There is really no conservative treatment for a bunion deformity other than shoe modification, padding, steroid injections, anti-inflammatories and orthotics. These treatments may alleviate the pain in the short term, but they probably will not help in the long term. If a person has a bunion deformity that is painful and cosmetically unappealing, then bunion surgery is warranted.
All patients who undergo bunion surgery should expect that orthotic usage and proper shoe gear will make their surgery more successful in the long term. There are risks involved with surgery, but thankfully fewer than 10 percent of patients ever experience complications.
When Is Bunion Surgery Appropriate?
Many podiatric surgeons believe there are certain criteria a patient should meet before surgery is deemed appropriate. These criteria include the following:
- You have been diagnosed with a bunion
- All conservative treatment methods have been exhausted and have provided no relief
- The bunion interferes with your daily activities
- Pain in the joint
- Chronic swelling of the big toe that does not improve with medication
- Toe deformities
- Toe stiffness or the inability to bend or straighten the big toe
- Pain relief options are not effective
- Swelling does not abate with anti-inflammatory medication
Unfortunately, the bunion may cause pain for long time while conservative treatment options are tried. Custom-made orthotics may take up to two weeks to be available for use. Padding, inserts, and other types of commercial products do not always relieve the pain effectively. You should speak with your podiatric surgeon and set up a timeline or treatment plan to explore all conservative options before considering surgery to treat your bunion.
Preparing for Bunion Surgery
If you elect to have bunion surgery, you will need to do certain things in order to prepare for the procedure. Your doctor may want you to complete a physical exam with your family physician to assess your health. Patients who have been diagnosed with heart or lung conditions or other chronic conditions may need to get preoperative medical clearance from their family physicians. Tests that may be performed to assess your health include:
- Blood samples
- Chest x-ray
- Urine sample
- Special foot x-rays
These tests also enable the podiatric surgeon who will be performing the bunion surgery to plan your procedure accordingly.
The Bunion Surgery Procedure
Most patients are required to arrive at the doctor’s office an hour or two before the surgery. Once admitted, an anesthesiologist will evaluate the patient and administer IV sedation if he feels it is necessary. The surgeon himself administers the numbing agents to the area of the foot where the surgery is to be performed.
It is important to know that there are numerous ways to perform bunion surgery, and the best option for you is not always the best option for another person. There are two categories of bunion surgery: head procedures and base procedures. Head procedures take place around the great toe joint, while base procedures take place near or at the metatarsal-cuneiform joint, which is behind the great toe joint.
During a head procedure, the doctor will cut the bone to move the head of the metatarsal, correcting the bunion. Internal pins and or screws are used to hold the bone in place. Head procedures are usually used in mild to moderate cases, or for people who cannot remain inactive for an extended period.
During a base procedure, the doctor will cut a semi-circular wedge out of the bone, rotating the bone to realign the great toe. The bone cut is then held in place with screws and/or plates. Sometimes, the metatarsal-cuneiform joint is fused as well, but only in cases in which certain criteria are met to indicate this fusion. These procedures are usually used in moderate to severe cases.
All bunion surgery includes soft-tissue work at the great toe joint and various levels of bone work. The type of surgery performed depends on the severity of the bunion, the type of foot the patient has, the patient’s age and activity level, whether the patient has other health issues that may affect healing, patient compliance, and other factors.
It should be noted that there are two types of bunions. A medial bunion is on the side of the foot, and a dorsal bunion is on top of the toe joint. These two types of bunions have different causes and they are treated differently. Podiatric surgeons may combine various procedures to achieve the optimum result for the patient. The podiatric surgeon should explain each procedure, and it is important that the patient listen to the surgeon while the procedure is being explained. The surgery that may have been performed on your friend or family member may not be the same surgery your doctor has in mind for you.
Othertypes of bunion surgeries and adjunct procedures include:
Arthrodesis: This procedure involves removing damaged joint surfaces, and the bone is fused with internal fixation devices. This procedure is generally used on patients who have severe dorsal bunions or arthritis, or when other types of bunion surgery fail
Repairing Tendons and Ligaments: This usually takes place around the big toe when the patient has a medial bunion caused by excessively tight tissues on one side of the joint. This creates an imbalance that causes the big toe to drift toward the others. This procedure involves shortening loose tissues around the joint, and is typically combined with an osteotomy (when the bone is cut to shorten, lengthen or change its alignment). This procedure is always performed in bunion surgery, whether bone work is performed or not. The level at which this procedure is performed again depends on the severity of the patient’s bunion.
