Bunions

Problem overview

Bunion is a popular name of big toe (hallux) deformity. The name comes from the Latin term hallux valgus (valgus toe). Bunions are an acquired affliction which mostly concerns women.

The foot deformity referred to as hallux valgus (bunion) only occurs in Patients with fallen transverse arches. It involves dislocation of the peripheral part of the first toe (hallux) towards the remaining toes and dislocation of the first metatarsal bone to the inside, towards the other foot. Bony outgrowths form at the top of the bending as a consequence of footwear pressure and partial displacement of the metatarsophalangeal joint, which results in soft tissue swelling. Swelling is frequently accompanied by first metatarsal bone head bursitis. The larger the deformity, the quicker the deformation progress.

In case of dislocation of the toe extensor ligament onto the lateral surface of the metatarsophalangeal joint, the deformity will be growing as a result of the very toe movement itself, without the participation of other factors.

Foot deformity referred to as hallux valgus may have numerous reasons:

  • occurrence in the family (genetic factor),
  • innate foot defects (e.g. flat feet),
  • overloading (obesity, carrying heavy weights over many years),
  • collagen structure anomalies (multi-joint flaccidity),
  • hormonal disorders (e.g. thyroid gland diseases, diabetes),
  • rheumatic diseases,
  • previous injuries,
  • inappropriate footwear.

Non-surgical treatment involves wearing of orthopaedic footwear inserts supporting the foot arch, body mass reduction, exercises aimed at strengthening inner foot muscles and shin muscles, diagnosing and possible treatment of constitutional diseases. Analgesic treatment involves physical therapy and pharmacotherapy.

Treatment overview

Surgical treatment is aimed at eliminating mechanical insufficiency of the forefoot, reducing pain, slowing down further deformity growth and foot appearance improvement (cosmetic effect). Clinical practice uses over 100 different surgical treatment types to correct hallux valgus. Enormous diversity of surgical methods applied to resolve the same problem results from deformity complexity and its different forms in individual Patients. There is no one, perfect, optimum surgical method. Each Patient must be qualified for treatment on an individual basis in order to allow selection of the most suitable type of surgery.

  1. Soft tissue surgery (without cutting the bones) – performed in the hypoemic area obtained by placement of a compression band over the thigh. The procedure involves uncovering of the first metatarsal bone and the first metatarsophalangeal joint. The more remote end of the first metatarsal bone is cleaned from osteophytes and bony outgrowths, and shaped to the desired form. Then, plastic surgery of the first metatarsophalangeal joint lateral capsule is performed to correct the toe position. After the treatment, the forefoot is relieved by wearing an orthosis (bunion shoe) for 4 weeks. Tiptoeing or wearing high heels is allowed after 7-8 weeks. Exercising in a relieved position begins 2-3 days after the treatment.
  2. Stiffening of the cuneometatarsal joint – hallux valgus reconstructive surgery in case of “soft” foot. As in the case of soft tissue surgery, the procedure is performed in the hypoemic area obtained by placement of a compression band over the thigh. The treatment involves uncovering of the first metatarsal bone, the first cuneometatarsal joint and the first metatarsophalangeal joint. The more remote end of the first metatarsal bone is cleaned from osteophytes and bony outgrowths, and shaped to the desired form. Then, plastic surgery of the first metatarsophalangeal joint lateral capsule is performed to correct the toe position. Subsequently, corrective osteotomy of the first foot ray is performed at the height of the first cuneometatarsal joint (the joint is cut out). The correction effect is maintained by fitting of a metal plate. The osteotomy area is additionally refilled by the Patient’s own bone transplant taken from the more remote end of the bone during removal of the bony outgrowths. Drains are left in the surgical wound for one day. Skin sutures from the surgical wound are removed approximately 14 days after the treatment. Rehabilitation begins 3-4 days after the treatment. The forefoot is relieved by wearing an orthosis (bunion shoe) for 6-12 weeks. Tiptoeing or wearing high heels is allowed after 12 weeks. Orthopaedic inserts are worn permanently. In most Patients, removal of the joining material is recommended after a few months or approximately one year.
  3. Single osteotomy – the procedure involves uncovering of the first metatarsal bone and the first metatarsophalangeal joint. The more remote end of the first metatarsal bone is cleaned from osteophytes and bony outgrowths, and shaped to the desired form. Osteotomy (section of the bone) is performed in its more remote part, allowing correction of the first metatarsal bone deformity and reconstruction of the lateral foot arch. The correction effect obtained is stabilised with one or two screws. Plastic surgery of the first metatarsophalangeal joint lateral capsule is performed to correct the toe position. Skin sutures from the surgical wound are removed approximately 14 days after the treatment. Rehabilitation begins 3-4 days after the treatment. The forefoot is relieved by wearing an orthosis (bunion shoe) for 6-12 weeks. Tiptoeing or wearing high heels is allowed after 12 weeks. Orthopaedic inserts are worn permanently. In most Patients, removal of the joining material is recommended after a few months or approximately one year.
  4. Double osteotomy – the procedure involves uncovering of the first metatarsal bone and the first metatarsophalangeal joint. The more remote end of the first metatarsal bone is cleaned from osteophytes and bony outgrowths, and shaped to the desired form. Osteotomy of the first metatarsal bone is performed in two places, allowing correction of the first metatarsal bone deformity and reconstruction of the lateral and longitudinal arch of the foot. The correction effect obtained is stabilised with screws, plates or Kirshner wire. Plastic surgery of the first metatarsophalangeal joint lateral capsule is performed to correct the toe position. Skin sutures from the surgical wound are removed approximately 14 days after the treatment. Rehabilitation begins 3-4 days after the treatment. The forefoot is relieved by wearing an orthosis (bunion shoe) for 6-12 weeks. Tiptoeing or wearing high heels is allowed after 12 weeks. Orthopaedic inserts are worn permanently. In most Patients, removal of the joining material is recommended after a few months or approximately one year.

