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Hallux valgus- Scarf osteotomy

    Overview

    Learn the Hallux valgus: Scarf osteotomy surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Hallux valgus: Scarf osteotomy surgical procedure.
    The Scarf osteotomy is a commonly performed operation for the correction of mild to moderate Hallux Valgus deformities. It is technically straight-forward and yields a stable metatarsal immediately suitable to partial weight-bear on with appropriate post-operative shoe-wear.
    It usually is performed together with a modified McBrides soft tissue release and on occasion with an Akin osteotomy to the proximal phalanx.
    Readers will also find the following OrthOracle techniques of interest:
    Chevron Osteotomy (for Hallux Valgus)
    Lateral MTP joint release ( modified McBrides procedure)
    Akin osteotomy
    Basal osteotomy for Hallux Valgus using Arthrex Low Profile Locking Proximal Opening Wedge Osteotomy Plate


    Indications

    INDICATIONS:
    A mild to moderate Hallux Valgus deformity ( as defined by the inter metatarsal angle on weight bearing X-rays ) with minimal associated arthritic change.
    The presence of an abnormal distal metatarsal articular angle (DMAA) with either of the above levels of deformity
    As a lengthening procedure for a short first ray( this is an uncommon indication).
    The design of osteotomy can also be used in the 5th metatarsal for bunionette correction.
    SYMPTOMS & ASSESSMENT:
    Patients with symptomatic Hallux Valgus will have pain predominantly from the medial eminence. Pain is classically when in shoe-wear (or more specifically tighter fitting shoe-wear) though will persist for a while when shoes have been removed.
    If there is a proportion of pain from the hallux independent of shoe-wear, or perhaps pain is actually reduced in shoe-wear despite a bunion being being present , then first metatarsophalangeal (MTP) arthritis may be present. Depending on its severity this may preclude an osteotomy , a 1st MTP fusion being a more predictable way of treating the combination of increased inter-metatarsal angle with an arthritic joint. It should be understood that more minor degrees of 1st MTP osteoarthritis would not preclude using a Scarf osteotomy and preserving the 1st MTP joint with a debridement or cheilectomy as appropriate . There are no absolutes and this is something for discussion with the patient in detail.
    Patients with 1st MTP arthritis in whom the joint is being preserved should be aware that the joint will likely be stiffer post-operatively and over a period of time their arthritis will likely progress. Hallux Valgus correction is not known to stop this risk (see paper by Bock et in the results section).
    Pain from other areas of the forefoot should be specifically questioned about. A first ray defunctioned by Hallux Valgus may lead to transfer metatarsalgia from the 2nd or 3rd metatarsals and Mortons neuromas are a common forefoot pathology that may co-exist with a bunion.
    In examining the patient the range of movement of the 1st MTP joint should be assessed .There should be a full (same as the other side) range of pain-free MTP movement from the joint. If the range is reduced it may be due to arthritis or abnormal joint alignment caused by the deformity.
    It is worth noting if pronation of the MTP joint is present. If this is significant an Akin osteotomy may be required to correct this element of the deformity. Also any significant Hallux Interphalangeus should be identified and correction also by Akin osteotomy considered. A definitive decision on this is usually made at the time of operation. An Akin osteotomy may also be required if during capsular closure there is a tendency for the MTP joint to continue deviating into valgus despite a stay stitch in the medial capsule.
    One should also make an assessment of the nature of the soft tissues, by how passively correctable the deformity is. A stiff soft tissue envelope will likely need a greater effort in surgical correction .With a slack soft tissue envelope it can be easy at the time of capsular closure to over-correct the deformity and predispose to developing a Hallux Varus.
    Other sources of pain from the forefoot should be actively looked for in every case (whether complained of or not). Common inter-current pathologies are transfer metatarsalgia (mainly from 2nd, 3rd and 4th metatarsal heads) where callosities are often associated and are painful on direct plantar compression. A Mortons’ neuroma (which will yield pain on compressing through the 2/3 or 3/4 web spaces) and lesser toe deformities may impinge in shoe-wear dorsally or produce plantar metatarsal head pain.
