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| | BUNIONS
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.
[Note that here and in many places of this " web" version of the monograph
the pictures an illustrations did not come through. Use the order form below if you would
like your own copy. Please include $1.00 for postage and handling.]
What
causes bunions?
Most bunions are caused by an inherited foot type that leaves the foot a little
bit unstable. Bunions 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. 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.
You might ask why two almost perfect
little feet are doing in a section
on bunions. Well, these are actually early
(juvenile) bunions. If you look very closely you might see some
findings commonly associated with bunions. There are the slightest of prominences of the typical bunions on the inside of the feet. Also note that the big toes are
deviated a little towards the lesser toes (called
hallux valgus). Finally
note that the nails on the big toes no longer point straight up but are rotated
slightly so that the top of the toe points toward the center of the body. These are early
(juvenile) bunions.
All bunions, even these juvenile bunions,
exhibit a singular quality -- they may stay the same size for a long time
but...
they
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 trickier. 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.
A QUESTION ON JUVENILE BUNIONS:
My daughter, five years old,
has bunions. The doctor said he had never seen bunions in someone so
young. He referred us to an orthopedic surgeon, but her appointment is
not until April! This concerns me, because her feet are growing so
fast, and I'm afraid they will get even worse (her big toe is turning toward
her other ones). Seven months seems awfully long for a first visit,
don't you think? Please let me know if I am overly concerned.
Thank-you.
Michelle R.
Dear Michelle R.
 It
is not at all unusual to see kids with bunions. The picture to the left shows
a mom on the left and an 9 year old girl on the right both with mild to
moderate bunions. Five years old is not too young. In almost every case there
are multiple issues causing the bunion to be so large at such a young age.
Many times these kids are highly intoed, that is they walk with their toes
pointing toward each other. Often they exhibit hyperflexibility
(double-jointed-ness). Almost always they are very flat footed. The usual
treatment for a 5 year old is to make an orthotic to reduce as much of the
pronation (flat footedness) as possible and observe them as they grow older.
Podiatrists and orthopedists usually want to wait until the child has finished
growing before wanting to surgically correct the bunion. And if they are no
bigger than the ones in the photo, maybe not even then unless they hurt. There
is another option for youngsters with bunions called epiphysiodesis. OK I
won't use that word again, but it means placing a stainless steel stapling
across part of the growth plate of the first metatarsal bone. This causes the
bunion to grow smaller during the so-called adolescent growth phase. Few
doctors do this so don't be surprised if your doctor has never heard of it. I
will be happy to send you a before and after photo of Leah who had this
procedure done if you just call my office [ (818) 707-3668 ]and ask for it.
What is hallux
interphlangeus?
I am sorry to have to use a name like
hallux interphalangeus. There is no non-medical name that I know of for this
condition. It occurs when there is a big angle between the two bones of the
big toe (like the photograph here). Look closely at the photo and you will see
that there is not much of a bunion bump. There is not a big angle between the
foot and the bone in the big toe closest to the foot. There is a big angle
between the two bones of he big toe. The bone by the nail is leaning towards
the 2nd toe and actually touching it. This is corrected with an "Akin"
bunionectomy where the bone correction is made in the toe itself. Sometimes
you can have hallux interphalangeus in addition to a bunion and both can be
corrected at the same time.
Do my bunions require surgery?
Bunions need surgical correction in any of three circumstances:
First, if your bunion(s) hurt wearing the shoes you need (or want) to wear to do the
things you need (or want) to do, think bunion surgery. If they only hurt in high fashion shoes that
are worn seldom – I generally do not advise bunion surgery if the other two criteria
are not met.
Second,
if the angle between the first two metatarsals (remember the victory
sign?) approaches 15 degrees and the angle between the toe and the foot approaches 30
degrees as measured on an X-ray, it is bunion surgery time. Above these numbers the ease
and success of 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 me with x-rays taken from another doctor or facility I will
ask if they were taken weight bearing. If they were taken while you were sitting on an
x-ray table, I will need to take new ones. If you go for a
bunion consult ask if your numbers are close to "15/30."
Third, 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.
