The Failed Hallux Valgus Instructionnal Course Lecture Canadian Orthopaedic Association Halifax June...

The Failed Hallux The Failed Hallux ValgusValgus

Instructionnal Course LectureInstructionnal Course LectureCanadian Orthopaedic Canadian Orthopaedic

AssociationAssociationHalifax June 2, 2007Halifax June 2, 2007

André Perreault M.D.André Perreault M.D.Montréal, private practiceMontréal, private practice

Failed for who?Failed for who?

Surgeon point of viewSurgeon point of view– Congruent jointCongruent joint

– Joint space Joint space (degenerative joint (degenerative joint disease)disease)

– Metatarsal lengthMetatarsal length

Failed for who?Failed for who?

Patient point of view:Patient point of view: – No bumpNo bump– Straight toeStraight toe– Cosmetic scar Cosmetic scar – Good motion…enough to wear high Good motion…enough to wear high

hellhell– No painNo pain– Almost: restituo ad integrum…Almost: restituo ad integrum…

Why did the original procedure Why did the original procedure failed?failed?

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

Wrong procedureWrong procedure for the problemfor the problem

Bad technique Bad technique of an adequate procedureof an adequate procedure– Inadequate Medial capsule plicationInadequate Medial capsule plication– Inadequate soft tissue release ( Inadequate soft tissue release ( Transverse lig., Transverse lig.,

ADD.H.)ADD.H.)

– Inadequate post-op. dressingInadequate post-op. dressing

Why did the Why did the original procedure original procedure failed?failed?

An expected complication An expected complication for that for that procedureprocedure

A complication non specific to the A complication non specific to the procedureprocedure

A misunderstanding of the expected A misunderstanding of the expected resultsresults

…………..Patient versus Surgeon Patient versus Surgeon expectation….expectation….


Complications after distal metatarsal Complications after distal metatarsal osteotomyosteotomy

Complications after proximal osteotomyComplications after proximal osteotomy Complication after Scarf osteotomyComplication after Scarf osteotomy Complications after Lapidus procedureComplications after Lapidus procedure Complication after Keller Resection Complication after Keller Resection

ArthroplastyArthroplasty





Post-ChevronPost-Chevron

Complications after distal Complications after distal metatarsal osteotomy metatarsal osteotomy 1. 1. ChevronChevron

Recurrent deformityRecurrent deformity MalunionMalunion StiffnessStiffness Avascular necrosisAvascular necrosis


Recurrent deformityRecurrent deformity MalunionMalunion StiffnessStiffness Avascular necrosisAvascular necrosis

Complications after distal metatarsal Complications after distal metatarsal osteotomy osteotomy 1. Chevron1. Chevron

* RECURRENT DEFORMITY* RECURRENT DEFORMITY

1. Plane of osteotomy1. Plane of osteotomy 2. DMAA2. DMAA 3. Too big deformity for the 3. Too big deformity for the

procedureprocedure 4. Loose capsulorraphy4. Loose capsulorraphy 5. …Lateral soft tissue release5. …Lateral soft tissue release

Chevron- Chevron- Recurrent deformityRecurrent deformity1.1. Plane of the osteotomyPlane of the osteotomy

Avoid:Avoid:– Doing the osteotomy in Doing the osteotomy in

line at line at right angle with right angle with the first metatarsalthe first metatarsal;;

– It is more unstable et It is more unstable et tend to go back to it’s tend to go back to it’s previous position previous position

– Tend to Tend to the bone length the bone length

(Stiffness)(Stiffness) InsteadInstead : the : the

osteotomy should be osteotomy should be done at done at right angle to right angle to the footthe foot

But: Avoid shorteningBut: Avoid shortening

Errors in Chevron Errors in Chevron OsteotomyOsteotomy

Here the osteotomy Here the osteotomy was done to done in was done to done in the axis of the bone, the axis of the bone, instead of the foot:instead of the foot:– Result: 4 weeks post-Result: 4 weeks post-

op: distal fragment op: distal fragment back to it’s original back to it’s original positionposition

So if needed to So if needed to lenghten the bone: lenghten the bone: a a good fixation neededgood fixation needed

Remove the Medial Remove the Medial EminenceEminence

parallel to the foot, not the parallel to the foot, not the metatarsal.metatarsal.

Chevron- Chevron- Recurrent Recurrent deformitydeformity2.2. The DMAA angleThe DMAA angle

Primo:Primo:– RECOGNIZERECOGNIZE

Danger:Danger:– Make a straight toe Make a straight toe

with an with an incongruent incongruent jointjoint out of a valgus out of a valgus toe but congruent toe but congruent jointjoint

– With time will displaceWith time will displace

Chevron- Chevron- Recurrent deformityRecurrent deformity3.3. Too big deformity for the Too big deformity for the

techniquetechnique

HV angle HV angle < 30 °< 30 °

IM angle < 14 °IM angle < 14 °

Chevron- Chevron- Recurrent Recurrent deformitydeformity4.4. Too loose capsulorraphyToo loose capsulorraphy

Tension should be just enough to prevent Tension should be just enough to prevent lateral lateral displacement displacement

– With AkinWith Akin : no over correction : no over correction – Without AkinWithout Akin : minimal overcorrection : minimal overcorrection

But Too tight capsulorraphy might lead to stiffness.But Too tight capsulorraphy might lead to stiffness.

AkinAkin

ChevronChevron

CapsulorraphyCapsulorraphy

P-1 P-1

Capsule Capsule

11stst Metatarsal Metatarsal

Chevron- Chevron- Recurrent Recurrent deformitydeformity5. … Lateral soft tissue 5. … Lateral soft tissue releaserelease Multiple studies: Multiple studies:

STR with distal osteotomy : SafeSTR with distal osteotomy : Safe Incidence of AVN is so lowIncidence of AVN is so low, , ≤ 1 %≤ 1 %

(periosteal stripping is more a concern),(periosteal stripping is more a concern), Most expert : Most expert : CautionCaution… if a STR is … if a STR is

needed needed

The indication is probably stretch…The indication is probably stretch… * Proximal osteotomy … * Proximal osteotomy …

* Adding a Akin procedure are safer. * Adding a Akin procedure are safer.


