Bunion Surgery

Bunion Surgery

Today we’re going to do a modified Wilson
osteotomy for this young lady’s bunion. It’s a pretty bad bunion. You can see when I load
the foot how bad this one is. And we look for flexibility to get a decent result and
the joint is flexible. I can manually adduct the toe and push the metatarsal head in which
is promising for such a bad foot. So, this is what we’re trying to aim for. The anesthesia
is complete. I did an ankle block and I’m just showing my landmarks. Here we can see
the plantar cortex, the dorsal cortex, the dorsal lateral cortex, and I’ve marked off
the extensor tendon and the joint. Here’s a side view, a medial view, and here is the
V that I’m going to make in the first metatarsal neck. And here’s the apex of the V which is
approximately where I’m going to make my incision which is the width of a #15 blade but I’m
gonna just check and make sure we’re frozen. Feel anything over here? No? Excellent. Right to bone. There it is. And there’s our medial incision. And I will introduce a shannon 44
to make the pilot hole or the fail-safe hole. So we’re gonna start the pilot hole or the
fail-safe hole. The patient feels buzzing but no pain, if she feels any pain I will
put more freezing in, or local anesthetic. And there you see we are half way between the dorsal and plantar
cortices according to my lines. Here’s an anterior view and you can see the shannon
is approximately parallel to the supporting surface. It’s okay if it’s plantar flexed
slightly but we don’t want to dorsiflex it. There you see, I’m a little bit proximal because
I want to get extra correction, and this is a dorsal view and right in the neck and we’re
aiming towards the second metatarsal at a right angle to the long axis. Okay, I’m gonna
make my second incision medial and plantar at the neck of the metatarsal close to where
the medial skin meets the plantar skin. Okay, we’ve made our second incision and I’m using a Locke elevator to free up the capsule. It’s really fairly easy to do from that incision.
So the capsule is now freed up. I’m going to begin to remodel the bump with a shannon
44 medium. I start with the shannon to just remove a little bit. And you want to be right
on bone, you should hear that lovely sound that the patients love so much. I’ve created
a little bit of space so now I can introduce a 3mm wedge burr which is, ah, which will
remove the hypertrophic bone a little bit easier. It’s not necessary to remove the entire
bump because when you perform the osteotomy the head is gonna shift laterally and it’s
no longer gonna be sticking out as much. So I’m gonna remove part of it now and then I
will do the osteotomy and then I will remodel whatever is left to be remodeled. As you can
see, we’ve remodeled a significant amount of the bone, but I’ve left part of it. Now,
we’re gonna get as much debris out as possible. It comes out as paste, there’s not a whole
lot here but there’s enough that we wanna clear it out. There’s the paste. Now we’re
going back into the fail-safe hole with a second shannon and I’m gonna perform the dorsal
cut. And you have to remember you’re pivoting from the opening here, so whichever way we
want the tip to go, your hand has to go the opposite way. So if I want the tip to go dorsal
and distally, my hand must move plantarly and proximally. And I’m cutting the lateral
cortex in a dorsal distal direction. Now we’re doing the dorsal cortex. We’re back in and
we’re gonna complete the dorsal cut. I’m now on my third shannon, I’m gonna go back into the fail-safe hole or the pilot hole and I’m gonna cut the plantar part of the V. Now I’m
cutting the lateral cortex in an inferior distal direction and my hand is going in a
superior proximal direction. We’re gonna complete the plantar cut. I’ve cut through the lateral
cortex and now I’m cutting the plantar cortex from lateral to medial. I’ve completed the
V and I’m just gonna confirm that by introducing a Locke elevator and I can feel that it’s
separated. Now I’m going to transpose the head laterally to reduce the IM angle. Now
I’m gonna check. This is a dorsal view and you can see the head has shifted laterally
toward the second metatarsal and it’s looking good. This is a lateral view, the head is
slightly plantar flexed, so when I fixate it I will dorsiflex it slightly, like that.
I’m going to now introduce my .045 K-wire. I’m gonna remove the excessive wire, I’m just
gonna twist it a little bit. Okay, I’ve checked with my XiScan, my fluoroscope, and the positioning
looked good, so I’m gonna put the second K-wire in. Perfect. Now I’m going to remove the excess.
And the fixation is complete. Okay, so we’ve done the Wilson osteotomy, I’ve remodeled
the bump, I will make it a little bit smoother, and I’ve done the K-wire fixation and you
can see the deformity has been reduced but we’re still going to do an adductor release
and an Aiken procedure. We’re going to do an adductor release and a partial lateral
