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Correlation of Knee and Hindfoot Deformities in Advanced Knee OA: Compensatory Hindfoot Alignment and Where It Occurs

  • Symposium: 2014 Knee Society Proceedings
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

Many patients undergoing TKA have both knee and ankle pathology, and it seems likely that some compensatory changes occur at each joint in response to deformity at the other. However, it is not fully understood how the foot and ankle compensate for a given varus or valgus deformity of the knee.

Questions/purposes

(1) What is the compensatory hindfoot alignment in patients with end-stage osteoarthritis who undergo total knee arthroplasty (TKA)? (2) Where in the hindfoot does the compensation occur?

Methods

Between January 1, 2005, and December 31, 2009, one surgeon (JJC) obtained full-length radiographs on all patients undergoing primary TKA (N = 518) as part of routine practice; patients were analyzed for the current study and after meeting inclusion criteria, a total of 401 knees in 324 patients were reviewed for this analysis. Preoperative standing long-leg AP radiographs and Saltzman hindfoot views were analyzed for the following measurements: mechanical axis angle, Saltzman hindfoot alignment and angle, anatomic lateral distal tibial angle, and the ankle line convergence angle. Statistical analysis included two-tailed Pearson correlations and linear regression models. Intraobserver and interobserver intraclass coefficients for the measurements considered were evaluated and all were excellent (in excess of 0.8).

Results

As the mechanical axis angle becomes either more varus or valgus, the hindfoot will subsequently orient in more valgus or varus position, respectively. For every degree increase in the valgus mechanical axis angle, the hindfoot shifts into varus by −0.43° (95% confidence interval [CI], −0.76° to −0.1°; r = −0.302, p = 0.0012). For every degree increase in the varus mechanical axis angle, the hindfoot shifts into valgus by −0.49° (95% CI, −0.67° to −0.31°; r = −0.347, p < 0.0001). In addition, the subtalar joint had a strong positive correlation (r = 0.848, r2 = 0.72, p < 0.0001) with the Saltzman hindfoot angle, whereas the anatomic lateral distal tibial angle (r = 0.450, r2 = 0.20, p < 0.0001) and the ankle line convergence angle (r = 0.319, r2 = 0.10, p < 0.0001) had a moderate positive correlation. The coefficient of determination (r2) shows that 72% of the variance in the overall hindfoot angle can be explained by changes in the subtalar joint orientation.

Conclusions

These findings have implications for treating patients with both knee and foot/ankle problems. For example, a patient with varus arthritis of the knee should be examined for fixed hindfoot valgus deformity. The concern is that patients undergoing TKA, who also present with a stiff subtalar joint, may have exacerbated, post-TKA foot/ankle pain or disability or malalignment of the lower extremity mechanical axis as a result of the inability of the subtalar joint to reorient itself after knee realignment. A prospective study is underway to confirm this speculation.

Level of Evidence

Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

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References

  1. Bouysset M, Hugueny P. The rheumatoid foot: pathomechanics, clinical and radiological features. Therapeutic conditions. In: Bouysset M, Tourne Y, Tillmann K, eds. Foot and Ankle in Rheumatoid Arthritis. Paris, France: Springer Verlag; 2006:9–48.

  2. Chandler JT, Moskal JT. Evaluation of knee and hindfoot alignment before and after total knee arthroplasty: a prospective analysis. J Arthroplasty. 2004;19:211–216.

    Article  PubMed  Google Scholar 

  3. Desai SS, Shetty GM, Song HR, Lee SH, Kim TY, Hur CY. Effect of foot deformity on conventional mechanical axis deviation and ground mechanical axis deviation during single leg stance and two leg stance in genu varum. Knee. 2007;14:452–457.

    Article  PubMed  Google Scholar 

  4. Keenan M, Peabody T, Gronley J, Perry J. Valgus deformities of the feet and characteristics of gait in patients who have rheumatoid arthritis. J Bone Joint Surg Am. 1991;73:237–247.

    CAS  PubMed  Google Scholar 

  5. Kraus VB, Vail TP, Worrell T, McDaniel G. A Comparative Assessment of Alignment Angle of the Knee by Radiographic and Physical Examination Methods. Hoboken, NJ, USA: Wiley Subscription Services, Inc, a Wiley Company; 2005.

    Google Scholar 

  6. Lee KM, Chung CY, Park MS, Lee SH, Cho JH, Choi IH. Reliability and validity of radiographic measurements in hindfoot varus and valgus. J Bone Joint Surg Am. 2010;92:2319–2327.

