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Nomkhondorj O, Chun DI, Park KR, Cho J. Weightbearing Computed Tomography (WBCT) Analysis of Subtalar Joint Dynamics in Hindfoot Valgus Malalignment. J Clin Med 2025; 14:2587. [PMID: 40283418 PMCID: PMC12027791 DOI: 10.3390/jcm14082587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2025] [Revised: 04/04/2025] [Accepted: 04/07/2025] [Indexed: 04/29/2025] Open
Abstract
Background/Objectives: Hindfoot valgus malalignment, characterized by the lateral deviation of the calcaneus and medial tilting of the talus, disrupts hindfoot biomechanics and increases strain on subtalar joint. This study evaluates weightbearing and non-weightbearing imaging modalities to identify dynamic alignment changes and their diagnostic implications. This study aims to (1) quantify changes in subtalar joint parameters between non-weightbearing computed tomography (NWBCT) and weightbearing computed tomography (WBCT) in patients with hindfoot valgus; (2) evaluate correlations between WBCT and standard radiographic parameters; and (3) identify radiographic predictors of subtalar joint status during weightbearing. Methods: We reviewed 70 patients with confirmed hindfoot valgus malalignment (hindfoot valgus angle >5°), identified through radiographic measurements. Of these, 32 underwent both NWBCT and WBCT, while 38 underwent WBCT alone. Hindfoot alignment angle (HAA) and hindfoot alignment ratio (HAR) were measured on hindfoot alignment radiographs, while heel valgus angle (HVA), talocalcaneal distance (TCD), subtalar joint subluxation (SL) and calcaneofibular distance (CF) were assessed on CT. Results: WBCT revealed significant increases in HVA and SL (both, p < 0.001) and decreases in TCD and CF (p < 0.001 and p = 0.002, respectively) compared to NWBCT, reflecting dynamic subtalar joint changes under weightbearing conditions. Receiver operating characteristic (ROC) analysis identified hindfoot alignment angle (HAA) as the most reliable predictor of talocalcaneal osseous contact, with a cutoff value of >9.25° based on Youden's index, yielding a sensitivity of 73% and specificity of 81.8%. Inter- and intra-observer reliabilities for all parameters were excellent (ICC > 0.81). Conclusions: WBCT provides critical insights into subtalar joint dynamics under physiological loads, surpassing NWBCT in assessing weightbearing-induced alignment changes. Although standard radiographic parameters, particularly HAA, can serve as reliable, cost-effective predictors of subtalar joint pathology in resource-limited settings, WBCT should still be preferred when available, especially in patients with significant malalignment or when detailed dynamic evaluation is needed to guide clinical decision-making.
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Affiliation(s)
- Otgonsaikhan Nomkhondorj
- Department of and Biomedical Science, Graduate School of Medicine, Hallym University, Chuncheon 24252, Republic of Korea;
- Department of Orthopaedic Surgery, Chuncheon Sacred Heart Hospital, Hallym University, Chuncheon 24252, Republic of Korea
| | - Dong-Il Chun
- Department of Orthopaedic Surgery, Soonchunhyang University Seoul Hospital, Seoul 04401, Republic of Korea;
| | - Kwang-Rak Park
- Department of Anatomy, College of Korean Medicine, Sangji University, Wonju 26339, Republic of Korea;
| | - Jaeho Cho
- Department of Orthopaedic Surgery, Chuncheon Sacred Heart Hospital, Hallym University, Chuncheon 24252, Republic of Korea
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Juric D, Donners R, Harder D, Burssens A, Nüesch C, Krähenbühl N. Integrating weightbearing CT findings into evaluation of conventional radiographs in progressive collapsing foot deformity. Foot Ankle Surg 2025; 31:273-277. [PMID: 39551641 DOI: 10.1016/j.fas.2024.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 09/28/2024] [Accepted: 11/04/2024] [Indexed: 11/19/2024]
Abstract
BACKGROUND Progressive collapsing foot deformity (PCFD) remains challenging to treat. Surgical planning depends on the amount and complexity of the deformity, which requires accurate differentiation through precise imaging. Weightbearing CT (WBCT) imaging has enhanced the three-dimensional (3D) assessment of PCFD. However, it remains unclear how PCFD findings on WBCT are related to the evaluation of conventional weightbearing radiographs. Therefore, we aimed to (1) compare specific X-ray measurements to corresponding WBCT measurements; (2) evaluate the reliability of X-ray measurements of interest; and (3) investigate whether X-ray measurements can infer osseous impingement in the subtalar joint region identified through WBCT. METHODS Two clinically established measurements were assessed on standardized weightbearing radiographs (manually) as well as on the WBCT datasets (auto-generated): (1) talo-calcaneal overlap (TCO, mm) and (2) talo-navicular coverage (TNC, °). In addition to the measurements, osseous impingement in the subtalar joint region was assessed on WBCT using three criteria, compared both inter- and intra-rater: (1) joint obliteration; (2) cyst formation; and (3) signs of secondary instability. Two of the criteria needed to be fulfilled to confirm subtalar impingement. RESULTS While no significant difference between X-ray and WBCT measurements was evident for TCO, significant differences were found for TNC. Inter- and intra-observer reliability was with an intraclass correlation coefficient > 0.9 excellent for both measurements on X-rays. The mean bias of measurement (between X-ray and WBCT) was 0.2 mm for TCO and -22 degrees for TNC. Cohen's Kappa for inter- and intra-rater reliability to assess patients for subtalar instability was > 0.9. The probability to infer subtalar impingement was ≥ 0.85 if TCO was > 15 mm or TNC was > 25 degrees on X-ray. CONCLUSION The examined imaging parameters are reliably assessable through conventional radiographs (TCO/TNC) or WBCT (osseous subtalar impingement). In situations where WBCT is unavailable, X-ray-assessed TCO and TNC can serve as predictors for osseous sinus tarsi impingement. This finding plays a pivotal role in evaluating PCFD patients, aiding in the surgical decision-making process between joint-preserving interventions (e.g., osteotomies) and joint-sacrificing procedures (e.g., realignment fusion). LEVEL OF EVIDENCE Level IV, observational study.
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Affiliation(s)
- Doria Juric
- Department of Orthopaedics, University Hospital Basel, Spitalstrasse 21, Basel 4031, Switzerland
| | - Ricardo Donners
- Department of Radiology and Nuclear Medicine, University Hospital Basel, Spitalstrasse 21, Basel 4031, Switzerland
| | - Dorothee Harder
- Department of Radiology and Nuclear Medicine, University Hospital Basel, Spitalstrasse 21, Basel 4031, Switzerland
| | - Arne Burssens
- Department of Orthopaedics, University Hospital Ghent, Corneel Heymanslaan 10, Gent 9000, Belgium
| | - Corina Nüesch
- Department of Orthopaedics, University Hospital Basel, Spitalstrasse 21, Basel 4031, Switzerland; Department of Spine Surgery, University Hospital Basel, Spitalstrasse 21, Basel 4031, Switzerland; Department of Biomedical Engineering, University of Basel, Hegenheimermattweg 167B/C, Allschwil 4123, Switzerland
| | - Nicola Krähenbühl
- Department of Orthopaedics, University Hospital Basel, Spitalstrasse 21, Basel 4031, Switzerland.
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Chun DI, Cho J, Won SH, Nomkhondorj O, Kim J, An CY, Yi Y. Weight-Bearing CT: Advancing the Diagnosis and Treatment of Hallux Valgus, Midfoot Pathology, and Progressive Collapsing Foot Deformity. Diagnostics (Basel) 2025; 15:343. [PMID: 39941273 PMCID: PMC11817285 DOI: 10.3390/diagnostics15030343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2024] [Revised: 01/05/2025] [Accepted: 01/27/2025] [Indexed: 02/16/2025] Open
Abstract
Since its introduction, weight-bearing computed tomography (WBCT) has gained prominence due to its ability to produce accurate three-dimensional images under natural loading conditions, making it particularly useful for assessing complex foot deformities. This review aimed to focus on the diseases of the foot and categorized the pathological conditions into forefoot disease (hallux valgus), midfoot disease (Lisfranc injuries and midfoot osteoarthritis), and progressive collapsing foot deformity. For each category, the authors detail how WBCT enhances diagnostic accuracy and informs treatment strategies. In hallux valgus, WBCT allows for more precise measurement of established parameters and reveals crucial information about metatarsal pronation and ray instability. For midfoot pathologies, WBCT's superiority in detecting subtle Lisfranc injuries and characterizing midfoot osteoarthritis is emphasized, highlighting the development of novel measurement techniques. The review extensively covers the application of WBCT in assessing the complex three-dimensional features of PCFD, including hindfoot valgus, midfoot/forefoot abduction, medial column instability, peritalar subluxation, and valgus tilting, presenting several WBCT-specific measurements and the use of distance mapping to quantify joint surface interaction. The authors conclude that WBCT, potentially enhanced through integration with artificial intelligence (AI), represents a significant advancement in foot and ankle care, promising improved diagnostic accuracy, streamlined treatment planning, and, ultimately, better patient outcomes.
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Affiliation(s)
- Dong-Il Chun
- Department of Orthopaedic Surgery, Soonchunhyang University Seoul Hospital, 59, Daesagwan-ro, Yongsan-gu, Seoul 04401, Republic of Korea; (D.-I.C.); (S.H.W.); (C.Y.A.)
| | - Jaeho Cho
- Department of Orthopaedic Surgery, Chuncheon Sacred Heart Hospital, Hallym University, 77, Sakju-ro, Chuncheon-si 24253, Republic of Korea;
| | - Sung Hun Won
- Department of Orthopaedic Surgery, Soonchunhyang University Seoul Hospital, 59, Daesagwan-ro, Yongsan-gu, Seoul 04401, Republic of Korea; (D.-I.C.); (S.H.W.); (C.Y.A.)
| | - Otgonsaikhan Nomkhondorj
- Institute for Skeletal Aging and Orthopedic Surgery, Chuncheon Sacred Heart Hospital, Hallym University, 77, Sakju-ro, Chuncheon-si 24253, Republic of Korea;
| | - Jahyung Kim
- Department of Orthopaedic Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Republic of Korea;
| | - Chi Young An
- Department of Orthopaedic Surgery, Soonchunhyang University Seoul Hospital, 59, Daesagwan-ro, Yongsan-gu, Seoul 04401, Republic of Korea; (D.-I.C.); (S.H.W.); (C.Y.A.)
