FOOT & ANKLE INTERNATIONAL
Copyright  2008 by the American Orthopaedic Foot & Ankle Society
DOI: 10.3113/FAI.2008.0282
The Minimally Invasive Osteotomy “S.E.R.I.” (Simple, Effective, Rapid, Inex-
pensive) for Correction of Bunionette Deformity
Sandro Giannini, M.D.; Cesare Faldini, M.D.; Francesca Vannini, M.D.; Vitantonio Digennaro, M.D.; Roberto Bevoni, M.D.;
ABSTRACT
Background: A bunionette is a deformity of the fifth metatarsal
bone with a varus deviation of the toe which can require
surgical correction. Although numerous bony or soft tissue
surgical procedures have been described, the ideal treatment
has not yet been identified. The aim of this study was to
retrospectively evaluate the results of a series of 50 consecutive
feet affected by symptomatic bunionette deformity treated
by S.E.R.I. (simple, effective, rapid, inexpensive) osteotomy.
Materials and Methods: Between February 1998 and March
2004, 50 feet with symptomatic type II-III bunionette deformity
in 32 patients (18 bilateral) underwent S.E.R.I osteotomy. The
average age of the patients at the time of operation was 33 ± 13
years. The average followup was 4.8 (range, 2 to 8) years.
Results: The average modified lesser toe AOFAS score increased
from 62.8 ± 15.2 points preoperatively to 94 ± 6.8 points at last
followup (p < 0.0005). The average fifth metatarsophalangeal
(MTP) angle decreased from 16.8 ± 5.1 degrees preoperatively
to 7.9 ± 3.1 degrees at final followup (p < 0.0005). The 4-
5 intermetatarsal angle (I.M.A) averaged 12 ± 1.7 degrees
preoperatively, while postoperatively was 6.7 ± 1.7 degrees (p <
0.0005). Complications included a skin inflammatory reaction
around the Kirschner wire and 2 symptomatic plantar callosities
under the fourth metatarsal heads. Conclusions: The minimally
invasive osteotomy is an effective and reliable technique for
the treatment of painful bunionette, and it achieved more than
90% excellent and good results with reduced surgical time and
complications.
Corresponding Author:
Sandro Giannini, M.D.
Professor of Orthopaedic and Trauma Surgery
University of Bologna
Istituti Ortopedici Rizzoli
Via G.C. Pupilli 1
40136 Bologna
Italy
E-mail: giannini@ior.it
For information on prices and availability of reprints, call 410-494-4994 x226
282
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Deianira Luciani, M.D.
Bologna, Italy
Key Words: Bunionette Deformity; Bunion Correction; Mini-
mally Invasive Surgery; Metatarsal Osteotomy; Forefoot
Surgery
INTRODUCTION
Bunionette is a painful valgus deformity of the fifth
metatarsal bone, associated with a varus deformity of the
fifth toe, a prominent fifth metatarsal head, inflamed over-
lying bursa, and callosity.13,19,23 Several prospective studies
indicate that the condition is 3 to 10 times more common
in women than in men, but the incidence and prevalence
remains unknown.25
The etiology of the bunionette deformity appears to be
multifactorial with various theories discussed throughout the
literature.4 Davis, who published the first paper dealing
with bunionette deformity in 1949, attributed the etiology
of the deformity to incomplete development of transverse
metatarsal ligament, resulting in splaying of the fifth ray.5
DuVries proposed three mechanisms, alone or in combi-
nation, to the formation of a bunionette: 1) hypertrophy of
the soft tissue overlying of the fifth metatarsophalangeal
(MTP) joint; 2) a congenitally wide or dumbbell shaped
fifth metatarsal head, and 3) lateral deviation of the fifth
metatarsal head.9 Other investigators also advocated these
same causes.17,30 Root et al. suggested that abnormal prona-
tion during gait results in hypermobility of the fifth ray
and subsequent abduction, eversion, and dorsiflexion of the
metatarsal, leading to a dorsilateral bunion.24 Nestor showed
that in feet with a symptomatic bunionette deformity, the 4 –5
intermetatarsal angle significantly increased to 9.6 degrees,21
while in normal feet the average angle is 6.2 degrees (range,
3 to 11 degrees).10 Additional influences include connec-
tive tissue disease or inflammatory arthritis, fifth MTP joint
trauma, neuromuscular disorders, or iatrogenic causes.25
According to Coughlin’s radiographical classification, the
bunionette deformities are subdivided into three types: type 1
is caused by a prominent lateral condyle; type 2 is caused by
Foot & Ankle International/Vol. 29, No. 3/March 2008
lateral bowing of the diaphysis of the metatarsal shaft; and
type 3 is characterized by an increased 4 –5 intermetatarsal
angles (IMA).4
Numerous bony or soft tissue procedures have been
described to date for the surgical treatment of painful
bunionettes, such as resection of the lateral one quarter
or third of the fifth metatarsal head,6,15 metatarsal head
resection,8,18 proximal or distal metatarsal osteo-
tomies,7,11,16,26,28 or use of prosthetic implants.1 Distal
osteotomies have gained increasing popularity due to reported
good results and versatility. Among these, S.E.R.I. tech-
nique, which was first proposed for hallux valgus correction
with satisfactory results,12 has been successively applied to
the bunionette as a simple, rapid, effective and inexpensive
surgical treatment (S.E.R.I.).
