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Surgery for bunions

Posted by Julie F on 11/01/00 at 03:38 (031743)

Dear Doctors

I'd like your advice, please. I have a bunion on my left (not my PF foot) big toe, which my podiatrist describes as a grade 3-4 hallux valgus. He says that the joint will without question become arthritic, and that I should have it treated surgically before it does.

I am 65 and have had this bunion since my early 20s. It is unsightly, and has pushed all the toes off to the left, but it has given me trouble (pain) only on the rare occasions when I've worn the wrong sort of shoes, and sometimes when I've done a really long all-day hike on rough ground. 99% of the time I'm unaware of it. The joint has good movement, and that hasn't changed even though the bunion has got bigger over the years.

I do not want to have surgery unless it is really unavoidable, but on the other hand if he is right I don't want to wait until the joint becomes arthritic, when it will not be as easy to treat as it would be now. On the other-other hand, I have lived more or less peacefully with it for 40+ years, and it may well see me out!

Another factor is that I am losing confidence in my podiatrist. He is obviously well thought of (he is head of podiatric medicine at Guy's and St Thomas's, one of the major teaching hospitals in the UK) but he seems to me to be overly keen on surgery (he is young and has just recently got his surgeon's qualifications). I have told him about ESWT (which he hadn't heard of) and though he said he was interested, and I told him how to find out about it, he hasn't researched it - this is why I am losing confidence.

Sorry this is so long. But I would be really grateful for your view on whether or not I should be considering surgery.

Many thanks and best wishes

Julie

Re: Surgery for bunions

Dr. Biehler on 11/01/00 at 08:37 (031747)

Bunion surgery is usually done to relieve pain. A side effect is that the surgery can cause the joint to stiffen up. If your foot is not causing you problems, I would not recomend the surgical option as a preventative measure. Dr. B.

Re: Surgery for bunions

wendyn on 11/01/00 at 08:55 (031750)

I second Dr B's opinion.

I developed a bunion at 19, I had it operated on at around 23. The bunion hurt me a lot (it was keeping me up at night) and it made it almost impossible to find shoes. The surgery was painful - but for me it was worth it.

What I don't understand, is why my doctor told me that the my joint was arthritic to begin with (and that my bunion would eventually come back) and your doctor is saying that somehow sugery will prevent arthritis.

My sister in law had bunion surgery even though it wasn't causing her problems. She is worse off now than before and she regrets having it done.

If it doesn't hurt you - and it isn't wrecking your other toes, I'd leave it alone.

To be on the safe side - get a second opinion from a reputable orthapedic surgeon that specializes in feet and ankles.

Re: Surgery for bunions

Julie F on 11/01/00 at 10:16 (031754)

Thanks very much, Dr B. I'm glad to have your advice: it supports my own instincts, and I'll maintain the status quo.

Re: Surgery for bunions

Julie F on 11/01/00 at 10:27 (031757)

Hi Wendy

Thanks for this. I'm instinctively against elective/preventive surgery, and I'm going to take Dr B's counsel. If the joint becomes arthritic, maybe when I'm 75 or 80, so be it, and I'll deal with it then.

I think my pod was saying, not that surgery would prevent arthritis, but that if (*when*, in his view) the joint did become arthritic, the the bone would have worn away, the surgery would have to be done differently, and would be more difficult and cause more problems. That may all be true - but I still don't think I want to be cut preemptively. I can foresee my being in the same situation as your sister-in-law, having spent a lot of money for a bad result. No thanks!

It's interesting you were told at 23 that your joint was arthritic. I was told that too, years ago - but it wasn't and isn't because the movement is normal and there is no pain. Maybe my chiropodist was using the word loosely. Do you think your doctor was? And has your bunion returned?

All the best, Julie

Re: Surgery for bunions

Dr. Biehler on 11/01/00 at 19:10 (031787)

Your welcome! Dr. B.

Re: Surgery for bunions

wendyn on 11/01/00 at 19:31 (031788)

Hmmm. I\'m on my way out to yoga so I\'ll give you the condensed version for now - more later.\\I have \(and had\) pain, I have \(and had\) restricted mobility. So - I guess by that definition, we could say for sure it is \(was\) arthritic. Mine is a dorsal bunion \(on top of my foot\). It baffled a few doctors along the way \(that\'s part of the long story\). But eventually our local bunion expert \(orthopedic surgeon\) saw it. She said they could take it off, and after she did she assured me that it would come back in 5 to 10 years. It\'s the 8 year mark, and in the last year or so - I have noticed it change in size \(growing\) and some increased pain.\\I apparently have it because of how I walk - my toe jams into the joint.

