Bunions or hallux valgus ('hallux' means the big toe and 'valgus' means abnormal bending towards the other toes) are more common in women and run in families. A bunion can cause discomfort, pain, swelling and redness in and around the big toe. If left untreated, it can make wearing shoes painful. Surgery is used to correct the abnormal bending of your big toe, and to reduce pain and pressure.

Bunion Surgery Candidates

One of the most common reasons for a total ankle replacement is rheumatoid arthritis. Other conditions that may call for total arthroplasty include osteoarthritis, a severe bone fracture or complications from previous ankle surgery. Symptoms of these conditions include severe pain and difficulty moving the ankle joint. Because the ankle is a weight-bearing joint, these conditions can make it difficult for a person to have a normal life.

The best candidates for total ankle replacement are those who are older than 50, not overweight and not extremely active. It's possible to hike, ride a bicycle or even ski after a total ankle replacement. But people who are runners or do heavy labor are not good candidates for ankle replacement. People who have diabetes, nerve problems in their legs or poor circulation also are not good candidates.

Bunion Surgery Alternatives

Non-surgical treatments, such as bunion pads and orthotic insoles, may help to reduce pain, but they won't stop the bunions from getting worse over time. Medicines (eg paracetamol, ibuprofen) can also help to reduce pain and swelling. If non-surgical treatments don't help, your GP may refer you to a podiatrist (a health professional who specialises in conditions that affect the feet).

Bunion Surgery Outcome & Benifits

After surgery, your ability to walk and do other activities is likely to improve. The big toe joint is generally less painful and, as a result, moves better. After the incision has healed and the swelling has gone down, the toe may look more normal than before.

Prepare for Bunion Surgery

Your surgeon will explain how to prepare for your operation. For example, if you smoke you will be asked to stop, as smoking increases your risk of getting a wound infection and slows your recovery.

Bunion surgery is usually done as a day-case operation, this means you will go home the same day.

You will usually be under general anaesthesia during the procedure so you will be asleep. Alternatively, you may have the surgery under local anaesthesia. This completely blocks the pain in your foot and you will stay awake during the operation. You may have a sedative with the local anaesthetic to help you relax.

If you are having a general anaesthetic, you will be asked to follow fasting instructions. Typically, you must not eat or drink for about six hours beforehand. However, some anaesthetists (doctors specialising in pain management and giving anaesthetic medicines for surgical procedures) allow occasional sips of water until two hours before a general anaesthetic.

Your surgeon will discuss with you what will happen before, during and after your procedure, and any pain you might have. This is your opportunity to understand what will happen, and you can help yourself by preparing questions to ask about the risks, benefits and any alternatives to the procedure. This will help you to be informed, so you can give your consent for the procedure to go ahead, which you may be asked to do by signing a consent form.

You may be asked to wear a compression stocking on the unaffected leg to help maintain circulation.

Bunion Surgery Overview

Surgery to remove a bunion usually takes less than an hour, but the time can vary.

Your surgeon will make a cut on the inner side of your foot, over your big toe joint. The operation may be done through small cuts rather than one big cut. This is called keyhole (minimally invasive) surgery.

The exact procedure you have depends on the type and size of your bunion. Usually your surgeon will remove some bone and may reposition bones, ligaments and tendons in your foot. Screws or wires may be used to keep the bones in place. These may stay in your foot, dissolve over time or be taken out in a second operation.

The general types of bunion surgery are:

• Removal of part of the metatarsal head (the part of the foot that is bulging out). This procedure is called exostectomy or bunionectomy.
• Realignment of the soft tissues (ligaments) around the big toe joint.
• Removal of a small wedge of bone from the foot (metatarsal osteotomy) or from the toe (phalangeal osteotomy).
• Removal of bone from the end of the first metatarsal bone, which joins with the base of the big toe (metatarsophalangeal joint). At the metatarsophalangeal joint, both the big toe and metatarsal bones are reshaped (resection arthroplasty).
• Fusion (arthrodesis) of the big toe joint.
• Fusion of the joint where the metatarsal bone joins the mid-foot (Lapidus procedure).
• Implant insertion of all or part of an artificial joint.
  

Surgical Steps

Generally, bunion surgery can be classified into two major categories:

1. head procedures (around the great toe joint).
2. Base procedures (near or at the joint behind the great toe joint).

