Bunion Surgery

OverviewThe surgical correction of bunions is dependent upon the severity of the deformity, the patient’s over-all health and activity level. Age and conditions such as diabetes do not preclude bunion surgery as a form of treatment.

There are several different approaches to the surgical correction of bunions. Most commonly, the surgery is performed in the area of the big toe joint. The bony prominence is removed and the bone is surgically fractured to allow realignment of the joint and straightening of the big toe joint. This surgery is designed so that the patient can walk on the foot almost immediately following the procedure; however, activity must be significantly curtailed for several weeks following the surgery. Typically, the patient is instructed to remain home from work for at least one week with the foot propped up and elevated above the heart throughout the day. If the patient’s job requires much standing or walking, they may be required to stay home from work for as much as six weeks. Often the patient may return to work sooner if they are placed in a removable below-the-knee walking cast. There are no short cuts to the healing time. Healing time is based upon basic physiological principles that are common to all human beings. Certain vitamins and nutrients may help with the healing process. Laser surgery does not alter the healing time and provides no significant advantage to the performance of the surgery.

Surgical Correction of Severe Bunion Deformity

If the bunion is more sever in nature surgery is performed further back on the bone in order to straighten the big toe. When surgery is performed in this area of the bone, there is greater instability of the bone after it is cut and moved into a corrected position. Generally, the surgeon will require the patient to wear a below-the-knee cast and use crutches for three to eight weeks. Initial bone healing takes six to eight weeks. This period of time can take longer in people who smoke.

The overall success rate and satisfaction of patients who have had bunion surgery is quite high. The most common complaint of patients is the healing time. This is particularly true if the patient is not adequately prepared or informed as to what to expect. Most patients experience minimal pain following the procedure and this pain is easily controlled with pain medication prescribed by the surgeon.

Possible Complications

Potential complications associated with the surgery are infection, over or under-correction of the bunion, joint stiffness, delays in healing or non healing of the bone, or healing of the bone in the wrong position. Most of these complications can be avoided by following the surgeon’s instructions. Walking on the foot without the protection of a post-operative shoe or cast, or against the surgeons advice can lead to a dislocation of the bone where it has been cut. This results in delays in healing, non-healing of the bone or healing of the bone in the wrong position. Allowing the bandage to get wet increases the risk of infection. The most critical time for an infection to occur is within the first three days following surgery. Infection can also occur following this period of time but is less common.

Joint stiffness following bunion surgery is common, but generally improves with time. Postoperative physical therapy is useful to improve the movement of the joint but is not always necessary.

Bunions on Both Feet- Considerations with Regard to Surgery

If a person has bunions on both feet, many surgeons feel that their patients recover quicker and with fewer complications if the surgery is performed on one foot at a time. Many surgeons prefer to wait a minimum of four to five weeks between surgeries. Other surgeons prefer that their patients wait longer between surgeries.

Place of Service and Anesthesia Considerations

Most often the bunion surgery is preformed in an outpatient surgery center or hospital. Some surgeons will perform this procedure in their office. Anesthesia for the surgery can range from a straight local anesthesia, given by injection into the area of surgery, to a general anesthesia with the administration of an anesthetic gas. A very common form of anesthesia is a combination of a local anesthesia and medicine given intra-venous to make the patient drowsy. This is commonly called twilight anesthesia.

Generally there is very little blood loss during surgery. Most often the surgeon will use some form of tourniquet to stop bleeding during surgery. Because the surgery can be performed in a relatively short period of time the use of a tourniquet is very safe. Technically, the tourniquet can be left in place for as long as 90 minutes safely in most cases. Surgeons who perform bunion surgery are very knowledgeable in the use of tourniquets. The potential for the need for a blood transfusion with bunion surgery is nearly non-existent.

Can My Bunion Come Back?

It is important to understand that bunion surgery does not correct the cause of the bunion. Therefore there is the possibility that the bunion can reoccur. How quickly a reoccurrence will occur is difficult to predict. It may take several years or just a matter of months for the bunion to begin to come back. Bunions are caused by abnormal movement of a set of joints below the ankle joint in the foot called the subtalar joints. To help prevent the bunion from reoccurring the patient should be prescribed a functional orthotic. These are custom-made shoe inserts that correct the abnormal function of the foot. Generally they will fit in normal shoes without requiring the use of larger shoes. Most foot surgeons will suggest the use of orthotics following bunion surgery to help prevent the reoccurrence of the deformity.

