Bunions are bony deformities affecting the big toe joint where the bones of the feet are misaligned.  The foot becomes wider, and the big toe deviates laterally, which can create problems with shoe fitting due to irritation of the bony prominence. Arthritis can also start to affect the joint.

There are several factors leading to bunion deformities.  The most significant one is heredity, where the tendency to develop bunions is passed down more often on the female side of the family. So, if your mother or grandmother had bunions, you would likely inherit them.  Biomechanical factors such as flat feet or excessive pronation, which is an inward rolling of the foot, can also influence the development of bunions.  Systemic diseases like rheumatoid arthritis will also affect bunions.  Contrary to popular belief, the shoes you wore when you were younger did not cause bunions.  Some people have never worn shoes that will develop bunions.  Footwear is an aggravating factor, not a causative factor. Wearing stilettos will irritate, speeding up the progression of bunion deformities and making bunions sore. Overall, hereditary factors are the most significant cause, so while you are not born with bunions, you are born with a tendency to develop bunions. 

Bunions are a progressive deformity that gets worse over time. Pressure on the smaller toes results in hammering and lateral deviation, particularly in the second toe, making the problems harder to fix if the deformity is uncorrected. Pain in the ball of the foot can also be related to bunions and the associated hammer toe deformities.

To begin with, using more appropriate footwear that doesn’t irritate the bunion and orthotic devices to help with structural foot problems. Modifying activities that aggravate the bunion can all help stop bunions from hurting, but none of these things will make the bunion any smaller or go away. Using night splints or wedges between the big toe and second toe helps pressure points between the toes but does not influence correcting bunions. Some specific exercises can help maintain the flexibility of the deformity, but the only way to correct a bunion deformity is through surgery. Surgery is recommended if the deformity has become quite pronounced and is causing pain or if it is causing problems with the smaller toes.

Surgery for bunions is performed on a day surgery or overnight stay in the hospital.  Various types of anaesthesia are used depending on the patient’s requirements, but most involve a “twilight” or light general anaesthetic and a long-acting local anaesthetic. Surgery involves correcting the soft tissue component by releasing ligaments and tendons that pull the big toe over and then addressing the bony part of the deformity by an osteotomy, which is a precise cut through the bone to realign the big toe joint and narrow the foot slightly. Excessive bony overgrowth is also removed.  Pins or screws are used to stabilize the cut through the bone, which are buried and do not protrude through the skin.  In most cases, the pins and screws do not need to be taken out, so they stay in place after healing has occurred and don’t cause any problems with airport metal detectors.

There are multiple surgical techniques for bunion deformities depending on the degree and flexibility of the deformity, how far the first metatarsal has splayed, and if there is arthritis in the joint. Bunion surgery can also be combined with correcting other toe deformities if they are present. Some bunion procedures may require a cast, which has a slightly increased risk of complications such as Deep Vein Thrombosis and the inconvenience of being cast.  Selecting a method that will give you the best long-term result with the least risk of complications and inconvenience, so we try to avoid using casts where possible.

Bunion surgery had a bad reputation for being painful, but this is not so much the case these days with better surgical and anaesthetic techniques. Blocking the pain at the surgery site with a long-acting local anaesthetic means that the brain never actually registers any pain until the local anaesthetic wears off; by this stage, the pain is much less. A simple analogy is when you stub your big toe, it hurts a lot when you stub the toe, but the pain reduces with time, so 8 – 10 hours later, the toe is throbbing but nowhere near as bad as when the injury first occurred. A long-acting local anaesthetic takes 8 – 10 hours and sometimes longer to wear off, so when it has, the pain of the surgery is reduced a lot. 

Several recent research studies show a significant increase in the quality-of-life measures related to pain, appearance, and function following bunion surgery. Similarly, patient satisfaction studies show that nearly 90% of patients are happy with the results of their bunion surgery.  This also means that 10% of patients are still unhappy with the results of their surgery for various reasons. However, in comparison to other surgeries, this is still very good.

