You can now watch the online webinars given by the Physicians of Proliance Orthopaedics & Sports Medicine when it’s convenient for you! We record our live webinars, and you can watch them on-demand.
WEBINAR: Put Your Right Foot Forward – Managing Bunions & Arthritis
PRESENTER: Dr. Thomas Chi
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The transcript from the webinar is below:
Moderator: Good evening and thank you for joining us for our webinar on Bunions and Arthritis. Tonight, we’re honored to be joined by Dr. Thomas Chi, he’s a board-certified Orthopedic surgeon and a fellow of The American Academy of Orthopaedic Surgeons. He specializes in foot and ankle.
Moderator: There is a chat bar over on the right-hand side of your screen, and you can go ahead and send in your questions throughout the entire presentation. And those are going to be private and go to Dr. Chi. At the end of the presentation, we’ll go through and try and answer as many questions as possible. If we don’t get to your question, we will follow up with you directly after the webinar. And other than that just please sit back, relax and enjoy the event, with that I’m going to hand it over to Dr. Chi.
Dr. Chi: Thank you, Jessica. Again, my name is Tom Chi, I am a partner at Proliance Orthopaedics & Sports Medicine. We have clinics in Bellevue, Issaquah and Redmond. I do mostly foot and ankle. I also do a knee arthroscopy surgery and replacement.
Dr. Chi: I’m going to talk about a common misconstrued problem which is bunions and arthritis, they’re oftentimes confused with each other. Patients come in with a bunion and everyone knows what a bunion is, it’s the big bump on the side of your foot. And it’s usually typically red and angry and patients will complain of pain. Oops, all the way, right over here where the bump is.
Dr. Chi: The best way to think of a bunion is really an angular deformity of the toe. If you look at the way the bones line up, the x-ray on the right side shows that these bones start this direction, go this direction and end up in this direction here. And the bump happens because this bone is prominent on the side, right over here. If you think of my arm as your toe, if my arm is bent, there’s a bump here we call that the elbow. But it’s really a normal bone it just out of the position, it’s an angular problem. So the bump of my elbow goes away when I straighten my elbow. And that’s what a bunion is.
Dr. Chi: Think of a bunion like scoliosis. If you look at a young girl with scoliosis, they oftentimes have a crooked spine. Here’s a crooked spine here and they have a hump on the right shoulder. Now the treatment for this hump on the right shoulder is not to shave down the shoulder blade. Similarly, with a bunion, the treatment is not the shave down the bump. It’s really to straighten in the spine.
Dr. Chi: So if the spine is straight, the hump of the shoulder goes away. On this X-ray rendition here’s a straight spine, here’s a crooked spine. So here is your crooked spine causing scoliosis or a bump. So again, the treatment for scoliosis similar to a treatment for a bunion is to straighten the curve. I heard a lot about curve recently.
Dr. Chi: Here’s an interesting side fact, we’re orthopaedic surgeons. This is Latin for ortho, meaning straighten and paed which is child. Not P-E-D, ped, which is foot but paed. We were actually not surgeons in our initial iteration. We were bonesetters and brace makers who straightened the crooked legs and backs of children, so we’re orthopaedic surgeons.
Dr. Chi: Let’s contrast this to arthritis. When you have arthritis, that implies damage or loss to the cartilage of a joint. Here’s a knee model here and the end of the bones are cut by this very slippery material we call cartilage. On the picture, we have a blue area here. Oops, let me do that again. Blue area here, that blue area represents very slippery cartilage. It’s like Teflon on the ends of your bones. Throughout your life the cartilage wears down and eventually you have no more padding on the ends of your bones and the raw bone, starts rubbing on the raw bone, and that causes a lot of pain and swelling.
Dr. Chi: Any damage to the cartilage would be interpreted as arthritis. You can have minor damage. Think of your cartilage like this asphalt in this road here. You can have a single crack in the asphalt, or a single crack in your cartilage and that’s a minor bit of arthritis damage to that cartilage. You can have lots of cracks in your cartilage or your asphalt and that’s more severe arthritis. And you can have a pothole in your ankle or your knee, or your toe for that matter and that’s more severe arthritis.