The aim of this study was to retrospectively evaluate
the results of a series of 50 consecutive feet affected by a
symptomatic bunionette deformity treated by S.E.R.I.
MATERIALS AND METHODS
From February 1998 to March 2004, 50 feet (18 bilateral,
9 right, 5 left) in 32 patients were treated for symptomatic
bunionette deformity. The series included 28 female (46 feet)
and 4 male (4 feet). The average age of the patients at the
time of surgery was 33 ± 13 (range, 16 to 60). All patients
gave informed consent for inclusion of their data in this
study. The average duration of clinical and radiographical
followup was 4.8 (range, 2 to 8) years.
A B
Fig. 1: Preoperative AP radiograph of the foot of a 43 year old woman (A), immediate postoperative AP radiograph (B), postoperative AP radiograph obtained
4 years after the operation, which showed the decrease of the 4 – 5 IMA and fifth MTP angle (C).
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A LINEAR DISTAL METATARSAL OSTEOTOMY 283
Preoperatively all patients experienced pain around the
lateral eminence of the fifth metatarsal head and 23 feet
had painful callosities and reactive overlying bursa. The
indication for surgical treatment was persistent painful defor-
mity despite nonoperative treatment, including large toe-box
shoes, padding, orthoses and antiinflammatory therapy. In
23 patients associated conditions were observed: 14 patients
were affected by hallux valgus, 7 by hammertoes, and 2
by Morton’s neuroma. All the associated conditions were
treated during the same surgical intervention: all the hallux
valgus received S.E.R.I. osteotomy of the first metatarsal
bone, all the hammertoes had percutaneous lengthening of
the extensor tendon, and in 4 cases an arthrodesis of the prox-
imal interphalangeal joint was performed and the neuromas
were removed.
Weightbearing AP radiographs were made preoperatively
(Figure 1A), immediately postoperatively (Figure 1B), 4
weeks after surgery and at the most recent followup eval-
uation (Figure 1C). According to Coughlin’s radiograph-
ical classification,4,5 all the patients had type 2 or type 3
bunionette deformities. At followup, the clinical evaluation
included a modified lesser toe AOFAS score. The results
were graded as excellent (90 to 100 points), good (80 to 89
points), satisfactory (70 to 79 points), and poor (less than 70
points).14
The radiographic evaluation compared pre-operative and
postoperative fifth MTP angles and 4 –5 IMA.
All continuous data were expressed as a mean and standard
deviation. A paired Student t-test was performed to analyse
the differences between preoperative and followup data. For
all tests, p < 0.05 was considered significant.
C
284 GIANNINI ET AL. Foot & Ankle International/Vol. 29, No. 3/March 2008

Statistical Analysis was carried out with the Statistical
Package for the Social Sciences (SPSS) software version 9.0
(SPSS Inc., Chicago, IL).
TECHNIQUE
The operation was performed under local or block anes-
thesia and a tourniquet was used at the ankle. The patient is
supine with the foot internally rotated with the medial side
of the foot on the operating table.
A 1-cm lateral incision was made just proximal to the
lateral eminence of the fifth metatarsal head through the
skin and subcutaneous tissue, down to bone. The soft
tissues were separated and held by two 5-mm retractors
(Figure 2A). The lateral aspect of the metatarsal neck was
now visualized. The complete osteotomy was performed
using a standard pneumatic saw with a 9.5 × 25 × 0.4-mm
blade (Hall surgical Linvatec corporation, Largo, FL)
(Figure 2B). The inclination of the osteotomy in the lateral
to medial direction was perpendicular to the fourth ray if
the length of fifth metatarsal bone was to be maintained.
