Weil Osteotomy for Lesser Metatarsalgia and Metatarsal Length Abnormalities

Indication. Symptomatic overload of a lesser metatarsal head — plantar pain and a plantar callus under the affected head, tenderness, and often a positive drawer test (more than 2mm of dorsal translation of the proximal phalanx, or pain, indicating plantar plate insufficiency) — that has failed non-operative care (stiff-soled shoe, metatarsal pad/dome orthotic, activity modification, NSAIDs and an intra-articular corticosteroid injection). The four clinical situations a Weil addresses: - Transfer metatarsalgia (the commonest indication). Pain under the 2nd MT head in about 80% of cases, 3rd MT in 15%, 4th MT in 5%. It results from first ray insufficiency (hallux valgus or rigidus, failed bunion surgery, a short or dorsiflexed 1st MT), which shifts load onto the lesser rays. Assessing and addressing the first ray is non-negotiable — a Weil alone will fail if the first ray is insufficient.

• Metatarsal length discrepancy. A long metatarsal causing disproportionate loading (iatrogenic after adjacent shortening, or congenital). The goal is to restore the Maestro metatarsal parabola; the Weil allows precise, controlled shortening of 2-6mm.
• Plantar plate insufficiency with MTP instability. A plantar plate tear or attenuation with MTP subluxation, dislocation or a crossover toe. The Weil decompresses the joint, reduces tension on the plantar structures and allows the tear to heal without formal repair in 80-90%.
• Freiberg disease, Stage II-III. Osteochondritis of the lesser metatarsal head (2nd MT in about 68%, 3rd MT in 27%). The Weil decompresses the joint, removes the damaged dorsal fragment and preserves the plantar articular surface. Assess the whole forefoot, not just the symptomatic ray. Before committing, exclude or plan for: - First ray insufficiency — a short or dorsiflexed 1st MT, hallux rigidus, or prior bunion surgery with excessive 1st MT shortening. If the 2nd MT is more than about 4mm longer than the 1st, suspicion is high. An insufficient first ray must be corrected (1st MT lengthening, plantar-flexion osteotomy, or MTP cheilectomy) before or at the same time as the Weil.
• A rigid claw or hammer toe needing PIP surgery — note that concurrent PIP arthrodesis of the same ray increases the floating-toe rate.
• Gastrocnemius tightness (Silfverskiöld test) and neurovascular status (dorsalis pedis and posterior tibial pulses, sensation, capillary refill). Contraindications. Absolute: active infection (osteomyelitis, septic arthritis), severe peripheral vascular disease (non-healing wound risk), inadequate soft-tissue cover, or severe medical comorbidity precluding surgery. Relative: poor bone quality (severe osteoporosis — nonunion/hardware failure), isolated lesser metatarsalgia without first ray assessment (will fail), a rigid claw/hammer toe needing PIP surgery, active Charcot neuroarthropathy, severe rheumatoid disease with multiple joint involvement, and a prior failed Weil for the same pathology. Pre-operative imaging. Weight-bearing AP (assess metatarsal lengths and the Maestro parabola, MTP subluxation, Freiberg changes, hallux valgus angle), weight-bearing lateral (first ray dorsiflexion, metatarsal declination, arch alignment) and oblique views (MTP arthritis, sesamoid position). Quantify the shortening needed radiographically: typical is 2-4mm, maximum 6mm. Consent specifically for: floating toe (10-15%), stiffness or reduced MTP motion (20-30%), transfer of metatarsalgia to an adjacent ray (5-10%), recurrent or under-corrected symptoms (10-15%), hardware issues (5-10%, including screw prominence and — if K-wires are used — pin-tract infection), dorsal digital nerve injury with permanent numbness of a toe border (3-5%), wound problems (3-5%), dorsiflexion malunion (5-8%), avascular necrosis of the metatarsal head (less than 1%) and nonunion (less than 2%). Setup. Supine, foot at the end of the table (a bump under the ipsilateral hip helps access), positioned for free AP and lateral fluoroscopy. Ankle block (tibial, deep and superficial peroneal, sural, saphenous nerves) is preferred; general anaesthesia is the alternative — local infiltration alone does not tolerate a tourniquet. Thigh tourniquet at 250-300mmHg OR an ankle tourniquet at 200-250mmHg (less painful with a regional block), exsanguinated with an Esmarch, limiting tourniquet time to 90-120 minutes. Loupe magnification (2.5-3.5x) is recommended for dorsal digital nerve identification. Have a microsagittal saw (0.5-1.0mm blade), small Hohmann retractors, a 2.0-2.5mm headless compression screw system (or 1.6mm K-wires) and a mini C-arm.

