Is The Weil Osteotomy Overused By DPMs?

Yes.

Although the Weil osteotomy provides an excellent surgical option for primary central ray pathologies, this author says it is not appropriate for most central metatarsal pathologies due to biomechanical factors and it is prone to complications.

By Patrick A. DeHeer, DPM, FACFAS

The Weil osteotomy has become a staple in forefoot surgery and is equally embraced by both the podiatric and orthopedic communities. I have observed that if you talk to any foot surgeons, this is not one of their favorite procedures to perform. Why is this the case? For a procedure so revered in the foot surgery world, it seems as if it should be a consistent favorite.

   The Weil osteotomy has become the procedure of choice for pre-dislocation syndrome and central ray metatarsalgia, but is it overused? To answer this question, one must consider the underlying etiologies of pre-dislocation syndrome and metatarsalgia. Then consider the consistently occurring complications that surgeons just accept with this procedure. This situation with this procedure is unlike that of any other procedure that I know of except perhaps first metatarsophalangeal joint (MPJ) implant arthroplasty.

   After one evaluates these factors objectively, the inappropriate use of this procedure becomes apparent. I would even go so far as to suggest that surgeons should rarely perform this procedure.

   Studies have shown that the Weil osteotomy often relieves the original symptoms for central metatarsal pathologies but commonly at the price of one or more of the documented complications.1-3 Complications consistently associated with this procedure include “floating toes,” transfer metatarsalgia, complication with fixation, delayed healing, joint stiffness and joint pain. The rates of complications are significant when one reviews the literature.4-8

   Primary central ray pathologies such as a long metatarsal respond very well to the Weil osteotomy. This requires shortening of the elongated metatarsal. Most central metatarsal pathologies, however, are due to functional biomechanical factors and not primary pathologies.

   Why then do surgeons perform this procedure so frequently? Perhaps the answer lies in the fact that prior options (such as the distal “V” osteotomy) for central metatarsal pathologies yielded such inconsistent results with even higher complication rates in my experience.

   I think the Weil osteotomy is often an “easier” solution technically and postoperatively for the surgeon than addressing the underlying pathology. As foot surgeons, we should know that employing primary central ray pathology procedures to treat biomechanical central ray pathologies is ludicrous.

Questioning The Use Of The Weil Osteotomy For Sub-Second Metatarsal Pathology And Hammertoe Deformity

Let us discuss the common scenario of sub-second metatarsal pathology with or without pre-dislocation syndrome and a hammertoe deformity. It is clear that first ray instability with resultant functional elevation is the true underlying cause of this condition.

   This leads to increased pressures beneath the second metatarsal head. The increased pressure results in inflammation, which subsequently leads to symptoms such as pain, swelling, stress reactions, crossover toe deformities and hammer digit syndrome.

   So how does shortening and plantarflexing the second metatarsal address these pathologies? The second metatarsal is actually without pathology. Then why would one operate on a “normal” bone?

   With any pathology, from flatfoot deformity to hallux abducto valgus, the key to any successful surgical outcome is to address all the levels of deformity. One should use the same approach for the painful sub-second metatarsal head or pre-dislocated second toe.

   If there is a digital deformity of the second toe, then repair of this occurs via a flexor tendon transfer or arthrodesis of the proximal interphalangeal joint. If there is dorsal medial deviation of the MPJ, then one utilizes a dorsal medial capsulotomy with or without tenotomy to rebalance the soft tissues.

   Is it really necessary to shorten the metatarsal further? I say no unless the MPJ deformity does not correct with the soft tissue release. If it does not, then either a plantar plate repair or the Weil osteotomy would be the next step intraoperatively. Sometimes “joint decompression” is very helpful for the more severe pre-dislocation deformities.

   The treatment for the severe dislocation of the second MPJ and resultant rigid hammertoe deformity is certainly marginal at best. One can best accomplish this with the stepwise approach ending in either the Weil osteotomy or plantar plate repair. Oftentimes, this will result in what has so adeptly been called the “dead stick” toe. The toe is straight, stiff and for the most part non-functional. The pain often improves with this approach but is it really any better than after an amputation, partial metatarsal head resection or plantar condylectomy? There is not enough documentation to support arthrodesis of the second MPJ.

