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. 2023 Sep 20;15(12):3243–3253. doi: 10.1111/os.13903

Biomechanical Comparison between Rotational Scarf Osteotomy and Translational Scarf Osteotomy: A Finite Element Analysis

Yan Li 1, Yue Wang 2, Feng Wang 1, Kanglai Tang 1,✉, Xu Tao 1,✉
PMCID: PMC10694014  PMID: 37731316

Abstract

Objective

Rotational Scarf osteotomy has its unique advantages in treating hallux valgus, but it also has certain drawbacks. The biomechanical differences between rotational Scarf and translational Scarf osteotomy are not clear evaluates the correction ability and biomechanical difference of two surgical methods for hallux valgus by finite element analysis.

Methods

The computerized tomography data of a hallux valgus patient were selected to establish a finite element model. The standard Scarf osteotomy was simulated based on the model, and the rotation and translation were performed, respectively. The size of the intermetatarsal angle, contact area, distal metatarsal articular angle and the absolute length of the first metatarsal was compared between the two groups. We completed the cartilage, ligament and other tissues on the bone model to establish a full foot model. We analyzed the troughing, plantar aponeurosis tension, plantar soft tissue, and ground stress and also observed the stability of the fracture site by a three‐point bending test.

Results

Both surgical methods may effectively correct the intermetatarsal angle. After rotational osteotomy, the contact area increased, and the length of the first metatarsal bone initially increased and then decreased compared to that in the translational group. Furthermore, rotational Scarf significantly increased the distal metatarsal articular angle. Mechanical analysis showed that the cancellous bone in the contact part of the fracture site in the translation group had greater stress, which was the reason for the occurrence of the troughing. Stress distribution of plantar aponeurosis, plantar soft tissue, and the ground showed no significant difference. The three‐point bending test showed that the separation of the broken ends of the rotational Scarf osteotomy model (0.133 mm) was slightly smaller than the translational group (0.147 mm).

Conclusion

Both surgical methods can successfully correct intermetatarsal angle (IMA). Compared to traditional translational Scarf osteotomy, rotational Scarf osteotomy is more conducive to postoperative stability and healing, but it also has certain drawbacks. In clinical practice, individualized surgical methods still need to be selected for different types of patients with hallux valgus.

Keywords: Biomechanics, Finite element, Hallux valgus, Rotational Scarf

This study aimed to elucidate the biomechanical differences between traditional translational Scarf osteotomy and a newly proposed rotational Scarf osteotomy for the treatment of hallux valgus (HV). Using finite element analysis, we developed an HV model with a Z‐shaped bone cut to simulate rotational Scarf and translational Scarf osteotomy. We believe that our study makes a significant contribution to the literature because we have elucidated some of the biomechanical differences between rotational Scarf and translational Scarf and have clarified the efficacy of this procedure for HV patients.

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Introduction

Hallux valgus (HV) is a very common clinical disease classified by the first ray of the first metatarsal deformity and manifests as the valgus deviation of the first phalanx and the first metatarsal adduction. 1 The incidence rate of hallux valgus in adults aged 18–65 years is 23%, while in the elderly aged over 65 years, the incidence is as high as 57%, mainly women. 2 Statistics indicate that, in addition to conservative management, there are over 100 surgical methods for hallux valgus, 3 , 4 including distal soft tissue surgery, Akin osteotomy, various osteotomy techniques for different positions, such as the proximal and distal metatarsals and the metatarsal trunk, first metatarsophalangeal joint fusion, first metatarsal wedge joint fusion, etc. Furthermore, the application of minimally invasive procedures in correcting hallux valgus deformity has shown promising clinical outcomes. 5 , 6

