OLT (Osteochondral lesions of the talus)

O.L.T. (Otherwise known as OCD of the talus)

This is a relatively common pathology that is seen at the Family Foot and Leg Center. We are not referring to an obsessive compulsive disorder of the foot, we are referring to cartilage damage within the ankle joint.

Pathology

Anterolateral lesions on the talar dome result from inversion and dorsiflexion forces, which cause the anterolateral aspect of the talar dome to impact the fibula. These lesions are usually shallower and more wafer-shaped than medial lesions, possibly because of a more tangential force vector that results in shearing-type forces.
Posttraumatic medial lesions are deeper and cup-shaped. They result from a combination of inversion, plantarflexion, and external rotation forces that cause the posteromedial talar dome to impact the tibial articular surface with a relatively more perpendicular force vector.
A study of the contact pressures on the talus with varying degrees of lateral ligament transections and ankle positions showed that the medial rim of the talus was subjected to high pressures, even without ligamentous transection. Results of another study implicated the difference in cartilage stiffness; the tibial cartilage is 18-37% stiffer than the corresponding sites on the talus.

The results of other studies indicated that the mean cartilage thickness is inversely related to the mean compressive modulus. These findings may lend credence to the clinically observed etiology of osteochondral lesions of the talus (OLTs) (ie, repetitive overuse syndrome in medial lesions and an acute traumatic event in lateral lesions).
Observations from biomechanical studies suggest that the size of the lesion may alter the contact stresses in the ankle. Statistically significant changes in contact characteristics occur with lesions larger than 7.5 mm × 15 mm; this finding indicates that lesion size may play a role in predicting long-term outcome.

Presentation

In most cases, the mechanism of injury is an inversion injury to the lateral ligamentous complex. Patients typically present with chronic ankle pain along with intermittent swelling and, possibly, weakness, stiffness, instability, and giving way.
Upon physical examination, assess joint laxity with the anterior drawer test and assess strength by comparison with the contralateral ankle. Physical examination findings of joint laxity are uncommon. Palpation may reveal tenderness behind the medial malleolus when the ankle is dorsiflexed, indicating a posteromedial lesion. Anterolateral lesions may be tender when the anterolateral ankle joint is palpated with the joint in maximal plantarflexion.

Treatment
Medical Therapy
Conservative management of osteochondral lesions of the talus (OLTs) should be attempted first. Symptomatic patients with negative findings on plain radiographs should undergo an initial period of immobilization, followed by physical therapy. Studies have shown that a trial of conservative therapy does not adversely affect surgery performed after conservative therapy has failed. Patients whose plain images indicate OLTs and those who remain symptomatic after 6 weeks should undergo additional evaluation with MRI.

Surgical Therapy
Surgical treatment depends on a variety of factors, including patient characteristics (eg, activity level, age, degenerative changes) and lesions (eg, location, size, chronicity). However, surgical treatment adheres to 1 of the following 3 principles:
1) Loose-body removal with or without stimulation of fibrocartilage growth (microfracture, curettage, abrasion, or transarticular drilling)
2) Securing OLTs to the talar dome through retrograde drilling, bone grafting, or internal fixation
3) Stimulating the development of hyaline cartilage through osteochondral autografts (osteochondral autograft transfer system [OATS], mosaicplasty), allografts, or cell culture (Carticel, Genzyme Biosurgery, Cambridge, Mass)

Arthroscopic intervention is associated with less surgical morbidity and joint stiffness, decreased rehabilitation time, and an increased functional outcome.

Postoperative Details
A postoperative rehabilitation program should be tailored to each patient's individual circumstances and goals by a licensed physical therapist. Rehabilitation can generally begin after healing is demonstrated, which may occur after 6-7 weeks of non–weightbearing status if drilling or internal fixation was performed. With the goal of attaining full ankle range of motion, physical rehabilitation includes active and passive range-of-motion exercises and a home program, edema control, and strength and proprioceptive training.

Follow-up

Pain following operative treatment of OLTs is common for up to a year. MRI changes, including edema, are slow to resolve and often match the patient's report of an achy feeling in the joint. After 6 months, a persistent effusion, a catching sensation, or severe pain signifies that healing is not progressing as intended, and further investigation with CT or MRI is appropriate.
For excellent patient education resources, visit eMedicine's Foot, Ankle, Knee, and Hip Center and Imaging Center. Also, see eMedicine's patient education articles Ankle Arthroscopy, Understanding X-rays, and Magnetic Resonance Imaging (MRI).

