01/05/2017 David E. Samuel, DPM
The MIS Akin Osteotomy (Joe Boylan, DPM)
I appreciate Dr. Boylan's post and non-
disparaging thoughts regarding treating other
doctors' complications. I can't agree more. We
all see them and do them and understand, that
we usually don't see bad surgery but bad
outcomes, that can happen to all of us.
However, if I saw one of my post-op x-rays with
the capital fragment teetering on a 2-4mm area
on the met shaft with what appears to be a
first met angle easily 18 deg, if not more, I
WOULD BE VERY WORRIED. Dr. Boylan is correct.
My residents are not taught this, will never be
taught this, and I hope when they move on to
their own careers, I will never see a post-op
film like this, with very large IM angle, and
this tiny bone to bone apposition of a capital
fragment, with their names on it.
There may be some limited use of a burr for
foot surgery, but not this. This is why we
teach them Lapidus, base wedge, opening wedge,
etc etc to appropriately correct deformity
within a reasonable standard of care for bunion
surgery. I'm sorry but this is no way standard
of care across the country nor should it ever
be, whether pod, ortho, etc. We have come a
long way. Much better training. Better
didactics, etc.
There are many ways to fix met primus varus,
all dealing with the appropriate management of
the first met angle. Whether someone likes a
Scarf or base type corrections or even decides
to under correct, based on age or bone stock is
certainly surgeons preference and within
reasonable standards. But I cannot see these
post-op films as ever being acceptable as
reasonable standard of care. My personal
feelings is that this can takes us all back if
we as a group accept this as okay. What I hear
is, 'can you believe this is what those
podiatrist do ?'
These forums are great for frank intra-
disciplinary discussion. It makes us all think
and I hope makes us all better. I cannot be the
only one out there who, after seeing these
films did not cringe a little. Otherwise,
meaning no disrespect at all, please let me
know if what I am saying is wrong or needs a
different look. Am I missing anything ? Is this
OK? Do others agree with me or should I be
looking at this whole thing differently?
David E. Samuel, DPM, Springfield, PA
01/05/2017 Burton J. Katzen, DPM
The MIS Akin Osteotomy (Joe Boylan, DPM)
Regarding Dr. Boylan's response concerning MIS
surgery, First, let me ask Dr. Boylan if he
actually had training and experience in MIS
surgery? Also, does he believe that none of
his patients have ended up in another
physician's office with less than optimal
results? That being said, assuming your limited
experience was 25 to 35 years ago, comparing
MIS surgery at that time to the present would
be the equivalent to comparing bloodletting to
today's modern medical treatment.
MIS is an accepted standard of care in almost
every other medical specialty. The MIS foot and
ankle procedures, instrumentation, and training
(all of us have originally be trained open) are
completely different than your experience. The
real tragedy of his post is not his uninformed
prejudice against MIS, but the fact that he
is closing young practitioners minds to
learning a skill that not only benefits
patients, is being performed throughout the
world, but they will need to survive going
forward given today's medical climate.
With that in mind, The Academy of Ambulatory
Foot and Ankle Surgery has established a
scholarship to bring young graduates to our LSU
Cadaver seminars with the hope that they will
lean a skill that, unfortunately up to now,
that has not been taught in the mainstream
residencies. I would advise you to consider
attending a seminar, and, I assure you, you
will meet the friendliest group in our
profession, along with some of the most
successful. And by the way, I don't know one
member who has ridden off in the sunset. I know
I haven't after 43 years.
Burton J. Katzen, DPM, Temple Hills, MD
01/03/2017 Alireza Khosroabadi, DPM
The MIS Akin Osteotomy (Brian Lee, DPM)
I am glad there has been some discussion here
in regards to MIS bunion procedure. I refer to
this procedure as transverse percutenous neck
osteotomy. I have been performing this
procedure for the past 4 years. I have
performed close to 400 of these and have had my
share of complications. As with any surgical
procedure once you perform enough of them you
start encountering complications. I have and
still continue modifying this procedure to make
it better at the same time pushing the limits
of it. This procedure is extremely powerful.
