What is a bunion?
A bunion is a prominence over the inside part of the foot where the big toe joins the rest of the foot. Pressure on the prominence from shoes causes pain and swelling due to inflammation. The bunion occurs when the foot bone connecting to the big toe (the first metatarsal) moves gradually towards the opposite foot. This is called hallux valgus* deformity. This leads to the big toe being pushed towards the second toe (away from the opposite foot) so that the big toe points away from the other foot.
Other problems can develop with a bunion. For example the second toe may overlap the big toe causing a cross-over toe deformity. With shoe pressure, corns and calluses develop.
What is the cause?
There is no single cause of bunions. It most commonly runs in families but may skip generations. High heel, pointed toe shoes are not the primary cause of the hallux valgus but they do cause it to be painful. Pressure from shoes may cause bunions, corns and calluses to develop where there is hallux valgus deformity.
How are bunions treated?
Before treatment of a painful bunion can begin, medical evaluation is needed. There are a number of other causes of pain in the big toe such as osteoarthritis, rheumatoid arthritis, infection and gout. Circulatory problems not only cause pain, but may also cause serious complications if surgery is attempted. Diabetes and cigarette smoking may diminish healing potential and increase the risk of infection.
Treatment may be surgical or non-surgical. The goal of non-surgical treatment is to relieve pressure on the foot and to prevent pressure sores and foot ulcers. This is accomplished by prescribing accommodative shoes with a wide toe box - sandals or extra depth shoes with soft moulded insoles. It may also be possible to relax the leather on shoes to make room for a bunion.
Surgery can correct painful bunions. The severity of the bunion deformity and the presence of any associated problems (for example painful arthritis) will determine the type of surgery that is recommended. X-rays are necessary to help plan for surgery.
Keyhole Bunion Surgery
Traditional bunion surgery involves a long incision of 5cm on the outer aspect of the big toe and foot. There is also a smaller incision in the region of the first webspace between the big and 2nd toes.
In keyhole surgery there are several incisions of approximately 3mm. Very fine burrs which rotate at high speed are used to make tiny precise bone cuts to allow the surgeon to correct the bunion deformity with minimal damage to the surrounding tissue. This less invasive surgery results in less soft tissue damage during the operation. There is a very low risk of infection and the recovery is expected to be more predictable.
Once the big toe is in the corrected position, screws are implanted to fix the bone in this position. The screws are designed to stay within the bone without causing pain or being palpable.
How long will my hospital stay be?
Patients are admitted to hospital on the day of surgery and meet the anaesthetist prior to surgery. The anaesthetist will discuss the anaesthetic involved. This may take the form of a general anaesthetic with an ankle block. The ankle block is the application of local anaesthetic around the ankle, which may provide pain relief in the foot and ankle for up to 12 hours after the operation.
In general, if a person has surgery on one foot then they stay in hospital for one to two nights and if they have bunion correction on both feet then they would stay in hospital for two to three nights.
What dressing will be used?
Following the operation a bulky dressing is applied around the foot. This should remain in place for approximately 2 weeks. It is important to keep the dressing dry to reduce the risk of post-surgical infection.
Will I experience post-operative pain?
The local anaesthetic block wears off approximately 6 to12 hours after the surgery. Some patients notice an increase in pain at this time, however when pain occurs, tablets generally provide sufficient pain relief. Rest, elevation of the foot/feet and pain medication are all helpful in relieving the pain for the first few days after the surgery.
The pain tends to be worse in the first 3-4 days after surgery. Minimising the time on one’s feet in the first week after leaving hospital helps recovery. Too high an activity level soon after surgery can prolong the recovery time and cause unnecessary setbacks.
Will I require rehabilitation?
The patient may fully weight bear on their feet with the aid of crutches after the surgery. In general, crutches may need to be used for 7-14 days after the surgery. Some patients find that they are comfortable earlier than this and can discard their crutches at that stage.
A postop shoe (a stiff soled sandal) is fitted after the operation. This needs to be worn for 2 weeks after the operation.
Week two to six: you will wear a pair of sneakers. You may wear ordinary shoes at the end of week six after surgery. By six months: you should be able to resume all normal activities without pain or discomfort
When can I return to normal activites?
- Sedentary work: 2-3 weeks depending on transport to work and ability to elevate foot at work.
- Physical work: 2-3 months depending on the nature of work involved.
- Driving: This will vary depending on whether you drive an automatic or manual car and whether the surgery is to the right foot. Surgery to the right foot may mean not being able to drive for 2-6 weeks. If the surgery is to the left foot and the person drives an automatic car then they may be able to return to driving within 2 weeks.
- Exercise: bike after 4 weeks and swim between 4-6 weeks. They may not be able to do running/jumping sports for 3 months.
Written by Dr Peter Lam, orthopaedic specialist