3D measurement techniques for the hindfoot alignment angle from weight-bearing CT in a clinical population

Chiara Pavani, Claudio Belvedere, Maurizio Ortolani, Mauro Girolami, Stefano Durante, Lisa Berti, Alberto Leardini, Chiara Pavani, Claudio Belvedere, Maurizio Ortolani, Mauro Girolami, Stefano Durante, Lisa Berti, Alberto Leardini

Abstract

Cone-beam CT (CBCT) scans now enable accurate measurements on foot skeletal structures with the advantage of observing these in 3D and in weight-bearing. Among the most common skeletal deformities, the varus/valgus of the hindfoot is the most complex to be represented, and a number of measure proposals have been published. This study aims to analyze and to compare these measurements from CBCT scans in a real clinical population with large such deformity. Ten patients with severe acquired adult flatfoot and indication for surgery underwent CBCT scans (Carestream, USA) while standing on that leg, before and after surgical correction. Corresponding 3D shape of each bone of the distal shank and hindfoot were defined (Materialise, Belgium). Six different techniques from the literature were used to calculate the varus/valgus deformity, i.e. the inclination of the hindfoot in the frontal plane of the shank. Standard clinical measurements by goniometers were taken for comparison. According to these techniques, and starting from a careful 3D reconstruction of the relevant foot skeletal structures, a large spectrum of measurements was found to represent the same hindfoot alignment angle. Most of them were very different from the traditional clinical measures. The assessment of the pre-operative valgus deformity and of the corresponding post-operative correction varied considerably. CBCT finally allows 3D assessment of foot deformities in weight-bearing. Measurements from the different available techniques do not compare well, as they are based on very different approaches. It is recommended to be aware of the anatomical and functional concepts behind these techniques before clinical and surgical conclusions.

Conflict of interest statement

The authors declare no competing interests.

© 2022. The Author(s).

Figures

Figure 1
Figure 1
A screenshot from the 3D reconstruction of the foot bones from a CBCT scan by Mimics Innovation Suite (Materialise, Belgium) software. Each bone segment has a different colour, in both the 3D view (bottom-right) and in the three anatomical planar views; in this antero-posterior slice (top-left), the tibia, fibula, calcaneus and talus bone segments are depicted. In the sagittal view (bottom-left), apparently the foot is an inclined ground, but this is accounted for to the inclination of the gantry in the present device, i.e. the foot is on the horizontal ground.
Figure 2
Figure 2
Representation of all the techniques for HAA calculation. In the frontal view, the longitudinal axis of the tibial distal diaphysis (black) and the hindfoot vertical axis (blue) are shown for each technique. For technique A, the three principal component axes of the PCA applied to the calcaneus are also shown. For techniques D and E, the sagittal views are also to better represent the posterior part of the calcaneus. Lastly, the bottom-right (RENDER) is the posterior view of the CBCT rendering of the same scan.
Figure 3
Figure 3
Boxplot with relevant outliers; the HAA measurements from all techniques for pre-op (top) and post-op (bottom). Outliers were not found in the pre-op values.

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