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Phone: 03 8595 1800 Fax: 03 8640 0692(please dial area code) Email: [email protected] Website: www.moati.com.au Correspondence: PO Box 8082, Tarneit Vic 3029

Mr. Siva Chandrasekaran Orthopaedic Surgeon

MBBS MSpMed MPhil (surg) FRACS

Quattro Specialist Centre 237 Hogan Road

Hoppers Crossing 3029

Masada Private Hospital 26 Balaclava Road St Kilda East 3183

Cotham Private Hospital 209 Cotham Road Kew 3101

Bunion Surgery Most people with bunions find pain relief with simple treatments to reduce pressure on the big toe, such as wearing wider shoes or using pads in their shoes. However, if these measures do not relieve your symptoms, Mr. Chandrasekaran may recommend bunion surgery.

There are different types of surgeries to correct a bunion. Bringing the big toe back to its correct position may involve realigning bone, ligaments, tendons, and nerves.

Are You a Candidate for Surgery?

In general, if your bunion is not painful, you do not need surgery. Although bunions often get bigger over time, doctors do not recommend surgery to prevent bunions from worsening. Many people can slow the progression of a bunion with proper shoes and other preventive care, and the bunion never causes pain or other problems.

It is also important to note that bunion surgery should not be done for cosmetic reasons. After surgery, it is possible for ongoing pain to develop in the affected toe — even though there was no bunion pain prior to surgery.

Good candidates for bunion surgery commonly have:

• Significant foot pain that limits their everyday activities, including walking and wearing reasonable shoes. They may find it hard to walk more than a few blocks (even in athletic shoes) without significant pain.

• Chronic big toe inflammation and swelling that does not improve with rest or medications • Toe deformity—a drifting in of the big toe toward the smaller toes, creating the potential for the

toes to cross over each other. • Toe stiffness—the inability to bend and straighten the big toe • Failure to obtain pain relief with changes in footwear • Failure to obtain pain relief from nonsteroidal anti-inflammatory drugs (NSAIDs), such as

ibuprofen and naproxen. The effectiveness of NSAIDs in controlling toe pain varies greatly from person to person.

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(Left) A bunion that has progressed to deformity with the big toe crossing over the second toe. (Right) An x-ray of the same bunion shows how far out of alignment the bones are.

Deciding to Have Bunion Surgery

After bunion surgery, most patients have less foot pain and are better able to participate in everyday activities.

As you explore bunion surgery be aware that so-called "simple" or "minimal" surgical procedures are often inadequate "quick fixes" that can do more harm than good. Although many bunion procedures are done on a same-day basis with no hospital stay, a long recovery period is common. It often takes up to 6 months for full recovery, with follow-up visits to Mr. Chandrasekaran sometimes necessary for up to a year.

It is very important to have realistic expectations about bunion surgery. For example, bunion surgery may not allow you to wear a smaller shoe size or narrow, pointed shoes. In fact, you may need to restrict the types of shoes you wear for the rest of your life.

As you consider bunion surgery, do not hesitate to ask Mr. Chandrasekaran questions about the operation and your recovery. Some examples of helpful questions to ask include:

• What are the benefits and risks of this surgery? • What are the possible complications and how likely are they to occur? • How much pain will there be and how will it be managed?

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Be sure to write down Mr. Chandrasekaran's answers so you can remember them at a later time. It is important to understand both the potential benefits and limitations of bunion surgery.

Surgical Procedures

In general, the common goals of most bunion surgeries include:

• Realigning the metatarsophalangeal (MTP) joint at the base of the big toe • Relieving pain • Correcting the deformity of the bones making up the toe and foot

Because bunions vary in shape and size, there are different surgical procedures performed to correct them. In most cases, bunion surgery includes correcting the alignment of the bone and repairing the soft tissues around the big toe.

Mr. Chandrasekaran will talk with you about the type of surgery that will best correct your bunion.

Repairing the Tendons and Ligaments Around the Big Toe

In some cases, the soft tissues around the big toe may be too tight on one side and too loose on the other. This creates an imbalance that causes the big toe to drift toward the other toes.

Surgery can shorten the loose tissues and lengthen the tight ones. This is rarely done without some type of alignment of the bone, called an osteotomy. In the majority of cases, soft tissue correction is just one portion of the entire bunion corrective procedure.

Osteotomy In an osteotomy, Mr. Chandrasekaran makes small cuts in the bones to realign the joint. After cutting the bone, Mr. Chandrasekaran fixes this new break with pins, screws, or plates. The bones are now straighter, and the joint is balanced.

Osteotomies may be performed in different places along the bone to correct the deformity. In some cases, in addition to cutting the bone, a small wedge of bone is removed to provide enough correction to straighten the toe.

As discussed above, osteotomies are normally performed in combination with soft tissue procedures, as both are often necessary to maintain the big toe alignment.

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X-rays taken from the top and the side of the foot show a bunion corrected with osteotomy.

