What is a bunion?

A bunion (hallux valgus) is a deformity of the great toe. Although it often looks as though a lump of bone has simply grown on the side of the foot, the problem is more complicated than this. The first metatarsal gradually moves towards the inside of the foot while the great toe moves in the opposite direction towards the lesser toes. This makes the head of the first metatarsal increasingly prominent and creates the characteristic bunion.

For some people a bunion causes very little trouble. For others it can become painful, rub in shoes and make walking or exercise increasingly uncomfortable. As the deformity progresses, the great toe can also crowd the lesser toes, sometimes contributing to crossover toes, corns and pain beneath the forefoot.

As a consultant orthopaedic foot and ankle surgeon, I assess patients considering bunion surgery in Colchester and Essex. My approach is not simply to remove the prominent lump. Successful bunion surgery aims to understand and correct the underlying deformity while preserving a comfortable, functional great toe.

If you are still deciding whether surgery is appropriate, you can read my separate guide to bunion symptoms, assessment and non-surgical treatment.

 

 

X-Ray of foot prior to correction of bunion showing a hallux valgus deformity

 

What is Scarf and Akin bunion surgery?

Scarf and Akin are two osteotomies (precise surgical cuts in bone) that are commonly used together to correct a bunion. Rather than simply shaving away the prominent bone, the operation allows the bones of the great toe to be realigned and the underlying deformity corrected.

The Scarf osteotomy is performed through the first metatarsal. The bone is divided in a controlled Z-shaped fashion, allowing the metatarsal head to be moved sideways into a more appropriate position. Once the correction has been achieved, the bone is usually held securely with two small screws.

The Akin osteotomy is a smaller correction performed in the proximal phalanx of the great toe. A small wedge of bone is removed to improve the alignment of the toe itself. It is commonly combined with a Scarf osteotomy when additional correction is required.

There are many different operations for bunions, and no single operation is appropriate for every foot. The procedure I recommend depends upon the severity and pattern of the deformity, the condition of the great toe joint, the shape and stability of the foot and the individual patient.

The aim of bunion surgery is therefore not simply to produce a straighter-looking toe. It is to correct the deformity while maintaining a comfortable, functional foot.

              X-Ray of same foot 6 weeks after SCARF & AKIN Surgery to correct the Bunion

 

Video of the Procedure

What to expect

Before the operation

Bunion surgery is an elective procedure, so we want you — and particularly the skin of your foot — to be in the best possible condition before surgery.

Please avoid cuts, grazes, blisters or sores on the foot in the period leading up to your operation. If you develop any broken skin, signs of infection, a fever or become generally unwell, please let us know. Occasionally this means surgery needs to be postponed. Although understandably disappointing, it is much safer to deal with a temporary problem first than to increase the risk of infection following foot surgery.

Any significant medical problems should also be as well controlled as possible before surgery. Your individual health, medication and anaesthetic requirements will be considered as part of your pre-operative assessment.

The day of surgery 

Bunion surgery is usually performed as a day-case procedure, meaning that most patients can return home on the same day.

The operation is usually performed under a general anaesthetic together with local anaesthetic around the foot to improve pain relief after surgery. The exact anaesthetic technique will be discussed with you and tailored to your individual circumstances.

Immediately after the operation 

At the end of the operation the wounds are closed and your foot is placed in a protective, padded bandage. This dressing is important: as well as protecting the wounds, it helps control swelling and supports the corrected position of the great toe during the early stages of recovery.

Walking after bunion surgery

Before you go home, you will be fitted with a special heel-wedge postoperative shoe. This protects the operated area by keeping most of your weight away from the front of the foot while still allowing you to walk.

You may weight-bear through the heel in the postoperative shoe, as comfort allows. Crutches are often helpful initially for balance and confidence while you become accustomed to walking in it.

The shoe should be worn whenever you are standing or walking and, initially, I usually advise wearing it at night as well to protect the operated toe from being accidentally knocked or caught in the bedding.

The heel-wedge shoe is normally required for approximately six weeks. At your six-week review, your progress and X-rays will be assessed before you are advised about returning to normal footwear.

 

Going home 

Before leaving hospital, the nursing and physiotherapy team will make sure that you are comfortable, able to mobilise safely in your postoperative shoe and are ready to go home.

