Delving into the World of Bunions: A Comprehensive Review with Dr. Mark Sheehan

Ever wished you could understand the nuanced world of bunions from a specialist's perspective? Brace yourself for a riveting discussion with Dr. Mark Sheehan, a foot and ankle connoisseur from the Kayal Orthopaedic Center, as we dissect the anatomy of the foot, focusing specifically on the big toe joint and the bones of the forefoot. Dr. Sheehan masterfully guides us through the essence of foot alignment and gait, their crucial role in diagnosing bunion deformities, and the potential for other deformities like flat foot to coexist.

With Dr. Sheehan's expertise, we delve into the labyrinth of diagnosing bunions and the interplay of two essential angles. Get ready to gain valuable insights into the typical presentation of this condition and the myriad surgical options available for bunion deformity. Be it a simple medial eminence resection, a distal metatarsal head osteotomy, or foot fusion, the chosen procedure depends on the severity of the bunion, and this is something we'll dissect in-depth. 

As we advance, we plunge into the rare condition of juvenile bunion deformities and the significance of their conservative treatment. Dr. Sheehan provides enlightening details on the prevalence of this condition, the need for more education on surgical treatments, and the potential for secondary problems arising from bunion deformities. Join us on this thrilling journey into the realm of bunions, where understanding these deformities paves the way for more effective treatments. Don't miss out on this captivating conversation; it's sure to change the way you view bunions forever.

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Episode Transcript

Robert A. Kayal, MD, FAAO (00:00):
Hello and welcome to another edition
of the Kale Ortho podcast.
Today is Tuesday, september12th 2023, and our special guest
today is our very own Dr MarkSheehan.
Dr Mark Sheehan, isa, foot andankle specialist at the Kale
Orthopedic Center, and we're soprivileged to have him with us
today.
Welcome to the podcast, drSheehan, thank you.

(00:20):
Thanks for having me, so happyto have you.
So why don't we just take thisopportunity, take a few minutes
and just introduce yourself toour community of viewers and
listeners?

Mark Sheehan, DPM (00:28):
Sure, so my name is Dr Mark Sheehan.
I was born and raised insoutheastern Connecticut.
I did my undergrad at theUniversity of Connecticut and
then from there went on to BerryUniversity School of Podiatric
Medicine down in Miami, florida,where I spent four years
educating myself on all thingsfoot and ankle.

(00:49):
From there I came back up northand did a rigorous three-year
surgical residency, based out ofHoboken, new Jersey and the
surrounding area.
And while I was there I wasfortunate enough to establish a
relationship with Dr ChadRappaport, who is one of the
other foot and ankle surgeonshere in our group, and he was

(01:10):
gracious enough to introduce you, to me, to you and Dr Kale, as
you know, and you were kindenough to take me on staff here
right in the heat of COVID,which I appreciate.
And I've been here about threeyears now It'll be three years
next month, so it's been threegood years.

Robert A. Kayal, MD, FAAOS (01:27):
It's been an awesome three years.
I've been so happy andprivileged and blessed to have
you, dr Sheehan, thank you.
Tell us a little bit about yourfamily.

Mark Sheehan, DPM (01:35):
So I am a new father as of last year.
I have a beautiful wife and aone-year-old son.
Now I also have a little dogthat we've had for about a
decade.
Now he's getting a little longin the tooth, but yeah, I'm just
really enjoying fatherhood andall the new things that you
experience each and every daywhen I go home.

(01:55):
So it's been a blast.

Robert A. Kayal, MD, F (01:57):
Exciting days.
I remember those very clearly.
Today's topic is going to be avery common condition called
bunions.
Bunions of the foot, also knownas halux valgus, is such a
common condition, especially inwomen, and we're just so
privileged to have Dr Sheehanhere to share his expertise on
this topic, so let's just jumpright in.

(02:17):
So first of all, dr Sheehan,I'd appreciate if you take a
couple of minutes to explain toour viewing and listening
audience exactly what a buniondeformity is.

Mark Sheehan, DPM (02:26):
Bunion deformity is probably the most
common element that I see whenit comes to problems of the
forefoot or of the toes.
I think it's honestly easier totalk about what a bunion isn't
initially, because very commonlyI'll have patients that come in
with bunion deformities whothink it's one thing when it's
really another.

(02:47):
They oftentimes will come incomplaining about a large bump
that has been growing on theinner aspect of their forefoot
for, usually several years.
That has become more painfuland more intolerable as time has
gone on, and they tend to beunder the impression that this
is an increased bony growth.

(03:07):
It's extra bone that's growingon the inner part of their foot,
or maybe a soft tissue mass orfluid buildup, something along
those lines when in realitywhat's happening is they're
developing a bunion deformity.
And a bunion deformity in thesimplest sense is a deformity in
which your great toe, or what'sknown as your halux, starts to
deviate towards the outer partof your foot or towards your

(03:30):
pinky toe.
While that's happening,essentially the joint at the
base of your big toe is startingto slowly but surely dislocate
and the bone that your big toeconnects to within your foot
also starts to move or todeviate in an opposite direction

(03:50):
, so it'll start to move towardsthe midline of your body or
towards the inner part of yourfoot.

Robert A. Kayal, MD, FAAOS (03:55):
Yeah , so just to be clear, I think
it's important for our audienceto understand what we talk about
when we talk about the hindfoot, the midfoot and the
forefoot.
So let's just demonstrate withthe model, if you don't mind All
right.

Mark Sheehan, DPM (04:06):
So here I have a foot model.
As you can see, and when we'rediscussing the foot as foot and
ankle surgeons, we like todivide the foot into three
different areas or threedifferent components.
You have the rear foot, whichis made up of these two bones.
Back here you have your heelbone and which is also known as
your calcaneus, and you haveyour tail is, which is the bone

(04:26):
that moves up and down in yourankle and allows the ankle to
move back and forth while you'rewalking.
You then have the midfoot,which is made up of a number of
small bones that don't do muchmoving at all within the middle
third of your foot, and then youhave the forefoot, which is
made up of these long bones,here known as your metatarsals,
and also the bones of your toes,which are known as your

(04:47):
phalanges.
Each lesser toe tends to havethree bones one, two and three,
while your great toe has onlytwo bones, one and two.
Right here, on the bottom of thefoot as well, this model
unfortunately doesn't have them,but on the bottom of your first
metatarsal head, right at thislocation, right here, there are
also two very normal bones tohave, known as your sesamoid

(05:09):
bones that play a very largerole, not only in ambulation,
but also when you're walking,with absorbing force and contact
with the ground as well.
In today's podcast, we're goingto be talking about bunion
deformities, as was previouslymentioned, which is going to
focus pretty much exclusively onwhat's known as your first
metatarsal phalangeal joint, oryour big toe joint, located

(05:31):
right here, and the bones thatwe'll specifically be talking
about are your first metatarsal,which is this long bone right
here, and the two bones of yourgreat toe, as well as the two
sesamoid bones that I previouslymentioned.

Robert A. Kayal, MD, FAAO (05:43):
Great .
Thank you so much, dr Sheehan,for that explanation.
Let's talk a little bit aboutthe prevalence and the
epidemiology of bunions.
Can you tell us something aboutwhich patients in particular
might be at increased risk ofdeveloping such bunion
deformities?

