Akin osteotomy without internal fixation combined with modified Bösch osteotomy for the treatment of moderate to severe hallux valgus

Akin osteotomy without internal fixation combined with modified Bösch osteotomy for the treatment of moderate to severe hallux valgus | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Akin osteotomy without internal fixation combined with modified Bösch osteotomy for the treatment of moderate to severe hallux valgus Zhiqi Zhang, Heng Zhang, Huarui Yang, Tongzhu Bao, Kangquan Shou This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7713475/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: Clinical efficacy of Akin osteotomy without internal fixation combined with modified Bösch osteotomy in treating moderate to severe hallux valgus deformity. Methods : Of the 94 patients who underwent bunion orthopedic surgery from September 2022 to January 2024 at our institution, 48 patients with moderate to severe hallux valgus underwent an Akin osteotomy without internal fixation combined with modified Bösch osteotomy. Clinical efficacy was assessed using the American Orthopedic Foot and Ankle Society’s Forefoot scale, Hallux valgus angle (HVA), Intermetatarsal angle (IMA), and Distal metatarsal articular angle (DMAA). Results : According to the relevant criteria, 42 of 48 patients were included in this study. All patients were followed for a mean of 23 (range 18–30) months. At last follow-up the AOFS Forefoot scale was 87.4±12.0, the HVA was 15.0±1.8°, the IMA was 9.5±1.7°, the DMAA was 6.9±1.5°, all of which showed statistical differences compared to preoperative values（ P< 0.0001）. The satisfaction rate was 93% in the total sample. There were no incision infections, no sensory paresthesia’s due to injury to the medial dorsal cutaneous nerve of foot, and no recurrences. Conclusion : Akin osteotomy without internal fixation combined with modified Bösch osteotomy for the treatment of moderate to severe hallux valgus provides satisfactory results, with small incisional scars, low risk of wound infection and nerve injury, stable internal fixation, and short rehabilitation time. Level of Evidence : Level IV, retrospective case series. Hallux valgus Bösch osteotomy Akin osteotomy Figures Figure 1 Figure 2 Introduction Hallux Valgus (HV) is a common foot deformity in Orthopedics and Foot and Ankle Surgery, characterized primarily by first metatarsal varus, hallux valgus, and medial osteophyte formation of the first metatarsophalangeal joint[1]. Epidemiological investigations have demonstrated that the overall prevalence stands at 23% among individuals aged 18 to 65 years, and rises to 36% in those aged over 65 years, with a significantly higher prevalence observed in females compared to males[2, 3]. Notably, among individuals aged 45 to 64 years, moderate to severe hallux valgus cases—defined as those with a hallux valgus angle (HVA) > 30° and an intermetatarsal angle (IMA) > 13°—account for more than 53% of the total cases in this age group[4]. Patients with severe hallux valgus often present with first metatarsophalangeal joint pain, limited mobility, and gait abnormalities. In severe cases, this may further lead to excessive loading on the second metatarsal, plantar calluses, and even ulcers, significantly impairing quality of life[5]. Therefore, the pursuit of safe, effective, and low-complication surgical treatment strategies has long been a research focus in the field of Foot and Ankle Surgery. Currently, surgery serves as the primary therapeutic modality for moderate-to-severe HV, with its core objectives being the correction of metatarsal varus and hallux valgus deformities, the restoration of first metatarsophalangeal joint function, and the alleviation of pain[6, 7]. Minimally invasive surgical techniques for HV include the first-generation Reverdin-Isham technique, the second-generation Bösch technique, and the third-generation Minimal Incision Chevron-Akin (MICA) technique represented by Chevron osteotomy combined with Akin osteotomy, among others[8-10]. The third-generation MICA technique employs chevron osteotomy combined with dual-screw internal fixation, which offers superior stability[11]. However, it requires specialized foot and ankle surgical instruments and is associated with reduced bone mass, leading to shortening of the first metatarsal by an average of 3 mm[9, 12]. The medial dorsal cutaneous nerve of the foot is a continuation of the medial superficial branch of the superficial peroneal nerve. This nerve is located 0.5–0.8 cm lateral to the midpoint of the ankle joint, pierces the superficial surface of the extensor retinaculum, and ultimately divides into the medial dorsal cutaneous branch, as well as the first and second plantar dorsal branches. Its innervation territory is distributed to the medial aspect of the dorsum of the foot, the dorsal aspects of the first and second toes, and the medial half of the third toe[13]. Makwana et al.[14] reported that injury to the medial dorsal cutaneous nerve of the foot, the medial branch of the bunion, can lead to loss of sensation, pain, scarring, and even the formation of neurocytomas, which can be severe disabling. Both the second-generation Bösch technique and the third-generation MICA technique carry the risk of injury to the medial dorsal cutaneous nerve of the foot[15-17]. The Akin osteotomy is extensively employed in combined surgeries due to its direct correction of hallux valgus deformity at the proximal phalanx of the hallux and improvement of hallux alignment. The Bösch osteotomy, as a distal first metatarsal osteotomy, effectively shortens the first metatarsal and reduces the IMA, making it particularly suitable for metatarsal hyper length-type HV.[18-20]. However, traditional combined surgical procedures remain plagued by multiple limitations. On one hand, most osteotomies rely on internal fixators (e.g., plates and screws) to maintain the stability of the osteotomy site. While this helps reduce the risk of postoperative displacement, it may predispose patients to complications such as internal fixator irritation, foreign body reactions, and skin irritation. Additionally, some patients may require a second surgery for fixator removal, thereby increasing trauma and medical costs[21]. On the other hand, the Bösch osteotomy alone demonstrates limited efficacy in correcting hallux valgus deformity itself—particularly that involving the proximal phalanx of the hallux—while conversely, the Akin osteotomy in isolation fails to address the fundamental pathology of first metatarsal varus. Consequently, neither osteotomy, when employed in isolation, is sufficient to fulfill the comprehensive correction requirements for moderate-to-severe HV[22]. Furthermore, existing studies on the combined application of Akin osteotomy and modified Bösch osteotomy have largely focused on internal fixation modalities. In contrast, systematic data regarding the clinical efficacy and safety evaluation of the non-internal fixation approach for this combined procedure remain lacking. Therefore, its potential advantages in reducing complications and accelerating postoperative recovery warrant urgent investigation. Based on the research gap, this study proposes to adopt the Akin osteotomy without internal fixation combined with modified Bösch osteotomy for the treatment of moderate-to-severe HV. It aims to achieve the dual objectives of "correcting first metatarsal varus + improving hallux valgus" through the synergistic effect of the two osteotomies, while avoiding injury to the medial dorsal cutaneous nerve of the foot. Materials & methods This study was approved by the Ethics Committee of Yichang Central People's Hospital and was performed in accordance with the Declaration of Helsinki (2024-309-01). 1.1 Inclusion exclusion criteria The inclusion criteria were as follows: ① Age ≥ 18 years. ② Preoperative HVA ≥ 20° and IMA between the first and second metatarsal bones > 11°[5]. ③ Was treated with an Akin osteotomy without internal fixation combined with modified Bösch osteotomy. The exclusion criteria were as follows: ① Individuals with systemic inflammatory diseases (e.g., rheumatoid arthritis or gout). ② History of bone or soft tissue trauma that may affect foot alignment. ③ History of hallux valgus correction surgery on the same foot. ④ Simultaneous bilateral surgery. ⑤ Overweight (BMI > 30 kg/m²). ⑥ Loss to follow-up. 1.2 Clinical data From 2022 to 2024, 94 patients were diagnosed with hallux valgus. Among them, 42 patients who met the above inclusion criteria were enrolled in the current study (Figure 1). The patients’ demographics and radiological characteristics were comprehensively reviewed. The demographic data included age, sex, and BMI. The radiologic features included the Hallux valgus angle (HVA), Intermetatarsal angle (IMA), and Distal metatarsal articular angle (DMAA). Clinical evaluations included American Orthopedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, and Coughlin satisfaction scale. Long-term complications and reoperation rates were recorded. All patients completed the questionnaire independently. 