Scarf Osteotomy Research Articles

Short Scarf Osteotomy for Hallux Valgus: Short-term and Medium-term Results

ABSTRACT Aim The scarf osteotomy, as popularized by Barouk, is a versatile osteotomy for the correction of moderate and severe hallux valgus deformity. However, this technique requires extensive exposure, fixation, and increased operative time, and is technically demanding. We describe and present our results of a short scarf osteotomy (SSO), which retains all the cuts of a standard scarf but requires a reduced exposure, less metalwork, less operating time, and is more economical. Materials and methods All patients who underwent SSO between January 2010 and December 2012 with minimum follow-up of 12 months were eligible for the study. Preoperative, intraoperative, and postoperative radiographs were available for radiological assessment. Results In this study, 84 patients and 94 feet were included; 90% of patients were satisfied overall, with 83% of patients recommending this surgery to a friend. The hallux valgus angle improved from a preoperative mean of 30.89° (17.4—46.8) to 12° (4—30) postoperatively (p = 0.0001). The intermetatarsal angle improved from a preoperative mean of 15.05° (10.3—21.1) to 7.14° (4—15.1) postoperatively (p = 0.0001). The average sesamoid coverage improved from grade 2.18 (1—3) preoperatively to 0.57 (0—2) postoperatively (p = 0.0001). The average American Orthopedic Foot and Ankle Score improved from 51.26 (32—88) preoperatively to 91.1 (72—100) postoperatively (p = 0.0001). Conclusion We believe that this osteotomy is a novel procedure producing good to excellent results in most cases of hallux valgus. Biologically, the decreased exposure should improve healing and reduce the risk of avascular necrosis. We strongly recommend this osteotomy for most cases of hallux valgus surgery. How to cite this article Dalal R, Rachha R, Leonard D, Chourasia A, Javed S. Short Scarf Osteotomy for Hallux Valgus: Short-term and Medium-term Results. J Foot Ankle Surg (Asia-Pacific) 2017;4(1):14-18.

First Metatarsophalangeal Contact Properties Following Proximal Opening Wedge and Scarf Osteotomies for Hallux Valgus Correction: A Biomechanical Study.

Proximal opening wedge osteotomy (POWO) is an established procedure for moderate to severe hallux valgus. A common concern of this procedure is that it results in lengthening of the first metatarsal, which could cause increased intra-articular pressure of the first metatarsophalangeal joint (MTP) and may ultimately lead to arthritis because of these altered mechanics. The purpose of this study was to use a cadaveric model to compare intra-articular pressures and articulating contact properties of the MTP joint following either scarf osteotomy or POWO. Fresh-frozen cadaveric below-knee specimens with pre-existing hallux valgus (n = 12) and specimens without hallux valgus (n = 6, control group) were used. The hallux valgus specimens were stratified into 2 groups (n = 6 each): POWO or scarf osteotomy. The groups were matched based on the degree of deformity. Peak intra-articular pressure, force, and area were measured in all normal, preoperative, and postoperative specimens with a simulated weightbearing model. These measurements were made with a pressure transducer placed within the first MTP joint. Postoperatively POWO group had slightly higher contact forces and pressures compared to the scarf group and lower contact forces and pressures than those of the normal group but were not statistically significant ( P > .05). Normal specimens had higher intra-articular force, pressure, and area than postoperative specimens but the difference was not found to be significant. First metatarsal lengthening was found in both the scarf and POWO specimens; however, neither increase was found to be significant ( P > .05). The results from this study show that after operative correction, contact properties of the fist MTP joint among normal, POWO, and scarf osteotomy groups revealed no significant differences. First MTP joints in those with hallux valgus had significantly lower contact force and pressure compared to those without hallux valgus. With little long-term outcomes of proximal opening wedge osteotomy, this study will help predict the possibility of future MTP joint arthritis.

Shortening Scarf osteotomy for correction of severe hallux valgus. Does shortening affect the outcome?

