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ORIGINAL ARTICLE
Year : 2017  |  Volume : 5  |  Issue : 2  |  Page : 91-94

Midterm outcome after correction of hallux valgus deformity using scarf osteotomy in adult population


1 Department of Clinical Affairs, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
2 Department of Clinical Affairs, College of Medicine, King Saud bin Abdulaziz University for Health Sciences; Department of Surgery, Division of Orthopaedic Surgery, King Abdulaziz Medical City, Riyadh, Saudi Arabia
3 Department of Surgery, Division of Orthopaedic Surgery, King Abdulaziz Medical City, Riyadh, Saudi Arabia

Date of Web Publication24-Apr-2017

Correspondence Address:
Laura Ibrahim Alolayan
King Saud bin Abdulaziz University for Health Sciences, P.O. Box 22490, Riyadh 11426
Saudi Arabia
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DOI: 10.4103/jhs.JHS_104_16

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  Abstract 

Context: Determining the efficacy of any surgical treatment is the key to achieve better practice and best outcomes for patients. Aims: This study is designed to address midterm outcome in adult patients with moderate-to-severe hallux valgus (HV), who underwent scarf osteotomy from 2012 to 2014. Settings and Design: This is a retrospective cohort study in which charts of all adult patients with moderate-to-severe HV who underwent scarf osteotomy from 2011 to 2014 were reviewed. Subjects and Methods: Between 2011 and 2014, 39 patients (41 feet) who underwent scarf osteotomy for correction of HV deformity were retrospectively evaluated. Standard weight-bearing dorsoplantar radiographs were obtained pre- and postoperatively. HV angle (HVA), intermetatarsal angle (IMA) and distal metatarsal articular angles (DMAA) were measured pre- and postoperatively to evaluate the efficacy of the surgery. The complication rate was reported. The average follow-up was 13.5 months, and the patients' mean age was 37 years. Statistical Analysis Used: Data were compared using Chi-square test or Fisher's exact test whichever was appropriate. All tests were two-sided, and a P> 0.01 was considered statistically significant. Results: The average preoperative HVA and IMA were 32° and 14.3°, which improved to 11° and 7.9°, respectively. The changes were statistically significant (P < 0.01). The average DMAA was 16° which was reduced to (12°); however, the change was not statistically significant (P > 0.18). Conclusions: This study suggests that scarf osteotomy surgery is a very versatile osteotomy in correcting moderate-to-severe HV deformity. It offers a greater degree of correction and stability, lower rate of complications and good outcome. However, long-term follow-up studies are still needed.

Keywords: Bunion, hallux valgus, hallux valgus/assessment, hallux valgus/prevalence, hallux valgus/radiograph, metatarsal osteotomy, scarf osteotomy


How to cite this article:
Alolayan LI, Alshehri MH, Almohawis AH, Alsumai TS, Alkenani NS. Midterm outcome after correction of hallux valgus deformity using scarf osteotomy in adult population. J Health Spec 2017;5:91-4

How to cite this URL:
Alolayan LI, Alshehri MH, Almohawis AH, Alsumai TS, Alkenani NS. Midterm outcome after correction of hallux valgus deformity using scarf osteotomy in adult population. J Health Spec [serial online] 2017 [cited 2020 Apr 7];5:91-4. Available from: http://www.thejhs.org/text.asp?2017/5/2/91/205071


  Introduction Top


Hallux valgus (HV) is one of the most common forefoot deformities encountered by orthopaedic surgeons.[1],[2],[3] It is described as the medial deviation of the first metatarsal and lateral deviation and/or rotation of the distal phalanx.[1] The prevalence of HV varies in epidemiological studies, with a crude prevalence of 31%.[3] Patients with HV deformity usually present with footwear restriction, painful bunion, metatarsalgia of the second metatarsal head and cosmetic concerns.[2],[3] Correction of HV is considered to be one of the greatest challenges faced by foot and ankle surgeons worldwide.[4]

