Considering bunion surgery can be very confusing. There is a tremendous
amount of information available and much of it is contradictory. You may
get information from your doctor, friends, internet and/or family
members. This section is designed to cut through the clutter, help you
identify the false information, and assist you in making an informed
decision. Before reading this section, be sure to read our page on
Bunions and Big Toe Joint Pain.
In most cases, we can treat the pain caused by bunions conservatively.
In fact, we feel strongly that surgery should be a last resort. We
surprise many bunion patients with our ability to help them avoid
surgery when they have been told previously they have no choice but
surgery. If you have tried all conservative treatment, however, and bunion pain is
causing pain or limiting your activity, surgery can be a very effective
option.
What is a bunion?
A bunion is when the big toe moves towards the 2nd toe and the bone
behind the big toe (closer to the ankle), 1st metatarsal, moves inwards
causing a bump on the inside of your foot. The medical Latin term for a
bunion is Hallux (big toe) abducto (big toe moving towards the 2nd toe)
valgus (big toe rotates inward).
When should you have bunion surgery?
At the Foot and Ankle Center of Washington we use the
following criteria as a guideline when determining if surgery is
indicated:
You have a bunion - determined by clinical exam and
x-rays.
You feel you have exhausted all conservative care. Conservative
therapy may include the following: • Functional orthotics, prescribed
and cast by your doctor and designed to relieve pressure within the
big toe joint. • Shoe Therapy, including proper shoes for your foot type
and activities and possible modifications to your shoes. • Accommodative padding. • Activity modifications. • Medications – short term therapy may help to reduce
inflammation. • Icing. • Injection therapy – rarely used but may help in treating an
inflamed bursa.
Bunion interferes with daily activities.
Pain inside the joint.
You would like surgery sooner than later.
The surgical procedure
There are a number of different ways to perform bunion
surgery. The best procedure for one person is not necessarily the best
for another. Some procedures allow you to walk much sooner meaning you
may not have to use crutches. Depending on your foot type the procedure
can have a greater risk for return of the bunion deformity. Other
procedures may require you to be on crutches for a few weeks – but may
offer a better long-term result.
Types of bunion surgery:
Generally, bunion surgery can be classified into two major categories:
1) Head procedures (around the great toe joint).
2) Base procedures (near or at the joint behind the great toe joint).
For a head procedure, the bone is cut and the head of the metatarsal
moved over to correct the bunion. Various types of bone cuts can be
performed depending on the necessary correction. Head procedures are
usually indicated for a mild to moderate bunion, or for patients who do
not feel they can be non-weight bearing for any length of time.
Head Procedure Bunionectomy - bone is cut just behind the joint and
moved over. Fixated with screw (shiny area center of bone behind great
toe joint).
Base procedures are performed around the base of the 1st metatarsal
(bone behind great toe). They include cutting a wedge out of the bone
(base wedge), making a semi-circular cut and rotating the bone (crescentic
osteotomy) and fusion of joint behind great toe joint (Lapidus
bunionectomy). Base procedures are usually indicated for a moderate to
severe bunion.
Lapidus bunionectomy – procedure performed at the base of the 1st
metatarsal.
Overall, there are many variables in selecting a bunion procedure and
the key to success is finding an experienced surgeon who understands
each variable and who has the skills to perform all types of procedures.
Some surgeons may not have the skills to perform base type procedures
and offer head procedures as your only choice.
There is substantial medical research showing which bunion procedures
are most effective in specific situations. At the Foot and Ankle Center
of Washington, we perform an examination of your lower leg and foot,
review your biomechanics and x-rays, and give you an understandable and
complete explanation of what choices you have, including what type of
procedure is in your best interest.
Who Should Perform Your Surgery?
The most important criteria to ensure good outcome for
your bunion surgery is to choose the right surgeon. The qualities that
make for a good bunion surgeon are:
Board Certified: Look for an experienced
surgeon who is board certified by the American Board of
Podiatric Surgery (only board recognized as a surgical board) in
Foot Surgery or Foot and Ankle Surgery. A more experienced
surgeon will also be certified in Reconstructive Rearfoot/Ankle
Surgery. [Note: Surgeons certified prior to 1990 are not
required to pass recertification examination and only need to
take a self assessment test. Surgeons certified after 1990 are
required to take and pass recertification examination.
Understanding of biomechanics: To choose
the best procedure, a surgeon must also have the ability to
evaluate your biomechanical structure including tightness of leg
muscles, foot and leg alignment, motion of the bones around the
bunion site, and midfoot and rearfoot alignment.
Extensive experience: An experienced
surgeon usually has a better ability to deal with intraoperative
or post operative complications and reduce the chance of
complications. Numerous studies have demonstrated that one of
the best predictors of surgical outcome is the experience of the
surgeon.