BackgroundTranslation and shortening of Scarf osteotomy allows correction of severe hallux valgus deformity. Shortening may result in transfer metatarsalgia. AimTo evaluate outcome of patients undergoing shortening Scarf osteotomy for severe hallux valgus deformities. Materials and MethodsFifteen patients (20feet, mean age 58 years) underwent shortening Scarf osteotomy for severe hallux valgus deformities. Outcomes were pre and postoperative AOFAS scores, IM and HV angles, patient satisfaction. ResultsMean follow-up was 25 months (range 22–30). The IM angle improved from a median of 18.60 (range 13.4–26.20) preoperatively to 9.70 (range 8.0–13.70) postoperatively (8.9; 95% CI=7.6–10.3; p<0.001). The HV angle improved from a mean of 43.2 (range 27.4–68.2) preoperatively to 13.6 (range 3.0–37.4) postoperatively (29.6; 95% CI=26.1–33.2; p<0.001).The median AOFAS score improved from 29.2 (range 14–60) preoperatively to 82.2 (range 55–100) postoperatively (53.0; 95% CI=48.0–58.5; p<0.001). All patients rated their satisfaction as either satisfied or very satisfied. None had symptoms of transfer metatarsalgia at final follow-up. All osteotomies united. ConclusionsShortening Scarf osteotomy is a viable option for treating severe hallux valgus deformities with no transfer metatarsalgia.

Effectiveness of Headless Bioabsorbable Screws for Fixation of the Scarf Osteotomy.

Scarf osteotomy has been used in hallux valgus surgery due to its large fixation surface for screws and low postoperative complications. However, screws may cause skin irritation from their head, which may require an additional surgical procedure to remove. This study included 115 patients (106 females and 9 males, 115 feet) who underwent hallux valgus correction with a scarf osteotomy using bioabsorbable screws between September 2010 and September 2012. Preoperative and postoperative 1-month and 1-year radiographic measurements, including intermetatarsal angle (IMA), hallux valgus angle (HVA), distal metatarsal articular angle (DMAA), proximal phalangeal articular angle (PPAA), and lateral translational distance (LTD), were obtained. American Orthopaedic Foot & Ankle Society (AOFAS) hallux/forefoot scores were used for patient satisfaction. Preoperative mean values of HVA, IMA, and PPA of 32.8 degrees, 14.6 degrees, and 7.52 degrees, respectively, improved to 10.7 degrees, 6.0 degrees, and 4.6 degrees, respectively at 1-year follow up (P < .05). The difference in LTD between the 1-month and 1-year follow-up was not statistically significant. AOFAS hallux/forefoot score improved from 69.1 to 96.1 at the 1-year follow up (P < .001). Complete screw absorption was not seen radiographically. Sixteen feet had complications reported. One patient complained of skin irritation over a small protrusion of the screw, and another patient had a foreign body reaction. There were 3 patients with neurologic injury from a popliteal block and 3 patients with dorsal cutaneous nerve symptoms. Four feet had metatarsal fracture during surgery. We found the scarf osteotomy using bioabsorbable screws to have satisfactory clinical and radiographic results with a low complication rate. Level IV, case series.

Hallux varus following scarf osteotomy

Hallux varus is an uncommon condition and majority of the cases are iatrogenic. It can occur as a result of any type of hallux valgus correction surgery and in our cases scarf osteotomy is not an exception. Treatment of this complication can be challenging and it is important to understand the factors that cause this deformity before embarking on surgical correction. Four cases of hallux varus following Scarf osteotomy (1% of our total Scarf osteotomy cases) and discuss the salient features of these patients. The authors ascertained the factors that caused iatrogenic hallux varus and formulated a classification of the nature of the deformity. The management of iatrogenic hallux varus based on our experience and proposed classification system has also been outlined and discussed.

