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Currently there is no consensus how hindfoot alignment (HA) should be assessed in CBCT scans. The aim of this study is to investigate how the reliability is affected by the anatomical structures chosen for the measurement. Materials and methods Datasets consisting of a Saltzman View (SV) and a CBCT of the same foot were acquired prospectively and independently assessed by five raters regarding HA. In SVs the HA was estimated as follows: transversal shift between tibial shaft axis and heel contact point (1); angle between tibial shaft axis and a tangent at the medial (2) or lateral (3) calcaneal wall. In CBCT the HA was estimated as follows: transversal shift between the centre of the talus and the heel contact point (4); angle between a perpendicular line and a tangent at the medial (5) or lateral (6) calcaneal wall; angle between the distal tibial surface and a tangent at the medial calcaneal wall (7). Intraclass correlation coefficients (ICC) were calculated to assess inter-rater reliability. A linear regression was performed to compare the different measurement regarding their correlation. Results 32 patients were included in the study. The ICCs for the measurements 1–7 were as follows: (1) 0.924 [95% CI 0.876–0.959] (2) 0.533 [95% CI 0.377–0.692], (3) 0.553 [95% CI 0.399–0.708], (4) 0.930 [95% CI 0.866–0.962], (5) 0.00 [95% CI − 0.111 to 0.096], (6) 0.00 [95% CI − 0.103 to 0.111], (7) 0.152 [95% CI 0.027–0.330]. A linear regression between measurement 1 and 4 showed a correlation of 0.272 ( p  = 0.036). Conclusions It could be shown that reliability of measuring HA depends on the investigated anatomical structure. Placing a tangent along the calcaneus (2, 3, 5, 6, 7) was shown to be unreliable, whereas determining the weight-bearing heel point (1, 4) appeared to be a reliable approach. The correlation of the measurement workflows is significant ( p  = 0.036), but too weak (0.272) to be used clinically.

Measuring standing hindfoot alignment: reliability of different approaches in conventional x-ray and cone-beam CT