Scarf and Weil osteotomies for correction of rheumatoid forefoot deformities: A review of 20 cases

The forefoot is commonly affected in rheumatoid arthritis. Little has been written of the results of metatarsophalangeal joint preservation in rheumatoid arthritis. We describe the results of the Scarf and Weil osteotomy for correction of forefoot deformities in patients with rheumatoid arthritis. Between 1996 and 1999, 17 patients (20 feet) underwent a Scarf osteotomy for their hallux valgus deformity and in 17 feet a Weil osteotomy of the lesser metatarsophalangeal joints. Radiographic examination was performed preoperatively and at a mean follow up of 65 months. A questionnaire was used at a minimum follow up of 6 years. The hallux valgus angle improved from 41° to 28° at follow up. The majority of the patients (79%) were satisfied with the result during follow-up. We found no wound infections, neuralgia or osteonecrosis of the first metatarsal. In three patients, a fusion of the first MTP joint was performed at follow up.In conclusion, the Scarf and Weil osteotomy is a useful method for MTP joint preserving surgery in rheumatoid forefoot deformities without severe impairment of the MTP joints.     

Results of Akin type proximal phalangeal osteotomy for correction of hallux valgus deformity

The results of 26 Akin proximal phalangeal osteotomies in 22 patients for hallux valgus deformities are reported. The average follow up was 53 months (range, 12 to 97 months). Subjectively, 16 feet had a satisfactory result (61.5%). Objectively, 14 feet met the criteria for a satisfactory result (53.8%). The authors found that the Akin osteotomy was unpredictable as an isolated procedure, and not indicated in a hallux valgus deformity with an incongruent joint.     

Rheumatoid Forefoot Reconstruction in Nonrheumatic Patients: Lesser Metatarsal Head Resection versus Osteotomy

In the literature, first metatarsophalangeal joint arthrodesis with lesser metatarsal head resection seems to be a reliable procedure in rheumatoid foot deformity. Maybe this procedure could be proposed in nonrheumatoid severe forefoot deformity (hallux valgus angle >40° and lesser metatarsophalangeal dislocation). The aim of this study was to compare radiological and clinical outcomes between lesser metatarsal head resection and lesser metatarsal head osteotomy in nonrheumatoid patients. Thirty-nine patients (56 feet) suffering from well-defined nonrheumatoid severe forefoot deformity were retrospectively enrolled in our institution between 2009 and 2015. Metatarsal head resection and metatarsal head osteotomy represented 13 patients (20 feet) and 26 patients (36 feet), respectively. In this observational study, a rheumatoid population (21 patients) was included as the control. The clinical outcome measures consisted of American Orthopaedic Foot and Ankle Society score, Foot and Ankle Ability Measurement, and Short Form-36. The radiological outcomes were: intermetatarsal angle, hallux valgus angle, and metatarsophalangeal alignment. Mean follow-up was 24 months. Satisfaction rate was, respectively, 92% for resection, 91% for osteotomy procedure, and 80% for surgery in rheumatoid patients. Short Form-36 global score was, respectively, 80.7 (52.5-96.4), 76 (57.7-93), and 68.3 (22.6-86). No functional outcome difference was found between resection and osteotomy procedures, except that the metatarsal head resection group had poorer results in sports activities than the osteotomy group. Complications were similar between osteotomy and resection (p > .05). The radiological outcomes were improved significantly from preoperative to postoperative. First metatarsophalangeal joint arthrodesis with lesser metatarsal head resection in nonrheumatoid severe forefoot deformity might be a good therapeutic option.     

Akin截骨联合第1跖骨截骨治疗拇外翻的疗效

目的 探讨Akin截骨联合第1跖骨截骨治疗拇外翻的疗效.方法 采用Akin截骨联合第1跖骨截骨治疗27例拇外翻患者(27足):Akin截骨联合Chevron截骨19例,Akin截骨联合Scarf截骨6例,Akin截骨联合Juvara截骨2例.比较术前及末次随访时的第1、2跖骨间夹角(IMA)与拇外翻角(HVA)的变化....     

