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Surgical Treatment of Bunions
Surgical Treatment of Bunions HERBERT R. MARKHEIM, M.D. * PAUL PHILLIPS, M.D.**
A bunion is a deformity of the forefoot, which is usually painful and is amenable to surgical correction with gratifying result to both patient and surgeon. The literature is replete with descriptions of the pathology and the methods for surgical correction.2 • 4, 6-10
ETIOLOGY AND INCIDENCE Some hereditary influence is noted in at least half of the patients who suffer from bunions. It is rarely seen as a clinical deformity prior to puberty, but it steadily progresses and becomes symptomatic in about the fifth decade of life. Women seem more prone to bunion than do men, by at least 10 to 1. The consensus 1 ,3,5 is that the cause of painful bunion is ill-designed and poorly fitted shoes, combined with a splay foot which spreads on weight bearing. A shoe that has a narrow toe-box seems to be responsible for converting the splay foot to symptomatic, painful bunion. The first metatarsal head splays against the shoe, the curve of which causes the great toe to deviate to the fibular side. There are practically no cases of symptomatic bunion in cultures in which shoes are never worn, although a wide forefoot and deviation of the great toe toward the fibular side are common.
DESCRIPTION The frame of reference used in this description will be that of the midsagittal axis of the foot. Thus, the medial side of the foot will be referred to as the tibial side and the lateral side, the fibular side. From the Orthopedic Section, Department of Surgery, Denver General Hospital, Denver, Colorado "Chief of Foot Clinic "'Resident in Orthopedic Surgery Surgical Clinics of North America- Vol. 49, No.6, December, 1969
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Fig. 1
R.
MARKHEIM, PAUL PHILLIPS
Fig. 2.
Figure 1. Bunion deformity. 1, Rotation of great toe. 2, Deviation of great toe. 3, Arthritic notch in metatarsal head. 4, Subluxed metatarsal phalangeal joint. 5, Prominent metatarsal head. 6, Bursa. 7, Abductor under metatarsal head. 8, Arthritic sesamoid. 9, Tight adductor. 10, Wedging of cuneiform. 11, Splayed first metatarsal. 12, Bowstringing of long extensor. Figure 2. Bunion deformity in gouty foot showing calcification in bursa and cyst formation.
The components of hallux valgus include a prominent condyle on the tibial side of the metatarsal, a painful red bursa, deviation of the great toe toward the second toe, and axial rotation of the great toe, so that the nail faces the tibial side of the foot (Fig. 1). The adductor muscle of the great toe is tightened and shortened. The capsular structures about the first metatarsophalangeal joint are contracted on the fibular side. The extensor of the great toe "bowstrings," causing the deviation of the great toe to become more accentuated. The abductor of the great toe slides beneath the condyle, causing axial rotation, and becomes a flexor of the great toe. The short flexor of the great toe, together with its sesamoid, then can be shown to be between the first and second metatarsal heads. Wedging of the cuneiform at its articulation occurs. There is a limitation of motion at the metatarsophalangeal joint because of the arthritic process. There may be osteophyte formation about the metatarsophalangeal joint, sometimes with bone accretion over the tibial condyle of the first metatarsal. The sesamoid on the fibular side of the metatarsal is frequently involved in the arthritic process and will show spur formation about it. This gives it the so-called "mushroom" appearance. The tibial side of the proximal phalanx produces a groove in the head of the metatarsal, wearing a malacic or arthritic indentation into the head of the metatarsal. In addition, an adventitious bursa is
SURGICAL TREATMENT OF BUNIONS
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produced, sometimes filled with fluid, and this may be infected as a result of incision or injection. The skin about the bunion is usually reddened, thickened, and coarse, and is extremely tender. This deformity is characteristically seen in the elderly in its symptomatic state. It may also be associated with rheumatoid arthritis and gout (Fig. 2). A less common form of bunion is the dorsal bunion, which is an arthritic process of the first metatarsophalangeal joint, with a true dorsal spur or exostosis. The so-called exostosis of a bunion is not truly an exostosis; it is merely the prominence of the condyle of the first metatarsal on the tibial side.
