Increased rates of delayed union after percutaneous Akin osteotomy

A new suture fixation technique for the Akin osteotomy of the proximal phalanx: You don't need any implant

BACKGROUND

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.

METHODS

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.

RESULTS

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 0454). Complications were 2 local pain and 1 wound infection cases in the suture and implant groups, respectively (p 0138, p 0197).

CONCLUSION

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

LEVEL OF EVIDENCE: 3

The Akin osteotomy without fixation in open hallux abducto-valgo correction surgery - A single center retrospective analysis of 286 cases

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

LEVEL OF EVIDENCE

IV retrospective cases series.

A new suture fixation technique for the Akin Osteotomy of the Proximal Phalanx: You don't need any implant

BACKGROUND

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.

METHODS

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.

RESULTS

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).

CONCLUSION

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

Percutaneus intermetatarsal ligament release and minimally invasive distal metatarsal osteotomy for treatment second intermetatarsal space syndrome

BACKGROUND AND OBJECTIVE

Since the description of the syndrome of the second intermetatarsal space, this is a common diagnosis among foot and ankle surgeons. However, no series have been published that consider this syndrome as its own entity. The objective of this study is to evaluate the clinical and radiological results of the release of the intermetatarsal ligament and minimally invasive distal metatarsal osteotomy in patients diagnosed with second space syndrome.

MATERIALS AND METHODS

An observational, longitudinal, retrospective study was carried out in patients with a clinical diagnosis of second space syndrome operated on using a minimally invasive technique. For the clinical results, the visual analog scale (VAS) for subjective pain, the Manchester-Oxford Foot Questionnaire (MOXFQ) and the scale for minor metatarsals and interphalangeals of the American Orthopedic Foot and Ankle Society (AOFAS-LMTS) were used for clinical-functional assessment. Consolidation or not of osteotomies was recorded and complications were recorded.

RESULTS

Twenty-nine feet in 29 patients were included in the study. After a mean follow-up of 39 months (25-50), clinically and statistically significant improvement was obtained in the scores: pain VAS, scales and subscales of the MOXFQ and the AOFAS-LMTS (p < 0.0001). All osteotomies healed at the end of follow-up and no major complications were recorded.

CONCLUSIONS

Percutaneous or minimally invasive surgery, in patients with second intermetatarsal space syndrome, obtains good clinical, functional and subjective results, with few complications. Therefore, we consider it an effective, safe and recommended technique in the hands of experienced surgeons.

Early Radiographic Outcomes of Minimally Invasive Chevron Bunionectomy Compared to the Modified Lapidus Procedure

Background

Minimally invasive (MIS) bunion surgery has become increasingly popular. Although early reports on outcomes have been encouraging, no study to date has compared outcomes from the MIS chevron and Akin procedures to the modified Lapidus procedure. Our primary aim was to compare early radiographic outcomes of the MIS chevron and Akin osteotomies to those of the modified Lapidus procedure in patients with comparable deformities, and secondarily to compare clinical outcomes.

Methods

Patients were retrospectively reviewed for inclusion from a prospectively collected foot and ankle registry. Patients were eligible if they underwent either the MIS bunionectomy or modified Lapidus procedure and had preoperative and minimum 5-month postoperative weightbearing radiographs. Forty-one patients who underwent MIS bunionectomy were matched to 41 patients who underwent Lapidus bunionectomy based on radiographic parameters. Demographics, radiographic parameters, complications, reoperations, and PROMIS scores were compared between groups.

Results

Both groups achieved similar radiographic correction. There was no significant difference in pre- or postoperative PROMIS scores between groups. Procedure duration was significantly faster in the MIS group (P < .001). Bunion recurrence (hallux valgus angle ≥20 degrees) occurred in 1 MIS patient and 2 Lapidus patients, with all patients asymptomatic. The most common reason for reoperation was removal of hardware (4 patients in the MIS group, 2 patients in the Lapidus group).

Conclusion

This is the first study to our knowledge to compare early radiographic outcomes between MIS bunionectomy and the modified Lapidus procedure in patients matched for bunion severity. We found that patients with similar preoperative deformities experience similar radiographic correction following MIS chevron and Akin osteotomies vs modified Lapidus bunionectomy. Further research is needed to investigate satisfaction differences between the procedures, longer-term outcomes, and which deformities are best suited to each procedure.

Level of Evidence

Level III, Retrospective case control study.

Litigation after hallux valgus surgery in France between 2000 and 2020: A review of the two national legal research databases

BACKGROUND

The objectives of this review were to: 1) describe reasons for lawsuits following primary hallux valgus surgery in France from 2000 to 2020; 2) to compare private and public practice.

METHODS

Civil (private practice) and administrative (public practice) court decisions in France between 2000 and 2020 were collected using the two leading legal data sources (Legifrance, Doctrine).

RESULTS

Seventy-two court decisions related to hallux valgus surgery were included. An appeal was filed in 93% of cases. Finally, 70.8% of the verdicts were in favor of the complainants. The average compensation awarded to a plaintiff was €55,333. The main reasons for complaint after hallux valgus surgery were: a failure to provide preoperative information (47.2%), post-operative pain/stiffness (38.9%), and infection (30.6%). A proven lack of information increased the risk of recognizing the occurrence of post-operative pain and stiffness as faulty from 13.3% to 61.5% (p = 0.01), and the average compensation from €25,330 to €76,716 (p = 0.04). The duration of the procedure was about 1.5 years longer in civil proceedings (p = 0.04). There was no significant difference between private and public activity litigation.

CONCLUSION

Clear and adapted patient information and its traceability could be a way to reduce the number of complaints and their consequences in case of disappointing results.