Chevron osteotomy in the treatment of hallux valgus

Fifty patients who underwent 80 chevron osteotomies for symptomatic hallux valgus were re-examined and assessed 4 years and 7 months (average) after surgery. Forty-five of the patients were satisfied with the result of their surgery, three patients suffered recurrence of their deformity and two had continuance of their symptomatology. The major complications noted were intraoperative intra-articular fracture of the metatarsal head in five feet, loss of initial repair in three feet, and tilt of the distal fragment (metatarsal head) in two feet. The Chevron osteotomy is a relatively simple procedure that corrects the varus deformity of the first metatarsal, realigns the valgus orientation of the metatarsal head, corrects the hallux valgus deformity, and improves symptomatology.     

Akin截骨术在拇外翻手术应用的探讨

背景：Akin截骨术能够纠正拇外翻手术中残留拇趾畸形但也存在并发症,总结探讨在拇外翻手术时联合应用Akin截骨治疗拇外翻的临床疗效并探讨使用指征。 方法：总结分析2006年10月至2010年10月,在拇外翻手术时联合应用Akin截骨术48足,软组织手术加Akin截骨术6足,chevon截骨术加Akin截骨术29足,跖骨基底截骨加Akin截骨术8足,第一跖楔关节融合加Akin截骨术5足。 结果：所有病例均获得随访,随访时间6个月至5年,平均30．3个月,未见拇外翻复发病例。术前拇外翻角为37．2°±8．9°,IMA为16．5°±6．7°;术后拇外翻角为13±6．8°,IMA为8．9°．±4．5°。术前AOFAS评分为（43±10．5）分,术后为（84±7．8）分,具有统计学意义。 结论：在拇外翻手术时,根据趾骨畸形情况联合应用Akin截骨术可以降低拇外翻手术复发率,临床效果确切,但需要严格掌握手术适应证。     

Clinical outcome after Chevron–Akin double osteotomy versus isolated Chevron procedure: a prospective matched group analysis

Background  

Hallux valgus is a frequent condition of the forefoot, resulting in cosmetic deformity and pain. Chevron osteotomy (CO) is widely employed for the treatment of hallux valgus. Chevron–Akin double osteotomy (CAO) was previously described and superiority over an isolated Chevron procedure was assumed. The objective of this study was to compare the short-to-middle term outcomes of CO and CAO.     

Chevron (Austin) distal metatarsal osteotomy for hallux valgus: comparison of pre- and post-surgical characteristics

The purpose of the study was to compare the range of motion, perceived pain and plantar loading characteristics of the Chevron (Austin) corrective procedures in treating hallux valgus (HV) 12 months postsurgically. Twenty-five female participants with the diagnosis of mild to moderate HV deformity were studied. All participants had a distal metatarsal osteotomy (Chevron (Austin)) to correct their deformity. First metatarsophalangeal and talocrural joint range of motion (ROM) and a 10-point analog pain scale were measured presurgically and 12 months post-surgically on each participant. Radiographic measures of hallux valgus and intermetatarsal (IM) angles were taken preoperatively and six weeks postoperatively for comparison. Five pressure distribution measurements were recorded of barefoot walking using the EMED-SF presurgically and 12 months postsurgically. Statistical analyses revealed that plantar loading is still altered 12 months postsurgically despite a decrease in perceived pain and adequate first metatarsophalangeal joint ROM. Greater loading occurred in the central forefoot (CFF) region with decreases in some of the loading parameters in the medial toe (MT) region postsurgically. Loading parameters in the lateral forefoot (LFF), heel (HL), midfoot (MF), and lateral toe (LT) were unchanged 12 months postsurgery compared to presurgery.     

Joint preserving surgery for rheumatoid forefoot deformities improves pain and corrects deformity at midterm follow-up

BackgroundRheumatoid arthritis is a chronic autoimmune disorder that commonly affects the metatarsophalangeal (MTP) joints. Conventional surgical treatment involves joint-sacrificing surgery to relieve pain and correct deformity.ObjectivesWe retrospectively reviewed 49 patients with rheumatoid forefoot deformities who underwent 66 joint preserving procedures with Scarf osteotomy of the first metatarsal and Weil's shortening osteotomy of the lesser metatarsals.MethodThere were 5 males and 44 females with mean age 56.1 years and mean follow-up 51 months. All patients were evaluated clinically and radiologically with hallux valgus angle (HVA) and inter-metatarsal angle (IMA).ResultsMean AOFAS score improved from 39.8 preoperatively to 88.7 at final follow-up. Subjectively patients reported their outcome as excellent in 49 feet (74%), good in 9 feet, fair in 7 feet and poor in 1 foot. Five feet had residual stiffness and 11 residual pain. Mean HVA and IMA decreased from 32° to 14° and from 15° to 11° respectively.ConclusionIn intermediate to severe stages of the disease, joint preserving surgery by Scarf osteotomy of the first MTP joint and Weil osteotomy of the lesser metatarsals may be performed as an alternative to joint-sacrificing procedures and should be considered as a complement to the various surgical treatments of the rheumatoid forefoot.     

