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Congenital cleft foot is a deformity characterised by genetic heterogeneity and a high degree of phenotypic variability. This together with its very low incidence is the reason for rather controversial opinions on the treatment. The authors present a case study of a boy with unilateral cleft foot classified as type III by Blauth-Borisch and type II by Abraham et al., who underwent a surgery at the age of 12 months. The defect was closed by rectangular soft tissue flaps, the intermetatarsal ligament connecting the first metatarsal head and the third metatarsal head was reconstructed with local fibrous tissue flap. The present hypermobility with extension position of the first ray were stabilised by the Kirschner wire inserted along the axis of the first ray from the dorsum of the talus through the middle of its head to the medial chondrogenic tarsal bones and further through the first metatarsal bone and the corrected metatarsophalangeal joint of the hallux. At the age of 6 years and 7 months, due to dynamic abductovalgus foot deformity, lengthening calcaneal osteotomy was also performed. Favourable clinical and radiographic outcomes of the used surgical technique were observed by the authors. The cleft foot as such shall be treated after a thorough evaluation of the patient and his/her necessary monitoring during the childhood. Key words: ectrodactyly, cleft foot, split hand/foot malformation.

Fractures of the fifth metatarsal base are among the most common fractures of the foot. They are typically caused by indirect violence during sports activities. This region is also a site where stress fractures occur frequently. Diagnosis is based on the patients medical history, clinical examination and imaging methods. The fundamental imaging method is radiography of the foot in three views. MRI is used primarily for early diagnosis of stress fractures. CT examination is beneficial mainly in complex foot injuries, in order to rule out associated fractures. Several classifications of fractures of the fifth metatarsal base have been published in the last 50 years, categorizing these fractures in terms of their location, appearance of the fracture line, type of treatment, healing and complications. Currently, the most frequently used one is the classification developed by Lawrence and Botte. Non-operative treatment is indicated in undisplaced or minimally displaced fractures, fractures in elderly patients and in patients contraindicated for surgery. The method of choice in undisplaced fractures is the Barouk boot with partial weight-bearing as tolerated by the patient, while displaced fractures up to 2 mm are fixed in a low plaster cast (Essex-Lopresti shoe). Operative treatment is indicated in fractures displaced by more than 2 mm or involving more than 30% of the articular surface of the cuboid-metatarsal joint. Internal fixation is most commonly performed with the use of intramedullary screw, tension wire band, K-wires or plates. Stress fractures are preferably treated by surgery to reduce the risk of non-union, delayed healing and the risk of refractures. The most common complications associated with treatment of fractures of the fifth metatarsal base include delayed healing, non-union development, refractures and patient discomfort.Key words: fractures of the fifth metatarsal base - diagnosis - treatment - complications.

PURPOSE OF THE STUDY In a long-term perspective, it is better to remove implants after fracture healing. However, subsequent full or excessive loading of an extremity may result in refracture, and the bone with holes after screw removal may present a site with predilection for this. The aim of the study was to find ways of how to decrease risk factors for refracture in such a case. This involved support to the mechanical properties of a bone during its remodelling until defects following implant removal are repaired, using a material tolerated by bone tissue and easy to apply. It also included an assessment of the mechanical properties of a bone after filling the holes in it with a newly developed biodegradable polymer-composite gel ("bone paste"). The composite also has a prospect of being used to repair bony defects produced by pathological processes. MATERIAL AND METHODS Experiments were carried out on intact weight-bearing small bones in dogs. A total of 27 specimens of metacarpal/metatarsal bones were used for ex vivo testing. They were divided into three groups: K1 (n = 9) control undamaged bones; K2 (n = 9) control bones with iatrogenic damage simulating holes left after cortical screw removal; EXP (n = 9) experimental specimens in which simulated holes in bone were filled with the biodegradable self-hardening composite. The bone specimens were subjected to three-point bending in the caudocranial direction by a force acting parallel to the direction of drilling in their middiaphyses. The value of maximum load achieved (N) and the corresponding value of a vertical displacement (mm) were recorded in each specimen, then compared and statistically evaluated. RESULTS On application of a maximum load (N), all bone specimens broke in the mid-part of their diaphyses. In group K1 the average maximum force of 595.6 ± 79.5 N was needed to break the bone; in group K2 it was 347.6 ± 58.6 N; and in group EXP it was 458.3 ± 102.7 N. The groups with damaged bones, K2 and EXP, were compared and the difference was found to be statistically significant (p ≤ 0.05). CONCLUSIONS The recently developed biodegradable polymer-composite gel is easy and quick to apply to any defect, regardless of its shape, in bone tissue. The ex vivo mechanical tests on canine short bones showed that the composite applied to defects, which simulated holes left after screw removal, provided sufficient mechanical support to the bone architecture. The results of measuring maximum loading forces were statistically significant. However, before the composite could be recommended for use in veterinary or human medical practice, thorough pre-clinical studies will be required.fracture fixation, mechanical testing, bone plate, cortical screw, refracture.

