The surgical treatment of metatarsalgia has been somewhat controversial. In most instances, conservative treatment should be attempted before surgical options are considered. To date, over 25 different lesser metatarsal osteotomies have been described. Lowell Scott Weil, Sr. was the first to describe an osteotomy of the metatarsal neck, parallel to the weightbearing surface. This allowed the metatarsal head to slide proximally, thus providing axial decompression (Fig. 21.1). In 1992, Weil first performed this procedure in Europe. The osteotomy quickly gained momentum in Europe where it was primarily utilized for surgical correction of severe deformities associated with metatarsal phalangeal contracture due to excessive metatarsal length. Some of these deformities had been previously treated by joint destructive procedures such as pan metatarsal head resection. The Weil osteotomy has recently gained popularity in North America based upon the simple technique, stable fixation, excellent union rates, and predictable results.

The Weil osteotomy is generally indicated for recalcitrant metatarsalgia, refractory to conservative care. Long metatarsals with or without transverse plane digital deformities, crossover toes, and subluxations/dislocations of the MTPJs are all specific indications for this procedure (Fig. 21.2). It has also been utilized to correct rheumatoid deformities at the MTPJ. The Weil osteotomy may be employed on one or more metatarsals based on the complexity of the forefoot deformities and overall length pattern of the adjacent metatarsals.

The Weil osteotomy, as any forefoot osteotomy, is not recommended in patients with severe sensory neuropathy as well as in patients with significant peripheral arterial disease. Surgically induced Charcot joint and abnormal healing have been reported following forefoot osteotomies in the presence of diabetic neuropathy. A partial or total metatarsal head resection may be preferred in these cases (1). There are no specific contraindications to the Weil osteotomy making it a very versatile and useful osteotomy.