Background
Adolescent hallux valgus is among the most difficult deformities to correct for foot and ankle surgeons. Although several osteotomies have been described and studied for correction of adult hallux valgus deformity, the presence of open physeal growth plates can limit the surgical correction in a juvenile deformity. High recurrence rates have been noted in this younger patient demographic3.
Adaptations of various osteotomies and use of multiple osteotomies have been described in the literature for juvenile hallux valgus1,2,4. Recently , Davids et al. reported their results of lateral hemi-epiphyseodesis of the first metatarsal as an alternative to other skeletal and soft tissue balancing procedures3. This was reported by Stephen Smith, DPM, 25 years ago but there has been no long term follow-up.
The Scarf bunionectomy was originally described and utilized by the senior author for over 2 decades5. The senior authors have successfully employed the Scarf osteotomy for correcting adult hallux valgus deformities. Principles of the Scarf osteotomy have also been applied to correct adolescent hallux valgus deformities.
There are limited long term results and lack of consensus regarding the most effective corrective procedure(s) for this deformity in a younger patient demographic. To our knowledge, there is no current literature that reports long-term results of the Scarf osteotomy in this patient population. The purpose of this study is to evaluate the long-term results of the Scarf osteotomy for correction of juvenile hallux valgus.
Materials and Methods
A retrospective query of patients having undergone the Scarf bunionectomy for correction of juvenile and adolescent hallux valgus deformity was performed. Patients were selected consecutively from the senior authors' clinic. Patients were requested to return to clinic for study clinical and radiographic follow up. Surgical inclusion criteria consisted of a painful medial prominence due to a bunion deformity unresponsive to conservative treatment.
Weight bearing pre- and postoperative anteroposterior (AP) and lateral (LAT)radiographs of the feet were evaluated with the patient in the weight-bearing position. Data recorded included: intermetatarsal (IM) 1-2 angle, hallux valgus angle (HVA), distal metatarsal articular angle (DMAA). First metatarsal length patterns were observed. Data recorded from the LAT radiograph evaluated first metatarsal declination. Complications were defined as hallux varus , transfer metatarsalgia, stress fractures, and recurrence of the deformity requiring revision surgery.
Post-operative patient satisfaction was assessed using a standard patient satisfaction survey. Post-operative subjective and objective measurements were calculated utilizing the ACFAS Scoring Scale for the First Metatarsophalangeal Joint & First Ray and AOFAS Hallux Metatarsophalangeal-Interphalangeal Scale.
Descriptive statistics, including mean and standard deviation were used to describe demographic, radiographic and follow-up data. Pre- and postoperative radiographic variables were compared. A paired Student's t-test was performed to compare normally distributed continuous variables. Statistical differences were considered to be significant when the p-value was < 0.05.
| Case Presentation |
 |
 |
Pre-operative photographs and AP radiographs of a 14y.o female patient with bilateral hallux valgus deformity.
- IMA: Left 13, Right 14
- HVA: Left 17, Right 27
- DMAA: Left 19, Right 22 |
 |
 |
Post-operative photograph and AP radiograph of this patient at 17 months. The patient is very satisfied with the appearance and function of both feet at follow-up.
- IMA: Left 4, Right 4
- HVA: Left 7, Right 14
- DMAA: Left 0, Right 8
|
| Table 1 |
Age at Surgery |
Follow up (Months) |
Sex |
Genetic Inheritance |
Return to Regular Activities
- RIGHT FOOT
|
Return to Regular Activities
- LEFT FOOT |
Return to Typical Shoes Gear (R, L) |
ACFAS Postoperative Score - (R,L)
|
AOFAS Postoperative Score - (R,L)
|
Complications |
| Patient 1 |
12 |
36 |
F |
Maternal |
4 wks |
4 wks |
6, 6 |
89,97 |
90,93
|
|
| Patient 2 |
13 |
12 |
F |
Maternal |
5 wks |
5 wks |
12, 12 |
97,100 |
100,93
|
|
Patient 3 |
14 |
19 |
F |
Maternal |
4 wks |
4 wks |
12, 12 |
100,94 |
100,93
|
|
Patient 4 |
15 |
16 |
F |
Maternal |
6 wks |
6 wks |
6, 6 |
100,97 |
100,95
|
|
| Patient 5 |
16 |
52 |
M |
Maternal |
6 wks |
6 wks |
6, 6 |
100,100 |
93,100
|
|
| Patient 6 |
17 |
210 |
F |
Maternal |
8 wks |
8 wks |
12, 12 |
57,95 |
93,100
|
Recurrence 18 yrs
post-op.
