Osteotomies for Bunionette

Deformity
Lowell Weil Jr, DPM*, Lowell Scott Weil Sr, DPM

KEYWORDS
• Bunionette • Osteotomy • Scarfette
• Surgical decision making • Minimal incision surgery
• Tailors bunion

A tailor’s bunion or bunionette deformity is a combination of an osseous and

soft-tissue bursitis located on the lateral aspect of the fifth metatarsal head and was
first described by Davies1 as a condition caused by splaying of the fifth metatarsal.
The condition is often present with hallux valgus deformity, both of which are noted
with a flexible splayfoot (Fig. 1).
Chronic shoe pressure over the lateral part of the fifth metatarsal head leads to hypertrophy
of the overlying soft tissue; bursal thickening; and less often, localized hyperkeratosis. In the
presence of hallux valgus deformity, the width of the forefoot is increased, thereby causing
increased pressure on the lateral side of the fifth metatarsal head. The cause of the deformity
of the fifth metatarsal head can be from a localized, enlarged bony prominence but most often
the true etiology is a rotational movement of the fifth ray at its articulation with the cuboid. The
fifth ray excessively pronates, leading to a progressive deformity that is accompanied by the
fifth toe seeking an adducto-varus position.2– 4 The condition can also occur as a result of a
structural deformity with both plantar flexion and abduction of the fifth ray, producing a plantar
keratosis as well as a bunionette deformity. The plantar keratosis condition is most frequently
seen in a cavus foot type.5
As in hallux valgus deformity, several retrospective studies indicate that the
condition is between 3 and 10 times more common in women than in men and has a
peak incidence during the fourth and fifth decades of life.2,6
Conservative treatments may resolve some of the associated bursitis or fifth
metatarsal–phalangeal joint, but will not likely create any long-term benefits.2

SURGICAL PLANNING

In 1990, Fallat and Bucholz7 described a classification system for surgical manage-
ment of symptomatic tailor’s bunion. Type 1 is an enlargement of the lateral aspe5ct
of the fifth metatarsal head; type 2, a lateral bowing of the distal aspect of the

The authors have nothing to disclose.

Weil Foot & Ankle Institute, 1455 Golf Road, Des Plaines, IL 60016, USA
* Corresponding author.
E-mail address: [email protected]

Foot Ankle Clin N Am 16 (2011) 689 –712

doi:10.1016/j.fcl.2011.08.012 foot.theclinics.com
1083-7515/11/$ – see front matter © 2011 Elsevier Inc. All rights reserved.
690 Weil & Weil

Fig. 1. Classic bunionette deformity.

pronated fifth metatarsal; type 3, an increased fourth–fifth intermetatarsal angle (4 –5

IMA); and type 4, a combination of two or more deformities. Coughlin8 postulated that
these criteria should enable the surgeon to better recognize the type of bunionette
deformity and assist in the choice of an appropriate surgical technique.
A key radiographic measurement associated with a bunionette deformity is the
intermetatarsal angle between the fourth and fifth metatarsals, which normally

Fig. 2. Short Scafette osteotomy.

 Osteotomies for Bunionette Deformity 691

Fig. 3. Short Scarfette osteotomy displaced 5 mm.

averages 4.5°.2,7 This finding will usually relate to the fifth metatarsal prominence
distance (protrusion of the lateral metatarsal head surface from the shaft, measured
by a line drawn along the lateral cortex of the fifth metatarsal shaft and another line
drawn along the lateral cortex of the fifth metatarsal head; normal, ⬍4 mm)10; 4 –5

Fig. 4. Long Scarfette osteotomy. Weil 1984 short Scarfette, Barouk 1995 long Scarfette.
692 Weil & Weil

Fig. 5. Long Scarfette osteotomy.

