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b. molenaers, j. vanlommel, p. deprez
Acta Orthopædica Belgica, Vol. 83 - 2 - 2017
Acta Orthopædica Belgica, Vol. 83 - 2 - 2017
When bunionette deformities are not responding to
conservative treatment, several surgical procedures
are available. Recently, minimal invasive techniques
have been proposed with good results. We present
our results of a strictly percutaneous 5th metatarsal
osteotomy to correct the deformity with bandage
after care. We present a retrospective review on 20
percutaneous distal oblique 5th metatarsal osteotomies
for correction of bunionette deformity. Aftercare
consisted of 5-6 weeks of corrective taping with
full weight bearing using a post-op shoe. Patients
were evaluated radiographically and clinically by
the American Orthopaedic Foot & Ankle Society
(AOFAS) Lesser Toe Metatarsophalangeal-Inter-
phalangeal scale, Visual Analogue scale (VAS) and
Coughlin classication. At a mean follow-up of
27.05 months, the AOFAS improved from a mean of
51 points to 91.6 points (max 100). 90% of patients
had good or excellent clinical result and a mean pain
score on the visual analog scale was 0.7 out of 10.
Radiographic evaluation showed a good correction
of the intermetatarsal and metatarsophalangeal
angle. We did not encounter any complications such
as infections, wound breakdown, neurovascular
problems, non-union or recurrence. The percutaneous
hardware free corrective osteotomy is an effective,
reliable and safe procedure concerning the treatment
of bunionette deformity. The results are comparable
with previously published outcomes of open and
minimal invasive procedures with considerable less
soft tissue damage, shorter operating time and the
lack of internal xation.
Keywords : foot, bunionette, percutaneous surgery
INTRODUCTION
A Tailor’s bunion is a painful deformity on the
lateral aspect of the 5th metatarsal. (6, 7, 21). It’s name
is derived from tailors who sustained these lesions
frequently due to their typical sitting position with
the legs crossed (29). Several retrospective studies
indicate that it is between 3 and 10 times more
frequent in women than men and has a peak incidence
between the fourth and fth decade of life (29). The
bunionnette is often seen in splayfoot disorders
and many times accompanied with a hallux valgus.
An enlarged fth metatarsal head (congenital or
traumatic) or a lateral angulated metatarsal shaft
do give a more prominent metatarsal head. (29)
Typically, these patients complain of pain on the
lateral side of the foot, more pronounced when
narrow shoes are worn. Often there is some callus
or inammation notable. In severe cases a bursa can
develop due to the chronic irritation, and over time
this can evolve into an ulceration.
According to Du Vries and Coughlin there are
3 different deformity types, based on weight-
No benefits or funds were received in support of this study.
The authors report no conflict of interests.
Acta Orthop. Belg., 2015, 83, 284-291
Percutaneous hardware free corrective osteotomy for bunionnette deformity.
Ben
molenaers,
Jan
vanlommel,
Patrick
deprez
From AZ St-Lucas, Brugge, Belgium
ORIGINAL STUDY
n Ben Molenaers1, MD
n Jan Vanlommel2, MD
n Patrick Deprez2, MD
1Orthopaedics-Traumatology, UZ Leuven and ZOL, Genk,
Belgium
2Orthopaedics-Traumatology Orthoclinic, AZ St-Lucas,
Brugge, Belgium.
Corresponding author: Ben Molenaers
E-Mail : Ben.Molenaers@uzleuven.be
© 2017, Acta Orthopædica Belgica.
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percutaneous hardware free corrective osteotomy for bunionnette deformity.
285
bearing dorsoplantar radiographs (gure 1). Type 1
is an enlargement of the head of the 5th metatarsal,
type 2 is characterized by a lateral bowing of the
5th metatarsal and type 3 is noted by an increased
intermetatarsal angle between the 4th and 5th
metatarsals (>8°). (1, 4, 6, 10, 15).
cases, percutaneous distal osteotomies have gained
popularity and recently several studies showed
good clinical en radiographic outcomes. (22, 24)
The possible advantage of percutaneous hardware
free surgery is the reduced risk of wound healing
problems and symptomatic hardware, as well as
improved cosmetics.
We present our short-term data in the ongoing
discussion about percutaneous hardware free distal
osteotomy in case of tailor’s bunion.
MATERIALS AND METHODS
We retrospectively reviewed the patients operated
between December 2009 and January 2013. The
percutaneous hardware free distal subcapital
osteotomy was performed on 20 feet (16 patients).
Mean age at surgery was 36.65 years (range 17-66)
and 80% of these patients were women (Table 1).
