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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

Hallux Valgus.

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

interest only.

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 -

HalluxValgus deformity.

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 -

Post-operative radiograph

of a patient who has had a

scarf osteotomy. She is only

four weeks from surgery

but has already returned to

full-time hairdressing.

New Techniques

for Managing

Painful Bunions

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