Akin magic

[Feli]

What have ppl's journey with Akin been?

It's a pretty polarizing procedure.... unless it's just a billing thing, where every bunion gets one (with external k-wire for later office "HWR").

For me personally:
Did 100+ Akin in residency (typically with Austin), probably scrubbed 200-300+ of them during residency.
I decided Akin was mostly just a billing thing and barely ever actually necessary, or it was 'cheater Akin' since the Austins were not corrective enough and were unlikely to hold long term on some of the bunions (shift from mostly Austin to more Lapidus at the time across podiatry). Besides, ortho doesn't really do much/any of the Akin, and they're generally smarter than us, right?

After residency, I did mostly Lapidus, some Austin and tried a few Mau... probably did less than 10 of the Akin in 10yrs after training tho.
Now, doing barely any Austin, nearly all Lapidus or first MPJ fusions... but a few more Akins (with staple) than my early years with my Lapidus tho (for rhomboid phalanx aka HIA angle).

I think the decision for me was to see the Lapidus (usually when doing the HWR and/or contralateral) that had healed well and IM angle is locked nice, yet they still have a bit of HAV angle with 1-2 digit abutment, which is usually cosmetic - yet still present. I used to think this was maybe inadequate lateral release, but they are almost invariably rhomboid proximal phalanx when you check the XR. Current conclusion: there are a certain (small minority) amount of bunions where it's good to do the Akin to correct the rhomboid and to put a bit of slack in the EHL/FHL line. I would guess it 10-20%ish?

I have also found isolated Akin - or reverse - to be a good way to handle over or undercorrective transverse position from first MPJ fusions. I have a retired surgeon nearby who put a lot of his MPJ fusions I've seen in too much transverse correction, and they have "cigar sign" 1-2 digits spread with medial hallux IPJ callus or even ulcer sites.... so I do HWR and reverse Akin.

...What is everybody else's Akin training or exp or uses?
Do a ton of them?
Barely ever?
How to fixate?

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[GreenHousePub]

I do a ton of them. Nearly everytime with bunion since I do MIS. Fixate with screws, never staples.

Kwire fixation with plans to do HWR removal later in office is fraud.

 

[Podstar]

We do a fair amount of them, but pretty much attending dependent. Personally when I get out; MIS, lapidus, chevron, whatever if the 1st and 2nd toe are still touching they are getting an Akin. I prefer screw over staple.

 

[Hybrocure]

Did them a lot in residency, but in private practice, much like with Austin’s, Akins feel sort of sketchy when you’re cutting with a saw. There’s a very fine line between being able to close the wedge vs just punching through the cortex completely. I never feel as confident doing Austin/akin as I do with fusions or joint replacements.

I use staples.

I think realistically even though we as a profession do them all the time there is very little actual justification to do so. It’s almost always done in a cosmetic sense to make the foot look better rather than for what the actual indication for surgery should be - pain.

 

[Shiyuan]

I do a fair amount of them. 9mm staple most of the time unless I keep a 0.045 K-wire in as well for extra security.

 

[heybrother]

Good thread. I'm no longer anti-Akin. People want the straight toe. You can show them their zero IM reduction but if the toes are touching they are going to want more. Interesting point from Feli regarding over correction in 1st MPJ fusion. I've been going back and forth on how much valgus to allow in 1st MPJ fusions. I had some patients who were very satisfied when I based the great toe position on the second toe but I found myself hating the x-rays. I starting questioning how straight I should put them but that can open a whole new box of worms. I had a patient tell me they hated how straight an ortho put their great toe and I had a recent case where a patient told me their straight toe rubbed on their shoe. Straight can actually look like varus some of the time. Check out these below - I was experimenting today with how straight to place a fusion. The 2nd image is a much more natural presentation clinically.

 

[Shiyuan]

People want the straight toe.

100%. Akin all the way if needed.

View attachment 378948

“What are those 2 big circles under there, doc? Is that arthritis? 😂

 

[wakaflocka88]

Good topic. I’ve been wondering the same thing when I finished residency. I rarely saw or did Akins in residency. Rarely. Even with Austin’s or Lapidus, which was the majority of our bunion cases.

After one year of practicing, no matter how close I got my sesamoids to near anatomic with lapidus, patients always felt their toe still was not as straight enough no matter what I show them on their XR.

