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Misnaming and Misunderstanding

Many terms develop to become derogatory, despite originating with a benign meaning.
Thus some terms transmogrify to become catagorised as “vile” or “despicable” and many other similar deprecating terms. This reflects the common human heuristic (a short cut), demonstrating the inability to quantify within a spectrum. Humans rely upon “binary” neurology. Therefore the instant (emotional) categorization (heuristic) is either “good” or “bad”, “desirable” or “undesirable”, “repulsive” or “attractive”.
Where a spectrum is presented, new and specific words are evolved to demarcate each position on the spectrum as a distinct entity: This is illustrated in the colour spectrum, where a multitude of words have been evolved to describe each component of that spectrum.
What if this wording goes wrong? What if the wrong word is accepted as valid?
In orthopaedic surgery, in relation to the descriptions of the commonest deformity suffered by humans, such a misnomer is universally accepted, which has allowed an incorrect concept to evolve. Subsequently a plethora of incorrect surgical procedures have been invoked and inflicted upon an un-suspecting public.
That word is “metatarsal” when it is (incorrectly) applied to the longest bone supporting the great toe. That bone is, correctly, a phalanx. Thus the (human) great toe has – like all the other toes and fingers – three phalanges. What determines the correct appellation? Many bones have characteristic sites of the “growth plates”, seen only in the growing bone. In the phalanges that growth plate is “proximal” that is towards the head. In the metatarsal it is “peripheral”, that is away from the head.

Therefore the great toe, correctly, has three phalanges. The true metatarsal is reduced to become the short “medial cuneiform”. Such changes might be related to the evolution of an “opposable” first ray in both the hand and the foot (as an atavistic expression in the foot). This is an important concept because the commonest deformity of the great toe exactly emulates the (similar) deformity in the second toe, which is named “clawing” in the lesser toes (if untreated that might become a “hammer toe”).
Thus the cause of this deformity of the great toe duplicates exactly the cause of a “clawed” second toe. Consequently the appropriate treatment of the great toe deformity should duplicate the treatment of a “clawed” lesser toe.
Hallux valgus (and “metatarsus primus varus”, another fallacious term) recurs, following “conventional” surgery. This has spawned a number of scientific papers addressing the question “Does excessive laxity of the ‘metatarso-cuneiform joint’ predispose to recurrence of the condition?”. This is fatuous, since the anatomy of that joint has no bearing on the cause of the pathology. That joint only has a bearing on the “Hallux Paradox” (see elsewhere)

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Hallux Valgus Paradox

Typical Hallux valgus does not cause a degenerative arthritis in the great “mt”p joint. Gross distortion, with subluxation of the phalanx, does produce degenerative changes, but of a different type.

However it is the “aligned” great toe which evolves into osteoarthritic damage (the “Hallux Rigidus”)

A problem which arise are that the symptoms of patients with pain at the “mt”p joint are not taken seriously at family practitioner level. There is a reason for that, which is the unsatisfactory and highly painful, surgery currently “conventional” for the great toe.

  1. Instead the patient is often advised to “wait until it gets worse”, before obtaining expert advice. The tragic outcome is that (otherwise preventable) destructive changes are allowed to evolve.
  2. Another problem is that “straightening” the great toe converts a hallux valgus (itself infrequently painful) into an incapacitating destruction of the great “mt”p joint. This is illustrated below.

The etiologies of these evolutions are clear, and easily comprehended.

 

How does the surgery I offer differ from “conventional” forefoot surgery?

How does the surgery I offer differ from “conventional” forefoot surgery?

This re-cap follows years of requests. Indeed this information-to-patients is obligatory in terms of Health Professional Council requirements.

Conventional surgery is based upon the belief that the age related deformities of the forefoot is caused by abnormalities of the bones, thus granting the domain to orthopaedic surgeons.

Consequently the surgical “correction” is aimed at the bones of the forefoot. This takes the form of dividing and angling the “metatarsal” of the great toe, and fixing that “correction” with plates and screws. The clawed lesser toes have some or all the joints ablated. These damaged lesser toes are then held in a “corrected” position by pins or screws driven down the marrow cavity of those toes. Following this surgery to bone it is hoped that these divided bones will heal and join, as fractured bones (usually) heal. This requires immobilisation for many weeks using plaster-of-Paris or surgical “boots”. Crutches are often required and ambulation is severely impaired for many weeks. The lesser toes become permanently rigid, often looking “awkward” and un-natural.

