Key takeaways
- Both operations move the bone back into line. Which one suits you depends on your foot.
- There’s no set rule. Surgeons look at the size of the bunion, the state of the joint, and what else needs treating before deciding which operation to perform.
- Keyhole surgery may be less painful in the early weeks, but swelling can still last for months.
- Large studies have found that both operations straighten the toe about as well, and patients are about as happy afterwards.
Imagine a keen runner with a bunion that rubs in every pair of trainers. She’s told she needs surgery, then finds that one clinic recommends keyhole surgery while another recommends an open operation. It can be confusing. The right choice depends on your foot, not on the name of the technique.
This guide talks about both in a balanced way, including where the evidence is mixed. It comes from the team working with Dr Francesc Malagelada, Consultant Orthopaedic Foot and Ankle Surgeon at The Royal London Hospital.
What's the difference between keyhole and open bunion surgery?
Both operations cut the bone and move it back into line. Keyhole surgery uses much smaller cuts.
A bunion (hallux valgus) is more than a bump. The joint has actually changed shape. The first metatarsal, which is the long bone behind your big toe, drifts inwards and the toe angles towards your other toes. Our guide covers the basics of what a bunion is and whether surgery is needed.
In keyhole (minimally invasive) surgery, the surgeon makes small cuts, divides the bone and moves it into position, guided by X-ray (NICE). One NHS leaflet says four cuts of 3mm are used.
In open surgery, one longer cut, usually around 5cm, lets the surgeon see the bone and joint. The bone is cut, moved and fixed with wires, small screws or plates (UCLH).
Which operation suits which foot?
There’s no set rule. Surgeons look at the size of the bunion, the state of the joint and what else needs fixing to decide which technique is more suitable.
Experts haven’t agreed on the best approach, and keyhole surgery is still debated, although it’s becoming more common (Cochrane). So it’s worth asking any surgeon why they recommend a particular operation for your foot.
An X-ray taken while you’re standing lets your surgeon measure two angles: how far your big toe leans (the hallux valgus angle), and how far the long bone behind it has drifted (the intermetatarsal angle). One widely used system grades bunions like this:
- Mild: big toe under 20°, bone under 11°
- Moderate: big toe 20 to 40°, bone 11 to 16°
- Severe: big toe over 40°, bone over 16°
Other systems use different cut-offs. A 2024 review found there’s no standard, so the same angle can count as mild, moderate, or severe depending on which system is used (Spindler et al., 2024).
The angles describe your bunion, but they don’t decide the operation on their own. Other things that affect the decision include:
- How flexible the joint at the base of your big toe is
- Whether there’s arthritis in that joint (see bunion vs hallux rigidus)
- Whether other toes need treatment too
- Your bone quality, age, and activity level
- Whether you’re having one foot done or both
- What matters most to you, such as scar size or how soon you return to normal shoes
Surgery isn’t the only option. If your bunion only causes a little pain, wide low-heeled shoes, pads and simple painkillers might be enough (NHS).
Is recovery really faster after keyhole surgery?
Not necessarily. Keyhole surgery may mean less pain early on, but the foot needs protection for a similar time after both operations. Swelling can last for months after either procedure.
Recovery claims often contradict each other. One clinic says keyhole recovery takes two to four weeks, while open surgery takes six to eight. Another says the time needed to wear normal shoes is the same in both. NHS leaflets show why: each unit has its own routine.
- After open surgery, one London NHS trust lets patients walk on the whole foot in a flat sandal when they go home. They then wear a wedge sandal for six weeks, with normal shoes from six to eight weeks (UCLH).
- After keyhole surgery, a Sussex NHS leaflet recommends putting weight only through your heel and using crutches for two weeks. Then you wear a flat shoe for five weeks (University Hospitals Sussex).
- Swelling can last up to six months, according to leaflets for both operations.
The NHS provides a general guide: keep your foot raised for at least two weeks, don’t drive for six to eight weeks, take two to 12 weeks off work and avoid sport for three to six months. Our recovery guide goes through it week by week.
What does the research say?
Overall, the research suggests keyhole and open surgery give similar results. There are some small differences, but they may not matter to you.
