Distance mapping and volumetric assessment of the ankle and syndesmotic joints in progressive collapsing foot deformity.


The early effects of progressive collapsing foot deformity (PCFD) on the ankle and syndesmotic joints have not been three-dimensionally quantified. This case-control study focused on using weight bearing CT (WBCT) distance (DM) and coverage maps (CM) and volumetric measurements as 3D radiological markers to objectively characterize early effects of PCFD on the ankle and syndesmotic joints. Seventeen consecutive patients with symptomatic stage I flexible PCFD and 20 matched controls that underwent foot/ankle WBCT were included. Three-dimensional DM and CM of the ankle and syndesmotic joints, as well volumetric assessment of the distal tibiofibular syndesmosis was performed as possible WBCT markers of early PCFD. Measurements were compared between PCFD and controls. Significant overall reductions in syndesmotic incisura distances were observed in PCFD patients when compared to controls, with no difference in the overall syndesmotic incisura volume at 1, 3, 5 and 10 cm proximally to the ankle joint. CMs showed significantly decreased articular coverage of the anterior regions of the tibiotalar joint as well as medial/lateral ankle joint gutters in PCFD patients. This study showed syndesmotic narrowing and decreased articular coverage of the anterior aspect of the ankle gutters and talar dome in stage I PCFD patients when compared to controls. These findings are consistent with early plantarflexion of the talus within the ankle Mortise, and absence of true syndesmotic overload in early PCFD, and support DM and CM as early 3D PCFD radiological markers.





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Publication Info

Dibbern, Kevin, Victoria Vivtcharenko, Nacime Salomao Barbachan Mansur, Matthieu Lalevée, Kepler Alencar Mendes de Carvalho, François Lintz, Alexej Barg, Andrew J Goldberg, et al. (2023). Distance mapping and volumetric assessment of the ankle and syndesmotic joints in progressive collapsing foot deformity. Scientific reports, 13(1). p. 4801. 10.1038/s41598-023-31810-6 Retrieved from https://hdl.handle.net/10161/27416.

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de Cesar Netto

Cesar de Cesar Netto

Instructor in the Department of Orthopaedic Surgery

The desire to explore, research, and understand things in great detail has been the driving force throughout my career. This passion drew me to Foot and Ankle, a subspecialty expanding in orthopedic knowledge with many unsolved mysteries. After completing my Medical School, Orthopedic Residency, and Foot and Ankle Fellowship at the renowned University of Sao Paulo, ranked number one in Latin America for several years, and after five years of clinical practice in Brazil, this desire to explore and understand also brought me to the United States. As part of my Ph.D. program with the University of Sao Paulo, I joined as a visiting scientist and research fellow for Dr. Lew Schon at the traditional MedStar Union Memorial Hospital in Baltimore-MD, where I developed an animal model of induced Achilles tendinopathy. 

As a practicing physician in Brazil, I achieved multiple goals in my early career. Academics have been a large component of my practice, allowing me to participate in young physicians' education and challenge my understanding of orthopedic fundamentals. As the elected Chief of Orthopaedic Residents from 2011 to 2013, I presented 245 lectures to orthopedic surgeons and in multidisciplinary conferences. My practice as an orthopedic surgeon in Sao Paulo allowed me to combine the Brazilian enthusiasm for soccer, serving as the team physician and Foot and Ankle advisor for the professional soccer team Sport Club Corinthians Paulista for almost five years.

As a Foot and Ankle surgeon, I constantly sought to confront the unsolved questions in our orthopedic practices. During my Ph.D. studies with the University of Sao Paulo, I aimed to maximize my research experience and clinical exposure. During my time in Maryland, I have engaged in multiple research projects, collaborating with MedStar Union Memorial and Johns Hopkins University to evaluate and clinically implement innovative imaging techniques, including weight-bearing CT, dynamic CT, 3D MRI, and metal artifact reduction sequence (MARS) MRI.

I was also amazed by the American medical system's resources that create opportunities for motivated physicians to excel in clinical work, educational teaching endeavors, and research investigations. While this balance requires dedication and precise time management, I have been fortunate to work with a variety of mentors who demonstrated to me how great it could be to practice in the US. With that in mind, I ended up deciding to pursue the Academic Pathway of the ABOS Certification. I have completed a total of three Orthopedic Foot and Ankle Fellowships in the US. The first was at the University of Alabama at Birmingham (UAB), the second at the Hospital for Special Surgery (HSS) in New York City, and the third and final at MedStar Union Memorial Hospital in Baltimore-MD. It was a long but very pleasant and rewarding pathway that allowed me to grow as a person, as a clinician, and as a surgeon while being fortunate to create lifetime bonds with several mentors. Once I was done with my fellowships, my objective was to combine my unique background with my innovative and instructive training and apply the acquired knowledge as an Academic Assistant Professor at the Department of Orthopedics of the Carver College of Medicine at the University of Iowa.

The almost four years in Iowa City have been a blast! The leadership of the Orthopedic Department entirely and constantly supported me, and together, we achieved a lot in a relatively short amount of time. I utilized my academic start-up grant to acquire the first Weight-Bearing CT scanner in the Country that allows the hip, knee, foot, and ankle to be scanned under load simultaneously. With the scanner, I founded and served as the Director of the University of Iowa Orthopedic Functional Imaging Research Laboratory (OFIRL), which rapidly achieved an established, recognized position in the research and orthopedic foot and ankle community. I also had the unique opportunity to care for the State of Iowa community suffering from orthopedic foot and ankle problems, always excelling in providing high-quality and passionate clinical and surgical care. I’ll be forever grateful to my leadership, partners, and colleagues in Iowa City, as well as my patients, who gave me the utmost opportunity to care for them.

As an Associate Professor in the Department of Orthopedics at Duke University, I hope to contribute further to the American society and North Carolina Community, taking excellent care of patients, teaching and mentoring medical students, residents, and fellows, and helping the orthopedic foot and ankle surgery research to excel.

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