Surgery for Hallux Valgus

What is Surgery for Hallux Valgus?

Hallux Valgus, more commonly known as bunions, is a common deformity. For many people, increasing pain and stiffness makes walking and fitting shoes difficult. Eventually, more conservative ways of managing bunions become inadequate and surgery becomes an option.

Surgical correction of hallux valgus can encompass a few different procedures, including:

  • Soft tissue realignment.
  • Osteotomy
  • Re-positioning the sesamoids.
  • Arthrodesis or Fusion.

The type of surgery chosen for you will depend on

  • the severity of your bunions
  • the state of the blood vessels, nerves and other tissues in your foot
  • your expectations after recovery.

The recovery from hallux valgus surgery lasts weeks to months. In the first few weeks after the operation you will need to avoid putting any weight on your foot and will have to spend lots of time with your foot elevated. After this, swelling and pain will gradually go down and you can physiotherapy will help speed your return to weight-bearing and wearing normal shoes.

It is very important to clarify what degree of activity you expect after recovering from surgery, and in particular if you wish to continue playing sports. In addition, you need to discuss the cosmetic outcome of surgery.

Who is this operation for?

Before deciding on whether you need surgery or not, it is important that you and your surgeon discuss what you want and expect from surgery. Reasons for considering surgery include:

  • Significant pain, unrelieved by other measures
  • Worsening deformity
  • Impact of life – activities for work, walking etc.

It is unlikely that a surgeon will perform an operation on purely cosmetic grounds. However, you should be happy with the way your foot looks following surgery. If you wish to wear open shoes for example, you can discuss the option of scars on only the sole of your foot. It may not always be possible for surgeons to accomodate your wishes, but this should be discussed before the operation takes place.

It is important to remember that while surgery can correct many problems, it cannot give you a brand new foot. Surgery aims to make life easier by reducing pain, making walking more bearable, and reducing tendency to fall.

Sometimes, despite good reasons for doing surgery, it is not possible or practical to take a patient to theatre. Some of these include:

  • Incapacity to withstand surgery – elderly, poor heart / lung function
  • Local factors – nerve or blood vessel comprimise in the foot

Your surgeon will discuss your fitness for surgery with you, and may ask you to do extra tests to prove your ability to tolerate the stress.

Complications

Surgeries for hallux valgus are performed frequently and are usually very successful. Some risks and complications associated with surgical correction of bunions includes:

  • Infection. Infection is a risk of any operation, and your surgeon will usually prescribe preventative antibiotics. If you do develop an infection, stronger or different antibiotics will usually cure you. The infection is usually in the skin or just beneath the scar, however very occasionally the infection can spread to the bone (‘osteomyelitis’). Diabetics and smokers are more prone to infection.
  • Deformity recurrence. After a few months you may notice your bunion ‘re-growing’. This cannot always be prevented, and may require more surgery. Sometimes the deformity is over-corrected, resulting in an outward position of your big toe.
  • Problems in the bone.
    • Avascular necrosis of the metatarsal head. If the blood supply to part of your bone is disrupted, the bone can begin to die. This is a rare complication but is always mentioned because it is so serious. It will usually be picked up on X-Ray in your follow-up appointments and may require extra surgery to remove the dead tissue.
    • Failure of the bones to heal (nonunion), or healing in the wrong position (malunion).
  • Ongiong pain
  • Nerve problems. If nerves are damaged or irritated during the surgery, you may experience numbness or tingling. This will usually resolve without treatment.
  • Hardware problems. The screws, pins and plates used to in orthopaedic surgery occasionally cause problems. This can happen if the hardware becomes loose, but more commonly is just a result of irritation between the soft tissues and the foreign object. This can be corrected by trimming or replacing hardware.

There are a number of other complications associated with all types of surgery, including:

  • Clots in the leg and lung
  • Heart and lung problems
  • Infection
  • Bleeding

Before the operation

Your surgeon will look very closely at your foot as well as taking several X-Rays. These will give your surgeon an idea about whether your bunion is:

  • Congruent. This means that the joint and involved bones fit together well, but the tendons and other ‘soft tissues’ around the joint are deforming the toe.
  • Incongruent
  • Degenerative

This classification allows your surgeon to decide which procedure is most appropriate for you. 

In addition to specific assessment of your foot, the doctors at the hospital will do a general, pre-operative assessment to ensure that surgery will be as safe as possible.

Preadmission Clinic | Preparing for Surgery

Before your operation, you will be seen at the Preadmission clinic to make sure you are fit for the operation and all the necessary tests are performed in preparation for the operation.

