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Bunions …
A Patient’s Guide
(Probably more than you ever wanted to know about bunions and
bunion surgery)
By:
Michael Zapf, D.P.M.
Diplomate, American Board of Podiatric Surgery
Fellow, American College of Foot and Ankle Surgery
Diplomate, American Board of Podiatric Orthopedics
Fellow, American College of Foot and Ankle Orthopedics
Associate Professor, California College of Podiatric Medicine
Assistant Clinical Faculty, L. A. County / U.S.C. Medical
Center
Voted Best Podiatrist by The last two L.
A. Daily News Readers Polls
From the office of
Michael Zapf, D.P.M. and Darren Payne, D.P.M.
28240 Agoura Road, Suite 101
Agoura Hills, CA 91301
Phone: (818) 707-3668
Fax: (818) 889-3655
227 W. Janss Road, Suite 315
Thousand Oaks, CA 91360
(805) 497-6979
Revision 7-25-2002 ©
(See this in living color on the web site: www.conejofeet.com)
Bunion Surgery A Patient’s Guide
What is a bunion?
A bunion – called hallux valgus in medical speak- is a bony deformity of the
first metatarsophalangeal joint – that is the joint where the big toe meets the
foot.
In a bunion two things happen at the same time. First the first and second
metatarsal bones angle away from each other much like your first two fingers
when you make a "Victory sign." (The metatarsal bones are the long ones behind
the toes – sorry for all the medical terminology.) The second thing that happens
is that the big toe starts to lean over toward the second toe. At first the
second toe acts as a buttress holding the big toe back (as is happening in the
photograph above). Often, however, the second toe gives up and allows the big
toe to creep under and lift it up. This is not a good sign for bunions. If a
bunion gets surgically corrected both the first metatarsal position and the big
toe position need to be put back to where they came from. This almost always
involves making a surgical cut, or fracture, in the bone(s). This is what we
mean by the phrase realignment of the bones.
What causes bunions?
Most bunions are caused by an inherited foot type that leaves the foot
a little bit unstable. Over many years the big toe gets pushed toward the lesser
toes and first metatarsal moves away from the second. Bunions can also develop
after 20-30-40 or more years of cramming them in fashion shoes and walking on
unforgiving surfaces. Other factors include ligament flexibility, flatness of
the feet, foot shape and things as esoteric as whether the metatarsal head is
more flat or round than normal. In non-shoe wearing populations it is estimated
that about 3-8% of adult women develop bunions. In shoe wearing populations the
number is much higher, perhaps 10-20% of adult women and somewhat lower in men.
The difference is, of course, the shoes. Some recent studies indicate that up to
90% of adult American women wear shoes that are smaller than their feet. If you
are curious ask us to measure your feet. We have measuring devices in
both offices.
One thing is true – however – no matter how small or big a bunion is – it
will never get smaller. There are no appliances or pads or creams that make them
smaller. They often get bigger – especially when the tendons going to the big
toe slip to the side of the joint. They can get so big that the likelihood for a
perfect correction diminishes. Bunions should not be ignored.
Could my bunions be prevented?
I have a master’s degree from UCLA in public health – the science of
prevention. There I learned how hard it is to prove prevention. You never
know what would have happened if you did not do the action designed to prevent
something - if that something never occurred. Let me apply this to bunions. If
you can correctly identify the cause of a bunion and can do something to correct
or stop the cause, you might be able to prevent a bunion. A young patient with
flexible flat feet and a family history of bunions will probably also
develop bunions. The inevitably of bunions might be lessened if the foot can
be held in a correct position during development. This is easy in principle –
make an orthotic that slips in the shoes that holds the foot in a
corrected position. (An orthotic is a custom-made shoe insert that is worn in
the shoes that holds the foot in a correct position.) But in practice it
works only to the degree that the patient will wear the devices whenever he or
she is walking. Once the foot is mature – bunion prevention is even dicier. But
in a perfect world every child with a flexible flat foot, especially in a family
with bunions, would have their feet protected with orthotics.
Do my bunions require surgery?
Bunions need surgical correction in any of three circumstances:
First, if they cause pain wearing the shoes you need to wear doing
the things you need to do. If it only hurts in high fashion shoes that are worn
seldom – I generally do not advise bunion surgery if the other two criteria are
not met. Another patient had pain from her rather small bunions when she ran.
Her bunion problem was solved with the proper width running shoes.
Second, they need to be fixed if they measure a large size on the
x-rays. If the angle between the first two metatarsals (remember the victory
sign?) approaches 15º as measured on an X-ray. Above that number the ease and
success of a bunion surgery decreases. When you go for your bunion consultation
you have every right to look at your x-rays and see how the angles are measured.
This x-ray must be taken with you standing with the full weight on the feet to
be meaningful and reproducible. If you come to us with x-rays taken from another
doctor or facility we will ask if they were taken weight bearing. If they were
taken while you were sitting on an x-ray table, we will need to take new ones.
The best results are done on small and medium bunions. Large bunions are defined
as those with the IM angle measuring more than 15º and the HA angle measuring
more than 30º (more on this later).
Finally, if x-rays indicate that there is damage to the joint
caused by the abnormal position of the joint, a bunion surgery should be
considered. Damage includes loss of the cartilage space between the bones and
cysts in the metatarsal head. Normally the bones on an x-ray do not look like
they touch because the cartilage cushion between them is "invisible" to an
X-ray. It is a bad sign if the bones appear to touch. This means a loss of
cartilage and inevitable arthritis. I believe that all bunions will eventually
develop arthritis and that even if we do not see it on the x-ray it is still
going on behind the scenes.
Small
medium
large bunions:
What about the pain behind my 2nd toe? Or a 2nd toe
dislocation?
