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Hi everyone. I would like to hear some opinions on post bunionectomy protocols. I work closely with a local orthopedic surgeon who wants to start using walker boots with a half inch heel wedge inside the boot following his bunionectomy surgeries. Is there anybody who has used or currently uses this protocol? I like the idea of the walker because of the rigid rocker bottom, but can't quite grasp the concept of the heel wedge.

Wouldn't that just transfer more weight to the forefoot? Thanks in advance for your responses.


Joe Eads, C.Ped

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From my understanding, i think his rational is that the half inch wedge will load the rearfoot longer allowing the tibia to transfer past midline ( as much as possible)which will apply less force on the hallux at toe-off.

It seems that adding any wedging under the heel would add more pressure to the forefoot?

Also, I think addressing the leg length discrep. that is now placed on the opposite leg would be important.

Any opinions?


Joe Eads, C.Ped

Hi Joe:
I use Cam walkers post bunionectomy but without any heel wedges. I usually use them for 2 weeks following the usually distal met osteotomy, then it's into a tennis shoe.

The post op dressing is thick so perhaps the surgeon is trying to offset this elevation under the forefoot with a heel lift. It's the only reason I can think of although extra weight on the heel post forefoot surgery is a GOOD thing.

I tell my patients that they should TRY to put more weight on the heel and outside of the foot.

Steve

__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA

Thanks for the info. I have not yet been able to catch up with the surgeon to discuss his rational, and have yet to see one of his pt.'s for this RX.




Joe Eads, C.Ped

Hi Steve,
if I have well understood after distal metatarsal osteotomy you use cam walker for two weeks and than allow patients to walk with tennis shoes?
what kind of fixation you use? and what kind of PT?
if you do also mallet finger or lesser metatarsal osteotomies and use K wires what do you do?
which is your protocol for middiaphyseal osteotomies?
I use a sort of modified MAU

I also utilize a "Cam Walker" type of removable walking cast for the majority of my stable distal or midshaft bunionectomy/osteotomies. I usually utilize screw fixation, and attempt to transition the patient into a sneaker at 3 weeks.

If for some reason K-wires are used due to bone stock, or some other reason, I keep the patient in the Cam Walker longer, since it's too soon to pull the K wire that soon, since the bone is theoretically at one of it's weakest points in bone healing at that time.

I have found that patients tolerate Cam Walkers extremely well and find the product very comfortable. Naturally, since they can be removed, you have to trust your patient. Due to the inherent design of the units, the "rocker" sole off-loads the surgical site adequately, yet the patient can still ambulate which eliminates calf atrophy, etc.

Additionally, I attempt to avoid the use of crutches as much as possible with my post op patients. I have seen more patients have complications as the result of instability via the improper use of crutches than any other cause. So I avoid crutches whenever possible.

If I remember correctly, I "convinced" Dr. Arbes to start using CamWalkers for his post op distal bunions and apparently he's also found the success I've experienced in the past.

On a side note.....all "CamWalkers" are NOT created equal. When utilizing these products for your patients I would look for several features. First, please make sure the bottom has an adequate "rocker bottom" to allow for off-loading of the surgical site. Secondly, make sure the bottom does not have too much medial to lateral instability. Some products on the market are relatively unstable from medial to lateral when the patient stands, and the boot actually rocks medially/laterally. And finally, the boots come in a low top and high top version. I don't believe it's necessary to utilize the high top version for a bunionectomy, but if you do, or are using a removable cast for other pathology and are using the high top version, please remember to consider that many patients have a very wide calf/lower leg. That will require a boot with uprights that are either relatively flexible or malleable to adjust and not "dig in" to the patient.

And I have never utilized a heel wedge for my post op patients within the boot.