Minimally Invasive Bunion Surgery: 5 Controversies in Correction and Recurrence Prevention
Two experienced foot and ankle surgeons debate 5 unresolved questions in minimally invasive bunion surgery, including frontal plane correction, lateral release, Akin osteotomy, proximal articular set angle correction, and ancillary procedures. Their contrasting approaches highlight how surgical priorities may differ even when the shared goal is durable hallux valgus correction.
Key Takeaways
- The surgeons differ on whether direct frontal plane correction is essential in distal metatarsal osteotomy or whether adequate lateral translation and hallux valgus angle reduction should take priority.
- Lateral release and Akin osteotomy remain key points of debate, with one approach favoring selective use and the other supporting more routine application to maintain alignment.
- Decisions regarding proximal articular set angle correction and ancillary procedures may depend on joint adaptability, deformity severity, associated pathology, and the surgeon’s broader biomechanical philosophy.
How Important is Frontal Plane Correction?
Surgeons should undertake this almost every time, something this author feels is in line with theories related to the Lapidus bunionectomy.
Lawrence A. DiDomenico, DPM, FACFAS
Similar to the lateral release theory and our experience with the Lapidus bunion surgery, we control the frontal plane by keeping the soft tissue attachments intact.1-3 A bunion is a progressive deformity that develops over a period of time to varying degrees. I view the typical bunion as a pronated process of the entire complex (distal phalanx, proximal phalanx, 2 sesamoids and metatarsal head/metatarsal) and not just the great toe.
While performing a MIS bunion surgery and making the first metatarsal osteotomy proximal to the sesamoids, and by not resecting the medial eminence and not performing a lateral release, the surgeon can keep this entire complex intact. After making the osteotomy, the surgeon can easily rotate the entire complex out of valgus from the malaligned position in the varus direction, into a neutral anatomic alignment, thus re-establishing the anatomic neutral alignment of the first MTPJ and sesamoid complex.
Once one reduces into neutral anatomic alignment, a K-wire serves as temporary fixation and for measurement for the definitive screw fixation. Because of this control of the first MTP complex, I do rotate the frontal plane into anatomic alignment in the majority of my MIS bunion procedures.
Frontal plane correction is not as important as it for a Lapidus procedure, instead, other parameters take priority.
Eric Baskin, DPM, FACFAS
While intraoperative fluoroscopic realignment of the sesamoid complex in the frontal plane (“owl eyes”) may be essential in Lapidus bunion surgery, this dogmatic concept does not always directly translate to MIS distal metatarsal osteotomies (DMO). In MIS DMO bunion surgery, proper and aggressive lateral translation of the metatarsal head and reduction of the hallux valgus angle (HVA) are the key factors in preventing recurrence and obtaining overall success.
When performing proper lateral translation of the metatarsal head, frontal plane correction occurs naturally due to the inherent forces and pulling generated by the surrounding soft tissue and tendinous attachments. Choi and colleagues demonstrated that sesamoid reduction following distal metatarsal osteotomy occurs primarily through lateral translation of the first metatarsal rather than true medial migration of the sesamoids.4 Okuda and team reported that lower postoperative HVA values were significantly associated with decreased recurrence following hallux valgus correction.5
Unlike Lapidus surgery, which is generally thought to lock the first metatarsal and sesamoid apparatus into a rectus frontal plane position via fusion, the first metatarsal-cuneiform joint (MCJ) after MIS DMO surgery remains fully mobile. It is theoretically “locked out” from the retrograde forces placed on the MCJ after significant lateral translation of the head.6 As weight-bearing begins, the joint starts to adapt and change position in the frontal plane immediately and over time. Therefore, the frontal plane position of the first metatarsal head obtained intraoperatively may not represent its long-term functional position over time.7
In my observation, surgeons with good intentions regarding frontal plane correction may inadvertently overcorrect the first metatarsal head intraoperatively, creating a varus malposition of the first MTPJ in the frontal plane despite satisfactory-appearing fluoroscopic radiographs. More importantly, if the metatarsal head is not adequately translated laterally and the hallux valgus angle (HVA) is not sufficiently corrected, frontal plane correction alone is unlikely to prevent recurrence, regardless of how ideal the intraoperative fluoroscopic images may appear.