    A rare condition is localised numbness/pain from the medial border of the Hallux due to compression of the Dorso-Medial Cutaneous nerve (which if present should be clearly documented as a pre-existing examination finding).
    Occasionally if the patient is asymptomatic from the perspective of pain they may still wish surgical correction and this should be discussed carefully with them if it is to be undertaken. Some female patients will be very embarrassed by the feet that they have inherited and developed . This may be to the extent that they avoid activities which require the exposure of the naked foot in public (such as swimming or beach activities) .If the pros & cons of treatment are explained and they are realistic about the recovery time and willing to engage in active rehabilitation post-operatively then I would deem surgery appropriate (and no different ethically than cosmetic surgery to other areas).
    In most cases whether to proceed with surgical treatment should be determined by the level of symptoms experienced by a patient.
    INVESTIGATION:
    Weight bearing AP & Lateral X-rays should be performed on all patients having surgery.
    The first question is whether there is significant arthritic change , to the extent that a fusion rather than an osteotomy should be considered.
    The 1/2 inter-metatarsal angle determines whether the deformity is mild , moderate or severe from the perspective of planning which type of osteotomy is likely to be required to produce an adequate correction of the deformity.
    With regards to radiographic criteria a mild Hallux Valgus could be said to be a Hallux Valgus angle (the degree of lateral angulation of the hallux relative to the first ray ) of less than 2o degrees and an inter-metatarsal angle of less than 11 degrees. A moderate deformity displays a Hallux Valgus angle of 20 to 40 degrees and an Inter-metatarsal angle of 11-18 degrees. A severe deformity a Hallux Valgus angle in excess of 4o degrees and inter-metatarsal angle over 18 degrees.
    A useful but not infallible rule of thumb is that if only the lateral sesamoid is uncovered then a Scarf osteotomy is likely to give adequate correction. If however the tibial sesamoid is also uncovered in part then a Basal osteotomy is likely to be required.
    When measuring the inter-metatarsal angle beware that it may appear erroneously low if all the metatarsals have a varus angulation. A measured moderate intermetatarsal angle under these circumstances may actually require a Basal osteotomy to correct it adequately.
    The distal metatarsal articular angle should also be measured, and if abnormal (angled to any notable extent into valgus relative to the long axis of the metatarsal shaft) then it is likely to require correction by differential movement of the scarf osteotomy (see post operative X-rays section). An Akin osteotomy may still be needed if the Hallux continues to deviate into valgus even after correction of the inter-metatarsal angle.
    The width of the metatarsal shaft versus the size of the increase in Inter-Metatarsal(I-M) angle is also worth noting. A larger I-M angle can be better corrected using the Scarf osteotomy if the metatarsal shaft is wide.
    The relative lengths of all the metatarsals should also be noted. If there is significant transfer metatarsalgia effecting the lesser toes toes (often associated with a relatively short 1st metatarsal ) then Weils osteotomies are likely to be required to these metatarsals (see Weils osteotomy operative technique).
    NON-OPERATIVE ALTERNATIVES:
    -Wide fitting shoe-wear.
    -Silicone spacers and toe splints will separate the digits but not effect the forefoot width in any corrective way.
    -In flat feet a medial arch orthotic may reduce medial column loading and reduce the forces through the medial eminence. They however add extra volume into a shoe and so may tighten shoe-wear fit and increase pain in this way.
    SURGICAL ALTERNATIVES:
    There are a large number of alternate diaphyseal osteotomies described to correct a similar level of deformity.
    A milder deformity will require a distal osteotomy such as a Chevron (see Atlas technique ) and a more severe deformity consideration of a basal osteotomy (see Atlas technique).
    CONTRAINDICATIONS:
    In a symptomatic Pes Planus with 1st Metatarso-cuneiform hyper-mobility consider a Lapidus procedure instead.
    Conditions or medications effecting soft tissue or bone healing need to be optimised prior to surgery ( and smoking avoided or minimised post-surgery).
    Patients with impaired neurological function (in whom fusion is more reliable)
    Juvenile deformity with open growth plates
    In patients with Hallux Valgus and moderate to severe joint disease (degenerate or inflammatory) an MTP fusion is likely to be required.