Mark Sheehan, DPM (05:59):
Sure, so my typical patient that I see the
average patient, I would say isusually a female in her 30s to
40s that has had this deformitydeveloping for the last several
years, maybe even the lastdecade or so.
There's definitely a higherprevalence of bunion deformities
found in the female population.
It's actually a 10 to 1 ratioaccording to some studies.

(06:22):
So this is something thatdefinitely affects women at a
much higher frequency than males.
For sure, bunions can affectpeople at any age, to be
completely honest with you, butthat tends to be where I see
most of the of the my patientscoming in.
There's also a geneticcomponent that is very prevalent
with bunion deformities as well.

(06:42):
I've seen some studies thathave shown up to a 90%
prevalence, where if grandma,grandpa, aunts or uncles,
brothers and sisters have abunion deformity, you're at an
increased risk of having thatbunion deformity as well.

Robert A. Kayal, MD, (06:58):
Certainly so.
There are what we calltypically intrinsic and
extrinsic causes of buniondeformities.
Intrinsic causes would be suchthings as genetics or medical
conditions that serve aspredispositions right.
Females in general have anincreased risk of developing
bunion deformities, butcertainly some medical

(07:19):
conditions such as rheumatoidarthritis or GAL, and also some
birth deformities such as spinabifida and down syndrome and
cerebral palsy, can certainlyincrease patients' risks of
developing bunion deformities.
But certainly withouthesitation.
I think both of us can clearlyagree that genetics is the
number one player, especially inwomen, but genetics is the

(07:41):
number one risk factor ofdeveloping bunion deformities.
Those are some of the intrinsiccauses of bunion deformities,
but extrinsic causes can alsocontribute as well.
What are some examples of that?

Mark Sheehan, DPM (07:53):
Sure.
So there's two main examplesthat I commonly see.
Number one is just your overallbiomechanics.
So in individuals who areover-pronators meaning when they
walk, the majority of theirweight, or more weight than
should be, is shunted towardsthe inner aspect of their foot.
So instead of walking with aneven distribution of weight

(08:14):
across the entire bottom of yourfoot, as you should with a
normal gait, these individualswalk more with weight on the
inner portion of the foot, andwhat that does is it pushes
their great toe in a lateral oran outward direction, and you
can imagine if you're doing that, step after step, for thousands
of steps every single day.
Eventually, the soft tissuestructures that are responsible

(08:35):
for keeping your great toe in analigned position are going to
feel the effects.
They're going to be weakenedand your toe is more likely to
start deviating in that position, therefore causing this bunion
deformity.
That's number one.
Number two is the types of shoegear that individuals tend to

(08:56):
wear.
If you're wearing a shoe thathas a tight what we call toe box
, which is the portion of theshoe that your toes reside in,
that toe box will squeeze on notonly your big toe but also your
pinky toe, and at the level ofthe big toe.
In the same way that being anover-pronator pushes the foot
towards the outer excuse mepushes the toe towards the outer

(09:18):
part of the foot, the, theTight toe box, will also push
the great toe towards the outerpart of the foot as well.
High heels, in my opinion, areprobably not even for bunions,
but just for problems with thefoot and the ankle in general,
probably the worst type of shoethat you can wear.
When it comes specifically tobunions Most high heels, as you

(09:41):
know they.
They have a very small toe boxand squeeze on your toes
excessively, but they also causeyou to contract your Achilles
tendon and the muscles in the inthe back of your leg, which
shunts or pushes more of yourbody weight towards your
forefoot and towards your greattoe, putting more Pressure and
more force on that, that jointwhere the bunion is forming, and

(10:02):
causing a bunion deformity inthat way as well.

Robert A. Kayal, MD, FAAOS (10:05):
I'll make sure that my wife does not
watch this podcast.

Mark Sheehan, DPM (10:09):
It's a tough battle to have.
Yeah, for sure.

Robert A. Kayal, MD, FAAOS (10:13):
Wow, make sure I cover my wife's
ears during this part of thepodcast.

Mark Sheehan, DPM (10:16):
Yeah, we're listening mine as well.

Robert A. Kayal, MD, FAAOS (10:21):
So that was all very interesting.
So, yeah, we, as orthopedicsurgeons and foot and ankle
surgeons, strongly recommend theusage of shoes with a wide toe
box for that reason.
You know, that's a very, veryinteresting point that you just
raised.
Can you demonstrate that theeffects of shoes with a pointy
toe on that model and and how itcan potentiate the progression

(10:44):
of the bunion deforming?

Mark Sheehan, DPM (10:45):
so this foot model right here would be what
your foot would look like in itsnatural state, with all the
toes in a properly alignedposition in a Normal shoe or in
a shoe that has plenty of spacein the toe box.
The toe box is going toencapsulate the toes, but it's
not going to squeeze on them, soit'll it'll go around the toes
like this, without applying anyoutward force or pressure to the

(11:06):
toes themselves.
When you're wearing a shoe thathas a tight toe box, what ends
up happening is similar to theway my hand is squeezing these
bones together.
The, the toe box does the samething, and if you're doing that
for hours at a time, day afterday, what eventually begins to
happen is this joint right hereis affected, it's weakened, it
because it starts to lose thebattle.

(11:27):
If you will causing this greattoe of the bones, of this two
toe, to move in this Directionand simultaneously causing this
bone here, the first metatarsal,to move in an equal and
opposite direction.
This way, so you, instead ofhaving a nice straight line, a
nice Biomechanical advantagewhen you're walking, an anatomic
alignment, you end up with thisDeviation and this angulation
within your toe that createsthat, that patho-neumonic or

(11:49):
that, that classic bump that yousee on the inner part of the
foot.

Robert A. Kayal, MD, FAAOS (11:52):
It's sort of over time, actually
molding the foot into a buniondeformity.
It is, yeah, yeah, so that'sexactly what's happening.
Yeah, so, dr Sheehan, howimportant is the role of the
plantar fascia and the architself in bunion deformities?

Mark Sheehan, DPM (12:08):
So that really plays a role when you're
talking about patients who areare overpronating.
That's that's gonna be whereyou see the plantar fascia come
into play.
That's we're gonna see a lot ofthe.
The soft tissue structures onthe bottom of your foot are
Going to be affected if you havea flat foot deformity.
If you're, if you'reoverpronating, that again causes

(12:32):
the majority of your weight toshift towards the inner aspect
of your foot, which is going tocause the again, instead of the
great toe having the ground pushit straight up and down with
every single step that you take,it's going to push it from the
inner part of your foot towardsthe outer part of your foot and
that will, over time, start tocause the soft tissue structures

(12:52):
to wear down and cause yourbunion deformity to develop.

Robert A. Kayal, MD, FAAOS (12:56):
So on that note, let's elaborate a
little bit and just discuss withus the typical gait cycle from
heel strike to push off for ourpatients, so they really
understand the mechanics of thethat great toe or the big toe
metatarsal phalangeal joint inparticular for.