Bunion Surgery – Distal Head ProceduresFirst metatarsal neck osteotomies are known by various names based on the individual who first described the procedure (e.g. Austin, Reverdin-Green, Kalish-Austin). Regardless of the procedure, the goal of all these procedures is the same, to remove the bump and realign the joint. The first part of all bunion procedures involves removing the bump of bone from the side of the 1st metatarsal head. This is performed in a manner so as not to damage the viable part of the joint and not to leave any irregularities of bone that can cause future irritation in shoes. Once this is completed, the podiatric surgeon will create an osteotomy (bone cut) through the first metatarsal that will allow shifting the bone and realigning the joint. Depending on the type of osteotomy, the actual shape of the bone cut can vary. In the case of the Austin bunionectomy, the bone cut is V-shaped with the “V” sitting on its side and the tip of the “V” pointing toward the joint. When this cut is completed, the head of the metatarsal and joint is shifted toward the 2nd toe. In this way the bone and joint are repositioned in a more normal position. The Reverdin-Green osteotomy is made in a similar location but is trapezoidal in shape rather than V-shaped. Both these procedures are stable bone cuts and provide good correction of mild to moderate deformities. The Kalish-Austin bunionectomy is a modification of the Austin bunionectomy. It also is a V-shaped bone cut but is typically used for greater degrees of bunion deformities.

Because bone is cut and repositioned, it is often preferred to fixate or hold the bone in place with some external device. In the case of the Austin and Reverdin-Green osteotomies, this is most often accomplished by the use of a stainless steel pin across the bone cut. This prevents accidental displacement and loss of correction. Over the past 5 years, it has become increasing more advantageous to use small stainless steel or titanium screws to provide compression of the bone and to hold the bone in position. This is the main advantage of the Kalish-Austin bunionectomy. By using the screws, bone will heal faster and will allow for earlier ambulation. The screws are typically left in permanently unless they cause irritation of the soft tissues while the pins are generally removed in the office setting in three to four weeks following the day of surgery. The surgery is generally preformed as an outpatient in a hospital or out patient surgery center. Anesthesia is the choice of the surgeon made in consultation with the patient and anesthesiologist. Anesthesia may be a general anesthesia, twilight anesthesia or a local anesthesia.

Post Operative Care

The postoperative course and rehabilitation following bunion surgery depends on the procedure and can vary amongst podiatric surgeons. Patients have varying levels of postoperative pain but quite often the pain is significantly less than what the patient anticipates. A period of total non-weight bearing with crutches may be recommended in the first 3 to 5 days. In many instances, the surgeon may allow the patient to bear full weight in a postoperative surgical shoe. In all cases patients are instructed to limit their activities and to elevate their feet above their heart during the first 3 to 5 days. After this, a resumption of gradual weight bearing with a special surgical shoe is begun. Walking without the postoperative shoe is strictly prohibited. In cases where a pin is used, return to full weight bearing with a stiff soled walking shoe is allowed after the pin has been removed, generally in 3 to 4 weeks following the bunion surgery. Screws provide increased stability when used to fixate bone cuts and most patients can return to full weight bearing and regular shoes in 3-4 weeks following the surgery. The postoperative and rehabilitative course is improved by the use of ice and elevation of the extremity as much as possible. One of the most important aspects of the postoperative treatment is early motion of the joint to prevent joint stiffness. In most cases, range of motion exercises are begun almost immediately following surgery. No matter what the form of bone fixation is used, pins or screws; bone healing will take 6 to 8 weeks or longer. During this period of time it is important that the patient not walk without shoes or in thin-soled shoes or sandals. Should the patient risk walking without an adequately supportive shoe, they risk re-fracturing the bone and increase the duration of healing.

