Get Dr Sean Ng's opinions on your questions! Only approved questions are displayed.
Your bunion looks like it is suitable for keyhole/ percutaneous/ minimally invasive surgery (MIS) correction.
You will still need a proper examination of your foot, and some X-rays. The advantages of keyhole surgery include less pain, less bleeding and risk of infection, and a much more acceptable cosmetic appearance. Hope this answers your question!
Dr Sean Ng
Thank you for your question. From the pictures, your bunions are definitely suitable for minimally invasive (MIS) / keyhole surgical correction.
I would have to examine them more thoroughly and look at the X-rays to be doubly sure. A painful bunion is an indication for surgery, and from your description, it seems that they are bothering you alot.
MIS correction would definitely be useful, and benefits include lesser pain, less risks of infection and bleeding.
They are also cosmetically much more presentable. This procedure is a medical procedure, so it is covered under insurance, and Medisave can be utilised as well.
Dr Sean Ng
Minimally invasive surgery (MIS) for mild to moderate cases of bunions. But it will depend on other factors as well.
There is a higher recurrence rate for severe bunions if MIS correction is done for them. I would need to examine your feet more thoroughly before I can let you know whether the MIS correction can be done.
Looking at the pictures, the left side is more severe than the right side (moderate). So I would say on first glance, MIS can be either right, or be a KIV MIS, or via a mini-open approach.
MIS bunion correction is not suitable for all patients, but it would definitely be something I would offer my patients if they were suitable for it. MIS feet surgery has many other applications, the pathology of the feet / ankles.
Please let me know if there are any other questions and I would be happy to answer them.
Dr. Sean Ng
If MIS surgery is done, the benefits would include less pain, less bleeding and less risk of infection.
The hospital stay is also shorter. It has as good a result as traditional open surgery (published results in international journals just last year).
Pain is definitely less than traditional open surgery, and I have had patients who even do not complain of any pain at all.
Patients would be able to weight bear the same day after surgery, in a special post-operative surgical sandal. So they would be able to ambulate straight away. There is no need for any casting/ plaster of Paris.
Bunion surgery is generally a very safe procedure. Risks will include surgical and anesthetic risks, and usually is between 1-2%.
Short term surgical risks include bleeding, infection, neurovascular damage and very rarely fracture; and anaesthetic risks include heart attacks and strokes/ brain damage. This is however very rare, and usually in the older folks with multiple medical problems.
Long terms potential complications would include recurrence of the bunion (though usually not as severe), and sometimes a reverse bunion (or hallux varus, where the big toe points inwards instead of outwards).
Example of a severe Hallux Valgus with overlapping and underlapping toes:
While I think that this a very subjective question, I believe that you can get an indication of from the doctor's experience and number of cases the he/she has done.
You must also feel comfortable with the surgeon you pick, so that you will trust the decisions he/she makes for you.
Almost every orthopaedic surgeon will know how to do a standard “open” bunion correction. However, the thing that will differentiate a particular surgeon from the rest would be if he/she can suggest (and perform) other ways of surgical correction that might be more suitable for the patient.
Take for example a keyhole / minimally invasive surgery (MIS) for bunion correction. Most patients have mild to moderate bunions, and that is most suitable for MIS corrective surgery. The are more advantages to performing MIS, such as reduced bleeding and risks of infection.
However, a MIS takes highly specialized skills and training, and it is a steep learning curve. There's only a handful of surgeons who are able to perform this type of surgery.
So, before you agree to getting a bunion correction done, it would be useful to seek a second opinion on whether MIS/ keyhole surgery would be a better alternative. And if your foot is suitable, there is absolutely no reason to get the correction done via the open method.
Medisave can be used for a bunion correction, as it is a medical indication. It is not a cosmetic operation. It depends on how much work is needed, whether one foot or both feet are done.
It also depends on whether how many toes in total are done, or whether there are any other adjunct procedures.
Sometimes some patients do require more than just the bunion to be corrected. Government subsidies are only available in a restructured hospital, and the amount of subsidy depends on whether you are a private (class A/ B1) or subsidized patient (class B2/C).
The final amount of Medisave utilization thus varies, but I would definitely say that it can be utilized.
Pre-operative investigations and fitness for surgery are of utmost importance. This is to ensure that the patient is suitable for surgery, and that both the surgeon and the anesthetist are comfortable with proceeding with the surgery.
Investigations would include blood tests, ECG, chest X-ray and any other investigations deemed necessary by the surgeon and/or anaesthetist. If one is planning for surgery, another good tip of course would be to do things to reduce the chances of the bunion getting worse, whilst waiting for the surgery.
This would usually be footwear education - try not to wear too tight or pointy shoes. If heels are necessary, a lower heel would be better than a 5” stiletto.