Mark Sheehan, DPM (13:13):
So when you're walking, a Normal gait or
normal ambulation requires aspecific distribution of your
body weight over the bottom ofyour foot, from heel strike,
which is where your foot firsthits the ground, to what we call
toe off, which is where the thelast tip of your big toe
Propels you off of the ground.
There's a very specific waythat your body weight needs to

(13:33):
be distributed across the bottomof your foot.
When you're walking, for anormal gait and normal
ambulation, when our heel firsthits the ground, or what's
called heel strike, the all ofthe weight from our body is
Distributed to the back part ofour foot or our hind foot.
As we start to roll from heelto toe, that weight moves Mostly

(13:55):
on the outer or the lateralaspect of our foot.
The inner arch of our footreally doesn't bear any weight
as we're, as we're walking.
And then, once that body weightstarts to move towards the
front part of our foot and westart to propel ourselves
forward In order to take ournext step, that weight quickly
shifts right to the great toe,essentially into the first
metatarsal phalangeal joint, thebig toe joint.

(14:18):
You know there's a reason thatthe big toe joint and the big
toe itself is so much biggerthan your lesser toes, your
second, third, fourth and fifthtoes, and that is because it's
the all-star of the team.
It's the one that's going to bethe strongest, it's the one
that's going to propel youforward and allow you to walk,
run, jump and do all theactivities that you like to do
on a daily basis.
The, because of that, your bigtoe joint is, is much stronger,

(14:42):
much more complex and reallymuch more important throughout
the gait cycle than any otherOther toe.
So when you have something likea bunion, deformity where that
great toe joint and that thatgreat toe are compromised, in a
way, it makes the, the Abilityto ambulate, the ability to
propel yourself forward, muchmore difficult and painful and
uncomfortable.

Robert A. Kayal, MD, FAAOS (15:02):
That was a beautiful description,
but I think we can eitherfurther that description with a
model presentation of that gaitcycle from heel strike to the To
the lateral column and thenultimately to the metatarsal
found giel joint for push-off.
So if you can just sort of do avideo Demonstration of that
gait cycle for our viewingaudience, I would appreciate
that.

Mark Sheehan, DPM (15:23):
Sure, during your typical gait cycle, when
your foot first hits the ground,the all of your weight is going
to be on your heel bone, rightat this level, right here.
As you start to roll from heelto toe and Propel yourself
forward, that weight moves onthe outer aspect of your foot.
So it's gonna move throughthese two bones, your outer, two
metatarsal bones.
It then very quickly shiftsacross the bottom of your foot,

(15:45):
across what we call yourmetatarsal heads, right to the
base of your big toe, where yourbig toe then propels you
forward.
So all of your body weight atone point during the gait cycle
is right at this joint and thenPropels forward through and out
the tip of your great toe andfor that reason it makes your,
your big toe the star of theshow.

(16:06):
It makes it the the strongest,most important player when it
comes to all of your toes andpropelling you forward and
allowing for a normal, healthygait cycle.

Robert A. Kayal, MD, FAAO (16:14):
Thank you, yes, that was a beautiful
analogy.
And All of that to reallyemphasize to our audience how
important it is that themetatarsal found giel joint of
the great toe is properlyaligned right.
It's so important in mechanicsof gait that the metatarsal
found giel joint is well alignedand those two bones, those two

(16:37):
little Sesameid bones, areperfectly positioned under the
metatarsal head of the firstmetatarsal and Once those bones
start to sublux or deviate tothe outside of the foot, all of
our body mechanics with respectto push-off are Negatively and
adversely affected.
So on that note, I think it'simportant that we describe the

(17:01):
proper alignment of the greattoe.
There are certain angles thatwe like to measure and talk
about Radiographically on x-rayto confirm that the patient's
alignment is normal.
We talk about the first intermetatarsal angle, we talk about
the hallux valgus angle.
And why don't we demonstratethat what our normal values are

(17:23):
for our patients?
So when we get to the pointwhen we start talking about
making the diagnosis of buniondeformities, they'll better
understand.

Mark Sheehan, DPM (17:32):
So when a patient comes in to see me, the
first thing that I'm going to dois I'm going to take an x-ray
of their foot, and at KailorOrthopedic Center we have x-ray
technology that allows me todraw out specific angles that
I'm looking for on the patient'sfoot that provide me with the
necessary information to educatethe patient fully on what I
think the best treatment forthem will be in regards to their

(17:55):
bunion deformity, based on theangulation treatment changes.
The more severe the deformity,obviously, the more aggressive
the treatment tends to have tobe.
So it's very important that Iassess and look at these
different radiographic angles toensure that I'm giving the
patient the proper treatmentthat is necessary.
The first angle that I alwayslook at is what's known as the

(18:16):
first intermeditarsal angle.
So that's an angle that's madebetween your first meditarsal
bone, which is this long bonehere, and your second meditarsal
bone, which is the meditarsaldirectly next to it.
The angle that is made betweenthose two bones gives me a lot
of information in regards to howsevere your bunion deformity is
.
A typical or a normal value forthis angle is nine degrees or

(18:38):
less.
As that angle begins toincrease, so does the severity
of the bunion deformity andtypically the treatment will
change as that severityincreases.
The second angle that I alwayslook at is what's known as the
Hallux valgus angle, which isthe angle that is made between
your great toe.
So these two bones right hereand the first meditarsal.
Again, this is a normal bonemodel.
Unfortunately we don't have amodel of a bunion, but you can

(19:00):
imagine, with a bunion deformity, your first meditarsal is going
to be deviating in thisdirection, as my fingers are
showing here, and your Hallux oryour great toe is going to be
deviating in this direction,which will create, instead of a
straight line, like you see here, an angulation.
That also tells me what type ofprocedure or treatment you may
need.
Typical value for the Halluxvalgus angle is 15 degrees or

(19:23):
less and, again, as it increases, typically so does the severity
of the deformity.

Robert A. Kayal, MD, FAAOS (19:27):
So thank you for all that
information, dr Sheehan.
That was very informative.
How do patients typicallypresent to the office when
they're being assessed for abunion, for instance?
What is their chief complainttypically and what is the
typical history of the presentillness when they present and
you ultimately end up diagnosingthem with a bunion deformity?
Sure?

Mark Sheehan, DPM (19:47):
So most patients tend to come to the
office complaining of usually apainful bump on the inner aspect
of their foot.
They don't really have a betterway of describing it and there
really is no better way todescribe it than just that it's
usually a bump or a growth thathas been occurring for several
years, sometimes even severaldecades, and has slowly but

(20:08):
surely been progressing in anegative way.
As a result of this growth onthe inner aspect of the foot,
this bump on the inner aspect ofthe foot, the patients tend to
find that they're having aharder time fitting into shoe
gear, and the shoe gear thatthey are able to fit into is
causing a lot of pain anddiscomfort at that joint,
specifically not only because ofthe rubbing and the friction

(20:29):
that occurs from not being ableto fit appropriately into the
shoes, but also because in a lotof cases the alignment of the
joint itself is so deviated,it's so malaligned and
malpositioned that theirbiomechanics, step after step,
every single day, is causingpain and discomfort where there
should be just a smoothmechanical movement of that

(20:49):
joint.

