Ever wished you could understand the nuanced world of bunions from a specialist's perspective? Brace yourself for a riveting discussion with Dr. Mark Sheehan, a foot and ankle connoisseur from the Kayal Orthopaedic Center, as we dissect the anatomy of the foot, focusing specifically on the big toe joint and the bones of the forefoot. Dr. Sheehan masterfully guides us through the essence of foot alignment and gait, their crucial role in diagnosing bunion deformities, and the potential for other deformities like flat foot to coexist.
With Dr. Sheehan's expertise, we delve into the labyrinth of diagnosing bunions and the interplay of two essential angles. Get ready to gain valuable insights into the typical presentation of this condition and the myriad surgical options available for bunion deformity. Be it a simple medial eminence resection, a distal metatarsal head osteotomy, or foot fusion, the chosen procedure depends on the severity of the bunion, and this is something we'll dissect in-depth.
As we advance, we plunge into the rare condition of juvenile bunion deformities and the significance of their conservative treatment. Dr. Sheehan provides enlightening details on the prevalence of this condition, the need for more education on surgical treatments, and the potential for secondary problems arising from bunion deformities. Join us on this thrilling journey into the realm of bunions, where understanding these deformities paves the way for more effective treatments. Don't miss out on this captivating conversation; it's sure to change the way you view bunions forever.
Ever wished you could understand the nuanced world of bunions from a specialist's perspective? Brace yourself for a riveting discussion with Dr. Mark Sheehan, a foot and ankle connoisseur from the Kayal Orthopaedic Center, as we dissect the anatomy of the foot, focusing specifically on the big toe joint and the bones of the forefoot. Dr. Sheehan masterfully guides us through the essence of foot alignment and gait, their crucial role in diagnosing bunion deformities, and the potential for other deformities like flat foot to coexist.
With Dr. Sheehan's expertise, we delve into the labyrinth of diagnosing bunions and the interplay of two essential angles. Get ready to gain valuable insights into the typical presentation of this condition and the myriad surgical options available for bunion deformity. Be it a simple medial eminence resection, a distal metatarsal head osteotomy, or foot fusion, the chosen procedure depends on the severity of the bunion, and this is something we'll dissect in-depth.
As we advance, we plunge into the rare condition of juvenile bunion deformities and the significance of their conservative treatment. Dr. Sheehan provides enlightening details on the prevalence of this condition, the need for more education on surgical treatments, and the potential for secondary problems arising from bunion deformities. Join us on this thrilling journey into the realm of bunions, where understanding these deformities paves the way for more effective treatments. Don't miss out on this captivating conversation; it's sure to change the way you view bunions forever.
Hello and welcome to another edition of the Kale Ortho podcast. Today is Tuesday, september 12th 2023, and our special guest today is our very own Dr Mark Sheehan. Dr Mark Sheehan, isa, foot and ankle specialist at the Kale Orthopedic Center, and we're so privileged to have him with us today. Welcome to the podcast, dr Sheehan, thank you. Thanks for having me, so happy to have you. So why don't we just take this opportunity, take a few minutes and just introduce yourself to our community of viewers and listeners?
Mark Sheehan, DPM:Sure, so my name is Dr Mark Sheehan. I was born and raised in southeastern Connecticut. I did my undergrad at the University of Connecticut and then from there went on to Berry University School of Podiatric Medicine down in Miami, florida, where I spent four years educating myself on all things foot and ankle. From there I came back up north and did a rigorous three-year surgical residency, based out of Hoboken, new Jersey and the surrounding area. And while I was there I was fortunate enough to establish a relationship with Dr Chad Rappaport, who is one of the other foot and ankle surgeons here in our group, and he was gracious enough to introduce you, to me, to you and Dr Kale, as you know, and you were kind enough to take me on staff here right in the heat of COVID, which I appreciate. And I've been here about three years now It'll be three years next month, so it's been three good years.
Robert A. Kayal, MD, FAAOS:It's been an awesome three years. I've been so happy and privileged and blessed to have you, dr Sheehan, thank you. Tell us a little bit about your family.
Mark Sheehan, DPM:So I am a new father as of last year. I have a beautiful wife and a one-year-old son. Now I also have a little dog that we've had for about a decade. Now he's getting a little long in the tooth, but yeah, I'm just really enjoying fatherhood and all the new things that you experience each and every day when I go home. So it's been a blast.
Robert A. Kayal, MD, FAAOS:Exciting days. I remember those very clearly. Today's topic is going to be a very common condition called bunions. Bunions of the foot, also known as halux valgus, is such a common condition, especially in women, and we're just so privileged to have Dr Sheehan here to share his expertise on this topic, so let's just jump right in. So first of all, dr Sheehan, I'd appreciate if you take a couple of minutes to explain to our viewing and listening audience exactly what a bunion deformity is.
Mark Sheehan, DPM:Bunion deformity is probably the most common element that I see when it comes to problems of the forefoot or of the toes.
Mark Sheehan, DPM:I think it's honestly easier to talk about what a bunion isn't initially, because very commonly I'll have patients that come in with bunion deformities who think it's one thing when it's really another.
Mark Sheehan, DPM:They oftentimes will come in complaining about a large bump that has been growing on the inner aspect of their forefoot for, usually several years. That has become more painful and more intolerable as time has gone on, and they tend to be under the impression that this is an increased bony growth. It's extra bone that's growing on the inner part of their foot, or maybe a soft tissue mass or fluid buildup, something along those lines when in reality what's happening is they're developing a bunion deformity. And a bunion deformity in the simplest sense is a deformity in which your great toe, or what's known as your halux, starts to deviate towards the outer part of your foot or towards your pinky toe. While that's happening, essentially the joint at the base of your big toe is starting to slowly but surely dislocate and the bone that your big toe connects to within your foot also starts to move or to deviate in an opposite direction, so it'll start to move towards the midline of your body or towards the inner part of your foot.
Robert A. Kayal, MD, FAAOS:Yeah, so just to be clear, I think it's important for our audience to understand what we talk about when we talk about the hind foot, the midfoot and the forefoot. So let's just demonstrate with the model, if you don't mind All right.
Mark Sheehan, DPM:So here I have a foot model. As you can see, and when we're discussing the foot as foot and ankle surgeons, we like to divide the foot into three different areas or three different components. You have the rear foot, which is made up of these two bones. Back here you have your heel bone and which is also known as your calcaneus, and you have your tail is, which is the bone that moves up and down in your ankle and allows the ankle to move back and forth while you're walking. You then have the midfoot, which is made up of a number of small bones that don't do much moving at all within the middle third of your foot, and then you have the forefoot, which is made up of these long bones, here known as your metatarsals, and also the bones of your toes, which are known as your phalanges. Each lesser toe tends to have three bones one, two and three, while your great toe has only two bones, one and two.