For a head procedure, the bone is cut and the head of the metatarsal moved over to correct the bunion. Various types of bone cuts can be performed depending on the necessary correction. Head procedures are usually indicated for a mild to moderate bunion, or for patients who do not feel they can be non-weight bearing for any length of time.

Base procedures are performed around the base of the 1st metatarsal (bone behind great toe). They include cutting a wedge out of the bone (base wedge), making a semi-circular cut and rotating the bone (crescentic osteotomy) and fusion of joint behind great toe joint (Lapidus bunionectomy). Base procedures are usually indicated for a moderate to severe bunion.

Overall, there are many variables in selecting a bunion procedure and the key to success is finding an experienced surgeon who understands each variable and who has the skills to perform all types of procedures. Some surgeons may not have the skills to perform base type procedures and offer head procedures as your only choice.

There is substantial medical research showing which bunion procedures are most effective in specific situations. At the Foot and Ankle Center of Washington, we perform an examination of your lower leg and foot, review your biomechanics and x-rays, and give you an understandable and complete explanation of what choices you have, including what type of procedure is in your best interest.

Repair of the Tendons and Ligaments Around the Big Toe

These tissues may be too tight on one side and too loose on the other, creating an imbalance that causes the big toe to drift toward the others. Often combined with an osteotomy, this procedure shortens the loose tissues and lengthens the tight ones.

Arthrodesis

Removal of the damaged joint surfaces, followed by the insertion of screws, wires, or plates to hold the surfaces together until it heals. Used for patients with severe bunions, severe arthritis, and when other procedures have failed.

Exostectomy

Removal of the bump on the toe joint; used only for an enlargement of the bone with no drifting of the big toe. This procedure is seldom used because it rarely corrects the cause of the bunion.

Resection Arthroplasty

Removal of the damaged portion of the joint, used mainly for patients who are older, have had previous bunion surgery, or have severe arthritis. This creates a flexible "scar" joint.

Osteotomy

The surgical cutting and realignment of the joint. Your orthopaedic surgeon will choose the procedure best suited to your condition.

Physical Therapy

You will need to rest until the effects of the general anaesthetic have passed. You may need pain relief to help with any discomfort as the anaesthetic wears off.

Your foot will usually be heavily bandaged after the operation or you may have a plaster cast. This is to protect your foot and help keep it correctly aligned. You will usually have crutches and a special shoe to wear.

A physiotherapist (a health professional who specialises in movement and mobility) may visit you after your operation and give you some advice about how to move around safely. If needed, your physiotherapist may arrange a further appointment to help your recovery.

Bunion Surgery Recovery

If you need pain relief, you can take over-the-counter painkillers such as paracetamol or ibuprofen. Always read the patient information leaflet that comes with the medicine and if you have any questions, ask your GP or pharmacist for advice.

General anaesthesia temporarily affects your co-ordination and reasoning skills, so you must not drink alcohol, operate machinery or sign legal documents for 48 hours afterwards.

If you are in any doubt about driving, contact your motor insurer so that you're aware of their recommendations, and always follow your surgeon's advice. You won't be able to drive while your foot is in the post-operative shoe.

It usually takes four to eight weeks for the bones in your foot to heal. You will usually be able to walk immediately afterwards wearing the post-operative shoe, but may need crutches for the first few weeks. You will normally be required to wear the shoe for approximately six weeks. Keep the dressing or cast dry and always wear your protective over-shoe when you are outside. Also, resting with your foot up on a stool can help to reduce any swelling.

Your surgeon will give you advice about when you can go back to work, as this will depend on the type of operation you have had, and what stresses or pressures your feet will be under (eg walking around or standing).

Bunion Surgery After Care

Take any pain medications your doctor has prescribed for at least the first couple of days. After this time, you can take them only when you experience foot pain. Over the counter pain medications can also be used as a substitute if you're not comfortable taking prescription drugs for an extended period.

Keep your foot elevated and be sure to use an ice pack for the first 48 hours after bunion surgery. This will keep the swelling down and also reduce bruising. You can continue to use an ice pack periodically as needed.

Avoid showering until the stitches are gone. Allowing the stitches to get wet can affect the healing process and lead to infection in some cases. Instead take a bath in the tub, keeping your foot out of the water. You may wish to place a plastic bag over your foot for added protection.

