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Thursday, September 12, 2013

Foot or Knee Surgery First: Email Advice

Dear Dr. Blake:

I have a too short first metatarsal due to surgery about 7 years ago.  In addition, my second and third toes are longer than my big toe.
Dr Blake's comment: A short first metatarsal is like removing the third leg off a tripod. If the first metatarsal is short, it tends to be above the ground, and as you move forward the lack of support on the first metatarsal will cause your arch to collapse. You can also develop a compensatory supinated gait which allows you to stay on the outside of your foot, but it is jarring to the knee, hip, and back. 

I was never able to walk correctly afterwards. My foot turns outward and now my second and third toes curve toward my big toe.  Also, the tendon in my big toe may be too short now.  There is pain under my knee on the same side as the tendon in my big shortened toe.

Thank you very much for the video on spica taping for big toe joint pain.  I  had a family member spica tape my big toe last night and oh what relief!  I was able to walk better today than I have been for a long time.

I am now in the situation where I need both knee and foot surgery.

Can you give me your thoughts about whether I should have knee replacement surgery or foot surgery first?  Is there a correct order in which to proceed?
Dr Blake's comment: Foot surgery typically requires a period of weight bearing on the tibia with a device called a RollaBout. You I am attaching a video I did of the device. If you think that your knee can tolerate that for several months, do the foot surgery first. However, we mainly recommend to our patients to have the knee surgery first since the walking is so limited for 3 months, and then when the knee can tolerate the RollaBout, go ahead with the foot surgery. 

Also, are there any other things I can do to provide relief while walking?  Any thoughts on surgical procedures that may help and non-surgical things that I could do that may help.
Dr Blake's comment: I spend all day trying to take feet like yours and design inserts to help balance out the weight. Based on gait abnormalities, I work with a physical therapist to make gait changes, and add appropriate strength and flexibility work. Go to the AAPSM website for a local podiatrist that can help you start. I am not a surgeon, so advice regarding surgery may be worth what you pay for that advice!!! I hope this helps. Rich

Thank you very much again for the spica taping video.

Thank You,

The patient responded again.

Dear Dr. Blake:

Thank you very much for responding to my email on your blog.   I appreciate this.  I am trying to find my way in order to fix my foot problem.  It hasn’t been easy.

My too short metatarsal is causing me to walk on the outside of my foot and my knee is bone on bone on one side and my hip hurts too.    I have what you called “supinated gait” and this has done damage to both my knee and hip.  You are “spot on” with what happened to me.

I contacted a three orthopedic foot surgeons this summer and each proposed a different way of treating my foot:

One wanted to perform a metatarsal fusion with bone graft on my big toe and then shorten the second and third toes.  (Healing time = 12 plus or minus 3 weeks)

Another wanted to do an osteotomy on the first toe .  And then shorten my second and third toes.  (Healing time  = 8 weeks)

The third surgeon I consulted wanted me to get my knee fixed first and then to do a tendon transfer to solve my walking problem  (Healing time about a year)

It has been very confusing for me, since each doctor has proposed a different solution to fix my foot.     Also,  I need to keep on working to bring in a paycheck.

I don’t know which procedure would work best for me since I am not a doctor and each person is proposing something different.    Do you have any insight on which procedures tend to work best to fix  a foot with a problem like mine?

Does a metartarsal fusion with bone graft usually work to solve a problem like mine?  I am afraid to have the joint fused  permanently.   Of the patients you have seen with a problem like mine, what procedure seems to help them best?   Do bone grafts usually fail?   I am afraid that the fusion will affect my gait.  However, I am not walking very well now.

That spica taping is helping me walk.

Thank you very much.   I appreciate it.

Dr Blake's response:
     I am not a surgeon, but I do follow patients whom have had surgery. Definitely have the knee surgery first, and begin working on orthotic devices that do the same function as the surgery. You can make orthotics to lessen a supinated gait, that act as a fused big toe joint, that bring the ground up to a short first metatarsal that is elevated, etc. The orthotic device, designed by a podiatrist, physical therapist, or orthotist should begin to discover how to make you comfortable and make your gait better. I have many patients avoid surgery be wearing orthotics or in the process of making the orthotics and analyzing the foot we learn what needs to happen in surgery. It is common in the San Francisco Bay Area for patients to have the instep fused in your case (where there is no pain in the big toe joint) and the first metatarsal dropped lower to bear weight during the procedure. This requires 8-10 non weight bearing, and then 3-6 months of gradually getting function back in the foot. You want to know a good orthotic person before you do this type of thing. I hope this helps some. Rich

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.