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Many patients who come in for second opinions on bunion surgery share a common frustration that they will often get different recommendations on the most appropriate surgery depending on who they ask. Part of the reason for this is that there is no one-size-fits-all bunion surgery. And while two experts may reasonably disagree on the most appropriate approach, not all bunion surgeries are created equally and require careful consideration before appropriate recommendations can be given.
Bunions, medically known as hallux valgus, are a common foot deformity characterized by a bony protrusion near the base of the big toe. This condition usually develops over time, often due to a combination of genetic predisposition, foot structure, environmental factors, activity levels, and shoe gear. Bunions can cause pain and difficulty walking, leading many to consider surgery when conservative options have failed. But with literally hundreds of types of bunion surgeries available, how do you know which one is right for you? Rather than trying to fit everything we know about bunions into a single blog post, I would like to present a series of posts sharing what we know about bunions and how to navigate the process of bunion surgery. In this post, we’re going to focus on some broad categories of bunion surgeries and their pros and cons. These groups will include: Soft-Tissue Rebalancing, Osteotomies, Arthrodesis, and Minimally Invasive Surgeries. Soft Tissue Rebalancing The most commonly performed bunion surgeries, for better or worse, focus on the area of the bump. As a bunion develops, this can lead to increasing strain on structures around the first metatarsophalangeal joint (the joint just behind the big toe). During this surgery, we rebalance the tissue around this joint through a series of smaller procedures. The goal is to reduce some of those deforming forces that will worsen a bunion over time and to realign the joint. The procedure may also involve shaving down the prominent bone. Soft tissue balancing may be used in conjunction with other types of bunion procedures as well. Pros: Faster recovery, weight bearing allowed after surgery Cons: Higher risk of recurrence, not effective for more severe bunions Osteotomy An osteotomy is a surgical procedure that involves cutting and repositioning bones. For bunions, these cuts can occur at different or even multiple points of the first metatarsal, or even the proximal phalanx (bone in the big to closest to the foot). Pros: faster recovery than arthrodesis type procedures, can address other deformities present outside the bunion Cons: Increased risk of recurrence, not suitable for severe bunions Arthrodesis (Fusion Surgery) Arthrodesis, or joint fusion, generally will be performed at the first metatarsaphalangeal joint or the first tarsometatarsal joint (Lapidus procedure). There are major differences in when we perform these two surgeries. While they usually take longer to heal than the previously discussed surgeries, they can address things like advanced arthritis, provide more stabilizing power, and can be effective in more severe cases. Additionally, any time we fuse a joint, the joint above and below that one usually have to share the load of the fused joint, which can possibly lead to other problems down the road. First metatarsophalangeal joint arthrodesis Pros: low recurrence risk, can be used to treat both arthritis and bunion at once, effective for severe bunions Cons: eliminates motion at the big toe joint, often requires a period of non weight-bearing, increased risks postoperatively Lapidus (First tarsometatarsal joint arthrodesis) Pros: low recurrence risk, stabilizes the foot, effective for severe bunions Cons: increased risks compared to less invasive options, may require short period of non-weightbearing, technically difficult surgery but numerous systems have been developed over the last decade to improve consistency Minimally Invasive Bunion Surgery Minimally invasive surgery is not new but has been seeing a resurgence lately as our tools improve and more patients are seeking faster recovery and less scarring. Most of the previously mentioned types of surgeries can be performed in this way, but this does not come without trade-offs. Skill at these surgeries requires skill first in their open counterparts. While there are many high-skilled surgeons performing these, much of their initial popularity was partly due to fact they could be performed in office, leading many who were unable to gain surgical privileges at hospitals or surgery centers to focus on these procedures. While I do occasionally perform these surgeries in the appropriate patient, I unfortunately spend much more time fixing others’ attempts at it. Pros: smaller incisions, less scarring, can often be done in-office Cons: higher risk of recurrence, limited studies on outcomes, higher risk of complications Choosing the most appropriate bunion surgery can, but does not have to be, a harrowing experience. Bunions are rarely, if ever, an emergency, so my best advice is to take your time, attempt evidence-based nonsurgical treatment, and get a couple of opinions. If you would like a first, second, or third opinion on which surgery would be most appropriate for you, or you would like help navigating non-surgical options, give us a call or schedule online!
