SCARF PROCEDURE: A Prospective Clinical, Radiographic, and Pedobarographic Evaluation

1. SCARF PROCEDURE: A Prospective Clinical, Radiographic, and Pedobarographic Evaluation Lowell Weil, Jr. Darren Bergman, Bobby Kuruvilla, Wendy Weil, Lowell Scott Weil, Sr. Weil Foot & Ankle Institute Des Plaines, IL USA

2. Goals of Study Investigate the effect of the Scarf Procedure on the load characteristics of the forefoot using an Emed gait analysis system Evaluate the postoperative radiographic changes following Scarf osteotomy Evaluate the preoperative and postoperative 1st MTP range of motion

3. Materials & Methods Prospectively enrolled 30 patients with unilateral or bilateral hallux valgus from June 2006 � December 2006 46 feet with Scarf or Scarf Akin were evaluated Three surgeons within one institution performed the procedures. Exclusion criteria: concomitant forefoot pathology (hammertoes, clawtoes, and metatarsalgia) requiring concomitant surgery. patients with excessive first ray instability requiring 1st metatarsal-cuneiform fusion.

4. Materials & Methods Lenticular capsulorraphy Intra-articular sesamoid release Osteotomy guide Screw fixation Capsular repair Subcuticular closure Bulky compressive bandage post-operative

5. Materials & Methods Lenticular capsulorraphy Intra-articular sesamoid release Osteotomy guide Screw fixation Capsular repair Subcuticular closure Bulky compressive bandage post-operative

6. Materials & Methods Lenticular capsulorraphy Intra-articular sesamoid release Osteotomy guide Screw fixation Capsular repair Subcuticular closure Bulky compressive bandage post-operative

7. Materials & Methods Lenticular capsulorraphy Intra-articular sesamoid release Osteotomy guide Screw fixation Capsular repair Subcuticular closure Bulky compressive bandage post-operative

8. Materials & Methods Lenticular capsulorraphy Intra-articular sesamoid release Osteotomy guide Screw fixation Capsular repair Subcuticular closure Bulky compressive bandage post-operative

9. Materials & Methods Lenticular capsulorraphy Intra-articular sesamoid release Osteotomy guide Screw fixation Capsular repair Subcuticular closure Bulky compressive bandage post-operative

10. Materials & Methods Lenticular capsulorraphy Intra-articular sesamoid release Osteotomy guide Screw fixation Capsular repair Subcuticular closure Bulky compressive bandage post-operative

11. Materials & Methods Lenticular capsulorraphy Intra-articular sesamoid release Osteotomy guide Screw fixation Capsular repair Subcuticular closure Bulky compressive bandage post-operative

12. Materials & Methods Lenticular capsulorraphy Intra-articular sesamoid release Osteotomy guide Screw fixation Capsular repair Subcuticular closure Bulky compressive bandage post-operative

13. Materials & Methods One week post-operative Bathing Return to closed athletic shoes Begin physical therapy 6-8 weeks post op Return to all activities to tolerance Return to all shoes to tolerance

14. Results Average age of the patients 37.8 years (14�76 years) Average follow-up time was 9.7 months (8-13months) 20 of the 30 patients(28/46 feet) required an Akin osteotomy in addition to the Scarf procedure Improvement of AOFAS score from 65.7 to 86.3 ACFAS 1st ray score improved from 63.2 to 86.8

15. Results The intermetatarsal angle: 14.3� pre-operatively 9.5� post-operatively The hallux valgus angle: 25.9� pre-operatively 10.2� post-operatively 1st metatarsal declination angle: 38.7� pre-operatively 20.9� post-operatively

16. Results 1st metatarsal phalangeal joint range of motion: 64.5�- 11.3�pre-operatively 68.7�- 11.3�post-operatively 2.6 weeks to return to work 3.1 weeks return to activities of daily living

17. TABLE Clinical and Radiographic Results Clinical Parameters Preoperative Follow up AOFAS score 65.6 86.3 ACFAS score 63.2 86.8 Hallux Dorsiflexion 64.5 68.7 Hallux Plantarflexion 11.3 11.3 Hallux valgus angle 25.9 10.2 Intermetatarsal angle 14.3 9.5 1st Met Declination angle 38.7 20.9

18. Results

19. Results Pedobarographic analysis showed medialization of peak plantar pressure following surgery Peak plantar pressure Increased under the hallux and first metatarsal Decreased under the 2nd, 3rd, 4th, and 5th metatarsals

20. Results

21. Results Two patients (2/46 feet) developed a stress fracture postoperatively which was treated with prolonged protection in a stiff soled shoe and healed uneventfully No other adverse events were noted.

22. Discussion These early results reinforce our belief that restoration of first ray peak pressure to physiologic loading is the key factor in restoring normal forefoot mechanics which lead to providing postoperative pain relief Early functional physical therapy, emphasizing plantarflexion, is critical to regaining proper plantarflexion strength of the hallux, which is crucial to reduce transfer pressures,initially described by Holmes Further investigation is needed to determine if the restoration of 1st ray plantarflexion is more important than the restoration of radiographic parameters in correcting forefoot load.

23. Contact:Lowell Weil, Jr.atlwj@weil4feet.com www.weil4feet.com