During the visit, you will be seen by a

  • doctor
  • nurse
  • anaesthetist (if necessary)

Tests

Tests that may be ordered for you include:

  • blood tests
  • Xray of your Chest
  • Urine Test
  • ECG

Preparing Your Skin

Your skin should not have any infections or irritations before surgery. If either is present, contact your orthopaedic surgeon for a program to improve your skin before surgery.

Tip

Carry a list of your medications with you including the name, dosage and how often you take it.

Medications

Our doctors will advise you which medications you should stop or can continue taking before surgery.

Get some help from your friends and family

Although you will be able to walk with crutches or a walker soon after surgery, you will need some help for several weeks with such tasks as cooking, shopping, bathing, and laundry. If you live alone, your orthopaedic surgeon’s office, a social worker, or a discharge planner at the hospital can help you make advance arrangements to have someone assist you at your home. A short stay in an extended-care facility during your recovery after surgery also may be arranged.

About the Operation

There are a number of different operations that can be performed to correct hallux valgus.

  • Soft tissue realignment. The abnormal position of the large toe strains the tendons and muscles between the first and second metatarsals, causing them to scar up and contract. Releasing these can assist in re-aligning the toe and reducing pain.
  • Osteotomy or trimming and reshaping bones. Edges of bone may be shaved off, or wedges may be cut away then the bones realigned to correct the deformity.
  • Re-positioning the sesamoids. The sesamoid bone is a small disc-schaped bone similar to your knee-cap, located beneath the ball of your big toe. It is often pulled out of position and may be corrected as part of your surgery.
  • Arthrodesis or Fusion. This is the most dramatic surgery. It is usually very successful at returning the foot to a relatively normal shape, however all flexibility in the toe is lost, making acitivites like running virtually impossible.

After the Operation

After your operation you will be taken back to the ward. A thick protective bandage will be wrapped around your foot, and local anaesthesia will keep your leg relatively numb and pain-free. As this anaesthesia wears off in the following 24 hours, nurses will administer other forms of pain-killers to keep you comfortable.

When you’re on the ward a team of nurses, physiotherapists and doctors will take care of you.

  • Feeling nauseous or constipated – this is common after surgery, and will sometimes require medications.
  • Special stockings – if your surgeon thinks you are at risk of DVT, of the development of clots in your leg, you may be asked to wear thick white stockings.

Are there any special situations I should be aware of?

Once you’re home…

  • You may have difficulty getting around.
  • When possible, elevate your leg. This will help reduce swelling and facilitate healing.

If you have any of the following symptoms you should call your doctor or come back to hospital:

  • Fever, swelling, redness, itching, excessive pain – these symptoms may suggest the wound has become infected. This can usually be treated effectively with antibiotics, and acting fast is the key to preventing major complications.
  • Toes that tingle or turn blue – your bandage may be too tight. Sometimes this happens when your foot swells. If you have diabetes you may have decreased sensation in your foot that you’re unaware of. It is important to check your foot often to make sure your bandage is not too tight.
  • Extreme pain – some unfortunate people suffer from a syndrome called reflex sympathetic dystrophy, or pain in excess of the surgical insult. It is believed that this is related to irritation of nerves.

Later on

Patients who have undergone surgery are usually asked to attend outpatient clinic for a check-up in a few weeks time. This is routine, and an important part of your care. At your outpatient appointment you can:

  • Discuss your surgery and how you have been feeling since.
  • Discuss the need for future care.

This visit is also important for your surgeon to check that later complications (eg avascular necrosis) are not developing.

Recovery and Rehabilitation

After the operation, you will need to remain non-weight bearing with your foot elevated for the first two to three days.

After this time you will need to wear a special shoe that shifts your weight away from your large toe. This usually continues for around 6 weeks, but during this time you can put your full weight through the foot.

You will start seeing a physiotherapist who will show you a number of exercises to maintain the flexibility of your joint. These will gradually progress into full strengthening and range of motion exercises over the weeks of your rehabilitation.

F.A.Q.s | Frequently Asked Questions

Can my bunion come back after surgery?

Yes, unfortunately bunions have been known to recur.

References

Hart, E. S., et al., ‘Current Concepts in the Treatment of Hallux Valgus’, Orthopaedic Nursing, Sep/Oct 2008, Vol. 27, No. 5, 274-280.

Mann Jeffrey A, et al., “Chapter 9. Foot & Ankle Surgery” (Chapter). Skinner HB: CURRENT Diagnosis & Treatment in Orthopedics, 4e: http://www.accessmedicine.com/content.aspx?aID=2321540