Is a Keystone Bone Anomaly The Main Cause of Pes Planus?

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Ahmet Payas, Sabri Batın This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3182349/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background In flexible pes planus, the height of the arcus pedis longitudinalis medialis (APLM) collapses during weight bearing. We think that this may be caused by anomalies in the bones that support the arches against the compression load. For this purpose, the volume (cm 3 ) and superficial area (cm 2 ) ratios of the foot bones were calculated using foot computed tomography (CT) images of individuals with pes planus and compared with healthy individuals Methods Fifteen pes planus patients diagnosed with pes planus in our clinic and with an APLM angle greater than 145 degrees and 15 healthy male participants were included. The foot computed tomography (CT) images of the participants were taken with a General Electric brand IQ model 32 detector CT device in accordance with the bone protocol, with a section thickness of 0.625 mm. Foot bones were segmented from the obtained CT images with the help of the 3D Slicer program. Results The os cuneiforme mediale and os cuneiforme intermedium volume and superficial area ratios of the pes planus group were significantly lower than the control group (p 0.05). Conclusion We think that pes planus is primarily caused by os cuniforme mediale and os cuneiforme intermedium developmental anomalies, which act as a keystone in the formation of arches. Pes Planus Arcus Pedis Longitudinalis Medialis Arcus Pedis Transversus Ossa Cuneiforme Tarsal Bones Figures Figure 1 Figure 2 Figure 3 Background Foot; It is responsible for carrying loads, reducing ground reaction force, providing adaptation to the ground, creating a rigid lever arm for effective propulsion, minimizing energy consumption and providing proprioception sense (1). The ability of the foot to perform these tasks in a healthy way depends on the preservation of the anatomical structure of the longitudinal and transverse arches of the foot (2,3). Disruption of the structure of the arcus pedis longitudinalis medialis (APLM), located on the inside of the foot and formed by the os calcaneus, os talus, os naviculare, ossa cuneiforme and ossa metatarsi I, II, III, causes foot deformities such as pes planus and pes cavus (4,5). The structures that support the anatomical structure of the APLM are examined under two headings as passive and active systems. While there are tarsal and metatarsale bones, plantar fascia and ligaments forming the arch in the passive system, there are intrinsic and extrinsic foot muscles in the active system (6). Passive structures are responsible for providing APLM stability by resisting the compression load (1). The most common pes planus deformity presents as hindfoot eversion and forefoot abduction due to the deterioration of stability and decreased height in the APLM (7-9). The prevalence of pes planus has been reported to be around 13% between the ages of 18-25, and 19-33.9% over the age of 65 (10,11). Pes planus; divided into flexible and rigid. Rigid pes planus is rare and usually develops during childhood, but can occur at any point in life. Flexible pes planus APLM height is normal when weight is not carried, but disappears with weight bearing. It has been suggested that the flexible pes planus is mostly caused by dysfunction in the muscles that support APLM (1,10,11). However, in a recent meta-analysis study, it was concluded that exercise and orthotic approaches to eliminate muscle dysfunction in adults with pes planus are not effective in improving pes planus (12). APLM is similar to the "stone bridge" system and has a keystone called "key stone", just like in stone bridges. The keystone bone is wedge-shaped and is located at the top of the arch. The keystone ensures that the arch is locked and does not collapse by distributing the weight that will be reflected on the arch proportionally to the other bones that make up the arch (SOURCE). Our hypothesis in this study; It is the idea that the flexible type pes planus develops from developmental anomalies in the bones that make up the APLM, and especially the bones that serve as the keystone. For this purpose, it is aimed to compare the results obtained by calculating the volume (cm 3 ) and superficial area (cm 2 ) of the bones that make up the APLM over the foot computed tomography (CT) images of individuals with pes planus. Methods Study; The cross-sectional cohort was conducted in a randomized controlled and prospective manner, adhering to the principles of the Declaration of Helsinki. The purpose and scope of the study were explained to the participants in detail and the consent form was signed. In addition, the study was approved by the Local Ethics Committee with the decision numbered 2023-05. Determination of Sample size and Study Groups The sample of this study was determined as α = 0.05, β = 0.19, effect size = 1.08 by posthoc power analysis using Gpower. The study and control groups consisted of at least 15 individuals. Pes Planus group (n = 15): Fifteen male participants with pes planus who were diagnosed with pes planus in our clinic and whose APLM angle was greater than 145 degrees were included. Inclusion criteria: Diagnosed with pes planus and having an APLM angle above 145 degrees ( 13 , 14 ). Exclusion criteria: Foot deformity other than pes planus, history of trauma or surgery affecting the ankle and foot, neuromuscular or musculoskeletal disease. Control group (n = 15): It consists of 15 male asymptomatic participants who did not show any signs of foot and ankle musculoskeletal pathology on physical examination. Inclusion criteria: Absence of any foot and ankle deformities, no history of trauma or surgery affecting the foot and ankle, and no musculoskeletal and neuromuscular disease. Body Mass Index (BMI) was calculated by using the participants' age, weight and height data in the formula [BMI = Weight/Height x Height (kg/m2)]. Definition of medial longitudinal arch angle The APLM angle measurement on the mediolateral radiograph is as follows; The angle formed between the line drawn to connect the lowest point of the talus head to the lowest point of the first metatarsale head and the lines connecting the lowest point of the talus head to the lowest point of the tuber calcanei is measured ( 15 ). The APLM angle in individuals with pes planus was evaluated by an orthopedic surgeon with at least 10 years of professional experience (Fig. 1 ). Computed tomography and calculation of foot bone volume The foot computed tomography (CT) images of the participants were taken with a General Electric brand IQ model 32 detector CT device in accordance with the bone protocol, with a section thickness of 0.625 mm. Segmentation of tarsal bones was done with the help of 3D Slicer program. 3D Slicer is a free, open source software application developed for segmentation from medical images. 3D Slicer is the collaborative product of several independent projects such as image visualization, surgical navigation and graphical user interface ( 16 ). For the segmentation process of the foot bones, the foot CT data of the participants were loaded into the 3D Slicer tool set and the segmentation process was started. After the images were opened in the 3D Slicer program, the "Segment Editor" option was selected from the "Modules" tab. After this process, new segmentation tabs were added via the “Segmentation” tab that opened on the screen. Using the “Threshold” tab on the first segmentation tab added, the “Threshold Range” setting was made to cover the anatomical borders of the foot bones to be measured. After these processes, the raw image is obtained by selecting the “Apply” and “Show 3D” options (Fig. 2 ). After obtaining the raw image, the "Islands" tab of the program is selected, and the "add selected island" tab is selected and the foot bone to be measured on the raw image is marked. During this process, if there are overflows or deficiencies in the anatomical borders of the selected foot bone, they are removed by using the "Erase", "Scissors" and "Paint" tabs. After these procedures, the volume (mm3) and superficial area (mm2) of the foot bone measured is accessed via the “Quantification” tab under the “Modules” tab (Fig. 2 ). Finally, the total volume and superficial area of all foot bones were calculated, and