Section: CME Category: Surgery

The Scarf - Why So Many Cuts?

Lowell Weil, Jr, DPM, MBA

Lowell Weil, Jr, DPM, MBA discusses a historic hallux valgus reconstruction procedure and the helpful surgical instruments and guides that help with reproducibility and increased successful outcomes. Dr Weil also discusses the steps to perform the post operative course for patients.

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Goals and Objectives
  1. Describe the history and basics of the scarf bunionectomy
  2. Review the step by step approach to performing a scarf bunoinectomy
  3. Explain the post operative course for patients undergoing a scarf bunionectomy
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    Release Date: 11/20/2018 Expiration Date: 12/31/2020

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    Lowell Weil, Jr Dr. Lowell Weil, Jr., DPM, MBA, FACFAS has nothing to disclose

  • Lecture Transcript
  • TAPE STARTS – [00:00]


    Speaker: Our next talk is going to be on one of the more common things that you are ever going to be treating, that's bunions and this is on the Scarf bunionectomy and there is no one better that I could ever think of to deliver this talk than Lowell Weil, Jr. and Lowell, I did not know that Chicago Based Weil Foot and Ankle Clinic was world famous. I did not know that but I consider myself enlightened. Lowell is one of the coach here to this meeting and he has got a very important podiatry business group that you will be hearing about later, I am sure. And so let's welcome Dr. Lowell Weil to teach us about Scarf bunionectomy.

    [Applause]

    Dr. Lowell Weil: Thanks Bob. How many of you in the room do distal metatarsal osteotomies for bunion? Can you raise it little higher? How many of you do primarily Lapidus? And how many of you do mid shaft osteotomy Scarf or similar? Okay, two of you. Okay. I gave a presentation, this presentation is relatively similar a couple of years ago at the American College of Foot and Ankle Surgeon's Annual Meeting. I give lectures on the Scarf quite a bit but this particular angle of lecture on the Scarf I thought was really interesting in terms of the assignment that I was given for ACFAS and it was actually termed the "Scarf, why so many cuts." And I thought it was interesting and it made me think and kind of created a different presentation than a typical presentation on the Scarf, which is just kind of why and how.

    [02:03]

    So the evolution of this particular lecture as a result of me having to rethink it and I think it's a fun for me, a really fun lecture because so many people who do the distal osteotomies, who do the proximal Lapidus, they don't necessarily appreciate why the Scarf is such an important part of what we do. In telling you that I do the Scarf, one of the things that I find important about the Scarf is that it has such great versatility that I am going to talk about in a second and what we were taught through school and residency and further CME training is that you should have different bunion procedures based on patient selection, deformity, all these different things. And when I lectured to younger people, residents and so forth, I always want them to understand that you can't do 10 things well. If you try to do 10 things, you really won't be good at any of them and you should narrow what you do so that you can consistently do the same thing and become really good at that same thing. And my goal today is not to suggest that people should switch to do the Scarf but is to somewhat narrow your mindset to try to pick procedures that you can correct the most amount of problems consistently because that's how you get the most consistent outcomes. So when I talk about doing the Scarf and people say how frequently you do the Scarf. In the area of bunion deformity that needs surgical correction, I perform the Scarf probably 98% of the time. And you might say, wow, that's way too much, but I think of the Scarf as a concept not a procedure.

    [04:01]

    So when I do the Scarf, it is taking a concept and applying it to the particular deformity and needs of the patient, so each Scarf is not the same. I am doing exactly the same thing, although the execution is relatively similar. So that's kind of conceptually what I want you to be thinking about because even if you are not going to end up doing the Scarf at the end of this lecture, I think there are some really important take-home messages that you can apply to the procedures that you do and it's important to think about those things. The term Scarf is a term that describes an interlocking joint. It's not a surgical procedure. It's legitimately a building term and let's kind of going to where that came from. The Scarf cut was known in prehistoric time, not really prehistoric but in ancient times as Jupiter's cut by carpenters. And we see the evidence of the Jupiter's cut in many ancient buildings. If we look here in the fifth century BC in Greece, this particular temple was built utilizing the Scarf. It's essentially Scarf interlocking joint to create stability when building. So we are talking about the evolution of building and here is a time when the Greeks are now creating these wonderful temples of size and scale that have never been created before. And they are utilizing this interlocking joint to span greater distances to create a more airy type of feel. In French market around 1600, it was built and you can see here I have got a red circle on the [indecipherable] [00:05:57]. This a French text that is actually calling something to Jupiter cut.

