Weil Osteotomy, North Bristol National Health Service Information Booklet

This document might mislead patients. Exerpts from this booklet are repeated in bold italics.

“You have been selected for a Weil Osteotomy”. This is patronising and unfair because the availability of alternate surgery is not mentioned. Why is it not said that the Weil osteotomy involves cutting through a perfectly normal, functional bone anticipating that it will eventually unite?

“If the main problem, or an important part of it, is that one of the metatarsals is too long relative to the others or points too far downwards the Weil Osteotomy would usually be advised. “  There is little reasoning here.  The irrationality of the “metatarsal parabola” concept has been addressed elsewhere on this web-site.  The other commonly bandied explanation is that the metatarsal head has “dropped”.  (As phrased here, “points too far downwards”)  This is also nonsensical, since during standing the metatarsal heads are all in contact with the floor surface.  They cannot “drop”.

“For some the joint at the toes base (“metatarso-phalangeal joint”) is so tight and stiff that it cannot easily be straightened.  A Weil Osteotomy of the metatarsal will relax the joint sufficiently to allow it to straighten and heal without excessive pressure”.  Is it claimed that the cause of “claw tows” and similar are caused by “tight joints”? The is no evidence  of any type for that. This is simply wild, misleading, speculation. There is no evidence whatever that the Weil Osteotomy “relaxes the joint”.  Indeed one of its claimed benefits is a tightening of the plantar plate.

“Will I have to go to sleep (general anaesthetic)?”

Alternatives suggested in this brochure are an “injection in the back, leg or around the ankle can be done to make the foot numb while you are awake”.  Presumably these alternatives are a spinal or epidural anaesthetic, sciatic block or local infiltration around the ankle. Why are they not described as such? Patients are usually well informed about these terms.

All these listed forms of regional anaesthesia have the disadvantage of being long acting.  All these are unpleasent when administered. with a variety of possible complications. “Ankle block” is notably painful.What is important in foot surgery, and particularly in the elderly, is that the anaesthetic should be reversed promptly, so as not to leave a dangerously insensate foot.  None of these procedures allow that, whereas there are others (not listed) which allow prompt return of sensation.

Regional Anaesthetic block is the management of choice. It has none of the complications or unpleasantness of general anaesthesia, and -not unimportant – is easily reversed allowing safe, tactile, walking. The later has great importance for the safety of the elderly.

What will happen afterwards?  “For the first two weeks you should avoid walking if possible and only put your weight to the heel”. Difficult and dangerous in the elderly.

Risks.  “About 8 in 10 people have an excellent result from the Weil Osteotomy.  Up to 2 in 10 do not for a number of reasons”. Much fairer to the patient is to say that “About two in ten have a poor result”. [The Weil Osteotomy possibly has a more than 20% chance of failure, depending upon various reviews.]  Is that acceptable that that the procedure fails for one in every five persons?  This leaflet then goes on to give excuses for failure.  All these appear fatuous.

 “The foot tends to swell up quite a lot after surgery.  Swelling is part of your body’s natural response to any injury and surgery is no exception.  In addition your foot is at the bottom of your body so fluid tends to collect in the tissues and cause swelling.  People vary in how quickly the swelling disappears after the operation and 6 months is not all that unusual.  Provided you are not having undue pain and inflammation there is probably nothing to worry about and you can afford to give it time”.  To imply that swelling of the lower limb should not be of concern is not correct.  Swelling of the lower limbs, of whatever cause, is undesirable. The reasons will not be listed here. There are good reasons to believe that anyone who has swelling of the lower limb three days after surgery should be treated with an elasticised stocking.

Another complication baldly listed is deep vein thrombosis and pulmonary embolism.  Is it not imperative that patients should be warned in advance of signs and symptoms of this condition?  Knowing of its existance, and seeking prompt medical attention should  any symptoms pointing to the possibility, is mandatory.

Diabetic Foot Ulcers

Meetings of diabetologists justifiably occupy much time debating the management of ulcers of the feet, since a significant percentage of diabetics develop intractable ulcers leading to amputations.

These medical meetings correctly emphasise the importance of sensation loss and insufficiency of blood perfusion. However there is another necessary factor in the cause of foot ulcers, which is seldom discussed in these meetings, the abnormalities of alignment of the skeletal structures of the foot.  Examples are clawing, veering and rotation of the toes and dislocations of the toe joints. These cause dangerous high foot-pressure areas which are a necessary prerequisite for foot ulcers.

