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

BackgroundWe reviewed the rates of and reasons for hallux valgus (HV) recurrence and the rates of avascular necrosis following Scarf osteotomy.MethodsWe searched the Cochrane Library, PubMed, and Embase databases for studies reporting operative management of HV using Scarf osteotomy. The primary endpoints were reasons for and rates of HV recurrence. The secondary endpoint was the rate of avascular necrosis.ResultsWe included 15 studies with 946 operations for HV. Seven studies reported no recurrence, six reported recurrence rates of 3.6–11.3%, one reported a recurrence rate of 30%, and one reported a recurrence rate of 78%. Thirteen studies (678 feet) reported other complications from Scarf osteotomy without avascular necrosis.ConclusionsAlthough HV recurrence is not uncommon following Scarf osteotomy, patient-related factors, surgical competence, and longer follow-up are more likely to be associated with recurrence. Avascular necrosis is an infrequent complication in HV patients treated using Scarf osteotomy.     

Scarf osteotomy for correction of hallux valgus. Surgical technique and results as compared to distal chevron osteotomy

With the Scarf osteotomy, a good correction of moderate hallux valgus can be obtained, comparable to the distal or proximal Chevron or crecentic osteotomy. Correction of the IMA averages between 5 degrees to 6 degrees. When used in combination with an adductor release and proximal phalangeal osteotomy, the indication can be extended to severe hallux valgus deformities as long as there is no arthrosis at the MTP joint. The Scarf osteotomy, however, is certainly a more extensive surgical procedure, with a longer learning curve than a distal Chevron osteotomy. With more than 1000 Scarf procedures performed, the author has not encountered one delayed union, even in osteoporotic bone, or an avascular necrosis. In two cases a stress fracture was encountered in the first 3 months after surgery, but these healed uneventfully with partial weight bearing for 5 weeks.     

Scarf osteotomy for correction of hallux valgus. Historical perspective, surgical technique, and results

The Scarf osteotomy has proven to be a versatile and powerful procedure to correct various degrees of hallux valgus deformity. Through modifications of bone-cut lengths and in combination with a phalangeal osteotomy, most hallux valgus deformities can be addressed. In cases of extreme hypermobility of the first ray or arthrosis of the first metatarsocuneiform joint, the Lapidus operation may be more appropriate. Hallux valgus rigidus or hallux valgus with severe rheumatoid joint disease usually requires alternative procedures. The results of the Scarf osteotomy compare favorably with the results reported for other popular bunion surgeries. When choosing a procedure, the clinician should consider that the Scarf osteotomy allows the patient to ambulate postoperatively without a cast or the use of crutches, to return to bathing and a closed athletic shoe in one week, and to have bilateral surgery, which maintains cost-effectiveness and returns the patient to his or her desired lifestyle more quickly. It has been said that surgery is both a science and an art. The author often believes that bunion surgery is more art than science, hence the success of so many procedures in one surgeon's hands and the failure in another's hands. The Scarf bunionectomy is a technically demanding procedure that has a large learning curve. Once mastered, however, the Scarf bunionectomy can provide a predictable and satisfying outcome for both patient and foot surgeon.     

Scarf osteotomy in hallux valgus: a review of 72 cases

The Scarf osteotomy is now widely used for the correction of hallux valgus. The aim of our study was to evaluate the results after Scarf osteotomy considering patient's satisfaction as well as the clinical and radiological results. Between 1996 and 1999, 72 feet underwent a Scarf osteotomy of the first metatarsal and, in 11 feet, an additional Akin osteotomy of the proximal phalanx, for the correction of hallux valgus (55 patients: 49 female, 6 male; mean age: 52 years). The hallux valgus angle improved significantly, from 32 degrees preoperatively to 18 degrees at follow-up (minimal follow-up: 6 years; mean: 7.5 years). A second operation was necessary in two patients because of recurrence of hallux valgus, and a fusion of the first metatarsophalangeal joint was performed in two patients. At the time of latest follow-up 78% of the patients were satisfied or very satisfied with the result. The Scarf osteotomy combined with Akin's closing wedge osteotomy is a safe and effective procedure for the treatment of moderate hallux valgus deformities.     

