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PURPOSE OF THE STUDY The outcome of surgical treatment in hallux valgus is sometimes unsatisfactory for both the patient and the surgeon. The valgus position of the big toe in the metatarsophalangeal joint is associated with a deviation to varus of the first metatarsal, resulting in the space between the first and second metatarsals called the intermetatarsal (IMT) angle. In most patients the angle is between 10 and 20 degrees. These patients were indicated for scarf osteotomy as this method has been reported to achieve good outcomes. The results are compared with the relevant literature data on foot osteotomy.
MATERIAL Our group involved 62 scarf osteotomies carried out on 49 patients who were followed up for an average of 18 months (range, 6-36 months). Three patients underwent surgery on both feet in one stage, five had bilateral surgery in two stages. The average pre-operative IMT angle was 16 degrees (range, 9-21 degrees) and the average hallux valgus angle was 37 degrees.
METHODS The patients were indicated for surgery on the basis of subjective complains and weight-bearing radiographs. Scarf osteotomy was performed by the Barouk technique. From a signle incision in the first intermetatarsal space, the lateral articular capsule was released, adductor tendon was dissected and sesamoid bones were reduced. The first metatarsal was exposed from an incision along its medial axis, the bunion was excised and Z-osteotomy of the metatarsal was performed. The distal fragment was shifted laterally, fixed with two 3.5 mm Poldi screws, and the capsule was closed under tension with transosseal suture. If necessary, an additional procedure on the big toe phalanges or osteotomy of the other metatarsals are carried out.From the second post-operative day the patients were allowed to walk on the heel, after removal of sutures they walked wearing a special sandal and, from the third week onwards, full weight-bearing was allowed. The average hospital stay lasted 4 days. The evaluation of post-operative results was based on radiograms, subjective feelings of the patients and clinical assessment of the range of big toe motion.
RESULTS Out of 62 operations carried out on 49 patients (average age, 41.5 years), 23 were performed on the right and 23 on the left foot; bilateral surgery was carried out in three patients in one stage and in five patients in two stages. Simultaneously, the Weil osteotomy was performed on six feet, Akin osteotomy of the big toe phalanges on five feet, Braggard surgery of the second toe on three feet, and scarf osteotomy of the fifth metatarsal on three feet. All feet were indicated for scarf osteotomy because of pain and, in 56 feet, also esthetic reasons were involved. The patients' subjective post-operative assessments were as follows: satisfaction with the outcome in 58 feet, pain associated with tight shoes in two feet, pain while walking in six feet, and dissatisfaction with the big toe shape in one patient.The average IMT angle of 16 degrees and hallux valgus angle of 37 degrees on the pre-operative radiograms showed improvements to 9 degrees and 18 degrees, respectively, on the post-operative X-ray. The sesamoid bones were reduced in all cases. After surgery the average range of motion was restricted as follows: plantar flexion by 7 degrees (to 23 degrees) and dorsal flexion by 6 degrees (to 54 degrees). The complications included one fracture of the head requiring osteosynthesis, one failure of fixation with repeat valgus osteotomy, three cases of insufficient correction of a valgus position that had to be treated by additional osteotomy of the first toe phalanges.
DISCUSSION Out of other types of osteotomy (Funk, Dega, spike osteotomy), outcomes similar to scarf osteotomy have been achieved only by the Austin procedure. However, in this, shifting of the distal fragment is limited and the results show that the Austin method should be preferred in deformities with an IMT angle of about 10 degrees. Scarf osteotomy in addition allows for early weight-bearing, does not produce shortening of the first metatarsal but permits its elongation and elevation by oblique osteotomy, if necessary. It can also be used for the fifth metatarsal. The drawbacks include a more complicated surgical technique and higher risk of complications; shifting of the distal fragment is also limited and, for this reason, scarf osteotomy is not effective in deformities with an IMT angle higher than 20 degrees.
CONCLUSIONS Scarf osteotomy is an effective procedure for a moderate valgus deformity of the big toe with an IMT angle between 10 and 20 degrees. It permits early weight-bearing of the treated extremity. It requires exact pre-operative planning and strict adherence to the operative technique.
The aim of this study was to investigate whether a Scarf osteotomy for hallux valgus correction achieves a good functional restoration with pain reduction, improved mobility, and hallux loading. Therefore, we prospectively studied 32 patients who had a Scarf osteotomy for unilateral hallux valgus. We performed clinical, radiographic, and pedographic evaluations after a mean followup of 33 months to assess clinical and functional outcomes. The mean postoperative American Orthopaedic Foot and Ankle Society score was 89 points. The hallux valgus angle improved from 32.5 degrees to 6.2 degrees , and the intermetatarsal angle improved from 15.5 degrees to 6.6 degrees . The postoperative pedographic patterns showed that the maximum force and impulse decreased under the lateral forefoot and increased under the medial forefoot and hallux. The first ray became more important in the roll-over process. There was a moderate relationship between satisfaction and postoperative hallux valgus angle. The Scarf osteotomy improved the pain situation, the walking capacity, and led to an improved contribution of the hallux in the roll-over process. Therefore, this surgical procedure restores forefoot function and normalizes plantar pressure patterns.
