Basal osteotomy of the fifth metatarsal for the bunionette

Consensus in percutaneous bunionette correction

PURPOSE

The percutaneous treatment of bunionette deformity has been demonstrated as a reliable and satisfying technique with low risk of complications. However, there are some obvious variations in the surgical technique and perioperative protocol. The purpose of this study is to analyze the currently used techniques and to look for some agreements.

HYPOTHESIS

There are some points of agreement in surgical technique and perioperative protocol when using a percutaneous technique to treat bunionette deformity.

METHODS

A survey was sent to 50 orthopedic surgeons with specific experience in percutaneous techniques. The questions were related to different aspects of the surgical bunionette procedure and the perioperative protocol.

RESULTS

A response rate of 92.0% was obtained. Several points of agreement were found. A condylectomy is rarely used while an osteotomy is performed in almost all procedures. This osteotomy is single (95.7%), complete (66.2-72.7%) and performed with a Shannon long burr (73.9%). The location of the osteotomy depends of the deformity (63.0%).

DISCUSSION

This study demonstrates some consensus in the use of the surgical technique and the perioperative protocol. The percutaneous oblique osteotomy is the preferred technique while a condylectomy is only rarely used.

LEVEL OF EVIDENCE

V, Survey study.

Direction and location of the nutrient artery to the fifth metatarsal at risk in osteotomy for bunionette

BACKGROUND

The aims of this study were to identify the artery feeding the fifth metatarsal and determine how bunionette osteotomy could injure this vessel.

METHODS

The nutrient artery entering the fifth metatarsal was investigated in 10 adult cadaveric lower limbs by barium injection and enhanced computed tomography.

RESULTS

The nutrient artery entered the medial aspect of the fifth metatarsal around the junction of the middle and proximal thirds obliquely from a distal direction (mean angle 36°) in the coronal plane in all cases; in the axial plane, the point of entry and direction of the artery was medial-plantar (mean angle 49°).

CONCLUSIONS

This report revealed direction and location of the nutrient artery entering the fifth metatarsal.

Clinical and radiographic outcomes of the Kramer osteotomy in the treatment of bunionette deformity

BACKGROUND

Bunionette deformity is a painful bony prominence of the 5th metatarsal. We evaluated outcomes of using a Kramer osteotomy to treat this condition.

METHODS

Retrospective study of patients treated with a Kramer osteotomy from 2003 and 2016. Outcome measures included Foot Functional Index (FFI) and radiographic measurements.

RESULTS

38 patients (43 feet) with an average follow-up of 55 months. Mean postoperative FFI¹ was 19.4. Mean 4-5 IMA² improved 3.9°, from 8.3° preoperatively to 4.4° on final postoperative films (p<0.01). Mean MTP-5³ angle improved 13.2° from 13.6° preoperatively to 0.4° at final follow-up (p<0.01). There were 5 delayed unions (11.6%) and 1 non-union (2.3%).

CONCLUSIONS

The Kramer osteotomy is an effective treatment option in patients with bunionette deformity, with significant correction of the 4-5 IM² and MTP-5³ angles and few complications.

Management of Bunionette Deformity

Bunionette deformity, historically known as tailor's bunion, is a forefoot protuberance laterally, dorsolaterally, or plantarlaterally along the fifth metatarsal head. Although bunionette deformity has been compared to hallux valgus deformity, it is likely due to a multifactorial, anatomic interplay between fifth metatarsal bony morphology and forefoot soft-tissue imbalance. Friction generated between the bony prominence, soft tissue, and associated constrictive footwear can result in keratosis, inflammation, pain, and ulceration. Symptomatic bunionettes are usually responsive to nonsurgical management. Surgical options are available based on the underlying bony deformity when nonsurgical treatment fails.

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.

Bunionette

PURPOSE

The purpose of this study is to review the most recent literature available on the treatment of bunionette (also named tailor's bunion) with percutaneous and minimally invasive techniques. Focusing especially on clinical outcomes, studies related to this type of techniques were examined in order to evaluate the success of this practice that is, fusion rate and complications. The hypothesis is that these techniques are safe and successful procedures.

