Introduction. Recurrence after surgical correction of hallux valgus may be related to coronal rotation of the first metatarsal. The scarf osteotomy is a commonly used procedure for correcting hallux valgus but has limited ability to correct rotation. Using weightbearing computed tomography (WBCT), we aimed to measure the coronal rotation of the first metatarsal before and after a scarf osteotomy, and correlate these to clinical outcome scores. Methods. We retrospectively analyzed 16 feet (15 patients) who had a WBCT before and after scarf osteotomy for hallux valgus correction. On both scans, hallux valgus angle (HVA), intermetatarsal angle, and anteroposterior/lateral talus-first metatarsal angle were measured using digitally reconstructed radiographs. Metatarsal pronation (MPA), alpha angle, sesamoid rotation angle and sesamoid position was measured on standardized coronal CT slices. Preoperative and postoperative(12 months) clinical outcome scores(MOxFQ and VAS) were captured. Results. Mean HVA was 28.6±10.1 degrees preoperatively and 12.1±7.7 degrees postoperatively. Mean IMA was 13.7±3.8 degrees preoperatively and 7.5±3.0 degrees postoperatively. Before and after surgery, there were no significant differences in MPA (11.4±7.7 and 11.4±9.9 degrees, respectively; p = 0.75) or alpha angle (10.9±8.0 and 10.7±13.1 degrees, respectively; p = 0.83). There were significant improvements in SRA (26.4±10.2 and 15.7±10.2 degrees, respectively; p = 0.03) and sesamoid position (1.4±1.0 and 0.6±0.6, respectively; p = 0.04) after a scarf osteotomy. There were significant improvements in all outcome scores after surgery. Poorer outcome scores correlated with greater postoperative MPA and alpha angles (r= 0.76 (p = 0.02) and 0.67 (p = 0.03), respectively). Conclusion. A scarf osteotomy does not correct first metatarsal coronal rotation, and worse outcomes are linked to greater metatarsal rotation. Rotation of the metatarsal needs to be measured and considered when planning hallux valgus surgery. Further work is needed to compare postoperative outcomes with rotational osteotomies and modified Lapidus procedures when addressing rotation

Introduction. Symptomatic hallux valgus is a common clinical problem, current trends is towards minimally invasive procedures. The goal of this study is to evaluate the outcome of minimally invasive chevron ostoetomy, comparing it with a matched group who had open chevron osteotomy. Methods. Prospective study, 54 patients. MIS group 25 patients between October 2009 and November 2010. Open group 29 patients between Feb 2008 and October 2010. Inclusion criteria included, mild to moderate hallux valgus, no previous history of foot surgery, no history of inflammatory arthritis, or MTPJ arthritis. All the operations were performed by the senior author. Functional outcome and pain were evaluated using pre and post operative Manchester Oxford Foot and ankle questionnaire (MOXFQ). IMA and HVA, avascular necrosis and union were assessed. Complications and satisfaction were recorded. Results. The MIS group with mean age at operation of 55, showed significant improvement in all the domains of the MOXFQ. Walking (p <0.018), foot pain (p = <0.013), social interaction (p = <0.001). The mean HVA and IMA corrections were 11.8° and 6.3°, (p < 0.001). The open group with mean age at operation of 55 years showed significant improvement in all domains of the MOXFQ, walking (p = <0.0001), foot pain (p = <0.002), social interaction (p = <0.0001). The HVA and IMA corrections were 10.5 and 5.9 degrees respectively (p = <0.001). The improvement in MOXFQ and HVA and IMA corrections were not statistically significant between the MIS and open groups. Discussion and Conclusion. Our results showed that the MIS chevron osteotomy is an effective procedure with minimal complications and satisfactory functional outcome, comparable to the open standard chevron osteotomy. Larger sample size is required to confirm our findings