metatarsal head distance (distance between the lateral cortex of the fourth metatarsal
head and the medial cortex of the fifth metatarsal head; normal, ⬍3 mm)11; and the
fifth metatarsal plantar-declination angle (horizontal bisection of the fifth metatarsal in
relation to the weight-bearing surface; normal, 108°).2 The normal length of the fifth

Fig. 6. A medial oblique sliding osteotomy of the fifth metatarsal head using an osteotome to create
the osteotomy. This osteotomy was performed through a 1-cm incision overlying the metaphyseal
area of the metatarsal area. (From Smith SD, Weil LS. Fifth metatarsal osteotomy for tailor’s bunion
deformity: minor surgery of the foot. Mt. Kiscoe, NY: Futura; 1971; with permission.)
 Osteotomies for Bunionette Deformity 693

Fig. 7. Giannini’s SERI procedure.

metatarsal is considered to be 12 mm shorter than the fourth metatarsal, producing

a gentle oblique taper from the central metatarsals in a lateral direction.2 These
findings and observations allow the surgeon to make the determination and selection
of the appropriate surgical osteotomy procedure.2
One additional observation that should be considered is the position of the bony
prominence, keratosis, or “bursitis” on the fifth metatarsal head, namely dorsolateral,
lateral, or plantar-lateral? This important finding may influence the decision of which
surgical procedure might be best indicated.9 For example, a plantar keratosis may
benefit from a procedure that elevates the metatarsal head along with angular
correction; a fifth metatarsal cheilectomy rather than an osteotomy may be appropri-
ate in a case with primarily dorsolateral prominence.

SURGICAL DECISION MAKING FOR BUNIONETTE DEFORMITY

The guidelines for bunionette surgery at the Weil Foot & Ankle Institute are as follows.
In some cases, the prominent dorsal or dorsolateral aspect of the fifth metatarsal
head is the symptomatic area and the IMA is normal. In these cases, without large
bunionette deformity, a simple dorsolateral cheilectomy is sufficient to alleviate
symptoms and an osteotomy is not needed. However, most cases with a bunionette
694 Weil & Weil

Fig. 8. Giannini’s SERI procedure.

demonstrate a 4 –5 IMA in excess of 6°. In these cases, an osteotomy is indicated. Our

algorithm calls for either a Weil Osteotomy (WO) suggested by Barouk,15 or a short
Scarfette osteotomy with an IMA between 5° and 8°. The WO is commonly
recommended because of its inherent stability in the sagittal plane, technical ease,
and rapid healing. In the case of an intractable plantar keratosis, a Scarfette
osteotomy is the procedure of choice because of its ability to correct the deformity
and elevate the head, diminish plantar pressure, and remain stable during healing.
As the IMA and bowing of the fifth metatarsal increase, the Scarfette is carried more
proximal, allowing for greater surface area for bony healing and stability (Figs. 2
and 3). It is never longer than 50% of the length of the fifth metatarsal and we make
it a point to stay away from the proximal meta-diaphyseal region to avoid any
potential for non-union in that area.
In cases of a plantar flexed fifth metatarsal head, as seen in a cavus foot, the long
Scarfette (Figs. 4 and 5) allows for dorsal as well as medial translation to render a
more favorable position.
When we encounter a failed case of bunionette correction, we prefer a metatarsal
arthroplasty and remove a few millimeters to a full centimeter from the distal articular
 Osteotomies for Bunionette Deformity 695

Fig. 9. Giannini’s SERI procedure.

surface and perform a plantar condylectomy. This does shorten the toe somewhat,
but it is a final correction of the deformity that renders a rapidly healing procedure for
a challenging situation.

SURGICAL OSTEOTOMY PROCEDURES

There are many procedures that have been described to correct a bunionette
deformity. The following are procedure that will be discussed in this article

Fig. 10. Chevron osteotomy for bunionette.

696 Weil & Weil

Fig. 11. Intraoperative image of chevron osteotomy.

