Weil osteotomy again

Weil’s osteotomy is claimed to correct a number of forefoot problems, including “metatarsalgia”, “claw toes”, “dislocations of the metatarso phalangeal joints”, lengthening metatarsals, shortening metatarsals and even “slimming the foot”! (Barouk). Some even claim that it can be used to correct veer. How any procedure designed to alter abnormalities in the vertical (sagittal)  plane can correct malalignment in the horizontal plane defeats me.

Any single surgical procedure which claimes a benefit for such different pathologies  (or pathologies of unknown cause, which is often the case in current forefoot surgery) must be regarded with the same scepticism warranted by blood-letting as a “catch all” cure.

One rationale justifying Weil’s osteotomy is that it purports to correct “Morton’s Foot”, where the second metatarsal is longer than the first. An irony here is that many types of surgery used for “bunions” shorten the first metatarsal, and so create a “Morton’s foot”.

The reality is that there is no rationale for this procedure. If it is of perceived to be beneficial, then it is purely by chance, and the procedure should then be regarded as a “noxious placebo“  [ http://drjpdriverjowitt.wordpress.com/curriculum-vitae/noxious-placebos/ ]

The following paper by podiatrists http://www.ncbi.nlm.nih.gov/pubmed/12043986?dopt=Citation claims the Weil to  be a good procedure, but see below:

“The surgical management of central metatarsalgia. Foot Ankle Int. 2002 May;23(5):415-9.

O’Kane C, Kilmartin TE. Department of Podiatric Surgery, Ilkeston Hospital, Derbyshire, England. claire@cokane5.fsnet.co.uk

Seventeen patients (20 feet) underwent Weil osteotomies of the second and third metatarsals for the treatment of central metatarsalgia and were reviewed at an average of 18 months postoperatively. Fourteen patients were completely satisfied with the results of their surgery (85%), one patient was satisfied, one patient satisfied with reservations and one patient was dissatisfied. The American Orthopaedic Foot and Ankle Society clinical rating scale improved by an average of 44 points. One patient had complete recurrence of symptoms, eight out of the 40 toes involved in surgery were floating, four toes were stiff, there were three cases of infection, and transfer metatarsalgia affected the fourth metatarsal in one case. The Weil osteotomy is an effective and safe procedure for the treatment of central metatarsalgia.”

However, when read from the point of view of complications, this paper is not encouraging because:

15% were less than completely satisfied
20% had floating toes
10% toes were stiff
7% had infection
2% had “transfer metatarsalgia.

Of course these complications are not additive arithmetically. It is likely that those who had complications had more than one complication. It is equally likely that those complications were not all confined to the 20% who had the floating toes, and it is here that the bald statistics hide the more important information about the spread of complications. As a result we simply do not know who had which complications.
Another difficulty is that the numbers are statistically small and the follow up relatively short, considering that these feet are to be used for the remainder of life. Finally people do adapt to disabilities and often underrate their disabilities on review. (see the paper on “bunions”)

Now consider the following paper by orthopaedic surgeons:

Trnka HJ, Gebhard C, Mühlbauer M, Ivanic G, Ritschl P. http://www.ncbi.nlm.nih.gov/pubmed/10063974

Department of Orthopaedic, Hospital Gersthof, Vienna, Austria. hans4hallux@aon.at

Hardly any surgical methods are available for metatarsalgia caused by a dislocated lesser metatarsophalangeal joint (MTP) that do not sacrifice the joint. We reviewed retrospectively the outcome of 60 metatarsal Weil osteotomies for correction of dislocated lesser MTP joints in 31 patients. Between 1995 and 1996, 31 consecutive patients were treated with a Weil osteotomy at 2 institutions. The Weil osteotomy is an oblique osteotomy of the metatarsal neck and shaft, parallel to the ground surface, that controls shortening of the metatarsal by internal fixation with screws or pins. At an average final follow-up of 30 (24-44) months, all patients were interviewed, using a standardized questionnaire based on the AOFAS Lesser Metatarsophalangeal-Interphalangeal Scale. Recurrent or transfer metatarsalgia, formation of callus, mobility and dislocation of the MTP were noted on physical examination. Dorsoplantar and lateral weightbearing radiographs taken preoperatively and at the time of final follow-up were examined for alignment of the metatarsal heads, subluxation or dislocation and for evidence of nonunion, or malunion of the metatarsal osteotomy. We had excellent results in 21 patients (42 osteotomies). A major complication was plantar penetrating hardware in 10 cases (3 screws and 7 pins). We conclude that the Weil osteotomy is a good method for correcting metatarsalgia caused by dislocation of the MTP joint.”

Twenty four percent (10/42) of the procedures had what the authors call “major complications”, and the phrasing seems to imply that there were other (perhaps “minor”) complications. Hardly the kind of risks many would knowingly accept.

I would welcome correspondence from those who perform Weil’s osteotomy justifying its use.

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64 Responses to “Weil osteotomy again”

  • Ryan:

    Hello, I have developed claw toes in the middle three toes as well as metatarsalgia due to foot surgery. I have cavovarus feet which was causing frequent and severe pain in my foot, especially my peroneal tendon. I put up with it for 5 years and tried conservative treatment (orthotics, physio etc). I decided to do the surgery by a respected foot and ankle surgeon in Sydney, Australia. This included a lateralizing calcaneal osteotomy, achilles lengenthening procedure, plantar fascia release, 1st MT osteotomy and a peroneal tendon transfer. That was almost a year ago and has fixed the peroneal tendon problem and my heel feels much straighter. I am happy with that aspect of the surgery. However, I have developed claw toes in my middle 3 toes and metatarsalagia. I remember before the surgery that he said claw toes was a risk. He says that as a result of the surgery, my foot weight bears differently and has caused these problems and that some tendons are stronger than others and has contributed to this. We are going to do a PIP arthrodesis on the middle 3 toes and inject cortisone in the MTP joint. He assures me that the arthrodesis will fix the toes and that hopefully fixing the claw toes and the cortisone will stop the metatarsalgia. If it doesn't, then I am looking at a Weil's osteotomy of the 3 middle toes. He suggested doing it all at once, but I am not so keen for that and want to see if straightening the claw toes will take pressure of the MTP joint and decrease the metatarsalalgia. I know your not a fan of the Weil's osteotomy, but I wanted to get your advice. I have tried conservative treatment such as good shoes and MT cushion and toe splints without getting much better. Regards, Ryan

