Sliding Distal Metatarsal Minimally Invasive Osteotomy (S-DMMO) for the Treatment of Tailor’s Bunion

Abstract

Bunionette, or Tailor’s bunion, refers to a painful lateral prominence at the fifth metatarsal head. Metatarsal osteotomies have proved to be a successful treatment, and have been described at the distal, diaphyseal, and proximal levels. Distal metatarsal osteotomies have been reported as effective in bunionette correction in several clinical studies. In the last decade, there has been a growing interest in the use of percutaneous or minimally invasive surgery for the treatment of this condition. Minimally invasive distal metatarsal metaphyseal osteotomy (DMMO) has proved to be successful when treating metatarsalgia. We present a surgical technique consisting in a distal osteotomy of the fifth metatarsal, which resembles DMMO, but requires a lateral displacement. We retrospectively investigated 38 feet from 32 patients with symptomatic bunionette deformity and showed good to excellent functional and clinical results. The S-DMMO proved to be a safe (low complication rate) and effective (adequate clinical results and powerful radiologic correction) procedure for the treatment of bunionette deformity.
Level of Evidence: Diagnostic Level 4. See Instructions for Authors for a complete description of levels of evidence.

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Sliding Distal Metatarsal Minimally Invasive Osteotomy
(S-DMMO) for the Treatment of Tailor’s Bunion
Jorge J. del Vecchio, MD,* Mauricio E. Ghioldi, MD,*
Miki Dalmau-Pastor, PhD, PT, DPM,†‡ Anuar E. Uzair, MD,*
and Lucas Chemes, MD*
Abstract: Bunionette, or Tailor’s bunion, refers to a painful lateral
prominence at the fifth metatarsal head. Metatarsal osteotomies have
proved to be a successful treatment, and have been described at the
distal, diaphyseal, and proximal levels. Distal metatarsal osteotomies
have been reported as effective in bunionette correction in several
clinical studies. In the last decade, there has been a growing interest in
the use of percutaneous or minimally invasive surgery for the treatment
of this condition. Minimally invasive distal metatarsal metaphyseal
osteotomy (DMMO) has proved to be successful when treating meta-
tarsalgia. We present a surgical technique consisting in a distal
osteotomy of the fifth metatarsal, which resembles DMMO, but requires
a lateral displacement. We retrospectively investigated 38 feet from 32
patients with symptomatic bunionette deformity and showed good to
excellent functional and clinical results. The S-DMMO proved to be a
safe (low complication rate) and effective (adequate clinical results and
powerful radiologic correction) procedure for the treatment of bunion-
ette deformity.
Level of Evidence: Diagnostic Level 4. See Instructions for Authors for
a complete description of levels of evidence.
Key Words: Tailor’s bunion, minimally invasive surgery, sliding
DMMO
(Tech Foot & Ankle 2018;00: 000–000)
HISTORICAL PERSPECTIVE
Bunionette, or Tailor’s bunion, refers to a painful lateral
prominence at the fifth metatarsal head. This disorder is
frequently associated with painful keratosis on the lateral or
plantar aspect of the fifth metatarsal head. Symptoms usually
include pain, erythema, hyperkeratosis, and swelling at the
lateral border of the fifth metatarsal head.
For severe or refractory cases, surgical intervention is
indicated. Surgeries are used to treat Tailor’s bunions.1–4
Resective surgery, reported to be ineffective or associated with
a high prevalence of morbidity, includes metatarsal head
resection, fifth metatarsal ray resection, and isolated soft tissue
procedures on the fifth metatarsophalangeal joint.5Resection of
the lateral third of the fifth metatarsal head can be useful with a
type 1 deformity.1However, disadvantages include deformity
recurrence, joint instability, and an incongruous joint. Resection of
the entire metatarsal head can be used as a salvage procedure.6,7
Metatarsal osteotomies have proved to be a successful
treatment, and have been described at the distal, diaphyseal, and
proximal levels. Proximal and diaphyseal osteotomies achieve
the best deformity correction at the expense of increased tech-
nical complexity, less fixation stability, and delay in bone
healing.8–10 Distal metatarsal osteotomies are effective in
bunionette correction in several clinical studies11,12 but have
been associated with the risk of osteonecrosis of the metatarsal
head.13–15 Open techniques have been associated with delayed
wound healing, pain related to osteosynthesis, and infection.11
In the last decade, there has been a growing interest in the
use of percutaneous or minimally invasive surgery (MIS) for
the treatment of this condition.14,16–18 MIS techniques are being
adopted in all surgical specialties, essentially because of its
FIGURE 1. Percutaneous portal. Made 5 mm proximally to the fifth MTP joint.
