Proximal fragment intermetatarsal angle (PFIA) increases after SCARF osteotomy

Category: Bunion Introduction/Purpose: Instability of the joint between the medial cuneiform and the first metatarsal is considered as one of the progression factors of Hallux valgus and its recurrence in some cases. We believe that we must increase the intermetatarsal angle of the proximal fragment during the correction by the SCARF osteotomy, seeking the greater degree of instability of this joint. Doing that, we can prevent further varus displacement, as we have reached the greater degree of instability. The purpose of this study was to evaluate if the SCARF osteotomy is able to increase the varus position of the base of the first metatarsal. Methods: This is a retrospective study with 32 patients with mild, moderate and severe hallux valgus, who were submitted to surgical treatment by the SCARF technique. All patients were operated by the same surgeon. Anteroposterior radiographs of the loaded foot were analyzed in the pre and postoperative (3 months) moments. We developed two measures to evaluate the position of the base of the first metatarsal: The Proximal Fragment Intermetatarsal Angle (PFIA), and the distance between the lateral cortex of the first metatarsal and the medial cortex of the second metatarsal (3 cm from the base of the first metatarsal). All measurements were made with a virtual ruler on magnified digital images and rounded to the nearest 0.1 mm. A 95% confidence interval was considered for statistical significant results (p<0,05). Results: The mean age of the sample was 44 years, with a predominance of females (62%). The mean pre-operative intermetatarsal angle was 14.9°, while in the postoperative period it was 5.2°, showing that there was correction of the metatarsal positioning. However, the PFIA increased to 17.8° at the post-operative period (p<0,05), showing a greater instability of the first metatarsal cuneiform joint, as the base of the first metatarsal was positioned in a more varus condition. In addition, we observed that there was an increase in the distance between the base of the first metatarsus and the second metatarsus after the surgical procedure, from 13.7 to 16 millimeters (p<0,05). Conclusion: We concluded that the SCARF osteotomy is able to increase the varus position of the base of the first metatarsal, leading to more instability at the first metatarsal cuneiform joint, and, in our opinion, less chance of recurrence in the long-term. A prospective and long-term is needed to prove this statement.

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Increased intermetatarsal angle of the proximal fragment after modified scarf osteotomy

Scientific Journal of the Foot & Ankle ◽

10.30795/scijfootankle.2018.v12.791 ◽

2018 ◽

Vol 12 (3) ◽

Cited By ~ 1

Author(s):

Henrique Maciel Prudente ◽

Daniel Soares Baumfeld ◽

Tiago Soares Baumfeld ◽

Benjamin Dutra Macedo ◽

Caio Augusto de Souza Nery

Keyword(s):

Hallux Valgus ◽

Metatarsal Head ◽

Proximal Fragment ◽

Level Of Evidence ◽

Intermetatarsal Angle ◽

First Metatarsal ◽

Scarf Osteotomy ◽

Proximal Stump ◽

First Ray

Objective: Hypermobility of the first ray can explain the correlation between the instability of this joint and the progression and recurrence of hallux valgus. The modified Scarf osteotomy allows rotation of the distal fragment, in addition to medial traction of the proximal fragment. We believe that if the deformity is corrected by maximizing the instability of the metatarsal-cuneiform joint so that medial inclination of the first metatarsal is no longer possible, then the risk of recurrence in the long term may be lower. Methods: The pre- and postoperative radiographs of 32 modified Scarf osteotomy cases were analysed. We compared already established angles for the radiographic analysis of the deformity, in addition to the creation of two new parameters for the evaluation of the varisation capacity of the osteotomy proximal stump. Results: There was correction of hallux valgus and the intermetatarsal angle, in addition to correction of the first metatarsal head in relation to the sesamoids. We found an increase of the medial inclination of the osteotomy proximal fragment, measured using the parameters proposed by the authors. Conclusion: The modified Scarf osteotomy corrects the conventional hallux valgus parameters, is able to increase the varisation of the proximal fragment of the first metatarsal, and may lead to greater instability in the first metatarsal-cuneiform joint, which, in our opinion, would lead to less chance of recurrence in the medium and long term. Level of Evidence IV; Diagnostic Studies.

