Tailor’s Bunion

A bunionette (also known as a tailor’s bunion) is a painful bony prominence, or bump, on the outside of the fifth (pinky) toe. Over time, the bunionette may worsen as the fifth toe moves inward and the fifth metatarsal (the bone connected to it) moves outward. Rubbing between the bump and tight shoes may also cause a callus to grow over the fifth toe area. All bunionettes can cause pain and pressure on the outside of the foot, though often they do not cause symptoms.

An osteotomy is a surgically performed cut of the bone. A fifth metatarsal osteotomy refers to a cut in the head, neck, or shaft of the bone to make it straighter and the bony prominence smaller. This reduces rubbing on the outer side of the foot and decreases or eliminates the pain.

Symptoms

Your foot and ankle orthopedic surgeon may recommend surgery if your bunionette (bump) is painful, does not improve with non-surgical treatment, and prevents you from wearing comfortable shoes. Non-surgical treatment options include wearing wider shoes, shaving the callus on the outer side of the fifth metatarsal, padding the area, removing pressure from the bump by using a donut pad, or using a pre-made or custom orthotic device.

Surgery should never be chosen before non-surgical measures have been tried. Surgery should be avoided if you have an infection at the fifth toe or around the surgical site, or if your toe has poor circulation. Poor circulation can be caused by smoking and diabetes and can lead to problems with wound healing after surgery. A fifth metatarsal osteotomy is not needed if the bone is well-aligned. Surgery should not be considered for ease of shoe wear if you are not having pain.

Treatment

This is an outpatient procedure, meaning the patient can go home the same day as surgery. The bump in the bone is cut down and the fifth metatarsal is cut, repositioned, and fixed in position to corrects its deformity and decrease pain.

Specific Technique

The location where the bone is cut varies depending on the shape of the bone. This procedure often is done along with shaving the outer side of the bump itself. The far end of the bone is then shifted inward, and held in place using sutures, wires, screws, or screws and a plate.

Recovery

The recovery will depend on the specific surgical technique used. After surgery, the patient may not be allowed to bear weight for up to six weeks, which will require the use of crutches or a knee walker. For the first two weeks after surgery, a splint with a bandage is worn, and the foot cannot get wet. For several weeks after surgery, the patient may have to elevate his or her foot above chest level to decrease swelling. Swelling may last for several months after surgery.

After a couple of weeks, the stitches are removed. In the following few weeks, the patient wears a boot to protect the foot. After another few weeks, the patient progresses to weight bearing and possibly physical therapy. The boot may be removed several weeks after surgery.

Sometimes, a bunionette is fixed as the same time as a bunion (a bump at the big toe). In that case, the recovery is determined by the procedure on the bunion.

Risks and Complications

All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots. Complications that may occur from a fifth metatarsal osteotomy include the bone taking a long time to heal or not healing at all. It is uncommon for the bunionette to come back.

Chevron Osteotomy

A Chevron osteotomy is a common surgery to treat a bunion. A bunion (also known as hallux valgus) is a misalignment of the knuckle of the big toe. This misalignment causes the big toe to turn toward the smaller toes. It often creates a bump at the base of the big toe. Bunions are not always painful, but this deformity generally will increase over time.

In a chevron osteotomy, the foot and ankle orthopedic surgeon cuts the end of the long bone leading to the big toe (metatarsal) and rotates the end of the bone to straighten the big toe. This procedure may be performed in conjunction with soft tissue adjustments around the joint. This osteotomy is mostly performed for mild to moderate bunion deformity. This bunion correction surgery relieves pain by restoring normal straightness to the first toe joint.

Diagnosis

Bunion surgery may be needed if your bunion has a painful bump or skin irritation over the bump. You may have already tried non-surgical treatments such as splints, toe spacers, and wider shoes without pain relief. While bunion surgery may improve the cosmetic appearance of the foot by making the toes straighter, it should never be performed primarily for this reason.

Bunion surgery also should not be performed if the bunions are painless and do not cause problems. You should avoid surgery if you have an active infection, poor blood flow, or uncontrolled diabetes. If you have a severe deformity or extensive arthritis in the affected joint, a Chevron osteotomy may not be the correct procedure for you.

Treatment

A Chevron osteotomy is performed as an outpatient procedure, meaning patients generally go home a few hours after surgery. The first toe joint is straightened and the painful bump at the base of the big toe is filed down. This generally relieves the pain associated with the bunion and gives the foot a more normal appearance.

