Comparative study of scarf and extended chevron osteotomies for correction of hallux valgus

Radiographic Outcomes of Hallux Valgus Deformity Correction With Chevron and Scarf Osteotomies

There is no gold standard in the treatment of hallux valgus deformity. The purpose of our study was to compare various aspects of radiographic assessment following scarf and chevron osteotomies and try to determine which technique helps achieve a more pronounced intermetatarsal angle (IMA) and hallux valgus angle (HVA) correction and produces lower rates of complications, including adjacent-joint arthritis. This study included patients who underwent hallux valgus correction with the scarf (n = 32) or chevron (n = 181) method with a follow-up period of over 3 years. We evaluated the following parameters: HVA, IMA, duration of hospital stay, complications, development of adjacent-joint arthritis. The scarf technique helped achieve a mean HVA and IMA correction of 18.3° and 3.6°, respectively, and the chevron technique helped achieve a mean correction of 13.1° and 3.7°, respectively. The achieved deformity correction in terms of both the HVA and IMA was statistically significant in both patient groups. The loss of correction assessed with the HVA was statistically significant only in the chevron group. Neither group showed a statistically significant loss of IMA correction. The duration of hospital stay, reoperation rates, and fixation instability rates were comparable in the 2 groups. Neither of the evaluated methods caused a significant increase in total arthritis scores in the evaluated joints. Our study showed good outcomes of hallux valgus deformity correction in both evaluated groups; however, scarf osteotomy yielded somewhat better radiographic outcomes in HVA correction and no loss of HVA correction at 3.5 years of follow-up.

Influence of sesamoid position after scarf osteotomy for hallux valgus on patient-reported outcome. A prospective cohor study

BACKGROUND

The objective was to evaluate the influence of the postoperative sesamoid position as measured with conventional radiographs on the patient-reported outcome after scarf osteotomy. The hypothesis was that incomplete reduction of the sesamoid would result in a decreased functional outcome.

METHODS

Eighty-two patients who underwent scarf osteotomy for hallux valgus were prospectively assessed for up to two postoperative years. The Self-Reported Foot and Ankle Score (SEFAS) was used to assess the quality of life, and the American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Scale (AOFAS) for the functional outcome. A visual analogue scale (VAS) assessed pain, and Likert scale for patient satisfaction. Radiologically, hallux valgus angle (HVA), first-second intermetatarsal angle (IMA), and sesamoid position were analyzed. According to the final sesamoid position, patients were classified as normal position (48 patients) and outlier position (34 patients). A power analysis, conventional and logistic regression statistical analysis were performed.

RESULTS

At the final follow-up, significant improvements in all clinical scores were observed for both groups (p = 0.001) with no significant difference in AOFAS score (p = 0.413), but SEFAS score (p = 0.023), VAS-pain (p = 0.006), and satisfaction (p = 0.014) were significantly better in the normal group than in the outlier group. There were significant differences between groups in final HVA (p = 0.042) and IMA (p = 0.040). In multivariate analysis, only lower VAS-pain score (OR 0.4, 95% CI 0.2-0.6; p = 0.039) and normal sesamoid position (OR 2.4, 95% CI 1.6-3.2; p = 0.012) were significant predictor of patient satisfaction.

CONCLUSION

At two postoperative years, normal sesamoid position as measured on weight-bearing radiographs was associated with lower pain and better patient satisfaction in patients underwent scarf osteotomy for moderate to severe hallux valgus.

Radiographic and clinical outcomes of minimally invasive surgery versus open osteotomies for the correction of hallux valgus

PURPOSE

Hallux valgus is a common disease which causes pain and dysfunction of the foot. Although numerous methods of procedures have been introduced, a single procedure cannot correct all deformities of hallux valgus. The study aims to evaluate the radiographic and clinical effectiveness of a new minimally invasive surgery (MIS) versus open Chevron-Akin procedures.

METHODS

This was a retrospective comparative study. Data were collected from May 2018 to January 2020. A total of 27 patients (31 feet) undergoing MIS for hallux valgus were included in this study. The average age of patients underwent MIS was 59.9 years. The mean follow-up was 25.1 months. Open osteotomies were performed in 30 patients (31 feet) during the same period. The mean age of these patients at the time of surgery was 59.1 years. The mean follow-up was 26.1 months. Pre-operative and post-operative radiographic outcome measures included HVA, IMA, DMAA, the Sgarlato's angle and the length of the first metatarsal, and distance between the dorsal cortex of first and second metatarsal necks. The AOFAS and VAS were used to assess foot function.

