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This is a mal-positioning or buckling of the big toe joint that results in pain and deformity. The joint can become enlarged and sometimes a painful swelling called a bursa can also develop. Bunions are not normally caused by shoes, although tightly fitting or inappropriate shoes can certainly make them painful. A similar problem called a bunionette or Tailor’s bunion can also develop at the base of the little toe.

The formation of a bunion can weaken the medial arch of the foot, which affects posture and walking and may also overload the 2nd metatarsal joint, causing a painful condition called Hallux Valgus and may encourage a partial dislocation of the joint called subluxation. In these cases, the osteotomy (cut in bone) is made further back in the foot to give greater correction and/or a greater level of control.

Procedures here would include a base wedge osteotomy and a Lapidus procedure. It is usually necessary when these procedures are used to fit a below knee plaster for some weeks after surgery.

Scarf/Akin Osteotomies – X-rays needed

In this procedure, a Z-shaped cut is made in the metatarsal bone, the bone is moved into the correction and fixed with titanium screws. The bump and any excess bone are then removed. Occasionally, a 2nd procedure is carried out at the same time in the 1st toe bone (Akin) to ensure that the toe is straight.

The advantages of the Scarf/Akin procedures are an early return to reasonable activity and driving (about 2 weeks). Only a bandage is applied after surgery, there is normally a low level of post-operative pain, and the procedure gives consistently good results after surgery. There are a number of possible, though unlikely, complications. Full details of these would be given at the time of consultation. Stiffness and swelling are common and may take some while after surgery to subside. The foot will continue to improve for one year after surgery.

Silvers Akin

This approach can be employed when the level of deformity is lower, the foot is stable, or when there is a degree of osteoporosis present. The incision will be made, as usual, on the inside of the toe joint so, as far as possible, the scar is hidden and this will also avoid damaging the major nerve. An envelope called the capsule surrounds the joint. A small piece of this is removed so that when the capsule is closed, it will be tighter. The bump of the bunion is carefully removed. The Akin procedure is then used to improve the straightness of the big toe. If the patient is osteoporitic, with a higher level of deformity, then a small bone under the big toe joint is removed to allow greater correction. The healing time is approximately the same as a Scarf/Akin procedure.

Base Wedge Osteotomy

A small wedge of bone is removed from the bone of the 1st metatarsal. This is normally fixed with a single screw. This procedure can be combined with a joint replacement (implant) or an Akin procedure. A plaster cast is normally applied for three weeks followed for another two weeks by a removable boot.

Lapidus Procedure

This operation is less commonly used than the others above. It can cause considerable shortening of the 1st metatarsal bone and, for this reason, a bone graft may also be required. The indications for this type of operation include:-

1. A high level of deformity.

2. Hypermobility.

3. Arthritis.

The cartilage at the base of the 1st metatarsal is removed, an angled piece of bone from the cuneiform (the adjacent bone) is then removed. Use of a bone graft may be required at this point. The joint is then fused (stiffened). Not only is the aim to straighten the metatarsal and joint, but also to angle the bone down so that it becomes weight-bearing.

Other Procedures

There are a large number of other procedures possible. These are listed only, full information would be given at the time of consultation.

• The Reverden/Green, which was also modified by Laird. This method is used where the angle of the articular surface of the head of the 1st metatarsal is mal-aligned (the PASA angle).

• The “L” osteotomy. An “L” shaped cut with a double cut on the upright of the “L” is made. A small piece of bone is taken from this area and transposed to the horizontal arm of the “L” to lower the metatarsal head. This is sometimes called a decompression osteotomy and is used in cases of early Hallux Rigidus (see separate section on Hallux Rigidus).

Bunions (Hallux Valgus) on list

The Keller procedure is an old operation, which involves cutting out the base of the 1st toe bone and remodelling the 1st metatarsal head. It is a destructive joint procedure and is normally reserved for very arthritic joints or bunions in the older patient where a reconstructive approach is not possible.

Fusion

This would be used where there are severe arthritic changes in the great toe joint. Both sides of the big toe joint are cut away and the joint fused or stiffened, using screws or plates to stabilise the bone whilst fusion is taking place. This has a narrow indication and side effects, i.e. instability of the ankle has been recorded.