- Email: [email protected]
Lateral sesamoid position in hallux valgus: Correlation with the conventional radiological assessment
Foot and Ankle Surgery 17 (2011) 308–311
Contents lists available at ScienceDirect
Foot and Ankle Surgery journal homepage: www.elsevier.com/locate/fas
Lateral sesamoid position in hallux valgus: Correlation with the conventional radiological assessment Yuvraj Agrawal MBBS, MRCS*, Aravind Desai MS (Orth), MRCS, MSc, MCh (Orth), Jaysheel Mehta MS (Orth), MRCS, MCh (Orth), FRCSEd (Tr & Orth) Department of Trauma and Orthopaedics, Rochdale Infirmary, Rochdale, Lancashire, UK
A R T I C L E I N F O
A B S T R A C T
Article history: Received 13 May 2010 Received in revised form 4 December 2010 Accepted 8 January 2011
Background: We aimed to quantify the severity of the hallux valgus based on the lateral sesamoid position and to establish a correlation of our simple assessment method with the conventional radiological assessments. Methods: We reviewed one hundred and twenty two dorso-plantar weight bearing radiographs of feet. The intermetatarsal and hallux valgus angles were measured by the conventional methods; and the position of lateral sesamoid in relation to first metatarsal neck was assessed by our new and simple method. Results: Significant correlation was noted between intermetatarsal angle and lateral sesamoid position (Rho 0.74, p < 0.0001); lateral sesamoid position and hallux valgus angle (Rho 0.56, p < 0.0001). Similar trends were noted in different grades of severity of hallux valgus in all the three methods of assessment. Conclusions: Our method of assessing hallux valgus deformity based on the lateral sesamoid position is simple, less time consuming and has statistically significant correlation with that of the established conventional radiological measurements. ß 2011 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Hallux valgus Radiological assessment Lateral sesamoid
1. Introduction Hallux valgus is a common affliction that can lead to restrictions of daily and recreational activities, difficulty in fashion shoe wear and decreased quality of life [1]. Hallux valgus (HV) deformity is assessed both clinically and radiologically. Clinical assessment includes global assessment of the foot, pain over the medial exostosis, range of movements at the first metatarsophalangeal joint (MTP), callosities and deformity of the first ray. Radiological assessment involves measuring the intermetatarsal angle (IMA12), hallux valgus angle (HVA), distal metatarsal articular angle (DMMA) and congruity of the 1st MTP joint. The literature recommends grading of the severity of deformity and an appropriate surgical procedure according to the degree of hallux valgus [2]. Various attempts to quantify the severity of HV deformity have been made on weight-bearing dorsoplantar (AP) radiographs. Some of these studies are to stage the extent of metatarsosesamoid displacement [3–10]. Sesamoid subluxation away from
* Corresponding author at: Specialist Registrar Department of Trauma and Orthopaedics, Northern General Hospital, Herries Road, Sheffield, South Yorkshire S5 7AU, UK. Tel.: +44 7950693876. E-mail address: [email protected] (Y. Agrawal).
the head of the first metatarsal (MT) is usually indicative of HV deformity [3]. Medial sesamoid position correlation with HV has been studied before but with some difficulty in defining it through the overlying head of the first metatarsal [4–6]. The position of the lateral sesamoid (LS) in relation to the head of the first metatarsal and its correlation with HV deformity has never been studied before. The aim of our study was to assess the pattern of position of the LS in relation to the first metatarsal head and to quantify the severity of the deformity as assessed with conventional radiological techniques (IMA1-2 and HVA). We also evaluated the correlation between this quick and simple radiological assessment technique and the conventional radiological angles. 2. Materials and methods Target: A total of 146 consecutive patients who underwent dorsoplantar (AP) radiographs of their feet or foot over the period of three months (July to September 2008) were identified. After applying the exclusion criteria, 122 radiographs from 67 patients were studied. Weight bearing AP radiographs were taken in a standardised manner with central beam angled at 158 and targeted at the third metatarsal. Bilateral radiographs were taken with the central beam directed at the centre of the cassette. Exclusion criteria: All the patients less than 20 years of age, with radiological evidence of any previous surgery or injury to the foot
1268-7731/$ – see front matter ß 2011 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.fas.2011.01.001
Y. Agrawal et al. / Foot and Ankle Surgery 17 (2011) 308–311
and those with non-weight bearing radiographs of feet were excluded from the study. Intervention: All the X-ray films hence identified were evaluated using the Centricity1 Web v3.0 digital viewing system by the first author. The reference used for the assessment is the lateral cortical border of the flare of the head of the first metatarsal bone and the position of lateral sesamoid (LS). We graded the relative position of the LS as normal, mild, moderate and severe (Fig. 1 and Table 1) [1,11]. The conventional angles, namely, the intermetatarsal angle (IMA1-2) and hallux valgus angle (HVA) were measured along with this assessment (Fig. 2). IMA1-2 was measured as described by Miller [12], measuring the angle formed by drawing longitudinal lines bisecting the shafts of the first and the second MT (Table 2).
