Enhanced reliability and time efficiency of deep learning-based posterior tibial slope measurement over manual techniques
Shang-Yu Yao
Department of Orthopedic Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City, Taiwan
Search for more papers by this authorXue-Zhi Zhang
Engineering Product Development, Singapore University of Technology and Design, Tampines, Singapore
Search for more papers by this authorSoumyajit Podder
Department of Biomedical Engineering, Chang Gung University, Taoyuan City, Taiwan
Search for more papers by this authorChen-Te Wu
Department of Medical Imaging and Intervention, Linkou Chang Gung Memorial Hospital, Taoyuan City, Taiwan
Search for more papers by this authorYi-Shen Chan
Department of Orthopedic Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City, Taiwan
Comprehensive Sports Medicine Center, Taoyuan Chang Gung Memorial Hospital, Taoyuan City, Taiwan
Department of Orthopedic Surgery, Keelung Chang Gung Memorial Hospital, Keelung City, Taiwan
Search for more papers by this authorCorresponding Author
Dan Berco
Comprehensive Sports Medicine Center, Taoyuan Chang Gung Memorial Hospital, Taoyuan City, Taiwan
Department of Electronics Engineering and Program in Nano-Electronic Engineering and Design, Chang Gung University, Taoyuan City, Taiwan
Correspondence Cheng-Pang Yang, Department of Orthopedic Surgery, Linkou Chang Gung Memorial Hospital, No. 5, Fuxing St, Guishan, Taoyuan City 333, Taiwan.
Email: [email protected]
Dan Berco, Department of Electronics Engineering and Program in Nano-Electronic Engineering and Design, Chang Gung University, No. 259 Wenhua 1st Rd, Guishan, Taoyuan City 333, Taiwan.
Email: [email protected]
Search for more papers by this authorCorresponding Author
Cheng-Pang Yang
Department of Orthopedic Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City, Taiwan
Comprehensive Sports Medicine Center, Taoyuan Chang Gung Memorial Hospital, Taoyuan City, Taiwan
Correspondence Cheng-Pang Yang, Department of Orthopedic Surgery, Linkou Chang Gung Memorial Hospital, No. 5, Fuxing St, Guishan, Taoyuan City 333, Taiwan.
Email: [email protected]
Dan Berco, Department of Electronics Engineering and Program in Nano-Electronic Engineering and Design, Chang Gung University, No. 259 Wenhua 1st Rd, Guishan, Taoyuan City 333, Taiwan.
Email: [email protected]
Search for more papers by this authorShang-Yu Yao
Department of Orthopedic Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City, Taiwan
Search for more papers by this authorXue-Zhi Zhang
Engineering Product Development, Singapore University of Technology and Design, Tampines, Singapore
Search for more papers by this authorSoumyajit Podder
Department of Biomedical Engineering, Chang Gung University, Taoyuan City, Taiwan
Search for more papers by this authorChen-Te Wu
Department of Medical Imaging and Intervention, Linkou Chang Gung Memorial Hospital, Taoyuan City, Taiwan
Search for more papers by this authorYi-Shen Chan
Department of Orthopedic Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City, Taiwan
Comprehensive Sports Medicine Center, Taoyuan Chang Gung Memorial Hospital, Taoyuan City, Taiwan
Department of Orthopedic Surgery, Keelung Chang Gung Memorial Hospital, Keelung City, Taiwan
Search for more papers by this authorCorresponding Author
Dan Berco
Comprehensive Sports Medicine Center, Taoyuan Chang Gung Memorial Hospital, Taoyuan City, Taiwan
Department of Electronics Engineering and Program in Nano-Electronic Engineering and Design, Chang Gung University, Taoyuan City, Taiwan
Correspondence Cheng-Pang Yang, Department of Orthopedic Surgery, Linkou Chang Gung Memorial Hospital, No. 5, Fuxing St, Guishan, Taoyuan City 333, Taiwan.
Email: [email protected]
Dan Berco, Department of Electronics Engineering and Program in Nano-Electronic Engineering and Design, Chang Gung University, No. 259 Wenhua 1st Rd, Guishan, Taoyuan City 333, Taiwan.
