Should I Have My Bunion Repaired?

This week we will focus on the types of surgical procedures used to correct painful bunion deformities that have not responded to conservative care. To reiterate, conservative treatment options should be considered and exhausted when possible before surgery becomes a reality. Types of conservative care include injections, padding/offloading and orthotic therapy. When conservative therapy fails your Podiatrist may recommend surgical correction through one of the procedures described below in attempt to realign the big toe and decrease the level of pain you have been experiencing. It is important to keep in mind when reviewing these procedures that your Podiatrist will select the right procedure for you based on the severity of your deformity.

Soft Tissue Procedures: A soft tissue procedure used for bunion correction is one that attempts to release any tendons and tighten the capsule around the involved joint, both of which are involved in deviating the big toe towards the lesser toes. By releasing these pieces of soft tissue the bones within the big toe will straighten out, align with the lesser toes and decrease the space that has been created between the first and second long bones in the foot. Typically, these procedures are used on patients who have mild deformities and minimal pain over the bump on their big toe. Soft tissue procedures can be performed alone, but are always performed when more corrective procedures are also performed.

Bone Procedures: There are two types of bone procedures that can be used to correct your bunion deformity. There is one procedure where cuts are made into the first long bone of the foot and another procedure where cuts are made in to one of the two bones in the big toe.

Procedures that make cuts into the first long bone of the foot are used for moderate deformities where there is a more significant deviation of the big toe towards the lesser toes. Patients who require such procedures typically have moderate pain that would not adequately reduce with only a soft tissue procedure. In bone procedures, a “V-shaped” cut is made in the first long bone of the foot allowing the bone to be shifted over, aligned with the lesser toes and held in place with a pin or screw.

Procedures that make cuts into one of the two bones in the big toe are used when one of those two bones are a contributing factor in the deformity. A wedge cut is made in one of the bones in the big toe and the bone is de-rotated and properly aligned with the long bone in the foot as well as with the lesser toes. It is stabilized with a pin or screw; the same pin or screw being used for fixation of the bone cut made in the long bone of the foot as described above.

Fusion Procedures: A fusion procedure is used when patients have big toe joints that are arthritic and destroyed, thus they cannot function even if the bones are placed in a corrected position, as would be done with a bone procedure. A fusion procedure removes any material within the joint space that is destroyed and places the long bone in the foot and the first bone in the big toe together, end-to-end. A pin or screw is used for fixation and after 6-8 weeks of healing, the joint is fused and motion is permanently eliminated. Elimination of movement at the joint significantly decreases pain in patients with such conditions.

As with any surgical procedure the risks and benefits should be considered and discussed with your Podiatrist. Complications with any of the bunion procedures described above can include infection, scarring, recurrence of deformity, and transfer pain among others, although the risks of any such complications are minimal. Patients should expect anywhere from 2-8 weeks of recovery depending on the procedure selected and they should expect pain during recovery; although pain is a personal thing and depends on the patients tolerance!

Bunions are Genetic, Aren’t They?

This question can be heard multiples times per week in a Podiatrists’ office, and the answer to the questions is: No, not exactly! Bunions have a variety of etiologies that can act alone or in combination with one another causing deformity of the first ray (1^st metatarsal and bones of the 1^st toe). Just because Mom or Pop may have a bunion, you didn’t inherit your bunions from them, you inherited their abnormal foot type.

Lets take a step backwards for a minute and talk about what exactly a bunion is. Hallux Abducto Valgus (bunion) is a triplanar, progressive deformity of the first metatarsal in which the hallux (great toe) is deviated towards the lesser toes (abducted) and rotated (valgus). HAV is one of the most common pathologies found in the lower extremity and is found in females more often than males by about a 4:1 ratio.

The most common etiology can be classified as a biomechanical abnormality: any condition whereby the 1^st ray cannot function optimally in comparison to the normal or rectus foot. This encompasses a variety of pathologies including a hypermobile first ray (excessive motion of the 1^st metatarsal and its articulations within the foot), inflammatory conditions of the 1^st joint, neuromuscular diseases, an elevated first ray (met primus elevatus), and metatarsus adductus (medial deviation of metatarsals 2-5), to name a few. These inherited conditions prohibit the foot from functioning optimally and your body is forced to compensate for such abnormalities leading to the formation of a bunion. Thanks Mom and Dad!!

Some other less common etiologies of Hallux Abducto Valgus include post-surgical malformation, equinus (inability to dorsiflex the ankle greater than 10 degrees past neutral), limb length discrepancies, and a history of trauma to the hallux.

To prevent the occurrence of bunions, one of the predisposing conditions must be identified and corrected early on, or avoided all together. Unfortunately, this is not typically the case with inherited biomechanical abnormalities. The conditions go unnoticed or are brushed-off as something that the child will “outgrow.” Most pediatric foot abnormalities will not be outgrown and early evaluation and identification of a pathology by a Podiatrist can allow the child to be monitored and/or treated conservatively throughout their development.

Treatments options include a vast array of choices from conservative to surgical and the choice depends largely on the patients pain and discomfort in combination with a physical and clinical examination of the condition. Your Podiatrist will ask you a variety of questions to determine how fast the deformity is progressing and what methods of treatment, if any, you have previously tried. They will examine the deformity clinically to determine where the pain is localized, the degree of soft tissue involvement, the condition of the joint, the rigidity of deformity, and the underlying etiology. Your Podiatrist will also take bilateral radiographs of your feet to evaluate the joint and bone positions in comparison to “standard” radiographic angles.

