Consensus for the Use of Weightbearing CT in the Assessment of Progressive Collapsing Foot Deformity

2020 ◽  
Vol 41 (10) ◽  
pp. 1277-1282
Author(s):  
Cesar de Cesar Netto ◽  
Mark S. Myerson ◽  
Jonathan Day ◽  
Scott J. Ellis ◽  
Beat Hintermann ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Expert Opinion ◽  
Subtalar Joint ◽  
Surgical Planning ◽  
Foot Deformity ◽  
Level Of Evidence ◽  
Hindfoot Alignment ◽  
Sinus Tarsi ◽  
Weightbearing Ct ◽  
Consensus Expert

Recommendation: There is evidence that the use of WEIGHTBEARING imaging aids in the assessment of progressive collapsing foot deformity (PCFD). The following WEIGHTBEARING conventional radiographs (CRs) are necessary in the assessment of PCFD patients: anteroposterior (AP) foot, AP or mortise ankle, and lateral foot. If available, a hindfoot alignment view is strongly recommended. If available, WEIGHTBEARING computed tomography (CT) is strongly recommended for surgical planning. When WEIGHTBEARING CT is obtained, important findings to be assessed are sinus tarsi impingement, subfibular impingement, increased valgus inclination of the posterior facet of the subtalar joint, and subluxation of the subtalar joint at the posterior and/or middle facet. Level of Evidence: Level V, consensus, expert opinion.

Assessment of Progressive Collapsing Foot Deformity Using Semiautomated 3D Measurements Derived From Weightbearing CT Scans

2021 ◽  
pp. 107110072110497
Author(s):  
Nicola Krähenbühl ◽  
Peter Kvarda ◽  
Roman Susdorf ◽  
Arne Burssens ◽  
Roxa Ruiz ◽  
...  
Keyword(s):  
Control Group ◽  
Foot Deformity ◽  
Healthy Individuals ◽  
Level Of Evidence ◽  
Hindfoot Alignment ◽  
3 Dimensional ◽  
3D Measurements ◽  
Sinus Tarsi ◽  
Relevant Variables ◽  
Small Cohort

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.

3D Biometrics for Hindfoot Alignment Using Weightbearing Computed Tomography

2019 ◽  
Vol 40 (6) ◽  
pp. 720-726 ◽  
Author(s):  
Jian Zhong Zhang ◽  
François Lintz ◽  
Alessio Bernasconi ◽  
Shu Zhang ◽  
Keyword(s):  
Computed Tomography ◽  
Comparative Study ◽  
Interobserver Reliability ◽  
Intraclass Correlation ◽  
Correlation Coefficients ◽  
Level Of Evidence ◽  
Hindfoot Alignment ◽  
Mean Values ◽  
Intraclass Correlation Coefficients ◽  
Prospective Comparative Study

Background: Weightbearing computed tomography (WBCT) is a useful tool for the assessment of hindfoot alignment (HA). Foot ankle offset (FAO) is a recently introduced parameter, determined from WBCT images using semiautomatic software. The aim of this study was to determine the clinical relevance and reproducibility of FAO for the evaluation of HA. Methods: A prospective comparative study was performed on consecutive patients requiring bilateral WBCT between September 2017 and April 2018. Based on the clinical assessment of HA, patients were divided into 3 groups: (1) normal alignment group (G1), (2) valgus (G2), and (3) varus (G3). FAO and long axial view (HACT) were measured on WBCT images, and the groups were compared. The reproducibility of FAO and HACT was determined through intraclass correlation coefficients (ICCs). Regression analysis was performed to investigate the correlation between the 2 methods. Overall, 249 feet (126 patients) were included (G1 = 115, G2 = 78, and G3 = 56 feet). Results: The mean values for FAO and HACT were 1.2% ± 2.8% and 3.9 ± 3.1, respectively, in G1; 8.1% ± 3.7% and 9.7 ± 4.9 in G2; and −6.6% ± 4.8% and −8.2 ± 6.6 in G3. Intra- and interobserver reliability was 0.987 and 0.988 for FAO and 0.949 and 0.949 for HACT, respectively. There was a good linear correlation between HACT and FAO ( R2 = 0.744), with a regression slope of 1.064. Conclusions: WBCT was a useful method for the characterization of HA. FAO was reproducible and correlated well with physical examination. Level of Evidence: Level II, prospective comparative study.

