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Scarf osteotomy for hallux valgus deformity: Radiological outcome, metatarsal length and early complications in 118 feet
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Scarf osteotomy for hallux valgus deformity: Radiological outcome, metatarsal length and early complications in 118 feet Christopher G. Lenz* ,1, Richard Niehaus, Ivo Knych, Karim Eid, Paul Borbas1 Cantonal Hospital Baden, Department of Orthopaedics and Traumatology, Im Ergel 1, 5404 Baden, Switzerland
A R T I C L E I N F O
A B S T R A C T
Article history: Received 18 June 2019 Received in revised form 25 November 2019 Accepted 3 January 2020 Available online xxx
Background: Scarf osteotomy has been widely used to restore axial orientation of the first ray in the treatment of hallux valgus deformity. The aim of the study was to present our radiological outcomes of bunion reconstruction, identify surgical complications in early follow-up, and assess to what extent a shortening of the first metatarsal is present after surgery as a possible cause of postoperative metatarsalgia. Methods: We enrolled 106 patients (118 feet) and assessed patients’ pre- and postoperative measurements of hallux valgus and intermetatarsal angles on weightbearing X-ray images. Three different methods of measuring metatarsal length were compared and early postoperative complications noted. Results: Hallux valgus angle decreased significantly by an average of 18.7 degrees and the intermetatarsal angle by 7.8 degrees. Using three methods of measuring metatarsal length, all showed significant shortening of the first metatarsal. Mean relative lengthening of the second metatarsal averaged 0.45 mm. The Coughlin method showed the highest interrater reliability (ICC = 0.96). Conclusions: Significant reduction of the hallux valgus angle and intermetatarsal angle was demonstrated with a low complication rate. There was significant shortening of the first metatarsal. The Coughlin method clearly demonstrated an excellent interrater reliability. Level of evidence: Level IV. © 2020 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Hallux valgus Scarf Metatarsal osteotomy Correction Shortening Metatarsalgia Hallux valgus angle Intermetatarsal angle
1. Introduction Hallux valgus deformity is a common forefoot disorder with a prevalence of 23% in patients aged between 18 and 65 years, and 36% in patients older than 65 years [1]. The condition is characterized by lateral deviation of the great toe and medial deviation of the first metatarsal, and is commonly accompanied by progressive subluxation of the first metatarsophalangeal joint. Numerous procedures have been described to correct hallux valgus deformity. Results following scarf osteotomy are generally satisfactory [2–11]. Nevertheless, results and complication rates have been highly variable in several studies [2,4,7,12,13]. We consider the scarf osteotomy a powerful tool in mild to severe deformities. As the correction of bunion deformity using a scarf osteotomy, with or without an additional Akin osteotomy, is the most common procedure undertaken in our general hospital, we sought to assess whether we are able to gain satisfactory
* Corresponding author. E-mail address: [email protected] (C.G. Lenz). All authors contributed equally to this work.
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radiological results with a low complication rate. Furthermore, inadvertent shortening of the first metatarsal after scarf osteotomy may represent a clinically-relevant problem causing transfer metatarsalgia, which can be observed after surgery. Techniques to avoid inadvertent shortening and troughing of the first metatarsal have been described [14,15]. Limited data exist on shortening of the metatarsal after scarf osteotomy. Thus, we also sought to answer the question whether there is significant shortening of the first metatarsal. A reliable and reproducible method to measure shortening of the first metatarsal is lacking [16]. We compared direct measurement methods with the method described by Coughlin [17], which measures the length of the second metatarsal.
2. Material and methods This study was a retrospective review of a consecutive series of patients who underwent hallux valgus correction with Scarf osteotomy, with or without additional Akin osteotomy, by two foot surgeons between May 2015 and July 2017 at a single orthopedic center. Ethics committee approval and consent was obtained to use
https://doi.org/10.1016/j.fas.2020.01.002 1268-7731/© 2020 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: C.G. Lenz, et al., Scarf osteotomy for hallux valgus deformity: Radiological outcome, metatarsal length and early complications in 118 feet, Foot Ankle Surg (2020), https://doi.org/10.1016/j.fas.2020.01.002
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Table 1 Classification of the radiological degree of severity of patients’ hallux valgus deformities.
Mild Moderate Severe
HVA
IMA
15–19 degrees 20–40 degrees >40 degrees
9–11 degrees 12–16 degrees >16 degrees
HVA, hallux valgus angle; IMA, intermetatarsal angle.
patient data for this study (ID 2018-00722). Inclusion criteria were mild to severe (Table 1) hallux valgus deformity with ongoing symptoms following conservative management. Although not every patient with a severe deformity qualified for a Scarf and an Akin osteotomy, we found 10 feet in which the procedure could be performed based on patient-tailored decision making. We consider Scarf osteotomy a valuable tool for hallux valgus angles of more than 40 degrees and an intermetatarsal angle of up to 20 degrees. Weightbearing radiographs preoperatively and at six or 12 weeks postoperatively had to be available in the patients’ medical records for inclusion. Exclusion criteria were previous surgery of the hallux, severe hindfoot deformity, osteoarthritis, or an incomplete series of weightbearing radiographs. Of 197 feet in 183 patients who underwent hallux valgus correction, 118 feet in 106 patients met the inclusion criteria and were included in the final analysis. All patients provided consent to undergo the surgical procedure. Surgeries were performed using the same operative techniques, including lateral soft tissue release of the metatarsalsesamoidal-phalangeal complex, Scarf osteotomy, additional procedure (Akin osteotomy), resection of the medial eminence, and medial capsulorraphy. Scarf osteotomy was performed by completing three bone cuts using an oscillating saw, and the cuts were marked and set as described by Barouk [3]. The need for an Akin osteotomy was assessed intraoperatively after the Scarf osteotomy and soft tissue balancing have been completed, and was indicated in patients with any hallux interphalangeus or residual valgus to realign the tendon of the extensor hallucis longus [11,18]. Primary outcome measures were correction of the hallux valgus angle, correction of the intermetatarsal angle according to Coughlin et al. (Fig. 1) [19,20], and shortening of the first metatarsal using three methods:
Fig. 2. Comparison of standing pre- and postoperative imaging findings showing the Coughlin method to evaluate metatarsal length on weightbearing dorsoplantar radiographs.
