Digital Morphological Examination of Adolescent Triple Foot Deformities: Flatfoot, Hallux Valgus, and Accessory navicular

Digital Morphological Examination of Adolescent Triple Foot Deformities: Flatfoot, Hallux Valgus, and Accessory navicular | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Digital Morphological Examination of Adolescent Triple Foot Deformities: Flatfoot, Hallux Valgus, and Accessory navicular Shenghu Fan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9498037/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 Objective This research aims to explore the causes of flatfoot, hallux valgus, and accessory navicular conditions within this specific group by conducting a digital morphological examination of foot CT scans from adolescents exhibiting these issues simultaneously. Method Between January 2023 and January 2025, our department enrolled 17adolescents (9 females and 8 males) diagnosed with tridysmorphic deformities.We used weight bearing CT images to analyze the affected foot and generated 3D digital images. A unique 3D coordinate framework was developed for each foot, allowing for the measurement and analysis of relevant parameters related to flatfoot, hallux valgus, and accessory navicular. Results There were no significant correlations observed between the hallux valgus angle(HVA)and the talonavicular coverage angle(TNCA), Kite angle, Meary angle, or pitch angle(P > 0.05). Likewise, the intermetatarsal angle (IMA) did not show significant correlations with TNCA, Kite angle, Meary angle, pitch angle, or flatfoot angle (P > 0.05). Furthermore, the distal metatarsal articular angle (DMAA)did not exhibit significant relationships with TNCA, Kite angle, Meary angle, or pitch angle (P > 0.05). The proximal articular fixation angle also lacked a significant correlation with the flatfoot angle. In contrast, the classification of accessory navicular bones was found to be related to angles associated with flatfoot but not to hallux valgus angles.The distribution of accessory navicular bone types was as follows Type I(3 instances), Type II(9 instances), and Type III(5 instances). The classification of sesamoid location included Type IV in 3 instances and Type V in 14 instances. Conclusions The origins of triple foot deformities in teenagers, including flatfoot, hallux valgus, and accessory navicular, are probably due to congenital factors. Although there are no definitive causal links between these three conditions, they may have an impact on one another. Orthopedics Hallux valgus Flatfoot Accessory navicular Morphology Adolescents Digital orthopedics 3D reconstruction Figures Figure 1 Figure 2 Introduction The foot is a intricate structure mainly responsible for bearing the body's weight. It is susceptible to deformities that can be either congenital or developed over time. Inclinical settings, it is common to find individuals between the ages of 10 and 19 [1] presenting with a combination of three specific foot deformities: flatfoot, hallux valgus, and an accessory navicular bone. These issues often lead to symptoms like hallux bursitis, pain in the accessory navicular area, and general discomfort in the footand ankle. Such deformities can hinder daily activities and adversely impact long-term health. The underlying causes of the triplet deformity involving flatfoot, hallux valgus, and accessory navicular bone in adolescents, along with the related pain, are not well understood. Furthermore, there is a lack of evidence establishing causal links between these three conditions, and there are no established clinical treatment protocols. This study involved a digital morphological analysis of foot CT scans from 17 adolescent patients diagnosed with the triplet deformity who were admitted to ourdepartment. The following report provides detailed findings. 1 Materials and Methods 1.1 Materials Between January 2023 and January 2025, 17 adolescent patients presenting with the triple deformities of flatfoot, hallux valgus, and accessory bone were recruited for the study. This cohort included 5 individuals with left-sided deformities, 4 with right-sided, and 8 with bilateral involvement. Comprehensive 3D foot reconstruction data, encompassing the ankle joint, were collected from 8 males and 9 females, aged between 10 and 19 years (average age13±2.3 years). Their body weights ranged between 42 and 50 kg(mean±SD: 45±5.0kg), while their heights varied from1.60 to1.65 m(average±SD :1.62±0.03 m). The Body Mass Index (BMI) for these patients was between 15.8 and 24.0 kg/m² (mean18.1±5.1 kg/m²). Inclusion criteria consisted of: (1)adolescents aged 10 to 19 years as defined by WHO [1] ; (2)presence of the triple deformity in the affected foot; (3)no prior treatment history; and(4)availability of complete clinical data. Exclusion criteria included:(1)individuals outside the specified age range; (2)any previous surgical interventions for foot fractures; (3)history of deformity correction; (4)prior conditions such as tumors, diabetic foot, rheumatoid arthritis, ortrauma; and(5)incomplete patient data.And informed consent to participate was obtained from all of the participants in the study. 1.2 Methods 1.2.1 Acquisition of CT Image Data and 3D Reconstruction CT imaging was conducted using a Siemens SENSATION 64-slice spiral CT scanner from Germany,with patients positioned to bear weight and their feet aligned parallel to each other. The scanning encompassed the full foot, including the ankle joint, with parameters set to 140 kV for voltage, 300 mA for current, a slice thickness of 0.6mm, and an inter-slice distance of 0.625 mm. The resulting CT scans were exported in DICOM format and saved on a computer. Subsequently, 3D reconstruction was carried out using Mimics software(version19.0, Materialise, Leuven, Belgium). (Fig 1.2.1 3D reconstruction process(A, B, C)) 1.2.2 Establishment and Measurement of Foot Coordinate System According to earlier studies [2] , a foot coordinate framework was defined with the central axis of the second toe serving as the X-axis, a horizontal plane that is perpendicular to the X-axis as the Y-axis, and the Z-axis, which is perpendicular to both the X and Y axes, meeting at point O( Fig 1.2.2 Foot coordinatesystem). The measured parameters consisted of the hallux valgus angle(HVA), the angles between the first and second metatarsals(IMA), the distal metatarsal articularangle(DMAA), the angle formed between the talus and the first metatarsal(TMA), the talonavicular coverage angle(TNCA), the talocalcaneal angle(Kite angle), the lateral angle between the talus and the first metatarsal(Meary angle), the calcaneal inclination angle(Pitch angle), as well as the magnification of the scaphoid. Picture A and B Images are segmented and regional values selected and adjusted as needed for reconstruction，picture C is the reconstructed full 3D. Fig 1.2.1 3D reconstruction process（A 、B C） 1.2.3 Statistical analysis The normalcy was assessed by performing the SPSS software(version25.0, Chicago, IL, USA)in order to perform the data analysis. A P-value below 0.05 suggested a normal distribution, whereas a P-value exceeding 0.5 asked the T-test for two different samples to test the significance ofthe data, which was requiredby the test. A P-value under 0.05 signified a meaningful difference or relationship between the groups, whilea P-value above 0.05 indicated the absence of a significant difference or relationship. 