High Yield Overview

WEIL OSTEOTOMY FOR LESSER METATARSALGIA AND METATARSAL LENGTH ABNORMALITIES

Dorsal approach to lesser metatarsal head | Oblique osteotomy parallel to weight-bearing surface | intermediate

Critical Danger Structures

Danger 1: Dorsal Digital Nerves

Location: 3-5mm from midline on medial and lateral borders of adjacent toes

Protection: Careful identification during superficial dissection, loupe magnification, gentle retraction with vessel loops if needed

Injury: 3-5% incidence - causes permanent numbness medial/lateral toe borders, neuroma formation

Danger 2: Plantar Neurovascular Bundles

Location: 8-10mm plantar to metatarsal head on medial and lateral sides, travel between metatarsal heads

Protection: Limit plantar dissection, avoid plantar cortex perforation with saw, control plantar penetration depth

Injury: Digital nerve numbness, arterial injury with vascular compromise, hematoma formation

Danger 3: Plantar Plate

Location: Plantar aspect of MTP joint - thick fibrocartilaginous structure connecting proximal phalanx to metatarsal head

Protection: Gentle plantar dissection if intact pre-operatively (often already torn), avoid excessive traction on toe

Injury: Iatrogenic tear if intact increases MTP instability, prolongs recovery

Danger 4: Metatarsal Head Blood Supply

Location: Retrograde intramedullary from diaphyseal nutrient artery, dorsal and plantar metaphyseal vessels

Protection: Preserve soft tissue attachments to capital fragment, avoid excessive periosteal stripping, copious irrigation

Injury: Avascular necrosis of metatarsal head (rare, less than 1% with good technique)

Danger 5: MTP Joint Articular Cartilage

Location: Dorsal articular margin of metatarsal head - critical landmark for osteotomy start point

Protection: Start osteotomy 2-3mm DISTAL to articular cartilage margin, careful marking before cutting

Injury: Intra-articular osteotomy causes chondral damage, accelerated arthritis, persistent pain

Mnemonic

PARALLELPARALLEL - Weil Osteotomy Key Technical Points

Mnemonic

FLOATINGFLOATING - Preventing Floating Toe After Weil Osteotomy

Primary Indications

Transfer Metatarsalgia

Most common indication - pain under 2nd MT head (80% of cases), 3rd MT 15%, 4th MT 5%
Results from first ray insufficiency (hallux valgus/rigidus, failed bunion surgery, short 1st MT)
Clinical: plantar callus under affected MT head, tenderness, positive drawer test
Radiographic: long metatarsal relative to adjacent MTs, disrupted metatarsal parabola
CRITICAL: Must assess and address first ray pathology - Weil alone will fail if 1st MT insufficient

Metatarsal Length Discrepancy

Long metatarsal causing disproportionate loading and pain
Iatrogenic (after adjacent MT shortening/amputation) or congenital
Goal: restore Maestro metatarsal parabola (2nd longest, 3 greater than 4 greater than 5, each 2-3mm shorter)
Weil allows precise controlled shortening 2-6mm

Plantar Plate Insufficiency with MTP Instability

Plantar plate tear/attenuation causing MTP joint instability, subluxation, or dislocation
Drawer test positive (greater than 2mm dorsal translation of proximal phalanx)
Crossover toe deformity (toe deviates over adjacent toe)
Weil decompresses MTP joint, reduces tension on plantar structures, allows healing without repair (80-90% success)

Freiberg Disease Stage II-III

Osteochondritis of lesser metatarsal head (2nd MT 68%, 3rd MT 27%)
Stage II: subchondral fracture, flattening
Stage III: central depression, loose bodies
Weil decompresses joint, removes damaged dorsal fragment, preserves plantar articular surface

Combination Pathology

Often multiple factors: long MT + plantar plate tear + MTP subluxation
Weil addresses all components through decompression and shortening

Contraindications

Absolute

Active infection (osteomyelitis, septic arthritis)
Severe peripheral vascular disease (non-healing wound risk)
Inadequate soft tissue coverage
Severe medical comorbidities precluding surgery

Relative

Poor bone quality (severe osteoporosis) - nonunion/hardware failure risk
Isolated lesser metatarsalgia without first ray assessment - WILL FAIL
Rigid claw/hammer toe requiring PIPJ surgery (Weil alone insufficient)
Active Charcot neuroarthropathy
Unrealistic patient expectations
Severe rheumatoid arthritis with multiple joint involvement
Prior failed Weil with same pathology