RESULTS

The preoperative HVA in MIS group and open group were 34.8° and 33.1° respectively. The post-operative HVA were 20.4° and 13.7°. The pre-operative IMA in MIS group and open group were 13.0° and 12.1°. The post-operative IMA were 11.4° and 5.5° respectively. The pre-operative DMAA were 14.8° and 15.1° respectively. The post-operative DMAA were 6.3° and 8.7°. The AOFAS increased from 44.0 to 90.2 in MIS group and from 47.6 to 89.5 in open group. The VAS decreased from 7.3 to 1.3 in MIS group and from 7.1 to 1.2 in open group.

CONCLUSION

Although open osteotomies were superior than MIS in HVA and IMA, MIS showed advantages in correcting DMAA. MIS provided equivalent functional outcomes compared to open surgery.

Distal chevron osteotomy versus different operative procedures for hallux valgus correction: a meta-analysis

Introduction

Distal chevron osteotomy is commonly used for the operative treatment of hallux valgus (HV). However, there are several operative procedures that can be used to treat HV. The aim of this meta-analysis was to compare the efficacy of distal chevron osteotomy with different operative procedures.

Materials and methods

A systematic search was conducted using the MEDLINE and EMBASE databases to identify randomized clinical trials (RCTs). The variables were radiological (hallux metatarsal phalangeal angle [HVA] and intermetatarsal angle [IMA]) and clinical (American Orthopaedic Foot & Ankle Society Score [AOFAS]). Heterogeneity was assessed with chi² and I² statistics. A random effects model was used for significant heterogeneity. Publication bias was evaluated with funnel plots.

Results

Ten studies involving 985 patients were evaluated in the meta-analysis. Distal chevron osteotomy was associated with a mean IMA correction 2.18° greater than the scarf procedure (MD − 2.18; 95% CI − 3.67, − 0.69; p = 0.004; I² = 0%). In addition, the proximal chevron was associated with a mean IMA correction 1.08° greater than the distal chevron (MD − 1.08; 95% CI − 1.86, − 0.29; p = 0.007; I² = 0%). The AOFAS assessment showed an overall advantage of 3.2 points in favor of the Lingdren group compared with distal chevron osteotomy (MD 3.20; 95% CI 0.37, 6.04; p = 0.03; I² = 0%).

Conclusions

Our findings indicate that distal chevron osteotomy provides a greater HVA correction than scarf osteotomy, and proximal chevron provides a larger IMA correction than distal chevron osteotomy. Lingdren osteotomy provides a greater AOFAS correction than distal chevron osteotomy.

Level of evidence

Level I, meta-analysis.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Modified Lapidus vs Scarf Osteotomy Outcomes for Treatment of Hallux Valgus Deformity

BACKGROUND

The Lapidus procedure and scarf osteotomy are indicated for the operative treatment of hallux valgus; however, no prior studies have compared outcomes between the procedures. The aim of this study was to compare clinical and radiographic outcomes between patients with symptomatic hallux valgus treated with the modified Lapidus procedure versus scarf osteotomy.

METHODS

This retrospective cohort study included patients treated by 1 of 7 fellowship-trained foot and ankle surgeons. Inclusion criteria were age older than 18 years, primary modified Lapidus procedure or scarf osteotomy for hallux valgus, minimum 1-year postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores, and minimum 3-month postoperative radiographs. Revision cases were excluded. Clinical outcomes were assessed using 6 PROMIS domains. Pre- and postoperative radiographic parameters were measured on anteroposterior (AP) and lateral weightbearing radiographs. Statistical analysis utilized targeted minimum-loss estimation (TMLE) to control for confounders.

RESULTS

A total of 136 patients (73 Lapidus, 63 scarf) with an average of 17.8 months of follow-up were included in this study. There was significant improvement in PROMIS physical function scores in the modified Lapidus (mean change, 5.25; P < .01) and scarf osteotomy (mean change, 5.50; P < .01) cohorts, with no significant differences between the 2 groups (P = .85). After controlling for bunion severity, the probability of having a normal postoperative intermetatarsal angle (IMA; <9 degrees) was 25% lower (P = .04) with the scarf osteotomy compared with the Lapidus procedure.