Scarf osteotomy, a “Z” shaped osteotomy of the first metatarsal shaft, has the advantage of mechanical stability, versatility, and wide clinical applicability. 7 , 8 However, complications after Scarf osteotomy are common, such as a high incidence rate of fracture at the broken end, troughing, and thumb stiffness, which limits its application range. 9 , 10 , 11 Given the disadvantages of Scarf osteotomy, such as postoperative complications, various improved Scarf osteotomies were proposed. 12 , 13 Murawski 12 proposed that rotational Scarf osteotomy for hallux valgus can effectively avoid troughing, and complications incidence is significantly lower than traditional translation Scarf osteotomy, especially for patients with large intermetatarsal angle (IMA). Moreover, Li et al. have made improvements to the scarf osteotomy, suggesting that the “Z” rotation osteotomy of the metatarsal shaft can significantly improve metatarsophalangeal joint alignment. 14

What are the biomechanical differences between rotational osteotomy and traditional translation Scarf osteotomy, whether the changes of rotational have more advantages, and how the troughing is avoided still need to be discussed in detail. This article established a model of hallux valgus foot through finite element analysis. Based on the model, two surgery methods were simulated: translational Scarf and rotational Scarf. Multiple indicators such as postoperative correction angle, troughing and postoperative stability of the two groups were analyzed to explore the effectiveness and advantages of rotational Scarf osteotomy.

Materials and Methods

Establishment of Bone Model

Based on previously reported patients, we enrolled a representative patient with hallux valgus who met the surgical criteria for Scarf osteotomy based on non‐weight‐bearing CT data. The patient was a 53‐year‐old female, weighing 60 kg and measuring 158 cm in height. She presented with a HVA of 37°, an IMA of 15°, and no concomitant foot disorders. There are 192 sections in the CT image, and the software Amira (5.3.3, Visage Imaging, Carlsbad, CA, USA) was used for model segmentation and surface smoothing. Hyper Mesh (V12.0, Altair, MI, USA) was used for grid and refinement, and cortical bone and cancellous bone were modeled, respectively. The right foot model consists of 28 bones, including 14 phalanges, five metatarsals, two sesamoids, and seven tarsals (including three wedge‐shaped bones, one navicular bone, one cuboid bone, one talus, and one calcaneus). There are 1,173,412 cells in the grid division of all tissues. The material properties are listed in Table 1, and the bone model is established (Figure 1). The CT data of the patients included in this study have obtained the informed consent of the patient. This study was approved by the Ethics Committee of the our hospital, with the approval number KY2019150. All Experiments were performed in accordance with the relevant guidelines and regulations.

TABLE 1.

Material properties of the model components.

Number of units
Tissue Young's modulus (MPa) 15 Poisson's ratio 16 , 17 Element type No operation Translational Scarf Rotating Scarf
Cortical bone 12,000 0.3 C3D4 257,598 300,494 307,258
Cancellous bone 300 0.3 C3D6 476,775 546,101 538,202
Articular cartilage 10 0.4 C3D6 27,157 27,157 27,871
Achilles tendon 1200 0.3 S4R 276 276 276
Ligaments Nonlinear spring element Spring A 18 , 19 526 526 526
External soft tissue 1.15 0.49 C3D4 356,800 357,917 360,696
Screw 11,000 0.3 C3D8 — 2240 2240
Total units 1,124,252 1,239,831 1,242,189
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Fig. 1.

Fig. 1

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Bone model of hallux valgus.

Comparison of Correction Ability

The ABAQUS (Simulia, Providence, RI, USA) software was used to simulate the “Z” shaped osteotomy of the model. The longitudinal osteotomy was performed at the center of the longitudinal axis of the first metatarsal shaft. The first metatarsal shaft was divided into five equal parts, one at the proximal end and one at the distal end. The osteotomy lines at both ends were at a 60° angle with the longitudinal axis osteotomy line (Figure 2). The two Scarf osteotomy methods are the same, but the difference lies in the movement mode after osteotomy. The translation group laterally shifted the distal bone block, while the rotation group rotated the distal bone block around the center point of the contact surface as the center to achieve the best angle for correction (Figure 3). The values of IMA, contact area, distal metatarsal articular angle (DMAA), and absolute length of the first metatarsal were recorded after each rotation of the distal metatarsal block for 1° and translation for 1 mm.

Fig. 2.

