Bunions

Episode 7 - Bunions

Dr. Eric Chehab:Welcome to IBJI's OrthoInform, where we talk all things ortho to help you move better, live better. I'm your host, Dr. Eric Chehab. With OrthoInform, our goal is to provide you with an in-depth resource about common orthopedic procedures that we perform every day today. It's my pleasure to welcome Dr. Steven Jasonowicz, a board-certified podiatrist who will be speaking about bunions of the foot. As a brief introduction, Dr. Jasonowicz graduated from the University of Northern Michigan in Marquette, Michigan in 2010. He then attended Kent State University in Cleveland, Ohio, where he graduated with his degree in podiatric medicine. Born and raised in Barrington, Illinois, Dr. Jasonowicz returned to the Chicago area for his residency at Loyola University Medical Center. Dr. Jasonowicz provides operative and non-operative care for a myriad of foot and ankle disorders, including fracture care, Achilles tendon disorders, plantar fasciitis, mid and fore foot deformities and arthritis.

Today, we will be discussing bunions and bunion treatment. So Steve, welcome to OrthoInform and thank you for being here.

Dr. Steve Jasonowicz:
Thanks so much for having me.

Dr. Eric Chehab:
So let's get right to it– What is a bunion?

Dr. Steve Jasonowicz:
A bunion is a little bit complicated to explain sometimes, but in the simplest terms, a bunion is a bump that folks will develop right at their big toe joint.

A lot of times patients will come into clinic complaining that they've developed a painful bump at their big toe joints, and they noticed that their big toe joint at the same time will deviate towards the outside of their foot.

Dr. Eric Chehab:
Why is that a problem for so many people?

Dr. Steve Jasonowicz:
The simplest answer is pain.

Most folks will come in and say, ‘Hey, I've noticed over time that I've been developing this bump on my foot.’ It seems to be getting bigger, or it could be staying the same size, but they complained that they're having trouble and pain with it. It could be as simple as they're not able to fit into the shoes that they want to, they can't participate in the activities that they want to.

So maybe it hurts when you're running or for some folks, they just don't like the way that it looks. And they want somebody to tell them, is it something to be concerned about or not.

Dr. Eric Chehab:
So with the pain and a bunion, is it important to differentiate whether it's pain and shoes or pain with bare feet?

Dr. Steve Jasonowicz:
Definitely. Bunions are a little bit controversial in terms of what we do with them. And I think that the easiest way to think about it is we treat the patient not the x-ray. So just because you may have a large bump there, if it doesn't hurt, to me, it doesn't necessarily mean that there's a problem, right?

If you're in an area or you have a career where you don't have to wear tight shoes, or you're not particularly active, you may have a large bump that's not a problem, or it doesn't cause you any pain, whereas somebody else might have a really mild bunion, but they can't fit into the shoes that they need to wear for work.  Or they're an active athlete and they can't run because it hurts. So, it really just depends on what your lifestyle is as to whether or not it's a problem or not, and whether or not we do something about it.

Dr. Eric Chehab:
So what causes the bump that creates the bunion deformity? What is the bunion deformity?

Dr. Steve Jasonowicz:
A lot of times when people come in, they'll see this bump on their foot and they'll say, ‘Oh my God, you know, growing extra bone on the side of my foot.’ And in reality, that's not the case. There is a little bit of arthritic changes in most bunions, and it's not uncommon that you will grow a little bit of spurring around there, a little bit of bones, but technically what the bunion is, is a deviation of your first metatarsal. So the bone behind your toe in relation to the second metatarsal next to it. It's not that you have an abnormal bone per se. It's just that a normal bone is starting to drift towards the middle of your foot. And when that happens, it becomes more prominent and your big toe at the same time, will angulate laterally sort of exposing more of a joint and a bone that you normally don't see.

And because of that, it can become painful, it can rub on your shoes, and we just notice it more.

Dr. Eric Chehab:
So I have to admit, I have a pretty simplistic approach when I talk about the function of the foot with my patients. And I'll talk about the big toe side of the foot as being the area for power. And I'll talk about the little toe side of the foot, the outside of the foot is being for balance. And that the foot is like a tripod with one at the heel one under the ball of the foot towards the big toe and one under the ball at the little toe. Is that a pretty accurate description of the general function of the foot?

