Technique

Approach. Although several authors, like L. S. Weil, use a transverse incision (for multiple osteotomies), we prefer performing the Weil osteotomy through longitudinal skin incisions, one incision for adjacent metatarsals. The metatarsal approach is located between the longus and the brevis extensor tendons.

Osteotomy. The type of osteotomy cut depends on the number of metatarsals and the degree of shortening. A long horizontal cut to shorten the metatarsal upper part of the meta-tarsal head avoids injury to the joint. A double layer is most often performed. The soft tissues are respected as far as possible. The relative metatarsal lengths are determined not with the heads but with the proximal fragment, except for the M1-M2 relationship.

The Maceira "3 steps" modified weil osteotomy (Fig. 17b4b) [102] is completely extra articular and shortens the metatarsal following his longitudinal axis, thus without any head lowering.

However, the fragmental area surface is relatively small; this technique seems to be reserved for small to medium displacements, although Maceira use it whatever the magnitude of the shortening.

Fixation is achieved by the special twist-off screw we developed with the French Pied Innovation Group*. It is compressive, self-tapping and flat-headed. It may be combined with the Weil and Schwartz Snap Of Compression Pin (S.O.C.Pin), which may also be used alone.

* M. Augoyard (Lyon), L. S. Barouk, M. Benichou (Montpellier), M. Maestro (Nice), J. Peyrot (Lyon), M. Ragusa (Grenoble), B. Valtin (Paris).

Osteotomy Maestro

Fig. 17b1. Weil lesser metatarsal osteotomy: technique. The approach.

1. Although a transverse approach is used by several authors, even by L. S. Weil himself, we use a longitudinal approach (2, 3), generally one incision for adjacent metatarsals, notably in order to avoid skin problem, and to facilitate the surgery in case of large metatarsal shortening.

2. Approach with hallux valgus correction.

3. Approach without hallux valgus correction.

4. Metatarsal approach between the longus and the brevis extensor tendons (5), setting two Hohmann retractors (5), cutting in most cases the lateral ligaments (6) and setting a special hinge retractor to protect the soft tissues (7).

Fig. 17b1. Weil lesser metatarsal osteotomy: technique. The approach.

1. Although a transverse approach is used by several authors, even by L. S. Weil himself, we use a longitudinal approach (2, 3), generally one incision for adjacent metatarsals, notably in order to avoid skin problem, and to facilitate the surgery in case of large metatarsal shortening.

2. Approach with hallux valgus correction.

3. Approach without hallux valgus correction.

4. Metatarsal approach between the longus and the brevis extensor tendons (5), setting two Hohmann retractors (5), cutting in most cases the lateral ligaments (6) and setting a special hinge retractor to protect the soft tissues (7).

Weil Double Cut Osteotomies

Fig. 17b2. Weil osteotomy technique: The cut.

1. a-b. In case of flat dorsal aspect of the head, the cut can be almost extra articular.

2. a-b. In case of round dorsal head, small removal of the head is necessary.

3. In all cases, the cut has to be the most horizontal as possible in order to shorten the metatarsal without lowering.

Fig. 17b2. Weil osteotomy technique: The cut.

1. a-b. In case of flat dorsal aspect of the head, the cut can be almost extra articular.

2. a-b. In case of round dorsal head, small removal of the head is necessary.

3. In all cases, the cut has to be the most horizontal as possible in order to shorten the metatarsal without lowering.

An X-ray control is necessary both to check the metatarsal length and the head rotation. At last, soft tissue surgery is performed as required on extensor or flexor tendon and on MTP joint, notably to correct remaining sagittal inclination.

Barouk Metatarsal Lengths

Fig. 17b3. Metatarsal parabola: shortening of the metatarsals.

1. This is the metatarsal parabola that has to be respected: Equality of the two first metatarsals - the 2nd metatarsal may be slightly longer but never the first -, then as a rule, 4, 6 and 12 mm decreasing length (studies of Tanaka, Maestro, Ragusa, Besse).

2. We have to respect in most cases the spontaneous proximal translation of the head, then to cut the peak on this level (a).

