Abstract
Background
Generally, scarf osteotomy is recommended for moderate-severe hallux valgus (HV) deformity. Although severe HV deformity is defined to be more than 40 degree (°), this definition of angular setting includes broad range of HV angle (HVA). Actually, very severe HV deformity such as more than 60° of the HVA is often seen. At present, whether scarf osteotomy would truly contribute to maintaining the correction status against such very severe deformity is elusive. Then, in this study corrective effectiveness of modified scarf osteotomy including very severe deformity (HVA ≥ 60°) was evaluated.
Methods
A retrospective, observational study of 93 feet [mean follow-up: 56.0 months after the surgery] was performed. Hallux scores of the Japanese Society for Surgery of the Foot (JSSF), a self-administered foot evaluation questionnaire (SAFE-Q), and pre-postoperative radiographic parameters were evaluated. The patients were categorized into three groups [44 feet: (mildly severe) 40° ≤ HVA < 50°, 30 feet: (moderately severe) 50° ≤ HVA < 60°, 19 feet: (very severe) HVA ≥ 60°].
Results
Both JSSF hallux and SAFE-Q score showed significant improvement in all groups, except social activity score in SAFE-Q, in very severe cases (P = 0.08). HVA also significantly improved in all groups without significant change of the HVA between post 1-month and final follow-up in each groups. No difference was seen among the three groups in complications after surgery and frequency of recurrence of HV deformity.
Conclusion
Modified scarf osteotomy has sufficient potential to be indicated for very severe (HVA ≥ 60°) deformity, but it might be recommended before the HVA reaches > 60° from the perspective of clinical score improvement.
Level of evidence
Level III.
Keywords: Modified scarf osteotomy, Very severe hallux valgus deformity, Corrective effectiveness, Clinical score
Introduction
Hallux valgus is a common condition with an estimated prevalence of 23% in adults [1].
Severe hallux valgus is defined when hallux valgus angle (HVA) was 40° or more, and /or the intermetatarsal angle (IMA), which is the angle between first and second metatarsals (M1-M2A), was more than 16° [2, 3]. In the situation that there are several surgical techniques for hallux valgus; distal osteotomies such as the Mitchell and Chevron methods [4, 5]; proximal osteotomies such as the Crescentic osteotomy by Mann et al. [6, 7]; diaphyseal osteotomies such as the Ludloff and scarf oeteotomies [8, 9]; Lapidus method for first tarsal metatarsal joint fixation [10], diaphyseal and proximal osteotomies have been reported to be utilized for severe halluxvalgus [11–13]. However, definition for severe hallux valgus includes broad range of HVA. Actually, very severe HV deformity such as more than 60° or 70° of the HVA is often seen in clinical experiences. At present, whether scarf osteotomy would truly contribute to maintaining the correction status against such very severe HV deformity is elusive. Then, in this study effectiveness of correction of HV deformity using diaphyseal osteotomies (modified scarf osteotomy) including very severe deformity (HVA ≥ 60°) was evaluated.
Methods
Study design and patient population
Retrospective observational study of 93 consecutive feet (76 patients) with a HVA ≥ 40° that underwent a modified scarf osteotomy, from February 2015 to September 2020. Tha data was accessed on 30th December, 2022. Other, metatarsal shortening offset osteotomies were also performed when there were painful lesser-toe MTP joint deformities (callosities) [14–18]. All patients treated with orthotics and foot stretching as conservative therapy and who had undergone previous hallux valgus surgery were excluded. The inclusion criteria were (1) HVA ≥ 40°, (2) a minimum follow-up of 2 years, and (3) the availability of preoperative and final follow-up dorsoplantar and lateral weight-bearing radiographs of the feet as well as clinical scores. Evaluations were performed dividing into 3 groups: (mildly severe) 40°≦ HVA < 50°, (moderately severe) 50°≦ HVA < 60°, and (very severe) HVA ≥ 60°.
The patient characteristics are shown in Table 1. As a human ethics, this research was performed in compliance with the Helsinki Declaration and approved by the Institutional Ethics Review Board of National Hospital Organization, Osaka Minami Medical Center (approval number: R4-28). Informed consent and consent to publication were obtained from all patients.
