What are the treatment options for Tailor's bunion?

Tailor's Bunion Treatment

Start with conservative management using wider shoes and padding, and only proceed to surgery if symptoms persist after 3-6 months of failed conservative treatment, selecting the surgical technique based on the specific anatomic deformity pattern.

Initial Conservative Management (First-Line Treatment)

Conservative treatment should be attempted first for all symptomatic Tailor's bunions, as most cases respond to non-operative management 1, 2.

• Footwear modification: Use extra-depth, wider shoes to accommodate the lateral fifth metatarsal head prominence 3, 1, 4
• Padding techniques: Apply protective padding over the bunionette to reduce friction between the bony prominence and footwear 4
• Orthotic devices: Consider custom orthoses if the bunionette results from excessive subtalar joint pronation causing abnormal pressure distribution 1
• Activity modification: Avoid constrictive footwear that generates friction leading to keratosis, inflammation, and pain 2

Duration of Conservative Trial

Continue conservative management for at least 3-6 months before considering surgical intervention 1, 2.

Surgical Management (When Conservative Treatment Fails)

Surgery is indicated when symptoms are not controlled with conservative measures and aims to decrease foot width and reduce the prominence 1, 4.

Surgical Decision Algorithm

Step 1: Measure the 4th-5th intermetatarsal angle on weight-bearing radiographs

Step 2: Select procedure based on deformity pattern:

Distal Osteotomy (Chevron-type)

• Indication: Lateral bow of the fifth metatarsal OR when medial translation of the metatarsal head by one-third of the shaft width produces a normal 4th-5th intermetatarsal angle 1, 4
• Technique options:
  • Open chevron osteotomy 4
  • Minimally invasive distal metatarsal osteotomy using percutaneous burrs without internal fixation 5, 6
• Advantage of MIS approach: Comparable outcomes to open techniques while avoiding soft tissue damage complications 5, 6

Diaphyseal Osteotomy

• Indication: Widened 4th-5th intermetatarsal angle that cannot be adequately corrected with distal osteotomy alone 4
• Technique: Mid-shaft osteotomy for correction of larger deformities 4

Proximal Osteotomy

• Indication: Larger deformities with significantly widened 4th-5th intermetatarsal angle 1
• Rationale: Provides greater correction potential for severe angular deformities 1

Lateral Eminence Resection (Rarely Appropriate)

• Very limited indication: Only in rare situations with isolated lateral prominence 4
• Major caveat: High risk of recurrence or overresection; generally not recommended as primary procedure 4

Minimally Invasive vs. Open Surgery

Minimally invasive techniques are increasingly preferred when expertise is available:

• Percutaneous osteotomy with burrs achieves comparable functional outcomes to traditional open techniques 5, 6
• Averts major complications from soft tissue damage 5
• No wound healing problems, infections, non-unions, or mal-unions reported in recent series 5
• Can be adapted to different deformity types 5, 6
• Usually does not require internal fixation 5, 6

Postoperative Management

• Redressive wrapping 6
• Partial pain-adapted weight bearing 6
• NSAIDs for 3-5 days 6
• Lymphatic drainage and intermittent cooling 6
• Radiographic assessment on postoperative day 1 and at 6 weeks 6
• Thromboembolic prophylaxis 6

Management of Recurrent Tailor's Bunion

Recurrence management remains controversial 1:

• First: Establish the cause of failure—was it under-correction or inappropriate initial procedure selection? 1
• If under-corrected or wrong initial procedure: Revision surgery may be helpful after identifying the failure mechanism 1
• Final salvage option: Resection arthroplasty, though unpopular, should be considered as the ultimate salvage procedure 1

Critical Pitfalls to Avoid

• Do not perform simple lateral eminence resection as primary treatment except in rare isolated prominence cases—high recurrence risk 4
• Do not proceed to surgery without adequate conservative trial of 3-6 months 1, 2
• Do not select surgical technique without careful preoperative radiographic assessment of the 4th-5th intermetatarsal angle and metatarsal morphology 4
• Avoid overresection of the lateral eminence, which can destabilize the fifth metatarsophalangeal joint 4