2 Results HVA did not show any significant correlations with the TMA、TNCA、Kite angle、Meary angle、or Pitch angle (P > 0.05)( Table 1 ). Furthermore, no notable relationship was observed between the HVA and the flatfoot angle. Similarly, the IMA exhibited no significantcorrelation with TMA, TNCA, Kite angle, Meary angle, or Pitch angle(P > 0.05), and it also did not relate to the flatfoot angle( Table 2 ). The DMAA also lacked significant correlation with TMA, TNCA, Kite angle, Meary angle, or Pitch angle (P > 0.05) (Table 3 ). Moreover, no meaningful correlation was found between the proximal articular fixation angle and the flatfoot angle. The classification of accessory navicular bones did not correlate with the hallux valgus angle but did show a correlation with the flatfoot angle (Table 4 ). Scaphoid bone subtypes were categorized as Type I(3 cases), Type II(9cases), and Type III(5 cases), while sesamoid locations were classified as Type IV(3cases)and Type V(14 cases). Table 1 HVA and flat foot related parameters HVA-TMA HVA-TNCA HVA-Kite HVA-Meary HVA-Pitch དྷ 0.121 -0.124 -0.078 0.095 0.098 ཐ 0.356 0.468 0.070 0.165 0.465 Table 2 Parameters related to IMA and flat foot དྷ IMA-TMA IMA-TNCA IMA-Kite IMA-Meary IMA-Pitch -0.096 0.095 -0.113 -0.098 0.105 ཐ 0.273 0.168 0.450 0.235 0.075 Table 3 Related parameters of DMAA and flat foot r TMA-DMAA TNCA-DMAA Kite-DMAA Meary-DMAA Pitch-DMAA 0.067 0.054 0.103 0.201 -0.131 P 0.068 0.066 0.075 0.054 0.083 Table 4 Parameters related to hallux and flat foot and subtypes of accessory navicularis TypeⅠ HVA IMA DMAA TMA TNCA Kite Meary Pitch P 0.317 0.216 0.324 0.025 0.023 <0.001 0.043 0.032 TypeⅡ P 0.230 0.145 0.278 0.036 0.043 0.034 0.037 0.041 TypeⅢ P 0.095 0.152 0.071 0.021 0.034 0.014 0.03 0.025 3 Discussion Recent studies into the causes of hallux valgus indicate a notable link between genetic factors and its onset during adolescence, with certain families showing patterns of X-linked dominant inheritance, especially among individuals who often wear narrow shoes [ 3 ] . Research on walking patterns has revealed that pronation and the collapse of the medial longitudinal arch in flatfoot are associated with a greater hallux valgus angle [ 4 ] . Adolescents suffering from hallux valgus are significantly more likely by a factor of 8 to 24 times also have flatfoot compared to their peers without the condition [ 5 ] . Nevertheless, some research indicates no significant difference in arch height between those with and without hallux valgus [ 6 ] . The relationship between the angle of flatfoot and the characteristics of the accessory navicular bone is still debated, with differing viewpoints: (1) No relationship. Jang [ 7 ] noted no substantial change in the Pitch angle after the removal and reattachment of the accessory navicular bone, implying no link to flatfoot. Similarly, Senses et al [ 8 ] found no significant alteration in Meary angle post-resection and tendon reconstruction. Karaet al [ 9 ] also noted that flatfoot radiological measurements were unaffected by the availability of the auxiliary navicular bone. (2) A relationship exists. Prichasuk et al [ 10 ] observed a more significant change in the Pitch angle among patients with an accessory navicular bone compared to those without, suggesting a connection to flatfoot. Park et al [ 11 ] showed that the accessory navicular bone was statistically correlated with flatfoot. The association between the hallux valgus angle and the features of the accessory navicular bone remains unresolved [ 12 – 15 ] . Some scholars argue that the accessory navicular bone could lead to dysfunction of the posterior tibial tendon,which may contribute to flatfoot and worsen hallux valgus [ 15 ] . However, the underlying causes of the adolescent triple deformity are still not well understood, and there is a lack of standardized diagnostic and treatment protocols. This research focused on examining factors associated with triple foot deformities by obtaining CT scans of the impacted limbs while bearing weight. Our study showed that the occurrence of Type I, II and III accessory navicular bones, with Type II occurring most frequently at a rate of 52.9%, was related to the flatfoot angle. Nonetheless, we did not notice a direct association between the subtype of accessory navicular bone and the flatfoot angle, nor did we find any correlation with the hallux valgus angle, aligning with several previous studies. The combination of flatfoot, hallux valgus, and accessory naviculus in teenagersis known as triple foot deformity, which is a multifaceted three-dimensional condition.This includes different degrees of forefoot abduction, midfoot varus, and hindfoot valgus. This deformity is often associated with congenital origins but can also be affected by environmental factors [ 16 – 18 ] . Clinically, it is frequently seen, with most individuals reporting discomfort around the ankle, while some may feel pain in the area of the accessory navicular. Symptoms of hallux valgus are generally mild and are often detected in childhood. As individuals reach adolescence, these symptoms become more pronounced, and the deformity tends to deteriorate [ 19 , 20 ] . If not address edpromptly, both the deformity and its symptoms are likely to worsen. Studies suggest that this trio of deformities may stem from genetic anomalies or systemic conditions that affect the development of bones, muscles, or ligaments,leading to acompounding effect of congenital issues.Once structural changes happen, they are usually permanent [ 21 ] . The formation of deformities is affected by the growth of skeletal muscles and various external factors. Consequently, treatment should aim not only at rectifying deformities and alleviating discomfort but also at enhancing muscle strength, realigning lower limb forces, and improving walking abilities. For asymptomatic individuals, conservative approaches may include orthopedic