I have performed this procedure on patients of
all ages. My youngest patient being 17 and
oldest 82. I have had some minor complications
such as pin track infection and some major such
as delayed union.
What you see in this x-ray is how I perform
this procedure now. The is probably my 6th or
7th modification of this procedure. I have
been able to address IM angles as high as 18 by
translating the capital fragment to almost a
100 % with no complications. In my early
experiment with this procedure, the fixation
was just a 2mm K-wire guided from the lateral
side of the hallux into the medullary canal of
the first metatarsal. The k wire was removed
at 4-5 weeks.
Let me list some advantages of this procedure:
*minimal dissection of soft tissue and
*periosteum which leads to faster healing, less
*pain and less edema
*less pain and edema
*faster WB (most patients are WB the next day)
*faster operating time
*no need for tourniquet
*cosmetic satisfaction
*little to no loss of ROM since the MPJ is not
invaded
all the above leads to greater patient
satisfaction
Here are some pitfalls which I have come across
and addressed in the past 4 years of modifying
this technique:
*dorsal displacement of the capital fragment
(some hand techniques during the displacement
has fixed this issue)
*possibility of axial rotation of the capital
fragment and also delayed union (I have
addressed this by adding a percutaneous
cannulated screw which remains even after the
K-wire is removed 4 weeks post-op)
*pin track infection (I have changed the
direction of the 2mm K-wire insertion and also
keeping it under the skin. This also lets the
patient get their foot wet after 10 days)
*there is a ledge that is normally created
after the displacement at the medial distal
part of the metatarsal neck at the level of the
osteotomy (I use a power rasp to shave this
area utilizing the same 10mm incision used to
put the cannulated screw.
*some restriction of ROM at the level of the
1st MPJ (lack of movement of 4 weeks was one of
the causes and by changing the direction of the
K-wire fixation this issue has been eliminated.
I am also performing a percutaneous lateral
release with a #64 beaver blade on moderate to
severe bunions. My patients stay in the
surgical shoe for 4 weeks.
If the patient has a true HA angle, I also
perform a percutaneous Akin. I also perform the
same transverse osteotomy for tailors bunion .
My choice of fixation is a 2.4 or 3.0
cannulated headless screw. I also have
addressed hypermobility with a separate
percutaneous procedure which I don’t have
enough follow up data to promote but early
results are very promising.
All and all, I have completely switched to
percutaneous procedures and I think there is
defiantly room for growth and I encourage more
surgeons to look in to MIS procedures.
My advice is: if you start doing these
procedures, make sure you select the right
patient. You want to have almost perfect
results at least at the beginning till you gain
some experience and gain more experience.
As I shared before, I had 3 delayed unions and
2 out of 3 of them stuck with me and we went
back and addressed the issue. One of my
patients didn’t want any further treatment and
went to another surgeon. This is when reality
hit me. My patient went to an orthopedic foot
and ankle surgeon and obviously he had nothing
but horrible things to say about my procedure
and how this was doomed to fail and she is
lucky to even her foot etc…. you figure out the
rest.
My patient made a complaint to the California
Podiatry board. The board looked in to it asked
for the medical records and because they also
have not seen anything like this, they called
me for a hearing. By no means, I am upset with
the board I think when they see something out
of the norm and a patient puts a complaint,
they should look in to it. I went for my
hearing and took my records and all the studies
from Europe, etc… I have not heard back but I
am assuming everything went fine.
The reason I am bringing this up is , if you
are going to take on doing something like this.
You need to be ready to be criticized and bad
mouthed by others and yes even by our own
colleagues.
50% of my patients come from out of state and
out of country. Most of them would rather have
their K-wire removal to be done by another
local podiatrist and I actually encourage that.