    • jp:

      I am also not a fan of calcaneal osteotomy, plantar fasciotomy, Achilles tendon lengthening, first metatarsal osteotomy and - in your case - the peroneal tendon transfer. There are (to my mind) alternatives which are less intrusive or safer than each of these. I can see no consistent, unifying rationality between each of this wide variety of anatomical assaults. If I can help you more - which I have not done to date - please send me the diagnostic reports from your surgeon and JPG the X-rays if possible. Perhaps your surgeon should buy the book which I have written?

      • Ryan:

        Out of curiosity, what would you do for a symptomatic cavovarus foot? I can't take the surgery back, but would you say the surgeon's proposal is fair to fix this new problem? I am getting some x-rays done in a few weeks and will send you the jpegs. I don't have any diagnostic from the surgeon sorry.

        • jp:

          Cavovarus foot is not a diagnosis in itself. That term alone is not sufficient to make a causative diagnosis. Perhaps your family doctor has information from the surgeon to understand that surgeon's interpretation of the presentation of the abnormality? I cannot give advice on the information which I have. There are no simple "quick fixes" for the (many) causes of foot deformities. Anticipate the jpegs. Best Wishes

        • jp:

          I do not think the claw toes are a new problem, but rather an expression of the complex old problem, revealed by the (only partly effective) surgery

        • jp:

          I have not received your x-rays know little about you, and would like to know your age and the period for which the cavus foot has troubled you. I do not know in which way, and which part of the foot is symptomatic. Therefore some general comments: If your cavus foot is "secondary", i.e. was normal at one stage, comment on the calcaneal osteotomy will be made. You clearly had a "hind foot equinus", meriting the Achilles tendon lengthening. I never do Achilles lengthening, as the healing is unpredictable, the scar often rubs on footwear, there is loss of (important) proprioception from that tendon, and desired length is difficult to control. Instead a calf slide avoids all these problems. Many surgeons are not familiar with the procedure - indeed I was asked yesterday, in the operating room, by an orthopaedic surgeon what it was. If the muscles controlling the hind foot were short, then there is a likely hood that the long flexor tendons to the forefoot (toes) were/are also short. Therefore when the hind-foot equinus was corrected, and the ankle dorsiflexion range increased, so the shortness of the long flexor tendons began to show with clawing of the toes. If this were the case those toes could be corrected by flexor tenotomy. Extensor tenotomies - widely practiced in Australia - should be avoided as these complicate the clawing, usually worsening it. Speaking to a colleague this morning he referred to the Vile Weill. Appropriate, unnecessary and meddlesome, as well as ineffective and with short lived benefit. Plantar fasciotomy should have been avoided; it produces significant late complications - usually mid-foot collapse. Anything else you need to know?

  • Irene c. Glaser:

    I have bad hammer toes of the 2-4th toes and just cancelled surgery since 4 of the 5 doctors I consulted thought I needed more extensive surgery (than just fusing, tendon lengthening, and inserting pins) since I have splayed and overly long metatarsal bones, too. The 4 docs mentioned the Weil procedure. The combination of my various abnormalities causes a bump on the bottom of my foot that hurts at times. Summer has been fine wearing open toed thong-type sandals--but winter's coming and wearing even wide box soft shoes wears on those toes and the bump--so my foot is frequently in pain. Sometimes, wearing my rocker shoes relieves the pain, but I am getting older and don't know how safe they are for older folks. After reading the information on this web site about Weil, I'm hesitant to do that. Does anyone know who I can trust to do a fantastic job in the Metropolitan Washington, DC area for this type foot surgery?

    • jp:

      Uncertainty, such as you have experienced, is unsettling. As you have surmised I believe that almost everything which you have been advised to do is irrational and does not address the cause of your foot problems. I hear your words every working day. You might well then ask "What should I do and who claims to be correct? If so why?" This is difficult for me to answer in short. However I can provide these answers, but because this needs an entire restructuring of thinking (and considerable opposition to what is well entrenched) I can only do that successfully by writing (what I hope will be) a comprehensive, all encompassing, rational monograph. I am doing that- amongst other commitments - and hope to publish shortly.

  • Lori:

    I was diagnosed with hallux rigidus last year after noticing that I couldn't bend my big toe up anymore, and was forming a large bone spur on top of the joint with worsening pain. The podiatrist said that he had never seen anyone this young (41) with so much damage in the joint and that it was caused by an elevatated metatarsal. I did not want a joint fusion, so he performed a cheiletomy and osteotomy (with 2 screws) to bring the metatarsal down and relieve jamming in the joint. I was non weight bearing for 6 weeks, then partial weight bearing in a boot. The first problem I noticed is that I could not bend my toe down. Once I was finally at full weight bearing in a normal shoe, I noticed pain in the ball of my foot. I was then diagnosed with post of transfer metatarsalgia. I have orthotics now, and they've made several adjustments, but I am still in a lot of pain. If I lift up to go "on my tip toes" I feel a big lump behind my toes, like I am standing on nothing but bone. I used to go walking and hiking all the time, but now I have to limit it to short excursions due to the burnign pain. I do not want to spend the rest of my life with these limitations! Xrays reveal that my first metatarsal was excessively shortened so now the second metarsal is too long. My last hope for relief is another surgery to shorten the second metatarsal. They did not specify which type of osteotomy would be used, but it sure sounds like a wiel. What other options would I have under these circumstances?

