CORRECTING A RECURRENT BUNION
Mrs. P is a 58 year old female presenting with a painful large recurring bunion where the great toe is under the bent 2nd toe of her left foot. She has pain in all shoe gear, even in sneakers due to rubbing of the shoe on the top of the 2nd toe and the protruding bone of the “bunion bump”. She had bunion surgery 5 years ago by another foot doctor and states that the bunion quickly reappeared and got worse over the last 2 years.
Examination reveals that Mrs. P had a very flexible flatfoot that completely flattened when she stood up. Her bunion was very large and looked worse with weight bearing. The 2nd toe was sitting on the great toe and there was a callus under the ball of her foot.
X-rays revealed a very large bunion which was originally fixed with a cut in the bone near the big toe joint (Austin Bunionectomy). The 2nd toe was long and bent. The space between the 1st and 2nd metatarsals was very large and not corrected at the first surgery.
Treatment – The first surgery did not address the flexibility of her foot and did not close down the space between the metatarsals enough. Therefore, I performed a redo surgery consisting of a Lapidus bunionectomy. This procedure fuses the metatarsal and the next bone further back on the foot, (the cuneiform) together in a straightened position. It is the procedure of choice for a very flexible flatfoot and hypermobile first ray. It stabilizes the movement without restricting motion of the big toe. The second metatarsal was shortened and the 2nd hammertoe was corrected. She was 8 weeks in a cast and used a knee scooter to get around. She had a realigned, straight foot and was comfortable walking in her sneakers in 10 weeks post-op.
Important note: There is no short-cut for a severe bunion deformity. A more complex procedure with a longer healing time is needed to correct this type of bunion. It is extremely important for the surgeon to choose the correct procedure to help prevent a poor result and/or recurrences of deformity and to significantly reduce the need for a second surgery.
MISDIAGNOSED ANKLE SPRAIN WAS REALLY A DISLOCATED FOOT
A 25 year old female presented to the emergency room with a swollen painful left foot after twisting her ankle. X-rays of her ankle were taken at the ER and since no fracture was seen she was sent home with an ankle wrap and told to follow up with a podiatrist.
Examination at my office revealed significant swelling of her ankle and foot compared to the opposite side. She was tender at the ankle but extremely painful across her foot. New X-rays were taken of both feet to look for subtle dislocations of the small joints across the top of her mid-foot. A LisFranc’s Fracture-dislocation was noted with a slight separation of the 1st and 2nd metatarsal bases in the middle of her foot.
There was a shift of the remainder of the lesser metatarsals in the same direction.
A CAT scan was ordered which showed small fractures to the 2nd metatarsal base not seen on x-ray.
Treatment required surgical realignment of LisFranc’s Joint with repositioning of the tendon caught in between the displaced bones. The patient went on to heal well after immobilization to allow the fractures and torn ligaments to heal.
Important note: Any time a patient sprains their ankle, ankle and foot x-rays are imperative to prevent missing a foot fracture that would otherwise be missed. Comparing both feet is usually necessary to help prevent missing subtle dislocations. If missed, this could lead to permanent damage and pain.
HEEL PAIN IS NOT ALWAYS PLANTAR FASCIITIS OR HEEL SPURS
Ms. M is a 45 year old who presented to the office with severe heel pain. It is only painful with weight bearing and the symptoms have been getting worse over the past week. She has been increasing her workout program including kick boxing.
Examination reveals point tenderness to the bottom of the right heel. There is a mild amount of swelling but no redness or signs of infection or puncture wound.
X-rays were taken which revealed a large spur on the bottom of the heel bone (calcaneus) which had broken off from the main bone.
Treatment consisted of placing her in a weight bearing cast for 4 weeks to heal the fracture. She was pain free after the 4 weeks and was then sent to physical therapy to stretch her calves. I also placed her in custom arch supports (orthotics) to prevent further pulling of the ligament attached to the spur ( plantar fascia). This will help reduce the risk for further inflammation and spur growth.
Important note: All heel pain should be evaluated by X-rays to avoid missing a fracture, cyst or tumor. Suspected soft tissue injuries should be evaluated by MRI only if they do not respond to conservative treatment.
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“I highly recommend Dr. Robyn Joseph’s practice. She is a wonderfully skilled doctor with a great bedside manner. I found her to be very caring with an honest concern in her patients health and needs. She went over my medical situation in total detail with my husband and I. She explained some negatives that might occur with my operation, so I was fully prepared. The operation was a success and I am very happy with the outcome. Her aftercare was excellent. I also need to compliment her support staff, who are all wonderful, friendly and helpful. This is a very well run practice. I even told my internist to keep sending patients to her.”