- Email: [email protected]
The use of post-operative reverse camber shoes following scarf osteotomy
Available online at www.sciencedirect.com
Foot and Ankle Surgery 14 (2008) 190–193 www.elsevier.com/locate/fas
The use of post-operative reverse camber shoes following scarf osteotomy Samantha Hook BSc (Hons), MBChB, MRCSa,*, Neil Walker BSc (Hons), MBChB, MRCSb, L. Cannon BSc, MBBS, FRCS, FRCS (TR&Orth), MS, Dip Sports Medc b
a Wessex Orthopaedic Rotation, Queen Alexandra Hospital, Cosham, Portsmouth, PO6 3LY, United Kingdom Trauma and Orthopaedic Department, Queen Alexandra Hospital, Cosham, Portsmouth, PO6 3LY, United Kingdom c Portsmouth NHS Trust, Royal Hospital Haslar, Gosport, Hants, PO12 2AA, United Kingdom
Received 11 June 2007; received in revised form 3 December 2007; accepted 4 February 2008
Abstract Background: Reverse camber shoes are a popular choice for immobilization following scarf osteotomy. There are no reports in the literature giving guidance on the duration of shoe use. Methods: Seventy-eight patients were reviewed. All had been advised to remain in reverse camber shoes until point of radiographic follow up. Data regarding time spent in shoes, associated adverse symptoms of shoes, and complications were recorded. Results: Three groups emerged. Group 1 (65 patients) wore the shoes for the instructed period of time. Group 2 (six patients) were those who removed the shoes early. Group 3 (seven patients) were those who wore the shoes following review. There were no differences in complication rates between the groups. Conclusion: The use of post-op shoes is for symptom control. Our practice now is to advise patients to wear their shoes for as long as they feel necessary rather than giving them a prescriptive time limit. # 2008 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. Keywords: Scarf osteotomy; Reverse camber shoe; Immobilisation
1. Introduction The scarf osteotomy is a carpentry term used to describe the Z step osteotomy and subsequent osteosynthesis technique used to reduce the first intermetatarsal angle in moderate to severe hallux valgus [1,2]. This versatile corrective technique, popularised by Weil in 1991 and Barouk in 1993 [3], has been used with great success and is widely used in Europe [3]. The scarf osteotomy because of the particular geometry of the cut is a stable fixation that allows immediate full weight bearing [4,5], which may be in a wooden soled shoe, soft soled shoe or wedge based shoe or even a normal shoe [6] (Fig. 1). Weil has shown the results of scarf osteotomies compare favourably with results for other popular bunion procedures. In addition this procedure allows early ambulation without the use of a cast or crutches and as such minimal restriction of bathing * Corresponding author. Tel.: +44 1962 849567. E-mail address: [email protected] (S. Hook).
and mobilisation. These factors plus the ability to have bilateral surgery, maintains cost effectiveness and an early return to a normal lifestyle [2]. A study by Kristen et al. suggested satisfactory healing time, as shown by a return to work, at an average of 5.8 weeks, and a return to sport at 8.3 weeks [1]. Most surgeons utilise post-operative shoes, of which many designs are available. Reverse camber shoes, i.e. those with a heel wedge, are a popular choice. There are no reports in the literature giving guidance on the duration of shoe use. The purpose of this study was to determine the optimum time of shoe use.
2. Methods Between January 2005 and June 2006 78 patients underwent a scarf osteotomy under the care of one of two foot surgeons in a single trust. Twenty-two of these patients had bilateral procedures. Operating lists, hospital
1268-7731/$ – see front matter # 2008 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.fas.2008.02.002
S. Hook et al. / Foot and Ankle Surgery 14 (2008) 190–193
191
3. Results
Fig. 1. The reverse camber shoe used in our hospital and a standard rigid soled post-operative shoe.