    • jp:

      Hallux rigidus is only one feature of a more widespread problem. The ritual of shortening / lengthening metatarsals is not convincing to me. I have seen failures too often. I would not allow that procedure to be performed on my foot. Do you have a tight Achilles tendon?

  • My podiatrist wants to perform the Weil Osteotomy on my second toe of right foot. Its starting to cross over big toe. Id send you picture if i could attach one here. I've read many negative or controversial thoughts about the surgery. Your thoughts on whether I should have it and the risk associated with something going wrong. If I don't have a Weil Osteotomy done what other choices do i have? I'm 51 and I'm 6-4 230 lbs and my past time is golf. I'm a right handed and I play all the time. Thanks for any insight Barry

    • jp:

      Thank you for the enquiry. As I understand it you have what I have termed “digitus valgus”. This is a variant of the deformities of the second toe – the others being in the axis of the ray while this is in the coronal plane. What differentiates digitus valgus from the claw toe is that there is seldom abrasion of the upper side of the toe against footwear with less urgency for pain relief. You will probably find that your great toe is also veering towards the little, and contributing to the mis-alignment. Further the rest of the lesser toes are probably all veering towards the great toe, which I have termed “wind sweeping”. What this means is that the deformity is a complex, involving several toes, which is unlikely to be “cured” by operating on the second toe alone (which seems to have been suggested). The advice given to you illustrates one of the irrationalities of the Weil osteotomy. This procedure was originally touted as a correction of the clawed toe. That is to say a correction in the axis of the ray. We now have someone advocating it as a procedure to correct deviation in the coronal plane, for which there is absolutely no logic. As I have said before the Weil has become a “catch all” surgical procedure, each new application having even less rationality. Readers will have wondered why, after criticizing “established” forms of forefoot surgery, I do not come forward with a better suggestion. One reason is that I want to have a long (25 years minimum) follow up, on a sample of several hundred procedures before publication. Another is that I wish to have such a new procedure carefully documented, with sufficiently accurate detail to ensure that it is performed exactly, and that it does not fall into disrepute by slovenly attempts at replication. Another reason is that I have been engaged in continued research. My prediction is that over the next year or so there will be an entire revision of the types of surgery which are now performed. Current surgery of forefoot deformities is irrational, with irreparable damage to perfectly normal bones and joints, with high complication rates and long term failures. Specific advice to you is to hold back for the present, as much more satisfactory surgical approaches can be expected in the not too distant future.

  • Jennie Campbell:

    I developed metatarsalgia in one foot about 2 years after joining a fitness center. It developed after I wore shoes that didn't provide sufficient cushioning and spent too much time on the treadmill and elliptical machines. My podiatrist injected cortisone in the joint of the second toe, and the pain completely vanished for 2 months. Eventually the pain returned to its original intensity. My doctor cautioned me that additional cortisone injections could cause weakening of the tissues that stabilize the joint, and suggested the Weil procedure if the pain returns after one more injection. I am averse to surgery, especially after reading many of the outcomes posted here. However the pain limits my mobility, and I'm "only" 52. My question is how long does it usually take for a problem to resolve on its own, and when should one conclude that the problem is probably not going to improve with conservative treatment? I plan to wait at least another 6 months, and will limit my exercise to cycling and swimming. Thank you so much for the information you provide.

    • jp:

      Thank you for your comprehensive letter. Metatarsalgia, sadly, is a progressive condition. Although it might have been precipitated by the gym activities it would likely have developed eventually, regardless. Is your second toe elevating or clawing? Is the pain primarily on the sole side? If so it is likely that you have torn the "plantar plate". This can be demonstrated by a competent ultrasonographer. Please see my post "Does ignorance still pervade foot surgery?" Please let me know how you progress...

      • Jennie Campbell:

        It's been almost a year since I posted, and wanted to provide a followup. I had joint pain in my second toe and was recommended for the Weil Osteomy. With a few lifestyle changes I've been able to live without much pain, and without cutting back on physical activity. The key for me was shoes. At the gym I wear "Crocs", those spongy ugly shoes that are wonderfully cushioned with nice wide toes. I noticed immediate relief once I switched from Birkenstocks to the Crocs. For dress shoes I wear a brand called "Ahnu". They are also wide toed and have a sole that is contoured and fully supports the toe and sole. My toe seems to have stabilized, but there is still a "V gap" between the second toe and big toe due to the joint malfunction. So although the disorder is progressive and won't ever heal on its own, it is possible to live comfortably enough with the problem until a treatment plan based on scientific evidence is available.

        • jp:

          Thank you for your note about your sensible approach. It will help the many others with this common problem, and dilemma. I assume the "joint malfunction" which you mention is at the second metatarso-phalangeal joint. A solution to that, a walk-in-walk-out day case procedure, performed under regional anaesthetic is available. But keep going with footwear modifications as long as that is practical. And avoid the extraordinary, irrational surgical thumbsucks currently marketed!

  • Kathryn Holt-Rix:

    Thank you for replying - I have another appointment in London on Monday for a follow up appointment regarding the insoles. I have another appointment to see the surgeon in about 4 months. I really don't know which way to turn as I have had so much conflicting advice. How can I go about finding a highly regarded surgeon for another opinion prior to deciding what to do next re any surgery? Any advice would be greatly appreciated

    • jp:

      Sadly there is a strong, virtually impenetrable, belief amongst foot surgeons in Britain that the symptomatic deformities in the feet are caused by abnormalities in the bones and joints. This is seldom the case, at least in the early stages. This is a variant on "if there is a hammer in the hand everything is treated like a nail": orthopaedic surgeons believe that they "do bones" and hence this near universal assault on bones. I am sorry, but I do not know of any "enlightened" surgeons in Britain.