Dr. Chi: This picture here shows a knee with slippery white cartilage everywhere but this focal area of arthritis, like this pothole over here. Now, anything that ends up causing damage to the cartilage would be arthritis. Osteoarthritis is what we normally talk about. That’s sometimes described as wear and tear arthritis. That’s from life and all the activities and since the cartilage doesn’t grow back throughout your lifetime, it just slowly wears down.
Dr. Chi: If you break your joint, let’s say you shatter your knee joint, you can damage the cartilage by cracking into the joint and that would be called traumatic arthritis. If you have a disease like rheumatoid arthritis, that’s where you make antibodies to your own body. And if you make antibodies to your cartilage such as rheumatoid arthritis, your own immune system will attack your joint. If you get an infection the bacteria is quite harsh to the cartilage and the bacteria can damage the cartilage. And of course, gout is a very harsh acidic crystal and it can damage the cartilage. So anything that causes damage to the cartilage would be called arthritis.
Dr. Chi: Now if you have arthritis of the great toe, we call that hallux rigidus. You might see similar terms such as hallux rigidus, hallux limitus, hallux elevatus or simply great toe metatarsalphalangeal arthritis or big toe arthritis. Here’s an x-ray on the left, the space between these two bones is where the cartilage is and we’re assuming that the cartilage is good because there’s even space everywhere. And on the x-ray on the right, there is no space between the two bones and the bones are rubbing against each other. And this would be called bone on bone arthritis.
Dr. Chi: This picture here shows big lumpy spurs on the toe. The toes are straight. It’s not a bunion, it’s just a lumpy thick bone spurs around the toes and that’s arthritis not a bunion. So let’s review a bunion is an angular deformity where the toes line up crooked, the big toe lines up crooked. I’d sometimes jokingly call it scoliosis of the foot or toe-liosis. We believe it’s because the ligaments that keep the foot stable are beginning to stretch out or fail, and the toe becomes unstable and the bunion starts swiveling.
Dr. Chi: Arthritis is loss or damage to the cartilage of a joint. Because of the loss or damage of the cartilage, you have more rubbing, more friction, more inflammation, swelling, pain and bone spurs then show up. All those things inflammation, swelling and pain, they’re the result of the arthritis. They’re the effect of the arthritis not the cause. I see some questions are coming up. Let me do this one pop quiz and then we’ll take a couple of questions.
Dr. Chi: Which one is a bunion and which one’s arthritis? Again, which one is a bunch of bone spurs and which one is an angular deformity? And hopefully you all get this right. This is the bunion, this is the arthritis. This toe is straight, this toe is crooked. In fact, here’s X-rays of that foot you just saw on the left, here’s that very crooked bone and after I did a bunion surgery, this toe will end up straight now. So this is that x-ray from before, here’s that very crooked foot here and this is what this patient looked like before, and this is what the patient looks like afterwards here.
Dr. Chi: Some people ask me if a bunion can cause arthritis. A bunion and arthritis are different but can a bunion cause arthritis? And the answer is sometimes. Here’s a car, presumably this car hit the curb and the tire was out of alignment and the rubber wears unevenly. So yeah, sometimes when you have a toe that’s crooked and the toe’s articulating with the bone in the incorrect fashion, sometimes the toe will wear it down quicker and the arthritis comes more prematurely because of the way the toe articulates and rubs on the wrong part of the toe.
Dr. Chi: Similarly, sometimes you have arthritis and because the joint doesn’t wear down evenly, the toe or in this case the finger will wear down crooked. So many of us as we get older, lose a little height because our cartilage’s beginning to wear down in our ankles and our knees, hips and our spine. And if they wear down evenly, then we just are a little bit shorter. But if it wears down unevenly, you can have crooked fingers, crooked spines and so yes, sometimes arthritis could cause a bunion. All right, let’s take a little break here.
Dr. Chi: We have a couple of questions coming in. And one of the questions is, “Do bunions cause thick toenails or is that another condition?” Well, thick toenails is unfortunately usually another condition, people with bunions don’t necessarily get the thick toenails. Thick toenails are most commonly from fungus, fungal growth and that’s a challenging problem to fix. And if anyone were to solve that they’d become very famous and wealthy because no one has quite solved fungal toenails to be reliable.
