Minimally invasive surgery is more mature and has treated more than 10,000 patients. Because of the need for osteotomy, recurrence is unlikely and the recovery period for clinical healing is about 2-3 months. For other conditions refer to the following description.
Bunion is a common clinical foot disease. The incidence in China is about 10-20%, nearly 100 million patients in China, 95% concentrated in women, the disease, in addition to deformity, often combined with bunion pain, hammer toe, plantar callus pain and other symptoms. With the development of the process of building a well-off society in China, the willingness of such patients to be treated is increasing and will become a new modern disease. Bunions are a common clinical condition with a high incidence, especially in women, up to 50% in some foreign countries, and the incidence is on the rise in recent years as more women wear high heels in China. Many patients are troubled by bunion disease for a long time, unable to participate in social activities, and even walking difficulties, bringing great inconvenience to life, and some patients even have low self-esteem due to aesthetic reasons. However, after the bunion is treated, the patient is able to be socially active again. Small incision manipulation for bunion treatment is a simple, efficient and safe minimally invasive treatment method, which is of great significance to improve people’s quality of life and protect the workforce.
I. What is a bunion?
A bunion is a condition in which the bunion flares outward and the heel of the bunion moves inward, making the front foot resemble a triangular “snake head”, which is called a bunion (commonly known as “goblet crutch” in Beijing). If the bunion is severe, it can be located under the second and third toes, which can cause the second and third toes to rise up and form a hammer toe over time. After the heel of the big toe (actually the first metatarsal) has moved inward, it makes the area protrude and easily rubs against the shoe, and over time, the skin and subcutaneous tissues there thicken, become red and swollen, and bursae form, resulting in bunions. This causes pain and even local ulceration and necrosis resulting in infection. Patients with bunions have a lot of combined calluses (hard calluses or “corns”) on the bottom of the foot because of abnormal forefoot biomechanics, which causes pain when walking and brings pain and inconvenience to work and life, and also affects aesthetic appearance.
How do bunions occur?
How does this disease occur? First of all, there is congenital heredity, according to our research statistics, 80% of patients have hereditary factors and most of them are maternal. Acquired factors include inappropriate weight bearing, standing and walking for too long, trauma, wearing stiff pointed shoes with high heels, etc., which cause force on the front of the foot when walking and squeeze the bunion to the outside, promoting and aggravating the occurrence of bunion. Rheumatoid arthritis and rheumatoid arthritis often result in bunion deformity due to joint destruction and subluxation.
What are the clinical manifestations of bunion?
Mostly seen in adults, with genetic factors, can occur in adolescence, middle and old age due to the weakening of the foot muscle, bunions can often be aggravated, and more women than men, the incidence of foreign than domestic, the incidence of China’s northern regions than the south, which is related to the habit of wearing high-heeled shoes and pointed shoes. In recent times, due to the invasion of Western footwear culture, the incidence of bunions among middle-aged and elderly women in China is on the rise.
Bunions are usually discovered by the patients themselves, and their symptoms are at most painful bunions. In normal people, the long axis of the bunion forms a sharp angle with the long axis of the metatarsal bone, and this angle is about 15°. There is also inversion between the first and second metatarsals within 9°. A bunion is only diagnosed if the bunion is tilted beyond the angle as above and is combined with bunion pain. Pain is the main symptom and the main basis for treatment. The pain is mainly from the medial side of the first metatarsal head and increases when walking. Some patients have painful calluses on the metatarsal surfaces of the second and third metatarsal heads. It is noteworthy that the deformity is not proportional to the pain; some deformities are obvious, but the pain is not very pronounced. Further, the second and third toe hammertoes and their callus pain are also important signs.
Fourth, how are bunions treated?
