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Saltzman view vs. Long leg axial for supramalleolar osteotomies

Discussion in 'Foot Surgery' started by studywithfury, Mar 18, 2013.

  1. studywithfury

    studywithfury Member

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    When you are planning supramalleolar osteotomies both saltzman and long leg axial views are typically utilized to measure frontal plane malignment at the hindfoot, ankle and lower leg. Which radiographical view do you prefer? Which radiographical view tells you more about the relationship between hindfoot, ankle and lower leg?

    Every text (Coughlin & Mann, McGlamry) and research article I've come across simply states both should be utilized in your pre-operative assessment of the deformity. BUT...I was curious to know what other foot and ankle surgeons here personally prefer and why.

    Thanks in advance
  2. drsarbes

    drsarbes Well-Known Member

    In my limited experience with this, I take several long leg axis views and correlate with my clinical assessment. This is done for calcaneal osteotomies not tibial osteotomies (which I do not perform)

  3. You may want to look at this radiographic research and radiographic view I invented during my biomechanics fellowship from 25 years ago to determine the frontal plane relationship of the plantar calcaneus to the ankle (Kirby KA, Loendorf AJ, Gregorio R: Anterior axial projection of the foot. JAPMA, 78: 159-170, 1988).

    For some reason, most surgical podiatrists don't even know that the anterior axial radiographic projection even exists. Drs. Joel Clark, Josh Gerbert and Bill Jenkins have obviously found it useful in their surgical practices for rearfoot surgeries (Clark JR, Gerbert J, Jenkin WM: The Kirby view: A radiographic view for flatfoot evaluation. JFAS, 43:436-439, 2004).
  4. studywithfury

    studywithfury Member

    Any particular reason you prefer the long leg axial over the Saltzman? Research has pointed that the LLA view is more reliable but any clinical research I have come across seems to utilize the Saltzman view as their hindfoot alignment view of choice.

    For example Frigg did studies in 2010 talking about the Saltzman view and it's role in determining optimal foot/ankle position in TAR and arthrodesis procedures. Please refer to attached articles.

    He also recently had a very interesting presentation on www.footinnovate.com as well on the same topic.
  5. drsarbes

    drsarbes Well-Known Member

    "Any particular reason you prefer the long leg axial over the Saltzman?"

    Yes, it's the one my tech knows how to take!

  6. studywithfury

    studywithfury Member


    Other than the positional relationship of the calcaneal tuber to the tibia and the evaluation of the STJ...is there any other essential information you get from the long leg axial radiographs?

    LLA hindfoot views give more of a positional rather than mechanical analysis of the hindfoot malalignment in my opinion.
  7. Studywithfury:

    Please tell me how these views allow for "evaluation of the subtalar joint"? In addition, how can these views, which don't include the knee, account for any prexisting tibial varum or tibial valgum in the distal half of the tibia that may not be present in the proximal half of the tibia?

    Please remember that force vectors acting relative to joint axes are what are important here, not what the position of the distal half of a long bone is. For example, if the patient had frontal plane bowing of the tibia so that proximal half of the tibia was in valgus and the distal half of the tibia was in varus, how much value do you think any of these radiographic views would be for determining the optimal frontal plane alignment of the foot and lower extremity post-surgically?

    Even though I have heard many surgical lecturers saying how great these views are for planning various surgeries, I am not convinced that they are actually of any biomechanical value, especially considering the lack of any scientific correlation of these radiographic views to dynamic function of the foot and lower extremity.
  8. studywithfury

    studywithfury Member

    I agree with your points but I would think long leg radiographs would alse be taken to assess for frontal plane bowing of the proximal tibia. I seriously doubt a surgeon would use the saltzman or long leg axial alone to assess frontal plane deformity...that doesn't make any sense.

    I also agree that there is minimal research correlating the hindfoot alignment views to dynamic function. Attached is one article I have found discussing a possible correlation with the saltzman view to dynamic foot floor pressures in fusions by Frigg in 2010. What are your thoughts on that?

    Lastly, the long leg axial view most certainly allows one to visualize any osseous deformity to the STJ. That's essentially the whole point of the radiographic view. I was not referring to STJ function. We are talking x-rays here are we not? The positioning of the pt's foot and ankle allows direct visualization of the middle and posterior subtalar facets in the long leg axial. Saltzman view allows for clearer visualization of the ankle joint. Hence why many podiatrists, in the literature, have recommended the use of both views when planning for surgery. Dr. Paley has even recommended this.
  9. How would you know there is a "frontal plane deformity" in the tibia unless you took a full leg radiograph? That is my point, why do a Saltzman view ever since it doesn't incorporate the whole tibia?

    Many podiatrists have recommended a lot of things in the literature over the years, many of which are found to be false at a later date. So, just because someone lectures on something at a large surgical seminar or series of surgical seminars or writes about it in a surgical textbook does not necessarily make it true.

    Please tell me how a long leg axial view radiograph allows one "visualize any osseous deformity to the STJ".

    Does it rule out three dimensional structural abnormalities within the three articular facets of the subtalar joint? No.

    Does it rule out osteoarthrosis within all three facets of the subtalar joint? No.

    Does it tell you anything about the three dimensional spatial location of the subtalar joint axis? No.

    Again, now, Study, please explain to all of us how a long leg axial view radiograph allows one "visualize any osseous deformity to the STJ".

    On further thought, do you know of any scientific study that shows that either a Saltzman view or long leg axial view is able to determine the spatial location of the STJ axis which actually does have significant mechanical effect on the weightbearing function (i.e. kinetics) of the foot and lower extremity? I don't.

    Therefore, with the above taken into account, the question then becomes as follows:

    if these radiographic studies, the Saltzman view and long leg axial view, don't help determine the STJ axis location, have nothing to do with gait function and likely have nothing to do with the internal and/or external forces acting across the joints of the foot and lower extremity during weightbearing activities or the external and internal moments acting across the STJ axis, why even take these radiographs in the first place??

    I am certainly hoping to get an explanation from you since the other podiatric surgeons I have asked this question don't seem to have a good answer for it other than "Dr. X said it worked for him in the ABC Surgical Seminar and I have been using it ever since".

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