Medial oblique sliding osteotomy (with fixation)

Medial, oblique slide osteotomy; minimally incision procedure (no fixation) 3,12
SERI (Giannini—Simple, Effective, Rapid, Inexpensive; with fixation)13
Chevron (distal osteotomy with or without fixation) 2– 4
Weil osteotomy15
Closing, lateral wedge osteotomy at metatarsal neck or proximal diaphysis2,3,14
Oblique diaphyseal osteotomy8
Scarfette.3,9,15

Medial Oblique Sliding Osteotomy

In 1971, Smith and Weil16 published a technique paper on a medial oblique sliding
osteotomy of the fifth metatarsal head using an osteotome to create the osteotomy.
This osteotomy was performed through a 1-cm incision overlying the metaphyseal
area of the metatarsal area (Fig. 6) The 12-mm osteotome was positioned so that an
angle was formed of 70° from distal lateral to proximal medial and undercut by 15°.
The purpose of this angle was to have the bone slide medially with little chance of
lateral subluxation. The undercut of the metatarsal head helped to avoid dorsal
migration of the head after surgery. A dressing was applied, bandaging the fifth toe in
an abducted position to ensure medialization of the metatarsal head. Patients were
advised to maintain guarded weight bearing for 1 week. The results were good with
respect to ultimate cosmetic appearance but chronic swelling and 3 to 4 months of
healing were necessary for complete resolution.

Minimal Incision Surgery

Bunionette correction via an osteotomy through a minimal incision may be performed
using several methods. Probber and White12 popularized the procedure. Under a
local anesthetic, a puncture incision was made at the lateral metaphysis of the flare
 Osteotomies for Bunionette Deformity 697

Fig. 12. Medial translation of the distal fragment correction.

of the fifth metatarsal head.12 A “dental cutting burr” was used to create a “blind”
osteotomy at a 90° angle to the metatarsal shaft. Some minimal incision surgeons
used fluoroscopy to verify the intraoperative position. The cut allowed for mobilization
of the fifth metatarsal head in a medial direction to correct the deformity. The bone
debris (paste) caused by the high-torque–low-speed burr was extirpated out through
the dermal opening and the wound irrigated and closed with a single 0.25-in.
Steri-strip. No fixation was utilized and a compression dressing was applied,
bandaging the fifth toe in an abducted position to ensure medialization of the
metatarsal head. Patients were permitted to ambulate immediately and return to work
as needed. Retrospective, uncontrolled results of the procedure were published with
relatively short-term follow-ups. However, personal observations of our senior author
(LSW) were remarkably good with respect to clinical outcome but with a high
complication rate. Wound problems caused by the heat of the rotary burr usually
healed uneventfully but some became infected. Chronic swelling lasting up to 3 to 5
months was not infrequent with this unfixed osteotomy. Non-union was infrequent,
perhaps because the bone paste caused by the rotary burr facilitated healing of the
osteotomy. Uncontrolled, dorsal elevation was observed that led to metatarsalgia
698 Weil & Weil

Fig. 13. Chevron osteotomy. (From Throckmorton JK, Bradlee N. Transverse V sliding osteot-
omy: A new surgical procedure for the correction of Tailor’s bunion deformity. J Foot Surg
1978;18:117–21; with permission.)