Exostectomy/cheilectomy: This procedure is used if the bunion is located on the toe joint—that is, if it is a dorsal bunion. The bump is removed to allow the great toe to extend without hitting the bump on top of the joint, which limits motion and causes pain. Exostectomies are rarely used to remove medial bunions because they do not correct the positional cause of the bunion.
Resection Arthroplasty: This procedure involves creating an increase in joint space by removing the damaged portion of the joint. This procedure is mainly used on older patients, those with severe arthritis, or those who have previously had unsuccessful bunion surgery. Typically, surgery takes about one hour, and patients are able to go home within two hours afterwards.
After Bunion Surgery
Once the procedure is over the recovery process will begin. Your recovery time will depend on the procedure you received, the type of fixation utilized, and other patient factors. For a head procedure, it is recommended that you avoid any vigorous exercise for up to six weeks after surgery. The patient is ambulatory after surgery and must wear a surgical shoe during the healing process. This is to protect the foot and to reduce the amount of weight applied to it. Patients who undergo a base procedure walk with crutches for six to eight weeks and wear a walking cast. If the patient undergoes a fusion, he or she will be on crutches for six to eight weeks.
After the cast has been removed and the crutches have been discarded, some patients will adjust more quickly than others as they go from protected ambulation to wearing regular shoes and resuming their regular routines. It can take up to six months for the cut bone to fully heal, and patients may continue to have swelling in the area of the surgery for up to six months. This is normal. The stitches used to close the incision are removed about ten days after surgery.
Here are some more basic rules to speed your recovery after bunion surgery:
- Always keep your foot elevated for a minimum of one week after surgery.
- Keep your foot dry for at least two weeks after surgery while the stitches are in.
- Never change the dressing after surgery, this should be left to the podiatric surgeon.
- The podiatric surgeon will remove the stitches within two weeks after surgery
Your doctor may give you a lasting anesthetic for the drive home and the remainder of the day. You will probably not be allowed to drive home after bunion surgery, even with a local anesthetic. If you have undergone surgery on your left foot, you should be able to drive within four days after surgery if your car has an automatic transmission rather than a stick shift. If you have undergone surgery on your right foot, however, you may not be allowed to drive until your doctor feels you are ready. You will also be given medication to ease the pain for the weeks to come. Antibiotics are not usually necessary. Try your best to limit your activities, and prepare accordingly by canceling all appointments and duties for at least six weeks after bunion surgery is performed. Talk with your doctor about when you will be allowed to resume your normal activities.
Once you are at home, you may be able to use a cold pack or ice to reduce pain. You should never use a heating pad. You should be able to shower normally as long as you are careful not to get the foot wet. You are not to wash the incision until after the stitches are removed. You should keep the bandage dry after surgery, and you should never change or alter the dressing unless instructed to do so by the podiatric surgeon. If your bandage becomes wet or bleeds through, you will need to return to the surgeon’s office immediately.
Risks of Bunion Surgery
Like most surgeries, bunion surgery is not without the risk of complications. Patients who are at greater risk include those who:
- Have poor nutrition
- Have recently been ill
- Abuse alcohol
- Have diabetes
- Have vascular disease
- Use certain drugs
Possible complications that can occur after surgery include:
- Recurrence of the bunion
- Nerve damage
- Continued pain
- Excessive bleeding
- Slow healing
Unfortunately, some people are prone to bunions, and for these people surgery will only solve the problem for a while. Patients who suffer from bunions should wear proper shoes and custom-made orthotics whether they have bunion surgery or not. This will help to inhibit the recurrence of bunions after surgery. If the patient does not follow the doctor’s surgery after-care instructions, he or she may experience complications such as infections or continuous pain.
Surgeries sometimes go wrong and cause additional problems such as nerve damage. It is important to understand that although these risks are real, fewer than 10 percent of patients experience these complications. It is also important to understand that different patients will undergo different surgical procedures and will experience different results. You should not rely on a friend’s or family member’s surgical experience to predict your own outcome. You should seek an experienced podiatric surgeon with whom you feel comfortable and whom you trust. Additionally, the result the patient sees in the end may not be what they have imagined, even if it is a good surgical result. For these and other reasons, bunion surgery should only be performed on patients who are in pain or are limited by deformity. This procedure is not recommended nor should it be performed merely for cosmetic reasons.
Talking to Your Doctor
Here are some questions you may or may not want to ask your doctor about bunion surgery:
- When will I be able to return to work/school?
- What symptoms will appear if an infection is present?
- Do I need to change my diet during my recovery?
- I have an old pair of crutches in my garage. Can I use those?
- If the bunion returns, will we have to do the surgery again?