 Extra
Bonus Criteria.
This picture shows a foot where the big toe has moved over and
under he 2nd toe. This is the so-called crossover toe deformity. It is difficult - nearly
impossible - to correct with any degree of success. If you see that your 2nd toe is
starting to lift and the big toe is starting to move over, please consider having your
bunions surgically corrected. It is always easier to fix a bunion than a crossover
deformity.
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 half of a small grape under the skin. Many times this
hurts more than the bunion. At
first the toe is still straight and in good alignment with the second metatarsal. As time
progresses the second toe can start to migrate. 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 and can be easily or readily corrected. It is easier to treat this condition if the
second toe had not moved to the right or left or lifted up forming a hammertoe.
Please correct your feet before the
second toe dislocates. The picture below 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.
This is a woman with pain from shoes that
rub the 2nd toe that is elevated and crossed over the big toe. This is the
"Kings-X" sign.
Click the kink below to see photos from he
correction. Notice how both the bunion is corrected and the 2nd toe
lays flat. This is considered a great result for the deformity she presented with to my
office.
 
To see the AFTER Pictures of this very bunion please go to -->
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. I recently "lost" a bunion patient to
an HMO when her employer changed insurance plans. She was sent by her new HMO to a
contracted orthopedist for her bunion surgery. She was told by this doctor that he
"did bunion surgery every week." She called the three facilities where he had
privileges and found that he had only done two in the last seven years! She successfully
petitioned her HMO to allow her to go to a foot surgeon who really does do bunion
surgeries every week.
Active Hospital Privileges: Surgeons typically
perform bunion
surgeries in a hospital or a Surgery Center. Hospitals have categories membership for staff physicians. Usually the
categories are courtesy, provisional and active, depending on how busy the
doctor is at the facility. As far as surgeons are concerned, you can be called
ACTIVE if you perform a certain minimum number of surgeries per year. In
short, busy surgeons are
classified as A quick way to determine if
your surgeon is reasonably active is to call your local hospital (my hospital is Los
Robles Medical Center at 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: 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 exam followed by a two-day oral exam. If they pass they
are Board Certified. Because this process is so onerous many podiatrists could
not meet these conditions. These doctors have created a number of alternative
boards. Despite how impressive 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, see
www.abps.org ).
Podiatrists certified by this board are allowed to join the American College
of Foot and Ankle Surgeons (
www.acfas.org
) 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. Dr. Zapf and Dr. Payne have both has
passed the rigorous Board Certification Exam by ABPS. Dr. Zapf has also
submitted his cases and passed the oral portion of the exam earning him Board
Certification status and the right to put D.A.B.P.S. after his name. Dr. Payne
is in the process of getting his cases in order and will be certified in a
year or two. Until then he is classified at Board Qualified.
The second approved board is actually more relevant to heel
pain. Being certified by the American Board of Podiatric Orthopedics and
Podiatric Medicine (thankfully abbreviated ABPOPPM but even that is still a
mouthful). Certification by this organization (see
www.abpoppm.org
) means that the doctor has achieved status in
the non-surgical (medicine and biomechanics) board of our profession. The cases
to document and the written and oral examination requirements are exactly like
the surgical board but slanted to non-surgical treatment of foot and ankle
problems. Being certified by the ABPOPPM makes you eligible to become a Fellow
of the American College of Foot and Ankle Orthopedics and Medicine (see www.acfaom.org ) and to use the initials
F.A.C.F.A.O.M. after his or her name.
Yes, Dr. Zapf is one of the few podiatrists who is both
Board Certified by both the ABPS (i.e. the surgery board) and ABPOPPM (the
orthopedic board) and a Fellow of both American College of Foot and Ankle
Surgeons (ACFAS) and the American College of Foot and Ankle Orthopedics and
Primary Care Medicine (FACFAOM). He has the right to put all this after his name:
Michael Zapf, D.P.M., M.P.H., D.A.B.P.S., F.A.C.F.A.S.,
D.A.B.P.O.P.P.M., F.A.C.F.A.O.M.
