Chevron osteotomy for bunionette

Midterm Outcomes of Sliding Distal Metatarsal Minimally Invasive Osteotomy to Treat Bunionette Deformity

BACKGROUND

Bunionette deformity is described as a painful bony prominence on the lateral aspect of the fifth metatarsal head. The present study prospectively assessed the clinical, functional, and radiographic outcomes of sliding distal metatarsal minimally invasive osteotomy (S-DMMO) used in a large series of patients with a midterm follow-up period.

METHODS

From December 2015 to December 2018, we evaluated 74 feet (57 patients). Radiologic (4-to-5 intermetatarsal angle, fifth metatarsophalangeal angle, the fifth metatarsal head width, lateral deviation angle, fifth metatarsal length, medial displacement, and elevation), clinician-reported scores (AOFAS score, visual analog scale [VAS]) and patient-reported outcomes measure (Foot and Ankle Ability Measure [FAAM] activities of daily living [ADL], FAAM sports, Manchester-Oxford Foot Questionnaire [MOXFQ], and patient satisfaction survey) were included in the analysis. The time to bone union was also assessed.

RESULTS

The average 4-to-5 intermetatarsal angle improved from 11.1 degrees preoperatively to 4.5 degrees postoperatively (P < .001), whereas the average fifth metatarsophalangeal angle improved from 15.7 degrees preoperatively to 4.8 degrees postoperatively (P < .001). The lateral deviation angle was found to be 2.2 degrees. The fifth metatarsal length decreased from 66.6 to 64.3 mm postoperatively. The average initial medial displacement was 4.67 mm preoperatively and 4.54 mm at final follow-up. The elevation of the fifth metatarsal head was 1.08 mm. The American Orthopaedic Foot & Ankle Society score improved from 54.3 ± 20.86 points preoperatively to 93.4 ± 17.3 (P < .001). VAS score decreased from 7.9 to 0.7 (P < .001). Also, FAAM ALD, FAAM Sport, and MOXFQ showed statistically significant differences (P < .001) between preoperative and postoperative periods. Patients found the procedure excellent in 89.1% of cases, very good in 5.4%, and good in 5.4%. Bone union was obtained at 8.1 weeks.

CONCLUSION

The most important finding of the present study is that S-DMMO showed improvement in function and pain associated with a high satisfaction rate. Also, we found substantial capacity to correct deformities and a low incidence of complications.

LEVEL OF EVIDENCE

Level IV, case series.

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.

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.

Percutaneous bunionette correction

BACKGROUND

Treatment of tailor's bunion is largely conservative. For severe or refractory cases surgical intervention is necessary. The aim of this study is to evaluate a percutaneous technique for correcting such bunionette deformities.

METHODS

Twenty-one procedures were performed on 20 patients using a percutaneous technique. Patients were scored using the American Orthopaedic Foot & Ankle Society (AOFAS) Lesser Toe Metatarsophalangeal-Interphalangeal Scale.

RESULTS

No wound healing problems, infections, non-unions or mal-unions occurred. Functional assessments revealed very good results. Radiographic evaluation confirmed good average correction of the fourth-fifth intermetatarsal angle and metatarsophalangeal angle.

CONCLUSIONS

This percutaneous technique is a reliable and effective approach for the treatment of bunionette deformity. The results obtained were comparable to those reported using traditional open techniques, but major complications due to soft tissue damage were averted. This technique can be adapted depending on the type of deformity, and does not require internal fixation.

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.

'Reverse' scarf osteotomy for bunionette correction: Initial results of a new surgical technique

BACKGROUND

The bunionette or tailor's bunion is a lateral prominence of the fifth metatarsal head. It is usually characterised by a wide intermetatarsal angle (IMA) between the 4th and 5th metatarsals, varus of the metatarsophalangeal (MTP) joint, pain and callus formation. Various distal, shaft and basal osteotomies have been described in the literature. We have described a reverse scarf osteotomy for bunionette correction.

PATIENTS AND METHODS

We have used a 'reverse' scarf osteotomy in 12 cases (10F: 2M) with a mean follow-up of 12 months (range 5-22 months) with radiographs and clinical scoring.

