The Foot: Pathology, Aetiology, Semiology, Clinical Investigation and Therapy

In orthopaedic surgery, the study of the foot has a special place. Familiarity with the congenital and acquired problems of in- flammation and arthrosis must be blended with an understand- ing of the mechanics of support and propulsion before a sure choice of effective treatment can be made. There is involvement of bones, joints, tendons, ligaments, soft tissues and integument, none of which can be treated in isolation. Superficial appraisal can lead to the cardinal error of facile diagnosis, and ignorance of the physiology of the organ and of the differences of expert opinion with respect to pathogenesis and basic therapeutic con- cepts invites inevitably poor management. In this book, I have attempted to interpret pathology, clinical presentation and treatment in the light of practical experience. I do not presume to be original, for many distinguished authors on the subject already. Lelievre (1952), Viladot et have written al. '1956), de Doncker and Kowalski (1970) and many others, preceded by Hohmann (1951), Morton (1935), Hauser (1950) and Boehler (1944), have all contributed significantly to our ba- sic knowledge and opened the way to understanding. The philosopher Alain wrote succinctly: "When it is fully com- prehended that there is no knowledge without experience and that one cannot conceive an idea unless there already exists a thought, no more need be said".

Table of Contents:
I Functional Structure, Diagnosis and Cutaneous Infections.- 1 Functional Structure of the Foot.- 1.1 General Considerations.- 1.1.1 Tibiotalocalcaneal Complex.- 1.1.2 Subtalar Complex.- 1.1.3 Midtarsal Joints.- 1.1.4 Metatarsal System.- 1.1.5 Ligaments.- 1.1.6 Muscles.- 1.2 The Foot Under Load.- 1.3 Dynamic Considerations.- 1.3.1 Ankle Joint.- 1.3.2 Subtalar Joint.- 1.3.4 Antetarsal Joint.- 1.3.5 Interphalangeal Joints.- 2 Diagnosis of Disorders of the Foot.- 2.1 History.- 2.2 Examination of Unloaded Foot.- 2.2.1 Integument.- 2.2.2 Vascular Supply.- 2.2.3 Nails.- 2.2.4 Disorders.- 2.2.5 Joints.- 2.3 The Loaded Foot: Static.- 2.4 The Loaded Foot: Dynamic.- 2.5 Special Investigations.- 2.5.1 Podometry.- 2.5.2 Radiography.- 2.5.3 Other Special Investigations.- 3 Painful Syndromes of the Foot and Other Parts.- 3.1 Muscle Pains.- 3.2 Tendinitis.- 3.3 Pain in Knee, Hip and Vertebral Column.- 3.4 Neuralgias.- 3.5 Classification of Relevant Foot Displacements.- 3.5.1 Balanced Pes Cavus.- 3.5.2 Bilateral Pes Planus.- 3.5.3 PesCavovarus.- 4 Mycoses.- 4.1 Clinical Features.- 4.1.1 Interdigital Intertrigo.- 4.1.2 Plantar Mycoses.- 4.1.3 Ungual Mycosis or Onyxis of Toes.- 4.2 Laboratory Examination.- 4.3 Treatment.- 4.3.1 Prophylaxis.- 4.3.2 Treatment of the Established Condition.- II Functional and Structural Disorders of the Forefoot.- 5 Painful Syndromes of the Forefoot.- 5.1 Causes.- 5.1.1 Muscular Weakness and Incoordination.- 5.1.2 Modifications of Longitudinal and Transverse Arches of Foot.- 5.1.3 Modifications of Frontal Configuration of Lisfranc Joint.- 5.2 Relationship Between Morphological and Clinical Features.- 5.2.1 Flat Triangular Forefoot Syndrome.- 5.2.2 Convex Triangular Forefoot.- 5.2.3 Simple Convex Forefoot.- 5.2.4 Cavus Forefoot.- 5.3 Symptoms.- 5.4 Principles of Treatment.- 6 The Flat Triangular Forefoot.- 6.1 Clinical Features.- 6.2 Treatment.- 6.2.1 Conservative.- 6.2.2 Operative.- 7 Simple Convex Forefoot.- 7.1 Clinical Features.- 7.1.1 Symptoms.- 7.1.2 Physical Signs.- 7.2 Treatment.- 7.2.1 Conservative.- 7.2.2 Operative.- 8 The Convex Triangular Forefoot.