Surgeon point of view



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Surgeon point of view

  • Surgeon point of view

    • Congruent joint
    • Joint space (degenerative joint disease)
    • Metatarsal length


Patient point of view:

  • Patient point of view:

    • No bump
    • Straight toe
    • Cosmetic scar
    • Good motion…enough to wear high hell
    • No pain
    • Almost: restituo ad integrum…


Stretching the indications (too big deformity for the procedure)

  • Stretching the indications (too big deformity for the procedure)

  • Wrong procedure for the problem

  • Bad technique of an adequate procedure

    • Inadequate Medial capsule plication
    • Inadequate soft tissue release ( Transverse lig., ADD.H.)
    • Inadequate post-op. dressing


An expected complication for that procedure

  • An expected complication for that procedure

  • A complication non specific to the procedure

  • A misunderstanding of the expected results

  • …….Patient versus Surgeon expectation….



Complications after distal metatarsal osteotomy

  • Complications after distal metatarsal osteotomy

  • Complications after proximal osteotomy

  • Complication after Scarf osteotomy

  • Complications after Lapidus procedure

  • Complication after Keller Resection Arthroplasty



Complications after distal metatarsal osteotomy

  • Complications after distal metatarsal osteotomy

  • Complications after proximal osteotomy

  • Complication after Scarf osteotomy

  • Complications after Lapidus procedure

  • Complication after Keller Resection Arthroplasty





Recurrent deformity

  • Recurrent deformity

  • Malunion

  • Stiffness

  • Avascular necrosis



Recurrent deformity

  • Recurrent deformity

  • Malunion

  • Stiffness

  • Avascular necrosis



1. Plane of osteotomy

  • 1. Plane of osteotomy

  • 2. DMAA

  • 3. Too big deformity for the procedure

  • 4. Loose capsulorraphy

  • 5. …Lateral soft tissue release



Avoid:

  • Avoid:

    • Doing the osteotomy in line at right angle with the first metatarsal;
    • It is more unstable et tend to go back to it’s previous position
    • Tend to  the bone length
    • (Stiffness)
  • Instead : the osteotomy should be done at right angle to the foot

  • But: Avoid shortening



Here the osteotomy was done to done in the axis of the bone, instead of the foot:

  • Here the osteotomy was done to done in the axis of the bone, instead of the foot:

    • Result: 4 weeks post-op: distal fragment back to it’s original position
  • So if needed to lenghten the bone: a good fixation needed

  • Remove the Medial Eminence

  • parallel to the foot, not the metatarsal.



Primo:

  • Primo:

    • RECOGNIZE
  • Danger:

    • Make a straight toe with an incongruent joint out of a valgus toe but congruent joint
    • With time will displace


  • HV angle < 30 °

  • IM angle < 14 °



Tension should be just enough to prevent lateral displacement

  • Tension should be just enough to prevent lateral displacement

    • With Akin : no over correction
    • Without Akin : minimal overcorrection
  • But Too tight capsulorraphy might lead to stiffness.





Multiple studies:

  • Multiple studies:

  • STR with distal osteotomy : Safe

  • Incidence of AVN is so low, ≤ 1 % (periosteal stripping is more a concern),

  • Most expert : Caution… if a STR is needed

  • The indication is probably stretch… * Proximal osteotomy …

  • * Adding a Akin procedure are safer.



Recurrent deformity

  • Recurrent deformity

  • Malunion

  • Stiffness

  • Avascular necrosis



Improper cuts may lead to instability

  • Improper cuts may lead to instability

  • Dorsiflexion or Plantarflexion

  • Lateral tilt if the translation too big

  • If the cut is at right angle to the foot or slightly caudal (shortening) usually these are very stable and some do not fix them…

  • For more security a fixation is advisable.

  • Orthosorb : If only translational instability

  • Otherwise: a more secure fixation



Shortening of 1rst Metatarsal:

  • Shortening of 1rst Metatarsal:

    • Excessive impaction (osteopenic)
    • Plane of osteotomy too caudal
    • Transfer Metatarsalgia
  • Treatment: (beside orthosis)

    • Lengthening of 1st Metatarsal (Rarely)
    • Shortening lesser Metatarsal ( Better)