Preoperative Assessment

Clinical Examination

Inspection
- Plantar callus location - directly under MT head indicates overload
- Crossover deformity - 2nd toe crossing over hallux medially
- Toe alignment - varus/valgus, rotation
- Hallux valgus severity, hallux rigidus
- Swelling, erythema at MTP joint
Palpation
- Tenderness localized to plantar MT head
- MTP joint synovitis
- Plantar plate integrity
Special Tests
- Drawer test: Stabilize MT head, pull toe dorsally - greater than 2mm translation or pain suggests plantar plate tear
- Lachman test: Dorsal subluxation of toe with longitudinal traction
- Vertical stress test: Passive dorsiflexion of MTP - pain suggests plantar plate pathology
- First ray mobility - dorsiflexion stiffness suggests hallux rigidus
- Gastrocnemius tightness - Silfverskiöld test
Neurovascular
- Pulses (dorsalis pedis, posterior tibial)
- Sensation - rule out neuropathy
- Capillary refill

Radiographic Assessment

Weight-bearing AP Foot
- Metatarsal lengths - Maestro concept assessment
- 2nd MT should be longest or equal to 1st
- Progressive shortening 3 greater than 4 greater than 5 (2-3mm each)
- MTP subluxation/dislocation
- Freiberg disease changes
- Hallux valgus angle, 1st MT position
Weight-bearing Lateral Foot
- First ray dorsiflexion
- Metatarsal declination angles
- Pes planus versus cavus alignment
Oblique Foot
- MTP joint arthritis
- Sesamoid position

Quantifying Shortening Needed

Radiographic method: Measure MT protrusion distance relative to 2nd MT
Typical shortening 2-4mm restores normal parabola
Maximum 6mm - beyond this, floating toe risk significantly increases
Consider staged procedures if greater than 6mm needed

First Ray Assessment - CRITICAL

Why it matters: Transfer metatarsalgia occurs FROM first ray insufficiency

Short first MT: Measure relative to 2nd MT - if 2nd MT greater than 4mm longer, high suspicion
Dorsiflexed first MT: Lateral X-ray - first MT elevated relative to lesser MTs
Hallux rigidus: Limited dorsiflexion, osteophytes, joint space narrowing
Failed bunion surgery: History of excessive 1st MT shortening
If first ray insufficient: Must address (1st MT lengthening, plantar flexion osteotomy, MTP cheilectomy) BEFORE or concurrent with Weil

Positioning and Setup

Patient Position

Supine with foot at end of table or with bump under ipsilateral hip for easier access
Foot fully visible for fluoroscopy (AP and lateral views)
Ensure C-arm can rotate freely

Anesthesia

Ankle block preferred (tibial, deep peroneal, superficial peroneal, sural, saphenous nerves)
General anesthesia alternative
Local infiltration inadequate for tourniquet tolerance

Tourniquet

Thigh tourniquet 250-300mmHg OR
Ankle tourniquet 200-250mmHg (less painful with regional anesthesia)
Exsanguinate with Esmarch bandage
Limit tourniquet time to 90-120 minutes

Equipment Required

Microsagittal saw (0.5-1.0mm blade)
Small Hohmann or Army-Navy retractors
2.0-2.5mm headless compression screw system OR 1.6mm K-wires
Fine instruments for small joint surgery
Loupe magnification 2.5-3.5x helpful for nerve protection
Fluoroscopy (mini C-arm adequate)

Step-by-Step Operative Technique

Step 1: Incision and Superficial Dissection

Incision Planning

Dorsal longitudinal incision 3-4cm over affected metatarsal head
Centered in intermetatarsal space (between extensor digitorum longus tendons)
For multiple MTs: separate incisions with minimum 1.5-2cm skin bridges

Skin Incision

Sharp scalpel incision through skin and subcutaneous tissue
Dissect down to level of extensor tendons

Nerve Protection

Identify and PROTECT dorsal digital nerve branches
Run 3-5mm medial and lateral to incision on borders of adjacent toes
Use loupe magnification for identification
Use vessel loops for gentle retraction if nerves crossing field
Injury rate 3-5% - causes permanent numbness

Exam Pearl

Examiner Focus: "Describe your approach and nerve protection."