release and I’m just checking with a 7/8″ to make sure we’re at the joint. Feels good.
I’m gonna get rid of the 7/8″ and introduce a #64. And we’re right where we want to be.
I’m at the plantar aspect of the joint, the plantar lateral aspect and I’m adducting the
toe as I do it. And you can feel the celery. And I’m not cutting the entire capsule, just
the plantar lateral capsule where the adductor tendon is. And that feels pretty good. You
can see the toe is a little bit straighter just from that release, and now I’m gonna
do an Aiken osteotomy at the base of the proximal phalanx. I’ll do my proximal phalanx osteotomy,
the so-called Aiken procedure, and I’m gonna make a fail-safe hole just lateral to the
extensor hallucis longus tendon, it’s gonna be right around here. I’m gonna make my opening
with a #64, you can make it slightly longer if you need to. And I’m making my incision
right down to bone, just slightly wider than the width of a #64. I’m going to now do the
fail-safe hole just lateral to the extensor tendon and medial to the lateral cortex. I’ve
checked the positioning with my XiScan and I’m going back in. It’s good, and I’m gonna
complete the osteotomy with a second short shannon. I’m now cutting the plantar cortex
from lateral to medial so my hand is moving in a lateral direction. I’ve cut the lateral cortex and now I’m cutting, I mean, the plantar cortex, now I’m cutting the medial cortex.
I’m gonna try to leave the lateral cortex intact. And that’s approximately what it’s
going to look like, the Aiken is done, the bump is reduced, the osteotomy has been performed.
I’m just going to go back into my plantar incision and make everything nice and smooth.
Now I’m gonna go back through the plantar opening and just make sure the osteotomy site
is nice and flush and there’s no plantar ledge – proximal plantar ledge – to irritate the
patient. That feels pretty good, actually. I like to get rid of as much of the debris
as possible so I’m going to flush with sterile saline. This is the osteotomy site. And I’ll
go back through the plantar incision where I removed the bump. Try not to splash your
cameraman. And I’m going to go back in with a small hand rasp. Make sure there’s nothing
in there that needs to come out. There’s nothing left, then I’m done. We’ve cleaned up the
foot, you finish with your sutures of choice – here I put a horizontal mattress and another
horizontal mattress plantarly – and dorsally, two simple sutures, one here for the Aiken,
and one here for the adductor. So we’re done, this is redundant skin, it will tighten up.
It is not necessary to remove it the way it is – the way you might consider doing it in
conventional surgery so the scars are much smaller. And that’s approximately what we’re
gonna end up with. Okay we’re gonna start with a non-stick dressing. And then some gauze
– a 4×4 over that. Betadine, please. Drip it on
the wire. Over here, the medial incision.
Over here, the inferior medial incision. Okay. And a little bit at the adductor and at the
Aiken. Good. Now I’m gonna put some 3x3s on either side of the wire ends so that the – to
reduce the irritation on them. I’ve put more 3x3s anterior and posterior to the K-wires
to reduce the pressure on them. I’m gonna wrap the foot with some conforming gauze or
whatever you like to use. And I’ll just put a 3×3 around the fifth met head. A little
bit extra. And I will adduct the toe in a slightly overcorrected position. If there
is concern about the head dorsiflexing, you can use a dancer’s pad under the metatarsal
head to relieve some of the plantar pressure that will dorsiflex the head of the metatarsal.
I’m gonna put a few pieces of hypoallergenic tape on the foot to hold everything in place.
It does not have to be tight because we have K-wire fixation. If you don’t have the K-wires,
then you must make it tight. We’ll overcorrect the great toe a little bit. Put some 3″ tape
around it to hold everything in place and make it look nice and neat. And these Band-Aids
are just covering up the areas where I did the ankle block. And there’s your finished
product. Tomorrow will be five weeks since we did the surgery. It’s looking good, and
I’m gonna put one more dressing on. Our patient will take it off at home next week. And she
wants to say a few words. -I’m so excited, my foot looks great, and I can’t wait to get
the next one done. -It is now April 7th, we did this bunion surgery on December 17th,
so it’s less than four months since we did the surgery. And we can see what it looked
like before and what it looks like now. And we can see that the toe is moving well, good
range of motion, and you can see that there was calluses and fissuring where the calluses
were cracking right here and now it’s nice and smooth which is usually the case after
bunion surgery. And you can see how much that bump has been reduced on top, and you can
see that the joint is still moving nicely. I’m very pleased. -Me too!

