You've talked to your doctor about having surgery to fix your bunions that have been killing you in all of your shoes. You've tried different shoes, anti-inflammatories, padding, maybe even injections, orthotics and a little physical therapy. You are more than ready to get them fixed! A little apprehension about surgery at this point is very normal. You have talked to your doctor about the risks and possible complications associated with surgery and you have a date picked out. Your biggest question is what to expect after surgery?
All bunion surgeries are not the same; just like every patient is not the same. You may have some medical issues or even social issues that can complicate your postoperative course. Talk to your surgeon about any specific questions that you have, but here are some general guidelines.
I will separate bunionectomies into three basic categories. Ask your surgeon what kind of bunionectomy they are performing to correct your foot.
Austin Bunionectomy
This can also be called a chevron bunionectomy, Kalish bunionectomy or even a modified Scarf bunionectomy. This is the most common type of bunionectomy performed in the United States today. Your surgeon takes the extra bone off from the side of the joint, then makes a cut in the bone to correct the angle causing your bunion; and then fixes the bone cuts with one or two screws. Wires, pins, and absorbable fixation can also be used.
- Dressing: A soft, compression dressing is placed on your foot and usually a short walking removable boot-type cast is placed over the dressing to protect your foot. You should keep this clean and dry until your stitches are taken out. Do not try to change the dressing yourself. If the dressing becomes wet, you should contact your surgeon to have it changed. Dirty, wet dressing can lead to infections!
- Weight-bearing: You may be placed on crutches for up to two weeks after surgery, depending on your particular surgery. Many people are allowed to weight bear on their heel after a few days, but make sure you discuss weight bearing specifics with your surgeon. You are usually in the walking cast for 4 weeks, then progress to a wide sneaker or tennis shoe for 4 more weeks. No running, jumping or playing with the other kids for at least 8 weeks, often 10 weeks.
- Pain management: Narcotic pain medication is often needed for a few days after surgery. This is usually a codeine based narcotic like Norco or Vicoden. For those patients that are allergic to codeine, Tramadol is commonly used. All narcoticscan make you a little sleepy and goofy, or in some cases, actually wired. They mayalso upset your stomach and make you constipated. Your surgeon will usually give you an anti-nausea medication like Phenergan or Zofran just in case the nausea is severe. If you are itching all over, you are having a codeine reaction and should call your doctor. Some patients prefer to try to tough it out and use just Tylenol or Advil. Many do well with Celebrex, which is a non-steroidal anti-inflammatory used for pain control. Keep the narcotics as a back up. Bunion surgery usually hurts for the first 48 hours after surgery then calms down. The worst time is 24-48 hours after surgery when the local anesthesia that was used to numb up your foot completely wears off. Ice and elevation almost constantly are the best way to manage your pain! They also help keep the swelling down that can lead to prolonged swelling, infection, joint stiffness and scarring. Ice is your friend!!
- Post-operative appointments: Every surgeon has their own protocols when it comes to post-operative follow up visits. You should talk to your doctor about their specific protocols. My protocol for an Austin bunionectomy is to see the patient 3 to 4 days after surgery; take an x-ray and change the bandage. I then see them at 12 to 14 days postop to take out their stitches. Their next visit is at 1 month postop; an x-ray is taken to determine if they can progress out of the walking cast and into a sneaker. The last postop visit is at 8 weeks; another x-ray is taken to determine if they can start running, jumping and playing with the other kids. If the patient does not already have custom orthotics pre-operatively, they will be precerted for this appointment so they can be fabricated.
- Realistic Expectations: No, we cannot make your foot perfect. Your bunion took years of wear and tear to form. 80 -90% better after surgery is a home run. Outcomes studies shoe 95-97% of patients have a good to excellent outcome. Stiffness, swelling, scarring and toe drift is normal. Osteoarthritis (wear and tear arthritis) is not alleviated by surgery. We have no way to make cartilage reform after it has been damaged. The best we can do is realign the joint so it is as functional as possible. Bunionectomies are done to alleviate pain, not to make a perfect looking foot. Every patient is different, so talk to your surgeon about realistic expectations. Most patients can get back to an active lifestyle 2-3 months after surgery. Almost no one can get into 4 inch heels after surgery! Shoe gear modification and orthotics are important post-operatively in order to prevent recurrence and progressive arthritic of the joint.