Bed rest is essential for about the first two weeks following bunion surgery. When you must get out of bed, be sure to wear a surgical shoe. Typically stitches are left in for 10-14 days. After the stitches are removed, you can start to gradually increase your walking time.

Stretching exercises should be performed within a few days of removing the stitches. Continue to perform these bunion surgery exercises on a daily basis until you regain full range of motion. Failure to exercise and stretch your foot can result in a number of unpleasant circumstances including increased scarring, stiffness, and loss of mobility that may eventually require a physical therapist.

Start wearing shoes around the house after the stitches come out. You may only be able to tolerate an hour or two at first but you can gradually increase this time until you're able to wear them comfortably the entire day. An ice pack may be necessary again during the first week you begin to wear shoes. Choose a wide comfortable pair of leather sneakers for comfort. All boots and high-heeled shoes should be avoided for six months after bunion surgery.

Apply a natural ointment to the scar area twice daily after the stitches have been removed. This will both improve the healing time and minimize the appearance of scars.

When You Return Home

After you return home, it will take time to adjust. Elevate your ankle, preferably above the level of your heart, when resting. At night, you should lie on your back with one or more pillows under your splinted ankle.

Feel free to walk as much as you like using crutches or a walker, but be sure not to put any weight on your ankle for the first six weeks after surgery or until the time specified by your surgeon.

Make certain that your ankle incision stays dry and is not draining. If you notice any drainage or foul odor from your incision, contact your surgeon right away. If your temperature reaches above 100.4 degrees or you notice any increased swelling or tenderness, call your surgeon immediately.

The range-of-motion exercises are very important to your recovery so you must do them at least two to three times a day.

Using a walker or crutches can become a little frustrating, but you will have it mastered in a few days. Take special care while becoming familiar with the device, and don't become over confident once you get the hang of it. This is when accidents can happen.

You can bathe but special precautions are necessary. Make sure that you protect the ankle from water by wrapping plastic wrap over the dressing.

Remain active after you return home, but do not over due it. Each person heals at their own rate, and it is difficult to predict when you will be able to resume your normal activities.

After about 8-12 days after surgery, you may have your first "post-operative" visit. Your surgeon will exam the ankle and may call for an x-ray evaluation to be sure the healing process is going well. Your sutures will probably be removed two weeks after surgery. You will be seen again at six weeks, and then at three months after surgery. A six-month exam is usually scheduled for new x-rays and an assessment of your progress.

For the first six weeks, use crutches and do not put any weight on the affected leg. At the six-week mark, you may begin to gradually put weight on the leg with the use of a cane or walker.

You may be able to begin driving an automatic shift car in six to eight weeks. If you have a manual transmission and your right ankle was operated on, you will not begin to drive for 12 weeks.

After 12 weeks, you can begin low impact, weight-bearing activities, such as walking, golfing, and bicycling on level surfaces. Avoid contact sports, weightlifting, and any activity that puts stress on the joint. Your surgeon may suggest that you use an ankle support for up to one year.

Do not be alarmed by the swelling, which can be expected for up to 12 months.

Bunion Surgery Possible Risks

Bunion removal is commonly performed and generally safe. However, in order to make an informed decision and give your consent, you need to be aware of the possible side-effects and the risk of complications of this procedure.

These are the unwanted, but mostly temporary effects of a successful treatment, for example feeling sick as a result of the general anaesthetic.

Your foot, especially your toe, will feel sore and have some swelling. This pain will gradually improve but it may take up to a year for the swelling to settle fully.

This is when problems occur during or after the operation. Most people are not affected. The possible complications of any operation include an unexpected reaction to the anaesthetic, excessive bleeding or developing a blood clot, usually in a vein in the leg (deep vein thrombosis, DVT).

Complications specific to bunion removal are uncommon but can include:

• Toe Stiffness - the tendons in your big toe may be damaged, affecting how well your toe moves
• Toe Numbness - the nerves in the toe may be injured
• Abnormal Toe Position - your big toe may heal out of line, bending outwards or upwards or be slightly shorter
• Slow Healing - this can cause ongoing pain and swelling
• Wound Iinfection - you may need antibiotics to treat an infection
• Re-Occurrence - the bunion may come back

The exact risks are specific to you and differ for every person, so we have not included statistics here. Ask your surgeon to explain how these risks apply to you.