First metatarsal neck osteotomies are known by various names based on the individual who first described the procedure (e.g. Austin, Reverdin-Green, Kalish-Austin). Regardless of the procedure, the goal of all these procedures is the same, to remove the bump and realign the joint. The first part of all bunion procedures involves removing the bump of bone from the side of the 1st metatarsal head. This is performed in a manner so as not to damage the viable part of the joint and not to leave any irregularities of bone that can cause future irritation in shoes. Once this is completed, the podiatric surgeon will create an osteotomy (bone cut) through the first metatarsal that will allow shifting the bone and realigning the joint. Depending on the type of osteotomy, the actual shape of the bone cut can vary. In the case of the Austin bunionectomy, the bone cut is V-shaped with the "V" sitting on its side and the tip of the "V" pointing toward the joint. When this cut is completed, the head of the metatarsal and joint is shifted toward the 2nd toe. In this way the bone and joint are repositioned in a more normal position. The Reverdin-Green osteotomy is made in a similar location but is trapezoidal in shape rather than V-shaped. Both these procedures are stable bone cuts and provide good correction of mild to moderate deformities. The Kalish-Austin bunionectomy is a modification of the Austin bunionectomy. It also is a V-shaped bone cut but is typically used for greater degrees of bunion deformities.

Because bone is cut and repositioned, it is often preferred to fixate or hold the bone in place with some external device. In the case of the Austin and Reverdin-Green osteotomies, this is most often accomplished by the use of a stainless steel pin across the bone cut. This prevents accidental displacement and loss of correction. Over the past 5 years, it has become increasing more advantageous to use small stainless steel or titanium screws to provide compression of the bone and to hold the bone in position. This is the main advantage of the Kalish-Austin bunionectomy. By using the screws, bone will heal faster and will allow for earlier ambulation. The screws are typically left in permanently unless they cause irritation of the soft tissues while the pins are generally removed in the office setting in three to four weeks following the day of surgery. The surgery is generally preformed as an outpatient in a hospital or out patient surgery center. Anesthesia is the choice of the surgeon made in consultation with the patient and anesthesiologist. Anesthesia may be a general anesthesia, twilight anesthesia or a local anesthesia.

Post Operative Care

The postoperative course and rehabilitation following bunion surgery depends on the procedure and can vary amongst podiatric surgeons. Patients have varying levels of postoperative pain but quite often the pain is significantly less than what the patient anticipates. A period of total non-weight bearing with crutches may be recommended in the first 3 to 5 days. In many instances, the surgeon may allow the patient to bear full weight in a postoperative surgical shoe. In all cases patients are instructed to limit their activities and to elevate their feet above their heart during the first 3 to 5 days. After this, a resumption of gradual weight bearing with a special surgical shoe is begun. Walking without the postoperative shoe is strictly prohibited. In cases where a pin is used, return to full weight bearing with a stiff soled walking shoe is allowed after the pin has been removed, generally in 3 to 4 weeks following the bunion surgery. Screws provide increased stability when used to fixate bone cuts and most patients can return to full weight bearing and regular shoes in 3-4 weeks following the surgery. The postoperative and rehabilitative course is improved by the use of ice and elevation of the extremity as much as possible. One of the most important aspects of the postoperative treatment is early motion of the joint to prevent joint stiffness. In most cases, range of motion exercises are begun almost immediately following surgery. No matter what the form of bone fixation is used, pins or screws; bone healing will take 6 to 8 weeks or longer. During this period of time it is important that the patient not walk without shoes or in thin-soled shoes or sandals. Should the patient risk walking without an adequately supportive shoe, they risk re-fracturing the bone and increase the duration of healing.

Possible Complications

Complications following bunion surgery are uncommon but may include infection, suture reaction, delayed or nonunion of the osteotomy, irritation from the pin or screws, stiff joint or recurrence of the deformity. Recurrence of the deformity can be halted or slowed with the use of functional foot orthotics. It is important to realize that surgery does not correct the cause of the bunion deformity. Functional foot orthotics however do address the cause of the deformity and their use are strongly encouraged following bunion surgery. A rare complication is the over correction of the bunion deformity. This condition, called Hallux Varus, may require additional surgery for its correction

This article should serve as a guideline for patients who are contemplating bunion surgery. The most commonly performed procedures for treatment of bunions have been discussed here. Procedures are selected based on surgeon's experience and preference. Patients are encouraged to discuss the surgery, the postoperative course and possible complications with their podiatric surgeon openly before consenting to surgical intervention.