As a bunion gets larger the first metatarsal bone bears less weight and the
second start to bear more that its fair share of weight. This is the start of
pain in the ball of the foot called metatarsalgia. The pain is
specifically at the site where the second toe meets the ball of the foot. This
area of the foot can swell so much that it looks like there is a small grape
under the skin. Many times this is the chief pain of a bunion and, frankly, it
means you waited too long to fix your bunion. While your first metatarsal
probably started life being parallel to the second as a bunion grows it moves
away and bears less weight. This has, in turn, a bad effect on the second toe
which can start to move. It can more toward the little toes if it is pushed by
the big toe. Other times it can move up and over the big toe. This is called a
second toe dislocation and is very difficult to fix. Having the second
toe dislocate is one of the tragic consequences of a neglected bunion. I caution
you to strongly consider a bunionectomy if there is pain behind the second toe
on the ball of the foot, especially if the x-rays show that the toe is still in
good alignment. Ask to see a copy of the "predislocation" information sheet if
you think you might have this problem.
This picture shows what I call a
"perfect bunion". There is a bump that hurts
but it should be readily corrected. The great part is the perfect alignment
of the second toe (the one next to the big toe). The middle shows a second toe
(and the third, fourth and fifth for that matter) that has given up and has been
pushed to the outside by the big toe. This is, admittedly, a very deformed foot
and the correction will be very difficult. Do not, I repeat do not, let
your feet get like this. Please correct your feet before the second toe
dislocates. The picture on the right shows a second toe that tried to fight back
but lost. It is happily sitting on top of the big toe. Again, this is a very
hard bunion to correct and could have been prevented with a more prompt bunion
surgery.
If you examine my feet and feel that surgery can wait, then what?
If your bunions are not particularly painful, the angle between the first and
second metatarsal is 13° or less, the big toe is not
resting under the second toe and there is no visible damage to the bunion joint
on your x-rays, then surgery can probably be postponed. I recommend that new
x-rays be taken every 6 to 24 months to watch for increases in any of the danger
signs.
If I need a bunion surgery, who should do it?
The only two classes of people qualified to correct a bunion surgically are
orthopedic surgeons and podiatric surgeons. Either profession has people who do
great bunions and those that do not. Here are some criteria you can use to
choose the great ones:
Number per year: There are many intricacies in bunion surgery and the
best results are done by people who do them week in and week out. Many surgeons
only do them occasionally. Ask your surgeon (or his or her office staff) how
many bunions the surgeon does each year. As a rule of thumb, you can expect a
better result if your surgeon does 20 or more bunion surgeries annually.
Active Hospital Privileges: Surgeons typically do their bunion surgeries
in the hospital or a Surgery Center. Hospitals have categories membership
categories for surgeons, depending on how many procedures the surgeon does per
year. Less active doctors are on courtesy, provisional or consulting status.
Busy surgeons are classified as ACTIVE. A quick way to determine if your
surgeon is reasonably active is to call your local hospital (Los Robles Medical
Center is 805-497-2727) and ask to speak to the Medical Staff Office. Ask if the
surgeon in question is on staff and is in the ACTIVE staff category.
Board Certification: Board Certification, at least in podiatry, requires
the surgeon to be in practice for a number of years and have 75 surgeries
reviewed by a board of experts. This qualifies him or her to take a two-day
written and a three-day oral exam. If they pass they are Board Certified.
Because this process is so onerous many podiatrists could not meet these
conditions. A number of alternative boards have been created by these doctors.
Despite how high-fallutin some of the other boards sound, in podiatry there is
ONLY ONE surgery board approved by the American Podiatric Medical Association:
The American Board of Podiatric Surgery (or ABPS).
Podiatrists certified by this board are allowed to join the American College
of Foot and Ankle Surgeons and are then allowed to proclaim that they are
Fellows of the American College of Foot an Ankle Surgeons and use the initials
FACFAS on their letterhead.
Yes, I am ABPS Certified and a member of the American College of Foot and
Ankle Surgeons. I have the right to put all this after my name:
Michael Zapf, D.P.M., M.P.H., F.A.C.F.A.S., F.A.C.F.A.O.M.
The last set of initials means I am a Fellow of the American College of Foot
and Ankle Orthopedics and Medicine. This means I am Board Certified by the only
other Board recognized by the American Podiatric Medical Association: The
American Board of Podiatric Orthopedics and Primary Care Medicine. The M.P.H.,
by the way, is my public health degree from U.C.L.A. in Infectious and Tropical
Diseases. (If you ever get yellow fever of the foot, you know who to talk to.)
I am on the Active staff of Los Robles Hospital and I do one or two bunion
surgeries a week (mostly at the Los Robles Surgery Center).
Dr. Payne is currently Board Qualified as determined by the
American Board of Podiatric Surgery. This means he has completed a Two Year
residency in foot surgery and passed the same test I did to become Board
Certified. After a year or two of gathering cases he will also be deemed Board
Certified. Politics of the organization do not allow him to say on business
cards that he is Board Qualified, but he is.
What about laser surgery?
LASERS cannot be used on bone. Bunions are a bone deformity. Those surgeons
that advertise they fix bunions with lasers are advertising fraudulently.
The ad I reprinted here is an actual yellow pages ad from two local (Glendale,
anyway) doctors. You can tell how they cleverly try to make it seem like the
before and after bunion ads are somehow related to the title: LASER TREATMENT.
Only after you call their office and make an appointment do you find out that
they didn’t really mean to mislead you but bunions cannot be fixed with a
laser. I think this is pretty cheesy. I suspect their entire practice is as
reliable as their advertising.
What about the tri-correctional surgery?