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Mitchell Osteotomy for Hallux Valgus: Long-term Follow-up and Gait Analysis

Foot & Ankle ◽

10.1177/107110078300300402 ◽

1983 ◽

Vol 3 (4) ◽

pp. 189-196 ◽

Cited By ~ 70

Author(s):

Kurt D. Merkel ◽

Yoshihisa Katoh ◽

Einer W. Johnson ◽

Edmund Y. S. Chao

Keyword(s):

Retrospective Study ◽

Gait Analysis ◽

Hallux Valgus ◽

Age Groups ◽

Intermetatarsal Angle ◽

First Metatarsal ◽

Long Term Follow Up

In this retrospective study of 96 Mitchell first-metatarsal osteotomies performed on 69 patients with an average follow-up of 7 years, we found that more than 86% were completely satisfied and that the procedure was equally effective in all age groups. Excessive first metatarsal shortening, dorsiflexion of the osteotomy, and failure to correct the intermetatarsal angle to 10° or less correlated with poorer results. This study demonstrates a relationship between metatarsal shortening and osteotomy plan-tarflexion. Gait analysis demonstrated that these patients do not have normal foot mechanics postoperatively.

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Proximal Oblique Crescentic Osteotomy in Hallux Valgus

Journal of the American Podiatric Medical Association ◽

10.7547/87507315-94-1-43 ◽

2004 ◽

Vol 94 (1) ◽

pp. 43-46 ◽

Cited By ~ 11

Author(s):

Ozcan Pehlivan ◽

Ibrahim Akmaz ◽

Can Solakoglu ◽

Ahmet Kiral ◽

Haluk Kaplan

Keyword(s):

Hallux Valgus ◽

Osteotomy Site ◽

Intermetatarsal Angle ◽

First Metatarsal ◽

Valgus Angle ◽

Before And After ◽

The Mean ◽

American Orthopaedic ◽

Severe Hallux Valgus

Twenty-six patients with moderate-to-severe hallux valgus deformities were evaluated before and after treatment. All of the patients had incongruent great toe joints. The patients underwent modified proximal crescentic osteotomy, which was termed proximal oblique crescentic osteotomy. The results were evaluated at an average follow-up time of 55 weeks. Objective criteria were hallux valgus angle, intermetatarsal angle, shortening of the first metatarsal, and angulation at the osteotomy site. Clinical evaluation was made according to the rating system of the American Orthopaedic Foot and Ankle Society. The mean correction of the hallux valgus and intermetatarsal angles was 22.1° and 9.9°, respectively. Short-term results indicate that proximal oblique crescentic osteotomy is effective in the treatment of hallux valgus; its advantages over other procedures include its technical ease and low rate of complications. (J Am Podiatr Med Assoc 94(1): 43-46, 2004)

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Shortened First Metatarsal Bone and Newly Developed Second Metatarsalgia after Parallel-shaped Modified Scarf Osteotomy for Hallux Valgus Deformity

Foot & Ankle Orthopaedics ◽

10.1177/2473011417s000381 ◽

2017 ◽

Vol 2 (3) ◽

pp. 2473011417S0003 ◽

Cited By ~ 1

Author(s):

Jae Wan Suh ◽

Ho-Seong Jang ◽

Hyun-Woo Park ◽

Sung Bae Park

Keyword(s):

