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Lower Limb: S. G. Hofstaetter, J. G. Hofstaetter, J. A. Petroutsas, F. Gruber, P. Ritschl, and H.-J. Trnka The Weil osteotomy: A SEVEN-YEAR FOLLOW-UP J Bone Joint Surg Br 2005; 87-B: 1507-1511 [Abstract] [Full text] [PDF]

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Authors' reply

Stefan G Hofstaetter, Hans J. Trnka Foot and Ankle centre Vienna, Austria   (12 January 2007)

The Weil osteotomy: a seven-year follow-up.

Narendra Ramisetty, Magdi E. Greiss   (13 March 2006)

The Weil osteotomy

Peter J Briggs, David Stainsby (Newcastle), P Whatmough (Blackburn), Jim Barrie (Blackburn)   (20 December 2005)

The Weil Osteotomy: A Seven Year Follow-Up

Quamar Bismil, Christopher PJ Wood, David M Ricketts   (20 December 2005)

Authors' reply 12 January 2007
Stefan G Hofstaetter, Department of Orthopaedic Surgery, Klinikum Wels, Austria, Foot & Ankle Fellow at Foot centre Vienna , Hans J. Trnka Foot and Ankle centre Vienna, Austria Send letter to journal: Re: Authors' reply stefanhofstaetter{at}gmx.at Stefan G Hofstaetter, et al.	Sir, We were interested to read Mr Ramisetty's comments. Clinical results of the Weil osteotomy with short term and long term results prove its value. A significant reduction in pain, disappearance of plantar callosities, increase of patients' satisfaction rate and walking ability are all reported.1-4 Mr Ramisetty stated that in the Weil osteotomy, the insertion of the plantar plates to the proximal phalanx is not dealt with. The plate part of the joint capsule has a substantial attachment to the proximal phalanx and the plantar fascia but, except for the collateral ligaments, it is without substantial fibrous attachment to the metatarsal head.5,6 We are convinced, as described by Hicks et al6 and Scheck,7 that rupture or elongation of the plantar plate in senile feet occurs where the plantar aponeurosis fuses with the plantar plate. With the Stainsby procedure (modified Keller's procedure)8,9 you sacrifice the remaining intact attachment of the plate to the proximal phalanx and the metatarsophalangeal joint (MTPJ) when excising the proximal 3/4 of the proximal phalanx. Moreover, the insertions of the interossei and the lumbricals at the base of the proximal phalanx hold the proximal phalanx in its neutral position.10,11 With the Stainsby procedure, you remove the insertion of the muscles and there is no way to obtain flexion in the MTPJ. In theory, the latter is possible with the Weil osteotomy and the joint remains intact. Mr Ramisetty states that with his method it is possible to release and replace the plantar plate. However, through the shortening effect of the Weil osteotomy, the plate becomes looser and releasing and replacing the plate under the metatarsal head is possible, although we doubt the long lasting effect of this manoeuvre. Scarring of the plate occurs. Nevertheless, the reversed windlass mechanism of the weakened plantar aponeurosis will not be strong enough to prevent a post-operative extension contracture, floating or stiff toes.1-4 Myerson et al12 showed in their study with second toe instability in 64 feet that the MTP joint, even after a flexor to extensor transfer, remains unstable. To date, the longest Stainsby procedure follow-up study9 had a follow-up period of three years and four months in 69 feet. The indication in this study was severe claw toes in rheumatoid feet and cannot be compared with our results as rheumatoid feet were excluded from our study. Unfortunately there are no clinical studies of the Stainsby procedure related to patient numbers/demographics nor statistical evaluation.8,9,13 The goal of the Weil osteotomy is firstly to decompress the MTPJ and secondly to alter load transmission through the forefoot by shifting the plantar fragment proximal to the area of the lesion where thicker and more compliant soft tissue is still present.14 However, instability of the MTPJ of the lesser toes by the rupture of the plantar plate is, and continues to be, a challenging problem.12 A randomised, controlled trial, to compare the Weil osteotomy with the Stainsby procedure would be of value. S.G. HOFSTAETTER, MD, H.J. TRNKA, MD, Foot Centre Vienna, Vienna, Austria. 