What is a Bunion?
A Bunion (hallux abducto valgus) is a deformity involving the big toe and the bones associated with it. It is a deformity in 3 different planes. A bunion is the shift of the big toe bones into improper positions leading to pain and loss of function. The players involved in a bunion are: the big toe (hallux), the big toe joint (1st metatarsophalangeal joint), the 1st long bone (1st metatarsal), the sesamoids, the mid-foot joint (1st metatarsal-cuneiform joint), and the 1st mid-foot bone (1st cuneiform).
Over time, the 1st metatarsal will swing away from the other long bones towards the other foot (medial); this is what is seen as the bump on the side of the foot. At the same time, the big toe will move out of its joint towards the 2nd toe (lateral). Now the head of the 1st metatarsal bone is sticking out leading to undo pressure from shoes and the ground. This constant pressure and friction on the bone will cause extra bone to form, leading to the bump that is seen on the side of the foot getting larger. The big toe will continue to shift towards the 2nd toe causing an unbalanced big toe joint. This can cause arthritis to develop in the joint due to the mal-positioned joint. In many cases the big toe will rotate so that the bottom of the big toe faces the 2nd toe. The force of the big toe pushing against the 2nd toe will cause the 2nd toe to cock up and become a painful hammertoe. A bunion deformity is always progressive. It will always get worse over time. The sesamoids will also be in a poor position taking on improper pressure and causing a sesamoiditis.
What are the Symptoms of a Bunion?
Not all bunions are painful. Someone may have a very severe bunion with no pain, while someone with a mild bunion can have significant pain. Patients can notice painful calluses develop (extra growth of hard skin). Most patients will complain of a deep ache and pain over the bump. There can be pain in the joint. There can be pain in the ball of the foot just behind the big toe. Some days may be more painful than others if the bursa (the gel-like sac of fluid between the bone and the skin) becomes inflamed from friction causing a bursitis. Numbness to the big toe can develop with constant friction of the skin and nerve over the bump protrusion. Over time, if arthritis develops in the joint, there will be pain within the joint when walking. A painful hammertoe may also develop.
What Causes a Bunion?
Bunions are primarily a genetic deformity. This means that most people that have a bunion inherited it from someone in their family before them. If someone is destined to acquire a bunion over time, they will form a bunion. However, there are factors that can increase the speed and severity in which the deformity will develop. Flat feet (pronation) are inherently unstable and tend to have loose ligaments around the 1st metatarsal leading to its shift. Significant use of high heel shoes with their small toe box can push the big toe closer to the 2nd toe.
How is a Bunion Diagnosed?
Diagnosis is achieved by a thorough clinical examination and x-rays of the patient. Dr. Soomekh will listen to the patient’s complaints, symptoms, and goals. The examination involves a hands-on analysis of the patient’s foot and evaluating their gait. Digital radiographs (x-rays) of the feet will be obtained in the office and reviewed with the patient. A specialized CT scan of the foot may be obtained in the office to evaluate the bunion in 3D for proper treatment. The positions of the bones and joints evaluated on the x-rays help to determine the severity of the deformity and any associated deformities.
How is a Bunion Treated?
Dr. Soomekh educates that early diagnosis and treatment of a bunion are the keys to successful treatment, faster recovery and painless lifestyle.
Conservative Treatment for a Bunion:
Conservative treatments rely on their ability to accommodate a bunion deformity. This can be achieved by wearing appropriate shoes with a wide toe box. If the shoe has room for the protruding bone, there can be less pain and discomfort. Any painful calluses can be removed in the office and will need to be maintained, as they will return. Toe spacers can alleviate the pressure of the big toe upon the 2nd toe. Padding over the bunion bump can take the pressure off the area. Ice and anti-inflammatories can reduce the irritation when there is a flare. Custom molded orthotics can be made as an important tool to slow the progression of the bunion and prevent recurrence after bunion surgery.
There is not a conservative way to stop a bunion from forming or progressing. There is no conservative way to reverse a bunion. Braces and straps cannot reverse the malposition of the joints and bones.
Surgical Treatment For A Bunion:
Dr. Soomekh will always recommend and attempt conservative treatment when appropriate. However, when a bunion deformity becomes painful and many shoes are difficult to wear, surgical repair may be indicated.
Is Bunion Surgery Painful?
Considering surgery can be intimidating. Foot surgery including bunion surgery is not supposed to be painful during recovery. When the skin and the soft tissues are handled with care and focus, most patients experience little to no pain immediately after surgery and throughout the recovery period. Dr. Soomekh takes great care and focus to minimize the chance of postoperative pain. The goal of bunion surgery is to realign the big toe and the 1st metatarsal, remove the bump, alleviate pain, allow a return to normal shoes, and allow a return to all activities. Most procedures allow for immediate walking and a return to work while wearing a special walking boot. Dr. Soomekh performs the procedures in an outpatient setting at state of the art facilities.
How do I Choose the Right Surgeon for bunion surgery?
Dr. Soomekh has significant experience in every aspect of bunion surgery. He is able to choose the exacting correct procedure for each individual patient because he has innovated the 6 main methods for surgical correction of a bunion. Every bunion is different and should not be treated exactly the same way each time. There are many different procedures and techniques to repair a bunion deformity. It is the responsibility of the surgeon to investigate each specific aspect of the bunion for each individual patient in order to formulate the proper procedure for repair. Dr. Soomekh will use the information gained from the patient’s symptoms, age, activity level, lifestyle goals, the severity of the deformity, the clinical examination, the patient’s gait, and the x-rays, to make a recommendation on the proper procedure. Dr. Soomekh will use a specialized CT scan of the foot to evaluate the bunion in 3D to help develop the surgical plan.