I would usually advice the patient to start ambulation slowly. Patients are able to weight bear immediately the same day after surgery, but of course there will be some discomfort.
As the pain improves with each passing day, patients will be able to walk more and more surely/ confidently. Always take care of the wound(s), and keep the dressings dry. When taking showers, I usually give my patients a cast protector.
This helps to keep the foot dry while showering. If MIS / keyhole surgery is done for patients, I usually see my patient weekly for follow up.
This is to check on their feet, and it allows me to take care of their wounds and do the necessary dressings to ensure optimal alignment of the big toe.
Bunions are not life and death surgery. It really is a matter of how much discomfort and pain it is causing you, and how much deformity there is.
The deformity can be that of just the big toe, or sometimes it may affect the other toes as the bunion gets progressively worse.
Bunions usually progress with time, and it is a 3D deformity. The big toe usually starts pointing outwards, and this is coupled with a rotational deformity. The big toe will then start squeezing the second toe, and may start to either over-ride (it goes above the second toe), or under-rides (goes below the second toe).
No matter how severe the deformity, bunions can usually be corrected. But the point to note is, a mild to moderate deformity can be corrected via keyhole/ MIS surgery.
A severe deformity has to be done via an open method, and not ameanable to keyhole correction. If other toes start becoming affected, keyhole surgery will not be suitable as well. And it makes surgery longer and more tedious, as I would have to correct the other toes involved as well, in addition to the bunion. This increases surgery time and effort, increases the risks, increases the post-surgical pain and discomfort etc.
For older patients, delaying surgery would also mean increased risks of surgery and anaesthesia, as they are now older and hence, a corresponding increased risk. So looking at the big picture, there is really no reason to delay unnececessarily, if the bunion causes pain and the deformity is starting to progress.
As mentioned above, I personally would think that keyhole/ MIS surgical correction would be the optimal way of correction.
The advantages are plenty, compared to a traditional “open” method. This would include less pain, less risks of infection and bleeding and damage.
And it is cosmetically much more acceptable to the patient. Most patients with bunions are females, and who would not want scars that are much smaller and aesthetically pleasing? The only point to note is whether one’s bunion is suitable for keyhole surgery (mild to moderate bunions).
And if so, only an experienced surgeon who has had plenty of experience in correcting bunions via this technique, should offer this method of correction. Keyhole surgery is always my first option for patients, if I feel their bunions are suitable for such correction.
Open traditional long-scar surgery for bunions, are usually reserved for severe deformities, or if there are any other associated problems in the other toes.
A very recent study was just published last year (2017) in an international orthopaedic journal, which showed that the pain scores of patients who underwent keyhole surgery were significantly less than that of patients who had traditional open surgery. Thus, a keyhole correction is always my top option, if the patient is suitable for that.
Pain is very subjective. On a scale of 1-10, patient A’s pain score of 2 may be patient B’s score of 7. Nonetheless, there are ways to try reduce the discomfort and pain.
Pre-operatively, the surgical technique would be the most important. Why would someone opt for a wound that is 8-10cm long, compared to one which is 1-2cm long?
Example of a open scar:
I would expect more pain from a longer and larger wound. Post-operatively, we would give medication to reduce inflammation and pain, and this helps in pain control and relief.
Generally speaking, the pain from keyhole surgery is less than that of the traditional method. A paper was published last year (2017) in an international orthopaedic journal, which showed that the pain scores of patients who underwent keyhole surgery were significantly less than that of patients who had traditional open surgery.
I have had patients that did not complain of any pain at all after surgery, or at most, a slight discomfort.
Bunion surgery is done via either the traditional open method or a keyhole/ MIS method. It depends on the severity of the bunion, and what technique the surgeon is competent and proficient in.
My first option would always be to offer a keyhole correction for a patient if I feel the bunion is suitable for such correction. The advantages for keyhole surgery are plenty.
Please refer to this post What are the best treatment options for bunion removal in Singapore and How can I find the best doctor for bunion surgery in Singapore to find out more about keyhole correction.
Bunion correction usually gives good results and satisfaction rates. As one of the causes for bunions are usually about 90% genetic, we will always quote a risk of recurrence of about 5-10%.
This does not depend on what technique is done, whether it is open or keyhole. So again, the important point to note is: if the results are the same between an open or keyhole correction, why would one not choose a technique that has less pain, less risks of infection and bleeding, and is cosmetically much more pleasing.
If done properly, a patient would be able to weight bear the same day after surgery.
I give my post-op patients a special post-op surgical shoe, that allows the patient to fully weight bear and walk on, the same day of surgery. This is applicable to both open and keyhole technique correction. Skin stitches are usually removed at about 2 weeks post-op.