Level of Evidence: Prognostic study, Level II (retrospective study).
What is the Barouk technique? Is that the one taught to Barouk by Lowell Weil?
The paper discusses only the displacement method, not the rotational technique in which considerably greater reduction in I.M. angle can be achieved. Good to see a paper on the subject though.
I do not have first hand knowledge of this but talking to those who know Barouk and Scott Weill I am led to believe those surgeons do not like, nor practice, the rotation scarf. Preferring instead the transposition scarf, correction of a very high angle is possible by overlap technique. The overlap can be very aggressive and at times it seems almost as if the medial cortex has been acquainted with the lateral cortex !
Initially sceptical, I have been using this same technique for a while now also. The results can be quite impressive but fixation, without access to the recommended cannulated screw system and / or C-arm, is technically more challenging.
When I started to use the transpositional technique I found it all too easy to result in 'troughing'. For this reason I tend to use the rotational technique, although a patient recently suffered a fracture of the met. - I gather that this has happened elsewhere; also, I have seen avascular necrosis reported with the rotational scarf, although I have yet to experience this. For lesser I.M. angles, I find Austin/distal L techniques perfectly adequate, bearing in mind that the I.M. angle will reduce approximately 2 degrees, simply by removing the distal/proximal tension, as in a Keller. In situations of 1st met. instablility I will use a Lapidus with or without a distal technique. 'Horses for Courses' I suppose.
I remember Barouk and Weil lecturing to the P.A. many years ago. Barouk was very happy to acknowledge that Weil had introduced him to the scarf and both Barouk and Weil disliked the use of their names used for the techniques ascribed to them. Then, both are excellent foot surgeons but I suppose that is the price of fame!
From time to time I find troughing can be a problem especially in the older patient with softer bone. If there are signs of this, and I assess this intra-operatively, before finalising fixation, I will use the rotation osteotomy instead.
Your are quite right of course. Horses for courses it is. I remain fond of the Reverdin Green and the many modifications. A most versatile procedure, when indicated.
Increasingly I feel the same about the Scarf osteotomy - incredibly versatile.
BACKGROUND: The scarf osteotomy is a versatile and reproducible procedure for the correction of moderate to severe hallux valgus deformity (intermetatarsal angle 12 to 20 degrees hallux valgus angle 20 to 46 degrees).
METHODS: We evaluated the results of 27 consecutive scarf osteotomies at an average followup of 16.1 months. Radiographic parameters, foot pressure analysis, and AOFAS scores were analyzed before and after surgery.
RESULTS: Hallux valgus angles improved from 34.5 to 16.9 degrees, intermetatarsal angles improved from 15.4 to 10.1 degrees, AOFAS scores improved from 54.5 to 86.5. There was no change between the preoperative and postoperative relative lengths of the first and second metatarsals, defined as the difference between the first and second metatarsal lengths. The measurement was based on the anteroposterior standing radiographs and measured by a line intersecting the midway point at the diaphyseal-metaphyseal junction of the metatarsal and extending from the most proximal to distal aspects of the bone. The angle of Meary (talo-first metatarsal angle) did not change, except in one patient. Foot pressure analysis showed no evidence of transfer metatarsal lesions. The complication rate was 1.1% including superficial infection and recurrence.
CONCLUSIONS: The scarf osteotomy provides a predictable and effective correction of moderate to severe hallux valgus deformities.
The Scarf osteotomy is now widely used for the correction of hallux valgus. The aim of our study was to evaluate the results after Scarf osteotomy considering patient's satisfaction as well as the clinical and radiological results. Between 1996 and 1999, 72 feet underwent a Scarf osteotomy of the first metatarsal and, in 11 feet, an additional Akin osteotomy of the proximal phalanx, for the correction of hallux valgus (55 patients: 49 female, 6 male; mean age: 52 years). The hallux valgus angle improved significantly, from 32 degrees preoperatively to 18 degrees at follow-up (minimal follow-up: 6 years; mean: 7.5 years). A second operation was necessary in two patients because of recurrence of hallux valgus, and a fusion of the first metatarsophalangeal joint was performed in two patients. At the time of latest follow-up 78% of the patients were satisfied or very satisfied with the result. The Scarf osteotomy combined with Akin's closing wedge osteotomy is a safe and effective procedure for the treatment of moderate hallux valgus deformities.