Dr. Steve Jasonowicz:
In simplistic terms, definitely. The foot is a really delicate structure and I think a lot of times it's undervalued and underestimated. It really is a fine balance between lots of different areas in the way that pressure is distributed in the way that we walk and a lot of times, if we throw any portion of that off in this particular conversation, in terms of a bunion if that first metatarsal starts to drift, it can definitely change the way that pressure is distributed across your foot and cause all sorts of problems– whether that's just more pain and even arthritis, it could be callusing, it can be swelling in some folks.

So it's really important that that normal kind of quote unquote tripod stays the way that it's supposed to be.

Dr. Eric Chehab:
And so how do people acquire bunion? Is it from injury or wear and tear? Is it genetic? what goes behind the formation of a bunion?

Dr. Steve Jasonowicz:
Great question. And I think the easiest answer is, I don't know, and I don't think anybody really knows– it's a pretty controversial topic and there's a lot of different thought processes on it.

And it ranges from shoe gear that can cause it, it ranges from genetics, and it ranges from biomechanics. And probably the right answer is I'm assuming some combination of all of those.

And just kind of briefly running through those, the shoe gear controversy or thought process is basically that if we're wearing shoes that are too tight in the forefoot– tends to be a little bit more common in women– that we're basically pushing our big toe over.

And when we do that, it causes the joint to almost sublux or sit in an abnormal position. And over time, the joint just adapts to that. And it kind of sticks into that position. So I definitely am a believer in that thought process and we for sure see it more commonly in women and people that are wearing tight shoes.

And I think that that does also lead us into the genetic component to it. You do notice that a lot of patients will come in and they'll say, ‘Oh yeah, you know, my mom or my grandma, she had really bad bunions too. Or I've got siblings that have bunions as well.’ And people have even done studies on that and they'll look at twins and they'll say, ‘One twin that has a bunion, does the other have a bunion as well?’

And that definitely can happen and it's more common, but then there's also the thought process: ‘Well, you know, maybe were those folks raised in the same environment? Do they wear the same type of shoes? Do they do the same type of activities?’

So I think that's a really difficult thing to, to prove or disprove. And then along the same lines, you can also talk about biomechanics, something in our world that we see a lot is pronation or flat feet. And in the simplest terms of that, basically when somebody has a flat foot, it can change the way that pressure is distributed along your foot, and cause other joints to abnormally wear.

And there's a thought process that certain joints on the inside of your foot can become destabilized and result in this bunion deformity developing or that first metatarsal starting to drift. But again, my personal thought is that it's probably a combination of all of those.

Dr. Eric Chehab:
Yeah. Is there a gender difference in bunions? Does it happen more commonly in men than women or women than men?

Dr. Steve Jasonowicz:
I would say that it definitely is more common in women, but again, sort of an interesting topic, right? Could you make the argument that, you know, women are wearing tighter shoes and that's the reason that it's that they're showing up maybe more symptomatically or coming into clinic, where men sometimes don't necessarily care that they've got a bump on their foot.

So the cosmetic issues, aren't a huge situation for them. They can wear shoes that have a wider toe box. So that's really difficult to say, but you know, at least in my practice, it is definitely more common that women will come in complaining of bunions and ultimately ended up having surgery for bunions.

Dr. Eric Chehab:
So that's interesting. I never thought of it that way. It just might be that because man can accommodate a bunion with different shoe wear more easily than women, that it just doesn't present to you as much, sure. That there actually may not be a gender difference in the occurrence of bunions, but there is a gender difference in terms of the problematic bunion.

Dr. Steve Jasonowicz:
Sure. Yeah. I would definitely agree with that. I mean, I see a fair number of bunions in guys and the vast majority of times, it's more of an incidental thing that they're there for something else. And we'll take an x-ray and we'll say, ‘Hey, you know, did you notice that you had a big bunion?’ And a lot of times it's not necessarily a problem for them, but that that's difficult to say for sure whether or not it truly is.

Dr. Eric Chehab:
Yeah. So, let's just talk about some treatment options. You mentioned that people will come to you because they have pain or deformity or swelling in their great toe area due to the bunion. What are some of the non-operative treatment strategies for bunion deformity?