TREATMENT Prophylaxis The proper fitting of shoes is paramount. Shoes should be worn which accept the foot in a weight-bearing position, so that there is no constriction by the shoe. The shoe should be fitted so that the widest portion of the foot is at the widest portion of the shoe. The proper fitting of shoes should be explained to all patients who have symptomatic bunions. An aid in explanation is to demonstrate to the patient how his foot spreads on weight-bearing and to convince him that the foot should be measured .for a shoe in its weight-bearing position. Other conservative measures useful in symptomatic treatment of bunion include making a cruciate cut in the shoe leather overlying the bunion, and using commercially available pads designed to relieve pressure over the bunion. Surgical Treatment INDICATIONS. Pain is the overriding consideration in the indication for surgery. This is caused by the bursitis. A second indication would be in those patients who are unable to obtain properly fitted shoes, due to the deformity. Surgery is rarely performed for cosmetic reasons. Age is no deterrent to surgery, which may be performed with or without tourniquet and under general, spinal, or local block anesthesia. PROCEDURES. A great many approaches to surgical treatment of the bunion have been published, and many men have contributed greatly to the better understanding of the surgical treatment of hallux valguS.2 ,4,6-10 The operative procedures are chosen according to the degree of pathology and the age of the patient. The bunion deformity may be classified into categories of mild, moderate, and severe. In mild cases and especially in young patients, the prominent tibial condyle of the first metatarsal is excised (Fig. 3). This is usually combined with some form of capsular release on the fibular side of the metatarsophalangeal joint, or with an adductor release to decompress the metatarsophalangeal joint and allow for correction of the deviated great toe. In this approach, the skin is incised through a dorso-tibial approach over the metatarsophalangeal joint. Care is taken to avoid the vessel8 and nerve. The bursa is dissected free from the bone and the tibial condyle of the metatarsal is removed flush with the shaft of the
1494
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MARKHEIM, PAUL PHILLIPS
metatarsal. The adductor tendon may then be dissected free from its insertion into the fibular sesamoid and the base of the proximal phalanx, and then sutured into the neck of the first metatarsal.7 The joint capsule on the fibular side of the metatarsophalangeal joint may be divided as another method of decompressing the joint and allowing for correction of the deviated great toe.9 The joint capsule on the tibial side of the metatarsophalangeal joint is then imbricated under sufficient tension to hold the great toe in the same line as the axis of the first metatarsal bone. The toe is thus held aligned with the metatarsal with a soft, pressure-type dressing. The moderately deformed foot is approached with the objective of releasing the soft tissue forces which are acting as the deforming
Figure 3. Simple bunionecttomy combined with adductor release.
U Q Figure 4.
Keller procedure.
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SURGICAL TREATMENT OF BUNIONS
mechanism. It has been found that the Keller procedure (Figs. 4, 5,and 6) releases the adductor of the great toe, returns the abductor of the great toe toward the tibial side of the foot, relatively lengthens the extensor tendon by shortening the proximal phalanx, decompresses the joint capsule, and removes the arthritic condyle, as well as performing an arthroplasty of the joint, which permits increased motion at the metatarsal phalangeal joint. It also allows for derotation of the great toe, so that the nail no longer faces the tibial side of the foot. It allows the great toe to be straightened and come to the axis of the metatarsal. Dorsiflexion of the great toe is improved. There can be full inspection of the joint area through this approach, whereby the sesamoids can be examined. If they are malacic, they can be removed by dissecting them free from the flexor tendons. There are relatively few disadvantages to the shortening of the great toe. In the severe form of bunion, especially in a young patient, a metatarsal osteotomy can be utilized (Figs. 7 and 8). This is frequently done in conjunction with the Keller procedure. Osteotomy of the shaft of the metatarsal is done in order to correct excessive deviation of the first metatarsal toward the tibial side of the foot. This osteotomy may be performed anywhere along the shaft, but we prefer to do it at the base of the first metatarsal. This operation has given satisfactory results in the severe bunion. The period of recovery from this procedure is much longer than for the other two procedures described. A plaster boot is necessary for a period of 5 to 6 weeks and, in addition, intramedullary fixation may be advisable.
Fig. 5
Fig. 6
Figure 5. Preoperative anteroposterior roentgenogram of bunion. Figure 6. Postoperative anteroposterior roentgenogram, following Keller resection.
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MARKHEIM, PAUL PHILLIPS
Figure 7.
Stamm procedure.
