Scarf osteotomy of the first metatarsal bone to correct hallux valgus deformity has benefited from a number of improvements over the past two decades, most notably regarding the internal fixation method. Internal fixation was deemed mandatory by the authors of early case-series studies. Maestro suggested eliminating the proximal screw by locking the two fragments distally: a notch was created via a medial extension of the cephalic part of the osteotomy, the plantar fragment was displaced laterally, and the distal end of the proximal fragment was then fit into the notch (secondary cut and interlocking joint technique). To further develop this concept and to increase the potential range of translation, we developed an original technique involving distal locking without shortening and proximal stabilisation by impaction of a cortical-cancellous bone graft taken from the medial overhanging edge of the proximal fragment. This original technical variant has not been reported previously.
As diabetes takes on pandemic proportions, it is crucial for the orthopedic surgeon to be aware of the issues involved in diabetic foot. Ulceration is related to neuropathy and to arterial disease, a vital prognostic factor for healing; infection plays an aggravating role, increasing the risk of amputation. At-risk feet need to be screened for. Ulcer classification is essential, to set treatment strategy and determine prognosis. Before any treatment is decided on, neuropathy, vascular insufficiency and infection should individually be assessed by clinical examination and appropriate additional work-up. Despite the International Consensus on the Diabetic Foot recommendations, management of diabetic foot in Europe still varies greatly from country to country, very few of which have established reference centers. Management of diabetic foot remains multidisciplinary; but it has been shown that the orthopedic surgeon should play a central role, providing a biomechanical perspective so as to avoid complications recurrence. Strategy notably includes prevention of at-risk foot, revascularization surgery (which should systematically precede orthopedic surgery in case of critical vascular insufficiency), and treatment of ulcers, whether these latter are associated with osteitis or not. Indications for "minor" amputation should be adequate, and meticulously implemented. "Acute foot" is a medical emergency, entailing massive empirically selected I.V. antibiotics to "cool" the lesion. Prophylactic surgery to limit further risks of ulceration is to be indicated with caution and only when clearly justified. France urgently requires accredited specialized multidisciplinary centers to manage severe lesions: deep and infected ulceration, advanced arteriopathy, and Charcot foot arthropathy.
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