Dr. Steve Jasonowicz:
So, when somebody comes and sees me for the first time for their bunion, the first thing that I always do is get an x-ray.

So I think it's important that we sit down and we look at it and explain to the patient what's going on. And an x-ray is also important because a lot of times a bunion will also go along with arthritic changes in their big toe joints. So, if there's arthritis in there, sometimes our treatment protocol will change a little bit.

So if it's more of an arthritic problem, then it's anti-inflammatories, icing it, resting it sometimes, and just taking some time away from it can help. And if it tends to be more arthritis than actually the bunion itself, and the bump causing irritation, you might even be able to do a corticosteroid injection for those folks.

But for most people, what I tend to tell them is you got to modify your shoe gear.  If we can just take the pressure off that area, that tends to help. So, wearing a shoe that has a wider toe box. And for some folks, that can be a little bit difficult– you know, if you just go to Dick's Sporting Goods to try and find a pair of shoes, you might not have great luck with that.

You really have to find a place that's going to sit down, measure your foot, not only for the length, but the width to try and find something that's going to accommodate your deformity. And that could even be difficult if you're in the business world and you have to wear high heels or dress shoes or something like that– it definitely can take a little bit of work to find something that's going to help you.

Dr. Eric Chehab:
I got to be honest with you, I haven't been in a shoe store in probably 25 years that actually measures your foot. I feel like I'm always measuring my own foot now. And just trying to buy a pair of shoes that kind of fits. Where do you find these places?

Dr. Steve Jasonowicz:
Yeah, I'm just as guilty. I mean, I could tell you that it's probably been years since I've measured my own foot, but they're out there, you know, there's still some independent places around. And if you look, I think in the ‘foot’ world, a lot of us tend to like New Balance as a shoe. And I also do like running stores in general– they'll sit down and spend the time with you to, to measure your foot and try on different shoes and see what works for you. And another kind of simple way to think of it. As I do think you get, what you pay for in terms of shoes. If you buy a really cheap pair of shoes, you get a cheap pair of shoes. Invest some time and money and finding what works best for you.

But there's other options too. Sometimes folks will come in and say, ‘Hey, you know, I saw this thing called a bunion splint. Does that work?’ I'm not necessarily a huge believer in those and typically what they are, devices that you'll strap to your toe. Sometimes during the day, sometimes when you're sleeping, that'll hold it in a corrected position.

I think that it's unlikely that that's going to move the bone back into place, but if it holds it in a better spot and alleviates the pain again, I don't really care where the bone is or what it's doing as long as you're getting the relief that you need. And then sometimes we'll even talk about orthotics or inserts that'll go into your shoe. Again, I'm not necessarily a huge believer that that's going to change the underlying deformity, but if it alleviates some of the pain and perhaps maybe prevent the bunion from getting worse, then there's some utility in that. But it's tough when you're talking about the position of the bone.

And I tell people you’ve got to be realistic. That bunion is probably always going to be there unless you are to have surgery to correct it. But again, just because the bump is there, it doesn't necessarily mean you have to have surgery.

Dr. Eric Chehab:
Let's move to surgery. There's something that sticks with me in my training, which was, one of our foot and ankle physicians told us that about a third of patients after a bunion correction can experience pain. Is that accurate?

Dr. Steve Jasonowicz:
I don't know if I would necessarily say a third, but I would tell people that they have to have realistic expectations.  As great as we think we are, nothing that we're going to do is going to completely make this, like you were 18 years old again, when you didn't have a bunion.

You're still having surgery on it. You're still going in and messing with joints. And they're always going to be a little bit different.

And there's different options–for some folks. it could be as simple as just shaving down the bunion, and for others, it can be larger fusions and other procedures that go along with it to completely rebalance your foot.

So it's really hard to compare one person's surgery to the next, because they're just not the same. I mean, a bunion is a pretty bread and butter thing in the foot and ankle world, but there's so many different types of procedures that you can do to address it. And there's a lot of factors that go into determining what procedure is best for what patient.

[00:12:40] Dr. Eric Chehab: I guess, in that discussion, the surgeon who was talking to me was basically trying to make the argument that pain is almost a, a requirement for having a bunion correction surgery preoperatively, because there's a non-zero incidence of pain post-operatively and having a painless, crooked foot might be better for most people than a painful straight foot.

