import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **Location**: Crosses incision line 2-3mm dorsal to typical approach **Protection**: Identify and retract during superficial dissection, stay on capsule **Location**: 8-10mm plantar to MTP joint line **Protection**: Limit plantar dissection during eminence removal, stay on bone **Location**: 12-15mm plantar to metatarsal shaft **Protection**: Maintain periosteal sleeve, avoid excessive plantar dissection **Location**: 4-5mm plantar to articular surface **Protection**: Visualize during eminence resection, avoid over-resection **Location**: 5mm lateral to lateral capsule **Protection**: Gentle lateral release staying on capsule, avoid blind dissection ## Indications ### Primary Indications - **Moderate-to-severe hallux valgus**: HVA 30-40°, IMA 13-18° - **Symptomatic bunion deformity** with pain, difficulty with shoe wear - **Failed conservative management**: appropriate shoes, orthotics, NSAIDs - **Adequate bone stock** for osteotomy and fixation - **Motivated patient** understanding rehabilitation requirements ### Special Considerations - **DMAA abnormality**: Can be addressed with rotational component - **Metatarsus primus varus**: IMA correction primary goal - **Short first metatarsal**: Scarf allows lengthening if needed - **High DASA**: Consider adjunct Akin osteotomy ### Contraindications **Absolute** - Active infection in surgical field - Inadequate vascularity to forefoot - Severe osteoarthritis MTP joint (consider arthrodesis) - Non-ambulatory patient **Relative** - Mild deformity (HVA <30°, IMA <13°) - consider chevron - Very severe deformity (IMA >20°) - consider proximal/MTP fusion - Significant medical comorbidities - Inflammatory arthropathy (higher recurrence risk) - Poor bone quality (osteoporosis) - Smoker (impaired healing) - Unrealistic patient expectations ## Pre-operative Assessment ### Clinical Evaluation - **Severity**: Measure HVA and IMA on weight-bearing AP radiographs - **DMAA assessment**: Lateral deviation of articular surface - **Sesamoid position**: Tibial sesamoid subluxation grade (0-3) - **Joint congruency**: Congruent vs incongruent joint - **MTP ROM**: Check for arthritis (limited ROM contraindication) - **Foot alignment**: Assess pes planus, metatarsus adductus - **Lesser toe deformities**: May need concurrent correction - **Neurovascular status**: Pulses, sensation, capillary refill ### Radiographic Planning - **Weight-bearing AP and lateral** foot radiographs - **Sesamoid axial view** if available - **Measure**: HVA (normally <15°), IMA (normally <9°), DMAA (normally <10°) - **Assess**: Sesamoid position, MTP joint congruency, arthritis - **Plan correction**: Estimate translation needed (roughly 1mm lateral translation corrects 2° of IMA) ### Patient Counseling - Expected outcomes: 85-90% satisfaction, significant pain relief - Recovery timeline: 6 weeks protected weight-bearing, 3-4 months return to activity - Complications: Recurrence 5-10%, transfer metatarsalgia 10-15%, nerve injury 5-10% - Hardware: Usually retained unless prominent - Footwear: May need wider toe box permanently ## Positioning and Preparation **Patient Position**: Supine with foot at end of table, bump under ipsilateral hip for neutral foot rotation **Anesthesia**: Ankle block (preferred - allows immediate post-op assessment) or general anesthesia **Tourniquet**: Ankle tourniquet (250mmHg) or thigh (300mmHg), exsanguinate with elevation **Equipment** - Small fragment set with 2.5-3.0mm headless compression screws - Sagittal saw with 0.5-1.0mm blade - K-wires for provisional fixation - Fluoroscopy (optional but helpful) - Microsagittal saw for Akin if planned **Setup**: Elevate foot on sterile towels or dedicated foot holder for access ## Operative Steps ### Step 1: Incision & Superficial Dissection **Technique**: Medial longitudinal incision 6-8cm extending from mid-proximal phalanx to mid-metatarsal shaft, centered over first metatarsal. Position 2-3mm dorsal to joint