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Bunion
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Description:
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The term bunion refers to a bump of bone that becomes prominent at
the great toe joint. A bunion is actually normal anatomy that has shifted
to a position where the bump becomes more noticeable and prominent.
Bunions become more common as we age but are not uncommon in teenagers and young
adults. Bunions are found more often in women than in men. Not all bunions are
painful. When painful, bunion pain is caused by two factors. The
first is direct pressure from shoes on the bunion. And the second source
of pain is due to arthritis that develops within the great toe joint. Bunions
are also called HAV, hallux valgus or hallux abducto valgus.
Do high heels contribute to the onset of bunions? The
degree to which shoes contribute to the onset of a bunion is
questionable.
There's no hard science to say that any particular type of shoe contributes to
the formation of a bunion. We can say with certainty that bunions
are an inherited disorder. More
specifically, we don't actually inherit a bunion, but we inherit a set
of bones, joints and ligaments in our feet and lower extremity that are
very similar to that which we would see in our parent's and our
grandparent's feet. The
same biomechanical events that took place to cause the parent's bunion
problems are recreated with each step in each new
generation.
Why does a bunion hurt? Bunions increase the width
of the forefoot. As the forefoot becomes wider, it becomes
increasingly more difficult to fit into a shoe. Bunions also
change the position of the joint and force the great toe joint to
function in a manner that promotes arthritis of the great toe joint.
As the arthritis becomes increasingly evident, the great toe will ache
both with and without shoes.
Bunions become more common as we age. Bunions aren't
really a product of old age, but rather a combination of genetic factors
that given enough time will develop into a bunion. Bunions are not
uncommon in teenagers and young adult. There are some very specific
biomechanical characteristics that contribute to the early development
of bunions in children. These characteristics are somewhat
technical but your doctor should take these into account before
prescribing treatment such as surgery. Surgical procedures for
pediatric bunions tend to be somewhat more aggressive in nature merely due to
the fact that the child has a lifetime in which the bunion may recur.
Treatment of Bunions
Should you have your bunion
corrected? Has your foot pain
affected your job? Has your pain
limited the kinds of shoes you like to wear? There's a number of different factors that ultimately affect
a patient's decision to have their
bunion corrected, but the single most important issue is pain.
Surgery is the only way to correct a
bunion. In poor surgical candidates,
bunion pads are helpful to relieve shoe
pressure. We always recommend patients try wider shoes with
softer shoe materials such as leather. A good leather
shoe can be stretched to accommodate a bunion. Clogs are also a
remarkably good solution for patients with bunions. Clogs offer a wide toe
box that can accommodate bunions and hammer toes.
Bunion surgery has a long
and colorful history. There's probably more than 400 different
combinations of procedures that are named after this doctor or that
doctor. Most doctors use just a handful of these procedures.
Surgeons are no different than anyone else. Once a surgeon finds a technique
that works
they have a tendency to stick with it.
Foot surgeons classify bunions based upon three criteria; (1)
Size of the bump (medial eminence) (2) abduction of the great toe and
(3) the inter-metatarsal angle. Each of these issues become a part
of the treatment plan and guide your doctor to determine which procedure
would be best for you.
When
planning bunion surgery, foot surgeons use x-rays as a blueprint to
evaluate surgical choices. The age of the patient is an issue to be
considered when planning a bunion surgery. We are much more
aggressive with younger patients and less so with older patients.
The younger the bunion patient, the more chance that patient has for the
bunion to recur during their lifetime. So subsequently, additional
considerations must be made when planning for bunion surgery in
children. Other pre-operative considerations include the patient's
occupation and the patient's overall health status.
A bunion procedure is
normally performed on an out-patient basis. Most bunionectomies are
performed under local anesthesia with IV sedation at a surgery center or hospital.
This is the preferred setting because it's the safest and most comfortable
setting for patients. Patients are given a sedative through
their IV that makes them very sleepy while their foot is anesthetized prior
to the procedure. In the hands of a skilled anesthesiologist, most
patients remember very little of their procedure and are ready to return
home in just a short time after their procedure is completed.
Most surgeons use a
long acting anesthetic in surgery that will keep the foot numb for up to
8 hours. This allows patients to get home and situated
comfortably. The two most important tools
used post-operatively to control pain are ice
and elevation. Foot surgery is unique in the fact that we're going
to be walking on an area of the body that recently underwent
surgery. Obviously that presents with some challenges. When
the foot is placed down below the level of the heart it's going to
swell. When it swells it is going to hurt, particularly during the
first few days following surgery. Patients who plan ahead and
spend time with their foot elevated use very little pain medication following
surgery. Ice is a must. Ice will help to reduce swelling
thereby controlling any pain without the use of narcotics.