Robert A. Kayal, MD, FAAO (20:49):
Thank you for that, dr Sheehan.
And when it comes to describingtheir past medical history or
their family history, very oftenthere's a family history of
bunion deformities, right, andsome of them might have multiple
medical comorbidities such asdiabetes or gal or rheumatoid
arthritis, and those arecontributing factors.
Certainly, as we've previouslydiscussed, how about on physical

(21:12):
examination?
What are the findings onphysical examination that make
you really consider that thispatient may have a bunion
deformity?

Mark Sheehan, DPM (21:19):
Sure, so the first thing I always look for
and usually see is what we callthe medial protuberance or the
medial eminence, which is thatbump that I've kept alluding to
throughout this podcast on theinner aspect of the foot.
That is a classic finding witha bunion deformity.
The flexibility of the joint issomething that I'm going to
look for.

(21:39):
Next, I want to see how mobilethis joint is, how contracted it
is, and that gives me a senseof how long the bunion has been
there for and what types ofprocedures I could potentially
do for this patient to try andmake them feel better.
Also, when I'm placing thatjoint through range of motion,
I'm assessing for pain at thesame time.
When you have a buniondeformity, you're at a

(22:00):
disadvantage biomechanically andthat joint tends to get worn
out.
The soft tissue structuresurrounding the joint tend to
get worn out.
There's inflammation thatoccurs in the area.
The shoes themselves can causeinflammation, so there's usually
a large component of painthat's present as well.
At the bunion deformity there'salso a high prevalence maybe
not a high prevalence, butdefinitely a good amount of

(22:22):
times where I see arthriticchanges at that joint as well,
which, as we know, can bepainful for the patient on top
of the bunion deformity.
So I'm looking for all thosethings.
When I'm putting the jointthrough range of motion, I'm
also going to have the patientstand up for me.
I'm going to look for otherdeformities that may be causing
the bunion or may be secondaryto the bunion.
So if I have a patient who hasa flat foot deformity, they're

(22:44):
more prone to developing abunion deformity as well as the
flat foot deformity and becauseof the flat foot deformity.
So if you have a patient thatcomes in thinking they just have
a bunion, that may only be partof their problem.
They may also have a flat footdeformity.
That needs to be addressed oneway or the other, because if you
just address the buniondeformity you're not addressing
the full picture.
The likelihood of having asuboptimal outcome when you

(23:06):
treat the bunion deformity ismuch higher, so you have to be
aware of that as well.
I'm also going to look at thelesser toes, the second toe in
particular, because the buniondeformity, or as the great toe I
should say, starts to movetowards the outer part of the
foot.
It's like a big bully.
It's bigger, it's stronger,it's more powerful than any
other toe and unfortunately thatsecond toe is usually standing

(23:27):
right in its path.
So the second toe if givenenough time and the bunion has
enough time to develop, thesecond toe is going to begin to
float or to dislocate up.
The soft tissue structures onthe bottom of the toe will start
to become torn or attenuatedand that second toe will
actually literally dislocate outof the joint and in really

(23:49):
severe cases it'll cross overthe first toe, creating what's
called a cross over second toedeformity.
So when you have that severe ofa bunion deformity you can't
just address the buniondeformity as well, you have to
address the second toe.
You have to fix thatsimultaneously or else you're
not doing the patient justiceAbsolutely.

Robert A. Kayal, MD, FAAOS (24:09):
And if there are anything like my
wife, you can't forget about theAchilles tendon, right?
If they're wearing high heelsall day, there's a good chance
that they're going to have anAchilles tendon contraction as
well.
So are there any imagingstudies that you can perform to
confirm your diagnosis, or didyou already just make your
diagnosis on physical exam?

Mark Sheehan, DPM (24:28):
So physical exam tells us a lot but, as with
any orthopedic issue, if youcan get imaging, you should get
imaging.
It's going to tell you a lotmore about what the actual
pathology you're dealing with is.
It's going to give you a lotmore detail and a lot more
information that allows you totreat the patient in an optimal
way.
The one imaging study that hasto be done, without question,

(24:48):
when you're dealing with abunion deformity or when you
think you're dealing with abunion deformity, is an x-ray.
We take an x-ray in threedifferent views so I'm able to
assess the foot from alldifferent angles.
We take it while the patient isweight bearing so I'm able to
see exactly how the footinterfaces with the ground and
how the bunion reacts when thereare ground reactive forces

(25:08):
acting on the foot while thepatient is standing.
And that imaging allows me todecide and determine and educate
the patient on what I think thebest procedures or treatment
going forward is for them, basedon their specific pathology.

Robert A. Kayal, MD, FAAOS (25:23):
Okay , so now the patient's given us
a history, comprehensive history.
You've done a physicalexamination.
You've obtained imaging.
You've now confirmed that thediagnosis is a bunion.
You've made your assessment.
How are you going to treatthese bunions?

Mark Sheehan, DPM (25:38):
So there's a number of ways to treat bunion
deformities.
In my practice, no matter whatwalks through my door, I always,
always try to treat the patientconservatively, first and
foremost, if I can.
Obviously there are somesituations where you have to
jump to surgery right away.
But if you can get away withtreating a patient
conservatively and it works forthem and they're able to avoid

(26:00):
the post-operative recovery timeof a surgery, some of the
discomfort that comes with thesurgery and just the effect it
has in their daily life, then Ithink that that's good medicine
being able to treat a patientconservatively first and
foremost.
The issue, if you will, with abunion deformity is there aren't
a lot of great conservativeoptions available, particularly
if you want a permanentcorrection.

(26:20):
What I try to do is determineokay, what is the actual source
of this patient's pain.
The overwhelming majority of thetime, shoe gear is a major
complaint.
It's the rubbing and theirritation of the bunion on the
inner aspect of the patient'sshoe.
Because the foot is wider, itno longer fits into a shoe and
so as you're walking, step afterstep, day after day, you have

(26:44):
rubbing, irritation and pain onthat inner aspect of the foot.
So the first thing I'll oftenmention to patients is hey, if
you're in high heels, get out ofthose high heels.
If your shoes are too tight anddon't have enough flexibility
in the toe box or enough give inthe toe box, you should try and
get a wider toe box, a shoethat has a wider, greater space
for you to place your toes in.

(27:05):
And look at the material thatyour shoe is made out of as well
.
You want a softer material,something that's going to be
more forgiving and have a littlebit more stretch to it so that
your foot can actually fit intoit.
That's number one.
Number two is if I havedetermined that part of the
problem the patient has is thatthey're slightly flat footed, or
if they overpronate and that'scausing the bunion deformity.

(27:27):
If it's a mild bunion deformity,I may just say hey, listen,
let's get you into a good pairof orthotics that's going to
correct the alignment of yourfoot while you're wearing them.
It's going to take some of thestress and strain and some of
the deforming forces off of yourbunion deformity and hopefully
help you prevent this fromprogressing in an aggressive
manner, and we might be able tomake you feel better just
through that.

(27:48):
If there is an arthriticcomponent involved and I think
that the arthritis is actuallycausing the majority of the
patient's pain, with range ofmotion of this joint and,
depending on the patient, I mayjust simply offer them
treatments that we typically usefor arthritis, such as
cortisone, interarticularcortisone injections,
anti-inflammatory medication,rice activity or icing activity

(28:12):
modification, things of thatnature.
But beyond that there's reallynot a lot of great conservative
measures that you can take,especially not when you're
trying to permanently correctyour bunion deformity.

