The Scarf Osteotomy with Minimally Invasive Lateral Release for Treatment of Hallux Valgus Deformity: Intermediate and Long-Term Results

Revision of Recurrent Hallux Valgus

Recurrence is a common complication after surgical correction of hallux valgus deformity. The reported incidence of recurrence after hallux valgus surgery has been shown to be as high as 64.7%. It has now received acceptance that a hallux valgus angle of more than 20° and an intermetatarsal angle of more than 10° should be classified as a recurrence. For the adequate correction, a number of different techniques need to be considered. According to the literature for more severe deformities, the arthrodesis of either the tarsometatarsal joint or the metatarsophalangeal joint seems to be the technique of choice.

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.

Prospective multicenter study assessing radiographic and patient outcomes following an instrumented mini-open triplanar tarsometatarsal arthrodesis with early weightbearing

This prospective, multicenter study assessed the radiographic, clinical, and patient-reported outcomes for hallux valgus (HV) correction performed with an instrumented 1st tarsometatarsal (TMT) system through a mini-open incision (≤4cm) with a biplanar plating construct and early return to weightbearing. One hundred and five patients were treated, with 75 and 11 patients completing their 12- and 24-month visits, respectively. The median (min, max) length of the primary dorsal incision was 3.5 cm (3.0, 4.0). Patients underwent an early weightbearing protocol with mean (95 % CI) of 7.9 (6.7, 9.1) days to weightbearing in a CAM boot. Significant improvements from baseline in mean radiographic measurements for Hallux Valgus Angle (HVA), Intermetatarsal Angle (IMA), Tibial Sesamoid Position (TSP), and osseous foot width (OFW) were maintained through 12 months. Using recurrence definitions of greater than 15° and 20° postoperative HVA, recurrence rates were 5.5 % (95 % CI: 1.5 %, 13.4 %) and 0.0 % at 12 months and 0.0 % for both thresholds at 24 months, respectively. Significant improvements in patient-reported outcomes [Visual Analog Scale (VAS), Manchester-Oxford Foot Questionnaire (MOxFQ) and Patient-Reported Outcomes Measurement Information System (PROMIS)] were maintained through 12 and 24 months. A clinically meaningful assessment of the scar appearance was observed in the POSAS scores. One (1.0 %) patient in the overall treated cohort of 105 required reoperation for removal of hardware due to pain. The results of this prospective, multicenter study on a mini-open 1st TMT system demonstrated improvements in radiographic correction, low recurrence, early return to activity with low complication rates, and improvements in patient-reported outcomes.

Subtalar arthroereisis for simultaneous treatment of flexible pes planus during surgical correction of hallux valgus

BACKGROUND

Scarf osteotomy is a well-established procedure for hallux valgus, yet recurrence rates range from 3.6% to 10%. Pes planus, which often coexisting with hallux valgus, is a risk factor for recurrence. This study aimed to evaluate the effectiveness of simultaneous correction of hallux valgus and flexible pes planus.

METHODS

A total of 85 feet with hallux valgus associated with adult flexible pes planus were retrospectively reviewed. All patients were treated with scarf osteotomy (SO). Subtalar arthroereisis using a HyProCure implant (SOH) was performed to correct hindfoot valgus based on shared decision-making. We collected and compared pre- and at least 2 year postoperative clinical outcomes (American Orthopaedic Foot & Ankle Society (AOFAS) forefoot, hindfoot score, Visual Analog Scale (VAS) pain intensity) and radiographic outcomes (hallux valgus angle (HVA), intermetatarsal angle (IMA), Meary's angle, talonavicular coverage angle (TNCA), and calcaneal pitch (CP) angle in both groups.

RESULTS

Of the cases reviewed, 51 feet were allocated to SO group, and 34 feet were in SOH group. Recurrence frequency was 5 feet (9.8%) in the SO group, while no recurrences were reported in the SOH group. There was no significant difference in AOFAS forefoot and VAS scores between the groups, However, the SOH group demonstrated significant improvement in AOFAS hindfoot scores and CP angle, as well as a greater reduction in Meary's angle and TNCA, compared to the SO group. Changes in HVA and IMA did not differ significantly between the groups. Three feet in the SOH group experienced sinus tarsi pain, which resolved after removal of the HyProCure implant.

CONCLUSIONS

Subtalar arthroereisis with a HyProCure implant is an effective treatment option for adult flexible pes planus associated with scarf osteotomy for hallux valgus, leading to a steady improvement in the patients forefoot deformity and increased patient satisfaction at least 2 years postoperatively.

Controversial Matters of Minimally Invasive Bunion Repair

New minimally invasive bunion surgery for hallux valgus (HV) has received attention in the last few years. A rapid growth in knowledge and techniques has been seen, with many publications, books, and experienced surgeons worldwide. Several variational advancements have emerged with the most common as a percutaneous subcapital osteotomy first metatarsal with long scaffolding minimally invasive (MI) screw placement. MI techniques are a great advancement in the treatment of all HV severities. Supportive literature has demonstrated that MI can achieve equal to better results compared to traditional open surgery, for metrics such as satisfaction, pain, and time to full recovery.

Sesamoid Bone Reduction in Hallux Valgus: Comparing Radiological Outcomes of Hallux Valgus Following Distal Chevron Osteotomy and Modified McBride Procedure

Background: Hallux valgus is a common forefoot disorder with hundreds of proposed management techniques. Distal chevron osteotomy with a modified McBride procedure has been traditionally recommended for mild hallux valgus because of its simple and less invasive nature with fewer complications, faster recovery, and reliable outcomes. In recent years, the indications for this procedure have expanded to include hallux valgus with severe deformities. This study aims to compare the radiographic outcomes of the surgical treatment for moderate versus severe hallux valgus patients from the perspective of sesamoid bone reduction. Materials and Methods: A retrospective review of medical records identified 99 feet from 94 patients that were treated with distal chevron osteotomy with a modified McBride procedure. These feet were divided by the preoperative hallux valgus angle and intermetatarsal angle into the moderate and severe groups. Results: Postoperative radiographic parameters significantly improved in both groups after treatment, indicating adequate deformity correction. Improvement in the sesamoid position was better in the moderate group compared to that in the severe group. The recurrence rate in the severe group was higher than that in the moderate group without statistical significance. Conclusions: Based on the radiographic results of the postoperative position following sesamoid reduction, the distal chevron osteotomy with a modified McBride procedure is effective for treating moderate hallux valgus deformities. However, this treatment strategy may be associated with a higher recurrence rate in cases of severe hallux valgus deformity. A complete reduction in the sesamoids should be emphasized during the management of severe hallux valgus deformity.

Patient-reported and radiological outcomes of short Scarf osteotomy fixed with a single screw: A prospective study of 271 osteotomies

The Scarf osteotomy involves inherent risks and technical challenges. The short scarf osteotomy with single screw fixation has emerged as an alternative approach. This study aims to evaluate the patient-reported outcome measures (PROMs), radiological outcomes, and complications associated with the short scarf osteotomy fixed with a single screw for hallux valgus correction. A prospective cohort study was conducted between October 2018 and October 2023 at a single center, encompassing 271 osteotomies. PROMs were collected prospectively preoperatively and at various postoperative intervals. Radiographic data, including hallux valgus angle (HVA) and intermetatarsal angle (IMA), were measured preoperatively and six weeks postoperatively. Complications were also documented. Statistically significant improvements were observed in all PROMs and were sustained up to 24 months postoperatively. The Visual Analog Scale (VAS) pain score demonstrated a significant reduction from 46.97 at baseline to 12.52 at 24 months (p < 0.001). Likewise, the EQ-5D score improved notably from 0.73 preoperatively to 0.81 at 24 months (p = 0.002). Analysis of the Manchester-Oxford Foot Questionnaire (MOXFQ) revealed substantial improvements across its pain, walking/standing, and social interaction domains over the same period, with all changes showing statistical significance (all p < 0.001). Radiographically, the mean HVA improved significantly from 31.33° preoperatively to 13.33° postoperatively (p < 0.001). Similarly, the mean IMA improved significantly from 14.67° to 7.66° (p < 0.001). The most common complication was superficial wound infection, effectively managed with oral antibiotics. The were no cases of avascular necrosis or fracture. In conclusion, the short Scarf osteotomy fixed with a single screw demonstrates favorable outcomes. These findings support its efficacy and safety as a treatment option, with potential advantages over the conventional technique. Further prospective studies are warranted to validate these findings.

