The Weil osteotomy

The Weil shortening osteotomy is a distal lesser metatarsal procedure, designed to shorten one or more of the central metatarsals (2nd, 3rd and sometimes the 4th) without elevating or depressing the metatarsal head. The head moves proximal to the existing plantar callus, and decompresses the metatarsophalangeal joint. The procedure should be reserved for cases that fail conservative treatment, and only used in cases where the affected metatarsals are comparatively long. Complications are

Fig. 8.13 Sesamoidectomy. (a) Intraoperative photograph, the ulcer has been excised, (b) The hypertrophic tibial (medial) sesamoid has been grasped with a bone clamp and is being removed from the wound.

similar to those associated with other metatarsal osteotomies.

Technique

The procedure is performed in the operating theatre under local anaesthesia with an ankle tourniquet. A dorsal longitudinal incision is made over the metatarsophalangeal joint and then deepened to the joint capsule. The capsule is dissected between the extensor digitorum longus and the extensor digitorum brevis. The capsule is reflected, allowing for release of the collateral ligaments. Two small Hohmann retractors are inserted under the metatarsal neck to provide sufficient exposure to the metatarsal head. The toe is plantar flexed and the osteotomy is performed with a long, thin sagittal saw blade. The osteotomy cut begins at the distal dorsal edge of the articular cartilage and is directed proximally, oblique to the metatarsal shaft, and as parallel as possible to the sole of the foot. The distal fragment is displaced proximally, 3-5 mm, and fixed with a single self-drilling, self-tapping partially threaded 2.0 mm screw. The screw is directed from dorsal-proximal to plantar-distal. The bone peak is then resected with a rongeur and smoothed with a burr (Fig. 8.15a-c). The joint capsule is closed with 3-0 absorbable (Dexon or Vicryl) sutures and the skin is closed with 4-0 absorbable subcuticular sutures, or nylon simple interrupted sutures.

Dressings and postoperative care

Standard dressings are utilized. The patient is allowed to ambulate with crutches and partial weightbearing, in a surgical shoe. Sutures are removed in 10-14 days and patients can return to their normal footwear in 2-4 weeks, as dictated by the clinical course.

Advantages

• Simple and reliable procedure

• Stability of the osteotomy with a large area of bone to bone contact

• Pressure relief beneath the metatarsal head

• Helpful for reduction of dorsally dislocated metatarsophalangeal joints

• Pressure relief beneath the metatarsal head

• Early return to weightbearing.

Complications

• Transfer lesions

• Recurrent symptomatic plantar keratosis

• Floating and stiff toes.

Fig. 8.15 The Weil lesser metatarsal shortening osteotomy, (a) The lesser toe is plantarflexed, and the oblique osteotomy cut begins at the distal dorsal edge of the articular cartilage, (b) Proximal displacement of the metatarsal head, approximately 3-5 mm. Note that the head of the metatarsal is now proximal to the plantar callus. Fixation is with a single 2.0 mm screw, (c) Resection and smoothing of the bone peak.

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