Short versus ‘Standard’ Scarf Osteotomy for Hallux Valgus Correction

Category: Bunion Introduction/Purpose: Scarf osteotomy is an established procedure for correction of hallux valgus deformity. The technique has evolved and is effectively used for all grades of deformities. Short osteotomy (short scarf/modified chevron) and single screw fixation is an effective option for correction of mild to moderate hallux valgus deformity leading to lesser soft tissue disruption, smaller scar and being cost effective. Aim of this study was to compare radiological parameters of hallux valgus correction by a ‘standard’ scarf osteotomy and 2-screw fixation with a short osteotomy and single screw fixation Methods: We performed a retrospective review of prospectively collected data. The cases were identified from theatre log. 37 consecutive patients, operated between January 2013 and December 2014, were included. All had mild deformity as defined by maximum pre-operative intermetartarsal angle of 13 degrees. 16(43%) had short osteotomy with single screw fixation (Group 1) and the remaining 21 (57%) had ‘standard’ scarf osteotomy with 2 screw fixation (Group 2). Preoperative and final postoperative weight bearing radiographs were independently reviewed by both authors. Radiological parameters assessed were Hallux Valgus Angle (HVA), Intermetatarsal Angle (IMA), Distal Metatarsal Articular Angle (DMAA) and Medial Sesamoid position.Sesamoid position was determined by dividing metatarsal head into three equal sections and recorded as more than 50% of medial sesamoid in a section. The three grades were 3(lateral), 2(central) and 1(medial).Both groups were comparable for distribution of age and pre-operative radiological measures. Mean duration of X-Ray follow up was 3 months (range 2-12). SPSS version 20 was used to perform statistical analysis. Results: Mean age of patients was 49 years +/- 13 years. Mean improvement in radiological measures in degrees was - HVA from 24.4 to 10.9 (Group 1) and 35.3 to 12.6 (Group 2), IMA 10.0 to 3.3 (Group 1) and 10.5 to 5.4 (Group 2), DMAA 8.5 to 5.4 (Group 1) and 10.9 to 5.8 (Group 2), Medial Sesamoid position changed from 3 to 1 for both groups. Wilcoxon Signed Rank test showed all these improvements to be significant. T-test showed that both groups were comparable, with no statistically significant difference, for improvements in all radiological parameters. Conclusion: Short osteotomy with single screw fixation is equally effective in correction of symptomatic mild hallux valgus deformity as compared to ‘standard’ scarf osteotomy with the advantage of a smaller scar, lesser soft tissue disruption. We believe it is also cost effective because of potential reduction in duration of surgery and the cost of the implant.

First Metatarsophalangeal Contact Properties are Similar Following Proximal Opening Wedge and Scarf Osteotomies

Category: Bunion Introduction/Purpose: Proximal opening wedge osteotomy (POWO) is an established correctional procedure for moderate to severe hallux valgus. A common concern of this procedure is that it results in lengthening of the metatarsal which could cause increased intra-articular pressure of the first metatarsophalangeal joint (MTP), and may ultimately lead to arthritis due to these altered mechanics. The purpose of this study was to use cadaveric models to compare intra-articular pressures and articulating contact properties of the MTP joint following either scarf osteotomy or POWO. These were compared to normal cadaveric specimens. Our hypothesis was that the intra-articular pressure of the first MTP joint would be greater following the POWO compared to the scarf osteotomy. Methods: Fresh-frozen cadaveric below knee specimens with pre-existing hallux valgus (n=12) and specimens without arthritis or hallux valgus (n=6, control group) were used. The hallux valgus specimens were stratified into two groups (n=6 each): POWO or scarf osteotomy. The groups were matched based on the degree of deformity. Peak intra-articular pressure, force, and area were measured in all normal, preoperative and postoperative specimens. These measurements were made with a pressure transducer (Tekscan, Boston, Massachusetts) while a 50 N dorsiflexion load was applied via a wired loop on the first toe over 5 seconds and then released. Secondary outcomes included range of motion (ROM) and radiographic measurements. ROM was measured pre and postoperatively under fluoroscopy. 1-2 intermetatarsal angle (1-2 IMA), hallux valgus angle (HVA), and metatarsal length were measured on simulated weight-bearing radiographs. Statistical analyses were performed using unpaired Student’s t-test, paired Student’s t-test, and ANOVA with Bonferroni correction for post-hoc analysis. Results: Postoperatively, although POWO group had slightly higher contact forces and pressures compared to the scarf group, they were lower than those of the normal group. These comparisons had no statistically significant differences (P&gt;0.05). Normal specimens had significantly higher force (P=0.012) and pressure (P=0.007) but similar contact area (P&gt;0.05) compared to the preoperative hallux valgus specimens. Contact area were similar in normal, POWO, and scarf groups. There was no significant difference in ROM between all three groups. The first metatarsal was lengthened 1.36 mm +/- 1.39 mm in the POWO group and lengthened 1.54 mm +/- 2.27 mm in the scarf osteotomy group. Conclusion: The results from this study show that after surgical correction, contact properties of the fist MTP joint among normal, POWO, and scarf osteotomy groups revealed no significant differences. First MTP joints in those with hallux valgus have significantly lower contact force and pressure compared to those without hallux valgus. Our results provide biomechanical evidence that first MTP joint biomechanics are similar after POWO and scarf osteotomy.