Lapidus Fusion
This can also be called a Lapidus bunionectomy or a First Metatarsal Cuneiform Fusion. This is the most common type of bunionectomy performed in younger patient with severe deformities and hypermobility (super flexible feet). Your surgeon makes a cut in the base of the metatarsal bone (long bone behind the big toe) and removes a wedge of the joint to correct the angle causing your bunion and realign the arch of the foot that is causing your hypermobility; then fixes the bone cuts with some type of compressive fixation. There are so many ways to fixate and stabilize the fusion that your hardware may include screws, plates, staples, wires, pins, and even absorbable fixation can also be used. I've even seen an external fixator used, but this is not common. Your surgeon will choose the best fixation for your fusion during your surgery.
- Dressing: A soft, compression dressing is placed on your foot and usually a short below-knee fiberglass cast is placed over the dressing to protect your foot. You should keep this clan and dry until your stitches are taken out. Do not try to remove the cast yourself. If the cast becomes wet, you should contact your surgeon to have it changed. Dirty, wet casts and dressings can lead to infections!
- Weight-bearing: You may be placed on crutches for up to 6 to 8 weeks after surgery, depending on your particular surgery. Many people are allowed to weight bear on their heel at about 6 weeks, but clarify this with your surgeon. You are usually in the hard cast for 4 to 6 weeks, but maybe up to 8. Then you are in a walking cast for 2 weeks, and progress to a wide sneaker or tennis shoe for 2 to 4 more weeks. No running, jumping or playing with the other kids for at least 10 weeks, often 12 weeks.
- Pain management: Narcotic pain medication is often needed for a few days to a few weeks after surgery. This is usually a codeine based narcotic like Norco or Vicoden. For those patients that are allergic to codeine, Tramadol is commonly used. All narcoticscan make you a little sleepy and goofy, or in some cases, actually wired. Theymay also upset your stomach and make you constipated. Your surgeon will usually give you an anti-nausea medication like Phenergan or Zofran just in case the nausea is severe. If you are itching all over, you are having a codeine reaction and should call your doctor. Some patients prefer to try to tough it out and use just Tylenol or Advil. Many do well with Celebrex, which is a non-steroidal anti-inflammatory used for pain control. Keep the narcotics as a back up. Bunion surgery usually hurts for the first 48 hours after surgery then calms down. The worst time is 24-48 hours after surgery when the local anesthesia that was used to numb up your foot completely wears off. Ice and elevation almost constantly are the best way to manage your pain! They also help keep the swelling down that can lead to prolonged swelling, infection, joint stiffness and scarring. Ice is your friend!! Put the ice behind your knee so it cools the whole leg.
- Post-operative appointments: Every surgeon has their own protocols when it comes to post-operative follow up visits. You should talk to your doctor about their specific protocols. My protocol for a Lapidus bunionectomy is to see the patient 3 to 4 days after surgery; take an x-ray and make sure they are doing OK with their pain management. I then see them at 12 to 14 days postop to change the cast and take out their stitches. Their next visit is at 6 weeks postop; an x-ray is taken to determine if they can progress out of the hard cast to a walking cast. They are again seen at 8 weeks, another x-ray is taken to determine if they can progess to a sneaker. The last postop visit is at 10 to 12 weeks; another x-ray is taken to determine if they can start running, jumping and playing with the other kids. If the patient does not already have custom orthotics pre-operatively, they will be precerted for this appointment so they can be fabricated. Some patients need physical therapy as well, this is determined usually at 8 to 10 weeks post-operatively.
- Realistic Expectations: No, we cannot make your foot perfect. Your bunion took years of wear and tear to form. 80 -90% better after surgery is a home run. Outcomes studies shoe 95-97% of patients have a good to excellent outcome. Stiffness, swelling, scarring and toe drift is normal. Osteoarthritis (wear and tear arthritis) is not alleviated by surgery. We have no way to make cartilage reform after it has been damaged. The best we can do is realign the joint so it is as functional as possible. Bunionectomies are done to alleviate pain, not to make a perfect looking foot. Every patient is different, so talk to your surgeon about realistic expectations. Most patients can get back to an active lifestyle 2-3 months after surgery. Almost no one can get into 4 inch heels after surgery! Shoe gear modification and orthotics are important post-operatively in order to prevent recurrence and progressive arthritic of the joint.
