Background: Since we are very successful in the operation of hallux valgus using a transverse sub-capital osteotomy fixated with an intramedullary angle-stable locking plate, and a tailors bunion is understood as a reversed hallux valgus, we have applied the operation also for such indication. Method: The osteotomy was carried out at a straight V. metatarsal subcapitally, and in case of an outwardly curved V. metatarsal at the bending location. The intramedullary plates are available in different designs and the plate and screws disappear completely in the bone, so the soft tissues are not disturbed. The head of the plate is either straight or curved in order to shift the distal fragment sufficiently. Results: 26 patients were operated within a period of 5 years (2008-2012). 21 patients were followed up after an average of 34.4 months. The IM angle IV/V could be improved by an average of 11.76 to an average of 4.10. This is a highliy significant pre- to postoperative difference of 7.66 (t = 15.07, p < 0.001). The AOFAS score was improved by an average of 42.24 points from 55.76 points preoperatively to 98.00 points postoperative. There was no pseudo-arthrosis and no wound healing impairment. All patients were either satisfied or very satisfied with the surgery. Conclusion: This method does not have the disadvantages of the other common operations of the Tailors bunion and is applied now as a standard method in this deformity.
Tailors bunion is used to describe a widening of the foot on the outside by prominence of the fifth metatarsal head and usually also of the soft tissues above [
The prominence (pseudo exostosis) of the fifth metatarsal is caused by a spreading of the metatarsals IV and V, which widens the foot and often forms a significant bump at the lateral side of the forefoot. Other causes are a hindfoot varus with or without pes adductus, the plantarflexion of the V. metatarsal, the outwardly curved V. metatarsal, the splayed V. metatarsal with and without ligamentous laxity. Increasingly, exterior factors such as shortened calf muscles or bad, and very tight footwear, as well as very high heels have an influence [
An important parameter of the spread of the metatarsals is the intermetatarsal angle between the fourth and fifth metatarsal, which is specified as normal up to 6.5 [
Conservative treatment options are rather limited and consist of insoles and customization of footwear in order to intercept the pressure. In its early phase, foot exercises may also slow down the formation of the splayfoot. The calf muscles should be stretched. However, the conservative measures usually help only at the beginning of the deformity and a surgical procedure is often necessary [
Standard operation procedures are mentioned as follows. The comments quote the opinion and experience of the authors of the individual operations, and published experiences from the literature are cited: The mere removal of the pseudo exostosis has modest possibilities according to the authors’ experience, as this is only a few millimeters wide and the symptoms usually persist after surgery.
The Austin/Chevron Ostetomie [
The long, oblique, diaphyseal osteotomy of the fifth metatarsal can effectively correct the IM angle [
The Scarf Osteotomy [
The base osteotomy with a closing wedge can correct the IM angle very well and is also suitable for curved outward metatarsals. Problems arise due to fixation, which requires relief in case wires or oblique screws are used. In addition, higher rates of nonunion were described [
A modification of this osteotomy is a displacement-ostetomy, where step-plates are used. The distal fragment is not only shifted towards varus but also shifted to the middle of the foot. The fixation is rigid, so that the patient does not need relief for a long period. This osteotomy appears to be particularly suitable for outward curved metatarsals. The plate is again located directly under the skin and as all the shoes here have direct contact with the foot, metal removals can be expected.
The aim of this work was to find a method which fulfills all the criteria of improvement or normalization of the IM angle IV/V, the normalization of the joint angle (DMAA) and the repositioning of the V. metatarsal head from a possible pressure zone in the shoe. The osteosynthesis should be loaded immediately and the plate should preferably not need to be removed.
A New Intramedulary Locking Plate for the Osteotomy of the V. Metatarsal in the Correction of the Tailors Bunion. Midterm results of 21 patients.
As the tailors bunion can be understood as a reversed hallux valgus [
The fixation was performed with the existing 30 mm long V-tek plate with 3 holes and with a specielly designed extra slim 30 mm plate with or without a 2 mm offset. This plate is inserted into the medullary space of the proximal portion of the metatarsal fragment. The insertion is usually very easy. Then, using a target device, the lateral and medial cortex is drilled from lateral, drilling through holes in the plate. There are two threaded holes in the proximal part of each plate. The drill diameter is 2 mm and the screws diameter is 2.7 mm. The screws fixate the plate angle-stable, due to the corresponding threads in the plates.
Screw lengths are in most cases 8 mm. Thereafter, the distal fragment is dorsoplantar aligned and the PASA angle may also be corrected. The plate has a thread hole for a 2.7 mm screw head. After the distal fragment is drilled with a 2 mm drill, the head of the fifth metatarsal is now screwed angle stable to the plate head. The screw length here is usually 12 mm. In case of pathological PASA angles, the head fragment can also be derotated, since in this type of fixation no full contact of the fragments is required. Due to the extremly rigid fixation only a point contact is sufficient. Therefore, a shift of 100% is possible, so you can place the distal bone fragment literally “next to” the proximal.
