Revisiting the tailor's bunion and adductovarus deformity of the fifth digit

Optimal Target Angle in Oblique Diaphyseal Osteotomy of the Fifth Metatarsal for Symptomatic Bunionette: A Retrospective Analysis

BACKGROUND

The effects of the osteotomy angle during oblique diaphyseal osteotomy of the fifth metatarsal on the clinical outcomes remain unclear. This study aimed to clarify the clinical and radiographic outcomes of this procedure, with a focus on the intraoperative osteotomy angle.

METHODS

This retrospective study included 30 female patients who underwent oblique diaphyseal osteotomy of the fifth metatarsal with single-screw fixation for symptomatic bunionette (36 feet, mean age, 68.3 years; mean follow-up, 22.5 months). The angles between the osteotomy line and the fifth metatarsal and screw insertion axes were measured as the osteotomy and screw insertion angles, respectively. Receiver operating characteristic curve analysis was performed to determine the cutoff value for the osteotomy angle. The metatarsophalangeal angle (MTPA) and intermetatarsal angle (IMA) between the fourth and fifth metatarsals were measured on dorsoplantar images. The Japanese Society for Surgery of the Foot (JSSF) scale was scored at the preoperative and final follow-up visits.

RESULTS

Screw backout was identified in 14 feet (38.9 %). The osteotomy and screw insertion angles were 35.9 and 62.2 degrees in the screw backout group and 24.6 and 71.2 degrees in the control group, respectively (P < .05). The osteotomy angle >31.1 degrees was a cutoff value of postoperative screw backout (sensitivity, 0.79; specificity, 0.96; area under the curve, 0.92). The mean MTPA and IMA were 21.0 and 12.3 degrees preoperatively and 9.3 and 8.2 degrees at the final follow-up, respectively. The mean JSSF scale score improved significantly from 59.9 to 95.3.

CONCLUSION

The osteotomy angle was greater and the screw was inserted more shallowly against the osteotomy line in the screw backout group compared with the control group. The optimal target angle of the osteotomy line to the fifth metatarsal axis should be <30 degrees intraoperatively for single-screw fixation.

From Etiology to Intervention: A Holistic Review of Bunion Pathophysiology and Care

In this review paper, we present the common etiology, presentation, diagnosis, and management of the following three common bunion formations: dorsal bunion, tailor's bunion, and hallux valgus (HV). Bunions are common pathologies that present to a variety of clinics, so it is important for providers to have a base understanding of these in order to provide the best care to patients. Many of these bunion formations have a variety of causes which allow providers to manage them before surgical intervention is required. The aim of this review paper is to bring attention and expanded insight on these common bunion presentations in order to minimize morbidity early on. The information provided in this review will allow both primary care and subspecialty physicians with the knowledge to accurately diagnose and optimally manage these bony deformities of the lower extremity.

Scarf osteotomy for reduction of tailors bunion deformities: Systematic review and meta-analysis

BACKGROUND

Tailors bunions are common forefoot deformities affecting the fifth MPJ, with challenging symptomatology often resistant to conservative care. Currently no gold standard exists for the surgical management of tailor's bunions, although the scarf osteotomy has been described as a versatile option for reducing these deformities.

METHODS

Relevant electronic databases were searched to collate all studies pertaining to tailors bunion correction using the scarf osteotomy between 2000 and 2021. Both surgeon and patient reported outcomes were required to be included in the systematic review. Methodological quality assessment and risk of bias was performed for each study. Statistical analysis of outcomes and complications was measured. Four small scale case series studies met the inclusion criteria.

RESULTS

All studies demonstrated a statistically significant reduction of 4th inter-metatarsal angles, improvement in clinical and patient reported outcome measures. 15% complication rate was identified, however recurring plantar hyperkeratoses were the most frequent, with one study suggesting a relationship with Pes Cavus. All four studies demonstrated significant methodological short comings and high risk of bias.

CONCLUSION

Scarf osteotomy provides good reduction of tailors' bunion deformities, demonstrates low complication rate and high patient satisfaction. Foot and Ankle surgeons should counsel patients' accordingly on risk of recurrence where hyperkeratosis is a key complaint.

Management of acute lesser toe pain

Patients with foot pain commonly present to their primary care physicians for their initial management and treatment. These patients and their respective foot or lesser toe pain can present the physician with a complex problem with a long differential list. Depending on the timing of the pain and underlying pathology, these differentials can be divided into acute and acute exacerbation of chronic conditions. This review categorizes the history, physical exam, radiological findings, conservative treatment, and surgical management for each major cause of lesser toe pain, whether acute or chronic. The acute conditions surrounding lesser toe pain in the adult population discussed are toe fractures, toe dislocations, and metatarsal head and neck fractures. The chronic pathologies surrounding lesser toe pain in the adult population evaluated in this review include metatarsalgia, Morton's neuroma, Freiberg infraction, brachymetatarsia, bunionettes, and lesser toe disorders.

