Bunions – Information for GPs
W79 Soft tissue operations on joint of toe
W791 Soft tissue correction of hallux valgus
W792 Excision of bunion NEC
W793 Syndactylisation of lesser toes
W798 Other specified soft tissue operations on joint of toe
W799 Unspecified soft tissue operations on joint of toe
W15 Division of bone of foot
W151 Osteotomy of neck of first metatarsal bone
W152 Osteotomy of base of first metatarsal bone
W153 Osteotomy of first metatarsal bone NEC
W154 Osteotomy of head of metatarsal bone
W155 Osteotomy of midfoot tarsal bone
W156 Cuneiform osteotomy of proximal phalanx with resection of head of
W157 Osteotomy of bone of foot and fixation HFQ
W158 Other specified division of bone of foot
W159 Unspecified division of bone of foot
W59 Fusion of joint of toe
W591 Fusion of first metatarsophalangeal joint and replacement of lesser
W592 Fusion of first metatarsophalangeal joint and excision of lesser
W593 Fusion of first metatarsophalangeal joint NEC
W594 Fusion of interphalangeal joint of great toe
W595 Fusion of interphalangeal joint of toe NEC
W596 Revision of fusion of joint of toe
W598 Other specified fusion of joint of toe
W599 Unspecified fusion of joint of toe
NHS Scarborough and Ryedale and Vale of York CCGs do not routinely commission surgery for asymptomatic hallux valgus (bunion), regardless of cosmetic appearance. Concerns about cosmetic appearance should not be referred to secondary care. These procedures will not be funded.
All patients should be referred to local podiatry services prior to referral to secondary care. (This does not affect the existing diabetic foot pathway)
URGENT referral to Podiatry required if patient has a skin ulcer not healing.
Requests for the removal of symptomatic bunions will ONLY be considered where:
- Appropriate conservative measures have been trialled for 3 months and have failed(2) (these include trying accommodative footwear, considering orthoses as advised by podiatry and using appropriate analgesia). OR
- In the view of the podiatrist, three months of conservative treatment is futile
AND the patient suffers from either
- Pain on walking (not relieved by appropriate analgesia) that causes significant functional impairment OR
- Deformity (with or without lesser toe deformity) that causes significant functional impairment or prevents them from finding adequate footwear OR
- Recurrent or chronic ulceration or infection
The clinician needs to ensure that the patient fulfils all the criteria before they are referred to secondary care.
Before referral patients must be informed that
- They will be unable to drive for 6-8 weeks
- It will take at least a further 2 months to regain full function
- They will be out of sedentary work for up to 6 weeks and out of physical work for up to 3 months
- The prognosis for treated and untreated Hallux Valgus is very variable
- Recurrence of deformity occurs in 8-15% patients
- There is very little good evidence with which to assess the effectiveness of either conservative or operative treatments or the potential benefit of one over the other
Treatment in all other circumstances is not routinely commissioned and should not be referred unless clinical exceptionality is demonstrated and approved by the Individual Funding Request panel prior to referral.
Summary of evidence / rationale
NICE CKS makes clear that referral for bunion surgery is indicated for pain and is not routinely performed for cosmetic purposes.
Conservative treatment may be more appropriate than surgery for some older people, or people with severe neuropathy or other comorbidities affecting their ability to undergo surgery.
Referral for orthopaedic or podiatric surgery consultation may be of benefit if the deformity is painful and worsening; the second toe is involved; the person has difficulty obtaining suitable shoes; or there is significant disruption to lifestyle or activities.
If the person is referred for consideration of surgery, advise that surgery is usually done as a day case. Bunion surgery may help relieve pain and improve the alignment of the toe in most people (85%–90%); but there is no guarantee that the foot will be perfectly straight or pain-free after surgery.
Complications after bunion surgery may include infection, joint stiffness, transfer pain (pain under the ball of the foot), hallux varus (overcorrection), bunion recurrence, damage to the nerves, fractures, metalwork removal and continued long-term pain.
There is very little good evidence with which to assess the effectiveness of either conservative or operative treatments or the potential benefit of one over the other.
Untreated Hallux valgus in patients with diabetes (and other causes of peripheral neuropathy) may lead to ulceration, deep infection and even amputation.