Bunions

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• Before and After Pictures of Bunion Surgery

One of the most commonly treated foot conditions are painful bunions. Patients with this condition will usually complain of pain when wearing shoes, especially narrow dress shoes, or with physical activity, such as walking or running.

Cause of Bunion Deformity

The classic bunion is a bump on the side of the great toe joint. This bump represents an actual deviation of the 1st metatarsal. In addition, there is also deviation of the great toe toward the second toe. In severe cases, the great toe can either lie above or below the second toe.

Shoes are often blamed for creating these problems. This, however, is inaccurate. It has been researched in primitive tribes where going barefoot is the norm and they also developed bunions. Bunions develop from abnormal foot structure and mechanics that places an abnormal pressure on the 1st metatarsal. This leads to stretching of supporting soft tissue structures such as joint capsules and ligaments with the end result being gradual deviation of the 1st metatarsal. As the deformity increases, there is an abnormal pull of certain tendons, which leads to the drifting of the great toe toward the 2nd toe. At this stage, there is also adaptation of the joint itself that occurs. This is typically followed by degeneration and arthritis of the great toe joint.

The fundamental driving force behind developing bunions as a result of faulty foot mechanics is genetics. Issues such as loose ligaments and flat feet, are inherited. The traits then act as the foundation for abnormal foot mechanics and lead to formation of bunions.

Red line: Abnormal bisection of first metatarsal -  Green line: Correct bisection if bone where not splayed out 

Normal bisection of metatarsal bones

The most common symptoms associated with this condition are pain on the side of the foot just behind the great toe. A red painful bump is usually present. Pain is usually brought on with walking or sports. Shoes don't cause bunions but will typically aggravate them. Stiff leather shoes or shoes with a tapered toe box are the prime offenders. This is why bunion pain is most common in women whose shoes have a pointed toe box. The bunion site will often be slightly swollen and red from the constant rubbing and irritation of a shoe. Occasionally, corns can develop between the 1st and 2nd toe from the pressure the toes rubbing against each other.

Treatment

Treatment falls into two broad categories, conservative and surgical. From a conservative standpoint, efforts are directed at correcting faulty foot mechanics with custom molded insoles and relief of symptoms. These include:

• Custom Orthosis to stabilize the abnormal motion of the hind and fore foot. 
• Shoe gear modification: Using shoes with larger toe boxed and more supple materials.
• Changes in activities: Try to avoid those things which cause symptoms.
• Anti-inflammatory medication for periodic relief this includes cortisone injections into the joint as well as oral medication.

Surgical management:

Goals of surgery:

The primary goal of bunion surgery is to relieve the pain associated with the deformity.  This is accomplished by:

• correcting the underlying abnormal metatarsal position by realigning it toward the second toe.
• Removing excessive bone formation on the bunion "bump"
• releasing the soft tissue tightness which is pulling the big toe towards the second toe.
• Tightening the soft tissues which are overly stretched on the bump side of the joint.
• Reestablish the correct alignment of the cartilage surfaces.
• Move the sesamoid bones into correct alignment.
• Realign the great toe.

Bunion surgery procedures are based on many factors, including health, age and lifestyle of the patient.  However, a critical factor in procedure choice is the grading of the bunion deformity.

Bunion deformity grading:

Bunions are grade by the severity into three broad categories:

• Mild: Patient's symptoms may include pain and throbbing with activities. There is a slight bump. There is no arthritis of the joint.
• Moderate: Patient's symptoms may include pain and throbbing most days regardless of activity level. Patient has difficulty wearing most styles of shoes without pain. There is a moderate bump. Some arthritis maybe present in the joint. The big toe is pressing firmly against the second toe.
• Severe: Patient's has pain daily. Large bump which is red and irritated from shoes and may deform shoes. Inability to wear all styles of closed shoes without pain. Arthritis is present within the joint. The big toe and second toe may overlap. The big toe cannot be straightened manually.

Proximal bunion surgery (proximal bunionectomy):

• Before and After Pictures of Bunion Surgery