Point-Counterpoint: Is A Lateral Release Necessary For Hallux Valgus Correction?
Kim and co-workers believe that the amount of lateral release also depends on the amount of lateral contracture and studied the role of intraoperative varus stress radiography to determine those cases in which surgeons could combine a lateral release with a distal Chevron osteotomy.6 They assessed the amount of lateral contracture by squeezing the metatarsal heads together under fluoroscopy intraoperatively and determining if one could passively reduce the hallux deformity. If one could reduce the deformity, then a lateral release in combination with a distal Chevron osteotomy worked well, even for higher intermetatarsal angles.
The authors also used tangential or axial fluoroscopy images to determine if one could reduce the metatarsal sesamoidal relationship and in those cases in which a metatarsal sesamoidal ligament release was not imperative.6
What is the answer? Is a lateral release necessary for hallux valgus correction? Yes, in the vast majority of cases. The amount of release and its necessity require a dynamic approach and continued intraoperative assessment on a case by case basis. One should undertake a reasonable and prudent workup of those patients, eliciting for a history of surgical correction of their bunions. Preoperative radiographic assessment must consider joint congruity or incongruity in spite of the intermetatarsal angle. It is unwise to perform a lateral release routinely on all patients without considering the specific merits and severity of each case.
Intraoperative decision making via stress X-rays can help determine the passive reducibility of the hallux abducto valgus as well as the metatarsal head sesamoid alignment. All lateral soft tissue contractures are not created equal nor are their contributions to the reducibility of the pertinent anatomical structures. We must appreciate that as one performs a lateral release, the intermetatarsal angle will reduce due to the reduction of the buckling effect of the phalanx on the metatarsal head. It is mandatory to confirm clinically that one has neutralized and reversed the pathological forces that drew the hallux into abduction and valgus while opening the intermetatarsal angle.
Applying sound knowledge of the anatomy and the lateral structures to be released is still the most consistent assurance against the risk of the most likely complication: recurrent or residual hallux valgus deformity.
Dr. Cicchinelli is a Fellow of the American College of Foot and Ankle Surgeons. He is a faculty member of the Podiatry Institute. Dr. Cicchinelli is in private practice in Mesa, Ariz.
1. Mann RA, Coughlin MJ. Hallux valgus-etiology, anatomy, treatment and surgical considerations. Clin Orthop. 1981; 157:31-41.
2. Oloff LM, Bocko AP. Application of distal metaphyseal osteotomy for treatment of 357 high intermetatarsal angle bunion deformities. J Foot Ankle Surg. 1998; 37(6):481-489.
3. Bai LB, Lee KB, Seo CY, Song EK, Yoon TR. Distal chevron osteotomy with distal 365 soft tissue procedure for moderate to severe hallux valgus deformity. Foot Ankle Int. 2010; 31(8):683-688.
4. Judge MS, LaPointe S, Yu GV, Shook JE, Taylor RP. The effect of hallux abducto valgus surgery on the sesamoid apparatus position. J Am Podiatr Med Assoc. 1999; 89(11-12):551-559.
5. Hromádka R. Lateral release in hallux valgus deformity. From anatomical study to surgical tip. Submitted for publication to J Foot Ankle Surg, 2011.
6. Kim HN. Distal Chevron osteotomy with lateral soft tissue release for moderate to severe hallux valgus. Submitted for publication to J Foot Ankle Surg, 2012.
For further reading, see “Point-Counterpoint: Bunion Surgery: Should You Perform A Lateral Release?” in the August 2009 issue of Podiatry Today. To access the archives, visit www.podiatrytoday.com.