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Bunionette

Manjunath Koti, MS(AIIMS), DNB(Orth), FRCS(Glas)
Department of Orthopaedic Surgery, University of Aberdeen Medical School, Polwarth Building, Foresterhill, Aberdeen AB25 2ZD, Scotland

Nicola Maffulli, MD, MS, PhD, FRCS(Orth)
Department of Trauma and Orthopaedic Surgery, Keele University School of Medicine, Thurnburrow Drive, Hartshill, Stoke on Trent, Staffordshire ST4 7QB, England. E-mail address: n.maffulli{at}keele.ac.uk

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

	Abstract

Top Abstract Introduction Clinical Presentation Etiology Imaging Studies Classification of Bunionette Management Scoring Systems Choosing a Procedure Overview References

 
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.

	Introduction

Top Abstract Introduction Clinical Presentation Etiology Imaging Studies Classification of Bunionette Management Scoring Systems Choosing a Procedure Overview References

 
The bunionette, or tailor’s bunion, is a painful osseous prominence on the lateral aspect of the head of the fifth metatarsal. The term tailor’s bunion originated in the nineteenth century, as it was thought to be common in tailors, who sit with their legs crossed, putting pressure on the outer borders of their feet, causing a hypertrophic skin callosity over the fifth metatarsal head. Davies¹, in 1949, reported that the condition was due to splaying of the fifth metatarsal. This prominence occurs in many individuals but seldom causes symptoms.

	Clinical Presentation

Top Abstract Introduction Clinical Presentation Etiology Imaging Studies Classification of Bunionette Management Scoring Systems Choosing a Procedure Overview References

 
The bunionette is commonly seen in adolescents and adults^2-4, with a female-to-male ratio that may range between 1:1 and 10:1^5-7. For unknown reasons, bunionette is surprisingly common in athletes, especially downhill skiers. Regardless of the etiology of bunionette, the abnormal swelling of the soft tissues over the lateral aspect of the head of the fifth metatarsal can cause pain. The patient may present with pain dorsolaterally, laterally, or plantarly in relation to the head of the fifth metatarsal, especially when wearing constricting shoes. Erythema and edema of the affected toe are often present; rarely (unless the patient is diabetic), the toe may become infected and the infection may lead to ulceration. With continuous pressure and chronic irritation over this osseous prominence, a secondary hyperkeratotic lesion on the lateral or plantar-lateral aspect of the fifth metatarsophalangeal joint is often seen, at times with formation of an adventitious bursa. The hyperkeratosis may cause the fifth toe to deviate medially at the metatarsophalangeal joint while the fifth metatarsal deviates laterally. This may be associated with varus fifth-toe deformity, hallux valgus (abnormal pronation of the first metatarsal), hindfoot varus (often seen in rheumatoid disease), and pes planus⁶.

	Etiology

Top Abstract Introduction Clinical Presentation Etiology Imaging Studies Classification of Bunionette Management Scoring Systems Choosing a Procedure Overview References

 
Normally, the fifth metatarsal deviates from the fourth metatarsal by approximately 5°. In addition, the head of the fifth metatarsal is generally broader than the shaft of the metatarsal. Therefore, it may be prominent over the lateral side of the foot, with pain caused by footwear. Later, the formation of a subcutaneous bursa may lead to local inflammation and infection.

Anatomical Causes
Pressure over the lateral aspect of the fifth metatarsal due to a tight shoe, the position of the foot (as in tailors), a prominent lateral condyle with excessive friction, and hypertrophy of the soft tissues over the lateral aspect of the metatarsal head may lead to bunionette formation^7-11. A short or dumbbell-shaped fifth metatarsal may also lead to formation of bunionette. Supernumerary ossicles attached to the lateral side of the fourth metatarsal, pushing the fifth metatarsal laterally; splaying (defined as an increased fourth-fifth intermetatarsal angle in combination with an increased first-second intermetatarsal angle); incomplete insertion or development of the transverse metatarsal ligament; and adductor hallucis (causing insufficient traction on the fifth metatarsal) have all been suggested as leading to bunionette formation^1,8.

