Bunion Surgery: What You Need to Know

The primary cause of bunions is genetics: inherited foot structure and faulty foot mechanics can make you more likely to develop them. For example, having low arches, flat feet, or a tendency to overpronate (when your feet roll inward when you move, causing them to overly flatten) can exert pressure that leads your big toe to curve toward your second toe.

Medical conditions like rheumatoid arthritis can increase the likelihood of developing bunions. But by far the biggest contributing factor is poorly fitting shoes, particularly those with a narrow, pointed toe that force your toes into an unnatural position.

Anyone can develop a bunion, but they’re 10 times more common in women because of their lighter bone structure and tendency to wear tight, narrow shoes that squeeze the toes together. This makes it more likely for a bunion to develop and for an existing bunion to worsen. High heels, which tip the body’s weight forward and place unnecessary pressure on the joints, exacerbate the problem.

Bunions may start out small, but they usually progress over time—which is why early treatment is so important. Because the metatarsal phalangeal (MTP) joint flexes with every step, the bigger the bunion gets, the more painful and difficult walking can become. As the bunion gets worse, permanent degenerative changes that occur as a result also increase, Dr. Levine explains. For instance, the MTP joint at the base of the big toe can become stiff and increasingly hard to bend—something known as hallux rigidus.

“Pain, significant deformity, and difficulty walking may be indications for a bunionectomy,” says Dr. Levine. 

Often, conservative treatment measures that take pressure off the MTP joint and improve foot mechanics are enough to relieve bunion pain. These include simple home remedies for bunions, such as icing the affected area, wearing shoes with a wider toe box and low heels, taking nonsteroidal anti-inflammatory drugs such as ibuprofen, wearing toe splints, and using orthotics (shoe inserts) to help position the foot correctly as it strikes the ground. 

Physical therapy and cortisone injections at the base of the big toe to temporarily reduce inflammation can also reduce foot pain.

If these nonsurgical treatment options fail, you may need surgical bunion correction to restore the toe to its normal position. 

There are nearly 100 different types of surgeries that can repair a bunion. Your surgeon will conduct a physical examination to classify your bunion as mild, moderate, or severe. This will include taking X-rays and making measurements to assess the angle between the first and second metatarsals (the bones that lead up to the bases of the big and second toe) and the angle of the big toe as it drifts toward the second toe. This will help determine which type of surgery is best for you.

Pros:

• Surgery repositions the bones, which often improves symptoms of a bunion. The surgery can significantly relieve pain and restore normal foot function, making it easier to walk.
• Most bunion surgery patients can walk out of the operating room wearing a surgical bandage and a surgical shoe or boot. If you have a simple bumpectomy, you may even be able to walk out of the office wearing a sneaker.
• Most people who have bunion surgery can resume their usual activities in six to 12 weeks. 
• The surgery can usually be performed via minimally invasive techniques, which require incisions that range from ⅛” to ½”, versus the 2” to 6” incisions used in traditional bunion surgery. 
• Surgery will reshape your foot, so you’ll be able to wear fashionable shoes more easily. However, to prevent a recurrence of your bunion, custom-made orthotics can be helpful. 

Cons:

• If your job requires standing or lifting, you may need to take two weeks (or longer) off work while you heal from bunion surgery, depending on the type of surgery performed. It can take up to 12 weeks for bones to fully heal after a complex surgery, and you may not be able to put all of your weight on your foot during this period. Your foot will be in a cast or special boot. In cases of aggressive surgery for a severe bunion, you may need the assistance of crutches to walk. 
• You may not be able to drive for a week or more after surgery. 
• Swelling gradually improves after a couple of months, but full recovery may take six months or longer, depending on the complexity of your procedure. 
• Bunions may form again after surgery, especially if you’re relatively young. This is the most common complication of bunion surgery, occurring in 16 percent of cases. It’s most likely when the bunion is shaved off and the underlying cause isn’t addressed. Wearing appropriate shoes and orthotics can help prevent this from happening. 
• According to the Cleveland Clinic, bunion surgery can fail, leaving patients with more pain, persistent deformity, and significant dissatisfaction and dysfunction. Many failures are the result of poor surgical decisions and/or technique, so it’s important to consult with a surgeon who has experience with a wide range of surgical techniques. You want to be sure you’re getting the right surgery for your condition. 
• Surgery repairs some of the deformity of your foot, but your foot won’t look perfect. Any scarring can be improved with over-the-counter products or in-office treatments like laser therapy. 
• Surgery often results in toe stiffness. You’ll be given range-of-motion exercises to help ensure that you regain full foot and toe mobility.

Almost all bunion surgery is performed on an outpatient basis in a hospital, surgical center, or doctor’s office, meaning you’ll go home after the surgery. You’ll need a ride, and someone should stay with you for the first 24 hours after surgery.

Prior to surgery, you’ll usually be given a local or regional anesthetic that numbs the foot from the ankle down, but you’ll be awake. You may also be given a sedative to help relax you, though some surgeons recommend spinal anesthesia, which numbs your body below your waist, or general anesthesia, which puts you to sleep. Dr. Levine uses local anesthesia and “conscious sedation,” performed by an anesthesiologist.

Surgery is typically done one foot at a time, often using minimally invasive techniques. 

The type of surgery your podiatric or orthopedic surgeon performs will depend on the severity of the bunion.

• For a mild bunion, your surgeon may choose to shave off the enlarged portion of the bone. Known as a bumpectomy, this results in a more normal appearance and narrows the foot. “While more normal shoes can be worn with a simple bumpectomy, the underlying mechanical abnormality is not corrected,” says Dr. Levine. So, while this procedure is relatively minor, with few complications and a short recovery time, recurrence can occur unless it’s performed in conjunction with other types of bunion surgery.

• Correcting a moderate toe deformity usually involves an osteotomy (cutting and repositioning the bone) to restore proper alignment to the toe. A common surgical procedure for moderate cases involves making a V-shaped cut at the toe end of the first metatarsal. Internal wires or screws hold the bones in alignment, and the surrounding ligaments and tendons are adjusted. The pins are removed after bone healing, but the screws are usually left in place. 
• To correct severe bunions, the surgeon makes a cut in the mid-shaft of the first metatarsal, rotates the bone, and fixes it in place with pins or screws. In some cases, a joint fusion is required to improve stability.

The level of pain during recovery will vary from person to person, says Dr. Levine. “Generally, you may experience some soreness for the first three to five days.” 

You’ll be given detailed aftercare instructions to help minimize pain and reduce swelling. This includes strong pain relievers and anti-inflammatories. 

You’ll also be instructed to keep your foot elevated (it will likely throb if not properly elevated), apply ice, and limit walking while you heal. 

Healing after an osteotomy takes four to six weeks, but you’ll be able to walk immediately in a surgical shoe or boot, which will be kept on for the full recovery period. After that sneakers are worn until the soft tissue swelling goes down. 

It can take longer than 10 weeks after an osteotomy to return to normal activity and exercise. However, “While there’s a longer recovery than with a simple bunionectomy, the surgery corrects the underlying mechanical problem and allows better restoration of foot anatomy,” says Dr. Levine. 

After surgery for a more severe bunion, a walking cast is placed for about eight weeks. This type of correction requires extensive healing time, according to Dr. Levine. “You must use crutches for four to six weeks and shouldn’t drive for four weeks.”