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20-02-2013 | Surgery | Article

Optimal preoperative hallux valgus assessment unclear


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medwireNews: Podiatrists lack guidance on the best way to use preoperative radiographs of hallux valgus, research suggests.

A survey of 28 podiatrists working in UK departments of podiatric surgery showed unanimous use of radiographs before the procedure, with 61% assessing digital, 7% film, and 32% both types of images.

However, only 71% of podiatrists took measurements from radiographs when planning the procedure.

"It would, therefore, appear that the assessment of alignment for 29% could be either subjective or determined using an alternative clinical assessment method," say John Malik (Netherton Health Centre, Dudley, UK) and Ian Mathieson (Cardiff Metropolitan University, UK).

"Although issues exist regarding the repeatability of radiographic measurements, objective measurements could well be advisable when evidencing decision making in this area of surgery."

All podiatrists who took measurements used the first intermetatarsal angle (IMA) to inform their procedure choice. Procedures became more proximal within the first metatarsal with increasing IMA, but none of the respondents said that they always based their decision on this measurement.

Just over half (54%) of respondents thought the IMA was a reliable measurement, but the researchers note that previous studies indicate a lack of standardized technique on taking this measurement and a significant level of error in the findings.

"An alternative approach, especially when taking into account the use of digital imaging, which facilitates calibration, might be to simply measure the distance between the first and second metatarsal, the 'intermetatarsal distance,'" the investigators say. "Ideally, the measure made should not only influence procedure selection, but also aid effective procedure execution in the clinical setting."

Among podiatrists using measurements, 90% also used the sesamoid position, with other measurements taken by 10-70% of respondents.

"Evidence has certainly shown that the sesamoid position postoperatively can influence deformity recurrence, and because the first metatarsal is bisected for measurement of the IMA already, the sesamoid position would appear to be a logical additional measurement," comment Malik and Mathieson in the Journal of Foot and Ankle Surgery.

Nevertheless, noting that none of the podiatrists were satisfied with their current method of radiographic assessment, the researchers conclude that their study highlights the need for additional research to establish evidence-based protocols for preoperative decision-making.

medwireNews ( is an independent clinical news service provided by Springer Healthcare Limited. © Springer Healthcare Ltd; 2013

By Lynda Williams, Senior medwireNews Reporter

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