This condition previously was thought to be a result of improper shoe gear. In actuality, it is a genetic disorder which can be inherited from either side of your family. Although shoes have not been shown as a cause of the condition, they often aggravate the condition and produce painful symptoms. Although this disorder often begins in early adolescent years, the majority of patients exhibiting this deformity and symptoms tend to be adults.
A bunion, otherwise known in the medical field as hallux abductovalgus (HAV) deformity, is actually a result of an increase in the space between the first and second metatarsals, which are the long bones in your feet. The first metatarsal deviates toward the mid-line of the body causing the great toe to drift toward the outside. As a result, a prominence develops on the inside of your foot, which compresses a nerve resulting in the pain you experience with shoes. If left untreated, this area continues to become more prominent and very often results in ulceration and infection, especially in diabetic patients and neurologically impaired patients.
Another type of deformity affecting the great toe and first metatarsal joint is known as hallux limitus. It is often confused with a bunion deformity and is treated in a similar fashion. It is primarily due to a malposition of the metatarsal in the sagittal plane, where the first metatarsal is elevated above its normal position. The result is a secondary jamming and degenerative joint disease.
Conservative treatment includes orthopedic shoes, prescription orthotics, nonsteroidal anti-inflammatories and intraarticular injections. Although these are not designed to correct the deformity, they often eliminate symptoms for a period of time. When this no longer provides the intended relief, and the deformity has progressed beyond limitations of conservative treatment, corrective surgery may then be indicated. Bunion surgery is divided into head procedures and base procedures. The severity of the deformity will dictate the type of procedure performed. Mild to moderate deformities are usually addressed at the metatarsal head where the inside prominence is removed. Next, a V-shape cut in the bone is made to allow us to shift the metatarsal head toward the second metatarsal. Most often, this is fixated with two 2.0 mm screws, which are not much larger than a straight pin.
If it is a severe deformity, the head procedure will not be adequate to address the shift of the metatarsal. In these cases, the surgery is aimed at reducing the separation at the base of the metatarsal. This typically involves removing a pie-shaped wedge of bone at the joint and fusing the metatarsal to the adjoining cuneiform. This is typically held in place with a screw and staple and requires a different postoperative course.
For the mild to moderate bunion deformity, patients are routinely kept in a surgical shoe for six weeks. Weight-bearing is allowed from the time of surgery, except for the first 2-3 days where patients must stay flat on their back with their leg elevated above their heart to reduce the edema and swelling in the foot, and allow for a quicker return to normal shoe wear.
In the fusion procedure, which is a more severe procedure, patients are not allowed to walk on their foot for a minimum of 2-4 weeks. At the end of this time, patients are typically placed into a cast, which must be worn for 4-6 weeks, depending on bone density, age and vascularity. After four weeks, patients may gradually increase weight-bearing on the foot. Usually at six weeks, patients can fully weight-bear in the cast without assistance from devices such as crutches, canes or walkers. With the more extensive first metatarsal cuneiform fusion surgery, an orthotic will often be recommended for use after a six-week postoperative period. The orthotic is an insert that will help provide support to decrease the amount of force placed on the first metatarsal cuneiform joint after it has been fused together. This will be determined by your surgeon’s discretion.
In rare circumstances, correction of the bunion deformity requires replacement of the joint. If this is the only procedure being done, healing is typically faster because there is no bone to heal. A silastic implant is the most common joint replacement.
Before Joint Replacement After Joint Replacement
As a result of recent developments in the types and techniques of procedures incorporated by our practice, we find that the majority of our patients experience little or minimal pain postoperatively. This is in part due to a long-acting anesthetic injected at the time of surgery, which allows for a smooth transition from the I.V. sedation to the home front. Secondly, we also incorporate nonsteroidal anti-inflammatories for suitable candidates in combination with pain medication, if necessary. In the majority of cases, pain can be markedly reduced by elevation of the operative foot after the surgery along with ice packs routinely given to our nondiabetic patients.
The vast majority of our surgeries, unless a medical condition necessitates otherwise, are done on an outpatient basis. Also, unless there is a need for general anesthesia, the normal routine is to provide anesthesia through a regional block with I.V. sedation.
We, the surgeons at Beaumont Foot Specialists, pride ourselves on the fact that we have done thousands of these procedures over the last 20 years. Our success rate with good patient compliance is in the high 90th percentile. Please realize that the surgeon is only 50 percent of the outcome with you, the patient, being the other 50 percent. Compliance with postoperative instructions is imperative to the successful outcome of your surgery. We find that if patients fulfill their part of the responsibility, it is usually a pleasant and rewarding experience.
Please ask the nurses or doctors any questions you may have at anytime during the course of your surgery. We strongly urge you to maintain an open line of communication, and we will be happy to address any questions or concerns that may arise. We value you as a patient and appreciate you choosing our practice for your foot care and surgical needs.