Bunion or hallux valgus is an abnormal bony bump formed due to the misalignment of the bone and soft tissues around the joint at the base of the big toe. Bunions cause a deviation of the big toe towards the other toes and can result in hammering and crossover of the second toe. Bunions formed on the little toe and fifth metatarsal are called bunionettes or tailor’s bunions. Excessive pressure and friction on the bunion by footwear can further lead to the development of a callus (painful area of thickened skin) or a bursitis (painful red fluctuant swelling).
Bunion surgery is performed to relieve pain and realign the soft tissues and bone causing the joint deformity. The forefoot often becomes narrower, and finding comfortable foot wear often becomes easier.
The most common cause of a bunion is prolonged wearing of ill-fitting footwear that compresses the toes into unnatural positions. This can include high heeled shoes, narrow shoes, shoes that are too small or pointy shoes with a narrow toe box. Genetics and certain disease conditions such as arthritis or polio may increase the risk of developing a bunion.
Bunions are much more prevalent in women than men, which may be associated with the use of heels and fashionable shoes by women.
Signs and symptoms
The signs and symptoms associated with bunions are as follows:
- Pain with ambulation when wearing shoes
- Swelling with red, calloused skin at the base of the big toe
- Decreased mobility in the big toe
- Inward turning of the big toe toward the second toe
- Bulging of a bony bump at the base of the big toe
- Formation of corns and calluses at the overlapping of the big toe and second toe
The diagnosis of a bunion by an orthopaedic surgeon includes taking a medical history, and performing a physical examination to assess the extent of misalignment and damage to the soft tissues. Your doctor may order X-rays to help determine the extent of damage and deformity of the toe joints.
Bunions can be treated with non-surgical and surgical approaches. Your surgeon initially will recommend conservative treatment measures with the goal of reducing or eliminating foot pain.
Conservative (non-surgical) approach
Such measures include wearing properly fitted shoes with specially designed shoe inserts (large toe box), bunion pads (to protect the bunion from pressure and friction), bunion splints, and taping of the bunions. Analgesics may be prescribed for relieving pain and inflammation.
Conservative treatments don’t usually prevent worsening of the bunion. If conservative measures fail to treat the bunion pain, then your surgeon may recommend a surgical procedure to remove the bunion.
There are several surgical options to treat a bunion but the common goal is to realign the joint, correct the deformity, and to relieve pain and discomfort. Surgery is carried out under the effect of a light general anesthetic and an ankle nerve block. It typically takes around 30 minutes to perform.
When you wake up, your toes will be realigned and you will be in no pain. These surgical procedures include:
- Repair of the tendons and ligaments: The soft tissues around the big toe may be tighter on one side and looser on the other creating an imbalance. This can result in drifting of the big toe towards the second toe. Your surgeon will shorten the loose tissue to tighten it and lengthen the tight tissues to loosen them. This procedure is often combined with an osteotomy (removal of bone pieces).
- Arthrodesis: Involves surgical fusion of the damaged bones, followed by insertion of screws, wires, or plates to support the joint while healing. This procedure is used for severe bunions or severe arthritis patients. The big toe will have limited movement after the procedure but the bunion will not come back. This type of surgery is rare for bunions.
- Osteotomy: Includes surgical cutting and realignment of the metatarsal bone in the foot. Your surgeon may combine osteotomy with a distal soft tissue realignment procedure which involves aligning the tissues in your foot along with bone alignment to improve foot stability and appearance. The realigned bones are then held in place with special screws buried within the bone. Osteotomy is the most common method of treatment and can be performed using open or minimally invasive technique. Most common types of osteotomies performed are scarf osteotomy (more powerful correction) and chevron osteotomy (for less severe bunions).
- Minimally invasive bunion surgery: This is an X-ray guided procedure, in which, typically, a chevron osteotomy will be performed. The front foot bones will be divided to realign the big toe. The divided bones of the big toe will be kept in place with special screws buried inside the bone. This type of surgery is best suited for less severe bunion.
The orthopaedic surgeon selects the appropriate surgical procedure based on the patient’s presentation.
Risks and complications
Apart from general complications related to any surgery, complications after bunion surgery can include infection, recurrence of bunion, nerve damage, stiffness, numbness, fracture, need for further surgery, and failure of implant, avascular necrosis and unresolved pain.
Patients should follow all instructions given by the orthopaedic surgeon. Common post-operative instructions include:
- Keep your dressing dry and do not remove it until your next post-operative appointment, which will typically be around 2 weeks.
- Elevate the foot as much as possible for the first six weeks to minimize swelling.
- Cover the foot to keep it dry while you bathe/shower
- Minimize walking on the affected foot for 6 weeks.
- Exercise and physical therapy are recommended for strengthening and restoring range of motion to the foot.
- Stopping smoking will drastically reduce the chances of complications following surgery.
- X-rays may be necessary after your operation.
- On an average, your incision sites will heal in 2 weeks, your bones will heal in 6 weeks and your swelling will also start to reduce at this stage.
When can I return to work after surgery?
This will depend on the type of work you do:
- Sedentary jobs: Return after 2 weeks, if able to maintain foot elevated at level of waist, otherwise 4 weeks off
- Standing/walking jobs: Return after 6 weeks, but may be sooner depending on comfort and swelling
- Manual/laboring jobs: Return after 8 weeks, but may be sooner depending on comfort and swelling.
When can I drive after surgery?
You need to be able to control the vehicle in an emergency. Can you stamp your foot down on the ground? For left-sided surgery, driving is probably safe 2 weeks post-operation if you are using an automatic transmission vehicle. For right sided surgery, driving is probably safe at 6 weeks post operation, once in a normal shoe. If you are unsure, please ask Mr. Ajis.
The operation can be performed as a day case procedure, under a local anesthetic ankle block, making the whole foot numb for 6-12 hours. You can be awake, sedated or have a general anesthetic during surgery, which takes about 45 minutes. Most patients do not experience significant pain after surgery with the modern techniques.
- Ankle Arthroscopy
- Hindfoot and ankle arthritis treatment
- Total ankle replacement
- Flatfoot correction
- Cavovarus foot correction
- Correction of common toe deformities
- Hammertoe correction
- Plantar fasciitis treatment
- Achilles tendinitis treatment
- Correction of congenital abnormalities
- Correction of arthritic and bone deformities
- Heel pain treatment