Mastering The Akin Osteotomy

Neal Blitz, DPM, FACFAS

   Surgeons can easily fixate oblique osteotomies with a screw. Transverse osteotomies lend themselves to staple fixation although surgeons trained on monofilament wire find that technique satisfactory.6 Percutaneous K-wire fixation is much less common since rigid internal fixation is commonplace. Surgeons have also used sutures. Roy and Tan noted that suture fixation has the advantages of a lower implant signature and a lower cost.7 The authors conceded that the thin cortex of the phalanx can be prone to failure during suture application.

   Surgeons often do not prefer plate fixation of primary hallux osteotomies as plates are bulkier than screw fixation and can cause soft tissue irritation. Low profile plates may be a more practical plating solution.

Common Mistakes When Considering An Akin

The Akin is a powerful procedure that can give the illusion of correcting a bunion by simply repositioning the toe. Accordingly, it is not uncommon for surgeons to choose to perform bunion procedures that may not fully correct the intermetatarsal angle and may compensate for the shortcoming with an Akin procedure.

   An example of this is when surgeons perform a distal first metatarsal osteotomy in conjunction with an Akin procedure for a bunion with a large intermetatarsal angle. While this may work in clinical practice, it is something to strongly consider avoiding as this combination may be more prone to cause bunion recurrence down the road.

Pertinent Insights On Using The Akin In Revision Bunion Surgery

I have found the Akin osteotomy to be particularly useful in revision bunion surgery, whether or not the patient previously had an Akin. Of course, an overcorrected Akin is the exception to this. Patients presenting with recurrent bunions complain of a toe that is still deviated or complain of the continued presence of a bunion. The possible reasons for recurrence are as follows: continued increased intermetatarsal angle, persistent medial eminence, unaddressed proximal articular set angle (PASA) deviation, incomplete adductor release and/or hallux interphalangeus. In my experience with recurrent bunions, there is a multifactorial cause for their recurrence.

   The most common cause of recurrent bunions that I treat involves a distal metatarsal osteotomy or Lapidus malunion. Patients undergoing both of these procedures often have had a previous McBride and there tends to be some scar tissue within the first MPJ, which can limit the ability to gain a completely congruent joint. Once I correct the intermetatarsal angle (with another procedure) and a revision McBride procedure, the Akin procedure can provide additional correction to achieve a more rectus toe.

How To Repair An Overcorrected Akin

As with any osteotomy, the Akin osteotomy can also be subject to overcorrection. An overcorrected Akin does not produce a hallux varus per se. Rather, it produces a toe with an adducted tip. The hallux toenail will generally dictate an overcorrection and one often identifies it intraoperatively, although it can become more pronounced postoperatively.

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