By Robyn Gant, Director
The term bunion refers to bony bump that develops on the inside of the big toe joint and is typically associated with the condition called hallux valgus. This deformity involves abnormal deviation of the first metatarsal inwards and the proximal phalanx of the big toe outwards with inward rotation of the big toe.
The bony bump that appears is actually the normal head of the first metatarsal protruding due to the abnormal metatarsal alignment, and increased soft tissue thickening as a result of pressure form the shoe. This bump is vulnerable to compression and friction from the shoe and can result in inflammation of the soft tissues that lie over the bump.
While the cause of this condition remains unknown the research has demonstrated that it often runs in families and affects women more than men. The role of footwear in the development of the hallux valgus remains controversial as it also occurs in populations that don’t wear shoes and may occur in only one foot.
As a consequence of this deformity there is abnormal compression on the outside of the great toe joint (first MTP joint) and uneven weight-bearing load on the two small sesamoid bones under the first metatarsal , which can lead to arthritis. Pain arising from this deformity in the earlier stages can often be well managed with specific soft tissue release and stretching to maintain mobility in the muscles and joints as well as footwear advice
As the deformity worsens the widening of the forefoot and enlargement of the bump makes shoe fit more difficult, and increased pain is associated with the progression of arthritis and compression between the first and second toes leading to corns and clawing of the second toe.
Correction of this deformity requires surgical realignment of the first metatarsal and proximal phalanx bones. Surgery to correct this deformity has in the past had a reputation for being extremely painful with the added complication of a loss of mobility in the big toe joint due to scarring from the long incisions crossing the big toe joint. These issues had made me reluctant to recommend bunion surgery to my clients. Over the past 20 years I have following this topic at the Australian Foot and Ankle Orthopaedic conferences with great interest as my own hallux valgus deformity progressed. A new minimally invasive surgical procedure and improvements in pain management using local anaesthetic both pre and post surgery in conjunction with general anaesthetic, have dramatically changed bunion surgery for the better. This procedure has been used extensively used in Europe and the UK for over 10 years and has more recently been taken up by some of our Foot & Ankle Orthopods in Australia. In this procedure three tiny incisions, the size of a pen tip, are used to cut and realign the bones using a burr. Fluoroscopy, a type of continuous X-ray imaging, allows the surgeon to see the bones clearly and determine the correct alignment, which is then fixed in place with 3 screws.With this procedure there is minimal scar tissue, faster healing, and no damage to tissues crossing the big toe joint, eliminating the complication of joint stiffness.
As my own right hallux valgus deformity had finally reached the severe stage with arthritis and shoe fit becoming more problematic, I decided consult Dr Gordon Slater in Double Bay who has been using this technique successfully since 2011. The risks and complications were explained carefully to me including infection, nerve pain and loosening of the screws which may need to be removed. My surgery was scheduled for 9th January at Sydney Day Surgery in Crown Street. I was back at home the same evening with my foot up and it was perfect timing to enjoy watching the Australian Open Tennis during my recovery. Here are my pre- and post-operative X-rays and the post-operative shoe I had to wear for 6 weeks, which allows weight-bearing on the heel.
Now you might be thinking OUCH! The truth is I had virtually no pain and very minimal swelling and was up and about the next day. I chose to rest and stay off my feet as much as possible to avoid straining the rest of my body with the awkward walk in the post-op shoe. The only pain I felt was when my bandage was too tight and loosening the bandage alleviated it immediately. I was able to move my toes up and down to maintain mobility within the limits of the bandages and used a pedal exerciser to keep my circulation moving. So what does my foot look and move like now? See for yourself by comparing the pre-operative alignment and mobility on the left with the 3 month post-operative images on the right.
As you can see the alignment and mobility are excellent and you will need good eyesight to spot the tiny scars on the inside of my right foot (indicated by the white arrow)! I managed to integrate some pleasant activities into my early rehab with a bit of hydrotherapy using a self sealing cast protector to keep my foot dry. I also had a beach holiday the week after I got out of the boot to get my foot moving and gradually increase my weight bearing before coming back to work.
I am now working on regaining my calf strength and balance and have returned to yoga. The screws are not causing any discomfort, but can be removed later if they become bothersome. All surgery carries risks and is not the right choice for some people, however, having experienced this procedure and had such a great outcome will help me guide my clients who do wish to seek a surgical option.
My left foot which only began to develop the deformity last year has progressed to a 30 degree angle so I might consider enjoying the Australian Open Tennis again next year from my couch with my left foot up.
More information about Minimally Invasive Foot Surgery and Dr Gordon Slater.
Any surgical or invasive procedure carries risks. Before proceeding, you should seek a second opinion from an appropriately qualified health practitioner.