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Failed Surgery for “Bunions”

 

Much which has been written about the abnormalities of the forefoot is irrelevant and is often frank disinformation.
The two commonest forms of surgery are:

1. “Bunionectomy”.
This is a brutal procedure which simply chisels off the metatarsal condyle – damaging perfectly normal bone and ultimately destroying  (almost always) perfectly normal joints.
Conceptually it is flawed, as it ignores the underlying causes.
Technically this is the crudest of surgery, often damaging or destroying the digital nerve, with the risk of a neuroma and permanent pain
It is irrational in that the very structures which keep the great toe from deviating towards the lesser toes are destroyed. The metatarso-phalangeal join is, in the long term, doomed by this procedure (see page Is “conventional” forefoot surgery proven as beneficial?)
Not surprisingly the long term outlook is poor and recurrence of problems inevitable.

2. “Metatarsal Osteotomy”. Many grandiose names are given to the variants such as Chevron, Akin, Scarf and many more, the titles implicating that these are scientifically established as valid treatment. What success there is, in the short term, is primarily by producing a cosmetic approval, plus the illusion the “what looks normal will function normally”. Again it ignores the underlying cause.

What studies which have been done have measured  the short term results (see “Noxious Placebos”), and this  academic poverty is conceded by the Cochrane reviews.
Again the long term outlook is poor, also resulting in destruction of the joint at the base of the great toe.
This causes pain, often incapacitating, in the last decade of life – the very period n when the patient is so dependent upon their feet for independence, and when maximum painless balance and stability are necessary to prevent falls.

The illustration below shows a typical long-term outcome. This woman had metatarsal osteotomies, “bunionettes” removed and arthrodesis of the toes. Each of these procedures produced progressive destructive changes in different parts of the foot. Far from protecting the joints, these joints became the victims of these procedures (see The Hallux Paradox)

It might be thought that she had in parallel a destructive arthropathy which produced these changes, independent of the osteotomy. This is not the case. None has ever been identified during careful monitoring, including that by her general practitioner husband. The result is that normal joints have been relentlessly destroyed as an effect of metatarsal osteotomies.

See this popular site:
Patient.co.uk http://www.patient.co.uk/doctor/Hallux-Valgus.htm from which is extracted the text below. Much of the text should be regarded with skepticism, some is diametrically wrong. Some is merely loose speculation, such as:
“Displacement of the joint gives the tendons mechanical advantage and this displaces the joint further. As this occurs, tension is created on the medial aspect of the joint (with compression laterally). Medial tension causes ligaments to pull and cause the bone to proliferate on the dorsomedial aspect of the first metatarsal head. Lateral tension causes the sesamoid apparatus to stick in a dislocated position laterally.”
“Prognosis (for bunion surgery). The outlook is highly variable, as is that of the patients who are treated. Hence there is a shortage of adequate trials to compare the outcomes of the various forms of treatment. A Cochrane review found very little good evidence on which to assess either conservative or operative treatments.9
Cochrane Database Syst Rev. 2004;(1):CD000964.

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