The Foot 15 (2005) 202–205

Weil Osteotomy of lesser metatarsals for metatarsalgia:A clinical and radiological follow-up

D.K. Sharma∗, N. Roy, A. ShenolikarHuddersfield Royal Infirmary, Huddersfield, UK

Abstract

Background: Failure of conservative treatment often necessitates operative intervention for metatarsalgia. Surgical treatment for metatarsalgiaremains controversial and as many as 20 different procedures have been described in the literature for metatarsalgia.Objectives: Weil Osteotomy has gained popularity because of its simplicity and inherent stability. The aim of this study was to assess theeffectiveness of Weil Osteotomy in the treatment of lesser toes metatarsalgia.Methods: Retrospective analysis of Weil Osteotomy performed at our institute. A total of 27 patients (30 ft) underwent Weil Osteotomy formetatarsalgia of 2, 3 or 4 rays after the failure of conservative treatment. These cases were reviewed post-operatively at an average of 12months.R s nocC n planningt©

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esults: VAS improved from 7.3 pre-operatively to 2.2 post-operatively (p < 0.001). Average AOFAS score was 68.7 (25–95. There waases of non or malunion.onclusions: Weil Osteotomy is simple and stable osteotomy with predictive shortening and displacement and should be consider i

he treatment for lesser toe metatarsalgia.2005 Elsevier Ltd. All rights reserved.

eywords: Metatarsalgia; Lesser toes; Surgery; Weil Osteotomy

. Introduction

Pressure metatarsalgia is a vague term and loosely defineds a painful, persistent foot condition characterised by plantarallus formation and prominent metatarsal heads. The conser-ative treatment consists of insoles and intrinsic foot exercise,hich may relieve symptoms temporarily or permanently.

f conservative treatment fails, then operative interventions recommended. The Weil Osteotomy (Fig. 1, illustrations–3), as credited to LS Weil, by Barouk[1], is an obliqueetatarsal head osteotomy. It is being increasingly used in

linical practice for metatarsalgia, intractable planter ker-tosis and metatarsophalangeal joint dislocation[2]. The

∗ Corresponding author at: 169 Kineton Green Road, Solihull, West Mid-ands B92 7EQ, UK. Tel.: +44 1217068783, +44 7980 858038 (mobile).

E-mail address: dksharma@doctors.org.uk (D.K. Sharma).

positive attributes of Weil Osteotomy are, it is an obliosteotomy hence provide large bone to bone contactthereby reducing the chances of non union, easy to usenal fixation as in our study by twist off screw. It is simplecontrol in the transverse and longitudinal planes thus aing surgeons to do precise correction. It can also be indicin shortening of single long metatarsal to restore themal metatarsal parabola and thereby reduce excessive ppressure[3].

2. Material and methods

Patients were recalled to special clinic and assessedpendently. Patients were evaluated radiologically and ccally by the American Orthopaedic Foot and Ankle Socclinical score, VAS and patient questionnaire. The paquestionnaire was as follow

958-2592/$ – see front matter © 2005 Elsevier Ltd. All rights reserved.

oi:10.1016/j.foot.2005.07.006

D.K. Sharma et al. / The Foot 15 (2005) 202–205 203

204 D.K. Sharma et al. / The Foot 15 (2005) 202–205

Fig. 1. Illustrations: (1) showing plane of Weil Osteotomy (angularosteotomy at 30◦); (2) twist off screw fixation (floating with a Barouk screw);and (3) dorsal wedge from the proximal fragment excised and final position(the final position with excision of dorsal fragment).

3. Results

We reviewed 27 patients undergoing operation on 30 ft.Ten patients underwent additional procedure (mainly Halluxvalgus and PIP fusion) to their feet at the same time.

The Cohort consist of 24 female and 3 male, average ageof the patients was 50 years youngest 41 years and old-est 77 years old. The average duration of follow up was12

months with minimal 7 months (five patients had follow up<12 months) and maximum follow up of 22 months. AOFASand VAS scores were calculated retrospectively. AverageAOFAS score was 68.7 (25–95). VAS improved from 7.3pre-operatively to 2.2 post-operatively. Twenty-two patientscomplained of moderate to severe pain pre operatively com-pared to three patients post-operatively, all have shorteningof more than 6 mm in radiographs. Twenty-one patients hadminimal or no limitation of daily and recreational activityand 25 patients wore normal footwear and 2 had metatarsalbar as insert. Eleven patients consulted chiropodist for theirtoes problem pre-operatively compared to 5 post-operatively.Moderate MTP joint stiffness was noted in 7 toes (ROM30–75◦) and severe restriction was noted in 5 toes (<30◦movement). IP joint movement was satisfactory in 11 toes.Average shortening was 4.43 mm (2–10 mm) and averageincrease of joint space was 1.42 mm (0–5 mm). There was nocases of non or malunion or pseudoarthrosis. Callus resolvedcompletely in all except six cases. These 6 ft had developedcallosity under the adjacent metatarsal though 3 of them arepainfully symptomatic, all of them were noticed to have short-ening of more than 6 mm. Floating toes was noted in fourcases, though it was mostly asymptomatic. Positive painlessdrawer test at the MTP joint were noted in 12 toes and painfuland positive in 6 toes. 13 patients were very pleased withtheir operation, 12 partly satisfy 1 was not sure and 1 wasn ationt

4

pre-d xiona tarsalh lpfulf oft TPj ot eenp nd as thea ssiond turnct headc ifyingt dget ead.L thati cinga ntarp lamedd t onlym d. Ourfi eed

ot happy and 20 patients would recommend this opero other people with similar problem.