The aim of the study was to evaluate the mid-term results in a group of selected patients undergoing corrective surgery for juvenile hallux valgus, using double osteotomy of the first metatarsal.The group included eight patients, seven girls and one boy, with a more severe form of this deformity treated by double osteotomy of the first metatarsal between 2010 and 2013. The indication for corrective surgery was serious pain when walking; all patients had previously undergone conservative treatment with no effect. All patients had pre-operative clinical examination, the affected foot was X-rayed with the patient standing and radiographic assessments of the intermetatarsal and hallux valgus angles were made. The evaluation of treatment outcomes was based on the scoring system of the American Orthopaedic Foot and Ankle Society (AOFAS) and X-ray images of the foot. The average follow-up was 37 months.Post-operatively, none of the patients reported pain while walking, only two of them experienced pain during sports activities. The average post-operative AOFAS score was 92 points. Both the intermetatarsal angle and the hallux valgus angle improved after surgery in all patients, with two reporting only mild hallux valgus deformity. One patient showed postoperative restriction of motion at the first metatarsophalangeal joint. This was the only complication recorded in association with the surgery.Almost all authors dealing with the treatment of hallux valgus deformity primarily prefer conservative therapy. However, this treatment is usually not very effective in severe forms of the disorder. Surgical management is indicated in symptomatic patients or in those with severe juvenile hallux valgus deformity. In paediatric patients it is necessary to respect the presence of an epiphyseal growth plate in the first proximal metatarsal and therefore it is often preferred to use distal first metatarsal osteotomy. At our department, Mitchell's osteotomy for hallux valgus deformity is usually used. However, post-operative outcomes are not satisfactory in severe forms of juvenile hallux valgus in which a high proportion of recurrent deformities is probably related to the growth potential of a juvenile bone. In such cases we use the Peterson and Newman procedure of double first metatarsal osteotomy, which can correct all three components of the deformity while maintaining functional first metatarsal length. This is a great advantage of the method. Although its authors have not reported any post-operative complications, the occurrence of restricted motion in the first metatarsophalangeal joint has been described in the relevant literature. The problem was also recorded in one patient of our group.Deformities of the forefoot and big toe are frequent orthopaedic disorders in children and adolescents. The results of this study confirm that the double first metatarsal osteotomy is an effective method of surgical treatment for serious hallux valgus deformities in paediatric and adolescent patients.

