Surgery, with Special Reference to Podiatry Part 25

Amputation of the head of the metatarsal bone gives uniformly good results.

The toe is straightened and flexible; ankylosis with this operation does not occur.

In operations for hallux valgus there are two distinct purposes acting as determining factors in making a choice in a given case as to which is indicated. These are: (1)the radical operation for the correction of the deformity, and (2)the palliative operation for the alleviation of symptoms by the removal of the hypertrophied portion of the metatarsal head which is exposed to pressure. Among operations in the first mentioned cla.s.s, the one known as the Mayo operation is, in all probability, the best. The entire head of the metatarsal is amputated, and the bursa is turned in over the cut end of bone, to diminish the amount of shortening and to prevent ankylosis of the joint. This latter consideration, however, is an unnecessary one, for in operations within this joint, ankylosis does not occur when the synovial surface of the phalanx is left undisturbed, even when the bursa is not employed as an intervening pad.

In the other cla.s.s of operations for the relief of symptoms, no attempt is made to straighten the toe. A wedge-shaped piece of the exostosis is removed, against which pressure has caused symptoms.

A palliative operation devised by Dr. Robert T. Morris of this city, is one easy of accomplishment and serves every purpose where a radical operation is interdicted. It is known as the "b.u.t.ton-hole" operation because of the fact that only a small incision is made immediately above the protuberant bone through which a sharp chisel is inserted, cutting off the offending "b.u.t.ton" of bone.

An operation which in the hands of the authors has proven of distinct value, and which has probably not been previously described eliminates both the deformity and its painful symptoms. This operation which is described below, is less severe than other radical operations and not very much more so than the usual palliative ones.

The incision is made on the dorsum of the great toe over the offending joint and just to the inner side of the extensor tendon. This tendon is held to the outer side, out of the way. The knife penetrates the capsule of the joint and opens it above and laterally.

An effort is made to preserve the integrity of the capsule below (floor) as _only the intra capsular end of the metatarsal is removed_.

These two factors are of the utmost importance. When the joint capsule is slit open along its dorsal and two lateral aspects, sufficient room is obtained for the insertion of the wire saw, and all of that portion of the metatarsal lying within the joint proper is removed. There is thus accomplished a correction of the deformity with very little shortening of the great toe. Usually its length after this operation is about the same as the second toe.

The next step in the operation is closure of the synovial sac or joint capsule. A st.i.tch on either side and two above are all that is necessary. The floor of the sac remains intact and nothing beneath it, in the ball of the foot, has been disturbed. Many operators invade this area and remove the sesamoids. This is unwarranted as the transverse level of the ball of the foot is lost, and the weight is put directly upon the newly formed joint, depriving it of its normal support, or of padding from below.

One other omission in this operation is that of the bursal flap over the raw end. This is found entirely unnecessary as results prove, and its omission hastens healing considerably. The bursa over the metatarsophalangeal articulation in these cases is nearly always inflamed, and consists of a mere fibrous pad. Its dissection from the normal position is a real loss at that site, and of questionable benefit over the cut bone, as motion in the joint is as good or better without it.

The skin closure is made without drainage, and _no wet dressing employed_ for fear of the solution filling the cavity whence the bone was removed and carrying with it infectious material. A dry sterile dressing is all that is required, and a splint to maintain a straight position for the toe.

Four or five days complete rest for the part are ordinarily sufficient. Following this, walking about the room is permitted with the aid of a stick. After ten days, when the patient can get about fairly well without the a.s.sistance of a stick, the foot may safely be shod with an "arctic" of sufficient size.

+CLUBFOOT OR TALIPES+

The most common form of clubfoot, and therefore the deformity of that character most frequently encountered, is characterized by inversion of the sole of the foot, elevation of the heel, and a twisting and turning of the front part of the foot. This deformity is typical of _congenital_ clubfoot, which, as stated, is the most common form of that deformity. The _acquired_ form is usually the result of infantile paralysis.

+Congenital Clubfoot+ is most frequently double, and males are more frequently affected than females; in unilateral or one-sided clubfoot, one side is not more frequently affected than the other.

+Etiology.+ Very little is known as to the cause of congenital clubfoot but it is not infrequently a.s.sociated with other congenital deformities. It appears to be hereditary in a great many instances.

