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Saturday, April 18, 2020

Surgical Complications Post Bunionectomy and Pes Cavus Foot

Hello Dr. Blake,

I hope you are doing well and staying healthy during these crazy times! 
I have been thinking of writing you for quite a while, but my question is quite lengthy.
 I have attached some x-rays and photos to this email, but I also have a CT cat scan
 and an MRI of my foot if having those would be better.
Dr. Blake's comment: Yes, send those to Dr. Rich Blake, 90 Beachmont Drive, 
San Francisco, CA, 94132 to see if those are revealing. 

I have developed a hallux claw toe in my right foot after I had a bunionectomy
 and tibial sesamoidectomy in 2014 and I am wondering
 if I should get surgery to prevent a joint fusion surgery in the future.
 My toe does not bother me terribly now. Every other day I can go on a 1 mile walk,
 with minimal discomfort. However, I have noticed that as time has gone on
 it has become progressively more sensitive 
(able to walk less and less mileage without the next day hurting)
 and I want to maintain a relatively active life as I am 33 and a mom.
 My right big toe does not really touch the ground, and my other four toes
 on the right foot are starting to develop hammertoes.
 My left foot also has hammertoes so I know I am prone to them,
 but they are still relatively mild on both feet.
 I have been recommended two different surgical techniques to prevent further problems 
down the line with my foot, and am wondering whether you think
 1) surgery is a good idea, and 2) if so, which surgery you think I should opt for.


Initial Breaking of Tibial Sesamoid with subsequent Surgery: I have high-arched feet, 
and have worn orthotics since age 13 or 14. 
I broke my tibial sesamoid after wearing heels to a party in 2013.
 It was described as a freak accident (as I guess most bone breaks are!) 
but people had always remarked at how high my arches were,
 so I guess the pressure was too much. 7 months later 
I was told there was no healing and it was recommended I have a tibial sesamoidectomy
 as well as a bunion surgery (chevron osteotomy), 
as I already had a bunion but the broken sesamoid was accelerating its progress.
 I wish I had found your blog back then, as it was described as a relatively easy surgery
 with minimal complications. After the surgery I went to physical therapy. 
It was always hard for the physical therapist to get my big toe to touch the ground even then.
 A year after the surgery I noticed my right big toe no longer touched the floor when barefoot.
 As long as I wore orthotics in shoes I was pain-free and comfortable
 and could go about my daily life. Walking barefoot was uncomfortable 
because the ball of foot was pushed into the floor without weight bearing from the big toe.
Dr. Blake's comment: This is a common problem with the tibial sesamoid removal 
which weakens the short flexor under the joint. This enables the tendon on the top
 of the toe to win, called the extensor.This dynamic imbalance pulls the toe up 
starting the hammertoe. With the pes cavus or high arched foot, you probably
 even before surgery had a tighter extensor ready to pull the toe up. With this being said, 
it does not explain why the PT could not get the toe down which let this get out of hand. 

Most Recent Setback: In May 2019 I wore a pair of heels on date night
 and walked about 10 minutes on the cement sidewalks. (No heels allowed in my closet again!) 
The next day my fourth toe and especially my big toe were very inflamed,
 and it took 5 months of me wearing a boot and daily icing in order for the symptoms
 to calm down. This is when I found your blog. During those 5 months
 I visited multiple podiatrists and two orthopedic surgeons to try and figure out
 why it was taking so long to heal. It was determined that I stretched the collateral ligaments
 in my stiff big toe. The second orthopedic surgeon had a nerve-conduction ordered
 to ensure I did not have charcot-marie-tooth disease, due to my high arches,
 raised toe, hammertoes and slight atrophy of right-side calf muscles. 
Luckily it was determined I do not have the condition, but both orthopedic surgeons 
commented on how raised my big toe was, and were concerned about how my foot
 would handle such biomechanical stresses for the duration of my lifetime. 
Both of them suggested some surgical techniques to prevent the further deterioration of my foot.
 I know you are not a proponent of “preventative surgery”, but I am wondering
 what you recommend in my case.
Dr. Blake's comment: All we know right now in this correspondence is that you 
have a very sensitive
big toe joint. I think everyone, except a few surgeons, would agree 
that an operated on joint, is and will
be forever a weaker joint. When you do hip surgery, and slightly less with knee surgery, 
you can 
establish great stability on the surgical site with the surrounding muscles. You
have great opportunity to really tone them up. The foot has some crucial
muscles to help, but as podiatrists we mainly have to rely on shoes, orthotics, 
accommodations, taping, 
etc, and physical therapy to breakdown scar tissue, remove inflammation, 
and stretch and 
strengthen the muscles up the leg to the hip. 

Current Pain and Issues:

1) My current symptoms are that my toe is quite stiff at the MTP joint, 
and semi-rigid at the IP joint. I have good range of motion with the toe going upwards
 but pretty limited motion when trying to force my toe down. 
 The bottom of my big toe is sore (scale of 2 out of 10) if I go on a 1 mile walk or more.
 If I go on these walks for more than a couple of days I have to take the next day off. 
Furthermore, the side of the top of my big toe gets sensitive too if I go on long walks
 or walk barefoot on hardwood floors. I have noticed this is because my big toe 
actually turns into the rest of my foot, in addition to the claw toe. 
It feels like the bone is pushing out? This varus has been increasing over time. 
Dr. Blake's comment: So, if you were in my office I would have you practice and get really good at
spica taping to hold the toe down for the next 8 weeks. Patients usually can advance 
from the easier KT 
or Rocktape to the 3M Nexcare Waterproof tape. You should have a PT over the next 
month to year 
(when corona quarantine is lifted) measure the amount of plantar flexion 
of the big toe joint which
we will compare to 3-6 months from now. 