Re: Surgery for bunions

Dr. Wishnie on 11/03/00 at 07:41 (031863)

Dear Julie:

Do not have surgery on your bunions! Lets take the worse scenario. Lets say your bunions get worse and the joint becomes completely arthritic. The procedure at that time would not be any more complicated now then before. In matter of fact, the outcome will most likely be better. Why? Because at that time you would be in so much pain that any relief is better than none. Presently, you do not have any pain, so what would you expect your outcome to be? Only cosmetic. If it ain't (sorry for the bad English) broke don't fix it.
Speaking about English, maybe you can help some of our American Doctors with their grammar.

Always good to hear from you. Let me know about what kind of problems and pains you are having and I will recommend the proper type of magnets.

Take care and stay well.

Dr. Wishnie

Re: Surgery for bunions

Julie F on 11/04/00 at 02:30 (031912)

Hello Dr Wishnie

Many thanks for your good advice, which I will take: I too believe that if it ain't broke.... and the last thing I want is to have to go to ground and stay off my feet for weeks; I can't afford the time and even if I could there are lots of things I'd rather be doing. But may I press you on one aspect of this matter, please? You say that the procedure 'would not be any more complicated now (i.e. after the joint has become arthritic) than before'. If that's so, then why has my podiatrist so definite in his suggestion that I 'do it now before it becomes arthritic'? Was he plain wrong to tell me that once the bone has degenerated the surgery would have to be performed differently, with a reduced chance of success? (He was not concerned about the cosmetic aspect, and neither am I.)

As I said in my first post, he is young, though definitely going places, and has only recently got his surgeon's badge and is perhaps over-enthusiastic about surgery. To be fair to him, he does say that surgery is a last resort for pf (but on the other hand he has not taken the trouble to investigate ESWT). Naturally I can't help contrasting this attitude with that of the experienced foot surgeons on this board including yourself who avoid surgery whenever possible and for whom it genuinely is a last resort.

My concern is not that he is not touting for custom - I'm sure he isn't - but that he may be plain wrong. I realize that there may be no hard-and-fast answer to the question, that there may be different surgical procedures (or different views on either side of the Atlantic) and that he may have a point. Or not. But my confidence in him is waning, so I'd like to know what you think.

My only 'real' problem is mild pf in my right heel. No first-thing-in-the-morning pain any more, bearable pain (discomfort, really) only after more unavoidable walking and standing than it likes. I am dealing with it and think it is getting better.I would be glad to know if you think magnets would help, and if so which ones.

What's all this about grammar? I wouldn't dream of presuming to help anyone with theirs, let alone the great doctors who give their time on this board to help people. We are all so grateful.

All the best, Julie

Re: Surgery for bunions

john h on 11/05/00 at 11:21 (031987)

i had surgery for 'hallux limitus' on my left great toe in aug 99 (chellectomy). i do not think this procedure differs very much from a bunionectomy. my toe has done well since the surgery and seems to have been successful. if i had continued to wait i could have done further damage to the joint and may have been faced with a fusion. this is not the case with a bunion. from all i read if it does not hurt and you can live with the looks and the restrictions it puts on your shoes then forget it. i also have hallux limitus on my right great toe and at some point will have to face that. this can cause major pain when walking and is basically an arthritic joint frequently brought on by activity. women have it more than men (shoes)

Re: Surgery for bunions

Julie F on 11/05/00 at 11:33 (031991)

John, thanks for this. I've made up my mind to live with my bunion - we have been sharing the same foot quite uneventfully for 4 decades, and if I ever need surgery will have it then. I think bunions can be congenital. I've never worn high heels/narrow toes, but my parents both had bunions and I think that's probably where I got mine.

I'm glad your surgery was successful.

