A Retrospective Review of the Weil Metatarsal Osteotomy for Lesser Metatarsal Deformities: An Intermediate Follow-up Analysis

A Retrospective Review of the Weil Metatarsal Osteotomy for Lesser Metatarsal Deformities: An Intermediate Follow-up Analysis Ian Beech, BSc(Hons), FCPodS,1 S Rees, PhD,2 and Mark Tagoe BSc(Hons), FCPodS3 The purpose of this retrospective clinical study was to determine the clinical results of the Weil metatarsal osteotomy. There were 51 patients (89 procedures), consisting of 10 males and 41 females, with a mean 53.1 ⫾ 11.9 years. Patients were evaluated for subjective improvement on a scale from 0 to 10, and asked if they would repeat the procedure. They were evaluated functionally using the American Orthopedic Foot and Ankle Society’s lesser metatarsal rating scale, and assessed for toe purchase and range of motion. Thirty-nine point two percent of patients reported a complete resolution of pain (10/10 points), with 13.7% reporting a score of ⱕ 5/10. Eighty percent of the patients would repeat the procedure. The most common complication was toe elevation in 33% of patients. Joint range of motion was reduced in most cases. Thirty five patients experienced no pain at end range of motion, 6 related significant pain and 9 patients experienced some pain. Patients who underwent the procedure as a prophylactic measure along with a first ray procedure formed a significant subgroup (31%). These patients also scored well in comparison to the remainder of patients, with a mean subjective score of 8.4/10 as compared with 7.9/10 for the remainder of patients. The prophylactic group also demonstrated a median functional rating scale score of 90, versus 80 for the remainder of patients. These findings suggest that the Weil metatarsal osteotomy is a useful procedure for metatarsalgia and may also be useful in preventing lesser metatarsalgia in conjunction with first metatarsal surgery. ( The Journal of Foot & Ankle Surgery 44(5):358-364, 2005) Key words: metatarsalgia, metatarsal osteotomy, Weil osteotomy

M etatarsalgia is a widely used term for tenderness and pain in the forefoot (1–5). It is a common presenting complaint, interfering with work, leisure and many sporting activities. Careful evaluation of the patient can usually determine the underlying etiology. Metatarsalgia can be subdivided into primary, secondary, functional and those pathologies that arise during the stance and propulsive phases of gait (1, 6). These main causes are listed in Table 1. Proximally, the metatarsal bases are aligned in an arch,

Address correspondence to: Ian Beech BSc(Hons), FCPodS, The West Middlesex University Hospital NHS Trust, Twickenham Road, Isleworth Middlesex TW7 6AF England; or Hillingdon Primary Care NHS Trust, Uxbridge, Middlesex UB7 7HJ, England. E-mail: ian.beech @hillingdon.nhs.uk 1 Podiatric Surgeon, The West Middlesex University Hospital NHS Trust, Middlesex, England; and Hillingdon Primary Care NHS Trust, Uxbridge, Middlesex, England. 2 Senior Lecturer, University of East London, London, England. 3 Consultant Podiatrist, West Middlesex University Hospital, and Visiting Professor, University of Ulster, Newtonabbey, England. Copyright © 2005 by the American College of Foot and Ankle Surgeons 1067-2516/05/4405-0005$30.00/0 doi:10.1053/j.jfas.2005.07.002

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but should come to lie in a uniform horizontal plane at the metatarsal head level. Abnormal declination of a metatarsal tends to result in a high pressure point during mid-stance. This can cause plantar calluses underlying the metatarsal head(s) (6, 7). The lengths of the 5 metatarsals are also arranged in a distinctive pattern to provide an equal transference of pressure across the forefoot from mid-stance through to toe-off. The most frequent pattern according to Villadot (8, 9) is 1⬍2⬎3⬎4⬎5. In cases where this pattern is abnormal, such as the presence of a long or short metatarsal, “propulsive” metatarsalgia may develop. This results from overloading of the distal aspect of the metatarsal head, or its neighbor (in the case of abnormally short metatarsals). Hyperkeratotic lesions tend to occur slightly anterior to the metatarsal head. Iatrogenic metatarsalgia following forefoot surgery is another common cause of this condition and has been reported by several authors (1, 3, 5). Corrective surgery may be indicated to redress the altered metatarsal parabola in order to provide a more uniform weight-bearing pattern. When first ray surgery is undertaken, some surgeons attempt to realign the metatarsal parabola by adjunctive surgery. This preemptive approach aims to avoid transference pressure

