Bunion Surgery Explained
Fixing a bunion deformity is a common procedure performed thousands of times each day across the country
. Unfortunately, many people have misperceptions about the nature of that procedure, how long recovery takes, and the anticipated pain level one would experience in recovery. This article will help answer these questions, and dispel misperceptions about the nature of bunion surgery.
A bunion is a very complex foot deformity that generally develops over a long period of time. This condition, also known as hallux abductovalgus, is much more than a simple bone bump on the side of the foot. Some children are born with feet that either already have the bone that causes the bunion in an outward position, or have too much flexibility of the feet so that the growth of the bunion is accelerated through early childhood. However, by far the majority of people who have bunions develop them due to flat or flattening feet. The process that creates the bunion slowly over time starts when a foot is too flexible and excessively flattens out when one stands on their feet. This flattening does not have to be severe, and many people are surprised to learn that they have a flat foot structure, as this is hard to properly notice on oneself. As the foot over-flexes, added pressure is created on the long bone that is positioned in the foot just before the start of the big toe. Called the first metatarsal, this stout bone is forced upward and outward due to ground pressure. When this occurs, the tissue on the side of the big toe joint away from the second toe begins to stretch, and the side of the big toe joint nearest the second toe begins to tighten due to the pull of a certain muscle in the foot. The eventual result after millions upon millions of steps over a period of years is a gradual drawing of the big toe toward (and sometimes over or under) the second toe, and a protrusion of the front and side of the first metatarsal towards the side of the foot. This process has nothing to do with tight shoes, as ones bones have not been moldable by external pressure since age four or five. Tight shoes aggravate bunion pain, and nothing more.
Not all bunions are painful. In fact, many bunions cause little to no discomfort, at least initially. Bunion pain when it does eventually develop tends to arise from pressure along the side of the foot where the bunion bump rubs against the shoe. Eventually, pain in the joint itself can develop independent of shoe pressure as mild arthritis of the big toe joint appears. Initial treatment can include wider shoes, stiffer shoes, anti-inflammatory medications, prescription shoe inserts, and padding. However, most cases of bunion pain eventually require surgical correction to fix the actual foot deformity.
Bunion surgery requires precise planning by the surgeon, as many factors have to be taken into account. In general, most bunions require some procedure that re-shifts the first metatarsal back to its proper position, with the toe following. The bone usually has to be cut and reset in a new position in order for this to work. The most important technical factors that need to be addressed regarding this procedure involve how severe the bunion is (i.e. how far over is the first metatarsal positioned into the side of the foot), as well as whether or not the great toe joint cartilage is tilted towards the second toe too far. Of other technical consideration is the position of the first metatarsal in an up or down direction, as well as the quality of the bone itself. All these factors determine where the bone needs to be cut, and any modifications that need to be made to the standard cuts to fix the deformity. Mild to moderate bunions usually can be corrected by a cut that is made towards the big toe joint. This cut is generally more stable, especially if it is held in place with bone screws (which stay in the foot unnoticed forever). The soft tissue around the joint also needs to be remodeled to allow the toe to straighten. Recovery from this procedure is easier, with six weeks in a walking cast or protective boot while the bone heals. Bunions that are severe or very unstable need to be corrected further back along the 1st metatarsal, or even the joint where it begins, at an area that is far less stable. More hardware is needed to keep the corrected bone in position while it heals. Recovery from these sets of procedures generally requires six to eight weeks non-weight-bearing in a cast. Sometimes, procedures need to be performed on both ends of the bone, such as when there is a severe bunion with an abnormal rotation of cartilage at the big toe joint. Other factors that must be considered when correcting a bunion include realistic expectations, future activity, and quality of ones bone. Some people simply have unrealistic expectations about what bunion surgery will actually fix. Bunion correction will reduce the deformity and help decrease or eliminate the pain it causes. It will not necessarily create a straight-as-an-arrow big toe (which will not fit well into shoes anyway), nor will it allow one to fit into a tight dress shoe or heel without any discomfort. Activity is another consideration, particularly for older people. If an older patient has limited activity, then a more aggressive correction may not be needed if all that is required is a reduction of pain. Along with this is a consideration for the quality of the bone to be operated on. If the bone is thin, or has poor density, alternative procedures may need to be considered.
Recovery from bunion surgery will generally take six to eight weeks, plus an additional one to three months to strengthen the foot into full activity and eliminate stiffness. Pain after surgery always depends on the individual and their tolerance, but the occasional rumor that bunion surgery is very painful to recover from is simply untrue. Factors unique to foot surgery contribute to unnecessary post-operative pain if one ignores their post-operative instructions. Simply put, he body will feel great after this surgery, and this often leads patients to attempt to be over active. The basic fact is that the foot will need rest, elevation, and icing following surgery. The majority of pain felt after the first several days following surgery is often due to inflammation from overactivity. By following a proper post-operative recovery program, the likelihood of developing significant post-operative pain is decreased. Some pain is to be expected in the first several days after surgery, but it is uncommon for pain medications not to eliminate much of this immediate post-operative pain.
As one can see, bunions can be quite painful, but are also easily corrected with surgery. The proper selection of procedures by the surgeon, along with reasonable expectations by the patient who correctly follows the post-operative instructions leads to a great result, and a speedy recovery.
by: Scott Kilberg DPM
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