Fig. 2

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“Z” shaped osteotomy.

Fig. 3.

Fig. 3

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Comparison of correction ability between two osteotomy methods.

Establishment of Full Foot Model

We completed the full foot model based on the bone model. After meshing each bone part in turn, the foot bone mesh model with regular shape and consistent size was obtained. The bone part was accurately modeled according to cortical bone and cancellous bone. At each bone joint, the cartilage bone surface was increased. Cartilaginous surfaces, appearing in pairs, were distributed on both sides of the joint. During the calculation, contact between each cartilage surface was established, and the friction coefficient of 0.1 was set to simulate the real joint force. 20 A membrane unit of 1mm × 1mm was added to the Achilles tendon to simulate it with a thickness of 5mm. Ligaments, fascia, and other structures were added and simulated by Spring A, a nonlinear spring element. The Spring A element conveniently simulates the ligament's characteristics that bear the force under tension and not under compression. Soft tissue was added to form the whole foot model. Soft tissue, using tetrahedron elements, was generated from the contour envelope surface.

The internal surface of the soft tissue was contacted with the internal bone part to simulate the real stress situation and establish a ground model. The ground was simulated by hexahedral elements, contact was set between the ground and the soft tissue outside the foot, and the real force on the ground and feet was simulated. Postoperative models were established in turn. In the two models of screw placement surgery, the screw part was simplified by the nail, and the nail and the bone hole were bonded to simulate the close connection of the screw. Finally, the finite element models of the hallux valgus patient (Figure 4) was established. The material properties of the model components are listed in Table 1.

Fig. 4.

Fig. 4

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Finite element models of hallux valgus.

Model Validation

As there was no cadaver model of hallux valgus patients, cadaveric biomechanical experiments could not be carried out, and it was necessary to find other alternatives for model verification. First, the model was verified by comparing the data in the previous literature, and the research data of Mao et al., 21 Zhang et al. 22 and Guo et al. 23 were compared. The results confirmed that the plantar pressure data between different research groups were similar. In addition, bone models with and without soft tissue were compared, although some differences in organization modeling were found, stress analysis was at the same order of magnitude. Therefore, we believed that the established finite element model of hallux valgus was effective and could be used for mechanical analysis.

Boundary and Loading Conditions

The boundary conditions for analysis were as follows. The upper section of the soft tissue and the bone were fully constrained. For the lower surface of the ground, all its degrees of freedom were constrained except for the upward degrees of freedom. A 300N upward load was applied at its reference point, and a 150N upward load was applied at the Achilles tendon (Figure 5). When the screw was screwed into the bone, it produced a force to compress the bone. This load greatly impacted the stress and stress of the bone. Therefore, it was necessary to simulate the bolt preload in detail during analysis. In the two surgical models of nail placement, a preload of 20 N was applied to the axial direction of the bolt before loading to simulate a tightening state. 24 The bolt pre‐tightening force should be maintained in the subsequent analysis (Figure 6).

Fig. 5.

Fig. 5

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Boundary and loading conditions.

Fig. 6.

Fig. 6

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Pre‐tightening force of simulated bolt.

Outcome Measures

The changes of IMA, the contact area of bone blocks, DMAA, and the trend of changes in the length of the first metatarsal after two groups were recorded. After loading the load, the stress and strain situation of the two surgical methods at the metatarsal bone blocks were compared, and the magnitude of plantar aponeurosis tension, plantar soft tissue, ground stress, and bone blocks separation between two groups were analyzed.

Results

Comparison of Correction Parameters

Both surgical methods significantly improve the correction of IMA (Figure 7A,B). Compared with the same IMA, the contact area of bone blocks in the two methods was calculated respectively. It showed that with the increase of correction angle, the advantage of the contact area in the rotation group was more prominent (Figure 7C). With regards to the length of the first metatarsal, as the correction angle increased, the roation group initially showed an increase and then a decrease in the difference in length of the first metatarsal. Within the range of 11° of surgical correction, the rotation group could increase the length of the first metatarsal bone within a certain range (Figure 7E). However, in terms of DMAA measurement, the rotation group showed a significant disadvantage and could significantly increase DMAA (Figure 7D).