Recurrent deformityRecurrent deformity

MalunionMalunion StiffnessStiffness Avascular necrosisAvascular necrosis

Complications after distal metatarsal Complications after distal metatarsal osteotomy osteotomy 1. Chevron : 1. Chevron : Mal-UnionMal-Union

Improper cuts may lead to instabilityImproper cuts may lead to instability

Dorsiflexion or PlantarflexionDorsiflexion or Plantarflexion

Lateral tilt if the translation too big Lateral tilt if the translation too big If the cut is at If the cut is at right angle to the footright angle to the foot or or

slightly caudal (shortening) usually these slightly caudal (shortening) usually these are very stable and some do not fix them…are very stable and some do not fix them…

For more security a fixation is For more security a fixation is advisable.advisable.Orthosorb : If only translational instabilityOrthosorb : If only translational instability

Otherwise: a more secure fixationOtherwise: a more secure fixation

Complications after distal Complications after distal metatarsal osteotomy metatarsal osteotomy 1. Chevron : 1. Chevron : Mal-UnionMal-Union

Shortening of 1rst Metatarsal:Shortening of 1rst Metatarsal:– Excessive impaction (osteopenic)Excessive impaction (osteopenic)– Plane of osteotomy too caudalPlane of osteotomy too caudal

Transfer MetatarsalgiaTransfer Metatarsalgia

Treatment: Treatment: (beside orthosis)(beside orthosis)– Lengthening of 1Lengthening of 1stst Metatarsal (Rarely) Metatarsal (Rarely)– Shortening lesser Metatarsal ( Better)Shortening lesser Metatarsal ( Better)


Recurrent deformityRecurrent deformity MalunionMalunion

StiffnessStiffness Avascular necrosisAvascular necrosis

Complications after distal Complications after distal metatarsal osteotomy metatarsal osteotomy 1. Chevron : 1. Chevron : StiffnessStiffness

If after correction the If after correction the join is join is incongruentincongruent……

Faillure to recognise Faillure to recognise the elevated DMAA the elevated DMAA > > 10 °10 °

Do a biplane ChevronDo a biplane Chevron

Avoid Dorsal incisionsAvoid Dorsal incisions Careful not to damage Careful not to damage

sesamoidsesamoid apparatus apparatus

Biplane Chevron Biplane Chevron

Complications after distal Complications after distal metatarsal osteotomy metatarsal osteotomy 1. Chevron : 1. Chevron : StiffnessStiffness

Correction of a Correction of a DMAADMAA– With a biplane With a biplane

chevronchevron


Recurrent deformityRecurrent deformity MalunionMalunion StiffnessStiffness

Avascular necrosisAvascular necrosis

Distal soft tissue release and Distal soft tissue release and Distal metatarsal osteotomyDistal metatarsal osteotomy

Avascular necrosisAvascular necrosis– Less than 1% after STRLess than 1% after STR– In fact, it is the In fact, it is the

excessive periosteal excessive periosteal stripping, but…stripping, but…

– Difficult salvage:Difficult salvage: Resection arthroplastyResection arthroplasty MTP FusionMTP Fusion

Post-MitchellPost-Mitchell

(Modified) Mitchell(Modified) Mitchell

Complications Post-MitchellComplications Post-Mitchell

1. Transfer Metatarsalgia1. Transfer Metatarsalgia– (Shortening of 1(Shortening of 1stst ) )

2.2. Mal-UnionMal-Union– Dorsi-FlexionDorsi-Flexion– Plantar-FlexionPlantar-Flexion– Medial or Lateral tiltMedial or Lateral tilt

3.3. Delay, Non-UnionDelay, Non-Union

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

– Lengthening of 1rst MetatarsalLengthening of 1rst Metatarsal Rarely indicated (risk Rarely indicated (risk of stiffness and of stiffness and

osteoarthrisis)osteoarthrisis)

– Shortening Lesser MetatarsalShortening Lesser Metatarsal Important to restore the normal cascade patternImportant to restore the normal cascade pattern Usually M2, but always check M3 for shortening Usually M2, but always check M3 for shortening

osteotomyosteotomy

– Weil osteotomyWeil osteotomy

Post-Mitchell -Post-Mitchell -1 1 TRANSFER TRANSFER METATARSALGIAMETATARSALGIA

Classical case post-Classical case post-MitchellMitchell

11stst Metatarsal shortening Metatarsal shortening Dorsi-Flexion mal-unionDorsi-Flexion mal-union

Better do both at initial Better do both at initial

surgery!surgery!

14°14°

40° 40°

Myerson modification Myerson modification My Modification My Modification

Since 2001Since 2001

Classical Weil Classical Weil

Factors in decision making: Factors in decision making: M-2 Shortening Osteotomy M-2 Shortening Osteotomy

Long 2nd metatarsal Long 2nd metatarsal M2M2>M1>M1

– Expected after Expected after MitchellMitchell

Look at M-3…Look at M-3…Donnatello

Post-Mitchell Post-Mitchell 2. Mal Union2. Mal Union:: in Dorsi-in Dorsi-FlexionFlexion

Dorsal open wedgeDorsal open wedge

Post-Mitchell Post-Mitchell Mal-UnionMal-Union in Plantar-in Plantar-FlexionFlexion

Post-Mitchell: Post-Mitchell: Mal-Union:Mal-Union: With With rotationrotation

Healing in medial rotationHealing in medial rotation

Lateral Lateral rotationrotation

Post-Mitchell: Post-Mitchell: 3. Delay 3. Delay HealingHealing

Rarely : non unionRarely : non union

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

Post-MitchellPost-Mitchell

So to avoid all these displacement: So to avoid all these displacement: – A fixation is neededA fixation is needed (not the cerclage (not the cerclage

wire)wire)

Modified MitchellModified Mitchell Selective Indications and PrinciplesSelective Indications and Principles

– Metatarsal length Metatarsal length absoluteabsolute importance importance Need a long 1Need a long 1stst Metatarsal Metatarsal oror Need to shorten at the same timeNeed to shorten at the same time the 2 the 2ndnd ( and 3 ( and 3rdrd

PRN PRN If the 1If the 1stst is not longer than the 2 is not longer than the 2ndnd or 3 or 3rdrd

– HV angle HV angle <40° ( 30-40)<40° ( 30-40)– IM angle <14°IM angle <14°– Need a Internal fixationNeed a Internal fixation________________________________________________Ideal Indication:Ideal Indication:– H Valgus with some degenerative changesH Valgus with some degenerative changes

