- Email: [email protected]
Dear Editor
6. 7.
8. 9. 10. 11.
MJ, Shurnas PS, Alvarez F. Hallux valgus and first ray mobility: a cadaveric study. Foot Ankle Int 25:537–544, 2004. Lapidus PW. Operative correction of the metatarsus varus primus in hallux valgus. Surg Gynec Obst 58:183–191, 1934. Lapidus PW. A quarter century of experience with the operative correction of the metatarsus varus in hallux valgus. Bull Hosp Jt Dis Orthop Inst 17:404, 1956. Lapidus PW. The author’s bunion operation from 1931 to 1959. Clin Orthop 16:119, 1960. Sangeorzan BJ, Hansen ST Jr. Modified Lapidus procedure for hallux valgus. Foot Ankle 9:262–266, 1989. McInnes BD, Bouche RT. Critical evaluation of the modified Lapidus procedure. J Foot Ankle Surg 40:71–90, 2001. Patel S, Ford LA, Etcheverry J, Rush SM, Hamilton GA. Modified lapidus arthrodesis: rate of nonunion in 227 cases. J Foot Ankle Surg 43:37– 42, 2004.
Dear Editor: Justice Potter Stewart famously said of pornography: “I know it when I see it.” Such has been the case with hypermobility, but I would politely suggest that such ambiguity may not be best for our patients. It is for this reason that I read with great interest the descriptive article by Weber, Hatch, and Jensen regarding the “first ray splay” test in the July 2006 issue of The Journal of Foot & Ankle Surgery. There is little question that the term “hypermobility” is full of clinical ambiguity. It has created a challenge for those attempting a practical, but reproducible, operational definition. The present concept put forth by the authors is an elegant offshoot of Lapidus’ 70-year-old diagnostic technique. In the final paragraphs, the authors term this a “subjective” assessment. I would challenge the authors along with other clinicians and investigators to consider that this concept has the potential to be far more objective (assuming constant force is delivered through a digit or device) than most other similar clinical interrogations presently available. This, in turn, might have the ability to produce a more objective definition of when and how to choose between very different first ray procedures. David G. Armstrong, DPM, PhD Professor of Surgery and Associate Dean Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science Director Center for Lower Extremity Ambulatory Research (CLEAR) at Rosalind Franklin University of Medicine and Science North Chicago, IL
Dear Editor: The authors would like to thank Dr. Blitz and Dr. Armstrong for their respective responses to our article “Use of the First Ray Splay Test to Assess Transverse Plane Instability Prior to First Metatarsocuneiform Fusion,” which appeared in the July 2006 issue of The Journal of Foot & Ankle Surgery. The topic of first ray instability is certainly one which deserves good discourse, careful consideration, and further inquiry.
I am most interested in our collective quest for more knowledge and research on this topic. As Dr. Blitz mentions, excellent cadaveric studies have been published which illustrate various aspects of sagittal plane contribution to first ray motion. Further studies are needed to expand our understanding of transverse plane motion. Only through additional research will we truly be able to say what contribution transverse plane motion has on overall stability (or instability). With respect to the level of fusion beyond the first metatarsal-cuneiform joint, we certainly do not have a perfect answer when faced with this surgical dilemma. Our selection of fusion between the medial cuneiform and base of the second metatarsal was based on several observations. Radiographically, we noted that when a “gap” or diastasis was present, it was most often seen between the medial cuneiform and the base of the second metatarsal. Additionally, we found that the use of this particular orientation of the transfixation screw as well as the performance of the dowel fusion was technically reproducible and did not require additional dissection or tissue trauma. Lastly, this fixation point is furthest from the axis of the lever arm, therefore yielding the greatest effect. I agree with Dr. Blitz regarding the use of the naviculocuneiform fusion in a case of midfoot fault at this level. Again, further research including cadaveric studies and pressure plate data after various midfoot fusions is warranted. We thank both responders for their level of interest in this subject matter. Indeed, as Dr. Armstrong states, “This concept has the potential to be far more objective.” We hope to provide that data in forthcoming studies. Anna K. Weber Chicago, Illinois