The greater number of cases appear without definable cause, except perhaps from intra-uterine pressure. There are, however, a number of these cases that are a.s.sociated with malformation of the bones of the foot and leg, such as absence of the scaphoid; defect of the tibia; fusion of a number of the tarsal bones.

+Pathology.+ The sharp adduction and plantar flexion, at the tarsal joints, produce a deformed position of the foot. As a result of these, the heel is small and elevated; the dorsum of the foot is prominent; and the outer border usually, and, in extreme cases, the dorsum of the foot, bears the weight of the body in walking and in standing; the sole of the foot is bent sharply in, and twisted at the tarsal joint.

In fact, all the bones are changed in shape, and the inner muscles, tendons and ligaments are shortened by contraction, while the ones to the outer side are lengthened.

The distortion of certain individual bones is of importance. The astragalus is the seat of the most important changes. It is tipped downward at its front end, and its posterior part articulates with the tibia, its anterior articular surface projecting under the skin; its neck is elongated and bent inward and downward, so that its scaphoid articulation faces inward and downward and not forward.

This is the most important change in clubfoot, because the anterior end of the astragalus, the head of the bone, carries inward and downward with it the scaphoid, the three cuneiforms, and the inner three metatarsal bones. The scaphoid articulates with the inner side rather than the front of the astragalus and, in extreme cases, forms a joint surface with the inner malleolus. It may be somewhat changed in shape, being flattened and drawn inward and upward.

The os calcis is generally poorly developed, and its front end is rotated downward, and bent inward; the outer surface of the bone is more convex and the inner surface more concave than normal, and since the anterior facet looks inward and downward, it carries with it the cuboid and the two external metatarsal bones. The changes in the other bones are not important; the chief obstacles to reduction lie in the os calcis and in the astragalus.

+Soft Parts.+ The muscles, ligaments, tendons, and fascia at the lower and inner side of the foot are shortened, and lengthened at the outer and upper side. The plantar fascia being one of the chief obstacles to reduction, the tendons are displaced, especially those on the inner side of the foot.

+Symptoms.+ Double clubfoot is usually accompanied by an awkward and unsteady gait, in which each foot is in turn lifted high to clear the foot on the ground, and the _toeing in_ is, of course, excessive. The weight is borne on the outer side of the foot, and all elasticity of gait is absent.

On the outer border of the foot, where the weight is borne, callosities and bursae develop; the calves of the legs are small, and the knee joint may be lax.

The gait in single clubfoot is less awkward, but characterized by the same features. The foot is rigid in the deformed position, and in cases of marked deformity, the foot cannot be manipulated into the normal position.

+Diagnosis.+ Congenital clubfoot cannot be mistaken for any other condition. The diagnosis is self-evident.

+Prognosis.+ There is no tendency of this deformity to right itself, or to improve. Early and proper treatment will, if continued long enough, insure a cure in children and an improvement in adult cases; but it must be remembered that there is a decided tendency to relapse, even after operation, unless the foot is kept in an overcorrected position for a number of years.

+Treatment.+ In young infants, treatment should be begun as early as two weeks after birth and should consist in frequent gentle ma.s.sage and manipulations. After the part can be brought into an overcorrected position by gentle manipulation, it should be put up in a plaster cast, for a period of three weeks and this treatment should be continued until the position of the foot is corrected.

The manipulations consist in grasping the dorsum of the foot gently but firmly with one hand, and holding the leg with the other. The foot is then dorsally flexed and everted. This treatment should be repeated at least three times a day and should not be rough enough to cause the infant to cry.

Treatment of clubfoot in older children and adults is a much more difficult proposition and consists in the combination of two or more methods of procedure.

In order to correct the extreme adduction in these cases, extreme force must sometimes be employed. This may be accomplished by bending and bearing down on the foot, with its outer border resting on the apex of a wooden wedge. The rotation of the foot is corrected by grasping the foot in one hand, and the heel in the other, and twisting with the necessary amount of force. The inversion of the sole is also corrected by the use of this wedge as a fulcrum.

In this way the tendo Achillis and the plantar fascia are stretched, and the dorsal flexion is secured by laying the patient on the face with the knee bent and the front of the thigh resting on the table.

