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Scarf and Akin osteotomies for moderate and severe hallux valgus
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Foot and Ankle Surgery 14 (2008) 194–203 www.elsevier.com/locate/fas
Scarf and Akin osteotomies for moderate and severe hallux valgus Clinical and radiographic results Ignacio Martı´nez Garrido MDa,*, Eduardo Rodrı´guez-Vellando Rubio MDa,1, Marta Navarro Bosch MDa,1, Marı´a Sa´nchez Gonza´lez MDa,1, Guillermo Bastida Paz MDb, Alfredo Juan Llabre´s MDa,1 a
Department of Orthopaedics, La Fe Hospital, University of Valencia, Avda Campanar 21, 46009 Valencia, Spain b Fundacio´n para la investigacio´n, La Fe Hospital, University of Valencia, Valencia, Spain Received 12 September 2007; received in revised form 18 January 2008; accepted 4 February 2008
Abstract Background: The scarf and the combined scarf-Akin procedures are reliable therapeutic tools and can obtain effective correction of symptomatic moderate to severe hallux valgus deformities. Methods: The data from 30 patients (37 feet) with moderate to severe hallux valgus deformity who had scarf osteotomies have been retrospectively reviewed. 32 Akin and 77 Weil osteotomies were also carried out at the same stage. The average follow-up was 22 months. Standardized methods of radiographic and clinical data collection were obtained before and after surgery. Patient satisfaction was assessed at follow-up. Results: Radiological assessment revealed a significant improvement ( p < 0.001) of the hallux valgus angle (mean reduction 17.48), the intermetatarsal angle (mean reduction 5.88), the medial sesamoid position (14% of the feet were grade 1 or less preoperatively and this rate increased to 84% at follow-up) and the DMAA (mean reduction 98). The complication rate was 19%. Clinical improvement was achieved with the AOFAS score increasing from 46 to 86 points ( p < 0.001). Conclusions: We conclude that the procedure has value in obtaining predictable correction of moderate to severe hallux valgus deformities. # 2008 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. Keywords: Scarf osteotomy; Akin osteotomy; Hallux valgus; Intermetatarsal angle; Medial sesamoid bone
1. Introduction Hallux valgus has become a common deformity of the forefoot. This complex condition clinically is characterized by a tilt of the great toe into valgus and the first metatarsal into varus causing a first ray insufficiency syndrome [1]. Over the past century more than 130 procedures aimed at surgical correction have been described. The choice of operation is mainly based on the severity of the deformity and on the presence of degenerative arthritis in the first metatarsophalangeal joint. Distal osteotomies of the first * Corresponding author at: C./Pedro III El Grande, 26, 38 - 8 , 46005 Valencia, Spain. Tel.: +34 963504935. E-mail address: [email protected] (I.M. Garrido). 1 Tel.: +34 963862700x62738; fax: +34 963987366.
metatarsal allow only correction for mild to moderate hallux valgus deformities. When dealing with more severe deformities more proximal osteotomies are used [2–4]. The scarf osteotomy represents an alternative operating technique now used by many forefoot surgeons. It was first described by Burutaran in 1976 to lengthen a first metatarsal with congenital shortness [5]. More recently the technique was developed by Gudas et al. [6] and particularly by Borrelli and Weil [7] in USA. In Europe, it became popular with Barouk [8–10]. This French orthopaedic surgeon placed this osteotomy in a global forefoot overview, improving the surgical technique and the method for internal fixation. Since 1996 we have been using this operation on a regular basis, usually associated to a closing medial wedge osteotomy (Akin osteotomy) on the first phalanx as our
1268-7731/$ – see front matter # 2008 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.fas.2008.02.003
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first choice for moderate (hallux valgus angle 20–408 and/or 1–2 intermetatarsal angle greater than 118 and less than 168) and severe (hallux valgus angle greater than 408 and/or 1–2 intermetatarsal angle greater than or equal to 168) hallux valgus deformities. For mild deformities (hallux valgus angle less than 208 and/or 1–2 intermetatarsal angle less than or equal to 118) our preference is to do distal osteotomies. The purpose of the present article is to demonstrate the value of the scarf and Akin osteotomies in a series of 30 consecutive patients with 37 affected feet.
2. Materials and methods Between November 2003 and July 2006, 30 patients (37 feet) suffering moderate to severe hallux valgus who underwent a scarf osteotomy were retrospectively evaluated. There were 17 left and 20 right feet involved. Bilateral procedures were performed on 7 of them. The most affected foot was operated on first. We wait a minimum of 6 months
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before we operate upon the second foot for the patient to be completely recovered. There were 27 women and 3 men. The average age at the time of surgery was 57 (range 37–70 years). Average postoperative follow-up was 22 months (range 12–39 months). All patients complained of pain localized on the medial eminence or first metatarsophalangeal joint. According to Coughlin [11] we considered normal values for the hallux valgus angle (HVA) and the intermetatarsal angle (IMA) those less than 158 and 98, respectively. Mild hallux valgus deformities are those with HVA less than 208 and/or IMA less than or equal to 118. In moderate deformities HVA is 20–408 and/or IMA is greater than 118 and less than 168. For severe deformities, HVA grater than 408 and IMA greater than or equal to 168 were considered. We indicated a scarf osteotomy for moderate and severe painful hallux valgus deformity without symptomatic relief with adequate nonoperative treatment for a minimum of 6 months. Patients with arthritis of the first metatarsophalangeal joint (AOFAS grade 3 and 4), rheumatoid arthritis
Fig. 1. (A) Preoperative radiograph of a 62-year-old woman with severe hallux valgus deformity: HVA = 308, IMA = 178, DMAA = 168. (B) Radiographic findings after 12 months of follow-up: HVA = 118, IMA = 68, DMAA = 48.
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and neurologic diseases affecting lower limbs were not included in the current series. In 21 patients (24 feet) we performed 77 additional Weil osteotomies of the lesser rays at the time of hallux valgus surgery for metatarsalgia associated with dislocation of the
MTP joints, claw or hammertoe deformities and/or increased relative metatarsal length. Clinical follow-up was obtained after 1, 3, 6, 12 months and at last follow-up. Radiographs were obtained during each visit. For the purpose of the present study, a single
Fig. 2. (A) Reference points for the roentgenographic measurements. For the first metatarsal the Mose sphere is used to locate the distal reference point at the center of the metatarsal head while the proximal reference point is located 1–2 cm distal to the proximal articular surface. Second metatarsal reference points are placed 1–2 cm proximal and distal to the articular surfaces. Proximal phalanx reference points are placed 1/2 to 1 cm proximal and distal to the articular surfaces. All reference points are located on a transverse line perpendicular to the long axis at a point equidistant from the outer border of the medial and lateral cortices of the respective bone. (B) The template that we used for the roentgenographic measurements. At the bottom of the template a protractor with onedegree increments minimizes sources of error from articulated devices when performing angular measurements. The Mose sphere consists of concentric circles separated by minimal increments. It utilizes the distal articular surface and the lateral cortical surface to define the center of the best-fit circle that applied to the metatarsal head.