Dear Editor: The article entitled “The Critical Analysis of Dudley Morton’s Concept of Disordered Foot Function” was of interest. The discussion regarding pressures under the ball of the foot was verification that a short and hypermobile first ray tends to increase pressure under the second metatarsal, a finding a surgeon quickly understands. The discussion, unfortunately, minimized the importance of the windlass mechanism as described by Hicks to fully appreciate the stability of the first ray. Without a windlass which produces stability of the foot structure in propulsion, the first ray will be unstable against weight-bearing forces, particularly as the heel everts and puts more pressure on the medial column of the foot. One can quickly see this in practice by maximally dorsiflexing the hallux and then only partially dorsiflexing the hallux. The resulting first ray instability of the latter maneuver can be readily appreciated. Once the windlass mechanism is looked at in more detail, I think this whole issue will become a lot more clear. Since this variable has been largely ignored by previous research, the picture
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certainly does not clarify easily. If we truly see a person walking with maximal dorsiflexion of the first MTP joint (a clinical rarity in private practice) we seldom see foot pathology. A great majority of my patients never walk with that kind of stability of the foot structure. Once the windlass mechanism is allowed to function normally, the weightbearing patterns along the ball of the foot change dramatically as the first ray plantarflexes though propulsion. This not only changes the pressure pattern on the ball of the foot but has a significant impact on the trajectory of force. I think future research considering how the windlass mechanism is functioning in conjunction with plantar pressure assessment will help to clarify this issue quite a bit. Thanks to the authors for trying to clarify a very important concept. Sincerely, James G. Clough, DPM, FASFS Dear Editor: We have reviewed the letter from Dr. Clough regarding his questions about the importance of the windlass mechanism and first ray stability. Our critical analysis of the literature described the writings of Dudley J. Morton and reviewed the important research published on first ray mobility and related pathologies. Our search of the literature did not find much information regarding whether shortness of first ray might influence the windlass mechanism of the foot, but we believe the windlass mechanism is of major structural importance in providing stability to the first ray. Grebing and Coughlin (1) reported in a small number of patients that there was increased first ray mobility in patients who had previously undergone a plantar fasciectomy. Rush et al (2) reported that after first ray alignment, first ray mobility decreased substantially and attributed this to the plantar aponeurosis. We concur with Dr. Clough that research is needed to more fully explain the role of the windlass mechanism in stabilizing the foot during gait propulsion. It seems logical to conclude that shortness of the first metatarsal could reduce the moment arm effect around which the plantar fascia tightens during terminal stance, and, therefore, shortness of the first metatarsal could disrupt the windlass mechanics and diminish the capacity of the first ray to carry weight. However, as Grebing and Coughlin (3) reported, true shortness of the first ray is an uncommon occurrence. Ward Glasoe, MA, PT, ATC Michael J. Coughlin, MD References 1. Grebing BR, Coughlin MJ. The effect of ankle position on the exam for first ray mobility. Foot Ankle Int 25:467– 475, 2004. 2. Rush SM, Christensen JC, Johnson CH. Biomechanics of the first ray. Part II: metatarsus primus varus as a cause of hypermobility. A three-
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THE JOURNAL OF FOOT & ANKLE SURGERY
dimensional kinematic analysis in the cadaver model. J Foot Ankle Surg 39:68 –77, 2000. 3. Grebing BR, Coughlin MJ. Evaluation of Morton’s theory of second metatarsal hypertrophy. J Bone Joint Surg 42-A:1375–1386, 2004.
