Hindfoot Varus Is Not Universally Present in Müller-Weiss Disease: A Clinical and Radiographic Analysis

Hindfoot varus has traditionally been considered a characteristic feature of Müller-Weiss disease (MWD), but its universality remains uncertain. This study evaluated hindfoot alignment in MWD using the Saltzman hindfoot alignment view.

Patients diagnosed with MWD between January 2015 and December 2025 were retrospectively reviewed. Feet were included if they met minimum diagnostic criteria and had complete clinical hindfoot photographs, Saltzman hindfoot alignment views, and weightbearing anteroposterior and lateral foot radiographs. Saltzman hindfoot alignment, clinical hindfoot alignment angle, Kite angle, and the lateral Meary-Tomeno angle were measured. Agreement between clinical and Saltzman categories was evaluated using Cohen kappa. Linear mixed effects model accounted for bilateral involvement.

The cohort comprised 103 patients (160 feet), with a mean age of 58.3 ± 8.8 years; 95 patients (92.2%) were women. Interobserver reliability was good to excellent, whereas intraobserver reliability was excellent. On the Saltzman view, 76 feet (47.5%) were varus, 19 (11.9%) neutral, and 65 (40.6%) valgus; 84 feet (52.5%; 95% CI, 44.8%-60.1%) demonstrated non-varus alignment. Exact 3-category agreement between clinical and Saltzman classifications was 81.3%, with substantial overall agreement (κ = 0.683, P < .001). Clinical hindfoot alignment angle and Kite angle were associated with Saltzman hindfoot alignment, whereas the lateral Meary-Tomeno angle was not significantly associated with Saltzman hindfoot alignment (P = .76).

Hindfoot varus was not universal in MWD. Clinical hindfoot appearance and Kite angle were associated with standardized coronal hindfoot alignment, whereas no statistically significant association was detected for the lateral Meary-Tomeno angle. These findings support direct assessment of hindfoot alignment and individualized, multiplanar evaluation before implementing a patient-specific treatment plan in patients with MWD.

Level III, retrospective cohort study.