Email: [email protected]
Search for more papers by this authorCorresponding Author
Cheng-Pang Yang
Department of Orthopedic Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City, Taiwan
Comprehensive Sports Medicine Center, Taoyuan Chang Gung Memorial Hospital, Taoyuan City, Taiwan
Correspondence Cheng-Pang Yang, Department of Orthopedic Surgery, Linkou Chang Gung Memorial Hospital, No. 5, Fuxing St, Guishan, Taoyuan City 333, Taiwan.
Email: [email protected]
Dan Berco, Department of Electronics Engineering and Program in Nano-Electronic Engineering and Design, Chang Gung University, No. 259 Wenhua 1st Rd, Guishan, Taoyuan City 333, Taiwan.
Email: [email protected]
Search for more papers by this authorShang-Yu Yao, Xue-Zhi Zhang, and Soumyajit Podder contributed equally to this study and as first authors.
Abstract
Purpose
Multifaceted factors contribute to inferior outcomes following anterior cruciate ligament (ACL) reconstruction surgery. A particular focus is placed on the posterior tibial slope (PTS). This study introduces the integration of machine learning and artificial intelligence (AI) for efficient measurements of tibial slopes on magnetic resonance imaging images as a promising solution. This advancement aims to enhance risk stratification, diagnostic insights, intervention prognosis and surgical planning for ACL injuries.
Methods
Images and demographic information from 120 patients who underwent ACL reconstruction surgery were used for this study. An AI-driven model was developed to measure the posterior lateral tibial slope using the YOLOv8 algorithm. The accuracy of the lateral tibial slope, medial tibial slope and tibial longitudinal axis measurements was assessed, and the results reached high levels of reliability. This study employed machine learning and AI techniques to provide objective, consistent and efficient measurements of tibial slopes on MR images.
Results
Three distinct models were developed to derive AI-based measurements. The study results revealed a substantial correlation between the measurements obtained from the AI models and those obtained by the orthopaedic surgeon across three parameters: lateral tibial slope, medial tibial slope and tibial longitudinal axis. Specifically, the Pearson correlation coefficients were 0.673, 0.850 and 0.839, respectively. The Spearman rank correlation coefficients were 0.736, 0.861 and 0.738, respectively. Additionally, the interclass correlation coefficients were 0.63, 0.84 and 0.84, respectively.
Conclusion
This study establishes that the deep learning-based method for measuring posterior tibial slopes strongly correlates with the evaluations of expert orthopaedic surgeons. The time efficiency and consistency of this technique suggest its utility in clinical practice, promising to enhance workflow, risk assessment and the customization of patient treatment plans.
Level of Evidence
Level III, cross-sectional diagnostic study.
CONFLICT OF INTEREST STATEMENT
The authors declare no conflict of interest.
Open Research
DATA AVAILABILITY STATEMENT
All relevant data required for training and testing of the AI model can be found at Open Science Framework (https://osf.io/5tazu/), following an embargo from the date of publication to allow for commercialization of research findings.