Sometimes he writes it: Michael Zapf, DPM, LMI* (* =
Lots More Initials).
:
This is the logo for the American
College of Foot and Ankle Surgery
If your doctor is a podiatrist he or she can only be board certified by the most
recognized board if your can find his or her name at this site --> ABPS. <--- Click here to check out your
doc
The M.P.H., by the way, is Dr. Zapf's Public
Health degree from
UCLA (Go Bruins!) in Infectious and Tropical Diseases. (If you ever get Yellow
Fever of the foot, he is your guy!)
Both Dr. Payne and Dr. Zapf are on the ACTIVE staff of Los
Robles Medical Center and The Los Robles SurgiCenter where they do most of
their surgeries.
What about laser surgery?
 First off, no matter what anybody says, even your trusted aunt
Martha, lasers cannot be used on a bone. And bunions are bone deformities.
Those surgeons who advertise that they fix bunions with lasers are advertising
fraudulently! The ad I reprint here is an actual yellow page ad from two local
(Glendale, CA, anyway) who appear to be intentionally misleading their
patients. Notice how the before and after picture of bunion surgery seem to be
related to the word LASER. Better it should be related to the word FRAUD!.
These two doctors are cheese balls and should not be allowed to getaway with
such a misleading ad. (So, there, now I've said it. Let the slander suits
begin.)
What about the touted “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.
Getting a lot of publicity
is the so-called tri-correctional bunion procedure. It is an elegantly designed
bunion procedure that has been around for many years, despite claims from some
doctors that they invented it. It involves rotating the metatarsal head when you
make bone cut number 2 in my diagram. I use this procedure every once in awhile
when the patient’s needs call for it. The old name is a Reverdin-Green-Laird
after three podiatric surgeons who contributed to its development. The name
“tricorrectional” is a public relations term for the same procedure. The doctors
who currently proclaim the tri-correctional bunionectomy as the
“end-all-and-be-all” of bunion surgery are practicing more public relations than
surgical innovation. The tri-correctional you see advertised on television also
involves a controversial method of fixation where the tip of a screw enters the
very delicate cartilage on the metatarsal head. I feel this method of fixation
can cause unnecessarily damage to the joint cartilage and set the stage for
future arthritis. You will not find me. or many other successful surgeons,
unnecessarily damaging the articular cartilage when there are other just as
successful and less risky methods of achieving the same bunion correction.
So What Do You Do In A Bunion Surgery?
 My
crude drawing demonstrates the basic steps in the most common type of bunion
performed in my practice and in most podiatry offices in the United States. It
was designed by Dr. Dale Austin and is commonly called an Austin Bunionectomy.
Other names are a “distal chevron” bunionectomy or a “bunionectomy with a distal
metatarsal osteotomy.”
No matter what you call it the same steps usually apply.
(1) Remove the bump of bone on the side of the foot. For small bunions you
might stop here. (2) A surgical fracture is made in the neck of the
metatarsal bone and the head of the bone is moved closer to the rest of the
foot. The bone is usually held in place with a wire, pin or screw. This holding
in place is called “fixation” and is currently the standard of care in bunion
surgery despite the fact that Dr. Austin never fixated one in 25 years of doing
the surgery. Those doctors who do not fixate the bunion with any method are
thought to increase the risk of slow healing or movement of the pieces after
surgery. Finally (3) the soft tissues helping to hold the big toe in a bad
position are cut and the toe is realigning. Step (3) is the all-important
“tendon balancing” or "lateral release” that should be part of
most bunion procedure.
Some disreputable doctors will advertise
that they can do bunions "without hospitalizations." This is another example of
disingenuous puffery. In the United States no one has been hospitalized for a
simple bunion surgery for almost 20 years. That is not true in other parts of
the world. European and Asian doctors frequently hospitalize bunion patients for
several days. This is reminiscent of how American doctors treated their patients
20 years ago.
Is Bunion Surgery
Painful?