Recurrent deformity

  • Recurrent deformity

  • Malunion

  • Stiffness

  • Avascular necrosis



If after correction the join is incongruent

  • If after correction the join is incongruent

  • Faillure to recognise the elevated DMAA > 10 °

  • Do a biplane Chevron

  • Avoid Dorsal incisions

  • Careful not to damage sesamoid apparatus



  • Correction of a DMAA

    • With a biplane chevron


Recurrent deformity

  • Recurrent deformity

  • Malunion

  • Stiffness

  • Avascular necrosis



Avascular necrosis

  • Avascular necrosis

    • Less than 1% after STR
    • In fact, it is the excessive periosteal stripping, but…
    • Difficult salvage:
      • Resection arthroplasty
      • MTP Fusion






1. Transfer Metatarsalgia

  • 1. Transfer Metatarsalgia

    • (Shortening of 1st )
  • 2. Mal-Union

    • Dorsi-Flexion
    • Plantar-Flexion
    • Medial or Lateral tilt
  • 3. Delay, Non-Union



If there is no malunion but only metatarsalgia from a short first metatarsal:

  • If there is no malunion but only metatarsalgia from a short first metatarsal:

    • Lengthening of 1rst Metatarsal
      • Rarely indicated (risk  of stiffness and osteoarthrisis)
    • Shortening Lesser Metatarsal
      • Important to restore the normal cascade pattern
      • Usually M2, but always check M3 for shortening osteotomy
        • Weil osteotomy


1st Metatarsal shortening

  • 1st Metatarsal shortening

  • Dorsi-Flexion mal-union











Long 2nd metatarsal M2>M1

  • Long 2nd metatarsal M2>M1

    • Expected after Mitchell
  • Look at M-3…









Healing in medial rotation

  • Healing in medial rotation

  • Lateral rotation



Rarely : non union

  • Rarely : non union

  • If the alignment is good, be patient, delay union (poor fixation) usually heal (in metaphyseal area)



So to avoid all these displacement:

  • So to avoid all these displacement:

    • A fixation is needed (not the cerclage wire)


Selective Indications and Principles

  • Selective Indications and Principles

    • Metatarsal length absolute importance
      • Need a long 1st Metatarsal or
      • Need to shorten at the same time the 2nd ( and 3rd PRN If the 1st is not longer than the 2nd or 3rd
    • HV angle <40° ( 30-40)
    • IM angle <14°
    • Need a Internal fixation
    • ________________________Ideal Indication:
    • H Valgus with some degenerative changes
      • That some decompression is needed
      • Might be osteoporotic ( witch is a contra-indication for screw fixation like in Ludloff, Scarf, Mann osteotomies)


Long term FU (Mean:21 years) n=105

  • Long term FU (Mean:21 years) n=105

    • 72% Totally satisfied
    • 16% Reservation: Pain, 6% Look, 3% ROM
  • AOFAS-Hallux MTP Score Compare to author 4 categories

    • Excellent group: AOFAS score: 95.2 37 %
    • Good : “ : 86.3 28.2%
    • 65% = Excellent +Good
  • 92.4 % would agree to undergo the operation again



Salvage treatment of failed Hallux Valgus operation with proximal first metatarsal osteotomy and distal soft- tissue reconstruction

  • Salvage treatment of failed Hallux Valgus operation with proximal first metatarsal osteotomy and distal soft- tissue reconstruction

  • Journal Foot & Ankle Int. Volume 19 number 3 March 1998

    • Harold B. Kitaoka, Gary l. Pazer
  • 15 patients after failed Distal proceducre ( Silver or Chevron)

  • TX: Crescentic Mann Osteotomy and Soft-tissue release

    • HV angle 33°  14 ° IM angle 12.6 ° 5.7 °
    • Complications: 44%
      • 3 Transfer Metatarsalgia
      • 2 Mal-Union
      • 1 Hallux Varus
      • 1 Non-Union






K. Johnson Classical: EHL tranfert:

  • K. Johnson Classical: EHL tranfert:

    • IP Fusion &
    • Total EHL cut distal
  • Modification:

    • Half of EHL
    • No need to fuse IP joint




Silver Bunionectomy (1923)

  • Silver Bunionectomy (1923)

    • Medial Eminence removal +
    • Adductor Hallucis divided +
    • Distal Capsular flap +
    • Overlapping Plantar & Dorsal capsule


Will it come back Doctor?

  • Will it come back Doctor?

