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Bunion surgery is a highly effective operation with high level of patient satisfaction. It is an option for those who have failed to manage their foot pain and discomfort with non-operative methods such as painkillers or changing footwear.
What is a bunion (Hallux Valgus)?
A bunion is the prominence of the bone on the inside of the foot at the base of the big toe. This is not an abnormal bone growth, but it is the normal head of the metatarsal bone that has drifted inwards (see the first X-ray) below. The big toe itself is then pushed outwards resulting in a bony prominence on the inside of the foot.
What does surgery involve?
Surgery to correct a bunion is not simply to remove the bone bump. The aim is to cut the metatarsal bone of the big toe so that the head (which is responsible for the appearance of the bump) is pushed into the foot (see figures below). This is referred to as an Osteotomy (bone cut). The shape of the Osteotomy gives the operation its name. There are many different types of Osteotomy used. I perform SCARF or CHEVRON osteotomies as these have the best record in the medical literature with the longest follow up and lowest recurrence rates.
There are over 100 different techniques and osteotomies described but the SCARF osteotomy has become the workhorse of bunion surgery as it has consistently performed well.
To do the surgery an incision (around 5-8cm) is made over the inner aspect of your big toe extending into the inner aspect of the foot. The tightened ligaments that are holding the big toe in the deformed positions are released. This can normally be done through the same incision however occasionally I may need to make a second incision in the web space of the big toe.
After the head is pushed away it is fixed with one or two small screws as seen in the second X-ray above. These are ‘headless’ and therefore buried deep in the bone and you are not going to feel them afterwards.
Sometimes another Osteotomy of the bone at the base of the big toe (proximal phalanx) may be necessary to fine tune the correction. Here a small wedge of bone is taken away from the inside of the bone to straighten the big toe. This is then fixed with another small screw or staple.
What are the risks of surgery?
This needs to be read together with the information on general risks of foot and ankle surgery but some of the more specific risks related to bunion surgery is below.
Nerve damage
Very fine sensory nerves (slightly larger than a strand of hair) run along the inner side of your big toe. Unlike many surgeons who do not specifically look for these nerves, I make sure that these are identified and protected throughout the operation. As such I feel that my rates of nerve damage are lower than average. At times however, they can be bruised or even damaged. This may result in temporary or permanent numbness on the side of your toe but is not of any other consequence. Sometimes the nerve may form a painful regrowth within the scar (neuroma) this may require further relatively minor surgery to excise.
Stiffness
I aim to preserve as much motion of your big toe as possible. Obviously, there is likely to be some stiffness after the surgery and this usually improves over the first 2 or 3 months and with physiotherapy. In around 1 in 100 cases the big toe may require a manipulation under Aneasthetic (MUA) with or without a cortisone injection to improve the movement. This is done after around 6 months from surgery if progress has plateaued.
Malunion or fracture
I perform the surgery under X-ray control and using the latest techniques to ensure the optimum position of the toe is achieved. Very occasionally however, the osteotomy may ‘slip’ or may be slightly mal positioned. Sometimes this happens if the bone fractures or the screws “cut out”. This is rare but may result in loss of position. The rates are higher in patients with osteoporosis. This may require repeat or revision surgery to improve. This is a rare situation occurring in less than 1 in 100 cases.
Over correction (hallux varus)
Occasionally the big toe may become over corrected. This means that your big toe is titling in instead of out and is generally not tolerated as it makes wearing shoes difficult. It will need revision surgery to correct. It is fortunately a very rare event and I have personally not yet had a patient who has suffered this complication, although I have treated ones from other surgeons. The rates are likely to be lower if surgery is performed under X-ray guidance.
Under correction
Occasionally the bunion correction may not be enough, and the toe may look tilted inwards. This is again unusual however it should be noted that the gap between the big toe and the second toe can close overtime when you started wearing shoes. Especially those with a narrow toe box. Whilst the bony bunion has gone you may notice the big toe titling in more than it had done in the period immediately following the surgery. This is not a sign of recurrence and should not cause any problems.
Recurrence
The bunions sometimes come back several years later. This is unusual with modern techniques and approaches but can occur if you are very hyper-mobile or the initial bunion deformity is very large.
Hardware prominence and need for removal.
The screws used are buried in bone however occasionally a slight prominence maybe noted. In rare circumstances this may be causing discomfort and if so after the bone has healed the screws can be removed. This will require a second operation.
Will the post-operative period be painful?
It is normal to experience pain following any surgery. Modern surgical and aneasthetic techniques however have meant that patients now experience far less pain following surgery. Effective anaesthetic blocks means your foot will be numb for most of the first 24 hours and sometimes longer. This when the pain can be at its worst and as such you will not feel this at all.
Stability of the osteotomy and strong fixation with the screws also means that the cut bones are not moving which is another reason people may feel pain.
As a result, most patients report very low levels of pain following bunion surgery often requiring minor pain medication use for the first few days only. It is not uncommon that patients end up not using any of their pain medication whatsoever.
Will my Scar be visible?
I perform the surgery through an incision around 50-60mm on the side of the big toe. This area heals very well, and the scar becomes very difficult to see after around 6 months. (See image below) – some people however can scar badly and in those instances the scar can be more obvious. The way in which your previous scars have healed (if you have any) is generally a good guide to future scar formation.
Will I be restricted in what type of shoes I wear?
A wide fitting or supportive shoe can be worn as early as 4 weeks but normally by 6 weeks post-surgery. As soon as the initial healing phase is over (up to 3 months but sooner in some) you can wear any type of shoe that you feel comfortable wearing. This also applies to high heels. I do advise that you restrict the time spent in high heel shoes and gradually wean yourself to wearing them in the first 6-12 months following surgery.
I have read about minimally invasive or Keyhole surgery; does this apply to me?
Minimally invasive bunion surgery or keyhole bunion surgery has become more popular in the last 5 years. It has gained a lot of interest, especially in nonmedical and tabloid press and social media. These techniques have the clear advantage of having smaller scars. With only 4 or 5 scars of 5mm wide instead of one at 60-80mm. This is a new technique however recent studies have shown it to be safe and effective.
I now offer this surgery in selected patients, especially those for whom traditional open surgery is not suitable. This may include those who have a very severe deformity and who would otherwise need fusion surgery (Lapidus) or those who may have skin healing concerns, because of a medical condition, or simply prefer this technique over traditional open surgery.
What happens on the day of surgery?
I perform bunion correction surgery as a day surgical procedure which means you can go home after your operation on the same day. Occasionally if the surgery happens late in the evening and you live far then it may be sensible to stay overnight.
The operation is under a general aneasthetic which means you will be fully asleep. A local aneasthetic block will be put around your ankle (ankle block) after you have been put to sleep. This means that when you wake up the ankle should be pain free and your foot will feel numb. This lasts for several hours and sometimes until the next day.
You will meet my anaesthetist before the operation who will be able to discuss your needs and concerns with you on the day.
A tourniquet is placed around your thigh or calf during the surgery to prevent blood obscuring vision in the operative field. This means that occasionally you may feel some discomfort related to the tourniquet post-surgery. This is normal and would resolve in 1 or 2 days.
You will meet our physiotherapists on the ward after the surgery. He or she will talk you through mobilising with the aid of crutches and in a special shoe. You can weight bear on your heel. Most patients only need crutches for a few days and can walk without support following that.
Please read the information on this website on VTE information as well as those on rehabilitation following forefoot surgery.