Bone infections of the foot and ankle

Osteomyelitis or bone infections

This is a relatively common pathology that we see at the Family Foot and Leg Center here in Naples, Florida. Many patients will end up with this devastating diagnosis and it will lead to a number of amputations across the country, with each year steadily increasing the number of foot and leg amputations primarily from patients with diabetes and the associated complications from such especially with neuropathy and vascular disease.

We try to utilize the most innovative technology to try and prevent this devastating complication (ie amputations) , with the use of state of the art external fixators, MicroVas microcirculatory therapy, wound care referrals, and closely working with infectious disease doctors for management of the systemic portion of treatment especially in the case of ankle osteomyelitis. This usually includes intravenous antibiotics and weekly monitoring of blood tests. Sometimes it includes partial amputations of toes, feet, or even the leg.

We pride ourselves on diabetic limb salvage, which essentially includes treatment of bone infections of the ankle and foot, as well as prevention of these problems. We also utilize specific rotation flaps for wound coverage and insertion of antibiotic bone spacers within the area of concern to aide in bone removal and replacement, to prevent major amputations and loss of legs. Most ulcerations of our diabetic patients that have been present for 3 months or more may lead to underlying bone infections in weight bearing areas of the foot if not adequately treated, and a qualified wound care specialist (of our practice we have 3 physicians for this) is essential for optimal outcomes.

We also provide excellent prophylactic treatment and maintenence of our diabetic patients with routine foot examinations and vascular studies to rule out limb threatening vascular disease, with proper referrals as needed. We pride ourselves on our abilities to not only treat, erradicate infection, and save legs and feet. But we also provide excellent maintenence therapies to our patients to prevent these outcomes entirely. We are part of a team of physicians, nurses, and health care practitioners who are entirely dedicated to our diabetic patients to maintain daily activities, walking, and prevention of serious complications stemming from the pathology of diabetes.

Any comments are welcome, as I am willing to respond to questions, comments, or concerns at any time.

Overview of Peroneal Tendon Issues

Clincal picture of dislocating peroneals in ankle neutral.

Many patients that we treat at our office have chronic ankle instability in the form of lateral tendon dislcocations, or chronic ankle sprains. Many times these patients are unclear as to how important these tendons are to the overal stability and function of the ankle joint. With abnormal tendon gliding and ligamentous attenuations and ruptures, these tendons may also become painful with patients who have chronic ankle sprains. This is a comprehensive overview of this pathology and treatment options to help out with the understanding of these clinical scenarios.

History of the Procedure
Disorders of the peroneal tendons have been reported infrequently. Monteggia described peroneal tendon subluxation in 1803, and this entity seems to be more commonly encountered than are disruptions of the peroneus longus or brevis alone. Nonetheless, peroneus brevis disorders have been described more often in the literature, with peroneus longus problems gaining more recent attention. However, much of the literature regarding both tendons is in the form of case reports.

Problem
The peroneal muscles make up the lateral compartment of the leg and receive innervation from the superficial peroneal nerve. The peroneus longus muscle originates from the lateral condyle of the tibia and the head of the fibula. The tendon of peroneus longus courses behind the peroneus brevis tendon at the level of the ankle joint, travels inferior to the peroneal tubercle, and turns sharply in a medial direction at the cuboid bone. The tendon inserts into the lateral aspect of the plantar first metatarsal and medial cuneiform.
A sesamoid bone called the os peroneum may be present within the peroneus longus tendon at about the level of the calcaneocuboid joint. The frequency with which an os peroneum occurs is controversial, with many supporting the idea that one is always present. However, the os peroneum may be ossified in only 20% of the population. The peroneus longus serves to plantar flex the first ray, evert the foot, and plantar flex the ankle.

The peroneus brevis originates from the fibula in the middle third of the leg. Its tendon courses anterior to the peroneus longus tendon at the ankle. It courses over the peroneal tubercle and inserts onto the base of the fifth metatarsal. The peroneus brevis everts and plantar flexes the foot.