the volume and superficial area ratios of each foot bone were calculated according to all foot bones (Fig. 3 ). The volume and surface area ratios of the bones obtained were compared between pes planus and healthy individuals. Statistical Analysis The data in the study were analyzed for normal distribution by considering 5 parameters (Skewness-Kurtosis, Std/Mean, Q-Q Plots, Histogram and Shapiro Wilk Test). Normally distributed parameters with sufficient number of data were shown as mean ± std. While Independent Samples T Test was applied in independent paired group comparisons, Related Samples T Test was applied in pairwise comparisons of dependent groups. In the study, α = 0.05 and p < α was considered significant. IBM SPSS 23.00 package program was used for statistical analysis. Results In the study, 20 individuals with pes planus were reached, and 15 of them were found to be suitable for inclusion criteria. The flowchart of the study is shown in Table 1. In the control group, 15 CT images that met the criteria were included in the study. The mean age of the pes planus and control groups was 28.2±2 years and 30.5±1 years, respectively. The mean APLM angle in individuals with pes planus was 155.2 degrees. Descriptive characteristics of the participants are presented in Table 2. There was no significant difference between the two groups in terms of baseline characteristics (p˃0.05). By calculating the total volume and superficial area of all foot bones, the volume and superficial area ratios of each foot bone were calculated according to all foot bones. The volume and surface area ratios of the bones obtained were compared. Os cuneiforme mediale and os cuneiforme intermedium volume ratios were increased by 14% and 24% in the control group compared to the pes planus group, respectively, and the difference between the groups was statistically significant (p0.05). When the superficial area ratios of the bones were compared between the groups, a significant difference was observed only in the cuniforme mediale and os cuneiforme intermedium (p<0.05). Os cuneiforme mediale and os cuneiforme intermedium superficial area ratios were calculated to be 10% and 30% lower in the pes planus group compared to the control group, respectively (Table 3). Discussion The alignment and harmony of the tarsal bones are passive structures that protect the arches of the feet. In the present study, it was determined that the volume and superficial areas of the bones, which are the keystones in the protection of the foot arches, are lower than those of healthy individuals. This causes the alignment and alignment of the tarsal bones to deteriorate, resulting in the development of pes planus. It makes tarsal bone anomaly indisputable in the etiopathogenesis of pes planus. Flexible pes planus in adults is usually seen with the continuation of pes planus seen in childhood ( 17 ). The normal development of the bones that make up the arch of the foot, and especially the bone in the upper middle part of the arch and called the keystone, is very important in the protection of the arch of the foot ( 5 ). Keystone bone; It is wedge-shaped and placed with the thin side down. Thanks to this special shape, it serves as a keystone in the protection of arcs by ensuring that the bones are tightly interlocked with each other. Postural changes such as abduction and supination in the forefoot and valgus in the hindfoot and heel are seen in pes planus caused by collapse in the APLM. This is an indication that the arcus pedis transversus (APT) has collapsed in pes planus ( 18 , 19 ). APLM; It is formed by os calcaneus, os talus, os naviculare, ossa cuneiforme and ossa metatarsale I, II, III, while APT is formed by the basis parts of metatarsale bones and os cuboideum and ossa cuneiformes. ( 4 , 5 ). At the intersection of both arches, there are ossa cuneiforme and ossa metatarsi I, II, III bones. When APLM and APT are considered as a whole, especially in terms of anatomical structure and location, os cuneiforme intermedium and mediale are keystones in this structure (4,20). We think that the flexible type of pes planus is caused by the developmental anomaly of the bones forming the arch of the foot. An anomaly that may develop in these bones, which serve as a keystone in the protection of the arches, will cause the arches to collapse and the muscles that actively support the arch to become insufficient ( 4 ). In pes planus, not only the APLM but also the collapse of the APT is observed ( 21 ). In the literature, keystones are mentioned for maintaining the arch height of the foot and the naviculare is shown as the keystone for maintaining the APLM height ( 4 ). However, in pes planus, APLM and APT collapse together and the bone in my keystone position changes. When APLM and APT are evaluated as a whole, there are os cuneiforme intermedium and mediale bones in the keystone position in shape and location ( 4 , 20 ) As far as we know, bone volume and superficial area have not been examined by segmentation of tarsal and metatarsale bones in individuals with flexible type pes planus in the literature. In this study, the ratio of the volume and superficial area of each tarsal and metatarsale bones to the volume and superficial area of the entire foot bone was calculated on foot CT images. In the study, both volume and superficial area ratios of the cuniforme mediale and os cuneiforme intermedium, which are the keystones at the intersection of the APLM and APT arches, were found to be lower in individuals with pes planus compared to healthy individuals. Knowing the mean value of the APLM angle is important for the detection of foot deformities. In the literature, the mean values of the APLM angle in patients with pes planus deformity were reported as 142.4º in the study by Cebulski-Delebarre et al, and 146.6º in the study by Ceccarini et al ( 13 , 14 ). In the present study, the mean APLM angle of individuals with pes planus was calculated as 155.2 degrees. These findings show that the severity of pes planus in individuals is above the average. Flexible pes planus in adults is usually seen with the continuation of pes planus seen in childhood ( 17 ). In the literature, there are stereological studies about tarsal bone measurements in childhood idiopathic pes planus. It has been suggested by Hemo et al that delayed ossification and abnormal development of tarsal bones will be effective in idiopathic pes planus ( 22 ). Cahuzac et al. They analyzed tarsal bone volumes in individuals with pes pes planus using magnetic resonance images of the foot. As a result, it was found that the foot bone volumes of individuals with pes planus were approximately 20% smaller than the healthy foot bone volumes ( 23 ). Itohara et al. They reported that talus volume and talus ossification center were lower in individuals with pes planus and suggested that pathological changes in bone structures with pes planus might be the cause ( 24 ). Itohara et al. It has been reported that both the volume and length data of the talus and calcaneus bones are smaller in individuals with pes planus than in healthy individuals ( 25 ). In the present study, the volume and superficial area ratio data of only the os cuneiforme mediale and os cuneiforme intermedium of individuals with pes planus were found to be significantly lower than the control group. In pes planus, there is simultaneous arch collapse in the APLM and APT. The anatomical structures of os cuneiforme mediale and os os cuneiforme intermedium, which are in the keystone position at the intersection of both arches, are wedge-shaped and are located with the thin side down. Thanks to this special shape, it is critical in protecting the arches by ensuring that the bones are tightly interlocked with each other. We think that the anomaly that will occur in the bones forming the arch will cause pes planus by first disrupting the alignment of the bones in the arch and then the harmony of the bones with each other. In some studies on pes planus, the length of the tarsal bones was measured in individuals with pes planus ( 23 , 26 ). In their study, Claaßen et al. investigated the anatomical features of the ossa cuniforme and measured the ossa cuniforme length, height and width, and joint surface values ( 27 ). Tarsal bones are short bones and their width and length cannot be distinguished. Therefore, we think that volume or superficial area measurement is more