Dr. Chi: Sometimes thick toenails come from circulation or other skin issues but the fungal toenails are the most common. And another question is, “What can be done to lessen the pain that hammertoes cause?” Hammertoes is a separate condition from bunions oftentimes related. The ligamentous failure of the bunion oftentimes goes hand in hand with ligamentous failure of the toes and the toes and being crooked.
Dr. Chi: Very similar to bunion, sometimes those hammertoes are caused by arthritis and sometimes they’re caused purely by ligamentous failure. And that’s a whole nother discussion we can engage in, in some future date. But the short answer to how do you make hammertoe pain better? Is either wear open-toed sandals or shoes that don’t rub on the toes, wear padding around your toes as much as possible or straighten the toes with a hammertoe surgery.
Dr. Chi: I‘d like to spend just a couple of minutes talking about the types of bunionectomies. There’s really three categories of where bunionectomies occur. We’ll get to this one called the Akin osteotomy in a minute. But the three major categories is a distal procedure, a proximal procedure and a lapidus procedure. A distal procedure cuts the bone at the end. The bone sort of starts off on the wrong direction but you straighten it by shifting the head in, and it puts the end of the bone in.
Dr. Chi: A proximal procedure cuts a bone somewhere on this and the bone starts off once again in the wrong direction but you cut it and you bring it straighter. And that gets the bone closer to where it belongs. And a lapidus or through the joint procedure fuses or eliminates this joint here, brings the entire bone straight here and all these procedures tightened up the ligament on the inner half that’s stretched out.
Dr. Chi: So if you imagine once again, here’s my arm. If this is the bone, I can cut that bone through the end and bring it in. I can cut it in the middle or towards the proximal end and bring it in more, and I can bring it all the way from the source and bring the whole thing in. And of course, when you do it through the source of the lapidus you get the most powerful correction. So a bigger bunion would usually demand something like a proximal or a lapidus procedure, whereas a smaller bunion you might be able to get away with a distal procedure. The reason we would do a distal procedure is because it is much less invasive. It’s a faster recovery, more reliable healing, less pain, less rehab. And so, we prefer to do the distal procedure when we can get away with them. And we resort to the lapidus procedures when we have a bigger bunion to correct.
Dr. Chi: And another question came in talking about a torsional or rotational component to the bunions. If you looked at the X-rays from before, you might see that the toe looks quite crooked. I’m trying to get to this picture right here. And this toe looks quite crooked, that toe is rotating. So yes, there is a rotational component to the bunions particularly, as they get more severe. And when you do a lapidus procedure, you can correct that rotational component far better than you can with the other procedures.
Dr. Chi: So the worse the bunion, the worse the rotation component, the more useful the lapidus becomes. Here’s an example of a distal bunionectomy. This happens to be called a distal chevron bunionectomy because the bone cuts, cut in a chevron shape. The head is cut it’s pushed in and I put a pin in there to hold it. And for a not too bad bunion, this is a useful procedure.
Dr. Chi: Here’s a proximal bunionectomy. This version is called a croshetic bunionectomy, the bone is cut in a rotational fashion and it’s hard to see in this x-ray but it’s kind of a rotational fashion this end of the bone is swiveled in and held with some hardware. And here’s a lapidus procedure. A more severe bunion with a lot more rotation to it. It’s brought in, I’m holding with two screws and the toe is now straight.
Dr. Chi: Now, some people get concerned about fusing that joint. In the lapidus procedure you eliminate and fuse this joint here, it disappears. And some patients will say, “Well, is it okay to fuse a joint? Anytime you fuse a joint, you’re losing the motion of that joint?” Well the Academy thinks that this joint should move zero to three degrees. And so fusing it doesn’t result in a lot of loss of motion because there is not much motion there. Now, that joint used to be a thumb in the chimpanzees. This joint moves a lot and the chimpanzees can grab bananas and sticks, and pick them up.
Dr. Chi: And the theory, current theory of evolution is that this joint with the invention of bipedal gait has become stiffer and stiffer, and stiffer to the point where it essentially doesn’t move in most people at all zero to three degrees. And evolutionary theory dictates that this joint should disappear over time.