Problems may arise in either of the tendons alone, or both may be involved with subluxation. The hallmark of disorders of the peroneal tendons is laterally based ankle or foot pain. Whether the problem is tendinous degeneration or subluxation, the clinical manifestation is pain. With time, loss of eversion strength may occur.

Problems arising with the peroneus longus include tenosynovitis and tendinous disruption (acute or chronic). The os peroneum may be involved with the degenerative process or as a singular disorder and can be fractured or fragmented. Longitudinal tears of the peroneus longus are uncommon but have been reported.
Longitudinal tears of the tendon are the most common problem seen with the peroneus brevis tendon. These may be single or multiple. Tendinitis and tenosynovitis also may occur.

Subluxation of both peroneal tendons may occur following an acute traumatic episode or may be of a more chronic nature.

Frequency
Disorders of the peroneal tendons are less common than other tendon problems involving the Achilles or posterior tibial tendons. However, it is impossible to estimate their true frequency in the United States or abroad.

Etiology
The precise etiology of peroneal tendon disorders depends somewhat on the specific problem being addressed. All disorders may result following a traumatic episode, direct or indirect, with a lateral ankle sprain being the most common trauma. Brandes and Smith have reported that 82% of patients with primary peroneus longus tendinopathy had a cavo-varus hindfoot.3 The presence of an os peroneum also has been postulated to predispose to peroneus longus rupture. Ruptures likewise have been reported to occur secondary to rheumatoid arthritis and psoriasis, as well as diabetic neuropathy, hyperparathyroidism, and local steroid injection.4,5,6
Longitudinal splits in the peroneus brevis tendon appear to result from mechanical factors. Repetitive or acute trauma causes the attritional ruptures. These ruptures may result from an incompetent superior peroneal retinaculum that allows the peroneus brevis to rub abnormally against the fibula.

Overcrowding from a peroneus quartus muscle also has been reported. The blood supply to the tendon has been shown to be adequate.

Subluxation of the peroneal tendons results from disruption of the superior peroneal retinaculum and usually involves avulsion of the retinaculum from its fibular insertion. The mechanism of injury typically involves an inversion injury to the dorsiflexed ankle with concomitant forceful contraction of the peroneals. Some patients have a more chronic presentation and cannot recall a traumatic episode. Congenital dislocations also have been reported. An inadequate groove for the peroneals in the posterolateral fibula may be a cause of subluxation as well.

Pathology of the longus and brevis tendons almost always occurs concurrently. Brandes and Smith noted a 33% incidence of concomitant problems.

Pathophysiology
Brandes and Smith have described and classified primary peroneus longus tendinopathy.3 They present 3 anatomic zones in which the tendon can be injured. Zone A is the level of the superior peroneal retinaculum. Zone B is the level of the inferior peroneal retinaculum. Zone C is the level of the cuboid notch. In their series, complete ruptures were most likely in zone C, while partial ruptures were more common in zone B. In the same study, surgical findings were classified into 3 groups. Group I pathology had no frank rupture but did have adhesions or thickening of the tendon. Group II pathology consisted of partial tears with some continuity of the tendon. Group III had complete ruptures with complete loss of continuity. All group III pathology occurred in zone C.

Other attempts have been made to classify peroneal tendon pathology. Sobel et al have presented a classification for tears of the peroneus brevis tendon as follows:7,8


•Grade 1 - Flattened tendon
•Grade 2 - Partial-thickness split less than 1 cm in length
•Grade 3 - Full-thickness split less than 2 cm in length
•Grade 4 - Full-thickness split more than 2 cm in length
Eckert and Davis have classified superior peroneal retinaculum (SPR) pathology as follows:9


•Grade I - SPR elevated from fibula
•Grade II - Fibrocartilaginous ridge elevated from fibula with SPR
•Grade III - Cortical fragment avulsed with SPR

Presentation
The patient with peroneal tendon pathology typically complains of laterally based ankle or hindfoot pain. The pain usually worsens with activity. However, presentation and diagnosis often are delayed. Patients may or may not recall a specific episode of trauma. Brandes and Smith reported that only 9 of 22 patients with primary peroneus longus tendinopathy recalled an inciting event and that the event was an average of 4.3 months prior to presentation.
Peroneal tendon subluxation or dislocation may present acutely following a traumatic injury to the ankle. However, it is not uncommon for these to present later with an uncertain history of trauma. Patients also may complain of snapping or popping in the ankle.