Gentle handling of tissue: A surgeon who
handles tissue with a gentle touch will help ensure that pain is
minimized and recovery time is reduced.
Performs surgery in peer reviewed hospital or
surgery center (surgery center not located in physician’s
office)
Defines realistic expectations and potential
problems: Be wary of a physician who seems to talk you into
surgery or makes surgery sound “too good to be true”.
Use of foot orthotics following surgery:
Bunion surgery does not usually alleviate all of the forces that
caused the bunion in the first place. This is because the
biomechanical cause of the bunion is often due to function in
another part of the foot. Surgery to correct the underlying
biomechanical cause would, in many situations, be too extensive
and involved to be a practical treatment option. In addition, it
is simply not necessary in most cases. Once the bunion is
corrected, foot orthoses will likely be used to improve foot
biomechanical function and help prevent return of the bunion
deformity. The orthotics can fit into many shoe types, including
women’s dress shoes. Note that if you already have orthotics,
you will likely need new ones after surgery to match the new
shape of your foot. Use this link for more information: custom
foot orthotics.
Not all Surgeons are Created Equal:
Be very careful in choosing the right surgeon. It is
particularly important to avoid those that make unrealistic claims
regarding bunion surgery. If you see or hear the following statements we
suggest you consider another surgeon:
"90 plus percent of patients have pain free
surgery": Most surgeons could make that claim since surgery
is generally performed with a local anesthetic block and the patient is sedated
or asleep during surgery. After surgery patients are given a long
term anesthetic block to allow them to usually go home pain free.
Look for a surgeon who gives realistic expectations and does not make surgery sound too good to be true.
“I created a better bunion surgery”: There are
several problems with this statement. First, all bunion surgery is a
variation on several basic types of procedures. There have been
substantial evolutionary changes over the years, but if you hear
anyone claiming that they have invented a procedure that is far
better than anyone else is using, you should have a healthy
skepticism. Second, there is no one “best” bunion surgery. The
correct procedure depends on your foot shape, ligament tightness,
biomechanics and other factors. Finally, in most all surgical
specialties, if a truly better procedure is developed it is adopted
by most good surgeons.
“My patients never have a bunion return”: It is
simply impossible to ethically guarantee that a bunion will not
return. The odds of a bunion returning are much less if the surgeon
chooses the right procedure and the patient follows all of their
post-operative instructions. Also the use of custom foot orthotics
(specifically prescribed to enhance normal function of the big toe
joint) after surgery can help prevent return of bunions. The reality
is a very small percentage of bunions will eventually return
regardless. Sometimes the forces leading to bunion formation are
just too great.
“My patients never require crutches”: This often
means that the surgeon only knows how to perform a simple type of bunionectomy. More complex bunion procedures may require the use of
crutches. In fact, even with a bunion procedure that allows early
weight bearing most surgeons will have their patients use crutches
for short period of time to reduce swelling and pressure on the
surgical site.
“Surgery is performed in our own surgery center”: Be
VERY cautious of a physician who performs bunion surgery in their
own office surgery center. Physicians who perform surgery in the
hospital must pass a credentialing process and be approved by a
committee to perform individual surgical procedures. Physicians in
the hospital are re-credentialed/evaluated on a regular basis. This
assures you the physician is qualified to perform your surgical
procedure and does not have an impairment. An office surgery center
must usually be approved, in order for them to bill Medicare, but
the physicians are not regulated. A physician may be deemed not
qualified to perform a procedure in the hospital but this does not
stop him/her from performing procedures in his/her own surgery
center. A physician operating in his/her own surgery center has no
one evaluating the quality of work. (We tend to see more
complications from patients who have had surgery in an office
surgery center).
“I feel your bunion is going to get worse so you
should have surgery as soon as possible”: Be cautious of a physician
who does not suggest conservative therapy before suggesting surgery.
“Surgery is virtually pain free, minimally
invasive”: Be cautious of a physician who makes the surgery sound
too good to be true. “Minimally invasive” bunion surgery was a term
used many years ago to describe bunion surgeries performed through a
very small incision. Due to significant numbers of complications
with minimally invasive bunion surgeries, it is not currently
recommended for bunion correction. A responsible surgeon will give
you realistic expectations and review possible complications. All
surgery, bunion or otherwise may have possible complications.
Dr. Douglas Hale is
one of the few surgeons in the Northwest who is board certified in both
Foot Surgery and Reconstructive Rearfoot/Ankle Surgery. He is a graduate
of the renowned Northwest Podiatric Surgical Residency based at Swedish
Medical Center – considered one of the five best Foot and Ankle Surgery
Residencies in the country. He is Chief of Podiatric Medicine at Swedish
Medical Center. Dr. Hale has over 14 years experience performing many
types of bunion surgery and is thus able to select the bunion procedure
to best fit your needs. He has the philosophy of doing what is best for
his patients, and keeps up to date on new procedures. He feels it is so
important to keep up on the latest procedures that he regularly
participates in Grand Rounds (patients with difficult medical and/or
surgical conditions are evaluated to determine a treatment plan) at
Swedish Medical Center. More information on Dr.