The first reports found in professional literature on the use of bisphosphonates as a treatment date back to 1972. We found the first report on the use of a bisphosphonate comprising nitrogen in its molecule in a publication from 1990. Some of the adverse effects of the particular types of bisphosphonates were described in the registration studies. At least two serious adverse effects of this group of medicines had not been described until 2000. We found the first description of jaw osteonecrosis in relation to the longterm application of bisphosphonates in a publication from 2002 and we found the first description of an atypical bone fracture originating without a corresponding traumatic event in a location with no presence of an osteolytic focus in an article from 2006. These so called atypical fractures, which are also called fractures without a corresponding traumatic event (low energy fractures), have been described to have occurred in femurs, in the pelvis and less frequently in the metatarsal area. "Atypical fractures" are linked to longterm administration of bisphosphonates, which significantly increases the bone density and impedes osteolysis but it simultaneously increases the fragility of bones and decreases their flexibility. The definition of an atypical fracture of the skeleton emphasises the fact that such fractures occur with an inadequately minimal force (energy) in the aforementioned predilection locations. In the following text we are describing a patient who has been treated for a multiple myeloma with an atypical fracture of the Metatarsal bone 2. This fracture occurred during a regular walk without any excessive load and the patient could not recall any corresponding injury or longer walking. The patient had been administered bisphosphonates for 34 months before the atypical metatarsal fracture occurred. The metatarsal bone fracture was treated through a nonweight bearing regime for the sole and the pain diminished within a single month. In comparison with the published data of atypical fractures, our case concerns a short interval between initiation of the bisphosphonate administration and the occurrence of the atypical fracture. In the available literature these fractures are described after more than a five year application of a bisphosphonate. New pain in the bearing skeleton in patients treated with bisphosphonates are therefore always subject to an imaging examination among others to exclude an atypical fracture due to an increased fragility of the bone.

To present the results of shortening scarf osteotomy of the fifth metatarsal as an option for the treatment of forefoot deformities with calluses and associated pain around the fifth metatarsal head.In nine patients, 12 osteotomies were performed between 2004 and 2007.The results were evaluated at the end of 2009. One patient had one-stage bilateral surgery two had two-stage bilateral surgery.Surgical treatment was indicated in patients in whom conservative treatment had failed, and after the evaluation of load radiographs of the forefoot. The operation (sec. Barouk) is standardly performed from a longitudinal incision and involves the excision of two bone blocks, 3 to 4 mm in width, from both fifth metatarsal fragments after the osteotomy. Fixation is achieved with two Poldi screws from mini-instrumentation.The procedure can be combined with surgery on the other metatarsals. The lower extremity is then immobilised in a cast for 3 weeks. Partial weight-bearing on the heel is allowed from the second post-operative day and full weight-bearing is permitted after X-ray examination at 6 weeks. The average hospital stay is four days.Nine patients (12 feet) underwent surgery. The average follow-up was 3.8 years (2 to 5). The average inter-metatarsal angle was 13 degrees before surgery and 4 degrees after it. The average valgus angle of the fifth metatarsophalangeal joint was 25 degrees pre-operatively and 5 degrees post-operatively. The average metatarsal shortening was 6.5 mm.Shortening shaft osteotomy allows for maximal medial translation of the fifth metatarsal and maximal correction of the angle between the fourth and fifth metatarsals. At one stage it permits metatarsal head medialisation, as does chevron osteotomy, as well as proximal translation of the head achieved by Weil osteotomy. The results of shortening scarf osteotomy have been better than those of an isolated Weil procedure, chevron osteotomy or bunionectomy. Percutaneous Krammer's method, BRT, shaft and proximal osteotomies are still discussed.Shortening scarf osteotomy of the fifth metatarsal is indicated when conservative treatment is unsuccessful in management of calluses and fifth metatarsal head deformities, particularly in flat-footedness. It can also be used in salvage procedures following failed surgery or in digitus quintus supraductus in adults. It requires experience with first metatarsal osteotomy and a precise operative technique.

