Background: Hallux valgus deformity is one of the most common chronic and progressive foot deformities. Surgical correction of the deformity plays a central role in the treatment of symptomatic hallux valgus. However, more than one hundred different surgical techniques have been described. Objective: To assess the radiological outcome of hallux valgus surgical correction using a scarf and akin osteotomies. Materials and methods: A cross-sectional hospital-based study was conducted on 25 adult patients (36 feet). Twenty-two females and two males with hallux valgus were treated with surgical correction using a scarf and akin osteotomies. All candidates were kept on regular postoperative, scheduled clinical follow-up programs for one year and assessed radiologically. Results: Twenty-five patients (36 feet) were included in this study. The hallux valgus angle significantly shifted to the normal range (less than 15°) after surgery, and the inter-metatarsal angle also improved to the normal range (less than 9°). Conclusion: Using scarf and akin osteotomies in treating moderate and severe hallux valgus deformity provides the satisfactory radiological outcomes in form of decreasing hallux valgus angle and inter-metatarsal angle.
Hallux valgus (HV) deformity is one of the most common chronic and progressive foot deformities [
There are a lot of risk factors for hallux valgus deformity. It can be divided into intrinsic and extrinsic factors. Genetic predisposition (70% of patients), increased distal metaphyseal articular angle (DMAA), ligamentous laxity, convex metatarsal head, second toe deformity or amputation, pes planus, and rheumatoid arthritis are important intrinsic factors. Extrinsic factors include inappropriate shoes with high heels and a narrow toe box.
The patient typically complains of pain over prominence at the MTP joint and difficulties wearing shoes because of medial eminence, and other functional disabilities with HV; due to that, surgery is usually indicated, depending on the degree of deformity based on the radiological findings as well as the physical examination findings. Radiological assessment includes weight-bearing anteroposterior (AP) and lateral imaging of the foot. The severity of the deformity is usually classified as mild when the hallux valgus angle (HVA) is up to 19˚, inter-metatarsal angle (IMA) up to 13˚, moderate when HVA is 20˚ to 40˚; and severe when HVA is > 40˚ and IMA > 20˚.
Surgical correction of the deformity has a major role in treating HV deformity, and >100 different surgical techniques have been described [
The scarf osteotomy is a Z-step cut in the first metatarsal bone used to reduce hallux valgus deformity’s increased inter-metatarsal angle (IMA). The term ‘‘scarf’’ is a carpentry term referring to a joint created by notching two pieces of wood. This osteotomy is used widely in France and the United States and continues to evolve and increase in popularity in the surgical community [
• General objective:
To assess the radiological outcome of hallux valgus after surgical correction using scarf and akin osteotomies.
• Specific objectives:
1) To measure the hallux valgus angle before and after surgery.
2) To compare the inter-metatarsal angle before and after correction
3) To identity the shape of the 1st metatarsal head, congruency of the 1st metatarso-phalangeal joint and the mmetatarsal Cascade.
Cross-sectional, hospital-based study.
The study was conducted at Future Hospital in Khartoum, Sudan. From January 2019 to December 2022.
Inclusion criteria were all adult patients from both genders with hallux valgus deformity who underwent acute surgical correction were included in this study. Patients with other foot deformities were excluded.
Total coverage of all patients with hallux valgus deformity was treated with acute surgical correction and met the inclusion criteria.
Data were collected using a structured questionnaire, and the questionnaire was designed and filled out by the first and second authors. Attached in the appendix, including the patient’s demographic data, history, examination findings, and radiographic assessment for the hallux valgus angle and inter-metatarsal angle, were measured before surgery and one year after surgery. These angles were measured from weight-bearing X-rays using computer software anteroposterior (AP) and lateral imaging of the foot. Collected questionnaires were revised for completeness and accuracy, and clearance. Data were entered using the Statistical Package for Social Sciences (SPSS) version 27.0 for data analysis.
Descriptive terministic in terms of frequency tables with percentages and graphs. Chi-square test to assess associations (P value of 0.05 or less is considered significant).
Small sample size and short follow-up period.