    Setup

    General or Regional anaesthetic
    Antibiotics & LMW Heparin on induction . LMW heparin to continue post-operatively.
    Laminar flow theatre if available
    Ankle tourniquet
    Patient placed supine
    Pre/post operative Nerve block (popliteal and / or inter-metatarsal )for analgesia
    High speed saw & wire driver / drill
    Lambotts osteotomes

    Operation – 1

    The skin incision for a Scarf osteotomy is placed at the junction of plantar and dorsal skin (approximately in the midline of the sagittal plane). It is commenced distally at the midpoint of the proximal phalanx(1) and extends generally close to wards the base of metatarsal.
    The first step when undertaking a Scarf osteotomy is to perform a lateral release (a modified McBrides proceedure, not shown here) in the first web space. This is done in an open fashion (see the separate Atlas technique on this). The tendons at risk in this part of the exposure are the Extensor Hallucis longus(EHL)and the Flexor Hallucis longus(FHL) .The Adductor Hallucis tendon is specifically released from its attachment to the lateral sesamoid as part of the release .
    Making an incision is aided by an assistant holding the phalanx in a reduced and anatomical position (as seen here). The incision is extended proximally in the midline of the 1st metatarsal shaft towards its base, point 2 on the image.
    A small deformity will require a shorter length of incision that doesn’t extend all the way to the metatarsal base.

    Once the skin incision is made carefully dissect the fat layer in the longitudinal line of the skin incision with fine tenotomy scissors. There is always another fascial layer superficial to the capsule (1) and deep to the fat which needs to be identified dorsally.The dorsomedial cutaneous nerve (DMCN, 2) sits here and should be carefully identified and reflected dorsally to avoid injury to it.
    If cut it will result in an unnecessary patch of numbness medially and on rare occasions a painful scar neuroma.

    Once the superficial layer containing the DMCN has been identified distally the dissection can be continued proximally (1) avoiding the line of the nerve and reflecting a full thickness soft tissue flap with sub-periosteal dissection .The proximal extent of the dissection for a standard Scarf osteotomy is marked by the plantar widening of the metatarsal base (3). There is often a vein transversely at this level(2) to be avoided. The Wests retractor (4) is used here.
    At this stage it is also worth making two parallel incisions that skirt the bone , plantar and dorsal , at the mid-point of the metatarsal shaft. These “pockets” will then be ready for insertion of the bone holding reduction forceps after the osteotomy has been translated into in new position, prior to fixation.

    A medially based horizontal capsulotomy (1) is performed in the midline to enable exposure of the metatarsal head. The attachments to the base of the proximal phalanx must not be released.The McDonalds retrtactor(2) is used to place the capsule under tension and ease its mobilisation . The proximal extent of the capsular release(3) should not extend far into the soft tissues attached at the plantar aspect of the metatarsal head in which important nutrient vessesls to the metatarsal head run. Dividing these risks producing osteonecrosis of the metatarsal head post-operatively.
    It is also most important that the capsular attachments to the base of the proximal phalanx are left fully intact and not dissected free as part of the exposure (which is not required). If these are violated then the medial capsular tightening at the end of the operation is not possible.

    The dorsal aspect of the metatarsal head also needs to be cleared of its capsular attachments. This should extend right across to the lateral aspect of the metatarsal head(1) as depicted by the blue arrow.
    The McDonalds is used to place the tissues under tension and facilitate this release.
    Any intra-articular plica within the MTP joint can be removed at this stage and it is also important to note any chondral lesions effecting the metatarsal head. Loose chondral flaps should be debrided and consideration given to microfracture of the defect with a fine 1mm K-wire.
    This needs to be recorded in the notes and the patient informed post-operatively. These lesions are most often asymptomatic though may progress later to more florid arthritic change (see results section for a paper on this point).

