A Patient information guide to Bunion Correction Foot and Ankle Unit Mr Amit Amin Mr Ali Abbasian BUNION CORRECTION (SCARF/AKIN) JAN 2016 1
What does surgery involve? Surgery to correct a bunion is not simply to remove the bump. The aim is to cut the metatarsal bone of the big toe so that the head (which is responsible for the appearance of the bump) is pushed into the foot (see figures). This is referred to as an Osteotomy (bone cut). The shape of the Osteotomy gives the operation it's name. There are many different types of Osteotomy used. Our surgeons usually perform SCARF or CHEVRON osteotomies as these have the best record in the medical literature. In order to do the surgery an incision is made over the inner aspect of your big toe extending into the inner aspect of the foot. The tightened ligaments that are holding the big toe in the deformed positions are released. This can normally be done through the same incision however occasionally we may need to make a second incision in the web space of the big toe. After the head is pushed away it is fixed with one or two small screws. These are 'headless' and therefore buried deep in the bone and you are not going to feel them afterwards. Sometimes another Osteotomy of the bone at the base of the big toe (proximal phalanx) may be necessary to fine tune the correction. Here a small wedge of bone is taken away from the inside of the bone to straighten the big toe. This is then fixed with another small screw or staple. What are the risks of surgery? As with any surgery complication can unfortunately occur. Whilst the majority of out patients do not suffer any of these it is important to be made aware of them. Below are the list of some of the complications that are seen in bunion surgery and a brief description of what can be done to resolve them. BUNION CORRECTION (SCARF/AKIN) JAN 2016 2
Nerve damage Very fine sensory nerves (slightly larger than a strand of hair) run along the inner side of your big toe. We make sure that these are identified and protected throughout the operation. At times they can be bruised or damaged. This may result in temporary or permanent numbness on the side of your toe but is not usually of any other consequence. Sometimes the nerve may form a painful regrowth within the scar (neuroma) this may require further relatively minor surgery to excise. Stiffness We aim to preserve as much motion of your big toe as possible. Obviously there is likely to be some stiffness after the surgery and this usually improves over the first 2 or 3 months and with physiotherapy. In rare occasions the big toe may require a Manipulation Under Anaesthetic (MUA) with or without a cortisone injection to improve the movement. We may suggest this to you if your toe is particularly stiff despite physiotherapy. Malunion We perform our surgery using the latest techniques and take great care to achieve the optimum position of the toe. Very occasionally the osteotomy may slip or may be malpositioned. This may require repeat surgery to improve if the appearance is not acceptable. Tendon Injury (FHL or Flexor Hallucis Longus) The tendon that helps bend the big-toe downwards, runs very close to the big toe bones and very rarely can inadvertently be cut during surgery. If this happens it is usually noticed during the surgery and it will be repaired at the same time. On occasions this may be noticed post op and secondary surgery may be necessary. Over correction (hallux varus) Occasionally the big toe may become over corrected, this occurs vary rarely but in most instances will need secondary surgery to correct the position. Avsacular Necrosis (AVN) The cutting of the head of the metatarsal can compromise the blood supply to the bone which in theory can result in a reduction of blood supply to the bone. We make our osteotomy with knowledge of the location of the main blood supply and do it under direct vision. This complication therefore occurs very rarely in our practice. BUNION CORRECTION (SCARF/AKIN) JAN 2016 3
Infection Wound breakdown or infection is uncommon after this surgery. It occurs in less than 1-2 in 500. The risks can be higher in those with diabetes or in smokers. If infection occurs you may need further surgery to clear out the joint and may require prolonged intravenous antibiotics. If you feel unwell, have a fever, there is oozing from the incisions or your leg feels hot and is red then you need to let us or your doctor know as soon as possible. Thrombosis A clot in the calf veins, deep vein thrombosis or DVT may rarely occur after bunion surgery. Occasionally the clot can break off and travel to the lungs (Pulmonary embolism). We assess your individual thrombosis risk pre-surgery and will provide you with blood thinning injections if your risk is thought to be high. Due to the very rare occurrence of DVT in those with a low individual risk, these medications are not routine for this procedure. We thus avoid their routine prescription, as they themselves have risks and side effects. What happens on the day of surgery? We perform the bunion correction as a day surgical procedure which means you can go home after your operation and on the same day. Occasionally if the surgery happens late in the evening, and you live far, then it maybe sensible