Bunionectomy

A bunionectomy is a surgical procedure to remove a bunion. A bunion, also called a hallux valgus, is an enlargement of bone or soft tissues around the joint at the base of the big toe that results in the formation of a bump. The bone that joins the big toe with the first metatarsal bone thickens and enlarges, tightening the tendons, which in turn causes the base of the big toe to angle out resulting in a painful bony deformity.

Causes of Bunions

The most common cause of a bunion is prolonged wearing of ill-fitting footwear that compress the toes into unnatural positions. This can include high heeled shoes, narrow shoes, shoes that are too small or pointy shoes with a narrow toe box. Genetics and certain disease conditions such as arthritis or polio may increase the risk of developing a bunion.

Bunions are much more prevalent in women than men, which may be associated with the use of heels and fashionable shoes by women.

Signs and Symptoms

The signs and symptoms associated with bunions include:

• Pain with ambulation when wearing shoes
• Swelling with red, calloused skin at the base of the big toe
• Decreased mobility in the big toe
• Inward turning of the big toe toward the second toe
• Bulging of a bony bump at the base of the big toe
• Formation of corns and calluses at the overlapping of the big toe and second toe

Diagnosis

The diagnosis of a bunion by an orthopedic surgeon includes taking a medical history and performing a physical examination to assess the extent of misalignment and damage to the soft tissues. Your doctor may order X-rays to help determine the extent of damage and deformity of the toe joints.

Treatment of Bunions

Your surgeon initially will recommend conservative treatment measures with the goal of reducing or eliminating foot pain. Such measures include wearing properly fitted shoes with specially designed shoe inserts, padding, or taping of bunions. Physical therapy and certain medications may be prescribed for relieving pain and inflammation.

If conservative measures fail to treat the bunion pain, then your surgeon may recommend a surgical procedure to remove the bunion.

There are many surgical options to treat a bunion but the common goal is to realign the joint, correct the deformity, and to relieve pain and discomfort. Your surgeon will discuss the different options available to you and a plan specific to your foot will be agreed upon before your surgery.

• Osteotomy is a common type of bunion surgery that involves surgical cutting and realignment of the toe joint. The orthopedic surgeon selects the appropriate surgical procedure based on the patient's presentation. There are 3 types of osteotomies, namely akin osteotomy, chevron osteotomy, and scarf osteotomy.
  • Akin Osteotomy: Akin osteotomy is usually performed under local anesthesia where your toe will be numbed and you will not feel any pain during the procedure. Your surgeon will make an incision along your big toe. The joint capsule is then opened, and the bunion is removed using a surgical saw. Your surgeon will then remove a wedge of bone from your big toe. Your toe is then brought back to its normal anatomical position and held together with surgical staples. The mobility of your big toe is examined, and the capsule and wound are re-approximated with sutures.
  • Chevron Osteotomy: A chevron osteotomy is usually recommended for mild to moderate bunion deformities. During this procedure, your surgeon will make an incision over your big toe. The joint capsule is opened and the bunion is removed using a surgical saw. A V shaped cut is made on the metatarsal bone of your big toe, and the bones are moved to bring your toe into its normal anatomical position. Screws or pins are used to hold the bones in their new position until healing occurs. The mobility of your big toe is examined, and the capsule and wound are re-approximated with sutures.
  • Scarf Osteotomy: Scarf osteotomy is usually recommended for moderate to severe bunion deformities and is performed under general anesthesia, where you will be asleep during the entire procedure. Your surgeon will make an incision along your big toe and open up the joint capsule to expose the bump. The bump on your big toe is then removed using a bone saw. Your first metatarsal bone is then cut in a Z shape and realigned to correct the deformity. Your surgeon will fix the cut bone with pins or screws. The joint capsule and surgical wounds are then re-approximated using dissolvable sutures keeping your toe in a straight position.
• Repair of the Tendons and Ligaments: The soft tissues around the big toe may be tighter on one side and looser on the other creating an imbalance. This can result in drifting of the big toe towards the second toe. Your surgeon will shorten the loose tissue to tighten it and lengthen the tight tissues to loosen them. This procedure is often combined with an osteotomy.
• Arthrodesis: Involves surgical fusion of the damaged bones, followed by insertion of screws, wires, or plates to support the joint while healing. This procedure is used for severe bunions or bunions associated with arthritis. The big toe will have limited movement after the procedure but the bunion will not come back. This type of surgery is rare for bunions.
• Minimally Invasive Bunion Surgery: This is an X-ray guided procedure, in which, typically, a chevron osteotomy will be performed. The first metatarsal will be cut as in the chevron osteotomy and the base of the big toe may also be cut to realign it. The divided bones will be kept in place with special screws buried inside the bone. This type of surgery is best suited for milder bunions.

Risks and Complications of Bunion Surgery

As with any surgery, complications can occur. Apart from general complications related to all surgeries, complications after bunion surgery can include:

• Infection
• Recurrence of the bunion
• Nerve damage
• Unresolved pain

In rare cases, a second surgery may be necessary to correct the problems.

Postoperative Care

Patients should follow all instructions given by the orthopedic surgeon. Common postoperative instructions include:

• Keep your dressing dry
• Avoid bearing weight on the foot by using crunches for a few weeks
• Elevate the foot above heart level to minimize swelling
• Exercise and physical therapy are recommended for strengthening and restoring range of motion to the foot
• Eating a healthy diet and quitting smoking will help with healing