Classification of the Os Calcis Subtalar Morphology in Symptomatic Flexible Pediatric Pes Planus Deformity Using Weightbearing CT and Distance Mapping

Background: The etiology of symptomatic pediatric pes planus (PP) deformity is unclear. Reduced os calcis subtalar joint (OCST) anterior facet morphology has been suggested to result in less support to the talar head and a higher propensity to develop PP deformity. Weightbearing computed tomography (WBCT) and distance mapping (DM) offer new opportunities to investigate PP deformity in general and the OCST specifically. The purpose of this study is to investigate the OCST morphology using DM and to classify PP subtalar subtypes with DM using Bruckner's A-D classification system. Methods Forty feet in 25 patients in a national referral center were evaluated for symptomatic PP deformity that failed nonoperative treatment. A WBCT scan was performed as part of the preoperative evaluation. Visualization of the distance distribution between the articulating surfaces of the subtalar joint was based on a DM technique. Intra- and interobserver agreement of the subtalar morphology was assessed using Bruckner's classification system. Results: The mean age was 10.7 +/- 1.4 years. The following mean +/- SD and median +/- ranges were semiautomatically measured for this group: Meary angle -21 +/- 8, calcaneal inclination 15 +/- 4 degrees, talar coverage angle 39 (range 32.6-49) degrees, and hindfoot moment-arm 16 +/- 5 mm. Classifying subtalar morphology using DM yielded an excellent intra- and interobserver agreement. The individual percentages of each individual subtype were calculated: type A 5%, type B 48%, type C 4%, and type D in 44%. Conclusion: This study demonstrated excellent intraobserver and interobserver agreement in classifying the OCST using DM. A higher prevalence of types B and D was observed compared to types A and C in this PP cohort.