How To Correctly Perform A Weil Osteotomy

The Weil osteotomy has become one of the most commonly performed surgeries on the foot in the world. Lowell Weil Sr., DPM, started performing a distal oblique metatarsal osteotomy in 1984 to treat intractable metatarsalgia.

The procedures that surgeons commonly performed at that time for this problem had high complication rates associated with them, most notably transfer metatarsalgia. Some studies suggested that the transfer metatarsalgia rate were as high as 50 percent for the procedures performed at that time.¹ The concepts of the distal oblique osteotomy that Dr. Weil performed were to shorten an elongated metatarsal accurately without creating elevation while easily being able to fixate the osteotomy. This would prevent transfer metatarsalgia. 

In 1990, Louis Samuel Barouk, MD, of Bordeaux, France visited Lowell Weil Sr. to learn some of his surgical procedures. Dr. Barouk applied many of these techniques to his practice and patients. His results were so favorable that he started holding surgical skills courses at his hospital to teach other European surgeons these procedures. Dr. Barouk named the procedure “the Weil osteotomy.”

Dr. Barouk went on to hold many courses in France with international surgeons in attendance and the Weil osteotomy gained popularity in Europe and around the world. Dr. Barouk has also published extensively on the Weil osteotomy with his greatest work being his textbook on foot surgery, which has gone into multiple editions and is a must for any surgical library with terrific illustrations and rationale.²

For years, I have seen people present on the Weil osteotomy at conferences in the United States as well as internationally. I have also been a part of cadaver trainings with industry and fellows of the American College of Foot and Ankle Surgeons teaching the Weil osteotomy. It has always surprised me that so many people present, teach or have learned the osteotomy incorrectly.

This was especially clear during the recent American Academy of Orthopaedic Surgeons Annual Meeting in Orlando, Fla. Two members of the Weil Foot and Ankle Institute, Erin Klein, DPM, MS, and Adam Fleischer, DPM, MPH, presented their research at this international conference, which also attracts over 30,000 attendees. During specialty day when disciplines split into lecture halls for their specialty only, there was a session of metatarsal and forefoot pathology with several presentations on the Weil osteotomy and plantar plate repair. Among those presenting was Judith Baumhauer, MD, who panned the Weil osteotomy and even quoted a Podiatry Today DPM Blog on why surgeons wrongly utilized the osteotomy.³ While others including Tim Daniels, MD, FRCSC refuted her statements, there remained an interesting controversy. As many before her, Dr. Baumhauer did not perform the osteotomy to its original specifications and ran into trouble as a result.

The indications for the Weil osteotomy are painful metatarsalgia originating from an elongated (most common) or plantarflexed metatarsal that has failed to respond to conservative care.

The surgeon makes a dorsal linear incision over the affected metatarsophalangeal joint. Make a linear incision to the side of the extensor tendons or between the extensor digitorum longus and brevis. Plantarflex the toe and expose the metatarsal head. Start an osteotomy in the dorsal articular surface of the metatarsal head and angulate it as parallel to the weightbearing surface as possible to create a long minimally angulated cut. By performing the osteotomy in this manner, one can shorten the metatarsal head with minimal plantar displacement. The usual amount of shortening rarely exceeds 2 to 3 mm.

If you start the osteotomy proximal to the metatarsal head, you will be forced to angulate the osteotomy in such a manner that results in plantar displacement of the metatarsal head as it shortens.This may cause plantar pain or a floating toe because the intrinsic muscles have been turned into dorsiflexors.

No matter the angle of the cut, if more than 3 mm of shortening occurs, the metatarsal head will become plantarly displaced, resulting in the same aforementioned problems. If more than 3 mm of shortening is necessary, then one must make a second parallel cut to elevate the metatarsal.

Should the surgeon desire no shortening but simply elevation, he or she can utilize a dorsally based wedge, leaving the plantar cortex intact to elevate the metatarsal head.

One can fixate the osteotomy with one or two threaded K-wires cut at the level of bone or through the use of one or two small screws (snap-off or otherwise).

Postoperative care depends on the concomitant procedures performed but usually is associated with bunion correction. Our standard postoperative protocol includes a bandage, surgical shoe and minimal weightbearing to tolerance for one week. At one week postoperative, patients return to athletic shoes and start physical therapy with an emphasis on plantarflexion of the metatarsophalangeal joint. Advise patients as to progressive weightbearing over the ensuing six weeks. Most patients return to normal stylish shoes at that time. Physical therapy continues for four to six weeks after they return to normal shoes or after surgery. Full recovery takes four to six months.

Many studies worldwide have proven the utility of the Weil osteotomy.^4,5 Performing the procedure properly can eliminate many of the problems that are commonly associated with the procedure. 

Next time that you are considering forefoot pain and surgical intervention, think about which procedure you can perform with minimal complications and early weightbearing.

I would encourage anyone who is trying to master forefoot surgery to take some time and read Barouk’s textbook. You won’t be sorry.

References

1. Derner R, Meyr AJ. Complications and salvage of elective central metatarsal osteotomies. Clin Podiatr Med Surg. 2009;26(1):23-35

2. Barouk LS. Forefoot Reconstruction. Springer-Verlag, Paris, First Edition, 2003, pp. 115-38.

3. DeHeer P. Are you taking the easy way out with the Weil osteotomy? Podiatry Today DPM Blog. Available at https://www.podiatrytoday.com/blogged/are-you-taking-easy-way-out-weil-osteotomy . Published Sept. 18, 2012. Accessed March 30, 2016.

4. Henry J, Besse JL, Fessy MH. Distal osteotomy of the lateral metatarsals: a series of 72 cases comparing the Weil osteotomy and the DMMO percutaneous osteotomy. Orthop Traumatol Surg Res. 2011; 97(6 Suppl):S57-65.

5. Khurana A, Kadamabande S, James S, Tanaka H, Hariharan K. Weil osteotomy: assessment of medium term results and predictive factors in recurrent metatarsalgia. Foot Ankle Surg. 2011; 17(3):150-7.