What is a bunion?

A bunion is a prominence over the inside part of the foot where the big toe joins the rest of the foot. Pressure on the prominence from shoes causes pain and swelling due to inflammation. The bunion occurs when the foot bone connecting to the big toe (the first metatarsal) moves gradually towards the opposite foot. This is called hallux valgus* deformity. This leads to the big toe being pushed towards the second toe (away from the opposite foot) so that the big toe points away from the other foot. This is called hallux valgus deformity.

Other problems can develop with a bunion. For example, the second toe may overlap the big toe causing a cross-over toe deformity. With shoe pressure, corns and calluses develop.

What is the cause?

There is no single cause of bunions. It commonly runs in families but may skip generations. High heel pointed toe shoes are not the primary cause of the hallux valgus but they do cause it to be painful. Pressure from shoes may cause bunions, corns and calluses to develop where there is hallux valgus deformity.

How are bunions treated?

Before treatment of a painful bunion can begin, medical evaluation is needed. There are a number of other causes of pain in the big toe such as osteoarthritis, rheumatoid arthritis, infection and gout. Circulatory problems not only cause pain but may also cause serious complications if surgery is attempted. Diabetes and cigarette smoking may diminish healing potential and increase the risk of infection.

Treatment may be surgical or non-surgical. The goal of non-surgical treatment is to relieve pressure on the foot and to prevent pressure sores and foot ulcers. This is accomplished by prescribing accommodative shoes with a wide toe box - sandals or extra depth shoes with soft moulded insoles. It may also be possible to relax the leather on shoes to make room for a bunion.

Surgery can correct painful bunions. The severity of the bunion deformity and the presence of any associated problems (for example painful arthritis) will determine the type of surgery that is recommended. X-rays are necessary to help plan for surgery.

Bunion Surgery

Bunion surgery involves an incision of on the outer aspect of the big toe and foot. A small saw is used to remove the prominence and make precise bone cuts to allow the surgeon to correct the deformity.

Once the big toe is in the corrected position, screws are implanted to fix the bone in this position. The screws are designed to stay within the bone without causing pain or being palpable.

Will I require rehabilitation?

The patient may weight bear on their feet with the aid of crutches after the surgery. In general, crutches may need to be used for 7-14 days after the surgery. Some patients find that they are comfortable earlier than this and can discard their crutches at that stage.

A postop shoe (a stiff soled sandal) is fitted after the operation. This needs to be worn for 6 weeks after the operation.

Week two to six: you will wear a pair of sneakers. By six months: you should be able to resume all normal activities without pain or discomfort

When can I return to normal activities?

• Sedentary work: 2-3 weeks depending on transport to work and ability to elevate foot at work.
• Physical work: 2-3 months depending on the nature of work involved.
• Driving: This will vary depending on whether you drive an automatic or manual car and whether the surgery is to the right foot. Surgery to the right foot may mean not being able to drive for 6 weeks. If the surgery is to the left foot and the person drives an automatic car then they may be able to return to driving within 2 weeks.
• Exercise: bike and swim after 6 weeks. They may not be able to do running/jumping sports for 3 months.

Many people develop a stiff big toe with limited movement. This condition is known as hallux rigidus. Arthritis is the most common cause of this condition. This condition causes the big toe joint to become increasingly painful, stiff and swollen. Patients often notice a painful lump on the top of the big toe joint (sometimes called a dorsal bunion). This can cause pain when wearing shoes.

Surgery for Painful Hallux Rigidus

There are three main surgical options: cheilectomy, arthroplasty (joint replacement) or fusion. The choice of procedure depends on the severity of the arthritis.

Cheilectomy: The spur of arthritic bone is removed from the upper surface of the joint with either a saw or chisel. Removal of the painful lump on the top of the big toe joint is aimed at eliminating pain and increase the big toe joint movement.

Cartiva arthroplasty: The spur of arthritic bone is removed from the upper surface of the joint and the central portion of the joint is resurfaced with a polyvinyl alcohol implant which has similar mechanical properties to cartilage. This allows the joint to remain mobile.

Fusion: The spurs of arthritic bone are removed, and the bones are held together with screws and/or plate until the bones join to form one bone. This removes all movement at the joint. This is the most reliable procedure in end stage arthritis.