effective and reliable than length measurement in tarsal bones. In the literature, it is stated that the formation of pes planus is caused by plantar fascia, ligament, intrinsic or extrinsic foot muscle deficiencies ( 28 – 30 ). However, in a recent meta-analysis study, it was concluded that exercise and orthotic approaches to eliminate muscle dysfunction in adults with pes planus are not effective in improving pes planus ( 12 ). According to the presented study, insufficiency of soft tissue such as muscle and ligament in pes planus is a secondary changing condition. The change in the alignment of the bones forming the arch causes a change in factors that are essential for muscle strength, such as the origo insertion of the muscles and the angle of pull. Therefore, over time, insufficiency of structures such as muscles and ligaments emerges. The present study had some limitations. The first is that it was studied on a small group of patients, and the second is that it is cross-sectional. Therefore, more cases and longer-term studies are needed. Conclusion In our results, both volume and superficial area ratios of cuniforme mediale and os cuneiforme intermedium were found lower in individuals with pes planus compared to healthy individuals. We think that the pes planus deformity, which occurs with the collapse of the arches of the feet, is caused by the cuniforme mediale and os cuneiforme intermedium developmental anomalies, which serve as the keystone in the APLM, APT arches. We speculate that the muscle and ligament weakness that occurs in individuals with pes planus develops secondary to the change in the alignment of the bones forming the arch. Our study is the first to show the relationship between pes planus and tarsal bone volume and superficial area. We believe that this study will shed light on the treatment of pes planus. Large-scale studies are needed to obtain clearer results. Abbreviations APLM : Arcus Pedis Longitudinalis Medialis BMI: Body Mass Index CT: Computed Tomography APT: Arcus Pedis Transversus Declarations Ethics approval and consent to participate The Hitit university, non-interventional research ethics committee granted approval for this study (date: 03.05.2023, number: 2023-05). Consent for publication Not applicable. Availability of data and material Not applicable. Competing interests The authors declare that they have no competing interests. Funding Not applicable. Authors' contributions Study concept and design: AP, SB. Literature Search: AP, SB. Analysis and interpretation of data: AP, SB. Drafting of the manuscript: AP, SB. All authors read and approved the final manuscript. Acknowledgements Not applicable. Authors' information (optional) Not applicable. 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Orthop Rev (Pavia). 2019 May 23;11(2):7876. doi: 10.4081/or.2019.7876. Angin S, Crofts G, Mickle KJ, Nester CJ. Ultrasound evaluation of foot muscles and plantar fascia in pes planus. Gait Posture. 2014;40(1):48-52. doi: 10.1016/j.gaitpost.2014.02.008. Okamura K, Fukuda K, Oki S, Ono T, Tanaka S, Kanai S. Effects of plantar intrinsic foot muscle strengthening exercise on static and dynamic foot kinematics: A pilot randomized controlled single-blind trial in individuals with pes planus. Gait Posture. 2020 Jan;75:40-45. doi: 10.1016/j.gaitpost.2019.09.030. Okamura K, Kanai S, Fukuda K, Tanaka S, Ono T, Oki S. The effect of additional activation of the plantar intrinsic foot muscles on foot kinematics in flat-footed subjects. Foot (Edinb). 2019 Mar;38:19-23. doi: 10.1016/j.foot.2018.11.002. Tables Table 1. Flow diagram of study inclusion and exclusion criteria Table 2. Descriptive Statistics of The Participants Control Group Pes Planus Group Sig. (p) Age 24.65±2.51 24.71±2.17 0.901 Kg 65.45±7.65 64.15±6.85 0.984 Height 1.68±0.55 1.70±0.48 0.988 BMI 20.15±1.73 20.49±2.52 0.920 Parametric data were presented as Mean±Standard Deviation (MEAN±STD) and Independent Samples T Test was used for statistical analysis. Non-parametric data were shown as Median (Minimum-Maximum) and Mann Whitney U Test was applied for pairwise comparisons. Table 3. Comparison of volume and superficial area data of foot bones between the group Bone Volume Ratio Values Bone Superficial Area Ratio Values Control Group Pes Planus Group Sig. (p) Control Group Pes Planus Group Sig. (p) Talus 22.41±1.58 23.91±2.02 0.061 18.34 (11.21-24.27) 17.13 (12.52-21.91) 0.285 Calcaneus 27.31±1.87 29.39±2.15 0.053 30.22 (8.53-36.78) 29.41 (26.40-34.59) 0.458 Os naviculare 6.39 (4.63-7.37) 6.12 (3.68-8.93) 0.369 5.68 (0.60-7.78) 5.29 (3.38-7.37) 0.512 Os cuboideum 5.54 (4.43-6.53) 5.30 (4.22-5.65) 0.069 7.03 (6.43-9.31) 7.03 (6.01-8.46) 0.382 Os cuneiforme mediale 5.71±0.62 4.97±0.75 0.010 5.72 (4.78-6.81) 5.21 (3.51-5.98) 0.009 Os cuneiforme intermedium 2.84 (2.35-3.92) 2.29 (1.77-2.90) <0.001 2.77 (2.36-3.81) 2.12 (1.75-2.47) <0.001 Os cuneiforme laterale 3.09 (2.33-4.20) 2.80 (2.06-3.56) 0.166 3.41 (3.01-4.84) 3.49 (3.01-4.12) 0.827 Os metatarsale (I) 8.93 (7.18-12.05) 8.50 (6.20-9.22) 0.058 9.48 (8.02-12.33) 8.90 (7.11-9.68) 0.055 Os metatarsale (II) 5.01±0.57 5.00±0.50 0.941 5.05 (4.01-8.03) 5.79 (4.57-6.93) 0.076 Os metatarsale (III) 4.16±0.52 3.98±0.45 0.335 4.58 (0.39-8.15) 5.22 (4.16-6.37) 0.061 Os metatarsale (IV) 3.91±0.53 3.97±0.73 0.815 4.23 (3.38-7.67) 5.10 (3.82-7.21) 0.057 Os metatarsale (V) 4.27 (3.34-5.70) 4.34 (3.72-5.64) 0.734 4.56 (3.46-7.22) 5.10 (3.61-6.31) 0.185 Parametric data were shown as Mean±Standard Deviation (mean±std) and Independent Samples T Test was used for statistical analysis. Non-parametric data were shown as Median (minimum-maximum) and Mann Whitney U test was used for pairwise comparisons. * Bone volume ratio value = (volume value of the measured bone*100)/total volume value of all foot bones * Bone superficial area ratio value = (superficial area value of the measured bone*100)/total superficial area value of all foot bones Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3182349","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":225494062,"identity":"67dd1fa3-eef8-4c98-be77-d59beb136aeb","order_by":0,"name":"Ahmet Payas","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9klEQVRIiWNgGAWjYBAC9mYEm/EBkODhI6SF5zCCzWwAEmAjqOUAgs0mASYJamFnfybxcYddYn//8WeVX3PsZNgYmB8+uoFPCzNDmuTMM8mJM27kmN2W3ZYMdBibsXEOHi32zAzHpHnbmBMbbvCw3ZbcxgzUwsMmjU8LDzNjG1BLfeL888efFUtuqydGCzMbUMvhxA0HEswYP247TIwWNmbLmWeOG2+8kWMszbjtOA8bMwG/8PAff3jj445q2Xnnjz/8+HNbtT0/e/PDx/i0AAGLBGMDg2MDkMXMA+Iz41cOVvIBqMUexGL8QVj1KBgFo2AUjEAAACFBRGxxSSwKAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0002-1629-9794","institution":"Amasya University Faculty of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Ahmet","middleName":"","lastName":"Payas","suffix":""},{"id":225494063,"identity":"fc76d3f0-202f-482d-9bfd-1390d3ee9d8e","order_by":1,"name":"Sabri Batın","email":"","orcid":"","institution":"Kayseri Training and Research Hospital","correspondingAuthor":false,"prefix":"","firstName":"Sabri","middleName":"","lastName":"Batın","suffix":""}],"badges":[],"createdAt":"2023-07-18 16:30:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3182349/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3182349/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":41642089,"identity":"ddaa51b6-ff26-4004-8261-e0348369cca0","added_by":"auto","created_at":"2023-08-16 14:29:54","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":154992,"visible":true,"origin":"","legend":"\u003cp\u003eMeasuring the medial longitudinal arch angle\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-3182349/v1/c67d3747206e5c157375e969.png"},{"id":41641095,"identity":"4f4d68b2-785f-438c-8a1c-1b4a7133b03e","added_by":"auto","created_at":"2023-08-16 14:21:54","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":611683,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSegmentation process to determine the volume and superficial area of the foot bones\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-3182349/v1/680aeefc636554eded859a06.png"},{"id":41641093,"identity":"5b5b175e-0ad7-47d3-9de9-ff0175c97729","added_by":"auto","created_at":"2023-08-16 14:21:54","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":224935,"visible":true,"origin":"","legend":"\u003cp\u003eImage of segmented foot bones\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-3182349/v1/1bf4f295f21e08ce5db81df6.png"},{"id":44814437,"identity":"5e738d8d-1f80-49aa-80e9-b9fe93e784a0","added_by":"auto","created_at":"2023-10-17 22:50:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1139316,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3182349/v1/0e310a9b-88a5-4b75-a5bd-b8ab4e0a0044.pdf"}],"financialInterests":"","formattedTitle":"Is a Keystone Bone Anomaly The Main Cause of Pes Planus?","fulltext":[{"header":"Background","content":"\u003cp\u003eFoot; It is responsible for carrying loads, reducing ground reaction force, providing adaptation to the ground, creating a rigid lever arm for effective propulsion, minimizing energy consumption and providing proprioception sense (1). The ability of the foot to perform these tasks in a healthy way depends on the preservation of the anatomical structure of the longitudinal and transverse arches of the foot (2,3).