Recovery time following a bunionectomy will vary
with the choice of procedure, the patient's occupation and general
health status. Most post-op patients can bear weight immediately
following surgery for short periods of time. Patients will be
limited for several days in walking and will return to about 50% of
their normal activities at 3 weeks. Most post-op bunion patients
will return to regular shoes at about 5-6 weeks post surgery.
The images below show the basic steps used in a bunion surgery
called a Modified Austin Procedure. An Austin procedure is the most
commonly performed bunionectomy today. Image 1 shows the dissection down
through the skin and joint capsule, exposing the head of the first metatarsal.
Image 2 shows the V cut (osteotomy) through the distal first metatarsal.
The distal fragment is then physically shifted towards the second toe and
fixated with screws (Image 3 and 4). Image 5 shows placement of a pain
pump catheter in the wound site. The final image shows placement of the
pain pump reservoir and final bandage.



 
Postoperatively, many doctors use a removable walking cast called
a cam walker to protect the surgical site
during healing. Additional post-op care may include a
forefoot compression sleeve to control
swelling or a bunion regulator to wear
while sleeping.
Another important
consideration in any surgery is family, friends, bosses and co-workers. Bunionectomy patients need to establish a few designated support people
before they have their surgery. Widows, widowers and single
parents are special cases and need to be sure they have enough support
at home for meals, laundry etc. And lastly, bosses and co-workers
are counting on realistic expectations of when you return to work
and when you do, are you going to limited in any way? If so, how
long? It's pretty easy to
see that the technical component of completing a bunionectomy is just
one part of a successful outcome.
Can a bunion return after being surgically corrected?
Occasionally. As a rough estimate (non-scientific), many doctors will estimate
the percentage of chance of recurrence of a bunion to be 60 minus your age.
So for a 50 year old patient, the percentage of chance that a bunion would
reoccur would be about 10%.

Post operative complications can occur but are uncommon with
bunionectomies. With any surgery you need to consider the possibility of
infection, delay in healing or scar formation. These are problems that can
occur in any surgery, even to the best of surgeons using the latest techniques.
One complication specific to bunionectomies is overcorrection of the bunion
resulting in hallux varus. Hallux varus is uncommon and is usually
associated with removal of the fibular sesamoid in a Modified McBride procedure.
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Turf Toe
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Description:
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Turf toe
is a term used in athletic circles to describe an injury to the great toe joint.
In non-athletic patients, turf toe is known by another name;
hallux
limitus. Hallux limitus describes a number of different contributing
factors that lead to pain and limited motion of the great toe joint. Turf
toe represents just one of the four reasons that patients develop hallux
limitus. Those four reasons include;
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Direct physical injury to the great toe joint (turf toe) - injury
to the articular cartilage or subchondral bone. These injuries
may be due impaction injuries or hyperextension/flexion of the
first MPJ.
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Functional hallux limitus -
biomechanical function that results in metatarsus primus
elevatus and subsequent repetitive jamming of the first MPJ.
- Structural hallux limitus - limited range of motion caused by a long
first metatarsal.
- Other conditions - synovitis,
crystal deposition diseases such as gout, systemic arthritis,
external physical influences such as Dupytren's contracture,
etc.
But before we go any further, we
need to understand that the terms turf toe and hallux
limitus are indeed related but aren’t really synonymous. The
fundamental difference between the two terms is the patient population that they
affect. Turf toe is a term used in athletic circles that refers to an injury of
the great toe joint. On the
other hand, when we discuss hallux limitus, we’re actually
referring to a broader, ‘non-athletic’ patient population and
need to include all four causes of hallux limitus.
Think of turf toe (hallux limitus)
as an isolated case of osteoarthritis limited to the great toe
joint. As the injury progresses, a series
of micro fractures will develop in the subchondral bone. The typical
soft spongy character of the metaphyseal bone (supporting bone
beneath the joint surface) changes to become
brittle and hard. The result is that the articular cartilage looses
its’ underlying support and becomes susceptible to damage. What you see on x-ray is the slow
progressive destruction of the joint.
Turf toe (hallux limitus) caused by a direct injury
to the joint may or may not initially be obvious. Athletes may not remember an
incident of pain since they’re often distracted by the event or
game in which they’re involved. The onset of direct injury to the
joint may be abrupt, but also may be insidious becoming increasingly
more painful as the season progresses. The joint pain will subside
with rest only to recur with increased activity. It’s not unusual
to see symptoms of turf toe resolve in the off season only to recur
with renewed exercise.
