A hush falls over the black-tie crowd standing in an ornate, candelit room overlooking the White House. As the bride and groom softly begin to recite their vows, a glamorous radio talk-show host delicately slides one foot out of a satin high-heeled pump, tilted her perfectly coiffed head and whispered, "I don't know about you, but my bunions are killing me."
To the uninitiated, "bunion" is little more than a funny word for a trivial medical complaint that is taken about as seriously as corns and ingrown toenails. But this painful deformity of the big toe joint plagues millions of bunion sufferers. It's also the subject of continuing controversy over whether the appropriate treatment involves surgery and whether podiatrists, who specialize in treating feet, or orthopedists -- medical doctors who treat limbs -- are best suited to care for bunion sufferers.
Horror stories about botched surgery are common, but so are happy endings.
"I can't tell you what a difference it's made in my life," enthuses Patricia Niemeyer, a nurse who had bunion surgery a year ago. "No more endless searches for comfortable shoes, no more throbbing pain at the end of the day. It's like having a brand-new foot."
On the other hand: "Just thinking about it makes my stomach churn," says one woman who agreed to talk on the condition that she not be identified. "I'm considering litigation, so I'm afraid to say anything except that if I'd known what a nightmare the operation would turn out to be, I never would have gone through with it."
While bunions are a common problem that affect millions of people, there's surprisingly little knowledge about who suffers from them and why.
Just about the only area of agreement among foot specialists is that the term bunion refers to a misaligned and enlarged metatarsal, or big toe, joint, which in turn can alter the structure and movement of other bones and ligaments in the foot.
Foot doctors report that virtually all of their bunion patients are women, but there's no research to document the commonly held view that there are many more women than men with painful bunions in the general population. As for what causes bunions, some experts believe that they are structural or functional abnormalities aggravated over the years merely by walking, although this theory doesn't explain why men seldom complain of bunion pain. Others speculate that a predisposition toward bunions may be passed from mother to daughter by a female-dominant gene.
By far the most popular theory is that bunion pain is exacerbated when women stuff otherwise symptom-free feet into ill-fitting or high-heeled shoes. "When women are young, they can blame their bunions on Mother Nature," says Washington orthopedic surgeon Dennis Harris. "But when they're older and insist on wearing tight shoes and high heels, they can blame themselves."
What to do about bunions is the subject of lively and sometimes acrimonious debate. Many specialists consider surgery a last resort, after more conservative alternatives such as comfortable shoes or custom-made shoe inserts, called orthotics, have been tried.
"I prefer to make the shoe fit the foot, rather than the other way around," says Harris.
Washington podiatrist Raymond Merkin concurs. "I'm more likely to talk my patients out of surgery than into it," he explains. "And I don't like to do any surgery more complicated than a simple bunionectomy, in which the bump is removed and perhaps a ligament is tightened. It doesn't make sense to put patients through the pain and disruption of more complex surgery for results that just aren't that great."
Paul Taylor, a Washington podiatrist, takes the opposite view. "It's true that a more-complicated operation like an osteotomy -- in which the bone is broken and realigned -- is more difficult to perform well and is considerably harder on patients in the short term," he says. "But the long-term results are far better than simpler procedures that simply don't attack the pathology of the bunion." Taylor says many of his new patients are women whose problems returned several years after their bunionectomies by other surgeons. "I'm doing osteotomies on them now that should have been done in the first place," he says.
Podiatrist Stuart Tessler estimates that there are 150 different kinds of bump-removing, bone-breaking, pin-fixing, tendon-altering bunion operations -- for which surgeons charge anywhere from $600 to more than $2,000. In addition to the considerable pain and long recuperation associated with surgical procedures that involve breaking load-bearing bones, the risk of infection and other complications is fairly high.
And, as Taylor notes, recurrences are not uncommon; the bunion grows back and must be filed down again. Tessler considers that about 15 percent of the bunion treatments he performs produce what he calls "unsatisfactory results" -- failure to correct the deformity, continuing joint pain or restricted movement of the big toe.
Orthopedist Harris says he's successful 90 percent of the time but adds that he considers operating on a bunion far tricker than repairing a ripped-up knee or replacing a hip. "Bunion surgery is like back surgery," he says. "Lots of risks, lots of pain -- and debatable results. I recommend it as a last resort." "Easy to Fix"
"What risks?" counters podiatrist Kenneth Benjamin, who has offices in three suburban Maryland locations and says he has a 98 percent success rate. "I'm not afraid of surgery," he says. "Bunions are easy to fix. Most of my patients are back at work in two days and back in their shoes with no pain whatsoever in three weeks."
Not all patients are so lucky. Four patients whom Benjamin operated on say they were out of work for up to two weeks after their bunion operations and were not able to wear shoes for a month to six weeks.
Nevertheless, the four agree that they are pleased with the results of their operations and would recommend surgery to their friends.
Tessler says that a patient's symptoms and diagnosis dictate which surgical procedure is used. Benjamin, on the other hand, claims that many practitioners only perform the operations they like or do well, no matter what the patient's diagnosis might indicate.
Benjamin, for example, prefers a technique in which tiny screws are used to bond broken bones; he and his associate have already used it on more than 100 patients, he says.
After recovering from surgery, some patients are fitted with orthotics -- individually fitted inserts made of plastic or a combination of plastic and foam rubber that conform to the bottom of the foot -- and are cautioned to eschew high heels and tight shoes forever. "The deforming forces are still there after surgery," says Alexandria podiatrist and sports-medicine specialist Ayne Furman, "so bunions can come back unless patients take care of their feet."
Taylor concurs. "It makes no sense to spend several thousand dollars having your feet operated on and then refuse to pay a few hundred more for orthotics and wear sensible shoes, both of which can help prevent a recurrence," he says.
