
==== Front
J Orthop Surg Res
J Orthop Surg Res
Journal of Orthopaedic Surgery and Research
1749-799X
BioMed Central London

39272201
5007
10.1186/s13018-024-05007-0
Systematic Review
Chevron osteotomy and scarf osteotomy for hallux valgus angle and intermetatarsal angle correction: a systematic review and meta-analysis of randomized controlled trials
Peng Yu-Ning 12
Peng Yu-Hsiang 3
Chen Carl P. C. carlchendr@gmail.com

12
1 grid.145695.a 0000 0004 1798 0922 Department of Physical Medicine & Rehabilitation, College of Medicine, Chang Gung Memorial Hospital at Linkou, Chang Gung University, 5, Fu-Hsin St., Kwei-Shan, Tao-Yuan, 333343 Taiwan
2 grid.145695.a 0000 0004 1798 0922 Department of Physical Medicine & Rehabilitation, College of Medicine, Chang Gung Memorial Hospital at Taoyuan, Chang Gung University, Guishan District, Taoyuan City, Taiwan
3 https://ror.org/00t89kj24 grid.452449.a 0000 0004 1762 5613 Department of Medicine, MacKay Medical College, Sanzhi District, New Taipei City, Taiwan
14 9 2024
14 9 2024
2024
19 56619 7 2024
16 8 2024
© The Author(s) 2024
2024
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Background

This systematic review and meta-analysis aimed to investigate the differences in hallux valgus angle (HVA), intermetatarsal angle (IMA), American Orthopedic Foot and Ankle Society (AOFAS) scores, and complication rates between chevron osteotomy and scarf osteotomy for correcting hallux valgus.

Methods

Two investigators independently searched for randomized controlled trials (RCTs) published from 2007 to 2018 on PubMed, Web of Science, and Cochrane Library databases. Next, chevron and scarf osteotomies were compared for their postoperative outcomes using HVA, IMA, and AOFAS scores and their complication rates. Meta-analysis was performed using Review Manager (version 5.3).

Results

Six RCTs—comprising 507 feet, of which 261 and 246 underwent chevron and scarf osteotomies, respectively—were included. The meta-analysis revealed that chevron osteotomy led to significantly smaller postoperative HVAs than scarf osteotomy (weighted mean difference [WMD] = -1.94, 95% CI = − 2.65 to − 1.29, P < .00001). However, the differences in postoperative IMA (WMD = − 0.44, 95% CI = − 1.10 to 0.22, P = .19), postoperative AOFAS scores (WMD = 0.75; 95% CI = − 5.32 to 6.82; P = .81), and complication rates (risk ratio = 1.22, 95% CI = 0.65–2.27, P = .53) between feet that underwent chevron and scarf osteotomies were nonsignificant.

Conclusions

Compared with scarf osteotomy, chevron osteotomy had significantly more favorable postoperative outcomes in terms of HVA correction, but not in terms of IMA, AOFAS scores, or complication rates.

Level of evidence

Level I, systemic review and meta-analysis.

Keywords

Hallux valgus
Chevron osteotomy
Scarf osteotomy
Hallux valgus angle
Intermetatarsal angle
Complication
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pmcBackground

Hallux valgus is a common forefoot deformity that often causes foot pain and walking disability [1]. In the general population, its prevalence was 23% in adults aged 18–65 years and 35.7% in those aged > 65 years—all with female preponderance [1]. Many patients choose to undergo surgery if conservative treatments fail. More than 200 types of surgical procedures for hallux valgus correction have been developed, but none are superior to others [2, 3]. Chevron osteotomy and scarf osteotomy are widely used for correcting hallux valgus. In chevron osteotomy, which is suitable for correction of mild and moderate hallux valgus in patients aged < 50 years, a V-shaped cut is created in the distal first metatarsal near the metatarsal head, and then the cut bone is fixed with a screw or suture. The excess bone on the medial side of the foot is then resected [4]. Scarf osteotomy is relatively more complex; it is thus used for correcting moderate-to-severe hallux valgus. In this procedure, a Z-shaped diaphyseal osteotomy is performed in the first metatarsal, and the metatarsal is further moved and fixed into a new position with 2 small screws. The procedure also involves the release of tight ligaments and tightening of loose ligaments (lateral releasing and medial plication) to balance the joint.(5) The advantages of chevron osteotomy include rapid healing, minimal shortening, and ease of operation, and its disadvantages include osteonecrosis and malunion. By contrast, the advantages of scarf osteotomy include increased stability and intermetatarsal angle (IMA) correction, and its disadvantages include high surgical difficulty, long operation time, and shortened first metatarsal [5–7] The first randomized controlled trial (RCT) comparing postoperative outcomes between chevron and scarf osteotomies was published by Deenik et al. [8]. in 2007. No significant differences were found in IMA correction, function, postoperative pain, and patient satisfaction. By contrast, in their 2018 RCT, Mahadeven et al. [9]. concluded that chevron osteotomy was superior to scarf osteotomy in correcting hallux valgus. The consensus regarding the efficiencies of chevron and scarf osteotomies is lacking; thus, conducting a study comparing the efficacy of these surgical procedures is vital. Therefore, the purpose of this systematic review and meta-analysis was to compare the postoperative outcomes of chevron osteotomy and scarf osteotomy, in terms of hallux valgus angle (HVA), IMA, American Orthopedic Foot and Ankle Society (AOFAS) scores, and complication rates.

