What is a Bunion?

What is a bunion?

A bunion, or hallux valgus, is an abnormal bony enlargement that develops on the inside of the foot near the base of the big toe.  As the bunion worsens the big toe begin to lean towards, and crowd, the other toes. The joint where a bunion develops is called the 1st metatarsophalangeal joint.  Initially bunions may not be painful but as they enlarge the “bump” begins to rub on shoes and can become red and painful.  If left untreated the joint becomes arthritic from the abnormal position of the bones. Once arthritis develops, bunions become more complicated to treat.  These severe or longstanding bunions may require an implant or joint fusion.

Bunions can also occur at the base of the little toe.  This is called a Tailor’s bunion or Bunionette. 

How did I get my bunion?

You can thank your parents, or grandparents.  Bunions are usually inherited. Poor foot mechanics are passed on through generations.  Poor foot mechanics can affect the normal balance of forces to the joints and tendons of the foot.  This will cause instability in the foot which can lead to the development of a bunion deformity. Other causes of a bunion include; injury to the foot, gout, and neuromuscular disorders.

Did tight shoes or pointy toe shoes cause my bunion?

Tight shoes and/or pointed toe shoes do not cause bunions.  Studies have been conducted in parts of Mexico and India where shoes are not even worn and people still developed bunions.  While shoes aren’t a direct cause of bunions, tight shoes may cause pain by putting pressure on the bony prominence. In addition, pointed toe shoes can cause someone, already predisposed, to develop a bunion faster.

Is there any conservative care for bunions?

Conservative treatment includes physical therapy, padding, taping, wearing comfortable shoes, and taking oral anti-inflammatory medication.  Conservative treatment is usually only successful if the bunion is mild. In the early stages of a bunion deformity there is usually only pain when something presses on the “bump”.  Purchase shoes that fit your feet, never force your foot to fit the shoe. Unfortunately, there is some truth to the saying “the prettier the shoe the worse they are for your feet”.  Look for shoes with a wide toe box, good arch support, and soft soles.  Custom orthotics prescribe by you podiatrist are very effective at balancing out the abnormal biomechanical forces that are causing the bunion to form.   

Continued pressure from shoes can result in the development of a bursa over the bunion.  This will cause the area to become red, swollen, and painful. In these instances, an injection of cortisone may be helpful.  

Should I have my bunion surgically corrected?

Bunions tend to be progressive and over time will worsen.  Addressing a bunion early is important because over time, secondary changes such as arthritis, spurring, cartilaginous damage, and bursitis occur.  In addition, the position of the big toe tends to crowd the lesser toes and over time will cause hammertoes toe develop.

What are the symptoms of a bunion?

The symptoms of a bunion can vary from person to person but generally include:

The appearance of a bump on the base of the big toe joint.

A dull ache with some shooting pain usually over the bump.

Redness and inflammation of the bump, usually from shoe pressure.

With long standing bunions or severe bunions, there is pain when moving the big toe.

Pain with walking or when wearing shoes.

What type of anesthesia is used during bunion surgery?

Bunion surgery may be performed under straight local, conscious sedation, or general anesthesia.  Conscious sedation is the most common. Conscious sedation, sometimes referred to as “twilight sleep”, involves starting an IV and administering a drug called Propofol.  Patients are relaxed and comfortable during the entire procedure and feel no pain. Bunion procedures take about two hours and while patients are technically conscious during the surgery, they usually don’t remember anything.

What can I expect after surgery?

This may vary widely based on exactly what procedure is performed.  Having said that, this is what the majority can expect.

Your foot will be bandaged and you will be put in a walking boot.  Most doctors inject local anesthetic during the procedure so when you wake up the foot will be nice and numb.  There will be some mild pain as the shots wear off which is usually well controlled with pain medication. Immediately after surgery your instructions are to remain “Non-weight bearing with bathroom privileges for the first 2-3 days.”  This means stay off the foot as much as possible but you are permitted to apply full weight on the foot, in the boot, to use the restroom, get to your bed, etc.

