KilmartinandO’KaneJournalofFootandAnkleResearch2010,3:2 http://www.jfootankleres.com/content/3/1/2 JOURNAL OF FOOT AND ANKLE RESEARCH RESEARCH Open Access Combined rotation scarf and Akin osteotomies for hallux valgus: a patient focussed 9 year follow up of 50 patients Timothy E Kilmartin1,2,3*, Claire O’Kane1 Abstract Background: The Cochrane review of hallux valgus surgery has disputed the scientific validity of hallux valgus research. Scoring systems and surrogate measures such as x-ray angles are commonly reported at just one year post operatively but these are of dubious relevance to the patient. In this study we extended the follow up to a minimum of 8 years and sought to address patient specific concerns with hallux valgus surgery. The long term follow up also allowed a comprehensive review of the complications associated with the combined rotation scarf and Akin osteotomies. Methods: Between 1996 and 1999, 101 patients underwent rotation scarf and Akin osteotomies for the treatment of hallux valgus. All patients were contacted and asked to participate in this study. 50 female participants were available allowing review of 73 procedures. The average follow up was over 9 years and the average age at the time of surgery was 57. The participants were physically examined and interviewed. Results: Post-operatively, in 86% of the participants there were no footwear restrictions. Stiffness of the first metatarsophalangeal joint was reported in 8% (6 feet); 10% were unhappy with the cosmetic appearance of their feet, 3 feet had hallux varus, and 2 feet had recurrent hallux valgus. There were no foot-related activity restrictions in 92% of the group. Metatarsalgia occurred in 4% (3 feet). 96% were better than before surgery and 88% were completely satisfied with their post-operative result. Hallux varus was the greatest single cause of dissatisfaction. The most common adverse event in the study was internal fixation irritation. Hallux valgus surgery is not without risk and these findings could be useful in the informed consent process. Conclusions: When combined the rotation scarf and Akin osteotomies are an effective treatment for hallux valgus that achieves good long-term correction with a low incidence of recurrence, footwear restriction or metatarsalgia. The nature of the osteotomies allows early return to normal shoes and activity without the need for postoperative immobilisation in a plaster cast. Introduction these were considered of dubious relevance to the The Cochrane review of hallux valgus surgery has dis- patient if they did not address their main concerns. In puted the scientific validity of hallux valgus research [1]. all the literature considered by the Cochrane review, just The review reported that although many studies were one study asked the patients if they were better than available on the surgical management of the condition, before surgery [2]. The review recommended that future final outcome measures were most frequently measured research should include patient focussed outcomes and at one year with just a few trials maintaining follow up follow up periods of at least 5 to 10 years. for 3 years. Scoring systems and surrogate measures In reviewing hallux valgus surgical outcomes it is such as x-ray measurements were commonly used but notable that a high proportion of patients, 25-33%, remain dissatisfied at final follow up [1]. Schneider and Knahr reviewed the expectations of both patients and *Correspondence:[email protected] surgeons in hallux valgus surgery [3]. Two hundred 1HillsboroughPrivateClinic,Hillsborough,CoDown,NorthernIrelandBT26 patients were interviewed and their principal concern 6AE,UK ©2010KilmartinandO’Kane;licenseeBioMedCentralLtd.ThisisanOpenAccessarticledistributedunderthetermsoftheCreative CommonsAttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,distribution,and reproductioninanymedium,providedtheoriginalworkisproperlycited. KilmartinandO’KaneJournalofFootandAnkleResearch2010,3:2 Page2of12 http://www.jfootankleres.com/content/3/1/2 was relief of foot pain when wearing a conventional procedure and introduced the rotation scarf osteotomy shoe. Importantly, the patients hoped that surgery [20] (Figure 1). This osteotomy is able to reduce higher would restore unlimited pain free walking, whereas intermetatarsal angles, while