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Should I have surgery?

Posted by Rick on 2/20/02 at 15:22 (074416)

Some Facts:
My bunion has caused my pain when playing tennis. I am active, 50,
and was planning to go on an extended hiking sabbatical and was
concerned the about possible pain developing which would
interfere etc. Presently I have what might be diagnosed as metatarsalgia with extended walking.

Had weight bearing x-rays done and went to ortho surgeon.

My Hallux Angle is 30 degrees & 1st intermetatarsal angle is 18 deg
but hallux does not yet go under or over the second toe.

Surgeon said if I elected to have the surgery ; he would perform a
Proximal Metatarsal Crescentic osteotomy & Mann soft distal procedure. Although he said this was not a required procedure for me, I could try orthotics etc. ; So I asked him if it were him would he
do it. and he answered in the affirmative.

I've since done quite a bit of research (couldn't find out exactly what
the Mann procedure is versus Silver or McBride) but that's not
my immediate concern.

QUESTION
I have not come across any professional guideline standards to know whether I should proceed with this
surgery? From the apparent pain and long recovery period people mention in discussion boards; one might draw the inference
that this surgery is not worth doing unless you are in sever pain which I'm not. But again my degree of Hallux valgus is classified as
severe?
What is your suggestion?

Re: Should I have surgery?

Ed Davis, DPM on 2/20/02 at 16:06 (074419)

It sounds like you may benefit from bunion surgery but I am not sure that I would recommend the combination of procedure you listed. The proximal crescentic osteotomy can have a very long recovery period. It is critical that the congruency of the big toe joint surfaces be taken into consideration. Neither procedure addresses that aspect although it would be necessary to look at your x-rays to be sure. Consider a second opinion.
Ed

Re: Should I have surgery?

Rick on 2/20/02 at 19:39 (074437)

Thanks for reply.
Actually, I'm currently investigating whom to visit for a second opinion;

Although I'm obviously a lay person in this area, I did find helpful
a web site which explained the x-rays etc called http://www.ej.rsna.org

Anyway, appartently my joint is not congrous but I suspect
between the deviated and subluxed classification. I gather
only the congrous category would be a contraindication for
the Silver or McBride procedure.

Question
1. On average how long is the recovery for the proximal crescentic
osteotomy ? and
2. Isn't there some guidelines for the lay person outling when
the procedure should be done or is the answer best found
by obtaining a second opinion? It would be nice if both existed

Thanks again for your reply, I appreciated it

Re: Should I have surgery?

Ed Davis, DPM on 2/20/02 at 21:54 (074449)

I was not able to link to the site listed.

The cartilage on the first metatarsal head, in longstanding bunion deformities adapts by gradually deviating laterally (measured as the PASA--proximal articular set angle). Normal PASA is 0 to 8 degrees. PASA greater than that generally requires an osteotomy at the first metatarsal head to re-align the cartilage.

All proximal osteotomies involve 6 to 8 weeks of non-weight bearing after surgery so recovery periods for that category of procedure is at least 3 months. Proximal osteotomies are generally indicated when the angle between the first and second metatarsals exceeds 16 to 17 degrees.
One way around this is to do a 'mid-shaft' procedure such as the Scarf procedure or a 'long arm' Austin--especially effective when the first metatarsal shaft is relatively wide.

In a nutshell, there is a set of critieria commonly used in the decision making process. It is much easier to explain with drawings than in writing so your surgeon should take the time to do so. It is less complicated than it sounds and will come together well when shown graphically.

One resource for referrals and info. is http://www.acfas.org
Ed

Re: Should I have surgery?

Ed Davis, DPM on 2/20/02 at 16:06 (074419)

It sounds like you may benefit from bunion surgery but I am not sure that I would recommend the combination of procedure you listed. The proximal crescentic osteotomy can have a very long recovery period. It is critical that the congruency of the big toe joint surfaces be taken into consideration. Neither procedure addresses that aspect although it would be necessary to look at your x-rays to be sure. Consider a second opinion.
Ed

Re: Should I have surgery?

Rick on 2/20/02 at 19:39 (074437)

Thanks for reply.
Actually, I'm currently investigating whom to visit for a second opinion;

Although I'm obviously a lay person in this area, I did find helpful
a web site which explained the x-rays etc called http://www.ej.rsna.org

Anyway, appartently my joint is not congrous but I suspect
between the deviated and subluxed classification. I gather
only the congrous category would be a contraindication for
the Silver or McBride procedure.

Question
1. On average how long is the recovery for the proximal crescentic
osteotomy ? and
2. Isn't there some guidelines for the lay person outling when
the procedure should be done or is the answer best found
by obtaining a second opinion? It would be nice if both existed

Thanks again for your reply, I appreciated it

Re: Should I have surgery?

Ed Davis, DPM on 2/20/02 at 21:54 (074449)

I was not able to link to the site listed.

The cartilage on the first metatarsal head, in longstanding bunion deformities adapts by gradually deviating laterally (measured as the PASA--proximal articular set angle). Normal PASA is 0 to 8 degrees. PASA greater than that generally requires an osteotomy at the first metatarsal head to re-align the cartilage.

All proximal osteotomies involve 6 to 8 weeks of non-weight bearing after surgery so recovery periods for that category of procedure is at least 3 months. Proximal osteotomies are generally indicated when the angle between the first and second metatarsals exceeds 16 to 17 degrees.
One way around this is to do a 'mid-shaft' procedure such as the Scarf procedure or a 'long arm' Austin--especially effective when the first metatarsal shaft is relatively wide.

In a nutshell, there is a set of critieria commonly used in the decision making process. It is much easier to explain with drawings than in writing so your surgeon should take the time to do so. It is less complicated than it sounds and will come together well when shown graphically.

One resource for referrals and info. is http://www.acfas.org
Ed