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Scarf Osteotomy for Correction of Hallux Valgus


Indications

Objective Indications

  • Moderate to severe hallux valgus deformities with

    • Increased hallux valgus angle (HVA) ≤50°

    • Increased intermetatarsal angle (IMA) ≤20°

    • Increased distal metatarsal articular angle (DMAA) ≤10°

  • Hallux valgus revision surgery for recurrence (Bock, 2009)

  • Bunionette deformity of fifth metatarsal (type 3, increased fourth–fifth IMA)

  • Modular corrections are feasible via the great versatility of the Scarf osteotomy

    • Lateralization of head-shaft fragment to reduce IMA

    • Transverse plane rotation to correct increased DMAA

    • Plantar displacement to increase first ray load

    • Elongation in cases of short metatarsal (congenital, iatrogenic)

    • Shortening in cases of long metatarsal

  • Dorsal displacement to decrease first ray or sesamoid load

  • Medialization of first metatarsal head (1MTH) in cases of hallux varus

Indications Pitfalls

  • Severe metatarsus primus varus deformity (IMA > 20°)

  • Increased medial slope of the first tarsometatarsal articular surface (higher risk of recurrence)

  • Increased DMAA

  • Hypermobile first tarsometatarsal joint (ligamentous laxity)

  • Symptomatic osteoarthritis of first metatarsophalangeal joint (1MTP) joint

  • Reduced bone mineral density (severe osteoporosis)

  • Rheumatoid arthritis

Controversies

  • Other techniques exist for operative correction of mild to moderate hallux valgus deformities ( )

    • Distal procedures: Chevron, Kramer, Boesch

    • Proximal procedures: crescentic metatarsal osteotomy, Ludloff osteotomy, proximal closing wedge osteotomy, proximal opening wedge osteotomy

    • Combined procedures: double/triple osteotomies

Examination/Imaging

Physical Examination

  • Palpation and range of motion (active and passive) of hindfoot, midfoot, and forefoot joints

  • Alignment of great toe (an additional Akin osteotomy might be necessary)

  • Clinical assessment of first ray hypermobility

  • Posture of foot, presence of plantar callosities, bursal or skin irritation at bunion

  • Tightness of gastrocnemius-soleus (assessed with flexed and extended knee, foot maintained with talonavicular joint reduced to eliminate transverse tarsal or subtarsal motion)

  • Pedobarography

Radiographic Assessment

  • Standard weight-bearing anteroposterior and lateral radiographs

  • Evaluate ( Fig. 2.1 ) HVA, IMA, and DMAA hallux interphalangeal angle

    • Articular shape (curved, chevron, or flat) and congruency of the 1MTP joint

    • Metatarsal index (length of first metatarsal in comparison with second metatarsal)

    • Evidence of arthritic changes

    FIG. 2.1, DMAA, Distal metatarsal articular angle; HVA, hallux valgus angle; IMA, intermetatarsal angle.

Surgical Anatomy

  • Vascular supply of first metatarsal ( Figs. 2.2 and 2.3 )

    • Dorsal and plantar metatarsal artery

    • Superficial branch of the medial plantar artery

    • Extensive network on the dorsal and lateral capsular aspects

    FIG. 2.2

    FIG. 2.3

  • Nerve supply to the first metatarsal ( Fig. 2.4 )

    FIG. 2.4

  • Superficial peroneal nerve

    • Deep peroneal nerve

    • Distal branch of the saphenous nerve

    • Dorsal and plantar sensory nerve branches around first metatarsal

  • Lateral soft tissues to be released

    • Lateral suspensory and anterior fibular sesamoid ligaments

    • 1MTP joint capsule

    • Lateral collateral ligament

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