line to avoid plantar digital nerve. **Key Points** - Longer incision than chevron (need shaft exposure) - Sharp dissection through subcutaneous tissue - Identify and protect dorsomedial cutaneous nerve branches - Use self-retaining retractors for exposure **Technical Tip**: "I make a medial longitudinal incision 6-8cm - longer than chevron because I need exposure of the entire metatarsal shaft for the scarf. I stay 2-3mm dorsal to the joint line to avoid the plantar digital nerve and carefully identify and protect the dorsomedial cutaneous nerve which crosses the field." - Dorsomedial cutaneous nerve injury (5-10% incidence) - runs 2-3mm dorsal - Medial plantar digital nerve if incision too plantar (8-10mm plantar to joint) - Inadequate incision length limiting osteotomy exposure ### Step 2: Capsulotomy & Exposure **Technique**: Inverted-L or linear capsulotomy along dorsomedial aspect of metatarsal and MTP joint. Extend proximally along entire metatarsal shaft to planned proximal osteotomy site. Preserve capsular flaps for later repair. **Key Points** - Full-length exposure critical for scarf - Identify and protect lateral capsule (preserve for sesamoid stability) - Expose medial eminence, metatarsal neck, and shaft - Palpate and identify plantar cortex (guides osteotomy) - Minimal periosteal stripping laterally (AVN risk) **Technical Tip**: "I perform capsulotomy extending the full length of the metatarsal shaft - this complete exposure is critical for scarf osteotomy. I carefully preserve capsular tissue for closure and identify the plantar cortex which will guide my osteotomy orientation to prevent troughing." - Excessive soft tissue stripping increases AVN risk (1-2%) - Lateral capsule damage destabilizes sesamoids - Loss of capsular tissue compromises closure and recurrence risk ### Step 3: Medial Eminence Resection **Technique**: Remove medial eminence with sagittal saw in line with medial border of metatarsal shaft. Typical resection 3-4mm. Smooth edges with rongeur. Palpate plantarly to ensure no plantar prominence. **Key Points** - Cut in line with shaft (not excessive resection) - Over-resection destabilizes sesamoid complex - Increases hallux varus risk - Check no plantar prominence with finger **Technical Tip**: "I resect the eminence in line with the medial shaft border - typically 3-4mm. Over-resection destabilizes the sesamoid complex and significantly increases hallux varus risk. I smooth the edges and confirm there is no plantar prominence that could cause ongoing symptoms." - Over-resection causing sesamoid instability and varus (2-5%) - Plantar digital nerve if cut extends plantarly - Thermal injury from saw - use irrigation ### Step 4: Scarf Osteotomy Planning - CRITICAL STEP **Technique**: Plan Z-shaped osteotomy with THREE cuts: 1. **HORIZONTAL LIMB**: Longitudinal along shaft, 2:1 ratio dorsal-to-plantar (dorsally based), PARALLEL to plantar cortex 2. **PROXIMAL VERTICAL LIMB**: 60° angle, exits DORSALLY 3. **DISTAL VERTICAL LIMB**: 60° angle, exits PLANTARLY Length covers middle 60-70% of metatarsal (typically 25-30mm). Mark carefully with methylene blue or electrocautery. **Critical Geometry** - Horizontal cut MUST be parallel to plantar cortex (prevents troughing) - 2:1 dorsal:plantar ratio = cut in dorsal 2/3 of shaft - Opposite orientations of vertical cuts provide stability - Adequate length prevents stress risers **Technical Tip**: "The scarf is Z-shaped with critical geometry. The HORIZONTAL limb must be at 2:1 dorsal-to-plantar ratio - this dorsally biased position prevents troughing which is the most common complication. The proximal limb exits DORSALLY while the distal limb exits PLANTARLY at 60° angles. This opposite orientation provides inherent stability and prevents dorsiflexion malunion." - Wrong ratio (1:1 or plantar-based) = TROUGHING malunion (5-10%) - Non-parallel cuts = instability and malunion - Horizontal limb too short = stress riser fracture (2-5%) - Incorrect angles alter stability ### Step 5: Horizontal Longitudinal Cut **Technique**: Using 0.5-1.0mm sagittal saw blade, make horizontal longitudinal cut along metatarsal shaft. Cut must be PARALLEL to plantar cortex. Place in DORSAL 2/3 of metatarsal (2:1 ratio). Length typically 25-30mm covering middle shaft. Continuous irrigation to prevent thermal necrosis. **Key Points** - Palpate plantar cortex continuously during cutting - Blade parallel to plantar surface throughout - Incomplete cut (stop before full penetration of far cortex) - Copious irrigation prevents thermal injury **Technical Tip**: "The horizontal cut must be PARALLEL to the plantar cortex - this is THE key technical point to prevent troughing which is the most common scarf complication at 5-10%. I continuously palpate the plantar cortex with my finger as I cut to ensure I'm maintaining parallel orientation. I place the cut in the dorsal 2/3 at exactly 2:1 ratio. Continuous irrigation prevents thermal necrosis." - Non-parallel cut = troughing (dorsiflexion malunion) - most common error - Thermal necrosis without irrigation causes AVN - Complete inadvertent fracture if saw exits unintentionally - Plantar penetration risks neurovascular bundle ### Step 6: Proximal Vertical Cut **Technique**: Make proximal vertical cut exiting DORSALLY at approximately 60° to horizontal cut. Connect to proximal end of horizontal cut. Complete through both cortices. Creates proximal arm of Z. **Key Points** - 60° angle to horizontal - Exit point on dorsal cortex - Complete cut through both cortices - Confirms mobility after cut **Technical Tip**: "The proximal cut exits dorsally at 60° angle to the horizontal limb. This creates the proximal arm of the Z. I ensure complete cuts through both cortices - incomplete cuts make translation difficult and risk intraoperative fracture during manipulation." - Incomplete cut = difficulty with translation, fracture risk during manipulation - Exit point too far dorsal or plantar alters geometry and stability - Propagation of cut beyond intended endpoint ### Step 7: Distal Vertical Cut **Technique**: Make distal vertical cut exiting PLANTARLY at 60° to horizontal cut. Connect to distal end of horizontal cut. Complete Z-shaped osteotomy. Capital fragment now mobile. **Key Points** - 60° angle opposite to proximal - Exit point on plantar cortex (carefully) - Confirm fragment mobility - Opposite orientations provide stability **Technical Tip**: "The distal cut exits plantarly at 60° - opposite orientation to the proximal cut. This completes the Z configuration. I confirm the capital fragment is mobile before attempting translation. The opposite orientations of the vertical cuts provide inherent rotational stability which is a key advantage of scarf geometry." - Cut too plantar = sesamoid injury risk - Incomplete cut = fracture during manipulation (2-5%) - Loss of proper cut orientation = loss of stability - Plantar neurovascular bundle at risk if cut too deep ### Step 8: Translation & Multi-Planar Correction **Technique**: Translate capital fragment LATERALLY - amount depends on IMA severity (typically 5-8mm, up to 10mm or 70% shaft width possible). **Multi-planar capability** (advantage of scarf): 1. **TRANSLATION**: Primary correction for IMA (lateral shift) 2. **ROTATION**: Correct DMAA abnormality 3. **SHORTENING**: Reduce soft tissue tension if needed 4. **PLANTARFLEXION**: Slight plantar translation prevents transfer metatarsalgia Impaction of fragments provides initial stability. **Key Points** - Primary goal: lateral translation for IMA correction - Rule of thumb: 1mm translation ≈ 2° IMA correction - Up to 70% shaft width translation possible - Avoid excessive translation (AVN risk) - Slight plantarflexion prevents transfer metatarsalgia - Rotation addresses DMAA **Technical Tip**: "Scarf allows true multi-planar correction which is its major advantage over chevron. My PRIMARY correction is lateral translation 5-8mm to address the IMA - roughly 1mm translation corrects 