How is a bunion managed?

Bunionette (Tailor's Bunion) Management

Initial management of symptomatic bunionettes should be conservative with accommodative footwear modifications, NSAIDs, and orthotics; surgery is reserved for patients who fail non-operative treatment and have persistent pain affecting quality of life.

Conservative Management (First-Line Treatment)

All patients with symptomatic bunionettes should begin with non-operative management, as most cases respond to conservative measures 1, 2, 3.

Footwear Modifications

• Wide toe-box shoes are essential to reduce friction between the lateral fifth metatarsal prominence and shoe wear 2, 3
• Avoid constrictive footwear that generates friction against the bony prominence, which causes keratosis, inflammation, pain, and potential ulceration 3

Medical Management

• NSAIDs are effective for reducing inflammation and pain associated with the bunionette deformity 1
• Address any associated keratosis or callus formation 3

Orthotic Interventions

• Custom orthotics may be beneficial if the symptomatic bunionette results from excessive subtalar joint pronation 2
• Toe spacers can provide symptomatic relief 1
• Splints and braces have supporting evidence for symptom management 1

Important Caveat

Conservative treatment may not provide long-term relief in all patients 1. However, cosmesis alone is never an indication for surgical intervention 1.

Surgical Management (When Conservative Treatment Fails)

Indications for Referral to Orthopedic/Foot Surgeon

Refer when the patient has:

• Painful prominence despite exhausted non-operative treatment 1
• Suitable operative candidacy 1
• Symptoms not controlled by conservative measures 2, 3

Surgical Planning Based on Deformity

The surgical approach depends on the underlying bony anatomy and severity of deformity 2, 3:

For mild-to-moderate deformities:

• Distal osteotomy is recommended if medial translation of the metatarsal head by one-third of the shaft width produces a normal fourth-fifth intermetatarsal angle 2
• Goal is to decrease foot width and reduce the prominence 2

For larger deformities:

• Proximal osteotomy should be performed when the intermetatarsal angle is significantly increased 2

Other surgical options include:

• Resection procedures (reserved as final salvage) 2
• Diaphyseal osteotomies 2

Contraindications and Special Considerations

• Smoking is a relative contraindication to surgery; cessation is strongly recommended before proceeding 1
• In pediatric or adolescent patients (juvenile bunionette), delay surgery until skeletal maturity 1

Management of Recurrent Deformity

• Establish the cause of failure before considering revision surgery 2
• If recurrence is due to under-correction or inappropriate initial procedure selection, revision may be helpful 2
• Resection should be considered as the final salvage procedure, though it remains unpopular 2

Key Clinical Pitfalls to Avoid

• Do not operate for cosmetic concerns alone 1
• Do not proceed with surgery in active smokers without counseling on cessation 1
• Do not perform surgery on skeletally immature patients 1
• Ensure proper procedure selection based on the specific anatomic deformity to avoid under-correction and recurrence 2