Bunionette Deformity (Tailor's Bunion)

A bunionette, historically the tailor's bunion, is a painful lateral prominence of the fifth metatarsal head. With it come lateral deviation of the fifth toe at the metatarsophalangeal (MTP) joint, a bursa over the prominence from chronic friction, and callus or thickened skin over the symptomatic area.

The name. In the pre-industrial era tailors sat cross-legged on the floor for hours while sewing, which put the lateral fifth metatarsal head in direct contact with a hard surface. The repetitive pressure produced bursa formation and pain, and the deformity took the trade's name.

Who gets it. It is present in approximately 0.25-1.0% of the general population and accounts for 3-4% of forefoot surgery, although the exact incidence is unknown because many cases are asymptomatic. There is a female predominance of 4:1 to 9:1, the peak age is 40-60 years, and it is often bilateral (40-60% of cases). It is more common in Western populations, an effect attributed to footwear.

Risk factors. The intrinsic factors belong to the patient and the foot:

• Genetics, with a familial predisposition in 30-50%
• Female sex, through a hormonal influence on ligament laxity
• Pes planus and the flexible flat foot
• Generalised ligamentous laxity and hypermobility syndromes
• Congenital metatarsal abnormalities, with lateral bowing present from birth

The extrinsic factors are constrictive footwear with a narrow or pointed toe box, high heels (which increase forefoot loading), prolonged occupational standing, running, ballet and gymnastics, and obesity, which increases the mechanical stress on the forefoot.

Associated deformities. Hallux valgus coexists in 30-40% and has its own section below. The fifth toe itself may overlap or underlap, or develop a flexion contracture of the interphalangeal joint, and these deformities may require concurrent correction.

The normal fifth ray. The fifth metatarsal is the lateral weight-bearing column and its head bears approximately 10% of forefoot load during stance. The ray is relatively mobile compared with the rigid medial rays (first through third): it pronates during weight acceptance and gives the lateral column stability through terminal stance and push-off. Peroneus brevis inserts on the fifth metatarsal base and exerts a lateral pull.

How the prominence becomes painful. In a bunionette the pressure concentrates on the lateral prominence of the head, and chronic friction between shoe and prominence produces an adventitial bursa as a protective response. The soft-tissue inflammation and pain are progressive, and capsular attenuation allows the fifth toe to drift into valgus.

Coughlin's classification is the standard system. It divides bunionettes into three types by the radiographic location of the structural abnormality, and it directly guides the choice of operation.

A bursa over the prominence is common in Type I. Combination deformities need careful radiographic analysis, and a single oblique shaft osteotomy can address both components. Recurrence after correcting a combination deformity is variable, 5-15%.

View larger

Fallat's classification is an alternative, less commonly used, built on the same ideas with different numbering: Type I is lateral deviation of the fifth metatarsal head, Type II lateral bowing of the shaft, and Type III enlargement of the head. Coughlin's is more widely accepted and is the one used in exam settings.

History. Pain over the lateral fifth metatarsal head is the most common presenting symptom. Patients also complain of the visible lateral bump, of being unable to wear the shoes they want and being limited to a wide toe box, and of skin problems: redness, a bursa, callus and occasional skin breakdown.

The pain. It is aching, burning or pressure-type and sits over the prominence. Tight shoes, high heels and prolonged walking or standing make it worse; wide shoes, going barefoot and rest relieve it. Ask what it costs the patient: how far shoe choice is limited, whether formal or dress shoes are possible, whether pain limits walking distance or exercise, and the effect on work, especially work that requires formal footwear.

Standing inspection. Look first at the whole foot: forefoot width and splay, a concurrent hallux valgus, arch height (planus, cavus or neutral) and lesser toe deformities such as hammer, claw or overlapping toes. Then the bunionette itself: the size and site of the prominence, the position of the fifth toe (valgus, varus, overlapping or underlapping), skin changes from erythema and an adventitial bursa to callus or ulceration, and the other foot for comparison.

Palpation. Point tenderness over the lateral fifth metatarsal head, and a tender bursa that is fluctuant if it contains fluid. Feel for plantar callus under the head, an intractable plantar keratosis, and palpate the fourth webspace, because an interdigital neuroma may coexist.

