Shortening Scarf osteotomy for correction of severe hallux valgus. Does shortening affect the outcome?

Rotation scarf + Akin osteotomy for severe hallux valgus with a new evaluation index: distance between the first and second metatarsals

BACKGROUND

Although rotation scarf + Akin osteotomy has been described for correcting hallux valgus deformity, the treatment efficacy of rotation scarf + Akin osteotomy for severe hallux valgus should be further studied. The purpose of our study was to evaluate the outcomes of rotation scarf + Akin osteotomy on severe hallux valgus.

METHODS

We conducted a retrospective study of patients with hallux valgus who underwent surgery using rotation scarf + Akin osteotomy in our hospital between June 2014 and January 2020. The parameters evaluated include (1) the hallux valgus angle (HVA), (2) intermetatarsal angle (IMA), (3) distal metatarsal articular angle (DMAA), (4) tibial sesamoid position (TSP), (5) the length of first metatarsal bone and (6) ratio between the vertical distance from the lateral of the first metatarsal head to the medial of the second metatarsal head and the vertical distance of lateral of the second metatarsal head to the medial of the third metatarsal head (MT-I to II/II to III distance). A visual analog scale (VAS) was used to evaluate the degree of pain before and at the last follow-up after the operation. The American Orthopaedic Foot & Ankle Society (AOFAS) Forefoot Score wasassessed before and at the last follow-up after the operation. Patient satisfaction assessment was also conducted at the time.

RESULTS

All radiological parameters including, HVA, IMA, DMAA and TSP,, significantly improved (p < 0.001). The length of the first metatarsal was shortened 3.1 mm on average. The MT-I to II/II to III distance was also reduced to 1.8 after surgery and 3.3 before surgery. The VAS score and AOFAS score was also statistically significant before operation and at the last follow-up after the operation (p < 0.001). Forty-one (82%) feet in patients were very satisfied or satisfied.

CONCLUSION

Rotation scarf + Akin osteotomy is demonstrated to be safe, effective, and feasible for correcting severe hallux valgus. It can obtain good long-term correction with a low incidence of recurrence and metatarsalgia. Postoperative satisfaction and functional recovery of patients are significantly improved. The MT-I to II/II to III distance, a new evaluation indicator, can be better evaluate the correction of hallux valgus.

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

INTRODUCTION

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

PATIENTS AND METHODS

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

RESULTS

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

DISCUSSION

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

CONCLUSION

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

LEVEL OF EVIDENCE

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

Shortening Scarf Osteotomy for Macrodactyly and Valgus of the Hallux in Acrodysostosis Lesser Toes Brachydactyly

Level V: Case report.

Planning tool for first metatarsal length in hallux valgus surgery

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Scarf osteotomy for hallux valgus deformity: Radiological outcome, metatarsal length and early complications in 118 feet

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 0.45mm. 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.

[Effectiveness of double metatarsal osteotomy for severe hallux valgus with increased distal metatarsal articular angle]

Objective

To summarize the technique and effectiveness of double metatarsal osteotomy for treating severe hallux valgus with increased distal metatarsal articular angle (DMAA).

Methods

Between June 2014 and December 2017, 64 patients (94 feet) of severe hallux valgus with an increased DMAA were treated with the double metatarsal osteotomy (distal metatarsal Reverdin osteotomy+proximal metatarsal open wedge osteotomy) combined with Akin osteotomy and soft tissue surgery to correct the deformity. There were 10 males (15 feet) and 54 females (79 feet) with an average age of 44.5 years (range, 26-66 years), including 34 of unilateral foot and 30 of bilateral feet. The Maryland metatarsophalangeal joint score of the American Orthopaedic Foot and Ankle Society (AOFAS) was 54.3±7.4 and the visual analogue scale (VAS) score was 6.0±2.0. The pre- and post-operative AOFAS score, VAS score, DMAA, hallux valgus angle (HVA), first-second intermetatarsal angle (1-2IMA), and the first metatarsal length (FML) were recorded and compared.

Results

All incisions healed by first intention. All patients were followed up 12-15 months, with an average of 13.2 months. The complications occurred in 4 feet, including 1 foot of hallux stiffness, 1 foot of numbness at the edge of the wound, 1 foot of metastatic metatarsalgia, and 1 foot of metatarsal bone necrosis. At 1 year after operation, the Maryland metatarsal joint score of AOFAS was 89.2±7.4, showing significant difference compared with preoperative score ( t=18.427, P=0.000); and the effectiveness was rated as excellent in 78 feet, good in 12 feet, poor in 3 feet, and bad in 1 foot, with an excellent and good rate of 95.7%. The VAS score was 1.5±2.0, showing significant difference compared with the preoperative score ( t=10.238, P=0.000). The X-ray films showed that the osteotomies achieved bony healing at 3 months after operation. There were significant differences ( P<0.05) in HVA, 1-2IMA, and DMAA between preoperation and 6 months and 1 year after operation; but no significant difference was found in FML between preoperation and 1 year after operation ( t=0.136, P=0.863).