    The medial exostosis is removed with an appropriately sized power saw. The blade should be relatively broad, thin but not too flexible and have a small arc of travel only, to assist accurate bone cutting. Only a small amount of bone need be removed normally.Once the soft tissues have been adequately freed off the metatarsal head it is “delivered” into the wound by placing a Homans’ retractor both dorsal and also plantar (A, B).
    If there is an element of early arthritic change effecting the dorsal metatarsal head then a small dorsal cheilectomy is performed at this stage.
    Once the exostosis is removed (not shown) a central hole is marked with the tips of tenotomy scissors. This point should be approximately in the midline of both the metatarsal shaft (2) as well as in the midpoint of the metatarsal head (1). This hole is a marker for where to cut to with the fine power saw for the Scarf osteotomy.

    The first scarf osteotomy cut is vertical, with the saw blade “dialled”towards 11 O’Clock (relative to the cut surface of the metatarsal head) and to the midpoint in the sagittal plane.
    It should also be aimed towards the 4th MTP joint when looking axially. This avoids shortening or lengthening the 1st metatarsal after displacing the osteotomy (which is the effect of aiming the cut too proximally or distally respectively).

    The second horizontal cut should split the shaft into approximately equal dorsal and plantar portions. The blade should also be angled plantar-wards (as is shown marked 1 in the left hand picture) from the horizontal.The right hand image shows how the second cut for Scarf osteotomy is made, along the length of the metatarsal shaft, 2. The vertical initial cut is marked 1. The best way to ensure that the horizontal cut is made mid-width of the shaft is ensuring that the dorsal and plantar limits of the metatarsal shaft have been adequately cleared of their soft tissue attachments prior to cutting, to allow accurate visualisation.
    This ensures that the metatarsal is also translated towards the sole of the foot when it is moved laterally and thus remains functional. Elevation of the metatarsal after translation could lead to defunctioning of the 1st ray (which can cause flattening of the medial arch and/or transfer metatarsalgia).
    With a larger deformity a longer horizontal cut should be made. For a smaller deformity the cut can be shorter.
    One should avoid breaching the 1st MTC joint proximally by not continuing this cut beyond the “flare” of the metaphyseal bone at the base of the metatarsal.

    Once the basal metaphyseal flare of bone is reached a second vertical and plantar cut is made. This should parallel as near as possible the distal vertical cut in the metatarsal head (1).In making the cut along the long axis of the metatarsal(2) it is vital that the plantar inclination of the blade is kept constant throughout for correct orientation of the scarf osteotomy. Once you start making this cut concentrate and keep on the same plane until the lateral cortex is adequately divided.
    An appropriately cut piece of suture packet makes an ideal guide if placed into the first osteotomy cut.
    If the above points are not respected then the osteotomy will not translate as freely or far as it can, thus compromising correction.

    Once the scarf osteotomy is completed it is useful to free up the cuts further by tapping a Lambotts osteotome across them. The lower portion of the osteotomy must be entirely mobile before translation of the fragment is undertaken.Before using the osteotome however the osteotomy should already be a bit mobile. If it is not then carefully pass the saw-blade through again. The most likely “sticking points” will be where the horizontal cut meets the vertical cuts either end.
    Be very careful not to use an osteotome that is either too thick or too wide. There is a risk of splitting the metatarsal head if using this action.
    Under no circumstances use a twisting movement with the osteotome whilst going over the cuts again. One risks splitting the metatarsal head distally if this it not respected.
    If you do split the head then it will need to be fixed (for which a bio-absorbable pin or small screw will work). This is not an additional stage of the operation to become experienced at. Post-operatively the patient will need to non-weight bear (or heel weight bear initially) if this occurs.

    Once the scarf osteotomy is mobile translate the lower portion laterally, thus narrowing the inter-metatarsal angle.If it does not translate adequately then the lateral (and deep) aspect of the saw cuts should be directly inspected for ridges/spikes which may be hindering movement. This is easily done using manual distraction to inspect the osteotomy cuts and revisiting and tapping out the bone cuts again with an appropriately sized Lambotts osteotome.
    How much translation is required is dependent upon the size of the deformity and how much can be done by the width of the metatarsal shaft. As a rule of thumb one should try to avoid translating the shaft by more than 50% of its width.

