Is The Miami Phalangeal Osteotomy A Viable Alternative To The Akin Osteotomy?

Michael M. Cohen, DPM, FACFAS

Imagine that you were running late on your way to the hospital to attend to an urgent patient. You have a choice of two routes. One route is longer because it uses two streets, each with a traffic light, and no place to make a U-turn and change direction if the traffic is heavy. The shorter route is a straight shot but has no traffic lights with options for U-turns if necessary.

   Which route would you take?

   Now imagine you are in the operating room and need to finalize your bunionectomy with a phalangeal osteotomy. You have two available options. Option one involves resecting a medially based wedge (Akin osteotomy) with two converging bone cuts, often requiring you to feather the cuts to fit and align the osteotomies while making an effort to keep the lateral hinge intact. All the while, you realize that under- or overcorrection will be difficult, if not impossible, to correct.

   Alternately, you could employ your second option, the oblique proximal phalangeal osteotomy (aka the Miami phalangeal osteotomy) and perform a single through and through osteotomy. There would be no need to feather your bone cuts. You would also have the ability to dial in your correction without the need for additional osteotomies or shortening should you need to fine-tune your correction.

   Which procedure would you do? The pragmatic response appears quite obvious: the second one.

   There are dozens of metatarsal osteotomies described in the literature for the correction of the hallux valgus deformity. Yet since 1925, the Akin medially based closing wedge osteotomy has remained essentially the sole phalangeal osteotomy in the surgeon’s armamentarium for the correction of hallux valgus.1 The osteotomy is designed to correct an aberrant distal articular set angle or excessive hallux interphalangeal angle. In reality, surgeons use the procedure to create the illusion of a rectus toe and medialize soft tissue structures.

   Despite the procedure and its various modifications, the Akin osteotomy is not benign. The disadvantages and reported complications are real. Some of these include: instability with loss of the hinge; shortening of 3 to 5 mm; intraarticular fracture and degenerative joint disease (8 to 9 percent); plantar angulation with malunion (13 to 24 percent); nonunion when bone apposition is less than 50 percent; and difficulties with fixation. Additionally, the procedure often compromises the medial capsule periosteal tissue needed for soft tissue plication.2-4

   Another disadvantage of the Akin procedure is the possibility for under- and overcorrection. It would be difficult if not impossible to correct an over-exuberant wedge resection with little to no ability for intraoperative fine-tuning if needed.

A Closer Look At Key Advantages And Indications For The Miami Phalangeal Osteotomy

At the American College of Foot and Ankle Surgeons national conference in 2002, I introduced the oblique proximal phalangeal osteotomy and subsequently published on the technique in 2003.5 The study described a single through and through osteotomy directed from proximal dorsal to plantar distal.

   The procedure eliminates many of the problems experienced with the Akin osteotomy by offering several advantages. It is technically easy to perform, offers a stable construct that results in minimal to no shortening, does not violate the medial soft tissue structures and preserves them for capsulorrhaphy. The osteotomy produces two flat, broad surfaces of bone, reducing the chances of nonunion. Finally, the technique is highly conducive to rigid fixation and allows immediate weightbearing and range of motion. Moreover, the osteotomy is precisely adjustable by allowing the surgeon to dial in the correction without the need to feather or perform additional bone cuts.

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