MTP Stiffness after Weil Osteotomy

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Generally, after the first cases were performed with enthusiastic results, surgeons observed some MTP stiffness, generally loss of plantar flexion, notably of the second ray. This is a second step; we observed the same chronology. However we have worked to analyze the causes, and adapted specific techniques and postoperative management.

Now we can write that we have virtually eliminated this complication, thanks to the respect of the pre, per and postoperative specific points.

Weil Osteotomy Complications

Fig. 17e2. Weil MTP stiffness prevention - preoperative aspects.

1. Contraindications of Weil osteotomy are trophic troubles with cold foot, very thin foot or cheloid scar tendency, or very anxious and young patient (2).

3, 4. Warning to the patient: "You have an advanced deformity: We must perform an invasive surgery which includes some postoperative care: Your participation is highly required for postoperative self-training of your toes".

Weil Osteotomy Complications

Fig. 17e1. Weil MTP stiffness

When this problem occurs, it is mainly on the 2nd ray and with loss of the ground contact. Now the MTP stiffness is very rare thanks to the prevention we detail on the following plates.

Fig. 17e1. Weil MTP stiffness

When this problem occurs, it is mainly on the 2nd ray and with loss of the ground contact. Now the MTP stiffness is very rare thanks to the prevention we detail on the following plates.

Weil Osteotomy

Fig. 17e3. Weil MTP stiffness prevention: intraoperative aspects.

1. Preserving the head cartilage as far as possible.

2. Performing a second layer to eliminate the spike (s) and provide plantar rotation of the toe (d).

3. Not setting the screw too distal but more proximally.

4. Preserving the soft tissue as far as possible (setting the screw without impairing the soft tissue).

5. Toe K-wiring excluding the MTP joints.

6. Correction of dorsal MTP flexion, notably by required lengthening of the extensor tendons.

Fig. 17e3. Weil MTP stiffness prevention: intraoperative aspects.

1. Preserving the head cartilage as far as possible.

2. Performing a second layer to eliminate the spike (s) and provide plantar rotation of the toe (d).

3. Not setting the screw too distal but more proximally.

4. Preserving the soft tissue as far as possible (setting the screw without impairing the soft tissue).

5. Toe K-wiring excluding the MTP joints.

6. Correction of dorsal MTP flexion, notably by required lengthening of the extensor tendons.

Preoperatively, contraindications are trophic troubles like cold feet or too thin feet, very anxious patients (CRPS syndrome), or mild deformity or mild pain (except for the 2nd metatarsal).

Intraoperatively, by respecting soft tissue, performing a double layer in most cases, a strong fixation, the lengthening of the extensor tendons and the accurate respect of relative metatarsal length.

Postoperatively, accurate toe strapping in plantar flexion, self-training notably for plantar motion of the MTP joints.

Apart from a case of a 2nd metatarsal osteotomy, we now perform a large shortening of the metatarsals by Weil osteotomy, which is the more reliable way to avoid MTP stiffness.

When the stiffness remains, after one post operative year, the MTP release provides usually good results (Fig. 17e5c). In this case, the percutaneous or mini invasive MTP release is a great improvement.

Fig. 17e4. Decreased 2nd toe active ground contact.

This picture to remind that there are no plantar interessous muscles on the 2nd metatarsal, that explains why the 2nd toe ground contact is more difficult, in this location, whatever the used procedure. (Pictures from the Sobota and the Sarrafian Anatomy books)

Weil Osteotomy Post Wire

Fig. 17e5a. MTP stiffness prevention: postoperative aspects 1.

1. Strapping in MTP plantar flexion.

2. When there is no K-wire, we have to make a DIP dorsal flexion strapping.

3. When there is a K-wire, strapping is easier (no DIP strapping).

Fig. 17e5a. MTP stiffness prevention: postoperative aspects 1.

1. Strapping in MTP plantar flexion.

2. When there is no K-wire, we have to make a DIP dorsal flexion strapping.

3. When there is a K-wire, strapping is easier (no DIP strapping).

Fig. 17e5b. Self-training: postoperative aspects 2.

1. Incorrect position since it is difficult not to contract the toe extensor muscles.

2. Correct position: The foot is relaxed and can be easily reached with the hand.

3. Better position: The contra-lateral knee is flexed.

4. Sometimes another person may be useful and effective for this training (here, the husband).

5. Plantar MTP flexion made by the index finger while the thumb make a still support. While maintaining this position DIP dorsal flexion is made with the other hand.

6. Toes are more easily self-moving in the knee flexed position and when the foot is held by the corresponding hand.

Fig. 17e5b. Self-training: postoperative aspects 2.

1. Incorrect position since it is difficult not to contract the toe extensor muscles.

2. Correct position: The foot is relaxed and can be easily reached with the hand.

3. Better position: The contra-lateral knee is flexed.

4. Sometimes another person may be useful and effective for this training (here, the husband).

5. Plantar MTP flexion made by the index finger while the thumb make a still support. While maintaining this position DIP dorsal flexion is made with the other hand.

6. Toes are more easily self-moving in the knee flexed position and when the foot is held by the corresponding hand.

Hallux Trainer

Fig. 17e5c. MTP stiffness treatment: infraoperative aspects 4.

After one postoperative year, if required (now very rarely), MTP surgical release is very successful. The metatarsal approach may be a bit difficult between the extensor tendons, through the fibrous tissue. A smooth "ciseau de Cauchoix" (DePuy set) is introduced in the MTP joint, as far as required: Bone excess and fibrous tissue are generally observed when the screw is too much distal.

4, 5. But same results are obtained by percutaneous or mini invasive MTP release: this is the procedure we use currently.

6. Excellent results are observed early, notably toe ground contact recovery.

Weil Osteotomy Recovery Time

Fig. 17e5d. MTP stiffness prevention: postoperative aspects 3.

1, 2. Tiptoes and toe ground contact training as soon as possible.

3. If required (now extremely rarely), MTP mobilisation under general or local anaesthesia on the 3rd postoperative month.

Fig. 17e5d. MTP stiffness prevention: postoperative aspects 3.

1, 2. Tiptoes and toe ground contact training as soon as possible.

3. If required (now extremely rarely), MTP mobilisation under general or local anaesthesia on the 3rd postoperative month.

Fig. 17f.Weil osteotomy stiffness? The best way to eliminate MTP stiffness is a large and harmonised shortening of the metatarsals with Weil osteotomy (and if necessary with M1 shortening by scarf, as in this picture).

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Responses

  • Joshua
    How to keep a toe down after a weil osteotomy?
    5 months ago
  • Terttu
    How to code weil osteotomy of great toe with hallux valgus fustion MTP?
    2 months ago

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