There are dozens, if not hundreds of different bunion procedures devised over
the years. Most of them have one thing or another wrong with them and get tossed
on the scrap heap of medicine. Some procedures have proven to be great and do
everything you would want a bunion surgery to do --- that is, correct the bunion
with a minimum of trauma and a likelihood that the correction will last forever.
There are several great procedures available that have stood the test of time.
It’s your foot surgeon’s job to choose the one right procedure for you and your
foot. There is no one right procedure for every bunion and one must be
leery if someone proclaims that there is only one answer.
An example of a good idea for correcting a bunion is the so-called
tri-correctional bunion procedure. It is an elegantly designed bunion procedure.
I investigated it very carefully before I choose not to perform it – at least
without modification. The procedure calls for a fixation where the tip of a
screw enters the very delicate cartilage on the metatarsal head. I was unwilling
to use a procedure that could unnecessarily damage this important tissue and
perhaps set the stage for future arthritis. I will re-evaluate this procedure in
a few years. Meanwhile, I will let other doctors experiment on their patients. I
prefer only to use methods that already have proven themselves over the years. I
can achieve every bit of correction needed with the bunion procedures that are
already available. A final issue with the tri-correctional procedure is that it
requires a second surgery for the removal of the fixation screw. Some
tri-correctional surgeons have financial interests in the surgery centers where
the second surgery is performed (ask them). These surgeons, maybe innocently,
want their patients to go back to their surgery center for screw removal.
While they might take it our ‘for insurance only’ they are making money on the
back end through their ownership interest in the facility where surgery is being
done. I think that a bunion procedure that requires two separate surgeries is
not very cost effective. I (Dr. Zapf) prefer to use bunion procedures that do
not require a second surgery that can cost additional thousands of dollars.
What do you do in a bunion surgery?
Most bunion surgeries involve (1) removing the bump on the side of the foot
(2) and realignment of the bone and (3) ligaments. The bump is removed with a
small surgical saw. The realignment is done either by loosening some and
tightening other soft tissue structures or by making a surgical fracture in the
first metatarsal and moving the bone to a corrected position. Once it is in its
new position the bone is usually held with some form of internal fixation. It
could be an absorbable or non-absorbable wire, a screw or even a bone staple.
The whole procedure takes less than one hour and is usually done with local
anesthesia and some sedation. The bone cut, itself, is very elegant. It is not a
straight cut through the bone but, instead, it is a "V" shaped cut, sometimes
called a chevron or an "Austin" bunionectomy after its inventor Dr. Dale Austin.
It is so intrinsically stable that some people do not even feel the need to use
any fixation at all.
Some bunion advertisements make a big deal about patients not needing
hospitalization with their specific bunion procedure. Well, truth be told, this
is a bit of disingenuous puffery; not in the same category as advertising laser
surgery, perhaps, but on the same line of thinking. Patients have not been
hospitalized for any bunion surgery since 1985 except in very rare or unusual
circumstances.
Will it hurt?
With the techniques available today for bunion surgery, pain during the
recovery period is a thing of the past. I find that most of my bunion patients
almost never take their full complement of pain pills – and many take only
three or less. This is the same experience with most of my foot surgeon
colleagues.
I do hear from time to time that there are some surgeons who warn their
patients that bunion surgery is always a painful experience. You might want to
avoid these doctors because they are probably telling the truth. In their hands
it probably is a painful experience.
What about "ZINGS"?
After bunion surgery some patients experience an unexpected electrical "zing"
in the area of the bunion surgery. The zing can come at any time, even
when resting in bed. The sensation lasts less than a second but it can be quite
unnerving. You might experience as many as a dozen a day (or none at
all.) The zings do not mean that anything is wrong. It is probably the
healing of the nerves that are retracted at the time of surgery. If you do
experience zings after surgery, they tend to go away after a week or two.
What does it cost?
Most foot surgeons charge between $1500 and $2000 for a single bunion
surgery. (One surgeon in the Valley charges a usurious $12,000!) My average fee
is $1900. Fees above $2500 are clearly excessive. Caveat emptor. The facility
fee (hospital or Surgery Center) is probably another $2000-4000. You can call
the business office of Los Robles Hospital (805-497-2727) or the Los Robles
Surgery Center (805-497-3737) to get specific prices on the facility fee for a
bunion surgery. Past experience proves that they are a little hard to pin down
on exact costs because there are several variables involved but you deserve a
reasonable estimate. Finally there is a charge for the anesthesiologist. This
probably hovers around $400-600. If your surgery is to be done at the hospital
your family doctor will need to give you a pre-operative check (called a pre-op
H&P or History and Physical). Your doctor will charge you for this visit at his
or her usual rate. At the Surgery Center I will usually perform this pre-op
check. If your have significant medical problems like diabetes, heart disease,
seizure disorders and the like I will still send you off to your family doctor
for a "pre-op H&P."
Will insurance pay for a bunion surgery?
Insurance companies nearly always pay for bunion surgery to the limits of
their policy. They do not regard this as a cosmetic condition.
As a service
my office staff will call your insurance company and verify coverage and get
that all important "pre-authorization." Even though we call you insurance
company you are ultimately responsible for all the charges incurred with your
surgery. We try our best but sometimes there are changes made by your employer,
your insurance company or others that we do not know about. Conceivably the
person we talk to on the phone can make a mistake. If any of these things
happen, you will be ultimately responsible for all the charges of your surgery.
Remember only insurance companies can say with a straight face the line,
"authorization of procedure does not guarantee payment."
What can go wrong?
Even if a bunion surgery is performed perfectly, things can still go wrong.
The complication rate for bunion surgery is probably between 2 and 3 per cent.