Fig. 7.

Fig. 7

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Comparison of different parameters. (A) Relationship between Angle of rotation and IMA. (B) Relationship between distance of translation and IMA. (C) Comparison of contact area between two groups after correcting the same IMA. (D) Comparison of DMAA after correcting the same IMA. (E) Comparison of first metatarsal length after correcting the same IMA.

Analysis of Troughing

When both methods were corrected to the state when IMA was 8°, rotating at 13° or translating at 4 mm, mechanical analysis was carried out. After full loading, the stress nephogram of the first metatarsal bone showed that the maximum stress of the model without operation occurred in the posterior lower part, the maximum stress was 0.024 MPa, and the bearing capacity of the cancellous bone was small. The maximum stress of the translation Scarf model occurred at the distal screw, with a maximum stress of 1.094 MPa. The maximum stress of the rotational Scarf model also occurred at the distal screw, with a maximum stress of 1.205 MPa. Among them, in the translational Scarf model, the cancellous bone has a large stress in the contact between the cancellous bone and the cortical bone, indicating that the opposite cortical bone will squeeze the cancellous bone at this place, which is the cause of the troughing (Figure 8).

Fig. 8.

Fig. 8

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Analysis of troughing (A) Stress nephogram of the model without operation; (B) The arrow shows that there is a large strain concentration in cancellous bone, indicating that the deformation of cancellous bone is large here; (C) There is no obvious strain concentration point at the arrow.

Analysis of Plantar Aponeurosis Tension

The plantar aponeurosis after full loading showed that the model's maximum tension without operation was 16.260 N, that of the translational Scarf model was 24.873 N, and the rotational Scarf model was 25.295 N. The distribution of the three was the same, and they were all located outside the sole of the foot (Figure 9).

Fig. 9.

Fig. 9

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Cloud diagram of plantar aponeurosis tension. (A) Tension nephogram of plantar aponeurosis in the model without operation; (B) Tension nephogram of plantar aponeurosis of translational Scarf model; (C) Tension nephogram of plantar aponeurosis in rotational Scarf model.

Stress Analysis of Plantar Soft Tissue

The analysis of the plantar soft tissue stress showed that the maximum stress of the model without operation was 0.213 MPa, located in the middle and outer sides of the plantar. The maximum stress of the translational Scarf model was 0.190 MPa, and that of the rotational Scarf model was 0.187 MPa, located at the foot root (Figure 10).

Fig. 10.

Fig. 10

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Stress nephogram of plantar soft tissue (A) Stress of plantar soft tissue of the model without operation; (B) Soft tissue stress of translational Scarf model; (C) Soft tissue stress of rotational Scarf model.

Stress Analysis of Ground

The analysis of ground stress showed that the maximum stress of the model without operation was 0.325 MPa, located at the foot root. The maximum stress of the translational and rotational Scarf models were 0.323 MPa and 0.323 MPa, respectively. The stress distribution of both models was consistent, and the maximum stress was located outside the middle foot (Figure 11).

Fig. 11.

Fig. 11

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Stress nephogram of ground (A) Stress of ground Stress of the model without operation; (B) Ground stress of translational Scarf model; (C) Ground stress of rotational Scarf model.

Three‐point Bending Test

The two ends of the first metatarsal were fixed, and a load of 100 N was applied in the middle to observe the separation at the contact point of the broken end. As the load increases, the separation gap increases (Figure 12). After increasing by five times, it was observed that the separation of the rotational Scarf was slightly smaller than that of the translational Scarf (the displacement of the rotational group was 0.133 mm, and that of the translational group was 0.147 mm).

Fig. 12.

Fig. 12

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Three‐point bending test (A): 100N was loaded at the midpoint of metatarsal bone; (B, C) Stress nephogram after loading; (D) Load displacement curve.