POSTOPERATIVE CARE Elevation of the foot and application of ice bags are used in all three of the procedures described. After removal of the sutures, warm, moist packs in an elevated position and massage are utilized to decrease the swelling caused by the trauma of surgery. Compression elastic bandages and elastic stockings are helpful during ambulation. Dependency following foot surgery produces swelling, culminating in interstitial fibrosis, pain, and stiffness.
COMPLICATIONS The complications commonly encountered in foot surgery include slough of wound margins, infection, gangrene, recurrence of deformity, overcorrection of the deformity, and metatarsalgia. Loss of the push-off function of the great toe occurs, particularly following the Keller or Mayo resections; thus, these procedures are probably contraindicated in the young or in athletic people. Inadequate preoperative assessment of circulation, combined with rough handling of tissues and tissue swelling, are usually found to be responsible for problems of wound breakdown, infection, and gangrene. The diabetic, of course, should be carefully evaluated, as the neurocirculatory deficiency requires a more careful approach. Overcorrection of the great toe has been reported. This occurs following excessive tightening of the joint capsule on the tibial side or by maintaining the great toe in overcorrection by the surgical dressing. The shortening of the great toe, which accompanies the Keller procedure, can be somewhat disconcerting to the patient, as the second toe then protrudes farther than the first.
1497
SURGICAL TREATMENT OF BUNIONS
Fig. 8
Fig. 9
Figure 8'. Postoperative anteroposterior roentgenogram. following Stamm procedure. Figure 9. Stress fractures of metatarsals 2 and 3 following Keller resection and resumption of weight-bearing.
Recurrence of the hallux valgus deformity may occur following the conservative operations.7 ,9 This may be explained by a breakdown or infection of the capsular reefing, allowing the toe to return to its original position, or by failure to recognize and correct an excessive deformity of the first metatarsal. It may also occur following inadequate release of tension on the fibular side of the metatarsophalangeal joint. Metatarsalgia is a very important complication of bunion surgery, which occurs when the weight of the body is not borne equally across the five metatarsal heads. This complication follows excision of the head of the first metatarsal.6 When the first metatarsal thus loses its weight-bearing function, excessive weight is then borne by the middle metatarsal heads across the forefoot, causing painful plantar callosities and metatarsalgia. Decapitation of the metatarsal heads is probably contraindicated, except in rheumatoid arthritis, where it can be done in conjunction with the Hoffman procedure. Dorsal contraction of the metatarsophalangeal joint will occur occasionally, so that the great toe will have a tendency to be in a cock-up position. If the flexor tendons are divided during bunion surgery, a cockup results, which is a significant disability to the patient. Numbness of the great toe may occur if the sensory nerves are divided in the surgical incision. Rarely, the patient will develop a considerable amount of osteoporosis of the foot during the postoperative period, and the possibility of stress fracture should be considered when the patient complains of pain in the other metatarsals on weight bearing (Fig. 9).
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MARKHEIM, PAUL PHILLIPS
REFERENCES 1. Du Vries, H. L.: Surgery of the Foot. St. Louis, C. V. Mosby Co., 1959. 2. Keller, W. L.: Surgical treatment of bunion in hallux valgus. New York Med. J., 80 :741742,1904. 3. Kelikian, H.: Hallux Valgus, Allied Deformities of the Forefoot and Metatarsalgia. Philadelphia, W. B. Saunders Co., 1965. 4. Lapidus, P. W.: Operative correction of metatarsus varus primus in hallux valgus. Surg. Gynec. Obstet., 58 :183, 1934. 5. Lewin, P.: The Foot and Ankle. 4th ed. Philadelphia, Lea and Febiger, 1959. 6. Mayo, C. H.: The surgical treatment of bunion. Ann. Surg., 48 :300, 1908. 7. McBride, E. D.: Conservative operation for bunions. J.A.M.A., 105 :1164, 1935. 8. McKeever, D. C.: Arthrodesis of the first metatarsophalangeal joint for hallux valgus, hallux ri'gidus, and metatarsus primus varus. J. Bone Joint Surg., 34A:129, 1952. 9. Silver, D.: The operative treatment of hallux valgus. J. Bone Joint Surg., 5 :225, 1923. 10. Stamm, T. T.: The surgical treatment of hallux valgus. Guys Hosp. Rep., 106:273-279, 1957.
