Orthopaedics & Traumatology: Surgery & Research 103 (2017) 1211–1216

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Original article

Radiologic analysis of hindfoot alignment: Comparison of Méary, long

axial, and hindfoot alignment views
T. Neri a,b,∗ , R. Barthelemy c , Y. Tourné d
a
Department of orthopaedic surgery, university hospital of Saint-Étienne, avenue Albert-Raimond, 42055 Saint-Étienne, France
b
Inter-university laboratory of human movement science, EA 7424, université de Lyon, UJM-Saint-Étienne, 42023 Saint-Étienne, France
c
Clinique du Mail, 38100 Grenoble, France
d
Clinique des Cèdres, 38432 Echirolles, France

a r t i c l e i n f o a b s t r a c t

Article history: Background: Among radiographic views available for assessing hindfoot alignment, the antero-posterior
Received 19 August 2016 weight-bearing view with metal cerclage of the hindfoot (Méary view) is the most widely used in France.
Accepted 24 August 2017 Internationally, the long axial view (LAV) and hindfoot alignment view (HAV) are used also. The objective
of this study was to compare the reliability of these three views.
Keywords: Hypothesis: The Méary view with cerclage of the hindfoot is as reliable as the LAV and HAV for assessing
Hindfoot alignment view hindfoot alignment.
Long axial view
Material and methods: All three views were obtained in each of 22 prospectively included patients. Intra-
Radiographic measurement
Hindfoot
observer and inter-observer reliabilities were assessed by having two observers collect the radiographic
measurements then computing the intra-class correlation coefficients (ICCs).
Results: The intra-observer and inter-observer ICCs were 0.956 and 0.988 with the Méary view, 0.990
and 0.765 with the HAV, and 0.997 and 0.991 with the LAV, respectively. Correlations were far stronger
between the LAV and HAV than between each of these and the Méary view. Compared to the LAV and
HAV, the Méary view indicated a greater degree of hindfoot valgus.
Discussion: Intra-observer reliability was excellent with both the LAV and HAV, whereas inter-observer
reliability was better with the LAV. Excellent reliability was also obtained with the Méary view. Combining
the Méary view to obtain a radiographic image of the clinical deformity with the LAV to measure the
angular deviation of the hindfoot axis may be useful when assessing hindfoot malalignment. A comparison
of the three views in a larger population is needed before clinical recommendations can be made.
Level of evidence: II, prospective study.
© 2017 Elsevier Masson SAS. All rights reserved.

1. Introduction The Méary antero-posterior weight-bearing view with metal

Among the radiographic views specifically designed to assess
hindfoot alignment, the hindfoot alignment view (HAV) or Saltz-
mann view [1] and the long axial view (LAV) [2] are widely used.
Both these views visualise the calcaneus and tibia without super-
imposition of other foot and ankle bones. In comparative studies
[3], both views exhibited good intra-observer and inter-observer
reliabilities, although inter-observer reliability was better for the
LAV. These views have been proven useful for guiding the surgical
correction of hindfoot malalignment [4,5] and for positioning ankle
arthrodesis [6].
cerclage of the hindfoot is less popular internationally but is the
most widely used view in France [7]. The Méary view provides
a good radiographic image of the clinical deformity but has not
been validated as a hindfoot alignment assessment tool in stud-
ies providing a high level of evidence. Furthermore, no study has
compared the reliability of the LAV, HAV, and Méary view.
The objective of this study was to compare the inter-observer
and intra-observer reliabilities of the LAV, HAV, and Méary’s view
with cerclage of the hindfoot. Our working hypothesis was that
the Méary view was as reliable as the LAV and HAV for assessing
hindfoot alignment.

2. Material and methods

∗ Corresponding author. Service d’orthopédie et traumatologie, department of

2.1. Population
orthopaedic Surgery, university hospital of Saint-Étienne, CHU de Saint-Étienne,
avenue Albert-Raimond, 42055 Saint-Etienne, France. A prospective single-centre study was conducted between
E-mail address: thomasneri@orange.fr (T. Neri). September 2014 and May 2015 at the Clinique du Mail radiology

http://dx.doi.org/10.1016/j.otsr.2017.08.014
1877-0568/© 2017 Elsevier Masson SAS. All rights reserved.
1212 T. Neri et al. / Orthopaedics & Traumatology: Surgery & Research 103 (2017) 1211–1216

Fig. 1. Méary antero-posterior weight-bearing view with metal cerclage of the hindfoot. A. Positioning of the patient. B. Example of a Méary view.

Fig. 2. Hindfoot alignment view: patient position with the beam angled at 20◦ to the floor and the film cassette perpendicular to the source.