databases and theatre logs were used to identify the patient cohort. All patients were operated on under the control of a thigh high tourniquet and were given one intravenous dose of 1.5 g cefuroxime prior to inflation of the tourniquet. A standard medial incision was used in all cases. Soft tissue releases were done either indirectly through this medial or using an additional incision in the dorsal first web space. Fixation of the osteotomy was achieved two cannulated Barouk screws (De Puy, Warsaw, Indiana, USA). Wounds were dressed with sterile gauze, wool and crepe holding the hallux in the correct position and left for two weeks until wound inspection. The patients were given crutches and mobilised fully weight bearing by the physiotherapists in reverse camber shoes prior to discharge. Two weeks postoperatively, the dressings were removed, and the patients given a small spacer for the first interspace or the hallux strapped, according to surgeon preference. Patients were then instructed to continue mobilizing in the reverse camber shoe until their radiographic follow up appointment at 6–8 weeks. A telephone survey was performed at a mean of 11 months following surgery. Data regarding time instructed to remain in shoes, actual time spent in shoes, use of crutches, associated adverse symptoms of shoes and complications were recorded and analysed.
Seventy-eight patients underwent scarf osteotomies. Twenty-two had bilateral procedures; 18 performed simultaneously, four staged with an average interval of 10 months (7–11 months) Three groups emerged (Fig. 2). Group 1 (65 patients) were those who remained in the shoes until radiographic follow up, 19 of these patients stated they could not remember how long they were instructed to wear the shoes or that they were not told a period of time. Group 2 (six patients) were those who removed the shoes before follow up (REMOVED EARLY). Group 3 (seven patients) were those who wore the shoes for a period of time following radiographic review (REMOVED LATE). The average time that each group wore the shoes postoperatively was: group 1, 5.8 weeks (maximum 16 weeks); group 2, 3.2 weeks (maximum 7 weeks); group 3, 7.1 weeks (maximum 10 weeks) (Fig. 3). The average time the shoes were worn by all patients was 5.7 weeks. The average time across all groups which patients were instructed to wear the shoes was 5.6 weeks. Sixteen patients felt the time they were instructed to wear the shoe was too long, however only six removed their shoes early. In contrast 14 patients felt they were instructed to remove their shoe too early, although only seven patients wore the shoe for longer than the stated time. Forty-seven patients felt the time instructed was just right although one of these patients still wore the shoe for an additional two weeks. Two of the patients who had staged bilateral procedures received differing instructions on the length of time to wear the shoe (patient 1, 9 weeks and 10 weeks and patient 2, 5 weeks and 6 weeks). In both cases, they felt that the shorter period was just right and the longer period too long. Three patients did not have any
Fig. 2. Number of patients in each group.
Fig. 3. Average number of weeks spent in shoe.
192
S. Hook et al. / Foot and Ankle Surgery 14 (2008) 190–193
GPs with oral antibiotics. None of these patients had a diagnosis of infection made by the operating surgeon at their first post-operative wound review. Two had paraesthesia around the scar and great toe, two had return of their deformity and one patient developed a post-operative deep venous thrombosis. There was no failure of osteosynthesis or fracture prior to union.
