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Scientific Articles:
Michael J. Coughlin and Carroll P. Jones
Hallux Valgus and First Ray Mobility. A Prospective Study
J Bone Joint Surg Am 2007; 89: 1887-1898 [Abstract] [Full text] [PDF]
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[Read Letter to the Editor] Drs. Coughlin and Jones respond to Dr. Greisberg
Michael Coughlin, M.D., Carroll P. Jones, M.D.   (13 November 2007)
[Read Letter to the Editor] Are we asking the right questions?
Justin K. Greisberg, M.D.   (31 October 2007)

Drs. Coughlin and Jones respond to Dr. Greisberg 13 November 2007
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Michael Coughlin, M.D. ,
Carroll P. Jones, M.D.

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Re: Drs. Coughlin and Jones respond to Dr. Greisberg

footmd{at}aol.com Michael Coughlin, M.D., et al.

We thank Dr. Greisberg for his letter and comments, and we appreciate the opportunity to clarify a number of facts we reported in our paper(1).

The purpose of this prospective clinical series was not to define the etiology of hallux valgus deformities. This is a topic of great interest for all of us, but a subject that is no closer to being defined now than in Morton’s era. In our published study, we evaluated the clinical and radiographic results of one surgical approach (the distal soft tissue realignment with proximal crescentic osteotomy) as a treatment for moderate and severe bunion deformities. We quantified the effect of this procedure on clinical and radiographic MC joint mobility, something that had not been done before.

Dr. Greisberg states that the Klaue device(2) has not been validated. He is incorrect and we call to his attention the article by Jones et al.(3) and Glasoe et al.(4). The Klaue device(2), although not widely used other than as a research device, was designed and described by Hansen and Klaue(2), and is a means to objectively quantify first ray sagittal excursion. Using this validated device, our results demonstrate that there is an association between increased first ray mobility and hallux valgus deformities; that so called “first ray hypermobility” does not necessitate a Lapidus procedure for a successful outcome; and that first ray mobility is routinely and significantly reduced following a distal realignment and first metatarsal osteotomy without an MC arthrodesis.

“Hypermobility” may be conceptual as Dr. Gresiberg suggests, but this is not a valid scientific description and the manual examination of first ray mobility does not allow quantification. Many articles have been published with no substantiation of first ray mobility other than the authors’ clinical impression(5-12). We agree with him that it has been described, defined, and taught for many years. However, we agree with Glasoe et al.(4) that this notion is based on an unreliable manual clinical examination.

Dr. Greisberg suggests that a Lapidus procedure is a logical solution as it addresses the first ray malalignment at the point of deformity. A proximal crescentic osteotomy, using the center of rotation axis(CORA), also achieves its correction at the MC joint. Contrary to Dr. Gresiberg’s notion, a metatarsal osteotomy does not necessarily create a secondary deformity. We do agree with him that a Lapidus procedure has many downsides including slow healing, occasional non union, and potential technical difficulties in the procedure. Furthermore, he misses the point in our article of the result of the metatarsal osteotomy. The transarticular fixation was temporary (six weeks in duration), and we submit that the first ray realignment was the main reason for the diminution in the first ray mobility.

As Dr. Greisberg comments, there are many unanswered questions. For many years, proponents of the Lapidus procedure have accepted Morton and Lapidus’ theories of first ray hypermobility without critical investigation of their merits. These are questions that we have asked and tried to answer; and we concluded, “we found little clinical evidence to substantiate their theories”.

It is unclear whether hallux valgus deformities develop secondary to metarsus primus varus, or vice-versa. Similarly, it is unknown whether increased mobility at the first metatarsocuneiform joint predisposes to subluxation in the axial plane, or is a secondary effect of a wide intermetatarsal angle. Additionally, a deviated or subluxated joint, in our opinion, does not necessarily equate to an unstable or hypermobile joint, as Dr. Gresiberg suggests. Deformities often develop slowly over time and may be inherently stiff, despite attenuation of the capsule and other soft-tissue structures. Regardless, our study does not settle these “chicken versus the egg” debates, but does provide important clinical support for joint sparing procedures, even in the setting of increased preoperative mobility.

We recognize that the Lapidus procedure does address the deformity at its proximal apex and provides powerful correction of a widened intermetatarsal angle. We find this a useful operation, and utilize it when appropriate. On the other hand, we believe we have answered one question with our quantification of first ray motion after a distal realignment and we conclude that a first metatarsocuneiform joint arthrodesis is not necessary to achieve realignment of the first ray and reduction of first ray mobility. We have effectively challenged the theories of Morton and Lapidus, and conclude that the Lapidus procedure is not the only approach to first ray “hypermobility”. We believe we are asking appropriate questions, indeed the right questions, but it will take many more studies to have all the answers.

References:

1. Coughlin MJ, Jones CP. Hallux valgus and first ray mobility. A prospective study. J Bone Joint Surg Am. 2007;89:1887-1898.

