Bunionette Treatment & Management
- Author: Christopher Brown, MBBS, FRCSC, FRACS, FAOrthA; Chief Editor: Vinod K Panchbhavi, MD, FACS more...
Surgery for bunionette 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. At present, the appropriateness of minimal incision surgery for management of this condition has not been established, though some percutaneous approaches appear promising. Future developments may include different osteotomies.
Absolute and relative contraindications for surgery include the following:
Pure cosmetic deformity
Severe diabetic arthropathy
Significant infection with bony involvement
Psychiatric disorders that prevent appropriate postoperative compliance
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 necessitate treatment with ablative rather than reconstructive procedures.
Treatment often can be nonoperative, involving the use of padding, shoe modification with arch supports or orthotic devices, anti-inflammatory medications, and, occasionally, corticosteroid injections into the bursae.
Type 1 lesions can be treated with condylectomy and capsular plication, though this is indicated only in the absence of any evidence of an increased intermetatarsal angle (IMA); it may be associated with a bursectomy or with nodule removal in patients with arthropathy; if the joint is severely arthritic, excision arthroplasty may be performed 
Type 2 lesions may respond well to a midshaft rotational osteotomy; lateral distal condylectomy can be added if warranted
These procedures can be performed on an outpatient basis. Assess general fitness for ankle block, popliteal block, or more general anesthesia.
Longitudinal lateral incisions are used with care to avoid injury to branches of the sural nerve. In distal procedures, a distally based capsular flap is created, and the lateral portion of the condyle is exposed. Take care to avoid excessive resection to prevent instability. Intraoperative low-dose fluoroscopy is very useful. If an osteotomy is carried out distally, avoid excessive medial displacement. The neck can be quite narrow, making fixation difficult. Pinning often is needed.
Midshaft osteotomies are best performed by rotating around a screw that is inserted into a partially osteotomized metatarsal. Completion of the osteotomy site is accomplished after the screw is partially inserted. Appropriate sloping of the osteotomy in two planes allows depression and correction of the IMA if needed.
Postoperative dressings are used for 6 weeks, with dressings being changed as necessary. Patients with midshaft and proximal osteotomy should be restricted to nonweightbearing ambulation for the full 6 weeks. Patients with more distal osteotomies can bear weight in a postoperative shoe as soon as 3 weeks after surgery.
Complications include the following:
Metatarsophalangeal (MTP) joint (MTPJ) pain and stiffness
Symptomatic hardware or infection
Recurrence can occur from poor procedure selection or performance or from progression of underlying pathophysiology (eg, arthropathy). Nonunion is a significant risk with proximal metatarsal osteotomy, though it can occur with midshaft osteotomies.
Return to normal footwear may take several months. Sporting activities that involve repetitive stresses (eg, basketball) should be delayed for 3 months if an osteotomy has been performed. Checking films to ensure adequate healing is prudent before high-stress activities are allowed.
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