Tessler doesn't think much of orthotics. "I'm not aware of any clinical evidence that they can help prevent recurrence," he says. As for sensible shoes, Benjamin has this to say: "Why would someone go through surgery if she had to go back to wearing the same ugly shoes she did before the operation? Telling a patient she can't wear high heels is admitting that you didn't cure the problem." A Question of Qualifications
Perhaps the most controversial issue is whether podiatrists, who are not medical doctors, are more qualified than orthopedists, who are, to perform bunion surgery. Three malpractice attorneys, two patients whose bunion operations turned out badly, and, not surprisingly, several orthopedic surgeons claim that many podriatrists are unqualified to perform such surgery.
But the reality is often more complicated. "I bet I've had 25 bunion cases, and all of them were against podiatrists," says Washington lawyer Robert Cadeaux. "I've got one woman who went in for a bunionectomy and six weeks later had to have her big toe amputated." Was he certain, Cadeaux is asked, that a podiatrist had performed the surgery? "Oops!" he says, pulling a file and reading aloud: "Bunionectomy performed May 2, 1988, by a board-certified orthopedic surgeon."
Many podiatrists seem unruffled by such sweeping indictments of their profession. They patiently point out that in four years of podiatric medical college, two or three years of residency and in their daily practices, the vast majority of their time is devoted to studying and working on feet. Orthopedic surgeons, on the other hand, spend little time focusing on feet in medical school or during their residency and rarely devote the majority of their practices to foot surgery.
"Why should we?" asks Jeff Neustadt, an orthopedic surgeon at Texas Scottish Rite Hospital for Crippled Children in Dallas. "If you had a choice between operating on bunions and working in a field where extraordinary surgical advances are being made every day in hand surgery, hip and shoulder replacement, multiple fractures and spinal deformities, would you choose bunions?"
Besides, he adds, "there are a million different surgical procedures for bunions, and few of them seem to work very well. It's a crap shoot for patients and a lousy deal for doctors, too. All it tells me is that nobody knows anything about bunion surgery." The Limping Legions
Meanwhile, legions of bunion sufferers are limping around trying to evaluate the risks and benefits of surgery before they agree to go under the knife.
"I went to see a foot doctor about my bunions a few years ago," recalls Jo Caldwell, a Bethesda travel agent. "The nurse came in while this guy was poking at my feet and asked what she should write on my chart. 'Preparing for surgery,' he said. I put on my clodhoppers, shuffled out of there and never went back." What would it take to get her to consider surgery? "I'd have to be in even more pain than I am now, and I'd have to know that I was in the hands of a really good surgeon," Caldwell says. "These feet have to last me a lifetime, so I'm not going to let just anyone mess around with them."
Caldwell is probably typical of large numbers of women who decide to live with pain, deformed feet and ugly shoes rather than take a chance on bunion surgery. But many others have gambled and won.
"My feet feel wonderful!" enthuses Jean Thomas, an administrative assistant at Wang Laboratories who went to podiatrist Tessler in 1981 for bunionectomies and osteotomies on both feet. "However, I understand that I'm one of the lucky ones," she continues, "because I talk to a lot of women at my part-time job selling shoes, and they tell me they're still in a lot of pain two and three years after their bunion operations."
Bethesda homemaker Patty Greeves had a bunionectomy on one foot by podiatrist Merkin a decade ago and says she has been pain-free ever since. "I didn't know there were any risks involved," she recalls. "I just knew my foot hurt all the time, and I had to do something about it."
Many happily-ever-after bunion stories are told by women who did their homework, seeking out competent, board-certified foot specialists and interviewing several of them -- as well as their patients -- before agreeing to surgery.
"I'm really pleased with my decision," says Patricia Roberts, an attorney with the Environmental Protection Agency who had bunionectomies on both feet last year after carefully considering her options. She says she chose orthopedist Harris because he explained the pros and cons of surgery and recommended that she consult a podiatrist colleague for a second opinion.
"Neither of them painted a particularly rosy picture," Roberts recalls, "but I appreciated their honesty and felt better knowing exactly what to expect after surgery." While she found her lengthy recuperation frustrating, Roberts says she'd make the same decision again. "The important thing is that my feet don't hurt anymore," she says. "I can even wear heels if I want to."
"Heels!" exclaims Lynn Miller, a secretary for the Burson-Marsteller advertising agency. "I can't even wear flats without limping, and I had surgery more than a year ago!" After one podiatrist recommended an osteotomy with temporary surgical pins and told her that she'd have several months of discomfort and inconvenience after the operation, Miller found another who told her what she wanted to hear. "The second one promised not to put pins in my feet and said I'd be dancing in high heels in two months," she recalls ruefully.
"So naturally I picked him. Not only did I wake up with these nails sticking out of my feet," she continues, "but I literally crawled around my apartment for weeks in excruciating pain and couldn't even wear sneakers after more than two months. Even now, my feet kill me all the time." By having bunion surgery, says Miller, "I exchanged pain for agony."
Kenneth Trombly, a Washington malpractice attorney who relates horrific tales of foot quackery, sounds more like a doctor than a lawyer in dispensing advice to bunion sufferers considering surgery. "First," he says, "I'd have a thorough medical workup to rule out arthritis, circulatory or nerve problems, diabetes or another condition unrelated to bunions. Next, I'd try alternatives like orthotics and good shoes. Then, I'd get a second opinion. Finally, I'd agree to surgery, but only with a board-certified surgeon."
"The issue isn't podiatrists versus orthopedists,' says orthopedist Harris. "It's about finding a skilled surgeon. The best ones are cautious about surgery. You don't sell bunion operations like used cars."
Nancy Debevoise is a Washington writer.