Frequently asked questions about Hallux Valgus
Hallux valgus is the most common foot condition. This progressive deformity manifests itself by an exaggerated deviation of the big toe towards the outside of the foot and by the appearance of a bump (or exostosis, commonly called "bunion") at the joint.
Questions about Foot Surgery | Hallux Valgus | Nice
When should I have surgery?
The pain, but especially the degree of this pain is the key word. For the same forefoot deformity, it will differ from one patient to another. The consequences of this pain, i.e. difficulties in walking and in putting on shoes, will lead to an indication for surgery.
It is important to point out to the patient that a hallux valgus will always evolve spontaneously towards self-aggravation, and that it is preferable to intervene surgically on an isolated hallux valgus rather than on an advanced hallux valgus that has caused the appearance of claw toes on the lateral radii by its deformation.
In the latter case, the surgery will be more difficult, the recovery longer and the risk of recurrence increased.
Is there an age limit for hallux valgus surgery?
Apart from the anaesthetic contraindications, there is no maximum age limit. Osteoporosis does not constitute a contraindication to surgery.
However, there is a minimum age corresponding to the end of puberty, to which we add a six-month delay for safety reasons. Thus, in the case of a congenital hallux valgus, which by definition appeared before the age of 15, the surgery can only be performed when the growth plates of the metatarsals and phalanges have completely disappeared in order not to endanger the growth potential.
Can I have both feet operated on in the same session?
Technically, both feet can be operated on at the same time. This is mainly of economic interest (only one surgical act, only one anesthesia, only one hospitalization, only one work stoppage).
If we place ourselves on the patient's side, we must explain to him or her precisely what the constraints of a bilateral operation are going to be (difficulties and possible instability when walking due to the wearing of two specific shoes during the first four weeks post-op).
What type of anesthesia will be used?
Loco-regional anesthesia has become the reference anesthesia. For Hallux Valgus surgery, a popliteal block is performed (putting the leg and foot to sleep). This loco-regional anesthesia has the advantage of being both an anesthesia allowing the realization of the intervention, but also a treatment against the postoperative pain thus realizing an analgesic block during the first 12 postoperative hours.
Combined with minimally invasive surgical techniques, locoregional anesthesia has made it possible to perform Hallux Valgus surgery on an outpatient basis.
How long will I have to stay in hospital?
Forefoot surgery, particularly hallux valgus surgery, is now performed on an outpatient basis thanks to the advent of :
- Minimally invasive surgery, which by reducing incisions, reduces the aggressiveness of the surgical act.
- loco-regional anesthesia, a much lighter anesthesia than general anesthesia
- Intravenous analgesia performed at home by a specialized network of liberal nurses Until recently, this intravenous analgesia implied a hospitalization to allow the use of a specific and bulky material ("an electric syringe"). Thanks to the analgesic diffuser (single-use, miniaturized intravenous device), this analgesia can be performed on an outpatient basis for greater patient comfort:
- Sleeping and eating at home
- Avoiding noise pollution in a health care facility
- To be surrounded by your own.
Will I suffer a lot?
Foot surgery still has a bad reputation when it comes to post-operative pain. Fortunately, there is now a very effective arsenal of therapies available for the treatment of this pain.
Thus, this management is based on a systematic prescription from the surgeon and/or the anaesthetist, but also on the patient's compliance with the instructions given during the preoperative consultation:
Chronologically, the management of postoperative pain begins with the creation of an analgesic block to ensure that the foot is completely asleep within 24 hours of the operation. This treatment alone requires monitoring and multi-daily injections of the local anesthetic through the catheter left in place on the operated limb, and therefore justifies the need for hospitalization. This procedure ensures the most complete indolence during the most painful postoperative phase, and thus reduces stress and anxiety, which most often contribute to the feeling of pain.
Once the patient has left the clinic, the relay is taken by painkillers prescribed by mouth. It is important that these be taken systematically in order to anticipate the onset of pain.
