Evolution of the Weil Osteotomy: The Triple Osteotomy

Advances in the Causes and Treatment of Floating Toes after the Weil Osteotomy: A Scoping Review

The floating toe deformity is classified as a forefoot deformity wherein the distal portion of the toe does not establish touch with the ground, resulting in a suspended or elevated position while the finger is in a relaxed state. At first, it garnered considerable interest as a complication It is worth noting that this condition is particularly common in children under the age of 8, which usually disappears as the individual reaches maturity. Studies have shown that with the aggravation of floating toe deformity, its adverse effects on patients' gait and overall quality of life also increase. Despite the prevalence of floating toe deformity in clinical settings, there is a lack of comprehensive literature investigating its underlying causes and potential preventive strategies. This scope review follows the preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (PRISMA-ScR) statement guidelines for scope reviews. The literature was obtained from various full-text databases, including China National Knowledge Infrastructure Database (CNKI), Wanfang Database, PubMed, and Web of Science Database. Our search focused on published literature related to floating toes, Weil osteotomy, and distal metatarsal osteotomy, up until March 1, 2023. The literature search and data analysis are conducted by two independent reviewers. If there are any disagreements, a third researcher will participate in the discussion and negotiate a decision. Furthermore, two experienced foot and ankle surgeons conducted a thorough literature analysis for this review. Sixty-two articles were included. Through the clinical analysis of the structural changes of the forefoot before and after operation, the classification of floating toe was described, the causes of pathological floating toe were summarized, and the possible intervention measures for the disease were put forward under the advice of foot and ankle surgery experts. We comprehensively summarize the current knowledge system about the etiology of floating toe and put forward the corresponding intervention strategy. We recommend that future studies will focus on the improvement of surgical procedures, such as the combination of Weil osteotomy, proximal interphalangeal (PIP) arthrodesis and flexor tendon arthrodesis.

Combined Distal Metatarsal and Akin Osteotomies for Concomitant Metatarsophalangeal and Interphalangeal Hallux Valgus: Clinical and Radiological Outcomes

Combined metatarsal and Akin-type proximal phalanx osteotomies represent a surgical solution for concomitant metatarso-phalangeal and inter-phalangeal hallux valgus. This retrospective observational study aimed to evaluate clinical and radiographic outcomes following combined distal linear metatarsal and Akin osteotomies. The study included 42 feet from 37 patients, with a mean follow-up of 27.1 (range 24-37) months. Mean surgical time was 16.54 ± 4.17 minutes. Pre- and postoperative clinical scores and radiological parameters were collected. Positive outcomes with a low recurrence and complications rates were reported. A statistically significant improvement in the Manchester-Oxford foot questionnaire, the EuroQol 5D-5L dimensions instrument, the visual analogue scale, the intermetatarsal angle, the hallux valgus angle, the distal metatarsal articular angle, and the interphalangeal angle correction was observed. Despite the results reported, further prospective studies are needed to identify the most suitable patients for this combined osteotomy approach.

Lateral metatarsal osteotomy

Lateral metatarsal osteotomy (LMO) aims to reposition the affected metatarsals in a chosen position. The approach may be open or percutaneous. There are several types of LMO, according to displacement: shortening, raising, translation or lengthening. Preoperative planning covers type and extent of displacement, osteotomy location and type (open or percutaneous), and number of metatarsals concerned. In the 1990s, older concepts of non-fixed osteotomies gave way to preoperative planning and calculated shortening, including the development of Weil shortening osteotomy. Diaphyseal lengthening or shortening osteotomy is mainly used for brachymetatarsia. The older concept of non-fixed lateral rays made a comeback with percutaneous first-ray surgery. Distal metatarsal minimally invasive osteotomy (DMMO) is the most effective, giving rise to variants such as distal oblique metatarsal minimally invasive osteotomy (DOMMO), to meet the requirements of greater displacement, especially in shortening and translation, and to be applicable in as wide a range of cases as possible. Presently, these percutaneous techniques have not demonstrated superiority over open surgery, and entail specific complications. Even so, they are now part of the armamentarium of forefoot surgery, as their minimal invasiveness corresponds to current trends in surgery, especially in the foot. Level of evidence: V.

Orthopaedic and plastic surgery collaboration in resolution of plantar heloma and metatarsalgia using lipofilling: a retrospective evaluation

BACKGROUND

Plantar heloma is a keratotic disorder that can be described as a circumscribed area of thickening with a central core that may penetrate the dermis. Although often considered a minor complaint, longstanding lesions can be debilitating and severely impact on person's quality of life. We present the first retrospective case series at long-term follow-up about the use of plantar lipofilling as a treatment for metatarsalgia caused by plantar heloma.