You will be prescribed post-op medications including prophylactic antibiotics, pain medication, and possibly an anti-inflammatory.  Stiches usually come out at 2 weeks after surgery and patients can be back in shoes in 3 to 4 weeks. It is not uncommon to have some residual swelling after surgery that may linger for up to a year.  This swelling is usually not painful and will eventually go away.

Are bunions painful?

Surprisingly, there is often little correlation between the size of a bunion and the amount of pain.  Some bunions are severe with very little pain while others appear mild but are agonizing. Treatment is usually guided by the degree of pain versus the appearance of a bunion.  

What can I expect when I visit the doctor for my bunion?

Your doctor will perform a comprehensive biomechanical evaluation to assess the dynamics of the foot.  An x-ray is also required to fully appreciate the position of the bones and degree of arthritis. X-rays are also very important to determine the important biomechanical aspect of the foot such as, length of bones, amount of pronation, and other biomechanically significant information.

Can children develop bunions?

Juvenile bunions are uncommon but do occur.  If your child is developing a bunion conservative care may be much more effective than in an adult because the bones are still developing and if caught early, proper inserts or strapping and bracing can realign the deformity.  There is also a minimally invasive procedure to correct a juvenile bunion, but it is time sensitive with respect to age, and there is a relatively small window of opportunity to perform the procedure based on the stage of skeletal maturity.  This procedure for Juvenile bunions is called a Lateral Hemiepiphysiodesis, (hyperlink to Juvenile Bunion under the pediatric section) and involves manipulating the growth plate in the foot to cause the bunion to correct itself.   

How are bunions surgically repaired?

Bunions are more complicated than most people think.  Depending on the characteristics of the bunion one of over 100 different surgical procedures may be performed.  Different factors will influence which procedure should be performed.

Some of the factors influencing which bunion procedure should be performed include…..

Age of patient

Weight of patient

Quality of bone

Degree of deformity

Length of bones

Activity level of the patient

Amount of pronation/supination

Position of big toe

Occupation of patient

Position of sesamoids

Co-morbidities of patient

Types of shoes worn

Bunion repairs are broadly grouped into 3 categories:

  1. Soft tissue repair with or without spur removal
  2. Osteotomies
  3. Joint destructive procedures

Soft tissue repair with spur excision

Soft tissue repair with or without spur excision involves simply shaving down the bump and adjusting the capsular structures to straighten out the toe.  This type of bunion correction is the simplest but has a higher reoccurrence rate, but when indicated is a highly effective and simple procedure.

This patient’s bunion was corrected with a small incision and release of the lateral side of the joint.

Endoscopic bunionectomy

While not technically a bunionectomy, there is a scoping procedure to clean out the bunion joint.  This procedure has been shown to significantly reduce pain and increase range of motion in the bunion joint.  The advantage to this procedure is that it is minimally invasive involving only a few very small incisions. Recovery is quick.  Patients can weight bear immediately and are back in regular shoes in days.

Bunions cause arthritis in the big toe joint.  As with the knees, ankles, or shoulders, the bunion joint can be scoped to clean out the arthritis.  The procedure is performed with the same instrumentation used for arthroscopy of the wrist and involves removal of inflammatory tissues, debris, and small spurs.  The procedure is also a great way to directly visualize the cartilage and other structures in the joint which can be a helpful diagnostic tool.

The procedure is similar to any other joint arthroscopy.  It involves several small incisions through which an arthroscopic camera is inserted.  Instruments such as probes, cautery tools, and shavers are used to perform the procedure.  Depending on the extent of damage in the joint, the procedure takes about 30 minutes.

This is a view inside the joint of a patient that had severe gout.  Notice the white material in the joint from uric acid build up. All this material was excised during a bunion scope and other arthritic debris that was found floating in the joint.

This patient had extensive tenosynovitis from long standing arthritis in his bunion.  The red material is called tenosynovitis. Tenosynovitis occurs from long standing arthritic changes in the joint where finger like projections with tortuous blood vessels develop in the joint.  These finger-like projections are painful and damaging to the joint. A shaver can be seen on the left side of the image removing this diseased tissue.

Osteotomies

Bunionectomies involving osteotomies are by far the most common type of bunionectomy.  The biomechanical abnormalities can be directly addressed by realigning the position of the bones in the foot.    

