Bunion scarf and akin osteotomy: 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 to reduce the pain arising from the joint or irritation from footwear.

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 what is going on.

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 one hour, but you should be ready to be at the hospital longer than this to allow for preparation and recovery.

If you decide on surgical management 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 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 interventions: scarf and akin osteotomies

About your operation

• An osteotomy is an operation where a bone is cut and moved into its correct position.
• A capital osteotomy describes the area where h the long bone (metatarsal) is cut and moved into its correct position.
• 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.
• Once the bones have been repositioned, they are secured by small screws or wires.
• The skin layers are stitched together, often with stitches that dissolve. Occasionally, if your skin is very sensitive or you are prone to problem scarring, non-dissolvable stitches will be used.
• Throughout the operation you will have a tight band, called a tourniquet, around the ankle to keep the blood away from your foot. This is sometimes uncomfortable but is immediately released after the operation.

Recovery after your operation

The first two to three days

• You must rest with your foot elevated to hip level.
• You should restrict your walking to bathroom visits only. If you have been given crutches, you must use them in the way shown. You may be able to bear a little weight on the foot.
• 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 department directly.
• If you have any concerns over your foot you should contact the department directly.
• The department is closed at the weekend. Out-of-hours, you should contact your GP or go to your local accident and emergency department.

Two weeks after surgery

• Two weeks after the operation you must attend for removal of the dressing.
• The skin should be healing well by this time and any non-dissolvable stitches will be removed.
• You should no longer need a bandage and should be able to wear a normal shoe again. This shoe does need to be roomy, for example a running trainer, because your foot will be quite swollen. If you do not have any, you will need to buy some prior to the surgery. You do not need to spend a lot of money on this shoe.
• At this stage, you can gradually and gently increase your activities. You will still need to rest between your activities.
• You will also be given a rigorous regime of exercises to regain strength and flexibility in the toe joint.
• One to two days after the stitches have been removed you can normally start bathing the foot.

Between two and eight weeks after surgery

• During this time the foot gradually returns to normal and you may be able to vary your footwear a little.
• There will still be noticeable swelling, especially towards the end of the day. This is quite normal at this stage.
• You may also return to work after six weeks, depending on the type of work and footwear required. For certain jobs this could be an unrealistic expectation.
• At six weeks you can usually return to driving, however you must feel able to perform an emergency stop. Please check with your insurance company about when your policy covers you to drive.
• Although normal everyday activities will be possible, sporting activities are still restricted at this stage.

Between eight and 12 weeks after surgery

• The foot should now be comfortable and returning to normal but there may still be some slight swelling.
• You can return to sporting activities/gym work at 12 weeks.

Six months after surgery

• The residual swelling should now be very slight, although the healing process continues for a year. You should be getting full benefit from the surgery.

Twelve months after the surgery

• All healing is now complete.

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 non-compliance (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 (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/non-union of the osteotomy 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.