Prior to surgery you will be asked to sign a consent form that includes these
complications. Among the unexpected complications are:
Infection. Any surgery that requires a cut in the skin can result in an
infection. Fortunately the frequency of bunion surgery infections is quite
low. If you do get one they are obviously treated with antibiotics.
Slow healing of the tissues involved. This can vary from the skin not
being closed in time for the sutures to be removed at two weeks to a delay in
the healing of the bone. A delay in bone healing is one of the most feared
complications. A delay in bone healing is sometimes seen when the bone
fracture site shows bone movement after surgery and sometimes there is no
apparent explanation. In 17 years of performing bunion surgery I have only
seen one case of delayed bone healing. If it happens there are several ways to
get a recalcitrant bone to heal, the most common of which is cast
immobilization and the use of a bone stimulator.
Numbness around the area of the surgery. There is a big nerve along the
bunion that is routinely identified and retracted out of the way. There are,
however, millions of other too-small-to-see nerves that will get sacrificed
during your bunion surgery. These will result in some degree of numbness as
you run your finger along the incision line. In my experience, no one has ever
felt this to be much of a complication, but I wanted you to be aware that it
is possible.
Prolonged pain and swelling. If you find that you need a refill of your
pain pills or cannot get into your tennis shoes in 4 weeks, you are
experiencing more pain and swelling than most bunion patients. The chart above
is an average recovery. If you are much longer than average I will work with
you to speed up your progress. Sometimes you will be sent to physical therapy.
Recurrence of the deformity. The fact that you have a bunion means that
you have some forces in your foot favoring their development. At surgery I
will do what I can to eliminate some of these forces at the level of the
bunion joint. But obviously if they include ligament laxity or severe
flat-footedness, I cannot correct these at surgery. These can be ameliorated
to some degree by wearing custom orthotics in an athletic-type shoe, but this
is impractical for many women. In general, the younger you are when you first
developed bunions the greater likelihood that you have significant foot forces
that led to your bunion. As a rule-of-thumb (rule-of-toe?), subtract your age
from 70 to get the percentage likelihood that your bunion will recur. (This
calculation is my own creation – there are no published articles on this.)
Under or over correction. In a bunion surgery the first metatarsal head
must be moved to a new position. Using my experience and judgment I move it
what I believe to be just the right amount every time. Since this involves a
judgment call there are times when, in retrospect, I realize that the bone
could have been moved a bit more or it was moved a bit less than it could
have. Out of every hundred surgeries, I probably move it too much or not
enough only a few times. Often the patient either does not notice it or does
not say anything about it until I point it out. If it is grossly under or over
corrected it can be only corrected with another surgery.
Lateral metatarsalgia. This ungainly term refers to pain under the
second or third metatarsal heads (see diagram) noticed after bunion surgery.
If the first metatarsal shortens excessively after surgery, excess weight can
be transferred to the second or third metatarsals. The most common cause of
excess shortening after surgery is excess bone resorption where the bone cut
was made. Pain under the second metatarsal is very common even in people who
have never had a bunion surgery. It is caused by a redistribution of weight
from the first metatarsal head to the second and third metatarsal heads. This
causes a pain and sometimes callus or swelling, in the 2nd and 3rd metatarsal
head region of the feet. Many people have some transfer of weight to the
second metatarsal head after surgery and some have clearly too much. Treatment
for this condition can involve cortisone injections, wearing of shoes with
some padding under the ball of the foot and the use of orthotics designed to
shift weight from the second metatarsal. Many of these techniques are
discussed in some of the articles published on my web site:
www.conejofeet.com.
Reduced motion of the bunion joint. Normal big toe joint motion is
about 70° up and 20°
down. Sometimes a bunion surgery will reduce this motion in either direction.
To prevent this complication I want my bunion patients to begin early exercise
of the toe joint. If there are early indications of restricted joint motion, I
will send you to physical therapy.
Sesamoiditis. The sesamoid bones are two peanut sized bones that sit
under the first metatarsal heads (the black circles in the Figure.) When you
walk, nearly all your weight is born by these two little bones when you raise
your heel. Before bunion surgery these little bones are usually out of
position. After surgery they are closer to their regular home. If they have
become arthritic they can hurt in their new, now-correct, location. Predicting
sesamoiditis is nearly impossible. Every once in a while a perfectly great
bunion surgery is thwarted by prolonged sesamoiditis.
One foot or two?
The complication rate for a bunion surgery is only a modest 1-3% with bunions
done one foot at a time. My liability insurance company told me an interesting
fact. The complication rate for two bunions operated on at the same time is
ten times that for a single bunion! That has the complication rate
approaching 30%. While I do not think my two-foot complication rate is that
high, it is higher than when only one foot is operated on. This is obvious when
you think about the problem. If both feet are operated on and you stumble, you
do not have a good foot on which to catch your fall. If you need to stand in the
kitchen or at the office, you do not have a good foot on which to rest your
weight. If it is all the same to you, it is better to do each foot at a
separate time rather than both at one time. The second foot can be done as
soon as five weeks after the first one.
Can bunions be done at the same time as other procedures like plastic
surgery?
I have done bunion surgeries at the exact time that plastic surgeons,
gynecologists and general surgeons have done procedures "higher up." Neither the
other surgeons nor I see any problem with this. For plastic surgery procedures
it actually makes additional sense. Many cosmetic procedures are not covered by
insurance. If the cosmetic procedure is done during a foot surgery, the foot
procedure can pay for the operating room and the anesthesiologist.
What about an assistant surgeon?
I believe that a bunion surgery is better performed with an assistant
surgeon. This opinion is shared by the American College of Podiatric Surgery,
which states that an assistant surgeon for a
bunion surgery is usual and customary. The
trained assistant surgeon is less likely to damage delicate nerves and arteries
when he or she is carefully holding them out of the way. Also when a bone cut is
to be made, it is very helpful to have two people look at the saw from two
different angles at the exact same time. With an assistant surgeon the procedure
is performed faster which decreases the risk of an infection. Less operating
room and anesthesiologist time means lower overall charges for the procedure.
