There are many procedures for hallux valgus and there are varying definitions of what constitutes a successful procedure. Accordingly, this author examines why bunionectomies fail, expounds on pertinent factors that impact healing and reduce recurrence risk, and explains how to advise patients on potential pitfalls of their surgery.
Hallux valgus reportedly occurs in 23 to 35 percent of the shoe-wearing population.1 We know that bunions are more prevalent in shoe wearing populations, older people and in women.1 To that end, bunion surgery is commonplace for the podiatric surgeon. In the literature, more than 100 procedures have been reported in the correction of hallux valgus, which means that there is no “gold standard” surgical approach to the correction of the deformity. Many of those 100 procedures have fallen out of favor. However, many options and their variations are well accepted and surgeons utilize them regularly.
A common question that patients ask me is, “What is the success rate for bunion surgery?” That is a good question that I have trouble answering.
The best I can tell my patients is that it works most of the time. Certainly, there are subjective and objective parameters to consider when deeming a bunion surgery successful. Most of us will opine that the surgeon is much more critical than the patient when determining good results. For the patient, pain must resolve and the appearance should be acceptable. From the surgeon’s perspective, success is based on a combination of appearance, function, range of motion of the great toe joint, and radiographic analysis.
Just like any other surgery, bunion surgery can fail. A list of the more common complications leading to failure include: loss of correction, under- or over-correction, delayed union, malunion or non-union of osteotomy or fusion, joint stiffness, nerve entrapment, and excessive shortening of the first metatarsal leading to lesser metatarsal overload. As we all know, other complications may include hardware failure/irritation, infection, prolonged swelling, deep venous thrombosis and complex regional pain syndrome. Luckily, most of these serious complications are relatively rare.
The most popular techniques that podiatric surgeons employ include distal metatarsal osteotomies, which are popular due to their consistent good results and uncomplicated postoperative protocol. Unfortunately, this type of technique, which we all feel very comfortable and confident with, cannot fix all bunion deformities. If an Austin type bunionectomy can fix 95 percent of bunion deformities, then you will have at least a 5 percent failure rate. This assumes that you have no complications every time you perform an Austin bunionectomy.
Of course, this is all theoretical and the point that I am making is that to be a skilled surgeon, you have to know when you can do your “favorite” procedure and when you need to do something that you are less comfortable performing. Remember the old adage: if all you have is a hammer, then everything is a nail.
Keys To Appropriate Procedure Selection
So how do you choose the appropriate bunion procedure to perform? Is it based on evaluation of the intermetatarsal angle on X-ray? Do you take measurements? Do you use templates? How does the clinical exam play a role in your decision making?