Minimally invasive surgery revolutionizes bunion treatment

This piece was originally published in the Medical Professionals Triad Magazine June 2022.

Picture a bunion patient, and you probably think of a woman in her retirement years. But bunions are surprisingly common and can affect patients of all ages, including teenagers who might be born with the condition. Treatments have advanced in recent years to help get patients back on their feet more quickly and pursue all the activities they enjoy, according to Snow Daws, MD, orthopedic surgeon with Novant Health Orthopedics & Sports Medicine in North High Point, and John Marcel, MD, orthopedic surgeon with Novant Health Orthopedics & Sports Medicine in Cotswold.

One minimally invasive surgery requires three or four small incisions, from 1 to 4 millimeters. The surgeon cuts and shifts the bone under X-ray guidance, then inserts screws to hold the bone in place through the incisions. “We can get really wonderful correction through tiny incisions. The patient won’t even be able to see the incisions when it’s all healed,” said Dr. Daws. We can get them into regular shoes faster, with much less swelling and minimal changes in range of motion. Newer techniques have really revolutionized treating bunions.”

There are still many misconceptions among patients, though, who sometimes ask if the painful “growth” on their big toe can’t just be cut off. A bunion is a deformity that develops on the first metatarsal and widens the forefoot. “Your big toe develops the large protrusion at its base on the inside of the foot. That protrusion causes pressure from shoe wear and redness, swelling and pain,” Dr. Marcel explained. Traumatic bunions can also develop after an injury around the big toe joint. Bunions are more common among women. There’s a little more ligamentous laxity in women, Dr. Daws said, giving them a wider range of motion in joints, which can lead to bunions. Bunions can also appear in people with flat feet. Ultimately, genetics is a strong indicator of who is likely to develop a bunion over their lifetime. “Many people are born with them,” Dr. Daws said. “I see tons of kids who have had them their whole life.” Bunions can worsen during times of hormonal change, such as puberty or pregnancy.

The most common group that Dr. Daws sees for bunions is women ages 30 to 45. Dr. Marcel said his typical surgery patients range from their 40s to their 70s. Most bunions are asymptomatic. Surgery isn’t recommended when the concerns are exclusively cosmetic. Nor is it indicated as a preemptive measure. A patient’s worry that her bunion might end up like her mother’s isn’t enough to warrant surgery, in part because it is possible a bunion could eventually return post-surgery. If the bunion isn’t excessively painful, the patient can adapt to it through pads, toe spacers and choice of shoes. Dr. Marcel estimated that about 50% of patients with severe deformities require surgery. For patients with moderate deformities, it’s closer to 20%. Patients who aren’t candidates for minimally invasive surgery have particularly severe bunions or other issues, such as limitations involving the soft tissue. For them, there are well over 100 traditional surgeries for bunions, Dr. Daws said. While techniques differ, they have in common the basic steps of cutting the bone and shifting it to straighten the toe. The surgery is typically outpatient, which means Dr Daws’ patients are able to walk the same day but on their heels, wearing a postoperative surgical shoe. Most patients can wear standard shoes four to six weeks after surgery. There are also two types of fusion surgery for bunions. One fuses the first metatarsal-phalangeal joint. The other fuses the first tarsometatarsal joint in the midfoot. Dr. Marcel reserves fusion surgery only for the most severe cases. It can correct severe bunions but also “eliminates one of the natural motion segments of the foot, and that does affect your biomechanics,” he said, adding that he has shifted to the minimally invasive technique most often.

Both surgeons find immense satisfaction in being able to improve a patient’s quality of life so significantly through surgery. Dr. Daws was drawn to foot and ankle surgery because it would allow her to treat patients of all ages. “I love the immediate gratification of surgery,” she said. “You go in and fix something, and in two hours you’ve taken care of that patient’s problem.”