02/20/2019    Sheldon Nadal, DPM

Pain 2nd MTPJ S/P Weil Osteotomy

If you look at the original x-rays, it appears
that metatarsals two and three are adducted. Not
surprisingly, the second and third toes are
abducted since the toes tend to move in the
opposite direction of the metatarsals. I think
the post-operative problem is due to the fact
that the surgeon decided to fixate the second
metatarsal osteotomy. Had he or she left it
unfixated, chances are that the metatarsal head
would have shifted slightly laterally. This
would have caused the second toe proximal
phalanx to shift slightly medially and give a
more congruent joint.

Personally, I would now simply perform an
unfixated transverse second metatarsal neck
osteotomy, using a rotating burr such as a
Shannon 44, proximal to the screw. I would
perform it from dorsal distal to plantar
proximal to prevent excessive dorsal movement of
the head, and from medial to lateral to allow
the head to shift slightly laterally. This will
also “decongest” the joint, reduce the
retrograde forces and should relieve the pain.

I would also do the third metatarsal at the same
time since this will be the second time the
second metatarsal is shortened. This will help
to prevent transfer of pressure to the third
metatarsal phalangeal joint. According to
Leventeen, the third metatarsal osteotomy
probably should have been performed when the
second metatarsal osteotomy was originally
performed. These techniques are taught at the
Academy of Minimally Invasive Foot and Ankle
Surgery. In my opinion, it is not necessary to
remove the screw, perform tendon transfers or
resect the base of the proximal phalanx. Keep it
simple.

Sheldon Nadal, DPM, Toronto, Canada

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