Scarf versus chevron osteotomy in hallux valgus: a randomized controlled trial in 96 patients.
Deenik AR, Pilot P, Brandt SE, van Mameren H, Geesink RG, Draijer WF. Foot Ankle Int. 2007 May;28(5):537-41.
BACKGROUND: The degree of correction of hallux valgus deformity using a distal chevron osteotomy is reported as limited. The scarf osteotomy is reported to correct large intermetatarsal angles (IMA). The purpose of this study was to evaluate if one technique gave greater correction of the IMA and hallux valgus angle (HVA) than the other.
METHODS: After informed consent, 96 feet in 83 patients were randomized into two treatment groups (49 scarf and 47 chevron osteotomies). The results were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) Hallux Valgus Scale and radiographic HVA and IMA measurements.
RESULTS: At 27 (range 23-31) months followup both groups improved. The AOFAS score in the chevron group improved from 48 to 89 points and in the scarf group from 47 to 91 points. In the chevron group the HVA corrected from 30 to 17 degrees, and in the scarf group the HVA corrected from 29 to 18 degrees. In both groups, the IMA was corrected from 13 to 10 degrees. The differences were not statistically significant. Three patients in the chevron group developed a partial metatarsal head necrosis. In the scarf group, four patients developed grade 1 complex regional pain syndrome compared to one patient in the chevron group.
CONCLUSIONS: No differences of statistical significance could be measured between the two groups with respect to the AOFAS score, HVA, and IMA. Although both groups showed good to excellent results, we favor the chevron osteotomy because the procedure is technically less demanding.
Complications of first ray osteotomies: a consecutive serie of 475 feet with first metatarsal Scarf osteotomy and first phalanx osteotomy.
Hammel E, Abi Chala ML, Wagner T.
Service d'Orthopédie Traumatologie, Centre Hospitalier de Pau, 4, boulevard Hauterive, 64046 Pau Université Rev Chir Orthop Reparatrice Appar Mot. 2007 Nov;93(7):710-9.
PURPOSE OF THE STUDY: Available studies on Scarf osteotomies of the first metatarsal (M1) and first phalange (P1) shortening and varus displacement have reported good results, but have have not focused on complications. We reviewed a consecutive series of 475 feet operated on over a five year period. Our goal was to determine the incidence of complications and to compare our data with reports in the literature. We wanted to know if association with Weil osteotomy on the lateral metatarsals affects the rate of complications.
MATERIAL AND METHODS: We used the following inclusion criteria: hallux valgus > 35 degrees , adult subject, with or without impact on the lateral ray, no prior foot surgery, no systemic disease, no other co-morbid condition. We distinguished two groups: group 1 with isolated first ray disease, and group 2 with hallux valgus and lateral metatarsalgia requiring surgery.
RESULTS: We determined the incidence of each complication. Metatarso-phalangeal joint (MTP1) stiffness was the most frequent complication: incidence declined with postoperative time: 41.7% at day 35, 5.7% at day 120. The joint was very stiff with defective pulp weight-bearing in 1.3% of the feet at 12 months. Late wound healing was observed in 5.7% of feet and secondary osteotomy displacement in 1%. Incidence of other complications, including operative site infection, was less than 1%. General complications were: reflex dystrophy (1.3%) and deep vein thrombosis (0.6%). Excepting a longer period of postoperative stiffness, we were unable to identify any change in the rate of postoperative complications in feet with an associated Weil osteotomy of the first ray.
DISCUSSION: Our findings confirm that Scarf M1 osteotomies with varus shortening of P1 generates fewer complications than the techniques used earlier. Certain complications have disappeared: nonunion after M1 and P1 osteotomy, great toe claw, symptomatic iatrogenic hallux valgus. Complications with a very low incidence in all series are: operative site infection, osteonecrosis of the M1 head, fracture of M1 at weight bearing. Notching of the two osteotomy pieces with elevation of the metatarsal head and transfer metatarsalgia has been reported by authors using short diaphyseal osteotomies. A stiff MTP1 remains the most frequent complication. Overtly stiff joints (30% loss of range of motion) were observed in 4.6% of our patients at 12 months; 1.3% had major stiffness (20 degrees extension, 0 degrees plantar flexion). This stiffness has been reported by others using the same technique but the risk factors have not been identified.
CONCLUSION: This prospective work enabled us to establish the rate of secondary complications of first ray surgery for M1 Scarf osteo-tomy and P1 osteotomy. Complications are rare, a further argument favoring use of these osteotomies. This statistical study enables us discuss the risk of complications at the preoperative interview, keeping in mind the specific elements inherent in each particular situation.