The osteotomy was inclined in a distal-proximal direction
up to 25 degrees, if shortening of the metatarsal bone
or decompression of the metatarsophalangeal joint was
necessary in cases of mild arthritis. More rarely, if a
lengthening of the fifth metatarsal bone was necessary, the
osteotomy was inclined in a proximal-distal direction up to
15 degrees.
The inclination of the osteotomy was perpendicular to the
fourth ray, with the exception of two cases in which a slight
inclination in a distal to proximal direction was made in order
to decompress the joint.

A B

C D

Fig. 2: Surgical technique: A 1-cm skin incision 1 cm in length and soft tissues are held by two 5-mm retractors (A). The metatarsal osteotomy is performed
with a standard pneumatic saw (B). The insertion of 2-mm Kirschner wire in the soft tissue of the lesser toe along the long axis in a proximal to distal direction
(C). The correction of the deformity by displacing the osteotomy and moving the metatarsal head as needed with the grooved small lever. The osteotomy is
stabilized by inserting the Kirschner wire into the diaphyseal canal in a distal to proximal direction (D). The skin is sutured using only one 3-0 absorbable
stitch (E).

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Foot & Ankle International/Vol. 29, No. 3/March 2008
In a dorsal to plantar direction, the osteotomy was
normally inclined about 15 degrees in a distal to proximal
direction, to control the dorsal translation of the metatarsal
head with weightbearing. Adjustment of the lateral to medial
translation of the metatarsal head was performed introducing
the Kirschner wire, more or less superficial with regard to
the lateral eminence. Adjustment of plantar translation of the
metatarsal head, performed less often than the dorsal transla-
tion, was obtained by introducing the Kirschner wire in the
upper aspect of the metatarsal head. If supination of the fifth
metatarsal bone was present, the correction is obtained with
derotation of the lesser toe to the neutral position.
With a small osteotome, the head was mobilized. A 1.8-
mm Kirschner wire was inserted into the soft tissue adjacent
to the bone in a proximal to distal direction along the longi-
tudinal axis of the fifth toe (Figure 2C). The Kirschner wire
exited at the lateral area of the tip of the toe, 5 mm from
lateral border of the nail; it was retracted with the drill up to
the proximal end of the osteotomy. Using a small grooved
lever to pry the osteotomy, the correction was obtained by
moving the metatarsal head depending on the pathoanatomy
of the deformity (Figure 2D). Stabilization of the correc-
tion was obtained by inserting the Kirschner wire into the
diaphyseal canal in a distal to proximal direction until its
proximal end reached the metatarsal base. If the cut edge
of the metatarsal was laterally prominent, a small wedge of
bone is removed. The skin was sutured with only one 3-0
absorbable stitch (Figure 2E). The Kirschner wire was bent
and cut at the tip of the toe.
Postoperative Management
A gauze compression dressing was applied and an AP x-
ray was performed to confirm correction of the deformity.
Ambulation was allowed immediately using shoes that allow
the weightbearing only on the hindfoot (talus shoes) Foot
elevation was advised when the patient was at rest. After
one month, the dressing, suture, and Kirschner wire were
removed. Passive and active exercises with cycling and
swimming were advised. Patients were advised to wear
comfortable shoes, gradually returning to former footwear.
RESULTS
All patients, except two (4%) were satisfied with their
result. The preoperative AOFAS forefoot score was 62.8 ±
15.1 points (range, 19 to 80) (p < 0.0005) Pre- and postoper-
atively it was 94 ± 6.8 points (range, 75 to 100). Thirty-eight
feet (76 %) were rated as excellent, 9 (18%) good, 2 (4 %)
fair and 1 (2 %) was considered poor. Pain was absent in 40
feet (80%), mild or occasional in 8 feet (16 %), moderate
or daily in 2 feet (4%). Function in 42 feet (84%) had no
limitations in daily and sport activities, 7 (14%) had minimal
limitations, and 1 foot (2%) had a severe limitation. Forty-
four patients (88%) were able to wear normal shoes.
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A LINEAR DISTAL METATARSAL OSTEOTOMY 285
All the osteotomies healed with radiographic evidence
of consolidation after an average of three months. All
the osteotomies remodelled over time, even in cases with
significant offset at the osteotomy (few millimeter of bony
contact).