Conclusion

For the patients with severe hallux valgus with increased DMAA, the double metatarsal osteotomy can significantly relieve the clinical symptoms and improve the imaging parameters with less postoperative complications.

Introduction the revolving scarf osteotomy for treating severe hallux valgus with an increased distal metatarsal articular angle: a retrospective cohort study

BACKGROUND

Hallux valgus(HV) with an increased distal metatarsal articular angle (DMAA) is one of the most common foot deformities among adults. Double metatarsal osteotomy (DMO) is effective in treating severe HV deformity with an increased DMAA. However, this technique presents the risk of avascular necrosis (AVN) of the metatarsal head and transfer metatarsalgia due to shortening of the first metatarsal. The aim of this study was to introduce a surgical procedure defined as revolving scarf osteotomy (RSO) and compare the clinical and radiological results of RSO and DMO performed for treating severe HV with an increased DMAA.

METHODS

First metatarsal osteotomies and Akin osteotomy were performed in 56 patients (62 ft) with severe HV with an increased DMAA in Honghui Hospital from January 2015 to December 2017. RSO was performed in 32 ft and DMO was performed in 30 ft. The Akin osteotomy was performed in both groups. The American Orthopedic Foot and Ankle Society (AOFAS) score, visual analogue scale (VAS) score, the hallux valgus angle (HVA), intermetatarsal angle (IMA), DMAA, and first metatarsal length (FML) and the rates of complications were compared preoperatively and postoperatively in the two groups.

RESULTS

The mean AOFAS score, VAS score, HVA, IMA, and DMAA showed significant improvements in both groups after surgery, but with no significant differences between the two groups. The postoperative FML was significantly larger in the RSO group than in the DMO group (p < 0.001). One of the 30 ft (3.3%) in the DMO group exhibited transfer metatarsalgia at 12 months postoperatively, while another foot (3.3%) in same group had avascular necrosis of the metatarsal head. One of the 30 ft (3.1%) in the RSO group had hallux varus.

CONCLUSIONS

No differences in the clinical and radiographic results were observed between the two groups with severe HV and an increased DMAA. However, RSO does not cause shortening of the metatarsal and AVN of the metatarsal head. A long-term, randomized, controlled prospective study with a larger sample would provide higher-level evidence for confirming the clinical efficacy and safety of RSO.

A Comparative Study of Mini-Scarf Versus Standard Scarf Osteotomy for Hallux Valgus Correction

Scarf osteotomy is widely used for hallux valgus treatment. More recently, a trend has begun toward the use of minimally invasive techniques, including the mini-scarf osteotomy, in which the diaphyseal cut is shortened. We compared the mini-scarf and traditional scarf osteotomy to determine whether the mini-scarf osteotomy is as effective as the scarf osteotomy in correcting mild to moderate hallux valgus and improving clinical function. We reviewed the cases of 37 consecutive patients during a 2-year period. A total of 21 (56.8%) patients had undergone scarf osteotomy and 16 (43.2%) had undergone mini-scarf osteotomy. The intermetatarsal, hallux valgus, and distal metatarsal articular angles and medial sesamoid position of the 2 groups were measured at 12 weeks postoperatively. The Manchester Oxford Foot Questionnaire scores and patient satisfaction were recorded at 28 months postoperatively. All radiologic parameters and Manchester Oxford Foot Questionnaire scores had significantly improved in both groups (p < .05 and p < .01 for mini-scarf and scarf, respectively). The medial sesamoid position had improved in all patients, with similar satisfaction between the 2 procedures (p = .43). The results of the present study have shown that the mini-scarf osteotomy for mild to moderate hallux valgus is as effective as the standard approach, with the potential benefit of a smaller scar and less soft tissue disruption.

How Do I Use the Scarf Osteotomy to Rotate the Metatarsal and Correct the Deformity in Three Dimensions?

The scarf osteotomy has become the workhorse procedure for a large proportion of foot and ankle surgeons, especially in Europe, in the treatment of hallux valgus. Such a versatile procedure should not be underestimated, and planning and thought should precede any such procedure. The angle of bone cuts and magnitude of translation dictate the final position, and all movement axes should be given equal attention.