Treatment of turf toe
Treatment of turf toe varies and may include rest, shoe
modifications, orthotics, steroid injections and surgery. The
success of non-surgical care will vary with the stage of injury,
the rate at which the injury is healing and how much osteoarthritis
has occurred (see our pages on
hallux limitus for staging). In stage 1 turf toe, use of a
dancer's pad can decrease pain by plantarflexing the first
metatarsal, thereby increasing the range of motion of the great toe
joint. A
turf
toe strap can help in stage 2 to limit motion of the joint. We see varying degrees of success with orthotics that
promote plantarflexion of the first ray, effectively treating
metatarsus primus elevatus and peroneus longus dysfunction. Simple
arch supports can make a significant difference in the symptoms of
turf toe. Most successful are
orthotics with a rigid Morton's extension beneath the great toe
joint. A Morton's extension is used to decrease the range of
motion of the joint. Alternatively, a full length, rigid,
carbon
graphite spring plate may also be used to limit range of motin
of the great toe joint.
Should a patient not respond to conservative care
of turf toe in a reasonable time period, we are not reluctant to suggest
surgical revision to address the problem whether it be revisions of
the joint defect, shortening of a long first metatarsal or
structural revision of metatarsus primus elevatus. As mentioned
before, the clinical appearance of dorsal lipping or visible
radiographic changes are suggestive of moderately advanced
osteoarthritis, a condition that can only be repaired by joint revision
or replacement.
Remember, turf toe is just one form of hallux limitus. Be sure to visit
our page on
hallux
limitus for a thorough discussion of this condition.
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Hallux Rigidus
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Description:
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Hallux rigidus is the term used to describe end-stage limited
range of motion of the great toe joint. Hallux rigidus is often referred
to as the final stage (stage 4) of
hallux
limitus. Hallux limitus is a progressive degenerative change in the
1st mpj.
Treatment of hallux rigidus
Conservative care of hallux rigidus focuses on the use of pads to
limit the range of motion of the great toe or devices to
stiffen the shoe.
Turf toe straps
are a great short term aid for symptoms of hallux limitus and hallux rigidus.
Turf toe
plates and
carbon spring plates are two examples of inserts that can be used to stiffen
the shoe. Shoe modifications are also used to decrease bending of the
forefoot. The most common modification is called an anterior rocker sole,
seen at right.
Surgical care of hallux rigidus may include a Keller bunionectomy,
great toe fusion or implant arthroplasty. A Keller bunionectomy is an old
procedure that utilizes the capsule of the great toe joint to create a new
joint. The capsule, or lining of the joint is interposed in the position
where the joint is resected. The disadvantage of the Keller bunionectomy
is that the great toe is usually much shorter and floppy post-op.
Fusion of the great toe joint is accomplished by resection of the
joint and fixation of the joint with crossed screws or a plate. A bone
graft is often used to supplement shortening created when the joint is resected.
The bone graft can be from bone bank bone or from the iliac crest (crest of the
pelvis). Fusion of the great toe joint requires a 6-8 week period of
non-weight bearing for proper healing.
Implant arthroplasty involves resection of the joint and
replacement of the joint with a flexible hinge. The following pictures
show the steps used to perform implant arthroplasty of the great toe joint.
Image 1 shows the pre-op planning and location of the incision. Images 2
and 3 show dissection of the joint and removal of arthritic spurring surrounding
the the joint. Image 4 shows the trial implant sizers. Images 5-8
show remodeling of the joint with preparation of the implant site. Image
9-12 shoe placement of the implant and final closure. This procedure is
performed at a hospital or surgery center under general anesthesia or local
anesthesia with sedation. The procedure takes about and hour to complete.
Patients can bear full weight on the foot immediately following surgery.



For additional information regarding the onset and development of hallux rigidus, please refer to
our pages on
hallux limitus.
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Hallux Limitus
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Description:
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 Hallux
limitus describes a condition where the hallux (great toe) is limited in
its' range of motion. This limited range of motion results in
jamming of the 1st metatarsal phalangeal joint (1st mpj or great toe
joint). Over time, repetitive jamming will contribute to arthritis
of the great toe joint. The most characteristic sign of hallux
limitus is a bump (exostosis) on top of the head of the 1st metatarsal.
In fact, many doctors also refer to hallux limitus as a dorsal bunion.
Hallux limitus is caused by four contributing factors. These
factors include the following;
1. A long 1st metatarsal. 2. An elevated 1st metatarsal. 3. An impaction injury of the 1st mpj resulting in an osteochondral defect (OCD) of
the joint. 4. Systemic diseases that cause injury to the joint such as rheumatoid
arthritis, lupus or gout.