Movement and stability. Test dorsiflexion and plantarflexion of the fifth MTP joint and the mobility of the fifth toe interphalangeal joints. Pain on motion suggests intra-articular pathology and crepitus indicates degenerative change. Medial-lateral stress of the fifth MTP joint assesses capsular integrity and instability.

Gait and shoes. A significantly painful bunionette may produce an antalgic gait; watch the foot through stance and push-off for lateral column overload or transfer to the fourth metatarsal. Examine the patient's usual shoes for toe box width, heel height, sole flexibility and asymmetric wear, correlate the pressure areas with the painful sites, and document any modification the patient has already made.

Algorithm

View larger

Conservative care comes first. It is the first-line approach for every bunionette, and every patient should have an adequate trial of 3-6 months minimum before surgery is considered. It is indicated for mild to moderate symptoms, for the patient unwilling or medically unfit for surgery, and at first presentation without previous conservative attempts.

Footwear is the most important modification, and a wide toe box is the essential change. Soft leather uppers stretch and accommodate, lace-up shoes allow the width to be adjusted, and custom or orthopaedic shoes are for severe deformity. High heels, which increase forefoot loading, and pointed toes are avoided.

Padding and orthoses. Bunionette pads or cushions, felt or gel pads, and a bunion shield or protective sleeve reduce direct pressure over the lateral head; toe spacers between the fourth and fifth toes are of limited benefit. Custom orthoses with lateral posting, metatarsal pads that redistribute forefoot pressure away from the fifth metatarsal, and arch support for a concurrent pes planus add to the offloading. Orthoses improve symptoms but do not correct the structural deformity.

Activity, medication and physiotherapy. Reduce high-impact activity during symptomatic periods, cross-train with low-impact alternatives such as swimming and cycling, wear proper footwear for all activities, and lose weight if obese to reduce forefoot loading. NSAIDs treat acute inflammatory episodes, alongside topical anti-inflammatory preparations and paracetamol if NSAIDs are contraindicated. Physiotherapy offers foot and ankle stretching, intrinsic muscle strengthening, gait training and biomechanical optimisation, and ice for acute flares.

Corticosteroid injection into the bursa over the fifth metatarsal head may give temporary relief for weeks to months and is useful for diagnostic confirmation, but it is not recommended as definitive treatment. A superficial injection risks skin atrophy and depigmentation.

What conservative care achieves. Appropriate shoe modification improves symptoms in 40-60%, most effectively in mild deformity where the problem is primarily extrinsic shoe pressure. It has limited benefit for significant structural deformity and does not prevent progression of the bony deformity, and many patients eventually require surgical correction.

Surgery is indicated for:

• A symptomatic bunionette despite an adequate conservative trial
• Pain significantly interfering with desired activities or footwear
• Progressive deformity causing increasing symptoms
• Recurrent skin breakdown, ulceration or chronic bursitis
• Cosmetic concern, as a relative indication only: the patient must understand the risks and have realistic expectations

Contraindications. The absolute ones are active infection in the surgical field, severe peripheral vascular disease with critical limb ischaemia, unrealistic expectations or poor understanding, and medical instability precluding elective surgery. Relative contraindications are mild symptoms adequately managed conservatively, poor expected compliance with post-operative restrictions, active inflammatory arthropathy (which may require a modified approach), significant comorbidities increasing perioperative risk, and an occupation requiring an immediate return to unprotected weight-bearing.

The operation follows the Coughlin type. The condylectomy and the chevron and proximal osteotomies are all done supine under an ankle tourniquet with small-fragment instruments and a microsagittal saw; the image intensifier is available for a condylectomy and essential for the two osteotomies.

View larger

View larger

Rationale. Reflecting the wider shift to percutaneous forefoot surgery, the distal chevron can be performed through a stab incision with a burr rather than an open arthrotomy. The aim is the same correction with less soft-tissue dissection, less stiffness and a smaller scar.

Technique. A percutaneous portal is made at the fifth metatarsal head-neck junction and a low-speed, high-torque Shannon/wedge burr is introduced under fluoroscopic control. A transverse or chevron-type osteotomy is completed through the bone while the surrounding periosteal soft-tissue sleeve is preserved. The capital fragment is displaced medially, then often left unfixed, held by the intact soft-tissue envelope, or fixed with a single percutaneous screw or K-wire; any residual lateral prominence is smoothed with the burr.