The most frequent valgus deformity of the big toe is often associated with a collapse of the traverse arc of the foot. The purpose of the present study was to assess the results of forefoot reconstruction by the Brandes-Keller resection arthro- plasty of the first metatarsophalangeal joint and the Helal metatarsal osteotomy when this deformity was present.A retrospective study of 40 consecutive patients with severe forefoot deformities was performed.The patients were treated at our department in the period from 1997 to 2003.The average age at the time of surgery was 54.7 years.Twelve patients underwent bilateral surgery. The results of 52 operations were evaluated.Each patient returned for a personal interview by an independent investigator and a clinical examination. A post-operative forefoot score was calculated according to the system of the American Orthopaedic Foot and Ankle Society (AOFAS). This 100-point scale includes items related to pain, level of activity, deformity and motion. The average AOFAS score was 85.5 points post-operatively. No pain was reported in 38 (75 %) forefeet, mild pain in 12 (23 5 %) forefeet and moderate pain in 1 (2 %) forefoot. The complications included slow healing of the wound in two patients (3.8 %) and asymptomatic pseudoarthrosis after metatarsal osteotomy in two patients (3.8 %). Five patients (9.6 %) reported persisting swelling of the foot dorsum for a period longer than 3 months. DISCUSSION In agreement with the majority of the published data we are of the opinion that the Brandes-Keller resection arthroplasty is a surgical method suitable to treat valgus deformities of the big toe with concomitant arthritis of the first metatarsophalangeal joint (MTP) in elderly patients whose weight-bearing demands are low. This treatment permits early post-operative weight-bearing. In younger patients with valgus deformity of the big toe without arthritis it is preferred to use techniques preserving the joint. The use of total replacement of the first MTP joint is open to discussion.The Brandes-Keller procedure with the Helal metatarsal osteotomy, if correctly performed in indicated cases, results in painless walking in patients with forefoot deformity.

To present the authors' own experience with Scarf osteotomy in a group of patients treated by this technique in their institution since 2004, together with emphasis on the aspects leading to successful outcome as well as to potential complications.Between May 2004 and January 2008, 70 operations were performed in 60 patients, 50 women and 10 men, with an average age of 56 years.The use of an appropriate surgical technique was decided on the basis of the IMA angle, as seen on an anteroposterior load radiograph of the forefoot. Scarf osteotomy was indicated when the angle was 12 to 20 degrees. There were 21 Scarf osteotomy procedures, 14 Scarf/Akin osteotomies and 35 operations combined with procedures on other rays.Pre-operative evaluation included HVA and IMA angles and the AOFAS score. Tourniquet-induced ischaemia was used and surgery was completed with lateral release of the soft tissues of the first metatarsophalangeal (MTP) joint. Osteotomy was always carried out extra-articularly, carefully avoiding damage to the vascular supply of the metatarsal head. It was fixed with original Barouk screws. At regular follow-ups, the radiographic findings, AOFAS score and patient's satisfaction with surgical outcome were assessed.The average follow-up was 26 months. The pre-operative values decreased from 37 to 15 degrees for the average HVA and from 18 to 8 degrees for the average IMA at 2 years after surgery. The average pre-operative AOFAS score of 48 increased to 91 points at 2 years post-operatively. At 6 months after surgery, the outcome was subjectively evaluated as excellent or good by 66 patients (94 %). One rapid progression of first MTP arthritis and one second metatarsal stress fracture were recorded. Two operative wounds showed prolonged healing. A first metatarsal stress fracture in the proximal part of osteotomy occurred in two cases, one of which required further surgery. DISCUSSION Our results are in full agreement with the published data, including the frequency and types of complications.These are, as indicated by both literature reports and our experience, most often due to an incorrect operative technique. This is true, in the first place, for fractures at the site of osteotomy as a result of an insufficiently tilted or a too short longitudinal cut of osteotomy, or wrongly applied fixation.Scarf osteotomy is a reliable and effective method for hallux valgus treatment. It provides excellent primary stability and permits good IMA correction up to 20 degrees. However, perfect management of the operative technique is a prerequisite for minimising the risk of serious post-operative complications.