MATERIALS AND METHODS

Six patients affected by plantar heloma associated to external metatarsalgia underwent plantar lipofilling. The surgical session was performed as an outpatient procedure. Clinical evaluation was performed using the AOFAS lesser metatarsophalangeal-interphalangeal (MTP-IP) score.

RESULTS

Mean AOFAS lesser MTP-IP score improved from a preoperative score of 66.6 ± 3.2 points (range 47-77 points) to a post-operative score of 92.8 ± 2.7 points (range 86-95 points); all patients were satisfied with the outcome at the final follow-up. Post-operative clinical examination at final follow-up showed an increase in thickness of the subcutaneous layer and a decrease of dermal layer thanks to the supporting and trophic action of fat cells.

CONCLUSIONS

Plastic regenerative procedures applicated to a typical foot and ankle surgery field, such as metatarsal overloading, metatarsalgia and forefoot problems, should be encouraged to allow new treatment horizons.

Hallux valgus with second metatarsalgia: Is second metatarsal Weil osteotomy necessary?

BACKGROUND

The role of concomitant Weil osteotomy to address second toe metatarsalgia during hallux valgus correction is unclear. We aimed to critically analyse outcomes of an additional Weil osteotomy versus isolated Scarf osteotomy.in the management of hallux valgus and second metatarsalgia.

METHODS

Patients with second toe metatarsalgia who underwent first metatarsal Scarf osteotomy for hallux valgus were enrolled retrospectively. Demographics, radiographic measurements and functional outcomes were assessed at baseline, 6-months and 2-years postoperatively. Between-group significance was established with Fisher exact test, Chi-square or Mann-Whitney U test. Within-group changes from baseline were assessed with paired t-test and Wilcoxon signed-rank test.

RESULTS

48 feet (34 isolated Scarf, 14 concomitant Weil osteotomy) were included. Both cohorts demonstrated significant improvements across all measures of functional outcome. However, patients with additional Weil osteotomy reported poorer short-term outcomes.

CONCLUSION

Superiority of additional Weil osteotomy versus isolated Scarf osteotomy in addressing second toe metatarsalgia or improving functional outcomes was not demonstrated.

Risks of injury in distal metatarsal minimally invasive osteotomy when comparing standard and modified techniques: A cadaveric study

BACKGROUND

The objectives of the study were to evaluate the structures at risk in distal metatarsal mini-invasive osteotomy (DMMO) and to compare standard and intraosseous approaches.

METHODS

DMMO was performed on the second and fourth metatarsals of 11 fresh-frozen cadaveric specimens. The standard technique was performed in 11 metatarsals. It was then compared to a modified intraosseous technique that entails starting inside the bone in 11 other metatarsals. The cadavers were dissected to identify unintentional injury to soft tissue structures.

RESULTS

In the standard group the most injured structures were the metatarsal joint capsules (MJC) (27%), extensor digitorum longus (EDL) (18%), and extensor digitorum brevis (EDB) (9%). The modified intraosseous group injured the EDL (27%), not the MJC (0%) and the EDB (0%). Distances between osteotomies and the dorsal metatarsal head articular surface (DMHAS) were 6.08 ± 3.99 mm in the standard and 9.92 ± 3.42 mm in the modified (p = 0.02).

CONCLUSION

The DMMO techniques most frequently injured the EDL. Intra-articular positioning of the osteotomy was more observed in the standard. Overall, it appears the modified method could be an alternative to the standard DMMO.

CLINICAL RELEVANCE

The modified minimally invasive DMMO has a comparable rate of potential iatrogenic injuries. This intraosseous procedure may present as an option when planning surgery to the lesser metatarsals.

LEVEL OF EVIDENCE

Level III. Comparative Cadaveric Study.

Can we correct first metatarsal rotation and sesamoid position with the 3D Lapidus procedure?

OBJECTIVE

We examine the technique and radiographic outcomes obtained with triplanar first tarsometatarsal arthrodesis (3D Lapidus) for the surgical correction of hallux valgus (HV). This procedure, apart from correcting angular deformity 1st-2nd intermetatarsal angle, HV angle, etc., is specifically intended to act on first ray pronation and place the sesamoids in their normal position, to alleviate the metatarsalgia often occurring in HV before and after surgery, possibly caused by their abnormal position. This study aims to examine the radiographic outcomes of the 3D Lapidus procedure.

MATERIALS AND METHODS

Retrospective study of 37 feet operated on from April 2019 to December 2019, with a minimum 1-year follow-up (mean 420 days), using the 3D Lapidus procedure. Radiographic outcomes were evaluated.

