Talectomy. A long-term follow-up evaluation

Of 26 talectomies with an average follow-up period of 20 years, 24 (92%) were judged to have satisfactory results. The average age at surgery was 10.25 years; however, there is no ideal age for performing talectomies. The results seem to be equally good regardless of the preoperative deformity. The procedure did produce stable, painless plantigrade feet. Talectomy has a place in orthopedic surgery today. However, this drastic procedure is indicated only in those feet where the deformity is rigid and severe, where a plantigrade foot is required in patients who are younger than the age usually recommended for triple arthrodesis, and where experience has shown that other, less radical approaches would be unsatisfactory.

Computed tomography of the hindfoot with rheumatoid arthritis

We are performing direct, coronally oriented computed tomographic (CT) scans of the subtalar joint in patients with rheumatoid arthritis. To date, 16 examinations have been performed in 14 patients, 5 of whom were scheduled to undergo subtalar arthrodesis. Scans were 4-7-mm thick and spanned the length of the subtalar joint. CT scans depicted and localized subtalar abnormalities clearly and precisely. On CT scans, patients showed a characteristic constellation of abnormalities including: soft tissue swelling, cartilage space narrowing, bony erosions, and a pes planovalgus alignment abnormality (consisting of increased heel valgus angulation, and a tendency toward flattening of the sustentaculum tali, and medial and downward slippage of the talar head). The clarity of the CT images facilitated the surgeon's pre- and postoperative evaluation. In particular, it was easy to plan the correction of the valgus deformity, anticipate any special requirements for reinforcing the articular surfaces, and assess the results of surgery. We conclude that coronal CT scans clearly demonstrate abnormalities and help the surgeon evaluate the rheumatoid hindfoot.

Pes cavovarus as a late consequence of peroneus longus tendon laceration

Peroneal weakness has been implicated as a cause of cavovarus foot in neuromuscular disease. The effect, however, of isolated peroneus longus deficiency has not been studied. We report the late development of a cavovarus foot in a child with isolated laceration of the peroneus longus tendon. The importance of this specific tendon in the maintenance of foot balance is discussed.

A simple method of arthrodesis of the first metatarsophalangeal joint

Eighty-seven feet have been reviewed after arthrodesis of the first metatarsophalangeal joint stabilised by chromic catgut. Radiological union was present in 90% of patients at the mean review time of six years. Twenty-four patients had significant metatarsalgia before operation and only two failed to improve afterwards. Excellent or good subjective results were reported in 94% of patients at review. Chromic catgut is advocated as a simple and effective method of stabilising an arthrodesis of the first metatarsophalangeal joint.

A simple device to obtain reliable foot radiographs of ambulatory and non-ambulatory Friedreich's ataxia patients

A simple radiographic apparatus standardizing foot position and simulating weight-bearing effects in the feet is described in this paper. It provides an effective means of obtaining reliable radiographic data for both ambulatory and non-ambulatory patients. This device is presently used in an on-going study on pes cavus in Friedreich's ataxia.

Evaluation of foot deformity using a three-dimensional geometric model

A three-dimensional geometric model of the foot's bony structure based on the use of a stereoradiographic technique is presented. To illustrate the potential of such a model it has been applied here to the study of cavus foot in a patient having Friedreich's ataxia. This model permits an accurate evaluation of this complex spatial foot deformity.

Hallux varus--a study of thirty cases

Although both congenital and acquired hallux varus have been described, the deformity has been considered uncommon. Contrary to this belief, we noted that it is fairly common in the unshod population. Analysis of 30 cases shows that congenital hallux varus is the most common type encountered and it is of three types, namely: primary, secondary, and teratogenic. The congenital primary and secondary varieties are apparently easy to treat in infancy, but if left untreated, they progress with age in unshod persons. The more severe grades of hallux varus are associated with medial deviation of the lateral toes. Hallux varus occasionally develops in unshod persons during the fourth, fifth, or sixth decades of life. This is referred to as the idiopathic hallux varus of middle age. The length of the first metatarsal, the first intermetatarsal angle, and the shape of the first metatarsal head appear to have no bearing on the causation of hallux varus. The progression of the deformity in congenital cases and the de novo development of the deformity in middle age appear to be related to the failure to use footwear.

A comprehensive review of hallux limitus

This paper will present a review of the literature on hallux limitus, including etiology, clinical findings, radiographic findings, and surgical treatment. Criteria for the treatment of this problem will also be presented.