␳0 = 0.70) and an expected ICC of 0.9 (H1: ␳1 = 0.90), with the alpha
risk set at 0.05, the number of patients needed to obtain 80% power
was 18 (36 feet). For the statistical analysis, the unit was the foot.
We included 22 patients who underwent a radiological assess-
ment of the hindfoot because of an ankle and/or hindfoot disorder
(ankle instability, n = 9; pes plano-valgus, n = 5; or hindfoot pain
with a lesion of the tibialis posterior or spring ligament, n = 8).
Exclusion criteria were as follows: unavailability of all three radio-
graphic views, history of foot and/or ankle surgery or trauma,
inflammatory disease, and ongoing growth.

2.2. Radiographic techniques

Fig. 3. Long axial view: patient position with the beam angled at 45◦ to the floor
and the patient standing on the film cassette.
office in Grenoble, France. The required sample size was estimated
as described by Walter et al. [8,9]. To maximise statistical power,
the unit for the sample size estimation was the patient and not the
foot. Assuming a minimum intra-class coefficient (ICC) of 0.70 (H0:
A Méary view, LAV, and HAV of both feet was obtained in all
patients. The settings were as follows: 75 kv, 40 mAs, 150 ms, and
150 cm source-to-film distance.
For the Méary view, a flexible malleable lead wire was passed
under the heel then wrapped up on either side around the malleo-
lus (Fig. 1) [7]. The X-ray beam was horizontal, along the axis of the
second metatarsal, parallel to the floor, and centred on the mid-
dle of the ankle. The cassette was placed behind the two heels,
perpendicularly to the direction of the beam.
The HAV was obtained with the patient standing on both feet,
positioned parallel to each other, on a radiolucent cassette-holding
box with a Plexiglas surface. The beam was angled 20◦ to the
floor and pointed at the middle of the ankle. The field of exposure
 T. Neri et al. / Orthopaedics & Traumatology: Surgery & Research 103 (2017) 1211–1216 1213

Fig. 4. Méary antero-posterior weight-bearing view with metal cerclage of the hindfoot: angular measurement of hindfoot alignment. A. The green line is the anatomical
axis of the tibia. B. The red line runs through the middle of the footprint of the hindfoot (delineated by the metal cerclage) and the middle of the talus.

Fig. 5. Hindfoot alignment view. A. Angular measurement of hindfoot alignment. B. Determination of the most distal point of the calcaneus.
1214 T. Neri et al. / Orthopaedics & Traumatology: Surgery & Research 103 (2017) 1211–1216

included half the tibia down to the calcaneus (Fig. 2) [1]. The cas-
sette was positioned perpendicular to the beam, i.e., inclined 20◦
from the vertical.
For the LAV, the beam was at a 45◦ angle to the floor and pointed
at the middle of the ankle. The field of exposure included the distal
two-thirds of the tibia down to the calcaneus (Fig. 3). The cassette
was horizontal, flat on the floor [2].

2.3. Foot position

For all three views, the patient was in the bipodal stance with the
body weight evenly distributed between the two lower limbs, in a
natural position. To minimise the influence of foot position on the
measurement values, thus allowing comparisons to other studies
and within this study, widely accepted, predefined foot positions
were used [10,11] For the LAV and HAV, the feet were about 80 mm
apart and in slight internal rotation so that the medial edges of the
two feet were parallel to each other. For the Méary views, the feet
were in the natural position (in slight external rotation). Despite
this difference in foot position across views, we decided to obtain
each view in the standardised manner described in the literature,
in order to reflect everyday practice.

2.4. Angular measurements on radiographs

Inter-observer reliability was evaluated by having two senior

observers (RB and TN) measure the hindfoot alignment angles
independently of each other. For the assessment of intra-observer
reliability, one of the observers (TN) measured the angles again 7
days after the first measurement session. Hindfoot alignment was
assessed based on the angle formed by the anatomical axis of the
tibia and the longitudinal axis of the calcaneus [12–14].
On the Méary view, the hindfoot alignment angle was measured
Fig. 6. Long axial view: hindfoot alignment is measured as the angle between the
anatomical axis of the tibia (green line) and the axis of the calcaneus (red line).
Table 1
Mean angular measurement values of hindfoot alignment (n = 44); positive values
indicate valgus deformity and negative values varus deformity.