Model Answer: "Dorsal longitudinal approach 3-4cm in intermetatarsal space between EDL tendons. I carefully identify and protect dorsal digital nerves on toe borders approximately 3-5mm from midline. Use loupe magnification and vessel loops for gentle retraction if needed. Injury causes permanent numbness medial/lateral toe borders in 3-5% - prevent with careful technique."

Critical Dangers - Superficial Dissection

Dorsal digital nerve injury - permanent numbness, neuroma (3-5% incidence)
Incision too long - increased nerve risk, poor cosmesis
Inadequate skin bridges if multiple incisions - skin necrosis
Aggressive retraction - neuropraxia

Step 2: Deep Dissection and Capsulotomy

Extensor Tendon Mobilization

Develop plane between EDL tendons
Retract tendons medially or laterally for exposure
No need to divide tendons

Dorsal Capsulotomy

Longitudinal incision through dorsal joint capsule over MTP joint
Extend 1.5-2cm proximally and distally
Full-thickness capsulotomy to visualize metatarsal head

Collateral Ligament Release

Release medial and lateral collateral ligaments from metatarsal head origins
Allows mobilization of capital fragment after osteotomy
Use sharp dissection with scalpel
Caution: Limit plantar dissection to avoid plantar neurovascular bundles (8-10mm plantar to MT head)

Joint Exposure

Hyperplantarflex toe to expose dorsal metatarsal head maximally
Small Hohmann retractors placed medially and laterally
Assess plantar plate from dorsal approach - if completely torn, may see plantar gapping

Exam Pearl

Technique Pearl: "I perform dorsal capsulotomy and release collateral ligaments medially and laterally - this mobilizes MT head for optimal osteotomy visualization. Hyperplantarflex toe to see full dorsal head. Often plantar plate already torn (reason for surgery) - Weil decompresses joint helping it heal without repair in 80-90%."

Critical Dangers - Deep Dissection

Plantar neurovascular bundle injury - limit plantar dissection beyond 8-10mm
Iatrogenic plantar plate tear if intact preoperatively
Inadequate exposure - difficulty performing accurate osteotomy
Excessive soft tissue stripping - AVN risk (rare)

Step 3: Weil Osteotomy Planning and Marking

Weil Osteotomy Principles

Oblique osteotomy through metatarsal neck PARALLEL to plantar weight-bearing surface
Allows capital fragment to slide proximally along osteotomy plane
Amount of proximal translation determines shortening (1mm translation = approximately 1mm shortening)

Critical Osteotomy Parameters

START POINT (Most critical landmark)
- 2-3mm DISTAL to dorsal articular cartilage margin
- Too proximal: enters joint, damages articular cartilage
- Too distal: inadequate shortening possible, stress riser in shaft
- Mark with methylene blue or electrocautery
ANGLE (Defines procedure success)
- Parallel to plantar weight-bearing surface when foot flat on ground
- Approximately 20-30° to long axis of metatarsal shaft (varies by MT)
- 2nd MT: typically 25°
- 3rd-4th MT: typically 20-22°
- Can use fluoroscopy to check angle
DIRECTION
- Proximal-dorsal to distal-plantar
- Following weight-bearing surface plane
LENGTH
- 15-20mm osteotomy length to allow adequate translation
- Longer osteotomy = more translation possible = more shortening possible

Marking the Osteotomy

Use methylene blue or electrocautery to mark start point and trajectory on bone
Double-check angle with fluoroscopy before cutting
Visualize final position of capital fragment after planned translation

Exam Pearl

Examiner Focus: "What defines the Weil osteotomy angle and why is it critical?"

Gold Standard Answer: "Weil osteotomy angle PARALLEL to plantar weight-bearing surface - approximately 20-30° to metatarsal shaft depending on MT. Start point 2-3mm DISTAL to dorsal articular cartilage margin. This geometry allows capital fragment to slide proximally along osteotomy, shortening metatarsal while maintaining articular surface parallel to ground for normal load distribution. Parallel to weight-bearing surface is THE key technical point that makes Weil work."