TABLE 1

Causes of metatarsalgia Primary

Secondary

Plantar corn lesions Abnormal metatarsal parabola Neuroma Trauma Brachymetatarsia Neoplastic bone tumors

Iatrogenic —post first ray surgery —met head resection Neurogenic —referred pain —tarsal tunnel syndrome Osteoarthritis Reduced fibro-fatty pad Stress fracture Capsulitis Friebergs infraction Foot function and type —pes cavus —pes planus Ischemia Poor footwear

metatarsalgia some months later, especially when the first ray is already short prior to surgery (10 –12). Historically, various surgical methods have been employed to resolve metatarsalgia. As early as 1916, Meisenbach (13) reported on transverse midshaft osteotomies without fixation. Later, metatarsal head resection with or without digital amputation and lesion excision was reported (14). Keilkian also reported on metatarsal head resection with syndactyly of the digit for stability (15). DuVries wrote on the simplicity of plantar condylectomies in curing plantar callouses (16). Giannestras had success with the step-cut midshaft shortening osteotomy, fixated with circalge wire (17). Thomas preferred a basilar approach with a dorsal closing wedge osteotomy without fixation (18). An oblique sliding osteotomy (from plantar to distal) at 45° provided encouraging results for Helal, who reported a realignment of toe deformities and the plantar fat pad (5). Schwartz published a study advocating a double oblique osteotomy with K-wire fixation (19). The procedure could be modified to accommodate long and/or plantar flexed metatarsals. Currently, there appears to be a general consensus that, in the absence of gross degenerative or inflammatory arthritis, joint preservation techniques should be adopted. Each of the various osteotomies works on the premise of elevating or shortening the metatarsals, or a combination of both, to alleviate overloading of the metatarsal head(s). Debate continues over the most acceptable position of the osteotomy on the metatarsal. Weil described an osteotomy made parallel to the weight-bearing surface, and then sliding the metatarsal head proximally, thus providing axial decompression (11, 12). The effect of the WMO is related to the adjustment of the metatarsal length formula. Elevation can be achieved if a parallel section is removed at the osteotomy site or a double saw blade is used to increase the amount of bone resected (20).

Patients have developed occasional problems following this procedure, including an elevated toe, pain on dorsiflexion, reduced active and passive range of motion (ROM), poor toe purchase, and proximal interphalangeal joint (PIPJ) flexor deformity (21–24). Such sequelae have been described in the few available papers published on this procedure (4, 21–24). The purpose of this paper was to report on the patient satisfaction and clinical outcomes of the WMO in the surgical management of lesser metatarsalgia. We also wanted analyze the prophylactic use of the WMO to address an aberrant metatarsal parabola following some first ray surgery.

Materials and Methods Patients were identified from surgical codes as having had a WMO performed by one of the authors (M.T.) during the past 5 years. Of these, only patients who were at least 1 year status post the index procedure were included. One quarter of these patients were randomly selected from a database and these 83 patients were invited to attend a clinical review. All patients had to be between ages 18 and 70 years of age. In addition, patients undergoing corrective hallux valgus surgery were included on the basis of an abnormal radiographic metatarsal formula as a result of a short first metatarsal (shorter than the third) before they underwent first metatarsal surgery. In such cases, the WMO was considered a “preventative” adjunctive procedure to avoid transfer metatarsalgia. Exclusions from the study were inadequate follow-up information, impaired healing, and any underlying neurological condition. A single clinician assessed all patients (I.B.). An audit tool was devised to establish the presenting complaint, presence of plantar callus, plantar pain and transference pressure areas. Subjective postoperative improvement was scored on a scale from 0 to 10 points, where a score of 10 signified a complete resolution of symptoms and 0 signified no improvement. The score was given verbally. Patients were also asked to comment whether they would undergo the surgery again (Yes/No/Don’t know). Finally, patients were invited to make observations as to the presence of complaints such as elevation of the toe(s), pressure lesions, scar formation or toe splaying. Toe purchase was measured by the “paper test” (25). A 10 cm strip of paper was placed under the toe corresponding to the WMO. Patients were asked to grip the paper while the clinician attempted to pull out the paper. A positive result was recorded if resistance was felt. Total joint ROM was clinically evaluated and was classified into 3 groups: Group A ⱖ 75°, group B ⫽ 30°–74°, group C ⱕ 30°. Pain at the end ROM of the operated metatarsals was assessed using a 10 point visual analogue scale (VAS). Furthermore, all

