Hi, I’m Dr. Ernest Isaacson and you’re about to see a video of an actual Bunionectomy. A Bunionectomy is a procedure that is performed for the correction of a bunion deformity. And a bunion deformity, as you may know, is a bone that protrudes on the side of the big toe joint. In the course of this deformity, the big toe starts to deviate toward the other toes and the metatarsal bone, which is the long bone behind the big toe, deviates away from the other metatarsals. This procedure can be performed as an outpatient procedure when other conservative methods fail. Now, the procedure you’re about to see is somewhat unique in that it uses a medial approach. This means that the incision is placed on the side of the foot. And afterwards, once everything heals, this usually results in a very cosmetic and almost invisible scar so that when a patient looks down at the foot, you almost can’t see that a procedure was performed. In addition, this is what we call a head procedure. That means that the head of the metatarsal bone is moved over, and this usually allows early weight-bearing as well. Now, keep in mind that the procedure you’re about to see is an actual procedure that I performed on one of my patients. As such, you may want to use some discretion in viewing the video.
The first step is to bring the patient into the room. The patient is placed on the operating room table in a supine position on their back. The next step is to apply a tourniquet. A tourniquet is used during the procedure to allow us to work in a dry field so that we will temporarily cut off the blood supply to the foot. This can be done very safely for up to two hours with no patient discomfort afterwards and it allows for us to complete the procedure without having to work within a more bloody field and allows the procedure to be done more efficiently. The next step is to make the skin incision. The skin incision for this procedure is placed along the inside of the foot, right over the big toe joint. This is what’s called a medial incision. The reason for this is two-fold. First, it allows us better exposure to the big toe joint. And second is that it’s a much more cosmetic incision and that it allows, in most cases after the incision heals, for a very cosmetic and very inconspicuous scar. In most cases, patients can’t even tell that there was actually a procedure performed.
The next step is to go through the layers of skin and soft tissue in such a way as what we call anatomic dissection. This allows us to dissect in layers and also to close in layers and to allow for a more anatomic and cosmetic closure. After the big toe joint is exposed and after we see the bone that’s along the side of the big toe joint, a saw is used to remove the extra bone from the bone on the big toe joint. Once this is removed, that bone is passed from the operative field. Next, the foot is turned and we create a V-shaped osteotomy, or bone cut, in the head of the metatarsal. Now, this is what’s traditionally known as an Austin bunionectomy. This is a very stable type of cut. Once the initial bone cut is complete, the head of the metatarsal is shifted over into a more corrected position and this will generally provide most of the correction we need for this bunionectomy procedure, although in some cases, if there are tight tendons around the big toe joints, some of those tendons may be released as well. Once that is completed, the construct is held together with a small bone screw.This is typically a 3 millimeter screw in diameter and anywhere between 14 and 20 millimeters long. This screw can stay in the foot indefinitely. In some rare cases, it does need to be removed. In the vast majority of cases, this screw will remain in the foot forever and does not need to be removed and also does not set off any metal detectors as patients often want to know. Once that step is completed, the remaining shelf of bone that’s along the side of the big toe joint is removed, again with the bone saw, and any rough edges are then smoothed with a power burr which will allow for a more smooth and a more contoured bone surface. The wound is cleaned with saline. Any extra joint capsule along the side of the big toe joint is then removed and is then sutured together in an anatomic position. The inside sutures are deep sutures that are placed inside the joint capsule as well as the tissue underneath the skin, are generally done with dissolving sutures. And these sutures will dissolve within the foot anywhere between a month to six months after the procedure with no residual effects. The last remaining layer of skin is then closed with an absorbable suture which will also dissolve into the skin and then butterfly strips are placed across the area.
You’ve just watched an actual bunionectomy performed by me on one of my patients in an outpatient surgery facility. Now, typically after the procedure, the patient is allowed to go home and walk in a special shoe which they will use for about 2 weeks after which time, patients generally transition into a comfortable shoe which they use for about 4 weeks. At the six week mark, most patients are able to get into their regular shoes and back to most of their regular activities. However, every patient is different and every foot is different. So, it’s important to have your individual foot evaluated and so we can go over the X-rays together and decide which procedure would be best for you.