FOOT & ANKLE INTERNATIONAL

Copyright © 2007 by the American Orthopaedic Foot & Ankle Society, Inc.
DOI: 10.3113/FAI.2007.0529

Surgical Strategies: Scarf Osteotomy for Hallux Valgus

J. Chris Coetzee, M.D.1 ; Pascal Rippstein, M.D.2

Minneapolis MN

BACKGROUND AND PROCEDURE A

Burutaran1 in 1973 described an osteotomy similar to the
one now known as the scarf which he used to lengthen the
first metatarsal. In 1983, Gudas and Zygmunt8 started to use
a true “Z-shaped” osteotomy of the first metatarsal to correct
hallux valgus deformities.8 It was Lowell Weil who in 1984
gave the name “scarf” to the osteotomy. The term “scarf”
is taken from the language of carpenters, in which a scarf
is defined as a joint made by cutting tapered opposing ends
that overlap. The interlocking or scarf has been used for
many centuries in carpentry, specifically to extend purlins B
and beams in the roof of a house or in boat construction. Its
primary value is its inherent stability, strength, and ability to
distribute load. Orthopaedically, it appeared to be the perfect
technique to borrow and incorporate into the complex issues
of stability, strength, and versatility needed for correction of
hallux valgus (Figure 1).
Since 1991, Barouk2 popularized the scarf osteotomy in Fig. 1: A and B, The scarf osteotomy is a stable overlapping and
Europe. He gave an account of his approach in Foot and interlocking joint.
Ankle Clinics in September 2000.2 Crevoisier et al.4 reported
84 patients treated with scarf osteotomy for hallux valgus osteotomy of the first phalanx in 75% resulted in overall high
deformity from 1995 to 1998, with an average followup satisfaction rates because of marked clinical and radiographic
of 22 months. At final followup, 39% of the patients (33 improvements. Jones et al.,5 in a prospective study of 24
of 84) were very satisfied, 50% (42 of 84) were satisfied, patients (35 feet) who were treated with scarf osteotomy and
and 11% (9 of 84) were not satisfied. The mean AOFAS Akin closing-wedge osteotomy for hallux valgus reported
score improved from 43 points preoperatively to 82 points. that 50% of the patients (12) were very satisfied, 42%
Among the 16 complications recorded, seven (8%) were (10) were satisfied, and 8% (2) were not satisfied at 20-
minor and nine (11%) required an additional procedure. They month followup. The mean American Orthopaedic Foot and
concluded that the scarf osteotomy of the first metatarsal Ankle Society (AOFAS) score improved from 52 points
with a lateral soft-tissue release and a basal closing wedge preoperatively to 89 at followup. The intermetatarsal and
hallux valgus angles improved from the mean preoperative
1
Orthopaedic Consultants PA, Minnesota Sports Medicine, Eden Prairie, MN values of 15 degrees and 33 degrees to 9 degrees and 14
2
Schulthess Klinik, Zurich, Switzerland
degrees, respectively. There was no appreciable change in the
Corresponding Author: mean pedobarographic measurements of the first and second
J. Chris Coetzee, M.D. metatarsals after surgery. One patient had an intraoperative
Orthopedic Consultants PA
Minnesota Sports Medicine fracture of the first metatarsal and one required further
Flagship Corporate Center surgery to remove a long distal screw which was irritating the
775 Prairie Center Drive, #250 medial sesamoid. They concluded that the scarf osteotomy
Eden, Prairie, MN 55344
E-mail: jcc@ocpamn.com combined with the Akin closing-wedge osteotomy was safe
For information on prices and availability of reprints, call 410-494-4994 X226 and effective for the treatment of hallux valgus.
529

