{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,11,4]],"date-time":"2026-11-04T04:24:20Z","timestamp":1793766260491,"version":"4.6.1"},"reference-count":26,"publisher":"Wiley","issue":"4","license":[{"start":{"date-parts":[[2023,1,3]],"date-time":"2023-01-03T00:00:00Z","timestamp":1672704000000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2023,1,3]],"date-time":"2023-01-03T00:00:00Z","timestamp":1672704000000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2023,1,3]],"date-time":"2023-01-03T00:00:00Z","timestamp":1672704000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"name":"Universit\u00e4tsklinik M\u00fcnchen"}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Knee surg. sports traumatol. arthrosc."],"published-print":{"date-parts":[[2023,4]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Many radiographic lower limb alignment measurements are dependent on patients\u2019 position, which makes a standardised image acquisition of long\u2010leg radiographs (LLRs) essential for valid measurements. The purpose of this study was to investigate the influence of rotation and flexion of the lower limb on common radiological alignment parameters using three\u2010dimensional (3D) simulation.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>\n                      Joint angles and alignment parameters of 3D lower limb bone models (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u200960), generated from computed tomography (CT) scans, were assessed and projected into the coronal plane to mimic radiographic imaging. Bone models were subsequently rotated around the longitudinal mechanical axis up to 15\u00b0 inward\/outward and additionally flexed along the femoral intercondylar axis up to 30\u00b0. This resulted in 28 combinations of rotation and flexion for each leg. The results were statistically analysed on a descriptive level and using a linear mixed effects model.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      A total of 1680 simulations were performed. Mechanical axis deviation (MAD) revealed a medial deviation with increasing internal rotation and a lateral deviation with increasing external rotation. This effect increased significantly (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.05) with combined flexion up to 30\u00b0 flexion (\u2212\u200925.4\u00a0mm to 25.2\u00a0mm). With the knee extended, the mean deviation of hip\u2013knee\u2013ankle angle (HKA) was small over all rotational steps but increased toward more varus\/valgus when combined with flexion (8.4\u00b0 to\u2009\u2212\u20098.5\u00b0). Rotation alone changed the medial proximal tibial angle (MPTA) and the mechanical lateral distal femoral angle (mLDFA) in opposite directions, and the effects increased significantly (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.05) when flexion was present.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Axial rotation and flexion of the 3D lower limb has a huge impact on the projected two\u2010dimensional alignment measurements in the coronal plane. The observed effects were small for isolated rotation or flexion, but became pronounced and clinically relevant when there was a combination of both. This must be considered when evaluating X\u2010ray images. Extension deficits of the knee make LLR prone to error and this calls into question direct postoperative alignment controls.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Level of evidence<\/jats:title>\n                    <jats:p>III (retrospective cohort study).<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1007\/s00167-022-07302-x","type":"journal-article","created":{"date-parts":[[2023,1,3]],"date-time":"2023-01-03T04:03:07Z","timestamp":1672718587000},"page":"1483-1490","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":40,"title":["Significant changes in lower limb alignment due to flexion and rotation\u2014a systematic 3D simulation of radiographic measurements"],"prefix":"10.1002","volume":"31","author":[{"given":"Josef","family":"Brunner","sequence":"first","affiliation":[{"name":"<!--<label>1<\/label>--> Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital LMU Marchioninistr. 15 81377 Munich Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1877-7673","authenticated-orcid":false,"given":"Maximilian","family":"J\u00f6rgens","sequence":"additional","affiliation":[{"name":"<!--<label>1<\/label>--> Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital LMU Marchioninistr. 15 81377 Munich Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maximilian","family":"Weigert","sequence":"additional","affiliation":[{"name":"<!--<label>2<\/label>--> Statistical Consulting Unit StaBLab LMU Munich Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hannah","family":"K\u00fcmpel","sequence":"additional","affiliation":[{"name":"<!--<label>2<\/label>--> Statistical Consulting Unit StaBLab LMU Munich Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nikolaus","family":"Degen","sequence":"additional","affiliation":[{"name":"<!--<label>1<\/label>--> Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital LMU Marchioninistr. 15 81377 Munich Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Julian","family":"Fuermetz","sequence":"additional","affiliation":[{"name":"<!--<label>1<\/label>--> Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital LMU Marchioninistr. 15 81377 Munich Germany"},{"name":"<!--<label>3<\/label>--> Department of Trauma Surgery BG Unfallklinik Murnau Murnau Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2023,1,3]]},"reference":[{"key":"e_1_2_11_2_2","unstructured":"AhrendMD BaumgartnerH IhleC HistingT Schr\u00f6terS FingerFInfluence of 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October 2022","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"18 December 2022","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"3 January 2023","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"The authors received no financial or material support for the research, authorship, and\/or publication of this article.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Conflict of interest"}},{"value":"The study was part of the research approved by the Ethics Committee of the Ludwig-Maximilians-University of Munich (No. 17-044).","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethical approval"}},{"value":"All authors have read and approved the 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