A bunion (hallux valgus) is a condition in which your big toe has a protruding bump its base on the inside of the foot. This bump occurs when your foot alignment changes and causes your big toe to move toward the smaller toes. Pain can occur from the pressure of the bump against your shoe, and if the big toe rubs against the second toe. Sometimes pain can occur in the ball of the foot as a result of the poor alignment.
Conservative, nonsurgical treatment for bunions include wearing only wide-toed and/or soft shoes, using “bunion pads” or toe spacers, and taking nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen. While toe spacers and devices to hold the big toe apart from the second toe may help with pain, they will not make the bunion go away. The alignment of the toe will not get better over time without surgical intervention.
Bunion removal surgery should not be done for cosmetic purposes only. It is performed on patients whose daily lives are affected by pain and difficulty wearing shoes even after trying wider, more comfortable footwear.
If you have tried wearing wider shoes, padding, toe spacers or other treatments but still have pain that is limiting your activity, you may be a candidate for surgical bunion correction.
The corrective surgery for bunion is known as a metatarsal osteotomy or bunionectomy. There are multiple techniques, but all involve cutting the bones and repositioning them with metal screws to straighten the big toe and reduce the bump on the side of the foot.
Traditionally, bunion surgery can be quite painful with a long recovery. However, some patients can benefit from newer, minimally invasive techniques that have significant advantages. Historically, these procedures have been performed through large incisions, but at HSS, I have perfected two special techniques to correct bunions through tiny incisions.
Minimally invasive bunion surgery is performed using a burr, instead of a saw, to cut the bone. This allows the cuts to be made “percutaneously,” or through tiny incisions on the foot, instead of the long incisions most often used in traditional techniques.
By avoiding large incisions, fewer soft tissues (skin, muscle, joint capsule, etc.) are disrupted, so the foot is less swollen and painful after surgery, allowing for immediate weight bearing, faster bone healing and return to baseline activity level. I perform two types of minimally invasive bunion correction, depending on the severity of a patient’s bunion:
[FPO illustration of foot anatomy]
Minimally invasive bunionectomy involves less pain, a faster recovery, and better cosmetic result due to the small incisions. Open surgery, however, is a more powerful correction for very severe bunion deformities and reduces the risk of recurrence in severe bunions.
I have noticed that my patients who have the minimally invasive technique take less pain medication, have better range of motion of their big toe, and are back in regular shoes in half the time of my patients who undergo the open technique.
This can be determined only through a physical examination of your foot. including seeing you stand, and assessing weight bearing X-rays of your foot. If you have a severe deformity associated with other foot problems that require surgical intervention, you may need a more involved, open procedure. It’s best to speak with your orthopedic foot and ankle surgeon to see which option is right for you.
The bunion surgeries I perform at Hospital for Special Surgery is not nearly as painful as traditional bunion surgery. All patients get a nerve block that numbs the foot for 24 hours after surgery. Patients are instructed to take ibuprofen and acetaminophen (Tylenol) for two to three days after surgery as well. Less than half the patients need stronger medication, and those that do take less than five pills.
When bunion surgery is performed as part of a larger foot surgery, the pain may be worse.
For every foot surgery, patients should stay off their feet and rest for the first two weeks. Typically, it is recommended that you keep the surgical area elevated 80% of the time during the first week and 50% of the time in the second week. Depending on the type of correction you have, you will be allowed to put weight on your foot either after 24 hours (for the PECA surgery) or after two to four weeks (for the minimally invasive Lapidus surgery). Most patients take at minimum two weeks off from work unless they work from home, and longer if they have to commute by public transportation or drive.
The full recovery period depends largely on whether you have minimally invasive or open surgery. Typically, minimally invasive surgery patients can walk in normal sneakers after about six weeks with the PECA procedure or eight weeks with the MIS Lapidus procedure (compared to 10 to 12 weeks after open surgery). From there, activity is increased as tolerated by the patient. Running and jumping are restricted for 12 weeks, but biking, spinning, walking and swimming are allowed to progress as the patient tolerates.
After PECA surgery, you will be fitted with a special surgical post-op shoe, and you can bear full weight almost immediately, after full feeling in your foot has been restored. For the first two weeks after surgery, you will need to limit your activity and keep your foot elevated about 50% to 80% of the time to decrease the swelling and allow the wounds to heal.
After the first two weeks, you may be given a bunion splint to maintain the postsurgical alignment. During this time, you can gradually increase your walking and resume normal activities of daily living.
You will continue to wear the special post-op shoe for about six weeks after surgery. Typically, you will be able to start wearing a normal sneaker after about six weeks, depending on your level of swelling and comfort. Most patients fit into flat, comfortable shoes and all sneakers and boots by three months postoperatively. Patients can experience some degree of swelling for 6 to 12 months after surgery that may limit high fashion shoe wear. This varies by individual, but if other surgery has also been performed on the foot, such as hammer toe corrections, the time it takes to get into regular shoes can increase. Typically, you will be able to wear a regular sneaker at about 10 to 12 weeks after surgery, and you can increase your activity as tolerated from there.
The majority of patients are very happy with their bunion operation. Assuming the patient follows the postoperative instructions carefully, the outcomes are very good. There are risks of bunion surgery, however. Recurrence of the bunion (the bunion coming back) can occur with any type of correction and this is not known to be increased in those who have the minimally invasive correction.
Recurrence may happen if the bunion isn’t fully corrected at the time of surgery or if the wrong bunion procedure was used. It may also occur if patients don’t follow the postoperative directions carefully. Overcorrection (“hallux varus”) is also a risk, but much less common. Either recurrence or over correction may require a revision operation. Delayed bone healing can occur with any foot surgery and is rare. This risk is increased if patients do too much too soon (against the doctor’s advice) and/or they have health issues that can affect bone healing. Some numbness around the incisions may be noted after the procedure. This typically goes away in three to six months. In rare cases it can persist. Bleeding, blot clots, and risks associated with anesthesia are also rare complications.
The recurrence rate (a bunion coming back after surgery) is about 20% over a patient’s lifetime. A mild bunion recurrence is well-tolerated by most patients. Significant bunion recurrences that cause problems and require further surgery are much less common.
Bunions are hereditary so certain conditions may make someone more prone to having the bunion come back. Any condition that causes hypermobility, or tissue flexibility, can be the cause of recurrence. If the bones don’t heal properly, the bunion can recur as well. Wearing sensible shoes (flat, comfortable) when possible may help maintain your bunion correction.
Schipper ON, Day J, Ray GS, Johnson AH. Percutaneous Techniques in Orthopedic Foot and Ankle Surgery. Orthop Clin North Am. 2020;51(3):403-422. doi:10.1016/j.ocl.2020.02.004.
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