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At Issue: Most efficient bunion treatments
Orthopedics Today asked surgeons: What is your treatment algorithm for the patient with a bunion? When is surgery indicated and when is surgery contraindicated?
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Henri Bensahel, MD
In children, a bunion doesn’t occur often. Thus, I use some slight orthosis for realignment of the great toe, as it is usually flexible and its deviation is reducible. Later, in teenagers and adolescents, if the bunion persists and is uncomfortable, surgery can be proposed. It use a bunionectomy combined with relaxation of the first metatarsal.
Henri Bensahel, MD, founder and president of the Federation of Children Orthopaedics, can be reached at 1 Avenue Foch, 94160 Saint-Mandé, France; +33-1-43-28-62-27; fax: +33-1-48-51-97-33; henriben@noos.fr.
Carol C. Frey, MD
The initial treatment of the patient with hallux valgus should be shoe modifications. These include: a high wide toe box, soft leather upper, increased width in the forefoot and avoidance of stitching and buckles around the bunion deformity. The nonsurgical approach is usually successful in the mild and moderate cases. Physical therapy, splints, pads, braces and foot orthoses are usually not that helpful, although a medial longitudinal arch support can decrease pressure on the bunion in a patient with an associated flatfoot.
No treatment is needed for the asymptomatic bunion. For the patient with continued symptoms, several procedures are available. Indications for these different procedures are based on severity, intramedullary angle and joint congruity.
Joint replacement is rarely indicated because of a high complication rate. The surgical indication is persistent pain despite shoe modifications. Contraindications include infection, poor vascular status, unreasonable patient expectations and degenerative changes at the first metatarsophalangeal (MTP) joint.
Carol C. Frey, MD, can be reached at 1200 Rosecrans Ave., Ste. 208, Manhattan Beach, CA 90266; 310-990-5253; fax: 310-615-0806; footfreymd@aol.com.
Franz Kopp, MD
I generally recommend a trial of conservative management for patients who present with a symptomatic bunion.
Footwear modification is the cornerstone of conservative treatment. Surgery is indicated only when conservative measures fail to relieve symptoms adequately. Factors to consider in determining the appropriate surgical procedure include the patient’s age and activity level, the patient’s expectations, the physical examination findings and the radiographic parameters, including the hallux valgus angle, intermetatarsal angle, distal metatarsal articular angle, joint congruency, interphalangeal angle and degree of arthrosis.
Contraindications to surgery include active infection, poor vascularity, an unreliable or noncompliant patient, or a patient with unrealistic expectations.
Franz Kopp, MD, can be reached at San Diego Orthopaedic Associates, 4060 4th Ave., 7th Floor, San Diego, CA 92103; 619-299-8500; fax: 619-299-3527.
Andrew H. Schmidt, MD
I haven’t operated on a bunion for over a decade, so it’s safe to say that I'm not qualified to answer this question. When I see a bunion, I tell the patient to wear accommodating footwear. I look for possible primary causes such as peritalar subluxation due to posterior tibial tendon insufficiency, and if none are present, I tell the patient to avoid surgery. If I see some clear cause of the bunion, then I refer the patient to an appropriate specialist.
Andrew H. Schmidt, MD, can be reached at Wayzata Orthopaedics PA, 2805 Campus Drive, Ste. 425, Plymouth, MN 55441; (763) 383-0770; fax: (763) 383-0777.