Aims. There is little information about how to manage patients with a recurvatum deformity of the distal tibia and osteoarthritis (OA) of the ankle. The aim of this study was to evaluate the functional and radiological outcome of addressing this deformity using a flexion osteotomy and to assess the progression of OA after this procedure. Patients and Methods. A total of 39 patients (12 women, 27 men; mean age 47 years (28 to 72)) with a distal tibial recurvatum deformity were treated with a flexion osteotomy, between 2010 and 2015. Nine patients (23%) subsequently required conversion to either a total ankle arthroplasty (seven) or an arthrodesis (two) after a mean of 21 months (9 to 36). A total of 30 patients (77%), with a mean follow-up of 30 months (24 to 76), remained for further evaluation. Functional outcome, sagittal ankle joint OA using a modified Kellgren and Lawrence Score, tibial lateral surface (TLS) angle, and talar offset ratio (TOR) were evaluated on pre- and postoperative weight-bearing radiographs. Results. Postoperatively, the mean score for pain, using a visual analogue scale, decreased significantly from 4.3 to 2.5 points and the mean American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score improved significantly from 59 to 75 points (both p < 0.001). The mean TLS angle increased significantly by 6.6°; the mean TOR decreased significantly by 0.24 (p < 0.001). Radiological evaluation showed an improvement or no progression of sagittal ankle joint OA in 32 ankles (82%), while seven ankles (18%) showed further progression. Conclusion. A flexion osteotomy effectively improved the congruency of the ankle joint. In 30 patients (77%), the joint could be saved, whereas in nine patients (23%), the treatment delayed a joint-sacrificing procedure. Cite this article: Bone Joint J 2019;101-B:682–690

Numerous procedures have been reported for the hallux valgus correction of the great toe. Scarf osteotomy is a versatile osteotomy to correct varying degrees of mild to moderate hallux valgus deformity. It can also be used for lengthening of the 1st ray as a revision procedure to treat metatarsalgia in patients who had previous shortening osteotomy. We wish to report a patient who had lengthening SCARF osteotomy for the metatarsalgia following previous hallux valgus correction and developed arthritis of the 1st MTPJ in a short term which required fusion. A 49 year old female patient was seen with pain and tenderness over the heads of the 2nd and3rd metatarsal of the right foot. She had hallux valgus correction 10years ago with a shortening osteotomy of the 1st metatarsal. She developed metatarsalgia which failed to conservative management. She had a lengthening SCARF osteotomy for the metatarsalgia in 2004. She had good symptomatic relief for two years and then started having pain over the 1st MTPJ. On examination she had limited movements of the 1st MTPJ and tenderness over the dorsolateral aspects of the 1st MTPJ suggestive of arthritis. Radiographs of the foot showed healed osteotomy with no evidence of AVN of the 1st MT head but features suggestive of osteoarthritis. She had fusion of the 1st MTPJ performed in 2008 for the arthritis following which symptoms resolved. This case highlights that arthritis of the 1st MTPJ can occur in the absence of an AVN of the metatarsal head and patients need to be warned of this potential complaining when having the lengthening SCARF osteotomy for metatarsalgia following a previous shortening osteotomy of the 1st ray

Aims. The aim of this study was to report a single surgeon series of consecutive patients with moderate hallux valgus managed with a percutaneous extra-articular reverse-L chevron (PERC) osteotomy. . Patients and Methods. A total of 38 patients underwent 45 procedures. There were 35 women and three men. The mean age of the patients was 48 years (17 to 69). An additional percutaneous Akin osteotomy was performed in 37 feet and percutaneous lateral capsular release was performed in 22 feet. Clinical and radiological assessments included the type of forefoot, range of movement, the American Orthopedic Foot and Ankle (AOFAS) score, a subjective rating and radiological parameters. . The mean follow-up was 59.1 months (45.9 to 75.2). No patients were lost to follow-up. Results. The mean AOFAS score increased from 62.5 (30 to 80) pre-operatively to 97.1 (75 to 100) post-operatively. A total of 37 patients (97%) were satisfied. At the last follow up there was a statistically significant decrease in the hallux valgus angle, the intermetatarsal angle and the proximal articular set angle. The range of movement of the first metatarsophalangeal joint improved significantly.. There was more improvement in the range of movement in patients who had fixation of the osteotomy of the proximal phalanx. Conclusion. Preliminary results of this percutaneous approach are promising. This technique is reliable and reproducible. Its main asset is that it maintains an excellent range of movement. Take home message: The PERC osteotomy procedure is an effective approach for surgical management of moderate hallux valgus which combines the benefits of percutaneous surgery with the versatility of the chevron osteotomy whilst maintaining excellent first MTPJ range of motion. Cite this article: Bone Joint J 2016;98-B:365–73

