Hallux valgus (Bunion)

Name of the operation:
Chevron osteotomy
Scarf osteotomy
Proximal osteotomy
Keller-Brandes procedure

When is the procedure indicated?
Increasing malalignment, pain, formation of pressure points with chronic inflammation, restriction of mobility.

Surgical procedure:
Joint-preserving procedure with osteotomy of the mid-foot bones in combination with correction of the soft tissues.
Joint removal is only used as a last resort to achieve freedom from pain.

Inpatient stay:
On ward: 1-3 days
Time off work: up to 12 weeks

Depending on procedure: forefoot pressure relief orthotic shoe for 4-6 weeks with partial to full weight-bearing on underarm crutches.

Hallux valgus
In the metatarsophalangeal joint of the great toe, the first metatarsal bone is connected to the proximal phalanx of the great toe.
As well as the joint capsule, it is also stabilised with muscles and tendons. The first metatarsophalangeal joint plays a key role in the human gait mechanism. For a normal gait, it is essential that the foot rolls normally via the great toe. Hallux valgus, or ‘bunion’, is an acquired malpositioning of this joint which can be caused by weakening of the arch of the foot and the formation of varying degrees of severity of splayed foot.
The condition is also characterised by a deformity of the great toe in the first metatarsophalangeal joint towards the side of the little toe.
The splaying of the first metatarsal bone looks like a new bone formation on the inside of the great toe and first metatarsophalangeal joint, known as a bunion (pseudoexostosis).

When is surgery indicated?
Surgery is required as soon as the patient becomes unable to bear the pain emanating from the great toe. This can occur very early on in some patients when marked bulging of the shoes is seen on the inside of the foot, the patient experiences pain on pressure or touch on the inside of the great toe or if the patient's weight-bearing when walking is restricted.

How is the procedure carried out?
Among the many and varied procedures used to treat hallux valgus, a distinction is made between joint-preserving procedures and those in which the joint is removed. Malalignment of the proximal phalanx of the great toe also needs to be taken into account. In some cases, a wedge of bone also needs to be removed in order to realign the axis correctly. With full consideration of the cause of the problem, our facility primarily carries out joint-preserving procedures. A number of the surgical options we offer are listed below. Your surgeon will discuss with you which is the most suitable for you.

How long is the inpatient stay?
Patients can generally expect to stay in hospital for 1-3 days. Rarely, if for example severe swelling occurs, a longer stay may be required.

What form will the follow-up take?
After the surgery, the patient is placed in an elastic support dressing that protects the foot for a few days. In most cases, an orthotic shoe that relieves the pressure on the forefoot and a toe spreader can then be fashioned and rolling weight-bearing commenced with walking aids (not suitable for Keller-Brandes procedures with plaster cast treatment for 4-6 weeks). After surgery, the corrected position is checked with X-rays. Until weight-bearing with half the patient's body weight, the daily administration of thrombosis injections will be required.

1. Chevron osteotomy (for slightly enlarged bone angle):
A V-shaped osteotomy is performed at the distal end of the first metatarsal bone, which then causes a shift of the toe towards the little toe. This shift is secured in place with a titanium screw (which does not need to be removed again). An accompanying soft tissue procedure is also regularly carried out to correct the misaligned capsule and muscle arrangements. This creates the desired correction of the great toe.

2. Proximal osteotomy (for an enlarged bone angle):
In this case, a wedge correction is carried out at the joint end of the first metatarsal bone nearest the ankle and secured in place with a small, specially-designed plate. Here too, care is taken to ensure correction of the soft tissues (muscles, tendons and capsule).

3. Scarf osteotomy (for an enlarged bone angle):
This is a procedure in which the first metatarsal bone is displaced along the shaft axis. As with the chevron osteotomy, it is combined with a corrective soft tissue procedure.

4. Keller-Brandes procedure:
The Keller-Brandes procedure is the final surgical option for relieving the pain caused by malalignment of the toe joints. In this procedure, the metatarsophalangeal joint is removed and the residual joint capsule sutured into the gap between the metatarsal bone and the proximal phalanx.