From the *Foot and Ankle Section, Orthopaedics Department, Favaloro Foundation—University Hospital, Buenos Aires, Argentine; †Human Anatomy and
Embriology Unit, Experimental Pathology and Therapeutics Department, University of Barcelona, Barcelona; and ‡Faculty of Health Sciences at Manresa,
University of Vic—Central University of Catalonia, Manresa, Spain.
The authors declare no conflict of interest.
Address correspondence and reprint requests to Jorge J. del Vecchio, MD, 461 Solis St., 1st Floor, Ciudad Autónoma de Buenos Aires (CABA), Argentine, CP
1078. E-mail: javierdv@mac.com.
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TECHNIQUE
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inherent advantages of less operative trauma, and preservation
of the blood supply. This has a direct impact leading to lower
morbidity rates and faster recovery with immediate weight-
bearing19—which happens also with some open surgeries.
Minimally invasive techniques also have the potential added
benefit for patients in whom wound healing is an issue.20
However, it has to be noted that MIS techniques have an
important learning curve, and experience is a key factor for its
effectiveness.
Minimally invasive distal metatarsal metaphyseal osteot-
omy (DMMO) has proved to be successful when treating
metatarsalgia in several clinical studies.21–23 The minimally
invasive technique described in this study is a modification of
the DMMO, which was popularized in Europe by Dr De Prado
et al.24,25
We present a surgical technique consisting in a distal
osteotomy of the fifth metatarsal, which resembles DMMO but
requires a medial displacement, for the treatment of Tailor’sbun-
ions. This procedure offers some advantages over other published
minimally invasive techniques. In 2014, Lui26 published a
percutaneous technique wherein patients were not allowed to bear
weight during the first 4 postoperative weeks. Our technique by
allowing immediate weight-bearing, stimulates bone consolidation,
and decreases postoperative soft tissue edema, as it promotes
venous drainage by early mobilization. The absence of osteosyn-
thesis provides a definite advantage over other minimally invasive
techniques, most of which are associated with superficial infection
(pins) or symptomatic skin irritation caused by a prominent fixation
device.16,27,28 In addition, the intramedullary K-wire position
makes it difficult to remove the bone excess of the lateral meta-
physeal region.
Michels et al29 described a technique with proximal
oblique osteotomy associated with a condilectomy. If the
osteotomy is performed more proximally, it may be unstable in
FIGURE 2. A–C, Creation of the working area.
FIGURE 3. Sliding distal metatarsal minimally invasive osteotomy with an angulation of 45 degrees.
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terms of cephalic control. In our described technique, it was not
necessary to resect any portion of the metatarsal head.
PREOPERATIVE PLANNING
Dorsoplantar and lateral weight-bearing radiographs are obtained.
Moreover, non-–weight-bearing medial oblique x-ray was per-
formed. The radiographic assessment includes evaluation of the
fifth metatarsophalangeal angle (MPA) and the 4 to 5 interme-
tatarsal angles. The 4 to 5 intermetatarsal angles are measured
between lines drawn through the center of the proximal and distal
ends of the fourth and fifth metatarsals. We categorized the cases
of bunionette deformity according to the Fallat’sclassification.30
Although this classification did not directly influence the
indication of S-DMMO, it provided information in relation to
the power of correction and displacement.
The patients were asked to complete a visual analog scale
(VAS) pain score.
Patient satisfaction was also assessed with use of the
Coughlin score. Postoperative outcomes were also graded, as
described by Coughlin,8as follows:
(1) Excellent: the patient had no problems, was very satisfied,
had mild or no pain, and was able to walk without difficulty.
(2) Good: the patient had a few problems, was satisfied, had
mild pain, was able to walk with or without difficulty, and
would still have undergone the operation under similar
circumstances.
(3) Fair: the patient had moderate pain, had limited walking
ability, and was in doubt about the success of the operation.
(4) Poor: the patient had continuous pain, with little improvement in
walking ability, and regretted having undergone the operation.
SURGICAL TECHNIQUE
The patient is placed in the supine position. The foot hangs over
the edge of the operating table, with the contralateral limb bent.
The procedure is performed under fluoroscopic guidance with a
C-arm. No tourniquet is required. All operations are performed
under regional anesthesia. A 3 mm stab percutaneous portal is
made 5 mm proximally of the fifth metatarsophalangeal joint,
medial or lateral to the extensor tendon, using a Beaver
Miniblade 64 (Fig. 1). The soft tissues are dissected from the
bone with a mini bone elevator. This creates a secure working
area and minimizes the risk of injury (Fig. 2).
