CHAPTER 3

INDICATIONS AND TECHNIQUE OF THE

WEIL OSTEOTOMY

Richard J. Zirm, DPM

INTRODUCTION metatarsal head. The shortening and transverse plane

position can be carefully controlled intra-operatively. A
The Weil osteotomy has become a popular technique for mini-C arm may be employed to check the position of the
the surgical treatment of resistant lesser metatarsalgia. capital fragment in surgery. The osteotomy is usually
Metatarsalgia is a vague, catch-all term that represents stabilized with a solitary screw driven from dorsal to
tenderness and pain in the plantar forefoot. Metatarsalgia plantar in the metatarsal head. The advantage to this
can develop from osseous, soft tissue, neurologic, vascular, osteotomy is the decompression of the metatarsopha-
or dermal etiologies. It is a somewhat common presenting langeal joint and the resultant relaxation of the
complaint that can interfere with normal ambulation, surrounding soft tissues. Generally the osteotomy is most
work, fitness, and recreation. often used on the second metatarsal. However, the same
Physical evaluation of the patient can determine the
underlying etiology. Metatarsalgia can be subdivided into
primary versus secondary causes as well as structural versus Table 1
functional causes (Table 1). A different combination of these
underlying factors can characterize symptoms that occur CAUSES OF METATARSALGIA
during the stance phase of gait versus the propulsive phase.
The surgical treatment of metatarsalgia has been Primary
somewhat controversial. Ideally, conservative treatment Plantar soft tissue lesions
should be exhausted before surgical options are considered. Abnormal metatarsal parabola
To date, more than 25 different lesser metatarsal Mortons foot
osteotomies have been described. Weil described an Neuroma
osteotomy made parallel to the weightbearing surface, then Trauma
sliding the metatarsal head proximally, thus providing axial Brachymetatarsia
decompression. The Weil osteotomy has recently gained in Bone Tumors
popularity based upon the simple technique, stable fixation, Secondary
excellent union rates, and predictable results. Iatrogenic
Indications for the Weil osteotomy have been extended First ray shortening
to include a relative long or plantarflexed metatarsal(s), Metatarsal head resection
transverse plane deformities of the metatarsophalangeal Neurogenic
joint, subluxation/dislocation of the metatarsophalangeal Referred pain
(MTP) joint, crossover toe deformity, correction of a Tarsal tunnel syndrome
rheumatologic deformity at the MTP joint and generalized Osteoarthritis
recalcitrant metatarsalgia, which is refractory to Rheumatoid arthritis
conservative care (Figures 1-5). Atrophied plantar fat pad
The overall physical examination must include the Stress fracture
evaluation of concomitant deformities such as hammertoe Capsulitis/bursitis/tedinitis
contractures, hallux valgus, and hypermobility of the first Friebergs infraction
ray. If these deformities are present, they must be surgi- Foot structure and function
cally addressed as well. Pes cavus
The Weil osteotomy has replaced a number of Pes planus
preceeding osteotomies by its ability to shorten the Inappropriate shoegear
metatarsal head without elevation or depression of the
10 CHAPTER 3

considerations including length patterns, transverse plane proximal interphalangeal joint contracture and a floppy
deformities, subluxations, and intractable plantar skin toe. The relaxed tension of the plantar fascial insertion at
lesions sometime merit the osteotomy to be preformed on the base of the proximal phalangeal base may produce a
the third and fourth metatarsal. floating toe. Long or prominent plantar fixation can also
Possible complications of the Weil osteotomy include cause postoperative pain and stiffness and needs to be
a dorsiflexed, nonpurchasing toe, pain on MTP joint removed once the osteotomy is healed.
dorsiflexion, reduced MTP joint range of motion,

Figure 1. Preoperative and postoperative view of a Figure 2. Preoperative and postoperative view of a
long second metatarasal. shortened first ray.

Figure 3. Preoperative and postoperative view of Figure 4. Preoperative and postoperative view of
hallux varus. hallux abducto valgus with second ray adductus.
 CHAPTER 3 11

