Bunions

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Absolutely! With over 50 types of bunion surgeries discussed in medical literature, it should not be surprising that many, if not most, have not stood the test of time.

Technological advances touch almost every aspect of our lives on a daily basis. Thanks to modern research and development, medicine has seen incredible advances, and that includes bunion surgery.

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Are outdated bunion surgeries still performed?

Unfortunately, just because many conventional bunion surgeries no longer offer acceptable outcomes, it doesn’t mean that they’re no longer performed. This happens for several reasons, including that some surgeons are simply not comfortable learning advanced surgical techniques and adopting new technologies.

It is very important to always remember that there is no such thing as a “best bunion surgery.” This is because each patient is different, as is their foot anatomy, bunion deformity, bone quality, lifestyle, and work demands. So, what may be perfect for one bunion patient could be terribly wrong for another.

Please note: we generally only recommend bunion correction surgery if conservative treatment options have failed. Learn more about non-surgical bunion treatment options here.

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7 Bunion Surgeries that have outlived their usefulness

In the interest of educating the general public, here’s a summary of some of the better known deprecated bunion surgeries. We’ve also included our thoughts as to why these approaches are generally no longer used.

1. The Traditional Tightrope Bunionectomy

In this procedure, a thin metal wire is wrapped around the first and second metatarsals and pulled tight. This shifts the first metatarsal into parallel alignment with the second metatarsal, thereby correcting its outward drift.

Unfortunately, this procedure has an unacceptably high rate of failure and increased risk of fracturing the second metatarsal. Tightrope procedures are typically performed in patients with compromised bone quality due to vascular conditions, soft bones (osteoporosis), and smoking.

Today, our surgeons perform an improved variant of this procedure, but on a very limited patient population. Known as the Tightrope FT, this procedure begins just like the classic tightrope: by threading a thin fiber-wire around the first and second metatarsals and tightening it – forcing the big to toe properly realign. The new twist: the first metatarsal head is removed in order to decrease stress on the bone, provide added stability to its base, and accommodate soft tissue remodeling.

2. Shaft Osteotomies

This is another procedure that all podiatrists learn in medical school and involves making a bone cut (osteotomy) along the mid-shaft of the metatarsal (the long bone leading to the base of the big toe) in order to correct its angle. The two halves are then held in place with two screws while the cut bone heals.

The shaft cutting approach, known as the "Z bunionectomy", has long been discarded as an effective procedure at the University Foot and Ankle Institute and the Bunion Institute. This is because of its higher potential for misalignment and failure resulting from inadequate hardware support.

3. Scarf Osteotomy

The scarf osteotomy involves making a Z-shaped cut along the shaft of the first metatarsal, splitting the mid-shaft of the bone in half along its vertical axis. (It's kind of like slicing open a baguette.) Next, the upper half of the metatarsal is rotated inward (toward the little toe) to line up the first metatarsal head with the base of the big toe. Two screws are used to hold the halves of the metatarsal in their new position. Any bone protruding from the bottom part of the “baguette” is trimmed off.

The scarf bunion surgery, while very effective at achieving a stable correction, is technically challenging, thus riskier than some other procedures that offer equivalent outcomes.

Although our surgeons have not totally stopped performing the scarf osteotomy, it is only used for very large bunions in patients who are unable to comply with non-weight-bearing restrictions during recovery.

4. Closing Wedge Osteotomy

As its name suggests, “the wedge osteotomy” is an orthopedic surgical procedure that involves cutting a “pie wedge” from the side of the first metatarsal to force it into straight alignment.

Like the other obsolete procedures described here, there’s simply no reason to perform such an invasive procedure when we have better procedures with much better long-term outcomes.

“The Wedge Bunionectomy is a cheating procedure that was used in the old days to straighten out the joint at the base of the big toe so that it’s perpendicular to the first metatarsal, creating a straight line from the metatarsal shaft to the tip of the big toe,” says Dr. Bob Baravarian, co-founder of University Foot and Ankle Institute and the Bunion Institute.

