Published: Foot & Ankle Specialist, February 2010

Scarf Osteotomy for the Correction of Adolescent Hallux Valgus

Author(s): Shine John, DPM, AACFAS,
Lowell Weil Jr, DPM, MBA, FACFAS,
Lowell Scott Weil Sr, DPM, FACFAS,
and Kari Chase, MS

Abstract: Adolescent hallux valgus deformity is a complex surgical condition. Although several techniques have been described to correct this deformity in adults, limitations exist for adolescents because of the presence of open growth plates and high recurrence rates. This retrospective study reports results of 7 patients (14 feet) using the Scarf osteotomy for correction of adolescent hallux valgus deformity. All patients underwent concomitant bilateral hallux valgus surgery. Radiographic evaluation measures included intermetatarsal 1-2 angle, hallux valgus angle, and distal metatarsal articular angle. Data recorded from the lateral radiograph evaluated the first metatarsal declination angle.

Postoperative patient satisfaction was assessed using a standard patient satisfaction survey. Postoperative, subjective, and objective measurements were calculated using the American College of Foot and Ankle Surgeons (ACFAS) Scoring Scale for the First Metatarsophalangeal Joint and First Ray and the American Orthopaedic Foot & Ankle Society (AOFAS) Hallux Metatarsophalangeal-Interphalangeal Scoring Scale. Average patient age and follow-up were 14.43 years and 57 months, respectively. There was 100% maternal inheritance of hallux valgus deformity. The average postoperative ACFAS Metatarsophalangeal Joint and First Ray Scale (module 1) score was 94.72, and the average AOFAS Hallux Metatarsophalangeal-Interphalangeal Scale score was 96.43. Complications included 1 patient who underwent revision surgery on 1 foot 18 years after the date of index surgery because of painful recurrence of the deformity. The authors believe the Scarf osteotomy is a safe, effective, and versatile procedure for the correction of juvenile and adolescent hallux valgus deformity.

Keywords: adolescent bunion; juvenile bunion; Scarf osteotomy; hallux valgus; hallux abductovalgus

Adolescent hallux valgus is among the most difficult bunion deformities for foot and ankle surgeons to correct. 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 demographic.1 Adaptations of various osteotomies and use of multiple osteotomies have been described in the literaturefor juvenile hallux valgus.2-4 Recently, Davids et al1 reported their results of lateral hemiepiphyseodesis of the first metatarsal as an alternative to other skeletal and soft-tissue balancing procedures. This was anecdotally reported by Stephen D. Smith, DPM, 30 years ago, but it was never published in the literature.

The Scarf bunionectomy was originally described and has been used by the senior author (L.S.W.) for more than 2 decades.5 The senior authors (L.S.W., L.W.) have successfully employed the Scarf osteotomy for correcting adult hallux valgus deformities in more than 5000 cases. 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 the longterm 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.Because of the availability of patient records, patients were selected from the senior authors’ clinic from 2002 to 2007. Patients were requested to return to the clinic for clinical study and radiographic follow-up. Original surgical inclusion criteria consisted of a painful medial prominence due to a bunion deformity and moderate or severe hallux valgus deformity. Weight-bearing preoperative and postoperative anteroposterior and lateral radiographs of the feet were evaluated (Figures 1-2). Data recorded included intermetatarsal 1-2 angle, hallux valgus angle (HVA), and distal metatarsal articular angle (DMAA).

Data recorded from the lateral radiograph evaluated the first metatarsal declination. Complications were defined as hallux varus, transfer metatarsalgia, stress fractures, and recurrence of the deformity requiring revision surgery. Postoperative patient satisfaction was assessed using a standard patient satisfaction survey. Postoperative subjective and objective measurements were calculated using the American College of Foot and Ankle Surgeons (ACFAS) Scoring Scale for the First Metatarsophalangeal Joint and First Ray and the American Orthopaedic Foot & Ankle Society (AOFAS) Hallux Metatarsophalangeal-Interphalangeal Scale. Descriptive statistics, including means and standard deviations, were used to describe demographic, radiographic, and follow-up data. Preoperative and postoperative radiographic variables were compared. A paired Student test was performed to compare normally distributed continuous variables. Statistical differences were considered to be significant when the P value was < .05.