Consensus for the Indication of Lateral Column Lengthening in the Treatment of Progressive Collapsing Foot Deformity

2020 ◽  
Vol 41 (10) ◽  
pp. 1286-1288
Author(s):  
David B. Thordarson ◽  
Lew C. Schon ◽  
Cesar de Cesar Netto ◽  
Jonathan T. Deland ◽  
Scott J. Ellis ◽  
...  
Keyword(s):  
Subtalar Joint ◽  
Consensus Statement ◽  
Talonavicular Joint ◽  
Foot Deformity ◽  
Foot Care ◽  
Level Of Evidence ◽  
Lateral Column ◽  
Fluoroscopic Imaging ◽  
Lateral Column Lengthening ◽  
Important Sign

Recommendation: Progressive collapsing foot deformity (PCFD) is a complex 3D deformity with varying degrees of hindfoot valgus, forefoot abduction, and midfoot supination. Although a medial displacement calcaneal osteotomy can correct heel valgus, it has far less ability to correct forefoot abduction. More severe forefoot abduction, most frequently measured preoperatively by assessing talonavicular coverage on an anteroposterior (AP) weightbearing conventional radiographic view of the foot, can be more effectively corrected with a lateral column lengthening procedure than by other osteotomies in the foot. Care must be taken intraoperatively to not overcorrect the deformity by restricting passive eversion of the subtalar joint or causing adduction at the talonavicular joint on simulated AP weightbearing fluoroscopic imaging. Overcorrection can lead to lateral column overload with persistent lateral midfoot pain. The typical amount of lengthening of the lateral column is between 5 and 10 mm. Level of Evidence: Level V, consensus, expert opinion. CONSENSUS STATEMENT ONE: Lateral column lengthening (LCL) procedure is recommended when the amount of talonavicular joint uncoverage is above 40%. The amount of lengthening needed in the lateral column should be judged intraoperatively by the amount of correction of the uncoverage and by adequate residual passive eversion range of motion of the subtalar joint. Delegate vote: agree, 78% (7/9); disagree, 11% (1/9); abstain, 11% (1/9). (Strong consensus) CONSENSUS STATEMENT TWO: When titrating the amount of correction of abduction deformity intraoperatively, the presence of adduction at the talonavicular joint on simulated weightbearing fluoroscopic imaging is an important sign of hypercorrection and higher risk for lateral column overload. Delegate vote: agree, 100% (9/9); disagree, 0%; abstain, 0%. (Unanimous, strongest consensus) CONSENSUS STATEMENT THREE: The typical range for performing a lateral column lengthening is between 5 and 10 mm to achieve an adequate amount of talonavicular coverage. Delegate vote: agree, 100% (9/9); disagree, 0%; abstain, 0%. (Unanimous, strongest consensus)

scholarly journals Evaluation of surgical outcomes of arthroscopic subtalar arthrodesis performed through two lateral portals

2018 ◽  
Vol 12 (4) ◽  
Author(s):  
Rafael Freitas Villela ◽  
João Murilo Brandão Magalhães ◽  
Rogério de Andrade Gomes ◽  
Anderson Humberto Gomes ◽  
Bernardo Cardoso Pinto Coelho ◽  
...  
Keyword(s):  
Surgical Outcomes ◽  
Case Series ◽  
Varus Deformity ◽  
Level Of Evidence ◽  
Hindfoot Alignment ◽  
Bone Consolidation ◽  
Subtalar Arthrodesis ◽  
Postoperative Score ◽  
Sinus Tarsi ◽  
The Mean

