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CurveBeam CT Imaging Technology is Right On Point

Ballet is an art of extremes. As such, the risk factors are high among dancers for developing chronic injury and weakened tissues throughout the lower half of their bodies. About 60% of ballet injuries affect the legs, hips, ankles or feet. Lateral ankle sprains and Posterior Ankle Impingement Syndrome, or the pinching sensation felt during repeated floor or barre work as the heel bone comes into contact with the talus bone, are chief among them.

By the age of 12, ballet dancers are generally considered ready to begin learning the en pointe technique which utilizes the unnatural convergence of the tibia, talus, and calcaneus to lock the ankles in place.

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pedCAT weight bearing CT scan of a ballerina en pointe.

While we do know this position may facilitate injury, prior to the advent of advanced CT imaging podiatrists had no method of accurately determining the exact anatomical position of either bones or tissue in this position.

CurveBeam, founded in 2009, designs and manufactures Cone Beam CT imaging equipment for the orthopedic and podiatric specialties. In 2012 CurveBeam’s pedCAT system received official clearance from the FDA, and in 2013, CE Mark approval. With the implementation of tools such as the pedCAT and CubeVue, CurveBeam’s custom visualization software, researchers finally have the capability to help ballet teachers better understand the demands of this position before introducing it to young students.

en pointe sag
pedCAT weight bearing CT scan of a ballerina en pointe

Pointe technique, when examined through an advanced imaging system, reveals the posterior portion of the talus resides beyond its articular surface, while the posterior portion of the tibia’s articular surface leaves the articular surface of the dome to rest on the posterior talus. The three bones converge. According to Dr. Jeffrey A. Russell, Ph.D, A.T., FIADMS:

“Attaining the full en pointe position requires contributions from movements between the bones in the foot. Examples of such movements include sliding between the talus and the navicular, the navicular and the medial cuneiform, and the medial cuneiform and the first metatarsal. These small increments of motion combine to provide approximately 30% of the plantar flexion range.”

pedCAT weight bearing CT ballet
pedCAT weight bearing CT scan of a ballet dancer en releve.

“In addition, it is noteworthy that the talus shifts slightly anterior from under the tibia as the ankle-foot complex moves en pointe. This subtlety arises because the converging tibia, talus, and calcaneus form a fulcrum that applies an anterior force to the talus, somewhat like a watermelon seed being squeezed from between one’s thumb and forefinger.”

Recently, Dr. Russell took to an advanced open MR scanner to review the upright and weight bearing position of uninjured ankles in six university-level dancers who had been dancing for an average of 13 years, and dancing en pointe for an average of seven years.

“All exhibited several traits in their ankle MRIs: the posterior portion of the articular surface of the tibia rested on a nonarticular surface of the posterior talus; the synovial sheaths of the flexor and fibularis tendons collected fluid; Kager’s fat pad was impinged by the posterior tibial plafond; and small ganglion cysts were apparent in one or more spots around the ankle and proximal foot.”

pedCAT weight bearing CT ballet
pedCAT weight bearing CT scan of a ballet dancer en releve

It’s an interesting find, and begs the question: do these conditions increase the likelihood of ballet dancers developing ankle osteochondritis or osteoarthritis?

Not only do advanced imaging systems such as the CurveBeam pedCAT – which was not used in this particular study – reveal the bones’ proper anatomic alignment, but they also enable a close investigation of cartilage quality, which isn’t possible with traditional MR imaging. Bilateral, weight bearing three-dimensional views of the foot and ankle are therefore the most cogent means for specialists to create comprehensive treatment regimens and surgeons to better visualize their surgery plans for better operation outcomes.

Most importantly, however, is Dr. Russell’s recent study confirms the use of orthopedic imaging to examine pointe dancers’ ankles in detail will only continue to offer more insight into the demands placed on the ankle by dancing in this way, ultimately leading to safer instruction, more accurate treatment of injuries, and faster recovery times.

Webinar Summary: Advanced CT Imaging in Foot and Ankle Surgical Considerations

We all know that X-rays and MRIs aren’t the be-all, end-all of diagnostic imagery.