Table 1.
Preoperative characteristics of patients in the three groups
| 40° ≤ HVA < 50° (n = 44) |
50° ≤ HVA < 60° (n = 30) |
HVA ≥ 60° (n = 19) |
P value | |
|---|---|---|---|---|
|
Age (y) (median, IQR) |
67.9 ± 11.2 (69, 61–75) |
66.5 ± 9.9 (68.5, 63.25-71) |
67.5 ± 11.8 (68, 62.5–73.5) |
N.S. |
| Male : Female (N) | 2:42 | 0:30 | 1:18 | N.S. |
| RA : Non-RA | 34:10 | 28:2 | 14:5 | N.S. |
|
RA disease duration (year) (median, IQR) |
21.6 ± 10.2 (20, 14–29) |
21.5 ± 12.7 (20, 12.5–30) |
24.7 ± 13.2 (27, 15–35) |
N.S. |
| Prednisolone usage (%) | 26.5 | 14.3 | 21.4 | N.S. |
|
Prednisolone dosage (mg/day) (median, IQR) |
1.1 ± 2.1 (0, 0–1) |
0.67 ± 1.4 (0, 0–0) |
1.0 ± 1.9 (0, 0-0.75) |
N.S. |
| Methotrexate usage (%) | 76.5 | 78.5 | 71.4 | N.S. |
| Biologics usage (%) | 26.5 | 25.0 | 28.5 | N.S. |
|
DAS28-CRP score (median, IQR) |
2.9 ± 0.93 (3.0, 2.29–3.43) |
2.9 ± 0.91 (2.9, 2.25–3.3) |
3.2 ± 0.81 (3.08, 2.78–3.21) |
N.S. |
|
Follow-up period (months) (median, IQR) |
53.8 ± 22.6 (60, 36–72) |
42.1 ± 24.6 (30, 25-58.75) |
37.9 ± 16.0 (27, 26-49.5) |
** |
|
HVA (°) (median, IQR) |
43.9 ± 2.9 (44, 41–46) |
54.0 ± 2.6 (54.5, 52–56) |
68.6 ± 10.3 (66, 61.5–68) |
†††, ***, §§§ |
|
M1-M2A (°) (median, IQR) |
15.5 ± 4.5 (15, 12–19) |
14.6 ± 3.9 (14, 12-16.25) |
15.9 ± 3.0 (15, 13.5–17) |
N.S. |
|
M1-M5A (°) (median, IQR) |
36.6 ± 6.0 (36, 32–41) |
35.8 ± 6.7 (37.5, 29.75–40.75) |
36.9 ± 4.6 (36, 33.5–39) |
N.S. |
|
M2-M5A (°) (median, IQR) |
21.0 ± 5.3 (20, 16–23) |
21.2 ± 6.2 (22, 16.25-26) |
20.9 ± 3.7 (21, 19-23.5) |
N.S. |
|
TCA (°) (median, IQR) |
4.8 ± 6.1 (5, 1–8) |
7.9 ± 6.5 (7, 3–12) |
2.5 ± 4.8 (1, 0-6.5) |
§§ |
|
Talo-1st metatarsal angle (°) (median, IQR) |
7.7 ± 10.7 (5, 0–14) |
7.4 ± 13.5 (7.5, 1.25–13.75) |
5.6 ± 7.8 (5, 0–10) |
N.S. |
|
Calcaneal pitch angle (°) (median, IQR) |
16.0 ± 4.5 (15, 13–18) |
16.2 ± 6.4 (15, 12.25–18.5) |
16.7 ± 6.4 (19, 12.5–20) |
N.S. |
|
Loading point index (median, IQR) |
0.56 ± 0.27 (0.58, 0.37–0.76) |
0.63 ± 0.20 (0.611, 0.47–0.74) |
0.46 ± 0.24 (0.58, 0.37–0.76) |
N.S. |
Data are presented as mean ± SD unless otherwise noted
Differences between the groups were determined by analysis of variance (ANOVA), the Mann-Whitney U-test, or the chi-squared test. (p < 0.05)
** 40° ≤ HVA < 50° vs. 60° ≤ HVA, P < 0.01
*** 40° ≤ HVA < 50° vs. 60° ≤ HVA, P < 0.001
††† 40° ≤ HVA < 50° vs. 50° ≤ HVA < 60°, P < 0.001
§§ 50° ≤ HVA < 60° vs. HVA ≥ 60°, P < 0.01
§§§ 50° ≤ HVA < 60° vs. HVA ≥ 60°, P < 0.001
N.S.; not significant, HVA; hallux valgus angle, IQR; Interquartile Range, DAS; disease activity score, RA; rheumatoid arthritis, M1-M2A; intermetatarsal angle between first and second metatarsals, M1-M5A; intermetatarsal angle between first and fifth metatarsals, M2-M5A: intermetatarsal angles between the second and fifth metatarsals, TCA; tibio-calcaneal angle
Surgical technique
All patients underwent the modified scarf procedure with medial capsular interposition as hallux valgus surgery as described previously [11, 12, 14–16]. Briefly, after diaphyseal horizontal osteotomy and internal fixation with screws (Acutwist, Acumed: USA), the flap of the medial capsule was interposed into the newly formed 1st MTP joint and then sutured to the lateral wall of the capsule and previously dissected abductor hallucis tendon. Controlling of distal metatarsal articular angle (DMAA) is important point. After, the osteotomy, distal fragment was adjusted to make DMAA 0 degrees, and then fixation was performed. Fifteen of the 93 feet underwent concomitant Akin osteotomy [19], if the first toe touched and pushed the second toe when the opened medial capsule was pinched by Kocher forceps [12]. Modified metatarsal shortening offset osteotomy was performed as described previously, if there were painful callosities in lesser toes [14–18]. After shortening osteotomy, the second, third, and fourth metatarsal heads were shifted dorsally, and the fifth metatarsal head was shifted medially. Kirschner-wires (K-wires) not screws, were utilized for internal fixation after lesser toes osteotomy/ correction, because juxta-articular bone with inflammatory diseases including RA is fragile and cortical bone is thin [11, 12, 14–16]. Mortise at distal end of proximal bone fragment was made, and then cortical bone of distal bone fragment (metatarsal head) is bitten into the mortise at distal end of proximal bone fragment. At this moment, primary fixation is obtaind, furthermore additional K-wires fixation contribute to further stronger fixation because of passing through some cortical/ hardened bone (subchondral bone of basal phalanx, metatarsal head, Lisfranc joint). For another reason, K-wire could contribute to maintaining the fixation position of luxated MTP joint. From these perspectives, K-wires were utilized. The osteotomy/correction sites were fixed with 1.2-mm or 1.0-mm intramedullary K-wires for 2 weeks [11, 12, 14–16].
Postoperative procedure
One day after surgery, active/passive range of motion (ROM) exercise was started, and heel heel walking was allowed. Two weeks after surgery, K-wires were removed, at the same time full weight-bearing was allowed with an arch support [11, 12, 14–16].
Radiographic assessment
Dorsoplantar and lateral weight-bearing radiographs were made. The HVA, the intermetatarsal angles between the first and second metatarsals (M1-M2A), the first and fifth metatarsals (M1-M5A), and the second and fifth metatarsals (M2-M5A) were measured. Displacement of the sesamoid bone was evaluated as described previously (Hardy grade) [20]. Most ideal position of the sesamoid bone is grade1, on the other hand most displaced position of sesamoid bone is grade 7. The grade of sesamoid displacement was divided into two groups: normal group (grade ≤ 4) and the displacement group (grade ≥ 5) [21]. The talo-1st metatarsal angle (Meary’s angle) and the calcaneal pitch angle were measured on the weight-bearing lateral foot radiographs to evaluate the level of flatfoot deformity [22, 23]. A radiograph of the subtalar joint (modified Cobey method) [24] was used to measure the tibio-calcaneal angle (TCA). A TCA angle ≥ 2° means a valgus. To check the site of the loading point in the ankle joint, the passing point of the loading axis in the distal plafond of the tibia (loading point index) was measured from 0 (medial end of the distal plafond of the tibia) to 1 (lateral end of the distal plafond of the tibia) [22, 23, 25], using a radiograph of the hip-to calcaneus view (HC view) [25]. Because it was confirmed and reported that mid-hindfoot deformity could have influences on occurring and/or exacerbating HV deformity [17, 26–29], mid-hindfoot deformity parameters were also measured and evaluated in this study. Recurrence of HV deformity was defined as an HVA of > 20° postoperatively [30]. Hallux varus was defined as an HVA of < 0°. A line connecting the centers of the first metatarsal head and the proximal articular surface of the first metatarsal was used to define its longitudinal axis of the 1st metatarsal bone [31]. Postoperative issues including bony fusion at the osteotomy site (whether bony fusion was completed) were checked on postoperative radiographs. The HVA, sesamoid position, M1-M2A, and M1-M5A were evaluated preoperatively, 1 month after surgery, and at final follow-up.
