Bunion surgery straightens the big toe by cutting and realigning the first metatarsal bone. In a randomized trial, 83 percent improved a year after surgery against 46 percent with insoles. This guide covers causes, treatment without surgery, chevron, scarf, Lapidus and minimally invasive surgery, risks, recovery and the stay.
About This Department
Orthopedics
Bunion surgery straightens the big toe by cutting and moving the bone behind it. Insoles ease the pain for a while, and the operation lasts.
In a Finnish trial of 209 patients with a painful bunion, 83 percent felt better a year after surgery, against 46 percent with insoles and 24 percent on a waiting list. Across 229 studies, 10.6 percent of patients were dissatisfied after the operation and 4.9 percent saw the deformity return. Send photos of your feet and a standing X-ray, and our foot and ankle team will tell you which correction fits.
83%
Patients improved a year after surgery, against 24% on a waiting list
23%
Adults with a bunion, rising to 35.7% over 65
10.6%
Dissatisfied after bunion surgery, pooled from 229 studies
A bunion, hallux valgus in medical terms, forms when the first metatarsal bone drifts toward the other foot and the big toe angles toward the little toes. The joint between them pushes out as a bump on the inside of the foot, rubbing on shoes.
What a bunion is
Why it hurts
Shoes press on it.
The bump rubs and swells, the big toe crowds the second toe and can push it into a hammer toe, and weight shifts onto the ball of the foot, which then aches under the second metatarsal head.
One in four adults
Nix and colleagues pooled 76 surveys of nearly 500,000 people. Bunions affected 23 percent of adults aged 18 to 65 and 35.7 percent of those over 65, with women affected far more than men, 30 against 13 percent.
Standing X-rays measure two angles that guide the operation.
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Bunion severity on a standing X-ray
Severity
Big toe angle
Angle between first and second metatarsals
Mild
Under 20 degrees
Under 11 degrees
Moderate
20 to 40 degrees
11 to 16 degrees
Severe
Over 40 degrees
Over 16 degrees
What causes bunions
Family history comes first, and many patients have a mother or grandmother with the same feet. Narrow, pointed shoes and high heels speed it up, and loose ligaments, flat feet and rheumatoid arthritis add to the risk. Shoes alone do not explain it, since bunions also appear in people who rarely wear them.
Treatment without surgery
Wide, soft shoes with a deep toe box, a bunion pad and a custom insole ease the rubbing. None of them straightens the toe, and a Finnish trial measured how far they go.
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Surgery, insoles or waiting, one year, 209 patients
Outcome
Surgery
Insoles
Waiting list
Felt improved at one year
83 percent
46 percent
24 percent
Pain relief at six months
Most
Some
Least
Footwear problems at one year
Fewest
More
Most
Surgical osteotomy is an effective treatment for painful hallux valgus. Orthoses provide short-term symptomatic relief.
Torkki and colleagues, randomized trial, JAMA, 2001
The operations
Shaving off the bump alone fails. The deformity sits in the bones behind it. Every lasting bunion operation cuts the first metatarsal, an osteotomy, and moves it back into line, then releases the tight tissue on the outer side of the big toe joint and trims the bump, so the toe sits straight and the joint lines up again. The bone heals in six weeks. Swelling takes months.
1
Anesthesia
A nerve block at the ankle with sedation or a light general anesthetic, so the foot stays numb for the first night.
2
Releasing the joint
The tight tissue on the outer side of the big toe joint is released.
3
Cutting and shifting the bone
The surgeon cuts the metatarsal and shifts the head toward the second toe, closing the gap between the bones.
4
Fixing
One or two small buried screws hold the bone while it heals over six weeks, and the bump is trimmed.
Chevron osteotomy, a V-shaped cut near the big toe joint, for mild and moderate bunions.
Scarf osteotomy, a long Z-shaped cut along the metatarsal, for moderate and some severe bunions.
Lapidus fusion, joining the base of the first metatarsal to the midfoot, for severe or unstable bunions and loose ligaments.
Akin osteotomy, a small wedge from the toe bone itself, added when the toe still angles after the main correction.
Minimally invasive bunion surgery
What the trials found
Minimally invasive surgery makes the bone cuts with a fine burr through incisions of a few millimeters, guided by X-ray, and fixes them with screws placed through the skin. A meta-analysis of seven controlled studies found the same correction and the same complication rate as open surgery, and an earlier review of nine studies found function scores slightly better after open surgery.
This meta-analysis found that hallux valgus treated with minimally invasive surgery did not result in improved clinical or radiologic outcomes compared with open surgery.
