OPERATIVE TREATMENT OF BUNIONS
Journal of the American Medical Association
DEFINITION The bunion is a painful bursitis superimposed on a hallux valgus. The degree of hallux valgus is by no means a criterion of the severity of the bunion (Fig. 1) . The Mayo operation for bunion is for the Fig. 1.-Moderate hallux valgus with painful bunion. relief of the painful bursitis and not a cosmetic operation for doing away with the deformity of the hallux valgus, though incidentally the deformity is reduced. For many years the operation1 about to be described has been used in
... has been used in the Mayo Clinic and has given such satisfactory results that I think it wise to further emphasize its usefulness. ANATOMY Briefly we may consider the anatomic findings in this deformity. It is not seen in children who have never worn stiff shoes nor is it noted in individuals who have always gone barefoot. In these normal feet the great toe is in line with or turns slightly inward from the inner border of the foot. It has been stated that in the bunion foot the great toe is the longest, whereas the second toe should be of the same length or even a little longer. While this is not invariably true, still in this type of foot, that is, with the great toe the longest, the deformity is often present. In hallux valgus a line drawn through the anteroposterior axis of the great toe courses anteriorly outward at an angle of 30 degrees or more. The condition has generally been caused by wearing too short a shoe and this information is many times voluntarily given by the patient. The tendon of the extensor proprius hallucis becomes displaced outward and further increases the deformity. The pressure and irritation of the shoe causes more or less of a chafing action on the skin over the prominent inner aspect of the head of the first metatarsal bone. This irritation in many cases causes a distinct hypertrophy of the end of the bone and small bony exostoses occasionally form. Nature comes to the rescue with the formation of a bursa and we then have a bunion. It is only when this bursa becomes inflamed, mechanically or by infections, that tenderness results and surgery is indicated. Many cases go on to sepsis. When this occurs, operation should not be undertaken until the infection has com¬ pletely subsided. Complete rest and alcohol dressings usually promptly clear up the infection. On top of the bursa may come a corn, adding further to the dis¬ tress and inconvenience of the patient. Thus it may be stated that the symptoms depend not on the defor¬ mity but on the inflammatory changes in the bursal sac causing oftentimes continual discomfort and pain. The proximal phalanx of the first toe articulates often only against part of the head of the first metatarsal, the inner portion of the head impinging against the skin of the inner side of the foot. Often in patients in middle life or beyond, rarely in the young, there is an associated arthritis with deposits. These patients do not obtain the great relief accorded the nonarthritic cases. They should not on this account be denied the benefits of the operation, since formation of the newjoint is a great relief. Fig. 2.-a, Removal of head of first metatarsal bone. Bursal flap dis¬ sected free; b, angle at which head of metatarsal is removed, showing short incision at right angles to long incision. The short incision removes the hypertrophy of the bone. All cases of hallux valgus do not cause inconvenience and many cases of moderate bunion had better not be interfered with surgically. Too often the cases are passed over lightly by the surgeon when the complaint is really a serious and disabling one to the patient and demands surgical interference. Bunion has long been looked on as a trifling condition, but to the individual with the pain it is anything but trifling.