1827 Gaylord Street Denver, Colorado 80206
A bunion is a deformity of the forefoot, which is usually painful and is amenable to surgical correction with gratifying result to both patient and surgeon. The literature is replete with descriptions of the pathology and the methods for surgical correction.2 • 4, 6-10
ETIOLOGY AND INCIDENCE Some hereditary influence is noted in at least half of the patients who suffer from bunions. It is rarely seen as a clinical deformity prior to puberty, but it steadily progresses and becomes symptomatic in about the fifth decade of life. Women seem more prone to bunion than do men, by at least 10 to 1. The consensus 1 ,3,5 is that the cause of painful bunion is ill-designed and poorly fitted shoes, combined with a splay foot which spreads on weight bearing. A shoe that has a narrow toe-box seems to be responsible for converting the splay foot to symptomatic, painful bunion. The first metatarsal head splays against the shoe, the curve of which causes the great toe to deviate to the fibular side. There are practically no cases of symptomatic bunion in cultures in which shoes are never worn, although a wide forefoot and deviation of the great toe toward the fibular side are common.
DESCRIPTION The frame of reference used in this description will be that of the midsagittal axis of the foot. Thus, the medial side of the foot will be referred to as the tibial side and the lateral side, the fibular side. From the Orthopedic Section, Department of Surgery, Denver General Hospital, Denver, Colorado "Chief of Foot Clinic "'Resident in Orthopedic Surgery Surgical Clinics of North America- Vol. 49, No.6, December, 1969
1491
1492
HERBERT
Fig. 1
R.
MARKHEIM, PAUL PHILLIPS
Fig. 2.
Figure 1. Bunion deformity. 1, Rotation of great toe. 2, Deviation of great toe. 3, Arthritic notch in metatarsal head. 4, Subluxed metatarsal phalangeal joint. 5, Prominent metatarsal head. 6, Bursa. 7, Abductor under metatarsal head. 8, Arthritic sesamoid. 9, Tight adductor. 10, Wedging of cuneiform. 11, Splayed first metatarsal. 12, Bowstringing of long extensor. Figure 2. Bunion deformity in gouty foot showing calcification in bursa and cyst formation.
The components of hallux valgus include a prominent condyle on the tibial side of the metatarsal, a painful red bursa, deviation of the great toe toward the second toe, and axial rotation of the great toe, so that the nail faces the tibial side of the foot (Fig. 1). The adductor muscle of the great toe is tightened and shortened. The capsular structures about the first metatarsophalangeal joint are contracted on the fibular side. The extensor of the great toe "bowstrings," causing the deviation of the great toe to become more accentuated. The abductor of the great toe slides beneath the condyle, causing axial rotation, and becomes a flexor of the great toe. The short flexor of the great toe, together with its sesamoid, then can be shown to be between the first and second metatarsal heads. Wedging of the cuneiform at its articulation occurs. There is a limitation of motion at the metatarsophalangeal joint because of the arthritic process. There may be osteophyte formation about the metatarsophalangeal joint, sometimes with bone accretion over the tibial condyle of the first metatarsal. The sesamoid on the fibular side of the metatarsal is frequently involved in the arthritic process and will show spur formation about it. This gives it the so-called "mushroom" appearance. The tibial side of the proximal phalanx produces a groove in the head of the metatarsal, wearing a malacic or arthritic indentation into the head of the metatarsal. In addition, an adventitious bursa is
SURGICAL TREATMENT OF BUNIONS
1493
produced, sometimes filled with fluid, and this may be infected as a result of incision or injection. The skin about the bunion is usually reddened, thickened, and coarse, and is extremely tender. This deformity is characteristically seen in the elderly in its symptomatic state. It may also be associated with rheumatoid arthritis and gout (Fig. 2). A less common form of bunion is the dorsal bunion, which is an arthritic process of the first metatarsophalangeal joint, with a true dorsal spur or exostosis. The so-called exostosis of a bunion is not truly an exostosis; it is merely the prominence of the condyle of the first metatarsal on the tibial side.