309
This technique has been shown to be the most accurate method in its measurement [13]. The hallux valgus angle (HVA) was measured by lines bisecting the shafts of the proximal phalanx of the great toe and the first MT (Table 2). Analysis: Initial statistical analysis showed that the cohort was unlikely from a normal distribution and hence a non-parametric test such as Shapiro–Wilcox test was used. Spearman’s rank correlation coefficient (Rho) was used to test linear relationship. Statsdirect v2.6.8 was used for statistical calculations. 3. Results A total of one hundred and twenty-two radiographs of sixtyseven patients were evaluated of which fifty-four (81%) were
Fig. 1. (a, b) Positions of lateral sesamoid (LS) in relation to the lateral border of the head of the 1st metatarsal.
Y. Agrawal et al. / Foot and Ankle Surgery 17 (2011) 308–311
310
Table 1 Severity grading on the basis of position of the lateral sesamoid (LS). Grade
Description
Normal Mild Moderate
LS lies medial to the lateral cortical border of the flare of the first metatarsal head 50% of the LS exposed lateral to the lateral cortical border of the first metatarsal head to the kissing of the medial border of the LS to the lateral cortical border Clear daylight passing via the space between LS and the lateral cortical border of the first metatarsal head
Severe
correlation between LSP and IMA1-2 was noted with a Spearman’s rank correlation coefficient Rho of 0.74 (p < 0.0001) and 95% confidence interval of 0.64–0.81. A good statistical correlation between LSP and HVA was also noted with a Spearman’s rank correlation coefficient Rho of 0.56 (p < 0.0001) and 95% confidence interval of 0.42–0.67. Similar trends of statistical correlation were noted within the different grades of severity as well in all the three assessments (Table 4). No statistical difference was found between the right and the left feet assessment. 4. Discussion
Fig. 2. Measurements of IMA1-2 (Miller’s technique) and HVA.
Table 2 The severity grading inter-metatarsal angle and hallux valgus angle [1,11]. Grade
Inter-metatarsal angle
Hallux valgus angle
Normal Mild Moderate Severe
<98 9–138 14–188 >188
=/<158 15–308 30–408 >408
females and thirteen (19%) males. The age range was between 22 and 84 years (mean 53.8 years SD 15.0). The mean values of the IMA1-2 were 7.68 0.8 SD for normal, 128 1.3 SD for mild, 15.88 1.2 SD for moderate and 20.38 1.6 SD for severe deformities. Likewise, the mean values of the HVA were 10.38 3.6 SD for normal, 238 4.3 SD for mild, 33.78 2.4 SD for moderate and 45.58 4.3 SD for severe deformities. The LS position (LSP) were evaluated as normal, mild moderate or severe (Table 3). Statistically significant correlation was noted between IMA1-2 and HVA with a Spearman’s rank correlation coefficient Rho of 0.62 (p < 0.0001) and 95% confidence interval of 0.48–0.70. High
Talbot and Saltzman [3] demonstrated that sesamoid subluxation off the head of the first metatarsal (MT) is indicative of HV deformity. It is now understood that during the progression of HV deformity, the head of the 1st MT drifts medially away from the sesamoids, whereas the sesamoids retain their anatomical relationship to the second MT [3,8,10]. The adductor hallucis tendon which inserts into the base of the proximal phalanx and the lateral sesamoid (LS), anchors the sesamoid complex. Consequently, no difference has been noted between the distance of the LS and second MT in patients with or without HV deformity [8,14] and pre and post distal osteotomy [15]. Defining the medial sesamoid through the overlapping first MT can be