We've already discussed the
about bunions on a
separate web page. That web page included some information on
conservative, non-surgical treatments, but when those conservative treatments
fail, it may be time to consider surgical intervention. The purpose of
this web page is to discuss some of the basic surgical procedures that exist to
correct painful bunions, if the prospect of surgical intervention is
To start, in order for you to
understand what is presented on this web page, it's important to review our web
bunions are assessed for surgery, as several terms used on this page (like
Intermetatarsal Angle, Hallux Abductus Angle, and PASA) are discussed there in
some depth, and it may be difficult to understand what's discussed here without
understanding those concepts.
When conservative measures
fail and you wish to try surgical options, how do you do the
Many people think that a bunion surgery
consists simply of lopping off the bunion bump. But surgical correction of bunion
deformities can be accomplished in a surprisingly large number of ways. In
fact, there have been more than 150 procedures described to correct a
While no means a comprehensive list of the techniques available to correct
this deformity, we've tried to compile a list of procedures that represent
common examples of procedures that might be chosen in a variety of surgical
order to manage the list of procedures discussed on this web page, we've divided
the procedures into several categories.
The procedures in this category are
chosen when there is an enlarged bony bump around the great toe joint.
These procedures may be chosen alone, although they are done so rarely because
simple bump removal does not address the reason the bump formed in the first
place. Hence, the deformity often tends to return.
procedure involves removal of the enlarge bump on the side of the
foot. As most bunion deformities have an enlarged bump, this is done
as part of most bunion surgeries--but not done frequently by itself, as it
doesn't address the cause of the deformity.
to a Silver procedure, in that it removes the bump on the side of the foot,
but this procedure adds a tendon balancing procedure to help pull the big
toe straight. Not frequently chosen as a procedure these days, as tendon
work is not usually enough to correct most bunion problems.
procedure involves removal of the bony bump on the top of the big toe
joint. (See web page on Hallux
Limitus and Hallux
Rigidus.) Used frequently for cases with mild to moderate
arthritic change in that area, but frequently done in combination with other
procedures, as it doesn't address the cause of the bump on the top of the
A McBride procedure is similar to the
Silver procedure in that it involves removing the bony bump and
performing a soft tissue release to realign the great toe.
This procedure is commonly chose for early bunion development, but
soft tissue procedures do not provide the same sort of correction as
do procedures involving bone cuts (known as
Head Osteotomies The
procedures in this class are all designed such that a bone cut (osteotomy) is
made in the region of the first metatarsal known as the head, which is located
just behind the great toe joint. Most procedures in this class are
designed to address a moderate degree of abnormality in the Intermetatarsal (IM)
angle that accompanies most bunion deformities, the deviated cartilagenous
surface (known as the PASA), or both.
Osteotomies performed in this region of
bone are relatively fast-healing, and many allow for immediate post-operative
(also known as the
Chevron Procedure) One
of the most commonly-performed bunion surgeries performed today, this
procedure involves a V-shaped cut into the side of the metatarsal bone, which allows the head of the
first metatarsal to be shifted over to address an abnormal Intermetatarsal
angle. It may be performed in such a way that allows
corrected as well. If properly stabilized, this procedure allows for immediate post-operative
variation of the Austin procedure, the Kalish involves a V cut with a long arm
of bone on
the top of the bone to better allow for screw fixation, which is more stable than
the K-wire fixation usually used with Austin procedures. The other
advantages are that the long arm also better Intermetatarsal angle
correction and for better correction of an abnormal PASA.
A triangular-shaped piece of bone is removed behind the big toe joint, thereby
allowing for correction of a misaligned cartilagenous joint surface (PASA). A
versatile procedure, the Reverdin has several modifications of this procedure
allow for different effects. For example, to allow the Intermetatarsal angle to be corrected,
there is the Reverdin-Laird.
to allow for the sesamoids and joint to be protected from the bone cut,
there is the Reverdin-Green.