On physical examination, there usually is tenderness to palpation along the course of the peroneal tendons. Edema also may be present. These disorders require a high level of suspicion. Even frank dislocations may be missed if not specifically evaluated.

A provocative test for peroneal pathology has been described. The patient's foot is examined hanging in a relaxed position with the knee flexed 90º. Slight pressure is applied to the peroneal tendons posterior to the fibula. The patient is then asked to forcibly dorsiflex and evert the foot. Pain may be elicited, or the tendons may be felt to sublux.

Indications
The primary indication for treating these disorders is pain. Nonsurgical treatment usually is attempted first. Failure of conservative measures is an indication for operative intervention.

Operative Considerations

With physical therapy, MRI, and need for primary or secondary repair will be determined based on overal health of the patient, as well as how effective nonsurgical measures have been. If the pain and resolution is not fully noted through physical therapy and bracing one should consider the possiblity of repair. If there are tendon tears associated with the pathology, repair is recommended. If an associated low muscle (peroneus quartius) or ruptured retinaculum is identified, repair is also likely required. We are experts in this pathology, and treat this regularly, and I feel a proper evaluation for this condition will be beneficial to anyone with recurrent ankle sprains, as well as pain in the lateral ankle.

Hammer Toes

Hammer toe
Hammertoes occur when the smaller toes of the foot become bent and prominent. The four smaller toes of the foot are much like the same fingers in the hand. Each has three bones (phalanges) which have joints between them (interphalangeal joints). The toes form a joint with the long bones of the foot (metatarsals) and it is this area that is often referred to as the ball of the foot.
Normally, these bones and joints are straight. A hammertoe occurs when the toes become bent at the first interphalangeal joint, making the toe prominent. This can affect any number of the lesser toes. In some cases, a bursa (rather like a deep blister) is formed over the joint and this can become inflamed (bursitis). With time, hard skin (callous) or corns (condensed areas of callous) can form over the joints or at the tip of the toe.

What causes hammertoes?
There are many different causes but commonly it is due to shoes or the way in which the foot works (functions) during walking. If the foot is too mobile and / or the tendons that control toe movement are over active, this causes increased pull on the toes which may result in deformity.
In some instances trauma (either direct injury or overuse from walking or sport) can predispose to hammertoes. Patients who have other conditions such as diabetes, rheumatoid arthritis and neuromuscular conditions are more likely to develop hammertoes.

Are women more likely to get the problem?
It is more common in women as they tend to wear tighter, narrower shoes with increased heel height. These shoes place a lot of pressure onto the joint and predispose to deformity. It is common for patients to wear shoes that are too small and this can predispose to the problem. In a study we have performed, 95% of patients were in the wrong size shoes.
Will it get worse?
At the start of the deformity, it is generally mobile which means that the toe can be straightened. However, with time, the joint become fixed or rigid. This can then affect the joint at the ball of the foot and, in severe cases, the joint capsule ruptures (tears) so that the joint becomes dislocated and the toe sits up in the air.

What are the common symptoms?
Deformity / prominence of toe
Pain
Redness around the joints
Swelling around the joints
Corn / Callous
Difficulty in shoes with deformity of the shoe upper
Difficulty in walking
Stiffness in the joints of the toe

How is it identified?

Clinical examination and a detailed history allow diagnosis. X-rays are often not required but can help to evaluate the extent of the deformity and the degree of arthritis within the joint.

What can I do to reduce the pain?
There are several things that you can do to try and relieve your symptoms:
Wear good fitting shoes with a deep toe box
Avoid high heels
Use a toe prop to straighten the toe if it is still mobile
Wear a protective pad over the toe
See a doctor at the Family Foot and Leg Center.

What can we as a specialist do to correct or reduce your symptoms?
If simple measures do not reduce your symptoms, there are other options:
Advise appropriate shoes
Advise exercises if the toes are still mobile
Show you how to strap the toe in a corrected position
Provide a splint or protection
Consider orthotics

Advise on surgery
The way in which your foot loads during walking can place increased stress on the ball of the foot and cause increased toe activity. Special shoe inserts (orthoses) can help to control foot movement. Whilst these are unlikely to resolve established deformity they may help reduce discomfort in the ball of the foot.

