Advertisements

Is “conventional” forefoot surgery proven as beneficial?

Deformities of the forefoot are the commonest orthopaedic deformity and firm evidence of success should go as assumed. Forefoot surgery is also a large industry and many would say that it would have to be successful if it were to persist as a profitable enterprise. However, do most people benefit and how predictable is the outcome? There are few statistics about the outcome of forefoot surgery, and those which exist are not encouraging.

One reasonably objective view is a meta-analysis  Cochrane Database: Intervention for treating hallux valgus (abductovalgus) and bunions. Ferrarid, Higgins J P, Williams R L. 

Their view, in précis, was:

The (available) methodological quality of the 12 included trials was poor and trial sizes were small.

Conclusion:

There is insufficient evidence …. to determine…. the most appropriate (treatment) for hallux valgus. It is notable that….patients remaining dissatisfied were consistently high (25%-33%) even when hallux valgus angle and pain had improved.

These trials considered only the treatment of Hallux Valgus. If other expressions of the malalignment abnormalities (including the lesser toes) had been taken into account the dissatisfaction percentage would have been higher.

****************************************************************************************************************

I know that there will be many people who say that their “conventional” surgery-to-bone was “the best thing that they did”. Therefore clearly some people do benefit. However worth debating is how long the benefit lasted and analysing that benefit. This is because “pseudo” or limited benefit is possible, as discussed below.

Body image

There is considerable body-image emotion associated with the feet. The appearance of the forefeet often exceeds (in body image importance terms) the appearance of the hands and even the face.  A beautician  had one toe a little shorter than the others.  She had not allowed anyone to see her feet for 16 years.  She even insisted that the radiography was performed through her socks, and was reluctant to show the foot to me. Once her toes were re-aligned she was entirely content, and proud to display her foot.  

If it looks good, then it must be good.

Apart from those who are motivated by vanity, there is a group who have the confused perception that if the foot looks “as a foot should” it must be functioning well. Obviously deformed feet can be corrected by re-alignment of the bones to appear – outwardly at least – to be normal.  However, whether this is functionally so is highly debatable.Often patients who had “conventional” forefoot surgery told me they were pleased with the result.  The conversation usually went something like this.

“Oh yes the surgery worked very well”.

“Why do you say that?”

“Well, just look at it, doesn’t it look perfect?”

“Yes it does look good.  Have you got back to using high-heeled shoes?”

“No.  I would never do that.  After all it was the high heels which caused my problem in the first place.  But now I have settled for low heels and things are just fine.  I can now use sandals and people can see my feet whereas in the past I could not go swimming.”

“Have you got back to jogging?”

“No, not at all.  I couldn’t dare do that ….”

That surgery was therefore successful from an aesthetic point of view and perhaps this is a sufficient reason for some people. 

  

Temporary relief of pain symptoms

There are, of course, a number of people who have had their pain relieved by surgery-to-bone.  Badly clawed toes are exceedingly painful and if fused into a straight, rigid and better aligned digit the pain is often relieved.  So this form of surgery is successful (in the short term).However, when measured overall it often isn’t as successful.  A single, painful clawed toe, having been straightened successfully, might cause, or be followed by, a number of other problems.  These include the progressive clawing of adjacent toes, or frequently by dislocation of the joint at the base of the toe (metatarso phalangeal joint) and pain under the metatarsal head of that ray.

The x-ray shows a great toe joint which has been slowly destroyed after the excision of a bunion. There may well have been an initial benefit, only to have less easily solved long term problem arise.

Reduced demands.

Much forefoot surgery occurs in the elderly, whose demands decrease often fairly rapidly.  Therefore the surgery in these people is relatively successful, but primarily because the function demanded is reduced.  Often the period of post-operative incapacity of many weeks or months tips the balance in the elderly between the previous activity and a new stage of relative inactivity. These people may never return to their previous levels of activity, and therefore place less demand on their feet and are less troubled as a result.

Statistical flaws.

It must also be remembered that the pain and incapacity of conventional surgery-to-bone is not inconsequential and large numbers of persons are deterred from having surgery. Their statistics therefore do not appear as either successes or failures. Seen in this way, conventional forefoot surgery is not successful.

 

 

 

This x-ray shows a great toe joint which has been slowly destroyed after the excision of a bunion. There may well have been an initial benefit, only to have less easily solved long term problem arise. Despite the surgery (or perhaps because of it) the deformity on the left (previously operated) foot is worse than the right (non-operated) foot.

 

 

 

 

 

 

 

 

 

 

 

 

 This diagram also illustrate the “conventional” surgery which has been performed on the left foot, with the “soft tissues” drawn in. A “bunion” (i.e. a piece of normal bone) has been removed, but notice that:

  1. The attachments of structures which normally prevent the great toe from veering towards the little toe have been destroyed (dots and solid black line), so it is no surprise that the deformity is now worse.
  2. The second toe is disrupted.
  3. The toe has slid off the metatarsal (open arrow).
  4. The joint has been worn away and the cartilage surface irreparably destroyed.
  5. Because there is no cartilage separation there is now painful bone-on-bone contact
  6. Note the prominence at the base of the right great toe (solid arrow), the so-called “bunion” – this is perfectly normal anatomy, not the “outgrowths” which it is often claimed to be. It is prominent only because the positions of the bones have been changed by soft-tissue tensions.

 

 

 

The British Medical Journal has attempted to evaluate the benefits of “conventional” surgery, as in the following http://clinicalevidence.bmj.com/ceweb/conditions/msd/1112/1112.jsp

This states that distal chevron osteotomy “Is likely to be beneficial” and is “more effective than no treatment or orthoses, but insufficient evidence to compare with other osteotomies or arthrodesis” This could be interpreted that the chevron osteotomy has an uncertain outcome. Failed chevron osteotomis performed by other surgeons will be illustrated in later posts on this site.

This BMJ paper says that the benefits of all other surgical and other treatments are of “Unknown effectiveness.” 

 

bmj.com/ceweb/conditions/msd/1112/1112.jsp

Advertisements

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

%d bloggers like this: