Bunion Surgery (Scarf Osteotomy & Minimal Invasive Surgery)

Left side (was the worst) 1 yr after surgery and Right side prior to surgery

A “Bunion” is an enlarged bump or prominence at the side of the Big toe. Its due to the Big toe or Hallux being pulled over to the side, making the metatarsal head very prominent. This bunion prominence becomes painful and swollen, eventually requiring treatment. Sadly, there are no braces or splints that can prevent it getting worse. Wider fitting shoes can certainly help, but there is only so much that can done with shoeware. Once the pain gets bad enough, this requires surgery - to remove the boney prominence and realign the hallux with "metatarsal osteotomies” to cut and reposition the bones.

The bunion often affects the lesser toes too, causing problems with Claw toes, Hammer Toes and Metatarsalgia (pain under the ball of the foot). This will need addressing at the same time as the bunion surgery.

Surgery

The goal of the surgery is to remove the bunion prominence and realign the toe so that it stays straight for ever. The most common type of surgery is cut and realign the metatarsal (commonly using a Scarf or Chevron osteotomy) and to cut and realign the toe (an akin osteotomy). See video below. This can be done using key hole or open techniques.

I use both techniques, choosing which one I think will address the problem best, depending on the severity of the hallux valgus and the degree of realignment required.

Open Surgery - SCARF Osteotomy

This operation is for painful or severely deformed bunions. It involves shaving the prominent bone and realigning the bones with an osteotomy (cut) of the metatarsal combined with a repair of the joint capsule and ligaments. This will produce a narrow foot and a straighter hallux (big toe). There may also be simultaneous surgery performed on the lesser toes, if indicated.

The capsule repair must be protected with the specialised dressing for 2 weeks and the osteotomy requires protection in the post operative shoe for 6 weeks.

Elevation of the foot above the pelvis (45 mins / hour) for the first 10 days is vitally important to prevent infection. Naturally, small periods of walking and standing are necessary.

This type of operation and the post operative shoe allow weight bearing (walking) immediately. Often this may be too uncomfortable for the first week. Crutches are usually necessary for the first for 4-6 weeks.

The surgery is routine, but the recovery is prolonged and swelling is the last feature to recover. Often shoeware will still be tight at the 6 week stage.

Driving is possible after 4 weeks, without the post-operative shoe. It will be 3-4 months before walking is comfortable and 5-6 months for running.

Minimally Invasive Surgery - “MICA"

This operation is for painful bunions. It involves keyhole surgery to realign the bones (metatarsal and phalanx) combined with release of tight deforming ligaments and tendons. This will produce a narrow foot and a straighter hallux (big toe). There may also be simultaneous surgery performed on the lesser toes, if indicated.

The surgery is usually performed as a daycase under general anaesthesia. The operation is performed with a special burr through 4-5 small incisions.

The foot must be protected in a requires protection in the post operative shoe for 6 weeks.

Elevation of the foot above the pelvis (45 mins/hour) for the first 7 days is vitally important to prevent infection. Naturally, small periods of walking and standing are necessary.

This type of operation and the post operative shoe allow weight bearing (walking) immediately. Often this may will be uncomfortable for the first week and crutches are usually necessary for the first for 2-4 weeks.

The surgery is routine, but the recovery is prolonged and swelling is the last feature to recover. Often shoeware will still be tight at the 6 week stage.

Driving is possible after 4 weeks, without the post-operative shoe. It will be 3-4 months before walking is comfortable and 5-6 months for running.

Risks of surgery

Stiffness & swelling

Initially the foot will be swollen and needs elevating. The swelling will disperse over the following weeks & months but will still be apparent at 6-9 months. The toe will be stiff but will normally regain its original movement.

Infection

There is always a risk of infection with surgery. You will be given 1 dose of intravenous antibiotics during surgery. The best way to reduce your chances of acquiring an infection is to keep the foot elevated for 7 days. If there is an infection, it normally resolves with a course of oral antibiotics.