This type of bunionectomy begins with the cutting off of the “bump”.  As a bunion develops a large bone spur or exostosis develops over the inside of the forefoot.  

While this bone spur requires removal, much of the “bump” seen with a bunion is from the metatarsal itself veering out causing it to become prominent.  For proper correction the metatarsal itself is then cut and slid over towards the other toes. This realigns the bone under foot correcting the biomechanical abnormality and narrowing the foot.  

There are over 30 different ways to cut the 1st metatarsal, the most common is called the Austin which is a chevron or “V” shaped cut in the 1st metatarsal bone.  The capital fragment is then shifted over and fixated.  This type of osteotomy is very stable and easy to fixate with screws.  

This type of bunionectomy is very successful and patients are usually very pleased with their outcomes.

What are the post-op instructions after bunion surgery?

Post-op instructions following bunion surgery are much the same regardless of what type of bunion surgery is performed with the exception of weight bearing status.  This will vary greatly depending on the specific surgical procedure. Having said that, as a very general guideline….

Weight Bearing:

With most types of bunionectomies you should remain non-weight bearing with bathroom privileges for the first 48 hours.  This means you can get up, and fully weight bear to get to the restroom, get to your bed, etc. But other than these essentials, you should stay off your foot.  After 2 or 3 days you can do some minimal walking around the house. You will be in a post-op shoe or boot for 2 to 3 weeks after surgery. Patients are usually back in regular (sensible) shoes at around 2 to 4 weeks.  Dress shoes including high heel shoes may take 3 months or longer to get back into.  

Elevation:

You should keep your foot elevated after surgery as much as possible.  You don’t have to be in bed, a recliner chair is fine or just put it up on the coffee table.  When elevating the foot with a pillow it is best to place the pillow long ways and support the back of the knee as well.  This will prevent hyperextension of the knee which can cause knee pain over time. Also, circulation to the foot is better if the knee is slightly flexed.  

Ice:

Ice the foot.  20 minutes off and 20 minutes on.  The ice pack does not have to be directly over the surgical site.  With all the dressings on the foot it is difficult for the cold to penetrate to the skin.  Instead place the ice pack further up on the ankle where there are no bandages. As long as the blood vessels going to the surgical site are cooled, this will help decrease post-op inflammation.  As an alternative, apply the ice pack to the back of the knee. The major blood vessels to the foot are closest to the skin in this location and can be effectively cooled to decrease inflammation.  

Medication:

Take medication as prescribed.

Are severe bunions harder to fix?

For severe bunions where the bone is extremely pronounced a special type of bunionectomy may be required.  To correct bunions of this severity the deformity must be addressed at the base of the metatarsal. By cutting the bone at the base, the degree of correction is exponentially increased.  This can be achieved with what is called a base wedge osteotomy or a Lapidus procedure.

A base wedge procedure is the same as the osteotomy described above only it is at the base of the metatarsal instead of the head of the metatarsal.  The down side to these base procedures is that they are less stable and requires more secure fixation and longer period of non-weight bearing after surgery.

Fixation with a plate is more commonly used vs screws with base procedures because of the extra stability plates provide.  

While more rigid fixation is required and post-op recovery is longer with this type of bunionectomy, the results are impressive because of the amount of correction a base wedge affords.  

The Lapidus Procedure is similar to the base wedge but it is even more proximal at the joint.

Joint destructive procedure

For severe bunions or bunions that have been present for many years, arthritis with eventually destroys the joint.  Once the cartilage has been destroyed there is increased pain in the bunion from “bone on bone” contact. In these instances the only solution is to fuse the joint or replace the joint.  

Should I get a joint replacement or have my bunion fused?

This decision is based on patient age, activity level, what type of shoes the patient will be wearing and how much down time the patient has during post-op recovery. Both a fusion and implant have pros and cons.  

The 1st metatarsal is fused with the proximal phalanx in the big toe.  The down side is obviously the joint will not move which may be a problem, especially for women who like to wear high heel shoes.  Usually with a fusion, patients are limited to about a 2-inch heel. The other major drawback to a fusion is recovery time. After surgery, the patient will require up to 6 to 8 weeks of non-weight bearing and they won’t be able to wear their regular shoes for 3 months.  