\u0026nbsp;Disruption of the structure of the arcus pedis longitudinalis medialis (APLM), located on the inside of the foot and formed by the os calcaneus, os talus, os naviculare, ossa cuneiforme and ossa metatarsi I, II, III, causes foot deformities such as pes planus and pes cavus (4,5). The structures that support the anatomical structure of the APLM are examined under two headings as passive and active systems. While there are tarsal and metatarsale bones, plantar fascia and ligaments forming the arch in the passive system, there are intrinsic and extrinsic foot muscles in the active system (6). Passive structures are responsible for providing APLM stability by resisting the compression load (1). The most common pes planus deformity presents as hindfoot eversion and forefoot abduction due to the deterioration of stability and decreased height in the APLM (7-9). The prevalence of pes planus has been reported to be around 13% between the ages of 18-25, and 19-33.9% over the age of 65 (10,11). Pes planus; divided into flexible and rigid. Rigid pes planus is rare and usually develops during childhood, but can occur at any point in life. Flexible pes planus APLM height is normal when weight is not carried, but disappears with weight bearing. It has been suggested that the flexible pes planus is mostly caused by dysfunction in the muscles that support APLM (1,10,11). However, in a recent meta-analysis study, it was concluded that exercise and orthotic approaches to eliminate muscle dysfunction in adults with pes planus are not effective in improving pes planus (12). APLM is similar to the \u0026quot;stone bridge\u0026quot; system and has a keystone called \u0026quot;key stone\u0026quot;, just like in stone bridges. The keystone bone is wedge-shaped and is located at the top of the arch. The keystone ensures that the arch is locked and does not collapse by distributing the weight that will be reflected on the arch proportionally to the other bones that make up the arch (SOURCE). Our hypothesis in this study; It is the idea that the flexible type pes planus develops from developmental anomalies in the bones that make up the APLM, and especially the bones that serve as the keystone. For this purpose, it is aimed to compare the results obtained by calculating the volume (cm\u003csup\u003e3\u003c/sup\u003e) and superficial area (cm\u003csup\u003e2\u003c/sup\u003e) of the bones that make up the APLM over the foot computed tomography (CT) images of individuals with pes planus.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e Study; The cross-sectional cohort was conducted in a randomized controlled and prospective manner, adhering to the principles of the Declaration of Helsinki. The purpose and scope of the study were explained to the participants in detail and the consent form was signed. In addition, the study was approved by the Local Ethics Committee with the decision numbered 2023-05.\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eDetermination of Sample size and Study Groups\u003c/h2\u003e \u003cp\u003eThe sample of this study was determined as α\u0026thinsp;=\u0026thinsp;0.05, β\u0026thinsp;=\u0026thinsp;0.19, effect size\u0026thinsp;=\u0026thinsp;1.08 by posthoc power analysis using Gpower. The study and control groups consisted of at least 15 individuals.\u003c/p\u003e \u003cp\u003ePes Planus group (n\u0026thinsp;=\u0026thinsp;15): Fifteen male participants with pes planus who were diagnosed with pes planus in our clinic and whose APLM angle was greater than 145 degrees were included.\u003c/p\u003e \u003cp\u003eInclusion criteria: Diagnosed with pes planus and having an APLM angle above 145 degrees (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eExclusion criteria: Foot deformity other than pes planus, history of trauma or surgery affecting the ankle and foot, neuromuscular or musculoskeletal disease.\u003c/p\u003e \u003cp\u003eControl group (n\u0026thinsp;=\u0026thinsp;15): It consists of 15 male asymptomatic participants who did not show any signs of foot and ankle musculoskeletal pathology on physical examination.\u003c/p\u003e \u003cp\u003eInclusion criteria: Absence of any foot and ankle deformities, no history of trauma or surgery affecting the foot and ankle, and no musculoskeletal and neuromuscular disease.\u003c/p\u003e \u003cp\u003eBody Mass Index (BMI) was calculated by using the participants' age, weight and height data in the formula [BMI\u0026thinsp;=\u0026thinsp;Weight/Height x Height (kg/m2)].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDefinition of medial longitudinal arch angle\u003c/h2\u003e \u003cp\u003eThe APLM angle measurement on the mediolateral radiograph is as follows; The angle formed between the line drawn to connect the lowest point of the talus head to the lowest point of the first metatarsale head and the lines connecting the lowest point of the talus head to the lowest point of the tuber calcanei is measured (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The APLM angle in individuals with pes planus was evaluated by an orthopedic surgeon with at least 10 years of professional experience (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003eComputed tomography and calculation of foot bone volume\u003c/h2\u003e \u003cp\u003eThe foot computed tomography (CT) images of the participants were taken with a General Electric brand IQ model 32 detector CT device in accordance with the bone protocol, with a section thickness of 0.625 mm.\u003c/p\u003e \u003cp\u003eSegmentation of tarsal bones was done with the help of 3D Slicer program. 3D Slicer is a free, open source software application developed for segmentation from medical images. 3D Slicer is the collaborative product of several independent projects such as image visualization, surgical navigation and graphical user interface (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). For the segmentation process of the foot bones, the foot CT data of the participants were loaded into the 3D Slicer tool set and the segmentation process was started. After the images were opened in the 3D Slicer program, the \"Segment Editor\" option was selected from the \"Modules\" tab. After this process, new segmentation tabs were added via the \u0026ldquo;Segmentation\u0026rdquo; tab that opened on the screen. Using the \u0026ldquo;Threshold\u0026rdquo; tab on the first segmentation tab added, the \u0026ldquo;Threshold Range\u0026rdquo; setting was made to cover the anatomical borders of the foot bones to be measured. After these processes, the raw image is obtained by selecting the \u0026ldquo;Apply\u0026rdquo; and \u0026ldquo;Show 3D\u0026rdquo; options (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). After obtaining the raw image, the \"Islands\" tab of the program is selected, and the \"add selected island\" tab is selected and the foot bone to be measured on the raw image is marked. During this process, if there are overflows or deficiencies in the anatomical borders of the selected foot bone, they are removed by using the \"Erase\", \"Scissors\" and \"Paint\" tabs. After these procedures, the volume (mm3) and superficial area (mm2) of the foot bone measured is accessed via the \u0026ldquo;Quantification\u0026rdquo; tab under the \u0026ldquo;Modules\u0026rdquo; tab (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Finally, the total volume and superficial area of all foot bones were calculated, and the volume and superficial area ratios of each foot bone were calculated according to all foot bones (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The volume and surface area ratios of the bones obtained were compared between pes planus and healthy individuals.