To the Editor:
We appreciate the opportunity to respond to Dr Webb’s letter
regarding our study. While Dr. Webb suggests that hindfoot valgus, pes planus, and
gastrocsoleus tightness lead to first ray hypermobility and metatarsus
primus elevatus, his supporting references (1,2,3,4,5) offer no objective
proof of his notion. In a separate report that we published (6) on the
demographics and radiographic data concerning the same cohort of patients
in the current study, we reported an 11% incidence of pes planus and
concluded that pes planus is no more common in patients with hallux
rigidus than in the normal population.
While Bingold (7) suggested an association of hallux rigidus and
Achilles tendon contracture, there were only four patients in the series (6)
who had five degrees or less of ankle dorsiflexion with the knee extended
and the foot in neutral alignment. We concluded that a tight Achilles
tendon is not associated with hallux rigidus.
Several reports have suggested an association of first ray
hypermobility and hallux rigidus (1,7,8,9,10,11,12,13) although objective
data was not presented in any of these reports. In our report (6), we used an
external caliper (Klaue’s device)(14) to quantify first ray mobility. We
noted an average first ray mobility of between 5 and 6 mms, and reported
no association between first ray hypermobility and hallux rigidus. Using
Klaue’s criteria (14) for determining hypermobility, only 1/127 feet were
considered hypermobile.
Many reports (1,5,9,10,11,15,16,17,18,19) have endorsed the concept of
metatarsus primus elevatus with little or no objective data. Several
techniques have been described to measure elevatus including Seiberg’s
technique (using two reference points)(22), Horton’s technique (using one
reference point)(23), and angular measurements (first metatarsal
declination angle-1-MDA)(24). We found Horton’s technique to give a
reliable and repeatable estimation of the first metatarsal elevatus.
In
our report on the demographics of this cohort of patients (6), we
also measured the first metatarsal declination angle. We reported a
correlation between the 1-MDA and the metatarsus primus elevatus as
measured with Horton’s technique. (r=.6, p=.03). While we found elevatus
to be uncommon, we observed increasing elevatus with an increasing grade or
severity of hallux rigidus. Based on this information, we believe that
elevatus is a secondary change rather than a primary cause of hallux
rigidus.
Lastly, Dr. Webb suggests that differences in the x-ray tube angle
can lead to distortion of the radiographic image (25) and suggests this as a
further explanation of why our data do not support his contention of an
association of hallux rigidus and metatarsus primus elevatus. During the
twenty-three years of this study, radiographs were taken in our office with the same standardized technique. We suggest
that while one might propose numerous reasons why our data do not
demonstrate an association of hallux rigidus and metatarsus primus
elevatus, the objective data are clear. Based on the results of our study, we believe that procedures such as
first metatarsal osteotomies to treat elevatus are rarely indicated and
are aimed at correcting a secondary rather than a primary problem. We further conclude that the two procedures we have described
(cheilectomy and arthrodesis) yield predicable, reliable and long-term
successful results when used with the grading system we described.
Sincerely yours,
Michael J. Coughlin M.D.
Idaho Foot and Ankle Fellowship Program
Boise, Idaho
Paul S. Shurnas M.D.
Columbia Orthopaedic Group
Columbia, MO
References:
1.Camasta C. Radiographic evaluation and classification of metatarsus
primus elevatus. In reconstructive Surgery of the Foot and Leg Update 94,
pp. 122-127, Edited by C.A. Camasta, The Podiatry Institute, Tucker, GA.
1994
2.Root M, Orien W, Weed J. Normal and abnormal function of the foot.