  • Kathryn Holt-Rix:

    I have had many foot problems over the years, mainly i have been told caused by a surgeon going bunion operations on both feet when I was 18 years old. I am now 44 and in the last year have had surgery weils osteotomy on the 2nd toe on Nov 2011 due to pain in the ball of the foot. This surgery was carried out again 6 months later in May 2012 as it hadn't worked. I am now in great pain under the 3rd toe and have been referred to an orthopaedic surgeon in London. He has given me 3 options 1. calf stretching exercises and insoles made up which I am trying at the moment but struggling with as they are too thick for nearly all footwear and have given me back pain. 2. To cut the calf muscle to lengthen it and operate on the 3rd toe. and a third option of (in his words) a major operation!! Any advice would be gratefully received, my quality of life is poor now and I am in pain all the time and feeling very depressed.

    • jp:

      I am sorry that you have had these problems which probably made your adolescence miserable. It is also disconcerting (and unfair on you) to give you the options and cause you to be responsible for making the choice and the decision. This type of dialogue usually means that the surgeon has not made a precise and exact diagnosis about the deforming causes. Instead he is getting into the arena of “don’t just stand there, do something –anything will do” Insoles take several forms: the ones suggested for you are probably “metatarsal shaft elevators”. It is unacceptable that they do not fit. The orthotist has a responsibility to provide you with a product which benefits you. Take them back and (politely) request improvement. If it is a “supinating insole” it is almost bound to fail. These are dispensed frequently and widely as a knee-jerk reaction by people who do not seem to understand the fundamental mechanics, and when given for the wrong reasons will, nor surprisingly, fail. You do not say what surgery is intended for the third toe – probably another Weil? Do not accept mysterious and undefined “major operation” as a diagnosis cum treatment. Your pattern of presentation is very typical, and the problems you have are all related to one another, not distinct entities which can be addressed piecemeal. Change your surgeon to someone who can give you an intelligent, cohesive, rational explanation of your condition and a well reasoned and logical treatment design.

  • Lily:

    It’s been two years since I wrote. I had been diagnosed with osteoarthritis of hands and feet, with a collapsed right forefoot, and told by a surgeon that I would have to have my big toes both fused, and a weil osteotomy on my 2nd right toe. No-one told me that the inflammation would subside – I thought I had it for life. Not only could I no longer paint or dance, but even getting out of the front door was a problem, let alone tooth brushing, making meals etc. I became suicidal. Well, now it’s two years later and the swelling and pain has gone. I have very lumpy joints, and I wear a metatarsal pad underfoot. In everyday terms I am more or less back to normal. I pay someone to cut the hedge now. I can do a little painting every day. I have even recently returned to flamenco with heavily adapted shoes, and a somewhat limited agenda. I have spent whole days walking on city tours, and even doing 5 mile walks in the countryside. My toes aren’t quite straight but on the other hand they haven’t bent any worse. I do some strengthening exercises. My arches were very collapsed at the time (and yet previously I had always worn out the outer side of my soles). By themselves they have straightened up. Right now they are rated as strong. I cannot tell you how thankful I am that I did not let a surgeon anywhere near my feet. As for the cause of it, I was always suspicious about the symmetry of toes and thumbs inflaming simultaneously and discarded the wear and tear theory. The podiatrist did eventually suggest that it might be due to hormonal disturbances post-menopause, which fitted in to my other experiences very convincingly. If so, she said, it might have just been a one-off episode. I just thought I‘d let you know what happened to me. There are so many surgeons out there who offer new “cures”, but with very little evidence, let alone those who offer the “gold standard” surgery (why is it called that?).

    • jp:

      Thank you for such a happy story! There are many "rheumatologic" conditions which are too frequently labeled "osteo-arthritis" or sometimes simply "arthritis" with the implication that there is only one type of joint affliction, and the assertion that it will inevitably proceed to crippling destruction. This, as you have demonstrated, is not necessarily the case.

    • jp:

      You have asked why "There are so many surgeons out there who offer new “cures”, but with very little evidence, let alone those who offer the “gold standard” surgery (why is it called that?)". One needs to understand "surgeon-talk": One reason that it is called “gold standard” surgery is that these surgeons are saying that it is the best they know (which does not mean the optimum or ultimate). Another reason is the advertising value and the innuendo is "My skills are such that you, lucky you, are receiving the gold standard of treatment provided by me (lucky you again).

    • Maria Snijders:

      Hi Lily, That is great to hear. I dance flamenco and have sore feet and developed a hammer toe in my 2nd right toe. Could you tell me what strenghtening exercises you did that made your arches strong again?

  • R. Post:

    My vigorous (skating, golf, etc.) 71 y.o. wife has, after impact 3 months ago, developed pain and swelling in the 2nd MTP area. She, a skater since childhood, has long had a splayed forefoot with bunion and mild hallux valgus. Now the second toe is becoming clawed, and the hallux valgus has increased. There is also moderate dorsal instability of the joint. Significant pain and swelling persist and have worsened. MRI shows a 2nd plantar plate rupture with edema, etc. It has been suggested that she have a Weil osteotomy with plantar plate repair; Lapidus fusion and realignment of the first M-C joint to take more weight under the 1st metatarsal head; and bunion exostectomy. Any thoughts, please. This is a lot of surgery, but the present situation is unsatisfactory with simple conservative measures.

