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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.

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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.

Noxious placebos

Placebo, originally meaning “to please”, has come to mean applications which are believed not to have a known biological effect. Since these applications (“placebos”) are assumed to be “inert”, and specifically not harmful, they have been used as a standard against which planned biological manipulations (“treatments”) can be measured objectively. In this way placebos are perceived to satisfyingly demonstrate a cause and effect chain from treatment to benefit

 

However, although having no rationale, placebos themselves can produce a subjective sense of benefit. The reasons are not understood, but could include the effect of having been a centre of attention, or a mystical belief that some type of interference or intrusion into the soma must have a potential benefit. Intermediary pathways have been demonstrated with changes in dopamine and the endorphins and activation of brain areas demonstrated by imaging.

 

Although these intermediary phenomena are interesting as correlated observations, they do not advance any comprehensive explanation of the linkage between cause (application/placebo) and benefit.

 

Subjective reporting by the patient is often used to measure the benefit of treatments. In some of these cases it may not be possible to distinguish between the benefits of placebo versus planned biologically manipulation (’treatment”).

 

Let us now consider applications (“placebos”) which have no comprehensible therapeutic value but are neither inert nor benign. There are many historical examples ranging from trephination and blood-letting to purging and emeticism. Many of these “non-benign” applications persist contemporarily, such as excoriation by witch doctors, bee-sting therapy, piercings and many more. While it will have been clear to all that these treatments were harmful, with obvious damage or perturbation to the body, they must also –in the long run- have been perceived to have been beneficial to have been continues. These forms of irrational treatment must be assumed to have placebo mediated (“placebo effect”) benefit, either objectively or (more likely) subjectively.

 

Some, no doubt, have their benefit more at a societal level than at the level of the patient. By this I mean that the beneficiary is a group, rather than an individual. Procedures such as trephining could have appealed to the bystanders (as a group) as a “Don’t just stand there, do something” action, or alternatively as a protection to society by ridding one of its members of evil. (The evil will have been in the form of “spirits”, since the expectation was that the spirit was imperceptible, and therefore the release was not expected to be perceptible). Human sacrifice, judicial hanging and suicide bombing may well have been the extreme expression of a placebo producing a societal benefit.

 

Where physical damage occurs, a biological response (and perhaps a psychological response, if a distinction exists) is to be expected. Pain will produce a humeral and neurological reaction, as also would loss of body fluids or extreme temperature changes.

 

I will call these noxious placebos.

 

If one progresses to formal surgical assaults, it seems likely that such placebo effects should also exist in that domain. This would be expected to be particularly so where the motivation for surgery is more subjective than objective, and where the measurement of “success” is a subjective evaluation. In these circumstances the objective measurement of the surgical benefit might be highly distorted. [See page “Is conventional forefoot surgery proven as beneficial”]. If this is the case it will invalidate most self (patient) reporting scales of benefit.

 

I am concerned that many areas of surgery of the foot might fall into the category of noxious placebos. This is because the rationale for many surgical procedures on the forefoot is obscure. Further, a single surgical procedure might be claimed to have a benefit for a number of anatomically distinct problems [see page “Weir 2”].

I am concerned to read about the high number of complications which occur, and yet the patient (and by extension surgeon) rating of the outcome is “success”.

 

Finally, the web has many diaries of people who have undergone surgery, and suffered extreme and prolonged discomfort, sometimes multiple surgeries, and although yet to recover are already “pleased with the outcome”. One example, amongst many, is man who is “Happy with the results…so far” below…

 

Junior Member

(male)

 

Join Date: Jun 2007

Location: New York, NY, USA

Posts: 31

Re: Flat Foot Reconstruction Surgery–Share your advice & experiences please!

Just a quick update from me: I saw my surgeon yesterday, the foot looks good and he’s cleared me to start physical therapy! Any advice on what I should be expecting? I’ve been pain-free for a while but I know that’s going to change as I start to put weight on it again. Basically he said that the next 2 weeks I go to therapy but don’t do anything differently at home; every week after that, I put 25% of my body weight down, so that after 4 more weeks I should be fully weight bearing. At that point I should get out of the boot and into some sneakers!

Hope everyone’s doing well.

lori, has your son had his consultation with the orthopaedic surgeon yet? I know it’s scarely to contemplate surgery for a child, but based on what you say about how’s it is impacting his life it does sound necessary. I am happy with the results of the surgery so far, and while many of us complain here, it does seem that most of us are really, truly glad to have had the surgery in the long run. Best wishes to your son.

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.