The patient must be aware that pain-relieving treatments are meaningless if they are not accompanied by scrupulous respect of the instructions given before the operation: all forefoot surgery requires the elevation of the operated limb as soon as the patient is in the chair or in bed, thus ensuring the best possible drainage after the operation (edema being a pain generator). As a guideline, "the feet should be placed above the heart". The fight against edema is imperative, since it is not only the cause of pain, but also slows down the healing process: indeed, any excessive edema can lead to skin disruption of the surgical wound which is no longer permeable, exposing the foot to infection. Raising the foot is not enough; it must be systematically combined with icing of the operated area: ice has anti-pain, anti-oedema and anti-inflammatory virtues, without any associated side effects, thus allowing for multi-day use.
Re-education and self-education, begun early on postoperative day 10-15, play a role in the treatment of pain thanks to the edema-draining function of massage therapy and passive mobilization of the foot.
Finally, the proper follow-up of the protocol for resuming support is also important in the treatment of pain. Indeed, the patient must know that any excessive resumption of this support in the four weeks following the operation is synonymous with oedema and therefore pain. Furthermore, support must be limited to its strict minimum during the first week post-op, or even, if necessary, be non-existent by using an English cane in case of displacement. Beyond the first week and until the end of the fourth postoperative week, support is always done with the help of a specific shoe, not exceeding two hours per day initially and then gradually increased.
In conclusion, the immediate postoperative analgesic block, which ensures that the foot is put to sleep during the most painful postoperative phase, and above all the instructions given to the patient concerning the treatment of edema and pain, make it possible to obtain comfortable postoperative results. All of this must not make us forget that the individual reaction to pain is different from one patient to another; moreover, any surgery, whatever it may be, causes pain, and the important thing is to ensure the best possible management of it in the interest of the patient.
Will my foot stay swollen for long?
Edema is the rule in foot surgery for several reasons: it is a surgery on a limb exposed to blood flow in the standing position; moreover, the typical patient requiring foot surgery (45/50 year old woman) often has venous insufficiency.
In the postoperative period, raising the foot above the level of the heart in the chair and in bed is imperative and promotes healing by limiting excessive traction on the sutured tissues.
Edema generally persists until the end of the fourth month postoperatively, but this is only an average value that can be revised upwards or downwards, depending on the patient's compliance, the degree of initial deformity of the foot, and the existence of an associated venous insufficiency.
The shoes must be adapted to the volume of the feet, until they have returned to a normal size.
After how long will I be able to walk and resume my activities?
The resumption of support is authorized immediately under cover of a specific shoe allowing the complete loading of the operated foot: it will be kept for four weeks.
To limit postoperative pain and edema as much as possible, it is recommended to limit any movement during the first postoperative week to a strict minimum, by not hesitating to use an English cane to allow complete relief of the operated foot.
Beyond this period, the cumulative daily walking time should be limited to two hours, in 15 to 20 minute increments, with an emphasis on short distances. The walking time will be gradually increased. In case of bilateral surgery, walking is possible with the help of English canes.
At the end of the four weeks of specific shoes, a soft flat shoe is put in place until the end of the 4th month.
The length of time off work depends on the professional activity. There is no problem with returning to work after two or three weeks, if the patient's professional situation does not require prolonged standing or walking. However, elevation of the foot, including at the workplace, should remain the rule. On average, patients benefit from one month's leave from work.
What about dressings?
The first dressing will be done postoperatively just before leaving the clinic, thus ensuring that the scar is progressing well and that there are no infectious processes.
Dressings are done every two days by a nurse at home until complete healing. The removal of the sutures is scheduled at D 15 post-op.
The foot may be washed the day after the wires are removed, unless otherwise instructed.
Can I take a shower or a bath?
Showering is allowed as long as the dressing is protected by a plastic bag. At present, there are waterproof devices on the market that allow bathing.
Is rehabilitation necessary?
Rehabilitation is essential and indispensable. It must be started early between D 10 and D 15 post-op. It must aim to maintain joint mobility by mobilizing the toes, which must be passive during the first four weeks. This mobilization will have a draining effect on the edema, as will the associated massage therapy.
At one month post-operatively, work on pulp support on the ground must be undertaken; standing on tiptoes cannot be considered before the third month post-operatively.