footwear, correctiveinserts, massage therapy, and muscle exercises [ 22 ] .However, a lot of patients have advanced which might need to be surgically operated. While there is no agreement onthe best timing for surgery, a range of orthopedic techniques is commonly employed, such as Chevron, Scarf, Reverdin, Akin, and Ludloff osteotomies, joint fusion, and less invasive methods. For issues related to the accessory navicular bone, options include simple excision and tendon repair [ 23 , 24 ] . Given that adolescents are at a critical stage of skeletal muscle development and have increased activity levels, prompt treatment is essential to avert permanent deformity progression. Techniques like joint bracing, minimally invasive hallux valgus surgery, and procedures for the accessory navicular bone provide benefits such as reduced trauma, faster recovery, and accurate results [ 25 , 26 ] . Clinical research supports the feasibility of performing simultaneous surgeries for triple deformities. This research has several constraints: (1) a limited number of participants; (2) anemphasis on three-dimensional anatomical aspects while neglecting soft tissue influences; (3) absence of comparative measurements before and after surgery; (4) a requirement for genetic investigations to examine the connection between the deformities. To sum up, although hereditary elements are viewed as the origin of triple foot deformities in adolescents, a definitive link between the deformities remains unclear. However, examining the traits of these deformities can assist in making informedtreatment choices. Abbreviations Computed Tomography(CT), Three Dimension(3D),Standard Deviation(SD),World Health Organization(WHO),hallux valgus angle(HVA), talonavicular coverage angle(TNCA),intermetatarsal angle (IMA),distal metatarsal articular angle (DMAA), Body Mass Index (BMI),the talocalcaneal angle(Kite angle), the lateral angle between the talus and the first metatarsal(Meary angle), the calcaneal inclination angle(Pitch angle) Declarations Consent to Participate:informed consent to participate was obtained from all of the participants in the study. Human Ethics and Consent: All authors included in accordance with the current international committee of medical journal editors, the authors were assigned with the highest level of writing in the work of the author. All authors agree to the content of the manuscript. Each author confirms the absence of any conflicts of interest. We were given permission to participate in this study from the Qujing First People's Hospital Institutional Review Board（No:IEC/AF/16/2023-01.0）.And all participants signed the informed consent form. Declaration of Helsinki:This study adheres to the Declaration of Helsinki. Consent to Participate:informed consent to participate was obtained from all of the participants in the study. Consent for publication:All authors agree to be published. Funding Statement: No funding. References ORGANIZATION W H (2006) Orientation programme on adolescent health for health care providers [J]. Geneva World Health Organization RENAULT JB, GATAN.AüLLO-RASSER DONNEZM et al (2018) Articular-surface-based automatic anatomical coordinate systems for the knee bones [J]. J Biomech 80:171–178 LI Z, LIU Z, SHI W et al (2024) Eligibility for knee arthroplasty is associated with increased risk of acquired hallux valgus - a Mendelian randomized study [J]. BMC Musculoskelet Disord, 25(1) MERRILL LEE et al (2018) Effect of Mechanical Axis Correction on Outcomes of Hallux Valgus Surgery [J]. The Journal of foot and ankle surgery: official publication of the American College of Foot and Ankle Surgeons. 57(1):111–115 CHANG A S, SON S W, PARK P et al (2024) Hallux valgus interphalangeus is more common in juvenile-onset hallux valgus than in adult-onset hallux valgus [J]. J Orthop Surg Res 19(1):1–6 LEWIS T L GORDOND (2022) RAY R. The Impact of Hallux Valgus on Function and Quality of Life in Females [J], vol 7. Foot & Ankle Orthopaedics, 1 JANG HS, PARK K H, PARK HW (2016) Comparison of outcomes of osteosynthesis in type II accessory navicular by variable fixation methods [J]. Foot & Ankle Surgery, p S1268773116304052 SENSES I (2004) Restoring the continuity of the tibialis posterior tendon in the treatment of symptomatic accessory navicular with flat feet [J]. J Orthop Sci Official J Japanese Orthop Association 9(4):408–409 KARA M (2020) BAYRAM S. Effect of Unilateral Accessory Navicular Bone on Radiologic Parameters of Foot [J], vol 42. Foot & Ankle International, 5 PRICHASUK S (1995) SINPHURMSUKSKUL O. Kidner Procedure for Symptomatic Accessory Navicular and Its Relation to Pes Planus [J], vol 16. Foot & Ankle International, pp 500–503. 8 PARK H, JIN HOSEO, JOON OHKIM (2015) HYUN WOO. The Relationship Between Accessory Navicular and Flat Foot: A Radiologic Study [J]. J Pediatr Orthop, 35(7) JUAN PRETELL-MAZZINI (2014) ROBERT, et al. Surgical treatment of symptomatic accessory navicular in children and adolescents [J]. American Journal of Orthopedics MINOKAWA S, YOSHIMURA I, KANAZAWA K et al (2023) Radiologic foot alignment and clinical outcome after percutaneous drilling for symptomatic accessory navicular in skeletally immature children [J]. Medicine 102(51):5 NAKAJIMA K (2025) Symptomatic Accessory Navicular Treated With Endoscopic Accessory Navicular and Partial Navicular Resection [J]. Foot & Ankle International, 46(2): 192–199 SMITH RIEMERT (2012) Management of dancers with symptomatic accessory navicular: 2 case reports [J]. J Orthop Sports Phys Therapy 42(5):465 WARIACH S, KARIM K, SARRAJ M et al (2022) Assessing the Outcomes Associated with Accessory Navicular Bone Surgery-a Systematic Review [J]. Curr Rev Musculoskelet Med 15(5):377–384 INAGAWA M, JUJO Y, SHIMOZONO Y et al (2025) Simultaneous bilateral surgery for accessory naviculars does not have a negative effect on postoperative outcome [J]. The Journal of Foot and Ankle Surgery LIANG JC, ZAN Q, CAO SH et al (2025) The impact of preoperative anxiety and depression on the prognosis of patients with painful accessory navicular [J], vol 20. Journal of Orthopaedic Surgery & Research, 1 BERNAERTS A, VANHOENACKER F M, PERRE S V D et al (2004) Accessory navicular bone: not such a normal variant [J]. JBR-BTR: organe de la Société royale belge de radiologie (SRBR) = orgaan van de Koninklijke Belgische Vereniging voor Radiologie (KBVR). 