Bunion- Hallux Valgus - Foot Surgery London

Bunion- Hallux Valgus

You have been directed to this section of the website because you have a bunion. Here, you will find information on what a bunion is and how it can be treated.

A bunion (hallux valgus) occurs when the 1^st metatarsal moves out of its normal position away from the 2^nd metatarsal. The big toe then drifts towards the 2^nd toe. Most patients complain of difficulty with footwear fitting, an inflamed or painful joint and occasionally irritation between the 1^st and 2^nd toes.

We do not know the exact causes of bunions but possible factors include a family history/genetics, foot function and footwear. Bunions become larger over the course of time.

Diagnosis:

The diagnosis is made following an examination of your foot. The severity of the condition is assessed through x-rays. There is no direct correlation between the size of a bunion and the degree of discomfort experienced.

Treatment Options:

Conservative care is aimed at making the foot more comfortable. There is no evidence that it will reduce deformity or prevent it from worsening. There is some evidence that suggests that shoes and insoles can reduce pain and also some limited evidence that night splints can reduce the progression of deformity in children. The options include:

Wide fitting shoes
Custom made footwear
Pads and protectors
Insoles (orthoses)
Toe separators
Night splints (children)
Anti inflammatory and pain relieving medication
Steroid injections

Surgical Intervention:

Surgical intervention is considered whenever a patient experiences sufficient pain on a regular basis or difficulties with footwear. Some patients also wish to have their bunion corrected to prevent further problems later in life. It is unwise to have surgery for cosmetic reasons, as there is always a small possibility that you could be worse off.

The aim of the surgery is to move the first metatarsal back towards the 2^nd metatarsal and in doing so, the big toe will move back into a straight position. This is achieved by cutting the 1^st metatarsal bone and resetting it in a new position. Unfortunately, bunion correction cannot be achieved by simply ‘shaving off the bump’ as this does not address the abnormal position of the 1^st metatarsal.

There are many different methods of bunion surgery and you will be involved in deciding which procedure is most suitable for you. Mr McCallum will discuss the options with you and advise which he feels suit you best. You will be advised of the advantages and disadvantages of the different options. The most important factor to consider when choosing the most suitable procedure is normally the size of the bunion. Your medical health, age and how active you are will also help in the decision making process.

It is a common belief that bunion surgery is largely unsuccessful. However, this is actually untrue in the vast majority of cases (approximately 85% of patients are happy with the outcome of surgery). Picking a procedure to suit a patient’s needs and wishes is very important in maximising the chance of having a good outcome following surgery. One of the most common things to affect the outcome of surgery is the presence of arthritis in the big toe joint before the surgery is performed. If this is present then your joint may be stiff and/or painful after the surgery and may require further treatment at a later stage. If surgery has been performed already and has to be revised, the outcome may not be as good as it may have been first time round.

The Operation:

There are two main procedures that Mr McCallum commonly performs to correct bunions.

Scarf (+/- Akin) Osteotomy
1^st metatarsal-cuneiform fusion/arthrodesis

Soft tissue procedures may also be performed in conjunction with bony work to balance out the joint.

Scarf Osteotomy

The scarf is normally indicated for moderate deformities.

The 1^st metatarsal bone is cut into two separate pieces as demonstrated in the diagram below. The position is corrected by moving the bone back into its correct position and the bone is held back together with two screws. Occasionally, a different method of fixation is used to hold the bone fragments together.

Correcting the position of the 1^st metatarsal normally causes the position of the big toe to also correct. If the big toe still leans towards the 2^nd toe then a small wedge of bone can be removed from the base of the big toe to straighten it further (Akin osteotomy) and this is held together with a wire.

Below are x-rays of a right foot with a bunion then post Scarf and Akin osteotomies 6-weeks later (with a wire through the 2^nd toe to correct a hammer toe).

Recovery:

After your operation, you will be placed into an Aircast walking boot and you will remain in this for a period of approximately 6-weeks. The Aircast is removable and you should take it off when resting so that you can mobilise your foot and ankle. It must be worn at all times when moving around.

Before you are discharged from the hospital, you will be shown how to use crutches so that you can partially weight bear on the foot whilst wearing the Aircast. It is advisable to use your crutches until Mr McCallum reviews you with a post-operative x-ray.

You should travel home by car and keep your foot elevated on the back seat where possible. When you go home, you must rest with the leg elevated for the first 2-4 days (essential walking only). It is important that you do not interfere with the dressings and that you keep them dry. You can buy a purpose made waterproof device from the chemist but if washing, you must exercise caution when putting the foot to the floor in a shower.

You will be reviewed within one week of your operation for a change of dressing and at the 2-week mark, the dressings will be removed and the suture tags will be cut. You will be shown how to perform range of motion exercises and from this point forward it is safe to get the foot wet. You will be reviewed again at the 6-week mark to ensure that the bone(s) are healing in a satisfactory manner. It is normally safe to transfer into your own comfortable footwear at this stage and gradually increase your activity levels. After 3-months, the bones should have healed sufficiently for you to resume full activity levels.