Once all the pieces of the examination have been considered together, it is most likely that conservative options will be exhausted prior to surgical intervention. Conservative treatments include: injections to decrease inflammation and alleviate pain; padding of the toe to decrease pressure with shoes; physical therapy to increase the range of motion at the joint and eliminate muscular imbalances that may be a causative factor; and orthotics, which attempt to realign the foot in a more optimal position decreasing the biomechanical abnormality that may be the root etiology of your HAV.

If the deformity is rigid and severely progressed, or if conservative treatments have been exhausted without resolution of pain, surgical options become a consideration. Next week we will discuss the types of surgical procedures that may be performed in treating your bunion, the pros and cons of such surgeries and the pre-operative and post-operative courses that should be expected.

Take Two: Common Winter Sports Injuries

1. Frostbite: Frostbite occurs when there is decreased blood flow and decreased heat delivery to the toes, but can also affect the fingers, nose and ears. Ice crystal formation takes place in the affected areas and depending on the severity of the injury can involved tendons, nerves, muscles or even bone. Symptoms include numbness, tingling, burning or loss of sensation to the area and color changes may be noted. Prognosis depends on the extent of the injury and determining this may takes weeks. In some cases amputation may be necessary or in less traumatic cases, increased prevention for reoccurrence is the only treatment. To prevent frostbite, make sure to take frequent hot-chocolate breaks from being out in the cold temperatures and investing in foot warmers to be placed between your socks and your boots will also be helpful!

2. Ankle Fractures: Ankle injuries, including sprains, strains and fractures are very common in the winter months as icy and snowy conditions lead to increased incidence of falls. According to Lauge-Hansen, an Ankle Fracture classification system, there are 4 main categories of ankle fractures classified by the position of the foot and the motion that takes place as the fracture occurs. The most common ankle fracture is classified as “Supination External Rotation” fracture (SER); meaning there is inward rotation of the ankle while the leg and body move in the opposite direction. In the most severe SER ankle fractures the tibia and fibula (bones of the leg) are broken and the ligaments surrounding the ankle are ruptured resulting in dislocation of the ankle joint. Patients suffering this type of injury will need surgical intervention to realign and stabilize the bones with internal hardware (pins and screws) in addition to repairing the ruptured ligaments. Be prepared for at least 6 to 8 weeks of complete immobilization. Preventing ankle fractures starts with wearing winter boots that have suitable traction on the bottom. Watch where you walk, and if it’s not necessary to leave the house during icy conditions, stay home and watch you’re favorite holiday movie!

3. Calcaneal (Heel) Fractures: Calcaneal fractures are less common than other type of the injury to the foot, but in the event that they do occur, they are severely debilitating. This type of injury is caused by a high impact vertical force that can occur after jumping out a window or more realistically, a fall from a ladder while hanging holiday decorations and lights! Calcaneal fractures present with severe pain and “Mondors Sign:” severe bruising of the heel that extends to both the medial (outside) and lateral (inside) areas of the foot. Due to mechanism of injury, patients often suffer associated injuries including spinal fractures. The treatment for Calcaneal fractures is much the same as that for Ankle fractures: surgical repair is necessary with the use of internal hardware and long periods of immobilization. Make sure that when you are hanging decorations this holiday season, you have a helper with you that can stabilize the ladder you’re climbing, preventing a fall.

As mentioned last week, taking preventative measures will decrease the incidence of injury, especially during the winter months. Consult your Podiatrist if you have any concerns or need suggestions for selecting appropriate “winter gear.” If you do experience a traumatic injury, get yourself to the Emergency Room as soon as possible, or call your Podiatrist for an emergency appointment.

What is Diabetic Neuropathy?

In 2002, according to the National Institute of Diabetes and Digestive and Kidney Disease, approximately 65% of those living with Diabetes also had some degree of correlated neuropathy. In many cases it is the symptoms of neuropathy that lead to the diagnosis of diabetes, because these symptoms indicate to the patient that there may be a larger disease process occurring.

Neuropathy by definition is disease or dysfunction of one or more peripheral nerves that typically causes numbness, weakness, or both. It is thought that a combination of factors adds to the incidence of neuropathy in diabetic patients, but it is directly related to poor sugar control. Nerves are very sensitive to change and when blood sugars are high, the sugar molecules tend to glycosylate both the small blood vessels and the small nerves. This glycosylation compresses the nerve to some degree and results in the symptomatic representation of neuropathy.

Several categories of neuropathy affect the diabetic population, but the most common type is Peripheral Neuropathy. Peripheral Neuropathy is also known as distal symmetric neuropathy, meaning symptoms present first in the toes and fingers on both the right and left sides of the body. As the neuropathy progresses it continues along the foot and hand towards the arms and legs. The sensory changes are minimal and at first may go unnoticed, but as the neuropathy progresses symptoms become more discernable. The best was to prevent and control the progression of diabetic neuropathy is to keep your blood glucose levels within normal range, thus protecting your nerves from glycosylating.

Comprehensive foot examinations by your Podiatrist can help diagnose peripheral neuropathies in the early stages and it is important to remember that if you are experiencing any changes in sensation to your toes or feet, you see your doctor immediately. Your Podiatrist will look for changes in light and sharp touch, vibration, reflexes and your ulceration risk. All of these components can hold clues to an early diagnosis of peripheral neuropathy.

If you have already been diagnosed with neuropathy it is still very important to follow-up with your Podiatrist for routine care, but more importantly to be doing your part at home. You must check your feet on a daily basis for any open areas, especially between the toes and for any color changes that may indicate problems. The largest complication associated with having diabetic neuropathy is the patients inability to feel, thus injuries that would be painful in a non-diabetic go unnoticed in a diabetic and can lead to ulceration, infection, and loss of digits. If you notice something unusual or different from the previous day, contact your Podiatrist for an appointment.