The following are basic categories for correction of a bunion deformity. Within each category, there are several different techniques available. In many cases, a combination of the procedures can be performed. The purpose of bunion surgery is to return the 1st metatarsal and the big toe (hallux) to its correct and anatomical position. The goal is to perform the best procedure that will result in the best correction, the least chance of recurrence, and the quickest recovery and return to normal and painless activities.
Surgery for a Mild to Moderate Bunion
Head Osteotomy, Chevron, Austin, V-cut
A small incision is made on the side of the big toe joint. The extra bump is removed. A precision cut is made at the head of the 1st metatarsal (osteotomy). This bone is now shifted over the original bone closer to the 2nd metatarsal, reducing the angle between them. This bone is then stabilized with 1 or 2 small screws. The screws hold the bone in its new corrected position while the bone heals. Once the bone heals, the screws are not needed and are generally not removed. The big toe is now realigned by releasing one set of ligaments and tightening the other set of ligaments bringing the big toe straight in the joint. Dr. Soomekh will then close the skin using plastic surgery techniques.
Surgery for Moderate to Severe Bunion
Opening Base Wedge Osteotomy
With a larger deformity, more of the 1st long bone needs to be shifted. This can be achieved by making an incision over the base of the 1st metatarsal. An precision wedge cut is made into the side of the long bone without going all the way through. The far end of the 1st metatarsal is tilted towards the 2nd metatarsal, reducing the angle between them. The open wedge is now stabilized with a specialized plate and screws. Over the healing time, the wedge will fill with bone, keeping the long bone in the correct position. In some cases a bone graft will be placed between the wedge. A second incision is made on the side of the big toe joint. The extra bump is removed. The big toe is now realigned by releasing one set of ligaments and tightening the other set of ligaments bringing the big toe straight in the joint. Dr. Soomekh will then close the skin using plastic surgery techniques.
Lapidus, 1st Metatarsal Cuneiform Fusion:
With a larger deformity, more of the 1st long bone needs to be shifted. The loose joint at the base of the 1st metatarsal is addressed to move the entire 1st metatarsal into a corrected position. This can be achieved by making an incision over the base of the 1st metatarsal and removing the joint (1st metatarsal cuneiform joint). The entire 1st metatarsal is shifted towards the 2nd metatarsal, reducing the angle between them. The 2 bones are then joined together in order to fuse the joint (joining 2 bones into 1). The position is held with 2 screws. Once the bone heals and fusion is achieved, the screws are not needed and are generally not removed. A second incision is made on the side of the big toe joint. The extra bump is removed. The big toe is now realigned by releasing one set of ligaments and tightening the other set of ligaments bringing the big toe straight in the joint. Dr. Soomekh will then close the skin using plastic surgery techniques. With this type of procedure, the long bone can never move out of position. Dr. Soomekh may use a specialized plate with the Lapidus procedure that can allow for bearing weight only 3 weeks after the surgery, rather than the traditional 6 weeks.
When the bone of the big toe itself is deviated towards the 2nd toe, an additional procedure can be performed to the hallux. The incision along side of the big toe joint is extended. A special cut is made into the toe bone (phalanx) removing a small wedge of bone. The far end of the bone cut is tilted to close the wedge, bringing the big toe into a corrected position. A small screw stabilizes the bone cut. Once the bone heals, the screws are not needed and are generally not removed.
In cases of a severe bunion when a fusion cannot be performed, a modified technique may be chosen. When the procedure is performed to shift the 1st metatarsal head and it is fixated with the screws and it is noted that more correction is need, an adjunct procedure can be performed. The base of the 1st metatarsal is anchored to the base of the 2nd metatarsal using strong stitches affixed to an absorbable plug (tight-rope). An incision is made to the side of the base of the 1st metatarsal. A drill hole is made through the base of the 1st metatarsal to the base of the 2nd metatarsal. The anchor is then placed through the hole and fixated to the 2nd metatarsal. While holding the 1st metatarsal in the correct position, the stitches are pulled tight and tied down to the bone, holding the long bone straight.
When left untreated, a bunion can lead to severe arthritis in the big toe joint, called hallux rigidus. In these cases, a traditional bunion correction may not reduce all the pain caused by the damaged joint. These patients may require a correction of the bunion through a fusion of the big toe joint. This procedure will solve two problems at one time, the improper angle of the toe and the painful arthritic joint. The fusion of this joint still allows for normal walking and some activity. An incision is made on the side of the big toe joint. Any extra bone around the joint is removed. The surfaces of each bone are prepared by removing all the remaining cartilage. The 2 bones are brought together and 2 small screws are placed across the joint. The screws hold the bone in its new corrected position while the bone heals into one. Once the bone heals, the screws are not needed and are generally not removed. In some cases a plate may also be used to hold the bones together to allow for earlier weight bearing. Dr. Soomekh will then close the skin using plastic surgery techniques.
Dr. Soomekh has perfected and reinvented these surgical procedures and techniques and is recognized by his peers as one of the top bunion specialists and bunion surgeons in the Los Angeles area.