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observer (ERV) performed the roentgenographic evaluation preoperatively and at last follow-up (Fig. 1), by measuring on standardized anteroposterior and lateral radiographs taken with the same weightbearing technique [12]. The parameters recorded included the intermetatarsal angle (IMA), the hallux valgus angle, the distal metatarsal articular angle (DMAA), medial sesamoid position, first metatarsophalangeal joint congruency and the first metatarsophalangeal joint arthritic changes. All these measurements were assessed using the methods recommended by the AOFAS committee as shown in Table 1 [13]. Reference points for the longitudinal axes bisecting the shafts of the first and second metatarsal and first phalanx of the hallux proposed by the AOFAS committee were determined [12]. We used the Mose sphere to accurately locate a reference point in the distal area of the first
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metatarsal, performing the center-of-head technique. A standard protractor was used when making angular measurements (Fig. 2). For practical purposes, as was done before [11], we considered the correction of every angular deformity as a percentage of the preoperative angular deformity (i.e., percentage correction of HVA = correction of HVA [in degrees]/preoperative HVA [in degrees]). Preoperative and postoperative clinical records were compared. The AOFAS clinical rating system [14], which includes both subjective and objective criteria, was used for clinical evaluation. At final follow-up all patients were interviewed about their satisfaction regarding pain relief and appearance categorizing them depending on their total satisfaction, satisfaction with reservations, and non-satisfaction.
Fig. 3. (A) We use an osteotomy guide to ease the scarf cuts. Note its trapezoidal shape for a better adaptation to the varus of the first metatarsal. First we insert a distal 1.5-mm kirschner-wire, directed in a lateral (perpendicular to the second metatarsal) and 25–308 plantar inclination (to be parallel to the plantar surface), at a point 5 mm proximally from the head cartilage and 2–3 mm under its medial dorsal edge exposed after the exostosis resection. With the aid of the guide we insert the proximal kirschner-wire parallel to the first one, at a point 2–3 mm above the medial border and 2 cm distal to the metatarso-cuneiform joint. Then we use a pneumatic oscillating saw through the cutting guide to perform the longitudinal cut between the two kirschner-wires. (B) To obtain the transverse cuts the guide is rotated to get a 60–708 inclination to the longitudinal cut. (C) Final appearance of the osteotomy after the removal of the kirschner-wires. (D) Direction of the scarf cuts from a dorsal-plantar (a), frontal (b) and sagittal (c) views.
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Table 1 Roentgenographic methods recommended by the AOFAS committee Measurement
Method a
Hallux valgus angle (HVA) First intermetatarsal angle (IMA) a Distal metatarsal articular angle (DMAA)a
Angle between mid-longitudinal axes of M1 and P1 Angle between lines bisecting the shafts of the M1 and M2 Angle between mid-longitudinal axes of M1 and a perpendicular to the line connecting the medial and lateral extent of the distal articular surface of M1
Medial sesamoid position (reference line: mid-longitudinal axis of M1)
Grade Grade Grade Grade
FMTPJ congruency (reference lines: parallel to M2 at the lateral extent of the articular surfaces of the head of M1 and base of P1)
Grade 0: no subluxation Grade 1: <2 mm Grade 2: >2 mm
FMTPJ arthritic changes
Grade Grade Grade Grade Grade
0: 1: 2: 3:
0: 1: 2: 3: 4:
no displacement <50% overlap >50% overlap complete displacement
no arthritic changes subchondral sclerosis joint space narrowing spurs, subchondral cysts end stage degenerative arthritis
M1: first metatarsal; M2: second metatarsal; P1: proximal phalanx. a Reference points specified in the text.
2.1. Surgical technique The surgical technique as described by Barouk was undertaken on all cases. The senior author (AJLL) performed the majority (81%) of the procedures. 35 operations were done as the primary procedure. Two secondary operations were carried out for recurrent deformities after previous failed distal soft-tissue procedures. An ankle pneumatic tourniquet (250 mmHg) was used. The procedure was performed with two separate skin incisions: first, a longitudinal dorsal incision in the first intermetatarsal space for the lateral metatarsophalangeal joint release; second, a strictly medial incision for the exostosectomy, the scarf osteotomy, the medial soft-tissue procedure and the first phalanx osteotomy (when indicated). As a technical detail for the scarf osteotomy, our first step is to insert a 1.5-mm Kirschner-wire with the correct lateral and plantar inclination in both the proximal and distal ends of the longitudinal cut. Then we use a pneumatic oscillating saw through an osteotomy guide (Dismeval S.L.1 Valencia, Spain) designed by the senior author (AJLL), which is extremely useful to ease the scarf cuts and to obtain the displacements desired (Fig. 3). The osteotomy is fixed with two special cannulated screws (Dismeval S.L.1 Valencia, Spain). Once the scarf osteotomy is performed, the load simulation test points out the insufficiency of the correction if there is any contact between the distal end of the great and second toes. In these cases, an additional Akin osteotomy of the first phalanx is needed. This osteotomy is fixed with a staple (Dismeval S.L.1 Valencia, Spain). Antibiotic and thromboembolic prophylaxis were administered routinely.
The mean hospital stay postoperatively was two days. Weightbearing on the heel with special shoes was allowed the day after operation. At the end of 6 weeks the postoperative shoe was no longer used. Results are expressed as mean and range. Data were tested for normality distribution. Chi-square with continuity correction or Fisher exact tests were used to assess differences between categorical variables. The Wilcoxon Matched-Pairs Signed-Ranks Test was used to assess differences between continuous variables. A two-sided p value of less than 0.05 was considered statistically significant.
3. Results Regarding the technique performed additional to the scarf osteotomy, an Akin osteotomy of the first phalanx was used in 26 patients (32 feet). Clinical and radiological parameters are summarized in Tables 2 and 3. Regarding the severity of the hallux valgus deformity, preoperatively it was moderate (HVA of 20–408) in 25 feet
Table 2 Data (mean value and range) of the clinical evaluation
AOFAS score (points) Global (max. 100) Pain (max. 40) Function (max. 45) Alignment (max. 15) Patient satisfaction (S/SR/NS)
Preoperative
Last follow-up
p value
46 17 25 4
86 35 37 13
<0.001 <0.001 <0.001 <0.001
–
(12–77) (0–30) (10–40) (0–15)
(47–100) (20–40) (22–45) (0–15)
(31/5/1)
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(21 patients) and severe (HVA greater than 408) in 12 feet (10 patients). At last follow-up, 16 feet had a normal hallux valgus angle (less than 158), 7 feet remained with a mild hallux valgus deformity (HVA < 208) and 14 feet with a moderate deformity (20–408). No feet with angles greater than 338 were detected. The average HVA was significantly reduced ( p < 0.001) from 348 (range 20–50) preoperatively to 16.68 (range 4 to 33) at final follow-up, for an average correction of 17.48 (average percentage correction of 51%). The average IMA was significantly reduced ( p < 0.001) from 158 (range 7–22) preoperatively to 9.48 (range 2–15) at final follow-up, for an average correction of 5.88 (average percentage correction of 38%). The average DMAA was significantly reduced ( p < 0.001) from 18.48 (range 10–40) preoperatively to 9.48 (range 0–18) at final follow-up, for an average correction of 98 (average percentage correction of 46%). The mean AOFAS score improved significantly ( p < 0.001) from 46 points (12–77) preoperatively to 86 points (47–100) at follow-up. Both correlation coefficients between the global AOFAS score and the HVA and the IMA were low (0.021 and 0.001, respectively). At the time of follow-up twenty-four patients (80%) were satisfied with the surgical result and would repeat the same procedure. Five patients (17%) were satisfied with reservations, and these included first MTP stiffness (one patient, one foot), recurrence of deformity (one patient, one foot), mild pain beneath the hallux sesamoids (one patient, one foot) and hallux varus (two patients, two feet). One patient (1 foot; 3%) was dissatisfied due to pain and problems with shoe wear equal than before surgery. 3.1. Complications No major complications due to the procedure were recorded in the intraoperative or in the immediate postoperative period. We had no cases of deep vein thrombosis or deep wound infection. The complication rate was 19% (six patients, seven feet). Only one major postoperative complication was encountered: one patient (one foot, 3%) suffered a stress fracture at the proximal first metatarsal osteotomy site that progressed to an asymptomatic non-union. At the moment of the review the patient was satisfied with reservations.
Fig. 4. Radiograph of a 60-year-old woman 1 year after a scarf osteotomy which shows a 48 hallux varus deformity due to excessive medial capsular plication.
Among the seven complications recorded, six (86%) were minor. Any of these patients required further surgery. One patient (one foot, 3%) presented mild hallux varus deformity (48) that was attributed to an excessively tightened medial capsulorraphy (Fig. 4). This patient was satisfied with reservations at follow-up due to minor discomfort with shoe wear but refused a new surgical procedure. Three
Table 3 Radiographic findings (mean, range)
HVA IMA DMAA Medial sesamoid position (G-0/G-1/G-2/G-3) FMPJ subluxation (G-0/G-1/G-2) FMPJ arthritic changes (G-0/G-1/G-2/G-3/G-4)
Preoperative
Last follow-up
Correction
% Correction
p value
34 (20–50) 15 (7–22) 18.4 (10–40) (0/5/18/14) (2/16/19) 0/28/9/0/0
16.6 ( 4 to 33) 9.4 (2–15) 9.4 (0–18) (10/21/6/0) (18/16/3) 0/28/9/0/0
17.4 5.8 9 – – –
51 38 46 – – –
<0.001 <0.001 <0.001 <0.001 – –
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patients (8%) had superficial wound infections which healed uneventfully, after administration of appropriate antibiotics. One patient (one foot, 3%) reported persistent numbness in the scar along the medial border of the first toe. Symptomatic first metatarsal joint stiffness was seen in one patient (one foot, 3%). We found no cases of osteonecrosis of the first metatarsal head or reflex sympathetic dystrophy. Four patients (11%) required further surgery to remove prominent osteosynthesis (two staples in the first phalanx and two screws in the metatarsal osteotomy) causing irritation. The pain solved when the hardware was removed after the osteotomies healed.
4. Discussion Several operative methods on the first metatarsal have been reported for hallux valgus deformity, such as distal osteotomies, diaphyseal osteotomies, as well as different proximal osteotomies. All of them share the same goal: improving the altered angular pathologies associated with hallux valgus without significant risks. The selection of a specific procedure must be found on the pathologic elements presented and its severity. Furthermore, it is widely accepted that no isolated technique can address the whole range of deformity of hallux valgus and that even technically well-performed procedures may fail. Distal metatarsal osteotomies are advocated for hallux valgus deformities with small intermetatarsal angles and bear the risk of avascular necrosis of the metatarsal head [15]. Basal osteotomies have been proven to effectively correct significant metatarsus primus varus. However, the amount of correction is limited by the distal articular lateral slope or DMAA unless a distal metatarsal osteotomy is added. Basal osteotomies are demanding technically and are not free of complications. Undesirable side effects include shortening and dorsiflexion of the first metatarsal from 28 to 82% of patients despite adequate fixation which may lead to lateral transfer metatarsalgia. In order to reduce these risks it often requires a period of casting and nonweightbearing [16,17]. The scarf osteotomy was performed on 30 patients (37 feet) with moderate to severe hallux valgus at our hospital during the period of the present study. The advantages of this Z-fashion osteotomy of the first metatarsal are its versatility and its reliability so that it results in a wide range of indications. It allows a lateral shift of up to two thirds of the surface of the plantar fragment including the metatarsal head. As a result of the plantar obliquity of the longitudinal cut, up to 5 mm of lowering can alleviate metatarsalgia under the second metatarsal head. The scarf works not only providing correction for deformities with large intermetatarsal angles but also the possibility of restoring the normal relationship of the metatarsophalangeo-sesamoid complex [18,9,10].
In the present series, the average correction of the HVA was 17.48 and the average correction of the IMA was 5.88. Lorei et al. estimated these corrections in 26.38 and 8.98, respectively [17]. Aslam et al. [19] performed 22 scarf osteotomies in 13 patients for hallux valgus deformities. Radiographic improvements included HVA from 31.58 to 148 (median correction 168) and IMA from 14.58 to 88 (median correction 68). Regarding the medial sesamoid position, 5 feet (14%) were grade 1 or less preoperatively and 31 feet (84%) were grade 1 or less at follow-up, for a significant improvement ( p < 0.001) in our current series. These results are comparable to observations by David-West et al. [20] who reported that 27% of 30 cases of hallux valgus were grades 1 or less preoperatively, and 97% of these feet were grades 1 or less at 13 months, showing a significant correction of the tibial sesamoid bone after the scarf procedure. At the same time the DMAA can easily be corrected by increasing the lateral displacement of the proximal end of the osteotomy compared to the distal end. The average correction of the DMAA in the present series (98) was significant. This coincides with other reports [19,21] that point out the benefit of realigning the cartilaginous surface of the distal first metatarsal. The fact that the intraobserver and interobserver reliability in the measurement of the DMAA is questioned in the literature should not to be forgotten [11,22,23]. Our results compared well with those reported in the literature (Table 4). We agree with Barouk [10] in considering surgery of forefoot as a single entity. In order to respect the harmony of the metatarsal arch, 77 Weil osteotomies of the lesser rays were performed in 24 feet. A negative metatarsal index presented preoperatively in 18 feet (49%) appeared postoperatively in 4 feet (11%). Thirty-two feet (87%) had an additional great toe first phalanx osteotomy as emphasized by the load simulation test intraoperatively. This coincides with other reports [24,25] that point out the benefits of accomplishing the correction by its varisation, shortening or derrotation effects. Others [19] have found sufficient reduction of HVA in almost all cases by the scarf without the need for a phalangeal osteotomy. In a recent paper, Malviya et al. [26] reported their functional and radiological results of scarf osteotomy with and without Akin in 69 patients with 99 procedures. These authors found no significant difference between their scarf osteotomy (54 patients, 74 toes) and scarf with Akin (17 patients, 25 toes) group, and concluded that adding Akin procedures increase the risk of complications and may not be indicated as a routine procedure. We agree with Martı´nez-Gime´nez et al. [21] and Wagner et al. [16] in considering that the soft-tissue procedures (both lateral release and medial tightening) are critical in correcting the first metatarsophalangeal joint subluxation thus diminishing the likelihood of progressive deformity. In 18 (49%) of the preoperative feet in our series, the first
93 91.1 9.1 12.3 7.2 8.3 16.1 17.4 53.2 54.6 18.4 20.7 15.7 15.8 38.2 37.1 54/74 17/25 Scarf Scarf and Akin Malviya et al. [26]
20.8
0.89 (0–2) 85.6 (47–100) 0.91 (0–2) – – 85 (50–100) – – – 86.5 (57–97) – 82 (39–100) 16.6 ( 4–33) 9.4 (2–15) 9.4 (0–18) 14 (5–31) 8 (3–16) 10 (0–16) 14 (2–32) 9 (2–15) 11 (3–25) 23 8 – 16.9 (5–40) 10.1 (8–20) – 17 10 10 2.24 (0–3) 46.3 (12–77) 2.27 (0–3) – – 52 (15–78) – – – 54.5 (34–78) – 43 (14–68) 18.4 (10–40) 13 (2–34) 14 (6–35) – – 13 15 (7–22) 14.5 (8–19) 15 (10–19) 16 15.4 (12–20) 16 34 (20–50) 31.5 (16–43) 33 (24–46) 43 34.5 (20–46) 32 30/37 13/22 24/35 49/53 21/27 71/84 Scarf (87% Akin) Scarf Scarf and Akin Scarf Scarf Scarf (75% Akin) Present study Aslam et al. [19] Jones et al. [30] Wagner et al. [16] Aminian et al. [18] Crevoisier et al. [25]