Despite these obvious facts, more and more insurance companies are
disallowing assistant surgeons for bunion surgeries. This is a cost saving
measure on their part and not an acknowledgment that an assistant is not
helpful. I have a working agreement with other podiatric surgeons. We all
assist each other. If the insurance company refuses to pay for an assistant
surgeon, one of these three will charge you for their services at a discounted
rate. The fee is usually $150 for the first hour and $100 for every hour
thereafter. Most bunion surgeries take just one hour. Even this rate is a
sacrifice. The assistant makes much less income than what they would have made
in their offices during the two hours it takes to travel to the surgery site,
assist and return to their office. We do this for each other because we all
understand the necessity of an assistant surgeon, even if the insurance
companies do not.
What is the post-operative care?
I divide the post-operative period into a four-week session followed by a
three-week session. A wooden-soled post-operative shoe is worn for the first
four weeks and athletic shoes are worn in the last three weeks. The initial
4-week period is marked by the need to rest and elevate the foot for three days
after which regular walking in the post-operative shoe can commence. Showering
or bathing where the foot gets wet is to be avoided for the two weeks that
sutures are in the foot. At the end of 4-weeks an x-ray is taken to assess
healing. If the x-ray indicates that there is adequate bone healing, you can
progress to wearing an athletic-type shoe. Regular walking activities can begin
as long as you do them in the athletic shoe and not barefoot or in sandals,
thongs or socks only. Fitness activities can begin after the seventh week when
the final x-rays indicate that healing is almost complete.
|
Bunion Post-Op Recovery Chart |
| Week |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
| P.O.Shoe |
ß Wear post-op shoe for 4
weeks à |
|
|
|
| Tennis shoe |
|
|
|
|
ß 3 weeks in tennis shoes
à |
| Elevation |
3d |
|
|
|
|
|
|
|
| Sutures In |
Sutures for 2 weeks |
|
|
|
|
|
| Keep Dry |
Keep dry until sutures out |
|
|
|
|
|
| Coban |
I like patients to wear compressive Coban for up to three
months after surgery à |
| X-rays |
|
|
|
|
X |
|
|
|
X |
| |
|
|
|
|
|
|
|
Can I shower or bathe?
You need to keep the wound dry for the first two weeks after surgery. A wet
wound can get infected. If this wound gets infected it puts the freshly cut bone
just under the incision at great risk. While you can jury-rig a trash bag with
duct tape they often fail. Instead we can sell you a ZeroSox shower protector
for $34. It works great. (The manufacturer will sell you one for
$35+tax+shipping at their web site: www.xerosox.com.)
As their advertising blurb states: The XeroSox is Completely Watertight. The
XeroSox Pro Pump is the only leg and arm protector in the world with the
patented vacuum seal. It is so completely and totally waterproof that you can
even dive off a diving board or ride the ocean waves and stay completely dry.
The XeroSox fits snugly yet comfortably during a shower, a bath, and even an
active swim. Unlike "modified garbage bag" products, the XeroSox cannot slip
off. You can't even pull it off!
When can I return to work/school?
Depending on the job, a bunion surgery will keep you off work for 4 days to 4
months. A flight attendant who needs to wear 2" pumps for 10 hours a day at
30,000 feet may well be off of work for 10-12 weeks. Someone with a job where
they can sit and have enough autonomy to elevate their feet when they want and
go home if the foot is too uncomfortable, can spend some time at the office in
as few as 4 days. Generally if I do the bunion surgery on a Thursday, patients
can go back to a mostly sitting job on the Monday 10 days later.
What kind of sutures will I get? How many?
The deep sutures are all absorbable and will dissolve on their own. Skin
sutures are made of a non-dissolving material like Nylon or polypropylene or
they can also be absorbable. I usually use a single suture for the skin of about
8" in length winds back and forth between the two skin edges and is reinforced
with adhesive Steri-strips. This single suture will be removed about 2 weeks
after surgery. The Steri-strips stay on until they fall off.
When can I drive?
If the left foot was operated on, driving can begin on the 4th
day. For bunions on the driving foot, driving is difficult. It is not wise to
remove the post-operative shoe to drive. Instead arranging for alternate
transportation for the first few weeks is very helpful. Some patients have
learned to drive with their left foot and some manage by using the right foot
for the gas and the left for the brake. My advice is to try this out before the
surgery in an empty parking lot (preferably one where my car is not parked.)
What prescriptions will I get after surgery?
I usually will give you two prescriptions for your surgery: a pain pill taken
as needed and an anti-inflammation pill to take "no matter what." My favorite
anti-inflammatory pills are Celebrex, Vioxx and Bextra. These are new and have
little, if any, chance to cause stomach discomfort or ulcers. They also do not
encourage bleeding like aspirin and all other anti-inflammatory medication. This
means we can start taking them a day or two before your surgery so you have a
good level of the medication in your sys tem at the time of surgery. The main
drawback of Celebrex, Vioxx and Bextra is the reluctance of some insurance
companies to cover them. If they won’t and you cannot afford these relatively
expensive medications, we can settle for a "regular anti-inflammatory" like
DayPro or Relefen. Just remember, because of their propensity to cause excess
bleeding, do not start them until after your surgery. For pain I usually
prescribe Vicoden but I am open to others if you have a favorite. Take your pain
pills only-if you have pain. Except in rare circumstances you will
not need to use your entire first batch of pain pills.
Will I hear anything? Will I have to be "put out"?
