import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **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 **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 **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 **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) **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 ## 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 1. **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 2. **Palpation** - Tenderness localized to plantar MT head - MTP joint synovitis - Plantar plate integrity 3. **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 4. **Neurovascular** - Pulses (dorsalis pedis, posterior tibial) - Sensation - rule out neuropathy - Capillary refill ### Radiographic Assessment 1. **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 2. **Weight-bearing Lateral Foot** - First ray dorsiflexion - Metatarsal declination angles - Pes planus versus cavus alignment 3. **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 **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." - 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 **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%." - 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** 1. **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 2. **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 3. **DIRECTION** - Proximal-dorsal to distal-plantar - Following weight-bearing surface plane 4. **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 **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." - 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 **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." - 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** 1. **Clinical Assessment** - MTP joint should reduce without tension - Toe in good alignment without dorsal subluxation - Palpate plantarly - no prominent bone from osteotomy 2. **Fluoroscopic Assessment** - AP view: metatarsal length relative to adjacent MTs - Should restore parabola - 2nd MT slightly longer than 3rd - Check that MTP joint reduced 3. **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 **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." - 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** 1. MTP joint reduced - toe in neutral alignment 2. No dorsal subluxation of toe 3. Capital fragment well-seated on shaft without step-off dorsally or plantarly 4. Appropriate shortening achieved (2-4mm typical) 5. No rotational deformity of toe 6. Palpate plantarly - no prominence from osteotomy edge **Fluoroscopic Assessment** 1. **AP View** - Metatarsal length appropriate relative to adjacent MTs - MTP joint reduced - No varus/valgus malalignment - Osteotomy fragments aligned 2. **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 **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." - 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** 1. **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 2. **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) 3. **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 **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." - 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** 1. **Dorsal Approach Repair** - Suture anchors placed in plantar metatarsal head - Sutures passed through plantar plate remnant from dorsal - Technically demanding - Avoids plantar incision 2. **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 **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." - 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 **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." - 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 **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." - 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 ## Immediate Post-operative Period (0-2 weeks) ### Weight-bearing Protocol - **Heel weight-bearing IMMEDIATELY** in postoperative shoe - Forefoot off-loaded initially - Crutches/walker if needed for balance (usually not required) - No cast or boot - allows early motion ### Dressing Management - Initial bulky dressing remains 2-3 days - Change to light dressing at first post-op visit - Gauze between toes maintained for 6 weeks to prevent adhesions - Keep dressing dry - shower with plastic bag protection ### Range of Motion - **Critical Difference from Bunion Surgery**: Early motion prevents stiffness - Start gentle PASSIVE ROM at 3-5 days (as soon as pain tolerable) - Patient or therapist moves toe through plantarflexion and dorsiflexion - 10 repetitions, 3-4 times daily - NO active motion yet (no patient muscle activation) - Pain with ROM is expected and acceptable - promotes healing, prevents adhesions ### Elevation and Ice - Elevate foot above heart level when resting - Ice 20 minutes every 2-3 hours - Reduces swelling and pain - Continue for first 7-10 days ### Medications - Analgesia: Acetaminophen 1g four times daily, tramadol or oxycodone for breakthrough - Avoid NSAIDs first 6 weeks (theoretical impaired bone healing) - DVT prophylaxis usually not needed (low-risk surgery) ## Early Recovery Period (2-6 weeks) ### Progressive Weight-bearing - **2-3 weeks**: Begin progressive forefoot weight-bearing as tolerated - Transition from heel-only to full foot contact in postop shoe - Progress based on pain and swelling - Most patients full weight-bearing by 4 weeks ### Suture Removal - 10-14 days for non-absorbable sutures - Subcuticular absorbable dissolve on their own ### Active ROM - **3 weeks**: Begin active ROM (patient uses own muscles) - Active plantarflexion, dorsiflexion, circumduction - 10-15 repetitions, 4-5 times daily - Goal: maintain or improve motion ### Buddy Taping - **CRITICAL**: Buddy tape operated toe to adjacent stable toe for 6-8 weeks - Prevents drift, provides support during healing - Tape during all weight-bearing activities - Can remove for ROM exercises and bathing ### Radiographic Follow-up - **4-6 weeks**: X-ray to assess healing - Look for: callus formation, maintained alignment, hardware position - Usually good healing by 6 weeks given inherent Weil stability ## Return to Function (6-12 weeks) ### Footwear Progression - **6-8 weeks**: Transition to regular supportive shoes - Wide toe box, cushioned sole, low heel - Continue buddy taping in regular shoes for 8 weeks total - Avoid narrow shoes, high heels initially ### Activity Progression - **6 weeks**: Light daily activities - **8 weeks**: Gradual return to exercise (walking, swimming, cycling) - **10-12 weeks**: Return to higher impact (running, jumping) if appropriate - **3-4 months**: Return to high heels if desired - Progress based on symptoms, not just time ### Orthotic Use - Metatarsal pad orthotic for forefoot offloading - Especially if multiple MTs operated or transfer risk - Can discontinue if asymptomatic at 4-6 months ### Physical Therapy - Consider formal PT if: - Stiffness developing (most common need) - Delayed recovery - Multiple MTs operated - Focus on joint mobilization, stretching, strengthening ## Long-term Follow-up (3-12 months) ### Expected Timeline to Full Recovery - **3 months**: Most routine daily activities pain-free - **6 months**: Return to all desired activities - **12 months**: Maximum medical improvement, final outcome - Swelling may persist up to 6-12 months (normal) ### Long-term Monitoring - Annual X-rays not needed if asymptomatic - Watch for transfer to adjacent MT (new plantar pain, callus) - Monitor for recurrence (suggests inadequate initial correction or first ray pathology) ### Patient Education - Footwear: avoid narrow toe box, excessive heel height long-term - Activity modification: minimize prolonged barefoot walking on hard surfaces - Orthotic use: consider long-term if symptoms recur with certain activities - Weight management: reduces forefoot loading ## Multiple Metatarsal Weil Modifications - If 2+ MTs operated: extend all timelines by 2-4 weeks - Greater soft tissue trauma, slower healing - ROM even more critical - higher stiffness risk - May need formal PT ## Red Flags Requiring Earlier Return - Severe increasing pain (infection, hardware failure, DVT) - Wound dehiscence, drainage, erythema (infection) - Toe malalignment worsening (hardware failure, loss of fixation) - Vascular compromise (cold, pale, painful toe) - New numbness/tingling (nerve compression from swelling/dressing) ## References 1. 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. 2. 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. 3. 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. 4. 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. 5. 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. 6. 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. 7. 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) 8. 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%). 9. 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. 10. 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

Weil Osteotomy for Lesser Metatarsalgia and Metatarsal Length Abnormalities