Discussing Surgical Insights on Tailor’s Bunions

Editors’ note: This content is comprised of highlights from a transcript, capturing the authentic conversation that took place. Some language may reflect the flow of live discussion rather than polished text.

Q: As a quick overview, what do you think is the most challenging aspect of surgically addressing Tailor’s bunions?

A: I think that the most challenging aspect of surgically addressing this deformity is (that) there are so many different ways to approach a fifth metatarsal osteotomy. There are so many diverse procedure options, and they can be deceivingly tricky. And sometimes you have to consider that you need triplane correction. You have to consider the type of Tailor’s bunion. Is it a type one, two, or three? And it’s not one-size-fits-all. 

So, it’s really important to remember all of those aspects. And again, there’s so many options. So, the traditional surgical management, which could be the open lateral approach, which is a sliding osteotomy versus a transverse oblique, a Scarf, and now the newer minimally invasive surgery technique. (The MIS approach) could still be different types of cuts, such as the transverse, the oblique, and a wedge. And then, you have a whole place card of different menu options of fixation. Are you going to let it float? Are you going to do wire fixation or screw fixation? There are so many different options, which are deceivingly tricky, and lots of different approaches.

Q: Since there are so many procedures that are available for this condition, what do you think surgeons should keep in mind when selecting a surgical approach? What factors should they be looking at to come to the best decision for each individual patient scenario?

A: One thing to keep in mind is, as I mentioned before, one size does not fit all. So, one should look at the different options and then look at the benefits for your patient population. Let’s start, for example, with the MIS option. So, what are the benefits? (These could include) smaller incisions, potentially quicker healing, sometimes less pain as well, because you’re not opening up all the soft tissue. And there’s (the consideration of) a decreased risk for infection and nonunion, and you also maintain higher vascular perfusion. So, a patient population that may benefit from that, (are sometimes those that) are older, since you don’t want to open them up, but then you also have to keep in mind, do they have osteoporosis? 

So, lots of critical thinking goes into this. And one more thing to think about is the condylectomy. When people go in and do a Tailor’s bunion correction, and they go in and do what we call a “bumpectomy,” you really have to be careful with that. Because, if you take too much bone, as I’m sure all of us have seen in our office as a second opinion, there can be complications. There’s a case that I use when I lecture about this, it was a patient with rheumatoid arthritis that had an aggressive condylectomy. It resulted in a stress fracture at the metatarsal neck because they just took too much. And so, it left them with a kind of pencil-thin metatarsal that resulted in more complications than (expected from) if they had just gone ahead with doing an osteotomy. So, the easy way out isn’t the right way out, because although it may be easier to heal from, with no fixation, and you go in and you just shave the bone, it’s still important to consider the patient population. Looking at, say, the open procedure and the different positives for that versus the MIS option, sometimes you can address larger angles, you do use fixation, you can get in there, make sure that the correction is adequate, it’s not invisible to you. And with MIS, there is sometimes a larger learning curve.

If we go into the complications with MIS, this can include irritation from the K-wires and in fixed osteotomies, hypertrophic callus. If you use an unfixed osteotomy, you just let it float. There is sometimes a high learning curve as well with MIS procedures. Sometimes people find, and I found that when I first started with MIS, the Tailor’s bunion was a really good way to start, because the osteotomy was more predictable. I didn’t have to use fixation and I got a good correction. But on the other hand, with the open complications, as with your traditional open fifth metatarsal osteotomies, you have incision healing complications, wound complications, and hardware complications. People have started doing these mini-open procedures, which may reduce risk, but there isn’t a lot of data to support that yet in the literature. 

So, the hypertrophic callus that I’m talking about is caused by micromotion. And I found a catch-22 with the MIS versus the open procedures. So, with the MIS procedures, that hypertrophic callus can sometimes become palpable. And so, the patients feel it in a different area compared to where they were feeling the fifth metatarsal head originally. And with the open procedure, for some reason in my office, I operate on a lot of small females and they end up feeling the hardware sometimes. So, I’ve noticed in my practice, the number one reason I take a patient back (to the operating room) is to remove the screws from my fifth metatarsal osteotomy. I’m careful to use the right size and all of that. But I just found that it’s much more prominent on those osteotomies.

