01/05/2023    Robert D. Phillips, DPM

Study of 1,583 Scarf Osteotomies Uncovers Outcome Stats (David Secord, DPM)

I note the discussion in the last couple of days
about recurrence rates after hallux valgus surgery.
This discussion makes me reflect on some recent
actions in our profession's residency education
standards.

The question has to be asked, what is an acceptable
recurrence rate? If it is 1/1000 or 5/100? If I
am one of the patients in which it occurs, I don't
care what the recurrence rate is. the fact that it
happened to me is of primary importance and I want
to know why. I also expect that the person who
performed the surgery also wants to know why. Did
that person do any type of exam before surgery
besides take a couple of x-rays on my feet?

As we look at the literature that examines success
rate or any type of hallux valgus surgery, we find
almost none are concerned with the etiology of
hallux hallux valgus. Almost all assume that all
hallux valgus deformities have a single etiology or
occur in a single type of foot. Yet any
experienced practitioner knows that hallux valgus
can occur in flat feet, feet with fairly normal
appearing arches, and in feet that are high arched.
Why do some flat feet develop hallux valgus and
some do not? This is never discussed. What is the
function of the feet that have recurrence and those
that do not? What studies have looked at this?
What was the pre-op function of those feet that had
recurrence and those that did not.

The biomechanical exam is intended to identify the
etiology of deformities such as hallux valgus. It
is not what we do before making something that goes
inside a shoe. It is composed of a goniometric
exam, a muscle testing exam and a functional exam.
The functional exam should include a videogait
analysis. Every practitioner today has in their
pocket a slow motion video recorder to make a
video gait analysis - on which they also make all
their phone calls. It would also be additionally
helpful to have a pedobarograph exam before the
surgery. Weightbearing CT is also a new technology
that may help identify function though in in a
static situation.

I am amazed at how much very expensive hardware
physicians use in trying to get good surgical
results, yet they do not take the time to really
examine the function of the foot before surgery and
they don't take time to examine the function of the
foot after surgery. If they do provide some type
of supportive therapy for the foot after surgery,
how many have annual followup exams to see if the
supportive therapy is working? I remember well a
discussion with Dr. Bill Orien (one of the
coauthors of Root's books) when he explained that
he started attending lectures on biomechanics given
by Dr. Root because he wanted better surgical
results. He was not really interested in making a
better arch support.

This last year, CPME 320 document was revised and
the required biomechanical examinations were
reduced from 75 to 50. It was stated by the head
of the committee this was in response to the
desires of the community of interest. I find it
interesting that the so called community of
interest no longer is really interested in the
etiology of hallux valgus, only in "fixing" it. I
note that there are a handful of residency programs
that do require more biomechanical exams of its
graduates, that seem to be as interested in their
graduates trying to understand the etiology and the
end result and not just being a good surgical
technician.

Even though the 320 document may have lowered the
requirements for biomechanical examinations, I
would encourage all program directors to set a
higher standard. In my opinion, a biomechanical
exam should be an integral part of almost every
pre-operative workup for an elective procedure and
there should also be a biomechanical exam on a good
percentage of post-op patients. The biomechanical
exam, should be considered to be at least as
important as the non-invasive vascular exam. How
many physicians have fancy NIV equipment and yet
don't have the simple equipment to do a goniometric
and gait exam? How many have pedobarograph
equipment? How many do weightbearing CT exams?

We see that podiatric school applicant numbers are
declining and we have to ask the question why. Are
we providing a better service to our patients than
anyone else can provide? Each practitioner should
ask themselves whether they would rather have their
bunion surgery performed by a physician who did a
full biomechanical exam including video gait
analysis, pedobarographic exam before and after
surgery or one who does not. If we do not, are we
putting time-limits, and insurance payments ahead
of patient interests? That is a question that each
must answer. If I am a prospective student, why
should I go to podiatry school rather than get an
MD/DO degree and then become a foot and ankle
surgeon? For those who want to be called, "foot
surgeons" rather than "podiatrists" are they
putting perceived status ahead of actual knowledge
and understanding that will lead to prevention and
to preventing recurrence?

Each practitioner has to ask these questions to
their own selves. If we really do our job, then we
have the opportunity of moving forward to a point
that these discussions about reoccurance rates of
hallux valgus will become a relic of the past.

Robert D. Phillips, DPM, Orlando, FL

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