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eThe data in the study were analyzed for normal distribution by considering 5 parameters (Skewness-Kurtosis, Std/Mean, Q-Q Plots, Histogram and Shapiro Wilk Test). Normally distributed parameters with sufficient number of data were shown as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;std. While Independent Samples T Test was applied in independent paired group comparisons, Related Samples T Test was applied in pairwise comparisons of dependent groups. In the study, α\u0026thinsp;=\u0026thinsp;0.05 and p\u0026thinsp;\u0026lt;\u0026thinsp;α was considered significant. IBM SPSS 23.00 package program was used for statistical analysis.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eIn the study, 20 individuals with pes planus were reached, and 15 of them were found to be suitable for inclusion criteria. The flowchart of the study is shown in Table 1. In the control group, 15 CT images that met the criteria were included in the study. The mean age of the pes planus and control groups was 28.2\u0026plusmn;2 years and 30.5\u0026plusmn;1 years, respectively. The mean\u0026nbsp;APLM\u0026nbsp;angle in individuals with pes planus was 155.2 degrees. Descriptive characteristics of the participants are presented in Table 2. There was no significant difference between the two groups in terms of baseline characteristics (p˃0.05).\u003c/p\u003e\n\u003cp\u003eBy calculating the total volume and superficial area of all foot bones, the volume and superficial area ratios of each foot bone were calculated according to all foot bones. The volume and surface area ratios of the bones obtained were compared. Os cuneiforme mediale and os cuneiforme intermedium volume ratios were increased by 14% and 24% in the control group compared to the pes planus group, respectively, and the difference between the groups was statistically significant (p\u0026lt;0.05). There was no significant difference between the groups in the volume ratios of the talus, calcaneus, os naviculare, os cuboideum, cuneiforme laterale, metatarsale 1,2,3,4,5 bones (p\u0026gt;0.05). When the superficial area ratios of the bones were compared between the groups, a significant difference was observed only in the cuniforme mediale and os cuneiforme intermedium (p\u0026lt;0.05). Os cuneiforme mediale and os cuneiforme intermedium superficial area ratios were calculated to be 10% and 30% lower in the pes planus group compared to the control group, respectively (Table 3).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe alignment and harmony of the tarsal bones are passive structures that protect the arches of the feet. In the present study, it was determined that the volume and superficial areas of the bones, which are the keystones in the protection of the foot arches, are lower than those of healthy individuals. This causes the alignment and alignment of the tarsal bones to deteriorate, resulting in the development of pes planus. It makes tarsal bone anomaly indisputable in the etiopathogenesis of pes planus.\u003c/p\u003e \u003cp\u003eFlexible pes planus in adults is usually seen with the continuation of pes planus seen in childhood (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). The normal development of the bones that make up the arch of the foot, and especially the bone in the upper middle part of the arch and called the keystone, is very important in the protection of the arch of the foot (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Keystone bone; It is wedge-shaped and placed with the thin side down. Thanks to this special shape, it serves as a keystone in the protection of arcs by ensuring that the bones are tightly interlocked with each other. Postural changes such as abduction and supination in the forefoot and valgus in the hindfoot and heel are seen in pes planus caused by collapse in the APLM. This is an indication that the arcus pedis transversus (APT) has collapsed in pes planus (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). APLM; It is formed by os calcaneus, os talus, os naviculare, ossa cuneiforme and ossa metatarsale I, II, III, while APT is formed by the basis parts of metatarsale bones and os cuboideum and ossa cuneiformes. (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). At the intersection of both arches, there are ossa cuneiforme and ossa metatarsi I, II, III bones. When APLM and APT are considered as a whole, especially in terms of anatomical structure and location, os cuneiforme intermedium and mediale are keystones in this structure (4,20). We think that the flexible type of pes planus is caused by the developmental anomaly of the bones forming the arch of the foot. An anomaly that may develop in these bones, which serve as a keystone in the protection of the arches, will cause the arches to collapse and the muscles that actively support the arch to become insufficient (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn pes planus, not only the APLM but also the collapse of the APT is observed (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). In the literature, keystones are mentioned for maintaining the arch height of the foot and the naviculare is shown as the keystone for maintaining the APLM height (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). However, in pes planus, APLM and APT collapse together and the bone in my keystone position changes. When APLM and APT are evaluated as a whole, there are os cuneiforme intermedium and mediale bones in the keystone position in shape and location (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eAs far as we know, bone volume and superficial area have not been examined by segmentation of tarsal and metatarsale bones in individuals with flexible type pes planus in the literature. In this study, the ratio of the volume and superficial area of each tarsal and metatarsale bones to the volume and superficial area of the entire foot bone was calculated on foot CT images. In the study, both volume and superficial area ratios of the cuniforme mediale and os cuneiforme intermedium, which are the keystones at the intersection of the APLM and APT arches, were found to be lower in individuals with pes planus compared to healthy individuals.\u003c/p\u003e \u003cp\u003eKnowing the mean value of the APLM angle is important for the detection of foot deformities. In the literature, the mean values of the APLM angle in patients with pes planus deformity were reported as 142.4\u0026ordm; in the study by Cebulski-Delebarre et al, and 146.6\u0026ordm; in the study by Ceccarini et al (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). In the present study, the mean APLM angle of individuals with pes planus was calculated as 155.2 degrees. These findings show that the severity of pes planus in individuals is above the average.\u003c/p\u003e \u003cp\u003eFlexible pes planus in adults is usually seen with the continuation of pes planus seen in childhood (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). In the literature, there are stereological studies about tarsal bone measurements in childhood idiopathic pes planus.\u003c/p\u003e \u003cp\u003eIt has been suggested by Hemo et al that delayed ossification and abnormal development of tarsal bones will be effective in idiopathic pes planus (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCahuzac et al. They analyzed tarsal bone volumes in individuals with pes pes planus using magnetic resonance images of the foot. As a result, it was found that the foot bone volumes of individuals with pes planus were approximately 20% smaller than the healthy foot bone volumes (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eItohara et al. They reported that talus volume and talus ossification center were lower in individuals with pes planus and suggested that pathological changes in bone structures with pes planus might be the cause (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eItohara et al. It has been reported that both the volume and length data of the talus and calcaneus bones are smaller in individuals with pes planus than in healthy individuals (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the present study, the volume and superficial area ratio data of only the os cuneiforme mediale and os cuneiforme intermedium of individuals with pes planus were found to be significantly lower than the control group. In pes planus, there is simultaneous arch collapse in the APLM and APT. The anatomical structures of os cuneiforme mediale and os os cuneiforme intermedium, which are in the keystone position at the intersection of both arches, are wedge-shaped and are located with the thin side down. Thanks to this special shape, it is critical in protecting the arches by ensuring that the bones are tightly interlocked with each other. We think that the anomaly that will occur in the bones forming the arch will cause pes planus by first disrupting the alignment of the bones in the arch and then the harmony of the bones with each other.