Radiographic and Clinical Outcomes of First Tarsometatarsal Joint Arthrodesis With a Biplanar Locking Plate System Versus the Modified Lapidus Technique With Crossed-Screw Fixation: A Retrospective Multicenter Comparison

Background: Hallux valgus (HV) is recognized as a triplanar deformity. A biplanar locking plate (BLP) system corrects this deformity through first tarsometatarsal joint (TMTJ) arthrodesis, with specialized reduction tools and cutting guides. Yet the optimal surgical technique and fixation construct for first TMTJ arthrodesis remains controversial. Purpose: We sought to compare the BLP system with a modified Lapidus (ML) technique with crossed-screw fixation in terms of radiographic outcomes, complications, and reoperations. Methods: In this retrospective multicenter study, we identified a series of consecutive patients who underwent first TMTJ arthrodesis for HV with either the ML procedure at institution A or the BLP system at institution B. Patients 18 years of age with a minimum of 6 months of postoperative radiographs were included. There were 130 patients, 65 in each group, including 121 women (93.8%) with a median age of 58 years and mean radiographic follow-up of 7.1 months. Data included preoperative and postoperative HV angle (HVA), intermetatarsal angle (IMA), and tibial sesamoid position (TSP), plus complications and reoperations. Statistical testing included Mann-Whitney U, Wilcoxon signed rank, Fisher exact, McNemar, and multivariable regression. Results: After adjusting for confounding variables, the BLP system was associated with significantly greater improvements in postoperative IMA and HVA but not TSP. There were no significant differences in rates of complications (ML: 18.4%; BLP: 9.2%) or reoperations (ML: 4.6%; BLP: 7.7%). Conclusion: This retrospective multicenter review found that the BLP system was associated with greater improvement in radiographic HV parameters compared with the ML procedure using crossed-screw fixation. Clinical significance is unclear as complication and reoperation rates were similar between groups. Further study in this regard is warranted.

Effects of 4 weeks of foot exercise on subjective outcome and foot plantar pressure in elite adolescent dancers with hallux valgus: a pilot study

BACKGROUND

Dancers have a higher prevalence of hallux valgus (HV) than the general population. However, no reports specifically addressing treatment strategies for HV in dancers, or their effectiveness have been published. This study aimed to determine the effects of 4 weeks of foot exercises on subjective clinical outcomes, the HV angle, and change of foot plantar pressure during specific dance techniques.

METHODS

Thirteen female elite adolescent dancesport athletes (age: 16.4 ± 3.3 years) completed the program. The HV angle was measured based on foot photographs. Clinical assessments were performed using the visual analog scale for first metatarsophalangeal (1st MTP) joint pain, and the Foot and Ankle Outcome Score. The changes in plantar pressure during two dance techniques (demi-pointe and plié) were measured. The plantar pressure was measured in six areas of the foot. All of these parameters were compared before and after the intervention by using chi-square tests and Student's paired t-test (statistical significance: p < 0.05).

RESULTS

The HV angle was significantly reduced from 20.1° to 15.4° after the intervention. Participants reported an average subjective completion rate of 70.3% ± 14.6% over 3 weeks, exhibiting no significant differences despite an apparent trend toward improvement. Significant changes were noted in 1st MTP joint pain and subjective outcomes, and toe function significantly improved in the "paper" movement. The foot-exercise program changed plantar pressure distribution during the demi-pointe and plié techniques, with increased hallux pressure and decreased 2nd-5th MTP joint pressure.

CONCLUSIONS

In elite adolescent dancesport athletes, 4 weeks of foot-exercise rehabilitation reduced the HV angle and improved in subjective outcome and function during the two dance techniques. Coaches should consider utilizing foot-exercise training programs in a dancer training program for HV.

Developing Machine Learning-Based Predictive Models for Hallux Valgus Recurrence Based on Measurements From Radiographs

BACKGROUND

Machine learning (ML) is increasingly used to predict the prognosis of numerous diseases. This retrospective analysis aimed to develop a prediction model using ML algorithms and to identify predictors associated with the recurrence of hallux valgus (HV) following surgery.

METHODS

A total of 198 symptomatic feet that underwent chevron osteotomy combined with a distal soft tissue procedure were enrolled and analyzed from 2 independent medical centers. The feet were grouped according to nonrecurrence or recurrence based on 1-year follow-up outcomes. Preoperative weightbearing radiographs and immediate postoperative nonweightbearing radiographs were obtained for each HV foot. Radiographic measurements (eg, HV angle and intermetatarsal angle) were acquired and used for ML model training. A total of 9 commonly used ML models were trained on the data obtained from one institute (108 feet), and tested on the other data set from another independent institute (90 feet) for external validation. Optimal feature sets for each model were identified based on a 2000-resample bootstrap-based internal validation via an exhaustive search. The performance of each model was then tested on the external validation set. The area under the curve (AUC), classification accuracy, sensitivity, and specificity of each model were calculated to evaluate the performance of each model.

RESULTS

The support vector machine (SVM) model showed the highest predictive accuracy compared to other methods, with an AUC of 0.88 and an accuracy of 75.6%. Preoperative hallux valgus angle, tibial sesamoid position, postoperative intermetatarsal angle, and postoperative tibial sesamoid position were identified as the most selected features by several ML models.

CONCLUSION

ML classifiers such as SVM could predict the recurrence of HV (an HVA >20 degrees) at a 1-year follow-up while identifying associated predictors in a multivariate manner. This study holds the potential for foot and ankle surgeons to effectively identify individuals at higher risk of HV recurrence postsurgery.

Long-Term Results After Hallux Valgus Correction with Distal Metatarsal Reversed-L (ReveL) Osteotomy: Factors That Influence Recurrence and the Clinical Outcome

Background

This study aimed to evaluate the long-term results of hallux valgus correction with a distal metatarsal reversed-L (ReveL) osteotomy.

Methods

Eighty-eight patients (131 feet) were evaluated after a mean follow-up of 14.2 years (range, 10 to 18 years). Weight-bearing foot radiographs were analyzed preoperatively, at 6 weeks postoperatively, and at the final follow-up for the following parameters: hallux valgus angle (HVA), intermetatarsal angle (IMA), first metatarsophalangeal joint (MTPJ) congruence angle, sesamoid position, presence of the round sign, and first MTPJ arthritis. The visual analog scale (VAS) and the Foot and Ankle Outcome Score (FAOS) assessed postoperative pain and function. Univariate and multivariable logistic regression analyses identified risk factors for hallux valgus recurrence and an inferior clinical outcome.

Results

All radiographic parameters significantly improved at the 6-week follow-up and the final follow-up (p < 0.001). The recurrence rate (HVA >20°) was 14%. A preoperative HVA of >28° (odds ratio [OR], 9.1; p = 0.02) and a 6-week postoperative HVA of >15° (OR, 4.6; p = 0.03) were independent risk factors for recurrence. At the final follow-up, all FAOS subscales resembled high postoperative function (median, 100 points [range of the interquartile range (IQR), 81 to 100 points]). A preoperative body mass index of >30 kg/m2 was associated with lower FAOS quality of life (QOL) (p = 0.04), and postoperative hallux varus was associated with lower FAOS activities of daily living (p = 0.048). Patients with first MTPJ arthritis of grade 2 or higher at the final follow-up had significantly lower FAOS subscales (p < 0.01) except for QOL. Hallux valgus recurrence did not influence the long-term outcome. A symptomatic implant was the main cause of revision (15%). In 94% of cases, the patients were satisfied with the hallux appearance and, in 92% of cases, the patients were satisfied with postoperative pain reduction.

Conclusions

Hallux valgus correction with a ReveL osteotomy led to high long-term satisfaction rates. A preoperative HVA of >28° and a 6-week postoperative HVA of >15° increased the risk of hallux valgus recurrence. First MTPJ arthritis was the leading cause of inferior clinical results, whereas radiographic hallux valgus recurrence had no impact on the clinical results. First MTPJ arthritis at the final follow-up was associated with an inferior clinical outcome, whereas radiographic hallux valgus recurrence had no impact on the long-term clinical results.

Level of Evidence

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Similar outcomes following scarf-Akin osteotomy compared to scarf-alone osteotomy for the treatment of hallux valgus: A systematic review and meta-analysis

BACKGROUND

The purpose of this systematic review and meta-analysis was to compare the clinical and radiographic outcomes between patients undergoing scarf osteotomy and scarf-Akin osteotomy for the management of hallux valgus deformity.

METHODS

A systematic review of the MEDLINE, EMBASE and Cochrane Library databases was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies reporting clinical data following scarf osteotomy and scarf-Akin osteotomy for the treatment of hallux valgus were included and assessed. The level and quality of evidence of the included studies were also evaluated.

RESULTS

Four studies were included. In total, 388 patients (408 toes) underwent scarf osteotomy alone and 287 patients (295 toes) underwent scarf-Akin osteotomy for the treatment of hallux valgus deformity. There was no difference in postoperative American orthopedic foot and ankle society scores (p = 0.7828), visual analog scale scores (p = 0.4558), hallux valgus angle (p = 0.5116), intermetatarsal angle (p = 0.4830), proximal to distal phalangeal articular angle (p = 0.2411) between the scarf alone cohort and the scarf-Akin cohort. Similarly, there was no difference in complication rates (p = 0.6881) nor secondary surgical procedure rates (p = 0.3678) between the 2 cohorts. Finally, there was a higher recurrence rate in the scarf-alone cohort (11.4%) compared to the scarf-Akin cohort (5.7%), but this was not statistically significant (p = 0.4414).

CONCLUSION

This systematic review demonstrates lower recurrence rates following scarf-Akin osteotomy compared to scarf osteotomy alone for the treatment of hallux valgus deformity. No difference in complication rates were noted between the 2 cohorts. Our review demonstrates that both the scarf osteotomy and the scarf-Akin osteotomy may be effective and safe procedures, however, the scarf-Akin osteotomy may provide more long-term benefit in the setting of moderate to severe hallux valgus.

