Bilateral bunionette in rheumatoid arthritis
Alok Chandra Agrawal, Ankit Kumar Garg, Deepak Kumar Garg, Rahul Ranjan
Department of Orthopaedics, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
|Date of Submission||11-May-2022|
|Date of Acceptance||12-May-2022|
|Date of Web Publication||15-Jun-2022|
Dr. Deepak Kumar Garg
Department of Orthopaedics, All India Institute of Medical Sciences, Raipur, Chhattisgarh
Source of Support: None, Conflict of Interest: None
Introduction: Tailor’s bunion or Bunionette deformities were described by Davies et al. as abnormal, painful bony prominence on the lateral aspect of the fifth metatarsal head. This prominence, though present in many individuals, seldom causes symptoms. Most deformities can be managed conservatively, and surgical interventions will be needed only for refractory cases presenting with chronic pain. Various surgical interventions (percutaneous, mini-open, open), including osteotomies at different level, has been described in the literature. Case: A thirty-three-year-old female house-maker presented with swelling over the bilateral fifth metatarsal lateral aspect and pain while walking for the last six months. The patient is a known case of Rheumatoid arthritis controlled on medication. The patient underwent Lateral exostectomy resection for bilateral swelling, At one year follow up, the patient had good functional outcome with no recurrence. Conclusion: Tailor’s bunion deformity, although morphologically common, is rarely symptomatic. Its management involves identifying the cause, thorough clinical and radiographic evaluation of the deformity, and deciding the best surgical procedure to obtain optimal results.
Keywords: Bunionette, rheumatoid arthritis, tailor’s bunion
|How to cite this article:
Agrawal AC, Garg AK, Garg DK, Ranjan R. Bilateral bunionette in rheumatoid arthritis. J Orthop Traumatol Rehabil 2022;14:90-3
|How to cite this URL:
Agrawal AC, Garg AK, Garg DK, Ranjan R. Bilateral bunionette in rheumatoid arthritis. J Orthop Traumatol Rehabil [serial online] 2022 [cited 2022 Jun 29];14:90-3. Available from: https://www.jotr.in/text.asp?2022/14/1/90/347365
Tailor’s bunion or bunionette deformities were described by Davies et al., as abnormal, painful bony prominence on the lateral aspect of the fifth metatarsal head. It is commonly seen in adolescence and adults with a slight female preponderance.,, Various etiological factors like – internal (abnormal fifth metatarsal head prominence, short metatarsals, congenital deformity of the foot, inflammatory arthropathies), or external factors such as (compression of forefoot due to tight shoes or posture, abnormal pressure loading on lateral aspect of the foot).,, This prominence, though present in many individuals, seldom causes symptoms. Usually, the fifth metatarsal deviates from the fourth metatarsal by approximately 5°. In addition, the fifth metatarsal head is generally broader than the shaft of the metatarsal itself and, therefore, may cause a prominence on the lateral side of the foot. The pain of which patients complain is caused by the conflict between the metatarsal head and the footwear. Later, the formation of a subcutaneous bursa may lead to local inflammation and infection. Most deformities can be managed conservatively, and surgical interventions will be needed only for refractory cases presenting with chronic pain. Various surgical interventions (percutaneous, mini-open, open), including osteotomies at different level, have been described in the literature.
We present a case of recurrence of bilateral bunionette deformity in a patient with rheumatoid arthritis managed successfully with lateral exostectomy and excellent functional outcome at a 1-year follow-up.
A 33-year-old female homemaker presented with swelling over the bilateral fifth metatarsal lateral aspect and pain when walking for the last 6 months. The patient is a known case of rheumatoid arthritis controlled on medication (methotrexate 15 mg weekly, sulfasalazine 500 mg daily, and hydroxychloroquine 200 mg daily) for the last 5 years. The patient has a history of similar swelling 1 year back, for which she underwent excision from a local practitioner. There is no history of intralesional steroid injections [Figure 1].
On examination, there is a swelling along the lateral aspect of the bilateral foot measuring approximately 3 cm × 2 cm in size, uniform in consistency, having a smooth surface, nontender, well-circumscribed, and slowly progressive over the last 6 months. The previous incision’s 2-cm scar mark healed with primary intention with no active wound/discharging sinus. There were no keratotic lesions, adventitial bursa formation, and deformity around foot and ankle. The range of motion of the 5th metatarsophalangeal joint and the 5th metatarsocuboid joint was within normal limits. Global forefoot posture and periarticular structure were within normal limits.
Radiological evaluation with weight-bearing anterior–posterior, lateral, and oblique radiographs was done to fully evaluate the forefoot’s structural alignment and osseous morphology and, specifically, the fifth metatarsophalangeal joint.
