How many times will a patient come to my office almost paralyzed with fear when talking about their bunion pain? Many patients are very concerned about bunion surgery. They have heard horror stories of severe pain and poor outcomes. These are usually not true. Bunion surgery is actually quite successful, on the right patient, done by the right doctor. Most patients have many questions about whether to have surgery and what to expect during and after surgery. This is an attempt to dispel the old wives tales and help you make a more informed decision about bunion surgery. It is important to remember that every patient is different and this information is only to help you prepare to discuss your surgery with your doctor.

Who should do your surgery? Podiatrist vs. Orthopedic Surgeon? A board-certified podiatric foot and ankle surgeon typically has much more experience in bunion surgery than the average orthopedic surgeon. An experienced, board-certified surgeon is really the key, regardless of his or her credentials (DPM, MD, DO).

Who should consider bunion surgery? If your foot hurts every day, in every pair of shoes, and conservative treatment has failed, which should include: wider shoes, anti-inflammatories, pads, orthoses, and possibly steroid injection; you are a candidate for bunion surgery.

Bunion surgery involves an incision along the top of the big toe joint and the removal and realignment of soft tissue and bone to restore normal joint alignment and relieve pain. The first metatarsal bone is often cut, realigned, and then stabilized with small screws. There are no guarantees that bunion surgery will completely relieve your pain due to wear and tear, the arthritic change in the joint, and nerve damage caused by the deformity. Most patients achieve at least 85% relief from their symptoms.

The selection of anesthesia is really specific to the patient and the procedure, but mild to moderate sedation to make you drowsy is often used during the procedure, along with a local anesthetic block, similar to the dentist. Some people require general anesthesia because of a history of complications from local anesthesia or other medical problems.

The procedure usually takes a little over an hour, depending on the type of surgery. A more complicated bunionectomy can take two hours or more.

Bunion surgeries are usually performed on an outpatient basis in a freestanding surgery center or in a hospital outpatient center.

There are many types of bunion surgeries, but the most common are:

1. Keller: Removal of part of the metatarsal head (the protruding part of the foot) and the base of the proximal phalanx (removal of part of the toe joint). This procedure is called a Keller bunionectomy. They usually work well in an arthritic joint, but they don’t allow the joint to function fully after surgery. Usually these are used in the elderly.

2. Austin or Chevron: realignment of the soft tissue ligaments around the big toe joint. Excision of part of the metatarsal head (the pons). The first metatarsal bone is then cut into a V shape and then moved laterally to realign the joint. The cut or osteotomy is then stabilized with a pin or two small screws. This is the most common procedure and is known as an Austin bunionectomy.

3. Lapidus: realignment of soft tissue ligaments around the big toe joint. Excision of part of the metatarsal head (the pons). A wedge of bone is then removed from the base of the first metatarsal and the adjacent bone (the cuneiform), as well as from the cartilaginous surface of the two bones. The cuneiform first metatarsal joint is then aligned and stabilized with two large screws or a plate. This increases the stability of the area and decreases the recurrence of the bunion deformity. This procedure is known as a Lapidus fusion and is usually performed on adolescents or adults with highly flexible foot deformities.

4. Other procedures: Fusion (arthrodesis) of the big toe joint or total joint implantation (arthroplasty) are also common, but are usually used when the joint is severely damaged and beyond repair.

The usual recovery period after bunion surgery is 8 weeks to 4 months, depending on the procedure and the health of the patient. Compliance also dictates how quickly a patient is cured. Swelling after surgery can last up to a year. In a Keller or Austin, the patient is usually unable to stand for a few days, then wears a walking cast or special shoe for 4 to 8 weeks. He can usually resume normal activity in 2 to 3 months.

In a Lapidus fusion, most patients are in a hard, non-weight-bearing below-the-knee cast for 8 weeks, then a walking cast for 2 weeks, and then sneakers for another month. You can resume your normal activity in about 4 months. Every patient is different. Patients with medical problems or osteopenia (soft bones) may require longer immobilization. Some patients require physical therapy after surgery.

There are risks involved in undergoing any type of surgery. No matter how good your surgeon is, if you don’t follow instructions, you may have a bad outcome. Scarring, prolonged swelling, joint stiffness, numbness, shortening of the big toe, degenerative arthritis, infection, and ongoing pain are the most common complications. More serious complications can include failure of the bone to heal or a serious infection that requires a second surgery.

After undergoing bunion surgery, most people are happy with the results. A survey conducted by the American College of Foot and Ankle Surgeons revealed that 95% of patients had good to excellent results from their bunion surgery. After you have surgery, your ability to walk and be active will likely improve. The big toe joint is usually much less painful and works better.

Even though your joint looks perfectly aligned and works quite well, some people are disappointed with bunion surgery. This is usually due to unrealistic expectations. You will still not be able to wear extremely high-heeled shoes after surgery, and it is unrealistic to think that your joint will be “perfect” or function as if it never had a problem. With realistic expectations, most patients are happy with their bunion surgery.