Fig. 3. Comparison of standing pre- and postoperative imaging showing the length of the first and second metatarsal bones to determine the ratio between the two lengths on weightbearing dorsoplantar radiographs.
1. assessing length as described by Coughlin (Fig. 2) [17]; 2. measuring the absolute length of the first metatarsal; 3. measuring the absolute length of the first metatarsal in relation to the length of the second metatarsal (Fig. 3).
Fig. 1. Comparison of standing pre- and postoperative images showing the hallux valgus angle and intermetatarsal angle on weightbearing dorsoplantar radiographs.
All measurements were performed on standardized pre- and postoperative weightbearing dorsoplantar radiographs of the foot by two independent observers. Deformity of the hallux valgus angle was graded as mild, moderate, or severe, and the intermetatarsal angle was graded as shown in Table 1 [21]. The secondary outcome measure was early postoperative complications (infections, metatarsalgia, irritation of hardware, fractures, CRPS, recurrence). Statistical analyses were performed using IBM SPSS Statistics (Version 22.0. Armonk, NY, USA). We used the paired Student's t test to compare pre- and postoperative measurements after assessing the normality of the data. Statistical
Please cite this article in press as: C.G. Lenz, et al., Scarf osteotomy for hallux valgus deformity: Radiological outcome, metatarsal length and early complications in 118 feet, Foot Ankle Surg (2020), https://doi.org/10.1016/j.fas.2020.01.002
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significance was set at P < 0.05. We used the two-way random, average measures, absolute agreement intraclass correlation coefficient (ICC) to determine the interrater reliability, which was evaluated according to Cicchetti et al., with reliability being ‘poor’ for ICC values less than 0.40, ‘fair’ for values between 0.40 and 0.59, ‘good’ for values between 0.60 and 0.74, and ‘excellent’ for values between 0.75 and 1.0 [22].
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Table 3 Complications, occurrence in number of feet, and required treatment. Complication
n=
Treatment
Infection - deep infection - superficial wound infection
4 (3.4%) 2 (1.7%) 2(1.7%)
Revision surgery in three patients Antibiotic treatment without revision surgery in one patient with superficial wound infection
Metatarsalgia
3 (2.5%)
Revision surgery and shortening of the metatarsal in one patient Conservative treatment with an insole and local injection in patients cases
Irritation of hardware
1 (0.8%)
Screw removal of seven months after index surgery
Fracture of the first metatarsal Fracture of the proximal phalanx (fracture of the lateral corticalis during Akin osteotomy) Mild CRPS
1 (0.8%)
Conservative treatment
1 (0.8%)
Second screw during index surgery, no problems postoperatively
1 (0.8%)
Vit. C, Calcitonin for 4 weeks; no residual symptoms after six weeks
Recurrent HV
1 (0.8%)
Revisions surgery 9 months after index surgery
Total
12 (10.2%)
3. Results The average age of the included patients was 51.3 (range, 14–83) years. Ninety-four (89%) of the patients were women, and the right foot was operated on in 69 patients (58%). Postoperative measurements on weightbearing radiographs were performed at an average of 9.6 (range, 4.3–110.3) weeks after surgery. The postoperative hallux valgus angle decreased significantly by an average of 18.7 degrees (6.8, P < 0.0001) and from 28.4 degrees preoperatively to 9.7 degrees postoperatively. The intermetatarsal angle also decreased significantly by a mean of 7.8 degrees (2.55, P < 0.0001), and from 12.9 degrees preoperatively to 5.1 degrees postoperatively. An Akin osteotomy was necessary in 86.4% of the toes in our study. We saw significant shortening of the first metatarsal independent of the measurement method. Mean absolute and relative shortening was 1.7 mm and 2.5%, respectively (3.1, P < 0.001). The ratio of the first metatarsal to the second metatarsal averaged 0.01 (0.07, p = 0.004). The mean relative lengthening of the second metatarsal, using the method described by Coughlin, was 0.45 mm (0.66, P < 0.0001). The Coughlin method had the highest interrater reliability of the three methods (ICC = 0.96), and was rated as excellent. Measuring the shortening of the first metatarsal length reached an excellent ICC at 0.76. However, the ratio of the first metatarsal length to the second metatarsal length demonstrated poor agreement between the observers (ICC = 0.28). An overview of the interrater results is shown in Table 2. Complications occurred in 12 patients (10.2%, Table 3). Four patients had delayed wound healing (3.4%), and of these, revision surgery was necessary in three patients. Three patients also experienced pain caused by metatarsalgia, and one patient required revision surgery and underwent a shortening osteotomy of the second metatarsal. The patient experienced no residual pain after six weeks postoperatively. The remaining two patients with metatarsalgia were successfully treated conservatively. Early implant removal because of irritating screws was performed in
CRPS, complex regional pain syndrome; Vit., vitamin; HV, hallux valgus.
one patient seven months postoperatively. Another patient suffered a fracture of the first metatarsal, which may have resulted from overuse secondary to a psychiatric diagnosis, as well as poor patient compliance. The fracture healed with conservative treatment. In one patient, the lateral corticalis of the proximal phalanx fractured during Akin osteotomy, and a second screw was inserted; the osteotomy healed uneventfully. One patient showed mild symptoms of complex regional pain syndrome. After four weeks of vitamin C and calcitonin administration, which can both relieve pain [23], the symptoms resolved completely. A 15-year-old female patient showed a relapse of hallux valgus with increasing deformity, and required revision surgery nine months after the index surgery. 4. Discussion
Table 2 Overview of results D: change between preoperative and postoperative values.
HVA preoperative ( ) HVA postoperative ( ) Correction of HVA ( ) IMA preoperative ( ) IMA postoperative ( ) Correction of IMA ( ) MT-I length preop. (mm) MT-I length postop. (mm) Correction of MT-I length (mm) MT-I/II ratio preoperative MT-I/II ratio postoperative D MT-I/II ratio Coughlin preoperative (mm) Coughlin postoperative (mm) D Coughlin change (mm)
Mean
SD
ICC
28.35 9.69 18.66 12.94 5.13 7.81 63.76 62.19 1.57 0.84 0.82 0.01 4.53 4.96 0.45
9.02 8.73 6.80 3.09 3.60 2.55 5.18 5.06 3.07 0.04 0.03 0.07 1.50 1.63 0.66
0.99 0.98 0.98 0.97 0.95 0.86 0.84 0.73 0.76 0.35 0.19 0.28 0.97 0.95 0.96
p-Value
<0.0001
<0.0001
<0.001
0.004
<0.0001
SD, standard deviation; ICC, intraclass correlation coefficient; HVA, hallux valgus angle; , degree; IMA, intermetatarsal angle; MT-I, first metatarsal bone; MT-I/II ratio, ratio between the length of metatarsal I and metatarsal II; preop., preoperative; postop., postoperative.