Cotton Osteotomy in Flatfoot Reconstruction: A Review of Consecutive Cases

The Cotton osteotomy or opening wedge medial cuneiform osteotomy is a useful adjunctive flatfoot reconstructive procedure that is commonly performed; however, the outcomes are rarely reported owing to the adjunctive nature of the procedure. The Cotton procedure is relatively quick to perform and effectively corrects forefoot varus deformity after rearfoot fusion or osteotomy to achieve a rectus forefoot to rearfoot relationship. Proper patient selection is critical because the preoperative findings of medial column joint instability, concomitant hallux valgus deformity, or degenerative joint disease of the medial column might be better treated by arthrodesis of the naviculocuneiform or first tarsometatarsal joints. Procedure indications also include elevatus of the first ray, which can be a primary deformity in hallux limitus or an iatrogenic deformity after base wedge osteotomy for hallux valgus. We undertook an institutional review board-approved retrospective review of 32 consecutive patients (37 feet) who had undergone Cotton osteotomy as a part of flatfoot reconstruction. All but 1 case (2.7%) had radiographic evidence of graft incorporation at 10 weeks. No patient experienced graft shifting. Three complications (8.1%) were identified, including 2 cases with neuritis (5.4%) and 1 case of delayed union (2.7%) that healed with a bone stimulator at 6 months postoperatively. Meary's angle improved an average of 17.75°, from ?17.24°± 8.00° to 0.51°± 3.81°, and this change was statistically significant (p < .01). The present retrospective series highlights our experience with the use of the Cotton osteotomy as an adjunctive procedure in flatfoot reconstructive surgery.     

Cotton Osteotomy in Flatfoot Reconstruction: A Case Report Highlighting Surgical Technique and Modified Incision to Protect the Medial Dorsal Cutaneous Nerve

The Cotton osteotomy or opening wedge medial cuneiform osteotomy is a useful adjunctive flatfoot reconstructive procedure that is rarely performed in isolation. The Cotton procedure is relatively quick to perform and effectively corrects forefoot varus deformity after rearfoot fusion or osteotomy to achieve a rectus forefoot to rearfoot relationship. Proper patient selection is critical, because preoperative findings of medial column joint instability, concomitant hallux valgus deformity, or degenerative joint disease of the medial column might be better treated with arthrodesis of the naviculocuneiform or first tarsometatarsal joints. Procedure indications also include elevatus of the first ray, which can be a primary deformity in hallux limitus, or iatrogenic deformity after base wedge osteotomy in hallux valgus. We present the case of an adolescent patient who underwent flatfoot reconstruction, including Cotton osteotomy for correction of forefoot varus that was accentuated after double heel osteotomy. This case highlights our preferred procedure technique, including the use of a nerve-centric incision design. The use of an oblique dorsal medial incision is primarily intended to minimize the risk of trauma to the medial dorsal cutaneous nerve. At 20 months postoperatively for the right extremity and 12 months postoperatively for the left extremity, sensation remained intact, and the patient had not experienced any postoperative nerve symptoms. The patient had returned to playing sports without pain or restrictions.     

