What is a Bunion?
A bunion is a condition affecting the bones of the big toe. The toe itself points outwards, towards the second toe. The metatarsal bone on the other side of the big toe joint points inwards. Together, they result in a prominence of the bones at the level of the big toe joint. The big toe can push the smaller toes sideways or underride the second toe, as shown on the left.
Bunions run in families. If your mother or father has a bunion, you are susceptible to developing them too, and this can even occur in childhood. The type of shoe that you wear may make this problem manifest itself earlier. High heels force the toes into the front of a shoe and this can mould the big toe and the little toe to form a bunion and bunionette ( a bunion of the little toe). During middle age, imbalances in muscles can cause bunions to get worse.
The big toe joint surfaces may no longer be congruent and this can lead to arthritis eventually. If the second toe is pushed up by the big toe, the second toe rubs on shoes and forms a hard area of skin.
If you have a bunion, it is best to see an orthopaedic surgeon who specialises in foot and ankle surgery. You should have xrays taken in a standing position – this is when the deformity is worst. It is also the position that your foot adopts in your shoe.
If your bunion is causing you pain, rubbing on your shoes or preventing you from wearing shoes, then surgery is a reasonable option. If you don’t have any symptoms, you should not have surgery until the bunion is causing you problems. There are risks associated with surgery – see ‘what your operation involves’. Unless you have symptoms, it is not worth taking these risks. An alternative to surgery is considering broad fitting shoes, but most patients have tried this before considering surgery. Insoles will not help your deformity and elastic socks and taping will not reverse the deformity.
How is the Surgery Performed?
The operation you have depends on how severe your bunion deformity is. A cut is required on the inner edge of the foot. All operations involve changing the alignment of the bones, and very little bone is actually cut off. The bone is carefully divided and one part is shifted sideways. The new position is held with special screws.
Mild to moderate bunions can be treated by cutting the bone in an arrowhead shape (chevron). Moderate to severe bunions require a Z shaped cut (so called ‘scarf’ cut) in the bone that allows rotation as well as sideways movement. Very severe deformities may require a crescent shaped cut (basal dome) at the base of the bone or fusion of one of the joints half way up the foot. I usually perform this surgery with a keyhole approach, but not everyone is suitable for this. An open approach involves a bigger incision, which is shown to the left.
Often, surgery is required for hammer toes or metatarsalgia if this exists, and it will be performed at the same time.
Surgery is carried out under general anaesthetic, but can be carried out with local anaesthetic injections behind the knee or around the ankle. The injections are normally given while you are asleep for your comfort. They can give good pain relief for the first day after the operation. You can go home the same day in the evening.
Risks of Surgery
Bleeding, infection, poor bone healing, poor skin healing, injury to tendons, injury to nerves, recurrence, and a need for further surgery.
There is a small risk of blood clots in the legs or lungs (DVT and PE), and there are also risks from anaesthesia – the process of being put to sleep for your operation.
Risks of Anaesthesia
The injection behind your knee is given using an ultrasound machine to guide the needle. There is a less than 1% chance of injury to the nerve. General anaesthetic also carries risks. These risks are proportional to your general health. You will need to be assessed for your fitness for surgery and an Anaesthetist will be able to advise you on your individual risk.
What Happens After Surgery?
You will have had injections to numb your foot so that you are not in pain after the operation. This injection will wear off after 18-24 hours, so you must take regular painkillers so that you are not in severe pain when the injection wears off. Ibuprofen and Diclofenac should not be used for more than a few days after the operation as they can interfere with bone healing.
The pain will settle over a few weeks. You may see blood stains on the dressings. This is normal and not a cause for alarm. If blood is dripping from the dressings however, return to hospital.
The foot will be swollen as well as sore. You should keep the foot elevated as much as possible for the first two weeks. Keep walking down to a minimum – going to the toilet or for meals. Letting the leg hang down will cause the foot to become more swollen. Most of the swelling will settle within the first few months, but swelling can continue for up to one year.
If you are resting on your sofa, keep your foot elevated on the back rest or arm rest. If you are resting in bed, then place a few pillows under the foot to keep it elevated.
You have been given a special shoe that does not allow you to put weight on the front of the foot. This is because the re-set bone is held together by two screws, and putting weight on it can dislodge the screws holding the bone. You should wear this continuously for the first two weeks, including in bed. After that, you should wear it whenever you are walking, even at home. Crutches are for balance only.
After two weeks, you will be seen in the clinic and the stitches will be removed. From this time, you will need to perform exercises to keep the toe mobile, as stiffness can easily occur. You should hold the re-set bone firmly and bend the toe up as far as possible and then down as far as possible. This is shown to the left. Repeat this exercise ten times, four times every day.
RETURNING TO WORK
You will be wearing the special shoe for six weeks, and we will then take an xray. I advise that you do not return to work before this, especially if you are on your feet all day at work. Most people can drive after 8 weeks. Remember that not everyone is the same, and some people take a longer time to recover from their surgery. Please request a sick note before you leave hospital, if you need one.