\u003c/p\u003e \u003cp\u003eIn some studies on pes planus, the length of the tarsal bones was measured in individuals with pes planus (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). In their study, Claa\u0026szlig;en et al. investigated the anatomical features of the ossa cuniforme and measured the ossa cuniforme length, height and width, and joint surface values (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTarsal bones are short bones and their width and length cannot be distinguished. Therefore, we think that volume or superficial area measurement is more effective and reliable than length measurement in tarsal bones.\u003c/p\u003e \u003cp\u003eIn the literature, it is stated that the formation of pes planus is caused by plantar fascia, ligament, intrinsic or extrinsic foot muscle deficiencies (\u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). However, in a recent meta-analysis study, it was concluded that exercise and orthotic approaches to eliminate muscle dysfunction in adults with pes planus are not effective in improving pes planus (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). According to the presented study, insufficiency of soft tissue such as muscle and ligament in pes planus is a secondary changing condition. The change in the alignment of the bones forming the arch causes a change in factors that are essential for muscle strength, such as the origo insertion of the muscles and the angle of pull. Therefore, over time, insufficiency of structures such as muscles and ligaments emerges.\u003c/p\u003e \u003cp\u003eThe present study had some limitations. The first is that it was studied on a small group of patients, and the second is that it is cross-sectional. Therefore, more cases and longer-term studies are needed.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn our results, both volume and superficial area ratios of cuniforme mediale and os cuneiforme intermedium were found lower in individuals with pes planus compared to healthy individuals. We think that the pes planus deformity, which occurs with the collapse of the arches of the feet, is caused by the cuniforme mediale and os cuneiforme intermedium developmental anomalies, which serve as the keystone in the APLM, APT arches. We speculate that the muscle and ligament weakness that occurs in individuals with pes planus develops secondary to the change in the alignment of the bones forming the arch. Our study is the first to show the relationship between pes planus and tarsal bone volume and superficial area. We believe that this study will shed light on the treatment of pes planus. Large-scale studies are needed to obtain clearer results.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eAPLM\u003c/strong\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eArcus Pedis Longitudinalis Medialis\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBMI:\u0026nbsp;\u003c/strong\u003eBody Mass Index\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCT:\u0026nbsp;\u003c/strong\u003eComputed Tomography\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAPT:\u0026nbsp;\u003c/strong\u003eArcus Pedis Transversus\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Hitit university, non-interventional research ethics committee granted approval for this study (date: 03.05.2023, number: 2023-05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe\u0026nbsp;authors\u0026nbsp;declare\u0026nbsp;that\u0026nbsp;they\u0026nbsp;have\u0026nbsp;no\u0026nbsp;competing\u0026nbsp;interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudy concept and design: AP, SB. Literature Search: AP, SB. Analysis and interpretation of data: AP, SB. Drafting of the manuscript: AP, SB. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; information (optional)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePita-Fernandez S, Gonzalez-Martin C, Alonso-Tajes F, Seoane-Pillado T, Pertega-Diaz S, Perez-Garcia S, Seijo-Bestilleiro R, Balboa-Barreiro V. Flat Foot in a Random Population and its Impact on Quality of Life and Functionality. J Clin Diagn Res. 2017 Apr;11(4):LC22-LC27. doi: 10.7860/JCDR/2017/24362.9697.\u003c/li\u003e\n\u003cli\u003ePuszczalowska-Lizis E, Krawczyk K, Omorczyk J. 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Foot (Edinb). 2019 Mar;38:19-23. doi: 10.1016/j.foot.2018.11.002.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Flow diagram of study inclusion and exclusion criteria\u003c/p\u003e\n\u003cp\u003e\u003cimg 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\"\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u0026nbsp;\u003c/strong\u003eDescriptive Statistics of The Participants\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"572\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.394045534150614%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.896672504378284%\" valign=\"bottom\"\u003e\n \u003cp\u003eControl Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.021015761821367%\" valign=\"bottom\"\u003e\n \u003cp\u003ePes Planus Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.68826619964974%\" valign=\"bottom\"\u003e\n \u003cp\u003eSig. (p)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.394045534150614%\" valign=\"bottom\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.896672504378284%\" valign=\"bottom\"\u003e\n \u003cp\u003e24.65±2.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.021015761821367%\" valign=\"bottom\"\u003e\n \u003cp\u003e24.71±2.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.68826619964974%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.901\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.394045534150614%\" valign=\"bottom\"\u003e\n \u003cp\u003eKg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.896672504378284%\" valign=\"bottom\"\u003e\n \u003cp\u003e65.45±7.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.021015761821367%\" valign=\"bottom\"\u003e\n \u003cp\u003e64.15±6.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.68826619964974%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.984\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.394045534150614%\" valign=\"bottom\"\u003e\n \u003cp\u003eHeight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.896672504378284%\" valign=\"bottom\"\u003e\n \u003cp\u003e1.68±0.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.021015761821367%\" valign=\"bottom\"\u003e\n \u003cp\u003e1.70±0.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.68826619964974%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.988\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.394045534150614%\" valign=\"bottom\"\u003e\n \u003cp\u003eBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.896672504378284%\" valign=\"bottom\"\u003e\n \u003cp\u003e20.15±1.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.021015761821367%\" valign=\"bottom\"\u003e\n \u003cp\u003e20.49±2.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.68826619964974%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.920\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eParametric data were presented as Mean±Standard Deviation (MEAN±STD) and Independent Samples T Test was used for statistical analysis. Non-parametric data were shown as Median (Minimum-Maximum) and Mann Whitney U Test was applied for pairwise comparisons.