Plantar Fascitis

                                Dr KS Dhillon

Introduction

Degenerative irritation of the plantar fascia at its origin at the heel causes plantar fasciitis. The plantar fascia plays an important role in the foot biomechanics. It comprises of three segments that arise from the calcaneus. The fascia supports the foot arch and absorbs shock. Although the condition is called fascitis there are no inflammatory cells in the fascia.

Plantar fasciitis is prevalent with many people experiencing heel pain. Although the cause of plantar fasciitis is multifactorial, most cases result from overuse stress. Classically it presents with sharp localized pain at the heel (1). Sometimes an X-ray may show a heel spur. Plantar fasciitis is often difficult to treat. Patient dissatisfaction is common. The treatment is nonsurgical in most cases.

Etiology

Plantar fasciitis is usually an overuse injury. It is primarily due to repetitive strain that causes micro-tears of the plantar fascia. It, however, can occur due to trauma or other causes. Some of the predisposing factors include pes cavus, pes planus, limited ankle dorsiflexion, prolonged standing or jumping, and excessive supination or pronation of the foot (2,3). Pes planus can increase strain at the origin of the plantar fascia. When there is pes cavus there can be excessive strain on the heel because the foot does not effectively evert or absorb shock. Patients with plantar fasciitis often have tightness in the soleus, gastrocnemius, and other muscles in the posterior leg. These tight muscles can alter the ambulatory normal biomechanics.

About 50% of patients with plantar fascitis have heel spurs. These spurs do not cause pain. Plantar fasciitis is often seen in runners and older adults. Other risk factors include heel pad atrophy, aging, obesity, occupations that require prolonged standing, and weight-bearing. Plantar fasciitis can be associated with various seronegative spondyloarthropathies. In about 85% of individuals, there are no known systemic factors.

Epidemiology

Heel pain is most commonly caused by plantar fasciitis. The exact prevalence and incidence of plantar fasciitis is not known. Annually about 1 million patient visits are due to plantar fasciitis. Plantar fasciitis accounts for about 10% of runner-related injuries and 11% to 15% of all foot symptoms. About 10% of the general population is affected by plantar fasciitis. Eighty-three percent of these patients are active working adults between the ages of 25 and 65 years. The peak incidence occurs in the general population between the age of 40 to 60 years (4). In about one-third of cases, the plantar fasciitis is bilateral. A higher prevalence of plantar fasciitis is seen in women as compared to men, in those aged 45 to 64 versus those aged 18 to 44, and in those with a body mass index >25 kg/m2 (5). In runners' prevalence rates as high as 22% have been reported.

Pathophysiology

Plantar fasciitis is essentially a degenerative condition. Besides the degenerative changes, the histological findings include granulation tissue,  collagen disarray, and micro-tears. There is a notable lack of traditional inflammation. Ultrasound often shows calcifications, intra-substance tears, and thickening and heterogeneity of the plantar fascia. These changes suggest a noninflammatory condition. A study by Jarde et al (6) which included magnetic resonance imaging showed chronic fasciitis in 8 cases and an old rupture of the plantar fascia in 30 patients. The micro-tears occur due to the repetitive stress of standing upright and weight-bearing.  The constant stretching of the plantar fascia due to standing upright and weight-bearing can lead to chronic degeneration of the fascia. This degeneration can eventually lead to pain during sleep or at rest.

History and Physical Examination

Patients usually present with progressive pain at the inferior medial aspect of the heel. In more severe cases the pain can radiate proximally. The patients often describe the pain as sharp and worse on getting up in the morning. Long periods of standing and sitting for prolonged periods can exacerbate the symptoms. Initially, pain decreases with ambulation and at the beginning of an athletic activity. It, however, increases throughout the day as the activity increases. 

Examination will show tenderness on the plantar aspect of the medial calcaneal tubercle at the site of the plantar fascial insertion. The pain can be reproduced by passive dorsiflexion of the foot and toes. The windlass or Jack test actively reproduces pain through passive dorsiflexion of the first metatarsophalangeal joint. It is positive if the pain is elicited (7). Secondary findings include a tight tendoachilles, pes cavus, or pes planus. 