So far only a handful of my patients have been
able to find surgeons who is comfortable enough
to do this simple removal. I do understand that
most of us don’t want to get in the middle of
some other surgeons work.
What is upsetting is some of our own colleagues
bad-mouthing me and the procedure. Granted
these patients are doing well but I have heard
my patients saying things like “the surgeon
said I would never be able to walk properly,
this is malpractice, you will never be in a
normal shoe again “the list is very long.
When a patient hears this from another surgeon
it really scares them and I usually get a call
or email, which I have to take time to answer.
I am so used to this now that when I have an
out of city patient I already warn them about
what other surgeons say about this procedure.
Fortunately once the patients heal their
concern goes away which is 95% of the time.
I even had two of my patient one from the
Philippines and one from Australia take a
flight back because they couldn’t find any
surgeons to pull their pin.
I am hoping more and more of surgeons at least
familiarize themselves with the procedure. If
you decide not to do it and if it doesn’t look
normal to you that doesn’t mean the procedure
is doomed.
I have just published a paper with my colleague
Dr. Brad Lamm DPM.
https://www.ncbi.nlm.nih.gov/pubmed/27600486
This is the first paper published in the US for
this kind of procedure. This is just our
technique. We are working on another paper for
tips and tricks and modifications. In 2 years,
we will have enough follow-ups to do a
retrospective study with our results.
Alireza Khosroabadi, DPM, Arcadia, CA
12/28/2016 Burton J. Katzen, DPM
The MIS Akin Osteotomy (Dieter J. Fellner, DPM)
I have been performing the MIS metatarsal
osteotomy for correction of hallux valgus
deformity since 1980, and let me first say that
I appreciate the need for extensive scientific
studies for any procedure that we want to
classify as an accepted standard of care.
Also, The Academy of Ambulatory Foot and Ankle
Surgery is extremely fortunate to have members
like Drs. Peacock, Nadal, and Isham who are
very scientifically-oriented in their
evaluations, and we are equally as fortunate to
have someone like Dr. Block who is finally
making the profession aware of the excellent
work performed on a daily basis by our members
here and all over the world.
That being said, my contribution to the
discussion only comes from a vast amount of
anecdotal experience involving thousands of
cases over many years. I do look forward in the
future to working with my esteemed colleagues
in producing a scientific study on the
procedure. The osteotomy is performed with four
separate cuts at differing angles to achieve
correction and lateral displacement of the
first metatarsal head with minimal dorsi or
plantar flexion (if not desired). In my
experience, I do not find it necessary to
perform lesser metatarsal osteotomies with few
exceptions, and I have rarely experienced
transfer lesions.
My own feeling is that by reducing the IM
angle, even if you are getting minimal
shortening, you are producing a more stable 1st
ray (sort of like holding your fist extended as
compared to tight against your body). Even in
some cases if you see a minimal amount of
dorsiflexion, it has not been my experience
that this produces a transfer lesion. After
correction is obtained, I find it necessary to
remove the "bump" in about 50% of the cases.
I will occasionally also perform and Akin MIS
procedure to obtain a more pleasing cosmetic
result. As far as long-term follow-up goes, we
traditionally phone our patients one year after
surgery, and the overwhelming majority are
extremely happy with the results and state they
are glad they had it done. We have been
following this procedure for about 3 years,
and, to date, no one has mentioned a transfer
lesion. I might also add that approximately 10-
15% of our bunion patients had one foot done
traditionally and never went back for the
second. These are the happiest patients.
In conclusion, my only advice to my colleagues
is that I believe these procedures have great
value in correcting a multitude of foot
problems with minimal down time to the patient
and out of the office time to the surgeon, and
I suggest these are skills that each individual
should learn and evaluate for themselves.
Burton J. Katzen, DPM, Temple Hills, MD
12/26/2016 Dieter J Fellner, DPM
The MIS Akin Osteotomy (Keith Gurnick, DPM)
On the question of the shortening of the first
metatarsal S/P osteotomy: this is really not an
issue, and might often be a desirable effect.