Methods

This systemic review and meta-analysis was designed on the basis of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [10] and the recommendations of the Cochrane Handbook for Systematic Reviews of Intervention [11]. Because this meta-analysis reviewed only previously published RCTs that did not involve any processing of individual patient data, institutional review board approval was unnecessary.

Systematic search for trials

We searched only for RCTs in the National Library of Medicine PubMed, Web of Science, and Cochrane Library databases. The following Medical Subject Headings were used in various combinations for the search: hallux valgus, chevron osteotomy, scarf osteotomy, hallux valgus angle, and intermetatarsal angle. RCTs included in our review were published between May 1, 2007, and February 27, 2018. We further reviewed reference lists of studies and bibliographies of relevant systematic reviews to search for additional trials.

Inclusion criteria

Two authors independently extracted data by applying the same standard criteria. Full articles were examined independently to determine whether they met the inclusion criteria. Discrepancies were resolved through discussion until a consensus was reached. The inclusion criteria were [1] RCT written in English; [2] comparison of chevron and scarf osteotomies in adult patients with hallux valgus; and [3] assessment of osteotomy outcomes using HVA, IMA, AOFAS scores, or complication rates as the main outcome variables. Exclusion criteria were [1] being a non-RCT, a cadaveric or animal study, or an RCT without a control group, and [2] incomplete outcome data.

Risk of bias assessment

Two authors independently evaluated each RCT based on the Cochrane risk-of-bias tool [11]. Seven categories of bias were evaluated: random selection, allocation concealment, blinding of participants and outcome assessment, outcome data, reporting bias, and other study biases. Three risk levels (low, unclear, and high) were summarized in each category. Discrepancies in scoring were resolved by discussion among the 3 authors.

Data extraction

Two authors independently reviewed and extracted the following information from each study: name of the first author, country of origin, publication year, study type, type of surgery, number of patients, number of feet, follow-up time, and outcome measures. All data were extracted from tables or texts in the original RCTs.

Data analysis

Meta-analysis was performed on Review Manager (version 5.3; The Cochrane Collaboration, The Nordic Cochrane Centre, Copenhagen, Netherlands). Risk ratios (RRs) and weighted mean difference [WMD] were used to compare continuous and dichotomous variables, respectively. P < .05 was set as the level of significance. All results are reported with 95% CIs. Higgins I2 statistic was used to assess the heterogeneity of individual RCTs. A fixed-effects model was used if no obvious heterogeneity existed (i.e., I2 < 50%); otherwise, a random-effects model was used (if I2 > 50% and P < .10).

Results

Literature search

The literature selection process is illustrated in Fig. 1. The initial literature search yielded 80 potentially eligible studies. In total, 38 studies were excluded due to duplication. The remaining 42 studies were screened for titles and abstracts, and 7 studies were excluded for the following reasons: not an RCT or a cadaveric and animal study. A total of 35 studies that had potential for inclusion were reviewed by their full texts. In total, 29 articles were excluded subsequently due to the following reasons: missing outcomes, no control group, or irrelevant outcomes. Finally, 6 RCTs [8, 9, 12-15] were included for further analysis.

Fig. 1 PRISMA flow chart of the literature search and selection process

Main characteristics of included studies

The 6 included RCTs comprised 507 feet: 261 in the chevron osteotomy group and 246 in the scarf osteotomy group. The patient characteristics and results of these RCTs are listed in Table 1. All RCTs were published between 2007 and 2018. Of the 6 included RCTs, 3 RCTs were conducted in the Netherlands [8, 12, 14] and one each in Egypt, [15] the United Kingdom, [9] and Australia [13]. Additional Akin osteotomies were performed in 4 cases in both groups in the study of Elshazly et al. [15]. Lee et al. [13] compared percutaneous modified chevron/akin osteotomies and open scarf/akin osteotomies of all groups for the correction of hallux valgus. Akin osteotomies were not reported in the other 4 RCTs [8, 9, 12, 14].

