Patients & Families

Dear Referring Physician,

Thank you very much for your consultation regarding female patient, DOB: 1/25/1967. I have reviewed the medical records that were provided as well as the imaging. My findings and opinion regarding her case follows:(1)

Chief complaint: Bilateral forefoot pain(2)

History Provided:(3)

She has suffered with bilateral hallux valgus for a few years, however, in 2015 following a 3-day trekking holiday the condition worsened considerably.

Walking is limited and has declined markedly over the last 2 years.

She describes pain as chronic, although reluctant to take oral analgesia she prefers topical treatments, ice packs etc. Although provided with Orthotics, she was never advised to change them after wearing them of 6-7 months, and consequently her foot pain increased. She is now waiting for new ones, and expects them next week.

Generally, in good health, no associated health problems that may affect her hallux valgus.

She is awaiting new pair of orthotics, only to be worn with comfortable low heeled walking shoes. She is reluctant to take oral analgesia despite chronic pain; prefers topical remedies such as ice packs.

No pain when wearing house slippers, otherwise pain is experienced when wearing all types of other foot wear. She expresses concern that having to wear orthotics in the summer will only increase her foot pain, as she is unable to wear sandals.

The patient has been advised that if it is progressing it was likely to continue to do so and so she should consider surgery sooner rather than later as it will be a smaller operation with greater probability of success. Currently the patient doesn't feel it is bad enough to warrant surgery.

Imaging:(4)

Radiographs that were provided consist of 3 views of each foot done in a weight bearing position. No fractures or dislocations are noted. Joint spaces appear well preserved. There is no soft tissue abnormality noted. There is a mild hallux valgus deformity of each foot. There appears to be a bipartite tibial sesamoid on the left. The sesamoids appeared to be well located underneath the first metatarsal head. There is some prominence to each medial eminence on the first metatarsals. Although I was not able to accurately measure the hallux valgus angle or the 1-2 intermetatarsal angle these do not seem much greater than values that have been determined in the normal, non-affected population.

Answers to Specific Questions:(5)

1. Is surgery needed?(6)

I do not believe that surgery is needed at this time. Perhaps the primary determinant for undergoing surgery is whether the patient feels that it is warranted given their current set of circumstances. The patient very clearly states that she "...doesn't feel it is bad enough to warrant surgery."

2. What is the recommended timeframe for the surgery?

It is quite possible that she will have worsening of the deformity with concomitant worsening of her pain and decrease in function. If this occurs reassessment of the value of surgical correction should be undertaken at that time.

3. Is it advisable to wait?

Yes

4. What are the risks a) if she has it now b) if she waits until she is more symptomatic?(7)

Some of the risks that surgery poses would be present whether it is performed now or in the future. These include but are not limited to wound healing complications, infection, nerve damage, blood vessel damage, failure to achieve correction, recurrence of deformity, joint stiffness, continuing pain and overcorrection of deformity. The complications might differ if she waits until she is more symptomatic if alternative methods of erection including soft tissue/bone fixation are used. These would be specific to the procedure that was used.

5. What other alternatives exist?

The alternatives that exist for the treatment of her problem include comfortable shoe wear with a wide toebox. Although I do not think that any one brand is superior to others I have found that Keen shoes are very effective in providing comfort in patients such as this. They have a large toebox and can be used for many different types of activities/active lifestyles. I would avoid fashionable shoes that have a narrow, tapered toebox with high heels.

In addition to altering shoe wear her current shoe wear might be able to be modified using a ball and ring shoe stretcher. The goal of this device is to stretch out the shoe upper material to better accommodate the medial eminence where most people have pain with hallux valgus deformity. These can be obtained on line for a quite modest price and can be used repeatedly and in all of the patient's shoe wear.

A silicone toe spacer can be placed between the first and second toes to realign the deformity and potentially provide her with some relief.

6. Based upon the history and images, what are your recommendations for the best patient outcome?

Currently, I would pursue non-operative means for controlling the patient's symptoms and to prevent progression of her deformity. If these fail to provide relief she may want to consider surgery when she feels that non-operative methods have been exhausted and that she has no alternative.

Summary:(8)

I do not advise her undergoing hallux valgus surgery at this time. I think that using the aforementioned non-operative methods could provide her with significant relief and allow her to participate in the activities that she would like to. If the deformity she has progresses and the feet become more painful she may want to consider surgery at that time. Unless there is a worsening of great magnitude in her deformity the surgical correction would not be that much more difficult to perform compared to the surgical procedures that could be considered currently.

Please do not hesitate to contact me in the future if there are additional questions or concerns. Thank you for the opportunity for providing treatment recommendations regarding this patient.

Sincerely,

Orthopedic Physician