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Does Alignment in the Hindfoot Radiograph Influence Dynamic Foot-floor Pressures in Ankle and Tibiotalocalcaneal Fusion?

  • Clinical Research
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

The Saltzman-el-Khoury hindfoot alignment view (HAV) is considered the gold standard for assessing the axis from hindfoot to tibia. However, it is unclear whether radiographic alignment influences dynamic load distribution during gait.

Questions/purposes

We evaluated varus-valgus alignment by the HAV and its influence on dynamic load distribution in ankle and tibiotalocalcaneal (TTC) arthrodesis.

Patients and Methods

We clinically assessed 98 patients (ankle, 56; TTC, 42) with SF-36 and American Orthopaedic Foot and Ankle Society (AOFAS) scores, visual hindfoot alignment, HAV angle, and dynamic pedobarography using a five-step method. For comparison, 70 normal feet were evaluated. Minimum followup was 2 years (average, 4.11 years; range, 2–6 years).

Results

The mean HAV angle was −0.8° ± 7.8° for ankle and −1.2° ± 6.9° for TTC arthrodesis. The HAV angle correlated with pedobarographic load distribution (r = 0.35–0.53). Radiographic alignment did not influence SF-36 or AOFAS scores; however, load distribution correlated to qualities of these scores. Visual alignment only predicted the corresponding HAV angle in 48%. To reproduce the dynamic load of healthy subjects, HAV angles of 5° to 10° valgus were needed.

Conclusions

Visual positioning is inadequate to determine intraoperative positioning and resulted in a varus position with a relatively large SD. The HAV should be used to assess the hindfoot alignment correctly. HAV angles of 5° to 10° valgus are needed to reproduce a physiologic gait pattern.

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References

  1. Backer M, Kofoed H. Passive ankle mobility: clinical measurement compared with radiography. J Bone Joint Surg Br. 1989;71:696–698.

    CAS  PubMed  Google Scholar 

  2. Baumann JH, Girling JP, Brand PW. Plantar pressures and trophic ulceration: an evaluation of footwear. J Bone Joint Surg Br. 1963;45:652–673.

    Google Scholar 

  3. Bosch K, Nagel A, Weigend L, Rosenbaum D. From “first” to “last” steps in life: pressure patterns of three generations. Clin Biomech (Bristol, Avon). 2009;24:676–681.

    Article  Google Scholar 

  4. Brinker M. Review of Orthopaedic Trauma. Philadelphia, PA: WB Saunders; 2001.

    Google Scholar 

  5. Buck P, Morrey BF, Chao EY. The optimum position of arthrodesis of the ankle: a gait study of the knee and ankle. J Bone Joint Surg Am. 1987;69:1052–1062.

    CAS  PubMed  Google Scholar 

  6. Burns J, Crosbie J, Hunt A, Ouvrier R. The effect of pes cavus on foot pain and plantar pressure. Clin Biomech (Bristol, Avon). 2005;20:877–882.

    Article  Google Scholar 

  7. Chang CH, Miller F, Schuyler J. Dynamic pedobarograph in evaluation of varus and valgus foot deformities. J Pediatr Orthop. 2002;22:813–818.

    Article  PubMed  Google Scholar 

  8. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40:373–383.

    Article  CAS  PubMed  Google Scholar 

  9. Child BJ, Hix J, Catanzariti AR, Mendicino RW, Saltrick K. The effect of hindfoot realignment in triple arthrodesis. J Foot Ankle Surg. 2009;48:285–293.

    Article  PubMed  Google Scholar 

  10. Cobey JC. Posterior roentgenogram of the foot. Clin Orthop Relat Res. 1976;118:202–207.

    PubMed  Google Scholar 

  11. Cobey JC, Sella E. Standardizing methods of measurement of foot shape by including the effects of subtalar rotation. Foot Ankle. 1981;2:30–36.

    CAS  PubMed  Google Scholar 

  12. Coester LM, Saltzman CL, Leupold J, Pontarelli W. Long-term results following ankle arthrodesis for post-traumatic arthritis. J Bone Joint Surg Am. 2001;83:219–228.