Evidence. In the Benavente series (28 patients, 31 feet, no fixation) the 4-5 IMA corrected from 10.3 to 4.8 degrees and the lateral deviation angle from 8.5 to 0.97 degrees, with a mean AOFAS gain of 29 points and only one asymptomatic delayed union.

Caveats. It is fluoroscopy- and skill-dependent, and thermal necrosis from the burr must be avoided with irrigation and a low speed. High-quality trials directly comparing it with open osteotomy are still lacking, so open osteotomy remains the reference standard.

View larger

Why they coexist. Both are expressions of a generalised splay foot. Nestor's radiographic study showed that bunionette feet have increased 1-2 and 4-5 intermetatarsal angles, so the same forefoot widening drives a medial prominence, the hallux valgus, and a lateral one, the bunionette.

Assess both borders. Measure the hallux valgus angle and 1-2 IMA medially and the 4-5 IMA and lateral deviation angle laterally, and establish which deformity is actually symptomatic.

Correct only what is symptomatic. An asymptomatic bunionette alongside a painful bunion, or the reverse, does not mandate correcting both. Operate on the symptomatic deformity and match each side's procedure to its own deformity: the Coughlin type laterally, hallux valgus severity medially.

When both are symptomatic. Correcting a first-ray and a fifth-ray osteotomy at the same sitting is attractive, with one anaesthetic and one recovery, and it is done. It does, however, create two osteotomies at the two widest, most tenuously vascularised borders of the forefoot, and a swollen foot that is harder to rehabilitate. Many surgeons therefore stage the corrections roughly 3-6 months apart, letting the first side heal and rehabilitate before the second. The decision balances patient preference and a single recovery against the greater swelling, stiffness and wound risk of simultaneous surgery on both borders.

View larger

View larger

View larger

Early Complications (Under 6 Weeks)

Wound problems. Infection occurs in 2-5%. Superficial infection, with erythema and drainage, is treated with oral antibiotics; deep infection may require debridement and IV antibiotics. Meticulous sterile technique, prophylactic antibiotics and gentle tissue handling prevent it.

Wound dehiscence (2-3%) is managed with local wound care and secondary healing if small, and revision closure if large or problematic. Skin-edge necrosis (1-2%) is more likely after previous surgery or with poor vascularity; dressings are usually sufficient and debridement is rarely required.

Nerves and vessels. Sural nerve injury or irritation, 5-10%, is the most common neurological complication. Most cases are temporary dysaesthesia or numbness that usually improves over 3-6 months, and permanent sensory change remains in 1-2%. Prevention is careful identification and protection of the sural branches during the approach, gentle soft-tissue handling without excessive stripping, meticulous haemostasis and gentle closure.

Plantar lateral digital nerve injury (1-2%) leaves the lateral fifth toe numb and is most concerning during a condylectomy, with its plantar dissection. Vascular compromise is rare (under 1%): haematoma is more common, and true arterial injury very rare.

Hardware. K-wire migration, a prominent screw head irritating the lateral side, and screw penetration into the MTP joint, which is checked on intraoperative fluoroscopy.

Late Complications (Over 6 Weeks)

Recurrence is the most common long-term complication overall, at 10-20% across all procedures: higher after condylectomy alone and lower after osteotomy, with the rates given under each technique. Inadequate initial correction is the most common cause; the others are the wrong procedure for the deformity type, loss of fixation or correction during healing, and progression of the underlying structural problem. Revision uses the osteotomy appropriate to the deformity now present. Prevention is accurate pre-operative classification and measurement, the right procedure for the type, adequate correction (4-5 IMA under 8 degrees), rigid fixation to hold it during healing, and a patient who complies with the post-operative restrictions.

Nonunion and delayed union follow 5-8% of proximal and 2-5% of distal osteotomies; a condylectomy has no osteotomy to fail. The risk factors are smoking, diabetes, excessive motion at the osteotomy and inadequate fixation. Delayed union is treated with extended protected weight-bearing and a bone stimulator, nonunion with revision osteotomy, bone graft and rigid fixation. Prevention is adequate bone-to-bone contact, rigid internal fixation (two screws for a proximal osteotomy), protected weight-bearing until radiographic healing, and optimising smoking cessation, diabetic control and nutrition.

