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Reliability and Validity of Radiographic Measurements in Hindfoot Varus and Valgus

Kyoung Min Lee, Chin Youb Chung, Moon Seok Park, Sang Hyeong Lee, Jae Hwan Cho and In Ho Choi J Bone Joint Surg Am. 2010;92:2319-2327. doi:10.2106/JBJS.I.01150

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C OPYRIGHT 2010
BY

T HE J OURNAL

OF

B ONE

AND J OINT

S URGERY, I NCORPORATED

Reliability and Validity of Radiographic Measurements in Hindfoot Varus and Valgus

By Kyoung Min Lee, MD, Chin Youb Chung, MD, Moon Seok Park, MD, Sang Hyeong Lee, MD, Jae Hwan Cho, MD, and In Ho Choi, MD
Investigation performed at the Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Sungnam, and the Department of Orthopaedic Surgery, Seoul National University Childrens Hospital, Seoul, South Korea

Background: Clinical decision-making in the treatment of foot deformities is based primarily on the results of the physical examination and the radiographic ndings. The purpose of this study was to determine the validity and reliability of commonly used radiographic measurements of hindfoot valgus and varus deformities. Methods: Seventy-two patients with hindfoot deformity (thirty-six hindfoot valgus, mean age 15.5 years; thirty-six hindfoot varus, mean age 30.2 years) were evaluated. Nine representative indices on weight-bearing radiographs were assessed. Three examiners measured the radiographic indices at two sessions, and intraobserver and interobserver reliability was determined. Discriminant validity of the radiographic measurements between hindfoot valgus and varus was evaluated. The correlation with pedobarographic ndings in evaluating the distribution of foot pressure during gait was assessed for convergent validity. Results: Naviculocuboid overlap, anteroposterior talonavicular coverage angle, anteroposterior talus-rst metatarsal angle, calcaneal pitch angle, and lateral talus-rst metatarsal angle showed excellent reliability. Naviculocuboid overlap, anteroposterior talonavicular coverage angle, and anteroposterior talus-rst metatarsal angle showed excellent discriminant validity (in terms of effect-size r) and convergent validity (in terms of correlation coefcients with pedobarography). Conclusions: Naviculocuboid overlap, anteroposterior talonavicular coverage angle, and anteroposterior talus-rst metatarsal angle are reliable and valid measures for the evaluation of hindfoot valgus and varus deformities. Level of Evidence: Diagnostic Level III. See Instructions to Authors for a complete description of levels of evidence.

algus and varus hindfoot deformities are common deformities in both children and adults. Many of these foot deformities require orthopaedic intervention, and the treatment goal is to address all of the aspects of the deformity and achieve a painless plantigrade foot. In general, clinical decision-making for foot deformities is based on physical examination and radiographic ndings. Radiographs of the foot are commonly used to evaluate foot deformities, and the weight-bearing anteroposterior and lateral views are used to obtain the standard measurements necessary for evaluation of the foot. In addition to qualitative assessment, specic radiographic indices have been used to quantify hindfoot deformity, and the reliability of these indices in normal subjects or subjects with specic diseases has been reported1,2. However, there are concerns that these measurements cannot explain all of the facets of foot deformity. For

example, the subtalar joint is not horizontal, and hindfoot valgus or varus does not occur simply in one plane. We hypothesized that the radiographic indices in hindfoot deformities may not be as reliable as previous reports have implied and that the anteroposterior or lateral projection of the foot may not always reect the amount of actual deformity. That is, some of the indices may not be valid in the evaluation of hindfoot deformities. There are no gold standards for measuring foot deformities. Therefore, measurement validity relies on the construct validity. This study examined the radiographic foot measurements in terms of both reliability and validity, as follows: (1) reliability, as assessed by the interobserver and intraobserver reliability in the radiographic measurements of hindfoot valgus and varus; (2) discriminant validity3, as determined by the differences in the measurements between

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benets or a commitment or agreement to provide such benets from a commercial entity.

