Hallux Valgus Before And After

Fig. 07c9. Excess of Ml lowering by scarf.

1. It results in an overpressure and metatarsalgia on the 1st ray.

2. It is sometimes combined with a small overcorrection of the sesamoids.

3. 4. The solution is the BRT elevation osteotomy performed in the base of M1, it is preferable to fix this osteotomy with the "20" memory staple, combined if required with the first MTP joint release.

Hallux Lapidus

Fig. 07c10. In a supinated forefoot or an hypermobile 1st ray, does the scarf replace the Lapidus procedure?

1, 2. We observed that each time we have a sufficient M1 lowering (large intermetatarsal angle), this lowering is sufficient to ensure both the long-lasting hallux valgus correction (3, 4) and to significantly improve the hindfoot valgus (5, 6). All these pictures are from the same patient with 2 years follow-up, left foot. When there is too much foot valgus, additional rearfoot procedures have to be performed (see Fig. 43V1b).

Fig. 07c10. In a supinated forefoot or an hypermobile 1st ray, does the scarf replace the Lapidus procedure?

1, 2. We observed that each time we have a sufficient M1 lowering (large intermetatarsal angle), this lowering is sufficient to ensure both the long-lasting hallux valgus correction (3, 4) and to significantly improve the hindfoot valgus (5, 6). All these pictures are from the same patient with 2 years follow-up, left foot. When there is too much foot valgus, additional rearfoot procedures have to be performed (see Fig. 43V1b).

Cut Bone Hallux

Fig. 07d1. First metatarsal elevation by scarf.

1, 2, 3. First of all, no M1 lowering is obtained performing the longitudinal cut horizontally. In this case, its distal end is on the center of the medial aspect of the head. But care has to be taken not to fragilize the lateral beam (a).

4, 5, 6. If we want elevation, we have to perform a distal closing wedge, the bone is mainly removed on the dorsal fragment. However, if a large wedge is removed, the resulting elevation will modify the orientation of the head articular surface, sometimes resulting in insufficiency of MTP plantar flexion.

Fig. 07d1. First metatarsal elevation by scarf.

1, 2, 3. First of all, no M1 lowering is obtained performing the longitudinal cut horizontally. In this case, its distal end is on the center of the medial aspect of the head. But care has to be taken not to fragilize the lateral beam (a).

4, 5, 6. If we want elevation, we have to perform a distal closing wedge, the bone is mainly removed on the dorsal fragment. However, if a large wedge is removed, the resulting elevation will modify the orientation of the head articular surface, sometimes resulting in insufficiency of MTP plantar flexion.

Elevation

Elevation is indicated when the hallux valgus is associated with a cavus foot or when the first metatarsal has too much plantar slope, resulting in a metatarsalgia of the first metatarsal head. Elevation is first obtained by a longitudinal cut horizontally instead of dorsally inclined and, above all, by a long distal edge resection. Elevation may result in a dorsal inclination of the cartilage, which leads to a slight decrease in the great toe's ground contact. So, the scarf elevation is reserved for severe first ray meta-tarsalgia or cavus foot with hallux valgus deformity.

Hallux Valgus Before And After Pictures

Fig. 07d2. Result of Ml elevation by scarf.

Same patient before the operation and one year after. Clinical and radiological aspects. Care has to be taken with elevation because the lateral surface is not so strong after the distal wedge removal.

Fig. 07d2. Result of Ml elevation by scarf.

Same patient before the operation and one year after. Clinical and radiological aspects. Care has to be taken with elevation because the lateral surface is not so strong after the distal wedge removal.

Lengthening

Burutaran [29] performed the scarf procedure as a lengthening of the metatarsal. Lengthening, however, makes the lateral shift more difficult and increases the longitudinal pressure, which may result in impairment of the first MTP joint or in decrease of its range of motion. Although lengthening is possible and easy with the scarf procedure, it should be reserved for young patients with normal first MP joints as suggested by Weil.

Metatarsal Lengthening

Fig. 07e. First metatarsal lengthening by scarf.

1, 2. Performed initially by Burutaran, the scarf lengthening uses two bone grafts, distal and proximal.

3, 4, 5, 6. A small lengthening may be performed in young patient with a good preoperative MTP radiological aspect and range motion.

7, 8, 9. But lengthening may result in 1st MTP stiffness, under or overcorrection. Here is one example of lengthening resulting in too long Ml and over MTP dorsal flexion: Care has to be taken with M1 lengthening.

Fig. 07e. First metatarsal lengthening by scarf.

1, 2. Performed initially by Burutaran, the scarf lengthening uses two bone grafts, distal and proximal.

3, 4, 5, 6. A small lengthening may be performed in young patient with a good preoperative MTP radiological aspect and range motion.

7, 8, 9. But lengthening may result in 1st MTP stiffness, under or overcorrection. Here is one example of lengthening resulting in too long Ml and over MTP dorsal flexion: Care has to be taken with M1 lengthening.