Comparison of 2 Oblique Fifth Metatarsal Osteotomies for the Management of a Bunionette

Background:

A bunionette is a painful prominence of the fifth metatarsal head. This study aimed to compare the clinical outcome of 2 corrective osteotomies, namely, the Mau-type and Ludloff-type osteotomies. We report results with regard to correction, healing, complications, and patient-reported outcomes.

Methods:

Thirty-two patients who underwent bunionette corrective surgery from March 2011 to May 2017 were included in the study. All patients had pre- and postoperative radiographs. The pre- and postoperative fourth-fifth intermetatarsal angles (IMAs) and postoperative fifth metatarsal bowing angle were measured. Radiographic union was assessed at 12 weeks. All patients completed the Self-Reported Foot and Ankle Score (SEFAS) questionnaire to assess clinical outcome. Thirty-two patients (43 feet) were available for follow-up and completed the SEFAS score. Twenty-two Mau-type and 21 Ludloff-type osteotomies were performed.

Results:

The mean pre- and postoperative IMA for Mau was 10.5 and 4.3 degrees, respectively, and for the Ludloff was 10.2 and 4 degrees, respectively, with no statistically significant difference between the 2 groups. The Mau caused more bowing with a mean of 9.8 degrees as compared to a mean of 3.5 degrees with the Ludloff. No patients in the Mau group reported clinical problems related to the increased bowing. All osteotomies united. The Mau cohort had a mean SEFAS score of 45 and the Ludloff cohort a mean of 46. No feet had fair or poor outcome scores.

Conclusion:

Patient satisfaction after bunionette correction with an oblique shaft rotational osteotomy was good. Orientation of the osteotomy did not affect outcomes. Postoperative bowing of the fifth metatarsal was greater with the Mau-type osteotomy. Postoperative fifth metatarsal bowing had no negative clinical effects. The trend in our unit has been a preference toward the Mau-type osteotomy as it is perceived to be more stable.

Level of Evidence:

Level III, retrospective comparative series.

Fifth Metatarsal Osteotomies for Treatment of Bunionette Deformity: A Meta-Analysis of Angle Correction and Clinical Condition

We assessed which type of osteotomy would be most suited for correcting an increased fourth to fifth intermetatarsal angle (IMA) and metatarsophalangeal angle (MPA) and would have the best results regarding the clinical condition and satisfaction. The study design was a systematic review and meta-analysis. The main outcome measures were the IMA, MPA, and American Orthopaedic Foot and Ankle Society Lesser Metatarsophalangeal-Interphalangeal scale and satisfaction scores. A systematic search was performed in Medline, Embase, Cochrane, SPORTdiscus, and CINAHL up to September 2016. Prospective and retrospective studies that had evaluated the outcomes of fifth metatarsal osteotomies to correct a bunionette deformity at all patient ages were included. The outcomes were determined from clinical or radiographic evaluations. The search yielded 28 studies suitable for inclusion in our meta-analysis. All groups of osteotomies achieved significant IMA changes, with proximal osteotomies resulting in significantly greater changes than diaphyseal or distal osteotomies. The overall effect of osteotomies on the MPA was of a significant reduction. Proximal and diaphyseal osteotomies both resulted in significant differences in MPA correction compared with distal osteotomies. The incidence of major complications was the least in the distal osteotomy group. The overall mean success rate of bunionette surgery was 93%. The patients were most satisfied with proximal osteotomies, followed by distal and diaphyseal osteotomies (100% and 92%, respectively). In conclusion, every type of osteotomy has the capability of significantly reducing the fourth to fifth IMA and MPA. The fewest complications occurred with distal osteotomies, and the greatest satisfaction score was achieved with proximal osteotomies. However, only 1 study evaluated these results for proximal osteotomies. Distal osteotomies resulted in a high satisfaction rate and were the most represented osteotomy in our meta-analysis. Thus, when major IMA and MPA reduction is not required, the distal osteotomy could be the treatment of choice owing to its low complication rate.

Reproducibility and Reliability of the Radiographic Angles Used to Assess Tailor's Bunions

BACKGROUND

Tailor's bunion, or bunionette, deformity is a common condition of the lateral forefoot. To aid in assessing the deformity, radiographic angular measurements are frequently used. The objective of this study was to determine the reliability and reproducibility of these angular measurements.

METHODS

Thirty unique weightbearing dorsoplantar digital radiographs of pathologic feet were compiled. For these 30 radiographs and for ten repeated radiographs, six practicing clinicians measured the following angles: the fourth to fifth intermetatarsal angle, the lateral deviation angle, and the fifth metatarsophalangeal angle. Both traditional and modified versions of the fourth to fifth intermetatarsal angle were included.

RESULTS

Intraclass correlation coefficient values were calculated for each of the angles studied. Intrarater reliability was highest for the fifth metatarsophalangeal angle and lowest for the lateral deviation angle. Intrarater reliability was higher for the traditional fourth to fifth intermetatarsal angle than for the modified version. The interrater reliability calculations revealed parallel findings.

CONCLUSIONS

Accurate assessment is critical when planning for surgical intervention. Awareness of the relative reliability of these radiographic angular measurements can aid in preoperative planning and may be of benefit in procedure selection.