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Results of Postoperative Hallux Valgus Correction After Middle Shaft (Scarf & Meyer) and the Proximal (Juvara)

Osteotomies of I Metatarsal Bone


Results of Postoperative more frequent among women then males

(10:1). It is manifested with lateral, exter-

Hallux Valgus Correction nal angulations of proximal phalange,

and metatarsal bone medially, with sepa-
ration of 1st and 2nd metatarsal bone and
After Middle Shaft (Scarf prominent soft tissue thickening above
medial surface of the 1st metatarsal bone.

& Meyer) and the Proximal

Valgus posture of the thumb often
causes deformity in form of mallet second
toe. Additional rotation outward of the

(Juvara) Osteotomies of I front part of the foot suffers more difficul-

ties in shoes. In case of shoes with nar-
row front often occurs burse hypertrophy
Metatarsal Bone above deformity. When the presented val-
gus subluxation is on 1st metatarsal joint
more frequent occurs osteoarthritis. This
is favorable for the collapse of the fron-
Zoran Hadziahmetovic , Narcisa Vavra Hadziahmetovic tal transversal foot arch which results in
Clinical center University of Sarajevo, Sarajevo, BiH metatarsus primus varus in hallux valgus
(HVD) deformity.
Original paper Majority of HVD is treated without
SUMMARY surgery. Prevention is the best choice with
BACKGROUND: In this paper we show the use of Mann algorithm in correction of hallux valgus adequate, adapted shoe form with wide
deformity (HVD). Follow up of complications were defined as: hallux varus, transfer metatar- front part for the fingers and soft sole. If
salgia, stress fractures and recurrence of the deformity with proximal metatarsal osteotomies
(Juvara and middle shaft Scarf & Meyer) in HVD rate (HVA 28 – 40 0, IMA 14 – 20 0). MATERIALS the bulge is present that night relieve
AND METHODS: A retrospective review was performed on 9 patients (14 surgical procedures) splintage can be used, interdigital separa-
who underwent a Juvara (7) and Scarf & Meyer (7) bunionectomy between January 2000 to tors, protective pads which increase shoes
January 2008 in Clinical center University of Sarajevo. Data recorded on the pre-and postop- comfort, prevent friction, decrease pres-
erative AP radiographs included: intermetatarsal angle 1-2 (IMA), hallux valgus angle (HVA)
and tibial sesamoid position. We also used Kitaoka score scale. Follow-up was performed in sure and painful irritation of the painful
all patients at average of 9.5 months. Statistical differences were considered to be significant tender HVD.
of p<0.05. RESULTS: Average age was 41.51 years. There were 7 females and 2 males. The Hallux valgus often is not an isolated
operative side included 8 right and 6 left feet. Secondary procedures included: Juvara (DSTP 3, disorder but complex deformity combined
Akin + DSTP 2) and Scarf & Meyer (DSTP 4, Akin + DSTP 1). Pre-operative and postoperative
radiographic findings were statistically significant different between the pre- and postopera- with the deformity and symptoms in oth-
tive correction of the severe HAD; IMA – Juvara (preoperative 18,93±1.43 0, postoperative er toes of the same foot. In case of HVD
4.81 0±1.72 0), p=0,001, Scarf & Meyer (preoperative 19,01±1,50 0, postoperative 4.99 there are disorders of:
0±1.68 0), p=0,001, HVA – Juvara (preoperative 35.28±9.06 0, postoperative 8.96±6.81 0), •• Intermetatarsal angle (IMA) which
p=0,001, Scarf & Meyer (preoperative 36,01 ± 7,60 0, postoperative 9.21 ± 6.55 0) p=0.001,
Tibial sesamoid position - Juvara (preoperative 4.95±0.92, postoperative 2.04±0.852), forms second axis if 1st and 2nd
p=0,001, Scarf & Meyer (preoperative 5.01±1.41, postoperative 1.91±0.93), p=0.001. metatarsal bone, and which is usu-
Complications included: under corrections, hallux varus, stress fractures, avascular necrosis, ally larger than 8 to 9 0 which is also
dorsal malunion not accepted. There were 2 cases of postoperative transfer metatarsalgia (M1 the upper limit of normal.
and M1/M2). Whole postoperative weight bearing, without crutch, was allowed after 6 weeks
and shoes worn after 5 weeks (3 bilateral and 1 unilateral bunionectomy). Other cases were •• Hallux valgus angle (HVA), which
allowed to bear weigh, without crutch, after longer period. Kitaoka score scale assessment measures the ratio of the second
average was very good for all cases. CONCLUSIONS: Our study evaluated that the Juvara and axis of the proximal phalange and
Scarf & Meyer osteotomies predictably and accurately correct severe HAV deformities (HVA < 1st metatarsal bone. It is larger than
40 0 and IMA>15 0) isolated or in the secondary procedures. Primary stability is successful.
We did not consider malposition and failure of bone healing or static foot as complications 15 to 20 0 which is the upper limit.
Key words: hallux valgus, proximal metatarsal osteotomies When HVA is over 30 t 35 0 this usu-
ally result in thumb pronation (fig-
Hallux (abducto) valgus - bunion (lat. bunio) is a primary Categories of HVD are marked as;
lateral thumb deviation with often combined deformity and •• Mild subluxation (HVA < 21 - 30°,
symptoms of whole anterior foot. According to etiology it can IMA < 12°, sesamoid < 50°)
occur after long term irritation with uncomfortable shoes, in- •• Moderate subluxation (HVA 31°-40°,
flammatory changes, arthritis or hereditary (metatarsus pri- IMA < 12 -16°, sesamoid 50-75%)
mus varus). Family history is positive among 50-65%. Defor- •• Severe subluxation (HVA > 40°, IMA
mity usually develops bilaterally after 35 years of age. It is > 16°, sesamoid > 75%)

