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Rotation Scarf & Akin Osteotomy (RSA) : Is It Safe?

Discussion in 'Foot Surgery' started by Dieter Fellner, Feb 15, 2005.

  1. Dieter Fellner

    Dieter Fellner Well-Known Member


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    In some regions in the UK the RSA has become a prevalent choice in the managment of hallux valgus deformity. Its advocates often implement early weight-bearing recommending a sneaker or similar two weeks post-operatively.

    A translation scarf appears to withstand weight bearing stresses well, when appropriate AO fixation is used, and cadaver studies have cofirmed this to be true. The eminent American Podiatrist Scott Weill even suggests wearing trainers one week after this surgery and this seems to work well. However, the intrinsic stability of this variation on the Scarf procedure has not been evaluated in the same way.

    I have had the opportunity to evaluate a number of RSA patients 6 months post-operatively. In this review I have encountered undiagnosed basal 1st metatarsal fractures, loss of alignment and recurrence of the deformity at an unacceptable rate. Also, often the 1st metatarsal position appears good on XRF 2/52 PO only to see a significant gap at 6/12.

    I am interested to hear from other surgeons with experience of this procedue and outcomes.
     
  2. podrick

    podrick Active Member

    scarf

    my opinion with regards to the scarf is that it can be inherintely unstable in certain patients,particularly patients over 55.when i was in residency we evaluated many scarfs that were at first described as malpositioned or with excessive motion leading to excessive bone callus.it was our belief then that what we were actually looking at were both fractures near the base as well as well as multiple stress fractures in the shaft of the metatarsal.
    this is not to say that in younger patients with better bone stock they didn't work well.
    however,they have a potential for lack of stability and avascular necrosis that far outweighs their benefis.i realize they are very popular in europe.but can anyone explain their advantage over let's say a reverdin (classic) with a closing base wedge,in order to correct a similar type of bunion.
     
  3. Ian Reilly

    Ian Reilly Active Member

    Dieter

    I agree with you. I have had more that a few over-rotations (pushing the limits for correction), troughing, basal fractures and recurrence. I know I don’t have the experience of some of our UK colleagues but have my reservations when doing this procedure. Yes, you can walk them a 2 weeks but it can never be as stable as a purely translated Z without rotation.

    I’m switching to basal chevrons/crescentics +/- modifications for my bigger angles. Ask me again in a year if I prefer these.

    Ian
     
  4. Dieter Fellner

    Dieter Fellner Well-Known Member

    Iain / Podrick

    Thank you for your observations.

    What are the factors that make this such a versatile and powerful procedure in the hands of one surgeon but capable of creating big headaches for others?

    Is this a technical issue or is it more widespread and undetected? Are all patients followed up and x-rayed routinely at 6 months?

    I suspect the angle of the longitudinal cut is a key component. The dorsal shelf has to be sufficiently thick and robust and I will direct this from dorsal to plantar in an oblique manner. Because I also insist on a gradual re-introduction to weight-bearing over a 4-6 weeks period I cannot isolate this as the only factor, but I have not seen a basal fracture complication when this is done.

    Proponents of this procedure will say that avoidance of a BKC and the risk of cast disease can be eliminated with a Scarf cut and metatarsus primus elevatus is rarely encountered which cannot be said for the basal osteotomy. In good hands a rotation scarf and akin is completed in 35 minutes or less, reducing surgical time.
     
  5. podrick

    podrick Active Member

    dieter,
    thanks for the insight i will re-examine the rotational scarf.i currently utilize a three to two osteotomy approach for my younger active patients with high im and hav angles,oblique base wedge with either a reverdin or an akin.this is dependent on whether the im elevation is coupled with a high pasa or just a high hav.
    however on my older patients i try to combine distal osteotomies,austin with akins,reverdin with akins or a fusion in severe deformities.i am concerned with using basilar osteotomies in the older population.
     
  6. Dieter Fellner

    Dieter Fellner Well-Known Member

    Age : A Healing Issue ?

    Rick,

    I understand the concern about healing capacity in the older patient but would say this: we must distinguish between chronological and physiological age. Unless there are specific factors to suggest otherwise, healing might not be impaired on the grounds of old age alone. I am not aware of any research to suggest otherwise.

    In my professional practice I have encountered remarkably sprightly octagonarians and frighteningly unhealthy 40-year old patients. The choice of procedure, our wise old sages advice, embraces many variables, age is but one of those factors.