Dr. Baravarian continues: “The truth is, if you move the first metatarsal over properly and rebalance the supporting ligaments, there is no need to make a wedge cut in the metatarsal bone. And in those rare cases when the big toe alone has drifted out of alignment, we can perform an Akin osteotomy to correct the big toe position so that it’s parallel to the second toe. In either event, removing a wedge of bone from the metatarsal poses risks to the nerves and circulation and makes little sense.”

5. McBride Bunionectomy

The McBride bunionectomy is only rarely performed, as it involves cutting the joint surface to change its slope. Because this approach avoids cutting and shifting the metatarsal bone, it doesn’t bring the bone into correct alignment.

Thus, the McBride is only used if the patient is a very poor surgical candidate who may not heal from a surgery where the bone is cut or a fixation device must be applied to bone. The McBride provides very limited correction when compared to other modern procedures, especially our miniBunion Minimally Invasive Bunionectomy™.

6. Exostectomy

We call this procedure “the cheater’s attempt at bunion removal." That’s because this procedure involves cutting the bony bump from the big toe joint and nothing else. Exostectomy alone is seldom used to treat bunions because it foregoes realignment of the involved bones and therefore does not correct the hallux valgus deformity. Even when combined with soft tissue procedures, exostectomy rarely corrects the cause of the bunion, so it quickly returns.

When performed today, exostectomy is just one part of a more comprehensive corrective surgery that includes a metatarsal osteotomy, as well as soft-tissue procedures. If a foot surgeon wants to perform an exostectomy without a metatarsal osteotomy, don’t let them.

7. Resection Arthroplasty

In this procedure, your doctor removes the damaged portion of the big toe joint and pulls the first metatarsal and toe into correct alignment. Once part of the original joint is removed, scar tissue fills the gap, creating a flexible pseudo-joint. Resection arthroplasty is reserved mainly for patients who are elderly, have had previous unsuccessful bunion surgery, or who have severe arthritis and want to avoid fusing the joint.

Because this procedure can change the “push off strength” of the big toe, which is critically important for walking, it is rarely recommended.

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Why choose the Bunion Institute for your bunion care?

If you are experiencing bunion pain, we’re always here to help. At the Bunion Institute, our mission is to provide the best bunion treatments available anywhere, so that our patients can be pain free and back to their daily activities as soon as possible.

Our nationally recognized bunion specialists offer the most advanced bunion care and the highest success rates in the nation. That’s because our foot surgeons are leaders in developing surgical techniques and technologies that advance bunion treatment for patients everywhere.

We realize that our patients lead busy lives. That’s why our clinics can include their own MRIs, CAT scanners, and x-ray machines to facilitate prompt diagnosis with minimal inconvenience to our patients. What’s more, several of our clinics have in-house physical therapy facilities which give our therapists immediate accessibility to our doctors and gives our doctors the ability to very closely monitor their patients’ progress.

For more information or to schedule a consultation, please call (855) 814-3600 or make an appointment online now.

At the Bunion Institute, we take our patients’ safety seriously. Our clinics’ and surgery centers’ Covid-19 patient safety procedures exceed all CDC recommendations. Masks are required in our institutes at all times.

We are conveniently located throughout Southern California and the Los Angeles area as our foot doctors are available at locations in or near Santa Monica, Beverly Hills, West Los Angeles, Manhattan Beach, Northridge, Downtown Los Angeles, Westlake Village, Granada Hills, and Valencia California, to name a few.

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What is a bunionette or Tailor’s bunion?

Ever hear the saying that good things come in small packages? Well, that certainly isn’t the case when it comes to bunionettes. Also known as “tailor’s bunions,” bunionettes are a painful bony overgrowth that forms at the base of the pinky toe (fifth toe) along the lateral border of the foot.

In anatomical terminology, bunionettes form at the joint at the base of the small toe formed by the distal end of the fifth metatarsal bone (a long bone of the forefoot) and the initial bone segment of the small toe.

