What is a bunion?

A bunion is a prominence over the inside part of the foot where the big toe joins the rest of the foot. Pressure on the prominence from shoes causes pain and swelling due to inflammation. The bunion occurs when the foot bone connecting to the big toe (the first metatarsal) moves gradually towards the opposite foot. This is called hallux valgus* deformity. This leads to the big toe being pushed towards the second toe (away from the opposite foot) so that the big toe points away from the other foot.

Other problems can develop with a bunion. For example the second toe may overlap the big toe causing a cross-over toe deformity. With shoe pressure, corns and calluses develop.

What is the cause?

There is no single cause of bunions. It most commonly runs in families but may skip generations. High heel, pointed toe shoes are not the primary cause of the hallux valgus but they do cause it to be painful. Pressure from shoes may cause bunions, corns and calluses to develop where there is hallux valgus deformity.

How are bunions treated?

Before treatment of a painful bunion can begin, medical evaluation is needed. There are a number of other causes of pain in the big toe such as osteoarthritis, rheumatoid arthritis, infection and gout. Circulatory problems not only cause pain, but may also cause serious complications if surgery is attempted. Diabetes and cigarette smoking may diminish healing potential and increase the risk of infection.

Treatment may be surgical or non-surgical. The goal of non-surgical treatment is to relieve pressure on the foot and to prevent pressure sores and foot ulcers. This is accomplished by prescribing accommodative shoes with a wide toe box - sandals or extra depth shoes with soft moulded insoles. It may also be possible to relax the leather on shoes to make room for a bunion.

Surgery can correct painful bunions. The severity of the bunion deformity and the presence of any associated problems (for example painful arthritis) will determine the type of surgery that is recommended. X-rays are necessary to help plan for surgery.

Keyhole Bunion Surgery

Traditional bunion surgery involves a long incision of 5cm on the outer aspect of the big toe and foot. There is also a smaller incision in the region of the first webspace between the big and 2nd toes.

In keyhole surgery there are several incisions of approximately 3mm. Very fine burrs which rotate at high speed are used to make tiny precise bone cuts to allow the surgeon to correct the bunion deformity with minimal damage to the surrounding tissue. This less invasive surgery results in less soft tissue damage during the operation. There is a very low risk of infection and the recovery is expected to be more predictable.

Once the big toe is in the corrected position, screws are implanted to fix the bone in this position. The screws are designed to stay within the bone without causing pain or being palpable.

How long will my hospital stay be?

Patients are admitted to hospital on the day of surgery and meet the anaesthetist prior to surgery. The anaesthetist will discuss the anaesthetic involved. This may take the form of a general anaesthetic with an ankle block. The ankle block is the application of local anaesthetic around the ankle, which may provide pain relief in the foot and ankle for up to 12 hours after the operation.

In general, if a person has surgery on one foot then they stay in hospital for one to two nights and if they have bunion correction on both feet then they would stay in hospital for two to three nights.

What dressing will be used?

Following the operation a bulky dressing is applied around the foot. This should remain in place for approximately 2 weeks. It is important to keep the dressing dry to reduce the risk of post-surgical infection.

Will I experience post-operative pain?

The local anaesthetic block wears off approximately 6 to12 hours after the surgery. Some patients notice an increase in pain at this time, however when pain occurs, tablets generally provide sufficient pain relief. Rest, elevation of the foot/feet and pain medication are all helpful in relieving the pain for the first few days after the surgery.

The pain tends to be worse in the first 3-4 days after surgery. Minimising the time on one’s feet in the first week after leaving hospital helps recovery. Too high an activity level soon after surgery can prolong the recovery time and cause unnecessary setbacks.

Will I require rehabilitation?

The patient may fully weight bear on their feet with the aid of crutches after the surgery. In general, crutches may need to be used for 7-14 days after the surgery. Some patients find that they are comfortable earlier than this and can discard their crutches at that stage.

A postop shoe (a stiff soled sandal) is fitted after the operation. This needs to be worn for 2 weeks after the operation.