This retrospective study of 118 feet in 106 patients assessed the correction of hallux valgus deformity, as well as the difference in length of the first metatarsal after corrective surgery. The objective of hallux valgus surgery is to correct the deformity by realigning the metatarsophalangeal joint without disrupting the biomechanical function and normal weightbearing ability of the first metatarsophalangeal joint complex. The power of the Scarf osteotomy in correcting the HVA is limited, as it can not or only to a very low extent correct the DMAA if increased. In those cases, an additional Akin can be considered in order to correct the HVA. The first finding of this study was that adequate correction could be achieved with a Scarf osteotomy and, if necessary, with an additional Akin osteotomy. Scarf osteotomy is a viable tool to correct mild to moderate deformities, as well as some severe deformities. In feet with a hallux valgus angle of more than 40 degrees and an intermetatarsal angle of up to 20 degrees, Scarf osteotomy can successfully correct the deformity. Both the hallux valgus angle and the intermetatarsal angle decreased significantly after surgery in our study. The hallux valgus angle
Please cite this article in press as: C.G. Lenz, et al., Scarf osteotomy for hallux valgus deformity: Radiological outcome, metatarsal length and early complications in 118 feet, Foot Ankle Surg (2020), https://doi.org/10.1016/j.fas.2020.01.002
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improved by 18.7 degrees and the intermetatarsal angle by 7.8 degrees, similar to findings in previous studies [2–11]. The second finding was the low overall complication rate of 10.2%, indicating that the procedure is safe; wound complications were seen in 3.4% of patients. The third finding was a small but significant shortening of the first metatarsal. We found a mean absolute shortening of the first metatarsal of 1.7 mm (range, 8.5 to 5.4 mm). Comparing different methods to determine metatarsal length, the method described by Coughlin [17] was the most reliable, with an ICC of 0.96. Measuring the absolute length of the first metatarsal and its ratio to the second metatarsal length should be avoided for decision making, as it appeared to be associated with errors. In the 2000s, when Scarf osteotomy became increasingly popular, poor outcomes gave rise to doubts about the value of the technique [12]. Modifications of the procedure improved postoperative results, especially regarding the common adverse event of troughing, which can be easily avoided. Scarf osteotomy is considered inherently stable and showed superior stability compared to proximal Chevron and proximal crescentic osteotomies in biomechanicall testing, and allows early weightbearing and exercise [24,25]. Ma et al. conducted a meta-analysis and found comparable results for both procedures (Chevron and Scarf osteotomy) without significant differences in the hallux valgus angle, intermetatarsal angle, American Orthopedic Foot and Ankle Society score, and complication rate [10]. Using a long arm in the horizontal cut, sufficient correction of the intermetatarsal angle can be achieved. It is generally agreed that there is no single operation to address all components of hallux valgus deformity of the forefoot; however, Scarf osteotomy represents a powerful, versatile, and reliable tool to correct hallux valgus deformity and avoids the possible complication of an elevated first metatarsal, which is associated with other metatarsal osteotomies of the proximal bone [26]. In the interest of completeness, Scarf osteotomy cannot solely correct hallux valgus deformity, and is always just one part of the entire corrective procedure; lateral release, excision of the medial eminence, and medial capsulorraphy complete a successful operative procedure [27]. There are several disadvantages and limitations of a Scarf osteotomy. Barouk reported a steep learning [3] curve and overall complications in recent studies range between 6% and 35% [12,28]. Intraoperative troughing is the main reason for the high complication rate, and this can be avoided, so we consider the overall complication rate to be on lower end of this range in recent years. Nevertheless, troughing is a serious complication resulting in a rotational malunion of the first metatarsal, and this is very difficult to amend. Smith et al. reported first metatarsal fractures in 3% associated with incomplete osteotomies of the first metatarsal or excess stress during screw insertion [28]. It is important to reach the plantar third of the metatarsal when completing the longitudinal cut proximally to have enough bone to avoid too much stress on the dorsal fragment and possible fracture. Postoperative stress fractures can occur and are thought to be secondary to suboptimal screw placement [11]. Meticulous screw placement and decreasing the obliquity of the distal cut should decrease the risk of stress fractures [11]. Scarf osteotomy creates a stable fixation due to the cuts of the osteotomy and the large area of cancellous bone that is fixed intraoperatively, which allows early weightbearing. Crevoisier et al. found that two of 84 feet had an unstable reconstruction due to inadequate screw length [4]. One case required revision surgery and the second case could be treated nonoperatively by means of secondary bone healing. The 3.4% rate of wound complications in our patients was comparable to other studies, which reported an incidence between 1.8% and 5.7% [7,29–31]. Troughing was not detected in our
patients intraoperatively and during follow-up. Irritating hardware and recurrent hallux valgus are rare (0.8%), although we refrain from interpretation because of the short follow-up and emphasis on radiological outcomes in our study. Overall, irritating hardware can often be attributed to prominent screws, but this is a rare complication [4,7,8]. Length alterations are an issue in hallux valgus surgery, especially in patients suffering primary metatarsalgia secondary to insufficiency of the first ray and possible length discrepancy between the metatarsal bones. There is evidence indicating a relationship between iatrogenic shortening of the first metatarsal and postoperative metatarsalgia [3,25], although some reports challenge this concept [32,33]. There are limited data regarding the amount of shortening that results after Scarf osteotomy. Smith et al. considered the shortening more pronounced following Scarf osteotomy compared with other osteotomies [28]. Fresion et al. detected a shortening of 2.2 mm without postoperative problems in their patients [34]. Furthermore, different projections during Xray imaging can alter angles and measurements of the length of the metatarsal bones [35]. Therefore, the exact amount of shortening that can be tolerated is unknown and is difficult to define. There is no perfectly precise way to measure length [16]. Our data showed a mean absolute shortening of the first metatarsal of 