Screw versus staple fixation for Akin osteotomy

INTRODUCTION

Akin osteotomies are commonly fixed with a screw or staple. Hardware-related symptoms are not uncommon. We compared the outcomes and costs of the two implants.

METHODS

We evaluated 74 Akin osteotomies performed in conjunction with first metatarsal osteotomy for hallux valgus. The osteotomy was fixed with a headless compression screw in 39 cases and a staple in 35 cases. We looked at the implant-related complications, removal of metalwork, revision, non-union and cost. Pre- and postoperative hallux valgus interphalangeal (HI) angles and length of the proximal phalanx were measured.

RESULTS

There was 100% union, no failure of fixation, no revision surgery and no delayed union in either group. The radiological prominence of screws was significant (p=0.02), but there was no significant difference in soft-tissue irritation (p=0.36) or removal of implants (p=0.49). Two cortical breaches (5.8%) occurred in staple fixation and 4 (10.2%) in screw fixation (not statistically significant (NS), p=0.50). The mean improvement in HI angle was 4.3° with screw fixation and 4.1° with staple fixation (NS, p=0.69). The mean shortening of the proximal phalanx was 2.5mm with screw fixation and 2.3mm with staple fixation (NS, p=0.64). The total cost was £1,925 for staple fixation and £4,290 for screw fixation.

CONCLUSIONS

Staple and screw fixation are reproducible modalities with satisfactory outcomes, but screw fixation is expensive. We conclude staple fixation is a cost-effective alternative.

Minimally Invasive vs Open Akin Osteotomy

BACKGROUND

Minimally invasive techniques of Akin osteotomy have grown in popularity, as early results suggest faster recovery, earlier return to work, and minimized wound healing problems. Preserving lateral cortex integrity during first phalanx osteotomy thereby presents a challenge because of the lack of direct visual control. This retrospective comparative study investigated clinical and radiographic outcomes of minimally invasive and open Akin osteotomy with different fixation methods and analyzed whether or not intraoperative violation of the lateral cortex caused loss of correction or delayed bone healing.

METHODS

One hundred eighty-four patients (210 feet) with symptomatic hallux valgus and pathologic interphalangeal angle (IPA) of at least 10 degrees underwent surgery combined with Akin osteotomy. Minimally invasive Akin osteotomies were fixed in 124 feet with 2 crossing percutaneous K-wires and compared to 86 Akin osteotomies by open technique with double-threaded (head and shank) screw fixation. At 1 day and 6 and 12 weeks postoperatively, IPA and bony consolidation were radiographically and clinically assessed.

RESULTS

Mean preoperative IPA was 13.4 ± 3.6 degrees in minimally invasive (MI) and 13.3 ± 3.5 degrees in open surgery (OS) cases (P > .05). Intraoperative breach of the lateral cortex occurred in 12 (13.9%) in OS and 64 (51.6%) in MI cases. Whereas the breach occurred in open technique mainly during manual correction by applying a medial closing force, it was caused predominantly by the use of the burr in minimally invasive technique. After 12 weeks, the mean IPA was 4.1 ± 1.4 degrees in MI and 4.8 ± 1.2 degrees in OS cases (P > .05). Bony consolidation was complete after 6 and 12 weeks in OS and MI, respectively. Three deep infections occurred in the OS Group after Lapidus arthrodesis and 2 deep infections were registered in the MI Group after minimally invasive chevron and Akin osteotomy. The infections were not at the site of the Akin osteotomy.

CONCLUSION

Breach of the lateral cortex did not impair bone healing or correction of IPA. Minimally invasive Akin osteotomy with K-wire fixation provided equivalent correction of IPA compared to open surgery with screw fixation.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

Percutaneous Transosseous Suture Fixation of the Akin Osteotomy and Minimally Invasive Chevron for Correction of Hallux Valgus

BACKGROUND

The objective of the study was evaluation of the clinical and radiologic outcomes and complications following the minimally invasive chevron procedure employing the Akin osteotomy with percutaneous transosseous suture as compared to screw fixation.

METHODS

Between 2018 and 2019, the authors performed 103 minimally invasive chevron (MIC) with Akin osteotomies. In 54 patients, the Akin osteotomy was performed with screw stabilization (group A), and in 49 with percutaneous transosseous suture (group B). Preoperatively and 1 year later, the authors employed anteroposterior and lateral weightbearing radiographs of the feet to evaluate interphalangeal angle (IPA), distal phalangeal articular angle (DPAA), proximal phalangeal articular angle (PPAA), intermetatarsal angle (IMA), hallux valgus angle (HVA), and functional result using the American Orthopaedic Foot & Ankle Society (AOFAS) hallux-metatarsophalangeal-interphalangeal scale. Furthermore, all additional procedures and complications were recorded.

RESULTS

Both groups demonstrated a statistically significant decrease of the value of HVA (group A: from 34.1° to 14.0°, group B: from 33.6° to 13.0°), DPAA (group A: from 12.1° to 4.0°, group B: from 11.5° to 3.4°), PPAA (group A: from 4.6° to 1.7°, group B: from 4.3° to 1.5°), IMA (group A: from 15.1° to 8.0°, group B: from 14.7° to 7.5°) and IPA (group A: from 14.1° to 6.3°, group B: from 12.9° to 5.1°). Functional improvement as measured using the AOFAS scale was achieved in both groups (group A: from 42 to 90 points, group B: from 40 to 89 points). No cases of bone nonunion or delayed union and permanent damage to the medial dorsal cutaneous nerve were seen. Two group B patients underwent conversion of the fixation of the Akin osteotomy to screws, 3 patients had their MICA screws and 1 Akin screw removed in the outpatient setting.

CONCLUSION

The minimally invasive chevron osteotomy with transosseous suture stabilization of the Akin osteotomy was a safe method with good functional results that were comparable to the outcomes achieved when using screw fixation.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.