What's one of the most common reasons bunions come back after surgery?
Metatarsus Adductus
Metatarsus Adductus
If this condition is missed pre-operative the likelihood of not getting the bunion reduced in surgery, the bunion recurring after surgery, or the patients not being happy with the outcome increases dramatically.
Metatarsus adductus means the long bones of the foot (the metatarsals) angle inward toward the center of the body instead of pointing straight ahead.
Metatarsus adductus does NOT go away with orthotics, physical therapy, or shoe changes. Although for many patients symptoms can be treated with custom inserts or orthopedic shoes the only way to fix this condition is surgery.
- The foot looks C-shaped from above
- The front of the foot is angled inward
- This is a structural alignment, not a muscle problem
- Many people are born with it and never know
Metatarsus adductus does NOT go away with orthotics, physical therapy, or shoe changes. Although for many patients symptoms can be treated with custom inserts or orthopedic shoes the only way to fix this condition is surgery.
Many patients are born with this condition. Clinically the appearance of a bunion can worsen over time.
|
|
In patients with metatarsus adductus:
If you straighten the toe but ignore the crooked foundation, the deformity often comes back.
How Common Is This?
Clinical research shows:
- The entire forefoot is already angled inward
- The bunion is being pushed by the overall foot structure
- Standard bunion surgery may straighten the toe temporarily
- Over time, the same inward forces cause the bunion to return
If you straighten the toe but ignore the crooked foundation, the deformity often comes back.
How Common Is This?
Clinical research shows:
- 20–30% of patients with bunions have metatarsus adductus
- Recurrence rates are significantly higher when it is not recognized
- Studies show 2–3× higher recurrence after traditional bunion surgery in these patients
We evaluate the metatarsus adductus in pre-operative bunion planning with what's now called the plum line.
3 of the past fellows from our practice OFAC (Will DeCarbo DPM, Robert Santrock MD, and Brett Smith DO) along with Drs. McAleer, Hatch, and Dayton published commonly used method in 2024.
3 of the past fellows from our practice OFAC (Will DeCarbo DPM, Robert Santrock MD, and Brett Smith DO) along with Drs. McAleer, Hatch, and Dayton published commonly used method in 2024.
|
This was intentionally published as open-source so all surgeons could access online without cost or a subscription due to this being such a commonly missed factor affecting bunion outcomes.
|
Here is how the Plum Line can help surgeons decide whether or not a patient's metatarsus adductus needs to be addressed to correct the bunion deformity.
- Typically these are severe bunions and either fixed with a Lapiplasty (Lapidus) alone or if the metatarsus adductus needs addressed then wedge cuts are performed to reduce the most affected metatarsals at their base (most commonly the second and third metatarsals ) and held in place along with a Lapiplasty (Lapidus) procedure all done at the same surgery
- Termed the Adductoplasty for metatarsus adductus can also be done in a less invasive manner.
|
Sgarlato’s Angle
|
|
|
Plumbline radiographic assessment method.
(A) cuneiform axis line is drawn linking two points marked at the medial aspect of the first TMT joint and the medial NC joint (B) a third point is marked at the lateral apex of the first TMT joint (C) the medial cuneiform axis is translated in a parallel fashion to the third point at the first TMT joint. - This line is then extended distally toward the second metatarsal head resulting in the formation of the Plumbline. In this example the Plumbline does not hit the 2nd metatarsal indicating no metatarsus adductus and therefore the bunion procedure does not have to address metatarsus adductus. |
|
|
Positive Plumbline.
3/2/1 tarsometatarsal corrective arthrodesis. (A) medial cuneiform axis line (B) plumbline crossing the second metatarsal (positive result) indicating the presence of metatarsus adductus (C) 3/2/1 corrective tarsometatarsal arthrodesis with normalization of the plumbline. In this example the Plumbline goes through the 2nd metatarsal and therefore the bunion cannot be reduced back in to correct alignment due to the 2nd metatarsal and subsequently 3rd metatarsal being in the way. |
|
The Metatarsus Adductus needs to be addressed before the bunion is fixed and this can be done during the same surgery all at once with an AdductoplastyTM and LapiplastyTM
What Adductoplasty aims to do:
Potential benefits:
Again, not every bunion is the same so the Adductoplasty is not for everyone, but in the right patient, it can be a game-changer with dramatic functional and cosmetic improvement.
- Realign the forefoot back under the body
- Restore the mechanical axis (plumb line)
- Reduce deforming forces on the big toe
- Improve long-term stability of bunion correction
Potential benefits:
- Lower recurrence rates
- Better weight distribution
- Improved shoe comfort
- More durable correction in complex feet
Again, not every bunion is the same so the Adductoplasty is not for everyone, but in the right patient, it can be a game-changer with dramatic functional and cosmetic improvement.
|
|
Takeaways for Patients
If your bunion:
If your bunion:
- Came back after surgery
- Never felt “right”
- Was corrected but drifted again
- Ask whether you have metatarsus adductus or get a second opinion to evaluate your metatarsus adductus.
- Some patients metatarsus adductus is considered flexible or reducible and can be addressed without the Adductoplasty however for the majority of patient with metatarsus adductus the Adductoplasty is needed to correct the route cause of the bunion deformity.
Final Thoughts on Bunions with Metatarsus Adductus
Bunions don’t recur because patients fail.
They recur because foot structure matters.
Recognizing metatarsus adductus—and addressing it when appropriate—can be the difference between temporary correction and lasting results.
If you’re considering bunion surgery or revision surgery, make sure your surgeon evaluates the whole foot, not just the bump.
Bunions don’t recur because patients fail.
They recur because foot structure matters.
Recognizing metatarsus adductus—and addressing it when appropriate—can be the difference between temporary correction and lasting results.
If you’re considering bunion surgery or revision surgery, make sure your surgeon evaluates the whole foot, not just the bump.
A couple of examples of Dr. Thomas' patients with bunions and metatarsus adductus before and after surgery.
|
|