Mark Sheehan, DPM:Right here, on the bottom of the foot as well, this model unfortunately doesn't have them, but on the bottom of your first metatarsal head, right at this location, right here, there are also two very normal bones to have, known as your sesamoid bones that play a very large role, not only in ambulation, but also when you're walking, with absorbing force and contact with the ground as well. In today's podcast, we're going to be talking about bunion deformities, as was previously mentioned, which is going to focus pretty much exclusively on what's known as your first metatarsal phalangeal joint, or your big toe joint, located right here, and the bones that we'll specifically be talking about are your first metatarsal, which is this long bone right here, and the two bones of your great toe, as well as the two sesamoid bones that I previously mentioned.
Robert A. Kayal, MD, FAAOS:Great. Thank you so much, dr Sheehan, for that explanation. Let's talk a little bit about the prevalence and the epidemiology of bunions. Can you tell us something about which patients in particular might be at increased risk of developing such bunion deformities?
Mark Sheehan, DPM:Sure, so my typical patient that I see the average patient, I would say is usually a female in her 30s to 40s that has had this deformity developing for the last several years, maybe even the last decade or so. There's definitely a higher prevalence of bunion deformities found in the female population. It's actually a 10 to 1 ratio according to some studies. So this is something that definitely affects women at a much higher frequency than males. For sure, bunions can affect people at any age, to be completely honest with you, but that tends to be where I see most of the of the my patients coming in. There's also a genetic component that is very prevalent with bunion deformities as well. I've seen some studies that have shown up to a 90% prevalence, where if grandma, grandpa, aunts or uncles, brothers and sisters have a bunion deformity, you're at an increased risk of having that bunion deformity as well.
Robert A. Kayal, MD, FAAOS:Certainly so. There are what we call typically intrinsic and extrinsic causes of bunion deformities. Intrinsic causes would be such things as genetics or medical conditions that serve as predispositions right. Females in general have an increased risk of developing bunion deformities, but certainly some medical conditions such as rheumatoid arthritis or GAL, and also some birth deformities such as spina bifida and down syndrome and cerebral palsy, can certainly increase patients' risks of developing bunion deformities. But certainly without hesitation. I think both of us can clearly agree that genetics is the number one player, especially in women, but genetics is the number one risk factor of developing bunion deformities. Those are some of the intrinsic causes of bunion deformities, but extrinsic causes can also contribute as well. What are some examples of that?
Mark Sheehan, DPM:Sure. So there's two main examples that I commonly see. Number one is just your overall biomechanics. So in individuals who are over-pronators meaning when they walk, the majority of their weight, or more weight than should be, is shunted towards the inner aspect of their foot. So instead of walking with an even distribution of weight across the entire bottom of your foot, as you should with a normal gait, these individuals walk more with weight on the inner portion of the foot, and what that does is it pushes their great toe in a lateral or an outward direction, and you can imagine if you're doing that, step after step, for thousands of steps every single day.
Mark Sheehan, DPM:Eventually, the soft tissue structures that are responsible for keeping your great toe in an aligned position are going to feel the effects. They're going to be weakened and your toe is more likely to start deviating in that position, therefore causing this bunion deformity. That's number one. Number two is the types of shoe gear that individuals tend to wear. If you're wearing a shoe that has a tight what we call toe box, which is the portion of the shoe that your toes reside in, that toe box will squeeze on not only your big toe but also your pinky toe, and at the level of the big toe. In the same way that being an over-pronator pushes the foot towards the outer excuse me pushes the toe towards the outer part of the foot, the, the Tight toe box, will also push the great toe towards the outer part of the foot as well.
Mark Sheehan, DPM:High heels, in my opinion, are probably not even for bunions, but just for problems with the foot and the ankle in general, probably the worst type of shoe that you can wear. When it comes specifically to bunions Most high heels, as you know they. They have a very small toe box and squeeze on your toes excessively, but they also cause you to contract your Achilles tendon and the muscles in the in the back of your leg, which shunts or pushes more of your body weight towards your forefoot and towards your great toe, putting more Pressure and more force on that, that joint where the bunion is forming, and causing a bunion deformity in that way as well.
Robert A. Kayal, MD, FAAOS:I'll make sure that my wife does not watch this podcast.
Mark Sheehan, DPM:It's a tough battle to have. Yeah, for sure.
Robert A. Kayal, MD, FAAOS:Wow, make sure I cover my wife's ears during this part of the podcast.
Mark Sheehan, DPM:Yeah, we're listening mine as well.
Robert A. Kayal, MD, FAAOS:So that was all very interesting. So, yeah, we, as orthopedic surgeons and foot and ankle surgeons, strongly recommend the usage of shoes with a wide toe box for that reason. You know, that's a very, very interesting point that you just raised. Can you demonstrate that the effects of shoes with a pointy toe on that model and and how it can potentiate the progression of the bunion deforming?
Mark Sheehan, DPM:so this foot model right here would be what your foot would look like in its natural state, with all the toes in a properly aligned position in a Normal shoe or in a shoe that has plenty of space in the toe box.
Mark Sheehan, DPM:The toe box is going to encapsulate the toes, but it's not going to squeeze on them, so it'll it'll go around the toes like this, without applying any outward force or pressure to the toes themselves. When you're wearing a shoe that has a tight toe box, what ends up happening is similar to the way my hand is squeezing these bones together. The, the toe box does the same thing, and if you're doing that for hours at a time, day after day, what eventually begins to happen is this joint right here is affected, it's weakened, it because it starts to lose the battle. If you will causing this great toe of the bones, of this two toe, to move in this Direction and simultaneously causing this bone here, the first metatarsal, to move in an equal and opposite direction. This way, so you, instead of having a nice straight line, a nice Biomechanical advantage when you're walking, an anatomic alignment, you end up with this Deviation and this angulation within your toe that creates that, that patho-neumonic or that, that classic bump that you see on the inner part of the foot.
Robert A. Kayal, MD, FAAOS:It's sort of over time, actually molding the foot into a bunion deformity. It is, yeah, yeah, so that's exactly what's happening. Yeah, so, dr Sheehan, how important is the role of the plantar fascia and the arch itself in bunion deformities?