The patient's gait should be evaluated for biomechanical factors or predisposing factors. Fat pad contusion or atrophy, stress fractures, and nerve entrapments such as tarsal tunnel syndrome should be considered in the differential diagnosis.

Evaluation

Plantar fasciitis is a clinical diagnosis. Imaging is of no value and is unnecessary. X-rays can be done and ultrasound evaluation can be carried out if the history or physical examination indicates other injuries or conditions or if the patient fails to improve after a reasonable amount of time. X-rays and ultrasound can show calcifications in the soft tissues or heel spurs on the inferior aspect of the heel (8). The ultrasound can show thickening and swelling of the plantar fascia (9). An MRI can be done to evaluate for tears, stress fractures, or osteochondral defects if the patient does not respond to conservative therapy after an extended time. 

In patients with plantar fasciitis, an MRI will show thickening of the plantar fascia and increased signal on inversion recovery (fat suppressed) images (10). Technetium scintigraphy can also successfully locate the inflammatory focus and exclude the presence of a stress fracture (11,12).

Management

Depending on the pain level, rest from the offending activity is the first-line treatment. Ice compresses and nonsteroidal anti-inflammatory drugs can help alleviate pain. Deep friction massage of the arch and insertion, along with the prescription of shoe inserts, orthotics, and night splints, can offer benefits (13). Prefabricated silicone heel inserts and stretching exercises, can also be helpful (14). The patients should be educated on proper stretching and rehabilitation of the Achilles tendon, plantar fascia, gastrocnemius, and soleus.

If the pain does not resolve with conservative measures, other more advanced or invasive techniques are required. These include botulinum toxin A, extracorporeal shock-wave therapy, or various injections such as dex prolotherapy, autologous platelet-rich plasma, or steroids (15-17). These more invasive and advanced techniques should be combined with conservative treatment. If conservative treatment fails then surgery may be required. For the therapy, a minimum of 6 weeks of treatment is required.  Stretching, icing, strapping of the heel, and modification of work-related activities are needed. A night splint can help patients who have recalcitrant pain (18).

Surgery is reserved as the last resort for treatment. It is usually reserved for patients who do not respond to nonoperative therapy for at least 6 to 12 months (19). A fasciotomy can be done through an endoscopic or open approach. A surgical release does not guarantee a successful outcome. Surgery can be associated with complications such as plantar fascia rupture, nerve injury, and flattening of the longitudinal arch. It is still uncertain whether stretching or controlling running intensity can prevent plantar fasciitis. Shock-absorbing footwear usually helps. A contoured foot orthosis can reduce injuries compared to a flat insole. 

Differential Diagnosis

Some of the differential diagnoses include:

Bone contusion

Neuropathic pain

Tendinitis

Calcaneus injury

Infection

Sickle cell bony pain

Osteoporosis

Malignancy

Considering and evaluating these conditions is important for an accurate diagnosis and proper treatment.

Prognosis

About 75% of cases resolve spontaneously within a year. Surgery is needed in about 5% of the patients. After surgery, the outcome is not consistently positive. The resolution of symptoms can take weeks to months after treatment (20). 

Plantar fasciitis requires time off from physically demanding work and sports and this can produce significant morbidity. Some patients will need an ambulatory device to avoid weight-bearing.

Complications

The following complications can result from plantar fasciitis:

• Fat pad necrosis

• Flattening of the arch

• Rupture of the tendon if corticosteroid injections are used

Conclusion

Plantar fasciitis is common and it affects many people, especially athletes and young people. If not appropriately managed it can be disabling. As no single treatment works for everyone, an interprofessional approach to plantar fasciitis is preferred. The doctor, physical therapist, pharmacist, and rehabilitation specialist are vital in managing symptoms and for patient education. Patients should be told that improvement in symptoms can take weeks or months. The patient may have to undergo physical therapy or wear a night splint. Patients should be taught how to stretch the plantar fascia through exercises.