Pes cavovarus following ankle fracture. A case report

Pes cavovarus as a late sequela of tibial shaft fractures is well recognized. A similar deformity following an ankle fracture is rare. The patient in the present report had a cavovarus deformity following a trimalleolar fracture. A deep posterior compartment syndrome may follow an ankle fracture and should be considered in any patient with unrelenting pain.

Hallux varus--surgical correction and review of the literature

Acquired hallux varus may follow correction of hallux abducto valgus by the modified McBride procedure. The authors discuss correction of both acquired and congenital hallux varus and show pre- and postoperative illustrations of both types.

Forefoot problems in cerebral palsy-diagnosis and management

Forefoot deformities in cerebral palsy include cavus, metatarsus adductus, hallux valgus and bunion, dorsal bunion, and toe flexion contractures. Both prevention and correction of these deformities are surgical. Some can be prevented by lengthening or tenotomy of the spastic muscle that causes the dynamic deformity which eventually becomes the fixed skeletal deformity. Fixed deformities need osteotomies and arthrodesis of the bones in addition to removing the force of the deforming muscle. Some forefoot problems are related to the mid and hind foot, e.g., hallux valgus due to spastic pes valgus. Severe cavus can develop after overzealous Achilles tendon lengthening and failure to separate forefoot from hindfoot equinus.

The hindfoot and its relation to rotational deformities of the forefoot

The movements occurring at the various joints of the foot are complex, and since deformities can arise at each joint, classification of the deformities of the foot can be confusing. The position of the hindfoot can be conveniently described using the relationship of the long axis of the calcaneus to the long axis of the tibia. The position of the forefoot can then be related to that of the hindfoot. Rotation of the forefoot occurs as a result of relative movements of the talus and calcaneus and is a noticeable feature of the valgus or flat foot. Various types of valgus foot are recognized, e.g., calcaneovalgus, equinovalgus or "vertical talus," and so-called "postural" valgus. A variation is described in which the hindfoot is valgus by definition, when the patient is standing, but in which after correction the talus moves into an abnormally horizontal position relative to the calcaneus and the forefoot assumes a position of marked supination, almost appearing to stand on its lateral edge. This deformity has been observed in paralytic conditions and also in an idiopathic form. It may be correctable if detected early but if allowed to progress may result in a persistent deformity, producing discomfort and excessive shoe wear. In the late stage correction of the hindfoot may, if the rotational component is not recognized, result in an unacceptable forefoot position.

Wedge osteotomy as a treatment for angular deformity of the fetlock in horses

Five young horses with fetlock varus deformities of 8 degrees or greater were treated by means of wedge osteotomy of the distal end of the 3rd metacarpal or metatarsal bone. Three patients were admitted to the Western College of Veterinary Medicine and 2 to Colorado State University. Their selection as surgical patients was based on the following criteria: (1) an angular limb deformity of 8 degrees or greater, (2) patient older than 120 days, (3) no evidence of lameness, and (4) no evidence of degenerative joint disease. The surgery was successful in all cases.

Vincristine neurotoxicity with residual equinocavus deformity in children with acute leukemia

Vincristine has been demonstrated to be a neurotoxic agent with distal axonal degeneration progressing proximally. Five children with acute lymphoblastic leukemia developed bilateral peroneal nerve palsies with equinocavus deformities. Three developed fixed contractures requiring surgical correction. One patient was braced prior to development of fixed deformity and the other had physical therapy preventing fixed deformities and did not require surgery. All of the children obtained complete return of peroneal nerve function. Proper bracing and/or physical therapy at the time of diagnosis of neurologic deficit will prevent fixed contractures and the necessity for surgery.

Spontaneous hallux varus: relation to poliomyelitis and congenital absence of the fibular sesamoid

Two case reports are presented of spontaneous hallux varus developing late in life. The first patient had longstanding poliomyelitis involving the foot, while the second patient had bilateral congenital absence of the lateral sesamoids. In the second patient the hallux varus was bilateral. The probable etiological relationship of these underlying disorders to the development of the spontaneous hallux varus is discussed.

Pedal manifestations of DISH

Diffuse idiopathic skeletal hyperostosis (DISH), also known as Forestier's disease, is an ossifying diathesis characterized by excessive bone formation at specific skeletal sites. The condition is best recognized for its spinal features. However, the tendency toward bone formation is often manifested in extraspinal locations, particularly the foot. The radiographical, pathological, and clinical features of the disorder are reviewed with special emphasis on the foot as a target organ. Abnormalities in the foot that suggest the diagnosis of DISH are emphasized.

