Scarf osteotomy without internal fixation for correction of hallux valgus: A clinical and radiographic review of 148 cases

SCARF Osteotomy: Where Does It Come from and Where Does It Go?

The SCARF osteotomy has been used in order to treat hallux valgus deformity for many years. Due to its inherent stability and versatile technique, the SCARF osteotomy can not only be used for primary mild deformities but also for moderate-to-severe deformities and as a technique for recurrent deformities. Multiple modifications have been published during the last decades, which have the potential to make the SCARF osteotomy an even safer technique with the potential of less complications. If applied correctly, the SCARF osteotomy delivers reliable results in comparison to other techniques.

Biomechanical Comparison between Rotational Scarf Osteotomy and Translational Scarf Osteotomy: A Finite Element Analysis

OBJECTIVE

Rotational Scarf osteotomy has its unique advantages in treating hallux valgus, but it also has certain drawbacks. The biomechanical differences between rotational Scarf and translational Scarf osteotomy are not clear evaluates the correction ability and biomechanical difference of two surgical methods for hallux valgus by finite element analysis.

METHODS

The computerized tomography data of a hallux valgus patient were selected to establish a finite element model. The standard Scarf osteotomy was simulated based on the model, and the rotation and translation were performed, respectively. The size of the intermetatarsal angle, contact area, distal metatarsal articular angle and the absolute length of the first metatarsal was compared between the two groups. We completed the cartilage, ligament and other tissues on the bone model to establish a full foot model. We analyzed the troughing, plantar aponeurosis tension, plantar soft tissue, and ground stress and also observed the stability of the fracture site by a three-point bending test.

RESULTS

Both surgical methods may effectively correct the intermetatarsal angle. After rotational osteotomy, the contact area increased, and the length of the first metatarsal bone initially increased and then decreased compared to that in the translational group. Furthermore, rotational Scarf significantly increased the distal metatarsal articular angle. Mechanical analysis showed that the cancellous bone in the contact part of the fracture site in the translation group had greater stress, which was the reason for the occurrence of the troughing. Stress distribution of plantar aponeurosis, plantar soft tissue, and the ground showed no significant difference. The three-point bending test showed that the separation of the broken ends of the rotational Scarf osteotomy model (0.133 mm) was slightly smaller than the translational group (0.147 mm).

CONCLUSION

Both surgical methods can successfully correct intermetatarsal angle (IMA). Compared to traditional translational Scarf osteotomy, rotational Scarf osteotomy is more conducive to postoperative stability and healing, but it also has certain drawbacks. In clinical practice, individualized surgical methods still need to be selected for different types of patients with hallux valgus.

First metatarsal single-screw minimally invasive chevron-akin osteotomy: A cost effective and clinically reliable technique

Purpose

The common disease hallux valgus results in foot discomfort and dysfunction. Less soft tissue damage and faster wound healing have made minimally invasive surgery (MIS) more popular. However, little research has compared the fixation results of minimally invasive chevron-akin (MICA) osteotomy thus far. In this study, the clinical and radiographic results of MICA with first metatarsal single- or dual-screw fixation are being examined.

Methods

A total of 107 feet of 103 patients with mild to moderate symptomatic hallux valgus treated MICA from January 2018 to June 2020 were retrospective evaluated, with at least 12-months follow-up. 51 patients underwent single-screw fixation procedures and 52 patients received dual-screw fixation procedures. Patients were assessed preoperatively and at the final follow-up with radiographic measurements [hallux valgus angle (HVA), intermetatarsal angle (IMA) and distal metatarsal articular angle (DMAA)] and clinical scores (american orthopaedic foot and ankle society (AOFAS) forefoot score, visual analog scale (VAS) and Manchester-Oxford Foot Questionnaire (MOxFQ) scores). The coughlin satisfaction scores were also obtained.

Results

Both groups showed significantly improved HVA, IMA and DMAA at the final follow-up (P < 0.001). Regarding clinical outcomes, the AOFAS, VAS and MOxFQ in two categories also significantly improved postoperatively (P < 0.001). There was no obvious difference in the clinical and radiographic outcomes between the two groups (HVA, P = 0.833; IMA, P = 0.073; DMAA, P = 0.35; AOFAS, P = 0.48; VAS, P = 0.86; MOxFQ, P = 0.87). However, the single-screw fixation group showed significantly lower operation time and less number of intraoperative fluoroscopy (P < 0.001). No serious complications were observed in either group. The single-screw fixation technique saves at least $1,086 compared with the dual-screw group.

Conclusion

At the final follow-up, both the single- and dual-screw fixation groups had comparable good to excellent clinical and radiographic outcomes, as well as a similar incidence of complications. Additionally, the single-screw fixation group reduces overall surgical costs, number of intraoperative fluoroscopy and operational time.