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530 COETZEE AND RIPPSTEIN
MODIFICATIONS
The underlying geometric basis and rationale for use
of the scarf osteotomy remain the same. As with most
orthopaedic procedures, multiple modifications have been
added to attempt to improve the procedure, expand the
indications, and limit complications. Different surgeons use
different versions of these modifications, but we have incor-
porated the following changes in our practice.
(1) The distal and proximal short arms of the Z are now
limited to 2 to 3 mm in depth. This theoretically
reduces the stability of the osteotomy even though this
has not been encountered clinically. The advantage
of the short cuts is that it avoids cutting into the
cancellous portion of the metatarsal and, therefore,
reduces the risk of troughing (Figure 2). This is
especially important if a “short” scarf is done for
less severe deformities. With a conventional scarf the
entire metatarsal has to be exposed. It is our opinion
that for less severe deformities this extensile exposure
is not necessary, and a short osteotomy can provide
an adequate correction. The most common problem
is “troughing” of the two halves of the metatarsal
shaft (Figure 4). This happens when the cortices wedge
into the softer cancellous bone of the metatarsal shaft,
causing a functional elevation or dorsiflexion of the
first ray that can lead to a pronated first metatarsal and
lesser metatarsal overload. This is more frequent in the
short scarf osteotomy in which the proximal limb of
the Z is in hard cortical bone with a soft cancellous
center. Shortening the short arms either eliminates the
problem or at least allows only 2 mm of subsidence.
Another way to limit troughing is to keep the long arm
of the Z as long as possible, which allows the short
arms to be in the metaphysis that has a less dense
cortex.
(2) The procedure is limited to younger people with strong
healthy bone that would prevent the troughing. In
some elderly patients, the cancellous bone is very soft
and cannot support the cortical overlay.
(3) Multiple adjustments are made as needed. Depending
on the direction of the long arm of the Z, the
Fig. 2: One major modification is to shorten the depth of the short arms of
the Z. This limits the amount the metatarsal can collapse, thereby avoiding
“troughing.”.
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Foot & Ankle International/Vol. 28, No. 4/April 2007
distal (capital) fragment can be displaced in a plantar
or dorsal direction. More common is angling the
long arm from dorsal-medial to plantar-lateral, which
displaces the capital fragment plantarly by 1 to 2
mm, increasing the weightbearing under the first
metatarsal (Figure 3). Plantarflexing or dorsiflexing
the first metatarsal or adding a rotational component
to the scarf osteotomy increases its stability and
versatility. The metatarsal can be lengthened a few
millimeters without compromising the stability of the
osteotomy by cutting the short arms of the Z parallel
from proximal-medial to distal-lateral. Depending on
the soft-tissue envelope, it is sometimes difficult to
actually move the capital fragment distally to lengthen
the metatarsal, and one should not try to over-lengthen
the metatarsal. In some feet with hallux valgus, there
is either congenital or iatrogenic shortening of the
first metatarsal. Bringing it close to the length of
the second metatarsal could limit lesser metatarsal
overload symptoms. Although seldom necessary, the
metatarsal can be shortenened by removing equal
segments on the short arms of the Z.
Results before Modifications
Rippstein and Zünd7 reported 73 scarf osteotomies in 57
patients (51 women and six men) followed clinically and
radiographically for an average of 23 (12 to 45) months. The
Fig. 3: Depending on the direction of the long arm of the Z cut, the capital
fragment of the first metatarsal can be displaced plantar, dorsal, or neutral.
Fig. 4: Troughing was a common early complication. This led to a
functional elevation of the first ray and a more complicated problem of
rotational malunion in some patients..
Foot & Ankle International/Vol. 28, No. 4/April 2007 SCARF OSTEOTOMY 531

mean age at the time of surgery was 51.2 (22.5 –78) years.
The average 1 –2 intermetatarsal angle was reduced from 12
to 6 degrees and the first metatarsophalangeal angle from
27 to 11 degrees. Patient satisfaction assessed on a visual
analog scale (10 points representing complete satisfaction)
reached a mean value of 9.2 points. The postoperative
AOFAS score was an average 93 (60 to100) points. Coetzee3
reported patients followed prospectively for a minimum of
1 year. The complication rate for this group was 47%
(some patients had multiple complications). This included
troughing in 35% (7 of 20 patients) with rotational malunion
that often accompanied it. Other complications included an
early recurrence (probably because of troughing), proximal
fracture, osteonecrosis, and delayed union. The preoperative
AOFAS score was a mean of 53 points. At 6 months the
mean was 54 (19 to 69), and at 12 months 62 (24 to 100).
The dissatisfaction rate was 45% (9 of 20 patients)