    • jp:

      Thank you for asking for my opinion. You describe the common presentation of “age related deformities of the forefoot”, and all components you list are related to one another, i.e. they occur concurrently or sequentially, and have the same cause. I run into difficulties in offering advice because my views are not shared by the literature or the vast majority of orthopaedic surgeons. The surgical route suggested to you is one which is ritually used, and involves post-operative immobilization of (at least) parts of the foot for several weeks and risks as described in another post on this web-site. Excision of the “bunion” (an imprecise term) probably means removing the very structures which arrest the valgus veer of the great toe. Rather than use the meaningless term bunion exostectomy, consider whether there are symptomatic cheiloses on the dorsum of the metatarsal head. Even if present these would probably be asymptomatic unless a shoe strap is abrading this area. Look at the shoes! The prime difficulty I have with the “conventional” community of foot surgeons is their failure of the to adequately explain causality. In something as mechanistic as the foot, a causal sequence is the sine qua non of attempts to improve function. I emphasise function since the perception prevails amongst lay and professional alike that “normal appearance” equates with “normal function”. This is, I suppose, an inherent quality of human behaviour. This might have been reinforced by various design philosophies which were evolved in the nineteen twenties and thirties, such as Bauerhaus. (“Structure equals function”). However this cannot be extrapolated to highly complex human structures which are, by definition, abnormal to begin with (otherwise they would not require treatment). Making the foot “look right” does not necessarily make the foot “function right” (see my post “noxious placebos” on this web-site.) Some causes of such foot abnormalities are traditionally postulated, such as “ill fitting shoes” (which is asinine, as explained in another post) or “genetic”. It is unquestionable that genetics play a part (we have investigated the genetics in detail). However there is a long distance between an intra-cellular abnormality which is present at birth to the gross expression in late life. Therefore it is necessary to explain the structural evolution of any genetic (or multifactorial) expression as the cause of deformities of the forefoot. This is the “missing link”. I believe that I can explain this evolution but, being complex and four dimensional, I can only do this in an extended thesis. I do not want to risk misinterpretation by incomplete understanding, or attempts to short cut. Further, the validity of my thesis needs long term auditing. My collection of case histories extends back over thirty years and includes many hundreds of patients in each of various sub-categories. This demands careful statistical presentation. This thesis will be published in the near future. From what you say I would guess that your wife’s most incapacitating feature is pain under the second metatarso-phalangeal joint. It is related to load. The tear of the plantar plate is secondary to the deformity, (perhaps this tear resulted from the “impact” you describe). “Repair” is unlikely to be effective, since the same loading forces which caused the tear in the first place will tear the plantar plate again (because there is no aspect in your wife's surgical menu that indicates that the underling force chain will be correction.) A useful temporary solution would be to inject steroid into the second mtp joint. This requires experience, and many failures of this are attributable to poor surgeon technique. I would insist that this is done under radiological imaging. Stay clear of shortening, elevating, angulating any of the metatarsals. After all that metatarsal anatomy has served your wife in its current shape for at least fifty years. Was it design deficient before? Clearly not. Therefore there must be another factor which has intruded in recent years (the “impact” was simply a precipitating, not causative event). Any discomfort in the medial aspect of the great metatarso-phalangeal joint is unlikely to lie in the joint itself, and more likely related to footwear. Golf shoes are particularly culpable for reasons which I will not expound upon now.

  • Su:

    Hi I had triple weils osteomy on 2nd 3rd and 4th toes as they clawed over badly and they cut my tendons this was done in June this year 2012 all toes are floating but the 2nd &3rd toes are very bent at the base and extremely painful I can't get any shoes or boots on can I get them to straighten them I can't get thru winter in flip-flops Help suggestions please Su From uk

    • jp:

      I so wish that I could help you, but I cannot. The best that I can do is to offer a general precaution to others about these osteotomies, which as you know and have seen produce much grief and often a negative benefit.

  • AK:

    I have had Weil's osteotomy for my 2nd and 3rd toe ( 1 month ago) b/c of chronic metatrsalgia and Mortons toe. I have started to weight bear with the air cast and as I increase my distance, I feel my old pain is back.. or maybe I am just imagining.. Is is normal to have pain on the early rehab and why the pain persist for a few days.. I am going nuts and thinking the surgery was a failure.. and my surgeon is on vacation :(((( thanks a lot for any respond !

    • jp:

      AK. As you know I am skeptical about the Weil osteotomy. I realise that it is commonly performed, and allows for a flourishing implant industry, often with significant benefits from industry to surgeon. I am sorry to say that the failure rate is significant, partly because of inferior diagnosis, and the use of the Weil as a one-stop-fix-all.

  • jonathan niles:

    I had a weil osteotomy on my 1st metatarsal for hallux limitus and it worked great my big toe feels amazing, however now the ball of my foot hurts and it seems as if i might be developing a callus just belwo my second metatarsal. I want to get this fixed are there any suggestions for a surgical procedure to shorten the 2nd met that will work if a weil is not the prefered method. currently using orthotics to manage pain until i can hopefully relieve it with a surgery

    • jp:

      I am glad the Weil has worked. There are a few variants on the Weil, and I do not know which one was used in your case. It is very unusual to use a Weil on hallux limitus since the problem is limited dorsiflexion of the great toe, and the Weil increase the plantar flexion - a contradiction. I would be cautious about the long term benefit of a Weil on the great toe. The same pathology which causes hallux rigidus is responsible for the changes in your second toe. The pain you have can have nothing to do with a "long metatarsal" (which is a common explanatory refuge used by some foot surgeons. The second metatarsal has been that length all your adult life, so why should the length now be a problem? Clearly there has been some intervening change. It cannot be the bone and therefore the problem must lie in the soft tissues. I would avoid having the second metatarsal shortened - frequently that make matters irreversibly worse.

  • Krystal-kay Hawkins:

    I was told that I have 2 dislocated toes on my left foot (the two next to my pinky toe) the weil osteotomy has been suggested to me but, I am hoping there may be an alternative. I am not in alot of pain just doing normal activities but had exaserbeted it last week doing a work out including light jogging. I have a large callous on the ball of my foot. I am also diabetic but have good control, the podiatrist informed me that if I do not have the surgery it could eventually lead to foot ulcers. Any advice you could give me is so appreciated.