Surgical treatment of bunion is still a major means of treating the disease, and there are more than 200 surgical methods, which can be summarized into five categories: Type I: osteotomy (with and without soft tissue release). Its excellent rate is between 76%-93% and there are reports of delayed healing and bone discontinuity at the osteotomy, and the excellent rate reported in China is 84%. However, the above-mentioned operations require large incisions and open osteotomies, internal fixation or/and external fixation in plaster, and the patient needs to be bedridden after the operation and cannot move on the ground for about 3 to 4 weeks, and the operation is more complicated, with greater soft tissue damage and slow recovery of the patient. The second type is osteotomy (with or without soft tissue surgery). Currently, the McBride procedure is widely used, but recurrent cases are seen in the clinic. In addition, cutting off the thumb adductor causes a new muscle balance disorder, which can lead to bunion deformity after surgery. The third type, joint fusion, is generally used for older, severe bunions, but postoperative loss of metatarsophalangeal joint function, painful arthritis of the interphalangeal joint occurs in about 10% of patients, and bone infection is caused by the internal fixation. The fourth category, metatarsophalangeal joint formation, severe bunion combined with osteoarthritis of the metatarsophalangeal joint has gradually eliminated joint fusion and metatarsophalangeal joint formation, replaced by the use of silicone rubber artificial prosthesis in the foot. The fifth category: simple soft tissue surgery, simple soft tissue surgery is not effective, the recurrence rate is high after surgery, the use is not widespread. The sixth category, artificial joint replacement.
In summary, the current bunion treatment at home and abroad mainly uses large incisions, intraoperative and postoperative should be fixed internally or plaster external fixation, slow recovery, intraoperative damage to the soft tissue of the forefoot, postoperative so that the weight bearing of the foot is affected, resulting in many comorbidities, although there are more than 200 kinds of methods, but there is no ideal treatment method. It will be the trend of the treatment of this disease to research a new method which is easy to operate, satisfactory orthopedic, no recurrence of deformity, less postoperative pain, no internal fixation, able to move on the ground after surgery, quick recovery and less comorbidities.
V. What is the treatment of bunion with small incisions?
The treatment of bunion is an unsolved problem in the orthopaedic community. The medical community believes that the more complex the surgical method of bunion, the worse the outcome. The simpler the surgical method for bunions, the better.
The Foot and Ankle Surgery Research Unit, headed by Professor Wen Jianmin, chief physician of the Orthopedic and Traumatology Hospital of the Chinese Academy of Traditional Chinese Medicine and Wangjing Hospital, has created a new method of treating bunions with small incisions and manipulation. Compared with the traditional method, this method has a combination of Chinese and Western medicine with small injury, small incision, no stitches, no plaster, no steel needles, fast healing, less pain, and the ability to move on the ground after surgery, and has cured more than 10,000 patients with an efficiency rate of 98.5%, which is at the leading level at home and abroad. Small incision is popular among patients because of the small damage.
What preparations do I need to make before the small incision surgery?
First of all, bunion surgery, like other surgeries, requires routine preoperative preparation, such as necessary laboratory tests, X-rays, electrocardiograms, etc., in order to clarify whether there are any contraindications to surgery. Contraindications are: (1) severe diabetic patients; (2) patients with acute infectious diseases; (3) severe rheumatoid arthritis; (4) fusion of bunions; and (5) severe nerve injury.
In addition, since the foot is often in a dirty environment, bacteria and molds tend to live here. Therefore, according to the characteristics of the foot, we use the preoperative external washing of the Chinese herbal medicine of heat and detoxification of the foot No. 1 (external foot washing for 3 days, 2 times/day, 1 time/half hour), which is especially important for those with foot infection, to further reduce the postoperative infection rate. Those without foot odor keep the foot in the best preoperative skin condition to avoid postoperative infections.
The doctor in charge will also take a detailed medical history, conduct a specialist examination, check the mobility of the bunion joint and the presence of callus, etc., and take general photographs of the foot, take footprints, conduct plantar biomechanical tests and other relevant tests, etc.
7. How is the specific surgical procedure for small incisions performed?
Simply put, it is to grind away the “goblet abductor” at the heel of the bunion, truncate the first metatarsal, and correct the deformity through manipulation. The specific steps are as follows.
1, routine disinfection of the surgical field, anesthesia using 1% lidocaine local anesthesia, at this time, you will feel some pain, which is also the most uncomfortable time of this surgery.
2.Use a small circular knife to cut the skin on the proximal medial side of the first toe bone straight to the toe bone.
3, Use a small foot surgery periosteal driver to separate between the bunion and the medial metatarsal head from the distal to the proximal end. The bunion is removed with a chipping drill and the medial metatarsal head is filed with a small foot surgeon’s file so that it is not angular.
4.Cut the skin at the base of the metatarsal head to reach the periosteum, and make a three-dimensional oblique truncation of the metatarsal head from the base of the metatarsal head from the inside to the outside, and rinse the bone debris in the operation field with saline after the truncation.
5, Chinese medicine techniques to rectify the deformity, the use of traction, connection, press, massage, push, take and other techniques.