A cross-sectional study on reliability and quality of YouTube® videos related to hallux valgus and evaluation of newly developed hallux valgus-specific survey tool

Objective

Previous studies have reported low quality and reliability on YouTube videos about various medical issues including videos related to hallux valgus (HV) treatment. Therefore, we aimed to evaluate the reliability and quality of YouTube videos on HV and develop a new HV-specific survey tool that physicians, surgeons, and the medical industry can use to create high-quality videos.

Methods

Videos viewed over 10,000 times were included in the study. We used the Journal of the American Medical Association (JAMA) benchmark criteria, global quality score (GQS), DISCERN tool, and new HV-specific survey criteria (HVSSC) developed by us to evaluate the quality, educational utility and reliability of the videos, the popularity of which was assessed using the Video Power Index (VPI) and view ratio (VR).

Results

Fifty-two videos were included in this study. Fifteen videos (28.8%) were posted by medical companies producing surgical implants and orthopedic products, 20 (38.5%) by nonsurgical physicians, and 16 (30.8%) by surgeons. The HVSSC indicated that the quality, educational value, and reliability of only 5 (9.6%) videos were adequate. Videos posted by physicians and surgeons tended to be more popular (p = 0.047 and 0.043). Although no correlation was detected among the DISCERN, JAMA, and GQS scores, or between the VR and VPI, we found correlations of the HVSSC score with the number of views and the VR (p = 0.374 and p = 0.006, respectively). A good correlation was detected among the DISCERN, GQS, and HVSSC classifications (rho = 0.770, 0.853, and 0.831, respectively, p = 0.001).

Conclusions

The reliability of HV-related videos on YouTube is low for professionals and patients. The HVSSC can be used to evaluate the quality, educational value, and reliability of videos.

Association of Visual Appearance on Outcomes After Hallux Valgus Surgery

BACKGROUND

In this study, our aim was to determine the effect of cosmetic improvement on patient satisfaction and functional scores in hallux valgus (HV) surgery.

METHODS

Preoperative foot photographs of 105 patients who had undergone chevron osteotomy for HV between 2016 and 2018 were taken. The patients were divided into 2 groups. Twenty-four months after surgery, the preoperative foot photographs were shown to patients in group 1 (n = 52) but not to patients in group 2 (n = 53). The groups were then compared using the visual analog scale (VAS), the American Orthopaedic Foot & Ankle Society Hallux Metatarsophalangeal-Interphalangeal (AOFAS Hallux MTP-IP), and the 36-Item Short Form Health Survey (SF-36) scores. Both groups were evaluated radiologically with preoperative and postoperative hallux valgus angles and intermetatarsal angles.

RESULTS

There was no difference between the 2 groups in terms of radiologic parameters either pre- or postoperatively, or AOFAS Hallux MTP-IP scores postoperatively. However, for group 1, the VAS was lower (0.4±0.8 vs 1.8±1.6, P = .003) and both the SF-36 physical functioning (88.3±18.1 vs 79.1±23.2, P = .017) and SF-36 mental health scores were higher (78.8±19 vs 69.2±16.3, P = .022).

CONCLUSION

Visualizing improvement in the cosmetic appearance of the foot appears associated with patients' perception of subjective pain and functional improvement. We recommend that preoperative foot photographs be taken and recorded.

LEVEL OF EVIDENCE

Level III, case-control study.

Fifth metatarsal scarf osteotomy without implant fixation

Fifth metatarsal shaft osteotomy has demonstrated efficacy for bunionette. We adapted screwless 1st metatarsal scarf osteotomy to the 5th ray. The technique consists in short osteotomy, translation and diaphyseal bone-suture. We report the first 25 operated feet, with mean AOFAS score 58.4 preoperatively and 94.9 postoperatively at a mean 25 months' follow-up. These results were comparable to reported data, whatever the deformity.

Does screwless scarf osteotomy for hallux valgus increase the risk of transfer metatarsalgia?

INTRODUCTION

The scarf osteotomy is a reliable surgical technique for treating hallux valgus. The aim of our study was to analyze the occurrence of transfer metatarsalgia after surgery on the first ray using a screwless Scarf osteotomy technique that we have been using in our department since 1995, which consists of stabilization by axial impaction without internal fixation. We hypothesized that the alleged shortening of the first metatarsal produced by this technique may be at the origin of postoperative metatarsalgia.

PATIENTS AND METHODS

This was a case series of first ray metatarsal screwless Scarf osteotomies reviewed in the medium term. We did a clinical and radiological review of all patients operated using this technique between 2012 and 2017 who did not meet the following exclusion criteria: procedure on the other lateral metatarsals, concurrent hindfoot pathology, incomplete medical records.