Preoperative Degenerative Changes at the Tibial Sesamoid-Metatarsal Joint in Hallux Valgus: Association With Postoperative Patient-Reported Outcomes After Modified Lapidus Procedure

Background

Degenerative changes at the sesamoid-metatarsal joints (SMJs) may be a source of pain following hallux valgus surgery. The aims of this study were to describe degenerative changes at the SMJs on weightbearing computed tomography (WBCT) scans and, secondarily, investigate their association with 1-year patient-reported outcome scores following a modified Lapidus procedure for hallux valgus. We hypothesized that reduced joint space in the SMJs would correlate with worse patient-reported outcomes.

Methods

Fifty-seven hallux valgus patients who underwent a modified Lapidus procedure had preoperative and minimum 5-month postoperative WBCT scans, and preoperative and at least 1-year postoperative PROMIS physical function (PF), pain interference, and pain intensity scores were included. Degenerative changes at the SMJs were measured using distance mapping between the sesamoids and first metatarsal head on preoperative and postoperative WBCT scans. The minimum and average distances between the first metatarsal head and tibial sesamoid (tibial-SMJ) for each patient preoperatively and postoperatively were measured. Sesamoid station was measured on WBCT scans using a 0 to 3 grading system. Linear regression was used to investigate the correlations between minimum preoperative and postoperative tibial-SMJ distances and 1-year postoperative PROMIS scores.

Results

The median minimum and average tibial-SMJ distances increased from 0.82 mm (interquartile range [IQR] 0.40-1.03 mm) and 1.62 mm (IQR 1.37-1.75 mm) preoperative to 1.09 mm (IQR 0.96-1.23 mm) and 1.73 mm (IQR 1.60-1.91 mm) postoperative (P < .001 and P < .001), respectively. In a subset of patients with complete sesamoid reduction, we found an association between preoperative minimum tibial-SMJ distance and 1-year postoperative PROMIS PF scores (coefficient 7.2, P = .02).

Conclusion

Following the modified Lapidus procedure, there was a statistically significant increase in the tibial-SMJ distance. Additionally, in patients with reduced sesamoids postoperatively, reduced preoperative tibial-SMJ distance correlated with worse PROMIS PF scores.

Level of Evidence

Level IV, case series.

A Cadaveric Study Verifying the Potential of a Rotational Biplanar Chevron Osteotomy to Correct the 3-Dimensional Hallux Valgus Deformity

INTRODUCTION

Metatarsal pronation is present in 87% of patients with hallux valgus (HV) deformity. The chevron osteotomy is commonly used worldwide to correct mild to moderate HV deformities. Many modifications have been described, but few address the rotational deformity of the first metatarsal. The rotational biplanar chevron osteotomy (RBCO), described by M. Prado et al, presents a variation of a biplanar chevron osteotomy that can be used to address first metatarsal rotation. The objective of this study is to investigate and verify the technique of the RBCO.

METHODS

We conducted our study performing an RBCO on 9 cadaveric limbs. The technique uses a medial-based wedge parallel to the plantar limb of the osteotomy to make the distal fragment free to correct rotation. A goniometer was used by 2 individual surgeons to control the rotational correction achieved.

RESULTS

The osteotomy was considered simple to perform and we experienced no complications, such as fractures or instability. The result was satisfactory alignment and adequate stability. On average, a 2 mm wedge resulted in 11° of rotational correction.

CONCLUSION

We predict that RBCO can safely be used for correcting the metatarsal rotation when necessary in mild to moderate HV deformity foot.

LEVELS OF EVIDENCE

Level IV.

A Radiologic Triangle Sign for Percutaneous Adductor Tendon Release (PATR): Cadaveric Study and Case Series

Background

Combining osteotomies and soft tissue procedures is believed to reduce sesamoids in their anatomical position and maintain long-term correction when treating hallux valgus deformity. This study determines if a radiologic association exists between a radiolucent sign and a full percutaneous adductor tendon release (PATR), including a cadaveric study and a consecutive case series. Another aim was to determine the intra- and interobserver reliability of these observations.

Methods

A prospective observational study was made between 2018 and 2019. First, a PATR was done on cadaveric specimens and, after the procedures, dissected to correlate what was seen fluoroscopically. The clinical group included 39 feet that presented mild-to-moderate HV deformity and were treated with percutaneous osteotomies associated with PATR.

Results

Observers 1 and 2 saw a radioscopic radiolucent sign in 100% of cadavers and the patient population. They also observed a triangle-shaped image with an incidence of 75%, which we have named the "triangle sign."

Conclusion

The triangle sign may be helpful in the intraoperative confirmation of PATR and latero-plantar capsule release using this percutaneous technique.

Level of Evidence

Level II, development of diagnostic criteria.

Republication of "Proximal Rotational Metatarsal Osteotomy for Hallux Valgus (PROMO): Short-term Prospective Case Series With a Novel Technique and Topic Review"

Background

Hallux valgus deformity consists of a lateral deviation of the great toe, metatarsus varus, and pronation of the first metatarsal. Most osteotomies only correct varus, but not the pronation of the metatarsal. Persistent postoperative pronation has been shown to increase deformity recurrence and have worse functional outcomes. The proximal rotational metatarsal osteotomy (PROMO) technique reliably corrects pronation and varus through a stable osteotomy, avoiding fusing any healthy joints. The objective of this research is to show a prospective series of the PROMO technique.

Methods

Twenty-five patients (30 feet) were operated with the PROMO technique. The sample included 22 women and 3 men, average age 46 years (range 22-59), for a mean prospective follow-up of 1 year (range 9-14 months). Inclusion criteria included symptomatic hallux valgus deformities, absence of severe joint arthritis, or inflammatory arthropathies, with a metatarsal malrotation of 10 degrees or more, with no tarsometatarsal subluxation or arthritis on the anteroposterior or lateral foot radiograph views. The mean preoperative and postoperative Lower Extremity Functional Scale (LEFS) score, metatarsophalangeal angle, intermetatarsal angle, metatarsal malrotation, complications, satisfaction, and recurrence were recorded.

Results

The mean preoperative and postoperative LEFS scores were 56 and 73. The median pre-/postoperative metatarsophalangeal angle was 32.5/4 degrees and the intermetatarsal angle 15.5/5 degrees. The metatarsal rotation was satisfactorily corrected in 24 of 25 patients. An Akin osteotomy was needed in 27 of 30 feet. All patients were satisfied with the surgery, and no recurrence or complications were found.

Conclusions

PROMO is a reliable technique, with good short-term results in terms of angular correction, satisfaction, and recurrence. Long-term studies are needed to determine if a lower hallux recurrence rate occurs with the correction of metatarsal rotation in comparison with conventional osteotomies.

Level of evidence

IV, prospective case series.

Recurrence Rates With Longer-Term Follow-up After Hallux Valgus Surgical Treatment With Distal Metatarsal Osteotomies: A Systematic Review and Meta-analysis

BACKGROUND

Recurrence of hallux valgus (HV) following corrective surgery is a frequent concern. A recent systematic review estimated recurrence of HV in only 4.9%, which may be an underestimation, as most included studies had short- to mid-term follow-up. The purpose of this systematic review and meta-analysis was to assess long-term outcomes of distal osteotomies of the first metatarsal (M1) to treat HV without inflammatory disease or degenerative arthritis, and to assess HV recurrence rates reported in studies that had a minimum follow-up of 5 years.

METHODS

This systematic review conforms to the PRISMA guidelines. The authors conducted a search using PubMed, Embase, and Cochrane Central Register of Controlled Trials databases. Studies that report outcomes of distal osteotomies of the M1 for noninflammatory and nondegenerative HV at a minimum follow-up of 5 years.

RESULTS

We found 17 eligible studies comprising 18 data sets, reporting outcomes of 4 categories of osteotomies: Chevron, Mitchell, Bösch, and "others." The HV recurrence rate was 64% considering the threshold of >15 degrees hallux valgus angle (HVA), 10% having >20 degrees, and 5% having >25 degrees.

CONCLUSION

At a minimum of 5 years following distal osteotomies of the M1, the mean weighted postoperative HVA was significantly higher for Mitchell osteotomies compared with the 3 other osteotomies reviewed. There were otherwise no significant differences in recurrence rates using the 3 HVA thresholds, or intermetatarsal angle among any of the surgical techniques reported in 2 or more studies. The pooled HV recurrence rates considering the various thresholds of HVA were as follows: 64% having >15 degrees, 10% having >20 degrees, and 5% having >25 degrees. The recurrence rates in the long term for all categories of surgical procedures suggest that better understanding of pathogenesis and prognosis of HV is required before modifying or introducing new surgical techniques.

LEVEL OF EVIDENCE

Level IV, meta-analysis.