Most patients will elect to have the procedure done under local anesthesia
with twilight-sleep sedation also called MAC or monitored anesthesia
care. With this method it is virtually impossible to worry about anything during
the procedure even if you are a bit awake. You are given a little extra during
the "painful parts" like receiving the local anesthesia. If you are the timid
type you can tell the anesthesiologist that you want to "hear nothing" during
the procedure and they will always comply with your request. For those teens and
younger patients and those who are extra-afraid I suggest a general anesthesia.
What about minimal incision surgery?
Minimal incision surgery (MIS) is a controversial procedure in podiatric
circles and I must confess ignorance about it. The term refers to a technique of
placing a high-speed bur into a tiny incision and moving it around to remove the
bunion. Some podiatric surgeons (I have never heard of an orthopedic surgeon
performing MIS) can do a lot of good with this procedure and some do a lot of
damage. I have seen bunions that were "fixed" with a MIS that left the foot a
near cripple. I have never seen that with the "open" or "classical" procedures
performed by most foot surgeons. Many of the MIS surgeons have developed a shady
reputation by advertising lunchtime bunionectomies and Band-aid
bunionectomies. Neither is true. While they can be performed in an hour’s
time, patients who return to work the same day are not helping their healing
process. I share the desire of the overwhelming majority of podiatric and
orthopedic surgeons to actually see the structures we are working on.
This is a photograph of an x-ray of a patient who had a minimal-incision
surgery. Notice that a lot of bone was blindly ground out of the bunion joint
leaving very little articulation between the head of the metatarsal and the toe
bone. This patient regrets that she was talked into a MIS.
What is hallux limitus?
Your big toe (called the hallux) should have 90°
-100° of "up" motion (called dorsiflexion) and 20°
-25° of down motion (plantarflexion.) It should move
freely without any restrictions, clicks, catches or feeling like there is
grinding. Foot biomechanics requires that the metatarsal move down in order for
the big to move up. In essence the toe ends up on top of the first metatarsal
when you raise your big toe.
A joint that has less "up motion" that needed is said to have hallux
limitus (pronounced "limit-us"). With hallux limitus patients experience
pain when running, walking uphill and eventually just walking. The bone in the
big toe is jammed against the metatarsal head, which causes inflammation and
pain. Often there is a build up of bone spurs around the head of the metatarsal
that you can feel with your finger and rubs in your shoe. This spur (called a
flag sign in podiatry-speak) can be seen on an x-ray. If an x-ray is taken
with the heel off the ground and the ball of the foot on the ground, the base of
the toe bone can be seen to impact the first metatarsal instead of sliding over
it. Hallux limitus makes patients shift the weight to the side of the foot and
it is not uncommon to see calluses under the lesser metatarsals, especially
under the second metatarsal (behind the second toe.)
Mild hallux limitus can be addressed with a slight modification to a
traditional bunion surgery. The metatarsal head can be shifted down and over
instead of just over toward the second metatarsal.
Moderate hallux limitus needs any one of several modifications to regular
bunion surgeries. My favorite procedure is known as the "Youngswick"
modification after Dr. Fred Youngswick of the California College of Podiatric
Medicine (my school, rah, rah, rah). Clever man that he is, he suggested taking
an extra wedge out of the top of the "V" or chevron bone cut in the first
metatarsal head. This will allow the first metatarsal head to move down and back
thereby allowing the big toe to move up and over the head and allow easier
walking and running. This is a very successful procedure and is commonly done by
many podiatric surgeons. Interestingly, it is nearly unknown in the orthopedic
community. If you need a Youngswick surgery I will probably suggest doing it at
Los Robles Hospital. The power equipment manufacturer has made special double
Yougswick blades that help in the performance of this procedure (Thanks
Striker!). The Surgery Center does not have these particular blades for this
equipment.
More severe hallux limitus is accompanied by near complete degeneration of
the joint with pain with any motion. This might require either of three
procedures: a Keller bunionectomy, a Keller bunionectomy with an implant or a
joint fusion.
A Keller bunionectomy, named after the civil war surgeon that invented
the procedure, involves the removal of the base of the toe bone next to the
metatarsal head. It is a joint destructive procedure and designed for those
people who want freedom of movement of the joint. The big toe is shorter after
the procedure and the joint does not have the same power it had prior to the
procedure. Recovery is very quick since only soft tissues need to heal. Transfer
of weight to the second metatarsal bone with resultant pain and callus is
common.
Those who do not want their big toe to shorten after a Keller bunionectomy
might elect to have an implant put into the joint. Traditional implants
are double stemmed with a hinge in the middle. More sophisticated implants are
the modular or two-piece. The developers of modular implants claim that they are
capable of bearing more weight and allowing more activities than double-stemmed
implants. There is some question about the validity of this claim. Nevertheless,
if a person under the age of 70 needs an implant, the doctor should look very
seriously at the modular variety.
An alternative to the modular is a metal "hemi" implant that is put in just
one side of the joint, usually the toe bone side. These implants have a long
track record of helping relieve the pain of hallux limitus and I have found them
to work very well. Pictured in this monograph is the one designed by Dr.
Lawrence of San Diego. I am very fond of this implant.
An alternative to implants in patients with severe hallux limitus is a
surgical fusion of the big toe bone to the first metatarsal. This results in
a stiff joint but one quite capable of bearing significant weight. The fusion is
done at an angle to allow patients to wear their favorite shoe heel height. For
men this would be a ¼ - ½ inches and women 1-1½ inches. In general orthopedic
surgeons are fond of fusions and podiatric surgeons are more likely to use an
implant.
What is drilling of the cartilage?
All of the joints of our body are covered by an articular cartilage that is
many times more slippery than ice. It allows our bones to glide over each other.
