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Short Term Evaluation of Combined Scarf and Akin Osteotomies for Treatment of Hallux Valgus. A Prospective Study.
Abstract
Background
Despite Scarf osteotomy was described earlier in the 20th century, it was popularized later in 2000 after modification of the original technique. The combined Scarf–Akin osteotomies were described for surgical correction of the hallux valgus, but with no significant consideration for the patient satisfaction.
Patients and methods
Twenty-three patients with unilateral painful hallux valgus deformity were treated with combined Scarf and Akin osteotomies. All patients were evaluated clinically (using American Orthopedic Foot and Ankle Society-Hallux Metatarsophalangeal–Interphalangeal scale scores) and radiologically (hallux valgus angle, intermetatarsal angle, union, evidence of degenerative changes, and joint congruity) after 12 months of follow-up. All the patients were then asked about their satisfaction and if they would undergo the same surgery under similar circumstances in the future.
Results
There were 15 females and eight males with an average age 38.8 ± 2.4 years. The mean preoperative American Orthopedic Foot and Ankle Society was 55.4 that significantly improved to 87.2 postoperatively ( P <0.001). There was a significant reduction of the mean hallux valgus angle and the mean intermetatarsal angle preoperatively and postoperatively ( P =0.03 and 0.034, respectively). One patient complained of a prominent screw postoperatively, while two patients suffered from superficial wound infection. At 12 months postoperatively, all operated patients were satisfied with their results and indicated that they would be happy to undergo surgery again under similar circumstances.
Conclusion
Despite the short follow-up period in our study, the combined Scarf and Akin osteotomies are a safe and effective method for treatment for hallux valgus deformity that provides statistically significant clinical and radiographic improvements with excellent patient satisfaction.
Level of evidence
Level-IV case-series study.
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Introduction: Scarf osteotomy can be a technically demanding procedure and early reports have shown high complication rates. Proponents, however, suggest that this type of osteotomy is versatile and allows for both translation and angulation correction of the hallux valgus (HV) deformity. The purpose of this study was to evaluate the clinical and radiological results of the scarf osteotomy procedure performed in our hospital.
Materials and methods: We retrospectively reviewed 31 feet in 25 patients with an average follow-up duration of 16 months (range: 6–30 months).
Results: On the latest follow up, 77% of the patients were satisfied with the result, with an average postoperative American Orthopaedic Foot and Ankle Society score of 88. The average improvement of HV angle was from 37.9° to 10.0°. The intermetatarsal angle improved from 16.0° to 8.0°. The average first metatarsal shortening was 0.3 mm. Neither delayed union nor osteonecrosis was observed.
Conclusion: Scarf osteotomy is a reliable procedure to achieve correction of HV deformity with good patient satisfaction.
Adolescent hallux valgus deformity is a complex surgical condition. Although several techniques have been described to correct this deformity in adults, limitations exist for adolescents because of the presence of open growth plates and high recurrence rates. This retrospective study reports results of 7 patients (14 feet) using the Scarf osteotomy for correction of adolescent hallux valgus deformity. All patients underwent concomitant bilateral hallux valgus surgery. Radiographic evaluation measures included intermetatarsal 1-2 angle, hallux valgus angle, and distal metatarsal articular angle. Data recorded from the lateral radiograph evaluated the first metatarsal declination angle. Postoperative patient satisfaction was assessed using a standard patient satisfaction survey. Postoperative, subjective, and objective measurements were calculated using the American College of Foot and Ankle Surgeons (ACFAS) Scoring Scale for the First Metatarsophalangeal Joint and First Ray and the American Orthopaedic Foot & Ankle Society (AOFAS) Hallux Metatarsophalangeal-Interphalangeal Scoring Scale. Average patient age and follow-up were 14.43 years and 57 months, respectively. There was 100% maternal inheritance of hallux valgus deformity. The average postoperative ACFAS Metatarsophalangeal Joint and First Ray Scale (module 1) score was 94.72, and the average AOFAS Hallux Metatarsophalangeal-Interphalangeal Scale score was 96.43. Complications included 1 patient who underwent revision surgery on 1 foot 18 years after the date of index surgery because of painful recurrence of the deformity. The authors believe the Scarf osteotomy is a safe, effective, and versatile procedure for the correction of juvenile and adolescent hallux valgus deformity.
