Use of Advanced Weightbearing Imaging in Evaluation of Hallux Valgus

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Key points

  • Weightbearing conventional radiographs provide limited, sectorized, and biased information regarding the complex and 3-dimensional nature of hallux valgus (HV) deformity, leading to potential misinterpretation and poor understanding.

  • Cone beam weightbearing computed tomography (WBCT) allows multiplanar 3-dimensional standing weightbearing imaging and a detailed evaluation of HV deformity.

  • WBCT allowed demonstration that the hypermobility of the first tarsometatarsal (TMT) joint occurs not only in

Hallux Valgus Angle

HV angle describes the amount of transverse plane valgus deviation of the proximal phalanx (PP) of the first toe over the head of the first metatarsal (M1), measured on AP views of weightbearing conventional radiographs (Fig. 1). Represented by the angle between the axis of the M1 and the PP of the first toe, it is considered normal if less than 15° of valgus angulation.5 It takes part of the staging system of the severity of the pathology in mild, moderate, and severe deformities. It is

Limitations of conventional radiographs and the rise of 3-dimensional multiplanar weightbearing imaging

Even though conventional radiographs have proven since x-rays were discovered by Wilhelm Conrad Roentgen in 1895, the 2-dimensional nature of this imaging modality in the characterization of complex 3-dimensional deformities is insufficient. Conventional radiographs provide sectorized and limited information of the HV deformity in the different planes, with well-known limitations regarding superimposition of structures, image magnification, x-ray source and patient positioning misalignment, and

Weightbearing cone beam computed tomography and hallux valgus deformity

Collan and colleagues54 were the first to report on the use of standing CB WBCT in the assessment of HV patients. They evaluated 10 patients with HV deformity and 5 controls. Patients underwent resting NWB and standing WB CBCT. They measured 2-dimensional and 3-dimensional HVA and IMA, as well as the rotational status of the M1 and PP of the first toe, using coronal plane images. They found that, when compared with controls, patients with HV deformity demonstrated significantly increased HVA

Weightbearing computed tomography artificial intelligence and automatic measurements: the next step

The recently published literature demonstrates that WBCT measurements provide a complete analysis of all 3-dimensional components of the HV deformity. However, the amount of data acquired during the examination is vast and can represent a burden, needing a critical amount of time and effort for adequate interpretation. The more accurate 3-dimensional measurements usually include the need for a manual or semiautomatic segmentation of each tarsal bone involved in the measure, using different

Summary and future perspectives

The pieces of evidence in the orthopedic literature supporting the use of CB WBCT imaging in the assessment of different complex deformities of the foot and ankle has been growing consistently.44, 45, 46, 47,59, 60, 61, 62, 63 It is the author’s opinion that standing CB WBCT will soon represent the gold standard imaging evaluation of foot and ankle pathologies, replacing WBCR. It is clear that the WBCR assessment of multiplanar pathologies is limited by multiple biases related to acquisition

Disclosure

Dr C. de Cesar Netto reports paid consultancy and share options for CurveBeam LLC, as well as paid consultancy for Ossio LTD. Dr C. de Cesar Netto is also a board member of the International Weight-Bearing CT Society. Dr M. Richter reports paid consultancy for CurveBeam LLC, Ossio LTD, Geistlich, and Intercus. He is also proprietor of R-Innovation and the current president of the International Weight-Bearing CT Society.

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