Bunion and Claw Toe surgery: Step by Step

• By correcting hallux valgus, we solve the problem of claw toes, as well as eliminating bunions... 
• Once the first symptoms of hallux valgus appear, it is very difficult to stop them and prevent the deformity from worsening.
• It is estimated that between 15 and 35 percent of the population suffers from hallux valgus in their feet.

Hallux valgus is the bony deviation that causes the uncomfortable and well-known bunions. It occurs in the first metatarsal of the big toe and is usually caused by a dislocation of the joint.

When hallux valgus develops, a bony lump develops on the side of the big toe. This deviation can eventually become infected due to the friction of this part of the skin with the footwear and the tension to which it is subjected, causing what we know as bunions.

With the deviation of the bone, the big toe starts to bump into the rest of the toes and presses on them, so that both the big toe and the rest of the toes become more and more deviated. This situation causes inflammation, redness and a lot of pain. 

If this deformity is not solved as soon as it is detected, the deviation continues to advance, pressing and affecting the rest of the toes, which can cause the curvature of the rest, which over time will lead to the formation of the so-called hammertoes, mallet toes or claw toes, the latter being the ones we will talk about in this article.

To simplify, we can say that hallux valgus causes bunions, which in turn end up causing deformities in the toes, mainly claw toes.

In this particular pathology, the joint is overloaded by the pressure of the big toe on the other toes, which ends up deforming them and leaving them in a situation of excessive flexion permanently. 

Hallux valgus and claw toe correction are performed in the same surgery. The main difference with conventional hallux valgus surgery is that the duration is longer, as correction of the stiff toes is necessary.

Prior to hallux valgus and claw toe surgery

The medical specialist is responsible for assessing the situation of hallux valgus. The presence of hallux valgus is easy to detect, as a protrusion of the big toe can be seen, but the intensity of the deformity must be assessed in order to know the most appropriate solution.

The first thing to do to know how to intervene will be to carry out a physical examination, paying attention at all times to the mobility of the joint and how affected the rest of the toes are. The doctor must be informed of the patient's usual activities, to find out what may have been the reasons or risk factors that may have led to the onset of hallux valgus.

Once we have reached this point, we must bear in mind that hallux valgus and its symptoms and consequences do not disappear on their own, but rather, if left untreated, worsen over time. The only solution is surgery.

Usually, when the bunions make it difficult for the patient to carry out their daily activities, mainly due to pain, is when the patient starts to think about surgery to solve the situation definitively.

Once the patient has decided to undergo surgery, it is the surgeon who must carry out an assessment of the foot, performing the appropriate tests, including X-rays, to select the most appropriate surgical technique for each case of each specific patient, as there are more than 130 surgical techniques to correct hallux valgus and its consequences.

It is very important to mention that many specialists warn that the laser technique to surgically intervene hallux valgus is not valid, as they state that the laser is useful for interventions in soft areas, not in hard areas such as bones.

When deciding on the type of surgery to be performed, it is very important that the patient keeps the surgeon informed about the medications he or she is taking, his or her daily activities and any other factors that may be relevant to the decision to have surgery.

Hallux valgus and claw toe surgery: step-by-step

Whichever type of surgery is to be performed, hallux valgus must be eliminated by aligning the big toe, the main aim being to completely remove the bunion and its main symptoms and consequences.

For the hallux valgus operation, the surgery is usually performed on an outpatient basis, so the patient does not have to be admitted to hospital and can be discharged the same day as the surgery, provided that no complications have occurred during the operation.

Surgery for hallux valgus repair is usually performed under regional anaesthesia, which only affects the foot to be operated on.

As with any surgical procedure under anaesthesia, the patient will most likely be prohibited from eating and drinking for 12 hours prior to surgery.

This type of surgery usually takes a little over an hour, but the time depends entirely on the surgical technique chosen, the skill of the surgeon and the severity of the deviation. In cases where claw or hammer toes are also corrected, the procedure may take a little longer.

Whichever surgical technique is used, the aim is the same: to put an end to hallux valgus, bunion and any other consequence that causes pain and makes daily life difficult for the patient.

The most common surgical techniques for the correction of hallux valgus and claw toes are percutaneous surgery without osteotomy and hallux valgus surgery with osteotomy.

Percutaneous surgery without osteotomy

Hallux valgus surgery without osteotomy is also known as "percutaneous surgery", and is minimally invasive surgery because the surgeon does not make large incisions to reach the deviation. This type of surgery is recommended for mild to moderate cases of hallux valgus. 

It is important to know that not all patients are suitable for this type of surgery and that each case must be assessed individually by the surgeon, as if the deviation is greater than 30º it is possible that it cannot be carried out using this technique.

The surgeon will first correct the hallux valgus. To do this, through an incision on the inside of the foot, near the bump, he will introduce a surgical tool that will allow him to "file" the bone to reduce the protrusion and return the foot to its normal shape. 

