C H A P T E R 14

Weil Osteotomy With Plantar Plate Repair: Tips for Success

Thomas A. Brosky, II, DPM
Adam Port, DPM
Jeanne Mirbey, DPM
INTRODUCTION WEIL OSTEOTOMY WITH DIRECT
The Weil osteotomy is an established and effective
PLANTAR PLATE REPAIR
osteotomy that is used for both the treatment of lesser The original description of the Weil osteotomy involves
metatarsalgia, and to aid in the reconstruction of lesser an oblique osteotomy cut within the metatarsal neck,
metatarsophalangeal joint (MPJ) subluxation or dislocation. originating within the dorsal one-quarter of the articular
The Weil osteotomy is particularly indicated in cases of cartilage. The osteotomy should be parallel to the weight-
relatively long or plantarflexed metatarsals. Additionally, the bearing surface of the foot, approximately 15° to 20° relative
procedure is useful in managing cross-over and subluxed to the long axis of the metatarsal, thereby creating a large
or dislocated hammertoe and can be used in a translation area of bone-to-bone contact, which can be easily fixated
fashion to realign the MPJ. The procedure has been (4). This long osteotomy also prevents plantarflexion of the
popularized due to its simple technique, ability for stable capital fragment, which aids in reducing the incidence of
fixation, excellent union rates, and predictable results (1). a floating toe phenomenon (4). Performing a double cut
More recently, this osteotomy has been used in conjunction or wafer cut osteotomy, which can be accomplished using
with repair of the plantar plate. Postoperative complications 2 blades on the same saw or by making 2 separate saw
after a Weil osteotomy can be minimized with appropriate cuts, allows for elevation of the head and further aids in
surgical technique (2). The authors will demonstrate that the prevention of floating toe phenomenon. Shortening of
the Weil osteotomy, when used in conjunction with repair the capital fragment should be 1-3 mm to prevent over-
of the plantar plate has manageable side effects and allows shortening and again, to prevent floating toe.
for excellent reproducible results. When performing this osteotomy in conjunction with
plantar plate repair, the capital fragment can be proximally
BACKGROUND
The pathomechanics of the plantar plate degeneration and/
or rupture involve increased plantar plate pressure due to
hallux valgus, first ray insufficiency, hammertoe deformity,
elongated lesser metatarsal, and gastrocnemius equinus.
One or a combination of these deformities can lead to
increased load at the lesser metatarsal head, particularly
at the second metatarsal due to its increased length in the
typical foot (2). This increased load leads to joint effusion
and increased stress on the plantar plate, thus leading to
degeneration or rupture. Other cases involve repetitive or
acute trauma from an injury or increase in activity (3).
Clinically, patients with plantar plate pathology present
with dorsiflexion or dorsal dislocation at the MPJ, often
with an accompanying hammered digit. Pain can often be
localized to the distal-plantar aspect of the MPJ. Some cases
present with additional medial or lateral deviation of the
proximal phalanx due to more medial or lateral degeneration
of the plate (Figure 1).
Figure 1. Transverse dislocation of the second digit.
68 CHAPTER 14