The intermetatarsal 4th–5th angle, (angle formed between the longitudinal bisection of the fourth metatarsal and the medial cortex of the fifth metatarsal; normal, <8°) was 11.1° and 10.1° for the right and left feet, respectively, as shown in [Figure 2].
|Figure 2: Intermetatarsal angle between 4th and 5th (calculated on AP View) of the bilateral feet (right, 11.1° and left, 10.1°)
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The fifth metatarsophalangeal angle, (degree of the medial deviation of the fifth digit in relation to the longitudinal bisection of the fifth metatarsal; normal, <10°) was found to be 10.7° and 10.8° for the right and left feet, respectively [Figure 3].
|Figure 3: Fifth metatarsophalangeal angle (right, 10.7° and left, 10.8°)
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The lateral deviation angle or lateral bowing, (angle formed between the medial cortex of the fifth metatarsal and bisection of the fifth metatarsal head and neck; normal, <3°) was 4.1° for both the right and left feet, respectively [Figure 4].
|Figure 4: Lateral deviation angle or lateral bowing (right, 4.1° and left, 4.1°)
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The patient was planned for lateral exostectomy. Under spinal anesthesia, through the dorsolateral incision, the fifth metatarsal head is exposed. The lateral one-quarter to one-third of the fifth metatarsal head is then resected in line with the lateral border of the lateral foot, rather than in line with the fifth metatarsal shaft, using a power saw. Following irrigation of the surgical site, the fifth digit is held in a slightly overcorrected abducted and plantarflexed position, and the abductor digiti minimi tendon is reattached to the surrounding deep tissue. The remaining deep tissues and skin edges are reapproximated, the wound was closed with 3-0 nylon suture, and a well-padded absorptive dressing was applied with below-knee slab support for 7 days. Intraoperative soft tissue and bony piece were sent for histopathological examination. Histopathological examination reports suggestive of fibro-collagenous tissue with areas of hyalinization and sparse lymphoplasmacytic infiltrates. No evidence of malignancy/atypia was noted. The patient was mobilized from day 2 using nonweight-bearing walking with a walker support for 2 weeks. After suture removal, the patient was allowed for gradual weight-bearing. The follow-up was done at 2 weeks, at 1 month, at 3 months, and then at 6 months and 1 year. The patient can walk pain-free, wear shoes, and perform all her routine activities. At a 1-year follow-up, there were no complications such as surgical site infection, wound dehiscence, recurrence, or angular deformity [Figure 5] and [Figure 6].
The bunionette are usually treated conservatively. Orthotics like change in shoes (wide toe box), metatarsal pads, metatarsal bars, avoiding high heels, and narrow shoes are often helpful. In acute inflammation due to bursitis, nonsteroidal anti-inflammatory drugs and steroid injections can be helpful. Only when there is failed conservative management should surgery be performed based on pre-operative evaluation (clinical and radiological) to assess pathological elements. The surgery aims to decrease lateral eminence prominence and the width of the foot while correcting various elements of deformity such as increased 4th–5th intermetatarsal angle, lateral deviation angle, and the fifth metatarsophalangeal angle.
Various surgical procedures have been described to address the deformities, such as resection of the metatarsal head and osteotomies at various levels, i.e., proximal, diaphyseal, and distal. Proximal variants provide good correction, but may impair bone vascularization and lead to nonunion. Diaphyseal osteotomy respects metatarsal head vascularization and does not induce transfer metatarsalgia, but is occasionally associated with delayed fusion. Distal osteotomies consolidate quickly, with less displacement;, excessive displacement may cause migration under 4th metatarsal or discomfort due to the proximal fragment bone spur, requiring resection. Furthermore, more vertical osteotomies are less stable. Each technique has its complications: cutaneous, infectious, and osseous (stability of the osteotomy assembly used, nonunion, or vascular necrosis); the authors generally recommend restricting displacement during the consolidation period. Osteosynthesis needs to respect the soft tissue, to avoid scarring issues and postoperative skin retraction.
In patients with enlargement of the metatarsal head, resection of the lateral surface of the fifth metatarsal head only is the procedure of choice. Resection procedures are simple and can give satisfactory results when preserving joint function and metatarsal length. Resection of the lateral third of the fifth metatarsal head is probably the most commonly used procedure. Patients can be rehabilitated without immobilizing the problems encountered with osteotomies, such as nonunion, malunion, and transfer metatarsalgia. The disadvantages are recurrence of deformity, joint instability, and incongruous joint, with possible dislocation of the fifth metatarsophalangeal joint. Flail toe and clawing of the fifth toe may also be made worse.
Since our patient had a recurrence of the lesion with minimal pathological changes in the angle, the lateral exostectomy has given excellent results with no recurrence. Our report is consistent with similar cases.
Tailor’s bunion deformity, although morphologically common, is rarely symptomatic. Its management involves identifying the cause, thorough clinical and radiographic evaluation of the deformity, and deciding the best surgical procedure to obtain optimal results. Before selecting a given procedure, the cause of the tailor’s bunion deformity should be ascertained. Factors like hyperkeratosis, hypermobile or plantarflexed fifth metatarsal, hypertrophy of the fifth meta-tarsal head, lateral bowing of the fifth metatarsal, and an increased fourth-fifth intermetatarsal angle should all be assessed.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]