TREATMENT Prophylaxis The proper fitting of shoes is paramount. Shoes should be worn which accept the foot in a weight-bearing position, so that there is no constriction by the shoe. The shoe should be fitted so that the widest portion of the foot is at the widest portion of the shoe. The proper fitting of shoes should be explained to all patients who have symptomatic bunions. An aid in explanation is to demonstrate to the patient how his foot spreads on weight-bearing and to convince him that the foot should be measured .for a shoe in its weight-bearing position. Other conservative measures useful in symptomatic treatment of bunion include making a cruciate cut in the shoe leather overlying the bunion, and using commercially available pads designed to relieve pressure over the bunion. Surgical Treatment INDICATIONS. Pain is the overriding consideration in the indication for surgery. This is caused by the bursitis. A second indication would be in those patients who are unable to obtain properly fitted shoes, due to the deformity. Surgery is rarely performed for cosmetic reasons. Age is no deterrent to surgery, which may be performed with or without tourniquet and under general, spinal, or local block anesthesia. PROCEDURES. A great many approaches to surgical treatment of the bunion have been published, and many men have contributed greatly to the better understanding of the surgical treatment of hallux valguS.2 ,4,6-10 The operative procedures are chosen according to the degree of pathology and the age of the patient. The bunion deformity may be classified into categories of mild, moderate, and severe. In mild cases and especially in young patients, the prominent tibial condyle of the first metatarsal is excised (Fig. 3). This is usually combined with some form of capsular release on the fibular side of the metatarsophalangeal joint, or with an adductor release to decompress the metatarsophalangeal joint and allow for correction of the deviated great toe. In this approach, the skin is incised through a dorso-tibial approach over the metatarsophalangeal joint. Care is taken to avoid the vessel8 and nerve. The bursa is dissected free from the bone and the tibial condyle of the metatarsal is removed flush with the shaft of the
1494
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R.
MARKHEIM, PAUL PHILLIPS
metatarsal. The adductor tendon may then be dissected free from its insertion into the fibular sesamoid and the base of the proximal phalanx, and then sutured into the neck of the first metatarsal.7 The joint capsule on the fibular side of the metatarsophalangeal joint may be divided as another method of decompressing the joint and allowing for correction of the deviated great toe.9 The joint capsule on the tibial side of the metatarsophalangeal joint is then imbricated under sufficient tension to hold the great toe in the same line as the axis of the first metatarsal bone. The toe is thus held aligned with the metatarsal with a soft, pressure-type dressing. The moderately deformed foot is approached with the objective of releasing the soft tissue forces which are acting as the deforming
Figure 3. Simple bunionecttomy combined with adductor release.
U Q Figure 4.
Keller procedure.
1495
SURGICAL TREATMENT OF BUNIONS
mechanism. It has been found that the Keller procedure (Figs. 4, 5,and 6) releases the adductor of the great toe, returns the abductor of the great toe toward the tibial side of the foot, relatively lengthens the extensor tendon by shortening the proximal phalanx, decompresses the joint capsule, and removes the arthritic condyle, as well as performing an arthroplasty of the joint, which permits increased motion at the metatarsal phalangeal joint. It also allows for derotation of the great toe, so that the nail no longer faces the tibial side of the foot. It allows the great toe to be straightened and come to the axis of the metatarsal. Dorsiflexion of the great toe is improved. There can be full inspection of the joint area through this approach, whereby the sesamoids can be examined. If they are malacic, they can be removed by dissecting them free from the flexor tendons. There are relatively few disadvantages to the shortening of the great toe. In the severe form of bunion, especially in a young patient, a metatarsal osteotomy can be utilized (Figs. 7 and 8). This is frequently done in conjunction with the Keller procedure. Osteotomy of the shaft of the metatarsal is done in order to correct excessive deviation of the first metatarsal toward the tibial side of the foot. This osteotomy may be performed anywhere along the shaft, but we prefer to do it at the base of the first metatarsal. This operation has given satisfactory results in the severe bunion. The period of recovery from this procedure is much longer than for the other two procedures described. A plaster boot is necessary for a period of 5 to 6 weeks and, in addition, intramedullary fixation may be advisable.
Fig. 5
Fig. 6
Figure 5. Preoperative anteroposterior roentgenogram of bunion. Figure 6. Postoperative anteroposterior roentgenogram, following Keller resection.
1496
HERBERT
R.
MARKHEIM, PAUL PHILLIPS
Figure 7.
Stamm procedure.
