Introduction
The term "tailor's bunion" initially described an acquired lesion that caused chronic pain and swelling over the lateral aspect of the fifth metatarsal head. These lesions often were present on tailors, whose traditional cross-legged sitting posture on benches resulted in pressure being placed on the lateral side of the foot, leading to the development of painful bunionettes. Davies described the lesion in the English literature in 1949.1
Type 1 lesion. Note enlarged head without marked angulation.
Type 2 lesion. Note the abnormal bowing of the metatarsal and the secondary angulation of the metatarsophalangeal joint.
Type 3 lesion. Note the increased angle between the fourth and fifth metatarsals. The angulation at the metatarsophalangeal joint is secondary to medial pressure on the phalanx.
Problem
A bunionette is a painful prominence on the lateral aspect of the fifth metatarsal head. While not as common as a medial bunion, it is a cause of chronic pain and shoe-fitting problems in individuals whose feet are characterized by a widened forefoot or in those who have a lateral splaying or prominence over the fifth metatarsal.2,3
Related eMedicine topic:
Bunion
Frequency
US
In Western society, the occurrence of bunionettes is related to narrow footwear on predisposed foot anatomy. The actual incidence is not accurately known, but it is far less of an isolated presenting problem than hallux valgus. However, it is commonly seen in patients who present with hallux valgus secondary to splaying of the forefoot. It may or may not be symptomatic at the same time. Females represent up to 90% of symptomatic patients in some series.
International
Few reports exist in the literature on the incidence in non-Western countries. This is probably a result of lesser wear of constricting shoes and hence, a lower occurrence rate.
Etiology
Causes can be extrinsic or intrinsic.4 Extrinsic causes can be traumatic, either acute or more commonly chronic (eg, tailors' working posture, footwear). Intrinsic causes can be related to structural abnormalities, such as congenital lateral bowing of the metatarsal shaft, abnormal intermetatarsal ligament insertion with prominence of the fifth metatarsal, brachymetatarsia, or primary hypertrophy of the metatarsal head. Congenital splayfoot is a more generalized congenital predisposing lesion. Iatrogenic causes can occur as a result of failed adjacent metatarsal surgery or residual malalignments from hindfoot surgery, which cause increased prominence of the fifth metatarsal. Inflammatory arthropathies also can cause bunionette deformities or soft tissue lesions in association with bony problems.
Pathophysiology
Pathologic lesions include an inflamed bursa overlying the lateral aspect of the metatarsal head, a bony enlargement of the head itself, or an increased intermetatarsal angle between the fourth and fifth metatarsals with secondary medial angulation of the phalanx and abnormal curvature of the fifth metatarsal. Recognition of the varying pathologies is an essential part of surgical management.
Presentation
Presenting symptoms usually include painful keratoses over the lateral aspect of the metatarsal head, but they also may be present on the plantar and dorsal aspects. Medial deviation of the fifth phalanx with some rotation is frequently seen. Differentiating whether the patient is truly having pain or whether the patient just finds his or her foot cosmetically unacceptable is important. Assessing whether the deformity is fixed or correctable also is important.5
Examination should assess other foot deformities, such as hallux valgus, planovalgus foot deformity, and equinus, and the presence of neuritic symptoms or systemic arthropathy.
Indications
Surgery is performed when symptoms of an unacceptable degree are not relieved by conservative treatments, such as shaving the callous or wearing wider shoes, silicon pads, softer shoe coverings, or sandals.
Relevant Anatomy
The underlying pathoanatomy and pathophysiology determine procedure selection. No single, universally acceptable procedure exists for all patients.
The pathoanatomy of the bunionette varies with different types of lesions. Usually, there is a component of prominence of the lateral aspect of the fifth metatarsophalangeal (MTP) joint. Stretching and attenuation of the capsule may occur with medial subluxation of the proximal phalanx. Both long flexors and extensors can be medial to the head, leading to a deforming force on the toe that increases with increasing deformity. Rotation of the phalanx also can occur.
The normal fourth and fifth intermetatarsal angle is approximately 6.2°, and the normal fifth MTP angle is about 10°. Pathological angles are in the range of 10° for the intermetatarsal angle and 16° for the MTP angle.
Contraindications
Absolute and relative contraindications to surgery include pure cosmetic deformity, vascular impairment, severe diabetic arthropathy, significant infection with bony involvement, psychiatric disorders that prevent appropriate postoperative compliance, severe osteoporosis, and severe progressive erosive arthropathies.
Some of these contraindications apply to specific reconstructive procedures. For example, severe refractory deformities, inflammatory conditions, and infected neuropathic arthritic or failed surgical procedures may require treatment with ablative rather than reconstructive procedures.
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References
Davies H. Metatarsus quintus valgus. Br Med J. 1949;1:664-5.
Ajis A, Koti M, Maffulli N. Tailor's bunion: a review. J Foot Ankle Surg. May-Jun 2005;44(3):236-45. [Medline].
Cooper PS. Disorders and deformities of the lesser toes. In: Myerson M, ed. Foot and Ankle Disorders. 2000:335-340.
Coughlin MJ. Etiology and treatment of the bunionette deformity. Instr Course Lect. 1990;39:37-48. [Medline].
Cohen BE, Nicholson CW. Bunionette deformity. J Am Acad Orthop Surg. May 2007;15(5):300-7. [Medline].
Legenstein R, Bonomo J, Huber W, Boesch P. Correction of tailor's bunion with the Boesch technique: a retrospective study. Foot Ankle Int. Jul 2007;28(7):799-803. [Medline].
Kitaoka HB, Holiday AD Jr, Campbell DC 2nd. Distal Chevron metatarsal osteotomy for bunionette. Foot Ankle. Oct 1991;12(2):80-5. [Medline].
Giannini S, Faldini C, Vannini F, Digennaro V, Bevoni R, Luciani D. The minimally invasive osteotomy "S.E.R.I." (simple, effective, rapid, inexpensive) for correction of bunionette deformity. Foot Ankle Int. Mar 2008;29(3):282-6. [Medline].
Vienne P, Oesselmann M, Espinosa N. Modified Coughlin procedure for surgical treatment of symptomatic tailor's bunion: a prospective followup study of 33 consecutive operations. Foot Ankle Int. Aug 2006;27(8):573-80. [Medline].
Weitzel S, Trnka HJ, Petroutsas J. Transverse medial slide osteotomy for bunionette deformity: long-term results. Foot Ankle Int. Jul 2007;28(7):794-8. [Medline].
Kitaoka HB, Holiday AD Jr. Lateral condylar resection for bunionette. Clin Orthop. May 1992;(278):183-92. [Medline].
Radl R, Leithner A, Koehler W. The modified distal horizontal metatarsal osteotomy for correction of bunionette deformity. Foot Ankle Int. Jun 2005;26(6):454-7. [Medline].
Further Reading
Keywords
bunionette, tailor's bunion, bunion, fifth metatarsalgia, opposite side bunion, fifth-toe deformities
