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

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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