All the best, Julie

Re: Surgery for bunions

Dr. Wishnie on 11/06/00 at 19:11 (032106)

Message Number 32107
Fractured 5th metatarsal View Thread
Posted by Melissa S on 11/06/00 at 19:12


Thank you so much for your reply. I had been wearing my orthodics for 3 weeks prior to swelling ie fracture it took some seraching on bones of the foot but my fracture is a longitudal split of 5th metatarsal behind proximal phalanx before tuberosity of cuboid bone. Question is could this have been caused by my orthodics? I do very heavy lifting and infrequent days of all day on feet on a concrete floor. Or would the orthodics have caused my peroneal brevis to pull off the bone causing the fracture?
Thank you for this sight!

Re: Surgery for bunions

john h on 11/10/00 at 12:07 (032447)

i will second the drs opinion that if the joint is arthritic it will be painful. you bet it is when you have hallux rigidis/limitus. especially when you walk to much. you can actually feel the crunching of the bone spurs when you manipulate your great toe in my case. the surgery was successful on my one toe but will have to do the other foot at some point

Re: Surgery for bunions

wendyn on 12/31/00 at 09:43 (035685)

Tina, I had a bunion removed when I was around your age. (I am now 32). The bunion gave me a lot of pain before I had it operated on. Yes - the surgery was painful. Was it worth it? For me - you bet. Even almost 10 years later....I still think it was the right decision. It's started to bother me on and off again in the last 2 years but still not to the point it was at before surgery.

Good luck, take your time with recovery!

Re: Surgery for bunions

Julie on 1/18/01 at 13:05 (036798)

Tina, Hi

I've been in India for the past three weeks and am just catching up with the board - so, sorry for the delay! I'm sure you're right to have the surgery, and I hope it will do the job for you. In my case, there was never any question about doing surgery for cosmetic reasons, my pod simply said that the joint WOULD without doubt become arthritic, so I ought to have it done before that happened. I felt this was wrong, and the views of Drs B and Z confirmed my instincts. IF the joint (which is very deformed and has pushed all my other toes off to the side) does become arthritic and painful, I'll reconsider. Until then - no thanks.

Good luck in February and remember to let us know how you fare afterwards.

All the best, Julie

Re: Surgery for bunions

Dr. Marlene Reid on 1/18/01 at 18:50 (036812)

Hi Julie,
I know I am new to this message board and I don't mean to step on any toes, but I feel I just have to give my opinion on the controversy of having a deformity corrected or waiting until arthritis sets in. I'm of the firm belief you fix something before it becomes arthritic because once arthritis is there, you can't turn back. Podiatric sx is not cosmetic. I advise my patients to look for these signs of progression: the big toe moving over more, aching more frequent, increased pressure in shoes, being less comfortable in shoes and pain. I can't tell you how many older people I come across that have HORRIBLE arthritic bunions that are so painful and the surgical options at that point are very limited.

Just another opinion to consider. But, I didn't hear your whole story and I haven't seen your xrays, etc., I'm just giving you some general info.

Re: Surgery for bunions

Dr. Marlene Reid on 1/18/01 at 18:57 (036814)

Well, I just read the whole thread where your comments came from and I have to agree that in Tina's case I would not perform surgery. If a patient is 65 years old, I would not recommend the same treatment as I would if someone was in their 30's or 40's. The problem with waiting until your in your 60's, 70's and beyond is that you don't have the circulation you did in your 30's and 40's. The post op recovery is also a whole different ballgame when you are older. However, some 60 year olds are very active and are more like 50 - so really each case is different. Just a few more thoughts-

Re: Surgery for bunions

Julie on 1/19/01 at 04:59 (036840)

Hi Marlene

What a long-lived thread this is growing into!

Many thanks for your interest and your thoughts. To make a long story short, my grade 3-4 hallux valgus and I have lived equably together for about 45 of my 65 years. It gives me no pain, and the joint has good movement. Your position is the same as my podiatrist's, and I can certainly see the sense of it. He was not suggesting surgery for cosmetic reasons, but for exactly the reason you state: that if the joint was to become arthritic, the options would be limited.

However, both Dr Zuckerman and Dr Biehler when I asked for their view were strongly of the 'if it ain't broke, don't fix it' opinion, and that is my own instinctive attitude to pre-emptive surgery too. Also, at my age there is a good chance that the present no-arthritis, no-pain state of affairs will see me out, particularly as I regularly exercise my toes, feet and ankles (I am a yoga practitioner and teacher).

So, yes, I know I am taking the risk you describe, but I am doing so consciously and for what I think, all in all, are good reasons. I will certainly keep an eye on it, and take action if it becomes necessary.

