How To Get Better Results With Bunion Surgery

Justin Franson, DPM, and Babak Baravarian, DPM

Bunion surgery is perhaps the most common procedure we perform in podiatry. Since bunions come in all shapes and sizes, several different types of procedures have emerged along with various refinements over the years.
Accordingly, let us take a closer look at what makes these procedures work well. Conversely, we need to ask some tough questions.Why do some bunion surgeries fail? Why do some people seem to recover better than others? How can we minimize poor outcomes? Our group has been involved in many revision bunion surgeries so there is a certain level of failures and complications.
In order to facilitate reproducible and successful short- and long-term results, surgeons must consider the impact of appropriate patient selection, patient education and expectations, procedure selection, technical aspects and postoperative care.

Key Patient Factors To Consider With Bunion Surgery
Granted, we are not able to choose the patients we see.We treat those who walk through the door and who are on our insurance plans. However, we are able to choose who we take to surgery. Being a discretionary physician in this regard will help produce more consistent results. For example, most of us would agree that a 65-year-old, one pack a day smoker who weighs 300 pounds is not an ideal candidate for a Lapidus procedure. Indications for purely cosmetic bunionectomies are questionable.
It is important to ask potential bunion surgery patients what they do on a daily basis. Ascertain what they do for work, how much time they can take off and if they have any upcoming trips. See if they have a deadline or a point when they need to be wearing regular shoes. Bear in mind that these “deadlines” can increase the anxiety level for both the patient and the surgeon.
If there is a narrow window for total healing time, avoid squeezing in a procedure. Prolonged post-op edema and pain seem to occur when someone is overly eager to accelerate healing. Patients who try to rush the healing are usually the ones who walk too much too early.We recommend placing a lot of responsibility on the patient after surgery. Explain to the patient that his or her healing is largely dependent upon the patient following your post-op protocol.
Smoking should be a relative contraindication to a Lapidus procedure or a first metatarsophalangeal joint (MPJ) fusion. While some smokers can heal a fusion, smoking certainly increases the risk for delayed union and nonunion of the arthrodesis. If the patient really needs a Lapidus, send him or her to a smoking cessation program. Otherwise, consider an alternative procedure.
Younger patients who develop bunions as young teenagers tend to have a more aggressive deformity that will require definitive corrective treatment to produce a good long-term result. If the patient needs a Lapidus or a base wedge osteotomy, do not shy away from it because the patient is only 16. Open growth plates will obviously play a role in the timing of surgery and the location of correction.
Do not hesitate to encourage patients to wait until they reach skeletal maturity in the first ray. You can address osseous correction more confidently if you are addressing a deformity involving closed growth plates.

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