| | - Young Yi
- Department of Orthopaedic Surgery, Sanggye Paik Hospital, Inje University College of Medicine, Seoul 01757, Republic of Korea
- Department of Orthopaedic Surgery and Rehabilitation, Yale School of Medicine, New Haven, CT 06510, USA
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Reddy SC, Netto CDC. Survey of Utilization of Weightbearing Computed Tomography Within AOFAS Membership. Foot Ankle Spec 2024:19386400241297605. [PMID: 39673471 DOI: 10.1177/19386400241297605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2024]
Abstract
BACKGROUND Weightbearing computed tomography (WBCT) has been increasingly employed to evaluate and treat patients with varied pathologies such as progressive collapsing foot deformity (PCFD), posttraumatic deformity, hallux valgus, ankle arthritis, Charcot arthropathy, lisfranc, and syndesmosis injuries. However, little is known regarding its overall availability to foot and ankle providers and how it is being used in clinical practice. The goal of this study is to assess the utilization of WBCT among AOFAS members, identify the indications for use in clinical practice and potential barriers for implementation. METHODS A survey was emailed to AOFAS members inquiring about the use WBCT in clinical practice. Practice and demographic information were also collected. A total of 220 responses were collected over a 2-month period. Respondents were queried with respect to the availability of WBCT in practice, indications for use, frequency of use, ownership of the scanner, and barriers to implementation. RESULTS 58% of respondents did not have access to WBCT. Most respondents were in practice 10 years or more (69%). Single-specialty private practice was the most common practice type (39%). Of those with access to WBCT, 5 or fewer scans were ordered per week (57% of respondents). Evaluation of hindfoot/ankle deformity was the most common indication (69% of respondents) with it being used as a preoperative evaluation tool approximately 25% of the time (57% of respondents). Radiology department owned WBCT in most institutions (34%). 75% of respondents with WBCT use it postoperatively less than 25% of the time. Of those without WBCT, 94% stated they would like to have it with cost being the most significant barrier to implementation. CONCLUSION Most respondents surveyed did not have access to WBCT, with cost being the greatest barrier. However, 94% of those without it would like to have access to it. For those with access, it is used 5 or fewer times per week with evaluation of hindfoot/ankle deformity being the most common indication. LEVEL OF EVIDENCE Level IV (Observational Study).
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Affiliation(s)
- Sudheer C Reddy
- Shady Grove Orthopaedics, Adventist HealthCare, Rockville, Maryland
| | - Cesar de Cesar Netto
- Division of Orthopedic Foot and Ankle Surgery, Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
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DiGiovanni GM, El Masry S, Jones A, Kim J, Deland JT, Ellis SJ, Conti MS. Change in Talar Axial Rotation and Pain Intensity Following Correction of Progressive Collapsing Foot Deformity. Foot Ankle Int 2024; 45:1222-1230. [PMID: 39351892 DOI: 10.1177/10711007241278940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/03/2024]
Abstract
BACKGROUND The talus is more internally rotated within the ankle mortise in progressive collapsing foot deformity (PCFD) patients. However, no studies have investigated the change in talar axial rotation (AR) in PCFD postoperatively. The primary aim was to investigate the change in talar AR following PCFD reconstruction. Secondary aims were to determine whether talar AR changes were associated with other radiographic measurements or specific procedures, and whether postoperative talar AR was associated with 2-year patient-reported outcome scores. METHODS Twenty-seven patients older than 18 years who underwent flexible PCFD reconstruction with preoperative and at least 5-month postoperative weightbearing computed tomographic (WBCT) scans and radiographs and had preoperative and at least 2-year postoperative PROMIS scores were included. Patients with talonavicular fusions were excluded. Talar AR was the angle between the transmalleolar axis and talar axis on WBCT scans, with smaller angles representing more internal rotation as described by Kim et al. Hindfoot moment arm, Meary angle, fibulocalcaneal and talocalcaneal distance, subtalar middle facet uncoverage, and talonavicular angle were measured on radiographs. RESULTS Postoperative talar AR was 49.7 degrees (IQR, 45.9, 57.3), which was more externally rotated than preoperative AR by a median of 8.3 degrees (IQR, 2.2, 15.7) (P > .001). The change in talar AR was not associated with changes in any radiographic parameter. Increasing external talar AR was associated with an increase in postoperative PROMIS pain intensity (rs = 0.38, 95% CI 0.00, 0.67). Lateral column lengthening and subtalar fusion procedures were not associated with changes in talar AR (P > .10). CONCLUSION PCFD reconstruction results in external rotation of the talus within the ankle mortise. Kim et al found that control patients had approximately 40 to 60 degrees of talar AR, which is similar to this study's corrected position of the talus. However, increasing talar external rotation resulted in worse postoperative PROMIS pain intensity, suggesting the possibility of overcorrecting the internal AR deformity.
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Affiliation(s)
- Grace M DiGiovanni
- Department of Foot and Ankle Surgery, The Hospital for Special Surgery, New York, NY, USA
| | - Seif El Masry
- Department of Foot and Ankle Surgery, The Hospital for Special Surgery, New York, NY, USA
| | - Agnes Jones
- Department of Foot and Ankle Surgery, The Hospital for Special Surgery, New York, NY, USA
| | - Jaeyoung Kim
- Foot and Ankle Division, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Jonathan T Deland
- Department of Foot and Ankle Surgery, The Hospital for Special Surgery, New York, NY, USA
| | - Scott J Ellis
- Department of Foot and Ankle Surgery, The Hospital for Special Surgery, New York, NY, USA
| | - Matthew S Conti
- Department of Foot and Ankle Surgery, The Hospital for Special Surgery, New York, NY, USA
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Kim J, Ellis S, Carrino JA. Weight-Bearing Computed Tomography of the Foot and Ankle-What to Measure? Clin Podiatr Med Surg 2024; 41:775-796. [PMID: 39237184 DOI: 10.1016/j.cpm.2024.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/07/2024]
Abstract
Weight-bearing computed tomography (WBCT) was introduced in 2012 for foot and ankle applications as a breakthrough technology that enables full weight-bearing, three-dimensional imaging unaffected by x-ray beam projections or foot orientation. The literature describing the use of WBCT in the treatment of foot and ankle disorders is growing, and this article provides an overview of what can be measured with WBCT.
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Affiliation(s)
- Jaeyoung Kim
- Foot and Ankle Service, Hospital for Special Surgery, 532 East 72nd Street, New York, NY, USA
| | - Scott Ellis
- Foot and Ankle Service, Hospital for Special Surgery, 532 East 72nd Street, New York, NY, USA
| | - John A Carrino
- Department of Radiology, Hospital for Special Surgery, 535 East 70th Street, New York, NY, USA.
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Bernasconi A, Dechir Y, Izzo A, D’Agostino M, Magliulo P, Smeraglia F, de Cesar Netto C, International Weightbearing CT Society, Lintz F. Trends in the Use of Weightbearing Computed Tomography. J Clin Med 2024; 13:5519. [PMID: 39337007 PMCID: PMC11432607 DOI: 10.3390/jcm13185519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2024] [Revised: 09/10/2024] [Accepted: 09/12/2024] [Indexed: 09/30/2024] Open
Abstract
Background: This review aimed to critically appraise the most recent orthopedic literature around cone beam weightbearing computed tomography (WBCT), summarizing what evidence has been provided so far and identifying the main research trends in the area. Methods: This scoping review was performed on studies published between January 2013 and December 2023 on the Pubmed database. All studies (both clinical and nonclinical) in which WBCT had been used were critically analyzed to extract the aim (or aims) of the study, and the main findings related to the role of this imaging modality in the diagnostic pathway. Results: Out of 1759 studies, 129 were selected. One hundred five manuscripts (81%) dealt with elective orthopedic conditions. The majority of the analyses (88 studies; 84%) were performed on foot and ankle conditions, while 13 (12%) studies looked at knee pathologies. There was a progressive increase in the number of studies published over the years. Progressive Collapsing Foot Deformity (22 studies; 25%) and Hallux Valgus (19 studies; 21%) were frequent subjects. Twenty-four (19%) manuscripts dealt with traumatic conditions. A particular interest in syndesmotic injuries was documented (12 studies; 60%). Conclusions: In this review, we documented an increasing interest in clinical applications of weightbearing CT in the orthopedic field between 2013 and 2023. The majority of the analyses focused on conditions related to the foot and the ankle; however, we found several works investigating the value of WBCT on other joints (in particular, the knee).
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Affiliation(s)
- Alessio Bernasconi
- Trauma and Orthopaedics Unit, Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (A.I.); (M.D.); (P.M.); (F.S.)
| | - Yanis Dechir
- Department of Orthopaedic and Trauma Surgery, Centre Hospitalier Universitaire (CHU) de Toulouse, 31300 Toulouse, France;
| | - Antonio Izzo
- Trauma and Orthopaedics Unit, Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (A.I.); (M.D.); (P.M.); (F.S.)
| | - Martina D’Agostino
- Trauma and Orthopaedics Unit, Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (A.I.); (M.D.); (P.M.); (F.S.)
| | - Paolo Magliulo
- Trauma and Orthopaedics Unit, Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (A.I.); (M.D.); (P.M.); (F.S.)
| | - Francesco Smeraglia
- Trauma and Orthopaedics Unit, Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (A.I.); (M.D.); (P.M.); (F.S.)
| | | | | | - François Lintz
- Department of Foot and Ankle Surgery, Ramsay Healthcare, Clinique de l’Union, 31240 Saint Jean, France;
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Cai Y, Zhao Z, Huang J, Yu Z, Jiang M, Kang S, Yuan X, Liu Y, Wu X, Ouyang J, Li W, Qian L. Morphological changes in flatfoot: a 3D analysis using weight-bearing CT scans. BMC Med Imaging 2024; 24:219. [PMID: 39160476 PMCID: PMC11331803 DOI: 10.1186/s12880-024-01396-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 08/07/2024] [Indexed: 08/21/2024] Open
Abstract
BACKGROUND Flatfoot is a condition resulting from complex three-dimensional (3D) morphological changes. Most Previous studies have been constrained by using two-dimensional radiographs and non-weight-bearing conditions. The deformity in flatfoot is associated with the 3D morphology of the bone. These morphological changes affect the force line conduction of the hindfoot/midfoot/forefoot, leading to further morphological alterations. Given that a two-dimensional plane axis overlooks the 3D structural information, it is essential to measure the 3D model of the entire foot in conjunction with the definition under the standing position. This study aims to analyze the morphological changes in flatfoot using 3D measurements from weight-bearing CT (WBCT). METHOD In this retrospective comparative our CT database was searched between 4-2021 and 3-2022. Following inclusion criteria were used: Patients were required to exhibit clinical symptoms suggestive of flatfoot, including painful swelling of the medial plantar area or abnormal gait, corroborated by clinical examination and confirmatory radiological findings on CT or MRI. Healthy participants were required to be free of any foot diseases or conditions affecting lower limb movement. After applying the exclusion criteria (Flatfoot with other foot diseases), CT scans (mean age = 20.9375, SD = 16.1) confirmed eligible for further analysis. The distance, angle in sagittal/transverse/coronal planes, and volume of the two groups were compared on reconstructed 3D models using the t-test. Logistic regression was used to identify flatfoot risk factors, which were then analyzed using receiver operating characteristic curves and nomogram. RESULT The flatfoot group exhibited significantly lower values for calcaneofibular distance (p = 0.001), sagittal and transverse calcaneal inclination angle (p < 0.001), medial column height (p < 0.001), sagittal talonavicular coverage angle (p < 0.001), and sagittal (p < 0.001) and transverse (p = 0.015) Hibb angle. In contrast, the sagittal lateral talocalcaneal angle (p = 0.013), sagittal (p < 0.001) and transverse (p = 0.004) talocalcaneal angle, transverse talonavicular coverage angle (p < 0.001), coronal Hibb angle (p < 0.001), and sagittal (p < 0.001) and transverse (p = 0.001) Meary's angle were significantly higher in the flatfoot group. The sagittal Hibb angle (B = - 0.379, OR = 0.684) and medial column height (B = - 0.990, OR = 0.372) were identified as significant risk factors for acquiring a flatfoot. CONCLUSION The findings validate the 3D spatial position alterations in flatfoot. These include the abduction of the forefoot and prolapse of the first metatarsal proximal, the arch collapsed, subluxation of the talonavicular joint in the midfoot, adduction and valgus of the calcaneus, adduction and plantar ward movement of the talus in the hindfoot, along with the first metatarsal's abduction and dorsiflexion in the forefoot.