Shoes with appropriate arch support may be required. The patient has to be advised to avoid long periods of standing. Individuals who are overweight have to lose weight. Stretching exercises have to be started. Individuals with acute symptoms have to avoid walking barefoot and limit repetitive exercises. 

Plantar fasciitis is a benign disorder, but if it is not adequately managed, it can be disabling and associated with moderate to severe foot pain. Symptom reduction occurs in 9 to 12 months in about 70% to 80% of patients. About 5% to 10% of the patients require surgical treatment (21). Plantar fasciitis in athletes can be associated with high morbidity despite appropriate treatment. Recurrences are not uncommon. The morbidity of plantar fasciitis is due to pain in the foot which produces difficulty in ambulation, limitation in doing exercises, and difficulty in weight bearing. Uneven ambulation can sometimes lead to hip and knee joint injury. Plantar fasciitis is one of the most common causes of worker's compensation claims in individuals who have to stand long hours.

References

1. Bm SA, Tiwari V, Bakde AM, Dwidmuthe S, Roy M. Ultrasonographic Assessment of Indian Patients With Plantar Fasciitis and Its Clinical Correlation: A Prospective Observational Study. Cureus. 2023 Mar;15(3):e35764.

2. Mørk M, Soberg HL, Hoksrud AF, Heide M, Groven KS. The struggle to stay physically active-A qualitative study exploring experiences of individuals with persistent plantar fasciopathy. J Foot Ankle Res. 2023 Apr 15;16(1):20.

3. Riddle DL, Pulisic M, Pidcoe P, Johnson RE. Risk factors for Plantar fasciitis: a matched case-control study. J Bone Joint Surg Am. 2003 May;85(5):872-7.

4. Nahin RL. Prevalence and Pharmaceutical Treatment of Plantar Fasciitis in United States Adults. J Pain. 2018 Aug;19(8):885-896.

5. LAPIDUS PW, GUIDOTTI FP. PAINFUL HEEL: REPORT OF 323 PATIENTS WITH 364 PAINFUL HEELS. Clin Orthop Relat Res. 1965 Mar-Apr;39:178-86.

6. Jarde O, Diebold P, Havet E, Boulu G, Vernois J. Degenerative lesions of the plantar fascia: surgical treatment by fasciectomy and excision of the heel spur. A report on 38 cases. Acta Orthop Belg. 2003 Jun;69(3):267-74.

7. Alshami AM, Babri AS, Souvlis T, Coppieters MW. Biomechanical evaluation of two clinical tests for plantar heel pain: the dorsiflexion-eversion test for tarsal tunnel syndrome and the windlass test for plantar fasciitis. Foot Ankle Int. 2007 Apr;28(4):499-505. 

8. Cho BW, Choi JH, Han HS, Choi WY, Lee KM. Age, Body Mass Index, and Spur Size Associated with Patients' Symptoms in Plantar Fasciitis. Clin Orthop Surg. 2022 Sep;14(3):458-465.

9. Lai TW, Ma HL, Lee MS, Chen PM, Ku MC. Ultrasonography and clinical outcome comparison of extracorporeal shock wave therapy and corticosteroid injections for chronic plantar fasciitis: A randomized controlled trial. J Musculoskelet Neuronal Interact. 2018 Mar 01;18(1):47-54.

10. McGonagle D, Marzo-Ortega H, O'Connor P, Gibbon W, Pease C, Reece R, Emery P. The role of biomechanical factors and HLA-B27 in magnetic resonance imaging-determined bone changes in plantar fascia enthesopathy. Arthritis Rheum. 2002 Feb;46(2):489-93. 

11. Drake C, Whittaker GA, Kaminski MR, Chen J, Keenan AM, Rathleff MS, Robinson P, Landorf KB. Medical imaging for plantar heel pain: a systematic review and meta-analysis. J Foot Ankle Res. 2022 Jan 22;15(1):4. 