    Once the desired translation of the Scarf osteotomy is achieved (as marked by the blue line 3) the bone is held with the reduction clamp (1). This is inserted into the plantar and dorsal pockets created previously by sharp dissection, on the midpoint of the metatarsal shaft.If the DMAA is abnormal then this can be corrected at this stage after direct lateral translation has occurred by rotation of the osteotomy. The base of the osteotomy is rotated laterally and the distal end medially which results in a corrective rotation of the metatarsal articular surface out of lateral inclination.
    A sign that this has been achieved will be a visible gap opening on the lateral aspect of the dorsal and distal transverse cut.

    It is not possible to be absolute about the appropriate amount of translation required to narrow the inter-metatarsal angle. However the amount by which the lateral sesamoid is uncovered (on the pre-operative AP X-ray ) gives a good approximation of how much to translate the plantar limb of the osteotomy.

    The distal metatarsal articular angle can be improved with a Scarf osteotomy by rotation of the two ends of the osteotomy during lateral translation.
    The direction of rotation is shown in the left sided image. The base of the plantar limb of the osteotomy is rotated laterally and the distal end is rotated medially after the initial direct lateral translation.
    The corrective effect on the DMAA after translation and rotation are shown in the right sided image.

    Once translation of the Scarf osteotomy is achieved, and before fixation and capsular plication, the MTP joint should be put through a range of movement.In particular attention should be paid to the “tracking” of the joint , namely does it still have a strong tendency to displace into valgus.

    If there is a tendency for deviation of the MTP into valgus during dorsiflexion then the DMAA should be corrected if this has not been done.
    If despite this significant dynamic valgus angulation continues then an Akin Osteotomy may be required (see later).

    The first guide wire for screw fixation(1) is placed distally from the head:neck junction (2) and angled plantar, distal and lateral.
    It is angled from dorso-medial to plantar lateral. Its length is seen directly by viewing the plantar aspect of the joint. Care should be taken not to place the wire too close distally to the osteotomy nor too close to the lateral cortex (2). In both cases if too small a bridge of bone is left the risk of post/intra operative fracture and loss of control/position is increased.

    A direct reading of the required screw length can be from the distal guide wire once it has been visually confirmed that it has not penetrated the metatarsal head.The plantar aspect of the metatarsal head is inspected (using a McDonalds to lever away the proximal phalanx) to ensure the guide wire has not penetrated it. Generally subtract 2-4mm from guide wire length for the distal screw required for a Scarf osteotomy. This avoids joint penetration by the screw.

    The distal drill hole of a scarf osteotomy is made using the long drill with the narrow barrel present on the set.Space is usually limited next to the reduction clamp (as seen here) due to the angle of entry required for the guide wire. Avoid drilling through the inferior surface of the metatarsal head. The hole must however be countersunk and this may require changing to the short drill supplied.

    The drill has been swapped to the short one and now the distal hole is being countersunk.

    By careful previous placement of the guide wire (not too far distal or lateral) one has ensured that an intact shelf of dorsal bone remains distally and laterally which provides a good surface for screw purchase as the distal screw is inserted.The common sizes of screw at this end of the osteotomy are 18-22 mm
    Previous countersinking will ensure that the head is not prominent. As the screw is tightened a good grip on the bone should be evident , with visible compression at the osteotomy site. If this does not occur the screw may not be long enough and the next size up should be considered.
    If upon screw tightening the osteotomy opens then the hole has been drilled to an inadequate depth and should be re-drilled slightly deeper.

    The basal guide wire is angulated “far lateral” to achieve a good grip on the bone. Its length will not necessarily be directly visible but attempt should be made to see the tip of the wire in the plantar lateral aspect of the proximal wound, before measuring, overdrilling and inserting the second screw.One may however have to rely on a loss of resistance to know just when the guide wire has penetrated the far lateral cortex.
    This wire is also measured (the screw required most often here being 14 -16 mm length). Again good compression should be produced once the screw is inserted.
    Once both screws are seated it is good practice to stress and load the osteotomy by manual pressure to ensure the screws have provided adequate fix. If there is any question of this not being the case (and the 2 main screws have been optimised in terms of size ) then a third and central screw is justified. It is very rare to need this.

    The now redundant overhang of medial bone following the Scarf osteotomy is trimmed away (1).All sharp edges are smoothed with the saw. The plantar-medial soft tissues (2) adherent to the capsule are very carefully sharp dissected a small amount to leave a clearly defined plantar-medial capsule for closure.