Results after Modification

Even with the initial poor results, the potential of the
osteotomy was appreciated. With the changes in opera-
tive technique and indications better results were obtained.
Between the authors the scarf osteotomy was the chosen
procedure in 184 patients with moderate metatarsus primus
varus and bunion deformities. Only patients with followup
longer than 2 years are included in the information presented.
One hundred and nine were women and 75 were men with
a mean age of 44 (17 to 65) years. The AOFAS hallux
metatarsophalangeal-interphalangeal scale, visual analog scale,
and patient satisfaction were monitored before surgery and
at 6 months and annually after surgery. All patients had
“idiopathic” bunions. No patient with rheumatoid arthritis,
insulin-dependent diabetes, or other major systemic abnor-
malities was included. None of the patients had previous
bunion surgery. Fig. 5: The minimal contact area between the two fragments that still allow
The decision to do a scarf osteotomy was made on the enough stability is one-third of the metatarsal width.
engineering principle of the procedure and a deformity that
required something more substantial than a simple distal
osteotomy. This included patients with an intermetatarsal was that they generally did well and did not see the need
angle between 13 and 20 degrees and a hallux valgus angle for further followup. The average 1 – 2 intermetatarsal angle
of less than 40 degrees. was reduced from 14 to 5 to 7 degrees and the first
The AOFAS hallux metatarsal-interphalangeal scale6 was metatarsophalangeal angle from 27 to 11 degrees. Patient
used before surgery at the time the decision was made to satisfaction assessed on a visual 0 –10 analog scale (10 points
intervene operatively, then at 6 and 12 months postopera- representing complete satisfaction) reached a mean value of
tively. Patient satisfaction was assessed for overall satisfac- 9.1 points. The mean preoperative AOFAS score was 54 (43
tion, function, appearance, and whether they would have the to 66). At 6 months it improved to 81 (53 to 100), and at
surgery again and if they would recommend it to a friend. A 24 months the mean was 92 (60 to 100). One hundred and
visual analog pain scale was used at the same time intervals. thirty-six patients (91%) were happy with their result, leaving
Weightbearing anteroposterior, lateral, and sesamoid radio- 14 with significant problems.
graphs were obtained before surgery and at the 6-month and The significant complications included severe undercorrec-
12-month followup visits. tion bilaterally in one patient, overcorrection in one, painful
Of the 184 patients, 150 were followed for at least 2 osteoarthritis of the first metatarsophalangeal joint in one,
years. One hundred and seventy-six had preoperative and a localized osteonecrosis of the metatarsal head in one,
6-month information, but the retention rate fell as time troughing in two, and recurrence of the hallux valgus in
went by. The trend with the group we lost contact with six. In another patient, a distal screw that was too long

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532 COETZEE AND RIPPSTEIN Foot & Ankle International/Vol. 28, No. 4/April 2007

Fig. 6: After adequate exposure of the medial side of the first metatarsal
and protection of the neurovascular structures, the Z-osteotomy is planned B
and marked on the metatarsal.

caused painful impingement on one of the sesamoids and was

removed. Minor complications included four patients with
dorsomedial hypesthesia of the big toe, and two superficial
infections treated with oral antibiotics. A minor secondary
displacement of the fragments was seen in one osteoporotic
patient without giving rise to symptoms.