The authors reviewed the records of 8 patients who underwent a distraction scarf osteotomy of the first metatarsal, and report the radiographic outcomes achieved with this procedure. The osteotomy was used to reestablish or maintain the length of the first metatarsal, without the use of a structural bone graft. The osteotomy was used as part of a revisional procedure for a failed bunionectomy in 4 patients. In the remaining patients, the procedure was used to preserve the length of the first metatarsal in conjunction with a Lapidus arthrodesis. The first and second metatarsals were measured radiographically, and the length of the first metatarsal was expressed as a percentage of the length of the second metatarsal. The average proportional increase in first metatarsal length obtained in the patients undergoing correction of the shortened first metatarsal was 7.08%, and the difference between the pre- and postoperative length of the first metatarsal was statistically significant (P = .0013) in these patients. Relative shortening of the first metatarsal was avoided in those patients undergoing distraction scarf osteotomy in conjunction with Lapidus arthrodesis.
We prospectively reviewed 22 patients (31 feet) who underwent a scarf osteotomy between January 2001 and March 2002. There were 20 females and 2 males. Ages ranged from 35 to 77 years (mean = 57 years). American Orthopedic Foot and Ankle Society (AOFAS) scores improved from a preoperative mean of 47.94 +/- 13.57 and increased significantly to 96.10 +/- 6.15 (P < .01) after 12 months. The hallux valgus angle improved in all patients from a preop mean of 31.4 +/- 8.0 degrees to 11.0 +/- 10.8 degrees at 12 months. The intermetatarsal angle improved from 13.0 +/- 4.2 degrees to 6.1 +/- 3.2 degrees. All of these changes were significant. Bony union was achieved in all patients. There were no significant changes in peak pressure, pressure/time, or force/time pedobarography noted after 12 months. Significant improvement in pain scores from preoperative mean of 21.29 +/- 11.0 to 32.90 +/- 9.57 at 5 years (P < .01) was noted and 90.9% of patients remained satisfied with the operation and would recommend the procedure. There were 2 complications. One patient experienced a traumatic neuroma and another avascular necrosis of the first metatarsal head. The scarf osteotomy is a safe and effective procedure with reproducible and excellent medium-term results
Hallux valgus is a common forefoot condition, with numerous operations described to correct the deformity. Debate remains as to the relative importance of correcting the position of the sesamoid apparatus.
Forty-six cases were reviewed. Preoperative and post-operative X-rays were used to measure forefoot width, inter-metatarsal angle (IM), hallux valgus (HV) angle and sesamoid position (Reynolds stations). Satisfaction was assessed via questionnaire.
Significant improvements were seen in all radiological parameters. 37/43 patients were satisfied with the result. Comparison between the satisfied and non-satisfied group revealed significant differences in the IM angle (p < 0.05) and HV angle (p < 0.05). However, patient satisfaction was not associated with post-op sesamoid position or change in sesamoid position (p > 0.05).
This study showed that scarf osteotomy, can successfully correct hallux valgus, with high levels of satisfaction. Satisfaction is associated with a greater correction of deformity. Improvement in sesamoid position was not associated with patient satisfaction
PURPOSE: We have reported the radiological and clinical outcome of scarf osteotomy in the treatment of moderate to severe hallux valgus among adolescent children.
METHOD: Data were collected retrospectively between April 2001 and June 2006. The pre- and post-operative intermetatarsal angle (IMA), hallux valgus angle (HVA) and distal metatarsal articular angle (DMAA) were determined. Patients were followed up for a mean of 37.6 months.
RESULTS: Thirteen patients with 19 operated feet were available at the time of the latest follow-up. There was significant improvement in the mean post-operative IMA, which was maintained to the last follow-up. There was statistically significant improvement in the 6-week post-operative HVA and DMAA. However, this was lost at the final follow-up. The mean American Orthopaedic Foot and Ankle Society score for the whole group was 80 (54-100).
CONCLUSION: This study indicates that scarf osteotomy should be used with caution in symptomatic adolescent hallux valgus, as there is a high recurrence rate.
Minimally invasive distal metatarsal osteotomies are becoming broadly accepted for correction of hallux valgus. We compared the duration of surgery, the length of hospital stay, the American Orthopaedic Foot and Ankle Society (AOFAS) score, and the Foot and Ankle Outcome Score (FAOS) in 36 patients who underwent a minimal incision subcapital osteotomy of the first metatarsal with 36 matched patients who had hallux valgus corrected by a scarf technique. The minimum follow-up was 2.1 years (mean, 2.5 years; range, 2.1-3.2 years). Patients having the osteotomy had similar AOFAS and FAOS scores with less operating time and earlier discharge. Less operative time may benefit the patients, and earlier discharge has financial implications for the hospital.