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° 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.
Four rating systems were developed by the American Orthopaedic Foot and Ankle Society to provide a standard method of reporting clinical status of the ankle and foot. The systems incorporate both subjective and objective factors into numerical scales to describe function, alignment, and pain.
At first, scarf osteotomy can be technically demanding. The aim of the author has been to develop an efficient technique, make it easier and more accurate, and to achieve immediate reproducibility of results. Neither the skin incision nor the length of the osteotomy result in postoperative edema, whereas the strong fixation enables very early functional recovery. Complications are rare and avoidable. The sum of the scarf's advantages results in a reliable surgical procedure. The scarf osteotomy is extremely versatile, because it allows a wide range of fragment displacement. This is why the scarf is not a single osteotomy but several. This means its indications are broad, from mild to the most advanced deformities, including arthritic, juvenile, iatrogenic, and even rheumatoid hallux valgus. The contraindications of scarf osteotomy are a very large hallux valgus deformity with a very thin first metatarsal; extremely deformed MPT joint, and hallux valgus combined with a severe pes planus and hypermobility of the first metatarsal (the Lapidus procedure is preferable at this stage). Finally, we should remember the two following points: 1. Whatever the indication, the scarf first metatarsal osteotomy is only one of the four steps necessary for correcting hallux valgus deformity: a) MTP lateral release, b) Scarf osteotomy, c) medial capsulorraphy, and d) great toe proximal osteotomy. 2. The scarf is just one element of the different procedures, including the Weil lesser ray osteotomy, which allow precise forefoot management according to each static disorder. These techniques have very significantly extended the indications for most static disorders where corrective surgery preserves the joints and their mobility.
Hallux valgus is a common foot deformation in adults, but evidence for effectiveness of surgical and conservative treatments for this condition is limited.
To compare the effectiveness of surgical and orthotic treatment with no treatment in patients with hallux valgus.
Randomized controlled trial conducted in 4 general community hospitals in Finland in 1997-1998, with a follow-up period of 12 months.
Two hundred nine consecutive patients (mean age, 48 years; 93% women) with a painful bunion and a hallux valgus angle 35 degrees or less.
Patients were randomly assigned to surgery (distal chevron osteotomy; n = 71), orthosis (n = 69), or a 1-year waiting list (control group, n = 69).
Pain intensity during walking on a visual analog scale (0-100), patient assessment of global improvement, number of painful days, cosmetic disturbance, footwear problems, functional status, and treatment satisfaction, compared among treatment groups.
Follow-up rates at 6 and 12 months were 99% and 98%, respectively. At 6 months, pain intensity decreased more in the surgical group than in the control group (adjusted mean differences, -20 [95% confidence interval (CI), -28 to -12]) and more in orthosis than in the control groups (adjusted mean difference, -14 [95% CI, -22 to -6. At 1 year, pain intensity decreased more in the surgical than in the control groups (adjusted mean difference, -19 [95% CI, -28 to -10]) and more than in the surgical and orthosis groups (adjusted mean difference, -14 [95% CI, -22 to -5]). At 1 year, 83%, 46%, and 24% in the surgery, orthosis, and control groups, respectively, thought they had improved compared with baseline (number needed to treat), 1.7 between surgical and control groups). Number of painful days, cosmetic disturbance, and footwear problems were least and functional status and satisfaction with treatment were best in the surgical group.
Surgical osteotomy is an effective treatment for painful hallux valgus. Orthoses provide short-term symptomatic relief.