Mark Sheehan, DPM:So that really plays a role when you're talking about patients who are are overpronating. That's that's gonna be where you see the plantar fascia come into play. That's we're gonna see a lot of the. The soft tissue structures on the bottom of your foot are Going to be affected if you have a flat foot deformity. If you're, if you're overpronating, that again causes the majority of your weight to shift towards the inner aspect of your foot, which is going to cause the again, instead of the great toe having the ground push it straight up and down with every single step that you take, it's going to push it from the inner part of your foot towards the outer part of your foot and that will, over time, start to cause the soft tissue structures to wear down and cause your bunion deformity to develop.
Robert A. Kayal, MD, FAAOS:So on that note, let's elaborate a little bit and just discuss with us the typical gait cycle from heel strike to push off for our patients, so they really understand the mechanics of the that great toe or the big toe metatarsal phalangeal joint in particular for.
Mark Sheehan, DPM:So when you're walking, a Normal gait or normal ambulation requires a specific distribution of your body weight over the bottom of your foot, from heel strike, which is where your foot first hits the ground, to what we call toe off, which is where the the last tip of your big toe Propels you off of the ground. There's a very specific way that your body weight needs to be distributed across the bottom of your foot. When you're walking, for a normal gait and normal ambulation, when our heel first hits the ground, or what's called heel strike, the all of the weight from our body is Distributed to the back part of our foot or our hind foot. As we start to roll from heel to toe, that weight moves Mostly on the outer or the lateral aspect of our foot. The inner arch of our foot really doesn't bear any weight as we're, as we're walking. And then, once that body weight starts to move towards the front part of our foot and we start to propel ourselves forward In order to take our next step, that weight quickly shifts right to the great toe, essentially into the first metatarsal phalangeal joint, the big toe joint.
Mark Sheehan, DPM:You know there's a reason that the big toe joint and the big toe itself is so much bigger than your lesser toes, your second, third, fourth and fifth toes, and that is because it's the all-star of the team. It's the one that's going to be the strongest, it's the one that's going to propel you forward and allow you to walk, run, jump and do all the activities that you like to do on a daily basis. The, because of that, your big toe joint is, is much stronger, much more complex and really much more important throughout the gait cycle than any other Other toe. So when you have something like a bunion, deformity where that great toe joint and that that great toe are compromised, in a way, it makes the, the Ability to ambulate, the ability to propel yourself forward, much more difficult and painful and uncomfortable.
Robert A. Kayal, MD, FAAOS:That was a beautiful description, but I think we can either further that description with a model presentation of that gait cycle from heel strike to the To the lateral column and then ultimately to the metatarsal found giel joint for push-off. So if you can just sort of do a video Demonstration of that gait cycle for our viewing audience, I would appreciate that.
Mark Sheehan, DPM:Sure, during your typical gait cycle, when your foot first hits the ground, the all of your weight is going to be on your heel bone, right at this level, right here. As you start to roll from heel to toe and Propel yourself forward, that weight moves on the outer aspect of your foot. So it's gonna move through these two bones, your outer, two metatarsal bones. It then very quickly shifts across the bottom of your foot, across what we call your metatarsal heads, right to the base of your big toe, where your big toe then propels you forward. So all of your body weight at one point during the gait cycle is right at this joint and then Propels forward through and out the tip of your great toe and for that reason it makes your, your big toe the star of the show. It makes it the the strongest, most important player when it comes to all of your toes and propelling you forward and allowing for a normal, healthy gait cycle.
Robert A. Kayal, MD, FAAOS:Thank you, yes, that was a beautiful analogy. And All of that to really emphasize to our audience how important it is that the metatarsal found giel joint of the great toe is properly aligned right. It's so important in mechanics of gait that the metatarsal found giel joint is well aligned and those two bones, those two little Sesameid bones, are perfectly positioned under the metatarsal head of the first metatarsal and Once those bones start to sublux or deviate to the outside of the foot, all of our body mechanics with respect to push-off are Negatively and adversely affected. So on that note, I think it's important that we describe the proper alignment of the great toe. There are certain angles that we like to measure and talk about Radiographically on x-ray to confirm that the patient's alignment is normal. We talk about the first inter metatarsal angle, we talk about the hallux valgus angle. And why don't we demonstrate that what our normal values are for our patients? So when we get to the point when we start talking about making the diagnosis of bunion deformities, they'll better understand.
Mark Sheehan, DPM:So when a patient comes in to see me, the first thing that I'm going to do is I'm going to take an x-ray of their foot, and at Kailor Orthopedic Center we have x-ray technology that allows me to draw out specific angles that I'm looking for on the patient's foot that provide me with the necessary information to educate the patient fully on what I think the best treatment for them will be in regards to their bunion deformity, based on the angulation treatment changes. The more severe the deformity, obviously, the more aggressive the treatment tends to have to be. So it's very important that I assess and look at these different radiographic angles to ensure that I'm giving the patient the proper treatment that is necessary. The first angle that I always look at is what's known as the first intermeditarsal angle. So that's an angle that's made between your first meditarsal bone, which is this long bone here, and your second meditarsal bone, which is the meditarsal directly next to it. The angle that is made between those two bones gives me a lot of information in regards to how severe your bunion deformity is. A typical or a normal value for this angle is nine degrees or less. As that angle begins to increase, so does the severity of the bunion deformity and typically the treatment will change as that severity increases.
Mark Sheehan, DPM:The second angle that I always look at is what's known as the Hallux valgus angle, which is the angle that is made between your great toe. So these two bones right here and the first meditarsal. Again, this is a normal bone model. Unfortunately we don't have a model of a bunion, but you can imagine, with a bunion deformity, your first meditarsal is going to be deviating in this direction, as my fingers are showing here, and your Hallux or your great toe is going to be deviating in this direction, which will create, instead of a straight line, like you see here, an angulation. That also tells me what type of procedure or treatment you may need. Typical value for the Hallux valgus angle is 15 degrees or less and, again, as it increases, typically so does the severity of the deformity.
Robert A. Kayal, MD, FAAOS:So thank you for all that information, dr Sheehan. That was very informative. How do patients typically present to the office when they're being assessed for a bunion, for instance? What is their chief complaint typically and what is the typical history of the present illness when they present and you ultimately end up diagnosing them with a bunion deformity? Sure?
Mark Sheehan, DPM:So most patients tend to come to the office complaining of usually a painful bump on the inner aspect of their foot.
