Role of the weight-bearing cone-beam CT in evaluation of flatfoot deformity

Abstract

Introduction: Till date, weight-bearing radiographs have been the cornerstone for planning surgeries on flatfoot. The technique, however, has limitations due to the superimposition of the bones and the lack of reproducibility. Weight-bearing CT with its unique design overcomes these limitations and enables cross-sectional imaging of the foot to be done in the natural weight-bearing position. In this paper, we report our initial experience in weight-bearing cross-sectional imaging of the foot for assessment of flatfoot deformity. Materials and Methods: Around 19 known cases of flatfoot were scanned on the weight-bearing CT. Each foot was then assessed for the various angles and also for the presence/absence of extra-articular talocalcaneal impingement and subfibular impingement. Other associated abnormalities like secondary osteoarthritic changes, were also noted. Results: The Meary, as well as the calcaneal angles, were abnormal, in all but one separate foot. Forefoot abduction was seen in 7 of the 19 feet. The hind foot valgus angle was greater than 10° in all patients. Extra-articular talocalcaneal impingement was seen in 13 of 19 feet. Secondary osteoarthritic changes were seen in 14 feet. Conclusion: Weight-bearing CT scan is a very useful technique for evaluation of flatfoot and associated complications. It overcomes the limitations of the radiographs by providing multiplanar three-dimensional assessment of the foot in the natural weight-bearing position and at the same time being easily reproducible and consistent for the measurements around the foot. The definite advantage over the conventional cross-sectional scanners is the weight-bearing capability.