translated for easy visualization of the plantar plate, thus TECHNIQUE DESCRIPTION
allowing for a direct repair technique. Numerous techniques
have been published that involve direct repair of the plantar A longitudinal skin incision is made over the dorsal aspect
plate without the Weil osteotomy including the Arthrex of the involved digit, from just proximal to the MPJ and
Complete Plantar Plate Repair System and Smith & Nephew extending distal to the PIPJ. Following anatomic dissection,
HAT-Trick Lesser Toe Repair System. Recently, the plantar sharp or blunt dissection is carried down to the deep fascia
plate has been implicated as an important stabilizer of the where any crossing vessels should be carefully ligated and
MPJ. In the past, some procedures attempted the joint divided. A transverse extensor tendon tenotomy is performed
repair without direct plantar plate repair. These procedures at the PIPJ and the tendon is reflected proximally, and a
involved stabilizing the MPJ with a Kirschner wire (K-wire) medial and lateral capsulotomy is performed allowing for
in an attempt to allow fibrosis to occur and thereby stabilize exposure of the MPJ.
the joint. This technique typically resulted in a stiff digit and The double cut osteotomy can be performed using 2
often led to a recurrent hammertoe deformity. Plantar plate blades on the same saw or by making two separate saw cuts.
repair using a direct plantar approach has been performed If the surgeon wishes to perform the joystick method for
in the past, however numerous complications including fixation, a K-wire is inserted into the capital fragment prior
painful scarring and prolonged immobilization have caused to the osteotomy. If 2 separate cuts are performed for the
this technique to fall out of favor. double cut osteotomy, the first cut is made at the metatarsal
Some proponents of direct plantar plate repair head, parallel to the longitudinal axis of the bone. The
techniques argue that the Weil osteotomy is not necessary capital fragment is then retracted plantarly using a thin
due to its relative complications. The osteotomy is osteotome in preparation for the double cut osteotomy.
associated with various complications including floating toe The second cut is oriented slightly distal-dorsal to proximal-
(36%), recurrence (12.5%), and transfer metatarsalgia (7%) plantar, creating a thin wedge-like fragment allowing for
(5). Other complications associated with the Weil include dorsiflexion of the capital fragment upon fixation. At this
delayed union, non-union, and malunion, which account time the wedge-like fragment is removed and the capital
for 3% of cases overall and are most often associated with fragment is ready for fixation.
significant comorbidities (5). The complication of floating Mobilization and fixation of the capital fragment
toe is increased when concurrent proximal interphalangeal using the joystick technique can now be performed. The
joint (PIPJ) arthrodesis is performed. joystick method uses the K-wire driven into the capital
In a study by Migues et al, floating toe occurred 15% fragment, prior to osteotomy. This can be used to aid
of the time without concurrent PIPJ arthroplasty and in appropriate positioning of the capital fragment in
increased to 50% when the Weil osteotomy was performed both the transverse (medial and lateral translocation) or
with a concurrent PIPJ arthroplasty (7). Floating toe longitudinal (lengthening or shortening) planes. This also
can also be prevented by avoiding plantarflexion of the aids in compression at the osteotomy site during temporary
metatarsal head by ensuring the osteotomy is parallel to the fixation with a vertical K-wire. Two screws can then be used
weight-bearing surface, or by using a wafer cut method with for fixation of the capilar fragment.
parallel osteotomies to achieve more shortening from the Exposure of the MPJ space is excellent and allows
osteotomy with minimal capital fragment proximal-plantar for good exposure of the plantar plate. The plantar plate
translation and therefore plantarflexion of the metatarsal can be carefully inspected and repaired primarily using
head (5). It should also be noted that while floating toe is a 2-0 Ethibond suture. Additional procedures can then be
common complication associated with the Weil osteotomy, performed including an PIPJ arthrodesis. The extensor
only a fraction of patients with this complication state that tendon can be lengthened as needed and should be repaired
they are unhappy with the results (10% in 1 study) (6). distally. The subcutaneous and skin layers are then closed.
There is an inverse relationship noted between recurrence
of symptoms in the second digit Weil and simultaneous first CASES
ray procedures, indicating a potential need for correction
Three cases are presented, which highlight the double cut
of asymptomatic hallux valgus in the presence of subluxed
or wafer cut technique, along with the joystick technique
second MPJ (8). Transfer metatarsalgia has been noted to
and adequate visualization for a direct plantar plate repair.
be a result of excessive shortening. In a retrospective review
These techniques can be used to aid in better control of
of the Weil metatarsal osteotomy, transfer metatarsalgia
osseous position and fixation and help reduce postoperative
was reduced to 1.1% by simply determining the amount of
complications.
shortening necessary preoperatively using anterior-posterior
radiographs to ensure proper metatarsal parabola (9).
 CHAPTER 14 69

Case 1.
An illustration of the double cut osteotomy is shown in
Figures 2-8.

Figure 2. Clinical presentation of a hammer toe Figure 3. Radiograph of same patient showing medial
with plantar plate degeneration with cross over dislocation of the second metatarsophalangeal joint.
second digit.

Figure 4. Saw placement for the Weil osteotomy after joint exposure. Figure 5. Retraction of the capital fragment in preparation for a double cut
osteotomy with an osteotome.
70 CHAPTER 14

Figure 6. Double cut osteotomy used for dorsiflexion of the capital

fragment and prevention of a floating toe.

