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Weil osteotomy again

Weil’s osteotomy is claimed to correct a number of forefoot problems, including “metatarsalgia”, “claw toes”, “dislocations of the metatarso phalangeal joints”, lengthening metatarsals, shortening metatarsals and even “slimming the foot”! (Barouk). Some even claim that it can be used to correct veer. How any procedure designed to alter abnormalities in the vertical (sagittal)  plane can correct malalignment in the horizontal plane defeats me.

Any single surgical procedure which claimes a benefit for such different pathologies  (or pathologies of unknown cause, which is often the case in current forefoot surgery) must be regarded with the same scepticism warranted by blood-letting as a “catch all” cure.

One rationale justifying Weil’s osteotomy is that it purports to correct “Morton’s Foot”, where the second metatarsal is longer than the first. An irony here is that many types of surgery used for “bunions” shorten the first metatarsal, and so create a “Morton’s foot”.

The reality is that there is no rationale for this procedure. If it is of perceived to be beneficial, then it is purely by chance, and the procedure should then be regarded as a “noxious placebo”  [ https://drjpdriverjowitt.wordpress.com/curriculum-vitae/noxious-placebos/ ]

The following paper by podiatrists http://www.ncbi.nlm.nih.gov/pubmed/12043986?dopt=Citation claims the Weil to  be a good procedure, but see below:

“The surgical management of central metatarsalgia. Foot Ankle Int. 2002 May;23(5):415-9.

O’Kane C, Kilmartin TE. Department of Podiatric Surgery, Ilkeston Hospital, Derbyshire, England. claire@cokane5.fsnet.co.uk

Seventeen patients (20 feet) underwent Weil osteotomies of the second and third metatarsals for the treatment of central metatarsalgia and were reviewed at an average of 18 months postoperatively. Fourteen patients were completely satisfied with the results of their surgery (85%), one patient was satisfied, one patient satisfied with reservations and one patient was dissatisfied. The American Orthopaedic Foot and Ankle Society clinical rating scale improved by an average of 44 points. One patient had complete recurrence of symptoms, eight out of the 40 toes involved in surgery were floating, four toes were stiff, there were three cases of infection, and transfer metatarsalgia affected the fourth metatarsal in one case. The Weil osteotomy is an effective and safe procedure for the treatment of central metatarsalgia.”

However, when read from the point of view of complications, this paper is not encouraging because:

15% were less than completely satisfied
20% had floating toes
10% toes were stiff
7% had infection
2% had “transfer metatarsalgia.

Of course these complications are not additive arithmetically. It is likely that those who had complications had more than one complication. It is equally likely that those complications were not all confined to the 20% who had the floating toes, and it is here that the bald statistics hide the more important information about the spread of complications. As a result we simply do not know who had which complications.
Another difficulty is that the numbers are statistically small and the follow up relatively short, considering that these feet are to be used for the remainder of life. Finally people do adapt to disabilities and often underrate their disabilities on review. (see the paper on “bunions”)

Now consider the following paper by orthopaedic surgeons:

Trnka HJ, Gebhard C, Mühlbauer M, Ivanic G, Ritschl P. http://www.ncbi.nlm.nih.gov/pubmed/10063974

Department of Orthopaedic, Hospital Gersthof, Vienna, Austria. hans4hallux@aon.at

Hardly any surgical methods are available for metatarsalgia caused by a dislocated lesser metatarsophalangeal joint (MTP) that do not sacrifice the joint. We reviewed retrospectively the outcome of 60 metatarsal Weil osteotomies for correction of dislocated lesser MTP joints in 31 patients. Between 1995 and 1996, 31 consecutive patients were treated with a Weil osteotomy at 2 institutions. The Weil osteotomy is an oblique osteotomy of the metatarsal neck and shaft, parallel to the ground surface, that controls shortening of the metatarsal by internal fixation with screws or pins. At an average final follow-up of 30 (24-44) months, all patients were interviewed, using a standardized questionnaire based on the AOFAS Lesser Metatarsophalangeal-Interphalangeal Scale. Recurrent or transfer metatarsalgia, formation of callus, mobility and dislocation of the MTP were noted on physical examination. Dorsoplantar and lateral weightbearing radiographs taken preoperatively and at the time of final follow-up were examined for alignment of the metatarsal heads, subluxation or dislocation and for evidence of nonunion, or malunion of the metatarsal osteotomy. We had excellent results in 21 patients (42 osteotomies). A major complication was plantar penetrating hardware in 10 cases (3 screws and 7 pins). We conclude that the Weil osteotomy is a good method for correcting metatarsalgia caused by dislocation of the MTP joint.”