87(5):250–252 JASIEWICZ B, POTACZEK T, K?CKI W et al (2008) Results of simple excision technique in the surgical treatment of symptomatic accessory navicular bones [J]. Foot Ankle Surg 14(2):57–61 KIM J, PARK C, MOON Y et al (2014) Concomitant calcaneo-cuboid-cuneiform osteotomies and the modified Kidner procedure for severe flatfoot associated with symptomatic accessory navicular in children and adolescents [J]. J Orthop Surg Res 9(1):131 SHI C, LI M, ZENG Q et al (2023) Subtalar arthroereisis combined with medial soft tissue reconstruction in treating pediatric flexible flatfoot with accessory navicular [J]. J Orthop Surg Res 18(1):55 FANG K, BI T, HONG A et al (2023) Efficacy of modified kidner procedure combined with subtalar arthroereisis treating adolescent type 2 painful accessory navicular with flexible flatfoot [J]. Front Pead 11(11):1258032 LIU X T-JG, L Y-X et al (2023) Is Kidner procedure necessary during subtalar arthroereisis for pediatric flexible flatfoot that combined with symptomatic type 2 accessory navicular? A retrospective comparative study [J]. Foot Ankle Surg, (5): 29 NASREDDINE A, DUNHAM A, MO M et al (2025) Surgical Treatment for Painful Pediatric Pes Planovalgus: How Does Subtalar Extra-articular Screw Arthroereisis Compare to the Standard Technique of Modified Evans Reconstruction? [J]. J Pediatr Orthop 45(9):559–565 NASH A, ALVAREZ C M, RENNER JB et al (2025) Long-Term Functional and Radiographic Outcomes of Untreated Tarsal Coalitions: A Community-Based Observational Study [J]. J Pediatr Orthop 45(7):7 Additional Declarations The authors declare no competing interests. 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. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-9498037","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":627861883,"identity":"2bbd365a-ff9f-4528-af69-f6d42512568b","order_by":0,"name":"Shenghu Fan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2ElEQVRIie3PsQqCQBzH8ZNAG/7gemH4BsFfBCepV/EIbBEJWto6EZp6gOstnJqvHFrqAaIGI6jVsSGi5iC8tob7zP8v/P6EaNofsji0qhrCmWllWVWrJCDB9EQ3jmwoc08oJsSBcBN1xGjutJUSey8REpni4cwdQvpujzclNI0qujtN8Mi4PyZDP5ANyYACore4GsU7GQoi2aopAXuHlD1LoziseQlKCUmQSijZUhhZrpbQJPA4xL4NLDcEKvzyHuZfHhC6prW93etp321MPuBv55qmadoXL8gfReaE20r9AAAAAElFTkSuQmCC","orcid":"https://orcid.org/0009-0004-8901-6136","institution":"Qujing Hospital Affiliated to Kunming Medical University (Qujing Central Hospital of Yunnan Province)","correspondingAuthor":true,"prefix":"","firstName":"Shenghu","middleName":"","lastName":"Fan","suffix":""}],"badges":[],"createdAt":"2026-04-22 15:07:14","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":true,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-9498037/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9498037/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107897492,"identity":"878eaa5c-7175-4e0e-989a-c2ace0876c6c","added_by":"auto","created_at":"2026-04-27 10:57:54","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":117275,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9498037/v1/773fba7ec1c821980a9e542d.jpg"},{"id":107897462,"identity":"a22dabc4-b36a-487d-9a2e-8c159d3e5980","added_by":"auto","created_at":"2026-04-27 10:57:48","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":73194,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9498037/v1/2151189f4df0e05ab271c886.jpg"},{"id":108006995,"identity":"1a347372-ee03-4f63-ab64-05b9fadc0b56","added_by":"auto","created_at":"2026-04-28 12:58:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":405541,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9498037/v1/776de1c8-3363-449e-a33e-38e4c9e59666.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eDigital Morphological Examination of Adolescent Triple Foot Deformities: Flatfoot, Hallux Valgus, and Accessory navicular\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe foot is a intricate structure mainly responsible for bearing the body's weight. It is susceptible to deformities that can be either congenital or developed over time. Inclinical settings, it is common to find individuals between the ages of 10 and 19\u003csup\u003e[1]\u003c/sup\u003e presenting with a combination of three specific foot deformities: flatfoot, hallux valgus, and an accessory navicular bone. These issues often lead to symptoms like hallux bursitis, pain in the accessory navicular area, and general discomfort in the footand ankle. Such deformities can hinder daily activities and adversely impact long-term health. The underlying causes of the triplet deformity involving flatfoot, hallux valgus, and accessory navicular bone in adolescents, along with the related pain, are not well understood. Furthermore, there is a lack of evidence establishing causal links between these three conditions, and there are no established clinical treatment protocols. This study involved a digital morphological analysis of foot CT scans from 17 adolescent patients diagnosed with the triplet deformity who were admitted to ourdepartment. The following report provides detailed findings.\u003c/p\u003e"},{"header":"1 Materials and Methods","content":"\u003cp\u003e1.1 Materials Between January 2023 and January 2025, 17 adolescent patients presenting with the triple deformities of flatfoot, hallux valgus, and accessory bone were recruited for the study. This cohort included 5 individuals with left-sided deformities, 4 with right-sided, and 8 with bilateral involvement. Comprehensive 3D foot reconstruction data, encompassing the ankle joint, were collected from 8 males and 9 females, aged between 10 and 19 years (average age13\u0026plusmn;2.3 years). Their body weights ranged between 42 and 50 kg(mean\u0026plusmn;SD: 45\u0026plusmn;5.0kg), while their heights varied from1.60 to1.65 m(average\u0026plusmn;SD :1.62\u0026plusmn;0.03 m). The Body Mass Index (BMI) for these patients was between 15.8 and 24.0 kg/m\u0026sup2;\u0026nbsp;(mean18.1\u0026plusmn;5.1 kg/m\u0026sup2;). Inclusion criteria consisted of: (1)adolescents aged 10 to 19 years as defined by WHO\u003csup\u003e[1]\u003c/sup\u003e; (2)presence of the triple deformity in the affected foot; (3)no prior treatment history; and(4)availability of complete clinical data. Exclusion criteria included:(1)individuals outside the specified age range; (2)any previous surgical interventions for foot fractures; (3)history of deformity correction; (4)prior conditions such as tumors, diabetic foot, rheumatoid arthritis, ortrauma; and(5)incomplete patient data.And informed consent to participate was obtained from all of the participants in the study.