Bunion surgery: Evolution of postoperative protocols

Research is starting to reveal that early weightbearing, physical therapy, or both after hallux valgus surgery is not as risky as some practitioners once thought, and such new postoperative protocols appear to be associated with improved outcomes.

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Clik here to view.By Barbara Boughton

Although bunion surgery is often effective at correcting underlying bone deformities, patients are frequently frustrated with the postoperative recovery—which can involve prolonged pain, swelling or periods of nonweightbearing in a cast or boot. In an effort to improve postoperative symptoms and enhance patient satisfaction, recent research has investigated the results of early weight-bearing and physical therapy protocols in the first few months after surgery.

Experts say there’s no cookie-cutter approach, since every patient’s deformity, surgery, and postoperative symptoms are different. Yet research is starting to reveal that using early weightbearing, physical therapy, or both is not as risky as some practitioners once thought. And although research has yet to conclude that early weightbearing or physical therapy improve long-term outcomes, recent studies do show these protocols can improve short-term symptoms and outcomes.

Depending on the surgery, early weightbearing in patients who have stable fixations with osteotomy can be a viable postoperative treatment option, according to Donald R. Bohay, MD, FACS, professor of orthopedic surgery at Michigan State University in East Lansing and director of the Grand Rapids Food and Ankle Fellowship program.

“There is some skepticism about early weightbearing after surgeries such as tarsometatarsal fusions,” Bohay said. “But even in these patients, early weightbearing may be a sound choice, since it can help to reduce swelling and hasten recovery.”

Recent studies, including one presented by Bohay and colleagues in July, indicate that early weightbearing after tarsometatarsal fusions can reduce symptoms without affecting union rates or complications during postoperative recovery. Patients who use early weightbearing are also more comfortable during postoperative recovery than those who are in a cast for a longer period.

“Historically, the fear was that early weightbearing risked nonunion or delayed union. But recent studies show that early weightbearing can be done within reasonable limits,” Bohay said.

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Evidence for early weight bearing

In 2010, a study in the Journal of Foot and Ankle Surgery was the first to demonstrate that early partial weightbearing after approximately two weeks after a modified Lapidus arthrodesis did not compromise outcomes.¹ In the study, 76 patients who underwent modified Lapidus arthrodesis on 80 feet were allowed protected weightbearing after the first postoperative visit. All 80 feet achieved successful union, and the mean time to union was just over 44 days. The duration of time to bone healing was, in fact, similar to rates reported in previous studies describing Lapidus procedures with longer durations of initial postoperative nonweightbearing, the researchers noted. There were no complications requiring surgical revision and no hardware was broken before solid bony fusion occurred.

“This study demonstrates that early weightbearing of the Lapidus arthrodesis can be performed without compromising correction or the rate of osseous union,” the researchers concluded.

A more recent study investigated immediate weightbearing after Lapidus procedures for severe hallux abductovalgus deformity with first ray hypermobility.² The surgeons used an external fixation device on 19 patients for a mean postoperative duration of 12 weeks. The most common complication was pin-tract infection in five patients, which was treated with oral antibiotics. Only one foot required early hardware removal. Most importantly, the mean patient pain score decreased significantly from 8.2 to .83 on a visual analog scale over the 37 weeks following surgery.

At the annual meeting of the American Orthopaedic Foot and Ankle Society, held in July in Long Beach, CA, Bohay and colleagues presented the preliminary results of a prospective, randomized controlled trial comparing early weightbearing and nonweightbearing after modified Lapidus arthrodesis.³ All patients were nonweightbearing for two weeks following surgery. The 48 patients who began weightbearing in a fixed ankle support boot at two weeks demonstrated a greater decrease in pain from baseline to 12 months than the 36 patients who began weightbearing six to eight weeks after surgery.