This study reviewed the subjective, clinical and radiological outcome of 71 patients (84 feet) treated by scarf osteotomy for hallux valgus deformity at our institution from 1995 to 1998 with an average follow-up time of 22 months (range, 17 to 48 months). At the time of follow-up, 39% of the patients were very satisfied, 50% were satisfied and 11% were not satisfied. The mean AOFAS score raised significantly from 43 points (14-68) preoperatively to 82 points (39 to 100) at follow-up (p < 0.001). The radiological angles including M1-M2, M1-P1, M1-M5 and DMAA improved significantly (p < 0.001). Among the 16 complications recorded, seven (8%) were minor and nine (11%) required an additional procedure. The scarf osteotomy of the first metatarsal coupled with a lateral soft-tissue release and, in three-quarters of our cases, with a basal closing wedge varisation osteotomy of the first phalanx, resulted in overall high satisfaction rate as well as significant clinical and radiological improvements in our series. Nevertheless, the range of motion of the first MP joint remained low: 30 degrees to 74 degrees in 52 patients (62%) and <30 degrees in four patients (5%). Furthermore, the mobility of the first ray as well as the consequences of the procedure in the sagittal plane need to be assessed more accurately, and this may be achieved by incorporating measurement of the plantar pressures in the forefoot area into the global rating system.
We prospectively reviewed 24 patients (35 feet) who had been treated by a Scarf osteotomy and Akin closing-wedge osteotomy for hallux valgus between June 2000 and June 2002. There were three men and 21 women with a mean age of 46 years at the time of surgery. The mean follow-up time was 20 months. Our results showed that 50% of the patients were very satisfied, 42% were satisfied, and 8% were not satisfied. The mean American Orthopaedic Foot and Ankle Society score improved significantly from 52 points pre-operatively to 89 at follow-up (p < 0.001). The intermetatarsal and hallux valgus angles improved from the mean pre-operative values of 15 degrees and 33 degrees to 9 degrees and 14 degrees, respectively. These improvements were significant (p < 0.0001). The change in the distal metatarsal articular angle was not significant (p = 0.18). There was no significant change in the mean pedobarographic measurements of the first and second metatarsals after surgery (p = 0.2). The mean pedobarographic measurements of the first and second metatarsals at more than one year after surgery were within the normal range. Two patients had wound infections which settled after the administration of antibiotics. One patient had an intra-operative fracture of the first metatarsal and one required further surgery to remove a long distal screw which was irritating the medial sesamoids. We conclude that the Scarf osteotomy combined with the Akin closing-wedge osteotomy is safe and effective for the treatment of hallux valgus.
Hypothesis/Purpose
The Scarf osteotomy has gained popularity as treatment of choice in parts of Europe and is based on sound structural principles. The excellent results reported by others could not, however, be reproduced by the author and the results are presented.
Methods
From January 1997 to June 1997 the Scarf osteotomy was selected in 20 consecutive patients (12 female and eight male patients, ages 18 to 60, mean: 41 years) with moderate metatarsus primus varus (IMA 13 to 20°) and hallux valgus deformities (less than 40°). The AOFAS Hallux Metatarsophalangeal-Interphalangeal Scale, visual analog scale and patient satisfaction were monitored prior to surgery, six and 12 months post-op. The patients were treated in a short leg cast, non-WB for two weeks followed by four weeks partial WB in a cast shoe. Routine post-bunion rehabilitation followed once the radiological and clinical diagnosis of healing was made.
Results
Multiple complications were encountered. The most common was “troughing” of the metatarsal with loss of height. This occurred in seven patients (35%). Other complications include delayed union (5%), rotational malunion (30%), proximal fracture (10%), infection (5%) and early recurrence of deformity in 25%. All 20 patients were available for follow-up at six months, and 19 of 20 at 12 months. The AOFAS score pre-op was a mean of 53. At six months a mean of 54 (19 to 69) and at 12 months 62 (24–100). Forty-five percent (9/20) were unsatisfied at one year and would not recommend the surgery to a friend.
Conclusions/Significance
The Scarf osteotomy has multiple potential pitfalls and should probably be reserved for moderate bunions in young people with good bone quality. There are multiple potential problems and the salvage of a failed Scarf osteotomy is difficult.