Try determining the frontal plane rotation of the sesamoid and first metatarsal with an X-ray. It isn’t possible. Correction of the hallux valgus rotation in bunion surgery depends largely on the repositioning of the sesamoidal apparatus which is impossible to assess without an axial view, and X-rays fall completely short when it comes to assessing these relational details from the vantage point of a single plane.

Such was the topic of discussion during the latest Curvebeam webinar led by Dr. Bob Baravarian, Director of University Foot and Ankle Institute in Southern California. He explained how weight-bearing 3-dimensional CT scans are changing the game of podiatric diagnostics.

Throughout the webinar, titled “Advanced CT Imaging in Foot and Ankle Surgical Considerations,” Dr. Baravarian offered a very straightforward presentation of the often-not-so-straightforward complexities of foot and ankle deformities and how advanced imaging technology can improve both surgical planning and surgical outcomes. He cited the example of hallux valgus among many others as “impossible to imagine treating without 3-D imaging technology” these days – given the results he’s seen with his patients and scope webinar 3of its applications.

Planning the frontal plane correction of first metatarsal.

“CT scans are very helpful in planning your frontal plane deformity correction of the first metatarsal to get an anatomic position which is really underestimated,” said Dr. Baravarian.

Multi-plane imaging now allows physicians to correct the frontal plane deformity of the metatarsal while simultaneously realigning the sesamoid. The capability is “critical,” said Dr. Baravarian, “for proper outcome with bunion corrections whether you’re doing a LAP or any kind of osteotomy.”

Identifying the cause of hypermobility of the first ray

When you look at a patient who has a significant flat foot deformity and a significant bunion deformity with some level of hyper-mobility of the first ray, 3D CT imaging allows you to locate the exact area in need of correction.

“In patients who have PTTD or even a pediatric flat foot case we really need to decide which planes of correction make the best sense,” said Dr. Baravarian.  “If I correct my first metatarsal, is my hind foot going to realign or is there an outstanding deformity that needs correction?”

webinar captureDetermining the level of arthritis in hallux rigidus and limitus cases. 

“I’m constantly surprised when I go into surgery and I plan a cheilectomy and I open up a joint and there’s significantly more arthritic changes or some kind of osteochondral legion that I couldn’t really see on the X-ray. Or, I plan to do an osteotomy and I go in and the level of arthritis is not as bad as expected,” said Dr. Baravarian.

It’s very difficult to determine the level of arthritis in a hallux rigidus or limitus case based on a radiograph alone. While MRIs are an excellent option for soft tissue imaging and diagnostic ultrasounds still provide accurate, real-time guidance for proper injections –neither of these methods makes sense for treating anatomic alignment and assessing structural deformities.

 

“With a 3D CT I’m able to look a little more in-depth into the joint and make a better decision prior to surgery.”

Identifying major deformities in complex fractures

Weight-bearing imaging systems allow you to place a foot in its anatomic position and adjust its deformity to see what level of correction you can get across multiple planes.

It “doesn’t makes sense,” according to Dr. Baravarian, “to plan the correction of a complex fracture without a sense of what’s going on inside the foot and ankle.”

Our traditional method of two-dimensional x-rays doesn’t provide the highest level of certainty that doctors need in order to administer the best care possible to their patients where deformity planning is essential for proper surgical outcomes.

Now, with the help of tools such as the pedCAT, a compact 3D weight-bearing CT imaging system, podiatrists have everything they need to create comprehensive treatment plans and more effective surgeries. Better outcomes. Less risk. And patients back on their feet faster than they ever expected.

You can access the entire webinar here. A FOOT Innovate membership is required to access the content. Membership is complimentary for foot & ankle specialists.

CurveBeam Announces First pedCAT Installation at an Accredited College of Podiatric Medicine

CurveBeam is proud to announce the installation of a pedCAT cone beam CT imaging system at Kent State University College of Podiatric Medicine.

Kent State is the first member of the American Association of Colleges of Podiatric Medicine to acquire weight bearing CT imaging technology.

“Kent State University is proud to be the first facility in the Northeast Ohio region to provide this ‘state- of-the-art” imaging modality,” said Dr. Allan Boike, Dean & Professor of Foot & Ankle Surgery at KSUCPM. “The CurveBeam pedCAT will allow the college to improve the foot and ankle health of the community while providing the highest quality education for our students and research opportunities for our faculty and residents.”