Since the cause of the deformity is not addressed, this “conventional” surgery is effectively “cosmetic” surgery. Unfortunately, also, “conventional” surgery is also not a permanent solution, and deterioration of the joint at the base of the great toe (developing degenerative osteoarthritis) is common. The other (un-operated) toes progressively (but at an unpredictable rate) “claw” and become uncomfortable, with corns on the top and calluses on the sole.

Recurrence of the deformity is a common occurrence following “conventional” surgical treatment of hallux valgus.(Arch Orthop Trauma Surg. 2012 Apr;132(4):477-85. doi: 10.1007/s00402-011-1447-6. Epub 2011 Dec 29.)

This “surgery-to-bone” for “bunions” and the other deformities of the forefoot was developed over a hundred years ago and has been passed down unaltered through generations of orthopaedic surgeons. Over one hundred forms of treatment for “bunions” have been described. Clearly there is not one which is convincingly superior to the others, and the selection of one form of correction as opposed to another is simply a “stab in the dark”.

It has been reported that of those subject to conventional “bunion” surgery over 30% suffered pain for at least two years (Foot Ankle Int. 2016 Oct;37(10):1071-1075. Epub 2016 Jun 19.) A recent paper presented in Europe claimed that in more than 30% of cases of “bunion” surgery were ultimately regarded as a failure.

I have been able to demonstrate (as I do for all my patients) that the problem is not in the bones of the toes, and “conventional” surgery damages – usually  irreparably – perfectly normal bones and joints, which then are expected to heal (effectively a gamble)

I have been able to show convincingly that the problem lies in the muscles serving the forefoot, and appropriate surgery demands that these soft tissues need to be corrected. This is the foundation cause to be addressed.  [The cause of the muscle imbalance requires a paper in its own right, and is unlikely to do with footwear]

A justified surgical axiom is that “if the cause is unknown the appropriate treatment is impossible”. To that end I have lectured to the South African Orthopaedic Association and the Foot and Ankle Society of South Africa, (“What REALLY causes Bunions?” – available on request).  By and large the message has been ignored for over twenty years, in defiance of objectivity.

The majority of persons with deformities of the forefoot are elderly, often living alone and dependent upon themselves entirely. Often financial resources are limited. Thus when I designed the procedure it was intended that this should be performed under regional anaesthesia (with a rapid return to a safe sensate foot) allowing the patient to be discharged from hospital the same day, able to walk independently, securely and safely [not encumbered by a cast or “boot” or (God forbid) crutches.] The procedure should be economical (with day-case discharge mostly) and not incur the costs of screws, plates, casts or boots.

What does the procedure NOT do?

Correction of the “bunion” might be slow or incomplete.  This is because long delays before seeking treatment (usually the case) allow progressive deterioration and multiple other irreversible changes at the base of the great toe (the “bunion”) . However this is likely irrelevant because it is the PAIN which drives people to surgery. The “bunions” become painless following this surgical management. The lesser toes often, or usually, lose the ability to “curl” or “claw”. However this is irrelevant, since the very reason the surgery is performed is to reverse “clawing”. In any event “conventional” surgery causes the toes to be rigidly inflexible and ugly. This disability has been over-ridden or ignored by those who harvest FDL at the level of the ankle joint

What is preserved, and develops progressively more, is the ability to “arch” the forefoot, necessary to hold slippers and other loose shoes in place.

Why has “conventional” surgery persisted? Partly because some of my colleagues know no better. I sympathise with them: this is what they were taught, their teachers have been taught this and have been taught so for generations.

However, some of my colleagues are content doing this surgery. It allows a high income, not only for the first procedure but for the subsequent removal of implanted metal. Further the “metal implant” industry is large, powerful and persuasive. Many of my colleagues have been “sponsored”  by the metal implant industry, at times with journeys paid to overseas congresses.

Then there is the widespread rigidity of medical science – a contented arrogant rigidity. Look at the history of discovery of Helicobacter for an example!

Many of my colleagues have been deprecating and defamatory towards me.  Some have prompted the idea of malpractice. In reality it is the “conventional” forefoot surgeons who are guilty of malpractice, by doing the wrong procedure for the wrong reasons.