Critical Dangers - Osteotomy Planning

Start point too proximal - intra-articular osteotomy, chondral damage, arthritis
Wrong angle (not parallel to weight-bearing) - altered load distribution, pain, malunion
Osteotomy too short - inadequate translation ability, undercorrection
Start point too distal - stress riser, insufficient shortening possible

Step 4: Osteotomy Performance

Saw Selection

Microsagittal saw with 0.5-1.0mm blade
Fine blade allows precise cutting

Cutting Technique

Position saw at marked start point 2-3mm distal to articular cartilage
Angle saw parallel to planned weight-bearing surface
Begin cut dorsally, direct proximally and plantarly
CRITICAL: CONTINUOUS copious irrigation during cutting - prevents thermal necrosis
Cut through dorsal cortex, medullary canal, plantar cortex
Exit plantarly in mid-diaphysis
Control depth to avoid excessive plantar penetration (plantar neurovascular bundle risk)

Completing the Osteotomy

Once both cortices cut, capital fragment should be mobile
If incomplete, use small osteotome to gently complete cut
Avoid excessive force - fracture risk

Verifying Complete Osteotomy

Capital fragment should translate freely along osteotomy plane
No bony hinge or incomplete cortex preventing motion

Exam Pearl

Safety Pearl: "I use microsagittal saw starting 2-3mm distal to cartilage, directing proximal-plantar parallel to weight-bearing surface. CONTINUOUS irrigation essential - prevents thermal necrosis and AVN risk. Cut through both cortices but control plantar penetration depth - neurovascular bundles 8-10mm plantar to MT head. Fragment mobile after complete osteotomy."

Critical Dangers - Osteotomy Performance

Thermal necrosis without irrigation - AVN risk
Plantar cortex incomplete - fracture during translation, malunion
Saw blade drifts from planned angle - wrong trajectory, joint entry
Excessive plantar penetration - flexor tendon injury, neurovascular bundle injury
Starting too proximal - articular cartilage damage

Step 5: Capital Fragment Translation

Proximal Translation

Translate capital fragment PROXIMALLY along osteotomy plane
Amount of translation determines shortening
Typical translation: 2-4mm (results in 2-4mm metatarsal shortening)
Maximum translation: 6mm (6mm shortening) - beyond this, floating toe risk increases significantly

Translation Technique

Grasp toe and apply gentle axial traction
Use small elevator or freer to mobilize capital fragment
Slide capital fragment proximally along osteotomy
Can use bone hook to pull fragment proximally if needed

Assessing Appropriate Shortening

Clinical Assessment
- MTP joint should reduce without tension
- Toe in good alignment without dorsal subluxation
- Palpate plantarly - no prominent bone from osteotomy
Fluoroscopic Assessment
- AP view: metatarsal length relative to adjacent MTs
- Should restore parabola - 2nd MT slightly longer than 3rd
- Check that MTP joint reduced
Length Comparison
- Compare to preoperative plan (typically 2-4mm shortening)
- If multiple MTs involved, ensure proper cascade restored

Avoiding Excessive Shortening

Shortening greater than 6mm: floating toe in 10-15%, transfer to adjacent MT, stiffness
Signs of excessive shortening: toe appears short, elevated, MTP hyperextended

Slight Dorsal Translation (Optional)

Can translate capital fragment dorsally 1mm in addition to proximal
Further unloads plantar MT head
Risk: Dorsiflexion malunion causing floating toe
Generally avoided - proximal translation alone preferred

Exam Pearl

Examiner Focus: "How much shortening and why is excessive shortening problematic?"

Model Answer: "I translate capital fragment proximally 2-4mm typical. Each 1mm proximal translation shortens MT by approximately 1mm. This decompresses MTP joint, reduces plantar pressure, restores metatarsal parabola with 2nd MT slightly longer than 3rd. AVOID excessive shortening greater than 6mm - causes floating toe 10-15%, transfer metatarsalgia to adjacent MT, stiffness. Limit shortening prevents these complications."