Once the bone area has been filed down, the surgeon will remove the bony debris through the incision and incise the claw toe release.

To correct claw toes, the surgeon must first review the case to determine whether the deformity is rigid or flexible in nature. 

If the deformity is flexible, through a series of incisions on the sole of the foot, the surgeon will make cuts in some tendons and in the joint capsule, releasing the tension in each of the affected toes.

After this, it is very likely that a series of wires will be placed to stabilise this correction and will have to be maintained for part of the recovery.

On the other hand, in the case of a rigid deformity, it may be necessary to make a series of cuts in the bone to correct it.

To avoid aggravation of claw toes, it is important to catch the deviation in time and correct it, since, as we have explained, the surgery becomes a little more delicate.

This operation takes between half an hour and an hour and a half, with recovery varying greatly depending on each case, although it is usually between a month and a half and three months.

After the surgery, the patient's foot is bandaged and the care and instructions to be followed during recovery are explained to the patient to make recovery as simple and quick as possible. 

If there have been no complications, the patient usually leaves the hospital the same day as the operation, usually within a couple of hours of the operation.

Once the patient is at home, they must wear special shoes for the time indicated by the surgeon and come for a check-up a week after the operation.

It is common for the surgeon to recommend the use of a spacer between the thumb and index toe so that the bone is correctly positioned and maintained. In addition, other orthopaedic materials may be necessary in the case of claw toe correction, and this will be indicated by the surgeon.

Both the bandage and the separator are usually worn for approximately one and a half months after the operation, although the specific time should be assessed by each surgeon depending on the situation of the individual patient.

This type of surgery is usually performed when the deviation of the bone is quite severe, usually when it exceeds 30º. 

Claw toes are usually corrected in surgery with osteotomy, as the deviation is greater and claw toes are more common.

It is a relatively simple, outpatient procedure that lasts between half an hour and an hour and a half.

In this type of surgery, the first metatarsal of the big toe (the bone that had shifted) is realigned so that it stays in its original shape.

The first thing that is done is to anaesthetise the patient, then the surgeon makes an incision in the area where the bunion is located and cuts the part of the bone that protrudes outwards.

Once the part of the bone that was causing the bunion has been cut away, several screws are placed in the bones to ensure that they are joined as they should be. In these surgeries, two screws are usually used or, depending on the severity of the hallux valgus, up to 3 or 4 screws accompanied by a plate. This must be determined by the surgeon on a case-by-case basis.

After this process has been carried out, the claw toes are released as previously mentioned in percutaneous surgery.

Once everything is finished, the incisions are sutured and the foot is bandaged.

Between 3 and 6 weeks after the operation, it is estimated that the patient will be able to put support on the foot, although full recovery after surgery does not usually take place until 3 or 4 months after the operation.

Postoperative period for hallux valgus surgery with osteotomy

Once the surgery is completed, the patient's foot is bandaged and recovery instructions are given; after a couple of hours the patient can leave the hospital if there have been no complications.

The doctor will most likely prescribe the use of painkillers and anti-inflammatory drugs to mitigate any pain that may occur in the operated area in the days following the operation.

When the patient is at home, recovering, he/she should follow a series of recommendations to ensure that recovery is as quick as possible, including the following:

• Avoid resting the foot for 3 or 4 weeks after the operation.
• Always wear comfortable footwear at all times during the 3 months after the operation.
• Do not drive for 1 month after the operation.
• Change the bandage as often as the doctors have determined.

The patient's return to work after this type of surgery will depend to a large extent on the nature of his or her profession and the effort and mobility it requires. 

For a job that does not require movement, such as office work, the patient may be able to return to work after approximately 15 days, but for jobs that involve standing or movement, it may take up to 3 months before returning to work.

In hallux valgus surgery, complications are rare and there are very few risks. In turn, the postoperative period is usually normal and uncomplicated.

On rare occasions, it is possible that, after surgery, the operated foot may be misaligned, nerves may be damaged or there may be an infection in the toe bones, although if the entire postoperative period is carried out correctly, this does not usually occur.

Occasionally, there is a possibility that hallux valgus may develop again and it is possible that bunions may recur.

After hallux valgus surgery, no matter what type it is, it is necessary to take a series of precautions to ensure a favourable recovery:

• Do not remove the bandage until the doctor says so and always keep it dry.
• Use crutches or a walker during the first few days to help you walk.
• Do not force the foot by supporting it during the days following the operation.

In any case, the doctor's instructions must always be followed to the letter, as depending on the specific condition of each patient, the doctor may indicate a series of different measures to be taken.

• The wound oozes some kind of discharge that soaks through the bandage.
• The pain does not stop with the medicines recommended by the doctor.
• You have a very high fever or chills.
• There is redness or swelling near the surgical site.
• It is very important to see a doctor whenever you have severe discomfort after surgery or if you suspect that something is wrong.