Arthrodesis In this procedure, Mr. Chandrasekaran removes the arthritic joint surfaces, then inserts screws, wires, or plates to hold the surfaces together until the bones heal. Arthrodesis is commonly used for patients who have severe bunions or severe arthritis, and for patients who have had previous unsuccessful bunion surgery.

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The x-ray on the left shows severe arthritis of the MTP joint. After arthrodesis (shown on the right), the entire foot is realigned. An advantage of arthrodesis is that no additional procedures are necessary to correct the bunion.

Exostectomy In this procedure, Mr. Chandrasekaran removes the bump from your toe joint. Exostectomy alone is seldom used to treat bunions because it does not realign the joint. Even when combined with soft tissue procedures, exostectomy rarely corrects the cause of the bunion.

Exostectomy is most often performed as one part of an entire corrective surgery that includes osteotomy, as well as soft-tissue procedures. If a doctor performs exostectomy without osteotomy, however, the bunion deformity often returns.

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The x-ray on the left shows a mild bunion bump before exostectomy. After the procedure (right), the bump has been shaved but the toe deformity remains and is actually worse; the big toe drifts closer to the other toes and the metatarsal bone sticks out further.

Resection Arthroplasty In this procedure, Mr. Chandrasekaran removes the damaged portion of the joint. This increases the space between the bones and creates a flexible "scar" joint. Resection arthroplasty is used mainly for patients who are elderly, have had previous unsuccessful bunion surgery, or have severe arthritis not amenable to an arthrodesis (see above). Because this procedure can change the push off power of the big toe, it is not often recommended.

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This x-ray shows a failed resection arthroplasty. Although the damaged bone of the MTP joint was removed, scar tissue did not fill the space between the bones. The bone edges are still in contact. The photograph shows that without the needed scar tissue, the big toe is shortened. This makes it more difficult to push off while walking.

Preparing for Surgery

Medical Evaluation Before your surgery, you may be asked to visit your family doctor for a complete physical examination. He will assess your health and identify any problems that could interfere with your surgery. If you have a heart or lung condition or a chronic illness you will need a preoperative medical clearance from your family doctor.

Medications Tell Mr. Chandrasekaran about any medications you are taking. He will tell you which medications you can continue taking and which you should stop taking before surgery.

Tests You may require several preoperative tests, including blood counts, a cardiogram, and a chest x-ray. You may also need to provide a urine sample.

To help plan your procedure, Mr. Chandrasekaran may order special foot x-rays. These x-rays should be taken in a standing, weight bearing position to ensure Mr. Chandrasekaran can clearly see the

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deformity in the foot. These x-rays assist Mr. Chandrasekaran in making decisions about where along the bone to perform an osteotomy in order to provide enough corrective power to straighten the toe.

Your Surgery

In planning your surgery, Mr. Chandrasekaran will consider several things, including how severe your bunion is, your age, your general health and activity level, and any other medical issues that may affect your recovery.

Almost all bunion surgery is done on an outpatient basis. You will most likely be asked to arrive at the hospital or surgical center 1 or 2 hours before your surgery.

Anesthesia After admission, you will be evaluated by a member of the anesthesia team. Most bunion surgery is performed with anesthesia that numbs the area for surgery but does not put you to sleep.

• Local anesthesia. An ankle block numbs just your foot. • Regional anesthesia. A popliteal block works for a longer period of time compared to an ankle

block and numbs more of the leg. The numbing medicine is injected behind the knee. • Spinal anesthesia. This injection will numb your body below your waist. • General anesthesia. This form of anesthesia will put you to sleep.

The anesthesiologist will stay with you throughout the procedure to administer other medications, if necessary, and to make sure you are comfortable.

Procedure Depending upon your bunion and the procedures you need, Mr. Chandrasekaran will make an incision along the inside of your big toe joint or on top of the joint. In some cases, more than one incision is needed to correct the bunion deformity.

This surgical photograph shows a saw cutting the bone to perform an osteotomy.

The surgical time varies depending on how much of your foot is malaligned. Surgery will take longer if your deformity is greater or if more than one osteotomy is required. Every bunion correction is a little bit different, and there is no reason to be concerned if your surgery takes more time.

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Afterward, you will be moved to the recovery room. You will be ready to go home in an hour or two. Be sure to have someone with you to drive you home.

(Left) The bunion that was shown at the beginning of this article as it appeared immediately after surgery. (Right) An x-ray showing the bones in alignment after surgery. Osteotomies were performed on both bones; screws and plates hold the bones in place.

Complications As with any surgical procedure, there are risks associated with bunion surgery. These occur infrequently and are usually treatable — although, in some cases, they may limit or extend your full recovery. Before your surgery, Mr. Chandrasekaran will discuss each of the risks with you and take specific measures to avoid complications.