With an osteotomy to decompress and reduce the
mechanical forces on the joint, this results in
the 'buckling' and displacement of the 1st
MTPJ.
There are two important caveats:
First, the sesamoid apparatus must be
positioned in the correct anatomical alignment,
in relation to the first metatarsal head. There
is very little tolerance to this rule, if a
surgeon wants to optimize on outcome, a
flexible 1st MTPJ and provide for a lasting
correction. Secondly, the sagittal alignment of
the first metatarsal must be balanced correctly
with the lesser metatarsals. This requires of a
surgeon a need to exercise due diligence,
intra-operatively to evaluate and adjust, as
required. This second requirement will take
into account the position and flexibility of
the segment and loading response - this is an
acquired skill, one that requires good
judgment.
If I have an issue with some of the minimally
invasive bunion surgery techniques, it is the
fact that a surgeon cannot always easily
evaluate effectively, to make such an
adjustment intra-operatively, when this is
required. The SERI procedure is a notable
exception.
When both criteria are satisfactorily met, the
1st metatarsal will correctly engage the
Windlass mechanism to allow for correct
function and weight distribution, in gait. In
such a circumstance, the absolute length of the
first metatarsal is almost irrelevant - or at
least a secondary concern. A short metatarsal
will not, then, automatically expose a patient
to the risk of transfer metatarsalgia, or
related issues.
Dieter J Fellner, DPM, NY, NY
12/23/2016 Don Peacock, DPM
The MIS Akin Osteotomy (Keith Gurnick, DPM)
I agree with Dr. Gurnick's conclusion with
regard to the necessity of weight-bearing
lateral x-rays for appropriate assessment. In
my original post, I included both AP and
lateral x-rays pre and post. Only the AP x-rays
were published.
This patient had a relatively small IM angle
and our differing measurements may reflect some
differences in how we are viewing the IM angle.
Our measurements are not drastically different,
and as Dr. Gurnick states good correction is
noted. Also both of us are getting improved
changes in the HA angle and IM post-operatively
to within the normal range.
I have plenty of other cases showing stronger
corrections in the IM for moderate to severe
bunions using MIS protocols. For these
patients, I use a procedure that I have
published called the PRIBB procedure and I
employ percutaneous fixation with this
procedure. You can look up that publication and
see more drastic IM angle corrections using
this MIS surgical technique. I would be happy
to post some of these as well.
There is some shortening and Dr Gurnick
measures 4-5 mm shortening. That's actually
good. The average shortening in a traditional
Austin is 4-6 mm in studies published (Klosick,
et al. ref in McGlamry). In this study an
average of 6 mm shortening was seen after the
Austin and only 5 patients out of the 85
complained of transfer metatarsalgia and the
shortening did not correlate with symptoms. X-
ray evaluation alone cannot predict transfer
metatarsalgia except in excessive shortening
cases. To combat the shortening seen using a
burr I describe how to do this in the PRIBB
technique.
Remember that studies show improvement of 1st
ray stability after bunion correction even in
the inevitable shortening we get with 1st ray
head osteotomies. Dr Gurnick's post is a nice
academic post and his points are all valid.
Lateral x-rays are mandatory for true bunion
surgery evaluation as he states and showing the
whole foot x ray is important. All posts would
be better evaluated if we show the laterals and
APs of the entire foot.
Don Peacock, DPM, Whiteville, NC
12/20/2016 Keith L. Gurnick, DPM
The MIS Akin Osteotomy (Don Peacock, DPM)
Without addressing Dr. Peacock's use of the Katzen
Modified MIS Wilson procedure for HAV/Bunion
correction in general, I'd like to address his
pre- and post-surgery x-ray angle interpretation
from the x-rays he sent us to review. I can't
agree with his measurements of either the pre-op
and 6 week post-operative x-rays. I am not trying
to be critical, but to be honest here. Here is
what I measured from his x-rays sent in.