Hypermobility of the first metatarsal bone in patients with Rheumatoid arthritis treated by lapidus procedure

ABSTRACT: BACKGROUND: Foot deformities and related problems of the forefoot are very common in patients with rheumatoid arthritis. The laxity of the medial cuneometatarsal joint and its synovitis are important factors in the development of forefoot deformity. The impaired joint causes the first metatarsal bone to become unstable in the frontal and sagittal planes. In this retrospective study we evaluated data of patients with rheumatoid arthritis who underwent Lapidus procedure. We evaluated the role of the instability in a group of patients, focusing mainly on the clinical symptoms and X-ray signs of the instability. METHODS: The study group included 125 patients with rheumatoid arthritis. The indications of the Lapidus procedure were a hallux valgus deformity greater than 15 degrees and varus deformity of the first metatarsal bone with the intermetatarsal angle greater than 15 degrees on anterio-posterior weight-bearing X-ray. RESULTS: Data of 143 Lapidus procedures of 125 patients with rheumatoid arthritis, who underwent surgery between 2004 and 2010 was evaluated. Signs and symptoms of the first metatarsal bone instability was found in 92 feet (64.3 %) in our group. The AOFAS score was 48.6 before and 87.6 six months after the foot reconstruction. Nonunion of the medial cuneometatarsal joint arthrodesis on X-rays occurred in seven feet (4.9 %). CONCLUSION: The Lapidus procedure provides the possibility to correct the first metatarsal bone varus position and its instability, as well as providing the possibility to achieve a painless foot for walking. We recommend using the procedure as a preventive surgery in poorly symptomatic patients with rheumatoid arthritis in case of the first metatarsal bone hypermobility.     

A new surgical procedure for iatrogenic hallux varus: reverse transfer of the abductor hallucis tendon: a report of 7 cases

Iatrogenic hallux varus is a possible complication of hallux valgus surgery following Mc Bride or Scarf osteotomy, with or without Akin osteotomy of the first phalanx. It may also occur following chevron osteotomy or Keller's procedure. One possibility for surgical revision of iatrogenic hallux varus is reconstruction of the lateral stabilising soft-tissue components of the first metatarsophalangeal joint. Until now, only dynamic tendon transfers, possibly combined with interphalangeal fusion, have been described. The aim of our study was to develop a static, anatomic reconstruction procedure. A new surgical technique of ligamentoplasty using the abductor hallucis tendon is described. The new method was applied in 7 feet (5 patients) with a mean follow-up over two years. Hallux varus deformities were operated by transplantation of the abductor hallucis tendon. Subsequent radiographs showed correction of most of the factors considered to be responsible for the iatrogenic deformity. The American Orthopaedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal (MTP-IP) score improved from 61 to 88. This new technique is a reliable, anatomic reconstruction with use of the tendon involved in the pathogenesis of the hallux varus deformity. No other functional tendon is used.     

Distal soft tissue procedure and proximal metatarsal osteotomy in hallux valgus

The results of a distal soft tissue procedure and a proximal metatarsal osteotomy in patients with symptomatic hallux valgus deformity were reviewed. The series consisted of 33 patients (47 feet; mean age of patients, 44 years). The average followup period was 48 months. At followup, 41 feet (29 patients, 85%) were free from pain at the first metatarsophalangeal joint. In six feet (four patients), the pain was improved but persisted. The mean hallux valgus angle was 38 degrees before surgery and 13.8 degrees after surgery. The mean intermetatarsal angle was 17.7 degrees before surgery and 7 degrees after surgery. The postoperative hallux valgus angle and intermetatarsal angle in patients who had pain at the first metatarsophalangeal joint after surgery were greater than those in patients without pain after surgery. This procedure corrects the hallux valgus deformity and relieves the symptoms, but careful attention should be paid to the surgical technique to obtain consistent and satisfactory results.     

Scarf osteotomy for hallux valgus—is an Akin osteotomy necessary?

Scarf osteotomy has gained popularity as one of the recommended procedures for moderate to severe hallux valgus. An Akin osteotomy may also allow additional correction but carries its own complications. The aim of this study was to assess the need for Akin osteotomy with a scarf procedure.We reviewed our results of scarf osteotomy with and without Akin in 69 patients with 99 procedures. Sixteen patients (25 feet) had an Akin osteotomy with a scarf procedure. Radiological results were analysed by measuring the hallux valgus angle (HVA), intermetatarsal angle (IMA), distal metatarsal articular angle (DMAA) and the position of the tibial sesamoid. AOFAS scores were collected prospectively. Patient satisfaction was determined by whether or not they would have the operation again for a similar condition.The mean age of the patients was 48.3 years (range 12–76) with a mean follow-up of 21 months. The mean improvement for the whole group in the IMA was from 15.8 to 7.9, HVA from 37.9 to 16.4 and DMAA from 19 to 9.9 was noted. The position of sesamoids improved from a mean of 5.8 to 2.3. The results were similar in both the groups and no significant difference was noted. AOFAS score improved from a mean of 53.6 preoperatively to 92.5 postoperatively. Three patients in the scarf group needed an Akin osteotomy as a revision procedure.Scarf osteotomy alone may be an effective procedure for moderate to severe hallux valgus. An Akin osteotomy may be indicated if residual hallux valgus is noted during surgery.     

