Are You Taking The Easy Way Out With The Weil Osteotomy?

Patrick DeHeer DPM FACFAS

There are a few procedures in our podiatric arsenal that we tend to overuse. I find the procedural volume of the Weil osteotomy particularly perplexing. I do not understand any central ray elevation or shortening osteotomy either.

In most cases, I cannot help but judge the Weil osteotomy as a wimpy solution to a more complex problem.

Do I perform the Weil osteotomy? I do use this procedure reluctantly on rare occasions.
Of all the central ray osteotomies, the Weil osteotomy is clearly the best in my opinion from a technical approach. If a metatarsal is truly pathologic (elongated), then choosing a Weil osteotomy is excellent. This is rare and those of you who think otherwise may want to go back and look over the metatarsal parabola relationship.

What about the “plantarflexed metatarsal"? This is even more rare. It is almost always a secondary deformity. Most of the time a hammer digit deformity is producing a retrograde force onto the metatarsal head, thereby plantarflexing it. The other scenario would be an adjacent hypermobility or elevated ray from prior surgery or injury causing increased loading of the proposed plantarflexed metatarsal. The reality of the “plantarflexed metatarsal” is that it is a perfectly normal bone. There is no pathology associated with the proposed bone to be shortened or elevated.

How often in any type of foot or ankle surgery do we operate on a normal bone? Never. Why operate on a non-pathologic bone? The non-pathologic bone is probably asking the same thing. So why do we operate on normal second metatarsals for predislocation syndrome when the second metatarsal is perfectly normal? Simple. It is easier for the surgeon from a technical standpoint and the patient from a healing standpoint. This is a win-win situation, right? Unfortunately, the long-term sequelae of this procedure or the well-documented complications would argue otherwise.

Regardless of the central ray pathology, the key to long-term success is to address the apex of the deformity or the underlying etiology. If there is a hammertoe plantarflexing the metatarsal head, it is much easier for everyone involved to fix the hammertoe.

The moment of indecision in the foot and ankle surgeon’s head occurs when there is a hyperkeratotic lesion beneath the said metatarsal head. Do you trust the hammertoe reduction to relieve the plantigrade pressure on the metatarsal head or do you also shorten/raise the metatarsal? If you fix the hammertoe correctly, trust it and leave the normal metatarsal alone. Your patient will thank you down the line.

What about the pesky predislocation syndrome of the second metatarsophalangeal joint? Most often, you must address two things: the hypermobility of the first ray and the equinus that led the hypermobility. First metatarsal cuneiform arthrodesis, gastrocnemius recession and a second digit realignment are the answers for a comprehensive approach to addressing the apex of the pathology and the resultant symptoms and secondary deformities. The second metatarsal is just fine where it is. Please leave it alone.

At alarmingly high rates, practitioners have documented a lack of toe purchase, stiffness of the metatarsophalangeal joint, arthritic changes, transfer metatarsalagia or lesions as complications with the Weil procedure.1-5

Why is the Weil osteotomy so popular? It is the path of least resistance. It is a much easier approach most of the time rather than doing what really should be done. What is my suggestion? Do what should be done or just have your patient get some new shoes.
Best wishes and stay diligent.

References
1. Highlander P, VonHerbulis E, Gonzalez A, Britt J, Buchman J. Complications of the Weil osteotomy. Foot Ankle Spec. 2011; 4(3):165-70.
2. 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):609-13.
3. Snyder J, Owen J, Wayne J, Adelaar R. Plantar pressure and load in cadaver feet after a Weil or chevron osteotomy. Foot Ankle Int. 2005; 26(2):158-65.
4. Podskubka A, Stĕdrý V, Kafunĕk M. [Distal shortening osteotomy of the metatarsals using the Weil technique: surgical treatment of metatarsalgia and dislocation of the metatarsophalangeal joint]. Acta Chir Orthop Traumatol Cech. 2002;69(2):79-84. Czech.
5. 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):358-64.

Comments

While I do think you cannot address a complex problem which is multifactorial with one procedure, I do think if you look in Europe, you will find they operate on "normal" bone all of the time. Barouk in particular and also Ronconi advocate making the parabola normal. This is based on data and physics. They will often perform osteotomies on all the metatarsals, even if the symptom is only on the 2nd ray.

I agree the Weil osteotomy, when used in isolation, is probably over utilized but I think it is better to have a toe that does not purchase than a painful one when walking. One must address all of the biomechanical issues of the patient. Looking at equinus is very important in this regard.

Hi Peter,

Thank you for your comments but honestly, just because they do it in Europe does not mean anything.

I still do not think operating on a normal bone makes any sense. As far as having a painful toe vs. a non-painful floating toe, why does it have to be one or the other? What I am saying is the metatarsal is a secondary deformity and by addressing the primary deformity, the pain should be resolved. Why does shortening a normal bone to treat the symptoms instead of fixing the true etiology make sense?

Best Wishes,

Patrick A. DeHeer, DPM

I love the valuable info you supply in your posts. I like your writing style.

Thank you Wesley. It is great to hear some feedback. Best wishes.

Patrick

Patrick,

I read your article with interest. The very fact that the Weil osteotomy is so commonly performed would speak at the usefulness of the procedure. The problem is not the over-utilization of one specific procedure, it is the basis of practice on anecdotal reports and opinion.

Certainly, years of practice and training can help to form a surgeon's procedural selections and what works best in his or hands. However, to say the Weil metatarsal osteotomy is a "wimpy solution" is to ignore the numerous studies that have been published supporting its usefulness and fairly high success rate. One could argue that the Lapidus and gastrocnemius recession are overutilized. How may factory practices exist in our profession where everyone with a bunion ends up with a Lapidus and gastroc recession? Does hypermobility of the first ray really exist? How long does any plantar pressure relief after a gastrocnemius recession actually last?

A properly performed Weil osteotomy can be a a very beneficial procedure. True MP joint pathology needs to be addressed at the MP joint. A discussion of the lesser MP joint is beyond the extent of my rebuttal. The metatarsal parabola certainly can have something to do with it. Also, European studies cannot be ignored as Maestro et al., through systematic analysis of "normal population" weightbearing foot radiographs, have helped to establish what truly is a "normal parabola." The Maestro criteria is a well followed measurement in European forefoot foot and ankle surgery.

There are usually more than two roads that lead to the same destination. Certainly in your hands, your techniques have been useful. However, the Weil osteotomy has well supported outcomes confirming its utilization in foot and ankle surgery.

If toe purchase is a problem, it is easily corrected by stacking two saw blades when performing the osteotomy so one can prevent plantarflexion of the head when it slides proximal.

Furthermore, any Weil osteotomy can be performed in combination with a plantar plate reefing or repair which tightens the joint capsule on the proximal phalanx and also prevents the floating toe.

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