12. Dasgupta B, Bowles J. Scintigraphic localisation of steroid injection site in plantar fasciitis. Lancet. 1995 Nov 25;346(8987):1400-1. 

13. Wapner KL, Sharkey PF. The use of night splints for treatment of recalcitrant plantar fasciitis. Foot Ankle. 1991 Dec;12(3):135-7. 

14. Pfeffer G, Bacchetti P, Deland J, Lewis A, Anderson R, Davis W, Alvarez R, Brodsky J, Cooper P, Frey C, Herrick R, Myerson M, Sammarco J, Janecki C, Ross S, Bowman M, Smith R. Comparison of custom and prefabricated orthoses in the initial treatment of proximal plantar fasciitis. Foot Ankle Int. 1999 Apr;20(4):214-21.

15. Majidi L, Saeb F, Alaei B, Khateri S, Ezzati Amini E, Nikoo MR. Comparison of the Effectiveness of Local Corticosteroid Injection and Extracorporeal Shockwave Therapy in Patients With Pes Anserine Bursitis: An Open-Label Randomized Clinical Trial. Med J Islam Repub Iran. 2023;37:10. 

16. Sneed D, Wong C. Platelet-rich plasma injections as a treatment for Achilles tendinopathy and plantar fasciitis in athletes. PM R. 2023 Nov;15(11):1493-1506. 

17. Karakılıç GD, Aras M, Büyük F, Bakırcı EŞ. Prolotherapy Versus Phonophoresis and Corticosteroid Injections for the Treatment of Plantar Fasciitis: A Randomized, Double-Blind Clinical Trial. J Foot Ankle Surg. 2023 May 07.

18. Nakhaee M, Mohseni-Bandpei M, Mousavi ME, Shakourirad A, Safari R, Kashani RV, Mimar R, Amiri H, Nakhaei M. The effects of a custom foot orthosis on dynamic plantar pressure in patients with chronic plantar fasciitis: A randomized controlled trial. Prosthet Orthot Int. 2023 Jun 01;47(3):241-252.

19. Davis PF, Severud E, Baxter DE. Painful heel syndrome: results of nonoperative treatment. Foot Ankle Int. 1994 Oct;15(10):531-5.

20. Fouda KZ, Ali ZA, Elshorbagy RT, Eladl HM. Effect of radial shock wave and ultrasound therapy combined with traditional physical therapy exercises on foot function and dorsiflexion range in plantar fasciitis: a prospective randomized clinical trial. Eur Rev Med Pharmacol Sci. 2023 May;27(9):3823-3832.

21. Martin RL, Irrgang JJ, Conti SF. Outcome study of subjects with insertional plantar fasciitis. Foot Ankle Int. 1998 Dec;19(12):803-11.

 

   Bunionette Deformity (Tailor's Bunion)

                                  Dr. KS Dhillon

Introduction

Bunionette refers to a prominence on the lateral aspect of the fifth metatarsal head. It may or may not be symptomatic. Bunionettes have traditionally been referred to as “tailor’s bunion” since it is prevalent among tailors, who sit cross-legged all day with the lateral edge of their feet rubbing on the ground. There are specific risk factors that predispose patients to this deformity. The deformity is usually treated conservatively. Surgical intervention may be needed for patients who continue to experience pain and disability.

Anatomy and pathophysiology

Symptomatic bunionette deformities are often associated with anatomic variations. Coughlin in 1990 (1) described several anatomic factors that can contribute to symptomatic bunionette deformities. These include:

• Congenital plantarflexed or dorsiflexed metatarsals

• Increased four to five intermetatarsal angle (IMA)

• Prominence of the metatarsal head

• Lateral bowing of the metatarsal shaft 

Typically the toe is adducted at the MP joint (fig 1). Congenital deformities such as brachymetatarsia and splayfoot have been linked to the development of bunionette deformities (2,3). Soft tissue abnormalities can accompany bunionette deformities. Ankle and hindfoot deformities and plantarflexed metatarsals are associated with plantar callosity and increased pressure on wearing shoes (4).

