Hallux valgus surgery

A "hallux valgus operation" in conventional parlance summarises all surgical corrections of a so-called hallux valgus, a bunion. The surgical therapy procedures offered by Dr Tonio Gottlieb are performed on an inpatient or outpatient basis, depending on the operation.

The course of treatment and therapy varies depending on the patient and is based on different criteria. These are:

• the severity of the hallux valgus deformity,
• the cause of the malposition,
• the intensity of the pain (here it is important to have an exact picture of the complaint and to know the suffering caused by it),
• the degree of mobility or the patient's demand for mobility
• the general and health status of a patient

In both severe and mild forms of hallux valgus, the origin is a separation of metatarsal bones I and II, to which the big toe and the second toe are attached. This separation of the two bones increases the angle between them. This enlargement can develop in very different ways over time and lead to pain and a wide variety of movement restrictions.

Basically, there are two therapeutic approaches with different characteristics to remedy hallux valgus and possibly reduce or completely get rid of the pain associated with it for many years.

One can decide between the symptomatic and the causative approach. The symptomatic approach treats the existing symptoms, i.e. the signs of hallux valgus. In the causal approach, on the other hand, the aim is to eliminate the cause of the hallux valgus.

What are the symptomatic therapies and surgical options for the treatment of hallux valgus?

In low to moderate degrees of hallux valgus, the angle between metatarsals I and II can be influenced by so-called joint-preserving and at the same time load-stable adjustments of the first metatarsal in such a way that the angle between these two metatarsals is reduced again and possibly returns to its original shape. Load-stable means that the foot can be fully loaded shortly after the operation.

In concrete terms, this means that in the case of a small splayed angle (intermetatarsal angle), the angle between the two inner metatarsals and thus the hallux valgus are corrected by a v-shaped bony conversion operation of the first metatarsal. This bony conversion (osteotomy) is called chevron osteotomy or surgery according to Austin and describes the surgical procedure including soft tissue correction.

The reduction of the angle works in such a way that the bone part far from the body is shifted towards the outer edge of the foot and the angle is thus reduced. In principle, this operation can also be performed in a minimally invasive way (MIS = minimally invasive surgery).

In the case of moderate hallux valgus deformities, i.e. those that are already somewhat larger and more pronounced, with an angle of 13-16°, another surgical procedure is more promising: instead of the v-shaped transection of the first metatarsal bone, as in the chevron osteotomy, the correction is carried out by means of a z-shaped incision, the Scarf osteotomy. If this incision includes soft tissue correction, it is called a Meyer Scarf operation.

The near-body or so-called base wedge osteotomy can basically correct any angle compared to the scarf and chevron osteotomy. In this hallux valgus surgical procedure, a wedge is removed from the base of the first metatarsal close to the body with the aim of ultimately reducing the spread between the first and second metatarsal again. This base-wedge osteotomy can also be used to treat high-grade, i.e. very pronounced, hallux valgus deformities.

This surgical treatment is also purely symptomatic, as the cause that led to the metatarsal bones moving apart is not treated. The advantage of this procedure is that the relief time of the foot in the healing phase can be reduced to approx. 4-6 weeks after the operation.

All of the above symptomatic procedures are surgical techniques that can straighten the big toe, i.e. reduce or even completely remove a hallux valgus. However, causes such as instability of the tarsal or metatarsal junction are not cured with these procedures. There are different opinions and publications on this among experts.

What are the causative surgical procedures for hallux valgus?

One of the main causes of limited weight-bearing capacity of the foot is instability between the tarsal and metatarsal bones. This can lead to hallux valgus or aggravate an existing hallux valgus. Therefore, stabilisation in this area of the foot is not only a therapy for hallux valgus, but also an increase in the load-bearing capacity of the foot.

With a lapidus arthrodesis, any degree of hallux valgus deformity can be eliminated causally and thus sustainably. Depending on the cause and origin of the hallux valgus, the mobility between metatarsal bones I and II and the tarsal bones is stiffened in this procedure and the foot is thus made more resilient.

The mobility of metatarsals I and II and the tarsal bones were originally necessary for the gripping function. Due to the bipedal gait, this gripping function has given way to a static function. This static function can even be better guaranteed without excessive mobility.