The Effect of First Metatarsophalangeal Arthrodesis on Transverse Plane Deviation of the Second Toe: A Retrospective Radiographic Study

The purpose of this retrospective, radiographic study was to examine the effect of first metatarsophalangeal arthrodesis on the transverse plane deviation of the second metatarsophalangeal joint. Sixty-nine patients (76 feet) were separated into 3 groups based on preoperative diagnosis: group 1, hallux valgus; group 2, hallux rigidus; and group 3, rheumatoid forefoot deformity with concomitant lesser metatarsal head resection. Intermetatarsal, hallux abduction, and second metatarsophalangeal angles were measured on preoperative and follow-up anteroposterior radiographs. Multivariate analysis found a significant postoperative change (P < .001) in both the intermetatarsal and hallux abduction angles for all groups, but no significant change in the second metatarsophalangeal angle for any group. There was also no significant difference in the number of patients with medial versus lateral second toe deviation in each group. The addition of a second ray procedure, such as a digital arthrodesis or second metatarsal decompression osteotomy, in groups 1 and 2 did not correlate to the amount of change in second metatarsophalangeal deviation. However, there was a significant correlation (r = .330; P = .004) between the amount of change in the hallux abduction angle and the amount of change in the second metatarsophalangeal angle. A lack of change in the second metatarsophalangeal angle in patients with hallux valgus and hallux rigidus suggests that the creation of a stable medial buttress may protect the lesser digits. However, in patients with rheumatoid, this lack of change denotes a postoperative recurrence of lateral deviation of the second toe despite lesser metatarsal head resection and stabilization of the hallux.     

Scarf osteotomy in hallux valgus: a review of 72 cases

The Scarf osteotomy is now widely used for the correction of hallux valgus. The aim of our study was to evaluate the results after Scarf osteotomy considering patient's satisfaction as well as the clinical and radiological results. Between 1996 and 1999, 72 feet underwent a Scarf osteotomy of the first metatarsal and, in 11 feet, an additional Akin osteotomy of the proximal phalanx, for the correction of hallux valgus (55 patients: 49 female, 6 male; mean age: 52 years). The hallux valgus angle improved significantly, from 32 degrees preoperatively to 18 degrees at follow-up (minimal follow-up: 6 years; mean: 7.5 years). A second operation was necessary in two patients because of recurrence of hallux valgus, and a fusion of the first metatarsophalangeal joint was performed in two patients. At the time of latest follow-up 78% of the patients were satisfied or very satisfied with the result. The Scarf osteotomy combined with Akin's closing wedge osteotomy is a safe and effective procedure for the treatment of moderate hallux valgus deformities.     

类风湿性关节炎前足畸形重建手术的近期疗效

目的探讨类风湿性关节炎前足畸形的手术治疗方法及近期疗效。方法 2007年1月-2009年8月,采用第1跖趾关节融合术联合第2～5跖趾关节成形术治疗7例类风湿性关节炎前足畸形女性患者。年龄56～71岁,平均62岁。病程5～30年,平均16年。患者均表现为双足外翻,第2～5趾合并锤状趾或槌状趾畸形,其中5足合并第2跖趾关节半脱位。根据美国矫形足踝协会(AOFAS)改良标准评分为(36.9±6.4)分。术前负重位X线片测量,第1跖趾关节外翻角度(46±5)°,第1、2跖骨间夹角(12±2)°。结果术后切口均Ⅰ期愈合。术后3～4个月X线片复查示第1跖趾关节达骨性融合。7例均获随访,随访时间2～4年,平均2.9年。患者跛行步态均较术前明显改善,行走时足部疼痛明显缓解。术后3个月X线片测量第1跖趾关节外翻角度为(17±4)°,第1、2跖骨间夹角为(11±2)°,与术前比较差异均有统计学意义(P<0.05)。术后2年根据AOFAS改良标准评分为(85.3±5.1)分,与术前比较差异有统计学意义(t=4.501,P=0.001)。1例于术后4年前足转移性跖骨痛复发,继续随访中未作特殊处理。结论第1跖趾关节融合术联合第2～5跖趾关节成形术治疗类风湿性关节炎前足畸形,可获得较好外翻矫形,重塑前足负重面,有效缓解行走时疼痛。     