Hallux limitus is graded in four stages;
| Characteristic Findings By Stage Of Hallux Limitus |
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Symptoms |
External appearance of the joint |
X-ray findings |
Treatment |
| Stage 1 |
Vague joint pain |
No change evident |
No changes noted |
Dancer's pad or sub 1 cut out in an orthotic |
| Stage 2 |
Increased frequency and duration of pain |
Mild dorsal exostosis |
Dorsal exostosis on lateral x-ray |
Carbon plate with Morton's extension. Possible
joint revision. |
| Stage 3 |
Pain with all activities |
Large dorsal exostosis |
Increased dorsal exostosis. Asymmetrical joint space narrowing |
Youngswick osteotomy with joint revision. |
| Stage 4 |
Significant pain with any range of motion of the
joint |
Enlargement of the entire joint |
Flattening of the joint with prolific spurring surrounding the
entire joint |
Joint replacement, fusion or Keller bunionectomy |
Treatment of Hallux Limitus
Evaluation of the range of motion of the 1st mpj can be performed in two
positions; relaxed and functional. In a relaxed position, with no resistance exerted by the calf,
the 1st mpj shows normal range of motion without pain. In a functional
position, when resistance is applied by the calf, the range of motion of the 1st
mpj changes and hallux limitus can be more appropriately assessed. The
term functional hallux limitus is applied to cases that have normal range of
motion in a relaxed position, but decreased range of motion in a functional
position.
Assessment of hallux limitus requires evaluation of the 1st mpj in
both a relaxed and functional position. Is there crepitus (grating
or cracking) with range of motion? Does the joint catch or pop?
Is there pain with range of motion? Each of these signs can
indicate a certain stage of hallux limitus.
Conservative care of stage 1 hallux limitus may include the use of a
dancer's
pad or orthotic custom made with a sub 1 cut out pad. These two types
of pads are used
in an attempt to increase the plantarflexion of the 1st metatarsal to improve
range of motion of the 1st mpj. As we progress into more advanced stages
of hallux limitus (2-4), the dancer's pads will no longer be effective. At
this stage, we change treatment to a
stiff insert with a rigid extension called a
Morton's extension. A Morton's extension is used to stiffen the shoe to
decrease painful range of motion. Another short term solution for stage
2-4 is to use a
turf toe strap to limit range of motion.
Injectable cortisone is often used to treat hallux limitus. There is
some debate as to the merit of using cortisone for the treatment of hallux limitus. As noted
above, the majority of cases of hallux limitus are due to aberrations in the
biomechanical properties of the 1st mpj. Therefore, common sense would say
that the most effective method of treatment for hallux limitus would be to
change or alter the biomechanical property that is casing problems. For
instance, if hallux limitus is due to a long first metatarsal, then shorten the
metatarsal. Cortisone cannot treat these biomechanical factors and
therefore must have only a minimal role in the treatment of hallux limitus.
There are a number of common surgical procedures used to correct hallux
limitus. One method of care is a procedure called a cheilectomy.
Cheil means lip and a cheilectomy is a procedure that focuses exclusively on
resection of the dorsal exostosis (the lip) of the 1st metatarsal head. A second
type of surgery for hallux limitus is a metatarsal osteotomy and cheilectomy.
The metatarsal osteotomy, often called a Youngswick's modification of an Austin
bunionectomy, creates an break in the bone that can either shorten or
plantarflex the head of the metatarsal. The osteotomy is important because
it addresses the primary reason for hallux limitus. It should be noted
that there is not universal agreement among doctors as to which of these
procedure is the best solution for hallux limitus.
Many surgeons believe that hallux limitus can be corrected with a simple
cheilectomy. The advantage to performing just a cheilectomy is that a
person will regain some range of motion and be back on their feet relatively
quickly. The disadvantage to performing just the cheilectomy without
osteotomy is that the primary biomechanical reason for hallux limitus will not be addressed.
In time, the dorsal lip will return and arthritis within the joint will
increase. The disadvantage of an osteotomy is that it increases the difficulty of the
surgery and increases healing time.
