Emphasizing The Importance Of Radiographs In Choosing A Bunion Procedure

Molly Judge DPM FACFAS

I have enclosed the radiographs (see above) that are associated with the case I presented in last month’s blog (http://www.podiatrytoday.com/blogged/can-you-select-a-bunion-procedure-b...). How does this change your procedure selection and are there any further tests you would order?

As you recall, I encountered a colleague who said he did not need to take radiographs and could tell from clinical evaluation which bunion procedure would best serve the patient. The majority of respondents to the last blog noted that they would not plan any surgical treatments without taking radiographs. I am encouraged by the near unanimous response regarding the need for radiographic evaluation.

To recap, the radiographs above are for a 51-year-old male who complained of “bump pain” on the sides of his feet, with pain worse on the right foot. He claimed the pain had been present for years and seemed to be getting much worse for the last five years. He denied trauma.

The patient had been a strength trainer for 20 years but recently retired and now drives a truck. He told me that his big toe has not moved that much and the bump makes the pain “unbearable” in footwear.

He described the pain as a stabbing sensation when he is weightbearing and a deep ache when he is off the foot. The intensity of the pain is 5/10 when walking into the office but the patient said it can be 10/10 if he is attempting prolonged weightbearing activity. He has not received significant improvement from multiple forms of conservative therapy, including modified shoe gear and oral anti-inflammatory agents such as ibuprofen.

As I related in the last blog, the clinical examination revealed a grossly enlarged prominence about the medial aspect of the first metatarsal of the left foot. Tenderness was evident with manipulation. The hallux was not reducible in the transverse plane despite applying pressure to the medial aspect of the first metatarsal head.

All we need now is to know now is whether anyone would pursue further diagnostic studies after reviewing the radiographs above. I look forward to hearing your comments.

Comments

This doesn't appear to be a straight bunion type issue. The joint is quite eroded and there is very little joint space. The bone is very osteopenic and looks to be cystic at the metatarsal head and proximal phalangeal base.

This may be more of a hallux rigidus type procedure selection. Implant or Fusion depending on patient's expected activity level over the next number of years. I may consider a CT scan to see just how cystic that bone really is if I'm considering a fusion.

Thanks for the insight. And you are right. This is not a straight forward bunion issue. From a clinical standpoint it does seem to be more of a hallux limitus type case. No CAT was done however. Given the fact that the inspiration for this blog was the idea that some believe they do not need x-rays to adequately treat bunions how would you proceed given this scenario and the benefit of the x-rays provided now? I can tell you that the patients serologic testing was within normal limits and specifically serum uric acid and 24-hour uric acid clearance was within normal limits as well. What procedure would you do to provide the most meaningful outcome for a patient with a 20-yr history of being an athletic trainer; collegiate level?

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