METHODS

In July 2015, a topical review of the PubMed/MEDLINE, EMBASE, and Google Scholar databases was conducted using the keywords percutaneous (OR mini-invasive OR minimally invasive) AND bunionette (OR tailor's bunion) AND treatment (OR surgery). Studies reporting the outcomes of the surgical treatment of bunionette were also included in our review.

RESULTS

The search yielded a total of 111 publications from PubMed/MEDLINE, EMBASE, and Google Scholar. After evaluating abstracts and full-text reviews, 9 articles were included in this review. Treatment methods were divided into 2 main surgical treatment categories: with or without fixation of the osteotomy. The most commonly used technique was that with fixation. The scores of success for techniques with and without fixation were 93.5 and 97.8, respectively.

CONCLUSION

The current evidence for the treatment of bunionette deformity is limited to retrospective case series. Therefore, no conclusion can be made regarding the gold standard technique for bunionette deformity. The results published are very satisfactory, but the literature is still poor.

LEVELS OF EVIDENCE

IV: Topical review.

The Reverse Ludloff Osteotomy for Bunionette Deformity

Background The typical bunionette deformity often presents as pain over the lateral margin of the fifth metatarsal head. There have been numerous operative treatments described for this pathology. The purpose of this study was to evaluate the results after a reverse Ludloff osteotomy in cases of severe bunionette deformities. Methods Between 2008 and 2012, 16 patients received a reverse Ludloff osteotomy of the fifth metatarsal due to a symptomatic type II or III bunionette that failed nonoperative treatment. We retrospectively reviewed charts, radiographic images, postoperative AOFAS (American Orthopaedic Foot and Ankle Society) lesser toe scores, and the EQ-5D at a mean of 41.9 months (range, 31-74 months) of follow-up. Additionally, limitation in activities of daily living, pain, and patient satisfaction were assessed. Results At latest follow-up, the mean AOFAS lesser toe score was 86.6 points and the mean EQ-5D score was 14.1. Fifteen patients had no or only little limitations. Fifteen out of 16 patients were satisfied or predominantly satisfied. Radiographic analysis showed for type II deformities a correction of the lateral bowing from 8.1° down to 0.67° (P < .001). The fourth-fifth intermetatarsal angle (4-5 IMA) improved from a mean of 13.2° to a mean of 5.2° (P < .001). The length of the fifth metatarsal was unchanged (P > .05). There were no observed complications, and no revision was necessary. Conclusion In the present study, the reverse Ludloff osteotomy had a high satisfaction rate and no complications. It provided radiographic correction of the deformity and may be considered in the surgical treatment of severe bunionette deformities.

LEVELS OF EVIDENCE

Therapeutic, Level IV: Case series.

Fifth Metatarsal Osteotomies

A tailor's bunion or bunionette deformity is a combination of osseous and soft tissue bursitis on the lateral aspect of the fifth metatarsal head. This article discusses 7 corrective measures: medial oblique sliding osteotomy with fixation, medial oblique slide osteotomy-minimal incision procedure without fixation, SERI (simple, effective, rapid, inexpensive) with fixation, chevron with or without fixation, closing, lateral wedge osteotomy at the metatarsal neck or proximal diaphysis, Weil osteotomy, and scarfette. These evidence-based techniques can be used by practitioners for medical management of their patients through evaluation, diagnosis, and prognosis. Complications are also addressed.