a challenge. Attempts have been made to establish a relationship between the amount of medial sesamoid (MS) subluxation and the severity of the HV deformity [4,5]. This was received with little enthusiasm because of difficulty in defining the MS on plain radiographs [6]. It was our observation that, due to the tendency of the first MT to drift medially and the LS to preserve its position, the LS is exposed further with progression of disease making it more obvious on the plain radiographs. Conventionally, it has been suggested that a tangential or axial sesamoid view should be obtained to assess the degree of sesamoid subluxation, particularly for congruent hallux valgus, in which the sesamoid can appear subluxated on the weightbearing AP radiograph, yet be anatomically reduced in their facets [1]. Kuwano et al. [6] compared the sesamoid rotation angle on the tangential sesamoid views to the AP views and concluded that the AP view was not valid for determining the grade of sesamoid position. Subsequently, Yildrim et al. [16] demonstrated a significant decrease in the sesamoid position with the increase in the dorsiflexion of MTP joint and hence proved the tangential views to be not reliable. Similar previous
Table 3 Results from evaluation of the radiographs using the conventional inter-metatarsal angle (IMA1-2), hallux valgus angle (HVA) and the described technique of assessment of position of the lateral sesamoid (LSP). Grade
Normal Mild Moderate Severe
IMA1-2
HVA
LSP
Degrees
N = 122
Measurements (mean SD)
Degrees
N = 122
Measurements (mean SD)
N = 122
<98 9–138 14–188 >188
22 44 42 14
6–9 (7.68 0.8) 9–13 (128 1.3) 14–18 (15.88 1.2) 18–25 (20.38 1.6)
<158 15–308 30–408 >408
30 57 25 10
2–15 15–30 30–39 40–54
16 38 49 19
(10.38 3.6) (238 4.3) (33.78 2.4) (45.58 4.3)
Y. Agrawal et al. / Foot and Ankle Surgery 17 (2011) 308–311
Table 4 Table showing statistical correlation between graded measurement (based on severity).
IMA vs HVA IMA vs LSP HVA vs LSP
Spearman’s rank correlation co-efficient (Rho)
Confidence interval (C.I.)
0.53 0.68 0.52
0.38–0.64 0.58–0.77 0.40–0.65
studies [3] showed little difference and satisfactory correlation between the positions of the sesamoids on the two different radiographs and hence we conducted this study using the standard AP radiographs. Coughlin and Freund [17] and Saltzman et al. [18] demonstrated that there is a very high inter-observer and intra-observer reliability within 5 degrees for measurement of the IMA1-2 (97%) and slightly less with HVA (86%). Our study has shown a high correlation between the IMA1-2 and LS position (Rho = 0.74, p < 0.0001). Hence, assessment of LS position in relation to the flare of first metatarsal head on a weight bearing AP radiograph should help clinicians to grade the severity of the HV deformity. This assessment is simple, less time consuming and correlates significantly with the IMA1-2. The correlation of LSP with HVA has been slightly less remarkable but still statistically significant. We had some reservations with this technique of assessment as it did not account for any pre-existing pes planus and pronation deformities. We do not consider it as a limitation of the technique as Saragas and Becker [14] have shown in their study that there is no association between these deformities and HV deformity. 5. Limitations of the study As this was a retrospective radiological study, clinical correlation was not studied. Patients with pre-existing inflammatory arthritis, infection or subtle neurological disorders may not have been excluded as their clinical notes were not evaluated.