to stay overnight. You will meet our Anaesthetist before the operation who will be able to discuss your needs and concerns with you on the day. A local anaesthetic block will be put around your ankle (ankle block) after you have been put to sleep. This means that when you wake up the ankle should be pain free and your foot will feel numb. This lasts for a few hours and sometimes to the next day. A tourniquet is placed around your thigh or calf during the surgery to prevent blood obscuring vision in the operative field. This means that occasionally you may feel some discomfort related to the tourniquet post surgery. This is normal and would resolve in 1 or 2 days. You will meet our physiotherapists on the ward after the surgery. He or she will talk you through mobilising with the aid of BUNION CORRECTION (SCARF/AKIN) JAN 2016 4
crutches and in a special shoe (figure). You can weight bear on your heel but must avoid toeing off. What happens after the surgery? Weeks 0-2 Heel weight bearing with crutches is allowed. It is very important to elevate your foot at heart level to control swelling. Please refer to our general post foot surgery advice leaflet. The bandaging should be left in situ and kept dry. Occasionally some blood may soak through this is normal but if it is excessive we may change the bandaging sooner. Please contact us for advice. You will be seen at 12-14 days post op for a wound check at which point the dressing can be reduced and any sutures removed. Weeks 2-6 At this stage your mobility would have improved significantly. We advise gentle big toe exercises on a daily basis. Try and curl your toe up and down as much as possible. You can use your hands to gently manipulate the toe to regain motion. Weight bearing on the heel to avoid excessive pressure on the front of the foot should continue. Elevation and icing is also important but would be necessary less frequently. You will see your surgeon at around the 6 week mark. He will assess the wounds and obtain X-rays to check the bone healing and alignment. 6-12 weeks You will be shown exercises to do to gain motion of your big toe and you should do these on a twice daily basis in this period spending 10-15 mins each time. Formal physiotherapy can commence at this stage. You will see your consultant at 3 months as a final check to ensure all is well and no further input is needed. Most patients will be discharged at this stage. 3-6 months You can now resume most of your usual activity. We recommend that high impact activity such as jogging should be introduced slowly and in increments of no more that 10-15% per week. BUNION CORRECTION (SCARF/AKIN) JAN 2016 5
6 months plus You should be back to normal at this stage although occasionally swelling especially after use and at the end of the day may persist for up to a year. You might find that shoes feel tight towards the end of the working day. This is normal and will slowly resolve. When can I start my routine? Work This depends on the type of work you do and the complexity of your foot deformity. As a general rule however, sedentary and desk based jobs can commence within 14 days. Especially if there are provisions for you to elevate the foot and also commute in without public transport. If your work is more physical or requires prolonged walking or standing then it is best to delay for 6 weeks. Driving This depends on how painful and swollen the foot is. You should feel safe and in control of the car before you consider driving. As a general rule we always say that you must be able to perform an emergency stop without undue pain in your foot. The Drivers Vehicle Licensing Agency (DVLA) regards it before your operation: as your responsibility to judge when you can safely control a car. Motor insurance companies vary in their policies, It is best to discuss your circumstances with your insurance company. If you drive an automatic car and the surgery is in your left foot then you can start driving as soon as the first week. If not then driving should not be contemplated until the protective shoe has been removed. Shower or Bath We recommend no bath (this applies to hot tubs or swimming pools too) for the first 6 weeks. A shower can be used from 2 weeks and after the bandaging is changed. It is important that waterproof protection of the operated foot is in place. Sports This is very variable and depends on the conditions of your ankle and on the particular sport. However most sports should be avoided for the first 3 months. BUNION CORRECTION (SCARF/AKIN) JAN 2016 6
Will my foot look normal after surgery? Correction of bunion is done for symptoms of pain and mechanical rubbing in shoes when attempts at foot wear modification have failed. It is not done as a cosmetic operation. The operated foot may not look exactly like your opposite foot (assuming it is normal) this is because there may be some residual swelling, subtle colour change, scar and thickening of the area. The big toe may also be in a slightly different alignment to the opposite toe. The appearance however would improve following the surgery and in most instances the feet are very similar looking however a matching cosmetic appearance of the feet should not be the aim of the operation. BUNION CORRECTION (SCARF/AKIN) JAN 2016 7