First Tarsometatarsal Joint Fusion for Hallux Valgus Deformity: A Retrospective Comparison of Two Fixation Constructs Regarding Initial Maintenance of Correction and Complications: Traditional Crossing Screw Fixation Versus Dorsomedial Locking Plate and Intercuneiform Compression Screw

Various fixation constructs exist to address hallux valgus when performing a first tarsometatarsal joint arthrodesis. The goal of this present study is to compare complication rates, and degree and maintenance of angular correction between a dorsomedial locking plate with intercuneiform compression screw construct versus traditional crossing solid screw fixation construct. The plate plus intercuneiform compression screw construct fixation utilized a combined sagittal saw and curette method of joint preparation while the crossed screw fixation group utilized a curette and bur technique. A retrospective review was conducted of consecutive patients who underwent a midfoot fusion using either constructs. Sixty four total feet in 56 patients were enrolled in the study. Twenty four consecutive patients (32 feet) who underwent a midfoot arthrodesis using the locking plate and intercuneiform fixation were fully fused (100%) by 10 weeks postoperatively, with no incidents of nonunion and one deep vein thrombosis event. Thirty two consecutive patients (32 feet) who underwent midfoot arthrodesis with crossing screw fixation had 2 nonunion events, one that was asymptomatic and the other that required a revision midfoot fusion. There was a statistically significant improvement from the pre-operative intermetatarsal angle, hallux abductus angle compared to the 10 week and 1 year radiographs (p < .05) for the entire cohort for both fixation constructs. There was a statistically significant increase in American College of Foot and Ankle Surgery first ray scores from pre-op to 1 year follow-up for both fixation constructs. Overall, the dorsomedial locking plate plus intercuneiform compression screw fixation construct better maintains Intermetatarsal angle (IMA) correction at midterm follow-up compared to the traditional crossing screw construct. Both cohorts overall demonstrate similar fusion rates at 10 weeks, nonunion events, incidences of broken hardware, hardware removal, deep vein thrombosis, neuritis at 1 year postoperatively, and hallux varus.

Five-Year Follow-up of Third-Generation Percutaneous Chevron and Akin Osteotomies (PECA) for Hallux Valgus

BACKGROUND

Recent large studies of third-generation minimally invasive hallux valgus surgery (MIS) have demonstrated significant improvement in clinical and radiologic outcomes. It remains unknown whether these clinical and radiologic outcomes are maintained in the medium to long term. The aim of this study was to investigate the minimum 5-year clinical and radiologic outcomes following third-generation MIS hallux valgus surgery in the hands of a high-volume MIS surgeon.

METHODS

A retrospective observational single highly experienced MIS surgeon case series of consecutive patients undergoing primary isolated third-generation percutaneous chevron and Akin osteotomies (PECA) for hallux valgus with a minimum 60-month clinical and radiographic follow-up. Primary outcome was radiographic assessment of the hallux valgus angle (HVA) and intermetatarsal angle (IMA) preoperatively, 6 months, and ≥60 months following PECA. Secondary outcomes included the Manchester-Oxford Foot Questionnaire, patient satisfaction, EuroQol-5D visual analog scale and the visual analog scale for pain.

RESULTS

Between 2012 and 2014, 126 consecutive feet underwent isolated third-generation PECA, with complete data available for 78 (61.9%) feet. The median follow-up was 65.0 (IQR 64-69; range 60-88) months. There was a significant improvement in radiographic deformity correction; the median IMA improved from 12.0 degrees (interquartile range [IQR]: 10.8-14.2) to 6.0 degrees (IQR: 4.2-7.3) (P < .001), and the median HVA improved from 27.2 degrees (IQR: 20.6-34.4) to 7.2 degrees (IQR: 3.4-11.6). Median MOXFQ Index score at ≥60-month follow-up was 2.3 (IQR: 0.0-7.8). The radiographic recurrence rate (defined as HVA >15 degrees) was 7.7% at final follow-up. The complication rate was 4.8%.

CONCLUSION

Radiologic deformity correction for the 78 feet we were able to follow that had third-generation PECA performed by a single highly experienced MIS surgeon was found to be maintained at a mean follow-up of average 66.8 months, with a radiographic recurrence rate of 7.7%. Clinical PROMs and patient satisfaction levels were high and comparable to other third-generation studies with shorter duration of follow-up.

LEVEL OF EVIDENCE

Level IV, retrospective cohort study.

Modified scarf osteotomy for hallux valgus: From a finite element model to clinical results

PURPOSE

Finite element (FE) analysis and clinical follow-up were used to evaluate the efficacy of modified scarf osteotomy for moderate-to-severe hallux valgus (HV).

METHOD

We retrospectively evaluated 42 patients (44 feet) who underwent modified rotational scarf osteotomy for moderate-to-severe HV at our institution between January 2010 and January 2019. Radiological indicators and subjective scores were recorded at different time points. To compare the results and elemental characteristics, a FE model of the metatarsophalangeal (MTP) joint that included anatomically realistic geometrical and structural characteristics was built. The biomechanical features and correction differences in dynamic loads as well as the incidence of troughing were estimated.

RESULTS

Both the hallux valgus angle (HVA) and intermetatarsal angle (IMA) showed significant improvement 6 weeks postoperatively (p < 0.05); additionally, the HVA increased from 6 weeks postoperatively to the last follow-up, while the IMA showed no significant changes (p > 0.05). The subjective scores significantly improved from the preoperative period to the last follow-up. The percentages of troughing and recurrence were remarkably low in our pilot study because of the innate stability of the modified rotated fixation.

CONCLUSION

Our preliminary findings suggest that modified rotational scarf osteotomy offers sufficient stability, correct HV deformity effectively, and good clinical outcomes for moderate to severe HV.

Short- and long-term results for severe hallux valgus correction using a first metatarsal distal osteotomy

PURPOSE

The purpose of this study is to analyze the short- and long-term results of severe hallux valgus (HV) treated with a L-Reverse osteotomy.

METHODS

Patients treated with L-Reverse osteotomy for severe HV between the years 2006-2015 were included. Patients were evaluated preoperatively, at 3 months and 4 or more years postoperatively. Changes in the HV angle (HVA) and intermetatarsal angle (IMA) were measured. Clinical outcomes were assessed using the AOFAS score.

RESULTS

28 patients were included. Pre-operative IMA changed from 18.1° (18-18.9°) to 7° (6.3-8.5°), and HVA from 38.5° (34.5-41.3°) to 10.0° (8.4-11.8°) at 3 month follow up (p < 0.005). Long term follow up was of 5.6 (4.9-6.4) years. IMA value was 7.5° (6.1°-8.1°) and HVA was 10.1° (6.7°-16.3°), with no statistical difference with initial correction (p = 0.14). Median AOFAS score was 92.7 (89-4-96.1).

CONCLUSION

L-Reverse osteotomy can achieve correction of HV severe deformities with good outcomes in long term follow up.

LEVEL OF EVIDENCE

III.

The Incidence of Complications Following Scarf Osteotomy for the Treatment of Hallux Valgus: A Systematic Review with Meta-Analysis

The Scarf osteotomy is a surgical procedure performed to correct a hallux valgus deformity. Multiple studies have supported use of the procedure with favorable outcomes. In contrast, there have been studies showing a significant complication rate with the procedure. Incidence of complications remains underreported in the literature. We performed a systemic review and meta-analysis examining a wide range of reported complications and associated clinical outcomes from the Scarf osteotomy. One hundred and sixteen publications were identified and 25 (21.6%) met our inclusion criteria. A total of 1583 Scarf procedures were included. Weighted mean follow-up was 26.4 months [range 12-168 months]. We found a 5.1% rate of recurrence, 3.5% rate of troughing, 1.0% rate of avascular necrosis, 1.8% rate of nonunion, 2.7% rate of malunion, 2.4% rate of infection, 5.3% rate of complex regional pain syndrome, and 3.4% rate of hallux varus. An average decrease in intermetatarsal angle of 6.3° was observed. No statistical difference was found in outcomes when comparing Scarf versus Scarf with additional procedure performed at time of surgery. To our knowledge, this systematic review and meta-analysis contains the highest number of Scarf procedures analyzed and presents complication rates on multiple adverse outcomes.

Development of a preoperative questionnaire to improve satisfaction with hallux valgus repair: A Delphi study

BACKGROUND

Satisfaction with hallux valgus repair is often poor, despite good surgical outcomes. Many tools have been developed to assess the outcome of the procedure; however none evaluate the association between the initial motive for repair and the reasons for post-surgical dissatisfaction. The aim of this study was to develop a new tool to analyse the subjective and objective expectations of individuals during a pre-operative consultation for hallux valgus repair in order to improve post-surgical satisfaction.

METHODS

We first collected the reasons for dissatisfaction with repair from the medical files of dissatisfied individuals. Then, a steering committee of 4 French experts in the management of hallux valgus designed a questionnaire based on the reasons for dissatisfaction. We then used the DELPHI method to validate the questionnaire: we submitted the questionnaire to a panel of 34 francophone experts in hallux valgus repair for rating in 4 rounds.

RESULTS

The medical files of 853 individuals were reviewed and a 52-item questionnaire relating to expectations from hallux valgus surgery was drafted. After the 4 rounds, a final 44 item questionnaire reached consensus. Thirteen items related to clinical and psychological profile, 5 to pain, 9 to physical activity, 4 to aesthetics and 13 to footwear.

CONCLUSION

This tool should facilitate gathering of individuals' expectations from hallux valgus repair to ensure realistic goals and reduce post-surgical dissatisfaction.