REFERENCES
- 1Ahmed, I., Salmon, L., Roe, J. & Pinczewski, L. (2017) The long-term clinical and radiological outcomes in patients who suffer recurrent injuries to the anterior cruciate ligament after reconstruction. The Bone & Joint Journal, 99-b, 337–343. Available from: https://doi.org/10.1302/0301-620X.99B3.37863
- 2Amerinatanzi, A., Summers, R.K., Ahmadi, K., Goel, V.K., Hewett, T.E. & Nyman, E. (2017) Automated measurement of patient-specific tibial slopes from MRI. Bioengineering (Basel), 4, 69. Available from: https://doi.org/10.3390/bioengineering4030069
- 3Amirtharaj, M.J., Hardy, B.M., Kent 3rd, R.N., Nawabi, D.H., Wickiewicz, T.L., Pearle, A.D. et al. (2018) Automated, accurate, and three-dimensional method for calculating sagittal slope of the tibial plateau. Journal of Biomechanics, 79, 212–217. Available from: https://doi.org/10.1016/j.jbiomech.2018.07.047
- 4Bayer, S., Meredith, S.J., Wilson, K.W., de Sa, D., Pauyo, T., Byrne, K. et al. (2020) Knee morphological risk factors for anterior cruciate ligament injury: a systematic review. Journal of Bone and Joint Surgery, 102, 703–718. Available from: https://doi.org/10.2106/JBJS.19.00535
10.2106/JBJS.19.00535 Google Scholar
- 5Beel, W., Schuster, P., Michalski, S., Mayer, P., Schlumberger, M., Hielscher, L. et al. (2023) High prevalence of increased posterior tibial slope in ACL revision surgery demands a patient-specific approach. Knee Surgery, Sports Traumatology, Arthroscopy, 31, 2974–2982. Available from: https://doi.org/10.1007/s00167-023-07313-2
- 6Boden, B.P., Sheehan, F.T., Torg, J.S. & Hewett, T.E. (2010) Noncontact anterior cruciate ligament injuries: mechanisms and risk factors. American Academy of Orthopaedic Surgeon, 18, 520–527. Available from: https://doi.org/10.5435/00124635-201009000-00003
- 7Brandon, M.L., Haynes, P.T., Bonamo, J.R., Flynn, M.I., Barrett, G.R. & Sherman, M.F. (2006) The association between posterior-inferior tibial slope and anterior cruciate ligament insufficiency. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 22, 894–899. Available from: https://doi.org/10.1016/j.arthro.2006.04.098
- 8Christensen, J.J., Krych, A.J., Engasser, W.M., Vanhees, M.K., Collins, M.S. & Dahm, D.L. (2015) Lateral tibial posterior slope is increased in patients with early graft failure after anterior cruciate ligament reconstruction. The American Journal of Sports Medicine, 43, 2510–2514. Available from: https://doi.org/10.1177/0363546515597664
- 9Dare, D.M., Fabricant, P.D., McCarthy, M.M., Rebolledo, B.J., Green, D.W., Cordasco, F.A. et al. (2015) Increased lateral tibial slope is a risk factor for pediatric anterior cruciate ligament injury: an MRI-based case-control study of 152 patients. The American Journal of Sports Medicine, 43, 1632–1639. Available from: https://doi.org/10.1177/0363546515579182
- 10Dejour, H. & Bonnin, M. (1994) Tibial translation after anterior cruciate ligament rupture. Two radiological tests compared. The Journal of Bone and Joint Surgery. British Volume, 76-B, 745–749. Available from: https://doi.org/10.1302/0301-620X.76B5.8083263
10.1302/0301-620X.76B5.8083263 Google Scholar
- 11Duerr, R., Ormseth, B., Adelstein, J., Garrone, A., DiBartola, A., Kaeding, C. et al. (2023) Elevated posterior tibial slope is associated with anterior cruciate ligament reconstruction failures: a systematic review and meta-analysis. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 39, 1299–1309.e6. Available from: https://doi.org/10.1016/j.arthro.2022.12.034
- 12Giffin, J.R., Vogrin, T.M., Zantop, T., Woo, S.L.Y. & Harner, C.D. (2004) Effects of increasing tibial slope on the biomechanics of the knee. The American Journal of Sports Medicine, 32, 376–382. Available from: https://doi.org/10.1177/0363546503258880