Twenty four percent (10/42) of the procedures had what the authors call “major complications”, and the phrasing seems to imply that there were other (perhaps “minor”) complications. Hardly the kind of risks many would knowingly accept.

I would welcome correspondence from those who perform Weil’s osteotomy justifying its use.

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31 Responses

  1. I am 6 months post op – Weils osteopathy on 2nd and 3rd, key hole on 4th and 5th and a planter plate repair. I am in considerable pain which I fear is not going to resolve. All toes 4 toes that were operated on are floating and all 5 extremely stiff and painful. I have a large lump on the bottom of my foot (ball of foot and just behind) which means I either walk on the inside or outside of my foot. Because of this I now seem to be developing a painful bunion. Despite physio I have not made any improvement for a couple of months and now feel things are actually deteriorating. I now have pain in my left knee and also my back, which I didn’t suffer from before the operation. I feel sure that because of the way I now walk that it is having a knock on effect on the rest of my body. I am feeling incredibly disappointed and worried about the future. Had I known the statistics relating to the complications and problems of this surgery I definite would not have gone ahead. Indeed I wish I had never had it done. When I last saw the surgeon it was suggested that further surgery may be necessary. As you can imagine I am very sceptical about going under the knife again. I have also now been refereed back to the orthotic department by the physio. Any advice of what I should do would be most welcome.

    • I am sorry to hear this tragedy, one I have heard many times.

      If further surgery is suggested you should ask for an exact description of the intended surgery. Should you choose that could be sent to me for comment. Otherwise I would be happy to look at your most recent x-rays (send by jpg or similar).
      It is not unlikely that your limp is causing pain in other parts of your body.

  2. My first post on this site was about one year ago almost to the day, the previous post November 8, 2010. Once again, the Weil osteotmy was done in Nov 2008 both feet at the same time. Diagnosis, pre dislocation sysndrome. Mar 2009, the screw was removed after causing a golf ball size lump on my right foot. Jan 2011 another procedure done to give the 2nd toe more flexibiity as was told the screw that came loose on the right foot tcaused the bone to heal improperly and an “excision” to file the bone down. So now, its 3 surgerys later on the right foot!

    The pain continues to be brutal, under the 2nd toe The Weil procedure a total failure. I am much worse since the procedure. Chicago, Illinois doctors dont know why I am in pain.

    So now its Nov 3 2011, three years since the double Weil. Let me tell you I am miserable.

    Now I am told I have a fragmented sesamoid on the right foot confirmed by MRI. I have the same pain under the big toe on the left foot. Perhaps, the Weil and shortening of the 2nd metatarsal caused excess stress to the big toe.

    I am serious when I write this. Can you come to Chicago, Illinois and rescue me Maybe I need to come to travel to you. Constant pain and now more surgery needed to remove the sesamoid. The ortohotics of little help.

    I would advise anyone who is considering this procedure absolutely NOT to have it.

    • I am skeptical about the diagnosis of a “fragmented sessamoids” and cynical about the term “confirmed by MRI”. There may be changes in the sessamoids, but are they the cause of your symptoms? The sessamoids often develop in several pieces, at times these parts are claimed (incorrectly) to be “fractured fragments”. At other time “bone edema” is demonstrated. There is much debate about what this feature on MRI really means. What is the MRI appearance of the left sessamoids? Certainly no assurance can be given that these MRI changes are the cause of your pain; they could be incidental happenings. Orthotics at best are placatory, at worst aggravating.

      • Thank you very much for all your time and advice. Yesterday, November 30th, I went to see an orthopeadic foot and ankle specialist.
        The doctor made no comment on my prior surgery’s but reviewed my recent MRI and took new X-rays. Her conclusion was that my problem iis an arthritic joint in the big toe joint on both feet. I was given cortizone shots in hope of pain relief. I was told if that did not work I would require surgery, a fushion of the big toe, Arthrodesis. That proceure would leave the big toe without any flexibility but would relieve the pain. What is your opinion about that procedure? Would I have trouble’s walking after that procedure?