311
Acknowledgments We acknowledge Dr Brian Derbyshire, Senior Statistician, Wrightington Hospital and Research Centre, Wigan, U.K., for his help with statistical analysis. References [1] Campbell J. In: Green Richardson, editor. Hallux valgus adult and juvenile in orthopaedic knowledge update—foot and ankle, vol. 3. AAOS; 2003. p. 3–15. [2] Robinson AHN, Limbers JP. Modern concepts in the treatment of hallux valgus. J Bone Joint Surg [B] 2005;87-B:1038–45. [3] Talbot KD, Saltzman CL. Assessing sesamoid subluxation: how good is the AP radiograph? Foot Ankle Int 1998;19:547–54. [4] Hardy RH, Clapham JCR. Observations on hallux valgus based on a controlled series. J Bone Joint Surg [B] 1951;33-B:376–91. [5] Coughlin MJ. Hallux valgus. J Bone Joint Surg [A] 1996;78-A:932–66. [6] Kuwano T, Nagamine R, Sakaki K, Urabe K, Iwamoto Y. New radiographic analysis of sesamoids rotation in hallux valgus: comparison with conventional evaluation methods. Foot Ankle Int 2002;23:811–7. [7] Smith RW, Reynolds JC, Stewart MJ. Hallux valgus assessment: report of research committee of American Orthopaedic Foot and Ankle Society. Foot Ankle 1984;5:92–103. [8] Mann RA, Coughlin MJ. Hallux valgus—etiology, anatomy, treatment and surgical considerations. Clin Orthop Relat Res 1981;157:31–41. [9] Rosenbaum de Britto S. The first metatarso-sesamoid joint. Int Orthop 1982;6:61–7. [10] Silver D. The operative treatment of hallux valgus. J Bone Joint Surg [A] 1923;5A:225–32. [11] Mann RA. Decision making in bunion surgery. Instr Course Lect 1990;39:3. [12] Miller JW. Distal first metatarsal displacement osteotomy: its place in the scheme of bunion surgery. J Bone Joint Surg [A] 1974;56-A:923–31. [13] Vo HV, Safiedine AM, Short T, Merrill T. A comparison of 4 common methods of hand-measured techniques with a computerized technique to measure the first intermetatarsal angle. J Foot Ankle Surg 2004;43(6):395–9. [14] Saragas NP, Becker JB. Comparative radiographic analysis of parameters in feet with and without hallux valgus. Foot Ankle Int 1995;16:139–43. [15] Esemenll T, Yildrim Y, Bezer M. Lateral shifting of the first metatarsal head in hallux valgus surgery: Effect on sesamoid reduction. Foot Ankle Int 2003;24:922–6. [16] Yildrim Y, C¸abukoglu C, Erol B, Esemenlli T. Effect of metatarsophalangeal position on the reliability of the tangential sesamoid view in determining sesamoid position. Foot Ankle Int 2005;26:247–50. [17] Coughlin MJ, Freund E. The reliability of angular measurements in hallux valgus deformities. Foot Ankle Int 2001;22:369–79. [18] Saltzman C, Brandser E, Berbaum K, DeGnore L, Holmes J, Katcherian D, et al. Reliability of standard foot radiographic measurements. Foot Ankle Int 1994;15:661–5.
Contents lists available at ScienceDirect
Foot and Ankle Surgery journal homepage: www.elsevier.com/locate/fas
Lateral sesamoid position in hallux valgus: Correlation with the conventional radiological assessment Yuvraj Agrawal MBBS, MRCS*, Aravind Desai MS (Orth), MRCS, MSc, MCh (Orth), Jaysheel Mehta MS (Orth), MRCS, MCh (Orth), FRCSEd (Tr & Orth) Department of Trauma and Orthopaedics, Rochdale Infirmary, Rochdale, Lancashire, UK
A R T I C L E I N F O
A B S T R A C T
Article history: Received 13 May 2010 Received in revised form 4 December 2010 Accepted 8 January 2011
Background: We aimed to quantify the severity of the hallux valgus based on the lateral sesamoid position and to establish a correlation of our simple assessment method with the conventional radiological assessments. Methods: We reviewed one hundred and twenty two dorso-plantar weight bearing radiographs of feet. The intermetatarsal and hallux valgus angles were measured by the conventional methods; and the position of lateral sesamoid in relation to first metatarsal neck was assessed by our new and simple method. Results: Significant correlation was noted between intermetatarsal angle and lateral sesamoid position (Rho 0.74, p < 0.0001); lateral sesamoid position and hallux valgus angle (Rho 0.56, p < 0.0001). Similar trends were noted in different grades of severity of hallux valgus in all the three methods of assessment. Conclusions: Our method of assessing hallux valgus deformity based on the lateral sesamoid position is simple, less time consuming and has statistically significant correlation with that of the established conventional radiological measurements. ß 2011 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Hallux valgus Radiological assessment Lateral sesamoid
1. Introduction Hallux valgus is a common affliction that can lead to restrictions of daily and recreational activities, difficulty in fashion shoe wear and decreased quality of life [1]. Hallux valgus (HV) deformity is assessed both clinically and radiologically. Clinical assessment includes global assessment of the foot, pain over the medial exostosis, range of movements at the first metatarsophalangeal joint (MTP), callosities and deformity of the first ray. Radiological assessment involves measuring the intermetatarsal angle (IMA12), hallux valgus angle (HVA), distal metatarsal articular angle (DMMA) and congruity of the 1st MTP joint. The literature recommends grading of the severity of deformity and an appropriate surgical procedure according to the degree of hallux valgus [2]. Various attempts to quantify the severity of HV deformity have been made on weight-bearing dorsoplantar (AP) radiographs. Some of these studies are to stage the extent of metatarsosesamoid displacement [3–10]. Sesamoid subluxation away from
* Corresponding author at: Specialist Registrar Department of Trauma and Orthopaedics, Northern General Hospital, Herries Road, Sheffield, South Yorkshire S5 7AU, UK. Tel.: +44 7950693876. E-mail address: [email protected] (Y. Agrawal).