RESULTS

Post operatively, mean IMA improved from 13.1° to 7.27° (range 2.0-11.5°); mean 5th MTP angle improved from 19.9° to 6.36° (range 2.8-9.0°) and postoperative mean AOFAS improved from 54.25 to 89.58 (range 70-100).

CONCLUSION

'Reverse' scarf osteotomy in the correction of bunionette deformity offers promising results in the short term.

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.

Transverse medial slide osteotomy for bunionette deformity: long-term results

BACKGROUND

Bunionette deformity of the fifth metatarsal infrequently requires operative treatment. This study presents the long-term results of a simple operative technique.

METHODS

Forty-four distal metatarsal medial slide osteotomies with pin fixation were performed for symptomatic bunionette deformity in 30 patients. After an average of 7 years and 8 months (range 69 to 110 months), 30 feet in 21 patients were available for clinical and radiographic evaluation.

RESULTS

The patients' subjective assessment was excellent and good in 81% and fair and poor in 19% of feet. The mean pain score on a visual analogue scale was 1.8 (range 0 to 7) and the mean American Orthopaedic Foot and Ankle Society (AOFAS) score was 88.2 (range 47 to 100). Postoperative complications included pin track infection in three feet and delayed union in one. One patient developed transfer metatarsalgia and another patient had repeat surgery for recurrent symptoms on both feet after 5 years.

CONCLUSIONS

This procedure combines technical simplicity with satisfactory and predictable long-term results in the operative treatment of bunionette deformity in the lateral forefoot.

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.

Tailor's bunion: a review

The tailor's bunion is a painful bony prominence on the lateral aspect of the fifth metatarsal head that occurs in many individuals, but seldom causes symptoms. This article reviews the current literature regarding the presentation, etiology, and management of the tailor's bunion. The first line of management should be conservative, with advice on shoe wear. Orthotics may be useful if a symptomatic tailor's bunion results from excessive subtalar joint pronation. Operative management, indicated when symptoms are not controlled nonoperatively, aims to decrease foot width and the prominence of the tailor's bunion. Procedures can be grouped into resections and distal, diaphyseal, and proximal osteotomies. A distal osteotomy is recommended if medial translation of the head for one-third of the width of the metatarsal shaft produces a normal fourth-fifth intermetatarsal angle. A proximal osteotomy can be performed in the face of larger deformities. The management of recurrent tailor's bunion is still controversial. If the recurrence is due to under-correction, or if the initial procedure was not the best suited to that particular patient, then revision surgery may be helpful, after the cause of the failure has been established. Although unpopular, resection should be considered as the final salvage procedure.

Bunionette deformity correction with distal chevron osteotomy and single absorbable pin fixation

Between January 1997 and July 2000, 10 patients with symptomatic bunionette deformity underwent 12 distal fifth metatarsal chevron osteotomies in which an absorbable poly-p-dioxanone suture (PDS) pin was used for fixation. Of the 10 patients, nine were female. Average age at operation was 41 years (range, 23-70). Mean duration of follow-up was 48 months (range, 6-81). All patients obtained clinical and radiographic union by 6 weeks, and there was no radiographic evidence of osteolysis, displacement, or avascular necrosis of the metatarsal head at final follow-up. There were no serious complications. The average postoperative AOFAS score was 93 of 100 possible. All patients were satisfied with the procedure and would have it again. Distal chevron osteotomy with a single, nonpredrilled PDS absorbable pin for the correction of symptomatic bunionette deformity is a reliable and effective technique that provides adequate fixation without complications.

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.

Bunionette

The bunionette, or tailor's bunion, is a painful osseous prominence on the lateral aspect of the head of the fifth metatarsal. This prominence occurs in many individuals but seldom causes symptoms. Orthotic devices may be useful if a symptomatic bunionette results from excessive pronation of the subtalar joint. Operative management to decrease the width of the foot and the osseous prominence is indicated when nonoperative treatment can no longer control symptoms and when the patient has special demands, particularly in sports. A proximal osteotomy is able to correct most deformities. A distal osteotomy is recommended if medial translation of the head for one-third of the width of the metatarsal shaft produces a normal fourth-fifth intermetatarsal angle.