Bunionettes got the moniker “tailor’s bunions” because persons who regularly place pressure on the outside of the foot, are at greater risk of developing a protruding bone on the outside of the foot that can cause pain. Just like tailors in olden days sitting crossed legged with the outer edge of their foot rubbing the ground.

What causes a bunionette deformity?

Bunionettes form in much the same way as bunions do: continuous pressure that’s placed on the little toe can eventually lead to the formation of a tender bony mass. Over time, the overlying skin will thicken or perhaps even form calluses, causing a visible deformity that can become painful. In extreme cases, the small toe will start to rotate inward. 

More common risk factors for developing bunionettes nowadays include wearing tight shoes, such as high heels that can place increased pressure on the small toes, or wearing shoes with a narrow toe box. These folks are also at greater risk of developing bunions. 

In very rare circumstances bunionettes may be caused by congenital problems (those present at birth) or by medical conditions like rheumatoid arthritis that can cause deformity of the long bones in the forefoot (the metatarsals). 

What are the symptoms of a bunionette?

Symptoms of a bunionette include:

• A visible lump on the outer edge of the base of the small toe (the fifth metatarsophalangeal joint)
• Pain localized to the joint between the small toe base and the fifth metatarsal head that occurs when something presses against the bump
• Inward rotation of the small toe
• Redness at the base of the little toe
• Soft tissue swelling at the base of the small toe
• A callus forming at the base of the small toe (known as a tailor’s bunion callus)

Interestingly, not all bunionettes are painful. In fact, during their early stages, bunionettes may be visible before they start becoming symptomatic. Obviously, the sooner bunionettes are treated, the higher the likelihood that the treatment will succeed.

How can I confirm if I have a bunionette?

Just as with bunions (hallux valgus) that affect the big toe, the signs of a bunionette deformity at the little toe are fairly easy to see. A trained podiatrist can confirm the diagnosis after examining your foot. An x-ray might be ordered to determine the extent of joint involvement that can guide how to best treat the condition. 

Is surgery the only way to treat bunionettes?

No! The good news is that most bunionettes often do well with conservative treatment. The obvious first step in tailor’s bunion treatment is to prevent bunions from getting worse by removing pressure from the base of the small toe and alleviating the pain (if you have any).

Conservative treatments for bunionettes include:

Shoe modifications

Switch to shoes with a wide toe box or, in warm climates, switching to sandals that apply no pressure to the area. Avoid pointy-toed shoes (like cowboy boots) and high heeled shoes that thrust your weight onto the ball of your foot. In some cases, you might need to go up one shoe size to get a roomier toe box.

Padding

Alternatively, your foot and ankle specialist might suggest using over-the-counter pads or custom-made orthotics to reduce pressure on the small toe joint. It’s important that the toe box of your shoe is roomy enough to accommodate the tailor’s bunion pad without increasing the pressure placed on the bunionette.

Icing

Intermittently applying an ice pack for 20-minute intervals, several times per day. To avoid freezer burns resulting from direct contact of ice on the skin, wrap the ice cubes or gel pack in cloth.

Anti-inflammatory medications

NSAIDs (nonsteroidal anti-inflammatory drugs) like ibuprofen, naproxen, Advil, or Aleve can help with swelling. Never take these on an empty stomach as they can cause gastrointestinal bleeding if you are not careful.

Injection therapy

Chronic pain might warrant treatment with steroids to decrease inflammation directly at the site.

When is surgery recommended for a bunionette?

Just as with a traditional bunion, the main reason to have correction surgery is to alleviate pain and improve function. In the rather rare event of a patient having a severe bunionette with painful internal rotation of the small toe that has failed conservative treatment, we might recommend a minimally invasive surgery to realign the small toe.

The surgical approach recommended by your doctor will be based on a combination of factors, including the joint wear demonstrated on x-ray findings, your age, activity level, lifestyle, and any underlying medical conditions. Of course, the recovery time after a tailor’s bunion surgery will be determined by the surgical approach selected.

Why choose the Bunion Institute for your bunion treatment or surgery?