   Simple metatarsalgia not associated with a hypermobile first ray is rarely a true plantarflexed ray. However, it is often a functional plantarflexed ray due to the retrograde pressure of a hammertoe deformity. Again, the apex of the deformity is not the metatarsal head but rather the proximal interphalangeal joint.

A Closer Look At Complications Of The Weil Osteotomy

When evaluating the effectiveness of any procedure, one must take into account the documented complications. A “floating toe” will occur 20 to 68 percent of the time after a Weil osteotomy, according to the literature.4,7 This occurs via dampening of the passive plantarflexion provided by the windlass mechanism. Studies have also documented stiffness of the metatarsophalangeal joint.5

   Hofstaetter and colleagues showed seven-year range of motion findings with only 32 percent of the patients having normal range of motion, 48 percent with moderately decreased range of motion and 20 percent with severely decreased range of motion. They also showed at seven years postoperatively that 32 percent of the patients had mild to moderate pain with range of motion.1

   In their intermediate study of the Weil osteotomy, Beech and co-workers showed that only 39.2 percent of
the patients had total resolution of symptoms.3 Additionally, 23 of the 51 patients in the study experienced some form of complication during the postoperative course.

In Conclusion

Clearly, the Weil osteotomy provides an excellent surgical option for primary central ray pathologies but most central ray pathologies are not primary deformities. Most of these pathologies are secondary due to biomechanical abnormalities or digital deformities.

   The key to successful surgical outcomes in foot and ankle surgery hinges on addressing all levels of deformity while taking into consideration the underlying biomechanical factors. In my opinion, the Weil osteotomy does not meet these criteria for consistent usage.

   Dr. DeHeer is a Fellow of the American College of Foot and Ankle Surgeons, and is a Diplomate of the American Board of Podiatric Surgery. He is also a team podiatrist for the Indiana Pacers and the Indiana Fever. Dr. DeHeer is in private practice with various offices in Indianapolis.

   For further reading, see “How To Address Predislocation Syndrome Of Lesser MPJs” in the March 2007 issue of Podiatry Today or “How To Conquer Crossover Second Toe Syndrome” in the August 2002 issue.

   To read Dr. DeHeer’s monthly blog, visit www.podiatrytoday.com/blogs.

References

1. Hofstaetter SG, Hofstaetter JG, Petroutsas JA, Gruber F, Ritschi P, Trnka HJ. The Weil osteotomy: a seven year follow-up. J Bone Joint Surg Br 2005; 87(11):1507–1511.
2. Trnka HJ, Muhlbauer M, Zettl R, Myerson MS, Ritschl P. Comparison of the results of the Weil and Helal osteotomies for the treatment of metatarsalgia secondary to dislocation of the lesser metatarsophalangeal joints. Foot Ankle Int 1999; 20(2):72–79.
3. Beech I, Rees S, Tagoe M. A retrospective review of the Weil metatarsal osteotomy for lesser metatarsal deformities: An intermediate follow-up analysis. J Foot Ankle Surg 2005; 44(5):358-364.
4. Migues A, Slullitel G, Bilbao F, Carrasco M, Solari G. Floating-toe deformity as a complication of the Weil osteotomy. Foot Ankle Int 2004; 25(9):609–613.
5. O’Kane C, Kilmartin TE. The surgical management of central metatarsalgia. Foot Ankle Int 2002; 23(5):415–419.
6. Vandeputte G, Dereymaeker G, Steenwerckx A, Peeraer L. The Weil osteotomy of the lesser metatarsals: a clinical and pedobarographic follow up. Foot Ankle Int 2000; 21(5): 370–374.
7. Perez HR, Reber LK, Christensen JC. The role of passive plantarflexion in floating toes following Weil osteotomy. J Foot Ankle Surg 2008; 47(6):520-526.
8. Trnka HJ, Gebhard C, Muhlbauer M, Ivanic G, Ritschl P. The Weil osteotomy for treatment of dislocated lesser metatarsophalangeal joints: good outcome in 21 patients with 42 osteotomies. Acta Orthop Scand 2002; 73(2):190-4.

Additional References

9. Trnka HJ, Nyska M, Parks BG, Myerson MS. Dorsiflexion contracture after Weil osteotomy: results of cadaver study and three-dimensional analysis. Foot Ankle Int 2001; 22(1): 47–50.

No.

This author cites the advantages of the Weil metatarsal osteotomy for addressing metatarsal overload, offers key intraoperative pearls and provides insights on how to minimize potential complications.