Percutaneous osteotomy of the fifth metatarsal for symptomatic bunionette

The bunionette is a lateral prominence of the fifth metatarsal head. Operative correction of a symptomatic bunionette is indicated if conservative treatment has failed to relieve the symptoms. Although numerous bony or soft tissue surgical procedures have been described, the ideal treatment has not yet been identified. The aim of the present study was to retrospectively evaluate the results of a series of 15 feet affected by symptomatic bunionette deformity treated by percutaneous osteotomy of the fifth metatarsal. From January 2009 to December 2009, 15 feet in 12 patients with symptomatic type 2 and 3 bunionette deformities were treated with percutaneous fifth metatarsal osteotomy, alone or combined with percutaneous shaving of the fifth metatarsal head. The mean patient age was 44 (range 18 to 56) years at surgery. The mean follow-up duration was 24 (range 16 to 28) months. The average lesser toe American Orthopaedic Foot and Ankle Society scale score increased from 61.8 ± 11.1 points preoperatively to 100 points at the last follow-up visit (p < .0001). The mean fifth metatarsophalangeal angle decreased from 18.8° ± 3.6° (range 13° to 26°) preoperatively to 1.7° ± 1.4° (range -2° to 4°) at the final follow-up visit, and this difference was statistically significant (p < .0001). The average 4-5 intermetatarsal angle was 11.2° ± 1.7° (range 9° to 15°) before surgery and 3.1° ± 1.3° (range 1° to 5°) after surgery, and this difference was also statistically significant (p < .0001). The mean interval to radiographic union was 9 (range 8 to 12) weeks postoperatively. The complications included 1 case of wound dehiscence. In conclusion, percutaneous osteotomy of the fifth metatarsal is an effective and safe technique for the treatment of painful bunionette.

Subcapital oblique osteotomy for correction of bunionette deformity: medium-term results

BACKGROUND

Many procedures have been described for correction of bunionette deformity. For symptomatic type I deformity, the authors have routinely performed a subcapital oblique osteotomy of the fifth metatarsal. The purpose of this study was to report the medium-term results of this procedure.

METHODS

This is a retrospective review of patients who underwent subcapital oblique osteotomy for correction of type I bunionette deformity. Patients were evaluated radiographically and clinically. Sixteen feet in 14 patients were available at final follow-up.

RESULTS

At a mean 2.9-year follow-up, 88% of patients had good or excellent clinical result, 88% of patients had no limitation in activity, and mean pain score on a visual analog scale was 1.6 out of 10. Radiographically, a statistical difference was found when we compared the preoperative and 6-week follow-up fifth metatarsophalangeal angle; however, no statistical difference was found in the fourth to fifth intermetatarsal angle at any time or in comparison of the preoperative and final follow-up fifth metatarsophalangeal angles.

CONCLUSION

We found the subcapital oblique osteotomy of the fifth metatarsal to provide reliable clinical results for correction of painful type I bunionette deformity.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

The intraosseous and extraosseous vascular supply of the fifth metatarsal: implications for fifth metatarsal osteotomy

BACKGROUND

Osteotomies of the fifth metatarsal may disrupt the nutrient artery and result in nonunion. The location of the nutrient artery foramen relative to the location of common osteotomies has not been described. The goal of this study was to describe the vascular supply of the proximal fifth metatarsal, including the artery of origin of the nutrient artery and the location of the nutrient artery foramen.

METHODS

Fifty-six adult cadaver specimens were amputated below the knee. The anterior tibial, posterior tibial, and peroneal arteries were injected with India ink and Ward's Blue Latex. The specimens were frozen for 48 hours and then thawed to room temperature. The soft tissues were débrided with sodium hypochlorite, and the extraosseous vascularity was recorded. The fifth metatarsal was then removed and the intraosseous vascular anatomy elucidated using a modified Spälteholz technique.

RESULTS

The dorsalis pedis, posterior tibial, and peroneal arteries branch in predictable patterns to supply the fifth metatarsal. The nutrient artery arose from the fourth plantar metatarsal artery in 100% of specimens and inserted into the plantar medial diaphysis in 83% of specimens. The nutrient artery foramen was an average of 26.8 mm (range, 19-40) from the medial aspect of the base of the fifth metatarsal.

CONCLUSIONS

When an operative approach to the fifth metatarsal is planned, care should be taken to avoid stripping the bone on the plantar and medial aspects.

CLINICAL RELEVANCE

Osteotomies placed within the proximal 40 mm of the bone carry a risk of disrupting the nutrient artery, resulting in possible nonunion.