maintaining excellent stabi- alignment and cosmesis of the hallux was considered of lity, thereby avoiding the complications and extended little importance by either surgeons or patients. When recovery time associated with more proximal osteo- the surgeons were interviewed (186 surgeons of the Ger- tomies or arthrodesis. Another significant advantage of man Austrian Orthopaedic Foot Surgery Society), their the rotation scarf osteotomy is that crossing the cortices primary concern was also pain and shoe fitting issues prevents ‘troughing’, a known complication of the trans- but in addition restoring adequate range of motion to positional scarf osteotomy which can lead to elevatus of the first MTP joint and relieving metatarsalgia. the metatarsal head [14]. Common complications specific to hallux valgus sur- In this study we attempted to learn more about the gery include recurrence of deformity, first metatarsopha- patient’s satisfaction withtheir surgical outcome as well langeal (MTP) joint stiffness and transfer metatarsalgia astheincidenceofcommoncomplicationsandtheirlong [4]. With the exception of recurrence, it is unlikely that term impact on the patient. We reviewed 50 cases (73 any of these known postoperative complications will be feet)andspecificallyaskedparticipantsiftheywerebetter of automatic concern to the patient prior to surgery. after their hallux valgus surgery. We also assessed them Their occurrence could, however, explain the high levels for transfer metatarsalgia and first MTP joint stiffness. of postoperative dissatisfaction even when hallux valgus Finally, weaskedparticipantstoreportany footwearfit- angles and first MTP joint pain have improved with sur- tingdifficulties. In thisway we hopedto provide further gery [1]. While many previous studies have focussed on information for patients on the risks and complications x-ray outcomes, the prevalence of these specific compli- specific to the rotation scarf and Akin osteotomies to cations provides a more patient focussed measure of the enableamorecomprehensiveinformedconsent. outcome of a particular procedure and will help sur- geons prepare the patients for informed consent. Methods The scarf osteotomy was first developed in 1926 by Between 1996 and 1999, 101 patients underwent com- Meyer but never achieved widespread use due to inade- bined rotation scarf and Akin osteotomies for the treat- quate fixation techniques [5]. Weil popularised the tech- ment of hallux valgus. In all cases the procedure was nique after describing an effective fixation technique performed by the primary author. All patients were con- using two AO screws [6,7]. The advantages of the tech- tacted and asked to participate in this study which was nique included: rigid compression of large areas of bone approved by the local Audit committee. 53 patients to bone contact providing a good environment for pri- returned to be involved in this study. 10 other patients mary bone healing and early return to normal weight were deceased, 24 were lost to follow up and 14 refused bearing activities and range of motion exercises prevent- to attend for review but were contacted by telephone ing joint stiffness and oedema [8]. The scarf osteotomy and participated in a brief telephone interview. also avoided the complication of metatarsus elevatus Of the 53 patients who returned for the study, 3 were associated with more proximal metatarsal osteotomies excluded (1 was suffering from multiple sclerosis, 1 [9], allowed accurate correction of the intermetatarsal from rheumatoid arthritis and 1 had undergone revision angle and could be modified to allow the metatarsal to surgery). Of the 50 participants included, all were be shortened or lengthened, and plantarly or dorsally female. 