Geometric analysis of the Weil osteotomy

Advances in the Causes and Treatment of Floating Toes after the Weil Osteotomy: A Scoping Review

The floating toe deformity is classified as a forefoot deformity wherein the distal portion of the toe does not establish touch with the ground, resulting in a suspended or elevated position while the finger is in a relaxed state. At first, it garnered considerable interest as a complication It is worth noting that this condition is particularly common in children under the age of 8, which usually disappears as the individual reaches maturity. Studies have shown that with the aggravation of floating toe deformity, its adverse effects on patients' gait and overall quality of life also increase. Despite the prevalence of floating toe deformity in clinical settings, there is a lack of comprehensive literature investigating its underlying causes and potential preventive strategies. This scope review follows the preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (PRISMA-ScR) statement guidelines for scope reviews. The literature was obtained from various full-text databases, including China National Knowledge Infrastructure Database (CNKI), Wanfang Database, PubMed, and Web of Science Database. Our search focused on published literature related to floating toes, Weil osteotomy, and distal metatarsal osteotomy, up until March 1, 2023. The literature search and data analysis are conducted by two independent reviewers. If there are any disagreements, a third researcher will participate in the discussion and negotiate a decision. Furthermore, two experienced foot and ankle surgeons conducted a thorough literature analysis for this review. Sixty-two articles were included. Through the clinical analysis of the structural changes of the forefoot before and after operation, the classification of floating toe was described, the causes of pathological floating toe were summarized, and the possible intervention measures for the disease were put forward under the advice of foot and ankle surgery experts. We comprehensively summarize the current knowledge system about the etiology of floating toe and put forward the corresponding intervention strategy. We recommend that future studies will focus on the improvement of surgical procedures, such as the combination of Weil osteotomy, proximal interphalangeal (PIP) arthrodesis and flexor tendon arthrodesis.

Biomechanical Analysis of the Change of the Metatarsophalangeal Joint’s Center of Rotation After Weil and Triple Weil Osteotomies: A Comparative Cadaveric Study

Background

The aim of the present biomechanical study on cadavers was to determine both the center of rotation of the metatarsophalangeal joints and the position of the tendons of the interosseous muscles after the Weil and triple Weil osteotomies, and to compare these parameters in order to clarify the pathogenesis of dorsal stiffness and floating toe.

Materials and methods

Seven fresh-frozen cadaveric feet were utilized. After completing the preparation of both the plantar and the dorsal surface, we performed the dissection of the entire second, third and fourth rays, and each ray was fixed to a wooden wall mounted on a movable frame. The biomechanical analysis was based on an equilibrium system made of pulleys, threads, and variable weights. Geometrical analysis of both osteotomies and fluoroscopy was used to determine the initial and final metatarsophalangeal joint’s center of rotation, as well as the change of interosseous muscles position.

Results

On comparing the results of the findings, we noticed that after Weil osteotomy, the metatarsophalangeal joint’s center of rotation was proximally and plantarly displaced by 3.5 mm compared to the control group, and by 3.7 mm in comparison to the triple Weil osteotomy group. In the latter, the center of rotation was displaced by 0.817 mm compared to the control group. Furthermore, after the Weil osteotomy, the position of the interossei tendon was above the metatarsal longitudinal axis.

Conclusion

In cases where a metatarsal shortening of 5 mm or greater is desired, the Weil osteotomy causes a statistically significant plantar displacement of the metatarsophalangeal joint’s center of rotation, compared to cases where triple Weil osteotomy is performed.

Incidence of and Functional Significance of Floating Toe After Weil Osteotomy

Background:

The most frequent complication after Weil osteotomies is a floating toe deformity, but there are no reports about its effect on the patient. In this study, we analyzed the consequences of floating toe deformities after the performance of a modified Weil osteotomy (MWO) or a modified Weil osteotomy with interphalangeal fixation (MWOIF).

Methods:

We performed a retrospective review with a prospective follow-up of 50 patients (98% women, 120 rays) who underwent MWO (65 rays) or MWOIF (55 rays), with a mean age of 54 ± 12 years and a minimum follow-up of 4 years (mean of 6 years). We analyzed the presence of floating toe deformity in MWO and MWOIF and the outcomes measured by the subjective satisfaction, Lower Extremity Functional Scale (LEFS), American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, and quality of prehension force between patients with or without floating toe deformity.

Results:

The mean floating toe incidence was of 57%, with no significant difference between operative techniques (48% MWO, 67% MWOIF; P = .053). Our analysis did not show differences in satisfaction, LEFS and AOFAS scores, or grip strength between the group of patients with or without floating toes.