Propensity Score ◽

Hallux Valgus ◽

Valgus Deformity ◽

Metatarsal Bone ◽

First Metatarsal ◽

Scarf Osteotomy ◽

Hallux Valgus Deformity ◽

Second Metatarsal ◽

The Mean

Category: Bunion Introduction/Purpose: The scarf osteotomy has gained in popularity for the treatment of a symptomatic hallux valgus deformity due to its inherent stability, versatility of correction and early mobilization. We have reported parallel-shaped modified scarf osteotomy(PSMSO) with good functional outcomes and no complication as stress fracture or troughing. However, we encountered second transfer metatarsalgia after the osteotomy. The scarf osteotomy can be shortened, but there was no specific amount of shortening that will produce transfer metatarsalgia in limitation of our literature review. In this study, we measured the shortening of first metatarsal length and investigated the relation of first metatarsal length and second transfer metatarsalgia after PSMSO for hallux valgus deformity. Methods: We retrospectively reviewed 168 consecutive PSMSOs performed in 124 patients with hallux valgus deformity between March 2009 and August 2015. Concomitant other pathologies of foot or previous second metatarsalgia were excluded. After excluding 45 cases, 123 cases in 88 patients were included. For clinical assessment, VAS, the AOFAS Hallux Metatarsophalangeal-Interphalangeal (AOFAS Hallux MTP-IP) Scale were obtained. The hallux valgus angle (HVA), the intermetatarsal angle (IMA), the distal metatarsal articular angle (DMAA), the first metatarsal length measured by a modified Davies and Saxby’s method and the protrusion of second metatarsal relative to first metatarsal using the Maestro’s method were assessed on standard weight bearing radiographs of the foot. For evaluation of the development of second transfer metatarsalgia, callosity or tenderness beneath the second metatarsal head was investigated. After identifying the lesion, we divided two groups with and without second transfer metatarsalgia and compared the variables after propensity score matching. Results: Mean follow-up period was 20.6±7.8 (12-66) months. The mean VAS and AOFAS Hallux MTP-IP score improved significantly (p<0.001). Significant corrections in the HVA, IMA and DMAA were obtained and the mean shortening of the first metatarsal length and the mean relative lengthening of second metatarsal protrusion were -3.1±2.5 mm and +2.5±2.8 mm at last follow-up (p<0.001, p<0.001). Eleven (8.9%, 11/123) cases developed second transfer metatarsalgia after PSMSO. After propensity score matching considered baseline characteristics, 9 cases with second transfer metatarsalgia were compared to 31 cases without it. The group with transfer metatarsalgia showed significant shortening in first metatarsal length and lengthening of second metatarsal protrusion relative to first metatarsal compared to those without the transfer lesion (-4.8±3.8 vs -2.0±2.1, p=0.013, +4.2±1.6 vs +1.9±2.1, p=0.005). Conclusion: Transfer metatarsalgia is one of numerous possible complications after scarf osteotomy. To avoid complications, we suggest that shortening of first metatarsal bone length should be minimized within -2 mm and second metatarsal protrusion relative to first metatarsal kept within +1.9 mm with considering the metatarsal parabola. If the shortening of first metatarsal was done over -4.8 mm, the additional procedure for second metatarsal may be considered.

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PO 18115 - Percutaneous hallux valgus correction using the Reverdin-Isham osteotomy

Scientific Journal of the Foot & Ankle ◽

10.30795/scijfootankle.2019.v13.992 ◽

2019 ◽

Vol 13 (Supl 1) ◽

pp. 15S

Author(s):

Fábio Lemos Rodrigues ◽

Luiz Carlos Ribeiro Lara ◽

Juan Antonio Grajales ◽

Lucio Carlos Torres

Keyword(s):

Hallux Valgus ◽

Hallux Valgus Angle ◽

Aofas Score ◽

Intermetatarsal Angle ◽

First Metatarsal ◽

Valgus Angle ◽

Angle Correction ◽

Age At Surgery ◽

The Mean

Objective: To analyze the outcomes of percutaneous hallux valgus correction using the Reverdin-Isham osteotomy through clinical and radiographic studies. Methods: We retrospectively evaluated 43 feet in 38 patients with mild or moderate hallux valgus from June 2009 to July 2018. The mean age at surgery was 59 years; the mean postoperative follow-up time was 79 months. All patients treated with the Reverdin technique modified by Isham were evaluated in the pre- and postoperative periods using the American Association Orthopedic Foot and Ankle Society (AOFAS) score; we radiographically measured the hallux valgus angle (HVA), the intermetatarsal angle (IMA) and the first distal metatarsal articular angle (DMAA). Results: The AOFAS score increased by an average of 55 points. On average, the HVA decreased by 14°, the IMA by 3° and the DMAA by 9°. The mean reduction in the length of the first metatarsal bone was 0.3 cm. Conclusion: This surgical technique was effective for hallux valgus correction, demonstrating good angle correction and a marked increase in the AOFAS score.