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TABLE 2 study

Demographic and clinical population data of

No. of Patients Sex – Male: Female Age: Mean ⫾ SD (range) Postoperative period (months) Osteotomies 2nd 3rd 4th 2⫹3 2⫹3⫹4 Total Feet – Right: Left

51 10:41 Mean 53.1 ⫾ 11.9 (15–74) Mean 18.8 (12–54) 21 0 1 20 9 89 20:31

regimen was a below-knee cast non–weight bearing for 4 weeks, followed by 2 weeks in a walking cast. Results

FIGURE 1

AOFAS hallux and metatarsal scoring scale (26).

patients were given a functional assessment score using the American Orthopaedic Foot and Ankle Society (AOFAS) lesser metatarsal grading system (26) (Fig 1). Operative Procedure A standard procedure was performed in all cases. A dorsal incision was made in the intermetatarsal space of the given metatarsal (not directly over the metatarsal in order to reduce the risk of extensor contracture). Sharp dissection was used to expose the distal aspect of the shaft, with careful reflection of the extensor tendons. Once the joint was visible the capsular structures were divested, exposing the metatarsal head. A fine oscillating saw was used to make an osteotomy parallel to the weight-bearing surface. The plantar fragment was translated proximally by the predetermined amount, as measured on the preoperative anteroposterior (AP) radiograph. The resultant overhang of bone was used to assess the amount of proximal translation. The osteotomy was fixated with either 1 or 2 1.5 mm cortical screws or a K-wire. The remaining overhang of bone was then removed and the wound was closed in layers. Patients who underwent a WMO in isolation or along with a midshaft or distal first metatarsal osteotomy were allowed to bear weight immediately, using crutches for support. A postoperative shoe was worn for 2 weeks, after which a training/lace shoe was used. For those who underwent a concurrent basilar 1st ray fusion, the postoperative 360

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Of the 83 patients included in the evaluation group, 32 failed to attend evaluation appointments on 2 occasions, leaving a final cohort of 51 patients (89 osteotomies). There were 10 men and 41 women, with procedures performed on 31 left feet and 20 right feet. The mean patient age was 53.1 ⫾ 11.9 years (range, 15–74). The mean postoperative period for review was 18.8 months (range, 12–54) (Table 2). The most common preoperative presenting complaint was plantar pain (n⫽18). Twelve other patients complained of an intractable plantar keratosis (IPK), and the procedure was performed prophylactically along with a first ray procedure in 16 cases. Finally, 5 patients presented with postoperative metatarsalgia that required further surgery. These patients had undergone previous first ray surgery and were now experiencing overload metatarsalgia due to shortening of the first metatarsal. Postoperatively, 39.2% reported total resolution of pain (10/10 points). 13.7% of patients scored 5 out of 10 or less. Twenty four patients (47%) reported intermediate relief with scores from 6-9 (Fig 2). Two patients gave a score of zero, ie, no improvement. Eighty percent of the patients (n⫽41) commented they would undergo the procedure again. The remainder said they would not have the surgery again. Four stated the procedure did not resolve the original problem. Two patients who underwent the procedure as a prophylactic measure in conjunction with first metatarsal surgery reported satisfaction with the first ray procedure. However, both now complained of chronic joint pain in the WMO site, not present preoperatively. One patient was concerned about a painful scar over the operative site. Another 3 patients stated that they would not undergo the procedure again based on its being performed solely under local anaesthesia, but would undergo again if general an-

FIGURE 2

FIGURE 3

Postoperative improvement scores.

