Background. The Weil osteotomy is successful in the management of metatarsalgia and toe deformity. The aim is to achieve controlled shortening whilst avoiding plantarflexion. Recognised complications of the Weil osteotomy include a ‘floating toe’ in up to 20% or more of cases. Aim. Can modification of the Weil osteotomy avoid the metatarsal head plantarflexion and subsequent dorsal subluxation of the interosseous muscle that is implicated in the development of a ‘floating toe’. Methodology. The 2nd, 3rd and 4th rays were dissected out en bloc with all tendons attached from 6 pairs of fresh frozen cadavers. The ray was fixed to a board and the tendons physiologically balanced via low-friction pulleys and light weights. This model is highly sensitive to alterations in moment arm of the tendons. Once the MTP joint was balanced these weights were not altered. After standard release of the dorsal capsule a Maceira or ‘triple-cut’ osteotomy was performed. This osteotomy was developed in order to permit shortening without plantar flexion of the metatarsal head. The osteotomy was performed using a image intensifier in order to maintain uniformity of the osteotomy cut. The neck was shortened by removing a 2mm slice of bone made with parallel cuts. The ray was photographed and x-rayed pre and post ‘surgery’ and the relationships of the interosseous tendon andcentre of rotation of the metatarsal head, tendon balance and toe posture were recorded. Results. The Maceira osteotomy can avoid plantarflexion of the metatarsal head The line of pull of the interosseous tendon can maintains it's normal relationship with the centre of rotation of the metatarsal head. None of the toes developed dorsiflexion. In fact, plantarflexion at the MTP joint could be seen. PIP ‘fusion’ resulted in dorsiflexion at the MTP joint in some toes

Flexor digitorum longus transfer and medial displacement calcaneal osteotomy is a well-recognised form of treatment for stage II posterior tibial tendon dysfunction. Although excellent short- and medium-term results have been reported, the long-term outcome is unknown. We reviewed the clinical outcome of 31 patients with a symptomatic flexible flat-foot deformity who underwent this procedure between 1994 and 1996. There were 21 women and ten men with a mean age of 54.3 years (42 to 70). The mean follow-up was 15.2 years (11.4 to 16.5). All scores improved significantly (p < 0.001). The mean American Orthopedic Foot and Ankle Society (AOFAS) score improved from 48.4 pre-operatively to 90.3 (54 to 100) at the final follow-up. The mean pain component improved from 12.3 to 35.2 (20 to 40). The mean function score improved from 35.2 to 45.6 (30 to 50). The mean visual analogue score for pain improved from 7.3 to 1.3 (0 to 6). The mean Short Form-36 physical component score was 40.6 (sd 8.9), and this showed a significant correlation with the mean AOFAS score (r = 0.68, p = 0.005). A total of 27 patients (87%) were pain free and functioning well at the final follow-up. We believe that flexor digitorum longus transfer and calcaneal osteotomy provides long-term pain relief and satisfactory function in the treatment of stage II posterior tibial tendon dysfunction.

Cite this article: Bone Joint J 2015;97-B:346–52.