Hallux Valgus (Bunion Deformity)
The big toe of the foot is called the
hallux. If the big toe starts to deviate inward in the direction of
the baby toe the condition is called hallux valgus. As the big toe
drifts over into valgus, a bump starts to develop on the inside of
the big toe over the metatarsal bone. This bone prominence on the
inner edge for the metatarsal is referred to as a bunion.
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Bunions are commonly hereditary but may also
be caused or aggravated by shoe wear. The condition is far more
common in women than in men and rarely occurs in individuals
who do not wear shoes. Once a bunion is present the deformity
of hallux valgus worsens slowly over time. |
The treatment of a bunion depends entirely
on how uncomfortable it is. Since the pain from a bunion is always
aggravated by shoe wear, the symptoms will often depend on the type
and size of shoes worn. The perception of pain or discomfort that
people experience however is quite varied. There are some individuals
who have small bunions that are very uncomfortable. This limits their
ability to wear shoes comfortably. On the other hand, some individuals
may have quite significant deformities that are annoying but do not
limit their activities in anyway.
Realistically, there are only two ways to treat a bunion. Either change
the size and shape of the shoe or change the size and shape of the
foot.
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This patient has bunions on both feet.
The bunions are large, and the big toes are deviated to the
outside of the foot (this is called hallux valgus).
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Once a bunion gets to be irritating or painful and shoe wear is uncomfortable,
surgery may be recommended. There are many different surgical procedures
that can be performed. The decision to perform one type of surgery
or another is based upon the extent and magnitude of the bunion deformity,
the presence of arthritis in the big toe joint, and the space between
the first and second metatarsals, which is called the intermetatarsal
angle.
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The angles shown here help us decide which
bunion operation would be the best. This is the angle between
the 1st and 2nd metatarsal. |
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The angles shown here help us decide
which bunion operation would be the best. This is the angle
between the big toe and the 1st metatarsal
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It is very rare that a bunion can be treated
by simply shaving down the bump of the bone. Invariably, the deformity
will recur and both the bunion and the hallux valgus will return.
Therefore, the shaving of the bunion, called an exostectomy,
is performed in conjunction with a cut of the first metatarsal bone
(which is called an osteotomy).
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Shaving of the bump or the bunion on the side
of the metatarsal is not usually successful when performed on
its own. Often a bone cut (an osteotomy) on the metatarsal needs
to be done in addition to the bunionectomy. |
Depending on the severity of the deformity,
this osteotomy can be done either at the end of the metatarsal (a
distal osteotomy) or if the deformity is more severe, the osteotomy
is performed at the base of the first metatarsal (a proximal osteotomy).
One of the more common distal metatarsal osteotomies that is performed
is called the chevron
osteotomy. Typically a small screw is inserted into the bone to hold
the metatarsal head in place and speed up bone healing. Following
a chevron osteotomy, walking is permitted in a surgical shoe the next
day after surgery, and the shoe is worn for approximately three to
four weeks before a more comfortable walking/running type shoe is
worn.
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An operation which I
use frequently is called the chevron osteotomy. It is a V-shaped
bone cut made in the metatarsal.
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Once the V-cut in the
metatarsal is made, the bone is shifted over and the remaining
edge of the bone is shaved down as shown here. |
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These are before and after pictures
of a 17 year old female with a painful bunion (hallux
valgus) corrected with a chevron osteotomy |
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One of the more popular proximal metatarsal
osteotomies that is performed is called the Myerson/Ludloff
procedure. This operation is performed for more advanced deformity.
Screws are inserted into the metatarsal to hold the bone cut secure
and speed up bone healing. Walking is permitted in a surgical shoe
following surgery. The shoe is worn approximately 5 weeks.
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The dotted red line
shows the direction of the cut on the metatarsal bone when performing
the Myerson/Ludloff bunion operation.
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Above and below are the X-Rays
of feet before and after the Myerson/Ludloff bunion operation.
In each foot, the metatarsal bone is held in place with
screws which are buried in the bone.
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This patient has severe
deformity of the foot and a standard type of bunion operation
can not be performed. |
For very severe bunion deformities where there
is considerable angulation between the first and second metatarsals
an osteotomy of the metatarsal may not be sufficient, and for these
patients, the joint between the first metatarsal and the cuneiform
bone is fused with screws, called the Lapidus procedure. This
realigns the metatarsal completely and stabilizes the bone, preventing
mobility and recurrent deformity.
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This patient had been unsuccessfully
treated with prior surgery. The deformity was severe and
well corrected after a Lapidus type bunion operation. |
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This is a picture taken 3 weeks after
a Lapidus type bunion operation. The deformity on the operated
foot was actually much worse than the one on the opposite foot. |
For patients who have arthritis of the big
toe joint associated with a bunion deformity an osteotomy is not performed.
The deformity is corrected through the joint either with a fusion
of the joint or by removing a portion of the joint (an arthroplasty).
Fusion of the big toe joint is an excellent operation since it corrects
the deformity, prevents the bunion from returning and eliminates the
arthritis simultaneously.
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This patient had been treated
previously with an incorrect bunion operation. Arthritis
of the big toe joint developed. This was treated by straightening
and fusion of the deformity. |
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