Specific Techniques

An incision is made on the inside of the foot over the joint of the big toe. The inflamed fluid sac between the skin and bone is removed. The end of the first metatarsal is cut in a V-shape and the head is moved toward the second toe. In some cases, the orthopedic surgeon may use removable wires or permanent screws to hold the end of the bone in its new place. The bony prominence on the inside of the foot is shaved to remove the painful bump. An additional procedure to tighten the soft tissue on the inside of the toe is performed with the osteotomy. Sometimes another procedure will be done to loosen the soft tissue on the outside of the joint. Orthopedic surgeons often use an X-ray machine in the operating room to verify that the toe is correctly aligned.

Recovery

A dressing will be applied by your surgeon in the operating room, and you will be given a special shoe or boot. You will have to avoid putting weight on the foot or only put weight on the heel for a period of time determined by your surgeon. The dressings are applied to hold the big toe in the straight position, so you should not change the dressings unless told to by your surgeon. Also, the dressings cannot get wet.

You will elevate your foot to chest level for the first few weeks after surgery. You may need to use crutches or a walker the first few days after this surgery, which help to reduce complications as well as pain and swelling. Your doctor may ask you to do range-of-motion exercises (bending the knee, hip, or ankle) to maintain flexibility and to avoid stiffness.

Stitches usually are removed two weeks after surgery. Your surgeon will discuss whether physical therapy is needed.

Prolonged swelling and challenges with reasonable shoes are very common following foot surgery and may last several months. Compression stockings and physical therapy can be helpful in reducing the swelling.

Risks and Complications

All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots. Potential complications with Chevron osteotomy include the bone failing to heal or disruption of the blood supply to the cut bone. Surgically corrected bunions have the potential for recurrence, even when the procedure was performed correctly. Patients can help prevent this by following their doctor’s post-operative instructions.

FAQs

Is it better to have my bunion fixed now, or should I wait?

When the pain of a bunion interferes with daily activities or shoe modification options don’t help you, it’s time to discuss surgical options with your foot and ankle orthopedic surgeon. Together you can decide if surgery is best for you. How long will I have to be off of my foot? For a brief period of time after surgery, you should not put weight on the foot. In some cases, your surgeon may allow you to walk on your heel only.

What do I do if my bunion comes back?

No matter how well your surgery may have gone, there is always the chance that your bunion may recur. Often the new bunion is not painful and surgery is not needed. However, if your bunion comes back with pain, then you should talk to your foot and ankle orthopedic surgeon about revision surgery.

Calcaneus Fracture

A calcaneus fracture is a broken heel bone. There are two types of calcaneus fractures: one involves the subtalar joint and one does not involve the joint.

The subtalar joint is formed by the calcaneus and the bone above it, which is called the talus. This joint allows side-to-side motion of the foot, which is important for walking on uneven surfaces. Calcaneal fractures that involve the subtalar joint are usually the most severe.

Symptoms

Symptoms of a heel fracture include pain, swelling and bruising of the heel. Patients usually are unable to walk. In fractures with severe swelling, blisters may develop around the heel.

Causes

High-energy injuries usually cause calcaneus fractures that involve the subtalar joint. Falls from a height and car accidents are the most common causes. Low-energy injuries such as twisting the ankle can cause smaller chips or bone fragments to break off from the edges of the calcaneus. These are called avulsion fractures. These do not usually involve the joint surfaces.

Diagnosis

X-rays along with physical examination are used to diagnose fractures of the calcaneus. A CT scan may be needed to look more closely at the pieces of the fracture or to see aspects that are not seen on the X-rays.

Treatments

Some heel fractures can be treated without surgery. The foot can be placed in a split or a removable fracture boot so that patients can work on ankle and foot motion. The amount of time that the patient has to keep weight off of the foot depends on the severity of the fracture.

Surgery may be recommended if the fracture involves the joint and pieces are displaced. A plate and/or screws may be used to hold the pieces of the fracture in place. With a severe fracture, a fusion of the subtalar joint also may be recommended.

Recovery

Recovery can take a long time. The period of non-weightbearing usually lasts for 8-12 weeks. Physical therapy can help with motion and improve the function of the foot.