        • Arthrodesis of the metatarso-phalangeal joint (technical words are used only for precision of description) or the base of the big toe is frequently used. There are some problems, which could include a convalescence of many weeks, and “fusing” at an angle which is awkward for you.
          The selection of surgery should take into account your age, and your activities.
          Whilst I have seen some great-toe arthrodeses go very wrong, there have also been good successes. Some football and soccer players (and this arthritis is common in them) return to their sports.
          One orthopaedic surgeon, whom I respect – an aficionado for the arthrodesis – told me of his success with a (veteran) sprinter. I do not know which side was arthrodesed – which could be important depending on the lead foot of the sprinter on the starting blocks. This illustrates the need for precision in selection and the design of such fusions.
          My own practice, emphatically in the elderly, is different.
          This web-site is not the place to display my alternate techniques. However, I am considering another web-site, which I hope will become “peer critical”, describing some techniques which might be improvements on existing methods.

  3. i am due to have a weil osteomy and a pipj joint fusion in a couple weeks just wondering if anyone has had this done and would like to share there experience more concerned about mobility after operation as i have a five yr old and need to get her to and from school

  4. I had a Weils osteotomy of the 2nd metatarsal and arthrodesis of the 2nd toe 5 months ago, the surgery really helped with the uncomfortable pain that I had in the bottom of my forefoot, but now pain is setting in the top of the foot and the second toe floats. Not to mention I have very little feeling in the big toe and second toe now it feels like needles. So sick of it, wondering if maybe I messed something up again since my temp pin was removed a week early.

    • Removing the pin through the arthrodesis would not have caused the symptoms you described. In fact there is a technique which does not require the pin at all, and preserves the movement in the toe, without the arthrodesis. The “floating” is probably because the toe is fixed in the straight position. However there is a good chance that it will come down to the floor level in the year after the surgery. If not it can usually be corrected easily. It is usually done as an office procedure.

  5. I have had worsening metatarsalgia over past two years. Original pain felt like proverbial “marble “in shoe and more recently it seems to be most directed to a swelling between 2nd and 3rd toe. There is occasional toe discomfort of the 2nd longer digit.

    Podiatrist said that the 2nd toe was “crossing” towards the first. It did have some medial rotation at the lower joint area inward towards the big toe, not a true “crossing”. Oriiginal DPM strapped the the second toe in a downward position with makeshift in-office splints that seemed to provide some relief during work day. He then designed orthotics with metatarsal bump that I wear with limited success. Whether I use this orthotic or not, end of day results in terrible burning at forefoot .

    A second DPM after MRI diagnosed “thickening of planatar plate” and “plantar plate predislocation syndrome”. He recommended a 2nd metatarsal shortening, flexor tendon transfer and hammertoe correction.

    I went for an orthopoedic opinion from an MD and he diagnosed “overuse injury involving plantar plate” on 1st visit . He was opposed to any surgery as proposed by the DPM. Follow up visit with same physician then diagnosed “Morton’s neuroma, 2nd web space” after injection with lidocaine and subsequent reduction of symptoms. I understand that this neuroma is most often between 3rd and 4th toe and moreso in women.

    Being really confused …I went to an orthopedic chief at major university who claimed that there could be combination of problems…2nd MP joint unstable and possible neuroma as well. He reviewed all X rays and MRI. He concurred with flexor tendon transfer procedure and neuroma excision if nerve is thickened or simply cut “ligament” where nerve is inflamed rubbing between 2nd and third toe for pain relief. This “neuroma” decision would be during surgery as he examines the area intraoperatively. He was against any toe shortening procedure as to problems with floating toe and difficult healing afterwards. He felt that inward rotaion of the longer 2nd toe could be secondary to plantar plate instability as opposed to being the causative force.

    Can you help me here with your opinion as it has varied from 3 differing DPM/physicians.