Hallux abductovalgus is one of the most common deformities addressed by foot and ankle surgeons. Surgically, it can be approached using a wide variety of procedures. After performing the first metatarsal osteotomy, the final step is often to realign the great toe in a rectus position. This is performed with an osteotomy of the proximal phalanx. The Akin osteotomy is a medially based closing wedge osteotomy of the proximal phalanx. When executing the osteotomy, the goal is not only to correct abduction, but also to keep the lateral cortex intact, which allows it to act as an additional point of fixation. However, the lateral cortex can be iatrogenically compromised during surgery or in the postoperative period. We investigated the frequency of disruption of the lateral cortex, osteotomy displacement, healing time, and the need for surgical revision associated with the Akin procedure. A total of 132 patients who had undergone Akin osteotomy were included in the present retrospective study. Intraoperative fluoroscopy showed the lateral cortex was compromised in 47 (35.6%) patients and remained intact for 85 (64.4%) patients. Of the 47 (35.6%) patients with lateral cortex disruption intraoperatively, 9 (19.1%) experienced displacement during the postoperative period, of whom, 3 (6.38%) required surgical revision. Although intact during surgery, the other 6 (4.55%) patients sustained lateral cortex fractures postoperatively, 2 (33.3%) of whom required surgical revision. A statistically significant difference was found between the integrity of the lateral cortical hinge and the healing time of the osteotomy. All the osteotomies with displacement postoperatively were noted to have lateral cortex failure, either during surgery or during the follow-up period.
The aetiology of Hallux Valgus is poorly understood, and a multiplicity of treatments have been advocated. The literature is reviewed and the aetiology, pathogenesis and an algorithm for operative treatment set out.
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.
Purpose of review The treatment of hallux valgus is dependent on multiple factors from clinical examination, patient considerations, radiographic assessment, and surgeon preference. Numerous techniques have been described to address this common disorder. The purpose of this paper is to provide an updated review of the surgical treatment of hallux valgus. Recent findings Operative management of hallux valgus involves a combination of both soft tissue and bony procedures. Various osteotomies, each demonstrating potential advantages and complications, may be selected based on the degree of deformity. Arthrodesis may be utilized to address severe deformities and first ray hypermobility. Minimally invasive techniques are now being employed with emphasis on cosmesis and reduced surgical exposure. Salvage techniques have also been recently described with improved clinical results. Summary While several well established surgical methods are available for hallux valgus, consensus regarding the best treatment has yet to be established. Ultimately, this decision-making process is multifactorial, and further investigation into more novel approaches may be warranted prior to their broad application. Appropriate surgical selection and proper technique will usually result in good to excellent outcomes.
The purpose of the study was to evaluate the increased correction possible with a mid shaft rotational osteotomy with the stability and ease of fixation associated with a scarf osteotomy.
Between September 1999 and September 2006, 63 patients underwent operative repair of 77 Tailor's bunion deformities. Twenty eight patients (36 feet) were available for a final review (nine males and 19 females). A further seven patients (nine feet) completed a questionnaire. The mean followup period for the 28 patients reviewed in clinic was 6.5 years, (79.5 months; SD, 22).
Eighty-six percent were completely satisfied, 11.4% were satisfied with reservations and 3% were dissatisfied. Ninety-one percent considered themselves better than before their surgery while 8.6% felt they were no better. Ninety-one percent of patients said they would undergo surgery under the same conditions again. Preoperatively, the mean 4-5 intermetatarsal angle measured on weightbearing X-rays was 9.9 degrees (SD, 2.2), the mean postoperative intermetatarsal angle was 5.7 degrees (SD, 2.0). The mean preoperative AOFAS score was 44.1 (SD, 14.5) and the mean postoperative score at 6-month review was 91.8 (SD, 20.2). The AOFAS score at final review was 88.1 (SD, 11.6).
The rotational scarf osteotomy was a reliable procedure for the correction of Tailor's bunion deformities. The osteotomy allowed for early mobilization and had few associated complications. The rotational scarf osteotomy facilitated correction of the intermetatarsal angle while maintaining excellent sagittal and transverse plane stability.