Dr. Steve Jasonowicz:
I would agree with that. I mean, I think there's always exceptions and we put things into categories where all the time you must have pain. That’s difficult to say, but in general, I would agree if you don't have pain, don't, don't get it fixed because you're probably not going to be happy with the results.

Of course, is there the one in a thousand person that may be as a businessperson, that doesn't hurt and they have to wear dress shoes for their job and you know, they're going to lose their job because they can't? I'm sure that can happen, but I would be very cautious with a situation like that.

Dr. Eric Chehab:
Okay. So let's go through the categories of bunion correction procedures. Are there other different types of procedures that you, you mentioned that earlier, for bunion correction?

Dr. Steve Jasonowicz:
Sure, sure. There's textbooks on that type of procedures that you can do, right?

Yeah, but in general, nobody is the same. And I think that everybody out there that, that does these sort of procedures probably has a handful that they do. And in my world, it really depends on what somebody is looking to get out of it, sort of how active they are, their age and how big the bunion is.

So we look at the bunion on the x-ray and depending on certain areas where they may or may not have arthritis and how large the bunion deformity is typically guides me in what my thought process is.

Now we'll always sit down with the patient and say, ‘Hey, here's the options. This is kind of my thought, and this is why I think you should have this procedure,’ but it's ultimately up to them. And I guess putting it in sort of simple terms, the most powerful procedure that I would do to fix a bunion is something called a first tarsal metatarsal joint fusion.

A lot of times people will call that a Lapidus procedure and it's sort of fallen a little bit more into favor recently. There's a few different thought processes behind it. The first, and the reason that I like to do it, is you're really correcting the deformity at the apex of it.

Dr. Eric Chehab:
So you’re correcting the deformity where it starts, which is not where the bump is, but before that before that angles off.

Dr. Steve Jasonowicz:
Yep. So you're still going in and, most of the time, shaving off the bump that's on the side of their big toe, but we're working a little bit farther back in the middle of their foot. And when you look at an x-ray, that really is where the bunion tends to come from, where that first metatarsal bone starts to drift over.

The thing with that procedure, and the reason that a lot of times people will make an argument that, that it's really well suited for a lot of folks, is that some people will claim that there's a rotational deformity in this as well. So there's a couple of little bones underneath your big toe joint called sesamoid bones. That when you look at the x-ray on certain views, you can tell that they tend to be sort of rotated out of position.

So a lot of times, if we can rotate that bone back, which we can do with this type of procedure, some folks feel that you do end up doing better. There's also the thought process too, that if you do this, the recurrence rate tends to be a little bit less. And, and I think that the easiest way to think about it is, you know with anything, the longer lever arm that you have, the more correction that you can get.

So if you're working just towards the end of the bone, where the bump is, sometimes folks that have a really big deformity, you just can't slide it over enough to get that correction. Now, the problem that we see sometimes with that fusion procedure back in the middle of your foot is that the recovery is just a little bit trickier.

You know, you're asking a joint to fuse, and a lot of times you're forced to be non-weightbearing. So it's a bit more of an undertaking and the recovery is a little bit rougher than others. So for some folks that have a more mild bunion, you can do a procedure that's more towards the joint and that can vary as well.

Typically, what we do is we cut the metatarsal bone and we slide it over, lots of different ways to do it. Lots of different shapes that you can make, these cuts and lots of different things that you can do as well to correct for rotational components of the deformity you can elevate or bring down the metatarsal, if you find that that the alignment of it is not quite right as well.

And sometimes along with those as well, we occasionally need to make a cut in the big toe itself to try and bring it over. If the correction just isn't enough and there's a lot of times adjacent procedures or additional procedures, that'll go with it.

We'll release some of the soft tissue between the first and the second metatarsal bone to try and get the alignment better as well. And for some folks, I'll also tell them if, ‘Hey, we look at your x-ray and there's a fairly decent arthritic component to this, maybe it's better that we just fuse your big toe joint, instead of trying to save it.’ It's a really a powerful procedure in fixing a lot of these problems. And if you fuse that big toe joint, there's really not a chance that your bunion can come back. But I also understand that it's not particularly something pleasant that a lot of people want to hear when they hear that word fusion that kind of scares them. So in the right person, that is definitely an option as well, but it's really something that you have to sit down with every patient and look at their x-ray and try and determine what's best for them and what they're looking to get out of it.