23 participants had undergone bilateral surgery displaced if required [10]. so a total of 73 feet were analysed. The average age at The scarf osteotomy has been extensively reviewed in the time of surgery was 57, (SD 10) and the average fol- recent literature [10-19]. To date the scarf has generally low up was 9 years 5 months (113 months, SD 11). The been used to correct moderate hallux valgus in the pre- clinical review was performed independently by the sec- sence of intermetatarsal angles of less than 15 degrees, ond author who had not previously been involved in the the limiting factor being that if the inferior fragment is initial surgical care of the participants. transposed too far laterally, fixation cannot be obtained Preoperatively the first-second intermetatarsal angle and there will be insufficient bone to bone contact to andhalluxvalgusangleweremeasuredonweightbearing produce stable union of the osteotomy. Thus the scarf bilateral x-rays. The x-ray tube was directed 15 degrees osteotomy may not be indicated in the treatment of from the vertical in the dorso-plantar direction. The severe hallux valgus with high intermetatarsal angles. beamwascentred on the navicular with a focal distance This is frustrating for the foot surgeon as all the advan- of 100 cm. Postoperatively the first MTP joint/hallux tages of the scarf osteotomy cannot be applied to valgus angle was measured using a digital goniometer patients with more severe deformity. In view of the lim- (Figure 2), as ethical approval for further irradiation of itations of the scarf osteotomy, Duke modified the the participants was not forthcoming. Intra-observer KilmartinandO’KaneJournalofFootandAnkleResearch2010,3:2 Page3of12 http://www.jfootankleres.com/content/3/1/2 Figure1Therotationscarfosteotomyrotatestheinferiorfragmentasopposedtotransposingitinthescarfostoeotomy.Byrotating thefragmentsgreaterreductionoftheintermetatarsalanglecanbeachievedandthecorticesofthemetatarsalfragmentsarecrossed preventingtroughing. KilmartinandO’KaneJournalofFootandAnkleResearch2010,3:2 Page4of12 http://www.jfootankleres.com/content/3/1/2 repeatability of the goniometer had previously been also recorded. Finally, the participants were asked if they established[21].Agoodcorrelation(r=0.63)betweenx- were happy with the appearance of their post surgical raymeasurementandgoniometricmeasurementhaspre- foot and would they be happy to undergo surgery under viously been found [22]. The range of dorsiflexion and similar circumstances in the future. plantarflexion of the MTP joint was also assessed using A number of adjunctive procedures were performed. thedigitalgoniometer(Figures3and4). In 22 feet a second toe proximal interphalangeal joint All the participants were then interviewed and asked if (PIPJ) arthroplasty was performed and in 9 feet PIPJ they were completely satisfied, satisfied with reservations arthroplasties of other toes were performed. 4 feet or dissatisfied with the results of their surgery. Restric- underwent a Weil osteotomy of the second metatarsal tions with footwear, or any activity restrictions because and 3 feet had neuroma excision from the third inter- of their feet were recorded. The participants were asked metatarsal space. With the exception of 1 participant if there was any pain or stiffness in the first MTP joint. who underwent an adjunctive second joint fusion, all Any pain or tenderness of the lesser MTP joints was participants were encouraged to return to lace-up or Figure2Goniometric measurementofthehalluxvalgus angleusingadigitalgoniometer (available fromNovaInstruments,Mill House,NewgatestreetRoad,GoffsOak,Herts.EN75RX). KilmartinandO’KaneJournalofFootandAnkleResearch2010,3:2 Page5of12 http://www.jfootankleres.com/content/3/1/2 Figure3Withtherestingnon-weightbearingpositionbeingconsideredthezerodegreeangle,thepassivehalluxdorsiflexionrange ofmotionwasmeasuredusingthedigitalgoniometer. running shoes at 2 weeks postoperatively. Between 4 deepened to the capsule ensuring adequate haemostasis. and 6 weeks off work and sport was recommended. The capsular incision was made as a double semi-ellipti- cal incision and the ellipse of tissue excised. Surgical technique A beaver blade was introduced into the joint capsule The procedure was performed in all cases under local between the metatarsal head and the sesamoid appara- anaesthetic ankle block on a day case basis. An ankle tus and the adductor hallucis tendon and lateral sesa- tourniquet was applied and a medial plantar skin inci- moid ligament were released from their respective sion running from the interphalangeal joint of the hallux insertions in the metatarsal head and proximal phalanx. to the base of the first metatarsal was made. This was The medial eminence of the first metatarsal was Figure4Passivehalluxplantarflexionrangeofmotionwasmeasuredfromtherestingpositionwhichwasconsideredzerodegrees. KilmartinandO’KaneJournalofFootandAnkleResearch2010,3:2 Page6of12 http://www.jfootankleres.com/content/3/1/2 resected at the sagittal groove. A guide wire was placed power to the hallux. (Figure 8). We also advised the par- just proximal to the metatarsal head articular surface ticipants to walk through the hallux on gait. These mea- and just inferior to the first metatarsal dorsal cortex. sures, we believe, may contribute to reducing the risk of The guide wire was directed plantarly in the direction of transfer metatarsalgia. the plantar surface of the third metatarsal head but per- pendicular to the long axis of the second metatarsal Results (Figure 5). An osteotomy guide was placed on the guide Patient reported outcomes wire and a power saw was then used to make the hori- In the 50 participants (73 feet) available for follow up zontal cut along the metatarsal shaft extending from 88% of the group (44 participants), were completely just proximal to the articular surface of the metatarsal satisfied, 8% (4 participants) were satisfied with reserva- head to the basal tuberosity. The distal cut was made tions and 4% (2 participants) were dissatisfied (Table 1). parallel with the guide wire and the proximal cut at 96% (48 participants) were better than before surgery approximately a 45° angle from medial proximal to lat- and 4% (2 participants) were no better. All but one of eral distal in order to allow the rotation to occur (Figure the study group indicated that they would be happy to 1). While it is possible to shorten the metatarsal by undergo surgery again under similar circumstances. 90% angling the distal cut in a proximal lateral direction, this of cases (66 feet) were happy with the cosmetic appear- was avoided as we consider any loss of first metatarsal ance. 10% (7 feet) were unhappy with the cosmetic length a predisposition to transfer metatarsalgia. The appearance, 3 had hallux varus and 2 had recurrent hal- lateral capsule was then released and the inferior frag- lux valgus. 2 participants felt their feet were still too ment rotated toward the second metatarsal to reduce wide. the intermetatarsal angle. The degree of rotation There were no activity restrictions in 92% of the group required was established pre operatively by measuring (46 participants). Walking distance was restricted to less the intermetatarsal angle on x-ray. We aimed to reduce than 3 miles in 2 participants. 1 participant felt she the intermetatarsal angle to 7°. One mm of rotation could no longer do yoga because of first MTP joint stiff- equals 1° of correction which could be measured by the ness and 1 participant had developed midfoot arthritis amount of overhanging bone of the superior fragment which was causing activity restriction due to pain. In once the metatarsal head was rotated. The bone frag- 94% of the group (69 feet), there was no metatarsalgia. ments were held with a scarf clamp and fixed with two Metatarsalgia occurred post operatively in 4% of the 2.0 cortical screws using AO technique (Figures 6 and group (3 feet), all of these had hallux varus. 1 partici- 7). The overhanging edges of bone were then removed pant had metatarsalgia prior to surgery and this was still from the medial side of the metatarsal shaft. An Akin present postoperatively. closing wedge osteotomy of the proximal phalanx was performed on all cases. The Akin osteotomy was fixated Footwear issues using a single 1.2 mm threaded k-wire (Figure 7). In 86% of the sample (63 feet) there were no footwear The capsule was then closed using 2-0 vicryl, figure of restrictions. High heels could not be accommodated in 8 sutures. The hallux was held in a plantarflexed posi- 14% (10 feet). This restriction was attributable to sur- tion as the capsule was closed [10]. As an ellipse of cap- gery in 7% of the sample (5 feet) where there was post- sule had previously been excised, closing the capsule operative first MTP joint stiffness. In one other case pulled the sesamoids into a corrected position under the internal fixation irritation was restricting the use of first metatarsal head. Tension on the capsular sutures court style shoes. Hallux varus, which had developed was increased to further draw the hallux into correction postoperatively, was causing footwear problems to 1 if necessary, though we believe that soft tissue correc- participant, and