Most people with bunions find pain relief with simple treatments to reduce pressure on the big toe, such as wearing wider shoes or using pads in the shoes. However, if these measures do not relieve symptoms, the surgeon may recommend bunion surgery.
There are different types of surgeries to correct a bunion. Bringing the big toe back to its correct position may involve realigning bone, ligaments, tendons.
Who is a Candidate for Surgery?
If a bunion is not painful, surgery is not required. Although bunions often get bigger over time, doctors do not recommend surgery to prevent bunions from worsening. Many people can slow the progression of a bunion with proper shoes and other preventive care, and the bunion never causes pain or other problems.
It is also important to note that bunion surgery should not be done for cosmetic reasons. After surgery it is possible for ongoing pain to develop in the affected toe, even though there was no bunion pain prior to surgery.
Suitable candidates for bunion surgery commonly have:
- Significant foot pain that limits their everyday activities, including walking and wearing appropriate shoes.
- Difficulty walking more than a few blocks (even in athletic shoes) without significant pain.
- Chronic big toe inflammation and swelling that does not improve with rest or medications
- Toe deformity—an inward drift of the big toe toward the smaller toes, creating the potential for the toes to cross over each other.
- Toe stiffness—the inability to bend and straighten the big toe
- Failure to obtain pain relief with changes in footwear
- Failure to obtain pain relief from paracetamol and/or nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen. The effectiveness of NSAIDs in controlling toe pain varies greatly from person to person.
The common goals of most bunion surgeries include:
- Realigning the metatarsophalangeal (MTP) joint at the base of the big toe
- Relieving pain
- Correcting the deformity of the bones making up the toe and foot
Because bunions vary in shape and size, there are different surgical procedures performed to correct them. In most cases, bunion surgery includes correcting the alignment of the bone and repairing the soft tissues around the big toe.
The surgeon will discuss with patients the type of surgery best suited to their condition.
Repairing the Tendons and Ligaments Around the Big Toe
In some cases, the soft tissues around the big toe may be too tight on one side and too loose on the other. This creates an imbalance that causes the big toe to drift toward the other toes.
Surgery can shorten the loose tissues and lengthen the tight ones. This is rarely done without some type of alignment of the bone, called an osteotomy. In the majority of cases, soft tissue correction is just one part of the entire bunion corrective procedure.
In an osteotomy, the surgeon makes small cuts in the bones to realign the joint. After cutting the bone, these breaks are fixed with pins, screws, or plates. The bones are now straighter, and the joint is balanced.
Osteotomies may be performed in different places along the bone to correct the deformity. In some cases, in addition to cutting the bone, a small wedge of bone is removed to provide enough correction to straighten the toe.
As discussed above, osteotomies are normally performed in combination with soft tissue procedures, as both are often necessary to maintain the big toe alignment.
An arthrodesis involves removing the arthritic joint and fusing the bones together by means of screws or plates. Arthrodesis is commonly used for patients who have severe bunions or severe arthritis, and for patients who have had previous unsuccessful bunion surgery.
The x-ray on the left shows severe arthritis of the MTP joint. After arthrodesis (shown on the right), the entire foot is realigned. An advantage of arthrodesis is that there will not be any recurrence of the bunion.
In this procedure, the surgeon removes the bump from the toe joint. Exostectomy alone is seldom used to treat bunions because it does not realign the joint. Even when combined with soft tissue procedures, exostectomy rarely corrects the cause of the bunion.
Exostectomy is most often performed as one part of an entire corrective surgery that includes osteotomy, as well as soft-tissue procedures. If a surgeon performs exostectomy without osteotomy, however, the bunion deformity often returns.
As with any surgical procedure, there are risks associated with bunion surgery. These occur infrequently and are usually treatable. However in some cases they may limit, prevent or lengthen full recovery. Before surgery, the surgeon will discuss each of the risks with the patient and take specific measures to avoid complications.
The possible risks and complications of bunion surgery include:
- Nerve injury
- Failure to relieve pain
- Failure of the bone to fully heal
- Stiffness of the big toe joint
- Recurrence of the bunion
- Blood clots
Recovery at Home
The success of surgery will depend in large part on how well the patient follows the surgeon's instructions at home during the first few weeks after surgery.
Patients will be discharged from the hospital with bandages holding the toe in its corrected position. Keeping the toe in position is absolutely essential for successful healing It is therefore very important to follow the surgeon's directions about dressing care. Dressings should be left intact until the first post operative visit. Interfering with the dressing could cause a recurrence of the bunion. It is essential to keep the wound and dressing dry. When showering or bathing, the foot should be covered with a firmly taped plastic bag.
Sutures will be removed about 2 weeks after surgery, but the foot will require continued support from dressings or a brace for 6 to 12 weeks.
The surgeon will prescribe pain medication to relieve surgical discomfort. Some medications are opioids and can be addictive. It is important to use opioids only as directed by the surgeon.
As soon as pain begins to improve, patients are advised to stop taking opioids and take simple/over the counter pain relief as required. Patients are encouraged to contact the surgeon’s rooms if pain has not begun to improve within a few days of surgery.
Elevation of the foot for the first few days after surgery , and the application of ice as recommended by the surgeon will assist in relieving swelling and pain. Ice should not be placed directly on the skin. Swelling of the foot is common for six months after bunion surgery.
The surgeon will give strict instructions about whether and when weight can be placed on the foot. Premature weight bearing can cause the bones to shift and the bunion correction can be lost. Adherence to the surgeons instructions is essential to avoid this occurring.
Some bunion procedures allow weight bearing immediately after the surgery. In these cases, patients must use a special surgical shoe to protect the bunion correction.
Many bunion surgeries require a period of no weight bearing to ensure bone healing. The surgeon will apply dressings, a brace or a cast to maintain the correct bone position. Crutches are usually used to avoid putting any weight on the foot. A newer device called a knee walker is a good alternative to crutches. It has four wheels and functions like a scooter. Instead of standing, the knee is placed on a padded cushion and the patient pushes along using the healthy foot.
In addition to no weight bearing, driving may be restricted until the bones have healed properly — particularly if the surgery is performed on the right foot.
No matter what type of bunion surgery is performed it is very important to follow the surgeon's instructions about weight bearing. Do not put weight on the foot or stop using supportive devices until the surgeon gives approval.
It will take several months for the bones to fully heal. When the initial rehabilitation has been completed the surgeon will advise on shoe wear. Athletic shoes or soft leather oxford type shoes will best protect the bunion correction until the bones have completely healed.
To help prevent the bunion from recurring, fashion shoes must not be worn until the surgeon allows it. Be aware that the surgeon may recommend that wearing high-heeled shoes may no no longer be possible.
Though uncommon, complications can occur following bunion surgery. During recovery at home, contact the surgeon if:
- The dressing loosens, comes off, or gets wet.
- The dressing is moistened with blood or drainage.
- The patient experiences side effects from postoperative medications.
Patients should contact the surgeon immediately if any of the following warning signs of infection occur:
- Persistent fever
- Shaking chills
- Persistent warmth or redness around the dressing
- Increased or persistent pain, especially a "sunburn" type pain
- Significant swelling in the calf above the treated foot or the onset of shortness of breath.
The majority of patients who undergo bunion surgery experience a reduction of foot pain, along with improvement in the alignment of the big toe. This makes shoe fitting easier and more comfortable. The length of recovery will depend upon the surgical procedures that were performed, and how well the patient has followed the surgeon's instructions.
Because a main cause of bunion deformity is a tight-fitting shoe, returning to that type of shoe can cause the bunion to return. Always follow the surgeon's recommendations for proper shoe fit.