under the fourth metatarsal head and this appeared to be the most adverse
complication that needed revision surgery. The great majority of cases yielded an
acceptable cosmetic result with no scarring or dorsal contracture. The procedure has
recently become popular with orthopedic surgeons in Spain, France, and Italy.
Because of the limited outcomes studies available and the tendency toward dorsal
malunion, however, it is difficult to recommend this technique routinely until more
extensive data are reported.
An alternative mini-incision technique utilizing fixation was reported by Giannini and
colleagues13 (Fig. 7). A 1-cm lateral incision is made just proximal to the lateral eminence
of the fifth metatarsal head through the skin and subcutaneous tissue, down to bone.
Once the lateral aspect of the metatarsal neck is visualized, the osteotomy is performed.
The inclination of the osteotomy in the lateral-to-medial direction is perpendicular to the
fourth ray if the length of the fifth metatarsal bone is to be maintained. The osteotomy is
inclined in a distal–proximal direction up to 25°, if shortening of the metatarsal bone or
decompression of the metatarsophalangeal joint is desired in cases of mild joint arthritis.
More rarely, if a lengthening of the fifth metatarsal bone was necessary, the osteotomy is
inclined in a proximal– distal direction up to 15°.
After creation of the osteotomy with the saw, the head is mobilized with a small
osteotome and medial translation of the metatarsal head is performed, introducing
the Kirschner wire superficial to the lateral eminence. Plantar translation of the
metatarsal head, if desired, is produced by introducing the Kirschner wire in the upper
aspect of the metatarsal head. A 1.8-mm Kirschner wire is inserted into the soft tissue
adjacent to the bone in a proximal-to-distal direction along the longitudinal axis of the
fifth toe. The Kirschner wire exits at the lateral area of the tip of the toe, adjacent to
 Osteotomies for Bunionette Deformity 699

Fig. 14. Manual translation and impact of head on shaft.

the lateral border of the nail; it is retracted with the drill up to the proximal end of the
osteotomy. The metatarsal head is then translated medially and the Kirschner wire is
advanced retrograde into the diaphyseal canal toward the metatarsal base (Fig. 8). If
the cut edge of the metatarsal is laterally prominent, a small wedge of bone is
removed. The skin is sutured with a single 3-0 stitch. The Kirschner wire is bent and
cut at the tip of the toe. Ambulation is allowed immediately using a postoperative shoe
that allows weight bearing only on the hind foot. After 1 month, the dressing, suture,
and Kirschner wire are removed (Fig. 9). Patients are allowed to return to normal
comfortable shoe wear, while gentle exercises with cycling and swimming are
advised.
Giannini and colleagues reported that 48 of 50 patients were satisfied with their
result. The preoperative American Orthopedic Foot and Ankle Society (AOFAS)
forefoot score was 62.8 ⫾ 15.1 points (range, 19 – 80) and postoperatively it was 94 ⫾
6.8 points (range, 75–100) (P⬍.0005). Thirty-eight (76%) feet were rated as excellent,
9 (18%) good, 2 (4%) fair, and 1 (2%) was considered poor. Pain was absent in 40
(80%) feet, mild or occasional in 8 (16%) feet, and moderate or daily in 2 (4%) feet.
Function in 42 (84%) feet had no limitations in daily and sport activities, 7 (14%) had
minimal limitations, and 1 (2%) foot had a severe limitation. Forty-four (88%) patients
were able to wear normal shoes.
All osteotomies healed radiographically at an average of 3 months. All the
osteotomies remodeled over time, even in cases with significant offset initially.
Radiographic evaluation demonstrated that the average fifth MTP angle was 16.8° ⫾
5.1° preoperatively and 7.9° ⫾ 3.1° (P⬍.0005) postoperatively. The 4 –5 IMA was
12° ⫾ 1.7° preoperatively and 6.7° ⫾ 1.7° postoperatively (P⬍.0005). No severe
complications, such as avascular necrosis of the metatarsal head or non-union of the
osteotomy, occurred. In 6 (12%) feet, the radiographic healing of the osteotomy
occurred over 4 months after surgery; however, no increased postoperative pain was
700 Weil & Weil

Fig. 15. Preoperative image of bunionette.

noted in these patients, nor was the clinical result compromised at final follow-up.
Further, no correlation was found between the delayed radiographic union and the
offset at the osteotomy; in fact, none of these cases displaced. One (2%) foot had a
skin inflammatory reaction around the Kirschner wire. Two (4%) feet reported
symptomatic plantar callosities under the fourth metatarsal heads. No dorsal sublux-
ation of the fifth metatarsophalangeal joint (MTPJ) was present. Further studies with
larger numbers of patients, longer follow-up, determination of the risk of dorsal
malunion or metatarsalgia, and stratification for severity of deformity are necessary
before recommending this procedure on a widespread basis.