4. Discussion Fig. 4. Appropriateness of time instructed to wear shoe.
comment on the duration for which they were told to wear the shoes. (Fig. 4) Crutches were given to all patients. The average length of time crutches were used was 4.3 weeks (0.25–16 weeks). Eleven patients did not use the crutches at all once they were home: two already used crutches, one of whom was awaiting a total hip replacement, and one patient used a wheelchair for 4 weeks. The average time it took patients to adapt to the reverse camber post-operative shoes was 4.9 days (1–21 days), one patient who had simultaneous bilateral procedure felt they never adapted to walking in the shoes and 40 patients said they adapted immediately. Thirteen (16%) patients stated they developed calf pain post-operatively when walking in the shoes. In one patient this was at one month, and attributable to a deep venous thrombosis. The remaining patients either did not develop calf pain, (55 patients, 71%) or did not remember whether they developed calf pain, (10 patients, 13%). The average duration of calf pain was 24.7 days. There were 10 patients who developed post-operative complications. Five had a post-operative infection, one of whom developed osteomyelitis and required a debridement. The remaining reported infections were diagnosed and treated by
Post-operative shoes function in several ways. They act as an external fixator and protect the surgical site, reduce motion during the healing phase and unload the operative site, allowing partial weight bearing and pain free ambulation during the post-operative period [7]. The ability of post-operative shoes to unload varying areas of the foot is dependent on its design features. A normal heel to toe gait results in increased forces under the first metatarsal head during the toe of phase of gait. In a flat footed gait there is simultaneous vertical force applied to the heel, third metatarsal head and first metatarsal head, although the foot floor reaction force is twice that measured at the third and first metatarsal heads. Peak forces under the forefoot during flat footed gait are about half those during heel to toe gait [7]. Shereff et al. have demonstrated a significant increase in loads carried by the forefoot when using a rocker heel on a cast, compared with a posteriorly placed heel. When using a rocker heel there is 55–70% of first metatarsal loading compared to barefoot walking; when using a posterior heel this is only 2% of the first metatarsal load compared with barefoot walking [7]. Carl et al. compared two types of forefoot relief shoes (the Barouk which is short heel, short sole and the Hannover which is short heel, complete sole) (Fig. 5). They showed the Barouk shoe to be effective in reducing both mean and peak plantar pressures under the forefoot and in addition that this type of design is also more reliable when
Fig. 5. Barouk (A) and Hannover (B) post-operative shoes.
S. Hook et al. / Foot and Ankle Surgery 14 (2008) 190–193
the shoe is used inappropriately by trying to load the mid and forefoot [8]. Trnka et al. demonstrated that the device affording the most protection, resulting in the lowest peak pressures under the first metatarsal head following six different metatarsal osteotomies was the wedge based post-operative shoe. They noted this to be particularly true in proximal crescentic and proximal chevron osteotomies which they found to be least stable and also in severely osteopaenic bone or those at risk of non-compliance [6]. Glod et al. has also demonstrated that the wedge based shoes benefited from a cantilever effect reducing forefoot pressures on average by 51.2% [9]. A study comparing a heel wedge shoe with a full length postoperative shoe by Lorei et al., demonstrated that although the full length shoe did relieve pressure under the forefoot this was not to the same extent as the Ortho wedge shoe. These wedge shoes redistributed the load to the hind foot [10]. Our study concentrated on one particular type of postoperative shoe, the heel wedge or reverse camber shoe, and was a subjective investigation of patients’ perception of the appropriateness of the length of time of post-operative immobilisation. It is clear that the majority of patients are compliant with post-operative instructions, wearing the shoes for the instructed period of time, even when they did not feel it was appropriate. Only a small number (13) wore the shoes for less time or for longer than instructed, although, significantly more felt that the length of time they were instructed to wear the shoe was inappropriate, with a roughly even split between those who felt it was too long and those who felt it was too short. The patients within group one who could not recollect the post-operative instructions wore the shoes for the same period of time as the remaining patients in this group 1 suggesting that a period of immobilisation of just less than 6 weeks is the optimum. One patient (a junior soldier) in group 2, despite recalling instructions to remain in the shoe for 6 weeks, was encouraged by his rehabilitation officer to undertake high impact exercise (including skipping) at 2 weeks. This gentleman recovered with no complications, highlighting the stability and robustness of this osteotomy. Patients generally found it easy to adapt to the reverse camber shoes; as a result 11 patients did not need crutches to aid their mobilisation. The remainder, with the exception of three patients who were already reliant on mobility aids, used their crutches on average for 1.5 weeks less than they wore the shoes. Although a side effect of the reverse camber shoe is calf pain related to enforced heel walking, only 13 patients developed this side effect, one of which was attributable to a deep venous thrombosis. Since it has been clearly shown that the scarf is a stable osteotomy, the use of post-op shoes is purely for symptom control.
193
5. Conclusions We have shown that the length of time for which patients find these shoes helpful varies widely, but that the majority settle on a very similar period of immobilisation. Although we only had small numbers who wore the shoes for less than the instructed period there were no adverse complications to suggest this was detrimental to the outcome of their surgery. Our practice now is to advise patients to wear their shoes for as long as they feel necessary rather than giving them a prescriptive time limit.