Results

Follow-up was performed in 14 feet (7 patients) at a mean of 57 months. The average age at the date of surgery was 14.43 ± 1.59 years (range, 12-17 years). There were 6 (86%) females and 1 (14%) male (Figures 3-5). Based on patient report at the time of final follow- up, 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 postoperative 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) score was 94.72, and the average AOFAS Hallux Metatarsophalangeal-Interphalangeal Scale score 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 1 foot (7%) 18 years after the date of initial surgery because of painful recurrence of the deformity. Complications are reported in Table 1.

Discussion

Treatment of juvenile and adolescent hallux valgus deformities is more complicated because of the reported higher recurrence rates and presence of open physeal plates.1 Often, these deformities are associated with an increased DMAA that should be corrected. 2 Our results correlate with this common finding. Depending on the severity of the deformity and presence of an increased DMAA, Coughlin2 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 used for moderate and severe deformities with an increased DMAA.2 George et al6 reported their results with the Scarf osteotomy in the adolescent population. With an average follow-up of 37 months in 13 patients with a total of 19 feet, they reported a loss of correction with both the HVA and DMAA at final follow-up. They suggested that the Scarf osteotomy be used with caution in symptomatic adolescent hallux valgus. We do not share these sentiments based on the results of our study. With our average follow- up of 57 months, we demonstrate dissimilar results and feel that the Scarf is effective in maintaining correction of all angular deviations.

The Scarf is advantageous for correction of juvenile and adolescent hallux valgus deformities in several facets. The Scarf is an extremely versatile, single osteotomy, which can be used 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. There was a very low complication rate noted in our study. Only 1 foot (7%) required revisionary surgery (18 years postoperatively) for symptomatic recurrence. The stability of the Scarf osteotomy allows for bilateral bunion correction to be performed concomitantly. All 7 patients (100%) had concomitant bilateral bunion correction. All patients, including the 1 patient who required revision on 1 foot, stated that they would undergo bilateral bunion surgery again.

Postoperative protocols are not cumbersome, unlike other osteotomy techniques that typically require 6 weeks of non–weight bearing. Patients are allowed immediate, limited weight bearing in a surgical shoe without crutch/ cane assistance 1 week after the procedure. All patients (100%) were allowed to ambulate in a roomy athletic sneaker following the first postoperative visit at 1 week. Formal physical therapy was instituted at that time to gain strength and flexibility in the great toe segment. Our results exhibited an early return to full activities at 5.29 weeks in this patient population.

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 and the small number of cases that we were able to recruit for follow-up evaluation.

Conclusion

Based on the results and our experience with numerous patients in the adolescent population, we believe the Scarf osteotomy is a safe, effective, and versatile procedure for correction of juvenile and adolescent hallux valgus deformity.

References

1. Davids JR, McBrayer D, Blackhurst DW. Juvenile hallux valgus deformity: surgical management by lateral hemiepiphyseodesis of the great toe metatarsal. J Pediatr Orthop. 2007;27(7):826-830.
2. Coughlin MJ. Juvenile hallux valgus: etiology and treatment. Foot Ankle Int. 1995;16(11):682-697.
3. 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;74(4): 496-502.
4. Amarnek DL, Jacobs AM, Oloff LM. Adolescent hallux valgus: its etiology and surgical management. J Foot Surg. 1985;24(1):54-61.
5. Weil LS. Scarf osteotomy for correction of hallux valgus: historical perspective, surgical technique, and results. Foot Ankle Clin. 2000;5(3):559-580.
6. George HL, Casaletto J, Unnikrishnan PN, et al. Outcome of the scarf osteotomy in adolescent hallux valgus. J Child Orthop. 2009;3(3):185-190.