Fig 1.

Evaluation

The bunionette deformity is more common in women than men. The reported ratios vary from 2:1 to 10:1. Bilateral deformity is common (5). Patients with symptomatic bunionette deformities usually present with pain at the lateral side of the forefoot. The pain is usually exacerbated by wearing closed shoes. Some patients have more pain in the plantar-lateral forefoot rather than on the lateral side. Other metatarsophalangeal (MTP) joint pathologies have to be ruled out during the examination. Non-Inflammatory, crystal, and inflammatory arthropathies have to be ruled out. In patients with suspected inflammatory arthritis, the rheumatoid nodules should be evaluated with ultrasound or MRI to assess the extent of the disease. The deformity and prominence in such cases are caused by chronic synovitis. The chronic synovitis causes capsular distension (6). Sometimes chronically inflamed bursal tissue can develop lateral to the bony prominence. This can worsen the clinical picture.

A complete ankle and foot examination is necessary to define the exact pathology and also to identify other co-existing pathologies. The clinician should look for pes planus and hindfoot (1,7,8). Splayfoot deformity arises When there are coexisting hallux valgus and bunionette deformities, splayfoot deformity arises (2). Coughlin carried out a study in 20 patients (30 feet) with symptomatic bunionettes refractory to conservative treatment who underwent longitudinal diaphyseal osteotomy, lateral condylectomy, and distal metatarsophalangeal realignment and found that 60% of patients required correction of additional deformities including hallux valgus, hallux rigidus, and hammertoe deformities, among others (30%, 10% and 7%, respectively (9). Examination of the skin and subcutaneous tissue is important. Lateral eminence swelling with either keratosis, erythema,  ulceration, or callosity has to be evaluated. Callosity can be present on the plantar aspect or laterally. In patients where these lesions extend to the plantar surface, elevation of the metatarsal head in addition to medialization should be carried out (4,10).

Radiographic examination starts with standard weight-bearing X-rays with anterior posterior and lateral views. There are several angles that have been described in the assessment of bunionette deformity. Most often, the 5th MTP joint angle (MTP-5 angle), the 4–5 IMA, and the fifth metatarsal lateral deviation angle are measured. The average MTP-5 angle is 10.2. Ninety percent of normal feet have an angle of 14 degrees or less (11).

The MTP-5 angle shows the medial deviation of the toe in relation to the metatarsal shaft. The average angle in normal feet is 10.2 degrees. In 90% of normal feet, the angle is 14 degrees or less (5,11). On average an MTP-5 angle of 16 degrees or more produces symptoms (4,5,9). Another angle that is commonly measured is the 4–5 IMA. The 4-5 IMA measures the divergence of the 4th and 5th metatarsals. When a line is drawn through the axis of each metatarsal, the 4–5 IMA angle is the angle at the intersection of the lines Fig 2.

The most common method to bisect The axis of the metatarsal can be bisected by using a line on the medial and lateral margins of the proximal metaphysis and the metatarsal neck (4,5,12). The average of the 4–5 IMA angle is 10.8 degrees (5). Fallat and Buckholz were of the opinion that the most consistent way to determine the axis of the 5th metatarsal shaft is to use a line adjacent and parallel to the medial surface of the proximal half of the metatarsal shaft (13).

 

Fig 2.

When comparing normal feet (6.5 degrees) to feet with bunionettes (8.7 degrees) they found a difference of 2 degrees. They found a change in 4–5 IMAs when foot position goes from inversion to eversion. There was a change of 3 degrees in 4–5 IMAs (13). The consensus settled on abnormal 4–5 IMAs values equal to or greater than 9 (4).