Chevron Osteotomy
Following the success of a stable construct for the Austin (chevron) hallux bunionec-
tomy, several authors,2 including Kitaoka,4 utilized a similar technique for the
bunionette deformity.
Through a dorsal or lateral incision, a lateral exostectomy was performed on the
fifth metatarsal head, removing a small amount of bone. A chevron osteotomy was
then performed in the cancellous bone of the metatarsal head (Figs. 10 and 11). The
head was mobilized and translated medially by about 3 to 6 mm (Figs. 12 and 13).
Using manual compression the fifth metatarsal head was firmly compressed from
distal to proximal (Fig. 14). The lateral overhanging ledge that remained was carefully
resected so as to not interrupt the osteotomy position. Later, some surgeons chose
to use fixation with a K-wire to avoid malunion and delayed healing (Figs. 15 and 16).
Currently, surgeons routinely use absorbable pins or small-diameter screws for
fixation (Fig. 17). Guarded weight bearing was recommended and most patients had
 Osteotomies for Bunionette Deformity 701

Fig. 16. Intraoperative fluoroscopic image of chevron with pin fixation.

a very favorable outcome. Healing usually took 2 to 3 months for resolution of swelling
and the cosmetic appearance was good. However, in larger deformities with a 4 –5
IMA ⬎8° to 10°, the width of the fifth metatarsal head just did not allow enough medial
displacement to reduce the deformity adequately. As such, this may be a good option
for smaller deformities or cases with outflaring of the distal metatarsal shaft that do
not require as large a correction.

Weil Metatarsal Osteotomy

Another option is the oblique sliding metatarsal osteotomy (or Weil osteotomy)
commonly performed on the central metatarsals for correction of clawtoes or
metatarsalgia. An osteotomy is created from the dorsum of the metatarsal head–neck
junction heading plantarward parallel to the plantar surface of the foot. The metatarsal
head is then translated medially to reduce the IMA and fixed with a dorsal-to-plantar
twist-off or solid lag screw. The lateral overhanging bone and lateral eminence are
trimmed off. Barouk15 recommends the Weil osteotomy for small to intermediate
deformities because of its inherent stability and ease of performing this procedure
(Fig. 18). However, like the chevron procedure, it has limitations in the narrow
metatarsal head; in such cases, the distal fragment can be translated only a small
amount to still have sufficient bony apposition for fixation and healing. Literature
reports on the use of this osteotomy for correction of the bunionette deformity are
sparse, but the senior author (LSW) has extensive personal experience with its use
and has found it to produce good clinical outcomes with a reproducible technique.
702 Weil & Weil

Fig. 17. Small diameter screw for fixation. (From Frankel JP, Turf RM, King BA. Tailor’s
bunion: clinical evaluation and correction by distal metaphyseal osteotomy with cortical
screw fixation. J Foot Surg 1989;28:237– 43; with permission.)

Proximal Closing Wedge Osteotomy

In cases of a severely widened 4 –5 IMA, distal osteotomies have insufficient power for
correction and a more powerful proximal osteotomy is preferred. In 1972, Gerbert and
colleagues14 presented preliminary results of a fifth metatarsal shaft osteotomy
described as a long oblique wedge resection.
A dorsal incision measuring 4 to 5 cm in length is placed directly overlying the fifth
metatarsal neck and shaft from the fifth metatarsal to the junction between the
proximal and middle one third of the fifth metatarsal. The incision is deepened directly
through the skin to the level of the capsule and periosteum overlying the fifth
metatarsal neck and shaft. A long oblique osteotomy was outlined from distal–medial
to proximal–lateral and terminating at the junction of the lateral shaft and base of the
fifth metatarsal. The osteotomy was performed in such a manner as to maintain the
proximal–lateral cortical–periosteal hinge. A small 2- to 3-mm medially based wedge
of bone was then resected from the proximal and medial portion of the fifth metatarsal
and the proximal–lateral hinge gently “feathered” as described previously (Figs.
19 –21). A small bone clamp is used to close the osteotomy, which rotates the distal
 Osteotomies for Bunionette Deformity 703