    [06:03]

    And on the inside of this market, you can see the Scarf interlocking joint to help create stability for wider spans. In ship buildings, it's really common to use the Scarf interlocking joint to create again the stability through the building. So when we apply this engineering building concept, what do we want to do when we are doing surgery in the foot and ankle? We want to create stability. We have got to take bones that we are moving, breaking and realigning and creating the stability that put them into shoes and then have them walk as quickly as we possibly can. So that's why the idea of Scarf is something that we applied to the correction of hallux valgus and bunions more than 30 years ago. So why the Scarf besides what I just talked about? The reproducibility and stability of the osteotomy, the versatility of correction, the ability for immediate guarded weightbearing, the ability to put people back in the gym shoes one week after surgery, the ability to perform the procedure bilaterally or why is that important. 70% of people who have bunions have them bilaterally. Many of those people want to have their surgery done on both feet at the same time. There is virtually minimal procedures that will allow you to do bilateral simultaneous correction and why is that important, I will talk about it more later but it's patient's ability to do one surgery, one recovery and get back to life as quickly as possible, which also decreases cost on patient's and society and we will talk more about that in a second.

    [08:08]

    The ability for early physical therapy and return to normal life. It is such a critical part of what we do that is under appreciated. We under appreciate the need in foot surgery to start physical therapy and get people going and I will touch about that more in a moment. Long-term predictability, there is virtually no other bunion surgery that has literature to support long-term predictability than the Scarf does. Almost no other procedure has the amount of peer reviewed, published research on its success. And then cosmetic result and I don't mean we do surgery for cosmetic reasons, but we do bunion surgery for cosmetic reasons and when I say that it's not the people are coming in like they might for to a plastic surgeon. But most patients who have bunions could find shoes that don't hurt. They might be this big and this wide and this deep but they can find them. They choose not to wear those shoes. They choose find shoes that they want to wear and if we are critical about it and honest about it, most people get bunion surgery are women and the women want to wear a certain style of shoes. It doesn't mean they are all looking for three-inch heel. But they aren't interested in wearing the shoes that make their feet maybe less painful. So we have to be cognizant of the fact that what we are doing has cosmetic implications to it. So when I talk about the scar from the reproducibility and stability, when I do the osteotomy, I use an osteotomy guide 100% of the time. My dad has done over 20,000 Scarf in his career and he does a 100% of them with osteotomy guide.

    [10:05]

    I have now done over 10,000 and I do 100% of them with an osteotomy guide. It creates reproducibility and stability with the bone cuts, which allows you to move faster, get him back and choose better and it's just a better way of doing it and one doesn't have to feel like they are too proud to use tools in surgery to make them a better surgeon. So the orientation of the cut itself is the distal cut is into the head of the metatarsal. Many people will confuse the scar from the Z and they are two different things. The Z as it was described is done in diaphyseal bone. The distal aspect of the Scarf is in the metaphyseal bone. It's in the head of the bone and there is a really distinct difference in that. First of all, there is more stability. If you are in the metaphyseal, there is more bone to move for correction and there is the elimination of that thing called troughing or channeling that one might get with the Z. The distal aspect of the osteotomy is in the dorsal one-third of the metatarsal and then proximally it's in the plantar one-third of the metatarsal, so it is not a 50-50 cut into the metatarsal. It's actually angled. The distal cut is more close to a 90-degree angle because that stays in the metaphyseal bone and it's a good block of bone so that you avoid the opportunity for troughing effect. And then so this is what the osteotomy looks like and what I want you to appreciate is the distal one-third and the proximal plantar one-third of this cut. It's a very long osteotomy. I am in the proximal flare of the plantar metatarsal because that is also in the metaphyseal bone.

