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Minimally Invasive Bunion Procedures


When discussing bunion pain with patients, I oftentimes hear from them that they'd like the bunion corrected but that "a friend or family member had it done and it was very painful" or "I would love to, but I can't be off my feet for too long due to work and family responsibilities". This always pains me because that must mean there are many people out there dealing with persistent bunion pain because they aren't aware of new advances in bunion surgery. Once we have the discussion and I list off the details and benefits of minimally invasive bunion surgery, patients tend to be much more interested and wish they had heard about it before. But what exactly is minimally invasive bunion surgery?

Minimally invasive surgery is becoming more popular throughout healthcare as technology continues to improve. In the foot and ankle, we are now providing many different surgeries through smaller incisions in order to decrease wound healing complications and provide less pain and more cosmetic results. In this post, I'd like to focus on minimally invasive (or "percutaneous") bunion surgery, but first, it is important to touch on what a bunion is and some of the other more traditional "open" forms of bunion surgery.

What is a bunion?

A bunion, or “hallux valgus,” is when your big toe has a bump at the base that protrudes, while the big toe itself pushes in towards the little toes. Patients tend to notice that this bump enlarges over time and believe that the bone must be getting bigger, but it is actually due to the bone progressively shifting over. Bunions are one of the most common foot problems among adults in the U.S. Studies show that 25-33% of adult Americans have bunion deformities, with the incidence of bunions significantly higher in women and older adults. This common irregularity can cause pain, difficulty with shoewear, and activity limitation. 

Conservative, nonsurgical treatment options for bunions include:

  • wearing supportive shoes with a wider toe box
  • silicone toe spacer, to be worn in the first web space to prevent rubbing of the big toe on the second toe
  • silicone bunion sleeve - to prevent friction of shoe rubbing on side of big toe joint
  • nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen
  • orthotics: to help control your foot mechanics to stabilize the biomechanics that is causing this progressive deformity at your big toe
  • great toe splints: worn, typically at night, in order to help train your muscles to hold the big toe joint in straight alignment
  • ** While toe spacers and devices to hold the big toe apart from the second toe may help with pain, they will not make the bunion go away. The only way to ultimately correct your bunion deformity is by surgery **

What is a bunionectomy?

A bunionectomy is a surgical procedure to remove the prominence and correct the alignment of your bunion deformity to allow the joints to be straight, work properly, and relieve pain. There are multiple techniques, but all involve cutting the bones and repositioning them with metal screws, plates, or staples in order to straighten the big toe and reduce the bump on the side of the foot. 

There are likely many of you reading this that have experienced it yourself or know a friend, family member, or colleague that had bunion surgery previously. They oftentimes talk about how painful it was or how long they had to be off their feet. However, some patients can benefit from newer, minimally invasive techniques that have significant advantages.

Types of bunionectomy procedures:

  • The decision to perform one type of surgery or another is typically based on the severity of the bunion deformity.
  • Bunions should rarely if ever be treated by simply “shaving” down the bump on the side of the big toe: if done alone, the deformity will recur and the bunion pain will return.
  • Distal first metatarsal osteotomy (oftentimes referred to as Chevron or Austin): cutting the 1st metatarsal (which is called an osteotomy) and then re-aligning the bone. The re-aligned bone is usually held in place with screws.
  • First tarsometatarsal joint fusion (oftentimes referred to as Lapidus): if the deformity is larger or if you have increased mobility at the 1st tarsometatarsal joint (NOT the big toe joint but the joint behind it in the midfoot), the traditional way is to fuse the tarsometatarsal joint. This joint has less motion so patients rarely notice any deficit in the range of motion. This entails an incision at the midfoot extending all the way to the big toe joint near the bunion. The bone is held in place with screws, plates, and/or staples. This typically requires the patient to be non-weight-bearing for 3-6 weeks. 
  • Minimally-invasive bunion surgery: due to advances in this new technology, this procedure can be used for both small AND large bunion deformities. Minimally invasive bunion surgery is performed using a burr, instead of a saw, to cut the bone. This allows the cuts to be made “percutaneously,” or through tiny incisions on the side of the foot, instead of the long incisions most often used in traditional techniques. By avoiding large incisions, fewer soft tissues (skin, muscle, joint capsule, etc.) are disrupted, so the foot is less swollen and painful after surgery, allowing for immediate weight-bearing, less stiffness, faster bone healing, and return to baseline activity level.

Can I have minimally invasive bunion surgery?

Not every patient and every foot are the same. The most important thing is that you be recommended the procedure that would best correct your deformity and decrease the chance of recurrence. This can be determined only through a physical examination of your foot. We will initially take weight-bearing x-rays to evaluate your foot structure, and then perform a physical exam to assess your alignment clinically to see if you have any increase or decrease in mobility around the joint and if you have any other contributing factors throughout your foot structure. If you have a severe deformity associated with other foot problems that require surgical intervention, you may need a more involved, open procedure.

Benefits to minimally invasive bunion correction?

  • Decreased post-surgical pain. A study by Chan et al in 2020 found that patients took an average of only 3.3 narcotic tablets TOTAL during the first 2 weeks. No patient was taking narcotics after 2 weeks. Most patients do well controlling their pain with just ibuprofen or Tylenol.
  • Less scarring
  • Minimal swelling
  • Faster recovery
  • Small incisions
  • Minimizes stiffness in the big toe - patients often have an excellent range of motion after surgery, even prior to attending physical therapy

 

Sources

(Vernois J, Redfern DJ. Percutaneous Surgery for Severe Hallux Valgus. Foot Ankle Clin. 2016 Sep;21(3):479-93. DOI: 10.1016/j.fcl.2016.04.002. PMID: 27524702.).

Jowett and Bedi suggested a learning curve of 53 cases (Jowett CRJ, Bedi HS. Preliminary Results and Learning Curve of the Minimally Invasive Chevron Akin Operation for Hallux Valgus. J Foot Ankle Surg. 2017 May-Jun;56(3):445-452. DOI: 10.1053/j.jfas.2017.01.002. Epub 2017 Feb 22. PMID: 28237566.).

 

After PECA/MICA bunionectomy, patients take on average 3.3 opioid tablets (Chan JJ, Guzman JZ, Nordio A, Chan JC, Cirino CM, Vulcano E. Opioid Consumption and Time to Return to Work After Percutaneous Osteotomy in Foot Surgery. Orthopedics. 2020 Jul 1;43(4):e334-e337. DOI: 10.3928/01477447-20200428-01. Epub 2020 May 7. PMID: 32379336.).

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