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Weil, Weil, Weil….!

Enquiries about the Weil Osteotomy have been frequent on this web-site. I have therefore asked on this site (and in conferences around the world) for both orthopaedic and podiatric communities 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 (by shortening a metatarsal)”. Here it is reasoned that an unusually long metatarsal is responsible for pain, 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.

Even the “benefit” of shortening is not universally agreed among the Weil exponents. The foundation design of the Weil is to angle the metatarsal in the sagittal plane. We therefor have those who explain that the length of the painful metatarsal is what needs to be corrected. Another school claims that it is the angle which need to be corrected. So which is it?

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 has a shorter metatarsal. The ultimate irrationality of this argument is that any given foot anatomy (perhaps with a long second metatarsal, or with a “non-parabolic” shape) can function perfectly well for fifty or sixty years before becoming painful.

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 – and has functioned perfectly during the times when the greatest loads have been on it,  youthful sport,  running, jumping, pregnancies, and the rest. So some would try to make us believe that after half a century of service, that bone suddenly becomes “too long”! Really!

The other pseudo-argument promoting the Weil goes like this (copied from a podiatric site): “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 a surgeon is going to try something surgically he should try the easiest “something””.

“Try” is the operative word.

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17 Responses

  1. Does that mean we can’t read the CD if we are not surgeons?

    My podiatrist says he has seen really disastrous results with calf lengthening – a sort of guessing game! Do you agree?

    The surgeon said a Weil’s but from what I have read that can be disastrous also. I feel further surgery of the type above could result in me being much worse off.
    Patsy

    • The instructions are intended to offer a new perspective to surgeons, and are highly technical. There is no exclusion, of course, but it is unlikely to be useful to anyone other than a surgeon.
      There are a number of ways of lengthening the calf muscles. One variant is lengthening the Achilles tendon, which at one time was purported to be the most common orthopaedic operation (I am sure that is not the case now)
      However, despite that history and tens of thousands of procedures previously performed there remains much debate about methods of lengthening the Achilles tendon. I have seen many very unsuccessful outcomes of Achilles tendon lengthening procedures.
      There are a number of other techniques including the injection of botulin toxin (Botox). All these require a level of educated surgical craftsmanship which is not universal.

  2. I thought the diagnosis of the problem with the 2nd toe was that the big toe was shortened during the bunionectomy, thereby adding to the loading on the long 2nd toe. I am concerned that shortening the 2nd toe would cause problems with the 3rd etc though. My surgeon said it “shouldn’t”. Sounds dicey! You say ‘it does not seem that there is a diagnosis of the underlying cause of your problems’. What other causes could there be?

    • You relate the common sequence of surgical quasi-reasoning. That reasoning train needs to go back one step. This is because the very same factors which caused the “bunion” are now, not unexpectedly, afflicting the second toe. Given time this cascade will ultimately involve all the toes. Therefore you are correct (but for the wrong reasons) that shortening the second toe might be a forerunner of third toe problems and so on. It is a pity that all the toes were not released at the first operative opportunity. See earlier comments on the fiction of “transfer metatarsalgia”.

      • I have been to another surgeon for a second opinion. He said that my calf muscle was tight and I should stretch it (fine). If that didn’t help he would lengthen the calf muscle (no, thanks!) and do a Weills osteotomy. He would shorten both 2nd and 3rd toes. He sounded very unconvinced. So was I!

        How is your powerpoint CD progressing?

        My orthotics are still being adjusted – my 2nd toe still gets sore if I walk far. Getting by on a day to day basis.

        In which state do you live, in case I happen to be visiting USA?

        • It is not unusual for the calf muscles to be tight and this tightness often plays a significant part in the deformity and the discomfort. It is often unrecognized: your surgeon deserves a star for that observation.
          We have tried calf stretching programs for over thirty years. I anticipate a barrage of offended responses from physiotherapists worldwide, but nevertheless I need to say that stretching has never resulted in anything other than temporary lengthening. On the other hand there is no downside, and it might work with your individual variance. Try it.
          Does you surgeon intend to shorten the toes by a Weil osteotomy, or an additional osteotomy to the toes? If so, where? If so why?
          Calf lengthening deserves a lecture in itself. I am strongly against Achilles tendon lengthening. Some reasons for this are in earlier responses, and a post dedicates to this will follow.
          The CD will describe the innovated surgical approaches which seldom include cutting bone, and is intended for surgeons. Marketing arrangements are in progress.