BACKGROUND: This study compares two diaphyseal osteotomies (scarf and Ludloff) which correct moderate to severe metatarsus primus varus. This is a single surgeon, prospective cohort study with clinical and radiological follow~up at 12 months.
MATERIALS AND METHODS: There were 57 patients in each group. Both groups were similar in terms of age, gender and preoperative deformity. Clinical assessment included visual analogue scale questionnaires for subjective assessment and functional activities and the American Orthopaedic Foot and Ankle Society (AOFAS) score. Standardized weight bearing radiographs were analyzed.
RESULTS: There was no statistically significant difference between the two groups at 6 and 12 months in subjective satisfaction, AOFAS score, improvement in functional activities and range of movements. The improvement in pain (at best) and transfer lesions at 12 months was significantly better in the scarf group (p < 0.05). The radiological results at 6 and 12 months including intermetatrsal angle (p < 0.001), hallux valgus angle (p < 0.01), distal metatarsal articular angle and seasmoid position (p < 0.05) were significantly better in the scarf osteotomy group. There were three cases (5%) of delayed union in the Ludloff group. Two of these healed with dorsiflexion malunion. One patient in the Ludloff osteotomy group developed a complex regional pain syndrome. There were two wound complications in the scarf group.
CONCLUSION: Overall the patients who had a scarf osteotomy had a superior outcome at 6 and 12 months.
Background: Scarf midshaft metatarsal osteotomy has become increasingly popular as a treatment option for moderate-to-severe hallux valgus deformities because of its great versatility. Numerous studies on Scarf osteotomy have been published. However, no prospective studies were available until 2002. Since then, only short-term follow-up prospective studies have been published. We present the results of a prospective study of 21 patients treated by Scarf osteotomy for hallux valgus with follow-up of 8 years.
Methods: Between August 1, 1999, and October 31, 1999, 23 patients (23 feet) with moderate-to-severe hallux valgus deformity were included. Clinical (American Orthopaedic Foot and Ankle Society score) and radiologic (hallux valgus angle, first intermetatarsal angle, and sesamoid position) evaluations were performed preoperatively and 1 and 8 years postoperatively.
Results: Clinical evaluation showed a significant improvement in the mean forefoot score from 47 to 83 (of a possible 100) at 1 year (P < .001). Radiographic evaluation showed significant improvement in the hallux valgus angle (mean improvement, 19°; P < .001) and in the intermetatarsal angle (mean improvement, 6°; P < .001). These clinical and radiographic results were maintained at the final evaluation 8 years postoperatively.
Conclusions: Scarf osteotomy tends to provide predictable and sustainable correction of moderate-to-severe hallux valgus deformitie
The Cochrane review of hallux valgus surgery has disputed the scientific validity of hallux valgus research. Scoring systems and surrogate measures such as x-ray angles are commonly reported at just one year post operatively but these are of dubious relevance to the patient. In this study we extended the follow up to a minimum of 8 years and sought to address patient specific concerns with hallux valgus surgery. The long term follow up also allowed a comprehensive review of the complications associated with the combined rotation scarf and Akin osteotomies.
Between 1996 and 1999, 101 patients underwent rotation scarf and Akin osteotomies for the treatment of hallux valgus. All patients were contacted and asked to participate in this study. 50 female participants were available allowing review of 73 procedures. The average follow up was over 9 years and the average age at the time of surgery was 57. The participants were physically examined and interviewed.
Post-operatively, in 86% of the participants there were no footwear restrictions. Stiffness of the first metatarsophalangeal joint was reported in 8% (6 feet); 10% were unhappy with the cosmetic appearance of their feet, 3 feet had hallux varus, and 2 feet had recurrent hallux valgus. There were no foot-related activity restrictions in 92% of the group. Metatarsalgia occurred in 4% (3 feet). 96% were better than before surgery and 88% were completely satisfied with their post-operative result. Hallux varus was the greatest single cause of dissatisfaction. The most common adverse event in the study was internal fixation irritation. Hallux valgus surgery is not without risk and these findings could be useful in the informed consent process.
When combined the rotation scarf and Akin osteotomies are an effective treatment for hallux valgus that achieves good long-term correction with a low incidence of recurrence, footwear restriction or metatarsalgia. The nature of the osteotomies allows early return to normal shoes and activity without the need for postoperative immobilisation in a plaster cast.