Because you have had an anaesthetic, you will need a responsible adult to take you home and someone should normally remain with you for at least the first 24 hours.

You will be given instructions about your medication, dressings and follow-up before leaving hospital. Your first postoperative appointment is usually at approximately two weeks, when the wound and swelling will be reviewed.

Recovery after Scarf and Akin bunion surgery

Pain relief 

The local anaesthetic will usually keep the foot comfortable for approximately 6–8 hours, although this varies between patients.

It is important to start taking the painkillers you have been prescribed before the local anaesthetic has completely worn off. This helps prevent pain building up and becoming more difficult to control.

Take your pain relief as directed on your discharge medication and do not exceed the recommended dose.

The first two weeks – “Toes Above Your Nose”

For the first two weeks, the most important part of your recovery is controlling swelling. I describe this to my patients as “Toes Above Your Nose.”

Recline or lie down with your foot well elevated on pillows or cushions so that your toes are above the level of your nose. This is much more effective than simply sitting with your foot on a footstool.

You may walk in your postoperative sandal, but during these first two weeks this should generally be limited to essential activities such as going to the bathroom and getting something to eat.

Good elevation reduces swelling, improves comfort and helps the wound to heal. The more time the foot spends down, particularly during the first few days, the more it is likely to swell and throb.

Leave all dressings alone.  If they become loose or dirty then seek nursing or medical help.

Wear the Heel Wedge Sandal Day and Night. The sandal protects the operation while the bones are healing and should normally be worn continuously, including at night, for the first 6 weeks. You may remove it briefly for washing or dressing changes when advised, but otherwise keep it on whenever you are standing, walking or sleeping.

At around 6 weeks, an X-ray is usually taken to assess bone healing. If everything is progressing satisfactorily, you can then begin to wean out of the sandal and into a comfortable, supportive shoe. This transition usually takes around 1–2 weeks, but swelling may mean that some normal shoes remain too tight for considerably longer.

Follow-up Appointments

2 weeks after surgery your wound will be checked by a member of the team, or occasionally by your local nurse. If the wound has healed satisfactorily, the bulky dressing can usually be reduced to a simple adhesive dressing.

At this stage you can begin to increase your activity gradually and you will not need to elevate the foot quite as strictly. However, swelling is still very common and elevation remains helpful if the foot becomes uncomfortable or swollen. Continue to wear the heel wedge sandal when walking.

Once the wound is fully healed, you can usually remove the sandal for washing. You will also be shown how to gently move the big toe joint to help regain movement and reduce stiffness.

6 weeks after surgery you will normally have an X-ray to assess the position of the correction and bone healing. If the X-ray and your clinical progress are satisfactory, you can begin to wean out of the heel wedge sandal and into a comfortable, supportive shoe. This usually takes around 1–2 weeks.

our own shoes or sandals can usually be introduced once you have been advised to wean out of the heel wedge sandal. Initially, choose wide, comfortable footwear with plenty of room around the forefoot and big toe.

Do not be surprised if some of your normal shoes remain too tight for several weeks. Swelling after bunion surgery can persist for several months, particularly towards the end of the day, and gradually improves with time.

Walking for exercise can be increased progressively as comfort allows. Higher-impact activities, including running and many sports, take longer and are usually reintroduced gradually over approximately 3–6 months, depending upon your recovery, bone healing and the demands of the activity.

Physiotherapy is not routinely required following straightforward SCARF/AKIN surgery, but may be helpful if there is persistent stiffness, weakness, difficulty returning to normal walking or a slower-than-expected recovery.

When can I return to work?

The time you need away from work depends considerably upon what your job involves.

For the first 2 weeks, the priority is wound healing and controlling swelling, so most patients should plan to remain off work and spend much of their time with the foot elevated.

If you have a desk-based or home-working job, you may be able to return after approximately 2 weeks, provided you can travel safely, wear the heel wedge sandal at work and regularly elevate the foot.

If your job involves prolonged standing or walking, you are likely to need longer away from work. A return at around 6 weeks may be more realistic, once the bones have begun to heal and you are starting to come out of the protective sandal.

For heavy manual work, climbing, working on uneven ground or occupations requiring safety footwear, return may take longer and should be discussed individually with your surgeon.