By Lowell Weil Jr., DPM, MBA, FACFAS

Problems in the ball of the foot, base of the lesser toes or metatarsophalangeal joints (MPJ) are known by many names. Metatarsalgia, metatarsal deformity, plantarflexed metatarsal, subluxed metatarsal, pre-dislocation syndrome and plantar plate pathology are some terms that physicians commonly use. While these different names have subtly different meanings, they all have common underlying issues. Some mechanical or physiologic force is causing stress to this area, resulting in pain. Usually, metatarsal overload is the underlying problem associated with all of the above terms.

   There are several causes of metatarsal overload. Biomechanical overload, the most common, falls into two categories: static phase overload and propulsive phase overload.
Static phase overload is when a particular metatarsal or several metatarsals are positioned more plantarly in comparison to adjacent metatarsals. This positioning causes increased pressure to the metatarsal(s) when standing. Ground reactive forces against the prominent metatarsal cause friction and pain to the particular metatarsal(s). This is often characterized by heavy callus formation to the plantar skin surface of the prominent metatarsal(s).

   Propulsive phase metatarsal overload occurs when a metatarsal or group of metatarsals are longer than adjacent metatarsals in comparison to the pathologic foot or, in some cases, in comparison to the contralateral foot. Subtle length differences are exploited when a person is going through the propulsive phase of gait and weightbearing is transitioning from the plantar aspect of the metatarsal heads to the toes for toe off.

   As that mechanism occurs, the MPJ dorsiflexes and all pressures go through the head and articular surface of the metatarsals. If one or more of the metatarsals are elongated in relative comparison, then there will be excessive force and time of force on that metatarsal head. The action is comparable to a pole vault with the long metatarsal or metatarsals “pole vaulting” through propulsion, causing excessive force and pressure.

   Another type of biomechanical metatarsal overload is iatrogenic. This occurs when an adjacent metatarsal has shortened as a result of surgical procedures to adjacent metatarsals. This can also be known as transfer metatarsal overload. It often occurs when a patient has undergone surgery on the first ray that has resulted in shortening of the first metatarsal or first ray, which causes increased pressure to the lateral metatarsal(s). It can also occur following first MPJ surgery that causes reduced plantarflexion of the first MPJ.

   Holmes showed through computerized gait analysis that through ambulation, the hallux gets the most forefoot pressure, followed by the second metatarsal head and then the first metatarsal head.1 When the first toe is unable to participate as fully in the stabilization of the forefoot during gait, the forces transfer to the second metatarsal head. This transfer is often associated with a cascade of problems to the lateral metatarsal heads and particularly the second metatarsal head.

Keys To Diagnosing Metatarsal Overload

One must consider a variety of factors in diagnosing these problems. Patients can present with pain to the ball of the foot, pain to the adjacent toe(s), progressive positional changes, such as medial or lateral deviation of the toe, as well as contracture of the toe at the MPJ or proximal interphalangeal joint (PIPJ). There may be swelling to the affected MPJ, more often plantarly. Patients can complain of subtle numbness into the toes, which is probably a result of positional abnormalities or swelling.

   Activities often exacerbate pain. Non-supportive shoes and going barefoot often increase the pain. Pain is often localized at the plantar or distal aspect of the metatarsal head.

   A plantar positioned metatarsal will often have a callus lesion but an elongated metatarsal usually does not. Long metatarsals may also put excessive pressure on the plantar plate, causing irritation, attenuation, tears or rupture. One can assess this by attempting a “drawer maneuver,” in which one stabilizes the metatarsal and moves the proximal phalanx dorsally, putting stress on the plantar plate. A positive test will be that the patient has pain and/or slippage of the joint with the maneuver in comparison to the non-symptomatic metatarsal.

   Often physicians confuse these diagnoses with neuromas, especially in the propulsive phase, metatarsal overload group. With the absence of plantar lesions and common subtle numbness and pain more distally, a false neuroma diagnosis is common. However, careful differentiation and localization of the pain from the distal metatarsal head to the very close proximity interspace can define the difference.

   Bilateral weightbearing radiographs are very important. One will usually appreciate a subtle or not so subtle metatarsal length pattern problem. The length pattern problem may involve one or more of the central metatarsals being long in comparison to adjacent metatarsals of the symptomatic foot. Alternately, there may be a subtle length difference between the symptomatic foot in comparison to the asymptomatic foot. This difference could be as little as 1 to 2 mm but that will be enough to create the underlying problems.

