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.
- 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:
- Head procedures (around the great toe joint).
- 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.
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.
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.
Call the Foot and Ankle Center of Washington to make an appointment with Dr. Douglas Hale to discuss your bunion surgery. If this is for a second opinion, be sure to bring any x-rays or other tests you have available.