Mark Sheehan, DPM:They don't really have a better way of describing it and there really is no better way to describe it than just that it's usually a bump or a growth that has been occurring for several years, sometimes even several decades, and has slowly but surely been progressing in a negative way. As a result of this growth on the inner aspect of the foot, this bump on the inner aspect of the foot, the patients tend to find that they're having a harder time fitting into shoe gear, and the shoe gear that they are able to fit into is causing a lot of pain and discomfort at that joint, specifically not only because of the rubbing and the friction that occurs from not being able to fit appropriately into the shoes, but also because in a lot of cases the alignment of the joint itself is so deviated, it's so malaligned and malpositioned that their biomechanics, step after step, every single day, is causing pain and discomfort where there should be just a smooth mechanical movement of that joint.
Robert A. Kayal, MD, FAAOS:Thank you for that, dr Sheehan. And when it comes to describing their past medical history or their family history, very often there's a family history of bunion deformities, right, and some of them might have multiple medical comorbidities such as diabetes or gal or rheumatoid arthritis, and those are contributing factors. Certainly, as we've previously discussed, how about on physical examination? What are the findings on physical examination that make you really consider that this patient may have a bunion deformity?
Mark Sheehan, DPM:Sure, so the first thing I always look for and usually see is what we call the medial protuberance or the medial eminence, which is that bump that I've kept alluding to throughout this podcast on the inner aspect of the foot. That is a classic finding with a bunion deformity. The flexibility of the joint is something that I'm going to look for. Next, I want to see how mobile this joint is, how contracted it is, and that gives me a sense of how long the bunion has been there for and what types of procedures I could potentially do for this patient to try and make them feel better. Also, when I'm placing that joint through range of motion, I'm assessing for pain at the same time. When you have a bunion deformity, you're at a disadvantage biomechanically and that joint tends to get worn out. The soft tissue structure surrounding the joint tend to get worn out. There's inflammation that occurs in the area. The shoes themselves can cause inflammation, so there's usually a large component of pain that's present as well. At the bunion deformity there's also a high prevalence maybe not a high prevalence, but definitely a good amount of times where I see arthritic changes at that joint as well, which, as we know, can be painful for the patient on top of the bunion deformity. So I'm looking for all those things. When I'm putting the joint through range of motion, I'm also going to have the patient stand up for me. I'm going to look for other deformities that may be causing the bunion or may be secondary to the bunion. So if I have a patient who has a flat foot deformity, they're more prone to developing a bunion deformity as well as the flat foot deformity and because of the flat foot deformity. So if you have a patient that comes in thinking they just have a bunion, that may only be part of their problem. They may also have a flat foot deformity. That needs to be addressed one way or the other, because if you just address the bunion deformity you're not addressing the full picture. The likelihood of having a suboptimal outcome when you treat the bunion deformity is much higher, so you have to be aware of that as well.
Mark Sheehan, DPM:I'm also going to look at the lesser toes, the second toe in particular, because the bunion deformity, or as the great toe I should say, starts to move towards the outer part of the foot. It's like a big bully. It's bigger, it's stronger, it's more powerful than any other toe and unfortunately that second toe is usually standing right in its path. So the second toe if given enough time and the bunion has enough time to develop, the second toe is going to begin to float or to dislocate up. The soft tissue structures on the bottom of the toe will start to become torn or attenuated and that second toe will actually literally dislocate out of the joint and in really severe cases it'll cross over the first toe, creating what's called a cross over second toe deformity. So when you have that severe of a bunion deformity you can't just address the bunion deformity as well, you have to address the second toe. You have to fix that simultaneously or else you're not doing the patient justice Absolutely.
Robert A. Kayal, MD, FAAOS:And if there are anything like my wife, you can't forget about the Achilles tendon, right? If they're wearing high heels all day, there's a good chance that they're going to have an Achilles tendon contraction as well. So are there any imaging studies that you can perform to confirm your diagnosis, or did you already just make your diagnosis on physical exam?
Mark Sheehan, DPM:So physical exam tells us a lot but, as with any orthopedic issue, if you can get imaging, you should get imaging. It's going to tell you a lot more about what the actual pathology you're dealing with is. It's going to give you a lot more detail and a lot more information that allows you to treat the patient in an optimal way. The one imaging study that has to be done, without question, when you're dealing with a bunion deformity or when you think you're dealing with a bunion deformity, is an x-ray. We take an x-ray in three different views so I'm able to assess the foot from all different angles. We take it while the patient is weight bearing so I'm able to see exactly how the foot interfaces with the ground and how the bunion reacts when there are ground reactive forces acting on the foot while the patient is standing. And that imaging allows me to decide and determine and educate the patient on what I think the best procedures or treatment going forward is for them, based on their specific pathology.
Robert A. Kayal, MD, FAAOS:Okay, so now the patient's given us a history, comprehensive history. You've done a physical examination. You've obtained imaging. You've now confirmed that the diagnosis is a bunion. You've made your assessment. How are you going to treat these bunions?
Mark Sheehan, DPM:So there's a number of ways to treat bunion deformities.
Mark Sheehan, DPM:In my practice, no matter what walks through my door, I always, always try to treat the patient conservatively, first and foremost, if I can. Obviously there are some situations where you have to jump to surgery right away. But if you can get away with treating a patient conservatively and it works for them and they're able to avoid the post-operative recovery time of a surgery, some of the discomfort that comes with the surgery and just the effect it has in their daily life, then I think that that's good medicine being able to treat a patient conservatively first and foremost. The issue, if you will, with a bunion deformity is there aren't a lot of great conservative options available, particularly if you want a permanent correction. What I try to do is determine okay, what is the actual source of this patient's pain.
Mark Sheehan, DPM:The overwhelming majority of the time, shoe gear is a major complaint. It's the rubbing and the irritation of the bunion on the inner aspect of the patient's shoe. Because the foot is wider, it no longer fits into a shoe and so as you're walking, step after step, day after day, you have rubbing, irritation and pain on that inner aspect of the foot. So the first thing I'll often mention to patients is hey, if you're in high heels, get out of those high heels. If your shoes are too tight and don't have enough flexibility in the toe box or enough give in the toe box, you should try and get a wider toe box, a shoe that has a wider, greater space for you to place your toes in. And look at the material that your shoe is made out of as well. You want a softer material, something that's going to be more forgiving and have a little bit more stretch to it so that your foot can actually fit into it.
Mark Sheehan, DPM:That's number one.
Mark Sheehan, DPM:Number two is if I have determined that part of the problem the patient has is that they're slightly flat footed, or if they overpronate and that's causing the bunion deformity.
