What is a bunion? This is a common condition which affects both men and women. Women suffer more commonly because of fashion footwear designs which cannot accommodate a broad foot. The medical term is Hallux valgus. The great toe moves against the smaller toes and slowly dislocates (figure 2), often with additional affects on the forefoot. Hammer toes, neuromata and pressure corns arise. Bunions or hallux valgus, HV for short, can affect children as well as adults.
More pain than usual can arise because of a soft sac develops under the skin and over the bone which enlargens as the toe deviates; this is the bunion or bursa (Figure 1). The sac develops from the joint lining and fills with fluid. The first toe joint become less effective for walking and the foot functions less efficiently and shoe fit a real problem.
Figure 1 Figure 2 Figure 3
Should hallux valgus be treated? Providing that your shoes can accommodate the increased foot width then it is not always necessary to treat the deformity with surgery. Men often do not need to have this treated compared to women. Children should not have the toe treated until they are old enough. This is because surgery performed too early may still lead to some return of the deformity - no matter how good the surgery is. Leave children until adulthood, ideally after 25 years if possible unless they are in great pain.
Why should I have my bunion treated? The great toe usually dislocates over a number of years but in some patients as quickly as six months. If you notice that the great toe is moving against the second toe, this could become dislocated (Figure 3). The foot will become wider making shoes difficult to fit. Pain under the foot and pressure against the outside toes may create other complaints. The joint starts to deteriorate inside and arthritis will cause the toe to become painful to bend. If the joint forms a hard swelling, this then suggests that the deterioration is quite marked. Not all bunions develop all these problems quickly. Patients with hallux valgus in older age often find chilling in the colder months quite painful over the skin, which can then ulcerate. Treatment is based upon symptoms and the need to improve shoe fit.
Do I have to have surgery to correct my bunion deformity? In short the answer is yes. Once developed, no matter what you do or wear the deformity progresses. You can wear wider shoes or protect the bump with foam sleeves. Using spacers between the toes will not cure the problem. An Argentinean doctor did find a night splint beneficial when used in children to stop the progress of the deformity; sadly as we grow older this simple remedy does not work. A British Podiatrist spent seven years studying treatment with arch supports (orthoses). Unfortunately in some patients the deformity can actually increase. Always seek advice firs
Can I have the bump removed alone? We only recommend this operation if you are frail and do not walk much. Removing the bump does not correct the deformity, although it can remove the pressure on the skin. The big toe will not correct and the deformity can become worse. Bump removal is called an exostectomy (Silver’s) and may be useful when dealing with the large bursa seen in figure 1. In reality a full correction can allow return to normal function so do not be persuaded to have a bump removed unless advised by a qualified foot surgeon (FCPodS, or BOFAS member)
Can I have the operation my friend had? No - unfortunately every patient is different. The quality of bone, the extent of deformity and requirements of each patient are different. There are three main types of operation - your podiatrist will select the best one suited for you.
An arthroplasty - some bone is taken away from the joint (often called a Keller)
An arthrodesis - the joint is made stiffer at one of two points
An osteotomy - the bone is moved and then pinned or screwed
Multiple deformities and hammertoes. Can I just have my second toe straightened?Unless you opt for an amputation the big toe must be corrected in order for the second digit to lie flat. If more toes are affected then multiple toe surgery is needed. Surgery is longer but the end result is worthwhile despite longer recovery.
I have heard it is very painful and I won’t walk for six months?This is untrue in most cases. There is no such thing as one surgery for all bunions. The extent of the deformity varies from patient to patient. Some operations are bigger than others. Everyone has a different pain threshold. In a podiatric survey of bunion surgeries, only 4% of patients found that pain was poorly controlled while 51% had little pain and the rest coped well with pain medication. For the first three days keep your leg and foot high. Use ice or bags of frozen peas to keep swelling down. You should be comfortable and walk a little with crutches by day 5-7. Please bear in mind any foot surgery will take 9 to 12 months to make a recovery. Swelling will last for 4 months before subsiding. Scar lines take 2 years to settle and the big toe may still remain stiff. The longer that you leave your surgery, and the older your age, the less chance that you will have in regaining good movement.
When can I go back to work? Do not go back too early. Allow two weeks for the worst swelling to go down and a further two weeks to start walking a little further. General guide is 4-6 weeks to work, 6-8 weeks to drive. Allow up to six months to fit most shoes because of swelling. Remember also that one foot will be narrower than the other foot if this is also deformed.
Do I need a cast? Podiatric surgery rarely needs a cast because we use small screws to hold the bone in place. Where we do use casts these are for short periods and only used when we need maximum stability. Screws need to come out in about 2% of patients.
And what about stitches? Stitches are removed at 2 weeks and you cannot bathe until this point but we will let you have a special cover for the shower.
What do I do if I am in pain at home? Call the emergency number given to you. Pain is badly controlled if you are crying, cannot hold a conversation or feel nauseous. Background pain is normal and you should not lose your appetite.
How long does surgery last? Single bunion surgeries last between 35-45 minutes.
Can I have this done under local anaesthetic? Yes, this is possible but we cannot do both feet together. As long as you are fit though a general anaesthetic can be provided and is more appropriate for the extremely worried and anxious patient. Sickness after surgery is the main concern for patients. We find this arises in less than 1% of patients in this practice.
What problems do I need to know about? Most problems are minor and fixable. 70% of patients can expect no problems and serious problems like thrombosis and complex regional pain syndrome affect few patients.
Please refer to Fact sheet 7 or Fact sheet 40 before signing a consent sheet.
Consultingfootpain. Podiatric Surgical Services. Mr D R Tollafield