Bunion solutions from an orthopedic surgeon

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient with the podcast that features experts from Central New York's only academic medical center.

I'm your host, Amber Smith. Bunions are bony bumps that may develop on the joint at the base of the big toe, and they can cause pain and stiffness and deformity that can be debilitating for some people. With me to talk about solutions for bunions is Dr. Scott Van Valkenburg. He's an assistant professor of orthopedic surgery at Upstate, and he specializes in the foot and ankle, so people with bunions are among the patients he cares for. Welcome to "The Informed Patient," Dr. Van Valkenburg.

Scott Van Valkenburg, MD: Thank you so much, and thanks for having me.

Host Amber Smith: What causes bunions?

Scott Van Valkenburg, MD: They're a very common thing that we see. The technical term for them is hallux valgus, so that's an interchangeable term you might see. It's mostly related to genetics and our DNA. And it's partly the way that we develop.

We think it's more of a process that occurs, in some people who are predisposed to it, but it occurs over a lifetime and generations, rather than any particular thing that the person does, individually.

Host Amber Smith: So the type of shoes I wear has nothing to do with it?

Scott Van Valkenburg, MD: That's a debate that's still goes on.

You know, in decades past it was felt that it was more related to shoewear. But now, with less people donning the type of shoes that was thought to cause them and still bunions being as evident as they ever were, it's thought to play a lesser role. So leaning more towards genetics and DNA rather than any formative thing, such as footwear.

Host Amber Smith: What is the average age for the patients that you see with bunions?

Scott Van Valkenburg, MD: There's something called juvenile hallux valgus, or bunions that begin occurring at a young age and in children in their teenage and adolescent years.

And then another, classification of a more typical degenerative type of bunion that typically occurs more in the fourth and fifth decades of life. So someone in their 40s and 50s. and they often start out as being minimally symptomatic. People often live with them for a number of years prior to maybe developing symptoms later on.

Host Amber Smith: Is it evenly divided among men and women?

Scott Van Valkenburg, MD: Women seem to be slightly more predisposed to it, and so that perhaps give some credence to the argument of shoewear, which may have some contributions, just not the major contribution.

Host Amber Smith: Do bunions have anything to do with arthritis, osteoarthritis?

Scott Van Valkenburg, MD: Great question. You know, a typical bunion is not truly related to arthritis. Now, a bunion that develops over time, and you have malalignment of that joint, that may then lead to arthritis, but a true bunion is not part of an arthritic process.

What's interesting is that oftentimes, bunions can be confused with arthritis because arthritis often leads to something that some people refer to as a dorsal bunion, meaning a bump or a bone spur off the very top or the dorsal surface of the joint. So rather than off the inner side, you know, protruding immediately or towards the inside of the foot, a bump protruding up, directly up, with a still well-aligned toe. And that is an arthritic process because the arthritis causes the bone spur dorsally. So you maysee or hear the term dorsal bunion, and that is an arthritic term.

Host Amber Smith: I was going to ask if when you see patients, are patients a pretty good judge of whether they've got bunions or not, or is it trickier?

Scott Van Valkenburg, MD: Yes, I would say that people, especially, I think, with modern internet and everything, people, a lot of times, do their own investigations and there's pictures and stuff, so they can compare their foot to others on websites and that kind of thing. But once in a while, and I would say it's less than 5%, but people sometimes do come in and think they have a bunion, and it's something else. But inevitably it turns out to be something in its own right as justification to talk about and be evaluated for. So I guess in general, I don't really encourage anybody to try to figure out their problem. If they're having pain or a problem,they can seek care and advice about it.

Scott Van Valkenburg, MD: Some people think that when they come to be evaluated for something, it means that they're to the point that they are going to have surgery or something. And that's never the case with orthopedic foot and ankle care.

Host Amber Smith: So pain might be one reason. Are there other reasons that someone should consult a doctor about their bunions?

Scott Van Valkenburg, MD: The short answer is painshould be the major driving factor for the decision to, think about a surgical intervention.

But again, similar to my last response, I guess it's never a bad idea, if you're wondering about it: Seek consultation.But if it's not painful, I wouldn't recommend surgery,with some minor exceptions. If it develops to be so significant and they're unable to get shoes on, obviously I have seen those patients, that their deformity is so significant, and even though they just are stoic people or have learned to cope with it, so they're not necessarily in pain, but they really ran out of shoewear options. Or also if they start developing significant deformities in the other toes that can be related to the bunion, sometimes that's an indication or a reason to do something.