Clinical assessment
Preoperative and postoperative assessment using the hallux scales of the Japanese Society for Surgery of the Foot (JSSF) scoring system were obtained [32, 33]. Furthermore, patients completed a self-administered foot evaluation questionnaire (SAFE-Q) [34] pre-operatively and at the time of final follow-up. Postoperative complications were also evaluated. These evaluations were not performed face-to-face, but using a consultation system. RA disease activity was evaluated using the DAS28-CRP score (disease activity score evaluated on 28 joints-C-reactive protein) [35] preoperatively.
Statistical analysis
Statistical analysis was performed under the hypothesis that modified scarf osteotomy is a useful even for very severe hallux valgus deformity (HVA ≥ 60°). All statistical analysis were investigated between the 3 groups divided by the grade of deformity (mildly, moderately, and very) within severe hallux valgus cases (HVA ≥ 40°). All data are expressed as the mean and standard deviation (SD). The differences in the measured variables between the 3 groups were analyzed with the analysis of variance (ANOVA), and differences between preoperative and postoperative data was assessed by a Mann-Whitney U-test. A p value of < 0.05. Concerning intraoperative events, postoperative complications, and Hardy grade at the final follow-up, Chi-square test was used to test between the three groups (p < 0.05). Significant change compared with the preoperative sesamoid position was detected by McNemar test (P < 0.05). Sample size estimations were performed using G*Power statistical power analysis software [36, 37]. In Wilcoxson/Mann-Whitney analysis, total sample size was indicated 48, when α = 0.05, β = 0.2, and effect size = 0.8. Although case number of 93 in this study was maximum possible at present, it was considered to be sufficient.
Results
Comparison of intraoperative events and postoperative complications in the 3 groups
As shown in Table 2, there was no intraoperative fracture at the osteotomy site in 3 groups. All cases achieved bony fusion at the osteotomy site. Radiographic evidence of the recurrence of HV (HVA of > 20°) was seen in 4 (9.1%) of the 44 feet in the mildly severe group, in 2 (6.7%) of the 30 feet in the moderately severe group, and in 2 (10.5%) of the 19 feet in the very severe group. Radiographic evidence of hallux varus was seen in 7 feet (15.9%) in the mildly severe group, in 2 feet (6.7%) in the moderately severe group, and in 2 feet (10.5%) in the very severe group. Delayed wound healing was seen in 2 feet (4.5%) in the mildly severe group, in 3 feet (10.0%) in the moderately severe group, and in 3 feet (15.8%) in the very severe group. Ankylosis of the hallux MTP joint was seen in no feet in the mildly and moderately severe groups, and seen in a foot (5.3%) in the seriously severe group. There were no significant differences between the 3 groups in these postoperative complication parameters.
Table 2.