    PubMed  Google Scholar 

  13. Cohen J. Statistical Power Analysis for the Behavioral Sciences. Ed 2. New York, NY: Routledge Academic; 1988.

    Google Scholar 

  14. Cooper DM, Dietz FR. Treatment of idiopathic clubfoot: a thirty-year follow-up note. J Bone Joint Surg Am. 1995;77:1477–1489.

    CAS  PubMed  Google Scholar 

  15. Coughlin M, Mann R, Saltzman C, eds. Surgery of the Foot and Ankle. Ed 8. Philadelphia, PA: Elsevier; 2007.

    Google Scholar 

  16. Duckworth T, Boulton AJ, Betts RP, Franks CI, Ward JD. Plantar pressure measurements and the prevention of ulceration in the diabetic foot. J Bone Joint Surg Br. 1985;67:79–85.

    CAS  PubMed  Google Scholar 

  17. Giannini S, Buda R, Faldini C, Vannini F, Romagnoli M, Grandi G, Bevoni R. The treatment of severe posttraumatic arthritis of the ankle joint. J Bone Joint Surg Am. 2007;89(suppl 3):15–28.

    Article  PubMed  Google Scholar 

  18. Hennessy MS, Molloy AP, Wood EV. Management of the varus arthritic ankle. Foot Ankle Clin. 2008;13:417–442, viii.

    Article  PubMed  Google Scholar 

  19. Holmes GB Jr, Timmermann L. A quantitative assessment of the effect of metatarsal pads on plantar pressures. Foot Ankle. 1990;11:141–145.

    PubMed  Google Scholar 

  20. Hutton WC, Dhanendran M. The mechanism of normal and hallux valgus feet: a quantitative study. Clin Orthop Relat Res. 1981;157:7–13.

    PubMed  Google Scholar 

  21. Johnson JE, Lamdan R, Granberry WF, Harris GF, Carrera GF. Hindfoot coronal alignment: a modified radiographic method. Foot Ankle Int. 1999;20:818–825.

    CAS  PubMed  Google Scholar 

  22. Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS, Sanders M. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int. 1994;15:349–353.

    CAS  PubMed  Google Scholar 

  23. MacWilliams BA, Armstrong PF. Clinical applications of plantar pressure measurement in pediatric orthopedics. Pediatr Gait. 2000;40:143–150.

    Google Scholar 

  24. MacWilliams BA, Cowley M, Nicholson DE. Foot kinematics and kinetics during adolescent gait. Gait Posture. 2003;17:214–224.

    PubMed  Google Scholar 

  25. Mann RA. Surgical implications of biomechanics of the foot and ankle. Clin Orthop Relat Res. 1980;146:111–118.

    PubMed  Google Scholar 

  26. Metaxiotis R, Accles W, Pappas A, Doederlin L. Dynamic pedobarography (DPB) in operative management of cavovarus foot deformity. Foot Ankle Int. 2000;21:935–947.

    CAS  PubMed  Google Scholar 

  27. Miller M. Review of Orthopaedics. Ed 4. Philadelphia, PA: WB Saunders; 2004.

    Google Scholar 

  28. Minns RJ, Craxford AD. Pressure under the forefoot in rheumatoid arthritis: a comparison of static and dynamic methods of assessment. Clin Orthop Relat Res. 1984:187:235–242.

    PubMed  Google Scholar 

  29. Morrey BF, Wiedeman GP Jr. Complications and long-term results of ankle arthrodesis following trauma. J Bone Joint Surg Am. 1980;62:777–784.

    CAS  PubMed  Google Scholar 

  30. Morris JM. Biomechanics of the foot and ankle. Clin Orthop Relat Res. 1977;122:10–17.

    PubMed  Google Scholar 

  31. Pagenstert GI, Hintermann B, Barg A, Leumann A, Valderrabano V. Realignment surgery as alternative treatment of varus and valgus ankle osteoarthritis. Clin Orthop Relat Res. 2007;462:156–168.

    Article  PubMed  Google Scholar 

  32. Rammelt S, Grass R, Zawadski T, Biewener A, Zwipp H. Foot function after subtalar distraction bone-block arthrodesis: a prospective study. J Bone Joint Surg Br. 2004;86:659–668.

    Article  CAS  PubMed  Google Scholar 

  33. Richter M, Frink M, Zech S, Vanin N, Geerling J, Droste P, Krettek C. Intraoperative pedography: a validated method for static intraoperative biomechanical assessment. Foot Ankle Int. 2006;27:833–842.

