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fixed using a postoperative dressing did not describe any
significant complications.14,22,26 Some surgeons employ the
percutaneous internal fixation achieved using a screw; it is
usually a Herbert screw introduced on the medial side of the
base of the proximal phalange, through the osteotomy crevice and lateral bone cortex.18,23,40 The literature presents
reports describing very good results of the Akin osteotomy
fixation performed as an open procedure using a single- or
double-channel transosseous suture.10,25,29,36,38,39
The first author of the present study has developed a
method of fixation employed in the Akin osteotomy of the
proximal phalanx of the big toe by means of the percutaneous
transosseous suture (ie, PTSA). Similarly, like open procedures, such an approach allows for reducing the costs of surgery and the risk of complications associated with using a
screw, such as soft tissue irritation.18 Moreover, such a fixation method allows for eliminating the risk of delayed union
or secondary displacement described in case of using external fixation achieved by means of big toe-adducting dressings. In the opinion of the first author, when the surgeon is
adequately experienced, PTSA is not more difficult or more
time-consuming when compared to fixation achieved using a
screw. Nevertheless, the present authors recommend employing more stable fixation using a screw or even 2 screws in
case of considerable instability resulting from full fractures
of the lateral cortex of the proximal phalanx of the big toe.
The literature on the subject presents 3 systematic
reviews that assess the results of managing hallux valgus
employing minimally invasive methods.3,7,28 The reports
show promising results, but also demonstrate the necessity
of a longer follow-up, standardization of the protocols, and
appropriate experience of the surgeon. Moreover, there are
no unambiguous criteria and definitions of minimally invasive and percutaneous surgery. Systematic reviews also
include open techniques starting from shorter skin incisions and performed with the use of traditional instruments;
in the majority of cases, such articles do not univocally
discriminate between the above techniques and percutaneous methods using proper burrs, mini-instruments, and
beaver blades. In view of the multitude of operative techniques, their modifications and lack of a sufficient number
of reports referring to a single operative technique (eg,
MICA), at present the literature is not unambiguous.
The present paper also has some limitations that should
be taken into consideration. First, the authors present a retrospective analysis with short-term results. Furthermore,
the results might have been affected by additional operative
procedures (phalangeal osteotomies, DMMO, etc). The
results illustrate the experiences of the first author and do
not represent the long learning curve associated with percutaneous procedures.

Conclusions
The minimally invasive chevron osteotomy with percutaneous fixation of the Akin osteotomy with a transosseous

Foot & Ankle International 41(9)
suture was a safe method that produced good functional
results that were comparable to those achieved using screw
fixation. The method was technically difficult and should
be used only when the operator acquires appropriate experience in percutaneous surgery.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this article. ICMJE forms for all authors are available online.

Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.

ORCID iD
Henryk Liszka MD, PhD,

https://orcid.org/0000-0003-4084-3777

Supplemental Material
Supplemental videos for this article are available online.

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https://www.orcid.org/0000-0003-4084-3777

Foot & Ankle International - September 2020

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