Conclusion:

The presence of a floating toe deformity was more frequent than generally believed but did not have a meaningful impact on the patient’s satisfaction or functional outcomes measured by the AOFAS and LEFS scales. There was no clear correlation between operative technique, floating toe, and quality of prehension force.

Level of Evidence:

Level III, retrospective comparative series.

Evolution of the Weil Osteotomy: The Triple Osteotomy

Weil osteotomy (WO) is the most common technique worldwide for the treatment of mechanical metatarsalgia. The main indication for WO is propulsive/third rocker metatarsalgia that is in relation with an abnormal length of a certain metatarsal with respect to the neighboring metatarsals in the frontal plane. Most clinical studies have showed good to excellent results after WO. However, complications such as floating toes led to evolution of WO and the development of the triple-cut WO that allows for shortening coaxial to the shaft without plantar translation of metatarsal head. Other variations of WO may treat other forefoot disorders.

Computed tomography measurements of the lesser metatarsal heads: Anatomic considerations for surgeons performing distal metatarsal osteotomies

BACKGROUND

The purpose of the current study was to provide a standardized, anatomical description of the lesser metatarsals to assist surgeons when planning distal metatarsal surgery and fixation.

METHODS

Eighty CT scans were included for assessment, based on a priori power analysis. Patient age was a mean 52.7±16.6 years (24-83). Metatarsals two through five were assessed in all patients. Three independent observers completed measurements for all metatarsals. Three measurements were made on all metatarsals, including a vertical height and metatarsal head and neck measurements. Statistical analysis was performed (alpha value 0.05). Inter-observer reliability was assessed for all measurements and intra-class correlation (ICC) reported.

RESULTS

A sequential decrease in metatarsal measurements was noted from the second to the fifth metatarsal. A mean vertical height measurement of 16.1±1.4mm (range, 13.4-19.4) was recorded for the second metatarsal, decreasing 13.0±1.1mm (range, 10.3-16.1) for fifth. There were no significant differences in metatarsal measurements based on gender in our study. Similar patient and metatarsal variability was seen head and neck measurements. Intraclass correlation coefficients (ICC) for metatarsal measurements were greater than 0.9 [95% CI; 0.936-0.991] correlation, denoting an 'excellent' interobserver reliability.

CONCLUSION

This study provides a baseline anatomical description of the distal metatarsals. These findings, including the variation found between patients and between metatarsal two through five, are relevant to surgeons planning and performing distal metatarsal osteotomies.

Weil and Dorsal Closing Wedge Osteotomy for Freiberg's Disease

BACKGROUND

Weil osteotomy is a type of distal osteotomy for the treatment of lesser metatarsalgia by shortening the metatarsal length. We applied Weil and dorsal closing wedge osteotomy for the treatment of Freiberg's disease.

METHODS

Between September 1, 2006, and December 31, 2011, we performed Weil and dorsal closing wedge osteotomy of the second metatarsal in 15 feet of 15 patients (12 women, three men) diagnosed as having Freiberg's disease. The mean patient age was 29 years (range, 19-51 years), and mean follow-up was 47 months (range, 36-72 months). Postoperative shortening of the metatarsal length was measured by comparing preoperative and postoperative radiographs. Visual analog scale scores, American Orthopedic Foot and Ankle Society lesser metatarsophalangeal-interphalangeal scores, and the passive range of motion of the metatarsophalangeal joint were evaluated at 24 months.

RESULTS

The mean postoperative shortening of the metatarsal length was 3.2 mm. The mean visual analog scale and American Orthopedic Foot and Ankle Society scores were 7.2 and 52.4 points preoperatively and 2.1 and 78.2 points at 24 months, respectively (P < .05). The mean range of motion of the metatarsophalangeal joint increased from 29.4° preoperatively to 46.5° postoperatively (P < .05). Various degrees of remodeling were observed at the dorsum of the metatarsal head at 24 months.

CONCLUSIONS

Weil and dorsal closing wedge osteotomy of the metatarsal seems to be effective for treating Freiberg's disease. It improves pain and function in terms of shortening the metatarsal length and restoring the metatarsophalangeal joint.

Percutaneous dorsal closing wedge osteotomy of the metatarsal neck in management of metatarsalgia

INTRODUCTION

Metatarsalgia can be caused by plantarflexion of a central metatarsal or discrepancies in the metatarsals' length. Nonsurgical management is usually sufficient to achieve satisfactory results. For those recalcitrant cases, metatarsal osteotomy is needed to relieve the pain. We describe a technique of percutaneous dorsal closing wedge osteotomy of the metatarsal to manage the recalcitrant metatarsalgia. A case series was reviewed retrospectively.