Will this cure the problem?
If the deformity is mobile, then this may help prevent progression although there have been no scientific studies to analyse the benefit. If the deformity is fixed, then orthotics will not cure the problem but may reduce the associated symptoms.

What will happen if I leave this alone?
Generally, the deformity becomes worse with time and slowly becomes fixed (stiff). This can cause discomfort in shoes. The position of the toe places increased stress on the ball of the foot and this can become painful. Corn and callous formation on the ball of the foot is not uncommon. In some cases, the metatarsophalangeal joint capsule ruptures, causing the toe to sit up in the air.

Can the deformity be reversed or cured?
The only effective way of correcting the deformity is to have an operation.

How does the operation correct the deformity?
There are a number of different operations. However, the most common operations are:
Tendon transfer
Digital arthroplasty
Digital arthrodesis
Tendon transfers involve taking the tendon from under your toe and re-routing it to the top of the toe so that the toe is pulled down. This can be used alone if the toe is mobile or in combination with the other two procedures. This can leave the toe a bit swollen and stiff.
Digital arthroplasty and arthrodesis involve the removal of bone from the bent joint to allow correction. An arthroplasty removes half the joint and leaves some mobility whilst an arthrodesis removes the whole joint and, following a period of time with a wire/pin protruding from the end of the toe, leaves the toe rigid.
In more severe cases, the tendon on the top of the toe and the joint at the ball of the foot need to be released to allow the toe to straighten. If there is severe stiffness at this joint, then the base of the bone at the bottom of the toe (phalanx) may need removing (basal phalangectomy) or the metatarsal shortened (Weil osteotomy).

Patients will often tell me this: "I have heard it is very painful."
The nature of surgery means that there will be pain and swelling, usually worse the night after surgery. However, with modern anaesthetic techniques and pain killers, this can be well controlled. The level of pain experienced varies greatly from patient to patient with some experiencing no significant discomfort.

Will I have to have a general anaesthetic (be asleep)?
Not if you did not want one. Many of these procedures are performed perfectly safely under local anaesthetic (you are awake). Some patients worry that they may feel pain during the operation but it would not be possible to perform the operation if this were the case. We often perform these procedures at our surgical suite over at the Gridley Building location, where often times these procedures are done within 30 minutes, and you leave right then in a surgical shoe with the dressing applied immediately after the procedure is completed.

Will I have to stay in hospital?
No. As long as you were medically fit and have adequate home support, many patients are able to have this type of operation performed as day surgery and go home.

Will I have to have a plaster cast?
Plaster casts are generally not required for this type of surgery.

Are there a lot of complications?
There are risks and complications with all operations and these should be discussed in detail with your specialist. However, with most foot surgery it is important to remember that you may be left with some pain and stiffness and the deformity may reoccur in the future. This is why it is not advisable to have surgery if the deformity is not painful and does not limit your walking. A thorough examination of your foot and general health is important so that these complications can be minimised.
Although every effort is made to reduce complications, these can occur. In addition to the general complications that can occur with foot surgery, there are some specific risks with toe surgery:
Persistent swelling which may be permanent
Recurrence of deformity / corn (this tends to be more of a problem with the little toe)
Regrowth of removed bone
Residual pain
Stiffness or flail (floppy) toe
The toe may not sit on the ground – floating toe (there is an increased risk of this with arthrodesis)
You may get discomfort in other parts of your foot during the recovery period. This generally settles.
There is always a possibility that the deformity may return in later life.

When will I be able to walk again and wear shoes?
In the majority of cases, you will able to walk with the aid of crutches within 2-4 days but you will remain somewhat limited for the first 2 weeks.
Some patients are able to return to wider shoes within two weeks with 60% of patients in shoes at 6 weeks and 90% in 8 weeks. This period is longer for arthrodesis as shoes cannot be worn until the wire/pin has been removed (generally 3-6 weeks).
Swelling generally starts to reduce at 6-8 weeks and the foot will be beginning to feel more normal at 3 months although the healing process continues for 1 year.

