Scarf osteotomy for correction of hallux valgus. Historical perspective, surgical technique, and results.

The Scarf osteotomy has proven to be a versatile and powerful procedure to correct various degrees of hallux valgus deformity. Through modifications of bone-cut lengths and in combination with a phalangeal osteotomy, most hallux valgus deformities can be addressed. In cases of extreme hypermobility of the first ray or arthrosis of the first metatarsocuneiform joint, the Lapidus operation may be more appropriate. Hallux valgus rigidus or hallux valgus with severe rheumatoid joint disease usually requires alternative procedures. The results of the Scarf osteotomy compare favorably with the results reported for other popular bunion surgeries. When choosing a procedure, the clinician should consider that the Scarf osteotomy allows the patient to ambulate postoperatively without a cast or the use of crutches, to return to bathing and a closed athletic shoe in one week, and to have bilateral surgery, which maintains cost-effectiveness and returns the patient to his or her desired lifestyle more quickly. It has been said that surgery is both a science and an art. The author often believes that bunion surgery is more art than science, hence the success of so many procedures in one surgeon's hands and the failure in another's hands. The Scarf bunionectomy is a technically demanding procedure that has a large learning curve. Once mastered, however, the Scarf bunionectomy can provide a predictable and satisfying outcome for both patient and foot surgeon.

The Cobb procedure for stage II posterior tibial tendon dysfunction.

Flexor digitorum longus transfer or augmentation is currently the most popular adjunctive procedure for the repair of an attenuated or ruptured tibialis posterior tendon. Although the procedure is efficacious, an important functional muscle is sacrificed. Results show that similar results can be achieved with a tenodesis procedure by way of a split anterior tibial tendon repair. The authors have modified the Cobb procedure, and do not create a hole through the medial cuneiform or navicular. The thick, fibrous periosteal tissue at the medial aspect of the cuneiform is a sufficient tunnel for securing and positioning the tibialis anterior tendon. An additional site of healing and potential complications are avoided. The Cobb procedure is a useful and successful treatment option for PTTD, provides strong autograft augmentation to the posterior tibial tendon without sacrificing function of other tendons, and offers the surgeon and patient predictable outcomes with long-term satisfaction.

Percutaneous plantar fasciotomy: a minimally invasive procedure for recalcitrant plantar fasciitis.

A retrospective study was done to evaluate patient pain level and satisfaction after a percutaneous plantar fasciotomy. Between 1990 and 1996, 51 patients underwent percutaneous plantar fasciotomy for chronic plantar fasciitis associated with heel pain syndrome. All patients had undergone at least 6 months of conservative therapy. A questionnaire incorporating a visual analog pain scale was used to determine the effectiveness and patient satisfaction of the procedure. Of 35 patients who responded to the questionnaire, 27 were female and eight were male, ranging in age from 31 to 76 years with an average age of 47 years. Follow-up time after surgery ranged from 12 to 57 months, with an average of 34 months. Utilizing a visual analog pain scale, results showed a preoperative pain level of 8.7 (+/- 1.2) with a range of 6-10. Pain level at follow-up was 2.1 (+/- 2.7) with a range of 0-10. Eighty-three percent of the patients stated that the procedure met or exceeded their expectations. Percutaneous plantar fasciotomy is a simple and cost-effective method for surgical intervention of chronic heel pain syndrome. Complications are rare and the results compare favorably with other reported more invasive and costly techniques.

Outcomes for surgical correction for stages 2 and 3 tibialis posterior dysfunction.

Between the years 1991 and 1996, 13 patients with stage 2 or 3 tibialis posterior dysfunction were evaluated following surgical reconstruction. Those patients with posterior tibial tendon tendinitis with a progressive flatfoot were categorized as having a stage 2 deformity according to Mueller's developmental stages of tibialis posterior dysfunction. Those patients with increasing severity of symptoms including a forefoot abductus component were classified as stage 3. There were five patients in stage 2, ranging in age from 53 to 80 years old; and there were eight patients in stage 3, ranging in age from 41 to 73 years old. Standard conservative care was utilized prior to surgical intervention in all cases. Follow-up was 12 months to 63 months. Patients in stage 2 underwent a Cobb reconstruction utilizing a split tibialis anterior tenodesis, and patients in stage 3 underwent an Evans lateral column-lengthening procedure combined with a Cobb procedure. Utilizing retrospective radiographic evaluation and patient interviews, results indicated that patients in stage 2 had a better patient satisfaction than those patients in stage 3. Although both patient groups had a 6-point average decrease in pain according to the 0- to 10-point visual analog pain scale, 50% of the patients undergoing a Cobb-Evans procedure felt that the procedure did not meet their expectations. Only one out of the five Cobb procedure patients felt that the procedure did not meet his expectations. The results of this limited study of patients with stage 3 tibialis posterior dysfunction suggest that although the lateral column lengthening with tendon augmentation renders good radiographic correction, many patients develop protracted lateral column pain and felt that surgery did not meet their expectations. Additional calcaneal osteotomies and arthrodesing procedures of the hindfoot may render a more satisfactory outcome.