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.
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.
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.
Overall the patients who had a scarf osteotomy had a superior outcome at 6 and 12 months.
A new procedure for the correction of hallux valgus was performed on 39 patients (66 feet). The follow-up period averaged 29 months, with a range of 24 to 32 months. The new procedure is a horizontally directed displacement Z-osteotomy in the head and shaft region of the first metatarsal. Rigid internal fixation is obtained with 3.5 or 2.7-mm bone screws. The surgeons' satisfaction rate of 79% compares favorably with the patients' complete satisfaction rate of 85%.
Numerous therapeutic options are available in treating the painful bunion. The procedure that accomplishes the desired results and correction must be carefully matched with the underlying pathologic deformity. For the majority of patients, in the author's hands, the Silver Triad (eminence resection, lateral release, and medial plication) combined with the Z-1st metatarsal osteotomy is the ideal procedure.
Hallux valgus is classified as an abnormal deviation of the great toe (hallux) towards the midline of the foot.
To identify and evaluate the evidence from randomised trials of interventions used to correct hallux valgus.
Medline (1966-October 1998), Embase (1980-1998), Cinahl (1982-1998), Amed (1993-1998), the Cochrane Controlled Trials Register, the Cochrane Musculoskeletal Injuries Trials Register and bibliographies of identified trials were searched. Hand searching of podiatry journals was undertaken. Date of the most recent search: October 1998.
Randomised or quasi-randomised trials of both conservative and surgical treatments of hallux valgus. Excluded were studies comparing areas of surgery not specific to the control of the deformity such as use of anaesthetics or tourniquet placement.
Methodological quality of trials which met the inclusion criteria was independently assessed by two reviewers. Data extraction was undertaken by one reviewer and confirmed by another. The trials were grouped according to the interventions being compared, but the dissimilarity in the comparisons prevented pooling of results.
The methodological quality of the 12 included trials was poor and trial sizes were small. Two trials involving 150 patients evaluated conservative treatments. There was no difference in outcomes between treatment and no treatment. Two trials involving 133 patients compared Keller's arthroplasty with other surgical techniques. In general, there was no advantage in using Keller's over the other techniques, particularly in terms of range of motion and intermetatarsal angle. Three trials involving 205 patients compared chevron (and chevron-type) osteotomy with other techniques. The chevron osteotomy offered no advantages in these trials. For some outcomes, other techniques gave better results. Three trials involving 157 patients compared outcomes between original operations and surgeon's adaptations. There was no advantage found for any of the adaptations. Two trials involving 95 patients evaluated methods of post-operative rehabilitation. The use of continuous passive motion appeared to give an improved range of motion and earlier recovery following surgery; early weightbearing was not found to be detrimental to final outcome.
There is insufficient evidence from randomised trials to determine which methods of either conservative, operative or post-operative treatment are the most appropriate for the hallux valgus. It is notable that the numbers of patients remaining dissatisfied at follow-up were consistently high (25 to 33%), even when the hallux valgus angle and pain had improved. Assessment of future research should focus on evaluating basic intervention types in eligible patients with similar degrees of deformity. Future research should include patient-focused outcomes, standardised assessment criteria and longer surveillance periods.
With the Scarf osteotomy, a good correction of moderate hallux valgus can be obtained, comparable to the distal or proximal Chevron or crecentic osteotomy. Correction of the IMA averages between 5 degrees to 6 degrees. When used in combination with an adductor release and proximal phalangeal osteotomy, the indication can be extended to severe hallux valgus deformities as long as there is no arthrosis at the MTP joint. The Scarf osteotomy, however, is certainly a more extensive surgical procedure, with a longer learning curve than a distal Chevron osteotomy. With more than 1000 Scarf procedures performed, the author has not encountered one delayed union, even in osteoporotic bone, or an avascular necrosis. In two cases a stress fracture was encountered in the first 3 months after surgery, but these healed uneventfully with partial weight bearing for 5 weeks.