Perioperative complications of the Scarf osteotomy

We reporting the perioperative complications during our early experience using the Scarf osteotomy to correct hallux valgus. A case note review was carried out for the first 100 Scarf osteotomy procedures completed by the senior author. There were six patients (6%) with perioperative complications. Four of these were intraoperative complications including a split first metatarsal in three cases, a shearing of the K-wire in one case and there were two cases of postoperative stress fracture. These complications should be considered by those beginning to master the Scarf osteotomy procedure and by surgeons teaching surgical trainees.     

Hallux valgus with second metatarsalgia: Is second metatarsal Weil osteotomy necessary?

BackgroundThe role of concomitant Weil osteotomy to address second toe metatarsalgia during hallux valgus correction is unclear. We aimed to critically analyse outcomes of an additional Weil osteotomy versus isolated Scarf osteotomy.in the management of hallux valgus and second metatarsalgia.MethodsPatients with second toe metatarsalgia who underwent first metatarsal Scarf osteotomy for hallux valgus were enrolled retrospectively. Demographics, radiographic measurements and functional outcomes were assessed at baseline, 6-months and 2-years postoperatively. Between-group significance was established with Fisher exact test, Chi-square or Mann-Whitney U test. Within-group changes from baseline were assessed with paired t-test and Wilcoxon signed-rank test.Results48 feet (34 isolated Scarf, 14 concomitant Weil osteotomy) were included. Both cohorts demonstrated significant improvements across all measures of functional outcome. However, patients with additional Weil osteotomy reported poorer short-term outcomes.ConclusionSuperiority of additional Weil osteotomy versus isolated Scarf osteotomy in addressing second toe metatarsalgia or improving functional outcomes was not demonstrated.     

Hallux varus following scarf osteotomy

Hallux varus is an uncommon condition and majority of the cases are iatrogenic. It can occur as a result of any type of hallux valgus correction surgery and in our cases scarf osteotomy is not an exception. Treatment of this complication can be challenging and it is important to understand the factors that cause this deformity before embarking on surgical correction. Four cases of hallux varus following Scarf osteotomy (1% of our total Scarf osteotomy cases) and discuss the salient features of these patients. The authors ascertained the factors that caused iatrogenic hallux varus and formulated a classification of the nature of the deformity. The management of iatrogenic hallux varus based on our experience and proposed classification system has also been outlined and discussed.     

Scarf and Weil osteotomies for correction of rheumatoid forefoot deformities: A review of 20 cases

The forefoot is commonly affected in rheumatoid arthritis. Little has been written of the results of metatarsophalangeal joint preservation in rheumatoid arthritis. We describe the results of the Scarf and Weil osteotomy for correction of forefoot deformities in patients with rheumatoid arthritis. Between 1996 and 1999, 17 patients (20 feet) underwent a Scarf osteotomy for their hallux valgus deformity and in 17 feet a Weil osteotomy of the lesser metatarsophalangeal joints. Radiographic examination was performed preoperatively and at a mean follow up of 65 months. A questionnaire was used at a minimum follow up of 6 years. The hallux valgus angle improved from 41° to 28° at follow up. The majority of the patients (79%) were satisfied with the result during follow-up. We found no wound infections, neuralgia or osteonecrosis of the first metatarsal. In three patients, a fusion of the first MTP joint was performed at follow up.In conclusion, the Scarf and Weil osteotomy is a useful method for MTP joint preserving surgery in rheumatoid forefoot deformities without severe impairment of the MTP joints.     