Thanks again, and all good wishes

Julie

Re: Surgery for bunions - PS

Julie on 1/19/01 at 05:04 (036841)

Marlene, I posted the response to your first message before reading your second, for which also many thanks. But regarding Tina's situation, I'd have thought that surgery _was_ the way to go, as her joint is already arthritic at the age of 24. Could you perhaps elaborate on your reasons for saying you would not perform surgery in her case?

Re: Surgery for bunions - PS

Dr. Reid on 1/19/01 at 09:52 (036855)

Sorry, I may have mixed you two up, I think I had one kid screaming downstairs and probable had the other fighting for the keyboard. But I think you know what I meant. I have heard of MANY older patients have sx recommended for them that I am in total disagreement with.

Re: Surgery for bunions

Dr. Biehler on 11/01/00 at 08:37 (031747)

Bunion surgery is usually done to relieve pain. A side effect is that the surgery can cause the joint to stiffen up. If your foot is not causing you problems, I would not recomend the surgical option as a preventative measure. Dr. B.

Re: Surgery for bunions

wendyn on 11/01/00 at 08:55 (031750)

I second Dr B's opinion.

I developed a bunion at 19, I had it operated on at around 23. The bunion hurt me a lot (it was keeping me up at night) and it made it almost impossible to find shoes. The surgery was painful - but for me it was worth it.

What I don't understand, is why my doctor told me that the my joint was arthritic to begin with (and that my bunion would eventually come back) and your doctor is saying that somehow sugery will prevent arthritis.

My sister in law had bunion surgery even though it wasn't causing her problems. She is worse off now than before and she regrets having it done.

If it doesn't hurt you - and it isn't wrecking your other toes, I'd leave it alone.

To be on the safe side - get a second opinion from a reputable orthapedic surgeon that specializes in feet and ankles.

Re: Surgery for bunions

Julie F on 11/01/00 at 10:16 (031754)

Thanks very much, Dr B. I'm glad to have your advice: it supports my own instincts, and I'll maintain the status quo.

Re: Surgery for bunions

Julie F on 11/01/00 at 10:27 (031757)

Hi Wendy

Thanks for this. I'm instinctively against elective/preventive surgery, and I'm going to take Dr B's counsel. If the joint becomes arthritic, maybe when I'm 75 or 80, so be it, and I'll deal with it then.

I think my pod was saying, not that surgery would prevent arthritis, but that if (*when*, in his view) the joint did become arthritic, the the bone would have worn away, the surgery would have to be done differently, and would be more difficult and cause more problems. That may all be true - but I still don't think I want to be cut preemptively. I can foresee my being in the same situation as your sister-in-law, having spent a lot of money for a bad result. No thanks!

It's interesting you were told at 23 that your joint was arthritic. I was told that too, years ago - but it wasn't and isn't because the movement is normal and there is no pain. Maybe my chiropodist was using the word loosely. Do you think your doctor was? And has your bunion returned?

All the best, Julie

Re: Surgery for bunions

Dr. Biehler on 11/01/00 at 19:10 (031787)

Your welcome! Dr. B.

Re: Surgery for bunions

wendyn on 11/01/00 at 19:31 (031788)

Hmmm. I\'m on my way out to yoga so I\'ll give you the condensed version for now - more later.\\I have \(and had\) pain, I have \(and had\) restricted mobility. So - I guess by that definition, we could say for sure it is \(was\) arthritic. Mine is a dorsal bunion \(on top of my foot\). It baffled a few doctors along the way \(that\'s part of the long story\). But eventually our local bunion expert \(orthopedic surgeon\) saw it. She said they could take it off, and after she did she assured me that it would come back in 5 to 10 years. It\'s the 8 year mark, and in the last year or so - I have noticed it change in size \(growing\) and some increased pain.\\I apparently have it because of how I walk - my toe jams into the joint.

Re: Surgery for bunions

Dr. Wishnie on 11/03/00 at 07:41 (031863)

Dear Julie:

Do not have surgery on your bunions! Lets take the worse scenario. Lets say your bunions get worse and the joint becomes completely arthritic. The procedure at that time would not be any more complicated now then before. In matter of fact, the outcome will most likely be better. Why? Because at that time you would be in so much pain that any relief is better than none. Presently, you do not have any pain, so what would you expect your outcome to be? Only cosmetic. If it ain't (sorry for the bad English) broke don't fix it.
Speaking about English, maybe you can help some of our American Doctors with their grammar.