Robert A. Kayal, MD, FAAOS (28:24):
When you see a bunion deformity, is
it always just the actual buniondeformity of the bone
prominence, or are there softtissue components that get
inflamed, that tend toaccentuate the deformity?
And if so, can those softtissue structures be injected as
well to try to shrink thatswelling and address the pain as

(28:44):
well?

Mark Sheehan, DPM (28:44):
Yeah, definitely.
The anatomy in that part ofyour foot is such that you have
what's called a bursal sac onthe inner aspect of your foot
right at that joint level.
Essentially, the bunion itselfcan cause that bursal sac to
become inflamed and becomewhat's known as bursitis.
Also, the rubbing of the shoeon that inner aspect of your

(29:06):
foot can also irritate thebursal sac as well, causing
bursitis, and very often, aswith any sort of inflammation,
you can usually try cortisoneinjections into that area to
address that and theinflammation in the bursitis as
well.

Robert A. Kayal, MD, FAAOS (29:19):
Yeah , when it comes to conservative
management, I think cortisoneinjections in those areas offer
our patients tremendous,tremendous relief, not only to
alleviate the pain anddiscomfort but oftentimes to
shrink that prominent swellingof that bursitis.
So I think that that's alsooften a very successful first
line level of treatment, alongwith all the other options that

(29:42):
you mentioned shoe wearmodification, etc.
Anti-inflammatories,non-steroidal
anti-inflammatories,motrinaduolive, ibuprofen things
like that can help shrink thepain and inflammation and
swelling as well.
Before we start talking aboutsurgical treatment options, I
think it's important for us todiscuss exactly what's happening

(30:04):
from a mechanical perspectiveand a tonical perspective.
At that metatarsal phalangealjoint, certain structures are
getting stretched and certainstructures are getting
contracted as this deformityprogresses and develops.
Why don't we speak to that alittle bit so that our patients
can understand the anatomy?
Because all of that is going toobviously come into play when

(30:26):
you surgically correct thedeformity.

Mark Sheehan, DPM (30:28):
Sure.
So I think what you have tounderstand first and foremost is
that your big toe joint, yourfirst metatarsal phalangeal
joint, is a very complex joint.
It's a very important joint, asI've mentioned previously, for
propulsion and for ambulation,and it has multiple bones within
that joint specifically, thatare attached by a vast complex
of not only ligaments but alsotendons as well, and it's a

(30:51):
balancing act.
There are ligaments on theouter aspect of the joint that
balance out the ligaments on theinner aspect of the joint.
There are tendons on the top ofthe joint that balance out
tendons on the bottom of thejoint, and so, as your bunion
begins to form, some of thoseligaments begin to contract,
some of those ligaments begin toget stretched out and there's
an imbalance that occurs.

(31:11):
I'll demonstrate that to youright now on a foot model, if
you'd like, perfect.
At any joint, and specificallyat this joint, there are
ligaments that connect bone tobone, so you can think of it
like a rope that connects onebone to the next.
On your first metatarsalphalangeal joint, there are
ligaments on the inner part ofthe joint, right here, and there
are balancing ligaments on theouter part of the joint, right

(31:33):
here, as your bunion begins todevelop and these two bones
begin to deviate towards theouter part of your foot or move
towards the outer part of yourfoot, and your first metatarsal
begins to move towards the innerpart of your foot, the
ligaments on the inner part ofthe metatarsal phalangeal joint,
of the great toe joint, aregoing to begin to stretch,
they're going to begin to loosen, which you obviously don't want

(31:54):
, but simultaneously theligaments on the outer part of
the joint are going to contract,and so that makes it much
harder for your deformity toever return back into a normal
position, and it makes it mucheasier, as these ligaments
continue to loosen and theseligaments continue to contract,
for your deformity to progressinto a more severe deformity
over time.

Robert A. Kayal, MD, FAAOS (32:13):
Okay , thank you for that
demonstration.
Dr Sheehan and I know wealready discussed some
conservative treatment options,but let's talk about the
surgical management of buniondeformities and how your
surgical choice of treatment isrelated to the severity of the
patient's bunion deformity.

Mark Sheehan, DPM (32:32):
Sure, when I have a patient in the office and
I've evaluated, evaluated themclinically, gone over their
x-rays, I've accumulated a largeamount of information that
allows me to determine, if theychoose to do surgery, what I
think the best type of surgeryfor them to have would be.
In foot and ankle medicalliterature there's actually over

(32:53):
100 different medicalprocedures, surgical procedures
that have been written aboutthroughout time in regards to
how to treat a bunion deformity.
But for me, my, the surgerythat I do tends to typically
fall into one of four categories, and that's based on the
severity of the bunion.
So when I look at your x-ray,when I'm measuring all the
different angles that I need tomeasure, it's going to tell me

(33:15):
if the bunion is mild, whichwould be a rather small bunion,
moderate bunion or severe bunion.
As you move from a mild bunionto a severe bunion, the surgical
treatment that I'm going torecommend to you is going to
change.
So the first surgery could beas simple as performing what's
called a medial eminenceresection, which is essentially

(33:36):
where I just go in.
I make an incision down to thatbump that you see on the inner
aspect of the foot that iscaused by the metatarsal head,
the bone that's there and Isimply resect as much of that
bone as I can.
I remove that bone, I take itout of the foot so that way
there's not as much of aprominence at that part of your
foot and hopefully you're ableto get back into shoe gear more
comfortably and just feel alittle bit better overall.

(33:58):
There's a very specific set ofpatients that that that would
benefit.
The downside to that type ofprocedure typically is that you
you're probably going to havesome form of a bunion when all
is said and done.
So it's really more for myolder patients, my sedentary
patients.
Maybe my patients aren'tconcerned that their bone is not
of a high enough quality wherethey're going to be able to heal

(34:20):
if I'm making any bone cuts orperforming fusions.
So it's a very specific type ofpatient that's going to get
that type of surgery with me.

Robert A. Kayal, MD, FAAOS (34:29):
And I think it's important to
emphasize on that note thatbunion surgery is not typically
performed for cosmetic reasons.
Right?
We're not doing this forcosmetic reasons.
We're doing this primarily formechanical reasons, and for
paint more than anything.
Right?
What other surgical options areavailable?
Right?

Mark Sheehan, DPM (34:48):
So the next option, the next most aggressive
option, if you will, would bewhat's called the distal
metatarsal head osteotomy, andso what I do in this procedure
is I make the same incision as Iwould for a medial eminence
resection.
I go down to the head of thefirst metatarsal and I make
what's called an osteotomy or abone cut.
In this particular case it's aV shaped cut into the head of

(35:14):
your first metatarsal and itseparates the head of the
metatarsal, so the portion ofthe metatarsal that is closest
to your toes, from the body orthe shaft of the metatarsal.
And what that allows me to dothen is to shift that head, or
what we call the capitalfragment, towards the outer part
of your foot, back into analigned and corrected position,

(35:34):
directly over your sesamoidbones and directly exactly where
the the metatarsal head shouldsit from a biomechanical
standpoint and an alignmentstandpoint.
I then hold that bone inposition using either one or two
screws that I place across thebone, and then we allow that
bone to heal over the nextseveral weeks with your foot in
a corrected position.