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Affiliation(s)
- Yuchun Cai
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, Guangdong, China
| | - Zhe Zhao
- Hand and Foot Surgery Department, The First Affiliated Hospital of Shenzhen University, Shenzhen Second People's Hospital, Shenzhen, Guangdong, 518035, People's Republic of China
| | - Jianzhang Huang
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, Guangdong, China
| | - Zhendong Yu
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, Guangdong, China
| | - Manqi Jiang
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, Guangdong, China
| | - Shengjie Kang
- School of Basic Medical Sciences, Southern Medical University, Guangzhou, Guangdong, China
| | - Xinghong Yuan
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, Guangdong, China
| | - Yingying Liu
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, Guangdong, China
| | - Xiaoliu Wu
- Radiologic Department, The First Affiliated Hospital of Shenzhen University, Shenzhen Second People's Hospital, Shenzhen, Guangdong, 518035, People's Republic of China
| | - Jun Ouyang
- Guangdong Provincial Key Laboratory of Digital Medicine and Biomechanics and Guangdong Engineering Research Center for Translation of Medical 3D Printing Application and National Virtual and Reality Experimental Education Center for Medical Morphology (Southern Medical University) and National Experimental Education Demonstration Center for Basic Medical Sciences (Southern Medical University) and National Key Discipline of Human Anatomy, Department of Spine Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), School of Basic Medical Sciences, Southern Medical University, Guangzhou, Guangdong, China.
| | - Wencui Li
- Hand and Foot Surgery Department, The First Affiliated Hospital of Shenzhen University, Shenzhen Second People's Hospital, Shenzhen, Guangdong, 518035, People's Republic of China.
| | - Lei Qian
- Guangdong Provincial Key Laboratory of Digital Medicine and Biomechanics and Guangdong Engineering Research Center for Translation of Medical 3D Printing Application and National Virtual & Reality Experimental Education Center for Medical Morphology (Southern Medical University) and National Experimental Education Demonstration Center for Basic Medical Sciences (Southern Medical University) and National Key Discipline of Human Anatomy., School of Basic Medical Sciences, Southern Medical University, Guangzhou, Guangdong, China.
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Andres L, Donners R, Harder D, Burssens A, Nüesch C, Krähenbühl N. Association Between Weightbearing CT and MRI Findings in Progressive Collapsing Foot Deformity. Foot Ankle Int 2024; 45:526-534. [PMID: 38419185 PMCID: PMC11083736 DOI: 10.1177/10711007241231221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
BACKGROUND Weightbearing computed tomography (WBCT) scans allow for a better understanding of foot alignment in patients suffering from progressive collapsing foot deformity (PCFD). However, soft tissue integrity (eg, spring ligament complex or tibialis posterior tendon) cannot be easily assessed via WBCT. As performing both WBCT and magnetic resonance imaging (MRI) might not be cost effective, we aimed to assess whether there is an association between osseous and soft tissue findings in WBCT and MRI. METHODS In this observational study, a consecutive cohort of 24 patients of various stages of PCFD (mean age 51 ± 18 years) underwent WBCT scans and MRI. Twenty-four healthy individuals of similar age, body mass index (BMI), and sex with WBCT scans were used as a control group. In addition to of osseous sinus tarsi impingement, 4 commonly used 3-dimensional (3D) measurements (talocalcaneal overlap [TCO], talonavicular coverage [TNC], Meary angle [MA], axial/lateral) were obtained using a dedicated postprocessing software (DISIOR 2.1, Finland) on the WBCT data sets. Sinus tarsi obliteration, spring ligament complex, tibiospring ligament integrity, as well as tibialis posterior tendon degeneration were evaluated with MRI. Statistical analysis was performed for significant (P < .05) correlation between findings. RESULTS None of the assessed 3D measurements correlated with either spring ligament complex or tibiospring ligament tears. BMI and TCO were found to be associated with tibialis posterior tendon tears. Seventy-five percent of patients with osseous sinus tarsi impingement on WBCT also showed signs of sinus tarsi obliteration on MRI. CONCLUSION Although WBCT reflects foot alignment and can reveal osseous sinus tarsi impingement in PCFD patients, the association between WBCT-based 3D measurements and ligament or tendon tears assessed via MRI is limited. WBCT appears complimentary to MRI regarding its diagnostic value. Both imaging options add important information and may impact decision making in the treatment of PCFD patients. LEVEL OF EVIDENCE Level IV, observational study.
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Affiliation(s)
- Lynn Andres
- Department of Orthopaedics, University Hospital Basel, Basel, Switzerland
| | - Ricardo Donners
- Department of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Dorothee Harder
- Department of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Arne Burssens
- Department of Orthopaedics, University Hospital Ghent, Gent, Belgium
| | - Corina Nüesch
- Department of Orthopaedics, University Hospital Basel, Basel, Switzerland
| | - Nicola Krähenbühl
- Department of Orthopaedics, University Hospital Basel, Basel, Switzerland
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Li J, Fang M, Van Oevelen A, Peiffer M, Audenaert E, Burssens A. Diagnostic applications and benefits of weightbearing CT in the foot and ankle: A systematic review of clinical studies. Foot Ankle Surg 2024; 30:7-20. [PMID: 37704542 DOI: 10.1016/j.fas.2023.09.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 08/16/2023] [Accepted: 09/01/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Foot and ankle weightbearing CT (WBCT) imaging has emerged over the past decade. However, a systematic review of diagnostic applications has not been conducted so far. METHOD A systematic literature search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines after Prospective Register of Systematic Reviews (PROSPERO) registration. Studies analyzing diagnostic applications of WBCT were included. Main exclusion criteria were: cadaveric specimens and simulated WBCT. The Methodological Index for Non-Randomized Studies (MINORS) was used for quality assessment. RESULTS A total of 78 studies were eligible for review. Diagnostic applications were identified in following anatomical area's: ankle (n = 14); hindfoot (n = 41); midfoot (n = 4); forefoot (n = 19). Diagnostic applications that could not be used on weightbearing radiographs (WBRX) were reported in 56/78 studies. The mean MINORS was 9.8/24 (range: 8-12). CONCLUSION Diagnostic applications of WBCT were most frequent in the hindfoot, but other areas are on the rise. Post-processing of images was the main benefit compared to WBRX based on a moderate quality of the identified studies.
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Affiliation(s)
- Jing Li
- Department of Orthopaedics, Ghent University Hospital, Ghent, Belgium
| | - Mengze Fang
- Department of Orthopaedics, Ghent University Hospital, Ghent, Belgium
| | - Aline Van Oevelen
- Department of Orthopaedics, Ghent University Hospital, Ghent, Belgium
| | - Matthias Peiffer
- Department of Orthopaedics, Ghent University Hospital, Ghent, Belgium
| | | | - Arne Burssens
- Department of Orthopaedics, Ghent University Hospital, Ghent, Belgium.
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Abstract
Weight-bearing computed tomography (WBCT) was introduced in 2012 for foot and ankle applications as a breakthrough technology that enables full weight-bearing, three-dimensional imaging unaffected by x-ray beam projections or foot orientation. The literature describing the use of WBCT in the treatment of foot and ankle disorders is growing, and this article provides an overview of what can be measured with WBCT.
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Affiliation(s)
- Jaeyoung Kim
- Foot and Ankle Service, Hospital for Special Surgery, 532 East 72nd Street, New York, NY, USA
| | - Scott Ellis
- Foot and Ankle Service, Hospital for Special Surgery, 532 East 72nd Street, New York, NY, USA
| | - John A Carrino
- Department of Radiology, Hospital for Special Surgery, 535 East 70th Street, New York, NY, USA.
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12
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Chien BY, Greisberg JK, Arciero E. Spring Ligament Reconstruction for Progressive Collapsing Foot Deformity: Contemporary Review. Foot Ankle Int 2023; 44:796-809. [PMID: 37341112 DOI: 10.1177/10711007231178538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
The spring ligament is one of the main stabilizers of the medial arch of the foot and the primary static supporter of the talonavicular joint. Attenuation or rupture of this ligament is thought to play a central role in the pathophysiology of progressive collapsing foot deformity. Traditional correction of flexible flatfoot consists of posterior tibial tendon augmentation along with various osteotomies or hindfoot fusions. Repair or reconstruction of the spring ligament has not been as widely pursued. In recent years, newer techniques have been explored and may improve outcomes of traditional procedures, or possibly entirely replace some osteotomies. Combined spring-deltoid ligament reconstruction is also gaining traction as a viable technique, particularly as the ankle begins to deform into valgus. This review summarizes the variety of nonanatomic and anatomic reconstruction techniques that have been described, including autologous tendon transfers, allografts, and synthetic augmentation. Although many have only been characterized in biomechanical cadaver studies, this article reviews preliminary clinical studies that have shown promising results. There is a need for more high-quality studies evaluating the clinical, radiographic, and patient-reported outcomes following spring ligament reconstruction.