\u003c/p\u003e\n\u003cp\u003eTable 3. Comparison of volume and superficial area data of foot bones between the group\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"951\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.558359621451103%\" valign=\"bottom\" style=\"width: 18.8195%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.49001051524711%\" colspan=\"3\" valign=\"bottom\" style=\"width: 33.296%;\"\u003e\n \u003cp\u003eBone Volume Ratio Values\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"39.11671924290221%\" colspan=\"3\" valign=\"bottom\" style=\"width: 37.6389%;\"\u003e\n \u003cp\u003eBone Superficial Area Ratio Values\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.599578503688093%\" valign=\"bottom\" style=\"width: 18.8195%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.12223393045311%\" valign=\"bottom\" style=\"width: 15.5623%;\"\u003e\n \u003cp\u003eControl Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.644889357218124%\" valign=\"bottom\" style=\"width: 12.1844%;\"\u003e\n \u003cp\u003ePes Planus Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.690200210748156%\" valign=\"bottom\" style=\"width: 5.5493%;\"\u003e\n \u003cp\u003eSig. (p)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.38672286617492%\" valign=\"bottom\" style=\"width: 16.7686%;\"\u003e\n \u003cp\u003eControl Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.01685985247629%\" valign=\"bottom\" style=\"width: 15.4416%;\"\u003e\n \u003cp\u003e\u0026nbsp;Pes Planus Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.690200210748156%\" valign=\"bottom\" style=\"width: 5.5493%;\"\u003e\n \u003cp\u003eSig. (p)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.599578503688093%\" valign=\"bottom\" style=\"width: 18.8195%;\"\u003e\n \u003cp\u003eTalus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.12223393045311%\" valign=\"bottom\" style=\"width: 15.5623%;\"\u003e\n \u003cp\u003e22.41±1.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.644889357218124%\" valign=\"bottom\" style=\"width: 12.1844%;\"\u003e\n \u003cp\u003e23.91±2.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.690200210748156%\" valign=\"bottom\" style=\"width: 5.5493%;\"\u003e\n \u003cp\u003e0.061\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.38672286617492%\" valign=\"bottom\" style=\"width: 16.7686%;\"\u003e\n \u003cp\u003e18.34 (11.21-24.27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.01685985247629%\" valign=\"bottom\" style=\"width: 15.4416%;\"\u003e\n \u003cp\u003e17.13 (12.52-21.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.690200210748156%\" valign=\"bottom\" style=\"width: 5.5493%;\"\u003e\n \u003cp\u003e0.285\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.599578503688093%\" valign=\"bottom\" style=\"width: 18.8195%;\"\u003e\n \u003cp\u003eCalcaneus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.12223393045311%\" valign=\"bottom\" style=\"width: 15.5623%;\"\u003e\n \u003cp\u003e27.31±1.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.644889357218124%\" valign=\"bottom\" style=\"width: 12.1844%;\"\u003e\n \u003cp\u003e29.39±2.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.690200210748156%\" valign=\"bottom\" style=\"width: 5.5493%;\"\u003e\n \u003cp\u003e0.053\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.38672286617492%\" valign=\"bottom\" style=\"width: 16.7686%;\"\u003e\n \u003cp\u003e30.22 (8.53-36.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.01685985247629%\" valign=\"bottom\" style=\"width: 15.4416%;\"\u003e\n \u003cp\u003e29.41 (26.40-34.59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.690200210748156%\" valign=\"bottom\" style=\"width: 5.5493%;\"\u003e\n \u003cp\u003e0.458\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.599578503688093%\" valign=\"bottom\" style=\"width: 18.8195%;\"\u003e\n \u003cp\u003eOs naviculare\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.12223393045311%\" valign=\"bottom\" style=\"width: 15.5623%;\"\u003e\n \u003cp\u003e6.39 (4.63-7.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.644889357218124%\" valign=\"bottom\" style=\"width: 12.1844%;\"\u003e\n \u003cp\u003e6.12 (3.68-8.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.690200210748156%\" valign=\"bottom\" style=\"width: 5.5493%;\"\u003e\n \u003cp\u003e0.369\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.38672286617492%\" valign=\"bottom\" style=\"width: 16.7686%;\"\u003e\n \u003cp\u003e5.68 (0.60-7.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.01685985247629%\" valign=\"bottom\" style=\"width: 15.4416%;\"\u003e\n \u003cp\u003e5.29 (3.38-7.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.690200210748156%\" valign=\"bottom\" style=\"width: 5.5493%;\"\u003e\n \u003cp\u003e0.512\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.599578503688093%\" valign=\"bottom\" style=\"width: 18.8195%;\"\u003e\n \u003cp\u003eOs cuboideum\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.12223393045311%\" valign=\"bottom\" style=\"width: 15.5623%;\"\u003e\n \u003cp\u003e5.54 (4.43-6.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.644889357218124%\" valign=\"bottom\" style=\"width: 12.1844%;\"\u003e\n \u003cp\u003e5.30 (4.22-5.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.690200210748156%\" valign=\"bottom\" style=\"width: 5.5493%;\"\u003e\n \u003cp\u003e0.069\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.38672286617492%\" valign=\"bottom\" style=\"width: 16.7686%;\"\u003e\n \u003cp\u003e7.03 (6.43-9.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.01685985247629%\" valign=\"bottom\" style=\"width: 15.4416%;\"\u003e\n \u003cp\u003e7.03 (6.01-8.46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.690200210748156%\" valign=\"bottom\" style=\"width: 5.5493%;\"\u003e\n \u003cp\u003e0.382\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.599578503688093%\" valign=\"bottom\" style=\"width: 18.8195%;\"\u003e\n \u003cp\u003eOs cuneiforme mediale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.12223393045311%\" valign=\"bottom\" style=\"width: 15.5623%;\"\u003e\n \u003cp\u003e5.71±0.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.644889357218124%\" valign=\"bottom\" style=\"width: 12.1844%;\"\u003e\n \u003cp\u003e4.97±0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.690200210748156%\" valign=\"bottom\" style=\"width: 5.5493%;\"\u003e\n \u003cp\u003e0.010\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.38672286617492%\" valign=\"bottom\" style=\"width: 16.7686%;\"\u003e\n \u003cp\u003e5.72 (4.78-6.81)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.01685985247629%\" valign=\"bottom\" style=\"width: 15.4416%;\"\u003e\n \u003cp\u003e5.21 (3.51-5.98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.690200210748156%\" valign=\"bottom\" style=\"width: 5.5493%;\"\u003e\n \u003cp\u003e0.009\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.599578503688093%\" valign=\"bottom\" style=\"width: 18.8195%;\"\u003e\n \u003cp\u003eOs cuneiforme intermedium\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.12223393045311%\" valign=\"bottom\" style=\"width: 15.5623%;\"\u003e\n \u003cp\u003e2.84 (2.35-3.92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.644889357218124%\" valign=\"bottom\" style=\"width: 12.1844%;\"\u003e\n \u003cp\u003e2.29 (1.77-2.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.690200210748156%\" valign=\"bottom\" style=\"width: 5.5493%;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.38672286617492%\" valign=\"bottom\" style=\"width: 16.7686%;\"\u003e\n \u003cp\u003e2.77 (2.36-3.81)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.01685985247629%\" valign=\"bottom\" style=\"width: 15.4416%;\"\u003e\n \u003cp\u003e2.12 (1.75-2.47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.690200210748156%\" valign=\"bottom\" style=\"width: 5.5493%;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.599578503688093%\" valign=\"bottom\" style=\"width: 18.8195%;\"\u003e\n \u003cp\u003eOs cuneiforme laterale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.12223393045311%\" valign=\"bottom\" style=\"width: 15.5623%;\"\u003e\n \u003cp\u003e3.09 (2.33-4.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.644889357218124%\" valign=\"bottom\" style=\"width: 12.1844%;\"\u003e\n \u003cp\u003e2.80 (2.06-3.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.690200210748156%\" valign=\"bottom\" style=\"width: 5.5493%;\"\u003e\n \u003cp\u003e0.166\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.38672286617492%\" valign=\"bottom\" style=\"width: 16.7686%;\"\u003e\n \u003cp\u003e3.41 (3.01-4.84)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.01685985247629%\" valign=\"bottom\" style=\"width: 15.4416%;\"\u003e\n \u003cp\u003e3.49 (3.01-4.