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772
valgus alignment in patients with AAFD is part of the staging
and operative planning of the disease5,21,22,28,29 and usually
involves clinical and radiographic evaluation in the standing
position.2,3 Different clinical and radiographic assessment
modalities have been proposed in the literature.7,10,11,20,33
Clinical evaluation of hindfoot coronal alignment is performed through observation of surface landmarks, including the skin, the Achilles tendon, and bony prominences. It
represents an attempt to predict the bone alignment of the
hindfoot. It has been shown to be unreliable even when performed by experienced observers, with or without the use of
goniometers.2,18,23,36
Radiographic assessment can potentially better demonstrate the true bone alignment of the hindfoot. However,
measurement of radiographic parameters of the foot and
ankle on conventional radiographs is significantly influenced by misalignment, overlapping and enlargement of
bone structures due to the projectional nature of the
images.4,32,37 Controlling for correct and reliable positioning of the foot and ankle during acquisition of the images
represents a challenge and an important limitation of any
radiographic measurement studies.32
Williamson et al38 proposed a new radiographic parameter
in the assessment of hindfoot alignment of patients with stage
II AAFD. The hindfoot alignment angle (HAA) takes into consideration specific bony anatomical landmarks to define the
axis of the calcaneus, including the lateral wall of the calcaneal
tuberosity laterally and the sustentaculum tali medially. The
landmarks are easily assessed and optimize the intraobserver
and interobserver reliability of the measurement. The authors
also demonstrated that the HAA represented an adequate tool
in the differentiation between flatfoot and normal patients and
that the angle correlated significantly with the hindfoot
moment arm, as described by Saltzman and el-Khoury.33
Successful clinical outcomes after AAFD reconstruction
are closely correlated with adequate hindfoot valgus correction.9,13 However, it is not clear if differences exist between
clinical and radiographic assessment of hindfoot valgus.35
The development of standardized clinical and radiographic
measurement tools to optimize the evaluation of hindfoot
alignment would allow more accurate assessment of treatment outcomes.
The purpose of this study was to assess whether in a controlled and prospective evaluation, accounting for standardized positioning of the lower extremity, there would be
significant correlation between clinical and radiographic
hindfoot alignment measurements, using the HAA, in
patients with stage II AAFD.
Methods
Institutional review board approval was obtained for this
prospective comparative study, which complied with the
Declaration of Helsinki and the Health Insurance Portability
Foot & Ankle International 39(7)
and Accountability Act (HIPAA). All participants signed a
written informed consent.
Study Design
We prospectively recruited consecutive patients from
February 2015 through October 2015. The inclusion criteria
consisted of a clinical diagnosis of symptomatic stage II
AAFD, indication for operative treatment, an age of 18
years or older, the ability to communicate effectively with
clinical study personnel, and the ability to stand still for
acquisition of weightbearing clinical pictures and radiographic studies. We excluded patients with major arthritic
findings in the subtalar, talonavicular, and/or calcaneocuboid joints; pregnant women; patients with prior operative
procedures in the affected foot and ankle; and patients with
clinical pictures and/or radiographic studies that did not fulfill necessary quality for assessment.
Patients
Twenty-nine patients (30 feet, 12 right side and 18 left side)
were included in the study. The cohort consisted of 17 men and
12 women, with a mean age of 51 years (range, 20-71 years)
and a mean body mass index (BMI) of 28.6 kg/m2 (range, 21.137.8 kg/m2). A CONSORT diagram of screened, excluded, and
included patients is presented in Figure 1.
Clinical Evaluation
All patients were clinically evaluated and diagnosed with
stage II AAFD. A series of clinical photographs were taken.
Patients were instructed to stand in a comfortable natural
stance position, facing away from the camera and with
hands hanging by the side of the body. The feet were maintained shoulder-width apart with relaxed longitudinal
arches. The medial border of each foot was positioned over
2 parallel lines that were drawn into the floor, controlling
for rotational misalignment. With the medial aspect of the
back of the heels along the predefined lines, the camera was
positioned at a distance of 110 cm from the foot (110 cm
heel-to-lens distance), to mimic the distance used in the
patient positioning during acquisition of the radiographic
images, and was horizontally centered in the midline of the
body. The camera was then adjusted to 3 clinically relevant
vertical angles representing the positioning of the feet in the
floor level (0 degrees), the same angulation used for a
Saltzman radiographic view (20 degrees), and a comfortable positioning for a clinician to be seated observing the
hindfoot alignment (40 degrees) (Figure 2):
** Ground-level view: camera positioned at ground
level, with 0 degrees of vertical angulation
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
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Foot & Ankle International - July 2018 - xi
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Foot & Ankle International - July 2018 - 2A
Foot & Ankle International - July 2018 - 2B
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Foot & Ankle International - July 2018 - 3A
Foot & Ankle International - July 2018 - 3B
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Foot & Ankle International - July 2018 - Cover3
Foot & Ankle International - July 2018 - Cover4
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