Postoperative complications.

aesthesia was used. It was also commented that postoperative analgesia could have been improved. Postoperative complications occurred in 23 of the 51 patients (Fig 3). The most common complication was toe elevation in 17 patients (33%). One patient developed a transfer lesion. Other concerns listed included swelling (n⫽1), hammer toe deformities (n⫽2), stiffness (n⫽1), and an inability to wear shoes (n⫽1). Stiffness of the related MTPJ(s) was evaluated clinically and compared to the preoperative range of motion. Postoperative joint ROM was found in most cases to be between 30°–74° (73% of the osteotomies). The second and third metatarsal groups exhibited the largest average difference in motion. Although most patients had an overall decrease in range of motion, 73% (n⫽48) of the osteotomies on the second MTPJ had end range of motion between 30 –75°, whereas of the third MTPJ procedures, 78% (n⫽22) had postoperative range of motion in the same range. The fourth toe exhibited the smallest postoperative change. Although there were only 10 procedures done on the fourth metatarsal, 8 of them had a postoperative range of motion that was greater than 75°

Clinical assessments of pain with ROM were measured by a VAS scale from 0 to 10 (Fig 4). This evaluation showed that 35 patients experienced no pain at end range of motion, while 6 reported a score of 10, and the remainder (n⫽9) reported between 2 and 8. One data set was missing. Toe purchase appeared to be more impaired in the second toe, where a greater number of negative results, 21/48 (43%), were recorded (2 data sets missing) (Fig 5). The third toe recorded 6/31 negative results, with the fourth toe exhibiting 1/9. Patients who underwent prophylactic lesser metatarsal surgery formed a significant subgroup in this study (31% of patients). On direct comparison of the prophylactic cohort against the remainder of the patients, the prophylactic group scored well (Table 3). Those who underwent a prophylactic WMO recorded a subjective improvement score mean of 8.4 (range, 2–10) as compared with 7.9 (range, 0 –10) for the remainder of the group. For the prophylactic group the postoperative median AOFAS score was 90 (range, 45–95), as compared to the remaining patients who exhibited a median AOFAS score of 80 (range, 50 –100). The 12 patients with a plantar lesion scored an average 8.6 ⫾ 1.3 improvement score with a median AOFAS score of 89. The remainder of the cohort gave a mean 7.9 improvement score, and a median post operative AOFAS score of 85. Discussion The results of this study provide an interesting assessment of the surgical outcome following the WMO. Tollafield evaluated 36 patients with plantar lesions and found that the procedure was successful in reducing, though not resolving 36% of painful callosities (22). In this study,

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FIGURE 4 Pain at END ROM.

FIGURE 5 Toe purchase.

the plantar lesion was the presenting complaint in only 23% of the patients, yet we had a higher success rate in this subgroup. Those who underwent surgery specifically for plantar lesions scored a high average improvement score, suggesting the surgery had adequately improved the symptoms suffered from the lesions in most cases. We also found these lesions to be associated with a ruptured plantar plate of the second MTPJ (chronic synovitis) with minor callous, rather than deep plantar keratinized lesions (1, 7, 27). This finding may be responsible for our higher success rate in this subgroup. 80% of patients indicated they would elect to undergo the procedure again. This was consistent with the pain relief achieved, as well as the improvement in the functional assessment score. The outcomes of the use of the WMO as prophylactic 362