Aims. The mainstay of surgical correction of hallux valgus is first metatarsal osteotomy, either proximally or distally. We present a technique of combining a distal chevron osteotomy with a proximal opening wedge osteotomy, for the correction of moderate to severe hallux valgus. Patients and Methods. We reviewed 45 patients (49 feet) who had undergone double osteotomy. Outcome was assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) and the Short Form (SF) -36 Health Survey scores. Radiological measurements were undertaken to assess the correction. The mean age of the patients was 60.8 years (44.2 to 75.3). The mean follow-up was 35.4 months (24 to 51). Results. The mean AOFAS score improved from 54.7 to 92.3 (p < 0.001) and the mean SF-36 score from 59 to 86 (p < 0.001). The mean hallux valgus and intermetatarsal angles were improved from 41.6. o. to 12.8. o. (p < 0.001) and from 22.1. o. to 7.1. o. , respectively (p < 0.001). The mean distal metatarsal articular angle improved from 23. o. to 9.7. o. The mean sesamoid position, as described by Hardy and Clapham, improved from 6.8 to 3.5. The mean length of the first metatarsal was unchanged. The overall rate of complications was 4.1% (two patients). Conclusion. These results suggest that a double osteotomy of the first metatarsal is a reliable, safe technique which, when compared with other metatarsal osteotomies, provides strong angular correction and excellent outcomes with a low rate of complications. Cite this article: Bone Joint J 2016;98-B:1202–7

We reviewed the outcome of distal chevron metatarsal osteotomy without tendon transfer in 19 consecutive patients (19 feet) with a hallux varus deformity following surgery for hallux valgus. All patients underwent distal chevron metatarsal osteotomy with medial displacement and a medial closing wedge osteotomy along with a medial capsular release. The mean hallux valgus angle improved from −11.6° pre-operatively to 4.7° postoperatively, the mean first-second intermetatarsal angle improved from −0.3° to 3.3° and the distal metatarsal articular angle from 9.5° to 2.3° and the first metatarsophalangeal joints became congruent post-operatively in all 19 feet. The mean relative length ratio of the metatarsus decreased from 1.01 to 0.99 and the mean American Orthopaedic Foot and Ankle Society score improved from 77 to 95 points. In two patients the hallux varus recurred. One was symptom-free but the other remained symptomatic after a repeat distal chevron osteotomy. There were no other complications. We consider that distal chevron metatarsal osteotomy with a medial wedge osteotomy and medial capsular release is a useful procedure for the correction of hallux varus after surgery for hallux valgus

The purpose of this study was to compare the results of proximal and distal chevron osteotomy in patients with moderate hallux valgus. We retrospectively reviewed 34 proximal chevron osteotomies without lateral release (PCO group) and 33 distal chevron osteotomies (DCO group) performed sequentially by a single surgeon. There were no differences between the groups with regard to age, length of follow-up, demographic or radiological parameters. The clinical results were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system and the radiological results were compared between the groups. At a mean follow-up of 14.6 months (14 to 32) there were no significant differences in the mean AOFAS scores between the DCO and PCO groups (93.9 (82 to 100) and 91.8 (77 to 100), respectively; p = 0.176). The mean hallux valgus angle, intermetatarsal angle and sesamoid position were the same in both groups. The metatarsal declination angle decreased significantly in the PCO group (p = 0.005) and the mean shortening of the first metatarsal was significantly greater in the DCO group (p < 0.001). We conclude that the clinical and radiological outcome after a DCO is comparable with that after a PCO; longer follow-up would be needed to assess the risk of avascular necrosis. Cite this article: Bone Joint J 2013;95-B:649–56

