To The Editor:
While we agree with many of the points brought forth in the article,
"Hallux Rigidus. Grading and Long-Term Results of Operative
Treatment"
(2003;85:2072-88), by Coughlin
and Shurnas, others bring up questions.
The authors indicated that metatarsus primus elevatus was not present in
the majority of the patients in their study. However, their method of
measuring the distance between the dorsal cortices of the first and second
metatarsals to evaluate metatarsus primus elevatus is susceptible to error. A
study by Camasta et al.1 illustrated that differences in the x-ray
tube head angle can cause distortion of the radiographic image. We believe,
therefore, that the authors' conclusion that metatarsus primus elevatus is not
a factor in the etiology of hallux rigidus should be reconsidered.
Seiberg et al.2 described a reproducible radiographic method of
evaluating metatarsus primus elevatus that measures the difference between the
dorsal cortices of the first and second metatarsals at two sites. The first
measurement is made 1.5 cm distal to the first metatarsal cuneiform joint, and
the second measurement is made 1.5 cm proximal to the first metatarsal head.
If the distal value is greater than the proximal one, then a true metatarsal
elevation is present.
Coughlin and Shurnas also did not mention whether they evaluated patients
for certain deformities that are associated with the development of hallux
rigidus. These deformities include compensated forefoot and hindfoot valgus
and gastrocnemius or gastrocnemius-soleus equinus. These deformities can cause
the subtalar joint to be abnormally pronated in the stance phase of gait. Such
abnormal pronation leads to hypermobility of the first ray, which is caused by
the inability of the peroneus longus to stabilize the ray when the peroneus
longus loses its mechanical advantage. This causes the first metatarsal to be
in an elevated position, which inhibits dorsiflexion of the proximal phalanx
on the first metatarsal during toe-off3-7. We believe, therefore,
that the failure of the authors to address the most common causes of this
deformity leads to an oversimplified picture of this complex condition.
M.J. Coughlin and P.S. Shurnas reply:
We appreciate the opportunity to respond to the letter by Dr. Webb and
colleagues regarding our study. While Dr. Webb and colleagues suggest that
hindfoot valgus, pes planus, and gastrocnemius-soleus tightness lead to
first-ray hypermobility and metatarsus primus elevatus, their supporting
references3-7
offer no objective proof of this notion. In a separate
report8 on the
demographic and radiographic data on the same cohort of patients described in
the current study, we reported an 11% prevalence of pes planus and concluded
that pes planus is no more common in patients with hallux rigidus than it is
in the normal population.
While Bingold and
Collins9 suggested
an association between hallux rigidus and Achilles tendon contracture, there
were only four patients in our previous
series8 who had
=5° 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 between first-ray
hypermobility and hallux
rigidus3,9-15,
although objective data were not presented in any of those reports. In our
report8, we used an
external caliper (Klaue's
device16) to
quantify firstray mobility. We noted an average first-ray mobility of between
5 and 6 mm and reported no association between first-ray hypermobility and
hallux rigidus. According to Klaue's
criteria16 for
determining hypermobility, only one of 127 feet were considered
hypermobile.
Many investigators have endorsed the concept of metatarsus primus elevatus
on the basis of little or no objective
data3,7,11-13,17-23.
Several techniques have been described to measure elevatus, including
Seiberg's technique (using two reference
points)2, Horton's
technique (using one reference
point)24, and a
technique involving measurement of the first metatarsal declination
angle25. We found
that Horton's technique provides a reliable and repeatable estimation of first
metatarsal elevatus.
In our report on the demographic data for this cohort of
patients8, we also
measured the first metatarsal declination angle. We reported a correlation
between the first metatarsal declination angle and metatarsus primus elevatus
as measured with Horton's technique (r = 0.6, p = 0.03). While we found
elevatus to be uncommon, we observed increasing elevatus in association with
an increasing grade or severity of hallux rigidus. On the basis of this
information, we believe that elevatus is a secondary change rather than a
primary cause of hallux rigidus.
Last, Dr. Webb and colleagues suggested that differences in the x-ray tube
angle can lead to distortion of the radiographic
image1 and suggested
that this is a further explanation of why our data do not support his
contention of an association between hallux rigidus and metatarsus primus
elevatus. During the twenty-three years of the current study, radiographs were
made 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 between hallux rigidus and metatarsus primus elevatus, the
objective data are clear. On the basis of 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 that we described
(cheilectomy and arthrodesis) yield predictable, reliable, and long-term
successful results when used with the grading system that we described.
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