Glossary of Terms
Bunion	Bump on the side of the foot at the base of the great toe
Bursitis	An inflammation of a fluid sac often found overlying a bunion
Fixation	Act of holding bones together, commonly require external devices such as pins, screws or plates
Hallux abductovalgus (HAV)	Medical term describing the deviation of the great toe toward the 2nd toe; common component of bunions
Metatarsal	A long bone of the foot that forms the ball of the foot
Orthoses	Devices made from a mold of the foot used to control abnormal motion of the foot; may be prescribed to prevent progression of bunion deformity or reoccurance following bunion surgery
Osteotomy	Surgical procedure that creates a cut in a bone to achieve realignment; a "surgical fracture"
Pronation	Motion of the foot which when excessive results in flattening of the arch; one possible cause of bunion formation
Toe box	Part of the shoe that covers the toes

About the Authors:
Kenneth W. Oglesby, D.P.M., Second-year podiatric surgical resident, Beth Israel Deaconess Medical Center, Boston, Mass.
John M. Giurini, D.P.M., Chief, Division of Podiatry, Beth Israel Deaconess Medical Center, Boston, Mass., Assistant Clinical Professor of surgery, Harvard Medical School, Boston, Mass.

Bone spurs of the toes most commonly occur on the fifth toe. They occur less frequently on the other toes. The areas of the fifth toe that can form bone spurs are the outside of the toe next to the toenail, the inside of the toe near the tip of the toe where the toe presses up against the fourth toe, and on the inside of the base of the fifth toe. When the spur is at the base of the fifth toe, it is often associated with a soft corn between the fourth and fifth toes (See surgical correction of soft corns). Bone spurs can also occur on the side of any toe. Bone spurs in the toes are associated with excessive pressure of the toes pressing on one another while wearing shoes.

Surgical Procedure

Surgical correction consists of making a small incision near the spur and smoothing the bone with a rasp or power burr. Quite often, this can be accomplished thru an incision small enough to require a single stitch. When the spur is adjacent to the toenail, a small section of the toenail may also be removed. On occasion, the spurring on the fifth toe may be associated with a mild, flexible contracture or curving of the toe. When this is the case, an additional incision may be required to release the tendon in the bottom of the fifth toe.

If the spur is at the base of the fifth toe and associated with a soft corn, a different surgical procedure is performed (See surgical correction of soft corns). A small bandage is placed over the surgical site. Sometimes a Band-Aid may be used. Quite often, the patient will be given a post-operative shoe to wear until they can comfortably get into a normal shoe. The stitches stay in place for seven to ten days. During this time, the area should be kept dry to help prevent infection. Frequently, the surgeon will allow the patients to change their own bandage on a daily basis. The day of surgery, the patient should significantly limit their activity to reduce the risk of bleeding.

What to Expect Following the Surgery

It usually takes a few weeks for the surgical site to completely heal, and activities should be limited or kept within normal reason during this period of time. "If the activity hurts, don't do it." The time required to be off from work will depend upon the demands of the job and the type of shoe that must be worn at work. If the patient's work is relatively sedentary, and they can return to work in a post-operative shoe, then they can generally return to work the day following surgery. If work requires standing or walking long hours, or requires work boots or sung fitting dress shoes, time off from work may be ten to fourteen days or more.

Possible Complications

Relatively few complications are associated with this type of surgery. Infection or reoccurrence of the bone spur can occur. If the patient is too active during the healing period, delays in healing can occur.

What is the Accessory Navicular? 
The accessory navicular (os navicularum or os tibiale externum) is an extra bone or piece of cartilage located on the inner side of the foot just above the arch. It is incorporated within the posterior tibial tendon, which attaches in this area.  

An accessory navicular is congenital (present at birth). It is not part of normal bone structure and therefore is not present in most people.  

 

What is Accessory Navicular Syndrome?
People who have an accessory navicular often are unaware of the condition if it causes no problems. However, some people with this extra bone develop a painful condition known as accessory navicular syndrome when the bone and/or posterior tibial tendon are aggravated. This can result from any of the following:

• Trauma, as in a foot or ankle sprain
• Chronic irritation from shoes or other footwear rubbing against the extra bone
• Excessive activity or overuse

Many people with accessory navicular syndrome also have flat feet (fallen arches). Having a flat foot puts more strain on the posterior tibial tendon, which can produce inflammation or irritation of the accessory navicular.

 

Signs and Symptoms of Accessory Navicular Syndrome
Adolescence is a common time for the symptoms to first appear. This is a time when bones are maturing and cartilage is developing into bone. Sometimes, however, the symptoms do not occur until adulthood. The signs and symptoms of accessory navicular syndrome include:

• A visible bony prominence on the midfoot (the inner side of the foot, just above the arch)
• Redness and swelling of the bony prominence
• Vague pain or throbbing in the midfoot and arch, usually occurring during or after periods of activity

 

Diagnosis
To diagnose accessory navicular syndrome, the foot and ankle surgeon will ask about symptoms and examine the foot, looking for skin irritation or swelling. The doctor may press on the bony prominence to assess the area for discomfort. Foot structure, muscle strength, joint motion, and the way the patient walks may also be evaluated.  

X-rays are usually ordered to confirm the diagnosis. If there is ongoing pain or inflammation, an MRI or other advanced imaging tests may be used to further evaluate the condition.

