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FootCare Update


									  FootCare Update
                                     Expert care from professionals who care.
                                                Volume II, No. 3; Spring, 2004

Foot surgeons need bio-mechanical
insight to realign deformed joints.
W        hat patients describe as a
         “Bunion” can be seen as a
painful swelling or prominence, with
                                               Why Surgical Intervention?
                                              The conservative treatment of
                                           bunion deformities is very often taken
                                                                                       od can weaken tissues, further pro-
                                                                                       gressing the deformity and making
                                                                                       repair more difficult.
or without additional bursal swelling,     care of by the patients themselves.            Also, overlying skin is almost
at the base and along the side of the      They self-medicate with over-the-           always thinned because of the defor-
big toe. It actually overlays the medi-    counter, non steroidal anti-inflamma-       mity and the steroids can result in fur-
al aspect of the first metatarsal head.    tory drugs (NSAIDs), if tolerated, and      ther cutaneous thinning, breakdown
   The great toe usually is deviated       they attempt to wear more comfort-          and even chronic ulceration.
laterally, in the direction of the 2nd                                                        Patient-Specific Surgery
toe. Often the second toe over lays
                                                                                          There are many different types of
the great toe and is cocked up or ham-
                                                                                       surgical procedures that correct the
mered. Much too narrowly defined by
                                                                                       bunion deformity. Based on clinical
the dictionary as “an inflammation
                                                                                       examination and x-ray findings, as
and swelling of a bursa sack at the
                                                                                       well as age and activity level, Dr.
base of the big toe,” a bunion defor-
                                                                                       Leavitt will custom design the proce-
mity actually involves the dislocation
                                                                                       dure for the patient. In addition to the
of the first metatarsal phalangeal joint
                                                                                       genetic predisposition for the defor-
and will gradually worsen and
                                                                                       mity, the surgeon must consider the
become arthritic if not treated.
                                                                                       mechanics of the foot in general when
     Why do bunions develop?                                                           considering etiology and in planning
   Bunions typically are inherited. Or          Typical bunion deformity.              surgical correction. Medical condi-
at least the predisposing bone, joint                                                  tions also must be considered includ-
                                           able footwear. They often attempt to
and soft-tissue structures are inherited                                               ing, chronic gouty arthritic attacks,
                                           use bunion shields or other over-the-
to the extent that bunion deformities                                                  rheumatoid or other collagen-vascular
                                           counter devices, which can accommo-
(with or without symptoms) are often                                                   diseases, connective tissue pathology
                                           date the bursal swelling, but have no
manifested in children and youth                                                       such as Down’s syndrome, Ehler-
                                           effect on minimizing the progression
before age 20. Males and females                                                       Danlos Syndrome, Marfans
                                           of the deformity or reversing it.
both can develop bunions, however                                                      Syndrome, generalized ligamentous
                                              Clinical treatment generally results
women tend to complain in greater                                                      laxity or neuromuscular conditions.
                                           in a recommendation for surgical
numbers because of particular shoe                                                     Lastly, traumatic injuries resulting in
                                           intervention if the conservative means
gear. Although shoes, by themselves,                                                   soft tissue derangement can also be
                                           have been exhausted. Although the
do not cause bunions, people with a                                                    contributing factors.
                                           injection of a painful bunion may be
foot type that is prone to this kind of                                                   Most bunion procedures are now
                                           performed, it is not advised. The
deformity, can aggravate the promi-                                                    performed on an out-patient basis in
                                           treatment not only does nothing to
nence with tighter shoe gear.                                                          the hospital. The surgery to repair a
                                           deal with the deformity, but the steri-
                                                                                       bunion deformity is reconstructive

                                Boston Arthritis & Spinal Surgery, PC
                                      Dr. Kenneth M. Leavitt
                  Doctor of Podiatric Medicine • Reconstructive Foot & Ankle Surgeon
                        * Board Certified in Foot Surgery by the American Board of Podiatric Surgery
 FootCare Update

