Ischemic Necrosis of the Toe: Causes, Treatment, and Recovery

Ischemic necrosis of the toes

Hello, about a year ago, while I was traveling in another city, I wore a pair of high sandals (the overall height, not just the front or back being higher) for a while.
I felt a slight stabbing pain in my right foot but thought it was due to something in the shoe and didn't pay much attention.
A few months later, the pain in my right big toe worsened (it hurt when pressed, and walking was slightly painful), and when I tried to lift my toe, I had to use my hand or external force to do so.
Concerned, I went to a major hospital to see an orthopedic specialist, who concluded that I had avascular necrosis and needed surgery.
To be more cautious, I consulted two other hospitals, but the other two doctors said that I only needed topical medication and heat therapy.
Later, through a friend's recommendation, I found a massage therapist who performed a similar technique, and after the session, my next X-ray showed improvement; at least the irregularities around the bone of my big toe had decreased and became much smoother, so the doctor said surgery was no longer necessary.

However, a year later, I returned not for the same issue but for foot inflammation, and during the X-ray, the doctor informed me that the condition of my right foot had worsened, with severe necrosis and bone debris.
(Currently, my right big toe does not hurt significantly while walking, but it does hurt when pressed, and visually, the tip of the toe protrudes more than the left foot.
I still cannot lift the toe normally.) Comparing the X-rays from two years ago, the differences are indeed significant; the irregularities in my right big toe are more pronounced, and there is a protruding sensation.
The doctor has once again suggested that I consider surgery.

I would like to ask if surgery is truly necessary in this situation.
If I choose not to have surgery, will the condition worsen or will the area of necrosis increase? Additionally, if surgery is performed, will there be any long-term side effects? How long will it take to walk normally again? What could have caused the avascular necrosis? Is there a possibility of recurrence after surgery? Hearing the doctor's diagnosis today was really disheartening; please help me! Thank you for taking the time to respond!

Niming, 10~19 year old female. Ask Date: 2016/07/15

Dr. Shi Guozheng reply Orthopedics

The necrosis of the second metatarsal bone in the foot is a relatively rare case.
If the pain does not improve, the physician recommends surgery.
You might consider seeking opinions from other doctors.
Without seeing your X-ray, I cannot provide a complete assessment.
Avascular necrosis typically occurs in the hip joint (femoral head), wrist joint (scaphoid bone), or ankle joint (talus bone), with injury being one of the causes.
Additionally, the use of corticosteroids can also lead to this condition, and there are some cases with unknown causes, referred to as idiopathic.
It is usually caused by interruption or obstruction of the blood supply to the bone.

Reply Date: 2016/07/15

More Info

Ischemic necrosis, also known as avascular necrosis, occurs when there is a loss of blood supply to a bone, leading to the death of bone tissue. In your case, it seems that the condition has progressed over the past year, leading to significant changes in the structure of your toe bones. This situation can be quite challenging, and I understand your concerns regarding the necessity of surgery and the potential outcomes.

Causes of Ischemic Necrosis
The primary cause of ischemic necrosis is a disruption in blood flow to the bone. This can occur due to various factors, including:
1. Trauma: Injuries, such as fractures or dislocations, can damage blood vessels and impede blood flow.

2. Pressure: Prolonged pressure on a bone, as might occur from wearing ill-fitting shoes, can restrict blood flow.

3. Medical Conditions: Conditions such as diabetes, lupus, or sickle cell disease can affect blood circulation.

4. Medications: Long-term use of corticosteroids is known to increase the risk of avascular necrosis.

5. Alcohol Use: Excessive alcohol consumption can also lead to fatty deposits in blood vessels, reducing blood flow.

Treatment Options
The treatment for ischemic necrosis can vary based on the severity of the condition:
1. Conservative Management: This includes rest, physical therapy, pain management, and possibly the use of orthotic devices. In your case, the initial conservative approach seemed to yield some improvement.

2. Medications: Non-steroidal anti-inflammatory drugs (NSAIDs) can help manage pain and inflammation. Bone health supplements, such as vitamin D and calcium, may also be recommended.

3. Surgery: If the necrosis is severe and conservative treatments fail, surgical options may be necessary. These can include:
- Core Decompression: Removing a portion of the bone to reduce pressure and allow for new blood vessels to grow.

- Bone Grafting: Transplanting healthy bone tissue to replace the necrotic area.

- Joint Replacement: In cases where the joint is severely damaged, a total joint replacement may be required.

Considerations for Surgery
Regarding your concerns about surgery:
- Necessity: If your condition is worsening and affecting your quality of life, surgery may be warranted to prevent further deterioration. The decision should be made in consultation with an orthopedic specialist who can evaluate the extent of the necrosis and the potential benefits of surgical intervention.

- Risks and Recovery: As with any surgery, there are risks involved, including infection, blood clots, and complications related to anesthesia. Recovery time can vary, but many patients can expect to return to normal activities within a few months, depending on the procedure and individual healing rates.

- Recurrence: There is a possibility of recurrence of ischemic necrosis, especially if underlying risk factors are not addressed. Post-operative care and lifestyle modifications are crucial to minimize this risk.

Conclusion
In summary, while conservative management may provide temporary relief, the progression of your condition suggests that surgical intervention could be necessary to prevent further complications. It is essential to have a thorough discussion with your orthopedic surgeon about the risks and benefits of surgery, as well as any alternative treatments that may be available. Seeking a second opinion from another orthopedic specialist can also provide additional insights and help you make an informed decision. Remember, addressing lifestyle factors such as footwear and overall health can significantly impact your recovery and future bone health.

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