Shortening of the First Metatarsal

Shortening by scarf presents the following specificities:

- It can be obtained by increasing the proximal inclination of the transverse cuts, reserved in my experience for shortening of less than 3mm, but L. S. Weil obtains more shortening with more oblique cut. Nevertheless, the shortening is principally provided by proximal and distal resection. Proximal resection is easy and accurate thanks to the PPE, which reveals the "no man's land" area from which the plantar fragment may be pulled and resected easily. The distal resection sometimes resulted in overcor-

rection (hallux varus), which is now avoided by the Maestro distal cut (Fig. 07f2).

- It is easy and accurate.

- Shortening by scarf does not result in elevation. Firstly, because the longitudinal cut has a proximal plantar inclination from the metatar-sal axis, thus being almost horizontal. Secondly, because the shortening is generally combined with lowering that can be as generous as when the osteotomy is performed without shortening (Fig. 07f5).

- In a dorsal plantar radiograph, the sesamoid bones are in a distal position in respect to the MTP joint but only for 2 to 5 weeks. After this period, radiographs show them to be moving backward, returning to their normal position.

Ai

Fig. 07f1a. Three main indications of M1 shortening.

1. Congenital excess of Ml length.

2. Severe deformity.

3. Arthritic hallux valgus.

Hallux Valgus Before After

Fig. 07f1b. Problems occurring when the first metatarsal remains too long.

1. Overcorrection of the deformity.

2, 3. Same patient: Overpressure and metatarsalgia on the 1st ray.

4, 5. Same patient: MTP less dorsal flexion on the side where Ml remains too long (right foot).

Fig. 07f1b. Problems occurring when the first metatarsal remains too long.

1. Overcorrection of the deformity.

2, 3. Same patient: Overpressure and metatarsalgia on the 1st ray.

4, 5. Same patient: MTP less dorsal flexion on the side where Ml remains too long (right foot).

-Nevertheless, the first metatarsal can only be shortened up to 5 mm less than the second metatarsal, in spite of combined lowering of the first metatarsal head. The harmony of the meta-tarsal curve has to be preserved. In this case, shortening of the lesser metatarsal by Weil osteotomy is indicated.

- The amount of predictable shortening depends on the preoperative examination. Clinically by the MTP dorsal flexion test, radio-graphically by taking into consideration the proximal location of the 1st phalanx basis. It is the ms point. But the real magnitude of M1

shortening is finally determined intraoperati-vely (Fig. 07f4).

- Shortening enables preservation of the MTP joint as far as possible, reducing the indications for MTP arthrodesis. The main effect of shortening is the longitudinal decompression of the MP joint and the first ray, which has two consequences:

1) Improving the dorsal MTP flexion, notably by a relative lengthening of the flexor brevis;

2) expanding the indications up to impaired MTP joints with advanced arthrosis, very large hallux valgus deformity and generally severe forefoot disorder, including the rheumatoid forefoot.

Juvenile Bunion Mitchell

Fig. 07f2. Technique of first metatarsal shortening by scarf.

1, 2, 3. Usual shortening by increasing the proximal obliquity of the transverse cuts does not shorten more than 3 mm. However, L. S. Weil performs a 45° proximally directed cut: In this case, the metatarsal will shorten of the same number of millimetres as it will laterally translate towards the 2nd metatarsal, i.e. 6-7 mm of both shortening and lateral displacement.

4, 5. Shortening by resection. Significant shortening is obtained by performing the Maestro (Nice, France) distal cut, which furthermore increases the fragmental contact area and preserves the MTP lateral ligament. Then, thanks to the ppe, the plantar fragment is easily and harmlessly pulled out medially to make the proximal resection.

6. X-ray aspect just after and one postoperative year with such a shortening.

Fig. 07f2. Technique of first metatarsal shortening by scarf.

1, 2, 3. Usual shortening by increasing the proximal obliquity of the transverse cuts does not shorten more than 3 mm. However, L. S. Weil performs a 45° proximally directed cut: In this case, the metatarsal will shorten of the same number of millimetres as it will laterally translate towards the 2nd metatarsal, i.e. 6-7 mm of both shortening and lateral displacement.

4, 5. Shortening by resection. Significant shortening is obtained by performing the Maestro (Nice, France) distal cut, which furthermore increases the fragmental contact area and preserves the MTP lateral ligament. Then, thanks to the ppe, the plantar fragment is easily and harmlessly pulled out medially to make the proximal resection.

6. X-ray aspect just after and one postoperative year with such a shortening.

Hallux Valgus Ray

Fig. 07f3a. The Ml shortening increases the MTP dorsal flexion (1).

1, 2. Preoperative dorsal flexion is diminished when the examiner attempts a passive correction of the deformity: X-ray shows a too long M1.

4, 5. Intraoperative same foot: Same decreased dorsal flexion with passive correction of the deformity.

6. M1 shortening.

7. Same foot: The dorsal flexion is recovered.

Fig. 07f3a. The Ml shortening increases the MTP dorsal flexion (1).

1, 2. Preoperative dorsal flexion is diminished when the examiner attempts a passive correction of the deformity: X-ray shows a too long M1.

4, 5. Intraoperative same foot: Same decreased dorsal flexion with passive correction of the deformity.