1.3 Statistical analysis The statistical analysis was conducted via SPSS 25.0 software (SPSS Inc., Chicago, USA). Categorical variables are expressed as frequencies and percentages. Comparisons between groups were conducted using the chi-square test. Continuous variables are expressed as the means ± standard deviations. The Kolmogorov‒Smirnov test was employed to ascertain the normality of the distribution. The paired t test was used to compare pre- and postoperative values for numerical variables, and proportion test for dichotomous variables. Surgical techniques The patient is placed in a supine position and subjected to spinal anesthesia or general anesthesia. A tourniquet is applied to the affected limb, and the lower limb is routinely sterilized and covered with a sterile surgical towel. A 1.5-cm oblique incision was made along the medial skin crease at the distal metaphyseal region of the first metatarsal, starting from the dorsomedial aspect of the first metatarsal neck and extending obliquely inferomedial to the plantar medial aspect of the first metatarsal head (Figure 2A). The skin was incised, followed by subcutaneous blunt dissection. A longitudinal incision was then made in the periosteum along the medial midline of the metaphyseal region, and subperiosteal dissection was performed using a miniature elevator, preserving the integrity of the periosteal sheath. After periosteal stripping, an oscillating saw blade is used to osteotomies perpendicular to the axis of the second metatarsal, followed by a wedge-shaped osteotomy at the base of the first phalanx, preserving as much of the contralateral cortex as possible. After satisfactory osteotomy, the distal end of the metatarsal head is pushed laterally about 1/3 to 1/2 of the diameter of the metatarsal head. A 2.0 mm Kirschner wire was then introduced at the distal end of the hallux, medially to the nail, and advanced disto-proximally through soft tissues and in the first metatarsal canal. When satisfied, it was temporarily fixed with a Kirschner wire, and after reaming with a hollow drill, a 3.5 mm diameter, 3.0 cm long double-threaded hollow nail (DOUBLE MEDICALTM, Metal hollow screws, Xiamen, China) was inserted for fixation (Figure 2B). The surgical incision was irrigated, and subsequently, the surgeon closed the skin incision with sutures. Postoperatively, the affected foot was elevated, and on the first postoperative day, the patient was instructed to wear forefoot weight-bearing reducing shoes for ambulation out of bed. The incision sutures were removed about 14 days after the operation. The special shoes were worn with partial weight-bearing activity after removal of the Kirschner pin at 6 weeks postoperatively and full weight-bearing walking at 3 months postoperatively. Results A total of 94 individuals were diagnosed with hallux valgus from 2022 to 2024. A total of 42 patients met the inclusion criteria and were included in the study; demographic data are shown in Table 1. All 42 cases were followed up for a median of 23 (range 18–30) months. At the last follow-up the AOFAS Forefoot scale increased from preoperative 45.5±16.4 to 87.4±12.0 ( P< 0.0001), the HVA degrees decreased from preoperative 33.8±2.5 to 15.0±1.8 ( P< 0.0001), the IMA degrees decreased from preoperative 14.0±2.1 to 9.5±1.7 ( P< 0.0001), and the DMAA degrees decreased from preoperative 19.2±1.9 to 6.9±1.5 ( P< 0.0001). Coughlin satisfaction rate showed 93% (76.2% excellent, 16.7% good, and 7% fair) in the total sample. The surgical incision healed by first intention without infection. There was no sensory numbness due to medial dorsal nerve injury. No delayed or non-union occurred at the osteotomy site. No metastatic metatarsal pain was present. No recurrence of hallux valgus was observed (Table 2, Figure 3). The results above indicate that the combination of Akin osteotomy without internal fixation and modified Bösch osteotomy demonstrates favorable efficacy in treating moderate to severe hallux valgus. Table 1 Baseline characteristics of participants (mean ± SD) Variables moderate to severe hallux valgus (n=42) Age (years) 45.7 ± 6.8 Sex(M/F) 4(9.5%)/38(90.5%) BMI (kg/m 2 ) 24.4±2.7 Left/Right 25(59.5%)/17(40.5%) BMI, body mass index Table.2 Table summarizing pre- and postoperative hallux valgus outcomes Variables Preoperative Postoperative Difference P -value AOFAS Forefoot scale 45.5±16.4 87.4±12.0 41.9±17.4 P< 0.0001 HVA, degrees 33.8±2.5 15.0±1.8 -18.8±3.8 P< 0.0001 IMA, degrees 14.0±2.1 9.5±1.7 -4.5±3.6 P< 0.0001 DMAA, degrees 19.2±1.9 6.9±1.5 -12.3±3.3 P< 0.0001 Satisfaction rate, % (n) Excellent Good Fair N/A 76.2% (32) 16.7% (7) 7% (3) N/A N/A AOFAS: American Orthopedic Foot and Ankle Society; HVA: hallux valgus angle; IMA: intermetatarsal angle; DMAA: Distal metatarsal articular angle. Discussion The prevalence of hallux valgus is as high as 35.7%[ 23 ] and is usually bilateral, with a high prevalence in women over 40 years of age. Hallux valgus significantly impacts patients' quality of life, particularly in moderate-to-severe cases characterized by HVA > 30° and IMA > 13°[ 4 ]. While surgical intervention is the cornerstone of treatment, existing techniques are plagued by limitations such as specialized equipment requirements, bone mass loss, neurovascular injury risk, and internal fixation-related complications[ 3 , 21 ]. This retrospective study addressed the critical gap in evidence regarding non-internal fixation combined osteotomies by evaluating the efficacy and safety of Akin osteotomy without internal fixation combined with modified Bösch osteotomy, yielding clinically meaningful findings that advance HV surgical management. The primary strength of this study lies in the consistent and significant improvements observed across both functional and radiological metrics. Postoperatively, the AOFAS Forefoot scale increased from 45.5 ± 16.4 to 87.4 ± 12.0 (P < 0.0001), exceeding the threshold of 80 points typically associated with "good" clinical outcomes[ 24 ]. This functional enhancement aligns with the marked correction of deformity: HVA decreased by 18.8 ± 3.8° (from 33.8 ± 2.5° to 15.0 ± 1.8°), IMA by 4.5 ± 3.6° (from 14.0 ± 2.1° to 9.5 ± 1.7°), and DMAA by 12.3 ± 3.3° (from 19.2 ± 1.9° to 6.9 ± 1.5°). These postoperative values fall within the normal anatomical range (HVA < 15°, IMA < 10°, DMAA < 8°)[ 25 ], confirming the technique’s ability to address both metatarsal varus and hallux valgus—the dual pathological cores of HV[ 26 ]. Notably, patient satisfaction reached 93%, with 76.2% rating it as excellent and 16.7% as good. This high satisfaction rate is likely attributed to the technique's avoidance of common complications. Of note was the absence of surgical site infection, medial dorsal cutaneous nerve injury, and recurrence of HV. This favorable safety profile underscores the anatomical precision and minimally invasive design advantages of the technique. The third-generation MICA technique (chevron + Akin with dual-screw fixation) is widely adopted for its stability but requires specialized foot and ankle instruments and results in 3 mm average shortening of the first metatarsal due to bone resection[ 9 ]. In contrast, our modified Bösch osteotomy allows adjustment of metatarsal length via osteotomy direction, preserves bone mass by avoiding excessive resection, and eliminates the need for specialized equipment. This addresses the key limitations of MICA identified[ 12 ], making the technique accessible to primary hospitals lacking advanced minimally invasive infrastructure. Our technique uses a temporary Kirschner wire followed by a single 3.5 mm double-threaded hollow nail, which avoids long-term internal fixation while maintaining osteotomy site stability—no cases of delayed union or displacement were observed. This aligns with the growing emphasis on "biological fixation" in orthopedics, reducing iatrogenic trauma and medical costs [ 27 , 28 ]. Isolated Bösch osteotomy fails to address proximal phalangeal valgus, while standalone Akin osteotomy cannot correct first metatarsal varus[ 22 ]. The combined approach in this study leverages the complementary strengths of both techniques: modified Bösch osteotomy corrects metatarsal varus and adjusts length, while Akin osteotomy directly realigns the hallux at the proximal phalanx. This synergy explains the superior correction of DMAA (a marker of articular alignment) compared to single-osteotomy series[ 29 , 30 ]. The medial cutaneous nerve of the foot is prone to injury during hallux valgus surgery[ 31 – 34 ]. Our 1.5 cm oblique medial incision, located along the first metatarsal’s medial crease, avoids the nerve’s typical course (0.5–0.8 cm lateral to the ankle midpoint)[ 13 ]. Blunt subcutaneous dissection and preservation of the periosteal sheath further minimize neurovascular trauma, consistent with anatomical studies highlighting medial incisions as safer for nerve protection[ 35 ]. The technique’s efficacy stems from several anatomical and procedural refinements: Osteotomy Design: Perpendicular osteotomy relative to the second metatarsal axis and preservation of the contralateral cortex enhance stability while allowing controlled lateral translation of the metatarsal head (1/3–1/2 diameter). This balances correction precision and bone healing. Minimally Invasive Principles: The small oblique incision reduces scarring and soft tissue disruption, contributing to primary wound healing in all cases. Subperiosteal dissection preserves blood supply, a key determinant of osteotomy union[ 36 ]. Postoperative Rehabilitation: Early partial weight-bearing (day 1 with forefoot-reducing shoes) and full weight-bearing at 3 months accelerate recovery compared to techniques requiring 6–8 weeks of non-weight-bearing. This aligns with