Male Hallux Valgus Corrected by Translational Osteotomy of First Metatarsal

Category: Bunion Introduction/Purpose: Male hallux valgus (HV) is less common and more severe than in females, and has been reported to be associated with higher Distal Metaphyseal Articular Angle (DMAA). Although valgus-producing osteotomies should increase DMAA, this has not been documented. This study evaluated the results of a translational osteotomy that counter-rotates the distal metatarsal articular surface in a varus direction to re-align the articular surface, and correct the DMAA. Methods: Prospectively collected pre-op and post-op data on 26 males with HV were retrospectively reviewed, at a minimum one-year followup. Radiographic data included hallux valgus (HVA), first-second intermetatarsal (IMA) angles, DMAA, medial sesamoid position (MSP), and first MTPJ congruence. Clinical outcomes included Visual Analog Score (VAS), SF-36, and AOFAS forefoot score. MTP range of motion (ROM) was measured. Preoperative radiographic and clinical data were compared to previously published cohort of female patients for the same measures. Paired t-tests compared clinical and radiographic outcomes pre- and postoperatively. Bowker’s Test was used to compare the rate of joint congruence. An alpha of 0.05 was considered significant. Student t-test and Fisher’s Exact Test were for comparison between males and females. Mean age of males with HV was 53.8 (SD=17.7), mean follow-up was 1.68 years. Results: Mean radiographic improvement: HVA 36.5º to 15.3º (P=0.0001); IMA 15.9 to 8.1 (P=0.0001); DMAA 13.3º to 6.4º (P=0.0003); MSP 2.8 to 1.2 (P=0.0001); congruence 4/26 to 22/26 (P=0.0001). Mean clinical improvements: VAS 5.7 to 1.0 (P=0.0001); AOFAS 49.6 to 84.7 (P=0.0001); SF36-P 44.7 to 51.2 (P=0.0004). MTP dorsiflexion decreased 58.3º to 51.8º (P=0.0276); plantarflexion 5.8º to 3.0º (P=0.0217). Higher mean preoperative angles in males versus females: HVA 35.8º versus 29º (P=0.0016); IMA 15.9º versus 13.0º, (P=0.0002), MSP 2.7 versus 2.5 (P=0.2012). No difference in DMAA, 13.6 versus 16.4 (P=0.2551). Congruence in males lower (5/27 versus 22/40, P=0.0048). No difference in VAS (5.6 versus 6.3, P=0.1767), AOFAS (50 versus 47.9, P=0.5085), SF-36p (45.1 versus 42.4, P=0.2656), dorsiflexion (57.9º versus 49.4º, P=0.0728), plantarflexion (5.8º versus 4.8º, P=0.7204). Conclusion: Prior studies reported the results of mixes of surgical procedures. This is the first large series of adult male HV treated with a single procedure, and the first using this counter-rotational modification of the Scarf osteotomy. The modified Scarf osteotomy combines translation varus counter-rotation to direct the articular surface more medially, explaining decreased DMAA, and with excellent radiographic and clinical outcomes. We demonstrate excellent radiographic and clinical outcomes in a large group of male HV treated with translational osteotomies.

Screwless scarf osteotomy for hallux valgus: Evaluation of radiologic correction.