Critical Dangers - Fragment Translation

Excessive shortening greater than 6mm - floating toe (10-15%), transfer metatarsalgia, stiffness
Inadequate shortening less than 2mm - persistent symptoms, undercorrection
Excessive dorsal translation - dorsiflexion malunion, cock-up toe deformity
Loss of articular congruity - early arthritis
Plantar prominence of osteotomy - persistent plantar pain

Step 6: Provisional Fixation and Position Assessment

K-wire Provisional Fixation

0.045-inch K-wire from dorsal capital fragment into proximal shaft
Perpendicular to osteotomy or slightly distal-to-proximal
Advances across osteotomy into proximal shaft 2-3cm
Provides temporary stability for position assessment

Clinical Assessment

MTP joint reduced - toe in neutral alignment
No dorsal subluxation of toe
Capital fragment well-seated on shaft without step-off dorsally or plantarly
Appropriate shortening achieved (2-4mm typical)
No rotational deformity of toe
Palpate plantarly - no prominence from osteotomy edge

Fluoroscopic Assessment

AP View
- Metatarsal length appropriate relative to adjacent MTs
- MTP joint reduced
- No varus/valgus malalignment
- Osteotomy fragments aligned
Lateral View (CRITICAL)
- Capital fragment not dorsally angulated (dorsiflexion malunion)
- Should be parallel to weight-bearing surface
- No plantar gapping at osteotomy
- No prominent dorsal step-off

Adjust if Needed

If position suboptimal, can remove K-wire and adjust before definitive fixation
Better to adjust now than accept malposition

Exam Pearl

Critical Check: "I use provisional K-wire to hold position while assessing clinically and fluoroscopically. Clinical: toe straight, MTP reduced, appropriate length. Fluoroscopy: AP confirms length/reduction, LATERAL critical to rule out dorsiflexion malunion. Palpate plantarly - no prominence from osteotomy would cause persistent pain. Can adjust now if needed before definitive fixation."

Critical Dangers - Provisional Fixation

K-wire penetrates plantar skin - remove and redirect
Accepting suboptimal position - persistent symptoms, malunion
Missing dorsiflexion malunion without lateral fluoroscopy - causes floating toe
K-wire in joint - remove and reposition

Step 7: Definitive Fixation

Fixation Options

Headless Compression Screw (Preferred - 85% of cases)
- 2.0-2.5mm diameter
- Headless design allows burial beneath bone surface
- No removal needed unless symptomatic
- Lower profile than headed screw

Screw Insertion Technique

Remove provisional K-wire
Drill from dorsal-distal capital fragment
Direction: perpendicular to osteotomy plane OR slightly distal-to-proximal
Advance through capital fragment, cross osteotomy, into proximal shaft
Measure length - typically 25-35mm depending on MT size
Insert headless compression screw
Screw compresses osteotomy as it advances
Bury screw head beneath dorsal cortex
Final fluoroscopy confirms:
- Screw crosses osteotomy
- Adequate compression
- No plantar penetration
- Head buried

K-wire Fixation (Alternative - 15% of cases)
- 1.6mm K-wire
- Dorsal-to-plantar direction
- Leave buried OR cut beneath skin
- Requires removal at 4-6 weeks
- Lower cost but pin tract infection risk (5%), removal required
- Adequate stability for Weil (inherently stable geometry)
Plate Fixation (Rare - less than 1%)
- Mini T-plate or straight plate
- Used for complex cases, revision surgery, poor bone quality
- Higher profile, more dissection
- Rarely needed for standard Weil

Fixation Verification

Fluoroscopy: screw/wire crosses osteotomy, appropriate length
No hardware prominence dorsally or plantarly
Osteotomy compressed and stable

Exam Pearl

Fixation Choice: "I fix with single 2.0-2.5mm HEADLESS compression screw perpendicular to osteotomy for compression. Headless means BURIED beneath bone, no removal needed, no shoe prominence. Screw from dorsal-distal to proximal-plantar. Alternative: K-wire cheaper but requires removal at 4-6 weeks with pin tract infection risk 5%. Weil geometry inherently stable so single screw adequate."

Critical Dangers - Definitive Fixation

Screw prominence if not headless - shoe irritation, requires removal
Screw too long - plantar penetration, plantar pain
Screw not perpendicular to osteotomy - inadequate compression, malunion
Hardware breakage (rare less than 1%)
K-wire migration if used - need to bury or remove early
K-wire pin tract infection 5% - antibiotics, early removal

Step 8: Soft Tissue Balancing

Plantar Plate Management

Conservative Approach (Preferred - 80-90% of cases)

Most plantar plate tears heal with Weil decompression ALONE
Shortening reduces tension on plantar structures
Allows tear to heal over 8-12 weeks
Success rate 80-90% without repair
Avoids plantar approach morbidity

Plantar Plate Repair (Selective - 10-20% of cases)