the head of the first metatarsal (MT) is usually indicative of HV deformity [3]. Medial sesamoid position correlation with HV has been studied before but with some difficulty in defining it through the overlying head of the first metatarsal [4–6]. The position of the lateral sesamoid (LS) in relation to the head of the first metatarsal and its correlation with HV deformity has never been studied before. The aim of our study was to assess the pattern of position of the LS in relation to the first metatarsal head and to quantify the severity of the deformity as assessed with conventional radiological techniques (IMA1-2 and HVA). We also evaluated the correlation between this quick and simple radiological assessment technique and the conventional radiological angles. 2. Materials and methods Target: A total of 146 consecutive patients who underwent dorsoplantar (AP) radiographs of their feet or foot over the period of three months (July to September 2008) were identified. After applying the exclusion criteria, 122 radiographs from 67 patients were studied. Weight bearing AP radiographs were taken in a standardised manner with central beam angled at 158 and targeted at the third metatarsal. Bilateral radiographs were taken with the central beam directed at the centre of the cassette. Exclusion criteria: All the patients less than 20 years of age, with radiological evidence of any previous surgery or injury to the foot
1268-7731/$ – see front matter ß 2011 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.fas.2011.01.001
Y. Agrawal et al. / Foot and Ankle Surgery 17 (2011) 308–311
and those with non-weight bearing radiographs of feet were excluded from the study. Intervention: All the X-ray films hence identified were evaluated using the Centricity1 Web v3.0 digital viewing system by the first author. The reference used for the assessment is the lateral cortical border of the flare of the head of the first metatarsal bone and the position of lateral sesamoid (LS). We graded the relative position of the LS as normal, mild, moderate and severe (Fig. 1 and Table 1) [1,11]. The conventional angles, namely, the intermetatarsal angle (IMA1-2) and hallux valgus angle (HVA) were measured along with this assessment (Fig. 2). IMA1-2 was measured as described by Miller [12], measuring the angle formed by drawing longitudinal lines bisecting the shafts of the first and the second MT (Table 2).
309
This technique has been shown to be the most accurate method in its measurement [13]. The hallux valgus angle (HVA) was measured by lines bisecting the shafts of the proximal phalanx of the great toe and the first MT (Table 2). Analysis: Initial statistical analysis showed that the cohort was unlikely from a normal distribution and hence a non-parametric test such as Shapiro–Wilcox test was used. Spearman’s rank correlation coefficient (Rho) was used to test linear relationship. Statsdirect v2.6.8 was used for statistical calculations. 3. Results A total of one hundred and twenty-two radiographs of sixtyseven patients were evaluated of which fifty-four (81%) were
Fig. 1. (a, b) Positions of lateral sesamoid (LS) in relation to the lateral border of the head of the 1st metatarsal.
Y. Agrawal et al. / Foot and Ankle Surgery 17 (2011) 308–311
310
Table 1 Severity grading on the basis of position of the lateral sesamoid (LS). Grade
Description
Normal Mild Moderate
LS lies medial to the lateral cortical border of the flare of the first metatarsal head 50% of the LS exposed lateral to the lateral cortical border of the first metatarsal head to the kissing of the medial border of the LS to the lateral cortical border Clear daylight passing via the space between LS and the lateral cortical border of the first metatarsal head
Severe
correlation between LSP and IMA1-2 was noted with a Spearman’s rank correlation coefficient Rho of 0.74 (p < 0.0001) and 95% confidence interval of 0.64–0.81. A good statistical correlation between LSP and HVA was also noted with a Spearman’s rank correlation coefficient Rho of 0.56 (p < 0.0001) and 95% confidence interval of 0.42–0.67. Similar trends of statistical correlation were noted within the different grades of severity as well in all the three assessments (Table 4). No statistical difference was found between the right and the left feet assessment. 4. Discussion
Fig. 2. Measurements of IMA1-2 (Miller’s technique) and HVA.
