Copyright © 2007 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Mark Easley, MD*,
Duke University Medical Center, Durham, North Carolina
Posted September 2007
The primary purpose of this study by Coughlin and Jones in
this issue of The Journal was to
assess patient outcome following a proximal crescentic osteotomy of the first
metatarsal and distal soft-tissue reconstruction for the management of moderate
to severe hallux valgus. This case series (level-IV evidence) is one of the few
prospective published investigations of corrective surgery for hallux valgus1-3.
The authors utilized the American Orthopaedic Foot and Ankle Society (AOFAS)
rating system, an assessment tool that, since the time this study was initiated,
has been associated with some limitations in measuring outcomes4. Despite
such a potential limitation, the favorable clinical and radiographic outcomes
reported by the authors at a mean follow-up of 2.25 years (minimum follow-up of
two years) suggest that a proximal crescentic osteotomy of the first metatarsal
combined with distal soft-tissue realignment is a reasonable surgical treatment
for moderate to severe hallux valgus. Mean pain scores, functional outcomes, subjective
assessment, and radiographic alignment significantly improved in this study
cohort (p < 0.01).
The secondary purpose of this study was to study the influence
of mobility of the first ray on the outcome of surgical correction of moderate
to severe hallux valgus, a factor previously studied by the senior author (M.J.C.)5-7.
Increased mobility of the first ray ("hypermobility") has been implicated in
the development of hallux valgus; this theory was popularized by Morton8-10 and supported by Lapidus11-13. On the basis of the concepts espoused
by Morton and Lapidus, some surgeons manage moderate to severe hallux valgus with
arthrodesis of the first tarsometatarsal joint and a distal soft-tissue
procedure (Lapidus procedure)14-16. Prospective level-I17 and level-IV14 studies have reported favorable outcomes after arthrodesis
of the first tarsometatarsal joint for the correction of primary and recurrent
hallux valgus.
The authors of this paper do not question that acceptable
results of a Lapidus procedure can be achieved. Instead, they question the
means by which the diagnosis of increased mobility of the first ray is
substantiated, a diagnosis prompting a potentially unnecessary arthrodesis of
the first tarsometatarsal joint. Hypermobility of the first ray is often diagnosed
when, on manual examination, there is subjective greater than physiologic
elevation of the first metatarsal. Objective criteria for making this diagnosis
include greater than physiologic elevation of the first metatarsal as measured
with the validated Klaue device; plantar gapping of the first tarsometatarsal
on weight-bearing sagittal radiographs; and radiographic appearance of hypertrophy
of the second metatarsal. In a previous investigation, the authors suggested
that there is no correlation between hallux valgus, mobility of the first ray,
and hypertrophy of the second metatarsal7. The current literature
provides insufficient evidence (level III to V) to substantiate or disprove the
theory that increased mobility of the first ray can lead to the development of
hallux valgus18.
The authors of the current study were careful to assess mobility
of the first ray and its associated findings by criteria identical to those
employed by Morton8-10 and Lapidus11-13. Preoperative
assessment with the Klaue calibration device, Harris mats, and weight-bearing
radiographs of the foot revealed that 19% of feet had greater than physiologic mobility
of the first ray, 15% of feet had pes planus (clinical and radiographic
assessment), and 23% of feet had plantar gapping on lateral radiographs. Within
the subgroups of patients studied, the authors did not observe correlations
between clinically determined hypermobility of the first ray and radiographic
plantar gapping or pes planus and hypermobility of the first ray. Although
correlations were noted preoperatively between mobility of the first ray and
hallux valgus and intermetatarsal angles, at the time of follow-up, only two
feet had objective clinical findings of increased mobility of the first ray and
only 7% had radiographic plantar gapping. In the feet with recurrent hallux
valgus deformity (5%), there was no correlation with preoperative increased mobility
of the first ray, and only one foot had hypermobility preoperatively. Additionally,
the authors found no correlation between limited ankle dorsiflexion (gastrocnemius
contracture) and magnitude of hallux valgus deformity, AOFAS score, or
outcomes.
In their paper, Coughlin and Jones have determined
prospectively that a proximal crescentic osteotomy of the first metatarsal combined
with a distal soft-tissue procedure provides acceptable outcomes in the
surgical management of moderate to severe hallux valgus with use of accepted
outcome measures at the time that their study was initiated. While the correlation
of hypermobility of the first ray and its implicated associated findings and
hallux valgus remains controversial, these authors suggest that the combination
of proximal crescentic osteotomy of the first metatarsal and distal soft-tissue
reconstruction effectively corrects moderate to severe hallux valgus even in
the presence of increased mobility of the first ray. The authors acknowledge the
limitations of their study (the AOFAS rating system, the assessment tools, and the
limited numbers of feet in several of the subgroups studied). However, they are
to be commended for assessing mobility of the first ray with use of the same
means described by the authors who popularized the theory of hypermobility of
the first ray.
Unfortunately, despite the exhaustive efforts in their
prospective case series, the level of evidence rests at level IV. To improve
the grade of recommendation in support of their findings, a high-quality
prospective randomized clinical trial that compares proximal crescentic osteotomy
of the first metatarsal and arthrodesis of the first tarsometatarsal joint is
warranted.
*The author did not receive any outside funding or grants in
support of his research for or preparation of this work. Neither he nor a
member of his immediate family received payments or other benefits or a
commitment or agreement to provide such benefits from a commercial entity. No
commercial entity paid or directed, or agreed to pay or direct, any benefits to
any research fund, foundation, division, center, clinical practice, or other
charitable or nonprofit organization with which the author, or a member of his
immediate family, is affiliated or associated.
References
1. Easley ME, Kiebzak GM, Davis WH, Anderson RB. Prospective, randomized comparison of proximal crescentic and proximal chevron osteotomies for correction of hallux valgus deformity. Foot Ankle Int. 1996;17:307-16.
2. Mann RA, Rudicel S, Graves SC. Repair of hallux valgus with a distal soft-tissue procedure and proximal metatarsal osteotomy. A long-term follow-up. J Bone Joint Surg Am. 1992;74:124-9.
3. Easley ME, Trnka HJ. Current concepts review: hallux valgus part II: operative treatment. Foot Ankle Int. 2007;28:748-58.
4. Baumhauer JF, Nawoczenski DA, DiGiovanni BF, Wilding GE. Reliability and validity of the American Orthopaedic Foot and Ankle Society Clinical Rating Scale: a pilot study for the hallux and lesser toes. Foot Ankle Int. 2006;27:1014-9.
5. Coughlin MJ, Jones CP, Viladot R, Glano P, Grebing BR, Kennedy MJ, Shurnas PS, Alvarez F. Hallux valgus and first ray mobility: a cadaveric study. Foot Ankle Int. 2004;25: 537-44.
6. Coughlin MJ, Shurnas PS. Hallux valgus in men. Part II: First ray mobility after bunionectomy and factors associated with hallux valgus deformity. Foot Ankle Int. 2003;24:73-8.
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8. Morton DJ. Hypermobility of the first metatarsal bone: the interlinking factor between metatarsalgia and longitudinal arch strains. J Bone Joint Surg. 1928;10:187-96.
9. Morton DJ. Significant characteristics of the Neanderthal foot. Nat History. 1926;26:310-4.
10. Morton DJ. The human foot; its evolution, physiology and functional disorders. New York: Columbia University Press; 1935.
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14. Coetzee JC, Resig SG, Kuskowski M, Saleh KJ. The Lapidus procedure as salvage after failed surgical treatment of hallux valgus: a prospective cohort study. J Bone Joint Surg Am. 2003;85:60-5.
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