  • This is one of the reasons of the bad reputation of Hallux Valgus surgery



McBride (1928)

  • McBride (1928)

    • Medial Eminence removal +
    • Release of Conjoint tendon
    • TRANSFER Conjoint tendon to 1st Meta. Head +
    • Removal of fibular sesamoid
  • Duvries-Mann modification of McBride

    • Adductor tendon cut and transfer to 1st Meta, head ( not the Conjoint tendon)
    • Suture Medial capsule of 2nd Meta to lat. Capsule of 1st Metatarsal head
    • No fibular sesamoid excision


First MTP fusion

  • First MTP fusion

  • Modified Keller resection arthroplasty

    • (Hamilton modification)
  • Valenti arthroplasty



Dorsi-Flexion: 10-15 ° to the floor

  • Dorsi-Flexion: 10-15 ° to the floor

    • 20°-30 ° to the 1st Meta
  • Valgus : 10 ° - 15°

  • Fusion rate : 88 % after failed H. Valgus surgery

    • 94% – 100 % at initial surgery
    • 94 % 2 Steinmann pins
    • 96 % 2 (3.5mm) cross screws
    • 97 % Multiple threaded K-wirws
    • 100% conical reamming and plate
    • Less with Interpositionnal Bone Graf after Failed Keller
    • Late IP Degeneration: 15 % (3 time more in Women)
    • increase with HV angle >20°




First MTP fusion

  • First MTP fusion

  • Modified Keller resection arthroplasty

    • (Hamilton modification)
  • Valenti arthroplasty





First MTP fusion

  • First MTP fusion

  • Modified Keller resection arthroplasty

    • (Hamilton modification)
  • Valenti arthroplasty



NB. The lower part of the joint and sesamoid apparatus are left intact

  • NB. The lower part of the joint and sesamoid apparatus are left intact





Salvage of a failed Keller Resection Arthroplasty

  • Salvage of a failed Keller Resection Arthroplasty

    • MACHANECK JR., FELIX; EASLEY, MARK E; GRUBER,FLORIAN; RITSCHL, PETER; TRNKA, HANS-JORG
    • JBJS A June 2004, Volume 86-A, Number 6 1131-1138
    • They recommend fusion ( they do not lengthen with a bone graft. 15 °of valgus, 20°Dorsiflexion ( M1-P1)
    • With 2 cross cannulated 3.0 mm screws
    • Often associated with metatarsal shortening osteotomy (mostly Weil osteotomy)
    • NB. Fusion rate with interposition graft is lower & more difficult


After more than 90 minutes of surgery…

  • After more than 90 minutes of surgery…



Some controversy

  • Some controversy

  • Classical: Lapidus fusion 1st M-Cuneiform+ STR

  • Signs of Ligamentous Laxity (Breighton criteria)

    • D-Flex small finger : 1 point per side
    • Thumb-Forearm : “
    • Elbow hyperextension >10° : “
    • Knee hyperextension >10° : “
    • Palm-Floor : 1 point
  • Value >5 : LIGAMENTOUS LAXITY

  • Squeeze test: You grab the patient foot at Metatarsal Head level;

  • If there is a total correction of the Hallux Valgus suggest Hypermobity

  • Otherwise: more rigid deformity

  • Tarso-Metatarsal Clinical Test: >4° in Saggital plane

  • Klaue device ( M.Caughlin) >9 mm (sagittal plane)



Radiologic signs:

  • Radiologic signs:

    • Dorsal elevation 1st Meta
        • (Plantar gap)
  • - Thickening 2nd Metatarsal medial

  • cortical shaft

  • - Arthritis of 2nd TM joint



Some recent studies didn’t show any difference with Osteotomy (proximal or distal) and Lapidus procedure !

  • Some recent studies didn’t show any difference with Osteotomy (proximal or distal) and Lapidus procedure !

    • Faber, Frank W.M., Mulder, Paul, Verhaar, Jan
      • Role of first Ray Hypermobility in the outcome of the Hohmann and the Lapidus Procedure. A prospective Randomizeial Involving One Hundred and One Feet
      • JBJS March 2004 Volume 86-A, number 3


Complications after distal metatarsal osteotomy

  • Complications after distal metatarsal osteotomy

  • Complications after proximal osteotomy

  • Complication after Scarf osteotomy

  • Complications after Lapidus procedure

  • Complication after Keller Resection Arthroplasty



















What would you do?

  • What would you do?