On average, it takes approximately 6-9 months for the foot to have fully recovered and it is not unusual to experience swelling, discomfort and stiffness during this time.

Aircast Airselect Walker

1^st metatarsal-cuneiform fusion/arthrodesis (Lapidus)

The Lapidus procedure is normally performed in cases of severe or unstable bunions. It is also performed in cases where the 1^st metatarsal-cuneiform joint is arthritic.

The procedure involves cutting a wedge of bone out of the joint and this allows the entire 1^st metatarsal to move back to a straight position. When straight, the two bones are secured together with a metal plate and screws.

This procedure does not take away the movement at your big toe joint.

Below are x-rays of a pre and post 1^st metatarsal-cuneiform fusion.

Recovery:

Before you are discharged from the hospital, you will be shown how to use crutches so that you can partially weight bear on the foot whilst wearing the Aircast. It is very important that you use both crutches at all times.

When you go home, you must rest with the leg elevated for the first 2-4 days (essential walking only). It is important that you do not interfere with the dressings and that you keep them dry. You can buy a purpose made waterproof device from the chemist but if washing, you must exercise caution when putting the foot to the floor in a shower.

You will be reviewed within one week of your operation for a change of dressing and an x-ray and at the 2-week mark, the dressings will be removed and the suture tags will be cut. You will be shown how to perform range of motion exercises and from this point forward it is safe to get the foot wet. You will be reviewed again at the 6-week mark when another x-ray will be taken to ensure that the bones are healing in a satisfactory manner. If all is well, you will be allowed to return to your own comfortable footwear (a running shoe is ideal) and gradually increase your activity levels. It is not unusual to have to remain in the Aircast for a further 2-4 weeks. After 3-months, the bones should have healed sufficiently for you to resume full activity levels.

On average, it takes approximately 12-months for the foot to have fully recovered and it is not unusual to experience swelling, discomfort and stiffness during this time.

Possible Complications following surgery:

Outlined below are the possible problems or the rare complications with serious outcomes following foot surgery In cases where there are no accurate audit results, published results from podiatric literature have been used.

Prolonged swelling taking more than 6-months to resolve can occur in 1 in 500 operations.
Haematoma- a painful collection of blood under the skin. This can increase the risk of developing an infection and may require further antibiotics and surgery to resolve.
Thick or sensitive scar.
Irritation from internal fixation. Screws and plates are only required whilst the bone is healing (during the first 3-months). However, fixation is not generally removed unless it causes a problem. This may occur in up to 10% of cases.
Adverse reaction to the post-operative pain-killers. 1 in 50 patents report that codeine preparations make them feel sick.
Infection of the soft tissue. 1 in every 83 operations.
Infection of bone- osteomyelitis. This is a serious complication and in severe cases, can lead to amputation.
Delayed healing of soft tissue or bone.
Circulatory impairment with loss of tissue. If severe this can lead to amputation.
Loss of sensation can occur although this is not normally permanent and can continue to improve over 18-months.
Deep vein thrombosis (blood clot). This can result in the clot travelling to the lung and this can be a life threatening condition. Deep vein thrombosis incidence is 3 in 1000 cases.
Complex pain syndrome- a condition where the nervous system dealing with pain over-reacts. This is a very painful condition that can result after even minor trauma. It normally requires management by specialists in this condition and does not always resolve. This is a rare condition that occurs in 3 in 2500 cases.
Recurrence of deformity or failure of the surgery.
Development of secondary problems such as overloading of adjacent joints- transfer metatarsalgia.

Specific complications related to bunion surgery:

Non-union of bone following surgery- higher for the Lapidus procedure at approximately 5%.
Delayed union- bone healing taking longer than average.
Fracture.
Joint stiffness.
Recurrence of symptoms or deformity.
Fixation irritation.
Transfer pain.

The risk of developing a complication can be minimised when the patient and all those concerned with the operation and aftercare work together. This starts with the pre-operative screening and continues through to the post-operative regime.

The pre-operative screening helps us determine whether you are fit for surgery or if any extra measures need to be considered to minimise your risk of developing a complication. It is important that you disclose your full medical history. If there is a query regarding your health then further investigations may be required and Mr McCallum will liaise with the appropriate medical specialists. Mr McCallum and the there team will ensure that your operation is carried out safely and effectively.

You can improve your healing process and reduce the risks by:

Adhering to the post-operative instructions, which include resting and elevating the operated foot. Keeping the wound dry and clean until advised otherwise. Please ask Mr McCallum if you are not sure what to do.
Having a healthy diet is important; this provides the nutrition required for healing.
Smoking is associated with a 20% increased risk of delayed or non-healing of bone.
Alcohol can interact with the drugs that are prescribed and can impair wound healing.
Post-operative mobilisation will be advised; this helps improve flexibility, strength and stability of your foot.