Internally, it takes about 3-4 months for the bones and soft tissues to heal. It also takes some time for the post-surgical swelling to come down.
I usually advice my patient to elevate their foot as much as possible. As the foot heals, patients are able to progressively do more things and physical activity. They would be able to walk more and more, and start doing brisk walking and progress on to light jogging and ultimately running and their usual pre-operative activity and sport.
For keyhole surgery, I also usually see my patients weekly after surgery. The post-operative dressing is especially important for keyhole correction, so that we can have optimal alignment and correction of the original deformity.
Here's an example of a MIS pre and post operative picture:
(Left foot) (Right foot)
Bunions get progressively worse with time. They do not reverse, and it really just depends when you want to get them corrected.
An example of a normal toes vs overlapping toes:
It is an anatomical and genetic problem, and they will not be able to reverse and go back to the normal shape. Please read this post (When should I have bunion surgery, and what will happen if my bunions are not removed) to find out more about the problems of delayed treatment.
If a patient is not keen for surgery, or not suitable for surgery (e.g. poor health), an alternative would be to use bunion straps. This is a special velcro strap that attempts to correct the deformity and hold it in place.
However, it usually has to be worn as long as possible (24/7), and it does not reverse the bunion at all. The deformity comes back once the strap is removed.
Hence, it is not a very popular orthotic to use. Some patients also use toe spacers. This is a piece of soft silicone that is placed between the big and second toes, to hold them apart. Again, it is temporary and does not reverse the bunion.
Patients are not able to wear many types of shoes if they choose to use the spacer, as it greatly increases the overall volume of the foot.
90% of bunions are inherently genetic. 10% is due to footwear - tight, pointy shoes. High heels.
So after bunion surgery, we always quote patients a risk of recurrence of 5-10%. Of course surgical technique is important.
What patients can do to reduce the risk of recurrence would be to wear broader/ open-toe shoes, that are not too tight. Wearing lower heels would also be good advice.
Of course sometimes patients have to attend functions where they might have to wear high heels/ stilettos. This is alright, but I generally advice patients to try cut that down as well.
Thanks for your questions. They are all pertinent to bunion correction, and should definitely be on a patient's thought process before going for surgery.
To answer your question, mild to moderate bunions are generally suitable for MIS correction. The orthopaedic surgeon has to examine your feet first - this is to look at the bunions, and as well as if there are any other potential pathology that may have to be corrected. eg. second toe deformities, a tight gastrocnemiuis-Achilles tendon complex etc. A hypermobile bunion may not be suitable for MIS correction as well, and another form of correction may have to be offered.
Next, the X-rays of the feet will have to be looked at, and be assessed, to see if the bunion is suitable for MIS correction.
Fitness for surgery is definitlely important, and most patients have no issue for surgery. Pre-operative investigations may be done as well to assess the fitness and suitability for surgery.
And finally, I think the most important consideration is whether the surgeon is able to provide this corrective procedure of MIS bunion surgery. If the patient is comfortable with the surgeon, and understands the whole MIS procedure, and IF the patient's bunion is suitable for MIS correction, then going ahead to have MIS correction of the deformity will be a good option.
Dr Sean Ng
Thank you for your questions regarding MIS bunion surgery.
In general, patients are able to weight bear the same or following day after surgery. A special post-op hard soled shoe is used, and patients usually are able to weight bear without any issue. Be it conventional open or MIS bunion correction, as the correction is stable, there should be no issue weight bearing.
Of course there will be some aches, but it is generally tolerable with medication, and I usually get the physiotherapist to help the patient out and start learning to walk and weight bearing. They will have another session the following morning after surgery, and should be good to go back home and continue weight bearing.
Hope this answers your questions,
Dr Sean Ng
This procedure was first started in Europe more than 10 years prior, and it is an established procedure for bunion correction.
MIS Bunion correction has been done in Singapore since 2012.
I’ve been doing this procedure for suitable patients since 2012. I have since performed hundreds of cases. It is a steep learning curve, and requires a lot of practice and experience, on suitable patients.
The benefits of MIS correction include less pain, less infection, less bleeding and better cosmesis.
Dr Sean Ng
If your bunion is painful, there are several ways to try reduce the pain.
One way is medication: anti-inflammatories. You can take some to reduce the inflammation and pain. This may not be permanent, and you may have to continue taking it as necessary.
Bunion straps/ spacers are another alternative, to help reduce the degree of deformity and hence reduce the pain.
Finally, if all the above do not work, you may want to consider surgical correction. Different methods of correction are available, depending on the severity of the bunions.
Hope the above helps.
Dr Sean Ng
I am a 34 year old female with Hallux Valgus. I would like to know what type of surgery I would need to correct this painful issue, and what is the healing time for the various surgical treatment options?