Dear Editor: We have recently read the article, “The Spike Osteotomy for Hallux Valgus: A Clinical and Radiological Evaluation” in the July/August 2006 issue of The Journal of Foot and Ankle Surgery, and we would like to address the author’s comparison to Mitchell’s osteotomy. The percentage of postoperative metatarsalgia in the Kartataglis et al (1) study on Mitchell’s osteotomy is 11.8%, which is not far from the 8% post-metatarsalgia rate associated with the spike osteotomy noted in this study. The Karataglis et al study involved 34 feet for 33.7 months follow-up, compared to 28 feet for 27 months in this study. Moreover it is stated that recurrence related to Mitchell’s osteotomy reported by Glynn et al (2) as 12.5% compared to no recurrence associated with spike osteotomy. But the Glynn et al study included 72 operations with over 10 years follow-up, while the Mittal et al study included only 28 feet over a 27-month follow-up period. Terziz et al’s (3) study of the Gibson and Piggott osteotomy concluded that spike osteotomy is an effective method of treating mild hallux valgus deformities. But the Mittal et al study showed the spike osteotomy to be a suitable operation for treatment of mild to moderate hallux valgus deformities. We will be grateful if the author could clarify if the advance in the inclusion of moderate hallux valgus deformity was due to modification of the procedure. The plantar displacement of the metatarsal head prevents metatarsalgia and avoids the shortening of the metatarsal bone, both of which are advantages of the spike osteotomy; however, follow-up is too short to make conclusive statements regarding complication rates. EN Ramamoorthy, MRCS Royal Preston Hospital Preston, UK
R Amr, MRCS Royal Preston Hospital Preston, UK
References 1. Karataglis D, Dinley RJ, Kapetanos G. Comparative study between Wilson and Mitchell metatarsal osteotomies for the treatment of hallux valgus in adults. Acta Orthop Belg 67:149 –56, 2001. 2. Glynn MK, Dunlop JB, Fitzpatrick D. The Mitchell distal metatarsal osteotomy for hallux valgus. J Bone Joint Surg Br. 62-B:188 –91, 1980. 3. Terzis GD, Kashif F, Mowbray MA. The Mayday distal first metatarsal osteotomy for hallux valgus: a review after the introduction of a new instrument. Foot Ankle Int 18:3–7, 1997 Jan;18(1):3-7.
8. 9. 10. 11.
MJ, Shurnas PS, Alvarez F. Hallux valgus and first ray mobility: a cadaveric study. Foot Ankle Int 25:537–544, 2004. Lapidus PW. Operative correction of the metatarsus varus primus in hallux valgus. Surg Gynec Obst 58:183–191, 1934. Lapidus PW. A quarter century of experience with the operative correction of the metatarsus varus in hallux valgus. Bull Hosp Jt Dis Orthop Inst 17:404, 1956. Lapidus PW. The author’s bunion operation from 1931 to 1959. Clin Orthop 16:119, 1960. Sangeorzan BJ, Hansen ST Jr. Modified Lapidus procedure for hallux valgus. Foot Ankle 9:262–266, 1989. McInnes BD, Bouche RT. Critical evaluation of the modified Lapidus procedure. J Foot Ankle Surg 40:71–90, 2001. Patel S, Ford LA, Etcheverry J, Rush SM, Hamilton GA. Modified lapidus arthrodesis: rate of nonunion in 227 cases. J Foot Ankle Surg 43:37– 42, 2004.
Dear Editor: Justice Potter Stewart famously said of pornography: “I know it when I see it.” Such has been the case with hypermobility, but I would politely suggest that such ambiguity may not be best for our patients. It is for this reason that I read with great interest the descriptive article by Weber, Hatch, and Jensen regarding the “first ray splay” test in the July 2006 issue of The Journal of Foot & Ankle Surgery. There is little question that the term “hypermobility” is full of clinical ambiguity. It has created a challenge for those attempting a practical, but reproducible, operational definition. The present concept put forth by the authors is an elegant offshoot of Lapidus’ 70-year-old diagnostic technique. In the final paragraphs, the authors term this a “subjective” assessment. I would challenge the authors along with other clinicians and investigators to consider that this concept has the potential to be far more objective (assuming constant force is delivered through a digit or device) than most other similar clinical interrogations presently available. This, in turn, might have the ability to produce a more objective definition of when and how to choose between very different first ray procedures. David G. Armstrong, DPM, PhD Professor of Surgery and Associate Dean Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science Director Center for Lower Extremity Ambulatory Research (CLEAR) at Rosalind Franklin University of Medicine and Science North Chicago, IL
Dear Editor: The authors would like to thank Dr. Blitz and Dr. Armstrong for their respective responses to our article “Use of the First Ray Splay Test to Assess Transverse Plane Instability Prior to First Metatarsocuneiform Fusion,” which appeared in the July 2006 issue of The Journal of Foot & Ankle Surgery. The topic of first ray instability is certainly one which deserves good discourse, careful consideration, and further inquiry.