That some decompression is neededThat some decompression is needed Might be osteoporotic ( witch is a contra-indication Might be osteoporotic ( witch is a contra-indication

for screw fixation like in Ludloff, Scarf, Mann for screw fixation like in Ludloff, Scarf, Mann osteotomies)osteotomies)

Late results of Modified Mitchell Procedure Late results of Modified Mitchell Procedure for the Treatment of Hallux Valgus for the Treatment of Hallux Valgus Fokter, Samo Karl Fokter, Samo Karl Foot & Ankle Int. Vol.5 May 99 Foot & Ankle Int. Vol.5 May 99

Long term FU (Mean:21 years) n=105Long term FU (Mean:21 years) n=105– 72% Totally satisfied72% Totally satisfied– 16% Reservation: Pain, 6% Look, 3% ROM16% Reservation: Pain, 6% Look, 3% ROM

AOFAS-Hallux MTP Score AOFAS-Hallux MTP Score Compare to Compare to author 4 categoriesauthor 4 categories– Excellent group: AOFAS score: 95.2 Excellent group: AOFAS score: 95.2 37 %37 %

– Good : “ : 86.3 Good : “ : 86.3 28.2%28.2%

– 65% = Excellent +Good65% = Excellent +Good 92.4 % would agree to undergo the operation 92.4 % would agree to undergo the operation

againagain

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

Journal Foot & Ankle Int. Volume 19 number 3 March 1998Journal Foot & Ankle Int. Volume 19 number 3 March 1998– Harold B. Kitaoka, Gary l. PazerHarold B. Kitaoka, Gary l. Pazer

15 patients after failed Distal proceducre ( Silver or 15 patients after failed Distal proceducre ( Silver or Chevron)Chevron)

TX: Crescentic Mann Osteotomy and Soft-tissue TX: Crescentic Mann Osteotomy and Soft-tissue releaserelease– HV angle 33HV angle 33°° 14 14 °° IM angle 12.6 IM angle 12.6 °° 5.7 5.7 °°

– ComplicationsComplications: 44% : 44% 3 Transfer Metatarsalgia3 Transfer Metatarsalgia 2 Mal-Union2 Mal-Union 1 Hallux Varus1 Hallux Varus 1 Non-Union1 Non-Union

Post-McBridePost-McBride

Post-Mc Bride: Post-Mc Bride: Hallux Hallux VarusVarus

Hallux Varus –TreatmentHallux Varus –Treatment**Extensor Hallucis Brevis (EHB) Procedure Extensor Hallucis Brevis (EHB) Procedure (Myerson)(Myerson)

K. Johnson Classical: K. Johnson Classical: EHL tranfert:EHL tranfert:– IP Fusion &IP Fusion &– Total EHL cut distalTotal EHL cut distal

Modification: Modification: – Half of EHLHalf of EHL– No need to fuse IP jointNo need to fuse IP joint

Hallux Varus –TreatmentHallux Varus –Treatment**Extensor Hallucis Brevis (EHB) My Extensor Hallucis Brevis (EHB) My ProcedureProcedure

(Base Proximally)(Base Proximally)

Simple bunionectomySimple bunionectomy

Silver BunionectomySilver Bunionectomy (1923)(1923)

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

capsulecapsule


Will it come back Will it come back Doctor?Doctor?

This is one of the This is one of the reasons of the reasons of the bad reputation bad reputation of Hallux Valgus of Hallux Valgus surgerysurgery


McBrideMcBride (1928) (1928)– Medial Eminence removal +Medial Eminence removal +– Release of Release of Conjoint tendonConjoint tendon– TRANSFER Conjoint tendon to 1TRANSFER Conjoint tendon to 1stst Meta. Meta.

Head +Head +– Removal of fibular sesamoidRemoval of fibular sesamoid

Duvries-Mann modification of McBrideDuvries-Mann modification of McBride– Adductor tendonAdductor tendon cut and transfer to 1 cut and transfer to 1stst

Meta, head ( not the Conjoint tendon)Meta, head ( not the Conjoint tendon)– Suture Medial capsule of 2Suture Medial capsule of 2ndnd Meta to lat. Meta to lat.

Capsule of 1Capsule of 1stst Metatarsal head Metatarsal head– NoNo fibular sesamoid excision fibular sesamoid excision

If the joint cannot be salvage If the joint cannot be salvage (arthrosis)(arthrosis) After Distal Osteotomy(Chevron- After Distal Osteotomy(Chevron-Mitchell)Mitchell)

First MTP fusionFirst MTP fusion

Modified Keller resection Modified Keller resection arthroplastyarthroplasty– (Hamilton modification)(Hamilton modification)

Valenti arthroplastyValenti arthroplasty

11stst MTP Arthrodesis MTP Arthrodesis Dorsi-Flexion:Dorsi-Flexion: 10-15 ° to the floor 10-15 ° to the floor

20°-20°-30 ° to the 130 ° to the 1stst Meta Meta Valgus :Valgus : 10 °10 ° - 15° - 15° Fusion rate :Fusion rate : 88 % after failed H. Valgus surgery 88 % after failed H. Valgus surgery

94% – 100 % at initial surgery94% – 100 % at initial surgery

94 % 2 Steinmann pins94 % 2 Steinmann pins

96 % 2 (3.5mm) cross screws96 % 2 (3.5mm) cross screws

97 % Multiple threaded K-wirws97 % Multiple threaded K-wirws

100% conical reamming and plate100% conical reamming and plate

Less with Interpositionnal Bone Graf after Failed KellerLess with Interpositionnal Bone Graf after Failed Keller

Late IP Degeneration:Late IP Degeneration: 15 % 15 % (3 time more in Women)(3 time more in Women)

increase with HV angle increase with HV angle >20°>20°

Complications Post-1Complications Post-1stst MTP MTP FusionFusion



Modified Keller resection Modified Keller resection arthroplastyarthroplasty (Hamilton modification)(Hamilton modification)


Cut EHB proximallyCut EHB proximally

Excise ¼ Proximal P-1 Excise ¼ Proximal P-1

Free up Dorsal capsule Free up Dorsal capsule With EHB slide it down With EHB slide it down

To FHBTo FHB

Bill Hamilton Capsular Bill Hamilton Capsular interposition (modification interposition (modification

of Keller resection arthroplasty of Keller resection arthroplasty

1/3 resection for 1/3 resection for

Regular KellerRegular Keller



Modified Keller resection Modified Keller resection arthroplastyarthroplasty– (Hamilton modification)(Hamilton modification)


Valenti 1Valenti 1stst MTP MTP Arthroplasty:Arthroplasty:

Extensive CheilectomyExtensive Cheilectomy NB. The lower part of the joint and NB. The lower part of the joint and

sesamoid apparatus are left intactsesamoid apparatus are left intact

WHY Keller for HV without WHY Keller for HV without Arthritis was done on that Arthritis was done on that

young patient ??? young patient ???