patient preferences for rapid return to daily activities. This study has several inherent limitations that warrant consideration. First, as a retrospective Level IV case series, it is susceptible to selection bias—patients with systemic inflammatory diseases or bilateral surgery were excluded, potentially limiting generalizability. Second, the sample size was small (n = 42), and the absence of a control group precluded direct comparison of efficacy and safety. Third, the mean follow-up of 23 months (range 18–30) is insufficient to evaluate long-term outcomes such as late recurrence or joint degeneration, which may manifest beyond 5 years[ 20 ]. Finally, we did not assess patient-reported outcomes beyond satisfaction. Conclusion The treatment effect of the Akin osteotomy without internal fixation combined with modified Bösch osteotomy in the treatment of hallux valgus deformity is satisfactory, which avoids the injury of the dorsal cutaneous nerve of the foot, avoids the repeated displacement of the metatarsal head after the osteotomy, and avoids the repeated X-ray fluoroscopies during the operation, and it can be adjusted the length of metatarsal bone through the direction of osteotomy, and it can be pronated, rotated, and the head of the metatarsal can be lifted or lowered, so it can preserve the amount of the metatarsal bones, and it shortens the operation time. The results showed that the amount of metatarsal bone was preserved, the operation time was shortened, and satisfactory orthopedic results could be obtained after the operation, which can be used as a reference for primary hospitals that do not have the conditions to carry out the third-generation MICA technique for the treatment of moderate-to-severe hallux valgus deformity. Declarations Funding There is no funding source. Conflicts of interest The authors declare that they have no conflict of interest. Consent for publication Written informed consent for publication was obtained from all participants. Informed consent Informed consent was obtained from all individual participants included in the study. Ethics approval This study has been approved by the Ethics Committee of the Yichang Central People's Hospital and considered by the Declaration of Helsinki (2024-309-01). Availability of data and materials The datasets used during the current study are available from the corresponding author upon reasonable request. References Nguyen US, Hillstrom HJ, Li W, Dufour AB, Kiel DP, Procter-Gray E, Gagnon MM, Hannan MT: Factors associated with hallux valgus in a population-based study of older women and men: the MOBILIZE Boston Study . Osteoarthritis Cartilage 2010, 18 (1):41-46. Lewis TL, Ray R, Gordon DJ: Time to maximum clinical improvement following minimally invasive chevron and Akin osteotomies (MICA) in hallux valgus surgery . Foot Ankle Surg 2022, 28 (7):928-934. Trnka HJ: Percutaneous, MIS and open hallux valgus surgery . EFORT Open Rev 2021, 6 (6):432-438. Aiyer A, Stewart S, Rome K: The effect of age on muscle characteristics of the abductor hallucis in people with hallux valgus: a cross-sectional observational study . J Foot Ankle Res 2015, 8 :19. Hecht PJ, Lin TJ: Hallux valgus . Med Clin North Am 2014, 98 (2):227-232. Palmanovich E, Ohana N, David S, Small I, Hetsroni I, Amar E, Sharfman ZT, Segal D, Atzmon R: Distal Chevron Osteotomy vs The Simple, Effective, Rapid, Inexpensive Technique (SERI) for Mild to Moderate Isolated Hallux Valgus: A Randomized Controlled Study . Indian J Orthop 2021, 55 (Suppl 1):110-118. Chin KM, Richardson NS, Campbell JT, Jeng CL, Christian MW, Cerrato RA: The Hallux Metatarsophalangeal Capsule: An Anatomic Study With Respect to Percutaneous Hallux Valgus Correction . Foot Ankle Int 2022, 43 (1):86-90. Del Vecchio JJ, Ghioldi ME: Evolution of Minimally Invasive Surgery in Hallux Valgus . Foot Ankle Clin 2020, 25 (1):79-95. Acevedo JI, Cedeno AA, Doty J, Mcwilliam J: Minimally Invasive Technique for Hallux Valgus Correction . Techniques in Foot & Ankle Surgery 2021, Publish Ahead of Print . Bosch P, Wanke S, Legenstein R: Hallux valgus correction by the method of Bosch: a new technique with a seven-to-ten-year follow-up . Foot Ankle Clin 2000, 5 (3):485-498, v-vi. Kurashige T: Radiographic and Clinical Results of Minimally Invasive Chevron Akin Osteotomy for Moderate to Severe Hallux Valgus Deformities . Foot Ankle Spec 2024, 17 (4):305-317. Castellini JLA, Grande Ratti MF, Gonzalez DL: Clinical and Radiographic Outcomes of Percutaneous Third-Generation Double First Metatarsal Osteotomy Combined With Closing-Wedge Proximal Phalangeal Osteotomy for Moderate and Severe Hallux Valgus . Foot Ankle Int 2022, 43 (11):1438-1449. Hu D, Hong X, Wei X, Lin H, Zhang F, Zheng H, Lin J: Anatomical Basis and Clinical Application of the First Metatarsal Proximal Perforator-Based Neurocutaneous Vascular Flap . Clin Anat 2020, 33 (5):653-660. Makwana N, Hossain M, Kumar A, Mbako A: The sentinel vein: an anatomical guide to localisation of the dorsomedial cutaneous nerve in hallux surgery . J Bone Joint Surg Br 2011, 93 (10):1373-1376. Solan MC, Lemon M, Bendall SP: The surgical anatomy of the dorsomedial cutaneous nerve of the hallux . J Bone Joint Surg Br 2001, 83 (2):250-252. Baravarian B, Ben-Ad R: Revision hallux valgus: causes and correction options . Clin Podiatr Med Surg 2014, 31 (2):291-298. Soares S, Campos G, Mota Gomes T, Medeiros F, Martin Oliva X: Anatomy of the Dorsomedial Cutaneous Nerve to Hallux and Surgical Implications According to the Severity of Hallux Valgus Deformity: A Cadaveric Study . J Foot Ankle Surg 2021, 60 (5):968-972. Guodong S, Yunxuan Z, Hongning Z, Xue L, Kangyong Y, Zhibin L, Yongzhan Z: Efficacy of minimally PCWO combined with Akin osteotomy on severe hallux valgus . Chinese Journal of Orthopaedics 2021, 41 (5):309 - 317. Lee M, Walsh J, Smith MM, Ling J, Wines A, Lam P: Hallux Valgus Correction Comparing Percutaneous Chevron/Akin (PECA) and Open Scarf/Akin Osteotomies . Foot Ankle Int 2017, 38 (8):838-846. Bernasconi A, Rizzo M, Izzo A, Vallefuoco S, Russo AP, Rossi V, Abate B, Guarino A, Mariconda M: Bösch osteotomy for hallux valgus correction: results at a mean 10-year follow-up . Arch Orthop Trauma Surg 2023, 143 (3):1293-1300. Kong LP, Yang JJ, Wang F, Liu FX, Yang YL: Minimally invasive open reduction of greater tuberosity fractures by a modified suture bridge procedure . World J Clin Cases 2022, 10 (1):117-127. Malagelada F, Sahirad C, Dalmau-Pastor M, Vega J, Bhumbra R, Manzanares-Cespedes MC, Laffenetre O: Minimally invasive surgery for hallux valgus: a systematic review of current surgical techniques . Int Orthop 2019, 43 (3):625-637. Klos K, Lenz M, Hofmann GO, Schubert W, Knobe M, Roth KE, Simons P, Aurich M: The Correction Potential of the Lateral Release of the Hallux Valgus: A Comparative Anatomical Study of Minimally Invasive Versus Open Surgical Technique Using a Dorsal Approach . Indian J Orthop 2022, 56 (5):887-894. Buck TMF, Lauf K, Dahmen J, Altink JN, Stufkens SAS, Kerkhoffs G: Non-operative management for osteochondral lesions of the talus: a systematic review of treatment modalities, clinical- and radiological outcomes . Knee Surg Sports Traumatol Arthrosc 2023, 31 (8):3517-3527. Harb Z, Kokkinakis M, Ismail H, Spence G: Adolescent hallux valgus: a systematic review of outcomes following surgery . J Child Orthop 2015, 9 (2):105-112. Wagner P, Wagner E: Republication of "Proximal Rotational Metatarsal Osteotomy for Hallux Valgus (PROMO): Short-term Prospective Case Series With a Novel Technique and Topic Review" . Foot Ankle Orthop 2023, 8 (3):24730114231195049. Liu YJ, Li ZL, Wang ZG, Wang Y, Zhou M, Wang AY, Cai X, Tang JS, Zhang WT, Gao L: [The clinical application and biomechanical study of reconstruction of anterior and posterior cruciate ligament with hamstring tendons knot implant fixation] . Zhonghua Wai Ke Za Zhi 2005, 43 (4):239-242. Jung GH, Park CM, Kim JD: Biologic fixation through bridge plating for comminuted shaft fracture of the clavicle: technical aspects and prospective clinical experience with a minimum of 12-month follow-up . Clin Orthop Surg 2013, 5 (4):327-333. Baca E, Kaya MG, Çiftçi MU: Double osteotomy in recurrence cases with distal metatarsal articular angle increase after hallux valgus distal surgery . Jt Dis Relat Surg 2025, 36 (2):420-427. Kyung MG, Park GY, Yang H, Lee DY: A Modified 90-Degree Distal Chevron Metatarsal Osteotomy for Correcting Moderate Hallux Valgus Deformity . J Clin Med 2023, 12 (21). Navarro-Cano E, Carrera A, Konschake M, Guevara-Noriega KA, Reina F: Percutaneous hallux valgus surgery: Anatomical study of its safety and effectiveness . Orthop Traumatol Surg Res 2023, 109 (8):103266. McGann M, Langan TM, Brandão RA, Berlet G, Prissel M: Structures at Risk During Percutaneous Extra-Articular Chevron Osteotomy of the Distal First Metatarsal . Foot Ankle Spec 2021, 14 (1):19-24. Chan CX, Gan JZ, Chong HC, Rikhraj Singh I, Ng SYC, Koo K: Two year outcomes of minimally invasive hallux valgus surgery . Foot Ankle Surg 2019, 25 (2):119-126. Tay AYW, Goh GS, Koo K, Yeo NEM: Third-Generation Minimally Invasive Chevron-Akin Osteotomy for Hallux Valgus Produces Similar Clinical and Radiological Outcomes as Scarf-Akin Osteotomy at 2 Years: A Matched Cohort Study . Foot Ankle Int 2022, 43 (3):321-330. Kaipel M, Reissig L, Albrecht L, Quadlbauer S, Klikovics J, Weninger WJ: Risk of Damaging Anatomical Structures During Minimally Invasive Hallux Valgus Correction (Bosch Technique): An Anatomical Study . Foot Ankle Int 2018, 39 (11):1355-1359. Arata J, Kumakiri M, Yamashita T, Kaito S: Nonincisional Osteotomy for Gradual Lengthening by Callus Distraction for Congenital Brachymetatarsia . J Foot Ankle Surg 2021, 60 (6):1293-1296. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7713475","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":526927521,"identity":"ce5799f7-c446-4f73-a64b-46d12a0f929a","order_by":0,"name":"Zhiqi Zhang","email":"","orcid":"","institution":"Yichang Traditional Chinese Medicine Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zhiqi","middleName":"","lastName":"Zhang","suffix":""},{"id":526927522,"identity":"3066b439-2fb5-4ccf-acab-57d625282c9e","order_by":1,"name":"Heng Zhang","email":"","orcid":"","institution":"the First College of Clinical Medical Sciences, China Three Gorges University \u0026 Yichang Central People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Heng","middleName":"","lastName":"Zhang","suffix":""},{"id":526927523,"identity":"1a641607-971c-4359-a090-6b865cf64389","order_by":2,"name":"Huarui Yang","email":"","orcid":"","institution":"the First College of Clinical Medical Sciences, China Three Gorges University \u0026 Yichang Central People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Huarui","middleName":"","lastName":"Yang","suffix":""},{"id":526927524,"identity":"e1128a20-66bc-4de9-a9e2-5eef456f9984","order_by":3,"name":"Tongzhu Bao","email":"","orcid":"","institution":"the First College of Clinical Medical Sciences, China Three Gorges University \u0026 Yichang Central People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Tongzhu","middleName":"","lastName":"Bao","suffix":""},{"id":526927525,"identity":"0bf9d9fa-c90e-49d3-a892-b6fa07d89852","order_by":4,"name":"Kangquan Shou","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2UlEQVRIiWNgGAWjYBACxmYInQBiPwASMgwMbMRrYTZgYDDgIagFBkBa2CSI0sLczp26mXePTR6/9NljFR/b/vDws7clMPyo2IbHYbzbbvM8SyuW7MtLuzmzzYBHsufYAcaeM7cJaDlwOHHDGR6z27xALQY30huYGdsIavkP1lJMipYDYC3MEC1pBwhquTnnQHKxZA+PseSMc8YgvyQcxOcXw/6z2268OWCXx8/DY/jhQ5mcHDDEDB/8qMCjpYGBgYkHXfQATvVAIA9y3A98KkbBKBgFo2AUAADQVlUzaciRuwAAAABJRU5ErkJggg==","orcid":"","institution":"the First College of Clinical Medical Sciences, China Three Gorges University \u0026 Yichang Central People's Hospital","correspondingAuthor":true,"prefix":"","firstName":"Kangquan","middleName":"","lastName":"Shou","suffix":""}],"badges":[],"createdAt":"2025-09-25 13:38:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7713475/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7713475/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":93337876,"identity":"3df994ec-0224-4b52-975a-b8c82e3ff197","added_by":"auto","created_at":"2025-10-12 14:12:22","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":414327,"visible":true,"origin":"","legend":"","description":"","filename":"Akin.docx","url":"https://assets-eu.researchsquare.com/files/rs-7713475/v1/558d0ff55d495fb7828b573e.docx"},{"id":93336240,"identity":"4b17d51d-474c-44db-aad8-cfff24233660","added_by":"auto","created_at":"2025-10-12 14:04:22","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":6586,"visible":true,"origin":"","legend":"","description":"","filename":"dad67fc812fc4dab9ce55213d1f98600.json","url":"https://assets-eu.researchsquare.com/files/rs-7713475/v1/931052658363645a76879674.json"},{"id":93336242,"identity":"e605083a-0acd-4862-85e1-4e61db0d2d90","added_by":"auto","created_at":"2025-10-12 14:04:22","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":93633,"visible":true,"origin":"","legend":"","description":"","filename":"dad67fc812fc4dab9ce55213d1f986001enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7713475/v1/3bfeeb5e877eb8dccf013a7a.xml"},{"id":93336248,"identity":"48a6f932-53da-454b-8b32-ea66d46e10f4","added_by":"auto","created_at":"2025-10-12 14:04:22","extension":"png","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":103736,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7713475/v1/169d2d998a283d53ac1ccec3.png"},{"id":93337875,"identity":"17b83884-e497-48ab-bac9-6bf6ef2a8273","added_by":"auto","created_at":"2025-10-12 14:12:22","extension":"jpeg","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":91712,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7713475/v1/eb43074835cbcfa02616513e.jpeg"},{"id":93336245,"identity":"0dd81b88-fc23-4f88-9966-a9ec9dd4a092","added_by":"auto","created_at":"2025-10-12 14:04:22","extension":"jpeg","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":115754,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7713475/v1/830ed3da68226c5efdc0a94a.jpeg"},{"id":93336244,"identity":"cb6325a5-2c2e-4bc2-98af-0455bcfce9cb","added_by":"auto","created_at":"2025-10-12 14:04:22","extension":"png","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":28322,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7713475/v1/d8e9ee7ea8c30f93ac974c64.png"},{"id":93336246,"identity":"003a19e1-0d2e-4978-9c60-a0e8394c1568","added_by":"auto","created_at":"2025-10-12 14:04:22","extension":"png","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":135046,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7713475/v1/2ec68680f851cbabcf82653a.png"},{"id":93336250,"identity":"1321ad92-b531-4623-9168-115f27ca46b8","added_by":"auto","created_at":"2025-10-12 14:04:22","extension":"png","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":145473,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7713475/v1/63f49029ae1b767357a196cd.png"},{"id":93336252,"identity":"b9f5d5c1-b30b-40a0-9633-ac3c39a7f1a2","added_by":"auto","created_at":"2025-10-12 14:04:22","extension":"xml","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":89468,"visible":true,"origin":"","legend":"","description":"","filename":"dad67fc812fc4dab9ce55213d1f986001structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7713475/v1/e856a4bef489079f57d6af42.xml"},{"id":93336251,"identity":"c93a87a9-f1c8-4367-b915-47021813c714","added_by":"auto","created_at":"2025-10-12 14:04:22","extension":"html","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":99805,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7713475/v1/457bab57e80a76d81b9d99c3.html"},{"id":93337874,"identity":"7e3da845-1b0d-472e-a31f-e75b68bfeed8","added_by":"auto","created_at":"2025-10-12 14:12:22","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":44607,"visible":true,"origin":"","legend":"\u003cp\u003eFlow chart showing patient cohort inclusion.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7713475/v1/8d0789d668db98404cbfd1df.png"},{"id":93336241,"identity":"7d1db812-bb65-40d6-8276-14cf57415873","added_by":"auto","created_at":"2025-10-12 14:04:22","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":277436,"visible":true,"origin":"","legend":"\u003cp\u003e(A) Modified Bösch osteotomy incision design; (B) Post-osteotomy fixation.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7713475/v1/c178544c686de1072fd56c60.png"},{"id":93366083,"identity":"35e38389-bb63-411d-b925-ac33bbaf0bd3","added_by":"auto","created_at":"2025-10-13 05:01:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2627808,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7713475/v1/ddd99b6f-8002-4d62-86da-7ef027bd596c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Akin osteotomy without internal fixation combined with modified Bösch osteotomy for the treatment of moderate to severe hallux valgus","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHallux Valgus (HV) is a common foot deformity in Orthopedics and Foot and Ankle Surgery, characterized primarily by first metatarsal varus, hallux valgus, and medial osteophyte formation of the first metatarsophalangeal joint[1].\u0026nbsp;Epidemiological investigations have demonstrated that the overall prevalence stands at 23% among individuals aged 18 to 65 years, and rises to 36% in those aged over 65 years, with a significantly higher prevalence observed in females compared to males[2, 3].\u0026nbsp;Notably, among individuals aged 45 to 64 years, moderate to severe hallux valgus cases—defined as those with a hallux valgus angle (HVA) \u0026gt; 30° and an intermetatarsal angle (IMA) \u0026gt; 13°—account for more than 53% of the total cases in this age group[4].\u0026nbsp;Patients with severe hallux valgus often present with first metatarsophalangeal joint pain, limited mobility, and gait abnormalities. In severe cases, this may further lead to excessive loading on the second metatarsal, plantar calluses, and even ulcers, significantly impairing quality of life[5].\u0026nbsp;Therefore, the pursuit of safe, effective, and low-complication surgical treatment strategies has long been a research focus in the field of Foot and Ankle Surgery.\u003c/p\u003e\n\u003cp\u003eCurrently, surgery serves as the primary therapeutic modality for moderate-to-severe HV, with its core objectives being the correction of metatarsal varus and hallux valgus deformities, the restoration of first metatarsophalangeal joint function, and the alleviation of pain[6, 7]. Minimally invasive surgical techniques for HV include the first-generation Reverdin-Isham technique, the second-generation Bösch technique, and the third-generation Minimal Incision Chevron-Akin (MICA) technique represented by Chevron osteotomy combined with Akin osteotomy, among others[8-10].