I recently read an excellent article in Foot and Ankle International entitled “Evidence-Based Medicine: What Is It And How Should It Be Used?”1 The article begins with a brilliant quote from Spindler and colleagues:
Traditionally, dogma has ruled the education of physicians: one need only recall the authoritative professor who by his name or her stature alone influenced how we evaluate and examine our patients. Despite the view that we rely on science to guide our approach to patients and to treatment decision making, physicians frequently change their practice based on the opinions of charismatic and dogmatic (albeit usually experienced) authority figures … Although often correct these changes in the practice of orthopaedics likely are influenced more by the volume of the authority’s voice and the persuasiveness of his or her tone than by the scientific validity of the message. During the last decade, a quiet revolution has rapidly been gaining momentum that will undoubtedly change the way that orthopaedics is being practiced. This movement is evidence-based medicine.2
It is refreshing to see that podiatric literature is embracing the trend toward evidence-based reporting of outcomes. This becomes particularly important when we are seeking valid information about surgical outcomes. As we are bombarded with new technologies promoted by commercial entities, it becomes critical that we step back and ask for high-level studies that verify that these technologies work, and that negative effects and contraindications have been clearly identified.
I have previously written about hallux rigidus, a condition that continues to challenge me in my own practice. I am grateful for the previous work of Tom Roukis, DPM, PhD, FACFAS, who recently published the fourth of his systematic reviews of various surgical procedures to treat hallux rigidus.3 This most recent review focused on clinical outcomes after isolated periarticular osteotomies of the first metatarsal for hallux rigidus. He reviewed four studies that involved a prospective design and included some form of subjective and objective data analysis with at least a 12-month duration of follow-up.
In the same issue of the Journal of Foot and Ankle Surgery, Brewster presents a systematic review comparing outcomes of total joint replacement and arthrodesis of the first metatarsophalangeal joint in the treatment of hallux rigidus.4 Brewster limited his review to papers that utilized the American Orthopaedic Foot and Ankle Society-Hallux Metatarsophalangeal Interphalangeal (AOFAS-HMI) scale to evaluate postoperative results. The systematic review used a total of five papers that evaluated results from arthrodesis and five papers that evaluated results from total joint replacement.
These two systematic reviews reaffirm my own experience in 30 years of surgical treatment of hallux rigidus. Total joint replacement is still unproven as a reliable procedure, especially in the athletic patient. Periarticular osteotomies have a high rate of postoperative metatarsalgia and need for revisional surgery. For grade I and II hallux rigidus conditions, isolated cheilectomy or in combination with phalangeal dorsiflexory osteotomy have excellent results with low rates of revisional surgery. Finally, arthrodesis of the first metatarsophalangeal joint appears to be an effective treatment for grade III and IV hallux rigidus with a very low rate of revisional surgery and high patient satisfaction.
None of the studies included in these systematic reviews are of the quality of “gold standard” evidence, which would be a multi-center double-blind randomized controlled trial. A study of this design would be nearly impossible to perform on patients with hallux rigidus. Both Roukis and Brewster point out the need for further studies that are closer to this gold standard and that will provide better standards for objective evaluation with long-term follow-up.3,4
Still, it is refreshing and extremely enlightening to see quality systematic reviews published in the podiatric literature that provide keen insight into treatment options for challenging pathologies. Now, instead of embracing the gospel proposed by charismatic and dogmatic authority figures, we can demand a higher level of reasoning, which is the essence of evidence-based medicine.
1. Pinney S, Glazebrook M, Baumhauer J, Thordarson DB, Richter M. Evidence-based medicine: What is it and how should it be used? Foot Ankle Int. 2010; 31(11):1033-1042.
2. Spindler KP, Kuhn JE, Dunn W, et al. Reading and reviewing the orthopaedic literature: A systematic, evidence-based medicine approach. J Am Acad Orthop Surg. 2005; 12(4):220-229.
3. Roukis TS. Clinical outcomes after isolated periarticular osteotomies of the first metatarsal for hallux rigidus: A systematic review. J Foot Ankle Surg. 2010; 49(6):553-560.
4. Brewster M. Does total joint replacement or arthrodesis of the first metatarsophalangeal joint yield better functional results? A systematic review of the literature. J Foot Ankle Surg. 2010; 49(6):546-552.