Hallux Valgus and Lesser toe conditions
Information for patients from the Trauma and Orthopaedics (T&O) Department
You have been given this leaflet because you have a Hallux Valgus or a lesser toe deformity. This information may help you understand your condition and what your treatment options are.
What is Hallux Valgus?
Commonly known as a bunion, it is often mistaken as just a bony prominence on the big toe, but is a complex deformity involving the long bone of the big toe (metatarsal) deviating away from the second toe metatarsal. This causes the soft tissues to work in a different way and results in the end of the big toe turning towards the second toe.
Patients often experience pain when they wear the wrong footwear (usually when the footwear has a narrow toe box). The pain tends to stop when the shoes are removed.
What happens if I ignore the condition?
If you ignore the condition you may develop pain under the balls of your lesser (smaller) toes or pain from deformities caused by the big toe squashing the smaller toes.
What are common lesser toe deformities?
These can be either a hammertoe (flexion of the joint closest to the ball of the foot) or mallet toe (flexion of the joint near the tip of the toe).
If the toe can be straightened this is flexible, if it cannot be straightened then it is a rigid deformity.
Patients with these deformities often develop pain from friction when the top of their toes rub in shoes; this friction often results in a callus (a thickened and hardened part of the skin) forming.
What causes these deformities?
It is not fully understood why these deformities appear. It can be because of your choice of foot wear, genetics / family history, or other foot conditions (such as flat feet or inflammatory joint disease).
Claw lesser toes are often linked with neurological disorders (such as Charcot-Marie-Tooth or Polio) or inflammatory arthropathy (a disease of the joints).
What are the treatments for Hallux Valgus and lesser toe deformities?
Changing foot wear to a soft wider shoe to give your foot space, as well as a smaller heel can be of help.
Over-the-counter bunion pads / sleeves and spacers can be used to help. Use these with caution though, as they can make finding appropriate foot wear more challenging because they widen your foot.
Surgery should only be considered after you have tried the treatments listed above.
What surgical options are available?
Most Hallux Valgus deformities can be managed surgically by breaking the long bone(metatarsal osteotomy) of the big toe and re-positioning this to correct the deformity. This bone shift of the metatarsal is then held by a small screw.
Sometimes a break in the bone (proximal phalanx) further along the big toe (akin osteotomy)is needed to complete the correction, this break is held with a small staple or screw. This procedure can be performed through a small incision (cut) on the side of the foot which cannot be seen from the top and fades with time.
If arthritis is present or the deformity is very severe, then a fusion procedure may be needed to correct the position of your toe. Other procedures may be performed at the same time if you have other lesser toe deformities.
For the lesser toe deformities; if the deformity is flexible and related to an elongated metatarsal, the metatarsal can be broken and shortened (osteotomy), and then held secure with a small screw. If the metatarsal is not elongated, there are some soft tissue releases (tendon lengthening or tenotomy) that can be done to correct the position of your toe.
When the deformity is rigid, the affected joint can be excised (cut out) and the joint fused straight. This is held with either a Kirschner wire (K-wire) that is removed in clinic after five weeks or with an implant that stays within the bone.
You will discuss these procedures with your surgeon before any treatment is decided. Your surgeon will discuss which treatment is more appropriate for your condition. You will have an opportunity to ask any questions or raise any concerns you may have.
Will I have a general anaesthetic?
The surgery is normally carried out under general anaesthesia (you will be asleep).
You will be given instructions at your preassessment appointment about when to stop eating/drinking, what to do with your medications, and where to come on the day of your surgery.
What happens if I ignore my condition?
The reason(s) why you came to the appointment may not get better and sometimes can get worse. It is difficult to predict.
How long will I have to stay in hospital?
Most of these procedures are performed as day surgery. However if you are having a fusion surgery you may be kept in hospital for one night.
You will need someone to drive you home after your surgery and someone must stay with you overnight.
How can I prepare for my surgery?
While you wait for your surgery date, you can start preparing for your operation. Research shows that fitter patients, who are able to improve their health and activity levels before surgery, recover more quickly. Taking an active role in planning and preparing for your operation will help you:
feel in control
leave hospital sooner, and
get back to normal more quickly.