Background. Until recently, surgical treatments for advanced ankle osteoarthritis have been limited to arthrodesis or ankle replacement. Supramalleolar osteotomy provides a joint-preserving option for patients with eccentric osteoarthritis of the ankle, particularly those with varus or valgus malalignment. Aim. To evaluate radiological and functional outcomes of patients undergoing shortening supramalleolar osteotomy for eccentric (varus or valgus) osteoarthritis of the ankle. Method. Prospective review of patients from 2008 onwards. Osteotomy was the primary surgical procedure in all patients after failure of non-operative measures. Pre-operative standing antero-posterior and Saltzman view radiographs were taken to evaluate degree of malalignment requiring correction. Radiological and clinical outcomes were assessed at 3, 6 and 12 months post-operatively. Radiographs were reviewed for time to union. Patients were assessed on an outpatient basis for ankle range of motion as well as outcomes using AOFAS scores. Results. 33 patients over a 7 year period. Mean follow-up was 25 months (range 22–30). Mean time to radiological union was 8.6 weeks (range 8–10); there were no cases of non-union. There was a statistically significant improvement in functional scoring (P< 0.001); mean AOFAS score improved from 34.8 (range 15–40) pre-operatively to 79.9 (range 74–90) at 12 months post-operatively. There was no significant change in pre- and post-operative range of motion. 2 patients required revision surgery at 12 months; one to arthrodesis and one to ankle replacement. Conclusion. Supramalleolar osteotomy is a viable joint preserving option for patients with eccentric osteoarthritis of the ankle. It preserves motion, redistributes forces away from the affected compartment and corrects malalignment, providing significant symptomatic and functional improvement

Moderate to severe hallux valgus is conventionally treated by proximal metatarsal osteotomy. Several recent studies have shown that the indications for distal metatarsal osteotomy with a distal soft-tissue procedure could be extended to include moderate to severe hallux valgus. The purpose of this prospective randomised controlled trial was to compare the outcome of proximal and distal Chevron osteotomy in patients undergoing simultaneous bilateral correction of moderate to severe hallux valgus. The original study cohort consisted of 50 female patients (100 feet). Of these, four (8 feet) were excluded for lack of adequate follow-up, leaving 46 female patients (92 feet) in the study. The mean age of the patients was 53.8 years (30.1 to 62.1) and the mean duration of follow-up 40.2 months (24.1 to 80.5). After randomisation, patients underwent a proximal Chevron osteotomy on one foot and a distal Chevron osteotomy on the other. At follow-up, the American Orthopedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal interphalangeal (MTP-IP) score, patient satisfaction, post-operative complications, hallux valgus angle, first-second intermetatarsal angle, and tibial sesamoid position were similar in each group. Both procedures gave similar good clinical and radiological outcomes. This study suggests that distal Chevron osteotomy with a distal soft-tissue procedure is as effective and reliable a means of correcting moderate to severe hallux valgus as proximal Chevron osteotomy with a distal soft-tissue procedure. Cite this article: Bone Joint J 2015;97-B:202–7

Metatarsalgia is a recognised complication following iatrogenic shortening of the first metatarsal in the management of hallux valgus. The traditional surgical treatment is by shortening osteotomies of the lesser metatarsals. We describe the results of lengthening of iatrogenic first brachymetatarsia in 16 females. A Scarf-type osteotomy was used in the first four cases and a step-cut of equal thicknesses along the axis of the first metatarsal was performed in the others. The mean follow-up was 21 months (19 to 26). Relief of metatarsalgia was obtained in the six patients in whom 10 mm of lengthening had been achieved, compared to only 50% relief in those where less than 8 mm of lengthening had been gained. One-stage step-cut lengthening osteotomy of the first metatarsal may be preferable to shortening osteotomies of the lesser metatarsals in the treatment of metatarsalgia following surgical shortening of the first metatarsal

We reviewed 91 patients (103 feet) who underwent a Ludloff osteotomy combined with additional procedures. According to the combined procedures performed, patients were divided into Group I (31 feet; first web space release), Group II (35 feet; Akin osteotomy and trans-articular release), or Group III (37 feet; Akin osteotomy, supplementary axial Kirschner (K-) wire fixation, and trans-articular release). Each group was then further subdivided into severe and moderate deformities. The mean hallux valgus angle correction of Group II was significantly greater than that of Group I (p = 0.001). The mean intermetatarsal angle correction of Group III was significantly greater than that of Group II (p < 0.001). In severe deformities, post-operative incongruity of the first metatarsophalangeal joint was least common in Group I (p = 0.026). Akin osteotomy significantly increased correction of the hallux valgus angle, while a supplementary K-wire significantly reduced the later loss of intermetatarsal angle correction. First web space release can be recommended for severe deformity. Additionally, K-wire fixation (odds ratio (OR) 5.05 (95% confidence interval (CI) 1.21 to 24.39); p = 0.032) and the pre-operative hallux valgus angle (OR 2.20 (95% CI 1.11 to 4.73); p = 0.001) were shown to be factors affecting recurrence of hallux valgus after Ludloff osteotomy. Cite this article: Bone Joint J 2013;95-B:803–8