Always good to hear from you. Let me know about what kind of problems and pains you are having and I will recommend the proper type of magnets.

Take care and stay well.

Dr. Wishnie

Re: Surgery for bunions

Julie F on 11/04/00 at 02:30 (031912)

Hello Dr Wishnie

Many thanks for your good advice, which I will take: I too believe that if it ain't broke.... and the last thing I want is to have to go to ground and stay off my feet for weeks; I can't afford the time and even if I could there are lots of things I'd rather be doing. But may I press you on one aspect of this matter, please? You say that the procedure 'would not be any more complicated now (i.e. after the joint has become arthritic) than before'. If that's so, then why has my podiatrist so definite in his suggestion that I 'do it now before it becomes arthritic'? Was he plain wrong to tell me that once the bone has degenerated the surgery would have to be performed differently, with a reduced chance of success? (He was not concerned about the cosmetic aspect, and neither am I.)

As I said in my first post, he is young, though definitely going places, and has only recently got his surgeon's badge and is perhaps over-enthusiastic about surgery. To be fair to him, he does say that surgery is a last resort for pf (but on the other hand he has not taken the trouble to investigate ESWT). Naturally I can't help contrasting this attitude with that of the experienced foot surgeons on this board including yourself who avoid surgery whenever possible and for whom it genuinely is a last resort.

My concern is not that he is not touting for custom - I'm sure he isn't - but that he may be plain wrong. I realize that there may be no hard-and-fast answer to the question, that there may be different surgical procedures (or different views on either side of the Atlantic) and that he may have a point. Or not. But my confidence in him is waning, so I'd like to know what you think.

My only 'real' problem is mild pf in my right heel. No first-thing-in-the-morning pain any more, bearable pain (discomfort, really) only after more unavoidable walking and standing than it likes. I am dealing with it and think it is getting better.I would be glad to know if you think magnets would help, and if so which ones.

What's all this about grammar? I wouldn't dream of presuming to help anyone with theirs, let alone the great doctors who give their time on this board to help people. We are all so grateful.

All the best, Julie

Re: Surgery for bunions

john h on 11/05/00 at 11:21 (031987)

i had surgery for 'hallux limitus' on my left great toe in aug 99 (chellectomy). i do not think this procedure differs very much from a bunionectomy. my toe has done well since the surgery and seems to have been successful. if i had continued to wait i could have done further damage to the joint and may have been faced with a fusion. this is not the case with a bunion. from all i read if it does not hurt and you can live with the looks and the restrictions it puts on your shoes then forget it. i also have hallux limitus on my right great toe and at some point will have to face that. this can cause major pain when walking and is basically an arthritic joint frequently brought on by activity. women have it more than men (shoes)

Re: Surgery for bunions

Julie F on 11/05/00 at 11:33 (031991)

John, thanks for this. I've made up my mind to live with my bunion - we have been sharing the same foot quite uneventfully for 4 decades, and if I ever need surgery will have it then. I think bunions can be congenital. I've never worn high heels/narrow toes, but my parents both had bunions and I think that's probably where I got mine.

I'm glad your surgery was successful.

All the best, Julie

Re: Surgery for bunions

Dr. Wishnie on 11/06/00 at 19:11 (032106)

Message Number 32107
Fractured 5th metatarsal View Thread
Posted by Melissa S on 11/06/00 at 19:12


Thank you so much for your reply. I had been wearing my orthodics for 3 weeks prior to swelling ie fracture it took some seraching on bones of the foot but my fracture is a longitudal split of 5th metatarsal behind proximal phalanx before tuberosity of cuboid bone. Question is could this have been caused by my orthodics? I do very heavy lifting and infrequent days of all day on feet on a concrete floor. Or would the orthodics have caused my peroneal brevis to pull off the bone causing the fracture?
Thank you for this sight!