Hallux valgus is a frequent static deformity of feet in shoe-wearing populations. Lasting problems usually require surgical management. The authors evaluate the long-term results of such treatment by either McBride's operation or chevron osteotomy, or by combination of both.A group of 72 patients with hallux valgus underwent 84 operations, with the use of McBride's procedure, chevron osteotomy or a combination of both, at the First Department of Orthopedic Surgery, St. Anne's Teaching Hospital in Brno, in the years 1993-1995. At 10-year follow-up they were evaluated on the basis of patients' subjective satisfaction and the degree of correction measured by hallux valgus angle (HVA) and intermetatarsal angle (IMA).Surgery is carried out under general or spinal anesthesia, with application of a pneumatic tourniquet, after a standard preparation of the operating field. In the modified chevron osteotomy, a "V"-shaped osteotomy of the distal metatarsal is created (V-osteotomy angle is 70 to 80 degrees), which allows the first metatarsal head to be shifted laterally. The modified McBride's procedure is based on transposition of the adductor hallucis tendon onto the first metatarsal head; lateral sesamoidectomy may be necessary. A combination of both techniques involves V-shaped osteotomy of the first metatarsal bone and transposizion of the adductor hallucis tendon, with lateral sesamoidectomy, when necessary. These surgical procedures always include excision of a bursa at the first metatarsal head, removal of a medial eminence of the first metatarsal head and lateral capsulotomy of the first metatarsophalangeal joint. The authors evaluated: 1) the degree of correction by comparing the HVA and IMA on pre-operative radiographs with those measured at 10 years after surgery; 2) subjective satisfaction of the patients who received a questionnaire asking about big-toe position, pain, problems associated with footwear, sores over the metatarsophalangeal joint of the big toe and mobility of this joint.Of the patients undergoing chevron osteotomy (20 procedures), 95 % reported satisfaction; the mean degree of correction was 13 degrees for HVA and 4 degrees for IMA. Of the patients undergoing McBride's procedure (45 operations), 60 % were satisfied; this group had the lowest mean degree of correction, i. e., 4.8 degrees for HVA and -0.6 degrees for IMA. Of the patients undergoing the combined technique (19 operations), 74 % reported satisfaction and the mean degree of correction was highest, i. e., 17.9 and 4.5 degrees for HVA and IMA, respectively. Two patients of this group developed hallux varus, but their HVA and IMA values were not included in the assessment because they would adversely affect the objective evaluation of all the patients. However, in the subjective evaluation of the whole group, these two unsatisfied patients were included.In agreements with the majority of published results, the authors conclude that a higher correction is achieved with chevron osteotomy than with McBride's operation. Subjective satisfaction reported in the literature is not consistent, but it is either similar in both procedures or better in chevron osteotomy. In this study, chevron osteotomy resulted in high patient satisfaction (95 %), good correction (HAV, 13 degrees ; IMA, 4 degrees ) and a minimum of complications. McBride's procedure resulted in the lowest correction (HAV, 4.8 degrees ; IMA, -0.6 degrees ) as well as the lowest satisfaction (60 %). Our results show that younger patients (up to about 35 years) responded with better outcomes. The combined method achieved the highest degree of correction (HAV, 17.9 degrees ; IMA, 4.5 degrees ) and 74 % satisfaction, but was associated with the risk of hallux varus development.If indication criteria are respected, surgical procedures are competently performed and good post-operative care is provided, it is not necessary to combine the operation techniques in order to achieve good long-lasting correction and patients' satisfaction.