Biomechanical Causes
The fifth metatarsal is the most mobile of the metatarsals, with a varus-valgus mobility of 10° to 20°¹². Lateral bending of the fifth metatarsal is the most common cause of bunionette^10,11,13. In most adolescents, the head of the fifth metatarsal is thin and responds to pressure by a tight shoe against it by bending laterally. Increased angular deviation between the fourth and fifth metatarsals, subluxatory pronation of the fifth metatarsal (associated with pronation of the subtalar and midtarsal joints), and excessive pronation due to hypermobility may also lead to bunionette formation^5,10,11,13. Congenital plantar or dorsiflexed fifth-ray deformities also may lead to bunionette⁹.

Mixed Causes
The increased frequency of bunionette deformity in patients with rheumatoid disease of the foot may be due to hyperpronation of the hindfoot and insufficiency of the intermetatarsal ligament. Repeated activities such as running may lead to thickening or inflammation of the bursa overlying it.

In patients with diabetes, advanced Charcot-Marie-Tooth disease, or spinal dysraphism, poor sensation over the foot with minor degrees of bunionette deformity may lead to severe ulceration with infection and loss of the entire fifth ray.

	Imaging Studies

Top Abstract Introduction Clinical Presentation Etiology Imaging Studies Classification of Bunionette Management Scoring Systems Choosing a Procedure Overview References

 
Objective definition of the radiographic anatomy of the symptomatic bunionette is lacking. Also, it is unclear how some of the measurements relate to the condition and to its management. Steel et al.¹⁴ recommended weight-bearing radiographs with the source of x-rays 12 in (30 cm) above the foot and tilted 15° for a dorsoplantar view. Lateral radiographs should be made with the cassette along the medial aspect of the foot and the x-ray source perpendicular to the cassette, which is 48 in (120 cm) away. A lateral radiograph enables proper evaluation of the longitudinal arches. Oblique radiographs are helpful for evaluating the fifth metatarsal head, lateral tubercle, metatarsal deviation, and lateral soft-tissue prominence¹⁵.

Fourth-Fifth Intermetatarsal Angle
The mean fourth-fifth intermetatarsal angle varies widely, in part because of the variety of measurement methods² (Fig. 1). The mean angle between the fourth and fifth metatarsals is 6.5°, with a range of 3° to 11°². In a series of 243 radiographs, the mean fourth-fifth intermetatarsal angle was 8°¹⁶. Another study showed that this angle was more than 10° on average in feet with a symptomatic bunionette¹⁷.

View larger version (16K): [in this window] [in a new window]   Fig. 1: Fig. 1 a: The fourth-fifth intermetatarsal angle as measured with one method. The angle is formed between a line along the medial and proximal portions of the shaft of the fifth metatarsal and a line drawn along the axis of the fourth metatarsal. This angle is more accurate than the one labeled b. b: The fourth-fifth intermetatarsal angle as measured with another method. The angle is formed between the long axes of the fifth and fourth metatarsals.

View larger version (12K): [in this window] [in a new window]   Fig. 2: Fig. 2 Measurement of the lateral deviation angle. On dorsoplantar radiographs, a line is drawn bisecting the midpoint of the articular surface of the head and neck of the fifth metatarsal. Another line is drawn adjacent and parallel to the medial surface of the proximal metatarsal, intersecting the first line and forming the lateral deviation angle (c).

View larger version (12K): [in this window] [in a new window]   Fig. 3: Fig. 3 The fifth metatarsophalangeal angle indicates the magnitude of medial deviation of the fifth toe in relation to the axis of the fifth metatarsal shaft.

	Classification of Bunionette

Top Abstract Introduction Clinical Presentation Etiology Imaging Studies Classification of Bunionette Management Scoring Systems Choosing a Procedure Overview References

 
Four types of bunionette have been described²⁰. In a series of thirty feet with symptomatic bunionette, Coughlin¹⁷ found three types. Type 1, enlargement of the lateral surface of the fifth metatarsal (Fig. 4), was seen in eight (27%) of the feet. The enlargement could be secondary to exostosis, a prominent lateral condyle, or a round or dumbbell-shaped metatarsal head. Type 2, lateral bowing of the distal aspect of the fifth metatarsal without hypertrophy of the metatarsal head (Fig. 5), was noted in seven (23%) of the feet. Type 3, an increase in the fourth-fifth intermetatarsal angle (Fig. 6) typical of splayfoot, was seen in fifteen (50%) of the feet.

