Foot & Ankle International - July 2018 - 777
de Cesar Netto et al
understanding that it poorly represents the complexity of
the 3-dimensional anatomic axis of the calcaneus.
Williamson et al38 described the HAA, a radiographic measurement that was used in our study, using the hindfoot alignment view. It was described as an option for a better definition
of the axis of the calcaneus and to more reliably quantify the
hindfoot valgus angle in patients with AAFD. The HAA takes
into consideration the 3-dimensional shape of the calcaneus,
using easy and accessible anatomical bony landmarks that
include the lateral calcaneal wall and the sustentaculum tali.
The calcaneal axis is determined by the bisecting line of 2
other lines that are drawn on the medial and lateral osseous
contour of the calcaneus, representing better the whole bone
anatomy of the calcaneus. The authors demonstrated good
intraobserver and interobserver reliability for HAA measurements, significant differences in the angle measurements when
comparing patients with AAFD and controls, and a strong
positive correlation between HAA and HMA.
To our knowledge, our study is the first to evaluate the
correlation between HAA and the measure of clinical hindfoot alignment in patients with AAFD. Interestingly, even
though we found significant correlation between them, values for angular alignment in valgus were significantly more
pronounced in the radiographic measurements (HAA) than
in the clinical measurements (STCA and RCSP). Different
from prior reports in the literature, these results indicate that
clinical assessment of hindfoot alignment in patients with
AAFD could underestimate the radiographic bone alignment. Prior studies have demonstrated that patients with
AAFD undergoing operative treatment achieve better functional and clinical results if the hindfoot is corrected to neutral or slight varus radiographic alignment, when assessed
by HMA.9,13 This amount of radiographic varus alignment
would be associated with a neutral or minimal heel valgus
alignment in the clinical evaluation. In other words, clinical
alignment would demonstrate increased valgus compared to
radiographic alignment. Even though it is assumed that the
normal clinical alignment of the heel is in slight valgus,
Saltzman and el-Khoury,33 in their landmark study, also
demonstrated radiographic varus alignment in asymptomatic volunteers, with a mean HMA of 3.2 mm of varus. We
believe that our contradictory findings of significantly
increased radiographic valgus alignment, compared to both
clinical alignment measures, are explained by the use of the
HAA. Using both the medial and lateral osseous contour of
the calcaneus as landmarks leads to a more anatomical and
3-dimensional definition of the axis of the calcaneus.
However, the inclusion of the sustentaculum tali, the most
medial aspect of the calcaneus, as one of the bone landmarks in the radiographic assessment of hindfoot alignment
leads to an important valgus inclination of the calcaneal
axis that could explain our findings.
Unfortunately, it is impossible to ascertain which of the
available radiographic measurements, including the HAA used
777
in our study, represents better the real 3-dimensional alignment
of the hindfoot.20,25,31,33 The option to use the HAA in our study
was made aiming to increase the reliability and the clinical
meaningfulness of the radiographic measurements.38 It is our
understanding that the advent of cutting-edge technology such
as weightbearing computed tomography (WBCT) and its
3-dimensional reconstructed images might help us to better
understand hindfoot alignment and to assess which of the
radiographic alignment measurements correlates better to real
positioning of the hindfoot.8,12,14,19,27,30
One important strength of our study is the fact that we
used a standardized approach in the assessment of clinical
hindfoot alignment. The proper assessment of clinical alignment represents an important challenge, and adequate methods are still debatable in the literature.3,16,18,25 We have
decided to use RCSP and STCA because they represent the
most commonly used systematic angular evaluation of clinical alignment of the hindfoot.1,17,18,25 Our assessment
included controlled positioning of the patients and their feet
and detailed alignment of the camera in multiple angulations to account for possible variability and misinterpretation of the alignment. Our measurements also included a
systematic measurement of the acquired images, with
sequential marking of multiple lines aiming to achieve the
most reliable measurement of RCSP and STCA. All these
factors contributed to the very high intraobserver and
interobserver reliability for clinical alignment measurements achieved in our study. Another important and unique
finding was that the different vertical angulations of the
photographs in 0, 20, and 40 degrees did not significantly
influence readings of the clinical alignment.
Our study has some important limitations. First, the
comparison of clinical and radiographic hindfoot alignment
was not performed in normal controls or in patients with
clinical varus alignment. It would be interesting to evaluate
if the same differences favoring increased HAA in valgus
alignment would be found patients without AAFD. Second,
no power analysis was performed. However, the statistically significant findings of our study demonstrate adequate
sample size. Third, even with the use of a standardized protocol for acquisition and interpretation of radiographic and
clinical images, with careful control for rotational misalignment, there is always some variability and inaccuracy in
performing the measurements.