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Affiliation(s)
- Bonnie Y Chien
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Justin K Greisberg
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Emily Arciero
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, USA
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13
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Zhang S, Sun C, Zhang J, Wang Z, Li S, Zhang M. Subchondral bone cysts remodel after correction of varus deformity in ankle arthritis. Foot Ankle Surg 2023; 29:419-423. [PMID: 37277300 DOI: 10.1016/j.fas.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 05/02/2023] [Accepted: 05/29/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND Subchondral bone cysts (SBCs) of the talus are frequently observed in ankle osteoarthritis (OA). It is unclear whether the cysts need direct treatment after correction of the varus deformity in ankle OA. The purpose of this study is to investigate the incidence of SBCs and the change after supramalleolar osteotomy (SMOT). METHODS Thirty-one patients treated by SMOT were retrospectively reviewed, and 11 ankles had cysts preoperatively. After SMOT without management of the cysts, the evolution of cysts was evaluated on weightbearing computerized tomography (WBCT). The American Orthopaedic Foot and Ankle Society (AOFAS) clinical ankle-hindfoot scale and a visual analog scale (VAS) were compared. RESULTS At baseline, the average cyst volume was 65.86 ± 60.53 mm3. The number and volume of cysts were reduced dramatically (P<.05), and the cysts vanished in 6 ankles after the SMOT. The VAS and AOFAS scores improved significantly after SMOT (P<.001), there was no significant difference between ankles with cysts and without cysts. CONCLUSIONS The SMOT alone without direct treatment of the SBCs led to a decrease in the number and volume of SBCs in varus ankle OA. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Shu Zhang
- Foot and Ankle Surgery Center, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Chao Sun
- Foot and Ankle Surgery Center, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Jianzhong Zhang
- Foot and Ankle Surgery Center, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Zhi Wang
- Foot and Ankle Surgery Center, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Shuyuan Li
- Department of Orthopaedic Surgery, University of Colorado School of Medicine, USA
| | - Mingzhu Zhang
- Foot and Ankle Surgery Center, Beijing Tongren Hospital, Capital Medical University, Beijing, China.
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14
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Dibbern K, Vivtcharenko V, Salomao Barbachan Mansur N, Lalevée M, Alencar Mendes de Carvalho K, Lintz F, Barg A, Goldberg AJ, de Cesar Netto C. Distance mapping and volumetric assessment of the ankle and syndesmotic joints in progressive collapsing foot deformity. Sci Rep 2023; 13:4801. [PMID: 36959355 PMCID: PMC10036322 DOI: 10.1038/s41598-023-31810-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 03/17/2023] [Indexed: 03/25/2023] Open
Abstract
The early effects of progressive collapsing foot deformity (PCFD) on the ankle and syndesmotic joints have not been three-dimensionally quantified. This case-control study focused on using weight bearing CT (WBCT) distance (DM) and coverage maps (CM) and volumetric measurements as 3D radiological markers to objectively characterize early effects of PCFD on the ankle and syndesmotic joints. Seventeen consecutive patients with symptomatic stage I flexible PCFD and 20 matched controls that underwent foot/ankle WBCT were included. Three-dimensional DM and CM of the ankle and syndesmotic joints, as well volumetric assessment of the distal tibiofibular syndesmosis was performed as possible WBCT markers of early PCFD. Measurements were compared between PCFD and controls. Significant overall reductions in syndesmotic incisura distances were observed in PCFD patients when compared to controls, with no difference in the overall syndesmotic incisura volume at 1, 3, 5 and 10 cm proximally to the ankle joint. CMs showed significantly decreased articular coverage of the anterior regions of the tibiotalar joint as well as medial/lateral ankle joint gutters in PCFD patients. This study showed syndesmotic narrowing and decreased articular coverage of the anterior aspect of the ankle gutters and talar dome in stage I PCFD patients when compared to controls. These findings are consistent with early plantarflexion of the talus within the ankle Mortise, and absence of true syndesmotic overload in early PCFD, and support DM and CM as early 3D PCFD radiological markers.
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Affiliation(s)
- Kevin Dibbern
- Department of Orthopedics and Rehabilitation, Carver College of Medicine, University of Iowa (UIOWA), 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | - Victoria Vivtcharenko
- Department of Orthopedics and Rehabilitation, Carver College of Medicine, University of Iowa (UIOWA), 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | - Nacime Salomao Barbachan Mansur
- Department of Orthopedics and Rehabilitation, Carver College of Medicine, University of Iowa (UIOWA), 200 Hawkins Drive, Iowa City, IA, 52242, USA
- Department of Orthopedics and Traumatology, Escola Paulista de Medicina, UNIFESP, São Paulo, Brazil
| | - Matthieu Lalevée
- Department of Orthopedics and Rehabilitation, Carver College of Medicine, University of Iowa (UIOWA), 200 Hawkins Drive, Iowa City, IA, 52242, USA
- Service d'orthopédie Traumatologie, Centre Hospitalier Universitaire de Rouen, Rouen, France
| | - Kepler Alencar Mendes de Carvalho
- Department of Orthopedics and Rehabilitation, Carver College of Medicine, University of Iowa (UIOWA), 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | | | - Alexej Barg
- Department of Orthopaedics, Trauma and Reconstructive Surgery, University of Hamburg, Hamburg, Germany
| | | | - Cesar de Cesar Netto
- Department of Orthopedics and Rehabilitation, Carver College of Medicine, University of Iowa (UIOWA), 200 Hawkins Drive, Iowa City, IA, 52242, USA.
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15
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Lalevée M, Barbachan Mansur NS, Lee HY, Ehret A, Tazegul T, de Carvalho KAM, Bluman E, de Cesar Netto C. A comparison between the Bluman et al. and the progressive collapsing foot deformity classifications for flatfeet assessment. Arch Orthop Trauma Surg 2023; 143:1331-1339. [PMID: 34859296 DOI: 10.1007/s00402-021-04279-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 11/24/2021] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Bluman et al., flatfoot classification is based on posterior tibial tendon (PTT) dysfunction leading to a chronological appearance of several foot deformities. An expert consensus recently proposed a new classification named Progressive Collapsing Foot Deformity (PCFD) in which the focus was shifted to five different independent foot and ankle deformities and their flexibility or rigidity. The aim of this study was to compare Bluman and PCFD classifications. We hypothesize that both classifications will be reliable and that the PCFD classification will allow a larger distribution of the different types of foot deformity. MATERIALS AND METHODS We performed a retrospective IRB-approved study including 92 flatfeet. Three foot and ankle surgeons reviewed patient files and radiographs to classify each foot using both classifications. Bluman classification was performed one time as initially described and a second time after removing the Angle of Gissane sclerosis sign. Interobserver reliabilities were determined with Fleiss' kappa values. RESULTS Interobserver reliabilities of Bluman and PCFD classifications were, respectively, substantial 0.67 and moderate 0.55. PCFD Class C and D reliabilities were, respectively, slight 0.07 and fair 0.28. The 276 readings were spread into 10 substages in Bluman and 65 subclasses in PCFD. The progressivity of the Bluman classification prevented the combination of flexible hindfoot valgus (II Bluman, 1A PCFD), midfoot abduction (IIB, 1B) and medial column instability (IIC, 1C) which was frequent in our study (112/276 readings, 40.6%). By removing the Angle of Gissane sclerosis sign from the Bluman classification, the prevalence of stage III decreased from 44.2 to 10.1%. CONCLUSIONS Bluman and PCFD classifications were reliable. The PCFD classification showed a larger distribution of different types of flatfeet but Classes C and D need better definition. The progressivity of Bluman classification causes inconsistencies and Gissane angle sclerosis sign is inappropriately used and might lead to incorrect surgical indications.
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Affiliation(s)
- Matthieu Lalevée
- Department of Orthopedics and Rehabilitation, Carver College of Medicine, University of Iowa, 200 Hawkins Dr, John PappaJohn Pavillion (JPP), Room 01066, Lower Level, Iowa City, IA, 52242, USA.,Department of Orthopedic Surgery, Rouen University Hospital, 37 Boulevard Gambetta, 76000, Rouen, France
| | - Nacime Salomao Barbachan Mansur
- Department of Orthopedics and Rehabilitation, Carver College of Medicine, University of Iowa, 200 Hawkins Dr, John PappaJohn Pavillion (JPP), Room 01066, Lower Level, Iowa City, IA, 52242, USA.,Department of Orthopedics and Traumatology, Paulista School of Medicine, Federal University of Sao Paulo, São Paulo, SP, Brazil
| | - Hee Young Lee
- Department of Orthopedics and Rehabilitation, Carver College of Medicine, University of Iowa, 200 Hawkins Dr, John PappaJohn Pavillion (JPP), Room 01066, Lower Level, Iowa City, IA, 52242, USA
| | - Amanda Ehret
- Department of Orthopedics and Rehabilitation, Carver College of Medicine, University of Iowa, 200 Hawkins Dr, John PappaJohn Pavillion (JPP), Room 01066, Lower Level, Iowa City, IA, 52242, USA
| | - Tutku Tazegul
- Department of Orthopedics and Rehabilitation, Carver College of Medicine, University of Iowa, 200 Hawkins Dr, John PappaJohn Pavillion (JPP), Room 01066, Lower Level, Iowa City, IA, 52242, USA
| | - Kepler Alencar Mendes de Carvalho
- Department of Orthopedics and Rehabilitation, Carver College of Medicine, University of Iowa, 200 Hawkins Dr, John PappaJohn Pavillion (JPP), Room 01066, Lower Level, Iowa City, IA, 52242, USA
| | - Eric Bluman
- Orthopedic Surgery, Brigham Health, 75 Francis Street, Boston, MA, 02115, USA.,Brigham and Women's Faulkner Hospital, Orthopaedic Center, 1153 Centre Street, Suite 5 South, Boston, MA, 02130, USA
| | - Cesar de Cesar Netto
- Department of Orthopedics and Rehabilitation, Carver College of Medicine, University of Iowa, 200 Hawkins Dr, John PappaJohn Pavillion (JPP), Room 01066, Lower Level, Iowa City, IA, 52242, USA.
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16
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Prevalence and pattern of lateral impingements in the progressive collapsing foot deformity. Arch Orthop Trauma Surg 2023; 143:161-168. [PMID: 34213577 DOI: 10.1007/s00402-021-04015-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 06/23/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The prevalence of lateral bony impingements [i.e., Sinus Tarsi (STI), Talo-Fibular (TFI) and Calcaneo-Fibular (CFI)] and their association with Peritalar Subluxation (PTS) have not been clearly established for progressive collapsing foot deformity (PCFD).This study aims to assess the prevalence of STI, TFI and CFI in PCFD, in addition to their association with PTS. We hypothesized that STI and TFI would be more prevalent than CFI. MATERIALS AND METHODS Seventy-two continuous symptomatic PCFD cases were retrospectively reviewed. Weightbearing computed tomography (WBCT) was used to assess lateral impingements and classified as STI, TFI and CFI. PTS was assessed by the percent of uncovered and the incongruence angle of the middle facet, and the overall foot deformity was determined by the foot and ankle offset (FAO). Data were collected by two fellowship-trained independent observers. RESULTS Intra-observer and inter-observer reliabilities for impingement assessment ranged from substantial to almost perfect. STI was present in 84.7%, TFI in 65.2% and CFI in 19.4%. PCFD with STI showed increased middle facet uncoverage (p = 0.0001) and FAO (p = 0.0008) compared to PCFD without STI. There were no differences in FAO and middle facet uncoverage in PCFD with TFI and without TFI. PCFD with CFI was associated with STI in 100% of cases. PCFD with CFI showed decreased middle facet incongruence (p = 0.04) and higher FAO (p = 0.006) compared to PCFD without CFI. CONCLUSIONS STI and TFI were more prevalent than CFI in PCFD. However, only STI was associated with PTS. Conversely, CFI was associated with less PTS, suggesting a different pathological mechanism which could be a compensatory subtalar behavior caused by deep layer failure of the deltoid ligament and talar tilt.
