Short versus ‘Standard’ Scarf Osteotomy for Hallux Valgus Correction

Category: Bunion Introduction/Purpose: Scarf osteotomy is an established procedure for correction of hallux valgus deformity. The technique has evolved and is effectively used for all grades of deformities. Short osteotomy (short scarf/modified chevron) and single screw fixation is an effective option for correction of mild to moderate hallux valgus deformity leading to lesser soft tissue disruption, smaller scar and being cost effective. Aim of this study was to compare radiological parameters of hallux valgus correction by a ‘standard’ scarf osteotomy and 2-screw fixation with a short osteotomy and single screw fixation Methods: We performed a retrospective review of prospectively collected data. The cases were identified from theatre log. 37 consecutive patients, operated between January 2013 and December 2014, were included. All had mild deformity as defined by maximum pre-operative intermetartarsal angle of 13 degrees. 16(43%) had short osteotomy with single screw fixation (Group 1) and the remaining 21 (57%) had ‘standard’ scarf osteotomy with 2 screw fixation (Group 2). Preoperative and final postoperative weight bearing radiographs were independently reviewed by both authors. Radiological parameters assessed were Hallux Valgus Angle (HVA), Intermetatarsal Angle (IMA), Distal Metatarsal Articular Angle (DMAA) and Medial Sesamoid position.Sesamoid position was determined by dividing metatarsal head into three equal sections and recorded as more than 50% of medial sesamoid in a section. The three grades were 3(lateral), 2(central) and 1(medial).Both groups were comparable for distribution of age and pre-operative radiological measures. Mean duration of X-Ray follow up was 3 months (range 2-12). SPSS version 20 was used to perform statistical analysis. Results: Mean age of patients was 49 years +/- 13 years. Mean improvement in radiological measures in degrees was - HVA from 24.4 to 10.9 (Group 1) and 35.3 to 12.6 (Group 2), IMA 10.0 to 3.3 (Group 1) and 10.5 to 5.4 (Group 2), DMAA 8.5 to 5.4 (Group 1) and 10.9 to 5.8 (Group 2), Medial Sesamoid position changed from 3 to 1 for both groups. Wilcoxon Signed Rank test showed all these improvements to be significant. T-test showed that both groups were comparable, with no statistically significant difference, for improvements in all radiological parameters. Conclusion: Short osteotomy with single screw fixation is equally effective in correction of symptomatic mild hallux valgus deformity as compared to ‘standard’ scarf osteotomy with the advantage of a smaller scar, lesser soft tissue disruption. We believe it is also cost effective because of potential reduction in duration of surgery and the cost of the implant

Are Hindfoot Procedures More Painful than Forefoot – A Prospective Cohort Study in Foot and Ankle Reconstructive Surgery?

Category: Other Introduction/Purpose: Several variables are thought to have an effect on the post-operative pain relief after reconstructive foot and ankle surgery. In the past decade, the role of regional nerve blocks in the management of post-operative pain has become established. The technique(s) of regional blocks varies between centers and the published literature on this subject is inconsistent. More recently, image guided regional nerve blocks for post-op pain relief in F&A surgery have gained popularity. Traditionally, hindfoot reconstructive procedures are deemed to be more painful than the surgery involving the rest of the foot. This prospective study was carried out to examine this question. Methods: 143 patients undergoing elective foot and ankle surgery were prospectively studied. In addition to the demographics, the details of the anaesthetic used were also recorded. 70 patients received peripheral nerve blockade with guidance either by a nerve stimulator or ultrasonography. The procedures were categorised into those belonging to the forefoot, midfoot, hindfoot or combined. The magnitude of pain was recorded immediately post-operatively, at 6 hours and at 24 hours after the surgery, using the visual analog scale (VAS, 0 as ‘no pain’ and 10 as ‘ the worst possible pain’). All adverse effects were recorded. The patients’ satisfaction at two weeks after surgery was also assessed. Kruskal-Wallis test was used to perform non-parametric analysis between the groups. For categorical data, Pearson’s Chi-square test was used. Significant difference was demonstrated by a p-value < 0.05. Results: There was no difference in post-operative, 6 hours or 24 hours VAS in the patients having the hindfoot surgery or those having surgery involving the rest of the foot. Although patients who underwent peripheral nerve block had a satisfactory initial pain relief, they experienced significantly more pain at 24 hours than those who did not have a block (Table 1). There was no significant difference in the hospital stay or patient satisfaction at two weeks. In total, 94% patients were satisfied with their anaesthetic and would not mind having it again. Conclusion: This study provides evidence that contrary to the popular belief, hindfoot surgery is not more painful than the surgery involving the rest of the foot. Our results showed that patients who received peripheral nerve block probably had rebound pain at 24 hours after the surgery. Further studies are needed to explore this relationship. The detailed information provided by this study about the mean (and SD) VAS at various time points after surgery can be used to predict post-operative pain based on various pre-operative surgical and anaesthetic parameters