Fig. 18. Preoperative and postoperative Weil osteotomy of the fifth metatarsal for
bunionette.

fifth metatarsal, capital fragment medially. If any gapping is present between the distal
and proximal capital fragments, reciprocal planing is used or the small wedge of bone
resected then morselized and packed within the gap as a bone graft. Fluoroscopy is
used to verify complete reduction of the deformity before performing final fixation with
a small, oblique screw, oriented from distal–lateral to proximal–medial at the junction
between the osteotomy and the fifth metatarsal shaft. The fifth digit is bandaged in a
slightly overcorrected and abducted and plantarflexed position. This technique does
not allow for immediate weight bearing because of the orientation and fragility of the
osteotomy and, therefore, should be protected non–weight-bearing in either a
short-leg cast or removable immobilization boot. Serial radiographs are obtained to
monitor osseous healing and, once verified, the patient is allowed to return to a roomy
athletic or oxford shoe with weight bearing to tolerance. This can occur from 6 to 8
weeks. Castle and colleagues,17 in a retrospective review of 26 long oblique wedge
resection osteotomies, found a mean 4 –5 IMA reduction of 1.58 (7.9 – 6.48) and a
mean lateral deviation angle reduction of 3.98 (4.1– 0.28). One osteotomy fractured
after a traumatic incident in the early postoperative period but there were no reported
704 Weil & Weil

Fig. 19. Closing medial wedge at neck and oblique shaft osteotomy for bunionette
deformity.

incidences of delayed union, malunion, or transfer lesions. This osteotomy appears

most useful for the correction of an abnormally large 4 –5 IMA.

Oblique Diaphyseal Osteotomy

Coughlin described an oblique mid-shaft osteotomy to correct an increases 4 –5 IMA
and/or an increased lateral bowing2,8 (Fig. 22). This oblique osteotomy is rotational
rather than translational, which helps to maintain metatarsal length and avoid
shortening. A lateral incision is created over the fifth metatarsal shaft and MTPJ. A
capsulotomy is performed at the joint and the lateral eminence resected. Before the
osteotomy, a proximal drill hole can be created for placement of a small diameter lag
screw. The oblique osteotomy is created with the saw from dorsal–proximal to
plantar– distal with the saw perpendicular to the shaft. The distal fragment can then be
rotated using the screw as a hinge, thereby reducing the IMA (Figs. 23 and 24). A
second screw is then inserted to stabilize the construct. Imbrication of the lateral MTP
capsule then corrects toe alignment to complete the procedure. In cases with a
plantar keratosis, the saw blade can be inclined slightly cephalad rather than
perpendicular to the diaphysis; when the osteotomy is rotated, this will slightly elevate
the metatarsal head and unload the area of the callus.
 Osteotomies for Bunionette Deformity 705

Fig. 20. Closing medial wedge at neck and oblique shaft osteotomy for bunionette
deformity.

Coughlin8 reported a series of 30 feet (20 patients) who underwent this procedure
with 31 months follow-up. Ninety-three percent had excellent or good clinical results.
The mean 4 –5 IMA corrected from 10.6° preoperatively to 0.8° postoperatively. All
osteotomies healed within 8 weeks, with only one case of a mild transfer lesion. He
concluded that internal fixation led to high rates of healing with low complications.
These findings were reproduced in another series by Vienne and coworkers.18 In this
series, 33 patients were followed prospectively after oblique diaphyseal osteotomy for
24 months. Ninety-one percent had excellent or good clinical outcomes, with similar
radiographic correction to Coughlin’s original series. They noted no instances of
delayed union or non-union. Both series did note a relatively high rate of the need for
hardware removal, likely due to the subcutaneous position of the fifth metatarsal and
screws.