Table 1 Characteristics of included trials

Study	Type of Study	Type of Surgery	No. of feet	Age (year)	Follow-up time (month)	Outcome Measures	
Deenik et al., 2007, (Netherlands) [8]	RCT	Chevron

Scarf

	47

49

	43 (18–65)

45 (18–65)

	27 (23–31)	HVA, IMA, AOFAS, Complications	
Deenik et al., 2008, (Netherlands)[12]	RCT	Chevron

Scarf

	70

66

	NA	31.2 (23–39)	HVA, IMA, AOFAS, Complications	
Mahadevan et al., 2015, (United Kindom) [9]	RCT	Chevron

Scarf

	60

49

	50.7 ± 14.1	12	HVA, IMA, Complications	
Jeuken et al., 2016, (Netherlands)[14]	RCT	Chevron

Scarf

	37

36

	56.3 ± 13.9

58.2 ± 14.1

	27	HVA, IMA, AOFAS	
Lee et al., 2017 (Australia) [13]	RCT	Percutaneous Chevron / Akin

Scarf / Akin

	25

25

	52.6 (20–76)

53.4 (25–75)

	6	HVA, IMA, AOFAS, Complications	
Elshazly et al., 2018 (Egypt) [15]	RCT	Long Chevron / Akin

Scarf / Akin

	22

21

	36.0 ± 12.16	25.9 ± 1.84	HVA, IMA, Complications	
No.: number; HVA: hallux valgus angle; IMA: intermetatarsal angle; AOFAS: American Orthopaedic Foot & Ankle Society; RCT: randomized controlled trial; NA: not availabl

Quality of the studies

Risks of all types of bias are plotted in Figs. 2 and 3. All RCTs claimed randomization, but 4 RCTs [8, 9, 13, 14] did not report the random sequence generation method. Moreover, 2 RCTs [12, 15] reported details of random sequence generation, 2 RCTs [8, 9] reported allocation concealment and 2 studies [9, 13] reported blinding of participants and personnel. Finally, only 1 study [13] indicated blinding of outcome assessors and thus indicated the use of double-blinding.

Fig. 2 Graph of risk of bias

Fig. 3 Summary of risk of bias

Meta-analysis results

Postoperative HVAs were compared between the chevron and scarf osteotomy groups (Fig. 4) in all 6 included RCTs [8, 9, 12, 15]. A fixed-effects model was used because heterogeneity among the included trials was mild (I2 = 38%, P = .16). Meta-analysis revealed that the chevron osteotomy group had significantly smaller postoperative HVAs than did the scarf osteotomy group (WMD = − 1.94, 95% CI = − 2.65 to − 1.29, P < .00001). In the fixed effect model, because heterogeneity is not assumed, the weights are primarily determined by sample size and precision. Consequently, studies with higher precision carry more weight in the overall analysis. In the study of Lee et al. [13], the standard deviations in both groups are the smallest among all the studies, resulting in this study receiving the greatest weight.

Fig. 4 Forest plot analysis of postoperative HVAs for the chevron and scarf osteotomy groups

Next, postoperative IMAs were compared between the chevron and scarf osteotomy groups in all 6 RCTs [8, 9, 12, 15] (Fig. 5). The heterogeneity of the results was high (I2 = 72%, P = .004); hence, we used the random-effects model. However, the differences in postoperative IMAs existed between the chevron and scarf osteotomy groups were nonsignificant (τ2 = 0.44, χ2 = 17.59, df = 5, WMD = − 0.44, 95% CI = − 1.10 to 0.22, P = .19).

Fig. 5 Forest plot analysis of postoperative IMAs for the chevron and scarf osteotomy groups

The postoperative AOFAS scores were compared between the chevron osteotomy and scarf osteotomy groups, with 3 RCTs [8, 12, 13] included (Fig. 6). Because the heterogeneity of the results was high (I2 = 91%, P < .0001), we employed the random-effects model. Meta-analysis revealed nonsignificant differences in postoperative AOFAS scores between the chevron and scarf osteotomy groups (τ2 = 25.58, χ2 = 21.57, df = 2, WMD = 0.75, 95% CI = − 5.32 to 6.82, P = .81). The postoperative AOFAS scores were also compared between the chevron osteotomy and scarf osteotomy groups in the study Jeuken et al. [14]. However, the standard deviations were not given in the study, the RCT is excluded in the forest plot (Fig. 6).

