When it comes to surgical treatment of very large bunion deformities, I think we all scratch our heads a little and have to ponder what to do. For the average run-of-the-mill deformity, it is pretty much a slam dunk. You do whatever you are comfortable with such as an Austin bunionectomy, Scarf bunionectomy, distal-L osteotomy, etc.
What I want to talk about is the jumbo bunion. I recently had a patient come into the office because his daughter just had bunion surgery by me and it was one of those run-of-the-mill Austin bunionectomies. He told me he had been to a couple of other podiatrists for treatment of his bunion. He was told that nothing could be done and he would just have to live with it.
Now I don't know about you but I feel like I can fix anything. Unless there is some other medical reason such as heart disease or peripheral arterial disease, I do not tell people that nothing can be done. I do, however, explain the difficulty and sometimes prolonged recovery with such a reconstruction. I do want to give options to patients. Ultimately, it is their decision if they want to live with it.
So what do you do with jumbo bunions? If there is a long first metatarsal, then a Lapidus may be a good option since you can get excellent proximal correction. If the first metatarsal is short, however, then you are probably looking at shortening the central metatarsals as well if you are doing a Lapidus.
Certainly age, activity level, relative stiffness of the joint/first ray and typical shoe gear play a role in decision making. I have found that geriatric patients can do well with a McBride bunionectomy if the main goal is to get a shoe on the foot without pain. I personally avoid the Keller bunionectomy with the exception of an arthritic joint in a geriatric patient with a low demand for activity.
When Should You Consider Fusion?
What about the scenario of a jumbo bunion in an active patient? Do not forget about the age-old fusion of the great toe joint. The beauty of the surgery is that you can take the most severe bunion deformity and reduce it so the toe is straight and the bump is gone. It works for rigid joints and extremely flexible joints. I always get nervous with very flexible joints because of the "boing" effect. It may look great on the table but in six weeks, the bunion is back.
When doing a fusion of the great toe joint in the active geriatric patient, a non-union occurs with some fair amount of frequency. Fortunately, most of these patients tend to get an asymptomatic pseudoarthrosis. Even though the X-rays may be ugly, the patient is generally happy.
In a properly positioned great toe joint fusion, patients can continue running and playing sports. With arthroplasty of the great toe joint, there is vulnerability for stress and strain, leading to implant failure or other problems such as lesser metatarsal overload due to first ray instability.
Most of these patients with jumbo bunions already know they have a severe deformity and they are not going to get the “typical” bunionectomy. I feel it is important to impress upon them the severity of their condition, which you can easily illustrate with X-rays of the "normal" foot and X-rays of a "typical" bunion. Now your patients can understand that due to the necessity of an advanced reconstruction technique, they may require a prolonged recovery including six weeks of non-weightbearing. This may be a far cry from the patient's daughter or friend who was back in a sneaker four weeks after surgery.
We learn that we should avoid fusions in the foot for various reasons. Maybe it is rigidity of the foot, development of neighboring joint arthritis or just a stigma that a fusion is a salvage procedure (end of the road technique). When it comes to the great toe joint, I personally do not feel there is much risk of developing arthritis elsewhere like in a hindfoot or ankle joint fusion.
If you think about the common condition of hallux rigidus, how different is that from a fusion of the joint? Generally, the worst "compensation" condition is hallux extensus (interphalangeal joint hyperextension), which tends to be asymptomatic. At least in a fusion, the great toe is in a better position than it is with hallux rigidus. As you know, the toe with hallux rigidus tends to be plantarflexed relative to the first metatarsal (hallux equinus) due to a spasm of the short flexor tendons.
So think of the surgery as removing the bunion and creating a hallux rigidus (without the arthritis pain) in which the toe is in optimum position for walking and running. Now you have created a stable first ray, a reconstruction that will rarely fail due to recurrence of deformity, and the likelihood of developing arthritis in the joint is nil.
Now on the other side of the coin, with the condition of hallux limitus or rigidus, I tend to be more willing to try a cheilectomy or decompression osteotomy than a fusion. The reason is simple. If the joint preservation surgery fails, then you can always do a fusion later. The postoperative course is easier for patients with joint preservation techniques. Return to function is quicker and there are fewer potential complications.
As you know, joint preservation techniques for hallux limitus and rigidus work well. When it comes to jumbo bunions, however, I do not think joint preservation surgeries have the same high rate of success rate as in hallux limitus/rigidus. Otherwise, I would leave the fusion technique for jumbo bunions as my back-up procedure.