Can Alternative Fixation Foster Better Outcomes With The Akin Osteotomy?

      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.

What Are The Advantages Of The Technique?

      Increasing stability requires a minimum pulling force of monofilament wire, which results in maintaining the cortical stability of drill holes and the lateral hinge. However, the smooth translocation of wire, without locking between the osteotomy site or the drill hole, results in decreased stress forces on osteotomy and minimizes surgical operating time.       More importantly, decreased surgical duration reduces the amount of anesthesia exposure to the patient in addition to decreasing tourniquet time. Moreover, the use of a suture retriever by a surgeon has the advantage of a greater margin of error in performing the cortical drill hole in that the cortical drill hole does not have to be parallel or congruent.       The use of a suture retriever is not limited to the above procedure. Utilizing a suture retriever, one could make other types of osteotomy fixations more efficiently. For example, surgeons could use a suture retriever for an Akin osteotomy to facilitate horizontal interosseous wire loop fixation through four cortical holes, which does not require an intact cortical hinge.7       Surgeons may utilize other types of fixation for base wedge osteotomies at the first ray. However, these fixations are time consuming and require more soft tissue dissection. A suture retriever could facilitate a less intensive dissection with base wedge osteotomies of the first ray, and allow a faster and easier procedure.

In Conclusion

      The focus of this article was to demonstrate the Weinert Modification Akin as a more efficient and practical method of applying monofilament wire fixation. Monofilament wire fixation has been utilized for many years with multiple practical applications.       However, its use requires a learning curve to become proficient and efficient. The suture retriever is a device that reduces that learning curve and allows a broader spectrum and ease of use for monofilament wire.       Dr. Weinert is the Chief of Podiatric Medicine and Surgery at Henry Ford Bi-County Hospital in Detroit, Mich.       Dr. Elkhalil is a resident at Henry Ford Wyandotte Hospital in Wyandotte, Mich.       Dr. Farah is a resident at Henry Ford Wyandotte Hospital in Wyandotte, Mich.       Dr. Burks is a Fellow of the American College of Foot and Ankle Surgeons, and is board certified in foot and ankle surgery. Dr. Burks practices in Little Rock, Ark.       Editor’s note: For related articles, see the August 2006 supplement “Techniques And Experiences In Foot And Ankle Surgery.”       Also visit the archives at www.podiatrytoday.com.
 

References:

1. Akin O. The treatment of hallux valgus: a new operative treatment and its result. Med Sentinel 33: 678, 1925.
2. Schwartz N, Hurley JP. Derotational akin Osteotomy: further modification. J Foot Surg 26: 419,1987.
3. Barouk LS. Osteotomies of the great toe. J Foot Surg 31:388, 1992.
4. Boberg A. Surgical procedure of the hallux, in comprehensive textbook of foot surgery, ed by ED McGlamry, AS Banks, MS Downey, P533, Williams & Wilkins, Baltimore, 1992.
5. Langford JH. ASIF Akin Osteotomy: a new method of fixation. JAPA 71: 390, 1981.
6. Levitsky DR, DiGilio J, Kander R, et. al. Rigid compression screw fixation of the first proximal phalanx osteotomy for hallux abducto valgus. J Foot Surg 21:65, 1982.
7. Schlefman SB. Akin Osteotomy with Horizontal Interosseous Wire-Loop Fixation. J Am Podiatr Med Assoc 89(4):1994-198, 1999.