More than 130 surgical techniques have been described for the correction of HV deformity.[5],[6],[7] Scarf osteotomy has recently gained a lot of popularity among surgeons.[5] It offers a greater degree of correction, stability and sustainability.[8] The Z-shaped cut (double chevron) in the first metatarsal bone was first introduced by Meyer in 1926.[9] It was also described by Burutaran in 1976.[10] Weil and Borelli in the USA [11] and Barouk in France contributed to its recent development.[12],[13] Scarf osteotomy has been widely used since then by many surgeons in the United States and across Europe. The name rose from its carpentry equivalent. The process of scarf osteotomy is done by making a Z-shaped step-cut in the first metatarsal bone.[14] A bunionectomy followed with a medial longitudinal cut is made along the length of the diaphysis of the first metatarsal bone, followed by realigning the metatarsal bone and reducing the intermetatarsal angle (IMA).[11],[12] Care is always taken to correct the distal metatarsal articular angle (DMAA). The head and the plantar cortical fragment are then stabilised with two screws [15]; although the technique that was implemented in this study used one or no screws for fixation.

This study aims to address midterm outcomes after scarf osteotomy in moderate-to-severe HV deformities in terms of radiological assessment and complications.[16]


  Subjects and Methods Top


This study was carried out between March 2011 and October 2014. Thirty-nine patients (41 feet) underwent scarf osteotomy for the correction of HV deformity. Our sample included 36 females and 3 males. The average age was 37 years (range: 18 - 66 years), and the average follow-up period was 13.5 months (range: 9 - 18 months). The main indications for the procedure were painful bunion, footwear restriction, pain under the second metatarsal head and failure of conservative treatment,[17] which included accommodative shoes with padding and strapping to ease footwear or digital pressure, orthoses that allow biomechanical foot control to achieve joint stability and relief and non-steroidal anti-inflammatory drug [15],[18] prescription to relieve pain caused by acute inflammatory process.[19] Three patients were excluded from the study due to missing data. All patients' data were obtained from their existing medical records where no identification data (names, medical record numbers) needed to be disclosed; therefore, consent was not needed. This study was approved by the Institutional Board of Review and Ethical Committee of King Abdullah International Medical Research Center.

Operative technique

Doctor nader S. Alkenani was the surgeon who performed the surgeries. Patients underwent General anesthesia and above-ankle sterile tourniquets were applied and inflated to 250 mmHg. A 5 - 6 cm medial skin incision just distal to the first metatarsal bone and soft tissue release was carried out, and then, the capsule was opened along the line of the incision respecting the dorsal and planter attachments of the capsule to the head. The medial eminence of the first metatarsal was then resected.[20] Moreover, a Z-shaped osteotomy was made (2.5 - 3 cm long); starting distally 5 mm from the articular surface, 2 - 3 mm from the dorsal surface and finished 5 mm from the metatarsal joint as illustrated in [Figure 1].[21] A lateral displacement of the distal segment was done 2 - 3 mm from the proximal plantar surface of the metatarsal to correct the deformity. If correction of the DMAA was needed, an open or closed wedge osteotomy of the dorsal distal segment was made, and fixation was achieved by the use of two 2.7 mm countersunk lagging screws, or sometimes, figure-of-eight suture was used.[20] The remaining bone on the metatarsal head and shaft was removed and stability was checked.[22] The essential capsular repair was done by a 0 Vicryl in figure-of-eight while the toe was held in maximum varus. Postoperative management included: Dressing for 3 weeks keeping the big toe in varus, wearing forefoot relieving shoes for 6 weeks starting next day postoperatively and finally, progressive weight-bearing from partial to full as tolerated. Physiotherapy was started after 3 weeks to improve function and movement.
Figure 1: Schematic diagram of scarf osteotomy.

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Radiological assessment

Standard weight-bearing dorsoplantar radiographs were obtained for the patients preoperatively, postoperatively and at follow-up. The parameters measured included: HV angle (HVA), IMA and DMAA. HVA is defined as the intersection of bisection of the first metatarsal and proximal phalanx, with a normal value of 10° - 15°.[23],[24] The intersection with bisection of the first and second metatarsals forms the IMA with a normal value of 7° - 9°. The DMAA is formed between the perpendicular line to the effective articular cartilage of the first metatarsal head and its intersection with bisection of the first metatarsal head and its intersection with bisection of the first metatarsal with a normal value of up to 8°.[23]

Statistical analysis

All data were entered and analysed using SPSS version 21. (manufactured by International Business Machines Corp., Armonk, New York, United States) Paired t-test was used. The comparison was made using Chi-square test or Fisher's exact test whichever was appropriate. Statistically significant values were defined by a P< 0.01.