   Further studies such as diagnostic ultrasound or magnetic resonance imaging (MRI) can help one understand if there is any swelling to the joint or bone, articular changes to the MPJ or plantar plate involvement. It has been my experience that the finding of neuroma on these studies does not determine that underlying problems are associated with nerve problems. Computerized footprint analysis can also be helpful to determine metatarsal overload through the ambulatory cycle but the technology is not readily available to many practitioners.

Pertinent Insights On Current Treatment Options

One can conservatively manage metatarsal overload without significant plantar plate involvement in 80 percent of patients. This occurs with some combination of shoe gear modifications (stiffer soled shoes, metatarsal bars, rocker bottom sole), custom or non-custom inserts with metatarsal accommodations (metatarsal pads, metatarsal bars, horseshoe pads), strapping and stabilization of the MPJ, anti-inflammatory medications, icing and activity modifications.

   We do not believe cortisone injections play a role in this problem except in very isolated and specific situations. In the last 10 years, we have accumulated over 100 cases of MPJ dislocation that occurred within six months of a cortisone injection with underlying metatarsal overload. While the cortisone injection may give immediate relief from symptoms, the risk of dislocation is too high for this to be considered a beneficial treatment.

   Over the years, studies have described dozens of surgical procedures to treat painful metatarsal problems. To treat metatarsal overload problems, surgeons have used partial or complete metatarsal arthroplasty, plantar condylectomy, minimal incision osteotomy, a vast array of shortening and elevating procedures, implants and soft tissue repairs such as plantar plate repair.2-4

   Unfortunately, these procedures come with a high rate of failure, transfer metatarsal overload, prolonged recovery and recurrence. The literature shows that the historic bony procedures have a transfer metatarsalgia rate of 18 to 60 percent.5 Furthermore, isolated plantar plate repair in a metatarsal overload situation would be like repairing a pathologic posterior tibial tendon in flatfoot without doing any corrective procedures to address the flatfoot. The recovery might be easier and the pain might go away for a while, but the problem will recur.

Assessing The Advantages Of The Weil Osteotomy

The Weil metatarsal osteotomy (WMO) was designed to predictably, accurately and reproducibly realign an elongated or plantarly positioned painful metatarsal. The configuration of the WMO allows for precise shortening of metatarsal(s) with stable fixation without changing the pressure to the plantar metatarsal head. This significantly decreases the chance of transfer metatarsalgia.

   The surgeon should configure the osteotomy in such a way where he or she makes the distal cut in the dorsal articular surface of the metatarsal head. By starting the osteotomy at this critical area, the surgeon can configure the osteotomy virtually parallel to the weightbearing surface. This ensures shortening will not cause plantarization of the metatarsal. Additionally, one should perform the osteotomy in the dense cancellous bone as doing so enhances stability for early mobilization and healing. The length and angle of the cut also allows for ease of fixation. Typically, we fixate the metatarsal with a single 2.4 mm threaded head screw.

   By starting the osteotomy proximal to the articular metatarsal surface (not a Weil osteotomy), one will have to create the cut at an angle that will frequently cause plantar displacement of the capital fragment with shortening. This non-Weil osteotomy will also cause less stability since it occurs within the less stable corticomedullary bone and fixation is more difficult to achieve.

   On the occasion that one is correcting a dislocation or when there is an unusual need for shortening of more than 3 mm, the surgeon needs to make an additional parallel cut in order to elevate the metatarsal head. The angle of the WMO prevents plantarization of the capital fragment when shortening is less than 3 mm. However, as the shortening passes 3 mm, there is some plantarization that one must avoid.

   When there is concomitant plantar plate pathology or dislocation, my facility has developed a technique whereby the surgeon can repair the plantar plate from a dorsal approach concurrently with the WMO. I reported this technique and the first two years of results at the 2010 American College of Foot and Ankle Surgeons Annual Scientific Conference.6

Essential Tips On Postoperative Management

Postoperatively, patients with Weil osteotomies wear bandages in slight plantarflexion of the MPJ and wear a surgical shoe for one week. After one week, we remove all bandages and patients wear an AFTR Brace (Bioskin). The AFTR Brace creates forefoot compression and has specially designed “Weil osteotomy, exercise and stabilization straps” that can function as a night splint, which holds the toe in slight plantarflexion.