Cheilectomy and osteotomies are procedures applicable to stage 2 and 3 hallux
limitus. In addition to these procedures, revision of the joint may be
performed to repair or induce regeneration of the cartilage. Transchondral
drilling is a technique used by many doctors to resurface the joint during
surgery. Transchondral drilling means that a fine drill is used to drill
through the hard layer of bone (subchondral bone) just beneath the surface of
the cartilage. Drilling provides access to bone cells in the marrow of the
bone that can become cartilage cells. Another technique used to resurface
the joint involves the use of a osteochondral graft often referred to as an OAT
procedure or osteo-articular transfer. OAT grafts can be harvested from
other joints (often the knee) to transfer to the damaged cartilage of the 1st
mpj. Synthetic bone
graft material can also be used for joint resurfacing.
Surgical repair of stage 4 hallux limitus again has
disagreement among doctors
as to the best choice of procedure. In stage 4, often referred to as hallux
rigidus, the surface of the joint is so badly damaged that the joint is not
salvageable.
Implant arthroplasty is one choice. Implant arthroplasty involves
resection of the joint and replacement of the joint with an implant. The
advantage of implant arthroplasty is that the implant will maintain the normal
length of the toe and preserve normal range of motion. Another technique
used in stage 4 hallux limitus is
fusion of the 1st mpj. Fusion of the
joint requires a period of non-weight bearing for proper healing. The
disadvantage of 1st mpj healing is that the toe may be shortened due to
resection of the joint. A bone graft may be taken from the hip to
supplement length. Another disadvantage of fusion is permanent stiffness of the 1st
mpj. The last option for stage 4 hallux limitus is a Keller bunionectomy.
A Keller bunionectomy is a procedure where the base of the great toe is resected
and a new joint created using a flap of the joint capsule. This technique
is called an interpositional arthroplasty; interposing the soft tissue to create
a joint. The advantage of a Keller bunionectomy is that it is easy for
patients to get back on their feet. The disadvantage is that the great toe
becomes loose, short and floppy. The following images show the surgical steps
used to correct stage 3 hallux limitus. This procedure is called the
Youngswick modification of an Austin bunionectomy. Image 1 shows the
pre-operative planning with incision line and joint space marked.
Image 2 shows exposure of the dorsal exostosis (also called a dorsal bump or
dorsal bunion). In image 3, we see an oscillating saw resecting the
dorsal exostosis. This procedure is called a cheilectomy. Image
4 shows erosion of the cartilage of the head of the 1st metatarsal (stage 3
chondromalacia). A 1.2 mm pin is Kirschner wire is being used to
perform subchondral drilling. Subchondral drilling can help to restore
damaged cartilage. Image 5 shows the osteotomy of the 1st metatarsal.
A 2 mm wedge is being take from the dorsal aspect of the osteotomy.
The osteotomy is outlined by blue dots. Image 6 shows the completed
osteotomy that has shortened and plantarflexed the 1st metatarsal.
Image seven shows fixation of the osteotomy with a single screw. Image
8 show the improved range of motion post-op. In image 9, the joint
capsule and deep tissue is closed. And image 10 shows final skin
closure.
Surgical correction of hallux limitus is performed at a hospital or
outpatient center. The procedure takes approximately 1 hours to
complete. A local anesthetic with sedation or general anesthesia is
used. Patients are able to bear weight on the foot immediately post-op
for limited periods of time. A walking cast will be used for 6 weeks
post-op. Variations in this procedure may include K wire fixation or
absorbable pin fixation.
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Forefoot Pain
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Description:
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The
forefoot consists of five metatarsal bones that originate in the midfoot and
descend at an angle to meet the toes. Each of the five metatarsal bones
terminate at the metatarsal phalangeal joints (mpj's). The plantar, or
bottom aspect of the mpj is often called the ball of the foot. Due to the
amount of load bearing applied to the forefoot in walking and running, the
forefoot is prone to a number of different injuries.
The distal portion of the forefoot consists of the 1st mpj and the
lesser mpj's (2-5). The great toe joint (1st mpj) is a bit unique in that
the anatomy of the great toe joint is a bit different than that of the lesser
mpj's. To a degree, the lesser mpj's act independently of the 1st mpj.
Therefore , any discussion of forefoot conditions should be broken into those
problems specific to the 1st mpj and those problems specific to the lesser mpj's
(2-5).
The following is a list of common forefoot conditions. To
find more information about these conditions, follow the highlighted link.
Forefoot conditions specific to the 1st mpj.
1.
Bunion
2.
Gout
3.
Hallux limitus
4.
Hallux rigidus
5.
Pseudogout
6.
Sesamoiditis and sesamoid fractures
7.
Turf toe
Forefoot conditions specific to the lesser mpj's (2-5).
1.
Bursitis
2.
Capsulitis
3.
Freiberg's Infraction
4.
Metatarsalgia
5.
Morton's Neuroma
6.
Metatarsal stress fractures
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