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operators used screws to stabilize the osteotomy,40,41 which
allowed for decreasing the number of complications associated with insufficient stability.18,19,23,34,35
Recent publications on the subject have not demonstrated
any significant differences in the outcomes of the minimally
invasive chevron Akin (MICA) and percutaneous chevron
Akin (PECA) procedures and open techniques.6,14,22,23,26,28 In
the MICA method, the chevron osteotomy of the first metatarsal bone is stabilized with 2 dedicated screws with beveled
heads (MICA screws), and to stabilize the Akin osteotomy, a
single screw is used (eg, the Herbert screw).34,35,40,41
The Akin osteotomy was described for the first time in
1925.1 In order to stabilize the osteotomy, Akin employed
a wooden tongue depressor. Subsequently, various modes
of internal fixation were developed, such as the Kirschner
wires, intraosseous wire loops, suture, staples, and plates
and screws.2,5,8,15,16,30-32,37 Staples and screws are the
most often used methods of fixation. Staples provide initial dynamic compression of the site of the osteotomy,
which, however, decreases with the distance from the
medial cortex.32 Screws provide stable fixation; however, they are at risk of being stress risers.10,32 Both staple
and screws may irritate skin and require a second procedure for removal.10 Because the osteotomy is performed
at the base of the proximal phalanx, it may heal without
rigid fixation because of the predominant cancellous
bone.10 One of the main advantages of transosseous
suture fixation is lack of implant-related complications
and lower costs.10,36,38,39 Although transosseous fixation
of the Akin osteotomy seems to be fragile, recent studies
have proven it to be equally effective and safe.10,25,29,36,38,39
The first author of the present article has developed the
method of percutaneous fixation of the Akin osteotomy
using a transosseous suture; the procedure is performed in
combination with the minimally invasive chevron osteotomy of the first metatarsal with 2 MICA screw fixation. The
objective of the study was to present the operative technique and clinical and radiologic outcomes of the percutaneous transosseous suture fixation of the Akin osteotomy
(PTSA) as compared to screw fixation, with both types of
the procedures performed in the course of minimally invasive hallux valgus correction. The literature on the subject
includes reports comparing the MIS and open methods in
operative hallux valgus treatment.14,22,23 Nevertheless, to
date, no study has been published that compared 2 different
stabilization methods as employed in the course of percutaneous correction of hallux valgus.

Methods
The study was retrospective and based on the medical histories, operative protocols, radiographic images, and outpatient medical charts. In the period from 2018 to 2019, the
authors performed a total of 103 percutaneous corrections

Foot & Ankle International 41(9)
of hallux valgus using the MICA procedure. The indications
included symptomatic hallux valgus (pain and/or conflict in
shoe selection). Qualification for the MICA procedure
included patients with mild, moderate, and advanced deformities (max. intermetatarsal angle [IMA] <20 degrees).
Patients with advanced degenerative lesions of the first
MTP joint, gout, rheumatoid arthritis, diabetes, neuropathy,
vascular diseases, high-grade atherosclerosis, history of
foot surgery, and infections were excluded from the study.
The latter group was either contraindicated from operative
treatment or qualified for another procedure, for example,
the Lapidus or first MTP joint arthrodesis. All the operative
procedures were performed by the first author, who participated in numerous training courses in percutaneous surgery
involving the forefoot. All consecutively treated patients
subjected to the MICA procedure in the years 2018-2019
were qualified. Follow-up was on average 12 months (range
from 10 to 14 months) postoperatively. All the above subjects had the minimally invasive chevron (MIC) osteotomy
with internal fixation with 2 MICA screws. Fifty-four
patients had Akin osteotomies with screw fixation (group
A, MICA), whereas in 49 subjects, stabilization was
achieved using percutaneous transosseous suture (group B,
the minimally invasive Chevron-percutaneous transosseous suture Akin [MIC-PTSA]). One year later, the authors
analyzed anteroposterior and lateral weightbearing radiographs of the feet to assess the pre- and postoperative interphalangeal angle (IPA), distal phalangeal articular angle
(DPAA), proximal phalangeal articular angle (PPAA),
intermetatarsal angle (IMA), hallux valgus angle (HVA),
and the functional outcome measured using the American
Orthopaedic Foot & Ankle Society (AOFAS) hallux-metatarsophalangeal-interphalangeal scale. All the additional
procedures and complications were also recorded.

Operative Technique
Minimally Invasive Chevron (MIC) (Video 1).  In order to perform percutaneous correction of hallux valgus with the
minimally invasive chevron (MIC) method, the surgeon
had appropriate instruments: an operative drive for MIS
foot surgery with a speed governor (200-40000 rpm, min.
torque 50 N/cm), a mini C-arm, beaver blade no. 64, a set of
miniature operative instruments, a set of operative cutters,
and MICA screws.
The procedure was performed without tourniquet. The
surgeon used palpation and fluoroscopic control to introduce a 1.4-mm Kirschner wire (K) medially at the level of
one-half of the median and one-third of the superior basis of
the first and very close to the first cuneometatarsal joint.
The wire was introduced distally and somewhat laterally
through the diaphysis and lateral cortex of the first metatarsal and was directed at the sesamoid bone (Figure 1A). The
K wire always passed through the lateral cortex of the first
Foot & Ankle International - September 2020

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