If you’re experiencing bunion pain, we’re here to help. Our nationally recognized foot and ankle podiatry experts offer the most advanced bunion solutions and the highest success rates in the nation. We are leaders in the research and treatment of all bunion conditions.

At the Bunion Institute (an affiliate of the University Foot and Ankle Institute), we take our patients’ safety seriously. Our facility’s Covid-19 patient safety procedures exceed all CDC recommendations. Masks are required in our institutes at all times.

To schedule a consultation, please call (855) 872-5249 or make an appointment now.

We are conveniently located through the Los Angeles area with locations in or near Santa Monica, Beverly Hills, West Los Angeles, Manhattan Beach, Northridge, Downtown Los Angeles, Westlake Village, Granada Hills, and Valencia California, to name a few.

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Our state-of-the-art minimally invasive bunionectomy offers immediate weight-bearing, less pain, and faster recovery than other types of traditional bunion surgery. Many patients have questions about our unique technique and what to expect before and after surgery. We hope this article answers your questions!

What to expect before Minimally Invasive Bunion Surgery?

Here is what you need to know as you prepare for minimally invasive bunion correction surgery:

• No eating or drinking after midnight before the surgery.
• Anesthesia and a “relaxing” medication will be given via IV in the surgery center's operating room; general anesthesia is not necessary for this type of procedure.
• Once you are comfortable and relaxed, your orthopedic surgeon will give you a nerve block to numb your foot.

Minimally invasive bunion surgery recovery

Immediately following the outpatient surgical procedure, your orthopedic surgeon will place a boot on your foot. The shoe should remain on until seen in the office for your first post-op visit. Once you are comfortable, you can go home with your chosen companion.

It is best to keep the foot elevated as much as possible during the car ride and while home to help reduce swelling. Crutches, a walker, or a wheelchair can be used, but MOST patients will not need them. You can place weight on the foot immediately following surgery.

Our patients rarely need pain medication of any significance. Most will take Advil and Tylenol for pain, but you will be given pain medication in case you need it.

About post bunion surgery checkups

We usually check your progress four times after your surgery, though if you feel you need more, we are more than happy to accommodate you. Here is a typical schedule and what usually happens at each visit.

Your post-surgery follow-up appointment (recovery time 1-2 weeks)

• • Your dressings will be changed, and follow-up X-rays will be taken.
  • You can now begin to get your very small incisions wet in a shower (but no soaking in a tub until your sutures dissolve).
  • You begin gentle range of motion exercises of the big toe to prevent stiffness.
  • You may resume driving in the special orthopedic shoe but should take care that you are comfortable braking and have full control of the car. We know this is obvious, be we have to mention that you should never take pain medication and drive!
  • A toe spacer or strapping should be used most of the time to hold the toe straight.
  • The orthopedic shoe or boot can now be removed at night, but we suggest wearing a sandal to protect the toe against bumps.

Your third follow-up appointment (recovery time 6-7 weeks)

• • X-rays for healing diagnosis may be done.
  • You can likely wear your own supportive shoes at this point (if comfortable). This may be done gradually over a week period and is not an instant shift from an orthopedic shoe to a supportive shoe.
  • You will likely be able to increase your normal activities. Know that it is normal for the soft tissue in your foot to swell after activities, for now.
  • Continue working on the big toe range of motion.
  • You may now stop using the toe spacer or strapping/taping unless it feels comfortable to keep doing it (for up to two months total after surgery). 

Your fourth follow-up appointment (12 weeks)

• • X-rays may be taken if healing was incomplete during your third visit. 
  • You can start running.
  • You can begin wearing heels.

Minimally Invasive Bunion Surgery and foot swelling

Swelling in the foot is usually the last issue to resolve, though many of our patients' swelling is no longer an issue after just eight weeks. Almost everyone else's swelling has resolved at 12 weeks, which is less than with other, more invasive techniques.

Of course, each patient heals at their own pace, everyone is different, and that is totally normal. You might take longer to heal, or possibly heal faster. Your doctor will always individualize your timeline as we see how you recover during each of your post-surgery appointments.