Pre-Op IM Angle
His measurement was 13 degrees
My measurement is 11 degrees
Pre-Op HA Angle
His measurement was 22 degrees
My measurement is 29 degrees
Post-Op IM Angle
His measurement was 8 degrees
My measurement is 10 degrees
Post-Op HA Angle
His measurement was 11 degrees
My measurement is 14 degrees
In all fairness, his post-op angle measurements,
regardless of his numbers or my numbers, do
indicate a nice correction, just not exactly as
dramatic as he states, but improved. But he did
not correct a 13 degree IM angle down to an 8
degree
IM angle. There is only minimal improvement in the
fibular sesamoid position and the distance between
the lateral aspect of the 1st metatarsal head and
the medial aspect of the 2nd metatarsal head
reduced from 8 mm to 7 mm, so it is 1 mm closer. You can't achieve 5 degrees of IM angle reduction
with 1 mm reduction.
Also, this patient ends up with 4-5 mm of 1st
metatarsal length shortening which could become
problematic over time Without knowing
anything about this patient (age, sex, weight,
foot structure, ROM, activity, shoes used) I'd
watch for sub 2nd metatarsalgia down the road,
and consider foot orthotics post-op.
Also, in this surgical case presentation and many
others as well, I do not know why we are shown
only forefoot AP x-rays to interpret.
It is much more comprehensive to see the entire
foot on both the standing (weight-bearing) AP and
the lateral views for pre-op and post-op
evaluation of surgical results.
In this patient example, note there is also a
metatarsus adductus foot type (look at the
obliquity of the base of the 2nd
metatarsal), and the MIS 1st metatarsal osteotomy
is almost mid-shaft. Unless the laterally pulling
force of the extensor hallucis brevis was
addressed, one would expect to see lateral
deviation of the hallux over time. A 6 week post-
op x-ray view is still short term result.
Also could you please send a pre-op and post-op
lateral x-ray so we can examine for any post-op
elevatus of the 1st metatarsal head of your non-
fixated mid-shaft 1st metatarsal M.I.S. osteotomy.
Keith L. Gurnick, DPM, Los Angeles, CA
12/15/2016 Don Peacock, DPM, MS
The MIS Akin Osteotomy (Brian Lee, DPM)
I would like to thank Dr. Lee for his kind
comments. I agree both with Dr. Lee and with
Dr. Sullivan. With respect to using the Akin
as an isolated procedure for HAV some
limitations do exist academically. I have
listed these limitations below. That is not to
say that the rules cannot be broken and there
is a vast void between academic outcomes and
patient satisfaction as we all know.
Here are the academic solo MIS Akin
contraindications:
1) IM angle over 15 degrees for procedure in HA
cases.
2) Rigid bunion deformity with mild to moderate
increase in the IM angle.
3) Significant deviated or subluxed first
metatarsal phalangeal joint with bunion.
4) In cases where the above pathology exists
(1–3), the Akin osteotomy should be per- formed
in conjunction with appropriate bunion
correction and first metatarsal osteotomy.
What I find most fascinating about the MIS Akin
osteotomy is its use in patient’s other than
our bunion sufferers. For example it's a great
procedure when modified with a dorsal wedge to
allow for reduction of pressure on the plantar
hallux leading to resolution of chronic
ulcerations. It can also be use in a similar
way to help with hallux rigidus decompression.
It's a very fast procedure to touch up a bunion
surgery performed with less than adequate
reduction of the HA angle etc, etc.
I have often used the procedure solo with great
clinical outcomes despite theoretical academic
restrictions. As an example, I have performed
this procedure on elderly patients with fairly
large IM angle’s that were only complaining of
the pain with the big toe hitting the second
toe causing a lesion or ulcer. Some of these
patients were not well-suited for more
aggressive procedures. It relieved their issues
without having to address the bunion in some
specific cases. Thanks for reading the article
and for participation in the discussion.
Don Peacock, DPM, MS, Whiteville, NC