Failed KellerFailed Keller Salvage of a failed Keller ResectionSalvage of a failed Keller Resection ArthroplastyArthroplasty

– MACHANECK JR., FELIX; EASLEY, MARK E; MACHANECK JR., FELIX; EASLEY, MARK E; GRUBER,FLORIANGRUBER,FLORIAN; RITSCHL, PETER; TRNKA, HANS-JORG; RITSCHL, PETER; TRNKA, HANS-JORG

– JBJS A June 2004, Volume 86-A, Number 6 1131-JBJS A June 2004, Volume 86-A, Number 6 1131-11381138

– They recommend fusion ( they do not They recommend fusion ( they do not lengthen with a bone graft. 15 lengthen with a bone graft. 15 °of valgus, °of valgus, 20°Dorsiflexion ( M1-P1)20°Dorsiflexion ( M1-P1)

– With 2 cross cannulated 3.0 mm screwsWith 2 cross cannulated 3.0 mm screws

– Often associated with metatarsal shortening Often associated with metatarsal shortening osteotomy (mostly Weil osteotomy)osteotomy (mostly Weil osteotomy)

– NB.NB. Fusion rate with interposition graft Fusion rate with interposition graft is lower & more difficultis lower & more difficult

A Podiatric A Podiatric SurgeonSurgeon in Montreal in Montreal

After more than 90 minutes of After more than 90 minutes of surgery…surgery…

11stst Ray Hypermobility Ray Hypermobility Some controversySome controversy Classical: Lapidus fusion 1Classical: Lapidus fusion 1stst M-Cuneiform+ STR M-Cuneiform+ STR Signs of Ligamentous Laxity Signs of Ligamentous Laxity (Breighton criteria)(Breighton criteria)

– D-Flex small finger : 1 point per sideD-Flex small finger : 1 point per side– Thumb-Forearm : “Thumb-Forearm : “– Elbow hyperextension Elbow hyperextension >10° : “>10° : “– Knee hyperextension >10° : “Knee hyperextension >10° : “– Palm-Floor : 1 pointPalm-Floor : 1 point

Value >5 : LIGAMENTOUS LAXITYValue >5 : LIGAMENTOUS LAXITY Squeeze test:Squeeze test: You grab the patient foot at Metatarsal Head level; You grab the patient foot at Metatarsal Head level; If there is a total correction of the Hallux ValgusIf there is a total correction of the Hallux Valgus suggest suggest

HypermobityHypermobity Otherwise: more rigid deformityOtherwise: more rigid deformity

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

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

11stst Ray Hypermobility Ray Hypermobility

Radiologic signs:Radiologic signs:– Dorsal elevation 1Dorsal elevation 1stst Meta Meta

– (Plantar gap)(Plantar gap)

- - Thickening 2Thickening 2ndnd Metatarsal medial Metatarsal medial

cortical shaftcortical shaft

- - Arthritis of 2Arthritis of 2ndnd TM joint TM joint

11stst Ray Hypermobility Ray Hypermobility

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

– Faber, Frank W.M., Mulder, Paul, Verhaar, JanFaber, Frank W.M., Mulder, Paul, Verhaar, Jan

Role of first Ray Hypermobility in the outcome of the Role of first Ray Hypermobility in the outcome of the Hohmann and the Lapidus Procedure. A prospective Hohmann and the Lapidus Procedure. A prospective Randomizeial Involving One Hundred and One FeetRandomizeial Involving One Hundred and One Feet

JBJS March 2004 Volume 86-A, number 3JBJS March 2004 Volume 86-A, number 3



Complications after proximal Complications after proximal osteotomyosteotomy

Complication after Scarf osteotomyComplication after Scarf osteotomy Complications after Lapidus procedureComplications after Lapidus procedure Complication after Keller Resection Complication after Keller Resection


Crescentic Proximal Crescentic Proximal OsteotomyOsteotomy


At 1 Year:At 1 Year:MetatarsalgiaMetatarsalgia

After WeilAfter WeilShortening:Shortening:


1 Year post-op1 Year post-op


1 Year Post-op: 1 Year Post-op:

Ludloff OsteotomyLudloff Osteotomy

Modified LudloffModified Ludloff

Modified Ludloff…ComplicationsModified Ludloff…Complications

Modified Ludloff…ComplicationsModified Ludloff…Complications

Plantar-flexionPlantar-flexionLost of FixationLost of Fixation

Hallux Valgus with Hallux Valgus with ArthrosisArthrosis

What would you What would you do?do?

Recurrence after Proximal Recurrence after Proximal ChevronChevron

5 Months after 5 Months after

Complication after Complication after Proximal osteotomyProximal osteotomy

Mal-UnionMal-Union– Dorsi-FlexionDorsi-Flexion– Plantar-FlexionPlantar-Flexion

Non-UnionNon-Union Excessive ShorteningExcessive Shortening Under-correctionUnder-correction Over-correctionOver-correction

Complications after Proximal Complications after Proximal Crescentic Osteotomy (Mann)Crescentic Osteotomy (Mann)

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

– 1. Incorrect orientation of the osteotomy1. Incorrect orientation of the osteotomy When patent lie supine: Hips are in external Rotation the cut tend to be When patent lie supine: Hips are in external Rotation the cut tend to be

PROXIMAL-MEDIAL to DISTAL-LATERAL PROXIMAL-MEDIAL to DISTAL-LATERAL elevation of Metatarsal head elevation of Metatarsal head

– 2. Positioning of the Osteotomy (ideal: 10-12 mm)2. Positioning of the Osteotomy (ideal: 10-12 mm) Too distal: * cortical bone… Heals less readilyToo distal: * cortical bone… Heals less readily

* Narrow shaft .… More unstable* Narrow shaft .… More unstable Too Proximal: Fixation is difficult or impossibleToo Proximal: Fixation is difficult or impossible

_ _ 3. Fixation of the Osteotomy3. Fixation of the Osteotomy

* * Fixation is problematic Fixation is problematic

Proximal: cancellous, short. Distal: Hard corticalProximal: cancellous, short. Distal: Hard cortical

Screw bestScrew best but sometime unstable and but sometime unstable and recurrence not rare.recurrence not rare.