With the techniques that we use, pain during the recovery from bunion surgery is a thing of
the past. Most bunion patients almost never take
their full complement of pain pills – and many take three or less (some none!). Recently
Dr. Zapf hit
the Trifecta of pain
free surgery. Not one of three Thursday bunion surgery patients took as much
as one pain pill. Now weI cannot guarantee that any patient will have no pain at all but it is low enough on the list to not qualify as a reason to be afraid of
surgery.
We do hear from time to time
that patients were told by orthopedic surgeons and
podiatrists to avoid bunion surgery because of pain. You might want to avoid
those doctors. They are probably telling the truth. In their hands their
patients probably are experiencing significant pain after surgery.
We often wonder what they do to cause so much pain to
their patients. But on further reflection – we don’t
want to know. But we do feel sorry for their patients.
What about ZINGS?
After bunion surgery patients frequently experience an
unexpected electric, shooting “zing” in the area of the bunion surgery that can
shoot right up the leg toward the knee. The zings come
out of nowhere and can come at any time, even in bed. The sensation lasts just a
second but it can be quite unnerving. You might experience a dozen a day or none
at all. The zing does note mean that anything is wrong. I believe that it has to
do with nerve healing after surgery. If you do experience zings they tend to go
away after a week or two.
What does a bunion surgery cost?
Most foot surgeons charge between $1500 and $2000 for a
single bunion surgery. (One surgeon in the San Fernando Valley charges a
usurious $121,000!). Our fee is the same $1900
we have charged since 1985. Fees
from other doctors above about $2500 are clearly excessive. Caveat emptor. The facility fee
(hospital or SurgiCenter) is probably another $1000-3000/ You can call the
business offices of Los Robles Regional Medical Center or the Los Robles
SurgiCenter to get their specific prices for the facility fee for a bunion
surgery. Past experience proves that they are a little hard to pin down on exact
costs but it is worth a try. Finally there is a charge for the anesthesiologist
(around $300-600). If you surgery is to be done at he hospital you will need a
“pre-operative heart and lung check” by your family doctor.
He or she will charge you for
their history and physical (H&P) at his or her usual charges.
For surgeries at the SurgiCenter,
Dr. Zapf and Dr. Payne will usually perform this pre-op check. If you have significant medical
problems like diabetes, heart disease lung disease or seizure disorders
they will
still send you off to your family doctor before surgery for a “pre-op H&P”.
Will my insurance cover a bunion surgery?
Insurance companies by and large always pay for bunion
surgery up to the limits of your policy. This is not regarded as a cosmetic
procedure. As a service my office will call you insurance company and verify
coverage and get that all important “pre-authorization.” Even though we do call
your insurance company you are still, of course, responsible for all the charges
incurred in 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 or be just
plain clueless. If any of these things happen, you will be responsible for all
the charges of your surgery. Remember only insurance companies can say with a
straight face: “authorization of the procedure does not guarantee payment.” (Try
that line at your local restaurant. “Ordering this meal does not guarantee that
I will pay for it.”)
What can go
wrong?
Even if a bunion surgery is
performed perfectly, things can still go wrong. The complication rate for
serious problems is probably 2 to 3 per cent and if you add minor annoyances,
move the complication rate up to 6 to 8 per cent. Prior to your procedure you
will be asked to sign a consent form that includes the complications I have
listed below. This consent experience, commonly referred to (with a smile) as
signing your life away does not give me permission to mess up. These are the
things that can go wrong even when no mistakes are made during the surgery.
These are the “less than desirable” outcomes.
1. Infection: Any surgery
that requires a cut in the skin can result in an infection. Fortunately the
frequency of a bunion surgery infection is quite low. If you do get an infection
it is obviously treated with antibiotics. The big risk is an infection in the
freshly cut bone around the bunion. This risk is increased if you get he wound
wet. You will be asked to keep it dry for two weeks after surgery.
2. Slow healing: If the skin heals slowly there will still be some part of
the incision that is not completely closed at 2 weeks. This is a minor nuisance.
The real problem with slow healing is the bone. If at 4 weeks and 7 weeks the
x-rays show that the bones are not healing correctly then we are possibly in
trouble. This is a potentially serious complication that can require crutches
and wearing a little walkman-like bone stimulator on your belt with wires going
down to your feet. In my hands this complication happens once in every 2500
bunion surgeries (once since 1985).
