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Does "bunion surgery" work?

It's fair to say that I have over-heard many a patient regale horror stories of a "friend of a friend" who after such a such operation never walked "right again". It's funny how with each telling I am sure the darker and grimmer the experiences alleged were.


The problem when answering this type of question is that this is a very non-specific question and encompasses a myriad of different patient types, operation types in a world where technology, expectation and thankfully training changes rapidly.


Let's begin by understanding what we mean by "bunion surgery". Technically it could mean any operation used to realign the big toe joint.


Figure 1 Scarf type osteotomy

In this example (above) the patient has had a pretty standard operation involving a realignment of the 1st metatarsal fixed with two small screws. This is was possible because the big toe joint, although slightly arthritic, was overall good enough to preserve. In contrast the picture below is one of my patients who has a big toe bent inwards a result of end stage arthritis in the joint. The red arrow highlights the "bump of bone" typically blamed for shoe fit problems!


Figure 2 1st MTPJ Fusion for severe o.a.

In this case it is not possible to preserve the joint in the same manner as was done for the first patient as the joint is simply too arthritic. In this situation the options are more limited and the patient has opted for a fusion of the toe joint.


Both patients have had very different surgeries for what they perceived to be the same problem "a bunion". In truth they are not the same problem but it easy to see why outcomes, experiences and perceptions about success and failure can become confused.


Success in surgery comes from understanding more about the patient expectations than it does from anything else. The job of the surgeon is to understand the perceived problem, determine the available options and to convey to the patient the implications of each. In doing this, subject to technical failure or complication the surgical outcome and patient expectation should closely align.


In selecting a procedure for hallux valgus correction one must also consider what can be technically achieved with bone carpentry skills and what can be endured by the patient physiologically. Where hallux valgus is severe straight-forward surgeries such as the "scarf type" osteotomy are insufficient to correct the deformity and mandate more complex operations such as the Lapidus procedure.


Figure 3 Lapidus


This procedure is both technically demanding on the surgeon but more importantly requires a prolonged period of cast immobilisation, non weight-bearing on crutches. For elderly or physiologically impaired patients this can be too great a challenge. Failure to offer this type of operation. Many patients still think that all bunion operations mean a period of six weeks in a cast when this is not true. For most patients only a proximal type surgery such as the Lapidus or Base Wedge osteotomy mandate postoperative cast immobilisation.


Success not only depends on the correction patient and procedure selection but also requires technical excellence.


Figure 4 Simply disaster


This patient consulted me for an opinion following bilateral bunion correction. Understandably she felt this was not a terrific outcome and evidently the only clue as to previous bunion surgery are the wires used to fix the metatarsal bone. This is most clearly a technical failure involving poor procedure selection and poor technical execution.


GETTING IT RIGHT

Nowadays most foot surgery is performed by specialists who dedicate their careers to this single field. This has brought improved outcomes for patients by ensuring that those performing these intricate operations have the knowledge and skills to help patients forward with the right operation performed to the highest technical standard.


SUMMARY

Not all bunion surgery is the same and each case has to be assessed on an individual basis. Surgery performed by specialists in this field help the vast majority of patients achieve excellent clinical outcomes.


REFERENCES

A longitudinal study of hallux valgus surgical outcomes using a validated patient centred outcome measure

https://www.sciencedirect.com/science/article/abs/pii/S0958259211000137


A review of surgical outcomes of the Lapidus procedure for treatment of hallux abductovalgus and degenerative joint disease of the first MCJ


https://www.sciencedirect.com/science/article/abs/pii/S095825920800059X



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