Outcomes of Scarf and Akin Osteotomy with Intra-Articular Stepwise Lateral Soft Tissue Release for Correcting Hallux Valgus Deformity in Rheumatoid Arthritis

Abstract

Background: The effectiveness of scarf and Akin osteotomy with intra-articular lateral soft tissue release for the correction of hallux valgus (HV) in patients with rheumatoid arthritis (RA) has not been elucidated.

Methods: A total of 36 feet in 28 patients with RA who had scarf and Akin osteotomy with intra-articular stepwise lateral soft tissue release between 2015 and 2020 at a single institute were investigated retrospectively, with a mean follow-up period of 32.0 ± 16.9 months. Radiographic evaluations including the HV angle, intermetatarsal angle, and sesamoid position were performed preoperatively and postoperatively. Clinical outcomes were assessed using the Japanese Society of Surgery of the Foot (JSSF) hallux scale and self-administered foot evaluation questionnaire (SAFE-Q).

Results: The procedure resulted in significant HV correction, with a recurrence rate of 13.9%. The JSSF scale and all five SAFE-Q subscale scores significantly improved (p < 0.05), with no major complications. More than 90% of cases achieved adequate lateral soft tissue release without sacrificing the adductor tendon of the hallux.

Conclusions: Intra-articular stepwise lateral soft tissue release in combination with scarf and Akin osteotomy provided satisfactory radiographic and patient-reported outcomes for the correction of HV in patients with RA with minimum lateral soft tissue release.

Keywords: akin osteotomy; hallux valgus; intra-articular release; joint-preserving arthroplasty; lateral soft tissue release; metatarsosesamoid suspensory ligament; rheumatoid arthritis; scarf osteotomy.

Figure 1

Intraoperative pictures showing the key steps in our procedure for correcting hallux valgus in patients with rheumatoid arthritis. (A) Lateral soft tissue release was performed intra-articularly through a single long medial longitudinal skin incision and a capsular incision at the first metatarsophalangeal joint. Blunt dissection of the lateral metatarsosesamoid suspensory ligament was performed using elevatorium followed by sharp dissection using dissection scissors. (B) Lateral soft tissue release was performed in a stepwise fashion until the manual correction of the intermetatarsal angle between the first and second metatarsals spontaneously corrected the hallux valgus deformity. It involved the following three steps: (1) dissection of the lateral metatarsosesamoid suspensory ligament, (2) lateral capsulotomy at the joint level, and (3) tenotomy of the adductor tendon insertion into the proximal phalanx. (C) Transverse part of scarf osteotomy was performed connecting two apexes; one was located at the center of the metatarsal head and the other at the plantar one-third of the metatarsal 10 mm distal to the first tarsometatarsal joint. (D) After the lateral translation of the distal fragment and internal fixations of the proximal and distal fragments with two cannulated headless screws, the prominent medial bone of the proximal fragment was excised in the shape of a wedge. (E) Excised fragment was impacted intramedullary in the plantar and proximal regions with the wedge turned backward and upside down.