2° IMA. SECONDARY corrections include: rotation to address DMAA abnormality, shortening to reduce tension in tight soft tissues, and slight plantarflexion to prevent transfer metatarsalgia. Impaction of the fragments provides excellent initial stability." - Excessive translation more than 70% width = instability and AVN risk - Dorsiflexion malposition = transfer metatarsalgia (10-15%) - Overcorrection = hallux varus (2-5%) - Loss of bony contact = nonunion risk ### Step 9: Provisional Fixation Assessment **Technique**: Hold correction manually or with K-wire and assess: - Alignment in all planes - Sesamoid reduction under head - No rotational deformity - Appropriate metatarsal length - Capital fragment sits flush on shaft (no step-off) - Fluoroscopy confirms position if available **Key Points** - Check before definitive fixation - Sesamoid reduction critical - No step-off dorsally or plantarly - Appropriate alignment **Technical Tip**: "Before final fixation I carefully check: good alignment in all planes, sesamoids reduced under the metatarsal head, no rotational deformity, and appropriate metatarsal length. Fluoroscopy is helpful to confirm position before screw insertion - much easier to adjust now than after screws are placed." - Fixing malpositioned fragments requires revision - Missing step-off creates prominence and pain - Unreduced sesamoids = high recurrence risk ### Step 10: Screw Fixation **Technique**: TWO SCREWS perpendicular to osteotomy plane. Headless compression screws preferred (2.5-3.0mm diameter). Insert PROXIMAL screw first for control, then DISTAL screw. Both achieve bicortical purchase. Lag screw technique for compression across osteotomy. **Key Points** - Two screws required (longer osteotomy than chevron) - Perpendicular to osteotomy plane maximizes compression - Headless screws avoid prominence and removal - Proximal screw first gives control - Lag technique provides compression - Bicortical purchase for stability **Technical Tip**: "I fix the scarf with TWO headless compression screws perpendicular to the osteotomy plane. I insert the proximal screw first which gives me control of the capital fragment, then the distal screw. Perpendicular placement is critical to achieve compression across the osteotomy. I use headless screws which avoid prominence and don't require routine removal - much better patient satisfaction." - Screw prominence if not headless (patient dissatisfaction) - Loss of correction if screws not perpendicular to osteotomy - Screw penetration into MTP joint space - Intraoperative fracture during screw insertion - Inadequate purchase in osteoporotic bone ### Step 11: Check Correction & Sesamoid Position **Technique**: Assess final correction: - **Clinical**: Straight alignment, toe points straight ahead, appropriate length, no rotation - **Radiographic**: Fluoroscopy confirms hardware position, alignment, sesamoid reduction - **Critical endpoint**: Sesamoids reduced under metatarsal head **Key Points** - Sesamoid reduction is CRITICAL endpoint - If not reduced: need lateral soft tissue release - Confirm no hardware complications - Check alignment in all planes **Technical Tip**: "I confirm the sesamoids are reduced under the metatarsal head - this is a critical endpoint that predicts long-term success. If the sesamoids are not reduced despite bony correction, I need to perform a lateral soft tissue release. Fluoroscopy confirms final alignment and proper hardware position without joint penetration." - Unreduced sesamoids = very high recurrence risk (up to 50%) - Missing rotational malalignment (subtle but important) - Hardware malposition into joint or with prominence ### Step 12: Lateral Release (if indicated) **Technique**: If sesamoids not reduced after bony correction: lateral soft tissue release required. **Approach options**: 1. Through medial incision if accessible 2. Separate dorsal incision between 1st-2nd metatarsals (preferred) **Release**: Lateral capsule, adductor hallucis tendon from