Mark Sheehan, DPM:If it's a mild bunion deformity, I may just say hey, listen, let's get you into a good pair of orthotics that's going to correct the alignment of your foot while you're wearing them. It's going to take some of the stress and strain and some of the deforming forces off of your bunion deformity and hopefully help you prevent this from progressing in an aggressive manner, and we might be able to make you feel better just through that. If there is an arthritic component involved and I think that the arthritis is actually causing the majority of the patient's pain, with range of motion of this joint and, depending on the patient, I may just simply offer them treatments that we typically use for arthritis, such as cortisone, interarticular cortisone injections, anti-inflammatory medication, rice activity or icing activity modification, things of that nature. But beyond that there's really not a lot of great conservative measures that you can take, especially not when you're trying to permanently correct your bunion deformity.
Robert A. Kayal, MD, FAAOS:When you see a bunion deformity, is it always just the actual bunion deformity of the bone prominence, or are there soft tissue components that get inflamed, that tend to accentuate the deformity? And if so, can those soft tissue structures be injected as well to try to shrink that swelling and address the pain as well?
Mark Sheehan, DPM:Yeah, definitely. The anatomy in that part of your foot is such that you have what's called a bursal sac on the inner aspect of your foot right at that joint level. Essentially, the bunion itself can cause that bursal sac to become inflamed and become what's known as bursitis. Also, the rubbing of the shoe on that inner aspect of your foot can also irritate the bursal sac as well, causing bursitis, and very often, as with any sort of inflammation, you can usually try cortisone injections into that area to address that and the inflammation in the bursitis as well.
Robert A. Kayal, MD, FAAOS:Yeah, when it comes to conservative management, I think cortisone injections in those areas offer our patients tremendous, tremendous relief, not only to alleviate the pain and discomfort but oftentimes to shrink that prominent swelling of that bursitis. So I think that that's also often a very successful first line level of treatment, along with all the other options that you mentioned shoe wear modification, etc. Anti-inflammatories, non-steroidal anti-inflammatories, motrinaduolive, ibuprofen things like that can help shrink the pain and inflammation and swelling as well. Before we start talking about surgical treatment options, I think it's important for us to discuss exactly what's happening from a mechanical perspective and a tonical perspective. At that metatarsal phalangeal joint, certain structures are getting stretched and certain structures are getting contracted as this deformity progresses and develops. Why don't we speak to that a little bit so that our patients can understand the anatomy? Because all of that is going to obviously come into play when you surgically correct the deformity.
Mark Sheehan, DPM:Sure. So I think what you have to understand first and foremost is that your big toe joint, your first metatarsal phalangeal joint, is a very complex joint. It's a very important joint, as I've mentioned previously, for propulsion and for ambulation, and it has multiple bones within that joint specifically, that are attached by a vast complex of not only ligaments but also tendons as well, and it's a balancing act. There are ligaments on the outer aspect of the joint that balance out the ligaments on the inner aspect of the joint. There are tendons on the top of the joint that balance out tendons on the bottom of the joint, and so, as your bunion begins to form, some of those ligaments begin to contract, some of those ligaments begin to get stretched out and there's an imbalance that occurs. I'll demonstrate that to you right now on a foot model, if you'd like, perfect.
Mark Sheehan, DPM:At any joint, and specifically at this joint, there are ligaments that connect bone to bone, so you can think of it like a rope that connects one bone to the next.
Mark Sheehan, DPM:On your first metatarsal phalangeal joint, there are ligaments on the inner part of the joint, right here, and there are balancing ligaments on the outer part of the joint, right here, as your bunion begins to develop and these two bones begin to deviate towards the outer part of your foot or move towards the outer part of your foot, and your first metatarsal begins to move towards the inner part of your foot, the ligaments on the inner part of the metatarsal phalangeal joint, of the great toe joint, are going to begin to stretch, they're going to begin to loosen, which you obviously don't want, but simultaneously the ligaments on the outer part of the joint are going to contract, and so that makes it much harder for your deformity to ever return back into a normal position, and it makes it much easier, as these ligaments continue to loosen and these ligaments continue to contract, for your deformity to progress into a more severe deformity over time.
Robert A. Kayal, MD, FAAOS:Okay, thank you for that demonstration. Dr Sheehan and I know we already discussed some conservative treatment options, but let's talk about the surgical management of bunion deformities and how your surgical choice of treatment is related to the severity of the patient's bunion deformity.
Mark Sheehan, DPM:Sure, when I have a patient in the office and I've evaluated, evaluated them clinically, gone over their x-rays, I've accumulated a large amount of information that allows me to determine, if they choose to do surgery, what I think the best type of surgery for them to have would be. In foot and ankle medical literature there's actually over 100 different medical procedures, surgical procedures that have been written about throughout time in regards to how to treat a bunion deformity. But for me, my, the surgery that I do tends to typically fall into one of four categories, and that's based on the severity of the bunion. So when I look at your x-ray, when I'm measuring all the different angles that I need to measure, it's going to tell me if the bunion is mild, which would be a rather small bunion, moderate bunion or severe bunion. As you move from a mild bunion to a severe bunion, the surgical treatment that I'm going to recommend to you is going to change. So the first surgery could be as simple as performing what's called a medial eminence resection, which is essentially where I just go in.
Mark Sheehan, DPM:I make an incision down to that bump that you see on the inner aspect of the foot that is caused by the metatarsal head, the bone that's there and I simply resect as much of that bone as I can. I remove that bone, I take it out of the foot so that way there's not as much of a prominence at that part of your foot and hopefully you're able to get back into shoe gear more comfortably and just feel a little bit better overall. There's a very specific set of patients that that that would benefit. The downside to that type of procedure typically is that you you're probably going to have some form of a bunion when all is said and done. So it's really more for my older patients, my sedentary patients. Maybe my patients aren't concerned that their bone is not of a high enough quality where they're going to be able to heal if I'm making any bone cuts or performing fusions. So it's a very specific type of patient that's going to get that type of surgery with me.
Robert A. Kayal, MD, FAAOS:And I think it's important to emphasize on that note that bunion surgery is not typically performed for cosmetic reasons. Right? We're not doing this for cosmetic reasons. We're doing this primarily for mechanical reasons, and for paint more than anything. Right? What other surgical options are available? Right?