Conflict of interest statement We the authors confirm there is no financial or personal relationships with other people or organisations that may have inappropriately influenced this work. All authors were fully involved in this study and the preparation of the manuscript. We confirm that the material has not been submitted for publication elsewhere.
References [1] Kristen KH, Berger C, Stelzig S, Thalhammer E, Posch M, Engel A. The scarf osteotomy for the correction of hallux valgus deformities. Foot Ankle Int 2002;23(3):221–9. [2] Weil LS. Scarf osteotomy for the correction of hallux valgus. Historical perspective, surgical technique and results. Foot Ankle Clin 2000;5(3):559–80. [3] Dereymaeker G. Scarf osteotomy for correction of hallux valgus. Surgical technique and results as compared to distal chevron osteotomy. Foot Ankle Clin 2000;5(3):513–24. [4] Barouk LS. Scarf osteotomy in the treatment of hallux valgus. Foot Dis 1995;2(1):35–48. [5] Barouk LS. Scarf osteotomy for hallux valgus correction. Local anatomy, surgical technique, and combination with other forefoot procedures. Foot Ankle Clin 2000;5(3):525–58. [6] Trnka H-J, Parks BG, Ivanic G, Chu I-T, Easley ME, Schon LC, Myerson MS. Six first metatarsal shaft osteotomies. Mechanical and immobilisation comparisons. Clin Orthop Relat Res 2000;381:256– 65. [7] Shereff MJ, Bregman AM, Kummer FJ. The effect of immobilisation devices on the load distribution under the foot. Clin Orthop Relat Res 1985;192:260–7. [8] Carl H-D, Pfander D, Swoboda B. Assessment of plantar pressure in forefoot relief shoes of different designs. Foot Ankle Int 2006;27(2): 117–20. [9] Glod DJ, Fettinger P, Gibbons RW. A comparison of weight bearing pressures in various post-operative devices. J Foot Ankle Surg 1996;35:149–54. [10] Lorei T, Klarner H, Rosenbaum D. Influence of post operative shoes on plantar pressure patterns. Z Orthop Ihre Grenzgeb 2006;144(2): 153–7.
Foot and Ankle Surgery 14 (2008) 190–193 www.elsevier.com/locate/fas
The use of post-operative reverse camber shoes following scarf osteotomy Samantha Hook BSc (Hons), MBChB, MRCSa,*, Neil Walker BSc (Hons), MBChB, MRCSb, L. Cannon BSc, MBBS, FRCS, FRCS (TR&Orth), MS, Dip Sports Medc b
a Wessex Orthopaedic Rotation, Queen Alexandra Hospital, Cosham, Portsmouth, PO6 3LY, United Kingdom Trauma and Orthopaedic Department, Queen Alexandra Hospital, Cosham, Portsmouth, PO6 3LY, United Kingdom c Portsmouth NHS Trust, Royal Hospital Haslar, Gosport, Hants, PO12 2AA, United Kingdom
Received 11 June 2007; received in revised form 3 December 2007; accepted 4 February 2008
Abstract Background: Reverse camber shoes are a popular choice for immobilization following scarf osteotomy. There are no reports in the literature giving guidance on the duration of shoe use. Methods: Seventy-eight patients were reviewed. All had been advised to remain in reverse camber shoes until point of radiographic follow up. Data regarding time spent in shoes, associated adverse symptoms of shoes, and complications were recorded. Results: Three groups emerged. Group 1 (65 patients) wore the shoes for the instructed period of time. Group 2 (six patients) were those who removed the shoes early. Group 3 (seven patients) were those who wore the shoes following review. There were no differences in complication rates between the groups. Conclusion: The use of post-op shoes is for symptom control. Our practice now is to advise patients to wear their shoes for as long as they feel necessary rather than giving them a prescriptive time limit. # 2008 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. Keywords: Scarf osteotomy; Reverse camber shoe; Immobilisation
1. Introduction The scarf osteotomy is a carpentry term used to describe the Z step osteotomy and subsequent osteosynthesis technique used to reduce the first intermetatarsal angle in moderate to severe hallux valgus [1,2]. This versatile corrective technique, popularised by Weil in 1991 and Barouk in 1993 [3], has been used with great success and is widely used in Europe [3]. The scarf osteotomy because of the particular geometry of the cut is a stable fixation that allows immediate full weight bearing [4,5], which may be in a wooden soled shoe, soft soled shoe or wedge based shoe or even a normal shoe [6] (Fig. 1). Weil has shown the results of scarf osteotomies compare favourably with results for other popular bunion procedures. In addition this procedure allows early ambulation without the use of a cast or crutches and as such minimal restriction of bathing * Corresponding author. Tel.: +44 1962 849567. E-mail address: [email protected] (S. Hook).