Objective: The purpose of this study is to present the surgical outcomes of twelve patients undergoing arthroscopic subtalar arthrodesis using two lateral portals (anterior and medial) in the sinus tarsi. Methods: A retrospective study was conducted with twelve patients (7 men and 5 women) with a mean age of 55.1 (36-74) years who underwent arthroscopic subtalar arthrodesis through the sinus tarsi between May 2015 and December 2016. The post-surgical follow-up was 12 months. Consolidation time and postoperative complications were evaluated, and a validated functional questionnaire from the American OrthopedicFoot and Ankle Society (AOFAS) and the visual analog scale (VAS) for pain were applied both before and after surgery. Results: The mean bone fusion time was 11.5 weeks. Bone consolidation was observed in all analyzed patients. Four patients developed late complications, three of which were related to screw positioning in the calcaneus, while one was related to residual hindfoot varus deformity. Screw-related complications are common with all subtalar arthrodesis techniques, and such complications are considered less relevant when evaluating the effectiveness of the presented technique. The mean preoperative AOFAS score was 42.3 (27-66) points, while the mean postoperative score was 83 (73-94) points. The mean preoperative VAS score for pain was 8.1 (5-10) points, and the mean postoperative score was 2.1 (0-5) points. The above data are similar to those reported in other published studies and reflect high bone consolidation rates. Conclusion: Arthroscopic subtalar arthrodesis through two lateral portals in the sinus tarsi is a safe and effective technique for the treatment of primary and secondary disorders of the subtalar joint. Correct positioning of screws and hindfoot alignment must be carefully ensured to avoid complications related to the synthesis material and hindfoot varus deformity. Level of Evidence IV; Therapeutic Studies; Case Series.

scholarly journals Hindfoot alignment using weight-bearing computed tomography

2020 ◽  
Vol 14 (3) ◽  
pp. 239-242
Author(s):  
Eduardo Pires ◽  
Carlos Lôbo ◽  
Cesar De Cesar Netto ◽  
Alexandre Godoy-Santos
Keyword(s):  
Computed Tomography ◽  
Weight Bearing ◽  
Treatment Decision ◽  
Metatarsal Head ◽  
Foot And Ankle ◽  
Level Of Evidence ◽  
Hindfoot Alignment ◽  
Treatment Decision Making ◽  
First Metatarsal ◽  
Block Test

Measurement of hindfoot malalignment and flexibility is essential for treatment decision-making in cavovarus foot deformity. Weight-bearing computed tomography (WBCT) shows greater diagnostic accuracy and allows the study of osteoarticular alignment in the physiological upright position. The most commonly used method for measurements on WBCT scans is the foot and ankle offset (FAO), which is based on the structural tripod of the foot: the calcaneus and the first and fifth metatarsal heads. During the Coleman block test, the first metatarsal head is not resting on the ground and, therefore, does not represent the physiological support of the tripod. We describe a new measurement, the forefoot/hindfoot offset (FHO), for assessing hindfoot alignment on WBCT scans. Level of Evidence V; Diagnostic Studies; Expert Opinion.

Titrating the Amount of Bony Correction in Progressive Collapsing Foot Deformity

2020 ◽  
Vol 41 (10) ◽  
pp. 1292-1295
Author(s):  
Scott J. Ellis ◽  
Jeffrey E. Johnson ◽  
Jonathan Day ◽  
Cesar de Cesar Netto ◽  
Jonathan T. Deland ◽  
...  
Keyword(s):  
Reconstructive Surgery ◽  
Wedge Osteotomy ◽  
Foot Deformity ◽  
Level Of Evidence ◽  
Opening Wedge ◽  
Lateral Column ◽  
Medial Cuneiform ◽  
Lateral Column Lengthening ◽  
Typical Range ◽  
Consensus Expert

Recommendation: There is evidence indicating that the amount of bony correction performed in the setting of progressive collapsing foot deformity reconstructive surgery can be titrated within a recommended range for a variety of procedures. The typical range when performing a medial displacement calcaneal osteotomy should be 7 to 15 mm of medialization of the tuberosity. The typical range when performing an Evans lateral column lengthening should be 5 to 10 mm of a laterally based wedge in the anterior calcaneus. The typical range when performing a plantarflexion opening wedge osteotomy of the medial cuneiform (Cotton) osteotomy should be 5 to 10 mm of a dorsal wedge. Level of Evidence: Level V, consensus, expert opinion.

