Hallux valgus surgery

Bunion surgery, 1st metatarsal osteotomy (Scarf and Akin), Minimally Invasive Chevron and Akin procedure (MICA)
Summary

This operation is performed for symptoms caused by bunions affecting the big toe.  The medical term for this condition is hallux valgus.  The main symptom from hallux valgus is rubbing and discomfort when wearing footwear due to the increased prominence of the “knuckle” of the big toe and crowding of the lesser toes.  Hallux valgus can lead to problems with the lesser toes as well such as clawing.

Surgery involves realigning the bones of the big toe.

Factors to Consider

You have been diagnosed with hallux valgus.  It is likely that you have already tried non-surgical treatments for your foot such as pain killers, footwear modification and insoles.  

If these measures have not improved your symptoms then the next logical step is to consider surgery.  Hallux valgus surgery is unlikely to restore your foot to normal but will narrow the foot to a more practical and cosmetic shape, consequently reducing the discomfort caused by hallux valgus. 

Description of Surgery

The operation can be performed as an open procedure or through a minimally invasive approach.  Surgery will vary between each patient depending on how severe the deformity is and whether arthritis is also present.  The principles of the surgery are to surgically cut the affected bone (osteotomy), realign the 2 bone fragments and fix them in their new position using screws or staples.  This is combined with soft tissue releases around the joints.  

Open surgery is required for more severe cases.  Lesser toe surgery is commonly performed at the same sitting if they are affected.  If arthritis is present then a 1st MTPJ fusion may be more appropriate.  

The operation takes about 1 hour.

Anaesthetic

The operation is usually performed under a general or spinal anaesthetic and so you will be given instructions as to when you need to stop eating and drinking (normally the night before) before you come into hospital.  

Your pain can be well controlled with local anaesthetic given during the operation.

What are the risks?

All operations involve an element of risk.  Hallux valgus surgery aims to improve the function and the appearance of the foot.  Patients will have varying expectations of surgery and it is important to know that the majority, 80-85%, are satisfied with the outcome.  

The big toe can feel weaker after surgery and this can cause a transfer of pressure onto the ball of the foot causing pain.  This is known as metatarsalgia.  Correcting the deformity can be challenging and in some patients the deformity will recur.  Rarely, the toe can deform the other way and point outwards.  

The risk of infection is small and is thought to be about 1%.  Most infections will settle simply with antibiotics.  Damage to nerves and blood vessels around the foot can occur but this is rare.  

Any surgery to the foot increases the risk of developing a clot in your leg (DVT).  Your surgeon will assess your risk of this prior to surgery and may offer you blood thinning medication if your risk is considered high.

After Surgery

Pain

Local anaesthetic will be used during the operation and so you will feel comfortable when you first wake up.  This can last up to 12 hours but the foot may be sore after it wears off.  You will be given a combination of pain killers to go home with.  

Dressings

You will wake up with your foot in a bandage with a heel weight bearing shoe.  This is a shoe that only allows you to put weight through the heel, thus protecting the osteotomy.  It is likely that you will need a heel weight bearing shoe for the first 6 weeks.  The surgeon will give you instructions as to when you can start to fully weight bear as this will depend on the appearances on the Xray.  

Physiotherapy

The physiotherapist should see you before the operation to explain some simple exercises you can do after the operation.  They will also ensure a physiotherapy appointment is made for you once you are fully weight bearing.  Physiotherapy can be arranged local to you.  

Driving

You can drive when you feel you are safe to drive.  This means that you feel confident that you have full control of your car and are able perform an emergency stop.  This will vary between patients but normally takes at least 6 weeks.  

Return to work

This depends on what your job is.  You should be able to return to a “desk job” within a few weeks of your surgery.  If you have a more manual job it can take up to 12 weeks before you feel ready to return to work.  Please discuss this further with your surgeon or physiotherapist if you feel unsure.  A sick note can be given to you at the time of your surgery if required.  Please ask the nurses on the ward if you need one.

What to expect

Recovery following surgery can be quite variable but the expectation is that “it takes 3 months to be fair, 6 months to be good and 12 months to be right”.