Insights on Tailor's Bunions
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Transcript
Dr. Spector (host): Welcome back to Podiatry Today Podcasts where we bring you the latest in foot and ankle medicine and surgery from leaders in the field. Today we're diving into the topic of Tailor's bunions with Dr. Priya Parthasarathy. There's a lot to consider when addressing this deformity and surgical intervention is no exception. We'll get into various available options, including MIS vs. open Approaches, what the literature is currently telling us, and hopefully even some pearls from her own experience. Dr. Parthasarathy is currently the president of the Maryland Podiatric Medical Association, and as an APMA spokesperson, she's been featured in the media, including The New York Times, Time Magazine, Washington Post, The Atlantic, The Today Show, Self magazine, Women's Running magazine, and many others. Dr. Parthasarathy has participated in numerous pediatric surgical mission trips to Honduras with Operation Footprint, and she is board certified by the American Board of Podiatric Medicine. Additionally, she is an esteemed member of our own editorial board here at Podiatry Today. Welcome and thank you so much for joining us. So just as a quick overview, what do you think is the most challenging aspect of surgically addressing Tailor's bunions?
Dr. Parthasarathy: So I think that the most challenging aspect of surgically addressing this deformity is there are so many different ways to approach a fifth metatarsal osteotomy. There's so many diverse procedure options, and they can be deceivingly tricky. And sometimes you have to consider that you need triplane correction. You have to consider the type of Tailor's bunion. Is it like a type one, two, or three? And not one size fits all. So it's really important to remember all of those aspects. And again, there's so many options. So the traditional surgical management, which could be the open lateral approach, which is a sliding osteotomy versus a transverse oblique and a Scarf and now the newer minimally invasive surgery technique which still could be different types of cuts such as the transverse, the oblique and wedge and then you have a whole you know place card of different menu options of fixation. Are you going to let it float? Are you going to do wire fixation or screw fixation? So many different options, deceivingly tricky, and lots of different approaches.
Dr. Spector: Since there's really no debate that there's just so many procedures that are available out there, I think one question I'd be really curious to hear your point of view on are what do you think surgeons should keep in mind then when they are selecting a surgical approach? What factors should they be looking at to come to the best decision for each patient?
Dr. Parthasarathy: So one thing to keep in mind is, as I mentioned before, one size does not fit all. So looking at the different options and then the benefits of looking at your patient population. So let's start, for example, with the MIS option. So what are the benefits? So smaller incisions, quicker healing, sometimes less pain as well because you're not opening up all the soft tissue. And there's definitely a decreased risk for infection and non-union, and you also maintain higher vascular perfusion. So a patient population that may benefit from that, you know, if they are sometimes older, you don't wanna open them up, but then you also have to keep in mind, you know, do they have osteoporosis? So lots of critical thinking goes into this. And one thing is the condylectomy. When you go in and people do a Taylor's bunion correction and they go in and do what we call a "bumpectomy." Okay? You really have to be careful with that. Because if you take too much bone, as I'm sure all of us have seen in our office as a second opinion, and there's a really good case that I use when I lecture about this, it was a patient with RA that had an aggressive condylectomy and it resulted in a stress fracture at the metatarsal neck because they just took too much. And so left them with kind of like a pencil thin metatarsal that resulted in more complications than the original procedure needed, you know, if they had just gone ahead with doing an osteotomy. So the easy way out isn't the right way out, because to me is obviously easier to heal from, no fixation, you go in and you just shave the bone, but it's important to consider the patient population. And looking at say the open procedure and the different positives for that versus the MIS is sometimes you can address larger angles, you use fixation, you can get in there, make sure that the correction is adequate, it's invisible to you. With MIS, there is sometimes a larger learning curve.