How long will my hospital stay be?

These procedures are usually day surgery operations. Patients are admitted to hospital on the day of surgery and meet the anaesthetist prior to surgery. The anaesthetist will discuss the anaesthetic involved. Local anaesthetic is injected around the surgical site following the operation.

How long will I take to recover?

The patient may walk straight after the operation. With cheilectomy and arthroplasty, crutches are required for the first few days after surgery depending on the patient’s comfort.

Patients are able to wear their own shoes after the dressing is removed.

With fusion, heel weight bearing is required for six weeks.

A twisting injury or going over on the ankle usually results in an inversion of the foot and ankle. This produces a spectrum of injuries to the lateral ankle. These injuries very commonly occur in running sports such as soccer, basketball and netball.

A bad ankle sprain results in tearing or rupture of the lateral ligaments (ATFL and CFL). These ligaments will heal but they heal with the ligaments in a stretched position. This causes the ankle joint to feel sloppy and increases the risk of the patient going over on the ankle in the future. Every time you go over on the ankle the ligaments may stretch a bit more and render the ankle more unstable. There is also a risk of damaging the ankle joint surface every time you go over on the ankle.

What treatment is required for Ankle Sprains?

Most ankle sprains (80%) recover completely with conservative treatment. Active rehabilitation is the mainstay of treatment for ankle instability. This involves physiotherapy that concentrates on soft tissue massage, range of motion exercises, peroneal muscle strengthening and proprioceptive retraining. Bracing may be helpful. However, If you continue to have instability despite a 3 month trial of physiotherapy treatment then surgery may be indicated. The patient can usually localize the pain to the front (anterior), back (posterior), inner side (medial) or outer side (lateral) of the ankle. This will determine the type of surgery performed.

Surgery for Anterior Ankle Pain

If the pain is anterior then articular (joint) surface injury and anterior ankle impingement should be considered.

1. Articular Surface Injury
   Articular surface injury may involve cartilage alone (chondral) or cartilage and bone (osteochondral). These patients will usually experience pain with walking, running and jumping activities. The pain is often worse with stairs or uneven ground. There may be start up pain where the patient has pain when he/she starts an activity such as running and the pain eases as the patient continues. With these lesions, the talar dome is more frequently injured than the tibia.
   Other symptoms with these lesions include:
• Ankle swelling
• Stiffness
• Weakness, or

• Giving way

2. Anterior Ankle Impingement
   This procedure is performed when the pain is worse with walking or running up hill, inclines or stairs. Squatting (eg with weight lifting) and landing after a jump (eg gymnastics or acrobatics) may make this pain worse. Sometimes the patient may be able to localize this pain to the inner or outer side of the ankle. There is limited range of ankle motion, particularly in dorsiflexion. Anterior ankle spurs are the most common cause of anterior impingement. The cause of the anterior spurs is unknown and they most likely are the result of repetitive minor injuries. Anterior impingement secondary to spur formation is quite common in athletes especially in soccer, rugby and basketball.

Surgery for Lateral Ankle Pain

Lateral ankle pain may be due to inflammation of the ankle joint from a recent sprain, peroneal tendon tear, peroneal tendon dislocation, or occult fractures.

1. Ankle synovitis
   This can cause anterolateral (front outer side of the ankle) ankle pain located just anterior to the lateral malleolus. The pain is usually worse with activities such as stair walking and running and relieved by rest. There may be associated ankle swelling or loss of joint motion.

2. Peroneal Tendon Tear
   This is commonly associated with lateral ligament instability. The peroneus brevis is more commonly torn than the peroneus longus. The tear is usually located at the level of the tip of the fibula. The person with a peroneal tendon tear does not often present acutely but will present later with persistent lateral ankle pain and swelling along the tendon. The lateral pain is located behind the lateral malleolus. The pain is worse with activity especially on uneven ground.

3. Peroneal Tendon Dislocation. Injury may occur with ankle sprains. It is due to forceful contraction of the peroneal tendons. The patient will often experience a popping sensation during the accident. The peroneal tendon may remain dislocated or it may reduce and cause repeated dislocation episodes with activities. There is posterolateral ankle pain and swelling behind the lateral malleolus. If there are repeated dislocation episodes, then there will be a snapping or popping sensation. The symptoms are worse on uneven ground.

