Authors' Reply to Letter to the Editor Meyr, Andrew J
The Journal of foot and ankle surgery,
2024 May-Jun, 2024-05-00, 20240501, Volume:
63, Issue:
3
Journal Article
This investigation aimed to better understand the complex relationship of common radiographic measurements performed during the perioperative evaluation of the hallux valgus deformity while ...accounting for interactions and potential interdependence. Several analyses utilizing the first intermetatarsal angle, hallux valgus angle, tibial sesamoid position, Engel's angle, subject age and subject gender were performed with varying independent and dependent variables. The hallux valgus angle (p < .001), tibial sesamoid position (p < .001), and Engel's angle (p < .001) were found to be independently associated with the first intermetatarsal angle. The first intermetatarsal angle (p < .001), tibial sesamoid position (p < .001), and Engel's angle (p < .001) were found to be independently associated with the hallux valgus angle. This suggests that there is significant interdependence of these variables during a preoperative radiographic examination. However, only the change in tibial sesamoid position (p < .001) was found to be independently associated with the change in the first intermetatarsal angle following surgical correction, while no studied variables were found to be independently associated with the change in hallux valgus angle following surgical correction. This suggests that correction of the intermetatarsal angle and tibial sesamoid position might not always reliably predict correction of the hallux valgus angle following surgical intervention. It might also suggest that additional procedures beyond metatarsal osteotomies are required to reliably correct the hallux valgus angle in some deformities. It is hoped that this investigation adds to the body of knowledge with respect to the perioperative radiographic evaluation of the hallux valgus deformity.
Critical analysis of the medical literature and an evidence-based approach to clinical practice and medical decision-making is of vital importance in contemporary podiatric practice. This article ...reviews the levels of clinical evidence and their application within this paradigm. This includes determining which level of evidence is most appropriate for a given methodology, as well as an appreciation of inherent limitations within each level of evidence. The article concludes with a discussion on the difference between statistical significance and clinical significance.
The finding of “hypermobility” has conventionally been considered as a dichotomous categorical variable in both clinical practice and in the literature. In other words, it is defined as being either ...“present” or “absent” in patients with hallux valgus. Yet it might be far more likely that this represents a continuous variable described by a bell-shaped distribution. Therefore the objective of this investigation was to consider hypermobility as a continuous variable, and to compare the sagittal plane first ray motion to radiographic parameters commonly used in the evaluation of the hallux valgus deformity by means of correlation analyses. The radiographs and measurements of 86 feet were included and measurement of sagittal plane first ray motion was performed with the validated Klaue device. No statistically significant correlation was observed between the total first ray motion with the first intermetatarsal angle (Pearson correlation coefficient 0.106; p = .333), hallux valgus angle (Pearson correlation coefficient −0.106; p = .330), nor sesamoid position (Pearson correlation coefficient 0.155; p = .157). The results of this investigation uniquely consider measurement of hypermobility as a continuous variable, and find no correlation between first ray sagittal plane motion and radiographic parameters associated with the hallux valgus deformity. These results might indicate that although the concept of hypermobility has traditionally been coupled with presentation of the hallux valgus deformity, this might simply represent the result of a historical confirmation bias.
Hallux valgus is a complex condition understood to involve pathomechanics in all 3 of the cardinal planes. Despite this, the bulk of its historical evaluation has been in the transverse plane, and ...one might argue that the traditional and more commonly performed univariate and bivariate analyses within the literature do not comprehensively describe the potential interrelationships between the planes during perioperative assessment. Therefore this investigation aimed to evaluate relationships between common radiographic parameters measured in the three cardinal planes by means of a multivariate regression analysis. Serial analyses utilizing the first intermetatarsal angle, hallux valgus angle, tibial sesamoid position, proximal articular set angle, Engel's angle, first metatarsal inclination angle, and the sesamoid rotation angle were performed with varying dependent and independent variables. The tibial sesamoid position (p < .001) and proximal articular set angle (p = .014) were found to be independently associated with the first intermetatarsal angle, while the hallux valgus angle (p = .712), Engel's angle (p = .646), first metatarsal inclination angle (p = .097), and sesamoid rotation angle (p = .099) were not. The tibial sesamoid position (p = .003), proximal articular set angle (p < .001), Engel's angle (p = .006), and sesamoid rotation angle (p = .003) were found to be independently associated with the hallux valgus angle, while the first intermetatarsal angle (p = .712) and first metatarsal inclination angle (p = .400) were not. The first intermetatarsal angle (p < .001), hallux valgus angle (p = .003), and proximal articular set angle (p = .015) were found to be independently associated with the tibial sesamoid position, while Engel's angle (p = .400), the first metatarsal inclination angle (p = .088), and the sesamoid rotation angle (p = .649) were not. These findings appear to question a direct relationship between the first intermetatarsal angle and hallux valgus angle, as well as potentially infer a relationship between the frontal plane with the hallux valgus angle.
Embracing Limitations Meyr, Andrew J.
The Journal of foot and ankle surgery,
January-February 2021, 2021 Jan-Feb, 2021-01-00, 20210101, Volume:
60, Issue:
1
Journal Article
A low-lying peroneus brevis muscle belly has been described as a risk factor for the development of peroneal tendon pathology, but this finding has primarily been described based on cohorts with ...pre-existing clinical findings. Therefore, the objective of this investigation was to evaluate the frequency of apparently abnormal low-lying muscle bellies from a series of subjects without clinical or imaging findings of peroneal tendon pathology. One hundred consecutive MRIs were reviewed with measurement of the distance from the distal peroneal myotendinous junction to the tip of the fibula. This distance was observed to be 23.9 ± 8.8 mm (10.8-55.4 mm; 95% confidence interval 22.2-26.7 mm). If one assumed that a myotendinous junction within 2 cm of the distal tip of fibula represented an abnormal low-lying muscle, then we observed 37% of extremities without clinical or radiographic evidence of peroneal tendon pathology that would be considered anatomically “abnormal.” When a low-lying muscle belly was defined as occurring within 2 cm of the distal tip of the fibula, then a probability analysis of our data distribution found a 32.6% probability for individuals to have an “abnormally” low-lying muscle belly. These results indicate that what has traditionally been defined intraoperatively as an abnormally low-lying peroneus brevis muscle belly might simply represent intraoperative confirmation bias of relatively normal structural anatomy.
Statistics is a set of tools used in medical decision-making no different than how a scalpel or a sagittal saw is used in the operating room. No foot and ankle surgeon is born with the inherent ...ability to perform, understand, and critically interpret them. Instead, it requires training and practice throughout the course of a career in medicine to develop a working proficiency. This article reviews the basic indications and interpretation of common descriptive and comparative statistical tests in the podiatric literature. Additionally, the concept of which tests are most appropriate for which investigational methodologies is introduced.
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