1000-2000 5 ьшò

– Likely to remain chronic/relapsing problem

Greater weight fluctuations, other impulsive behaviors, childhood obesity, low self-esteem, family history of alcohol abuse, psychiatric comorbidity, and personality disorder diagnoses (e.g., avoidant personality disorder) may predict poor prognosis.

Mortality rate: 0.4%. The death rate for bulimia nervosa is much lower than that for anorexia nervosa. Patients who remain in remission for >1 year have a better long-term outcome.

COMPLICATIONS

Substance use disorder

Osteopenia/osteoporosis

Stress fracture

Gastric dilatation

Boerhaave syndrome

Mallory-Weiss tears

Pseudo-Bartter syndrome

Spontaneous pneumomediastinum

Potassium depletion, cardiac arrhythmia, cardiac arrest

Suicide

Pregnancy Considerations

Maternal and fetal problems if pregnant

Binging/purging behaviors may persist, increase, or decrease with pregnancy.

Increased risk for preterm delivery, operative delivery, and infants with low birth weight should be managed as high risk.

REFERENCES

1.Cotton MA, Ball C, Robinson P. Four simple questions can help screen for eating disorders. J Gen Intern Med. 2003;18(1):53–56.

2.Hay PP, Bacaltchuk J, Stefano S, et al. Psychological treatments for bulimia nervosa and binging. Cochrane Database Syst Rev. 2009;(4):CD000562.

3.Shapiro JR, Berkman ND, Brownley KA, et al. Bulimia nervosa treatment: a systematic review of randomized controlled trials. Int J Eat Disord. 2007;40(4):321–336.

4.Cooper Z, Fairburn C. Cognitive behavior therapy for bulimia nervosa. In: Grilo C, Mitchell J, eds. The Treatment of Eating Disorders. New York, NY: The Guilford Press; 2010:243–270.

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5.Bacaltchuk J, Hay P, Trefiglio R. Antidepressants versus psychological treatments and their combination for bulimia nervosa. Cochrane Database Syst Rev. 2001;(4):CD003385.

6.Bellini M, Merli M. Current drug treatment of patients with bulimia nervosa and binge-eating disorder: selective serotonin reuptake inhibitors versus mood stabilizers. Int J Psychiatry Clin Pract. 2004;8(4):235–243.

ADDITIONALREADING

American Psychiatric Association. Practice Guideline for the Treatment of Patients with Eating Disorders. 3rd ed. Washington, DC: American Psychiatric Association; 2006. http://www.psychiatry.org/. Accessed November 28, 2017.

National Institute for Health and Care Excellence. Eating Disorders: Core Interventions in the Treatment and Management of Anorexia Nervosa, Bulimia Nervosa and Related Eating Disorders (NICE Guidelines). London, United Kingdom: National Institute for Health and Clinical Excellence; 2004. http://www.nice.org.uk. Accessed November 28, 2017.

CODES

ICD10

F50.2 Bulimia nervosa

CLINICALPEARLS

Asking “Are you satisfied with your eating patterns?” and/or “Do you worry that you have lost control over how much you eat?” may help to screen for an eating problem.

Weight is not severely lowered as in anorexia nervosa.

Consider using a stepped care approach. Start with a guided self-help program using instructional aids; next, begin CBT (e.g., 16 to 20 sessions over 4 to 5 months).

SSRIs, particularly fluoxetine (60 mg daily), may be helpful as a first step or as an adjunctive treatment with CBT.

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BUNION (HALLUX VALGUS)

Jennifer G. Chang, MD

BASICS

DESCRIPTION

Lateral deviation of the great toe (Hallux abducto valgus derives from the Latin for “big toe askew.”)

Associated with medial deviation of the 1st metatarsal, leading to a medial prominence of the 1st metatarsophalangeal (MTP) joint (also known as “Bunion”); progressive subluxation of the 1st MTPjoint is common.

System(s) affected: musculoskeletal/skin

EPIDEMIOLOGY

Predominant age: more common in adults

–Estimated 23% in adults aged 18 to 65 years

–Estimated 35.7% in elderly >65 years

Predominant sex: female > male by ~2:1

Prevalence

Prevalence increases with age particularly in females.

Juvenile hallux valgus

– More common in girls (>80% of cases) Commonly bilateral

Pain is not usually the presenting symptom.

ETIOLOGYAND PATHOPHYSIOLOGY

Multifactorial. Contributing factors include the following:

Valgus deviation of the hallux promotes varus position of the 1st metatarsal.

Medial MTPjoint capsule stretches and attenuates, whereas the lateral capsule contracts.

Metatarsal head moves medially, shifting the sesamoid bones to a more lateral position.

Extensor hallucis longus deviates laterally.

Lateral and plantar migration of abductor hallucis moves the great toe into plantar flexion and lateral pronation.

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Medial collateral ligament stretches and eventually ruptures due to this deviation, decreasing stability and causing progressive subluxation of the 1st MTPjoint.