3.
Numbness: You cannot do surgery without
cutting at least a few small nerves leaving a decrease in sensation around the
wound. Sometimes, despite the best of intentions, a slightly larger nerve gets
clipped and there is complete numbness on the top of the big toe about the size
of a dime. This numbness either goes away after time or decreases in intensity
until it is no longer noticed. This process can take 6-12 months. I have heard
rumors that the occasional patient really dislikes this sensation and is unhappy
with the surgery. Fortunately this has not happened with me.
4.
Scarring. All wounds heal by scarring.
Scarring is part of surgery. The length of the wound does not have any effect on
the time it takes to heal or the thickness or color of the scar. A maxim in
surgery is that surgical wounds heal from side to side not end to end. Wounds on
some patients can practically disappear after a year or so. Wounds on
particularly light or dark skinned people can be very prominent. Some people are
prone to thick scars, called hypertrophic, and some, especially those
with very dark skin, can even form a raised area called a keloid. To
minimize scarring I take a little extra time to close the wound and use a
running subcuticular suture with fine suture material called Prolene. In my
suture method one single stitch is used and the suture snakes back and forth
just below the skin. The so-called railroad tracks of traditional suturing are
avoided.
5.
Prolonged pain and swelling. If you find
that you need a refill of your pain pills, cannot get into tennis shoes in 4
weeks or cannot wear regular shoes at 7 or 8 weeks after surgery, then you are
experiencing prolonged pain or swelling. The cart above describes where you
should be on the post-surgery timetable. If you are taking longer than normal
anywhere on the scale you might be sent to physical therapy for pain or swelling
reduction or to increases range of motion.
6.
Recurrence of the deformity. The fact that
you have a bunion at all means that something is not right. Either some bones
are at angles they should not be at or there are muscles pulling in directions
they should not pull. Maybe you have ligamentous laxity, a too round metatarsal
head, an elevated first metatarsal or a metatarsus adductus foot. Don’t worry
about knowing what these mean – just know that there are a lot of forces that go
into making a bunion. A bunion surgery corrects the obvious bunion deformity but
it cannot address all the forces favoring bunion formation. The number of forces
tending to form a bunion and your age when you first notice it helps to predict
the permanence of a bunion correction. As a general rule-of-thumb
(rule-of-hallux?) subtracting the age you are when you have a bunion surgery
from 70 will give you an idea of the odds of a bunion recurrence. This is the
Zapf rule and it is just my idea – there is no scientific basis for this rule –
just my opinion.
7. Under or over
correction. In a bunion surgery the first
metatarsal head must be moved to a new position. Like all bunion  surgeons I use my experience and judgment to 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.
These photographs are from a patient who came to me
disappointed with her previous bunion experience. Look carefully and you will
see that the big toes are leaning away from the foot. Technically this is called
hallux varus and is difficult to repair. I know the surgeon who did
this surgery and he is an excellent surgeon who just happened to get an
unfortunate result.
 On
the other hand this is a surgical "failure" performed by a surgeon
in the San Fernando Valley who does not do much foot surgery. He tried once
and did not like the result. Then he tried three more times and each time the
foot got worse. This patient is quite unhappy. There is no way to reliably and
perfectly fix this foot. The take home lesson here is go to a busy foot
surgeon who has lots of experience and doesn't get too creative.
8. 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 elsewhere in this web site.
9. Reduced motion of the bunion joint. Normal big toe joint motion is about 70° up and 20° down. Some times a bunion
surgery will reduce this motion in either direction. This is a frustrating complication.
We
have seen cases where the motion on the table is 80° just
before we bandage the foot and only half that three days later. To prevent this
complication we want our bunion patients to begin early exercise of the toe joint. Sometimes
patients can be their own worst enemy if they are afraid to move the bunion joint after
surgery. If there are early indications of restricted joint motion,
we will likely
send you to physical therapy.