Recent studies have also questioned whether sesamoid position on postoperative radiographs are independently predictive of recurrence after distal osteotomy procedures. Kim and colleagues found that postoperative lateral sesamoid displacement on standing radiographs did not necessarily correlate with hallux valgus recurrence following distal chevron osteotomy.8
In my experience, a reliable intraoperative indicator of adequate frontal plane correction is the position of the hallux toenail with the foot loaded, simulating weight-bearing. In my opinion, this is a much more accurate functional parameter of optimal correction than intraoperative fluoroscopic imaging of the sesamoids. The “toenail principle” can still apply when the surgeon chooses to fine-tune frontal plane correction using a K-wire joystick technique or commercially available jig.
Ultimately, I contend that the long-term success of MIS DMO bunion correction is determined by appropriate HVA correction and restoration of hallux toenail alignment rather than by radiographic sesamoid position.9
With What Frequency Should Surgeons Perform a Lateral Release in MIS Bunion Surgery?
Dr. DiDomenico says not often—only as a next intraoperative step when osteotomy correction does not reduce the deformity.
A lateral release in hallux valgus (bunion) surgery is a soft tissue procedure performed to release the contracture of the tendon and the muscle pull on the lateral aspect of the proximal phalanx of the great toe. This allows the surgeon to realign and position the base of the proximal phalanx while the lateral pull of the proximal phalanx of the great toe relieves tension.10-12
Do this because, during the development of a bunion, the strong adductor hallucis muscle and the lateral joint capsule contract, developing a hallux valgus deformity, oftentimes with a valgus rotation.
The lateral release achieves two goals:
- releases tension as it cuts the tight lateral contracted capsular tissue; and
- detaches the tight adductor hallucis tendon from the lateral aspect the proximal portion of the proximal phalanx of the great toe and stops it from pulling the toe out of anatomic alignment.
By removing this lateral pull and contracture by freeing these tissues and contractures, it allows the surgeon to place the base of the great toe back into a more normal alignment and position.
In my experience (LAD), it is extremely unusual that one cannot achieve adequate reduction of the base of the great toe relative to the metatarsal/metatarsal head, thus realigning the MTPJ while simultaneously realigning intermetatarsal angle (IM) into anatomic alignment. One can accomplish this when performing a MIS bunionectomy with the shift of the distal capital fragment or a Lapidus bunionectomy and the intermetatarsal angle reduction while performing a Lapidus bunionectomy.
In the late 1990s, I recognized that frontal plane rotation was an integral part of the pathological process of an HAV deformity to varying degrees. The sesamoids do not independently malalign/displace/sublux. The entire complex (great toe, sesamoid complex, first MTPJ and the entire first metatarsal) are pronated/rotated over many years in this pathologic position. With this information, I rarely performed a lateral release. By leaving the soft tissues intact (in the malaligned position), I was able to grasp the great toe with all of its attachments (interphalangeal joint of the great toe, the 2 sesamoids and their ligamentous attachments to the metatarsal, and the soft tissues/ligaments of the MTPJ complex maintained) and rotate the entire unit (distal phalanx, proximal phalanx, the 2 sesamoids, and the entire first metatarsal) as one unit.
This was only accomplished if there was no dissection to perform a medial eminence resection and if no lateral release was performed, thus maintaining stability to the entire great toe, sesamoid complex and first metatarsal. By not performing a lateral release and shifting the head of the first metatarsal over and near/more parallel to the second metatarsal and second metatarsal head, this essentially lengthened/decreased the tension of the adductor tendon without involving sharp dissection.
With the Lapidus bunionectomy, leaving the first MTPJ complex as is in the pathologic position, we then resected only the first tarsometatarsal (TMT-1) ligaments and capsular structures, resected the TMT-1 joint, and then rotated the great toe, which in turn, rotated the entire unit as one. Because all the attachments of the distal phalanx, the proximal phalanx, the sesamoid complex and the first MTPJ remained intact, once freeing the TMT-1, one could mobilize and rotate the entire complex as one singular unit, therefore eliminating the additional potential risk with the dissection at the first MTPJ. By performing the medial eminence resection and/or a lateral release, this would destabilize the first MTPJ complex therefore making this described rotation of the entire complex impossible.