metatarsalgia, which had developed tion is largely temporary and correction should be postoperatively, was restricting the use of thin-soled achieved almost exclusively with the osteotomies. Skin fashion shoes in 1 case. Two participants had developed was then closed using 5-0 vicryl subcuticular sutures. hammer toe deformities of the 2nd digit that restricted Postoperatively all but one patient who underwent a shoes. simultaneous second metatarso-cuneiform joint fusion wore a surgical shoe and used crutches for two weeks. Joint alignment, range of motion and pain After two weeks, dressings were removed and the parti- Preoperatively the mean hallux valgus angle measured cipants were encouraged to wear lace up or running on weight bearing bilateral x-rays was 37 degrees (SD shoes and begin returning to normal activities. The par- 7). The mean first-second intermetatarsal angle was 16 ticipants were advised to perform range of motion exer- degrees (SD 3). At final follow-up the goniometric mea- cises against the resistance of a powerband. In particular surement of the first MTP joint/hallux valgus angle was flexion exercises were encouraged to restore flexor 10 degrees (SD 6). The mean dorsiflexion at the first KilmartinandO’KaneJournalofFootandAnkleResearch2010,3:2 Page7of12 http://www.jfootankleres.com/content/3/1/2 Figure5Placementoftheguidewiretoachieveplantardisplacementofthemetatarsalheadwiththeosteotomy. MTP joint was 54 degrees (SD 14.6) and the mean plan- degrees. Hallux varus occurred in 4% (3 feet). Postopera- tarflexion 15 degrees (SD 8) - normal ranges are tive soft tissue infection managed with oral antibiotics reported to be 65 to 90 degrees dorsiflexion and 15 to occurred in 4% of the sample (3 feet). 1 participant 20 degrees plantarflexion [23-25]. required revision surgery for hallux varus and 25% of Hallux valgus recurrence with first MTP joint/hallux the sample (18 feet) required removal of the distal meta- valgus angles in excess of 15 degrees was noted in 8% of tarsal screw. the sample (6 feet). In 2 participants the hallux valgus No stiffness of the first MTP joint was reported by 92 angle was 22 degrees and in 4 participants it was 20 percent of the sample (67 feet). First MTP joint stiffness Figure6RotationscarfandAkinosteotomiespre-operativex-ray. KilmartinandO’KaneJournalofFootandAnkleResearch2010,3:2 Page8of12 http://www.jfootankleres.com/content/3/1/2 Figure 7 Postoperative x-ray of the rotation scarf and Akin osteotomies in the right foot. This x-ray demonstrates fixation of the osteotomy,realignmentofthesesamoidsandreductionoftheintermetatarsalandhalluxvalgusanglewhilepreservingthelengthofthe metatarsal. occurred in 8% (6 feet) and in 5 feet this caused foot- shoe styles which previously have been difficult [3]. In wear restrictions. In this subset, the mean dorsiflexion this context, hallux valgus surgery could be seen as a was 46 degrees (SD 19, range 22 to 74 degrees) and the high risk intervention because although it may allow mean plantarflexion was 10 degrees (SD 1.6, range 0 to easier footwear accommodation, it carries the possibility 10 degrees). In 94% of the group (69 feet), there was no of rendering the foot painful due to the specific compli- first MTP joint pain. First MTP joint pain was present cations of first MTP joint pain and stiffness and transfer in 3% of the group (two feet) and in both cases there metatarsalgia. Recurrence of hallux valgus is also a dis- was hallux varus. In 2 other feet there was occasional appointing outcome for many patients [28], because joint pain. once again it recreates the shoe fitting problems. None of the 14 participants contacted by telephone Foot surgeons may find it difficult to accept the possi- had required revision surgery at other facilities. All were bility that they could be performing hallux valgus cor- happy with the outcome of their surgery. No further rection for cosmetic reasons but female interest in information was gathered from these telephone fashionable, high-heeled footwear is high. In this series interviews. of participants we believe we only performed surgery when conservative measures failed to alleviate symptoms Discussion or when participants could not accommodate their foot In the original cohort of 101 patients undergoing the in conventional shoes, or when the hallux was so