02/22/2019    Don Peacock, DPM, MS

Pain 2nd MTPJ S/P Weil Osteotomy

RE: Pain 2nd MTPJ S/P Weil Osteotomy (Tip
Sullivan, DPM)
From: Don Peacock, DPM

Dr. Sullivan my experience has been good with
the percutaneous metatarsal osteotomy compared
to the the Weil which I did for years. Recently,
Henry, et al. published a study that compared
the classic fixated Weil osteotomy with a non-
fixated percutaneous distal percutaneous
metatarsal osteotomy (DMMO). The percutaneous
DMMO procedure is an extra-articular osteotomy
without internal fixation. Thomas Bauer also
published findings on the non-fixated DMMO with
more than 150 patients. All but a few patients
had complete resolve in their symptoms and no
non-union.

What has been documented is post op pain and
swelling up to 3 months after DMMO. The surgical
recovery is longer after DMMO than the fixated
Weil. At 3 months 29% of the Weil patients had
swelling versus 59% of the patients after the
MIS DMMO. However, in the DMMO group the edema
was transient and completely gone at 12 months
with very few patients experiencing ongoing pain
(Henry et al). These results are better than the
reported Weil at 12 months.

There is relatively little comparative
literature comparing the Weil to the DMMO. In
the literature, the DMMO seems to yield less
postoperative stiffness but the tradeoff is
prolonged swelling and post op pain.
Symptomatic non-union is less than 1% in the
non-fixated DMMO (Redform D, Vernois J). This is
higher than the Weil group but still low.

I have done many non-fixated DMMOs and I have
seen 1 non-union in a 5th metatarsal MIS
osteotomy. I have not seen a non-union in the
DMMO group with metatarsals 2, 3, or 4 so far. I
have done many Weil osteotomies as well. I have
had more success with the MIS PMO when it comes
to resolving the patient’s pain long-term. To
combat the prolonged swelling I place patients
in a pneumatic CAM walker for 6 weeks. This
wards off some of the post-operative swelling.

The DMMO has been successful in my hands.
However, I lean toward correcting equinus by
gastrocnemius recession for most of my forefoot
pain patients and stay away from metatarsal
osteotomes if possible. It's way more
predictable and has more research backing. It
could probably have been used in the OP patient
without all the subsequent complications. Always
remember equinus as a source of forefoot pain.
The recession is easier and safer to fix than
multiple metatarsal osteotomies. The recovery is
much less. It takes a bigger incision to do the
gastrocnemius recession but its less invasive
than the DMMO or the Weil.

Don Peacock, DPM, MS, Whiteville NC

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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