4. Fracture of the Anterior Process of the Calcaneus
   This can occur with a lateral ankle sprain. It is an avulsion fracture of the bifurcate ligament. The patient presents with persistent lateral ankle pain following an ankle sprain. The pain and tenderness is maximal in an area that is about 2 cm anterior and 1 cm inferior to the anterior surface of the lateral malleolus.

5. Fracture of the Lateral Process of the Talus (the snow boarder’s fracture)
   The patient presents with localized pain, swelling and bruising anterior to the lateral malleolus. There is tenderness around the lateral malleolus. Thus, this fracture clinically appears like a lateral ankle sprain. This and the fact that the plain radiographs often do not show the fracture or have only subtle changes are the reasons why this fracture is frequently diagnosed late in patients who have had a presumptive diagnosis of an ankle sprain. The symptoms do not resolve with physiotherapy and the patient presents with chronic lateral ankle pain.

6. Fracture of the Tuberosity of the Fifth Metatarsal
   This follows an inversion injury to the ankle. This can be associated with an ankle sprain. This injury represents an avulsion fracture of the base of the fifth metatarsal, which is where the peroneus brevis tendon inserts.

Surgery for Posterior Ankle Pain

Posterior ankle pain may be due to posterior ankle impingement. Posterior ankle impingement may be secondary to repetitive injury. For example, it occurs more commonly in ballet dancers who do Pointe work, basketballers or in the leading foot of fast bowlers.

Posterior ankle impingement may be due to several causes. The most common cause of painful posterior ankle impingement is due to the presence of an os trigonum. This is the un-united posterolateral tubercle of the talus. Its incidence is about 10% and occurs in both ankles in up to 50% of cases.

They will complain of pain in the area of the posterior heel or deep in the back of the ankle. The pain is aggravated by Pointe work, jumping or running activities or when they stand on the tip of their toes or if they wear high heel shoes.

Ankle Arthroscopy is the technique of choice for treatment of:

• joint surface damage (chondral or osteochondral lesions)
• painful ankle spurs (treatment of footballer’s ankle)
• joint inflammation (synovitis) after an ankle sprain
• loose bodies

What is arthroscopic surgery?

Arthroscopic surgery is sometimes referred to as “keyhole surgery” as it is performed through very small incisions. The major advantages of arthroscopic surgery are that it is associated with a faster recovery due to less pain and earlier mobilisation of the ankle than after conventional open surgery. This is possible due to less damage to the surrounding skin, ligaments and tendons.

This surgery is performed as a day surgery procedure.

How is this arthroscopic surgery performed?

The operation is done through 2 small incisions (portals) approximately 5mm long over the joint. An arthroscope (telescope to look into the ankle joint) is used. Local anaesthetic is injected into the joint and around the portals. This usually provides good pain relief for up to 12 hours after the operation. Some patients notice an increase in pain after the local anaesthetic wears off, however this is usually relieved by tablets by mouth.

Which patients are candidates for ankle reconstruction surgery?

This surgery is recommended for patients who experience recurrent ankle sprains despite a course of physiotherapy treatment. The aim of surgery is to prevent the development of ankle arthritis and to reduce the risk of developing ankle joint damage as each episode of ankle sprain may lead to ankle joint injury.

Patients with ankle joint problems such as ankle joint surface damage (chondral or osteochondral lesions), synovitis, bony impingement spurs and loose bodies in association with ankle lateral ligament instability may also require an ankle arthroscopy performed at the same time as the lateral ligament reconstruction.

How is the surgery performed?

The ankle lateral ligament reconstruction surgery is performed though a small 2 - 3cm incision over the tip of the fibula. The ligaments are shortened and reattached onto the fibula with the aid of 2 small anchors. The anchors stay in the tip of the fibula permanently unless it causes irritation. Local anaesthetic is injected around the incision site. This usually provides good pain relief for up to 6 hours after the operation. There is some increase in pain after the local anaesthetic wears off at which time tablets by mouth will usually provide sufficient pain relief.