ORIGINAL PAPER vol 17 no 1 MARCH 2009 27

Results of Postoperative Hallux Valgus Correction After Middle Shaft (Scarf & Meyer) and the Proximal (Juvara) Osteotomies of I Metatarsal Bone

bined deformity with symptoms in

whole anterior foot. In case of large
HVA from 30 – 35 0 occurs abnormal
rotation while m. abductor hallucis ad-
duct thumb from the foot sagital plain
retracting in into valgus and stretching
medial capsular ligament in insertion
in the base of proximal phalanx and
insertion into capsular plate. Lateral
capsule of the basal joint is retracted.
Flexor hallucis brevis, flexor hallucis
longus, adductor halucis and exten-
sor hallucis longus increases valgus
moment in the metatarsophalangeal
joint making the deformity even worse.
Deep transversal intermetatarsal lig-
ament which runs between plantar
Figure 1. (a, b) Hallux valgus deformity with prolapse of transversal plates in metatarsophalangeal joints
arch, thickening and painful clavus in from part of the foot does not have the insertion point at the
metatarsal head. Sesamoid flute at the
Surgical focus in case of HVD is on: plantar surface of the first metatarsal bone head is
•• 1st Metatarsophalangeal joint (MTPJ) varia- flattened and partially or completely moved within
tions in bone anatomy and soft tissue of this first metatarsal space. In such situation patient does
joint determines its stability and tendency to de- not distribute the weight to this segment but trans-
formity toward valgus. Shape of the metatarsal fer it on other metatarsal heads which increase the
bone head plays important role in valgus ten- risk for occurrence of metatarsal bones.
dency. More oblique head is less stabile and of- This clearly indicates that this deformity can-
ten cause of deformity with external force (e.g. not be studied only in horizontal plain (by evalu-
to narrow shoes). Flat head is more stabile and ation of metatarsal varus and metatarsophalangeal
with less chance of HVD in opposite case joint is valgus) but also trough possibility of metatarsal el-
incongruent or subluxated. evation, shortening and changes in distal metatarsal
•• Distal metatarsal joint angle is second feature articular angle.
in occurrence of HVD and represents the rela- From this reason correction of these angles must
tion between the joint surface of the metatarsal be the goal in selecting surgical technique in case of
bone head to second axis of the 1st metatarsal established deformity. Depending on their oversize
bone (normal is < 10 °; for average normal foot preferred is Mann algorithm for surgeries on; soft
it is 7°). tissues, bone or combined. These are: correction of
•• Proximal phalangeal joint angle is formed with valgus deformity of the proximal phalange, extrac-
intersection of line along second axis of the tion of egsostosis from dorsomedial aspect of the 1st
proximal phalange and line along proximal metatarsal head together with burs, correction of 1st
joint area of the proximal phalange. This angle metatarsal bone deformity (metatarsus primus var-
s normally< 10° us), correction of the tension in thumb extensor, cor-
•• Metatarsocuneiform joint; The shape and orien- rection of other combined deformities and joint sub-
tation of this joint vary and disturb medial in- luxation. (1)
clination of the first metatarsal bone. Extreme Surgical options are grouped into several cat-
medial leaning is joined with instability egories as: distal soft-tissue procedure (DSTP)*, os-
•• Sesamoides located in the tendon of the flexor teotomy of the proximal phalange and first metatar-
hallucis brevis. In case of valgus deformity are sal bone (distal, medial and proximal – (PSTO), ar-
not lay centrally below metatarsal bone head throdesis (1st MTPJ and 1st tarsomethatarsal joint),
but are diverted medially and rotate in MTPJ. resection, as well as mutual combination. So when
Thumb is proned. Rotation is marked as 1st 0 speaking about congurent 1st MTPJ recommended
if it is < 25°, 2nd 0 > 25°,3rd 0 > 45°. are; Chevron technique (distal “V” osteotomy of 1st
•• Other factors; pes planus deformity, thumb pro- metatarsal bone) or Akinov procedure (varisation
nation, shortening of the Achilles tendon, mus- osteotomy of proximal phalange) with egsostecto-
cular balance (4 groups of muscles and tendons my. In case of prominent degenerative changes of
goes trough 1st MTPJ and inserts to the proxi- 1st MTPJ indicated is arthrodesis, while in case of
mal part of the proximal phalange). incongurence with following feature choice is on:
•• HVA < 28 0,IMA < 14 0 / Mitchell procedure,
Pathological mechanism of hallux valgus Chevron technique (< 50 years), DSTP with or
Presence of HVD implies also frequently com- without PSTO/