Re: Surgery for bunions

john h on 11/10/00 at 12:07 (032447)

i will second the drs opinion that if the joint is arthritic it will be painful. you bet it is when you have hallux rigidis/limitus. especially when you walk to much. you can actually feel the crunching of the bone spurs when you manipulate your great toe in my case. the surgery was successful on my one toe but will have to do the other foot at some point

Re: Surgery for bunions

wendyn on 12/31/00 at 09:43 (035685)

Tina, I had a bunion removed when I was around your age. (I am now 32). The bunion gave me a lot of pain before I had it operated on. Yes - the surgery was painful. Was it worth it? For me - you bet. Even almost 10 years later....I still think it was the right decision. It's started to bother me on and off again in the last 2 years but still not to the point it was at before surgery.

Good luck, take your time with recovery!

Re: Surgery for bunions

Julie on 1/18/01 at 13:05 (036798)

Tina, Hi

I've been in India for the past three weeks and am just catching up with the board - so, sorry for the delay! I'm sure you're right to have the surgery, and I hope it will do the job for you. In my case, there was never any question about doing surgery for cosmetic reasons, my pod simply said that the joint WOULD without doubt become arthritic, so I ought to have it done before that happened. I felt this was wrong, and the views of Drs B and Z confirmed my instincts. IF the joint (which is very deformed and has pushed all my other toes off to the side) does become arthritic and painful, I'll reconsider. Until then - no thanks.

Good luck in February and remember to let us know how you fare afterwards.

All the best, Julie

Re: Surgery for bunions

Dr. Marlene Reid on 1/18/01 at 18:50 (036812)

Hi Julie,
I know I am new to this message board and I don't mean to step on any toes, but I feel I just have to give my opinion on the controversy of having a deformity corrected or waiting until arthritis sets in. I'm of the firm belief you fix something before it becomes arthritic because once arthritis is there, you can't turn back. Podiatric sx is not cosmetic. I advise my patients to look for these signs of progression: the big toe moving over more, aching more frequent, increased pressure in shoes, being less comfortable in shoes and pain. I can't tell you how many older people I come across that have HORRIBLE arthritic bunions that are so painful and the surgical options at that point are very limited.

Just another opinion to consider. But, I didn't hear your whole story and I haven't seen your xrays, etc., I'm just giving you some general info.

Re: Surgery for bunions

Dr. Marlene Reid on 1/18/01 at 18:57 (036814)

Well, I just read the whole thread where your comments came from and I have to agree that in Tina's case I would not perform surgery. If a patient is 65 years old, I would not recommend the same treatment as I would if someone was in their 30's or 40's. The problem with waiting until your in your 60's, 70's and beyond is that you don't have the circulation you did in your 30's and 40's. The post op recovery is also a whole different ballgame when you are older. However, some 60 year olds are very active and are more like 50 - so really each case is different. Just a few more thoughts-

Re: Surgery for bunions

Julie on 1/19/01 at 04:59 (036840)

Hi Marlene

What a long-lived thread this is growing into!

Many thanks for your interest and your thoughts. To make a long story short, my grade 3-4 hallux valgus and I have lived equably together for about 45 of my 65 years. It gives me no pain, and the joint has good movement. Your position is the same as my podiatrist's, and I can certainly see the sense of it. He was not suggesting surgery for cosmetic reasons, but for exactly the reason you state: that if the joint was to become arthritic, the options would be limited.

However, both Dr Zuckerman and Dr Biehler when I asked for their view were strongly of the 'if it ain't broke, don't fix it' opinion, and that is my own instinctive attitude to pre-emptive surgery too. Also, at my age there is a good chance that the present no-arthritis, no-pain state of affairs will see me out, particularly as I regularly exercise my toes, feet and ankles (I am a yoga practitioner and teacher).

So, yes, I know I am taking the risk you describe, but I am doing so consciously and for what I think, all in all, are good reasons. I will certainly keep an eye on it, and take action if it becomes necessary.

Thanks again, and all good wishes

Julie

Re: Surgery for bunions - PS

Julie on 1/19/01 at 05:04 (036841)

Marlene, I posted the response to your first message before reading your second, for which also many thanks. But regarding Tina's situation, I'd have thought that surgery _was_ the way to go, as her joint is already arthritic at the age of 24. Could you perhaps elaborate on your reasons for saying you would not perform surgery in her case?

Re: Surgery for bunions - PS

Dr. Reid on 1/19/01 at 09:52 (036855)

Sorry, I may have mixed you two up, I think I had one kid screaming downstairs and probable had the other fighting for the keyboard. But I think you know what I meant. I have heard of MANY older patients have sx recommended for them that I am in total disagreement with.