....I am in agreement with Dr Magoun1 that it is important, to correct pelvic dysfunctions before obtaining standing postural radiographs. This correction is, indeed, a necessary first step for postural radiographs to translate accurately a patient's leg length discrepancy into the sacral base unleveling that is measured using this technique. It is for this reason that—as I described in the three paragraphs before "Radiographic Findings" in my case report4—I note that the patient's pelvic dysfunction was corrected with restoration of pelvic symmetry before the postural radiographs were obtained.
I am fascinated by Dr Magoun's disregard for standard postural radiographs, which he refers to as "an unnecessary technicality" after pointing out the importance of administering osteopathic manipulative treatment before obtaining them.1 Although I congratulate Dr Magoun on his ability to prescribe heel lifts based solely on clinical evaluation, I will continue to use the quantitative measurement of sacral base unleveling to prescribe heel lifts, as described by Willman,5 Kuchera and Kuchera,6 and others.
Dr Alsager2,3 noted in his letters that, for postural radiographs to be valid, sacral base unleveling must be measured in reference to a vertical plumb line. The use of such a plumb line is an extremely important part of this technique. In my clinical practice, I use lead wire (like that used for tying flies for fishing), with a lead weight at the end, suspended from the ceiling, allowing gravity to provide a true vertical reference. Dr Alsager3 also expressed concern about the lack of a plumb line in the radiographic images shown in my case report.4 I would like to note that these radiographs were taken using a leveled bucky, and the markings and measurements in the radiographic images are merely representations of the actual markings and measurements used during evaluation of the patient.
Another concern expressed by Dr Alsager3 is important to discuss: where does the clinician draw the horizontal reference lines for femoral head height on a radiographic image when there is an artificial hip? And perhaps a more important, related question might also be asked: where does the clinician draw the vertical reference lines off the femoral heads when there is an artificial hip in the radiographic image? These are two conundrums to which I believe my case report4 provides ready solutions. ...
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