The goal: expose the metatarsal head through a dorsal approach, cut an oblique osteotomy parallel to the plantar weight-bearing surface starting just distal to the articular cartilage, translate the capital fragment proximally to shorten and decompress the MTP joint, fix it with a buried headless screw, and balance the soft tissues — all while protecting the dorsal digital nerves and the plantar neurovascular bundles. The exposure and osteotomy geometry are laid out step by step below (and in depth on the dorsal approach to the lesser metatarsals page).

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Rehabilitation | Phase | Timing | Weight-bearing & motion | Milestones | |-------|--------|-------------------------|------------| | 1 | 0-2 weeks | Heel weight-bearing immediately in a postop shoe; bulky dressing 2-3 days then light; start gentle passive ROM at 3-5 days (10 reps, 3-4x/day); elevate and ice | Pain control, wound check | | 2 | 2-6 weeks | Progressive forefoot weight-bearing from 2-3 weeks (full by ~4 weeks); sutures out 10-14 days; begin active ROM at 3 weeks; buddy-tape 6-8 weeks | X-ray at 4-6 weeks for healing/alignment | | 3 | 6-12 weeks | Regular supportive shoes at 6-8 weeks (wide toe box); gradual return to walking, swimming, cycling; metatarsal-pad orthotic | Light daily activities pain-free | | 4 | 3-12 months | Higher-impact activity from 10-12 weeks; high heels from 3-4 months; PT if stiff | Maximum medical improvement at ~12 months | Most patients are back to desk work by about 2 weeks, routine daily activities pain-free by 3 months, and full activity by 6 months (swelling may persist 6-12 months). For multiple rays, extend all timelines by 2-4 weeks. Red flags for early return: severe increasing pain, wound drainage or erythema, worsening toe malalignment, a cold/pale toe, or new numbness. Complications

Epidemiology. Metatarsalgia is among the commonest forefoot complaints; transfer metatarsalgia to the 2nd ray is the leading indication for a Weil and is strongly associated with first ray insufficiency (hallux valgus/rigidus, failed bunion surgery, a short or dorsiflexed 1st MT) and with female sex and the fifth to seventh decades. Freiberg disease (infraction) affects the 2nd MT head in about 68% and the 3rd in about 27%. Pathoanatomy. The lesser MTP joint is stabilised dorsally by the extensor mechanism and capsule, and plantarly by the plantar plate (a fibrocartilaginous structure anchoring the proximal phalanx to the metatarsal head) reinforced by the collateral ligaments and the deep transverse intermetatarsal ligament. Chronic overload — most often from an insufficient first ray shifting load laterally — attenuates or tears the plantar plate, allowing dorsal subluxation of the proximal phalanx, a crossover toe, and focal plantar pressure under the metatarsal head (the plantar callus). A metatarsal that is too long disrupts the normal metatarsal parabola and concentrates load on one head.

Key evidence. The modern Weil osteotomy supplanted the older Helal diaphyseal osteotomy after Trnka (1999) showed it gave zero recurrent metatarsalgia (versus 27% for Helal) and zero transfer lesions (versus 41%), maintaining MTP reduction in 84% versus 36%. The longest outcome data (Hofstaetter, 2005) reported good-to-excellent results in 88% at seven years, with AOFAS improving from 48 to 83, at the cost of a 12% redislocation rate and floating-toe and stiffness as the chief complications. The largest pooled complications dataset (Highlander, 2011; 1131 osteotomies across 17 studies) found floating toe to be the most frequently reported complication (a pooled 36% radiographic occurrence — the symptomatic rate is lower), recurrence in 15%, transfer metatarsalgia in 7%, and delayed/non/malunion collectively in 3%. Migues (2004) identified concurrent PIP arthrodesis of the same ray as a modifiable risk factor for floating toe. On the soft-tissue side, Nery (2012) showed that for fixed deformity or severe instability, direct dorsal plantar plate repair combined with a Weil restored MTP stability (AOFAS 52 to 92) — supporting selective, not routine, repair.