PECA BUNION CORRECTION
HALLUX VALGUS SURGERY: PECA (PERCUTANEOUS CHEVRON AIKEN)
Hallux valgus and the bunion
What is it?
The big toe of the foot is called the hallux. If the big toe starts to deviate inward in the direction of the baby toe the condition is called hallux valgus. As the big toe drifts over into valgus, a bump starts to develop on the inside of the big toe over the metatarsal bone. This bone prominence on the inner edge for the metatarsal is referred to as a bunion.
Bunions are commonly hereditary but may also be caused or aggravated by shoe wear. The condition is far more common in women than in men, and rarely occurs in individuals who do not wear shoes. Once a bunion is present the deformity of the hallux valgus worsens slowly over time.
The treatment of a bunion depends entirely on how uncomfortable it is. Since the pain from the bunion is always aggravated by shoe wear, the symptoms will often depend on the type and size of shoes worn. The perception of pain or discomfort however is very varied, hence there are some individuals who have a small bunion, but which is very uncomfortable, since this limits their ability to wear shoes comfortably or exercise. On the other hand, some individuals may have quite significant deformities which they find is an annoyance, but does not limit their activities in anyway.
Realistically, there are only two ways to treat a bunion: either change the size and shape of the shoe, or the size and shape of the foot. Due to the styles of shoes, it is obviously much easier to change the size and shape of the shoe in the male than the female.
Treatment is far easier when the big toe remains flexible. As the toe joints stiffen, then the ability to correct the deformity and keep the big toe flexible is quite limited, and a fusion of the toe needs to be performed.
Once the bunion gets to be irritating or painful interfering with various activities of daily living, and shoe wear is uncomfortable, surgery may be recommended. There are many different surgical procedures that can be performed and the decision to perform one type of surgery or another is based upon the extent and magnitude of the bunion deformity, the presence of arthritis in the big toe joint, and the space between the first and second metatarsal, which is called the intermetatarsal angle (IMA).
An IMA less than 15° falls in the mild-to-moderate range and more than this, severe range.
PECA bunionectomy (keyhole minimally invasive surgery)
This operation is designed to correct the big toe deformity, the bunion, as well as the deviated position of the 1st metatarsal.
3 tiny keyhole incisions are made along the inside of the big toe with one longer incision approximately 1 cm made at the base of the first metatarsal.
An additional keyhole incision is made on the outside of the big toe knuckle to release the lateral capsular structures.
In order to correct the 1st metatarsal, a bone cut (an osteotomy) is made through a keyhole incision.
The type of osteotomy which I use is called a straight cut transverse chevron osteotomy. The bone cut is fixed with 2 screws placed from a separate incision to hold the bone in place. The screws typically stay in forever, unless you are able to feel it, then it can be removed if uncomfortable at a later stage and the bones have all healed.
A second bony cut (Aiken osteotomy) is also performed through another keyhole incision at the base of the proximal phalanx of the big toe in order to achieve final correction of deformity and correct the pull of the flexor tendon on the underside of the big toe.
You should wear a stiff soled shoe for one or two months. As with all types of bunion surgery, you will be able to wear shoes more comfortably. This does not mean however that you will be able to wear narrow tight shoes.
It will take about two months for the bone to heal before you can start to exercise comfortably, and another 6-9 months for all the swelling in the foot to decrease to the point where you are not aware that you have had had a surgery.
An orthotic arch support MAY be important but NOT necessary for your recovery. You will be referred to one of my orthotists following a computer analysis of the pressure of the foot, and a customised orthotic will be made for your foot (not an off-the-shelf product) to be worn whilst recovering from surgery.
Major advantages over open procedures to having a minimally invasive bunion correction:
- Return to walking and NORMAL activities of daily living by about 4-6 weeks, this procedure DOES NOT speed up bone healing which is mandatory 6-8 weeks and hence exercise and high intensity impacts may only begin at this stage.
- Shoe wear from 2 weeks.
- Improved proprioception of the hallux.
- Aesthetically pleasing scars.
- Less wound complications.
- Less swelling.
- Less pain.
- Ability to have both feet surgically corrected at the same time.
General recovery facts
- You can expect mild to moderate pain for the first 3-5 days.
- You are allowed to walk on the foot the day after surgery in the post operative shoe supplied.
- Many patients are however not able to walk on the foot because of pain.
- You may use crutches or a walker if you need support.
- You may drive an automatic car by about 10 days if it is your right foot, and 7 days if your left foot, however this should be if only absolutely necessary.
- You may drive a manual by about 10 days if it is your right foot, and 14 days if it is your left foot, however this should be if only absolutely necessary.
- The foot needs to be bandaged for about 2 weeks.
- You will not be able to get the foot wet while the foot is bandaged.
- You can start light nonimpact exercising under direction at about 6 weeks.
- You will be able to wear a sneaker type shoe at about 2 weeks.
- During recovery do not walk at all without the surgical shoe.
- The foot will remain puffy and swollen for 4-6 weeks and continue improving from 2 months to 9 months.
- At approximately 2-3 months most patients are not aware that they have had any surgery performed.
- Range of motion of the big toe is inevitably stiffer immediately post operatively and with physiotherapy will improve continuously.
Before & After Pics
3 months post op
Specific post-operative recovery
- Foot is wrapped in a below-knee cast from theater.
- Foot wrapped in bulky bandage and surgical shoe.
- Do not remove surgical shoe – even at night.
- Start walking on heel and outside of the foot.
- Ice, elevate, take pain medication as prescribed.
- Expect numbness in foot 12-24 hours then pain.
- Blood drainage through bandage is expected, do not panic unless continuous bleeding occurs.
- Do not change bandage under any circumstances, contact my rooms before any such thoughts cross your mind.
- Ice, elevate the leg, and take pain medication regularly.
- Expect numbness in foot 12 hours.
- Bloody drainage through cast can sometimes be expected.
- Do not change or tamper with the dressing.
- First follow-up in the office, X-rays taken if any incidents have occurred (falls, pain out of proportion, recurrence).
- Wound inspection with dressing Sister.
- Most of the time absorbable sutures are used and do not need to be removed and these will dissolve with time.
- Dressing changed.
- Sneakers with a straight medial border and supportive sole.
- Bunion sleeve/strapping supplied for the next 4-6 weeks.
- Wound therapy commences with micropore and Bactroban dressings for the next 4-6 weeks.
- Second followup at 6 weeks.
- Bunion dressing/Strapping if needed on a weekly basis
- Continued use of flat post operative shoe.
- Physiotherapy commences as this is helpful in decreasing the swelling of the foot and improving range of motion for the next 1-2 months.
- Light nonimpact exercise may commence to pain and swelling.
- Expect swelling in the foot for about 6 to 9 months.
- Third followup in rooms at 12 weeks with weight-bearing control x-ray.
- Impact exercise may commence to pain and swelling.
- Discontinuation of hallux strapping.
- Continued range of motion exercises.
- Six-month followup in consultation with weight-bearing control x-ray.
- Pictures taken for comparison to preoperative state.
- Functional outcome score taken.
- 1-year followup in consultation rooms with weight-bearing control x-ray.
- Pictures and video taken for comparison to preoperative state.
- Functional outcome score taken.
- Patient is usually discharged at this stage.