MATERIALS AND METHODS

From March 2010 to March 2013, percutaneous dorsal closing wedge osteotomy of the metatarsal neck has been performed in 33 patients. Thirty six feet with 63 metatarsals were operated on. Thirty two second metatarsals, 22 third metatarsals, 5 fourth metatarsals and 4 fifth metatarsals were operated on.

RESULTS

All the osteotomy sites healed up without any transverse plane deformity. The painful callosities subsided except in one operated metatarsal. Recurrence of painful callosities occurred in 2 operated metatarsals. Transfer metatarsalgia occurred in 2 feet. Floating toe deformity occurred in 2 operated rays. There was no nerve injury noted. Two patients had delayed wound healing with serous discharge and the wounds were eventually healed up with wound dressing.

CONCLUSION

Percutaneous dorsal closing wedge osteotomy of the metatarsal neck is an effective and safe surgical treatment of recalcitrant metatarsalgia.

Second metatarsal osteotomies for metatarsalgia: a robotic cadaveric study of the effect of osteotomy plane and metatarsal shortening on plantar pressure

Symptom relief of recalcitrant metatarsalgia can be achieved through surgical shortening of the affected metatarsal, thus decreasing plantar pressure. Theoretically an oblique metatarsal osteotomy can be oriented distal to proximal (DP) or proximal to distal (PD). We characterized the relationship between the amount of second metatarsal shortening, osteotomy plane, and plantar pressure. We hypothesized that the PD osteotomy is more effective in reducing metatarsal peak pressure and pressure time integral. We performed eight DP and eight PD second metatarsal osteotomies on eight pairs of cadaveric feet. A custom designed robotic gait simulator (RGS) generated dynamic in vitro simulations of gait. Second metatarsals were incrementally shortened, with three trials for each length. We calculated regression lines for peak pressure and pressure time integral vs. metatarsal shortening. Shortening the second metatarsal using either osteotomy significantly affected the metatarsal peak pressure and pressure time integral (first and third metatarsal increased, p < 0.01 and <0.05; second metatarsal decreased, p < 0.01). Changes in peak pressure (p = 0.0019) and pressure time integral (p = 0.0046) were more sensitive to second metatarsal shortening with the PD osteotomy than the DP osteotomy. The PD osteotomy plane reduces plantar pressure more effectively than the DP osteotomy plane.

Lesser metatarsophalangeal joint instability: prospective evaluation and repair of plantar plate and capsular insufficiency

BACKGROUND

Anatomical dissection of the second metatarsophalangeal (MTP) joint suggests that the plantar plate is the major stabilizing structure of the joint due to its central location and multiple important attachments. Many surgical procedures have been recommended when conservative treatment has failed, but some have had limited clinical success. The aim of our prospective study was to show the results obtained in the treatment of a group of patients with plantar plate tears by direct repair through a dorsal approach combined with a Weil metatarsal osteotomy with a minimum followup of 12 months.

METHODS

We prospectively treated 28 patients (55 MTP joints) with lesser MTP joint instability, but only 22 patients (40 MTP joints) were treated by the direct repair of the plantar plate and were included in the study. All of them had initial complaints of acute forefoot pain with the subsequent development of deformity and instability of the MTP joints. All patients were evaluated clinically, radiographically, (plain radiographs and MRI exam), and by MTP joint arthroscopy. With this data, a direct correlation between the clinical staging and the anatomical grading for plantar plate dysfunction of each patient was determined

RESULTS

The plantar plate of the second MTP joint was the most commonly affected joint (63%), and Grade III type tear (transverse and/or longitudinal extension tear) was the most frequent type. With the surgical treatment, we were able to markedly improve the parameters studied (pain, medial or dorsomedial deviation of the toe, joint stability, muscle balance, and joint congruence) to acceptable levels, The AOFAS score improved substantially from an average of 52 points preoperatively to 92 points postoperatively.

CONCLUSION

The direct plantar plate repair combined with a Weil osteotomy and lateral soft tissue reefing can restore the normal alignment of the MTP joint. We have demonstrated that the anatomic repair of the plantar plate can correct the deviation of the affected toe (medial, dorsal, dorsomedial or dorsolateral), which lead to diminished pain with improved functional scores.

Biomechanical comparison of lag screw versus self-drilling screw fixation of oblique metatarsal osteotomy

BACKGROUND

Several fixation methods for a Weil metatarsal osteotomy have been proposed. Lag screw fixation has been described as the preferred fixation technique. The self-drilling screw has been introduced and can be used for fixation of the Weil osteotomy. The current study compared self-drilling screws with lag screw fixation.

