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The mitchell and scarf osteotomies for hallux valgus correction: a retrospective, comparative analysis using plantar pressures. J Foot Ankle Surg. 2006 Nov-Dec;45(6):400-9
Dhukaram V, Hullin MG, Senthil Kumar C
Quote:
A retrospective analysis was performed to describe the effects of Mitchell and Scarf osteotomies on plantar pressure distribution and their relevance to the clinical outcome. This study evaluated 28 patients who underwent operations for moderate to severe hallux valgus deformities over a period of 3 years at 2 different centers. Twenty-two Mitchell and 22 Scarf osteotomies were performed on 28 patients with a mean follow-up of 23 months (13-62 months). The average postoperative American Orthopaedic Foot and Ankle Society scores after Mitchell and Scarf osteotomies were 74 and 84, respectively. A control group of 15 individuals with 20 healthy feet were included for comparison. The plantar pressures were documented with the Musgrave footplate. The pressure distributions under the first metatarsal head were within normal limits in both study groups compared with the control group (P = .77). After Mitchell osteotomies, deficient load bearing was noted under the hallux (P = .007), coupled with overloading of the second and third metatarsal heads (P = .01). But after the Scarf procedures, increased weight bearing was noted at the heel (P = .04) and midfoot (P = .09), with better load distribution under the hallux. However, it was not comparable with the control group. Correlation of American Orthopaedic Foot and Ankle Society scores and pressure variables demonstrated a significant positive correlation with hallux loading (P = .001). This study demonstrates that adequate hallux loading is imperative for a better outcome of the procedure. Mitchell and Scarf osteotomies do not restore the load-bearing function of the foot to normal, whereas hallux loading plays an important role for a better outcome of the procedure.
Fixation of Mitchell's osteotomy with bioabsorbable pins for treatment of hallux valgus deformity.
Nikolaou VS, Korres D, Xypnitos F, Lazarettos J, Lallos S, Sapkas G, Efstathopoulos N. Int Orthop. 2008 Oct 28. [Epub ahead of print]
Quote:
We hypothesised that the use of bioabsorbable pins in Mitchell's osteotomy would improve the outcome of patients treated for hallux valgus deformity. A total of 68 patients underwent Mitchell's osteotomy to correct hallux valgus deformity: 33 patients (group A) underwent Mitchell's osteotomy augmented with bioabsorbable pins and 35 patients were treated with the classic operative procedure (group B). Hallux valgus angle (HVA), intermetatarsal angle (IMA), the American Orthopaedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal scale and the visual analogue score (VAS) for pain were measured preoperatively and postoperatively. There was no statistically significant difference between the two groups as far as the improvement of the IMA, HVA and AOFAS scale were concerned. Patients of group A had significantly less postoperative pain and returned to their previous activities earlier than patients of group
Fixation of Mitchell's osteotomy with bioabsorbable pins for treatment of hallux valgus deformity. Nikolaou VS, Korres D, Xypnitos F, Lazarettos J, Lallos S, Sapkas G, Efstathopoulos N.
Patients of group A had significantly less postoperative pain and returned to their previous activities earlier than patients of group B. The use of the pins did not improve the final outcome of the osteotomy. However, it allowed for faster rehabilitation due to less postoperative pain.
Some seemingly good things about this study:
There were no significant differences in subject age and gender between groups.
The same surgeon performed all procedures
Post-op protocols were the same for both groups
Estimates of random variability were provided (SD’s) in addition to actual P values
The surgical procedures are well described
Some seemingly not so good things:
Subjects were not randomized to groups. Subjects in group A (pins) were selected according to radiographic signs of osteoporosis. This difference between groups could be a confounding variation, eg post-op pain levels may have been lower in Group A because the bones were softer ?
Subjects were not blinded to their group allocation. Subjects in group A (pins) may have had greater expectations regarding the treatment than subjects in Group B (classic procedure). The placebo effect was not controlled for, and raises a question about the findings for subjective pain reduction, where subjects in Group A (pins) reported significantly lower pain levels at 4 wks post-op.
It would have been a good idea if the researcher who asked the questions about pain levels at follow-up was blinded to the group allocation, otherwise there could be inadvertent suggestion about how well the recovery was going.
The conclusion quoted above implies a statistically significant difference in convalescence (time to return of previous activities) between groups, which was not the case (0.059). Close though, and would be more meaningful if the effect size (d) had been calculated.
I take my hat off to those who conduct clinical research in surgery ...
Regards,
Andrew
Last edited by a.mcmillan : 31st October 2008 at 01:12 AM.
