Hallux Valgus and Lesser Toe Deformities
Hallux valgus (bunions)
Hallux valgus, also known as a bunion, is caused when the great toe drifts towards the second toe, causing a prominence on the inside of the foot. This can lead to pain when the prominent bone rubs on the inside of shoes. Bunions may be hereditary (run in families) or can develop over time due to a combination of factors including an imbalance of muscles in the foot and/or having hypermobile joints. Wearing high heeled shoes does not cause bunions but may be a contributing factor in susceptible individuals.
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Lesser toe deformities
There are different types of lesser toe deformities (hammer toe, claw toe, mallet toe and curly toe). Most commonly they affect the second toe in combination with a bunion, but may be present without a bunion. They are caused by muscle imbalances within the foot and lead to painful areas of hard skin from rubbing inside shoes.
Pain may be worse during walking. Occasionally the joint at the base of the toe can dislocate, causing the bone to be prominent at the sole of the foot. This can be a further source of pain.
What are hallux valgus (bunions) and lesser toe deformities?
Assessment
Your surgeon will assess your foot and how the bunion or lesser toe deformity affects you. This normally involves asking about relevant medical conditions, examining your foot and performing x-rays. This information will be used to advise on the best treatment for you - this may be non-surgical or surgical.
Non-Surgical Treatment
Most bunions and lesser toe deformities can be managed without surgery. This involves use of wide-fitting shoes which also have a deep toe box. Cushioned pads, tubing, spacers and splints made from materials such as silicone or foam can be used to reduce rubbing on prominent areas of the foot. Areas of hard skin or callosities may be shaved down by Podiatrists.
Surgery
This is generally reserved for those with severe bunions or inflexible lesser toe deformities, or for patients in which all non-surgical treatments have failed. Surgery is not an appropriate treatment if sought purely for cosmetic purposes.
Most bunion and lesser toe surgery is performed as a day case requiring either general or regional anaesthesia.
Bunion Surgery
Greater understanding of the causes of bunions has allowed for the development of patient specific surgery. Your surgeon will advise you on the best surgery for your foot.
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In most cases, an osteotomy (where the bone is cut and realigned in a corrected position) is required. The most commonly performed osteotomy for correction of bunions is called a Scarf osteotomy. This involves cutting the first metatarsal and using screws to hold the bone in the realigned position while it heals. At the same time the tight soft tissues attached to the outside of the big toe are released to further improve the position of the toe.
Occasionally a further osteotomy of the big toe (known as an Akin) is requ to achieve the best outcome. A single screw or staple is needed to stabilize the bone.
Lesser Toe
Depending on the type and severity of lesser toe deformity, this may involve releasing tight tendons (tenotomy), lengthening tendons, fusing joints in the toe or the shortening of metatarsals. Sometimes a combination of these procedures is required.
Often a special metal wire known as a Kirschner or K-wire is used to hold the toe straight whilst it heals. The tips of these wires are left protruding from the toes so that they may be removed in the clinic, usually six weeks after surgery. Removal of these wires is not usually painful.
Lesser toe surgery can be performed at the same time as surgery to correct bunions.
So when can I...
Leaving Hospital
Most patients leave hospital the same day. Some patients may need to stay overnight.
Medication
The hospital will ensure you have the correct medication & pain relief when you go home. This can be different for each patient
Manual job
Around 12 weeks; may need to modify activities for 3-4 months
Driving
Normally 6 weeks.
When you no longer need to wear your protective post-operative shoe.
The law states that the patient should be in complete control of the car, it is your responsibility to ensure this and to inform your insurance company about your surgery.
If you drive an automatic car and have had left foot surgery you may be able to resume driving sooner. Again, it is advised you contact your insurer to ensure your insurance is valid.
This is only a guide. It It will be different for each patient. Speak to your healthcare team if you have any questions.
Sedentary job
2-4 weeks as tolerated, providing you don't need to be on your feet for long periods.
Sport
6-12 weeks depending.
Intensive sports and recreational activities may only be recommenced after all soft tissue and bones have healed.
As a guide, a return to running or contact sports should only be considered three months after surgery.
What are the risks?
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Wound infection - rare and usually involves the skin. Occasionally a deep infection can occur, the risk is less than 1%.
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Stiffness – The foot and ankle can become stiff after surgery. This normally resolves with time and you may be reffered to Physiotherapy.
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On-going pain – X% of patients will have some on-going discomfort / pain after surgery.
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Anaesthetic - This is the medication used to numb the area for the operation. You should discuss this with the Doctor. It will be different for each patient.
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Blood clot - It is important you inform your surgeon if you have a blood clotting disorder or have ever suffered from a blood clot in the leg (deep vein thrombosis / DVT) or lung (pulmonary embolism or PE), or if there is a strong family history of blood clots. Medication to thin the blood after surgery may be required if this applies to you. Thankfully blood clots are uncommon after forefoot surgery and we do not routinely need to give blood thinners after surgery.If you develop painful leg swelling , chest pain, shortness of breath of difficulty in breathing after your surgery you should seek urgent medical attention – contact NHS 111 or attend the Emergency Department for assessment.
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Reoccurence of Bunion or Lesser Toe Deformity Fortunately this is rare – further surgery may be required.
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Over-Correction -A rare occurrence – further surgery may be required.
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Non-Union -This is term used to describe osteotomies (bone cuts) or joint fusions which do not heal. This is more common in smokers and diabetic patients. Smoking cessation is strongly advised prior to surgery.
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Metalware Prominence -The screws used to stabilise bone cuts are normally buried in the bone and do not cause problems. However sometimes they can become prominent over time. They can be removed with further surgery if required.