Progressive Collapsing Foot Deformity: Consensus on Goals for Operative Correction

2020 ◽  
Vol 41 (10) ◽  
pp. 1299-1302 ◽  
Author(s):  
Bruce J. Sangeorzan ◽  
Beat Hintermann ◽  
Cesar de Cesar Netto ◽  
Jonathan Day ◽  
Jonathan T. Deland ◽  
...  
Keyword(s):  
Body Mass Index ◽  
Health Status ◽  
Soft Tissue ◽  
Host Factors ◽  
Joint Motion ◽  
Foot Deformity ◽  
Level Of Evidence ◽  
Soft Tissue Failure ◽  
Complex Algorithm ◽  
Consensus Expert

Recommendation: In the treatment of progressive collapsing foot deformity (PCFD), the combination of bone shape, soft tissue failure, and host factors create a complex algorithm that may confound choices for operative treatment. Realignment and balancing are primary goals. There was consensus that preservation of joint motion is preferred when possible. This choice needs to be balanced with the need for performing joint-sacrificing procedures such as fusions to obtain and maintain correction. In addition, a patient’s age and health status such as body mass index is important to consider. Although preservation of motion is important, it is secondary to a stable and properly aligned foot. Level of Evidence: Level V, consensus, expert opinion.

CT Analysis of the Posteromedial Fragment of the Posterior Malleolar Fracture

2019 ◽  
Vol 40 (6) ◽  
pp. 648-655 ◽  
Author(s):  
Amir Reza Vosoughi ◽  
Malwattage Lara Tania Jayatilaka ◽  
Benjamin Fischer ◽  
Andrew P. Molloy ◽  
Lyndon W. Mason
Keyword(s):  
Computed Tomography ◽  
Surgical Planning ◽  
Injury Pattern ◽  
Computed Tomography Scan ◽  
Malleolar Fracture ◽  
Level Of Evidence ◽  
Posterior Malleolar Fracture ◽  
Posterior Malleolus ◽  
Ct Analysis ◽  
Tomography Scan

Background: To date, there have been no studies describing the characteristics of posteromedial fragment in the posterior malleolus fracture. The aim was to investigate the variability of posteromedial fracture fragments to enable better surgical planning. Methods: All Mason and Molloy type 2B fractures, defined as fracture of both the posterolateral and the posteromedial fragments of the posterior malleolus, from our database were identified to analyze the preoperative computed tomography scan. The posteromedial fragment was investigated in 47 cases (mean age, 46.6 years; 11 male, 36 female). Results: Morphologically, the fracture could be divided into 2 subtypes: (1) a large pilon intra-articular fragment (mean of X axis: 33.0 mm, Y: 30.7 mm, Z: 31.7 mm) presented in 29 cases with mean interfragmentary angle of 32.1 and back of tibia angle of 32.7 degrees (this was seen in 25 of 27 cases with supination injury pattern); and (2) a small extra-articular avulsion fragment (mean of X axis: 9.6 mm, Y: 13.2 mm, Z: 11.5 mm) present in 18 cases with a mean interfragmentary angle of 11.0 and back of tibia angle of 10.1 degrees. It was seen in 80% of pronation injuries. Conclusion: The avulsion type of the posteromedial fragment of posterior malleolus fracture was more common in pronation injuries, likely the result of traction by the intermalleolar ligament, and the pilon type was more common in supination injuries, likely the result of the rotating talus impaction. Because of the intra-articular involvement, we believe the pilon type should undergo fixation to achieve articular congruity, unlike the avulsion type which may only function as a secondary syndesmotic stabilizer. Level of Evidence: Level III, retrospective comparative series.

