Hi! I’m Dr. Randale Sechrest, your host for eOrthopod.tv.
Recently I had the opportunity to interview Dr. Neal Blitz. Dr. Blitz is a foot surgeon, a reconstructive foot surgeon in New York. He holds the position of Chief of Foot Surgery at Bronx-Lebanon Hospital in New York. Dr. Blitz also maintains a private practice at 56th and Park Avenue in Manhattan.
Dr. Blitz did his training at Swedish Hospital in Seattle, Washington and from there an after orthopedic fellowship in Dresden, Germany. Dr. Blitz has authored many peer review articles as well as contributed to the Huffington Post on Foot Health.
Join with me now while we discuss bunion surgery with Dr. Blitz.
DR. SECHREST: When they show up in your office on the first visit, how are you going to evaluate that person?
DR. BLITZ: For the most part on the first visit when somebody comes in for bunion surgery, we evaluate them in a few ways.
The first thing we do, of course, is we look at their overall structure of their foot and just the general appearance. The second thing that we look at is how the foot functions. So, I would do a physical examination, check the mobility of the foot, and check the size of the bunion and the quality of the range of motion of the big toe joint. The third thing we do is we get x-rays to look the structure of the foot on the inside.
DR. SECHREST: We have a good idea of what causes bunions in this day and age. Is this something that is developmental, genetic, something that is coming from shoe wear? What leads to a bunion?
DR. BLITZ: There are several causes of bunions. Most commonly people think that bunions are genetic and that is true. If your grandmother had a bunion, there is a good chance that you could inherit a bunion. There is some sort of genetic predilection or predisposition to developing bunions but it’s not 100 percent.
Shoe gear is another thing that causes bunions, which is why we see a lot more bunions in women. Women tend to wear more high heeled-shoes, which sort of flattens out the foot, increases instability in the foot in general and also the pointy-toed shoes on the foot also causes bunions. Think of the foot as a piece of clay, where the pointy-toed shoes really sort of starts modeling the shape of the foot or the big toe to sort of push over towards the other toes. That, in and of itself, will cause a bunion.
DR. SECHREST: Let’s talk a little bit about shoe wear. Is there any ideal shoe that you would recommend that people should wear to prevent bunions?
DR. BLITZ: As far as show gear goes to prevent bunions there really is no ideal shoe. What I usually tell my patients is you want to sort of prevent the progression of a bunion. With that, you want to avoid shoes that we know can contribute to a bunion such as high heels and really pointy-toed shoes.
The other thing that I recommend to women very concerned about being stylish and protecting their feet is to limit their time wearing high heeled shoes. A popular thing to do is to wear your high heels at work or at a function and then put other shoes on or your more sensible shoes on in your travel plans such as walking, taking the subway or driving. That’s important.
As far as an ideal shoe, I do recommend you want a shoe with some real structure to it and some stability. You want shoes with a wide toe box. You don’t want a shoe in general that you could just sort of fold up into a ball because that doesn’t really offer a lot of structure to somebody with a bunion.
I’m going to take the other side of that too and say that it’s probably a good idea to also go barefooted at times. A lot of foot doctors will tell you don’t do that. But, I’m a big believer of actually getting the muscles of the foot to work. You don’t want the muscles of the foot to become completely inactive or dependent. If you’re barefoot that actually causes the muscles in the foot to work a little bit more so it is a good idea to do that too but you don’t want to live barefoot and you don’t want to live in a high heel shoe.
DR. SECHREST: Let’s talk a little bit more about evaluation of the foot. Do you recommend any special test on that first visit? I’m assuming you get x-rays on the first visit, but what about any special test like an MRI scan and CT scan? Any of those things necessary?
DR. BLITZ: On your first evaluation when seeing a doctor for a bunion the most common thing we get is an x-ray. That’s all you pretty much need. You don’t need to have a special test like an MRI or a CT scan or a bone scan. Every now and again if the surgeon or your doctor thinks there is something greater going on in your foot you may get an MRI; but, usually that is not the case and not necessary. A simple standing x-ray is all you need.
DR. SECHREST: Let’s talk a little bit about early treatment for bunions. When you see this person, you’ve done your assessment, you’ve done the necessary tests and you’re pretty convinced you know what’s going on. How are you going to start in terms of treatment recommendations with that patient?