28 vol 17 no 1 MARCH 2009 ORIGINAL PAPER

Results of Postoperative Hallux Valgus Correction After Middle Shaft (Scarf & Meyer) and the Proximal (Juvara) Osteotomies of I Metatarsal Bone

•• HVA < 40 0, IMA > 15 0 /

DSTP with PSTO, Mitchell/
•• HVA > 40 0, IMA < 20 0 /
DSTP with PSTO, Artrodesis
of MTPJ/
•• Hipermobile 1st MTCJ / Ar-
trodesis of 1st MTPJ and meta-
tarsocuneiform joint/ (1)
•• *DSTP procedure involves; lat-
eral “release” of the joint calf
of the 1st MTPJ, tendon of ad-
ductor hallucis and transver-
sal metatarsal ligament, medi-
al extraction of egsostosis and
reefing of the medial capsule.
In general proximal metatarsal
osteotomies are indicated in case Figure 2. H. R. (1958/ ♀) Metatarsus primus varus combined with hallux
of severe deformities in case when abducto valgus deformity (IMU 25 0, HVU 32 0); Surgical correction with
IMA > 15 in other cases distal ones proximal nail shape abduction osteotomy of the 1st metatarsal bone (Juvara)
are recommended. (2) There is a se- and adduction osteotomy of the proximal phalange (Akin); A/ X-ray before
the surgery of the frontal foot with significant HVD; B/ Osteotomy planning
ries of proximal diaphisis osteoto- before surgery (sketch); C/ X-ray of a HVD correction after 12 months
mies. Among proximal character-
istic are; Lapidus, Loison, Logrosci-
no, Balasescu, Ruch – Banks, Pat-
ton – Zelichowski, Juvara, Lenoix
– Baker, Kotzenberg, Rocyn Jones a
dijafizarnih; Ludloff, Mau, Scarf &
Meyer and others. (3-10)
Proximal osteotomies are more
popular for severe deformities be-
cause they allow larger correction
than the distal ones. Several prox-
imal osteotomies showed good re-
sults. (11,12,13,14) But majority of
proximal osteotomies does not have
inherent stability or resistance on
forces in sagital plain which re-
quires several weeks of plaster Figure 3. B.J. (1965/ ♀) metatarsus primus varus combined with HVD
immobilization. (11,13,14,15) Be- (IMA 200,HVA 280); Surgical correction with diaphisis abduction „Z”
sides that these osteotomies are of- osteotomy of the 1st metatarsal bone (Scarf & Meyer)*+ DSTP; A/ before
ten with delayed healing and late surgery X-ray of the frontal part of foot with HVD; B/ Pre surgical osteotomy
transfer of metatarsalgia and poor planning (sketch); C/ X-ray of HVD correction after 18 months
healing with dorsal angulations or
shortening of the 1st metatarsal bone. (11,15) determined deformity n range of HVA 28 – 40 0, and
Diaphisis osteotomy shows more resistance in IMA of 14 – 20 0.
sagital plain on force and had unique stability on
the biomechanic cadaver tests. (11,12,13,14,15) One 3. MATERIAL AND METHODOLOGY
of them is Scarf osteotomy as widely used procedure Within proclaimed indication field with retro-
and very popular in the USA and Europe. (15,16,17) spective study we analyzed 14 HVD cases with os-
Scarf proved and anticipate, versatile strong proce- teotomy of the 1st metatarsal bone for 9 patients (7
dure in correction of various degrees of HVD and diaphisis – Scarf/Meyer and 7 proximal – Juvara) in
shortening of the 1st metatarsal bone. (15, 18,19, 20) time period from January 2000 – January 2008. Sur-
gical procedure was performed at the Clinic for or-
2. RESEARCH GOAL thopedics and trauma surgery (4) and Clinic for plas-
According to above mentioned algorithm we de- tic – reconstructive surgery (5) of the Clinical Center
termined goals of the research, to determine; prima- of Sarajevo University. In each case before the sur-
ry stability on place of fusion, process of bone con- gery, based on X-ray evaluation are estimated: HVA,
solidation and foot functioning in case of hallux val- IMA and sesamoid position (AP, foot profile and ax-
gus deformity after osteotomy (proximal Juvar and ial sesamoid projection). Preoperative sketch is done
midle shaft Scarf – Meyer). Before the surgery we (drawing of HVD) based on which with virtual oste-