This re-education must necessarily be associated with self-education, at a rate of three times a day for the first two months post-op. It helps the patient to become aware of his operated foot, and must be limited to passive mobilization according to a technique shown by the surgeon in consultation. The first sessions can be done with the help of a physiotherapist.
When should I contact my surgeon before a scheduled consultation?
In case of fever, significant local pain, redness, or discharge from the wound, it is essential to contact your surgeon. The same applies if pain appears in the leg or calf with abnormal swelling of the foot.
Do I need to be under anesthesia to remove the metal hardware?
Screws and metal pins are used in foot surgery. In the case of hallux valgus surgery, this material is buried in the bone and is therefore left in place permanently.
In the case of claw toe surgery, a temporary pinning of four weeks is sometimes necessary, the pins come out of the skin, their removal requires neither anesthesia nor hospitalization; it will be performed in consultation.
Can I wear high heels again?
It is essential to avoid wearing shoes with high heels and/or pointed toes, only those not exceeding 4 cm are tolerated. In the opposite case, the patient is exposed to a recurrence.
Are there any specific risks associated with forefoot surgery?
Any operation involves short or long term risks; those most often encountered are :
* Healing problems due to poor management of postoperative edema resulting in traction on the sutured tissue.
* Infection, which is most often limited to a superficial infection limited to the skin, the origin of which can be linked to a delay in healing or to the general state (diabetes). Exceptionally, it can be deep with a picture of osteitis which is often problematic. Treatment involves local care that may be associated with appropriate antibiotic therapy.
* Algo neurodystrophy is most often limited to a spontaneously resolving pain syndrome, with, in its most severe form, inflammatory signs, hypersudation and diffuse demineralization of the bone, in response to the local aggression of the procedure; but this is usually only seen in the most anxious patients.
* Recurrence exists as in any surgical intervention: it is quantified at 6% and can occur in the short, medium and long term. In general, the results of forefoot operations are good and the quality of life is improved. The causes of recurrence are diverse:
- excessive laxity of the toe
- lack of compliance by the patient who has excessively reproduced in the postoperative period the causes of the initial deformity: very often the wearing of rigid shoes with pointed toes and/or high heels.
- technical error of the surgeon
- use of old surgical techniques, which should be abandoned, and which have contributed to giving forefoot surgery a bad reputation, particularly because of recurrences, but also because of the persistence of iatrogenic pain. The surgical technique currently recommended has been reliable for more than 10 years.
* Thromboembolic complications justifying postoperative antithrombotic prophylaxis.
- BONE COMPLICATIONS:
The osteotomy (fracture performed by the surgeon) may present a delay in consolidation which will have few consequences other than the persistence of pain until complete consolidation. Delayed consolidation is sometimes observed for up to a year.
Pseudoarthrosis is a lack of bone consolidation six months after the operation, which may require a new operation to heal the bone in case of pain.
Bone necrosis (death of bone that is no longer vascularized around the osteotomy area) is rare (<2%).
These bone complications are favored by smoking, obesity, alcohol, osteoporosis, vitamin D deficiency, diabetes, corticosteroid treatments...
- JOINT STIFFNESS:
Any joint movement can lead to a temporary or permanent stiffening of the joint. This stiffness may require re-education or re-operation.
- RESIDUAL PAIN:
The risk of residual pain, particularly in the joints, is inherent to all types of surgery. Although hallux valgus surgery regularly results in the disappearance of the pain syndrome related to the causal deformity, it is nevertheless true that in some cases joint pain may persist, raising the question of moderate osteoarthritis, particularly in the metatarsal-tesamoid space, even if the standard radiological workup is considered normal.
- MIGRATION AND BREAKAGE OF EQUIPMENT :
Surgical management involves the mobilization of bone segments, requiring the placement of surgical hardware. Like any material
Surgical implants can be responsible for complications, due to their own fragility (material breakage) or migration due to excessive mechanical stress on the bone structures where they are implanted (resumption of intensive walking too early, obesity, standing on tiptoe before three months post-op...). Thus, this surgical material may sometimes need to be reoperated in order to remove it.
Finally, and at a distance from the operation, once the postoperative period has passed and the pathology has healed, this material can also be removed when it is responsible for local discomfort or conflict.