Specific operation: the operator tracts the distal end of the bunion longitudinally with one hand, pushes the truncated metatarsal head from inside to outside with the other hand, and staggers it with the backbone by about one bone cortex and rectifies the metatarsal head so that it does not shift to the dorsal and metatarsal sides, and straightens the flexor and extensor tendons and other soft tissues.
6. The bunion is fixed in the inversion position with bandages and adhesive tape.
The length of the surgical incision does not exceed 1 cm, the incision does not need to be sutured, it is best to have X-ray and TV surveillance during the operation, postoperative radiographs, if the bunion is serious, a small incision can be made to cut the bunion muscle, but for moderate bunions it is not advocated to cut the bunion muscle, we believe that blindly cutting the bunion muscle can cause the intrinsic muscles of the foot to lose balance and affect the function of the foot, for those who have tight bunions, a small incision can be made to extend the bunion muscle, for those who have For those who have hammertoe or callus, interphalangeal arthroplasty or metatarsal head elevation can be used. For those who have hammertoe and callus are not serious, only the bunion can be corrected, and after the bunion is corrected, hammertoe and callus can also be improved or disappear.
What should I do if I have a painful hammertoe or callus on the bottom of my foot?
Patients with bunions, especially those with moderate or severe bunions, have different degrees of hammertoe deformity due to the bunion turning outward, squeezing other toes, lifting the second and third toes (especially the second toe), overlapping with the bunion, causing the metatarsophalangeal joint to overstretch and the proximal interphalangeal joint to flex, becoming a hammertoe, and the dorsal side of the toe joint being rubbed and squeezed by the shoe surface, resulting in callus pain, generally speaking, those with bunion angles over 35° have different degrees of hammertoe deformity, due to the second metatarsal toe being subluxated The second metatarsal head is pressed down and the metatarsal head touches the ground before the other metatarsal heads, plus the second and third metatarsal trunks have less dorsal extension than the fourth and fifth metatarsal trunks due to the limitation of the metatarsal cuneiform joint, which increases the weight of the second metatarsal head and forms a painful callus under the metatarsal head.
Hammertoe is a complicating deformity of the bunion and is more prevalent in the second and third toes. In the treatment of severe bunions combined with hammertoe deformity, we also use small incisions to perform interphalangeal arthroplasty and, depending on the patient’s symptoms, to perform submetatarsal head osteotomy and elevation of the second, third, and fourth metatarsal heads. However, we also found that in many patients with mild hammertoes, the hammertoes and corpus callosum disappeared with postoperative exercise. This suggests that it may be related to the postoperative reconstruction of muscle balance. Therefore, postoperative functional exercise is very important.
IX. Possible postoperative conditions and matters requiring attention.
Possible conditions that may be encountered after surgery.
1. Swelling: Your foot will be swollen to varying degrees after surgery, and the swelling can be reduced by limiting the foot’s activities and padding the foot. Because the foot is far from the center of the body, swelling after foot surgery takes a little longer than surgery on other parts of the body. Therefore, we use blood-stasis-activating, swelling and pain-relieving drugs after surgery to reduce and shorten the swelling time.
2, pain: after surgery, the general wound will have pain, especially in the first 1-2 days after surgery, a few people will feel heavier pain. At this time, pain medication can be taken. If you are allergic to any pain medication, please tell your doctor in time. If the wound is still painful after discharge, you should see your doctor to rule out the possibility of wound infection.
3. Bleeding: Sometimes, you will notice a small amount of blood oozing from the wound through the bandage. Please do not panic, this often happens after surgery. There is a saying in Chinese medicine that “if the stagnant blood does not go away, new blood will not be born”. If the blood continues to seep out or soak your clothes, the doctor will treat it at his discretion. When you return home from the hospital, you should rest. You can sit in a chair or bed and keep your foot elevated. The foot should be positioned above the level of the heart. Elevating the foot with a few pillows can be helpful in reducing foot swelling.
Occasionally the bandage can be too tight, making the affected foot bruised or ischemic and causing severe ischemic necrosis of the toes. If the affected foot becomes bruised or pale, and the pain is severe, please call your doctor for prompt attention. Do not get the bandage wet in the shower. You can either take a bath or wrap the foot in a plastic bag in the shower. If you accidentally get the bandage wet, change it promptly. You should also not move the wound dressing easily to avoid wound infection.