J Bone Joint Surg Am. 2010;92:2319-27

doi:10.2106/JBJS.I.01150

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Fig. 1-A

Figs. 1-A, 1-B, and 1-C The radiographic measurements for hindfoot varus (left side of each gure) and hindfoot valgus (right side of each gure). Fig. 1-A On the lateral weight-bearing radiographs, the calcaneal pitch angle (CP) is the angle between a line drawn along the edge of the plantar soft-tissue shadow and a line drawn along the lower margin of the calcaneus. The lateral talocalcaneal angle (TC) is the angle between a line drawn along the lower margin of the calcaneus and a line drawn through the midpoints of the talar head and neck. The tibiocalcaneal angle (TibioCalc) is the angle between a line drawn along the lower margin of the calcaneus and a line bisecting the long axis of the tibia. The lateral talus-rst metatarsal angle (Talo-1MT) is the angle between a line bisecting the long axis of the rst metatarsal bone and a line drawn through the midpoints of the talar head and neck. The metatarsal stacking angle (MT stacking) is the angle between a line drawn at the lower margin of the fth metatarsal and a line drawn from the fth metatarsal base to the rst metatarsal head.

different groups (varus and valgus), which is one aspect of construct validity; and (3) convergent validity, as determined by the correlation between the radiographic indices and pedobarographic measurements, which is another aspect of construct validity. Materials and Methods his study was approved by the institutional review board at our hospital, which waived informed consent. The

patients were randomly selected from a review of the medical records. The inclusion criteria were as follows: (1) clinically diagnosed hindfoot deformity (hindfoot valgus or varus) between January 2004 and May 2009. The diagnosis was based on the clinical information, including the patients history, underlying diseases, and physical examination. The angle between the long axis of the calf and vertical axis of the heel in the weight-bearing position was assessed to diagnose the hindfoot valgus and varus qualitatively4; (2) availability of

Fig. 1-B

On the lateral weight-bearing radiographs, the naviculocuboid overlap (A/B) is the overlapped portion of the navicular and cuboid divided by the vertical height of the cuboid. The medial-lateral column ratio (C/D) is the distance between the distal tip of the rst metatarsal head and the proximal margin of the posterior talar dome divided by the distance between the most proximal margin of the posterior aspect of the calcaneus and the distal-most margin of the fth metatarsal head.

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Fig. 1-C

On the anteroposterior weight-bearing radiograph, the talonavicular coverage angle (TN) is the angle between a line bisecting the anterior articular surface of the talus and another line bisecting the proximal articular surface of the navicular. The anteroposterior talus-rst metatarsal angle (Talo-1MT) is dened as the angle between a line bisecting the anterior articular surface of the talus and a line bisecting the long axis of the rst metatarsal.

the weight-bearing foot radiographs (both anteroposterior and lateral views). Foot radiographs were made with use of a UT 2000 x-ray machine (Philips Research, Eindhoven, The

Netherlands) at a source-to-image distance of approximately 100 cm and set to 50 kVp and 5 mAs, with the patient in the standing position. The patients were radiographed barefoot;

TABLE I Patient Demographics* Hindfoot Valgus Group Age standard deviation (yr) Sex (M:F) Causes of deformities (no. of cases) 15.5 4.2 21:15 Idiopathic planovalgus (27) Cerebral palsy (9) Hindfoot Varus Group 30.2 18.0 20:16 Cerebral palsy (14) Residual poliomyelitis (10) HMSN (3) Guillain-Barr syndrome (1) e Peroneal nerve injury (2) Congenital clubfoot (2) Unknown cause (4) *HMSN = hereditary motor sensory neuropathy.