    • jp:

      It is probable that you have soft tissue contractures causing these dislocations. This might be related to the diabetes - a common occurrence exacerbates by being over-weight . It is correct that you run a high risk of developing sole ulcers if untreated. You need an orthopaedic surgeon with experience in the management of diabetic problems, ideally on in a team of diabetologists

  • Steve White:

    I had Weil Osteotomy on 4th MT on Oct 2009 and there has been no follow-up at all and I have found there is no intention to follow-up by the hospital. The reason for the 4th MT was that it had dropped due to non-intevention for a 5th MT spiral neck fracture in 2005, which was left displaced laterally upwards 4mm by trainee in A&E. Since April 2010 I have had severe leg muscle pains up to top of hip due to pain in the 4th MT. It may be due to penetrating hardware I don't know yet. I have private ultrasound investigation soon.

  • Ronald Klinenberg:

    My first post on this site was about one year ago almost to the day, the previous post November 8, 2010. Once again, the Weil osteotmy was done in Nov 2008 both feet at the same time. Diagnosis, pre dislocation sysndrome. Mar 2009, the screw was removed after causing a golf ball size lump on my right foot. Jan 2011 another procedure done to give the 2nd toe more flexibiity as was told the screw that came loose on the right foot tcaused the bone to heal improperly and an "excision" to file the bone down. So now, its 3 surgerys later on the right foot! The pain continues to be brutal, under the 2nd toe The Weil procedure a total failure. I am much worse since the procedure. Chicago, Illinois doctors dont know why I am in pain. So now its Nov 3 2011, three years since the double Weil. Let me tell you I am miserable. Now I am told I have a fragmented sesamoid on the right foot confirmed by MRI. I have the same pain under the big toe on the left foot. Perhaps, the Weil and shortening of the 2nd metatarsal caused excess stress to the big toe. I am serious when I write this. Can you come to Chicago, Illinois and rescue me Maybe I need to come to travel to you. Constant pain and now more surgery needed to remove the sesamoid. The ortohotics of little help. I would advise anyone who is considering this procedure absolutely NOT to have it.

    • jp:

      I am skeptical about the diagnosis of a "fragmented sessamoids" and cynical about the term "confirmed by MRI". There may be changes in the sessamoids, but are they the cause of your symptoms? The sessamoids often develop in several pieces, at times these parts are claimed (incorrectly) to be "fractured fragments". At other time "bone edema" is demonstrated. There is much debate about what this feature on MRI really means. What is the MRI appearance of the left sessamoids? Certainly no assurance can be given that these MRI changes are the cause of your pain; they could be incidental happenings. Orthotics at best are placatory, at worst aggravating.

  • kerry:

    i am due to have a weil osteomy and a pipj joint fusion in a couple weeks just wondering if anyone has had this done and would like to share there experience more concerned about mobility after operation as i have a five yr old and need to get her to and from school

    • jp:

      There can be no doubt that the Weil and its variants have benefitted many people (but see Noxious Placebos on this website). Techniques, such as time and methods of immobilization vary with the surgeon. Therefore I can give you no firm prospectus - which in any event should be provided to you by your surgeon. However here are some analyses of the outcomes on the Weil. The following emphasise problems of the Weil osteotomy. Up to 60% complication rate is reported. Also reported, the "floating toe" consequence, and the inadvisability of a PIP arthrodesis http://cat.inist.fr/?aModele=afficheN&cpsidt=16116764 http://fas.sagepub.com/content/early/2011/04/12/1938640011402822.abstract

  • Danna:

    I had a Weils osteotomy of the 2nd metatarsal and arthrodesis of the 2nd toe 5 months ago, the surgery really helped with the uncomfortable pain that I had in the bottom of my forefoot, but now pain is setting in the top of the foot and the second toe floats. Not to mention I have very little feeling in the big toe and second toe now it feels like needles. So sick of it, wondering if maybe I messed something up again since my temp pin was removed a week early.

    • jp:

      Removing the pin through the arthrodesis would not have caused the symptoms you described. In fact there is a technique which does not require the pin at all, and preserves the movement in the toe, without the arthrodesis. The "floating" is probably because the toe is fixed in the straight position. However there is a good chance that it will come down to the floor level in the year after the surgery. If not it can usually be corrected easily. It is usually done as an office procedure.

  • David:

    I have had worsening metatarsalgia over past two years. Original pain felt like proverbial "marble "in shoe and more recently it seems to be most directed to a swelling between 2nd and 3rd toe. There is occasional toe discomfort of the 2nd longer digit. Podiatrist said that the 2nd toe was "crossing" towards the first. It did have some medial rotation at the lower joint area inward towards the big toe, not a true "crossing". Oriiginal DPM strapped the the second toe in a downward position with makeshift in-office splints that seemed to provide some relief during work day. He then designed orthotics with metatarsal bump that I wear with limited success. Whether I use this orthotic or not, end of day results in terrible burning at forefoot . A second DPM after MRI diagnosed "thickening of planatar plate" and "plantar plate predislocation syndrome". He recommended a 2nd metatarsal shortening, flexor tendon transfer and hammertoe correction. I went for an orthopoedic opinion from an MD and he diagnosed "overuse injury involving plantar plate" on 1st visit . He was opposed to any surgery as proposed by the DPM. Follow up visit with same physician then diagnosed "Morton's neuroma, 2nd web space" after injection with lidocaine and subsequent reduction of symptoms. I understand that this neuroma is most often between 3rd and 4th toe and moreso in women. Being really confused ...I went to an orthopedic chief at major university who claimed that there could be combination of problems...2nd MP joint unstable and possible neuroma as well. He reviewed all X rays and MRI. He concurred with flexor tendon transfer procedure and neuroma excision if nerve is thickened or simply cut "ligament" where nerve is inflamed rubbing between 2nd and third toe for pain relief. This "neuroma" decision would be during surgery as he examines the area intraoperatively. He was against any toe shortening procedure as to problems with floating toe and difficult healing afterwards. He felt that inward rotaion of the longer 2nd toe could be secondary to plantar plate instability as opposed to being the causative force. Can you help me here with your opinion as it has varied from 3 differing DPM/physicians.

