Planning before the day
The operation begins well before the incision. The surgeon reviews the symptoms, examination, weight-bearing X-rays, medical history, medications, allergies and relevant investigations. The proposed correction, possibility of additional procedures, expected weight-bearing status and recovery restrictions should be discussed in advance. Patients are also given instructions about fasting, medication adjustments, transport and postoperative support according to the hospital and anaesthetic plan.
Anaesthesia
Bunion surgery may be performed under general anaesthesia, sedation with regional or local anaesthesia, or another combination selected with the anaesthetist. A local or regional block is often used to reduce pain during the early postoperative period even when general anaesthesia is chosen. The exact approach depends on patient health, preference, procedure duration, facility and anaesthetic assessment. No anaesthetic is risk free, so its benefits and risks are discussed separately by the anaesthetic team.
Positioning and surgical preparation
The patient is positioned so the foot can be accessed safely. The skin is cleaned with antiseptic solution and sterile drapes are applied. A tourniquet may be used to reduce bleeding and improve visualisation, although practice varies. The surgical team confirms the patient, side, planned procedure and required equipment through the formal safety checklist.
Surgical exposure
In an open Austin procedure, an incision is generally made along the inside of the big-toe joint. Care is taken around superficial nerves and blood vessels. The joint capsule is opened in a controlled fashion and retained for later repair. The medial prominence and the metatarsal head are visualised. In minimally invasive variations, smaller portals and fluoroscopic imaging may be used, but the underlying objective remains controlled realignment.
Creating the osteotomy
A V-shaped cut is made through the distal first metatarsal using a surgical saw or burr, depending on the technique. The location and orientation are planned to preserve adequate bone stock, maintain stability and protect the metatarsal-head blood supply. The head fragment is then shifted laterally by the amount required for correction. Intraoperative imaging may be used to confirm alignment and fixation placement.
Contouring and soft-tissue work
After translation, the remaining medial shelf or prominence is contoured. Tight or unbalanced soft tissues may be released or repaired where clinically indicated. The medial capsule is commonly tightened to support alignment, but the amount of correction should be controlled to avoid excessive tension. If the big toe itself remains angled, an Akin osteotomy may be added according to the preoperative and intraoperative findings.
Internal fixation
The osteotomy is usually secured using one or more screws. The surgeon checks that fixation is stable, the screw position is satisfactory and the joint can move without obvious impingement. The amount of correction, sesamoid relationship and overall toe position are assessed. The fixation method and number of screws can vary with the exact osteotomy, bone quality and surgeon preference.
Closure and dressing
The capsule is repaired, and the skin is closed with sutures or another closure method. A carefully applied dressing supports the toe and protects the wound. A postoperative shoe, sandal or boot is fitted according to the planned protocol. The dressing is part of the correction during the early period and should not be altered unless the surgical team has instructed the patient to do so.
Immediate postoperative care
After surgery, the patient is monitored until the anaesthetic has worn off sufficiently and discharge criteria are met. Instructions generally cover elevation, wound protection, medication, permitted weight bearing, exercises, signs of possible complications and the first review. The patient should have appropriate transport and support because driving is not permitted immediately after anaesthesia and may remain restricted while the foot cannot safely operate vehicle controls.
Variation between patients
This description is an overview, not a promise that every operation follows an identical sequence. Some patients require only the Chevron osteotomy, while others need an Akin osteotomy, soft-tissue balancing or treatment of another forefoot problem. Operative choices may also change if unexpected cartilage damage, bone quality or anatomy is identified. Informed consent should include these reasonable possibilities before surgery.