With today’s improved and more stable surgical technologies, such as locking plates, early weightbearing after Lapidus procedures is possible without compromising hardware. Scientific literature^2,4 has also shown early weightbearing can help return patients to normal shoe gear and provide a quicker recovery than extended periods of nonweightbearing, according to Keith Cook, DPM, director of Podiatric Medical Education at University Hospital in Newark, NJ. Early weightbearing also reduces the risks associated with prolonged nonweightbearing, such as deep venous thrombosis, joint stiffness, muscle atrophy, and osteopenia.

“The complications associated with weightbearing too early are usually seen when the fixation isn’t solid, and in those cases, there’s a risk of nonunion, delayed union, malunion, or hardware failure,” Cook said.

Considerations

Often decisions about whether to recommend early weightbearing after a bunion procedure depend on the severity of the deformity, the type of surgery and fixation used, as well as individual patient characteristics, according to podiatrists and orthopedic surgeons.

“Early weightbearing is more possible with bunion surgeries that involve just soft tissue work or stable bone cuts. Certainly, with today’s locking fixations, there’s a trend toward getting patients on their feet and walking sooner,” said Alan MacGill, DPM, FACFAS, a certified foot and ankle specialist in Boynton Beach, FL.

Patients who undergo soft tissue procedures and stable bone cuts made in the distal metatarsal head may be able to bear weight immediately. Yet, most patients minimize their walking until the pain and swelling have improved over a few days, MacGill said.

More proximal metatarsal procedures, including the Lapidus arthrodesis, are different, MacGill noted.

“If I have used locking fixation, I will keep these patients nonweightbearing for two weeks, and then let them ambulate in a CAM boot for another four to six weeks. Clinical and radiographic improvement dictate how fast I can transition them into a walking shoe or sneaker,” he said.

In MacGill’s clinical experience, patients who put weight on the foot too early can increase postoperative pain and swelling, as well as risk loss of correction and possible delayed bone healing, he said.

Yet patient characteristics also need to be kept in mind when deciding on postoperative weight-bearing protocols. An earlier return to function may improve patient satisfaction, said Daniel Guss, MD, MBA, an instructor at Harvard Medical School and an orthopedic surgeon on the Foot and Ankle Service at Massachusetts General Hospital and Newton-Wellesley Hospital, all in the Boston area.

“It’s difficult to be nonweightbearing for an extended period of time. The foot is simply geared to walk, and wants to bear weight,” Guss said. “For many patients having to be nonweightbearing for a prolonged period will make a huge impact on their daily lives. And for some patients, this type of postoperative recovery is just not realistic.”

Postoperative physical therapy

Postoperative protocols after bunion surgery also include exercises to improve range of motion and strength and to decrease stiffness and uncomfortable scarring. In the past, referring a patient to physical therapy was often a highly individual matter—a choice that relied just as much on the surgeon’s preference as the type of bunion surgery and the patient’s postoperative symptoms.

“Even today there are a fair number of patients who are not referred to rehabilitation after bunion surgery,” said Judith Gelber, PT, OCS, assistant professor of physical therapy and neurology at Washington University in St. Louis, MO.

In her clinical experience, postoperative physical therapy has the potential to shorten the recovery period after surgery by decreasing pain and increasing strength, range of motion, and mobility more rapidly, Gelber said.

“With physical therapy, we can often get patients on their feet sooner and back to their lives sooner,” she said.

Physical therapy after bunion surgery can help decrease stiffness and swelling and the patient’s return to a normal gait pattern in the short term,^5,6 but there needs to be more scientific research about the long-term outcomes before any definitive conclusions can be made about its benefits, Guss said.

A well-trained physical therapist can also help desensitize the foot after surgery and decrease scarring through warm and cold baths and postoperative massage. Whether physical therapy is needed to help ease pain often depends on the individual patient and his or her postoperative symptoms, Bohay said.

“Pain is very idiosyncratic,” he noted. “Some patients don’t need physical therapy at all to help with pain, while others will need it three times a week after surgery.”

Another advantage to physical therapy is that it encourages postoperative exercise in a structured environment, MacGill said.

“Some patients will participate actively in exercising their foot after surgery, while others need a physical therapist to enhance range of motion and strengthen the foot through targeted exercise. I recommend physical therapy on a case-by-case basis. If patients aren’t progressing and experiencing significant improvements through postoperative home exercise after four weeks, then I’ll refer them to physical therapy,” he said.