The pedCAT is the only cone beam CT imaging system that allows for bilateral, weight bearing CT images of the foot & ankle. Due to its compact size and low radiation exposure, the pedCAT is an an ideal solution for CT imaging at the podiatric point-of-care. Recent articles in orthopedic journals demonstrate weight bearing CT imaging is a valuable research tool that is shedding new light on even our basic understanding of foot & ankle biomechanics and deformities.

“Our initial euphoria in acquiring the pedCAT weight-bearing cone beam CT has only been eclipsed by actually getting to use it first-hand,” said Dr. Lawrence Osher, Director of the Radiology Department. “Simply put, this is an utterly amazing tool in the podiatric diagnostic and research armamentarium.  The ability to do 3D and multi-planar reconstructions on a weight-bearing foot and ankle, coupled with the prospect of marrying structure and function, opens up a seemingly endless array of research opportunities.  Bounded only by our creativity, we at KSUCPM look forward to adding significantly to the pool of knowledge in the medical literature.”

The pedCAT was funded through a research grant from the Ohio College of Podiatric Medicine (OCPM) Foundation, which was established to promote podiatric medical education and research.

“Dean Boike is to be commended for his foresight in procuring this advanced apparatus which further enables the College to maintain and expand its competitive edge in podiatric medical education,” said Dr. David Nicolanti, Executive Director of the OCPM Foundation. “In addition, this weight bearing CT imaging system provides a basis for enhancing collaboration between the College and foot and ankle specialists, from all medical stratums throughout the state of Ohio and the encompassing region.”

The College has a number of weight bearing CT research initiatives planned.

The pedCAT is located at the Cleveland Foot and Ankle Clinic’s midtown office at 7000 Euclid Ave in Cleveland. Weight bearing CT services will be offered to the clinic’s patients.

Weight Bearing CT Sheds Light on Understanding of Rotational Dynamics in Syndesmosis

As the orthopaedic and podiatric specialties continue to advance, there is great potential for technology like CurveBeam’s pedCAT system to revolutionize care.

Recent research highlighted the importance of weight bearing scans to the understanding of foot and ankle anatomy, suggesting a role for pedCAT in both a research and clinical setting. “Rotational Dynamics of the Normal Distal Tibiofibular Joint with Weight-Bearing.

Computed Tomography” a 2016 study published in Volume 37 of
syndesmosisFoot & Ankle International sought to determine the normal range of motion for uninjured distal tibiofibular joints. Researchers hoped this reference would be useful as a comparison when assessing injured and repaired ankles.

Until recently, all measurements of this motion had been conducted on cadavers or through non-weight bearing scans. In contrast, this study used a weight-bearing CT (WBCT) system to survey the ankles of 32 subjects as they stood on one foot, then the other.

They found a “total movement of 1.5 mm and rotation of 3 degrees” in the syndesmosis as the average across subjects. However, the study also found that intersubject variation was extremely high, meaning different people had vastly different ranges of motion despite similar orthopaedic histories.

These differences were not correlated with sex or age. Intrasubject variation, or the difference in movement between a person’s right and left foot, was significantly smaller and more consistent, less than 1 mm on average.

The study therefore concluded “the contralateral ankle should be used as a reference when dynamic alignment of the distal tibiofibular joint is studied.”

In other words, surveying a person’s uninjured ankle will give a better idea of what is normal movement for that particular individual than comparing the injured ankle to a standardized range, like the one this study endeavored to produce.

CurveBeam’s pedCAT technology could have helped researchers eliminate possible errors in these findings. In the article, researchers admitted “it is possible that we were unable to optimize posture and rotation identically on both sides “ as a result of the limited field of view of the imaging equipment.

The device used in the study could only scan a partial foot in a scan. Test subjects had to stand on one foot, then twist and then switch and twist again. Researchers were unable to measure the force with which the subjects moved on each side.

The pedCAT’s field of view accommodates bilateral imaging, which would have allowed researchers to survey both weight bearing feet at the same time, providing helpful insights. The research indicates the importance of weight bearing measurements of a person’s right and left ankle to determine their normal range of motion.