RESULTS

Of 114 feet, 96 were included in the study and 18 were excluded. The mean follow-up was 1 year and 8 months [1-4years]. The mean AOFAS score was 90.3 and 96% of patients were either satisfied or very satisfied with the outcome. All the parameters improved significantly: shoe wearing, pain, function, alignment. Fourteen feet had transfer metatarsalgia, which appeared during the first year postoperative (AOFAS 75/100). Ten other complications occurred: two Morton's neuromas, three cases of complex regional pain syndrome, one superficial infection, one paresthesia, two recurrences with surgical revision, one nonunion. No general complications were found. Based on radiographs, the mean M1 shortening was 3.3mm (6.3mm in metatarsalgia group versus 3.0 mm in the non-metatarsalgia group, P=0.2) and the mean angular correction was 16.2° (±6°).

DISCUSSION

The overall results of screwless Scarf osteotomy are comparable and satisfactory, allowing large deformities to be corrected (28°±8° preoperatively in our cohort). M1 shortening and the transfer metatarsalgia rate appear to be higher than with other techniques.

CONCLUSION

Screwless scarf osteotomy of M1 yields good functional and radiological outcomes in the medium term. However, it appears to cause more shortening and transfer metatarsalgia.

LEVEL OF EVIDENCE

IV Retrospective, non-interventional in current practice (Recommendation grade C, low level of scientific proof).

Scarf Osteotomy for Correction of Hallux Valgus Deformity in Adolescents

Objective

To report the radiological and clinical outcomes of the modified scarf osteotomy for the treatment of hallux valgus deformity in adolescents.

Methods

This retrospective study analyzed 21 patients (31 feet) who underwent a modified scarf osteotomy for correcting juvenile hallux valgus deformity between March 2015 and January 2017. There were 3 male (3 feet) and 18 female (28 feet) patients. The average age at the time of surgery was 28.6 years (range, 20–35). Patients were postoperatively followed up in the outpatient department for 12–18 months. Clinical and radiological assessments were performed preoperatively and postoperatively at 1 year. Moreover, postoperative complications were recorded. Statistical analyses for differences between preoperative and postoperative values were performed.

Results

All the 21 patients were postoperatively followed up for 12–18 months, with an average of 13.2 ± 2.5 months. Clinical assessment showed that the American Orthopaedic Foot and Ankle Society score was increased from preoperative 58.0 ± 5.8 to postoperative 94.2 ± 6.6 points, respectively, and the visual analog scale score was remarkably decreased from preoperative 6.0 ± 2.0 to postoperative 1.5 ± 2.0 points at 1 year follow‐up. Further radiological assessment showed that the hallux valgus angle was 37.5° ± 9.2°, 14.1° ± 6.5°, and 14.5° ± 6.5° before surgery, half a year after surgery, and 1 year after surgery, respectively; the intermetatarsal angle was 14.1° ± 4.4°, 4.8° ± 3.2°, and 5.5° ± 4.9°, respectively; and the distal metatarsal articular angle was 31.0° ± 3.5°, 7.2° ± 2.3°, and 7.5° ± 2.1°, respectively. They were significantly improved at half a year after surgery and 1 year after surgery compared to those before surgery. Complications occurred in two patients (9.5%) who had numbness on the skin of the edge of the medial incision, and the symptoms were relieved after 10 months. There was no clinical recurrence in all patients. One of the 31 feet had hallux varus, which was corrected in a second operation. Notably, a postoperative radiograph of a typical case whose both feet had hallux valgus deformity and underwent modified scarf osteotomy and additional Akin osteotomy showed adequate correction of the hallux valgus angle (HVA, 11°), intermetatarsal angle (IMA, 6°), and distal metatarsal articular angle (DMAA, 8°) on left foot compared to preoperative HVA (28°), IMA (13°), and DMAA (35°).

Conclusion

The modified scarf osteotomy can effectively correct the adolescent hallux valgus deformity, which is worth popularizing.

Transfer of abductor hallucis tendon combined with scarf osteotomy versus single scarf osteotomy in moderate to severe hallux valgus deformity: a comparative retrospective cohort study

Background

Scarf osteotomy (SO) was broadly applied in moderate to severe hallux valgus (MSHV), and the results were satisfactory. However, due to the complicated pathologic changes in hallux valgus, the ideal surgical treatment is still controversial. Transfer of the abductor hallucis tendon combined with Scarf osteotomy (TAHTCSO) was an innovative alternative technique. This retrospective cohort study aimed to define if TAHTCSO mode resulted in improved outcomes as compared with the single SO in MSHV.