Effect of the Reversed L-Shaped Osteotomy on the Round Sign: Not All Hallux Valgus Deformities May Need Proximal Derotation to Correct the Radiographic Appearance of Metatarsal Pronation

Background

Metatarsal pronation has been claimed to be a risk factor for hallux valgus recurrence. A rounded shape of the lateral aspect of the first metatarsal head has been identified as a sign of persistent metatarsal pronation after hallux valgus correction. This study investigated the derotational effect of a reversed L-shaped (ReveL) osteotomy combined with a lateral release to correct metatarsal pronation. The primary hypothesis was that most cases showing a positive round sign are corrected by rebalancing the metatarsal-sesamoid complex. We further assumed that the inability to correct the round sign might be a risk factor for hallux valgus recurrence.

Methods

We retrospectively evaluated 266 cases treated with a ReveL osteotomy for hallux valgus deformity. The radiologic measurements were performed on weightbearing foot radiographs preoperatively, at an early follow-up (median, 6.2 weeks), and the most recent follow-up (median, 13 months). Univariate and multivariate logistic regression analyses identified risk factors for hallux valgus recurrence (hallux valgus angle [HVA] ≥ 20 degrees).

Results

A preoperative positive radiographic round sign was present in 40.2% of the cases, of which 58.9% turned negative after the ReveL osteotomy (P < .001). Hallux valgus recurred in 8.6%. Risk factors for recurrence were a preoperative HVA >30 degrees (odds ratio [OR] = 5.3, P < .001), metatarsus adductus (OR = 4.0, P = .004), preoperative positive round sign (OR = 3.3, P = .02), postoperative HVA >15 degrees (OR = 74.9; P < .001), and postoperative positive round sign (OR = 5.3, P = .008). Cases with a positive round sign at the most recent follow-up had a significantly higher recurrence rate than those with a negative round sign (22.7% vs 5.9%, P < .001).

Conclusion

The ReveL osteotomy corrected a positive round sign in 58.9%, suggesting that not all hallux valgus deformities may need proximal derotation to negate the radiographic appearance of the round sign. A positive round sign was found to be an independent risk factor for hallux valgus recurrence. Further 3-dimensional analyses are necessary to better understand the effects and limitations of distal translational osteotomies to correct metatarsal pronation.

Level of Evidence

Level IV, case series.

Correlation of Loss of Correction With Postoperative Radiological Factors After Distal Chevron Osteotomy in Dependence of Concomitant Akin Osteotomy

Loss of correction is frequently observed following hallux valgus correction and is associated with recurrence of a hallux valgus deformity. The purpose of this study was to correlate loss of correction and radiological parameters following distal chevron (Group C) and combined chevron/akin (Group AC) osteotomy. A total of 859 feet were included for analysis and grouped according to treatment with a distal chevron osteotomy alone or a combined chevron/akin osteotomy. Radiographs were evaluated preoperatively, postoperatively, after 6 weeks, 3 months and, if available, at long term follow-up with a mean of 34.2 (range 7.5-155.3) months. With the exception of the proximal to distal phalangeal articular angle (PDPAA), preoperative deformity was comparable between both groups. Significant correction of all examined parameters (p < .001) was seen. Loss of correction at 6 weeks with minor deterioration until follow-up was also detected, with group AC somewhat better than Group C. A strong correlation with loss of correction was found for the postoperative hallux valgus angle (HVA) (p < .002), intermetatarsal angle (IMA) (p < .001), distal metatarsal articular angle (DMAA) (p < .002), positioning of the sesamoids (p < .002) and joint congruity (p < .035) in Group C and for the DMAA (p < .033) and HVA (p < .046) in Group AC. Multiple postoperative radiological parameters correlated with loss of correction following distal chevron osteotomy. In Group AC only postoperative HVA and DMAA determined loss of correction. Correction of the deformity in Group AC showed greater stability.

The use of intramedullary devices for fixation of metatarsal osteotomies in hallux valgus surgery - A systematic review

BACKGROUND

Hallux valgus is a common foot condition with numerous surgical techniques described. Minimally invasive surgery is becoming more popular, with resultant development of suitable fixation devices. The aim of this systematic review was to evaluate the evidence on the use of intramedullary devices in hallux valgus first metatarsal corrective osteotomies, and describe clinical and radiological outcomes, with an overview of techniques and implants used.

METHODS

We searched PubMed, Medline, Embase and EMCare databases, conforming to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Radiological outcomes including the hallux valgus angle (HVA) and intermetatarsal angle (IMA) were recorded, as well as clinical outcome scores and complications. Methodological quality of included studies was assessed using the MINORS score.

RESULTS

Ten studies were included, comprising 696 feet in 745 patients. Data pooling and metanalysis was not possible due to overall low quality of evidence. Four implants were reported (Endolog, ISO Plate, V-Tek Plate, Link Fixator) and used with distal first metatarsal osteotomies, with improvement in HVA, IMA, and clinical outcome scores comparable to other fixation techniques. There were no reported cases of non-union. Complication rates were variable (all cause range of 0-21%) across all studies, with an overall low rate.

CONCLUSION

Intramedullary devices are viable and safe to use for hallux valgus first metatarsal osteotomies, with comparable radiological and functional outcomes to other techniques. Current evidence base is of low methodological quality, therefore high quality studies are required to further evaluate these devices.

Effectiveness of hallux valgus surgery on improving health-related quality of life: A follow up study

BACKGROUND

Hallux valgus (HV) negatively impacts health-related quality of life (HRQoL). Patientreported outcome measures (PROMs) are increasingly used in clinical studies of the foot and ankle. We aimed to evaluate the effect of HV surgery on PROMs (i.e., pain scales, general HRQoL, and region-specific scales) and radiological angles. Additionally, we aimed to determine whether the effect on these outcomes depends on the type of surgery (including open and percutaneous techniques) and if it is influenced by potential confounding factors (i.e., age, HVA, 1-2 IMA, body mass index (BMI), and distal metatarsal articular angle (DMAA).

METHODS

This was a longitudinal prospective study. We collected the clinical data of all patients who underwent surgery for symptomatic HV deformity in the orthopedic department of the Virgen de la Luz Hospital of Cuenca (Spain).The clinical outcomes were assessed using the American Orthopedic Foot and Ankle Society (AOFAS) Hallux metatarsophalangeal-interphalangeal (HMI) scale, visual analogue scale (VAS), Manchester Oxford foot questionnaire (MOXFQ), short form health survey (SF-12) and European Quality of Life-5 Dimensions (EQ-5D).

RESULTS

A total of 72 patients (70 women, 97.2%) were included in the study 72 (72 feet).The AOFAS pre-post-surgery score changed from 42.16 (SD: 10.11) to 83.31 (SD: 6.23). Considering AOFAS domains, the pre-post change was from 14.17 (SD: 9.15) to 33.19 (SD: 4.69) for pain, from 27.22 (SD: 3.90) to 37.94 (SD: 2.78) for function, and from 0.78 (SD: 2.38) to 12.18 (SD: 3.45) for alignment. For other clinical outcomes was VAS score from 5.01(SD: 1.26) to 1.26 (SD: 0.96) and MOXFQ score from 61.44 (SD: 7.09) to 12.35 (SD: 4.85). SF-12 (physical) changed from 36.26 (SD: 5.32) to 47.06 (SD: 4.82), SF-12 (mental) from 38.23 (SD: 8.04) to 46.49 (SD: 4.16), and EQ5-D from 0.64 (SD: 0.008) to 0.90 (SD: 0.10).

CONCLUSIONS

Our data confirmed the improvements in the clinical and radiological outcomes after HV surgery, and provided some evidence of these improvements not depending on the type of surgery or on some potential confounding factors such as BMI, HVA, 1-2 IMA, and DMAA.

Managing Complications of Foot and Ankle Surgery: Hallux Valgus

Hallux valgus deformity is nowadays one of the most common and symptomatic disorders affecting the foot. Surgical corrections of hallux valgus deformity are among the most common orthopedic procedures. Despite the general high success rate complications can occur. The treatment of complications start before the first incision has been performed by thorough preoperative planning and choice of the right procedure. Once the complication is evident, thorough planning is necessary to address the patient's individual needs. In this paper the treatment of recurrent hallux valgus, hallux varus, malunion, and avascular necrosis are discussed.

Imaging Findings and First Metatarsal Rotation in Hallux Valgus

BACKGROUND

Failure to identify and correct malrotation of the first metatarsal may lead to recurrent hallux valgus deformity. We aimed to identify the proportion of hallux valgus patients with increased first metatarsal pronation using weightbearing computed tomography (WBCT) and to identify the relationship with conventional radiographic measurements.

METHODS

WBCT scans were analyzed for 102 feet with a hallux valgus angle (HVA) and intermetatarsal angle (IMA) greater than or equal to 16 and 9 degrees, respectively. Metatarsal pronation angle (MPA), alpha angle, sesamoid rotation angle (SRA), and sesamoid position were measured on standardized coronal WBCT slices. Pronation was recorded as positive. Hindfoot alignment angle (HAA) was assessed using dedicated software. Pearson correlation and multiple regression analyses were used to assess differences between groups.