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17
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Weight-bearing cone-beam CT: the need for standardised acquisition protocols and measurements to fulfill high expectations-a review of the literature. Skeletal Radiol 2022; 52:1073-1088. [PMID: 36350387 DOI: 10.1007/s00256-022-04223-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 10/24/2022] [Accepted: 10/24/2022] [Indexed: 11/11/2022]
Abstract
Weight bearing CT (WBCT) of the lower extremity is gaining momentum in evaluation of the foot/ankle and knee. A growing number of international studies use WBCT, which is promising for improving our understanding of anatomy and biomechanics during natural loading of the lower extremity. However, we believe there is risk of excessive enthusiasm for WBCT leading to premature application of the technique, before sufficiently robust protocols are in place e.g. standardised limb positioning and imaging planes, choice of anatomical landmarks and image slices used for individual measurements. Lack of standardisation could limit benefits from introducing WBCT in research and clinical practice because useful imaging information could become obscured. Measurements of bones and joints on WBCT are influenced by joint positioning and magnitude of loading, factors that need to be considered within a 3-D coordinate system. A proportion of WBCT studies examine inter- and intraobserver reproducibility for different radiological measurements in the knee or foot with reproducibility generally reported to be high. However, investigations of test-retest reproducibility are still lacking. Thus, the current ability to evaluate, e.g. the effects of surgery or structural disease progression, is questionable. This paper presents an overview of the relevant literature on WBCT in the lower extremity with an emphasis on factors that may affect measurement reproducibility in the foot/ankle and knee. We discuss the caveats of performing WBCT without consensus on imaging procedures and measurements.
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Richter M, Schilke R, Duerr F, Zech S, Andreas Meissner S, Naef I. Automatic software-based 3D-angular measurement for Weight-Bearing CT (WBCT) provides different angles than measurement by hand. Foot Ankle Surg 2022; 28:863-871. [PMID: 34876354 DOI: 10.1016/j.fas.2021.11.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/12/2021] [Accepted: 11/27/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Purpose of this study was to compare automatic software-based angular measurement (AM, Autometrics, Curvebeam, Warrington, PA, USA) with previously validated measurement by hand (MBH) regarding angle values and time spent for the investigator for Weight-Bearing CT (WBCT). METHODS Five-hundred bilateral WBCT scans (PedCAT, Curvebeam, Warrington, PA, USA) were included in the study. Five angles (1st - 2nd intermetatarsal angle, talo-metatarsal 1-angle (TMT) dorsoplantar and lateral projection, hindfoot angle, calcaneal pitch angle) were measured with MBH and AM on the foot/ankle (side with pathology). Angles and time spent of MBH and AM were compared (t-test, homoscedatic). RESULTS The specific pathologies were ankle osteoarthritis/instability, n = 147 (29%); Haglund deformity/Achillodynia, n = 41 (8%); forefoot deformity, n = 108 (22%); Hallux rigidus, n = 37 (7%); flatfoot, n = 35 (7%); cavus foot, n = 10 (2%); osteoarthritis except ankle, n = 82 (16%). The angles differed between MBH and AM (each p < 0.001) except the calcaneal pitch angle (p = 0.05). The time spent for MBH / AM was 44.5 ± 12 s / 1 ± 0 s on average per angle (p < 0.0011). CONCLUSIONS AM provided different angles as MBH and can currently not be considered as validated angle measurement method. The investigator time spent is 97% lower for AM (1 s per angle) than for MBH (44.5 s per angle). Cases with correct angles in combination with almost no time spent showed the real potential of AM. The AM system will have to become reliable (especially in diminishing positive and negative angle values as defined) and valid which has to be proven by planned studies in the future. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Martinus Richter
- Department for Foot and Ankle Surgery Rummelsberg and Nuremberg, Germany.
| | - Regina Schilke
- Department for Foot and Ankle Surgery Rummelsberg and Nuremberg, Germany
| | - Fabian Duerr
- Department for Foot and Ankle Surgery Rummelsberg and Nuremberg, Germany
| | - Stefan Zech
- Department for Foot and Ankle Surgery Rummelsberg and Nuremberg, Germany
| | | | - Issam Naef
- Department for Foot and Ankle Surgery Rummelsberg and Nuremberg, Germany
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Richter M, Duerr F, Schilke R, Zech S, Meissner SA, Naef I. Semi-automatic software-based 3D-angular measurement for Weight-Bearing CT (WBCT) in the foot provides different angles than measurement by hand. Foot Ankle Surg 2022; 28:919-927. [PMID: 35065853 DOI: 10.1016/j.fas.2022.01.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 12/28/2021] [Accepted: 01/06/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND The purpose of this study was to compare semi-automatic software-based angular measurement (SAM) with previously validated measurement by hand (MBH) regarding angle values and time spent for the investigator for Weight-Bearing CT (WBCT). METHODS In this retrospective comparative study, five-hundred bilateral WBCT scans (PedCAT, Curvebeam, Warrington, PA, USA) were included in the study. Five angles (1st - 2nd intermetatarsal angle (IM), talo-metatarsal 1-angle (TMT) dorsoplantar and lateral projection, hindfoot angle, calcaneal pitch angle) were measured with MBH and SAM (Bonelogic Ortho Foot and Ankle, Version 1.0.0-R, Disior Ltd, Helsinki, Finland) on the right/left foot/ankle. The angles and time spent of MBH and SAM were compared (t-test, homoscesdatic). RESULTS The angles differed between MBH and SAM (mean values MBH/SAM; IM, 9.1/13.0; TMT dorsoplantar, -3.4/8.2; TMT lateral. -6.4/-1.1; hindfoot angle, 4.6/21.6; calcaneal pitch angle, 20.5/20.1; each p < 0.001 except the calcaneal pitch angle, p = 0.35). The time spent for MBH / SAM was 44.5 ± 12 s / 12 ± 0 s on average per angle (p < 0.001). CONCLUSIONS SAM provided different angles as MBH (except calcaneal pitch angle) and can currently not be considered as validated angle measurement method (except calcaneal pitch angle). The investigator time spent is 73% lower for SAM (12 s per angle) than for MBH (44.5 s per angle). SAM might be an important step forward for 3D-angle measurement of WBCT when valid angles are provided.
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Affiliation(s)
- Martinus Richter
- Department for Foot and Ankle Surgery Rummelsberg and Nuremberg, Germany.
| | - Fabian Duerr
- Department for Foot and Ankle Surgery Rummelsberg and Nuremberg, Germany
| | - Regina Schilke
- Department for Foot and Ankle Surgery Rummelsberg and Nuremberg, Germany
| | - Stefan Zech
- Department for Foot and Ankle Surgery Rummelsberg and Nuremberg, Germany
| | | | - Issam Naef
- Department for Foot and Ankle Surgery Rummelsberg and Nuremberg, Germany
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Kim J, Rajan L, Fuller R, Sofka C, Cororaton A, Demetracopoulos C, Ellis S, Deland J. Radiographic Cutoff Values for Predicting Lateral Bony Impingement in Progressive Collapsing Foot Deformity. Foot Ankle Int 2022; 43:1219-1226. [PMID: 35699393 DOI: 10.1177/10711007221099010] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Lateral bony impingement is a major cause of lateral foot pain in progressive collapsing foot deformity (PCFD). Weightbearing computed tomography (WBCT) provides better sensitivity than standard radiographs for detecting impingement. However, many orthopaedic centers have not yet acquired WBCT imaging. This study aimed to (1) investigate the correlation of common radiographic parameters measured on standard weightbearing radiographs with talocalcaneal and calcaneofibular distance assessed with WBCT and (2) establish radiographic cutoff values to detect bony impingement as identified on WBCT. METHODS Ninety-one patients treated for PCFD with standard preoperative radiographs and WBCT were identified. Patients with asymmetric ankle arthritis (talar tilt >2 degrees) were excluded. The talocalcaneal distance at the sinus tarsi and calcaneofibular distance were measured in multiplanar reconstructed WBCT images. Impingement was defined as direct abutment between bones. The relationships between WBCT measurements and 4 common parameters (talonavicular coverage angle [TNC], talo-first metatarsal angle, calcaneal pitch, and hindfoot moment arm [HMA]) in standard radiographs were assessed with Pearson correlations. Receiver operating characteristic curve analysis evaluated the ability of radiographic cutoffs to detect sinus tarsi or calcaneofibular bony impingement, and the area under curve (AUC), sensitivity, specificity, negative and positive predictive value (PPV) were calculated. RESULTS Talocalcaneal distance narrowing at the sinus tarsi strongly correlated with TNC (r = 0.64, P < .001), and the calcaneofibular distance narrowing correlated with the HMA moderately yet best among the parameters (r = 0.55, P < .001). TNC (AUC = 0.837, 95% CI 0.745-0.906) and HMA (AUC=0.959, 95% CI 0.895-0.989) provided the best predictive ability for sinus tarsi and calcaneofibular bony impingement, respectively. A TNC threshold of 41.2 degrees had a 100% PPV for predicting sinus tarsi impingement, whereas an HMA threshold of 38.1 mm had a 100% PPV for calcaneofibular impingement. CONCLUSION This study provides evidence that TNC and HMA measurements made on standing radiographs could be used to indicate potential lateral bony impingement in PCFD. Narrowing of talocalcaneal distance best correlated with abduction deformity of the foot, and the narrowing of calcaneofibular distance was best correlated with valgus hindfoot deformity. LEVEL OF EVIDENCE Level III, case control study.
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Affiliation(s)
- Jaeyoung Kim
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Lavan Rajan
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Robert Fuller
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Carolyn Sofka
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Agnes Cororaton
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | | | - Scott Ellis
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Jonathan Deland
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
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Holbrook HS, Bowers AF, Mahmoud K, Kelly DM. Weight-Bearing Computed Tomography of the Foot and Ankle in the Pediatric Population. J Pediatr Orthop 2022; 42:321-326. [PMID: 35475942 DOI: 10.1097/bpo.0000000000002168] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Newer cone-beam computed tomography (CT) technology has grown in popularity for evaluation of foot and ankle pathology in the weight-bearing (WB) position. Many studies have demonstrated its benefits within the adult population, but there is a paucity of its use within the pediatric literature. The purpose of this study was to describe the indications and clinical findings of WBCT within a pediatric population. METHODS A retrospective cohort of 68 patients (86 extremities) who underwent WBCT for a variety of conditions were compared with 48 patients (59 extremities) who underwent traditional supine nonweight-bearing (NWB) CTs. Clinical indications, demographic data, radiation doses, and cost were obtained from the medical record. WBCTs were obtained in a private outpatient orthopaedic clinic, and the conventional NWBCTs were obtained within a hospital-based system. RESULTS The most common indications for obtaining a WBCT and NWBCT in our study were fracture, tarsal coalition, and Lisfranc injury. The average WBCT radiation dose was 0.63 mGy for patients <100 lbs and 1.1 mGy for patients >100 lbs undergoing WBCT. For NWBCTs, the average radiation dose was 7.92 mGy for patients <100 lbs and 10.37 mGy for patients greater than 100 lbs. There was a significant reduction in radiation dose for all patients who underwent WBCT (P<0.0001 vs. 0.002). The average reimbursement for NWBCTs was $505 for unilateral studies and $1451 for bilateral studies. The average reimbursement for the WBCTs was $345 for unilateral studies and $635 for bilateral studies. CONCLUSIONS WBCT offers a new modality for studying complex foot and ankle pathoanatomy in the pediatric population at a reduced radiation exposure and reduced cost. LEVEL OF EVIDENCE Level III-a retrospective comparative study.
