Hallux abducto valgus (HAV), or bunion deformity, is one of the most common presentations in foot and ankle practice [1, 2]. It is a complicated multiplanar pathology and is characterised by lateral deviation and valgus rotation of the hallux and medial deviation of the first metatarsal [1, 3, 4]. It has been reported that approximately 23% of adults aged between 18 and 65 years have the deformity which increases to 35.7% of the population above 65 years of age . It has a higher female predilection and can often result in a decreased quality of life . HAV is often intractable despite conservative care, ultimately requiring a surgical correction after a failure of conservative care [1, 2]. Over a hundred different surgical solutions have been proposed throughout the literature [6, 7]. Schrier et al  suggested that up to a third of patients operated on for HAV may be dissatisfied with the outcome of their surgery (though the paper they attribute this value to in fact demonstrated good patient outcomes). Nonetheless, patient reported outcomes are now crucial in capturing and evaluating treatment effectiveness.
The aim of the study was to collate post-operative sequalae from patients undergoing a common podiatric surgical procedure, over a large geographical area in the United Kingdom (UK), from five different surgical units in both the public and private sectors. This will highlight the overall satisfaction and complication rate and allow the authors to highlight common themes to aid the consenting process for future patients.
Bunion surgery using the Scarf (+/- Akin) osteotomy
Although no single surgical procedure has shown superiority, the Scarf osteotomy is a popular choice in HAV correction due to its versatility in treating mild, moderate and even severe HAV deformity [9-13]. The ‘Scarf’ term is derived from a carpentry method where two pieces of wood are joined together with the long ends overlapping. This creates stability via a construct which can resist tension and compression forces . The Scarf osteotomy was traditionally be performed via translation (see Figs. 1 and 2) or rotation of the osteotomy, the latter technique utilised for deformities with higher intermetatarsal angle (IMA) . Lopez et al  went further to combine the translation and rotation procedures to form the trotation Scarf osteotomy (see Figs. 3 and 4) to address a higher IMA. The Scarf osteotomy is often undertaken alongside an Akin osteotomy (a phalangeal, closing wedge, osteotomy) to augment the hallux abductus component of the HAV deformity .
Fixation of the Scarf osteotomy may vary from surgeon to surgeon but most commonly, two points of internal fixation are used. In more recent years, cannulated compression screws have been used where AO cortical screws were the norm. Some surgeons choose to use a Kirschner wire and a screw as there chosen two points of fixation, e.g. Lopez et al . The Akin osteotomy is fixed with a single threaded Kirschner wire, staple or screw, as the intact lateral hinge is utilised as the second point of fixation.
PASCOM-10 and the PSQ-10
Foot health outcome measurement tools can be used to improve service delivery by collating and evaluating parameters such as pain, foot function, footwear, and mobility . The Podiatric Audit of Surgery and Clinical Outcome Measurement system (PASCOM) was developed by the College of Podiatry in 1997 with the updated PASCOM-10 introduced to the podiatric surgery profession in the UK in 2010 . It provides a structured framework in which to collate and compare data relating to the characteristics, outcome, and patient experiences of foot surgery . It is a web-based database of podiatric procedures and outcomes which allows for retrospective reviews .
PASCOM-10 has three domains with the first encompassing the surgical treatment, the second relating to post-operative sequelae with the final section housing the patient satisfaction questionnaire (PSQ-10), . The PSQ-10 questionnaire has ten questions (see Appendix 1) with the first asking the patient, in their own words, about their expectations about their surgery. The following nine answers are scored with a maximum of 100 points. Higher scores are an indication of high levels of satisfaction, whilst a minimum score of zero indicates the opposite [18,20]. The PSQ-10 has not undegone formal validation, although it has reliably demonstrated that satisfaction rates have not change over time [18,20].
In Northampton, consent for the recoding and use of PASCOM data is done capturing the following at a pre-surgery health questionnaire, completed by the patient:
Section 12: Surgery Audit – helping us improve our clinical outcomes
To the patient: I understand that the clinician wishes to maintain my data on PASCOM-10, a web-based surgery audit system (with high level password protection). This will be used for anonymised data regarding my treatment outcomes and PASCOM information is held within my patient records. The purpose for using this database is to monitor the results and benefits of my treatment. I understand that my data will be anonymised so that no personal information can be retrieved. I can view my electronic PASCOM-10 record if I wish. When my data is used in reports my name will not appear and I cannot be identified. I also consent to be contacted by the podiatric surgery department to take part in any future research or evaluation. If I decline this does not affect my normal rights to have treatment, nor will I be treated differently in any way.
I give my permission for my information to be used in this way:
……………………………………………… Signature of patient/date
To use PASCOM-10 data for this review, permission was sought and given from the respective NHS Trust clinical governance departments.