Fifth metatarsal osteotomy is performed at 45 degrees
using an Isham straight flute burr (Vilex Inc., McMinnville,
TN) (Figs. 3, 4). The distal fragment of the fifth metatarsal is
displaced medially, with a manual “sliding”maneuver, cor-
recting the deformity, and this is maintained with a gauze
(Fig. 5). Thus, no internal or external fixation is needed. A
potential advantage of the oblique osteotomy is the ability to
easily elevate the metatarsal head, as it is translated medially,
by angling the osteotomy slightly with a plantar-lateral to
FIGURE 4. Cadaveric model: (1) 5th MTP joint; (2) orientation of
sliding distal metatarsal minimally invasive osteotomy.
FIGURE 5. A,B, Manual and medial displacement of the head of the fifth metatarsal. C, Stabilization with a gauze.
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dorsal-medial direction. This is desirable when a plantar cal-
losity is present in addition to lateral pain.
If a lateral prominence of the fifth metatarsal head persists after
sliding of the osteotomy, the prominence is reduced using the Isham
wedge burr 3.1 (Vilex Inc.). Incisions are closed using 4-0 Ethilon
suture (Ethicon Endo-Surgery, Blue Ash, OH).
In cases with an added adduction deformity of the fifth
toe, the following percutaneous procedures could be associated:
medial capsulotomy, extensor tenotomy, flexor tenotomy, and
phalangeal osteotomy.
Bandage is a very important tool in MIS, as no internal
fixation is used. Dressings stabilize the osteotomy during the
first 6 weeks after surgery.
Radiographic control (6-week follow-up of patient #21) is
shown in Figure 6.
POSTOPERATIVE MANAGEMENT
The surgeries are performed on an outpatient basis. In the first
3 days, elevation and rest were recommended to minimize
swelling, pain, and inflammation, although full weight-bearing
was allowed in a postoperative shoe (until the fourth week)
immediately. All patients were followed-up at 1 week for wound
check, at 6 weeks, 12 weeks, and 6 months with radiographs, and
at 12 months for clinical assessment.
RESULTS/COMPLICATIONS
We retrospectively evaluated 38 feet from 32 patients, with
symptomatic bunionette deformity, who were treated at our
hospital, consecutively, between 2012 and 2016. The mean
follow-up was 49.76 months (range, 7 to 113 mo). The average
age was 48 (range, 26 to 76) years.
The associated surgical procedures were the following:
modified Bosch,31,32 Akin,33,34 percutaneous intra-articular Chev-
ron osteotomy (PICO),35 and DMMO23 among others (Table 1).
The average preoperative 4 to 5 intermetatarsis angle was
10.88 (range, 5 to 16) degrees, whereas the average post-
operative 4 to 5 intermetatarsis angle showed a reduction to
3.77 (range, 1 to 9) degrees. The average preoperative MPA
was 21 (range, 10 to 34) degrees, whereas the average post-
operative fifth MPA decreased to 6 (range, −7 to 15) degrees.
FIGURE 6. A–C, X-ray. Result case # 21.
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The average medial displacement of the fifth metatarsal was
3.73 mm (range, 2 to 6 mm). The patients had a type I (n =15),
type III (n =22), and 1 type IV Fallat’s deformity.
The average improvement in VAS score was 7.23. The
average preoperative VAS score was 8.28 (range, 6 to 10), and
average postoperative VAS score was 1.05 (range, 0 to 3).
Patient’s subjective satisfaction according to the Coughlin
classification was excellent in 31 feet (81.57%), good in 5 feet
(13.15%), and regular in 1 foot (2.63%).
All patients were able to return to their sports activities in an
average period of 8.3 weeks (range, 7 to 11 wk). There were no
major complications in our series of patients (nerve, superficial or
deep infections, or deep vein thrombosis). There was no malunion,
nonunion, or osteonecrosis. Two patients (2 feet, 5.2%) complained
of a prominent lateral lump over the osteotomy site, and both needed
reoperation (percutaneous bone resection).
POSSIBLE CONCERNS, FUTURE OF THE
TECHNIQUE
The S-DMMO proved to be a safe (low complication rate) and
effective (adequate clinical results and powerful radiologic
correction) procedure for the treatment of bunionette deformity.
It also offers certain advantages over the percutaneous techniques
described (immediate weight-bearing, no need for osteosynthesis or
for condilectomy). It is necessary to emphasize the importance of
prevention of complications by a correct surgical procedure
(specificinstrumentsarerequired)andaclosepostoperative
follow-up.
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TABLE 1. Demographics and Results of S-DMMO
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24 Clinodactyly 11 3 14 6 7 0 Excellent 6
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28 12 8 14 9 8 0 Excellent 3
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A, average; An., Angle; DMMO, distal metatarsal minimally invasive osteotomy; MD, metatarsal’s displacement; MTFA, metatarsophalangeal angle; PICO, percutaneous
intra-articular Chevron osteotomy; Po., postoperative; Pr., preoperative; S-DMMO, sliding distal metatarsal minimally invasive osteotomy; VAS, visual analog scale.
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