Table 2 The severity grading inter-metatarsal angle and hallux valgus angle [1,11]. Grade
Inter-metatarsal angle
Hallux valgus angle
Normal Mild Moderate Severe
<98 9–138 14–188 >188
=/<158 15–308 30–408 >408
females and thirteen (19%) males. The age range was between 22 and 84 years (mean 53.8 years SD 15.0). The mean values of the IMA1-2 were 7.68 0.8 SD for normal, 128 1.3 SD for mild, 15.88 1.2 SD for moderate and 20.38 1.6 SD for severe deformities. Likewise, the mean values of the HVA were 10.38 3.6 SD for normal, 238 4.3 SD for mild, 33.78 2.4 SD for moderate and 45.58 4.3 SD for severe deformities. The LS position (LSP) were evaluated as normal, mild moderate or severe (Table 3). Statistically significant correlation was noted between IMA1-2 and HVA with a Spearman’s rank correlation coefficient Rho of 0.62 (p < 0.0001) and 95% confidence interval of 0.48–0.70. High
Talbot and Saltzman [3] demonstrated that sesamoid subluxation off the head of the first metatarsal (MT) is indicative of HV deformity. It is now understood that during the progression of HV deformity, the head of the 1st MT drifts medially away from the sesamoids, whereas the sesamoids retain their anatomical relationship to the second MT [3,8,10]. The adductor hallucis tendon which inserts into the base of the proximal phalanx and the lateral sesamoid (LS), anchors the sesamoid complex. Consequently, no difference has been noted between the distance of the LS and second MT in patients with or without HV deformity [8,14] and pre and post distal osteotomy [15]. Defining the medial sesamoid through the overlapping first MT can be a challenge. Attempts have been made to establish a relationship between the amount of medial sesamoid (MS) subluxation and the severity of the HV deformity [4,5]. This was received with little enthusiasm because of difficulty in defining the MS on plain radiographs [6]. It was our observation that, due to the tendency of the first MT to drift medially and the LS to preserve its position, the LS is exposed further with progression of disease making it more obvious on the plain radiographs. Conventionally, it has been suggested that a tangential or axial sesamoid view should be obtained to assess the degree of sesamoid subluxation, particularly for congruent hallux valgus, in which the sesamoid can appear subluxated on the weightbearing AP radiograph, yet be anatomically reduced in their facets [1]. Kuwano et al. [6] compared the sesamoid rotation angle on the tangential sesamoid views to the AP views and concluded that the AP view was not valid for determining the grade of sesamoid position. Subsequently, Yildrim et al. [16] demonstrated a significant decrease in the sesamoid position with the increase in the dorsiflexion of MTP joint and hence proved the tangential views to be not reliable. Similar previous
Table 3 Results from evaluation of the radiographs using the conventional inter-metatarsal angle (IMA1-2), hallux valgus angle (HVA) and the described technique of assessment of position of the lateral sesamoid (LSP). Grade
Normal Mild Moderate Severe
IMA1-2
HVA
LSP
Degrees
N = 122
Measurements (mean SD)
Degrees
N = 122
Measurements (mean SD)
N = 122
<98 9–138 14–188 >188
22 44 42 14
6–9 (7.68 0.8) 9–13 (128 1.3) 14–18 (15.88 1.2) 18–25 (20.38 1.6)
<158 15–308 30–408 >408
30 57 25 10
2–15 15–30 30–39 40–54
16 38 49 19
(10.38 3.6) (238 4.3) (33.78 2.4) (45.58 4.3)
Y. Agrawal et al. / Foot and Ankle Surgery 17 (2011) 308–311
Table 4 Table showing statistical correlation between graded measurement (based on severity).
IMA vs HVA IMA vs LSP HVA vs LSP
Spearman’s rank correlation co-efficient (Rho)
Confidence interval (C.I.)
