0198-0211/91/1202-0132$03.00/0 FOOT& ANKLE Copyright Q 1991 by the American Orthopaedic Foot and Ankle Society, Inc.
Letters to the Editor Dear Editor: I read the article by Drs. Brand and Smith, “Rupture of the Flexor Hallucis Longus after Hallux Valgus Surgery: Case Report and Comments on Technique for Adductor Release” (Foot and Ankle 11(6):407-410, 1991) with interest. Although it remains unclear as to whether adductor release at the time of chevron osteotomy actually contributes to a better result, it should be possible to accomplish such release without causing injury. I applaud the authors for stressing the importance of a careful technique to avoid flexor mechanism injury, but their technique raises two concerns. The suggestion that this lateral release be accomplished under direct vision may encourage the surgeon to perform a wider exposure, stripping more of the soft tissues from the metatarsal head and neck, which should be avoided. In addition, the use of a #15 scalpel blade, as illustrated in the article, provides ample opportunity to inadvertently lacerate the flexor mechanism. The surgeon may wish to consider an alternate method utilizing a small end-cutting blade (such as a Beaver #69). Maintaining the scalpel handle in the plane of the metatarsal heads, the surgeon may divide the lateral capsule and adductor tendon without damaging more plantar situated structures. Axial traction on the hallux allows the blade to be passed to the lateral capsule without injury to articular cartilage, and provides tactile and audible feedback as the capsule is divided.
Donald C. Campbell, II, M.D. Rochester, Minnesota REPLY: Dr. Campbell’s letter is appreciated because it brings attention to the feasibility of doing a lateral release during a bunionectomy, and the need for caution while doing so. The letter presents a practical alternative to our (authors’ and Dr. Edward Leventon’s) method of releasing the capsule. However in response to Dr. Campbell’s critique, additional stripping of soft tissue should not be necessary to visualize the lateral capsule if the hallux is placed in accentuated valgus as traction is applied. The valgus position brings the lateral capsule closer to the medial side. The Beaver #69 blade suggested by Dr. Campbell may be especially helpful in cases in which the joint is too tight to allow a direct view of the lateral capsule. In such cases, not having the special Beaver blade available, we have been able to divide the capsule and adductor without direct vision using the standard #15 scalpel blade. It is particularly important that the flat portion of the blade be pressed against the base of the phalanx as the cutting edge divides the soft tissue. Pressing the flat of the blade against the phalanx helps prevent “plunging” and injuring the nearby neurovascular structures and flexor tendon.
Jefferson C. Brand, Jr., M.D. Ronald W. Smith, M.D.
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