Elsevier

Foot and Ankle Surgery

Volume 25, Issue 4, August 2019, Pages 488-494
Foot and Ankle Surgery

Clinical and radiological outcomes after Weil osteotomy compared to distal metatarsal metaphyseal osteotomy in the treatment of metatarsalgia—A prospective study

https://doi.org/10.1016/j.fas.2018.03.002Get rights and content

Highlights

  • Compared to the Weil procedure the duration of surgery and tourniquet times were significantly shorter for the DMMO procedure.

  • The DMMO offers a good alternative to the WO in treating static metatarsalgia with comparable results to the WO.

  • Fewer patients with postoperative stiffness, lack of toe purchase and less reduction in ROM in the DMMO group than in the Weil group, although not statistically significant.

  • The DMMO is gaining popularity, but clinical studies are scarce.

Abstract

Background

The distal metatarsal metaphyseal osteotomy (DMMO) may have lower complication rates than the Weil osteotomy (WO) due to its extraarticular location and its minimal invasive nature. This study compares the clinical and radiological outcomes and complications after DMMO and WO.

Methods

We compared 30 patients with WO (Group A) to 30 patients with DMMO (Group B). Ten males and 50 females with a mean age of 57.7 were included. 45 WOs and 73 DMMOs were evaluated in 60 patients.

Allocation to Group A or B were random, indications comparable.

The outcome was measured clinically using the Visual Analogue Scale Foot and Ankle and radiologically with an average follow up period of 13 months.

Results

Clinical examination six weeks postoperatively showed swelling of the forefoot in 66.7% for Group A and in 73.3% for Group B. Swelling subsided in the course of time, but postoperative stiffness, lack of toe purchase and range of motion deficits did not change in the course of time. All osteotomies healed. The VAS-FA improved for both groups. Tourniquet time and operating time were lower and radiation doses higher in Group B.

Conclusions

The DMMO resulted in a comparable patient satisfaction and comparable radiological healing compared to WO and appears to be a valid alternative to the WO.

Introduction

Static metatarsalgia of the forefoot is a frequent condition and is in many cases a sequelae to first ray deficiency. Metatarsalgia means pain and tenderness in the forefoot and below the metatarsal heads. There are many causes of metatarsalgia, and it can be difficult to treat adequately. Prevalence of metatarsalgia is approximately 10% in a population, with a female preponderance [1]. First line treatment of metatarsalgia is non-operative with orthotics or cushioning, but when non-operative management fails, surgery may be indicated [2]. Surgery aims at shortening and raising the metatarsal head in order to relieve pressure under the metatarsal heads and restoring ideal forefoot morphology [3], [4].

The Weil osteotomy (WO) is an intra-articular osteotomy widely used in surgical treatment of metatarsalgia, but also resulting in stiffness of the metatarsophalangeal joint (MTPJ) in up to 30% of the patients. Elevation of the toe postoperatively was found in 25–33% of the patients after the Weil procedure [4], [5], [6]. Highlander et al. [7] reported floating toe in 36%, recurrence of metatarsalgia in 15% and transfer metatarsalgia in 7% of the patients operated with the WO. The WO has for many years been the most popular distal lesser metatarsal osteotomy for treating imbalance of the forefoot and static metatarsalgia [8].

The distal metatarsal metaphyseal osteotomy (DMMO) is an extraarticular osteotomy performed using minimally invasive technique which theorectically results in less postoperative stiffness and may therefore represent a viable alternative to the WO in treating metatarsalgia operatively [1], [8], [9], [10], [11]. Henry et al. [4] found no differences in outcome when comparing the two methods regarding joint stiffness, but longer recovery time in the DMMO group. Dhukaran et al. [12] found a minimal risk of neurovascular and tendon injury associated with minimally invasive techniques in the forefoot.

The DMMO is gaining popularity, but clinical studies are scarce.

Section snippets

Aims

The aim of this study is to compare the outcome of the WO and the DMMO regarding function, complications and patient satisfaction at six weeks postoperatively, and at a final follow-up minimum six months after index surgery, at an average 13 months follow-up postoperatively.

The aim of this article is to provide data in order to allow surgeons a better base for decision making when choosing between open surgery and minimally invasive surgery in the forefoot.

Material and methods

A manual search through all surgical reports for WOs performed between 1/8/2009 and 5/8/2011 were carried out ().

The first 30 patients who had the WO performed and had at least six months clinical follow-up and radiologic assessment at six months post-op were included (Group A).

A manual search through all surgical reports between 1/1/2014 and 17/9/2014 for DMMOs was performed.

The first 30 patients who had the DMMO performed and had at least 6 months clinical follow-up and radiologic assessment

Demography and patient characteristics

Group A, WO Group, consisted of 30 patients with a total of 45 WOs.

Group B, DMMO Group, consisted of 30 patients with a total of 73 DMMOs.

General information regarding Group A and Group B is displayed in Table 1.

Group A and B were comparable regarding age, gender, follow-up period and surgery performed on the first ray. The average surgery time was 36 min, 95% CI: 17–54, P < 0.001 shorter and the average tourniquet time was 27 min, 95% CI: 12–42, P < 0.001 shorter for the DMMO procedure in Group B,

Discussion

The WO is an intra-articular, non-dynamic, open distal osteotomy requiring internal fixation. The aim is to shorten and elevate the metatarsal head [16]. The shortening and elevation of the metatarsal head aim at off-loading the forefoot and relieving metatarsalgia. Vandeputte et al. [17] found a significantly decreased load under the metatarsal heads after the WO. Other studies have shown no decrease or even increase in load under the metatarsal head after the WO [18].

The DMMO is an

Conclusion

Compared to the Weil procedure the duration of surgery and tourniquet times were significantly shorter and hypertrophic scarring was less prevalent for the DMMO procedure. The radiation time was significantly longer in the DMMO group. VAS-FA scores increased significantly following surgery and no differences were detected between procedures.

The DMMO offers a good alternative to the WO in treating static metatarsalgia. It is a safe procedure with few complications and with good clinical outcome.

Conflicts of interest

The authors declare no conflicts of interest associated with this publication.

Acknowledgements

Miss Sarah Schutz for supporting the authors in conducting the phone interviews in November 2016. MD, Ph.D. Dennis Winge Hallager for statistical analysis.

References (18)

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Permanent address: Hvidovre University Hospital, Foot and ankle Department, Kettegaards Allé 30, 2650 Hvidovre.

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