The scarf osteotomy is a standard procedure to correct hallux valgus. Recent modifications in the technique allow for important translations of the bone fragments without the need for screw fixation. We performed the first prospective analysis of radiographic parameters after a screwless scarf osteotomy. Prospective study of pre- and postoperative standing radiographs of the feet let us quantify angle reduction and shortening, lengthening or lowering of the first metatarsal. 100 patients undergoing a screwless scarf osteotomy were evaluated radiographically before and after surgery. The 1-2 IM angle, HVA, length of the first metatarsal, protrusion length and height of the first metatarsal head were measured. The mean 1-2 IM angle was reduced significantly, to a normal range. The mean reduction of the first metatarsal length and protrusion length was 0.3 and 0.14cm respectively. The metatarsal head was lowered 0.3cm on average. A minimal mean reduction of the first metatarsal length was observed, but it is possible to lengthen the first metatarsal if necessary. In 23% of cases, an increase of protrusion length was obtained. The screwless scarf osteotomy results in a good correction of the 1-2 IM angle and HVA. If necessary, plantarisation of the first metatarsal head could be obtained. Secondary displacement was seen in 1 patient. IIa, prospective controlled trial.

Shortening Scarf osteotomy for correction of severe hallux valgus. Does shortening affect the outcome

Shortening Scarf osteotomy for correction of severe hallux valgus. Does shortening affect the outcome

Scarf osteotomy combined with hyprocure stent gives better result in the treament of hallux valgus

Subtalar arthroereisis refers to the implantation of a sinus tarsi implant for the treatment of flexible flatfoot. The purpose of this study was to compare the ability to correct the flatfoot deformity and contact pressure of the posterior subtalar joint between two types of self-locking wedge implants and between two different positions for the same device in a cadaveric flatfoot model.The flatfoot model was created in ten cadaver feet through ligament sectioning and cyclic loading. Three kinds of arthroereisis procedures were evaluated: Talar-Fit (type I self-locking wedge implant) anchored in the sinus portion of the tarsal sinus (T-sinus group), Talar-Fit in the canalis portion (T-canalis group), and HyProCure (type II) in the canalis portion (H group). Corrective ability in the sagittal and transverse planes were measured with clinometers. Contact pressure was measured with pressure-sensitive films.T-canalis group provided more sagittal (mean difference for size 10 mm: 1.9°, P = 0.014; mean difference for size 11 mm: 3.1°, P = 0.037) and transverse (mean difference for size 8 mm: 1.8°, P = 0.049; mean difference for size 11 mm: 2.2°, P = 0.049) corrections than T-sinus group. The flattening process shifted the peak pressure of the posterior subtalar joint to the posteromedial side (P < 0.05) and arthroereisis helped the distribution of contact pressure restore uniformity (all P > 0.05).A self-locking wedge implant inserted in the canalis portion of the tarsal sinus achieved better correction than an implant inserted in the sinus portion.

Technique tip: Simultaneous first metatarsal lengthening and metatarsophalangeal joint fusion for failed hallux valgus surgery with transfer metatarsalgia.

Failed hallux valgus surgery may result in residual or recurrent hallux valgus, and as well transfer metatarsalgia. The present technical tip concerns the combination of fusion of the first metatarsophalangeal (MTP) joint and lengthening of the first metatarsal (MT) through a scarf osteotomy. Six patients underwent the presented technique, all for the indication of failed hallux valgus surgery with shortening of the first MT and degenerative changes in the 1st MTP joint. Follow-up at six months revealed all patients had complete healing of the osteotomy and arthrodesis sites. They were all asymptomatic and fully active, completely satisfied with the outcome. Combined fusion of the first MTP joint and lengthening of the first MT through a scarf osteotomy results in an excellent outcome in patients with failed hallux valgus surgery with shortening of the first MT and degenerative changes in the 1st MTP joint.