We performed a retrospective study on 178 Scarf osteotomies with a mean follow-up of 44.9 months (range 15-83 months). Clinical rating was based on the forefoot score of the American Orthopaedic Foot and Ankle Society (AOFAS). Weight bearing X-rays were used to perform angular measurements and assess the first metatarsophalangeal joint (MTP 1). At follow-up the mean AOFAS score had improved significantly (p < 0.001), but only 55% of the feet showed a perfect realignment of the first ray. Patients with a hallux valgus angle exceeding 30 degrees and pre-existing degenerative changes at the MTP 1 joint displayed inferior clinical results (p < 0.05). Nearly 20% of the patients suffered from pain at the MTP 1 joint. This was clearly attributed to an onset or worsening of distinct radiographic signs of arthritis (p < 0.05) resulting in painfully decreased joint motion. Comparing radiographic appearance three months postoperatively and at follow-up, we found that radiographic criteria (hallux valgus, first intermetatarsal angle, hallux valgus interphalangeus, MTP 1 joint congruency, arthritic lesions at MTP 1) worsened with time.
The Scarf osteotomy was described as a technique to correct a metatarsus primus varus in primary hallux valgus surgery, but it is unclear whether the technique could correct recurrent hallux valgus when an initial procedure failed to provide any or an adequate lateral displacement of the metatarsal head.
We asked whether the Scarf osteotomy could reduce pain, improve the AOFAS score, reduce the deformity, and prevent further recurrence when used as a revision procedure.
Patients and Methods
Of 41 patients (45 feet) we treated for failed initial operations, we retrospectively reviewed 35 (39 feet) who underwent a Scarf osteotomy. We administered a VAS for pain and the AOFAS score preoperatively and postoperatively. Preoperative and postoperative radiographs were taken to assess the hallux valgus angle [HVA] and intermetatarsal angle [IMA]. The minimum followup was 24 months (mean, 42 months; range, 24–89 months).
The mean VAS for pain improved from 5.9 to 0.4 points. The mean AOFAS score improved from 56 to 90 points. The radiographic evaluation showed improvement of the mean HVA from 30° to 8° and improvement of the IMA from 13° to 4°. Complications included one asymptomatic recurrence with a 20°-HVA, one overcorrection with a 3°-varus deformity, and pain attributable to irritation caused by screws in five patients.
As a revision procedure the Scarf osteotomy clinically and radiographically corrected recurrent hallux valgus recurrence in most patients.
BACKGROUND: Many procedures have been developed to correct hallux valgus deformity using distal soft tissue realignment, metatarsal osteotomy, and periodically, a proximal phalanx osteotomy (Akin). The ideal metatarsal osteotomy allows for varying degrees of correction with reliable improvement in deformity and patient satisfaction.
QUESTIONS/PURPOSES: We evaluated the results after scarf osteotomy with respect to American Orthopaedic Foot and Ankle Society (AOFAS) scores, patient satisfaction, radiographic results, and complications. PATIENTS AND METHODS: We evaluated 29 patients (34 feet) during an 18-month period who underwent a unilateral scarf osteotomy combined with distal soft tissue realignment. Preoperative and postoperative AOFAS scores, patient satisfaction, and radiographic data were used to evaluate the effectiveness of the procedure. Complications were recorded. Minimal followup was 12 months (average, 26.4 months; range, 12-48 months).
RESULTS: The mean AOFAS scores improved from 61.5 to 90.3. At final followup, 94% of patients were satisfied with the surgery. The hallux valgus angle improved from 34.6 degrees to 14.9 degrees and the intermetatarsal angle improved from 15.8 degrees to 7.2 degrees postoperatively. A combined Akin osteotomy was performed in only four cases. Complications included superficial wound infection (one), recurrence (two), and troughing (three).
