Which Bunion Surgery is Right for Me? Part 1 – Types of Bunion Surgeries

Many patients who come in for second opinions on bunion surgery share a common frustration that they will often get different recommendations on the most appropriate surgery depending on who they ask. Part of the reason for this is that there is no one-size-fits-all bunion surgery. And while two experts may reasonably disagree on the most appropriate approach, not all bunion surgeries are created equally and require careful consideration before appropriate recommendations can be given. 
Bunions, medically known as hallux valgus, are a common foot deformity characterized by a bony protrusion near the base of the big toe. This condition usually develops over time, often due to a combination of genetic predisposition, foot structure, environmental factors, activity levels, and shoe gear. Bunions can cause pain and difficulty walking, leading many to consider surgery when conservative options have failed. But with literally hundreds of types of bunion surgeries available, how do you know which one is right for you? 
Rather than trying to fit everything we know about bunions into a single blog post, I would like to present a series of posts sharing what we know about bunions and how to navigate the process of bunion surgery. In this post, we’re going to focus on some broad categories of bunion surgeries and their pros and cons. These groups will include: Soft-Tissue Rebalancing, Osteotomies, Arthrodesis, and Minimally Invasive Surgeries.  

Soft Tissue Rebalancing 
The most commonly performed bunion surgeries, for better or worse, focus on the area of the bump. As a bunion develops, this can lead to increasing strain on structures around the first metatarsophalangeal joint (the joint just behind the big toe). During this surgery, we rebalance the tissue around this joint through a series of smaller procedures. The goal is to reduce some of those deforming forces that will worsen a bunion over time and to realign the joint. The procedure may also involve shaving down the prominent bone. Soft tissue balancing may be used in conjunction with other types of bunion procedures as well. 
Pros: Faster recovery, weight bearing allowed after surgery 
Cons: Higher risk of recurrence, not effective for more severe bunions 
 
Osteotomy 
An osteotomy is a surgical procedure that involves cutting and repositioning bones. For bunions, these cuts can occur at different or even multiple points of the first metatarsal, or even the proximal phalanx (bone in the big to closest to the foot).  
Pros: faster recovery than arthrodesis type procedures, can address other deformities present outside the bunion 
Cons: Increased risk of recurrence, not suitable for severe bunions 
 
Arthrodesis (Fusion Surgery) 
Arthrodesis, or joint fusion, generally will be performed at the first metatarsaphalangeal joint or the first tarsometatarsal joint (Lapidus procedure). There are major differences in when we perform these two surgeries. While they usually take longer to heal than the previously discussed surgeries, they can address things like advanced arthritis, provide more stabilizing power, and can be effective in more severe cases. Additionally, any time we fuse a joint, the joint above and below that one usually have to share the load of the fused joint, which can possibly lead to other problems down the road. 

​First metatarsophalangeal joint arthrodesis  
Pros: low recurrence risk, can be used to treat both arthritis and bunion at once, effective for severe bunions 
Cons: eliminates motion at the big toe joint, often requires a period of non weight-bearing, increased risks postoperatively 
 
Lapidus (First tarsometatarsal joint arthrodesis) 
Pros: low recurrence risk, stabilizes the foot, effective for severe bunions 
Cons: increased risks compared to less invasive options, may require short period of non-weightbearing, technically difficult surgery but numerous systems have been developed over the last decade to improve consistency 
 
Minimally Invasive Bunion Surgery 
Minimally invasive surgery is not new but has been seeing a resurgence lately as our tools improve and more patients are seeking faster recovery and less scarring. Most of the previously mentioned types of surgeries can be performed in this way, but this does not come without trade-offs.  Skill at these surgeries requires skill first in their open counterparts. While there are many high-skilled surgeons performing these, much of their initial popularity was partly due to fact they could be performed in office, leading many who were unable to gain surgical privileges at hospitals or surgery centers to focus on these procedures. While I do occasionally perform these surgeries in the appropriate patient, I unfortunately spend much more time fixing others’ attempts at it.  
Pros: smaller incisions, less scarring, can often be done in-office 
Cons: higher risk of recurrence, limited studies on outcomes, higher risk of complications 
 
Choosing the most appropriate bunion surgery can, but does not have to be, a harrowing experience. Bunions are rarely, if ever, an emergency, so my best advice is to take your time, attempt evidence-based nonsurgical treatment, and get a couple of opinions. If you would like a first, second, or third opinion on which surgery would be most appropriate for you, or you would like help navigating non-surgical options, give us a call or schedule online!