\u003c/p\u003e\n\u003cp\u003e1.2 Methods\u003c/p\u003e\n\u003cp\u003e1.2.1 Acquisition of CT Image Data and 3D Reconstruction\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCT imaging was conducted using a Siemens SENSATION 64-slice spiral CT scanner from Germany,with patients positioned to bear weight and their feet aligned parallel to each other. The scanning encompassed the full foot, including the ankle joint, with parameters set to 140 kV for voltage, 300 mA for current, a slice thickness of 0.6mm, and an inter-slice distance of 0.625 mm. The resulting CT scans were exported in DICOM format and saved on a computer. Subsequently, 3D reconstruction was carried out using Mimics software(version19.0, Materialise, Leuven, Belgium). (Fig 1.2.1 3D reconstruction process(A, B, C))\u003c/p\u003e\n\u003cp\u003e1.2.2 Establishment and Measurement of Foot Coordinate System\u003c/p\u003e\n\u003cp\u003eAccording to earlier studies\u003csup\u003e[2]\u003c/sup\u003e, a foot coordinate framework was defined with the central axis of the second toe serving as the X-axis, a horizontal plane that is perpendicular to the X-axis as the Y-axis, and the Z-axis, which is perpendicular to both the X and Y axes, meeting at point O( Fig 1.2.2 Foot coordinatesystem). The measured parameters consisted of the hallux valgus angle(HVA), the angles between the first and second metatarsals(IMA), the distal metatarsal articularangle(DMAA), the angle formed between the talus and the first metatarsal(TMA), the talonavicular coverage angle(TNCA), the talocalcaneal angle(Kite angle), the lateral angle between the talus and the first metatarsal(Meary angle), the calcaneal inclination angle(Pitch angle), as well as the magnification of the scaphoid.\u003c/p\u003e\n\u003cp\u003ePicture A and B Images are segmented and regional values selected and adjusted as needed for reconstruction，picture C is the reconstructed full 3D. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFig 1.2.1 3D reconstruction process（A 、B \u0026nbsp; \u0026nbsp; C）\u003c/p\u003e\n\u003cp\u003e1.2.3 Statistical analysis\u003c/p\u003e\n\u003cp\u003eThe normalcy was assessed by performing the SPSS software(version25.0, Chicago, IL, USA)in order to perform the data analysis. A P-value below 0.05 suggested a normal distribution, whereas a P-value exceeding 0.5 asked the T-test for two different samples to test the significance ofthe data, which was requiredby the test. A P-value under 0.05 signified a meaningful difference or relationship between the groups, whilea P-value above 0.05 indicated the absence of a significant difference or relationship.\u003c/p\u003e"},{"header":"2 Results","content":"\u003cp\u003eHVA did not show any significant correlations with the TMA、TNCA、Kite angle、Meary angle、or Pitch angle (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05)( Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Furthermore, no notable relationship was observed between the HVA and the flatfoot angle. Similarly, the IMA exhibited no significantcorrelation with TMA, TNCA, Kite angle, Meary angle, or Pitch angle(P\u0026thinsp;\u0026gt;\u0026thinsp;0.05), and it also did not relate to the flatfoot angle( Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The DMAA also lacked significant correlation with TMA, TNCA, Kite angle, Meary angle, or Pitch angle (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Moreover, no meaningful correlation was found between the proximal articular fixation angle and the flatfoot angle. The classification of accessory navicular bones did not correlate with the hallux valgus angle but did show a correlation with the flatfoot angle (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Scaphoid bone subtypes were categorized as Type I(3 cases), Type II(9cases), and Type III(5 cases), while sesamoid locations were classified as Type IV(3cases)and Type V(14 cases).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eHVA and flat foot related parameters\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eHVA-TMA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHVA-TNCA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHVA-Kite\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHVA-Meary\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eHVA-Pitch\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eདྷ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.121\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.124\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.078\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.095\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.098\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eཐ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.356\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.468\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.070\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.165\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.465\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParameters related to IMA and flat foot\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eདྷ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIMA-TMA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIMA-TNCA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIMA-Kite\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIMA-Meary\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eIMA-Pitch\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.096\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.095\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.113\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.098\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.105\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eཐ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.273\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.168\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.450\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.235\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.075\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRelated parameters of DMAA and flat foot\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003er\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTMA-DMAA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTNCA-DMAA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eKite-DMAA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMeary-DMAA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePitch-DMAA\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.067\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.054\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.103\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.201\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.131\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.068\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.066\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.075\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.054\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.083\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParameters related to hallux and flat foot and subtypes of accessory navicularis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTypeⅠ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHVA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIMA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDMAA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTMA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTNCA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eKite\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMeary\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003ePitch\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.317\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.216\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.324\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.043\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.032\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTypeⅡ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.230\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.145\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.278\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.036\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.043\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.034\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.037\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.041\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTypeⅢ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" 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\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.025\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"3 Discussion","content":"\u003cp\u003eRecent studies into the causes of hallux valgus indicate a notable link between genetic factors and its onset during adolescence, with certain families showing patterns of X-linked dominant inheritance, especially among individuals who often wear narrow shoes\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. Research on walking patterns has revealed that pronation and the collapse of the medial longitudinal arch in flatfoot are associated with a greater hallux valgus angle\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. Adolescents suffering from hallux valgus are significantly more likely by a factor of 8 to 24 times also have flatfoot compared to their peers without the condition\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. Nevertheless, some research indicates no significant difference in arch height between those with and without hallux valgus\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. The relationship between the angle of flatfoot and the characteristics of the accessory navicular bone is still debated, with differing viewpoints: (1) No relationship. Jang\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e noted no substantial change in the Pitch angle after the removal and reattachment of the accessory navicular bone, implying no link to flatfoot. Similarly, Senses et al\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e found no significant alteration in Meary angle post-resection and tendon reconstruction. Karaet al\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003ealso noted that flatfoot radiological measurements were unaffected by the availability of the auxiliary navicular bone. (2) A relationship exists. Prichasuk et al \u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003eobserved a more significant change in the Pitch angle among patients with an accessory navicular bone compared to those without, suggesting a connection to flatfoot. Park et al\u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e showed that the accessory navicular bone was statistically correlated with flatfoot. The association between the hallux valgus angle and the features of the accessory navicular bone remains unresolved\u003csup\u003e[\u003cspan additionalcitationids=\"CR13 CR14\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. Some scholars argue that the accessory navicular bone could lead to dysfunction of the posterior tibial tendon,which may contribute to flatfoot and worsen hallux valgus\u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. However, the underlying causes of the adolescent triple deformity are still not well understood, and there is a lack of standardized diagnostic and treatment protocols.\u003c/p\u003e \u003cp\u003eThis research focused on examining factors associated with triple foot deformities by obtaining CT scans of the impacted limbs while bearing weight. Our study showed that the occurrence of Type I, II and III accessory navicular bones, with Type II occurring most frequently at a rate of 52.9%, was related to the flatfoot angle. Nonetheless, we did not notice a direct association between the subtype of accessory navicular bone and the flatfoot angle, nor did we find any correlation with the hallux valgus angle, aligning with several previous studies.\u003c/p\u003e \u003cp\u003eThe combination of flatfoot, hallux valgus, and accessory naviculus in teenagersis known as triple foot deformity, which is a multifaceted three-dimensional condition.This includes different degrees of forefoot abduction, midfoot varus, and hindfoot valgus. This deformity is often associated with congenital origins but can also be affected by environmental factors\u003csup\u003e[\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e. Clinically, it is frequently seen, with most individuals reporting discomfort around the ankle, while some may feel pain in the area of the accessory navicular. Symptoms of hallux valgus are generally mild and are often detected in childhood. As individuals reach adolescence, these symptoms become more pronounced, and the deformity tends to deteriorate\u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e. If not address edpromptly, both the deformity and its symptoms are likely to worsen. Studies suggest that this trio of deformities may stem from genetic anomalies or systemic conditions that affect the development of bones, muscles, or ligaments,leading to acompounding effect of congenital issues.Once structural changes happen, they are usually permanent\u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe formation of deformities is affected by the growth of skeletal muscles and various external factors. Consequently, treatment should aim not only at rectifying deformities and alleviating discomfort but also at enhancing muscle strength, realigning lower limb forces, and improving walking abilities. For asymptomatic individuals, conservative approaches may