Fig.1Hallux Valgus and Bunion
Hallux valgus is a common condition, which affects women more than men.
Over time the big toe starts to bend and deviate towards the smaller toes causing a large, painful bump or bunion on the inside of the foot. This can also be associated with the 2nd toe crossing the big toe. Hardened skin forms underneath the foot at the level of the knuckle joint of the 2nd toe. This combination of changes results in pain and redness over the bunion joint itself and underneath the foot. You may also experience bending or clawing of the 2nd toe with rubbing against footwear and pain may be felt on the hardened skin of the 2nd toe. “Hallux valgus” is the medical term for the big toe pointing too much towards the lesser toes. The “bunion” is the often painful lump on the inside of the foot at the base of the hallux valgus (Fig. 1). Although we don’t fully understand what causes hallux valgus, there does seem to be a tendency for it to run in families but certainly the wearing of high heels seems to accelerate the development of bunions. Treatment of hallux valgus can be either surgical or non-surgical.
Often changing the type of footwear, reducing heel height and getting shoes that are a little bit more spacious, particularly in the toe area, is often enough to reduce symptoms of pain or rubbing. If this settles the symptoms sufficiently then often there is no need to do anything further. Sometimes the use of insoles or inserts in your shoes can help cushion and alleviate pain underneath the foot.
If non-surgical treatments don’t work and the pain is too great and starts to interfere with daily activities or the use of everyday shoe wear, then surgery can be used. This aims to change the position of the big toe and the foot , improving the forces through the sole of the foot to reduce or even completely alleviate the pain that the bunion is causing. The goal of surgery is to obtain pain relief. The fact that your foot and toes all become more “foot shaped” is considered a bonus!
Types of Operation
There have in fact been over a hundred different types of operation described to treat bunions and it would be impossible to go through all of these in this information leaflet. However two of the most common operations used to treat this condition surgically are the SCARF and CHEVRON procedures. These are operations carried out on the 1st metatarsal bone. Occasionally with a more severe bunion, a more significant correction is used further up in the middle of the foot. Finally if it is agreed between yourself and your surgeon that your hallux valgus has got so severe it cannot be corrected back to a normal position, a fusion of the bunion joint may be suggested in order to give you a pain free, stable foot. The Chevron procedure is usually used for a mild bunion but one, which none the less still causes pain and symptoms. It is a smaller cut at thebottom end of the metatarsal bone of the big toe. The cut in the bone is done in a ‘V’ shape (a ‘chevron’), when looked at from the side. This enables the big toe bunion joint to be moved outwards towards the outer aspect of the foot (Fig. 2). The bunion can then be shaved away and the tight, soft tissues can be re-tensioned to correct the position of the great toe. Often a small screw or pin may be used to hold the 2 parts of the cut bone together whilst they heal. It is usual to use dissolvable sutures (stitches) and therefore none need to be removed once the wound has healed.
What Happens on the Day
This procedure is usually done as a day case. You will be able to go home at the end of the day but we would normally expect someone to be with you during the first night following surgery. You will be able to walk on your heel and you will have crutches to support you in the post operative period. There will be a bulky dressing around your foot. Once you have gone home you will need to elevate and rest your foot for the first week or two. You can potter around at home but not go for long distance walking. This is in order to minimise any swelling, aching and discomfort that may arise from the swelling. The dressings are usually taken down and the wound inspected at your GP surgery 1 -2 weeks post operatively. We would also recommend rubbing in moisturising cream onto and around the wound itself, once it has healed, to keep it supple. As the scar matures over the subsequent weeks, the moisturising helps to prevent it getting hard and tender and the act of rubbing the cream also helps to desensitise any scar. You will normally then be seen back in the out patients by your consultant at approximately 4 – 6 weeks post operatively. It is not always necessary to obtain an x-ray. This procedure is usually very successful and the bone usually heals without any problems. We would normally expect you to be able to get back to work within a few weeks. For office based or more sedentary type jobs, where you can rest and elevate your foot, you may be able to get back as early as 4 weeks. Otherwise it is usually 6 – 8 weeks. Heavier or more manual type work may need at least 8-10 weeks. Driving: the main requirement for you to be able to drive is to do an emergency stop confidently and use the controls of the car with both feet. If you have an automatic car and have had an operation on your left foot you may not need to cease driving at all. The swelling from the operation may take 3 or even 6 months to fully settle and during that time you will be able to wear closer fitting shoe wear as the swelling settles.