Bunions, aka hallux abductovalgus (HAV), are one of the most common surgical procedures podiatrists do. Many of you know what a bunion is, but in case you don't just look at the circled portion in the photo above.
There are many, many different types of bunion procedures. Just glancing over a review book of mine there is over 25 listed. However, most are outdated and hardly ever (if ever) performed. Without a doubt there are 2 surgical treatments of bunions that are the most common: Chevron (aka Austin) bunionectomy and a Lapidus (aka 1st tarsal-metatarsal joint arthrodesis) procedure. My goal is to explain this as simple as I can so you know what each is.
A Chevron bunionectomy is a procedure used for mild to moderate bunions. A “V” shaped cut with a saw is made near the end (distal) of the bone. The bone is then slid over and held in place with 1 or 2 screws. Below is an attempt at explaining the Chevron bunionectomy with the Leaning Tower of Pisa (analogous to a left foot bunion). If you could fix the Tower of Pisa to make it straight, would you start more at the top, middle, or would you start at the base? It’s a similar principle when correcting bunions. Below is an extremely simplistic representation of a Chevron bunionectomy. The point of me doing this is to show you the principle of the Chevron vs the Lapidus.
Notice the I didn’t really correct the root cause of the problem in the photo above. But is it straighter? Yes.
Now onto the Lapidus. The Lapidus procedure is used to correct moderate to severe bunions, however the procedure is done at the base of the bone. Unlike the Chevron which is simply a cutting of the bone and shifting over, the Lapidus is an arthrodesis (fusion) of the base of the 1st metatarsal to the bone before it (the medial navicular bone). Again, below is my representation of the Lapidus procedure using the Leaning Tower of Pisa as an example.
Again, these are gross oversimplifications of the procedure to help you understand. Many will argue that the Lapidus is a superior procedure because it corrects the bunion at the root of the problem, and there is some truth to that. There are pros and cons to each procedure, and I won’t go over each and every single one, so I will briefly discuss the main ones. As for pros, the Lapidus is a heck of a good procedure if done right and the bones fuse together correctly. It can correct moderate bunions as well as large bunions. Long term, I feel the Lapidus is a superior procedure as it does correct the problem at its root so reoccurence is less likely. Cons? Non-union, which basically means the bone doesn’t adequately fuse together. This is a big concern too as incomplete fusion is estimated to be around 10%, which is high. To know all the studies that quote the non-union rate just go to the middle of the article in this link. Also, despite the picture depicting otherwise, the Lapidus is a technically more difficult procedure that is more involved. A chevron, to me atleast, is easier to learn while the Lapidus takes more time to master. All this means is find someone who is comfortable and good at doing the selected procedures (ask!). Below is imaging to compare the hardware between the two. On the right is the Chevron (just pay attention to the bunion repair, not the hammertoe correction and pins) and left is Lapidus.
Now a Chevron is an excellent procedure as well. It’s easy to do, corrects mild to moderate bunions and patients seem happy the majority of the time. One of the biggest cons of this procedures is the reoccurence rate, and this is hit or miss. For some patients this procedure takes care of the problem for life, others the bunion is back in 10 years or so. So keep this in mind.
Well that’s it. The biggest piece of advice is know what you are getting into with bunion surgery and pick a good surgeon. Did you know swelling after bunion surgery may take up to 4-6 months to completely resolve? Despite being told, most patients forget this fact. So ask questions and be prepared. Finding a good surgeon is the most important part. It isn’t as simple as an ingrown toenail where you simply get it removed and your back to full activity the next day. You ask 100 doctors the same question you will get 100 different answers. For instance, some podiatrists say to weight bear immediately after surgery with the Lapidus procedure while others say no way and to keep them off the foot for atleast 6 weeks. Bottom line is find a doctor who is well trained and has tested and tried his method. Talk to friends, co-workers, previous patients, whatever. With that in mind, I’d say withold bunion surgery as long as it’s not too painful. Wear good shoes with a wide toe box and good orthotic. Forget about “bunion splints” and all those gadgets out there claiming to magically cure bunions. If the pain is interfering with your day to day activities, then I say it is likely time for surgery.
Dr. Sean Reyes
24/7 Podiatrist in Las Vegas