Historically, a lack of appreciation of the factors causing bunions meant that surgical techniques did not address the underlying causes, so they sometimes reoccurred. A better understanding of what caused the deformity and addressing these issues means the likelihood of reoccurrence is far lower with improved surgical techniques. 

Bunions will slowly get worse over time, and as they get worse, they also become more challenging to correct. Secondary deformities, such as hammer toes, begin to develop.  An interesting and pertinent research study looking at slips and falls in elderly nursing home residents showed that the most consistent factor was the presence of bunion and hammer toe deformities.  This seemed an unusual finding, but when you think about it, this is logical because toes, particularly the big toe, are used to help balance, so if they significantly deviate, this reduces your ability to fine-tune balance.

A typical situation is people in their 50s and 60s put off having surgery because they are too busy or say their bunions are not causing them a lot of discomfort even though they have a significant bunion. As the deformity progresses, by the time they get around to deciding to have the surgery, quite often other health issues have come up, which make the surgery more risky and a more extended recovery period as well as having a more prominent bunion, which is more likely to have arthritis along with deformity of the smaller toes as a result of the larger, more prominent bunion all which requires additional surgery and overall much more difficult to correct.  In some situations, patients get to an age where it is not a viable option to have surgery due to deterioration in their general health. They then must put up with the bunions, which create significant problems with their mobility and put them at higher risk of falls, which can affect their lives considerably.

Another research study was performed in Finland on middle-aged females with bunion deformities, and it split patients into three groups.  One group had no treatment, the second used modified shoes and orthotic devices, and the third had surgery.  Patients in the three groups were compared after one year and two years.  After two years, the group having surgery had less pain, better shoe fitting, and was more satisfied with the appearance of their feet than the other two groups, which suggested bunion surgery is best done earlier than later. When you consider the issues of increased deformities, greater likelihood of arthritis, slips and falls in the elderly, and increased risk of surgery when you are older, it is generally better to have bunion surgery when you are younger rather than putting it off until when you are older and having a lot of problems. The decision when to have surgery often revolves around when you can take the time out to recover. As bunion surgery is an elective surgical procedure, you can plan the surgery around the time that suits you, such as when you have the least number of commitments but also fit in with other family members or friends who may assist you in the initial period when you need to rest.  No time is a good time for busy people, but at least you have the luxury of planning for your surgery.  There is no sense rushing into this surgical procedure to find that you do not have the time off your feet to get a good result.

Whilst the pain associated with bunion deformity and techniques for bunion surgery have significantly improved, the time required of your feet has not changed considerably. It takes time to heal, and we cannot speed up this process.  All patients heal at different rates depending on age, circulation, and general health.  As a general guide, your activities will be limited to 2 weeks. You should not be on your feet any more than 10 – 15 minutes in any given hour and no more than 2 hours per day, which allows enough time for getting meals, showering, and moving about.  From 2 – 4 weeks, you can start increasing your activity until you’re on your feet 30 minutes every hour, increasing so that by 6 weeks, you can resume normal daily activities.  Most people can start sporting activities within 3 – 4 months from surgery, depending on the sport. Getting back into high heels and fashion shoes can take time and depends on the amount of swelling, which will vary from one person to the other. Some minor swelling and discomfort can continue for 6 – 12 months. People who rest up early recover quicker and resume regular activity faster, so it is essential to rest up in the early stages.

This depends on your occupation, how long you must stand on your feet, and what type of shoes you must wear. If you sit all day at work and have your feet elevated, you can return to work quickly, often around two weeks. If you must do some walking, four weeks is best. If you stand all day and must wear enclosed shoes, six weeks off work is needed.

If you drive an automatic car and we are operating on your left foot, you can generally drive within a few days.  If we are operating on your right foot or you drive a manual car, we would typically suggest you don’t drive for at least 3 – 4 weeks or until you can fit an everyday shoe back on your foot, as bulky bandages and post-operative shoes can make it challenging to operate pedals.  If we are operating on both feet, generally, it is not advisable to drive for at least 6 weeks.

