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Introduction

A bunion is a painful swelling at the base of the big toe.  It occurs in people who have a wide forefoot. The big toe becomes angulated and points across the foot. The medical name for this is hallux valgus.

The protruding bone rubs on the inside of shoes, which is painful. In more severe cases, the big toe may cause overcrowding of the smaller toes, resulting in hammer-toe deformity, painful corns or pain underneath the ball of the foot.

 

 

What causes bunions?

The exact cause is unknown, but bunions run in families. They are more common in women. They can occur at any age, but tend to either be present in adolescence or develop later on in life. Wearing tight or high-heeled shoes makes bunions more painful, but may not be the cause of the problem. In some cases bunions are caused by arthritis.

 

Treatment options

Non-surgical

Wide fitting flat shoes will reduce the pain associated with a bunion. There are various splints, straps and pads available which may help reduce symptoms but they do not correct the problem.

 

Surgical

If a bunion is not painful, it is best to try and avoid surgery.  Doing an operation for purely cosmetic reasons is not recommended.

There are lots of different operations for bunions, but the most commonly used is known as the Scarf Akin osteotomy.

The first metatarsal bone is cut along its length in order to correct the angle and reduce the width of the foot. The bone is held with screws. The bunion is removed and the ligaments around the toe adjusted to prevent recurrence.

In most cases, a second bone cut is required to fully straighten the toe. A small wedge of bone is removed from the base of the toe.

If a hammer toe has developed, this can be corrected at the same time, by straightening the toe and holding it with a wire which is removed in clinic after six weeks.

How long does it take to recover?

It is important to appreciate that a bunion correction is a fairly major procedure. The two main weight bearing bones in the forefoot are cut and will have to heal. Just like healing a broken bone, this normally takes six to eight weeks. During this time your foot will be sore and swollen, especially if it is not properly elevated.

Until the bones are healed you must not bear weight through the front of your foot. The soft tissues take a further six weeks to heal fully. Most people have some swelling and aching for up to six months after the operation. This is a long time, and can be frustrating. Keeping the foot elevated as much as possible will help.

 

Do I have to stay in hospital?

In most cases, no. Most people go home the same day. Bunion surgery is usually done under a general anaesthetic (you will be asleep). When you wake up you will be seen by a physiotherapist who will help you walk safely. You will be given painkillers to take home. If you have pre-existing medical or mobility problems we may keep you in hospital overnight, but will discuss this with you before surgery.

 

Can I walk after surgery?

After the operation you will be sent home with a special sandal which allows you to support your weight through the heel. Although you can walk short distances to and from the bathroom, for example, for the first two weeks, the swelling and aching will be considerable and you should stay at home with your foot elevated. You can gradually build up your activity over the next few weeks, but you must keep the foot up as much as possible.

 

How can I minimise pain and swelling?

Swelling is common after bunion correction. Excessive swelling is painful, increases bleeding and wound healing problems or infection can result. You must keep the foot raised higher than your heart. This can be achieved by lying flat on a sofa with several pillows beneath your calf. At night, keep the foot on pillows at the end of the bed.

For the first two weeks your foot should be up almost constantly. Swelling can last up to six months, so you should keep your foot up as much as possible during this time.

 

When will I be seen in clinic?

After two weeks, we will check the wound in clinic. The stitches are dissolvable but the ends will be trimmed. If it is healing well, you can gradually increase your activity, but it is important to remain wearing the special sandal. Most of the time your foot should be elevated.

After six weeks the position and healing of the bone is checked with an x-ray. If this is satisfactory then you can walk in a normal shoe.

 

When can I go back to work?

This depends on the type of work you do. Most people need six weeks off work. After two weeks, if you have an office job and can sit with your foot up, you may feel able to return for short days. For jobs which require standing for long periods or wearing work boots it can take up to three months.

 

When can I drive?

You cannot drive for six weeks. When you return to driving, let your car insurance company know that you have had an operation.

 

What can go wrong?

Most patients undergo bunion surgery without problems. However, complications may occur in some cases and it is important to understand this before deciding to have an operation.

 

Complications of anaesthetic – the anaesthetic is brief, so complications are unusual. If you have concerns regarding the anaesthetic you should discuss them at the pre-assessment clinic. 

Infection  and wound healing problems – superficial infections may occur in up to 10% of cases. It is more common in diabetics or smokers. In severe cases the bone may become infected, requiring further surgery. The best way to avoid infection is to keep the foot elevated and keep the wound clean and dry until it has healed (around 10-14 days). You must stop smoking before surgery.

Nerve damage – a small nerve which gives sensation to the big toe runs over the bunion. It may have already been stretched or damaged. Around 5% of patients have a patch of numbness after surgery. This usually gets better with time. 

Blood clots – Deep venous thrombosis (DVT) or pulmonary embolism (PE) is very rare after bunion surgery. All patients are assessed for risk of blood clots and if necessary blood thinning medication can be given.  Let us know if you have previously had a blood clot or take the contraceptive pill or HRT. If you develop a swollen calf, breathing difficulty or chest pain after surgery, contact your GP or attend A&E. 

Pain and swelling – this is very common after foot surgery and may last for up to six months. The foot should be elevated to reduce swelling. This is most important in the first six weeks after the operation.  In 1-2% of patients chronic regional pain syndrome (CRPS) may develop. It generally improves with time but sometimes medications may be needed.

Stiffness – after surgery the big toe joint will be stiff. After six weeks you can start stretching the joint to get it moving. Occasionally physiotherapy is needed.

Non-union – the operation involves cutting the bones. Healing usually occurs within six to eight weeks, but sometimes this can be longer. Smokers and diabetics are most at risk. Very rarely the bone fails to heal and further surgery may be needed.

Malunion – sometimes the bone may heal in the wrong position. The risk is increased if you do not wear the protective sandal for the first six weeks. Malunion can result in persistent pain beneath the ball of the foot. This can usually be treated with an insole.  Sometimes further surgery is needed.

Recurrence – Rarely the bunion may recur. This is more common in very young people, men or in very severe cases. Although the objective is to allow you to wear normal footwear without pain, few people manage to get back into high heeled or pointed shoes.

 

Who should you contact if you have a problem after surgery?

 

You will have clinic appointments two and six weeks after the operation. It is often helpful to write any questions down beforehand so you don’t forget them.

 

If you have a problem at any other time, please contact Mr Willmott's secretary on:

 

(01424) 755470 ext 2011 for NHS patients

(01424) 834115 for private patients

 

In an emergency contact your GP

or attend the A&E department.