In conclusion, our study demonstrated significant correlation between radiographic and clinical hindfoot alignment
in patients with stage II AAFD. Radiographic measurements of HAA demonstrated significantly increased valgus
alignment of the hindfoot compared to a standardized clinical evaluation. The results of our study suggest that clinical
evaluation of hindfoot alignment in patients with AAFD
potentially underestimates the bony valgus deformity. One
should consider these findings when using clinical evaluation in the treatment algorithm of flatfoot patients.
Table of Contents for the Digital Edition of Foot & Ankle International - July 2018
Contents
Foot & Ankle International - July 2018 - Intro
Foot & Ankle International - July 2018 - Cover1
Foot & Ankle International - July 2018 - Cover2
Foot & Ankle International - July 2018 - i
Foot & Ankle International - July 2018 - ii
Foot & Ankle International - July 2018 - Contents
Foot & Ankle International - July 2018 - iv
Foot & Ankle International - July 2018 - v
Foot & Ankle International - July 2018 - vi
Foot & Ankle International - July 2018 - vii
Foot & Ankle International - July 2018 - viii
Foot & Ankle International - July 2018 - 1A
Foot & Ankle International - July 2018 - 1B
Foot & Ankle International - July 2018 - ix
Foot & Ankle International - July 2018 - x
Foot & Ankle International - July 2018 - xi
Foot & Ankle International - July 2018 - xii
Foot & Ankle International - July 2018 - 2A
Foot & Ankle International - July 2018 - 2B
Foot & Ankle International - July 2018 - xiii
Foot & Ankle International - July 2018 - xiv
Foot & Ankle International - July 2018 - xv
Foot & Ankle International - July 2018 - xvi
Foot & Ankle International - July 2018 - xvii
Foot & Ankle International - July 2018 - xviii
Foot & Ankle International - July 2018 - xix
Foot & Ankle International - July 2018 - xx
Foot & Ankle International - July 2018 - xxi
Foot & Ankle International - July 2018 - xxii
Foot & Ankle International - July 2018 - xxiii
Foot & Ankle International - July 2018 - xxiv
Foot & Ankle International - July 2018 - xxv
Foot & Ankle International - July 2018 - xxvi
Foot & Ankle International - July 2018 - 3A
Foot & Ankle International - July 2018 - 3B
Foot & Ankle International - July 2018 - 763
Foot & Ankle International - July 2018 - 764
Foot & Ankle International - July 2018 - 765
Foot & Ankle International - July 2018 - 766
Foot & Ankle International - July 2018 - 767
Foot & Ankle International - July 2018 - 768
Foot & Ankle International - July 2018 - 769
Foot & Ankle International - July 2018 - 770
Foot & Ankle International - July 2018 - 771
Foot & Ankle International - July 2018 - 772
Foot & Ankle International - July 2018 - 773
Foot & Ankle International - July 2018 - 774
Foot & Ankle International - July 2018 - 775
Foot & Ankle International - July 2018 - 776
Foot & Ankle International - July 2018 - 777
Foot & Ankle International - July 2018 - 778
Foot & Ankle International - July 2018 - 779
Foot & Ankle International - July 2018 - 780
Foot & Ankle International - July 2018 - 781
Foot & Ankle International - July 2018 - 782
Foot & Ankle International - July 2018 - 783
Foot & Ankle International - July 2018 - 784
Foot & Ankle International - July 2018 - 785
Foot & Ankle International - July 2018 - 786
Foot & Ankle International - July 2018 - 787
Foot & Ankle International - July 2018 - 788
Foot & Ankle International - July 2018 - 789
Foot & Ankle International - July 2018 - 790
Foot & Ankle International - July 2018 - 791
Foot & Ankle International - July 2018 - 792
Foot & Ankle International - July 2018 - 793
Foot & Ankle International - July 2018 - 794
Foot & Ankle International - July 2018 - 795
Foot & Ankle International - July 2018 - 796
Foot & Ankle International - July 2018 - 797
Foot & Ankle International - July 2018 - 798
Foot & Ankle International - July 2018 - 799
Foot & Ankle International - July 2018 - 800
Foot & Ankle International - July 2018 - 801
Foot & Ankle International - July 2018 - 802
Foot & Ankle International - July 2018 - 803
Foot & Ankle International - July 2018 - 804
Foot & Ankle International - July 2018 - 805
Foot & Ankle International - July 2018 - 806
Foot & Ankle International - July 2018 - 807
Foot & Ankle International - July 2018 - 808
Foot & Ankle International - July 2018 - 809
Foot & Ankle International - July 2018 - 810
Foot & Ankle International - July 2018 - 811
Foot & Ankle International - July 2018 - 812
Foot & Ankle International - July 2018 - 813
Foot & Ankle International - July 2018 - 814
Foot & Ankle International - July 2018 - 815
Foot & Ankle International - July 2018 - 816
Foot & Ankle International - July 2018 - 817
Foot & Ankle International - July 2018 - 818
Foot & Ankle International - July 2018 - 819
Foot & Ankle International - July 2018 - 820
Foot & Ankle International - July 2018 - 821
Foot & Ankle International - July 2018 - 822
Foot & Ankle International - July 2018 - 823
Foot & Ankle International - July 2018 - 824
Foot & Ankle International - July 2018 - 825
