Bunion Surgery (Hallux Valgus Surgery) Procedure Guide

A bunion is a bony bump protruding from the base of the big toe away from the foot. The big toe bends towards the neighbouring toes, and it rotates away from them (so the nail faces the opposite foot). The foot also widens to meet the protrusion. In severe cases, the big toe can become so bent that it crosses over or under the neighbouring toe. It is a progressive disease and worsens with time, and the only way to remove a bunion is through surgery.

It’s common to hear a bunion called hallux valgus. Hallux is the name of the big toe, and valgus means to point towards the vertical midline of the body. If a bunion forms on the little toe, it is called a bunionette or Tailor’s toe.

Symptoms

Symptoms from the deformity are most noticeable when patients are wearing shoes, but in more severe cases, they can also be felt at rest.
Many patients will experience the following symptoms, which get progressively worse if not treated:

• Pain and soreness
• Burning sensation
• Inflammation
• Numbness
• Hard skin on the bottom of the foot
• Callous or corn on the bunion
• Difficulty walking

What causes bunions?

Bunions are commonly believed to be caused by wearing tight, pointed shoes, but many orthopaedic surgeons think it is actually due to a structural deformity in the foot that causes a bunion to form over time. This deformity is most likely inherited genetically and so bunions often run in families. The pressure on the foot and toes when wearing tight, pointed shoes can speed up bunion formation.

Bunions in more depth

The bones in the big toe are called the phalanges bones, and the large foot bone connecting to it is called the 1st metatarsal bone. These two bones meet at a joint in the base of the big toe, the metatarsophalangeal joint (MTP joint). Pressure exerted on the big toe towards the neighbouring toes causes the phalanges bones to realign and bend at an angle. This also causes the 1st metatarsal bone to drift away from the 2nd metatarsal bone and rotate. Patients often mistake the bony protrusion as extra bone growth, but it is actually the MTP joint moved outwards, and the head of the 1st metatarsal bone rotated (this head would unusually be on where the ball of the foot is).

Symptoms such as pain and a burning sensation are more sharply felt because of a small fluid-filled sac next to the MTP joint called a bursa. Bursas are found at many different joints in the body, and they are there to cushion the joint and help reduce friction between the muscles as they move. Trauma and repeated pressure against the bursa can cause inflammation. As a result, the area will become more sensitive to pain and soreness when applying pressure. If they are very inflamed, they can make the bunion even larger.

What does surgery aim to achieve?

The aim of surgery is tailored to each patient, and the orthopaedic surgeon will discuss the achievable goals with the patient prior to surgery. Hallux valgus surgery will generally include:

• Realigning and straightening the big toe and foot bones
• Remove the bony protrusion
• Improve symptoms and be able to return to everyday life

The goal of surgery is the removal of the bunion, not treating the cause. There is no cure for this, and preventative measures are critical to helping prevent reoccurrence.

As the severity of bunions and the surgical technique needed can differ from patient to patient, it is not possible to give an exact quote without being assessed first. Other factors that can influence the cost include the number of follow-up appointments, if physiotherapy is included/needed, the type of anaesthesia used, and how many scans are required.

Prices are usually between £4000 to £7500.

Which patients are suitable for bunion surgery?

Surgery is not the best option for all patients. Surgery is normally only recommended after non-surgical treatments have been tried first and when symptoms are severe enough to affect patients’ daily lives. Surgery is only offered to patients when their bunions negatively affect their daily lives. It should not be performed for purely cosmetic reasons.

In cases where symptoms are very severe, surgery may be offered before exhausting non-surgical treatments.

Typical symptoms to warrant surgical intervention include:

• Severe or constant pain when walking in sensible shoes
• Unable to fit into sensible shoes due to deformity
• Big toe crossing the neighbouring toe or toes (or close)
• Long term inflammation and swelling when resting (even if taking medication)

Non-surgical methods

Non-surgical treatments can be used to help delay bunion progression and alleviate symptoms. These include:

• Changing footwear to have a larger space for toes
• Paddings such as corn plasters or pads over the bunion in sore spots
• Insoles to correct flat feet and provide arches
• Avoiding activities that aggravate the bunion
• Anti-inflammatory medication such as NSAIDs (not appropriate for all patients)
• Corticosteroid injection(s). These are rarely used but may sometimes be recommended to alleviate inflamed bursa padding the MTP joint.

Braces, splints and toe separators are sometimes offered in more mild cases, but the effects are often short-lived.