mala- combined rotation scarf and Akin osteotomies 98% were ligned that it was beginning to underide the second toe female. All 50 participants that returned for assessment and deform previously normal structures within the related to this study were female. The higher incidence foot. On the basis of Schneider and Khnar’s study [3], of symptomatic hallux valgus in females is well docu- we recognise the importance of footwear postoperatively mented [26,27], but there is far less consideration of and fixed on this as a patient focussed outcome. what drives female patients to undergo surgery and At an average of 9.5 years after their operation, 86% of what their expectations of surgery are [3]. Hallux valgus the sample were unrestricted in their footwear choice in is often caused by shoe fitting issues wherein many of that they could wear high heels. Patients that can wear the symptoms are caused by footwear irritation and the high heeled shoes comfortably are unlikely to be suffer- expectations of surgery are a return to a wide range of ing from painful first MTP joint stiffness or from KilmartinandO’KaneJournalofFootandAnkleResearch2010,3:2 Page9of12 http://www.jfootankleres.com/content/3/1/2 Figure8Postoperativeflexionexercisesusingapowerband.Thepatientisaskedtorepeatedlyplantarflexthehalluxwhileincreasingthe resistanceofthepowerband. transfer metatarsalgia. In this way the ability to wear a Recurrence of hallux valgus occurred in 8% of the par- range of shoes is also an indication of foot function. In ticipants in this study. This is a disappointing outcome this sample just 4% were found to be suffering from as it means the patient is once more at risk of develop- transfer metatarsalgia, but 8% were aware of first MTP ing the whole range of symptoms associated with hallux joint stiffness and in 6% there was joint pain. valgus. However, cases of recurrent hallux valgus were The management of transfer metatarsalgia and first considered mild as a maximum hallux valgus angle of MTP joint stiffness following hallux valgus correction 22 degrees was observed. This is close to the normal has received little attention in the literature and is cer- reported range of 15 degrees or less [29]. tainly an area with much potential for further investi- Hallux varus developed in just 3 feet but at interview gation. We sought to prevent both problems by asking these participants appeared more unhappy with their patients to mobilise and strengthen the first MTP joint outcome than any other participant in the study. We immediately postoperatively with simple flexions of the consider hallux varus a significant though rare complica- first MTP joint. At two weeks postoperatively we tion leading to progressive joint degeneration and pain, asked patients to use a powerband (rubber band exer- metatarsalgia and footwear fitting problems. Its real sig- ciser) to perform plantarflexion and dorsiflexion exer- nificance lies in the degree of dissatisfaction it creates cise of the first MTP joint against the resistance of the with patients often presenting with multiple symptoms. powerband. We also advised patients to propel through Hallux varus occurs when the tibial sesamoid is posi- the first MTP joint and hallux on gait so as to avoid tioned medial to the first metatarsal head [30-32]. In the guarding the first MTP joint. If the hallux cannot be rotation scarf and Akin osteotomies hallux varus may be plantarflexed, propulsion power from the hallux is a consequence of excessive reduction of the intermeta- reduced and we believe the patient is more likely to tarsal angle by the metatarsal osteotomy. Alternatively, propel from the lesser MTP joints, which then become excessive mobilisation of the sesamoids following bruised, inflamed and painful. Intraoperatively we detachment of the fibular sesamoid suspensory ligament, always attempted to maintain the length of the first especially when combined with release of the adductor metatarsal and displace the metatarsal head in a plan- hallucis tendon, will risk hallux varus. Over tightening tarly direction as part of the rotation scarf osteotomy. the medial capsule during deep closure will compound This again, we believe, may minimise the possibility of this effect by pulling the tibial sesamoid medial to the transfer metatarsalgia. metatarsal groove. An excessively