Bunionectomy

Definition

A bunionectomy is a surgical procedure to excise, or remove, a bunion. A bunion is an enlargement of the joint at the base of the big toe and is comprised of bone and soft tissue. It is usually a result of inflammation and irritation from poorly fitting (narrow and tight) shoes in

A bunion results in a bony overgrowth in the foot, causing the big toe to curve outward. To repair this, an incision is made in the top of the foot (A). The overgrowth and fluid-filled sac called a bursa are removed (B). The phalanx bone of the big toe is shortened to straighten it (C). The foot is realigned, and the incision is closed (D). (

Illustration by GGS Inc.

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Purpose

A bunionectomy is performed when conservative means of addressing the problem, including properly fitting, wide-toed shoes, a padded cushion against the joint, orthotics, and anti-inflammatory medication, are unsuccessful. As the big toe moves sideways, it can push the second toe sideways as well. This can result in extreme deformity of the foot, and the patient may complain not only of significant pain, but of an inability to find shoes that fit.

Demographics

Bunion formation can be hereditary, which means that if the individual's mother or father had the condition, he or she is at an increased risk of developing one as well. Bunions can also be a result of a congenital deformity, which means that the individual was born with an anatomical condition that made the development of a bunion more likely. Women are nine to 10 times more likely to develop bunions than men. The American Orthopaedic Foot & Ankle Society reports a study estimating that about 88% of women wear shoes that are too small and that 55% have developed bunions. The condition may begin to form in adolescence. Other conditions that contribute to bunion formation include flat-footedness, a tight Achilles tendon, and rheumatoid arthritis. The earlier the diagnosis, the better the chance that significant deformity will be avoided.

Description

Bunions become more common later in life. One reason is that with age the foot spreads and proper alignment is not maintained. In addition, the constant friction of poorly fitting shoes against the big toe joint creates a greater problem over time. Ignoring the problem in its early stages leads to a shifting gait that further aggravates the situation.

Once surgery has been decided on, the extent of the procedure will depend on the degree of deformity that has taken place. There are several different surgical techniques, mostly named after the surgeons who developed them, such as McBride, Chevron, and Keller. The degree and angle of deformity as well as the patient's age and physical condition play a significant role in the surgeon's choice of technique, which will determine how much tissue is removed and whether or not bone repositioning will occur. If bone repositioning is done, that part of the surgery is referred to as an osteotomy ( osteo means bone). The type of anesthesia, whether ankle block (the most common, in which the foot is numb but the patient is awake), general, or spinal, will depend on the patient's condition and the anticipated extent of the surgery. For surgery done on an ambulatory basis, the patient will usually be asked to arrive one to two hours before the surgery and stay for about two to three hours after the procedure. The procedure itself may take about an hour.

The surgeon will make an incision over the swollen area at the first joint of the big toe. The enlarged lump will be removed. The surgeon may need to reposition the alignment of the bones of the big toe. This may require more than one incision. The bone itself may need to be cut. If the joint surfaces have been damaged, the surgeon may hold the bones together with screws, wires, or metal plates. In severe cases, the entire joint may need to be removed and a joint replacement inserted. If pins were used to hold the bones in place during recovery, they will be removed a few weeks later. In some mild cases, it may be sufficient to repair the tendons and ligaments that are pulling the big toe out of alignment. When finished, the surgeon will close the incision with sutures and may apply steri-strips as an added reinforcement. A compression dressing will be wrapped around the surgical wound. This helps to keep the foot in alignment as well as help reduce postoperative swelling.

Diagnosis/Preparation

Intense pain at the first joint of the big toe is what most commonly brings the patient to the doctor. Loss of toe mobility may also have occurred. Severe deformity of the foot may also make it almost impossible for the patient to fit the affected foot into a shoe. The condition may be in either foot or in both. In addition, there may be a crackling sound in the joint when it moves. Diagnosis of a bunion is based on a physical examination , a detailed history of the patient's symptoms and their development over time, and x rays to determine the degree of deformity. Other foot disorders such as gout must be ruled out. The patient history should include factors that increase the pain, the patient's level of physical activity, occupation, amount of time spent on his or her feet, the type of shoe most frequently worn, other health conditions such as diabetes that can affect the body's ability to heal, a thorough medication history, including home remedies, and any allergies to food, medications, or environmental aspects. The physical exam should include an assessment while standing and walking to judge the degree to which stability and gait have been affected, as well as an assessment while seated or lying down to measure range of motion and anatomical integrity. An examination of the foot itself will check for the presence of unusual calluses, which indicate abnormal patterns of friction. Circulation in the affected foot will be noted by checking the skin color and temperature. A neurological assessment will also be conducted.

Conservative measures are usually the first line of treatment and target dealing with the acute phase of the condition, as well as attempting to stop the progression of the condition to a more serious form. Measures may include:

• rest and elevation of the affected foot
• eliminating any additional pressure on the tender area, perhaps by using soft slippers instead of shoes
• soaking the foot in warm water to improve blood flow
• use of anti-inflammatory oral medication
• an injection of a steroidal medication into the area surrounding the joint
• systematic use of an orthotic, either an over-the-counter product or one specifically molded to the foot
• the use of a cushioned padding against the joint when wearing a shoe

If these measures prove unsuccessful, or if the condition has worsened to significant foot deformity and altered gait, then a bunionectomy is considered. The doctor may use the term hallux valgus when referring to the bunion. Hallux means big toe and valgus means bent outward. In discussing the surgical option, it is important for the patient to clearly understand the degree of improvement that is realistic following surgery.