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TABLE II Summary of the Radiographic and Pedobarographic Measurements* Hindfoot Valgus Group (mean SD [range]) Lateral radiographs CP () LatTC () TibioCalc () Lat talo-1MT () MT stacking () NC overlap (%) ML column ratio Anteroposterior radiographs AP TN coverage () AP Talo-1MT () Pedobarographs Valgus/varus index 0.33 0.28 (0.55 to 0.79) 0.25 0.39 (0.87 to 0.51) 31.6 13.7 (3.6 to 62.8) 27.0 11.1 (6.3 to 47.5) 13.8 15.9 (45.4 to 15.9) 18.8 16.8 (48.5 to 13.0) 9.3 4.9 (9.0 to 18.6) 47.2 10.6 (21.0 to 68.0) 75.2 6.7 (61.6 to 91.0) 20.5 11.0 (2.3 to 42.0) 5.5 6.7 (27.6 to 13.1) 68.6 17.3 (30 to 100) 0.97 0.04 (0.86 to 1.03) 15.2 6.7 (1.9 to 29.5) 44.5 13.1 (14 to 75.8) 69.5 8.1 (53.3 to 90.5) 2.8 13.5 (36.8 to 21.7) 8.2 6.4 (16.8 to 19.2) 7.3 9.5 (0 to 33) 0.97 0.06 (0.85 to 1.10) Hindfoot Varus Group (mean SD [range])

*SD = standard deviation, CP = calcaneal pitch angle, LatTC = lateral talocalcaneal angle, TibioCalc = tibiocalcaneal angle, Lat talo-1MT = lateral talus-rst metatarsal angle, MT stacking = metatarsal stacking angle, NC overlap = naviculocuboid overlap, ML column ratio = mediallateral column ratio, AP TN coverage = anteroposterior talonavicular coverage angle, AP Talo-1MT = anteroposterior talus-rst metatarsal angle.

and (3) performance of pedobarography. All radiographic measurements were performed with use of a picture archiving and communication system (PACS) (IMPAX; Agfa HealthCare, Mortsel, Belgium) software. Patients with a history of prior foot surgery or a severe equinus deformity who could not achieve toe-to-heel contact on the ground were excluded. Selecting the Items of Radiographic Measurements Prior to the study, the radiographic measurements to be assessed were selected from literature reviews and consensus by the orthopaedic surgeons. Previous studies were reviewed1,2,5-10, and one of the authors (K.M.L.) selected the items that we believed would be relevant to measure hindfoot valgus and varus. Items were chosen on the basis of a consensus among four orthopaedic surgeons, who constituted a consensus development panel3. We intended to include as many radiographic measurements as possible. Radiographic measurements were selected by eliminating redundant methods and those not used frequently. The four panelists (C.Y.C., M.S.P., S.H.L., and K.M.L.) were orthopaedic surgeons with twenty-one, nine, eight, and six years of experience, two of whom specialized in pediatric orthopaedic surgery and two in adult foot and ankle surgery. One of the authors (M.S.P.) was a moderator, and each item was chosen by consensus by the panel. The discussion focused mainly on the clinical relevance and importance of each measurement. Overall, nine measurements were chosen for evaluation. The following seven items were measured on the lateral foot radiographs: calcaneal pitch angle8, lateral talocalcaneal angle5, tibiocalcaneal angle5, lateral talus-rst metatarsal angle5, metatarsal stacking angle1, naviculocuboid overlap1, and

medial-lateral column ratio1. Two items were measured on the anteroposterior foot radiographs, the talonavicular coverage angle10 and the anteroposterior talus-rst metatarsal angle5 (Figs. 1-A, 1-B, and 1-C). Intraobserver and Interobserver Reliability Three examiners (a pediatric orthopaedic surgeon [S.H.L.], a foot and ankle surgeon [K.M.L.], and an orthopaedic surgery resident [J.H.C.], with eight, six, and three years of orthopaedic experience, respectively) were used to assess the intraobserver and interobserver reliability of the radiographic measurements. A prior sample size estimation by precision analysis indicated that a minimum of thirty-six feet should be assessed for both the hindfoot valgus and hindfoot varus groups. The measurements were performed by the three examiners in two sessions, with a three-week interval between sessions11. Each examiner was blinded to the other measurements and to all patient data. All measurements were collected by a research assistant who did not otherwise participate in the study. Discriminant Validity Discriminant validity is one facet of construct validity. It is the ability to detect relevant differences between various subgroups of subjects or patients. In this study, Cohens d and effect-size r were assessed between the hindfoot valgus and hindfoot varus groups. Convergent Validity Convergent validity, which is another type of construct validity, occurs when the scales of a measurement correlate as expected with the related scales of another measurement. In this study,