22 6 24 14 16.1 22
HVA
Follow-up Patients/ Preoperative (month) feet HVA Surgery Series
Table 4 Comparison with previously published data
IMA
DMAA
Sesamoid position
AOFAS
Postoperative
IMA
DMAA
Sesamoid position
AOFAS
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metatarsophalangeal joint congruency was grade 0 or 1, and 19 (51%) was grade 2. In the postoperative feet 34 (92%) were grade 0 or 1, showing a correction of the first metatarsophalangeal joint subluxation. As in other published articles [21,24] we have found no significant deterioration of previous metatarsophalangeal joint arthritic changes after the scarf osteotomy. It may be attributable to the decrease of axial longitudinal pressure in the metatarsophalangeal joint after shortening of the first metatarsal and/or the first phalanx when required. Due to the inherent stability of the osteotomy in spite of very large displacements, immediate weightbearing and early functional recovery is possible. It is difficult to compare the published series because they include different method of data collection [27]. In order to make the comparative analysis of our results more accurate and according to the criteria stated by the AOFAS research committee, a precise description of reliable angular measurements and specific reference points is presented. The Mose sphere helps us to define accurately the distal reference point for the first metatarsal. This method avoids spurious effects of medial eminence resection or double density seen on postoperative radiographs after a scarf osteotomy. We always used the same measurement device (protractor) on standardized weightbearing radiographs in order to minimize this source of error. Clinical assessment was undertaken using the AOFAS clinical rating system and an interview about subjective satisfaction regarding pain relief and appearance. Both tools have come into widespread use as foot and ankle outcome instruments [28,29]. The AOFAS score of 86 points at follow-up showed a good clinical outcome for the hallux and compared well with the scores reported in other studies [30,21,25]. At the time of follow-up 80% of the patients were satisfied, 17% were satisfied with reservations and 3% were not satisfied. It should be enphasized that the degree of clinical improvement was not parallel to the radiographic results. As in other published articles [30,31] we have found a low correlation (<0.45) between the radiological results (for the HVA and IMA) and the global AOFAS score. Jones concluded that the AOFAS score may not be adequate for assessing outcome and that other aspects of skeletal correction not currently included may be required [30]. One could criticize this study because we did not use computer-assisted measurements on digital radiographs to evaluate our results. Several authors demonstrate that electronic measurements help to reduce sources of inter and intraobserver error resulting from the process of manual measurement [22,32]. A second possible criticism of our study is that in the current series we compared the roentgenographic data preoperatively and at last followup, without taking into account the intermediate radiographic measurements. Therefore, the distinction between undercorrection (an inadequate initial procedure) and
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recurrence (increasing deformity with time) was not well defined. It was beyond the purpose of our study to analyze postoperative foot-loading data using pedographic measurements performed in recent series [30,17]. One of the objections of the scarf is that it was noted to be a technical demanding procedure. Furthermore, relatively high rate of complications like fractures, over and undercorrection, excessive shortening with transfer metatarsalgia, delayed union and avascular necrosis have been recorded in literature [33,34]. Our complication rate (19%) was comparable to those previously reported [30,17,31,25]. Nevertheless in our series the greater part of them (86%) were minor and did not alter the final results. There is a steep learning curve for the surgeon to master the scarf osteotomy and results of surgery during learning period may be associated with technical difficulties. We have found the unexpected low rate of intraoperative complications in our series to be related to two causes: first, between 1996 and 2006 (a 10 year period), more than 500 scarf osteotomies were performed by the senior author (AJLL) to correct hallux valgus deformities; second, the availability of more sophisticated instruments as the osteotomy guide used for the osteotomies performed during the period of the present study. Noteworthy is the high rate of removing symptomatic hardware after scarf and Akin procedures. In the series by Jones et al. [30], implant removal as a second operation occurred in 1 of the 35 feet (3%). Therefore, while four of our thirty patients (four feet, 11%) required a second operation, the convenience of using low profile hardware should be considered in all patients. In the light of our observations and the literature reviewed, we believe that the scarf, combined when needed with an Akin procedure, is safe, effective and provide good results in the treatment of moderate to severe hallux valgus deformities. Although larger series need to be analyzed, in our opinion the presented technique is a good alternative in comparison with proximal osteotomies in properly selected patients.
Acknowledgement We thank Cassandra Rosenblum for her help in the preparation and translation of this manuscript.
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[3] Mann RA, Rudicel S, Graves SC. Repair of hallux valgus with a distal soft tissue procedure and proximal metatarsal osteotomy. A long-term follow-up. J Bone Joint Surg 1992;24A:124–9. [4] Zembsch A, Trnka HJ, Rtischl P. Correction of hallux valgus. metatarsal osteotomy versus escisio´n arthroplasty. Clin Orthop 2000;376:183–94. [5] Burutaran JM. Hallux valgus y cortedad anato´mica del primer metatarsiano (correccio´n quiru´rgica). Actual Me´d Chir Pied 1976;13:261–6. [6] Gudas CJ, Laros GS, Zygmunt KH. Z bunionectomy with internal screw fixation. J Am Podiatr Med Assoc 1989;79:57–63. [7] Borrelli AH, Weil LS. Modified Scarf bunionectomy: our experience in more than 1000 cases. J Foot Surg 1991;1:609–22. [8] Barouk LS. Forefoot reconstruction. New York: Springer Verlag; 2003 . pp. 23–71. [9] Barouk LS. Scarf osteotomy for correction of hallux valgus: local anatomy, surgical technique and combination with other forefoot procedures. Foot Ankle Clin 2000;5:525–57. [10] Barouk LS. Oste´otomie Scarf du premier me´tatarsien. Me´d Chir Pied 1994;10:111–20. [11] Coughlin MJ. Hallux valgus in men: effect of the distal metatarsal articular angle on hallux valgus correction. Foot Ankle Int 1997;18: 463–70. [12] Coughlin MJ, Saltzman CL, Nunley II JA. Angular measurements in the evaluation of hallux valgus deformities: a report of the Ad Hoc Committee of the American Orthopaedic Foot & Ankle Society on angular measurements. Foot Ankle Int 2002;23:68–74. [13] Smith RW, Reynolds JC, Stewart MJ. Hallux valgus assessment: report of research committee of American Orthopaedic Foot and Ankle Society. Foot Ankle Int 1984;5:92–103. [14] Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS, Sanders M. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int 1994;15:349–53. [15] Sammarco J, Idusuyi OB. Complications after surgery of the hallux. Clin Orthop 2001;391:59–71. [16] Wagner A, Fuhrmann R, Abramowski I. Early results of Scarf osteotomies using differentiated therapy of hallux valgus. Foot Ankle Surg 2000;6:105–12. [17] Lorei TJ, Kinast Ch, Kla¨rner H, Rosenbaum D. Pedographic, clinical, and functional outcome after scarf osteotomy. Clin Orthop 2006; 451:161–6. [18] Aminian A, Kelikian A, Moen T. Scarf osteotomy for hallux valgus deformity: an intermediate followup of clinical and radiographic outcomes. Foot Ankle Int 2006;27:883–6. [19] Aslam N, Lavis G, Porter D, Cooke PH. A radiographic evaluation of the scarf osteotomy for the correction of hallux valgus. Foot Ankle Surg 2004;10:35–9. [20] David-West KS, Moir JS. Radiological assessment of tibial sesamoid position after Scarf steotomy for hallux valgus correction. Foot Ankle Surg 2002;8:209–12. [21] Martı´nez-Gime´nez JE, Ma´s-Martı´nez JJ, Salinas-Gilabert JE. Tratamiento del hallux valgus mediante osteotomı´a de ensamblaje (scarf). Rev Ortop Traumatol 2003;47:400–5. [22] Coughlin MJ, Freund E. The reliability of angular measurements in hallux valgus deformities. Foot Ankle Int 2001;22:369–79. [23] Easley ME, Trnka HJ. Current concepts review: hallux valgus part 1: pathomechanics, clinical assesment, and nonoperative management. Foot Ankle Int 2007;28:654–9. [24] Jarde O, Trinquier-Lautard JL, Gabrion A, Ruzic JC, Vives P. Hallux valgus traite´ par une oste´otomie de Scarf du premier me´tatarsien et de la premie`re phalange associe´e a´ une plastie de ´ladducteur. Revue de chirurgie orthope´dique 1999;85:374–80. [25] Crevoisier X, Mouhsine E, Ortolano V, Udin B, Dutoit M. The scarf osteotomy for the treatment of hallux valgus deformity: a review of 84 cases. Foot Ankle Int 2001;22:970–6. [26] Malviya A, Makwana N, Laing P. Scarf osteotomy for hallux valgus— is an Akin osteotomy necessary? Foot Ankle Surg 2007;13:177–81. [27] Schneider W, Knahr K. Metatarsophalangeal and intermetatarsal angle: different values and interpretation of postoperative results
I.M. Garrido et al. / Foot and Ankle Surgery 14 (2008) 194–203 dependent on the technique of measurement. Foot Ankle Int 1998;19:532–6. [28] Baumhauer JF, Nawokcenski DA, DiGiovanni BF, Wilding GE. Reliability and validity of the American Orthopaedic Foot and Ankle Society clinical rating scale: a pilot study for the hallux and lesser toes. Foot Ankle Int 2006;27:1014–9. [29] Monga P, Kumar A, Simons A. Outcome following surgery for hallux valgus: the patients’ perspective. Foot Ankle Surg 2006;12: 95–8. [30] Jones S, Al Hussainy H, Ali F, Betts RP, Flowers MJ. Scarf osteotomy for hallux valgus: a prospective clinical and pedobarographic study. J Bone Joint Surg 2004;86B:830–6.
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[31] Kristen KH, Berger C, Stelzig S, Thalhammer E, Posch M, Engel A. The SCARF osteotomy for the correction of hallux valgus deformities. Foot Ankle Int 2002;23:221–9. [32] Panchbhavi VK, Trevino SG. Evaluation of hallux valgus surgery using computer-assisted radiographic measurements and two direct forefoot parameters. Foot Ankle Surg 2004;10:59–63. [33] Coetzee JC. Scarf osteotomy for hallux valgus repair: the dark side. Foot Ankle Int 2003;24:29–33. [34] Smith AM, Alwan T, Davies MS. Perioperative complications of the Scarf osteotomy. Foot Ankle Int 2003;24:222–7.
Foot and Ankle Surgery 14 (2008) 194–203 www.elsevier.com/locate/fas
Scarf and Akin osteotomies for moderate and severe hallux valgus Clinical and radiographic results Ignacio Martı´nez Garrido MDa,*, Eduardo Rodrı´guez-Vellando Rubio MDa,1, Marta Navarro Bosch MDa,1, Marı´a Sa´nchez Gonza´lez MDa,1, Guillermo Bastida Paz MDb, Alfredo Juan Llabre´s MDa,1 a
Department of Orthopaedics, La Fe Hospital, University of Valencia, Avda Campanar 21, 46009 Valencia, Spain b Fundacio´n para la investigacio´n, La Fe Hospital, University of Valencia, Valencia, Spain Received 12 September 2007; received in revised form 18 January 2008; accepted 4 February 2008
Abstract Background: The scarf and the combined scarf-Akin procedures are reliable therapeutic tools and can obtain effective correction of symptomatic moderate to severe hallux valgus deformities. Methods: The data from 30 patients (37 feet) with moderate to severe hallux valgus deformity who had scarf osteotomies have been retrospectively reviewed. 32 Akin and 77 Weil osteotomies were also carried out at the same stage. The average follow-up was 22 months. Standardized methods of radiographic and clinical data collection were obtained before and after surgery. Patient satisfaction was assessed at follow-up. Results: Radiological assessment revealed a significant improvement ( p < 0.001) of the hallux valgus angle (mean reduction 17.48), the intermetatarsal angle (mean reduction 5.88), the medial sesamoid position (14% of the feet were grade 1 or less preoperatively and this rate increased to 84% at follow-up) and the DMAA (mean reduction 98). The complication rate was 19%. Clinical improvement was achieved with the AOFAS score increasing from 46 to 86 points ( p < 0.001). Conclusions: We conclude that the procedure has value in obtaining predictable correction of moderate to severe hallux valgus deformities. # 2008 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. Keywords: Scarf osteotomy; Akin osteotomy; Hallux valgus; Intermetatarsal angle; Medial sesamoid bone
1. Introduction Hallux valgus has become a common deformity of the forefoot. This complex condition clinically is characterized by a tilt of the great toe into valgus and the first metatarsal into varus causing a first ray insufficiency syndrome [1]. Over the past century more than 130 procedures aimed at surgical correction have been described. The choice of operation is mainly based on the severity of the deformity and on the presence of degenerative arthritis in the first metatarsophalangeal joint. Distal osteotomies of the first * Corresponding author at: C./Pedro III El Grande, 26, 38 - 8 , 46005 Valencia, Spain. Tel.: +34 963504935. E-mail address: [email protected] (I.M. Garrido). 1 Tel.: +34 963862700x62738; fax: +34 963987366.
metatarsal allow only correction for mild to moderate hallux valgus deformities. When dealing with more severe deformities more proximal osteotomies are used [2–4]. The scarf osteotomy represents an alternative operating technique now used by many forefoot surgeons. It was first described by Burutaran in 1976 to lengthen a first metatarsal with congenital shortness [5]. More recently the technique was developed by Gudas et al. [6] and particularly by Borrelli and Weil [7] in USA. In Europe, it became popular with Barouk [8–10]. This French orthopaedic surgeon placed this osteotomy in a global forefoot overview, improving the surgical technique and the method for internal fixation. Since 1996 we have been using this operation on a regular basis, usually associated to a closing medial wedge osteotomy (Akin osteotomy) on the first phalanx as our
1268-7731/$ – see front matter # 2008 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.fas.2008.02.003
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first choice for moderate (hallux valgus angle 20–408 and/or 1–2 intermetatarsal angle greater than 118 and less than 168) and severe (hallux valgus angle greater than 408 and/or 1–2 intermetatarsal angle greater than or equal to 168) hallux valgus deformities. For mild deformities (hallux valgus angle less than 208 and/or 1–2 intermetatarsal angle less than or equal to 118) our preference is to do distal osteotomies. The purpose of the present article is to demonstrate the value of the scarf and Akin osteotomies in a series of 30 consecutive patients with 37 affected feet.