If one leaves the entire complex intact, and reduces the intermetatarsal angle, this would put the great toe, along with the entire sesamoid complex and the first metatarsal/metatarsal head into anatomic alignment. While performing a Lapidus bunionectomy this maneuver allowed the first MTPJ joint to be reduced, put the first MTPJ closer/nearer to the second metatarsal phalangeal joint and parallel to the second metatarsal and MTPJ, while simultaneously derotating the entire first MTPJ and first metatarsal head out of a valgus position and into a neutral position.
Since performing MIS bunion surgery, I have used the same technique philosophy by performing the distal first metatarsal osteotomy proximal to the sesamoids and leaving all the soft tissues intact about the first MTPJ. In my experience, this allows rotation of the entire unit while performing the distal shift with the MIS bunion surgery, hence there is no need, or rarely the need, to perform a lateral release.
Considering the Risk of AVN. Avascular necrosis (AVN) of the first metatarsal head is an infrequent but documented complication during bunion surgery. It typically occurs when a lateral soft tissue release—performed to realign the toe—is combined with extensive surgical dissection, which inadvertently seeps or strips the vital blood supply feeding the bone.13-15 The blood supply to the first metatarsal head is highly dependent on extramedullary (capsular) vessels, which run along the dorsal and lateral sides of the joint.14
Aggressive exposure to access the MTPJ damages these small vessels, critically reducing perfusion to the metatarsal head. A simultaneous osteotomy increases the risk of vascular compromise.13,14,16
Consistent with the lateral release and frontal plane rotation theory along with experience, I do not perform the lateral release and instead rely on good reduction techniques in order to eliminate this seldom but nonetheless potential risk while performing bunion surgery. With the philosophy of performing the first metatarsal osteotomy proximal to the sesamoid complex and not performing a lateral release or medial eminence resection, I feel this approach reduces the chance of developing AVN of the first metatarsal complex.
Dr. Baskin contends that frequent execution of a lateral release could prevent frontal plane malrotation of the hallux over the long term.
The lateral release is often omitted in MIS DMO bunion surgery when the surgeon is satisfied with intraoperative reduction of IM angle, HVA correction, and hallux toenail alignment (frontal plane), including a reasonable concern for overcorrection into hallux varus. However, this approach may be shortsighted.
Over time, progressive valgus drift in the frontal plane may develop within months or up to over a year postoperatively. Patients often neither notice, nor complain, about this subtle malposition, though it is readily apparent to the surgeon. This gradual rotational drift of the proximal phalanx can compromise long-term alignment and patient satisfaction.17
For this reason, in my practice, I generally perform a lateral release in all but the mildest deformities when residual lateral tethering remains after osseous correction. The goal is to relax the contracted lateral structures, facilitate hallux realignment, and further reduce the HVA. In many cases, I limit the release to the adductor hallucis tendon insertion and preserve the lateral capsule and collateral ligaments when adequate correction can be achieved without releasing them.18
Although concern for hallux varus is understandable, in my experience, the long-term benefits in maintaining alignment and improving patient satisfaction outweigh the relatively small risk of overcorrection when the lateral release is performed routinely and judiciously.
What is the Role of an Akin Osteotomy in MIS Bunion Surgery?
Surgeons should not implement this universally, as Dr. DiDomenico feels it is not necessary if one achieves transverse and frontal plane correction.
As it relates to an Akin osteotomy, my thoughts and experience are that, more times than not, an Akin osteotomy is not necessary. With the philosophy of anatomical alignment with the bunion reduction, including good reduction of the 3 planes of deformity, there seems to be little need to add an Akin osteotomy. In most cases, the shape and configuration of the proximal phalanx is “normal” and the proximal phalanx exhibits no pathological alignment. In the few cases that there is a pathologic shape/configuration to the proximal phalanx, I will perform an Akin, but in my experience this is not common. In my observation, an Akin can assist with a better rectus position, however, I also note that there is a sacrifice of a slight unusual clinical appearance of the great toe with an Akin osteotomy postoperatively.