Careful clinical and radiological assessment of patients was handled before surgery. Counselling and consent were obtained. Spinal anesthesia was chosen in this series, and a tourniquet was applied to all patients. The sesamoid apparatus, adductor halluces tendon, and lateral sesamoid ligament were freed from the insertion in the metatarsal head and proximal phalanx through a dorsal incision in the joint capsule between the metatarsal head. A medial incision at the sagittal groove removed the first metatarsal’s medial eminence. A guide wire was placed proximal to the metatarsal head articular surface and inferior to the first metatarsal dorsal cortex. The guide wire was pointed planetary at the third metatarsal head’s plantar surface but perpendicular to the second metatarsal’s long axis. A power saw was cut horizontally along the metatarsal shaft from proximal to the articular surface of the metatarsal head to the basal tuberosity after positioning an osteotomy jig on the guide wire. To enable rotation, the proximal cut was performed at roughly a 45˚ angle from medial proximal to lateral distal, parallel to the guide wire. The inferior fragment then rotated toward the second metatarsal to lessen the inter-metatarsal angle after the lateral capsule was freed. By measuring the inter-metatarsal angle on an X-ray anterior-posterior and oblique views, it was possible to determine the required degree of rotation before surgery. The inter-metatarsal angle was intended to be reduced to 7˚. The bone fragments were held with a clamp and fixed with two 2.0 millimeters cortical screws. The medial side of the metatarsal shaft then had the overhanging margins of the bone cut off. In each example, the proximal phalanx underwent an Akin closing wedge osteotomy. The Akin osteotomy was fixed using bone staples. Finale X-rays were checked by fluoroscopy, wound dressing and sterile dressing were performed after 2 weeks follow up stitches were removed. Immobilization in a walker boot was applied for two months, followed by physiotherapy sessions. All patients had their physiotherapy sessions at the same center, and the same protocol was done for them. X-rays were taken immediately after surgery, then at four weeks, 12 weeks, and six months.
This study included 25 participants and 36 feet. The average age was 62.2 years old. The main age group included 11 patients (44%), ranging in age from 60 to 69 years. There were 9 patients over the age of 70 (36%) and 5 patients under the age of 60 (20%) (
The postoperative shape of the first metatarsal head was round in 16 feet, intermediate in 6 feet, and marginal in 14 feet, according to the study (
| HV angles | Pre | Post | ||||||
|---|---|---|---|---|---|---|---|---|
| R | L | R | L | |||||
| N | % | N | % | N | % | N | % | |
| <15 normal | 0 | 0.0 | 0 | 0.0 | 5 | 31.3 | 7 | 35.0 |
| 15 - 20 mild | 0 | 0.0 | 0 | 0.0 | 5 | 31.3 | 8 | 40.0 |
| 21 - 39 moderate | 9 | 56.2 | 13 | 65.0 | 6 | 37.5 | 5 | 25.0 |
| >39 severe | 7 | 43.8 | 7 | 35.0 | 0 | 0.0 | 0 | 0.0 |
| Total | 16 | 100.0 | 20 | 100.0 | 16 | 100.0 | 20 | 100.0 |
| P value | 0.026 | 0.017 | ||||||
| MI angle | Pre | Post | ||||||
|---|---|---|---|---|---|---|---|---|
| R | L | R | L | |||||
| N | % | N | % | N | % | N | % | |
| <9 normal | 0 | 0.0 | 0 | 0.0 | 7 | 43.8 | 7 | 35.0 |
| 9 - 11 mild | 4 | 25.1 | 2 | 10.0 | 6 | 37.5 | 5 | 25.0 |
| 12 - 17 moderate | 8 | 50.0 | 9 | 45.0 | 2 | 12.5 | 8 | 40.0 |
| >17 severe | 4 | 25.0 | 9 | 45.0 | 1 | 6.3 | 0 | 0.0 |
| Total | 16 | 100.0 | 20 | 100.0 | 16 | 100.0 | 20 | 100.0 |
| P value | 0.014 | 0.018 | ||||||
| Shape of the 1st MT head | R | L | ||
|---|---|---|---|---|
| N | % | N | % | |
| Rounded | 6 | 37.5 | 10 | 50.0 |
| Intermediate | 2 | 12.5 | 4 | 20.0 |
| Marginal | 8 | 50.0 | 6 | 30.0 |
| Total | 16 | 100.0 | 20 | 100.0 |
| Congruency of MTP joint | R | L | ||
|---|---|---|---|---|
| N | % | N | % | |
| Incongruent | 4 | 31.3 | 4 | 19.0 |
| Congruent | 11 | 68.8 | 17 | 81.0 |
| Total | 16 | 100.0 | 20 | 100.0 |
cascade after surgery in this study, and it was found to be disturbed in 27 feet and normal in 9 feet (
Recurrence of the deformity was encountered in 2 feet (5.5%) and couldn’t be correlated statistically with either the shape of the metatarsal head or the congruence of the 1st MTP.
