I would like to discuss my preferred treatment method for the tailor’s bunion. It is funny. When you walk into the treatment room and your schedule states that the chief complaint is a “bunion,” you sometimes are taken aback when it is a tailor’s bunion and not a traditional bunion (hallux valgus). For hallux valgus repair that we do every week, it is typically a slam-dunk Austin.
When it comes to the tailor’s bunion, we sometimes have to scratch our heads to figure out what to do. Do we do something simple like shave the bump? If you are going to do an osteotomy, do you do the same type of osteotomy and fixation every time (like you do with hallux valgus)? I think we all experiment a little more with the osteotomy in a tailor’s bunion. Fixation can be trickier with a small bone like the fifth metatarsal. Raising the bone is needed more so than with hallux valgus repair. Therefore, a simple medial shift is not always the remedy.
Surgery for the tailor’s bunion includes simple exostectomies with or without an osteotomy. My advice to you is that if the tailor’s bunion is a minor secondary complaint to a hallux valgus and you are going to fix both, then consider a simple exostectomy. If the tailor’s bunion is the primary complaint, then I feel obligated to do an osteotomy. I have been burned by under-correction of a tailor’s bunion when I did an exostectomy but I have never had trouble with overcorrection of a tailor’s bunion.
One can repair most tailor’s bunions with a distal osteotomy. In rare instances, surgeons will need to perform a base procedure with a very large fourth intermetatarsal angle. So what is your procedure of choice for a tailor’s bunion that requires a distal osteotomy?
I have tried just about every way to cut the bone. I have used the reverse Austin, transverse and oblique osteotomies, long dorsal and plantar arm osteotomies. They all work.
I used to do an oblique osteotomy, which gives good correction and is very simple. Fixation can occur with a K-wire. The only problem I have found is that there is typically a lot of secondary bone healing, which causes bone callus and sometimes delayed healing as noted on X-rays. Even though the patient is doing fine clinically, the X-rays do not look so good. Not that I am treating X-rays but it is nice to show your patient a healed osteotomy at six weeks. In addition, the K-wire tends to be prominent and usually needs removal. It is tricky to get screw fixation with a transverse or oblique osteotomy.
My preferred method is a long plantar arm osteotomy. It is structurally very sound and is stable with weightbearing. The osteotomy is amenable to screw fixation and, as a result, can promote primary bone healing. I prefer solid core cortical screws for fixation of the osteotomy. Although one can fixate with cannulated screws, I am a firm believer in cortical bone fixation when feasible.
Do not forget to assess the skin prior to performing the surgery. If there is a callus on the plantar aspect of the fifth metatarsal head, then you can elevate the metatarsal head using the axis guide technique, which has been popularized for the Austin bunionectomy.
In closing, just remember to not fall into the trap of “it’s just a tailor’s bunion” and do an exostectomy. In residency, we jokingly said, “If it is bad enough for surgery, then it is bad enough for an osteotomy.” I have never been disappointed with performing an osteotomy but I vividly remember kicking myself for not doing one.