5 Months after

  • 5 Months after



Mal-Union

  • Mal-Union

    • Dorsi-Flexion
    • Plantar-Flexion
  • Non-Union

  • Excessive Shortening

  • Under-correction

  • Over-correction



Mal-Union: the most common complication (Dorsi-Flexion,Recurrence

  • Mal-Union: the most common complication (Dorsi-Flexion,Recurrence

    • 1. Incorrect orientation of the osteotomy
      • When patent lie supine: Hips are in external Rotation the cut tend to be PROXIMAL-MEDIAL to DISTAL-LATERAL  elevation of Metatarsal head
    • 2. Positioning of the Osteotomy (ideal: 10-12 mm)
      • Too distal: * cortical bone… Heals less readily
      • * Narrow shaft .… More unstable
      • Too Proximal: Fixation is difficult or impossible
  • _ 3. Fixation of the Osteotomy

  • * Fixation is problematic

  • Proximal: cancellous, short. Distal: Hard cortical

  • Screw best but sometime unstable and recurrence not rare.



Mal-Union

  • Mal-Union

    • Dorsi-Flexion: Sometimes difficult to correct
      • TX: Some type of plantar osteotomy
      • If excessive shortening: BONE GRAFTING
  • - Plantar-Flexion:

  • * Dorsi-Flexion osteotomy

  • To avoid shortening : a crescentic osteotomy can be done in the sagittal plane

  • * Non-Union: rarely. If occurs: Bone grafting



Mal-Union

  • Mal-Union

    • Dorsi-Flexion
    • Plantar-Flexion
  • Non-Union

  • Excessive Shortening

  • Under-correction

  • Over-correction



Excessive Shortening

  • Excessive Shortening

    • Can be a significant problem
    • Similar as after Mitchell Oseotomy
    • Sometimes: Lengthening 1st meta
    • Generally: Shortening 2nd ( ? + 3rd )


Mal-Union

  • Mal-Union

    • Dorsi-Flexion
    • Plantar-Flexion
  • Non-Union

  • Excessive Shortening

  • Under-correction

  • Over-correction



Under-correction (of IM angle)

  • Under-correction (of IM angle)

    • TX: another Crescentic Osteotomy
        • or an Open wedge Osteotomy
  • Over-correction:

    • Often result in a HALLUX VARUS


Indications for Proximal Osteotomy

  • Indications for Proximal Osteotomy

    • IM angle > 14 ° (13-15 °) + STR
    • HV angle > 40 ° (30-40 °)
      • Goal: To correct the intermetatarsal angle)
  • Contraindication:

    • 1st MTP Osteoarthritis
    • DMAA >15-20° ( Unless Double osteotomy)
    • (Severe H Valgus with Hypermobility)




Excessive Lateral Soft Tissue Release *Interruption of Lateral Conjoint Tendon

  • Excessive Lateral Soft Tissue Release *Interruption of Lateral Conjoint Tendon

  • (Overpull of Abductor Hallucis)

  • Excision of Lateral sesamoid

  • Excessive medial capsule tightening

  • Excessive Medial Eminence removing

  • Overcorrection of IM angle

  • Excessive Overcorrection with Postop dressing



Excessive Lateral Soft Tissue Release

  • Excessive Lateral Soft Tissue Release

  • *Interruption of Lateral Conjoint Tendon

  • (Overpull of Abductor Hallucis)

  • Excision of Lateral sesamoid

  • Excessive medial capsule tightening

  • Excessive Medial Eminence removing

  • Overcorrection of IM angle

  • Excessive Overcorrection with Post-op dressing



TECHNIC 1

  • TECHNIC 1

  • 1. Adductor Hallucis

    • Identified and isolated from Flexor Hallucis Brevis with Hemostat clamp.
    • No need to relocate on Meta. neck
    • (Conjoint tendon: Add. Hallucis + FHB)
  • 2. Metatarso-Sesamoid suspensor Lig.

    • (to free the fibular sesamoid, that can after be relocated under the Metatarsal head
  • Not cutting the: Metatarso-Phalangial Lig.

      • (Collateral lig.) re.: Risk of H. Varus
  • N.B. Deep Transverse Metatarso-phalangial Ligament doesn’t need to be cut





TECHNIC 2

  • TECHNIC 2

  • 1. Conjoint tendon (PIB: Phalangial Insertion Band)

  • 2. Metatarso-Sesamoid suspensor Lig.

    • (to free the fibular sesamoid, that can after be relocated under the Metatarsal head
  • Not cutting the: Metatarso-Phalangial Lig.