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Z-osteotomy in hallux valgus: clinical and radiological outcome after Scarf osteotomy

Orthopedic Reviews ◽

10.4081/or.2009.e4 ◽

2009 ◽

Vol 1 (1) ◽

pp. 4 ◽

Cited By ~ 1

Author(s):

Marcus Jaeger ◽

Michael Schmidt ◽

Alexander Wild ◽

Bernd Bittersohl ◽

Susanne Courtois ◽

...

Keyword(s):

Range Of Motion ◽

Hallux Valgus ◽

Metatarsophalangeal Joint ◽

Mean Value ◽

Surgical Approaches ◽

Radiological Outcome ◽

Scarf Osteotomy ◽

Post Surgery ◽

The Mean

Correction osteotomies of the first metatarsal are common surgical approaches in treating hallux valgus deformities whereas the Scarf osteotomy has gained popularity. The purpose of this study was to analyze short- and mid-term results in hallux valgus patients who underwent a Scarf osteotomy. The subjective and radiological outcome of 131 Scarf osteotomies (106 hallux valgus patients, mean age: 57.5 years, range: 22-90 years) were retrospectively analyzed. Mean follow-up was 22.4 months (range: 6 months-5 years). Surgical indications were: intermetatarsal angle (IMA) of 12-23°; increased proximal articular angle (PAA>8°), and range of motion of the metatarsophalangeal joint in flexion and extension >40°. Exclusion criteria were severe osteoporosis and/or osteoarthritis. The mean subjective range of motion (ROM) of the great toe post-surgery was 0.8±1.73 points (0: full ROM, 10: total stiffness). The mean subjective cosmetic result was 2.7±2.7 points (0: excellent, 10: poor). The overall post-operative patient satisfaction with the result was high (2.1±2.5 points (0: excellent, 10: poor). The mean hallux valgus angle improvement was 16.6° (pre-operative mean value: 37.5°) which was statistically significant (p<0.01). The IMA improved by an average of 5.96° from a pre-operative mean value of 15.4° (p<0.01). Neither osteonecrosis of the distal fragment nor peri-operative fractures were noted during the follow-up. In keeping with our follow-up results, the Scarf osteotomy approach shows potential in the therapy of hallux valgus. 筻

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HV Patients Show Greater Pronation of the First Metatarsal than Normals

Foot & Ankle Orthopaedics ◽

10.1177/2473011417s000030 ◽

2017 ◽

Vol 2 (3) ◽

pp. 2473011417S0000

Author(s):

Bradley Campbell ◽

Stephen Conti

Keyword(s):

Regression Analysis ◽

Hallux Valgus ◽

Three Dimensional ◽

Basic Sciences ◽

Weak Correlation ◽

Intermetatarsal Angle ◽

First Metatarsal ◽

Second Metatarsal ◽

Three Dimensional Models ◽

Standard Radiographs

Category: Basic Sciences/Biologics, Bunion, Midfoot/Forefoot Introduction/Purpose: The progression of the hallux valgus (HV) deformity demonstrates dorsiflexion and abduction; concomitant pronation has not received adequate documentation and the extent of pronation in the pathology is unknown even though correction of the deformity may need to address all three angles. To overcome the inability of standard radiographs to capture pronation, we have developed a means to assess the three dimensional deformity using CT scans. Our goal was to document the extent of pronation/supination both of the first phalanx with respect to the first metatarsal and of the first metatarsal with respect to the second metatarsal. Furthermore, we wanted to regress pronation against the intermetatarsal (IMA) angle of hallux valgus patients. Methods: Three-dimensional models were reconstructed from loaded and unloaded CT files of patients (10 HV, 10 normal). The orientations of specific bones, in anatomic directions, were determined by selecting landmarks on the surface of the phalanx and of the first and second metatarsals. The resulting calculations output a set of angles to determine the pronation/supination of the first metatarsal relative to the second and of the first phalanx relative to the first metatarsal. A regression analysis was conducted to extrapolate any relationship between adduction and pronation (known intermetatarsal and pronation). Results: The average pronation of the first metatarsal relative to the second metatarsal was 19.8 ± 7.1 and 28.3 ± 10.8 in the normal and HV groups respectively (p < 0.05). The influence of weightbearing demonstrated pronation angle differences that were greater in the normal group than in the HV group for both the IM pronation and the HV pronation (p < 0.05) (Figure 1). The differences in HV angles and IM angles between normal and HV patients were 22° and 7° respectively. The regression analysis of the pronation and intermetatarsal angle was not found to be significant, with a weak correlation (r2 = 0.26). Conclusion: The pronation of the first metatarsal relative to the second metatarsal between normal and HV patients is significantly different. While the first metatarsal had measurable pronation in patients with hallux valgus but that value was not predicted by the IMA. The findings of this study indicate pronation should be considered in any surgical technique that seeks to restore native configurations.