\u0026nbsp;The third-generation MICA technique employs chevron osteotomy combined with dual-screw internal fixation, which offers superior stability[11]. However, it requires specialized foot and ankle surgical instruments and is associated with reduced bone mass, leading to shortening of the first metatarsal by an average of 3 mm[9, 12].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe medial dorsal cutaneous nerve of the foot is a continuation of the medial superficial branch of the superficial peroneal nerve. This nerve is located 0.5–0.8 cm lateral to the midpoint of the ankle joint, pierces the superficial surface of the extensor retinaculum, and ultimately divides into the medial dorsal cutaneous branch, as well as the first and second plantar dorsal branches. Its innervation territory is distributed to the medial aspect of the dorsum of the foot, the dorsal aspects of the first and second toes, and the medial half of the third toe[13].\u0026nbsp;Makwana et al.[14]\u0026nbsp;reported that injury to the medial dorsal cutaneous nerve of the foot, the medial branch of the bunion, can lead to loss of sensation, pain, scarring, and even the formation of neurocytomas, which can be severe disabling.\u0026nbsp;Both the second-generation Bösch technique and the third-generation MICA technique carry the risk of injury to the medial dorsal cutaneous nerve of the foot[15-17].\u003c/p\u003e\n\u003cp\u003eThe Akin osteotomy is extensively employed in combined surgeries due to its direct correction of hallux valgus deformity at the proximal phalanx of the hallux and improvement of hallux alignment.\u0026nbsp;The Bösch osteotomy, as a distal first metatarsal osteotomy, effectively shortens the first metatarsal and reduces the IMA, making it particularly suitable for metatarsal hyper length-type HV.[18-20].\u0026nbsp;However, traditional combined surgical procedures remain plagued by multiple limitations. On one hand, most osteotomies rely on internal fixators (e.g., plates and screws) to maintain the stability of the osteotomy site. While this helps reduce the risk of postoperative displacement, it may predispose patients to complications such as internal fixator irritation, foreign body reactions, and skin irritation. Additionally, some patients may require a second surgery for fixator removal, thereby increasing trauma and medical costs[21].\u0026nbsp;On the other hand, the Bösch osteotomy alone demonstrates limited efficacy in correcting hallux valgus deformity itself—particularly that involving the proximal phalanx of the hallux—while conversely, the Akin osteotomy in isolation fails to address the fundamental pathology of first metatarsal varus. Consequently, neither osteotomy, when employed in isolation, is sufficient to fulfill the comprehensive correction requirements for moderate-to-severe HV[22].\u0026nbsp;Furthermore, existing studies on the combined application of Akin osteotomy and modified Bösch osteotomy have largely focused on internal fixation modalities. In contrast, systematic data regarding the clinical efficacy and safety evaluation of the non-internal fixation approach for this combined procedure remain lacking. Therefore, its potential advantages in reducing complications and accelerating postoperative recovery warrant urgent investigation.\u003c/p\u003e\n\u003cp\u003eBased on the research gap, this study proposes to adopt the Akin osteotomy without internal fixation combined with modified Bösch osteotomy for the treatment of moderate-to-severe HV. It aims to achieve the dual objectives of \"correcting first metatarsal varus + improving hallux valgus\" through the synergistic effect of the two osteotomies, while avoiding injury to the medial dorsal cutaneous nerve of the foot.\u003c/p\u003e"},{"header":"Materials \u0026 methods","content":"\u003cp\u003eThis study was approved by the Ethics Committee of Yichang Central People\u0026apos;s Hospital and was performed in accordance with the Declaration of Helsinki (2024-309-01).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.1\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eInclusion exclusion criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe inclusion criteria were as follows: ① Age \u0026ge; 18 years. ② Preoperative HVA \u0026ge; 20\u0026deg; and IMA between the first and second metatarsal bones \u0026gt; 11\u0026deg;[5]. ③ Was treated with an Akin osteotomy without internal fixation combined with modified B\u0026ouml;sch osteotomy.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe exclusion criteria were as follows:\u0026nbsp;① Individuals with systemic inflammatory diseases (e.g., rheumatoid arthritis or gout). ② History of bone or soft tissue trauma that may affect foot alignment. ③ History of hallux valgus correction surgery on the same foot.\u0026nbsp;④\u0026nbsp;Simultaneous bilateral surgery.\u0026nbsp;⑤\u0026nbsp;Overweight (BMI \u0026gt; 30 kg/m\u0026sup2;).\u0026nbsp;⑥\u0026nbsp;Loss to follow-up.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.2 Clinical data\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFrom 2022 to 2024, 94 patients were diagnosed with hallux valgus. Among them, 42 patients who met the above inclusion criteria were enrolled in the current study (Figure 1). The patients\u0026rsquo; demographics and radiological characteristics were comprehensively reviewed. The demographic data included age, sex, and BMI. The radiologic features included the Hallux valgus angle (HVA), Intermetatarsal angle (IMA), and Distal metatarsal articular angle (DMAA). Clinical evaluations included American Orthopedic Foot \u0026amp; Ankle Society (AOFAS) ankle-hindfoot score, and Coughlin satisfaction scale. Long-term complications and reoperation rates were recorded. All patients completed the questionnaire independently.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.3 Statistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe statistical analysis was conducted via SPSS 25.0 software (SPSS Inc., Chicago, USA). Categorical variables are expressed as frequencies and percentages. Comparisons between groups were conducted using the chi-square test. Continuous variables are expressed as the means \u0026plusmn; standard deviations. The Kolmogorov‒Smirnov test was employed to ascertain the normality of the distribution. The paired t test was used to compare pre- and postoperative values for numerical variables, and proportion test for dichotomous variables.\u003c/p\u003e"},{"header":"Surgical techniques","content":"\u003cp\u003eThe patient is placed in a supine position and subjected to spinal anesthesia or general anesthesia. A tourniquet is applied to the affected limb, and the lower limb is routinely sterilized and covered with a sterile surgical towel. A 1.5-cm oblique incision was made along the medial skin crease at the distal metaphyseal region of the first metatarsal, starting from the dorsomedial aspect of the first metatarsal neck and extending obliquely inferomedial to the plantar medial aspect of the first metatarsal head (Figure 2A). The skin was incised, followed by subcutaneous blunt dissection. A longitudinal incision was then made in the periosteum along the medial midline of the metaphyseal region, and subperiosteal dissection was performed using a miniature elevator, preserving the integrity of the periosteal sheath. After periosteal stripping, an oscillating saw blade is used to osteotomies perpendicular to the axis of the second metatarsal, followed by a wedge-shaped osteotomy at the base of the first phalanx, preserving as much of the contralateral cortex as possible. After satisfactory osteotomy, the distal end of the metatarsal head is pushed laterally about 1/3 to 1/2 of the diameter of the metatarsal head. A 2.0 mm Kirschner wire was then introduced at the distal end of the hallux, medially to the nail, and advanced disto-proximally through soft tissues and in the first metatarsal canal. When satisfied, it was temporarily fixed with a Kirschner wire, and after reaming with a hollow drill, a 3.5 mm diameter, 3.0 cm long double-threaded hollow nail (DOUBLE MEDICALTM, Metal hollow screws, Xiamen, China) was inserted for fixation (Figure 2B). The surgical incision was irrigated, and subsequently, the surgeon closed the skin incision with sutures.\u003c/p\u003e\n\u003cp\u003ePostoperatively, the affected foot was elevated, and on the first postoperative day, the patient was instructed to wear forefoot weight-bearing reducing shoes for ambulation out of bed. The incision sutures were removed about 14 days after the operation. The special shoes were worn with partial weight-bearing activity after removal of the Kirschner pin at 6 weeks postoperatively and full weight-bearing walking at 3 months postoperatively.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 94 individuals were diagnosed with hallux valgus from 2022 to 2024. A total of 42 patients met the inclusion criteria and were included in the study; demographic data are shown in Table 1. All 42 cases were followed up for a median of 23 (range 18\u0026ndash;30) months. At the last follow-up the AOFAS Forefoot scale increased from preoperative 45.5\u0026plusmn;16.4 to 87.4\u0026plusmn;12.0 (\u003cem\u003eP\u0026lt;\u0026nbsp;\u003c/em\u003e0.0001), the HVA degrees decreased from preoperative 33.8\u0026plusmn;2.5 to 15.0\u0026plusmn;1.8 (\u003cem\u003eP\u0026lt;\u0026nbsp;\u003c/em\u003e0.0001), the IMA degrees decreased from preoperative 14.0\u0026plusmn;2.1 to 9.5\u0026plusmn;1.7 (\u003cem\u003eP\u0026lt;\u0026nbsp;\u003c/em\u003e0.0001), and the DMAA degrees\u0026nbsp;decreased from preoperative 19.2\u0026plusmn;1.9 to 6.9\u0026plusmn;1.5 (\u003cem\u003eP\u0026lt;\u0026nbsp;\u003c/em\u003e0.0001). Coughlin satisfaction rate showed 93% (76.2% excellent, 16.7% good, and 7% fair) in the total sample. The surgical incision healed by first intention without infection. There was no sensory numbness due to medial dorsal nerve injury. No delayed or non-union occurred at the osteotomy site. No metastatic metatarsal pain was present. No recurrence of hallux valgus was observed (Table 2, Figure 3).