At surgery this cartilage appears a white as snow. If the cartilage is damaged
it becomes thin and yellow. Eventually it can flake off leaving raw bone
exposed. Joint motion with exposed cartilage is both damaging and painful. If
your foot surgeon notices that there are areas where this cartilage is missing,
he or she may try to stimulate new cartilage formation. Drilling tiny holes into
the exposed bone does the stimulation. Around every small hole your body will
grow a little circle of fibrocartilage. Fibrocartilage is not as good as
articular cartilage but it is much better than raw exposed bone
Can new cartilage be encouraged to grow?
The following information is taken from the best-selling book The
Arthritis Cure by Jason Theodosakis; M.D. Dr. Theodosakis is a well-known
physician at the University of Arizona. His greater claim to fame is that he was
baby-sat by my wife, Jackie, back in their hometown of Schiller Park, Illinois.
(I think my wife was only 3 at the time).
He reports that two commonly available over-the-counter food supplements can
aid in restoring healthy cartilage. Glucosamine sulfate helps to grow new
cartilage and Chondroitin sulfate brings water into the new cartilage. I
suggest that every bunion patient (and every arthritis sufferer, for that
matter) consider taking these two supplements for several months after their
bunion surgery and any time that their cartilage is drilled. (Note, kip, knee,
elbow and shoulder surgery frequently involve drilling of the bone as well.)
The appropriate dose is described in the table and should be divided up into
2 to 4 doses taken throughout the day with meals. Glucosamine comes in four
equally useful forms: hydrochloride, hydroiodide, n-acetyl and sulfate. The
sulfate form is the most common but all four are, more or less, equivalent.
Those with a thyroid condition should avoid the iodide form.
| If you weigh |
You should take |
| Less than 120
pounds |
1,000 mg of
glucosamine plus 600 mg of Chondroitin sulfates |
| Between 120 and 200
pounds |
1,500 mg of
glucosamine plus 1,200 of Chondroitin sulfates |
| Over 200 pounds |
2,000 mg of
glucosamine plus 1,600 mg of Chondroitin sulfates |
The Chondroitin comes only as a sulfate. There are many studies that document
that the Chondroitin and the glucosamine reduce arthritis individually and
together they are more effective than they are by themselves. It would be best
to take both. You can get both in a product called Pain Free made by
Schiff and sold at Costco/Price Club and many pharmacies.
Vitamin C and the mineral manganese are needed to use these two supplements
properly. Be sure you take them separately if these two are not included in the
supplements that you purchase. Manganese up to 50 milligrams per day seems to be
safe. Between 500 and 4,000 milligrams of vitamin C is the required dose and
should also be broken up into several doses throughout the day.
What other diet or vitamin advice do you have?
FIRST: NO HERBALS FOR 2 WEEKS BEFORE SURGERY! Many herbal preparations and
diet pills (like Merida) mix unfavorably with anesthetic agents with sometimes
dire consequences. Do not take Ginkgo, St. John's Wort or any other non-vitamin
herbal product for one week prior to the surgery or it will be cancelled by the
anesthesiologist.
One anesthesiologist even requires a two-week abstinence.
Before undergoing any surgery, you should make sure that you have a diet that
provides an adequate amount of all the vital nutrients necessary for healing and
reduction of inflammation. If you are unsure of your diet, high quality and
potent supplements can be quite helpful. Supplements are not regulated by the
Food and Drug Administration (FDA), so they may not contain in fact what they
say on the label. It is best to buy name brand products from companies you
trust.
There are some theories that the accumulation of free radicals can contribute
to arthritis. These can be counteracted by either eating a variety of food
groups each and every day or by taking a quality anti-oxidant food supplements.
The supplement should contain the following ingredients:
Vitamin A, beta carotene, the carotenoids – 5,000 IU (international units)
Vitamin C – 500 – 4,000 mg (milligrams: 1,000 milligrams = 1 gram)
Vitamin E – 100-400 IU (international units)
Selenium – 55-200 mcg (micrograms)
Boron – 3 mg for adults
Bioflavonoids – some of the 4,000 kinds found in foods (these go by the names
Citrus bioflavonoids, rutin, quercetin, hesperidin, catechins, ginko biloba,
milk thistle extracts and wine proanthocayanidins)
Note: If you choose to supplement your diet with fish oils, refrain from
taking them a week prior to any surgery. They can interfere with the ability of
blood to clot. An excessive intake of fish oils can also lead to an overdose of
vitamins A and D if you are already taking these two from other sources. When in
doubt, ask me and I can help you choose the right nutrient supplementation to
get you through your surgery.
Testimonials
This is the greatest thing ever! I just saw my beautiful foot for the first
time [after the bandages were removed] and I got it without ANY pain! I can
hardly believe all this can be done and it doesn’t hurt! I took one pain pill
thinking it would begin to hurt a lot after surgery (even though Dr. Zapf said
it wouldn’t) and it has been great. I wish I had done it sooner!!! Next year I'm
buying some great sandals for the first time in maybe ten years at least!!!
Thank you, Dr. Zapf.
Cheryl B, Agoura
(Day of surgery) I had bunion surgery in the morning – SurgiCenter was
extremely pleasant and professional…. (I had) no pain during or after the
surgery…filled my pain prescriptions and took one (pain pill) the night of
surgery, only fearing I might have pain, which I did not. I kept my foot iced
and elevated for three days but was able to easily move wearing the special shoe
the SurgiCenter gave me.
(4 days post-op) I had my post op check up. The doctor was impressed by how
well I walked…he changed the dressing on my foot and I resumed my life.
(2 weeks post-op) I had my sutures removed and had my foot wrapped (with
Coban) and still had no pain.
(5 weeks post-op) I am wearing tennis shoes and pretty much am back to
normal. I took some Yoga classes and all was good.