Mark Sheehan, DPM:So the next option, the next most aggressive option, if you will, would be what's called the distal metatarsal head osteotomy, and so what I do in this procedure is I make the same incision as I would for a medial eminence resection. I go down to the head of the first metatarsal and I make what's called an osteotomy or a bone cut. In this particular case it's a V shaped cut into the head of your first metatarsal and it separates the head of the metatarsal, so the portion of the metatarsal that is closest to your toes, from the body or the shaft of the metatarsal. And what that allows me to do then is to shift that head, or what we call the capital fragment, towards the outer part of your foot, back into an aligned and corrected position, directly over your sesamoid bones and directly exactly where the the metatarsal head should sit from a biomechanical standpoint and an alignment standpoint. I then hold that bone in position using either one or two screws that I place across the bone, and then we allow that bone to heal over the next several weeks with your foot in a corrected position. When I do that, when I move that metatarsal head over, typically your toe will move back into a corrected position in an equal and opposite manner. So as I'm moving the metatarsal head back into a corrected position, the soft tissue structures that are connected to it allow the toe to move back into a corrected position as well. However, when I am doing this procedure intraoperatively, I'm also looking to balance out soft tissue. If necessary, I'm looking to possibly perform what's called an achinosteotomy, which is where I make a small bone cut on the proximal phalanx or the base of your first toe, the bone of your of the base of your first toe. I do whatever I need to to align the foot perfectly back into a straightened position so that from a biomechanical standpoint, from a cosmetic standpoint and from a just an ambulatory standpoint in general, you're able to have a perfect foot again.
Mark Sheehan, DPM:The third surgical option available to patients is reserved for individuals who have a more severe bunion deformity. These are the patients that I've had the bunion deformity, usually for a long period of time. They're really struggling to get into their shoes, they're having a lot of pain and the deformity itself is much larger than someone who's only had a bunion for, say, a couple of years. This procedure is called the lapidus procedure and what I do is, instead of addressing the bunion deformity at the big toe joint.
Mark Sheehan, DPM:I actually go further back into the midfoot, I go to the base of the first metatarsal and I realign that entire bone back into a corrected position. I then hold that bone in its corrected position by fusing the bone at the base. So I'll take plates and screws and I will prepare the joint to be fused. So that way, when I put your bone back into the position that it should be in and then I hold it in place with these plates and screws over the following weeks, that site will fuse together, it'll solidify. It's almost like cementing the bone in place so that your first metatarsal is corrected. And by doing that, by correcting the alignment of the first metatarsal, the great toe, your big toe, will also move back into a corrected and aligned position as well, therefore correcting your bunion deformity.
Robert A. Kayal, MD, FAAOS:It seems like the more severe the deformity, the more proximal your surgery gets right. So the less severe or the more mild cases can be treated primarily at the great toe joint, the metatarsal phalangeal joint. And as the deformity has become more severe or recurrent deformities, the operations themselves become bigger, larger, more invasive and more proximal, closer more to the ankle right than the forefoot itself. And we didn't really talk about. I know you mentioned the lapidus procedure or the fusion of the metatarsal joint, but that can also be performed for instability at that joint correct.
Mark Sheehan, DPM:Correct. Yeah, so sometimes when I'm dealing with patients who have a flat foot deformity or, if I, patients who are hypermobile at that joint meaning they're ligaments that are holding the bones in place are too lax and too loose that's a great procedure to do there as well because, as I mentioned before, it solidifies that bone into place. Those bones and that joint is no longer going to be moving. Everything is rock solid, so that's not going anywhere.
Robert A. Kayal, MD, FAAOS:So what's the fourth surgical option that you consider when evaluating patients with bunions?
Mark Sheehan, DPM:Sure. So the fourth option, similar to the medial eminence resection, this is an option that's reserved for a very specific subset of my patients, but this is to actually fuse the big toe joint. So I'm fusing the first metatarsal and the base of your big toe. I typically reserve this for patients who have some sort of underlying pathological condition or some sort of underlying disease, most specifically, individuals who come in with rheumatoid arthritis or history of rheumatoid arthritis.
Mark Sheehan, DPM:When you have rheumatoid arthritis in your hands and in your feet, you get what's called ulnar deviation of the digits, meaning that all of your toes really, or all of your fingers, if the disease is allowed to progress for a long enough period of time, will begin to deviate towards the outer part of your foot, and so when that happens to your great toe, that's by and large what a bunion is.
Mark Sheehan, DPM:The problem is when you try to do surgical procedures as I've already mentioned, the lapitis procedure, the distal metatarsal head osteotomies on someone who has rheumatoid arthritis, because that joint is so unstable and they have that underlying disease process, the likelihood of a recurrence developing over time, whether that be a year after the surgery or 10 years after the surgery, is very high. So we need to do something that's a little bit more aggressive for these patients, and typically that is to fuse the bones at the at the great toe joint so that the toe is in a aligned and corrected position overall and it stays that way. It's the soft tissue doesn't have a chance to pull that toe back into a deformity.
Robert A. Kayal, MD, FAAOS:Yeah, absolutely, and I think that principle is applicable also to inflammatory conditions such as gao and cerebral palsy down syndrome. There's other conditions that I know you would often indicate patients for fusions. So in general, dr Sheehan, when it comes to the post-op, of course, after your surgical management of bunion deformities, what's typical for your patients, Sure.
Mark Sheehan, DPM:So when I'm addressing the patient with an osteotomy meaning I'm making a bone cut and I'm shifting bone over maybe I'm doing some soft tissue rebalancing, where I'm cutting certain soft tissues or suturing together other soft tissues to rebalance the foot and the structure of the foot. When I do that type of procedure my goal is to get the patient back onto their foot as soon as humanly possible. So I allow all of my patients who have either a medial eminence resection, where I'm just removing a portion of their bone, or who have a distal metatarsal head osteotomy, where I'm shifting the the metatarsal head over and holding it in place with screws, to begin walking on their foot as soon as possible. I tell all my patients you can walk the next day if you want to. It's going to be in a hard sold postoperative shoe. You'll have crutch assistance if necessary and you're going to have a little bit of pain and discomfort, but if you can tolerate it, you can. You can. You can walk flat footed, you can walk on your heel, you can place some weight down through the foot and begin to ambulate as soon as it's tolerable for you.
Mark Sheehan, DPM:Those patients all bone typically takes about six to eight weeks to heal in adults. So I get them out of the postoperative shoe. Once I have good x-ray evidence, good Radiographic evidence, of healing across that osteotomy site, I'll get them back into a regular shoe at that point and I'll usually recommend a course of physical therapy as well because, as they're healing, whenever we do any sort of dissection there's always some Scarring that's going to occur during the healing process. So we want to try and loosen up that scarring and Get their range of motion to the to the great toe joint back as quickly as humanly possible.