Dr. Baskin shares that he finds that almost always performing an Akin osteotomy in these cases addresses cosmesis and puts the final touches on preventing recurrence.
From my perspective, the Akin osteotomy is an essential adjunct in MIS DMO bunion surgery. The amount of correction required depends on intraoperative parameters such as IM angle, HVA, lateral translation of the first metatarsal, and overall aesthetic alignment, all of which are key considerations in MIS bunion surgery.4
Beyond its cosmetic appeal, I believe that the Akin osteotomy serves as a powerful deterrent against recurrence. Even when the intraoperative fluoroscopic HVA and IMA are fully corrected and the first metatarsal head is in a rectus position, I routinely perform an Akin osteotomy if the hallux appears cosmetically imperfect or if residual valgus rotation of the proximal phalanx persists. Similar to a lateral release, I typically refrain from performing this procedure in mild deformities, where the additional correction may be unnecessary. My goal is to attempt to complete the surgery with the interphalangeal joint and MTPJ parallel to each other fluoroscopically and have a rectus toenail appearance in the frontal plane.
Should Surgeons Undertake PASA Correction Via Counterclockwise Transverse Rotation of the Metatarsal Head Prior to Fixation?
Dr. DiDomenico says yes, when it is necessary to realign the joint.
As it relates to PASA correction, it is my experience that PASA is a radiographic, static snapshot of the static, stable malaligned position represented at the time of the weight-bearing radiograph. The foot is a dynamic structure that has slight motion in nonpathologic feet and excessive motion in the pathological foot. The ground does not move, and in combination with the patient's weight and axial load, the foot has to absorb the load with motion at many joints to adapt and accommodate. Historically, surgeons selected bunion surgery procedures on static weight-bearing radiographs. Because of this, many procedures address this static radiographic pathology.
In my opinion and experience, in order to correct the PASA deformity, one places the head of the first metatarsal into a more neutral anatomic alignment when performing MIS bunion surgery. Historically, PASA correction is via an osteotomy based on that static, malaligned, 2-dimensional radiographic snapshot. The appearance of the shape of the metatarsal head changes radiographically with position. PASA is a 3-dimensional finding because of the pathologic position at the time of the static weight-bearing radiograph. By placing the distal capital fragment into a more neutral aligned position, I feel the PASA position can be improved/corrected with the appropriate rotation and pivoting.
Conversely, Dr. Baskin does not rotate the metatarsal head to address the PASA, unless essential in specific situations.
I typically do not preemptively rotate the first metatarsal head counterclockwise in the transverse plane (as in a Scarf or Vogler osteotomy) prior to fixation when correcting joint alignment. While this maneuver corrects the proximal articular set angle (PASA), in my experience it can also increase the risk of recurrence, particularly in deformities with large IM angles by compromising the IM angle correction. It has been my experience that despite abstaining from PASA correction, the MTPJ alignment adjusts and adapts naturally over time due to ground reactive forces coupled with the tensities generated by surrounding soft tissue and tendinous attachments. Achieving maximal lateral translation to correct the IM angle, along with appropriate hallux valgus angle (HVA) reduction, remains the critical tenets for preventing recurrence, and not PASA correction.
There are, however, specific clinical situations in which counterclockwise rotation PASA correction during MIS DMO bunion surgery may be necessary. This most often arises in older patients with severe deformity who have longstanding cartilaginous joint adaptation, joint contractures, or stiff or arthritic joints that limit full HVA reduction. Revision surgeries may also impose limitations that necessitate transverse head rotation to correct for PASA and HVA. In these cases, the IM angle is reduced as much as possible, and PASA correction may require significant counterclockwise rotation to achieve full joint reduction. Frequently the surgeon will observe 100% lateral translation of the head, but is unable to reduce the MTP. The valgus position of the hallux may even press up against the adjacent toes, forcing metatarsal head transverse counterclockwise rotation towards the midline to restore alignment, in addition to lateral release. While this maneuver can achieve satisfactory joint reduction, it often produces a prominent medial eminence in its aftermath that must be aggressively contoured with a burr, sometimes extensively, to optimize both cosmetic and functional outcomes. While the X-ray may look unorthodox, the clinical presentation and result is consummate.