100 thoughts on “Bunion Surgery

  1. Hello Dr. Nadal, I was just curious if you endorse or recommend toe separators and/or shoes with foot shaped toebox (like the Altra brand) for everyday use.

  2. Is there a chance of recurrance with the minimally invasive surgery? I live in Montréal and my doctor here dont want do to this surgery on me. There are advising me against it. My bunions are smaller than the one on this video. Full time university student, spinning instructor, I need to get back on my feet as soon as possible. Alexandra  (would definitely consider coming to TO for consultation if you think its a good idea)

  3. Very impressive, very pleasing. Like musical rendering from a maestro. You made it seem like child's play – salute to your deep understanding and mastery of the closed procedure.

  4. I am wondering if you can do corrective foot surgery to a foot that has had prior surgery that needs more correction?

  5. If my doctor was like "Do you mind if I videotape your surgery?" I'd be like "As you perform it? Ha . . . ha ha no freaking way!" Let me just carve into your foot, and now you see it is bleeding . . . I am not distracted in any way . . . just explaining the creepy stuff I'm doing to a camera . . . leaving out what could possibly go wrong. Not that's not scary, just terrifying.

  6. I've been avoiding surgery for a very long time and now that the pain is unbearable I was thinking of finally doing it. After watching this I'm not so sure… The recovery time must be brutal!

  7. Having one done next week.  I want that big sucker out and then they'll do the right foot later.  This one is different than another one I seen where they cut and put screws in.

  8. I had to have surgery as my bunion was so acute it had dislocated toe next to it.  It was the best thing have had done.  The pain was minimal. The scar is so very neat and I can now walk normally.  Thanks to a wonderful surgeon.

  9. is it bad to crack my big toe with the bunion I do it almost every minute that I have I also pull it and it pops should I stop or does it help please answer

  10. I'm suppose to have this surgery (or similar) in a couple months. Im 18. I'm also a pre-nursing student. My question is; this seems like such little dressing considering you just preformed surgery. Online I've even seen people wearing casts. I was told I would get a "half cast." Is the patient expected to literally walk out of the hospital after the surgery? The foot would still be numb, correct? Will they be wheeled to their car or given crutches? My doctors said something about being able to walk on the foot? This confuses me. Also, I've only even been out under a general before. When you have "twilight," how aware is the patient?

    Thanks for taping for us and sharing! Much appreciated!

  11. Just open her foot and remove the bone why you do this? she of curse had a lot of pain because of your way 😒

  12. My elementary school teacher had a bunion surgery , she was gone for 2 weeks the rest of 5th grade and returned to teach the final week of school and that was 5 years y. I'm in 9th grade now

  13. I was born with the opposite of club feet. Wore the bar and special shoes and insoles when I was a kid. I'm 20 now and have bunions and super flat feet…special shoes and stuff are expensive so I don't really get them. After watching this…I do not want this and maybe I should look into special stuff for my feet again…

  14. I’m in need of having this surgery as I’m in pain from the arthritis! Can you get all the arthritis out of the toe? I’ve seen more and more people after surgery using a mini scooter type apparatus that you can lay your leg on to get around!

  15. My name is Eva and I’m 11 (I’m turning 12 on April 25) and I had bunions when I was 8 if not earlier and I had one bunion surgery when I was 10 and then another when I was 11 and then they are coming back and the metal pin in my foot you can see it and I’m scared I’m gonna have to get another surgery…

  16. Please everyone get your bunions done as soon as you can!!! Im 26 and i wish i would of gotten them done with i was 18-19 the sonner the better!! I will actually get my other foot done next week i am thinking about making a recovery video!!

  17. Most surgeries Iv seen cut open from the side exposing the entire bone. Iv never seen it done from a tiny incision . It looks a little strange
    And the other toes are separated spaced out. It looks weird still

  18. My bunion disappeared after I regularly (sort of) exercise/ stretching 🙂 After wearing shoes, I tend to stretch my toes.

  19. Did not expect to see a pair of cheap harbor freight wire cutters being used in this procedure.
    Edit: I mean at least buy craftsman, they have a lifetime warranty. Lol

  20. Yes but her 2nd toe is so far away from her big toe now looks kinda crazy I guess she did if the pain purposes not appearance

  21. I have a bunion and seeing this surgery makes me feel weak already. I don't think I can do this, my courage left me :(((

  22. I recently got a bunion after i overextended my toe whilst skating, are people able to do sports again after bunion surgery?

  23. I just don't get it with this new procedure. I had a Bunion surgery 20 years ago, using the open skin procedure, and the recovery is just the same. But with this new procedure seems like more chances for anything to go wrong since there is no view of what's happening inside while performing the surgery, any debris or pieces could be left inside, etc.

  24. Aghhhhhhhh 'the sound the patients love to hear'!!!!! For me, it sounded like the drill at the dentists!!! Worse I have an appointment next Thursday. Think I will forget about my bunions 🙁

  25. This procedure looks cleaner because it doesn't cut open the skin. But is there any portion of the bone removed?
    In the other procedure where the skin is cut open, they show that the bunion bump is removed and the toe bone is cut to be realigned.

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