改良Scarf截骨术治疗拇外翻的临床疗效

目的探讨改良Scarf截骨术治疗拇外翻的临床疗效。方法应用改良Scarf截骨术治疗拇外翻患者68例(92足),比较手术前后拇外翻角(HVA)、第1、2跖骨间角(IMA)及远端关节面固有角(DMAA)的变化。末次随访时,采用AOFAS评分标准评价疗效。结果68例患者均获得随访,时间9~12个月。末次随访时,HVA、IMA、DMAA均较术前显著减小(P<0.01),AOFAS评分较术前显著升高(P<0.01),疗效优、良、可分别为82、5、5足,治疗优良率为94.6%。结论改良Scarf截骨术是矫正拇外翻畸形的可靠技术,纠正畸形效果满意,能有效缓解疼痛。     

Scarf osteotomy for hallux valgus repair: the dark side

HYPOTHESIS/PURPOSE: The Scarf osteotomy has gained popularity as treatment of choice in parts of Europe and is based on sound structural principles. The excellent results reported by others could not, however, be reproduced by the author and the results are presented. METHODS: From January 1997 to June 1997 the Scarf osteotomy was selected in 20 consecutive patients (12 female and eight male patients, ages 18 to 60, mean: 41 years) with moderate metatarsus primus varus (IMA 13 to 20 degrees) and hallux valgus deformities (less than 40 degrees). The AOFAS Hallux Metatarsophalangeal-Interphalangeal Scale, visual analog scale and patient satisfaction were monitored prior to surgery, six and 12 months post-op. The patients were treated in a short leg cast, non-WB for two weeks followed by four weeks partial WB in a cast shoe. Routine post-bunion rehabilitation followed once the radiological and clinical diagnosis of healing was made. RESULTS: Multiple complications were encountered. The most common was "troughing" of the metatarsal with loss of height. This occurred in seven patients (35%). Other complications include delayed union (5%), rotational malunion (30%), proximal fracture (10%), infection (5%) and early recurrence of deformity in 25%. All 20 patients were available for follow-up at six months, and 19 of 20 at 12 months. The AOFAS score pre-op was a mean of 53. At six months a mean of 54 (19 to 69) and at 12 months 62 (24-100). Forty-five percent (9/20) were unsatisfied at one year and would not recommend the surgery to a friend. CONCLUSIONS/SIGNIFICANCE: The Scarf osteotomy has multiple potential pitfalls and should probably be reserved for moderate bunions in young people with good bone quality. There are multiple potential problems and the salvage of a failed Scarf osteotomy is difficult.     

Ostéotomie scarf dans le traitement de l’hallux valgus: à propos de 26 cas

The aim of this study was to evaluate Scarf osteotomy, associated or not with phalangeal osteotomy, for the treatment of hallux valgus, and to determine its limits. We performed a retrospective review of 24 patients (26 feet) who had been treated by Scarf osteotomy for hallux valgus between July 2000 and June 2005 in the orthopedic traumatology department of University Hospital Centre (CHU) in Casablanca. The results were carefully evaluated according to Groulier scores. The mean follow-up time was 2 years and 6 months. The average age at surgery was 37.5 and the majority of patients were female; 79.2% of the patients were satisfied or very satisfied. According to the Groulier scores, 65.4% of the outcomes were good or very good. There was a correlation between the treatment satisfaction index and clinical symptoms (metatarsalgia and stiff hallux). There was a statistically significant decrease in hallux valgus (36.3 to 16.3°), metatarsus varus (15.8 to 7.3°) and distal metatarsus articular angle (28.5 to 14.8°). The cut-off limits for deformations difficult to correct satisfactorily were MP > 36°, MV angle > 16° and AADM > 14°. Performing a phalangeal osteotomy in addition can improve the radiological results, but it is very difficult to obtain satisfactory correction if the initial deformations are severe, even if associated with Scarf osteotomy.     