The outcome of surgical treatment in hallux valgus is sometimes unsatisfactory for both the patient and the surgeon. The valgus position of the big toe in the metatarsophalangeal joint is associated with a deviation to varus of the first metatarsal, resulting in the space between the first and second metatarsals called the intermetatarsal (IMT) angle. In most patients the angle is between 10 and 20 degrees. These patients were indicated for scarf osteotomy as this method has been reported to achieve good outcomes. The results are compared with the relevant literature data on foot osteotomy.Our group involved 62 scarf osteotomies carried out on 49 patients who were followed up for an average of 18 months (range, 6-36 months). Three patients underwent surgery on both feet in one stage, five had bilateral surgery in two stages. The average pre-operative IMT angle was 16 degrees (range, 9-21 degrees) and the average hallux valgus angle was 37 degrees.The patients were indicated for surgery on the basis of subjective complains and weight-bearing radiographs. Scarf osteotomy was performed by the Barouk technique. From a signle incision in the first intermetatarsal space, the lateral articular capsule was released, adductor tendon was dissected and sesamoid bones were reduced. The first metatarsal was exposed from an incision along its medial axis, the bunion was excised and Z-osteotomy of the metatarsal was performed. The distal fragment was shifted laterally, fixed with two 3.5 mm Poldi screws, and the capsule was closed under tension with transosseal suture. If necessary, an additional procedure on the big toe phalanges or osteotomy of the other metatarsals are carried out. From the second post-operative day the patients were allowed to walk on the heel, after removal of sutures they walked wearing a special sandal and, from the third week onwards, full weight-bearing was allowed. The average hospital stay lasted 4 days. The evaluation of post-operative results was based on radiograms, subjective feelings of the patients and clinical assessment of the range of big toe motion.Out of 62 operations carried out on 49 patients (average age, 41.5 years), 23 were performed on the right and 23 on the left foot; bilateral surgery was carried out in three patients in one stage and in five patients in two stages. Simultaneously, the Weil osteotomy was performed on six feet, Akin osteotomy of the big toe phalanges on five feet, Braggard surgery of the second toe on three feet, and scarf osteotomy of the fifth metatarsal on three feet. All feet were indicated for scarf osteotomy because of pain and, in 56 feet, also esthetic reasons were involved. The patients' subjective post-operative assessments were as follows: satisfaction with the outcome in 58 feet, pain associated with tight shoes in two feet, pain while walking in six feet, and dissatisfaction with the big toe shape in one patient.The average IMT angle of 16 degrees and hallux valgus angle of 37 degrees on the pre-operative radiograms showed improvements to 9 degrees and 18 degrees, respectively, on the post-operative X-ray. The sesamoid bones were reduced in all cases. After surgery the average range of motion was restricted as follows: plantar flexion by 7 degrees (to 23 degrees) and dorsal flexion by 6 degrees (to 54 degrees). The complications included one fracture of the head requiring osteosynthesis, one failure of fixation with repeat valgus osteotomy, three cases of insufficient correction of a valgus position that had to be treated by additional osteotomy of the first toe phalanges.Out of other types of osteotomy (Funk, Dega, spike osteotomy), outcomes similar to scarf osteotomy have been achieved only by the Austin procedure. However, in this, shifting of the distal fragment is limited and the results show that the Austin method should be preferred in deformities with an IMT angle of about 10 degrees. Scarf osteotomy in addition allows for early weight-bearing, does not produce shortening of the first metatarsal but permits its elongation and elevation by oblique osteotomy, if necessary. It can also be used for the fifth metatarsal. The drawbacks include a more complicated surgical technique and higher risk of complications; shifting of the distal fragment is also limited and, for this reason, scarf osteotomy is not effective in deformities with an IMT angle higher than 20 degrees.Scarf osteotomy is an effective procedure for a moderate valgus deformity of the big toe with an IMT angle between 10 and 20 degrees. It permits early weight-bearing of the treated extremity. It requires exact pre-operative planning and strict adherence to the operative technique.

Multiple toes may develop on the medial or lateral side of the forefoot or in its middle. This may involve duplication of only the distal phalanx or the whole hallux including the metatarsal. In a duplicated big toe, the phalanx to be maintained, because short muscles of the leg are attached to it, is usually localized medially. A rare case of dysplasia of the first metatarsus, following a resection indicated in childhood for a hallux triples, is described in a 20-year-old girl. In order to remove hallux insufficiency and an overloading of the middle metatarsals, the authors decided to carry out a one-stage prolongation of the first metatarsal, using an autologous tricorticcal graft collected from the pelvis and a dynamic compression plate. No surgical treatment of the middle metatarsals was indicated because a disproportionate, short foot would result. Both the subjective and objective status of the patient at 6 months after the operation showed that the non-standard prolongation procedure was correctly indicated and allowed for physiological loading of the foot and restoration of normal walking.