You may have read that keyhole surgery makes a bunion less likely to come back, or gives a longer-lasting result. We haven’t found good evidence for that.
A large 2022 review looked at 310 studies covering 24,231 feet. Both operations straightened the toe by similar amounts, and patients rated their results in a similar way. About 9 in 10 people were happy after either operation: 91.6% after open surgery and 89.6% after keyhole. The authors said this small gap may not make a real difference to patients (Aran et al., 2022).
Another 2022 review compared 790 patients treated with keyhole surgery and 838 with open surgery, across 22 studies. People had less pain in the early weeks after keyhole surgery, the operation was quicker, and they went home sooner. By the end of the studies, there was no real difference in pain or complications. The authors concluded keyhole surgery was more effective, mainly because of less early pain, shorter operations, and some X-ray measurements (Frontiers in Surgery, 2022).
Both reviews combine studies of different types, so the results are averages across many surgeons and bunion sizes.
What are the risks of each approach?
Both operations have similar risks. Serious ones are rare, but you should understand them before you go ahead.
One London NHS trust puts the risk of a serious joint infection, or a long-term pain condition called complex regional pain syndrome, at under 1 in 100 cases (UCLH, above). Blood clots and overcorrection, where the big toe points inwards, are also rare (Royal United Hospitals Bath).
Smaller problems are more common. The big toe is often slightly stiffer. Scars can be sensitive, though this usually settles. Numbness often improves but may be permanent. The NHS adds that your toe may be weaker, might not be perfectly straight, and could still hurt. The bunion can also come back.
Do keyhole operations use screws?
Some pages say keyhole surgery uses no metal, while others say screws are standard. NICE says the bones may be held with wires, screws or plates, so it varies. The NHS says screws or staples are often left in permanently. One leaflet says embedded screws shouldn’t need removing later, while a London trust notes that, rarely, a screw can lose its hold. It can be confusing, so ask your surgeon how they plan to hold the bone in place, and what happens if it needs attention later.
What if the NHS is an option?
NHS bunion surgery is only available to people who meet set criteria, and keyhole techniques aren’t usually funded.
NHS England will fund bunion surgery if you keep getting ulcers or infections. It will also fund it if you still have moderate to severe pain that affects your daily life after three months of non-surgical treatment. It won’t fund surgery that’s mainly for appearance. It also won’t fund keyhole techniques unless they’re part of a research study or audit (NHS England). Local rules can differ, so your GP is the best place to start.
Private care is the other route. Our keyhole bunion surgery page explains how it works.
Questions to ask any surgeon
Whichever operation you’re offered, ask:
- Why do you recommend this technique for my foot, and what would make you change your mind?
- How many of these operations do you perform each year?
- How often do your patients have complications, or find their bunion comes back?
- How will you hold the bone in place, and might you need to switch to open surgery during the operation?
Get an expert opinion on your foot injury
Mr Francesc Malagelada is a Consultant Trauma and Orthopaedic Surgeon and a senior trauma consultant at the Royal London Hospital, where he treats ankle fractures of all severities. You don’t need a GP referral to book a specialist assessment.
Frequently asked questions
Will my bunion come back?
It can, after either operation. The NHS says the younger you are, the higher the chance it will return. When the surgery is well performed, the chances are low. Ask your surgeon how they plan to reduce the chance of the bunion returning.
When can I drive after bunion surgery?
The NHS advises no driving for six to eight weeks. One NHS leaflet says you can drive an automatic car after two weeks if only your left foot was operated on, but not to drive a manual car for six weeks. You need to be able to perform an emergency stop in your own shoes, which is unlikely before about eight weeks.
Will I have a general anaesthetic, and will I stay overnight?
Most people have a general anaesthetic, although some have a local one, and most go home the same day (NHS). Your surgeon and anaesthetist will advise which suits you.
How long will I be off work?
The NHS gives a range of two to 12 weeks off work after bunion surgery, depending on your job and how well your recovery goes. Tell your surgeon what your job involves so they can give you a realistic date.
When can I exercise or run again?
The NHS advises no sport for three to six months after bunion surgery. Your surgeon will confirm when your foot is ready, so ask what to avoid until then and when you can build back up.