So going into the complications with MIS, irritation from the K wires and fixed osteotomies, hypertrophic callus, if you use an unfixed osteotomies, so if you just let it float. And there is sometimes a high learning curve as well. Sometimes people find, I found that when I first started with MIS, the Tailor's bunion was a really good way to start because the osteotomy was more predictable. I didn't have to use fixation and I got a good correction. But on the other hand, with the open complications, so your traditional open fifth metatarsal osteotomies, You have incision healing and wound complications, hardware complications, and then people have started doing these mini open procedures, which may reduce risk, but there isn't a lot of data to support that yet in the literature. So the hypertrophic callus that I'm talking about is caused by micromotion. And I found a catch -22 with the MIS versus the open procedures. So with the MIS procedures, that hypertrophic callus can sometimes become palpable. And so the patients feel it in a different area compared to where they were feeling the fifth metatarsal head originally. And with the open procedure, for some reason in my office, I operate on a lot of small females and they end up feeling the hardware sometimes. So I've noticed in my practice, the number one reason to take a patient back is to remove the screws from my fifth metatarsal osteotomy. I'm careful to use the right size and all of that. But I just found that it's much more prominent on those osteotomies.
Dr. Spector: So you mentioned a lot of great practical implementation components of determining the best situation for each patient since it isn't one size fits all. But is the literature providing us any particular guidance as of late on procedure selection?
Dr. Parthasarathy: So on procedure selection, particularly not significantly, however, there are different newer clinical research on minimally invasive versus more traditional scar fasciotomy, which I'll dive into a little bit later. But looking at the MIS approach, there has been good literature. So the Foot and Ankle Orthopedics in 2024, the July issue looked at minimally invasive surgery for management of bunionette deformity using 5th metatarsal osteotomy, a systemic review and meta -analysis. They looked at 942 potential cases and 580 patients. All studies show statistically significant improvement in clinical outcomes. The The common complication was the hypertrophic callus that we had discussed earlier, which self-resolved over time without surgical intervention. So as we were discussing about procedure selection, I mean, as we are seeing in foot and ankle surgery in general, the MIS approach is really becoming a leader in changing our approach to what we do with traditional osteotomies. And here is a recent 2024 study with a large patient population that shows improved results. And I'm seeing more and more literature with MIS. And that may and probably should influence our procedure selection.
Dr. Spector: So what have you found personally in your hands to be a sound approach to this pathology?
Dr. Parthasarathy: I have traditionally and still find good reproducible results. I have lectured at several conferences and have had a really great discussion with my colleagues on the different types of procedures that they have found works in their hands and it varies significantly as we discussed earlier. I have been able to reproduce great correction with the open modified scarf osteotomy. This is a podcast, so I can't really draw it for you, but it is almost a full traditional Scarf with a more angled dorsal and plantar cut, and I can get a significant shift with two small screws that are very tiny, and these are really good for those very large IM angles that almost have that IM angle starting from the proximal aspect of the fifth metatarsal. They're very challenging. And if you don't use adequate correction there, the patient's still gonna have issues because the problem's not only at the head, but it's also coming from proximally.
There is also good research out there from the Foot publication out of Scotland in May, 2023, scarf osteotomy for reduction of Tailor's bunion deformities, systemic review and meta-analysis. So this was an electronic database search to collate all of these studies pertaining to Tailor's bunion corrections using the Scarf osteotomy between 2000 and 2021. All studies demonstrate a statistically significant reduction of fourth intermetatarsal angles, improvement in clinical and patient-reported outcome measures. there's about a 15% complication rate identified. And they noticed that the one complication was recurring plantar hyperkeratosis right at that fifth metatarsal itself.
I haven't personally encountered that in my practice and have not had an issue with non-union as I make sure my fixation captures all cortices and I have good compression along the site, and I do make sure I optimize their bone health prior to any osteotomies now. Big push now, I do check vitamin D levels and supplement them prior to doing osteotomies, and that's really helped with my outcomes. It's my procedure of choice. Why? Because there's a large IM angle correction. I find it very easily reproducible, which I know that the MIS does have a higher learning curve, but ... hardware removal.
Dr. Spector: Is there anything else that you'd like the audience to know about these new perspectives on approaching Tailor's bunions?
Dr. Parthasarathy: Again, diverse procedure options and not one size fits all, but MIS is really proving successful long-term outcomes as we could see with the previous study as well. Always do a lab as we all know prior to trying it in the OR as I find that fifth metatarsal osteotomiesare challenging and to figure out what works best in your hands.
Dr. Spector: Well, thank you so much for sharing your insights with us today, and thank you to the audience for tuning in. You can be sure to find this and other episodes of Podiatry Today Podcasts on your favorite podcast platforms and on PodiatryToday.com. I'm Dr. Jennifer Spector, Assistant Editorial Director for Podiatry Today, and we look forward to you joining us next time.