Intraoperative events and postoperative complications in the three groups
| 40° ≤ HVA < 50° | 50° ≤ HVA < 60° | HVA ≥ 60° | P value | |
|---|---|---|---|---|
| Concomitant Akin osteotomy | 7 (15.9) | 2 (6.7%) | 6 (31.6%) | N.S. |
| Non-union at osteotomy site | 0 | 0 | 0 | N.S. |
| Delayed wound healing | 2 (4.5%) | 3 (10%) | 3 (15.8%) | N.S. |
| Radiographic evidence of recurrent hallux valgus | 4 (9.1%) | 2 (6.7%) | 2 (10.5%) | N.S. |
| Radiographic evidence of hallux varus | 7 (15.9%) | 2 (6.7%) | 2 (10.5%) | N.S. |
| Ankylosis of hallux MTP joint | 0 | 0 | 1 (5.3%) | N.S. |
| Re-operation | 0 | 1 (3.3%) | 0 | N.S. |
The chi-square test was used to test for differences between the three groups (p < 0.05)
N.S: not significant, HVA, hallux valgus angle; MTP, metatarsophalangeal
Comparison of clinical outcomes between the 3 groups and comparing preoperative and postoperative results
No significant differences was observed between the 3 groups in both JSSF hallux score and all components of the SAFE-Q scores at the final follow-up (Table 3). Comparing preoperative and postoperative scores, all groups showed significant improvement after surgery, except in the index of the social functioning of SAFE-Q score in very severe group (preoperatively 52.4 ± 38.1 to postoperatively 72.0 ± 32.4; P = 0.080) (Table 3).
Table 3.
Changes in JSSF hallux total and SAFE-Q scores in the three groups
| 40° ≤ HVA < 50° (Preop.) |
50° ≤ HVA < 60° (Preop.) |
HVA ≥ 60° (Preop.) |
40°≤ HVA < 50° (Final follow-up) |
50°≤ HVA < 60° (Final follow-up) |
HVA ≥ 60° (Final follow-up) |
|
|---|---|---|---|---|---|---|
|
Total JSSF hallux score (median, IQR) |
39.3 ± 12.4 (39, 34–46) |
38.9 ± 12.7 (39, 35–45) |
33.4 ± 15.6 (37, 19–44) |
87.2 ± 9.8*** (90, 82–95) |
88.7 ± 6.8*** (90, 87–92) |
87.6 ± 6.5*** (88, 85–92) |
| SAFE-Q scores | ||||||
|
Pain and pain-related (median, IQR) |
48.0 ± 19.4 (46.6, 34.9–62.2) |
51.1 ± 25.9 (47.0, 37.1–74.4) |
47.4 ± 26.1 (44.4,26.175.0) |
86.9 ± 13.0*** (90.3, 83.3–96.0) |
89.7 ± 8.8*** (90.6, 87.8–93.3) |
82.8 ± 17.2*** (85.4, 75.6–96.1) |
|
Physical functioning (median, IQR) |
58.3 ± 21.5 (58.0, 43.2–75.0) |
54.0 ± 25.2 (58.0, 29.5–76.7) |
52.1 ± 29.3 (63.6, 29.6–77.3) |
83.5 ± 15.9*** (88.6, 75.6–97.7) |
81.2 ± 14.9*** (87.3, 77.3–92.6) |
76.6 ± 18.4** (79.5, 66.0-87.5) |
|
Social functioning (median, IQR) |
57.4 ± 27.3 (54.2, 37.5–76.1) |
52.8 ± 31.1 (64.6, 33.3–75.0) |
52.4 ± 38.1 (62.5, 14.6–89.6) |
83.6 ± 16.8*** (89.6, 75.0-100.0) |
85.7 ± 18.8*** (91.7, 75.0-100.0) |
72.0 ± 32.4 (87.5, 41.7–97.9) |
|
General health and well-being (median, IQR) |
52.5 ± 25.1 (50.0, 35.0–70.0) |
51.2 ± 30.9 (60.0, 25.0-73.8) |
53.3 ± 38.5 (60.0, 14.2–87.5) |
86.4 ± 14.2*** (90.0, 75.0-100.0) |
82.8 ± 18.1*** (90.0, 80.0–95.0) |
78.4 ± 25.1* (90.0, 60.0-97.5) |
|
Shoe-related (median, IQR) |
35.6 ± 23.9 (33.3, 23.0–44.0) |
35.6 ± 20.7 (37.5, 16.7–50.0) |
40.8 ± 28.6 (41.7, 20.9–54.2) |
73.2 ± 21.7*** (75.0, 60.4–91.7) |
74.2 ± 17.3*** (75.0, 66.7–83.3) |
61.8 ± 27.3* (66.7, 50.0-83.3) |
Data are presented as mean ± SD unless otherwise noted. Analysis of variance (ANOVA) was used to test for differences between the three groups (p < 0.05). Differences between pre- and postoperative data were assessed using the Mann–Whitney U-test (* p < 0.05, ** p < 0.01, *** p < 0.001)
HVA; hallux valgus angle, JSSF; Japanese Society for Surgery of the Foot, SAFE-Q; self-administered foot evaluation questionnaire, IQR; Interquartile Range
Comparison of radiographic outcomes between the 3 groups
