The Validity and Absolute Reliability of Lower Extremity Angle Values on Full-Leg Standing Radiographs Using the TraumaMeter Software

Featured Application TraumaMeter v.873 was designed to increase the accuracy of specific measurements at the spine level. The system meets the characteristics of open-source and modular functions and has been extended to perform angular measurements on lower extremity X-ray studies with high reliability.Abstract To establish classifications and to obtain pre- and post-operative information on patient-specific alignments, it is necessary to measure different angular values accurately and precisely, mainly on weight-bearing, full-length anteroposterior X-rays of the lower limbs (LLRs). This study evaluated angular measurements' validity and absolute reliability on LLRs with a self-developed, computer-aided measurement system (TraumaMeter v.873). Eight independent observers measured the preoperative mechanical hip-knee-ankle (mHKA) angle of 52 lower extremities (26 cases) in a blinded fashion on three occasions separated by two weeks. We obtained an intra-observer mean bias error (MBE) of 0.40 degrees, a standard deviation (SD) of 0.11 degrees, and a 95% confidence interval (CI) of 0.37 degrees-0.43 degrees. We also obtained an inter-observer MBE of 0.49 degrees, an SD of 0.15 degrees, and a 95% C of 0.45 degrees-0.53 degrees. The intra-observer MBE for the measurement pair between the second and the first measurement round (T2T1) was 0.43 degrees, the SD was 0.13 degrees, and the 95% CI was 0.39 degrees-0.47 degrees; the MBE between the third and the second round (T3T2) was 0.37 degrees, with an SD of 0.10 degrees and a 95% CI of 0.34 degrees-0.40 degrees; and the MBE between the third and the first round (T3T1) was 0.40 degrees, with an SD of 0.10 degrees and a 95% CI of 0.37 degrees-0.43 degrees. The interobserver MBE for the first round of measurements was 0.52 degrees, with an SD of 0.16 degrees and a 95% CI of 0.48 degrees-0.56 degrees; the MBE for the second round was 0.50 degrees, with an SD of 0.15 degrees and a 95% CI of 0.46 degrees-0.54 degrees; and the MBE for the third round was 0.46 degrees, with an SD of 0.14 degrees and a 95% CI of 0.42 degrees-0.50 degrees. There were no statistically significant differences in the inter-observer errors for the three tests. In the case of the intra-observer analysis, there were differences between T2T1 and between T3T2, but these differences were minimal, with no overlaps in the lower or upper values, respectively, of the confidence intervals. These results led us to conclude that the TraumaMeter v.873 software extension for measuring lower-limb angles in LLRs is an accurate tool with low intra- and inter-observer variability.