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measure have not been published before. However, the potential benefits of prophylactic foot surgery in general have been alluded to in the diabetic population (28 –30). In these studies, the aim was to avoid predicted ulceration by reducing high pressure areas with a reconstructive approach. The concept of a shortening osteotomy is a means to avoid transfer metatarsalgia commonly experienced after first metatarsal osteotomy. The results of this study give credence to this surgical strategy. A degree of caution should be exercised given the small sample size. Furthermore, despite the high satisfaction ratings and AOFAS scores, 23% of patients in the prophylactic group reported they would not undergo the procedure again. The reasons given were pain and stiffness in an area where they previously had none. Finally, careful patient selection is crucial when the risk of transference metatarsalgia is low. The toe purchase test results (Fig 5) demonstrated that the second toe is most prone to loss of purchase power. The reason for this may be its intimate association with the first ray and it is often the longest ray. In a study by Berkum and Hetherington (31), toe purchase remained in 23 of 25 digits, although the evaluation method was not mentioned. Pedowitz (32) found that 6 out of 49 patients did not demonstrate adequate toe purchase and attributed this to preoperative digital contracture. A cause for the digital imbalance and predisposition for toe dorsiflexion was proposed by Trnka et al. (21). They suggested a change in the center of rotation of the MTPJ may have caused dysfunction of the interossei. Anecdotally, pain and stiffness in the toe was a common complaint at short- or immediate-term follow-up evaluation. This study found that pain does not persist, because the majority of patients (n⫽35) had no pain at a mean 18.8

TABLE 3 cohort

Comparison of postop AOFAS and subjective improvement score between prophylactic group and remainder of the

Prophylaxis WMO Group n⫽16 (No. Osteotomies ⫽ 26) AOFAS Improvement score

Median 90 Mean 8.4

SD 11.9 SD 2.0

Pure WMO Group n⫽35 (No. Osteotomies ⫽ 72) Range 45–95 Range 2–10

months follow-up, with only 3 patients scoring 5 or above on the VAS score. Postoperative MTPJ stiffness was consistent with results of other studies (4, 22, 23, 33). Barouk commented on a similar finding but suggested the reduced ROM was temporary (10). Leventen reported only one patient with reduced passive ROM at the MTPJ postoperatively (34). The current study found a significant number with reduced ROM at medium term follow-up, although the impact on foot function appeared minimal. Transfer pressure lesions were rare (2%). This low incidence is in agreement with some other authors (4, 23, 24). Other problems included digital deformities. These were subjective concerns for the patient, but it could not be verified whether the digital deformities were a direct result of the surgery. Clinically, they appeared mild. The majority of patients in this study demonstrated a substantial benefit from the surgery, with 72.5% indicating a high degree of improvement in their condition. The most common postoperative problem following the Weil osteotomy was an elevated toe. The WMO requires a dorsal incision with an accompanying risk of a raised scar and contracture. Kilmartin (20) stated that scar tissue is a risk with this procedure and may result in pain on dorsiflexion. In the present study, a skin incision was made in the intermetatarsal space and division of the joint capsule was performed laterally in an attempt to avoid this complication. 33% of our patients exhibited “floating”/elevated toes, as compared to 20% reported by O’Kane and Kilmartin (23). Contracture of the dorsally incised joint capsule as a cause of digital elevation is an area that warrants further study. Measures to address this include vigorous post-operative stretching exercises. In resistant cases, tendon lengthening may be considered, although the success rate requires evaluation. Reliable radiographic evidence would be very helpful to determine how much shortening is clinically relevant and how the metatarsal formula changes on weight bearing and during gait (change in metatarsal parabola and metatarsal protrusion distance). Despite our best efforts, reliable data could not be obtained from the radiographs. The main problems were the consistency of the beam angle and focal film distance. Interestingly, Trnka et al. (24) also commented on the unreliability and accuracy of radiographs

