Measurements and Protocols Used for Weight-Bearing Cone-Beam CT Scans for Evaluating the Alignment of the Foot and Ankle: A Systematic Literature Review

Abstract

Category: Hindfoot; Midfoot/Forefoot Introduction/Purpose: Weight bearing CT has been widely used recently to provide detailed 3D information of the foot and ankle. Orthopedic surgeons have been exposed to this new technology, but do not have the equivalent tools to use to explore it. A lot of metrics were directly borrowed from plain radiographic imaging, while some new parameters were developed using traditional axes and angular concepts but on only one specific WBCT view out of hundreds of scans. Some metrics used similar measurement concepts, but on 3D reconstructed bones, while a few new parameters were introduced based on semi 3D and 3D thinking. Small sample sizes, obscure inclusion/exclusion criteria, and skewed validation methods are noted, and a thorough review of WBCT-based measurements used in foot and ankle is warranted. Methods: A literature search was conducted in two databases: PubMed (MEDLINE) and EMBASE (Elsevier). The main search terms and logics were: ((foot) OR (ankle) OR (hindfoot) OR (midfoot) OR (forefoot)) AND ((WBCT) OR (Weightbearing CT) OR (Cone beam CT scan) OR (PedCAT)). A longer string of key words was utilized to further narrow down the results to WBCT imaging associated with foot and ankle pathologies. The terms were expanded using the MeSH and Emtree expansion features of PubMed and EMBASE, respectively. All articles were reviewed by two independent senior foot and ankle surgeons based on pre-designed exclusion criteria. Off-topic articles were removed, and remaining articles were categorized based on measurement techniques. All articles were managed using Zotero. (Figure 1) Results: A total of 216 articles were selected for retrieval and further organized by measurement techniques. Seven groups were set by the type of the methodology used. Among them, 123 studies utilized traditional 2D measurement parameters (eg, hindfoot moment arm, Meary’s angle, talonavicular uncoverage, hallux valgus angle, etc.), 8 introduced new parameters but based on 2D axial/angular concepts (eg, middle facet subluxation percentage and angle), 22 used semi-automated 3D measurement techniques (3D segmentation + 2D axial and angular methods), 19 using semi-3D measurement techniques (Foot and Ankle Offset), 29 measured real 3D parameters (volume evaluation in the syndesmosis and Lisfranc joints, distance mapping), 3 morphological studies used 3D segmentation and sphere fitting. The advantages and disadvantages of each type of measurement were carefully examined and explored. Conclusion: 3D imaging measurements with WBCT appear to be highly variegated. Axial and angular measurements do not apply well to irregular bones and there is a low reproducibility in 3D scenarios. Although inter- and intraobserver reproducibility scores have been reported in multiple studies, they were only part of the validation system that should be done. A high correlation between parameters such as 2D and 3D hindfoot angles has been reported, but debate remains as to whether one method of measurement is more accurate than the other. Furthermore, variations in analytical methods warrant a more uniformly defined coordinate or anatomical system.