Tailor’s Bunion

• Tailor’s Bunion

Dear Editor:

I read with great interest the article titled “Tailor’s Bunion: Is Fixation Necessary?” by Drs. Jane Pontious, Joel Brook, and Howard Hillstrom, in the February 1996 issue of the Journal. While I believe their findings are noteworthy, some additional considerations regarding nonfixated distal oblique fifth metatarsal osteotomies may deserve mentioning.

The radiographs included in the article depict the oblique osteotomy as being placed in what some may consider to be the distal diaphysis, and at an angle that begins to closely approximate the sagittal plane. If this is indeed the case, metatarsal shortening and a delayed consolidation rate would seem predictable. Furthermore, the “proximal” placement of this distal osteotomy would fail to take advantage of the strong capsular and ligamentous attachments in the distal metaphysis and metatarsal neck, promoting dorsal excursion of the capital fragment.

It is therefore suggested that if the osteotomy were to begin just behind the lateral condyle of the metatarsal head, and course obliquely at an angle that is less acute than those shown in the article, some disadvantages of the distal oblique osteotomy could be overcome. Using this approach: 1) patients relate a nonpainful “clicking” sensation only during the first 2 or 3 days postoperatively as fracture-site-hematoma organizes; 2) radiographs show secondary bone callus at 5 to 6 weeks postoperatively; 3) anticipated secondary bone callus forms a nodule at the dorsum of the metatarsal neck that is asymptomatic and remodels over the course of several months postoperatively; and 4) patients return to normal soft shoes 4 weeks postoperatively. Did the authors have the same experience with this modification?

Thomas M. DeLauro, DPM

Divisions of Medical and Surgical Sciences

New York College of Podiatric Medicine

53 E 124th St

New York, NY 10035

• Author’s Response

Dear Editor:

I would like to thank Dr. Thomas DeLauro for his interest and comments on our recent article. Dr. DeLauro has some considerations concerning the placement of the osteotomy in the radiographs in the article. The radiographs he mentioned were presented in the complications section of the lecture and represent two of the many complications identified. These radiographs were in no way intended to represent the proper placement of the osteotomy. The orientation of the planes of the osteotomy and the location of the osteotomy itself will dictate the functional relationship of the metatarsal head.

A general technique in performing an obliquetype osteotomy for the correction of tailor’s bunion is to place the osteotomy in the metaphyseal bone immediately proximal to the dorsal epicondylar ridge from distal lateral to proximal medial. With this particular type of osteotomy, as with all osteotomies, there should be minimal stripping of the soft tissue and vascularity to the distal fragment. This allows for good osseous union of the osteotomy in a normal fashion. My personal approach is to fixate tailor’s bunion osteotomies. Fixation of these osteotomies provides for good stability of osseous fragments regardless of the location of the osteotomy. Although location and design are important factors in osteotomy stability, fixation and postoperative support are increasingly recognized as important determinants of a successful surgical result.

It has been well documented in the literature that weightbearing, even in the patient with stable fixation, can introduce forces that may disrupt the newly established surgical alignment of the osteotomy. As stated in the article, the complications resulting from tailor’s bunion surgery can be directly related to the dorsal transposition of the capital fragment. In our study, failure to fixate fifth metarsal osteotomies led to transfer lesions (whether symptomatic or not) and metarsalgia. Performing this procedure with fixation led to decreased complications and more accurate metatarsal alignment

I would like to add that patients within the study whose osteotomies were fixated returned to their normal shoes earlier than patients with nonfixated osteotomies. I hope this helps clarify Dr. DeLauro’s questions.

Jane Pontious, DPM

Department of Surgery

Pennsylvania College of Podiatric Medicine Eighth at Race St

Philadelphia, PA 19107