Week two to six: you will wear a pair of sneakers. You may wear ordinary shoes at the end of week six after surgery. By six months: you should be able to resume all normal activities without pain or discomfort

When can I return to normal activites?

• Sedentary work: 2-3 weeks depending on transport to work and ability to elevate foot at work.
• Physical work: 2-3 months depending on the nature of work involved.
• Driving: This will vary depending on whether you drive an automatic or manual car and whether the surgery is to the right foot. Surgery to the right foot may mean not being able to drive for 2-6 weeks. If the surgery is to the left foot and the person drives an automatic car then they may be able to return to driving within 2 weeks.
• Exercise: bike after 4 weeks and swim between 4-6 weeks. They may not be able to do running/jumping sports for 3 months.

Hallux Rigidus

Many people develop a stiff big toe with limited movement. This condition is known as hallux rigidus. Arthritis is the most common cause of this condition. This condition causes the big toe joint ot become increasingly painful, stiff and swollen. Patients often notice a painful lump on the top of the big toe joint (sometimes called a dorsal bunion). This can cause pain when wearing shoes.

Surgery for Painful Hallux Rigidus

This type of surgery is known as a cheilectomy. Traditionally it involves an incision of 4cm centred over the big toe joint. The ridge of arthritic bone is removed from the upper surface of the joint with either a saw or chisel. Removal of the painful lump on the top of the big toe joint is aimed at eliminating pain and increase the big toe joint movement.

Keyhole Surgery for the Stiff Big Toe

The surgeon starts by making a 3mm incision on the side of the big toe. The prominent bony ridge is removed by a fine high speed burr under xray guidance. The joint is then meticulously flushed out to remove any bone debris. The incision is taped with a steristrip and does not require stitches.

How long will my hospital stay be?

This procedure is a day surgery operation. Patients are admitted to hospital on the day of surgery and meet the anaesthetist prior to surgery. The anaesthetist will discuss the anaesthetic involved. Local anaesthetic is injected around the surgical site following the operation.

What dressing will I require?

Following the operation a bulky dressing is applied around the foot. This should remain in place for approximately 2 weeks. It is important to keep the dressing dry to reduce the risk of post-surgical infection.

How long will I take to recover?

The patient may walk straight after the operation. Crutches may be required for the first few days after surgery depending on the patient’s comfort.

Patients are able to wear their own shoes after the dressing is removed.

What is an Ankle Sprain?

A twisting injury or going over on the ankle usually results in an inversion of the foot and ankle. This produces a spectrum of injuries to the lateral ankle. These injuries very commonly occur in running sports such as soccer, basketball and netball.

A bad ankle sprain results in tearing or rupture of the lateral ligaments (ATFL and CFL). These ligaments will heal but they heal with the ligaments in a stretched position. This causes the ankle joint to feel sloppy and increases the risk of the patient going over on the ankle in the future. Every time you go over on the ankle the ligaments may stretch a bit more and render the ankle more unstable. There is also a risk of damaging the ankle joint surface every time you go over on the ankle.

What treatment is required for Ankle Sprains?

Most ankle sprains (80%) recover completely with conservative treatment. Active rehabilitation is the mainstay of treatment for chronic ankle instability. This involves physiotherapy that concentrates on soft tissue massage, range of motion exercises, peroneal muscle strengthening and proprioceptive retraining. Bracing may be helpful. However, If you continue to have instability despite a 2-3 month trial of physiotherapy treatment then surgery is indicated.
The patient can usually localize the pain to the front (anterior), back (posterior), inner side (medial) or outer side (lateral) of the ankle. This will determine the type of surgery performed.

Surgery for Anterior Ankle Pain

If the pain is anterior then articular (joint) surface injury and anterior ankle impingement should be considered.

