In 1871 Hueter described the bunion deformity and an operative procedure for its correction. l Since that time more than 100 different surgical approaches have been described.2 The literature on bunions is voluminous, and there has been great controversy regarding their etiology, and even greater concerning "conservative" versus "radical" treatment.3'4 We now understand that the etiology is multi-factorial. Heredity, poor shoe wear, a long great toe, neurologic disturbances, etc., are a few of the common etiologic factors.5 Choosing appropriate treatment has become easier in the light of this understanding.
The bunion deformity is generally a combination of two bony angular deformities (Figure I). The great toe is angled laterally (hallux valgus), and the first metatarsal, medially (metatarsus primus varus). These angular displacements, of themselves, are usually not disabling. Symptoms will occur in association with the production of bursitis along the medial border where the shoe may rub. This is a richly innervated area and symptoms may become quite exquisite. A second source of painful symptoms is the metatarsophalangeal-sesamoid joint. As the great toe is displaced into valgus, the extensor and flexor tendons "bowstring" laterally, further increasing the deforming forces (Figure 2). The proximal phalanx and the sesamoid bones begin to sublux laterally. The lack of articular congruity produces degenerative arthritis with resultant degenerative spurring, synovitis and symptoms of pain.
Figure 1. A standing anteroposterior roentgenogram illustrating the common hallux valgus and metatarsus primus varus seen with the adolescent bunion deformity.
Figure 2. Repetitive contraction of the Great toe tendons in association with hallux valgus will cause a "levering effect," producing metatarsus primus varus.'
In the pediatric population patients with bunions generally present in early adolescence. Rarely will one see a child with early deformity before the age of I O. In this adolescent population there is almost always a strong family history for the bunion deformity. The female-tomale ratio in presentation is approximately nine to one. Because the deformity is usually early in presentation, symptoms of painful bursitis or degenerative arthritis have not yet begun. The patient is generally presented by a parent who is afraid "She'll grow up to have ugly feet that look like mine." Occasionally a distraught teenager will present, upset that her feet "don't look like everyone else's."
An understanding of the etiologic factors associated with the production of bunions will assist in diagnosis and treatment. Figure 3 is a compilation of well-documented factors associated with the production of bunions. Adolescent bunions almost always arise due to hereditary or genetic predisposition. The predisposition is probably of variable penetrance, with poor shoe wear (a tight toe box) aggravating the deformity. The preponderance of females with this condition outnumber males nine to one, and this undoubtedly is due both to heredity and to the use of high-heeled shoes or those "stylish" shoes with narrow, pointed toes.
Increasingly, we are becoming aware that the flexible, flat, pronated foot with a long Great toe is predisposed to the bunion deformity. The pronation of the forefoot produces a valgus force across the Great toe, increasing the hallux valgus deformity (Figure 4). This foot is very difficult to treat because ligamentous laxity will predispose to recurrence even after adequate surgical correction.
Figure 3. A compilation of etiological factors seen in association with the production of bunions.5
Figure 4. Two weight- bearing photographs of an adolescent bunion patient. Support under the medial arch reduces the valgus deformity of the Great toe."
Juvenile rheumatoid arthritis and neurogenic imbalance are rarely seen as the cause of bunions in the adolescent population. However, they must be considered in the differential diagnosis. Roentgenograms of the feet should be evaluated to rule out early arthriticj oint changes in addition to measuring the degree of angular deformity. Children under the age of 10 who present with a bunion deformity and alterations in gait must be evaluated to rule out spastic cerebral palsy.
When adolescents present with the cosmetic bunion deformity, it is unlikely that they have been experiencing any real symptoms of pain. It is difficult to recommend surgery in the face of an asymptomatic foot. However heredity plays a strong role in the production of these bunion deformities. It is therefore predictable that the deformity will get worse when this hereditary predisposition has caused such an early presentation even before the patient has a history of wearing poor-fitting shoes. The challenge then is to determine which patients should be observed, which should be treated non-operatively, and lastly, which require surgery.