6. M1 shortening.

7. Same foot: The dorsal flexion is recovered.

Hallux Valgus Effekt

Fig. 07f3b. M1 shortening and MTP dorsal flexion (2): M1 shortening versus P1 shortening.

1. Only 1st metatarsal shortening increases the MTP dorsal flexion since the flexor hallucis brevis (fhb) and plantar fascia are relaxed. The P1 shrotening cannot have the same effect since it is distal from the fhb phalanx insertion.

2. MTP longitudinal decompression after M1 shortening.

3. 4, 5. The mechanism of MTP dorsal flexion increasing with M1 scarf shortening. 6, 7. Same foot before and after M1 shortening by scarf.

Fig. 07f3b. M1 shortening and MTP dorsal flexion (2): M1 shortening versus P1 shortening.

1. Only 1st metatarsal shortening increases the MTP dorsal flexion since the flexor hallucis brevis (fhb) and plantar fascia are relaxed. The P1 shrotening cannot have the same effect since it is distal from the fhb phalanx insertion.

2. MTP longitudinal decompression after M1 shortening.

3. 4, 5. The mechanism of MTP dorsal flexion increasing with M1 scarf shortening. 6, 7. Same foot before and after M1 shortening by scarf.

Metatarsal Shortening

Fig. 07f4. Assessment of need and amount of first metatarsal shortening.

1 to 4. Preoperative assessment.

1, 2. In this case, the MTP dorsal flexion is not decreased with the correction of intermetatarsal angle and hallux valgus: No need of M1 shortening.

3. In this case, the MTP dorsal flexion is decreased with the same correction: Need of M1 shortening.

4. The amount of metatarsal shortening As far as the ms point (the more proximal part - lateral - of the 1st phalanx basis).

5. 6. Intraoperatively we always check the dorsal MTP flexion after performing the lateral release and medial approach of the first metatarsal (M1).

5. No need of M1 shortening.

6. Need of M1 shortening.

Fig. 07f4. Assessment of need and amount of first metatarsal shortening.

1 to 4. Preoperative assessment.

1, 2. In this case, the MTP dorsal flexion is not decreased with the correction of intermetatarsal angle and hallux valgus: No need of M1 shortening.

3. In this case, the MTP dorsal flexion is decreased with the same correction: Need of M1 shortening.

4. The amount of metatarsal shortening As far as the ms point (the more proximal part - lateral - of the 1st phalanx basis).

5. 6. Intraoperatively we always check the dorsal MTP flexion after performing the lateral release and medial approach of the first metatarsal (M1).

5. No need of M1 shortening.

6. Need of M1 shortening.

Metatarsals Proximal Osteotomy

Fig. 07f5. Relationships between M1 shortening and M1 lowering.

1, 2. Shortening without lowering may result in 2nd ray transfer metatarsalgia (scarf early experience).

3. a: The longitudinal cut does not follow the axis of the 1st metatarsal, so that the 1st metatarsal shortening by scarf does not provide elevation. b: Thanks to the plantar obliquity of the longitudinal cut, M1 lowering by scarf is automatically combined with the lateral shift.

4. This lowering should compensate the shortening but does not cancel the necessity to harmonize the metatarsal parabola. On this example, Weil osteotomy on the lesser metatarsals is combined.

Fig. 07f5. Relationships between M1 shortening and M1 lowering.

1, 2. Shortening without lowering may result in 2nd ray transfer metatarsalgia (scarf early experience).

3. a: The longitudinal cut does not follow the axis of the 1st metatarsal, so that the 1st metatarsal shortening by scarf does not provide elevation. b: Thanks to the plantar obliquity of the longitudinal cut, M1 lowering by scarf is automatically combined with the lateral shift.

4. This lowering should compensate the shortening but does not cancel the necessity to harmonize the metatarsal parabola. On this example, Weil osteotomy on the lesser metatarsals is combined.

Weil Osteotomy Operation

Fig. 07f6. Scarf Ml shortening: Relationships with the lesser metatarsals.

1, 2, 3. Arthritic hallux valgus: The M1 shortening is compensated by lowering. But this example is a limit: If the correction is longer than 8 mm we also have to shorten the 2nd metatarsal.

4. Shortening was needed to correct 27° of IM angle, while preserving correct MTP range motion; in this case, combination of Weil M2 shortening.

5. Shortening of Ml already shorter than M2. Since there was metatarsalgia on the lesser rays and the 1st MTP joint was painless, a joint preservative solution was adapted. Shortening of M1 and harmonized shortening of the lesser metatarsals.

Fig. 07f7a. Three main indications and results for Ml shortening.

1, 2. Congenital excess of Ml length. 3, 4. Arthritic hallux valgus.

Fig. 07f7a. Three main indications and results for Ml shortening.

1, 2. Congenital excess of Ml length. 3, 4. Arthritic hallux valgus.

Hallux Valgus Indication

Fig. 07f7b. Three main indications and results for Ml shortening.

1, 2, 3. Severe forefoot deformity, three cases.

In each example, note that the appropriate metatarsal shortening was determined by the location of the basis of the 1st phalanx (ms point). This shortening not only increases the MTP dorsal flexion but also ensures the deformity correction cohatever its grade.

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