Shortening Scarf Osteotomy for Treatment of Hallux Rigidus Deformity

Purpose: To evaluate the effect of shortening scarf osteotomy on pain relief and range of motion (ROM) of the first metatarsophalangeal joint in hallux rigidus patients. Materials and Methods: Twenty-three cases of 19 patients who had been treated with shortening scarf osteotomy for the hallux rigidus between January 2007 and December 2013 were reviewed. The mean follow-up period was 21.4 months, and the mean age was 59.2 years. The first metatarsal bone was shortened until the ROM of the first metatarsophalangeal joint was greater than 80° or 40° of dorsiflexion. The length shortened by scarf osteotomy was measured. The authors also measured and compared the joint interval difference of the standing foot using an anteroposterior radiography. Moreover, the difference of ROM of the first metatarsophalangeal joint between the preoperative and final follow-up periods was also compared. The clinical results were evaluated and compared using the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system and visual analogue scale (VAS) score. Results: The mean shortening length was about 6.5 mm (range, 4∼9 mm). The joint space has been increased to 1.8 mm, and the ROM of the first metatarsophalangeal joint has also been increased to 18.4° after the operation. In three cases, the postoperative ROM has been decreased to less 10°. The AOFAS score has been improved from 41.7 (range, 32∼55) to 86.2 (range, 65∼95), and the VAS score was also decreased from 3.7 (range, 3∼5) to 1.3 (range, 0∼3). Two cases have shown no decrease in pain even after the operation. Conclusion: Shortening scarf osteotomy was found to decrease joint pain by decompressing the pressure of the first metatarsophalangeal joint. This osteotomy also helped improve the ROM of the first metatarsophalangeal joint. Shortening scarf osteotomy can be considered one of the effective methods for joint preservation.

L’OSTEOTOMIE DE SCARF SANS OSTEOSYNTHESE METALLIQUE DANS LE TRAITEMENT DE L’HALLUX VALGUS MODERE A SEVERE

The objective of this work was to confirm the feasibility of the modificaton of Scarf Osteotomy made by Maestro in our context by relating the results at midterm of nine feet wich underwent hallux valgus surgery following this change. Material and Methods: It was a prospective study of seven (7) years including all patient presenting hallux valgus deformity following surgery by the technique of Maestro. Eight (8) patients with average age of 39.1 years were included with a bilateral case. Functional evaluation was done using AOFAS score. The morphological results were evaluated by measurement of induced shortening, hallux valgus angle, intermetarsal angle and Distal Metatarsophalangeal Articular Angle before and after surgery. Complications had been reported. Results: The follow-up average was 3.6 years. Satisfaction index shown 66.6% of patients very satisfactory and only one was unsatisfied. M1P1, M1M2 angles and the DMAA were improved respectively in preoperative and at the last follow-up from 34.4 to 9.4, 17.2 to 7.7 and 18.4 to 6.2. Fusion was effective in all patients 2 months after surgery without secondary displacement. The AOFAS score was earned from 58.2 to 89. Conclusion: Reproductible alternative in our context with good functional and anatomical results. Keys words: Hallux valgus, Osteotomy, Scarf, Osteosynthesis, Maestro.

Modification of the Scarf Osteotomy for Treatment of Hallux Valgus

Scarf osteotomy is a technique in the management of hallux valgus, which has been seen to grow in popularity in recent years, mainly because of its versatility in correction of the deformity. We describe a modification of the technique for the Scarf osteotomy to utilize the excised bone, produced as part of the standard technique, as an autologous bone graft. We present the outcomes of a consecutive series of patients operated upon by the senior author, using this technique. Level of Evidence: Treatment Benefits Level 4 (Case series). See Instructions for Authors for a complete description of levels of evidence.

Surgical Treatment of Severe Forefoot Deformity

Treatment results of 61 years old patient with severe forefoot deformity - right-side transverse-longitudinal stage II platypodia: right-side II-III degree deforming arthrosis of 1st metatarsophalangeal joint, hallus valgus with subluxation, combined 1st metatarsophalangeal joint contracture, pain syndrome, are presented. Surgical treatment included operation by Schede, lateral release of 1stmetatarsophalangeal joint, SCARF osteotomy of 1st metatarsal bone, Akin osteotomy of proximal hallux phalanx and tenoplasty of dorsal hallux flexor. As a result correction of right forefoot deformity was achieved, pain syndrome was arrested and weight bearing ability of the right foot was restored.