Nerve damage

A nerve supplying the skin on the side of the toe is at risk of damage. Usually it is just bruised and will recover. If the damage is permanent, it will leave a small patch of numbness. This does not normally cause any disability.

Undercorrection

Occasionally, the deformity of the toe is not wholly corrected. This is more common in severe cases. Rarely, this is problematic and requires further surgery.

Overcorrection

Very rarely, the toe can be over-straightened so that it angles away from the foot (hallux varus). This is a rare complication and usually requires further surgery.

Correction of Deformity

Excellent long lasting corrections are achieved. Naturally in the more severe cases, some recurrence can occur but usually with no or few symptoms. It is very rare to need revision surgery.

Blood Clots “DVT"

Because you will be walking on it immediately there is no need for any anticoagulation unless you are “high risk” with a previous history or family history of blood clots. The oral contraceptive pill will need to be stopped several weeks prior to surgery - please check this.

Preparation for Surgery

You should have received a letter detailing the codes and costs for the surgery and giving instructions on where to go and at what time. Please check these details carefully as you will be liable for any costs not covered by your insurers.

You will need to be nil-by-mouth – No food for 6 hours before surgery. Clear fluids can be taken for up to 2 hours before the operation.

MRSA status

Before or on admission to hospital a nasal swab will be taken to screen for MRSA. There is a small chance this is positive. If so your operation will be moved to the end of the list or rarely to another day to prevent cross infection.

Anaesthetic

The surgery is normally a daycase procedure, performed under a general anaesthetic with a local anaesthetic “Ankle Block" for additional pain relief. With modern anaesthetic techniques, It is no longer a very painful operation and most patients report discomfort afterwards.

Immediately after surgery

Following surgery, the toe is protected in a specialised dressing and postoperative shoe.

You will be seen by a physiotherapist on the ward, who will advise on walking and early rehabilitation. You will be allowed home only when you are comfortable and capable.

Recovery from surgery

The capsule repair must be protected with the specialised dressing for 2 weeks and the osteotomy requires protection in the post operative shoe for 6 weeks.

Elevation of the foot above the pelvis (45 mins per hour) is is vitally important to prevent infection. Naturally, small periods of walking and standing are necessary.

This type of operation and the post operative shoe allow weight bearing (walking) immediately. Often this may be too uncomfortable for the first week and crutches are usually necessary for the first for 1-2 weeks.

Swelling

Many patients worry about the swelling. It is a natural response to the surgery and is slow to settle in this type of surgery - it takes 3 months to fit into all types of shoeware and 6-9 months to go.

Walking & Exercise

You can walk on the foot immediately, in the protective shoe. For the first 1-2 weeks you will be “housebound” looking after and elevating the foot. Each week the foot will be able to do more.

At 3-4 weeks light exercise can be done on the cross trainer or static bicycle.

In general it takes 3 months to walk a mile and 6 months to run a mile (usually it is a bit quicker than this!)

Physiotherapy

This can be started after 2 weeks.

Pain relief and take home medications

You will be given high doses of prescription painkillers to take home. Use these for the first 5-7 days and reassess.

Washing and Bathing

It’s important to keep the dressing completely dry – the nurses will show you how to do this with a waterproof cover.

Activity and time off work

In general, up to 4 weeks off work is required for sedentary posts such as office work, 6 weeks for standing or walking posts, 8 weeks for manual / labour posts.

When can I start to drive again?

The DVLA states that it’s the responsibility of the driver to ensure they are always in control of the vehicle. For the Left Foot, driving should be possible after a few days in an automatic car. Otherwise it is a minimum of 4 weeks to drive.

It remains your responsibility to drive safely and you should also check with your vehicle insurer to confirm you are covered.

Results of surgery

This type of surgery is very reliable and durable and works indefinitely for the majority. However the foot is a very complex area and although rare, recurrences do happen - understandably these are more common in the severe cases.