Surgical correction of symptomatic hallux valgus deformity aims at relieving the symptoms and improving the alignmentin the current study, the most affected age group (44%) was between 60 and 69 years old, with those under 60 years old being the least affected (20%). This was consistent with the findings of Hylton B. Menz and fellows [
The majority of patients were females (88%), and only 3 patients (12%) were males. This is common in the literature; Christopher G. Lenz and his colleagues [
In this study, 10 patients were affected bilaterally (40%), and also 10 patients (40%) operated on the left side only, and only 5 patients (20%) had the operation on their right foot. Michael J. Coughlin et al. [
Our patients were followed up after surgery more than 12 months in 18 patients (72%), (6 - 12 months) in 4 patients (16%), and in less than 6 months) in 3 patients (12%). A.-K. Nilsdotter and his colleagues [
Our results showed that, according to radiological measures, the angle of hallux valgus significantly shifted to the normal range. The mean hallux valgus angle has improved from 36.2 before surgery to 16.9 one year after the procedure. The inter-metatarsal angle had also shifted to the normal range. The mean inter-metatarsal angle has been reduced from 19.4 before the operation to 9.5 one year after the correction. Both changes were statistically significant (P value < 0.05).
| Metatarsal Cascade | R | L | ||
|---|---|---|---|---|
| N | % | N | % | |
| Disturbed (short first metatarsal) | 4 | 25.0 | 5 | 25.0 |
| Normal | 12 | 75.0 | 15 | 75.0 |
| Total | 16 | 100.0 | 20 | 100.0 |
Ignacio Martínez Garrido and his fellows [
It is still debatable if the first metatarsal (MT) head shape and the hallux valgus deformity are related. In the current study, the postoperative shape of the 1st MT head was rounded at 16 feet, intermediate at 6 feet, and marginal at 14 feet. The first metatarsal head’s lateral edge was investigated by Okuda and his colleagues [
Moreover, Satoshi Yamaguchi et al. examination of the first metatarsal head’s lateral edge [
The congruence of the first metatarsophalangeal (MTP) joint after the surgical correction is important in predicting the recurrence of deformity. Several researches have demonstrated a strong correlation between postoperative MTP joint incongruence and hallux valgus recurrence. In our study, the postoperative incongruence of the metatarsophalangeal joint was encountered in 7 joints, and 28 joints were congruent. Yan Li et al. [
In this study we also evaluated the postoperative alignment of metatarsal cascade. It was found disturbed (short first metatarsal) in 9 feet and normal in 27 feet. Following treatment of hallux valgus, Christopher G. Lenz and his colleagues [
Finally, our study shows that surgical correction of hallux valgus using a scarf and akin osteotomies significantly improves radiological measures. This is supported by Ignacio Martínez Garrido and his fellows [
Surgical management of moderate and severe hallux valgus deformity with a combination of scarf and akin osteotomies provides satisfactory radiological outcomes. This was reflected by restoring the normal values of the hallux valgus angle and inter-metatarsal angle in most patients. However, the metatarsal cascade and the length of the 1st metatarsal can be affected after the procedure. The results of this study couldn’t correlate the shape of the 1st metatarsal head with the recurrence of the deformity.
First and foremost, we thank Allah for lighting our path and allowing us to finish this work. We are grateful to our colleagues who contributed to bringing this work to light. We are grateful to our families for devoting themselves at this time to provide various forms of assistance. Thank you very much.
We declare that we have:
- Written permission was obtained from the administrative authority of Future hospital.
- Confidentiality was considered intentional, and data was used anonymously by using code Numbers instead of names to participants’ identities and keep secure, and information was used for research purposes only.
S. N: Orthopaedics surgeon, conceptualization, methodology, resources, project administration, writing original draft.
M. H: Orthopedic resident, conceptualization, data collection, methodology, assist in writing original draft.
A. K: Orthopedic resident, conceptualization, assist in data collection, writing original draft.
H. A: Orthopedic surgeon, data curation, resources, validation, review and editing.
M. F: Orthopedic surgeon, resources, visualization, validation, and assisting in analysis & editing.
O. G: House officer, data curation, formal analysis, software, and assisting in writing original draft.
The manuscript has been read and approved by all the authors.
The authors declare that they have no competing interests.
Nogdallah, S., Osman, M.A., Fatooh, M., Khairy, A.M.M., Abd-Elmaged, H.M.A. and Nubi, O.G. (2023) The Radiological Outcome of Surgical Correction of Hallux Valgus with Combined Scarf and Akin Osteotomies. Open Journal of Orthopedics, 13, 84-96. https://doi.org/10.4236/ojo.2023.133010
The radiological outcome of surgical correction of hallux valgus using combined scarf and akin osteotomies
Questionnaire
Serial No: __________
PR number: ________
1) Age (years): _______
2) Gender:
Male ☐ Female ☐
3) The side of operation:
Right ☐ Left ☐ Bilateral ☐
4) The duration of follow-up (months): _______
5) Hallux valgus angle:
Pre-operative ☐ Post-Operative ☐
6) Inter-metatarsal angle:
Pre-operative ☐ Post-Operative ☐
7) Meta-tarsal cascade:
Normal ☐ Disturbed ☐
8) The shape of the first meta-tarsal head:
Rounded ☐ Intermediate ☐ Marginal ☐