Bunions      (continued)                   The Bio-mechanics of Bunions
                                               Bunions rarely develop without either the pre-existing or ongoing development of
and generally involves cutting of
                                           deformity of the first metatarsal phalangeal joint, such that there is the development of
bone and repositioning the
                                           joint dislocation, joint irritation and a resultant bony prominence of a portion of the first
malaligned first metatarsal joint.
                                           metatarsal head. Overlying tissues become irritated solely because of the underlying
Some form of fixation (wire, pin or
                                           protuberance with or without additional overlying irritation from shoe gear.
screw) is used to hold the bone in
                                               Bunion deformities can take various forms including: hallux valgus - a drifting of the
position during healing. The most
                                           hallux or great toe in the direction of the second toe, causing retrograde force upon the
long-standing deformities may have
                                           first metatarsal head with a resultant drifting of the first metatarsal away from the second
significant alteration of the bone
                                           metatarsal/second toe. As the great toe drifts laterally toward the second toe, the medial
structure along with arthritic changes
                                           and lateral sesamoids, two intra-articular bones which articulate with the bottom of the
in the metatarsal joint. In these cases,
                                           first metatarsal head, begin to drift laterally under the stress. The permanent relocation
an implant is used to replace the
                                           or dislocation of the sesamoids from their preferred position, in following the direction of
damaged joint and maintain align-
                                           the great toe, is what helps to accentuate and maintain the deformity.
ment with satisfactory range of
                                               Hallux abducto-valgus--not only does the great toe begin to maintain a valgus posi-
motion. The severity of the deformi-
                                           tion, but the lateral sesamoid (closest to the second metatarsal head) begins to dislocate
ty and the patient’s age, lifestyle and
                                           and relocate upward along the side of the first metatarsal head next to the second
work situation will usually influence
                                           metatarsal. The sesamoid, being invested within the joint structures and effectively
whether one foot or both feet are
                                           attached to the bottom of the proximal phalanx, begins to take with it and rotate the
done at the same time. Thirty to forty
                                           great toe into what is known as a valgus position. Hallux abducto-valgus deformities are
per cent of the time, the bony angu-
                                           more challenging to repair and indicate a more prolonged and advanced deformity.
lar deformity is so great that a proce-
                                               As the sesamoids, which should articulate within the sesamoidal grooves begin to dis-
dure known as a “base wedge” must
                                           locate and articulate with mismatched surfaces, there are two serious consequences of
be performed. In these cases, the
                                           this ongoing dislocation: 1) Relocation of the extensor and flexor tendons to the great
patients’ feet must be non-weight-
                                           toe, and 2) Retrograde of reverse force by the base of the proximal phalanx back
bearing for two weeks and they must
                                           against the first metatarsal head, pushing it away from the second metatarsal. This dislo-
use crutches.
                                           cation enables an ongoing and sometimes rapid progression of the deformity. Patients
      Post-op Recovery Period              will often relate a dramatic increase or occurrence of their deformity over a 2-3 month
   Most bunion procedures use some         period.
type of walking boot or shoe post-
                                              Potential complications following             cedures in each and every case.
operatively but patients can walk
                                           bunion surgery include post-operative               There is no such thing as a ‘cook-
with caution immediately. All
                                           infection, delayed healing, prolonged            book’ bunion surgery. The reputation
patients are encouraged to take at
                                           swelling and joint stiffness.                    of bunion surgery is either very good
least one week off from work after
                                              Fortunately these complications,              or very bad depending almost solely
bunion surgery.
                                           though infrequent, can be treated to             upon the technical expertise of the sur-
   They usually can return to some
                                           preserve a good result.                          geon. In our practices the outcome is
form of regular enclosed shoe gear in
                                              Basically the aim of the foot sur-            very dependable because of a thor-
three to nine weeks following the
                                           geon is to appreciate the importance of          ough peri-operative approach to each
                                           joint realignment, the maintenance of            individual and serious review of any
    Is surgery really necessary?           bone length and position in respect to           less than adequate results in order to
   Bunion surgery is elective; howev-      the other metatarsals and most impor-            help prevent subsequent problems
er the deformity is progressive and        tantly, individually tailoring those pro-        with other patients.
non-reverseable if not surgically cor-
rected. Important factors to be con-
sidered in the decision to have
surgery are 1) discomfort from the                                   Kenneth Martin Leavitt, D.P.M.
bunion or other toes, 2) inability to                           Fellow, American College of Foot & Ankle Surgeons
wear desired shoes and 3) limitations                     223 Cyprus Street, #200 • Brookline, Massachusetts 02445 USA
made on the patient’s lifestyle and                             TEL: 617-730-9814 • FAX: 617-730-9819
career activity levels.                            • E-MAIL: •

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