SCARF PROCEDURE: A PROSPECTIVE CLINICAL, RADIOGRAPHIC, AND PEDOBAROGRAPHIC EVALUATION

Abstract

We prospectively enrolled and evaluated 30 patients with unilateral or bilateral hallux valgus. At the time of our preliminary follow-up, 8 patients (14 feet) with unilateral or bilateral hallux valgus who had either a Scarf or a combined Scarf-Akin procedure from June 2006 to December 2006 were evaluated. Three surgeons practicing within one practice performed the procedures. Exclusion criteria for this study included concomitant forefoot pathology, such as hammertoes, clawtoes, and transfer metatarsalgia, which required concomitant surgery. We also excluded patients with excessive first ray instability which would have required 1st metatarsal-cuneiform fusion. The average age of the patients at surgery was 37.8 years (range, 14–76 years).

Average follow-up time was 6.5 months. Four of the eight patients (8/14 feet) required an Akin osteotomy in addition to the Scarf procedure. Patients showed an average improvement of AOFAS score from 65.7 to 86.3. The ACFAS 1st ray score improved from 63.2 to 86.8. The intermetatarsal and hallux valgus angles improved from mean pre-operative values of 14.3° and 25.9° to 9.5° and 10.2°, respectively. Similarly, the 1st metatarsal declination angle also improved from a mean of 38.7° pre-operatively to 20.9° post–operatively. There was no significant change in first metatarsal dorsiflexion before and after surgery (64.5 to 68.7). Pre op and post op plantarflexion was also assessed. The mean hallux plantarflexion remained virtually identical at 11.3 degrees of motion. Pedobarographic analysis showed medialization of peak plantar pressure following surgery. Peak plantar pressure increased under the hallux (Increasing from 91.5 kPa to 144.6 kPa) and first metatarsal while decreasing under the 2nd, 3rd, 4th, and 5th metatarsals following surgery. Average time to return to work and to activities of daily living were 2.6 weeks and 3 weeks respectively.

We conclude that the Scarf osteotomy and Akin closing wedge osteotomy of the proximal phalanx of the great toe appear to be safe and effective for the treatment of hallux valgus and restoration of normal forefoot pressure. Our data suggest the Scarf osteotomy normalizes the function of the hallux during the propulsive phase of the gait cycle. This was reflected in the increased peak pressure under the first metatarsal head and the reduction of peak pressure under the second metatarsal head. We have found pedobarography to be useful as a pre-operative tool and to assess outcomes in forefoot surgery.