Such deformities worsen progressively[i], and once deformation has started ulceration in the insensate foot becomes inevitable with time. Therefore these abnormalities require correction immediately they appear, immediately the toes begin to claw, immediately the calluses show on the soles, and immediately any abrasions or corns appear on their feet.

Most non-diabetics with these foot deformities readily seek treatment because they are prompted by pain.

However, those who cannot feel do not complain, and so often progress to ulcers, with eventual loss of the foot by amputation

Naturally vascular supply surgery might also be necessary but, once the ulcers have appeared, other treatments like full contact casts, debridement of ulcers and bone, and various forms of direct application are all too little, too late, and often fail.

This is a tragedy because correction of the anatomical alignment of the forefoot (claw toes, hammer toes, “bunions”, corns calluses, metatarsal high pressure, and similar) can usually be easily, safely and permanently corrected by soft tissue releases. This reduces the incidence of ulceration dramatically and lessens the amputation rate.

Soft tissue realignment procedures are performed regularly on non-diabetics. Why then are they not performed in the far more urgent circumstances of diabetic sensation loss?

One reason is that podiatric and orthopaedic management commonly involves dividing and realigning perfectly normal bones, and often destroying perfectly normal joints. These procedures are dangerous (particularly in diabetics) because divided bones might not unite. Bones infected subsequent to surgical damage are exceedingly difficult to treat. Plates, screws, pins, spacers and Silastic hinges implanted in “conventional” surgery all increase the risks of infection. Further, bone surgery necessitates long periods of immobilisation which is detrimental to the physiology of the lower limb, producing yet another set of dangerous complications[ii]: Those without feeling run a high risk of abrasion by casts or other “immobilising” devices.

Clearly “conventional” surgery to bone is precluded in those without sensation or with complicated diabetes.

The belief that it is necessary to operate on bone has come about, and become entrenched dogma, because of irrationality. Bones cannot produce deformities and it is irrational to assault them. Deformities can only be caused by soft tissues pulling the bones into misalignment. The target for correction should therefore be the deforming soft tissues.

Because diabetologists have also been lead into this misapprehension they shy away from referring their patients for appropriate surgery, to the detriment of those who rely on their advice.

Soft tissue surgery is often performed successfully and safely on diabetics and those with sensory loss.

Leaving foot skeletal abnormalities in diabetics and sensory loss feet in the hope that complications will not occur is a misguided invitation to catastrophe.

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[i] For various reasons the skeletal deformities of the foot are far more common in diabetics and those with vascular and neurological disease.

[ii] These include oedema, deep vein thrombosis, fungal dermatitis and sensitivities to the contact material.

Diabetic Foot Ulcers

Meetings of diabetologists justifiably occupy much time debating the management of ulcers of the feet, since a significant percentage of diabetics develop intractable ulcers leading to amputations.

These medical meetings correctly emphasise the importance of sensation loss and insufficiency of blood perfusion. However there is another necessary factor in the cause of foot ulcers, which is seldom discussed in these meetings, the abnormalities of alignment of the skeletal structures of the foot.  Examples are clawing, veering and rotation of the toes and dislocations of the toe joints. These cause dangerous high foot-pressure areas which are a necessary prerequisite for foot ulcers.

Such deformities worsen progressively[i], and once deformation has started ulceration in the insensate foot becomes inevitable with time. Therefore these abnormalities require correction immediately they appear, immediately the toes begin to claw, immediately the calluses show on the soles, and immediately any abrasions or corns appear on their feet.

Most non-diabetics with these foot deformities readily seek treatment because they are prompted by pain.

However, those who cannot feel do not complain, and so often progress to ulcers, with eventual loss of the foot by amputation

Naturally vascular supply surgery might also be necessary but, once the ulcers have appeared, other treatments like full contact casts, debridement of ulcers and bone, and various forms of direct application are all too little, too late, and often fail.

This is a tragedy because correction of the anatomical alignment of the forefoot (claw toes, hammer toes, “bunions”, corns calluses, metatarsal high pressure, and similar) can usually be easily, safely and permanently corrected by soft tissue releases. This reduces the incidence of ulceration dramatically and lessens the amputation rate.

Soft tissue realignment procedures are performed regularly on non-diabetics. Why then are they not performed in the far more urgent circumstances of diabetic sensation loss?

One reason is that podiatric and orthopaedic management commonly involves dividing and realigning perfectly normal bones, and often destroying perfectly normal joints. These procedures are dangerous (particularly in diabetics) because divided bones might not unite. Bones infected subsequent to surgical damage are exceedingly difficult to treat. Plates, screws, pins, spacers and Silastic hinges implanted in “conventional” surgery all increase the risks of infection. Further, bone surgery necessitates long periods of immobilisation which is detrimental to the physiology of the lower limb, producing yet another set of dangerous complications[ii]: Those without feeling run a high risk of abrasion by casts or other “immobilising” devices.