  Results Top


The average preoperative HVA was 32° (range: 21° - 48°), which improved to 11° (range 3.3° - 25°) postoperatively (P < 0.01). The average preoperative IMA was 14.3° (range: 7° - 25°), which improved to 7.9° postoperatively (range: 1.7° - 15°) (P < 0.01). DMAA preoperatively was 16° (range: 6° - 33°), which reduced to 12.2° (range: 6° - 24°); however, the change in DMAA was not statically significant (P = 0.18). [Table 1] shows details of the radiological assessment.
Table 1: Details of radiological assessment of hallux valgus, intermetatarsal and distal metatarsal articular angles in patients with hallux valgus deformity

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Complications were reported in two patients. One patient needed the removal of a symptomatic distal screw, and another patient who was undergoing chemotherapy suffered from a fracture at fixation site, which healed completely.


  Discussion Top


Scarf osteotomy has been shown to be an effective procedure for the correction of HV deformity.[11],[23],[25] It offers a greater deal of correction with a low incidence of complications.[9] In 2000, Barouk described the procedure as technically demanding, although through efficient technique, scarf osteotomy indications could be extended from mild to most advanced deformities including iatrogenic, arthritic and even rheumatoid HV.[20]

The main objective in this study was to assess the degree of radiological correction of HV deformity in moderate-to-severe cases. It was found that there was an improvement in both HVA and IMA, the angles improved to 11° and 7.9°, respectively. However, the DMAA did not show a significant improvement after the procedure (from 16° to 12°) [Figure 2]. These results were similar to multiple prior published papers.[11],[23],[26]
Figure 2: Radiograph of one patient with hallux valgus deformity (left) and 2 months after scarf osteotomy (right).

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The secondary objective in this study was to find out the rate of complications due to scarf osteotomy procedure. Studies have shown promising clinical outcomes after scar osteotomy; however, there was an incidence of complication in about 4 - 10% of the cases.[23],[24] A study done by Coetzee encountered multiple complications including: delayed union, rotational malunion, infection and early recurrence of the deformity.[27] Coetzee showed that scarf osteotomy has some complications and it is more recommended for young patients with moderate bunions and good bone health.[20] Another study by Kilmartin and O'Kane reported the following complications after scarf osteotomy: recurrence (8%), hallux varus (4%) and infection (4%).[28] In this study, the rate of complication was 5% and it included removal of distal screw due to pain and fracture at the site of fixation.

There are a number of limitations in this study; the first being not including clinical assessment using the American College of Foot and Ankle Surgeons Score. Second, the average follow-up time was short (an average of 13.5 months) compared to published papers. These limitations restricted us to successfully evaluate the effectiveness of the procedure in the long run.


  Conclusions Top


This study suggests that scarf osteotomy surgery appears to be effective in correcting moderate-to-severe HV deformity. It offers a greater degree of correction and stability, lower rate of complications and good outcome in the short-term. However, long-term follow-up studies are still needed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Vanore JV, Christensen JC, Kravitz SR, Schuberth JM, Thomas JL, Weil LS, et al. Diagnosis and treatment of first metatarsophalangeal joint disorders. Section 1: Hallux valgus. J Foot Ankle Surg 2003;42:112-23.  Back to cited text no. 1
    
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Roddy E, Zhang W, Doherty M. Prevalence and associations of hallux valgus in a primary care population. Arthritis Rheum 2008;59:857-62.  Back to cited text no. 2
    
3.
Mann RA, Coughlin MJ. Hallux valgus - Etiology, anatomy, treatment and surgical considerations. Clin Orthop Relat Res 1981;157:31-41.   Back to cited text no. 3
    
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Berg RP, Olsthoorn PG, Pöll RG. Scarf osteotomy in hallux valgus: A review of 72 cases. Acta Orthop Belg 2007;73:219-23.  Back to cited text no. 4
    
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Fakoor M, Sarafan N, Mohammadhoseini P, Khorami M, Arti H, Mosavi S, et al. Comparison of clinical outcomes of scarf and chevron osteotomies and the mcbride procedure in the treatment of hallux valgus deformity. Arch Bone Jt Surg 2014;2:31-6.  Back to cited text no. 5
    
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De Vil JJ, Van Seymortier P, Bongaerts W, De Roo PJ, Boone B, Verdonk R. Scarf osteotomy for hallux valgus deformity: A prospective study with 8 years of clinical and radiologic follow-up. J Am Podiatr Med Assoc 2010;100:35-40.  Back to cited text no. 8
    
