What is a Bunionectomy (and What Should You Expect)?

Dr. Anthony Ferguson, MD

The feet are vital to our daily function, and dealing with chronic foot pain caused by a bunion can be debilitating. If you’ve started looking into treatment for bunions, you might be asking yourself a thousand questions such as “What causes a bunion?”, “ What are my treatment options?”, and “ What is a bunionectomy?”

Orthopedic surgeon Dr. Anthony Ferguson, MD, of Wisconsin Bone and Joint and orthopedic surgeon at the Orthopaedic Hospital of Wisconsin, can answer your questions. Dr. Feguson specializes in treating foot and ankle conditions and is an expert in helping patients get back on their feet. 

Today, Dr. Ferguson discusses bunions, treatment options, and surgery. 

What is a Bunion?

A bunion is the large bump that forms when your big toe is angled towards the outside of the foot. The technical name for this is hallux valgus. As the toe shifts further and further to the outside of the foot, a bone spur develops on the inside. This makes the bunion appear worse. A thick callus typically develops the prominent bone rubs on the shoe. As the bunion worsens, both the callus and the joint becomes very painful.  

Most patients only go to their doctor when the pain becomes bothersome. Even with a severely angled toe, patients typically function well as long as the toe remains relatively pain-free.  

What Causes Bunions?

The exact cause of bunions remains a source of debate, even among orthopedic foot and ankle specialists. Several factors may play a role, including footwear, heredity, flat feet, excessive joint laxity, and abnormal bone alignment and/or length.  

Women are more frequently affected by bunions than men, but this may be because of the footwear differences between women and men. However poorly fitting shoes aren’t the only cause. As most people who wear fashionable footwear do not develop bunions, there are undoubtedly problems within the foot that are made worse by shoes. Plus, footwear is not to blame in the rare cases of congenital and juvenile bunions, as there are often abnormalities of the joints and bones themselves.

Will My Bunion Progress?

Patients often ask if their bunions will get worse over time. The answer for most patients is that we don’t know which bunions will remain stable and which ones will progress. Even if a surgeon does predict that a bunion will likely worsen, it is almost impossible to predict the speed at which the progression will occur. 

Some patients with mild bunions will not significantly progress, while others worsen rapidly. Anticipating when an asymptomatic toe will become painful is probably the most challenging question of all to answer. A patient with a mild bunion may hurt significantly worse than another with a severe one.  

However, there are cases when a surgeon can predict the progression of a bunion. This is important for both the patient and the orthopedic surgeon because the advancement of the deformity might significantly alter the surgical technique recommended. Mild bunions usually require a less extensive surgical procedure than very severe bunions. These questions are best discussed with your orthopedic surgeon since all surgical plans are individual to each patient.

How Do You Treat a Bunion?

Prevention 

Conservative treatment of bunions begins with prevention. This means wearing proper footwear. We can’t do anything about our genetics, but we can buy shoes with enough room in the toe box and a heel that is of reasonable height. One excellent visual example is to have a person stand on a sheet of paper and use a pen or pencil to outline the foot onto the piece of paper. Once you have the drawing, lay each pair of shoes over this outline and compare the sizes. It may reveal just how narrow the typical pointed, high-heeled pump is relative to the size of the foot.  

Bunions and Diabetes

When a diabetic person has a bunion, this is an especially concerning condition. People with diabetes must take very meticulous care of their feet. The abnormal alignment of the bunion and the prominent bony bump and overlying callus predispose the foot to excessive rubbing within the shoe. Excessive rubbing can lead to skin breakdown and blistering. This may result in the formation of a diabetic ulcer, which can be devastating and require prompt, expert treatment to prevent serious complications. Diabetics must maintain a comprehensive foot care program and should discuss this with their primary physician. Proper footwear is a critical component of this program.

Orthotic Devices

Orthotic devices have not displayed the ability to prevent the progression of a bunion, but for certain patients, they can provide a degree of symptom relief. Others benefit from stretching, pads, or night splints, but these devices also do not alter the natural evolution of the process. Patients with a bunion in combination with arthritis typically feel better in stiff-soled shoes that limit motion of the painful joint.  