The only disadvantage, which you as a patient should accept as sustainably rewarding, is that relief is required during the healing phase. This is about 8 weeks. The extremely positive and important side effect from this surgical procedure is that the hallux valgus, i.e. the bunion of the big toe, disappears as a result of this surgical procedure. The results from lapidus arthrodesis are very aesthetically pleasing in addition to being long-lasting.

Dr. Gottlieb selects the right procedure for hallux valgus surgery with you

The decision which of these procedures to choose depends not only on the deformity but also on the patient's expectations and level of suffering. Age, special wishes for sport and exercise or even enduring pain for several years and the like also play a role here.

Much is subjective and should be discussed openly with the attending physician. At the same time, the surgical effort must be compared to the risks.

It must also be taken into account that a symptomatic approach or no correction at all can also involve risks: Damage that can occur over time is severely limited mobility and mobility. These in turn can lead to complete instability of the foot and to a severely limited performance associated with it. The type of operation therefore also depends on your exact symptoms and your expectations and goals.

Depending on how severe the pain is, what the underlying causes are, how many years you have been suffering or how severely your mobility is restricted, Dr. Gottlieb will decide together with you on a specific surgical procedure or combine different procedures depending on the circumstances.

Wounds generally heal better when they are not exposed to mechanical stress, such as that which occurs in everyday life. In the context of inpatient treatment, optimal protection of the foot and the surgical area can be ensured. In the case of minor operations, however, protection in the private environment may be sufficient. In these cases, outpatient treatment is possible.

Dr Gottlieb, the specialist foot surgeon in Berlin, advises coming to his consultation early:

"The aim is to maintain or restore your mobility as well as possible. After a detailed examination, I will recommend the most suitable procedure for you."

 

What complications can occur with a hallux valgus surgery?

Basically, the established surgical procedures that Dr. Gottlieb uses can be classified as very low-risk, especially due to his many years of experience. Before any potential hallux valgus surgery, possible risk factors are individually clarified and discussed with you. This allows us to check whether you fulfil the prerequisites for having such an operation.

An operation is considered as soon as complaints are present that cannot be adequately treated with conservative means. These complaints include:

• Increasing pain in the bunion and foot
• Swellings
• Joint irritation
• Inflammations
• Shoe fit problems
• Pressure points
• frequent feelings of instability
• Restriction of the load-bearing capacity of the feet
• Pain due to overloading of other regions (metatarsalgias)
• Pain due to wear and tear of adjacent joints (arthrosis)
• Impending ulcers, which can also be painless
• With diagnosed diabetes mellitus

Of course, a hallux valgus operation is not an emergency operation. Careful consideration of the pros and cons is required. The risks of the operation must be weighed against the discomfort and the effort involved. These must be presented very precisely and also very patient-individually in advance. Therefore, let Dr. Tonio Gottlieb advise you comprehensively and give you a clear recommendation for action.

When should hallux valgus surgery not be recommended?

This question is not easy to answer. The guideline is: If the complaints together with the risks without surgery do not justify the risks of surgery, surgery should not be performed. Here, too, subjective feelings play a role in the decision-making process.

Reasons that could stand in the way of an operation are always considered by Dr. Gottlieb in the patient's overall picture in order to be able to decide appropriately whether a hallux valgus operation should actually take place. His experience gained in numerous patient cases forms the basis for a well-founded treatment recommendation.

Are the costs reimbursed by the health insurance fund?

The costs of hallux valgus surgery are covered by statutory and private health insurance funds if medically necessary. This means that if an operation is useful or even unavoidable for restoring healthy joint function or stopping the progression of joint wear, it will be paid for by the health insurance funds. However, the individual insurance status of a patient must be considered in detail.

The costs of surgery for patients with statutory health insurance who can be treated as inpatients in a hospital providing basic and standard care are covered by the health insurance fund. Outpatient costs must always be settled according to the doctors' fee schedule. Reimbursement depends on the health insurance fund or the individual insurance contract.

How long is one usually unable to work after a hallux valgus surgery?

The length of the inability to work is determined depending on the surgical procedure and the patient's occupation. If you have a sedentary occupation, you can resume work after about 2 weeks, depending on the healing process. In the case of standing professions, the resilience must be assessed individually after about 8 weeks.

The goal after hallux valgus surgery is to relieve and protect the foot. After two weeks, wound healing is usually complete and the integrity of the foot must be restored. This goal can be achieved as early as possible through physiotherapy and the familiar use of the feet can thus be resumed promptly. This concept serves the early restoration of your quality of life.

