The Foot Consultant
IF IT DOESN'T HURT DON'T FIX IT
"WHY THIS ADVICE CAN DAMAGE YOUR HEALTH"
Ok, my main job involves operating on feet and you might think therefore that as with any surgeon my first thought when treating a patient is to offer an operation.
Well, I can promise you that you're wrong. My general approach is to keep the surgical option until last. After all if you look at the data for most operations few if any truly achieve 90%+ success. Even surgeries claiming 95% success mean that for every hundred operations five people will be disappointed to one degree or another.
Since qualifying way back in 1990 I have had a high threshold to offer surgery to patients and this approach has served me and more importantly my patients well. To many people's frustration I make people work through the most basic of conservative measures before contemplating any invasive treatments at all.
Take one of the most common causes of heel pain, plantar fasciitis, of which I see at least three or four cases of week. Having confirmed the diagnosis myself, as it is often isn't plantar fasciitis at all, treatment begins with the least risk interventions. This typically includes a discussion around footwear, activity modifications, specific stretching and perhaps the use of a simple foot orthoses. In these patients the medical literature and my own experience can confirm that the overwhelming majority (around 80%) of patients will see improvement in their symptoms with nothing more than these simple measures. Many of the patients that don't improve demonstrate less engagement with the tedium of my stretching regimes.
In contrast there are clinicians whom are eager to administer injections of corticosteroids early in the treatment journey often encouraged by patients who may perceive greater value in this approach. Unfortunately, the clinical evidence clearly shows poor long term outcomes with this approach with complications including fascial rupture and recurrence of the problem.
SO WHEN IS ELECTIVE SURGERY THE RIGHT OPTION?
In most circumstances surgery is reserved for situations where a patient is in pain and the clinician and patient agree that several conditions are met:
Symptoms are impacting on quality of life
All reasonable "less risky" approaches have been exhausted
Surgery has a realistic prospect of a successful outcome
The risks of surgery are outweighed by the potential benefit.
Although, in most cases when we talk about symptoms we are referring to pain, many patients seek out medical advice because of the impact a condition is having on their day to day activities.
Only recently I consultant ENT surgeon presented with chronic heel pain which was manageable at home but impacting on her work where she would have to stand for hours operating.
Such decisions are often complex and a topic for future discussion. What is critical is that such decisions are reached in harmony with patients and if dealing with children engage all stakeholders.
WHEN IS THIS EQUATION DIFFERENT?
In short the emphasis shifts if a delay in surgical intervention may be associated with increased risk or diminished success rate.
HOW IS THIS RELEVANT TO HALLUX VALGUS (BUNIONS)
The balance of this decision-making process is subtly different in hallux valgus (bunions) because delays in treatment can limit the available treatment options later in life with implications for future surgical risks, recovery time and probability of successful outcome.
To re-cap hallux valgus is a complex deformity of the forefoot and not simply a bump over the big toe joint. Hallux valgus involves progressive splaying of the forefoot with an increased gap between the 1st and 2nd metatarsals (red arrow).
As the big toe moves to point toward the 2nd toe the outer aspect of the metatarsal head is exposed. Changes in the contact pressures across the joint result in re-modelling of the bone and formation of a "bump". Cartilage is gradually lost over the outer of the joint (black arrows). The combined effects make shoe fit progressively more difficult. The small sesamoid bones that sit under the 1st metatarsal become mal-aligned and damage to the cartilage surface of the big toe joint develops.
Overtime this mal-alignment results in altered mechanics and formation of skin and soft tissue changes. The function of the big toe joint is progressively impaired.
LACK OF SYMPTOMS
Of course patients with bunions don't start out like but rather they typically experience a progressive degree of deformity almost going unnoticed until significant structural changes have already developed. An early consultation with the family doctor mostly results in advice to leave it alone until it becomes very painful. Here lays the problem. Left unchecked the deformity almost always will progress with the potential to change the surgical options.
THE BASICS OF BUNION SURGERY
The primary goal of bunion surgery is anatomical realignment, preservation of the joint and restoration of function of the big toe joint. These are all inter-related. In this example you can see that on the left the big toe is pointing toward the second, there is a large distance between the 1st and 2nd metatarsals (yellow arrow). The sesamoid bones are also displaced (red arrows). A Tailors bunion is also present (around the 5th toe joint.
Because the deformity is moderate surgical correction can be achieved with a relatively straight-forward operation. In this case I have employed a "scarf" type osteotomy. The operation has several advantages:
Relatively uncomplicated procedure
Bone geometry is stable after surgery
Requires no cast after surgery
Rapid weight-bearing is possible post surgery
Return to footwear typically around 4-6 wks
WHAT IS THE IMPACT IF LEFT UNTREATED?
Many patients will see an increased rate of progression with their bunions as the anatomy holding the big toe straight is weaker than the structures pulling the big toe out of position. Once it starts to drift out of alignment it is common for the rate of deterioration to increase.
The problem now is that the more straight-forward procedures such as the scarf type osteotomy are not capable of correcting bunions of this severity. This is then changes the surgical options for the patient and mandates more complex surgeries such as the Lapidus procedure.
This type of surgery is significantly more complex and carries a higher risk of complication by comparison to the scarf type procedure. Differences include:
Operation time roughly double
Requires a cast or boot for six weeks after surgery
Overall recovery time is over double that of a scarf type surgery
Increased risk of big toe joint stiffness
Increased risk of metatarsalgia.
WHAT ADVICE TO GIVE TO PATIENTS?
It is fair to say I have seen many patients over the years who have been bitterly disappointed to learn that had they sought advice sooner they would have avoided the need for a complex proximal (Lapidus or similar) operation to correct their bunion. Sooner or later patients will look to seek a legal remedy for inappropriate advice.
I am certainly not suggesting for one moment that all patients require bunion surgery simply because their big toes aren't perfectly straight. What I am saying is that patients deserve to receive expert advice and careful counselling about their options and the timing of surgery so they maintain the opportunity for the best outcome with minimal risk.