Complications after Complications after Proximal Osteotomy- Proximal Osteotomy-

TreatmentTreatment Mal-UnionMal-Union

– Dorsi-Flexion:Dorsi-Flexion: Sometimes difficult to Sometimes difficult to correctcorrect

TX: Some type of plantar osteotomyTX: Some type of plantar osteotomy If excessive shortening: BONE GRAFTINGIf excessive shortening: BONE GRAFTING

- - Plantar-Flexion:Plantar-Flexion:

* * Dorsi-Flexion osteotomyDorsi-Flexion osteotomy

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

* * Non-Union: Non-Union: rarely. If occurs: Bonerarely. If occurs: Bone graftinggrafting





Excessive ShorteningExcessive Shortening

– Can be a significant problemCan be a significant problem – Similar as after Mitchell OseotomySimilar as after Mitchell Oseotomy– Sometimes: Lengthening 1Sometimes: Lengthening 1stst meta meta– Generally: Shortening 2Generally: Shortening 2ndnd ( ? + 3 ( ? + 3rdrd ) )





Under-correction Under-correction (of IM angle)(of IM angle)– TX: another Crescentic OsteotomyTX: another Crescentic Osteotomy

or an Open wedge Osteotomyor an Open wedge Osteotomy

• Over-correction:Over-correction:• Often result in a Often result in a HALLUX VARUSHALLUX VARUS

Complications after proximal Complications after proximal osteotomyosteotomy

Key: PreventionKey: Prevention

Indications for Proximal OsteotomyIndications for Proximal Osteotomy– IM angle IM angle > 14 ° (13-15 °) > 14 ° (13-15 °) + STR+ STR– HV angle > 40 ° (30-40 °)HV angle > 40 ° (30-40 °)

Goal: To correct the intermetatarsal angle)Goal: To correct the intermetatarsal angle)

Contraindication:Contraindication:– 11stst MTP Osteoarthritis MTP Osteoarthritis– DMAA >15-20° ( Unless Double DMAA >15-20° ( Unless Double

osteotomy)osteotomy)– (Severe H Valgus with Hypermobility) (Severe H Valgus with Hypermobility)

Hallux Varus after proximal Hallux Varus after proximal osteotomyosteotomy

Hallux Varus after HV CorrectionHallux Varus after HV Correction

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

(Overpull of Abductor Hallucis)(Overpull of Abductor Hallucis)

• Excision of Lateral sesamoidExcision of Lateral sesamoid• Excessive medial capsule tighteningExcessive medial capsule tightening• Excessive Medial Eminence removingExcessive Medial Eminence removing• Overcorrection of IM angleOvercorrection of IM angle• Excessive Overcorrection with Postop Excessive Overcorrection with Postop

dressingdressing

Hallux Varus after HV TreatmentHallux Varus after HV Treatment

Excessive Lateral Soft Excessive Lateral Soft Tissue Tissue ReleaseRelease

*Interruption of Lateral Conjoint Tendon*Interruption of Lateral Conjoint Tendon (Overpull of Abductor Hallucis)(Overpull of Abductor Hallucis)

• Excision of Lateral sesamoidExcision of Lateral sesamoid• Excessive medial capsule tighteningExcessive medial capsule tightening• Excessive Medial Eminence removingExcessive Medial Eminence removing• Overcorrection of IM angleOvercorrection of IM angle• Excessive Overcorrection with Post-op dressingExcessive Overcorrection with Post-op dressing

MTP Lateral Soft tissue MTP Lateral Soft tissue ReleaseRelease

TECHNIC 1TECHNIC 1 1.1. Adductor HallucisAdductor Hallucis

– Identified and isolated from Flexor Hallucis Identified and isolated from Flexor Hallucis Brevis with Hemostat clamp. Brevis with Hemostat clamp.

– No need to relocate on Meta. neckNo need to relocate on Meta. neck (Conjoint tendon: Add. Hallucis + FHB)(Conjoint tendon: Add. Hallucis + FHB)

2.2. Metatarso-Sesamoid suspensor Lig.Metatarso-Sesamoid suspensor Lig.– (to free the fibular sesamoid, that can after be (to free the fibular sesamoid, that can after be

relocated under the Metatarsal headrelocated under the Metatarsal head Not cutting the: Metatarso-Phalangial Lig.Not cutting the: Metatarso-Phalangial Lig.

(Collateral lig.) (Collateral lig.) re.: Risk of H. Varusre.: Risk of H. Varus

N.B.N.B. Deep Transverse Metatarso-phalangial Deep Transverse Metatarso-phalangial Ligament Ligament doesn’tdoesn’t need to be cut need to be cut

MTP Lateral Soft tissueMTP Lateral Soft tissue

Flexor Hallucis Brevis

Adductor Hallucis

Fibular Sesamoid Sesamoid

Metatarso-sesamoid suspensor Lig

MTP Lateral collateral Lig.

Conjoint tendon= PIB

PIB= Phalangial Insertion PIB= Phalangial Insertion BandBand

MTP Lateral Soft tissue MTP Lateral Soft tissue ReleaseRelease

TECHNIC 2TECHNIC 2 1.1. Conjoint tendon (Conjoint tendon (PIB: Phalangial PIB: Phalangial

Insertion Band)Insertion Band) 2.2. Metatarso-Sesamoid suspensor Lig.Metatarso-Sesamoid suspensor Lig.

– (to free the fibular sesamoid, that can after be (to free the fibular sesamoid, that can after be relocated under the Metatarsal headrelocated under the Metatarsal head

Not cutting the: Metatarso-Phalangial Lig.Not cutting the: Metatarso-Phalangial Lig. (Collateral lig.) (Collateral lig.) re.: Risk of H. Varusre.: Risk of H. Varus

N.B.N.B. Deep Transverse Metatarso-phalangial Deep Transverse Metatarso-phalangial Ligament Ligament doesn’tdoesn’t need to be cut need to be cut

MTP Lateral Soft tissueMTP Lateral Soft tissue

Flexor Hallucis Brevis

Adductor Hallucis

Fibular Sesamoid Sesamoid

Metatarso-sesamoid suspensor Lig

MTP Lateral collateral Lig.

