What Causes a Bunion?

Bunions are largely genetic though they can be exacerbated and accelerated by wearing improper shoes. They can often be traced to an instability at the base of the first metatarsal as it articulates with the midfoot. The angle between the first and second metatarsal widens and the bunion area becomes more prominent medially, at the inside of the foot. The big toe usually begins to drift into an opposite or laterally deviated position (toward the 2^nd toe). Shoes with a tight and narrow toe box can create or make a bunion worse over time. People with a flattening arch have a higher probability to develop a bunion deformity.

Moderate bunion deformity	An elevated bunion decofmrity is a common finding associated with callus under ball of foot

Do Bunions Hurt?

Bunions come in all shapes and sizes and symptoms vary. Bunions can be painless, and when they are surgical treatment is generally not recommended. In most cases however, bunions usually become a painful condition. They make shoe fitting difficult and rubbing in shoes causes local inflammation, bursitis, swelling, and pain. The bone can become bruised and inflamed and bone cysts are common in this area. As bunions get worse over time, because there is a misalignment of the big toe joint, premature arthritis can begin to develop. This will cause a deeper pain in the big toe joint and makes successful treatment more extensive and difficult. This is the reason why earlier treatment is often easier and more successful because underlying adaptive and arthritic changes have not formed.

Left Foot: Status post bunion surgery	Right Foot: Awaiting bunion surgery

How Are Bunions Evaluated?

Though bunions are a local foot problem a thorough review of each patient is necessary to appreciate contributing factors such as medical history, family history, career and life activities, shoe preferences, daily shoe requirements, physical activity and previous injuries etc. This is followed by a clinical examination of the foot, ankle, and leg to appreciate the whole picture and understand the biomechanics of the lower extremity. Range of motion is evaluated in the big toe joint as well as the surrounding joints. Gait analysis is often observed as well. Joint motion, including the flexibility and reducibility of the bunion is important to understand how the bunion may respond to treatment.

Imaging of bunions usually just requires x-rays; they are important to evaluate the level of deformity, determine sesamoid position, measure angles, and to assess the integrity of the big toe joint. Bunions can only be appropriately evaluated on x-ray with weight-bearing x-rays; this is when the patient is standing in a normal stance position with weight loaded equally on both feet. If x-rays are taken without bearing weight on the foot a physician cannot fully appreciate the level of deformity of a bunion. It is a dynamic area of the foot and should be assessed in it’s full weight bearing glory.

Pre operative clinical evaluation of bunion under riding 2nd toe prior to surgery.	Weight bearing evaluation of same bunion seen on left post surgery. Not hidden incision and corected 2nd toe.

Surgical Treatment for Bunions

At some point surgery may be recommended to correct bunion deformities. This is usually when it becomes painful on a regular basis, affects shoe choice, and when the discomfort limits activities. Surgery is usually discouraged if there is no pain and if cosmesis is the main driving force.

General goals for surgical treatment of bunions are:

• Reduction in pain
• Long-term correction of the deformity
• Return to full function and activity

Surgical Procedures for Bunions

Because bunions come in all shapes and sizes there are a myriad of procedures with a range of indications. Surgical procedures for the painful bunion are outlined below as well as the general indications for that type of procedure.

• Simple “bumpectomy”: this is indicated for mild bunions with a small deformity. This is generally not the best long-term choice for a younger individual. Recovery is rapid and often allows a return to a tennis shoe within 2-3 weeks.
• Tightrope bunionectomy: this is a newer advanced surgical technique that involves an internally placed suture that provides bone realignment and support in a corrected position. This often avoids a bone cut and has become a popular option for the right foot type/bunion.

• Classic Chevron osteotomy: this is probably the most popular bunion surgery that is performed. It’s v-shape is stable, allows for bone correction, and modifications of the classic chevron cut can be done to allow for joint realignment and increased stability. Fixation choices vary; at UFAI typically, a double screw fixation construct is chosen because it allows for stable fixation allowing for earlier weight bearing and range of motion. Weight bearing is allowed right away protected in a walking boot.
• Reverdin type osteotomy: this procedure allows for strong realignment correction of the joint and is used for a certain type of bunion. It is usually fixated with a single screw.
• Akin phalangeal osteotomy: this procedure is a wedge correction at the base of the big toe to correct an angulated big toe. It is often done in combination with a corrective procedure of the metatarsal and bunion area.
• Metatarsal shaft procedures (SCARF): this procedure is popular internationally and allows for strong correction of a higher intermetatarsal angle. It can be fixated with multiple screws or a plate. It has an advantage because it can be used to precisely adjust for any necessary lengthening or shortening of the first metatarsal.
• Base wedge osteotomy: this procedure can be used to correct more severe types of bunions with higher intermetatarsal angles. There are some disadvantages to this procedure such as greater shortening of the metatarsal (closing wedge) or the need to heal a bone graft (opening wedge). It also has a higher tendency to elevation of the first metatarsal which is a negative position that leads to complications at the big toe joint. This is not a common procedure of choice at UFAI; in our opinion a similar foot type that needs this strong correction is better treated with the Lapidus type procedure.
• Lapidus procedure (wedge corrective fusion of the 1^st metatarsal cuneiform joint): this allows for a powerful correction of the more severe bunion types and is especially indicated in younger individuals where long-term correction is required. It allows for stabilization of a flexible flatfoot, and provides strong correction at the root source of many bunions which is instability at the midfoot.