2. Materials and methods Between November 2003 and July 2006, 30 patients (37 feet) suffering moderate to severe hallux valgus who underwent a scarf osteotomy were retrospectively evaluated. There were 17 left and 20 right feet involved. Bilateral procedures were performed on 7 of them. The most affected foot was operated on first. We wait a minimum of 6 months
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before we operate upon the second foot for the patient to be completely recovered. There were 27 women and 3 men. The average age at the time of surgery was 57 (range 37–70 years). Average postoperative follow-up was 22 months (range 12–39 months). All patients complained of pain localized on the medial eminence or first metatarsophalangeal joint. According to Coughlin [11] we considered normal values for the hallux valgus angle (HVA) and the intermetatarsal angle (IMA) those less than 158 and 98, respectively. Mild hallux valgus deformities are those with HVA less than 208 and/or IMA less than or equal to 118. In moderate deformities HVA is 20–408 and/or IMA is greater than 118 and less than 168. For severe deformities, HVA grater than 408 and IMA greater than or equal to 168 were considered. We indicated a scarf osteotomy for moderate and severe painful hallux valgus deformity without symptomatic relief with adequate nonoperative treatment for a minimum of 6 months. Patients with arthritis of the first metatarsophalangeal joint (AOFAS grade 3 and 4), rheumatoid arthritis
Fig. 1. (A) Preoperative radiograph of a 62-year-old woman with severe hallux valgus deformity: HVA = 308, IMA = 178, DMAA = 168. (B) Radiographic findings after 12 months of follow-up: HVA = 118, IMA = 68, DMAA = 48.
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and neurologic diseases affecting lower limbs were not included in the current series. In 21 patients (24 feet) we performed 77 additional Weil osteotomies of the lesser rays at the time of hallux valgus surgery for metatarsalgia associated with dislocation of the
MTP joints, claw or hammertoe deformities and/or increased relative metatarsal length. Clinical follow-up was obtained after 1, 3, 6, 12 months and at last follow-up. Radiographs were obtained during each visit. For the purpose of the present study, a single
Fig. 2. (A) Reference points for the roentgenographic measurements. For the first metatarsal the Mose sphere is used to locate the distal reference point at the center of the metatarsal head while the proximal reference point is located 1–2 cm distal to the proximal articular surface. Second metatarsal reference points are placed 1–2 cm proximal and distal to the articular surfaces. Proximal phalanx reference points are placed 1/2 to 1 cm proximal and distal to the articular surfaces. All reference points are located on a transverse line perpendicular to the long axis at a point equidistant from the outer border of the medial and lateral cortices of the respective bone. (B) The template that we used for the roentgenographic measurements. At the bottom of the template a protractor with onedegree increments minimizes sources of error from articulated devices when performing angular measurements. The Mose sphere consists of concentric circles separated by minimal increments. It utilizes the distal articular surface and the lateral cortical surface to define the center of the best-fit circle that applied to the metatarsal head.
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observer (ERV) performed the roentgenographic evaluation preoperatively and at last follow-up (Fig. 1), by measuring on standardized anteroposterior and lateral radiographs taken with the same weightbearing technique [12]. The parameters recorded included the intermetatarsal angle (IMA), the hallux valgus angle, the distal metatarsal articular angle (DMAA), medial sesamoid position, first metatarsophalangeal joint congruency and the first metatarsophalangeal joint arthritic changes. All these measurements were assessed using the methods recommended by the AOFAS committee as shown in Table 1 [13]. Reference points for the longitudinal axes bisecting the shafts of the first and second metatarsal and first phalanx of the hallux proposed by the AOFAS committee were determined [12]. We used the Mose sphere to accurately locate a reference point in the distal area of the first
197
metatarsal, performing the center-of-head technique. A standard protractor was used when making angular measurements (Fig. 2). For practical purposes, as was done before [11], we considered the correction of every angular deformity as a percentage of the preoperative angular deformity (i.e., percentage correction of HVA = correction of HVA [in degrees]/preoperative HVA [in degrees]). Preoperative and postoperative clinical records were compared. The AOFAS clinical rating system [14], which includes both subjective and objective criteria, was used for clinical evaluation. At final follow-up all patients were interviewed about their satisfaction regarding pain relief and appearance categorizing them depending on their total satisfaction, satisfaction with reservations, and non-satisfaction.
Fig. 3. (A) We use an osteotomy guide to ease the scarf cuts. Note its trapezoidal shape for a better adaptation to the varus of the first metatarsal. First we insert a distal 1.5-mm kirschner-wire, directed in a lateral (perpendicular to the second metatarsal) and 25–308 plantar inclination (to be parallel to the plantar surface), at a point 5 mm proximally from the head cartilage and 2–3 mm under its medial dorsal edge exposed after the exostosis resection. With the aid of the guide we insert the proximal kirschner-wire parallel to the first one, at a point 2–3 mm above the medial border and 2 cm distal to the metatarso-cuneiform joint. Then we use a pneumatic oscillating saw through the cutting guide to perform the longitudinal cut between the two kirschner-wires. (B) To obtain the transverse cuts the guide is rotated to get a 60–708 inclination to the longitudinal cut. (C) Final appearance of the osteotomy after the removal of the kirschner-wires. (D) Direction of the scarf cuts from a dorsal-plantar (a), frontal (b) and sagittal (c) views.
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Table 1 Roentgenographic methods recommended by the AOFAS committee Measurement
Method a
Hallux valgus angle (HVA) First intermetatarsal angle (IMA) a Distal metatarsal articular angle (DMAA)a
Angle between mid-longitudinal axes of M1 and P1 Angle between lines bisecting the shafts of the M1 and M2 Angle between mid-longitudinal axes of M1 and a perpendicular to the line connecting the medial and lateral extent of the distal articular surface of M1
Medial sesamoid position (reference line: mid-longitudinal axis of M1)
Grade Grade Grade Grade
FMTPJ congruency (reference lines: parallel to M2 at the lateral extent of the articular surfaces of the head of M1 and base of P1)
Grade 0: no subluxation Grade 1: <2 mm Grade 2: >2 mm
FMTPJ arthritic changes
Grade Grade Grade Grade Grade
0: 1: 2: 3:
0: 1: 2: 3: 4:
no displacement <50% overlap >50% overlap complete displacement
no arthritic changes subchondral sclerosis joint space narrowing spurs, subchondral cysts end stage degenerative arthritis
M1: first metatarsal; M2: second metatarsal; P1: proximal phalanx. a Reference points specified in the text.
2.1. Surgical technique The surgical technique as described by Barouk was undertaken on all cases. The senior author (AJLL) performed the majority (81%) of the procedures. 35 operations were done as the primary procedure. Two secondary operations were carried out for recurrent deformities after previous failed distal soft-tissue procedures. An ankle pneumatic tourniquet (250 mmHg) was used. The procedure was performed with two separate skin incisions: first, a longitudinal dorsal incision in the first intermetatarsal space for the lateral metatarsophalangeal joint release; second, a strictly medial incision for the exostosectomy, the scarf osteotomy, the medial soft-tissue procedure and the first phalanx osteotomy (when indicated). As a technical detail for the scarf osteotomy, our first step is to insert a 1.5-mm Kirschner-wire with the correct lateral and plantar inclination in both the proximal and distal ends of the longitudinal cut. Then we use a pneumatic oscillating saw through an osteotomy guide (Dismeval S.L.1 Valencia, Spain) designed by the senior author (AJLL), which is extremely useful to ease the scarf cuts and to obtain the displacements desired (Fig. 3). The osteotomy is fixed with two special cannulated screws (Dismeval S.L.1 Valencia, Spain). Once the scarf osteotomy is performed, the load simulation test points out the insufficiency of the correction if there is any contact between the distal end of the great and second toes. In these cases, an additional Akin osteotomy of the first phalanx is needed. This osteotomy is fixed with a staple (Dismeval S.L.1 Valencia, Spain). Antibiotic and thromboembolic prophylaxis were administered routinely.