Clearly “conventional” surgery to bone is precluded in those without sensation or with complicated diabetes.

The belief that it is necessary to operate on bone has come about, and become entrenched dogma, because of irrationality. Bones cannot produce deformities and it is irrational to assault them. Deformities can only be caused by soft tissues pulling the bones into misalignment. The target for correction should therefore be the deforming soft tissues.

Because diabetologists have also been lead into this misapprehension they shy away from referring their patients for appropriate surgery, to the detriment of those who rely on their advice.

Soft tissue surgery is often performed successfully and safely on diabetics and those with sensory loss.

Leaving foot skeletal abnormalities in diabetics and sensory loss feet in the hope that complications will not occur is a misguided invitation to catastrophe.

---

[i] For various reasons the skeletal deformities of the foot are far more common in diabetics and those with vascular and neurological disease.

[ii] These include oedema, deep vein thrombosis, fungal dermatitis and sensitivities to the contact material.

Weil, Weil, Weil!

 

In this website enquiries about the Weil Osteotomy  have been frequent. In this web-site (and in conferences around the world) I have asked the surgical community, both orthopaedic and podiatric, to explain how the Weil works. Just what does it do to correct pain? Despite many thousands of hits on my web-site no one has come forward with a valid explanation.

In the literature two pseudo-explanations are offered.

“Restoration of the metatarsal parabola”. Here it is reasoned that an unusually long metatarsal is responsible, particularly the second. It is claimed that the “normal foot” has the metatarsals forming a neat parabolic curve. Is there any evidence for that? Not that I can find. Foot shapes come in great variety. A lifetime of looking at feet has never revealed a “better” or “correct” shape.

Most feet function well for the first three-quarters of life, irrespective of significant variances. There is no hard evidence either that a “long” metatarsal is more prone to pain than a short one. What is true is that the second metatarsal often happens to be the first to become painful, and (by chance association) the second metatarsal also happens to be the longest.

But even if that association (long metatarsal = pain) should be correct, the argument immediately fails when Weil osteotomies are offered on multiple toes, or on a toe which is painful but with a shorter metatarsal.

The ultimate irrationality of this argument is that any given foot anatomy (perhaps with a long metatarsal, or with a “non-parabolic” shape) can function perfectly well for fifty or sixty years. When that foot becomes painful is it because the metatarsal is “long”?

Of course it is not – that metatarsal has had the same length all those years – not only that but it has functioned perfectly when the greatest loads have been on it, with youthful activity, running and jumping, pregnancies, and the rest. So some would try and make be believe that after half a century of service, a bone suddenly becomes “too long”! Really!

The other pseudo-argument promoting the Weil goes like this:

“When conservative modalities have been exhausted, you may consider over 20 surgical techniques, ranging from condylectomies to oblique osteotomies at the proximal, mid-shaft or distal metatarsal levels. Of these procedures, the Weil osteotomy has gained popularity, based upon the simple technique and stable fixation.”

This is another way of saying “If you are going to try something surgically try the easiest “something”.

“Try” is the operative word.

Corns, Callouses and Bunions

The following appeared recently in Timesonline http://www.timesonline.co.uk/tol/life_and_style/health/article5675591.ece
“Corns and calluses are usually the result of a bone prominence rubbing against another bone, causing hard skin. You can get that corrected surgically, so the corn doesn’t come back. It is an easy condition to treat and you won’t have to spend the rest of your life visiting the chiropodist.
People are often badly advised on bunions – prominent and painful lumps caused by an outcrop of bone near the big toe joint. If you don’t get them treated surgically, there is a risk that your big toe will become less functional and your second toe overloaded. This can lead to hammer toes, a condition that makes wearing any footwear, not just fashion shoes, difficult.
Mark Davies is a foot surgeon and founder of the London Foot and Ankle Centre http://www.bofas.org.uk”

