Dr. Eduard Rabat, Orthopedic Surgeon, Traumatologist and specialist in Foot and Ankle Surgery and head of the “Foot and Ankle Surgery Unit” at Hospital Quirón Barcelona, explains how to treat bunions or hallux valgus, an annoying deformity of the big toe, when they should be operated and what are the best surgical techniques.
Are all bunions the same, do they all hurt?
What is popularly known as bunionette and scientifically called hallux valgus is a complex deformity of the forefoot, and one of the most common, where several factors coexist:
- the degree of separation between the first and second metatarsal bones.
- the drop or deviation of the big toe towards the fifth toe
- the bulge on the inner side of the foot
We could say that all bunions present the same pathophysiology but with different degrees of severity depending on the severity of the elements we have just mentioned.
In relation to pain, it must be said that not all hallux valgus are painful, and that pain is not directly proportional to a greater or lesser degree of deformity. Patients with huge bunions and hardly any pain and small deformities that make their lives impossible come to the clinic.
If pain is not always present, what problems does a patient with a deformed forefoot present?
Indeed, we must speak of deformed forefoot. The bunion, even if it is not the painful element, creates a series of alterations in the rest of the forefoot that are the ones that bring the patient for consultation. One of the worst ones consists of placing the foot sideways when walking, which we call supination gait. This is common to all patients with hallux valgus.
The deviation of the first toe ends up deforming the lateral hammertoes or claw and the supination gait causes a displacement of the load zone of the first metatarsal to the lateral metatarsals. This phenomenon, with the passage of time, induces the appearance of calluses in the metatarsal that can end up being very painful, what we know as metatarsalgia.
So we start with a bunion that does not hurt and we end up finding a completely deformed forefoot with pain in several points, usually the toes and the metatarsal.
To understand the suffering that the patient may experience, let’s think of a man or woman working on their feet all day or part of it with a closed shoe, enduring all this friction and pain continuously.
When is bunion surgery recommended?
It would be convenient to start by saying when “no” surgery should be performed. In foot surgery we have a maxim, which is never to operate on a patient who has no pain or difficulty. A bunion should never be operated on for purely aesthetic reasons, in the sense that one can operate on a nose or a breast; this can lead to enormous failures.
A hallux valgus is surgical when it causes pain or when the degree of deformity is so severe that it prevents the use of normal footwear. In other words, the patient cannot wear ordinary shoes because then the pain appears quickly.
Once the intervention has been decided, should all the deformities be corrected or only the bunion?
It is always recommended to correct all deformities at once, although this may entail a longer recovery time.
The goal of surgery is to restore harmony in the function of the foot. This is achieved on the basis of seeking to restore normal anatomy, maintaining maximum joint mobility, which is essential to be able to walk without problems, wear fashionable shoes and practice sports. In this sense, we cannot leave elements to be corrected that may later cause pain.
Are operated feet aesthetically acceptable?
It is of the utmost importance that an operated foot is aesthetically beautiful. Even more so if we take into account that the vast majority of our patients are women and that in our society the foot is shown and shown off for many months of the year with open shoes.
Women take great care of the aesthetics of their feet, as much as their hands, and that is why we use surgical techniques that seek a natural correction as close as possible to a normal foot, without unsightly scars (minimally invasive surgery), which then allow the use of the shoe they want.
But, in addition, we must consider that normally a beautiful foot, after surgery, will correspond to a functionally correct foot.
Most recommended surgical techniques to correct bunions
We always say that a forefoot surgery should be able to correct all the deformities that it presents. We must avoid miraculous techniques that only eliminate the bump adjacent to the big toe. Recovery from surgery in these cases is as fast as the recurrence of the deformity and pain.
To correct hallux valgus, the normal axes of the bones must be reestablished and this is only achieved by cutting the bones (osteotomies) and modifying their position. That is why in a large number of cases the use of screws or some other osteosynthesis material is required to keep them in their correct position. This is not inconvenient and does not represent any additional suffering for the patients.
Open surgery, percutaneous surgery?
Depending on the training and preferences of each specialist in traumatology, these techniques can be performed in the traditional way (open surgery) or by minimally invasive surgery (percutaneous surgery).
Personally, in most cases I use percutaneous surgery because of the advantages it offers patients. With this type of surgery we can apply the same techniques as in open surgery. They offer a high degree of efficacy but in a minimally invasive way.
Minimal or no pain, absence of scars, outpatient procedures with a quick return to work and social life. Nowadays patients cannot afford to abandon their work activity for a long time and that is why surgery must be adapted to their needs.