Now it’s only lapidus for me and 99% get an Akin even if the toe is straight on the table. Even if I take a tiny wedge and staple, at least I know it’ll prob keep toe straight forever. I also don’t do lateral release with my lapidus.

The Austin akin I’ve done in the last year even on 60-70s elderly ladies never got the correction I like post op. No more DMOs for me unless big contraindication.

And RVU

 

[wakaflocka88]

Did them a lot in residency, but in private practice, much like with Austin’s, Akins feel sort of sketchy when you’re cutting with a saw. There’s a very fine line between being able to close the wedge vs just punching through the cortex completely. I never feel as confident doing Austin/akin as I do with fusions or joint replacements.

I use staples.

I think realistically even though we as a profession do them all the time there is very little actual justification to do so. It’s almost always done in a cosmetic sense to make the foot look better rather than for what the actual indication for surgery should be - pain.

I use a k wire as close to the opposite cortex and that way your saw can never break it.

 

[Sweatshirt]

Always consent your lapidus for possible akin even if you don't think you'll need it. Like what was said above, patients don't care about the perfect IM angle. They only care about a straight toe

 

[air bud]

I essentially never do akins. Did some in residency. Always out of the proximal metaphysis with base parallel to joint. Staple fixation. Never done more oblique longer osteotomy with screw fixation.

 

[air bud]

Good thread. I'm no longer anti-Akin. People want the straight toe. You can show them their zero IM reduction but if the toes are touching they are going to want more. Interesting point from Feli regarding over correction in 1st MPJ fusion. I've been going back and forth on how much valgus to allow in 1st MPJ fusions. I had some patients who were very satisfied when I based the great toe position on the second toe but I found myself hating the x-rays. I starting questioning how straight I should put them but that can open a whole new box of worms. I had a patient tell me they hated how straight an ortho put their great toe and I had a recent case where a patient told me their straight toe rubbed on their shoe. Straight can actually look like varus some of the time. Check out these below - I was experimenting today with how straight to place a fusion. The 2nd image is a much more natural presentation clinically.

View attachment 378947View attachment 378948

Also, love this method of reduction. I don't use crossing screw plate only. This method of temp fixation allows for straightline compression of the plate when compressing via the plate. If this is in way of screws when fixation then will throw oblique one as secondary fixation then remove main one.

 

[NatCh]

People want the straight toe.

^This

Even with a good Lapidus and good reduction in the 1st MTP position sometimes the hallux has a kink in it and needs a distal Akin to make it look good and not touch the 2nd toe. I typically use a compression staple.

 

[NatCh]

I had a patient tell me they hated how straight an ortho put their great toe and I had a recent case where a patient told me their straight toe rubbed on their shoe.

Yep, this is a conundrum for sure. Some people want all toes as straight as possible, some want a slight angle. I recall removing the dressing on what I would've called a picture perfect correction. The patient wrinkled her nose and asked why the big toe was so straight. She was a rancher and liked cowboy boots. I've since learned to really take note of their footwear preferences. Snap shirt, Wranglers, and cowboy boots? Slight angle okay. Arc'teryx jacket, Brooks joggers, and Altras? Rectus AF.

 

[DYK343]

I consent every bunionectomy for an akin and tell the patient its a 50/50 if I am going to do it and I wont know until I am in there. 50% of the time I akin.

Single staple fixation. I go dorsal plantar on my staple instead of medial lateral. Its just easier and doesnt rub on shoes/cause a pinch callus.

Akins work and they work well until they dont. If i get a staple (or screw) break its always the akin. If they have poor bone stock or seem like they are going to be really active I do two staples now.

 

[Carbon13]

Previously, I would always perform a transverse wedge with staple fixation in addition to my Lapidus.
Since I've switched to mostly MIS bunions. I now do an MIS akin as well. Oblique cut with screw fixation. I find this method superior.
At the end of the day a bunion surgery is very cosmetic. Women want the toe straight, pain free & straight. Which is hard to maintain with the amount of abuse the foot takes. Additionally, I've learned not to trust soft tissue correction as it's too dynamic. I rarely do releases. Just osteotomies.

Anyways, back to studying for HVAC exam

 

[NatCh]

Women want the toe straight, pain free & straight. Which is hard to maintain with the amount of abuse the foot takes. Additionally, I've learned not to trust soft tissue correction as it's too dynamic. I rarely do releases. Just osteotomies.