Clearly, most patients with a bunion deformity do not require surgery. Patients with asymptomatic feet who are seen only for a precautionary check should not have surgery. Patients without deformity who are seen only because there is a strong family history, also need no treatment. Patients who have a mild medial exostosis whose roentgenograms show good articular congruency (joint alignment) need no treatment. Simply put, patients with asymptomatic feet or static deformity do not require treatment.
Patients with painful feet or progressive deformity require treatment. It is important that treatment be directed toward improving appearance and reducing symptoms of pain. The treatment results will not improve function nor will they allow a return to "stylish" shoes.
A small group of patients are eligible for non-operative treatment. Patients with a flexible flat foot and early bunion deformity can benefit from the use of a custommolded medial arch support, avoidance of ill-fittingshoes, and the use of a Great toe spacer between the first and second toe (Dr. Scholl's, Inc.) These patients and families should be aware that treatment is directed not toward improvement but prevention of further deformity.
Some patients present with a long Great toe which extends at least one centimeter past the second. This causes difficulty with shoe wear and early hallux valgus will be seen. The use of open-toed shoes and sandals, and a Great toe spacer, again, can be helpful.
Surgery is undertaken only in the face of severe deformity, progression of deformity, or with symptoms of chronic pain. The patient and the parents must understand the goals and risks of surgery . 6 They must be aware that the patient's feet are not normal, and that correcting the deformity will not remove the predisposition toward that bunion deformity. They must also understand that the surgery will not be done with the goal of allowing the patient to resume wearing high-heeled or pointed-toe shoes. The postoperative patient may still have to wear wider shoes or shoes with a medial arch support. It must be understood that complications can occur in spite of skillfully performed surgery, and that re-operation may be necessary.
Reconstructive bunion surgery is technically quite demanding. It requires precise surgical skill and a knowledge of anatomy, biomechanics, and a variety of surgical options to optimally correct each patient's individual anatomic variations. Patients with bunions need a specialist who has extensive surgical experience and interest in foot disorders. General surgeons and podiatrists with limited surgical ability should not do reconstructive foot surgery. Neither do all orthopedic surgeons have the training to perform skilled foot surgery. Most regions have one or more orthopedic surgeons who have cultivated special interest or ability in foot surgery and most county medical societies know of these individuals. In the interest of advancing the practice of superior foot surgery, a group of orthopedic surgeons have formed the American Orthopaedic Foot Society.*
There are over 100 different operations designed to correct pain and deformity associated with bunions. It is not our intention hereto explore the technique or rationale for this multitude of procedures. In skilled hands operative results can be extremely gratifying (Figure 7). To err, however, is to risk foot function for practically an entire productive lifetime.
1. Hueter C: Klinik der Gelenkkrandheiten ed I, Leipzig, FCW Vogel, 1871, ? 339.
2. Kelikian H: Hallux Valgus, Allied Deformites of the Forefoot and Metatarsalgia. Philadelphia, Saunders, 1965.
3. Bonney G, MacNab 1: Hallux valgus and hallux rigidus: A critical survey of operative results. J Bone Joint Surg 34B:366-373, 1952.
4. Piggott H: The natural history of hallux valgus in adolescence and early adult life. J Bone Joint 5wr«42B:749-755, 1960.
5. Scranton PE. Rutkowski R: Anatomic variations in the first ray: Part 1. Anatomic aspects related to bunion surgery. Clin Orth 151:244-255. 1980.
6. Wagner W: Technique and rationale: Bunion surgery. Orthopaedics 3: 1040/052, 1981.
7. Helal B: Surgery for adolescent hallux valgus. Clin Orth 157:5-63, 1981.
8. Orthopedic Surgery in Infancy and Childhood. 5th ed, Baltimore: Williams and Wilkins Co., 1981.