    And there is this: we do not [?yet]have a "definitive" procedure that satisfies every patient's and/or clinician's needs and expectations.

    Although I am critical of some aspects of the RSA this procedure appears to satisfy many, if not all, patients even when complications occur. And on top of all that, in doing so the RS osteotomy mocks the significance of PASA without any apparent ill effect.

    At the same time I have witnessed excellent corrections addressing directly and predominantly the PASA with Reverdin Green Laird Todd procedure, in the mild to moderate IMA patient.

    How is it that such a prevalent condition as HAV can respond favourably to a range of different procedures? Why is it that research has failed both to identify definitively the causative factors directing this pathlogy, and those procedures that appear adequately to correct the deformity?

    And if this is truly the case, it makes sense to adopt a uniform approach. The RSA is versatile. Good fixation is possible. Early mobilization is achievable. Crutches and POP casts can be avoided. Deformity often is well corrected and patient satisfaction appears high.
     
  7. NewsBot

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    Articles:
    1
    Scarf osteotomy for hallux valgus—is an Akin osteotomy necessary?
    Ajay Malviya, Nilesh Makwana and Patrick Laing
    Foot and Ankle Surgery
    Volume 13, Issue 4, 2007, Pages 177-181

     
  8. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Scarf and Akin osteotomies for moderate and severe hallux valgus Clinical and radiographic results
    Ignacio Martínez Garrido, Eduardo Rodríguez-Vellando Rubio, Marta Navarro Bosch, María Sánchez González, Guillermo Bastida Paz and Alfredo Juan Llabrés
    Foot and Ankle Surgery; Volume 14, Issue 4, 2008, Pages 194-203
     
  9. Jose Antonio Teatino

    Jose Antonio Teatino Well-Known Member

    Dear colleagues:
    For interested in this technique, I recommend the reading of a French author.
    Forefoot recostruction-second edition
    Louis Samuel Barouk
    ISBN-13: 978-2-287-25251-8
    Kindly:
    Jose Antonio Teatino
    Professor of Surgery
    The Academy of Ambulatory Foot & Ankle Surgery
     
  10. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Symptomatic Medial Exostosis of the Great Toe Distal Phalanx: A Complication Due to Over-correction Following Akin Osteotomy for Hallux Valgus Repair.
    Villas C, Del Río J, Valenti A, Alfonso M.
    J Foot Ankle Surg. 2009 January - February;48(1):47-51.
     
  11. Jose Antonio Teatino

    Jose Antonio Teatino Well-Known Member

    Dear colleagues:
    In our experience we have found postoperative pain in the zone medial-plant of the articulation interfalángica, more usually than by on-correction in the processing of the hallux valgus (hallux varus iatrogenic), by not to have corrected wise the position of the valgus digital.
    We should evaluate the angle ungueal in the pre-operating one, and to maintain it horizontal to the plan of the floor in the post-operating one.
    If besides, limitation of the mobility is produced metatarsus-flanges, enlarges the conflict with the footwear in the union with its sole.
    Kindly:
    Jose Antonio Teatino
    Professor of surgery
    The Academy of Ambulatory Foot & Ankle Surgery
     

    Attached Files:

  12. NewsBot

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    Articles:
    1
    Scarf-Akin Osteotomy Correction for Hallux Valgus: Short-term Results from a District General Hospital.
    Kerr HL, Jackson R, Kothari P.
    J Foot Ankle Surg. 2010 January - February;49(1):16-19.
     
  13. NewsBot

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    Articles:
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    Rotational scarf and akin osteotomy for correction of hallux valgus associated with metatarsus adductus.
    Larholt J, Kilmartin TE.
    Foot Ankle Int. 2010 Mar;31(3):220-8.
     
  14. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Percutaneous hallux valgus correction using the Reverdin-Isham osteotomy.
    Bauer T, Biau D, Lortat-Jacob A, Hardy P.
    Orthop Traumatol Surg Res. 2010 May 18. [Epub ahead of print]
     
  15. NewsBot

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    Articles:
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    A Rotational Scarf Osteotomy Decreases Troughing When Treating Hallux Valgus.
    Murawski CD, Egan CJ, Kennedy JG.
    Clin Orthop Relat Res. 2010 Oct 26. [Epub ahead of print]
     
  16. NewsBot

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    Articles:
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    Patient Reported Outcomes following the combined rotation scarf and Akin's osteotomies in 71 consecutive cases.
    Maher AJ, Kilmartin TE.
    Foot (Edinb). 2010 Dec 9. [Epub ahead of print]
     
  17. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
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    Fixation of Akin osteotomy for hallux abductus with absorbable suture.
    Tóth K, Kellermann P, Wellinger K.
    Arch Orthop Trauma Surg. 2010 Oct;130(10):1257-61.
     