Restoring Sesamoid Position in Scarf Osteotomy: A Learning Curve

Incomplete reduction of the sesamoid is a known risk factor for recurrence of the deformity after scarf osteotomy for correction of hallux valgus. The purpose of the present study was to determine whether a learning curve exists for successfully restoring the sesamoid position in scarf osteotomy. We reviewed 71 consecutive cases (71 feet) of scarf osteotomy performed on female patients during a 2.5-year period by the same surgeon. The cases were divided into 3 groups according to the date of surgery, with the first 24 cases assigned to group 1, the next 24 to group 2, and the last 23 to group 3. We compared the median sesamoid position of the 3 groups at 6 weeks postoperatively and patient reported satisfaction at 6 months postoperatively. The sesamoid position ranged from 1 to 7, using the Hardy and Clapham classification system. The median sesamoid position for all patients had improved from 7 preoperatively to 2 postoperatively. The postoperative sesamoid position was significantly better for the second and third groups than for the first (p < .05), and 92% of the patients were satisfied with the procedure. We have concluded that a learning curve to optimally restoring the position of the sesamoid in scarf osteotomy is present and that this has a direct effect on reducing the risk of recurrence of the deformity.

Bunion Surgery Works--Except When It Doesn't: Commentary on an article by Peter Bock, MD, et al.: "The Scarf Osteotomy with Minimally Invasive Lateral Release for Treatment of Hallux Valgus Deformity. Intermediate and Long-Term Results".

Commentary Hallux valgus remains, in many ways, the flagship condition of orthopaedic foot and ankle practice, occupying prominent early chapters in standard textbooks and continuing to fill journals at all levels of academic discourse. It also continues to be a largely soluble problem—except when it isn’t. The relatively high overall satisfaction rates reported in Level-IV follow-up studies, seemingly regardless of specific technique, render the analysis of the small number of clinical failures difficult. The challenge in all studies of the condition has transformed from that of painting a broad picture of success in the many to understanding what failed in the maddening few. The paper by Bock et al. is not revolutionary, nor is it fully generalizable beyond the Scarf osteotomy, but it does hold incremental lessons large and small toward this end. The first incremental lesson is simple. The patients undergoing the procedure perceived themselves to be better for having done so, and that perception lasted, on balance, at least ten years. The chief psychometric instrument used in the study, the American Orthopaedic Foot & Ankle Society (AOFAS) scoring system, prohibits any finer analysis of this statement. The score is nonvalidated and contains subscores that are likely highly interrelated; it cannot be presumed to behave in a linear fashion or produce normally distributed data. The authors have appropriately recognized these limitations and modified their analyses accordingly. Median scores rather than means are reported for these data, and nonparametric statistical methods are used. Additionally, the usual limitations of a Level-IV study apply: the patients have themselves chosen to undergo the procedure and surgeon selection bias is inevitable. Less powerful statistics and a less powerful methodology lead to a less powerful conclusion; this group of selected patients perceived themselves to be better than they were preoperatively. How much so remains indeterminate. The second lesson is more surprising. Radiographic recurrence was unmasked by the long-term follow-up at a remarkably high rate. Recurrent deviation of the toe proved to be a necessary but not sufficient condition for clinical failure: while nearly all patients with long-term pain had a recurrence, not all recurrences were painful. Just who suffers a recurrence and why remain elements of debate. The authors have noted that both higher intermetatarsal angles and more severe stations of sesamoid subluxation were significant risk factors. The former may represent an inherent limitation of the Scarf osteotomy itself. While a detailed case-by-case failure analysis is not presented, it is possible that subtle tarsometatarsal instability in either the axial or sagittal plane may be at work or that the osteotomies were themselves slightly undercorrected. In either case, the residual osseous deformity may overpower a toe held straight on the basis of soft-tissue balancing alone. The sesamoids and, by extension, the first metatarsophalangeal joint itself represent a more subtle potential source of recurrence. The concept is not a new one. Sesamoid station has been shown to be a risk factor for recurrence on the basis of preoperative and early postoperative radiographs. Disordered tracking of the sesamoids relative to the plantar crista of the metatarsal head may, in fact, be relatively underemphasized in preoperative analysis1,2. Similarly, dysplasia of the metatarsal head itself has been demonstrated to be associated with radiographic recurrence3. In the current study, a limited soft-tissue procedure without full release of the lateral sesamoid ligament was performed; it therefore can be assumed that any residual lateral contracture may be clinically important only when higher degrees of preoperative deformity are encountered. Hallux valgus surgery remains an orthopaedic success story, but that story remains tempered by a surprisingly high rate of radiographic recurrence and a low but obstinate rate of clinical failure. The rough elements of success are clear regardless of the specific surgical technique: correct the intermetatarsal angle and achieve a stable first ray. To further improve outcomes, the devil appears to reside in the details, and there are lots of details. Our challenge, as this study further illustrates, is to learn in which ones he makes his home.