1. Barouk LS. Weil's metatarsal osteotomy in the treatment of metatarsalgia. Orthopade 1996;25-4:338-44. 2. Hart R, Janecek M, Bucek P. The Weil osteotomy in metatarsalgia. Z Orthop Ihre Grenzgeb 2003;141-5:590-4. 3. Hofstaetter SG, Hofstaetter JG, Petroutsas JA, et al. The Weil osteotomy: a seven-year follow-up. J Bone Joint Surg [Br] 2005;87-B:1507-11. 4. Muhlbauer M, Trnka HJ, Zembsch A, Ritschl P. Short-term outcome of Weil osteotomy in treatment of metatarsalgia. Z Orthop Ihre Grenzgeb 1999;137-5:452-6. 5. Deland JT, Lee KT, Sobel M, DiCarlo EF. Anatomy of the plantar plate and its attachments in the lesser metatarsal phalangeal joint. Foot Ankle Int 1995;16-8:480-6. 6. Hicks JH. The mechanics of the foot. II. The plantar aponeurosis and the arch. J Anat 1954;88-1:25-30. 7. Scheck M. Etiology of acquired hammertoe deformity. Clin Orthop Relat Res 1977-123:63-9. 8. Stainsby GD. Pathological anatomy and dynamic effect of the displaced plantar plate and the importance of the integrity of the plantar plate- deep transverse metatarsal ligament tie-bar. Ann R Coll Surg Engl 1997;79-1:58-68. 9. Briggs PJ, Stainsby GD. Metatarsal head preservation in forefoot arthroplasty and the correction of severe claw toe deformity. Foot and Ankle Surgery 2001;7-2:93-101. 10. Gray H. Anatomy of the Human Body. 1918;20th ed. 11. 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 2001;22-1:47-50. 12. Myerson MS, Jung HG. The role of toe flexor-to-extensor transfer in correcting metatarsophalangeal joint instability of the second toe. Foot Ankle Int 2005;26-9:675-9. 13. Hossain S, Dhukaram V, Sampath J, Barrie JL. Stainsby procedure for non-rheumatoid claw toes. Foot and Ankle Surgery 2003;9-2:113-8. 14. Weijers RE, Walenkamp GH, van Mameren H, Kessels AG. The relationship of the position of the metatarsal heads and peak plantar pressure. Foot Ankle Int 2003;24-4:349-53.
The Weil osteotomy: a seven-year follow-up. 13 March 2006
Narendra Ramisetty, Specialist Registrar in Orthopaedics West-Cumberland Hospital, Whitehaven, Cumbria, UK, Magdi E. Greiss Send letter to journal: Re: The Weil osteotomy: a seven-year follow-up. narenrami{at}yahoo.co.uk Narendra Ramisetty, et al.	Sir, We read this paper with interest. We congratulate the authors for achieving and sharing the good results of this procedure. We believe that Weil osteotomy may not address the exact cause of pain in dislocated metatarsophalangeal joints (MTPJ) for the following reasons: Weil osteotomy essentially shifts the metatarsal head proximally; in MTPJ dislocation, the plantar plates are subluxed dorsally1 which leads to metatarsalgia. The plantar plates are attached to the proximal phalanx. In the operation, the insertion of the plantar plates to the proximal phalanx is not dealt with and hence they remain dorsally subluxed, which may lead to persistent metatarsalgia under the shifted metatarsal head. We would be interested to know the authors' view on this. The Weil osteotomy also leads to a post-operative increase in the coronal height of the forefoot, causing painful swelling.2 This has been confirmed by a recent cadaver study showing no decrease in the load at the metatarsal head after Weil osteotomy but an increase in plantar pressure.2 On the other hand there are other studies