Increased recurrence in Scarf osteotomy for mild & moderate hallux valgus with Meary’s line disruption

BackgroundScarf osteotomy for hallux valgus is a successful procedure. Neverthless recurrence of deformity is reported as 5–8%. First ray instability is a recognised risk factor for recurrence. We investigate whether a radiographic marker such as Meary’s line can be used to predict recurrence.This paper aims to test the null hypothesis that there is no difference in recurrence for mild and moderate hallux valgus treated with Scarf osteotomy in the presence of a disrupted Meary's line compared to an intact line.MethodsAt a minimum of 3 months follow up we retrospectively analysed radiographs, theatre and clinic notes of 74 (n = 74) consecutive patients treated with Scarf osteotomy for mild and moderate hallux valgus at a single centre. The patients were divided into Group A (n = 30) — patients who on pre-operative weight bearing radiographs had a disrupted Meary’s line, and Group B (n = 44) — those with a normal Meary’s line on pre-operative weight bearing radiographs.ResultsOur results demonstrate statistically significant five times higher odds of recurrence in Group A compared to Group B with an odds ratio of 5.2 p = 0.006 [95% CI 1.6–17]. On this basis we reject the Null hypothesis.ConclusionIn this paper, we link a disrupted Meary’s line with risk of recurrence of deformity. We demonstrate that, when Scarf osteotomy is used to correct mild and moderate hallux valgus in the presence of a broken Meary’s line, the odds of recurrence as compared to the same procedure being performed with an intact line are 5.2 times higher.Alternative corrective techniques such as the Lapidus procedure warrant further investigation for the treatment of mild and moderate hallux valgus in the presence of Meary’s line disruption.     

Six first metatarsal shaft osteotomies: mechanical and immobilization comparisons

Because malunion (usually with dorsal elevation of the first metatarsal) has been reported after the treatment of severe hallux valgus deformities by proximal osteotomies, the current study was designed to compare the sagittal stability of six different metatarsal shaft osteotomies: the proximal crescentic, proximal chevron, Mau, Scarf, Ludloff, and biplanar closing wedge osteotomies. A plate was used in the biplanar closing wedge osteotomy; all others used screws for fixation. Ten fresh-frozen, human anatomic lower extremity specimens were used for each osteotomy. Failure loads were measured as units of force (newtons) and converted to pressure (kilopascals). Then the F-Scan system, which uses a thin insole to measure plantar pressure, was used to evaluate the pressure under the first metatarsal of seven volunteers using four types of shoes. According to the results, in patients with normal bone stock who are compliant, any of the four shoe types tested may be used after a Ludloff, Scarf, biplanar wedge (plantar screw fixation), or Mau osteotomy, but the wedge-based shoe should be used after a proximal crescentic or chevron osteotomy or for patients with severe osteopenic bone.     

Scarf osteotomy for hallux valgus—is an Akin osteotomy necessary?

Scarf osteotomy has gained popularity as one of the recommended procedures for moderate to severe hallux valgus. An Akin osteotomy may also allow additional correction but carries its own complications. The aim of this study was to assess the need for Akin osteotomy with a scarf procedure.We reviewed our results of scarf osteotomy with and without Akin in 69 patients with 99 procedures. Sixteen patients (25 feet) had an Akin osteotomy with a scarf procedure. Radiological results were analysed by measuring the hallux valgus angle (HVA), intermetatarsal angle (IMA), distal metatarsal articular angle (DMAA) and the position of the tibial sesamoid. AOFAS scores were collected prospectively. Patient satisfaction was determined by whether or not they would have the operation again for a similar condition.The mean age of the patients was 48.3 years (range 12–76) with a mean follow-up of 21 months. The mean improvement for the whole group in the IMA was from 15.8 to 7.9, HVA from 37.9 to 16.4 and DMAA from 19 to 9.9 was noted. The position of sesamoids improved from a mean of 5.8 to 2.3. The results were similar in both the groups and no significant difference was noted. AOFAS score improved from a mean of 53.6 preoperatively to 92.5 postoperatively. Three patients in the scarf group needed an Akin osteotomy as a revision procedure.Scarf osteotomy alone may be an effective procedure for moderate to severe hallux valgus. An Akin osteotomy may be indicated if residual hallux valgus is noted during surgery.     