When will I be able to drive again?
When you feel able to perform an emergency stop. This is generally between 4-8 weeks post operatively but you should always check with your insurance company first.
When will I be able to return to work?
If you are able to get a lift and have a job that is not active and you can elevate your foot, you may be able to return after 1-2 weeks. Generally, patients return to work between 4-8 weeks depending on the type of job, activity levels and response to surgery.
When will I be able to return to sport?
Although the healing process continues for up to 1 year, you should be able to return to impact type activity at around 3 months. This will depend on the type of operation you have and how you respond to surgery.

Hopefully this is an effective run down of various questions commonly asked by my patients here, and if you come up with more please comment and the questions will be answered.

DT

NAIL LASER UPDATE

Onychomycosis is a common infection of the nail, and it may affect approximately 6.5% to 8.7% of the North American population. Visual description includes: yellowed, discolored, thickened and flakey nail / nail debris. The fungus causes a breakdown of the keratin within your nail plate. The byproduct is termed subungal debris which harbors both keratin and fungal elements. The same fungus that is responsible for toenail fungus is also responsible for athletes feet aka tinea pedis. An infected nail can act as a breeding ground for recurrent athlete's feet and mold.

The Family Foot & Leg Center is now proud to present the custom , gentle cool touch laser for your fungal nails in addition to keryflex total nail resurfacing technology.

http://www.gentlenaillaser.com/resources/BeforeAfter.pdf

Why the cool touch laser vs others? The cool touch uses a 1320 nm beam, a much safer and cooler beam than the 1064 nm of the competition. For additional safety and comfort, a cryogen spray is used when the nail is heated to the optimal treating temperature. A large 10mm beam diameter, controlled depth provides a reproducible safe procedure while treating the offending pathogen.
The laser is not new to the medical profession, but the use in treating fungal nails has picked up steam recently as additional research is being done. Lasers have been used for vein removal, wart distruction, removal of fine lines / wrinkles, hair, acne and tatoo removal. We at the Family Foot and Leg Center (FFLC) have done our research into various laser modalities currently on the market and has found the 1320 nm laser by cool touch to be the most effective and gentle on the nail bed but tough on fungal cells. We also have a 1064 nm laser (similar to the competition) but we reserve such for spider veins and less sensitive areas.

Initially, a comparison was made between the Noveon and Pinpointe lasers. With more research,different promising options became clear that combined superior treatment and safety features. While the Noveon was promising, it failed its initial FDA approval for onychomycosis and ran into financial problems. Additionally, some of the lower wavelengths had questionable results and the safety features with the Noveon added additional costs to the procedure. As of this writing, the Noveon is not available but may be in the future. It should also be noted that the laser also was initially developed for dental procedures. All of the lasers mentioned here have been FDA cleared for podiatry, dermatology and general surgery use. So they are appropriate for toenail treatments if proven worthy by your doctor.

As research proceeded, Dr. Katz liked the Cooltouch CT3 Plus Zoom laser, one of the most proven lasers on the market today with a track record. The Cooltouch allows for various types of skin treatments for many issues. Dr. Katz points out that toenails are simply modified skin, so the Cooltouch laser makes sense. He also liked the higher wavelength of the beam and feels that the hard thick nail can be more safely penetrated and treated with this different wavelength. In addition there are added features that improve the appearance of the nail by resurfacing, similar to skin resurfacing and rejuvenation. This is only a Cooltouch feature.

The CoolTouch CT3Plus CoolBreeze produces 1320nm laser energy that is specifically absorbed by water and water associated with collagen in the tissues of the nail matrix. The laser is so sophisticated that it can detect and reach the proper target temperature set by the doctor leading to death of the fungus. The treatment then stops immediately and then the nail is cooled with a spray. This allows for fungal death without damaging the skin or the nail growth plate. Cooltouch's impeccable safety emanates from its incorporating pulsed cooling and real-time temperature feedback into its treatments. In addition, the CoolBreeze Handpiece features an adjustable spot size from 3 mm to 10 mm allowing for adjustments based on nail size for most effectiveness. Other lasers currently being used do not incorporate these advanced features for patients leading to less desirable outcomes and minimal safety features. The Cooltouch laser can be completely controlled. The treatment temperature to kill the fungus can occur automatically while incorporating safety. Each patient can receive a customized treatment leading to the best possible outcome. This is truly unique.