DR. BLITZ: The treatment for bunions typically is divided into surgical options and non-surgical options. We typically start with the non-surgical things first.
When we are talking about non-surgical options, the first thing that comes to mind is oral anti-inflammatories such as over-the-counter Motrin and even prescription Motrin when the bunion itself is very inflamed.
Other simple things that I try to do are things that patient can pick-up in the drug store pharmacy such over-the-counter arch supports that gives some structure to the foot to see if that doesn’t help to alleviate some of the symptoms.
Another thing that we try is pads on the bunion and that can really help out a lot, especially if women are getting a lot of irritation or men are getting a lot of irritation from shoe gear although it is more common in women and simple pads like Moleskin work really good.
Another thing that we try is spacers between the first and second toes. There are silicone spacers you can put right between those toes and that hold the toes apart. That does a really good job of alleviating some of the pressure at the big toe joint, especially if you have more big toe joint pain from your bunion.
A third thing that we can do which is a little more invasive is sometimes your doctor can give you injections around the big toe joint if it is really inflamed and red. That decreases what is called a bursa that is an inflamed area.
Those are pretty much the non-surgical treatment for bunions.
Every now and again we can try physical therapy and that is really good if the muscles of the foot are weak but for the most part the non-surgical options involve anti-inflammatories, arch supports, change in shoe gear, activity modifications and simple shoe gear modifications such as padding and splints.
DR. SECHREST: How do you know when this fails? When patients come back and they say I’m not satisfied that we’re making progress with non-operative treatment, what leads you to have the discussion about surgical options?
DR. BLITZ: Patients usually lead the discussion for surgery. For the most part they will have tried some amount of non-surgical options such as padding, shoe gear changes, some lifestyle activity changes and then they get to a point that they say that they have tried all these things and I’m thinking about surgery. What are my options?
More often than not, at least it is not my common practice to tell patients you need bunion surgery because you’ve got a bunion. That doesn’t really happen too often.
Usually it’s the patient bringing on the discussion.
DR. SECHREST: When you start having that discussion, what are the sorts of things that you begin to talk with patients about in terms of the surgical options?
DR. BLITZ: Let’s talk about bunion surgery. The first thing that a surgeon needs to do is evaluate the foot to figure out exactly how big the bunion is. Bunions are divided into small, medium and large.
The surgery for a small bunion is very different than the surgery for a large bunion. The recovery for a small bunion is also quite different than the surgery for a large bunion and that has changed quite a bit today and we will talk about that a little bit more.
For the most part, surgery involves shaving down a little bit of the bone at the big toe joint. There sometimes is a little bit of extra bone there so that is shaved off. But that is not the bulk of the procedure. The bulk of bunion surgery comes from just how the bone and how the joint is recreated and put into a proper, better position.
When you have a small bunion a surgeon will go ahead and do a special bone cut near the big toe joint to move over just the top part of the bone and realign the big toe. Also realign just the top part of the bone. The surgeon is not actually fixing the entire deviated bone.
When you have a large bunion the surgery is a little different. You actually have to go a little further back on the bone and you have to swing the entire bone back into the right position or the correct position. You also do some work at the big toe joint as well to fix some soft tissue stuff that goes on there. But at the back part of the bone, there is a bone mending procedure called lapidus bunionectomy, which is a bone fusion and that’s done to hold the bone in place and that’s more of a structural realignment of the foot.
DR. SECHREST: I’m aware that you have actually created a new procedure or at least a modification of the lapidus procedure that I think you term the bunionplasty. Can you explain a little bit about that?
DR. BLITZ: In general, while there are over 150 operations that have been described for bunion surgery, surgeons really just use a handful of procedures today. Again, it’s either a bone cut near the big toe joint, sometimes the bone cut involves that entire bone and the third way is to do a bone mending procedure called lapidus bunionectomy to swing the entire bone back into the proper position.
I want to talk to you about a bunionplasty. A bunionplasty is a plastic surgery approach to bunion surgery. What does that really mean? It means that we take specific care or specific attention to the cosmetic aspect or the cosmetic outcome of the procedure. We still accomplish the same bone work that needs to be done but we do it in such a way that we have an improved cosmetic outcome.
This is done three ways: minimal incision, plastic surgery techniques where we minimize the scarring and the third way is called hidden incision.