1.7 mm (range, 8.5 to 5.4 mm), and we identified three patients who suffered metatarsalgia postoperatively. The first patient had a shortening of 5.9 mm of the first metatarsal with a preoperative Coughlin index of 5.48. This patient underwent shortening osteotomy of the second and third metatarsals 10 months after the index surgery and did not complain of residual pain three months after surgery. The second patient had a lengthening of the first metatarsal of 1.2 mm with a Coughlin index of 3.31, and suffered metatarsalgia of the second ray three months after surgery. This was successfully treated using an insole with retrocapital support. The third patient had a shortening of 6.9 mm and a Coughlin index of 7.47 on preoperative radiographs three months after surgery. After a local steroid injection beneath the second and third metatarsal heads, the patient was pain free. None of these patients had metatarsalgia before surgery. Although these numbers are small and not highly representative, our findings may reflect an inconsistency with previous findings. We compared three established methods of measurement. Because a reliable and reproducible measurement method is lacking [16], there is no threshold to support the decision to perform an additional shortening osteotomy in the presence of transfer metatarsalgia. It is important to acknowledge that shortening that occurred in our patients following Scarf osteotomy, although the mean shortening of 1.7 mm should not raise major concerns. Furthermore, it does not help to differentiate between patients with symptomatic hallux valgus and metatarsalgia, who require shortening osteotomy, from those where restoring a competent first ray leads to abatement of symptoms. It is difficult to identify patients who might develop metatarsalgia postoperatively; measuring the first metatarsal length does not appear to be the sole crucial parameter. Kaipel et al. challenged the concept of metatarsalgia resulting from increased lesser metatarsal length by demonstrating a missing correlation between metatarsal length and maximal peak pressure under the corresponding metatarsal heads [33]. There are several limitations of our study. First was the short follow-up, which resulted because treatment in the majority of patients did not need to be continued, and most patients were not willing to consent to further consultations. However, our intention in this study was to determine the amount of correction after surgery, for which a short follow-up was sufficient. Additionally, early complications such as infection, the amount of correction, and residual pain in patients with persistent or postoperative onset
Please cite this article in press as: C.G. Lenz, et al., Scarf osteotomy for hallux valgus deformity: Radiological outcome, metatarsal length and early complications in 118 feet, Foot Ankle Surg (2020), https://doi.org/10.1016/j.fas.2020.01.002
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of transfer metatarsalgia can be identified in a short follow-up. Another limitation is that we did not gather objective information using scores, which slightly impairs the presentation of our results, although we focused on radiological results. Persistent pain, which would produce a lower score, was considered a complication, and would have been detected or listed if identified. In conclusion, we were able to show that the Scarf osteotomy is a safe, powerful, and reliable tool to correct hallux valgus deformity. Knowledge and awareness of possible pitfalls and a large range of complications and care are required to achieve a good outcome. There is a significant amount of shortening of the first metatarsal, which has to be considered, especially in patients with predominant metatarsalgia preoperatively. Conflict of interest None of the authors declare a conflict of interest. Funding No external funding was obtained for this study. Acknowledgment We thank Peter Mittwede, MD, PhD, from Edanz Group (www.edanzediting.com/ac) for editing a draft of this manuscript. References [1] Nix S, Smith M, Vicenzino B. Prevalence of hallux valgus in the general population: a systematic review and meta-analysis. J Foot Ankle Res 2010;3:21. [2] 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. [3] Barouk LS. Scarf osteotomy for hallux valgus correction. Local anatomy, surgical technique, and combination with other forefoot procedures. Foot Ankle Clin 2000;5:525–58. [4] Crevoisier X, et al. The scarf osteotomy for the treatment of hallux valgus deformity: a review of 84 cases. Foot Ankle Int 2001;22:970–6. [5] Dereymaeker G. Scarf osteotomy for correction of hallux valgus. Surgical technique and results as compared to distal chevron osteotomy. Foot Ankle Clin 2000;5:513–24. [6] Jeuken RM. Long-term follow-up of a randomized controlled trial comparing scarf to chevron osteotomy in hallux valgus correction. Foot Ankle Int 2016;37:687–95. [7] Jones S, et al. Scarf osteotomy for hallux valgus. A prospective clinical and pedobarographic study. J Bone Joint Surg Br 2004;86:830–6. [8] Lipscombe S. Scarf osteotomy for the correction of hallux valgus: midterm clinical outcome. J Foot Ankle Surg 2008;47:273–7. [9] Lorei TJ, et al. Pedographic, clinical, and functional outcome after scarf osteotomy. Clin Orthop Relat Res 2006;451:161–6.
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[10] Ma Q, Liang X, Lu J. Chevron osteotomy versus scarf osteotomy for hallux valgus correction: a meta-analysis. Foot Ankle Surg 2018;25(6)755–60 (Epub ahead of print). [11] Molloy A, Widnall J. Scarf osteotomy. Foot Ankle Clin 2014;19:165–80. [12] Coetzee JC. Scarf osteotomy for hallux valgus repair: the dark side. Foot Ankle Int 2003;24:29–33. [13] Weil L. Scarf osteotomy for correction of hallux valgus. Historical perspective, surgical technique, and results. Foot Ankle Clin 2000;5:559–80. [14] Takakura Y, et al. Lengthening of short great toes by callus distraction. J Bone Joint Surg Br 1997;79:955–8. [15] Toth K, et al. The effect of first ray shortening in the development of metatarsalgia in the second through fourth rays after metatarsal osteotomy. Foot Ankle Int 2007;28:61–3. [16] Chauhan D, Bhutta MA, Barrie JL. Does it matter how we measure metatarsal length? Foot Ankle Surg 2011;17:124–7. [17] Coughlin MJ. Crossover second toe deformity. Foot Ankle 1987;8:29–39. [18] Coughlin MJ. A.R. Hallux valgus. In: Coughlin MJ SC, Anderson RB, editors. Mann’s surgery of the foot and ankle. . p. 201–79. [19] Coughlin MJ. Hallux valgus. J Bone Joint Surg Am 1996;78:932–66. [20] Coughlin MJ, Saltzman CL, Nunley 2nd 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. [21] Hardy RH, Clapham JC. Observations on hallux valgus; based on a controlled series. J Bone Joint Surg Br 1951;33-B:376–91. [22] Cicchetti D. Guidelines, criteria, and rules of thumb for evaluating normed and standardized assessment of instruments in psychology. Psychol Assess 1994;6:284–90. [23] Harden RN, et al. Complex regional pain syndrome: practical