Robert A. Kayal, MD, FAAOS:So you'll start that immediately. The early range of motion of the I usually have them.
Mark Sheehan, DPM:If they can tolerate it, I'll have them do some at-home range of motion where they they either try to bend the toe themselves or they manipulate with their hand to some degree. Once I am confident that the bone has healed adequately, that's when I put them into an actual regimented course of physical therapy right now. Now that differs in comparison to when I perform a fusion, because when you do a fusion, you're trying to trick the body into thinking that there isn't a joint there any anymore. Where there has been a joint for the patient's entire life, you need to allow the body the necessary recovery time and and healing time for that joint to fuse to, to heal across and to become bone. The less movement or potential for movement that you have at that joint, the better, which is why we go in with plates and screws and perform these, these Constructs that hold everything in as as rigid or as close to as rigid of a position as possible. So, with that in mind, what I, what I do, my postoperative protocol when I'm doing a lapidus procedure, if I'm doing a fusion of the great toe joint, is to have the patient remain non-weight bearing for at least four weeks, meaning they'll be off the foot with either Crutches a walker.
Mark Sheehan, DPM:I prescribe knee scooters very frequently. That's much more tolerable for patients and I have them stay off the foot for this period of time, sometimes even longer, sometimes six weeks, sometimes eight weeks. It depends on when. I see good Evidence of fusion on x-ray so that I can safely tell the patient Okay, your bone is, your bone is healed, the fusion has been successful.
Mark Sheehan, DPM:You can get back to walking at this point. I'll usually at that point put them into a walking boot. I don't want to just take them from you know six weeks of not putting any weight on their foot and say, all right, get back into Sneakers and go for it. I'll put them into a walking boot and allow them to slowly transition and get used to their their new foot so they can start putting weight down through the foot comfortably in a boot for a course of several weeks. I'll have them start physical therapy at that time. I'll have them start at home range of motion and then, once they're comfortable walking fully in that boot, I'll get them out of the boot, back into regular shoe gear, continue the physical therapy if necessary and have them on their way as soon as possible.
Robert A. Kayal, MD, FAAOS:That's great. That's great. I think it would be nice to take this opportunity to just demonstrate for our viewing audience some pictures and photographs of Patients with mild, moderate and severe bunion deformities. Sure.
Mark Sheehan, DPM:This is an x-ray of what I would consider to be a normal foot. This foot does not have a bunion deformity. This is a very normal, well aligned and well positioned foot and x-ray. As you can see, the Angle between the first and the second metatarsal the first intermediate arseal angle, is about nine degrees or less. The Halix valgus angle is 15 degrees or less. The big toe itself is just pointed in a in a straight position. It's in good, proper alignment. This patient is going to be able to propel themselves forward adequately. They're going to have good, pain-free Ambulation and good range of motion at their big toe joint. You can also see that the two sesamoid bones sitting below the first metatarsal head are in fact below that first metatarsal head. They're in a good position as well. They haven't deviated In a lateral direction or towards the outer part of the foot. Everything about this x-ray to me is Showing a good, anatomically aligned and positioned foot overall. Now let's compare and contrast that normal x-ray to this x-ray that I have before you. This is what I would consider to be a mild to moderate bunion deformity. You can see that the first inter metatarsal angle or the angle between the first and the second metatarsal bones is Increased to some degree. There's Deviation of the two bones of the great toe towards the outer part of the foot, which creates an increase in the angle between the great toe bone and the first metatarsal, or or an increase in the first or in the halix valgus angle. And you can also see that the what we call the fibular sesamoid is Sticking out and and much more prominent and apparent on this x-ray, instead of sitting directly underneath the first metatarsal head in the position that it should be. And finally, let's compare those first two x-rays to this x-ray here.
Mark Sheehan, DPM:In this x-ray, I would consider this to be a severe bunion deformity. You can see that there is a much larger increase in the first inter metatarsal angle. You can see that there's almost complete dislocation of the great toe at the big toe joint. You can even, if you look closely, begin to see what appears to be some arthritic changes occurring in that joint as well, which is most likely one of, if not the main, source of pain for the patient in this specific instance. This type of Sir, this type of deformity, as we mentioned previously, would require a Surgery known as a lapidus procedure, in which I'm going to fuse the first metatarsal at the at its base, after realigning the first metatarsal into a corrected position over the sesamoid bones and Subsequently correcting the alignment of the great toe so that it sticks in a Straightforward position on the foot as well.
Mark Sheehan, DPM:This is an image of what I prototypically see with patients who come in complaining of bunion deformities. You can clearly see that they have a we call a large medial eminence or a bump growing on the inner aspect of the forefoot. In this unfortunate patient they have a deformity on both feet. You can also see that the great toe, and to some degree the lesser toes as well, are not pointing straight ahead. They're deviating and moving towards the outer portion of the foot, which Puts the patient at a biomechanical disadvantage. It makes it so that their foot is no longer anatomically aligned and it Reeks havoc in a way on the big toe joint so that step after step, they're more prone to developing pain and discomfort at the first toe, at the great toe joint, which is usually what brings them into my office to begin with so thank you so much, dr Sheehan, for that demonstration for our viewing audience, I think.
Robert A. Kayal, MD, FAAOS:Lastly, I'd like to just broach upon a topic called Juvenile bunion deformity, a very small subset of patients that you may see rarely in the office With these juvenile bunions. Can you comment on the prevalence and treatment of juvenile bunion deformities?
Mark Sheehan, DPM:Sure so as you alluded to, juvenile bunions are significantly more rare than their counterparts in adults, adult bunion deformities. Typically with a juvenile bunion there's some underlying pathology that is causing the bunion to to form. This could be Alligamentous laxity problems. So individuals who have Ellers-Danlos syndrome, marfan syndrome, all these different diseases that cause hyper laxity or loosening of the ligaments in the in the patient's foot, there can also be or in their entire body, I should say there can also be underlying or a muscular Problem. So you can have patients with cerebral palsy, spina bifida, an array of different neuromuscular Diseases and disorders that cause an imbalance of the musculature Throughout a patient's body and in their foot, specifically at the first metatarsal phalangeal joint, at the big toe joint. So whenever I have a patient that comes in who is a Teenage or a preteen, even children who are in an elementary school and they have a Bunion deformity, particularly individuals who have more severe bunion deformities, I'm always asking the patient themselves and more times and not the parents if there's on any underlying Neurological disorders, diseases, if they had a normal, a normal birth or any sort of traumatic birth experience. I'm trying to get out why the patient has this deformity, because it's not something that has just progressed over time in the way that an adult Bunion deformity typically does.
