Wednesday, December 12, 2018

Bunions and hallux valgus: To operate or not?

When ladies complain of sore feet, they usually have a bunion or hallux valgus, or both. So what is the difference?

Hallux means big toe and valgus describes an anatomical position, where the big toe is tilted and faces the smaller toes on the same foot. The forefoot looks like an arrowhead.

Bunions describe an inflamed bursa or bursitis. Bunions often are found over the big toe joint. A bursa is a fluid filled sack which naturally protects the joint beneath from shearing stress. When the skin rubs against tight ill fitting shoes a bursitis or bunion may form.

For perfectly good anatomical reasons females prefer tighter fitting shoes and whilst hallux valgus is common to both sexes women are more prone to suffer from bunions due to internal sheer and friction between the shoe lining and the skin.

There are more than 150 operations for hallux valgus and one critic of forefoot surgery was Hans Rudolph Mayer, a Swiss medic. He believed many surgical procedures had been designed by men principally to alter the female foot not for functional reasons. but instead to fit stereotypical female shaped shoes. He called this the Cinderella Principle. Meyer believed the practice was still common among orthopaedic surgeons despite more female surgeons and improved procedures.

In the early nineties a small number of patients with hallux valgus surgery were followed up . In the study they measured patient's attitudes to the after affects of the operation and combined this with real life measurements of the forefoot. Eighty (80%) of the subjects declared they were satisfied with the outcome of their operations but almost 90% presented with a significant reoccurrence of hallux deviation (of the original condition). Most respondents cited satisfaction as being able to wear "decent shoes again". Ironically the term ‘decent’ here refers to tighter fitting court shoes.

Surgeons involved in orthopaedic care of the forefoot determine their therapeutic management and outcomes on six main criteria: pain, pathology, age, profession, expectations and choice of method. A painful foot is no reason to consider surgery alone and the professionals will attempt to avoid invasive techniques if necessary. Depending on the pathology and other circumstances will influence the decision to operate or not. Age is extremely important and in younger individuals the goal is a good long-term cosmetic result, whereas freedom from pain with enhanced mobility are common objectives in older people. Occupational and professional demands as well as social obligations are always taken into consideration. Aesthetic preconceptions especially in elective care need to be clearly talked through (informed consent). If the surgeon encourages unrealistic wishes, the patient maybe unhappy even with a surgically satisfactory outcome. Although as witnessed by the hallux valgus study, even when a less than perfect surgical outcome results the patient may well consider the procedure successful because they can wear fashionable shoes again. When surgery is chosen, the physician and patient should agree to whether the surgical process is reconstructive, resection based or for the purpose of stabilisation. Sometimes it is possible to combine these techniques.


In Walt Disney’s version of Cinderella the glass slipper was broken by the grotesque ugly sister. However in the original version of the fairytale, Cinderella's shoes was not make of glass but from fur and the wicked mother cut her daughters feet in order to fit the shoe.

Reviewed 12/12/2018

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