Methods

Of 73 patients (92 ft) with MSHV, 36 (45 ft) were treated through TAHTCSO and 37 ones (47 ft) through SO. The patients were assessed clinically and radiographically with a 24-month follow-up. They were assessed pre-operatively and post-operatively with intermetatarsal angle (IMA), hallux valgus angle (HVA), distal metatarsal articular angle (DMAA), first metatarsophalangeal joint range of motion (1#MTP ROM), as well as American Orthopaedic Foot and Ankle Society (AOFAS) forefoot scores and postoperative complications of surgery.

Results

Both cohorts had the same baseline feathures. All patients were followed up from 24 to 40 months, with a mean of 28.3 months. Patients in the TAHTCSO cohort had significantly decreased HVA at 6 months (p < 0.0001), 12 months (p < 0.0001), and 24 months (p < 0.0001) after surgery. 1#MTP had been increased slightly with non-statistic sense (p>0.05). IMA, DMAA and AOFAS also had not significantly difference at all followed time after surgery as compared with the SO cohort. The healing of osteotomies was observed within 8 weeks in the two cohorts. Two cases of hallus varus had been found in SO cohort and there were no cases of delayed healing and bone non-union in both cohorts.

Conclusion

In this retrospective cohort study, TAHTCSO had sufficient maintenance of the correction and improved functional performance thereby was a good alternative for MSHV, though it did not display a better result for MSHV compared to SO.

Cost-Utility Study of the Economics of Bunion Correction Surgery

BACKGROUND:

Bunion correction surgery is a very common procedure to improve patients' pain and physical function attributable to a misaligned first metatarsophalangeal joint. The objective of this study was to apply a health utility framework to estimate the cost utility of bunion correction surgery.

METHODS:

Patients were prospectively recruited from the population of patients seen in a lower-extremity orthopedic clinic and scheduled for isolated bunion surgery. Participants completed EuroQoL's EQ-5D(3L) to measure patients' current general health preoperatively and 6 months postoperatively. Participants' change in quality-adjusted life years (QALYs) were calculated by comparing the difference between postoperative utility values and preoperative utility values. The study had 95 patients representing 53% of eligible patients.

RESULTS:

The mean preoperative utility value was 0.6816 and the mean postoperative value was 0.7451, a statistically significant difference denoting an improvement in self-reported health. The cost per QALY, assuming gains in health accrued for 15 years, was $4911 (the 95% confidence interval ranged from $4736 to $5088). The cost per QALY was highest among the oldest patients. Assuming gains in health accrued for 20 years, the cost per QALY was $3922.

CONCLUSION:

This study demonstrated that bunion correction surgery was inexpensive relative to its gains in health compared with commonly applied thresholds for women and men in all age groups, though the gains were not uniformly distributed across age categories. Future research should examine the impact of recurrence on the robustness of these findings.

LEVEL OF EVIDENCE:

Level III, comparative study.

Results of Scarf Osteotomy Without Implant Fixation in the Treatment of Hallux Valgus

BACKGROUND

The main goal of the study was to evaluate the costs, clinical and radiologic results, and complications of hallux valgus surgery using scarf osteotomy, depending on the type of fixation (with or without screws).

METHODS

We evaluated 169 patients who underwent scarf osteotomy between January 2013 and August 2016. The patients were separated into 3 groups depending on the type of stabilization: A, 2 screws (50 patients); B, modified with 1 screw (55 patients); C, modified without implant (64 patients). We assessed duration of surgery, additional procedures, pre- and postoperative hallux valgus angle (HVA) and intermetatarsal angle (IMA) on anteroposterior and lateral foot weightbearing radiographs, the American Orthopaedic Foot & Ankle Society (AOFAS) hallux-metatarsophalangeal-interphalangeal scale for the clinical assessment preoperatively and at the 12-month follow-up. We recorded all the complications and compared the costs between the groups.

RESULTS

Both the average HVA (A: from 33.7 to 12.6 degrees, B: 35.0 to 13.2 degrees, C: 34.7 to 12.4 degrees) and IMA (A: from 14.9 to 7.5 degrees, B: 15.2 to 6.9 degrees, C: 15.5 to 7.8 degrees) decreased in all groups without significant intergroup differences. The average AOFAS score improved in all the groups (A: from 40 to 88 points, B: 38 to 89 points, C: 42 to 91 points). A similar complication rate was observed (A: 9%, B: 10%, C: 11%). In group C, we noted a shorter time of surgery, and the procedure was the most cost-effective.

CONCLUSION

Scarf osteotomy without implant stabilization was faster and cost-effective and gave comparable results. It was technically demanding and required patient compliance.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.