Reason: attachment
The purpose of this study was to evaluate the outcome of a modified technique of Mitchell’s osteotomy for treatment of moderate to severe hallux valgus deformity with the aims of reducing first metatarsal shortening and osteonecrosis. Between February 2001 and December 2007, a total of 69 patients (90 feet) underwent Mitchell’s corrective osteotomy for moderate to severe hallux valgus deformity. Mean duration of follow-up after surgery was 37 months. Clinical outcome was assessed using the AOFAS Hallux Metatarsophalangeal-Interphalangeal score preoperatively; at 6 weeks, 6 months, 12 months postoperatively; and at annual follow-ups thereafter. Standard weight-bearing radiographs were obtained at each visit. Fifty-nine patients (80/90 feet, 89%) were completely satisfied, whereas 10 patients (10/90 feet, 11%) were satisfied with minor reservations owing to minor complications. Global AOFAS score improved from 43.7 (range, 20 to 77) preoperatively to 85.4 (range, 55 to 100) at final follow-up (P < .01). Eighty-eight (98%) of 90 feet were completely pain free. There was a statistically significant improvement in mean hallux valgus angle, intermetatarsal angle, and distal metatarsal articular angle at final follow-up. There were no cases of deep infection, nonunion, or osteonecrosis of first metatarsal head. None of the patients had shortening of the first metatarsal bone by more than 3 mm. In conclusion, our modified surgical technique with a combination of bony correction and adequate capsular reefing is a simple procedure to correct moderate to severe hallux valgus deformity that results in high levels of patient satisfaction, successful deformity correction, and controlled shortening of the first metatarsal, as well as minimal recurrence of deformity.)
Clinical and radiographic analysis of the operative procedure results according to the method of Mitchell and Keller used for correction of hallux valgus deformities.
Georgieva D, Poposka A, Zafirova-Ivanovska B. Prilozi. 2011 Jul;32(1):199-209.
Quote:
The aim of this study is to make a correlation of the clinical and radiographic results after performing two different surgical procedures for correction of hallux valgus deformity. Material and methods: The study included 70 patients having hallux valgus deformity of the foot, and they were divided into two groups. The first group (Group 1) was composed of 35 patients who were treated by osteotomy of the I-st metatarsal bone according to Mitchell, while the second group (Group 2) was also composed of 35 patients who were treated by resectional arthroplasty according to Keller. Clinical (pain and metatarsalgia, as well as most dominant symptoms) and radiographic examinations (I metatarsophalangeal angle and I intermetatarsal angle) were analysed comparatively during the evaluation. The analysis of the clinical and radiographic results was performed pre-operatively and post-operatively for the two groups. Results: According to their sex, the patients were 5 men and 65 women. Using the method of Mitchell, pain as a clinical symptom post-operatively was found in only 3 patients out of the 35 with operated feet, while in the other group of patients treated by the method of Keller, there was no presence of pain in any of the patients. Comparatively, this does not present a statistically significant difference (p > 0.05). Nor do, the differences in the distribution of metatrsalgia incidence show a statistical significance between the two groups (p > 0.05). There is no significant difference (p > 0.05) in the patients of the two groups concerning the pre-operative mean dimension values of the I metatarsophalangeal angle and I intermetatarsal angle. However, the radiographic analysis of the same angles in both groups, one year post-operatively, showed a high statistically significant difference (p < 0.001).
Summary: Mitchell's operative technique could be recommended as an effective procedure for the correction of hallux valgus and metatarsus primus varus in young and middle-aged patients, while the resection arthroplasty according to the method of Keller is recommended for older patients with arthrotic changes.
I don't think I've ever performed a Mitchell Osteotomy in my whole career. As I resident, I performed a few, but the osteotomy is akward, the fixation isn't nearly as stable as other osteotomy, and from what I've read there are higher incidences of AVN due to the osteotomy. There are also higher rates of complications if the patients are non compliant aren't there?
I'm not sure there are any Podiatrist in my region that don't use a basic Chevron for their very basic bunion deformity correction.
BACKGROUND:
The authors have performed more than 1500 cases of a Mitchell osteotomy and traditionally used two crossed pins for fixation. The previous series showed some complications related to pin tract infection, pin migration, and transfer metatarsalgia. Since 2009, the authors have used a compression screw for fixation and made some technical modifications and the results are reported in this article.
METHODS:
A total of 95 patients underwent a Mitchell ostotomy to correct hallux valgus deformity with fixation with multi-use compression (MUC) screws. Hallux valgus angle (HVA), intermetatarsal angle (IMA), the American Orthopaedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal scale were measured preoperatively and postoperatively.