Conjoint tendon= PIB

PIB= Phalangial Insertion PIB= Phalangial Insertion BandBand

Metatarso-sesamoidSuspensor Lig.

ADD.Hallucis

EHL

ABD.Hallucis

FHL Fibular Sesamoid





Scarf OsteotomyScarf Osteotomy

General Indications:General Indications:– Same as Proximal Osteotomy IM Same as Proximal Osteotomy IM

>14-18°>14-18°– More versatileMore versatile– More stableMore stable– More demandingMore demanding

SCARF SCARF OSTEOTOMYOSTEOTOMY

Scarf OsteotomyScarf OsteotomyBarouk, L.S., Barouk, L.S., SCARF OSTEOTOMY FOR HALLUX VALGUS CORRECTIONSCARF OSTEOTOMY FOR HALLUX VALGUS CORRECTION

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

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

HVA: 35.2° HVA: 35.2° 16.4 °16.4 °

IMA: 17.4° IMA: 17.4° 10.2°10.2°

ROM: 75 ° (DF: 65° PF: 10°)ROM: 75 ° (DF: 65° PF: 10°) Complications:Complications:

– 2 Stress fractures ( at proximal osteotomy site)2 Stress fractures ( at proximal osteotomy site)– 4 Recurrences (HVA 4 Recurrences (HVA >25°) 2 need capsuloplasty>25°) 2 need capsuloplasty– 5 Over-correction5 Over-correctionHallux Varus (Learnig curve: 8%Hallux Varus (Learnig curve: 8%3%)3%)– 3% Prominent Hardware, less with Threaded head screws.3% Prominent Hardware, less with Threaded head screws.– 3 Osteonecrosis ( 2 need arthrodesis)3 Osteonecrosis ( 2 need arthrodesis)– Rare : Under-correction or Stiffness (early mobilization) Rare : Under-correction or Stiffness (early mobilization)

Revision of Failed Foot Surgery: a critical Revision of Failed Foot Surgery: a critical analysis analysis KILMARTIN, TE. J. Foot Ankle Surg. 41: KILMARTIN, TE. J. Foot Ankle Surg. 41: 309-315, 2002309-315, 2002

Off 244 patients refer by GP after Off 244 patients refer by GP after all all type off type off failed foot surgery, 218 treated with revision failed foot surgery, 218 treated with revision surgery:surgery:– 152 (66 %) :Failed first ray Surgery152 (66 %) :Failed first ray Surgery

42% : After Mitchell Procedure42% : After Mitchell Procedure 14% : After Keller14% : After Keller 14% : After First MTP Fusion14% : After First MTP Fusion 8.6% : After Silver ( Bumpectomy+ STR)8.6% : After Silver ( Bumpectomy+ STR)

– Diagnosis Diagnosis ( 244 patients)( 244 patients) 34% : Transfer Metatarsalgia34% : Transfer Metatarsalgia 26% : Recurrent H. Valgus26% : Recurrent H. Valgus 18% : Lesser digit deformity18% : Lesser digit deformity 5% : Continued pain over 1 MTP5% : Continued pain over 1 MTP

Revision of Failed Foot Surgery: a critical Revision of Failed Foot Surgery: a critical analysis analysis KILMARTIN, TE. J. Foot Ankle Surg. 41: KILMARTIN, TE. J. Foot Ankle Surg. 41: 309-315, 2002309-315, 2002

Revision surgeryRevision surgery– 32%: Lesser Metatarsal surgery32%: Lesser Metatarsal surgery

Weil or SchwartzWeil or Schwartz

– 23%: Lesser Toe surgery23%: Lesser Toe surgery– 21%: First Metatarsal-Phalanx 21%: First Metatarsal-Phalanx

Scarf-AkinScarf-Akin

– 4% : First & Lesser Metatarsal4% : First & Lesser Metatarsal Scarf-Akin and Weil or SchwartzScarf-Akin and Weil or Schwartz

86% Might have been avoid86% Might have been avoid



Complications after proximal osteotomyComplications after proximal osteotomy Complication after Scarf osteotomyComplication after Scarf osteotomy Complications after Lapidus Complications after Lapidus

procedureprocedure Complication after KellerComplication after Keller

11stst Metatarsal-Cuneiform arthrodesis: Metatarsal-Cuneiform arthrodesis: The Lapidus Procedure The Lapidus Procedure

Indication for Lapidus Procedure:Indication for Lapidus Procedure:– Severe Hallux ValgusSevere Hallux Valgus, With , With HypermobilityHypermobility

(Instability of the Metatarso-Cuneiform (Instability of the Metatarso-Cuneiform joint) in saggital plane, particularly with joint) in saggital plane, particularly with Generalize Ligamentous LaxityGeneralize Ligamentous Laxity mostly in: mostly in: Hallux Valgus JuvenileHallux Valgus Juvenile with High with High 1-2 Inter-Metatarsal angle IM angle >18° 1-2 Inter-Metatarsal angle IM angle >18°

– OA 1OA 1stst TMT TMT– Sometime in adult flatfoot from PTTDSometime in adult flatfoot from PTTD

Should Should not not be done if 1be done if 1stst Metatarsal is short Metatarsal is short ((or Open Epiphysisor Open Epiphysis

Complications after Lapidus ProcedureComplications after Lapidus Procedure

1. Non-union1. Non-union 2. Mal-Union: Dorsi-Flexion 2. Mal-Union: Dorsi-Flexion

(mostly)(mostly) 3. Excessive Shortening 3. Excessive Shortening

Complications Lapidus ProcedureComplications Lapidus Procedure

1. Non-UNION1. Non-UNION (10-12%....7% to (10-12%....7% to 50%!!)50%!!)– Significantly more common than Mal-UnionSignificantly more common than Mal-Union

Very high ratesVery high rates Frequently symptomaticFrequently symptomatic Need: Need: Multiple screw fixation Multiple screw fixation andand

– Cast Immobilisation Cast Immobilisation and and

A period ofA period of non-weight bearingnon-weight bearing ( 4-( 4-6 weeks)6 weeks)

((Union rate better withUnion rate better with Bone Grafting) Bone Grafting)