showing decreased load and reduction of the dislocated MTPJ with good results.3,4 We believe the Weil osteotomy is a good procedure for patients with a long second metatarsal causing metatarsalgia without dislocation of MTPJ. We perform Stainsby's procedure (modified Keller's procedure)1,5 for the metatarsalgia caused by dislocated MTPJs. In this procedure the metatarsal length is maintained and plantar plates are returned to their original position. Extensor tenotomy is performed. We excise the proximal 3/4ths of the proximal phalanx and suture the divided extensor tendon to the flexor tendon and stabilise the proximal phalanx to the metatarsal head with a k wire. Excision of the proximal part of the proximal phalanx allows the plantar plates to be released and replaced. N. RAMISETTY, AFRCS, Specialist Registrar in Orthopaedics, M.E. GREISS, FRCS Orth, Consultant Orthopaedic surgeon, West Cumberland Hospital, Cumbria, UK. 1. Stainsby GD. Pathological anatomy and dynamic effect of the displaced plantar plate and the importance of the integrity of the plantar plate-deep transverse metatarsal ligament tie-bar. Ann R Coll Surg Engl 1997;79:58-68. 2. Snyder J, Owen J, Wayne J, Adelaar R. Plantar pressure and load in cadaver feet after a Weil or chevron osteotomy. Foot Ankle Int 2005;26:158-65. 3. Trnka HJ, Gebhard C, Muhlbauer M, Ivanic G, Ritschl P. The Weil osteotomy for treatment of dislocated lesser metatarsophalangeal joints: good outcome in 21 patients with 42 osteotomies. Acta Orthop Scand 2002;73:190-4. 4. Vandeputte G, Dereymaeker G, Steenwerckx A, Peeraer L. The Weil osteotomy of the lesser metatarsals: a clinical and pedobarographic follow-up study. Foot Ankle Int 2000;21:370-4. 5. Hossain S, Dhukaram V, Sampath J, Barrie JL. Stainsby procedure for non-rheumatoid claw toes. Foot and Ankle Surgery 2003;9:113-18.
The Weil osteotomy 20 December 2005
Peter J Briggs, Consultant Orthopaedic Surgeon Freeman Hospital, Newcastle upon Tyne, David Stainsby (Newcastle), P Whatmough (Blackburn), Jim Barrie (Blackburn) Send letter to journal: Re: The Weil osteotomy peter.briggs{at}nuth.nhs.uk Peter J Briggs, et al.	Sir, We read with interest the recent article reporting a seven-year review of the outcome of the Weil osteotomy. The authors reported floating toes (toes that do not make contact with the ground) in 68% of those operated on. This is consistent with other reports of this operation.1-3 The lesser toes normally share in load transfer in late stance, and a floating toe interferes with this, so the loading and pressure distribution in the forefoot must be altered. Whilst the metatarsophalangeal joints (MTPJ) have been reduced, the function of the toes is impaired. Trnka and colleagues4 have previously examined the biomechanics of persistent dorsiflexion of the toes after Weil osteotomy in a cadaver study. They found that proximal displacement of the metatarsal head always lowers the rotation axis of the metatarsophalangeal joint (MTPJ). The tendons of the interossei come to lie dorsal to this joint axis and so these muscles become dorsiflexors. This explanation is repeated in the recent paper. Other procedures have been associated with floating toes. Myerson et al5 reported this complication after flexor-extensor transfer and soft tissue releases of the MTPJ even without Weil osteotomy. Migues et al2 reported that floating toes were commoner after a proximal interphalangeal fusion was combined with a Weil osteotomy. We suggest that another factor is important in the persistent dorsiflexion of the toes. The principle plantar-flexor of the toes at the MTPJ is the plantar aponeurosis through the reversed windlass mechanism.6,7 The importance of this mechanism in the normal foot has been demonstrated