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Bunionette Treatment & Management

  • Author: Christopher Brown, MBBS, FRCSC, FRACS, FAOrthA; Chief Editor: Vinod K Panchbhavi, MD, FACS  more...
 
Updated: Apr 07, 2016
 

Approach Considerations

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.[7] Future developments may include different osteotomies.

Absolute and relative contraindications for surgery include the following:

  • Pure cosmetic deformity
  • Vascular impairment
  • Severe diabetic arthropathy
  • Significant infection with bony involvement
  • Psychiatric disorders that prevent appropriate postoperative compliance
  • Severe osteoporosis
  • 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.

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Medical Therapy

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.

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Surgical Therapy

Surgical procedures are determined by the pathoanatomy (see Workup, Imaging Studies),[8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18]  as follows:

  • 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 [19]
  • Type 2 lesions may respond well to a midshaft rotational osteotomy; lateral distal condylectomy can be added if warranted
  • Type 3 lesions of moderate degree may respond to lateral condylectomy and distal metatarsal osteotomy [8, 20] ; oblique and chevron-type osteotomies are common [9] ; large deformities require a midshaft or proximal osteotomy [21]

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.

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Postoperative Care

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.

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Complications

Complications include the following:

  • Malunion
  • Nonunion
  • Nerve injury
  • 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.

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Long-Term Monitoring

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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Contributor Information and Disclosures
Author

Christopher Brown, MBBS, FRCSC, FRACS, FAOrthA Clinical Lecturer, Department of Orthopaedics and Trauma, University of Adelaide, Australia

Christopher Brown, MBBS, FRCSC, FRACS, FAOrthA is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Australian Orthopaedic Association, American Orthopaedic Foot and Ankle Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Vinod K Panchbhavi, MD, FACS Professor of Orthopedic Surgery, Chief, Division of Foot and Ankle Surgery, Director, Foot and Ankle Fellowship Program, Department of Orthopedics, University of Texas Medical Branch School of Medicine

Vinod K Panchbhavi, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Orthopaedic Trauma Association, Texas Orthopaedic Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Styker.

Additional Contributors

James K DeOrio, MD Associate Professor of Orthopedic Surgery, Duke University School of Medicine

James K DeOrio, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society

Disclosure: Received royalty from Merete for other; Received royalty from SBi for other; Received royalty from BioPro for other; Received honoraria from Acumed, LLC for speaking and teaching; Received honoraria from Wright Medical Technology, Inc for speaking and teaching; Received honoraria from SBI for speaking and teaching; Received honoraria from Integra for speaking and teaching; Received honoraria from Datatrace Publishing for speaking and teaching; Received honoraria from Exactech, Inc for speaking a.

Acknowledgements

Nancy Cullen, MD, FRCSC, FRACS Senior Visiting Medical Officer, Clinical Lecturer, Department of Orthopaedics and Trauma, University of Adelaide, Australia

Nancy Cullen, MD, FRCSC, FRACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons and American Orthopaedic Foot and Ankle Society

Disclosure: Nothing to disclose.

References
  1. Davies H. Metatarsus quintus valgus. Br Med J. 1949. 1:664-5.

  2. Ajis A, Koti M, Maffulli N. Tailor's bunion: a review. J Foot Ankle Surg. 2005 May-Jun. 44(3):236-45. [Medline].

  3. Cooper PS. Disorders and deformities of the lesser toes. In: Myerson M, ed. Foot and Ankle Disorders. 2000:335-340.

  4. Coughlin MJ. Etiology and treatment of the bunionette deformity. Instr Course Lect. 1990. 39:37-48. [Medline].

  5. Cohen BE, Nicholson CW. Bunionette deformity. J Am Acad Orthop Surg. 2007 May. 15(5):300-7. [Medline].

  6. Shimobayashi M, Tanaka Y, Taniguchi A, Kurokawa H, Tomiwa K, Higashiyama I. Radiographic Morphologic Characteristics of Bunionette Deformity. Foot Ankle Int. 2016 Mar. 37 (3):320-6. [Medline].

  7. Laffenêtre O, Millet-Barbé B, Darcel V, Lucas Y Hernandez J, Chauveaux D. Percutaneous bunionette correction: results of a 49-case retrospective study at a mean 34 months' follow-up. Orthop Traumatol Surg Res. 2015 Apr. 101 (2):179-84. [Medline].

  8. Legenstein R, Bonomo J, Huber W, Boesch P. Correction of tailor's bunion with the Boesch technique: a retrospective study. Foot Ankle Int. 2007 Jul. 28(7):799-803. [Medline].

  9. Kitaoka HB, Holiday AD Jr, Campbell DC 2nd. Distal Chevron metatarsal osteotomy for bunionette. Foot Ankle. 1991 Oct. 12(2):80-5. [Medline].

  10. 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. 2008 Mar. 29(3):282-6. [Medline].

  11. 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. 2006 Aug. 27(8):573-80. [Medline].

  12. Weitzel S, Trnka HJ, Petroutsas J. Transverse medial slide osteotomy for bunionette deformity: long-term results. Foot Ankle Int. 2007 Jul. 28(7):794-8. [Medline].

  13. Weil L Jr, Weil LS Sr. Osteotomies for bunionette deformity. Foot Ankle Clin. 2011 Dec. 16(4):689-712. [Medline].

  14. Masquijo JJ, Willis BR, Kontio K, Dobbs MB. Symptomatic bunionette deformity in adolescents: surgical treatment with metatarsal sliding osteotomy. J Pediatr Orthop. 2010 Dec. 30(8):904-9. [Medline].

  15. Guha AR, Mukhopadhyay S, Thomas RH. Reverse' scarf osteotomy for bunionette correction: Initial results of a new surgical technique. Foot Ankle Surg. 2012 Mar. 18(1):50-4. [Medline].

  16. Magnan B, Samaila E, Merlini M, Bondi M, Mezzari S, Bartolozzi P. Percutaneous distal osteotomy of the fifth metatarsal for correction of bunionette. J Bone Joint Surg Am. 2011 Nov 16. 93(22):2116-22. [Medline].

  17. Weil L Jr, Consul D. Fifth Metatarsal Osteotomies. Clin Podiatr Med Surg. 2015 Jul. 32 (3):333-53. [Medline].

  18. Maher AJ, Kilmartin TE. Scarf osteotomy for correction of Tailor's bunion: mid- to long-term followup. Foot Ankle Int. 2010 Aug. 31 (8):676-82. [Medline].

  19. Kitaoka HB, Holiday AD Jr. Lateral condylar resection for bunionette. Clin Orthop. 1992 May. (278):183-92. [Medline].

  20. Radl R, Leithner A, Koehler W. The modified distal horizontal metatarsal osteotomy for correction of bunionette deformity. Foot Ankle Int. 2005 Jun. 26(6):454-7. [Medline].

  21. Waizy H, Olender G, Mansouri F, Floerkemeier T, Stukenborg-Colsman C. Minimally Invasive Osteotomy for Symptomatic Bunionette Deformity Is Not Advisable for Severe Deformities: A Critical Retrospective Analysis of the Results. Foot Ankle Spec. 2012 Jan 31. [Medline].

 
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Type 1 bunionette. Note enlarged head without marked angulation.
Type 2 bunionette. Note abnormal bowing of metatarsal and secondary angulation of metatarsophalangeal joint.
Type 3 bunionette. Note increased angle between fourth and fifth metatarsals. Angulation at metatarsophalangeal joint is secondary to medial pressure on phalanx.
 
 
 
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