What is a bunion?
When your big toe is angled towards the second toe, the deformity is called a bunion (hallux valgus). This causes a bump on the side at the base of the big toe. The skin over the angled joint then tends to rub on the inside of shoes. This may cause thickening and inflammation of the overlying skin. The second toe can become so crowded that it becomes 'clawed,' and crosses over the big toe.
In most cases it is not clear why a hallux valgus deformity develops. There may be some hereditary (genetic) tendency to have a weakness of this joint. In some cases, it is associated with a joint problem such as osteoarthritis or rheumatoid arthritis
What are the treatment options?
Not all bunions require an operation and surgery is always a last resort. The decision depends on the level of symptoms such as pain in your foot and footwear difficulty.
One option is to leave it alone. The bunion may or may not get worse over time but if it does get worse it can still be treated. Surgery should not be undertaken in order to prevent a bunion from getting worse, but rather to treat a bunion that is painful despite conservative measures.
Non-surgical treatments include:
Wider and softer fitting foot wear
Toe spaces and nights splints
Surgery for bunions involves straightening the big toe by cutting and straightening the foot bones (osteotomy). The bones are then fixed with small screws. These screws usually stay in and are not routinely removed. Other procedures maybe involved to straighten other parts of the foot. Your surgeon will discuss these procedures with you.
What is an osteotomy?
A small incision is made on the side of the bump. An ‘osteotomy’ is an operation when the bone is cut and moved into a correct position to straighten the toe. The bone is held with screws, and allows the bone to heal in the new position. The bony bump is trimmed at the same time.
What are the benefits of surgery?
The aim of bunion surgery is to ease your pain and discomfort and straighten the big toe. You should continue to wear roomy and sensible shoes. An operation may not make your foot narrow enough to wear tight narrow shoes.
Summary of surgery
The surgery is usually performed as a day case. It is usually performed under a general anaesthetic. Local anaesthetic is often given at the end of the surgery to help with pain relief. The bony bump is removed and the bone is cut and repositioned to straighten the toe. The bone is held with screws and/or staples. If the other toes need straightening, then this will also be carried out and held straight with a temporary wire. This wire stays in for 6 weeks and is removed in clinic. You will have a big bulky bandage and a post-surgical shoe to wear.
After your surgery
Your foot will be in a bulky bandage and wearing a post-surgical shoe. You may be given a nerve block for pain relief which can last for 24 hours or more. You should keep your foot elevated on a chair/pillow and take regular painkillers.
Advice after surgery
The foot should be strictly elevated for the first 2 weeks to avoid excessive swelling which could compromise the wound. Aim to keep the foot elevated for 55 minutes of every hour
The dressings should not be disturbed unless there is a concern with the wound. At around 2 weeks after surgery, you will return to the clinic to have the bandages and stitches removed. After this the wound can be dressed with a simple light dressing.
You may shower after the stitches have been removed and the wound is fully healed. Keep the wound and surrounding area dry and clean.
You are allowed to bear weight in the post op shoe. You may need crutches. The physiotherapist will show you how to use them. You will need to wear the shoe for 6 weeks. After this time, you can wear flat soled shoes.
It may take several weeks before you can drive. Please check with your insurer.
Going back to work depends on the activity undertaken at work and should be discussed with your surgeon.
Excellent pain relief is noticed quite quickly which improves until the toe has fused, which can take 3 months. It may take 3-6 months before swelling subsides and when you can resume recreational walking and light sporting activities. This is a normal recovery. Often a full recovery takes much longer than one would expect – this can be up to a year. If you are slower than these times do not panic, they are only averages, but let your surgeon know when you attend clinic.
What are the risks with surgery?
The general risks with surgery include
Bleeding – rarely may there be bleeding which results in a collection of blood under the wound. Bruising is common after this procedure
Swelling – common after surgery and can take many months to eventually settle down. Elevation is key to reducing this.
Stiffness – exercises are important to reduce the stiffness in the big toe after surgery
Infection – infections can be treated with antibiotics. Deeper infections which are much rarer may require further surgery
Nerve damage – This can result in numbness over the scar but is generally not a problem. Occasionally a scar may be sensitive. Most settle down, but very few may require further treatment
Clots in leg/lung – your risk of clots will be assessed prior to surgery and appropriate treatment/advise will be given.
The specific risks to this surgery include
Deformity – sometimes the toe may still be at an angle. This may or may not require further surgery.
Metal prominence – Sometimes the metalwork can be prominent under the skin. This can be removed at a later date
Recurrence – the deformity may come back. This may require further surgery.
Metatarsalgia – Sometimes other parts of the foot may undergo undue pressure when walking. This is often treated with insoles.
Fracture – If the bone fractures during surgery, this will be fixed immediately. Sometimes a temporary wire and plaster maybe required. The post-operative shoe is there to prevent fractures after surgery, these could require another operation to treat.
Chronic regional pain – This is excessive pain after surgery and is a very rare complication.
Amputation – this is extremely rare. However deep infections or chronic pain may result in amputation.
Exercises after surgery
It is important to do exercises to maintain movement in the toes and to reduce stiffness.
Immediately after surgery
Move the ankle up and down as much as you can to keep the ankle joint mobile and supple
4 weeks after surgery
Move the big toe up and down as much as you feel comfortable. Wiggle the other toes as much as you can
6 weeks after surgery
Try to pick up a tissue off the floor using your toes. You may not be able to pick up the tissue but the action helps move the toes and strengthen the muscles.
If I have any questions or concerns?
These guidelines are to help you understand your operation. This level of detail may cause concern, anxiety, or uncertainty. Please let your doctor or nurse know so that we may address these issues.
We aim to see you back in the clinic at regular intervals to monitor your progress and answer any questions you may have during your recovery.
If there is concern regarding the wound, such as increased redness, pus, discharge, or pain, then seek medical attention either at your GP or nearest Emergency department.
Above all else, please do not proceed with surgery unless you are satisfied and understand all you want to know about the operation.