lateral base proximal phalanx **Critical**: PROTECT lateral digital neurovascular bundle (5mm lateral to capsule) **Key Points** - Indicated if sesamoids unreduced - Release lateral capsule and adductor - Stay on capsular layer - Protect neurovascular bundle 5mm lateral - Recheck sesamoid position after release **Technical Tip**: "I perform lateral release if sesamoids remain unreduced after bony correction. I release the lateral capsule and detach the adductor hallucis tendon from the base of the proximal phalanx. The critical danger is the lateral digital neurovascular bundle which runs 5mm lateral to the capsule - injury causes numbness and chronic pain. I stay on the capsular layer and use gentle dissection." - Lateral digital neurovascular injury (5mm from capsule) causes numbness - Overcorrection if too aggressive = hallux varus (2-5%) - Vascular compromise to hallux from excessive release ### Step 13: Akin Osteotomy (adjunct procedure) **Technique**: Add Akin osteotomy if: 1. Residual HVA greater than 15° after scarf correction 2. DASA greater than 10° (interphalangeal valgus component) 3. To optimize final correction and alignment Medial-based closing wedge at proximal phalanx base, 2-3mm wedge. Fix with single headless screw or staple. **Key Points** - Common adjunct (30-40% of cases) - Addresses interphalangeal component - Small wedge (2-3mm adequate) - Single screw or staple fixation - Avoid overcorrection **Technical Tip**: "Akin osteotomy is a common adjunct to scarf - I add it in about 30-40% of cases when there's residual HVA greater than 15° after the metatarsal correction or when DASA is elevated above 10° indicating interphalangeal valgus. It's a medial closing wedge at the base of the proximal phalanx, typically 2-3mm. I must be careful not to overcorrect which causes interphalangeal varus deformity." - Overcorrection = interphalangeal varus deformity - Inadequate fixation = displacement - IP joint stiffness from periosteal stripping - Neurovascular injury if dissection too aggressive ### Step 14: Capsular Repair **Technique**: MEDIAL CAPSULE REEFING critical for soft tissue balance. Imbricate (overlap) medial capsule using "pants-over-vest" or "vest-over-pants" technique. Balance tension - adequate to maintain correction but not causing stiffness. Use absorbable sutures (2-0 or 3-0 Vicryl). **Key Points** - Soft tissue balance as important as bone - Overlap capsule for imbrication - Balanced tension (not too tight, not too loose) - Too loose = recurrence from laxity - Too tight = stiffness, overcorrection - Multiple interrupted sutures **Technical Tip**: "I reef the medial capsule to address the soft tissue laxity and maintain the correction - this soft tissue component is as important as the bony correction. I overlap the capsular edges (imbrication) with carefully balanced tension. Too loose allows recurrence from medial laxity, too tight causes stiffness and possible overcorrection. I aim for the toe to rest in slight overcorrection but still mobile." - Overtightening = stiffness, limited ROM, overcorrection - Inadequate closure = recurrence from persistent medial laxity (5-10%) - Devascularization from excessive handling ### Step 15: Closure & Bunion Dressing **Technique**: - Subcutaneous closure with absorbable sutures (3-0 Vicryl) - Skin with subcuticular 4-0 Monocryl or interrupted 4-0 nylon - **BUNION DRESSING** essential: - Gauze between 1st and 2nd toes - Toe maintained in corrected position with gauze padding - Circumferential compression wrap (not too tight) - Stiff-soled postoperative shoe **Key Points** - Layered closure - Bunion dressing maintains correction - Gauze between toes prevents drift - Compression controls swelling - Postop shoe protects osteotomy **Technical Tip**: "I close in layers and apply a proper bunion dressing which is essential to maintain the toe in corrected alignment during early healing. I place gauze between the 1st and 2nd toes to prevent drift back into valgus, apply circumferential