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TABLE II (continued) P Value Normal Alignment (mean SD [range])

1

Denition of Larger Value

<0.001 0.324 0.002 <0.001 0.084 <0.001 0.453 <0.001 <0.001 <0.001

17 6.0 (5 to 32) 49 6.9 (36 to 61) 69 8.4 (44 to 86) 13 7.5 (1 to 35) 8 2.9 (1 to 13) 47 13.8 (22 to 85) 0.9 0.1 (0.8 to 1.1) 20 9.8 (5 to 39) 10 7.0 (3 to 28) Not available

Dorsiexion Valgus and abduction Plantar exion Midfoot planus Supination Pronation Longer medial column Abduction Abduction Lateral pressure

the radiographic measurements were compared with pedobarographic measurements. The pedobarographic measurements were obtained with use of a high-resolution pressure assessment system (Tekscan, South Boston, Massachusetts). The system consisted of a 2180-cm2 pressure-sensitive oor mat containing 3.9 pressure-sensing cells/cm2. The foot pressures were recorded at a rate of 50 Hz. The examination began with the patient standing 2 m away from the oor mat, which was not hidden in the oor. Each patient was instructed to look ahead and begin walking at a self-selected speed. The pressure readings were collected with the foot completely on the pressure surface before, during, and after the stance phase. After the pressure readings were obtained, the information that was collected was processed with use of software specically designed for research with the Tekscan system. The area of measurement was divided into equal anterior, middle, and posterior thirds, and into equal medial and lateral halves. This produced the following ve sections: medial forefoot (MFF), lateral forefoot (LFF), medial midfoot

(MMF), lateral midfoot (LMF), and the heel. The peak pressure and pressure-time integral were retrieved for each of the ve segments of the foot, and these data were processed to produce the valgus/varus index, which is dened as ((MMF 1 MFF) 2 (LMF 1 LFF))/(MMF 1 MFF 1 LFF 1 LMF) (Fig. 2)12. The foot-pressure measurement index was calculated by one of the authors (K.M.L.), and the correlation between the radiographic measurements and valgus/ varus index was assessed to determine the convergent validity. Statistical Methods A prior sample-size analysis was carried out to determine the minimum number of patients required. In this study, the reliability was calculated with use of intraclass correlation coefcients13 at a target value of 0.8. The 95% condence interval was set to 0.2, and the minimum sample size was thirty-six feet with a Bonett approximation14. For the purpose of statistical independence, only the data from a single foot in each patient were included for statistical analysis.

TABLE III Discriminant Validity of Radiographic Measurements* Anteroposterior Radiographs NC Overlap 4.47 0.91 ML Column Ratio 0.18 0.09 AP TN Coverage 3.06 0.84 AP Talo-1MT 3.22 0.85

Lateral Radiographs CP Cohens d Effect-size r 1.00 0.45 LatTC 0.24 0.12 TibioCalc 0.77 0.36 Lat Talo-1MT 1.89 0.69 MT Stacking 0.42 0.20

*CP = calcaneal pitch angle, LatTC = lateral talocalcaneal angle, TibioCalc = tibiocalcaneal angle, Lat Talo-1MT = lateral talus-rst metatarsal angle, MT stacking = metatarsal stacking angle, NC overlap = naviculocuboid overlap, ML column ratio = medial-lateral column ratio, AP TN coverage = anteroposterior talonavicular coverage angle, AP Talo-1MT = anteroposterior talus-rst metatarsal angle.