1. Articular Surface Injury
   Articular surface injury may involve cartilage alone (chondral) or cartilage and bone (osteochondral). These patients will usually experience pain with walking, running and jumping activities. The pain is often worse with stairs or uneven ground. There may be start up pain where the patient has pain when he/she starts an activity such as running and the pain eases as the patient continues. With these lesions, the talar dome is more frequently injured than the tibia.
2. Anterior Ankle Impingement
   This procedure is performed when the pain is worse with walking or running up hill, inclines or stairs. Squatting (eg with weight lifting) and landing after a jump (eg gymnastics or acrobatics) may make this pain worse. Sometimes the patient may be able to localize this pain to the inner or outer side of the ankle. There is limited range of ankle motion, particularly in dorsiflexion. Anterior ankle spurs are the most common cause of anterior impingement. The cause of the anterior spurs is unknown and they most likely are the result of repetitive minor injuries. Anterior impingement secondary to spur formation is quite common in athletes especially in soccer, rugby and basketball.

Surgery for Lateral Ankle Pain

Lateral ankle pain may be due to inflammation of the ankle joint from a recent sprain, peroneal tendon tear, peroneal tendon dislocation, or occult fractures.

1. Ankle synovitis
   This can cause anterolateral (front outer side of the ankle) ankle pain located just anterior to the lateral malleolus. The pain is usually worse with activities such as stair walking and running and relieved by rest. There may be associated ankle swelling or loss of joint motion.
2. Peroneal Tendon Tear
   This is commonly associated with lateral ligament instability. The peroneus brevis is more commonly torn than the peroneus longus. The tear is usually located at the level of the tip of the fibula. The person with a peroneal tendon tear does not often present acutely but will present later with persistent lateral ankle pain and swelling along the tendon. The lateral pain is located behind the lateral malleolus. The pain is worse with activity especially on uneven ground.
3. Peroneal Tendon Dislocation
   Skiing is a common cause of this. It may also occur with ankle sprains. It is due to forceful contraction of the peroneal tendons as the skier edges the skis into the snow while making a turn. It may also occur with ankle sprains. The patient will often experience a popping sensation during the accident. The peroneal tendon may remain dislocated or it may reduce and cause repeated dislocation episodes with activities. There is posterolateral ankle pain and swelling behind the lateral malleolus. If there are repeated dislocation episodes then there will be a snapping or popping sensation. The symptoms are worse on uneven ground.
4. Fracture of the Anterior Process of the Calcaneus
   This can occur with a lateral ankle sprain. It is an avulsion fracture of the bifurcate ligament. The patient presents with persistent lateral ankle pain following an ankle sprain. The pain and tenderness is maximal in an area that is about 2 cm anterior and 1 cm inferior to the anterior surface of the lateral malleolus.
5. Fracture of the Lateral Process of the Talus (the snow boarder’s fracture)
   The patient presents with localized pain, swelling and bruising anterior to the lateral malleolus. There is tenderness around the lateral malleolus. Thus this fracture clinically appears like a lateral ankle sprain. This and the fact that the plain radiographs often do not show the fracture or have only subtle changes are the reasons why this fracture is frequently diagnosed late in patients who have had a presumptive diagnosis of an ankle sprain. The symptoms do not resolve with physiotherapy and the patient presents with chronic lateral ankle pain.
6. Fracture of the Tuberosity of the Fifth Metatarsal
   This follows an inversion injury to the ankle. This can be associated with an ankle sprain. This injury represents an avulsion fracture of the base of the fifth metatarsal, which is where the peroneus brevis tendon inserts.

Surgery for Posterior Ankle Pain

Posterior ankle pain may be due to posterior ankle impingement. Posterior ankle impingement may be secondary to repetitive injury. For example it occurs more commonly in ballet dancers who do Pointe work or in mens leading foot of fast bowlers.

Posterior ankle impingement may be due to several causes. The most common cause of painful posterior ankle impingement is due to the presence of an os trigonum. This is the un-united posterolateral tubercle of the talus. Its incidence is about 10% and occurs in both ankles in up to 50% of cases.