While bunion surgery is not a big surgery compared to a knee or hip replacement, the unique thing about feet is that when you stand, not only does your whole-body weight go on your foot, but blood and other fluids always run in one direction, downwards. Feet are at the end of the line so that they will swell more.  There is swelling associated with any surgery; however, it is much worse in feet and needs to be managed. Along with compression bandages, you need to keep your foot elevated and use ice packs much like the principals used in treating sports injuries such as an ankle sprain where we use the acronym “RICE,” which stands for Rest, Ice, Compression, Elevation.  Ice has excellent anti-inflammatory effects, which help reduce swelling and discomfort. Using ice packs is very helpful immediately following the surgery and later on if you have been too active on your feet.

For the first couple of weeks, you will have quite a bulky compression bandage, and we will supply you with a post-op sandal to walk around.  You must wear this shoe as it splits your foot.  By 3 – 4 weeks, we will still use a compression bandage, but it will be much thinner. Most people can start wearing roomy sneakers at this stage. Depending on your swelling, you may be required to wear a thin compression bandage for up to 3-4 months after the surgery.

If you are in good health, the risks are minimal.  Smokers carry a much higher risk of complications and are also much slower to heal.  As you get older, risks will increase.  There are risks associated with any surgery, but particularly with surgery in the foot and leg, Deep Vein Thrombosis (D.V.T.) can occur and increases with age, obesity, previous history of D.V.T. or any estrogen-based medication such as the oral contraceptive or hormone replacement therapy.  If you have any of these risk factors, you may be required to have anti-coagulation therapy after the surgery.  Overall, the risk of Deep Vein Thrombosis is about the same as a long plane flight with bunion surgery.  Infection is also a risk, and with bunion surgery, we will give you a single dose of intravenous antibiotic at the time of surgery. This is the standard protocol for this type of procedure, and the infection rate is between 1 – 2%, so it is pretty low.  Over-correction or under-correction of bunion deformity can also occur and depends on the surgeon’s skill, the technique chosen, and the degree of deformity.  We tend to slightly under-correct bunion deformities as most shoes taper slightly inwards at the toes, and most people have a slight degree of lateral deviation of the big toe. A big toe that is too straight can create some shoe pressure problems and, under correction, has a more natural, normal appearance.  Complex Regional Pain Syndrome (C.R.P.S.) is another complication that most people have never heard of. It is rare but can happen following foot surgery, where the foot and leg can become quite painful and more swollen than usual or change colour from mottled white to dark blue. It is caused by the sympathetic nervous system going into overdrive and is treatable.  Another complication is non-union or delayed healing of the bone, which can occur in patients with osteoporosis or those who are heavy smokers. Thick scars can be a problem with some people prone to Keloid or hypertrophic scars, with joint stiffness also occurring due to scarring or if exercises to get the big toe joint moving following the surgery are not done. Following the instructions after surgery, such as not being on your feet too much, doing the recommended exercises, and using compression bandages, is essential to reducing complications and getting a good result.

A lot of people were put off bunion surgery because they were told it was painful, took a long time to recover, and it did not work, or they were worse off after the surgery. Indeed, this may have been the case several years ago; however, that is not so much the case these days, so bunion surgery does not deserve the reputation it once had.  This bad reputation has meant we see a lot of older people with quite extreme bunion deformities who now have a lot of difficulties that could have been avoided had they had appropriate bunion surgery from someone skilled and knowledgeable about not just surgery but foot surgery. This is where podiatric surgeons have a lot to offer, as we can provide advice and treatment that is both surgical and nonsurgical. Given the improved techniques and good outcomes demonstrated in peer-reviewed research, we recommend surgery. It may not always be the best option for all people. Still, it is also better to have proper assessment and advice from an expert in bunion surgery than to regret it later when you are too old, not having taken time off to have surgery to correct the deformity.