The hidden incision is a type of bunionplasty where the incision is no longer put on the top of the foot, it is put on the inside of the foot hidden along the border of the foot. Surgeons have been doing that for quite some time but they have been doing it for the small bunions, not so much for the large bunions.
Now, with the use of internal fixation devices and modern techniques that happen on the inside of the bones, surgeons can do the bone work from the side so it makes their life easier but it actually makes the ability to do this bunionplasty or this hidden incision from the inside with larger bunions.
Again, a bunionplasty is a plastic surgery approach for bunions.
DR. SECHREST: Are you finding that some of the benefits are earlier mobilization? Do you get over this operation better or is it just more cosmetic?
DR. BLITZ: As far as the recovery goes after bunion surgery with bunionplasty, it’s pretty much divided into walking right away or not walking right away.
The old techniques involve cast and crutches, which is not the case any more. Pretty much the school of thought has been that if you had a mild bunion you were able to walk right away in a small surgical shoe. If you have a larger bunion and surgeons had to do more bone work you had to be put in a cast with crutches for 6-8 weeks.
Nowadays, with these specialized techniques, surgeons can get the patient moving a lot quicker than they used to.
I have been a pioneer in bunion surgery for the last 10 years and actually have been involved in the development of certain medical instrumentation and implants to hold the bone steady during the healing process and with the use of this; I’m able to get the patients walking immediately after the surgery no matter the size of the bunion.
In my practice, the cast with crutches is pretty much gone. All patients after bunion surgery, for the most part, are walking right away in a post-operative shoe which is a small surgical shoe limited to the foot. Patients are getting around, not running around. That’s how I like to put it.
That has been a big change because bunion surgery is not what it used to be. The cast and crutches, at least in my experience, are not any more. Most patients, again, are getting around with a cane or crutch for support. The healing for bunion surgery is about 6 weeks.
DR. SECHREST: Let’s talk a little bit about the nuts and bolts of the surgery. This, I’m assuming, is something that is done as an outpatient, you don’t have to stay the night in the hospital.
DR. BLITZ: Bunion surgery is not done as an in-patient procedure; at least, not in the United States. Bunion surgery is an out-patient procedure that means you go home the same day. The anesthesia for bunion surgery is usually local with sedation and sometimes I recommend more involved anesthetics such as a general if a lot more bone work is being done. But, for the most part, it’s local with sedation with sometimes general.
DR. SECHREST: What type of anesthesia does this require? General? Local?
DR. BLITZ: The type of anesthesia used for bunion surgery is usually local with sedation. Sometimes we will use more involved anesthesia such as general but for the most part that’s reserved for when more bone work is being done.
DR. SECHREST: How long should a patient expect to be on crutches or some type of support as they leave the hospital?
DR. BLITZ: Patients leaving the hospital after bunion surgery are usually walking in a small surgical shoe. They can be given crutches and/or a cane for more support but they are usually walking with some assisted aid. The days of casting and crutches are much less common and in my practice and my experience are over for bunion surgery.
It takes six weeks for the bone to mend and patients are somewhat limited in that they are not doing too much during that time. But, they are usually able to return to work depending on their job, especially if it is a more sedentary job, within a week or two after the surgery.
It takes about, again, six weeks for the bone to mend and it’s about two months before you are back to some really good everyday activities, regular shoes and really getting around. Three months before you are running around and six months before you have forgotten you have even had the surgery.
DR. SECHREST: It’s been a fascinating discussion about bunions and your new technique called bunionplasty to actually address this deformity.
Is there anything that you think patients need to know that we haven’t discussed up to this point in the conversation?
DR. BLITZ: As far as patients are concerned, if I was a patient looking to have bunion surgery I would definitely go to the internet and at least sort of learn about bunion surgery and try to understand what techniques and procedures are available so that you are more educated.
I think the internet has changed medicine in general and you can get a lot of information.
I think it’s always a good idea to be informed. I think it’s important to get the latest and best techniques in health care in general, especially when it comes to bunion surgery. The surgery today is very different than it was I will tell you three and five years ago. Try to find somebody that is practicing to the most modern care.
DR. SECHREST: I want to thank you for discussing this with patients today. I’m sure our viewers will appreciate it. I look forward to further discussions in the future.
Thank you very much.