0.53 0.68 0.52
0.38–0.64 0.58–0.77 0.40–0.65
studies [3] showed little difference and satisfactory correlation between the positions of the sesamoids on the two different radiographs and hence we conducted this study using the standard AP radiographs. Coughlin and Freund [17] and Saltzman et al. [18] demonstrated that there is a very high inter-observer and intra-observer reliability within 5 degrees for measurement of the IMA1-2 (97%) and slightly less with HVA (86%). Our study has shown a high correlation between the IMA1-2 and LS position (Rho = 0.74, p < 0.0001). Hence, assessment of LS position in relation to the flare of first metatarsal head on a weight bearing AP radiograph should help clinicians to grade the severity of the HV deformity. This assessment is simple, less time consuming and correlates significantly with the IMA1-2. The correlation of LSP with HVA has been slightly less remarkable but still statistically significant. We had some reservations with this technique of assessment as it did not account for any pre-existing pes planus and pronation deformities. We do not consider it as a limitation of the technique as Saragas and Becker [14] have shown in their study that there is no association between these deformities and HV deformity. 5. Limitations of the study As this was a retrospective radiological study, clinical correlation was not studied. Patients with pre-existing inflammatory arthritis, infection or subtle neurological disorders may not have been excluded as their clinical notes were not evaluated.
311
Acknowledgments We acknowledge Dr Brian Derbyshire, Senior Statistician, Wrightington Hospital and Research Centre, Wigan, U.K., for his help with statistical analysis. References [1] Campbell J. In: Green Richardson, editor. Hallux valgus adult and juvenile in orthopaedic knowledge update—foot and ankle, vol. 3. AAOS; 2003. p. 3–15. [2] Robinson AHN, Limbers JP. Modern concepts in the treatment of hallux valgus. J Bone Joint Surg [B] 2005;87-B:1038–45. [3] Talbot KD, Saltzman CL. Assessing sesamoid subluxation: how good is the AP radiograph? Foot Ankle Int 1998;19:547–54. [4] Hardy RH, Clapham JCR. Observations on hallux valgus based on a controlled series. J Bone Joint Surg [B] 1951;33-B:376–91. [5] Coughlin MJ. Hallux valgus. J Bone Joint Surg [A] 1996;78-A:932–66. [6] Kuwano T, Nagamine R, Sakaki K, Urabe K, Iwamoto Y. New radiographic analysis of sesamoids rotation in hallux valgus: comparison with conventional evaluation methods. Foot Ankle Int 2002;23:811–7. [7] Smith RW, Reynolds JC, Stewart MJ. Hallux valgus assessment: report of research committee of American Orthopaedic Foot and Ankle Society. Foot Ankle 1984;5:92–103. [8] Mann RA, Coughlin MJ. Hallux valgus—etiology, anatomy, treatment and surgical considerations. Clin Orthop Relat Res 1981;157:31–41. [9] Rosenbaum de Britto S. The first metatarso-sesamoid joint. Int Orthop 1982;6:61–7. [10] Silver D. The operative treatment of hallux valgus. J Bone Joint Surg [A] 1923;5A:225–32. [11] Mann RA. Decision making in bunion surgery. Instr Course Lect 1990;39:3. [12] Miller JW. Distal first metatarsal displacement osteotomy: its place in the scheme of bunion surgery. J Bone Joint Surg [A] 1974;56-A:923–31. [13] Vo HV, Safiedine AM, Short T, Merrill T. A comparison of 4 common methods of hand-measured techniques with a computerized technique to measure the first intermetatarsal angle. J Foot Ankle Surg 2004;43(6):395–9. [14] Saragas NP, Becker JB. Comparative radiographic analysis of parameters in feet with and without hallux valgus. Foot Ankle Int 1995;16:139–43. [15] Esemenll T, Yildrim Y, Bezer M. Lateral shifting of the first metatarsal head in hallux valgus surgery: Effect on sesamoid reduction. Foot Ankle Int 2003;24:922–6. [16] Yildrim Y, C¸abukoglu C, Erol B, Esemenlli T. Effect of metatarsophalangeal position on the reliability of the tangential sesamoid view in determining sesamoid position. Foot Ankle Int 2005;26:247–50. [17] Coughlin MJ, Freund E. The reliability of angular measurements in hallux valgus deformities. Foot Ankle Int 2001;22:369–79. [18] Saltzman C, Brandser E, Berbaum K, DeGnore L, Holmes J, Katcherian D, et al. Reliability of standard foot radiographic measurements. Foot Ankle Int 1994;15:661–5.