  18. NewsBot

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    Articles:
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    Biomechanical Comparison of Internal Fixation Techniques for the Akin Osteotomy of the Proximal Phalanx.
    Chacon Y, Fallat LM, Dau N, Bir C.
    J Foot Ankle Surg. 2012 Jul 19
     
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    BIFOCAL METATARSAL AND AKIN OSTEOTOMIES IN THE TREATMENT OF COMPLEX HALLUX VALGUS
    N.D. Riley, C. Hobbs, B. Rudge and C. Clark
    J Bone Joint Surg Br 2012 vol. 94-B no. SUPP XLIII 12
     
  20. drsarbes

    drsarbes Well-Known Member

    I have to put my 2 cents in here....

    years ago after having performed several SCARFS (rotational or not, almost all with an Akin osteotomy) I just could not see the benefits over a modified Austin, particularly with the increased amount of bone work and exposure needed.

    It seemed to me, at the time and still today, that this procedure was devised mainly utilizing "osseous" templates rather than real life anatomy and surgical technique. At a time when incisions were getting smaller and post operative periods shrinking, it was interesting that this procedure became as popular as it did.

    I'm sure many will disagree, particularly those that have gone on to make this their favorite bunion procedure.
    Apparently surgery remains an art-form.

    Steve
     
  21. Dieter Fellner

    Dieter Fellner Well-Known Member

    Steve,

    The Scarf, along with it's many variations, can produce powerful correction even in the presence of advanced malalignment. In the right hands this approach will manage IMA 20+ and up to 30 degrees. The scarf can be used to shorten , and lengthen, dorsiflex and plantarflex, address PASA and IMA - in short, the scarf is the single most versatile procedure that will accommodate almost all variations of hallux valgus.

    The Scarf, as practiced by many, is a near full length M1 osteotomy and can take correction of CORA (if you are an advocate of Paley's principles) much closer to the point of origin. When I look at the long term outcome of the Austin I see a marked deformity created in bone in an attempt to address a bony malalignment,

    There is no true deformity in the metatarsal. The scarf does, I think, make a better job of it. At the same time it is a stable procedure capable of allowing a patient to return to sneakers s/p 2 weeks. The scarf provides the foot with such a degree of stability, it is almost never necessary now to consider a Lapidus to stabilize the medial column.

    The incision is placed medial, usually, and along with plastic surgery technique the scar is not only hidden from the direct gaze of the observer looking down at the foot, but also usually fades nicely and becomes cosmetically very acceptable.

    There is now, an embarrassment of wealth in the literature extolling the virtues of the scarf - which is not one procedure, but many. Incredibly versatile, robust and reliable.

    As you note, horses for courses.

    ~Dieter
     
    Last edited: Oct 10, 2012
  22. Dieter:

    You sound like a man of experience with this procedure. How many Scarf procedures have you done?
     
  23. Dieter Fellner

    Dieter Fellner Well-Known Member

    Hi Dr. Kirby,

    To the order of 450-500, prior to my US relocation. Since then, I have been preaching the scarf bible to anyone who cares to listen. I have discovered the technique is not uniformly acknowledged on the east coast. And for all the same reasons that caused my hesitation / reluctance.

    It took some 5 years of baby steps transition to both, fully accept the principle, and acquire the surgical finesse necessary to get the full potential out of it. Haven't looked back, since.

    Cordially,

    Dieter
     
  24. Dieter:

    Very impressive numbers. Now you need to come over to Sacramento and teach me how to do the procedure better!!:drinks
     
  25. Dieter Fellner

    Dieter Fellner Well-Known Member

    Dr. Kirby:

    Hook me up with a Residency program, and it's done deal!:cool:

    ~Dieter
     
  26. Dieter:

    Be sure to apply to the Kaiser Sacramento program since I have been training their surgical residents on foot orthoses, biomechanics, sports medicine and the biomechanics of surgery now for the past 20+ years.:drinks
     
  27. Dieter Fellner

    Dieter Fellner Well-Known Member

  28. Don Green's San Diego program is one that feeds into Kaiser Sacramento. The other one comes from VA Albuquerque, I think. Both seem to be excellent programs. The 3rd year residents spend a half day a week learning biomechanics/sports medicine/surgical biomechanics in my private office. These residents get great all-round training and most of them end up being leaders in their communities when they finish up here, from what I have seen over the past 23 years of being part of the residency training program.
     
