Updated: 9/8/2021

Bunionette Deformity

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  • summary
    • Bunionette Deformities, commonly called tailor's bunion, are prominences on the lateral aspect of the 5th metatarsal head that most commonly occur as a result of compression of the forefoot.
    • Diagnosis is made clinically with presence of a prominence on the lateral aspect of the 5th metatarsal head, often associated with pain and callus formation.
    • Treatment can be nonoperative with shoe modifications for mild and minimally symptomatic cases. Surgical management is indicated for progressive deformity and difficulty with shoe wear
  • Epidemiology
    • Demographics
      • commonly seen in adolescents and adults
      • 2-4x more common in women
      • often bilateral deformities
  • Etiology
    • Pathophysiology
      • mechanism of disease
        • extrinsic causes
          • compression of forefoot (e.g. tight shoes)
          • abnormal loading on the lateral aspect of the foot
        • intrinsic causes
          • congenital deformities (e.g. splayfoot, brachymetatarsia)
          • inflammatory arthropathies
          • residual malalignments from surgery
      • pathoanatomy
        • boney prominence +/- bursitis over lateral aspect of 5th metatarsal head
        • increased 4-5 intermetatarsal angle (normal 6.5-8 degrees)
        • increased lateral deviation angle (normal 0-7 degrees)
        • increased width of MT head (normal <13mm)
        • lateral bowing of the 5th metatarsal bone
    • Associated conditions
      • varus MTP joint
      • pes planus
  • Classification
    • Bunionette Deformity Classification
      Type I
      Enlarged 5th MT head or lateral exostosis
      Type II
      Congenital bow of 5th MT, normal 4-5 IMA
      Type III
      Increased 4-5 IMA (most common)
  • Presentation
    • History
      • effect on activities and employment
    • Symptoms
      • cosmetic deformity
        • medial deviation of 5th toe
        • prominence of the 5th metatarsal head
      • pain
        • lateral bunion
        • plantar callus
        • worse with constrictive shoe wear
    • Physical exam
      • inspection
        • plantar or lateral hyperkeratosis
        • widened forefoot
        • erythema and swollen 5th bunion
        • check shoe wear
      • motion
        • often painless passive ROM of 5th MTP joint
  • Imaging
    • Radiographs
      • recommended views
        • standard weight-bearing films, dorsoplantar, lateral & oblique films
      • characteristic findings
        • increased 4-5 IMA (normal 6.5-8 degrees)
        • increased lateral deviation angle (normal 0-7 degrees)
        • increased width of MT head (normal <13mm)
    • CT scan
      • indications
        • ancillary studies rarely required
        • may be used if there is associated trauma or malignancy
  • Treatment
    • Nonoperative
      • NSAIDS, shoe wear modification, orthotics, keratosis padding, callous shaving
        • indications
          • indicated as first-line treatment of all types
          • asymptomatic deformities
        • techniques
          • semi-rigid shoe inserts
          • wide based shoes
          • stretching the forefoot of existing shoes
        • outcomes
          • 75-90% success rate
    • Operative
      • lateral condylectomy
        • indications
          • symptomatic Type I deformities
        • technique
          • resection of lateral third of the 5th MT head
          • combine with tightening of lateral MTP joint capsule
        • outcome
          • does not require extended period of immobilization
      • distal metatarsal osteotomy
        • indications
          • Type 2 and 3 deformities if IMA is < 12 degrees
        • technique
          • different techniques described
            • chevron-medializing osteotomy (most common)
            • distal transverse osteotomy
            • peg-and-slot type osteotomy
            • stepcut osteotomy
          • better stability of fragments with internal fixation (e.g. K-wire or screw)
          • may be combined with distal condylectomy and tightening of lateral capsule
        • outcomes
          • chevron osteotomy is biomechanically the strongest construct compared to the other proximal osteotomies
      • oblique diaphyseal rotational osteotomy
        • indications
          • symptomatic Type 2 and 3 if IMA is > 12 degrees
        • technique
          • shave plantar aspect 5th MT head if plantar callosity present
          • proximal osteotomy should be avoided due to poor blood supply in this region of the metatarsal
          • fixation achieved with screw
        • outcomes
          • may produce 5th MT shortening
      • metatarsal head resection
        • indications
          • salvage procedure only
          • leads to unacceptable instability of MTP joint
  • Complications
    • Recurrence
      • is the most common complication with condylectomy alone
    • Transfer metatarsalgia
      • seen with isolated metatarsal head resection
    • Claw toe
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(SBQ12FA.63) Figure A shows a clinical image of a 45-year-old female who complains of swelling and pain over the lateral aspect of the fifth metatarsophalangeal joint. She has tried all nonoperative recommendations with no improvement. Figure B shows an AP radiograph of her foot. What surgical treatment is indicated in this scenario?

QID: 3870
FIGURES:
1

Lateral Condylar Resection

57%

(1237/2157)

2

Metatarsal Head Resection

6%

(125/2157)

3

Distal Osteotomy

23%

(500/2157)

4

Proximal Osteotomy

8%

(178/2157)

5

Diaphyseal Osteotomy

5%

(109/2157)

L 4 C

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(OBQ11.134) Distal chevron osteotomies are most indicated for which of following scenarios involving a bunionette deformity?

QID: 3557
1

Type I deformities in patients who will not tolerate weight bearing restrictions post-operatively

2%

(53/2241)

2

Patients with a laterally bowed fifth metatarsal, no keratotic lesions, and a normal 4-5 intermetatarsal angle

44%

(976/2241)

3

Patients who remain symptomatic after prior extensive lateral condylar resection

7%

(147/2241)

4

Type III deformity with a 4-5 intermetatarsal angle of 13 degrees

28%

(633/2241)

5

Painful type I deformity with associated intractable lateral keratotic lesions

18%

(404/2241)

L 4 C

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(OBQ10.250) A diaphyseal fifth metatarsal osteotomy is the optimal surgical treatment for which of the following patients who has failed nonsurgical management?

QID: 3355
1

28-year-old woman with a Jones fracture nonunion

2%

(71/3534)

2

50-year-old woman with a physiologic bow to the 5th metatarsal and a lateral prominence of the 5th metatarsal head

18%

(623/3534)

3

54-year-old woman with a widened 4-5 intermetatarsal angle and a lateral prominence of the 5th metatarsal head

73%

(2594/3534)

4

35-year-old woman with prominent lateral condyle of her 5th metatarsal head, without bowing of the metatarsal and with normal 4-5 intermetatarsal angle

5%

(182/3534)

5

60-year-old woman with rheumatoid arthritis and a plantar plate rupture

1%

(50/3534)

L 2 C

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