Mark Sheehan, DPM:When it comes to treating patients for bunion deformities, the strategy changes a little bit. We I Try to avoid and it's recommended that you try to avoid surgery unless it's absolutely necessary, and that's for a number of reasons. Number one these are children, so you want to try and treat them conservatively as as much as possible initially and avoid the, the trauma and the postoperative process of having having a surgery done. Number two is the patients are still growing. They have open growth plates there, the foot is still developing and so when you perform surgery, particularly a surgery where you're going to be addressing bone and potentially cutting bone, you have to be aware of these open growth plates. You have to be aware of the fact that the patient is still growing, because if you cause any damage to those growth plates, you can stunt the the growth of that bone and you can cause harm. Essentially, you can force the patient to have that bone not grow in a normal manner as they continue to mature and get older.
Robert A. Kayal, MD, FAAOS:And even if you don't cause harm to the growth plate, given the fact that the growth plates are over, given the fact that those growth plates are still open, there's a much higher recurrence rate. Right, absolutely.
Mark Sheehan, DPM:Yeah, very much so, and that that's a very good point, because when, when we do decide to treat juvenile bunions surgically, because there's such a high recurrence rate due to the typical underlying Pathologies or diseases that that patient may unfortunately be dealing with, we have to be more aggressive with our surgical approach. Typically, fusions are are the way to go there. They're the surgery that were were recommending to the patient and their parents, and when you do that, you bring those growth plates into play first and foremost, but secondarily. Fusions are permanent. So if you're performing a fusion on someone who's eight, nine, 10 years old, they have that fusion for the rest of their life. They no longer have the ability to use that joint for the rest of their life. So there has to be usually a lot more education for the patient and their parents. That's involved when you're speaking to them about their options, and you need to be way more careful and way more diligent about choosing the correct patient to perform a surgery on, just because of the nature of the surgery itself.
Robert A. Kayal, MD, FAAOS:Yeah. So the point is it's a rare condition, thank God anyway. And when we do see those patients, if we do end up recommending surgery, we try and work in earnest to try to delay it, at least until they're skeletally mature what we call skeletally mature and the growth plates have closed, because at that time we can treat them more like adults and there certainly would be a lower recurrence rate. So we try to treat them as conservatively as possible until they're done growing Correct. Well, this has been a very enlightening conversation with you, dr Sheehan, very informative. I think it's important for us to communicate to our viewing audience a major take home here, because we talked a lot about bunion deformities, the etiology, the presentation, the treatment. But I think it's important to emphasize and reemphasize the fact that bunion deformities are not just a cosmetic problem.
Robert A. Kayal, MD, FAAOS:A lot of patients look at their feet and they're concerned about the aesthetics and the cosmesis of their feet and they wanna get their bunions addressed because of the cosmesis.
Robert A. Kayal, MD, FAAOS:And we don't do typically bunion surgery for cosmetic reasons. We do them for the mechanical reasons that we discussed and the secondary problems that can develop because of these mechanical problems and the deleterious effects that bunion deformities have on gait, the crowding phenomenon. The bunions can often lead to hammer toes and other deformities transverse metatarsalgia issues that can cause patients problems intractable plantar keratosis we haven't even mentioned about those. There's a lot of secondary problems that can occur from bunions. So what is your take home message to our patients about their bunions? Should they just continue to self monitor and observe their bunions or will they be better served by seeing a physician like you early on, so you can help quarterback their care, to monitor them, to help guide them when you are able to potentially pick up on problems like transverse metatarsalgia that's developing, or hammer toe deformities or intractable plantar keratosis that are deformity and calluses that can cause major problems to them down the road?
Mark Sheehan, DPM:Yeah, and I think that's a great point. I think, first and foremost, bunions cosmetically they don't look the best. There's clearly an abnormality noted with the foot, but the bigger take home is that a bunion deformity is a biomechanically disadvantaged foot, and our feet are so important to our everyday life. We use them literally thousands of times per day. So if you have a bunion deformity, your foot is working suboptimally. I think, as with most things, the sooner you get into see a physician, have them evaluate any problems that you think you may have, whether it be a bunion or otherwise the better off you're gonna be ultimately, because I see this every day. I know how this can progress, I know how this will progress and I know the potential problems that will form as a result of a progressing bunion deformity. So the sooner you can get into see me or a foot and ankle surgeon in general, the better off you're gonna be ultimately, because I'm gonna be able to guide you. I'll be able to hold your hand and tell you hey, listen, this is what I need you to do now to try and slow this progression down. This is what you can do to be more comfortable. This is what I can do for you. To make you more comfortable, I can educate you on what's going on. I can kind of take the questions out of your mind so that you know exactly what you're dealing with and how it has the potential to affect you going forward. I think it's a good point that you made.
Mark Sheehan, DPM:Very not very often, but frequently I'll have patients that come in and they say, hey, they know what they have. They say, hey, I have a bunion deformity. I would like this treated surgically, I would like this fixed. And the first question that's always out of my mouth is does it hurt you or you're having any pain or discomfort? And if that answer is no very rarely am I going to recommend surgery at that point for them. This is not a cosmetic problem. We're in the business of trying to help people get out of pain. We're in the business of trying to help people live their daily lives as optimally as they can. So we are not in the cosmetics business, for lack of a better term. We do surgery to try and help patients live their life fully.
Robert A. Kayal, MD, FAAOS:But the good news for those patients that are seeking resolution of their bunions for cosmetic reasons is that most of them ultimately have secondary problems that will force our hand to fix those bunion deformities. So for us, we're fixing these bunion deformities for mechanical reasons and as a bonus, the patients' cosmetic or aesthetic issues are addressed but that's probably the best way I can describe it Big bonus for them. But we're doing it for all the right reasons, not the aesthetic and cosmetic reasons. But in the end, if your bunion is that bad and that's severe and that prominent, chances are you will have these crowding phenomenon issues that we are concerned about as orthopedic and foot and ankle surgeons and we'll end up probably fixing that anyway for those reasons. Correct. So thank you so much for spending this time with us, dr Xi, and this has been very informative, very enlightening. I appreciate you taking the time out of your busy schedule to inform our audience about this relatively prominent and debilitating condition called Halix Valgus, bunion Deformities, and thank you so much for joining us.
Mark Sheehan, DPM:Thank you very much for having me. I appreciate it. Thank you so much.