    • jp:

      It seems that you had two orthopaedic and two podiatric opinions which varied remarkably. Your symptoms are typical in every way, and it is no surprise that you are left wondering how a standard symptom pattern can have different solutions. To begin, it is highly unlikely that you have a Morton's "neuroma". As you say it almost inevitably occurs between the third and fourth rays, for good anatomical reasons (which I will enlarge upon in a future post). The benefit of the cortisone injection would be a general benefit to the damaged adjacent structures, and the resulting benefit is not of diagnostic value viz-à- viz Morton’s neuroma. This entity is caused by the deforming changes in the forefoot and, when these are properly corrected, disappears spontaneously. That is why it is commoner in females, who have a higher incidence of forefoot deformation. The glib removal of this nerve (which is what many surgeons suggest) can cause significant pain, similar to an amputation neuroma, which is difficult or impossible to treat. I think that your surgeon wants to cut the intermetatarsal ligament, but that also produces its own set of problems. Morton's neuroma, incidentally, does not fit the histopathological morphology of a neuroma, and should not be called such. MRI diagnosis is fallible. The reason that opinions vary so much is that the understanding, by so many professionals in the field, of the causal sequence is limited. Recently I asked the Head of Foot and Ankle unit at a world famous institution if he understood the cause of these abnormalities, and he was frank enough to say that he did not. Others are not as honest. As a result hundreds (literally) of procedures have been tried in a “random therapeutic walk”. The Weil osteotomy is only one example. Space here does not permit me to explain the relatively complex sequence of events in the evolution of your problem (and its management), but I will write to you directly over the next few weeks, in order to explain both the cause and the rational treatment.

  • Stephanie:

    I had a Weil 10 months ago on my second toe. The recovery has been long and frustrating....BUT I no longer have the intense pain that I had prior to surgery. My toe floats ever so slightly and at times I still favor it causing me to be off balance. I have been able to resume ALL activities though and have even started running! I can do all of the things with my children that I could not before due to the pain. This procedure although difficult, really really helped my quality of life. Having an amazing doctor is a huge part of the success!

    • jp:

      Thank you Stephanie for the perspective. It is correct that some recipients of the Weil osteotomy do improve. But it is equally true that many people who have forefoot deformities and pain also improve spontaneously, without surgery. The mechanisms behind the lessening of these symptoms requires an essay in its own right, which is not appropriate here. There are a number of distinct causes of pain associated with the forefoot deformities, notably in the second toe. These include the pains produced by increased toe tip impact, abrasions on the top of the toe at the proximal inter-phalangeal joint level, corns, "soft" (interdigital) corns, plantar callocities, ulceration, changes in the nail and nail bed and pain (and arthrosis) in the metatarso-phalangeal joint. You have not said which was the cause of your pain. The proponents of the Weil have never been able to explain to me how the Weil corrects each of these different types of pain, by a single “all-encompassing” procedure. (And I have spoken to many “world experts” at Foot and Ankle conferences internationally). It is equally true that many who have had the Weil suffer, at best, a prolonged and expensive convalescence to find they are no better and at worst that they have more or different symptoms post operatively. The clawing which I suppose you had in the second toe is, unfortunately, a harbinger of troubles in the rest of your foot, at some time in the future.

  • Lila:

    I've seen a surgeon who recommended fusing both big toes and Weils osteotomy on one 2nd toe which has slight hammer and pain underfoot. I don't think I'm anywhere near going through these procedures; the more I read, the worse it seems. Although dancing has been my passion, I'd rather totter round the house than risk some of these outcomes, at least until the pain becomes unbearable. The surgeon was not very good at explaining necessity of procedures, or the outcomes. I would .like to see a justification for this procedure, too... has no-one replied?

    • jp:

      Whilst popular, fusing the great toes has many problems, including inter-operator variability of success. Said another way some surgeons are less successful with these fusions than others. Many people who have had great toe fusions have returned to dancing, soccer, and running - but many have not. Some are much worse, like the woman I will be trying to reconstruct tomorrow. My views on the Weil are well recorded. However, all this does not help you, and many others, to get back into the world of function. I am therfore preparing a DVD on my research on these abnormalities and their management, for distribution to orthopaedic surgeons. This is likely to be ready by the (northern) summer.

      • ps:

        Is this DVD ready. You have responded to all complaints, so I assume you are expert in corrective foot surgery. I am very anxious to see this research.

        • jp:

          These techniques are well developed, and established by 30 years of follow up, on large numbers of patients. Please tell me who you are...

  • Lorraine:

    I had a Weil in March 2008, the result was infection, an 11 mm screw was taken out 6 weeks post op - (I never knew screw was in), I now walk with a floating toe, pain in ball of foot, have to wear orthotics, closed shoes, tackies in very hot SA weather, or just suffer the pain of walking in open shoes without orthotics. I went back to the doctors, but their opinion is to continue with conservative treatment (orthotics) and no invasive surgery. I will try my best to come and see you in 2011. I am not on medical insurance, which is a problem. Embarrassing as government surgery was done. Now I am stuck. Awful to have to walk like this for the rest of my life, unless God does a miracle (another surgeon recommended K-wire, BRT) - happy 2011, Lorraine.

    • jp:

      This sad tale is sent to me frequently (not many are published) The Weil is doomed to fail often, because it does not address the underlying problem.