Being able to accurately assess their syndesmosis on one side will help physicians more accurately assess and repair damages to the other.

CurveBeam’s pedCAT technology is the ideal imaging solution because it allows physicians to scan and survey ankles side-by-side for increased accuracy and ease.

CurveBeam and its technical solutions have the potential to revolutionize orthopaedic and podiatric research and care. Visit us at curvebeam.com to learn how pedCAT and other CurveBeam technologies can make a difference in your practice!

pedCAT Shown to be Most Effective Imaging Option for Mülller-Weiss Disease

The CurveBeam pedCAT imaging system was recently recommended as an incredibly beneficial option for the treatment and analysis of Mülller-Weiss disease. While the disease can be detected in its early stages with magnetic resonance imaging and radiographs, there is a considerable advantage to using weight-bearing computed tomography (WBCT) for diagnosis and evaluation.

Mülller-Weiss involves a painful deformity caused by osteonecrosisKöhler_I and fragmentation of the navicular, most commonly occurring in adults and disproportionately in female patients. The pedCAT, a cone beam CT imaging system, provides an opportunity for early diagnosis and better preoperative analysis, resulting in improved treatment. Standard computed tomography (CT) in itself beneficial for several reasons.

First, it allows for easier examination of the extent of the deformity and for evaluation of any surrounding arthritis. With CT data, surgeons can evaluate and plan for any future attempts at remedying the deformity.

However, because standard CT scans are not weight bearing, they do not provide an accurate view of the relationship between the hindfoot and midfoot deformity. pedCAT WBCT scans allow doctors to go one step further than standard CT scans.

pedCAT 3D datasets can be fully manipulated in order to provide an opportunity for in-depth analysis before proceeding with surgery on a complex deformity. In addition, the pedCAT provides for a better patient experience as the procedure only takes between 19 and 48 seconds, depending on the extent of the deformity.

Weight Bearing CT scan. (Top Left) straight subtalar alignment. (Top right) Anteroposterior view shows navicular bone stock. (Bottom left) Sagittal slice shows features of subtalar varus, superior talonavicular arthritis. (Bottom right) straight subtalar alignment. Source: Foot & Ankle Specialist.
Weight Bearing CT scan. (Top Left) straight subtalar alignment. (Top right) Anteroposterior view shows navicular bone stock. (Bottom left) Sagittal slice shows features of subtalar varus, superior talonavicular arthritis. (Bottom right) straight subtalar alignment. Source: Foot & Ankle Specialist.

The pedCAT also cuts down on radiation, with a low dose of 1.4 μSv, an amount that is not significantly higher than the 0.7 μSv dosage of the traditional three radiographs of a foot taken to identify Mülller-Weiss. Overall. the pedCAT allows for an accurate and thorough analysis that cannot be achieved through normal X-rays, MRIs nor bone scans.

When creating a treatment plan for Mülller-Weiss disease, the goal is to reestablish a balanced foot, which may require realignment surgery or surgery involving a structural graft.

Due to the complexity inherent in any attempt at treatment, pedCAT imaging is ideal, as it allows doctors to accurately gauge the amount of medial column shortening as well as determine the navicular bone stock and density.

Identifying these key details as accurately as possible is imperative for operations such as calcaneal osteotomy to properly restore alignment or repairing the medial column length.

muller weiss1
Weight bearing CT scan. (Top left) Subtle subtalar varus. (Top right) Anteroposterior view with increased cut thickness allows accurate determination of lateral navicular compression in weight bearing position. (Bottom left) Sagittal slice allows accurate determination of talonavicular and potential subtalar and naviculo-cuneiform arthritis. (Bottom right) Thus demonstrates amount of subtalar varus in weight bearing position. Source: Foot & Ankle Specialist

While a combination of weight bearing X-Ray and unloaded CT scanning are sometimes suggested as an alternative, the degree of the deformity caused by Mülller-Weiss will not be accurately represented.

It is only through WBCT scanning that a true picture of the dynamics within the foot will be understood. pedCAT is a compact and ultra low-dose system, which aims to make such 3D scanning possible for clinics.