RESULTS

Mean HVA was 29.8±9.4 degrees and mean IMA was 14.1±3.7 degrees. Mean MPA was 11.9±5.8 (range 0-26) degrees and mean alpha angle was 11.9±6.8 (range -3 to 29) degrees. In a previous study, we demonstrated the upper limit of normal MPA as 16 degrees and alpha angle as 18 degrees. Based on these criteria, we identified abnormal metatarsal pronation in 32 feet (31.4%). We found a strong positive correlation between SRA and HVA/IMA (R = 0.67/0.60, respectively, P < .001). IMA and HAA weakly correlated with MPA and alpha angle (IMA: R = 0.26/0.27, respectively, P < .01; HAA: R = 0.26/0.27, respectively, P < .01). Regression analyses suggested that increasing IMA was the most significant radiographic predictor of increased pronation. In this cohort, there was no correlation between HVA or sesamoid position and MPA / alpha angle (HVA: P = .36/.12, respectively, sesamoid position, P = .86/.77, respectively).

CONCLUSION

In this cohort of 102 feet that met plain radiographic criteria for hallux valgus deformity, first metatarsal pronation was found abnormal in 31.4% of patients. We found a weak association between the IMA and hindfoot valgus, but not the HVA.

The Correction Potential of the Lateral Release of the Hallux Valgus: A Comparative Anatomical Study of Minimally Invasive Versus Open Surgical Technique Using a Dorsal Approach

Background

Lateral release (LR) is an integral part of surgical correction of hallux valgus. A comparison was made between the open and minimally invasive LR techniques using a dorsal approach. The reliability and safety of the two methods were compared. Besides, the release of specific structures was investigated with special emphasis on ascertaining if the release was partial or a total one.

Methods

In this study on cadavers, LR was performed on nine pairs of foot and ankle specimens. The group assignments were randomized for each case. The operations were followed by anatomical preparation, data collection, photo documentation, and statistical analysis.

Results

A statistically significant advantage was observed with the open dorsal approach as there was a complete release of the adductor hallucis muscle from the lateral sesamoid and the lateral metatarsosesamoid ligament (p = 0.015 in each case). In terms of releasing the adductor hallucis muscle from the proximal phalanx, the lateral joint capsule, and the lateral collateral ligament, none of the investigated procedures showed better performance. However, open dorsal access tends to show a higher degree of release more frequently.

Conclusions

Splitting of the lateral joint capsule, including the lateral collateral ligament and lateral metatarsosesamoid ligament via the dorsal approach can be performed reliably and completely using the open surgical technique. The open dorsal technique shows better rates of detachment when the adductor hallucis muscle is released from the lateral sesamoid. Both techniques resulted in incomplete release of the adductor hallucis muscle from the proximal phalanx.

Study Type

Therapeutic-investigating the results of a treatment.

Level of Evidence

II (Prospective cohort study).

Supplementary Information

The online version contains supplementary material available at 10.1007/s43465-021-00575-3.

Third-Generation Minimally Invasive Chevron-Akin Osteotomy for Hallux Valgus Produces Similar Clinical and Radiological Outcomes as Scarf-Akin Osteotomy at 2 Years: A Matched Cohort Study

BACKGROUND

The minimally invasive chevron-Akin (MICA) osteotomy is an increasingly popular technique for the correction of hallux valgus. However, there is a paucity of literature comparing it with traditional open techniques. The purpose of this study was to compare the clinical and radiological outcomes of the MICA osteotomy using a new-generation MICA screw and scarf-Akin osteotomy for hallux valgus correction.

METHODS

Thirty cases of MICA osteotomy were propensity score matched 1:1 with a control group of 30 scarf-Akin osteotomy cases. The groups were matched for age, sex, body mass index, preoperative visual analog scale (VAS) score, American Orthopaedic Foot & Ankle Society (AOFAS) metatarsophalangeal-interphalangeal (MTP-IP) score, 36-Item Short-Form Health Survey (SF-36) physical component score (PCS) and mental component score (MCS), preoperative hallux valgus angle (HVA) and intermetatarsal angle (IMA), and concomitant procedures. Outcomes were compared at 6 and 24 months postoperatively. Early postoperative VAS scores were also compared.

RESULTS

Both groups demonstrated significant improvements in VAS score, AOFAS score, and SF-36 PCS and MCS at 6 and 24 months postoperatively. For the MICA group, HVA improved from 23.5 to 7.7 degrees, and IMA improved from 13.5 to 7.5 degrees. For the scarf-Akin osteotomy group, HVA improved from 23.7 to 9.3 degrees, and IMA improved from 13.6 to 7.8 degrees. The first 24-hour postoperative VAS score was significantly lower in the MICA group compared with the scarf-Akin group (2.0 ± 2.0 vs 3.4 ± 2.6, P = .029). However, there was no significant difference in clinical or radiological outcomes between the groups at 6 and 24 months.

CONCLUSION

The MICA procedure with the new-generation MICA screw is an attractive option for the correction of hallux valgus, yielding similar midterm radiological and clinical outcomes compared with the well-established scarf-Akin osteotomy. The first 24-hour postoperative VAS score in the MICA group was also statistically lower, although its clinical significance remains to be determined.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Interdigital vs Transarticular Lateral Release With Scarf Osteotomy

BACKGROUND

We compare the clinical and radiographic outcomes of the interdigital approach vs the medial transarticular approach for lateral release combined with scarf osteotomy.

METHODS

Seventy-seven feet with moderate to severe hallux valgus underwent scarf osteotomy and lateral soft tissue release, using an interdigital approach (n = 36) vs medial transarticular approach (n = 41). The clinical measurements (range of motion, American Orthopaedic Foot & Ankle Society [AOFAS] score) and radiographic data were evaluated preoperatively and at final follow-up (93-124 months postoperatively). Additionally, the numeric pain rating scale and Foot and Ankle Outcome score [FAOS] were assessed postoperatively.

RESULTS

The AOFAS score improved from 60 (q1 = 54, q3 = 70) to 93 (q1 = 85, q3 = 98) in the transarticular group, and from 59 (q1 = 50, q3 = 64) to 95 (q1 = 85, q3 = 100) in the interdigital group. The hallux valgus angle improved from 35.7±6.5 degrees to 15.5±7.6 degrees in the transarticular group, and from 36.0±6.8 degrees to 12.9±13.0 degrees in the interdigital group. The intermetatarsal angle improved from 16.5±2.5 degrees to 6.5±2.7 degrees within the transarticular group and from 17.2±2.5 degrees to 7.3±4.3 degrees in the interdigital group. None of the clinical or radiographic parameters showed any significant differences between the treatment groups.

CONCLUSION

Comparison of outcomes between the interdigital approach and the transarticular approach for lateral soft-tissue release with scarf osteotomy are equally successful. The transarticular approach can thus be considered safe and effective, with the additional benefits of just one scar as opposed to 2.

LEVEL OF EVIDENCE

Level III, therapeutic.

Assessing the Rotation of the First Metatarsal on Computed Tomography Scans: A Systematic Literature Review

BACKGROUND

Hallux valgus is a multiplanar deformity that is often treated on the basis of 2-dimensional (2D) parameters and radiographs. Recurrence rates after surgical correction remain high, and failure to correct pronation of the metatarsal is increasingly stipulated as being part of the problem. Multiple methods of assessing metatarsal pronation have been proposed.

METHODS

We performed a systematic literature review identifying studies that measured metatarsal pronation and torsion on computed tomography (CT) scans. Specific methodology, patient groups, results, and reliability assessments were all reported.

RESULTS

We identified 14 studies that fulfilled the inclusion criteria. Eleven studies measured 2D values on CT scan, and 3 studies used computer-based 3-dimensional (3D) modeling and artificial intelligence systems to help calculate pronation. Metatarsal pronation angle, α angle, sesamoid rotation angle, and measurements for torsion were the most commonly used methods. All angles and measurements were performed as 2D measurements, but the metatarsal pronation angle was also performed with 3D modeling. Reliability and reproducibility of the α angle and metatarsal pronation angle were excellent, despite being performed on studies with small numbers.

CONCLUSION

Multiple methods have been reported to demonstrate first metatarsal pronation on CT, of which the α angle and the metatarsal pronation angle are the most pragmatic and useful in a clinical setting. Further work is needed to further validate the reliability of these measurements in larger series and to identify normal pronation and metatarsal torsion on weightbearing imaging. Further work is required to determine whether addressing pronation reduces recurrence rates and improves outcomes in surgery for hallux valgus.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

The effect of Scarf osteotomy on the distal metatarsal articular angle in hallux valgus: a case series

BACKGROUND

Hallux valgus is a deformity of the forefoot involving a phalangeal valgus and a metatarsal adductus. In most cases its correction requires surgical treatment with different types of osteotomies. The best known is Scarf osteotomy.

AIM

To study the effet of Scarf osteotomy on distal metatarsal articular angle (DMAA) as well as the validitiy of this angle and the value of its correction after review of the literature.

METHODS

It was a retrospective study including patients operated on for severe hallux valgus by a Scarf osteotomy. The clinical assessment was based on the the American-Orthopedic-Foot-and-Ankle-society (AOFAS) score. Radiologically, we calculated the metatarsophalangeal angle, the inter-metatarsal angle and the DMAA. This assessment was performed preoperatively and one year postoperatively.