This paper tests the null hypothesis that there is no difference in recurrence for mild and moderate hallux valgus treated with Scarf osteotomy in the presence of a disrupted Meary's line compared to an intact line. At a minimum of 3 months follow up we retrospectively analysed radiographs, theatre and clinic notes of 74 consecutive patients treated with Scarf osteotomy for mild and moderate hallux valgus at a single centre. The patients were divided into Group A (n=30) – patients who on pre-operative weight bearing radiographs had a disrupted Meary's line, and Group B (n=44) – those with a normal Meary's line on pre-operative weight bearing radiographs. Our results demonstrate a statistically significant higher recurrence in group A compared to Group B with an odds ratio of 5.2 p = 0.006 [95% CI 1.6–6]. The association between a disrupted Meary's line and increased risk of recurrence for Scarf osteotomy remains valid and strengthened to an odds ratio of 7.1 p = 0.015 [95% CI 1.46 −34.4] when adjusted for confounding variables of age, sex and pre-operative IMA. On this basis we reject the Null hypothesis. In group A two out of 30 patients required revision surgery whilst none of the 44 patients in group B needed revision. In Group A the degree of IMA correction achieved equalled 8.1 degrees with a pre and post IMA of 16.0 and 7.9 degrees respectively. For Group B the degree of correction was 8.0 degrees with a pre and post IMA of 14.3 and 6.3 degrees respectively. Eight complications were reported in Group A and 9 in Group B. Our results demonstrate a statistically significant increased risk of recurrence when scarf osteotomy is performed for mild and moderate hallux valgus in the presence of a disrupted Meary's line

Background:. The Chevron osteotomy is straightforward, requires less dissection and allows earlier rehabilitation than some other osteotomies. However it is generally perceived as unsuitable for severe deformities even though a 2012 meta-analysis and an earlier RCT failed to show any advantage of the scarf over the chevron. We aim to assess the correctability of severe HV comparing the correction, the clinical outcomes and complications of the Chevron osteotomy with other techniques employed in a consecutive series. Methodology:. We reviewed a series of 92 cases of severe hallux valgus (IMA >17° regardless of the HVA). The follow-up period varied from 1 to 4 years. Pre-operative x-rays and final post-operative weight-bearing x-rays were performed. Outcome scores (MOXFQ and AOFAS), IMA, HVA and foot width were collected. Complications were monitored. Results:. There were 97 cases of severe hallux valgus performed during the study period, 55 were treated with a large-shift modified Chevron osteotomy, 42 with a number of other techniques that included Ludloff, Basal or Scarf osteotomy and also fusion in the form of a Lapidus or 1. st. MTP. The average pre-operative measurements were IMA of 19.1°, HVA of 40°, osseous forefoot width of 93.2 mm and the forefoot: hindfoot ratio was 3.11. Post-operatively the measurements were IMA of 9.2 and HVA of 9.76, the osseous forefoot width was 82.8 mm and the forefoot: hindfoot ratio was 2.57. Radiological outcomes for the Chevrons were similar to the alternative techniques though the rate of recovery was better. There is an increase in the rate of screw removal after a large shift Chevron osteotomy, reasons for this are discussed. Conclusion:. The Chevron osteotomy is successful in the management of severe hallux valgus. It has the advantage of being a stable osteotomy that permits immediate weight-bearing and movement of the MTP joint