There are different growth phases of the nail and fungus and the best results occur when the patient receives at least 2 treatments. The cost of 2 treatments with the Cooltouch is usually the same or less compared to only one treatment with the Pinpointe laser. This certainly benefits the patient.

Dr. Katz feels that the laser is superior to all other remedies for fungal toenails. However, patients need to follow a comprehensive maintenance regimen to prevent recurrence of the toenail infection.

Forfoot Deformity

A bunion is essentially a shift of the toe bones into the improper position causing pain and loss of function. The deformity involves the big toe and the long bone behind the big toe, the 1st metatarsal. Over time, the 1st metatarsal will begin to move towards the other foot (medial) while the big toe will move out of joint towards the 2nd toe (lateral). As the end of the 1st metatarsal bone begins to stick out, it will be under pressure from shoes and the ground. This constant pressure and friction will cause extra bone formation, leading to the bump that is seen on the side of the foot. The big toe will continue to shift towards the second toe causing an unbalanced big toe joint. Over time arthritis can develop in the joint due to the mal-positioned joint. A bunion deformity is always progressive. It will always get worse over time.



Severe bunion deformity with shift of the great toe under the second toe and hammertoe of the second toe.


Symptoms:
A bunion deformity does not always have to be associated with pain. Some patients have a very severe deformity and no pain, while others with a mild deformity have severe pain. Patients usually will have pain right over the bump with continued irritation and bruising to the bone from shoe gear and the ground forces. As the deformity progresses, pain will then be noticed in the joint itself when the big toe is moving. The big toe is very important during the gait cycle for pushing off the ground. With this imbalance of the joint there is a loss of the proper range of motion of the big toe joint leading to an inefficient gait. Over time arthritis will develop in the joint as the cartilage is scraped away each time the joint moves. The pain can be of different degrees depending on the degree of deformity, shoe gear, and activity level.

Causes:
Bunions are usually a genetic deformity. There is an imbalance of the muscles and the ligaments that are holding the 1st metatarsal in place. As this joint becomes weaker over time, the long metatarsal bone will begin to shift medially. The big toe is then under stress and begins to shift laterally under the pressure of the joint and shoes. Shoes with a tight and narrow toe box can help to create and make a bunion worse over time. High heeled shoes can also worsen and cause a bunion. Patients will a flat foot type (pronation) have a higher chance of having a bunion in the future.

Symptoms:
A bunion deformity does not always have to be associated with pain. Some patients have a very severe deformity and no pain, while others with a mild deformity have severe pain. Patients usually will have pain right over the bump with continued irritation and bruising to the bone from shoe gear and the ground forces. As the deformity progresses, pain will then be noticed in the joint itself when the big toe is moving. The big toe is very important during the gait cycle for pushing off the ground. With this imbalance of the joint there is a loss of the proper range of motion of the big toe joint leading to an inefficient gait. Over time arthritis will develop in the joint as the cartilage is scraped away each time the joint moves. The pain can be of different degrees depending on the degree of deformity, shoe gear, and activity level.

Diagnosis:

A clinical examination of the foot is done first. It is very important that the structure and biomechanics of the patient’s entire foot is examined. In order to identify the severity of the deformity, the stability of the joints around the bones involved is essential. The doctor will analyze the gait pattern of the patient. The doctor will identify if there is pain with joint movement and if the big toe can easily be re-located back into the joint. X-ray evaluation is essential in order to determine the degree of the bone shift and specific angles and the relationships between the bones.

Treatment Options:
Conservative treatments for bunions are limited. Wider shoe gear and accommodation for the deformity can be used to take the pressure off the area. Bracing and spacers are often used to brace the big toe back into position and can take some of the pressure of the big toe. However, this does not address the deformity and shift in the metatarsal bone. Furthermore, the bracing techniques are only work when used, once the brace is removed, the big toe will immediately go back into its deformed position. Custom molded Orthotics can take some pressure off the big toe and redistribute the forces of the ground through the rest of the foot. Orthotics can slow the progression of the deformity. There is no way to stop the progression or reverse the deformity without literally moving the bones back into the correct position and realigning the joint. This can only be accomplished through surgery.