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Affiliation(s)
- Hayden S Holbrook
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, Le Bonheur Children's Hospital
| | - Alexander F Bowers
- College of Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Karim Mahmoud
- Augusta Orthopedics and Sports Medicine Specialists, Augusta, GA
| | - Derek M Kelly
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, Le Bonheur Children's Hospital
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22
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Shrestha R, Sill AP, Haug LP, Patel KA, Kile TA, Fox MG. Postoperative Ankle Imaging, 2022. Semin Musculoskelet Radiol 2022; 26:203-215. [PMID: 35654090 DOI: 10.1055/s-0042-1750841] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Postoperative ankle imaging requires knowledge of the underlying surgical techniques, the usefulness of various imaging modalities, as well as an appreciation for the desired clinical outcomes. Surgical procedures discussed in this article are tibiotalar fracture fixation, tibiotalar, subtalar, and tibiotalocalcaneal arthrodesis, total ankle arthroplasty, talar osteochondral lesion repair and grafting, lateral ligamentous repair and reconstruction, and peroneal and Achilles tendon repair and reconstruction. Imaging can play a vital role in determining if the expected outcome has been achieved and identifying complications, with particular emphasis placed on the use of radiographs, computed tomography (including weight-bearing), magnetic resonance imaging, and ultrasonography.
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Affiliation(s)
- Roman Shrestha
- Department of Radiology, Mayo Clinic Arizona, Phoenix, Arizona
| | - Andrew P Sill
- Department of Radiology, Mayo Clinic Arizona, Phoenix, Arizona
| | - Logan P Haug
- Department of Radiology, Mayo Clinic Arizona, Phoenix, Arizona
| | - Karan A Patel
- Department of Orthopedics, Mayo Clinic Arizona, Phoenix, Arizona
| | - Todd A Kile
- Department of Orthopedics, Mayo Clinic Arizona, Phoenix, Arizona
| | - Michael G Fox
- Department of Radiology, Mayo Clinic Arizona, Phoenix, Arizona
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23
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Lôbo CFT, Pires EA, Bordalo-Rodrigues M, de Cesar Netto C, Godoy-Santos AL. Imaging of progressive collapsing foot deformity with emphasis on the role of weightbearing cone beam CT. Skeletal Radiol 2022; 51:1127-1141. [PMID: 34693455 DOI: 10.1007/s00256-021-03942-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 10/13/2021] [Accepted: 10/13/2021] [Indexed: 02/02/2023]
Abstract
The term progressive collapsing foot deformity (PCFD) is currently recommended as the replacement to adult-acquired flatfoot deformity and posterior tibial tendon dysfunction to better reflect its pathology, which consists of a complex three-dimensional deformity involving the foot and ankle. The new consensus has also provided a new classification that requires clinical and radiographic findings for patient stratification into each class. However, conventional radiographs are susceptible to errors resulting from the inadequate positioning of patients, incorrect angulation of the X-ray tube, and overlapping of bone structures. Weightbearing cone beam computed tomography (WBCBCT), which has greater diagnostic accuracy than conventional radiograph, is useful for evaluating progressive collapsing foot deformity to determine medial arch collapse, hindfoot alignment, peritalar subluxation, posterior subtalar joint valgus, intrinsic talus valgus, and lateral extra-articular bone impingement. The present review aimed to discuss the new recommendations for nomenclature, classification, and imaging evaluation of PCFD, with an illustrative and quantitative focus on the measurements used in conventional radiography and WBCBCT. The measurements presented here are important criteria for decision-making.
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Affiliation(s)
- Carlos Felipe Teixeira Lôbo
- Lab. Prof. Manlio Mario Marco Napoli, Faculdade de Medicina, Universidade de São Paulo, R. Ovidio Pires de Campos, 333, São Paulo, SP, 05403-010, Brazil.
| | - Eduardo Araújo Pires
- Lab. Prof. Manlio Mario Marco Napoli, Faculdade de Medicina, Universidade de São Paulo, R. Ovidio Pires de Campos, 333, São Paulo, SP, 05403-010, Brazil
| | - Marcelo Bordalo-Rodrigues
- Lab. Prof. Manlio Mario Marco Napoli, Faculdade de Medicina, Universidade de São Paulo, R. Ovidio Pires de Campos, 333, São Paulo, SP, 05403-010, Brazil.,Hospital Sírio Libanês, São Paulo, Brazil
| | - Cesar de Cesar Netto
- Department of Orthopedic Foot and Ankle Surgery, University of Iowa School of Medicine, Iowa City, IA, USA
| | - Alexandre Leme Godoy-Santos
- Lab. Prof. Manlio Mario Marco Napoli, Faculdade de Medicina, Universidade de São Paulo, R. Ovidio Pires de Campos, 333, São Paulo, SP, 05403-010, Brazil.,Hospital Israelita Albert Einstein, Av. Albert Einstein, 627, São Paulo, SP, 05652-900, Brazil
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24
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Kyung MG, Cho YJ, Lee J, Lee W, Kim DY, Lee DO, Lee DY. Relationship between talofibular impingement and increased talar tilt in incongruent varus ankle osteoarthritis. J Orthop Surg (Hong Kong) 2022; 29:23094990211045219. [PMID: 34872417 DOI: 10.1177/23094990211045219] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PurposeThis study aimed to evaluate the relationship between talofibular impingement and increased talar tilt in incongruent varus ankle osteoarthritis. Methods: Incongruent varus ankle osteoarthritis was defined as a talar tilt of more than 4° on standard ankle anteroposterior radiographs. We retrospectively reviewed 30 patients with unilateral incongruent varus ankle osteoarthritis with normal alignment of the contralateral ankle. All patients underwent bilateral weightbearing computed tomography and standing plain radiographs. The talar tilt and the distance between the talar lateral process and lateral malleolar tip were measured from a standing ankle anteroposterior radiograph of both sides. Talar and fibular spurs were assessed on the coronal and axial views of weightbearing computed tomography. After simulating the correction of the talar tilt in varus ankle osteoarthritis, talofibular bony impingement was reassessed. Results: On the varus side, the distance between the talar lateral process and the lateral malleolar tip was significantly shorter than that on the contralateral side (p < .001). Talar spur was present in the varus side of all 30 patients on the axial view of weightbearing computed tomography and in the control side of 10 patients. After the simulation of talar tilt correction, talofibular impingement (overlap) occurred in all 30 patients with a larger extent in the severe talar tilt subgroup (p < .001). Conclusion: Talofibular impingement by lateral gutter osteophytes is closely related to increased talar tilt in patients with incongruent varus ankle osteoarthritis. Therefore, lateral gutter osteophytes should be resected to stabilize mortise and improve clinical outcomes.
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Affiliation(s)
- Min Gyu Kyung
- Department of Orthopaedic Surgery, 58927Seoul National University Hospital, Seoul, Republic of Korea
| | - Yun Jae Cho
- Department of Orthopaedic Surgery, 371135Hanil General Hospital, Seoul, Republic of Korea
| | - Junpyo Lee
- Department of Orthopaedic Surgery, 58927Seoul National University Hospital, Seoul, Republic of Korea
| | - Wonik Lee
- Department of Orthopaedic Surgery, 58927Seoul National University Hospital, Seoul, Republic of Korea
| | - Dae-Yoo Kim
- Department of Orthopaedic Surgery, 65365Inje University Busan Paik Hospital, Busan, Republic of Korea
| | - Dong-Oh Lee
- Department of Orthopaedic Surgery, 58927Seoul National University Hospital, Seoul, Republic of Korea
| | - Dong Yeon Lee
- Department of Orthopaedic Surgery, 58927Seoul National University Hospital, Seoul, Republic of Korea.,58927Seoul National University College of Medicine, Seoul, Republic of Korea
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25
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Krähenbühl N, Kvarda P, Susdorf R, Burssens A, Ruiz R, Barg A, Hintermann B. Assessment of Progressive Collapsing Foot Deformity Using Semiautomated 3D Measurements Derived From Weightbearing CT Scans. Foot Ankle Int 2022; 43:363-370. [PMID: 34617817 DOI: 10.1177/10711007211049754] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND In progressive collapsing foot deformity (PCFD), hind- and midfoot deformities can be hard to characterize based on weightbearing plain radiography. Semiautomated 3-dimensional (3D) measurements derived from weightbearing computed tomography (WBCT) scans may provide a more accurate deformity assessment. In the present study, automated 3D measurements based on WBCT were used to compare hindfoot alignment of healthy individuals to patients with PCFD. METHODS The WBCT scans of 20 patients treated at our institution with either a flexible (N = 10) or rigid (N = 10) PCFD were compared with the WBCT scans of a control group of 30 healthy individuals. Using semiautomated image analysis software, from each set of 3D voxel images, we measured the talar tilt (TT), hindfoot moment arm (HMA), talocalcaneal angle (TCA; axial/lateral), talonavicular coverage (TNC), and talocalcaneal overlap (TCO). The presence of medial facet subluxation as well as sinus tarsi/subfibular impingement was additionally assessed. RESULTS With the exception of the TCA (axial/lateral), the analyzed measurements differed between healthy individuals and patients with PCFD. The TCA axial correlated with the TNC in patients with PCFD. An increased TCO combined with sinus tarsi impingement raised the probability of predicting a deformity as rigid. CONCLUSION Using 3D measurements, in this relatively small cohort of patients, we identified relevant variables associated with a clinical presentation of flexible or rigid PCFD. An increased TCO combined with sinus tarsi impingement raised the probability of predicting a deformity as rigid. Such WBCT-based markers possibly can help the surgeon in decision-making regarding the appropriate surgical strategy (eg, osteotomies vs realignment arthrodesis). However, prospective studies are necessary to confirm the utility of the proposed parameters in the treatment of PCFD. LEVEL OF EVIDENCE Level III, case-control study.