- 13Grassi, A., Macchiarola, L., Urrizola Barrientos, F., Zicaro, J.P., Costa Paz, M., Adravanti, P. et al. (2019) Steep posterior tibial slope, anterior tibial subluxation, deep posterior lateral femoral condyle, and meniscal deficiency are common findings in multiple anterior cruciate ligament failures: an MRI case-control study. The American Journal of Sports Medicine, 47, 285–295. Available from: https://doi.org/10.1177/0363546518823544
- 14Grassi, A., Signorelli, C., Urrizola, F., Macchiarola, L., Raggi, F., Mosca, M. et al. (2019) Patients with failed anterior cruciate ligament reconstruction have an increased posterior lateral tibial plateau slope: a case-controlled study. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 35, 1172–1182. Available from: https://doi.org/10.1016/j.arthro.2018.11.049
- 15Hashemi, J., Chandrashekar, N., Gill, B., Beynnon, B.D., Slauterbeck, J.R., Schutt Jr., R.C. et al. (2008) The geometry of the tibial plateau and its influence on the biomechanics of the tibiofemoral joint. The Journal of Bone and Joint Surgery-American Volume, 90, 2724–2734. Available from: https://doi.org/10.2106/JBJS.G.01358
- 16Hohmann, E., Tetsworth, K., Glatt, V., Ngcelwane, M. & Keough, N. (2021) Medial and lateral posterior tibial slope are independent risk factors for noncontact ACL injury in both men and women. Orthopaedic Journal of Sports Medicine, 9, 23259671211015940. Available from: https://doi.org/10.1177/23259671211015940
- 17Hudek, R., Schmutz, S., Regenfelder, F., Fuchs, B. & Koch, P.P. (2009) Novel measurement technique of the tibial slope on conventional MRI. Clinical Orthopaedics & Related Research, 467, 2066–2072. Available from: https://doi.org/10.1007/s11999-009-0711-3
- 18Kataoka, K., Nagai, K., Hoshino, Y., Shimabukuro, M., Nishida, K., Kanzaki, N. et al. (2022) Steeper lateral posterior tibial slope and greater lateral-medial slope asymmetry correlate with greater preoperative pivot-shift in anterior cruciate ligament injury. Journal of Experimental Orthopaedics, 9, 117. Available from: https://doi.org/10.1186/s40634-022-00556-x
- 19Liu, Z., Jiang, J., Yi, Q., Teng, Y., Liu, X., He, J. et al. (2022) An increased posterior tibial slope is associated with a higher risk of graft failure following ACL reconstruction: a systematic review. Knee Surgery, Sports Traumatology, Arthroscopy, 30, 2377–2387. Available from: https://doi.org/10.1007/s00167-022-06888-6
- 20Lu, Y., Pareek, A., Yang, L., Rouzrokh, P., Khosravi, B., Okoroha, K.R. et al. (2023) Deep learning artificial intelligence tool for automated radiographic determination of posterior tibial slope in patients with ACL injury. Orthopaedic Journal of Sports Medicine, 11, 23259671231215820. Available from: https://doi.org/10.1177/23259671231215820
- 21Mandalia, V., Bayley, M., Bhamber, N., Middleton, S. & Houston, J. (2023) Posterior tibial slope in anterior cruciate ligament surgery: a systematic review. Indian Journal of Orthopaedics, 57, 1376–1386. Available from: https://doi.org/10.1007/s43465-023-00947-x
- 22Meier, M.P., Hochrein, Y., Saul, D., Seitz, M.T., Klockner, F.S., Lehmann, W. et al. (2022) Morphological analysis of the tibial slope in 720 adult knee joints. Diagnostics (Basel, Switzerland), 12, 1346. Available from: https://doi.org/10.3390/diagnostics12061346
- 23Naendrup, J.H., Drouven, S.F., Shaikh, H.S., Jaecker, V., Offerhaus, C., Shafizadeh, S.T. et al. (2020) High variability of tibial slope measurement methods in daily clinical practice: comparisons between measurements on lateral radiograph, magnetic resonance imaging, and computed tomography. The Knee, 27, 923–929. Available from: https://doi.org/10.1016/j.knee.2020.01.013
- 24Narahashi, É., Guimarães, J.B., Filho, A.G.O., Nico, M.A.C. & Silva, F.D. (2024) Measurement of tibial slope using biplanar stereoradiography (EOS®). Skeletal Radiology, 53, 1091–1101. Available from: https://doi.org/10.1007/s00256-023-04528-9