View larger version (42K): [in this window] [in a new window]   Fig. 4: Fig. 4 Type-1 bunionette (enlargement of the lateral surface of the fifth metatarsal).

View larger version (88K): [in this window] [in a new window]   Fig. 5: Fig. 5 Type-2 bunionette (lateral bowing of the distal aspect of the fifth metatarsal without hypertrophy of the metatarsal head).

View larger version (58K): [in this window] [in a new window]   Fig. 6: Fig. 6 Type-3 bunionette (an increase in the fourth-fifth intermetatarsal angle).

The above is a morphological classification of a small sample. To our knowledge, no large population studies have been performed, and it is possible that the various types overlap with each other.

	Management

Top Abstract Introduction Clinical Presentation Etiology Imaging Studies Classification of Bunionette Management Scoring Systems Choosing a Procedure Overview References

 
Conservative Management
In the absence of evidence-based guidelines, we recommend shoes with a wide toe-box, especially if the patient wears narrow or high-heeled shoes. We have found that semi-rigid shoe inserts, metatarsal pads, metatarsal bars, and stretching of the shoes may provide some relief. Débridement of hyperkeratotic lesions with padding of the fifth metatarsal head may alleviate the pain. Orthotic devices may be useful if the symptoms are due to excessive pronation of the subtalar joint. When the pain is acute, as with an inflamed bursa, we prescribe nonsteroidal oral analgesics and anti-inflammatory medications as well as steroid injections to help to reduce the discomfort. In our practice, we do not use corticosteroid injections, but we have seen other surgeons injecting them in the area of the bunionette without evident adverse effects.

Operative Management
Operative management is indicated when nonoperative treatment can no longer control symptoms and when the patient has special demands, particularly in sports. The aim of operative treatment is to decrease the width of the foot and the prominence of the bunionette. The procedures described can be divided into resections and osteotomies. Amputations have also been described.

Resections
Resections are simple. The aim of all is to narrow the width of the forefoot. Several such procedures have been described^8,21, including resection of the lateral third of the fifth metatarsal head³ and resection of the entire fifth metatarsal head²². Resection can give satisfactory results in patients with rheumatoid arthritis and can be used as a salvage procedure in patients with intractable sepsis in that area. Patients may participate in rehabilitation without immobilization. The disadvantages are recurrence of deformity, joint instability, and production of an incongruous joint, with possible dislocation of the fifth metatarsophalangeal joint. Flail toe and clawing of the fifth toe may be made worse. Also, widening of the foot leading to transfer metatarsalgia (pain in the adjacent metatarsal or metatarsals following iatrogenic changes in the loading of the forefoot after a metatarsal has been operated on), and shortening of the fifth metatarsal with a transfer lesion under the fourth metatarsal head, can occur. Resection procedures are not effective for bunionettes with associated intractable plantar keratosis under the fifth metatarsal head, and we rarely limit our operative procedure to a simple resection.

Metatarsal Osteotomies
Metatarsal osteotomies are indicated when it is necessary to narrow the forefoot, maintaining the length of the metatarsal and the function of the metatarsophalangeal joint. Historically, some surgeons left the osteotomy site free or impacted the metatarsal head into the proximal fragment²³. The present tendency, which we advocate, is to use internal or percutaneous fixation. An internally fixed distal osteotomy controls postoperative dorsal displacement of the distal fragment and produces little shortening, with predictable healing time, prevention of further displacement on weight-bearing, and better maintenance of correction²⁴.

Distal Osteotomies
Distal osteotomies provide satisfactory correction but a less marked mean correction than that obtained with a basal osteotomy. Distal osteotomies also enable correction of the fourth-fifth intermetatarsal angle and offer the advantage of reduced postoperative disability. A large number of distal-osteotomy procedures have been described, but most are mainly of historical interest.