CURRENT INDICATIONS

The scarf osteotomy is mainly used to correct mild to

moderate hallux valgus deformities. It also can be used to
correct a bunionette deformity of the fifth metatarsal, espe-
Fig. 7: A, Two short arms of the Z cut perfectly parallel. This is
cially type 3 (abnormally wide 4 –5 intermetatarsal angle).
required to allow the capital fragment are to displace laterally. To lengthen
Since the scarf osteotomy is an “overlapping” osteotomy (the the metatarsal, both short arms should project from medial-proximal to
distal fragment with the metatarsal head is moved laterally lateral-distal and still be parallel. B, The short arms converging, which makes
underneath the proximal fragment), the limit of the correc- it impossible for the osteotomy to displace laterally.
tion with this osteotomy is not primarily the value of the
1 –2 intermetatarsal angle, but essentially the width of the
• The lower extremity is sterilely prepared and draped,
first metatarsal (the wider the first metatarsal, the bigger the
and the tourniquet is inflated to 250 mmHg after gravity
correction). The minimal overlapping between the two frag-
exsanguination.
ments that still allows enough stability is one third of the
• The skin incision runs medially and longitudinally over
metatarsal width. Very experienced surgeons might push this
the first metatarsophalangeal joint, extending from about
to one-fourth overlap (Figure 5).
the proximal half of the proximal phalanx to the mid-
Specific contraindications are the rare “true” first ray insta-
part of the first metatarsal.
bility (instability due to ligamentous laxity around the first
• The capsule of the metatarsophalangeal joint is then
Lisfranc joint rather than failure of the windlass mechanism
exposed, taking care not to injure the dorsal and plantar
secondary to the hallux valgus deformity), osteoarthritis of
sensory nerve branches.
the metatarsophalangeal joint, and severe osteoporosis.
• The metatarsophalangeal capsule is longitudinally inci-
sed and the dorsal aspects of the proximal phalanx
OPERATIVE TECHNIQUE and of the first metatarsal are subperiostally freed from
the overlying soft tissues. The soft tissues on the
plantar aspect of the first metatarsal are not detached
• The patient is placed supine with a tourniquet placed to preserve the blood supply to the distal fragment
according to preference and anesthesia is administered. (Figure 6).

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Foot & Ankle International/Vol. 28, No. 4/April 2007 SCARF OSTEOTOMY 533

Fig. 8: With the short arms of the Z cut parallel, lateral displacement of the
capital fragment is easily performed.

• With the medial aspect of the first metatarsal exposed,

a three-cut Z-osteotomy is performed. The longitudinal
cut starts at the level of the metatarsal head, 5 mm from
the joint at the junction between the dorsal third and
the plantar two thirds of the metatarsal. Depending on
the severity of the deformity to be corrected, this cut B
can be made longer or shorter, usually reaching the
proximal part of the diaphysis. In the frontal plane, this
cut is parallel to the weightbearing plane or slightly
oblique from dorsal-medial to plantar-lateral to bring
the metatarsal head more plantar if required. It has been
the experience of the authors that such a plantarization
rarely is required, because the restoration of the windlass
mechanism with the correction of the hallux valgus
deformity restores stability to the first ray.
• The first transverse cut is made distally and dorsally,
perpendicular to the long axis of the second metatarsal
if the length of the first metatarsal has to remain equal.
The transverse cut usually runs parallel to the cartilage
line of the metatarsal head. To lengthen the metatarsal,
the transverse (short) cut is oriented in the horizontal
Fig. 9: A, The capital fragment is displaced laterally while the proximal
plane from medial-proximal to distal-lateral at an angle fragment is held with a clamp. The osteotomy is then temporarily stabilized
that will allow distal translation. If shortening of the first with a Kirschner wire. B, Two screws are used to securely stabilize the
metatarsal is desirable, the transverse cut will have to osteotomy.
be oriented from medial-distal to lateral-proximal in the
horizontal plane; the more oblique the cut and the larger • The second transverse cut is made strictly parallel to the
the lateral shift are, the more shortening will occur. first transverse cut, plantar at the proximal end of the
• Another way to shorten the metatarsal is to remove a longitudinal cut (Figure 7A). One should take care to
segment of bone of the amount of the desired shortening avoid making this cut convergent to the first one since
by making a second cut just proximal to the first one. this would prevent the shifting of the head fragment
The authors prefer this technique for shortening since (locking effect) (Figure 7B).
the shortening is much more predictable. • For a first metatarsal shortening, the size of the proximal