      • (Collateral lig.) re.: Risk of H. Varus
  • N.B. Deep Transverse Metatarso-phalangial Ligament doesn’t need to be cut







Complications after distal metatarsal osteotomy

  • Complications after distal metatarsal osteotomy

  • Complications after proximal osteotomy

  • Complication after Scarf osteotomy

  • Complications after Lapidus procedure

  • Complication after Keller Resection Arthroplasty



General Indications:

  • General Indications:

    • Same as Proximal Osteotomy IM >14-18°
    • More versatile
    • More stable
    • More demanding




Barouk, L.S., SCARF OSTEOTOMY FOR HALLUX VALGUS CORRECTION

  • Barouk, L.S., SCARF OSTEOTOMY FOR HALLUX VALGUS CORRECTION

  • Foot and Ankle Clinics, Volume 3, September 2000, 525-580

  • * Results: (123 feet, 76 patients) FU 3 to 46 months (13)

  • HVA: 35.2° 16.4 °

  • IMA: 17.4°  10.2°

  • ROM: 75 ° (DF: 65° PF: 10°)

  • Complications:

    • 2 Stress fractures ( at proximal osteotomy site)
    • 4 Recurrences (HVA >25°) 2 need capsuloplasty
    • 5 Over-correctionHallux Varus (Learnig curve: 8%3%)
    • 3% Prominent Hardware, less with Threaded head screws.
    • 3 Osteonecrosis ( 2 need arthrodesis)
    • Rare : Under-correction or Stiffness (early mobilization)


  • Off 244 patients refer by GP after all type off failed foot surgery, 218 treated with revision surgery:

    • 152 (66 %) :Failed first ray Surgery
          • 42% : After Mitchell Procedure
          • 14% : After Keller
          • 14% : After First MTP Fusion
          • 8.6% : After Silver ( Bumpectomy+ STR)
    • Diagnosis ( 244 patients)
          • 34% : Transfer Metatarsalgia
          • 26% : Recurrent H. Valgus
          • 18% : Lesser digit deformity
          • 5% : Continued pain over 1 MTP


Revision surgery

  • Revision surgery

    • 32%: Lesser Metatarsal surgery
      • Weil or Schwartz
    • 23%: Lesser Toe surgery
    • 21%: First Metatarsal-Phalanx
      • Scarf-Akin
    • 4% : First & Lesser Metatarsal
      • Scarf-Akin and Weil or Schwartz
  • 86% Might have been avoid



Complications after distal metatarsal osteotomy

  • Complications after distal metatarsal osteotomy

  • Complications after proximal osteotomy

  • Complication after Scarf osteotomy

  • Complications after Lapidus procedure

  • Complication after Keller



Indication for Lapidus Procedure:

  • Indication for Lapidus Procedure:

    • Severe Hallux Valgus, With Hypermobility (Instability of the Metatarso-Cuneiform joint) in saggital plane, particularly with Generalize Ligamentous Laxity mostly in: Hallux Valgus Juvenile with High 1-2 Inter-Metatarsal angle IM angle >18°
    • OA 1st TMT
    • Sometime in adult flatfoot from PTTD
  • Should not be done if 1st Metatarsal is short (or Open Epiphysis



1. Non-union

  • 1. Non-union

  • 2. Mal-Union: Dorsi-Flexion (mostly)

  • 3. Excessive Shortening



1. Non-UNION (10-12%....7% to 50%!!)

  • 1. Non-UNION (10-12%....7% to 50%!!)

    • Significantly more common than Mal-Union
      • Very high rates
      • Frequently symptomatic
      • Need: Multiple screw fixation and
        • Cast Immobilisation and
        • A period of non-weight bearing ( 4-6 weeks)
        • (Union rate better with Bone Grafting)


Popularize by Sig. Hansen

  • Popularize by Sig. Hansen

  • Minimal articular resection

  • C1 M1

  • M1 M2

  • Big Screws (4.0-4.5)

  • Lag Screw tech.

  • Local Bone Graft



Ian M. Thompson; Donald R. Bohay; John G. Anderson

  • Ian M. Thompson; Donald R. Bohay; John G. Anderson

  • Foot & Ankle Int. Volume 26 Number 9, September 2005

  • 201 feet

  • Non-Union : 4 % ( 8 cases)

  • 5 Had previous Bunion Surgery

  • 2 Smokers

  • 1 diabetic

  • Of 201 feet, 25 (12%) had Recurrence after Previous Bunion Surgery.

