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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.


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.


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.


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.



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.


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.

Contributor Information and Disclosures

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.


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.

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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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