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Bunion (Hallux Valgus)

What is a bunion?

The medical term for this is hallux valgus. Hallux means big toe and valgus means that the toe deviates to the outside of the foot. The term Bunion really just means a bump. It is derived from the Latin word bunio, which means turnip! As the toe becomes deformed as well as causing a cosmetic deformity it affects the function of the foot.

The foot tends to become more flat and you can get pain under the forefoot area and over the bony prominence on the inside of the foot from rubbing on footwear. As the deformity progresses the big toe can act as a bully pushing the other toes out of the way. It is usually the 2nd and 3rd toes that are affected. This can result in a dislocation of the other toes or can cause the toes to claw as they try to get out of the way. This can then cause problems with footwear as the toes rub on the shoes and corns develop on the tops of the toes.

What are the treatments that are available?

Because there are many factors involved with the cause of a bunion there is no one single treatment for bunions. There are over 100 different operative procedures described in the medical literature to deal with bunions.

Put simply there are two main ways of treating a bunion:

1, Change the shape of your footwear or adapting it to minimise your symptoms.

2, Change the shape of your foot by surgery.

Looking at the footwear there are many options. These include wider shoes (Wide toe box), softer leather shoes, sandals in the summer months, and custom made bespoke shoes with extra depth and width. There are also various silicone spacers and supports available that can be used to take the pressure off the bunion and help to prevent rubbing on any footwear.

If you have a flat foot then an insole with an arch support may also help reduce some of the symptoms.
The goals of surgery are to realign and balance the big toe so that it and the foot functions more normally. This is usually done by a combination of tendon and ligament releases and by making cuts in the bones (osteotomy) and fixing the bones in a slightly different position. The bone cuts are usually fixed with screws or a staple and this is stable which allows for early mobilisation and weight bearing without the need for plaster in most cases. Sometimes however if the bunion deformity is more severe then the deformity has to be corrected by permanently fusing a joint (arthrodesis) and this will usually need protecting in a plaster cast (POT).

What is the cause of my bunion?

There is not a single cause of bunions. It can be caused by joint destruction as seen in various forms of arthritis such as rheumatoid arthritis. Muscle imbalance as seen in conditions such as polio and cerebral palsy can also be a factor.

In most people however there is a genetic component to the condition. So you will often find that different generations of the same family will have similar deformities in their feet. The shape of some people’s bones in the foot and the angles between them do predispose to an imbalance of the muscle and tendons passing across the joints into the big toe. As we get older some of the muscles in the foot don’t work as well and all these factors can combine to cause a bunion. The age at which the deformity starts is variable and the speed at which is can progress is also variable and not very easy to predict with any accuracy.

High-heeled “court” shoes have in the past been blamed as the cause for bunions. This is not strictly true but they will make the symptoms worse and can cause corns to develop due to pressure on the foot. If the symptoms are only present when wearing these types of shoes then the simplest treatment is to change the types of shoes you wear.

There are other conditions such as gout, arthritis and infection that can also give rise to pain in the big toe. Circulation problems can also cause pain in the foot and can give rise to serious complications if surgery is undertaken. Diabetes can also cause problems in the foot and if surgery is undertaken can decrease healing potential and increase the risk of infection.

So medical assessment is essential to make sure the correct diagnosis is made and therefore the correct treatment is started.

The decision on when to have surgery depends on the level of symptoms. Everyone is different and some people will have very severe deformities but function very well with very little pain and inconvenience. Others may have minimal pain and the main problem is the inability to get into a normal shoe. If however a bunion is pain free then surgery would not be recommended as the risks of surgery may outweigh the potential benefits but this decision need to be made by the patient once they are aware of what the surgery involves and the time taken for recovery and the potential complications.

The most common surgical procedure performed for a bunion is a scarf osteotomy of the first metatarsal. This is sometimes combined with an akin osteotomy of the proximal phalanx. (See x rays below) This is performed under a general anaesthetic together with a local anaesthetic block around the ankle, which helps to provide pain relief in the postoperative period by giving you a partially numb foot. Most patients can get into a broad soft trainer type shoe at six weeks after the surgery and you can usually go back to driving at this stage.

The foot will still tend to swell and this can take up to eighteen months to fully settle. Most patients will have been discharged from the clinic three months after the surgery. Overall 90 – 95% of patients who have this type of surgery have a good or excellent result.