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This year's ACFAS conference in Phoenix, Arizona and a recent internet survey by Podiatry Today1 got me thinking about surgery. Look at the figure below for the results of a small survey about treating bunions surgically versus nonsurgically.
 Despite the small number of participants, I find it interesting that the respondents were split almost down the middle on whether conservative care is mandatory before bunion surgery.
This has always been a somewhat contentious issue for podiatry as a profession, but also for me personally in my practice. Are there some conditions that should be treated surgically right off the bat? Why do we bother treating some pedal conditions nonsurgically first, if we predict treatment will fail?
Before we go into detail on this, let me first stipulate a couple of things:
 I don't like the term "conservative" as an alternative to "surgical." Sometimes surgery is the more conservative approach. Casting a displaced unstable ankle fracture in a healthy patient is, I would argue, the less conservative approach. Let's call this nonsurgical versus surgical treatment.- Some problems just have to be surgically handled. Abscesses need to be drained. Many displaced fractures need to be reduced and fixated. Some amputations must occur.
- Some problems should be treated nonsurgically first because we see a large percentage of patients improving with nonsurgical care. The obvious example here is plantar fasciosis.
- Other problems should probably be surgically treated but are usually nonsurgically treated first.
 Hallux valgus with bunion deformity falls into this fourth category. In 15 years of involvement with podiatry, I've never once seen a bunion resolve with nonsurgical care. Splints, braces, orthoses, and various physical therapy maneuvers do not now and will never reverse the abducted position of the hallux and subluxed position of the joint. Sorry, folks, it's just not going to happen.
Having established that, even though these methods might not reverse the problem, they may help deal with some of the symptoms. Wearing shoes with a wider toe box or sandals will decrease the medial bump abrasion that often brings our patients in, but it still doesn't reverse the deformity. Custom foot orthoses may help offload the joint and improve foot function, but, again, it won't reverse the deformity. If you think it does, feel free to submit your research study demonstrating at least a case series with serial images to prove it.
In fact, one of the best studies currently available comparing surgery and nonsurgery for bunions was published in 2001 in JAMA. Torkki and colleagues randomly assigned 209 patients to either foot orthoses, surgery, or "watchful waiting." At a follow-up of six and 12 months, patients who underwent surgery perceived greater pain reductions and functional status than those in the orthosis or waiting groups. The authors concluded, "Surgical osteotomy is an effective treatment for painful hallux valgus. Orthoses provide short-term symptomatic relief."2
We now have strong research evidence that surgery leads to better outcomes. We also know that this deformity cannot be nonsurgically reduced. Additionally, it is well understood that osteoarthritis is more rapidly advanced in joints with deformity. Yet despite this, many of us still treat bunions nonsurgically. In many cases, I too advise the same for my patients, especially the ones without pain.
Why do we do this?
We simply don't want to be sued and have it revealed that we chose surgery as a first line treatment. Let's say you have a patient with a bunion deformity. She presents to your office with an ingrowing toenail, and the bunion is an ancillary finding. After taking good care of her toenail, she asks you about her bunion. It's been there for several years and does not bother her. She's never treated it. Despite this, you advise her that surgery is necessary to prevent future pain and arthritis. After agreeing, she undergoes a metatarsal osteotomy. At six months postoperative, she now has pain that was absent before the surgery. In a patient that was previously painless and without any prior treatment, it becomes a challenge for you to defend yourself in court. In fact, bunionectomies are one of the most common reasons podiatrists are sued (most likely due to the shear number of them we do).
So, what to do with this conundrum? Each of us has to decide how we will practice in situations such as these. For myself, I consider surgery for patients with pain, worsening deformity, or the inability to tolerate shoes. For those without pain, I advocate foot orthoses to reduce the forces that caused the deformity and move to surgery when the patient's situation changes. As much as I feel surgery is the most appropriate treatment, it's too risky to go against the stream of current practice.
Conservative versus surgical. You decide. But remember your patients live with your decisions.
Best wishes,
Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]
References
- Podiatry Today Online, Is Conservative Care Mandatory Prior To Bunion Surgery? – by Allen Jacobs, DPM 04/21/11.
- Torkki M, et al. JAMA. 2001; 285(19): 2474-2480.
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