Osteotomies for bunionette deformity

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 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 Steinke (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. 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 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.