Introduction. Hallux valgus surgical correction has a variable but significant risk of recurrence. Symptoms result from an iatrogenic first brachymetatarsia following the index surgical procedure. First metatarsal shortening has been shown to correlate with the onset of transfer metatarsalgia. We describe the use of the scarf osteotomy to both correct the recurrent deformity and lengthen the shortened first metatarsal. Methods. 36 lengthening scarf osteotomies were undertaken in 31 patients. Clinical (AOFAS and SF12 scores) and radiographic measures (IMA, HVA) were taken pre- and post-operatively. The maximum theoretical lengthening was 10mm, to prevent first MTP joint stiffness post-operatively. The actual lengthening was determined and measured intra-operatively. Results. There were 28 female and three male patients, with mean age at presentation 53.4 years. The mean follow-up was 3.9 years. Four cases were lost to follow-up. The mean first metatarsal lengthening achieved was 4.9mm (range 1–8mm). All of the osteotomies united without complication. The mean IMA reduction was 4.0° (p<0.001) and HVA 13.0° (p<0.001). The mean AOFAS score increase was 33.8 (p<0.001). There was no correlation between change in IMA and AOFAS score (r=−0.13) or between improvement in HVA and AOFAS score (r=−0.02). There was a positive trend but no correlation (r=0.28) between amount of metatarsal lengthening and change in AOFAS score. The inter- and intra-observer correlation was excellent. The SF12 physical sub-domains improved more than the mental sub-domains. Conclusion. We describe the largest series of lengthening scarf osteotomies for recurrent hallux valgus and symptomatic iatrogenic first brachymetatarsia. The significant improvement in both clinical and radiographical measures suggests the procedure is successful, with a low complication rate. Lengthening did not reduce the MTPJ range of movement. We hypothesise that restoring both the length and alignment enables greater weight-bearing under the first metatarsal head, reducing biomechanical transfer metatarsalgia

In recent years the Weil osteotomy has become the dominant technique employed by most surgeons for distal metatarsal osteotomy. This is generally a reliable technique but problems with stiffness can frequently occur in the operated metatarso-phalangeal joints. We present our experience with a minimally invasive distal metatarsal extra-articular osteotomy technique. This technique utilises a high-speed burr via a tiny skin portal to perform a distal metatarsal extra-articular osteotomy under image intensifier guidance without the need for fixation. A consecutive series of 55 osteomies in 21 patients were included in the study. All osteotomies were performed for metatarsalgia/restoration of metatarsal cascade. The mean age was 49 (38-78), and 20/21 were female. The senior author performed all surgery. All patients were allowed to weight bear immediately in a postoperative shoe and then an ordinary shoe from 4-6 week post-operatively. Mean follow-up was 8 months (4-13) and patients were assessed clinically and scored using the AOFAS scoring system and a subjective outcome score. The mean AOFAS score improved significantly postoperatively. All patients were very satisfied/satisfied with the outcome. Two patients had minor superficial portal infections, which resolved with oral antibiotics. One patient reported irritating numbness and stiffness in toes (1st case performed). Most patients reported swelling persisting to 3-4 months. There was one symptomatic delayed at 4 months treated successfully with short air boot immobilisation. There were no mal unions. This series suggests that MIS distal metatarsal osteotomy results compare well with outcomes reported with modern open techniques such as the Weil. We now favour an MIS distal metatarsal osteotomy technique for most indications due to the minimal stiffness observed postoperatively as well as much reduced surgical time without the need for tourniquet

Introduction. The aim of this study was to assess whether routine X-Rays at six weeks altered the subsequent management of patients who underwent a Scarf osteotomy. Materials and Methods. Between 1997 and 2010, 218 consecutive primary scarf osteotomies of the first metatarsal were performed by two foot and ankle surgeons in a single unit. 71 were combined with an Akin closing wedge osteotomy of the proximal phalanx of the great toe and soft tissue release. Additional osteotomies were performed on the lesser toes in 30 cases. Intraoperative X-Rays were taken. We retrospectively looked at clinic letters for all patients who attended six weeks post operatively and recorded the outcomes following X-Rays. Results. 209 patients were assessed six weeks post operatively with radiographs of the foot. 9 patients were lost to follow up. Four patients (1.9%) were identified as having complications at the osteotomy: recurrence of deformity seen in two patients, delayed union with failure of fixation, and painless hypertrophic nonunion. Discussion. Only a very small proportion of patients developed complications at the osteotomy site following a Scarf osteotomy for hallux valgus. Both cases of recurrence were diagnosed clinically. Failure of fixation was due to poor patient compliance. No revision procedures were planned for any patients. Conclusion. The senior author no longer requests postoperative X-Rays routinely. We believe that the majority of patients may be safely and successfully assessed clinically following Scarf osteotomy without the need for routine X-Rays

