1. My Adaptation of Weil’s Osteotomy (for the other metatarsals)

        The main goal is to bring back the harmony of the metatarsals’ length. This is particularly important after the Hallux Valgus has been treated. A shortening of the 1st metatarsal in comparison with the 2nd, or a raising of the 1st metatarsal head will bring about a secondary metatarsalgia.

         This osteotomy allows the reduction of the metatarso-phalangeal displacement by decreasing the length of the metatarsal. This modification of the procedure provides for the slight raising of the metatarsal head and the correction of its collapse, and, in the end, the cure of plantar calluses. After several hundred operations, I can say that all these osteotomies healed well. However, if the bone is osteoporosic or that affixing with a screw is precarious, it is better to choose another alternative, since the risk of failure is too high.

        If the toe has been hammer-shaped for several years, it will often stay up in the air, defying gravity, in spite of both capsulotomy and lengthening of the extensor tendon.

The typical Weil osteotomy is a one-line section which shortens the metatarsal. M. Myerson has recently offered a variation in which an excision of a bevel at the supero-distal base will raise the head, but will also keep the toe up so it can’t reach the ground in most cases. Two years before, I had amended the surgery, removing a complete 2-to-3-mm bone slice which raised the metatarsal head a bit (as well as shortened the metatarsal).

            Displacement of 2nd MTP, treated with modified Weil osteotomy.

             The joint often stays partially displaced in spite of the osteotomy, so that, even after the lengthening of the dorsal structures, the toe still won’t reach the ground. Of course, patients would rather it did, but this result is not really a problem.

            I also perform a Girdlestone tendon transfer (i.e.: transfer of the long flexor on the P1 dorsum). This can be adequate to correct the residual subluxation of the MTP. I do this together with an interphalangeal proximal fusion.

In some cases when the toe is stiffer, it might be necessary to perform a plantar closed-bevel osteotomy at the P1 base, with an IPP fusion.

Particular care must be given to very stiff feet presenting a metatarsal collapse with plantar callosities. In such cases, even a modified Weil osteotomy might not be sufficient and a raising osteotomy (for instance a vertical Chevron) is required.

2. Hammer Toe

MTP hyper-extension, IPP flexion

If the toe is flexible, and can be passively corrected, the complete extension to IPP can be achieved.

Girdlestone Tendon Transfer: This is done only when the tissues are soft enough in order to avoid a fusion (or arthrodesis) of the interphalangeal proximal articulation which would make a small and temporary wire necessary.

The surgeon divides the 2 bands of the deep flexor and transposes them to a dorsal position, crossing one over the other, reducing the MTP hyper-extension, and affix its tendons to one another as well as the extensor tendon. Not only this hyper-extension is lessened, but the surgeon can also correct a medial or lateral deviation according to the tension applied to one of the tendinous bands.

Stiff tissues which cannot be passively reduced

Inter-phalangeal proximal (IPP) arthrodesis with long flexor tenotomy.

The IPP fusion (arthrodesis) corrects this (Inter-phalangeal proximal) acute and rigid flexion by permanently immobilizing this joint.

A small wire is put in place for four weeks. The goal of the long flexor tenotomy is to avoid a mallet toe (i.e. a flexion at IPD (inter-phalangeal distal) level which otherwise would become established in time.

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