RESULTS

We collected 37 cases of evolved hallux valgus. The average AOFAS score went from 60.7 to 85.8 / 100 postoperatively with a gain of 25 points. We've noted a significant correction of the 3 angular measurements at one year postoperatively (the metatarsophalangeal angle, the inter-metatarsal angle and the DMAA) which went from 38.8° to 20.5°, from 17° at 10° and 13.5° to 8.5° respectively (p<0.05).

CONCLUSION

The literature has shown that there is no consensus regarding the effect of HV surgery on the DMAA. As for the accuracy, reproducibility and interest of correcting this angle we deduce that the DMAA is an interesting measure in the pathology of HV. Its correction seems not to be necessary in order not to hamper the correction of metatarsus varus. But in cases where the preoperative DMAA is high (> 15 °), efforts should be made to correct it to avoid recurrence.

Prevalence and Predisposing Factors for Recurrence after Hallux Valgus Surgery: A Systematic Review and Meta-Analysis

Recurrence is a frequent and undesirable outcome after hallux valgus (HV) surgery. However, the prevalence of HV recurrence and the pre- and postoperatory factors associated with it have not been adequately studied. This study aimed to quantify the prevalence rate of HV recurrence and to analyze its predisposing factors. MEDLINE and EMBASE databases were systematically searched for observational studies including individuals undergoing HV surgical correction. The random-effects restricted maximum likelihood model was used to estimate the pooled effect size (correlation coefficient (r)). Twenty-three studies were included, yielding a total of 2914 individuals. Pooled prevalence of HV recurrence was 24.86% (95% confidence interval (CI), 19.15 to 30.57, I² = 91.92%, p = 0.00). Preoperative HV angle (HVA) (r = 0.29; 95% CI, 0.14 to 0.43) and preoperative intermetatarsal angle (IMA) (r = 0.13; 95% CI, 0.00 to 0.27) showed a moderate positive relationship with recurrence. Postoperative HVA (r = 0.57; 95% CI, 0.21 to 0.94) and sesamoid position (r = 0.46; 95% CI, 0.31 to 0.60) showed strong relationships with recurrence. In conclusion, preoperative HVA, IMA, and postoperative HVA and sesamoid position are significant risk factors for HV recurrence, and the association of these factors with recurrence is affected by age.

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).

A Systematic Approach to the Surgical Correction of Combined Hallux Valgus and Metatarsus Adductus Deformities

The presence of metatarsus adductus (MTA) adds complexity to the diagnosis and treatment of hallux valgus (HV). Identification and careful analysis of these combined deformities is of paramount importance. The inability to completely correct HV and an increased incidence of recurrence has been established when MTA deformity is present. We present an option for correction of the combined deformities with multiplanar angular correction arthrodesis of the first, second, and third tarsometatarsal (TMT) joints.

Treatment of hallux valgus by Scarf osteotomy - rates and reasons for recurrence and rates of avascular necrosis: A systematic review

BACKGROUND

We reviewed the rates of and reasons for hallux valgus (HV) recurrence and the rates of avascular necrosis following Scarf osteotomy.

METHODS

We searched the Cochrane Library, PubMed, and Embase databases for studies reporting operative management of HV using Scarf osteotomy. The primary endpoints were reasons for and rates of HV recurrence. The secondary endpoint was the rate of avascular necrosis.

RESULTS

We included 15 studies with 946 operations for HV. Seven studies reported no recurrence, six reported recurrence rates of 3.6-11.3%, one reported a recurrence rate of 30%, and one reported a recurrence rate of 78%. Thirteen studies (678 feet) reported other complications from Scarf osteotomy without avascular necrosis.

CONCLUSIONS

Although HV recurrence is not uncommon following Scarf osteotomy, patient-related factors, surgical competence, and longer follow-up are more likely to be associated with recurrence. Avascular necrosis is an infrequent complication in HV patients treated using Scarf osteotomy.

Functional and Radiographic Outcomes of Minimally Invasive Intramedullary Nail Device (MIIND) for Moderate to Severe Hallux Valgus

BACKGROUND

This study was aimed at assessing clinical and radiographic outcomes of the Minimally Invasive Intramedullary Nail Device (MIIND) to correct moderate to severe hallux valgus (HV) and the long-term persistence of its effects.

METHODS

This case series study involved 100 patients, 84 women and 16 men (mean age, 59 years), who underwent the MIIND procedure with a mean follow-up of 97 months. Assessment was performed preoperatively, postoperatively, at 6 and 12 months, and at last follow-up. Clinical outcomes were evaluated with American Orthopaedic Foot & Ankle Society (AOFAS) scores, visual analog scale (VAS), and patient satisfaction. Intermetatarsal angle (IMA), metatarsophalangeal hallux valgus angle (HVA), distal metatarsal articular angle (DMAA), and tibial sesamoid position were assessed. Statistical analysis was performed.

RESULTS

The mean AOFAS score improved from 57.9 to 90.5 points, VAS scale was 1.5 ± 2.0, and patients' satisfaction was 8.7 ± 1.4. The mean correction of the HVA and IMA showed a significant correction; however, the effect of time was not statistically significant on DMAA. Sex (P = .047), severity (P = .050), associated procedures (P = .000), and preoperative angle (P = .000) showed significant association with HVA correction and its persistence over time. Age was not statistically significant. Complications were 9 cases of superficial wound infection and 6 recurrences.

CONCLUSIONS

The MIIND technique proved a viable procedure to correct moderate to severe HV with a low rate of complications and recurrence, producing significant correction of most radiographic parameters assessed and their persistence, even at long term.

LEVEL OF EVIDENCE

Level IV, case series study.

Planning tool for first metatarsal length in hallux valgus surgery

BACKGROUND

The precise planning of metatarsal (MT) I length in hallux valgus surgery is important. However, currently no tool exists which allows the surgeon to reliably predict this parameter.

METHODS

30 virtual 3-dimensional hallux valgus surgeries were performed on varied deformation models based on cadaveric feet scans. The shortening of the first ray during distal metatarsal I osteotomy for different osteotomy angles were measured. An algebraic 2-dimensional calculation was done and compared to the results obtained from the 3-dimensional models.

RESULTS

Inadvertent shortening of the first metatarsal bone can be as much as 8 mm depending on the amount of intermetatarsal angle (IMA) correction and osteotomy angle. Comparison of the 3 dimensional simulations and the 2 dimensional model resulted in a very strong correlation (R > 0.99 p < 0.00001). Based on our findings an anterior pointing osteotomy of approximately 10° is necessary to restore the length in distal metatarsal I hallux valgus surgery.

CONCLUSION

A slight misdirection of the osteotomy plane in distal hallux valgus surgery may result in relevant unwanted alterations in first metatarsal bone length and triangulation by eye is insufficient in this complex geometrical situation without appropriate planning. The present study provides surgeons a practical tool to plan and control the change of first metatarsal length during hallux valgus procedure through exact orientation of the osteotomy angle. If no alteration of length is intended, it may be generalized that an anterior direction of the cut relative to the second metatarsal bone will preserve the length of the first metatarsal bone.

The Role of Weightbearing Computed Tomography Scan in Hallux Valgus

BACKGROUND

Hyperpronation of the first metatarsal in hallux valgus (HV) is poorly understood by conventional weightbearing radiography. We aimed to evaluate this parameter using weightbearing computed tomography (WBCT) and to understand its association with other standard measurements.

METHODS

Retrospective evaluation of WBCT and weightbearing radiographs (WBXRs) was performed for 20 patients with HV feet and 20 controls with no such deformity. Axial computed tomography images of both groups were compared for the first metatarsal pronation angle (alpha angle) and tibial sesamoid subluxation (TSS) grades. The HV angle (HVA), first-second intermetatarsal angle (IMA), first metatarsal-medial cuneiform angle (MMCA), Meary's angle, and calcaneal pitch (CP) angle of the study and control groups were compared on both WBXR and the corresponding 2-dimensional images of WBCT. All measurements were independently performed by 1 musculoskeletal radiology fellow and 1 foot and ankle surgical fellow. Measurements were averaged and interobserver reliability was calculated.

RESULTS

The HV group demonstrated significantly higher values for TSS grade (P < .001) but not for alpha angle (P = .121) compared with controls. Likewise, significantly elevated HVA and IMA were noted in the HV group on both imaging modalities, while no such differences were observed for the CP angle. Higher MMCA and Meary's angle in the HV group were evident only on WBXR (MMCA, P = .039; Meary's, P = .009) but not on WBCT (MMCA, P = .183; Meary's, P = .171).Among all, the receiver operating characteristic (ROC) curves demonstrated the greatest area under the curve (AUC) for HVA, followed by IMA. The alpha angle performed only just outside the range of chance (AUC, 0.65; 95% CI, 0.52-0.69). The Pearson's correlations of the alpha angle, in the HV group, revealed a significant linear relationship with TSS grade and with HVA on WBXR, and only trended toward a weak linear relationship with IMA and with HVA on WBCT.