and mobilisation. These factors plus the ability to have bilateral surgery, maintains cost effectiveness and an early return to a normal lifestyle [2]. A study by Kristen et al. suggested satisfactory healing time, as shown by a return to work, at an average of 5.8 weeks, and a return to sport at 8.3 weeks [1]. Most surgeons utilise post-operative shoes, of which many designs are available. Reverse camber shoes, i.e. those with a heel wedge, are a popular choice. There are no reports in the literature giving guidance on the duration of shoe use. The purpose of this study was to determine the optimum time of shoe use.
2. Methods Between January 2005 and June 2006 78 patients underwent a scarf osteotomy under the care of one of two foot surgeons in a single trust. Twenty-two of these patients had bilateral procedures. Operating lists, hospital
1268-7731/$ – see front matter # 2008 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.fas.2008.02.002
S. Hook et al. / Foot and Ankle Surgery 14 (2008) 190–193
191
3. Results
Fig. 1. The reverse camber shoe used in our hospital and a standard rigid soled post-operative shoe.
databases and theatre logs were used to identify the patient cohort. All patients were operated on under the control of a thigh high tourniquet and were given one intravenous dose of 1.5 g cefuroxime prior to inflation of the tourniquet. A standard medial incision was used in all cases. Soft tissue releases were done either indirectly through this medial or using an additional incision in the dorsal first web space. Fixation of the osteotomy was achieved two cannulated Barouk screws (De Puy, Warsaw, Indiana, USA). Wounds were dressed with sterile gauze, wool and crepe holding the hallux in the correct position and left for two weeks until wound inspection. The patients were given crutches and mobilised fully weight bearing by the physiotherapists in reverse camber shoes prior to discharge. Two weeks postoperatively, the dressings were removed, and the patients given a small spacer for the first interspace or the hallux strapped, according to surgeon preference. Patients were then instructed to continue mobilizing in the reverse camber shoe until their radiographic follow up appointment at 6–8 weeks. A telephone survey was performed at a mean of 11 months following surgery. Data regarding time instructed to remain in shoes, actual time spent in shoes, use of crutches, associated adverse symptoms of shoes and complications were recorded and analysed.
Seventy-eight patients underwent scarf osteotomies. Twenty-two had bilateral procedures; 18 performed simultaneously, four staged with an average interval of 10 months (7–11 months) Three groups emerged (Fig. 2). Group 1 (65 patients) were those who remained in the shoes until radiographic follow up, 19 of these patients stated they could not remember how long they were instructed to wear the shoes or that they were not told a period of time. Group 2 (six patients) were those who removed the shoes before follow up (REMOVED EARLY). Group 3 (seven patients) were those who wore the shoes for a period of time following radiographic review (REMOVED LATE). The average time that each group wore the shoes postoperatively was: group 1, 5.8 weeks (maximum 16 weeks); group 2, 3.2 weeks (maximum 7 weeks); group 3, 7.1 weeks (maximum 10 weeks) (Fig. 3). The average time the shoes were worn by all patients was 5.7 weeks. The average time across all groups which patients were instructed to wear the shoes was 5.6 weeks. Sixteen patients felt the time they were instructed to wear the shoe was too long, however only six removed their shoes early. In contrast 14 patients felt they were instructed to remove their shoe too early, although only seven patients wore the shoe for longer than the stated time. Forty-seven patients felt the time instructed was just right although one of these patients still wore the shoe for an additional two weeks. Two of the patients who had staged bilateral procedures received differing instructions on the length of time to wear the shoe (patient 1, 9 weeks and 10 weeks and patient 2, 5 weeks and 6 weeks). In both cases, they felt that the shorter period was just right and the longer period too long. Three patients did not have any
Fig. 2. Number of patients in each group.
