Bunion (Lapidus and Akin) operation: A guide for patients

What are bunions?

• A bunion, known medically as hallux valgus, is an abnormal alignment of the big toe. The first metatarsal, which is the inside long bone of the forefoot, begins to drift towards the other foot. Meanwhile, the big toe deviates across towards the smaller toes.
• The big toe joint becomes more prominent, widening the ball of the foot, which can cause footwear fitting difficulties, joint inflammation and pain. Poor joint alignment may also cause abnormal joint wear and tear, resulting in arthritic changes.
• As the bunion progresses, the smaller toes become crowded and may adopt abnormal positions with painful corns or calluses.
• You may also experience pain under the second toe ‘knuckle’ joint because the big toe is not functioning properly.

What causes bunions?

• Although shoes are often thought to be the cause, bunions are most likely to be an inherited condition. They can often be seen in different generations in one family.
• Shoes, which are tight fitting in the toe area, will make the problem worse.
• Bunions are also associated with joint diseases, such as rheumatoid and osteoarthritis.
• The way in which the foot works during walking can affect the big toe joint. Abnormal movement has been thought to influence bunion formation.

Who do bunions affect?

• Anyone can get bunions, even children. Women present more commonly than men and this may be due to the differences in types of shoes between the genders. Most evidence indicates that bunions are a progressive condition, which worsen over time. It is, therefore, more common to see bunions in middle and later age.

Treatment options

Depending on the degree of pain, deviation of your big toe and extent of smaller toe involvement, there are several options:

Non-surgical treatments

• Joint padding and protective shields
• Gel/silicone wedges between the toes
• Avoiding high heels
• Surgical footwear
• Bunion night splints – these have been shown to reduce the progression of a bunion in children
• Cortisone (steroid) injections
• Insoles (orthoses).

Surgical treatment

More than 120 operations have been reported for treating bunions, some more effective than others.

The type of recommended surgery is based around you, your bunion (type, size and degree of pain) and lifestyle requirements after surgery. As a result, not everyone is offered exactly the same surgery; the surgery is tailored to you as an individual.

Intended benefits of an operation

The aims of a bunion operation are to correct the big toe position and reduce pain from the joint or irritation from footwear.

About day case surgery under local anaesthetic

Surgery is carried out under local anaesthetic as a day case. This means that you are awake during the operation but a screen will prevent you from seeing the surgery.

To numb your foot, you will either be given some injections around your ankle or behind the back of the knee. You can eat and drink on the day of surgery; there is no need for fasting.

The operation may take up to ninety minutes, but you should be ready to be at the hospital longer than this to allow for preparation and recovery.

If you decide on surgery you will be invited back to attend a pre-surgical clinic. A member of the nursing team will take your medical history. If you are on any medication, please bring a list with you. This is a good opportunity to ask us any questions and discuss any concerns you may have about the procedure.

You must have a competent adult at home for the first day and night after surgery.

Surgical intervention: Lapidus arthrodesis and Akin osteotomy

About your operation

• An arthrodesis is an operation where the surfaces of a joint are removed and the two bony surfaces brought together and held in position with either screws or plates.
• A Lapidus arthrodesis is where the first metatarsal and neighbouring bone, the cuneiform, is fused. This type of operation is usually reserved for large bunions or osteo-arthritic changes at the joint.
• An Akin osteotomy is where a wedge of bone is removed from the big toe bone (proximal phalanx) to straighten it. It is common for this type of surgery to slightly shorten the big toe.
• Throughout the operation, you will have a tight band, a tourniquet, around the ankle to keep the blood away from your foot. This is sometimes uncomfortable but is immediately deflated after the operation.
• Following the Lapidus procedure the foot is normally placed in a non-weight-bearing cast for six to eight weeks, to stop any weight being put on the foot. Failure to do this can stop the bony surfaces fusing and can lead to other complications.
• You will be in the cast for six to eight weeks. You will need to take up to twelve weeks off work especially if your job involves long periods of standing, walking or manual labour.
• After the six to eight weeks you will have to partial weight bear for a further two weeks. This will be explained to you at the appropriate time.

Recovery after your operation

Following this procedure you will be in a non-weight bearing cast for up to eight weeks.

The first two days

• You will be in a plaster of Paris below knee cast for the first two weeks. This cast is rather heavy but allows for foot swelling. You should not walk on the foot which had surgery.
• You must rest, with your feet up, as much as possible. You should restrict your walking to bathroom visits only and when getting about you must use your crutches. The nursing team will show you how to use your crutches and provide you with written information.
• If you experience pain, you should take the prescribed painkillers. Any pain is usually worse for the first two days.
• If you are still experiencing pain after three to four days that is not relieved by the painkillers, you should contact the podiatric surgery department.
• If you have any concerns over your foot you should contact the department directly.

The department is closed at the weekend, so you should contact your GP or go to your local accident and emergency department.

Two weeks after surgery

The plaster of Paris cast will be removed and replaced with a lightweight fibreglass cast, which stays on for a further four to six weeks. You must continue to bear NO weight on the foot and use the crutches.

Between six and eight weeks after surgery

• An x-ray will be taken to assess bony healing.
• Providing there is sufficient bony healing, the cast is removed.
• You will then be able to lightly bear weight through your foot (partial weight-bearing) using your crutches and a boot which will be provided.
• Partial weight-bearing is carried out for a further two weeks. No high-impact activities are allowed.

Ten weeks after surgery

• You can begin to fully weight-bear on the foot and gently start to return to normal activities. You should still avoid high-impact activities and remain in a trainer.
• You can now return to driving; however, you must feel able to perform an emergency stop without hesitation or pain. Please check with your insurance company about your cover.
• You may return to work but this is dependent on the type of work and footwear required for your job. For certain jobs, return to work in less than 12 weeks can be an unrealistic expectation.

Twelve weeks after surgery

Although the foot should now be comfortable and returning to normal, there will still be noticeable swelling, particularly towards the end of the day; this is normal.

Nine months after surgery

Residual swelling should now be slight, although the healing process continues for 18 months. You should be getting the full benefit of the surgery.

Eighteen months after surgery

All healing is now complete, swelling should be completely resolved.

Frequent or serious risks

All operations carry a small risk of complications. In foot surgery, complications are uncommon and most resolve without permanent disability or pain.

General and specific complications of this procedure include:

• infection (two in 100)
• delayed healing of the skin (eight in 100)
• non-compliance of patients (four in 100)
• bone break associated with noncompliance (two in 100)
• prolonged swelling post operatively (four in 100)
• thick or sensitive scar formation (four in 100)
• loosening or movement of the screws or wires used to fix the bones (two in 100)
• the toe may not be perfectly straight
• the toe may become stiff which could affect the heel height of the shoes you wear (incidence: one in 100)
• recurrence of the bunion (two in 100)
• development of secondary pain or tenderness under the second toe knuckle joint (three in 200)
• delayed or non-union of the fusion site
• blood clot deep vein thrombosis (DVT).

Complications following foot surgery are rare but can happen. It is important to remember that if a complication arises you will be need to visit the hospital more frequently and there could be a significant impact on your recovery and return to work time. Foot surgery should be avoided if only for cosmetic gains.