Bunion surgery: types, recovery and results

Is surgery right for me?

For background on the condition, see bunions. Surgery may be worth discussing if:

• pain in the bunion persists despite well-fitting shoes, padding and other non-surgical measures
• the bunion limits walking, work or exercise, or you can’t find shoes that are comfortable
• the deformity is progressing, or causing problems for the neighboring toes
• the potential benefit clearly outweighs the risks and the recovery time for you^[2,3]

Surgery is not a good choice for someone who wants only a cosmetic change, for someone who cannot follow the post-operative restrictions, or in the presence of certain circulation or wound-healing problems until they are addressed. Adolescents are usually advised to wait until the skeleton has stopped growing.^[7]

The main types of operation

Because so many techniques exist, it helps to think in terms of what the operation is doing.^[1,2]

• Soft-tissue balancing. Tight tissue on the outside of the big toe joint is released and the stretched tissue on the inside is tightened, to help hold the toe in a straighter position. It is usually combined with a bone procedure.
• Distal (chevron-type) osteotomy. A V-shaped cut near the head of the first metatarsal lets the surgeon shift the head toward the midline. It is commonly used for mild to moderate deformities.
• Shaft or proximal osteotomy (for example the scarf osteotomy). A cut farther back allows more correction when the angle between the first and second metatarsals is larger.
• Lapidus procedure. Fusion of the joint at the base of the first metatarsal (the first tarsometatarsal joint) corrects the deformity at its source and is used for some larger deformities or when this joint is unstable.^[4]

Screws, small plates or other implants hold the bones in their new position while they heal. The Cochrane review of surgical interventions identified 25 randomized trials, most comparing one osteotomy with another. Most trials were at risk of bias, and the evidence does not point to a single best operation.^[8]

Minimally invasive or open?

“Minimally invasive” bunion surgery performs the bone cut through very small incisions, guided by X-ray imaging, instead of one larger incision. It is the subject of much interest, and research so far suggests it can give results similar to open surgery in suitable patients, without proven superiority:

• A meta-analysis of randomized and prospective controlled studies found no clinically important difference in pain, function, alignment or complications between minimally invasive and open surgery, and warned that limitations in the studies may have inflated the apparent benefits of the minimally invasive approach.^[1]
• In one randomized trial, minimally invasive surgery was associated with better early wound appearance at six weeks, and one-year results were similar.^[9]
• In another, minimally invasive scarf surgery gave equivalent results with a shorter operation and less pain immediately after surgery, but more radiation exposure from the X-ray guidance.^[10]
• A different meta-analysis found similar X-ray correction but better functional scores with open surgery, and suggested minimally invasive techniques suit mild-to-moderate deformities.^[11]

See minimally invasive foot surgery for a broader discussion.

What the day of surgery involves

• Where: at a hospital or ambulatory surgery center where Dr. Ozturk has privileges. Most people go home the same day.
• Anesthesia: chosen with the anesthesia team. Bunion surgery is commonly done with a regional nerve block plus sedation, or with a general anesthetic. See preparing for foot and ankle surgery.
• The operation: usually one to two hours, depending on the procedures combined. Additional procedures on the lesser toes or the arch are sometimes done at the same time.
• Afterward: a bandage, and a protective shoe or boot. Your surgeon will explain how much weight you can put on the foot.

Recovery

Recovery depends on the operation, on the fixation used, and on your healing. In general, healing takes place over weeks to months, and swelling can last for several months.^[7,3] Your surgeon will give you a schedule for weight-bearing, dressing changes, stitch removal, exercises, and return to shoes, driving, work and exercise. See recovery after foot and ankle surgery.

For a Lapidus fusion, there has traditionally been an extended period without weight on the foot. A systematic review of eight studies of early weight-bearing (within two weeks) reported a nonunion rate of 3.6%, and a meta-analysis found that a longer time until full weight-bearing correlated with nonunion, and that plantar plating allowed earlier weight-bearing; these studies are not from randomized trials, so protocols vary between surgeons.^[12,4]

Results and risks

• Satisfaction and recurrence. In a review of 229 studies, patient dissatisfaction after surgery averaged about 11%, and the recurrence rate was about 5%.^[5] Reported recurrence is higher when it is measured at five years or more and defined by a smaller angle: after distal osteotomies, 64% of feet had a hallux valgus angle over 15 degrees, 10% over 20 degrees and 5% over 25 degrees.^[6]
• Complications. Risks include infection, recurrence, stiffness or persistent pain of the big toe joint, nerve irritation and numbness, delayed or non-healing of the bone, prominent hardware, and, less commonly, over-correction.^[2,5,4] Pain in the joint of the big toe after surgery is reported in about 1.5%.^[5]
• General surgical risks such as bleeding, blood clots and anesthesia risks are discussed before surgery, and smoking and poorly controlled diabetes raise the risk of wound and healing problems.^[13,14]

Questions to ask before deciding

• What is the size of my deformity, and which operation do you recommend for it — and why?
• Would a minimally invasive approach be suitable for me, and what are the trade-offs?
• What non-surgical treatment have I tried, and is there anything else worth trying first?
• How long will I be on crutches or in a boot, and when can I drive, work and exercise?
• What is a realistic result for my foot, and what is the chance the bunion returns?

When to seek care