lerEXPO Highlights: The “Cheater Akin” Osteotomy | Who is it Really Cheating?

By Bradley P. Abicht, DPM, FACFAS

Over the past century, the Akin osteotomy has earned the nickname “cheater Akin,” a term that reflects both its simplicity and the skepticism surrounding its standalone value. However, a deeper look into the history and evolving practices of podiatric and orthopedic surgeons reveals a more nuanced role for this procedure.

A Brief History of the Akin Osteotomy

The Akin osteotomy was first described in a 1925 paper¹. Initially it involved creating a fracture in the proximal phalanx of the great toe to straighten it. This historic approach became part of bunion surgery’s evolution, initially used as an isolated procedure. However, as surgical techniques advanced, the Akin osteotomy began to serve as an adjunctive measure when traditional osteotomies could not sufficiently correct a deformity, earning it the nickname “cheater Akin.” .   

In modern approaches, the Akin is often planned as an integral part of the overall correction strategy, working synergistically with the metatarsal osteotomy to not only straighten the toe but also to influence the biomechanics and reduce recurrence. It’s no longer viewed as a secondary procedure but rather a component of a comprehensive correction. Today, the Akin osteotomy’s role has expanded beyond mere correction to include influencing the function and alignment of the great toe joint within MIS and percutaneous approaches.

When to Use Akin Osteotomy

Key evaluation criteria for adding an Akin osteotomy to a bunion procedure include the proximal to distal phalangeal articular angle (PDPAA). Clinical evidence suggests that if this angle exceeds 8 degrees, an Akin osteotomy can significantly improve both the correction and longevity of the surgical outcomes by preventing recurrence.

When performed in conjunction with a metatarsal osteotomy, the Akin osteotomy offers several biomechanical advantages beyond just straightening the great toe. Cadaveric studies have shown that an Akin can supinate the insertion of the flexor hallucis brevis (FHB) tendon and medializes the vector pull of the flexor hallucis longus (FHL) tendon, bringing their forces more in line with the long axis of the first metatarsal. This realignment of the soft tissue helps to improve the overall mechanics of the great toe joint and contributes to a more stable correction, potentially leading to lower recurrence rates of the bunion deformity.

Other factors to consider are: is this a primary or revision surgery? If it is a revision, is there scar tissue from the prior surgery? Is the hallux touching or pressing against the second toe (a positive toe touch sign). If it in fact is, it suggests that further medial deviation of the big toe needs to be addressed. In such cases, the surgeon will typically proceed with performing a percutaneous Akin osteotomy to create a small space between the big toe and the second toe, aiming for a slight under correction to account for potential settling postoperatively.

The Akin Osteotomy and Social Media

A social media survey of foot and ankle surgeons on LinkedIn² indicated a high rate of Akin osteotomy usage in conjunction with hallux valgus correction, with many surgeons reporting using it in 80% to 99% of their cases. Common reasons cited for this frequent use include the desire to achieve optimal straightening of the toe, improve cosmesis, positive influence joint mechanics, and to reduce the risk of bunion recurrence by affecting the vector pull of tendons like the EHL, FHB, and FHL. One surgeon noted that they rarely regret performing an Akin but have regretted not doing one when a satisfactory correction wasn’t achieved.

In summation, the label “cheater Akin” is outdated and fails to reflect the procedure’s value in modern hallux valgus correction. Isolated Akin osteotomies may have limited standalone indications, but their impact on radiographic parameters such as intermetatarsal angle (IMA), hallux valgus angle (HVA), and tibial sesamoid position (TSP), as well as their influence on biomechanics through tendon vector forces, demonstrate their clinical relevance. When used synergistically with a primary bunion procedure, Akin osteotomies can help reduce the risk of recurrence. The decision to incorporate an Akin is multifactorial, involving preoperative imaging, clinical evaluation, surgical goals, and intraoperative findings such as the toe touch sign. The choice of surgical technique—open, minimally invasive, or percutaneous—also plays a critical role. Continued research is essential to further define its role and refine surgical indications.

Bradley P. Abicht, DPM, FACFAS, is the Department Chair of Podiatric Medicine and Surgery at emplify Health by Gundersen in La Crosse, Wisconsin. He is a leader in minimally invasive (MIS) and percutaneous foot and ankle surgical procedures as well as foot and ankle reconstructive surgery, foot and ankle arthroscopy, and foot and ankle sports injuries. An educator to residents and medical students, he is frequently published in peer reviewed journals. A renown national and international speaker and founder of the annual Western WI Foot & Ankle. He also serves as the Medical Director of lerEXPO, Associate Editor of FASTRAC and hosts GaitKeepers Journal Club.