Is The Weil Osteotomy Overused By DPMs?
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.