Sliding Oblique Metaphyseal Osteotomies²⁵
Sliding oblique metaphyseal osteotomies are easy to perform, are easy to teach, and are followed by a predictable postoperative course. The procedure has not resulted in nonunion in any of our patients. Given its location, this osteotomy affords good cancellous bone contact. A distal metaphyseal osteotomy of the fifth metatarsal with cortical-screw fixation offers a good level of correction with minimal morbidity and complications²⁶. If appropriate preoperative planning is performed and the principles of internal fixation are strictly adhered to, the risks of potential complications such as angular displacement, shortening, nonunion, and transfer lesions are minimized. The distal fragment should be transposed medially or medially and inferiorly. The osteotomy allows the head to recede proximally and medially (Figs. 7-A and 7-B). The biomechanics of the foot do not change, and a tender callosity under the head of the fourth metatarsal or subluxation of the fifth digit usually does not occur.

View larger version (15K): [in this window] [in a new window]   Fig. 7-A: a: Technique for sliding oblique metaphyseal osteotomy. The oblique osteotomy is started at the fifth metatarsal neck and is angled 40° to 45° in a proximal direction. b: The head is receded proximally and medially, and the distal 7 mm of the proximal fragment is removed if the proximal recession is impaled by the spike.

View larger version (76K): [in this window] [in a new window]   Fig. 7-B: A Kirschner wire is used to maintain stability.

Chevron Osteotomies²⁷
The chevron osteotomy is probably the type of osteotomy most commonly used in North America for the treatment of bunionette. We find it technically demanding because of the small osseous contact area and because the bone cuts must be very precise. However, it can be used not only to narrow the forefoot slightly and to relieve lateral pressure but also to reduce plantar pressure if a concomitant symptomatic callus of the head of the fifth metatarsal is present.

Metatarsal Diaphyseal Osteotomies
Metatarsal diaphyseal osteotomies allow greater correction than do distal metatarsal osteotomies, they do not interrupt the blood supply to the metatarsal head, and, when internally fixed, they produce no major risk of a transfer lesion.

Indications for a diaphyseal osteotomy are a bunionette deformity associated either with an increased intermetatarsal angle or with lateral metatarsal deviation or bowing. Realignment of the metatarsophalangeal joint with resection of the lateral prominence to correct the deviated fifth toe can be performed simultaneously if necessary. The most commonly used diaphyseal osteotomy is the oblique diaphyseal osteotomy¹⁷. This osteotomy allows a greater degree of correction of the deformity, but delayed union and even nonunion are reported to be more common than they are with metaphyseal osteotomies¹⁷.

For a bunionette with a lateral and plantar keratosis, the orientation of the osteotomy is altered slightly so as to not only rotate the distal fragment medially but to slightly elevate it as well. For this purpose, the saw blade is angled slightly upward from lateral to medial to elevate the fifth metatarsal head. The osteotomy, however, is oriented in a dorsal-proximal to plantar-distal direction.

For a bunionette with only a plantar keratosis, greater elevation of the distal fragment and increased obliquity of the osteotomy are necessary.

Proximal Osteotomies
The prerequisites for proximal osteotomies are that the deformity lie entirely within the metatarsal, the fifth metatarsophalangeal joint be free of arthritis, and the intermetatarsal angle be >9°^7,9,10,27. A proximal osteotomy may be performed when the epiphysis is open and when a distal osteotomy has failed. Disadvantages include delayed union and nonunion, which may occur because of interruption of the extraosseous and intraosseous blood vessels that anastomose at the base of the fifth metatarsal.

Several such procedures have been described, especially in the podiatric literature^5,9,19,28. Most proximal osteotomies are technically demanding^5,28, and some are based on complex trigonometric calculations²⁸.

Although we do not have direct experience with it, we agree that an opening-wedge osteotomy²⁹ procedure is especially indicated in young patients, as it does not involve the epiphysis of the fifth metatarsal and avoids inadvertent damage to the metatarsophalangeal joint.