Scarfette Osteotomy
Based on the favorable results of the Scarf procedure for hallux valgus deformity, Weil
proposed a “reverse scarf procedure” for the bunionette deformity.9 Barouk later
popularized the procedure and gave it the name Scarfette.15 The 3-cm, laterally
706 Weil & Weil

Fig. 21. Closing medial wedge at neck and oblique shaft osteotomy for bunionette
deformity.

based incision is carried directly through the capsule and periosteum which are
sharply reflected to expose the dorsal and plantar lateral aspects of the fifth
metatarsal head and neck. A minimal lateral exostectomy is performed with a power
saw. The scarf-shaped cut, about 2.5 cm long, is outlined from dorsal distal to plantar
proximal on the fifth metatarsal head and neck (Fig. 25). A 60° dorsal– distal
osteotomy is performed 3 mm proximal to the articular cartilage of the fifth metatarsal
head. Next, the central horizontal osteotomy directed from superior to inferior is
performed with the saw held in slight dorsal angulation so as not to plantar displace
the osteotomy fragment. Lastly, a proximal 60° plantar osteotomy is performed at the
proximal plantar extent of the horizontal osteotomy (see Fig. 25).
The neck of the fifth metatarsal shaft bows plantarly, so it is important to note that
the proximal portion of the osteotomy does not end up at mid-shaft. It should be at
the plantar 1/3 of the metatarsal shaft to avoid potential stress fracture. A small, thin
osteotome is inserted in the osteotomy and gently rotated to verify completion of the
osteotomy. With traction on the fifth digit, the fifth metatarsal head is gently
manipulated in a medial direction to reduce the deformity. Once completed, a small
clamp is placed on the lateral fifth metatarsal shaft and the osteotomy fragment.
Fixation was initially performed with manual impaction and capsulorraphy but
 Osteotomies for Bunionette Deformity 707

Fig. 22. Oblique diaphyseal osteotomy. (From Coughlin MJ. Correction of the bunionette
with midshaft oblique osteotomy. Orthopedic Trans 1998;12:30 –1; with permission.)

some cases developed displacement, so fixation with a buried threaded 1.6-mm

pin or 2.5 mm screw was used thereafter. Once adequate correction is obtained,
the osteotomy fragment is impacted on the metatarsal (Fig. 26). The remaining
lateral head, neck, and shaft are carefully removed and smoothed with power
instrumentation (Fig. 27). The periosteum and capsule are repaired with 3-0
absorbable suture. A running subcuticular stitch followed by Steri-strips are used
to repair the skin. The postoperative period was standard for each patient. This
included a bulky dressing with the fifth toe bandaged in abduction and a surgical
shoe with patients using guarded weight bearing, immediately after surgery. At the
first postoperative appointment 1 week later, all patients were transitioned into a
running shoe and started physical therapy for strengthening and range-of-motion
exercises.
Follow-up was performed in 50 patients at an average of 12 months.19 The average
age was 50.23 ⫾ 14.31 years. There were 44 (88%) females and 6 (1.2%) males. The
operative side included 27(54%) right and 23 (46%) left feet. Preoperatively the mean
4 –5 IMA, LDA, and fifth MTPJ angles were 10.34° ⫾ 2.40°, 4.15° ⫾ 4.08°, and 15.56° ⫾
6.83°, respectively. Nineteen (38%) patients had a type 2 deformity and 31 (62%)
patients had a type 3 deformity. The 19 patients with a type 2 deformity had a mean
LDA of 9.0° ⫾ 3.46°. Postoperatively at 1 year, the mean 4 –5 IMA, LDA, and fifth
MTPJ angles were corrected to 1.80° ⫾ 2.21°, 0.24° ⫾ 0.46°, and 2.40° ⫾ 7.94°,
respectively. Postoperative correction of the 4 –5 IMA, LDA, and fifth MTPJ angles
were statistically significant (P⬍.001). Complications included one undercorrection
and seven hardware removals.
708 Weil & Weil

Fig. 23. Preoperative oblique mid-shaft Coughlin osteotomy.