Performance of the surgery itself does not guarantee elimination of the ailments suffered so far. The final treatment effect is closely related with observing the doctor’s recommendations and undergoing the full cycle of rehabilitation treatments, adapted to the individual needs of each Patient.

Side effects and complications

Performance of any medical intervention may involve the risk of side or adverse effects. These may include body temperature increase after the treatment, temperature increase in the operated joint, reddening of the joint skin and of the surgical wound area, separation of the wound, which is connected with a prolonged treatment process. Hematomas (skin bruising with local tenderness) appear in the surgical wound area. Painfulness appears for several weeks after the treatment, with the strongest pain experienced for 2-3 days after the treatment and after beginning of the rehabilitation process. Skin sensation disorders occur in the surgical wound area.

The most frequent complication is swelling of the joint, which persists for several weeks and hinders rehabilitation. In terms of frequency, the second complication is swelling of the whole limb. This ailment is related to standstill in venous and lymphatic circulation, which may lead to vein inflammation and thrombosis which requires weeks’ long treatment and deteriorates rehabilitation effects. In some cases, a thick scar develops in the area where surgical cuts were performed. Pain and sensation disorders, including skin hyperesthesia, may appear in this area. A very rare complication is unplanned bone fracture or fracture of implants during the treatment. In occasional cases, vessels or nerves in the operated limb may be damaged or infection of the surgical wound may develop.

So-called late complications include development of scar changes within the surgical wound, including hyperesthesia and pain. These may be accompanied by limited movement range of the toe metatarsophalangeal joint. In case of surgeries which require bone section, the bones may not knit, the correction obtained may become destabilised and another surgery may be needed.

After each stage of the reconstruction treatment, a tendency related to deformity return may appear. To a large extent, the pace of this process depends on observing medical and rehabilitation recommendations.

The risk of complications is several times higher in case of emaciation or obesity.

Alternative treatment

  • pharmacotherapy: medicines improving nerve functioning, analgesic and anti-inflammatory medicines administered generally (pills, suppositories, intramuscular injections) or locally in the form of ointments, gels and local injections;
  • physical therapy – iontophoresis;
  • rehabilitation – kinesiotherapy, analgesic and anti-inflammatory physical therapy;
  • electrostimulation of the damaged nerve.
Klinika Ambroziak

al. Gen. W. Sikorskiego 13/U1
02-758 Warszawa

pon-pt: 10:00-20:00
sob: 10:00-18:00

Szpital Ambroziak

ul. Młynarska 2a
05-500 Piaseczno

pon-pt: 10:00-20:00
sob: zamknięte