You are in: eMedicine Specialties > Orthopedic Surgery > FOOT AND ANKLE BunionetteArticle Last Updated: Jul 13, 2004AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  Author: Christopher Brown, MBBS, FRCS(C), FRACS, FAOrthA, Clinical Lecturer, Department of Orthopaedics and Trauma, University of Adelaide, Australia Christopher Brown is a member of the following medical societies: American Academy of Orthopaedic Surgeons and American Orthopaedic Foot and Ankle Society Coauthor(s): Nancy Cullen, MD, FRCSC, FRACS, Senior Visiting Medical Officer, Clinical Lecturer, Department of Orthopaedics and Trauma, University of Adelaide, Australia; Linda Ferris, MBBS, BScMed, Chairman, Department of Orthopaedics, Modbury Public Hospital; Clinical Lecturer, Department of Orthopaedics and Trauma, University of Adelaide, Australia Editors: James K DeOrio, MD, Director of Foot and Ankle Fellowship Program, Assistant Professor of Orthopedic Surgery, Orthopedic Surgery, St. Luke's Hospital, Jacksonville, Florida; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Shepard R Hurwitz, MD, Executive Director Designate, American Board of Orthopaedic Surgery; Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital; Jason H Calhoun, MD, FAAOS, Chairman, J Vernon Luck Distinguished Professor, Department of Orthopedic Surgery, University of Missouri Author and Editor Disclosure Synonyms and related keywords: tailor's bunion, fifth metatarsalgia, opposite side bunion INTRODUCTIONSection 2 of 12
  The term "tailor's bunion" initially described an acquired lesion that caused chronic pain and swelling over the lateral aspect of the fifth metatarsal head. These lesions often were present on tailors, whose traditional cross-legged sitting posture on benches resulted in pressure being placed on the lateral side of the foot, leading to the development of painful bunionettes. Davies later described the lesion in the English literature in 1949. ProblemA bunionette is a painful prominence on the lateral aspect of the fifth metatarsal head. While not as common as a medial bunion, it is a cause of chronic pain and shoe-fitting problems in individuals whose feet are characterized by a widened forefoot or in those who have a lateral splaying or prominence over the fifth metatarsal. FrequencyUS In Western society, the occurrence of bunionettes is related to narrow footwear on predisposed foot anatomy. The actual incidence is not accurately known, but it is far less of an isolated presenting problem than hallux valgus. However, it is commonly seen in patients who present with hallux valgus secondary to splaying of the forefoot. It may or may not be symptomatic at the same time. Females represent up to 90% of symptomatic patients in some series. International Few reports exist in the literature on the incidence in nonwestern countries. This is probably a result of less wear of constricting shoes and hence, less occurrence. EtiologyCauses can be extrinsic or intrinsic. Extrinsic causes can be traumatic, either acute or more commonly chronic (eg, tailors' working posture, footwear). Intrinsic causes can be related to structural abnormalities such as congenital lateral bowing of the metatarsal shaft, abnormal intermetatarsal ligament insertion with prominence of the fifth metatarsal, brachymetatarsia, or primary hypertrophy of the metatarsal head. Congenital splayfoot is a more generalized congenital predisposing lesion. Iatrogenic causes can occur as a result of failed adjacent metatarsal surgery or residual malalignments from hindfoot surgery, which cause increased prominence of the fifth metatarsal. Inflammatory arthropathies also can cause bunionette deformities or soft tissue lesions in association with bony problems. PathophysiologyPathological lesions include an inflamed bursa overlying the lateral aspect of the metatarsal head, a bony enlargement of the head itself, or an increased intermetatarsal angle between the fourth and fifth metatarsals with secondary medial angulation of the phalanx and abnormal curvature of the fifth metatarsal. Recognition of the varying pathologies is an essential part of surgical management. ClinicalPresenting symptoms usually include painful keratoses over the lateral aspect of the metatarsal head, but they also may be present on the plantar and dorsal aspects. Medial deviation of the fifth phalanx with some rotation is frequently seen. Differentiating whether the patient is truly having pain or whether the patient just finds his or her foot cosmetically unacceptable is important. Assessing whether the deformity is fixed or correctable also is important. Examination should assess other foot deformities, such as hallux valgus, planovalgus foot deformity, and equinus, and the presence of neuritic symptoms or systemic arthropathy. INDICATIONSSection 3 of 12
Surgery 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. RELEVANT ANATOMYSection 4 of 12
The underlying pathoanatomy and pathophysiology determine procedure selection. No single, universally acceptable procedure exists for all patients. The pathoanatomy of the bunionette varies with different types of lesions. Usually, there is a component of prominence of the lateral aspect of the fifth metatarsophalangeal (MTP) joint. Stretching and attenuation of the capsule may occur with medial subluxation of the proximal phalanx. Both long flexors and extensors can be medial to the head, leading to a deforming force on the toe that increases with increasing deformity. Rotation of the phalanx also can occur. The normal fourth and fifth intermetatarsal angle is approximately 6.2°, and the normal fifth MTP angle is about 10°. Pathological angles are in the range of 10° for the intermetatarsal angle and 16° for the MTP angle. CONTRAINDICATIONSSection 5 of 12
Absolute and relative contraindications to surgery include pure cosmetic deformity, vascular impairment, severe diabetic arthropathy, significant infection with bony involvement, psychiatric disorders that prevent appropriate postoperative compliance, severe osteoporosis, and 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 require treatment with ablative rather than reconstructive procedures. WORKUPSection 6 of 12
Lab Studies
Imaging Studies
Other Tests
StagingOther than the pathoanatomic classification (see Workup, Imaging Studies), no specific staging classifications for the lesion exist. Some authors have referred to mild or severe deformity, but no indication is given to define the limits used. TREATMENTSection 7 of 12
Medical therapyTreatment 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 therapySurgical procedures are determined by the pathoanatomy.
Preoperative detailsThese surgeries can be performed on an outpatient basis. Assess general fitness for ankle block, popliteal block, or more general anesthesia. Intraoperative detailsLongitudinal 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 detailsPostoperative 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. Follow-upReturn 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. COMPLICATIONSSection 8 of 12
Complications include malunion, nonunion, nerve injury, 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. OUTCOME AND PROGNOSISSection 9 of 12
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. FUTURE AND CONTROVERSIESSection 10 of 12
Minimal incision surgery is not appropriate for management of this condition. Future progress may include different osteotomies. MULTIMEDIASection 11 of 12
REFERENCESSection 12 of 12
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