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.

Rethinking orthopaedic and forefoot surgery.

This post continues the page Stop! Wrong way! in relation to orthopaedic management

Deformities of the forefoot. These include “bunions”, Morton’s “neuroma”, clawed toes and “flat foot” (whatever that is intended to mean). It is unlikely that any group of elective procedures has been performed, in total ignorance of the causative factors, more often, by more people, in more ways, than various forms of surgery to the forefoot.

Fractures being “set” as soon as possible after the injury. This damaging policy produces significant, irreversible, complications. It will be addressed in a separate post on this site at a later date.

Finger-tip injuries. These common injuries produced a plethora of surgical treatments, from skin grafts and”rotational flaps” to “cross-finger flaps”. These required not-inconsequential surgery, sometimes under general anaesthetic, were expensive and incapacitating for various periods, and unnecessary. Harvest was taken from uninjured areas of the palm and other fingers, scarring those. The best results however have been shown to be obtained by doing nothing beyond usual wound care! The body’s capacity to heal itself at that site is not unexpected, being as easily and frequently injured as the fingers are.

“Traction” for so called “slipped discs” (mostly that diagnosis was incorrect, in the event). Tens of thousands of patient-days were lost by placing these unfortunates in hospital and attaching weights by cords to their legs, literally tethering them to their bed for days or weeks. This was entirely ineffective since the friction of the legs prevented transmission of any “traction” to the discs. The management was adversely effective, since most low back pain improves more rapidly with movement (ideally in water). Deep vein thrombosis would be expected to be increased by this form of immobility. I wonder how many died of resulting pulmonary embolisms.

 Osteomyelitis. Antibiotic usage and aggressive resection of bone is often counter productive and dangerous. The loss of the limb might result from some current management policies. This is addressed in a separate post on this site.

Is there a solution to my foot problem?

 

 

 

(Name withheld) Thanks again for your emails. In March this year, I had a Weil’s Osteotomy so as to correct my hammer toe which was the one next to my big toe and not the middle toe like the toe in your photograph. Since the first operation in March, then again in April, when they removed the screw as my body rejected it – it is now October, the toe is still very stiff and it is still floating (looking awful is the least). I saw a podiatrist a few times and he has now done a wedge on the middle toe next to the hammer toe which was operated on, he told me that all my body weight is now on the toe next to the operated toe, or something to that effect. The very worst of course for me is the hard lump/callous which is now underneath my foot, like a tight knot lump there and if I don’t wear an orthotic insole for walking, I’ve had it – even when I do wear one, the throbbing recurs. I can’t take pain tablets all the time, so I am just learning to live with it. After what I went through, if there is a solution?

Response: The Weil osteotomy is discussed in the pages

The patient in the picture which you refer to had four procedures before I got to see it. The second toe (next to the great) on the left had some kind of osteotomy, and was “floating” perhaps like yours. The third toe probably looks as your second toe did pre-operatively. The hard lump is a direct result of your toe abnormality, and can be predicted to worsen progressively unless surgically corrected. There is, very definitely, a solution. I look forward to seeing you and explaining the mechanism and background of your problem.