    [12:04]

    So it's from metaphysis to metaphysis to create that stability and by making a long osteotomy like this, you can move more of the bone, which positively impacts CORA is something that you find important. The ability to translate a huge amount of the bone is allowed with the Scarf. So this is, I would say, an average amount of correction that I might perform. This is not at the highest end. So this is like a 50% correction in terms of movement of the bone and we will put it much further if needed and I will show you some examples of that. But you can see how much bone is moved, which allows for a couple of things. One is you are moving more of the metatarsal, so there is going to be long-term structural integrity. It's also easier for fixation with the long osteotomy in doing it this way. When I fixate, this is my fixation technique. I put one screw into the head of the metatarsal like you might with a distal osteotomy of an Austin or Chevron and that is just into the metaphyseal bone and then the second proximal point of fixation is bicortical. So you can see the angle of these two pieces of fixation. And this is a postoperative example of a large correction. You can see a good alignment and if you were to measure CORA, you would see it's a perfectly corrected CORA. You can see here I have done an Akin and I am not here to talk about an Akin specifically today, but I performed an Akin in about 80% of the correction I do. And I don’t believe in the term cheater Akin. There is deformity within a phalanx that can't be corrected no matter what you do in a metatarsal or a fusion proximally, so it's important to balance the position of the toe with an Akin.

    [14:08]

    You can see here just another versatility in terms of moving the bone. There is some met adductus here and we still get an excellent alignment postoperatively. Here is an extremely large deformity. I think few people would say they could take on with an osteotomy and not either a proximal fusion at the first TMT or a fusion of the first metatarsal phalangeal joint. So this is a patient, large correction. The procedure was done bilaterally, concomitantly. So they had both feet done at the same time and this is -- you can see a really nice outcome. Again, just another one where we are getting nice alignment of the first metatarsal phalangeal joint. Even if it's not a big deformity, my desire to do the Scarf again over and over again. I get really good at this and as I get good at this, there is that reproducibility and even though this could be handled, let's say with Chevron or Austin, the opportunity for me to put two screws and do it knowing that I have got the Scarf interlocking joint allows me to get that moving faster and I feel much better about getting two screws on an osteotomy than maybe just one. And then in the case that you have to do some shortening here, I would say that the first metatarsal is a bit long here. The angulation of the osteotomy is such that actually just as you are moving it laterally, it creates some shortening and the way I do that is when I put my osteotomy guide in, I am just angulating it more proximally so that we are just kind of moving the bone down the hill and you can see a nice realignment of that first metatarsal to second metatarsal parabola. In the last five or six years, the idea of frontal plane deformity as a component to bunions has become very popular.

    [16:08]

    Some don't believe it, some do. And I listen a lot to people. I don't sit here and say what I do is always the best. I love to listen to other people who have experience and take their experience and try to apply it into what I do. So there is a guy, I don't know if you guys are familiar with. His name is Paul Dayton. Paul Dayton is in Iowa and Paul Dayton, I think, has been really the most important person to bring forward the idea of frontal plane deformity with bunion correction. And I have listened to Paul on multiple occasions. I kind of thought it was bit of BS when he was talking about with frontal plane but then one day he and I were lecturing back to back and I heard his lecture a couple of times but at this particular moment, I don't know was it due to the coffee I drank that morning but I opened my mind to what he was having to say and what he was showing the way he was using a Lapidus to correct frontal plane problems. And I thought he made a lot of sense in terms of that frontal plane problem. And then I was in cadaver lab with him about six months later and we started playing around with cadavers that had bunions and looking at the idea of frontal plane deformity and looking at how the peroneus longus actually worsened, frontal plane deformity did not actually improve it. And so just kind of doing a lot of the stuff, I started to realize that in my belief that there is a component of frontal plane deformity that exists in the development of bunions. But I am not willing to do a Lapidus in those cases because I am very happy with my results with my Scarf. But I did appreciate that maybe the Scarf was not fully addressing this problem. So I came up with the idea of correcting the frontal plane with a Scarf.