Rheumatoid forefoot reconstruction. A long-term follow-up study

BACKGROUNDS: The purpose of the present study was to assess the results of reconstruction of the rheumatoid forefoot with arthrodesis of the metatarsophalangeal joint of the great toe, resection arthroplasty of the metatarsal heads of the lesser toes, and open repair of hammer-toe deformity (arthrodesis of the proximal interphalangeal joint) of the lesser toes when this deformity was present. METHODS: A retrospective study of forty-three consecutive patients (fifty-eight feet) with severe rheumatoid forefoot deformities was performed. Six patients (six feet) died before the most recent follow-up, and five patients (five feet) were excluded because a subtotal procedure had been performed. No patient was lost to follow-up. Thus, the study included thirty-two patients (forty-seven feet) in whom reconstruction of a rheumatoid forefoot had been performed by the author. RESULTS: All first metatarsophalangeal joints had successfully fused at an average of seventy-four months (range, thirty-seven to 108 months) postoperatively. The average postoperative hallux valgus angle was 20 degrees and the average postoperative angle subtended by the axes of the proximal phalanx and the metatarsal of the second ray (the MTP-2 angle) was 14 degrees, demonstrating that a stable first ray protected the lateral rays from later subluxation. One hundred and thirty-two (70 percent) of the 188 lesser metatarsophalangeal joints were dislocated preoperatively, compared with thirteen (7 percent) postoperatively. The result of the procedure (as rated subjectively by the patient) was excellent for twenty-three feet, good for twenty-two, and fair for two. There were no poor results. The average postoperative score according to the system of the American Orthopaedic Foot and Ankle Society was 69 points. Postoperative pain was rated as absent in eighteen feet, mild in twenty-five, moderate in four, and severe in none. Fifteen feet were not associated with any functional limitations, twenty-eight were associated with limitation of recreational activities, and four were associated with limitation of daily activities. At the time of the most recent follow-up, no special shoe requirements were reported. Fourteen feet (30 percent) had a reoperation for the removal of hardware from the first metatarsophalangeal joint, a procedure on the interphalangeal joint of the great toe, or additional procedures on the lesser toes or lesser metatarsophalangeal joints. CONCLUSIONS: In the present study, arthrodesis of the first metatarsophalangeal joint, resection arthroplasty of the lesser metatarsal heads, and repair of fixed hammer-toe deformities with intramedullary Kirschnerwire fixation resulted in a stable repair with a high percentage of successful results at an average of six years after the procedures.     

Treatment of hallux valgus with an increased distal metatarsal articular angle: evaluation of double and triple first ray osteotomies

During a 12-year period in which 878 hallux valgus corrections were performed, 18 patients (21 feet) with symptomatic hallux valgus deformity and an increased distal metatarsal articular angle (DMAA) underwent periarticular osteotomies (double or triple first ray osteotomies). They were studied retrospectively at an average follow-up of 33 months. The surgical technique comprised a closing wedge distal first metatarsal osteotomy combined with either a proximal first metatarsal osteotomy or an opening wedge cuneiform osteotomy (double osteotomy). When a phalangeal osteotomy was added, the procedure was termed a "triple osteotomy." The average age of the patients at the time of surgery was 26 years. At final follow-up, the average hallux valgus correction measured 23 degrees and the average 1-2 intermetatarsal angle correction was 9 degrees. The DMAA averaged 23 degrees preoperatively and was corrected to an average of 9 degrees postoperatively. One patient developed a postoperative hallux varus deformity, and one patient developed a malunion, both of which required a second surgery. A hallux valgus deformity with an increased DMAA can be successfully treated with multiple first ray osteotomies that maintain articular congruity of the first metatarsophalangeal joint.