Consider ONLY if:
- Complete plantar plate rupture with severe instability
- MTP dislocation not reducible with Weil alone
- Failed conservative Weil previously

Repair Techniques

Dorsal Approach Repair
- Suture anchors placed in plantar metatarsal head
- Sutures passed through plantar plate remnant from dorsal
- Technically demanding
- Avoids plantar incision
Plantar Approach Repair
- Small 2cm plantar incision between metatarsal heads
- Direct visualization of plantar plate
- Repair with suture anchors or direct suture
- Risk: plantar neurovascular bundle injury (8-10mm from MT head)
- Risk: painful plantar scar
- Generally avoided if Weil decompression adequate

Crossover Toe Management

If significant crossover deformity persists after Weil:
- Consider flexor-to-extensor tendon transfer (Girdlestone-Taylor procedure)
- Transfers FDL to extensor hood
- Provides dynamic correction, reduces flexion deformity
- Adds 15-20 minutes to procedure

Exam Pearl

Plantar Plate Decision: "PLANTAR PLATE TEARS: Most heal with Weil decompression alone - shortening reduces tension allowing healing without repair in 80-90%. I do NOT routinely repair - avoids added time, complexity, and morbidity. Consider repair ONLY if complete rupture with severe instability. For crossover toe: flexor-to-extensor transfer (Girdlestone-Taylor) provides dynamic correction."

Dangers - Soft Tissue Balancing

Unnecessary plantar plate repair - added morbidity, plantar scar pain, longer surgery
Missing need for repair in severe instability - persistent subluxation, poor outcome
Plantar approach - plantar neurovascular bundle injury 8-10mm from MT head
Overtight repair - limited MTP motion, stiffness

Step 9: Capsular Closure

Dorsal Capsule Closure

Close dorsal capsule with 3-0 or 4-0 absorbable sutures (Vicryl, PDS)
Can reef (imbricate) dorsally if capsule lax
Provides dorsal restraint to prevent dorsal subluxation
Avoid overtightening - should allow full plantarflexion ROM

Capsular Reefing Technique

Place sutures from distal capsule (on proximal phalanx) to proximal capsule (on metatarsal)
Slight overlap (2-3mm) provides dorsal stability
Test ROM after closure - full plantarflexion should be possible

Collateral Ligament Management

Usually heal without formal repair
Can repair if significantly disrupted (rare)
Usually adequate healing with immobilization

Extensor Tendon

Replace in anatomic position
No formal repair needed in most cases

Exam Pearl

Capsule Closure: "I close dorsal capsule with balanced tension using absorbable sutures. Can reef dorsally 2-3mm for stability but avoid overtightening - want full plantarflexion ROM. Test ROM after closure. Collateral ligaments usually heal without formal repair. Gentle closure - compromised soft tissue envelope common in chronic metatarsalgia."

Dangers - Capsular Closure

Overtight dorsal closure - limited plantarflexion, stiffness (20-30% complication)
Inadequate closure - dorsal instability (rare)
Suture through extensor tendon - tendon adhesions, limited motion

Step 10: Wound Closure

Subcutaneous Closure

4-0 or 5-0 absorbable sutures (Vicryl)
Minimize skin tension
Careful technique - dorsal foot skin thin with limited soft tissue

Skin Closure

Options:
1. Subcuticular absorbable (4-0 Monocryl) - preferred for cosmesis, no removal
2. Interrupted non-absorbable (5-0 nylon) - allows earlier suture removal if wound issues
Steri-strips for support

Dressing

Soft gauze between toes to maintain alignment and prevent adhesions
If multiple toes operated, ensure each separated with gauze
Non-adherent dressing over incision
Soft compression wrap (Kerlix, Coban) - not too tight
Postoperative stiff-soled shoe with forefoot off-loading if available

Exam Pearl

Closure Technique: "I close skin meticulously - thin dorsal foot skin prone to complications 3-5%. Subcuticular absorbable for cosmesis, no removal needed. Gauze BETWEEN TOES prevents adhesions and maintains alignment - critical. Soft dressing allows early gentle motion - NOT immobilized like bunion. Postop shoe with forefoot off-loading ideal."

