The painful and bony bump that develops on the inside of the foot (at the big toe joint) is called a bunion. It is also referred to as hallux valgus. Bunions develop gradually. Pressure on the joint of the big toe, like by tight pointy shoes, can cause the big toe to lean toward the second toe. When the big toe subluxates outwards over time, it results in a bunion bump.
While anyone can get bunions, the condition is more common in women.
Bunions form when the bones that make up the metatarsophalangeal joint (MTP) moves out of alignment—the metatarsal bone shifts toward the inside of the foot while the big toe’s phalanx bones angle toward the second toe. The MTP joint will also get enlarged and will protrude from the inside of the forefoot.
While bunions start out small, they often get worse over time. Since the MTP joint is flexed with each step, walking can become more difficult and painful the bigger the bunion gets.
In severe cases, the appearance of the foot is altered significantly—the big toe may angle over or under the second toe and pressure from the big toe can force the second toe out of alignment. Calluses may also develop when the toes rub against each other, resulting in walking difficulty and additional discomfort.
If the bunion is not painful, surgery will not be necessary. While bunions have the tendency to get bigger over time, surgery is not resorted to when the goal is to prevent the condition from worsening. Candidates for bunion surgery often have:
- Severe foot pain that can make walking difficult. Others will find it hard walking more than a few blocks without experiencing pain.
- Swelling and chronic toe inflammation that does not respond to medications or rest.
- Toe deformity
- Stiffness of the toe (inability to straighten or bend the big toe)
- Bunions that does not respond to conservative treatment interventions (lifestyle changes, NSAIDs, etc.)
- Inability to wear closed shoes comfortably
Generally, the procedure aims to relieve pain, correct the deformity and realign the MTP joint at the big toe’s base.
Since bunions vary in size and shape, different surgical procedures are required to correct them. In most cases, the procedure will involve repairing the soft tissues found around the big toe and correcting the bone’s alignment. The doctor will recommend the type of surgery that will best correct the condition.
1. Osteotomy – In an osteotomy, small cuts are made in the bones to realign the joint. After the bone has been cut and realigned, the new break is fixed using screws, pins, or plates. The bones will then become straighter and the joint will become more balanced. To correct the deformity, osteotomies may be carried out in various places along the bone. In other cases, aside from cutting the bone, a small wedge of bone is removed to help straighten the toe. Osteotomies are also typically performed together with soft tissue procedures to maintain the alignment of the big toe.
2. Exostectomy – In this procedure, the bump is removed from the toe joint. However, exostectomy alone is only used to treat bunions if there is no need to realign the joint. Exostectomy is often performed as part of an overall corrective surgery (alongside osteotomy and soft-tissue procedures). If exostectomy is performed without realignment osteotomy, the condition often recurs.
3. Resection Arthroplasty – This procedure involves removing the joint’s damaged portion. Resection arthroplasty is often performed on elderly patients, those who have severe arthritis, and those who have had an unsuccessful bunion surgery. However, since the procedure can alter the big toe’s push off power, it is often not recommended.
Prior to the surgery, the overall health of the patient will be assessed and likely medical conditions that can interfere with the surgery are identified. Various preoperative tests like chest X-ray, cardiogram, and blood count may also be required. The doctor will also take into account several factors before recommending surgery including the severity of the condition, the patient’s activity level, age, and general health, and other medical conditions that may affect recovery. Surgical time will vary depending on how malaligned the foot is.
Understandably, surgery will take longer if the deformity is greater or if more than one osteotomy will be necessary.
As in any surgical procedure, bunion surgery also comes with certain risks. While complications from bunion surgery are rare and often treatable, they can limit or extend the recovery time. Some of the possible complications and risks include:
- Nerve injury
- Stiffness (of the big toe joint)
- Recurrence of deformity
Part of the success of the procedure will depend on the patient’s adherence to the doctor’s instructions for the first few weeks after the procedure. Regular follow-up visits with the doctor will also be necessary to ensure the foot heals properly.
1. Dressing Care – The wound and the dressing should be kept dry at all times. When bathing or showering, the affected foot should be covered with a waterproof bag. Two weeks after the procedure, the sutures will be removed. However, continued support should be provided (using a brace) for at least 6 to 12 weeks.
2. Medications – To relieve surgical discomfort, pain medications will be prescribed. In addition to painkillers, antibiotics are also prescribed to keep infections at bay.
3. Exercise and Physical Therapy – To help restore the foot’s range of motion and strength, certain exercises have to be performed. For instance, a physical therapist may recommend exercises using surgical bands or marbles to help restore toe motion and strengthen the ankle.