    • Out of these: 20% had Non-Union after Modified Lapidus


2. MAL-UNION

  • 2. MAL-UNION

    • Technically difficult re.: Dorsal incision : Poor visualisation Re.: depth of bone ۩ MEDIAL INCISION
      • Some Plantar-Flexion of the ray usually require to compensate the shortening ( too much sesamoid pain)
  • 3. SHORTENING:

    • Relative to joint resection


Complications after distal metatarsal osteotomy

  • Complications after distal metatarsal osteotomy

  • Complications after proximal osteotomy

  • Complication after Scarf osteotomy

  • Complications after Lapidus procedure

  • Complication after Keller Resection Arthroplasty



Salvage of a Failed Keller Resection Arthroplasty

  • Salvage of a Failed Keller Resection Arthroplasty

  • Machacek Lr., Felix and all.

  • JBJS-A Vol. 86-A, Number 6, June 2005

  • Complications: Cock-up toe, Recurrent H Valgus, Flail toe, metatarsalgia.

  • Group A- Treated with Fusion (29 feet), FU: 36 months

  • 90% healed. AOFAS score: 76/90

  • Needed surgery: 17% need refusion (3 Mal-Union & 2 non-union)

  • 62% Needed Lesser Metatarsal shortening ( Weil,Helal,etc.)

  • Group B- Re-Keller or STR (EHL Z-Lenghtening) (18 feet), FU:74 monhs

  • AOFAS score: 46/90 Non-Satisfied: 61%

  • Cock-up: 67 % Recurrence:39% Rigidus:11%

  • Conclusion: Fusion much better, but more demanding



The Lapidus procedure as salvage After Failed Surgical Treatmen of Hallux Valgus. A Prospective Cohort Study

  • The Lapidus procedure as salvage After Failed Surgical Treatmen of Hallux Valgus. A Prospective Cohort Study

    • COETZEE, J.CHRIS;, RESIG,SCOTT G.,; KUSKOWSKI,MICHAEL; SALEH, KHALED J.
    • JBJS-A January 2003,Volume 85-A Number 1 60-65
  • Here it is only recurrent H. Valgus

  • AOFAS score 47.687.9

  • Visual Analog Pain Scale 6.2 1.4

  • Very satisfied: 77% Satisfied : 4% Somewhat satisfied: 19% Dissatisfied: 0

  • C1M1 & M1M2



Grimes, J.S., Coughlin, M. Foot & Ankle InternationalVol.27, No. 11 / 887-893/ Nov. 2006

  • Grimes, J.S., Coughlin, M. Foot & Ankle InternationalVol.27, No. 11 / 887-893/ Nov. 2006

  • The only well documented long-term results of salvage of failed hallux valgus procedures by arthrodesis of the first MTP



Here M.J. Coughlin expose his results for Failed H. Valgus treated with fusion and not only for those with arthrosis

  • Here M.J. Coughlin expose his results for Failed H. Valgus treated with fusion and not only for those with arthrosis

  • 55% recurrence H. Valgus, 24% H. Varus, etc.

  • 82% have Lesser toes complaints

  • AOFAS score of 73 (Excellent 39%, Good 33%

  • Fair 24% , Poor 3%)

  • 79% would have the surgery again







Review of All Orthopaedic surgeries witch led to litigation: (USA- Glyn Thomas)

  • Review of All Orthopaedic surgeries witch led to litigation: (USA- Glyn Thomas)

    • Most: Foot surgery : 23 %
      • Out of this:
  • 64% : Lesser metatarsal neck Osteotomy



Good discussion

  • Good discussion

  • Need to repeat and repeat

  • When they listen…( i.e. Not looking at their Question list, or not thinking at their next question, most do not really understand the technical explanations.

  • They tend to underestimate minor warnings

  • So… you need to be clear and need to emphasis mostly on what would be a realistic result.



1. Recognize why the first surgery failed

  • 1. Recognize why the first surgery failed

    • Don’t repeat the initial error…
  • 2. Look the Whole Foot (re. Lesser Metatarsals)

  • 3. Look if there are Degenerative changes







Osteotomy parallel to the sole of the foot

  • Osteotomy parallel to the sole of the foot

  • Ex.: 5 mm shortening =

  • 2 mm plantar displacement

  • The problem in rigid foot with IPK, tend to displace the “BUMP” more proximal



With a wedge resection above the 25° cut

  • With a wedge resection above the 25° cut

  • 5 mm shortening =

  • 0.8 mm plantar displacement

  • The problem: the toe is higher and do not touch the ground

  • (but: no functional signification; cosmetic concern only)



A complete removal of 2 to 3 mm slice

  • A complete removal of 2 to 3 mm slice

  • At an angle of 15 to 20 °

  • Can correct sub-luxation MTP and IPK in many cases.

