Surgery of the Lateral Rays, and severe disorders of the 

Forefoot                                                                                                 
Louis Samuel et Pierre Barouk
 
Introduction
To treat successfully the severe disorders of the forefoot, it is necessary to take into account the
whole forefoot, and to use many procedures we have  already described or developped.
We first describe the different techniques required, then how to combine them.
 
 
The techniques we use
 
Métatarsals 
Weil Osteotomy. Main technical  points (fig.1) . Cut :the most horizontal possible. A second
layer is almost always required. make the head free to have the  correct and free proximal sliding.
Respect of the metatarsal parabola . Tightness after Weil Osteotomy: 1. Prevention:
Apart these  intra operative features; large proximal sliding (as far the ms point),post operative
bandage and training. 2: treatment :per cutaneous or mini invasive MTP release, one year post
operatively. Indications: Avoid a single metatarsal Osteotomy (2 minimum). Above all, MTP
Dislocation, or whatever severe lateral disorder.
Metatarsal oblique basal Osteotomy(BRT)  technique  long and horizontal cut, second
layer very close from the first one :assessment: only by plantar  palpation of the metatarsal head.
Fixation: preferably by a FRS 2.5 Screw. Indication: only metatarsalgia, particularly iatrogenic
Toes
Avoid the PIP Fusion or arthroplasty: prefer the PIP Plantar release,(plantar capsular section, and 
flexor brevis disinsertion) so that the toe length is preserved, compensating the metatarsal
shortening
Soft Tissues
Extensor tendon lengthening, and, if required, distal section of the long flexor tendon; the tendon
transfers are not necessary.
 
Required Techniques
1. Scarf with shortening
2. Weil Osteotomy with a second layer
3. Shortening focused on the ms point (projection of the proximal phalanx on the
corresponding metatarsal); this projection determines the shortening of the metatarsal
4. Preservation of the metatarsal parabola
 
 
Joint Preserving surgery in severe forefoot disorders :
This joint preservation is allowed by the Shortening of the metatarsals which has the following
specificities: 1.large shortening (average: more than 1 cm)  2. focused on the ms point of the most
deformed ray  3. Preservation of the metatarsal parabola- i.e. harmonized shortening of the other
metatarsals, including the first one if required-.
To reach such a shortening, we use the Scarf Osteotomy on the first ray, the Weil Osteotomy on
the lateral rays, with a Open procedure (in this cases, no percutaneous surgery) This metatarsal
shortening allows and is compensated by the respect of the length of the toes, avoiding the PIP
fusion or arthroplasty
A soft tissue surgery is combined (see above).
 
Problems or drawbacks
-  MTP Tightness ? In fact the metatarsal shortening ,which is very large in these cases, avoid
almost always the tightness.
    Nevertheless, if a tightness occurs, the MTP  per cutaneous release resolves this problem.
- remaining or transfer metatarsalgia  (5%) : the BRT Osteotomy is a good solution, sometimes
combined with a MTP Release.
 
Résults, Conclusions
In almost all cases of severe forefoot disorders, it is possible to obtain a good and long lasting
correction while preserving the MTP Joint.  
The main Indications are: advanced hallux valgus, with whole forefoot disorders, revision surgery in
severe cases, MTP Dislocations, and at last even the rheumatoid forefoot, in which we can
 preserve 85% of the MTP Joints and the Metatarsal heads.
All these results are maintained with a long follow up.
So that the traditional surgery, with the first MTP Joint Fusion and lesser metatarsal head
resection, has its indication significantly decreased, limited to major impairment of the MTP Joint
and Heads (15% of  cases)
 

Indication and Results of the joint preserving surgery in severe forefoot disorders
1. 1. Iatrogenic forefoot
2. 2. Advanced Hallux valgus
3. 3. Rheumatoid forefoot
 
 
Personal references
 
- Barouk LS. Correction des désordres statiques sévères de l’avant pied par
chirurgie extra articulaire.
  Maitrise orthopédique. Gicep. Paris.N° 144- 6.2.
 
- Barouk LS . Forefoot Reconstruction. A Book + 2 CD ROMS. Paris. Springer
2005.. 

- Barouk LS & P. Rheumatoid Forefoot . In: Foot& Ankle Clinic. Elsevier     Vol
12 .N°3, Sept 2007
 
all details and complete references in our   web site... www.barouk-ls-p.com
 
 
 
We describe successively the two osteotomies we use : one distal (Weil), the other proximal (BRT)
 
 [ DISTAL OSTEOTOMY (WEIL) ] [ PROXIMAL OSTEOTOMY (BRT) ]
 
Lowell Scott Weil
LS Weil is not only the inventor of the distal oblique
osteotomy of the lesser metatarsals; he also
provides the word “Scarf” to the osteotomy of the
first metatarsal, makes the first clinical studies of
this osteotomy, and contributes to spread it
worldwide. He has been making also many studies
and inventions on the treatment of Foot Pathology
 He  improves the relationships between the
Orthopedic surgeons and the podiatrists, first by
himself, and as past president of the American
college of Foot& ankle surgeons and Editor of “the
journal of foot & ankle surgery”.
His “Weil Foot & Ankle institute” is a model of a very
effective organisation of foot diseases treatment
and research.
 
