The hind- and midfoot alignment computed after a medializing calcaneal osteotomy using a 3D weightbearing CT
A medializing calcaneal osteotomy (MCO) is a surgical procedure frequently performed to correct an adult acquired flatfoot (AAFD) deformity. However, most studies are limited to a 2D analysis of 3D deformity. Therefore, the aim is to perform a 3D assessment of the hind- and midfoot alignment using a weightbearing CT (WBCT) preoperatively as well as postoperatively.
Eighteen patients with a mean age of 49.4 years (range 18–67) were prospectively included in a pre–post-study design. A MCO was performed and a WBCT was obtained pre- and postoperative. Images were converted into 3D models to compute linear and angular measurements, respectively, in millimeters (mm) and degrees (°), based on previously reported landmarks of the hind- and midfoot alignment. A regression analysis was performed between the displacement of a MCO and the obtained postoperative correction.
The mean 3D hindfoot angle improved significantly preoperative compared to postoperative (p < 0.001). This appeared according to a linear relation with the amount of medial translation in a MCO (R2 = 0.84, p < 0.001). The axes of the tibia showed significant coronal as well as axial changes (p < 0.05). Analysis of the midfoot showed significant changes in the navicular height and rotation as well as the Méary angle (p < 0.05). Additionally, a linear trend between the midfoot measurements and amount of medial translation in a MCO was observed, but not significant (p > 0.05).
This study demonstrates an effective 3D correction of an AAFD by a MCO according to a linear relationship. The concomitant formula can be used to perform a preoperative planning. The novelty is the comparative 3D weightbearing CT assessment of both the computed hind- and midfoot alignment after a medializing calcaneus osteotomy. This could improve accuracy of the currently performed preoperative planning in clinical practice.
KeywordsMedializing calcaneal osteotomy Computed pre- and postoperative assessment Weightbearing CT Adult acquired flatfoot deformity
The authors wish to thank Maxwell Weinberg, as a research coordinator at the University Orthopaedic Center of Utah for his attributive linguistic and structural support. The authors would like to thank Dr. Stephanie De Buyser, as a statistician at the University Hospital of Ghent for her statistical review.
Weightbearing CT International Study Group actively contributing members are as follows: Richter M, Barg A, Lintz F, de Cesar Netto C, Burssens A and Scott J. Ellis.
This work was supported by a grant from the Clinical Research Fund University Hospital of Ghent, Belgium, Klinisch Onderzoeks Fonds (KOF; #KW/1594/ORT/001/001) and Fonds voor Wetenschappelijk Onderzoek (FWO; #V424118 N).
Compliance with ethical standards
Conflict of interest
Arne Burssens, MD, performed a paid consultancy for Curvebeam outside the submitted work. Alexej Barg, MD, has nothing to disclose. Esther van Ovost, BMSc, has nothing to disclose. Aline Van Oevelen, BMSc, has nothing to disclose. Tim Leenders, MD, has nothing to disclose. Matthias Peiffer, MD, has nothing to disclose. Irina Bodere, Ir has nothing to disclose. WBCT ISG receives logistic funding from Curvebeam, Planmed and Carestream outside the submitted work. Emmanuel Audenaert, MD, PhD, has nothing to disclose. Jan Victor, MD, PhD has nothing to disclose.
- 1.Myerson MS, Badekas A, Schon LC (2004) Treatment of stage II posterior tibial tendon deficiency with flexor digitorum longus tendon transfer and calcaneal osteotomy. Foot Ankle Int 25(7):445–450Google Scholar
- 4.McCormack AP, Ching RP, Sangeorzan BJ (2001) Biomechanics of procedures used in adult flatfoot deformity. Foot Ankle Clin 6(1):15–23Google Scholar
- 5.Alley MC, Shakked R, Rosenbaum AJ (2017) Adult-acquired flatfoot deformity. JBJS Rev 5(8):e7Google Scholar
- 6.Haddad SL, Myerson MS, Younger A, Anderson RB, Davis WH, Manoli A (2011) Adult acquired flatfoot deformity. SAGE Publications Sage CA, Los AngelesGoogle Scholar
- 7.Blackman AJ, Blevins JJ, Sangeorzan BJ, Ledoux WR (2009) Cadaveric flatfoot model: ligament attenuation and Achilles tendon overpull. J Orthop Res 27(12):1547–1554Google Scholar
- 10.Chan JY, Williams BR, Nair P, Young E, Sofka C, Deland JT, Ellis SJ (2013) The contribution of medializing calcaneal osteotomy on hindfoot alignment in the reconstruction of the stage II adult acquired flatfoot deformity. Foot Ankle Int 34(2):159–166Google Scholar
- 11.Iaquinto JM, Wayne JS (2011) Effects of surgical correction for the treatment of adult acquired flatfoot deformity: a computational investigation. J Orthop Res 29(7):1047–1054Google Scholar
