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Tuesday, April 8, 2014

Tuesday's Patient Question of the Week: How to deal with Bunion Surgery Complications?

Dear Dr. Blake,
I imagine you must get many of these emails.  I stumbled upon your blog by reference of an enthusiastic patient of yours.  Coincidentally, I live in the Bay Area.
I have a series of complications which has led from flare-up to constant chronic pain and immobility.  I have eliminated all exercise except swimming and lifting weights.  Walking and standing are hard; I used to be very active.  I have a slight build so my weight is not an issue.  I am just wondering how to proceed, how to find an expert, whether surgery is appropriate (I am scared of this as I have had 6 in all but I do not want this current condition to be my new norm).  My summary, if I may indulge you, is as follows:

Image of a bunion patient whose previous surgery had failed and the toe collapses towards the 2nd toe and off the big toe joint causing arthritic pain. 

After no luck with orthotics for painful bunions, in March 2002, I had my left foot worked on ( a bunionectomy).  In June, 2002, I had my right foot bunionectomy-same doctor- an orthopedic surgeon.  One outcome of that surgery is that the big toe bone has become shortened and my first metatarsal head is misaligned with the second and third.

The bunions came back five years later; in August 2007 and December 2007, I had my left then right foot done respectively, by different surgeons.   The surgery, shaving rather than cutting the bones, was much easier to recover from.
Dr Blake's comment: Bunion surgeries vary immensely, and typically the longer the post op course, and the more bone work done, the longer the bunion correction will hold. There are also so many factors like severity of pronation, width of foot, general ligamentous looseness, and bone structure to name a few that can help determine the longevity of these surgeries. Surgeons have their preference, but in discussing with them, see if you can determine why they choose a particular type for you. Definitely get a second opinion and do not mention what the first surgeon plans on doing. See if they are on the same page or miles apart. 

In 2011, I developed bone spurs and was diagnosed with hallus ridigus which amounted to a 40% loss of mobility in my foot due to arthritis so I had surgery on the bone spurs (by my big toe).  My left foot was worked on in August 2011. 
Dr Blake's comment: Surgery on any joint weakens the joint leading to gradual onset of potential problems in the future. This is typically very slow process, so it is unusual that arthritis set in after your second surgery. I am assuming that there was no mention of arthritis in the first and second surgeries. Something does not make sense, but you have what you have right now. Bone spur surgery on the big toe joint, AKA joint cleanout, AKA joint arthroplasty, AKA cheilectomy is definitely a very skilled procedure and needs some luck in going to work. I highly recommend this surgery over implant or fusion for Hallux Limitus since it works well normally (at least for many years). 

 The doctor also removed screws in my feet from the previous surgery and he shaved a “bunionette” off the right side of my left foot, so in August I had two parts of my foot worked on.  I was healing okay until I tripped about six weeks later and broke my middle toe on that same foot.  This set me back immensely.

My second bone spur surgery was in March, 2012 on my right foot.I was healing well, in general, and was running by fall of 2012 just a little.  I did lots of yoga until I injured my left foot in January 2013.  I took time off and by March, got a cortisone shot in my left foot.  I had had one in 2012 at some point for swelling.  I began physical therapy in March/April of 2013 and had been seeing my PT currently once every two weeks. I'm now upping it to once a week.

Current problems since June:  Metatarsalgia, sesamoiditis, arthritis, poor flexion in the ankle due to tight calves (and on my feet all day due to teaching), thin padding on the bottom of the feet and stressed metatarsal heads, minor pain from Taylor's bunion on right foot.  Left foot, overall, is much worse than right.  I tried a chiropractor this summer with no positive outcome.  I sometimes get acupuncture and massage.  I'm also wearing a metatarsal pad, mainly on my left foot (Jill's Gels) and am now trying toe stretchers.  I have rocker-bottom shoes and have been unsuccessful with new orthotics.

Another orthopod is recommending surgery to align the metatarsal heads.  I have a second opinion upcoming with another orthopod.  I am also considering a visit to the Mayo Foot/Ankle Clinic in Arizona.  I will do anything to  get my mobility back.  If you have any advice as to who to see or how to proceed, I would be so grateful.  I am very lost on this journey.

Best Regards and thank you for what you do.
Sara (name changed)

Dr Blake's response:

     Hey Sara, thank you so very much for your email. I will try to help you. Your journey is not unusual unfortunately for many patients that have bunions and probably some underlying arthritis. But, it has been alot of surgery for you. I would be cautious about more surgery at this point, since something must be amiss. Someone has to explain how you got to this point in so much pain. And then explain what can be done for it. Since your pain is so widespread across your left foot, you should be in a removable boot for 3 months to place that foot in the Immobilization Phase of Rehab. During that 3 months, get MRIs (if affordable) on both feet to see what is wrong. Have someone into orthotics figure out how to off weight sore areas. Daily ice both feet 3 times daily for 10-15 minutes to cool them down, and take NSAIDs. Try to analyze the % of pain from each area. When you present to the medical profession with these issues, it is overwhelming. Focus on one problem (the most problematic) if possible and get that well, then move on to lesser problems. See a pain specialist if you are having trouble with day to day activities, or if the present docs can not help with the pain. Pain causes more pain, and you can get into vicious cycles. Check the information on this blog on handling nerve pain. I hope this helps somewhat. 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.