How a minor bunion can turn into a nightmare - The "ordinary" bunionectomy

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The bunion is perhaps one of the more common foot problems among adults in the United States.  For this reason, care and treatment of bunions is often one of the first things taught to podiatry students, and treatment and repair of bunions is generally very common in podiatry practices. 

Unfortunately, with bad care, a common and minor foot discomfort can turn into a nightmare that can impact you for the rest of a patient's life.

A typical example of this would be a young woman in her early 40's – we'll call her Kate – who notices one day that she's feeling some rubbing on the inside edge of her left foot when she wears certain shoes.  The discomfort is slight, but Kate is an avid hiker and decides that she'll get it looked at to see if it can be easily repaired. 

Using a Google search Kate finds a podiatrist who has an office near where she works.  She goes in to see him and he very quickly diagnoses a hallux valgus deformity – better known as a bunion.  A hallux valgus is a deformity primarily of the big toe of the joint, which causes the top portion of the toe to angle itself inward towards the second toe.

In forming his diagnosis, the doctor performs a quick exam and takes one x-ray which, he tells Kate, confirms his diagnosis of a hallux valgus deformity.

At this point the doctor has multiple options, he can start with conservative treatment which would include prescribing a special footwear or attempting to tape the toe in proper position, or he can perform one of a number of available surgical procedures.  Perhaps the most common is a version of a “routine” bunionectomy and osteotomy. 

A metatarsal bunionectomy and osteotomy is a relatively minor procedure – when performed appropriately - which involves first removing (or, as podiatrists often say, “scraping”) a portion of the bone to try and straighten out the toe; this is typically accompanied by a small cut into the bone and removal of a small wedge of bone in order to straighten the joint.  The joint is then held together by screws, pins or a plate. 

In describing the procedure, the podiatrist tells Kate that it's a very minor “scraping” of the bunion; is something that he does all the time, and has very few potential complications.  He does not tell her that there is any real chance of the need for a second (or third, or fourth) surgery if the bunionectomy goes wrong, nor does he tell her that there are several normal complications that can occur following surgery.  

The following day Kate finds herself on the operating table – at which point she is handed a consent form by the operating nurse to sign.  After quickly glancing at the form she signs it, hands it back, and is wheeled into surgery.

As with every surgery there are a number of problems that can occur with a routine bunionectomy and osteotomy, both intraoperatively (during the operation) and post-operatively (after the operation).  There are of course the usual risks – death, negative reaction to anesthesia; etc.  But there are also more practical problems that can occur. 

One of the most significant (and far too common) problems that can occur during and following a routine bunion surgery is the development of a hallux varus, where the big toe veers out, away from the other toes on the foot. (Think of this like driving a car.  If you find yourself slowly drifting to the right you need to correct – but not overcorrect – your steering.  If you correct too far the opposite way you'll find yourself in a ditch on the left side of the road.  The valgus is the drift to the inside, the varus is the drift to the outside).

A hallux varus can be caused by a number of things, but most commonly as it relates to a bunionectomy it is caused by 1) excessive resection (or removal) of bone during the procedure; 2) unnecessary removal of the fibular sesamoid (a small bone on the inside of the toe); or 3) excessive tightening of the soft tissue during the correction of the toe alignment. 

If the section of bone removed during a bunionectomy is too large it will result in an overcorrection, causing the toe to drift in the opposite direction and allowing the hallux varus to develop.  Removal of excessive bone is not the only cause of a hallux varus, but it is one of the more common.

A post-surgical hallux varus can generally be observed two ways post-operatively – on films (x-rays, primarily) and through clinical examination.  The problem is that often the toe is swollen immediately post-surgery, and many podiatrists (wrongly) operate under the assumption that the alignment of the toe is actually okay when in fact it is not. 

The failure to observe the improper alignment during the short-term post-surgical window can be a problem, unfortunately, because one of the ways to help fix an overcorrection is to apply strapping, taping or padding in an effort to hold the toe in proper alignment in hopes that it will then heal itself that way.  This is considered and is often referred to as a “soft-tissue” problem, and is the preferred conservative treatment of a hallux varus, if possible.

Unfortunately, no amount of strapping will heal a toe from which far too much bone was removed.  In those cases, the overcorrection is simply too large to allow the joint to do anything other than pull the toe in the opposite direction.  Now you have a large toe that looks like it is drifting off by itself, with a large gap between the toe and the rest of the foot.  This is a problem.

First, despite the fact that the patient initially went in with minor discomfort, the new condition of the toe likely causes even more discomfort – you are now attempting to “jam” the foot into a shoe.

Second, and more significantly, the patient now has to compensate for the missing bone and poor toe alignment.   This overcompensation will often create problems in the other toes and bones of the foot and, if not properly corrected, can result in among other things the development of a significant problem walking.

If the hallux varus cannot be corrected with conservative treatment, follow up surgery may be necessary.  And this, of course, is where further problems come in, particularly where excessive bone removal is the cause of the hallux varus.  The surgeon might try to “tighten” the tissues on the opposite side of the toe – to pull the toe back into alignment – but the problem with this is that because the patient has lost so much bone on the outside of the toe she will very likely develop gait problem as a result of having to compensate for the lost bone on the outside of the foot.

So now the patient - who initially went to the doctor simply because of a slight toe discomfort – is faced with the prospect of a surgery to fuse the joint in place – which may or may not correct the problem and which will very likely lead to the need for additional medical treatment later down the road.    

We have represented people in Kate's position – who went to a podiatrist for a routine and minor problem, only to come out on the other end far worse after having had multiple surgeries (many of which were necessary to correct a problem from the first).  Too often (in our opinion), some podiatrists are quick to perform surgeries that are either unnecessary all together, or are much too aggressive under the circumstances. 

Only through a complete review of the available medical records, films and photographs (yes, your podiatrist should be taking before and after photos) can a determination be made as to whether the doctor deviated from accepted standards of care, but if you have questions about problems from seeing a foot doctor contact us today.

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