Relative strength of tailor's bunion osteotomies and fixation techniques

A paucity of data is available on the mechanical strength of fifth metatarsal osteotomies. The present study was designed to provide that information. Five osteotomies were mechanically tested to failure using a materials testing machine and compared with an intact fifth metatarsal using a hollow saw bone model with a sample size of 10 for each construct. The osteotomies tested were the distal reverse chevron fixated with a Kirschner wire, the long plantar reverse chevron osteotomy fixated with 2 screws, a mid-diaphyseal sagittal plane osteotomy fixated with 2 screws, the mid-diaphyseal sagittal plane osteotomy fixated with 2 screws, and an additional cerclage wire and a transverse closing wedge osteotomy fixated with a box wire technique. Analysis of variance was performed, resulting in a statistically significant difference among the data at p <.0001. The Tukey-Kramer honestly significant difference with least significant differences was performed post hoc to separate out the pairs at a minimum α of 0.05. The chevron was statistically the strongest construct at 130 N, followed by the long plantar osteotomy at 78 N. The chevron compared well with the control at 114 N, and they both fractured at the proximal model to fixture interface. The other osteotomies were statistically and significantly weaker than both the chevron and the long plantar constructs, with no statistically significant difference among them at 36, 39, and 48 N. In conclusion, the chevron osteotomy was superior in strength to the sagittal and transverse plane osteotomies and similar in strength and failure to the intact model.

Subcaptial oblique fifth metatarsal osteotomy versus distal chevron osteotomy for correction of bunionette deformity: a cadaveric study

The aim of this study was to compare a distal subcapital oblique fifth metatarsal with a distal chevron osteotomy for correction of bunionette deformity.

MATERIALS AND METHODS

Twenty cadaveric feet were randomly assigned to undergo either a subcapital oblique or chevron osteotomy of the distal fifth metatarsal. Radiographic measurements, including 4-5 intermetatarsal angle (IMA), fifth metatarsophalangeal angle (5-MPA) and foot width, were compared between the 2 groups.

RESULTS

Foot width and 5-MPA was significantly decreased in both groups with no difference between the groups. The 4-5 IMA was not significantly altered in either group.

CONCLUSION

Decrease in foot width and 5-MPA was similarly achieved with either distal chevron or subcapital oblique osteotomy of the fifth metatarsal in normal cadaveric specimens. No significant difference was found between the 2 techniques in any of the radiographic parameters measured.

Minimally invasive osteotomy for symptomatic bunionette deformity is not advisable for severe deformities: a critical retrospective analysis of the results

Bunionette, or tailor's bunion, is a painful protrusion on the plantar and/or lateral aspect of the fifth metatarsal head. Until recently, there have been very good results reported in literature when minimally invasive therapy is used to treat this deformity. In this study, the authors critically review the outcome of patients operated by the minimal invasive technique. A total of 31 feet were retrospectively reviewed with a mean follow-up of 52 months (range 14-106 months). The results were related to the preoperative severity of the bunionette deformity. The mean intermetatarsal angle IV/V was reduced from 12° to 7.5° postoperatively. The American Orthopaedic Foot and Ankle Society score showed good and excellent values (80-100 points) at follow-up in 16 (12 type I, 4 type III) feet. Fourteen (2 type I, 5 type II, 7 type III) feet were rated as satisfactory (60-80 points) and one (type III) foot with fair (56 points). Nine patients (5 type II and 4 type III) indicated that they would not undergo the operative procedure again. Our results show inclusive evidence that minimal invasive osteotomies have a good clinical outcome in the treatment of high-grade deformities. The best future option is to consider the classification of the deformity before a minimally invasive operation is to take place.

Osteotomies for bunionette deformity

A variety of surgical osteotomy procedures have been described for the bunionette deformity.Metatarsal osteotomies narrow the forefoot, maintain the length of the metatarsal, and preserve function of the metatarsophalangeal joint. Distal metatarsal osteotomies produce less correction and reduce postoperative disability; however, they pose a risk of inadequate correction because of the small width of the fifth metatarsal head and transfer lesions if shortened or dorsiflexed excessively. The sliding oblique metaphyseal osteotomy described by Smith and Weil (without fixation) and later by Steinke (with fixation) is easy to perform and provides good cancellous bone contact. Fixation is sometimes difficult and bone healing can take a few months owing to the unstable construct of this osteotomy. Kitaoka described a distal chevron osteotomy, which provides lateral pressure relief and reduced plantar pressure. This osteotomy is currently the most common procedure used; however, it may prove difficult to perform if the deformity is large and the bone is narrow. Diaphyseal osteotomies are indicated when greater correction is needed; however, they require more dissection and there is greater postoperative convalescence with non–weight bearing for several weeks. Proximal base osteotomies may be used to address significantly increased 4–5 IMAs or when a large degree of sagittal plane correction is required. Approaches that have been described include opening and closing base wedges and basal chevrons. Advantages to this approach are the ability to avoid epiphyseal plates in pediatric patients and maintain function of the MTPJ, while disadvantages include inherent instability of the location of the osteotomy, embarrassment of intraosseous and extraosseus blood supply of the metatarsal, and technical demand. Non–weight bearing is essential for several weeks. The Scarfette procedure is a combination head–shaft procedure, which is indicated to treat mild to moderate transverse and sagittal plane deformities.9,19. The inherent stability of the osteotomy and ability for early weight bearing of the Scarfette makes this our procedure of choice when selecting treatments for patients with a bunionette deformity.