Dr. Chi: Now of course we don’t always get evolution right, but that’s at least our current theory and it seems to work. The question that came in that said, “is there a torsional component to the bunion?” That bunion there looks like it’s trying to be a thumb. What’s really fascinating is the shape of this joint is still very similar to the shape of the joint of your hand. That joint has a capacity to rotate like a chimpanzee’s thumb, but the ligaments prevent it from rotating. Just like juvenile onset scoliosis, some people will have ligamentous failure early in life and you’ll see these 16-year olds with terrible bunions. And some people through life, time, age and attrition in life, the ligaments just stretch out and fail, and then you get these horrible bunions because the ligaments have failed and the joint is capable of moving that way.
Dr. Chi: Back to that Akin osteotomy. This is oftentimes done in conjunction with a regular bunion. Some patients have what I call a banana toe. It’s not really so much that they have a bunion, it’s just the toe itself has a kind of a crazy crook to it. And in those severe situations, we take a little wedge out the toe and shut it down. Here’s that wedge coming out here. Now we shut it down to take the banana out of the toe. Some patients need this most done but it’s a little adjunct procedure to the bunionectomy as we sometimes do.
Dr. Chi: Let’s shift gears and talk about surgery for big toe arthritis. There’s four categories of this, one is what I call the 100,000 mile tune up that’s to clean out the joint of all the debris and bone spurs and loose cartilage. Another category is to change the position of the toe to make it more functional rotational osteotomy or shortening osteotomy. And anytime any joint ends up at the end of the line with really no cartilage, no function, and a lot of pain. We either replace the joint such as we do in a hip replacement or a knee replacement or fuse a joint such as what we do for instance, in a spinal fusion. So a fusion makes the two bones become one solid bone. They don’t move anymore, there’s no scratchy rough surfaces to cause pain, but the toe doesn’t move or the joint doesn’t move anymore.
Dr. Chi: So here’s a cheilectomy or the 100,000 mile tune-up you take the arthritic joint, you open it up, you remove the boulders, you look in the joint to remove the loose cartilage, or the broken cartilage or damaged cartilage. And if there’s enough cartilage leftover, and if the joint’s not too damaged, it oftentimes helps. It’s never perfect and eventually the cartilage keeps degenerating, and eventually their arthritis progressed, the bone spurs come back, the pain gets worse and we get to bone on bone arthritis later. And if you buy the patient 10 years with a clean out job, it’s usually a pretty good deal. And if you try to do a clean out job with a toe that’s too far gone, it doesn’t help very much. It doesn’t solve the underlying problem which is the looser and missing of the damaged cartilage. So I like to say, “with these operations we can only take away, we can’t add.” We don’t yet know how to put new cartilage into a joint.
Dr. Chi: When the toe gets very arthritic, the toe gets stuck in the down position and if the toe is kind of jammed down. And every time you, your heel leaves the ground you’re jammed, the bones present to each other. You can do an Akin osteotomy and take a wedge out and put the toe in a more functional position. It doesn’t increase the range of motion, it just puts a toe in a slightly better position hopefully, for walking. One of the problems is some people get a bit of a cock-up toe by putting the toe there. And sometimes the top of the toe rubs on the shoe. It’s a reasonable thing to do, if you have a toe that’s stuck down and sometimes buys you a bit of time.
Dr. Chi: Here’s a procedure that I don’t recommend, don’t like to do. It’s called a shortening osteotomy, you remove the bone spurs and you shorten the bone, to essentially it takes the balls of the big toe off the ground. So it doesn’t bear as much weight. And in oftentimes it works because the big toe is not pushing off on the ground as much, and it feels better. Unfortunately, by taking the weight off the big toe, most patients develop pain in the second toe cause the second toe has to do all the work and they get hammertoes, stress fractures, and arthritis and other problems. And I undo more of these operations than almost any other big toe type of surgery. So I don’t recommend this. It does make the big toe feel better, but it causes a secondary problem.
Dr. Chi: As we were talking about arthritis, a question came in as to whether we should do a bunionectomy to avoid arthritis. That’s a very, very good question, and I don’t know the answer to that. But I would say that, not all people who have bunions develop arthritis, and not all people with arthritis have bunions. I’ve seen some pretty severe bunions. When I opened up the toe, there is virtually no arthritis.