  29. NewsBot

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    OUR INITIAL EXPERIENCE USING MINIMALLY INVASIVE CHEVRON AND AKIN OSTEOTOMY FOR HALLUX VALGUS CORRECTION: SHORT TERM RESULTS
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    Bone Joint J 2013 vol. 95-B no. SUPP 21 1
     
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    Measurement & assessment of pain reduction 6 months following combined scarf akin’s osteotomies +/- 2/3 toe correction for hallux valgus
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  32. drsarbes

    drsarbes Well-Known Member

    Hi Dieter:
    Looking at this OLD thread from last year......Apparently I never read your reply post. Sorry.

    Wondering if you are still enamored with the SCARF?
    Also looking at your post from last October, you mentions lengthening the metatarsal. Have you lengthened many and how is the ROM on follow up?
    Can you also comment on what "marked deformity" you were referring to on the Austin type osteotomies?
     
  33. Dieter Fellner

    Dieter Fellner Well-Known Member

    HI Steve,

    Yes indeed I am. But I refer in particular to the Barouk Scarf-Akin modification, and I dare say, Fellner modification which evolves naturally with experience. I have never lengthened the 1st metatarsal when addressing the virgin bunion. And for the reason you allude to: 1st MTPJ jamming is a likely sequela. A key component of lasting correction is decompression, offset by 1st met plantar flexion. In my experience, the correct saggital plane position will determine the risk of lesser metatarsalgia, not the absolute length of the 1st metatarsal (within reason).

    The being said, in my current capacity as PGY-1 resident, there is no opportunity to indulge my passion. On one occasion, I was able to convert skeptics, when I received an impromptu invitation to act as surgical instructor during an externship at one of the NYC hospitals. I have an open minded Residency Director who may, in all likelihood indulge my convictions, in Year 2.

    As for the Austin - the capital fragment is translated laterally creating a deformity in the bone. This has become a point of interest. I am exploring HAV correction without cutting bone as the primary means to address HAV. A work in progress.

    Best,

    Dieter
     
  34. drsarbes

    drsarbes Well-Known Member

    Hello Dieter.

    I was under the impression that you were practicing. Good to hear that you have a passion for foot surgery.

    As for someone who has the same passion for the Austin (I might add with the Arbes modification - TIC) as you do for the SCARF,
    I would argue that ANY osteotomy causes a "deformity" and in fact, given enough time and by the graces of Wolff's Law, these diminish. Merely based on the fact that an AP post SCARF "looks" more anatomic because of the overall shape of the metatarsal doesn't mean you have created less "deformity. In addition, I've come to appreciate the over-emphasis we sometimes place on the radiograph and how it related clinically.

    Interesting how most surgeons gravitate to a particular bunion procedure or other based upon their expertise (read good results) regardless of possible poor outcomes obtained by others. I would venture to guess that after 500 or 1000 bunionectomies we all develop our myraid of modifications, often perhaps not even appreciating their arrival.

    As for non osseous correction of bunions ........ Good luck, just don't re invent the McBride! LOL


    Steve
     
  35. Dieter Fellner

    Dieter Fellner Well-Known Member

    Steve,

    Your impression is correct. I served for 20 years prior to my US relocation. I can construct a compelling argument why the Austin doesn't make the cut. But this will have to wait, another day.

    As for McBride: most certainly not.

    Best,

    Dieter
     
  36. drsarbes

    drsarbes Well-Known Member

    Ahhhhh. Where are you from?

    Why the move?

    As for " I can construct a compelling argument why the Austin doesn't make the cut"..................... my dad always said "don't argue with success."


    Steve
     
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    Last edited by a moderator: Sep 22, 2016
  39. Ian Reilly

    Ian Reilly Active Member

    Nice video Steve...!
     
  40. NewsBot

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    Articles:
    1
    Measurement & assessment of pain reduction six months following combined scarf akin’s osteotomies +/- 2/3 toe correction for hallux valgus
    Irvine Nake, Derek Santos, Gary Boon, Francis Babi, David Cartwright, Anthony Maher, Lee Murphy, Tosin Adekunle, Martin Murgatroyd, Sally Plant, Jackie Ludlam and Mavis Clark
    Journal of Foot and Ankle Research 2014, 7(Suppl 2):A6 doi:10.1186/1757-1146-7-S2-A6
     
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