Bunion surgery gets an upgrade

Standard bunion surgery can leave you off your feet for weeks. Now, a minimally invasive surgical technique, pioneered by Mediclinic Morningside orthopaedic surgeon Dr Daniel Nunes, promises to change the lives of those affected.

Bunions are painful, unsightly deformities of the foot – and they can affect anyone. Dr Daniel Nunes, an orthopaedic surgeon at Mediclinic Morningside, says the condition is surprisingly common, and if untreated, can lead to a range of side-effects.

“A bunion is a biomechanical fault that is handed down genetically,” he says. “Most patients complain of the pain, and the unsightly lump on their toe, and if you leave it too long, a bunion can leave you with a very broad foot, leading to issues with footwear. This can affect the way you walk, and have a huge effect on your quality of life.” Treatment options for this condition have traditionally been limited to either devices that aim to provide symptom relief or open surgery. A new, minimally invasive procedure, which Dr Nunes is helping to showcase in South Africa, offers a new approach. A bunion develops when the first metatarsal – the main bone of the big toes, which extends up the foot – begins to drift outwards.

This can happen for a variety of reasons, says Dr Nunes. “The tip of the big toe is tethered by a tendon that pulls the toe down. So as the proximal bone drifts outwards and remains tethered, it gives the impression of a bone growing sideways, but the core issue is actually instability of that big toe.” Over time, as this drift worsens, the toe can begin to rub against the inside of shoes and develop calluses as a result.

This also becomes very painful, and without treatment, patients can develop osteoarthritis of the joint. The toe can then dislocate and rotate. Another complication of a bunion, Dr Nunes says, is that is can affect the neighbouring toes. “This can lead to a host of lesser-known deformities, such as crossover toe, an under-riding toe, a claw toe – these will differ from one person to the next, and they bring their own issues, too.” Dr Nunes estimates that as many as 90% of bunion cases are idiopathic, and in most cases, they affect women.

“There is no definite cause,” he says. “No one has isolated a gene, but some research does suggest that you may be more likely to develop a bunion if someone else in your family has one. Trauma and rheumatoid arthritis can also lead to a bunion developing, but in most cases, we simply don’t know the cause.” Dr Nunes says conservative bunion treatment options generally address the symptoms. “There are custom-made footwear options for those with bunions, with broader-than-usual toe boxes. Some off-the-shelf devices, such as toe spacers and silicone covers, that promise to help.” Usually, these products are a new patient’s first port of call, he says, as they promise to address the rubbing effect and the pain associated with a developing bunion. But over time these products become cumbersome and inconvenient, and in most cases, bunion patients resort to surgery.

Open surgery is the standard treatment option to reverse the development of a bunion. Known as a chevron osteotomy, this surgery involves cutting into the bone of the first metatarsal, high up the foot, to realign the head of the toe. “This surgery involves a lot of tissue stripping,” says Dr Nunes. “We have to lift the tissue up and out of the way, realign the bone and rotate the toe properly, and place a small screw into the bone.”

However, most patients who have open surgery report swelling around the scar for months after the operation, even once the stitches have healed, says Dr Nunes. This can lead to complications of its own – the scar can tear, or develop an abscess, or lead to keloids – and the overall effect is a grumpy patient, he says, who regrets having had surgery and will wait months or even up to a year to see the benefits. The minimally invasive approach promises to get bunion surgery patients back on their feet quicker, and with less pain. “This is exactly the same surgical principle, but performed in a very different way,” says Dr Nunes.

“Dr Peter Lam, a foot and ankle surgeon in private practice in Sydney, Australia, developed a soft-tissue burr, similar to a dentist’s drill, which is capable of giving surgeons all the access we need via tiny incisions.” How tiny? Dr Nunes says that while open surgery results in a long series of stitches halfway up the foot, this device requires only a single stitch. “The incisions are about 3 millimetres in length,” he says. “The upshot is that patients are able to fit their feet back into a shoe, walk around, and even drive, two to three weeks after surgery.” After open surgery, by contrast, doctors would not allow their patients to take part in any activity at all until six weeks of bed-ridden recovery.

Dr Nunes is one of only three South African doctors trained in using the burr. He aims to showcase its benefits in his own practice and present them in congresses across SA, in the hope that more doctors will adopt the approach. “For patients, this is the gold standard of bunion surgery,” he says. “It’s a faster procedure, with a lot less pain and swelling. They get back on their feet, and back to their daily lives, a lot quicker.”