The mean hospital stay postoperatively was two days. Weightbearing on the heel with special shoes was allowed the day after operation. At the end of 6 weeks the postoperative shoe was no longer used. Results are expressed as mean and range. Data were tested for normality distribution. Chi-square with continuity correction or Fisher exact tests were used to assess differences between categorical variables. The Wilcoxon Matched-Pairs Signed-Ranks Test was used to assess differences between continuous variables. A two-sided p value of less than 0.05 was considered statistically significant.
3. Results Regarding the technique performed additional to the scarf osteotomy, an Akin osteotomy of the first phalanx was used in 26 patients (32 feet). Clinical and radiological parameters are summarized in Tables 2 and 3. Regarding the severity of the hallux valgus deformity, preoperatively it was moderate (HVA of 20–408) in 25 feet
Table 2 Data (mean value and range) of the clinical evaluation
AOFAS score (points) Global (max. 100) Pain (max. 40) Function (max. 45) Alignment (max. 15) Patient satisfaction (S/SR/NS)
Preoperative
Last follow-up
p value
46 17 25 4
86 35 37 13
<0.001 <0.001 <0.001 <0.001
–
(12–77) (0–30) (10–40) (0–15)
(47–100) (20–40) (22–45) (0–15)
(31/5/1)
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(21 patients) and severe (HVA greater than 408) in 12 feet (10 patients). At last follow-up, 16 feet had a normal hallux valgus angle (less than 158), 7 feet remained with a mild hallux valgus deformity (HVA < 208) and 14 feet with a moderate deformity (20–408). No feet with angles greater than 338 were detected. The average HVA was significantly reduced ( p < 0.001) from 348 (range 20–50) preoperatively to 16.68 (range 4 to 33) at final follow-up, for an average correction of 17.48 (average percentage correction of 51%). The average IMA was significantly reduced ( p < 0.001) from 158 (range 7–22) preoperatively to 9.48 (range 2–15) at final follow-up, for an average correction of 5.88 (average percentage correction of 38%). The average DMAA was significantly reduced ( p < 0.001) from 18.48 (range 10–40) preoperatively to 9.48 (range 0–18) at final follow-up, for an average correction of 98 (average percentage correction of 46%). The mean AOFAS score improved significantly ( p < 0.001) from 46 points (12–77) preoperatively to 86 points (47–100) at follow-up. Both correlation coefficients between the global AOFAS score and the HVA and the IMA were low (0.021 and 0.001, respectively). At the time of follow-up twenty-four patients (80%) were satisfied with the surgical result and would repeat the same procedure. Five patients (17%) were satisfied with reservations, and these included first MTP stiffness (one patient, one foot), recurrence of deformity (one patient, one foot), mild pain beneath the hallux sesamoids (one patient, one foot) and hallux varus (two patients, two feet). One patient (1 foot; 3%) was dissatisfied due to pain and problems with shoe wear equal than before surgery. 3.1. Complications No major complications due to the procedure were recorded in the intraoperative or in the immediate postoperative period. We had no cases of deep vein thrombosis or deep wound infection. The complication rate was 19% (six patients, seven feet). Only one major postoperative complication was encountered: one patient (one foot, 3%) suffered a stress fracture at the proximal first metatarsal osteotomy site that progressed to an asymptomatic non-union. At the moment of the review the patient was satisfied with reservations.
Fig. 4. Radiograph of a 60-year-old woman 1 year after a scarf osteotomy which shows a 48 hallux varus deformity due to excessive medial capsular plication.
Among the seven complications recorded, six (86%) were minor. Any of these patients required further surgery. One patient (one foot, 3%) presented mild hallux varus deformity (48) that was attributed to an excessively tightened medial capsulorraphy (Fig. 4). This patient was satisfied with reservations at follow-up due to minor discomfort with shoe wear but refused a new surgical procedure. Three
Table 3 Radiographic findings (mean, range)
HVA IMA DMAA Medial sesamoid position (G-0/G-1/G-2/G-3) FMPJ subluxation (G-0/G-1/G-2) FMPJ arthritic changes (G-0/G-1/G-2/G-3/G-4)
Preoperative
Last follow-up
Correction
% Correction
p value
34 (20–50) 15 (7–22) 18.4 (10–40) (0/5/18/14) (2/16/19) 0/28/9/0/0
16.6 ( 4 to 33) 9.4 (2–15) 9.4 (0–18) (10/21/6/0) (18/16/3) 0/28/9/0/0
17.4 5.8 9 – – –
51 38 46 – – –
<0.001 <0.001 <0.001 <0.001 – –
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patients (8%) had superficial wound infections which healed uneventfully, after administration of appropriate antibiotics. One patient (one foot, 3%) reported persistent numbness in the scar along the medial border of the first toe. Symptomatic first metatarsal joint stiffness was seen in one patient (one foot, 3%). We found no cases of osteonecrosis of the first metatarsal head or reflex sympathetic dystrophy. Four patients (11%) required further surgery to remove prominent osteosynthesis (two staples in the first phalanx and two screws in the metatarsal osteotomy) causing irritation. The pain solved when the hardware was removed after the osteotomies healed.
4. Discussion Several operative methods on the first metatarsal have been reported for hallux valgus deformity, such as distal osteotomies, diaphyseal osteotomies, as well as different proximal osteotomies. All of them share the same goal: improving the altered angular pathologies associated with hallux valgus without significant risks. The selection of a specific procedure must be found on the pathologic elements presented and its severity. Furthermore, it is widely accepted that no isolated technique can address the whole range of deformity of hallux valgus and that even technically well-performed procedures may fail. Distal metatarsal osteotomies are advocated for hallux valgus deformities with small intermetatarsal angles and bear the risk of avascular necrosis of the metatarsal head [15]. Basal osteotomies have been proven to effectively correct significant metatarsus primus varus. However, the amount of correction is limited by the distal articular lateral slope or DMAA unless a distal metatarsal osteotomy is added. Basal osteotomies are demanding technically and are not free of complications. Undesirable side effects include shortening and dorsiflexion of the first metatarsal from 28 to 82% of patients despite adequate fixation which may lead to lateral transfer metatarsalgia. In order to reduce these risks it often requires a period of casting and nonweightbearing [16,17]. The scarf osteotomy was performed on 30 patients (37 feet) with moderate to severe hallux valgus at our hospital during the period of the present study. The advantages of this Z-fashion osteotomy of the first metatarsal are its versatility and its reliability so that it results in a wide range of indications. It allows a lateral shift of up to two thirds of the surface of the plantar fragment including the metatarsal head. As a result of the plantar obliquity of the longitudinal cut, up to 5 mm of lowering can alleviate metatarsalgia under the second metatarsal head. The scarf works not only providing correction for deformities with large intermetatarsal angles but also the possibility of restoring the normal relationship of the metatarsophalangeo-sesamoid complex [18,9,10].