Revision Right foot |
| Patient 7 |
18 |
53 |
F |
Maternal |
4 wks |
4 wks |
6, 6 |
100,100 |
100,100
|
|
| Averages |
14.43 |
57 |
|
100% Maternal |
5.29 wks |
5.29 wks |
8.57/8.57 |
91.86/97.57
|
96.57/96.29 |
|
| TABLE 2
|
Average Pre-op
|
Average Post-op
|
P-value
|
| First Intermetatarsal Angle
|
14.29 ±2.60
(range: 8-18)
|
5.64 ±2.29
(range: 4-13)
|
0.001
|
| Hallux Valgus Angle
|
27.43 ±8.53
(range: 9-40)
|
12.79 ±6.76
(range: 0-24)
|
0.001
|
| Distal Metatarsal Articular Angle
|
24.50 ±9.11
(range: 9-36)
|
8.79 ±6.76
(range: 0-20)
|
0.001
|
Results
Follow-up was performed in 14 feet, 7 patients, at an average of 57 months. The average age at the date of surgery was 14.43±1.59 (range, 12-17). There were 6 (86%) females and 1 (14%) male. Maternal bunion inheritance was reported by 100% of patients (Table 1). All patients underwent bilateral bunion correction on the same date. Three patients had open growth plates at the date of surgery. Three feet (21%) had an Akin osteotomy performed on the date of surgery.
Table 2 contains radiographic preoperative and postoperative data. Statistical differences were noted in the preoperative and postoperative measured angles.
Patients returned to athletic/running type sneaker at post-operative day 7. Postoperative return to full activities was at an average of 5.29 weeks (Table 1).
The average postoperative ACFAS Metatarsophalangeal Joint and First Ray Scale (Module 1) was 94.72 and AOFAS Hallux Metatarsophalangeal-Interphalangeal Scale was 96.43.
At follow up examination, all patients (100%) stated that they would have concomitant bilateral bunion surgery performed again and would recommend bunion surgery to a relative.
One patient underwent revision surgery for one foot (7%) 18 years after the date of initial surgery due to painful recurrence of the deformity.
Discussion and Conclusions
Treatment of juvenile and adolescent hallux valgus deformities is more complicated due to the higher recurrence rates and presence of open physeal plates3. Often, these deformities are associated with an increased DMAA that should be corrected1. Our results correlate with this common finding. Depending on the severity of the deformity and presence of an increased DMAA, Coughlin suggested the use of a soft tissue procedure with a single or double first ray osteotomy for complete correction of hallux valgus deformities. Double osteotomies were utilized for moderate and severe deformities with an increased DMAA1.
The Scarf is advantageous for correction of juvenile and adolescent hallux valgus deformities in several facets. The Scarf is extremely versatile, single osteotomy, which can be utilized for mild to severe hallux valgus deformities, as demonstrated in this study. The presence of an open first metatarsal growth plate does not affect or limit the degree of angular correction that can be obtained. Rather than addition of a separate osteotomy, correction of an increased DMAA can be incorporated using a simple modification of the Scarf osteotomy. Correction was maintained at an average follow up of 57 months.
The stability of the Scarf osteotomy allows for bilateral bunion correction to be performed concomitantly. All 7 patients (100%) had concomitant bilateral bunion correction and all would undergo bilateral bunion surgery again. There was a very low complication rate noted in our study. Only one foot (7%) required revisionary surgery for symptomatic recurrence.
Post-operative protocols are not stringent or cumbersome as with other osteotomy techniques. Patients are restricted to immediate limited weight-bearing in a surgical shoe without crutch/cane assistance for one week after the procedure. All patients (100%) were allowed to ambulate in a roomy athletic sneaker. Our results exhibited an early return to full activities at 5.29 weeks.
Excellent scores were attained using the ACFAS Metatarsophalangeal Joint and First Ray Scale (Module 1) and AOFAS Hallux Metatarsophalangeal-Interphalangeal Scale to assess postoperative subjective, functional and radiographic satisfaction. Limitations of this study are the lack of preoperative scores for the aforementioned scales.
Based on the results, we believe the Scarf osteotomy is a safe, effective and versatile procedure for correction of juvenile and adolescent hallux valgus deformity.
- Coughlin MJ. Juvenile Hallux Valgus: etiology and treatment. Foot Ankle Int. 1995 Nov;16(11):682-97.
- Petratos DV, Anastasopoulos JN, Plakogiannis CV, Matsinos GS. Correction of adolescent hallux valgus by proximal crescentic osteotomy of the first metatarsal. Acta Orthop Belg. 2008 Aug;74(4):496-502.
- Davids JR, McBrayer D, Blackhurst DW. Juvenile hallux valgus deformity: surgical management by lateral hemiepiphyseodesis of the great toe metatarsal. J Pediatr Orthop. 2007 Oct-Nov;27(7):826-30.
- Amarnek DL, Jacobs AM, Oloff LM. Adolescent hallux valgus: its etiology and surgical management. J Foot Surg. 1985 Jan-Feb;24(1):54-61.
- Borrelli AH, Weil LS. Modified Scarf bunionectomy: Our experience in more than one thousand cases. J Foot Surg. 1991 30:609-612
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