10. 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 (think Shaquille O'Neil the great Laker center
who developed sesamoiditis after his bunion surgery)
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. Our liability insurance company told
us an interesting fact. The complication rate for two bunions operated on at the same time is ten
times that for a single bunion! That means the complication rate approaching
30%!! While we do not think our 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?
We have done bunion surgeries at the exact time that plastic surgeons, gynecologists, orthopedists and
general surgeons have done procedures "higher up."
The other surgeons usually do not
see a 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 pays for the operating room
and the anesthesiologist.
What about an assistant surgeon?
We believe that a bunion surgery is better performed with an assistant surgeon. This
opinion is shared by the American College of Foot and Ankle Surgery, which states that an
assistant surgeon for a bunion surgery is usual and customary. Compared to doing it alone
or with just an operating room helper, a 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. Think
of the analogy of hanging a large picture. You may want a friend to stand back a few feet and tell you if it
straight and the right height. A second pair of eyes from a different angle can give you a
very different perspective. 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. They get their information from a
book written by Roberts and Millman which is an accounting form. Funny,
we don't remember
any accountant asking me for technical advice. Well why do insurance companies rely on the
guidelines of an accounting firm for their decisions on health care. Could it be, oh,
maybe MONEY? We suspect it does.
We have a working agreement with
each other and 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 $200 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. Other surgeons
in other places may have a very different opinion on assistant surgeons so if you are
reading this on the Internet - ask them what their practice is.
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 for the most common
bunion procedures |
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Week
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P.O.Shoe
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ß Wear post-op shoe
for 4 weeks à
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Tennis shoe
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ß 3 weeks in tennis
shoes à
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Elevation
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Sutures In
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Keep Dry
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Coban
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I like patients to wear compressive Coban for up
to three months after surgery à
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X-rays
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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.
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 and Vioxx.
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 system at the time of surgery. The main drawback of
Celebrex and Vioxx 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 lunch time 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.
A big toe (called a hallux) should have 70° -90° 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.
Said
Jane B. about her Youngswick performed 6 years earlier:
"Dr.
Zapf provided an alternative to fusing the joint in my large toe which
would have left me with a lifetime limp. His method of reconstruction has
given me my life back - hiking in the creek bed in Topanga Canyon and
gardening on our hilly property is no problem. Thanks Dr. Z"
Jane,
you are very welcome. Thank you for your kind comments.
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 as 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. The photo shows the holes or
"fenestrations" drilled into the head of the first metatarsal head at the time
of surgery. This patient had a loss of cartilage on the head of the
metatarsal.
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
my wife, Jackie, was his baby sitter back in their hometown of Schiller Park, Illinois. (I
think my wife was only 3 at the time) (Hi! Jason, from Jackie, if you ever see this web page!).
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, hip, 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
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You should take
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Less than 120 pounds
|
1,000 mg of glucosamine plus600 mg
of chondroitin sulfates |
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Between 120 and 200 pounds
|
1,500 mg of glucosamine plus1,200
of chondroitin sulfates |
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Over 200 pounds
|
2,000 mg of glucosamine plus1,600
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 canceled 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, gingko biloba,
milk thistle extracts and wine proanthocayanidins)
Testimonials
[For the sake of privacy I have
eliminated actual names and phone numbers from the web page. They area available
on the actual monograph.]
·
(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! I have sent you a
bunch of patients for bunion surgery and they are also doing great.
Jody R, Westlake
Village
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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
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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!!! Thanks you, Dr. Zapf
Cheryl B. Agoura
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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 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) xxx-xxxx 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
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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)
XXX_XXXX for any reason.
Mary Jane P – Newbury
Park
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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 on for a dinner on December 5. I made
a bow for my goofy shoe instead. Dr. Z was fantastic!!
Karleen W – Thousand Oaks
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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 to walk without pain."
Carol W
·
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. M, RN. (805)
XXX_+XXXX
·
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. Dr. 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 F, 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. H
Pictures and
photographs
Note :
The photographs show a "gap" between
the big toe and the second toe. This is intentional. The gap will disappear the
moment regular shoes are worn. If there is no gap the moment the surgery is
done there is great risk that the bunion will look "uncorrected" in short
order.
.gif)
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