Dr. Eric Chehab:
So if I can summarize a bit, the bunion correction surgeries can be categorized into the fusion type procedures that are done more towards the middle of the foot–and the benefit of that is you can correct the larger deformity. You can correct rotation.

And then you can also fuse the joint, which can make it a more durable procedure over time.

Dr. Steve Jasonowicz:
I would agree with that. Yeah.

Dr. Eric Chehab:
And then the drawback is it can be a little bit more of a involved recovery, a more prolonged period of non-weight bearing or protected weightbearing.

And that would be considered a potential drawback for that type of procedure. And then you also mentioned the metatarsal slides, where you cut the bone and you correct it within the bone itself. And the benefit of that is generally an easier, more straightforward recovery, but you have limits in how much you can correct the deformity.

So not every deformity could be addressed by a slide type procedure. And with those procedures, you may have other associated soft tissue procedures, either with the fusion or with the slides, more towards the end of the toe, where you might want to tighten one side or loosen the other side to straighten out the toe.

Dr. Steve Jasonowicz:
Exactly. That was a great way to summarize it.

Dr. Eric Chehab:
Is there any prep that people need to do before surgery, any sort of special shoe wear they need to buy an advance or any special therapy that they need to buy in advance? Is that anything that you'd recommend like that

Dr. Steve Jasonowicz:
Not typically, in terms of the shoes and stuff that you're going to wear afterwards, we usually take care of all of that for you.

So if you're doing one of those procedures, that happens to be a little bit smaller and you may be able to walk on it right away, that could be as simple as a post-op shoe or a boot that's usually given to you at the hospital or the surgery center by your doctor, before the surgery.

The fusions, where you're not going to be able to walk on it, you might need crutches and things like that. Um, the thing that I would caution folks on is if you are going to be non-weightbearing, it's something that you want to practice ahead of time. Right? So for some folks, I may send them to a therapist and say, ‘Hey, is this patient safe to stay off of their foot?’

You know, for the next two weeks, four weeks, six weeks, whatever it's going to be. Because last thing you want to do is surgery on somebody and then find out that, you know, there's going to be bedridden, because they can't manage or they fall and they break a hip because they're trying to, you know, recover from their foot.

Dr. Eric Chehab:
That's a really good point. I don't think we do enough of that assessment preoperatively and people's ability to be non-weightbearing.

Dr. Steve Jasonowicz:
And I think something that other folks oftentimes don't think about is when you're talking about surgery on your right foot, what is that going to mean for you in terms of driving?

So it's a little bit of a tricky situation. And some folks feel that they can drive right away. I personally don't think that that's the safest thing. And even though there's going to be a point, maybe six weeks in where I say, ‘Hey, you can get back into a regular shoe.’ Does that mean that even though I say, ‘Hey, you can drive from my standpoint,’ that you're going to feel confident enough to slam on the brakes?

So you really have to have a good support system and be ready to manage this. Because even though it's not necessarily the largest surgery out there, it can be a little bit of a lifestyle change when you can't drive yourself to places that you need to get to.

Dr. Eric Chehab:
Yeah. And the driving and the walking and everything, I think you really start appreciating your feet when you don't have them underneath you.

Take us through the recovery. Let's start with the fusion type procedures. What's the first week look like the first month and then the first six months?

Dr. Steve Jasonowicz:
There's no one recovery that everybody goes through and every doctor has their own protocol, but just kind of summarizing briefly for me, if we were to do this Lapidus type procedure, this fusion in the middle of your foot, I typically tell folks to plan on being non-weight-bearing for two weeks.

So meaning when you wake up from surgery, you're going to have a sort of a soft cast or a splint on, and then you're going to come and see us in clinic a couple of weeks out. We're going to take your stitches out. And if things look good, then we get you one of those big ski boot looking devices and let you start putting some pressure on it.