RESULTS

The intermetatarsal angle decreased from a mean value of 16.42° to 5.62° (p < 0.0001). The HV angle decreased from a mean value of 32.12° to 8.05° (p < 0.0001). The preoperative first metatarsocuneiform angle, with a mean value of 21.86°, was null after arthrodesis (p < 0.0001). The tibial sesamoid position, according to the Hardy and Clapham classification, decreased from a mean value of 4.84 to 1.27 after surgery, within normality (p < 0.0001).

DISCUSSION

Correction of the deformity in a single plane is generally insufficient. It is necessary to act on the three planes of space to correct the deformity, obtain good outcomes, and avoid recurrence.

CONCLUSIONS

Radiographic outcomes of triplanar correction with the 3D Lapidus procedure are excellent, achieving statistically significant differences in all parameters studied.

Comparison of the Weil and Triple Weil Osteotomies: A Clinical Retrospective Study

Introduction: The Weil and triple Weil osteotomies are two widely used procedures in the surgical treatment of metatarsalgia. The aim of this comparative retrospective study was to evaluate the functional results and determine the complications of the two types of osteotomies in a series of patients who underwent surgery due to third rocker metatarsalgia.

Material and methods: In this paper, 71 patients were included between September 2015 and October 2020. The average age was 58 years old (age range: 28-72). Of all the patients, 27 suffered from metatarsalgia due to systemic (extra-regional) or regional diseases were excluded. The remaining 44 patients, after six months of unsuccessful conservative treatment, underwent surgery. Based on the preoperative planning to restore the peripheral parabolic curve of the metatarsals, when a shortening of less than or equal to 3 mm was required, a Weil osteotomy was performed. However, when a shortening of more than 3 mm was required, a triple Weil osteotomy was performed. Therefore, two groups of patients were formed, and a total of 90 osteotomies were performed. During the postoperative period, all the patients were clinically and radiographically assessed. The American Orthopedic Foot and Ankle Society (AOFAS) score was used for the assessment of the functional result, while the pain was assessed using the Visual Analogue Scale (VAS).

Results: The mean follow-up was 24 months. The average operative time for the Weil and the triple Weil osteotomies was 22.8 minutes and 31.5 minutes, respectively. In group A, preoperatively, the average AOFAS score was 31/100, and postoperatively, it was 89/100. In group B, the corresponding values were 30/100 and 93/100, respectively. In group A, the preoperative VAS score was 7.8/10, while the postoperative VAS score was 1.3/10. In group B, the corresponding values were 8.2/10 and 1.7/10, respectively. In group A, stiffness had a percentage equal to 60.9%, and a floating toe was noticed in 16 osteotomies. In group B, superficial infection represented the commonest complication, with an incidence of 25.6%.

Conclusion: Both Weil and triple Weil osteotomies are effective procedures in the surgical treatment of patients who suffer from third-rocker metatarsalgia. In both cases, correct preoperative planning is of paramount importance for the outcome. However, in terms of the appearance of the floating toe, it seems that in cases where a ray’s shortening of more than 3 mm is required, the triple osteotomy is superior to the Weil osteotomy.

One-Stage Lengthening and Minimally Invasive Distal Metatarsal Metaphyseal Osteotomy (DMMO) for Brachymetatarsia

Level of Evidence: Level V.

Flexor tenodesis procedure in the treatment of lesser toe deformities

In this technical report study, we describe the use of a flexor tenodesis procedure in the treatment of lesser toe deformities (LTD). Using a specific implant, both the flexor digitorum longus and brevis tendons are attached to the plantar aspect of the proximal phalanx, allowing dynamic correction of flexible deformities of metatarsophalangeal and interphalangeal joints. Good clinical results and absence of complications were observed in a series of 3 patients, with considerable correction of the LTD, and absence of substantial residual floating toe or metatarsophalangeal joint stiffness. LEVEL OF EVIDENCE: V - Technical Report/Case Report/Expert Opinion.

Splay Toe after Freiberg-Köhler's Osteonecrosis: A Case Report of a Successful Operative Treatment in a Rare Multiplanar Foot Deformity

"Splay toe" is a rare deformity of the forefoot and often causes the occurrence of metatarsalgia and dysfunction while walking or weight bearing. Since it involves a deviation in the sagittal and transversal planes, often combined with a malrotation, surgical correction can be challenging. We describe a case of splay toe deformity in the forefoot causing metatarsalgia in a 62-year-old female patient with a former avascular osteonecrosis of the 2 metatarsal head Smillie stage V of Freiberg-Köhler's disease causing a splay toe between the 2^nd and the 3^rd rays. There are only few reports in the literature, and a clear treatment strategy has not been defined, yet, although, it has been described that most of these patients are operated more than once. In the presented case, we performed a successful treatment by a combined surgical technique consisting in modified Weil's osteotomy and the transfer of the extensor brevis tendon. We sustain that for correction of a multiplanar deformity of lesser toe deformities osseous correction as well as tendon transfer lead to successful therapy.