As shown in Fig. 1, For the HVA, M1-M2A, and M1-M5A, significant improvements were observed in all 3 groups, furthermore no significant differences in these parameters were observed between the 3 groups at the final follow-up (Table 4). In each 3 groups, these angles showed no significant increases from 1 month after surgery to the final follow-up. In addition, distribution of medial sesamoid bone position was improved in all groups, and there was no significant difference of the distribution between 3 groups (Table 4). When sesamoid bone position was classified normal or displacement, most of feet showed good sesamoid position in all group, however progression to displaced sesamoid position from 1 month after surgery to the final follow-up was seen in 2 feet (4.5%) in mildly severe group, and 1 foot (5.3%) in very severe group. The talo-1st metatarsal angle (Meary’s angle) showed no significant difference between HV recurrence group (4.9 ± 19.3°) and non-recurrence group (9.1 ± 10.7°). There was also no significant difference when examining only RA cases: HV recurrence group (2.8 ± 18.9°) and non-recurrence group (7.6 ± 10.2°). (Table 5).
Fig. 1.
Representative cases of each three groups. A: The foot with 47°of HVA in a 70-year-old woman (40°≤HVA < 50° group). Standing x-ray images at preoperative (A-1) and final follow-up (A-2). B: The foot with 55°of HVA in a 63-year-old woman (50°≤ HVA < 60° group). Standing x-ray images at preoperative (B-1) and final follow-up (B-2). C: The foot with 93° of HVA in a 45-year-old woman (HVA ≥ 60° group). Standing x-ray images at preoperative (C-1), just after surgery (C-2), and final follow-up (C-3). In this case, patient also complained the painful callosities on the bottom of 2nd and 3rd MTP joint, so metatarsal shortening offset osteotomy was added
Table 4.
Changes in radiographic parameters in the forefoot and distributions of medial sesamoid position (hardy grade)
| 40° ≤ HVA < 50° | Preop. | 1 mo. Postop. | Final follow-up |
|
HVA (median, IQR) |
43.9 ± 2.9 (44, 41–46) |
8.4 ± 7.3*** (8, 4–13) |
9.2 ± 11.0*** (10, 1–16) |
|
M1-M2A (median, IQR) |
15.5 ± 4.5 (15, 12–19) |
6.9 ± 4.5*** (6, 4–9) |
6.3 ± 4.6*** (5, 3–8) |
|
M1-M5A (median, IQR) |
36 ± 6.0 (36, 32–41) |
20.9 ± 6.0*** (19, 17–24) |
19.8 ± 6.3*** (19, 15–23) |
| Hardy grade | |||
| 1 to 4 (N) | 2 | 38# | 36 (81.8%)# |
| 5 to 7 (N) | 42 | 6# | 8 (18.2%)# |
| 50° ≤ HVA < 60 | Preop. | 1 mo. Postop. | Final follow-up |
|
HVA (median, IQR) |
54.0 ± 2.6 (54.5, 52–56) |
9.5 ± 5.6*** (7.5, 5.25-13) |
9.2 ± 7.8*** (8.5, 4.5-12.75) |
|
M1-M2A (median, IQR) |
14.6 ± 3.9 (14, 12-16.25) |
5.6 ± 3.3*** (5, 4–7) |
5.8 ± 4.4*** (4.5, 3–10) |
|
M1-M5A (median, IQR) |
35.8 ± 6.7 (37.5, 29.75–40.75) |
18.8 ± 7.0*** (18.5, 15-22.5) |
18.2 ± 5.4*** (17, 14–22) |
| Hardy grade | |||
| 1 to 4 (N) | 2 (4.5%) | 29 (96.7%)# | 29 (96.7%)# |
| 5 to 7 (N) | 28 (95.5%) | 1 (3.3%)# | 1 (3.3%)# |
| HVA ≥ 60° | Preop. | 1 mo. Postop. | Final follow-up |
|
HVA (median, IQR) |
68.6 ± 10.3 (66, 61.5–68) |
10.4 ± 7.7*** (10, 4–16) |
8.3 ± 12.1*** (9, 1-15.5) |
|
M1-M2A (median, IQR) |
15.9 ± 3.0 (15, 13.5–17) |
6.7 ± 3.8*** (7, 5–8) |
5.9 ± 3.5*** (6, 3.5–8.5) |
|
M1-M5A (median, IQR) |
36.9 ± 4.6 (36, 33.5–39) |
20.3 ± 3.7*** (21, 17.25-23) |
17.8 ± 5.2*** (16, 15-21.5) |
| Hardy grade | |||
| 1 to 4 (N) | 0 (0%) | 18 (94.7%)# | 17 (89.5%)# |
| 5 to 7 (N) | 19 (100%) | 1 (5.3%)# | 2 (10.5%)# |
Data are presented as mean ± SD unless otherwise noted. Analysis of variance (ANOVA) and the Mann-Whitney U-test were used to test for differences between preoperative, 1 month postoperative and final follow-up data (*** p < 0.001). # A significant change compared with the preoperative proportion was detected using the McNemar test (p < 0.05)