Scarf osteotomy for correction of Tailor's bunion: mid- to long-term followup

BACKGROUND

The purpose of the study was to evaluate the increased correction possible with a mid shaft rotational osteotomy with the stability and ease of fixation associated with a scarf osteotomy.

MATERIALS AND METHODS

Between September 1999 and September 2006, 63 patients underwent operative repair of 77 Tailor's bunion deformities. Twenty eight patients (36 feet) were available for a final review (nine males and 19 females). A further seven patients (nine feet) completed a questionnaire. The mean followup period for the 28 patients reviewed in clinic was 6.5 years, (79.5 months; SD, 22).

RESULTS

Eighty-six percent were completely satisfied, 11.4% were satisfied with reservations and 3% were dissatisfied. Ninety-one percent considered themselves better than before their surgery while 8.6% felt they were no better. Ninety-one percent of patients said they would undergo surgery under the same conditions again. Preoperatively, the mean 4-5 intermetatarsal angle measured on weightbearing X-rays was 9.9 degrees (SD, 2.2), the mean postoperative intermetatarsal angle was 5.7 degrees (SD, 2.0). The mean preoperative AOFAS score was 44.1 (SD, 14.5) and the mean postoperative score at 6-month review was 91.8 (SD, 20.2). The AOFAS score at final review was 88.1 (SD, 11.6).

CONCLUSION

The rotational scarf osteotomy was a reliable procedure for the correction of Tailor's bunion deformities. The osteotomy allowed for early mobilization and had few associated complications. The rotational scarf osteotomy facilitated correction of the intermetatarsal angle while maintaining excellent sagittal and transverse plane stability.

The minimally invasive osteotomy "S.E.R.I." (simple, effective, rapid, inexpensive) for correction of bunionette deformity

BACKGROUND

A bunionette is a deformity of the fifth metatarsal bone with a varus deviation of the toe which can require surgical correction. Although numerous bony or soft tissue surgical procedures have been described, the ideal treatment has not yet been identified. The aim of this study was to retrospectively evaluate the results of a series of 50 consecutive feet affected by symptomatic bunionette deformity treated by S.E.R.I. (simple, effective, rapid, inexpensive) osteotomy.

MATERIALS AND METHODS

Between February 1998 and March 2004, 50 feet with symptomatic type II-III bunionette deformity in 32 patients (18 bilateral) underwent S.E.R.I osteotomy. The average age of the patients at the time of operation was 33 +/- 13 years. The average followup was 4.8 (range, 2 to 8) years.

RESULTS

The average modified lesser toe AOFAS score increased from 62.8 +/- 15.2 points preoperatively to 94 +/- 6.8 points at last followup (p < 0.0005). The average fifth metatarsophalangeal (MTP) angle decreased from 16.8 +/- 5.1 degrees preoperatively to 7.9 +/- 3.1 degrees at final followup (p < 0.0005). The 4-5 intermetatarsal angle (I.M.A) averaged 12 +/- 1.7 degrees preoperatively, while postoperatively was 6.7 +/- 1.7 degrees (p < 0.0005). Complications included a skin inflammatory reaction around the Kirschner wire and 2 symptomatic plantar callosities under the fourth metatarsal heads.

CONCLUSIONS

The minimally invasive osteotomy is an effective and reliable technique for the treatment of painful bunionette, and it achieved more than 90% excellent and good results with reduced surgical time and complications.