Host Amber Smith: Do you need an X-ray to get to the diagnosis of bunions?

You should, definitively, if you're going to start thinking about ways to manage it, because I always tell patients there's no real normal foot, and you're speculating a lot to look at a foot from the outside and try to determine everything you need to about it. A weight-bearing X-ray, it's kind of like playing a detective and usually the most vital information that we have. We can tell a lot, and it's funny because the difference between a non-weight-bearing X-ray and a weight-bearing X-ray are really significant, but a weight-bearing X-ray tells, a big, and typically an accurate story about that foot.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith, talking with orthopedic surgeon Scott Van Valkenburg about bunions.

What about conservative measures? Changing shoes, wearing inserts, sleeping with corrective devices on your feet -- do they ever correct bunions?

Scott Van Valkenburg, MD: I think people have different philosophies about that, but my philosophy is that no, there's nothing that I've seen out there or encountered that actually provides true correction, meaning that X-ray is going to be similar, whether you put a splint on it overnight or not. That being said, I do think that conservative measures are the best way to start, and the goal of the conservative treatment is not necessarily correction but minimizing symptoms and making it something that can be lived with. So early conservative measures include wider shoes. And the good thing is that with modern shoewear, most athletic-type shoes, sneakers, are made with a mesh top, or mesh body, rather than the old leather shoes, and so there are more accommodative (options).

So at any given shoe store there's a lot of options that can accommodate for that bunion. And then, other measures: Sometimes I'll utilize a toe spacer or a little bunion pad, which again, sometimes when the patient is wearing it, it can provide some symptom relief, but I'm very careful to make sure a patient understands that there shouldn't be an expectation that when they take the thing off, it's going to be straighter. Because it typically isn't.

Host Amber Smith: What about anti-inflammatories or cortisone injections? Have you ever seen those be helpful?

Scott Van Valkenburg, MD: Anti-inflammatories certainly can be helpful. Sometimes people have a painless bunion, painless deformity, and then they develop an inflammatory process because of the bump, you know, perhaps they were wearing or doing some activity or wearing, you know, hiking boots for a long period of time one day, and then they get a kind of a bursitis what we call an adventitial bursitis, meaning an inflammatory change in the tissue directly over the bump. That can certainly be addressed with anti-inflammatory medications. I typically do not use cortisone injections for bunions, unless it's one of the bunions that has started causing arthritis; cortisone injections are more a treatment for arthritis of the big toe.

Host Amber Smith: What happens if someone leaves, if they have severe bunions and they leave them untreated? Are the bunions just going to keep getting worse?

Scott Van Valkenburg, MD: Oftentimes they do progress. Now, obviously there's a limitation on that. They can't progress forever.I've seen in my practice some pretty significant ones, ones where the big toe goes underneath the second toe or even the second and third toe.

And I would say that, I've never seen someone's condition develop, some problem with their ankle or knee or hip or something, because of a bunion. So again, it's not as if it's an urgent or dire need to have it addressed, but if it is a problem in its own right, meaning that if they're having pain or if it's causing balance issues or something like that, then that's something that might be addressed.

Host Amber Smith: If someone's interested in surgery, what do you tell them to consider?

Scott Van Valkenburg, MD: Well, typically we go right to the X-ray and try to classify the deformity as, is it a kind of a mild, medium or severe? There's a litany of types of procedures, all with different corrective potential, meaning how much of a deformity they can correct. And also each procedure has a different recovery and different risk of complications and different types of complications. So often, the art form of surgery is to try to customize the right type of procedure for any given patient.

Oftentimes the ones that provide less correction, so the less-powerful osteotomies (bone-cutting surgeries), are easier to recover from and (have) lower complication risks. And then when you get to really big deformities, you have to do a little more, and oftentimes those procedures carry a slightly higher complication risk.

But there is usually a very nice balanceyou can find.

Host Amber Smith: Are the surgeries always done, is it an open procedure, or are you doing any sort of laparoscopic stuff?