View larger

Transfer metatarsalgia. Pain shifts to the adjacent metatarsal heads, usually the fourth and sometimes the third, in 5-15% depending on procedure and technique. Relative shortening or elevation of the fifth metatarsal shifts load to the adjacent rays. The risk factors are excessive medial displacement causing shortening over 3-4 mm, dorsiflexion of the fifth metatarsal, and a pre-existing long fourth metatarsal. Prevention means limiting fifth metatarsal shortening to 2-3 mm at most, avoiding dorsiflexion to keep the sagittal alignment, maintaining the metatarsal parabola on the lateral radiograph, and considering a Weil osteotomy of the fourth metatarsal if it is already overloaded pre-operatively.

Treatment is conservative first: a metatarsal pad proximal to the painful head, custom orthotics with selective metatarsal relief, and rocker-bottom soles. If that fails, a Weil osteotomy of the fourth (or third) metatarsal shortens it by 2-3 mm and restores the parabola.

Malunion. Dorsal, plantar or rotational malalignment at the osteotomy, or excessive or insufficient medial displacement, can cause transfer symptoms, recurrent deformity or altered gait mechanics. A symptomatic malunion may require corrective revision osteotomy.

Stiffness and arthritis. Fifth MTP stiffness affects 10-20% of patients but is usually not functionally significant, because the fifth MTP has less motion than the first; aggressive early range-of-motion exercises help prevent it. Progressive degenerative arthritis is rare unless the articular surface was violated during surgery, and is treated with NSAIDs, intra-articular steroid injection and activity modification, with salvage fusion if severe.

Persistent pain. Complex regional pain syndrome is rare (under 2%), neuroma of the sural nerve branches occurs in 2-3%, and hardware irritation in 5-10%, higher with K-wires and lower with buried screws; residual deformity from inadequate correction is the other cause. Management depends on the cause: hardware removal, neuroma excision, revision surgery or referral to pain management.

Global Epidemiology

Bunionette deformity is a common but under-reported forefoot condition. There is no dedicated international registry (unlike arthroplasty), so prevalence data come from radiographic and clinic-based series rather than population registries.

• Prevalence: Estimated at roughly 0.25-1.0% of the general adult population; true figure uncertain because many cases are asymptomatic.
• Sex and age: Strong female predominance (commonly cited 4:1 or higher), peak presentation in the fourth to sixth decades.
• Bilaterality and association: Frequently bilateral; coexists with hallux valgus in a substantial minority, reflecting generalised forefoot splay (increased 1-2 and 4-5 intermetatarsal angles documented radiographically by Nestor et al).
• Footwear influence: Higher symptomatic rates in populations habitually wearing narrow, constrictive, or high-heeled footwear; constrictive shoes are an aggravating factor superimposed on underlying bony morphology rather than the sole cause.

Society Guidance: Side-by-Side

No single society publishes a dedicated bunionette clinical practice guideline; recommendations are consensus- and review-derived. Across major bodies the principles converge.

Registry and Evidence Notes

• No implant registry applies: Bunionette osteotomy uses screws or wires rather than registered implants, so survivorship data come from case series and meta-analysis, not national joint registries.
• Best available pooled evidence: A meta-analysis of 28 studies (Martijn et al, 2018) reports an overall success rate of approximately 93% across osteotomy types, with proximal osteotomies giving the largest IMA correction and distal osteotomies the fewest major complications.
• Cautionary historical data: Long-term series of distal metatarsal head resection showed unacceptable transfer metatarsalgia and poor results, establishing that ablative resection should be avoided in favour of length-preserving osteotomy.