Median 80 Mean 7.9

SD 12.1 SD 2.5

Range 50–100 Range 0–10

with regard to clinical measurements, necessitating exclusion of these results from their study. Gait analysis pre- and postoperatively would also assist in understanding any functional changes related to metatarsal length and position. Conclusion The WMO was shown to be a useful procedure for symptom relief in some of the most common causes of metatarsalgia. It may also be helpful, as a prophylactic measure for the avoidance of pressure transference metatarsalgia following first metatarsal osteotomies. Common complications include elevation of associated lesser toes, particularly the second toe. A reduced range of motion in the associated MTPJ was also common. References 1. Grace DL. The lesser rays. In Surgery of Disorders of the Foot and Ankle, edited by B Helal, D Rowley, Martin Dunitz, 1996. 2. Wolf MD. Metatarsal osteotomies for the relief of painful metatarsal callosities, J Bone Joint Surg 55A:1760 –1762, 1973. 3. Jimenez AL, Fishco WD. Lesser ray deformities. In: McGlamry’s Comprehensive Textbook of Foot & Ankle Surgery, 3rd ed, pp 322– 353, edited by AS Banks, MS Downey, DE Martin, SJ Miller. Baltimore, Williams and Wilkins, 2001. 4. Trnka HJ, Muhlbauer M, Zettl R, Myerson MS, Ritschl P. Comparison of the results of the Weil and Helal osteotomies for the treatment of metatarsalgia secondary to dislocation of the lesser metatarsophalangeal joints. Foot Ankle Int 20:72–79, 1999. 5. Helal B. Metatarsal osteotomy for metatarsalgia. J Bone Joint Surg 57-B:187–192, 1975. 6. Root ML, Orien WP, Weed JH. Muscle function of the foot during locomotion. In: Normal and Abnormal Function of the Foot, vol 2, pp 171–181, Clinical Biomechanics Corporation, Los Angeles, 1977. 7. Lauf E, Glenn WM. Asymmetric V osteotomy: a predictable surgical approach for chronic central metatarsalgia. J Foot Ankle Surg 35:550 – 559, 1996. 8. Viladot A. Patologia del Antepie, 3rd ed, Ediciones Toray, Barcelona, 1981. 9. Bojsen-Moller F. Anatomy of the forefoot, normal and pathologic. Clin Orthop 142:10 –18, 1979. 10. McKeever DC. Arthrodesis of the first metatarsaphalangeal joint for hallux valgus, hallux rigidus, and metatarsus primus varus. J Bone Joint Surg 34A:129, 1952. 11. Barouk LS, Personal communication, March 2000.

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12. Barouk LS, Weil’s metatarsal osteotomy in the treatment of metatarsalgia. Orthopade 25:338 – 44, 1996. 13. Meisenbach RO. Painful anterior arch of the foot: an operation for its relief by means of raising the arch. Am J Orthop Surg 14:206 –211, 1916. 14. Davis GF. Cure for hallux valgus: the interdigital incision. Surg Clin North Am 1:651, 1917. 15. Kelikian H. Hallux valgus, allied deformities of the forefoot and metatarsalgia, p 503, Philadelphia, WB Saunders, 1965. 16. DuVries HL. New approach to treatment of intractable verrucae plantaris. JAMA 152:1202, 1953. 17. Giannestras NJ. Shortening of the metatarsal shaft for the correction of the plantar keratosis, Clin Orthop 4:225–227, 1954. 18. Thomas BF. Levelling the tread. J Bone Joint Surg 56B:314 –319, 1974. 19. Schwartz N, Williams JE, Macinko D. Double oblique lesser metatarsal osteotomy; J Am Podiatr Assoc 73:218 –220, 1983. 20. Kilmartin TE. Distal lesser metatarsal osteotomies: a review of surgical techniques designed to avoid non-union and minimize transfer metatarsalgia. Foot 8:186 –192, 1998. 21. Trnka HJ, Nyska M, Parks BG, Myerson MS. Dorsiflexion contracture after the Weil osteotomy: results of cadaver study and three-dimensional analysis, Foot Ankle Int 22:47–50, 2001. 22. Tollafield D. An audit of lesser metatarsal osteotomy by capital proximal displacement (Weil osteotomy). Br J Podiatry Feb;4(1):15–19, 2001. 23. O’Kane C, Kilmartin TE. The surgical management of central metatarsalgia. Foot Ankle Int 23:415– 419, 2002. 24. Trnka HJ, Gebhard C, Muhlbauer M, Ivanic G, Ivanic PR. The Weil osteotomy for treatment of dislocated lesser metatarsophalangeal joints. Acta Orthop Scand 73:190 –194 2002. 25. de Win MML, Theuvenet WJ, Roche PW,.de Bie RA, van Mameren

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Additional Reference 1. Vandeputte G, Dereymaeker G, Steenwerckx A, Peeraer L. The Weil osteotomy of the lesser metatarsals: a clinical and pedobaragraphic follow-up study. Foot Ankle Int 21:370 –374, 2000.