ORIGINAL PAPER vol 17 no 1 MARCH 2009 29

Results of Postoperative Hallux Valgus Correction After Middle Shaft (Scarf & Meyer) and the Proximal (Juvara) Osteotomies of I Metatarsal Bone

otomy we determined size and palaces of bone inci- in phase of initial force on a front foot, but which
sions, bone translation, angle correction as well as disappears after 2 and 3.5 months. Full load for 5
places for screws. For definite evaluation (before and (57.14%) patients started after 5 weeks (± 3.09) from
after surgery) of status we used Kitaoka score (21) surgery (3 bilateral and 2 unilateral HVD osteoto-
scale which accept subjective criteria (pain, func- mies). Remaining 4 (42.85%) patients were outside
tioning restriction, load restriction, shoes restric- upper limits of followed parameters (2 bilateral and
tions and general patient dissatisfaction). This scale 2 isolated HVD osteotomies). Before the surgery
contains also impartial criteria such as persistent planned metatarsal parable is followed so we didn’t
tenderness of the plantar ceratosis, pain when mov- have to shorten the 1st metatarsal bone. This is con-
ing MTPJ, radiography abnormalities such as: osteo firmed with checking of passive dorsal flexion dur-
necrosis, hallux varus, separation, joint subluxation ing surgery up to 50 0.
and arthrosis). Average good result is marked when After surgery individual and total subjective
the patient does not have any of the above men- and independent Kitaoka score was as in average
tioned problems; good with one or two; and unsuc- good for all patients.
cessful with more than two features.
All patients after the surgery had a compressive 5. DISCUSSION
bandage for the foot and lower leg. Neither one had Correction of HVD in our sample did not re-
plaster of paris immobilization except recommend- quired additional surgical procedures due to pos-
ed restriction of load and gradual leaning during 1 sible over correction, fragments dislocation or pos-
to 3 months. With movement of 1st MTPJ (strength- sible poor healing. Some authors in case of Scarf os-
ening exercises and range of motion) started 7 days teotomy had up to 6% of over corrections, and in 5%
after the surgery. Respondents were continuously of patients there was stress fractures in the dorsum
followed during period from 1 to 12 months. cortex of the metatarsal bone .(11,12,13)
Statistical evaluation is conducted after evalua- On the other hand all nail shape osteotomies in
tion of functioning tests, before and after surgery X- 1st metatarsal bone are possibly unstable or inabili-
ray (Kitaoka score). Compared are variables before ty to control bending due to vertical reactive force in
and after the surgery. Statistical difference was con- contact with surface. This result in dorsal elevation
sidered as significant when the value was p < 0.05. of the metatarsal heads and progressive angulations
on place of fixation. (22) Previous studies tried to
4. RESULTS focus more stability of the proximal osteotomies on
Average time for follow-up of the patients was fixation techniques rather than type, and geometry
9.5 months. Bilateral osteotomies were done in 5 of the osteotomy. (23,24)
cases, but in neither case in one surgery. Average pa- On a transversal bone model with stability index
tient’s age was 41.51 (± 11.89). Male to female ratio of 7 (min) up to 20% (max) worked S.E. D’Andrea,
was 7:2, and right and left foot 8 : 6. Except two ex- C. C. Southerland, 2000. They compared Juvara os-
plorative osteotomies also done was additional sur- teotomies (fixation with one screw “single” and two
geries in Juvara osteotomy (DSTP 3, Akin osteotomy “double”) with Sglartto osteotomy type (“hinge” and
+ DSPT 2), and for Scarf osteotomy (DSPT 4, Akin “ non-hinge”). They found that “double” Juvara os-
+ DSPT 1). teotomy had stability index of 19.4% which is much
With X-ray before and after the surgery we de- larger compared to “single” 12.3%. Oppose to this
termined statistically significant difference be- Sglartto “non-hinge” had stability index of 8.9 %,
tween correction of HVD in IMA before surgery (Ju- and “hinge” 7.2 %. (25) High stability showed also
vara) 18.93 ± 1.430, after surgery 4.81° ± 1.720 (p = single Juvara osteotomy in 5 cases (6 surgeries from
0.001), and Scarf ; 19.01 ± 1.50 0, after surgery 4.99° which one was bilateral) in the research conducted
± 1.680 (p=0.001). during 1999/2002 with follow-up period of 3.5 up to
HVA for Juvara osteotomy after the surgery 5 months. (26)
was measured in 35.28 ± 9.060, after surgery 8.96 Previous data goes in favor that for the stabil-
± 6.810 (p= 0.001), while for the Scarf osteotomy it ity of the osteotomy extremely important is well
was 36.01 ± 7.600, and after surgery 9.21 ± 6.550 planned and prepared site, as well as selection and
(p=0.001). application of the osteosynthesis material.
Tibia sesamoid position (Juvara) before surgery Jarde et al. on a series of 37 patients after Scarf
4.95 ± 0.92, after surgery 2.04 ± 0.852, while Scarf osteotomy noticed predominant metatarsalgia in M2
before surgery was 5.01 ± 1.41, and after the surgery among patients with abnormalities in the frontal foot
1.91 ± 0.93 (p= 0.001). arc. (27) Pain was constant. In case of 36 patients
Complications in form of poor correction of hal- also recommending was to wear special more com-
lux valgus, hallux varus, stress fractures or lack of fortable shoes with or without orthrosis. CT analysis
healing, avascular head necrosis in 1st metatarsal of these patients determines lowered 1st metatarsal
bone was not noticed. Transfer of metatarsalgia is bone by 2mm with sufficient correction but insuffi-
noticed in 2 cases in group with Scarf osteotomy cient load. This goes in favor of metatarsalgia, which
in projection M1 and M1/M2 which was expressed were present also in 2 our patients just after the sur-