\u003c/p\u003e\n\u003cp\u003eThe results above indicate that the combination of Akin osteotomy without internal fixation and modified B\u0026ouml;sch osteotomy demonstrates favorable efficacy in treating moderate to severe hallux valgus.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1 Baseline characteristics of participants (mean \u0026plusmn; SD)\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 48.4574%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51.5426%;\"\u003e\n \u003cp\u003e\u003cstrong\u003emoderate to severe hallux valgus (n=42)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.4574%;\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51.5426%;\"\u003e\n \u003cp\u003e45.7 \u0026plusmn; 6.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.4574%;\"\u003e\n \u003cp\u003eSex(M/F)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51.5426%;\"\u003e\n \u003cp\u003e4(9.5%)/38(90.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.4574%;\"\u003e\n \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51.5426%;\"\u003e\n \u003cp\u003e24.4\u0026plusmn;2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.4574%;\"\u003e\n \u003cp\u003eLeft/Right\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51.5426%;\"\u003e\n \u003cp\u003e25(59.5%)/17(40.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cem\u003eBMI,\u003c/em\u003e body mass index\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable.2\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eTable summarizing pre- and postoperative hallux valgus outcomes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreoperative\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostoperative\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDifference\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003eAOFAS Forefoot scale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e45.5\u0026plusmn;16.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e87.4\u0026plusmn;12.0\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e41.9\u0026plusmn;17.4\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u0026lt;\u0026nbsp;\u003c/em\u003e0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003eHVA, degrees\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e33.8\u0026plusmn;2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e15.0\u0026plusmn;1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e-18.8\u0026plusmn;3.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u0026lt;\u0026nbsp;\u003c/em\u003e0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003eIMA,\u0026nbsp;degrees\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e14.0\u0026plusmn;2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e9.5\u0026plusmn;1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e-4.5\u0026plusmn;3.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u0026lt;\u0026nbsp;\u003c/em\u003e0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003eDMAA,\u0026nbsp;degrees\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e19.2\u0026plusmn;1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e6.9\u0026plusmn;1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e-12.3\u0026plusmn;3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u0026lt;\u0026nbsp;\u003c/em\u003e0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003eSatisfaction rate, % (n)\u003c/p\u003e\n \u003cp\u003eExcellent\u003c/p\u003e\n \u003cp\u003eGood\u003c/p\u003e\n \u003cp\u003eFair\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e76.2% (32)\u003c/p\u003e\n \u003cp\u003e16.7% (7)\u003c/p\u003e\n \u003cp\u003e7% (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eAOFAS: American Orthopedic Foot and Ankle Society; HVA: hallux valgus angle; IMA: intermetatarsal angle; DMAA: Distal metatarsal articular angle.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe prevalence of hallux valgus is as high as 35.7%[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] and is usually bilateral, with a high prevalence in women over 40 years of age. Hallux valgus significantly impacts patients' quality of life, particularly in moderate-to-severe cases characterized by HVA\u0026thinsp;\u0026gt;\u0026thinsp;30\u0026deg; and IMA\u0026thinsp;\u0026gt;\u0026thinsp;13\u0026deg;[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. While surgical intervention is the cornerstone of treatment, existing techniques are plagued by limitations such as specialized equipment requirements, bone mass loss, neurovascular injury risk, and internal fixation-related complications[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. This retrospective study addressed the critical gap in evidence regarding non-internal fixation combined osteotomies by evaluating the efficacy and safety of Akin osteotomy without internal fixation combined with modified B\u0026ouml;sch osteotomy, yielding clinically meaningful findings that advance HV surgical management.\u003c/p\u003e\u003cp\u003eThe primary strength of this study lies in the consistent and significant improvements observed across both functional and radiological metrics. Postoperatively, the AOFAS Forefoot scale increased from 45.5\u0026thinsp;\u0026plusmn;\u0026thinsp;16.4 to 87.4\u0026thinsp;\u0026plusmn;\u0026thinsp;12.0 (P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), exceeding the threshold of 80 points typically associated with \"good\" clinical outcomes[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. This functional enhancement aligns with the marked correction of deformity: HVA decreased by 18.8\u0026thinsp;\u0026plusmn;\u0026thinsp;3.8\u0026deg; (from 33.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5\u0026deg; to 15.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8\u0026deg;), IMA by 4.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.6\u0026deg; (from 14.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1\u0026deg; to 9.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7\u0026deg;), and DMAA by 12.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.3\u0026deg; (from 19.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9\u0026deg; to 6.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u0026deg;). These postoperative values fall within the normal anatomical range (HVA\u0026thinsp;\u0026lt;\u0026thinsp;15\u0026deg;, IMA\u0026thinsp;\u0026lt;\u0026thinsp;10\u0026deg;, DMAA\u0026thinsp;\u0026lt;\u0026thinsp;8\u0026deg;)[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], confirming the technique\u0026rsquo;s ability to address both metatarsal varus and hallux valgus\u0026mdash;the dual pathological cores of HV[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eNotably, patient satisfaction reached 93%, with 76.2% rating it as excellent and 16.7% as good. This high satisfaction rate is likely attributed to the technique's avoidance of common complications. Of note was the absence of surgical site infection, medial dorsal cutaneous nerve injury, and recurrence of HV. This favorable safety profile underscores the anatomical precision and minimally invasive design advantages of the technique.\u003c/p\u003e\u003cp\u003eThe third-generation MICA technique (chevron\u0026thinsp;+\u0026thinsp;Akin with dual-screw fixation) is widely adopted for its stability but requires specialized foot and ankle instruments and results in 3 mm average shortening of the first metatarsal due to bone resection[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In contrast, our modified B\u0026ouml;sch osteotomy allows adjustment of metatarsal length via osteotomy direction, preserves bone mass by avoiding excessive resection, and eliminates the need for specialized equipment. This addresses the key limitations of MICA identified[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], making the technique accessible to primary hospitals lacking advanced minimally invasive infrastructure.