Figure 7. The double osteotomy fragment.

Case 2.
An illustration of the joystick method with K-wire is shown
in Figures 9-15.

Figure 8. Segment of bone removed from the double osteotomy.

Figure 9. Preoperative radiograph showing the

medially dislocated second digit.
 CHAPTER 14 71

Figure 10. Dissection to the Figure 11. Saw placement for osteotomy with Kirschner wire in place.
metatarsophalangeal joint with Kirschner
wire used for the joystick method.
Insertion into the capital fragment prior
to the osteotomy.

Figure 12. Medial translation of the capital fragment with Figure 13. Kirschner wire used for compression
Kirschner wire. with temporary fixation in place.
72 CHAPTER 14

Figure 15. Preoperative and postoperative radiographs with congruent

Figure 14. Screw fixation with two screws. second metatarsophalangeal joint. Note that a second proximal
interphalangeal joint arthrodesis along with a first metatarsophalangeal
joint arthrodesis were also performed.

Case 3.
Illustration of excellent plantar plate exposure for direct
repair after a double cut Weil osteotomy is shown in Figures
16-19.

Figure 16. Excellent exposure of the plantar plate is Figure 17. After adequate exposure, the plantar
achieved after the double cut Weil osteotomy. plate can be carefully inspected and primarily
repaired or tightened as needed.
 CHAPTER 14 73

Figure 18. Extensor tendon Z-lengthening is

performed and the tendon is repaired and re-
approximated distally. Figure 19. Before and after clinical and radiographs
for the double cut Weil osteotomy, direct plantar plate
repair, and fixation of the capital fragment using the
joystick method.

DISCUSSION REFERENCES
The authors believe that the complications previously 1. Garcia-Fernandez GG. Comparative study of the Weil osteotomy
with and without fixation. Foot Ankle Surg 2011;17:103-7.
mentioned are of little significance if managed appropriately 2. Reddy VB. Metatarsal osteotomies: complications. Foot Ankle Clin
and intraoperatively. Additionally, it is believed that excellent 2018;23:47-55.
results can be obtained by combining a Weil osteotomy 3. Akoh CC, Phisitkul P. Plantar plate injury and angular toe deformity.
Foot Ankle Clin 2018;23:703-13.
with direct plantar plate repair. In a 2007 study by Gregg 4. Vandeputte G. The Weil osteotomy of the lesser metatarsals: a
et al, 95% of patients with concomitant plantar plate repair clinical and pedobarographic follow-up study. Foot Ankle Int
and a Weil osteotomy demonstrated no or only mild 2000;21:370-4.
pain postoperatively (10). In 2011, Weil and colleagues 5. Highlander P. Complications of the Weil osteotomy. Foot Ankle
Spec 2011;4:165-70.
demonstrated that combined plantar plate repair and a Weil 6. Migues A. Floating-toe deformity as a complication of the Weil
osteotomy reduced the visual analog pain scale scores from osteotomy. Foot Ankle Int 2004;25:609-13.
7.3 preoperatively to 1.7 postoperatively (11). 7. Pepyne E, Schneider H. A guide to performing an effective Weil
osteotomy. Podiatry Today 2017;30:20-5
From a review of the literature and the authors’ 8. Myerson M, Jung HG. The role of toe flexor to extensor transfer in
personal experience, it can be concluded that direct plantar correcting metatarsophalangeal joint instability of the second toe.
plate repair combined with a Weil osteotomy gives patients Foot Ankle Int 2005;26:675-9.
9. Beech I, Rees S, Tagoe M. A retrospective review of the Weil
the best result in terms of treatment of the rupture and metatarsal osteotomy for lesser metatarsal deformities: an
correction of the osseous deformity. intermediate follow-up analysis. J Foot Ankle Surg 2005;44:358-64.
10. Gregg J. Plantar plate repair and Weil osteotomy for metatarsophalangeal
joint instability. Foot Ankle Surg 2007;13:116-21.
11. Weil L Jr. Anatomic plantar plate repair using the Weil metatarsal
osteotomy approach. Foot Ankle Spec 2011;4145-50.
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