Assessment of Hindfoot Alignment Comparing Weightbearing Radiography to Weightbearing Computed Tomography

2021 ◽  
pp. 107110072110141
Author(s):  
Christopher B. Arena ◽  
Yantarat Sripanich ◽  
Richard Leake ◽  
Charles L. Saltzman ◽  
Alexej Barg
Keyword(s):  
Computed Tomography ◽  
Intraclass Correlation ◽  
Correlation Coefficients ◽  
Motion Artifact ◽  
Imaging Modalities ◽  
Moment Arm ◽  
Varus Alignment ◽  
Level Of Evidence ◽  
Hindfoot Alignment ◽  
Highly Correlated

Background: Hindfoot alignment view (HAV) radiographs are widely utilized for 2-dimensional (2D) radiographic assessment of hindfoot alignment; however, the development of weightbearing computed tomography (WBCT) may provide more accurate methods of quantifying 3-dimensional (3D) hindfoot alignment. The aim of this study was to compare the 2D calcaneal moment arm measurements on HAV radiographs with WBCT. Methods: This retrospective cohort study included 375 consecutive patients with both HAV radiographs and WBCT imaging. Measurement of the 2D hindfoot alignment moment arm was compared between both imaging modalities. The potential confounding influence of valgus/varus/neutral alignment, presence of hardware, and motion artifact were further analyzed. Results: The intraclass correlation coefficients (ICCs) of interobserver and intraobserver reliability for measurements with both imaging modalities were excellent. Both modalities were highly correlated (Spearman coefficient, 0.930; P < .001). HAV radiographs exhibited a mean calcaneal moment arm difference of 3.9 mm in the varus direction compared with WBCT (95% CI, –4.9 to 12.8). The difference of hindfoot alignment between both modalities was comparable in subgroups with neutral/valgus/varus alignment, presence of hardware, and motion artifact. Conclusion: Both HAV radiographs and WBCT are highly reliable and highly correlated imaging methods for assessing hindfoot alignment. Measurements were not influenced by severe malalignment, the presence of hardware, or motion artifact on WBCT. On average, HAV radiographs overestimated 3.9 mm of varus alignment as compared with WBCT. Level of Evidence: Level III, retrospective comparative study.

Consensus for the Indication of a Medializing Displacement Calcaneal Osteotomy in the Treatment of Progressive Collapsing Foot Deformity

2020 ◽  
Vol 41 (10) ◽  
pp. 1282-1285 ◽  
Author(s):  
Lew C. Schon ◽  
Cesar de Cesar Netto ◽  
Jonathan Day ◽  
Jonathan T. Deland ◽  
Beat Hintermann ◽  
...  
Keyword(s):  
Achilles Tendon ◽  
Vertical Axis ◽  
Longitudinal Axis ◽  
Lateral Position ◽  
Foot Deformity ◽  
Level Of Evidence ◽  
Calcaneal Osteotomy ◽  
Distal Aspect ◽  
Typical Range ◽  
Consensus Expert

Recommendation: There is evidence that the medial displacement calcaneal osteotomy (MDCO) can be effective in treating the progressive collapsing foot deformity (PCFD). This juxta-articular osteotomy of the tuberosity shifts the mechanical axis of the calcaneus from a more lateral position to a more medial position, which provides mechanical advantage in the reconstruction for this condition. This also shifts the action of the Achilles tendon medially, which minimizes the everting deforming effect and improves the inversion forces. When isolated hindfoot valgus exists with adequate talonavicular joint coverage (less than 35%-40% uncoverage) and a lack of significant forefoot supination, varus, or abduction, we recommend performing this osteotomy as an isolated bony procedure, with or without additional soft tissue procedures. The clinical goal of the hindfoot valgus correction is to achieve a clinically neutral heel, as defined by a vertical axis from the heel up the longitudinal axis of the Achilles tendon and distal aspect of the leg. The typical range when performing a MDCO, while considering the location and rotation of the osteotomy, is 7 to 15 mm of correction. Level of Evidence: Level V, consensus, expert opinion.

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