Dr. Chi: So if you’re that unlucky person who’s bunion is causing arthritis, then the answer would be yes, get the toe straightened before the joint wears down, eccentrically. But surprisingly, that doesn’t always happen because we can’t always predict who’s going to get arthritis or not. I generally don’t recommend a bunionectomy for someone who is not symptomatic. If the toe is beginning to get arthritic, if it’s beginning to have some pain, if it is beginning to rotate or change faster over time, that’s I think a reasonable reason to do the bundle.
Dr. Chi: Here’s replacement, there are pictures on the left, the top and the side one is called cartiva, that’s our latest and greatest new, big toe replacement. I call it a jelly donut, you basically make a hole and put a jelly donut in, so $3,000 jelly donut I think, but it’s a little bumper or [inaudible 00:22:57] that goes between the bones. And it’s interesting. It’s kind of minimally invasive. That’s a fairly easy operation to do with not too many side effects. The problem is that it’s early, it’s young. We don’t really know what the long-term effects or success of this surgery is going to be. We do know that at the two-year mark it has about a 10% failure rate, and our most recent four-year data shows about a 17.8% failure rate. And that in surgery is kind of high at the six-year mark or the 10-year mark, it’s probably just going to keep going up.
Dr. Chi: I like to say that if you’re winning 80% of the time in Las Vegas, you ought to stay there and make a lot of money. But this is your body, this is not Las Vegas, so personally I don’t like the 20% failure rate or the 17.8% failure rate. I’m nervous it’s going to go higher and higher. So I don’t formally recommend this operation. I have done it at patient requests, and some of them will probably do well, some of them will probably have a failure. This surgery is easy to revise to a fusion if need be, which is the only reason I do it. If you look at the history of big toe replacement joints the lesion, the total toe, the hemicap, the prostop, the silastic, all these different versions. These have all largely been failures and largely abandoned.
Dr. Chi: So the history of big toe replacement surgery has not been very kind. And I have a suspicion that the cartiva may fall in that same footsteps. And it may be something we’re very fascinated with for five to 10 years. And then perhaps maybe not be quite as interested if it does fail at a high rate down the line.
Dr. Chi: The gold standard for arthritis of the big toe is a fusion. And just like a spinal fusion, you take the two bones, you grind them up a little bit so they have raw rough surfaces. You trick the toe to think that the two bones are a fracture. You hold them together with some type of metal, in this case I’m using a titanium plate and screw construct and the toe bones grow into each other. They become one solid bone and the pain goes away because nothing is scratching and moving.
Dr. Chi: If you have a bit of a arthritic bunion or arthritic toe with a crookedness, you can fuse it straight of course, which I did here. So that the big toe no longer rubs and steps on the second toe, it kicks the second toe up. So you can fuse it straight and that gets rid of any secondary bunion that you might have. It’s a surprisingly successful operation. You do lose the motion of the big toe, but most patients don’t seem to mind that especially when the pain goes away. The function of your foot is to be a stable platform. And if you have a mobile foot that’s painful and you can’t push up because of pain, it generally doesn’t work very well. So I like to say in the hands function’s all about mobility, you need your hands to move in order to be functional.
Dr. Chi: Whereas on the foot function is all about stability, a painless stable platform, you can push to climb the stairs or chase the bus, or run after the dog. And if it’s painful or unstable foot, it doesn’t work very well. So we tend to resort to fusions more readily in the foot, whereas, we tend to avoid them in the hand. The function of the foot is dictated by the stability.
Dr. Chi: So with that, I’ll leave you with this, “Faces need to look good; hands and feet need to work! Your feet are valuable tools and you should take care of them.” And if they start breaking down with work, you can find us at Proliance and we will fix them for you. With that I’ll end, and I’ll open up to any further questions.
Moderator: Fantastic, thanks Dr. Chi. Now, we’ll take a couple of minutes here, we’ve answered some of the questions throughout the presentation. If anyone would like to send us a question via chat, we’ll get to that now. We’ll give you a moment and if we don’t see any others come in, then we’ll just let you know that this will be available for replay and we will send it out to you via email. And of course you can always visit us at www.posm.com, Proliance Orthopaedics & Sports Medicine.
Dr. Chi: Thank you! Good evening, everybody.