The Great Toe Proximal Phalanx Osteotomy: The Final Step of the Bunionectomy

First metatarsophalangeal joint fusion is a proven and effective surgical procedure used to address arthritis and angular deformity of the first metatarsophalangeal joint. Currently, first metatarsophalangeal joint fusion is widely accepted as an index surgical option to create a stable and lasting correction for first metatarsal phalangeal pathology but also to address complex first ray conditions. Recognizing the distinction between an acceptable functional position of the first metatarsophalangeal fusion as opposed to a nonfunctional position has raised questions regarding whether modifications should be made in surgical technique when addressing adjacent joint deformity, particularly significant hallux interphalangeus deformity. We describe a surgical technique to address hallux interphalangeus deformity concomitantly with first metatarsophalangeal fusion.

Description of a large cohort of Akin osteotomies without fixation (286 feet), to depict the mean angular correction, to analyze complication rates and to pull over with rates described in the literature with other techniques.

Retrospective single-center cohort study. Five radiologic measurements analyzed preoperatively and postoperatively until fusion was completed. Evaluation of all peri- and postoperative complication rates. Evaluation of correlation between complications and the presence of diabetes mellitus (DM), smoking and rheumatic disease.

Between 2011 and 2018, 222 patients, 286 feet (147 left, 139 right) met the inclusion criteria. We found an average difference between pre-op and post-op at 3 months of distal articular set angle (DASA) of 7.0 degrees and average interphalangeal joint obliquity angle (IPOA) of 12.0 degrees (p < 0.001).

All cases achieved fusion but in 5.9 % (17/289 cases) of cases, we observed delayed consolidation. The average union time in these cases was 22.1 weeks.

Hyperextension of the distal fragment (mal union in plantar flexion) was observed in 7 cases (2.4 %). None of the 7 cases required correction.

Out of 286 surgeries, 8 (2.7 %) required reoperation, but only one case for a hypocorrection required Akin's re osteotomy. Regarding the inter- and intra-observer correlations, good and excellent reliability are observed for all parameters under consideration.

The absence of internal fixation would appear not to impair osteotomy healing and complication rates compared with techniques with fixation would not appear to be worse. The results are encouraging; nevertheless, we believe that further studies need to be performed in order to confirm the data.

IV retrospective cases series

Various fixation methods have been described for Akin osteotomy, based on using metal implants or transosseous sutures. The aim of this study was to evaluate radiological outcomes and complications of closing wedge Akin osteotomy based on a crossed suture configuration of the joint capsule rather than using implants. The null hypothesis is that a crossed suture has comparable radiological results to other techniques, with no additional complications.

It’s a retrospective study. Patients who underwent Akin osteotomy fixed either with implant or joint capsule suture between 2015 and 2018 were included. Distal articular set angle corrections in pre- and postoperative anteroposterior foot x-rays were calculated by 2 observers. Complications, such as pain, infection, non-union and need of surgery revision, was compared at 1 year follow-up.

89 patients, 30 in the implant group and 59 in the suture group. Mean distal articular set angle corrections were 6.43 (SD 5.54) and 7.36 (SD 5.48) degrees in the implant and suture groups, respectively, without statistically significant differences (p 0.454). Complications were 2 local pain and 1 wound infection cases in the suture and implant groups, respectively (p 0.138, p 0.197).

Akin osteotomy with suture fixation yields comparable radiological results to metal implant fixation methods without increasing the associated complications.

At the time of the first report on the feasibility of corrective osteotomies of the distal phalanx (DP) of the great toe there were no published studies addressing this type of surgery. Along this line, and throughout our clinical experience, this paper tries to show the clinical benefits of hallux DP osteotomies when correcting interphalangeal valgus deformities (IHV) of the great toe, either with open or percutaneous procedure.

This is a review of 18 cases in which a DP osteotomy was performed in 2 different institutions, 8 cases were performed using open technique and 10 cases percutaneously. The correction obtained was analyzed by measuring the distal articular set angle (DASA), obliquity angle (AP1), asymmetry angle (AP2), and global distal phalanx deviation (GDPD) angle before and after the surgery on dorso-plantar weight-bearing radiographs in all cases. Clinical results were also recorded.

Excellent clinical and radiological results were achieved with both techniques in all patients with no complications. The average DP angular deformity correction in terms of AP1, AP2 and GDPD angles were 4.58º ± 5.55º, 8.95º ± 4.77º and 16.53º ± 7.26 respectively. In 10 cases an Akin osteotomy was associated.

In cases with valgus deviation in the hallux DP, a corrective osteotomy of the DP alone or associated to osteotomy of the PP should be considered as a useful tool. The technique is feasible and has no technical difficulties for an orthopedic surgeon with experience on feet surgery.

The Akin osteotomy is widely used to correct the hallux valgus and different fixation techniques have been proposed. Currently most of these procedures coexist, with disagreement on which offers the best results. The aim of this study is to compare the radiological outcome of the original Akin’s technique with one in which a staple was used to stabilize the osteotomy. We also assessed whether other factors unrelated to the osteosynthesis could influence the radiological outcome.

We retrospectively reviewed data from 118 patients who underwent a scarf and Akin osteotomy. In 60 patients the Akin osteotomy was fixed with a staple and in 58 cases no staple was used. Hallux valgus angle (HVA), distal articular set angle (DASA), interphalangeal angle (IPA) and tibial sesamoid position were measured. The presence of lateral cortex disruption of the phalanx was also included in the analysis.

Six variables significantly influenced the radiological results of the Akin osteotomy: preoperative HVA, IPA and tibial sesamoid position, laterality, postoperative cortical disruption and use of a staple.

Ours results suggest that the original Akin’s technique seems to offer equal or better results than a variation in which a staple is added to stabilize the osteotomy.

This is a level III retrospective case-control study.

The authors propose a joint-preserving surgery for rheumatoid forefoot deformities as an alternative to the “classic” surgical approach to the rheumatoid forefoot. The main principle is joint preservation by shortening osteotomies of all the metatarsals performed at the primary location of the rheumatoid forefoot lesions, namely the metatarsophalangeal (MTP) joints and metatarsal heads. A scarf osteotomy is normally performed on the first ray. A Weil osteotomy is performed on the lesser metatarsals. Excellent correction of the hallux valgus deformity in the rheumatoid forefoot can be achieved with a scarf osteotomy in 92% of cases without the need for MTP joint arthrodesis. Similarly, 86% of the lateral metatarsal heads can be preserved using Weil osteotomies.