All medical records were reviewed, all patients were
contacted and information concerning the study was
provided. Informed consent was obtained. Patients
were reviewed one year after surgery or longer at
the time of this investigation. The study protocol
was approved by the ethical committee of our
institution. One skilled ankle and foot surgeon (P.D)
performed all the interventions using the below
described method.
The Indication for surgery was a tailor’s bunion
resistant to conservative treatment, including shoe
wear adaptation and oral anti-inammatory drugs.
In 1 patient a classical hallux valgus correction was
performed simultaneously (Patient 6). All patients
were followed for at least 1 year (average 27, 05
months) (Table 1).
We refer to the technique described by De Prado
and the Grecmip (group of research and study into
minimally invasive surgery of the foot and ankle)
(24). Though without performing a condylectomy.
Adequate percutaneous surgical instruments
are essential and the surgeon should be trained in
percutaneous operation techniques.
Surgery was performed under general anesthesia
or a locoregional popliteal block without tourniquet.
The patient was positioned in dorsal decubitus
distal on the table. After draping, the foot is placed
directly on the mini c-arm.
Fig. 1. — Pre-op Tailor’s bunion bilateraal (Type 1).
Conservative treatment such as oral anti-
inammatories, topical keratolytics, shoe wear
changes or orthoses can solve most of the complaints
though often will not produce long lasting relief
(29). When these are found to be insufcient,
operative possibilities are developed to address the
complaints and anatomy. There are a great variety
of different techniques available though most
include osteotomies to correct the bony deformity.
The purpose of surgery is to decrease the width
of the forefoot as well as the prominence of the
bunionette. (29) Lonely soft tissue procedures do
have high recurrence rates especially when dealing
with type 2 and 3 bunionette’s. In these specic
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Acta Orthopædica Belgica, Vol. 83 - 2 - 2017
Tabel I. — Patient characteristics
Patient Gender Age Type Side IM angle
4-5
MTP
angle
AOFAS VAS FU
(months)
pre post pre post Pre Post pre post
1 M 31 1 re 7 5 9 0 37 90 4 4 18
2 F 21 3 re 13 6 21 10 63 100 1 0 20
21 3 li 14 8 28 14 63 100 1 0 20
3 F 66 2 re 7 1 21 9 73 78 1,5 0,5 28
4 M 52 3 li 13 7 25 18 32 93 6 0 26
52 3 re 10 3 23 12 32 100 6 0 26
5 M 65 3 re 14 8 20 9 62 93 4 0 32
6 F 34 2 re 9 6 17 3 70 70 5 3 19
7 F 25 2 li 9 5 19 8 37 100 6,5 0 16
8 F 38 2 li 8 1 22 8 29 100 5 0 28
38 2 re 8 5 16 8 60 100 3 0 26
9 F 64 2 re 9 3 23 11 52 90 5 3 26
10 F 18 2 li 9 7 19 10 62 100 6 0 20
11 F 17 3 re 13 6 23 10 70 100 4 0 16
*12 F 21 3 li 13 6 26 9 37 95 7 0 32
22 3 re 10 7 22 6 37 68 7 3 29
13 F 30 3 re 11 6 23 12 42 100 8 0 42
**14 F 64 1 re 6 6 14 8 25 70 10 0 53
15 F 22 1 re 6 4 13 9 80 100 6 0 44
16 F 32 2 li 7 1 30 8 57 85 4 0 20
Average 36,65 9,8 5,05 20,7 9,1 51 91,6 5 0,675 27,05
OAFAS : American Orthopaedic Foot & Ankle Society Lesser Toe Metatarso-phalangeal-Interphalangeal
score.
In most cases the osteotomy is made just proximal
to the metatarsal head at the metaphysis. In type
3 we go slightly more proximal to obtain more
correction. The osteotomy was always complete
(no closing wedge) with a medial translation of the
metatarsal head and was always conducted under
direct uoroscopic guidance.
With a small beaver blade, a dorsal step wound
(2mm) was made under uoroscopic guidance
lateral to the extensor tendons at the level where
the osteotomy should be performed. The osteotomy
was performed uently by placing the percutaneous
burr directly lateral to the bone in a 45 ° direction
(preventing dorsal displacement), making a small
groove while going plantarly and changing the burr
from a vertical oblique position into a horizontal
position. Still in the same movement, the osteotomy
is completed by pulling the rotating burr from plantar
proximal to distal dorsal in a oblique 45°plane. The
metatarsal head spontaneously moves medially
(gure 2 and 3). With a small percutaneous rasp the
bone debris can be removed.