diagnostic and treatment guidelines, 4th edition. Pain Med 2013;14:180–229. [24] Newman AS, et al. A biomechanical comparison of the Z step-cut and basilar crescentic osteotomies of the first metatarsal. Foot Ankle Int 2000;21:584–7. [25] Trnka HJ, Parks BG, Ivanic G, Chu IT, Easley ME, Schon LC, et al. Six first metatarsal shaft osteotomies: mechanical and immobilization comparisons. Clin Orthop Relat Res 2000;381:256–65. [26] Schuberth JM, Reilly CH, Gudas CJ. The closing wedge osteotomy. A critical analysis of first metatarsal elevation. J Am Podiatry Assoc 1984;74:13–24. [27] Barouk L. New osteotomies of the forefoot and their therapeutic role. In: Valtin B, editor. Forefoot surgery. Paris: Expansion scientifique francaise; 1996. p. 13–24. [28] Smith am, Alwan T, Davies MS. Perioperative complications of the Scarf osteotomy. Foot Ankle Int 2003;24:222–7. [29] Kristen KH, et al. The SCARF osteotomy for the correction of hallux valgus deformities. Foot Ankle Int 2002;23:221–9. [30] Perugia D, et al. The scarf osteotomy for severe hallux valgus. Int Orthop 2003;27:103–6. [31] Kerr HL, Jackson R, Kothari P. Scarf-akin osteotomy correction for hallux valgus: short-term results from a district general hospital. J Foot Ankle Surg 2010;49:16–9. [32] Karpe P, et al. Shortening Scarf osteotomy for correction of severe hallux valgus. Does shortening affect the outcome? Foot (Edinb) 2016;29:45–9. [33] Kaipel M, Krapf D, Wyss C. Metatarsal length does not correlate with maximal peak pressure and maximal force. Clin Orthop Relat Res 2011;469(4):1161–6. [34] Freslon M, et al. Scarf osteotomy for the treatment of hallux valgus: a review of 123 cases with 4.8 years follow-up. Rev Chir Orthop Reparatrice Appar Mot 2005;91:257–66. [35] Richter M, et al. PedCAT for 3D-imaging in standing position allows for more accurate bone position (angle) measurement than radiographs or CT. Foot Ankle Surg 2014;20:201–7.
Please cite this article in press as: C.G. Lenz, et al., Scarf osteotomy for hallux valgus deformity: Radiological outcome, metatarsal length and early complications in 118 feet, Foot Ankle Surg (2020), https://doi.org/10.1016/j.fas.2020.01.002
Foot and Ankle Surgery xxx (2019) xxx–xxx
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Scarf osteotomy for hallux valgus deformity: Radiological outcome, metatarsal length and early complications in 118 feet Christopher G. Lenz* ,1, Richard Niehaus, Ivo Knych, Karim Eid, Paul Borbas1 Cantonal Hospital Baden, Department of Orthopaedics and Traumatology, Im Ergel 1, 5404 Baden, Switzerland
A R T I C L E I N F O
A B S T R A C T
Article history: Received 18 June 2019 Received in revised form 25 November 2019 Accepted 3 January 2020 Available online xxx
Background: Scarf osteotomy has been widely used to restore axial orientation of the first ray in the treatment of hallux valgus deformity. The aim of the study was to present our radiological outcomes of bunion reconstruction, identify surgical complications in early follow-up, and assess to what extent a shortening of the first metatarsal is present after surgery as a possible cause of postoperative metatarsalgia. Methods: We enrolled 106 patients (118 feet) and assessed patients’ pre- and postoperative measurements of hallux valgus and intermetatarsal angles on weightbearing X-ray images. Three different methods of measuring metatarsal length were compared and early postoperative complications noted. Results: Hallux valgus angle decreased significantly by an average of 18.7 degrees and the intermetatarsal angle by 7.8 degrees. Using three methods of measuring metatarsal length, all showed significant shortening of the first metatarsal. Mean relative lengthening of the second metatarsal averaged 0.45 mm. The Coughlin method showed the highest interrater reliability (ICC = 0.96). Conclusions: Significant reduction of the hallux valgus angle and intermetatarsal angle was demonstrated with a low complication rate. There was significant shortening of the first metatarsal. The Coughlin method clearly demonstrated an excellent interrater reliability. Level of evidence: Level IV. © 2020 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Hallux valgus Scarf Metatarsal osteotomy Correction Shortening Metatarsalgia Hallux valgus angle Intermetatarsal angle
1. Introduction Hallux valgus deformity is a common forefoot disorder with a prevalence of 23% in patients aged between 18 and 65 years, and 36% in patients older than 65 years [1]. The condition is characterized by lateral deviation of the great toe and medial deviation of the first metatarsal, and is commonly accompanied by progressive subluxation of the first metatarsophalangeal joint. Numerous procedures have been described to correct hallux valgus deformity. Results following scarf osteotomy are generally satisfactory [2–11]. Nevertheless, results and complication rates have been highly variable in several studies [2,4,7,12,13]. We consider the scarf osteotomy a powerful tool in mild to severe deformities. As the correction of bunion deformity using a scarf osteotomy, with or without an additional Akin osteotomy, is the most common procedure undertaken in our general hospital, we sought to assess whether we are able to gain satisfactory
* Corresponding author. E-mail address: [email protected] (C.G. Lenz). All authors contributed equally to this work.
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radiological results with a low complication rate. Furthermore, inadvertent shortening of the first metatarsal after scarf osteotomy may represent a clinically-relevant problem causing transfer metatarsalgia, which can be observed after surgery. Techniques to avoid inadvertent shortening and troughing of the first metatarsal have been described [14,15]. Limited data exist on shortening of the metatarsal after scarf osteotomy. Thus, we also sought to answer the question whether there is significant shortening of the first metatarsal. A reliable and reproducible method to measure shortening of the first metatarsal is lacking [16]. We compared direct measurement methods with the method described by Coughlin [17], which measures the length of the second metatarsal.
2. Material and methods This study was a retrospective review of a consecutive series of patients who underwent hallux valgus correction with Scarf osteotomy, with or without additional Akin osteotomy, by two foot surgeons between May 2015 and July 2017 at a single orthopedic center. Ethics committee approval and consent was obtained to use
https://doi.org/10.1016/j.fas.2020.01.002 1268-7731/© 2020 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: C.G. Lenz, et al., Scarf osteotomy for hallux valgus deformity: Radiological outcome, metatarsal length and early complications in 118 feet, Foot Ankle Surg (2020), https://doi.org/10.1016/j.fas.2020.01.002
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Table 1 Classification of the radiological degree of severity of patients’ hallux valgus deformities.