. Discussion

Weil Osteotomy is simple and stable osteotomy withictive shortening and displacement and avoids dorsiflet the distal fragment. It reduces the load under the metaead and also provides axial decompression which is he

or the reduction of dorsally dislocated MTP joint. Onehe complication mentions in literature is stiffness of Moint subsequent to Weil Osteotomy[4]. In response this some modification to the original technique have broposed. In a cadaveric study by Trnka et al.[5], it has beeemonstrated that metatarsal head depression occurredngular plane of Weil Osteotomy increased. This depreisplaced the axis of rotation of the joint plantarly and inan lead to stiffness at MTP joint. Melamed et al.[6] thoughthat too much plantar displacement of the metatarsalan produce transfer metatarsalgia and proposed modhe Weil Osteotomy by removing the dorsally based weo minimise plantar displacement of the metatarsal hau et al.[2] in a matched pair study have demonstrated

ncreased plantar translation of metatarsal head with plamore oblique cut did not significantly increase pla

ressure and dorsal wedge removal as proposed by Meid not unload the metatarsal head. They concluded thaetatarsal head resection unloaded the metatarsal hea

nding is similar to Lau et al. study that you do not n

D.K. Sharma et al. / The Foot 15 (2005) 202–205 205

modification of original technique to achieve good results.If there is shortening of metatarsal by more than 6 mm, itmanifest by callosity under the head of adjacent metatarsaland could lead to transfer metatarsalgia. Trnka et al.[7]had shown higher satisfaction, less incidence of recurrenceand transfer lesion in patients managed by Weil Osteotomycompared to Helal Osteotomy.

The floating toe or dosiflexion contracture observed in ourseries 7 (20%) has been similarly reported in literature[7–9].This is believed to be due to change in the axis of motion of theMTP joint as a consequence of depression of the metatarsalhead. This in turn causes interossei to become dorsiflexorsrather than stabilising planter flexors[5].

The weakness of present study are that it is retrospectivestudy and has short follow up of only 12 months. We needlonger follow up to determine its pros and cons in the surgicalmanagement of metatarsalgia.

5. Conclusion

Short term results in our study showed good pain relief andpatient satisfaction. Patients should be warned about chancesof stiffness in MTP and IP joint post-operatively though itdoes not cause significant disability as in our series. Cau-tion should be exercised specially in cases of short adjacent

metatarsal and avoid excessive shortening to reduce chancesof transfer metatarsalgia.

References

[1] Barouk LS. Weil’s metatarsal osteotomy in the treatment of meta-tarsalgia. Orthopade 1996;25:338–44.

[2] Lau JTC, Stamatis ED, Parks BG, Schon LC. Modifications of theWeil Osteotomy have no effect on plantar pressure. Clin Orthop RelRes 2004;421:194–8.

[3] Kilmartin TE. Digital metatarsal osteotomies: a review of surgi-cal techniques designed to avoid non-union and minimize transfermetatarsalgia. Foot 1998;8:186–92.

[4] Vandeputte G, Dereymaeker G, Steenwercks A, Peeraer L. The WeilOsteotomy of the lesser metatarsals. Foot Ankle Int 2000;21:370–4.

[5] Trnka HJ, Nyska M, Parks BG, Myerson MS. Dorsiflexion contrac-ture after the Weil Osteotomy: results of cadaver study and threedimensional analysis. Foot Ankle Int 2001;22:47–50.

[6] Melamed EA, Schon LC, Myserson MS, Parks BG. Two modificationsof the Weil Osteotomy: analysis on saw bone models. Foot Ankle Int2002;23:400–5.

[7] Trnka HJ, Muhlbauer M, Zettl R, Myerson MS, Ritschl P. Compari-son of the results of the Weil and Helal Osteotomy for the treatmentof metatarsalgia secondary to the dislocation of lesser metatarsopha-langeal joints. Foot Ankle Int 1999;20:72–9.

[8] O’Kane C, Kilmartin TE. The surgical management of centralmetatarsalgia. Foot Ankle Int 2002;23:415–9.

[9] Gibbard KW, Kilmartin TE. The Weil Osteotomy for the treatmentof painful plantar keratoses. The Foot 2003;13:199–203.