Point-Counterpoint: Is A Lateral Release Necessary For Hallux Valgus Correction?
- Volume 25 - Issue 4 - April 2012
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The hallux is intimately invested into the sesamoid apparatus via the plantar plate. This thick, dense fibrocartilaginous structure links the base of the proximal phalanx to the sesamoids. A study by Tanaka and colleagues looked at the relationship of the first metatarsal, second metatarsal and hallux in normal feet and those with hallux valgus, and confirmed this anatomic relationship.5 The authors demonstrated that with increasing degrees of metatarsus primus varus, the hallux did not drift medially with the first metatarsal but maintained its proximity to the second metatarsal and therefore the sesamoids as well.
“The base of the proximal phalanx in the hallux valgus foot was located on the same point as in the normal foot,” concluded Tanaka and colleagues.5 The authors concluded that hallux valgus is due to metatarsus primus varus and correction should include a lateral transfer of the metatarsal head.
David and co-workers reviewed the anatomy and function of the sesamoid apparatus.6 The muscles that insert into the sesamoids are vital in both structure and function to the normal foot. They help bind the first ray to the lesser rays, coordinate all of the forces on the five metatarsals and are involved in both shock absorption and propulsion.
Therefore, it has been established that in hallux valgus deformity, the sesamoids are in their normal anatomic position, the sesamoid complex is vital to propulsion, shock absorption and stability of the forefoot, and the hallux does not move medially as the first metatarsal moves into varus. The question then arises: Should we separate the sesamoids from their ligamentous and musculotendinous attachments if they are anatomically positioned and play a vital function in foot mechanics?
De-Emphasizing The Lateral Release: What The Studies Reveal
Certainly, the answer is not clear. Authors on both sides of the debate argue for or against interspace release, but there are few randomized, prospective, comparative studies. It does appear that as we move forward, the importance of releasing lateral structures is being minimized.
Lee and colleagues conducted a large prospective study comparing a Chevron osteotomy with and without soft tissue release.7 Seventy-four feet had soft tissue release and 78 had no release. The average pre-op hallux abductus angle was 29 degrees and the intermetatarsal angle was 16 degrees. Average post-op follow-up was 1.7 years with release and 2.1 years without release. The authors noted the post-op hallux abductus angle, intermetatarsal angle and AOFAS foot score differences were insignificant between the two groups. However, range of motion of the MPJ was significantly lower in the group with the interspace release.
In a prospective, randomized series in 1994, Resch compared 62 patients who underwent a Chevron osteotomy alone to 44 patients who underwent a Chevron osteotomy plus an adductor tenotomy.8 There was no difference in the satisfaction rate between the two groups.
I published a paper comparing results of Austin bunionectomy with and without interspace release.9 This long-term study looked at the results of 29 patients and 37 feet without any lateral release through an isolated medial incision. All patients had a minimum of one year of follow-up and an average follow-up of 18.4 months. I compared these results to the patients who had an Austin bunionectomy with complete interspace release in the study performed by Judge and colleagues several years earlier.4 Judge performed the measurements in both studies, acting as a neutral observer. This maintained consistency and affords a more accurate comparison between the two studies.