A phased return can sometimes be helpful. Remember that even when you are safe to work, the foot may still swell considerably during the day and benefit from periods of elevation.

When can I drive?

You should not drive while wearing the heel wedge sandal or while your ability to control the vehicle safely is impaired by pain, swelling or medication.

If you have had right foot surgery, you will normally need to wait until you have come out of the heel wedge sandal and can comfortably wear a normal shoe. Before returning to driving you must be able to walk comfortably and perform an emergency stop quickly, forcefully and without hesitation or pain. For most patients this is unlikely to be before approximately 6 weeks, and sometimes takes longer.

If you have had left foot surgery and drive an automatic car, you may be able to return to driving earlier, provided the left foot is not required to operate the vehicle, you can get in and out safely, and you are no longer taking medication that could impair driving.

If you drive a manual car, surgery to either foot may affect your ability to operate the pedals safely and you should not return until you can do so normally.

Ultimately, you are responsible for ensuring that you are safe and in full control of the vehicle. You should also check the requirements of your motor insurer if you are uncertain about returning to driving.

 

What are the Risks of SCARF +/- AKIN Osteotomy?

All surgery carries risks which need to be balanced against the potential benefits of the operation. SCARF +/- AKIN osteotomy is a commonly performed and generally reliable operation for correcting a bunion, but complications can occur. These include:

Wound bleeding. Some bleeding into the dressings immediately after surgery is quite common and usually settles with elevation and compression. Significant bleeding or development of a large haematoma is uncommon and very rarely requires a return to theatre.

Infection. A superficial wound infection can usually be treated successfully with antibiotics. Occasionally a deeper infection can develop involving the bone, screws or staple. This is uncommon but can require prolonged antibiotics and sometimes further surgery, including removal of metalwork.

Problems with wound healing. Occasionally part of the wound can be slow to heal. This is more likely in people who smoke, have diabetes, poor circulation or other conditions affecting healing. Further dressings or treatment may be required and, rarely, further surgery.

Nerve irritation, numbness or sensitivity. Small nerves supplying sensation to the great toe run close to the surgical approach and can be bruised, stretched or occasionally damaged. Temporary numbness or altered sensation is relatively common and usually improves with time. Occasionally an area of permanent numbness, hypersensitivity or a painful nerve can remain.

Fracture. The bones are deliberately cut during an osteotomy and, rarely, an unintended crack or fracture can occur. This may alter the fixation required, the period of protection after surgery or, very occasionally, require further surgery.

Delayed union or non-union. The bone cuts normally heal reliably, but occasionally healing takes longer than expected (delayed union) or fails to unite completely (non-union). Smoking significantly increases this risk. Further protection, bone stimulation or occasionally another operation may be necessary.

Loss of correction or malunion. The bone can occasionally heal in a position different from that intended or the correction can alter during healing. Minor changes may cause no problem, but significant malalignment can cause pain or difficulty with footwear and may require further surgery.

Prominent or painful metalwork. The screws or staple used to hold the osteotomies are normally left permanently in place. Occasionally they become prominent or uncomfortable once the swelling has settled. If the bones have fully healed, troublesome metalwork can usually be removed at a later date.

Avascular necrosis (AVN). Very rarely, the blood supply to part of the first metatarsal head can be compromised, causing damage or collapse of the bone. This is an uncommon but potentially significant complication and can lead to pain, stiffness or arthritis and may require further treatment.

Stiffness of the great toe joint. Some loss of movement is common initially because of swelling and scar tissue. Movement usually improves during recovery, but some patients are left with persistent stiffness. Occasionally this can be painful or interfere with activities.

Arthritis of the great toe joint. A bunion and arthritis can coexist. Correcting the bunion does not remove established arthritis, and arthritis may develop or progress subsequently. If significant painful arthritis develops in the future, further treatment — occasionally including fusion of the great toe joint — may be required.

Recurrence of the bunion. Although the aim is to provide a lasting correction, a bunion can gradually recur. This can occur because of the original severity of the deformity, the shape and mechanics of the foot, ligament laxity or changes occurring over time. Most recurrence does not require further surgery, but occasionally revision surgery is considered.

Over-correction (hallux varus). Rarely, the great toe can be corrected too far in the opposite direction and begin to point away from the lesser toes. A minor degree may cause few problems, but significant hallux varus can be painful and may require further treatment or surgery.