Excessive lateral bowing of the fifth metatarsal shaft can contribute 

to the development of a painful bunionette (1,4,9,14,15). In these patients, the 4–5 IMA may be normal. A lateral curvature of the 5th metatarsal diaphysis causes the deformity. According to Fallat and Buckholz, this measurement is the angle created by a line parallel and adjacent to the proximal medial surface of the fifth metatarsal and a line representing the axis of the distal metatarsal (13). Nestor et al (5) did not find a difference in lateral bowing between symptomatic bunionettes and controls. Fallat and Buckholz, however, found an average lateral bowing of 8.1 degrees compared to controls (2.6 degrees) (13). The estimated incidence of patients who undergo surgery for symptomatic bunionettes who present with bowing of the 5th metatarsal shaft ranges from 10% to 23% (4). The width of the 5th metatarsal head also contributes to symptomatic bunionettes. The normal width of the 5th metatarsal head is about 13 mm, and it varies from 11 to 14 mm (13,16). The incidence of an abnormally large metatarsal width ranges from 16% to 33% (4).

Classification

Coughlin suggested a classification system based on radiographic parameters for bunionettes that is widely used today (9).

• Type 1 refers to an enlarged 5th metatarsal head

• Type 2 refers to normal 4–5 IMA with an increased lateral bow of the 5th metatarsal shaft

• Type 3 refers to an increased 4–5 IMA

Type 3 is the most common type in patients with symptomatic bunionettes. This makes the 4–5 IMA the most important factor to play a role in symptomatic bunionettes (4).

Nonoperative Treatment

Literature regarding successful nonsurgical treatment options for symptomatic bunionettes is limited. According to Shi et al more than 90% of patients with symptomatic bunionette deformities resolve without invasive treatment (7). Non-operative treatment should always be attempted before any surgery is carried out. Non-operative management usually involves symptomatic treatment of pain and the callosities. Shoe modification with a wider toe box can help patients control pain. Callosities can be managed with protective pads and shaving. Grice et al showed the efficacy of corticosteroid injections in the treatment of little toe MP joint synovitis (17). No long-term studies have, however, shown improvement of symptoms with non-surgical management.

Operative Treatment

The operative treatment of bunionette deformities will largely depend on the type of deformity. The classification system of bunionette deformities helps doctors establish an algorithm that can be used to treat these deformities. The surgical treatment options include:

• Metatarsal head resection

• Proximal or midshaft oblique osteotomies

• Distal chevron osteotomies

• Subcapital oblique osteotomies

• Scarf osteotomy, 

• Ludloff variant osteotomy

Metatarsal head resection is associated with poor outcomes. It is only reserved for unhealthy patients, or in patients with an infectious or inflammatory process. 

Kitaoka and Holiday reported poor results at 8 years follow-up in 7 patients (11 feet) undergoing metatarsal head resections (18). The poor outcomes included persistent lateral forefoot prominence, transfer metatarsalgia, and painful fifth toe deformity. The authors recommend against the use of metatarsal head resections. Nonetheless, metatarsal head resection does have a role in rheumatoid arthritis patients. In a retrospective study of 56 rheumatic feet, Reize et al showed successful results in terms of cosmetic and functional outcomes as well as pain control following resection of the first through fifth metatarsal heads for long-standing rheumatoid forefoot deformity (19).

Distal chevron osteotomy is a popular technique for the treatment of Type I bunionette deformities. Kitaoka et al performed 19 distal chevron metatarsal osteotomy operations in 13 patients with painful bunionettes. At a 7.1-year follow-up, they reported good outcomes without failures (20). The MTP 5 angle, IMA 4–5 angle, and forefoot width improved at follow-up. They had one case of transfer metatarsalgia and one case of wound infection. Boyer and Deorio reported good outcomes in 10 patients with symptomatic bunionette deformity who underwent 12 distal fifth metatarsal chevron osteotomies in which an absorbable poly-p-dioxanone suture (PDS) pin was used for fixation. All patients had radiographic union and high patient satisfaction (21).

Type I bunionette deformities can also be treated by a subcapital oblique osteotomy. Cooper and Coughlin in a retrospective review of 16 feet in 14 patients with a follow-up of approximately 3 years, showed good clinical results for correction of type I deformities (14). There was improved patient satisfaction and pain control. However, there was no significant improvement in IMA 4–5 angle post-operatively. This procedure has more flexibility than the chevron osteotomy. Besides translating the metatarsal head laterally, the metatarsal head can be elevated to alleviate plantar pressure.