Depending on the surgical procedure used, these approaches of Dr Tonio Gottlieb's foot surgery practice apply to aftercare:

If the hallux valgus has been corrected in a manner after which full weight-bearing is allowed foot can be carried out immediately in a bandage shoe (approx. 6 weeks wearing time)

The dressings are changed 7 days after the operation and the stitches are removed after 14 days. Accompanying physiotherapy takes place as needed after 14 days earliest.

The progress control is carried out in this rhythm:

Clinical progress checks take place every 14 days, more often if necessary, an X-ray check approx. 5-6 weeks after surgery and a final clinical and radiological check approx. 12 months after surgery.

If the correction of the hallux valgus has been carried out through stabilization of the tarsal / metatarsal junction, a short phase of relief is carried out for 2 weeks in a plaster cast. This allows complete regeneration to take place and follow-up care to restore the functions of the foot.

The stitches are removed at the same time as the first dressing change 14 days after the operation. This is followed by the fitting of a plaster replacement boot (called an orthosis or walker) for the foot and lower leg. At the same time, physiotherapy begins as needed. The walker is taken off again after about 6 weeks. The resumption of weight-bearing can be supported with insoles for 4 weeks.

Clinical follow-up checks are carried out every 14 days, more often if necessary, an X-ray check is carried out approx. 6 weeks after the operation; the increase in load is also carried out after approx. 6 weeks, depending on the X-ray result. A final clinical and radiological check is carried out approx. 12 months after the operation.

The aim is to restore your ability to do sports usually 12 weeks after the operation so that you can get back to your usual movements as quickly as possible.

How long does any pain last after a hallux valgus operation?

During the anaesthetic, the foot is treated with a so-called foot block. With such a foot block, the nerves that supply the foot are washed around with a painkiller. This gives you freedom from sensation and pain for up to 10 hours after the operation, as this is usually the time of greatest pain due to the operation.

Afterwards, the emergence of pain is prevented by a targeted, fixed pain medication. Once the patient is pain-free, the painkillers are gradually reduced to achieve an optimal dosage.

How long does the swelling last after a hallux valgus surgery?

After a hallux valgus operation, swelling of the affected joint may occur temporarily. This swelling continues to decrease over time. However, the extent and duration of the swelling varies from patient to patient and also depends on the surgical procedure used and the extent of the operation involved.

The process of swelling reduction can be professionally accelerated by lymph drainage and by elevating the operated foot. Appropriately soft and wide footwear can also be worn while the swelling persists.

Is a special form of gymnastics useful after hallux valgus surgery?

The aim of aftercare for a hallux valgus operation is to fully mobilise the operated joint again and put weight on it.

One of the most important follow-up treatments of an operated metatarsophalangeal joint is therefore physiotherapy. Dr. Gottlieb will give you instructions for self-performed physiotherapeutic exercises as soon as wound healing permits.

Optimum aftercare is usually achieved by using a physiotherapist to perform manual therapy after the wound has healed.

Additional lymphatic drainage can also speed up the reduction of swelling after surgery, as explained earlier. Lymphatic drainage can be a further strengthening for your foot so that flexibility and movement can be regained as quickly as possible.

Does surgery reduce the likelihood of getting hallux valgus again?

The likelihood of getting a new hallux valgus depends on the primary surgical procedure chosen. The more the therapy is aimed at correcting the cause, the lower the risk of getting a new deformity. Symptomatic operations such as Austin, Meyer-Scarf or basic wedge osteotomies of the first metatarsal bone have the advantage that the affected foot can be put under weight-bearing stability more quickly. However, the higher risk of relapse (recurrence risk) must be considered a disadvantage.

With a lapidus arthrodesis and only with the original technique, a hallux valgus can no longer occur - after correct indication, performance of the operation and completely healed correction.

If, against all odds, a hallux valgus should recur on the same foot, you would like a second opinion, are dissatisfied with your hallux valgus surgery or are still not pain-free, you are in the best hands with the foot and ankle surgeon Dr. Tonio Gottlieb.

As a recognised foot surgeon and one of the few who has the entire foot and body statics in view, you can rely on his years of foot expertise. Make an appointment now at Dr Tonio Gottlieb's specialist foot surgery practice. Even in times of the Covid 19 virus, you can make a personal consultation appointment at any time by appointment.