Severe hallux valgus deformity is conventionally treated with proximal metatarsal osteotomy. Distal metatarsal osteotomy with an associated soft-tissue procedure can also be used in moderate to severe deformity. We compared the clinical and radiological outcomes of proximal and distal chevron osteotomy in severe hallux valgus deformity with a soft-tissue release in both. A total of 110 consecutive female patients (110 feet) were included in a prospective randomised controlled study. A total of 56 patients underwent a proximal procedure and 54 a distal operation. The mean follow-up was 39 months (24 to 54) in the proximal group and 38 months (24 to 52) in the distal group. At follow-up the hallux valgus angle, intermetatarsal angle, distal metatarsal articular angle, tibial sesamoid position, American Orthopaedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal score, patient satisfaction level, and complications were similar in each group. Both methods showed significant post-operative improvement and high levels of patient satisfaction. Our results suggest that the distal chevron osteotomy with an associated distal soft-tissue procedure provides a satisfactory method for correcting severe hallux valgus deformity. Cite this article: Bone Joint J 2013;95-B:510–16

Müller Weiss disease (MWD) is characterized by lateral navicular necrosis which is associated with a varus alignment of the subtalar joint, varying degrees of arthritis of the talonavicular-cuneiform joints and a paradoxical flatfoot deformity in advanced cases. Although arthrodesis of the hindfoot is commonly used, we present the results of a previously unreported method of treatment using a calcaneus osteotomy incorporating a wedge and lateral translation. Fourteen patients with MWD who were treated with a calcaneus osteotomy were retrospectively reviewed. There were seven females and seven males with an average age of 56 years (range 33–79), and included one grade 5, five grade 4, four grade 3 and four grade 2 patients. Patients had been symptomatic for an average of eleven years (range 1–14), and all underwent initial conservative treatment with an orthotic support that posted the heel into valgus. The primary indication for surgery was a limited but positive response to the use of the orthotic support, and a desire to avoid an arthrodesis of the hindfoot. Results. Patients were followed for an average of three years following the procedure (range 1 – 7 years). Patients rated their pain on a visual analogue pain scale as an average of 8 (range 6–9) prior to surgery and an average of 2 postoperatively (range 0–4). The AOFAS scores improved from a mean of 29 (range 25 – 35) preoperatively to a mean of 79 (range 75–88) postoperatively. Hindfoot range of motion remained and the extent of arthritis of the navicular complex was unchanged. No patient has since required an arthrodesis. Since the majority of MWD patients respond to an orthotic support which changes the load of the hindfoot and forefoot, we believed that patients would respond positively to a calcaneal osteotomy as an alternative treatment

Background. The Weil osteotomy is successful in the management of metatarsalgia and toe deformity. The aim is to achieve controlled shortening whilst avoiding plantarflexion. Recognised complications of the Weil osteotomy include a ‘floating toe’ in up to 20% or more of cases. Aim. Can modification of the Weil osteotomy avoid the metatarsal head plantarflexion and subsequent dorsal subluxation of the interosseous muscle that is implicated in the development of a ‘floating toe’. Methodology. The 2nd, 3rd and 4th rays were dissected out en bloc with all tendons attached from 6 pairs of fresh frozen cadavers. The ray was fixed to a board and the tendons physiologically balanced via low-friction pulleys and light weights. This model is highly sensitive to alterations in moment arm of the tendons. Once the MTP joint was balanced these weights were not altered. After standard release of the dorsal capsule a Maceira or ‘triple-cut’ osteotomy was performed. This osteotomy was developed in order to permit shortening without plantar flexion of the metatarsal head. The osteotomy was performed using a image intensifier in order to maintain uniformity of the osteotomy cut. The neck was shortened by removing a 2mm slice of bone made with parallel cuts. The ray was photographed and x-rayed pre and post ‘surgery’ and the relationships of the interosseous tendon andcentre of rotation of the metatarsal head, tendon balance and toe posture were recorded. Results. The Maceira osteotomy can avoid plantarflexion of the metatarsal head The line of pull of the interosseous tendon can maintains it's normal relationship with the centre of rotation of the metatarsal head. None of the toes developed dorsiflexion. In fact, plantarflexion at the MTP joint could be seen. PIP ‘fusion’ resulted in dorsiflexion at the MTP joint in some toes