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In some regions in the UK the RSA has become a prevalent choice in the managment of hallux valgus deformity. Its advocates often implement early weight-bearing recommending a sneaker or similar two weeks post-operatively.
A translation scarf appears to withstand weight bearing stresses well, when appropriate AO fixation is used, and cadaver studies have cofirmed this to be true. The eminent American Podiatrist Scott Weill even suggests wearing trainers one week after this surgery and this seems to work well. However, the intrinsic stability of this variation on the Scarf procedure has not been evaluated in the same way.
I have had the opportunity to evaluate a number of RSA patients 6 months post-operatively. In this review I have encountered undiagnosed basal 1st metatarsal fractures, loss of alignment and recurrence of the deformity at an unacceptable rate. Also, often the 1st metatarsal position appears good on XRF 2/52 PO only to see a significant gap at 6/12.
I am interested to hear from other surgeons with experience of this procedue and outcomes.
my opinion with regards to the scarf is that it can be inherintely unstable in certain patients,particularly patients over 55.when i was in residency we evaluated many scarfs that were at first described as malpositioned or with excessive motion leading to excessive bone callus.it was our belief then that what we were actually looking at were both fractures near the base as well as well as multiple stress fractures in the shaft of the metatarsal.
this is not to say that in younger patients with better bone stock they didn't work well.
however,they have a potential for lack of stability and avascular necrosis that far outweighs their benefis.i realize they are very popular in europe.but can anyone explain their advantage over let's say a reverdin (classic) with a closing base wedge,in order to correct a similar type of bunion.
I agree with you. I have had more that a few over-rotations (pushing the limits for correction), troughing, basal fractures and recurrence. I know I don’t have the experience of some of our UK colleagues but have my reservations when doing this procedure. Yes, you can walk them a 2 weeks but it can never be as stable as a purely translated Z without rotation.
I’m switching to basal chevrons/crescentics +/- modifications for my bigger angles. Ask me again in a year if I prefer these.
What are the factors that make this such a versatile and powerful procedure in the hands of one surgeon but capable of creating big headaches for others?
Is this a technical issue or is it more widespread and undetected? Are all patients followed up and x-rayed routinely at 6 months?
I suspect the angle of the longitudinal cut is a key component. The dorsal shelf has to be sufficiently thick and robust and I will direct this from dorsal to plantar in an oblique manner. Because I also insist on a gradual re-introduction to weight-bearing over a 4-6 weeks period I cannot isolate this as the only factor, but I have not seen a basal fracture complication when this is done.
Proponents of this procedure will say that avoidance of a BKC and the risk of cast disease can be eliminated with a Scarf cut and metatarsus primus elevatus is rarely encountered which cannot be said for the basal osteotomy. In good hands a rotation scarf and akin is completed in 35 minutes or less, reducing surgical time.
dieter,
thanks for the insight i will re-examine the rotational scarf.i currently utilize a three to two osteotomy approach for my younger active patients with high im and hav angles,oblique base wedge with either a reverdin or an akin.this is dependent on whether the im elevation is coupled with a high pasa or just a high hav.
however on my older patients i try to combine distal osteotomies,austin with akins,reverdin with akins or a fusion in severe deformities.i am concerned with using basilar osteotomies in the older population.
I understand the concern about healing capacity in the older patient but would say this: we must distinguish between chronological and physiological age. Unless there are specific factors to suggest otherwise, healing might not be impaired on the grounds of old age alone. I am not aware of any research to suggest otherwise.
In my professional practice I have encountered remarkably sprightly octagonarians and frighteningly unhealthy 40-year old patients. The choice of procedure, our wise old sages advice, embraces many variables, age is but one of those factors.
And there is this: we do not [?yet]have a "definitive" procedure that satisfies every patient's and/or clinician's needs and expectations.
Although I am critical of some aspects of the RSA this procedure appears to satisfy many, if not all, patients even when complications occur. And on top of all that, in doing so the RS osteotomy mocks the significance of PASA without any apparent ill effect.
At the same time I have witnessed excellent corrections addressing directly and predominantly the PASA with Reverdin Green Laird Todd procedure, in the mild to moderate IMA patient.
How is it that such a prevalent condition as HAV can respond favourably to a range of different procedures? Why is it that research has failed both to identify definitively the causative factors directing this pathlogy, and those procedures that appear adequately to correct the deformity?
And if this is truly the case, it makes sense to adopt a uniform approach. The RSA is versatile. Good fixation is possible. Early mobilization is achievable. Crutches and POP casts can be avoided. Deformity often is well corrected and patient satisfaction appears high.
Scarf osteotomy has gained popularity as one of the recommended procedures for moderate to severe hallux valgus. An Akin osteotomy may also allow additional correction but carries its own complications. The aim of this study was to assess the need for Akin osteotomy with a scarf procedure.
We reviewed our results of scarf osteotomy with and without Akin in 69 patients with 99 procedures. Sixteen patients (25 feet) had an Akin osteotomy with a scarf procedure. Radiological results were analysed by measuring the hallux valgus angle (HVA), intermetatarsal angle (IMA), distal metatarsal articular angle (DMAA) and the position of the tibial sesamoid. AOFAS scores were collected prospectively. Patient satisfaction was determined by whether or not they would have the operation again for a similar condition.
