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JBJS Essent Surg Tech. 2018 Oct 24;8(4):e27. doi: 10.2106/JBJS.ST.18.00004. eCollection 2018 Dec 26.

Modified Scarf Osteotomy with Medial Capsular Interposition in Great Toe and Metatarsal Shortening Offset Osteotomy in Lesser Toes for Rheumatoid Deformity.

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Department of Orthopaedics, Osaka University Graduate School of Medicine, Suita, Japan.
Department of Orthopaedics, Osaka Rosai Hospital, Sakai, Japan.
Nampei Orthopaedics and Rheumatology Clinic, Katsuragi, Japan.
Department of Orthopaedics/Rheumatology, National Hospital Organization, Osaka Minami Medical Center, Kawachinagano, Japan.
Department of Orthopaedics, Japan Community Health Care Organization (JCHO), Osaka Hospital, Osaka, Japan.



Arthrodesis of the first metatarsophalangeal (MTP) joint has been recommended for severe hallux valgus deformity in patients with rheumatoid arthritis. We developed an alternative procedure that preserves motion of the first MTP joint while restoring alignment and balance to the forefoot. This procedure was shown to be effective in a series of 60 patients with a 3-year follow-up.


We perform a modified Scarf osteotomy, with the longitudinal first metatarsal cut parallel to the sole of the foot and with shortening of the metatarsal to realign the first ray. This is combined with an interpositional capsular arthroplasty of the first MTP joint and shortening offset osteotomies of the lesser metatarsals.


Alternatives include arthrodesis of the first MTP joint combined with resection arthroplasty of the lesser MTP joints, or of all 5 MTP joints, or perhaps interpositional (total) joint arthroplasty for severe rheumatoid forefoot deformity/destruction.


The purpose of the modified Scarf osteotomy is preservation of motion of the first MTP joint and protection against destruction of the rheumatoid joint. The metatarsal shortening offset osteotomy provides rigid stabilization at the site of osteotomy after dynamic correction to make the transverse arch.

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