    [18:02]

    So I developed this guy and I will show you how that is but each of these slots is a different degree of angulation. So this is a neutral position of the guide where I will make one cut like this and then you can see I have slaughtered it into the next position, which is a 15-degeee angular cut and then I will make a second cut like that and then this is what it looks like if you look at -- I put two saw blades in there. You can see the converging nature of those saw blades and then I am going to remove this wedge of bone. You can see the cuts are finished and I am removing the wedge of bone medially to then essentially positively correct in effect frontal plane deformity. So I have corrected the frontal plane deformity and now I have also slit it over to correct intermetatarsal deformity. So I have now corrected this multiple plane deformity in one osteotomy. And this is an example of somebody before I am done with the case. After I have just done the osteotomies, you can see the amazing correction. I think you can see some frontal plane correction in a toe after I have done this frontal plane Scarf procedure. This is a patient with met adductus huge deformity. This is a tough, tough case to do. And utilizing this frontal plane correction, which I termed the Scarf plasty to get the correction all into one. So those are my concepts regarding the actual procedure itself. Let's talk about what I think is never discussed often enough, which is our postoperative course. For me postoperatively, patients are in immediate guarded weightbearing whether they are unilaterally corrected or bilaterally corrected without the use of crutches, without the use of walker.

    [20:02]

    The patients go home in a surgical shoe and a bandage and I tell them you are able to walk around your house to go from the bed to the couch to the bathroom but that's the extent of your activity for the first week after surgery. Mostly, you are just keeping your feet elevated and talking it easy. This is what patients looked like one week postoperatively. So I take their bandage. So I don't see them until about 7 to 10 days after surgery. So this is a patient who I saw one week after surgery. We have taken her bandages off and you can see what her feet looked like immediately after the bandage was taken off. Great correction. I used subcuticular 5-0 Vicryl so there is no external stitches. I used Steri-Strips and at this point you can see she has minimal swelling. She is going to be able to start getting her feet wet with a shower. She is going to go back in the gym shoes. She is going to start physical therapy. I am going to brace her foot with this all the way to the left. This is a brace that I used that they sleep in to keep swelling down and then there are straps that are attached to help with physical therapy. It's an elastic brace that helps with physical therapy. You can see in the middle picture, I have got a physical therapist starting at one week, increasing mobility to the joint and they are going to start active flexion. During the day, they are going to wear a compression sock. You can see that on the right picture. That keeps swelling down, so they are going to wear compression sock into a gym shoe and the gym shoe that they are going back into is the same gym shoe that they wore preoperatively. It's not a new bigger gym shoe. It's the same gym shoe that they have been wearing. And this is what it looks like, similar patient not the same patient but back in the gym shoes. This is one week postoperatively. You can see the compression socks on and the gym shoes.

    [22:04]

    This patient, the one that I just showed you, this is what her feet looked like six weeks post operatively and she took a picture the day before she came in. She was back into a heel and at a dance class. She is the lady right there. She was in a dance class with a bit of heel on six weeks after surgery. This is the flexion that she exhibited six weeks after surgery. One of the most underappreciated things is the need for plantar flexion strength and range of motion of the first toe after first ray surgery. There is a lot of literature that would support the need of plantar flexion of the hallux to properly unload the lesser metatarsal. If you don't have good plantar flexion of the first toe, weight bearing goes immediately to the second metatarsal. So you will increase the rate of second metatarsalgia, stress fracture whatever it is. Too many times we think we need to get dorsiflexion postoperatively in the first MPJ. Dorsiflexion rarely is a problem for me. It's plantar flexion that’s a problem. So as you are thinking about your cases, no matter what you take away from this, one of the things I want you to think about is getting people in physical therapy and getting them working on plantar flexion. Lots of us, podiatrist, foot and ankle orthopedist don't do physical therapy after forefoot surgery. Why? An orthopedic surgeon would never do a total knee, total hip, total shoulder or any other of those joint surgery and not send them to physical therapy. Yet, we have got more bones, more muscles that are small. The small muscles in the foot have a hard time getting back to normal activity after surgery and we are not going to shove them into the shoe and tell them to walk all day.