Fig. 3. Average number of weeks spent in shoe.
192
S. Hook et al. / Foot and Ankle Surgery 14 (2008) 190–193
GPs with oral antibiotics. None of these patients had a diagnosis of infection made by the operating surgeon at their first post-operative wound review. Two had paraesthesia around the scar and great toe, two had return of their deformity and one patient developed a post-operative deep venous thrombosis. There was no failure of osteosynthesis or fracture prior to union.
4. Discussion Fig. 4. Appropriateness of time instructed to wear shoe.
comment on the duration for which they were told to wear the shoes. (Fig. 4) Crutches were given to all patients. The average length of time crutches were used was 4.3 weeks (0.25–16 weeks). Eleven patients did not use the crutches at all once they were home: two already used crutches, one of whom was awaiting a total hip replacement, and one patient used a wheelchair for 4 weeks. The average time it took patients to adapt to the reverse camber post-operative shoes was 4.9 days (1–21 days), one patient who had simultaneous bilateral procedure felt they never adapted to walking in the shoes and 40 patients said they adapted immediately. Thirteen (16%) patients stated they developed calf pain post-operatively when walking in the shoes. In one patient this was at one month, and attributable to a deep venous thrombosis. The remaining patients either did not develop calf pain, (55 patients, 71%) or did not remember whether they developed calf pain, (10 patients, 13%). The average duration of calf pain was 24.7 days. There were 10 patients who developed post-operative complications. Five had a post-operative infection, one of whom developed osteomyelitis and required a debridement. The remaining reported infections were diagnosed and treated by
Post-operative shoes function in several ways. They act as an external fixator and protect the surgical site, reduce motion during the healing phase and unload the operative site, allowing partial weight bearing and pain free ambulation during the post-operative period [7]. The ability of post-operative shoes to unload varying areas of the foot is dependent on its design features. A normal heel to toe gait results in increased forces under the first metatarsal head during the toe of phase of gait. In a flat footed gait there is simultaneous vertical force applied to the heel, third metatarsal head and first metatarsal head, although the foot floor reaction force is twice that measured at the third and first metatarsal heads. Peak forces under the forefoot during flat footed gait are about half those during heel to toe gait [7]. Shereff et al. have demonstrated a significant increase in loads carried by the forefoot when using a rocker heel on a cast, compared with a posteriorly placed heel. When using a rocker heel there is 55–70% of first metatarsal loading compared to barefoot walking; when using a posterior heel this is only 2% of the first metatarsal load compared with barefoot walking [7]. Carl et al. compared two types of forefoot relief shoes (the Barouk which is short heel, short sole and the Hannover which is short heel, complete sole) (Fig. 5). They showed the Barouk shoe to be effective in reducing both mean and peak plantar pressures under the forefoot and in addition that this type of design is also more reliable when
Fig. 5. Barouk (A) and Hannover (B) post-operative shoes.