\u003c/p\u003e\u003cp\u003eOur technique uses a temporary Kirschner wire followed by a single 3.5 mm double-threaded hollow nail, which avoids long-term internal fixation while maintaining osteotomy site stability\u0026mdash;no cases of delayed union or displacement were observed. This aligns with the growing emphasis on \"biological fixation\" in orthopedics, reducing iatrogenic trauma and medical costs [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIsolated B\u0026ouml;sch osteotomy fails to address proximal phalangeal valgus, while standalone Akin osteotomy cannot correct first metatarsal varus[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The combined approach in this study leverages the complementary strengths of both techniques: modified B\u0026ouml;sch osteotomy corrects metatarsal varus and adjusts length, while Akin osteotomy directly realigns the hallux at the proximal phalanx. This synergy explains the superior correction of DMAA (a marker of articular alignment) compared to single-osteotomy series[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe medial cutaneous nerve of the foot is prone to injury during hallux valgus surgery[\u003cspan additionalcitationids=\"CR32 CR33\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Our 1.5 cm oblique medial incision, located along the first metatarsal\u0026rsquo;s medial crease, avoids the nerve\u0026rsquo;s typical course (0.5\u0026ndash;0.8 cm lateral to the ankle midpoint)[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Blunt subcutaneous dissection and preservation of the periosteal sheath further minimize neurovascular trauma, consistent with anatomical studies highlighting medial incisions as safer for nerve protection[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe technique\u0026rsquo;s efficacy stems from several anatomical and procedural refinements:\u003c/p\u003e\u003cp\u003eOsteotomy Design: Perpendicular osteotomy relative to the second metatarsal axis and preservation of the contralateral cortex enhance stability while allowing controlled lateral translation of the metatarsal head (1/3\u0026ndash;1/2 diameter). This balances correction precision and bone healing.\u003c/p\u003e\u003cp\u003eMinimally Invasive Principles: The small oblique incision reduces scarring and soft tissue disruption, contributing to primary wound healing in all cases. Subperiosteal dissection preserves blood supply, a key determinant of osteotomy union[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePostoperative Rehabilitation: Early partial weight-bearing (day 1 with forefoot-reducing shoes) and full weight-bearing at 3 months accelerate recovery compared to techniques requiring 6\u0026ndash;8 weeks of non-weight-bearing. This aligns with patient preferences for rapid return to daily activities.\u003c/p\u003e\u003cp\u003eThis study has several inherent limitations that warrant consideration. First, as a retrospective Level IV case series, it is susceptible to selection bias\u0026mdash;patients with systemic inflammatory diseases or bilateral surgery were excluded, potentially limiting generalizability. Second, the sample size was small (n\u0026thinsp;=\u0026thinsp;42), and the absence of a control group precluded direct comparison of efficacy and safety. Third, the mean follow-up of 23 months (range 18\u0026ndash;30) is insufficient to evaluate long-term outcomes such as late recurrence or joint degeneration, which may manifest beyond 5 years[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Finally, we did not assess patient-reported outcomes beyond satisfaction.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe treatment effect of the Akin osteotomy without internal fixation combined with modified B\u0026ouml;sch osteotomy in the treatment of hallux valgus deformity is satisfactory, which avoids the injury of the dorsal cutaneous nerve of the foot, avoids the repeated displacement of the metatarsal head after the osteotomy, and avoids the repeated X-ray fluoroscopies during the operation, and it can be adjusted the length of metatarsal bone through the direction of osteotomy, and it can be pronated, rotated, and the head of the metatarsal can be lifted or lowered, so it can preserve the amount of the metatarsal bones, and it shortens the operation time. The results showed that the amount of metatarsal bone was preserved, the operation time was shortened, and satisfactory orthopedic results could be obtained after the operation, which can be used as a reference for primary hospitals that do not have the conditions to carry out the third-generation MICA technique for the treatment of moderate-to-severe hallux valgus deformity.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere is no funding source.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study has been approved by the Ethics Committee of the\u0026nbsp;Yichang Central People's Hospital and considered by the Declaration of Helsinki (2024-309-01).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eNguyen US, Hillstrom HJ, Li W, Dufour AB, Kiel DP, Procter-Gray E, Gagnon MM, Hannan MT: \u003cstrong\u003eFactors associated with hallux valgus in a population-based study of older women and men: the MOBILIZE Boston Study\u003c/strong\u003e. \u003cem\u003eOsteoarthritis Cartilage \u003c/em\u003e2010, \u003cstrong\u003e18\u003c/strong\u003e(1):41-46.\u003c/li\u003e\n\u003cli\u003eLewis TL, Ray R, Gordon DJ: \u003cstrong\u003eTime to maximum clinical improvement following minimally invasive chevron and Akin osteotomies (MICA) in hallux valgus surgery\u003c/strong\u003e. \u003cem\u003eFoot Ankle Surg \u003c/em\u003e2022, \u003cstrong\u003e28\u003c/strong\u003e(7):928-934.\u003c/li\u003e\n\u003cli\u003eTrnka HJ: \u003cstrong\u003ePercutaneous, MIS and open hallux valgus surgery\u003c/strong\u003e. \u003cem\u003eEFORT Open Rev \u003c/em\u003e2021, \u003cstrong\u003e6\u003c/strong\u003e(6):432-438.\u003c/li\u003e\n\u003cli\u003eAiyer A, Stewart S, Rome K: \u003cstrong\u003eThe effect of age on muscle characteristics of the abductor hallucis in people with hallux valgus: a cross-sectional observational study\u003c/strong\u003e. \u003cem\u003eJ Foot Ankle Res \u003c/em\u003e2015, \u003cstrong\u003e8\u003c/strong\u003e:19.\u003c/li\u003e\n\u003cli\u003eHecht PJ, Lin TJ: \u003cstrong\u003eHallux valgus\u003c/strong\u003e. \u003cem\u003eMed Clin North Am \u003c/em\u003e2014, \u003cstrong\u003e98\u003c/strong\u003e(2):227-232.\u003c/li\u003e\n\u003cli\u003ePalmanovich E, Ohana N, David S, Small I, Hetsroni I, Amar E, Sharfman ZT, Segal D, Atzmon R: \u003cstrong\u003eDistal Chevron Osteotomy vs The Simple, Effective, Rapid, Inexpensive Technique (SERI) for Mild to Moderate Isolated Hallux Valgus: A Randomized Controlled Study\u003c/strong\u003e. \u003cem\u003eIndian J Orthop \u003c/em\u003e2021, \u003cstrong\u003e55\u003c/strong\u003e(Suppl 1):110-118.\u003c/li\u003e\n\u003cli\u003eChin KM, Richardson NS, Campbell JT, Jeng CL, Christian MW, Cerrato RA: \u003cstrong\u003eThe Hallux Metatarsophalangeal Capsule: An Anatomic Study With Respect to Percutaneous Hallux Valgus Correction\u003c/strong\u003e. \u003cem\u003eFoot Ankle Int \u003c/em\u003e2022, \u003cstrong\u003e43\u003c/strong\u003e(1):86-90.\u003c/li\u003e\n\u003cli\u003eDel Vecchio JJ, Ghioldi ME: \u003cstrong\u003eEvolution of Minimally Invasive Surgery in Hallux Valgus\u003c/strong\u003e. \u003cem\u003eFoot Ankle Clin \u003c/em\u003e2020, \u003cstrong\u003e25\u003c/strong\u003e(1):79-95.\u003c/li\u003e\n\u003cli\u003eAcevedo JI, Cedeno AA, Doty J, Mcwilliam J: \u003cstrong\u003eMinimally Invasive Technique for Hallux Valgus Correction\u003c/strong\u003e. \u003cem\u003eTechniques in Foot \u0026amp; Ankle Surgery \u003c/em\u003e2021, \u003cstrong\u003ePublish Ahead of Print\u003c/strong\u003e.\u003c/li\u003e\n\u003cli\u003eBosch P, Wanke S, Legenstein R: \u003cstrong\u003eHallux valgus correction by the method of Bosch: a new technique with a seven-to-ten-year follow-up\u003c/strong\u003e. \u003cem\u003eFoot Ankle Clin \u003c/em\u003e2000, \u003cstrong\u003e5\u003c/strong\u003e(3):485-498, v-vi.\u003c/li\u003e\n\u003cli\u003eKurashige T: \u003cstrong\u003eRadiographic and Clinical Results of Minimally Invasive Chevron Akin Osteotomy for Moderate to Severe Hallux Valgus Deformities\u003c/strong\u003e. \u003cem\u003eFoot Ankle Spec \u003c/em\u003e2024, \u003cstrong\u003e17\u003c/strong\u003e(4):305-317.\u003c/li\u003e\n\u003cli\u003eCastellini JLA, Grande Ratti MF, Gonzalez DL: \u003cstrong\u003eClinical and Radiographic Outcomes of Percutaneous Third-Generation Double First Metatarsal Osteotomy Combined With Closing-Wedge Proximal Phalangeal Osteotomy for Moderate and Severe Hallux Valgus\u003c/strong\u003e. \u003cem\u003eFoot Ankle Int \u003c/em\u003e2022, \u003cstrong\u003e43\u003c/strong\u003e(11):1438-1449.\u003c/li\u003e\n\u003cli\u003eHu D, Hong X, Wei X, Lin H, Zhang F, Zheng H, Lin J: \u003cstrong\u003eAnatomical Basis and Clinical Application of the First Metatarsal Proximal Perforator-Based Neurocutaneous Vascular Flap\u003c/strong\u003e. \u003cem\u003eClin Anat \u003c/em\u003e2020, \u003cstrong\u003e33\u003c/strong\u003e(5):653-660.\u003c/li\u003e\n\u003cli\u003eMakwana N, Hossain M, Kumar A, Mbako A: \u003cstrong\u003eThe sentinel vein: an anatomical guide to localisation of the dorsomedial cutaneous nerve in hallux surgery\u003c/strong\u003e. \u003cem\u003eJ Bone Joint Surg Br \u003c/em\u003e2011, \u003cstrong\u003e93\u003c/strong\u003e(10):1373-1376.\u003c/li\u003e\n\u003cli\u003eSolan MC, Lemon M, Bendall SP: \u003cstrong\u003eThe surgical anatomy of the dorsomedial cutaneous nerve of the hallux\u003c/strong\u003e. \u003cem\u003eJ Bone Joint Surg Br \u003c/em\u003e2001, \u003cstrong\u003e83\u003c/strong\u003e(2):250-252.\u003c/li\u003e\n\u003cli\u003eBaravarian B, Ben-Ad R: \u003cstrong\u003eRevision hallux valgus: causes and correction options\u003c/strong\u003e. \u003cem\u003eClin Podiatr Med Surg \u003c/em\u003e2014, \u003cstrong\u003e31\u003c/strong\u003e(2):291-298.\u003c/li\u003e\n\u003cli\u003eSoares S, Campos G, Mota Gomes T, Medeiros F, Martin Oliva X: \u003cstrong\u003eAnatomy of the Dorsomedial Cutaneous Nerve to Hallux and Surgical Implications According to the Severity of Hallux Valgus Deformity: A Cadaveric Study\u003c/strong\u003e. \u003cem\u003eJ Foot Ankle Surg \u003c/em\u003e2021, \u003cstrong\u003e60\u003c/strong\u003e(5):968-972.