compression to control swelling, and provide a stiff-soled postoperative shoe which protects the osteotomy for the critical first 6 weeks." - Wound dehiscence (5-10%) - especially in thin skin overlying eminence - Loss of correction if inadequate dressing applied - Vascular compromise from overly tight dressing - Skin necrosis from pressure points ## Immediate Post-operative (0-2 weeks) **Week 1-2** - Bunion dressing maintained - Strict elevation above heart level - Ice therapy 20 minutes every 2 hours - Heel and midfoot weight-bearing ONLY in stiff-soled shoe - NO forefoot loading - Pain control: multimodal analgesia - DVT prophylaxis if appropriate (aspirin or LMWH) **Wound Check**: 48-72 hours - Assess neurovascular status - Check dressing not too tight - Reinforce bunion dressing if needed **Suture Removal**: 10-14 days - Remove sutures when wound healed - Apply new bunion dressing - Continue protected weight-bearing ## Early Phase (2-6 weeks) **Protected Weight-Bearing** - Continue heel/midfoot weight-bearing only - Stiff-soled shoe at all times when ambulating - Bunion dressing until 2-3 weeks - Transition to light compression stocking **Range of Motion** - Start passive ROM exercises at 2-3 weeks - Gentle dorsiflexion and plantarflexion - Avoid forced manipulation - PT referral if needed **Radiographic Assessment** - X-ray at 6 weeks to confirm union - Check alignment, hardware position - Assess sesamoid position ## Intermediate Phase (6-12 weeks) **Week 6-8**: If radiographic union confirmed - Transition out of postoperative shoe - Progress to supportive athletic/walking shoes - Wide toe box essential - Begin progressive weight-bearing through forefoot - Increase ROM exercises **Week 8-12** - Normal supportive shoes - Resume most daily activities - Swimming, cycling allowed - Continue foot strengthening exercises - Avoid impact activities ## Late Phase (3-6 months) **3-4 Months** - Impact activities allowed (running, jumping) - Return to sport if pain-free - Continue supportive footwear - May still have some swelling (normal) **6 Months** - Maximal improvement achieved - Final radiographs to document outcome - May consider fashion footwear cautiously - AVOID high heels until 6 months minimum ## Long-term **Footwear Advice** - May need wider toe box permanently - Limit high heel use - Supportive shoes for exercise - Custom orthotics if pes planus **Activity Modification** - No long-term restrictions if healed - Normal athletic participation - Monitor for recurrence signs **Follow-up Schedule** - 2 weeks: Suture removal - 6 weeks: X-ray and clinical assessment - 3 months: Progress check - 6 months: Final outcome assessment - Annual: If ongoing concerns ## Complications and Management See Complications tab for detailed recognition and management strategies. ### Additional Complications **Nonunion** (rare, 1-2%) - Large contact area makes this uncommon - Risk factors: smoking, NSAIDs, poor fixation - Presents as persistent pain, motion at osteotomy - Management: revision fixation with bone graft, address modifiable factors **Stiffness/Reduced ROM** (15-25%) - Some ROM loss expected - Prevention: early gentle ROM at 2-3 weeks - Management: aggressive PT, possible manipulation under anesthesia if severe **Wound Complications** (5-10%) - Dehiscence, infection, skin necrosis - Higher risk in thin skin over eminence - Prevention: careful closure, appropriate dressing tension - Management: local wound care, antibiotics if infected, possible revision closure **Hardware Prominence** - Avoid by using headless screws - Management: screw removal after union (6 months) **Complex Regional Pain Syndrome** (1-2%) - Disproportionate pain, skin changes, stiffness - Early recognition critical - Management: aggressive PT, desensitization, neuropathic pain medications, sympathetic blocks ## Key Studies ### Scarf vs Chevron Osteotomy **Comparative Effectiveness** - Both highly effective for hallux valgus correction - Scarf handles more severe