HVA; hallux valgus angle, IQR; Interquartile Range, M1-M2A; intermetatarsal angle between first and second metatarsals, M1-M5A; intermetatarsal angle between first and fifth metatarsals
Table 5.
Difference of Meary’s angle between non-recurrence group and recurrence group
| Non-recurrence in total cases |
Recurrence in total cases |
P Value | |
|---|---|---|---|
| Meary’s angle (°) | 9.1 ± 10.7 | 4.9 ± 19.3 | 0.676 |
|
Non-recurrence in RA cases |
Recurrence in RA cases |
||
| 7.6 ± 10.2 | 2.8 ± 18.9 | 0.868 |
Differences between the groups were determined by the Mann-Whitney U-test. RA: rheumatoid arthritis
Discussion
In this study, within severe hallux valgus deformity cases, no significant difference was observed between mildly severe (40°≤HVA < 50°), moderately severe (50°≤HVA < 60°), and very severe (HVA ≥ 60°) groups both in clinical and radiographic outcomes after modified scarf osteotomy. Recurrence rate after the surgery has also no difference between the 3 groups. Although it has been reported that the lateral shift of the postoperative medial sesamoid position is risk factor for recurrence of hallux valgus, medial sesamoid position also improved in all groups, at the same time there was no significant difference in the distribution of medial sesamoid position after surgery between 3 groups (Table 4). Because Hardy grade generally indicates the degree of lateral displacement of sesamoid bones, which correlates with the grade of HV deformity [21], reduction of sesamoid position should be more difficult in very severe deformity than mildly severe cases. At the same time, it was expected to show the progression of lateral displacement in severe HV deformity cases in this study. However, no difference of sesamoid position after surgery was observed regardless of the grade of the severity within severe cases. Taken together, massive reduction of the alignment and sesamoid position could be achieved by modified scarf osteotomy, subsequently keeping the corrected position could be possible even in very severe hallux valgus deformity. However, progression of lateral displacement of sesamoid was confirmed from 1 month after surgery to the final follow-up in some cases, so further observation should be maintained, because sesamoid reduction is important to prevent the recurrence of HV deformity [21]. Because it is reported that recurrence rate of hallux valgus deformity after scarf osteotomy was 6～30% [38, 39], recurrence rate of current study (10.5%) even in very severe cases is proper to be considered equal to or better than previous study. Although HV recurrence could be involved in flatfoot (pes planus) deformity, fortunately there was no significant difference of flatfoot indicator between non-recurrence and recurrence groups (Table 5). On the other hand, M1-M2A in the current study showed between 14.6° and 15.9°; there was no significant difference between 3 groups within severe HV cases, even though usually M1-M2A is increasing with HVA increasing from mild to moderate, and to severe HV deformity. Another factor including pronation deformity of 1st metatarsal bone might have correlation with increasing of HVA in severe HV deformity. In the future, discussion for these issues should be done. Taken together, modified scarf osteotomy has a capability to be utilized to correct the very severe HV deformity and maintain the corrected position.