CONCLUSIONS: Our results suggest the scarf osteotomy produces improved AOFAS scores, high percentage of patient satisfaction, and effective correction of hallux valgus deformities. Using our scarf technique of rotation combined with translation minimizes the need for an Akin osteotomy while still obtaining good correction and avoids associated complications described in the literature
Scarf osteotomy of the first ray combined with Weil distal oblique shortening osteotomies of the lateral rays has recently been proposed for the treatment of global rheumatoid forefoot deformities because of the perceived benefit of sparing the metatarsal-phalangeal joints. Furthermore, it has been proposed that undergoing this form of global forefoot reconstruction is reliable based on specific preoperative and intraoperative techniques used to realign the individual rays. Finally, it has been proposed that performing global forefoot reconstruction in the rheumatoid patient population can be safely performed and does not prevent the ability to perform revision surgery. The author undertook a systematic review of electronic databases and other relevant sources to identify material relating to Scarf osteotomy of the first ray combined with Weil distal oblique shortening osteotomies of the lateral rays for the treatment of global rheumatoid forefoot deformities. Information from peer-reviewed journals, as well as from non-peer-reviewed publications, abstracts and posters, textbooks, and unpublished works, was also considered. In an effort to procure the highest quality studies available, studies were eligible for inclusion only if they involved patients undergoing Scarf osteotomy of the first ray combined with Weil distal oblique shortening osteotomies of the lateral rays, evaluated patients at mean follow-up of 12-months or longer duration, commented on the reliability of metatarsal realignment, and included details of complications, as well as the incidence and severity of wound-healing complications. Two studies were identified that met the inclusion criteria involving only 8 patients (8 feet) with 1 patient undergoing surgical revision in the form of arthrodesis secondary to development of a septic first metatarsal-phalangeal joint. Partial incision dehiscence developed in 2 patients, 1 healed with local wound care and the other led to the septic first metatarsal-phalangeal joint mentioned previously. Finally, stress fracture of the third metatarsal and fourth metatarsals developed that healed without problems in one other patient. Rather than providing strong evidence for or against the use of Scarf osteotomy of the first ray combined with Weil distal oblique shortening osteotomies of the lateral rays for the treatment of global rheumatoid forefoot deformities, the results of this systematic review make clear the need for methodologically sound prospective cohort studies and randomized controlled trials that focus on the use of this form of surgical intervention.
The Z-scarf osteotomy is used for hallux valgus deformity correction by foot and ankle surgeons worldwide. Inverting the Z-scarf osteotomy configuration strengthens the construct in both sawbone and cadaver models, but clinical results of this configuration have not been reported in the literature. This retrospective study evaluates the subjective and intermediate-term postoperative radiographic results of 73 inverted Z-scarf osteotomy procedures for hallux valgus correction in 55 patients from January 1994 to December 2003. The modified University of Maryland 100-Point Painful Foot Center Scoring System demonstrated 52 patients (95%) with good to excellent results at a mean follow-up of 5 years (range 2-11 years). Radiograph measurements revealed the following: first-second intermetatarsal angle mean, 6.1° (range 2-14°), average reduction 4.6°; hallux abductus angle mean, 11.0° (range -8-30°), average reduction 10.1°; tibial sesamoid position mean, 2.3; first metatarsal protrusion distance mean, -2.1 mm. Two patients (2 of 73 feet) developed major complications: one progressed to clinically acceptable hallux varus; another sustained compromise of one fixation screw with minor displacement at the distal osteotomy that healed in satisfactory position after non-weight-bearing immobilization. There were no cases of osteonecrosis, delayed union, or nonunion. The inverted Z-scarf osteotomy, with advantages in both mechanical strength and technique of execution over the traditional configuration, demonstrates high patient satisfaction, restoration of normal radiographic parameters, and a low complication rate in this study.
Hallux valgus is a complex progressive deformity affecting the forefoot. The main pathologic anatomy concerns the first metatarsophalangeal joint, including a varus or medial deviation of the first metatarsal and pronation deformity in the longitudinal axis. The goal of this study was to evaluate a series of consecutive patients over a 2-year period after a scarf osteotomy of the first metatarsal.A scarf osteotomy was performed on 31 consecutive patients with moderate to severe hallux valgus deformity (intermetatarsal angle, 13-22°; hallux valgus angle, 20-44°). Twenty-nine women and 2 men had an average age of 57 years (range, 21-71 years) at the time of surgery. Preoperative and postoperative evaluations included standing anteroposterior and lateral radiographs, American Orthopaedic Foot and Ankle Score (AOFAS) score, physical examination, and foot pressure analysis by weight-bearing ink prints. Patients were evaluated radiographically and clinically in the initial postoperative period (≤1 month), intermediate postoperative period (2-6 months), and final follow-up (12-36 months). Twenty-eight feet were available for analysis. Five of the 28 feet had concurrent surgeries on the lesser toes for hammer-toe correction or preoperative metatarsalgia. Paired Student t test on the 28 feet showed a statistically significant improvement (P<.0001) between pre- and postoperative intermetatarsal angle, hallux valgus angle, and AOFAS score. One foot had recurrence of the hallux valgus deformity. Paired analysis of variance of the 27 feet without recurrence showed a statistically significant improvement in the pre- and postoperative parameters (P<.0001). From this subset, the multiple-comparison Student-Newman-Keuis post hoc test showed a statistically significant (P<.0001) preservation of the correction in the intermediate follow-up period to final follow-up at an average 28 months.
The study compared three-dimensional (3D) changes in geometry of the first metatarsal following scarf osteotomy performed on standardised Sawbone® models by consultant foot and ankle surgeons. The study considered the inter-surgeon variances in interpretation and performance of the scarf osteotomy with respect to intra-surgeon variances.
