Patient Information for Bunion Surgery
A bunion (hallux valgus) is the movement of the 1st metatarsal away from the 2nd with the big toe drifting towards the second toe. Most patients complain of pain, a prominent joint, and problems with shoes. Bunions are considered to be a progressive condition. The cause of bunions is unknown, but possible factors include a family history, foot function, footwear and some medical conditions.
This is a clinical diagnosis made by examining the foot. The severity of the condition is normally assessed by an X-ray. There is no direct correlation between the size of the deformity and the degree of symptoms experienced.
Treatment options Conservative
This is aimed at managing the symptoms using:
- Wide fitting shoes
- Bunion pads
- Night splints (children)
- Painkillers and anti-inflammatories
The aim of the surgery is to get the first metatarsal aligned almost parallel to the second metatarsal. This will move the big toe back into a straight position. Sometimes this approach needs to be helped by re-balancing the soft tissue around the joint, or taking a small wedge of bone out of the big toe. Moving the first metatarsal back into its proper position requires cutting the bone (osteotomy). The outcome of your operation will be dependent on the condition of your joint (degree of arthritis) prior to the surgery. The quality of the joint often deteriorates with the passage of time. There are numerous operations to correct bunions, but essentially they fall into two categories: transposition and rotational osteotomies (see diagram).
A transposition osteotomy is where the bone is cut and moved across. The amount of correction available is restricted by the width of the bone. Transposing the bone greater than half distance can result in instability. It is ideally suited to moderate deformities. In severe cases a rotational osteotomy is preferred. Here a greater degree of correction is available, although this type of procedure is less stable and runs a greater risk of non or delayed bone healing. This operation also takes longer to heal and to settle down.
Professor Tagoe will advise you on the right procedure to correct your deformity. However, the decision to proceed with surgery or continue with conservative care remains yours.
This is a transposition osteotomy. It is normally indicated for mild to moderate deformities. The new position of the first metatarsal is maintained with 2 screws improving its stability. Once the bone has fully healed, the screws are no longer required. However, we only remove them if they cause irritation.
An Aircast boot will be placed on your leg in theatres. This is removable and should be taken off at rest and the foot and ankle mobilised. You will be shown how to partially weight bear on the foot using the Aircast Walker and crutches. The crutches are generally only used while the foot remains numb (24-48hrs). Thereafter you can fully weight bear in the Aircast for a total of 6 weeks.
You must rest with the leg elevated for the first 48 hours (essential walking only). It is important that you do not interfere with the dressings and keep them dry. You can buy a purpose made waterproof cover to keep the leg dry, from the hospital or chemist. You will be seen for a dressing change 3-4 days post-surgery. 2 weeks following the surgery the dressing will be removed and the suture tags cut. Range of motion exercises for the joint will be started. From this point you can wash your foot. After 6 weeks you can gradually return to comfortable shoes and low impact activities. It is normally 3 months after your operation before high impact activities including running can be started, as it takes this length of time for the bone to heal.
It is normally six or seven months before patients have fully recovered. Swelling and an ache around the surgical site are common during this period.
Pre and post operative X-rays following the Scarf procedure
Lapidus (Metatarsal Cuneiform Fusion)
This involves a fusion of the first metatarsal cuneiform joint, allowing the first metatarsal to be rotated back into a straight position. It is normally reserved for severe deformities. Once the corrected position has been obtained it is usually maintained with a plate and screws.
Pre and post operative Lapidus
An Aircast boot will be placed on your leg in theatres. This is removable and should be taken off at rest and the foot and ankle mobilised. You will be shown how to partially weight bear on the foot using crutches and this will need to be continued for 6 weeks.
You must rest with the leg elevated for the first 48 hours. (essential partial weight-bearing only). You will be seen 3-4 days post-surgery when the wound will be checked and the foot x-rayed. A follow up appointment will be made for 2 weeks post surgery when the dressing will be removed and the suture tags cut. Range of motion exercises for the joint will be started. From this point you can wash your foot. 6 weeks after the operation the foot will be X-rayed and in the absence of any adverse signs you will be advised to return to a trainer. From this point on a gradual increase of low impact activities is possible. 12 weeks post surgery the 2 bones have normally united allowing a return to high impact activities including running, Once out of the Aircast boot and fully weight bearing you can drive your car once you feel safe.
It is normally a year before patients have fully recovered. Swelling and an ache around the surgical site being common complaints up until this point.
Outcome following the Lapidus
An audit using a 100 point clinical rating system was used to assess pain, function and alignment, a score of 100 being perfect. The average score before surgery was 47.33. Following the surgery the average outcome was 91.08 within our department. The risk of a non-union at the fusion site was 2%.
Possible Complications following suregery
Approximately 900 patients undergo foot surgery annually within the Department of Podiatric Surgery at West Middlesex University Hospital. Most patients have an uneventful recovery.
Outlined below are the common problems or those rare complications with serious outcomes. In cases where we don’t have accurate audit we have used published results from the podiatric literature. These are accompanied by an asterisk *.
- Prolonged swelling taking more than 6 months to resolve occurs 1 in every 500 operations*
- Haematoma – a painful accumulation of blood within the operation
- Thick and or sensitive scar.
- Adverse reaction to the post-operative pain 1 in every 50 patients report that the codeine preparations can make them feel sick.*
- Infection of soft The incidence is 1 in every 83 operations*
- Delayed healing of soft
- Circulatory impairment with tissue loss occurred in 3 out of 9000 patients over a 10-year
- Deep vein thrombosis, a complication of which would be a clot that dislodges and settles in the This is potentially a life threatening condition. Within the published literature, deep vein thrombosis requiring treatment after surgery is 0.3% *
- Chronic pain syndrome: this is where the nervous system dealing with pain over reacts in a prolonged manner often to a minor This normally requires management by specialist in this condition and doesn’t always resolve. This is a rare complication with no audit data available.
Specific complications following bunion surgery:
- Non-union of bone following the Lapidus at 2%.
- Delayed union (slow healing)
- Joint stiffness and pain
- Reoccurrence of symptoms or deformity
- Fixation irritation
- Transfer pain
The risk of having 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 rehabilitation exercises.
Pre-operative screening of your health allows us to determine whether you are fit for surgery. It is important that you disclose your full medical history. If there is a query regarding your health, then further investigations or the advice of other surgical and medical specialties will be sought. Professor Tagoe and the theatre team will ensure that the operation is performed effectively and with the minimum of trauma.
You can improve the healing process and reduce the risks of complications by:
- Adhering to the post-operative instructions, which include resting and elevating the operated Keeping the wound clean and dry until advised otherwise is essential. Please ask the nurse or Podiatric surgeon if you are not sure what to do.
- Having a healthy diet is This provides the nutrition required for healing.
- Smoking is associated with a 20% increased risk of delayed or non-healing of
- Alcohol can interact with the drugs that we will prescribe and in excess can impair wound
- Post-operative mobilisation will be This helps improve the flexibility, strength and stability of your foot.