Medication

Generally, medications have a limited role in the treatment of bunions. Over-the-counter Tylenol is typically well-tolerated, as are anti-inflammatory medications such as Advil, Motrin, Aleve, and their generic equivalents. All medications will need to be brought to the attention of your orthopedic surgeon, especially if the patient is contemplating surgery, since they may need adjusting both before and after surgery.

What is a Bunionectomy?

A bunionectomy (bunion surgery) encompasses a broad spectrum of procedures from the relatively straightforward, to the highly complex. The exact procedure recommended by an orthopedic surgeon will be individualized to each patient and based on the specific nature of the bunion and the experience of the surgeon. 

The details of each technique are beyond the scope of this discussion as entire surgical textbooks are written on the subject but it is important to discuss the general goals of the surgery and what one can expect in terms of recovery and potential complications.

It is important to remember that the goal of bunion surgery is almost always to improve pain and thereby improve function, not as a cosmetic procedure or to allow patients to return to very narrow, pointed shoes with very high heels. Realistic expectations and goals are critical to a successful outcome and must be discussed with your orthopedic surgeon. Generally, if a bunion is pain-free, surgery is not indicated.

For a mild to moderate bunion, the two primary goals of surgery are to remove the bump (medial exostosis) and to improve the abnormally angled toe. The technique used to remove the bump is fairly standard, and bump removal is a part of every surgical procedure. The specific methods available to correct the abnormal angle vary considerably.  

Soft Tissue Procedures 

Soft tissue procedures release or lengthen abnormally tight and contracted tissues combined with the tightening or augmentation of the abnormally stretched and lengthened tissues. These procedures might be performed alone or in combination with a bony procedure.

Bony Procedures 

Bony procedures entail cutting the bone. This is called an osteotomy. It allows for shifting the position of the bone and will thereby allow for much more correction. Most moderate and virtually all severe bunions require some form of bony procedure to allow for sufficient correction of the abnormal alignment. Depending on the specific technique, hardware is often needed to maintain the corrected position and expedite bone healing. This may take the form of one or more pins or screws.

Fusion Bunion Surgery 

When a bunion is very severe or is associated with advanced arthritis, surgeons will often recommend a fusion. By fusing the bones in a corrected position, the bunion is corrected and the chance for recurrence of the deformity is eliminated. Overall, the function is excellent after a fusion, and patients will walk normally and can return to virtually all the sports they participated in before the surgery. However, they cannot wear very high heels since the toe will be made stiff and unable to extend to accommodate a high heel.  

After a Bunionectomy 

The exact recovery time will vary tremendously based on the individual patient, the specific procedure required, and the type of demands placed on the foot during work, sports, and leisure activities. It is best to discuss this with your orthopedic surgeon since they can account for all the pertinent variables.  

Bunion surgery is generally a very safe and effective procedure, however, it is still surgery. Any procedure must be taken very seriously and only undertaken when the patient understands the potential risks, benefits, and alternatives. The overall complication rate with bunion surgery is very low, and when compared to similar procedures it is well tolerated.  

As with all surgical procedures, there are always the risks of injury to nerves and blood vessels, bleeding, infection, and wound healing problems. We discussed earlier that bunions usually result from a combination of footwear and abnormal forces within the foot itself. This means that there will always be a chance that the bunion may return, even if the procedure and the recovery go perfectly. The good news is that the likelihood of developing a bunion recurrence that requires a repeat surgery is quite rare. Some stiffness in the toe is possible but is usually not a significant complaint. Fortunately, all of these complications are rare, and most patients are satisfied with the results.

Summary

Bunions represent a complex and wide variety of problems that result in a painful great toe that deviates outward and has a prominent bony and soft tissue bump on the inner aspect of the ball of the foot. The exact cause remains unclear, but it almost always involves poor footwear choices and anatomical and hereditary abnormalities within the foot. Whether or not a bunion will progress is difficult to predict, but even mild cases can be painful and symptomatic. Surgery is reserved for symptomatic bunions and is a very safe and effective procedure yielding satisfactory results in the majority of patients. Surgical techniques, recovery times, and return to work status are tailored to each patient and can be discussed with your orthopedic surgeon. 

If you’re dealing with bunion pain, don’t hesitate to make an appointment with one of our talented orthopedic specialists. The professionals at the Orthopaedic Hospital of Wisconsin are here to help you discuss your treatment options from finding the right orthotic devices and physical therapy exercises, to helping you start the process of bunion surgery.