1st MTP fusion has entered the chat

 

[Scrantonicity]

Done maybe 3 Akins in my career (11+ years). I only do Austin or Lapidus. I just do a pretty aggressive medial capsulorrhaphy, and that toe goes straight as an arrow. I tend to overdo it just a little, since that 2-0 Vicryl tends to relax a bit with the swelling. Then reinforce/splint it with my dressing and let it scar in. Only a couple times I remember it breaking loose and wishing I had done an Akin...but yeah, I really don't like them and I think they look stupid on X-ray (not that the patient cares about that but oh well).

 

[Sweatshirt]

Done maybe 3 Akins in my career (11+ years). I only do Austin or Lapidus. I just do a pretty aggressive medial capsulorrhaphy, and that toe goes straight as an arrow. I tend to overdo it just a little, since that 2-0 Vicryl tends to relax a bit with the swelling. Then reinforce/splint it with my dressing and let it scar in. Only a couple times I remember it breaking loose and wishing I had done an Akin...but yeah, I really don't like them and I think they look stupid on X-ray (not that the patient cares about that but oh well).

Just curious, what do you do when the patient is a clear 1st MPJ fusion candidate? Refer it out?

 

[air bud]

Just curious, what do you do when the patient is a clear 1st MPJ fusion candidate? Refer it out?

Probably talking about joint preservation type procedures

 

[Scrantonicity]

Just curious, what do you do when the patient is a clear 1st MPJ fusion candidate? Refer it out?

Lol…just curious, you do Akins with 1st MPJ fusions?

 

[GreenHousePub]

Lol…just curious, you do Akins with 1st MPJ fusions?

I'd only recommend doing them if you are interested in paying insurance companies back a lot of money

 

[Feli]

I consent every bunionectomy for an akin and tell the patient its a 50/50 if I am going to do it and I wont know until I am in there. 50% of the time I akin.

Single staple fixation. I go dorsal plantar on my staple instead of medial lateral. Its just easier and doesnt rub on shoes/cause a pinch callus...

Yeah, that's where I'm at now... after doing 100s of bunions in residency, 100+ since, and seeing the f/u of mine and many other docs.

I did consent a few for Akin and did under 3% or maybe 1% Akin for years.

Now, I will consent near every bunion (not first MPJ fusion!), but I bet I will still be under 10% or definitely under 20% Akin.

I think Weil is the procedure that I really underestimated coming out of training, but Akin was one I underestimated a bit also.

 

[DYK343]

Yeah, that's where I'm at now... after doing 100s of bunions in residency, 100+ since, and seeing the f/u of mine and many other docs.

I did consent a few for Akin and did under 3% or maybe 1% Akin for years.

Now, I will consent near every bunion (not first MPJ fusion!), but I bet I will still be under 10% or definitely under 20% Akin.

I think Weil is the procedure that I really underestimated coming out of training, but Akin was one I underestimated a bit also.

Perfect sesamoids or not too often I dont like the looks of the hallux. I dont believe in soft tissue correction for bunions (medial capsulotomy). If that is needed I akin instead.

Welcome to the club. Be careful of the hardware breakage. Its going to happen.

 

[Feli]

Perfect sesamoids or not too often I dont like the looks of the hallux. I dont believe in soft tissue correction for bunions (medial capsulotomy). If that is needed I akin instead.

Welcome to the club. Be careful of the hardware breakage. Its going to happen.

Yeah, I did a ton of Akin residency with various fixations but saw very few long term f/u. I just honestly thought Akin was mainly a billing thing (sorta still do) in the way that arthroeresis and EPF were and never paid a ton of attention to it.

I have done all Akins since coming out with 1 staple + hinge or 2 staples... haven't had a hardware fail for Akin staples, but we shall see. I do NWB on everything osseous for at least a 2-3 weeks just for edema and pain and skin healing reasoning.

...Soft tissue release is always debatable. I have done the lateral capsule and adductor release on over 90% bunions and medial eminence resect on probably over 80%... webspace stab release like orthos if doing Lapidus where MPJ joint is good and not needing any met head resect.
I'm just not a believer that the IM angle fix negates the adductor pull, and the IM will gradually slip based on research - even for Lapidus. That IM fix negating need for adductor release just seems impossible to me with the pre-op exams and the recurrences from other doc DMOs and undercorrected Lapidus that I see, so I think it's a passing fad to skip adductor release (the idea just fits MIS and Lapidus age). I agree don't go crazy re-sewing the first MPJ capsule, though (I just do linear capsulotomy to do resect of dorsal or medial eminence as needed, adductor release... no medial capsulotomy/capsulorraphy).