MATERIALS AND METHODS

A Weil metatarsal osteotomy was performed on the second, third, and fourth metatarsals of five matched pairs of fresh frozen cadaver feet. The feet of each pair were randomly assigned ical to fixation with either a 2.0-mm cortical lag screw or a 2.0-mm self-drilling screw. The second metatarsals were stressed using cantilever bending. The third and fourth metatarsals were stressed under a shear force. Yield load, deformation at yield load, structural stiffness, and energy stored at yield load were recorded.

RESULTS

There were no statistically significant differences (p < 0.05) noted. However, there was a trend toward greater biomechanical stability with the lag screw.

CONCLUSION

There were no significant differences in the stability of fixation of the self-drilling screw and lag screw. There was a trend toward the lag screw fixation being more stable.

CLINICAL RELEVANCE

The clinical significance of this trend is uncertain but suggests there is not a large difference between the two methods of fixation.

Complications of the Weil osteotomy

Introduction. The Weil osteotomy is commonly used for multiple forefoot pathologies yielding metatarsalgia. Despite its common use, the Weil osteotomy is associated with a high complication rate. Methods. A literature review was undertaken with predetermined criteria. To maximize the articles for review, prospective and retrospective studies were considered as well as multiple indications. Seventeen articles qualified for analysis, and study format, patient demographics, surgical indication, and complication rates were documented. The data obtained were totaled and evaluated for trends. Results. Details of 1131 Weil osteotomies are reported. The most commonly reported complication of the Weil osteotomy was floating toe, reported in 233 cases, with an overall occurrence of 36%. Recurrence was reported in 15% of the cases. Transfer metatarsalgia was reported in 7% of the cases, whereas delayed union, non-union, and malunion were collectively reported in 3% of the cases. Discussion. There is no consensus regarding utilization of the Weil osteotomy with prophylactic surgery, plantar plate repair, and adjunctive interphalangeal arthrodesis. These variables may alter complication rates and provide new avenues for research.

Surgery of the central rays

The purpose of this article is to address the isolated causes of osseous central metatarsalgia that are related to an elongated metatarsal and brachymetatarsalgia. The authors focus on surgically addressing shortened and elongated metatarsals, surgical complications, and revisional surgery.

Management of the second and third metatarsal in moderate and severe hallux valgus

Hallux valgus is a common disorder of the forefoot that results from medial deviation of the first metatarsal and lateral deviation and/or rotation of the great. The management of hallux valgus is usually focused on the malalignment of the first ray, however, some patients report that pain at the plantar aspect of second and/or third metatarsal head(s) is more severe than the first metatarsophalangeal joint. In order to alleviate the metatarsalgia, we developed an oblique sliding osteotomy to manage the second metatarsal. This article reports the results of 17 feet that were treated with oblique sliding osteotomy. Average patient age was 55.3 years. The transverse arch of all patients had sagged, and all patients had painful calluses below the lesser metatarsals. Functional outcome was evaluated with the hallux valgus angle, intermetatarsal angle, proximal articular and distal articular set angles, and American Orthopaedic Foot and Ankle Society scoring system. The mean hallux valgus angle was 37.6 degrees preoperatively and 13.2 degrees postoperatively (mean correction, 24.4 degrees) and the mean intermetatarsal angle was 14.6 degrees preoperatively and 6.8 degrees postoperatively (mean correction, 8.8 degrees). American Orthopaedic Foot and Ankle Society scores improved from an average of 58 preoperatively to 87 postoperatively. Based on appearance and function, the outcomes of 16 feet were satisfactory. Pain of the forefoot was ameliorated and Mielke scores of 14 feet were either very good or good (82.3%) and satisfactory for 2 feet. Final follow-up was an average of 16 months and all patients were ambulating normally. We thus conclude that this surgical technique is effective in patients with moderate or severe hallux valgus.

An adaptation of Weil's osteotomy of the lesser metatarsal neck

Weil's osteotomy is a useful technique for the treatment of central metatarsalgia and lesser metatarsophalangeal joint dislocation. In this report, we describe a technical maneuver that involves predrilling and tapping holes that can be used to guide translocation of the capital fragment of the metatarsal. This configures the final hole that will be used for single screw placement to secure the osteotomy in the position of correction. This technical tip is useful in regard to establishing the intraoperative orientation of the osteotomy and screw placement, and enables the use of a single, generic screw for stabilization of the realigned metatarsal.

Complications and salvage of elective central metatarsal osteotomies

In order to provide proper treatment intervention, the foot and ankle surgeon must develop a further understanding of the pathoanatomy and pathomechanics leading to specific surgical complications of central metatarsal osteotomies. In addition to providing the authors' experiences and potential solutions with regard to these complications, a clear definition of the progression of the complication course is presented. The specific complications of floating toe deformity, metatarsalphalangeal joint stiffness, recurrent metatarsalgia, transfer lesions, malunions, and nonunions are discussed.