In all cases a burr of 2mm diameter and 15mm
long (Integra, Newdeal) was used. Burr speed was
maximal 9000 rpm to avoid skin burns. The skin is
closed with a single stitch (gure 4).
A splint dressing was applied post-operatively
to hold the correct position of the fth metatarsal
head after the osteotomy (gure 5). This bandage is
essential for the success of the procedure. It holds
the medial translated fth metatarsal head in the
right position. Therefore it’s important the taping
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percutaneous hardware free corrective osteotomy for bunionnette deformity.
287
weight bearing for 1 or 2 weeks was allowed with a
hard soled shoe. Early forefoot weight bearing was
allowed if tolerated. The bandage was rst changed
after 1 and 2 weeks and removed after 4 weeks.
Afterwards a simple taping around the forefoot was
advised for 2-3 weeks (gure 6).
Clinically the patients were evaluated using
the American Orthopaedic Foot & Ankle Society
(AOFAS) Lesser Toe Metatarsophalangeal-
Interphalangeal Scale. It provides a subscore
counting for subjective and objective outcomes like
pain sensation, functional capacity and radiographic
alignment. Even so patient satisfaction was classied
Fig. 2. — Post-op X-ray AP view left
Fig. 3. — Post-op Lateral view left
is performed by the surgeon himself. Fluoroscopic
check is necessary after the application in the
operation theatre and radiographs are made at 1 and
four weeks.
The rst week rest, elevation and ice applications
are recommended. Immediately after surgery, heel
Fig. 4. — Clinical view post-op wound left
Fig. 5. — Clinical view post-op bandage post-operatively
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of pain or a pain free operation site at nal follow-up
(pain score pre-op 13, post-op 37, max 40, P < 0.05).
Function subscores increased from 31.6 towards
42.1 post-operatively with a maximum of 45 points
(P < 0.05) (Table 2). Clinically union occurred at 6
weeks (no pain when walking). No complications
like infection, wound breakdown, nerve or vascular
injuries were noted during the follow-up visits.
According to the Coughlin classication the
subjective satisfaction was in 15 feet excellent,
3 feet good and 2 feet fair. The Visual Analogue
Scale (VAS) improved from mean number 5 pre-
operatively to 0.7 post-operatively (P < 0.05)(Table
1, 2). One patient, known with bromyalgia, was
slightly dissatised with the result though a great
reduction in pain was achieved. She had a little
callous development more distally on the fth toe but
she refused any other surgery. All patients returned
to their pre-operative activity level and those who
were unable to perform sports before surgery could
resume their sport activities after surgery.
The intermetatarsal angle (normal < 8°) decreased
from 9.8° to 5° and the fth metatarsophalangeal
angle (normal < 10°) decreased from 20, 7° to 9,
1° both at the time of latest follow-up (Table 1). In
nearly all patients a limited bone remoddeling was
seen after 4 weeks and all united at nal follow-up
(last visit) (gure 7, 10). No major complications
as non-union, osteonecrosis or late displacement
occurred.
DISCUSSION
Even though a tailor’s bunion seems to be a small
problem, it can have a great inuence on quality
of life, cause frustrations and work problems. If
conservative treatment is not sufcient, operative
correction will be mandatory. Several procedures are
described and proposed depending on the deformity.
(7, 17, 23, 33). As shown by Kitaoka et al (17) partial
metatarsal head resection can be performed with a
Type 1 deformity. A metatarsal head resection can be
performed, mostly as a salvage procedure as it will
induce joint instability and transfer metatarsalgia.
(9, 12, 16)
As for rst ray deformities, several osteotomies
have been described for the fth metatarsal
with the Coughlin Score as excellent, good, fair and
poor. The Visual Analogue Scale was recorded pre-
and post-operatively.
Radiographic assessment consisted of anteropos-
terior and lateral weight bearing x-rays of the foot
pre-operatively and post-operatively at week 4 and
at nal follow-up. The metatarsophalangeal angle
and intermetatarsal angle were compared to evalu-
ate the correction as well to assess consolidation.
RESULTS
In all cases, wound healing occurred without any
problems. Oedema was present for several weeks
but did not interfere with daily live and was not seen
as a problem by most of the patients. One patient
was known to have bromyalgia and one patient
sustained severe burning wounds (including the
foot), these inuenced the outcomes negatively
(Table 2). The mean OAFAS Lesser Toe Metatarso-
phalangeal-Interphalangeal score improved from 51
points to 91.6 points at nal follow-up. (max 100,
P < 0.05). All patients mentioned a great reduction
Fig. 6. — Clinical view post-op bandage after 4 weeks
Tabel II. — Results
Pre-op Post-op P-value
Mean OAFAS
(Max 100)
51 91,6 P<0,05
Pain OAFAS
(Max 40)
13 37 P<0,05
Function OAFAS
(Max 45)
31,6 42,1 P<0,05
VAS scale 5 0,7 P<0,05
OAFAS : American Orthopaedic Foot & Ankle Society Lesser
Toe Metatarso-phalangeal-Interphalangeal score.