Juvenile rheumatoid arthritis of the foot

Rheumatoid arthritis occurring in children under 16 years of age is defined as juvenile rheumatoid arthritis. It is more common in females and the peak incidence is between 1 and 3 years of age. It can present in different forms. Mono- and pauciarticular type is complicated by iridocyclitis in 20%. Growth disturbances are common. Any conceivable combination of foot deformities can occur. Some of the secondary deformities can be prevented with conservative care. Principals of soft tissue and bony surgery have been outlined.

Roentgenographic study of cavus foot deformity in Friedreich ataxia patients: preliminary report

The preliminary results based on a three year retrospective study in cavus foot deformity of forty-four Friedreich ataxia patients regularly seen at the Neuromuscular Disease Clinic of Sainte-Justine Hospital have been presented. An accurate "weight-bearing" foot stereoradiographic technique has been recently developed by our group. Since the follow-up period with this device is not sufficient to provide statistical information, the conventional non-weight bearing technique has been utilized in this study to enable a possible comparison between the radiographs of ambulant and non-ambulant patients. Due to the present technique, the results of this study must be interpreted with caution. For 132 pairs of radiographs, 28 parameters have been analyzed. Four of these, namely the calcaneal inclination angle, the first metatarsal inclination angle, the inferior cortex of calcaneus-first metatarsal angle and the first-fifth metatarsals angle, were of particular interest. From these parameters, a preliminary quantitative description of cavus foot deformity in Friedreich's ataxia has been attempted. Three stages of evolution have been tentatively identified for this type of neurological disorder.

Kinematics of the foot

Orthogonal stereoradiographs are frequently utilized in determining three-dimensional geometrical parameters of human body segments. They have been applied here in the estimation of the length and elongation of the ligaments of the normal foot. Three small spherical metallic markers were respectively encrusted into the tibia and fibula, the seven bones of the tarsus and into the five metatarsals of an amputated lower limb to identify uniquely their spatial location. The foot was then positioned on a rotating platform. Standardized antero-posterior and lateral radiographs were taken. Afterwards the foot was dissected and the proximal and distal insertions of most of its ligaments were located by means of spherical markers. A second series of orthogonal radiographs were taken of each of the fourteen bones. The radiographs were digitized. The length of each ligament and elongation for a simple and complex movements were calculated by means of a computer program. The results of a simple movement of rotation representing a normal 20 degree dorsiflexion at the talocrural joint and of complex movements of rotation stimulating an abnormal high arch such as encountered in Friedreich's ataxia are presented and discussed.

[Treatment of splayfoot with prolapse of the metatarsal heads by Helal's Oblique Metatarsal Osteotomy (author's transl)]

The authors describe the technique of oblique osteotomy of the distal metatarsals after Helal, for treating splayfoot with prolapse of the metatarsals heads. It was performed on 189 metatarsals in 76 patients. The operation is technically straightforward, inexpensive and, with the appropriate indication, an efficacious intervention with a high success rate.

Pes planus: radiographic changes with foot orthoses and shoes

Radiographic evaluation of 10 children with bilateral pes planus was performed. Radiographs taken barefoot, with a Thomas heel, with an over-the-counter insert, with two specially molded plastic foot orthoses were used. No significant change was seen after the donning of these appliances in their comparison to barefoot evaluation. The conclusion is that there was not a significant change radiographically of these feet by the utilization of any of the appliances.

Lupus foot

Images

[The rheumatoid foot. Origin of deformations]

Deformations of the foot are a logical and predictable function of the biomechanics of the foot and the constraints undergone by the articulations of the foot, that are unstabilized by the inflammatory process. They result from the combination of three factors : anevolutive teno-articular synovitis, predictible forces (the weight of the extrinsic muscle, the anti-physiological foot), and the congenital morphotype of the foot. Typical deformations (peroneal " coup de vent " of the toes, triangular metatarsus), differ on the clinical level in keeping with the morphotype but respond to the same mechanism. The " coup de vent peronier " remains the most characteristic deformation and is furthered by the excentric action of the extrinsic muscles, and in particular the foot muscle. The common denomination of deformations of the back part of the foot is represented by the valgus calcanean, linked to the action of the weight on the orsion forces that is more or less modified. A better knowledge of the cause of these deformations would make it possible to avoid, if not their apparition, at least their worsening.

