Fig.2Scarf osteotomy and bunion removal
Fig.3Wedge of bone to be removed from the toe
Fig.4The toe bone is held with a staple or screw
What is hallux valgus?
Hallux valgus is a common condition frequently affecting 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 (Fig. 1). This can also be associated with the 2nd toe crossing the big toe. Hardened skin forms underneath the foot at the level of the ball 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, a so-called “corn”.
“Hallux valgus” is the medical term for the big toe pointing towards the lesser toes too much. The “bunion” is the lump on the inside of the foot at the base of the hallux valgus, which is often painful.
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.
None Surgical Treatment
Often changing the type of footwear, reducing heel height and getting shoes that are a little bit more spacious, particularly in the toe area, may be enough to reduce symptoms of pain or rubbing. If the symptoms improve 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.
Surgical Treatment Options
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 shoes then surgery can be used. This aims to change the position of the big toe and 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!
The Scarf Osteotomy
The scarf procedure is for more moderate and severe forms of hallux valgus. It is used to both to bring the toe back into a straightened position and also to move the metatarsal bone of the foot outwards and downwards in order to share the load more evenly underneath the sole of the foot. This has the benefit of reducing the pressure underneath the second toe and also reducing the width of the foot and the bunion so that shoe wear is more comfortable. The procedure involves making two cuts in the skin. One is along the inside of the foot and the other is on the top of the foot in between the first and second toes. Through these incisions, the metatarsal bone of the foot is cut and re-aligned (Fig. 2). The bunion is removed and the tight soft tissues are re-tensioned to straighten the great toe.
Sometimes further correction of the position of the toe is required after the scarf osteotomy. A further procedure may be done on the first toe bone. A wedge is removed from the inner side of the bone and the correction is held with a staple or screw. This is known as an Atkin osteotomy.
Dissolvable stitches are used to close the skin meaning that none need to be removed. You will have a bulky dressing around the foot and a wedge shaped shoe on which to walk post operatively. This forces you to put more weight through the heel and off-load the front of the foot whilst the operation heals and the bone knits. You will be shown how to use the crutches before discharge from the hospital.
During the first week or so you will need to elevate and rest the foot as there is usually quite significant swelling associated with the operation. This will settle down but may take 3-6 months to completely settle. The dressings are usually reduced and the wound inspected at about 1-2 weeks post-op and you will then usually be seen by your Consultant at about 6 weeks post operatively.
It is unusual for anyone to be able to drive much before 8 weeks. You need to be able to perform a safe emergency stop before insurance companies are happy for you to drive fully on the roads again.
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 do not go for a long walk. This is in order to minimise any swelling, aching and discomfort.
The dressings are usually taken down and the wound inspected at your GP surgery 1 -2 weeks post operatively. We would also recommend rubbing moisturising cream (e.g. E45) onto and around the wound 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 the scar.
You will normally be seen back in the out patients clinic by your Consultant at 4 – 6 weeks post operatively. It is not always necessary to obtain an x-ray. This procedure is usually very successful and the bone tends to heal without any problems. We would normally expect you to be able to get back to work within a few weeks. For office-based or 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.
As the swelling settles over the six months after the operation, you may wear increasingly close-fitting shoes as feels comfortable.
Complications may occasionally occur after surgery but are thankfully uncommon. They include: infection, non-union (bone not knitting where it’s been cut), injury to nerves or arteries (giving a numb patch on the foot), neuroma (tender spot on the scar, which may be painful if touched), scars, incomplete correction of the deformity, recurrence of the deformity, haematoma (a collection of blood under the wound), wound healing problems and foot pain.
We hope this information is useful and if you have any more questions. Please feel free to discuss these with your Consultant.
If you have any difficulties before or after the procedure, please call the number below during office hours or the hospital directly.