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Proximal Rotational Metatarsal Osteotomy for Hallux Valgus (PROMO)

Foot & Ankle Orthopaedics ◽

10.1177/2473011418790071 ◽

2018 ◽

Vol 3 (3) ◽

pp. 247301141879007 ◽

Cited By ~ 1

Author(s):

Pablo Wagner ◽

Emilio Wagner

Keyword(s):

Hallux Valgus ◽

Case Series ◽

Valgus Deformity ◽

Metatarsal Osteotomy ◽

Level Of Evidence ◽

Reliable Technique ◽

Intermetatarsal Angle ◽

Hallux Valgus Deformity ◽

The Mean ◽

Prospective Case Series

Background: Hallux valgus deformity consists of a lateral deviation of the great toe, metatarsus varus, and pronation of the first metatarsal. Most osteotomies only correct varus, but not the pronation of the metatarsal. Persistent postoperative pronation has been shown to increase deformity recurrence and have worse functional outcomes. The proximal rotational metatarsal osteotomy (PROMO) technique reliably corrects pronation and varus through a stable osteotomy, avoiding fusing any healthy joints. The objective of this research is to show a prospective series of the PROMO technique. Methods: Twenty-five patients (30 feet) were operated with the PROMO technique. The sample included 22 women and 3 men, average age 46 years (range 22-59), for a mean prospective follow-up of 1 year (range 9-14 months). Inclusion criteria included symptomatic hallux valgus deformities, absence of severe joint arthritis, or inflammatory arthropathies, with a metatarsal malrotation of 10 degrees or more, with no tarsometatarsal subluxation or arthritis on the anteroposterior or lateral foot radiograph views. The mean preoperative and postoperative Lower Extremity Functional Scale (LEFS) score, metatarsophalangeal angle, intermetatarsal angle, metatarsal malrotation, complications, satisfaction, and recurrence were recorded. Results: The mean preoperative and postoperative LEFS scores were 56 and 73. The median pre-/postoperative metatarsophalangeal angle was 32.5/4 degrees and the intermetatarsal angle 15.5/5 degrees. The metatarsal rotation was satisfactorily corrected in 24 of 25 patients. An Akin osteotomy was needed in 27 of 30 feet. All patients were satisfied with the surgery, and no recurrence or complications were found. Conclusions: PROMO is a reliable technique, with good short-term results in terms of angular correction, satisfaction, and recurrence. Long-term studies are needed to determine if a lower hallux recurrence rate occurs with the correction of metatarsal rotation in comparison with conventional osteotomies. Level of evidence: IV, prospective case series.

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Radiographic Outcomes after Fixation of Distal Metatarsal Osteotomy for Hallux Valgus Using a Tension Band Construct

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00428 ◽

2019 ◽

Vol 4 (4) ◽

pp. 2473011419S0042

Author(s):

Alexander Volpi ◽

Robert Zbeda ◽

Christopher Katchis ◽

Lon Weiner ◽

Stuart Katchis

Keyword(s):