CONCLUSION

Although the modified Lapidus procedure led to a higher probability of achieving a normal IMA, both procedures yielded similar improvements in 1-year patient-reported outcome measures.

LEVEL OF EVIDENCE

Level III, retrospective cohort.

Percutaneous, intra-articular, chevron osteotomy (PeICO) for the treatment of mild-to-moderate hallux valgus: a case series

PURPOSE

Treatment for hallux valgus (HV) remains challenging. Third-generation percutaneous procedures try to reproduce chevron-type osteotomies to replicate their benefits, such as intrinsic stability and reproducibility. We report the first results using a percutaneous, intra-articular, chevron osteotomy (PeICO) technique that mimics the classic intra-articular open chevron procedure, associated with a percutaneous adductor tendon release (PATR) for the treatment of mild-to-moderate HV.

METHODS

From May 2015 to October 2018, a total of consecutive 114 feet (74 patients) were included. Primary outcome measures included radiographic (hallux valgus and intermetatarsal angles) and clinical parameters such as visual analog scale (VAS), FAAM Activities of Daily Living (ADL), and FAAM Sport, AOFAS Score, and MOXFQ, preoperatively and at final follow-up (Minimum 18 months). A patient satisfaction survey was also performed. Pronation and length of the first metatarsal were also assessed. Secondary outcomes included fluoroscopic time, length of surgery, complications, recurrence, and re-operation rates.

RESULTS

At 24.09 months on average, the AOFAS score improved from 52.1 points preoperatively to 91.1 (p < 0.001) at the latest follow-up. VAS decreased from 6.3 to 1. Also, FAAM ALD, FAAM Sport, and MOXFQ showed statistically significant differences (p < 0.001) when comparing pre-operative and post-operative periods. Patients found the procedure to be excellent in 82% and very good in 13.5% of cases. Our global complication and re-operation rates were 5.26% and 3.5% (screw removal), respectively.

CONCLUSION

PeICO combined with PATR proved to be a safe, reliable, and effective technique for the correction of mild-to-moderate HV deformity.

Midterm Results Following Minimally Invasive Distal Chevron Osteotomy: Comparison With the Minimally Invasive Reverdin-Isham Osteotomy by Means of Meta-analysis

BACKGROUND/AIM

To date, multiple different surgical techniques have been established for hallux valgus surgery, with each technique having its unique advantages and limitations. The open distal chevron osteotomy is widely accepted, but increasing patient demands have led several minimally invasive (MIS) techniques to be described in recent years. The aim of this study was to compare outcomes after minimally invasive (MIS) distal chevron osteotomy and the minimally invasive Reverdin-Isham method.

PATIENTS AND METHODS

We assessed clinical and radiographic outcomes after MIS chevron osteotomy in 57 feet of 49 consecutive patients with a mean follow-up of 58.9 (range=39.0-85.4) months. Outcomes after MIS Reverdin-Isham osteotomy were analyzed by means of a systematic literature review with a minimum follow-up of 6 months.

RESULTS

Radiographic outcomes were significantly better in the MIS chevron cohort for intermetatarsal angle (p<0.001), hallux valgus angle and distal metacarpal articular angle (p<0.05). Concerning clinical outcomes, both methods provided comparable improvement.

CONCLUSION

MIS distal chevron osteotomy in mild to moderate hallux valgus deformity correction results in superior radiographic outcomes compared to the MIS Reverdin-Isham osteotomy. Sufficient correction of IMA cannot be achieved with the MIS Reverdin-Isham osteotomy.

Minimally invasive vs open distal metatarsal osteotomy for hallux valgus - A systematic review and meta-analysis

BACKGROUND

Numerous publications of the late 20th century have presented the radiological outcome of open technique for distal metatarsal osteotomy for mild to moderate hallux valgus and the clinical outcomes by means of well-established scoring systems which have been published and make these open techniques today's benchmark and gold standard. Minimally invasive procedures reduce surgical trauma because they are performed without large incisions, and injury to the soft tissues is limited. This has the theoretical advantages of improved recovery and decreased rehabilitation times. There is however limited literature to prove the same for minimally invasive surgery for hallux valgus.Our aim was thus to pool all available comparative literature on minimally invasive hallux valgus surgery done for mild to moderate hallux valgus versus open surgical approaches.