[Pantalar arthrodesis. A follow up study of 45 operations (author's Transl)]

The authors have studied the long term results of 45 Pantalar arthrodesis realised either in one stage, or in two stages. Technical details are given for obtaining a good positioning during the surgical procedure. It was found that post operative complications were more frequent than after more limited operations. The long term results were satisfactory, provided a good positioning. Residual equinus deformities were better tolerated than deformities in pronation or supination. It was noted no consequences on neighboring joints.

The use of scintigraphy in the diagnosis and management of traumatic foot lesions in ballet dancers

In this paper we report the use of the technetium-99m diphosphonate bone scan in the diagnosis and management of traumatic bone lesions in the ballet dancer's foot. Nine illustrative case histories are given. We conclude that this is a useful technique particularly in the recognition of stress lesions not identified by conventional radiography.

[The operative therapy of the acquired pes plano-valgus and pes planus of the child (author's transl)]

The author shows the importance of the development of the leg axis for the diagnosis and the indication for the treatment of the acquired infantile pes plano-valgus and pes planus. Only when this development is finished an operative therapy can be indicated. The experience gained on a very treat number ofpatients shows that it is evident that the best method is the transposition of the tendons M. fib. III or IV. The author also discusses the reasons for indication and the limitation of this operation. (The author prefers the modified techniques of K. Niederecker (1959) based on the idea of E. Müller (1903).

Haemophilic arthropathy in the joints of the hands and feet

Radiographs of the hands and feet of 72 haemophilic patients were reviewed for peripheral joint involvement. Fifty patients or 69% had changes in the small joints of their hands and/or feet with a total of 160 abnormal joints. In the hands the metacarpo-phalangeal joints were predominantly involved (42 of 50 joints), and in the feet, the metatarso-phalangeal joints (68 of 110 abnormal joints), as well as the posterior subtalar joint (36 of 110 joints). Röntgen abnormalities were characterized by irregularity and/or flattening of the articular cortices. The involvement of the small peripheral joint in haemophilic patients has not been a primary consideration in previous clinical and radiographic studies because of the more common and more debilitating changes in the large joints. The recognition of involvement of the small joints is described to avoid misinterpretation of the röntgen findings and to appreciate the incidence of involvement, especially with the increased availability of replacement therapy.

[Study of weight-bearing changes of normal and abnormal feet by frontal tomography (author's transl)]

Roentogenographic examination with emphasis upon frontal tomography was applied to clarify the positional relationship between the calcaneus and talus, and to measure weight-bearing changes of these bones on normal and abnormal feet in frontal plane. studied were conducted on 30 left feet of normal adults, 18 left feet of normal children, and 37 feet of 19 children affected with cerebral palsy, and 19 feet with unilateral or bilateral foot disorders other than cerebral palsy. Statistical analysis of the in patients with diseases results gave the following results. The 30 feet of normal adults were without definite trend for internal or external rotation, medical or lateral shift, though the calcaneus in the sinus tarsi was found to lower to an average extent of 1.68 +/- 0.68mm. The 8 feet of normal children were also without definite trend of rotation or shift. The calcanei of some of children's flat feet with cerbral palsy were found to fluctuate markedly up and down and also medialy and laterally. But the weightbearing change was in most cases with cerebral palsy stayed within normal ranges. The 19 feet with disorders other than cerebral palsy were found to lie within the normal ranges of lowering, rotation and shift. The author's modification of Méary's method was able to be used quantitatively and qualitatively. This method showed that feet with calcaneus varus of calcaneus valgus deviate markedly from the normal feet based in the evidence of average precentage. The analysis by this quantitative method was found to agree well with that by frontal tomography.

The radiological features of alcoholic ulcero-osteolytic neuropathy in Blacks

The radiological features in the bones and the angiographic changes in the vessels of the lower limbs of 15 chronic alcoholic men are discussed. The distal arteries demonstrate the features of neovascularization. Infective and resorptive changes in the bones of the forefeet are described. These features are related to chronic infection or to the toxic effects of the alcohol.

A controlled study of ANA+ RF- arthritis

Thirty (7.5%) of 401 adult rheumatoid arthritis (RA) patients were antinuclear antibody positive (ANA+) and rheumatoid factor negative (RF-), and 15 of 16 patients who were followed for a year or longer remained so. Clinical, other laboratory, and radiographic parameters were compared among this group and 90 matched RA controls divided into ANA+RF+, ANA-RF+, and ANA-RF- groups. All groups were identical, except the ANA-RF- group, which had significantly fewer nodules and less destructive disease than the other three.

