Foot and Ankle Surgery
How does a bunion form?
The bunion is an exostoses of new bone and soft tissue.The bulk of what we
call a bunion is the metatarsal head that has drifted inwards (see Figure 1a,1b).
On squeezing into a shoe, there is an increased laterally directed pressure
on the phalanx of the big toe. Initially, the toe corrects itself when the shoe
is removed but with time the deformity becomes stuck down and fixed.The
proximal phalanx of the big toe pushes the metatarsal head more medially,
worsening the deformity. Many patients also have a positive family history for
What simple non-surgical methods can we try
when they first present?
Appropriate shoe wear is the key. I advise patients to wear soft lace-up leather
shoes or trainers for commuting to work or walking long distances.They can
keep a pair of formal shoes under their desk for meetings. Heels greater than
an inch are best avoided as the foot tends to slide down the shoe squashing the
toes into the toe box of the shoe. Silicone spacers or bunion cushions may help
but can widen the foot further, making shoe wear more difficult.
When would we consider surgery?
If the patient has tried the above measures but the foot still hurts on a daily
basis or if the patient develops a hammer 2nd toe.
What does surgery entail?
By the time a patient presents to their GP, the deformity is usually advanced
and the metatarsal needs to be broken and reset so that the foot is narrower
and of a more natural shape. For a moderate deformity, the bone is broken
(osteotomy) close to the metatarsal head, using a chevron shaped bone cut.
More advanced deformities need correction closer to the apex of the deformity
at the base of the metatarsal.The scarf osteotomy is a popular osteotomy
that runs the length of the metatarsal. If the joint is very arthritic then fusion
procedure may be necessary.
The Keller’s procedure, the operation we would have heard of as medical
students in which part of the proximal phalanx is removed, is now of historic
Is the operation painful and slow to recover from?
No.This is one area where we have made drastic progress.The main reason
bunion surgery was painful in the past was that bones were held with plaster
only allowing grating from the cut bone ends and a chance that the fixation
could be lost.We now use small screws and specialist bone cuts to ensure
solid fixation of the bone.This allows earlier weight-bearing and movement
in the toes, ensuring faster rehabilitation and a better long-term outcome. In
surgery, the use of selective ankle nerve blocks with marcaine numbs the toes,
minimising initial post-operative pain.Within two weeks, patients are usually
walking in soft sandals or trainers (see Figure 2a, 2b).
Figure: 1a and 1b -
From the radiograph
it is apparent that the
metatarsals are splaying
apart.The medial bump is
not just an exostoses but a
prominent metatarsal head.
Figure: 2a and 2b -
of a patient who has had a
scarf osteotomy. She is only
four weeks from surgery
but has already returned to
Painful bunions or HalluxValgus can cause aching feet, difficulties with shoe wear, problems with
the lesser toes and, if untreated, predisposition to arthritis of the big toe. Historically, surgical
correction of bunions has had a poor reputation. Newer techniques are associated with better
results, reduced pain and stiffness and allow immediate weight-bearing.
For further information, please contact Mr Sam Singh’s secretary on
020 7234 2167