METHODS

A PubMed, Embase and Scopus search was performed using the keywords ('hallux valgus' OR bunion) AND ('minimally invasive' OR percutaneous) AND osteotomy. A total of 473 records were identified and out of which nine studies were included in the final review.

RESULTS

Most available studies are either randomized control trials, or prospective cohort studies providing good level of evidence. Radiological analysis showed similar correction with both MIS and open osteotomies. In functional analysis results were different with open techniques providing better results in terms of AOFAS score. (p < 0.0001). VAS score and complication rate were similar in both groups.

DISCUSSION/CONCLUSION

We conclude that based on available literature MIS provides equivalent radiological outcomes with respect to open surgery but functionally despite the promising results (good to excellent in most series), the outcomes in terms of function are not as good as open surgery. MIS techniques provide satisfactory outcomes for mild-to-moderate severity of hallux valgus though not as good as open surgery. There is evolving literature for this relatively new procedure. Longer duration of follow up and bigger numbers would allow for more meaningful data analysis and conclusions to be drawn as more studies come forward.

Scarf versus long chevron osteotomies for the treatment of hallux valgus: A prospective randomized controlled study

BACKGROUND

The aim of this study is to compare scarf osteotomy and long chevron osteotomy in treatment of hallux valgus deformity regarding operative time, power of correction and complications.

DESIGN

A prospective randomized controlled comparative trial.

METHODS

48 cases with hallux valgus were divided randomly in 2 groups (21 treated by scarf and 22 treated by long chevron osteotomy and 5 were missed during follow up), average age 36 years, follow up time was average of 25.9 months. Patients were assessed clinically, radiologically, and functional scoring system of American College of Foot and ankle Surgeons (ACFAS)was used both pre and postoperatively.

RESULTS

Operative time was 69min in scarf group compared to 63min to long chevron group, radiological correction showed no statistically significant difference between both groups while functional improvement in ACFAS score was in favour of long chevron group 69.1% compared to scarf group 57.5% CONCLUSIONS: Both osteotomies possess almost identical corrective power of the IMA (intermetatarsal angle) and similar clinical outcomes with slightly shorter operative time and subjective technical simplicity for the long chevron osteotomy.

Comparison of Radiographic and Clinical Results After Extended Distal Chevron Osteotomy With Distal Soft Tissue Release With Moderate Versus Severe Hallux Valgus

BACKGROUND:

We compared the radiographic and clinical outcomes of moderate and severe hallux valgus treated by extended distal chevron osteotomy (EDCO) and distal soft tissue release (DSTR).

METHODS:

We performed a retrospective analysis comparing the utility of EDCO for the treatment of moderate (36 patients, 46 feet) and severe (36 patients, 42 feet) hallux valgus. The radiologic outcomes were evaluated based on the preoperative and 3-year follow-up x-rays. The clinical results were investigated based on the 3-year follow-up Manchester-Oxford Foot Questionnaire (MOXFQ), patient satisfaction, and postoperative complications.

RESULTS:

The mean postoperative intermetatarsal angle, hallux valgus angle, tibial sesamoid position, and relative metatarsal bone length were significantly different compared with the preoperative values for both the moderate and severe groups ( P < .001). At 3-year follow-up, intergroup differences were observed in the mean postoperative intermetatarsal angle ( P = .001), hallux valgus angle ( P = .003), and tibial sesamoid position ( P = .013); however, mean radiographic results were within the normal range for both groups. There were no intergroup differences for either the first metatarsal bone length ( P = .172) or shortening ( P = .621). No significant difference in MOXFQ ( P = .525) was evident between the groups at 3-year follow-up. In satisfaction analysis, 82.6% of the moderate group reported good to excellent results, as did 81.0% of the severe group ( P = .815). A total of 7 complications were reported in each group ( P = 1.000).

CONCLUSION:

The present study showed that midterm mean radiographic results of both moderate and severe hallux valgus treated by EDCO with DSTR were favorable, and those values were within the normal range. Clinical outcomes were comparable between the 2 groups, including overall efficacy. Based on these results, we recommend EDCO with DSTR as an efficient and reliable operative option for both moderate and severe hallux valgus.

LEVEL OF EVIDENCE:

Level III, retrospective comparative study.