Hallux Valgus ◽

Postoperative Period ◽

Weight Bearing ◽

Line Tension ◽

Tension Band ◽

Metatarsal Osteotomy ◽

First Metatarsal ◽

Distal Metatarsal Osteotomy ◽

The Mean

Category: Bunion Introduction/Purpose: Hallux valgus is a common deformity of the forefoot. There are over 130 procedures described to correct hallux valgus. Classically, the treatment of mild to moderate hallux valgus is with a distal metatarsal osteotomy. A variety of fixation techniques have been described for use with this osteotomy most of which require partial or non-weight bearing until the osteotomy is healed. Tension Band fixation is a well-known principle in orthopedic surgery. The goal of the present study is to radiographically assess the maintenance of distal first metatarsal osteotomy fixation using a novel tension band device (Re+Line tension band bunion plate system, Nextremity Solutions) with immediate post-operative weight-bearing. Methods: The patient database for one surgeon was retrospectively reviewed for patients that underwent hallux valgus correction with the Re+Line tension band device between 2014 and 2017. Postoperative protocol included a soft dressing, firm surgical shoe, and weight-bearing as tolerated with a cane. Patients were excluded if fixation was achieved with something other than a tension band construct. Radiographs were obtained and reviewed retrospectively by 3 authors. Pre and postoperative hallux valgus (HVA) and intermetatarsal angles (IMA) were measured as described previously in the literature, and the changes in correction compared. Maintenance of correction and hardware integrity were assessed at final follow-up after weight bearing as tolerated in a surgical shoe in the postoperative period. Statistical analysis was performed using a Wilcoxon signed-rank test for the changes in HVA and IMA. Results: There was a total of 72 patients and 76 toes that underwent hallux valgus correction with a tension band construct, at a mean follow-up of 4.36 months. 68 of 72 patients were female. The average age was 60.8 years old. The mean preoperative HVA was 27.1 degrees. The mean postoperative HVA was 6.14 degrees, with a mean correction of 20.22 degrees (p<0.001). The mean preoperative IMA was 14.14 degrees. The mean postoperative IMA was 6.10 degrees, with a mean correction of 7.98 degrees (p<0.001). There was loss of reduction found in 6 of 76 toes (7.89%).There were zero cases of hardware failure. All osteotomies healed at final follow-up. Conclusion: This study shows successful radiographic outcome after hallux valgus correction using a tension band construct and allowing immediate full weight-bearing in a surgical shoe in the postoperative period. Significant deformity correction was achieved and maintained and all osteotomies healed. The Re+Line tension band bunion correction system can be safely used as a successful option to fix distal first metatarsal osteotomies, while allowing patients to fully weight bear in a surgical shoe postoperatively and potentially return to activities faster than when using traditional fixation methods. Future studies are needed to assess functional outcomes and patient satisfaction with this novel technique.

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Comparison of Postoperative Height Changes of the Second Metatarsal Among 3 Osteotomy Methods for Hallux Valgus Deformity Correction

Foot & Ankle International ◽

10.1177/1071100716666566 ◽

2016 ◽

Vol 38 (1) ◽

pp. 20-26 ◽

Cited By ~ 5

Author(s):

Jun Young Choi ◽

Yu Min Suh ◽

Ji Woong Yeom ◽

Jin Soo Suh

Keyword(s):

Hallux Valgus ◽

Deformity Correction ◽

Metatarsal Head ◽

Valgus Deformity ◽

Metatarsal Osteotomy ◽

Level Of Evidence ◽

First Metatarsal ◽

Scarf Osteotomy ◽

Hallux Valgus Deformity ◽

Second Metatarsal

Background: We aimed to compare the postoperative height of the second metatarsal head relative to the first metatarsal head using axial radiographs among 3 different commonly used osteotomy techniques: proximal chevron metatarsal osteotomy (PCMO), scarf osteotomy, and distal chevron metatarsal osteotomy (DCMO). Methods: We retrospectively reviewed the radiographs and clinical findings of the patients with painful callosities under the second metatarsal head, complicated by hallux valgus, who underwent isolated PCMO, scarf osteotomy, or DCMO from February 2005 to January 2015. Each osteotomy was performed with 20 degrees of plantar ward obliquity. Along with lateral translation and rotation of the distal fragment to correct the deformity, lowering of the first metatarsal head was made by virtue of the oblique metatarsal osteotomy. Results: Significant postoperative change in the second metatarsal height was observed on axial radiographs in all groups; this value was greatest in the PCMO group (vs scarf: P = .013; vs DCMO: P = .008) but did not significantly differ between the scarf and DCMO groups ( P = .785). The power for second metatarsal height correction was significantly greater in the PCMO group (vs scarf: P = .0005; vs DCMO: P = .0005) but did not significantly differ between the scarf and DCMO groups ( P = .832). Conclusions: Among the 3 osteotomy techniques commonly used to correct hallux valgus deformity, we observed that PCMO yielded the most effective height change of the second metatarsal head. Level of Evidence: Level III, retrospective comparative series.

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