    • It seems that you had two orthopaedic and two podiatric opinions which varied remarkably. Your symptoms are typical in every way, and it is no surprise that you are left wondering how a standard symptom pattern can have different solutions. To begin, it is highly unlikely that you have a Morton’s “neuroma”. As you say it almost inevitably occurs between the third and fourth rays, for good anatomical reasons (which I will enlarge upon in a future post). The benefit of the cortisone injection would be a general benefit to the damaged adjacent structures, and the resulting benefit is not of diagnostic value viz-à- viz Morton’s neuroma. This entity is caused by the deforming changes in the forefoot and, when these are properly corrected, disappears spontaneously. That is why it is commoner in females, who have a higher incidence of forefoot deformation. The glib removal of this nerve (which is what many surgeons suggest) can cause significant pain, similar to an amputation neuroma, which is difficult or impossible to treat. I think that your surgeon wants to cut the intermetatarsal ligament, but that also produces its own set of problems.
      Morton’s neuroma, incidentally, does not fit the histopathological morphology of a neuroma, and should not be called such. MRI diagnosis is fallible.
      The reason that opinions vary so much is that the understanding, by so many professionals in the field, of the causal sequence is limited. Recently I asked the Head of Foot and Ankle unit at a world famous institution if he understood the cause of these abnormalities, and he was frank enough to say that he did not. Others are not as honest. As a result hundreds (literally) of procedures have been tried in a “random therapeutic walk”. The Weil osteotomy is only one example. Space here does not permit me to explain the relatively complex sequence of events in the evolution of your problem (and its management), but I will write to you directly over the next few weeks, in order to explain both the cause and the rational treatment.

  6. I had a Weil 10 months ago on my second toe. The recovery has been long and frustrating….BUT I no longer have the intense pain that I had prior to surgery. My toe floats ever so slightly and at times I still favor it causing me to be off balance. I have been able to resume ALL activities though and have even started running! I can do all of the things with my children that I could not before due to the pain. This procedure although difficult, really really helped my quality of life. Having an amazing doctor is a huge part of the success!

    • Thank you Stephanie for the perspective. It is correct that some recipients of the Weil osteotomy do improve. But it is equally true that many people who have forefoot deformities and pain also improve spontaneously, without surgery. The mechanisms behind the lessening of these symptoms requires an essay in its own right, which is not appropriate here.
      There are a number of distinct causes of pain associated with the forefoot deformities, notably in the second toe. These include the pains produced by increased toe tip impact, abrasions on the top of the toe at the proximal inter-phalangeal joint level, corns, “soft” (interdigital) corns, plantar callocities, ulceration, changes in the nail and nail bed and pain (and arthrosis) in the metatarso-phalangeal joint. You have not said which was the cause of your pain.
      The proponents of the Weil have never been able to explain to me how the Weil corrects each of these different types of pain, by a single “all-encompassing” procedure. (And I have spoken to many “world experts” at Foot and Ankle conferences internationally).
      It is equally true that many who have had the Weil suffer, at best, a prolonged and expensive convalescence to find they are no better and at worst that they have more or different symptoms post operatively.
      The clawing which I suppose you had in the second toe is, unfortunately, a harbinger of troubles in the rest of your foot, at some time in the future.

    • Stephanie – Who did your surgery, and in what city?

  7. I’ve seen a surgeon who recommended fusing both big toes and Weils osteotomy on one 2nd toe which has slight hammer and pain underfoot. I don’t think I’m anywhere near going through these procedures; the more I read, the worse it seems. Although dancing has been my passion, I’d rather totter round the house than risk some of these outcomes, at least until the pain becomes unbearable. The surgeon was not very good at explaining necessity of procedures, or the outcomes. I would .like to see a justification for this procedure, too… has no-one replied?

    • Whilst popular, fusing the great toes has many problems, including inter-operator variability of success. Said another way some surgeons are less successful with these fusions than others. Many people who have had great toe fusions have returned to dancing, soccer, and running – but many have not. Some are much worse, like the woman I will be trying to reconstruct tomorrow. My views on the Weil are well recorded. However, all this does not help you, and many others, to get back into the world of function. I am therfore preparing a DVD on my research on these abnormalities and their management, for distribution to orthopaedic surgeons. This is likely to be ready by the (northern) summer.

      • Is this DVD ready. You have responded to all complaints, so I assume you are expert in corrective foot surgery. I am very anxious to see this research.