Discussion

This study used finite element analysis to simulate rotational and translational Scarf osteotomy, and compared their biomechanics. The results showed that both surgical methods were successful in correcting IMA. Rotational Scarf osteotomy can significantly increase the fracture site contact area, and effectively avoid troughing. It also had fracture site separation smaller than the traditional translational Scarf osteotomy, which is conducive to postoperative stability and healing. However, rotational Scarf osteotomy also has disadvantages, which can increase distal metatarsal articular angle accordingly. For patients with large distal metatarsal articular angle, other surgical methods should be considered clinically.

The Correction Ability of Two Surgical Methods

Traditional Scarf osteotomy is associated with many postoperative complications, including fracture, troughing, and stiffness, with rates of these complications reaching 10%, 35%, and 41.7%, respectively. 12 , 25 , 26 Several researchers have proposed modification to the traditional Scarf osteotomy 27 , 28 in order to reduce postoperative complications and improve the surgical indications. Murawski et al. introduced the use of rotational Scarf osteotomy to effectively prevent troughing, but noted that it may increase DMAA within a certain range. 12 Boksh et al. 28 compared the postoperative efficacy of classic Scarf osteotomy with mini Scarf osteotomy and found that both procedures had significant therapeutic effects, with mini Scarf osteotomy being more suitable for mild to moderate cases. Young et al. 27 applied an improved proximal Scarf osteotomy for moderate to severe hallux valgus cases and observed significant improvements in radiological parameters and clinical efficacy; however, no statistically significant difference was found compared to classical Scarf osteotomy.

In previous studies, the angle (HVA, IMA, and DMAA) used to evaluate imaging examinations depended on the bisection of the metatarsal axis. Since osteotomy destroys the long axis of the first metatarsal, the measurement results were inaccurate no matter whether the median or midpoint of the longitudinal axis was used for measurement after osteotomy. 29 A digital goniometer was recommended by many researchers to measure HVA. 15 , 30 As mentioned in previous studies, we selected the line connecting the midpoint of the proximal and distal articular surfaces to calculate the angle 31 , 32 , 33 Finite element modeling was used to compare the two methods of IMA correction on a three‐dimensional model. The results demonstrated that both surgical methods could significantly correct IMA. Furthermore, it was observed that the rotational osteotomy provided a more advantages contact area at the fracture site. A larger contact area was associated with improved postoperative stability, indicating better healing capability. With the increase of the correction angle, this advantage was more obvious, which guaranteed postoperative stability maintenance.

Although the relationship between the length of the first metatarsal bone and hallux valgus deformity is unclear, many scholars believe that the shortening of the first metatarsal bone is significantly positively related to the postoperative metastatic metatarsal pain, delayed healing, or nonunion of the broken end. 32 , 33 , 34 By measuring the absolute length of the first metatarsal bone, the difference between the two groups was not linear when correcting different IMA. The length of the first metatarsal bone in the rotational group was significantly longer than in the translational group within the correction of 11°, especially in the correction of 3–8°. Furthermore, the length of the first metatarsal bone in the translational group was longer than that in the rotational group after the correction of 12°. It is an effective way to increase the length of the first metatarsal bone or press down the metatarsal bone when performing post osteotomy swing. Nevertheless, the rotational Scarf increases the DMAA because of an laterally rotation with the center point of the osteotomy site. Our results also show that a bigger rotation angle was associated with a larger postoperative DMAA. For patients with a large preoperative DMAA or subluxation of the metatarsophalangeal joint, this mode of operation is not advantageous. Therefore, rotational Scarf is most effective for patients with a small preoperative DMAA.

The Biomechanical Difference of Two Surgical Methods

Rotational Scarf can also reduce the extent of the troughing. The finite element model analysis demonstrated that, after rotating, the fracture site of the rotational group was the contact between bone cortex to cortex, while that of the translational group was the direct contact between bone cortex to cancellous. The cancellous bone had a large strain concentration, which was a large deformation, indicating that it could cause troughing easily. On the contrary, the rotation group avoided this shortcoming successfully, and the complications caused by troughing after operation from the source. In addition, due to troughing, the cortical bone of the proximal bone block was embedded into the cancellous bone of the distal bone block, resulting in a supination state of the distal metatarsal head relative to the proximal metatarsal bone, which may be a reason for the recurrence of hallux valgus. The stress at the contact part of the rotated metatarsal bone was mainly concentrated on the cortical bone, which could not only avoid the troughing to the maximum extent but also avoid the rotation deformity of the distal metatarsal head from the force line.