Kilmartin20 reported on 63 patients who underwent operative repair of 77 tailor’s

bunion deformities with a Scarfette technique between September 1999 and Sep-
tember 2006. Eighty-six percent were completely satisfied, 11.4% were satisfied with
reservations, and 3% were dissatisfied. Ninety-one percent considered themselves
better than before their surgery whereas 8.6% felt they were no better. Ninety-one
percent of patients said they would undergo surgery under the same conditions again.
Preoperatively, the mean 4 –5 IMA measured on weight bearing radiographs was 9.9°
(SD, 2.2) and the mean postoperative IMA was 5.7° (SD, 2.0). The mean preoperative
AOFAS score was 44.1 points (SD, 14.5) and the mean postoperative score at
6-month review was 91.8 (SD, 20.2). The clinical improvement was maintained, with
the AOFAS score at final review 36 months of 88.1 (SD, 11.6).

SUMMARY

A variety of surgical osteotomy procedures have been described for the bunionette
deformity.
Metatarsal osteotomies narrow the forefoot, maintain the length of the metatarsal,
and preserve function of the metatarsophalangeal joint. Distal metatarsal osteotomies
produce less correction and reduce postoperative disability; however, they pose a
 Osteotomies for Bunionette Deformity 709

Fig. 24. Postoperative oblique mid-shaft Coughlin osteotomy.

risk of inadequate correction because of the small width of the fifth metatarsal head
and transfer lesions if shortened or dorsiflexed excessively. The sliding oblique
metaphyseal osteotomy described by Smith and Weil (without fixation) and later by
Steinke21 (with fixation) is easy to perform and provides good cancellous bone
contact. Fixation is sometimes difficult and bone healing can take a few months owing
to the unstable construct of this osteotomy. Kitaoka described a distal chevron
osteotomy, which provides lateral pressure relief and reduced plantar pressure.4 This
osteotomy is currently the most common procedure used; however, it may prove
difficult to perform if the deformity is large and the bone is narrow. Diaphyseal
osteotomies are indicated when greater correction is needed; however, they
require more dissection and there is greater postoperative convalescence with
non–weight bearing for several weeks. Proximal base osteotomies may be used to
address significantly increased 4 –5 IMAs or when a large degree of sagittal plane
correction is required. Approaches that have been described include opening and
closing base wedges and basal chevrons. Advantages to this approach are the
ability to avoid epiphyseal plates in pediatric patients and maintain function of the
MTPJ, while disadvantages include inherent instability of the location of the
710 Weil & Weil

Fig. 25. Scarfette cut for bunionette. Note the proximal low cut.

osteotomy, embarrassment of intraosseous and extraosseus blood supply of the

metatarsal, and technical demand. Non–weight bearing is essential for several
weeks. The Scarfette procedure is a combination head–shaft procedure, which is
indicated to treat mild to moderate transverse and sagittal plane deformities.9,19
The inherent stability of the osteotomy and ability for early weight bearing of the
Scarfette makes this our procedure of choice when selecting treatments for
patients with a bunionette deformity.

Fig. 26. Distal fragment displaced medially, then impacted and fixed with threaded pin or
screw.
 Osteotomies for Bunionette Deformity 711

Fig. 27. Scarfette displacement with very stable construct.

ACKNOWLEDGMENTS

The authors express a special thank you to Thomas Roukis, DPM, for his help with
illustrations and photos.
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