Modified Lapidus Modified Lapidus procedureprocedure

Popularize by Popularize by Sig. HansenSig. Hansen

Minimal articular Minimal articular resectionresection

C1C1 M1 M1 M1M1 M2 M2 Big Screws (4.0-Big Screws (4.0-

4.5)4.5) Lag Screw tech.Lag Screw tech. Local Bone GraftLocal Bone Graft

Fusion rate of 1Fusion rate of 1stst TMT arthrodesis in TMT arthrodesis in MODIFIEDMODIFIED Lapidus and Flatfoot Lapidus and Flatfoot

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

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

201 feet 201 feet

Non-Union : 4 % ( 8 cases)Non-Union : 4 % ( 8 cases)5 Had previous Bunion Surgery5 Had previous Bunion Surgery

2 Smokers2 Smokers

1 diabetic1 diabetic Of 201 feet, 25 (12%) had Recurrence after Previous Of 201 feet, 25 (12%) had Recurrence after Previous

Bunion Surgery.Bunion Surgery.– Out of these: 20% had Non-Union after Modified Out of these: 20% had Non-Union after Modified

LapidusLapidus

Complications Lapidus Complications Lapidus ProcedureProcedure

2. MAL-UNION2. MAL-UNION– Technically difficultTechnically difficult re.: Dorsal incision : Poor re.: Dorsal incision : Poor

visualisation Re.: depth of bonevisualisation Re.: depth of bone ۩۩ MEDIAL MEDIAL INCISIONINCISION Some Plantar-Flexion Some Plantar-Flexion of the ray usually require to of the ray usually require to

compensate the shortening ( too much compensate the shortening ( too much sesamoid sesamoid pain)pain)

3. SHORTENING:3. SHORTENING:– Relative to joint resectionRelative to joint resection



Complications after proximal osteotomyComplications after proximal osteotomy Complication after Scarf osteotomyComplication after Scarf osteotomy Complications after Lapidus procedureComplications after Lapidus procedure

Complication after Keller Resection Complication after Keller Resection ArthroplastyArthroplasty

Complications after Complications after KellerKeller Salvage of a Failed Keller Resection ArthroplastySalvage of a Failed Keller Resection Arthroplasty

Machacek Lr., Felix and all.Machacek Lr., Felix and all. JBJS-A Vol. 86-A, Number 6, June 2005JBJS-A Vol. 86-A, Number 6, June 2005

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

Group A-Group A- Treated with Treated with FusionFusion (29 feet), FU: 36 months (29 feet), FU: 36 months 90% healed. AOFAS score: 76/9090% healed. AOFAS score: 76/90

Needed surgery: Needed surgery: 17% need refusion (3 Mal-Union & 2 non-union) 17% need refusion (3 Mal-Union & 2 non-union) 62% Needed Lesser Metatarsal shortening ( Weil,Helal,etc.)62% Needed Lesser Metatarsal shortening ( Weil,Helal,etc.)

Group B-Group B- Re-Keller or STRRe-Keller or STR (EHL Z-Lenghtening) (18 feet), FU:74 monhs (EHL Z-Lenghtening) (18 feet), FU:74 monhs AOFAS score: 46/90 Non-Satisfied: 61%AOFAS score: 46/90 Non-Satisfied: 61% Cock-up: 67 % Recurrence:39% Rigidus:11%Cock-up: 67 % Recurrence:39% Rigidus:11%

Conclusion: Conclusion: Fusion much better, but more demandingFusion much better, but more demanding

Recurrent H. Valgus without arthrosis:Recurrent H. Valgus without arthrosis:The Lapidus procedureThe Lapidus procedure

The Lapidus procedure as salvage After Failed The Lapidus procedure as salvage After Failed Surgical Treatmen of Hallux Valgus. A Surgical Treatmen of Hallux Valgus. A Prospective Cohort StudyProspective Cohort Study– COETZEE, J.CHRIS;, RESIG,SCOTT G.,; COETZEE, J.CHRIS;, RESIG,SCOTT G.,;

KUSKOWSKI,MICHAEL; SALEH, KHALED J.KUSKOWSKI,MICHAEL; SALEH, KHALED J.– JBJS-A January 2003,Volume 85-A Number 1 60-65JBJS-A January 2003,Volume 85-A Number 1 60-65

Here it is only recurrent H. ValgusHere it is only recurrent H. Valgus AOFAS score 47.6AOFAS score 47.687.987.9 Visual Analog Pain Scale 6.2Visual Analog Pain Scale 6.2 1.4 1.4 Very satisfied: 77% Satisfied : 4% Somewhat Very satisfied: 77% Satisfied : 4% Somewhat

satisfied: 19% Dissatisfied: 0satisfied: 19% Dissatisfied: 0 C1C1M1 & M1M1 & M1M2M2

First Metatarsophalangeal Joint First Metatarsophalangeal Joint Arthrodesis as a Treatment for Failed Arthrodesis as a Treatment for Failed Hallux Valgus SurgeryHallux Valgus Surgery

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

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

First Metatarsophalangeal Joint Arthrodesis First Metatarsophalangeal Joint Arthrodesis as a Treatment for Failed Hallux Valgus as a Treatment for Failed Hallux Valgus SurgerySurgery

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

55% recurrence H. Valgus, 24% H. Varus, etc.55% recurrence H. Valgus, 24% H. Varus, etc. 82% have Lesser toes complaints82% have Lesser toes complaints AOFAS score of 73 (Excellent 39%, Good 33%AOFAS score of 73 (Excellent 39%, Good 33%

Fair 24% , Poor 3%)Fair 24% , Poor 3%)

79% would have the surgery again79% would have the surgery again

The number 1 The number 1 complication of complication of Hallux Valgus Hallux Valgus

surgery is not on the surgery is not on the first ray !first ray !

Transfer Transfer Metatarsalgia is Metatarsalgia is

the No. 1 problem the No. 1 problem after bunion after bunion

surgery. Usually surgery. Usually 22ndnd Metatarsal Metatarsal..

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

ThomasThomas))

– Most: Most: Foot surgery : 23 %Foot surgery : 23 %

Out of this: Out of this:

64% : Lesser metatarsal neck 64% : Lesser metatarsal neck Osteotomy Osteotomy

Patients Expectations vs Realistic Patients Expectations vs Realistic ResultsResults

Good discussionGood discussion Need to Need to repeatrepeat and repeat and repeat When they listen…( i.e. Not looking at When they listen…( i.e. Not looking at

their their Question list, Question list, or not thinking at their or not thinking at their next question, most next question, most do not really do not really understandunderstand the technical explanations. the technical explanations.