osteotomy may vary according to the angle of the

metatarsal declination. The angle of the osteotomy must
increase toward the more lateral metatasals because they
are less plantarflexed than the second metatarsal.
In severely plantarflexed metarsals, a second osteotomy
is performed in effect to remove a slice of bone to further
dorsiflex the capital fragment. An easier, more stable tip is
to use a double saw blade or a thicker saw blade to obtain the
same goal of removing more bone to dorsally elevate the
metatarsal head.
When the osteotomy is completed, the metatarsal head
will suddenly shift to a more proximal position. There is a
certain neutral position that reflects the relaxation of the
surrounding soft tissues that feels just right. Then with
manual pressure, a solitary K-wire or bone clamp is used to
temporarily fixate the osteotomy. The position can be
Figure 5. Preoperative and postoperative view of checked by fluoroscopy at this time. The metatarsal head
digital adductus. position can be changed from 2- to 10-mm with 3- to
5-mm being the normal amount of shortening.
The osteotomy can be slightly angulated in the frontal
plane if more dorsal excursion is desired. The head can also
TECHNIQUE TIPS AND PEARLS be rotated and translocated somewhat in more difficult
transverse or crossover toe cases. However, too much
A 3.5- to 4.0-cm linear incision is made over the distal manipulation of the osteotomy or displacement of capital
third of the lesser metatarsal ending at the base of the fragment can sacrifice the overall stability of the construct.
proximal phalanx. This will reduce the chance of scar for- Do not be too extreme. A standard parallel Weil osteotomy,
mation that can contribute postoperative dorsal contrac- without any geometric modifications has been found to be
ture. If digital work is done at the same time, a lazy-S successful in treating most forefoot malalignments.
incision is made over the MTP joint as the incision ends A solitary screw driven from proximal dorsal to distal
dorsally over the middle phalanx. plantar into the metatarsal head is usually sufficient. There
The extensor tendons are then retracted laterally and are a multitude of different screws that can be used for this
the dorsal periosteum and capsule are incised with the toe purpose including the twist-off screw by Depuy. I prefer the
dorsiflexed to protect the articular cartilage. The collateral Synthes modular hand set screws. These are noncannulated
ligaments are partially incised to fully expose the metatarsal with a smaller head that is not prominent. They have
head. They do not need to be completely resected. Next, excellent purchase due to the increased thread excursion,
a McGlamry elevator may be used to release the plantar and they can be minimally tapped as they will self tap once
plate adhesions at the joint especially in the case of a started into the capital fragment.
significant contracture. The McGlamry elevator strips the The one consensus regarding screws is that a 12-mm
plantar synovial attachments (vincula), allowing the screw will fit in the vast majority of adult metatarsals
plantar plate to shift more proximally with the osteotomy. without penetrating the plantar metatarsal head. This
There is rarely vascular compromise to the capital fragment obviates the need to measure the pilot hole. I usually use
and avascular necrosis of the head is extremely rare. a 2.0-mm screw in most adults for fixation of the Weil
The McGlamry elevator can double as a retractor for osteotomy. A 2.4-mm screw is useful in larger adults and
the ensuing osteotomy. The head should be fully visualized a 1.6-mm can be used in a very slight individual. The
before the osteotomy is made. The osteotomy is started resulting dorsal overhanging bone ledge is then resected
2-mm inferior to the most dorsal aspect of the articular with a rongeur.
cartilage at an approximately 25 angle with respect to the Postoperatively, most patients are maintained partial
metatarsal shaft. The osteotomy can be as long as 2.5- to weightbearing in an Orthowedge shoe using crutches or a
3-cm in standard foot conditions. walker to support their upper body weight. The patient can
The plane of the osteotomy is made parallel to the be transferred into a standard surgical shoe at 4 weeks with
ground as if the foot was bearing weight. The angle of the early radiographic signs of osseous healing. A severely
12 CHAPTER 3

dorsiflexed toe that is released may benefit from a 0.045 extensor tendon is lengthened in a Z-plasty fashion as are
K-wire across the MTP joint for 4 to 6 weeks. In milder all of the soft tissues that are dorsally contracted with the
cases, splinting or a Betadine splint is useful for the initial sequential release. A K-wire can be carefully passed across
three weeks. The patient should initiate rigorous sagittal the reconstructed metatarsophalangeal joint to either side
plane exercises once early bone healing has occurred. of the screw when necessary. These measures greatly
The most common reported complication is the decrease the incidence of a nonpurchasing toe.
floating toe. One theory suggests the Weil osteotomy Significantly unstable, dorsiflexed toes will require a
changes the center of rotation of the MTP joint. The concomitant flexor tendon transfer.
interosseous muscles then act more as dorsiflexors than The Weil osteotomy is an effective and safe procedure
plantarflexors contributing to a nonpurchasing toe. I for the treatment of plantar, central metatarsal symptoms
usually will perform a proximal interphalangeal joint caused by a relatively long metatarsal. Complications can be
arthrodesis in concert with a Weil osteotomy when controlled with a judicious amount of shortening of
indicated. I strive to avoid excessively shortening the toe the metatarsal while avoiding plantar depression of the
while performing the arthrodesis to preserve the stronger capital fragment. Ancillary procedures directed at correcting
plantarflexory lever arm associated with an arthrodesis. coexistent pathology must be considered in compound
The arthrodesis should be mildly flexed by bending the deformities.
K-wire after it is inserted into the toe. In addition, the long