- 12.Kido M, Ikoma K, Imai K, Maki M, Takatori R, Tokunaga D, Inoue N, Kubo T (2011) Load response of the tarsal bones in patients with flatfoot deformity: in vivo 3D study. Foot Ankle Int 32(11):1017–1022Google Scholar
- 13.Zhang Y, Xu J, Wang X, Huang J, Zhang C, Chen L, Wang C, Ma X (2013) An in vivo study of hindfoot 3D kinetics in stage II posterior tibial tendon dysfunction (PTTD) flatfoot based on weight-bearing CT scan. Bone Joint Res 2(12):255–263Google Scholar
- 14.Barg A, Bailey T, Richter M, Netto C, Lintz F, Burssens A, Phisitkul P, Hanrahan CJ, Saltzman CL (2017) Weightbearing computed tomography of the foot and ankle: emerging technology topical review. Foot Ankle Int 39(3):376–386Google Scholar
- 15.Lintz F, Cesar Netto CD, Barg A, Burssens A, Richter M, Group WBCIS (2018) Weight-bearing cone beam CT scans in the foot and ankle. EFORT Open Rev 3(5):278–286Google Scholar
- 17.de Cesar Netto C, Schon LC, Thawait GK, da Fonseca LF, Chinanuvathana A, Zbijewski WB, Siewerdsen JH, Demehri S (2017) Flexible adult acquired flatfoot deformity: comparison between weight-bearing and non-weight-bearing measurements using cone-beam computed tomography. J Bone Joint Surg Am 99(18):e98Google Scholar
- 18.Kuo C-C, Lu H-L, Lu T-W, Lin C-C, Leardini A, Kuo M-Y, Hsu H-C (2013) Effects of positioning on radiographic measurements of ankle morphology: a computerized tomography-based simulation study. Biomedical Eng Online 12(1):131Google Scholar
- 19.Burssens A, Peeters J, Peiffer M, Marien R, Lenaerts T, WBCT ISG, Vandeputte G, Victor J (2018) Reliability and correlation analysis of computed methods to convert conventional 2D radiological hindfoot measurements to a 3D setting using weightbearing CT. Int J Comput Assist Radiol Surg 13(12):1999–2008Google Scholar
- 20.Saltzman CL, El-Khoury GY (1995) The hindfoot alignment view. Foot Ankle Int 16(9):572–576Google Scholar
- 21.Younger AS, Sawatzky B, Dryden P (2005) Radiographic assessment of adult flatfoot. Foot Ankle Int 26(10):820–825Google Scholar
- 22.Auricchio F, Marconi S (2016) 3D printing: clinical applications in orthopaedics and traumatology. EFORT Open Rev 1(5):121–127Google Scholar
- 23.Shrout PE, Fleiss JL (1979) Intraclass correlations: uses in assessing rater reliability. Psychol Bull 86(2):420Google Scholar
- 24.Faul F, Erdfelder E, Buchner A, Lang A-G (2009) Statistical power analyses using G* Power 3.1: tests for correlation and regression analyses. Behav Res Methods 41(4):1149–1160Google Scholar
- 26.Baig M, Baig U, Tariq A, Din R (2017) A prospective study of distal metatarsal chevron osteotomies with K-wire fixations to treat hallux valgus deformities. Cureus 9(9):e1704Google Scholar
- 27.Todd M, Lalliss S, DeBerardino T (2008) A simplified technique for high tibial osteotomy with early radiographic follow-up results. Tech Knee Surg 7(3):172–177Google Scholar
- 28.Amis AA (2013) Biomechanics of high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 21(1):197–205Google Scholar
- 29.Spratley EM, Arnold JM, Owen JR, Glezos CD, Adelaar RS, Wayne JS (2013) Plantar forces in flexor hallucis longus versus flexor digitorum longus transfer in adult acquired flatfoot deformity. Foot Ankle Int 34(9):1286–1293Google Scholar
- 30.Nickisch F, Anderson RB (2006) Post-Calcaneus Fracture Reconstruction. Foot and ankle clinics 11(1):85–103Google Scholar
- 31.Stephens HM, Sanders R (1996) Calcaneal malunions: results of a prognostic computed tomography classification system. Foot Ankle Int 17(7):395–401Google Scholar
- 32.Conti MS, Ellis SJ, Chan JY, Do HT, Deland JT (2015) Optimal position of the heel following reconstruction of the stage II adult-acquired flatfoot deformity. Foot Ankle Int 36(8):919–927Google Scholar
- 33.Cöster MC, Bremander A, Rosengren BE, Magnusson H, Carlsson Å, Karlsson MK (2014) Validity, reliability, and responsiveness of the Self-reported Foot and Ankle Score (SEFAS) in forefoot, hindfoot, and ankle disorders. Acta Orthop 85(2):187–194Google Scholar
- 34.Richter M, Lintz F, Zech S, Meissner SA (2018) Combination of PedCAT weightbearing CT with pedography assessment of the relationship between anatomy-based foot center and force/pressure-based center of gravity. Foot Ankle Int 39(3):361–368Google Scholar
- 35.Reilingh M, Tuijthof G, Van Dijk C, Blankevoort L (2011) The influence of foot geometry on the calcaneal osteotomy angle based on two-dimensional static force analyses. Arch Orthop Trauma Surg 131(11):1491–1497Google Scholar
- 36.Ma B, Kunz M, Gammon B, Ellis RE, Pichora DR (2014) A laboratory comparison of computer navigation and individualized guides for distal radius osteotomy. Int J Comput Assist Radiol Surg 9(4):713–724Google Scholar
- 37.Wei M, Chen J, Guo Y, Sun H (2017) The computer-aided parallel external fixator for complex lower limb deformity correction. Int J Comput Assist Radiol Surg 12(12):2107–2117Google Scholar