3. 5. Since the metatarsal length assessment is difficult when looking at the heads, we prefering making the resection on the proximal metatarsal fragment.

3. The 3rd metatarsal (b) is cut for having 4mm less than the 2nd one (a). 4. The 4th metatarsal (c) must be 6 mm less than the 3rd one. 5. The 5th metatarsal must be 12 mm less than the 4th one.

Fig. 17b3. Metatarsal parabola: shortening of the metatarsals.

1. This is the metatarsal parabola that has to be respected: Equality of the two first metatarsals - the 2nd metatarsal may be slightly longer but never the first -, then as a rule, 4, 6 and 12 mm decreasing length (studies of Tanaka, Maestro, Ragusa, Besse).

2. We have to respect in most cases the spontaneous proximal translation of the head, then to cut the peak on this level (a).

3. 5. Since the metatarsal length assessment is difficult when looking at the heads, we prefering making the resection on the proximal metatarsal fragment.

3. The 3rd metatarsal (b) is cut for having 4mm less than the 2nd one (a). 4. The 4th metatarsal (c) must be 6 mm less than the 3rd one. 5. The 5th metatarsal must be 12 mm less than the 4th one.

Fig. 17b4a. Weil osteotomy technique: the 2nd layer.

1, 4, 5. It is necessary to expose the plantar aspect of the proximal fragment in order to assess the top of the angulation made by the osteotomy cut (e). Then two cases are encountered:

1. The peak is thin, we only make a proximal closing wedge.

2. The peak is too thick: Bone removal both proximal and distal.

3. Final result: The spike prominence(s) has disappeared, the head is elevated and also well rotated, which increases the toe ground contact and enlarges the plantar head cartilage area. At last, the fragmental contact is correct.

Fig. 17b4a. Weil osteotomy technique: the 2nd layer.

1, 4, 5. It is necessary to expose the plantar aspect of the proximal fragment in order to assess the top of the angulation made by the osteotomy cut (e). Then two cases are encountered:

1. The peak is thin, we only make a proximal closing wedge.

2. The peak is too thick: Bone removal both proximal and distal.

3. Final result: The spike prominence(s) has disappeared, the head is elevated and also well rotated, which increases the toe ground contact and enlarges the plantar head cartilage area. At last, the fragmental contact is correct.

Fig. 17b4b. Trnka, Myerson and Maceira observations and technique modification.

1. Trnka and Myerson (93) observed that after Weil osteotomy, the metatarsal head center is located among the interosseous muscle so that the active plantar flexion of the proximal phalonx is not possible: however, this observation does not take into account the Weil osteotomy performed with a second layer.

2. The Maceira "3 steps" osteotomy, following the Trnka and Myerson observation, is a shortening of the metatarsal following its longitudinal axis thus it does not need a second layer. However, the fragmental contact area is not so large than in our Weil technique and the cut is oblique, this resulting in a less strong osteosynthesis.

Osteosynthesis Hand And Foot Surgery

Fig. 17b5. Weil osteotomy technique: final assessment of the plantar head location.

It is mostly made by palpation or by looking directly at the heads (1, 2). If one head is too low (2), we have to perform a basal dorsal wedge BRT osteotomy (3) (see later).

Hallux Overlapping 2nd Toe

Fig. 17b6. Weil osteotomy. Head transversal displacement for crossover 2nd toe.

1, 2, 3. In overlapping 2nd toe, the 2nd metatarsal head is in a lateral location and has to be medially displaced.

4. Operative view before and just after the Weil osteotomy: The medial head shift is spontaneous and is sufficient to correct the deformity. We just have to fix the head, avoiding any transversal rotation (X-ray control).

Fig. 17b6. Weil osteotomy. Head transversal displacement for crossover 2nd toe.

1, 2, 3. In overlapping 2nd toe, the 2nd metatarsal head is in a lateral location and has to be medially displaced.

4. Operative view before and just after the Weil osteotomy: The medial head shift is spontaneous and is sufficient to correct the deformity. We just have to fix the head, avoiding any transversal rotation (X-ray control).