Transfer metatarsalgia. Altering the position and loading of the first metatarsal can occasionally increase pressure beneath the lesser metatarsal heads, causing pain in the ball of the foot. This usually settles with time, footwear modification or insoles, but occasionally persists and requires further treatment.

Persistent pain. Although the purpose of surgery is to improve pain and function, no operation can guarantee a completely pain-free foot. Some discomfort, swelling or altered sensation can persist despite satisfactory correction and healing.

Complex Regional Pain Syndrome (CRPS). Rarely, the foot develops a disproportionate and prolonged pain response following surgery. This can be associated with swelling, sensitivity, colour or temperature changes and stiffness. Early recognition and treatment with medication, physiotherapy and specialist pain management may be required. In some cases symptoms can be prolonged.

Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE). A blood clot can develop in a vein in the leg following surgery and, rarely, travel to the lungs. The individual risk is assessed around the time of surgery and preventative measures are used when appropriate. You should seek urgent medical attention if you develop unexpected calf swelling or pain, chest pain or shortness of breath.

Further surgery. Any of the complications above may occasionally require another operation. This could include removal of metalwork, treatment of infection, revision of an osteotomy, correction of recurrent or excessive deformity, or another procedure for persistent pain or arthritis.

Loss of the great toe. This is an exceptionally rare complication. Severe infection or catastrophic loss of the blood supply to the toe could theoretically result in amputation, but this would be extraordinarily unusual following routine bunion surgery.

How do I know if I have a complication?

Some pain, swelling and bruising are normal after bunion surgery, particularly during the first few weeks. These should gradually improve rather than progressively worsen.

Please seek medical advice if you develop:

• Increasing pain that is not settling with elevation and the pain relief you have been advised to take.
• Increasing redness, warmth or swelling around the wound, particularly if this is getting worse rather than better.
• Discharge, pus, persistent bleeding or an unpleasant smell from the wound or dressing.
• Fever, chills or feeling generally unwell.
• Marked swelling or pain in the calf, particularly if it is different from the expected swelling around the operated foot, as this can occasionally indicate a blood clot (DVT).
• Sudden shortness of breath, chest pain or coughing up blood — seek urgent medical attention, as these can be symptoms of a pulmonary embolism.
• A toe that becomes unusually pale, blue, cold or increasingly numb.
• Severe or disproportionate pain, particularly if associated with marked sensitivity, colour or temperature change in the foot.

If you are concerned that something is not progressing as expected, it is better to contact the hospital or clinical team for advice rather than wait until your next appointment.

Most complications can be successfully treated, although occasionally further treatment or surgery may be required. Despite appropriate surgery and treatment, it is not possible to guarantee a perfect or completely symptom-free result.

Bunion surgery should therefore be undertaken to treat significant symptoms rather than for cosmetic reasons alone. The symptoms and limitations caused by your bunion need to be sufficient to justify the risks and recovery involved with surgery.

We would also not normally recommend bunion surgery simply to prevent problems that might occur in the future if the bunion is currently causing little or no difficulty.

Your individual risks will be discussed with you before surgery. Certain factors — including smoking, diabetes, circulation problems and some medical conditions or medications — may increase the risk of complications and can influence whether or when surgery should be undertaken.

What are the alternatives?

A bunion (hallux valgus) is not usually a dangerous condition, and there is normally no medical requirement to have it corrected simply because it is present. Surgery is therefore a choice based upon the severity of your symptoms, the effect the bunion has on your everyday life and whether the potential benefits of surgery justify the risks and recovery involved.

Doing nothing is always an option. If your symptoms are manageable, it is perfectly reasonable simply to live with the bunion.

Non-surgical measures can help to manage symptoms and include:

• Wider, softer footwear with sufficient space around the toes.
• Avoiding shoes that put pressure directly over the bunion.
• Padding or protective sleeves over the prominent area if footwear causes rubbing.
• Insoles or orthotics where other aspects of foot mechanics are contributing to symptoms.
• Simple pain relief or anti-inflammatory medication when appropriate.
• Toe spacers or bunion splints if you find them comfortable.

These measures may make the bunion more comfortable, but they do not reliably correct the underlying bony deformity in an adult. Splints and toe spacers may temporarily alter the position of the toe while they are being worn, but they should not be expected to permanently straighten the bunion.