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Affiliation(s)
- Nicola Krähenbühl
- Department of Orthopaedics, University Hospital Basel, Basel, Switzerland
| | - Peter Kvarda
- Department of Orthopaedics, Kantonsspital Baselland, Liestal, Switzerland
| | - Roman Susdorf
- Department of Orthopaedics, Kantonsspital Baselland, Liestal, Switzerland
| | - Arne Burssens
- Department of Orthopaedics, Kantonsspital Baselland, Liestal, Switzerland
| | - Roxa Ruiz
- Department of Orthopaedics, Kantonsspital Baselland, Liestal, Switzerland
| | - Alexej Barg
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA
| | - Beat Hintermann
- Department of Orthopaedics, Kantonsspital Baselland, Liestal, Switzerland
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26
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de Cesar Netto C, Saito GH, Roney A, Day J, Greditzer H, Sofka C, Ellis SJ, Richter M, Barg A, Lintz F, de Cesar Netto C, Burssens A, Ellis SJ, Deland J, Ellis SJ. Combined weightbearing CT and MRI assessment of flexible progressive collapsing foot deformity. Foot Ankle Surg 2021; 27:884-891. [PMID: 33358266 DOI: 10.1016/j.fas.2020.12.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 11/12/2020] [Accepted: 12/01/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND The objective of this study was to evaluate the correlation between Weightbearing CT (WBCT) markers of pronounced peritalar subluxation (PTS) and MRI findings of soft tissue insufficiency in patients with flexible Progressive Collapsing Foot Deformity (PCFD). We hypothesized that significant correlation would be found. METHODS Retrospective comparative study with 54 flexible PCFD patients. WBCT and MRI variables deformity severity were evaluated, including markers of pronounced PTS, as well as soft tissue degeneration. A multiple regression analysis and partition prediction models were used to evaluate the relationship between bone alignment and soft tissue injury. P-values of less than .05 were considered significant. RESULTS Degeneration of the posterior tibial tendon was significantly associated with sinus tarsi impingement (p = .04). Spring ligament degeneration correlated to subtalar joint subluxation (p = .04). Talocalcaneal interosseous ligament involvement was the only one to significantly correlate to the presence of subfibular impingement (p = .02). CONCLUSION Our results demonstrated that WBCT markers of pronounced deformity and PTS were significantly correlated to MRI involvement of the PTT and other important restraints such as the spring and talocalcaneal interosseus ligaments. LEVEL OF EVIDENCE Level III, Retrospective comparative study.
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Affiliation(s)
- Cesar de Cesar Netto
- The Hospital for Special Surgery, New York, NY, US; University of Iowa, Department of Orthopaedics and Rehabilitation, Iowa City, IA, US.
| | | | - Andrew Roney
- The Hospital for Special Surgery, New York, NY, US
| | - Jonathan Day
- The Hospital for Special Surgery, New York, NY, US
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- International Weight Bearing CT Society, Brussels, Belgium
| | | | - Alexej Barg
- The Hospital for Special Surgery, New York, NY, US
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27
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Zeitlin J, Henry J, Ellis S. Preoperative Guidance With Weight-Bearing Computed Tomography and Patient-Specific Instrumentation in Foot and Ankle Surgery. HSS J 2021; 17:326-332. [PMID: 34539274 PMCID: PMC8436345 DOI: 10.1177/15563316211026325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 05/05/2021] [Indexed: 11/16/2022]
Abstract
The use of preoperative and intraoperative guidance in foot and ankle surgery has grown substantially in recent years. Weight-bearing computed tomography (WBCT) and patient-specific instrumentation (PSI) are used in total ankle arthroplasty (TAA) to achieve precise bone cutting and implant positioning, and intraoperative 3-dimensional (3D) imaging has been used to reduce complications and improve clinical outcomes in other foot and ankle surgical procedures. This narrative review of the literature focuses on the evidence supporting the use of WBCT and PSI in TAA and looks at other promising technologies used to guide foot and ankle surgery.
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Affiliation(s)
| | | | - Scott Ellis
- Hospital for Special Surgery, New York, NY, USA
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28
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Abstract
Advanced imaging modalities have, in very recent years, enabled a considerable leap in understanding progressive collapsing foot deformity, evolving from a simple confirmation of clinical diagnostic using basic measurements to minute understanding of soft tissue and bone involvements. MRI and weight-bearing cone-beam computed tomography are enabling the development of new 3-dimensional measurement modalities. The identification of key articular and joint markers of advanced collapse will allow surgeons to better indicate treatments and assess chances of success with conservative therapies and less invasive surgical procedures, with the hope of improving patient outcomes.
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29
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Conti MS, Ellis SJ. Spare the Talonavicular Joint! The Role of Isolated Subtalar Joint Fusion in the Treatment of Progressive Collapsing Foot Deformity. Foot Ankle Clin 2021; 26:591-607. [PMID: 34332737 DOI: 10.1016/j.fcl.2021.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Surgical management of progressive collapsing foot deformity continues to evolve. Previous studies have demonstrated that fusion of the talonavicular joint results in limited hindfoot motion and, therefore, may accelerate adjacent-joint arthrosis. Recent literature has supported using alternative arthrodesis constructs that spare the talonavicular joint, such as naviculocuneiform or isolated subtalar fusions, which may maintain some hindfoot motion through the talonavicular joint yet adequately address a patient's deformity. Concomitant reconstructive procedures may be used in addition to subtalar fusion to address severe deformities. Isolated subtalar fusions may be considered in cases of sinus tarsi or subfibular impingement deformities.
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Affiliation(s)
- Matthew S Conti
- Academic Training Department, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA. https://twitter.com/matthew_conti
| | - Scott J Ellis
- Foot and Ankle Service, Hospital for Special Surgery, 523 East 72nd Street, 5th Floor, New York, NY 10021, USA.
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30
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Auch E, Barbachan Mansur NS, Alexandre Alves T, Cychosz C, Lintz F, Godoy-Santos AL, Baumfeld DS, de Cesar Netto C. Distal Tibiofibular Syndesmotic Widening in Progressive Collapsing Foot Deformity. Foot Ankle Int 2021; 42:768-775. [PMID: 33508965 DOI: 10.1177/1071100720982907] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Lateral overload in progressive collapsing foot deformity (PCFD) takes place as hindfoot valgus, peritalar subluxation, and valgus instability of the ankle increase. Fibular strain due to chronic lateral impingement may lead to distraction forces over the distal tibiofibular syndesmosis (DTFS). This study aimed to assess and correlate the severity of the foot and ankle offset (FAO) as a marker of progressive PCFD with the amount of DTFS widening and to compare it to controls. METHODS In this case-control study, 62 symptomatic patients with PCFD and 29 controls who underwent standing weightbearing computed tomography (WBCT) examination were included. Two fellowship-trained blinded orthopedic foot and ankle surgeons performed FAO (%) and DTFS area measurements (mm2). DTFS was assessed semiautomatically on axial-plane WBCT images, 1 cm proximal to the apex of the tibial plafond. Values were compared between patients with PCFD and controls, and Spearman correlation between FAO and DTFS area measurements was assessed. P values of less than .05 were considered significant. RESULTS Patients with PCFD demonstrated significantly increased FAO and DTFS measurements in comparison to controls. A mean difference of 6.9% (P < .001) in FAO and 10.4 mm2 (P = .026) in DTFS was observed. A significant but weak correlation was identified between the variables, with a Þ of 0.22 (P = .03). A partition predictive model demonstrated that DTFS area measurements were highest when FAO values were between 7% and 9.3%, with mean (SD) values of 92.7 (22.4) mm2. CONCLUSION To our knowledge, this was the first study to assess syndesmotic widening in patients with PCFD. We found patients with PCFD to demonstrate increased DTFS area measurements compared to controls, with a mean difference of approximately 10 mm2. A significantly weak positive correlation was found between FAO and DTFS area measurements, with the highest syndesmotic widening occurring when FAO values were between 7% and 9.3%. Our study findings suggest that chronic lateral impingement in patients with PCFD can result in a negative biomechanical impact on syndesmotic alignment, with increased DTFS stress and subsequent widening. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Elijah Auch
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA, USA
| | - Nacime Salomao Barbachan Mansur
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA, USA.,Federal University of São Paulo, São Paulo, Brazil
| | | | - Christopher Cychosz
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA, USA
| | | | | | | | - Cesar de Cesar Netto
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA, USA
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31
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Abstract
Undiagnosed medial ankle instability can be a prerequisite for pathogenic progression in the foot, particularly for adult acquired flatfoot deformity. With the complex anatomy in this region, and the limitations of each individual investigational method, accurately identifying peritalar instability remains a serious challenge to clinicians. Performing a thorough clinical examination aided by evaluation with advanced imaging can improve the threshold of detection for this condition and allow early proper treatment to prevent further manifestations of the instability.
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Affiliation(s)
- Yantarat Sripanich
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, USA; Department of Orthopaedics, Phramongkutklao Hospital and College of Medicine, 315 Rajavithi Road, Tung Phayathai, Ratchathewi, Bangkok 10400, Thailand
| | - Alexej Barg
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, USA; Department of Orthopaedics, Trauma and Reconstructive Surgery, University of Hamburg, Martinistr. 52, Hamburg 20246, Germany.
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32
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Conti MS, Caolo KC, Nguyen JT, Deland JT, Ellis SJ. Preoperative Patient-Reported Outcome Measures Relationship With Postoperative Outcomes in Flexible Adult-Acquired Flatfoot Deformity. Foot Ankle Int 2021; 42:268-277. [PMID: 33148056 DOI: 10.1177/1071100720963077] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Previous studies have demonstrated that procedure-specific thresholds using preoperative patient-reported outcome scores may be used to predict postoperative outcomes. The primary purpose of this study was to determine if preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) thresholds could be used to predict which patients would clinically improve at 2 years postoperatively following reconstruction of their flexible adult-acquired flatfoot deformity (AAFD). METHODS PROMIS physical function, pain interference, and depression scores were prospectively collected preoperatively and at a minimum of 2 years postoperatively for 75 feet with flexible AAFD. Minimal clinically important differences (MCIDs) were calculated to establish significant postoperative improvement. Receiver operating characteristic curves and area under the curve analyses were employed to determine whether preoperative PROMIS scores could be used to predict postoperative outcomes. RESULTS The PROMIS physical function receiver operating characteristic curve analysis (area under the curve = 0.913, P < .001) found that a preoperative PROMIS physical function score greater than 45.7 resulted in a 14.3% probability of achieving the MCID, whereas a preoperative score of less than 40.8 had a 97.7% probability of achieving the MCID. A preoperative PROMIS pain interference score (area under the curve = 0.799, P < .001) less than 54.1 had only a 23.1% probability of achieving the MCID at 2 years postoperatively. CONCLUSIONS Preoperative PROMIS physical function and pain interference scores could be used to predict postoperative improvement in patients with flexible AAFD. These results may help surgeons counsel patients regarding the anticipated benefit of surgery. LEVEL OF EVIDENCE Level III, retrospective comparative series.