Implants have a much quicker recovery time and depending on the procedure patients can bear weight within days and are back in shoes in 2 weeks.  The downside to implants is that they can wear out over time. How long an implant lasts depends on many factors including age of patient, activity level of patient, type of implant, etc.  Metal implants obviously last longer than silicone implants, but metal implants tend to eventually result in adaptive bony changes that can become problematic.

Bunion Joint Implants

Joint implants come in many forms; metal, silicone, ceramic, and many styles; one piece two piece.  You and your doctor will decide which is best for you based on your age, activity level, and degree of joint damage.  

Two Piece Metal Implant:

One piece implant:

Metal Hemi-Implant (Metatarsal head)

One piece implant:

Metal Hemi-Implant (Phalangeal base)

Double Stem Silastic(silicone) Implant:

Can joint implants wear out?

Yes, joint implants are put under tremendous forces in the foot.  Silastic or Silicone implants can break apart and disintegrate over time.  How long they last depend on how active the patient is. They can last anywhere from 10 to 20 years.  

The above x-ray shows a Silastic (silicone) implant after 17 years.  The implant is mostly destroyed with bony changes taking place around the implant.

Although this metal implant did not break apart or disintegrate, after 9 years in the body it sunk into the bones with one piece turning almost 90 degrees.

Joint Fusion

Another option for a bunion with severe cartilage destruction is fusion.  Fusions are an excellent way to eliminate pain and realign the joint. Following a fusion, the foot is still fully functional with minimal long-term problems.  The downside to a fusion is obviously the lack of motion at the joint. This can be an issue, particularly with females who like to wear heels. Having said that, with fusions most patients can easily get back into a 2-inch heel.  Any higher than this usually poses a problem. Most patients that are candidates for a fusion have bad arthritis and very limited motion at the joint anyway, so don’t notice much decrease in range of motion after surgery.

The other down side to a fusion, as compared to an implant, is recovery time.  Once the joint is surgically fused it is important to stay off the foot until the two bones fused together.  This can require up to 2 months off the foot.

Joint fusions require some sort of fixation device such as staples, plates or screws.  

What is a bunionette (Tailor’s bunion)?

A bunionette, or Tailor’s bunion as they are also called, is a bony enlargement on the outside of the forefoot near the little toe.  They are the same as a regular bunion but on the other side of the foot. The area will become red and enlarged and is often painful, especially in shoes. The condition is often accompanied by a painful callus over the area as a result of the pressure. They are slow growing and can present on both feet.  The condition can develop from having a large bone spur in the area or from an abnormal curvature of the bone on the outside of the foot.

How did I get my Bunionette?

You can thank your Mom or Dad.  Yes, bunionettes are usually inherited.  They can present at any age but usually develop after age 30.  Bunionettes appear to be more common in females, probably due to the shoes women wear.  Tight shoes, pointed toe shoes, and high heels all tend to contribute to the development of a bunionette.

How is a bunionette different from a regular bunion?

A bunionette is similar to a regular bunion, it just occurs on the other side of the foot.  Bunionettes involves the bone that the little toe connects with called the fifth metatarsal.  A regular bunion involves the bone the big toe connects with called the first metatarsal. It is not uncommon to have both a bunion and a bunionette on the same foot.  This is most likely due to the fact that bunions and Tailor’s bunions tend to occur in feet with looser ligaments allowing the bones in the feet to spread apart.
What should I do about my bunionette?

If a bunionette is not painful the best treatment is accommodating the area with a wider shoe.  Additionally, there are pads and custom molded inserts which can be fabricated to protect the area.  Patients that experience occasional aches and pains in the area of their bunionette can be treated with anti-inflammatory medication, local padding, and cortisone injections.

Is there a surgery to fix a bunionette?

Yes, for patients with a severe deformity or those with chronic pain, surgery may be indicated.  The procedure involves removal of the enlarged bony prominence and possible an osteotomy or realignment of the bone.  Either way it is considered a minor outpatient procedure that takes about 2 hours. Patients are permitted to walk immediately after the procedure in a special post-op shoe.  Stitches are removed in 2 weeks and patients are usually back in shoes at 4-6 weeks.

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