The osteosythesis can be fully loaded immediately after surgery and patients can resume activites immediately using postoperative shoes or a sandal. After suture removal, patients wore normal comfort shoes. Figures 1-8 show the result of a failed previous surgery after the correction displacing the distal fragment and fusing with the new intramedullary locking plate. Figures 9-14 show a patient with tailors bunion and the correction displacing the distal fragment about 100%, which is possible due to the extremly rigid internal fixation with the intra- medullary locking plate.
The study was a retrospective clinical study and the t-test was used for the statistical analysis.
Between January 2008 and December 2012, 26 patients with tailors bunion underwent operation in our two units. For straight metatarsals a subcapital osteotomy was carried out, for curved metatarsals the osteotomy was respectively done at the proximal beginning point of the outward bend of the V. Metatarsal. 6 patients were operated on both sides but not in one stage. In addition to the Tailors bunion, further interventions were performed for 18 patients at the forefoot, such as the correction of hallux valgus, hammer toes, or splay foot with metatarsalgia.
Except postoperative hematomas (20%) and the standard swelling (85%), which disappeared after a short time, no post-operative complications occured. All osteotomies healed within 6 to 8 weeks. This was verified radiographically.
21 patients were followed up clinically and radiologically after an average of 34.4 months (15 - 72 months). Out of 21 patients, the plate had to be removed in 4 cases (19.04%).
The IM angle IV/V could be improved from an average of 11.76 (between 8 and 16) to an average of 4.10 (between 2 and 8) (
The AOFAS score was averagely 55.76 points preoperatively between 29 - 80 points. Postoperatively, the AOFAS score was on average 98.0 points-between 90 and 100 points, which is a significant improvement (t = 13.17, p < 0.001) (
Patients were also asked about their satisfaction with the surgery. They could choose between: very satisfied, satisfied, adequate or not satisfied.
18 patients reported being very satisfied and 3 patients were satisfied with the surgical result.
Before OP (n = 21) | After OP (n = 21) | Difference | ||||
---|---|---|---|---|---|---|
Variable | Mean | s.d | Mean | s.d | Mean | s.d |
IM angle | 11.76 | 2.54 | 4.10 | 1.63 | −7.66 | 2.27 |
The IM angle IV/V could be improved from an average of 11.76 (between 8 and 16) to an average of 4.10 (between 2 and 8). This is a highliy significant pre- to postoperative difference of 7.66 (t = 15.07, p < 0.001).
Before OP (n = 21) | After OP (n = 21) | Difference | ||||
---|---|---|---|---|---|---|
Variable | Mean | s.d | Mean | s.d | Mean | s.d |
AOFAS score | 55.76 | 13.57 | 98.00 | 3.16 | 42.24 | 14.34 |
The AOFAS score was averagely 55.76 points preoperatively between 29 - 80 points. Postoperatively, the AOFAS score was on average 98.0 points―between 90 and 100 points, which is a significant improvement (t = 13.17, p < 0.001).
The simple transverse osteotomy of the V. Metatarsal, fixed with the intramedullary, angle stable locked plate has proven to be a safe surgery in the treatment of Tailors bunion. It addresses the pathology of the deformity, because the osteotomy can be performed depending on the deviation of the Fifth Metatarsal, so either subcapitally, or in case of outwardly bent metatarsals at the location of the bend, i.e. the shaft or even the base area.
Due to the great strength of the osteosynthesis implants, a displacement of up to 100% of the distal fragment can be carried out, which offers this procedure a great range of correction. In addition to the correction of the IM angle, a pathological PASA or DMAA can be corrected by a distal fragment rotation, because in this method, only a point of contact with the osteotomy-partner is needed. Additionally, the correction of a supinated or pronated V. toe is possible by axial derotation. Disadvantages of other operations could be avoided, as the low correction options in the case of pure pseudo-exostosis resection, or of the Chevron osteotomy, or the operational difficulty of Scarf osteotomy or the subcutaneous layer of the plate in the outside mounted osteosynthesis at a base displacement osteotomy.
Due to the very stable osteosynthesis, no pseudoarthrosis and no wound healing impairment cases occurred among our patients.
The surgery is technically very simple and the learning curve is quick. The patients reported very little or even no pain after surgery; most were treated on an outpatient or day surgery basis. The mobilization was performed immediately after surgery with special shoes or comfortable sandals, which allowed immediate normal ambulation. All patients were allowed to resume activity and full loading of the foot immediately in accordance with the pain. All implant parts in the proximal osteotomy partner are fully incorporated in the bone, so that the soft tissues are not disturbed in the shoe. The plate head is screwed outside the essence of the displacement at the distal fragment. The majority of patients (18 patients) were very satisfied with the operation; the remaining 3 patients were satisfied.
The authors declare no conflict of interests. The informed consent was obtained from all patients before the opera- tion.
Michael Vitek,Hannes Kugler,Felix Fink,Joachim Niemeier, (2016) A New Intramedulary Locking Plate for the Osteotomy of the V. Metatarsal in the Correction of the Tailors Bunion. Midterm Results of 21 Patients. Open Journal of Orthopedics,06,171-183. doi: 10.4236/ojo.2016.67025