High- vs Limited-Resource Practice Variation

• Classification reliability: The Coughlin types are widely taught, but combination deformities are the most common presentation, and inter-observer agreement on type assignment (especially distinguishing shaft bowing from increased IMA) is imperfect. Many surgeons treat by the magnitude of IMA and the apex of deformity rather than rigidly by type number.
• Open versus minimally invasive osteotomy: Percutaneous distal chevron osteotomy shows promising correction and low complication rates in contemporary series, but high-quality comparative trials against open techniques are lacking. Adoption is driven by equipment availability and surgeon training.
• Optimal osteotomy level for large IMA: Proximal osteotomy gives the greatest IMA correction but carries higher nonunion risk and longer recovery; diaphyseal (shaft) osteotomy is a versatile middle ground. The threshold IMA at which to move from distal to proximal correction is not firmly defined and varies between authors.
• Cosmetic indication: Surgery purely for appearance remains controversial given real complication rates (recurrence, transfer metatarsalgia, nerve injury); careful expectation-setting is essential.
• Defining recurrence: Reported recurrence rates vary partly because studies differ in whether recurrence is defined radiographically (return of IMA) or clinically (symptomatic prominence), limiting direct comparison.

Comparative Outcomes by Procedure Type

Factors Affecting Outcomes

1. Coughlin MJ. Treatment of bunionette deformity with longitudinal diaphyseal osteotomy with distal soft tissue repair. Foot Ankle. 1991;11(4):195-203. PMID 1855704.

2. Davies H. Metatarsus quintus valgus. Br Med J. 1949;1(4604):664-665.

3. Fallat LM, Buckholz J. An analysis of the tailor's bunion by radiographic and anatomical display. J Am Podiatr Med Assoc. 1980;70(12):597-603.

4. Nestor BJ, Kitaoka HB, Ilstrup DM, et al. Radiologic anatomy of the painful bunionette. Foot Ankle. 1990;11(1):6-11.

5. Diebold PF. Basal osteotomy of the fifth metatarsal with intermetatarsal pinning: a new approach to bunionette. Foot Ankle. 1991;12(1):40-45.

6. Kitaoka HB, Holiday AD Jr. Lateral condylar resection for bunionette. Clin Orthop Relat Res. 1992;(278):183-192.

7. Polzer H, Polzer S, Brumann M, et al. Diagnosis and treatment of the bunionette deformity. Foot Ankle Clin. 2018;23(1):49-63.

8. Kelikian AS, ed. Sarrafian's Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2011.

9. Steinke MS, Boll KL. Hohmann bunionectomy versus lateral condylectomy procedures: a comparison study. J Am Podiatr Med Assoc. 1989;79(6):269-275.

10. Martijn HA, Sierevelt IN, Wassink S, Nolte PA. Fifth metatarsal osteotomies for treatment of bunionette deformity: a meta-analysis of angle correction and clinical condition. J Foot Ankle Surg. 2018;57(1):140-148. PMID 29268897.

11. Di Giovanni CW, Greisberg J. Core Knowledge in Orthopaedics: Foot and Ankle. Philadelphia: Mosby Elsevier; 2007.

12. Kitaoka HB, et al. Bunionette: review of surgical treatment. Foot Ankle Int. 1990;11(2):93-97.

13. Dermon AJ, et al. Distal chevron osteotomy with lateral condylectomy for treatment of symptomatic bunionette. Foot Ankle Int. 2012;33(9):755-761.

14. Diebold PF, Bejjani FJ. Basal osteotomy of the fifth metatarsal with intermetatarsal pinning: a new approach to tailor's bunion. Foot Ankle. 1987;8(1):40-45.

15. Benavente Valdivia JC, Thull DM. Minimally invasive distal chevron osteotomy for symptomatic bunionette: clinical and radiologic results of a 31-case retrospective study. Foot Ankle Orthop. 2022;7(2):24730114221099022. PMID 35615075.

16. Kitaoka HB, Holiday AD, Campbell DC. Distal Chevron metatarsal osteotomy for bunionette. Foot Ankle. 1991;12(2):80-85. PMID 1773999.

17. Kitaoka HB, Holiday AD. Metatarsal head resection for bunionette: long-term follow-up. Foot Ankle. 1991;11(6):345-349. PMID 1894226.

18. Shi GG, Humayun A, Whalen JL, Kitaoka HB. Management of bunionette deformity. J Am Acad Orthop Surg. 2018;26(19):e396-e404. PMID 30130354.

19. Nestor BJ, Kitaoka HB, Ilstrup DM, Berquist TH, Bergmann AD. Radiologic anatomy of the painful bunionette. Foot Ankle. 1990;11(1):6-11. PMID 2210536.