Fig. 6 Forest plot analyses of postoperative AOFAS scores for the chevron and scarf osteotomy groups

Postoperative complications between the chevron and scarf osteotomy groups were analyzed, with 5 RCTs [8, 9, 12, 13, 15] included (Fig. 7). The heterogeneity between studies was homogenous (I2 = 0%, P = .48); thus, the fixed-effects model was applied for the calculation of RRs and 95% CIs. Meta-analysis revealed that no significant differences in postoperative complication rates existed between chevron osteotomy and scarf osteotomy groups (RR = 1.22, 95% CI = 0.65–2.27, P = .53). Postoperative complications between the chevron and scarf osteotomy groups were not compared in the study of Jeuken et al. [14].

Fig. 7 Forest plot analysis of postoperative complication rates for the chevron and scarf osteotomy groups

Discussion

This systematic review and meta-analysis compared the effectiveness of chevron and scarf osteotomies based on the outcomes measured as HVA, IMA, AOFAS score, and complication rate. In total, 6 RCTs including 507 feet were included in the meta-analysis, and chevron osteotomy was found to afford superior postoperative HVA correction, but the differences in postoperative IMA, AOFAS scores, and complication rates remained nonsignificant.

To our knowledge, this is the first systematic review and meta-analysis comparing chevron and scarf osteotomies for hallux valgus based on RCTs alone. Two previously published meta-analyses revealed the following: Smith et al. [5] reviewed 31 studies comprising 1351 patients and found that scarf osteotomy provided better IMA correction when used for hallux valgus than did chevron osteotomy. However, the authors noted that the studies included were of low quality and comprised RCTs and prospective and retrospective case-control and case-series studies. Ma et al. [16] reviewed 3 RCTs and 1 non-RCT, and their meta-analysis revealed nonsignificant differences between chevron and scarf osteotomies in the treatment of hallux valgus by the outcome measurements of HVA, IMA, AOFAS score, and complication rate. In our study, we included more recent RCTs published after 2017.

A 10-year follow-up study reported that chevron osteotomy, first described in 1976, was an effective operative strategy for hallux valgus correction [17]. A large cohort study conducted with 336 patients by van Groningen et al. [18] also supported that chevron osteotomy for hallux valgus offered acceptable scores in patient-reported outcome measures and favorable radiological improvement of HVA and IMA. Scarf osteotomy can provide strong fixation with early functional recovery times [19]. However, scarf osteotomy can be technically complicated because it involves 3 different cuts, each of which should be perfectly oriented to form the appropriate correction [19] Complications include delayed union, rotational malunion, and osteomyelitis [20]. The preference of a surgeon for choosing between chevron or scarf osteotomy is mainly influenced by training and ability. Surgeons who prefer chevron osteotomy believe that it requires fewer bone cuts, shorter operation times, and simplified operation compared with scarf osteotomy. One study reported that chevron osteotomy is also more cost-effective than scarf osteotomy [21].

In terms of the consistency of lateral release or no release of the first metatarsophalangeal (MTP) joints across the included trials, all studies mentioned lateral release during chevron osteotomy; five RCTs [8, 9, 12–14] noted lateral release during scarf osteotomy; one RCT [15] stated that no release during scarf osteotomy. Extensor digitorum brevis release was not mentioned in all included trials.

Our study had several limitations. First, only a few RCTs were included in the meta-analysis. More RCTs with larger sample sizes should be included. AOFAS scores were used as a measurement of postoperative outcomes in only 3 RCTs. Second, the RCTs included all had small sample sizes. In total, 84 patients with 109 feet were included in the largest RCT [9]; and only 43 patients with 43 feet were included in the smallest RCT [15]. Small sample sizes may affect significance. Future studies should be designed with more patients included to further investigate postoperative outcomes between chevron and scarf osteotomies.

Conclusion

Our systematic review and meta-analysis suggested that chevron osteotomy was superior to scarf osteotomy in terms of postoperative HVA correction, but not postoperative IMA, AOFAS score, and complication rate.

Acknowledgements

Not applicable.

Author contributions

Conceptualization, Yu-Ning Peng, Yu-Hsiang Peng, Carl PC Chen; Formal analysis, Yu-Ning Peng, Yu-Hsiang Peng; Methodology, all authors; Investigation, Yu-Ning Peng, Yu-Hsiang Peng, Carl PC Chen; Writing – Original Draft Preparation, Yu-Ning Peng, Yu-Hsiang Peng, Carl PC Chen; Writing – Review & Editing, Yu-Ning Peng, Yu-Hsiang Peng; Supervision, Carl PC Chen; Project Administration, Carl PC Chen.

Funding

This research received no external funding.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Ethical review and approval were waived for this study because this is a systematic review and meta-analysis, and the included RCTs had all received the IRB.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Yu-Ning Peng and Yu-Hsiang Peng contributed equally to this work.
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