In Clinical Biomechanics Vol 2, Clinical Biomechanics Corp, Los Angeles,
1977
3.Roukis T, Jacobs P, Dawson D, Erdmann B, Ringstrom J. A prospective
comparison of clinical radiographic, and intraoperative features of hallux
rigidus. J. Foot Surg. 41:76-95, 2002
4.Shereff M, Baumhauer J. Hallux Rigidus and Osteoarthrosis of the
first metatarsophalangeal joint. Current Concept review. JBJS: 80A: 898-
908, 1998
5.Vanore J, Christensen J, Kravitz S, Schuberth J, Thomas J, Weil LS,
Zlotoff H, Couture S. Diagnosis and treatment of first metatarsophalangeal
joint disorders. Section 2: Hallux Rigidus. J. Foot Ankle 42:124-136,
2003
6.Coughlin M, Shurnas P. Hallux Rigidus: Demographics, etiology and
radiographic assessment. Foot Ankle Int. 24:731-743, 2003
7.Bingold A, Collins D: Hallux Rigidus. J Bone Joint Surg
1950;32B:214-222.
8.Cohen M, Roman A, Liessner P: A modifiation of the Regnauld
procedure for hallux limitus. J Foot Surg 1992;31:498-503.
9.Drago J, Oloff L, Jacobs A: A comprehensive review of hallux
limitus. J Foot Surg. 1984;23:213-220.
10.Geldwert J, Rock G, McGrath M, Mancuso J: Cheilectomy: still a
useful technique for Grade I and Grade II hallux limitus/rigidus. J Foot
Surg. 1992;31:154-159.
11.Jack E: The aetiology of hallux rigidus. Br J Surg. 1940; 27:492
-497.
12.Kurtz D, Harrill J, Kaczander B, Solomon M: The Valenti procedure
for hallux limitus: a long-term follow-up and analysis. J Foot Ankle
Surg. 1999;38:123-130.
13.Saxena A: The Valenti procedure for hallux limitus/rigidus. J
Foot Ankle Surg. 1995;34:485-488.
14.Klaue K, Hansen S, Masquelet A: Clinical, quantitative assessment
of first tarsometatarsal mobility in the sagittal plane and its relation
to hallux valgus deformity. Foot Ankle Int. 1994;15:9-13.
15.Bonney G, Macnab I: Hallux valgus and hallux rigidus. J Bone
Joint Surg 1952;34B:366-385.
16.Cavolo D, Cavallaro D, Arrington L: The Waterman osteotomy for
hallux limitus. J Am Pod Assoc. 1979;69:52-57.
17.Cosentino G: The Cosentino modification for tendon interposition
arthroplasty. J Foot Ankle Surg 1995;34:501-508.
18.Dananberg H: Gait style as an etiology to chronic postural pain.
Part I functional hallux limitus. J Am Podiatr Med Assoc 1993;83:433-441.
19.Dananberg H: Gait style as an etiology to chronic postural pain.
Part II proximal compensatory process. J Am Podiatr Med Assoc 1993;83:615-
624.
20.Lundeen R, Rose J: Sliding oblique osteotomy for the treatment of
hallux abducto valgus associated with functional hallux limitus. J Foot
Ankle Surg. 2000;39:161-167.
21.Pontell D, Gudas C: Retrospective analysis of surgical treatment
of hallux rigidus/limitus: clinical and radiographic follow-up of hinged,
silastic implant arthroplasty and cheilectomy. J Foot Surg. 1988;27:503-
510.
22.Seiberg M, Felson S, Colson J, Barth A, Green R, Green D. Closing
base wedge versus Austin Bunionectomies for metatarsus primus adductus.
JAPMA 84:548-563, 1994
23.Horton G, Park Y, Myerson M: Role of metatarsus primus elevatus
in the pathogenesis of hallux rigidus. Foot Ankle Int. 1999;20:777-780.
24.Bryant A, Tinley P, Singer, K: A comparison of radiographic
measurements in normal, hallux valgus, and hallux limitus feet. J Foot
Ankle Surg 2000;39:39-43.
25.Camasta C, Pontious J, Boyd R. Quantifying magnifidcation in pedal
radiographs. JAPMA 81:545-648, 1991
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