Bunionette Treatment & Management

Treatment often can be nonoperative with padding, shoe modification with arch supports or orthotic devices, anti-inflammatory medications, and occasionally, corticosteroid injections into the bursae.

Surgical procedures are determined by the pathoanatomy.^{[6, 7, 8, 9, 10, 11, 12, 13, 14]}

• Type 1 lesions can be treated by condylectomy and capsular plication. This is indicated only if no evidence of increased intermetatarsal angle exists. It may be associated with a bursectomy or with nodule removal in patients with arthropathy. If the joint is severely arthritic, excision arthroplasty can be used.^[15]
• Type 2 lesions can respond well to a midshaft rotational osteotomy. Lateral distal condylectomy can be added to this.
• Type 3 lesions of moderate degree can respond to lateral condylectomy and distal metatarsal osteotomy.^{[6, 16]} Oblique and chevron-type osteotomies are common.^[7] Large deformities require a midshaft or proximal osteotomy.^[17]

These surgeries 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 2 planes allows depression and correction of the intermetatarsal angle 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 non–weight-bearing 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.

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 is prudent to ensure adequate healing before allowing high-stress activities.

For excellent patient education resources, visit eMedicine's Foot, Ankle, Knee, and Hip Center. Also, see eMedicine's patient education article Chronic Pain.

Complications include malunion, nonunion, nerve injury, metatarsophalangeal (MTP) joint pain and stiffness, and 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, although it can occur with midshaft osteotomies.

Relief of pain and alignment usually can be obtained. When cosmesis is the only reason for surgery, satisfaction is less likely because minor symptoms may persist for some months following surgery. Continuing progression of underlying arthropathic disease also may lead to recurrence and unsatisfactory results.

Minimal incision surgery is not appropriate for management of this condition. Future progress may include different osteotomies.