How many times will a patient come into my office almost paralyzed with fear when talking about their bunion pain? Many patients are very apprehensive about bunion surgery. They have heard horror stories of severe pain and bad outcomes. These are usually not true. Bunion surgery is actually quite successful, in the right patient, done by the right doctor. Most patients have a lot of questions about whether they should have surgery and what to expect during and after surgery. This is an attempt to dispel old wive’s tales and help you to make a more informed decision about bunion surgery. It is important to remember that every patient is different and this information is just to help you prepare to discuss your surgery with your doctor.
Who should do your surgery? Podiatrist versus orthopedic surgeon? A board-certified podiatric foot and ankle surgeon usually has much more experience in bunion surgery than the average orthopedic surgeon. An experienced, board-certified surgeon is really the key, no matter what their credentials (DPM, MD, DO).
Who should consider bunion surgery? If your foot hurts every day, in every pair of shoes, and you have failed conservative treatment which should include: wider shoes, anti-inflammatories, padding, orthotics, and possibly steroid injection; you are a candidate for bunion surgery.
Bunion surgery involves an incision along the top of the big toe joint and the removal and realignment of soft tissue and bone to restore normal joint alignment and to relieve pain. The first metatarsal bone is often cut, realigned and then stabilized with small screws. There are no guarantees that a bunion surgery will fully relieve your pain because of wear and tear arthritic change to the joint and nerve damage from the deformity. Most patients achieve at least 85% relief of their symptoms.
Anesthesia selection is really patient and procedure specific, but light to moderate sedation, to make you sleepy, coupled with a local anesthetic block, similar to the dentist, is often used during the procedure. Some people do require general anesthesia due to a history of local anesthetic complications or other medical problems.
The procedure usually takes a little more than an hour, depending on the type of surgery. A more complicated bunionectomy can take two hours or more.
Bunion surgeries are usually done on an outpatient basis at a free standing surgery center or outpatient center at a hospital.
There are many kinds of bunion surgeries, but the most common are:
1. Keller: Removal of part of the metatarsal head (the part of the foot that is bulging out) and the base of the proximal phalanx (removal of part of the toe joint). This procedure is called a Keller bunionectomy. These usually work well in an arthritic joint but do not allow for complete joint function after surgery. Usually these are used in the elderly.
2. Austin or Chevron: Realignment of the soft tissue ligaments around the big toe joint. Excision of part of the metatarsal head (the bump). Then, the first metatarsal bone is cut in a V-fashion then moved laterally to realign the joint. The cut or osteotomy is then stabilized with a pin or two small screws. This is the most common procedure and is known as an Austin bunionectomy.
3. Lapidus: Realignment of the soft tissue ligaments around the big toe joint. Excision of part of the metatarsal head (the bump). Then, removal of a wedge of bone from the base of the first metatarsal and the bone adjacent to it (the cuneiform) as well as the cartilage surface of the two bones. The first metatarsal cuneiform joint is then aligned and stabilized with two large screws or a plate. This increases the stability of the area and decreases recurrence of a bunion deformity. This procedure is known as a Lapidus fusion and is usually performed in adolescents or adults with really flexible foot deformities.
4. Other Procedures: Fusion (arthrodesis) of the big toe joint or Total Joint Implant (arthroplasty) are also common, but usually used when the joint is severely damaged and is not repairable.
The usual recovery period after bunion surgery is 8 weeks to 4 months, depending on the procedure and the health of the patient. Compliance also dictates how fast a patient heals. Swelling after surgery can last for up to a year. In a Keller or Austin, the patient is usually completely off their feet for just a few days, then in a walking cast or special shoe for 4 to 8 weeks. You can usually resume normal activity in 2 to 3 months.
In a Lapidus fusion, most patients are in a hard below knee cast completely non-weight bearing for 8 weeks, then a walking cast for 2 weeks, then a sneaker for another month. You can resume normal activity in about 4 months. Every patient is different. Patients with medical problems or osteopenia (soft bone) may require longer immobilization. Some patients require physical therapy after surgery.
There are risks involved in having any type of surgery. No matter how good your surgeon is, if you do not follow directions you may have a bad outcome. Scarring, prolonged swelling, a stiff joint, numbness, shortening of the big toe, degenerative arthritis, infection and continued pain are the most common complications. More serious complications can include non-healing of bone or a severe infection requiring a second surgery.
After having bunion surgery, most people are happy with the results. A survey by the American College of Foot and Ankle Surgeons revealed 95% of patients with good to excellent outcomes form their bunion surgery. After having surgery, your ability to walk and be active is likely to improve. The big toe joint is usually much less painful and functions better.
Even though their joint looks perfectly aligned and functions quite well, some people are disappointed with their bunion surgery. This is usually due to unrealistic expectations. You will still not be able to wear extremely high heeled shoes after surgery and it is unrealistic to think that your joint will be “perfect” or function like it never had a problem. With realistic expectation, most patients are happy with their bunion surgery.