Correction of tailor's bunion with the Boesch technique: a retrospective study

BACKGROUND

The Boesch technique(1,2) is a minimally-invasive and time-saving subcutaneous subcapital metatarsal osteotomy. Since 1984, we have been using this osteotomy technique for patients with a symptomatic tailor's bunion in whom conservative treatment has failed. This distal osteotomy is stabilized by a combination of a Kirschner wire and a special dressing. The results of this technique in patients with symptomatic tailor's bunion were reviewed.

METHODS

Between March, 1998, and June, 2002, surgery was done in 77 feet of 65 patients with a mean age of 64.6 years. The mean followup was 56.6 (range 14 to 79) months. The 100-point American Orthopaedic foot and Ankle Society (AOFAS) Lesser Metatarsophalangeal-Interphalangeal Scale was used for scoring.

RESULTS

86.4% of 57 patients (66 feet) were free of pain at final followup. The mean 4-5 intermetatarsal angle was 12 degrees before and 8 degrees after surgery. The mean lateral deviation of the fifth metatarsal was 5.7 degrees before and 5.1 degrees after surgery. The mean fifth metatarsophalangeal angle was 17.8 degrees before and 6.2 degrees after surgery. The mean preoperative 100-point AOFAS score was 59.1 (range 23 to 88) and the postoperative score, 95.2 (range 73 to 100). The overall results were excellent in 87.9%, (58 feet) good in 6.1% (4 feet), and satisfactory in 6.1%; none was poor.

CONCLUSIONS

The advantages of the subcutaneous subcapital Boesch technique are that it is time saving, it causes less bone and soft-tissue trauma, and it is performed under local anesthesia without a tourniquet. It is an effective operative option for symptomatic tailor's bunion; excellent and good clinical and radiographic results were found in 86.4% (57 patients, 66 feet) of the patients.

Bunionette deformity

The bunionette, or tailor's bunion, is a lateral prominence of the fifth metatarsal head. Most commonly, bunionettes are the result of a widened 4-5 intermetatarsal angle with associated varus of the metatarsophalangeal joint. When symptomatic, these deformities often respond to nonsurgical treatment methods, such as wider shoes and padding techniques. When these methods are unsuccessful, surgical treatment is based on preoperative radiographs and associated lesions, such as hyperkeratoses. In rare situations, a simple lateral eminence resection is appropriate; however, the risk of recurrence or overresection is high with this technique. Patients with a lateral bow to the fifth metatarsal are treated with a distal chevron-type osteotomy. A widened 4-5 intermetatarsal angle often requires a diaphyseal osteotomy for correction.

Modified Coughlin procedure for surgical treatment of symptomatic tailor's bunion: a prospective followup study of 33 consecutive operations

BACKGROUND

Symptomatic tailor's bunion is a painful osseous and soft-tissue prominence at the lateral aspect of the fifth metatarsal head. If conservative treatment fails, surgery is necessary to correct the deformity and to relieve the symptoms. The "Coughlin" procedure is an established corrective diaphyseal realignment osteotomy. The purpose of this study was to analyze the results of a modification of the Coughlin procedure in a series of 24 consecutive patients.

METHODS

Between October, 1999, and August, 2002, we performed a modified Coughlin procedure for painful tailor bunions in 24 patients (33 feet). An additional bunionectomy was done only if the fifth metatarsal head remained prominent after the osteotomy (20 feet). The average age of the patients was 45 years. All patients were evaluated preoperatively and postoperatively using the AOFAS forefoot score, and the correction of the fourth-fifth intermetatarsal angle was assessed on full weightbearing dorsoplantar radiographs. The average followup was 24 months for objective and 39 months for the subjective results.

RESULTS

There were no intraoperative and postoperative complications. The mean AOFAS score increased from 55 points preoperatively to 95 points at followup. At longest followup the subjective results were rated as good or excellent in 22 patients (97%). No difference in subjective patient satisfaction was seen whether bunionectomy was done or not. The mean fourth-fifth intermetatarsal angle improved from 10.4 degrees preoperatively to 1 degree at followup. Six patients (18%) required screw removal which was carried out on an outpatient basis under local anesthesia.

