Q) I am considering surgery for hallux valgus (bunion), which is increasingly causing me pain. I am told this will involve breaking thetoe and then straightening it, as well as cutting away the bunion itself. Can you tell me what the risks are for this type of surgery, and whether it's effective? Also, are there any alternatives?-D.B., Carlisle
A) Hallux valgus (HV) is a deformity of the foot in which the big toe is deviated towards the other toes. Although the condition is commonly called a 'bunion', this term actually refers to the swell-ing that forms on the side of the joint at the base of the big toe as a result of the deformity.
HV affects 10 women for every man. It may be that genetic and anatomical factors predispose women to the condition, but the main reason is that women are more likely to wear ill-fitting footwear and shoe styles that push the toes into an HV position. High-heel shoes, in particular, place abnormal stress on the bones and muscles of the foot.
Nevertheless, the exact cause of the deformity remains unknown, as it's even been found in non-shoe-wearing populations.
Surgery to correct HV is normally carried out when the deformity makes wearing footwear a problem or when foot function is affected and the joint becomes overly painful. Usually, surgery is only considered after several conservative methods have first been tried, including orthoses (shoe inserts specially designed to alter foot function and press-ure distribution), toe spreaders and night splints.
However, although these 'treatments' may help to relieve some of the symptoms of HV, most foot specialists agree that conservative measures cannot fix the actual HV deformity (MMW Fortschr Med, 2006; 148: 37, 39-40). In fact, a recent review concluded that foot othoses and night splints are no more beneficial in improving outcomes-such as pain and quality of life-than no treatment at all (Cochrane Database Syst Rev, 2004; 1: CD000964). It's easy to see, therefore, why most people with HV consider surgery at some stage.
There are currently more than 130 surgical techniques for the correction of HV. The most simple procedure-called an 'exostectomy' or 'bunionectomy'-is to shave off the bony prominence on the side of the toe. More complex procedures involve removal of a small wedge of bone from the foot (metatarsal osteotomy) or from the toe (phalangeal osteotomy) to 'straighten' the HV deformity. Tendons and ligaments around the big toe may also be surgically corrected.
Studies suggest that surgery is effective at correcting HV and reducing pain. A review of 21 trials found that surgery was better than either conservative treatment or no treatment, although good-quality studies are lacking (Cochrane Database Syst Rev, 2004; 1: CD000964). Indeed, this review found no evidence to suggest that one type of surgical procedure is better than another, although a more recent study concluded that better results are achieved with a chevron osteotomy (a type of metatarsal osteotomy) than with McBride's operation, which involves only the soft tissues (tendons) of the foot. Chevron osteotomy resulted in "high patient satisfaction (95 per cent), good correction and a minimum of complications," said the researchers (Acta Chir Orthop Traumatol Cech, 2007; 74: 105-10).
However, as with all operations, there are risks, including side-effects from the anaesthetic and the possibility of infection. Other complications include delayed healing of the incision, numbness or tingling, haematoma, limitation of joint motion, transfer lesions (areas of corns or callus) and the development of hallux varus, where the big toe points away from the second toe. Also, if the HV is due to deforming forces when weightbearing, then the toe may remain in a bent-back position-the common 'cock-up' deformity. So, there's no guarantee that surgery will cure HV for good; both the deformity and the resulting bunion can recur (Cochrane Database Syst Rev, 2004; 1: CD000964).
Happily, there's a totally non-invasive alternative treatment that's been proven to work. Marigold therapy has been researched and developed over the past 25 years by registered podiatrist and homeopath Dr M. Taufiq Khan. Using Tagetes patula instead of the usual Calendula officinalis, he has developed a range of natural medications for the skin, bones and nails of the lower limbs. For HV and bunions, the treatment involves application of the marigold paste to the bunion, and wearing a protective pad for up to two months.
In an eight-week, randomized, double-blind, placebo-controlled study at the Royal London Homoeopathic Hospital, marigold therapy proved to be safe and effective for all ages, achieving total relief of pain as well as a reduction of swollen soft-tissue density (35 per cent) and HV angle (30 per cent) (Focus Altern Complement Ther, 2001; 6: 83). Another study resulted in similarly impressive results (J Pharm Pharmacol, 1996; 48: 768-70).
For more information on marigold therapy, go to www.marigoldfootcare.com .
Easing the pain
- Cushion the bunion and wear roomy shoes
- Use anti-inflammatory herbs such as chamomile, ginger and Arnica
- Soak the foot in warm water or apply ice
- Try ultrasound therapy (J Manip Physiol Ther, 1991; 14: 527-9)
- Try acupuncture or deep-friction massage.