- 25Petrigliano, F.A., Suero, E.M., Voos, J.E., Pearle, A.D. & Allen, A.A. (2012) The effect of proximal tibial slope on dynamic stability testing of the posterior cruciate ligament- and posterolateral corner-deficient knee. The American Journal of Sports Medicine, 40, 1322–1328. Available from: https://doi.org/10.1177/0363546512439180
- 26Rahnemai-Azar, A.A., Abebe, E.S., Johnson, P., Labrum, J., Fu, F.H., Irrgang, J.J. et al. (2017) Increased lateral tibial slope predicts high-grade rotatory knee laxity pre-operatively in ACL reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy, 25, 1170–1176. Available from: https://doi.org/10.1007/s00167-016-4157-3
- 27Shultz, S.J., Schmitz, R.J., Benjaminse, A., Collins, M., Ford, K. & Kulas, A.S. (2015) ACL Research retreat VII: An update on anterior cruciate ligament injury risk factor identification, screening, and prevention. Journal of Athletic Training, 50, 1076–1093. Available from: https://doi.org/10.4085/1062-6050-50.10.06
- 28Smith, H.C., Vacek, P., Johnson, R.J., Slauterbeck, J.R., Hashemi, J., Shultz, S. et al. (2012) Risk factors for anterior cruciate ligament injury: a review of the literature - part 1: neuromuscular and anatomic risk. Sports Health: A Multidisciplinary Approach, 4, 69–78. Available from: https://doi.org/10.1177/1941738111428281
- 29Tensho, K., Kumaki, D., Yoshida, K., Shimodaira, H., Horiuchi, H. & Takahashi, J. (2023) Does posterior tibial slope laterality exist? A matched cohort study between ACL-injured and non-injured knees. Journal of Experimental Orthopaedics, 10, 132. Available from: https://doi.org/10.1186/s40634-023-00702-z
- 30Todd, M.S., Lalliss, S., Garcia, E., DeBerardino, T.M. & Cameron, K.L. (2010) The relationship between posterior tibial slope and anterior cruciate ligament injuries. The American Journal of Sports Medicine, 38, 63–67. Available from: https://doi.org/10.1177/0363546509343198
- 31Tong, L., Xue, S., Chen, X. & Fang, R. (2023) Artificial intelligence-based detection of posterior tibial slope on X-ray images of unicompartmental knee arthroplasty patients. Journal of Radiation Research and Applied Sciences, 16, 100615. Available from: https://doi.org/10.1016/j.jrras.2023.100615
- 32Utzschneider, S., Goettinger, M., Weber, P., Horng, A., Glaser, C., Jansson, V. et al. (2011) Development and validation of a new method for the radiologic measurement of the tibial slope. Knee Surgery, Sports Traumatology, Arthroscopy, 19, 1643–1648. Available from: https://doi.org/10.1007/s00167-011-1414-3
- 33Wang, Y., Yang, T., Zeng, C., Wei, J., Xie, D., Yang, Y. et al. (2017) Association between tibial plateau slopes and anterior cruciate ligament injury: a meta-analysis. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 33, 1248–1259.e4. Available from: https://doi.org/10.1016/j.arthro.2017.01.015
- 34Wen, D., Bohlen, H. & Wang, D. (2023) Paper 24: reliability of posterior tibial slope measurement on magnetic resonance imaging versus computed tomography. Orthopaedic Journal of Sports Medicine, 11, 2325967123S2325900050. Available from: https://doi.org/10.1177/2325967123S00050
10.1177/2325967123S00050 Google Scholar
- 35Wordeman, S.C., Quatman, C.E., Kaeding, C.C. & Hewett, T.E. (2012) In vivo evidence for tibial plateau slope as a risk factor for anterior cruciate ligament injury: a systematic review and meta-analysis. The American Journal of Sports Medicine, 40, 1673–1681. Available from: https://doi.org/10.1177/0363546512442307
- 36Zeng, C., Cheng, L., Wei, J., Gao, S., Yang, T., Luo, W. et al. (2014) The influence of the tibial plateau slopes on injury of the anterior cruciate ligament: a meta-analysis. Knee Surgery, Sports Traumatology, Arthroscopy, 22, 53–65. Available from: https://doi.org/10.1007/s00167-012-2277-y
- 37Zhang Y., Chen Y., Qiang M., Zhang K., Li H., Jiang Y., et al. (2018) Comparison between three-dimensional CT and conventional radiography in proximal tibia morphology. Medicine 97, e11632. https://doi.org/10.1097/md.0000000000011632
