What are the management options for bunions (hallux valgus)?

Bunion Management

Start with conservative management using accommodative footwear and pressure-relieving measures; reserve surgery only for patients with persistent pain despite exhausted conservative treatment, as cosmesis alone is not an indication for operative intervention. 1

Initial Conservative Approach

Conservative management should be the first-line treatment for all symptomatic bunions 1:

• Extra-depth or depth shoes are essential to accommodate the medial prominence of the bunion deformity 2
• Customized pressure-relieving orthoses should be prescribed for patients with increased plantar pressures 2
• NSAIDs have evidence supporting their use for symptomatic relief 1
• Orthotics, splints/braces, and toe spacers have demonstrated efficacy, though long-term relief may be limited 1
• Daily foot inspection and proper skin care with moisturizers for dry, scaly skin 2

Important Caveats for Conservative Care

Patients should avoid self-care of ingrown nails and calluses that may develop secondary to bunion deformities 2. For diabetic patients specifically, bunions represent a significant risk factor for ulceration and potential amputation, requiring heightened vigilance 2.

Surgical Management Indications

Surgery should only be considered when specific criteria are met 1:

• Painful prominence persists despite conservative treatment
• Patient has exhausted all non-operative options
• Patient is a suitable operative candidate
• Recurrent ulcerations not amenable to conservative footwear therapy (particularly in diabetic patients) 2

Surgical Contraindications and Timing

• Cosmesis alone is NOT an indication for operative management 1
• Smoking is a relative contraindication to surgery; cessation is strongly recommended before proceeding 1
• In pediatric or adolescent patients (juvenile bunion), surgery should be delayed until skeletal maturity 1

Special Population Considerations

Diabetic Patients with Bunions

This population requires heightened attention and modified management 2:

• Risk stratification is essential - patients with loss of protective sensation or peripheral arterial disease require more frequent monitoring 2
• Referral to foot care specialists is recommended for moderate to high-risk diabetic patients 2
• Custom-molded shoes may be necessary for extreme bony deformities that cannot be accommodated with commercial therapeutic footwear 2
• Patients with visual difficulties, physical constraints, or cognitive problems may need assistance from family members for proper foot care 2

Referral Algorithm

Refer to an orthopaedic surgeon when 1:

1. Patient has a painful prominence
2. Non-operative treatment has been exhausted
3. Patient is a suitable operative candidate

Surgical reconstruction should be approached by experienced surgeons who understand both the complexities of the deformity and the patient's overall health status 2.

Surgical Approaches

When surgery is indicated, multiple techniques exist including minimally invasive percutaneous methods that have gained popularity with positive outcomes 3. However, the specific surgical technique should be determined by the operating surgeon based on deformity characteristics and patient factors.