Rheumatoid arthritis affects the foot very frequently. The transversal arch of the foot gradually declines due to the inflammation, the metatarsal heads protrude in the sole of the foot which is accompanied by painful bunions and sometimes also skin necrosis. The great toe turns into a valgus position and pronation. Walking is very painful.The authors evaluate a group of patients operated on for the deformities of the forefoot between 1995 and 2002.In the deformities of the forefoot the authors use resection of the heads of II-V metatarsals. They use a plantar surgical approach during which they remove bunions under the heads of the metatarsals. Then they gradually perform resection of the heads of--V metatarsals. In case of the great toe they prefer resection after Keller. In 5 cases they used fusion of the MTP joint of the great toe. They use fusion only in cases of a marked valgus position of the great toe. Where I MTT was in a significantly varus position, they applied in 3 cases the Lapidus procedure.Between 1995 and 2002 they operated on 92 patients, in 38 of them the surgery was performed bilaterally. Evaluation covered 130 surgeries. In 85 cases the patients had rheumatoid arthritis, in 7 the basic diagnosis was psoriatic arthritis. The group included 72 women and 20 men. The average age at the time of surgery was 38.4 years. Eighty-two (63.1%) patients were without pain 7 (5.4%) patients had severe pain. The authors monitored the occurrence of revalgization of the great toe after Keller resection arthroplasty--of 77 patients revalgization occurred in 23 cases (29.8%). The complications included 3 times a late infect 1-2 years after the surgery after the protrated infect of the organs, 3 times a skin necrosis between the great toe and 2nd metatarsal, when prior to the surgery there was a significant valgus deformity and after the correction of the great toe there was a skin tension in this region, 6 times a delayed healing of the wound on the sole of the foot.The authors present different surgical techniques of the forefoot and the great toe of the foot used by different authors.As the patients suffer from a polyarticular affection the emphasis is put on the individual approach and a properly timed operation. In this respect of vital importance is the cooperation involving a rheumatologist, orthopaedic surgeon, physical therapist and prosthetic department. Orthopaedic insoles and orthopaedic shoes are an integral part of the comprehensive therapy. Surgical treatment is not very demanding for patients and in most cases it brings a significant relief.

Weil technique of the distal shortening osteotomy of metatarsal is a relatively new method of the surgical treatment of metatarsalgia and dislocation of metatarsophalangeal (MTP) joints. A retrospective study evaluates the first experience in Weil osteotomy at the authors' department.Between May 1999 and the end of 2000 twelve patients (14 feet) were operated on in which the Weil technique of the osteotomy was performed on 28 metatarsals. Indication for the surgery was chronic metatarsalgia with dislocation of the MTP joint, with excessive length of one or more lesser metatarsals, with insufficiency of the first ray after the surgery of hallux valgus and metatarsalgia after the resection of the head of II metatarsal. All patients were women, average age of 57 years (range, 50-68 years) at the time of operation. The average follow-up is 9 months (range, 6-24 months). Dislocated prior to operation were 9 MTP joints, in 2 cases a deformity of 2nd digit of the digitus supraductus type was operated on.The patients evaluated subjectively the functional and cosmetic outcomes of the surgery. Clinical evaluation related to recurrence or transfer of difficulties to the head of the neighbouring metatarsal, range of motion of the MTP joint, function and grip of the digit. Radiograph was used for the evaluation of the metatarsal index, post-operative shortening of II metatarsal, reduction of dislocation in the MTP joint and healing of osteotomy.Satisfied with the functionla and cosmetic results of the operation were 83% patients (10 of 12). Recurrence of metatarsalgia was not found in any patient, transfermetatarsalgia in one patient. Reduction of the range of motion in the MTP joint (plantar flexion) by more than 50% was recorded in 43% operated on metatarsals and in all metatarsals after the reduction of the dislocation. Acceptable function and strength of the digit evaluated by the ability to press by the digit a sheet of paper against the floor was preserved in most of the operated on metatarsals--86% (24 of 28). Average shortening of II metatarsal was 5.6 mm. All dislocated MTP joints were reduced postoperatively. Dislocation recurred in 2 cases. Avascular necrosis of the head of II metatarsal after the reduction of the dislocation was encountered in one case.The small number of recurrences and transfermetatarsalgia proves that Weil osteotomy allowing a controlled shortening of metatarsal with a fixation is a reliable method in the solution of metatarsalgia. The operation directly on the joint allows reduction of the dislocation of the MTP joint. Shortening of metatarsal facilitates reduction and reduces axial pressure in the MTP joint. Recurrence of dislocation is reported between 15% and 22%. After a more difficult reduction and danger of redislocation some authors recommend a temporary transfixation of the MTP joint by K-wire. The disadvantage of the operation is a frequent temporary limitation of the range of motion in the MTP joint which is caused by the opening of the articular capsule and its subsequent contraction. No author reports any problems with the healing of the osteotomy. The results in our group of patients are comparable with the results published by other authors.Weil osteotomy allows a planned controlled shortening of metatarsal with a stable fixation. Osteotomy heals well. Osteotomy is intraarticular which on one side provides the possibility to correct dislocation in the MTP joint, however, on the other hand it poses a risk of the limitation of the range of motion of this joint. The main contribution the authors see in the new possibility of surgical treatment of more severe matatarsalgia and deformities of the forefoot with the preservation of joints.