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In this assumption, thirty-six feet for each group were representative of the radiographic measurements (i.e., the cases were considered to be random factors) from a population with hindfoot deformities. The intraclass correlation coefcients and their 95% condence intervals were used to summarize the intraobserver and interobserver reliability and were calculated in the setting of a two-way random-effect model, assuming a single measurement and absolute agreement. An intraclass correlation coefcient of 1 indicates perfect reliability, and an intraclass correlation coefcient of >0.8 indicates excellent reliability15. A Kolmogorov-Smirnov test was used to identify the normality of the variables. An independent sample t test and a calculation of effect-size r with Cohens d16 were used to present the discriminant validity of the measurements. The Pearson correlation coefcients were used to determine the convergent validity of the weight-bearing radiograph measurements regarding a specic foot deformity. In this study, the Pearson correlation coefcient and the intraclass correlation coefcient were characterized as poor (0.00 to 0.20), fair

(0.21 to 0.40), moderate (0.41 to 0.60), good (0.61 to 0.80), or excellent (0.81 to 1.00)17. A p value of <0.05 was considered signicant. Source of Funding There was no external funding source for this investigation. Results f the 301 patients with weight-bearing foot radiographs and pedobarographs, seventy-two patients with a foot deformity (thirty-six with hindfoot valgus and thirty-six with hindfoot varus) were selected randomly (i.e., a single foot from each patient was selected randomly to ensure statistical independence). The mean age and standard deviation of the patients with hindfoot valgus was 15.5 4.2 years (range, twelve to thirty-one years), and the mean age of the patients with hindfoot varus was 30.2 18.0 years (range, eight to sixty-seven years). There were twenty-one male subjects and fteen female subjects in the hindfoot valgus group, and twenty male subjects and sixteen female subjects in the hindfoot varus group (Table I).

Fig. 2

The pedobarograph was divided into ve segments: the heel, medial midfoot (MMF), lateral midfoot (LMF), medial forefoot (MFF), and lateral forefoot (LFF). The image on the left depicts left hindfoot varus, and the image on the right depicts right hindfoot valgus.

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TABLE IV Convergent Validity of Radiographic Measurements Presented as Correlation Coefcients with Valgus/Varus Index in Pedobarography* Anteroposterior Radiographs NC Overlap 0.639 <0.001 ML Column Ratio 0.023 0.855 AP TN Coverage 0.613 <0.001 AP Talo-1MT 0.628 <0.001

Lateral Radiographs CP r p 0.146 0.240 LatTC 0.110 0.374 TibioCalc 0.138 0.266 Lat Talo-1MT 0.386 0.001 MT Stacking 0.337 0.005

*CP = calcaneal pitch angle, LatTC = lateral talocalcaneal angle, TibioCalc = tibiocalcaneal angle, Lat Talo-1MT = lateral talus-rst metatarsal angle, MT stacking = metatarsal stacking angle, NC overlap = naviculocuboid overlap, ML column ratio = medial-lateral column ratio, AP TN coverage = anteroposterior talonavicular coverage angle, AP Talo-1MT = anteroposterior talus-rst metatarsal angle. p < 0.05.

Calcaneal pitch angle, tibiocalcaneal angle, lateral talus-rst metatarsal angle, naviculocuboid overlap, anteroposterior talonavicular coverage angle, anteroposterior talus-rst metatarsal angle, and valgus/varus index showed signicant differences between the hindfoot valgus group and the hindfoot varus group (Table II). Measurement of the calcaneal pitch angle and naviculocuboid overlap, the talonavicular coverage angle, and the anteroposterior talus-rst metatarsal angle showed satisfactory overall reliability. Most of the radiographic measurements showed goodto-excellent reliability for clinical use (see Appendix). In terms of discriminant validity, the naviculocuboid overlap showed the highest Cohens d and effect-size r and was the most valid method for discriminating between a hindfoot valgus deformity and a hindfoot varus deformity, followed by the anteroposterior talus-rst metatarsal angle and the anteroposterior talonavicular coverage angle (Table III). In terms of convergent validity, naviculocuboid overlap showed the highest correlation coefcient (r = 0.639, p < 0.001) with the valgus/varus index as determined by pedobarography. The anteroposterior talus-rst metatarsal angle and the anteroposterior talonavicular coverage angle were also found to have a signicant correlation with the valgus/varus index (r = 0.628, p < 0.001; and r = 0.613, p < 0.001, respectively), and the mediallateral column ratio had the lowest correlation coefcient with the valgus/varus index (r = 20.023, p = 0.855) (Table IV). Discussion e believe that the reliability and validity of many foot radiographic measurements have not been claried, although such measurements are used frequently. In this study, the naviculocuboid overlap, the anteroposterior talus-rst metatarsal angle, and the talonavicular coverage angle were found to be reliable and valid methods for discriminating hindfoot valgus and varus deformities, reecting pressure distribution in the foot during walking. Some limitations of this study should be addressed before discussing these ndings in detail. First, the diagnosis of foot deformities was simplied as either hindfoot valgus or hindfoot varus. Although these deformities are common in clinical situations, the study results may not be applicable to