Q: Is the literature providing us any particular guidance as of late on procedure selection?

A: On procedure selection, not particularly significantly, however, there are different newer clinical research findings on minimally invasive versus more traditional Scarf osteotomy, which I’ll dive into a little bit later. But looking at the MIS approach, there has been good literature. In Foot and Ankle Orthopedics in 2024, the July issue looked at minimally invasive surgery for management of bunionette deformity using fifth metatarsal osteotomy, via a systemic review and meta-analysis.¹ They looked at 942 potential cases and 580 patients. All studies showed statistically significant improvement in clinical outcomes. The common complication they cited was the hypertrophic callus that we had discussed earlier, which self-resolved over time without surgical intervention. So, as we are seeing in foot and ankle surgery in general, the MIS approach is really becoming a leader in changing our approach to what we do with traditional osteotomies. And here is a recent 2024 study with a large patient population that shows improved results. I’m seeing more and more literature with MIS. And that may, and probably should, influence our procedure selection.

Q: What have you found personally, in your hands, to be a sound approach to this pathology?

A: I have traditionally, and still find, good reproducible results. I have lectured at several conferences and have had a really great discussion with my colleagues on the different types of procedures that they find works in their hands and it varies significantly, as we discussed earlier. I have been able to reproduce great correction with the open modified Scarf osteotomy. This is a podcast, so I can’t really draw it for you, but it is almost a full traditional Scarf with a more angled dorsal and plantar cut, and I can get a significant shift with two small screws that are very tiny. These are really good for those very large intermetatarsal (IM) angles that almost have that IM angle starting from the proximal aspect of the fifth metatarsal. They’re very challenging. And if you don’t use adequate correction, the patient’s still going to have issues because the problem’s not only at the head, but it’s also coming from proximally.

There is also good research out there from the Foot publication, out of Scotland, in May 2023. This was an electronic database search to collate all of these studies pertaining to Tailor’s bunion corrections using the Scarf osteotomy between 2000 and 2021. All studies demonstrate a statistically significant reduction of fourth intermetatarsal angles, and improvement in clinical and patient-reported outcome measures. There’s about a 15% complication rate identified. And they noticed that the one (primary) complication was recurring plantar hyperkeratosis right at that fifth metatarsal itself.²

I haven’t personally encountered that in my practice and have not had an issue with nonunion, as I make sure my fixation captures all cortices and I have good compression along the site. I do make sure I optimize their bone health prior to any osteotomies now. There’s a big push now, I do check vitamin D levels and supplement them prior to doing osteotomies, and that’s really helped with my outcomes. It’s my procedure of choice. Why? Because there’s a large IM angle correction. I find it very easily reproducible, which I know that the MIS does have a higher learning curve, but ... hardware removal.

Q: Is there anything else that you would like the audience to know about these perspectives on approaching Tailor’s bunions?

A: Again, diverse procedure options are available, and they are not one-size-fits-all, but MIS is really proving successful long-term outcomes, as we could see with that one previous study. Always do a (skills) lab, as we all know, prior to trying it in the OR, as I find that fifth metatarsal osteotomies are challenging and to figure out what works best in your hands. Dr. Parthasarathy is currently the president of the Maryland Podiatric Medical Association, an APMA spokesperson, and has participated in surgical mission trips with Operation Footprint. She is board certified by the American Board of Podiatric Medicine and a Fellow of the American Society of Podiatric Surgeons. Additionally, she is a member of the Podiatry Today editorial advisory board. 

References

1.    Lewis TL, Lam P, Alkhalfan Y, Ray R. Minimally invasive surgery for management of bunionette deformity (Tailor’s bunion) using fifth metatarsal osteotomies: A systematic review and meta-analysis. Foot Ankle Orthop. 2024;9(3):24730114241263095. 
2.    Coll MC, Beech MI. Scarf osteotomy for reduction of tailors bunion deformities: Systematic review and meta-analysis. Foot (Edinb). 2023;55:101982.