(35:54):
When I do that, when I movethat metatarsal head over,
typically your toe will moveback into a corrected position
in an equal and opposite manner.
So as I'm moving the metatarsalhead back into a corrected
position, the soft tissuestructures that are connected to
it allow the toe to move backinto a corrected position as
well.
However, when I am doing thisprocedure intraoperatively, I'm

(36:15):
also looking to balance out softtissue.
If necessary, I'm looking topossibly perform what's called
an achinosteotomy, which iswhere I make a small bone cut on
the proximal phalanx or thebase of your first toe, the bone
of your of the base of yourfirst toe.
I do whatever I need to toalign the foot perfectly back
into a straightened position sothat from a biomechanical

(36:36):
standpoint, from a cosmeticstandpoint and from a just an
ambulatory standpoint in general, you're able to have a perfect
foot again.
The third surgical optionavailable to patients is
reserved for individuals whohave a more severe bunion
deformity.
These are the patients thatI've had the bunion deformity,
usually for a long period oftime.
They're really struggling toget into their shoes, they're

(36:57):
having a lot of pain and thedeformity itself is much larger
than someone who's only had abunion for, say, a couple of
years.
This procedure is called thelapidus procedure and what I do
is, instead of addressing thebunion deformity at the big toe
joint.
I actually go further back intothe midfoot, I go to the base of
the first metatarsal and Irealign that entire bone back

(37:19):
into a corrected position.
I then hold that bone in itscorrected position by fusing the
bone at the base.
So I'll take plates and screwsand I will prepare the joint to
be fused.
So that way, when I put yourbone back into the position that
it should be in and then I holdit in place with these plates
and screws over the followingweeks, that site will fuse

(37:40):
together, it'll solidify.
It's almost like cementing thebone in place so that your first
metatarsal is corrected.
And by doing that, bycorrecting the alignment of the
first metatarsal, the great toe,your big toe, will also move
back into a corrected andaligned position as well,
therefore correcting your buniondeformity.

Robert A. Kayal, MD, FAAOS (37:59):
It seems like the more severe the
deformity, the more proximalyour surgery gets right.
So the less severe or the moremild cases can be treated
primarily at the great toe joint, the metatarsal phalangeal
joint.
And as the deformity has becomemore severe or recurrent
deformities, the operationsthemselves become bigger, larger

(38:20):
, more invasive and moreproximal, closer more to the
ankle right than the forefootitself.
And we didn't really talk about.
I know you mentioned thelapidus procedure or the fusion
of the metatarsal joint, butthat can also be performed for
instability at that jointcorrect.

Mark Sheehan, DPM (38:38):
Correct.
Yeah, so sometimes when I'mdealing with patients who have a
flat foot deformity or, if I,patients who are hypermobile at
that joint meaning they'religaments that are holding the
bones in place are too lax andtoo loose that's a great
procedure to do there as wellbecause, as I mentioned before,
it solidifies that bone intoplace.
Those bones and that joint isno longer going to be moving.

(38:59):
Everything is rock solid, sothat's not going anywhere.

Robert A. Kayal, MD, FAAOS (39:02):
So what's the fourth surgical
option that you consider whenevaluating patients with bunions
?

Mark Sheehan, DPM (39:07):
Sure.
So the fourth option, similarto the medial eminence resection
, this is an option that'sreserved for a very specific
subset of my patients, but thisis to actually fuse the big toe
joint.
So I'm fusing the firstmetatarsal and the base of your
big toe.
I typically reserve this forpatients who have some sort of

(39:29):
underlying pathologicalcondition or some sort of
underlying disease, mostspecifically, individuals who
come in with rheumatoidarthritis or history of
rheumatoid arthritis.
When you have rheumatoidarthritis in your hands and in
your feet, you get what's calledulnar deviation of the digits,
meaning that all of your toesreally, or all of your fingers,

(39:49):
if the disease is allowed toprogress for a long enough
period of time, will begin todeviate towards the outer part
of your foot, and so when thathappens to your great toe,
that's by and large what abunion is.
The problem is when you try todo surgical procedures as I've
already mentioned, the lapitisprocedure, the distal metatarsal
head osteotomies on someone whohas rheumatoid arthritis,

(40:10):
because that joint is sounstable and they have that
underlying disease process, thelikelihood of a recurrence
developing over time, whetherthat be a year after the surgery
or 10 years after the surgery,is very high.
So we need to do somethingthat's a little bit more
aggressive for these patients,and typically that is to fuse
the bones at the at the greattoe joint so that the toe is in

(40:33):
a aligned and corrected positionoverall and it stays that way.
It's the soft tissue doesn'thave a chance to pull that toe
back into a deformity.

Robert A. Kayal, MD, FAAOS (40:42):
Yeah , absolutely, and I think that
principle is applicable also toinflammatory conditions such as
gao and cerebral palsy downsyndrome.
There's other conditions that Iknow you would often indicate
patients for fusions.
So in general, dr Sheehan, whenit comes to the post-op, of
course, after your surgicalmanagement of bunion deformities

(41:02):
, what's typical for yourpatients, Sure.

Mark Sheehan, DPM (41:04):
So when I'm addressing the patient with an
osteotomy meaning I'm making abone cut and I'm shifting bone
over maybe I'm doing some softtissue rebalancing, where I'm
cutting certain soft tissues orsuturing together other soft
tissues to rebalance the footand the structure of the foot.
When I do that type ofprocedure my goal is to get the

(41:25):
patient back onto their foot assoon as humanly possible.
So I allow all of my patientswho have either a medial
eminence resection, where I'mjust removing a portion of their
bone, or who have a distalmetatarsal head osteotomy, where
I'm shifting the the metatarsalhead over and holding it in
place with screws, to beginwalking on their foot as soon as
possible.
I tell all my patients you canwalk the next day if you want to

(41:48):
.
It's going to be in a hard soldpostoperative shoe.
You'll have crutch assistanceif necessary and you're going to
have a little bit of pain anddiscomfort, but if you can
tolerate it, you can.
You can.
You can walk flat footed, youcan walk on your heel, you can
place some weight down throughthe foot and begin to ambulate
as soon as it's tolerable foryou.

(42:09):
Those patients all bonetypically takes about six to
eight weeks to heal in adults.
So I get them out of thepostoperative shoe.
Once I have good x-ray evidence, good Radiographic evidence, of
healing across that osteotomysite, I'll get them back into a
regular shoe at that point andI'll usually recommend a course
of physical therapy as wellbecause, as they're healing,

(42:31):
whenever we do any sort ofdissection there's always some
Scarring that's going to occurduring the healing process.
So we want to try and loosen upthat scarring and Get their
range of motion to the to thegreat toe joint back as quickly
as humanly possible.

Robert A. Kayal, MD, FAAOS (42:44):
So you'll start that immediately.
The early range of motion ofthe I usually have them.