They tend to They tend to underestimateunderestimate minor minor warningswarnings

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


1. 1. Recognize whyRecognize why the first surgery failed the first surgery failed– Don’t repeat the initial error…Don’t repeat the initial error…

2. 2. Look the Look the Whole FootWhole Foot (r (re. Lessere. Lesser Metatarsals)Metatarsals)

3. Look if there are 3. Look if there are Degenerative changesDegenerative changes

Weil osteotomyWeil osteotomy

Classical Weil Classical Weil osteotomyosteotomy

Osteotomy parallel to Osteotomy parallel to the sole of the footthe sole of the foot

Ex.: 5 mm shortening Ex.: 5 mm shortening ==

2 mm plantar 2 mm plantar displacementdisplacement

The problem in The problem in rigid footrigid foot with with

IPK, IPK, tend to displace the tend to displace the “BUMP” more proximal“BUMP” more proximal

Weil: Myerson’s Weil: Myerson’s modificationmodification

With a wedge resection With a wedge resection above the 25above the 25° cut° cut

5 mm shortening =5 mm shortening = 0.8 mm plantar 0.8 mm plantar

displacementdisplacement

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

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

Weil: My modificationWeil: My modification

A complete removal of A complete removal of 2 to 3 mm slice2 to 3 mm slice

At an angle of 15 to 20 At an angle of 15 to 20 °°

Can correct sub-Can correct sub-luxation MTP luxation MTP andand IPK IPK in in many cases.many cases.

Not indicated in very osteoporotic Not indicated in very osteoporotic patients)patients)

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


Results & Complications:Results & Complications: KH. Kristen, C. Berger, S. Steizig, E. Thaihammer, M. Posch, A. EngelKH. Kristen, C. Berger, S. Steizig, E. Thaihammer, M. Posch, A. Engel

The SCARF Osteotomy for the Correction of Hallux Valgus The SCARF Osteotomy for the Correction of Hallux Valgus DeformitiesDeformities

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

– 89 patients Post-op HV: 1989 patients Post-op HV: 19° IM: 6.6 °° IM: 6.6 ° Return to Work: 6 weeks, to Sports: 8.3 weeks Return to Work: 6 weeks, to Sports: 8.3 weeks

Complications:Complications: 7 7 Recurrence 6%Recurrence 6%

4 4 Hallux Limitus Hallux Limitus (ROM <40°)(ROM <40°)

2 Superficial infections2 Superficial infections

1 Dislocation of distal fragment1 Dislocation of distal fragment


Results & ComplicationsResults & Complications

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

2 years FU2 years FU HV angle 32HV angle 32°°11°11° IM angle 14°IM angle 14°6°6° Complications: Complications: 1 Osteonecrosis Meta. 1 Osteonecrosis Meta.

HeadHead– 1 Painful Over-correction1 Painful Over-correction


Results & ComplicationsResults & Complications : : Valentin, B; Leemrijse, Th:Valentin, B; Leemrijse, Th: Scarf osteotomy of the first Scarf osteotomy of the first

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

56 patients 5 years FU56 patients 5 years FU HV 38.5HV 38.5° ° 19° 19° IM 16.6° IM 16.6° 11° 11°

Complications:Complications:– 15 Hallux Limitus15 Hallux Limitus


– Results & ComplicationsResults & Complications

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

– 53 cases 14 months FU53 cases 14 months FU– HV angle: 43° HV angle: 43° 23°23°– IM angle : 16°IM angle : 16°8°8°

– Complications:Complications: 2 Fractures of 12 Fractures of 1stst Metatarsal ( at distal screw Metatarsal ( at distal screw

level)level)

Scarf OsteotomyScarf Osteotomy Wagner, A; Fuhrmann, R; Abramovsky, I: Early results of Scarf Wagner, A; Fuhrmann, R; Abramovsky, I: Early results of Scarf

osteotomies using differentiated therapy of hallux valgus. Foot and osteotomies using differentiated therapy of hallux valgus. Foot and Ankle surgery 6:105-112, 2000Ankle surgery 6:105-112, 2000

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

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

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

Late results of Modified Mitchell Procedure Late results of Modified Mitchell Procedure for the Treatment of Hallux Valgus for the Treatment of Hallux Valgus Fokter, Samo Karl Fokter, Samo Karl Foot & Ankle Int. Vol.5 May 99 Foot & Ankle Int. Vol.5 May 99

Long term FU (Mean:21 years) n=105Long term FU (Mean:21 years) n=105– 72% Totally satisfied72% Totally satisfied– 16% Reservation: Pain16% Reservation: Pain– 6% Reservation: Apparence6% Reservation: Apparence– 3% Reservation: ROM3% Reservation: ROM– 4% Not satisfied4% Not satisfied

AOFAS-Hallux MTP Score AOFAS-Hallux MTP Score Compare to author 4 Compare to author 4 categoriescategories– Excellent group: AOFAS score: 95.2 Excellent group: AOFAS score: 95.2 37 %37 %

– Good : “ : 86.3 Good : “ : 86.3 28.2% 28.2% 65% = Exc.65% = Exc.+Good+Good

– Satisfactory : “ : 67.7 Satisfactory : “ : 67.7 21.4%21.4%– Poor : “ : 55.4 Poor : “ : 55.4 13.6% 13.6%

Late results of Modified Mitchell Late results of Modified Mitchell Procedure for the Treatment of Hallux Procedure for the Treatment of Hallux Valgus Valgus Fokter, Samo Karl; Podobnik Fokter, Samo Karl; Podobnik Foot & Ankle Int. Vol.5 May 99 Foot & Ankle Int. Vol.5 May 99

Initially At FU Initially At FU Mean HV angle 33Mean HV angle 33°° 17 17°° Mean IM angle Mean IM angle 22.5 22.5 °° 7.7 7.7°°

21% recurred over medial eminence21% recurred over medial eminence 13.3 IPK under 213.3 IPK under 2ndnd Metatarsal Metatarsal

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

92.4 % would agree to undergo the operation 92.4 % would agree to undergo the operation againagain

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