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534 COETZEE AND RIPPSTEIN Foot & Ankle International/Vol. 28, No. 4/April 2007

segment to be removed should be the same as the one
of the distal cut.
• The plantar-distal portion is translated laterally to close
the intermetatarsal gap (Figure 8). If necessary, rotation
can be simultaneously done to correct any pathological
distal metatarsal angle.
• If the required distal metatarsal articular angle correc-
tion is important, the proximal-lateral corner of the head
fragment can impinge the second metatarsal, preventing
a full correction; in such a situation, this corner should
be resected.
• A Kirschner wire is temporarily inserted from the
proximal fragment distally into the distal fragment,
taking care to not place it where the distal screw will
be placed for definitive fixation. The use of such a
Kirschner wire instead of a clamp prevents the stripping
of the soft tissues underneath the distal fragment,
preserving its vascularity better (Figure 9).
• A simulated loading test is now performed on the
forefoot. The big toe should be reduced or nearly
reduced on the metatarsal head and the metatarsal
head should be reduced over the sesamoid bones. If
this is not the case, either an Akin osteotomy or an
additional lateral soft-tissue release with tenotomy of
the adductor tendon is done, depending on the cause for
the residual subluxation. The sesamoid reduction can
be checked clinically and radiographically with a mini
C-arm.
• Two mini-fragment screws (2.0 or 2.7 mm) are used
to secure the osteotomy. The screw choice obviously is
surgeon-specific.
• The exposed medial eminence and dorsomedial meta-
tarsal shaft are removed.
• If there is any residual hallux valgus deformity, then the
cause of this residual deformity should be treated first
(e.g., lateral soft-tissue release, increased shift of distal
metatarsal fragment, Akin osteotomy) before closing the
capsule medially, because the capsule will not be able
to hold the correction over time if the hallux valgus
deformity is not adequately corrected by osteotomy and

A
B

Fig. 10: A, A typical case with a moderate metatarsus primus varus and hallux valgus deformity. B, An adequate correction of the intermetatarsal angle as
well as the hallux valgus. An Akin osteotomy also was performed to obtain complete correction of the hallux valgus.

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Foot & Ankle International/Vol. 28, No. 4/April 2007
soft-tissue release as required to maintain the correction
(Figure 10).
Postoperative Care
Rippstein and Zünd6 allowed their patients to be weight-
bearing as tolerated from the first postoperative day, either
in a special postoperative shoe shifting the body weight to
the heel and unloading the forefoot or in a good shoe with
a strong insole. Coetzee3 allowed his patients heel-touch
weightbearing for 2 weeks in a postoperative shoe followed
by 4 weeks or partial weightbearing before starting a rehabil-
itation program. No difference in outcome was seen between
the two protocols.
SUMMARY
The scarf is an effective osteotomy that allows correction
of mild to moderate intermetatarsal angles. The correction
is obtained on one side by the adjustable length of the
osteotomy and the “Z-shape” which provides stability even
with displacement up to two-thirds the width of the first
metatarsal shaft. The weakness of this osteotomy is the
technical demands with many potential complications from
technical errors. This osteotomy is, therefore, recommended
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SCARF OSTEOTOMY 535
for surgeons who are confident and comfortable doing the
procedure.
REFERENCES
1. Burutaran JM: Hallux valgus y cortedad anatomica del primer
metatarsano (correction chirurgica). Actual Med. Chir. Pied. XIII:261 –
266, 1976.
2. Barouk, LS: Scarf osteotomy for hallux valgus correction. Local
anatomy, surgical technique, and combination with other forefoot
procedures. Foot Ankle Clin. 5(3):525 – 558, 2000.
3. Coetzee, JC: Scarf osteotomy for hallux valgus repair: the dark side.
Foot Ankle Int. 24:29 – 33, 2003.
4. 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. 22:970 – 976, 2001.
5. 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. 86-B:830 – 836, 2004.
6. Kitaoka, HB; Alexander, IJ; Adelaar, RS; et al: Clinical rating system
for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int.
15:349 – 353,1994
7. Rippstein, P; Zünd, T: The scarf osteotomy for the correction of hallux
valgus. Operat. Orthop. Traumatol. 9:101 – 112, 2001.
8. Zygmunt, KHZ; Gudas, CJ; Laros, GS: Bunionectomy with internal
screw fixation. J. Am. Podiatr. Med. Assoc. 79:322 – 329, 1989.