Foot & Ankle International - July 2018 - 826
Foot & Ankle International - July 2018 - 827
Foot & Ankle International - July 2018 - 828
Foot & Ankle International - July 2018 - 829
Foot & Ankle International - July 2018 - 830
Foot & Ankle International - July 2018 - 831
Foot & Ankle International - July 2018 - 832
Foot & Ankle International - July 2018 - 833
Foot & Ankle International - July 2018 - 834
Foot & Ankle International - July 2018 - 835
Foot & Ankle International - July 2018 - 836
Foot & Ankle International - July 2018 - 837
Foot & Ankle International - July 2018 - 838
Foot & Ankle International - July 2018 - 839
Foot & Ankle International - July 2018 - 840
Foot & Ankle International - July 2018 - 841
Foot & Ankle International - July 2018 - 842
Foot & Ankle International - July 2018 - 843
Foot & Ankle International - July 2018 - 844
Foot & Ankle International - July 2018 - 845
Foot & Ankle International - July 2018 - 846
Foot & Ankle International - July 2018 - 847
Foot & Ankle International - July 2018 - 848
Foot & Ankle International - July 2018 - 849
Foot & Ankle International - July 2018 - 850
Foot & Ankle International - July 2018 - 851
Foot & Ankle International - July 2018 - 852
Foot & Ankle International - July 2018 - 853
Foot & Ankle International - July 2018 - 854
Foot & Ankle International - July 2018 - 855
Foot & Ankle International - July 2018 - 856
Foot & Ankle International - July 2018 - 857
Foot & Ankle International - July 2018 - 858
Foot & Ankle International - July 2018 - 859
Foot & Ankle International - July 2018 - 860
Foot & Ankle International - July 2018 - 861
Foot & Ankle International - July 2018 - 862
Foot & Ankle International - July 2018 - 863
Foot & Ankle International - July 2018 - 864
Foot & Ankle International - July 2018 - 865
Foot & Ankle International - July 2018 - 866
Foot & Ankle International - July 2018 - 867
Foot & Ankle International - July 2018 - 868
Foot & Ankle International - July 2018 - 869
Foot & Ankle International - July 2018 - 870
Foot & Ankle International - July 2018 - 871
Foot & Ankle International - July 2018 - 872
Foot & Ankle International - July 2018 - 873
Foot & Ankle International - July 2018 - 874
Foot & Ankle International - July 2018 - 875
Foot & Ankle International - July 2018 - 876
Foot & Ankle International - July 2018 - 877
Foot & Ankle International - July 2018 - 878
Foot & Ankle International - July 2018 - 879
Foot & Ankle International - July 2018 - 880
Foot & Ankle International - July 2018 - 881
Foot & Ankle International - July 2018 - 882
Foot & Ankle International - July 2018 - 883
Foot & Ankle International - July 2018 - 884
Foot & Ankle International - July 2018 - Cover3
Foot & Ankle International - July 2018 - Cover4
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_december2020
https://www.nxtbook.com/nxtbooks/sage/psychologicalscience_demo
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_october2020
https://www.nxtbook.com/nxtbooks/sage/fai_202009
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_august2020
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_june2020
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_april2020
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_february2020
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_december2019
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_october2019
https://www.nxtbook.com/nxtbooks/sage/fai_201909
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_july2019
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_june2019
https://www.nxtbook.com/nxtbooks/sage/canadianpharmacistsjournal_05062019
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_april2019
https://www.nxtbook.com/nxtbooks/sage/sri_supplement_201903
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_february2019
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_december2018
https://www.nxtbook.com/nxtbooks/sage/tec_20180810
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_october2018
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_julyaugust2018
https://www.nxtbook.com/nxtbooks/sage/fai_201807
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_june2018
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_april2018
https://www.nxtbook.com/nxtbooks/sage/sri_supplement_201803
https://www.nxtbook.com/nxtbooks/sage/slas_discovery_201712
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_february2018
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_december2017
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_november2017
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_october2017
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_september2017
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_julyaugust2017
https://www.nxtbook.com/nxtbooks/sage/fai_supplement_201709
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_june2017
https://www.nxtbook.com/nxtbooks/sage/hospitalpharmacy_may2017
https://www.nxtbook.com/nxtbooks/sage/fai_201706
https://www.nxtbook.com/nxtbooks/sage/fai_201607
https://www.nxtbookmedia.com