The procedure for the treatment of splayfoot reported by Giannestras³⁰ consists of excision of the bunion and bunionette with preservation of the excised bone through a separate incision. The forefoot is compressed at the mid-metatarsal level, and a threaded Kirschner wire is then passed transversely through the neck of the fifth metatarsal and underneath the fourth, third, and second metatarsals as well as through the neck of the first metatarsal. The wire is cut just beyond the medial cortex of the first metatarsal. The proximal end of the wire is allowed to protrude slightly beyond the skin surface laterally. Transverse osteotomies are performed at the base of the fifth and the first metatarsal. They are then opened as much as possible, filled with bone graft taken from the excised bunion and bunionette, and impacted.

We have used the basal chevron osteotomy⁶. If correction is also needed in the sagittal plane (as determined by the position of the hyperkeratosis over the metatarsal head), an appropriate wedge can be removed plantarly or, more often, dorsally from the distal fragment. The metatarsal is shifted toward or away from the plantar surface before the Kirschner wires are driven into the fourth metatarsal. The removed bone wedge is then used as a graft on the opposite surface.

	Scoring Systems

Top Abstract Introduction Clinical Presentation Etiology Imaging Studies Classification of Bunionette Management Scoring Systems Choosing a Procedure Overview References

 
Despite the large number of procedures described, uncertainty remains regarding the most satisfactory one because of the lack of a standard scoring system.

Kitaoka and Leventen²³ used both subjective criteria (pain, functional restriction, shoe-wear restriction, objectionable cosmetic appearance, and general patient dissatisfaction) and objective criteria (tender lateral condylar process, tender intractable plantar keratosis, painful metatarsophalangeal motion, and radiographic abnormalities such as osteonecrosis, nonunion, joint subluxation, and arthrosis). A good result meant that the patient had none of these findings; a fair result, one or two; and a failure, more than two.

Buchbinder⁵ rated the results in his patients as good to excellent if there was no residual discomfort, no recurrence of the lesion, no transfer lesion, and normal healing. Results were rated as fair if there was some postoperative discomfort with or without a transfer lesion and as poor if there was residual discomfort, a delayed or painful union at the operative site, a transfer lesion, or recurrence of the original lesion.

Coughlin¹⁷ graded his patients’ postoperative results as excellent (the patient has no problems, is very satisfied, has mild or no pain, and is able to walk without difficulty), good (the patient has a few problems, is satisfied, has mild pain, is able to walk with or without difficulty, and would still have the operation under similar circumstances), fair (the patient has moderate pain, has limited walking ability, and is in doubt about the success of the operation), or poor (the patient has continued pain, has little improvement in walking ability, or regrets having had the operation).

The 75-point scoring system³¹ assesses pain, functional restrictions, footwear restrictions, alignment, metatarsophalangeal joint stiffness, and the presence of a tender callus. The results are defined as good (70 to 75 points), fair (60 to 65 points), or poor (<60 points).

The 100-point scoring system³² includes 70 points for symptoms (pain, decreased tolerance of activity, altered shoe-wear, patient perception of cosmetic appearance, and overall acceptance of the foot) and 30 points for the findings on physical examination (tenderness, deformity, and presence of callosities or metatarsalgia).

These scoring systems are very similar, but the results are difficult to compare. Thus, for uniform assessment of the postoperative results, a standard scoring system that is comprehensive, reliable, simple, and easy for the surgeon to use and that can be used preoperatively and postoperatively still needs to be developed.

	Choosing a Procedure

Top Abstract Introduction Clinical Presentation Etiology Imaging Studies Classification of Bunionette Management Scoring Systems Choosing a Procedure Overview References

 
In patients with lateral keratosis, shaving and padding of the metatarsal head may alleviate the symptoms. For a type-1 bunionette with or without intractable keratosis, lateral condylectomy or combined (lateral and plantar) condylectomy may be sufficient. For a type-2 bunionette, a distal osteotomy with or without resection of the lateral condyle is indicated. For a type-3 bunionette, operative treatment must be tailored according to the magnitude of the deformity. 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. If such correction can be performed only by translating the head fragment >50%, a proximal osteotomy is indicated, considering that each 1 mm of medial transposition of the distal fragment produces 1° of relative reduction of the intermetatarsal angle^7,9,10,20,27. For a type-4 bunionette, it is not uncommon to use the operative procedure with which the surgeon is most comfortable, with additional procedures, such as lateral condylectomy, performed to correct the other elements of the deformity^7,27.