This procedure also allows for screw fixation. To allow the head of the bone
to be raised or lowered, there is the Reverdin-Todd
procedure. Another variation is the
procedure, which is performed in the same area as the standard Reverdin, but
it involves a C-shaped bone cut to rotate the cartilage into
place. One big advantage to this procedure over the traditional
Reverdin is that it does not involve removing a wedge of bone, and so it
does not shorten the bone.
procedure is basically the same as a Reverdin procedure (described below),
except that it is performed somewhat further from the great toe joint.
The advantage of this is that it protects the joint surface and sesamoids
that lie to the bottom of the metatarsal, both of which can be compromised
by a true Reverdin. Modifications to the Reverdin procedure have
addressed these concerns. The disadvantage to this procedure is that
it heals more slowly than the Reverdin.
Z-osteotomy is similar to the Austin procedure, except that a Z-shaped bone
cut is made instead of a V-shaped bone cut. The Z-osteotomy is
designed to correct an
abnormal intermetatarsal angle. The interlocking pieces afford great
post-operative stability, but disadvantages include: more dissection
is required, and more bone must be cut, both of which cause additional
damage to tissues.
shortened version of the original Z-Osteotomy. This procedure is
designed to allow for the additional stability of the Z-osteotomy, but
diminish the amount of dissection required.
Procedure This procedure
is performed by making a vertical cut in the metatarsal head, and the
cartilagenous surface is rotated into realignment. Fairly unstable, this procedure is
less frequently performed than other more-stable procedures.
Procedure Like the DRATO
procedure, the Hohmann procedure is performed by making a vertical cut in
the bone, which allows for correction of a mis-aligned cartilagenous
surface, as well as the correction of an enlarged intermetatarsal
angle. The Hohmann procedure is considered unstable, and for this
reason, other more-stable procedures are used more commonly.
procedure is described in the Head
osteotomies section because much of
the bone cut is performed in the head of the metatarsal. But because
part of the bone cut extends well into the shaft, a Kalish procedure may
also be described as a shaft osteotomy.
Vogler Procedure (Off-Set
V) The bone cut is very
similar to the Kalish procedure, but a Vogler or Off-Set V procedure is performed further back from the great toe joint.
Because the Kalish is performed in a quicker-healing area of bone, the
Vogler procedure is reserved more for patients with contraindications for
making a bone cut in that area.
Ludloff Procedure An
oblique bone cut made diagonally through the first metatarsal. This
for correction of the IM angle and PASA, but it is much more unstable than
procedures with interlocking pieces, such as the Kalish or
oblique osteotomy, this one made in the opposite orientation to the Ludloff.
Same advantages and disadvantages as the Ludloff.
An old-time bunion procedure that used
to be a very commonly performed procedure. The advantage of the procedure is
that it can correct the IM angle, though other procedures can correct the IM
angle to a greater degree. Disadvantages are: No interlocking
pieces like the Austin, Kalish, or Z-osteotomy, so quite unstable compared
to these newer procedures. It's also performed in a relatively
slow-healing portion of bone, and it's more difficult to fixate than other
procedures. Because of its disadvantages, the Mitchell
procedure is rarely performed in the podiatric community any
Procedure Another old-time
procedure designed to correct the IM angle. The Wilson is rarely
performed today because of its instability and tendency towards slow
Closing Base Wedge
Osteotomy (CBWO) or
removing a V-shaped piece of bone at the base of the
first metatarsal. With the V-shaped portion of
bone gone, the metatarsal can be straightened to
correct large IM angles. (See figure to the
right.) The advantage to this procedure is
that it can provide a lot of correction in severe
The disadvantages to this procedure are
that screw fixation is difficult because of the orientation of the bone cut,
making non-weight-bearing mandatory following the procedure. And
this procedure shortens the first metatarsal, which is not always
desirable. In the figure to the right you can see an actual X-ray of a
bunion that was corrected with this technique.
involves the same basic type of cut as the Closing Base Wedge Osteotomy,
except it is performed diagonally across the bone to allow for better screw
fixation. Three versions of this procedure exist--the Juvara A, B, and
C, each with specific indications.
Osteotomy Also known as the Arcuate
Weinstock Procedure, this procedure
involves a C-shaped bone cut made at the base of the first metatarsal.