 

[podiatryresident]

After residency, I did mostly Lapidus, some Austin and tried a few Mau... probably did less than 10 of the Akin in 10yrs after training tho.
Now, doing barely any Austin, nearly all Lapidus or first MPJ fusions... but a few more Akins (with staple) than my early years with my Lapidus tho (for rhomboid phalanx aka HIA angle).

I think the decision for me was to see the Lapidus (usually when doing the HWR and/or contralateral) that had healed well and IM angle is locked nice, yet they still have a bit of HAV angle with 1-2 digit abutment, which is usually cosmetic - yet still present. I used to think this was maybe inadequate lateral release, but they are almost invariably rhomboid proximal phalanx when you check the XR. Current conclusion: there are a certain (small minority) amount of bunions where it's good to do the Akin to correct the rhomboid and to put a bit of slack in the EHL/FHL line. I would guess it 10-20%ish?

Hi Dr. Feli, what is your preferred method for Lapidus ? 2 screws, 1 screw 1 plate, lapifuse ? Do you use saw ? Thank you so much

 

[Feli]

Hi Dr. Feli, what is your preferred method for Lapidus ? 2 screws, 1 screw 1 plate, lapifuse ? Do you use saw ? Thank you so much

I almost always do long saw bunion blade (helps to use inject needle first, to get joint orientation... like in many papers or Chang orig ~2005 text), osteotome to finish plantar and snap the joint faces out, make sure to get plantar edges out (rongeur or similar), fenestrate both sides, plantar translate the met a bit to compensate for shortening, temp pin for position, steel lag screw, flatten dorsal lip on cunieform for plating... steel lock plate dorsal.

Saw resect is just much faster and lets you take the wedge triangle from cunieform side.
I sometimes do 2 or 3 screws (less wound problems and HWR chance), but you're definitely not as well-protected for a fall or WB early post op. Lock plate also gives you better construct if you run into bone that's not as solid as you though it'd be... and that happens all the time.

There are a lot of ways to do it fine... I do what works for me, is cost effective, is fairly quick and reproducible. You can do them in well under an hour typically.

You can do hand/power resect of the joint without saw if there is little or no angular deformity (not usually the reason for a Lapidus... moreso just a 1TMT fusion there). Sig Hansen book and stuff is generally good, but it's stupid to do most Lapidus with hand resect and think you'll correct any appreciable angular deformity. Hand resect is fine for MPJ1 fusion or some other joints that are concave/convex or you're not trying to re-align, but Lapidus is a flat joint and almost always a slight to significant angular correction.

 

[Bluecollarmed]

We do tons of Akins in residency. Some docs do one *almost every lapidus, like 98%. True MIS is 50/50 (and by true MIS I mean perc bur, not an incision that’s 70% of a standard chevron). I’ve seen a handful of patients now with great correction clinically and on films who still have the hallux touching the 2nd toe that come back for an isolated akin. And no it wasn’t a planned thing to collect more cash lol. Always a wishy washy decision that comes back around. In practice if I spend more than a couple seconds looking at it and debating one I’m probably doing it.

 

[Forcewielder]

Good topic. I'm newer but in residency I saw all of 1 or 2 Akins ever. Our program frowned upon them and always preached good IM correction is all that's needed. However, I've done enough now that I'm rethinking the Akin. I've had awesome Lapidus that the 1st and 2nd toes still touch. Nothing that hurts, but the patients always comment on it because that and the bump are the 2 things they notice preoperatively.

 

[NatCh]

Good topic. I'm newer but in residency I saw all of 1 or 2 Akins ever. Our program frowned upon them and always preached good IM correction is all that's needed. However, I've done enough now that I'm rethinking the Akin. I've had awesome Lapidus that the 1st and 2nd toes still touch. Nothing that hurts, but the patients always comment on it because that and the bump are the 2 things they notice preoperatively.

Yep, even with good IM correction if the patient has a crooked hallux (hallux abductus interphalangeus) then the toes will touch. People with a big IMA often have this deformity. It seems like a distal Akin is indicated more frequently than an Akin just for that reason.

 

[Shiyuan]

Does anyone recommend a particular bunion MIS system?