        • These techniques are well developed, and established by 30 years of follow up, on large numbers of patients.
          Please tell me who you are…

  8. I had a Weil in March 2008, the result was infection, an 11 mm screw was taken out 6 weeks post op – (I never knew screw was in), I now walk with a floating toe, pain in ball of foot, have to wear orthotics, closed shoes, tackies in very hot SA weather, or just suffer the pain of walking in open shoes without orthotics. I went back to the doctors, but their opinion is to continue with conservative treatment (orthotics) and no invasive surgery. I will try my best to come and see you in 2011. I am not on medical insurance, which is a problem. Embarrassing as government surgery was done. Now I am stuck. Awful to have to walk like this for the rest of my life, unless God does a miracle (another surgeon recommended K-wire, BRT) – happy 2011, Lorraine.

    • This sad tale is sent to me frequently (not many are published) The Weil is doomed to fail often, because it does not address the underlying problem.

  9. I had a surgery three years ago to remove a bunion. The doctor also preformed a correction for a very slight hammer toe condition that has devastated my live. I have a constant pain and or discomfort. It wakes be in the middle of the night and I seldom go to sleep without putting my foot out from under the cover. I need help.

    I have been through therapy, Vitamin and Lyrica treatments. I have seen a podiatrist and another orthopedic surgeon. No one can offer a solution and I am now waiting to see another specialist. No one see to recognize my urgency with this condition and I need advice to get relief.

    • Please tell me where you have pain, great or second toe, sole or skin of toe? Do you have an operation report?

    • Similar problem
      On my left ankle,
      toe tips where screw are
      On upper part of foot
      Unable to cover the foot when I sleep due to burning on my foot

      • Thank you for the response: Another unsatisfactory outcome.
        In Weil osteotomy the screws are in the metatarsal heads, not the tips of the toes. Did you also have intramedllary screws used to straighten the toes? If so, those could be removed.
        It is also possible that the digital nerves became involved in the Weil surgery.

  10. I had a Weil Osteotomy on Both feet in Nov 2008.
    The pain after surgery is much, much more intense than prior to surgery. Its brutal. The three other Doctors in my area tell me after looking at my X-rays that the surgery was a success!! Hmm, If so successful then why is the pain far more intense after the procedure.. No answers. I suffer everday of my life, Its BRUTAL.

    • In reply to Anonymous
      96.24.28.46
      I am so sorry that you have had this experience. I agree absolutely, success is to be measured by relief of presenting symptoms and functional return. That is the sine qua non. X-rays are irrelevant as a measure of success.
      If you would lie to e-mail (jpeg) photographs of your feet, and pre-operative x-rays I might be able to make useful comments. It disturbs me that my colleagues persist in their irrational approach.
      Best Wishes

  11. i had a double weil procedure on 2nd and 3rd metattarsals 1 year ago and have suffered with much worse pain since the operation as i am an active person and the operation has left me with a wide splayed foot walking on side of big toe and 4th toe producing constant pain and callouses on these pressure points. my 2nd and 3rd toes are floating despite months of physio therapy to improve the range of movement. they only reach the ground by clawing and i have stiffness, odd sensation and pain all through my foot and toes. my dr has referred me to a pain management specialist for counselling and medication but I believe he never should have done this surgery for pain in the ball of my foot and doubt this is a successful op for anyone. how can you walk on 2 shorter toes??? the rationale of the surgery doesnt even sound logical please help!

    • Foot and ankle surgeons around the world have justified the Weil osteotomy as “the only joint sparing procedure available for claw toes “.

      Whilst sparing joints is to be applauded, the rationale in your case is fallacious because:
      The object of the treatment is to abolish pain. If that pain arises in a joint which has an arthrosis or “synovitis” there is not a lot of sense in preserving it unaltered.

      The “joint” is not just the bone and cartilage. For a joint to function there must be normal function of the tendons, capsule and other finely designed structures about the joint. If these structures are damaged (as they are in the Weil) then the joint loses function (as in your case) and the joint can hardly be considered to be “preserved”.

      Since I understand that steroid injected into your joint helped temporarily, this points to your pain’s origin in the joint.

      What you need now is an excision arthroplasty of that joint. This can be a tricky procedure, and needs experience. You should be able to walk from the surgery the same day, with little (if any) pain, and return to former activities in 10 days.

  12. Hello, I had the Weil Procedure nine months ago. I am in pain all of the time, my toe sits slightly on top of the third one and my Doctor isn’t offering a solution. Would you be able to offer me any advice or recomend someone, in Columbus, OH?

    • Please tell me the reason for the procedure, and whether the pain you have now is different to any pre-operative pain you might have had.

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