The lower leg is then vertical, and by bearing down on the front of the foot with the necessary amount of force, dorsal flexion of the foot is secured, and by hooking the fingers around the os calcis, its position is improved.

A modified Thomas wrench may be used in the correction of clubfoot; but this must be done with great care, as the violence practised in this method, the tearing of the ligaments and other soft parts, is often attended with great danger; osteomyelitis, tuberculosis, neuritis, and even death from fat embolism, and extensive sloughing of the soft parts are not infrequently seen after the use of this and other bone crushing instruments.

The removal of a wedge of bone from the outer side of the foot and the removal of the neck of the astragalus are employed. Tenotomy and the transplantation of tendons are also often practised, when other methods of treatment fail.

+Acquired Clubfoot.+ The cause of acquired clubfoot maybe infantile paralysis, joint disease, traumatism, or it may be due to affections of the brain or spinal cord.

+Paralysis.+ Infantile paralysis affecting the muscles of the front and outer side of the lower leg, will result in a condition similar to congenital clubfoot. Other paralytic causes are: spastic or cerebral paralysis, hereditary ataxia, etc.

+Traumatic.+ A condition resembling clubfoot may result from improperly treated fractures of the ankle-joint or tarsal bones.

+Joint Disease.+ In tuberculosis, arthritis deformans, and other diseases of the ankle-joint, a condition similar to clubfoot is sometimes seen as a result of muscular contraction.

+Talipes Equinus+ is rarely congenital. It is usually due to infantile paralysis of the extensor muscles, or to cicatrical contraction of the calf muscles, as a complication of hip disease. It varies from inability to flex the ankle beyond a right angle, to walking on the heads of the metatarsal bones. The astragalus is partially displaced forward and forms a prominence on the dorsum of the foot; the plantar fascia is shortened and callosities and bursae are formed under the heads of the metatarsal bones. Primarily, the obstacle to reduction is the tense Achilles tendon, and in advanced cases the shortened plantar fascia and posterior ligament of the ankle-joint const.i.tute obstacles.

+Talipes Equino-Varis+ (down and in foot) is the most common form of this deformity.

It is either congenital or acquired, and in the latter case it is due to infantile paralysis of the extensor and peroneal muscles. The heel is drawn up, and the anterior half of the font is drawn inwards and inverted. The inner border of the foot is shortened, and in neglected cases the patient walks on the outer side of the cuboid, under which a bursa is formed. Secondary contraction of the plantar fascia, ligaments, and short plantar muscles follows. There is a great increase in the obliquity of the neck of the astragalus in congenital cases, so that the scaphoid and anterior half of the foot, together with the dorsal tendons are carried inward. As a result of the equinus, the upper surface of the astragalus projects forward, and only its posterior portion comes in contact with the tibia and fibula.

The ligaments of the inner side of the foot are shortened and the shape of the other tarsal bones is secondarily altered.

+Talipes Equino-Valgus+ (down and out foot). This condition is rare as a congenital deformity. The anterior half of the foot is deflected outward, and the inner border comes in contact with the ground. The scaphoid is placed outward, and the head of the astragalus projects into the sole.

The acquired variety results from paralysis of the tibialis posticus and flexors, with secondary contraction of the peronei muscles.

+Talipes Calcaneus+ is rare as a congenital deformity. It is usually the result of infantile paralysis of the muscles of the calf. The patient walks on the heel, and the anterior half of the foot is drawn up.

Valgus or varus are a.s.sociated with it; the more common form is talipes calcaneo-valgus.

+Talipes Cavus+ (Pes Cavus), or hollow foot, is a condition in which the arch of the foot is greatly exaggerated. It is rarely congenital but is frequently seen in connection with clubfoot, especially in its paralytic forms. In its mildest form, it exists in a highly arched foot, often hereditary. It may also be the result of too short shoes (Chinese ladies' foot).

+Treatment.+ The condition is best remedied by division of the contracted soft parts, a forcible reduction of the bones, held in place by plaster of Paris. When the patient begins to walk, it is advisable to have a stiff, flat, steel plate placed in the length of the shoe between the layers of the leather sole, running from which, over the dorsum of the foot, is a stout leather strap. At each step, downward pressure is thus exerted on the dorsum of the foot.