Diaphyseal osteotomies are carried out when there is increased lateral bowing or IMA 4–5 angles. To correct bunionette deformities, Coughlin described an oblique osteotomy of the metatarsal shaft in conjunction with lateral condylectomy and distal MTP realignment. He reported 93% of good or excellent outcomes in 30 feet (9). More recently, Waizy et al showed improvement in patient satisfaction, lateral bowing, and radiographic measurements of IMA 4–5 angle with a reverse Ludloff osteotomy for type II and III bunionette deformities. They had no complications or revision procedures (22). Shi et al (7) reported several studies that reported similar outcomes with Ludloff variants and scarf osteotomies for type II and type III bunionette deformities.

Very proximal fifth metatarsal osteotomies are not recommended because of concerns of nonunion. Tenous blood supply to the proximal metaphyseal-diaphyseal region and higher stresses on the bone in this region can contribute to poor healing. Despite this, some doctors continue to carry out these osteotomies to address bunionette deformities with increased IMA 4–5 angles. Okuda et al (23) reported the outcome of proximal dome-shaped osteotomy in 8 patients (10 feet). They found significant improvement in MTP 5 angle and IMA 4–5 angles. The results were good in all 8 patients. There were, however, 3 cases of delayed union at the osteotomy site. They found that all 3 cases of delayed union had osteotomies that were more proximal than those with expected union rates. Therefore, they advised against performing osteotomies at sites that are too proximal.

In recent years, minimally invasive surgical techniques have become popular for several ankle and foot conditions. Giannini et al (24) reported excellent results in 32 patients (18 bilateral) using a transverse distal metatarsal osteotomy, for type II and III deformities. Waizy et al (25) reported their results using a similar technique in 31 feet. They, however, found good to excellent results in 16 feet, satisfactory in 14, and poor results in 9 feet. The results were inferior for type II and III deformities. According to them, this technique should only be used for type I deformity.

There are many variations in the post-operative care. Some doctors opt for non-weight bearing for 6 weeks. In these patients, the foot is placed in a splint following surgery and later a short leg cast is applied for 6 weeks. After 6 weeks the patient is allowed weight-bearing activities in a post-operative shoe. The patient is expected to return to normal activities at 8–10 weeks. Other doctors prefer a post-operative protocol that involves immediate heel-weight bearing in a post-operative shoe for 6 weeks. The patient is gradually allowed full weight bearing and is expected to return to normal activities between 8–10 weeks postoperatively.

Complications

The overall complication rate is low following correction of bunionette deformity (7). Some of the complications include: 

• Malunion

• Nonunion

• Recurrence

• Wound complications

• Avascular necrosis

• Transfer metatarsalgia

Avascular necrosis and nonunion can result from excessive soft tissue stripping during the surgery. Inadequate immobilization of the osteotomy site due to poor or lack of internal fixation can also lead to nonunion and malunion. Extension of the proximal osteotomy into watershed areas can increase the risk of delayed union. 

Since the metatarsal is small sized, distal osteotomies are at risk of instability due to poor fixation or overcorrection. Chevron osteotomies that translate more than 50% can lead to instability. Transfer metatarsalgia may occur if the fifth metatarsal is excessively elevated or shortened. The lateral dorsal cutaneous branch and sural nerve are at risk with any bunionette procedure and must be protected. A study by Malagelada et al (26) found that the nerve has variability and they described safe zones to protect it during minimally invasive techniques. When the procedure of choice fails to address the underlying driver of the deformity, recurrence of deformity is seen in all types of bunionette deformity. Hence, the chances of recurrence will be reduced if there is an adequate understanding of the types of deformities and the corresponding surgery. 