Mark Sheehan, DPM (42:48):
If they can tolerate it, I'll have them do
some at-home range of motionwhere they they either try to
bend the toe themselves or theymanipulate with their hand to
some degree.
Once I am confident that thebone has healed adequately,
that's when I put them into anactual regimented course of
physical therapy right now.
Now that differs in comparisonto when I perform a fusion,
because when you do a fusion,you're trying to trick the body

(43:11):
into thinking that there isn't ajoint there any anymore.
Where there has been a jointfor the patient's entire life,
you need to allow the body thenecessary recovery time and and
healing time for that joint tofuse to, to heal across and to
become bone.
The less movement or potentialfor movement that you have at

(43:32):
that joint, the better, which iswhy we go in with plates and
screws and perform these, theseConstructs that hold everything
in as as rigid or as close to asrigid of a position as possible
.
So, with that in mind, what I,what I do, my postoperative
protocol when I'm doing alapidus procedure, if I'm doing
a fusion of the great toe joint,is to have the patient remain

(43:54):
non-weight bearing for at leastfour weeks, meaning they'll be
off the foot with eitherCrutches a walker.
I prescribe knee scooters veryfrequently.
That's much more tolerable forpatients and I have them stay
off the foot for this period oftime, sometimes even longer,
sometimes six weeks, sometimeseight weeks.
It depends on when.
I see good Evidence of fusionon x-ray so that I can safely

(44:15):
tell the patient Okay, your boneis, your bone is healed, the
fusion has been successful.
You can get back to walking atthis point.
I'll usually at that point putthem into a walking boot.
I don't want to just take themfrom you know six weeks of not
putting any weight on their footand say, all right, get back
into Sneakers and go for it.
I'll put them into a walkingboot and allow them to slowly

(44:35):
transition and get used to theirtheir new foot so they can
start putting weight downthrough the foot comfortably in
a boot for a course of severalweeks.
I'll have them start physicaltherapy at that time.
I'll have them start at homerange of motion and then, once
they're comfortable walkingfully in that boot, I'll get
them out of the boot, back intoregular shoe gear, continue the
physical therapy if necessaryand have them on their way as

(44:55):
soon as possible.

Robert A. Kayal, MD, FAA (44:56):
That's great.
That's great.
I think it would be nice totake this opportunity to just
demonstrate for our viewingaudience some pictures and
photographs of Patients withmild, moderate and severe bunion
deformities.
Sure.

Mark Sheehan, DPM (45:09):
This is an x-ray of what I would consider
to be a normal foot.
This foot does not have abunion deformity.
This is a very normal, wellaligned and well positioned foot
and x-ray.
As you can see, the Anglebetween the first and the second
metatarsal the firstintermediate arseal angle, is
about nine degrees or less.

(45:29):
The Halix valgus angle is 15degrees or less.
The big toe itself is justpointed in a in a straight
position.
It's in good, proper alignment.
This patient is going to beable to propel themselves
forward adequately.
They're going to have good,pain-free Ambulation and good
range of motion at their big toejoint.
You can also see that the twosesamoid bones sitting below the

(45:52):
first metatarsal head are infact below that first metatarsal
head.
They're in a good position aswell.
They haven't deviated In alateral direction or towards the
outer part of the foot.
Everything about this x-ray tome is Showing a good,
anatomically aligned andpositioned foot overall.
Now let's compare and contrastthat normal x-ray to this x-ray

(46:13):
that I have before you.
This is what I would considerto be a mild to moderate bunion
deformity.
You can see that the firstinter metatarsal angle or the
angle between the first and thesecond metatarsal bones is
Increased to some degree.
There's Deviation of the twobones of the great toe towards
the outer part of the foot,which creates an increase in the

(46:35):
angle between the great toebone and the first metatarsal,
or or an increase in the firstor in the halix valgus angle.
And you can also see that thewhat we call the fibular
sesamoid is Sticking out and andmuch more prominent and
apparent on this x-ray, insteadof sitting directly underneath
the first metatarsal head in theposition that it should be.

(46:55):
And finally, let's comparethose first two x-rays to this
x-ray here.
In this x-ray, I would considerthis to be a severe bunion
deformity.
You can see that there is amuch larger increase in the
first inter metatarsal angle.
You can see that there's almostcomplete dislocation of the
great toe at the big toe joint.
You can even, if you lookclosely, begin to see what

(47:18):
appears to be some arthriticchanges occurring in that joint
as well, which is most likelyone of, if not the main, source
of pain for the patient in thisspecific instance.
This type of Sir, this type ofdeformity, as we mentioned
previously, would require aSurgery known as a lapidus
procedure, in which I'm going tofuse the first metatarsal at

(47:43):
the at its base, afterrealigning the first metatarsal
into a corrected position overthe sesamoid bones and
Subsequently correcting thealignment of the great toe so
that it sticks in aStraightforward position on the
foot as well.
This is an image of what Iprototypically see with patients
who come in complaining ofbunion deformities.
You can clearly see that theyhave a we call a large medial

(48:08):
eminence or a bump growing onthe inner aspect of the forefoot
.
In this unfortunate patientthey have a deformity on both
feet.
You can also see that the greattoe, and to some degree the
lesser toes as well, are notpointing straight ahead.
They're deviating and movingtowards the outer portion of the
foot, which Puts the patient ata biomechanical disadvantage.

(48:32):
It makes it so that their footis no longer anatomically
aligned and it Reeks havoc in away on the big toe joint so that
step after step, they're moreprone to developing pain and
discomfort at the first toe, atthe great toe joint, which is
usually what brings them into myoffice to begin with so thank
you so much, dr Sheehan, forthat demonstration for our

(48:52):
viewing audience, I think.

Robert A. Kayal, MD, FAA (48:54):
Lastly , I'd like to just broach upon a
topic called Juvenile buniondeformity, a very small subset
of patients that you may seerarely in the office With these
juvenile bunions.
Can you comment on theprevalence and treatment of
juvenile bunion deformities?

Mark Sheehan, DPM (49:13):
Sure so as you alluded to, juvenile bunions
are significantly more rarethan their counterparts in
adults, adult bunion deformities.
Typically with a juvenilebunion there's some underlying
pathology that is causing thebunion to to form.
This could be Alligamentouslaxity problems.

(49:34):
So individuals who haveEllers-Danlos syndrome, marfan
syndrome, all these differentdiseases that cause hyper laxity
or loosening of the ligamentsin the in the patient's foot,
there can also be or in theirentire body, I should say there
can also be underlying or amuscular Problem.
So you can have patients withcerebral palsy, spina bifida, an

(49:57):
array of differentneuromuscular Diseases and
disorders that cause animbalance of the musculature
Throughout a patient's body andin their foot, specifically at
the first metatarsal phalangealjoint, at the big toe joint.
So whenever I have a patientthat comes in who is a Teenage
or a preteen, even children whoare in an elementary school and

(50:19):
they have a Bunion deformity,particularly individuals who
have more severe buniondeformities, I'm always asking
the patient themselves and moretimes and not the parents if
there's on any underlyingNeurological disorders, diseases
, if they had a normal, a normalbirth or any sort of traumatic
birth experience.
I'm trying to get out why thepatient has this deformity,

(50:42):
because it's not something thathas just progressed over time in
the way that an adult Buniondeformity typically does.
When it comes to treatingpatients for bunion deformities,
the strategy changes a littlebit.
We I Try to avoid and it'srecommended that you try to
avoid surgery unless it'sabsolutely necessary, and that's
for a number of reasons.