Minimally invasive versus open chevron osteotomy for hallux valgus correction: a randomized controlled trial

PURPOSE

The purpose of this study was to compare a minimally invasive chevron osteotomy technique (MIS group) and the well-established open chevron technique (OC group) for correction of hallux valgus deformity.

METHODS

Patients who were scheduled to undergo a hallux valgus surgery by means of a distal chevron osteotomy were randomly assigned to one of the two groups. Pre-operatively, six weeks, 12 weeks, and nine months post-operatively the following outcome parameters were determined: Visual Analog Scores (VAS) of pain, the American Orthopedic Foot and Ankle Society (AOFAS) forefoot score, radiographic outcome measures, range of motion (ROM), and patient satisfaction.

RESULTS

Forty-seven cases were analyzed (25 MIS group; 22 OC group). Both operative techniques achieved significant correction of the hallux deformity. The intermetatarsal angle (IMA) improved from 15.1° to 5.8° in the OC and from 14° to 6.8°in the MIS group, whereas the hallux valgus angle (HVA) improved from 28.3° to 8.5° in the OC versus 26.4° to 6.9° in the MIS group. No significant differences were observed between the groups by any of the determined outcome parameters. Regarding patient satisfaction, statistically significant differences were found between MIS and open surgery 12 weeks post-operatively in favour of the MIS group (p = 0.022).

CONCLUSION

With the minimally invasive chevron osteotomy, radiological and clinical outcome is comparable to the open technique.

Extended plantar limb (modified) chevron osteotomy versus scarf osteotomy for hallux valgus correction: A randomised controlled trial

BACKGROUND

The purpose of this RCT was to compare the extended plantar limb (modified) chevron osteotomy with the scarf osteotomy in correcting hallux valgus deformity and improving functional scores and patient satisfaction.

METHODS

Patients were randomly assigned and kept blind to surgical allocation. Cases requiring additional procedures including the Akin osteotomy were excluded. Outcomes were measured at 1 year following surgery.

RESULTS

84 patients (109 feet) were analysed (60 modified chevron; 49 Scarf). The mean age was 50.7 years (75F: 9M). Post-operative intermetatarsal angle (IMA) was significantly lower in the modified chevron group (5.8° versus 6.9°, p=0.045). Hallux valgus angle and distal metatarsal articular angle were similar. The magnitude of IMA correction with the modified chevron was also significantly greater (9.1° versus 7.1°, p=0.007). Both osteotomies produced comparable MOxFQ scores and satisfaction ratings.

CONCLUSION

The modified chevron was superior to the scarf osteotomy in correcting IMA in hallux valgus deformity.

Surgery for the correction of hallux valgus

This study sought to determine the medium-term patient-reported and radiographic outcomes in patients undergoing surgery for hallux valgus. A total of 118 patients (162 feet) underwent surgery for hallux valgus between January 2008 and June 2009. The Manchester-Oxford Foot Questionnaire (MOXFQ), a validated tool for the assessment of outcome after surgery for hallux valgus, was used and patient satisfaction was sought. The medical records and radiographs were reviewed retrospectively. At a mean of 5.2 years (4.7 to 6.0) post-operatively, the median combined MOXFQ score was 7.8 (IQR:0 to 32.8). The median domain scores for pain, walking/standing, and social interaction were 10 (IQR: 0 to 45), 0 (IQR: 0 to 32.1) and 6.3 (IQR: 0 to 25) respectively. A total of 119 procedures (73.9%, in 90 patients) were reported as satisfactory but only 53 feet (32.7%, in 43 patients) were completely asymptomatic. The mean (SD) correction of hallux valgus, intermetatarsal, and distal metatarsal articular angles was 18.5° (8.8°), 5.7° (3.3°), and 16.6° (8.8°), respectively. Multivariable regression analysis identified that an American Association of Anesthesiologists grade of > 1 (Incident Rate Ratio (IRR) = 1.67, p-value = 0.011) and recurrent deformity (IRR = 1.77, p-value = 0.003) were associated with significantly worse MOXFQ scores. No correlation was found between the severity of deformity, the type, or degree of surgical correction and the outcome. When using a validated outcome score for the assessment of outcome after surgery for hallux valgus, the long-term results are worse than expected when compared with the short- and mid-term outcomes, with 25.9% of patients dissatisfied at a mean follow-up of 5.2 years.

Cite this article: Bone Joint J 2015;97-B:208–14.