They will complain of pain in the area of the posterior heel or deep in the back of the ankle. The pain is aggravated by Pointe work, jumping or running activities or when they stand on the tip of their toes or if they wear high heel shoes.

Ankle Arthroscopy is the technique of choice for treatment of:

• joint surface damage (chondral or osteochondral lesions)
• painful ankle spurs (treatment of footballer’s ankle)
• joint inflammation (synovitis) after an ankle sprain
• loose bodies

What is arthroscopic surgery?

Arthroscopic surgery is sometimes referred to as “keyhole surgery” as it is performed through very small incisions. The major advantages of arthroscopic surgery are that it is associated with a faster recovery due to less pain and earlier mobilisation of the ankle than after conventional open surgery. This is possible due to less damage to the surrounding skin, ligaments and tendons.

This surgery is performed as a day surgery procedure.

There are two types of arthroplasty:

• Subtalar Arthroscopy is most commonly performed for posterior ankle impingement from an os trigonum bone.
• Metatarsophalangeal Joint Arthroscopy is mainly performed on the big toe and second toe. This is the technique of choice for treatment of joint surface damage (chondral or osteochondral lesions) and loose bodies.

How is this arthroscopic surgery performed?

The operation is done through 2 small incisions (portals) approximately 5mm long over the appropriate joint. An arthroscope (telescope to look into the ankle joint) is used. Local anaesthetic is injected into the joint and around the portals. This usually provides good pain relief for up to 12 hours after the operation. Some patients notice an increase in pain after the local anaesthetic wears off, however this is usually relieved by tablets by mouth.

What dressings and physiotherapy will I require?

At the end of surgery, a bulky dressing is applied. This should remain in place for 5 days. During this time the dressing should be kept dry. Physiotherapy exercises commence 1-2 weeks after the operation. A physiotherapy protocol is provided for the patient’s physiotherapist. The patient may weight bear as tolerated after the operation. Crutches are recommended for a few days after the operation until the patient is comfortable walking.

When can I return to work?

Return to work and sport will depend on the type and severity of the joint problem that is being treated and the type of work and sport involved. Dr Lam is able to provide an indication of the expected return to work and sport prior to surgery.

Which patients are candidates for ankle reconstruction surgery?

This surgery is recommended for patients who experience recurrent ankle sprains despite a course of physiotherapy treatment. The aim of surgery is to prevent the development of ankle arthritis and to reduce the risk of developing ankle joint damage as each episode of ankle sprain may lead to ankle joint injury.

Patients with ankle joint problems such as ankle joint surface damage (chondral or osteochondral lesions), synovitis, bony impingement spurs and loose bodies in association with ankle lateral ligament instability may also require an ankle arthroscopy performed at the same time as the lateral ligament reconstruction.

How long will my hospital stay be?

The surgery may be performed as a day surgery procedure. The patient may weight bear as tolerated after the operation. Crutches are recommended for a few days after the operation until the patient is comfortable walking.

How is the surgery performed?

The ankle lateral ligament reconstruction surgery is performed though a small 2cm incision over the tip of the fibula. The ligaments are shortened and reinserted into the fibula with the aid of 2 small bony anchors. The anchors stay in the tip of the fibula permanently unless it causes irritation. Local anaesthetic is injected around the incision site. This usually provides good pain relief for up to 6 hours after the operation. There is some increase in pain after the local anaesthetic wears off at which time tablets by mouth will usually provide sufficient pain relief.

What dressings will be used following surgery?

At the end of surgery, a bulky dressing is applied. An ankle stirrup brace or backslab would also be applied. The bulky dressing should remain in place for at least 2 weeks as this provides cushioning against the pressure of the brace on the wound. During this time the dressing should be kept dry.

What physiotherapy is required?

Formal physiotherapy exercises commence 2 weeks after the operation. A physiotherapy protocol is provided for the patient’s physiotherapist. A short walking boot is used when walking until 6 weeks after the surgery to protect the lateral ligament reconstruction.