Can Alternative Fixation Foster Better Outcomes With The Akin Osteotomy?

By Anthony Weinert, DPM, Ali Elkhalil, DPM, and Ahmad Farah, DPM

      Practitioners have described various osteotomies for the proximal hallux. However, the Akin closing wedge osteotomy is currently the most common procedure. Podiatric surgeons commonly employ the transverse plane closing wedge osteotomy for the correction of hallux abductus interphalangous deformity. One may also use this as an additional procedure for the correction of hallux abductovalgus deformity.       Akin noted that one should perform the closing base wedge osteotomy at the proximal one-third of the proximal hallux and orient it in the transverse plane with adduction and in an extraarticular fashion.1       Schwartz, Barouk, Boberg, Langford and Levitsky have implemented many modifications over the years.2-6 However, these implementations were meant to change the fixation options rather than to improve the correction that one obtains.       Accordingly, let us take a closer look at an innovative alternative method of fixation to an Akin osteotomy, namely the Weinert modification. We believe this method results in a more stable fixation with fewer complications and risks.

Step-By-Step Pointers On The Fixation Technique

      One would use a 2- to 3-cm incision to expose the diaphysis of the proximal phalanx dorsal medial. The surgeon may also use an extension of an incision that was used for a first ray procedure. Utilizing a sagittal saw, resect a medial-based wedge with two double osteotomies. The first osteotomy orientation is medial-proximal to lateral-proximal, and perpendicular to the diaphyseal axis of the proximal hallux. The second osteotomy orientation is distal-medial to lateral-proximal. Osteotomy orientation could vary depending on the surgeon’s preference and the severity of the osseous deformity. For any intended orientation, it is important to preserve the lateral cortex.       Utilizing a 1.5-mm diameter burr or drill bit, proceed to drill cortical holes. In order to allow the suture retriever to pass from the cortical drill hole, through the medullary canal and into the osteotomy site, one drill hole should be 1.5-mm. However, the second cortical drill hole should allow the passage of the monofilament stainless steel wire. It is preferable to select the proximal cortical hole for the suture retriever since the proximal hallux base is more stable due to soft tissue insertion. Therefore, this stability allows better threading manipulation and pulling maneuver.       Once the suture retriever exits through the proximal medullary portion of the proximal hallux osteotomy, advance a double-stranded stainless steel monofilament wire through the distal cortical hole. This allows the monofilament wire to exit from the distal medullary end of the proximal hallux osteotomy.       Proceed to utilize the mechanical technique of the suture retriever so a female loop can open and expand, and serve as an anchor to the monofilament wire. Once the suture retriever is locked, establish a secure grip to monofilament wire. With a gentle pull, make a smooth translocation of monofilament wire from the proximal osteotomy site through the medullary canal and into the proximal cortical drill hole.       Close the osteotomy, grasp the two free ends of wire, wrap them around each other and tighten them. Cut the wire end short and feed it into one drill hole. This buries the wire and prevents future irritation to the patient. Once the osteotomy is secure, no further manipulation at the site is needed.       Upon the completion of fixation, a copious amount of irrigation is necessary. Approximate the periosteum and deep fascial layer, coapt them and secure them, utilizing 3-0 vicryl. Then approximate the subcutaneous layer using 4-0 vicryl suture and coapt the skin utilizing 5-0 vicryl in a subcuticular fashion.

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