After surgery, you should wear the special orthopedic shoes with soft front opening supervised by our department. For the first two weeks after surgery, the activity level should be indoor activities and self-care, and you should not do unnecessary walking as much as possible. Two weeks later, the amount of activity can be increased, about six weeks after surgery, the general osteotomy healing, to bandage fixation, wear looser shoes, most patients can wear normal shoes after six months, postoperative bandage fixation and change of medication is very important, to be reviewed by experienced doctors, generally 3-6 days after surgery to open the incision to change medication, such as incision healing, can be fixed every two weeks bandage, until the osteotomy healing, generally 5-6 weeks or so. After 2, 4, 6, 12 weeks, 6 months, and one year after surgery, X-rays should be taken to understand the postoperative recovery, and after one year, plantar mechanics test should be performed to understand the change of plantar pressure after surgery. These are very important because it generally takes one or two years for an osteotomy to heal strongly and the same amount of time is generally needed for the biomechanics of the foot to change and determine whether you can perform prolonged weight-bearing activities. Also, foot biomechanics can provide information about other conditions in the foot.
After surgery until the clinical healing of the osteotomy, we use herbs to promote blood circulation and healing of the fracture, and after six weeks of bandage removal, we use herbs to promote blood circulation and healing and reduce swelling (2 times/day, 1 time/half hour, the time of use depends on the time of swelling and pain in the foot) to promote blood circulation and make the soft tissue and joint’s to recover more quickly. After the operation, Chinese herbal medicines to invigorate blood circulation and remove blood stasis and strengthen bones and kidneys were used internally to promote fracture healing. After the bandage is removed, external washing with Chinese herbs to promote blood circulation and accelerate the recovery of foot function is used to activate blood stasis and reduce swelling.
X. How to practice after surgery?
Post-operative functional exercise is extremely important for the recovery of bunion after surgery. Generally speaking, it is not advisable to start exercising on the day after surgery due to the damage of local blood vessels. 24 hours later, you can exercise the bunion and ankle joint. On the one hand, it promotes the healing of the osteotomy end, and on the other hand, it avoids the functional impairment caused by the postoperative adhesions.
In addition, most of the patients with corpus callosum obtained improvement or no significant changes in the corpus callosum after the small incision, but a small percentage of patients patients experienced aggravation of the corpus callosum condition and pain in the metacarpal area, which was mainly due to the special condition of the foot. This is because the formation of the corpus callosum has a lot to do with the patient’s age, weight, occupation, physical fitness, and the condition of the ankle joint and midfoot hindfoot, all of which can directly affect the intrinsic stability of the foot. Further, orthopedic surgery makes the foot anatomy change, recovery is slow, and patients need a certain recovery adaptation period. For patients whose corpus callosum cannot be improved after surgery, patients can perform functional exercises of the foot muscles, such as ankle flexion and extension rotation, toe convergence to the metacarpal, stepping on a ball or sand, and heel walking to strengthen the internal and external muscles of the foot, which can have good results. For patients with pain in the metacarpal area, special metatarsal pads can also be used, and then combined with functional exercises, the effect is more obvious. For particularly serious patients, metatarsal head osteotomy and elevation can be implemented.
What is the effectiveness of the small incision method for bunion treatment and will it recur?
The efficacy of the new method of treating bunions with small incisions is remarkable. We have followed up 535 operated patients from 93 to 97 years, and its recurrence rate is extremely low, less than one in a thousand. Therefore, it was generally well received by the patients. We have also cured many central leaders and their families, and many foreign patients have come from far away to China for treatment. Many patients who had recurrence after bunion surgery in foreign hospitals also came in droves. For this reason, our department has researched the small incision approach to treat recurrent deformities after bunion surgery. Generally speaking, all postoperative recurrent bunion deformities other than the Keller procedure can be revised with the small incision method.
12. How can bunions be prevented?
The prevention of bunions is very important. For patients with early or mild bunions, bunion braces can be used to help reduce symptoms. In addition, for post-operative patients or mild bunions in the choice of shoes with a flat and wide toe, the heel should not be too high, for early lesions, the pain is mild, non-surgical treatment can be used, including massage, moving the bunion to the inside of the foot, walking barefoot in the sand, forging the foot muscle, hot compresses and rest, the first toe on both sides of the rubber band for traction in the opposite direction, four times a day, each time 5 -10 minutes. Or put rubber strips on all toes, toes to do the separation action if the patient also suffers from corpus callosum, flatfoot or heel pain, etc., can also be used at the same time metatarsal pad, flatfoot pad or heel pad.