Calcaneus fractures are significant injuries. Pain, stiffness, and swelling may last for months or indefinitely depending on the severity. Most people are able to return to work and recreational activity once their recovery is complete.

Risks and complications

Healing of the surgical incision can be a problem after surgical treatment of heel bone fractures. These usually resolve with local wound care, however, deep infections can occur and may need more surgical treatment. Other complications can include permanent stiffness of the subtalar joint after a calcaneus fracture, limiting side-to-side motion of the foot. Fractures that involve the subtalar joint can develop arthritis over time. Painful arthritis is treated with injections, bracing and sometimes a surgery to fuse the subtalar joint.

Calcaneus fractures may cause heel widening, making it difficult to fit into a shoe. This may be able to be treated surgically.

Additionally, the tendons that pass along the outer border of the calcaneus can become damaged or irritated. This can be treated with bracing or surgery.

FAQs

When can I return to exercise and activity?

Fractures of the heel bone can be devastating injuries. Returning to exercise and recreational activity can be difficult. Most people can resume low-impact exercise (swimming, biking, or elliptical machine use) a few months after their injury. Returning to high-impact exercise (running, jumping, and hopping) takes longer. Sometimes the injury is so severe that returning to high-impact activity is not possible.

Calcaneal Osteotomy

The calcaneus, or heel bone, plays an important role in walking. A calcaneal osteotomy is a controlled break of the heel bone, performed by a foot and ankle orthopedic surgeon, to correct deformity of the foot and ankle.

The heel bone can be realigned to achieve a different orientation, which can correct many different deformities and foot/ankle problems. For example, abnormally high or low arches can be addressed with a calcaneal osteotomy. The ultimate goals of all osteotomies are to relieve pain, improve alignment and walking, and reduce the likelihood of arthritis.

Diagnosis

If your pain is worsening or you have a deformity of the foot and ankle that is not responding to other treatments, a calcaneal osteotomy may be part of your surgical reconstruction plan. Discuss your options with your foot and ankle orthopedic surgeon. If you are at high risk for medical complications, the risks of surgery may outweigh the potential benefits.

Treatment

A calcaneal osteotomy commonly is combined with other procedures to reconstruct the foot. This type of surgery usually is an outpatient procedure, meaning you can go home the same day as surgery, but will vary depending on each patient and surgeon.

Specific

Techniques In a calcaneal osteotomy, an incision is made on the outer or lateral side of the foot. After the bone is cut, it is moved to the desired location and fixed in place. Most often, surgical implants such as screws hold the bones together and support healing.

The four most common types are the Evans, Dwyer, Medial Shift, and Lateral Shift.

Evans osteotomy: If you look down at your foot, you can see an inside edge and outside edge of the foot. For the foot to be straight, the inside edge of the foot and outside edge of the foot must be similar lengths. An Evans osteotomy is a controlled break that makes the outside part of the foot longer to help make the foot straight. Often a bone graft is used. The procedure may be performed on patients with flatfoot deformity.

Dwyer osteotomy: This is a break that removes an outside-based wedge of bone from the calcaneus in order to realign the foot. It is sometimes performed on patients with abnormally high arches.

Medializing osteotomy: In this procedure, the heel bone is cut and moved towards the inside part of the foot to help restore a fallen arch. Arthritis, loss of tendon function, and injury are some causes of a fallen arch.

Lateralizing osteotomy: This is another osteotomy for abnormally high arches. In this procedure, the heel bone is cut and shifted to the outside to reduce the arch and improve alignment.

Recovery

You will be placed in a splint or boot. Depending on your surgeon’s preference, the splint may be changed to a cast in 1-2 weeks. You will have to keep weight off your foot for 4-6 weeks. At that point, progressive weight bearing usually can start. Getting back to regular activities typically takes 3-6 months and swelling will improve slowly. If you have another foot or ankle procedure done at the same time, your recovery may be longer.

Risks and Complications

All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots.

The potential complications associated with calcaneal osteotomies are nerve and tendon injury, failure of the bone fragments to heal together, loss of correction of the deformity, painful hardware and infection. Your orthopedic surgeon will discuss the risks and benefits of surgery with you in detail.

FAQs

What are the chances that my bone will not heal?

This is uncommon and can happen approximately five percent of the time. Smoking, infection, and poor circulation all are potential risk factors. Should you choose to have surgery, your doctor will discuss these risks with you.