Mild Moderate Severe
HVA
IMA
15–19 degrees 20–40 degrees >40 degrees
9–11 degrees 12–16 degrees >16 degrees
HVA, hallux valgus angle; IMA, intermetatarsal angle.
patient data for this study (ID 2018-00722). Inclusion criteria were mild to severe (Table 1) hallux valgus deformity with ongoing symptoms following conservative management. Although not every patient with a severe deformity qualified for a Scarf and an Akin osteotomy, we found 10 feet in which the procedure could be performed based on patient-tailored decision making. We consider Scarf osteotomy a valuable tool for hallux valgus angles of more than 40 degrees and an intermetatarsal angle of up to 20 degrees. Weightbearing radiographs preoperatively and at six or 12 weeks postoperatively had to be available in the patients’ medical records for inclusion. Exclusion criteria were previous surgery of the hallux, severe hindfoot deformity, osteoarthritis, or an incomplete series of weightbearing radiographs. Of 197 feet in 183 patients who underwent hallux valgus correction, 118 feet in 106 patients met the inclusion criteria and were included in the final analysis. All patients provided consent to undergo the surgical procedure. Surgeries were performed using the same operative techniques, including lateral soft tissue release of the metatarsalsesamoidal-phalangeal complex, Scarf osteotomy, additional procedure (Akin osteotomy), resection of the medial eminence, and medial capsulorraphy. Scarf osteotomy was performed by completing three bone cuts using an oscillating saw, and the cuts were marked and set as described by Barouk [3]. The need for an Akin osteotomy was assessed intraoperatively after the Scarf osteotomy and soft tissue balancing have been completed, and was indicated in patients with any hallux interphalangeus or residual valgus to realign the tendon of the extensor hallucis longus [11,18]. Primary outcome measures were correction of the hallux valgus angle, correction of the intermetatarsal angle according to Coughlin et al. (Fig. 1) [19,20], and shortening of the first metatarsal using three methods:
Fig. 2. Comparison of standing pre- and postoperative imaging findings showing the Coughlin method to evaluate metatarsal length on weightbearing dorsoplantar radiographs.
Fig. 3. Comparison of standing pre- and postoperative imaging showing the length of the first and second metatarsal bones to determine the ratio between the two lengths on weightbearing dorsoplantar radiographs.
1. assessing length as described by Coughlin (Fig. 2) [17]; 2. measuring the absolute length of the first metatarsal; 3. measuring the absolute length of the first metatarsal in relation to the length of the second metatarsal (Fig. 3).
Fig. 1. Comparison of standing pre- and postoperative images showing the hallux valgus angle and intermetatarsal angle on weightbearing dorsoplantar radiographs.
All measurements were performed on standardized pre- and postoperative weightbearing dorsoplantar radiographs of the foot by two independent observers. Deformity of the hallux valgus angle was graded as mild, moderate, or severe, and the intermetatarsal angle was graded as shown in Table 1 [21]. The secondary outcome measure was early postoperative complications (infections, metatarsalgia, irritation of hardware, fractures, CRPS, recurrence). Statistical analyses were performed using IBM SPSS Statistics (Version 22.0. Armonk, NY, USA). We used the paired Student's t test to compare pre- and postoperative measurements after assessing the normality of the data. Statistical
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significance was set at P < 0.05. We used the two-way random, average measures, absolute agreement intraclass correlation coefficient (ICC) to determine the interrater reliability, which was evaluated according to Cicchetti et al., with reliability being ‘poor’ for ICC values less than 0.40, ‘fair’ for values between 0.40 and 0.59, ‘good’ for values between 0.60 and 0.74, and ‘excellent’ for values between 0.75 and 1.0 [22].
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Table 3 Complications, occurrence in number of feet, and required treatment. Complication
n=
Treatment
Infection - deep infection - superficial wound infection
4 (3.4%) 2 (1.7%) 2(1.7%)
Revision surgery in three patients Antibiotic treatment without revision surgery in one patient with superficial wound infection
Metatarsalgia
3 (2.5%)
Revision surgery and shortening of the metatarsal in one patient Conservative treatment with an insole and local injection in patients cases
Irritation of hardware
1 (0.8%)
Screw removal of seven months after index surgery
Fracture of the first metatarsal Fracture of the proximal phalanx (fracture of the lateral corticalis during Akin osteotomy) Mild CRPS
1 (0.8%)
Conservative treatment
1 (0.8%)
Second screw during index surgery, no problems postoperatively
1 (0.8%)
Vit. C, Calcitonin for 4 weeks; no residual symptoms after six weeks
Recurrent HV
1 (0.8%)
Revisions surgery 9 months after index surgery
Total
12 (10.2%)
3. Results The average age of the included patients was 51.3 (range, 14–83) years. Ninety-four (89%) of the patients were women, and the right foot was operated on in 69 patients (58%). Postoperative measurements on weightbearing radiographs were performed at an average of 9.6 (range, 4.3–110.3) weeks after surgery. The postoperative hallux valgus angle decreased significantly by an average of 18.7 degrees (6.8, P < 0.0001) and from 28.4 degrees preoperatively to 9.7 degrees postoperatively. The intermetatarsal angle also decreased significantly by a mean of 7.8 degrees (2.55, P < 0.0001), and from 12.9 degrees preoperatively to 5.1 degrees postoperatively. An Akin osteotomy was necessary in 86.4% of the toes in our study. We saw significant shortening of the first metatarsal independent of the measurement method. Mean absolute and relative shortening was 1.7 mm and 2.5%, respectively (3.1, P < 0.001). The ratio of the first metatarsal to the second metatarsal averaged 0.01 (0.07, p = 0.004). The mean relative lengthening of the second metatarsal, using the method described by Coughlin, was 0.45 mm (0.66, P < 0.0001). The Coughlin method had the highest interrater reliability of the three methods (ICC = 0.96), and was rated as excellent. Measuring the shortening of the first metatarsal length reached an excellent ICC at 0.76. However, the ratio of the first metatarsal length to the second metatarsal length demonstrated poor agreement between the observers (ICC = 0.28). An overview of the interrater results is shown in Table 2. Complications occurred in 12 patients (10.2%, Table 3). Four patients had delayed wound healing (3.4%), and of these, revision surgery was necessary in three patients. Three patients also experienced pain caused by metatarsalgia, and one patient required revision surgery and underwent a shortening osteotomy of the second metatarsal. The patient experienced no residual pain after six weeks postoperatively. The remaining two patients with metatarsalgia were successfully treated conservatively. Early implant removal because of irritating screws was performed in
CRPS, complex regional pain syndrome; Vit., vitamin; HV, hallux valgus.