CONCLUSION

The modified Coughlin procedure is a technically safe and reliable procedure for treatment of painful tailor's bunion. In our experience, it yields good or excellent results with high patient satisfaction and a low complication rate. Internal screw fixation leads to stable bony fusion with full weightbearing immediately postoperatively and is associated with a relatively low rate of implant removal.

The tailor's bunionette deformity: a field guide to surgical correction

The author presents a detailed review of the Tailor's bunionette deformity of the fifth metatarsal with special emphasis on radiographic analysis and surgical correction. The surgical techniques discussed include (1) partial metatarsal head ostectomy; (2) metatarsal head resection; (3) minimal incision osteotomy; (4) osteotomies about the metatarsal head-neck, shaft, and base; and (5) ancillary soft tissue procedures. Techniques employed to prevent and correct potential complications are discussed in detail for each osteotomy.

Proximal dome-shaped osteotomy for symptomatic bunionette

The results of a dome-shaped osteotomy of the proximal third of the fifth metatarsal in patients with symptomatic bunionette deformity were reviewed. The series was comprised of eight patients (10 feet; mean age of patients, 21 years). The average followup was 30 months. All patients were free from pain at the fifth metatarsophalangeal joint and were satisfied with the results of this procedure. The mean angle between the longitudinal axes of the fifth metatarsal and the proximal phalanx was 18.9 degrees before surgery and 2.6 degrees after surgery. The mean angle between the longitudinal axes of the fourth and fifth metatarsals was 12.2 degrees before surgery and 4.8 degrees after surgery. The overall results were good in all 10 feet. Three feet had delayed union at the osteotomy site, but union was obtained in all feet. The osteotomy site of the fifth metatarsal in feet with delayed union was more proximal than that of the other feet. Therefore, proximal osteotomy of the fifth metatarsal should be done not at the base, but at the proximal site of the diaphysis to prevent delayed union. A proximal dome-shaped osteotomy corrects the deformity and relieves the symptoms, but careful attention should be paid to the osteotomy site.

Complications of lesser toe surgery

Surgical procedures for lesser toe problems are among the most common surgeries done on the foot. In a shoe wearing population, the incidence of lesser toe pathologic disorders is high. The complications associated with lesser toe surgery can be troublesome for patients and physicians. Understanding the possible common complications and how to avoid them is essential to maximizing satisfactory clinical results.

Osteotomies of the fifth metatarsal

Although the literature is limited primarily to retrospective small case series of the operative technique of fifth metatarsal osteotomies with a short follow-up, some important information can be learned. Stabilization of the osteotomy with Kirschner wire fixation appears to decrease dorsal displacement of the distal fragment and distal osteotomies; this leads to decreased incidence of transfer metatarsalgia. Kirschner wire fixation is advocated. The proximal chevron osteotomy of the fifth metatarsal, although stable, has a 20% delayed union rate, most likely resulting from the unique vascular anatomy in this region. The radiographic and clinical results appear to be compatible between distal and proximal osteotomies. Based on this information, primary use of a proximal osteotomy technique is not recommended. The oblique diaphyseal osteotomy technique requires an incision for the osteotomy as well as a distal incision at the metatarsophalangeal joint for correction of this joint. Hardware removal was performed in most patients, and the complications included two cases of delayed union. Time to healing was reported to be 8 weeks, 1.5 times the reported time to healing in distal chevron osteotomies. A significant radiographic correction was noted with the oblique diaphyseal osteotomy; however, radiographic measurements can be altered with foot position and lack of x-ray standardization and technique. Kitaoka et al found no correlation with the degree of radiographic correction and post-operative clinical symptoms. The authors agree with Kitaoka et al that the oblique diaphyseal osteotomy should be reserved for patients who fail an initial distal osteotomy technique. Distal oblique osteotomies appear to have less stability and more complications with malunion, transfer metatarsalgia, and delayed union and should be abandoned for a more stable chevron technique. The distal chevron osteotomy has a small incidence of transfer metatarsalgia; however, it appears to improve the clinical radiographic appearance of [table: see text] the foot with a shortened time to healing (4 to 6 weeks). A biplanar technique can be employed with a distal chevron osteotomy to improve plantar callosity symptoms. More studies are needed to examine critically patient outcomes with uniplanar and biplanar techniques using the distal chevron osteotomy.