Radiographic evaluation demonstrated that the average
fifth MTP angle was 16.8 degrees ± 5.1 preoperatively and
7.9 degrees ± 3.1 (p < 0.0005) postoperatively. The 4 –5
IMA was 12 degrees ± 1.7 preoperatively and 6.7 degrees
±1.7 postoperatively (p < 0.0005).
No severe complications, such as avascular necrosis of
the metatarsal head or non-union of the osteotomy occurred.
In 6 feet (12%), the radiographic healing of the osteotomy
occurred over four months after surgery; however, no
increased postoperative pain was noted in these patients,
nor was the clinical result compromised at final followup.
Furthermore, no correlation was found between the delayed
radiographic union and the offset at the osteotomy; in fact,
none of these cases displaced. One foot (2%) had a skin
inflammatory reaction around the Kirschner wire. Two feet
(4%) reported symptomatic plantar callosities under the
fourth metatarsal heads. No dorsal subluxation of the fifth
MTP was present.
DISCUSSION
Numerous bony or soft tissue procedures have been
described for the surgical treatment of painful bunionettes.
Resection of the lateral quarter or third of the fifth metatarsal
head was proposed for the surgical treatment of mild symp-
tomatic deformity. This procedure can be performed as an
isolated procedure or in conjunction with other surgical
techniques.6,15 Head-shaving was recommended when hyper-
trophy of the lateral aspect of the fifth metatarsal without
soft tissue or structural deformity represent the primary
pathology.6,15 Currently some authors feel these surgical
procedures have been nearly abandoned.25 Metatarsal head
resection is recommended by some authors in cases with
severe osteopenia, exstensive degenerative joint changes, or
previous failed surgery. Good results with regard to transfer
metatarsalgia improvement (3%) have been reported but a
residual fifth toe malalignment sometimes requiring salvage
surgery.1,8,18
Proximal osteotomies have the potential advantage of
providing a high degree of correction.7,28 However Shereff
et al.27 in a vascular study showed a confluence of extra-
osseous vessels along the proximal and medial metatarsal.
Interruption of this confluence could lead to delayed union
or non union of proximal metatarsal osteotomies and a signif-
icant rate of delayed union has been reported clinically.22
Distal metatarsal osteotomies have been reported as effec-
tive in bunionette correction in several clinical studies.11,16,26
Schabler et al.,26 performed 24 distal oblique osteotomies
with no fixation devices reporting a rate of subjective patient
286 GIANNINI ET AL.
satisfaction of 96%. The author concluded that the configura-
tion of the osteotomy affords inherent stability and prevention
of sagittal plane malalignment. Nevertheless, in a series of 17
oblique distal metatarsal with no internal fixation, Sponsel29
reported delayed or nonunion in four cases.
Several complications have been reported for distal
osteotomies fixed with screws or bioabsorbable devices, due
to the fixation devices themselves including: soft tissue irri-
tation, malposition of the screws resulting in plantar penetra-
tion, lytic changes, and fractures at the site of fixation.2,3,23
Chevron osteotomy is currently widely used, even with the
possibility of a medial metatarsal head dislocation and the
necessity for capsulotomy.2,20
The S.E.R.I. minimally invasive distal osteotomy proposed
in this paper was found to be a reliable and adequate surgery
for bunionette treatment. It does not need a capsulotomy
nor a permanent internal fixation devices, but it achieved
good clinical results with minimal morbidity. All but two of
the patients in this series were satisfied with the procedure
with the clinical improvement reflected by the AOFAS score
increasing 31.2 ± 13.2 (p < 0.0005).
No technical problems were observed in the series. In all
the cases, the fifth metatarsal head was translated according
to the parameters of the deformity and stabilized with
an optimal rate of bone healing. A correction of all the
radiographic parameters was obtained, such as a correction
of 5.3 degrees ± 1.9 degrees (p < 0.0005) of the 4 –5
intermetatarsal angle, and a correction of 8.9 degrees ± 3.9
degrees (p < 0.0005) of the fifth MTP angle.
The direct lateral approach to the fifth metatarsal head
without the need for an image intensifier make this technique
simple, effective and rapid to perform with a short learning
curve. The technique is inexpensive due to the reduced
operative time and since fixation is successfully achieved
with a simple Kirschner wire.
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