 
 
 
 
 
 
 

 
DISTAL OSTEOTOMY (WEIL)
 
L.S. Weil described this technique : he performed it in Europe the first time in our service, in Bordeaux in
1992. 
The Weil osteotomy is a long osteotomy oblique and proximally directed from the upper part of the
metatarsal head.
It is fixed by a dedicated twist of screw ( DePuy ).
 
This osteotomy provides a displacement which may be a medial or lateral but which will be in most cases
a proximal sliding. This bring the metatarsal head proximal from keratosis in case of métatarsalgia. But
above all this osteotomy results in a longitudinal decompression which is certainly the best procedure to
correct the MTP dislocation and also, in most cases, the claw toes.
 
The only problem encountered should be a post operative MTP stiffness, but we now how to avoid and to
correct. Anyway, the MTP stiffness is almost no more observed  in case of a large and harmonized
proximal sliding of the metatarsal head (longitudinal decompression).
 
TECHNIQUE
 
 
 
 
 
 
 
1- The osteotomy has to be the
most horizontal as
possible preserving as far as
possible the head cartilage
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
2- a large proximal sliding is always
required, in the forefoot severe
disorders.
 
Click to enlarge picture
3- The second layer is required in
most cases.
 
   
 Fixation of the Weil osteotomy by
the twist off screw
1. The twist off

screw ( DePuy ) .
a)       support
b)      breaking part
c)       flat head
d)      unthreaded part for
compression
e)      Tip
 
2. First introduction of a 1 mm
K. Wire, one cm proximal from the
distal end of the upper fragment 

 
  3. therefore, the screw has to
Click to enlarge picture be located in a deeper part of
the head, and at an equal
distance of the fragments
extremities.

 
4. Setting the twist off screw
with a slow motion motor: stop the
motor just when the head is the
bone contact and break the support
forwardly., and finish with a screw
driver

 
5. AVI of the fixation.
[ Flux vidéo  ]
 
   
INDICATIONS  and  RESULTS
 
1 - Metatarsalgia
 
The metatarsal head slides
proximally backwards the keratosis
but does not have elevation, except
in case of performing a double
longer
An advanced métatarsalgie is an
excellent indication to the Weil
osteotomy.
If the result is insufficient (rare) the
BRT osteotomy, performed
secondarily, is a good indication
(see the chapter: problems
encountered).
 
 
 
 
2 - Correction of
Severe Claw Toes
 
 
 
 
 
 
 
In such severe claw toes,
whatever the cause, the
weil Osteotomy, provides
a good Result, thanks to
  the Longitudinal
Click to enlarge picture decompression
sometimes, a local surgery
is required (see chapter
“claw toes”).

 
 3 - Metatarso phalangeal
dislocation
 
 
The Weil osteotomy is obviously the
best treatment of the MTP
dislocation and this without
additional procedure (tendon
transfer), arthroplasty or fusion.
 
 
 
 
 
 
But this is obtained at the only
condition to have  sufficient (large)
proximal sliding exactly located  on
the ms point (see also the chapter
“global application").
 
Anyway, take care to respect the
metatarsal parabola.
 
 
 
 Luxaciones
métatarso falangica
                                                                                     Click to enlarge picture
4 - Transversal  deviations 
of the Toes
 
 
 - In medial deviation (<=left)
In overlapping second toe, the Weil
osteotomy displaces automatically
the metatarsal head medially,
correcting the toe deviation.
 
 
 - In lateral  wind swept (right =>) ,
we note also a transversal
displacement of the head but the
proximal sliding is certainly the most
important to correct the lateral wind
swept.
The Weil osteotomy is the best
procedure to correct this lateral
deviation, above all in advanced
cases.
 
 
 
   
POST OPERATIVE PERIOD
In the Weil osteotomy, the post
operative period is very important
particularly in order to avoid MTP
stiffness.
Bandage, with the plantar strapping
and training are obligatory. They are
perfectly modified and simple.
 

Click to enlarge picture

   
PROBLEMS ENCOUNTRED
First,  in advanced deformities, the
Weil osteotomy is an excellent
procedure without any problems
which may occur,particularly the MTP
stiffness is almost never encountered
since we perform a large and
harmonized (metatarsal parabola)
proximal sliding of the metatarsal
 
head.
 
Nevertheless, if there is problems, 2
kinds of problems may be
encountered: a) the recurrence or
transfer of métatarsalgie, b) the MTP
stiffness.
 
  
a) recurrence or transfert of
métatarsalgia
 
In the rare cases where there is
an insufficient correction of
métatarsalgie, the secondary
BRT metatarsal proximal
elevation osteotomy provides
good results, at the condition to
correct of necessary any
insufficiency of plantar flexion in
the MTP joint (see next
paragraph)
.

 
 
b) MTP stiffness
 
We already see how to avoid (post
operative period, nevertheless if
  there is stiffness, the correction is
  now easy and simple : we perform
one year post operatively a mini
invasive MTP dorsal release.
However no stiffness occurs in large
and harmonized shortening .
. 

             
 
 
If there is nevertheless an MTP
stiffness, it is easily corrected by a
mini invasive dorsal release,
performed one year after the primary
Surgery
I this figure, we se the pre- revision
aspect, then the intra operative
aspect after release of the 2 nd and
3rd MTP joints, then after the 4th and 5
video Weil (cliquez)
flux  th rays release, then the post
  operative aspect
[ Top ]