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.690200210748156%\" valign=\"bottom\" style=\"width: 5.5493%;\"\u003e\n \u003cp\u003e0.827\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.599578503688093%\" valign=\"bottom\" style=\"width: 18.8195%;\"\u003e\n \u003cp\u003eOs metatarsale (I)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.12223393045311%\" valign=\"bottom\" style=\"width: 15.5623%;\"\u003e\n \u003cp\u003e8.93 (7.18-12.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.644889357218124%\" valign=\"bottom\" style=\"width: 12.1844%;\"\u003e\n \u003cp\u003e8.50 (6.20-9.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.690200210748156%\" valign=\"bottom\" style=\"width: 5.5493%;\"\u003e\n \u003cp\u003e0.058\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.38672286617492%\" valign=\"bottom\" style=\"width: 16.7686%;\"\u003e\n \u003cp\u003e9.48 (8.02-12.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.01685985247629%\" valign=\"bottom\" style=\"width: 15.4416%;\"\u003e\n \u003cp\u003e8.90 (7.11-9.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.690200210748156%\" valign=\"bottom\" style=\"width: 5.5493%;\"\u003e\n \u003cp\u003e0.055\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.599578503688093%\" valign=\"bottom\" style=\"width: 18.8195%;\"\u003e\n \u003cp\u003eOs metatarsale (II)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.12223393045311%\" valign=\"bottom\" style=\"width: 15.5623%;\"\u003e\n \u003cp\u003e5.01±0.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.644889357218124%\" valign=\"bottom\" style=\"width: 12.1844%;\"\u003e\n \u003cp\u003e5.00±0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.690200210748156%\" valign=\"bottom\" style=\"width: 5.5493%;\"\u003e\n \u003cp\u003e0.941\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.38672286617492%\" valign=\"bottom\" style=\"width: 16.7686%;\"\u003e\n \u003cp\u003e5.05 (4.01-8.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.01685985247629%\" valign=\"bottom\" style=\"width: 15.4416%;\"\u003e\n \u003cp\u003e5.79 (4.57-6.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.690200210748156%\" valign=\"bottom\" style=\"width: 5.5493%;\"\u003e\n \u003cp\u003e0.076\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.599578503688093%\" valign=\"bottom\" style=\"width: 18.8195%;\"\u003e\n \u003cp\u003eOs metatarsale (III)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.12223393045311%\" valign=\"bottom\" style=\"width: 15.5623%;\"\u003e\n \u003cp\u003e4.16±0.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.644889357218124%\" valign=\"bottom\" style=\"width: 12.1844%;\"\u003e\n \u003cp\u003e3.98±0.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.690200210748156%\" valign=\"bottom\" style=\"width: 5.5493%;\"\u003e\n \u003cp\u003e0.335\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.38672286617492%\" valign=\"bottom\" style=\"width: 16.7686%;\"\u003e\n \u003cp\u003e4.58 (0.39-8.15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.01685985247629%\" valign=\"bottom\" style=\"width: 15.4416%;\"\u003e\n \u003cp\u003e5.22 (4.16-6.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.690200210748156%\" valign=\"bottom\" style=\"width: 5.5493%;\"\u003e\n \u003cp\u003e0.061\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.599578503688093%\" valign=\"bottom\" style=\"width: 18.8195%;\"\u003e\n \u003cp\u003eOs metatarsale (IV)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.12223393045311%\" valign=\"bottom\" style=\"width: 15.5623%;\"\u003e\n \u003cp\u003e3.91±0.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.644889357218124%\" valign=\"bottom\" style=\"width: 12.1844%;\"\u003e\n \u003cp\u003e3.97±0.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.690200210748156%\" valign=\"bottom\" style=\"width: 5.5493%;\"\u003e\n \u003cp\u003e0.815\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.38672286617492%\" valign=\"bottom\" style=\"width: 16.7686%;\"\u003e\n \u003cp\u003e4.23 (3.38-7.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.01685985247629%\" valign=\"bottom\" style=\"width: 15.4416%;\"\u003e\n \u003cp\u003e5.10 (3.82-7.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.690200210748156%\" valign=\"bottom\" style=\"width: 5.5493%;\"\u003e\n \u003cp\u003e0.057\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.599578503688093%\" valign=\"bottom\" style=\"width: 18.8195%;\"\u003e\n \u003cp\u003eOs metatarsale (V)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.12223393045311%\" valign=\"bottom\" style=\"width: 15.5623%;\"\u003e\n \u003cp\u003e4.27 (3.34-5.70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.644889357218124%\" valign=\"bottom\" style=\"width: 12.1844%;\"\u003e\n \u003cp\u003e4.34 (3.72-5.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.690200210748156%\" valign=\"bottom\" style=\"width: 5.5493%;\"\u003e\n \u003cp\u003e0.734\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.38672286617492%\" valign=\"bottom\" style=\"width: 16.7686%;\"\u003e\n \u003cp\u003e4.56 (3.46-7.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.01685985247629%\" valign=\"bottom\" style=\"width: 15.4416%;\"\u003e\n \u003cp\u003e5.10 (3.61-6.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.690200210748156%\" valign=\"bottom\" style=\"width: 5.5493%;\"\u003e\n \u003cp\u003e0.185\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eParametric data were shown as Mean±Standard Deviation (mean±std) and Independent Samples T Test was used for statistical analysis.\u0026nbsp;Non-parametric data were shown as Median (minimum-maximum) and Mann Whitney U test was used for pairwise comparisons.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003eBone volume ratio value = (volume value of the measured bone*100)/total volume value of all foot bones\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003eBone superficial area ratio value = (superficial area value of the measured bone*100)/total superficial area value of all foot bones\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Pes Planus, Arcus Pedis Longitudinalis Medialis, Arcus Pedis Transversus, Ossa Cuneiforme, Tarsal Bones","lastPublishedDoi":"10.21203/rs.3.rs-3182349/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3182349/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eIn flexible pes planus, the height of the arcus pedis longitudinalis medialis (APLM) collapses during weight bearing. We think that this may be caused by anomalies in the bones that support the arches against the compression load. For this purpose, the volume (cm\u003csup\u003e3\u003c/sup\u003e) and superficial area (cm\u003csup\u003e2\u003c/sup\u003e) ratios of the foot bones were calculated using foot computed tomography (CT) images of individuals with pes planus and compared with healthy individuals\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eFifteen pes planus patients diagnosed with pes planus in our clinic and with an APLM angle greater than 145 degrees and 15 healthy male participants were included. The foot computed tomography (CT) images of the participants were taken with a General Electric brand IQ model 32 detector CT device in accordance with the bone protocol, with a section thickness of 0.625 mm. Foot bones were segmented from the obtained CT images with the help of the 3D Slicer program.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe os cuneiforme mediale and os cuneiforme intermedium volume and superficial area ratios of the pes planus group were significantly lower than the control group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). There was no difference between the groups in the volume and superficial area ratios of the other foot bones (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eWe think that pes planus is primarily caused by os cuniforme mediale and os cuneiforme intermedium developmental anomalies, which act as a keystone in the formation of arches.\u003c/p\u003e","manuscriptTitle":"Is a Keystone Bone Anomaly The Main Cause of Pes Planus?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-08-16 14:21:49","doi":"10.21203/rs.3.rs-3182349/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a6e96a5c-d294-4cb9-a386-1c737e406ead","owner":[],"postedDate":"August 16th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-10-17T22:42:24+00:00","versionOfRecord":[],"versionCreatedAt":"2023-08-16 14:21:49","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3182349","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3182349","identity":"rs-3182349","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}