CONCLUSION

The alpha angle, a measure of abnormal hyperpronation of the first metatarsal, was an independent factor that may coexist with other parameters in HV, but in isolation had limited diagnostic utility. "Abnormal" alpha angles were even observed in individuals without HV. Increases in IMA and MMCA were not necessarily associated with similar increases in alpha angle, despite moderate correlations with TSS grade and HVA on WBXR. Nevertheless, the WBCT was a useful method for assessing hyperpronation and guiding surgical management in individual cases.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

The effect of hallux valgus open and percutaneous surgery on AOFAS scale: a systematic review and meta-analysis

PURPOSE

To estimate the comparative effect of open and percutaneous hallux valgus (HV) surgery on patients' quality of life (QoL) using the American Orthopedic Foot and Ankle Society (AOFAS) scale including total score and individual domains (pain, function, and alignment).

METHODS

MEDLINE, EMBASE, Cochrane Library, and Web of Science databases were systematically searched from inception to March 2020 for studies on the effect of HV surgery on patients' QoL using the AOFAS score. A standardized mean difference score was calculated on the total AOFAS score and on each AOFAS domain (pain, function, and alignment) using Cohen's d index.

RESULTS

Considering the 53 published studies included, the pooled effect size (ES) estimates for the AOFAS total score were 3.69 (95% CI 3.37-4.01; I² = 95.5%) for open surgery and 3.40 (95% CI 2.99-3.80, I² = 88.2%) for percutaneous surgery. The total pooled ES estimate was 3.61 (95% CI 3.35-3.87, I² = 94.5%). Considering the pain domain, the pooled ES estimates were 2.21 (95% CI 1.98-2.43, I² = 64%) for open surgery and 2.52 (95% CI 1.83-3.20, I² = 92.6%) for percutaneous surgery. For the function domain, the pooled ES estimates were 1.37 (95% CI 0.93-1.81, I² = 91%) for open surgery and 2.28 (95% CI 1.10-3.47, I² = 96.8%) for percutaneous surgery. Finally, the pooled ES estimates for the alignment domain were 3.99 (95% CI 3.51-4.47, I² = 85.7%) for open surgery and 2.66 (95% CI 2.23-3.09, I² = 78.5%) for percutaneous surgery.

CONCLUSION

Our data support that HV surgery increases the total AOFAS score as well as the AOFAS scores by domain (pain, function, and alignment). Furthermore, our data show that HV surgery increases patients' QoL, after both open and percutaneous surgery, without differences between them.

Pes Planus Deformity and Its Association With Hallux Valgus Recurrence Following Scarf Osteotomy

BACKGROUND

Hallux valgus recurrence is an unsatisfactory complication, with many causes postulated. This study investigated the effect of pes planus on recurrence after scarf osteotomy.

METHODS

A total of 183 feet were retrospectively reviewed. All patients were treated with a scarf osteotomy and if required Akin osteotomy. We measured preoperative lateral talus first metatarsal angle (T1MA) to study pes planus; an angle of under -4 degrees was considered pes planus. We measured pre and postoperative hallux valgus angle (HVA), intermetatarsal angle (IMA), and sesamoid location. In total 164 feet were suitable for inclusion, with follow-up of at least 6 months (10 males and 154 females, mean age: 52 years).

RESULTS

Recurrence frequency (HVA greater than 15 degrees) was 27 feet (16%). Hallux valgus recurrence was not influenced by gender (P value = .66) or preoperative IMA (P value = .48). Preoperative HVA greater than 35 degrees was associated with increased frequency of recurrence (P value = .004). Those with T1MA less than -10 degrees demonstrated progression in HVA and deterioration in sesamoid location up to 6 months postoperatively (P value = .038). HVA did not progress beyond 6 months. The prevalence of recurrent hallux valgus with normal T1MA was 1%, in T1MA -4 to -10 degrees it was 29% and in T1MA less than -10 degrees it was 47% (P value <.001). Breaks in T1MA less than -4 degrees were found at the naviculocuneiform joint in 68% of feet in this series.

CONCLUSION

The prevalence of hallux valgus recurrence correlated with the severity of pes planus.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Percutaneous Lateral Release in Hallux Valgus: Anatomic Basis and Indications

In the last decade, minimally invasive or percutaneous surgery has evolved rapidly through the development of novel techniques. Treatment of hallux valgus deformity is one of the indications for percutaneous surgery, both for bony and soft tissue correction. The release of the structures on the lateral part of the first metatarsophalangeal joint (lateral release) is one of the best indications for percutaneous surgery in the forefoot. In this article, a detailed description of the anatomy of the metatarsophalangeal joint is provided, along with the indications and tips to perform a safe percutaneous lateral release.

Does preoperative deformity diminish radiographic outcome after hallux valgus correction with scarf osteotomy?: A retrospective study of 102 cases

BACKGROUND

Scarf osteotomy is a frequently used technique to correct moderate to severe hallux valgus deformities. Recurrence of a deformity is a commonly reported complication after surgery. The aim of our study was to evaluate the impact of preoperative deformity on radiological outcome in terms of postoperative loss of correction after scarf osteotomy.

METHODS

102 patients, in which a hallux valgus deformity was corrected with an isolated scarf osteotomy were included. Weightbearing radiographs were analyzed preoperatively, postoperatively, after 6 weeks and after three months (mean 10.9 months SD 17.2 months). The following radiological parameters were used for analysis: the intermetatarsal angle (IMA), the hallux valgus angle (HVA), the distal metatarsal articular angle (DMAA), position of the sesamoids, first metatarsal length, and first metatarsophalangeal joint congruity.

RESULTS

Significant correction of IMA, HVA, DMAA, sesamoid position and joint congruity was achieved (p < 0.001). The IMA improved from 15.8 ± 2.3 to 4.3 ± 2.8°, the HVA from 32.6 ± 6.8 to 9.1 ± 7.2, and the DMAA from 11.4 ± 6.9 to 8.4 ± 5.2°, respectively. In contrast to DMAA, throughout followup we could detect loss of correction for HVA and for IMA amounting 6.3° ± 5.8 and 3.8° ± 2.8 respectively. Loss of HVA correction revealed a significant correlation with preoperative DMAA, but not with the other preoperative radiological parameters.

CONCLUSIONS

Preoperative deformity does not correlate with postoperative loss of correction after scarf osteotomy, except DMAA.

CLINICAL RELEVANCE

Our results may be helpful in counseling patients regarding recurrence of hallux valgus deformity after scarf osteotomy.

LEVEL OF EVIDENCE

Therapeutic, Level IV, retrospective case series.

Scarf osteotomy for the treatment of moderate to severe hallux valgus: Analysis of predictors for midterm outcomes and recurrence

BACKGROUND

Controversies remain regarding the predictors for outcomes and recurrence after scarf osteotomy for hallux valgus deformity.

METHODS

Sixty-two patients (70 feet) underwent scarf osteotomy for hallux valgus deformity. The radiological angles, tibial sesamoid position, articular congruence, demographics, comorbidities, AOFAS, VAS and SF-12 scores, and the postoperative compliance were tested as predictors for outcomes and recurrence.

RESULTS

After a mean 38±15.4 months follow-up, all of the radiological angles, the total AOFAS, PCS-12 and VAS scores significantly improved (all P<0.001). Preoperative MCS-12 was directly related to the total postoperative AOFAS score (P=0.003). A higher number of cardiovascular risk factors negatively affected the postoperative total AOFAS score, VAS and PCS-12 (β=-3.42, P=0.030; β=0.262, P=0.022; β=-0.181, P=0.025, respectively). The BMI influenced postoperative PCS-12 (β=-0.244, P=0.002). Preoperative HVA was directly related to postoperative DMAA (P=0.002) and tibial sesamoid position (P=0.005). Preoperative joint incongruence and postoperative noncompliance were associated with recurrence (P=0.043 and P=0.035, respectively).

CONCLUSIONS

Satisfactory results can be expected after scarf osteotomy. Higher BMI and number of cardiovascular risk factors, and low mental status should be carefully considered when counselling patients for this procedure. Adherence to postoperative care instructions influences deformity recurrence.

Long-term clinical outcomes of scarf osteotomy in regional hospital Hong Kong

Background:

Lack of local data concerning the long-term clinical outcomes of scarf osteotomy in Hong Kong.

Methods:

This is a retrospective review of 75 patients (88 feet) who underwent scarf osteotomy with a mean follow-up of 94.20 months (60–144 months). Clinical ratings were based on visual analog scale (VAS) and American Orthopaedic Foot & Ankle Society (AOFAS) scale. Weight-bearing radiographs were used to perform angular measurements: (i) hallux valgus angle (HVA), (ii) intermetatarsal angle, (iii) distal metatarsal articular angle, and (iv) tibial sesamoid position before operation and at the time of latest follow-up.

Results:

The mean overall AOFAS scales improved from 29.66 (5–49) points preoperatively to 86.83 (39–100) points at the time of final follow-up. The VAS improved from 6.61 (5 to 9) to 0.66 (0 to 4). The average HVA correction was 25.42 (8–46). The 8- to10-year recurrence rate (HVA > 20) was 31.80%. A higher degree of preoperative HVA predicts higher recurrence rate.

Conclusion:

Scarf osteotomy is an effective procedure for symptom control and improvement in radiological parameters for hallux valgus deformity. However, recurrence rate is relatively high.