1, bunion, commonly known as bigfoot, is the most common foot deformity. According to foreign statistics, the prevalence of bunion is 3% in people aged 15-30, 9% in people aged 31-60, and 16% in people older than 60. The bunion deformity is mainly manifested by the lateral tilt of the bunion and the inversion of the first metatarsal.
The angle between the two metatarsals increases, the metatarsophalangeal joint is semi-dislocated, and the first metatarsal head forms a bone superfluity on the inner side of the foot. After long-term friction from shoes, the local skin will thicken and become red and inflamed in severe cases, forming a “bunion”. When the bunion is severe, the second toe can be squeezed to the dorsal side by the bunion, forming a hammer finger. At the same time, due to the outward shift of the main weight-bearing area of the forefoot.
2, three metatarsal head weight-bearing increase, the formation of plantar callus over time, accompanied by pain, that is, the so-called “metastatic metatarsalgia”. In addition, the presence of the bunion deformity increases the stress load on the lateral metatarsal bones and makes the trabecular structures susceptible to cumulative stress, which can cause fatigue fractures of the lateral metatarsals due to excessive concentration of stress. Bunion patients have limited dorsiflexion of the bunion, and the body compensates for this by adjusting the activities of other parts during walking, which in turn often leads to lesions of the knee and lumbar spine, seriously affecting health. Therefore, we need to pay attention to the bunion deformity and severe bunions require the necessary surgical intervention to restore the normal foot biomechanics. A good surgical procedure not only relieves pain, but also restores as much normal foot shape as possible, thus bringing function and aesthetics into harmony.
Etiology of bunions.
Bunion deformities are mostly seen in women, with a male to female ratio of about 1:40. There are many causes of bunions, about half of which are related to genetic factors, and the prevalence of children of mothers with bunions increases significantly. Since women have weaker ligaments in their feet than men, they are more likely to develop bunions under the same genetic conditions. In addition, the flexibility of the ligaments decreases with age, which is why bunions are more common in middle-aged and older women.
Other common causes of bunions are.
1. Shoe wearing habits. Women often wear high-heeled shoes, pointed shoes, the whole body weight is easily concentrated in the front of the foot, pointed shoes often force the forefoot forced squeezed in a narrow triangular area, making the toes in a long-term abnormal state, in the long run will gradually form bunion deformity.
2, the bunion, the first metatarsal, the medial cuneiform bone where the first metatarsal column increased mobility.
3. Abnormal foot structure. The common one is flat foot, and other structural abnormalities include over-length of the first metatarsal, inversion of the first metatarsal, and bunion rotation front deformity, etc.
4, joint inflammation. Rheumatoid arthritis, gout and other pathologies often destroy the normal balance structure of the soft tissues and bone joints of the foot, resulting in bunion deformity by the combined effect of various internal and external factors.
5.Other. Trauma, cerebral palsy and other causes of neuromuscular lesions often cause imbalance in the soft tissue muscles of the foot, especially the first metatarsophalangeal joint, which can also produce bunions.
Clinical manifestations of bunions: Pain is the main symptom of bunions, and the presence of bunion deformity and painful medial bunions of the first metatarsophalangeal joint are the main clinical manifestations. However, the degree of deformity is not directly proportional to the pain, and pain is not necessarily present when the deformity is obvious. In addition to pain caused by bunions, other signs such as hammertoes of the second and third toes and plantar callus are also important in producing painful symptoms. The x-ray presentation varies with the severity of the disease.
Pain.
1, pain caused by bunions
2.Pain caused by hammertoe
3.Pain caused by plantar callus
4, pain caused by stress concentration in the lateral metatarsal bones
5 pain caused by postural substitution in the knee, hip and lumbosacral region.
Deformity: bunion, inversion of the first metatarsal, medial bones of the first metatarsophalangeal joint, hammertoe of the second and third toes, etc.
X-ray: the first metatarsophalangeal joint is semi-dislocated, the bunion is displaced to the midline, the bunion angle is >15 degrees, and the angle between the first and second metatarsals is >10 degrees as the basic manifestation.
According to the clinical manifestations and X-ray changes, the development of bunion can be divided into three stages.
1.Early stage: mild symptoms, pain is not serious, no subluxation of the first metatarsophalangeal joint on X-ray.
2.Middle stage: the bunion deformity is obvious, the bunion pain is more severe, and the x-ray shows the bunion proximal joint is semi-dislocated to the lateral side and the second toe hammer-shaped deformity.
3.Late stage: In addition to the bunion pain, the metatarsophalangeal joint is swollen and painful, and osteoarthritis is seen in the metatarsophalangeal joint on X-ray.
Treatment of bunion: divided into conservative treatment and surgical treatment.
Conservative treatment: Only applicable to early stage patients.
1. Non-specific treatment.
Rest, reduced activity, and wearing loose shoes can reduce pain. Topical drugs such as fotarine can be applied locally when pain is present, or non-steroidal anti-inflammatory and analgesic drugs such as Cilazol can be taken orally. Hot compresses and physical therapy are also effective. Sometimes local closure of the painful area is also possible. However, most conservative treatments are symptomatic but not causative, and cannot fundamentally relieve pain, and are prone to relapse after a period of time.
2.Wearing orthopedic brace.
There are many different types of braces to correct bunions, and different types and degrees of bunions need to be matched with different types of braces. Usually, the brace is worn at night for 8 hours a day for 3 months, which can reduce the painful symptoms to some extent and slow down the development of further deformation of the bunion.