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Affiliation(s)
- Matthew S Conti
- Foot and Ankle Service, Hospital for Special Surgery, New York, NY, USA
| | - Kristin C Caolo
- Foot and Ankle Service, Hospital for Special Surgery, New York, NY, USA
| | - Joseph T Nguyen
- Biostatistics Core, Hospital for Special Surgery, New York, NY, USA
| | - Jonathan T Deland
- Foot and Ankle Service, Hospital for Special Surgery, New York, NY, USA
| | - Scott J Ellis
- Foot and Ankle Service, Hospital for Special Surgery, New York, NY, USA
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33
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Kim J, Day J, Seilern Und Aspang J. Outcomes Following Revision Surgery After Failed Kidner Procedure for Painful Accessory Navicular. Foot Ankle Int 2020; 41:1493-1501. [PMID: 32762355 DOI: 10.1177/1071100720943843] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The Kidner procedure is performed to treat painful accessory navicular syndrome, with varying results. Recurrent pain remains a complication, and to date, there is a paucity of literature regarding the causes of recurrent pain and surgical outcomes of revision. METHODS Twenty-one patients who underwent revision surgery for recurrent pain after the Kidner procedure were identified. All patients had their tendon inspected and treated, and all had a medial displacement calcaneal osteotomy. Revision was indicated after 6 months of failed conservative therapy. Pre- and postrevision radiographic measurements included lateral talo-first metatarsal angle (Meary's angle), talonavicular coverage angle, calcaneal pitch, and hindfoot moment arm (HMA). Meary's angle >4 degrees was considered a planus deformity and HMA >9.1 mm was considered a hindfoot valgus deformity; patients fulfilling both criteria were categorized as having planovalgus deformity. Measurements in the contralateral foot were performed to determine whether alignment of the involved side was attributed to failed treatment or a preexisting deformity. Visual analog scale and Foot and Ankle Outcome Scores were compared and average follow-up was 20.1 months (range, 14-26). RESULTS Preoperatively, 20 of 21 (95%) patients had a form of valgus heel alignment (planovalgus, n = 11; hindfoot valgus only, n = 9), and 1 had an isolated planus deformity. The contralateral side revealed similar deformity, with 17 of 21 (81%) patients having a form of valgus heel alignment (planovalgus, n = 13; hindfoot valgus only, n = 4) and 4 patients with an isolated planus deformity. All patients underwent realignment surgery with medial displacement calcaneal osteotomy. All radiographic parameters except Meary's angle (P = .885) significantly improved postoperatively along with significantly improved clinical outcomes. CONCLUSION Recurrent pain following the Kidner procedure was associated with valgus heel alignment. Revision surgery including realignment procedure alleviated pain and improved functional outcomes with minimal complications. Therefore, we recommend assessing heel alignment in patients presenting with recurrent pain following the Kidner procedure. LEVEL OF EVIDENCE Level IV, case series.
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34
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Abstract
Weight-bearing CT (WBCT) scans of the foot and ankle have improved the understanding of deformities that are not easily identified on radiographs and are increasingly being used by orthopaedic surgeons for diagnostic and preoperative planning purposes. In contrast to standard CT scans, WBCT scans better demonstrate the true orientation of the bones and joints during loading. They have been especially useful in investigating the alignment of complex pathologies such as adult-acquired flatfoot deformity in which patients have been found to have a more valgus subtalar joint alignment than in a normal cohort and high rates of subfibular impingement. Studies using WBCT scans have also provided new insight into more common lower extremity conditions such as hallux valgus, ankle fractures, and lateral ankle instability. WBCT scans have allowed researchers to investigate pronation of the first metatarsal in patients with hallux valgus compared with normal feet, and patients with lateral ankle instability have been found to have more heel varus than healthy control subjects. Understanding the application of WBCT scans to clinical practice is becoming more important as surgeons strive for improved outcomes in the treatment of complicated foot and ankle disorders.
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Affiliation(s)
- Matthew S Conti
- From the Foot and Ankle Service, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
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35
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Richter M, Lintz F, de Cesar Netto C, Barg A, Burssens A. Results of more than 11,000 scans with weightbearing CT - Impact on costs, radiation exposure, and procedure time. Foot Ankle Surg 2020; 26:518-522. [PMID: 31239196 DOI: 10.1016/j.fas.2019.05.019] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 05/29/2019] [Accepted: 05/31/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Weightbearing CT (WBCT) has been proven to more precisely measure bone position than conventional weightbearing radiographic series (R) and conventional CT (CT). The purpose of this study was to assess the benefit of using WBCT instead of R and/or CT as the standard imaging modality, evaluating image acquisition time, radiation dose, and cost-effectiveness. METHODS All patients who obtained a WBCT as part of standard of care from July 1, 2013 until March 15, 2019 were included in the study. Image acquisition time (T), radiation dose (RD) per patient, and cost-effectiveness were analyzed and compared between the time period using WBCT (yearly average) and the parameters from 2012, i.e. before the availability of WBCT (RCT group). RESULTS 11,009 WBCT scans were obtained from 4987 patients (4,987 scans (45%) before treatment; 6,022 scans (55%) at follow-up). On a yearly average, 1,957 WBCTs (bilateral scans) and an additional 10.6 CTs (bilateral feet and ankles) were obtained (WBCT group). In 2012, 1,850 Rs (bilateral feet, dorsoplantar and lateral, metatarsal head skyline view) and 254 CTs were obtained from 885 patients (RCT group). The mean yearly RD was 4.3/4.8uSv for the WBCT/RCT groups (mean difference of .5uSv; a decrease of 10% for the WBCT group; p<.01). Yearly mean T was 114/493h in total (3.3/16.0min per patient) for WBCT/RCT groups (mean difference of 379h; a 77% decrease for the WBCT group; p<.01). Yearly cost-effectiveness was a mean profit of 43,959/-723 Euros for WBCT/RCT groups. CONCLUSIONS 11,009 WBCT scans from 4,987 patients over a period of 5.6 years at a foot and ankle department resulted in 10% decreased RD, 77% decreased T, and increased financial profit (51 Euros per patient) for the institution.
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Affiliation(s)
- Martinus Richter
- International Weight-Bearing CT Society, Gent, Belgium; Department for Foot and Ankle Surgery Rummelsberg and Nuremberg, Germany.
| | - Francois Lintz
- International Weight-Bearing CT Society, Gent, Belgium; Clinique de l'Union, Foot and Ankle Surgery Centre, Toulouse, France
| | - Cesar de Cesar Netto
- International Weight-Bearing CT Society, Gent, Belgium; Department of Orthopedics and Rehabilitation, Carver College of Medicine, University of Iowa, Iowa City, USA
| | - Alexej Barg
- International Weight-Bearing CT Society, Gent, Belgium; Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA
| | - Arne Burssens
- International Weight-Bearing CT Society, Gent, Belgium; Department of Orthopaedics and Traumatology, University Hospital of Ghent, Gent, Belgium
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36
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Willey MC, Compton JT, Marsh JL, Kleweno CP, Agel J, Scott EJ, Bui G, Davison J, Anderson DD. Weight-Bearing CT Scan After Tibial Pilon Fracture Demonstrates Significant Early Joint-Space Narrowing. J Bone Joint Surg Am 2020; 102:796-803. [PMID: 32379120 DOI: 10.2106/jbjs.19.00816] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Posttraumatic osteoarthritis (PTOA) is a common and early sequela of tibial pilon fractures resulting in substantial long-term disability. New approaches are needed to objectively and reliably quantify early disease progression in order to critically assess the impact of interventions aimed at preventing or mitigating PTOA. Weight-bearing computed tomography (WBCT) scans provide a means for measuring joint space while the ankle is in a loaded, functional position. We assessed the interrater and intrarater reliability of a standardized, regional method to quantify joint-space loss following tibial pilon fracture compared with the uninjured contralateral ankle. METHODS We prospectively enrolled 20 patients with intra-articular tibial pilon fractures that were surgically treated at 1 of 2 level-I trauma centers. Six months after injury, bilateral ankle WBCT scans were obtained. Joint space was measured by 4 reviewers at 9 discrete regions of the tibiotalar articulation on sagittal images. Measurements were repeated by reviewers 2 weeks later. To characterize the measurement method, interrater correlation coefficient estimates and test-retest reproducibility were calculated. RESULTS The mean tibiotalar joint space was 21% less in the injured ankles compared with the contralateral uninjured ankles (p < 0.0001). The middle-lateral and middle-central regions of the joint demonstrated the greatest decrease in joint space between injured and uninured ankles. The interrater correlation coefficient of the measurement technique was 0.88, and the test-retest reproducibility was 0.80, indicating good reliability and reproducibility of the method. CONCLUSIONS We developed a simple, standardized, and reliable technique to quantify tibiotalar joint space following tibial pilon fracture on WBCT. Significant loss of joint space is seen 6 months after the injury. This tool can be used to longitudinally quantify loss of joint space following pilon fracture and assess the impact of interventions to reduce PTOA.
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Affiliation(s)
- Michael C Willey
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Jocelyn T Compton
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - J Lawrence Marsh
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Conor P Kleweno
- Department of Orthopaedics and Sports Medicine, Harborview Medical Center, University of Washington Medicine, Seattle, Washington
| | - Julie Agel
- Department of Orthopaedics and Sports Medicine, Harborview Medical Center, University of Washington Medicine, Seattle, Washington
| | - Elizabeth J Scott
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Gabrielle Bui
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - John Davison
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Donald D Anderson
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa
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37
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Conti MS, Garfinkel JH, Ellis SJ. Outcomes of Reconstruction of the Flexible Adult-acquired Flatfoot Deformity. Orthop Clin North Am 2020; 51:109-120. [PMID: 31739874 DOI: 10.1016/j.ocl.2019.08.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Reconstruction of the flexible adult-acquired flatfoot deformity (AAFD) is controversial, and numerous procedures are frequently used in combination, including flexor digitorum longus transfer, medializing calcaneal osteotomy (MCO), heel cord lengthening/gastrocnemius recession, lateral column lengthening (LCL), Cotton osteotomy or first tarsometatarsal fusion, and spring ligament reconstruction. This article summarizes recent studies demonstrating that patients have significant improvements after operative treatment of flexible AAFD. It reviews current literature on clinical and radiographic outcomes of the MCO, LCL, and Cotton osteotomies. The authors describe how this information can be used in surgical decision making in order to tailor operative treatment to an individual patient's deformity.
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Affiliation(s)
- Matthew S Conti
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Jonathan H Garfinkel
- Cedars-Sinai Medical Center, 444 S. San Vicente Boulevard, Suite 603, Los Angeles, CA 90048, USA
| | - Scott J Ellis
- Department of Orthopaedic Foot and Ankle Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA.
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38
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AAFD: Conventional Radiographs are not Enough! I Need the Third Dimension. TECHNIQUES IN FOOT AND ANKLE SURGERY 2019. [DOI: 10.1097/btf.0000000000000234] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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