There are several limitations in this study. First, mean follow-up period in this study was 56.0 months after surgery. In addition, the follow-up period in very severe cases is 37.9 months; rather shorter period as compared with mildly severe group (53.8 months). In the future, investigation in long-term period with more increased number of cases also should be done. Second, participants in this study was only severe HV group (HVA ≥ 40°). However, because it is recognized that there is no correlation between preoperative HVA and HVA at final follow-up after the modified scarf osteotomy regardless of the severity of HV both in non-inflammatory cases and RA cases [11], it is considered proper to compare within only severe HV cases in this study. Third, only social activity score in SAFE-Q score could not show the significant improvement in very severe cases (P = 0.08), suggesting that although deformity could be corrected enough by modified scarf osteotomy, surgery against the case of HVA within 60° might be recommended to obtain more improved social function. Forth, in the current study, there is no evaluation and discussion of first metatarsal pronation and/or first ray hypermobility. Lapidus procedure is also utilized for severe HV cases with instability and/or laxity of 1st tarsometatarsal (TMT) joint. This point also should be further discussed in the future within the long term follow-up period. Furthermore, definition of very severe HV deformity (HVA ≥ 60°: in current study) also should be further discussed in the future.
Conclusion
In conclusion, modified scarf osteotomy can be indicated for very severe (HVA ≥ 60°) deformity, but it might be preferable to perform before HVA becomes > 60° from the perspective of clinical score improvement.
Acknowledgements
The authors wish to express their profound gratitude to all of the medical assistants, physical therapists, and rheumatologists of National Hospital Organization, Osaka Minami Medical Center and Osaka University Hospital for their excellent support.
Abbreviations
- HV
Hallux valgus
- HVA
Hallux valgus angle
- JSSF
Japanese Society for Surgery of the Foot
- SAFE-Q
Self-administered foot evaluation questionnaire
- M1-M2A
Intermetatarsal angles between the first and second metatarsals
- M1-M5A
Intermetatarsal angles between the first and fifth metatarsals
- M2-M5A
Intermetatarsal angles between the second and fifth metatarsals
- TCA
Tibio-calcaneal angle
- HC view
Hip-to calcaneal view
- DAS28-CRP
Disease activity score evaluated on 28 joints-C-reactive protein
- SD
Standard deviation
Author contributions
All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Takaaki Noguchi, Makoto Hirao, Hideki Tsuboi, Jun Hahimoto, Yuki Tabuse, Yusei Higuchi, Kosuke Ebina, Yuki Etani, Gensuke Okamura. Conceptualization was done by Takaaki Noguchi, Makoto Hirao, and Seiji Okada. The first draft of the manuscript was written by Takaaki Noguchi and Makoto Hirao, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.
Funding
This work did not receive any grants from funding agencies in the public, commercial, or not-for-profit sectors.
Data availability
All data generated or analysed during this study are included in this published article.
Declarations
Ethics approval and consent to participate
This research was performed in compliance with the Helsinki Declaration and approved by the Institutional Ethics Review Board of National Hospital Organization, Osaka Minami Medical Center (approval number: R4-28). Informed consent to participate was obtained from all of the participants.
Consent for publication
The authors affirm that human research participants provided informed consent for publication of the images in Fig. 1and inducing the conclusion from clinical data.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Data Availability Statement
All data generated or analysed during this study are included in this published article.