• Joint replacement (have limited application, but with severe arthritis, may be considered): joint replacement can be used for correction of a mild bunion deformity with severe arthritis in the big toe joint. Successful big toe joint replacement has not been well supported in the medical literature; this procedure should be carefully selected and reserved for special cases. If chosen wisely it can be a nice procedure for the correct foot.
• Keller bunionectomy: this is an old procedure that is usually reserved for an older individual with severe arthritis of the big toe joint. It involves removal of the bone at the base of the toe often with soft tissue interposed in the joint to cushion and act as a spacer. It is a less common procedure at UFAI.
• Joint fusion: for severe bunion deformities combined with significant instability of the big toe joint or combined with severe arthritis, fusion of the big toe joint can be a predictable slam-dunk correction. It’s downside is slower healing time, loss of range of motion, and the need for a period of non weight bearing.

Surgery has become more refined over the years. With most procedures advanced surgical techniques can be applied to allow for earlier weight bearing range of motion, and a quicker return to full activity. University Foot & Ankle Institute is a leader in advanced surgical techniques and procedures to correct bunion deformities. Because bunions come in all shapes and sizes the approach to surgical correction must be malleable to each particular patient and each bunion deformity. There is not a “one-size fits all” bunion surgery. Bunion surgery should be chosen to gain a long-term, lasting correction of the deformity. The surgeons at the University Foot & Ankle Institute use strategies to gain a rapid return to function and activity, reduce pain and swelling, and achieve excellent long term results.

What is typical recovery time for bunion surgery?

While this obviously depends on the procedure performed, some basic principles can be summarized. Many people can return to work within 3-5 days following a corrective bunion surgery, protected in a pneumatic compression walking boot.

Quickest Healing Time

Simple “bumpectomies” and Keller procedures allow for a very quick recovery period. A return to a normal shoe can be achieved as quickly as 2-3 weeks following surgery.

Standard Healing Time

Most bunion surgeries fall into this category and require a 10-14 day period of keeping the foot dry and bandaged. Protected weight bearing in a boot is usually permitted right away. Crutches are usually not needed. Transition out of the boot and back into a regular shoe is usually about 4 weeks after surgery.

Longer Healing Time

The Lapidus procedure, base wedge osteotomies, or joint fusions require a period of “non weight-bearing”, where crutches, a scooter, or wheelchair are needed. This period of staying off the foot usually lasts for 4-6 weeks. Improved fixation and fusion techniques utilized by the surgeons at University Foot & Ankle Institute have shortened recovery time and are decreasing the total time on crutches.

Important Note: we strongly encourage patients to NOT compromise on the correct procedure by choosing one that allows a quicker recovery.

How can we achieve excellent bunion surgery outcomes?

The surgeons at the University Foot & Ankle Institute are dedicated to optimal outcomes with corrective bunion surgery. Excellent outcomes can be achieved through adherence to the following principles:

• Choice of the appropriate procedure for the individual patient (**there is not a “one size fits all” procedure).
• Excellent surgical technique in carrying out the procedure
• Advanced fixation and fusion techniques
• Plastic surgery suturing techniques to minimize scarring
• Adequate healing time and limited activity for the prescribed time frame
• Early range of motion
• Physical therapy and rehab

What if I had bunion surgery and it didn’t work?

Bunions are a dynamic area of the foot. Appropriate surgical correction usually requires bone realignment, joint repositioning, and soft tissue balancing of the tendons and joint capsule and ligaments. If a bunion surgery was unsuccessful, revision surgery should be carefully planned and studied out. The surgeons at the University Foot & Ankle Institute are trained and prepared to perform revision bunion surgeries. Revision surgery is always more complex and requires appropriate planning and understanding of what went wrong with the initial procedure. We welcome difficult revision cases and often work together in determining the best approach to gain a satisfactory outcome.

The University Foot & Ankle Institute Advantage

The University Foot & Ankle Institute is a renowned center for corrective bunion surgery, from the simple to the more complex, multiple-procedure revision cases. We are involved in research and journal publications on bunion surgery, and aim to stay at the forefront of advanced surgical techniques.

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