Point-Counterpoint: Is A Lateral Release Necessary For Hallux Valgus Correction?
- Volume 25 - Issue 4 - April 2012
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In my study, the intermetatarsal angle decreased by an average of 9.89 degrees and the hallux abductus angle reduced by 14 degrees.9 The greatest changes were in feet with intermetatarsal angles greater than 15 degrees. Overall, joint congruity was consistent with no evidence of recurrence. This compared favorably with the previously mentioned multicenter study, which reported an average reduction of 7.93 degrees of the intermetatarsal angle and 17.14 degrees of hallux abductus angle correction.4 The results demonstrated increased correction in the intermetatarsal angle by 2 degrees but 3 degrees less of hallux abductus angle correction in bunions with no interspace release in comparison to correction with interspace dissection.
I was consistently able to obtain better correction of the intermetatarsal angle by avoiding interspace release.9 A look at the anatomy reveals there are no significant structures that attach the first to second metatarsals proximally. All soft tissue intermetatarsal stability is in the distal forefoot. The intermetatarsal ligaments and the transverse and oblique heads of the adductor tendon provide transverse plane stability to the first ray. Severing these structures with an interspace release can contribute to instability and may help to explain why better intermetatarsal angle correction occurred without any lateral release. Anyone who has performed a complete lateral release can attest to placing the finger in the interspace and passing it to the plantar aspect of the foot, confirming all intermetatarsal soft tissue structures are now absent.
There was an approximate 2 to 3 percent increase in hallux abductus correction with a lateral release.9 A careful examination of postoperative X-rays often revealed a subtle varus angulation of the hallux when the lateral release was performed. This may explain the difference. Additionally, in the 15 years since I have stopped doing interspace releases, I have not had a single case of hallux varus.
Anecdotally, I have also seen a significant improvement in MPJ range of motion by eliminating the interspace dissection. This has been confirmed in studies from both Lee and co-workers and Granberry and Hickey.7,10
Additionally, in my study, I obtained sesamoidal axial projections on all bunions pre- and post-op.9 Relocation of the sesamoids into their anatomic grooves occurred without release of the fibular sesamoidal ligament.
The concept of interspace release to remove deforming forces and allow relocation of the metatarsal head over the sesamoid apparatus is based upon the theory that metatarsus primus varus is secondary to hallux valgus. In 1928, McBride emphasized the importance of the lateral intrinsic musculature in the development of hallux valgus deformity.11 In 1977, Root and colleagues described the four stages of hallux valgus deformity.12 Their concept was that instability of the MPJ led to hallux abductus with secondary adductus of the first metatarsal.
More recent publications have clearly demonstrated the sesamoids and base of the hallux do not move in relation to the second metatarsal.13 The sesamoids also play a vital role in shock absorption and propulsion. Based upon these anatomical/mechanical facts, it is difficult to justify stripping these bones of their soft tissue attachments. Several studies have now clearly demonstrated complete correction of bunions without a lateral release and maintenance of that correction for at least two years.7,8 This concept is based upon anatomic facts and not theoretical conjecture regarding the development of hallux abducto valgus deformity.
Dr. Boberg is a faculty member of the Podiatry Institute and is in private practice in St. Louis. He is a former Director of Residency Training at SSM DePaul Hospital in St. Louis. Dr. Boberg can be reached via e-mail at: firstname.lastname@example.org .