Functional benefits

Physical therapy can be important for returning patients to functional mobility, according to Suzanne Hawson, PT, MPT, OCS, a physical therapist at the University Foot and Ankle Institute in Valencia, CA, and a part-time faculty member in the Physical Therapy Program at California State University, Northridge. As well as aiding in postoperative recovery, physical therapy may help correct improper foot function that may have resulted from walking with a bunion over an extended period—and which may persist even after the corrective surgery.

“With really bad bunions, patients tend to avoid putting weight on the medial side of the foot. With physical therapy, we can restore normal forefoot motion by reducing pain and swelling there,” Hawson said.

Limited range of motion is one of the most common reasons for referral to physical therapy after bunion surgery, according to Hawson. As well as pain, symptoms that can restrict range of motion after bunion surgery include effusion, edema, scarring, and connective tissue restriction in the joint capsule and impaired tendon gliding, according to a review article authored by Hawson and published in Clinics in Podiatric Medicine and Surgery in 2014.⁷

In Hawson’s clinical experience, physical therapy can effectively improve pain and range of motion and decrease muscle guarding through joint mobilization techniques. Other physical therapy modalities that improve pain and range of motion after bunion surgery include transcutaneous electrical nerve stimulation, ultrasound, cryotherapy, and low level laser therapy,^8-10 Hawson said.

Incisional scarring can also affect joint function and can be persistently painful for more than 30% of patients after bunion surgery,¹¹ she said. Yet, techniques such as manual therapy, low level light therapy, and use of a combination of silicone gel and vitamin C can be used to reduce scarring and mobilize scar adhesions,^12-14 Hawson said.

Persistent swelling is another common complaint after bunion surgery. Such edema can significantly affect range of motion and function after bunion surgery.

“When fluid starts to build up in the foot, there’s not a lot of room for it to drain because the foot is usually in a dependent position,” she said. “Edema can be very uncomfortable and can keep the muscles from functioning properly. As a result, it’s more difficult for the foot joints to move normally, which affects gait.”

Physical therapy techniques that can be successfully used to decrease edema after bunion surgery include massage that promotes lymph drainage, and application of electrical stimulation, ultrasound, cryotherapy, and taping.

Decreased strength can also be a persistent problem after bunion surgery,¹⁵ and this loss of strength can affect the patient’s gait,⁴ Hawson said. Normal gait requires not only good range of motion but also strength and proper muscle timing, she noted. Although hallux valgus correction typically is associated with a more normal distribution of plantar pressures during gait, postoperative plantar loading often is not completely restored.^16-20 All of these functions can be improved with physical therapy exercises aimed at a patient’s specific weaknesses and foot dysfunction.

Are there any risks in using physical therapy after bunion surgery? Progressing too quickly and mobilizing a joint too aggressively can result in discomfort and soreness, Hawson noted.

“Most patients will notice this kind of soreness during therapy or shortly afterward, so it’s important for the patient and therapist to maintain good communication throughout the rehabilitation process,” she said.

One of the most important roles for the physical therapist, however, is education about the type of shoe to wear after surgery, she said.

“To enhance normal gait pattern and to walk without pain, a patient often needs a stiff-bottomed shoe during the recovery period. Often patients do well with athletic shoes with stiff soles which can be adjusted as swelling decreases,” Hawson said.

Physical therapists and other lower extremity clinicians can also provide advice about suitable orthotic devices—as well as shoes—that can address biomechanics and aid in the recovery process after bunion surgery. Even after bunion surgery, Hawson said, some patients will require custom orthoses to address poor foot biomechanics, while other patients can derive significant benefit from over-the-counter devices.

Without expert advice on shoes or foot orthoses, patients will often experiment on their own, she noted. As a result, patients may end up with products that may not be helpful for their recovery, which can be costly and lead to frustration, she said.

Barbara Boughton is a freelance writer based in the San Francisco Bay Area.