RISK FACTORS

Familial predisposition

Abnormal biomechanics (i.e., flexible flat feet)

Joint laxity; pronation of hindfoot; Achilles tendon contracture; pes planus (fallen arches)

Metatarsus primus varus

Amputation of second toe

Inflammatory joint disease

Neuromuscular disorders

Improper footwear, narrow toe box

GENERALPREVENTION

Proper footwear may decrease the progression of the disease.

COMMONLYASSOCIATED CONDITIONS

Medial bursitis of the 1st MTPjoint (most common)

Hammertoe deformity of the 2nd phalanx

Plantar callus

Metatarsalgia

Degeneration of 1st metatarsal head cartilage

Pronated feet; ankle equinus

Onychocryptosis (ingrown toenail)

Entrapment of the medial dorsal cutaneous nerve Synovitis of the MTPjoint

DIAGNOSIS

Based on clinical exam

Radiographs are used for staging.

HISTORY

Painful MTPjoint (most common symptom in adults)

Abnormal position of great toe

Enlargement of the MTPjoint medially (patients complain of a “bump”)

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Shoes don’t fit properly

Pain on ambulation

Skin irritation, blistering, callus formation at 1st MTP

PHYSICALEXAM

Observe gait; may be antalgic due to pain

Increased distal metatarsal articular angle (DMAA)

Medial prominence at the MTPjoint

Skin changes: inflammation, blistering, callus or ulceration at the MTPjoint

Great toe overor underriding the second toe Examine the entire first ray for:

–1st MTPrange of motion

–1st tarsometatarsal mobility

–Neurovascular integrity

–Degenerative osteoarthritis

DIFFERENTIALDIAGNOSIS

Trauma

– Turf toe; sesamoiditis; stress fracture Infection

– Osteomyelitis; septic arthritis Joint disorder

– Osteoarthritis; rheumatoid arthritis; pseudogout; gout Tendon disorder

– Tendinosis; tenosynovitis; tendon rupture Other

– Bursitis; ganglia; foreign body granuloma

DIAGNOSTIC TESTS & INTERPRETATION

Weight-bearing APand lateral radiographs (sesamoid view optional) to assess:

–Joint congruency and degenerative changes

–Lateral sesamoid bone displacement

–Rounded 1st MT head

–Longer 1st metatarsal

Radiographic parameters:

–Hallux valgus angle (HA): Long axis of the 1st MT and proximal phalanx is normally <15 degrees.

–Intermetatarsal angle (IM): Between long axis of 1st and 2nd MT is

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normally <9 degrees.

–DMAA: Between 1st MT long axis and line through base of distal articular cap is normally <15 degrees.

–Hallux valgus interphalangeus: Between long axis of distal phalanx and proximal phalanx is normally <10 degrees.

TREATMENT

Primary indication for treatment is pain.

There are conservative and surgical approaches.

Surgical treatment is generally more effective in improving pain but has attendant risks.

GENERALMEASURES

Nonoperative treatment options may improve symptoms and delay the progression of hallux valgus deformity, although high-quality evidence is limited:

Proper fitting footwear: low-heeled, wide-toe shoes to decrease stress on MTP joint (i.e., wide toe box)

Orthoses to correct foot alignment (pes planus and overpronation). Improving gait may prevent bunion formation and reduce pressure on the MTP.

Night splinting: In theory, splinting stabilizes and balances soft tissue structures around the MTP. Limited evidence shows improvement in degree of angulation in mild hallux valgus.

Manual and manipulative therapy (MMT): stretches contracted soft tissue

Foot exercises and stretching to improve intrinsic foot muscle strength and increase range of motion

Pads/spacers: Pads decrease friction on the MTPjoint. Atoe spacer in the 1st interdigital space may reduce pain (1)[C].

MEDICATION

Topical and PO medications (NSAIDs) can be used to relieve pain and swelling. Other topical options include capsaicin cream.

Corticosteroid injections improve pain.

ADDITIONALTHERAPIES

Custom orthoses are a safe intervention that may decrease pain at 6 and 12

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months compared with no treatment; however, this improvement is less than that seen with surgical intervention (2)[B].

SURGERY/OTHER PROCEDURES

Surgery is indicated for patients with severe pain, dysfunction, or persistent symptoms that do not abate with conservative therapy.

>150 different surgical techniques to treat hallux valgus:

–No technique is proven superior; no universally accepted standard exists for procedure selection.

–Choice of technique depends on disease severity, radiographic findings, and patient/surgeon-specific factors.

There are arthrodesis: fusion of the 1st MTPjoint; reserved for severe and/or recurrent hallux valgus (rarely performed)

Arthroplasty: removing the joint or replacing it with a prosthesis

Exostectomy/bunionectomy: removing the medial bony prominence of the MTPjoint

Soft tissue realignment: alters the function of surrounding ligaments and tendons; used for minor, flexible deformities

Osteotomy and realignment: can correct large deformities, but evidence of long-term outcome is lacking (3)[C]

Mini-tight rope procedure: use of a FiberWire to correct the misalignment of the deformity

Surgery may decrease pain and improve foot alignment.