one patient seven months postoperatively. Another patient suffered a fracture of the first metatarsal, which may have resulted from overuse secondary to a psychiatric diagnosis, as well as poor patient compliance. The fracture healed with conservative treatment. In one patient, the lateral corticalis of the proximal phalanx fractured during Akin osteotomy, and a second screw was inserted; the osteotomy healed uneventfully. One patient showed mild symptoms of complex regional pain syndrome. After four weeks of vitamin C and calcitonin administration, which can both relieve pain [23], the symptoms resolved completely. A 15-year-old female patient showed a relapse of hallux valgus with increasing deformity, and required revision surgery nine months after the index surgery. 4. Discussion
Table 2 Overview of results D: change between preoperative and postoperative values.
HVA preoperative ( ) HVA postoperative ( ) Correction of HVA ( ) IMA preoperative ( ) IMA postoperative ( ) Correction of IMA ( ) MT-I length preop. (mm) MT-I length postop. (mm) Correction of MT-I length (mm) MT-I/II ratio preoperative MT-I/II ratio postoperative D MT-I/II ratio Coughlin preoperative (mm) Coughlin postoperative (mm) D Coughlin change (mm)
Mean
SD
ICC
28.35 9.69 18.66 12.94 5.13 7.81 63.76 62.19 1.57 0.84 0.82 0.01 4.53 4.96 0.45
9.02 8.73 6.80 3.09 3.60 2.55 5.18 5.06 3.07 0.04 0.03 0.07 1.50 1.63 0.66
0.99 0.98 0.98 0.97 0.95 0.86 0.84 0.73 0.76 0.35 0.19 0.28 0.97 0.95 0.96
p-Value
<0.0001
<0.0001
<0.001
0.004
<0.0001
SD, standard deviation; ICC, intraclass correlation coefficient; HVA, hallux valgus angle; , degree; IMA, intermetatarsal angle; MT-I, first metatarsal bone; MT-I/II ratio, ratio between the length of metatarsal I and metatarsal II; preop., preoperative; postop., postoperative.
This retrospective study of 118 feet in 106 patients assessed the correction of hallux valgus deformity, as well as the difference in length of the first metatarsal after corrective surgery. The objective of hallux valgus surgery is to correct the deformity by realigning the metatarsophalangeal joint without disrupting the biomechanical function and normal weightbearing ability of the first metatarsophalangeal joint complex. The power of the Scarf osteotomy in correcting the HVA is limited, as it can not or only to a very low extent correct the DMAA if increased. In those cases, an additional Akin can be considered in order to correct the HVA. The first finding of this study was that adequate correction could be achieved with a Scarf osteotomy and, if necessary, with an additional Akin osteotomy. Scarf osteotomy is a viable tool to correct mild to moderate deformities, as well as some severe deformities. In feet with a hallux valgus angle of more than 40 degrees and an intermetatarsal angle of up to 20 degrees, Scarf osteotomy can successfully correct the deformity. Both the hallux valgus angle and the intermetatarsal angle decreased significantly after surgery in our study. The hallux valgus angle
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improved by 18.7 degrees and the intermetatarsal angle by 7.8 degrees, similar to findings in previous studies [2–11]. The second finding was the low overall complication rate of 10.2%, indicating that the procedure is safe; wound complications were seen in 3.4% of patients. The third finding was a small but significant shortening of the first metatarsal. We found a mean absolute shortening of the first metatarsal of 1.7 mm (range, 8.5 to 5.4 mm). Comparing different methods to determine metatarsal length, the method described by Coughlin [17] was the most reliable, with an ICC of 0.96. Measuring the absolute length of the first metatarsal and its ratio to the second metatarsal length should be avoided for decision making, as it appeared to be associated with errors. In the 2000s, when Scarf osteotomy became increasingly popular, poor outcomes gave rise to doubts about the value of the technique [12]. Modifications of the procedure improved postoperative results, especially regarding the common adverse event of troughing, which can be easily avoided. Scarf osteotomy is considered inherently stable and showed superior stability compared to proximal Chevron and proximal crescentic osteotomies in biomechanicall testing, and allows early weightbearing and exercise [24,25]. Ma et al. conducted a meta-analysis and found comparable results for both procedures (Chevron and Scarf osteotomy) without significant differences in the hallux valgus angle, intermetatarsal angle, American Orthopedic Foot and Ankle Society score, and complication rate [10]. Using a long arm in the horizontal cut, sufficient correction of the intermetatarsal angle can be achieved. It is generally agreed that there is no single operation to address all components of hallux valgus deformity of the forefoot; however, Scarf osteotomy represents a powerful, versatile, and reliable tool to correct hallux valgus deformity and avoids the possible complication of an elevated first metatarsal, which is associated with other metatarsal osteotomies of the proximal bone [26]. In the interest of completeness, Scarf osteotomy cannot solely correct hallux valgus deformity, and is always just one part of the entire corrective procedure; lateral release, excision of the medial eminence, and medial capsulorraphy complete a successful operative procedure [27]. There are several disadvantages and limitations of a Scarf osteotomy. Barouk reported a steep learning [3] curve and overall complications in recent studies range between 6% and 35% [12,28]. Intraoperative troughing is the main reason for the high complication rate, and this can be avoided, so we consider the overall complication rate to be on lower end of this range in recent years. Nevertheless, troughing is a serious complication resulting in a rotational malunion of the first metatarsal, and this is very difficult to amend. Smith et al. reported first metatarsal fractures in 3% associated with incomplete osteotomies of the first metatarsal or excess stress during screw insertion [28]. It is important to reach the plantar third of the metatarsal when completing the longitudinal cut proximally to have enough bone to avoid too much stress on the dorsal fragment and possible fracture. Postoperative stress fractures can occur and are thought to be secondary to suboptimal screw placement [11]. Meticulous screw placement and decreasing the obliquity of the distal cut should decrease the risk of stress fractures [11]. Scarf osteotomy creates a stable fixation due to the cuts of the osteotomy and the large area of cancellous bone that is fixed intraoperatively, which allows early weightbearing. Crevoisier et al. found that two of 84 feet had an unstable reconstruction due to inadequate screw length [4]. One case required revision surgery and the second case could be treated nonoperatively by means of secondary bone healing. The 3.4% rate of wound complications in our patients was comparable to other studies, which reported an incidence between 1.8% and 5.7% [7,29–31]. Troughing was not detected in our