To help with this, you may be contacted by a member of the One You Kent (OYK) team. OYK work in the community, and help patients improve their general health. This includes help and advice on:
Stopping smoking
Losing weight
Getting more exercise
More information can be found on the following web sites.
One You Kent (Kent Community Health)
Fitter Better Sooner Toolkit (Royal College of Anaesthetists)
What happens when I arrive at the hospital?
When you arrive at the hospital you will be seen by the nurses, a physiotherapist, and doctors who will explain your procedure. Please use this time to ask any questions.
You will be asked to change into a hospital gown and stockings.
How will I feel after surgery?
You will be given painkillers to help with any discomfort after your operation. Everyone reacts to the anaesthetic differently. Feeling sick is common and we do our best to avoid this.
What happens after surgery?
Your foot will be in bandaging. You will have a surgical shoe so you can weight-bear whilst protecting your foot, unless you have been told not to by your surgeon.
You will be given crutches for support. Please use these as advised by your doctor.
It is important to elevate (raise) your ankle as much as possible in the first few weeks after your surgery. We recommend you move your ankle as much as possible.
What will happen at my follow-up appointments?
Your bandaging will be removed at your two week appointment and your dressings changed. If you had bunion surgery, at this stage you will be allowed to bend your big toe to help prevent stiffness.
You will need to wear your surgical shoe for weight-bearing for another five to six weeks.
If a wire has been used to hold a lesser toe fusion, this wire will be removed in clinic at your five week appointment. Your skin will need protecting for a further week until the site of the K-wire is fully healed.
If you have had a soft tissue release for lesser toe deformity surgery and no wires have been used to hold your toe in place, you can go back to wearing comfortable shoes if your wound has fully healed at two weeks.
What are the risks?
As with any surgery there are risks, and these will be discussed in more detail when you speak with your surgeon. However, common complications include the following.
You can expect swelling for up to six months, particularly in the evenings.
Stiffness can be expected after fusion surgery. If you have had a non-fusion procedure a physiotherapist can show you stretching exercises that can help you avoid stiffness.
A recurrence of the deformity is rare but can still happen. This may mean you have to have more surgery at a later date.
Overcorrection is also rare but can be significant. If it does happen you may need further surgery.
Infection rates are low, and antibiotics are given before any surgical treatment begins. However, if infection does happen this can cause significant problems. If you get a skin infection, this can be managed with antibiotics. If there is a deep infection, it may be necessary to remove any unhealthy bone, combined with a long course of antibiotics.
Nerve injury can result in numbness or tingling over your toe. If a neuroma (nerve swelling) develops, this can cause pain in your affected toe (particularly after Hallux Valgus surgery).
Non-union (when the bones do not join together successfully) can sometimes happen with osteotomy and fusion surgery. There is increased risk of this happening in smokers and it may result in pain if the metalwork then loosens. If you smoke we recommend that you stop before surgery and do not start again until the fusion has healed or, better still, quit altogether.
Although rare, metalwork can become noticeable through your skin and cause pain from irritation. If this continues the metalwork may need to be removed.
Deep Vein Thrombosis (DVT) / Pulmonary Embolism (PE) is rare with this surgery. However anticoagulation medication is given after surgery to try to prevent clots forming whilst you are not able to move your leg. This is a preventative measure, but a clot can still form despite this.
When can I start my normal activities again?
Returning to impact sports should be possible three to six months after your operation. However brisk walking and low impact sport activities can be started earlier.
When can I drive again?
This is a difficult question to answer. Your healthcare professionals are not able to take responsibility for this. You will need to check with your insurance company as to when they will be willing to insure you to drive again. It is important not to be in a cast or boot when driving, and you must be able to do an emergency stop safely before driving again.
When can I return to work?
This will depend on how much your work needs you to put weight on your affected foot. If your work is sedentary (you mainly sit at a desk) and you can keep your foot elevated, then you can return to work after two weeks. If this is not possible and your job is more active, you should expect to return to work after six to eight weeks.
What if I have any questions or concerns once I return home?
You can contact the team secretary through the hospital switchboard if you have any questions before your surgery (please refer to your appointment letter).
After surgery you can call the team secretary, the ward, or your GP if you have any further concerns or questions. If you are concerned and cannot get in touch with anyone go to your nearest Emergency Department.