30 vol 17 no 1 MARCH 2009 ORIGINAL PAPER

Results of Postoperative Hallux Valgus Correction After Middle Shaft (Scarf & Meyer) and the Proximal (Juvara) Osteotomies of I Metatarsal Bone

gery, but there wasn’t any disorder of foot stability. metatarsal osteotomy: A long-term follow-up. J Bone
Correction of footwear was not recommended and Joint Surg Am. 1992;74(1):124-9.
pain decreased and disappeared rather fast. 13. Nyska M, Trnka HJ, Myerson MS. Proximal meta-
tarsal osteotomies: a comparative geometric analy-
6. CONCLUSION sis conducted on sawbone models. Foot Ankle Int.
Both osteotomies are indicated in all cases 2002;23(10):938-45.
when HVA < 400 and IMA > 150, as isolated pro- 14. Acevedo JI, Sammarco VJ, Boucher HR, Parks BG,
cedures or combined with DSTP or adduction oste- Schon LC, Myerson MS. Mechanical comparison of
otomy of the proximal thumb phalange. cyclic loading in five different first metatarsal shaft
They showed satisfactory primary and second- osteotomies. Foot Ankle Int. 2002;23(8):711-6.
ary stability during the whole follow up period. 15. Vora AM, Myerson MS. First metatarsal osteot-
In neither one case we did not notice signs of omy nonunion and malunion. Foot Ankle Clin.
compromised bone healing, poor positioning of the 2005;10(1):35-54.
fragments or disorder of foot stability. 16. Barouk LS, Barouk P. Reconstruction De l avant Pied,
Dominant metatarsalgia in two Scarf osteoto- 2nd ed. Paris: Springer; 2006.
mies disappeared in rather short time period after 17. Weil LS, Borreli AB. Modified scarf bunionectomy:
the procedure. our experience in more than 1000 cases. J Foot Surg.
Each osteotomy requires good presurgical plan 1991;30:609-22.
and application of osteosynthesis which will enable 18. Weil LS. Scarf bunionectomy. Foot Ankle Clin.
stable fusion site. 2000;5:149-69.
19. Weil LS. Long – term results of the SCARF bunionec-
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