Scarf截骨治疗中重度[足母]外翻的短期疗效分析

背景：野外翻是最常见的前足畸形,越来越受到矫形外科医生的重视,其治疗方式多种多样,如何选择适合的手术方式是治疗成功的关键。目的：探讨Scarf截骨术治疗[足母]外翻的疗效。方法：2010年7月至2012年6月,我院采用Scarf截骨术治疗中重度跽外翻患者47例（61足）,男5例（7足）,女42例（54足）;年龄20-78岁,平均52．2岁。比较手术前后[足母]外翻角及第1、2跖骨间角纠正程度。采用AOFAS评分评估患者临床症状改善情况。结果：所有患者均获得随访,随访时间4-8个月,平均6个月。[足母]外翻角由术前42．6。减小至12．9°,平均减小29．7°。第1、2跖骨间角由术前18．4°减小至8．9°,平均减小9．5°。AOFAS评分由术前49．9分增加至术后86．2分,平均增加26．5分。并发症发生率10％。结论：Scarf截骨术治疗中重度躅外翻可以获得较好的短期临床结果,但需严格掌握手术适应证。     

Minifragment screw fixation of the Scarf osteotomy

BACKGROUND: Various techniques have been used for internal fixation of Scarf osteotomies. Stability of fixation plays an important role in determining the outcome. We prospectively studied 23 consecutive cases of hallux valgus treated with a scarf osteotomy, which were internally fixed with AO mini fragment screws. The aim of our study was to evaluate the clinical efficacy of the AO mini fragment screw used as fixation device in Scarf osteotomy. MATERIALS AND METHODS: Twenty-three feet (1 male, 16 female) were evaluated. Bilateral procedures were performed on six patients. Mean age was 46 years. The mean followup was 18 months. One surgeon performed all the procedures. RESULTS: 43.5% of the patients were very satisfied, 52.2% were satisfied and 4.34% were not satisfied. All osteotomies united without any hardware complications. The mean global AOFAS score improved significantly from a preoperative score of 55 points to 91.95 (p < 0.001). The intermetatarsal, hallux valgus angle, and DMMA improved from the mean preoperative values of 15.9 degrees, 31.2 degrees, and 14.1 degrees to 9.1 degrees, 15.2 degrees, and 8.4 degrees, respectively (p < 0.001 for all). One patient developed a superficial wound infection, which responded to antibiotics and one patient developed a painful spur at first MTPJ. CONCLUSION: We conclude that this is a safe and simple technique of fixing a Scarf osteotomy. It is cost effective, provides stable fixation and maintains correction until the osteotomy unites.     

Scarf截骨治疗躅外翻的短期疗效分析

背景：拇外翻为足踝外科常见病、多发病,目前以各种手术治疗为主,术后效果及复发率有较大差异。目的：探讨Scarf截骨联合其他手术方式治疗中、重度拇外翻的短期疗效。方法：2008年7月至2010年6月,采用Scarf截骨治疗中、重度坶外翻患者33例（41足）,男4例（4足）,女29例（37足）;年龄24-69岁,平均51．7岁。在Scarf截骨的基础上部分患者联合第一跖趾关节骨赘切除、软组织松解及拇趾近节趾骨Akin截骨等手术方式。采用美国足踝外科协会（American Orthopedic FootandAnkle Society,AOFAS）Maryland拇跖趾关节评分系统进行疗效评估。随访时摄足负重位X线片并测量拇外翻角（halluxvalgusangle,HVA）和第一、二跖骨间角（intermetatarsalangle．IMA）。结果：所有患者均获随访,时间12-36个月,平均20．4个月。HVA由术前32．78。矫正至10．18°,IMA由术前11．57。矫正至6．26。。Maryland拇跖趾关节评分：90-100分28足（68．3％）,80-89分11足（26．8％）,70-79分2足（4．9％）,优良率为95．1％（39／41）。结论：Scarf截骨术具有较好的自身稳定性,纠正畸形能力强,愈合快,坚固的内固定可使患者早期下地活动,并发症相对较少,联合其他手术方式是治疗中、重度拇外翻的理想方法。     