Meta-analysis of 395 feet, 2023
Smaller scars.
Correction on X-ray matching open surgery.
A learning curve.
Swelling and recovery time close to open surgery in the trials, so the smaller incision does not translate into a faster return to normal shoes or to sport, which surprises many patients who choose it for that reason.
Our approach
We choose the technique by the deformity. Mild and moderate bunions suit either approach, and we discuss scar size against the longer track record of open surgery, while severe and unstable bunions need an open scarf or Lapidus correction.
Results and risks
The pooled rates of postoperative patient dissatisfaction and postoperative first metatarsophalangeal pain were 10.6% and 1.5%, respectively.
Review of 229 studies, Journal of Bone and Joint Surgery, 2018
Recurrence and dissatisfaction
The overall rate of recurrent deformity was 4.9%.
Barg and colleagues, systematic review, 2018
Recovery week by week
1
Day of surgery
Home the same day or the next, walking on the heel in a stiff-soled post-operative shoe.
2
Two weeks
Stitches out, a toe spacer and gentle toe exercises.
3
Six weeks
X-ray, then a wide trainer as swelling allows.
4
Three to six months
Most shoes and sport, with swelling settling fully by six to twelve months.
Bunion procedures compared
Angles decide.
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Bunion procedures compared
Procedure
Suits
Weight on the foot
Chevron
Mild to moderate bunions
Heel weight from day one
Scarf
Moderate to severe bunions
Heel weight from day one
Minimally invasive
Mild to moderate bunions
Heel weight from day one
Lapidus fusion
Severe or unstable bunions
Protected for four to six weeks
The stay in Istanbul
Call the team the same day
A wound that reddens, leaks or opens, a temperature of 38 degrees or more, a toe that turns white or blue, or a calf that swells and aches.
Stay five to seven days in Istanbul for the first dressing and wound check before you fly, with the foot raised and an aisle seat. Both feet together suits some patients. One at a time makes the first weeks easier. A companion can sleep in your room, coordinators speaking English, Arabic, French, Russian, Serbian, Romanian and Spanish arrange the hotel and a wheelchair at the airport, and follow-up after you return home runs through them with an X-ray at six weeks reviewed by our surgeon. The cost depends on the technique and on one or both feet, and the estimate after the free review lists it.
The evidence in short
Number of painful days, cosmetic disturbance, and footwear problems were least and functional status and satisfaction with treatment were best in the surgical group.
Finnish randomized trial, JAMA, 2001
Bunion surgery FAQ
Can a bunion be fixed without surgery?
No. Wide shoes, pads and insoles ease the pain, and only an osteotomy straightens the toe.
Is minimally invasive bunion surgery better?
Trials found the same correction and complications as open surgery, with smaller scars. Severe bunions still need an open operation.
Will the bunion come back?
In 4.9 percent across 229 studies. Correcting the angle between the metatarsals fully lowers the risk.
When can I walk after bunion surgery?
The same day, on the heel in a special shoe. Normal wide shoes follow at around six weeks.
Can both feet be done at once?
Yes. Walking is harder in the first two weeks, so many patients choose one foot at a time.
References
Torkki M, Malmivaara A, Seitsalo S, et al. Surgery vs orthosis vs watchful waiting for hallux valgus: a randomized controlled trial. JAMA. 2001;285(19):2474-2480.
Nix S, Smith M, Vicenzino B. Prevalence of hallux valgus in the general population: a systematic review and meta-analysis. Journal of Foot and Ankle Research. 2010;3:21.
Barg A, Harmer JR, Presson AP, et al. Unfavorable outcomes following surgical treatment of hallux valgus deformity: a systematic literature review. Journal of Bone and Joint Surgery (American Volume). 2018;100(18):1563-1573.
Alimy AR, Polzer H, Ocokoljic A, et al. Does minimally invasive surgery provide better clinical or radiographic outcomes than open surgery in the treatment of hallux valgus deformity? A systematic review and meta-analysis. Clinical Orthopaedics and Related Research. 2023;481(6):1143-1155.
Singh MS, Khurana A, Kapoor D, et al. Minimally invasive vs open distal metatarsal osteotomy for hallux valgus: a systematic review and meta-analysis. Journal of Clinical Orthopaedics and Trauma. 2020;11(3):348-356.
Editor's note
Written by the Biruni Hospital medical editorial team. Reviewed by Assoc. Prof. Dr. Necdet DEMİR, Orthopedics and Traumatology.