Windswept Deformity

Fig. 17b7. Weil osteotomy. Head transverse displacement for lateral wind-swept toe.

In this deformity, the head has to be shifted laterally but above all proximally, to ensure the reliability of the correction.

Fig. 17b7. Weil osteotomy. Head transverse displacement for lateral wind-swept toe.

In this deformity, the head has to be shifted laterally but above all proximally, to ensure the reliability of the correction.

Weil Osteotomy

Fig. 17b8. Weil osteotomy technique. Fixation by the twis-off screw (DePuy).

1. The best way to coaptate the fragments is a plantar pushing of the head with a finger while maintaining the dorsal fragment (Banaleck clamp).

2. Then the operator holds the metatarsal head with a small clamp and with the other hand makes a pre-drill with a thin K-wire just in the dorsal fragment (3). Then the special twist-off screw is set with a slow motion motor, as far as the screw head be in bone contact.

5. At this moment, breaking the support is performed by a forward motion (not by continuing the screw rotation). For this it is recommended not to have a speed motor rotation. We use preferably the Aesculap motor.

6. The fixation is always finished with the screw driver.

4. The twist-off screw is then above all a snap-off screw. It is composed of a support (a) with a thin attach to facilitate the rupture (b). The head is flat (c). There is a no threaded part to provide compression (d). Self perforation tip (e). The use of thin K-wires is nevertheless recommended to have more time to break the support.

7. f-g. Incorrect position of the screw (too distal) resulting in MTP stiffness.

8. h. Correct location of the screw (1 cm from the top of the metatarsal head).

Fig. 17b9. Weil osteotomy technique: fixation by the SOC pin.

The SOC pin is devised by L. S. Weil and N. Schwartz. It also provides fragment compression and has a self rupture of the support. We use thin pin in complement to the twist-off screw, particularly in osteoporotic bones (3).

Fig. 17b9. Weil osteotomy technique: fixation by the SOC pin.

The SOC pin is devised by L. S. Weil and N. Schwartz. It also provides fragment compression and has a self rupture of the support. We use thin pin in complement to the twist-off screw, particularly in osteoporotic bones (3).

Fig. 17b10. In the second and in the fifth metatarsals, the FRS 2.5 screw may be used instead of the twist off screw ; in the fifth metatarsal, we use almost only the FRS screw, because of secondary problem between the head of the twist off screw and the shoe. In the second metatarsal, and eventually in the others, we use the FRS screw only in case of insufficiency of fixation by the twist off screw.

Fig. 17b11. Weil osteotomy technique. Peak smoothing.

1. Generally the peak is thin and smoothing is not necessary.

2. Nevertheless, we have sometimes to smooth it. In this case, we add some bone wax.

Hammertoe Wire

Fig. 17b12. Weil osteotomy technique. Metatarsal head rotation check; toe K-wiring.

1, 2, 3. It is difficult to assess the rotation head clinically. So we use an X-ray control. The white arrow indicates a lateral 3rd head rotation. Then we make a little unscrewing, we turn the head with a small clamp and we finish the screwing.

4, 5. We set a K-wire which does not cross the MTP joint, for ensuring the hammer toe correction when necessary.

6. Once the K-wiring is made, we can assess the necessity to perform extensor tendon lengthening.

Fig. 17b12. Weil osteotomy technique. Metatarsal head rotation check; toe K-wiring.

1, 2, 3. It is difficult to assess the rotation head clinically. So we use an X-ray control. The white arrow indicates a lateral 3rd head rotation. Then we make a little unscrewing, we turn the head with a small clamp and we finish the screwing.

4, 5. We set a K-wire which does not cross the MTP joint, for ensuring the hammer toe correction when necessary.

6. Once the K-wiring is made, we can assess the necessity to perform extensor tendon lengthening.

Crossover Toes Surgery

Fig. 17b13. Weil osteotomy technique. Correction of remaining toe transverse inclination.

1 to 4. In case of toe lateral inclination remaining, we perform medialisation of extensor brevis tendon (2) and lateral MTP release (3). Same foot: result (4). 5, 6. Medial release in case of toe medial inclination remaining. 7. Final checking by LST.

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