondral lesions. This refined diagnosis resulted in more appropriate treatment options, such as a resurfacing procedure to repair the issue at the heart of the problem.

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Another case involved a 61-year-old man who liked to stay active by biking and running. He presented with pain in his right foot. An x-ray revealed a malunion of the fibula and some arthritis. A total ankle replacement was subsequently performed, and the man resumed his active lifestyle. After five years, however, he returned complaining of increasing pain in the same foot. This time, a WBCT was taken, and the clinic saw the full extent of the problem. They discovered an impingement of the bone as well as a settling of the talar component into the talus, which was causing a talar fracture. Without this scan, it is likely that minor (and insufficient) treatments would have been considered. The patient chose to undergo an entire talus replacement, so he could keep cycling, a healthy activity that he enjoyed.

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These cases, as well as others outlined by Dr. Parekh, illustrate the significant difference that WBCT scanners such as the CurveBeam pedCAT can make in a physician’s ability to treat patients. Even beyond these new perspectives offered, there are other benefits to the patient, most significantly, reduced radiation exposure. While traditional CT scans have radiation levels around 2000 sieverts, the pedCAT only emits about 2 sieverts of radiation. Curve Beam is also releasing the LineUP, which will facilitate total lower body scans, from floor to knees.

By giving physicians a complete view of a patient’s extremities and the interactions of the bones, ligaments, and joints within, CurveBeam aids in providing the best treatment possible to patients. You can learn more about CurveBeam here!

Joan Oloff is Making Fashion More Functional

All too often, our choice of wardrobe comes down to function or fashion. We sacrifice comfort to look good, or we sacrifice taste so that we can be comfortable during long days on the job. Increasingly, however, companies are seeking to create pants, dress shirts and shoes that combine runway aesthetic with around-the-house comfort. In a fashion landscape dominated by established brands, it can be difficult for a start-up to stand out. By providing customers with clothing and accessories that look great but can also be worn on the job, new brands are able to break through this barrier.

Few designers exemplify this innovative spirit as much as Joan Oloff. A podiatrist by training, Joan set out to make the first line of orthopedically correct high heels. After seeing the issues that traditional high heels cause in her patients, Joan knew there had to be a way to design beautiful shoes that wouldn’t negatively impact the health of the wearer’s feet down the road.

The challenge was taking elements already common in athletic and walking shoes, like offloading pressure points, incorporating shock-absorption and providing proper support, and finding a way to implement these same features in heels. Over the course of four years, Joan worked with designers and manufacturers, in both Los Angeles and Italy, to make her line of shoes fit her standards. It was difficult. The manufacturers didn’t want to do things her way. But she pushed ahead.

“If I’m not going to be a game-changer, if I’m not going to disrupt the way high heels are made, there’s no point for me to do this,” Joan said in an interview with the San Francisco Chronicle.

Her perseverance paid off and today, Joan Oloff’s shoes have built-in arch support, cushioning material in the ball of the foot and a lower heel pitch, all of which allow the entire foot to comfortably share the body’s weight. Perhaps the most impressive aspect of her line is simply the diversity of options. Made by hand, the latest collection has everything from sandals to knee-high boots. The beauty of the line, combined with the comfort of the shoes, have garnered Joan a loyal following. One surgeon in Santa Fe owns ten pairs of the shoes as they allow her to work without discomfort be it in her office, visiting patients or even conducting an hours-long surgical procedure.

While her customers all praise her shoes, Joan also has proof to back up her claims that she makes healthy heels. Using CurveBeam’s revolutionary pedCAT technology, Joan is able to show weight-bearing CT scans of her shoes in action. When compared side-by-side with the same scans of someone wearing standard heels, it is obvious that Joan’s shoes provide evenly distributed support and stable positioning while other shoes have toe crimping and no arch support, creating a painful experience for the wearer.

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Just like Joan Oloff, CurveBeam is dedicated to changing the game. By creating innovative 3D scanning technology that provides a complete view of a patient’s lower extremities, the pedCAT has given podiatrists, physical therapists, and others the ability to give their patients the proper treatment they need. Learn more about pedCAT here.

Why CurveBeam Technology is Even Changing the Way We Talk

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Languages are constantly shifting and changing. As our experiences change, new terminology and ways to express the world around us are required. In a time when the medical field is experiencing technological breakthroughs that redefine the way we treat patients, it should be no surprise that the language used in some medical fields may quickly become outdated.