Some patients may have little to no improvement in symptoms despite interventions. Providers should establish realistic expectations prior to surgery.

In pediatric patients, surgery should generally be delayed until skeletal maturity (4)[C].

COMPLEMENTARY& ALTERNATIVE MEDICINE

Marigold ointment may reduce pain and soft tissue swelling related to bunion.

ONGOING CARE

FOLLOW-UPRECOMMENDATIONS

Postoperative treatment includes physical therapy, physiotherapy, supportive

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footwear, continuous passive motion, or manual manipulation.

Time until full weight bearing depends on the surgical procedure.

PROGNOSIS

Patient outcome varies depending on biomechanical factors, severity of the deformity, and treatment modality used. The radiologic HAangle predicts surgical outcomes. Patients with an HAangle <37 degrees have a higher chance of having the deformity successfully corrected with surgery compared with patients with an HAangle >37 degrees (5)[B].

COMPLICATIONS

Risks associated with surgery include infection, persistent pain, and poor cosmetic result.

Additional risks vary with the surgical procedure. Other complications may include:

–Early swelling

–Hallux varus

–Recurrence of bunion

–Metatarsal fracture

–Decreased sensation over the 1st metatarsal or phalanx

REFERENCES

1.Tehraninasr A, Saeedi H, Forogh B, et al. Effects of insole with toe-separator and night splint on patients with painful hallux valgus: a comparative study. Prosthet Orthot Int. 2008;32(1):78–83.

2.Torkki M, Malmivaara A, Seitsalo S, et al. Surgery vs orthosis vs watchful waiting for hallux valgus: a randomized controlled trial. JAMA. 2001;285(19):2474–2480.

3.Choi JH, Zide JR, Coleman SC, et al. Prospective study of treatment of adult primary hallux valgus with scarf osteotomy and soft tissue realignment. Foot Ankle Int. 2013;34(5):684–690.

4.Chell J, Dhar S. Pediatric hallux valgus. Foot Ankle Clin. 2014;19(2):235– 243.

5.Deenik AR, de Visser E, Louwerens JW, et al. Hallux valgus angle as main predictor for correction of hallux valgus. BMC Musculoskelet Disord. 2008;9:70.

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ADDITIONALREADING

Dayton P, Sedberry S, Feilmeier M. Complications of metatarsal suture techniques for bunion correction: a systematic review of the literature. J Foot Ankle Surg. 2015;54(2):230–232.

Dux K, Smith N, Rottier FJ. Outcome after metatarsal osteotomy for hallux valgus: a study of postoperative foot function using revised foot function index short form. J Foot Ankle Surg. 2013;52(4):422–425.

Holmes GB, Hsu AR. Correction of intermetatarsal angle in hallux valgus using small suture button device. Foot Ankle Int. 2013;34(4):543–549.

Khan MT. The podiatric treatment of hallux abducto valgus and its associated condition, bunion, with Tagetes patula. J Pharm Pharmacol. 1996;48(7):768– 770.

Mafulli NI, Longo UG, Marinozzi AN, et al. Hallux valgus: effectiveness and safety of minimally invasive surgery. A systematic review. Br Med Bull. 2011;97:149–167.

Nix S, Smith M, Vicenzino B. Prevalence of hallux valgus in the general population: a systemic review and meta-analysis. J Foot Ankle Res. 2010;3:21.

Nix SE, Vicenzino BT, Collins NJ, et al. Characteristics of foot structure and footwear associated with hallux valgus: a systematic review. Osteoarthritis Cartilage. 2012;20(10):1059–1074.

Perera AM, Mason L, Stephens MM. The pathogenesis of hallux valgus. J Bone Joint Surg Am. 2011;93(17):1650–1661.

Smith SE, Landorf KB, Butterworth PA, et al. Scarf versus chevron osteotomy for the correction of 1–2 intermetatarsal angle in hallux valgus: a systematic review and meta-analysis. J Foot Ankle Surg. 2012;51(4):437–444.

Trnka HJ, Krenn S, Schuh R. Minimally invasive hallux valgus surgery: a critical review of the evidence. Int Orthop. 2013;37(9):1731–1735.

CODES

ICD10

M20.10 Hallux valgus (acquired), unspecified foot

M20.11 Hallux valgus (acquired), right foot

M20.12 Hallux valgus (acquired), left foot

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CLINICALPEARLS

Avoid footwear with high heels, pointed toe boxes, or inadequate toe space to reduce development or progression of bunions.

Surgery generally results in superior outcomes for pain relief in appropriately selected patients.

No single surgical method has shown to be superior for long-term pain relief. Establish realistic expectations prior to surgery to improve patient satisfaction with surgical outcomes.

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