Intraoperative cone-beam CT for correction of periaxial malrotation of the femoral shaft: A surface-matching approach

Limb length, alignment and rotation can be difficult to determine in femoral shaft fractures. Shaft axis rotation is particularly difficult to assess intraoperatively. Femoral malpositioning can cause deformity, pain and secondary degenerative joint damage. The aim of this study is to develop an intraoperative method based on cone-beam computed tomography (CBCT) to guide alignment of femoral shaft fractures. We hypothesize that bone surface matching can predict malrotation even with severe comminution. A cadaveric femur was imaged at 16 femoral periaxial malrotations (-51.2° to 60.1°). The images were processed resulting in an unwrapped bone surface plot consisting of a pattern of ridges and valleys. Fracture gaps were simulated by removing midline CT slices. The gaps were reconstituted by extrapolating the existing proximal and distal fragments to the midline of the fracture. The two bone surfaces were then shifted to align bony features. Periaxial malrotation was accurately assessed using surface matching (r² =0.99, slope 1.0). The largest mean error was 2.20° and the average difference between repeated measurements was 0.49°. CBCT can provide intraoperative high-resolution images with a large field of view. This quality of imaging enables surface matching algorithms to be utilized even with large areas of comminution.