The analysis used an accurate digitising system to measure and record points on the Sawbone® models in 3D space. Computer software performed vector analysis to calculate 3D rotations and translations of the first metatarsal head as well as the inter-metatarsal angle. Bone cut lengths and displacements were measured using a digital Vernier caliper. One surgeon performed the osteotomy 10 times to form an intra-surgeon control dataset, while 10 different surgeons each did one scarf osteotomy to form an inter-surgeon test dataset.
Both surgical groups produced reductions in the 3D inter-metatarsal angle with non-significant differences between the groups (p > 0.05). In contrast, the test group demonstrated highly significant (p = 0.000) greater variance compared with the control dataset for all of the variables associated with surgical technique. In addition, there were highly significant (p = 0.02 and 0.002) greater variances in the interpretation of the degree to which the metatarsal head should be translated medially (X) and inferiorly (Z). There was also a significant (p = 0.001) increase in variances in the rotations about the dorsi/plantar-flexion (X) axis.
The only significant differences (all p = 0.000) attributable solely to differences in mean values were in proximal–distal (Y) translation, pronation (Y) rotation and medial (Z) rotation. The test group applied greater medial and plantar-flexion rotation of the metatarsal head than the control surgeon and significantly less (p = 0.000) shortening of the first metatarsal than the control surgeon.
The results of this geometric study demonstrate the versatility of the scarf osteotomy. As a result of the multi-planar nature of the osteotomy, there is a potential risk of producing unintended rotational mal-unions in all three planes. These rotational mal-unions may account for some of the poorer outcomes documented within the literature.
Although this thread is old, I thought I'd add my comments.
I'm a big fan of the scarf. I feel it allows me to get significant IM reduction greater than a distal osteotomy and allow a much easier recovery than a base wedge, opening or closing. I do the rotational scarf rather than the transpositional as I too experienced troughing in the past. I have had success with both cannulated and noncsnnulated screws. the medial incision allows for excellent visualization of the screw position. Often I combine scarfs with Akins.
I have had great success with scarf procedures for large bunions that would not have faired well with distal osteotomies.
Scarf osteotomy versus metatarsophalangeal arthrodesis in forefoot first ray disorders: Comparison of functional outcomes.
Desmarchelier R, Besse JL, Fessy MH; The French Association of Foot Surgery (AFCP). Orthop Traumatol Surg Res. 2012 Aug 27.
Scarf osteotomies of the first metatarsal and metatarsophalangeal arthrodesis are the two most frequent surgical forefoot reconstructive procedures.
We compared functional results of isolated arthrodesis of the first metatarsophalangeal joint with an isolated Scarf osteotomy of the first metatarsal.
MATERIALS AND METHODS:
This was a retrospective, observational, continuous study of patients operated between 1993 and 2008. After patients who had undergone a procedure on the lateral rays, extremely elderly patients, lost to follow-up patients and those with incomplete questionnaires had been excluded, there remained two comparable groups of 25 patients. Mean age was 60 in the arthrodesis group [41-70] and 59.8 in the Scarf group [47-71]. The Scarf group included 25 hallux valgus (100%) compared to 16 hallux valgus (64%) and nine hallux rigidus (36%) in the arthrodesis group. Complications were recorded. Evaluation of functional results was based on the most recent functional or quality of life scores (AOFAS, FFI, FAAM, SF 36) and a questionnaire on physical and athletic ability.
There was no significant difference in the rate of complications between the two groups. There was no difference in pain according to the AOFAS score with 35.6/40 (±6.5) in the Scarf group and 34.5 (±5.9) in the arthrodesis group. Global satisfaction was also similar between the Scarf and arthrodesis groups: 91.4% and 90% of very satisfied or satisfied patients, respectively. The FFI score was higher in the Scarf group than in the arthrodesis group: 8.6 (±20.1) and 19.8 (±17.7) respectively. Functional results were better in the Scarf group than in the arthrodesis group with a FAAM Daily Activity score of 80.2 (±12.1) compared to 68 (±7.2), a FAAM Sports Activity score of 29.7 (±6.7) compared to 25.2 (±7.6) and a FAAM Global Function score of 94% (±10.8) compared to 87% (±15.7), respectively. The Global SF36 score was higher in the Scarf group than in the arthrodesis group: 70.9% (±14.1) and 62.3% (±20.6) respectively, which was due to a higher Mental Health score in the Scarf group: 68.7% (±14.2) and 60.4% (±19.3) respectively. In the area of sports activities the Scarf group practiced more hiking than the arthrodesis group (74% versus 42% respectively). There was no difference for other activities.
DISCUSSION AND CONCLUSION:
This study provides detailed information on the level of physical and sports activities that are practiced following these procedures, so that the patient can be better informed.