Scott Van Valkenburg, MD: The standard currently is still open procedures. Now there are some in the country, most notably one of my mentors, Dr. Johnson, down in New York now, who are pioneering a minimally invasive bunion surgery. It doesn't use arthroscopy, but it uses X-rays, and small incisions with a very high-speed burr that can cut just bone, it's safe to cut just bone, beneath the skin. It is something that I've practiced on it in a lab setting, but haven't adopted in practice yet. I'd still say that the standard is still open osteotomies.

Host Amber Smith: So are you basically, taking out the part of the bone that is the bunion? You're just cutting it off or shaving it off? Is that sort of the goal?

Scott Van Valkenburg, MD: That is one of the goals. It's a component of it, but actually if done in isolation, it does not resolve the problem. It tends to be a failure. So in orthopedic training, we pretty much avoid just shaving down the bunion. There are some indications where something that is really bothering them, where we end up educating and deciding like, listen, this is not going to correct the problem, and it might progress, but we're just going to shave down the bunion. But I would say that is quite rare. Typically, in order to actually correct the issue, the surgeon would need to remove some of the bump, but then also reshape the bone by cutting it, or what's called doing an osteotomy, meaning you cut the bone. We cut it in a certain orientation so that it can be altered, change the shape of it, move the head or the ball part of the joint over to the outer side of the foot so that it is back in the position that it ought to be in.

Host Amber Smith: What is recovery like? How soon does the person get back on their feet?

Scott Van Valkenburg, MD: The majority ofbunion procedures typically are two weeks, with minimal weight bearing, meaning maybe a little bit on the heel, but I put patients in a splint. It's small, almost the size of a typical hiking boot, and give them crutches and just a little weight on the heel for the first couple of weeks.

Then after two weeks, as long as the incisions look good, usually it's a walking boot and weight bearing as tolerated. There are some procedures, like a fusion procedure, where, we limit the weight bearing for another two to four weeks, but most of them, people can be weight bearing after two weeks.

Host Amber Smith: If a person has bunions on both feet, do you ever operate on both feet at the same time?

Scott Van Valkenburg, MD: I received some sage advice from a mentor once who indicated he had tried that once and to never do it.

And I think one of the things is people often just think, oh, it's just a bunion, what can go wrong? Surgery can be a complex thing, and it's imperative for those first two weeks to care for it and stay off of it and keep it elevated.

And no matter how you cut it, if you did both sides at the same time, you would be compromising the other side to some degree. Now that may not always lead to a complication, but I think it would create a higher risk of complication than it would be if you just did one at a time, so I would definitively advise not to do both.

Host Amber Smith: After a bunionectomy, can a person expect to be free of bunions for the rest of their life?

Scott Van Valkenburg, MD: Unfortunately, the honest answer to that is no. Your tissues, your body continues to go through degenerative changes, and the movement of the first metatarsal, meaning swaying out into what forms a bunion, can continue. The recurrence rate after having a bunion surgery is somewhere in the 15 to 20% range in the (medical) literature. That's variable depending upon the type of procedure is done, but it can return. When it does, my experience is that it oftentimes is to a more limited degree, and the symptoms aren't significant.

I'd say it's quite rare. Bunion procedures are very frequent, very common, and it's pretty rare that I see someone 10 or 15 or 20 years after a bunion procedure where that side's bothering them more. Oftentimes, I'll see a patient who had a bunion surgery 15 years ago, and now is here to look at the other side, and when you look back on the other side, it looks like you still have some deformity there, but I would say that 90% plus have indicated that that doesn't bother them, and they want a similar result on their other side.

Host Amber Smith: If a bunion re-forms after a person has already had surgery, what are their options? I mean, can they have a second surgery?

Scott Van Valkenburg, MD: They can. On the menu of types of procedures for bunion correction, you may be picking from a different side of the menu. It does oftentimes limit some of the types of procedures you can do, but inevitably there is something that can be done. I would say that this is a process. I still have never encountered a situation that I say, well, nothing can be done there. There's always something we can do to help, to try to help.

Host Amber Smith: Well, I appreciate you making time for this interview, Dr. Van Valkenburg.

Scott Van Valkenburg, MD: Thanks for having me.

Host Amber Smith: My guest has been Dr. Scott Van Valkenburg, an assistant professor of orthopedic surgery at Upstate who specializes in the foot and ankle. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York. Find our archive of previous episodes at upstate.edu/info.

I'm your host, Amber Smith, thanking you for listening.