POSTOPERATIVE CARE Elevation of the foot and application of ice bags are used in all three of the procedures described. After removal of the sutures, warm, moist packs in an elevated position and massage are utilized to decrease the swelling caused by the trauma of surgery. Compression elastic bandages and elastic stockings are helpful during ambulation. Dependency following foot surgery produces swelling, culminating in interstitial fibrosis, pain, and stiffness.
COMPLICATIONS The complications commonly encountered in foot surgery include slough of wound margins, infection, gangrene, recurrence of deformity, overcorrection of the deformity, and metatarsalgia. Loss of the push-off function of the great toe occurs, particularly following the Keller or Mayo resections; thus, these procedures are probably contraindicated in the young or in athletic people. Inadequate preoperative assessment of circulation, combined with rough handling of tissues and tissue swelling, are usually found to be responsible for problems of wound breakdown, infection, and gangrene. The diabetic, of course, should be carefully evaluated, as the neurocirculatory deficiency requires a more careful approach. Overcorrection of the great toe has been reported. This occurs following excessive tightening of the joint capsule on the tibial side or by maintaining the great toe in overcorrection by the surgical dressing. The shortening of the great toe, which accompanies the Keller procedure, can be somewhat disconcerting to the patient, as the second toe then protrudes farther than the first.
1497
SURGICAL TREATMENT OF BUNIONS
Fig. 8
Fig. 9
Figure 8'. Postoperative anteroposterior roentgenogram. following Stamm procedure. Figure 9. Stress fractures of metatarsals 2 and 3 following Keller resection and resumption of weight-bearing.
Recurrence of the hallux valgus deformity may occur following the conservative operations.7 ,9 This may be explained by a breakdown or infection of the capsular reefing, allowing the toe to return to its original position, or by failure to recognize and correct an excessive deformity of the first metatarsal. It may also occur following inadequate release of tension on the fibular side of the metatarsophalangeal joint. Metatarsalgia is a very important complication of bunion surgery, which occurs when the weight of the body is not borne equally across the five metatarsal heads. This complication follows excision of the head of the first metatarsal.6 When the first metatarsal thus loses its weight-bearing function, excessive weight is then borne by the middle metatarsal heads across the forefoot, causing painful plantar callosities and metatarsalgia. Decapitation of the metatarsal heads is probably contraindicated, except in rheumatoid arthritis, where it can be done in conjunction with the Hoffman procedure. Dorsal contraction of the metatarsophalangeal joint will occur occasionally, so that the great toe will have a tendency to be in a cock-up position. If the flexor tendons are divided during bunion surgery, a cockup results, which is a significant disability to the patient. Numbness of the great toe may occur if the sensory nerves are divided in the surgical incision. Rarely, the patient will develop a considerable amount of osteoporosis of the foot during the postoperative period, and the possibility of stress fracture should be considered when the patient complains of pain in the other metatarsals on weight bearing (Fig. 9).
1498
HERBERT
R.
MARKHEIM, PAUL PHILLIPS
REFERENCES 1. Du Vries, H. L.: Surgery of the Foot. St. Louis, C. V. Mosby Co., 1959. 2. Keller, W. L.: Surgical treatment of bunion in hallux valgus. New York Med. J., 80 :741742,1904. 3. Kelikian, H.: Hallux Valgus, Allied Deformities of the Forefoot and Metatarsalgia. Philadelphia, W. B. Saunders Co., 1965. 4. Lapidus, P. W.: Operative correction of metatarsus varus primus in hallux valgus. Surg. Gynec. Obstet., 58 :183, 1934. 5. Lewin, P.: The Foot and Ankle. 4th ed. Philadelphia, Lea and Febiger, 1959. 6. Mayo, C. H.: The surgical treatment of bunion. Ann. Surg., 48 :300, 1908. 7. McBride, E. D.: Conservative operation for bunions. J.A.M.A., 105 :1164, 1935. 8. McKeever, D. C.: Arthrodesis of the first metatarsophalangeal joint for hallux valgus, hallux ri'gidus, and metatarsus primus varus. J. Bone Joint Surg., 34A:129, 1952. 9. Silver, D.: The operative treatment of hallux valgus. J. Bone Joint Surg., 5 :225, 1923. 10. Stamm, T. T.: The surgical treatment of hallux valgus. Guys Hosp. Rep., 106:273-279, 1957.
1827 Gaylord Street Denver, Colorado 80206