The authors present their philosophy of the surgical treatment of metatarsus primus varus by oblique basal closed osteotomy of 1st metatarsal, evaluate and generalize the results achieved also with regard to the age of patients.The evaluation covers a group of patients operated on for the mentioned static defect since 1995 with a minimal interval of 12 months after the surgery. From this general group a subgroup has been subsequently singled out of children and adolescents up to the age of 18. The general group included 24 patients in which 31 surgeries were performed. The subgroup of children and adolescents comprised 10 patients in which the surgery was performed in 12 feet.Monitored in both group was age, sex, osteotomy laterality, the presence of distal operation. Post-operative monitoring focussed on the following data: the time interval after the operation, subjective satisfaction, range of motion of Ist metatarsophalangeal joint, the incidence of complications. Evaluation covered post-operative correction of individual angles and the shortening of Ist metatarsal by comparison of pre- and post-operative radiograph.Evaluated in the whole group were 22 patients, in the group of children and adolescents 8 patients, with average time interval of 3 years after the operation. On the basis of the surgery average correction of intermetatarsal angle by 10.5 degrees was achieved in both groups, average correction of valgosity by 18 degrees in the basic group and by 10 degrees in the group of adolescents.The results are evaluated globally on the basis of specialized literature. The authors present their philosophy of the solution of the issues of metatarsus primus varus as a static defect by different surgical techniques, formulate a clear strategy of the use of distal surgery and discuss its efficiency in relation to the patient's age.Oblique basal closed osteotomy of Ist metatarsal within a comprehensive solution of the static defect of hallux valgus is recommended to the broad orthopaedic public as a surgery which in view of the authors can bring good results in children and adolescents. In adults they recommend to indicate this surgery in the mentioned cases in combination with a distal operation.

The authors present four-year surgical experience using Helal's oblique metatarsal subcapital osteotomy to manage metatarsalgy of various etiology. A total of 109 patients (131 feet) were operated on during the observance period. The amount of 79 patients (108 feet) were revised on the average 21 months after the surgery. According to Gainor's score excellent results were achieved in 76.9 per cent of cases, 3 patients were re-operated on for a relapsing preoperational condition. The indication for Helal's metatarsal osteotomy is the finding of metatarsalgy with reducible metatarsal capitula.

The author presents longterm experience with the surgical treatment of metatarsalgia by subcapital osteotomy. Operated on were 903 metatarsals in 281 patients. The operation brought relief in 96.5 per cent of cases. The article presents the surgical technique, indications for and complications of the method.

At the Orthopaedic Clinic of the Institute for In-Service Training of Physicians and Pharmaceuts of the Teaching Hospital at Bulovka in Prague Helal's metatarsal osteotomy was performed between 1979-1987 in 54 patients for obstinate pain in the forefoot. Evaluated were 41 patients which underwent the operation minimum two years ago. The control group comprised 38 female and 3 male patients, the average age was 54 years. In 17 patients the operation was performed bilaterally. Thus in total we evaluated 58 osteotomies according to Helal. Excellent result was found out in 19 patients (46 per cent), good result in 20 patients (48 per cent). Only in 4 cases there occurred complications (2 cases of superficial infection, 1 case of thrombophlebitis, 1 case of painful pseudoarthrosis), out of which only the last one required another intervention. Helal's osteotomy seems to be a simple effective operation with a shortterm hospitalization and good postoperative results.