The advantage over the Closing Base Wedge and Juvara procedures is that
there is comparatively no loss of bone length, as no wedge of bone is
removed. The disadvantage is that the osteotomy is quite unstable. For this reason, this procedure is not done so frequently as
the traditional Closing Base Wedge or Juvara procedures. Modifications
can be made to this osteotomy, however, that improve the stability of this
procedure. When the patient has pathology at each end of the
metatarsal, the Crescentic procedure is frequently coupled with a Reverdin,
Austin or some other head procedure.
Opening Base Wedge
Procedure (Trethoan) The Opening
Wedge Osteotomy involves making a cut in the base of the first metatarsal
and inserting a V-shaped piece of bone on the side of the first metatarsal
to address the Intermetatarsal angle. The advantage of the procedure
is that it doesn't remove bone, indeed, it adds bone. But you need to
use a bone graft for this procedure, and it is very slow
procedure involves making the same V-shaped bone cut as the Austin
procedure, only making the bone cut at the base of the first
metatarsal. Allows more correction than the traditional Austin
Proximal to the First Metatarsal
the fusing of the first metatarsal bone with the midfoot (specifically, the
first cuneiform bone). The idea with this is that the deformity of the
increased intermetatarsal angle is based at this joint, so fusing this joint
will stabilize the bunion. Sometimes the Lapidus is performed with
additional fusions of other joints. A particularly good procedure for very
flexible individuals and for younger patients who are prone to quicker
return of bunion deformities. Drawbacks include its slow-healing
nature, its need to be immobilized and non-weight bearing, and that it
shortens the first metatarsal.
Stamm Procedure (Opening
wedge in first cuneiform) Instead
of removing a piece of bone to allow the intermetatarsal bone to be
corrected, this procedure allows for adding a wedge of bone in the cuneiform
to effect the same purpose. Its drawbacks are that it is even more
slow-healing than a Lapidus, requires a graft, and must be kept non-weight
bearing for a long time while the graft incorporates into the
Joint Salvage Procedures
of procedures is chosen when there is a substantial amount of arthritis in
the big toe joint, but an attempt is made to keep the natural
joint. (If you're interested in this category of procedures, you
may wish to visit our web page for
limitus and hallux rigidus, as well.)
Procedure In cases with severe arthritis,
this procedure can be chosen to permanently bend the bone in the great
toe. In theory, this allows the patient to roll forward off the bent
toe, without causing excessive painful bending the big toe
Waterman Procedure Similar
to the Bonney-Kessel, the Waterman involves a bone cut made in the first
metatarsal instead of the big toe.
details under the heading Bump Removal
Ness Procedure In cases where the first
metatarsal is elevated from the ground (which often causes arthritis in the
big toe joint), it may be dropped with this procedure.
Procedure See details under the
heading Head Osteotomies above.
procedures are performed only when there is a great deal of arthritis in the
big toe joint, and the joint is no longer salvageable. (If you're
interested in this category, you may wish to visit our web page for
limitus and hallux rigidus, as well.)
Metatarsophalangeal Joint Arthrodesis This
involves fusing the big toe joint. Fixes the intermetatarsal angle
well, and resolves joint pain, but slow healing, and results in no toe
motion, something which can be annoying to some people.
of entire metatarsal head. Almost
never performed, except in severe cases of arthritis, trauma, infection, or
other exceptional circumstances. More of a historical
Similar to the Hueter, except that it
removes a smaller portion of the metatarsal head. Again, like the
Hueter procedure, not frequently chosen.
and silicone implants exist and may be implanted in cases of severe
Keller Procedure (First
Metatarsophalangeal Joint Arthroplasty) Involves
removing the base of the big toe. Results in great, pain-free motion,
but the patient loses push-off power of the big toe, and the big toe looks a
little short aesthetically.
resection A modification of the
Keller procedure. Involves taking an angular piece of the top of the
big toe and the first metatarsal to increase range of motion.
Soft Tissue Procedures These
procedures are almost never done by themselves, but are some examples of many
procedures that can be performed along with a primary bunion procedure to
augment the main procedure.
Adductor Transfer This
procedure is designed to address the tendon that pulls the big toe
abnormally towards the second toe (common with bunion deformities).
