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VOL. 85-B, No. 5, JULY 2003 683e treated 35 brachymetatarsal rays of 18 feet in 12 patients by one-stage lengthening with interpositional bone grafts or by gradual lengthening with callotasis combined with shortening of the adjacent metatarsals and phalanges. Definition of the two parabolas which connect the metatarsal heads and the tips of the toes, and recognition of three patterns of metatarsal length, were helpful guides in treatment. In total, 36 excisions of the phalanges and/or the metatarsals were undertaken. The mean shortening was 8 mm.The radiological results were satisfactory. The mean values were as follows: one-stage lengthening, length gain, 1.3 cm; healing index, 1.3 months/cm; percentage increase, 30%; gradual lengthening, length gain, 2.0 cm; healing index, 2.0 months/cm; percentage increase, 50%. Associated shortening of an adjacent bone can avoid the disadvantages of one-stage lengthening which may not achieve target length and can result in neurovascular complications. Reduction of the target length enables the surgeon to carry out one-stage instead of gradual lengthening. It also shortens the length of treatment in the group undergoing callotasis and improves cosmesis.J Bone Joint Surg [Br] 2003;85-B:683-90.Received 7 August 2002; Accepted after revision 7 February 2003Brachymetatarsia is diagnosed when one metatarsal ends5 mm or more proximal to the parabolic arc. 1 It usuallyoccurs in a single metatarsal, and the fourth ray is most fre-quently affected. The causes of brachymetatarsia may becongenital, post-traumatic, postsurgical, or linked to spe-cific disease processes such as Down’s syndrome, Apert’ssyndrome, Albright’s osteodystrophy, sickle-cell anaemia,diastrophic dwarfism, and poliomyelitis. 1-3 Bra-chymetapody, when there are multiple abnormally shortmetatarsals, is a serious cosmetic problem. 1,4Despite potential complications, the surgical correctionof brachymetatarsia tends to favour lengthening procedures.One-stage lengthening with an interpositional bone graftand gradual lengthening by callotasis are the two techniquesmost widely used. 1,2,5-8 In evaluating a patient withbrachymetatarsia, numerous variables must be assessed,including the number of rays affected, the amount of length-ening required, the method of lengthening, the possibility ofcombined adjacent shortening, the sources of bone grafts,the options for internal and external fixation, soft-tissuecontracture, and the tension of the skin.Our aim was to evaluate the feasibility of combinedlengthening and shortening of adjacent metatarsal andphalangeal bone using the parabola formed by the tips of thetoes (Fig. 1) and three metatarsal types (Fig. 2) as guides. 9Patients and MethodsWe studied 35 examples of brachymetatarsia in 18 feet (12patients) which we had treated by either one-stage lengthen-ing with an interpositional bone graft (five patients with aunilateral fourth ray and one with unilateral fourth and fifthray brachymetatarsia), or gradual lengthening by callotasis(five patients with bilateral first and fourth raybrachymetatarsia). The study also included one patient withfirst, third, fourth, and fifth metatarsal involvement on bothfeet treated by second metatarsal and proximal phalangealshortening. All patients were treated by combined adjacentmetatarsal or phalangeal shortening (Table I). Because ofthe relatively young age of the patients in our study, the pri-mary reason for surgical correction was cosmetic rather thanfunctional. Before operation, four patients complained ofproblems with hygiene in the area of the recessed fourthweb. One had a plantar keratosis beneath the fourth toewhich gave mild discomfort, but her major concern was cos-metic. In one patient the problem was caused by injury, 11had congenital conditions. There were nine females andthree males. The mean period of follow-up was three years.WLower limbThe management of brachymetatarsiaH. T. Kim, S. H. Lee, C. I. Yoo, J. H. Kang, J. T. SuhFrom Pusan National University Hospital, Pusan, KoreaH. T. Kim, MD, Associate ProfessorS. H. Lee, MD, ResidentC. I. Yoo, MD, ProfessorJ. H. Kang, MD, ResidentJ. T. Suh, MD, ProfessorPaediatric Orthopaedic Unit, Department of Orthopaedic Surgery, PusanNational University Hospital, 1Ga-10, Ami-Dong, Seo-Gu, Pusan, Korea602-739.Correspondence should be sent to Dr H. T. Kim.©2003 British Editorial Society of Bone and Joint Surgerydoi:10.1302/0301-620X.85B5.13733 $2.00