Restoring The Metatarsal Parabola With The Weil Osteotomy

By Thomas Cusumano, DPM

Metatarsalgia may develop from osseous, neurological, vascular or dermal etiologies. The causes are numerous and commonly involve a cavus foot structure, a long second metatarsal, short first metatarsal, hypermobile first ray, iatrogenic pain from forefoot surgery or manifest from a rheumatology-induced systemic disease. When symptoms persist, you may see callus lesions develop under the affected metatarsal. Keep in mind that these lesions can lead to stress fractures and compensation-induced pains in the lower extremity and back.
Conservative treatments range from pressure-reducing pads with foot strapping to oral antiinflammatory medications. When conservative modalities have been exhausted, you may consider over 20 surgical techniques, ranging from condylectomies to oblique osteotomies at the proximal, mid-shaft or distal metatarsal levels. Of these procedures, the Weil osteotomy has gained popularity, based upon the simple technique and stable fixation.1,2
Controversy exists involving floating versus fixated osteotomies. The benefit of employing rigid internal fixation is it allows you to control surgical positioning of the osteotomy. Indeed, rigid internal fixation with the Weil osteotomy should be strongly encouraged when multiple osteotomies to the metatarsals are necessary.

Key Diagnostic Considerations
When the patient has localized pain at the plantar aspect of the second MPJ, a structural etiology may be present. Intensity of the pain may vary from a dull ache or throbbing sensation to a debilitating pain. He or she may experience the symptoms during increased physical activity or (more commonly) with normal daily activities. Keep in mind that chronic second metatarsal pain is a problem seen in a wide spectrum of patients. It may occur in the workplace or it could affect a recreational walker or athlete.
A disrupted metatarsal parabola from a long metatarsal will show a characteristic callus lesion. A Morton’s foot has a short first metatarsal and will cause a pressure overload at the second metatarsal. An elongated or plantarflexed second metatarsal will have similar presenting symptoms. Pain around the plantar aspect of the second MPJ develops from chronic pressure and inflammation, resulting from the weightbearing forces of the long second metatarsal relative to the adjacent metatarsals and the nucleated callus.
As noted above, when conservative therapy fails, proceed to consider surgical options based upon the clinical and structural presentation of the foot. Proper diagnosis of all present osseous deformities is essential. You must evaluate concomitant deformities, such as a hammertoe contracture, hallux valgus and hypermobility. Neglecting these combined deformities in the surgical arena increases the risk of a poor result with reoccurrence, transfer callus lesions, persistent pain and iatrogenically induced deformities that can be more difficult to treat than the initial problem.

Assessing The Radiographic Findings
To evaluate the bone structure, you need to compare the second metatarsal to the adjacent metatarsals, along with evaluating the patient’s foot type. In order to rule out the need for a joint replacement implant arthroplasty procedure, be sure to evaluate osteoarthritic changes to the forefoot. You may discover cortical hypertrophy, stress fractures or a bone lesion, which you should treat with the standard method of care.

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