 

[Weirdy]

Does anyone recommend a particular bunion MIS system?

Have done:
Crossroads Minibunion (1st met intramedullary)
Crossroads Dynabunion (Lapidus, has the compression blocks)
2 screw for distal transverse osteotomy
Austin w/ a burr + perc screw

Still prefer traditional ways. Dissect. Its right there. You can visualize everything, get correction you want.

For true MIS with a burr- straight transverse with 2 screws or Austin- requires practice and a feel for where your burr is cutting, what shape it will make pending which direction you twist or angle.
Same with K wire firing to get your screws where you want them -wire skiving off cortex, etc, there's jigs and better wires for this now.
If you can get that down and replicate consistently in OR- go for it.

Open to hearing other experiences. Am not an attending.

 

[Shiyuan]

Still prefer traditional ways. Dissect. Its right there. You can visualize everything, get correction you want.

100%. For the right patient, thought MIS would be something to look into more.

 

[shadesofgrey]

I have used the arthrex and stryker system. I prefer arthrex, I like their jig better and not sure if stryker has the parallel guide. The learning curve is steeper than i thought it would be. Had some amazing results, had a few that I pray to god no one else ever sees the xrays. In general I'm happy with the technique, and the patient satisfaction has been good. Just realize your early cases are probably going to take much longer than your open cases.

 

[GreenHousePub]

Does anyone recommend a particular bunion MIS system?

I use Stryker for all of mine. Really happy with the results. I switched to only MIS from open.

 

[NatCh]

The learning curve is steeper than i thought it would be. Had some amazing results, had a few that I pray to god no one else ever sees the xrays.

At the training session I made a nice mess of the cadaver. Kahplooie.

 

[heybrother]

At the training session I made a nice mess of the cadaver. Kahplooie.

"I made a nice MIS of the cadaver. Kahplooie."

 

[shadesofgrey]

At the training session I made a nice mess of the cadaver. Kahplooie.

Yeah I did two cadaver labs prior to my first MIS case, knew all the steps down pat and walked in more confident than I ever have for a first time new technique. It was a major **** show, took so much longer than an open bunionectomy.

For comparison sake, I consider my surgical skills to be about average.

 

[NatCh]

"I made a nice MIS of the cadaver. Kahplooie."

Well done.

 

[NatCh]

Yeah I did two cadaver labs prior to my first MIS case, new all the steps down pat and walked in more confident than I ever have for a first time new technique. It was a major **** show, took so much longer than an open bunionectomy.

For comparison sake, I consider my surgical skills to be about average.

**** happens sometimes. Hopefully all's well that ends well. During a case using the Lapiplasty equipment I turned my head for one second and heard a "ping" as the compressor hit the floor. Out of the corner of my eye I could see the Rep furiously texting someone and I pictured it going something like "OMG OMG OMG" Fortunately I'm thoroughly comfortable doing a plain old boring Lapidus so I was able to party on.

 

[dtrack22]

I use Stryker now simply because they were willing to let a power unit and 3 hand pieces live at the hospital for free. Arthrex wanted us to purchase the unit/hand pieces. Never used the Arthrex jig as it didn’t exist before I made the switch so I free handed all of them. The only issue I ran into with Arthrex was the fact that the distributorship only had 1 or two power units and hand piece sets at the time for a very large region (from a mileage/distance standpoint). Had one case where the power unit didn’t get shipped in on time and had to go old fashioned with k-wire fenestration and osteotome to make the osteotomy. Wasn’t a big deal since I had done it that way before, but it was annoying and there was a fear that it could happen again. Depending on your distributor, and the fact that they probably have way more available units at this point in time, it probably doesn’t matter at all which set you use. I prefer to book as much stuff as I can with a single rep/company in a day so if I found myself using more Arthrex or Stryker for other cases, that’s probably how I would decide on which system to train on and use.

 

[billBOB213]

Yeah I did two cadaver labs prior to my first MIS case, knew all the steps down pat and walked in more confident than I ever have for a first time new technique. It was a major **** show, took so much longer than an open bunionectomy.

For comparison sake, I consider my surgical skills to be about average.