2. Klaue, K; Hansen, ST; Masquelet, AC: Clinical, quantitative assessment of first tarsometatarsal mobility in the sagittal plane and its relation to hallux valgus deformity. Foot Ankle Int. 15: 9-13, 1994.

3. Jones C, Coughlin M, Pierce-Villadot R, Golano P, Kennedy M., Shurnas P., Grebing B, The validity and reliability of the Klaue device.. Foot Ankle International 26:951-956, 2005

4. Glasoe W, Allen M, Saltzman C, Ludewig P, Sublett S. Comparison of two methods used to assess first ray mobility. Foot Ankle Int. 23:248-252, 2002

5. Lapidus, P. W.: Operative correction of metatarsus varus primus in hallux valgus. Surg Gynecol Obstet, 58: 183-191, 1934. 2.

6. Lapidus, P. W.: A quarter of a century of experience with the operative correction of the metatarsus varus primus in hallux valgus. Bull Hosp Joint Dis, 17(2): 404-21, 1956.

7. Bacardi, B. E., and Boysen, T. J.: Considerations for the Lapidus operation. J Foot Surg, 25: 133-8, 1986.

8. Bednarz, P. A., and Manoli, A., 2nd: Modified lapidus procedure for the treatment of hypermobile hallux valgus. Foot Ankle Int, 21: 816- 21, 2000.

9. Clark, H. R.; Veith, R. G.; and Hansen, S. T., Jr.: Adolescent bunions treated by the modified Lapidus procedure. Bull Hosp Jt Dis Orthop Inst, 47(2): 109-22, 1987. 43.

10. Johnson K, Kile T. Hallux valgus due to cuneiform-metatarsal instability. J. Southern Orthop. 3:273-282, 1994

11. Myerson, M. S., and Badekas, A.: Hypermobility of the first ray. Foot Ankle Clin, 5: 469-84, 2000.

12. Sangeorzan, B. J., and Hansen, S. T., Jr.: Modified Lapidus procedure for hallux valgus. Foot Ankle, 9: 262-6, 1989.
Are we asking the right questions? 31 October 2007
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Justin K. Greisberg, M.D.,
Orthopaedic Surgeon
Columbia University, New York, New York

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Re: Are we asking the right questions?

justingreisberg{at}hotmail.com Justin K. Greisberg, M.D.

To The Editor:

I read with great interest “Hallux valgus and first ray mobility” by Coughlin and Jones(1). I would like to congratulate the authors on a comprehensive study addressing very timely questions. However, I am a bit puzzled at the conclusions.

In the final sentences, the authors conclude, “There is little clinical evidence to substantiate … [that] increased mobility at the first metatarsocuneiform can lead to hallux valgus”(1). But earlier in the paper, the authors state, “We believe that the metatarsocuneiform joint is the key to development and progression of hallux valgus”(1). Aren’t these two statements at odds with each other? The authors acknowledge the role of the metatarsocuneiform joint in the deformity, but they question the concept of joint instability.

I am aware of the debate in the recent past between various foot & ankle “schools” on osteotomy versus metarsocuneiform fusion for hallux valgus. Unfortunately, I think we are all missing the ‘forest from the trees’. The concept of 1st metatarsal hypermobility or instability was introduced to suggest that first metatarsocuneiform deviation was a necessary step, and perhaps the first step, in the development of hallux valgus.

The Klaue device, which measures vertical translation of the first ray through the medial naviculocuneiform and first metatarsocuneiform joints, has not been proven, nor widely accepted, as a measure of first ray instability. Instability may be more concept than physical measurement. One might argue that there must be some degree of metatarsocuneiform instability to allow the joint to deform at all.

Perhaps the Klaue device is not “asking the right questions.” We need to think about the problems fundamentally.

Everyone would agree that hallux valgus arises from deformity at the first metatarsophalangeal and metatarsocuneiform joints in most or all patients. In no case does it arise from an acquired angulation in the first metatarsal bone. The most logical solution is to address the deformity by restoring normal alignment at the joints as is done with a modified Lapidus procedure. Any metatarsal osteotomy is creating a secondary deformity to compensate for the primary one.

That is not to say that every patient is best served with a modified Lapidus procedure. There are downsides, including slow recovery, technical difficulty, and nonunion. The end must justify the means, and for many patients these problems with the Lapidus procedure outweigh the advantages. For these patients, a metatarsal osteotomy may be the perfect compromise.

The authors have established that vertical translation of the first ray improves following proximal metatarsal osteotomy with temporary transarticular fixation. They have not proven that instability of the first ray is not a cause of hallux valgus. Furthermore, we still can not determine how hallux valgus deformity begins. What is the first step? What is the necessary pathophysiology? As is the case too often in medicine, we are left with more questions than answers.

I again congratulate the authors on addressing such a controversial issue, but the concept of first metatarsal instability remains alive.

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 .

Reference:

1. Coughlin MJ, Jones CP. Hallux valgus and first ray mobility. A prospective study. J Bone Joint Surg Am. 2007;89:1887-1898.