S. Hook et al. / Foot and Ankle Surgery 14 (2008) 190–193
the shoe is used inappropriately by trying to load the mid and forefoot [8]. Trnka et al. demonstrated that the device affording the most protection, resulting in the lowest peak pressures under the first metatarsal head following six different metatarsal osteotomies was the wedge based post-operative shoe. They noted this to be particularly true in proximal crescentic and proximal chevron osteotomies which they found to be least stable and also in severely osteopaenic bone or those at risk of non-compliance [6]. Glod et al. has also demonstrated that the wedge based shoes benefited from a cantilever effect reducing forefoot pressures on average by 51.2% [9]. A study comparing a heel wedge shoe with a full length postoperative shoe by Lorei et al., demonstrated that although the full length shoe did relieve pressure under the forefoot this was not to the same extent as the Ortho wedge shoe. These wedge shoes redistributed the load to the hind foot [10]. Our study concentrated on one particular type of postoperative shoe, the heel wedge or reverse camber shoe, and was a subjective investigation of patients’ perception of the appropriateness of the length of time of post-operative immobilisation. It is clear that the majority of patients are compliant with post-operative instructions, wearing the shoes for the instructed period of time, even when they did not feel it was appropriate. Only a small number (13) wore the shoes for less time or for longer than instructed, although, significantly more felt that the length of time they were instructed to wear the shoe was inappropriate, with a roughly even split between those who felt it was too long and those who felt it was too short. The patients within group one who could not recollect the post-operative instructions wore the shoes for the same period of time as the remaining patients in this group 1 suggesting that a period of immobilisation of just less than 6 weeks is the optimum. One patient (a junior soldier) in group 2, despite recalling instructions to remain in the shoe for 6 weeks, was encouraged by his rehabilitation officer to undertake high impact exercise (including skipping) at 2 weeks. This gentleman recovered with no complications, highlighting the stability and robustness of this osteotomy. Patients generally found it easy to adapt to the reverse camber shoes; as a result 11 patients did not need crutches to aid their mobilisation. The remainder, with the exception of three patients who were already reliant on mobility aids, used their crutches on average for 1.5 weeks less than they wore the shoes. Although a side effect of the reverse camber shoe is calf pain related to enforced heel walking, only 13 patients developed this side effect, one of which was attributable to a deep venous thrombosis. Since it has been clearly shown that the scarf is a stable osteotomy, the use of post-op shoes is purely for symptom control.
193
5. Conclusions We have shown that the length of time for which patients find these shoes helpful varies widely, but that the majority settle on a very similar period of immobilisation. Although we only had small numbers who wore the shoes for less than the instructed period there were no adverse complications to suggest this was detrimental to the outcome of their surgery. Our practice now is to advise patients to wear their shoes for as long as they feel necessary rather than giving them a prescriptive time limit.
Conflict of interest statement We the authors confirm there is no financial or personal relationships with other people or organisations that may have inappropriately influenced this work. All authors were fully involved in this study and the preparation of the manuscript. We confirm that the material has not been submitted for publication elsewhere.
References [1] Kristen KH, Berger C, Stelzig S, Thalhammer E, Posch M, Engel A. The scarf osteotomy for the correction of hallux valgus deformities. Foot Ankle Int 2002;23(3):221–9. [2] Weil LS. Scarf osteotomy for the correction of hallux valgus. Historical perspective, surgical technique and results. Foot Ankle Clin 2000;5(3):559–80. [3] Dereymaeker G. Scarf osteotomy for correction of hallux valgus. Surgical technique and results as compared to distal chevron osteotomy. Foot Ankle Clin 2000;5(3):513–24. [4] Barouk LS. Scarf osteotomy in the treatment of hallux valgus. Foot Dis 1995;2(1):35–48. [5] Barouk LS. Scarf osteotomy for hallux valgus correction. Local anatomy, surgical technique, and combination with other forefoot procedures. Foot Ankle Clin 2000;5(3):525–58. [6] Trnka H-J, Parks BG, Ivanic G, Chu I-T, Easley ME, Schon LC, Myerson MS. Six first metatarsal shaft osteotomies. Mechanical and immobilisation comparisons. Clin Orthop Relat Res 2000;381:256– 65. [7] Shereff MJ, Bregman AM, Kummer FJ. The effect of immobilisation devices on the load distribution under the foot. Clin Orthop Relat Res 1985;192:260–7. [8] Carl H-D, Pfander D, Swoboda B. Assessment of plantar pressure in forefoot relief shoes of different designs. Foot Ankle Int 2006;27(2): 117–20. [9] Glod DJ, Fettinger P, Gibbons RW. A comparison of weight bearing pressures in various post-operative devices. J Foot Ankle Surg 1996;35:149–54. [10] Lorei T, Klarner H, Rosenbaum D. Influence of post operative shoes on plantar pressure patterns. Z Orthop Ihre Grenzgeb 2006;144(2): 153–7.