[Essential flat foot in the child. Definition, diagnosis and therapeutic indications (author's transl)]

There exists considerable confusion in the definition and classification of essential flat foot in the child. In an attempt to put an end to this confusion, the authors define the radiological characteristics and course of the abnormality. The latter is defined radiologically on lateral films of the foot whilst weight bearing by study of the angle of the calcaneum over the horizontal (Angle C) and by the measurement of the angle of talo-calcaneal divergence (Angle T.C.D.). Three groups may be distinguished on this basis: Group I - of minimal gravity; Group II - which may correct itself spontaneously and is, in general, well tolerated; Group III - which alone requires surgical correction. Treatment is only surgical in severe forms and is based upon the "Horseman" operation, orthopaedic treatment by special soles being rarely indicated.

Macrodactyly in the foot

Seven patients with macrodactyly in the foot are reported. None showed any stigmata of neurofibromatosis and all were found to have excessive accumulation of fibro-fatty tissue as the most striking pathological feature. It is suggested that this may represent the basic lesion in this condition. The literature is reviewed and attention is drawn to the differences between macrodactyly in the hand and in the foot.

External rotational deformities in club feet

External rotation of both a structural and functional nature occurs in the lower limb of some patients with club feet. These external rotational deformities are due to two unrecognized and untreated combined deformities within the hindfoot and mid-foot: hindfoot varus and talo-navicular subluxation. If allowed to persist, they will eventually produce external rotation above the level of the ankle. This results in a condition that may be named "The Medial Malalignment Syndrome."

Posterior displacement osteotomy of the calcaneus

In cases of established calcaneus after anterior poliomyelitis the deformity can be greatly reduced by combining an extensive plantar release with an oblique transverse osteotomy of the calcaneus that permits displacement upwards and backwards of the posterior weight-bearing part of the bone. The procedure greatly improves the mechanical advantage of subsequent tendon transplantations to the heel. Between 1956 and 1969 fifteen such osteotomies were carried out and the long-term results have been reviewed.

Etiology of acquired hammertoe deformity

The most important feature of acquired hammertoe deformity is hyperextension of the proximal phalanx. The position of the proximal phalanx at the normal metatarsophalangeal joint is subject to the antagonistic action of the extensors and intrinsic flexors. The plantar joint capsule and the attached extensions of the plantar aponeurosis make an important contribution to the dynamic balance of this joint. The balance is distrubed in acquired hammertoe deformity because of age-related inefficiency of the plantar structures (the intrinsic flexors, the plantar joint capsule, and the plantar aponeurosis). This concept evolved from clinical obervations and measurements from roentgenograms of the feet of patients from different age groups. Hyperextension of the toes can be corrected by increasing tension on plantar structures. Dorsiflexion of the lesser toes, as measured on lateral weightbearing roentgeograms, is significantly increased in older age groups as compared with younger ones (means of 33 degrees, 33 degrees, 39 degrees 37, degrees vs 23 degrees, 24 degrees, 25 degrees, 25 degrees). These observations suggest elongation of the plantar structures beyound physiological length. Higher-heeled shoes worn for many years may be responsible because they maintain dorsiflexion of the toes and stretching of the plantar structures even during the foot flat interval of the walking cycle. Hyperextension of the proximal phalanx may be the primary deformity. In this position, the long extensor loses its tendodesing effect and flexion deformity of the proximal interphalangeal joint results.

Subungual exostosis

This report is intended to focus attention on the often occurring, but seldom reported, subungual exostosis. Familiarity with its clinical characteristics should enable the physician to make a preoperative diagnosis or at least include it in the differential diagnosis of any subungual growth. Establishing the practice of x-raying all subungual tumors may save the physician's ego from the trauma of a missed diagnosis. More importantly, however, it may save the patient from unnecessary and at times even unnecessarily drastic surgery.

The hallux and rheumatiod arthritis

The purpose of this report is to consider involvement of the great toe by rheumatoid arthritis, defining significant deformities, describing clinical patterns and discussing the pathomechanics of these findings, in what is an ongoing disease. 200 consecutive patients admitted to hospital with classical or definite rheumatoid arthritis were screened for pain or deformity of the great toe. Feet that had undergone previous surgery or had other underlying pathology were excluded from the series. 194 feef were found to have halluceal involvement. Although hallux valgus was the commonest deformity it was found in combination with other significant deformities in many cases. Hallux rigidus was an important lesion in this series as was interphalangeal hyperextension. Other important lesions encountered were metatarsus primus varus and medial rotation of the toe; their relationship to hallux valgus is discussed.