Hai-En Peng, DPM - Podiatrist, Foot/Ankle Surgeon, Southern California, Thousand Oaks

NEW ADVICE ON TOE-JOINT DISORDERS

(Thousand Oaks, CA, 2004) -- Whether or not to consider foot surgery for conditions affecting the joint at the base of the big toe, including bunions and arthritis is a difficult decision.

However, according to Hai-En Peng, DPM, new clinical practice guidelines developed by a panel of leading experts on forefoot conditions from the American College of Foot and Ankle Surgeons offer some help. They provide options for physicians and patients to consider when assessing the benefits and risks of various treatments and also for determining the type of surgical procedure that is most appropriate based on age, lifestyle and severity of the condition.

At the base of the big toe is the first metatarsophalangeal joint (1st MTP). It is the most complex joint of the foot, where bones, tendons and ligaments work together to transmit and distribute the body's weight, especially during movement.

"If the joint is painful and interferes with walking, physical activities and regular exercise, non-operative treatments should be considered first," said Peng.

Dr. Peng added that bunions are the 1st MTP joint disorder most frequently treated by podiatric foot and ankle surgeons and that first-line treatment involves educating patients about the condition and evaluating their footwear. "At first, we recommend that patients to wear wider, low-heeled shoes, use bunion pads, apply ice and take over-the-counter analgesic medications. These options are designed to relieve pain and make it easier to walk and engage in physical activities, but they do not address the underlying cause of bunions," said Peng.

Contrary to popular belief, bunions are aggravated, not caused, by shoes. Bunions usually occur from inherited faulty biomechanics that put abnormal stress on the 1st MTP joint.

"Various non-surgical approaches can help prevent aggravation of bunions and other MTP-related problems, and for many patients that might be enough to keep them active and on their feet," said Peng. "Bunions, however, are progressive, so if non-operative treatments bring little or no symptomatic improvement, surgical intervention should be considered. If the initial evaluation and treatment were performed by a primary care physician, the patient should be referred to a podiatric foot and ankle surgeon," he added.

Surgical options depend on severity and lifestyle

Different surgical techniques are used at the discretion of the surgeon to achieve the desired correction. Determining which procedure is most appropriate for specific patients involves consideration of several factors, such as bunion severity, age, possible onset of arthritis and the desired level of physical activity a patient wants to achieve following surgery.

"Patients with a moderate to severe bunion should discuss the anticipated outcomes of various procedures with the surgeon to make sure they select the most appropriate option. For example, the lifestyle of someone involved in competitive sports differs from an elderly patient who simply wants to walk without pain," said Peng.

Less severe or Stage 1 bunions may not show significant protrusion, and surgery is performed to repair tendons and other soft tissue and remove a small amount of bone. Procedures to correct more severe bunions (Stage 2) involve removal of the bump or minor realignment of the big toe joint. Stage 3 bunions usually are very severe and disabling. Surgery in these cases consists of extensive joint realignment, reconstruction, implants or joint replacement.

Other 1st MTP joint disorders

First MTP-related problems also occur from repetitive trauma to the area and from the ravages of arthritis. Dr. Peng said that, over time, avid tennis players and golfers put continuous stress on the 1st MTP joint that eventually can wear out the cartilage and lead to the onset of arthritis. This condition, known as hallux rigidus, causes loss of movement and pain in the joint.

"Those who experience pain in the joint without evidence of protrusion symptomatic of a bunion should consider it a warning sign that the joint has been traumatized and they are advised to have it evaluated and treated before arthritis sets in," said Peng. "In most situations, non-operative treatments can be prescribed to provide relief, but others with advanced cases might need surgery, especially when the protective covering of cartilage deteriorates, leaving the joint damaged and with decreased range of motion."

Dr. Hai-En Peng has practiced in Thousand Oaks for 1-2 years and is located at 415 E Rolling Oaks Dr., Suite 210.