The mean age of the patients was 48.3 years (range 12–76) with a mean follow-up of 21 months. The mean improvement for the whole group in the IMA was from 15.8 to 7.9, HVA from 37.9 to 16.4 and DMAA from 19 to 9.9 was noted. The position of sesamoids improved from a mean of 5.8 to 2.3. The results were similar in both the groups and no significant difference was noted. AOFAS score improved from a mean of 53.6 preoperatively to 92.5 postoperatively. Three patients in the scarf group needed an Akin osteotomy as a revision procedure.
Scarf osteotomy alone may be an effective procedure for moderate to severe hallux valgus. An Akin osteotomy may be indicated if residual hallux valgus is noted during surgery.
Re: Rotation Scarf & Akin Osteotomy (RSA) : Is It Safe?
Scarf and Akin osteotomies for moderate and severe hallux valgus Clinical and radiographic results
Ignacio Martínez Garrido, Eduardo Rodríguez-Vellando Rubio, Marta Navarro Bosch, María Sánchez González, Guillermo Bastida Paz and Alfredo Juan Llabrés Foot and Ankle Surgery; Volume 14, Issue 4, 2008, Pages 194-203
Quote:
Background
The scarf and the combined scarf-Akin procedures are reliable therapeutic tools and can obtain effective correction of symptomatic moderate to severe hallux valgus deformities.
Methods
The data from 30 patients (37 feet) with moderate to severe hallux valgus deformity who had scarf osteotomies have been retrospectively reviewed. 32 Akin and 77 Weil osteotomies were also carried out at the same stage. The average follow-up was 22 months. Standardized methods of radiographic and clinical data collection were obtained before and after surgery. Patient satisfaction was assessed at follow-up.
Results
Radiological assessment revealed a significant improvement (p < 0.001) of the hallux valgus angle (mean reduction 17.4°), the intermetatarsal angle (mean reduction 5.8°), the medial sesamoid position (14% of the feet were grade 1 or less preoperatively and this rate increased to 84% at follow-up) and the DMAA (mean reduction 9°). The complication rate was 19%. Clinical improvement was achieved with the AOFAS score increasing from 46 to 86 points (p < 0.001).
Conclusions
We conclude that the procedure has value in obtaining predictable correction of moderate to severe hallux valgus deformities.
Re: Rotation Scarf & Akin Osteotomy (RSA) : Is It Safe?
Dear colleagues:
For interested in this technique, I recommend the reading of a French author.
Forefoot recostruction-second edition
Louis Samuel Barouk
ISBN-13: 978-2-287-25251-8
Kindly:
Jose Antonio Teatino
Professor of Surgery
The Academy of Ambulatory Foot & Ankle Surgery
Re: Rotation Scarf & Akin Osteotomy (RSA) : Is It Safe?
Symptomatic Medial Exostosis of the Great Toe Distal Phalanx: A Complication Due to Over-correction Following Akin Osteotomy for Hallux Valgus Repair.
Villas C, Del Río J, Valenti A, Alfonso M. J Foot Ankle Surg. 2009 January - February;48(1):47-51.
Quote:
The authors present the case of a 54-year-old female who developed a painful compression lesion localized to the medial aspect of the base of the distal phalanx of the great toe as a complication of hallux valgus surgery. Preoperative radiographic evaluation of the patient's foot revealed the first ray to be longer than the second, a 12 degrees first intermetatarsal angle, a 33 degrees hallux abductus angle, and an exostosis at the medial aspect of the base of the hallux that was not considered by the surgeon to be important. Correction of the hallux valgus deformity was performed with a combination of scarf and Akin osteotomies, and the intermetatarsal and hallux abductus angles reduced to 2 degrees and 8 degrees , respectively. By 2 months postoperative, the patient was complaining of pain at the medial aspect of the distal phalanx of the hallux associated with shoe pressure. The pain correlated both clinically and radiologically with the exostosis at the base of the distal phalanx, and had become symptomatic only after the hallux had been operatively realigned. At 6 months postoperative, percutaneous exostectomy was undertaken to remove the exostosis. Pain relief was complete, thereafter, and after 2 years of postoperative follow-up the patient remained pain free. The clinical importance of a medial exostosis localized to the base of the distal phalanx of the hallux must be taken into consideration whenever hallux valgus correction is undertaken, and this is particularly important whenever an Akin osteotomy is being considered
Re: Rotation Scarf & Akin Osteotomy (RSA) : Is It Safe?
Dear colleagues:
In our experience we have found postoperative pain in the zone medial-plant of the articulation interfalángica, more usually than by on-correction in the processing of the hallux valgus (hallux varus iatrogenic), by not to have corrected wise the position of the valgus digital.
We should evaluate the angle ungueal in the pre-operating one, and to maintain it horizontal to the plan of the floor in the post-operating one.
If besides, limitation of the mobility is produced metatarsus-flanges, enlarges the conflict with the footwear in the union with its sole.
Kindly:
Jose Antonio Teatino
Professor of surgery
The Academy of Ambulatory Foot & Ankle Surgery
Rotation Scarf & Akin Osteotomy (RSA) : Is It Safe?
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