VAS: Visual analogue scale
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percutaneous hardware free corrective osteotomy for bunionnette deformity.
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Fig. 7. — Post-op 4 weeks AP view left
Fig. 8. — Post-op week 12 AP left
Fig. 9. — Post-op week 12 lateral
ray including proximal, diaphyseal and distal
osteotomies. (5, 6, 8, 11, 18, 19, 25, 30, 31, 32, 33).
The goal of these procedures is to narrow the
forefoot resulting in less compression at the fth
metatarsal head. (19) All osteotomies do have their
specic indications and complications. Proximal
osteotomies are indicated when the intermetatarsal
angle is greater than 9° and the deformity is
located over the entire metatarsal. Though there is
a greater risk of non-union caused by interruption
of the vascularity (3, 8, 26, 31). The same goes
for the diaphyseal osteotomies, although less
correction can be achieved compared to proximal
osteotomies. Still higher rates of non- and delayed
union are noted.(5, 30, 31) Distal osteotomies are
most commonly performed due to the higher rates
of union reported but with a limited potential for
correction. Therefore these are ideal in type II-III
deformities (5, 6, 18, 19, 25).
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post-operative rehabilitation regimen was more
or less identical. Both studies present comparable
results and this on all investigated outcomes like the
clinical, functional and radiographic parameters.
By avoiding a condylectomy we could reduce the
operating time and we may cause less soft tissue
damage leading to a faster recovery. These potential
advantages did not make any difference in the
outcome scores. General satisfaction of the patients
are both high. When pronounced deformity is
encountered the percutaneous metatarsal osteotomy
can slightly be proximised to allow greater
correction possibilities.
As mentioned in the studies (23, 24) radiographic
bone healing is delayed with respect to clinical
healing (gure 8, 9). It is important to know that
the early success is not directly related to the
radiological outcome, but rather the clinical and
pain free experience. In general, clinical healing can
be expected after 6 weeks, allowing normal shoes
to be worn securely starting at 4 to 6 weeks. Bony
healing can take up to 3 months or sometimes even
longer. Limitation of heavy physical activities is
recommended during this time frame (Figure 6, 7,
8, 9).
This study has some limitations as the retro-
spective character and relatively small sample size.
There wasn’t a control group either. On the other
hand this study has some potential strengths as it
focused on all indications of bunionette deformities.
All patients were treated by the same surgeon
using one and the same procedure. Evaluation was
performed by an independent observer using several
standard evaluation scores (AOFAS Lesser Toe
Metatarsophalangeal-Interphalangeal scale, Visual
Analogue scale (VAS) and radiographic evaluation).
CONCLUSIONS
Our study conrms the good outcome of a
percutaneous hardware free distal osteotomy in
tailor’s bunion deformities. The procedure is suited
for the 3 different types of deformities with small
alterations on the surgical procedure. Patients
satisfaction is high, quick recovery can be expected
without malunions and very low complication rates,
such as infection and absent hardware friction. As
Common complications of forefoot surgeries
are loss of alignment, delayed-/non-union, transfer
metatarsalgia, infections, soft tissue irritation due
the xation techniques, fractures and recurrence of
deformity. (13, 14, 19, 20, 24, 28, 31, 33).
Recently there have been several studies
published who presented new minimally invasive
distal osteotomy techniques with good results.(15,
22, 23) Some of the studies used stabilization in order
to maintain reduction. (15, 22). Michels et al showed
the possibility to adapt the osteotomy according to
the deformity and correct the intermetatarsal angle
in minimal invasive procedures (24) Even without
in situ stabilization there was no higher rate of
recurrence (24).
Our technique differs from Michels et al. because
we performed a metatarsal osteotomy without
adjacent condylectomy of the metatarsal head. The
Fig. 10. — Post-op 1 year left
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percutaneous hardware free corrective osteotomy for bunionnette deformity.
291
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reported in previous articles and shown in our study,
clinical healing precedes radiological union.
This study conrms this procedure to be useful as
a standard technique for the percutaneous interested
foot- and ankle surgeon treating a tailors bunion.
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