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The response to the question below was authored by Marc Mitnick DPM

Loose screw

by Hannah
(Burlington, Iowa, USA)

bunion osteotomy

bunion osteotomy

bunion osteotomy
loose screw fixation


Loose screw/Too much bone removed/Sitting too high




July 9, 2010 I had a bunion and tailors bunion corrected surgically on my right foot. I was no weight bearing for two and a half months, then partial with crutches (walking full boot)for about a month, then walking with boot no crutches.

June of 2012 I saw a completely different podiatrist (I have moved out of state) who evaluated my foot and took x-rays. This doctor told me that one screw is sitting about .25"-.50" out of the bone at any given time depending on movement and footwear. I'm assuming it's worse now as the pain has been getting worse. Also, that the surgeon cut too much bone from the first metatarsal off and set the placement too high. This is causing me to overcompensate and roll my foot forward (I've tried custom prescription shoe inserts and they have not helped).
This doctor told me that it's possible to go in and readjust things, but it's not guaranteed and would require shortening the first metatarsal even more which would defeat the purpose. He basically said I'm out of luck and will have this problem for the rest of my life.

I am constantly in a lot of pain and I am left with limited mobility. It's reached a point where I can no longer wear shoes without debilitating pain (even with trying to adjust my foot around in the shoe). So much so that it has prevented me from being able to hold a job that requires me to be on my feet and I am currently in the process of applying for disability.

I'm wondering, is this second doctor correct? Should I attempt to have the surgery to try and fix the bone placement, despite additional shortening of the bone? I am including a few photos of my x-rays taken June of 2012. I am only 22 years old. This has already had a horrible impact on my life, I'm afraid the worst is yet to come.

RESPONSE

Hi Hannah,

Let me start off by saying there is no easy way out for you. I agree with your second doctor in that the osteotomy with the screws was performed to far forward on the first metatarsal. The problem with that is that the bone in that area of the metatarsal in not conducive to healing from surgical breaking and also
may or may not explain why the screw is loose.
All things being equal, if the osteotomy (surgical breaking of bone) had healed, then the screw could simply be removed. It is not clear by your narrative if that is where you are having pain, but if so, then the screw could be removed. The problem, because of where the osteotomy was performed, may still not be completely healed. It has been three years since the surgery and certainly time wise, you should have been healed.
Your second problem is that the first metatarsal bone is too short compared to the rest of the metatarsal bones. A shortened first metatarsal bone can be an issue when it comes to walking.
I do not know what kind of orthotic you have, but there are orthotics that will help stabilize that problem although it sounds like your pair has not helped.
I would recommend an MRI to see if the osteotomy where the screw lies has healed or not, because if it has not, it needs to be dealt with, especially if you are having pain in that portion of the bone.
If the bone has healed and it is just the screw that it bothering you, then as I said earlier, the screw could be removed.
Other than that, I do not know what kind of surgery the second podiatrist is recommending. At all costs, you want to avoid surgery that will further shorten the first metatarsal bone.
If the final outcome is that the osteotomy has never closed and that is why you are having pain then the only procedure you might want to consider would be a bone graft in that site, in an effort to lengthen the bone and allow it to align better with the other metatarsals.
That would be a decision that would have to be well thought out and I would suggest you have more than one opinion (mine does not count, because I cannot actually examine you).
You are only 22 and I do not want to see fall into a situation that I have seen numerous times over the years; people having multiple surgical revisions in hopes of improving their foot problem, only to find out the foot worsens with each subsequent surgery.

Marc Mitnick DPM
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Sep 25, 2013
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Additional questions
by: Hannah(originalposter)

I'm not sure if you'll see these questions/comments. If you do, I hope you'll be able to answer. If not I understand.

Thank you very much for your initial response; it's given me a lot of excellent and appreciated insight.

The pain I have been experiencing is not located at any joint; it's located where the bone was broken. I feel two different kinds of pain in that area. One (I'm assuming is the screw) is very sharp, like the tissue inside is being cut with a razor blade. This pain escalates to being completely unbearable if the skin above it is touched even barely.
The other is a deep ache that is also quite sharp. That area also cracks/pops in the way that a knuckle would. It's completely audible to me and anyone near me as well as physically painful. I can feel the crack/adjustment whenever it happens. I am 100% certain this is not a joint. It happens a few inches down from the joint connecting the toe.

How big of a problem is this along with everything else? How urgent is it that I have this addressed? I had no idea that there was a possibility that the bone may not have healed correctly.

Hi Hannah,

The sharp feeling of pain may very well be the screw backing out. Certainly pressing on that spot would also cause pain as well, simply because there is virtually no fat in that part of the foot, so you are pressing the skin directly into the screw.
The deep ache and feeling of a "pop" may very well be due to the fact that the bone never healed; you may have what is known as a non-union which as the name implies means the surgically broken bone never healed. I alluded to the fact, as did the second podiatrist, that the osteotomy was placed in an area of bone that is not the best place for bone healing to occur.
As I suggested earlier, I would recommend an MRI to get a clear picture of what is going on in this particular area.
-if the bone is healed, then you might consider just having the screw removed.
-if the bone is not healed and you have a non-union, based on the amount of pain you are experiencing, you would probably require a second surgery. A bone graft would probably have to be performed which may, in the long run, lengthen the first metatarsal which would give you better bone alignment.
In answer to your last question, there is no immediate urgency, as you have been living with this problem for three years; its all about how much pain you are in.
As far as the surgery itself, it would be similar to your first surgery with the added risk that the bone graft might not take. In an otherwise young healthy adult, that is a very low risk.
Since having repeated surgeries on the same portion of the foot is never a great thing, in my opinion, make sure you consult with more than one foot surgeon prior to consenting to any further procedures.
Good luck!
Marc Mitnick DPM

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Mayo Clinic

Johns Hopkins Medicine

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Arthritis Foundation

University of Rochester Medical Center

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Drugs.com

American Academy of Pediatrics

Penn State Medical Center

National Institutes of Health

Columbia University Department of Rehabilitation

ScienceDirect

Stanford Health Care

Illinois Bone and Joint Institute

Mount Sinai Hospital

Institute for Chronic Pain

University of Florida Health

American Family Physician

Cedars-Sinai

University of Maryland Medical Center

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