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Birmingham Orthopedic Foot and Ankle Clinic - Bunions


Bunion Correction by Scarf and Akin Osteotomy

BUNIONECTOMY with Distal Head Osteotomy

BUNIONECTOMY with Wedge Osteotomy


What is a bunion?

A bunion is a bony prominence that grows on the side of the ball of the big toe. (1st Metatarsal Head).

The bony prominence consists partly of abnormal bone growth and is partly due to uncovering of the ball of the toe as the big toe slides over to one side.

Why are bunions painful in some persons?

Pain arises from 2 sources -1. Bunion 2. Ball Joint of big toe (1st MTP joint)

Pressure from footwear: The symptoms of discomfort are due to direct pressure from shoes on the bunions. A bursa (fluid filled sac) forms over the bunion, which accounts for the bunion appearing to turn red and swell up at times.

Abnormal joint motion: Pain also arises from inside the joint where the big toe is forced to move in a skewed fashion within restrictive shoes. At surgery most joints have some amount of abnormal cartilage wear and ARTHRITIS (not unlike a car tyre which is out of alignment and has uneven wear!)

Wearing shoes, which are wide and spacious at the front and have soft leather on the upper portion will help ease symptoms.

Why is pain not over the bunion but around the rest of the toes in some persons?

I call this the “DOMINO EFFECT” of the bunion. The abnormal tilt of the big toe causes it to lean on the 2nd, which is pushed up and out, sometimes causing a CLAW TOE (severe curling ), HAMMER TOE (mild curling) or MALLET TOE (curling only at the tip of the toe) deformity. The 2nd toe then pushes on the 3rd and 3rd on the 4th. An abnormally high pressure then passes through the ball of the 2d and 3rd toes, as they are pushed down towards the ground, causing pain.

The ball of the 2nd and 3rd toes are particularly vulnerable to pain, in those feet where they are very long and are placed well beyond the ball of the big toe (long metatarsals).

Sometimes there are other problems causing forefoot pain, which are unrelated to the bunion like neuromas, stress fractures, etc.

Domino Effect

Figure 1:

a. The bunion with uncovering of the ball of the big toe (metatarsal head)

b. The “Domino Effect” of the big toe pushing on the lesser toes

NOTE: More images of skeletal anatomy available under “Glossary” tab

What are the essentials of bunion surgery?

(Detailed animated images provided under Hallux Valgus section)

a. Bunion Excision: Removal of the bunion (abnormal bony bump)

b. Metatarsal osteotomy : Cutting bone to push the ball (metatarsal head) of the toe inwards to make is less prominent and to restore normal alignment with the big toe. One or two screws are used to fix the bone in the new position. Surgeons use one of several types of cuts to shift the bone and the ones used commonly are called SCARF and CHEVRON cuts.

c. Phalangeal osteotomy : This is a cut made in the bone within the toe (proximal phalanx) to shift the toe to a straight alignment from its abnormally tilted position. A wedge of bone is removed to help this shift and this is also referred to as an AKIN OSTEOTOMY. The bone is held with a staple or a screw

d. Lateral Release: A tight band holding the toe in the tilted position at the ball joint is released. This requires a cut in the space between the 1st and 2nd toe.


Figure 2:

A. Shifting the ball of the big toe is like shifting the head under a hat, to make the hat sit on the centre of the head. B. The green line indicates a lateral release, which is similar to cutting a tight strap on one side of the hat.

When should surgery be considered for bunions?

The rate of progression (worsening of tilt) varies widely between individuals and some may have small bunions with no symptoms or progression for several years and they do not require surgery. I recommend surgery where the patient has pain or when the tilt of the big toe is severe enough to cause deformities in the adjoining toes.

Is surgery painful?

No. Although pain is expected immediately after surgery, blocking the nerves, which transmit the pain, prevents this happening. Most patients tend to prefer the option of going to sleep under general anaesthesia (GA) during surgery and some choose to remain awake while the foot remains numb. Patients, who prefer GA, will receive injections around the nerves, after they go to sleep.

Further mild pain is well controlled by tablets given at discharge from the hospital. Keeping the foot elevated for the first 2 weeks reduces swelling and pain.

How long will I be off work?

2-7 wks depending on the type of work. A special shoe (no cast) is worn for 6 weeks and full weight bearing is allowed. Driving is not advised for 6 weeks. Elevation at home for the first 2 weeks is recommended. After this where transport facilities and safe work environment is available, some patients who do desk based work, return to their jobs. I recommend keeping the foot up on a stool or chair to the extent possible between 2 to 6 weeks. Those who drive to work and do non-desk based jobs, return after 6 or 7 weeks.

Addendum to the printable PDF document within the animations above.

* The choice of surgery is dependant on the extent of the deformity

* Associated deformities in the other toes may need additional surgery as severe tilting of the big toe has a “Domino” effect on the other toes pushing them out of alignment.

* Percutaneous Bunion Surgery- (Minimally invasive surgery for cutting and realigning bone)

Although slowly increasing in popularity, published long term studies are not available, to look at the proportion of successes and failures. The benefits have been extensively debated at national meetings in America and UK where I have been present and the jury is out. Early papers showed a high failure rate but since then the procedure has been modified and special instruments have been developed.

I have undergone specific training for performing this key hole procedure and this surgery will be available shortly for appropriate patients who wish to undergo percutaneous surgery.

*This document is a general information sheet and is meant to be read in conjunction with a BOFA clinic consultation and is not meant for self diagnosis which could be harmful.
*All surgical procedures have a small potential for complications and some are influenced by individual factors (severity of the deformity, blood circulation, obesity, diabetes, smoking etc). These will be discussed during the clinic consultation and noted in the consent form, a copy of which will be given to you.