\u003c/li\u003e\n\u003cli\u003eGuodong S, Yunxuan Z, Hongning Z, Xue L, Kangyong Y, Zhibin L, Yongzhan Z: \u003cstrong\u003eEfficacy of minimally PCWO combined with Akin osteotomy on severe hallux valgus\u003c/strong\u003e. \u003cem\u003eChinese Journal of Orthopaedics \u003c/em\u003e2021, \u003cstrong\u003e41\u003c/strong\u003e(5):309 - 317.\u003c/li\u003e\n\u003cli\u003eLee M, Walsh J, Smith MM, Ling J, Wines A, Lam P: \u003cstrong\u003eHallux Valgus Correction Comparing Percutaneous Chevron/Akin (PECA) and Open Scarf/Akin Osteotomies\u003c/strong\u003e. \u003cem\u003eFoot Ankle Int \u003c/em\u003e2017, \u003cstrong\u003e38\u003c/strong\u003e(8):838-846.\u003c/li\u003e\n\u003cli\u003eBernasconi A, Rizzo M, Izzo A, Vallefuoco S, Russo AP, Rossi V, Abate B, Guarino A, Mariconda M: \u003cstrong\u003eB\u0026ouml;sch osteotomy for hallux valgus correction: results at a mean 10-year follow-up\u003c/strong\u003e. \u003cem\u003eArch Orthop Trauma Surg \u003c/em\u003e2023, \u003cstrong\u003e143\u003c/strong\u003e(3):1293-1300.\u003c/li\u003e\n\u003cli\u003eKong LP, Yang JJ, Wang F, Liu FX, Yang YL: \u003cstrong\u003eMinimally invasive open reduction of greater tuberosity fractures by a modified suture bridge procedure\u003c/strong\u003e. \u003cem\u003eWorld J Clin Cases \u003c/em\u003e2022, \u003cstrong\u003e10\u003c/strong\u003e(1):117-127.\u003c/li\u003e\n\u003cli\u003eMalagelada F, Sahirad C, Dalmau-Pastor M, Vega J, Bhumbra R, Manzanares-Cespedes MC, Laffenetre O: \u003cstrong\u003eMinimally invasive surgery for hallux valgus: a systematic review of current surgical techniques\u003c/strong\u003e. \u003cem\u003eInt Orthop \u003c/em\u003e2019, \u003cstrong\u003e43\u003c/strong\u003e(3):625-637.\u003c/li\u003e\n\u003cli\u003eKlos K, Lenz M, Hofmann GO, Schubert W, Knobe M, Roth KE, Simons P, Aurich M: \u003cstrong\u003eThe Correction Potential of the Lateral Release of the Hallux Valgus: A Comparative Anatomical Study of Minimally Invasive Versus Open Surgical Technique Using a Dorsal Approach\u003c/strong\u003e. \u003cem\u003eIndian J Orthop \u003c/em\u003e2022, \u003cstrong\u003e56\u003c/strong\u003e(5):887-894.\u003c/li\u003e\n\u003cli\u003eBuck TMF, Lauf K, Dahmen J, Altink JN, Stufkens SAS, Kerkhoffs G: \u003cstrong\u003eNon-operative management for osteochondral lesions of the talus: a systematic review of treatment modalities, clinical- and radiological outcomes\u003c/strong\u003e. \u003cem\u003eKnee Surg Sports Traumatol Arthrosc \u003c/em\u003e2023, \u003cstrong\u003e31\u003c/strong\u003e(8):3517-3527.\u003c/li\u003e\n\u003cli\u003eHarb Z, Kokkinakis M, Ismail H, Spence G: \u003cstrong\u003eAdolescent hallux valgus: a systematic review of outcomes following surgery\u003c/strong\u003e. \u003cem\u003eJ Child Orthop \u003c/em\u003e2015, \u003cstrong\u003e9\u003c/strong\u003e(2):105-112.\u003c/li\u003e\n\u003cli\u003eWagner P, Wagner E: \u003cstrong\u003eRepublication of \u0026quot;Proximal Rotational Metatarsal Osteotomy for Hallux Valgus (PROMO): Short-term Prospective Case Series With a Novel Technique and Topic Review\u0026quot;\u003c/strong\u003e. \u003cem\u003eFoot Ankle Orthop \u003c/em\u003e2023, \u003cstrong\u003e8\u003c/strong\u003e(3):24730114231195049.\u003c/li\u003e\n\u003cli\u003eLiu YJ, Li ZL, Wang ZG, Wang Y, Zhou M, Wang AY, Cai X, Tang JS, Zhang WT, Gao L: \u003cstrong\u003e[The clinical application and biomechanical study of reconstruction of anterior and posterior cruciate ligament with hamstring tendons knot implant fixation]\u003c/strong\u003e. \u003cem\u003eZhonghua Wai Ke Za Zhi \u003c/em\u003e2005, \u003cstrong\u003e43\u003c/strong\u003e(4):239-242.\u003c/li\u003e\n\u003cli\u003eJung GH, Park CM, Kim JD: \u003cstrong\u003eBiologic fixation through bridge plating for comminuted shaft fracture of the clavicle: technical aspects and prospective clinical experience with a minimum of 12-month follow-up\u003c/strong\u003e. \u003cem\u003eClin Orthop Surg \u003c/em\u003e2013, \u003cstrong\u003e5\u003c/strong\u003e(4):327-333.\u003c/li\u003e\n\u003cli\u003eBaca E, Kaya MG, \u0026Ccedil;ift\u0026ccedil;i MU: \u003cstrong\u003eDouble osteotomy in recurrence cases with distal metatarsal articular angle increase after hallux valgus distal surgery\u003c/strong\u003e. \u003cem\u003eJt Dis Relat Surg \u003c/em\u003e2025, \u003cstrong\u003e36\u003c/strong\u003e(2):420-427.\u003c/li\u003e\n\u003cli\u003eKyung MG, Park GY, Yang H, Lee DY: \u003cstrong\u003eA Modified 90-Degree Distal Chevron Metatarsal Osteotomy for Correcting Moderate Hallux Valgus Deformity\u003c/strong\u003e. \u003cem\u003eJ Clin Med \u003c/em\u003e2023, \u003cstrong\u003e12\u003c/strong\u003e(21).\u003c/li\u003e\n\u003cli\u003eNavarro-Cano E, Carrera A, Konschake M, Guevara-Noriega KA, Reina F: \u003cstrong\u003ePercutaneous hallux valgus surgery: Anatomical study of its safety and effectiveness\u003c/strong\u003e. \u003cem\u003eOrthop Traumatol Surg Res \u003c/em\u003e2023, \u003cstrong\u003e109\u003c/strong\u003e(8):103266.\u003c/li\u003e\n\u003cli\u003eMcGann M, Langan TM, Brand\u0026atilde;o RA, Berlet G, Prissel M: \u003cstrong\u003eStructures at Risk During Percutaneous Extra-Articular Chevron Osteotomy of the Distal First Metatarsal\u003c/strong\u003e. \u003cem\u003eFoot Ankle Spec \u003c/em\u003e2021, \u003cstrong\u003e14\u003c/strong\u003e(1):19-24.\u003c/li\u003e\n\u003cli\u003eChan CX, Gan JZ, Chong HC, Rikhraj Singh I, Ng SYC, Koo K: \u003cstrong\u003eTwo year outcomes of minimally invasive hallux valgus surgery\u003c/strong\u003e. \u003cem\u003eFoot Ankle Surg \u003c/em\u003e2019, \u003cstrong\u003e25\u003c/strong\u003e(2):119-126.\u003c/li\u003e\n\u003cli\u003eTay AYW, Goh GS, Koo K, Yeo NEM: \u003cstrong\u003eThird-Generation Minimally Invasive Chevron-Akin Osteotomy for Hallux Valgus Produces Similar Clinical and Radiological Outcomes as Scarf-Akin Osteotomy at 2 Years: A Matched Cohort Study\u003c/strong\u003e. \u003cem\u003eFoot Ankle Int \u003c/em\u003e2022, \u003cstrong\u003e43\u003c/strong\u003e(3):321-330.\u003c/li\u003e\n\u003cli\u003eKaipel M, Reissig L, Albrecht L, Quadlbauer S, Klikovics J, Weninger WJ: \u003cstrong\u003eRisk of Damaging Anatomical Structures During Minimally Invasive Hallux Valgus Correction (Bosch Technique): An Anatomical Study\u003c/strong\u003e. \u003cem\u003eFoot Ankle Int \u003c/em\u003e2018, \u003cstrong\u003e39\u003c/strong\u003e(11):1355-1359.\u003c/li\u003e\n\u003cli\u003eArata J, Kumakiri M, Yamashita T, Kaito S: \u003cstrong\u003eNonincisional Osteotomy for Gradual Lengthening by Callus Distraction for Congenital Brachymetatarsia\u003c/strong\u003e. \u003cem\u003eJ Foot Ankle Surg \u003c/em\u003e2021, \u003cstrong\u003e60\u003c/strong\u003e(6):1293-1296.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Hallux valgus, Bösch osteotomy, Akin osteotomy","lastPublishedDoi":"10.21203/rs.3.rs-7713475/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7713475/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose: \u003c/strong\u003eClinical efficacy of Akin osteotomy without internal fixation combined with modified Bösch osteotomy in treating moderate to severe hallux valgus deformity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: Of the 94 patients who underwent bunion orthopedic surgery from September 2022 to January 2024 at our institution, 48 patients with moderate to severe hallux valgus underwent an Akin osteotomy without internal fixation combined with modified Bösch osteotomy. Clinical efficacy was assessed using the American Orthopedic Foot and Ankle \u003cem\u003eSociety’s Forefoot scale, \u003c/em\u003eHallux valgus angle (HVA), Intermetatarsal angle (IMA), and Distal metatarsal articular angle (DMAA).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: According to the relevant criteria, 42 of 48 patients were included in this study. All patients were followed for a mean of 23 (range 18–30) months. At last follow-up the AOFS Forefoot scale was 87.4±12.0, the HVA was 15.0±1.8°, the IMA was 9.5±1.7°, the DMAA was 6.9±1.5°, all of which showed statistical differences compared to preoperative values（\u003cem\u003eP\u0026lt; \u003c/em\u003e0.0001）. The satisfaction rate was 93% in the total sample. There were no incision infections, no sensory paresthesia’s due to injury to the medial dorsal cutaneous nerve of foot, and no recurrences.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: Akin osteotomy without internal fixation combined with modified Bösch osteotomy for the treatment of moderate to severe hallux valgus provides satisfactory results, with small incisional scars, low risk of wound infection and nerve injury, stable internal fixation, and short rehabilitation time.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLevel of Evidence\u003c/strong\u003e: Level IV, retrospective case series.\u003c/p\u003e","manuscriptTitle":"Akin osteotomy without internal fixation combined with modified Bösch osteotomy for the treatment of moderate to severe hallux valgus","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-12 14:04:17","doi":"10.21203/rs.3.rs-7713475/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e15f6875-5fa9-4b65-87b0-13a61aec7980","owner":[],"postedDate":"October 12th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-13T04:53:50+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-12 14:04:17","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7713475","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7713475","identity":"rs-7713475","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}