(8 weeks post-op) All in all, a very positive experience with very little
discomfort and no complications. I have already scheduled the surgery for my
other foot in 2 months!
Jody R, Westlake Village
I had my bunion surgery about six years ago and I must say that it was a
great experience…the surgery was excellent…I never took a pain pill. I had the
bunion on the right foot done 20 years ago by a doctor in Van Nuys but it came
back…now I am able to walk 20 miles a week in my Saucony running shoes…Dr. Zapf
provided excellent in-office instructions and the surgery center was excellent
(I was in the hospital for my previous bunion)…the only complaint that I have is
that I did not fix my tailor’s bunion on the right foot at the same time
Christa K, Agoura Hills
I had bunion surgery 6 weeks ago and everything is going fine. I still walk
with a little limp because the foot is a little stiff in my shoes but there is
no pain, swelling and the scar is almost invisible… the whole process was a
piece of cake. I wouldn’t hesitate to do it, again. It was less severe than I
ever expected. I am basically a chicken and I don't like pain. This surgery was
essentially pain free. When I heard that it involved cutting the bone I
anticipated pain but pain wasn’t to be the case ... I’ll tell you a secret: I
never even filled the pain pill prescription and I only took the
anti-inflammatory medications for a week…I have been walking, standing and
gardening with no pain…Before the surgery I was leery and put it off for a long
time. Now I am glad I decided to do it…If you need a spokesperson for bunion
surgery, I will be glad to do it
Peggy L-B, Thousand Oaks
I had my first surgery on June 11 on the left foot (that’s the S. Mary
photograph at the end of this monograph). I returned to work on June 23. By
the 7th of July I was back in tennis shoes. I scheduled my second
surgery for August 27 and returned to work on September 9.
This has been one of the easiest surgeries I have ever gone through. It is so
nice to see my feet and they actually look normal now. Besides, I have gone down
½ size in shoes since my first surgery
The staff in Dr. Zapf’s office are some of the most caring and helpful people
I have ever met. Also, the staff of the Outpatient Surgery facility at the Los
Robles Hospital was extremely caring and helpful.
Dr. Zapf is one of the finest surgeons I have ever had the opportunity to
know. I have been telling everyone I know to see him if they have any problems
with their feet. Please call me (805) 376-6712 between 8 and 5 if you want more
information.
Mary S., Thousand Oaks
A bunionectomy (with Dr. Zapf) is a pretty much painless surgery. [I had]
minimal discomfort for about a week; actually more uncomfortable than painful
took no pain meds. I had a slight amount of numbness on top of the toe but after
three months it is coming back. I have slight momentary aches. I followed the
doctor’s instructions immediately after surgery and there were no problems with
swelling…I am very pleased with the whole process…I can walk ¾ of a mile at a
decent pace.
Karen D, Thousand Oaks
Should you have bunion surgery done by Dr. Michael Zapf? Yes, Yes, Yes!! My
surgery was six weeks ago and I’m walking and wearing shoes without pain. I
can’t say enough wonderful things about Dr. Zapf, his caring staff and the staff
at the Los Robles Surgery Center, They all work exceptionally well together.
Thank you, Dr. Zapf. Anyone can call me at (805) 498-1939 for any reason.
Mary J P – Newbury Park
My greatest concern before my bunion surgery was how long I would not be able
to ride my horse, let alone care for my family. Not only was there no pain,
recovery was very quick. I was back to work 6 days after surgery and back in the
saddle 5 Saturdays after surgery. It almost seemed too easy and painless. I’m
having my right foot done in early December and I’m looking forward to it. Now,
I just wish I hadn’t waited so long to have my bunions removed. Maureen
M – Thousand Oaks
I had surgery December 2, today is December 31 and I am going for a long
walk!! What a way to start the New Year with no pain! Surgery was a breeze! The
1st 3 days I spent with my foot elevated and reading. I took a pain
pill the first night, not because I needed it but I figured I should. I can’t
wait to have the other foot done. One bad thing was I couldn’t get my Christmas
sock of for a dinner on December 5. I made a bow for my goofy shoe instead. Dr.
Z was fantastic!! Karleen Wooster – Thousand Oaks
I could really tell the difference when I first put on my tennis shoes
and started walking again. I thought, "Oh, so this is what it feels like
toe walk without pain." Carol Warmby
I am a 73-year-old woman. Dr. Zapf removed bunions from both of my feet. I
had no pain after the operations, which were a year apart. My feet are normal
after years of not being able to buy shoes to fit my painful feet. Helen E.
McKinnon, R.N. (805) 497-2467
Dear Dr. Zapf, I wanted to thank you for everything. Thank you for all the
time you spent with me before the surgery explaining the procedure and answering
my questions. You have a gift for explaining complicated ideas and making hem
simple and clear. I thank you for your kindness and your concern. I could tell
from the beginning that you have a loving heart and that you really care about
the patient. You are a wonderful person and a fantastic physician. P.S. I also
think that you have chosen a great staff. They are very nice and helpful to the
patient. Eunice L., Camarillo, CA
I have had two bunion surgeries performed by Dr. Zapf in the past 5 years.
Both surgeries went extremely well with no pain and very little discomfort. Sr.
Zapf and his staff are wonderful to work with and it is a joy to be able to wear
shoes without pain. Thank you, Dr. Zapf! Penny Foster, Newbury Park
I had the Youngswick (bunion) procedure three years ago. I had to take only
one pain pill. I had almost no motion before the surgery and the motion I had
was painful. Now I have movement and can wear heels that I could not wear
before. I followed Dr. Zapf’s instructions on exercise as he told me. I am very"
happy with the result.
Judith A. Hatfield
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