It all depends how you're healing, right? So we're going to take x-rays along the way. And if the bone is healing, then give or take around that six week, eight week mark, depending on how you're doing is when we would probably want to start some physical therapy to get that joint moving. I think physical therapy after any of these procedures is really important because that great toe joint just becomes so scarred in.

And you want that motion, right? We're trying to save the motion in that joint. And at that time, give or take around the six, eight week mark, depending on how you're doing it might mean that we transition you to a post-op shoe, which looks like a very fancy sandal. Or sometimes just a regular athletic or gym shoe, that's got a little bit of extra room in there to accommodate that swelling. Now, just because you may be able to walk on it relatively normal at that time does not mean that you're going to be pain-free it's still going to be swollen. It's still going to ache and we're not out of the woods quite yet.

It usually is around that three to four month mark, when I think most of us are fairly confident to say, ‘Hey, this fusion is healing the way that we want it to, you can start to get back to some of those more high-impact activities,’ but with any surgery that I do, and I would think that most of my colleagues probably would say the same, that I'm really a believer that it takes about a year, to a year and a half to get to that point where I'd say, it's not going to get better, you're just not going to notice the, the improvement so quickly, you know, your, your week one to two, you're going to say, ‘Hey, it doesn't hurt quite as much as it did, but you know, month six to seven,’ you're not going to notice that much of a change, but when you go back and say, ‘yeah, you know, it was this better in the summer than it was in the spring.’ I think that's where you're going to notice that those changes.

Dr. Eric Chehab:
So if I can summarize that, the first two weeks are typically non-weightbearing. Between weeks two and six protective weight bearing with the boot. Maybe a crutches, maybe not. And then by six weeks, most people are progressing to more full weight bearing. Maybe coming out of that boot into a more normal shoe.

And then physical therapy starting at about six weeks, once you're in a position to be really able to do something and then usually by three to four months, having the door opened to doing more higher impact activities.

Dr. Steve Jasonowicz:
Yep. Assuming that you're feeling well enough to do those things. Okay.

Dr. Eric Chehab:
And what about the slide procedures? The ones where you're not correcting as large a deformity, not doing the fusion, but cutting the bone and then letting that heal

Dr. Steve Jasonowicz:
Well, so one of the reasons that I really liked the slide procedure is that you can, for the most part walk on at the same day. So for a lot of folks, we will put you in a post-op shoe and say, Hey, you can walk out of the hospital. That doesn't necessarily mean that you should go to Target and walk down every aisle on your way home. But it means you can still get up to, you know, go from the living room to the kitchen or the bathroom or whatever you have to do.

Same general protocol, where I will typically see you back in a couple of weeks, take your stitches out. If the skin looks good and then we ride it out in either that fancy shoe or that boot until you get to about six weeks again, eight weeks, assuming that the x-rays look good and things are healing the way that we want them to, then I'll typically tell, you can get into a regular shoe, a wider shoe, a gym shoe, athletic shoe, again, start your physical therapy.

And again, once you get to that three, four month mark, and I'm really confident that that bonus healing then I typically take your restrictions off and say, ‘Hey, if you feel good to do it, go for it, but expect it still the swell and still to be a little bit achey.’

Dr. Eric Chehab:
Yeah. So that slide osteotomy allows for much less complicated initial recovery, but in general, the timeline is about the same in terms of getting patients back to their athletic selves of doing more high impact activity at about three to four months.

Dr. Steve Jasonowicz:
Exactly. Yep.

Dr. Eric Chehab:
And then the improvement will occur over the course of a year, year and a half, but obviously the farther down the road you go, the more incremental that improvement will be.

And what about complications of bunion surgery? Anytime we do an operation, we're obviously doing this with the best of intentions for our patients, but sometimes, unforeseen or known complications can occur.

What are some of the common complications that can occur for bunion correction surgery?

Dr. Steve Jasonowicz:
I guess I would preface it by saying, you know, elective surgery like this, complications are rare, but they do occur and it's something that everybody has to be prepared for sort of the conversation that, that I tell folks when they come in and see me is that I tend to have a little OCD about this. And if something happens along the way and we take an x-ray and I say, ‘I just don't like the way that this is healing.’ I'm not scared to say, ‘Hey, we got to go back and fix this before it is a disaster a year down the line.’ Again, that's very rare to happen, but be prepared that something could change your course down the line, but like any surgery, the thing that we worry about probably the most is the chance of an infection, right? The chance of getting an infection with an elective foot surgery, these days is relatively low, but that's where we'd like to keep a close eye on you in clinic.