   Additionally, the patient begins to wear an athletic shoe and begins physical therapy with an emphasis on plantarflexion of the MPJ and weightbearing to tolerance. The Weil osteotomy exercise strap also helps in the rehabilitation as patients use the straps for resistance strengthening of the MPJ (plantarflexion and dorsiflexion). Patients may immediately bear weight to tolerance with no vigorous physical activity on their feet until six weeks postoperatively.

Reducing The Risk Of The ‘Floating Toe’ Complication

We have closely followed the results of the Weil osteotomy and have presented these results nationally and internationally on multiple occasions. There has been a resolution of symptoms in 96 percent of those who have undergone the osteotomy. We have seen a transfer metatarsal overload of 5 percent.

   In our initial studies, we evaluated a “floating toe” in 18 percent of patients. Many studies have reported this complication.7,8 However, with many modifications to the procedure over the years, we have gotten that down to under 10 percent.

   We believe the critical aspects to prevent this complication are:
   • proper angle of the cut to prevent plantarization;
   • shortening of less than 3 mm in standard WMO;
   • removal of parallel piece in cases of shortening more than 3 mm;
   • incorporating a dorsal approach plantar plate repair in any patient who has suspicion of plantar plate pathology;
   • aggressive postoperative physical therapy to encourage plantarflexion of the MPJ; and
   • utilization of braces and splints like the AFTR Brace.

Final Words

Metatarsal problems are among the most common complaints for patients presenting at a foot and ankle practice. Accurate diagnosis of the underlying etiology of the pathology is paramount to the success of treatment. While a high majority of patients with these problems will receive successful treatment with non-operative care, predictable surgical alternatives must be available for those who fail.

   The Weil metatarsal osteotomy is a reproducible, accurate and predictable surgical procedure to address painful metatarsal overload and plantar plate pathology. The procedure is relatively easy to perform with simple, stable fixation and a quick return to closed shoes and activities of daily life. With proper surgical technique and aggressive postoperative course, one can substantially reduce reported complications.

   Dr. Weil is the President of the International Society of Medical Shock Wave Therapy (www.ismst.com). He is the first podiatric physician to hold this office. He is also the Fellowship Director of the Weil Foot and Ankle Institute in Des Plaines, Ill.

References

1. Holmes GB, Timmerman L. A quantitative assessment of the effects of metatarsal pads on plantar pressures. Foot Ankle 1990; 11(3):141-145.
2. Buxbaum FD. Surgical correction of metatarsophalangeal joint dislocation and arthritic deformity: the partial head and plantar condylectomy. J Foot Surg. 1979 Spring;18(1):36-40.
3. White DL. Minimal incision approach to osteotomies of the lesser metatarsals. For treatment of intractable keratosis, metatarsalgia, and tailor's bunion. Clin Podiatr Med Surg. 1991 Jan;8(1):25-39.
4. Flamme CH, Wülker N, Kuckerts K, Rühmann O. Long-term outcome of arthroplasty of the first metatarsophalangeal joint. Z Orthop Ihre Grenzgeb. 1998 May-Jun;136(3):250-4.
5. Derner R, Meyr AJ. Complications and salvage of elective central metatarsal osteotomies. Clin Podiatr Med Surg. 2009 Jan;26(1):23-35.
6. Weil L Jr., Weil L Sr., Malinoski K. Correction of 2nd MTP instability utilizing a Weil osteotomy and dorsal approach plantar plate repair – a new technique and early results. Poster exhibition at American College of Foot and Ankle Surgeons Annual Scientific Conference, Las Vegas, 2010. Submitted for publication.
7. Migues A, Slullitel G, Bilbao F, Carrasco M, Solari G. Floating-toe deformity as a complication of the Weil osteotomy. Foot Ankle Int 2004; 25(9):609–613.
8. Perez HR, Reber LK, Christensen JC. The role of passive plantarflexion in floating toes following Weil osteotomy. J Foot Ankle Surg 2008; 47(6):520-526.

   For further reading, see “Restoring The Metatarsal Parabola With The Weil Osteotomy” in the July 2002 issue of Podiatry Today, “Essential Insights On Hallux Valgus” in the March 2005 issue or “Emerging Concepts In Treating Second Crossover Toe Deformity” in the October 2009 issue.