There is also no need to have surgery simply to prevent a bunion from becoming worse in the future. Progression varies considerably between individuals, and some bunions change very little over many years.

Surgery becomes a reasonable option when the bunion is causing persistent pain, difficulty with footwear or restriction of activities despite sensible non-operative measures, and when those symptoms are significant enough for you to accept the recovery and potential risks of an operation.

 

Other types of bunion surgery.

There are many different operations available to correct hallux valgus, and SCARF/AKIN is not the correct operation for every bunion. The choice of procedure depends upon the severity and pattern of the deformity, the shape and stability of the foot, the condition of the great toe joint and individual patient factors.

Other osteotomies. Different bone cuts can be used to correct the first metatarsal and/or great toe. These include distal metatarsal osteotomies such as a Chevron and, increasingly, minimally invasive (keyhole) techniques. These operations have their own advantages and disadvantages and may be more appropriate for some bunions.

Lapidus fusion. For some more severe bunions, particularly where there is instability or deformity involving the joint at the base of the first metatarsal, a Lapidus procedure may be recommended. This involves correcting the deformity and fusing the first tarsometatarsal joint.

1st MTP joint fusion. If there is significant arthritis, severe deformity or certain recurrent bunions, fusion of the great toe joint may be a better option than an osteotomy. The toe is corrected into an appropriate position and the joint is permanently fused. This is a very reliable way of treating pain and deformity but permanently removes movement from the great toe joint.

Minimally invasive bunion surgery (MIS). Bunion correction can also be performed through several small incisions using specialised instruments and X-ray guidance. This is not simply the same operation performed through smaller scars: it uses different osteotomy and fixation techniques. MIS can offer advantages in appropriately selected patients, but open and minimally invasive surgery both have potential benefits and complications. The most appropriate technique depends upon the individual deformity and the surgeon’s assessment.

 

Is a bunion the same as arthritis?

No. A bunion (hallux valgus) and arthritis of the great toe (hallux rigidus) are different conditions, although it is possible to have both.

A bunion is primarily a deformity. The great toe gradually moves towards the lesser toes while the first metatarsal moves in the opposite direction, producing the characteristic prominence on the inner side of the foot. The “bump” is therefore not simply a new growth of bone.

Pain from a bunion is commonly caused by pressure from footwear over the prominence, although the altered position of the great toe can also crowd the lesser toes and contribute to pain beneath the forefoot.

Hallux rigidus, by contrast, results from degeneration of the great toe joint. The smooth cartilage covering the joint becomes damaged and the joint may become stiff and painful. Bone spurs can develop, often producing a prominence on the top of the joint.

A useful distinction is that bunion pain is often particularly noticeable in shoes because of pressure on the prominence, whereas an arthritic great toe may hurt when the joint itself moves and can therefore be painful even when barefoot.

Some patients have both hallux valgus and arthritis of the great toe joint. This is important because significant arthritis may alter the operation that is recommended; in some cases an osteotomy such as SCARF/AKIN may not be the most appropriate treatment.

A Final Note

This information is intended to help you understand bunion surgery, what the recovery involves and the potential benefits and risks of treatment. It is a guide and does not replace the individual discussion you will have with your surgeon.

Everyone is different, and your bunion, general health, lifestyle and expectations all form part of deciding whether surgery is appropriate and which operation is most suitable.

Some people want considerably more detail than others. Please ask as many questions as you need to. You should not proceed with surgery until you feel that you understand the proposed operation, its alternatives, the recovery involved and the important risks, and are comfortable with your decision.

Reading a comprehensive list of possible complications can understandably be concerning. Remember that the purpose of discussing these risks is not to suggest that they are likely to happen, but to allow you to make a properly informed decision.

If anything on this page worries you or is unclear, please discuss it with me at your consultation.

Next Steps

If your bunion is causing pain, making footwear difficult or restricting the activities you want to do, you are welcome to arrange a consultation with Mr Tim Williams, Consultant Orthopaedic Foot & Ankle Surgeon, to discuss your options.

A consultation does not commit you to surgery. We can assess your foot, review appropriate X-rays where required and discuss whether continued non-operative treatment, SCARF/AKIN surgery or another form of bunion correction would be most appropriate for you.

Arrange a consultation