I am most interested in our collective quest for more knowledge and research on this topic. As Dr. Blitz mentions, excellent cadaveric studies have been published which illustrate various aspects of sagittal plane contribution to first ray motion. Further studies are needed to expand our understanding of transverse plane motion. Only through additional research will we truly be able to say what contribution transverse plane motion has on overall stability (or instability). With respect to the level of fusion beyond the first metatarsal-cuneiform joint, we certainly do not have a perfect answer when faced with this surgical dilemma. Our selection of fusion between the medial cuneiform and base of the second metatarsal was based on several observations. Radiographically, we noted that when a “gap” or diastasis was present, it was most often seen between the medial cuneiform and the base of the second metatarsal. Additionally, we found that the use of this particular orientation of the transfixation screw as well as the performance of the dowel fusion was technically reproducible and did not require additional dissection or tissue trauma. Lastly, this fixation point is furthest from the axis of the lever arm, therefore yielding the greatest effect. I agree with Dr. Blitz regarding the use of the naviculocuneiform fusion in a case of midfoot fault at this level. Again, further research including cadaveric studies and pressure plate data after various midfoot fusions is warranted. We thank both responders for their level of interest in this subject matter. Indeed, as Dr. Armstrong states, “This concept has the potential to be far more objective.” We hope to provide that data in forthcoming studies. Anna K. Weber Chicago, Illinois
Dear Editor: The article entitled “The Critical Analysis of Dudley Morton’s Concept of Disordered Foot Function” was of interest. The discussion regarding pressures under the ball of the foot was verification that a short and hypermobile first ray tends to increase pressure under the second metatarsal, a finding a surgeon quickly understands. The discussion, unfortunately, minimized the importance of the windlass mechanism as described by Hicks to fully appreciate the stability of the first ray. Without a windlass which produces stability of the foot structure in propulsion, the first ray will be unstable against weight-bearing forces, particularly as the heel everts and puts more pressure on the medial column of the foot. One can quickly see this in practice by maximally dorsiflexing the hallux and then only partially dorsiflexing the hallux. The resulting first ray instability of the latter maneuver can be readily appreciated. Once the windlass mechanism is looked at in more detail, I think this whole issue will become a lot more clear. Since this variable has been largely ignored by previous research, the picture
VOLUME 45, NUMBER 6, NOVEMBER/DECEMBER 2006
443
certainly does not clarify easily. If we truly see a person walking with maximal dorsiflexion of the first MTP joint (a clinical rarity in private practice) we seldom see foot pathology. A great majority of my patients never walk with that kind of stability of the foot structure. Once the windlass mechanism is allowed to function normally, the weightbearing patterns along the ball of the foot change dramatically as the first ray plantarflexes though propulsion. This not only changes the pressure pattern on the ball of the foot but has a significant impact on the trajectory of force. I think future research considering how the windlass mechanism is functioning in conjunction with plantar pressure assessment will help to clarify this issue quite a bit. Thanks to the authors for trying to clarify a very important concept. Sincerely, James G. Clough, DPM, FASFS Dear Editor: We have reviewed the letter from Dr. Clough regarding his questions about the importance of the windlass mechanism and first ray stability. Our critical analysis of the literature described the writings of Dudley J. Morton and reviewed the important research published on first ray