I can find little to agree with Mark Davies. Neither corns nor callouses are “the result of a bone prominence rubbing against another bone”. Corns are a response of the skin to abrasion against footwear and calluses are a complex (but easily corrected) foot-floor interface problem. A “soft corn” is unusual, but does result from follow pressure between the toes, almost always when there is an “osteophyte” (a small arthritic prominence from the joint) present.
“Bunions” are not caused by “an outcrop of bone”, and I invite anyone to demonstrate such an outcrop to me. “Bunions” are a prominence of an entirely normal metatarsal bone pushed into an abnormal position . Cutting a “bunion” away damages a normal bone and its benefit is short-term and mostly cosmetic. This destructive surgery usually causes long term problems in the great toe joint. The very structures which prevent the great toe from “veering” are destroyed by this procedure: shoul anyone therfore be surprised that cutting away “bunions” causes the great toe to veer even more?
Veering of the great toe is totally unrelated to “hammering” of the lesser toes, and therefore advising correction of a big toe on the basis that it will benefit the lesser toes is entirely incorrect. The abnormalities of the lesser toes are entirely independent of abnormalities in the great toe.  Lesser toe abnormalities will continue to progress regardless of what surgery is performed on the great toe.

Are conventional explanations about “bunions” valid?

Hello Dr Driver-Jowitt. 

Thank you for suggesting I read your brochure about finding out more about foot problems on the internet. The first hit I found on Google just gave a quick overview of the different types of bunion surgery. The first they listed was for correcting the ligaments: Repair of the Tendons and Ligaments Around the Big Toe These tissues may be too tight on one side and too loose on the other, creating an imbalance that causes the big toe to drift toward the others. Often combined with an osteotomy, this procedure shortens the loose tissues and lengthens the tight ones. http://orthoinfo.org/booklet/view_report.cfm?Thread_ID=7&topcategory=Knee

(Name withheld by request)

Thank you for the enquiry. I am familiar with this paper, issued by the American Academy of Orthopaedic Surgery and co-developed by the American Orthopaedic Foot and Ankle Society. The Academy is a prestigious organization and it is disappointing that unsupported and irrational information is projected in this document. I am not aware that there is any evidence supporting the above suppositions. The comment about “tissues being too tight and too loose” is more an effect than a cause. Much of the paper discusses tight footwear as the causative factor, and the site says:” By far the most common cause of bunions is the prolonged wearing of poorly fitting shoes”.

As demonstrated in your case, the primary deformity is not the inward veer of the toe but the protrusion of the metatarsal away from the little toe. It is not possible for a tight shoe to cause the metatarsal to protrude outwards against the shoe.

The reality is that the deformity is zigzag, with the toe veering inward (towards the little toe) and the metatarsal veering outward (away from the little toe) and towards the shoe wall.

It is also improbable that your shoes were “too tight” when your deformity developed as a school-girl. Any shoe tight enough to produce a deformity, like any deforming force anywhere in the body, would be intolerably painful long before a permanent deformity could develop.

Many “Explanations” are not more than wild unsupported conjecture, without any validity or possibility of substantiation. Consider this suggestion by a surgeon discussing his “pain free” surgery in the online edition of a national newspaper.”Female hormones also soften this tissue, which is why women are prone to bunions”. http://www.dailymail.co.uk/health/article-1051558/Pain-free-surgery-cured-bunions-just-minutes.html

If this is the case why is a “bunion” often only on one side? Why do men and pre-adolescent girls get “bunions”? They don’t have “softening hormones”. This idea is simply fantasy.

More valid than the above “explanations” is the following statement by Drs Coughlin and Jones:” The…etiology of hallux valgus deformities…is a topic of great interest for all of us, but…is no closer to being defined now than in Morton’s era.” [Thomas George Morton 1835 -1903] http://www.ejbjs.org/cgi/eletters/89/9/1887#5193

I notice that one of the corrections suggested is aimed at dividing the bone of the metatarsal (an “osteotomy“). If the deforming forces were caused by pressure from the shoe acting on the toe, what is the rationale for a surgically attack the metatarsal?

The “exostectomy” described is nonsensical to me. There is no “exostosis” (i.e. no abnormal outgrowth of bone). The prominence is the normal bone, which is made prominent by the angular deformity, as I demonstrated to you. To remove the structures as in the diagram is quite wrong: The very ligaments which prevent the angular veer, and prevent the deformity from increasing, are having their attachments to the shaft of the bones  removed, and are therefore rendered ineffective.

I am sceptical about the claim that: “Many studies have found that 85 to 90 percent of patients who undergo bunion surgery are satisfied with the results.” Notice also the contrary comment “In fact, you will have some shoe restrictions for the rest of your life.”

A more realistic and objective assessment of the outcome of “conventional” surgery for deformities of the forefoot is the following meta-analysis in the Cochrane Database Intervention for treating hallux valgus (abductovalgus) and bunions. Ferrarid, HigginsJP, Williams RL. This paper is not optimistic about the outcomes of conventional surgery as it is at present

I would like to discuss your management further when you x-rays are available.