aggressive Akin KilmartinandO’KaneJournalofFootandAnkleResearch2010,3:2 Page10of12 http://www.jfootankleres.com/content/3/1/2 Table 1Summaryofoutcomes forthe 50 femaleparticipants (73 feet) at anaverage 9.5years postoperative rotation scarfand Akinosteotomies forhallux valgus Outcome Percentage Patientsatisfaction 88%completelysatisfied 8%satisfiedwithreservations 4%dissatisfied Cosmeticappearance 10%unhappywithcosmeticappearance Footwearrestrictions 14%couldnotwearhighheels GoniometricmeasurementoffirstMTPjointpostop MeanHalluxvalgusangle10°SD6 Meandorsiflexion54°SD4.6 Meanplantarflexion15°SD8 FirstMTPjointstiffness 8% Physicalactivityrestriction 8% Metatarsalgia 6% FirstMTPjointpain 6% Halluxvalgusrecurrence 8% Halluxvarus 4% Postopsuperficialwoundinfection 4% Internalfixationremoval 25% Revisionsurgery 1patientforhalluxvarus osteotomy will also pull the hallux into varus. Of all consequence of reducing the metatarsus primus varus, these potential causes of hallux varus, the Akin osteot- realigning the sesamoids, and crucially, shortening the omy is the easiest to assess intraoperatively and certainly first metatarsal, which relaxed the soft tissue contrac- if the hallux appeared in varus after performing the tions around the MTP joint and in effect, allowed the Akin osteotomy, the wedge of bone would be re-inserted hallux to ‘spring’ straight [3]. In contrast, the rotation and the osteotomy fixed. The position of the tibial sesa- scarf osteotomy used in this study did not shorten the moid was also assessed intraoperatively and if it was not first metatarsal and hence the hallux position was sitting directly inferior to the medial sesamoid groove, addressed separately by the Akin osteotomy. The Akin the rotation of the inferior fragment would be reduced osteotomy allows a very deliberate and controllable cor- before internal fixation was performed. Over tightening rection of the hallux position and its use in combination of the medial capsule will pull the hallux into varus as with the rotation scarf probably explains why recurrence the capsule is sutured. Sutures can be removed at this of hallux valgus, an important cause of patient dissatis- point, a smaller bite of the capsule taken and less ten- faction in most hallux valgus surgery studies and a uni- sion applied to the suture. versal finding in one long-term follow up study of the Clearly, in the three cases of hallux varus in this study Mitchell osteotomy [28], occurred in just 6 feet in this one or all of these predisposing factors continued to study of 73 hallux valgus corrections. malalign the MTP joint. This complication, however, The most common adverse event in the study was must be considered alongside the relatively low inci- internal fixation irritation. One quarter of the partici- dence of hallux valgus recurrence, which we believe is a pants required removal of the distal screw from the consequence of the ability of the rotation scarf and Akin metatarsal shaft due to footwear irritation. In most cases osteotomies to address all components of the hallux val- the participants found that the distal screw was irritated gus deformity. In particular, we believe addressing the by the proximal edge of the toe box in court style shoes. position of the hallux with the Akin osteotomy is vital Currently, the distal screw is now countersunk more to ensure that the hallux lies parallel but not abutting aggressively and placed as proximal on the metatarsal the second toe. Pressure of the hallux against the second shaft as possible to achieve the greatest depth of soft tis- toe will cause the proximal phalanx to act like a wedge sue coverage and reduce proximity to the shoe toe box. driving the first metatarsal once more into varus [33]. In this study we evaluated the long-term outcomes of The place for the Akin osteotomy in combination with the rotation scarf and Akin osteotomies to treat partici- first metatarsal osteotomy is increasingly acknowledged pants with severe hallux valgus associated with in the literature [10,34,35]. Traditionally, however, hal- high intermetatarsal angles usually in excess of 15 lux valgus repair involved osteotomy of the first meta- degrees [36]. Normally in these circumstances more tarsal only. The position of the hallux improved as a proximal osteotomies or indeed fusions of the first