Do Ancillary Procedures Impact Outcomes?
Dr. DiDomenico says yes, especially gastroc recession.
As it relates to ancillary procedures, typically there is a tight gastrocnemius contracture with most foot and ankle pathology, and I find this is consistent and true with HAV deformities. One must know how to perform an accurate Silfverskiold test in order to appropriately assess and address the global deformity. A Silfverskiold test is a clinical exam used to determine whether a limited ankle dorsiflexion stems from a tight gastrocnemius muscle or tight Achilles tendon (gastroc and soleus). No one is born with a bunion; thus this is often a biomechanical development of pathology stemming from a tight posterior muscle group. Gastrocnemius contracture is a major biomechanical driver that develops, accelerates, and worsens a bunion deformity. When the posterior muscle group is structurally shortened/contracted, it restricts normal upward movement/dorsiflexion of the ankle during ambulation.1-3
To accommodate and move forward, the body compensates by pronating, collapsing the arch and transferring excessive weight/pressures onto the medial foot, specifically the first ray, and creating a degree of instability or hypermobility. This continuous biomechanical overload forces the first metatarsal to shift dorsally and oftentimes medially (forming a HAV deformity), and pulling the hallux into malalignment hence a progressive bunion deformity.
In my experience, addressing the tight posterior muscle group is necessary to help eliminate recurrence of the HAV. By treating the global deformity, I find that lengthening the posterior muscle group provides a better and more complete reduction of the deformity and it provides for less likely recurrence. Additionally, gastrocnemius recession can take place endoscopically, making the recovery and cosmetics of the procedure very appealing for both the patient and the surgeon.
Ancillary procedures are not a universally routine component of Dr. Baskin’s MIS bunion approach.
I perform ancillary hindfoot procedures in conjunction with MIS DMO bunion surgery only when there is a symptomatic indication, such as flatfoot deformity, debilitating equinus, or posterior tibial tendon dysfunction (PTTD). These hindfoot adjunctive procedures are traditionally intended as adjuncts to prevent recurrence, rather than as routine components of bunion correction. Current literature reports symptomatic recurrence rates as low as 1% when bunion correction is performed with minimally invasive techniques.19 Many historical ancillary procedures were performed in alignment with Lapidus dogma, but in my experience, they are largely unnecessary when MIS DMO is performed correctly.
Moreover, in the spirit of minimally invasive foot surgery, less procedures are "less invasive." Reducing the number of ancillary procedures not only promotes faster recovery but also minimizes scarring, contributing to a more aesthetically pleasing outcome. In properly selected cases, MIS DMO alone is sufficient to address hallux valgus, with ancillary hindfoot procedures reserved strictly for cases with specific symptomatic pathology.
Dr. DiDomenico is a Fellow of the American College of Foot and Ankle Surgeons, an Adjunct Professor at Kent State University College of Podiatric Medicine, and a Director of Fellowship Training at NOMS Healthcare in Youngstown, OH.
Dr. Baskin is a Fellow of the American College of Foot and Ankle Surgeons, practicing in New Jersey.