include orthopedic footwear, correctiveinserts, massage therapy, and muscle exercises\u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e.However, a lot of patients have advanced which might need to be surgically operated. While there is no agreement onthe best timing for surgery, a range of orthopedic techniques is commonly employed, such as Chevron, Scarf, Reverdin, Akin, and Ludloff osteotomies, joint fusion, and less invasive methods. For issues related to the accessory navicular bone, options include simple excision and tendon repair\u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e. Given that adolescents are at a critical stage of skeletal muscle development and have increased activity levels, prompt treatment is essential to avert permanent deformity progression. Techniques like joint bracing, minimally invasive hallux valgus surgery, and procedures for the accessory navicular bone provide benefits such as reduced trauma, faster recovery, and accurate results\u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/sup\u003e. Clinical research supports the feasibility of performing simultaneous surgeries for triple deformities.\u003c/p\u003e \u003cp\u003eThis research has several constraints: (1) a limited number of participants; (2) anemphasis on three-dimensional anatomical aspects while neglecting soft tissue influences; (3) absence of comparative measurements before and after surgery; (4) a requirement for genetic investigations to examine the connection between the deformities.\u003c/p\u003e \u003cp\u003eTo sum up, although hereditary elements are viewed as the origin of triple foot deformities in adolescents, a definitive link between the deformities remains unclear. However, examining the traits of these deformities can assist in making informedtreatment choices.\u003c/p\u003e "},{"header":"Abbreviations","content":"\u003cp\u003eComputed Tomography(CT), Three Dimension(3D),Standard Deviation(SD),World Health Organization(WHO),hallux valgus angle(HVA), talonavicular coverage angle(TNCA),intermetatarsal angle (IMA),distal metatarsal articular angle (DMAA), Body Mass Index (BMI),the talocalcaneal angle(Kite angle), the lateral angle between the talus and the first metatarsal(Meary angle), the calcaneal inclination angle(Pitch angle)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eConsent to Participate:informed consent to participate was obtained from all of the participants in the study.\u003c/p\u003e\u003cp\u003eHuman Ethics and Consent: All authors included in accordance with the current international committee of medical journal editors, the authors were assigned with the highest level of writing in the work of the author. All authors agree to the content of the manuscript. Each author confirms the absence of any conflicts of interest. We were given permission to participate in this study from the Qujing First People\u0026apos;s Hospital Institutional Review Board（No:IEC/AF/16/2023-01.0）.And all participants signed the informed consent form.\u003c/p\u003e\n\u003cp\u003eDeclaration of Helsinki:This study adheres to the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003eConsent to Participate:informed consent to participate was obtained from all of the participants in the study.\u003c/p\u003e\n\u003cp\u003eConsent for publication:All authors agree to be published.\u003c/p\u003e\n\u003cp\u003eFunding Statement: No funding. \u0026nbsp; \u0026nbsp; \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eORGANIZATION W H (2006) Orientation programme on adolescent health for health care providers [J]. Geneva World Health Organization\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRENAULT JB, GATAN.A\u0026uuml;LLO-RASSER DONNEZM et al (2018) Articular-surface-based automatic anatomical coordinate systems for the knee bones [J]. J Biomech 80:171\u0026ndash;178\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLI Z, LIU Z, SHI W et al (2024) Eligibility for knee arthroplasty is associated with increased risk of acquired hallux valgus - a Mendelian randomized study [J]. BMC Musculoskelet Disord, 25(1)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMERRILL LEE et al (2018) Effect of Mechanical Axis Correction on Outcomes of Hallux Valgus Surgery [J]. The Journal of foot and ankle surgery: official publication of the American College of Foot and Ankle Surgeons. 57(1):111\u0026ndash;115\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCHANG A S, SON S W, PARK P et al (2024) Hallux valgus interphalangeus is more common in juvenile-onset hallux valgus than in adult-onset hallux valgus [J]. J Orthop Surg Res 19(1):1\u0026ndash;6\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLEWIS T L GORDOND (2022) RAY R. The Impact of Hallux Valgus on Function and Quality of Life in Females [J], vol 7. Foot \u0026amp; Ankle Orthopaedics, 1\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJANG HS, PARK K H, PARK HW (2016) Comparison of outcomes of osteosynthesis in type II accessory navicular by variable fixation methods [J]. Foot \u0026amp; Ankle Surgery, p S1268773116304052\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSENSES I (2004) Restoring the continuity of the tibialis posterior tendon in the treatment of symptomatic accessory navicular with flat feet [J]. J Orthop Sci Official J Japanese Orthop Association 9(4):408\u0026ndash;409\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKARA M (2020) BAYRAM S. Effect of Unilateral Accessory Navicular Bone on Radiologic Parameters of Foot [J], vol 42. Foot \u0026amp; Ankle International, 5\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePRICHASUK S (1995) SINPHURMSUKSKUL O. Kidner Procedure for Symptomatic Accessory Navicular and Its Relation to Pes Planus [J], vol 16. Foot \u0026amp; Ankle International, pp 500\u0026ndash;503. 