Metal artifact reduction MRI for total ankle replacement sagittal balance evaluation

Cesar de Cesar Netto, Lew C. Schon, Lucas Furtado da Fonseca, Apisan Chinanuvathana, Steven E. Stern, Jan Fritz

Research output: Contribution to journalArticlepeer-review

2 Scopus citations


Background: Restoration of anatomical relationship between talus and tibia is crucial for longevity of total ankle replacement (TAR). Weight-bearing (WB) radiographs are the standard for evaluating the sagittal balance alignment, but are prone to rotational misalignment and altered measurements. Metal artifact reduction sequence (MARS) MRI allows visualization of periprosthetic landmarks and alignment of the image plane to the true sagittal axis of the implant. The purpose of this study was to compare TAR sagittal balance measurements on MARS MRI and WB radiographs. Methods: Twenty-three subjects with TAR [10 men/13 women, age 60 (41–73) years; 13 (3–24) months post-op] underwent MARS MRI and standard lateral WB radiographs. Standardized MARS MR images were aligned to the sagittal talar component axis. Three observers performed sagittal balance alignment measurements twice in an independent, random and blinded fashion. Lateral Talar Station (LTS), tibial axis-to-talus (T-T) ratio and normalized tibial axis-to-lateral-process (T-L) distance were measured. Concordance correlation coefficients (CCC) and intraclass correlation coefficients (ICC) were used for statistical analysis. In addition, mixed effects linear models were employed to assess overall concordance of the two image types. Results: The intraobserver agreement was excellent for radiographic (CCC = 0.96) and MRI (CCC = 0.90–0.97) measurements. Interobserver agreements were good-to-excellent with overall slightly higher agreements for MRI (ICC = 0.78–0.94) than radiography (ICC = 0.78–0.90) measurements. The T-T ratios of radiographs and MRI showed a high degree of concordance, whereas LTS was significantly lower on MRI when compared with radiographs, and T-L distance showed notable disagreement between the two imaging types. Conclusion: Sagittal balance measurements performed on standardized weight-bearing radiographs and standardized MARS MRI demonstrate substantial correlation and similarity. Given its high intra and interobserver agreement, MARS MRI may be helpful for the evaluation of TAR sagittal balance. Level of evidence: Level II - Prospective Comparative Study.

Original languageEnglish (US)
Pages (from-to)739-747
Number of pages9
JournalFoot and Ankle Surgery
Issue number6
StatePublished - Dec 2019


  • MRI
  • Metal artifact reduction
  • Sagittal balance
  • Total ankle arthroplasty
  • Total ankle replacement

ASJC Scopus subject areas

  • Orthopedics and Sports Medicine


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