Mastering The Akin Osteotomy

Neal Blitz, DPM, FACFAS

Although the Akin osteotomy has limited use as an isolated procedure for surgeons, it is still a valuable adjunct procedure. This author explores when to perform an isolated Akin and which procedure to choose, offers a guide to effective fixation and discusses how to address an overcorrected Akin.

The Akin is the best bunion procedure to perform in conjunction with another bunion surgery.1 By itself, the Akin bunionectomy has limited utility in today’s practice. The benefit of performing a concomitant Akin is to gain additional correction of the big toe. However, it is important to understand the limitations of the Akin and how over-reliance on the Akin can lead to a failed bunion surgery.

   An Akin is a hallux osteotomy of the proximal phalanx for the purposes of correcting an abduction deformity of the big toe. Since surgeons first utilized the Akin with bunion deformities, the term “Akin bunionectomy” is commonplace.

   In the early years of bunion surgery, prior to advanced internal fixation and bone cutting techniques, the Akin was a hallmark procedure for correcting bunions by realigning the big toe only, doing nothing for correcting the true cause of a bunion, which is mostly a malaligned first metatarsal bone. The Akin gave the appearance of correcting a bunion by producing a straight big toe.

   As surgeons moved toward bunion correction with metatarsal osteotomies, they would perform the Akin when the metatarsal correction was “not enough” to produce a straight toe. In this situation, the Akin was a “cheat” to the metatarsal bunion procedure, leading to the term “cheater’s Akin.”

   Today, we consider the terminology “Akin bunionectomy” outdated. The correct terminology to use is “Akin procedure/osteotomy” or anatomically as a “hallux osteotomy.”

When Is An Isolated Akin Indicated?

Isolated Akin procedures still occur today but in much less common circumstances. Patients who have an intrinsic deformity of the hallux without a bunion are candidates for an isolated procedure. Pointy toe shoes for women have produced this deformity, which often occurs closer to the interphalangeal joint. Some patients may have “bunions” from a prominent medial eminence of the first metatarsal (with a well aligned metatarsal) along with hallux abduction. These patients may require an Akin procedure along with metatarsal exostectomy, though some would consider this a bunion surgery operation.2

   Frey and colleagues reported on initial and long-term results of 45 Akin procedures.2 The authors noted excellent and good results in 89 percent of patients with the most common technical problem in 22 percent of the patients being plantar angulation at the osteotomy site. They acknowledged that an Akin procedure alone is rarely indicated to correct hallux valgus and in most patients, one must perform a proximal phalangeal osteotomy in combination with some other procedure to correct all components of the hallux valgus deformity.

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