What is a Bunion?
A bunion is not a dangerous growth, cancer or some strange deformity. Bunions occur when abnormal motion and external pressure act on joints involving the big toe and 1st metatarsal resulting in dislocation and bone overgrowth at the 1st Metatarsal-Phalangeal joint (base of the big toe).
Most shutter at the mention of the word “Bunion”. The truth is that once understood, a bunion is actually quite an interesting musculoskeletal deformity with a variety of treatment options that can bring considerable pain and cosmetic relief.
Where did my bunion come from?
No one really knows for sure. Some cases are more clear cut than others. Certain family's can demonstrate generation after generation of members with bunions showing a clear genetic component. Others are the only members of their family with the problem, yet have a long history of wearing tight fitting high heels. The causes are varied and can be somewhat complex. One thing is quite clear, once you have a significant bunion deformity you have a good chance of going under the knife if you want it truly fixed.
What are my Treament Options?
The key to treatment is to exhaust conservative measures such as trying new shoes, modifying old shoes, orthotics, taping, bracing, ice, rest, NSAIDS, stretching etc. If after truly giving these ideas a serious attempt and the bunion still causes you discomfort then surgery may be in order. This is true especially if you experience pain both with shoes and without shoes. Surgery should never be decided upon unless you are experiencing significant pain that is disrupting your lifestyle.
With bunions, the procedure to correct the deformity is straightforward in most cases. Keep in mind that if pain is already present and persistent, surgery may be the answer. If you rarely experience pain, the chance of creating new chronic pain goes up after surgery. This is the classic risk of undergoing surgery purely for cosmetic surgery. Surgical procedures to correct bunions for cosmetic reasons alone are usually avoided unless the deformity is causing serious emotional discomfort. The risks of infection, chronic new pain, nerve entrapment, scar tissue etc outweigh the benefits of correcting a painless bunion in the majority of cases.
Bunion surgery can involve tendon, joint capsule, and soft tissue work alone or be combined with various types of bone cuts with shifting of bone fragments back into correct alignment. The severity of the deformity along with the relative flexibility of the patients foot will determine how invasive the surgery needs to be and the location of the bone cuts as well as the length of recovery.
The majority of cases can be corrected with soft tissue work and a simple bone cut just behind the big toe on a bone called the 1st metatarsal. The most common cut is called an Austin Procedure. This surgery allows the patient to bear weight almost immediately on the foot following surgery.
If the patient has a very flexible foot or the real problem is judged to be further back on the foot, then a more involved surgery called a Lapidus Procedure may be necessary. This procedure requires that the patient place no weight on the foot for 6-8 weeks when the surgeon uses traditional screws and plates. Newer approaches may allow for weight bearing 2-3 weeks after surgery in a CAM boot. A newer type of procedure involving external fixation that uses a fixation apparatus outside the skin with metal rods allowing the patient to bear weight almost immediately on the foot. This option requires daily pin care to help avoid infection at the site of entry into the skin of the foot.
X-ray of a Lapidus Procedure:
There are many variations and alternatives to these two popular procedures, some include fusing the big toe joint forever, using artificial implants or amputating the toe all together. If you ever doubt what your Doctor or Surgeon is telling you, please feel free to ask them for a second opinion or seek one out on your own. It's your foot, your own set of wheels, don't commit to surgery until you're convinced that it is necessary and appropriate.
What are the expected outcomes?
Pain and swelling can persist for 1-2 months or even 6 months to a year after surgery. Physical therapy, compression therapy and home exercises such as stretching are usually implemented to speed recovery.
High levels of pain after surgery are usually well controlled with medication and normally peak at 2-3 days after surgery with a quick decline in the first 1-2 weeks. A number of patients have reported having little to no pain throughout the entire process. These are usually the patients who take their pain meds regularly as directed. The key is to stay ahead of your pain, not wait for it to knock you flat.
Most patients who had very painful bunions to begin with are quite happy with the outcomes of their surgery. Those who pursued the surgery for cosmetic reasons alone sometimes show up in clinic complaining of new pain or lingering pain that they didn't expect to have to deal with.
As always, these posts are not meant to be complete or all inclusive but rather as place to start your research. Please pop me an e-mail with any questions you may have on any topics on your mind regarding the foot and ankle.
Dan Preece, DPM
Dan Preece, DPM & Darren Groberg, DPM