Pain, swelling, 2nd Metatarsal stress fractures and osteoporosis 10 months post op bunionectomy

by Katherine
(Richmond, VA)

I had a simple bunionectomy with no hardware, etc. in January of this year. I have yet to be pain free and have suffered stress fractures, swelling and was recently told my x-rays showed osteoporosis of the 2nd metatarsal. One physician told me the bone was cut too short during the bunionectomy and this is causing all my problems. A customized orthotic was prescribed. Another physician says that's not the case but that there's an underlying pathology causing the problems. I had extensive blood work showing my Vit D was low and was prescribed large doses of Vit D. I was sent to a neurologist for an EMG that revealed some nervve damage and some peripheral neuropathy in both feet (I've never had any symptoms of this before - my pulses are good; wounds heal quickly; I'm not diabetic)

Since the two doctors differ so much, I am going to seek a 3rd or possibly a 4th opinion. Do you have any idea why only the 1 bone (2nd Metarsal) would have osteoporosis? And, why I might be developing stress fractures after a bunionectomy? I also might add I had a Bone Density Test a few months ago which was within normal limiits. She even told me it looked good for my age - 56.

I've always been active, outdoors any chance I get, eat healthy. I could stand to lose 15 - 20 lbs and I do smoke just under a pack. I don't drink and there's no history of osteoporosis or peripheral neuropathy in our family.

I would appreciate your thoughts.

Thank you so much for your time.

RESPONSE
Hi Katherine,
Keeping in mind that I am basing my opinion on just the information provided by you and have not had the opportunity to actually examine you, here goes....
Chances are you do not have just osteoporosis of just one metatarsal bone (although anything is common), because it sounds to me like you have what is known as a long second metatarsal bone (relative to the length of the first metatarsal). This is a common situation and because of it, the second metatarsal bone bears more weight than it should. This fact plays quite a bit into your problem.
1. Because it bears more weight than it should, it would be the last metatarsal bone, not the first, to undergo osteoporosis. You have probably read that exercise helps reduce osteoporosis; well since this bone is under more stress when walking, then the others, due to its excessive length, it is essentially being exercised.
2. Because the second metatarsal bone is probably longer than the first metatarsal, any bunion procedure that has the effect of shortening the first metatarsal bone will have the negative impact of adding more stress to the second metatarsal bone. Thus the added stress to the second metatarsal bone would be the cause of the stress fracture. Basically the surgery has caused a forefoot imbalance.
You mention you do not have any hardware in your foot but I cannot think of a bunion procedure where too much bone was cut and there would not be any hardware inserted, unless you had what is known as a Keller bunionectomy and had too much bone removed from the base of the big toe which would also create more pressure on the second metatarsal bone.
I am not sure the nerve damage has anything to do with anything and is just an incidental finding.
The first thing that needs to be done is to get the stress fracture healed and then an appropriate orthotic will have to be constructed that will take pressure off the second metatarsal bone, so that there is less chance of fracture.
In some cases surgery may be required on the second metatarsal in order to shorten it and create a more uniform arc of all the metatarsal heads.
I think you are doing the right thing by getting a third or even a fourth opinion and seeing if you can get two doctors to come up with the same conclusion. Once you have found two that agree, go with the one you feel more comfortable with.

Marc Mitnick DPM
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