July highlighted article: Multiplanar Semiautomatic Assessment of Foot and Ankle Offset in Adult Acquired Flatfoot Deformity

Multiplanar Semiautomatic Assessment of Foot and Ankle Offset in Adult Acquired Flatfoot Deformity

Cesar de Cesar Netto, MD, PhD, Katrina Bang, BS, Nacime Salomao Mansur, MD, PhD, Jonathan H. Garfinkel, MD, Alessio Bernasconi, MD, PhD, Francois Lintz, MD, MSc, FEBOT, Jonathan T. Deland, MD, Scott J. Ellis, MD



Semiautomatic 3-dimensional (3D) biometric weightbearing computed tomography (WBCT) tools have been shown to adequately demonstrate the relationship between the center of the ankle joint and the tripod of the foot. The measurement of the foot and ankle offset (FAO) represents an optimized biomechanical assessment of foot alignment. The objective of this study was to evaluate the correlation between FAO and traditional adult acquired flatfoot deformity (AAFD) markers, measured in different planes. We hypothesized that the FAO would significantly correlate with other radiographic markers of pronounced AAFD.


In this retrospective comparative study, we included 113 patients with stage II AAFD, 43 men and 70 women, mean age of 53.5 (range, 20-86) years. 3D coordinates (x, y, and z planes) of the foot tripod (most plantar voxel of the first and fifth metatarsal heads, and calcaneal tuberosity) and the center of the ankle joint (most proximal and central voxel of the talar dome) were assessed by 2 blinded and independent fellowship-trained orthopedic foot and ankle surgeons. The FAO was automatically calculated using the 3D coordinates by dedicated software. Multiple WBCT parameters related to the severity of the deformity in the coronal, sagittal, and transverse planes were manually measured.


We found overall good to excellent intra- (range, 0.75-0.99) and interobserver (range, 0.73-0.99) reliability for manual AAFD measurements. FAO semiautomatic measurements demonstrated excellent intra- (0.99) and interobserver (0.99) reliabilities. Hindfoot moment arm (HMA) (P < .00001), subtalar horizontal angle (P < .00001), talonavicular coverage angle (P = .00004), and forefoot arch angle (P = .0001) were the only variables found to significantly influence and correlate with FAO measurements, with an R2 value of 0.79. An HMA value of 19.8 mm was found to be a strong threshold predictor of increased values of FAO, with mean values of FAO of 6.5 when the HMA was lower than 19.8 mm and 14.6 when the HMA was equal to or higher than 19.8 mm.


We found that 3D WBCT semiautomatic measurements of FAO significantly correlated with some traditional markers of pronounced AAFD. Measurements of FAO were also found to be slightly more reliable than the manual measurements. The FAO offers a simple and more complete biomechanical and multiplanar assessment of the AAFD, representing in a single measurement the 3D components of the deformity.

Author´s Comment

Since I started working with Weightbearing Computed Tomography (WBCT) as a Research Fellow in Baltimore-Maryland back in 2014, I realized that this technology could represent a game-changer in the understanding and treatment of Adult Acquired Flatfoot Deformity (AAFD). It is not difficult to accept the concept that two-dimensional conventional radiographic images are not enough to provide a complete assessment of this multiplanar and multifocal complex pathology. The initial excitement of having the three-dimensional (3D) WBCT datasets available soon became a considerable challenge and sort of frustration when I started trying to apply traditional classic AAFD measurements such as talus-first metatarsal angle

Cesar de Cesar Netto

Assistant Professor
Foot and Ankle Surgeon
Department of Orthopaedic and Rehabilitation
University of Iowa, Carver College of Medicine

Leave a Comment