    At this stage both the dorsal (3) as well as the plantar (2) capsule needs to have any superficial adherent soft tissues carefully sharp dissected sufficient to see where the capsular sutures will be placed. It is normal that the Dorso-medial cutaneous nerve will be seen (though not shown here). It would be unusual to encounter the plantar digital nerve (1) seen here. The plantar dissection does not need to be this extensive.

    It is important that the capsule has remained firmly attached to the base of the proximal phalanx (1) in the earlier stages of the scarf osteotomy. This allows a capsular reefing to bring the hallux back into normal alignment at the level of the MTP joint.

    Operation – 2

    A v shaped wedge of medial capsule is excised (1) from the inferior section of the capsule.This should be at the level of the MTP joint. Its apex should lie a fair way (but not all the way) down the visible medial capsule.

    The medial capsule is sutured with a 1 vicryl suture which runs from a plantar proximal point (1) to dorsal and distal(2) and returns through the plantar distal capsule back to plantar and proximal.Good bites of capsule should be taken.

    The final bite of capsule (3) is taken distal and inferior to close the scarf osteotomy.
    The plantar proximal (1) and dorsal distal (2) capsular bites are already taken.
    This is a key step. If the correction is adequate then a single suture under appropriate tension should produce a stable , anatomical correction.

    The effect of capsular closure is clearly seen between these two images.
    On the left the suture has been placed but not tightened. The “V” shaped excision of the plantar capsule is easily seen. In the image on the right the suture has been tightened and with the “V” shaped capsular defect has closed, indicating tightening of the medial capsule.
    It is important at this stage of the scarf osteotomy to be mindful as to how much tension is placed upon this suture. It is certainly possible to over correct the deformity and this should be avoided. With a single suture placed the MTP should be put through a range of movement. If it continues with a tendency towards valgus angulation during dorsiflexion then an Akin osteotomy is indicated.
    This is detailed at https://www.orthoracle.com/library/the-akin-osteotomy/.
    A very tight medial capsular closure “fighting against the deformity” until the final suture should be avoided.This may stabilise and correct on-table but the joint is more at risk of subsequent recurrence.
    If you have a healthy threshold for performing the Akin (and have used the Scarf for an appropriate case) then I would anticipate needing it in 60% of cases or so.
    A clicking sensation at this stage indicates that the suture is catching on the osteotomy and should be removed and redone. Essentially smaller “bites” of capsule should be taken to reduce the chance of the suture abrading on the medial cut surface of the metatarsal head.

    Once the correct tension in closure has been achieved the amount of redundant capsule can be assessed and excised.A double breasting in closure of the capsule is not required and adds unwanted medial bulk.This excess capsule is excised(1) to allow enough remaining capsule for easy apposition of the edges.

    Further single 1 vicryl sutures are placed to close the proximal aspects of the capsule.A second plicating type of suture as described may be required and is placed slightly more proximally, especially if the deformity corrected has been large.
    More commonly (as here) one or two oblique capsular sutures(1) are placed to tighten and close the capsule less aggressively. It is important to pay attention to the angulation of the MTP through out closure and not over-correct which may encourage development of a Hallux Varus.

    The medial capsule closed with one plicating(1) and two oblique(2,3) 1 vicryl sutures. Diluted aqueous betadine is rinsed through the superficial tissues and closure completed with vicryl sutures.
    Not infrequently there is redundant medial skin and this should be excised before skin closure with a subcuticular suture.

    Skin closure ideally is with a 3.0 vicryl suture, though non-absorbable nylon may be required in poor quality tissue.The acute change in forefoot width, with reduction in the 1/2 intermetarsal angle, and correction of the valgus angulation of the first MTP joint is clearly demonstrated in these on-table photographs.

    X-rays pre (left) and post (right) operatively of a Scarf osteotomy.
    Note the correction of the inter-metatarsal angle and re-covering of the lateral sesamoid. Note also the correction of the hallux valgus angle.
    Lateral films(not shown) are also always required to demonstrate appropriate screw length. It is in particular key that the distal screw does not penetrate the plantar cortex, which risks producing irritation of the sesamoids. The more proximal screw can sit slightly beyond the plantar cortex as it is not a weight bearing surface.