Dangers - Wound Closure

Wound dehiscence 3-5% - thin skin, tension, poor vascularity
Skin necrosis - excessive tension, compromised blood supply
Tight dressing - vascular compromise, compartment syndrome
Inadequate toe separation - adhesions, toe drift, malposition

Weil Osteotomy - FRACS Exam Quick Reference

High-Yield Exam Summary

References

Trnka HJ, Muhlbauer M, Zettl R, et al. Comparison of the results of the Weil and Helal osteotomies for the treatment of metatarsalgia secondary to metatarsophalangeal instability. J Bone Joint Surg Am. 1999;81(12):1760-1768.
- Classic comparison study showing Weil superior outcomes with 85% good/excellent results versus 70% for Helal osteotomy. Established Weil as preferred technique for lesser metatarsalgia with MTP instability.
Vandeputte G, Dereymaeker G, Steenwerckx A, et al. The Weil osteotomy of the lesser metatarsals: a clinical and pedobarographic follow-up study. Foot Ankle Int. 2000;21(5):370-374.
- Pedobarographic analysis demonstrating significant reduction in plantar pressures under operated metatarsal heads (average 35% reduction). Confirmed biomechanical rationale for procedure.
Migues A, Slullitel G, Bilbao F, et al. Floating-toe deformity as a complication of the Weil osteotomy. Foot Ankle Int. 2004;25(9):609-613.
- Identified floating toe incidence of 15% in 72 osteotomies. Key risk factors: excessive shortening greater than 6mm, dorsiflexion malunion, immobilization. Recommended limiting shortening and early mobilization.
Hofstaetter SG, Hofstaetter JG, Petroutsas JA, et al. The Weil osteotomy: a seven-year follow-up. J Bone Joint Surg Br. 2005;87(11):1507-1511.
- Long-term outcomes study: 74% patient satisfaction at 7 years. Complications: stiffness 30%, floating toe 12%, transfer metatarsalgia 8%. Emphasized importance of early range of motion protocols.
Beech I, Rees S, Tagoe M. A retrospective review of the Weil metatarsal osteotomy for lesser metatarsal deformities: an intermediate follow-up analysis. J Foot Ankle Surg. 2005;44(5):358-364.
- Review of 52 procedures with average 2.8-year follow-up. AOFAS scores improved from 52 to 84 (p less than 0.001). Recurrence rate 12% correlated with failure to address first ray pathology.
Highlander P, VonHerbulis E, Gonzalez A, et al. Complications of the Weil osteotomy. Foot Ankle Spec. 2011;4(3):165-170.
- Systematic review of complications: stiffness 20-30% (most common), floating toe 10-15%, transfer metatarsalgia 5-10%, recurrence 10-15%. Provided comprehensive prevention strategies for each complication.
Pascual Huerta J, Arcas Lorente C, Garcia Carmona FJ. The Weil osteotomy: a comprehensive review. Rev Esp Cir Ortop Traumatol. 2012;56(5):415-421.
- Comprehensive technical review covering indications, surgical technique, fixation options, and outcomes. Emphasized angle parallel to weight-bearing surface as key technical point. (Spanish literature, widely cited internationally)
Nery C, Coughlin MJ, Baumfeld D, et al. Lesser metatarsophalangeal joint instability: prospective evaluation and repair of plantar plate and capsular insufficiency. Foot Ankle Int. 2012;33(4):301-311.
- Evaluated plantar plate repair with Weil osteotomy: 91% good/excellent results. Found similar outcomes with and without plantar plate repair, suggesting Weil decompression alone sufficient in most cases (80-90%).
Melamed EA, Schon LC, Myerson MS, et al. Two modifications of the Weil osteotomy: analysis on sawbone models. Foot Ankle Int. 2002;23(5):400-405.
- Biomechanical study analyzing effect of osteotomy angle. Confirmed angle parallel to weight-bearing surface (20-30° to shaft) provides optimal load distribution and allows predictable shortening.
Maestro M, Besse JL, Ragusa M, et al. Forefoot morphotype study and planning method for forefoot osteotomy. Foot Ankle Clin. 2003;8(4):695-710.
- Introduced Maestro metatarsal parabola concept: 2nd MT longest, 3 greater than 4 greater than 5 progressively shorter 2-3mm each. Established radiographic planning principles for Weil osteotomy to restore normal forefoot mechanics.

Weil Osteotomy for Lesser Metatarsalgia and Metatarsal Length Abnormalities