This tendon is known as the Adductor Hallucis Tendon, and it may be detached
from the great toe (allowing it to better straighten) and reattached to the
sesamoids to straighten them back onto the metatarsal.
Alternative to the Adductor Transfer
procedure, the Adductor Hallucis Tendon can simply be cut from the big toe
bone, without attempting to reattach it to straighten the
a bunion has existed for a long period of time, the covering to the big toe
joint over the bump often becomes stretched. A capsulorraphy procedure
involves taking a wedge of tissue from the stretched capsule to tighten it
When the sesamoids have become scarred
down from being misaligned so long, they can be loosened from their
soft-tissue contracture via a mobilization procedure.
the sesamoid(s) are so diseased to function normally, one--or rarely both--of
the sesamoids may need to be removed.
EHL Tendon Lengthening
The Extensor Hallucis Longus Tendon (a
tendon that pulls your toe upwards) can sometimes be a deforming factor in a
bunion deformity. It may need to be lengthened or altered in one of
several possible ways to address this.
tendons may be transferred in a bunion procedure. We've already
discussed the Adductor Hallucis Tendon above, but the Abductor Hallucis,
Extensor Hallucis or Flexor Hallucis Tendons may also be transferred on
Procedures These procedures are
adjunctive procedures, not frequently done in isolation. These
procedures aim to straighten a big toe when there is a bowing deformity
within the big toe, itself.
Akin Procedure The
best known and most frequently chosen procedure in this group. Several
variations exist: A Proximal
Akin involves removing a wedge of bone
from the base of the first big toe bone, then straightening the toe and
holding the pieces together, usually with a pin or wire. A Distal
Akin is the same procedure performed
farther from the toe joint and closer to the toe nail. The Proximal
and Distal Akin procedures are chosen based on where the abnormal curvature
is centred. An Oblique Akin is
performed with the wedge of bone removed in an angular fashion diagonally
across the first great toe bone. This procedure is usually chosen to
allow for screw insertion. A Cylindrical
Akin shouldn't really be called an
Akin at all, as there is no wedge of bone removed. Rather, this
procedure involves making a curved cut in the base of the first big toe
bone, thereby allowing the rest of the toe to be realigned. The advantage of this procedure is that
there is no bone removed in the procedure, so it shortens the big toe less
than the other Akin procedures above. The disadvantage is that it is
less stable post-operatively, and really needs excellent
Schumacher Procedure This
procedure was devised by Dr. Schumacher to straighten the great toe like an
traditional Akin, but with the advantage of not removing any bone--just as
the Cylindrical Akin does. This procedure allows the correction to be achieved
without shortening the big toe--in fact in can be lengthened slightly.
The advantage over the Cylindrical Akin is that it is more stable
post-operatively. The disadvantage is that somewhat more
soft-tissue dissection is required than with either the traditional Akin or
the Cylindrical Akin.
Regnauld Procedure This
procedure is designed specifically to shorten an excessively long big
toe. Not frequently performed, as there are other, technically easier ways to accomplish
procedure involves performing a Silver procedure (described in the Bump
Removal Procedures section) in
combination with a Lateral Release (described in the Soft
Tissue Procedures section).
procedure is a Closing Base Wedge Osteotomy (CBWO) (described in the Base
Osteotomies section) to close down an enlarged
intermetatarsal angle, coupled with a Reverdin procedure (described in the Head
Osteotomies section) to reorient the
Discussed above in the
Procedures Proximal to the First Metatarsal
section, this procedure is basically an Opening Base Wedge Osteotomy (OBWO), (see
details under the heading Base
Osteotomies) to correct an enlarged
intermetatarsal angle, with a Keller procedure added to remove a severely
arthritic joint (see details under the heading Joint
I've listed 57 procedures
above, but there are actually dozens of
other procedures, especially when you consider all the possibilities just from
combining two or three of these procedures to address multiple abnormalities.
Some of these
combinations are named after people like the two listed above. Others are
simply the original names of the procedures combined with hyphens. For
example, one could choose an Austin-Keller,
a Reverdin with a Medial Capsulorraphy,
and so forth.