Keller Bunionectomy
This can also be called an "old lady" bunionectomy or an Arthroplasty of the First MPJ. This is the most common type of bunionectomy performed on older patients with severe deformities and less than optimal bone stock. Your surgeon takes the extra bone off from the side of the joint, then makes a cut in the bone removing part of the joint. Then a wedge of soft tissue is placed in between the pieces of bone to alleviate bone on bone contact. The joint is the pinned straight so it will scar in this straightened position. The pin is usually paced so that it is sticking out the end of your toe so that it can be easily removed in 3 to 4 weeks.
- Dressing: A soft, compression dressing is placed on your foot and usually a funny wedge shoe that makes you weight-bear only on your heel is placed over the dressing to protect your foot and keep you from bending your pin. You should keep this clean and dry until your stitches are taken out. Do not try to change the dressing yourself. If the dressing becomes wet, you should contact your surgeon to have it changed. Dirty, wet dressing can lead to infections!
- Weight-bearing: You may be placed on crutches or a walker for up to 2 to 4 weeks after surgery, depending on your particular surgery. Many people are allowed to weight bear on their heel almost right away, but clarify this with your surgeon. You are usually in the wedge shoe for 4 weeks , then progress to a wide sneaker or tennis shoe for 4 more weeks with a soft splint worn at night to splint your toe in the optimal position. No running, jumping or playing with the other kids for at least 8 weeks, often 10 weeks.
- Pain management: Narcotic pain medication is often needed for a few days after surgery. This is usually a codeine based narcotic like Norco or Vicoden. For those patients that are allergic to codeine, Tramadol is commonly used. All narcotics can make you a little sleepy and goofy, or in some cases, actually wired. Theymay also upset your stomach and make you constipated. Your surgeon will usually give you an anti-nausea medication like Phenergan or Zofran just in case the nausea is severe. If you are itching all over, you are having a codeine reaction and should call your doctor. Some patients prefer to try to tough it out and use just Tylenol or Advil. Many do well with Celebrex, which is a non-steroidal anti-inflammatory used for pain control. Keep the narcotics as a back up. Bunion surgery usually hurts for the first 48 hours after surgery then calms down. The worst time is 24-48 hours after surgery when the local anesthesia that was used to numb up your foot completely wears off. Ice and elevation almost constantly are the best way to manage your pain! They also help keep the swelling down that can lead to prolonged swelling, infection, joint stiffness and scarring. Ice is your friend!!
- Post-operative appointments: Every surgeon has their own protocols when it comes to post-operative follow up visits. You should talk to your doctor about their specific protocols. My protocol for a Keller bunionectomy is to see the patient 3 to 4 days after surgery; take an x-ray and change the bandage. I then see them at 12 to 14 days postop to take out their stitches. Their next visit is at 1 month postop; an x-ray is taken to determine if the pin can be removed; and if they can progress out of the wedge shoe and into a sneaker. They are also given a soft night splint when the pin is removed. The last postop visit is at 8 weeks; another x-ray is taken to determine if they can start running, jumping and playing with the other kids. If the patient does not already have custom orthotics pre-operatively, they will be precerted for this appointment so they can be fabricated.
- Realistic Expectations: No, we cannot make your foot perfect. Your bunion took years of wear and tear to form. 80 -90% better after surgery is a home run. Outcomes studies shoe 95-97% of patients have a good to excellent outcome. Stiffness, swelling, scarring and toe drift is normal. Osteoarthritis (wear and tear arthritis) is not alleviated by surgery. We have no way to make cartilage reform after it has been damaged. The best we can do is realign the joint so it is as functional as possible. Bunionectomies are done to alleviate pain, not to make a perfect looking foot. Keller bunionectomies are performed to make your foot fit in a normal shoe. Every patient is different, so talk to your surgeon about realistic expectations. Most patients can get back to an active lifestyle 2-3 months after surgery. Almost no one can get into 4 inch heels after surgery! Shoe gear modification and orthotics are important post-operatively in order to prevent recurrence and progressive arthritic of the joint.
That is the skinny on what to expect after a bunionectomy. Make a list and ask your surgeon about the specifics of your post-operative course. A well-informed patient is usually a compliant patient.