X rays to determine the exact angle of displacement of the big toe and potential involvement of the second toe will be taken. The angles of the two toes in relation to each other will be noted to determine the severity of the condition. Studies in both a standing as well as a seated or lying down position will be considered. These will guide the surgeon at the time of the surgery as well. In addition, blood tests, an EKG, and a chest x-ray will most likely be ordered to be sure that no other medical condition has gone undiagnosed that could affect the success of the surgery and the patient's recovery.

Aftercare

Recovery from a bunionectomy takes place both at the surgical center as well as in the patient's home. Immediate post-surgical care is provided in the surgical recovery area. The patient's foot will be monitored for bleeding and excessive swelling; some swelling is considered normal. The patient will need to stay for a few hours in the recovery area before being discharged. This allows time for the anesthesia to wear off. The patient will be monitored for nausea and vomiting, potential aftereffects of the anesthesia, and will be given something light to eat, such as crackers and juice or ginger ale, to see how the food is tolerated. Hospital policy usually requires that the patient have someone drive them home, as there is a safety concern after having undergone anesthesia. In addition, the patient will most likely be on pain medication that could cause drowsiness and impaired thinking.

It is important to contact the surgeon if any of the following occur after discharge from the surgical center:

• fever
• chills
• constant or increased pain at the surgical site
• redness and a warmth to the touch in the area around the dressing
• swelling in the calf above the operated foot
• the dressing has become wet and falls off
• the dressing is bloody

While the patient can expect to return to normal activities within six to eight weeks after the surgery, the foot is at increased risk for swelling for several months. When the patient can expect to bear weight on the operated foot will depend on the extent of the surgery. The milder the deformity, the less tissue is removed and the sooner the return to normal activity level. During the sixto-eight-week recovery period, a special shoe, boot, or cast may be worn to accommodate the surgical bandage and to help provide stability to the foot.

Risks

All surgical procedures involve some degree of risk. The most likely problems to occur in a bunionectomy are infection, pain, nerve damage to the operated foot, and the possibility that the bunion will recur. Sharing all pertinent past and present medical history with the surgical team helps to lower the chance of a complication. In addition to the risk of the surgery itself, anesthesia also has risks. It is important to share with the anesthesia team the list of all the vitamins, herbs, and supplements, over-the-counter medications, and prescription medications that the patient is taking.

Normal results

The expected result will depend on the degree of deformity that has occurred prior to surgery, the patient's medical condition and age, and the adherence to the recovery regimen prescribed. Some degree of swelling in the foot is normal for up to six months after the surgery. Once wound healing has taken place, the surgeon may recommend exercises or physical therapy to improve foot strength and range of motion. It is important to be realistic about the possible results before consenting to the surgery. Since over-pronation of the foot is not corrected with the surgery, orthotics to help keep the foot/feet in alignment are usually prescribed.

Morbidity and mortality rates

According to the American Orthopaedic Foot & Ankle Society, less than 10% of patients undergoing bunionectomy experience complications, and 85–90% of patients feel the surgery was successful.

Alternatives

It may be possible to avoid surgery by preventing bunion growth from worsening. Wearing shoes that are the right size and shape is a key factor. Try on new shoes in the afternoon when the foot is more tired and perhaps has some fluid buildup. Rather than going by size alone, make sure the shoe fits well, and that there is proper arch support. Additionally, there should be enough space in the toe box for the toes to wiggle around.

If diagnosed early, an injection of a steroidal anti-inflammatory medication around the joint may be enough to decrease the irritation in the area and allow the joint to recuperate. This, along with proper shoes, may halt progression of the condition. If there is no pain accompanying the bunion, surgery is not necessary. Some people find that a cream containing the same ingredient as found in chili peppers, capsaicin, applied locally to the joint can decrease the pain. However, once deformity and its accompanying severe pain has occurred, it is unlikely that surgery can be avoided.

Resources

BOOKS

Barker, L. Randol, John R. Burton, and Phillip D. Zieve, eds. Principles of Ambulatory Medicine. 5th edition. Baltimore: William & Wilkins, 1999.

Skinner, Harry B. Current Diagnosis & Treatment in Orthopedics. Appleton & Lange, 2000.

ORGANIZATIONS

American Orthopaedic Foot & Ankle Society. 2517 Eastlake Avenue East, Seattle, WA 98102. http://www.aofas.org . American Podiatric Medical Association. http://www.apma.com .

Esther Csapo Rastegari, RN, BSN, EdM

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Bunionectomies are performed by orthopedic surgeons, podiatric surgeons, and general surgeons. In selecting a surgeon, it is best to consider those who perform at least 20 bunionectomies each year. Most bunionectomies are performed as same-day, or ambulatory, surgery, in which the patient goes home the same day of the procedure. Sometimes a patient's condition may warrant staying overnight in the hospital.

QUESTIONS TO ASK THE DOCTOR

• How many bunionectomies do you perform each year?
• Are there any clinical trials for new medications or new types of procedures available?
• What complications have you seen with this procedure?
• What choices do I have for anesthesia?
• What can I expect during the recovery period?
• When can I return to my work and other regular activities?
• How soon after the surgery can I drive?
• How much improvement can I expect after surgery?