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.
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