The metatarsal head has a medial and lateral tubercle upon which the collateral ligaments originate. These structures are important not only in the stability of the joint but also in marking an anatomic location for the main blood vessels that provide arterial flow to the metatarsal head [19] (Fig. 8.2). Dissection of the metatarsal head should aim to avoid detaching the collateral ligaments from the metatarsal head for two distinct reasons. First, the collateral ligaments are important sagittal plane-stabilizing structures for the lesser MTP joint [2, 18, 20]. Second, severance of the collateral ligaments may also cause damage to the blood vessels and could, potentially, increase the risk of avascular necrosis and delayed healing to the metatarsal osteotomy site [19].

The Weil metatarsal osteotomy was originally described as an intra-articular osteotomy that is created as close to parallel to the weight-bearing surface of the foot as possible. Surgically, this means that the osteotomy is started within the cartilage of the metatarsal head [21]. Proper angulation of the osteotomy (typically 15°) will lead to direct proximal translation with minimal plantar translation of the capital fragment [22]. Improper angulation of the osteotomy will lead to plantarization of the capital fragment and could potentially result in continued forefoot pain postoperatively (Fig. 8.3). It is also important to avoid over-penetration of the plantar cortex of the metatarsal with the saw blade. There is a nutrient artery that enters the metatarsal plantarly that may be at risk if this occurs [19].

The Weil metatarsal osteotomy was described to shorten the metatarsal 1–3 mm in length in order to avoid plantarization of the capital fragment [1]. When the osteotomy is performed at the prescribed 15° angle, there will not be plantar translation if the bone is shortened less than 3 mm [22]. If the metatarsal is to be shortened more than 3 mm in length, a second parallel osteotomy must be created in order to avoid plantarization of the capital fragment. When a review of the literature regarding this osteotomy is undertaken, it should be noted that many studies report a shortening of 4–10 mm with this osteotomy and a rate of postoperative floating toes as high as 36% [13, 15, 22, 23]. It should be noted that this osteotomy was not originally designed to shorten the metatarsal in that capacity and that the rate of postoperative floating toes may be related to the amount of shortening performed.

Aggressive shortening can lead to transfer metatarsalgia as the corrected metatarsal could take on a length that overloads the adjacent metatarsal(s). If there is a concern about the postoperative length of the second or the adjacent metatarsals, correcting this at the initial procedure, rather than waiting until problems develop later, may be beneficial [22].

Fixation for the Weil osteotomy should follow basic AO principles . This will assure primary bone healing and decrease the rate of nonunions that occur. As noted above, maintenance of the blood supply to the metatarsal will also decrease the incidence of this complication.

As with any procedure, postoperative care is important and can vary from surgeon to surgeon. The postoperative regimen utilized in our institution [21] includes the patient being in a bandage and a surgical shoe for 7–10 days. At that time, the patients are instructed to return to athletic shoes with guarded weight bearing and aggressive physical therapy commences. Physical therapy focuses on strengthening of the intrinsic muscles of the foot and restoring the muscle balance to the MTP joint. There is a significant emphasis placed on the strength of the plantarflexory muscles and mobility in that direction. Additionally, the patient is instructed to utilizing nighttime bracing with the toe strapped in a plantarflexed position. This will decrease the amount of dorsal scar tissue that forms, theoretically decreasing the rate of floating toes that occur.

Recently, there has been a considerable emphasis on the correct diagnosis of the causative factor of metatarsalgia. Traditionally, it has been thought that the long metatarsal or “unharmonious parabola ” [24] is the sole problem. However, more recent literature [18, 25–28] focuses on the plantar plate as a cause of deformity and pain in the forefoot with particular emphasis on differentiating plantar plate pain from neuroma pain [25, 28].

The plantar plate is the main stabilizer of the lesser MTP joint, particularly in the direction of plantarflexion [2, 18, 28]. This structure is approximately 2 cm in length and 1 cm in width and can vary in thickness from 2 to 5 mm [16, 17, 29]. The plantar plate is composed of a combination of type 1 (75%) and type 2 (21%) collagen that is woven together to create a fibrocartilaginous structure . The dorsal fibers of the plantar plate are longitudinally orientated, while the plantar aspect of the plantar plate has horizontally orientated fibers that are continuous with the deep transverse intermetatarsal ligament [18]. The lateral edges of the plantar plate serve as the attachment of the accessory collateral ligament and the deep slips of the plantar fascia. The plantar fascia has the additional role of providing the pulley-like structure that allows the flexor tendons to provide plantarflexion to the MTP joint (Fig. 8.4) [17].

With understanding of the anatomy of the lesser MTP joint, it is clear that the plantar plate may have a role in lesser MTP joint pain . Mann et al. [30] described a monoarticular synovitis of the lesser MTP joint capsule in 1985 and thought that this may be a new diagnosis. Now, however, it is recognized that the inflamed capsule and synovitis of the joint may actually be a prodrome to a plantar plate tear [30, 31]. If this problem is underdiagnosed or missed, an underlying osseous deformity [32] may lead to pathology in the plantar plate, collateral ligaments, or both. Ninety-five percent of patients with plantar plate pathology can be diagnosed clinically [25–27] with the symptoms of pain, edema, and a positive drawer sign. When you have a patient with a positive drawer sign and an increased lateral deviation of the third MTP joint on AP radiographs, this should alert the astute clinician to the potential presence of plantar plate pathology [26].