Surgery: Once a bunion causes persistent pain or severe deformity, surgery is required. Surgery can reduce the pain and correct the deformity to improve the function of the foot. Purpose of surgery: The primary purpose is to relieve pain.
Treatment goals.
1. correction of the bunion deformity.
2.Removal of hyperplastic bones and bursa.
3.correction of the first metatarsal inversion and repositioning of the seed bone system.
4.Adjustment of metatarsal head weight-bearing and correction of combined deformities (callus, hammertoe, etc.).
5.Stabilize the first metatarsal row
Surgical treatment itself is less traumatic, and surgery can be considered for those with severe pain.
There are many surgical methods, and the appropriate method should be chosen according to the degree of deformity. In addition, the surgery is very skillful, such as the operation is not fine will affect the overall efficacy, and then the equipment used for surgery should also be fine, because the skin of the foot is thin, it is generally recommended to use imported small plates and screws, some domestic plates and screws are too big and too thick, which will affect the efficacy of the surgery. Therefore, it is important to choose an experienced surgeon. The following are some specific surgical methods introduced.
1.Soft tissue surgery
This type of surgery aims to correct the bunion angle (HVA) and is represented by the McBride surgery and has been modified by several scholars. The main components of the surgery are the severance of the contracted bunion muscle at the end of the lateral base of the bunion, resection of the medial tuberosity of the first metatarsal, lateral release of the bunion capsule, and medial tightening. The efficacy of this procedure alone is more certain in mild bunions without enlargement of the first and second intermetatarsal angles (IMA). For bunions with significant IMA enlargement, this procedure usually needs to be combined with other osteotomies.
2.Osteotomy
Bunion osteotomy: Used to correct bunions with interphalangeal joint.
First metatarsal neck osteotomy: There are more of these surgical methods, mainly Austin and Mitchell, and they have been repeatedly modified. The purpose of the procedure varies slightly from procedure to procedure and is primarily to correct excessive valgus of the IMA and the first metatarsal head. This type of surgery has good results for mild to moderate bunions. However, in cases where the deformity of the first metatarsal is more pronounced, this type of surgery cannot achieve perfect orthosis.
First metatarsal base osteotomy: In cases with significant IMA enlargement, the first metatarsal base osteotomy can effectively correct IMA, and can also correct the elevation and internal rotation deformity of the first metatarsal by rotating back and depressing the metatarsal head, which can effectively restore the shape of the transverse arch of the foot. There are various methods of first metatarsal osteotomy, such as “V” (chevron) osteotomy, transverse osteotomy and curved osteotomy. However, in cases where the joint surface of the first metatarsal head is obviously turned out, only the correction of the first metatarsal inversion can increase the joint surface of the first metatarsal head turned out, and the first metatarsal neck osteotomy can be added at this time.
3.Medial osteotomy of the first metatarsal head
The Mayo procedure is the preferred procedure for bunion cases that only show inflammation of the bunion.
4.Joint fusion
First metatarsophalangeal joint fusion: it can be considered for severe joint lesions and joint instability. clutton believes that metatarsophalangeal joint fusion in a good position is a permanently satisfactory treatment and emphasizes the importance of internal fixation. it is generally believed that a good joint fusion must be.
1, have good cancellous bone contact surfaces.
2, The bunion is fixed in a functional position.
3, Have strong internal fixation and be able to bear weight early.
4.Fast functional recovery.
The metatarsophalangeal joint fixation position is generally considered to be 20-30 in dorsiflexion as the most appropriate, and greater than 30 will produce metatarsal pain syndrome, which will achieve the desired results in the short term after surgery. fitzcra1d reported that the postoperative period also allowed participation in sports activities with a success rate of 90%, but produced painful arthritis of the interphalangeal joint in 10% of cases during long-term follow-up.
First metatarsal cuneiform fusion: It should be used in more severe bunions, overactive first metatarsal cuneiform joint, severe painful plantar callus and collapse of the transverse and longitudinal arches of the foot, and is a more effective surgical procedure.
5.Arthroplasty
First metatarsophalangeal arthroplasty: The Keller procedure to remove the proximal end of the proximal phalanx of the bunion is still respected by some scholars. For elderly bunion patients whose pain is mainly caused by severe bunion arthritis, the Keller procedure is relatively simple and does resolve the pain in some patients, but because the Keller procedure shortens the bunion, the plantarflexion of the bunion, which is already partially deformed, is further reduced, which will aggravate the pain of the plantar base. This type of surgery should be avoided or strictly indicated.
First metatarsophalangeal joint prosthesis replacement: Due to the serious shortcomings of joint fusion and the Keller procedure, and the successful use of major joint arthroplasty in recent years, the development and use of artificial prostheses for the foot and hand has been promoted. Artificial arthroplasty of the first metatarsophalangeal joint can provide good function after bunion surgery, prevent recurrence of deformity, and be painless after surgery.
The following points should be noted during the artificial joint replacement.
1. Local skin is intact, bone support exists and extension and flexion muscle kinetics are intact.
2. Surgical operation should be meticulous.
3.Surgical instruments should be matched.
4.Soft tissues should not be injured.
5.Good postoperative drainage should be available.
6.Intraoperative and postoperative application of prophylactic antimicrobial agents.
7.Postoperative fixation on the force line.
8.Persons who have had septic arthritis are contraindicated.