Patient Information
Metatarsal Osteotomy (bunion surgery)
Author: Simon H Palmer
Brief description:
• You have been recommended to have surgery to treat your bunion. A bunion is a lump at the base of the big toe, which is caused by a sideways drifting and angulation of the big toe.
• Here, we explain some of the aims, benefits, risks and alternatives to this procedure (operation/treatment). We want you to be informed about your choices to help you to be fully involved in making any decisions.
• Please ask about anything you do not fully understand or wish to have explained in more detail.
• If you would like this information in another format or language or would like help completing the form, please ask a member of our staff. Please bring this form with you to hospital
You will be asked to read this form carefully, and you will be asked sign it to confirm that you have read it and had a chance to ask your surgeon any questions before your operation.
Remember, you can change your mind about having the procedure at any time
About Metatarsal Osteotomy
A bunion is not a bump on the bone itself, it is caused by a change in angulation of the bones in the foot. Sometimes, it is painful in itself, but more commonly it causes symptoms by pressure on footwear or, on occasions, by crowding or crossing of the smaller (lesser) toes. Indeed, the second toe can become so crowded that it becomes clawed, and can cross over the big toe.
Realistic Expectations About Bunion Surgery
An important factor in deciding whether to have bunion surgery is understanding what the procedure can and cannot do. The vast majority of patients who undergo bunion surgery experience a dramatic reduction of foot pain after surgery, along with a significant improvement in the alignment of their big toe. Some people however will experience occasional pain in their bunion after surgery. Bunion surgery will not necessarily allow you to wear a smaller shoe size or narrow-pointed shoes. In fact, you may have some shoe restrictions for the rest of your life. Remember that the main cause of the bunion deformity is a tight fitting shoe. If you return to that type of shoe wear, your bunion may reappear.
Minimally Invasive Surgery for Bunion Treatment
Surgical correction of hallux valgus rebalances the big toe, correcting the various features of the deformity. While several well-established surgical methods are available for hallux valgus (more than 130 different operative methods), consensus regarding the best management has yet to be established. In 2004, a systematic review of the published literature concluded that there was no compelling evidence of advantages of any of these methods over any other particular type of surgery.
Minimally invasive trauma and orthopaedic surgery is increasingly common. These techniques have the theoretical advantage of decreasing recovery and rehabilitation times, because surgical exposure and deep soft tissue dissection are less extensive and possibly gentler. These techniques hold the promise to provide better clinical outcome for patients who would not recover well from traditional open approaches.
The main advantages of minimally invasive hallux valgus correction are the shorter surgical times, less soft tissue damages and higher patient acceptance to the approach. These features propose minimally invasive surgery as an effective tool for medically compromised patient, such as patients with diabetes mellitus, chronic non-infected, non-healing ulceration secondary to peripheral sensory neuropathy and structural forefoot deformity.
The clinical results obtained with minimally invasive procedures for the correction of mild-to-moderate hallux valgus deformity are comparable to those obtained with other percutaneous distal metatarsal osteotomies and to most series of open (or traditional) surgical procedures. These techniques are a modern innovation in bunion surgery but research studies have been published supporting the techniques for over 10 years. Obviously more studies and reports are appearing in the scientific literature all the time. If you would like to read some of these reports, some are highlighted in the NICE guidance documents from 2009(see below). Please note these documents are awaiting modernisation. Please also see the review of the published data from Professor Maffulli from 2011.
http://www.nice.org.uk/nicemedia/live/12187/47567/47567.pdf
http://www.nice.org.uk/nicemedia/live/12187/45824/45824.pdf
http://bmb.oxfordjournals.org/content/97/1/149.full.pdf+html
Before your procedure
• The surgery is usually carried out under a special day case surgery general anaesthetic. Local anaethetic is not used as a high pressure cuff is applied to the thigh before surgery which can cause discomfort if awake. Also any patient movement during the surgery can cause imprecise surgery. The operation is usually performed as a day-case procedure.
• You will be invited to attend a pre-assessment clinic when you will be seen by one of the specialist screening nurses. You will need to be screened for a germ called MRSA which can cause nasty infections in surgical patients. If you are a carrier of this bacteria you will need treatment before surgery (showering and topical ointments)
• At this clinic, we shall ask you for details of your medical history and carry out any necessary clinical examinations and investigations. This is a good opportunity for you to ask us any questions about the procedure, but please feel free to discuss any concerns you might have at any time.
• You will be asked if you are taking any tablets or other types of medication - these might be ones prescribed by a doctor or bought over the counter in a pharmacy. It helps us if you bring details with you of anything you are taking (for example: bring the packaging with you).
During the procedure
• Before your procedure, you will be given a chance to meet the anaesthetist who will explain the anaesthetic procedure.
• An osteotomy is an operation in which the bone (in this case the metatarsal bone) at the base of the toe is divided and replaced into a more correct position. The operation aims to straighten the great toe, and narrow the forefoot. Because the operation involves dividing the bone, the foot has to be held in position while the bone heals together again. In the majority of cases, small screws and or wires are used. The foot is usually protected in a special post- operative shoe for six weeks after surgery. If a wire is used these are usually removed 4 weeks after surgery in the outpatient department.