(51:03):
Number one these are children,so you want to try and treat
them conservatively as as muchas possible initially and avoid
the, the trauma and thepostoperative process of having
having a surgery done.
Number two is the patients arestill growing.
They have open growth platesthere, the foot is still
developing and so when youperform surgery, particularly a

(51:26):
surgery where you're going to beaddressing bone and potentially
cutting bone, you have to beaware of these open growth
plates.
You have to be aware of thefact that the patient is still
growing, because if you causeany damage to those growth
plates, you can stunt the thegrowth of that bone and you can
cause harm.
Essentially, you can force thepatient to have that bone not

(51:47):
grow in a normal manner as theycontinue to mature and get older
.

Robert A. Kayal, MD, FAAOS (51:51):
And even if you don't cause harm to
the growth plate, given the factthat the growth plates are over
, given the fact that thosegrowth plates are still open,
there's a much higher recurrencerate.
Right, absolutely.

Mark Sheehan, DPM (52:01):
Yeah, very much so, and that that's a very
good point, because when, whenwe do decide to treat juvenile
bunions surgically, becausethere's such a high recurrence
rate due to the typicalunderlying Pathologies or
diseases that that patient mayunfortunately be dealing with,
we have to be more aggressivewith our surgical approach.
Typically, fusions are are theway to go there.

(52:25):
They're the surgery that werewere recommending to the patient
and their parents, and when youdo that, you bring those growth
plates into play first andforemost, but secondarily.
Fusions are permanent.
So if you're performing afusion on someone who's eight,
nine, 10 years old, they havethat fusion for the rest of
their life.
They no longer have the abilityto use that joint for the rest

(52:46):
of their life.
So there has to be usually alot more education for the
patient and their parents.
That's involved when you'respeaking to them about their
options, and you need to be waymore careful and way more
diligent about choosing thecorrect patient to perform a
surgery on, just because of thenature of the surgery itself.

Robert A. Kayal, MD, FAAOS (53:02):
Yeah .
So the point is it's a rarecondition, thank God anyway.
And when we do see thosepatients, if we do end up
recommending surgery, we try andwork in earnest to try to delay
it, at least until they'reskeletally mature what we call
skeletally mature and the growthplates have closed, because at

(53:22):
that time we can treat them morelike adults and there certainly
would be a lower recurrencerate.
So we try to treat them asconservatively as possible until
they're done growing Correct.
Well, this has been a veryenlightening conversation with
you, dr Sheehan, veryinformative.
I think it's important for usto communicate to our viewing

(53:42):
audience a major take home here,because we talked a lot about
bunion deformities, the etiology, the presentation, the
treatment.
But I think it's important toemphasize and reemphasize the
fact that bunion deformities arenot just a cosmetic problem.
A lot of patients look at theirfeet and they're concerned about
the aesthetics and the cosmesisof their feet and they wanna

(54:04):
get their bunions addressedbecause of the cosmesis.
And we don't do typically bunionsurgery for cosmetic reasons.
We do them for the mechanicalreasons that we discussed and
the secondary problems that candevelop because of these
mechanical problems and thedeleterious effects that bunion

(54:24):
deformities have on gait, thecrowding phenomenon.
The bunions can often lead tohammer toes and other
deformities transversemetatarsalgia issues that can
cause patients problemsintractable plantar keratosis we
haven't even mentioned aboutthose.
There's a lot of secondaryproblems that can occur from

(54:44):
bunions.
So what is your take homemessage to our patients about
their bunions?
Should they just continue toself monitor and observe their
bunions or will they be betterserved by seeing a physician
like you early on, so you canhelp quarterback their care, to
monitor them, to help guide themwhen you are able to

(55:07):
potentially pick up on problemslike transverse metatarsalgia
that's developing, or hammer toedeformities or intractable
plantar keratosis that aredeformity and calluses that can
cause major problems to themdown the road?

Mark Sheehan, DPM (55:24):
Yeah, and I think that's a great point.
I think, first and foremost,bunions cosmetically they don't
look the best.
There's clearly an abnormalitynoted with the foot, but the
bigger take home is that abunion deformity is a
biomechanically disadvantagedfoot, and our feet are so

(55:46):
important to our everyday life.
We use them literally thousandsof times per day.
So if you have a buniondeformity, your foot is working
suboptimally.
I think, as with most things,the sooner you get into see a
physician, have them evaluateany problems that you think you
may have, whether it be a bunionor otherwise the better off
you're gonna be ultimately,because I see this every day.

(56:08):
I know how this can progress, Iknow how this will progress and
I know the potential problemsthat will form as a result of a
progressing bunion deformity.
So the sooner you can get intosee me or a foot and ankle
surgeon in general, the betteroff you're gonna be ultimately,
because I'm gonna be able toguide you.
I'll be able to hold your handand tell you hey, listen, this
is what I need you to do now totry and slow this progression

(56:31):
down.
This is what you can do to bemore comfortable.
This is what I can do for you.
To make you more comfortable, Ican educate you on what's going
on.
I can kind of take thequestions out of your mind so
that you know exactly whatyou're dealing with and how it
has the potential to affect yougoing forward.
I think it's a good point thatyou made.
Very not very often, butfrequently I'll have patients

(56:53):
that come in and they say, hey,they know what they have.
They say, hey, I have a buniondeformity.
I would like this treatedsurgically, I would like this
fixed.
And the first question that'salways out of my mouth is does
it hurt you or you're having anypain or discomfort?
And if that answer is no veryrarely am I going to recommend
surgery at that point for them.
This is not a cosmetic problem.

(57:13):
We're in the business of tryingto help people get out of pain.
We're in the business of tryingto help people live their daily
lives as optimally as they can.
So we are not in the cosmeticsbusiness, for lack of a better
term.
We do surgery to try and helppatients live their life fully.

Robert A. Kayal, MD, FAAOS (57:34):
But the good news for those patients
that are seeking resolution oftheir bunions for cosmetic
reasons is that most of themultimately have secondary
problems that will force ourhand to fix those bunion
deformities.
So for us, we're fixing thesebunion deformities for
mechanical reasons and as abonus, the patients' cosmetic or

(57:55):
aesthetic issues are addressedbut that's probably the best way
I can describe it Big bonus forthem.
But we're doing it for all theright reasons, not the aesthetic
and cosmetic reasons.
But in the end, if your bunionis that bad and that's severe
and that prominent, chances areyou will have these crowding
phenomenon issues that we areconcerned about as orthopedic

(58:20):
and foot and ankle surgeons andwe'll end up probably fixing
that anyway for those reasons.
Correct.
So thank you so much forspending this time with us, dr
Xi, and this has been veryinformative, very enlightening.
I appreciate you taking thetime out of your busy schedule
to inform our audience aboutthis relatively prominent and

(58:41):
debilitating condition calledHalix Valgus, bunion Deformities
, and thank you so much forjoining us.

Mark Sheehan, DPM (58:46):
Thank you very much for having me.
I appreciate it.
Thank you so much.