deformity (IMA up to 18° vs 13° for chevron) - Similar satisfaction rates (85-90%) - Scarf allows greater translation (up to 70% vs 50%) - Multi-planar correction advantage for scarf ### Long-term Outcomes **Radiographic Results** - HVA improvement: 30-40° to 10-15° (average 25° correction) - IMA improvement: 13-18° to 6-9° (average 8° correction) - Sesamoid reduction in 90-95% of cases - Maintained correction at 5-10 years **Patient Satisfaction** - 85-90% satisfied or very satisfied - Significant pain reduction (VAS improvement 6-7 to 1-2) - Return to normal footwear in 80-90% - Return to sport by 4-6 months ### Complication Rates **Meta-analysis Data** - Overall complication rate: 20-30% - Troughing: 5-10% (most common technical error) - Recurrence: 5-10% - AVN: 1-2% - Hallux varus: 2-5% - Transfer metatarsalgia: 10-15% - Nerve injury: 5-10% - Reoperation rate: 5-10% ### Modifications and Variations **Extended Scarf** - Longer horizontal cut for very severe deformity - Allows greater translation - Higher technical demands **Scarf-Akin Combination** - Addresses both metatarsal and phalangeal components - Used in 30-40% of cases - Better correction of high DASA **Mini-Scarf** - Shorter construct for moderate deformity - Less invasive but less powerful correction - Intermediate between chevron and full scarf ## Australian Context ### Medicare MBS Items - Item 49866: Osteotomy, metatarsal bone (including hallux valgus correction) - Fee: Approximately AUD $600-800 (schedule fee) - Private: AUD $3,000-6,000 total including hospital ### PBS Medications - Post-operative analgesia: Paracetamol/oxycodone combinations - NSAIDs: Consider gastric protection - Neuropathic pain: Gabapentin (if nerve injury) ### DVT Prophylaxis - Follow Australian Orthopaedic Association guidelines - Low-risk procedure: early mobilization, aspirin - Higher risk: LMWH for 14 days ## References 1. Barouk LS. Scarf osteotomy for hallux valgus correction. Local anatomy, surgical technique, and combination with other forefoot procedures. Foot Ankle Clin. 2000;5(3):525-558. PMID: 11232396. 2. Crevoisier X, Mouhsine E, Ortolano V, Udin B, Dutoit M. The scarf osteotomy for the treatment of hallux valgus deformity: a review of 84 cases. Foot Ankle Int. 2001;22(12):970-976. PMID: 11783924. 3. Jones S, Al Hussainy HA, Ali F, Betts RP, Flowers MJ. Scarf osteotomy for hallux valgus. A prospective clinical and pedobarographic study. J Bone Joint Surg Br. 2004;86(6):830-836. PMID: 15330023. 4. Coetzee JC. Scarf osteotomy for hallux valgus repair: the dark side. Foot Ankle Int. 2003;24(1):29-33. PMID: 12540078. 5. Kristen KH, Berger C, Stelzig S, Thalhammer G, Posch M, Engel A. The SCARF osteotomy for the correction of hallux valgus deformities. Foot Ankle Int. 2002;23(3):221-229. PMID: 11934064. 6. Aminian A, Kelikian A, Moen T. Scarf osteotomy for hallux valgus deformity: an intermediate followup of clinical and radiographic outcomes. Foot Ankle Int. 2006;27(11):883-886. PMID: 17144947. 7. Deenik A, van Mameren H, de Visser E, et al. Equivalent correction in scarf and chevron osteotomy in moderate and severe hallux valgus: a randomized controlled trial. Foot Ankle Int. 2008;29(12):1209-1215. PMID: 19138484. 8. Bock P, Kluger R, Kristen KH, et al. The Scarf osteotomy with minimally invasive lateral release for treatment of hallux valgus deformity: intermediate and long-term results. J Bone Joint Surg Am. 2015;97(15):1238-1245. PMID: 26246258. 9. Adam SP, Choung SC, Gu Y, O'Malley MJ. Outcomes after scarf osteotomy for treatment of adult hallux valgus deformity. Clin Orthop Relat Res. 2011;469(3):854-859. PMID: 20700675. 10. Chong A, Nazarian N, Chandrananth J, Tacey M, Shepherd D, Tran P. Surgery for the correction of hallux valgus: minimum five-year results with a validated patient-reported outcome tool and regression analysis. Bone Joint J. 2015;97-B(2):208-214. PMID: 25628283.

Scarf Osteotomy for Moderate-Severe Hallux Valgus

Scarf Osteotomy for Moderate-Severe Hallux Valgus