    [24:04]

    And we are going to say you don't need physical therapy. Why? That's crazy. Why wait until six, eight weeks after surgery when somebody has developed stiffness, pain, problems and then tell the therapist, undo that. That's too late. Get them going as early as possible. And I really, really emphasize these. I do physical therapy on 100% of my foot and ankle surgery with the exception of something maybe like a neuroma or hammertoe. Everything else gets physical therapy. At six weeks, I will allow patients to begin weightbearing exercise. I allow them to do nonweightbearing exercise as quickly as a week or two after surgery. They can do stationary bike, rowing machine, weightlifting as long as they are sitting and even some yoga activities. But at six weeks postoperatively, they can get back on a treadmill, back on elliptical or walking outside and then move forward from there based on their comfort. I want to talk a little bit about bilateral concurrent surgery as you can see in this patient. It is something that I do regularly and a lot of people will say to me, where they are going to put weight on their foot? How they are going to do that? Isn't there a higher complication rate? And then people will say to me, don't you get paid less? The answer to that last one, yeah. I do get paid less. If I do one foot and then six weeks later or 10 weeks later or three months later, I do the second foot, I do get paid more. But are we doing this to get paid more or we doing this to take care of our patients in the best way we possibly can? And so I am going to make a very strong argument that doing surgery if you can do it both feet at the same time isn't the best interest of the patient. And if you are taking care of your patient and their best interest, it will actually come back and pay back later because you will end up getting more patients who appreciate that kind of care.

    [26:00]

    So I have been doing bilateral surgery my entire career. And nine years ago, we published a series of 252 consecutive bunions. And this was published in the Foot & Ankle Specialists in 2009. And we looked at 252 consecutive bunions, some of which were just unilateral bunions because it was just unilateral deformity and some of these patients were bilateral because they have bilateral deformity. And we did a lot of statistical analysis but there is couple of quick and dirty things that I want to talk about. Return to work. There was no statistical difference between these two. But if you look at the difference, the bilateral group returned to work 17 days after surgery, the unilateral group 20 days. No statistical difference but the bilateral group went to work faster. Return to activities of daily life, no statistical difference but the bilateral group went back to daily life at 15 days and unilateral group at 19 days. Basically, the point I want to drive home with this is that people returned to life at basically the same rate if you do both feet at the same time. We also looked at complication rate. No difference in complication rate and any of the other things. There were no difference but these were two big take-home messages that I want people to think about. So as I look at nine-year follow-up and not just me but we looked at some of the world literature, this is published out of Great Britain. There is a study done by a Ph.D., DPM. 50 patients, 73 procedures, 88% and his group were completely satisfied, 96% were better than before surgery, 86% had no foot restrictions and only 4% had metatarsalgia, which is a very low rate of metatarsalgia for postoperative bunion correction.

    [28:00]

    When I look at our 34, almost 35 years of experience doing the Scarf and then the evolution and modifications that I have talked about today, it is definitely technically demanding surgery. It is not for any inexperienced surgeon and It is not for someone who has never done before, do on and understand it. It is definitely a hard procedure that you need to maybe spend some time on cadaver getting good at or have somebody take you through it. But when you get good at it, there is no turning back. There is nobody I know that once they learned the Scarf, it goes back into something else. That's the one that is people do once they get it. Versatility and indications, no matter the IM, low, high I can do it. Elevatus, I can lower it. Length, I can shorten it. Frontal plane correction, I showed how we can address that now. Age, I can do a 9-year-old or 12-year-old who has open growth plates because it doesn’t impact open growth plates and we published a paper on our juvenile bunion correction with Scarf. Geriatric, I have done it on people in their 80s because bone quality while important, the stability of the osteotomy allows for early weightbearing. I showed the ease of fixation. The greater reproducibility and we have a low complication rate. I can't stress enough the immediate guarded weightbearing. As things change in orthopedics and foot and ankle care earlier and earlier weightbearing becomes important. Can they be performed by bilaterally? I certainly have shown that we can and I still think it's important to get our patients back in their shoes as early as possible and to meet the needs of our patient population who want to be active. And I certainly know and the publication in the world shows that there is long-term predictability when it comes to the Scarf procedure. These are two of my kids. I used to take them to surgery when they were little kids and then here they are all grown up. But it actually kind of follows the evolution of the Scarf for me. This is when I first started doing it and this is more recent. If you have any questions to me, here is my email address. I am really happy for you to email me with questions about this or anything else that you might think that I have some input in. Thank you so much for your attention. Thank you so much for getting up in the morning with me. If you want to ask me any questions, I will be in the back of the room or in the exhibit hall at the end of this. Thank you so much.

    [Applause]


    TAPE ENDS - [30:39]