8\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePARK H, JIN HOSEO, JOON OHKIM (2015) HYUN WOO. The Relationship Between Accessory Navicular and Flat Foot: A Radiologic Study [J]. J Pediatr Orthop, 35(7)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJUAN PRETELL-MAZZINI (2014) ROBERT, et al. Surgical treatment of symptomatic accessory navicular in children and adolescents [J]. American Journal of Orthopedics\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMINOKAWA S, YOSHIMURA I, KANAZAWA K et al (2023) Radiologic foot alignment and clinical outcome after percutaneous drilling for symptomatic accessory navicular in skeletally immature children [J]. Medicine 102(51):5\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNAKAJIMA K (2025) Symptomatic Accessory Navicular Treated With Endoscopic Accessory Navicular and Partial Navicular Resection [J]. Foot \u0026amp; Ankle International, 46(2): 192\u0026ndash;199\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSMITH RIEMERT (2012) Management of dancers with symptomatic accessory navicular: 2 case reports [J]. J Orthop Sports Phys Therapy 42(5):465\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWARIACH S, KARIM K, SARRAJ M et al (2022) Assessing the Outcomes Associated with Accessory Navicular Bone Surgery-a Systematic Review [J]. Curr Rev Musculoskelet Med 15(5):377\u0026ndash;384\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eINAGAWA M, JUJO Y, SHIMOZONO Y et al (2025) Simultaneous bilateral surgery for accessory naviculars does not have a negative effect on postoperative outcome [J]. The Journal of Foot and Ankle Surgery\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLIANG JC, ZAN Q, CAO SH et al (2025) The impact of preoperative anxiety and depression on the prognosis of patients with painful accessory navicular [J], vol 20. Journal of Orthopaedic Surgery \u0026amp; Research, 1\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBERNAERTS A, VANHOENACKER F M, PERRE S V D et al (2004) Accessory navicular bone: not such a normal variant [J]. JBR-BTR: organe de la Soci\u0026eacute;t\u0026eacute; royale belge de radiologie (SRBR) = orgaan van de Koninklijke Belgische Vereniging voor Radiologie (KBVR). 87(5):250\u0026ndash;252\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJASIEWICZ B, POTACZEK T, K?CKI W et al (2008) Results of simple excision technique in the surgical treatment of symptomatic accessory navicular bones [J]. Foot Ankle Surg 14(2):57\u0026ndash;61\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKIM J, PARK C, MOON Y et al (2014) Concomitant calcaneo-cuboid-cuneiform osteotomies and the modified Kidner procedure for severe flatfoot associated with symptomatic accessory navicular in children and adolescents [J]. J Orthop Surg Res 9(1):131\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSHI C, LI M, ZENG Q et al (2023) Subtalar arthroereisis combined with medial soft tissue reconstruction in treating pediatric flexible flatfoot with accessory navicular [J]. J Orthop Surg Res 18(1):55\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFANG K, BI T, HONG A et al (2023) Efficacy of modified kidner procedure combined with subtalar arthroereisis treating adolescent type 2 painful accessory navicular with flexible flatfoot [J]. Front Pead 11(11):1258032\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLIU X T-JG, L Y-X et al (2023) Is Kidner procedure necessary during subtalar arthroereisis for pediatric flexible flatfoot that combined with symptomatic type 2 accessory navicular? A retrospective comparative study [J]. Foot Ankle Surg, (5): 29\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNASREDDINE A, DUNHAM A, MO M et al (2025) Surgical Treatment for Painful Pediatric Pes Planovalgus: How Does Subtalar Extra-articular Screw Arthroereisis Compare to the Standard Technique of Modified Evans Reconstruction? [J]. J Pediatr Orthop 45(9):559\u0026ndash;565\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNASH A, ALVAREZ C M, RENNER JB et al (2025) Long-Term Functional and Radiographic Outcomes of Untreated Tarsal Coalitions: A Community-Based Observational Study [J]. J Pediatr Orthop 45(7):7\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Kunming Medical University","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":"Hallux valgus, Flatfoot, Accessory navicular, Morphology, Adolescents, Digital orthopedics, 3D reconstruction","lastPublishedDoi":"10.21203/rs.3.rs-9498037/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9498037/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eThis research aims to explore the causes of flatfoot, hallux valgus, and accessory navicular conditions within this specific group by conducting a digital morphological examination of foot CT scans from adolescents exhibiting these issues simultaneously.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eBetween January 2023 and January 2025, our department enrolled 17adolescents (9 females and 8 males) diagnosed with tridysmorphic deformities.We used weight bearing CT images to analyze the affected foot and generated 3D digital images. A unique 3D coordinate framework was developed for each foot, allowing for the measurement and analysis of relevant parameters related to flatfoot, hallux valgus, and accessory navicular.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThere were no significant correlations observed between the hallux valgus angle(HVA)and the talonavicular coverage angle(TNCA), Kite angle, Meary angle, or pitch angle(P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Likewise, the intermetatarsal angle (IMA) did not show significant correlations with TNCA, Kite angle, Meary angle, pitch angle, or flatfoot angle (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Furthermore, the distal metatarsal articular angle (DMAA)did not exhibit significant relationships with TNCA, Kite angle, Meary angle, or pitch angle (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The proximal articular fixation angle also lacked a significant correlation with the flatfoot angle. In contrast, the classification of accessory navicular bones was found to be related to angles associated with flatfoot but not to hallux valgus angles.The distribution of accessory navicular bone types was as follows Type I(3 instances), Type II(9 instances), and Type III(5 instances). The classification of sesamoid location included Type IV in 3 instances and Type V in 14 instances.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe origins of triple foot deformities in teenagers, including flatfoot, hallux valgus, and accessory navicular, are probably due to congenital factors. Although there are no definitive causal links between these three conditions, they may have an impact on one another.\u003c/p\u003e","manuscriptTitle":"Digital Morphological Examination of Adolescent Triple Foot Deformities: Flatfoot, Hallux Valgus, and Accessory navicular","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-27 10:57:01","doi":"10.21203/rs.3.rs-9498037/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":"ea24d220-7245-46c9-906a-71f32da7673f","owner":[],"postedDate":"April 27th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":66829186,"name":"Orthopedics"}],"tags":[],"updatedAt":"2026-04-27T10:57:06+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-27 10:57:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9498037","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9498037","identity":"rs-9498037","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}