Before being offered surgery, patients may also benefit from treating underlying health conditions to relieve some symptoms and slow progression. Conditions that have been linked to bunions include:

• Rheumatoid arthritis
  • Inflammation of the toe joint can lead to erosion and is more likely to form a bunion
• Gout
• Psoriatic arthritis

The procedure

Bunions can be removed using various surgical techniques. The orthopaedic surgeon will suggest techniques that best suit a patient's individual needs.

General description of the techniques
Following a cut near the base of the big toe, small cuts are made into the bones to realign them into their correct position. Pins and screws are used to fix the bones into position (these are usually left in place). The bony protrusion is also shaved down at the same time. The operation is often performed under a general anaesthetic (so patients are not awake), and most patients go home the same day.

Surgical techniques in more depth:

An incision can be made from the base of the big toe near the metatarsophalangeal joint (MTP) and runs along the 1st metatarsal bone. It can stretch to around midway up the foot or be smaller depending on how much access the surgeon needs. The incision could be on top or on the side of the foot; this can sometimes be called the traditional method. This method is more frequently used for patients requiring severe correction. For less severe corrections, the surgeon may make a smaller incision on the base of the toe.

There is a less frequently used technique known as minimally invasive surgery. This procedure is performed under the guidance of an X-ray. It involves making an incision into the base of the big toe or, in some cases, an incision further up the foot. This method has been associated with an increase in complications and so is less likely to be recommended.

The bony lump of the bunion is shaved down, and soft tissue (including tendons and ligaments) around the joint is rebalanced. Most patients are likely to have an osteotomy (cutting of bone) on the 1st metatarsal bone of the foot to realign it into its correct position, closer to the 2nd metatarsal bone. There are two different methods for an osteotomy:

Transposition osteotomy

A segment of the 1st metatarsal bone is cut and is slid across to be closer to the 2nd metatarsal bone. This brings the joint into better alignment. The placement of the cut into the bone depends on the degree of correction needed; for greater correction, the cut is made further up the foot.
The new position is held by screwing the new bone segment to the unmoved segment. The pins and screws used for this are often left and do not need to be removed. This is more suitable for less severe bunions. Names belonging to this type of surgery are, Scarf and Capital surgery; they differ in how the surgeon cuts and separates the bone.

Rotation osteotomy

In this surgery, a small wedge is cut out high up in 1st metatarsal bone. The lower part of the bone can then be rotated and moved into alignment with the 2nd metatarsal bone; this also pulls the MTP joint into a better position. Pins and screws are used to the bone to fix it to its new position. These can be left in place. This surgical procedure is often called Lapidus surgery and is usually used for more severe bunion correction.

Akin surgery

Similar to rotation surgery, a small wedge can be cut into one of the big toe bones and rotated into better alignment. Pins are screwed into the bone to fix it to its new position. This is used when the big toe is particularly bent. Although it can be performed on its own, it is usually done in combination with rotation or transpositional surgery when needed.

Other techniques

Although less common, in certain cases of severe arthritis, arthrodesis surgery may be recommended. For this, the surfaces of arthritic bones may be removed and screws, wires or plates fix the bones into a new, straightened position.

For patients with badly damaged MTP joints, the joint can be removed, and a new flexible ‘scar joint’ can be made.

Anaesthetic choice

Most patients will have a general anaesthetic for the surgery, meaning they will not be conscious and awake during the operation. Usually, patients go home the same day as surgery, but sometimes the surgeon may recommend a one night stay. A local anaesthetic may also be injected into the foot to help with pain immediately after surgery.

Regional or spinal anaesthesia may be used instead of general anaesthesia. This involves numbing different parts of the body, including the foot, but patients remain conscious.
In minor bunion surgery, a local anaesthetic can be injected into the area to numb it; this is sometimes combined with intravenous sedation to help relax the patient.

What will happen at an initial consultation with an orthopaedic surgeon?

The orthopaedic surgeon will assess the foot and ask patients to describe their symptoms and how it affects their life. An X-ray of the foot will also be performed on the day if one has not been taken recently.

Patients will not necessarily be recommended surgery initially, and non-surgical treatments may be advised. If this is the case, a comprehensive plan will be given. If surgery is considered the best option, the surgeon will discuss how the surgery will be performed, including the techniques, anaesthetic to be used, aftercare planned and, the risks and complications.

Taking a full list of medications is helpful as the surgeon will give advice if any need to be stopped before surgery. Any questions the patient has will be answered.