Keywords

Extremity CT - flatfoot - pes planus - weight-bearing CT

Publication History

Received: 09 July 2019

Accepted: 08 October 2019

Article published online:
21 July 2021

• References

• 1 Peeters K, Schreuer J, Burg F, Behets C, Van Bouwel S, Dereymaeker G. et al. Alterated talar and navicular bone morphology is associated with pes planus deformity: A CT-scan study. J Orthop Res 2013; 31: 282-7
• 2 Toullec E. Adult flatfoot. Orthop Traumatol Surg Res OTSR 2015; 101 Suppl (01) S11-7
• 3 Godoy-Santos AL, Cesar Netto C. Weight-Bearing Computed Tomography International Study Group. Weight-bearing computed tomography of the foot and ankle: An update and future directions. Acta Ortop Bras [online] 2018; 26: 135-9
• 4 Lintz F, Cesar Netto C. Weight Bearing CT International Study Group. Weight-bearing cone beam CT scans in the foot and ankle. EFORT Open Rev 2018; 3: 278-86
• 5 Ferri M, Scharfenberger AV, Goplen G, Daniels TR, Pearce D. Weightbearing CT scan of severe flexible pes planus deformities. Foot Ankle Int 2008; 29: 199-204
• 6 Van Bergeyk AB, Younger A, Carson B. CT analysis of hindfoot alignment in chronic lateral ankle instability. Foot Ankle Int 2002; 23: 37-42
• 7 Yoshioka N, Ikoma K, Kido M, Imai K, Maki M, Arai Y. et al. Weight-bearing three-dimensional computed tomography analysis of the forefoot in patients with flatfoot deformity. J Orthop Sci 2016; 21: 154-8
• 8 Zhang Y, Xu J, Wang X, Huang J, Zhang C, Chen L. et al. An in vivo study of hindfoot 3D kinetics in stage II posterior tibial tendon dysfunction (PTTD) flatfoot based on weight-bearing CT scan. Bone Joint Res 2013; 2: 255-63
• 9 Burssens A, Peeters J, Buedts K, Victor J, Vandeputte G. Measuring hindfoot alignment in weight bearing CT: A novel clinical relevant measurement method. Foot Ankle Surg 2016; 22: 233-8
• 10 Carrino JA, Al Muhit A, Zbijewski W, Thawait GK, Stayman JW, Packard N. et al. Dedicated cone-beam CT system for extremity imaging. Radiology 2014; 270: 816-24
• 11 de Cesar Netto C, Schon LC, Thawait GK, da Fonseca LF, Chinanuvathana A, Zbijewski WB. et al. Flexible adult acquired flatfoot deformity: Comparison between weight-bearing and non-weight-bearing measurements using conebeam computed tomography. J Bone Joint Surg Am 2017; 99: e98
• 12 de Cesar Netto, Shakoor D, Dein EJ, Zhang H, Thawait GK, Richter M. et al. Influence of investigator experience on reliability of adult acquired flatfoot deformity measurements using weightbearing computed tomography. Foot Ankle Surg 2019; 25: 495-502
• 13 Demehri S, Muhit A, Zbijewski W, Stayman JW, Yorkston J, Packard N. et al. Assessment of image quality in soft tissue and bone visualization tasks for a dedicated extremity cone-beam CT system. Eur Radiol 2015; 25: 1742-51
• 14 Gupta R, Cheung AC, Bartling SH, Lisauskas J, Grasruck M, Leidecker C. et al. Flatpanel volume CT: Fundamental principles, technology, and applications. Radiographics 2008; 28: 2009-22
• 15 Biswas D, Bible JE, Bohan M, Simpson AK, Whang PG, Grauer JN. Radiation exposure from musculoskeletal computerized tomographic scans. J Bone Joint Surg Am 2009; 91: 1882-9
• 16 Schulze D, Heiland M, Thurmann H, Adam G. Radiation exposure during midfacial imaging using 4- and 16-slice computed tomography, cone beam computed tomography systems and conventional radiography. Dentomaxillofac Radiol 2004; 33: 83-6
• 17 Tuominen EK, Kankare J, Koskinen SK, Mattila KT. Weight-bearing CT imaging of the lower extremity. AJR Am J Roentgenol 2013; 200: 146-8
• 18 Zbijewski W, De Jean P, Prakash P, Ding Y, Stayman JW, Packard N. et al. A dedicated cone-beam CT system for musculoskeletal extremities imaging: Design, optimization, and initial performance characterization. Med Phys 2011; 38: 4700-13
• 19 Chi TD, Toolan BC, Sangeorzan BJ, Hansen Jr ST. The lateral column lengthening and medial column stabilization procedures. Clin Orthop Relat Res 1999; 81-90
• 20 Pedowitz WJ, Kovatis P. Flatfoot in the Adult. J Am Acad Orthop Surg 1995; 3: 293-302
• 21 DiGiovanni JE, Smith SD. Normal biomechanics of the adult rearfoot: A radiographic analysis. J Am Podiatry Assoc 1976; 66: 812-24
• 22 Kaschak TJ, Laine W. Surgical radiology. Clin Podiatr Med Surg 1988; 5: 797-829
• 23 Donovan A, Rosenberg ZS. Extra-articular lateral hindfoot impingement with posterior tibial tendon tear: MRI correlation. Am J Radiol 2009; 193: 672-8
• 24 Burssens A, Van Herzele E, Leenders T, Clockaerts S, Buedts K, Vandeputte G. et al. Weightbearing CT in normal hindfoot alignment-Presence of a constitutional valgus?. Foot Ankle Surg 2018; 24: 213-8
• 25 Malicky ES, Crary JL, Houghton MJ, Agel J, Hansen Jr ST, Sangeorzan BJ. Talocalcaneal and subfibular impingement in symptomatic flatfoot in adults. J Bone Joint Surg Am 2002; 84: 2005-9
• 26 Recht MP, Grooff P, Ilaslan H, Recht HS, Sferra J, Donley BG. Selective atrophy of the abductor digiti quinti: An MRI study. Am J Roentgenol 2007; 189: W123-7
• 27 Hirschmann A, Pfirrmann CW, Klammer G, Espinosa N, Buck FM. Upright cone CT of the hindfoot: Comparison of the non-weight-bearing with the upright weight-bearing position. Eur Radiol 2014; 24: 553-8
• 28 Kido M, Ikoma K, Imai K, Maki M, Takatori R, Tokunaga D. et al. Load response of the tarsal bones in patients with flatfoot deformity:In vivo 3D study. Foot Ankle Int 2011; 32: 1017-22
• 29 Ellis SJ, Deyer T, Williams BR, Yu JC, Lehto S, Maderazo A. et al. Assessment of lateral hindfoot pain in acquired flatfoot deformity using weightbearing multiplanar imaging. Foot Ankle Int 2010; 31: 361-71
• 30 Apostle KL, Coleman NW, Sangeorzan BJ. Subtalar joint axis in patients with symptomatic peritalar subluxation compared to normal controls. Foot Ankle Int 2014; 35: 1153-8
• 31 Colin F, Horn Lang T, Zwicky L, Hintermann B, Knupp M. Subtalar joint configuration on weightbearing CT scan. Foot Ankle Int 2014; 35: 1057-62
• 32 Krahenbuhl N, Tschuck M, Bolliger L, Hintermann B, Knupp M. Orientation of the subtalar joint: Measurement and reliability using weightbearing CT scans. Foot Ankle Int 2016; 37: 109-14
• 33 Probasco W, Haleem AM, Yu J, Sangeorzan BJ, Deland JT, Ellis SJ. Assessment of coronal plane subtalar joint alignment in peritalar subluxation via weight-bearing multiplanar imaging. Foot Ankle Int 2015; 36: 302-9