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Shortly after Kelly and I first moved to Bellingham, we began looking for a dentist. I have always (fairly) consistently brushed, flossed, and gotten yearly cleanings, and other than a few fillings and wisdom teeth removal, I have been pretty lucky with my oral health. That is, at least, until COVID. Between my work schedule and the difficulties finding a dentist during the beginning of the pandemic, I had gone over two years without a cleaning (I know, I know), and needed someone to help get me back on track.
I found a local provider, and after an initial meet-and-greet, got a cleaning scheduled. The results of my initial exam sounded promising, but I did have some early signs of gum disease. About 50% of people over the age of 30 have some level of this, but I wanted to do all I could to keep this from causing issues down the line. Along with recommendations for some more frequent cleanings, it was also recommended that I get a saliva test to check for the presence of certain bacteria that may be used to guide future treatments such as antibiotic selection for more serious cleanings if needed. While the test wasn't covered by insurance, I was assured this was evidence-based and because the doctor recommended it and I was trying to again get serious about my oral health, I agreed. Besides, this guy has hundreds of five-star Google reviews. He must be legit, right? My teeth felt pretty great after my visit, and the dentist seemed cool, so I left feeling much better about things. Those feelings started changing once I decided to learn more about the test that was ordered. While there was research available discussing potential links between certain types of bacteria and gum disease, there wasn't any data suggesting that this test is actually useful, and as a result, no professional dental association currently recommends its use. I thought that surely I must be mistaken, and spent a substantial amount of time looking into international research on the topic. There was nothing to suggest my dentist had made a good recommendation. After confronting the dentist, he tried pointing to a few studies suggesting the possible links previously mentioned, but nothing to actually support recommending the test. I was not only upset that I had wasted money on a useless test, but that others in my community were doing the same. Either this dentist knew the test had no legitimate scientific backing and was using insufficient evidence to mislead patients and to line his own pockets, or he believed without evidence that it should be guiding his treatment, which can be incredibly dangerous. Neither of these options were acceptable to me, so I again began searching for a different dentist that I could trust with my oral health. I was very fortunate to have taken numerous undergraduate and graduate courses in statistics, as well as participating in research projects throughout my education, giving me tools to help navigate the complex world of medical research and biostatistics. As medicine is constantly evolving, being able to read and interpret research is necessary to stay up to date and ensure you are both providing the best care, and importantly, not doing harm. Providing this type of care is utilizing evidence-based medicine (EBM), and is an essential guiding principle that helps ensure the highest quality of patient care. Let's delve into why embracing evidence-based medicine is crucial for both healthcare providers and patients! The Foundation of Quality Care: At its core, evidence-based medicine revolves around making clinical decisions based on the best available evidence from well-designed research studies, clinical trials, and systematic reviews. This approach emphasizes using data, rather than anecdotal experiences or tradition, to inform medical decisions. By determining the validity of, and integrating the latest scientific findings into practice, healthcare providers can offer treatments and interventions that are proven to be safe, effective, and tailored to individual patient needs. Benefits of Evidence-Based Medicine:
The Journey from Research to Practice: The journey from research to clinical practice involves several steps, each crucial in integrating evidence-based medicine:
Challenges and Nuances: While evidence-based medicine offers significant advantages, its application also faces challenges. Variability in patient characteristics, limited availability of high-quality evidence, and the need to balance clinical expertise with research data are all factors that require careful consideration. For example, just because multiple well-constructed studies on a particular treatment done in Miami, Florida show excellent results, this doesn't necessarily mean we would have the same findings if we did the same study in Bellingham, Washington. This doesn't necessarily mean there was a problem with the research design, but rather, seemingly small differences between the two cities' populations (amount of sunlight, diet, levels and types of exercise, etc, etc) can mean drastically different results. This is why understanding population and individual patient characteristics is a critical part of delivering the best care. Empowering Informed Healthcare: As patients become more engaged in their healthcare journey, the demand for transparent, evidence-based decision-making is on the rise. Embracing EBM empowers patients to actively participate in their care, making informed choices aligned with their preferences and values. Evidence-based medicine is the cornerstone of modern healthcare, ensuring that medical decisions are rooted in scientific research, leading to improved patient outcomes and optimal resource utilization. By fostering a culture of continuous learning, critical appraisal of research, and thoughtful clinical implementation, at Bellingham Bay Foot & Ankle Specialists, we deliver the highest standard of care to our patients. |
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