Prevalence of Metatarsus Adductus in Symptomatic Hallux Valgus and Its Influence on Functional Outcome.

Metatarsus adductus (MA) increases the risk of developing symptomatic hallux valgus (HV). This study aimed to determine the prevalence of MA in patients with symptomatic HV and to evaluate how it affected the functional outcome after scarf osteotomy. Between January 2007 and June 2012, a total of 206 patients who underwent scarf osteotomy for symptomatic HV at a tertiary hospital were included. The metatarsus adductus angle (MAA) was determined using the Modified Sgarlato method, and these patients were categorized into 2 groups: MA (MAA > 20 degrees); and Control (MAA ≤ 20 degrees). The patients were prospectively followed for 2 years. The prevalence of MA was 33% (68/206) with a mean MAA of 24 ± 4 degrees (range = 20-39). There was a 21 ± 12 degrees and 18 ± 9 degrees improvement in hallux valgus angle for the MA and Control groups, respectively (P = .061), whereas there was a 6 ± 4 degrees and 6 ± 3 degrees improvement in intermetartarsal angle for the MA and Control groups, respectively (P = .475). The visual analog scale, AOFAS Hallux Metatarsophalangeal-Interphalangeal Scale, and Physical and Mental Component Scores were comparable between the 2 groups both preoperatively and at 2 years' follow-up (all P > .05). Two patients in the control group required revision surgery for recurrence symptomatic HV. The authors conclude that MA did not predispose the patient to poorer functional outcome after scarf osteotomy with the advent of good operative techniques. Level II, prospective comparative study.

Scarf osteotomy without osteosynthesis in hallux valgus treatment

Hallux valgus is the most frequent deformity of the forefoot pathology, especially among the female population. This deformation involves a medial deviation of the first metatarsal head and a lateral deflection, with often, a pronation to hallux. Hallux valgus is for more than a century and a half, a forefoot osteoarticular deformity, which has most fired the imagination of surgeons who were interested in this disease and its treatment. Many surgical techniques and variants have been described over the years reaching about 150 therapeutic procedures. Scarf osteotomy technique was first described by Burutaran in 1976, developped by Weil and Borelli in 1990 and popularized in France by Barouk. We use for the treatment of hallux valgus an osteotomy Scarf without using internal fixation (osteosynthesis). This technique has been described by Maestro in 1999. In our retrospective series of 35 feet operated in our department, we investigated the clinical and radiological results in order to evaluate our results and demonstrate the reliability and reproducibility of the technique we use. Technical changes to the classic Scarf made by Maestro consist in the realization of a proximal transverse and oblique osteotomy, the realization of a cutout in the medial side of the metatarsal head where is embedded the distal side corner of the proximal fragment, the replacement of the distal bone screw by an osteosuture and the replacement of the proximal screw by the isolation of the bone area, resected to the detriment of the proximal fragment after lateral shifting at the proximal portion of the osteotomy. Scarf osteotomy without osteosynthesis, fulfills all the requirements for being a technique of choice in the treatment of hallux valgus providing excellent results for a low complication rate.