Review Question - QID 597

The second metatarsal osteotomy (Weil), is an intra-articular osteotomy that achieves longitudinal decompression through shortening and will correct the longer 2nd metatarsal in relation to the first metatarsal. The first metatarsal bears half the weight of the forefoot and this patient's plantar callosity under the 2nd metatarsal head is clinical evidence of abnormal pressure transfer due to the longer 2nd metatarsal (seen in Figure A). The foot tripod can also be altered by hallux valgus as the proximal phalanx moves into valgus, the splay between the first and second rays increases (IM angle), the metatarsal moves into varus and elevates, and weight-bearing is transferred from the 1st metatarsal head to the the 2nd metatarsal head. A shortening osteotomy with extensor tendon and dorsal capsular release is the most appropriate option listed to address the second MTP metatarsalgia.

The Weil osteotomy of the metatarsal head is preferable to the Helal osteotomy of the metatarsal shaft to correct metatarsalgia due to higher rates of nonunion and pseudarthrosis with shaft osteotomies as demonstrated in the article by Trnka et al. Illustration A shows the difference between the Weil osteotomy (osteotomy B) and the Helal osteotomy (osteotomy A).