as illustrated in Fig. 4 as the angle formed by the anatomical axis
of the tibia (green line) and the line running through the middle
of the footprint of the hindfoot (delineated by the metal cerclage)
and the middle of the talus (red line). On the HAV (Fig. 5), one of the
lines defining the hindfoot alignment angle was drawn through the
most distal point of the calcaneus resting on the floor (red dot) and
the point at the intersection of the tangent to the talar dome with
the axis of the tibia (red line). The other line defining the angle was
the tibial axis (green line) [1,14,15]. Finally, on the LAV, the hind-
foot alignment angle was formed by the calcaneal axis (red line)
and the tibial axis (green line) (Fig. 6) [3,15,16]. The calcaneal axis
was defined by two points: one of the points was on the horizon-
tal line 7 mm proximal to the most distal part of the calcaneus and
divided into a 40%/60% ratio, where the 40% segment started at the
lateral side; and the other point was the middle of the horizontal
line 30 mm proximal to the most distal part of the calcaneus. On
all three views, hindfoot alignment could be neutral (0◦ ), in valgus
(positive angle value), or in varus (negative angle value).
2.5. Statistical analysis
The hindfoot alignment angle was measured on each of the three
views for each study foot. The data were entered into a secure
®
Microsoft Excel file (Microsoft Corp., Redmond, WA, USA). Sta-
tistical analyses were performed using SPSS software (Statistical
Package for the Social Sciences, IBM, Armonk, NY, USA).
Quantitative variables were described as mean ± SD. Intra-
observer and inter-observer reliabilities were assessed by com-
puting the intra-class correlation coefficients (ICCs) separately for
each view. The ICC values were compared to the theoretical min-
imum value of 0.7, using a one-tailed test with alpha set at 0.05.
The 95% confidence interval (95% CI) was computed for each ICC
value. Pearson’s correlation coefficient was used to assess corre-
Mean ± SD Range
Méary 6.09◦ ± 0.21◦ −2.8◦ to 20.20◦
HAV 0.21◦ ± 0.22◦ −14.80◦ to 13.90◦
LAV 0.73◦ ± 0.10◦ −14.70◦ to 15.60◦
Méary: Méary radiographic view (antero-posterior weight-bearing view with metal
cerclage of the hindfoot); HAV: hindfoot alignment view; LAV: long axial view.
lations between angular measurements obtained using different
views. Student’s test was applied to evaluate the significance of the
Pearson’s correlation coefficient values. The foot was the unit for
these analyses. ICC values greater than 0.7 were taken to indicate
good reliability and those greater than 0.9 excellent reliability.
3. Results
3.1. Population
Of 35 selected patients, 22 (44 feet) were included. There were
12 females and 10 males with a mean age of 48.5 ± 22.0 years
(range, 17–79 years). Varus hindfoot deformity was noted bilater-
ally in 7 patients and unilaterally in 1 patient and valgus hindfoot
deformity bilaterally in 6 patients and unilaterally in 2 patients.
Hindfoot alignment was normal in the remaining 6 patients. The
reason for obtaining radiographs of the hindfoot were lateral ankle
instability (n = 7), hindfoot pain (n = 6), suspected posterior ankle
impingement syndrome (n = 2), tibio-talar osteoarthritis (n = 3), pes
plano-valgus (n = 2), and fibular tenosynovitis (n = 2).
3.2. Mean hindfoot angle values
The mean hindfoot angle value was highest on the Méary view.
The mean difference was +5.88◦ vs. the HAV and +5.36◦ vs. the LAV
(Table 1).
 T. Neri et al. / Orthopaedics & Traumatology: Surgery & Research 103 (2017) 1211–1216
Table 2
Intra-class correlation coefficient values for intra-observer and inter-observer reliabilities (n = 44).
LAV
Intra-observer CCI [95%CI] 0.997* [0.994–0.998]
Inter-observer CCI [95%CI] 0.991* [0.983–0.995]
ICC: intra-class correlation coefficient; 95% CI: 95% confidence interval; LAV: long axial view; HAV: hindfoot alignment view; Méary: Méary radiographic view (antero-posterior
weight-bearing view with metal cerclage of the hindfoot).
*
P < 0.05.
Table 3
Pearson’s coefficient values for correlations between mean angular measurement
values on the different radiographic views (n = 44).
Pearson’s correlation coefficient
LAV vs. HAV 0.889*
Méary vs. HAV 0.635*
Méary vs. LAV 0.661*
LAV: long axial view; HAV: hindfoot alignment view; Méary: Méary radiographic
view (antero-posterior weight-bearing view with metal cerclage of the hindfoot).
*
P < 0.05.
3.3. Intra-observer and inter-observer reliability assessments
The intra-observer and inter-observer ICC values were 0.956 and
0.988 for Méary’s view, 0.990 and 0.765 for the HAV, and 0.997 and
0.991 for the LAV, respectively (Table 2).
Comparing the ICC values to the theoretical value of 0.7 showed
that intra-observer reliability was excellent with all three views
(P < 0.001). Inter-observer reliability, in contrast, was excellent only
with the Méary view and LAV (P < 0.001).
3.4. Correlations among radiographic views
Table 3 reports the correlation coefficient values between the
means of the values obtained using the three views (values for
the two sides, values obtained by the two observers, and values
obtained twice by the same observer). The mean values obtained
by both observers showed significant correlations across the three