• Occasionally, the big toe is also divided, a procedure known as an Akin Procedure.
• The nerves of the foot are also anaesthetised during the procedure with a long-acting local anaesthetic so the foot will be numb and usually pain free after the procedure. This can last 12-14 hours.
After the procedure
• After the operation, you will wake up with your foot in a bandage. The day after surgery the foot is always sore, but the pain can be helped with painkillers which will be given to you on the day of surgery.
Eating and drinking: After the operation, you will be able to eat and drink when you are awake again. How quickly you return to a normal diet will depend on how you feel. Most patients recover their appetite very quickly.
When you can leave hospital: Most people who have had this type of procedure will be able to leave hospital on the day of the operation.
Getting around and about: When you are discharged from hospital, to start with, you will need to rest your foot and keep it elevated (above your heart level) most of the time for the first two weeks. You are able to weight bear through the heel when walking. You will find that when your foot is lowered, it will throb and swell which is to be avoided. With time, you will find you can keep the foot down for longer periods of time. At around two weeks after surgery, you will return to the outpatient clinic for removal of your suture (stitch). You can have this performed by your local GP practice nurse if travelling to the clinic is difficult. The nurse will need to redress any wires that have been inserted. You will need to return at 4 weeks usually to have your wire removed. This is a very easy and quick procedure that usually causes minimal discomfort, however it is reasonable to take some painkillers before coming to clinic if you are concerned. Once the wire is removed you will be provided with a Valgulok removable splint for your big toe. You should wear this at much as possible through the day and night for two weeks then at night only for 2 months.
Special measures you need to take after the procedure: On average, you should expect to wear the post-operative shoe for six weeks. After this, you will need to wear an open-toed sandal, preferably with adjustable straps. After six to eight weeks most people can usually wear a wide comfortable shoe or trainer shoe. You will be given more detailed information about any other special measures you need to take after the procedure. You will also be given information about things to watch out for that might be early signs of problems (for example: infection).
When you can resume normal activities including work: It is usually two to three months from the operation before you can expect to resume either recreational walking or light sporting activities. Most people are walking reasonably comfortably in shoes by 6 to 8 weeks. If your right foot is undergoing surgery or you have a manual car you will not be able to drive for 6 weeks. If your left foot is being operated on and you have an automatic car you will be able to drive after two weeks. Before you return to driving you must test that you can hit the brake pedal with force without restriction beforehand.
• If your recovery is slower than these times, do not be alarmed because they are only averages. If you think your recovery is being too slow please let your surgeon know when you attend the clinic.
Check-ups and results: Before you leave hospital, you will be given details of when you need to return to see us. At this time, we can check your progress and discuss with you any further treatment we recommend.
Intended benefits of the procedure
• The surgery is designed to reduce the pain in your foot caused by a bunion and prevent it recurring.
Who will perform my procedure?
• This procedure will be performed by Mr Palmer
Alternative procedures that are available
• Early, minor bunions can respond well to the use of foot splints or braces, although the effects are often short-lived. Wearing corn plasters or pads can also relieve symptoms of local pressure. Shoes can be specially made or adapted to accommodate the bunion within a broad front (toe-box).
• Some bunions are caused by having a flat foot and/or after collapse of the arches; these can be helped by wearing arch supports in your footwear.
More severe symptomatic bunions can only be corrected by surgery. This surgery should only be undertaken if the symptoms are significant and appropriate non-surgical treatment has been considered. You should not have this surgery for cosmetic reasons alone.
Serious or frequently occurring risks
This surgery is a commonly performed and is generally considered a safe operation. For most people the benefits are greater than the disadvantages. However, all surgery does carry some element of risk. Smoking and diabetes increases the risk of a complication. Despite the great care that is taken with the operation and afterwards, a small number of people (up to 10%) may have a less-than-perfect result due to problems listed below. These figures are from previous published scientific studies on patients who have undergone bunion surgery throughout the world.
• Recurrence of the bunion (up to 1% in long term follow up studies). May need further surgery if becomes painful.
• Over-correction of the great toe (so that it points inwards) 1%. May require further surgery.
• Stiffness and pain in the toe. Usually due to the presence of early arthritis in the great toe joint. Incidence is not well reported but is probably < 3%. This usually resolves with physiotherapy but occasionally may need to be accepted if the joint is painless. Significant stiffness and arthritis may require further surgery in the form of a joint fusion (joint is fused so it does not move so pain is abolished)
• Sensitisation of the foot caused by interference during the operation to the small nerves and blood vessels of the foot (up to 5%)
• Non-healing of the bone. This rare with very few cases reported in the scientific literature but is likely to be higher in smokers and diabetics. In time all osteotomies seem to heal. (<1%)
• Development of pain or a corn under the second toe caused by weight transfer to the second toe. Can require an insole in the shoe or further surgery on the 2nd or 3rd metatarsal. Up to 5% in some studies
• Infection of the toe/foot, (which can usually be treated with antibiotics but rarely can lead to a deep bone infection) 1-2%
• The complications of any surgery, such as thrombosis (a blood clot) 2%.
• Occasionally, the foot can be worse after surgery than it was before. On occasions this worsening is not correctable if it is due to nerve pain (chronic regional nerve pain) except by having an appointment with a pain specialist - 2%.