various other foot deformities. Second, the two groups in this study had a substantial difference in patient age, which might have confounded the results due to age-related changes in hindfoot anatomy, and the degree of ossication in the osseous landmarks could have affected the reliability of the test results. Third, the radiographic measurements were compared with the pedobarographic valgus/varus index for convergent validity. Some might argue that pedobarographic measurement is inaccurate; however, although pedobarographic measurement is not a gold standard, it is believed to be a relevant tool that has been used in many studies for surgical outcome assessment18-22. Therefore, we assumed that convergent validity of the radiographic measurements could be assessed by correlation with the pedobarographic index. Fourth, subjects with a severe equinus deformity who could not achieve total plantar contact during gait were excluded because the radiographic and pedobarographic measurements for those subjects might be distorted or not dened properly. The study results therefore cannot be generalized, as a considerable proportion of foot deformities are associated with an equinus deformity. Fifth, for severely deformed feet, the hindfoot and forefoot cannot be evaluated appropriately with use of a single lateral radiographic image and should instead be evaluated with use of two separate images focusing on the forefoot and hindfoot, respectively. However, in this study, all feet were evaluated on a single radiographic image made perpendicularly to the long axis connecting the heel center and the second metatarsal head. Sixth, ankle deformities were not considered in the inclusion and exclusion criteria; however, severe hindfoot deformities often coincide with ankle deformities and therefore some of the foot deformities could have been secondary to an ankle deformity. This group of patients may have had different characteristics from those of patients with primary hindfoot deformities, and these differences might have affected the study results. Seventh, although a period of three weeks between repeated measurements has previously been used to determine intraobserver reliability11, this period is somewhat short and may have increased the measured intraobserver reliability. However, our results also showed comparable interobserver reliability, which is independent of recall.

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The diagnostic criteria for a foot deformity, including hindfoot valgus and hindfoot varus, are clinical and depend on a visual inspection. The diagnosis in this study population was based primarily on the gross appearance of the foot. We believe that the results from our study may be useful when trying to clarify a diagnosis or when attempting to objectively quantify the severity of a foot deformity. The calcaneal pitch angle measurement is widely used in the evaluation of foot deformities because it is intuitive and easy to understand and because dening the landmarks on a lateral foot radiograph is a relatively simple process. Despite its relatively high reliability, however, it has been shown to be a less valid method for discriminating hindfoot valgus and varus deformities. Therefore, it is important to reevaluate the value of this radiographic measurement for clinical use. The medial-lateral column ratio showed the lowest reliability of the radiographic measurements. This low reliability is believed to be caused by the overlap of the ve metatarsals, which makes it difcult to identify the distal margin of the metatarsal head. The naviculocuboid overlap measurement was found to be a valid method for discriminating between hindfoot valgus and varus deformities. In our study, the minimum value of this measurement in hindfoot valgus was 30%, and the maximum value of this measurement in hindfoot varus was 33%. However, by denition, the naviculocuboid overlap measurement does not consider the direction of overlap. For example, both severe varus, in which the cuboid is located below the navicular on the lateral radiograph, and severe valgus, in which the cuboid is located above the navicular on the lateral radiograph, would result in a naviculocuboid overlap of zero, though there was no case in which the cuboid was above the navicular in this study. Furthermore, this radiographic measurement does not discriminate between the severity of a severe