  3. The end of the 2nd, now very long toe in proportion to the big toe, is now quite twisted. The surgeon want to cut some bone out a bit further down the toe to shorten it and I understand the joint will be fused accordingly. The joint becomes inflammed after any exercise including walking. Not so bad wearing running shoes ie. with padding.

    On the pad under the 2nd toe it feels bruised, sometimes it is as if there is a bit of a lump in there and sometimes there is a sharp pain. He wants to do a parallel oblique osteotomy.
    Patsy

    • The pain in the pad under the second toe is probably related to tearing of the “plantar plate” (on the sole side of the metatarsal-phalangeal joint). Some surgeons, in heroic endeavour, claim that they can repair this structure. Such a repair is highly improbable, since the loads are high, and the factors which caused the tear in the first instance are not resolved. The anatomy of the plantar plate can usually be demonstrated by a skilled radiologist using ultrasound.
      It is not clear to me which joint of your second toe is becoming inflamed (or do you mean painful, which is not a synonym)

      • I have been to an excellent podiatrist who is making me orthotics which he says will redistribute the loading back to the big toe and off the 2nd toe. He says thid should solve the problem of the pain on the underneath of the foot at the base of the 2nd toe.
        I would appreciate your comments about the success or otherwise of shortening the 2nd toe in my circumstances because it does seem to have real problems.

        • A useful rule is to try only one form of treatment at a time. Simultaneous forms of treatment make it difficult to tell which is the most beneficial. Therefore, use the orthotics first and see if they live up to promise.
          It seems that the intended purpose of the surgery is to “fuse” the last joint of your second toe, and obliterating the joint. This is a conventional way of addressing pain in the joints of the toes. However, it does not seem that you yet have a diagnosis of the underlying cause of your problems. If this is not addressed it might be that over time the remainder of your toes will also have problems.

  4. Thank you. I gather that I should not proceed with surgery at this time.I really need your alternative suggestions as soon as possible!
    Patsy

    • You might need surgery if your symptoms are severe. Only you know how incapacitating is the discomfort. My comment was a caution as to the selection of the correct type of surgery. What type of surgery has been proposed?

    • I am not a physician but had 3 surgeries on my forefoot. The initial Weil procedure involved shortening my 2nd and third toes. This has resulted in numerous problems and a great deal of pain. I have done a lot of research into this area of surgery and am still searching for a surgeon that I can trust to help clear up my problems. What I do know is that when you shorten a toe, the metatarsal head is displaced. This can be detrimental because you have essentially changed the structure of the foot. The forefoot was designed in such a way as to have all 5 metatarsal heads support the weight bearing load of pushing off from your step. This amounts to several tons a day. By changing the distribution, you can overload one or more toes. Once the metatarsal is cut, there is no turning back, The key is to find a surgeon who understands the mechanics of the foot to provide a an accurate diagnosis

  5. I am one of the unfortunate recipients of the Weil osteotomy a little over 2 years ago and it has dramatically changed my life for the worse because of the ongoing pain and immobility. I have later had two subsequent surgeries to correct the damage but it only gets worse.

    How do I find an extremely competent forefoot sugeon who could possibly correct some of my problems? I am willing to travel anywhere on earth to find the right treatment.

    • Yours is the type of sad letter which I often receive. Intentionally I have not, at least not on this website, attempted to explain why the Weil is flawed, and what should be done instead. That was because I wanted to explain, in detail, supported by hard evidence and long follows up (more than twenty five years minimum) the alternative techniques. This is coming to fruition now in the form of a PowerPoint CD, which I hope will change the approaches currently used.

      • I recently had bunion surgery which is doing well. Unfortunately the big toe had to be shortened and the 2nd toe was already long. Th eend joint is now twisting and there is pain on the pad under the 2nd toe. What advice do you give?

        • Often surgery is performed on the great toe alone. This can be a problem since the cause underlying the great toe deformity also affects (to a greater or lesser extent) all the toes. Once the big toe is less symptomatic the next most commonly affected toe (usually the second) can give symptoms. This is often called “transfer metatarsalgia”. I do not believe that “transfer metatarsalgia” exists. The term is unfortunate since it has given rise to the irrationality that the second toe should be shortened as well. I do not believe that is the appropriate way to correct the symptoms, and that surgery often produces it own set of complications.

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