How best to prepare for surgery

It’s good to be prepared before surgery as it may improve outcomes and help aid recovery. Surgeons will give specific advice to patients before having surgery, but some general guidance is likely to include:

General foot care and hygiene

• Keeping the foot clean, including cleaning between toes every day
• Treat any infections such as athlete’s foot
• Avoid activities that make ulcers more prone to happen ( this can delay surgery)

General health

• Stop smoking
  • This is shown to slow the healing of soft tissue and bones.
• Weight-loss
  • For patients that are overweight, weight loss will help reduce pressure on the foot

Prepare the home

• Patients will need to have their foot raised for a few weeks following surgery; having extra pillows for lying down or having a footstool will help
• Considering the best way to wash
  • The bandages will not be able to get wet for a few weeks following surgery. It is best to discuss with the surgeon or nurse how best to wash, sometimes waterproof bags can be recommended to protect the foot from splashes
• Stock up on groceries
• Mobility will be affected, especially in the first few weeks; having everything needed such as cooking appliances in easy to reach places will help
• Moving any unnecessary appointments (such as hairdressers)

Aftercare

The exact timeframes are different from patient to patient and are very dependent on the type of hallux valgus surgery performed. It is important to follow the surgeon’s and post-op team’s advice. Some general points are bullet-pointed here, and a more detailed timeframe can be found below.

General points

• Foot pain for a few days to a week
• Crutches are needed up to six weeks
• Returning to office work after six weeks (working from home potentially sooner)
• Returning to manual work after three months
• Leisurely walking after three months
• Return fully to normal activities around six months

First 2 weeks

Following surgery, patients will have a dressing applied to the wound and a tight bandage wrapped around the foot. Most patients are discharged the same day as their operation, but sometimes an overnight stay is needed. It’s likely that crutches will be given, and sometimes, a special orthopaedic shoe may need to be worn. This shoe redistributes pressure from the toes to the heel. Patients will be shown how to use these before discharge.

Pain and swelling in the foot are normal following surgery, and the surgeon will prescribe pain relief; how long these are needed vary from patient to patient, but more than a few weeks is not typical.

For the first few weeks, patients are encouraged to keep walking to a minimum and keep the foot elevated when resting to prevent swelling. Excessive weight onto the foot, especially early into recovery, can move the bones out of their new position.

A follow-up appointment usually happens between 7 to 14 days following surgery. The patient’s surgeon or post-op nurse will examine the foot, remove bandages and stitches (if not dissolvable stitches), and patients are likely to have an X-ray to ensure everything is healing well. A new foot brace/ splint will be fitted to hold the toe position in place.

Weeks 2 to 6

Gentle toe exercises for home are likely to be given to the patient, and with the brace/ splint, patients may start walking again on the heel of the foot and find they are much more mobile. Many patients may return to light desk work at home, but returning to the office might take up to six weeks following another follow-up appointment. In this six week follow-up, an X-ray is taken, and the brace/splint is removed.

6 weeks to 6 months

Patients may be advised from about six to eight weeks that they may return to driving. Following the exercise program and any physiotherapy is important to help prevent stiffness and improve movement. Patients with manual jobs may look to return to work around three months, but patients should seek advice from their post-op team before doing so. Recreational walking and light sports may be restarted from months three to six (some patients may start earlier), but six months following surgery is a typical goal for many patients to return to full normal activities.

6 to 12 months

Most of the swelling and function is likely to be normal around six months, but it can take up to a year for everything to settle down. It’s important for patients to bear in mind that the foot and toe may not be 100% perfect the toes may feel stiffer or weaker than before surgery and not be perfectly straight.

Risks and Complications

Hallux valgus surgery is not considered minor surgery, and it is important that patients understand the risks and complications and discuss them with their surgeon.

• Infection
• Blood clots in the legs or lungs
• Damage to nerves in the foot
  • Can lead to tingling sensation, numbness or pain
• Overcorrection of the bunion
  • The toe may point too far in the opposite direction
• Bones not healing correctly
• Prominent pins
  • A later surgery can be performed to remove them if this occurs
• Stiffness in the big toe
• Weight transfer to the 2nd toe
  • May cause corn to form on the toe
• Failure to treat pain
• Delayed healing and swelling
• The bunion may come back

Many of the risks and complications below can be minimised by following the surgeon’s post-operative advice.

All of the information found on our website is sourced from highly reputable experts, government-approved authorities and is widely used by healthcare professionals.

• American Academy of Orthopaedic Surgeons https://orthoinfo.aaos.org/en/treatment/bunion-surgery/
• NHS:https://www.nhs.uk/conditions/bunions/
• NHS:https://www.wsh.nhs.uk
• NHS: https://www.wyevalley.nhs.uk
• British Orthopaedic Foot and Ankle Association https://www.bofas.org.uk
• NHS: https://www.roh.nhs.uk

Our content is written by our Medical Quality Managers and Patient Care Advisers, all of who have medical backgrounds and training. Before publishing, all the information is reviewed by a surgeon specialised within the relevant field.