In the rare circumstance that your swelling takes longer to resolve, a compression sleeve may be used instead of a sock to reduce it and aid in your recovery. 

Lastly, there are always risks with any surgery, which can include infection, wound healing problems, scarring, and swelling. Luckily these are very rare in our minimally invasive surgeries. But if they do occur, just know that they can affect your post-operative recovery timeline and outcome.

Why choose the Bunion Institute for your bunion care?

If you’re experiencing bunion pain, we’re here to help. Our nationally recognized foot and ankle podiatry experts offer the most advanced foot surgery solutions and the highest success rates in the United States. We are leaders in the research and treatment of all bunion (hallux valgus) conditions.

At the Bunion Institute (an affiliate of the University Foot and Ankle Institute), we take our patients’ safety seriously. Our facility’s Covid-19 patient safety procedures exceed all CDC recommendations. Masks are required in our institutes at all times.

To schedule a consultation, please call (855) 872-5249 or make an appointment now.

We are conveniently located through the Los Angeles area with locations in or near Santa Monica, Beverly Hills, West Los Angeles, Manhattan Beach, Northridge, Downtown Los Angeles, Westlake Village, Granada Hills, and Valencia California, to name a few.

Read More

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Patients often confuse bunions (Hallux Valgus) with Big Toe Arthritis (Hallux Limitus) because both conditions can cause pain and a bump or even enlargement of the big toe joint. But it's important to understand that they are actually very different conditions.

What’s a Bunion (Hallux valgus)?

A bunion or hallux valgus is when the joint formed between the base of the first segment of the big toe (the proximal phalanx) and the far end of the first metatarsal bone of your foot falls out of alignment. Specifically, the big toe moves laterally so that its tip points toward the little toe, and the first metatarsal bone drifts outward so that its tip points toward your opposite foot. 

The net result is that your first metatarsal and great toe are no longer in straight alignment but rather form a "V" with its apex at the first metatarsal head pointing toward the opposite foot. This process begins gradually and, at first, the bump at the first metatarsophalangeal joint (MTP joint) is rather subtle and usually felt to be just a minor annoyance.  

Eventually (and sometimes quickly) symptoms worsen when shoes start rubbing on the bump. When that happens and pain begins, it’s wise to seek follow-up with a podiatrist. While at first the range of motion of the foot isn't affected by a bunion, if the deformity is allowed to progress unchecked it can cause greater problems. The great toe joint can actually start to dislocate, prompting significant joint pain and degeneration that can affect forefoot function and, eventually, your gait.

What is Big Toe Arthritis?

Big Toe Arthritis (technically known as “Hallux Limitus,” "Hallux Rigidus," or “rigidus arthritis of the great toe joint”) occurs when the joint between the first bone segment of the big toe and the first metatarsal bone begins to degenerate. This leads to the destruction of the cartilage that lines the ends of the bones, the formation of bone spurs as the bone attempts to regenerate, and decreased range of motion at the toe joint.

Big Toe Arthritis results in stiffness, progressive pain, joint swelling, and tenderness. At this point, physical therapy and conservative treatments will be of little help. When arthritis becomes severe, a joint replacement (known as arthroplasty) or a joint fusion (an arthrodesis) might be recommended.

Some people may be predisposed to arthritis of the big toe because of the biomechanical design of their toe joints. In others, osteoarthritis can become much worse as the result of an injury or from repetitive micro-trauma due to walking in high-heeled shoes or engaging in certain sports, for instance.

How to tell the difference between a Bunion and Big Toe arthritis  

The symptoms of big toe arthritis are quite different than those of bunions. Big toe arthritis usually starts with joint stiffness that can be accompanied by swelling and redness. This usually progresses to a decrease in range of motion in both dorsiflexion and plantar flexion (upward and downward bending), a crunching sensation during movement, and eventually the formation of a bump along the top (or dorsal surface) of the joint. 

