Bunions or hallux valgus is a common foot deformity that is a frequent reason for consulting a foot specialist or podiatrist, either for aesthetic reasons, due to pain or the appearance of other foot injuries as a result of altered gait or due to pressure and rubbing caused by footwear.
There are risk factors for the development of bunions. In this regard, we can mention several extrinsic or external factors, as well as factors specific to the individual at the level of the foot and general or systemic factors.
Footwear: inappropriate use of narrow-toed shoes or high-heeled shoes.
Body weight: the greater the weight, the greater the likelihood of changes in the feet that can lead to the appearance of bunions.
Hereditary factors: genetics is responsible for the predisposition, this is most noticeable in cases of juvenile onset hallux valgus.
Gender differences: the male to female ratio is 1:15 according to a study by the Autonomous University of Barcelona. Although it is believed that footwear has a greater influence on women. It has also been shown that the metatarsophalangeal joint of the first toe is more rounded and smaller in women, and therefore less stable.
Elastic or lax ligaments.
Age: more frequent between 40 and 60 years of age.
Metatarsus primus varus.
Anatomical variants of the first toe joint.
Short or retracted Achilles tendon.
Non-surgical remedies to prevent bunions
There are preventive measures we can take to avoid the appearance of bunions, especially if there is a family history. At the same time, there are conservative treatments when the deformity is in its initial phase. Basically, these are aimed at walking and footwear habits, orthotic and physiotherapeutic measures.
Changes in footwear
Wear appropriate footwear: wide toe box and avoid high heels, less than 4 cm.
Use shoe pads if necessary.
Physiological toe shoes (orthopaedic use).
Application of local cold to reduce swelling in the area after prolonged walking.
Exercising the toes can prevent or delay the formation of bunions.
Exercises to strengthen the flexor of the first toe: mobilise the metatarsophalangeal joint of the first toe and stretch.
Achilles tendon stretching.
Allows realignment or reduction of the deformity in cases of mild hallux valgus allowing mobilisation of the joint. It can also play a role in reducing pain in some cases:
Insoles: to compensate for the pressure exerted on the forefoot.
Splints: to correct the position of the first toe and delay the rupture of the joint capsule that occurs as the deformity progresses.
Interdigital separators: reduce the deformity temporarily.
Bumpers: protect the deformity from rubbing against footwear.
Functional bandage: to partially reduce pain and deformity.
Surgery to treat bunions
Surgery is the only option when conservative treatment is insufficient and pain and/or deformity of the forefoot progresses. It is a definitive option as bunions do not recur, unless an inadequate surgical technique is used or all associated deformities have not been corrected.
Objectives of bunionette or hallux valgus surgery:
Decrease symptoms: pain to rubbing injuries to the feet.
Restore motor function to correct gait problems.
Bunion surgery corrects the following deformities:
Reduce the intermetatarsal angle.
Reposition the metatarsophalangeal joint.
Place the sesamoids below the metatarsal head.
Improve the weight-bearing ability of the first phalanx.
Align the hallux into a straight position.
Control or correct factors that cause the deformity.
Bunion operation with osteotomy
Osteotomies are cuts made in the bones in order to correct a deformity or angulation. The most commonly used percutaneous foot surgery techniques involve one or more osteotomies.
There are several sites where osteotomies are performed. In the case of hallux valgus, they are performed both above and below the deformity. Although these osteotomies can vary according to the degree of severity, the patient’s pathological history and the associated deformities. In general, they can be performed:
Distal osteotomy of the first metatarsal.
Osteotomy of the base of the first phalanx.
Proximal osteotomy of the first metatarsal.
Bunion operation without osteotomy
There are more recently proposed minimally invasive techniques that do not involve any type of osteotomy.
This is an alternative that has been developed to avoid the complications inherent with osteotomies.
The purpose of this type of technique is to correct the intermetatarsal angle (IAM) and the first metatarsal is fixed in the appropriate position by means of plates, support buttons or screws, usually to the second metatarsal.
Different AIM correction devices have been designed such as:
Surgery for bunions and claw toes
Hallux valgus is the most common deformity of the forefoot. It includes several alterations of the foot that occur simultaneously.
Firstly, there is a medial deviation of the first metatarsal together with a lateral deviation and rotation of the first toe. This results in a prominence or exostosis of the head of the first metatarsal, which is the most visible and recognisable deformity of bunions.
It is also a progressive deformity, which is very difficult to stop by means of conservative treatment and surgery is finally resorted to as a definitive measure for resolution.
In many cases, gait disturbances cause further disturbances in the forefoot and are often associated with toe deformities such as “claw toes”.
What are claw toes?
It is a deformity of the toes characterised by a bending of the joint at the base of the second toe, while the middle joint bends downwards.
It is caused by muscle imbalance and can be flexible or rigid. It can be treated with physiotherapy and orthoses in cases of flexible claw toes, but resolution is usually ultimately surgical in all cases.
What is the operation for hallux valgus and claw toes like?
The association of bunions with toe deformities such as “claw toes” is very common. Therefore, it is necessary to carefully evaluate each case in order to correct all defects with surgery and to guarantee the success of the procedure, as well as to avoid recurrence or complications.
Before hallux valgus and claw toe surgery
The initial clinical examination should include the preparation of a clinical history and corresponding radiological evaluation, in which certain data of interest for the exact assessment of the deformity of the rearfoot as well as other associated manifestations are specified.
Interrogation: symptoms and evolution.
Inspection: both in sagittal and transverse planes.
Mobility of the first toe joint.
Presence or not of subluxation of the first joint or any other type of joint pathology.
Assess swelling and pain.
Presence of exostosis.
Crepitus and pain indicating osteoarticular alterations.
Assess presence of hypermobility or instability of the first toe.
Assessment of the range of mobility in different planes.
Radiology: which allows measurement of the 4 basic angles and bone alterations in the rest of the fingers.