by others,8,9 and its failure has been shown to be a cause of lesser toe deformity.10,11 Shortening of the metatarsal will render the reversed windlass mechanism even less effective, allowing the toe to drift into dorsiflexion. Clearly the biomechanics of the MTPJ and the lesser toes is poorly understood. We do not dispute that the change in axis of the Weil osteotomy may contribute to the development of floating toes, but suggest that defunctioning of the reversed windlass mechanism may also be important and warrants further study. P.J. BRIGGS, Consultant Orthopaedic Surgeon, D. STAINSBY, Freeman Hospital, Newcastle upon Tyne, UK. P. WHATMOUGH, J. BARRIE, Blackburn, UK. 1. Davies MS, Saxby TS. Metatarsal neck osteotomy with rigid internal fixation for the treatment of lesser toe metatarsophalangeal joint pathology. Foot Ankle Int 1999; 20:630-635. 2. Migues A, Slullitel G, Bilbao F, Carrasco M, Solari G. Floating-toe deformity as a complication of the Weil osteotomy. Foot Ankle Int 2004; 25:609-13. 3. Vandeputte G, Dereymaeker G, Steenwerckx A, Peeraer L. The Weil osteotomy of the lesser metatarsals: A clinical and pedobarographic follow-up study. Foot Ankle Int 2000; 21:370-374. 4. Trnka H-J, Nyska M, Parks BG, Myerson MS. Dorsiflexion contracture after the Weil osteotomy: results of cadaver study and three-dimensional analysis. Foot Ankle Int 2001; 22:47-50. 5. Myerson MS, Jung HG. The role of toe flexor-to-extensor transfer in correcting metatarsophalangeal joint instability of the second toe. Foot Ankle Int 2005; 26:675-679. 6. Hicks JH. The mechanics of the foot II. The plantar aponeurosis. J Anat 1954; 88:25-31. 7. Hicks JH. The foot as a support. Acta Anatomica 1955; 25:34-45. 8. Stainsby GD. Pathological anatomy and dynamic effect of the displaced plantar plate and the importance of the integrity of the plantar plate - deep transverse metatarsal ligament tie-bar. Ann Roy Coll Surg Engl 1997; 79:58-68. 9. Hamel AJ, Donahue SW, Sharkey NA. Contributions of active and passive toe flexion to forefoot loading. Clin Orthop 2001; 393:326. -334 10. Scheck M. Etiology of acquired hammertoe deformity. Clin Orthop 1977; 123:63-69. 11. Pontious J, Flanigan KP, Hillstrom HJ. Role of plantar fascia in digital stabilization: a case report. J Am Podiatr Med Assoc 1996; 86:43-47.
The Weil Osteotomy: A Seven Year Follow-Up 20 December 2005
Quamar Bismil, Specialist Registrar in Orthopaedics and Trauma Princess Royal Hospital, Haywards Heath, West Sussex, Christopher PJ Wood, David M Ricketts Send letter to journal: Re: The Weil Osteotomy: A Seven Year Follow-Up quamar.bismil{at}btinternet.com Quamar Bismil, et al.	Sir, We read this article with interest. The paper highlights the challenge of managing metatarsalgia with subluxed or dislocated metatarsophalangeal joints. The authors present their experience with a small case series (level IV evidence) concerning the Weil osteotomy. We would like to make the following points: 1. The stated aim is to assess the use of the Weil osteotomy in treating painful subluxed or dislocated metatarsophalangeal joints. However, this series encompasses four different operative groups: Weil osteotomy with PIPJ excision arthroplasty; Weil osteotomy with PIPJ arthrodesis and EHL lengthening; Weil osteotomy with PIPJ excision arthroplasty and 1st metatarsal osteotomy; and Weil osteotomy with PIPJ arthrodesis, EHL lengthening and 1st metatarsal osteotomy. Consequently, we feel it is difficult to draw conclusions about the Weil osteotomy from this data. 2. We note a 12% failure of these procedures to correct the MTP subluxation/ dislocation. Q. BISMIL, Specialist Registrar in Orthopaedics and Trauma, C.P.J. WOOD D.M. RICKETTS Princess Royal Hospital, Haywards Heath, West Sussex, UK.