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Foot & Ankle International 39(7)
Table 2. R2, Parameter Estimate, Intercept, and P Values for Linear Regression Models Evaluating the Correlation Between Clinical
Hindfoot Alignment (in 3 Different Vertical Camera Angulations of 0, 20, and 40 Degrees) and Radiographic Hindfoot Alignment.
Hindfoot Moment Arm
Clinical Hindfoot
Resting calcaneal stance position
0 degrees
20 degrees
40 degrees
Standing tibiocalcaneal angle
0 degrees
20 degrees
40 degrees
Hindfoot Alignment Angle
R2
Parameter
Estimate
Intercept
P Value
R2
Parameter
Estimate
Intercept
0.1
0.1
0.1
0.7
0.8
0.7
11.1
10.5
11.9
.02a
.002a
.003a
0.1
0.2
0.2
0.8
0.9
0.8
14.6
14.3
15.8
0.1
0.1
0.1
0.7
0.6
0.4
10.3
10.8
13.8
.006a
.003a
.02a
0.2
0.2
0.2
0.9
0.8
0.6
12.3
13.0
16.3
P Value
.007a
.001a
.00090a
.0002a
<.0001a
.001a
a
P < .05.
from the RCSP (CI, 11.0-14.5; P < .0001) and 11.0 degrees
from the STCA (CI, 9.2-12.8; P < .0001). The STCA was
also found to demonstrate slightly increased valgus alignment compared to RCSP (mean difference, 1.8 degrees; CI,
0.5-3.0; P = .0027).
Discussion
Our prospective comparative study demonstrated significant correlation between clinical and radiographic hindfoot
alignment evaluation in patients with AAFD, with substantial to almost perfect intraobserver and interobserver reliability for RCSP, STCA, HMA, and HAA. Clinical and
radiographic angular measurements were found to correlate
to each other, but the radiographic alignment, measured by
the HAA, demonstrated increased values for hindfoot
valgus compared to both clinical measurements (STCA and
RCSP). Our study findings indicate that clinical evaluation
could be used to predict bone alignment of the hindfoot in
patients with AAFD, but one should consider that it probably represents an underestimation of the valgus alignment
by 10 to 15 degrees.
Our results differ from prior studies that evaluated correlation between clinical and radiographic hindfoot alignment. Slullitel et al35 recently demonstrated weak correlation
between clinical and radiographic hindfoot alignment in
asymptomatic patients with different rearfoot alignments
and without AAFD. Their clinical evaluation was performed
subjectively by visual examination and interpretation of 4
different clinical pictures (posterior view of both lower
limbs, isolated posterior view of the hindfoot, anterior and
medial views of the foot). They then divided the patients
into 3 different groups (neutral, valgus, and varus alignment) and did not detail how the clinical hindfoot alignment
was measured. Regarding radiographic assessment, differently from our study, they used a long axial radiographic
view and a single calcaneal line as a reference for alignment
Figure 5. Graphical box plotting of the comparison between
hindfoot alignment angle (HAA), standing tibiocalcaneal angle
(STCA), and resting calcaneal stance position (RCSP). Significant
differences (*) were found between the measurements (P <
.0001), with radiographic HAA being significantly more valgus
compared to both clinical alignment measurements (STCA and
HAA).
and axial positioning of the calcaneus. The long axial view
has been shown to be possibly less influenced by rotational
malalignment during image acquisition6 and to provide a
more reliable assessment of angular measurements of hindfoot alignment compared to the hindfoot alignment view.31
However, the latter represents a more widespread and routinely used radiographic technique, which has excellent
reliability in the assessment of HMA33 and allows angular
measurements of hindfoot alignment that significantly correlate with measures performed in the long axial view.25
Another variable that might have influenced the results of
the referenced study is the fact that they used the osseous
contour of the lateral calcaneal wall as an isolated landmark
for assessing the axis of the calcaneus. Although this technique has been reported in the literature,20,34,35 it is our
Table of Contents for the Digital Edition of Foot & Ankle International - July 2018
Contents
Foot & Ankle International - July 2018 - Intro
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Foot & Ankle International - July 2018 - i
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Foot & Ankle International - July 2018 - Contents
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Foot & Ankle International - July 2018 - Cover3
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