And, you know, God forbid, it looks like it's getting a little bit red, then maybe we need to put you on an antibiotic. And on the extreme end, it could mean that you have to go back and have surgery to clean things out again.

Dr. Eric Chehab:
What is that risk when you say relatively low in the single digit percentages or what?

Dr. Steve Jasonowicz:
Definitely single digits. Yeah, definitely single digits. Yeah. And the other thing that I always tell folks too, is people will get sometimes a little bit worked up over the thought of having hardware in them forever. Right. So they screws and plates and people say ‘Hey, do these need to come out?’

Typically, I like to leave them in forever. My thought is, if there's no problem with it, it's not causing you any pain or irritation. We leave it in forever, but it's not uncommon in some folks over time that screws will loosen. They can become prominent. Sometimes they can cause other issues. So, yeah. And, and a fair number of folks, years down the line, it's not unheard of that we might have to take those screws and plates out. It's also not uncommon in bunions that you can later on develop arthritis in your big toe joint. And I think that some folks don't necessarily understand that and they'll come back years later and say, ‘Hey, you know, I had this bunion fixed 10 years ago, whoever did it, didn't do a good job.  It's come back.’

And a lot of times that's not the case. It's just that you've developed another problem. Cause something that's completely different, but looks kind of the same, you know, from your eyes. On the other hand, it is possible too, that even when you do those more powerful procedures, that bunions can recur, it's a very fine balance in your foot with the way that you're walking, the muscles that are stabilizing that side of your foot and what you're doing that sort of, uh, determines whether or not this procedure holds and whether or not you develop another bunion over time.

Again, it's rare, but it's definitely something that I've seen where people have had bunions corrected. It just wasn't maybe a powerful enough procedure or for whatever reason it recurred.

Dr. Eric Chehab:
So again, just to summarize that some of the things that can happen would be number one infection.

Rare but possible, but treatable with antibiotics or maybe another surgery to wash it out.

Number two, the bones don't heal quite the way that we want them to heal either they're too slow or it's just not reacting the way that was anticipated. And so that sometimes might need to be redone, or the course of treatment might need to be extended just to allow it to heal more thoroughly and better.

Number three, the development of arthritis. That's not the bunion recurring, but more that. A secondary problem has resulted that may or may not have resulted because of the surgery is just that you're developing arthritis and wear and tear in the big toe joint. And then the fourth one is yes, sometimes these bunions do recur because some of the same mechanics that caused the bunion to happen in the first place, whether it's the wear and tear or the genetics or all these other factors, they're still there–they don't go away–could cause the bunion to recur. Exactly. In general, what is the expected longevity and prognosis after a bunion correction surgery?

Dr. Steve Jasonowicz:
In the folks that I see, the vast majority of them are very happy that they had the procedure, and it's more the exception rather than the rule that you need something else down the line.

So most people that, that have their bunion procedure, it can be a lifelong fix for this problem. Again, you just have to be sort of prepared for the unexpected. I don't think going in there and expecting that you're going to have your bunion fixed and that this may never be a problem again is realistic.

For the vast majority of people that does happen, and they're very happy with their procedure and you never have to do anything with it again. But again, it's, it's not unheard of that. You know, maybe 10, 15 years down the line, you could develop something else with it, whether it's arthritis in that joint, sometimes us going in there and messing with the alignment of that bone can result in callouses that will develop at other spots in your foot or even just kind of changing the overall biomechanics of your foot that can result in lots of different issues, arthritis in the middle of your foot, changes in the way that you walk, or sometimes the inability to do some of the activities that you did before. But again, the vast majority of people that have bunions are very happy afterwards. And I think we'll come in and say, ‘why didn't I do this sooner?’

Dr. Eric Chehab:
After bunion correction surgery, how do you approach the pain management? Because a lot of patients, obviously with any surgery can be intimidated by pain. So how do you manage pain after bunion surgery?

Dr. Steve Jasonowicz:
Everybody's a little bit different. And some folks that I see are really nervous about the pain and other folks will say, ‘Hey, you know, I've had lots of different surgeries. I don't need any pain medication. I'm just going to tough this out.’