patients intraoperatively and during follow-up. Irritating hardware and recurrent hallux valgus are rare (0.8%), although we refrain from interpretation because of the short follow-up and emphasis on radiological outcomes in our study. Overall, irritating hardware can often be attributed to prominent screws, but this is a rare complication [4,7,8]. Length alterations are an issue in hallux valgus surgery, especially in patients suffering primary metatarsalgia secondary to insufficiency of the first ray and possible length discrepancy between the metatarsal bones. There is evidence indicating a relationship between iatrogenic shortening of the first metatarsal and postoperative metatarsalgia [3,25], although some reports challenge this concept [32,33]. There are limited data regarding the amount of shortening that results after Scarf osteotomy. Smith et al. considered the shortening more pronounced following Scarf osteotomy compared with other osteotomies [28]. Fresion et al. detected a shortening of 2.2 mm without postoperative problems in their patients [34]. Furthermore, different projections during Xray imaging can alter angles and measurements of the length of the metatarsal bones [35]. Therefore, the exact amount of shortening that can be tolerated is unknown and is difficult to define. There is no perfectly precise way to measure length [16]. Our data showed a mean absolute shortening of the first metatarsal of 1.7 mm (range, 8.5 to 5.4 mm), and we identified three patients who suffered metatarsalgia postoperatively. The first patient had a shortening of 5.9 mm of the first metatarsal with a preoperative Coughlin index of 5.48. This patient underwent shortening osteotomy of the second and third metatarsals 10 months after the index surgery and did not complain of residual pain three months after surgery. The second patient had a lengthening of the first metatarsal of 1.2 mm with a Coughlin index of 3.31, and suffered metatarsalgia of the second ray three months after surgery. This was successfully treated using an insole with retrocapital support. The third patient had a shortening of 6.9 mm and a Coughlin index of 7.47 on preoperative radiographs three months after surgery. After a local steroid injection beneath the second and third metatarsal heads, the patient was pain free. None of these patients had metatarsalgia before surgery. Although these numbers are small and not highly representative, our findings may reflect an inconsistency with previous findings. We compared three established methods of measurement. Because a reliable and reproducible measurement method is lacking [16], there is no threshold to support the decision to perform an additional shortening osteotomy in the presence of transfer metatarsalgia. It is important to acknowledge that shortening that occurred in our patients following Scarf osteotomy, although the mean shortening of 1.7 mm should not raise major concerns. Furthermore, it does not help to differentiate between patients with symptomatic hallux valgus and metatarsalgia, who require shortening osteotomy, from those where restoring a competent first ray leads to abatement of symptoms. It is difficult to identify patients who might develop metatarsalgia postoperatively; measuring the first metatarsal length does not appear to be the sole crucial parameter. Kaipel et al. challenged the concept of metatarsalgia resulting from increased lesser metatarsal length by demonstrating a missing correlation between metatarsal length and maximal peak pressure under the corresponding metatarsal heads [33]. There are several limitations of our study. First was the short follow-up, which resulted because treatment in the majority of patients did not need to be continued, and most patients were not willing to consent to further consultations. However, our intention in this study was to determine the amount of correction after surgery, for which a short follow-up was sufficient. Additionally, early complications such as infection, the amount of correction, and residual pain in patients with persistent or postoperative onset
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of transfer metatarsalgia can be identified in a short follow-up. Another limitation is that we did not gather objective information using scores, which slightly impairs the presentation of our results, although we focused on radiological results. Persistent pain, which would produce a lower score, was considered a complication, and would have been detected or listed if identified. In conclusion, we were able to show that the Scarf osteotomy is a safe, powerful, and reliable tool to correct hallux valgus deformity. Knowledge and awareness of possible pitfalls and a large range of complications and care are required to achieve a good outcome. There is a significant amount of shortening of the first metatarsal, which has to be considered, especially in patients with predominant metatarsalgia preoperatively. Conflict of interest None of the authors declare a conflict of interest. Funding No external funding was obtained for this study. Acknowledgment We thank Peter Mittwede, MD, PhD, from Edanz Group (www.edanzediting.com/ac) for editing a draft of this manuscript. References [1] Nix S, Smith M, Vicenzino B. Prevalence of hallux valgus in the general population: a systematic review and meta-analysis. J Foot Ankle Res 2010;3:21. [2] 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. [3] Barouk LS. Scarf osteotomy for hallux valgus correction. Local anatomy, surgical technique, and combination with other forefoot procedures. Foot Ankle Clin 2000;5:525–58. [4] Crevoisier X, et al. The scarf osteotomy for the treatment of hallux valgus deformity: a review of 84 cases. Foot Ankle Int 2001;22:970–6. [5] Dereymaeker G. Scarf osteotomy for correction of hallux valgus. Surgical technique and results as compared to distal chevron osteotomy. Foot Ankle Clin 2000;5:513–24. [6] Jeuken RM. Long-term follow-up of a randomized controlled trial comparing scarf to chevron osteotomy in hallux valgus correction. Foot Ankle Int 2016;37:687–95. [7] Jones S, et al. Scarf osteotomy for hallux valgus. A prospective clinical and pedobarographic study. J Bone Joint Surg Br 2004;86:830–6. [8] Lipscombe S. Scarf osteotomy for the correction of hallux valgus: midterm clinical outcome. J Foot Ankle Surg 2008;47:273–7. [9] Lorei TJ, et al. Pedographic, clinical, and functional outcome after scarf osteotomy. Clin Orthop Relat Res 2006;451:161–6.
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Please cite this article in press as: C.G. Lenz, et al., Scarf osteotomy for hallux valgus deformity: Radiological outcome, metatarsal length and early complications in 118 feet, Foot Ankle Surg (2020), https://doi.org/10.1016/j.fas.2020.01.002