两种截骨术式治疗中重度拇外翻影像学效果与临床疗效的系统评价

目的：系统评价Chevron截骨术与Scarf截骨术治疗中重度拇外翻的影像学效果和临床疗效。方法：计算机检索PubMed、Embase、Cochrane Library、中国生物医学文献数据库（CBM）、中国期刊全文数据库（CNKI）、万方期刊全文数据库（Wanfang Data）关于Chevron截骨术与Scarf截骨术治疗拇外翻的随机对照研究（RCT）,检索时限从建库至2018年6月。由2名研究者独立按照纳入和排除标准筛选文献,评价纳入文献的偏倚风险和提取相关观察指标后,采用RevMan 5.3.5软件进行Meta分析。比较两种截骨术式术后拇外翻角（HVA）、1-2跖骨间角（IMA）、跖骨远端关节面固有角（DMAA）、美国骨科足踝外科协会评分（AOFAS）、术后切口并发症以及患者满意度。结果：最终纳入6篇随机对照研究文献,共507例（足）患者,92.5%的患者为中重度拇外翻,其中Chevron截骨术261例（足）,Scarf截骨术246例（足）。Meta分析结果显示：Chevron截骨术在矫正HVA方面优于Scarf截骨术[MD=-1.95,95% CI （-2.64,-1.27）,P<0.000 01]。而两种方法在IMA[MD=-0.42,95% CI （-1.04,0.21）,P=0.19],DMAA[MD=0.78,95% CI （-0.72,2.29）,P=0.31],AOFAS评分[MD=2.47,95% CI （-2.38,7.33）,P=0.32],术后切口并发症[RR=1.09,95% CI （0.54,2.20）,P=0.82],患者满意度[RR=1.00,95% CI （0.96,1.05）,P=0.92]方面比较差异无统计学意义。结论：Chevron截骨术操作简单、跖骨短缩少、创伤小,在治疗中重度拇外翻矫正HVA方面优于Scarf截骨术,在IMA、DMAA、AOFAS评分、并发症、患者满意度方面二者效果相似。     

Three-dimensional analysis of different first metatarsal osteotomies in a hallux valgus model

BACKGROUND: This study evaluates and compares three-dimensional (3-D) changes in geometry of the first metatarsal (MT1) independent of soft tissue corrections of 5 common osteotomies: three distal (Chevron, Mitchell, and Wilson), one proximal (Stephens basal), and one combined proximal/distal (Scarf), using standardized synthetic bone models. MATERIALS AND METHODS: A digitizing system was used to measure and record points on the synthetic bone models in 3-D space. Computer vector analysis calculated 3-D rotations and translations of the MT1 head plus the conventional intermetatarsal angle (IMA) and distal metatarsal articular angle (DMAA). RESULTS: The Wilson and Mitchell's osteotomies produced significant shortening (p < 0.001) in contrast to the three other osteotomies. All the osteotomies produced a reduction in the 3-D IMA. The Scarf and Stephens basal osteotomies reduced the DMAA. All of the osteotomies resulted in lateral translations and depression of the MT1 head. While there were no significant (p > 0.05) translational differences between the Scarf and Stephens basal osteotomies, there were rotational differences, with the Stephens basal producing significantly more plantar flexion (p = 0.000) and pronation (p < 0.001) than the Scarf. CONCLUSION: This geometric study indicated many of the MT1 head changes following metatarsal osteotomy to be out-of-plane translational and multiplanar rotations which cannot be determined using AP radiographs alone. CLINICAL RELEVANCE: We advocate judicious choice of osteotomy to achieve the desired correction of hallux valgus in each individual.     

Technique for Preventing Troughing in Scarf Osteotomy

Scarf osteotomy is a common operative procedure for mild-to-moderate hallux valgus. We describe a simple supportive technique that prevents troughing intraoperatively without additional bony procedures.