    PubMed  Google Scholar 

  34. Richter M, Zech S. Computer assisted surgery (CAS) guided arthrodesis of the foot and ankle: an analysis of accuracy in 100 cases. Foot Ankle Int. 2008;29:1235–1242.

    Article  PubMed  Google Scholar 

  35. Richter M, Zech S, Bay R. 3D imaging (ARCADIS)-based computer assisted surgery (CAS) for nail placement in combined ankle and subtalar fusion. Foot Ankle Int. 2008;29:1249–1252.

    Article  PubMed  Google Scholar 

  36. Saltzman CL, Brandser EA, Berbaum KS, DeGnore L, Holmes JR, Katcherian DA, Teasdall RD, Alexander IJ. Reliability of standard foot radiographic measurements. Foot Ankle Int. 1994;15:661–665.

    CAS  PubMed  Google Scholar 

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

    CAS  PubMed  Google Scholar 

  38. Saltzman CL, Nawoczenski DA, Talbot KD. Measurement of the medial longitudinal arch. Arch Phys Med Rehabil. 1995;76:45–49.

    Article  CAS  PubMed  Google Scholar 

  39. Simoneau GG, Ulbrecht JS, Derr JA, Becker MB, Cavanagh PR. Postural instability in patients with diabetic sensory neuropathy. Diabetes Care. 1994;17:1411–1421.

    Article  CAS  PubMed  Google Scholar 

  40. Stockley I, Betts RP, Rowley DI, Getty CJ, Duckworth T. The importance of the valgus hindfoot in forefoot surgery in rheumatoid arthritis. J Bone Joint Surg Br. 1990:72:705–708.

    CAS  PubMed  Google Scholar 

  41. Stokes IA, Faris IB, Hutton WC. The neuropathic ulcer and loads on the foot in diabetic patients. Acta Orthop Scand. 1975;46:839–847.

    Article  CAS  PubMed  Google Scholar 

  42. van Bergeyk AB, Younger A, Carson B. CT analysis of hindfoot alignment in chronic lateral ankle instability. Foot Ankle Int. 2002;23:37–42.

    PubMed  Google Scholar 

  43. Ware JE, Kosinski M, Dewey JE. How to Score Version 2 of the SF-36 Health Survey. Lincoln, RI: QualityMetric Inc; 2000.

    Google Scholar 

  44. Weseley MS, Koval R, Kleiger B. Roentgen measurement of ankle flexion-extension motion. Clin Orthop Relat Res. 1969;65:167–174.

    Article  CAS  PubMed  Google Scholar 

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Acknowledgments

We thank Dr. Dougall and Dr. Russell from the Department of Foot and Ankle Surgery, University of Calgary, Canada, for support and providing cases. We also thank Laura Hinz and Leah Diaz for helping to follow the patients.

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Authors and Affiliations

  1. Department of Orthopaedics, University of Calgary, Calgary, Canada

    Arno Frigg MD & Beth Pederson MD

  2. Human Performance Laboratory, University of Calgary, Calgary, Canada

    Arno Frigg MD, Benno Nigg PhD, Elysia Davis MSc & V. Valderrabano MD, PhD

  3. Department of Orthopaedic Surgery, University of Basel Hospital, Spitalstrasse 21, CH-4031, Basel, Switzerland

    Arno Frigg MD & V. Valderrabano MD, PhD

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  1. Arno Frigg MD
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  2. Benno Nigg PhD
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  3. Elysia Davis MSc
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  5. V. Valderrabano MD, PhD
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Correspondence to Arno Frigg MD.

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Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

Each author certifies that his or her institution approved the human protocol for this investigation and 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 Department of Orthopaedic Surgery and Human Performance Laboratory of the University of Calgary.

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Frigg, A., Nigg, B., Davis, E. et al. Does Alignment in the Hindfoot Radiograph Influence Dynamic Foot-floor Pressures in Ankle and Tibiotalocalcaneal Fusion?. Clin Orthop Relat Res 468, 3362–3370 (2010). https://doi.org/10.1007/s11999-010-1449-7

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  • DOI: https://doi.org/10.1007/s11999-010-1449-7

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