In addition, we also analyzed the stress distribution of plantar aponeurosis, plantar soft tissue, and ground. The results showed no significant difference between translational and rotational Scarf osteotomy. Unal's study, 35 through a three‐point bending test, first observes the degree of separation at the fracture site near the metatarsal wedge joint to judge the fixation strength. We took out the first metatarsal separately and performed a three‐point bending test. It was found that after loading, the separation of broken ends in the rotational Scarf osteotomy model was slightly smaller than that in the translational Scarf, and the gap gradually increased with the increase of load, which also showed that the rotation group could more effectively maintain the stability of broken ends after surgery.

This study has some limitations that should be addressed. First, although the finite element results have verified the difference between rotational and translational Scarf osteotomy to some extent, clinical follow‐up results are still required for confirmation. Second, since the finite element model did not fully reflect the true structure of the foot, it is necessary to conduct biomechanical experiments on cadaver specimens to confirm our findings. In addition, because rotational Scarf osteotomy will appropriately increase DMAA, which will have adverse effects on postoperative recurrence. It is currently advocated that rotational Scarf osteotomy applies to patients with moderate to severe hallux valgus with small DMAA. In the future, it is still necessary to follow up patients with moderate to severe hallux valgus with mismatched metatarsophalangeal joints who have undergone rotational Scarf osteotomy.

Clinical Significance

Both surgical methods were successful in correcting IMA. In clinical practice, for different types of hallux valgus, surgeons need to comprehensively evaluate the patient's specific situation and choose personalized surgical methods. Rotational Scarf osteotomy has certain advantages in avoiding postoperative complications, but it is not recommended for patients with larger DMAA.

Conclusion

Both surgical methods, rotational Scarf osteotomy and traditional translational Scarf, are effective in correcting IMA. However, compared to traditional translational Scarf, rotational Scarf osteotomy could extend the length of the first metatarsal bone within a certain range, significantly increase the contact area of the fracture site, and effectively avoid troughing. Mechanical analysis revealed that the rotation group exhibited less separation of fracture sites, promoting improved postoperative stability and healing. However, there was no significant difference in stress distribution in the plantar aponeurosis, plantar soft tissue, and ground between the two groups. However, rotational Scarf osteotomy also has disadvantages, which can increase DMAA accordingly. For patients with large DMAA, it is necessary to consider combining other surgical methods.

Author Contributions

All authors contributed to the study conception and design. Y.L. and Y.W. participated in the experimental design, implementation, data analysis and manuscript writing. F.W. was responsible for data processing. KL.T. and X.T. conducted the conception, designed and manuscript writing. All authors participated in the revision of the article and approved the final manuscript.

Conflict of Interest Statement

The authors declare no conflict of interest.

Ethical Statement

This study was approved by the Ethics Committee of the first affiliated hospital of army medical university, with the approval number KY2019150.

Acknowledgments

Thanks Liu Jiming and Wang Zhong from Daping Hospital for their help in the finite element analysis. This work was supported by the “20210006413972363 + Chief Scientist of Chongqing”, “4139Z2C2 + personalized training program for leading talents”, “202100074174DH + Research on sports injury repair and reconstruction” and “Chongqing Natural Science Foundation Innovation Group Science Fund: Sports injury repair and reconstruction research innovation group (cstc2020jcyj‐cxttX0004)”.

Yan Li and Yue Wang should be considered joint first author.

Yan Li and Yue Wang are equal contributors.

Contributor Information

Kanglai Tang, Email: tangkanglai@hotmail.com.

Xu Tao, Email: taoux@hotmail.com.

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