If the patient has a plantar-flexed fifth metatarsal, correction should be aimed at both the sagittal and the coronal plane. In patients with splayfoot deformity, correction should reduce the size of the forefoot by either bone procedures³⁰ or combined bone and soft-tissue procedures³³.

Management of Postoperative Complications
Probably because of publication bias or the high quality of the operative procedures performed, few data are available on the prevalence of postoperative complications.

As with any operative procedure, surgeons should respect the basic principles of asepsis to prevent infection. Even when percutaneous Kirschner-wire fixation is used, infection can generally be avoided by covering the surgical wound and the wire and by making sure that the skin around the wire is released at the time of surgery. Patients should also be advised against getting the involved foot wet.

Accurate surgical technique and adherence to principles of good fixation can prevent malunions and nonunions. However, if the postoperative radiographs show that the correction is insufficient, removal of the fixation device and insertion of new, appropriately placed fixation is required. We have no experience in the management of nonunions, but in these cases bone-grafting and internal fixation may be needed.

Syndactylization of the fourth and fifth toes, which is technically simple and can produce good cosmetic results, can be performed for failed fifth-toe arthroplasty or for a flail fifth toe²⁰. However, we have no experience with this procedure.

Transfer metatarsalgia can occur if the distal part of the fifth metatarsal has been displaced dorsally. If this has happened, a corrective osteotomy at the appropriate level should be performed with internal fixation to prevent recurrence of the problem.

Recurrent Bunionette
Recurrent bunionette is not uncommon^3,5,31. However, clear guidelines on how to manage it are lacking. We use the following criteria^3,10,27,31: if the recurrence is due to undercorrection or if the initial procedure was not the ideal one, revision surgery may be helpful after the cause of the failure has been established. Subluxation of the fifth metatarsophalangeal joint is a common cause of recurrence. Several types of revision procedures should be considered to address the cause of failure. For a failed distal procedure (osteotomy or resection), either a repeat distal procedure or, less commonly, a prosthetic replacement of the fifth metatarsophalangeal joint may be considered. Other options, such as mid-shaft and proximal osteotomies, may also be considered. Although unpopular, resection should be thought of as the final salvage procedure. We reserve resection for elderly patients with low activity levels. We always stress to them that, if the symptoms are not ameliorated by the procedure, most often nothing else can be done.

	Overview

Top Abstract Introduction Clinical Presentation Etiology Imaging Studies Classification of Bunionette Management Scoring Systems Choosing a Procedure Overview References

 
Bunionette deformity, although common, is rarely symptomatic. Its management involves identifying the cause, performing thorough clinical and radiographic evaluation of the deformity, and deciding the best treatment to obtain optimal results if conservative management is unsuccessful. A variety of operative procedures aimed at distal, diaphyseal, or proximal correction may be considered. Before selecting a specific procedure, the surgeon should ascertain the cause of the bunionette deformity. The presence and/or site of a hyperkeratosis, a hypermobile or plantar-flexed fifth metatarsal, hypertrophy of the fifth metatarsal head, lateral bowing of the fifth metatarsal, and an increased fourth-fifth intermetatarsal angle should all be assessed. As simple procedures are safe and have predictable results in appropriately selected patients, they should not be ignored in favor of procedures that are more complex. The ultimate goals of surgery are to obtain excellent long-term cosmetic and functional results, to prevent complications or recurrences, and to have a shorter period of convalescence.

Note: Many thanks are given to Mr. Nigel Lukins for his help in preparing the figures. The help of Miss Linda Lothian is also gratefully acknowledged.

	References

Top Abstract Introduction Clinical Presentation Etiology Imaging Studies Classification of Bunionette Management Scoring Systems Choosing a Procedure Overview References

 

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