Bunionette

A bunionette (also known as a tailor’s bunion) is a painful bony prominence, or bump, on the outside of the little (pinky) toe. Over time, the bunionette may worsen as the little toe moves inward and the fifth metatarsal (the bone connected to it) moves outward. Rubbing between the bump and tight shoes may also cause a callus to grow over the area. All bunionettes can cause pain and pressure on the outside of the foot, though often they do not cause symptoms.

Treatments

The initial treatment of a bunionette is non-surgical. This can include wearing shoes that are roomier with a wide toe box to avoid rubbing on the bony prominence. Padding the little toe using a toe sleeve may reduce discomfort as well.

If your bunionette is painful even after wearing wide, comfortable shoes, if you cannot wear comfortable shoes because of the size of your bunionette, or if you continue to have problems after non-surgical treatment, your foot and ankle orthopedic surgeon may recommend surgery. The goals of this surgery are to remove the bony prominence and correct alignment to decrease pain. Surgery should be avoided if you have poor circulation or uncontrolled diabetes, if you are a chronic steroid user, or if you smoke cigarettes. These are risk factors for delayed healing of incision and bone.

Bunionette surgery is usually an outpatient surgery, meaning you can go home the same day as the surgery. It involves removing the bony prominence of the bunionette. In a larger bunionette that is causing an alignment problem, breaking the fifth metatarsal bone and restoring normal alignment may be necessary. Your foot and ankle orthopedic surgeon will explain what kind of surgery is needed for you and why.

Specific Techniques

The type of surgery to correct the bunionette depends on the shape of the fifth metatarsal bone, type of bunionette, and patient’s wishes.

• If you have a painful prominence without a bony growth, the surgery usually involves removing the painful soft tissue of the little toe.
• If you have a Type 1 bunionette, it means you have an enlarged bump at the outer end of the fifth metatarsal head (where the toe meets the foot). During surgery, this bony growth is removed.
• Sometimes the bony protuberance is so big that the bone of the fifth metatarsal needs an osteotomy, which is breaking the bone to realign it. The bone is cut and moved towards the fourth metatarsal to correct the alignment.
• If you have a curved shape to your little toe (Type 2 bunionette) or angle (Type 3 bunionette) between the fourth and fifth metatarsal, your surgeon will often do an osteotomy. This osteotomy is done to straighten out the fifth metatarsal.
• If a bunionette deformity is treated with an osteotomy, the bone may be held straight with a steel wire, screw, or plate and screws, depending on the surgeon’s preference.

Recovery

After the surgery, patients may need to stay off their operated foot with no weight or heel weight bearing on it for a period of weeks. Patients will need to wear a post-surgical shoe or a short CAM boot on their foot to keep it protected after surgery. You may also need to use crutches or a walker depending on your activity level and pain. In severe deformities, some surgeons will place a short leg splint to better protect the surgical correction. The specific amount of time that your foot needs to be protected after surgery depends on the type of surgery and the surgeon’s protocol. The operated foot will need to be elevated above the level of the heart as much as possible for at least the first few days. This will help to decrease swelling.

Your stitches are usually taken out 2-3 weeks after surgery. You will be asked to not soak your foot or get the surgical area wet until your stitches are out.

Your foot and ankle orthopedic surgeon may ask you to do knee and ankle exercises at home after surgery. This can help maintain your joint motion and flexibility. If your doctor thinks that you need physical therapy after the soft tissue and bone is healed, he or she will discuss that with you.

Swelling is the last thing to improve for most patients after bunionette surgery. It can take 6-12 months for your foot’s swelling to completely improve after surgery.

Risks and Complications

All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots. Potential complications after bunionette surgery are rare. Possible problems include bleeding from the wound, injured nerves around the little toe, poor wound healing or bone healing if an osteotomy is done, and the possibility of recurrence of the bunionette.

FAQs

If my bunionette deformity is treated without surgery, can I ever wear high heels and pointed shoes?

Wear pointed-toe shoes as little as possible. This does not mean that you cannot ever wear these shoes, but you should limit the time wearing them in order to decrease pain and the chance that the bunionette will get worse.

If I’m treated with surgery, will the deformity come back?

Most bunionettes do not come back after being treated with the right type of surgery. The surgery should correct the underlying cause of the problem. However, wearing shoes that are too narrow can still cause irritation and inflammation at the operated little toe.