Scarf osteotomy versus first metatarsophalangeal arthrodesis for severe hallux valgus: a retrospective comparative study.

BACKGROUND: Surgical correction of severe hallux valgus (HV) remains challenging. Surgical treatment may be joint preserving, such as Scarf osteotomy, or non-joint preserving, such as first metatarsophalangeal joint (MTP1) arthrodesis. To our knowledge, no study has directly compared these two procedures in severe HV. This study therefore aimed to address four questions: (1) Does MTP1 arthrodesis provide a higher rate of very satisfied patients than Scarf osteotomy at a minimum one-year follow-up? (2) Does it reduce the need for footwear adaptation? (3) Does it reduce residual pain? (4) Are complication rates different between the two procedures?

HYPOTHESIS: We hypothesized that MTP1 arthrodesis would result in a higher rate of very satisfied patients than Scarf osteotomy.

PATIENTS AND METHODS: A single-center, single-surgeon retrospective study was conducted between 2015 and 2021. Severe HV was defined as a lateral sesamoid displaced beyond 75% of the first intermetatarsal space on weight-bearing anteroposterior radiographs. Sixty-one feet in 47 patients (14 bilateral cases) with a minimum one-year follow-up were included: 25 treated by MTP1 arthrodesis and 36 by Scarf osteotomy, with a median follow-up of 52.5 months (IQR 34-80). The primary outcome was the rate of very satisfied patients at last follow-up, assessed by a self-administered questionnaire (very satisfied, satisfied, moderately satisfied, or dissatisfied). Secondary outcomes were footwear adaptation, persistent pain, complications, and recurrence. Radiographic outcomes were available for 57 feet (23 arthrodeses, 34 Scarf osteotomies).

RESULTS: Arthrodesis was associated with better outcomes than Scarf osteotomy, including a higher rate of very satisfied patients, 15/25 (60%) versus 10/36 (28%) (p = 0.012), less footwear adaptation, 4/25 (16%) versus 16/36 (44%) (p = 0.025) and less persistent pain, 3/25 (12%) versus 14/36 (39%) (p = 0.022). Delayed wound healing occurred in 2/25 feet (8%) in the arthrodesis group and 3/36 (8%) in the Scarf group. In the Scarf group, hallux varus occurred in 3/34 feet (9%), MTP1 osteoarthritis in 9/34 (26%), and overall recurrence in 9/34 (26%). No nonunion, revision surgery, or hardware removal was recorded in either group.

DISCUSSION: The comparison of severe HV treatment by MTP1 arthrodesis or Scarf osteotomy revealed a higher satisfaction rate and better functional outcomes in patients treated by MTP1 arthrodesis in our study. Despite the limitations of this study, MTP1 arthrodesis appears to be a valuable option for severe HV.

LEVEL OF EVIDENCE: III; Retrospective comparative study.