Nowhere is this truer than in orthopedic pathology diagnoses. In January’s issue of the Lower Extremity Review (LER), Ian Engelman’s article “Saying ‘PTTD” Is Misleading: It’s time for a new lexicon to distinguish pathologies” focuses on just one segment of the field to show the issues inherent in the current vocabulary. One of the main problems, for instance, is that the words used to describe what is occurring vary from profession to profession. This means that an orthopedic surgeon, a podiatrist and a physical therapist could all be discussing the same issue, but each use a different, and sometimes conflicting, term for the same pathology.

Engleman argues that as our ability to understand what is occurring in the foot progresses, our language should to. He refers to the organizing principle, stating that, “Better and more specific terms lead to better, more specific understanding of the origin of the pathological condition.” (Engelman, 2018). So much of our language regarding the movement of and connections within the foot regard on comparisons to mechanics in our everyday lives, such as a set of hinges or a mechanical bridge. By merely making analogies, rather than creating a specific and universal set of terms based on careful analysis, misdiagnoses or improper treatment can occur.

According to Engelman we are coming up on a paradigm shift in the world of orthopedics. This is primarily due to the integration of 3D imaging into the treatment of the lower extremities. CurveBeam’s pedCAT technology, Engelman says, is particularly groundbreaking as it allows for 3D, weight-bearing analysis, eliminating much of the guesswork about how the parts of the foot are operating in real-life conditions.

Engelman’s article highlights the limitations placed by utilizing a 2D vocabulary in a field that is beginning to integrate 3D technology. He gives suggestions for how he would linguistically alter the terms used by the industry:

  • “Normal foot” – This one may seem obvious, but before the capabilities provided by 3D scanning technology there was no way to establish a true baseline. Now there is a way to establish the ideal interactions and alignments within a patient’s foot to determine how far away from the norm they are.
  • “Talar escape” – This term is used to describe a spring ligament failure. While this aberration is easier to identify than most, the terms for it have traditionally varied across specialties
  • “Lateral Column Flat Foot” – In the past, much of the reason given for plantar ligamentous failure has been directed towards the medial column within the foot. When examined closer using modern technology, however, Engelman notes that there can be healthy medial columns while flat footedness still occurs, meaning the causality lies more with the ligament interacting with the lateral column. Engelman suggests several terms like this, where there is a linguistic need for events previously not recognized with 2D scans.

As well as making efforts to improve and expand the professional vocabulary, Engelman also urges clinics to begin to implement devices like the CurveBeam pedCAT and CubeVue software. That way there can at least be a visual representation of exactly what is occurring in a patient’s foot, even if there is not yet a way to put it into words. To learn more about CurveBeam’s innovative products, visit http://www.curvebeam.com/ and see how 3D imaging can revolutionize your clinic’s treatment practices.

CurveBeam: Moving Orthopedics Forward

Scroll to the bottom of this post to access a technical comparison chart of the CurveBeam LineUP* and similar systems from other vendors.

If you’re part of a forward-thinking orthopedic practice, you’re constantly looking for ways to offer the best in patient care, while also improving operations.

Cone Beam CT imaging is an attractive ancillary service because 3D extremity imaging provides physicians a better view of fractures, dislocations, and arthritic degeneration than plain radiographs. Point-of-care CT imaging is also convenient for patients, as they do not need to make an appointment for and travel arrangements to a separate imaging facility.

Administrators may vet more than one Cone Beam CT imaging vendor when determining which solution is the best fit for their practice.

As you complete your evaluation, we’d like to emphasize three things that set CurveBeam apart:

  1. Emphasis on customer service – The CurveBeam team lives by the credo of going above and beyond to exceed our customers’ expectations. We work closely with all stakeholders during the pre-installation process and regularly follow up to proactively assist with ongoing workflow, IT or marketing items. We are vested in making sure each of our sites successfully integrates our technology.
  2. Fair and standard pricing – We are transparent in our pricing. We have a published, standard price for each system and we work hard to keep costs as low as possible. We don’t believe in inflated list prices that only serve as a negotiation tactic.
  3. Commitment to innovation – We are constantly looking to the future to improve performance and usability in all aspects. We either make system upgrades standard or easily achievable within an operating budget so that you can always be on the cutting edge.

To further help you in your evaluation process, CurveBeam has put together a chart comparing the CurveBeam LineUP* with similar systems from other vendors. Just provide your name and email address to have it sent directly to your inbox.

*The CurveBeam LineUP is investigational only and is not available for sale in the United States.

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