 

Treatment: Non-Surgical Approaches 
The goal of non-surgical treatment for accessory navicular syndrome is to relieve the symptoms. The following may be used:

• Immobilization. Placing the foot in a cast or removable walking boot allows the affected area to rest and decreases the inflammation.
• Ice. To reduce swelling, a bag of ice covered with a thin towel is applied to the affected area. Do not put ice directly on the skin.
• Medications. Oral nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may be prescribed. In some cases, oral or injected steroid medications may be used in combination with immobilization to reduce pain and inflammation.
• Physical Therapy. Physical therapy may be prescribed, including exercises and treatments to strengthen the muscles and decrease inflammation. The exercises may also help prevent recurrence of the symptoms.
• Prescription Orthotic devices. Custom orthotic devices that fit into the shoe provide support for the arch, and may play a role in preventing future symptoms.  These are not over the counter inserts these are prescription medical devices made by a physician. 
• No barefeet.  We highly recommend not going barefoot around the house, Vionic slippers or flip-flops work extremely well. 

Even after successful treatment, the symptoms of accessory navicular syndrome sometimes reappear.  When this happens, non-surgical approaches are usually repeated.

 

When Is Surgery Needed? 
If non-surgical treatment fails to relieve the symptoms of accessory navicular syndrome, surgery may be appropriate. Surgery may involve removing the accessory bone, reshaping the area, and repairing the posterior tibial tendon to improve its function. This extra bone is not needed for normal foot function.

Surgery for Ankle Pain

This patient presented to the office with chronic ankle pain after having sustained multiple ankle sprains.  The patient was very active including running, weight lifting and basketball.  The physical exam revealed pain with range of motion and a limited range of motion.  Pre-operative xrays and MRI was obtained.

 

This pre-operative view of the patients ankle reveals a large bone spurs at the anterior lip of the tibia and neck of the talus.

This view demostrates decrease range of motion of the ankle as the patient dorsiflexes the joint.

This post-operative xay shows removal of the bone spurs.  The patient had an arthroscopic debridement of the ankle joint to remove the spurs and scar tissue that was present.

Hammertoes occur from contracture normally of the interphalangeal joints of the toes.  These can occur in conjunction with other types of foot deformities like bunions or flat feet.  These are fairly straightforward to fix surgically and have a very short recovery. One of the most important things I can encourage is to make sure other foot deformities are evaluated and treated.  Normally the surgical procedure involves removing a small section of bone and pinning the toe for about 4 weeks.  Most people are walking usually in a boot to protect the toes and physical therapy is not normally required.  At the Bellevue foot surgery Center this procedure can normally performed and less than half an hour people often go back to work the next day.  There are additional options for patients that don’t want third toes pinned, we continues internal splinting.  Hammertoe deformity and wanted to discuss either conservative or surgical care we would be happy to review your options.  If you live in Issaquah, Bellevue, Seattle, Redmond, Sammamish, Maple Valley and Renton please call us at 425–391–8666. 

Pain and swelling around the joint is often indicative of arthritis.  There are many treatment options available for arthritis including bracing, injections and surgery.  Today I’ll focus on arthritis of the great toe joint or the first MTPJ.  This is a chronic condition we see often described as hallux limitus or hallux rigidus.  Many times patients have had injuries like turf toe or spraining of the toe joint, however this can be genetic as well.  Usually pain presents with activities and often limits patient’s ability to play sports or running.  Proper evaluation usually involves an x-ray see x-ray below was a good example of arthritis of the big toe joint.

The picture above shows pretty severe arthritis of the big toe joint.  This patient would require fusion of the toe or arthrodesis in order to provide long-term pain relief.  This procedure is relatively straightforward usually involves 2 screws and a period of weightbearing in a boot for 6-8 weeks.  Patients can return to activities that they did preoperatively with a limitation of inability to wear high heel shoes.  There are other procedures available for osteoarthritis of the great toe joint if it is not as severe as the above xray including; opening up the joint space to increase range of motion or just cleaning up the joint.  If you currently have great toe pain and live in Seattle, Bellevue, Issaquah, or anywhere on the East side like Maple Valley call the Bellevue foot surgery Center division of the Issaquah foot and ankle specialists at 425-391-8666.  Our clinic has an onsite surgery center which will save you thousands of dollars versus going to an Outpatient Surgery Center or the hospital.

We have quite a few patients who’ve expressed interest in the removal screws and plates and/or pins. They’ve previously had surgery and would like their hardware taken out, often times because of irritation. Generally there appears to be an inflammatory-type reaction that some people experience from the retained hardware. Hardware removal is a very simple procedure that can be done in our surgery center oftentimes in less than 30 minutes. There’s usually hardly any recovery time, including minimal time off work if not just the day of surgery. Postoperative pain is often not present. We have very few people take any pain medication after this hardware removal. A common question patients have concerns the hole left behind by the hardware. Normally, new bone formation covers the hole in a relatively short period of time. If you have any questions about hardware removal or would like to be evaluated for hardware removal, please feel free to contact us at 425-391-8666.