mobility and related pathologies. Our search of the literature did not find much information regarding whether shortness of first ray might influence the windlass mechanism of the foot, but we believe the windlass mechanism is of major structural importance in providing stability to the first ray. Grebing and Coughlin (1) reported in a small number of patients that there was increased first ray mobility in patients who had previously undergone a plantar fasciectomy. Rush et al (2) reported that after first ray alignment, first ray mobility decreased substantially and attributed this to the plantar aponeurosis. We concur with Dr. Clough that research is needed to more fully explain the role of the windlass mechanism in stabilizing the foot during gait propulsion. It seems logical to conclude that shortness of the first metatarsal could reduce the moment arm effect around which the plantar fascia tightens during terminal stance, and, therefore, shortness of the first metatarsal could disrupt the windlass mechanics and diminish the capacity of the first ray to carry weight. However, as Grebing and Coughlin (3) reported, true shortness of the first ray is an uncommon occurrence. Ward Glasoe, MA, PT, ATC Michael J. Coughlin, MD References 1. Grebing BR, Coughlin MJ. The effect of ankle position on the exam for first ray mobility. Foot Ankle Int 25:467– 475, 2004. 2. Rush SM, Christensen JC, Johnson CH. Biomechanics of the first ray. Part II: metatarsus primus varus as a cause of hypermobility. A three-
444
THE JOURNAL OF FOOT & ANKLE SURGERY
dimensional kinematic analysis in the cadaver model. J Foot Ankle Surg 39:68 –77, 2000. 3. Grebing BR, Coughlin MJ. Evaluation of Morton’s theory of second metatarsal hypertrophy. J Bone Joint Surg 42-A:1375–1386, 2004.
Dear Editor: We have recently read the article, “The Spike Osteotomy for Hallux Valgus: A Clinical and Radiological Evaluation” in the July/August 2006 issue of The Journal of Foot and Ankle Surgery, and we would like to address the author’s comparison to Mitchell’s osteotomy. The percentage of postoperative metatarsalgia in the Kartataglis et al (1) study on Mitchell’s osteotomy is 11.8%, which is not far from the 8% post-metatarsalgia rate associated with the spike osteotomy noted in this study. The Karataglis et al study involved 34 feet for 33.7 months follow-up, compared to 28 feet for 27 months in this study. Moreover it is stated that recurrence related to Mitchell’s osteotomy reported by Glynn et al (2) as 12.5% compared to no recurrence associated with spike osteotomy. But the Glynn et al study included 72 operations with over 10 years follow-up, while the Mittal et al study included only 28 feet over a 27-month follow-up period. Terziz et al’s (3) study of the Gibson and Piggott osteotomy concluded that spike osteotomy is an effective method of treating mild hallux valgus deformities. But the Mittal et al study showed the spike osteotomy to be a suitable operation for treatment of mild to moderate hallux valgus deformities. We will be grateful if the author could clarify if the advance in the inclusion of moderate hallux valgus deformity was due to modification of the procedure. The plantar displacement of the metatarsal head prevents metatarsalgia and avoids the shortening of the metatarsal bone, both of which are advantages of the spike osteotomy; however, follow-up is too short to make conclusive statements regarding complication rates. EN Ramamoorthy, MRCS Royal Preston Hospital Preston, UK
R Amr, MRCS Royal Preston Hospital Preston, UK
References 1. Karataglis D, Dinley RJ, Kapetanos G. Comparative study between Wilson and Mitchell metatarsal osteotomies for the treatment of hallux valgus in adults. Acta Orthop Belg 67:149 –56, 2001. 2. Glynn MK, Dunlop JB, Fitzpatrick D. The Mitchell distal metatarsal osteotomy for hallux valgus. J Bone Joint Surg Br. 62-B:188 –91, 1980. 3. Terzis GD, Kashif F, Mowbray MA. The Mayday distal first metatarsal osteotomy for hallux valgus: a review after the introduction of a new instrument. Foot Ankle Int 18:3–7, 1997 Jan;18(1):3-7.