What is bunion surgery about?
A bunion looks like a bump on the inside aspect of your big toe joint. This is a foot deformity that is seen very commonly and treated in a variety of ways. Seeing the bunion with the naked eye, many people assume that this bump they see is extra bone that has grown – a bone spur almost. However, in most cases, the prominence you see is normal bone (not extra) that has slowly dislocated out of normal position, making it more prominent. Not every foot or bunion is the same. An evaluation by a profession is always needed to find out what kind of treatment you are a candidate for. Getting into the more interesting part, Lapiplasty is a bunion procedure which as been developed and refined over the last several years-close to a decade now. Surgeons have been correcting bunions long before this, but many sought a better solution. We wanted something that was more likely to be a permanent solution and there was something about the x-rays afterward surgery that left us wanting better for our patients—even though our patients seemed happy with their outcome.
Bunion procedures available now include removal of the ‘prominent’ bone, osteotomy (or a cut of the bone) with repositioning, fusion of the big toe joint (if arthritis is also present) or a procedure called the Lapidus. Removal of the prominent bone has become exceedingly less popular as, more often than not, the bone being removed is normal bone, not extra as you may think by looking down at your foot. An osteotomy helps to realign the joint, but creates a curvature in an otherwise normally shaped bone. Fusing the big toe joint is necessary in some cases and works well, but isn’t appropriate for the vast majority of bunions.
The Lapidus procedure has been around for a very long time. It addresses the instability of the joint near the arch. The relative laxity of this particular joint is responsible for most bunions that develop. With a traditional Lapidus procedure, the joint is repositioned to ensure the prominence near the big toe is reduced and the joint is then held in place with any combination of bone plates, screws or staples. With the way this joint is held in place, it is recommended that the patient not bear weight (walk or stand) for anywhere from 6-10 weeks. The results of a Lapidus procedure can be great, but not walking for a long period of time carries risk and of course inconvenience in the short term.
Another reason that the Lapidus procedure has been improved upon with the Lapiplasty system is the reliability and efficiency possible with repositioning the foot structure to correct the bunion. While the x-rays of your foot are 1 dimensional, our feet operate in all three dimensions. Not only does the bone behind the big toe lean inwards towards the other foot, but there is a rotational component which needs to be addressed.
What's wrong with the "old way"?
With a simple bunion, whereby the bone is purely “shaved down,” there is normal bone that is removed. This is not optimal and because this type of procedure does not address the instability which caused the bone to appear prominent in the first place, recurrence of the bunion is highly likely. Most people would prefer not to have to have bunion surgery – and certainly would prefer not to have to have it more than once.
With an osteotomy procedure, the bone behind the big toe is cut and shifted into a new position, which reduces the prominence by the big toe and can even help realign the big toe joint. This procedure results, however, in a curved appearance of a previously straight and healthy bone. These osteotomy procedures heal at the rate a fracture would (around 8-10 weeks) and are usually held in place with screws. You can very often walk after surgery, which reduces post-operative risks for complication. However, there is a joint under the big toe joint, where the metatarsal bone articulates with 2 small bones called sesamoids. These sesamoids are the most noticeable on x-rays when you have a bunion because of the rotational element of the bunion. An osteotomy procedure cannot properly realign these bones or reduce the rotation of the metatarsal so the toe may still lean and the range of motion can still be altered. In cases where the bone is properly repositioned, there is still often instability which can lead to recurrence.
Why is Lapiplasty so great?
The Lapiplasty system was designed to allow more predictable and efficient correction of bunions and allow for near immediate weightbearing on the foot. In fact, the configuration of plates and screws for this type of procedure make it so that your foot will heal better if you walk on the foot after surgery. While this doesn’t mean you do all the activities you did leading up to surgery right away, there are huge benefits to walking right after surgery.
How does walking affect my health?
Walking on your feet assists in bone health. The more demand on the bone, the stronger it will get in response to that daily stress. If someone is unable to walk for an extended period of time, the bone softens and when the person returns to walking, it can increase risk for fractures and stress fractures especially if returning to activity is not done slowly.
Walking also activates your calf pump. We all know what the calf is - that muscle on the back of your lower leg. We know this is important for walking and climbing stairs, but the physical contraction of this muscle has another great effect. It gently squeezes on the veins in the leg which assists in blood flow returning to the heart for circulation. If your calf pump is taken out of the equation for blood flow and circulation, the blood in the veins can pool which results in increased swelling as well as increased risk that the blood will clot within the vein, resulting in deep vein thrombosis or pulmonary embolism. Both of these condition can be fatal. While devices have been designed over the years to simulate this muscle contraction, walking is the most effective way to ensure your veins are functioning properly – especially after surgery.
Being able to use both feet after surgery also allows patients more stability and less risk of during the post-operative period. Standing to wash your hands, walking upstairs and getting to and from the bathroom after surgery can be difficult with post-surgical pain alone. Having to then coordinate using crutches or a walker adds another element which makes your function much more difficult.
Why do you love Lapiplasty?
The Lapiplasty procedure allows anatomical reduction of a bunion. This means that it is as though we turn back the hands of time on your foot until the bone is in the position it was before the bunion developed. Then by fixating the joint in the arch in this position, we are greatly reducing the risk that the bunion will recur. The stability that is re-established in the arch can also have the effect of slowing progression of other foot deformities and conditions. As your foot transitions weight while you walk, having instability in the joint that causes bunions to form can result in increased stress to other areas in the forefoot. There are many patients with bunions seen at our office, but not all have pain in the big toe joint. Some actually have pain in the ball of the foot either near the 2nd toe or even closer to the baby toe and it is because of this abnormal weight transition from the instability in the foot.
So when should I treat my bunion?
The most appropriate course of care for bunions starts with a thorough evaluation. This allows our doctor to properly classify the type of bunion you have as well as the severity. This is done with an examination of your feet and also x-rays. Our office offers digital x-rays on site, which means that you will likely get to see what is going on on the inside on the same day as your visit. We take 3 standard pictures of the foot and an additional view is often recommended to evaluate the sesamoid bones we spoke about earlier. The treatment for bunions usually starts with discussing how to stabilize and support the foot structure. Whether you are reading this article because you are ready to move forward with surgery or you are reading and wondering when in your life you will be ready – treatment starts with the use of custom orthotics.
So, should I wait until it really hurts to do anything?
In cases where our patients come in with concerns of a small, mildly painful bunion that they worry about because of a family history (ie. They don’t want their feet to look like their mom/dad’s someday) we cast for and recommend consistent use of custom orthotics. These are a conservative treatment that helps to support and correct foot structure from the outside in. This translates to effectively slowing down the progression of the bunion and often will assist with pain relief because the foot is better able to transition weight rather than stressing one area of the foot more than another.
When is surgery the answer?
In cases where a patient comes in for treatment and has daily difficulties with activities and has trouble finding shoes that accommodate the prominence, surgical options can be introduced into the conversation. No conservative treatment will correct a bunion, as this deformity progresses slowly over the course of many years and because of this, the foot structure and joints adapt to the new position. This is why many patients with bunions seek surgical treatment. Custom orthotics are still needed after surgery to assist in the function of the rest of the foot and to optimize big toe joint motion. With bunion correction, it can be a powerful change in the appearance of your foot, but does not reconstruct the other areas of the foot that lead to instability resulting in a bunion.
Lapiplasty is the answer to a lot of concerns that have been posed in decades of fixing bunions. With the advanced technique and far less rigorous post-operative course, it is amazing how well patients now do after bunion surgery. If you have a bunion and want to know more information, please call our office today.