    Post Operative

    Surgery is performed as a day-case or overnight stay
    LMW Heparin required for 2 weeks post-operatively
    Weight bear using appropriately stiff post operative shoe for 4-6 weeks
    Crutches likely required 1-2 weeks
    Patient are taught self-mobilisation of the MTP from 1 week post op, both active and passive. A thera-band is useful for this .The key is achieving dorsi-flexion early. My routine is to suggest 20 -30 cycles of plantar/dorsi-flexion using & against the thera-band three times per day. Physio supervision from 4 weeks if patients haven’t achieved an adequate range.
    Kellers bandage/post operative splint for 4-6 weeks post-operatively. How this is applied is critical. Any tendency to over or under correction at the MTP level occurring in this immediate post-operative period should be actively managed by corrective splint age.
    Dressings to continue 24/7 until all wounds are dry.
    From 4 weeks the patients should cleanse the foot twice a day, once in a salt water bath and once by bathing/showering
    Dressings ,especially to medial wounds , to continue for the first month in normal shoe-wear.
    Appropriate shoe-wear fit is vital in the first month or so after the post-op shoe
    I advise fit-flops , Uggs , wider fits or open sandals. Stiffer heels ( platform or wedge ) are encouraged in women , from when comfortable , to promote MTP dorsi-flexion.
    Patients may static bike & swim from 4-6 weeks(once out of bandaging) , cross-train from 6-8 weeks and re-start light jogging on treadmill from 9 weeks at soonest .

    Recommended Reading

    Scarf osteotomy for correction of Hallux Valgus. Historical perspective, surgical technique and results.
    Foot and Ankle clinics. 2000. 5(3):559-579.
    L S Weil, DPM.
    A good review of the technical aspects and technique and results from a large single institution series. The osteotomy used also for more severe deformity (IM angles of 17-23 degrees). 889 cases reviewed from notes & X-Rays. Mean IM angle 10 degrees (15 pre-op ,range 11-23). Very slight reduction in range of movement. Incidence of Hallux Varus reduced over the study period from 5% to 3%. 3 cases of avascular necrosis post-operatively. No recurrence rate specified.
    Modern concepts in the treatment of Hallux Valgus.
    J Bone Joint Surg.2005.87-B;1038-1045
    A.H.N.Robinson, J.P.Limbers
    A good review Article
    Scarf osteotomy for Hallux Valgus.A prospective and pedobarographic study.
    J Bone Joint Surg.2004.86-B.830-836
    S.Jones, H.Al Hussainy, F.Ali, R.P.Betts, M.J.Flowers.
    35 feet reviewed prospectively
    IMA improved from mean of 15 degrees to mean of 9 degrees.
    92% of patients either satisfied or very satisfied with the result. 8% not satisfied. 11% incidence of post-operative stiffness
    Emergency brake response time after first metatarsal osteotomy.
    J Bone Joint Surg. 2008.90-A;1660-1664
    G.Holt, M.Kay, C.S.Kumar.
    28 patients matched with a control group and reaction times at various stages assessed using a standardised testing rig.
    6 weeks before reaction times returned to normal post surgery.
    A very useful paper though I would question the robustness of the information when applied to current practice. Reaction times measured only at 2 & 6 weeks post-operatively, patients heel weight bearing until 6 weeks post operatively and no standardisation(or advice ) on the shoes worn by patients during the testing.
    Hallux Valgus and cartilage degeneration in the first metatarsophalangeal joint.
    J Bone Joint Surg. 2004. 86-B(5):669-673
    P.Bock ,K-H. Kristen ,A. Kroner ,A. Engel.
    An intra-operative observational study of chondral lesions within the 1st MTP joint (including the sesamo-phalangeal articulations)seen at time of corrective Hallux Valgus surgery. Almost 70% of 265 1st MTP joints displayed some degree of lesion, the severity of which correlated with the severity of the pre-surgical deformity.

    Reference

    • orthoracle.com

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