Treating Bunions Through Surgery

We've already discussed the basics 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 entertained.  

To start, in order for you to understand what is presented on this web page, it's important to review our web page how 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 procedure?  

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 bunion.    

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 categories. 

In order to manage the list of procedures discussed on this web page, we've divided the procedures into several categories.  

Bump Removal Procedures  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.  

  • Silver  This 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.  

  • Hiss Similar 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.   

  • Cheilectomy  This 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 joint.  

  • McBride 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 osteotomies).   

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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 ambulation.  

  • Austin Procedure (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 PASA to be corrected as well.  If properly stabilized, this procedure allows for immediate post-operative ambulation. 

  • Youngswick Procedure  A modification to the Austin Procedure that allows you to shorten and drop the metatarsal head, in cases where arthritis and limitation of motion is developing at the great toes joint.  

  • Kalish Procedure  A 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.  

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  • Plantar V Procedure  An inverted Kalish procedure--with the long arm directed on the bottom of the foot.   Same advantages as the Kalish, but testing has shown this orientation to be less stable than the original Kalish.  

  • Reverdin Procedure  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 Crescentic Reverdin 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.    

  • Peabody Procedure  This 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 The 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.    

  • Scarf Procedure  A 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.  

  • DRATO 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.  

  • Hohmann 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.  

Shaft Osteotomies 

  • Kalish Procedure  This 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 procedure allows for correction of the IM angle and PASA, but it is much more unstable than procedures with interlocking pieces, such as the Kalish or Z-osteotomy.  

  • Mau Procedure  Another oblique osteotomy, this one made in the opposite orientation to the Ludloff.  Same advantages and disadvantages as the Ludloff.  

  • Mitchell Procedure  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 longer.   

  • Wilson 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 healing.  

Base Osteotomies  

  • Closing Base Wedge Osteotomy (CBWO) or Louisan-Balacescu Procedure involves 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 cases. 

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.    

  • Juvara Procedure  The Juvara 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.  

  • Crescentic Osteotomy  Also known as the Arcuate Osteotomy or 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 healing.  

  • Proximal Chevron  This 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 procedure.  

Procedures Proximal to the First Metatarsal 

  • Lapidus Procedure  Involves 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 bone.    

Joint Salvage Procedures for Arthritis  This class 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 hallux limitus and hallux rigidus, as well.)

  • Bonney-Kessel 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 joint.  

  • Waterman Procedure Similar to the Bonney-Kessel, the Waterman involves a bone cut made in the first metatarsal instead of the big toe.  

  • Cheilectomy  See details under the heading Bump Removal Procedures above.  

  • Van 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.   

  • Youngswick Procedure  See details under the heading Head Osteotomies above.  

Joint Destructive Procedures  These 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 hallux limitus and hallux rigidus, as well.)

  • First 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.  

  • Hueter Procedure   Involves the removal of entire metatarsal head.  Almost never performed, except in severe cases of arthritis, trauma, infection, or other exceptional circumstances.  More of a historical procedure.  

  • Mayo Procedure   Similar to the Hueter, except that it removes a smaller portion of the metatarsal head.  Again, like the Hueter procedure, not frequently chosen.  

  • Implants  Metal and silicone implants exist and may be implanted in cases of severe arthritis. 

  • 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.  

  • Valenti "V" 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.  

  • Lateral release  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 sesamoids.  

  • Capsulorraphy  When 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 up. 

  • Sesamoid mobilization  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.  

  • Sesamoid removal  When 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.  

  • Tendon Transfer  Several 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 occasion.  

Supplementary 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 fixation.  

  • 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 this goal.  

Combination Procedures     

  • McBride Procedure  This 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).

  • Logroscino Procedure This 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 cartilage.   

  • Stamm Procedure  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 Destructive Procedures).

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 Youngswick-Akin, a Reverdin with a Medial Capsulorraphy, and so forth.  





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The Achilles Foot Health Centre
S. A. Schumacher, D.P.M., F.A.C.F.A.S., F.A.C.F.A.O.M.  
Dr. S. A. Schumacher, Podiatric Corporation  

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