September highlighted article Author’s Comment

Anatomical Study of Minimally Invasive Lateral Release Techniques for Hallux Valgus Treatment

Jordi Vega MD

Assistant Professor

Foot and Ankle Surgeon

Foot and Ankle Unit, iMove Tres Torres, Barcelona, Spain.

Human Anatomy Unit, Department of Pathology and Experimental Therapeutics, School of Medicine and Health Sciences. University of Barcelona, Barcelona, Spain.

MIFAS by GRECMIP (Minimally Invasive Foot and Ankle Society), Merignac, France.

 

Miki Dalmau-Pastor, PhD
Associate Professor

Human Anatomy Unit, Department of Pathology and Experimental Therapeutics, School of Medicine and Health Sciences. University of Barcelona, Barcelona, Spain.

MIFAS by GRECMIP (Minimally Invasive Foot and Ankle Society), Merignac, France.


The collaboration between Anatomists and Surgeons has been the basis of the work that we have been doing over the years around the Foot and Ankle. This collaboration allows anatomic knowledge to improve, and surgical techniques to advance. This is especially true in minimally invasive and arthroscopic techniques. In minimally invasive surgery, there is not a direct visualization of the anatomical structures, while in arthroscopy this visualization is achieved with a camera; in both cases this is different to what’s observed in classical anatomic textbooks, which makes so important a profound anatomical knowledge.

Our effort to validate and increase the evidence surrounding all minimally invasive and arthroscopic procedures is shared with MIFAS by GRECMIP (Minimally Invasive Foot and Ankle Society), an international group of research and teaching of minimally invasive foot and ankle surgical techniques (www.grecmip.org). Thanks to the author’s collaboration in this paper, minimally invasive techniques continue evolving.

We’ve worked in anatomical studies about minimally invasive procedures for hallux valgus in the past. However, we never made a research study on the hallux arthrolysis or lateral release. Lateral release on the first MTP joint is a common procedure during hallux valgus treatment. Several minimally invasive lateral release techniques have been described, but no anatomical studies were conducted to verify if the release of the structures was satisfactory.

Minimally invasive lateral release is usually performed through a percutaneous approach placed in the first web space. The blade is introduced and directed to the lateral part of the proximal phalanx base of the hallux, where the adductor tendon inserts. This step has to be controlled with x-ray. From this point, the surgeon is able to release a number of structures, depending on the direction of the blade.

From authors experience, two minimally invasive lateral release techniques were the most commonly used, and therefore were the ones deserving our attention when designing this study:

  • An isolated lateral release, which aims release the adductor tendon (AR).
  • An extensive percutaneous lateral release (EPLR), aiming a release of the suspensory ligament, adductor tendon, and any lateral sesamoid attachments, including the phalanx-sesamoid ligament, the lateral head of the flexor hallucis brevis tendon, and the deep transverse metatarsal ligament.

The procedures were performed in 22 feet by two of the authors. Next, feet were dissected to verify if the structures claimed to be released were indeed satisfactory released, and if any undesirable injury was found.

Results showed that both techniques achieved a satisfactory release of the adductor tendon (partial release in most EPLR cases, and full release in most AR cases). In addition, EPLR was successful in releasing the intended additional structures. No neurological injuries were found and one undesired release of flexor hallucis longus in the AR group was detected.

Results proved that the lack of direct visualization of the structures did not impair the effectiveness of its release. In addition, our results showed that a minimally invasive lateral release was more effective than an open lateral release, as the anatomical studies published to date showed a lower reliability in releasing both the adductor tendon and the lateral attachments of the lateral sesamoid.

In the light of these results, we concluded that a minimally invasive lateral release of the first MTP joint is a safe and effective procedure that can be easily performed as an adjunct to both minimally invasive and open techniques treating hallux valgus.

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