radiographic views. Nevertheless, the correlation between the val-
ues on the HAV and LAV was considerably stronger (Pearson
coefficient, 0.889) compared to the correlations between the values
on the Méary view and on the LAV (0.635) or HAV (0.661).
4. Discussion
The results reported here indicate excellent intra-observer reli-
ability of the angular measurement of hindfoot alignment with all
three radiographic views. Inter-observer reliability, in contrast, was
better with the LAV and Méary view than with the HAV. Reliabil-
ity of angular measurements of hindfoot alignment seemed similar
with the Méary view and LAV. This excellent reliability supports
the use of the Méary view and LAV for the radiographic assessment
of hindfoot malalignment.
Our data are original, as no previous studies have compared
the reliability of the Méary view, LAV, and HAV. Nevertheless,
despite the preliminary sample size estimation, the number of
patients was too small to determine the normal range of radio-
graphic hindfoot angular measurements or the exact indications of
each radiographic view in clinical practice. Another source of bias
that limits the representativeness of the results is that all patients
initially sought medical advice for foot or ankle symptoms.
Only very few studies of the Méary view are available. How-
ever, our results seem consistent with those of previous studies,
which found similar angle values and supported the same conclu-
sions regarding the comparison of the LAV and HAV [3]. The lower
inter-observer reliability of the HAV may be ascribable to several
1215
HAV Méary
0.990* [0.982–0.994] 0.956* [0.919–0.975]
0.765 [0.602–0.862] 0.988* [0.978–0.993]
factors. First, the method described by Saltzman and El-Khoury to
determine the calcaneal axis [1] involves identifying the lowest
point of the weight-bearing calcaneus. This is a difficult step that
has poor reproducibility, particularly between two observers. Sec-
ond, the projection of the calcaneus is shorter on the HAV than on
the LAV. The shorter a segment between two points used to define
an axis, the greater the impact of small measurement errors on the
determination of that axis.
In keeping with earlier reports, we found that the mean angular
measurements of hindfoot alignment differed across radiographic
views, ranging from close to 0◦ on the LAV and HAV to about 6◦
of valgus on the Méary view [17]. Similarly, values on the LAV
and HAV correlated closely with each other and less closely with
those on the Méary view. Thus, the LAV and HAV may assess
different aspects of hindfoot deformities compared to the Méary
view. Several hypotheses, which would require evaluation in addi-
tional studies, can be put forward to explain these differences. One
hypothesis is that the degree of leg rotation may affect hindfoot
alignment measurements [18]. The foot was in the natural posi-
tion for the Méary view and in slight medial rotation for the LAV
and HAV [3]. Johnson et al. [12] found no significant difference in
hindfoot alignment between the natural foot position (i.e., with
lateral rotation) and the medially rotated position. Our results, in
contrast, suggest that medial foot rotation may produce angle val-
ues in greater hindfoot varus on projection views, leading to values
in greater valgus on the Méary view. Another hypothesis involves
the fact that the Méary views were obtained separately for each
foot, whereas both feet were imaged simultaneously for the LAV
and HAV. This difference may hinder comparison of the views and
induce rotation affecting the projection of the hindfoot axes. Finally,
a third hypothesis involves the differences in the radiological land-
marks used for the three views: the LAV and HAV rely only on
projections of bone axes, whereas the Méary view uses both a bony
landmark (the talus) and a soft tissue landmark (the heel circled by
the wire) [19].
Thus, although the three views investigate the same hindfoot
deformities, they are not strictly comparable, as they rely on some-
what different measurement methods [20]. However, they are
complementary, with the Méary view apparently quantifying the
clinical hindfoot deformity and the LAV characterising the bone
malalignment. Further studies are needed to determine the exact
indications of each radiographic view when assessing hindfoot
abnormalities in everyday clinical practice.
5. Conclusion
Intra-observer reliability is excellent for both the LAV and the
HAV, whereas LAV has better inter-observer reliability. The LAV
therefore deserves preference over the HAV as a tool for angular
measurements of hindfoot malalignment. Measurements on the
Méary view with cerclage of the hindfoot seem reproducible.
Although measurements on the three views correlate signifi-
cantly with one another, the LAV and HAV do not seem to assess
the same aspects of hindfoot deformities as does the Méary view.
The three views seem helpful and complementary. Nevertheless,
further comparative assessments in larger number of patients
1216 T. Neri et al. / Orthopaedics & Traumatology: Surgery & Research 103 (2017) 1211–1216
will have to be performed before recommendations for everyday
practice can be made.
Disclosure of interest
The authors declare that they have no competing interest.
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