But in general, the way that I do this with the bigger procedures that involve more of the middle of your foot, I'll have the anesthesiologists do a block, so they'll make your leg nice and numb during the surgery. The nice part about that is usually get about 24 hours of pain relief, but it's important as those blocks wear off.

And even if we do a procedure a little bit farther down in your toes, we'll still numb it up just in a little bit of a different way that you take your pain medication that we prescribe you after surgery. I think you want to try and stay ahead of it rather than chase the pain. And if you get a couple of days into it and say, ‘Hey, it's not that bad,’ and you want to switch to over the counter Tylenol or Advil, that's totally fine. Everybody's a little bit different. It's not uncommon that I see people will come in a few days after their surgery. And they say, ‘Hey, I'm not taking that prescription pain medication anymore.’ And then like anything, there's some folks that have a little bit of a harder time managing their pain.

We have to have realistic expectations that it is surgery. It does involve the bone. There's going to be some pain and discomfort, and we're not trying to get rid of all the pain. We're just trying to make it manageable. But for most folks, it's not a huge ordeal. And within a couple of weeks, I would say the vast majority of people should be off of the prescription pain medication and be able to manage it with something over the counter.

Yeah. Now if you're on it and walking around, that's a little bit of a different situation. Sometimes those folks will have some more issues, but for the vast majority of people within a couple of weeks, they're doing okay

Dr. Eric Chehab:
And some of the nonpharmacologic treatments for the discomfort…

Dr. Steve Jasonowicz:
Yeah. I'm a big believer in, you know, rest it, elevate it, put it up, put some ice on there.

Sometimes that's a little bit more difficult when you've got a big dressing on there. What I usually tell folks is you can put a bag of ice behind your knee. There's arteries that go back there and we can cool the blood down as it goes down to your foot. The more you keep it up, the better the swelling is controlled.

The less swelling there is, usually there's less throbbing and there's less pain associated with it. So there definitely are things that you can do. And by no means, are you going to be stuck on the prescription pain medications that we give you afterwards.

Dr. Eric Chehab:
Does movement help wiggling the toes?

Dr. Steve Jasonowicz:
Yeah, so that that's a little bit of a tricky thing we, we do in theory, kind of want you to move things a little bit in the joints so that they don't become adhered and sort of scarred down.

But at the same time, when we're trying to get a fusion or we're moving those bones around and we're cutting them, we do just need them to be still. So I typically don't encourage patients to sit there and try and move things. I leave that up to the physical therapist when you get to that point to stretch it out for me.

Dr. Eric Chehab: So any other items that you'd like to share with us about bunion correction?

Dr. Steve Jasonowicz: Most people are very happy with this, but I think that you have to go into it understanding that it's going to take a long time to heal.

It's a process. And within a matter of months, most people feel pretty good and are relatively back to normal, but you have to be willing to go through the recovery process. And if you're not willing to take those months and the time off of your foot, if it's needed, those are sometimes the folks that don't have the most ideal outcomes.

And foot surgery can be a little bit tricky. A lot of times I'll see folks coming in, they'll say, ‘Hey, you know, my neighbor just had their knee replaced or their hip replaced. And they were up walking it hours after surgery.’ And I say, this is not the same situation here. Your foot is different. It's going to swell. It's going to be painful. And these are tiny little joints that we're trying to get to heal and, and very particular spots.

So it can be really delicate and everybody's course is different. I always tell folks, don't get scared. If you see somebody out there who says, ‘Hey, I had my bunion fixed and it didn't necessarily work,’ or they had a bad outcome, not everybody's bunion is the same. And what you really need to do is go and get an x-ray talk to somebody who does these sort of procedures and see what your options are because their problem might have been totally different than yours.

And again, the vast majority of people that have bunions are really happy with it and would say, ‘why didn't I do this sooner?’

Dr. Eric Chehab:
My guest is Dr. Steven Jasonowicz. Thank you so much for shedding light on bunion, correction and bunion deformity. This has been very helpful for many of our patients, and I really appreciate your taking the time to be with us.

Dr. Steve Jasonowicz:
Happy to be here. Thanks for having me.