Hale is available here.
Podiatric Surgeon or Orthopedic Surgeon?
Both Podiatric and Orthopedic surgeons perform foot surgery. The
question often arises as to who is more qualified. The reality is that
it depends on the surgeon. There are exceptional Podiatric foot surgeons
and exceptional Orthopedic foot surgeons. Conversely, there are mediocre
surgeons in each profession.
From day one of their training, Podiatric surgeons know they will be
treating foot and ankle conditions, thus early on they receive in-depth
education on foot and ankle conditions as well as broad education in
general medical conditions. The first years of medical education for
MDs, DOs, and DPMs are generally the same. In fact, in many cases, the
students are taught by the same teachers or in the same class room. This
general training in medicine allows both the Orthopedist and the
Podiatrist to detect medical conditions affecting the lower extremities
as well as deal with surgical patients who have medical conditions.
Unlike other specialties, Podiatric surgeons receive significant
training in biomechanics during their education allowing a unique view
of how foot surgeries can affect the lower extremity.
Board certified Podiatric Foot and Ankle surgeons are the surgical
specialists of the Podiatric profession. American College of Foot and
Ankle Surgeons (ACFAS) members are graduates of accredited U.S.
Podiatric medical schools, who have completed surgical residency
programs of up to three years.
Fellows of the College are certified by the American Board of Podiatric
Surgery, the surgical board for foot and ankle surgery recognized by the
Joint Committee on the Recognition of Specialty Boards. Many have
additional fellowship training in various aspects of foot and ankle
surgery. All ACFAS members are dedicated to surgical excellence in the
treatment of foot and ankle disorders.
What Do Podiatric Foot and Ankle Surgeons Treat?
Foot and ankle surgeons treat a wide variety of foot and ankle
conditions:
• Structural conditions
• Trauma-related injuries
• Skin and nail conditions
• Congenital deformities
Foot and ankle surgeons are uniquely qualified to detect the early
stages of diseases that exhibit warning signs in the lower extremities,
as well as manage those foot conditions which can pose an ongoing threat
to a patient's overall health. Such illnesses include diabetes,
arthritis and cardiovascular disease.
In general an Orthopedist who specializes in Foot and Ankle surgery
complete a general residency in Orthopedics and a 1 year fellowship in
Foot and Ankle Surgery.
Prior to Surgery
• Arrange for a ride home.
• Do not plan on any long trips for at least two weeks after surgery.
• If you have significant medical problems, you may need medical
clearance through your Primary Care Physician (PCP) since they know the
most about your medical history. Schedule a history and physical with
your PCP, no more than 30 days prior to surgery.
• If you live alone, it is best to arrange for someone to stay with you
for the first 24 hours.
• Wash your foot the night before and morning of surgery to reduce
bacterial count.
• Stop using anti inflammatory medication 5 - 7 days before surgery
(examples: aspirin, ibuprofen, Advil and Aleve).
• If you are taking any blood thinners, such as Coumadin, we will need
to determine whether you can just stop the medication or go on a shorter
acting blood thinner prior to surgery.
• Do not eat or drink anything after midnight the night before surgery.
Day of Surgery
Surgery is performed in the hospital or a multispecialty surgery center.
Most foot and ankle surgeries are day surgeries and you will go home the
day of surgery. You will generally be given a local anesthetic and
anesthesia per your Anesthesiologist. You will be constantly monitored
by an Anesthesiologist. You will speak with the Anesthesiologist prior
to your procedure and he/she will help you choose the best anesthesia
based on your medical health and complexity of your case. Anesthetic
choices are typically local anesthetic with sedation, general anesthesia
and spinal anesthetic. Most forefoot cases can be performed with local
anesthesia and sedation.
After surgery you will possible be given a long acting anesthetic. You
will also receive pain medication. You will need to arrange for a ride
home. Patients are not allowed to drive home on the day of surgery.
Recovery from surgery
Weight bearing on your foot depends on your procedure. A head procedure
allows for immediate weight bearing but we still feel that it is best to
use crutches for 1-2 weeks. Base procedures require crutches for a
longer period of time.
• First week after surgery keep your foot elevated as much as possible.
• Keep your foot dry for at least 2 weeks after surgery. • One week after surgery you will have your dressing changed. • Second week after surgery your sutures will be removed.
Dr. Hale will advise you when you can increase weight bearing and
activities depending on your surgical procedure.
Best results are achieved when patients are compliant with after surgery
instructions. If you have any questions after surgery always feel free to call Dr.
Hale day or night.