varus or valgus deformity. Nineteen of the thirty-six varus feet in this study showed a naviculocuboid overlap of zero, although the severity of the varus deformity varied among the nineteen. This represents a oor or ceiling effect of this measurement and thus does not reect the degree of the deformity in severe varus or valgus feet. Therefore, although naviculocuboid overlap is a useful method for discriminating between hindfoot valgus and varus deformities, care should be taken when applying this method to severe deformities. The talonavicular coverage angle and the anteroposterior talus-rst metatarsal angle showed excellent reliability and favorable discriminant validity. Initially, we believed that these measurements would not reect hindfoot valgus and varus deformities; however, the two measurements on the anteroposterior radiographs were reliable and valid methods for differentiating between hindfoot valgus and varus deformities. These results appear to reect the complicated nature of hindfoot valgus and varus deformities and suggest that hindfoot valgus and varus are not isolated coronal plane deformities. It is believed that pressure measurements of the foot during gait would be more relevant than radiographic measurements because they could possibly reect the pressure exerted on the plantar surface, which could help to identify pathologic biomechanics and subsequently localize the cause of foot pain19,23-26. Therefore, this study evaluated the convergent validity of the radiographic measurements by comparing them with the valgus/varus foot pressure distribution index. Naviculocuboid overlap, anteroposterior talonavicular coverage angle, and anteroposterior talus-rst metatarsal angle showed good convergent validity. A higher discriminant validity was obtained with these measurements than with the valgus/varus index. In summary, the results of this study are in concurrence with those of two previous studies1,2 in terms of the reliability of

TABLE V Clinical Relevance of Each Radiographic Measurement* Discriminant Validity (effect-size r) Convergent Validity (correlation r)

Reliability (ICC) Lateral radiographs CP LatTC TibioCalc Lat talo-1MT MT stacking NC overlap ML column ratio Anteroposterior radiographs AP TN coverage AP talo-1MT wwwww wwwww wwwww wwww wwww wwwww wwww wwwww www

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NS NS NS ww ww wwww NS wwww wwww

wwwww wwwww

*Stars indicate level of signicance: w = 0 to 0.2, ww = 0.2 to 0.4, www = 0.4 to 0.6, wwww = 0.6 to 0.8, wwwww = 0.8 to 1.0; ICC = intraclass correlation coefcient; CP = calcaneal pitch angle; NS = not signicant; LatTC = lateral talocalcaneal angle; TibioCalc = tibiocalcaneal angle; Lat talo-1MT = lateral talus-rst metatarsal angle; MT stacking = metatarsal stacking angle; NC overlap = naviculocuboid overlap; ML column ratio = medial-lateral column ratio; AP TN coverage = anteroposterior talonavicular coverage angle; AP Talo-1MT = anteroposterior talusrst metatarsal angle.

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TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O LU M E 92 -A N U M B E R 13 O C T O B E R 6, 2 010
d d d

R E L I A B I L I T Y A N D VA L I D I T Y O F R A D I O G R A P H I C M E A S U R E M E N T S I N H I N D F O O T VA R U S A N D V A L G U S

the radiographic indices. In the present study, however, we also examined each radiographic measurement in terms of its discriminant and convergent validity, and we believe that the results add an objective diagnostic guideline (Table V) to the current vague criteria used to evaluate hindfoot valgus and varus deformities. Appendix Tables showing the results of the reliability tests are available with the electronic version of this article on our web site at jbjs.org (go to the article citation and click on Supporting Data). n
NOTE: The authors thank Mi Seon Ryu for data collection and support.

Kyoung Min Lee, MD Chin Youb Chung, MD Moon Seok Park, MD Sang Hyeong Lee, MD Jae Hwan Cho, MD Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, 300 Gumi-Dong, Bundang-Gu, Sungnam, Kyungki 463-707, South Korea. E-mail address for M.S. Park: pmsmed@gmail.com In Ho Choi, MD Department of Orthopaedic Surgery, Seoul National University Childrens Hospital, 28 Yeongon-Dong, Jongno-Gu, Seoul 110-744, South Korea

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