Point-Counterpoint: Is A Lateral Release Necessary For Hallux Valgus Correction?

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Author(s): 
Luke D. Cicchinelli, DPM, FACFAS, and Jeffrey Boberg, DPM

Yes.

Offering key anatomical pearls and biomechanical insights, this author notes that a lateral release is beneficial in the majority of surgical procedures for patients with hallux abducto valgus.


By Luke D. Cicchinelli, DPM, FACFAS

Have I ever performed surgery for the correction of hallux abducto valgus deformity without performing a lateral release and been happy with the clinical outcome? Yes. However, the vast majority of patients electing to undergo this surgery will benefit from the inclusion of some component of a lateral release, which helps ensure a more lasting and reliable result.

   Would anyone argue that a medial release is not an integral part of the correction of hallux varus? This is doubtful. Is a medial release beneficial for the knee, another joint with a large sesamoid? Does a maltracking patella benefit from a lateral release? Sure, at least as a component of the surgical reconstruction.

   Reflect on all the bunion surgeries you have performed over the years in which you and/or the patient were not completely satisfied with the radiographic or clinical result. What has been the common denominator in the failure to obtain perfection? Chances are the answer is residual or recurrent hallux valgus because of residual metatarsus primus varus or persistent and recurrent lateral drift of the hallux. Why? This is due to incomplete and/or temporary realignment of the metatarsal head over the sesamoid complex, which ensures a stably repaired, congruent first metatarsophalangeal joint (MPJ).

   In fact, in spite of over 130 described procedures for correcting bunions, we know that any procedure will work if it corrects the bunion and all 130 have worked at some point for someone but no one procedure works for all. The lateral release is no different.

   Let me simplify my position in this debate to what I will call the ABCs of bunion surgery. A is for anatomy, which is invariable and well described. A also stands for agonists, antagonists and axis of advantage around an articular axis. B is for biomechanics and for buckling, and the balance of them both. This is the balance or imbalance of A and B. C stands for congruence, cadaveric correlation and clinical confirmation. A full appreciation of the ABCs of bunion surgery readily leads to the conclusion that a lateral release is an integral component of achieving a reversal of the etiological forces that cause a bunion.

What You Should Know About Anatomy

Muscle-tendon complexes, ligaments, capsule and bone necessarily surround any joint. The pertinent structures surrounding the first MPJ are well understood. At the muscle tendon level on the plantar, medial and lateral sides of the joint, the abductor tendon heads oppose the adductor tendon heads, and the sesamoids are nestled in the heads of flexor hallucis brevis. The antagonistic muscles either work in concert or against each other, lending stability or perpetuating instability of the joint and the position of the great toe. The lateral ligaments include the deep transverse metatarsal ligament that binds the sesamoid apparatus to the plantar plates of the second MPJ plus the metatarsal sesamoid (suspensory) ligament and lateral collateral ligament.

   The first MPJ is a four-bone joint where the sesamoids must reside in their grooves on the base of the metatarsal head and are intimately linked to the base of the phalanx. Which of these structures in the “lateral release” do hallux valgus surgeons routinely consider? Do we consider all structures or some structures in some cases and other structures in other cases?

   With no uniformity in what constitutes a lateral release in spite of invariable anatomy, its necessity or lack thereof requires inherent consideration. There is an absolute tendency to perform a lateral release by rote, or not perform a lateral release and then focus on the osseous procedures required to correct the intermetatarsal angle. This is shortsighted and erroneously assumes that all bunions are created equal. The deformity requires a more flexible and real-time analysis intraoperatively.

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