  • Not indicated in very osteoporotic patients)

  • All healed, except ~ 1 % ( screw loosening or fracture)



Results & Complications:

  • Results & Complications:

  • KH. Kristen, C. Berger, S. Steizig, E. Thaihammer, M. Posch, A. Engel

  • The SCARF Osteotomy for the Correction of Hallux Valgus Deformities

  • Foot and Ankle surgery Volume 23 Number 3 220-228, March 2003

    • 89 patients Post-op HV: 19° IM: 6.6 °
      • Return to Work: 6 weeks, to Sports: 8.3 weeks
      • Complications: 7 Recurrence 6%
        • 4 Hallux Limitus (ROM <40°)
        • 2 Superficial infections
        • 1 Dislocation of distal fragment


Results & Complications

  • Results & Complications

  • Rippstein, P; ZUnd, I: Clinical and radiological midterm results of 61 scarf osteotomies for hallux valgus deformity. Synopsis book, Second internat. AFCP spring meeting, Bordeaux May, 2000

  • 2 years FU

  • HV angle 32°11°

  • IM angle 14°6°

  • Complications: 1 Osteonecrosis Meta. Head

    • 1 Painful Over-correction


Results & Complications :

  • Results & Complications :

  • Valentin, B; Leemrijse, Th: Scarf osteotomy of the first metatarsal: A review of the first 56 cases (5 years follow-up) and improvement of the surgical technique. Synopsis book, Second internat. AFCP spring meeting, Bordeaux May, 2000

  • 56 patients 5 years FU

  • HV 38.5°  19°

  • IM 16.6°  11°

  • Complications:



Results & Complications

    • Results & Complications
    • Wagner, A; Fuhrmann, R; Abramovsky, I: Early results of Scarf osteotomies using differentiated therapy of hallux valgus. Foot and Ankle surgery 6:105-112, 2000
    • 53 cases 14 months FU
    • HV angle: 43° 23°
    • IM angle : 16°8°
    • Complications:
      • 2 Fractures of 1st Metatarsal ( at distal screw level)


Wagner, A; Fuhrmann, R; Abramovsky, I: Early results of Scarf osteotomies using differentiated therapy of hallux valgus. Foot and Ankle surgery 6:105-112, 2000

  • Wagner, A; Fuhrmann, R; Abramovsky, I: Early results of Scarf osteotomies using differentiated therapy of hallux valgus. Foot and Ankle surgery 6:105-112, 2000

  • Rippstein, P; ZUnd, I: Clinical and radiological midterm results of 61 scarf osteotomies for hallux valgus deformity. Synopsis book, Second internat. AFCP spring meeting, Bordeaux May, 2000

  • Valentin, B; Leemrijse, Th: Scarf osteotomy of the first metatarsal: A review of the first 56 cases (5 years follow-up) and improvement of the surgical technique. Synopsis book, Second internat. AFCP spring meeting, Bordeaux May, 2000

  • The SCARF Osteotomy for the Correction of Hallux Valgus Deformities KH. Kristen, C. Berger, S. Steizig, E. Thaihammer, M. Posch, A. Engel Foot Ankle International Volume 23 number 3 march 2002



Long term FU (Mean:21 years) n=105

  • Long term FU (Mean:21 years) n=105

    • 72% Totally satisfied
    • 16% Reservation: Pain
    • 6% Reservation: Apparence
    • 3% Reservation: ROM
    • 4% Not satisfied
  • AOFAS-Hallux MTP Score Compare to author 4 categories

    • Excellent group: AOFAS score: 95.2 37 %
    • Good : “ : 86.3 28.2% 65% = Exc.+Good
    • Satisfactory : “ : 67.7 21.4%
    • Poor : “ : 55.4 13.6%


Initially At FU

  • Initially At FU

  • Mean HV angle 33° 17°

  • Mean IM angle 22.5 ° 7.7°

  • 21% recurred over medial eminence

  • 13.3 IPK under 2nd Metatarsal

  • Overall satisfaction at 21 y. FU: Excellent +Good: 65%

  • 92.4 % would agree to undergo the operation again



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