    Article  PubMed  Google Scholar 

  7. Mullaji A, Shetty G. Persistent hindfoot valgus causes lateral deviation of weightbearing axis after total knee arthroplasty. Clin Orthop Relat Res. 2011;469:1154–1160.

    Article  PubMed Central  PubMed  Google Scholar 

  8. Paley D. Principles of Deformity Correction. Berlin, Germany: Springer; 2002:1–18.

    Book  Google Scholar 

  9. Reilingh ML, Beimers L, Tuijthof GJM, Stufkens SAS, Maas M, Dijk CN. Measuring hindfoot alignment radiographically: the long axial view is more reliable than the hindfoot alignment view. Skeletal Radiol. 2010;39:1103–1108.

    Article  PubMed Central  PubMed  Google Scholar 

  10. Saltzman CL, el-Khoury GY. The hindfoot alignment view. Foot Ankle Int. 1995;16:572–576.

  11. Sheehy L, Felson D, Zhang Y, Niu J, Lam Y, Segal N, Lynch J, Cooke TD. Does measurement of the anatomic axis consistently predict hip-knee-ankle angle (HKA) for knee alignment studies in osteoarthritis? Analysis of long limb radiographs from the multicenter osteoarthritis (MOST) study. Osteoarthritis Cartilage. 2011;19:58–64.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  12. Sobel M, Stern SH, Manoli A II, Bohne WHO. The association of posterior tibialis tendon insufficiency with valgus osteoarthritis of the knee. Am J Knee Surg. 1992;5:59–64.

    Google Scholar 

  13. Souter WA. Surgical strategy in surgery of the lower limb in rheumatoid arthritis. In: Bouysset M, Tourne Y, Tillmann K, eds. Foot and Ankle in Rheumatoid Arthritis. Paris, France: Springer Verlag; 2006:229–236.

    Chapter  Google Scholar 

  14. Stanish WD, Curwin S. Tendinitis: Its Etiology and Treatment. Lexington, MA, USA: DC Heath & Co; 1984.

    Google Scholar 

  15. Stufkens SA, Barg A, Bolliger L, Stucinskas J, Knupp M, Hintermann B. Measurement of the medial distal tibial angle. Foot Ankle Int. 2011;32:288–293.

    Article  PubMed  Google Scholar 

  16. Tiberio D. Pathomechanics of structural foot deformities. Phys Ther. 1988;68:1840.

    CAS  PubMed  Google Scholar 

  17. Tillman K. The Rheumatoid Foot: Diagnosis, Pathomechanics, and Treatment. New York, NY, USA: Thieme Medical Publishers, Inc; 1979:48.

  18. Winter DA. Biomechanics of Human Movement. New York, NY, USA: John Wiley & Sons Inc; 1979.

    Google Scholar 

  19. Yehyawi TM, Callaghan JJ, Pedersen DR, O’Rourke MR, Liu SS. Variances in sagittal femoral shaft bowing in patients undergoing TKA. Clin Orthop Relat Res. 2007;464:99–104.

    PubMed  Google Scholar 

Download references

Acknowledgments

We thank Yubo Gao PhD, for assistance with statistical analysis.

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Authors and Affiliations

Authors

Corresponding author

Correspondence to John J. Callaghan MD.

Additional information

One of the authors certifies that he (AA) has or may receive payments or benefits, during the study period an amount USD 100,000 to USD 1,000,000 from Arthrex (Naples, FL, USA), an amount less than USD 10,000 from Arthrosurface (Franklin, MA, USA), and an amount USD 100,000 to USD 1,000,000 from MTP Solutions (Logan, UT, USA). One of the authors certifies that he (JJC) has or may receive payments or benefits, during the study period an amount more than USD 1,000,001 from DePuy (Warsaw, IN, USA) and an amount less than USD 10,000 from Lippincott Williams & Wilkins (Riverwoods, IL, USA).

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research ® editors and board members are on file with the publication and can be viewed on request.

Clinical Orthopaedics and Related Research ® neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA-approval status, of any drug or device prior to clinical use.

Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

This work was performed at the University of Iowa Hospitals and Clinics, Iowa City, IA, USA.

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Norton, A.A., Callaghan, J.J., Amendola, A. et al. Correlation of Knee and Hindfoot Deformities in Advanced Knee OA: Compensatory Hindfoot Alignment and Where It Occurs. Clin Orthop Relat Res 473, 166–174 (2015). https://doi.org/10.1007/s11999-014-3801-9

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  • DOI: https://doi.org/10.1007/s11999-014-3801-9

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