RESULTS:
~There were statistically differences between the preoperatively and postoperatively HVA, first IMA, and AOFAS hallux metatarsophalangeal-interphalangeal scores. Five patients (8/137 feet, 5.8%) underwent removal of the screw because of screw tip irritation. Eight patients (9/137 feet, 6.5%) had transfer metatarsalgia of the second metatarsal, with two of them caused by dorsal tilt of the metatarsal head. One patient (1/137 feet, 0.7%) had undercorrection. There was no superficial infection, deep infection, nonunion, or osteonecrosis of the first metatarsal head.
CONCLUSION:
On the basis of the results observed in this study, it appears that the use of a multi-use compression screw provides satisfactory stabilization of the modified Mitchell osteotomy and was not associated with any serious complications. The modified technique also helped reduce transfer metatarsalgia.
Background: The aim of this study was to evaluate the use of mini-plate and screw fixation to stabilize the first metatarsal osteotomy in patients undergoing Mitchell bunionectomy, with the outcomes of interest being radiological alignment and the time to bony union.
Methods: We used mini-plates and screws in 43 feet of 25 patients to avoid cast immobilization and prevent osteotomy displacement. The mean age at operation was 45.4 ± 13.4 years (range, 17.0-65.0 years). The mean follow-up was 16.9 ± 3.6 months (range, 12.0-30.0 months). The hallux valgus angles, intermetatarsal angles, and American Orthopaedic Foot and Ankle Society (AOFAS) forefoot scores were evaluated preoperatively and at postoperative month 12.
Results: The mean preoperative value for the hallux valgus angle was 35.9 ± 4.4 degrees (range, 26.0-45.0 degrees) and for the intermetatarsal angle was 12.1 ± 1.4 degrees (range, 10.0-15.0 degrees). The mean postoperative value for the hallux valgus angle was 16.0 ± 2.12 degrees (range, 12.0-20.0 degrees) and for the intermetatarsal angle was 7.7 ± 1.2 degrees (range, 5.0-10.0 degrees). The mean AOFAS score was 50.5 ± 12.8 points (range, 30.1-76.0 points) preoperatively and 75.9 ± 11.3 points (range, 43.3-92.3 points) at postoperative month 12. Improvement of range of motion of the metatarsophalangeal joint, pain relief, and satisfactory alignment of the first ray were achieved in 41 feet (95.3%).
Conclusions: We recommend this fixation for Mitchell’s bunionectomy because it provided stable fixation without the need for casting.
Mitchell's Osteotomy With Mini-Plate and Screw Fixation for Hallux Valgus.
Kalender AM, Uslu M, Bakan B, Ozkan F, Erturk C, Altay MA, Guner S, Kalender M. Foot Ankle Int. 2013 Feb;34(2):238-43.
Quote:
Background: The aim of this study was to evaluate the use of mini-plate and screw fixation to stabilize the first metatarsal osteotomy in patients undergoing Mitchell bunionectomy, with the outcomes of interest being radiological alignment and the time to bony union.
Methods: We used mini-plates and screws in 43 feet of 25 patients to avoid cast immobilization and prevent osteotomy displacement. The mean age at operation was 45.4 ± 13.4 years (range, 17.0-65.0 years). The mean follow-up was 16.9 ± 3.6 months (range, 12.0-30.0 months). The hallux valgus angles, intermetatarsal angles, and American Orthopaedic Foot and Ankle Society (AOFAS) forefoot scores were evaluated preoperatively and at postoperative month 12.
Results: The mean preoperative value for the hallux valgus angle was 35.9 ± 4.4 degrees (range, 26.0-45.0 degrees) and for the intermetatarsal angle was 12.1 ± 1.4 degrees (range, 10.0-15.0 degrees). The mean postoperative value for the hallux valgus angle was 16.0 ± 2.12 degrees (range, 12.0-20.0 degrees) and for the intermetatarsal angle was 7.7 ± 1.2 degrees (range, 5.0-10.0 degrees). The mean AOFAS score was 50.5 ± 12.8 points (range, 30.1-76.0 points) preoperatively and 75.9 ± 11.3 points (range, 43.3-92.3 points) at postoperative month 12. Improvement of range of motion of the metatarsophalangeal joint, pain relief, and satisfactory alignment of the first ray were achieved in 41 feet (95.3%).
Conclusions: We recommend this fixation for Mitchell's bunionectomy because it provided stable fixation without the need for casting
Mitchel vs Scarf osteotomy
Linear Mode