Also begin to experiment with the dancer's padding idea to shift weight from the 1st metatarsal
 and toe 
onto all the other toes in whatever shoes you can.  

Surgical Options:

1) First Doctor (Scar Tissue Removal):

a. Concern: The first orthopedic surgeon was concerned that without the use of my big toe
 the ball of my foot would take too much pressure and I could therefore damage
 my remaining sesamoid or put too much weight on the other four toes, 
causing an acceleration in the hammertoes in this foot. He noted that the IP joint
 was still flexible, and thought I had developed a claw toe largely because of
 scar tissue buildup from the first surgery in the MTP joint. 
He thought my symptoms would be greatly improved if I could get
 another 20 degrees downward or so from the big toe.
Dr. Blake's comment: He has the right idea. We need the joint measured so we can 
document this 
improvement. We need the tape and dancer's padding to do what he wants his surgery to do
 at this time. 
3-5 times a daily you need to stretch down the big toe at the ball of the foot joint.
 Hold 30 seconds, relax
5 seconds, and hold another 30 seconds. You need to straighten the IPJ which is
 flexible by pulling the 
toe out again 30 seconds times 2. You need to strengthen the EHL by pulling 
the toe up at the IPJ only, 
you have to hold the proximal phalanx down. You need to strengthen the FHB
 you have left (same 
exercise as in my video on bunion). Do these once daily in evening and build from 
10 to start of each 
to 30 over next 6 weeks (adding 5 more every 10 days or so). 

b. Timing: No rush, whenever is convenient for me and my family life.

c. Surgery: He recommended a 1st MTP dorsal capsule release and EHC scar release. 
Since there would be no bone being cut during this surgery, recovery would be relatively simple.

d. Recovery: Two weeks in a short cam boot and two weeks in a surgical shoe, 
with physical therapy afterwards.
Dr. Blake's comment: I think from the 2 photos above people can get an idea 
of your downward 
restriction of that joint. The 2 surgeries suggested are on the top of the joint
 to release things, but what 
if the whole problem is coming from the tibial sesamoid removal and blockage 
there to bring the toe. 
That makes more sense, since the surgical done effected the bottom more than the top.
 When you try to 
push the toe down, as in the photo above, where do you feel you are restricted? 
Do you feel tightness on 
the top limiting the downward motion, or do you feel a block in that downward
 motion from the joint 
itself? I am going to have you do my self mob routine from several weeks and 
see if you can get the joint 
looser. Now, for sure, you can have all the restrictions on top, 
and you will sense the restrictions inside, 
so this is not perfect, but I would like to make as logical a guess. 

2) Second Doctor (More Extensive Toe Reconstructive Work):

a. Concern: The second doctor seems quite concerned about the structure of my foot and toe
 (he originally ordered the nerve-conduction test for CMT) and is concerned that if the structure
 of my foot is left the way it is I will have significant degenerative changes
 on my toe going forward. He seemed pretty confident that if I left the toe 
untouched in its current state I would have to have a joint-fusion surgery in the future,
 possibly in both the IP and MTP joint. He said I really want to avoid a joint-fusion surgery
 and thinks this surgery would have an 80% chance of success.

b. Timing: Recommend to do the surgery within a year as he is concerned that my toe 
will stiffen if left in the current state.

c. Surgery: More substantial surgery. I would have a 1st metatarsal crescentic osteotomy,
 toe lengthening, IP joint arthrotomy and possible FHL lengthening.
Dr. Blake's comment: Let me start with the last 2: The arthrotomy just means 
to free up the joint (which
hopefully you can do with stretching or pulling the joint straight 
twice daily, and FHL lengthening
means to weaken it so it does not pull downward on the end of the toe so much.
 Let's mobilize, stretch, tape,
strengthening and off load as we have discussed.
 The image you sent talks to the osteotomy and toe 

d. Recovery: 6 weeks in a boot with no driving during that time. This is daunting to me
 since I am a stay at home mom right now taking care of a toddler (and I don’t have a yard!),
 but I would do it in order to better my chances of long-term foot health. 
Full recovery would be 6 months. Physical therapy afterwards.

So that is a summary of my problem. What are your thoughts on whether I should opt for a surgery, 
and if so, which surgery would you opt for? I am cautious since the first surgery
 I had took almost 1.5 years to feel better, but I want to maintain mobility! 
Do you think I need to get surgery or I will end up with a joint fusion later in life? 
I would appreciate your thoughts and advice on my issue. 
Let me know if you need more information…ie videos or the CT scan or MRI I also have.

Thank you for your time!

Dr. Jill's Sesamoid pad can help

Dr. Blake's comment: The side view xray of your cocked up toe and 
high arch showed nothing amiss, nothing obvious to cause concern.
The view from the top of your foot showed that the first surgery left 
the first metatarsal too short, thus the tendons retracting and creating 
the hammertoe. Yes, you can go back and correct for that mistake, but 
the rest of the joint looks perfect. A small bunion is starting so when you 
the spica taping try to straighten the toe slightly at the same time. Start 
wearing large toe separators sold everywhere, and use yoga toes 4-5 times
a week as a 30 minute stretch. What I do not know if it is best to do the dancer's
padding or a Morton's extension. I think you should see what feels better with 
a week of each. I use adhesive felt from Alimed 1/8 inch to create my Morton's Extensions 
and dancer's padding.
The morton's extension could go from the ball of the foot with a cut out for the
 good fibular sesamoid 
to the end of the toe. This all makes the most sense for the next 3 months. 
Hope this helps. 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.