Conclusions

Bunionette deformity is less common than hallux valgus and other forefoot disorders. It can, however, be a source of significant disability and pain. A proper evaluation is required with close examination of the entire ankle and foot. Initial treatment usually focuses on symptomatic relief. Several surgical options are available when conservative treatment fails. Excellent outcomes can be obtained with proper surgical selection and technique.

References

1. Coughlin MJ. Etiology and treatment of the bunionette deformity. Instr Course Lect 1990;39:37-48.

2. Bishop J, Kahn A, Turba JE. Surgical correction of the splayfoot: the Giannestras procedure. Clin Orthop Relat Res 1980;234-8. 

3. Schimizzi A, Brage M. Brachymetatarsia. Foot Ankle Clin 2004;9:555-70.

4. Cooper MT. The Bunionette Deformity: Overview and Classification. Tech Foot Ankle Surg 2010;9:2-4.

5. Nestor BJ, Kitaoka HB, Ilstrup DM, et al. Radiologic anatomy of the painful bunionette. Foot Ankle 1990;11:6-11.

6. Brooks F, Hariharan K. The rheumatoid forefoot. Curr Rev Musculoskelet Med 2013;6:320-7.

7. Shi GG, Humayun A, Whalen JL, et al. Management of Bunionette Deformity. J Am Acad Orthop Surg 2018;26:e396-404.

8. Ceccarini P, Rinonapoli G, Nardi A, et al. Bunionette. Foot Ankle Spec 2017;10:157-61.

9. Coughlin MJ. Treatment of bunionette deformity with longitudinal diaphyseal osteotomy with distal soft tissue repair. Foot Ankle 1991;11:195-203.

10. Cooper MT, Coughlin MJ. Subcaptial Oblique Fifth Metatarsal Osteotomy Versus Distal Chevron Osteotomy for Correction of Bunionette Deformity. Foot Ankle Spec 2012;5:313-7.

11. Steel MW, Johnson KA, DeWitz MA, et al. Radiographic Measurements of the Normal Adult Foot. Foot Ankle 1980;1:151-8.

12. Schoenhaus H, Rotman S, Meshon AL. A review of normal inter-metatarsal angles. J Am Podiatry Assoc 1973;63:88-95.

13. Fallat LM, Buckholz J. An analysis of the tailor’s bunion by radiographic and anatomical display. J Am Podiatry Assoc 1980;70:597-603.

14. Cooper MT, Coughlin MJ. Subcapital oblique osteotomy for correction of bunionette deformity: medium-term results. Foot Ankle Int 2013;34:1376-80.

15. Yancey HA. Congenital lateral bowing of the fifth metatarsal. Report of 2 cases and operative treatment. Clin Orthop Relat Res 1969;203-5.

16. Zvijac JE, Janecki CJ, Freeling RM. Distal oblique osteotomy for tailor’s bunion. Foot Ankle 1991;12:171-5.

17. Grice J, Marsland D, Smith G, et al. Efficacy of Foot and Ankle Corticosteroid Injections. Foot Ankle Int 2017;38:8-13.

18. Kitaoka HB, Holiday AD. Metatarsal head resection for bunionette: long-term follow-up. Foot Ankle 1991;11:345-9.

19. Reize P, Leichtle CI, Leichtle UG, et al. Long-term results after metatarsal head resection in the treatment of rheumatoid arthritis. Foot ankle Int 2006;27:586-90.

20. Kitaoka HB, Holiday AD, Campbell DC. Distal Chevron metatarsal osteotomy for bunionette. Foot Ankle 1991;12:80-5.

21. Boyer ML, Deorio JK. Bunionette deformity correction with distal chevron osteotomy and single absorbable pin fixation. Foot ankle Int 2003;24:834-7.

22. Waizy H, Jastifer JR, Stukenborg-Colsman C, et al. The Reverse Ludloff Osteotomy for Bunionette Deformity. Foot Ankle Spec 2016;9:324-9.

23. Okuda R, Kinoshita M, Morikawa J, et al. Proximal dome-shaped osteotomy for symptomatic bunionette. Clin Orthop Relat Res 2002;173-8.

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