This was my experience as well, I did a couple of cadaver labs before the first case. I always do an akin with mine, and prefer MIS bunion to open Austin’s. My best advice is do a couple cadaver labs to get comfy. I think the actual burr part is easy….we can get that feel of that easy enough as surgeons. The hardest part for me was the positioning (of everything-my mini c, patient, where I would be sitting for a R vs L bunion, etc). It is very different than what we all trained on, so you feel just out of sorts during the first case-or atleast I did.
During the cadaver lab try to imagine the position of everything. Oh and the bad part about cadaver with MIS is the leg isn’t attached to a patient (obviously), so it just isn’t totally the same. You can manipulate and do things that you can’t in the real deal. So it’s easy in the lab to just angle the foot perfect and throw your wires. This all might sound a little dramatic but if you’ve tried it you will understand what I’m saying, as the actual first case is just different than anything you’ve done before.
And I would look at some of the better known Ortho MIS guys on LinkedIn (and some pods like Loder and Siddiqui). I screen shot a lot of their posts where they gave out pearls on positioning and where to aim etc, I still review them before cases.
I still use a jig, and I use arthrex. One day I’ll stop but not today.

I’m eventually wanting to branch out into lapidus MIS and 1st MPJ fusions. But I’m a big believer in MIS. The HTs I’ve done this far have been great. And fwiw I would also say I’m average surgeon, don’t do nearly what I used to outta residency as I have dialed it down to doing stuff I like and can control.
I would be a lot better at MIS but my surgical load isn’t crazy high either.

 

[shadesofgrey]

This was my experience as well, I did a couple of cadaver labs before the first case. I always do an akin with mine, and prefer MIS bunion to open Austin’s. My best advice is do a couple cadaver labs to get comfy. I think the actual burr part is easy….we can get that feel of that easy enough as surgeons. The hardest part for me was the positioning (of everything-my mini c, patient, where I would be sitting for a R vs L bunion, etc). It is very different than what we all trained on, so you feel just out of sorts during the first case-or atleast I did.
During the cadaver lab try to imagine the position of everything. Oh and the bad part about cadaver with MIS is the leg isn’t attached to a patient (obviously), so it just isn’t totally the same. You can manipulate and do things that you can’t in the real deal. So it’s easy in the lab to just angle the foot perfect and throw your wires. This all might sound a little dramatic but if you’ve tried it you will understand what I’m saying, as the actual first case is just different than anything you’ve done before.
And I would look at some of the better known Ortho MIS guys on LinkedIn (and some pods like Loder and Siddiqui). I screen shot a lot of their posts where they gave out pearls on positioning and where to aim etc, I still review them before cases.
I still use a jig, and I use arthrex. One day I’ll stop but not today.

I’m eventually wanting to branch out into lapidus MIS and 1st MPJ fusions. But I’m a big believer in MIS. The HTs I’ve done this far have been great. And fwiw I would also say I’m average surgeon, don’t do nearly what I used to outta residency as I have dialed it down to doing stuff I like and can control.
I would be a lot better at MIS but my surgical load isn’t crazy high either.

This 100%. The cut with the burr is easy. Throwing the guide wire can be a nightmare. Hard angle and the wire wants to skive distally down the metatarsal, in the cadaver those aren't issues. It was reassuring to hear Siddiqui and some of the other guys speak and have many of the same issues when they first started. On the plus side, I do think my overall surgical skills improved doing MIS. I felt my residency training was quite subpar, and having to throw those wires forces was beneficial, though painful during the initial learning phases.

 

[Feli]

...I would be a lot better at [X] but my surgical load isn’t crazy high either....

Says every podiatrist ever. ^^

But hey... "everyone's a surgeon" and all are 3 year trained.

 

[billBOB213]

And I love it that way

 

[Shiyuan]

Anyone do this “SERI” procedure??? Been around for a little while it seems.

 

[Shiyuan]

Anyone do this “SERI” procedure??? Been around for a little while it seems.

Ressurrecting this. Another name is the Bosch. Any thoughts/experience?

 

[heybrother]

Ressurrecting this. Another name is the Bosch. Any thoughts/experience?

I tried pulling all the free/accessible articles on them a few years ago. My memory is they involve an intra-articular Steinman that runs up the medial hallux into the metatarsal shaft. The fixation does not actually cross the metatarsal head which means technically the head can still rotate or reposition. Someone had a commentary somewhere in which they indicated they were throwing another wire for more fixation (maybe DeHeer, maybe not). I know the x-rays for a large transposition look ridiculous but I'd say - just learn to throw the screws / master the system so you can derive the full potential benefits. Trivial incisions. No external hardware. No intra-articular injury.