The possible risks and complications of bunion surgery include:

• Infection • Nerve injury • Failure to relieve pain • Failure of the bone to fully heal • Stiffness of the big toe joint • Recurrence of the bunion

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Recovery at Home

The success of your surgery will depend in large part on how well you follow Mr. Chandrasekaran's instructions at home during the first few weeks after surgery. You will see Mr. Chandrasekaran regularly for several months — occasionally up to a year — to make sure your foot heals properly.

Mr. Chandrasekaran will apply your dressing in a specific way to keep the bones in correct position.

Dressing Care You will be discharged from the hospital with bandages holding your toe in its corrected position.

Because keeping your toe in position is essential for successful healing, it is very important to follow Mr. Chandrasekaran's directions about dressing care. Do not disturb or change the dressing without talking to Mr. Chandrasekaran. Interfering with proper healing could cause a recurrence of the bunion.

Be sure to keep your wound and dressing dry. When you are showering or bathing, cover your foot with a plastic bag.

Your sutures will be removed about 2 weeks after surgery, but your foot will require continued support from dressings or a brace for 6 to 12 weeks.

Medications Mr. Chandrasekaran will prescribe pain medication to relieve surgical discomfort. The most effective medications for providing postsurgical pain relief are opioids. These medications are narcotics, however, and can be addictive. It is important to use opioids only as directed by Mr. Chandrasekaran.

As soon as your pain begins to improve, stop taking opioids. Talk to Mr. Chandrasekaran if your pain has not begun to improve within a few days of your surgery.

In addition to pain medicine, Mr. Chandrasekaran may prescribe antibiotics to help prevent infection in your wound for several days after surgery.

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Swelling Keep your foot elevated as much as possible for the first few days after surgery, and apply ice as recommended by Mr. Chandrasekaran to relieve swelling and pain. Never apply ice directly on your skin. It is common to have some swelling in your foot from 6 months to a year after bunion surgery.

Bearing Weight Mr. Chandrasekaran will give you strict instructions about whether and when you can put weight on your foot. Depending upon the type of procedure you have, if you put weight on your foot too early or without proper support, the bones can shift and the bunion correction will be lost.

Some bunion procedures allow you to walk on your foot right after the surgery. In these cases, patients must use a special surgical shoe to protect the bunion correction.

Many bunion surgeries require a period of no weightbearing to ensure bone healing. Mr. Chandrasekaran will apply dressings, a brace, or a cast to maintain the correct bone position. Crutches are usually used to avoid putting any weight on the foot. A newer device called a knee walker is a good alternative to crutches. It has four wheels and functions like a scooter. Instead of standing, you place the knee of your affected foot on a padded cushion and push yourself along using your healthy foot.

In addition to no weightbearing, driving may be restricted until the bones have healed properly — particularly if the surgery was performed on your right foot.

No matter what type of bunion surgery you have, it is very important to follow Mr. Chandrasekaran's instructions about weightbearing. Do not put weight on your foot or stop using supportive devices until Mr. Chandrasekaran gives approval.

Physical Therapy and Exercise Specific exercises will help restore your foot's strength and range of motion after surgery. Mr. Chandrasekaran or physical therapist may recommend exercises using a surgical band to strengthen your ankle or using marbles to restore motion in your toes.

Always start these exercises slowly and follow instructions from Mr. Chandrasekaran or physical therapist regarding repetitions.

Specific exercises such as the marble pick up exercise will help restore full motion to your foot.

Shoe Wear It will take several months for your bones to fully heal. When you have completed the initial rehabilitation period, Mr. Chandrasekaran will advise you on shoewear. Athletic shoes or soft leather oxford type shoes will best protect the bunion correction until the bones have completely healed.

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To help prevent your bunion from recurring, do not wear fashion shoes until Mr. Chandrasekaran allows it. Be aware that Mr. Chandrasekaran may recommend that you never return to wearing high-heeled shoes.

Avoiding Complications Though uncommon, complications can occur following bunion surgery. During your recovery at home, contact Mr. Chandrasekaran if:

• Your dressing loosens, comes off, or gets wet. • Your dressing is moistened with blood or drainage. • You develop side effects from postoperative medications.

Also, call Mr. Chandrasekaran immediately if you notice any of the following warning signs of infection:

• Persistent fever • Shaking chills • Persistent warmth or redness around the dressing • Increased or persistent pain, especially a "sunburn" type pain • Significant swelling in the calf above the treated foot, especially if there is a "charley horse"

pain behind the knee, or if your develop shortness of breath.

Outcomes

The majority of patients who undergo bunion surgery experience a reduction of foot pain, along with improvement in the alignment of their big toe. The length of your recovery will depend upon the surgical procedures that were performed, and how well you follow Mr. Chandrasekaran's instructions.

Because a main cause of bunion deformity is a tight-fitting shoe, returning to that type of shoe can cause your bunion to return. Always follow Mr. Chandrasekaran's recommendations for proper shoe fit.

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