  • John:

    I had a surgery three years ago to remove a bunion. The doctor also preformed a correction for a very slight hammer toe condition that has devastated my live. I have a constant pain and or discomfort. It wakes be in the middle of the night and I seldom go to sleep without putting my foot out from under the cover. I need help. I have been through therapy, Vitamin and Lyrica treatments. I have seen a podiatrist and another orthopedic surgeon. No one can offer a solution and I am now waiting to see another specialist. No one see to recognize my urgency with this condition and I need advice to get relief.

    • jp:

      Please tell me where you have pain, great or second toe, sole or skin of toe? Do you have an operation report?

      • June:

        Hi, I have just read all your comments. I am wondering what you would recommend that a person with a hammer toe do? I live in the Portland Oregon area, and the Dr. I saw recommended the Weil proceedure. I put it off because I need to be able to walk the next few months as my only Granddaughter is getting married in July in Houston and want to be able to attend all the parties.

        • jp:

          The word "hammer toe" means a number of different things, often different to different people. What is important is that the cause of the deformity be reversed. Ask your orthopaedist what he believes to be the primary cause. If he cannot tell you, look elsewhere.

        • jp:

          I am not enthusiastic about the Weil osteotomy, which often has a number of residual problems as you will have seen from the website papers. At times it is not as simple as straightening the toe, particularly if there is damage at the metatarsal-phalangeal joint. Arthrodesis (fusing) the toe in a straight position is common. However it might be that you can "tide things over" by protecting the upper surface of the toe (where it usually abrades against the shoe upper). While this is no more than a temporary solution usually, I have found the best dressing by far to be to wrap the toe with electricians' PVC insulating tape. I will shortly publish the technique which I use in the correction of this deformity.

  • Anonymous:

    I had a Weil Osteotomy on Both feet in Nov 2008. The pain after surgery is much, much more intense than prior to surgery. Its brutal. The three other Doctors in my area tell me after looking at my X-rays that the surgery was a success!! Hmm, If so successful then why is the pain far more intense after the procedure.. No answers. I suffer everday of my life, Its BRUTAL.

    • jp:

      In reply to Anonymous I am so sorry that you have had this experience. I agree absolutely, success is to be measured by relief of presenting symptoms and functional return. That is the sine qua non. X-rays are irrelevant as a measure of success. If you would lie to e-mail (jpeg) photographs of your feet, and pre-operative x-rays I might be able to make useful comments. It disturbs me that my colleagues persist in their irrational approach. Best Wishes

  • Anonymous:

    i had a double weil procedure on 2nd and 3rd metattarsals 1 year ago and have suffered with much worse pain since the operation as i am an active person and the operation has left me with a wide splayed foot walking on side of big toe and 4th toe producing constant pain and callouses on these pressure points. my 2nd and 3rd toes are floating despite months of physio therapy to improve the range of movement. they only reach the ground by clawing and i have stiffness, odd sensation and pain all through my foot and toes. my dr has referred me to a pain management specialist for counselling and medication but I believe he never should have done this surgery for pain in the ball of my foot and doubt this is a successful op for anyone. how can you walk on 2 shorter toes??? the rationale of the surgery doesnt even sound logical please help!

    • jp:

      Foot and ankle surgeons around the world have justified the Weil osteotomy as "the only joint sparing procedure available for claw toes ". Whilst sparing joints is to be applauded, the rationale in your case is fallacious because: The object of the treatment is to abolish pain. If that pain arises in a joint which has an arthrosis or "synovitis" there is not a lot of sense in preserving it unaltered. The "joint" is not just the bone and cartilage. For a joint to function there must be normal function of the tendons, capsule and other finely designed structures about the joint. If these structures are damaged (as they are in the Weil) then the joint loses function (as in your case) and the joint can hardly be considered to be "preserved". Since I understand that steroid injected into your joint helped temporarily, this points to your pain's origin in the joint. What you need now is an excision arthroplasty of that joint. This can be a tricky procedure, and needs experience. You should be able to walk from the surgery the same day, with little (if any) pain, and return to former activities in 10 days.

  • Anonymous:

    Hello, I had the Weil Procedure nine months ago. I am in pain all of the time, my toe sits slightly on top of the third one and my Doctor isn't offering a solution. Would you be able to offer me any advice or recomend someone, in Columbus, OH?

    • jp:

      Please tell me the reason for the procedure, and whether the pain you have now is different to any pre-operative pain you might have had.

  • Ronald:

    Thank you very much for all your time and advice. Yesterday, November 30th, I went to see an orthopeadic foot and ankle specialist. The doctor made no comment on my prior surgery's but reviewed my recent MRI and took new X-rays. Her conclusion was that my problem iis an arthritic joint in the big toe joint on both feet. I was given cortizone shots in hope of pain relief. I was told if that did not work I would require surgery, a fushion of the big toe, Arthrodesis. That proceure would leave the big toe without any flexibility but would relieve the pain. What is your opinion about that procedure? Would I have trouble's walking after that procedure?

  • jp:

    Arthrodesis of the metatarso-phalangeal joint (technical words are used only for precision of description) or the base of the big toe is frequently used. There are some problems, which could include a convalescence of many weeks, and "fusing" at an angle which is awkward for you. The selection of surgery should take into account your age, and your activities. Whilst I have seen some great-toe arthrodeses go very wrong, there have also been good successes. Some football and soccer players (and this arthritis is common in them) return to their sports. One orthopaedic surgeon, whom I respect - an aficionado for the arthrodesis - told me of his success with a (veteran) sprinter. I do not know which side was arthrodesed - which could be important depending on the lead foot of the sprinter on the starting blocks. This illustrates the need for precision in selection and the design of such fusions. My own practice, emphatically in the elderly, is different. This web-site is not the place to display my alternate techniques. However, I am considering another web-site, which I hope will become "peer critical", describing some techniques which might be improvements on existing methods.

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