References
1. DiDomenico LA, Fahim R, Rollandini J, Thomas ZM. Correction of frontal plane rotation of sesamoid apparatus during the Lapidus procedure: a novel approach. J Foot Ankle Surg. 2014;53(2):248-251. doi:10.1053/j.jfas.2013.12.002
2. DiDomenico LA, Luckino FA III. Addressing the impact of frontal plane rotation on bunion repair. Podiatry Today. 2015;28(4). Accessed September 9, 2026. https://www.hmpgloballearningnetwork.com/site/podiatry/addressing-impact-frontal-plane-rotation-bunion-repair
3. DiDomenico LA, Flynn Z, Richie D Jr. Point-counterpoint: is frontal plane correction essential for addressing bunion deformities? Podiatry Today. April 2017. Accessed September 9, 2026. https://www.hmpgloballearningnetwork.com/site/podiatry/point-counterpoint-frontal-plane-correction-essential-addressing-bunion-deformities
4. Choi YR, Lee SJ, Kim JH, Kim TH, Oh CH. Effect of metatarsal osteotomy and open lateral soft tissue procedure on sesamoid position: radiological assessment. J Orthop Surg Res. 2018;13:11. doi:10.1186/s13018-017-0712-y
5. Okuda R, Kinoshita M, Yasuda T, et al. Hallux valgus angle as a predictor of recurrence following proximal metatarsal osteotomy. J Orthop Sci. 2011;16(6):760-764. doi:10.1007/s00776-011-0136-1
6. Nunes GA, Ferreira GF, Baumfeld T, Pereira Filho MV, Baumfeld D, Lam P. Minimally invasive Chevron Akin: locking the metatarsal-cuneiform joint. Foot Ankle Spec. 2024;17(4):336-342. doi:10.1177/19386400221079155
7. Bello-Tejeda LL, Perez-Aznar A, Sebastia-Forcada E, Miralles-Muñoz FA, Lizaur-Utrilla A, Vizcaya-Moreno MF. Sesamoid position change over 2 years after distal chevron osteotomy for moderate to severe hallux valgus: a prospective cohort study. Foot Ankle Int. 2023;44(2):95-103. doi:10.1177/10711007221146192
8. Kim TH, Choi YR, Lee HS, Bak GG, Moon SH. Relationship between hallux valgus recurrence and sesamoid position on anteroposterior standing radiographs after distal chevron metatarsal osteotomy. Foot Ankle Int. 2023;44(2):130-138.
9. Baskin ES. Prevention of MIS HAV recurrence. Presented at: American College of Foot and Ankle Surgeons Annual Scientific Conference; February 1-4, 2024; Tampa, FL.
10. Schneider W. Distal soft tissue procedure in hallux valgus surgery: biomechanical background and technique. Int Orthop. 2013;37(9):1669-1675. doi:10.1007/s00264-013-1959-5
11. Blitz NM, DiDomenico LA. Bunion surgery: should you perform a lateral release? Podiatry Today. 2009;22(8). Accessed September 9, 2026. https://www.hmpgloballearningnetwork.com/site/podiatry/bunion-surgery-should-you-perform-a-lateral-release
12. Ling SKK, Lui TH, Yung PSH. Arthroscopic lateral soft tissue release for hallux valgus. J Foot Ankle Surg. 2020;59(1):210-212. doi:10.1053/j.jfas.2019.01.021
13. Kuhn MA, Lippert FG III, Phipps MJ, Williams C. Blood flow to the metatarsal head after chevron bunionectomy. Foot Ankle Int. 2005;26(7):526-529. doi:10.1177/107110070502600705
14. Wallace GF, Bellacosa R, Mancuso JE. Avascular necrosis following distal first metatarsal osteotomies: a survey. J Foot Ankle Surg. 1994;33(2):167-172.
15. Fishco W, Ray R. Point-counterpoint: should you release the soft tissues in a bunionectomy? Podiatry Today. Published May 2015. Accessed September 9, 2026. https://www.hmpgloballearningnetwork.com/site/podiatry/point-counterpoint-should-you-release-soft-tissues-bunionectomy
16. Pochatko DJ, Schlehr FJ, Murphey MD, Hamilton JJ. Distal chevron osteotomy with lateral release for treatment of hallux valgus deformity. Foot Ankle Int. 1994;15(9):457-461. doi:10.1177/107110079401500901
17. Galli SH, Johnson N, Davis WH, Anderson RB, Jones CP III, Cohen BE. Patient reported outcomes and recurrence following 127 primary Lapidus surgeries for hallux valgus. Foot Ankle Orthop. 2020;5(4):2473011420S00222. doi:10.1177/2473011420S00222
18. Vernois J, Redfern DJ. Percutaneous Surgery for Severe Hallux Valgus. Foot Ankle Clin. 2016 Sep;21(3):479-93. doi: 10.1016/j.fcl.2016.04.002. PMID: 27524702.
19. Lewis TL, Ray R, Miller G, Gordon DJ. Third-generation minimally invasive chevron and Akin osteotomies (MICA) in hallux valgus surgery: two-year follow-up of 292 cases. J Bone Joint Surg Am. 2021;103(13):1203-1211. doi:10.2106/JBJS.20.01178
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