This is very different from bunions which are characterized by a bump forming along the outer side of the toe that isn't very painful at first. Bunions also have little, if any, limitation in joint movement and no crunching sensation.

The pain of hallux rigidus is a result of bone spurs that can restrict motion and foot function as your walking pattern changes when your body tries to offload the sore joint. Pain can also result from loose bone fragments that break off from the bone spurs and get trapped in the joint. The etiology of bunion pain, on the other hand, results from the soft tissue of the metatarsal head rubbing on the inside of the shoe. 

Weight-bearing x-rays taken while standing show clear-cut radiographic differences between bunions and MTP joint arthritis. Bunions are characterized by a V-shaped medial deformity (known as abducto valgus or a hallux valgus deformity) resulting from hypermobility of the MTP joint. This causes the first metatarsal head to point toward the opposite foot and the distal tip of the great toe to point toward the little toe of the same foot. 

This contrasts with radiographs of an arthritic big toe that are characterized by joint space narrowing, bone spurs (called osteophytes) visible at the ends of the bones, and, in extreme cases, early signs of fusion at the MTP joint.

What happens when Bunions and Big Toe arthritis occur together?

Bunions and big toe arthritis can occur together in what is considered a more complex foot deformity.

Sometimes arthritis can develop in the presence of a bunion due to the prolonged abnormal position of the joint. This can occur when the bunion deformity is advanced and the MTP joint sustains repetitive trauma or a distinctive injury that sets the arthritis in motion. 

Similarly, there can sometimes be a subtle bunion component to big toe arthritis because the MTP joint can degenerate in an asymmetric fashion due to bone spurs. This deformity is often corrected at the time of a joint clean-up surgery.

Bunions vs. Big Toe Arthritis: how do treatments vary?

Aggressive treatment of big toe arthritis (hallux limitus) is crucial during its early stages.

Once joint cartilage has been destroyed, there is nothing a physician or surgeon can do to create more cartilage. Research is underway seeking to replace or regrow cartilage, but we are many years from a solution.

In its early stages, hallux limitus can be controlled with conservative treatment using a custom orthotic or over the counter plantar inserts to take the pressure off the big toe and redistribute it through the rest of the foot. If that fails, a surgical procedure known as a cheilectomy involves the resection of scar tissue and painful bone spurs from the joint. This permits better range of motion and slows the progression of arthritis.

Some patients benefit from a surgical treatment known as an osteotomy that shortens the first metatarsal relative to the second metatarsal. This not only gives the first MTP joint better clinical biomechanics but also creates more joint space. If left untreated, Hallux limitus can lead to complete joint destruction necessitating a joint fusion (arthrodesis) or even a joint replacement (arthroplasty).

On the other hand, treatment for a conventional bunion can often be delayed until it becomes painful.

During their relatively asymptomatic early stages, bunions are considered a cosmetic concern and are treated by placing a silicone wedge between the first and second toe to force the first toe to line up with the first metatarsal.

With bunions, the MTP joint does not usually become damaged until the advanced stages of this condition. Nonetheless, it's important to seek follow up with a foot ankle specialist once bunions begin to hurt to avoid permanent joint injury. But a bump in the absence of foot pain can wait.

Why choose the Bunion Institute for your bunion care?

If you’re experiencing bunion pain, we’re here to help. Our nationally recognized foot and ankle podiatry experts offer the most advanced bunion solutions and the highest success rates in the nation. Our Doctors of Podiatric Medicine (DPMs for short) have years of experience and are leaders in the research and treatment of all bunion conditions.

At the Bunion Institute (an affiliate of the University Foot and Ankle Institute), we take our patients’ safety seriously. Our facility’s Covid-19 patient safety procedures exceed all CDC recommendations. Masks are required in our facilities at all times.

To schedule a consultation, please call (855) 872-5249 or make an appointment now.

We are conveniently located through the Los Angeles area with locations in or near Santa Monica, Beverly Hills, West Los Angeles, Manhattan Beach, Northridge, Downtown Los Angeles, Westlake Village, Granada Hills, and Valencia California, to name a few.

Read More