Possible Complications

Complications following bunion surgery are uncommon but may include infection, suture reaction, delayed or nonunion of the osteotomy, irritation from the pin or screws, stiff joint or recurrence of the deformity. Recurrence of the deformity can be halted or slowed with the use of functional foot orthotics. It is important to realize that surgery does not correct the cause of the bunion deformity. Functional foot orthotics however do address the cause of the deformity and their use are strongly encouraged following bunion surgery. A rare complication is the over correction of the bunion deformity. This condition, called Hallux Varus, may require additional surgery for its correction

This article should serve as a guideline for patients who are contemplating bunion surgery. The most commonly performed procedures for treatment of bunions have been discussed here. Procedures are selected based on surgeon’s experience and preference. Patients are encouraged to discuss the surgery, the postoperative course and possible complications with their podiatric surgeon openly before consenting to surgical intervention.

Glossary of Terms
Bunion Bump on the side of the foot at the base of the great toe
Bursitis An inflammation of a fluid sac often found overlying a bunion
Fixation Act of holding bones together, commonly require external devices such as pins, screws or plates
Hallux abductovalgus (HAV) Medical term describing the deviation of the great toe toward the 2nd toe; common component of bunions
Metatarsal A long bone of the foot that forms the ball of the foot
Orthoses Devices made from a mold of the foot used to control abnormal motion of the foot; may be prescribed to prevent progression of bunion deformity or reoccurance following bunion surgery
Osteotomy Surgical procedure that creates a cut in a bone to achieve realignment; a “surgical fracture”
Pronation Motion of the foot which when excessive results in flattening of the arch; one possible cause of bunion formation
Toe box Part of the shoe that covers the toes

About the Authors:
Kenneth W. Oglesby, D.P.M., Second-year podiatric surgical resident, Beth Israel Deaconess Medical Center, Boston, Mass.
John M. Giurini, D.P.M., Chief, Division of Podiatry, Beth Israel Deaconess Medical Center, Boston, Mass., Assistant Clinical Professor of surgery, Harvard Medical School, Boston, Mass.

Bunion Surgery – Shaft ProceduresHallux valgus or bunion deformities have may different surgical techniques for their correction. One group of procedures that your surgeon may use is the shaft osteotomies. These osteotomies are different from the head osteotomies and also the procedures performed at the base of the metatarsal or at the metatarsocuneiform joint, because they are performed in the middle of the first metatarsal.

The shaft osteotomies were designed to use internal fixation (screws) and to correct larger deformities. In most of these cases, your surgeon will use 2 screws to fixate the osteotomy. The osteotomy is longer than the head procedures and has more inherent stability because of more bone contact. Also these procedures can correct larger deformities then the head procedures and about the same deformities as the base procedures.

There are two basic shaft osteotomy procedures that your doctor may talk to about: The Z bunionectomy or the offset V bunionectomy. These osteotomies are very similar and are used interchangeably, based on different patient characteristics, by most surgeons that perform these procedures. The decision to use these procedures over other procedures is typically surgeon preference. In most cases, these procedures are used for patient with mild to severe structural bunions without hypermobility. In old patients with poor bone stock, the surgeon may opt for other procedures.

What is the post-operative course?

Typically, the patient is allowed to bear weight immediately after surgery in the a surgical shoe. Some doctors may have you use crutches for one to two weeks or use a slipper cast. This is surgeon’s preference. It is not unusual for the front part of your foot to look bruised after the surgery. So at the first dressing change, do not be surprised if your toes and the top of your foot are bruised. This will dissipate in 3-6 weeks. At two weeks after surgery, the sutures are typically removed and at three weeks most patients are advanced into a surgical shoe. After the first or second week, your surgeon may have you start range of motion of your big toe joint. It is important that you follow your doctor’s instructions on all range of motion exercises to help return motion to the operative foot. As with all surgery on the foot and ankle, the limiting factor to advance into different shoe gear is swelling. This swelling can last up from 6 months to one year after surgery. Typically most patients returned to pre-operative dress shoes in 6 to 8 weeks after surgery.

With any surgery, complications are possible. Every procedure has unique complications and your surgeon will discuss these with you before surgery. Make sure that you ask any questions that you have about the surgery with your surgeon.