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Meyer M. Eine neue modifikation der hallux valgus operation. Zbl Chir 1926;53:3265-8.  Back to cited text no. 9
    
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Burutaran JM. Hallux valgus Y cortedad anatomica del primer metatarsano (correction quingica). Actual Med Chir Pied 1976;13:261-6.  Back to cited text no. 10
    
11.
Weil LS, Borelli AN. Modified scarf bunionectomy: Our experience in more than 1000 cases. J Foot Surg 1991;30:609-22.  Back to cited text no. 11
    
12.
Barouk LS. Osteotomie scarf du premier metatarsien. Med Chir Pied 1994;10:111-20.  Back to cited text no. 12
    
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Jones S, Al Hussainy HA, Ali F, Betts RP, Flowers MJ. Scarf osteotomy for hallux valgus. A prospective clinical and pedobarographic study. J Bone Joint Surg Br 2004;86:830-6.  Back to cited text no. 13
    
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15.
Robinson AH, Limbers JP. Modern concepts in the treatment of hallux valgus. J Bone Joint Surg Br 2005;87:1038-45.  Back to cited text no. 15
    
16.
McKean RM, Bergin PF, Watson G, Mehta SK, Tarquinio TA. Radiographic evaluation of intermetatarsal angle correction following first MTP joint arthrodesis for severe hallux valgus. Foot Ankle Int 2016. pii: 1071100716656442.  Back to cited text no. 16
    
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Karabicak GO, Bek N, Tiftikci U. Short-term effects of kinesiotaping on pain and joint alignment in conservative treatment of hallux valgus. J Manipulative Physiol Ther 2015;38:564-71.  Back to cited text no. 17
    
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Hallux Valgus Treatment and Management. Hallux Valgus Treatment and Management: Approach Considerations, Medical Therapy, Surgical Options. Available from: http://www.emedicine.medscape.com/ article/1232902-treatment#d9. [Last cited on 2016 Sep 13].   Back to cited text no. 18
    
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Mann RA, Rudicel S, Graves SC. Repair of hallux valgus with a distal soft-tissue procedure and proximal metatarsal osteotomy. A long-term follow-up. J Bone Joint Surg Am 1992;74:124-9.  Back to cited text no. 19
    
20.
Barouk LS. Scarf osteotomy for hallux valgus correction. Local anatomy, surgical technique, and combination with other forefoot procedures. Foot Ankle Clin 2000;5:525-58.  Back to cited text no. 20
    
21.
Hong-Geun J. Foot and Ankle Disorders: An Illustrated Reference. Berlin: Springer-Verlag Berlin Heidelberg; 2016. p. 23.  Back to cited text no. 21
    
22.
Saragas NP. Technique tip: Preventing “troughing” with the scarf osteotomy. Foot Ankle Int 2005;26:779-80.  Back to cited text no. 22
    
23.
Jones AL. Recombinant human bone morphogenic protein-2 in fracture care. J Orthop Trauma 2005;19 10 Suppl:S23-5.  Back to cited text no. 23
    
24.
Kristen KH, Berger C, Stelzig S, Thalhammer E, Posch M, Engel A. The SCARF osteotomy for the correction of hallux valgus deformities. Foot Ankle Int 2002;23:221-9.  Back to cited text no. 24
    
25.
Crevoisier X, Mouhsine E, Ortolano V, Udin B, Dutoit M. The scarf osteotomy for the treatment of hallux valgus deformity: A review of 84 cases. Foot Ankle Int 2001;22:970-6.  Back to cited text no. 25
    
26.
Adam SP, Choung SC, Gu Y, O'Malley MJ. Outcomes after scarf osteotomy for treatment of adult hallux valgus deformity. Clin Orthop Relat Res 2011;469:854-9.  Back to cited text no. 26
    
27.
Coetzee JC. Scarf osteotomy for hallux valgus repair: the dark side. Foot Ankle Int. 2003;24:29-33.  Back to cited text no. 27
    
28.
Kilmartin TE, O'Kane C. Combined rotation scarf and Akin osteotomies for hallux valgus: A patient focussed 9 year follow up of 50 patients. 12 J Foot Ankle Res 2010;3:2.  Back to cited text no. 28
    


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