New Consensus Statement On Hallux Valgus Provides Collaboration And Clarity

A recent article in press in The Journal of Foot and Ankle Surgery presented the most recent American College of Foot and Ankle Surgeons’ Clinical Consensus Statement, looking at hallux valgus. An eight-member panel reviewed the available literature and provided opinions on a series of 13 statements. Of these, the panel determined that five statements were “appropriate,” including points regarding the nature of the condition, juvenile versus adult hallux valgus, radiographic evaluation, the impact of procedure selection on outcomes, and the role of physical medicine and rehabilitation in hallux valgus correction. Three statements related to procedural decision-making, biologic augmentation, and functional outcome measures resulted in a determination of “neither appropriate nor inappropriate.” The panel deemed one statement “inappropriate” (hallux valgus should only be addressed surgically with joint preserving procedures.). Lastly, the panelists did not come to a consensus on four statements.

The authors stress that this consensus is not meant as a formal guideline, evidence review, or recommendation, rather it aims to inspire discussion and a compilation of viewpoints and available evidence.

Caitlin S. Zarick, DPM, FACFAS, one of the consensus panelists, shares that the creation of such a statement on hallux valgus was a unique opportunity that allowed for reflection on information regarding the diagnosis and treatment of hallux valgus.

“The consensus statements open the door to discussion revolving around certain topics,” she explains. “I think the creation of clinical consensus statements are extremely important because they not only gather information from literature but also from the experience of the team creating the statements. It is important to understand how our colleagues are evaluating and treating hallux valgus and to combine that with what is supported in the literature. I think it is the mixture of this information that makes the clinical consensus statements worthwhile and important for the profession.”

Kwasi Y. Kwaadu, DPM, FACFAS, another panel member, says he was pleased to experience such openness from providers of all different backgrounds truly considering the information at hand.

“We have all been taught some things about hallux valgus during our graduate studies that are frankly pretty consistent from institution to institution, but not reliably consistent with our practice patterns,” he says.

Dr. Kwaadu adds that consensus statements such as this are foundations for growth for individual providers, and ultimately the medical community at-large.

Another panel member, Ellianne M. Nasser, DPM, FACFAS, relates that she found the statements where the panel was unable to reach a consensus particularly noteworthy, including:

• The natural course of the hallux valgus deformity might be interrupted with non-surgical interventions;

• The presence of first ray hypermobility directly affects the prognosis of the hallux valgus deformity and intervention outcome;

• Procedural selection for hallux valgus should be based on severity of the deformity; and

• The post-operative course for hallux valgus should involve a period of non-weightbearing immobilization.

“The inability to reach consensus on these statements emphasizes the controversial methods and theories behind treatment of hallux valgus,” she explains. “Some of these statements are consistent with current podiatric education, and the lack of consensus highlights a shift in modern podiatric surgical practice.”

Could Bilateral Computed Tomography Have An Impact On Subtle LisFranc Injuries?

By Jennifer Spector, DPM, FACFAS, Managing Editor

A recent study published in Archives of Orthopaedic and Trauma Surgery found that using bilateral foot computed tomography (CT) scans was a reliable and efficient choice in diagnosing and formulating a treatment plan for subtle LisFranc injuries. According to the study, clinicians miss around one in five of these injuries on plain radiographs.

The authors compared measurements on plain films and bilateral CTs with respect to diagnostic efficiency and surgical decision-making in patients with subtle LisFranc injury (n=30) that presented over a six-year period. They measured the distances between the medial cuneiform and the second metatarsal base, along with the distance between the first the second metatarsal bases. Researchers used greater than one mm of diastasis on CT scan as a surgical indication. Of the 30 patients studied, 24 underwent surgical treatment and six non-surgical treatment. The side-to-side difference of the cuneiform-metatarsal measurement was more sensitive than that of the intermetatarsal measurement.

H. John Visser, DPM, FACFAS points out that additional challenges with subtle LisFranc injuries include the attainment of fully weight-bearing AP and oblique films post-injury due to pain.

“Thus, often signs of diastasis are not present,” he explains. “Suspicion of a subtle LisFranc injury is always present when one presents with midfoot edema, even if minimal. However, a positive Hunter’s sign, (unable to go up on one’s toes) is indicative of a midfoot injury. Thus clinical “suspicion” is of utmost importance. Abduction stress views under anesthesia are of most help, but not normally convenient to perform.”

Accordingly, Dr. Visser feels this study could serve as a useful diagnostic tool, as he adds the comparative imaging does correspond to the injury involving the plantar portion of the LisFranc ligament.

“Diagnosis of this injury at initial presentation is critical,” says Dr. Visser, Director of Residency Training in Podiatric Surgery for DePaul SSM Health Center in St. Louis.

“With this testing of comparative CT, the diagnosis of medial cuneiform-to-second metatarsal diastasis can lead to the simple use of a “home run” screw. This avoids arthrodesis consideration and spares the patient of long-term disability.”

Might Textured Foot Orthoses Improve Gait For Those With Autism?

By Jennifer Spector, DPM, FACFAS, Managing Editor

A recent study in the Journal of Biomechanics revealed that textured foot orthoses reduced pressure under all the toes and the first metatarsal in boys with autism spectrum disorders (ASDs). Thirty boys, divided by the researchers into two groups (with and without ASD) contributed plantar pressure data during gait both with and without the use of textured foot orthoses. Higher peak force values in these same areas when not using the textured orthoses became evident, likely due to the tendency to toe-walk, according to the authors. The study researchers conclude that such orthotics could help boys with ASD move more safely.

Robert M. Conenello, DPM, FACFAS, a Global Clinical Advisor for the Special Olympics Fit Feet Program, notes that the differences evident when utilizing textured insoles for this cohort is a very important finding. However, he points out that in his experience, some patients with special needs may have increased sensory issues. In light of this, he recommends caution regarding long-term use of a textured insole, especially since the exact geography of the textured insole was not clear. He also feels that the authors’ suggestion that many patients with ASD are toe-walker is an unfounded generalization.

“I believe that clinicians need to treat their special needs patients as they would any other patient,” says Dr. Conenello, in practice in Orangeburg, NY. “Help educate the patient and their caregivers on foot strength, mobility, and proper shoe selection with lower drops and a wide toe box."