In the present series, the average correction of the HVA was 17.48 and the average correction of the IMA was 5.88. Lorei et al. estimated these corrections in 26.38 and 8.98, respectively [17]. Aslam et al. [19] performed 22 scarf osteotomies in 13 patients for hallux valgus deformities. Radiographic improvements included HVA from 31.58 to 148 (median correction 168) and IMA from 14.58 to 88 (median correction 68). Regarding the medial sesamoid position, 5 feet (14%) were grade 1 or less preoperatively and 31 feet (84%) were grade 1 or less at follow-up, for a significant improvement ( p < 0.001) in our current series. These results are comparable to observations by David-West et al. [20] who reported that 27% of 30 cases of hallux valgus were grades 1 or less preoperatively, and 97% of these feet were grades 1 or less at 13 months, showing a significant correction of the tibial sesamoid bone after the scarf procedure. At the same time the DMAA can easily be corrected by increasing the lateral displacement of the proximal end of the osteotomy compared to the distal end. The average correction of the DMAA in the present series (98) was significant. This coincides with other reports [19,21] that point out the benefit of realigning the cartilaginous surface of the distal first metatarsal. The fact that the intraobserver and interobserver reliability in the measurement of the DMAA is questioned in the literature should not to be forgotten [11,22,23]. Our results compared well with those reported in the literature (Table 4). We agree with Barouk [10] in considering surgery of forefoot as a single entity. In order to respect the harmony of the metatarsal arch, 77 Weil osteotomies of the lesser rays were performed in 24 feet. A negative metatarsal index presented preoperatively in 18 feet (49%) appeared postoperatively in 4 feet (11%). Thirty-two feet (87%) had an additional great toe first phalanx osteotomy as emphasized by the load simulation test intraoperatively. This coincides with other reports [24,25] that point out the benefits of accomplishing the correction by its varisation, shortening or derrotation effects. Others [19] have found sufficient reduction of HVA in almost all cases by the scarf without the need for a phalangeal osteotomy. In a recent paper, Malviya et al. [26] reported their functional and radiological results of scarf osteotomy with and without Akin in 69 patients with 99 procedures. These authors found no significant difference between their scarf osteotomy (54 patients, 74 toes) and scarf with Akin (17 patients, 25 toes) group, and concluded that adding Akin procedures increase the risk of complications and may not be indicated as a routine procedure. We agree with Martı´nez-Gime´nez et al. [21] and Wagner et al. [16] in considering that the soft-tissue procedures (both lateral release and medial tightening) are critical in correcting the first metatarsophalangeal joint subluxation thus diminishing the likelihood of progressive deformity. In 18 (49%) of the preoperative feet in our series, the first
93 91.1 9.1 12.3 7.2 8.3 16.1 17.4 53.2 54.6 18.4 20.7 15.7 15.8 38.2 37.1 54/74 17/25 Scarf Scarf and Akin Malviya et al. [26]
20.8
0.89 (0–2) 85.6 (47–100) 0.91 (0–2) – – 85 (50–100) – – – 86.5 (57–97) – 82 (39–100) 16.6 ( 4–33) 9.4 (2–15) 9.4 (0–18) 14 (5–31) 8 (3–16) 10 (0–16) 14 (2–32) 9 (2–15) 11 (3–25) 23 8 – 16.9 (5–40) 10.1 (8–20) – 17 10 10 2.24 (0–3) 46.3 (12–77) 2.27 (0–3) – – 52 (15–78) – – – 54.5 (34–78) – 43 (14–68) 18.4 (10–40) 13 (2–34) 14 (6–35) – – 13 15 (7–22) 14.5 (8–19) 15 (10–19) 16 15.4 (12–20) 16 34 (20–50) 31.5 (16–43) 33 (24–46) 43 34.5 (20–46) 32 30/37 13/22 24/35 49/53 21/27 71/84 Scarf (87% Akin) Scarf Scarf and Akin Scarf Scarf Scarf (75% Akin) Present study Aslam et al. [19] Jones et al. [30] Wagner et al. [16] Aminian et al. [18] Crevoisier et al. [25]
22 6 24 14 16.1 22
HVA
Follow-up Patients/ Preoperative (month) feet HVA Surgery Series
Table 4 Comparison with previously published data
IMA
DMAA
Sesamoid position
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metatarsophalangeal joint congruency was grade 0 or 1, and 19 (51%) was grade 2. In the postoperative feet 34 (92%) were grade 0 or 1, showing a correction of the first metatarsophalangeal joint subluxation. As in other published articles [21,24] we have found no significant deterioration of previous metatarsophalangeal joint arthritic changes after the scarf osteotomy. It may be attributable to the decrease of axial longitudinal pressure in the metatarsophalangeal joint after shortening of the first metatarsal and/or the first phalanx when required. Due to the inherent stability of the osteotomy in spite of very large displacements, immediate weightbearing and early functional recovery is possible. It is difficult to compare the published series because they include different method of data collection [27]. In order to make the comparative analysis of our results more accurate and according to the criteria stated by the AOFAS research committee, a precise description of reliable angular measurements and specific reference points is presented. The Mose sphere helps us to define accurately the distal reference point for the first metatarsal. This method avoids spurious effects of medial eminence resection or double density seen on postoperative radiographs after a scarf osteotomy. We always used the same measurement device (protractor) on standardized weightbearing radiographs in order to minimize this source of error. Clinical assessment was undertaken using the AOFAS clinical rating system and an interview about subjective satisfaction regarding pain relief and appearance. Both tools have come into widespread use as foot and ankle outcome instruments [28,29]. The AOFAS score of 86 points at follow-up showed a good clinical outcome for the hallux and compared well with the scores reported in other studies [30,21,25]. At the time of follow-up 80% of the patients were satisfied, 17% were satisfied with reservations and 3% were not satisfied. It should be enphasized that the degree of clinical improvement was not parallel to the radiographic results. As in other published articles [30,31] we have found a low correlation (<0.45) between the radiological results (for the HVA and IMA) and the global AOFAS score. Jones concluded that the AOFAS score may not be adequate for assessing outcome and that other aspects of skeletal correction not currently included may be required [30]. One could criticize this study because we did not use computer-assisted measurements on digital radiographs to evaluate our results. Several authors demonstrate that electronic measurements help to reduce sources of inter and intraobserver error resulting from the process of manual measurement [22,32]. A second possible criticism of our study is that in the current series we compared the roentgenographic data preoperatively and at last followup, without taking into account the intermediate radiographic measurements. Therefore, the distinction between undercorrection (an inadequate initial procedure) and
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recurrence (increasing deformity with time) was not well defined. It was beyond the purpose of our study to analyze postoperative foot-loading data using pedographic measurements performed in recent series [30,17]. One of the objections of the scarf is that it was noted to be a technical demanding procedure. Furthermore, relatively high rate of complications like fractures, over and undercorrection, excessive shortening with transfer metatarsalgia, delayed union and avascular necrosis have been recorded in literature [33,34]. Our complication rate (19%) was comparable to those previously reported [30,17,31,25]. Nevertheless in our series the greater part of them (86%) were minor and did not alter the final results. There is a steep learning curve for the surgeon to master the scarf osteotomy and results of surgery during learning period may be associated with technical difficulties. We have found the unexpected low rate of intraoperative complications in our series to be related to two causes: first, between 1996 and 2006 (a 10 year period), more than 500 scarf osteotomies were performed by the senior author (AJLL) to correct hallux valgus deformities; second, the availability of more sophisticated instruments as the osteotomy guide used for the osteotomies performed during the period of the present study. Noteworthy is the high rate of removing symptomatic hardware after scarf and Akin procedures. In the series by Jones et al. [30], implant removal as a second operation occurred in 1 of the 35 feet (3%). Therefore, while four of our thirty patients (four feet, 11%) required a second operation, the convenience of using low profile hardware should be considered in all patients. In the light of our observations and the literature reviewed, we believe that the scarf, combined when needed with an Akin procedure, is safe, effective and provide good results in the treatment of moderate to severe hallux valgus deformities. Although larger series need to be analyzed, in our opinion the presented technique is a good alternative in comparison with proximal osteotomies in properly selected patients.
Acknowledgement We thank Cassandra Rosenblum for her help in the preparation and translation of this manuscript.
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