We know that in order to realign the joint, the first metatarsal must be repositioned and fixated in the proper position. This can be accomplished by three basic types of procedures. First MPJ fusion, Offset Austin and Lapidus bunionectomy are the ideal procedures as they limit the chance of the bunion deformity from returning.

The choice of the procedure to be performed will be dictated by the severity of the deformity.


Mild Bunion Deformity
In mild and moderate bunion cases, we try to allow patients to have a more rapid recovery and limit the amount of time they need to spend off their feet. The Tightrope and Offset Austin bunion procedures allow immediate weight on the foot in a boot and also allow for rapid return to shoes. The choice of procedure best for each patient depends on the deformity size, the stiffness of the 1st metatarsal and the ease of realignment of the 1st metatarsal during the clinical exam.



Drawing of a bunoin prior surgery. Note poor alignment of the great toe and the 1st metatarsal. Grey shaded are will be removed during surgery and dotted line shows the region of bone cut.



Drawing of bunion after surgery. Note the shift of the 1st metarsal towards the second meatarsal for realignment of the column and fixation of the bones together with the two screws from top to bottom.





Clinical representations of pre and post surgery of mild bunion corrections.


Severe Bunion Deformity
In severe bunion cases, the 1st metatarsal is dramatically shifted away from the second metatarsal and there is looseness of the 1st metatarsal at the base of the bone. This is a difficult problem to correct unless the entire 1st metatarsal is realigned and held stable so it does not shift again. The Lapidus procedure allows for the 1st metatarsal to be repositioned with ideal correction and limited to no chance of bunion return. Recovery is slightly more difficult due to the need for crutches but the result is well worth it in difficult and severe cases. Some patients even require fusion of the first metatarsophalangeal joint secondary to this variation of deformity.

Hypermobility

The underlying cause of severe bunions is thought to be at the medial cuneiform joint and not at the great toe joint. If there is looseness of the medial cuneiform joint, there is motion of the metatarsal allowing the metatarsal to move out of position resulting in a bunion. The metatarsal may also move up resulting in poor position on the ground and collapse of the arch.

Clinical Pictures

Orthopedics versus Podiatrics

This is a common question that I will encounter, and I thought I would enlighten our readers about how I tend to answer this:

Who is better for foot and ankle treatment, a podiatric surgeon or orthopedic surgeon ?

This is a long debated topic which spans several other forums, and may actually not have a defined answer in general. I feel this question would be best answered in paragraphs headed, "it depends".

"It depends" on training.

I will offer several reasons for this statement. The first being that not all orthopedic surgeons have the same training. The same holds true for podiatric surgeons. Some podiatrists are not surgically trained, and a pathology may require such an intervention. Many orthopedic doctors tend to spend more time on knees and hips, some have fellowships in shoulders and foot and ankle surgery training is minimal as a general rule. Surgically trained podiatrists must have ABPS board qualification or certification for adequate credentials, especially for more complex surigcal needs of patients, such as ankle fusions or calcaneal fracture open reductions. These podiatrists spend 3 years doing complex foot and ankle surgery and some even have an additional year of fellowship training as well.

Most podiatrists feel comfortable treating forefoot deformities like bunions and hammertoes, and if they have surgical priveleges they may treat these conditions quite well. Many orthopedic surgeons will not routinely treat foot and ankle conditions that podiatrists see in their offices every day. The few that are fellowship trained in foot and ankle surgery are more apt to treat these various conditions without too much trouble. Overal, if you are researching a new doctor for your feet, I believe it is necessary to know the qualifications of your doctor prior to making the appointment.

"It depends" on your problem.

If you suffer from heel pain, or nail issues, most podiatrists are able to effectively treat these conditions quite efficiently without surgical interventions. Again, if a blade is part of the treatment protocol needed to relief painful symptoms, it may be necessary to know what boards your doctor is part of. All of the podiatrists at FFLC are ABPS qualified, and that means we are able to surgically treat any foot and ankle condition. If you choose to go the orthopedic route for your care, you may need to know whether the physician has a fellowship in foot and ankle and is commonly seeing people for their feet issues.

We see the most common problems for foot and ankle pain here, as well as some of the most complex problems. We do this every day and that's all we do. Experience and volume speaks well for the abilities of our doctors to not only treat these conditions well, but treat them often.