- 8.1 Clinical Features.- 8.1.1 Symptoms.- 8.1.2 Physical Signs.- 8.2 Treatment.- 8.2.1 Conservative.- 8.2.2 Operative.- 9 The Cavus Forefoot.- 9.1 Clinical Features.- 9.1.1 Symptoms.- 9.1.2 Physical Signs.- 9.2 Treatment.- 9.2.1 Conservative.- 9.2.2 Operative.- 9.3 Iatrogenic Cavus Forefoot.- 10 Convex Forefoot with Insufficiency of the First Ray.- 10.1 Congenital Familial Forefoot of Duddley Morton.- 10.1.1 Etiology.- 10.1.2 Clinical Presentation.- 10.1.3 Treatment.- 10.2 Congenital Short First Metatarsal.- 10.2.1 Etiology.- 10.2.2 Clinical Presentation.- 10.2.3 Treatment.- 10.3 Acquired Short First Metatarsal.- 10.4 Short Great Toe.- 10.5 Hypermobility of First Metatarsal.- 10.5.1 Clinical Presentation.- 10.5.3 Treatment.- 11 Selective Overloading of Metatarsal Heads.- 11.1 First Metatarsal.- 11.1.1 Congenital Hypertrophy.- 11.1.2 Acquired Equinus Deformity.- 11.1.3 Hypertrophy of Sesamoids.- 11.1.4 Iatrogenic Conditions.- 11.2 Congenital Hypertrophy of First and Second Metatarsals.- 11.3 Second, Third and Fourth Metatarsals.- 11.3.1 Etiology.- 11.3.2 Clinical Presentation.- 11.3.3 Treatment.- 11.4 Fifth Metatarsal.- 11.4.1 With Clawing of Toe.- 11.4.2 With Reduced Vertical Mobility.- 11.4.3 With Equinus of Metatarsal Associated with Longitudinal or Forefoot Cavus or of Iatrogenic Origin.- 11.4.4 With Plantar Cutaneous Atrophy.- 12 Insufficiency of the Central Metatarsals.- 12.1 Etiology.- 12.2 Clinical Presentation.- 12.3 Treatment.- 12.3.1 Conservative.- 12.3.2 Operative.- 13 Disorders of the Sesamoids.- 13.1 Congenital Bipartite or Tripartite Sesamoid.- 13.2 Dystrophy or Aseptic Necrosis (Renander's Disease).- 13.3 Fracture.- 13.4 Exostosis.- 13.5 Sesamoiditis from Overloading.- 14 Metatarsalgia.- 14.1 General Considerations and Classification.- 14.2 Diffuse Metatarsalgia.- 14.2.1 Clinical Presentation.- 14.2.2 Longitudinal Displacement.- 14.2.3 Displacement of Metatarsal Heads.- 14.2.4 Functional Disorders.- 14.2.5 Medical Causes.- 14.3 Localised Metatarsalgia.- 14.3.1 Clinical Presentation.- 14.3.2 Congenital.- 14.3.3 Acquired.- 14.4 Subcutaneous Soft Tissue Metatarsalgia.- 14.4.1 Hygroma.- 14.4.2 Articular Synovial Cyst.- 14.4.3 Intermetatarsal Syndrome of Claustre.- 14.4.4 Morton's Neuroma.- 14.4.5 Neoplasm.- 14.5 Cutaneous Metatarsalgia.- 14.5.1 Callus.- 14.5.2 Verruca.- 14.5.3 Perforating Plantar Ulcer.- 14.5.4 Plantar Fistula.- 14.5.5 Radiodermatitis.- 15 Pes Cavus.- 15.1 General Considerations.- 15.1.1 Longitudinal Cavus.- 15.1.2 Dorsal Longitudinal Arch.- 15.1.3 Disordered Loading of Forefoot and Hindfoot.- 15.1.4 Transverse Displacement.- 15.2 Pathological Changes in Tissues.- 15.2.1 Soft Tissues.- 15.2.2 Bones.- 15.2.3 Joints.- 15.3 Physiological Pes Cavus.- 15.4 Idiopathic Acquired Pes Cavus.- 15.4.1 Etiology.- 15.4.2 Balanced Cavus Foot.- 15.4.3 Cavovalgus Foot.- 15.4.4 Cavovarus Foot.- 15.5 Neurological Pes Cavus.- 15.5.1 Anterior Cavus.- 15.5.2 Posterior Longitudinal Pes Cavus.- 15.6 Pes Equinocavus.- 15.7 Other Forms of Pes Cavus.- 15.7.1 Encephalitic Pes Cavus.- 15.7.2 Medullary Syndromes.- 15.7.3 Myopathic Pes Cavus.- 15.7.4 Polyneuritis.- 15.7.5 Post-Traumatic Pes Cavus.- 16 Pes Planovalgus.- 16.1 Idiopathic Pes Planovalgus.- 16.1.1 Summary of Aims of Treatment.- 16.1.2 Juvenile Pseudo Pes Planus.- 16.1.3 Juvenile Pes Planus.- 16.1.4 Adolescent Pes Planovalgus.- 16.1.5 Adult Pes Planovalgus.- 16.2 Congenital Pes Planovalgus.- 16.2.1 Congenital Convex Pes Planovalgus (Vertical Talus).- 16.2.2 Planovalgus with Tarsal Coalition.- 16.3 Post-Traumatic Pes Planovalgus.- 16.4 Myopathic Pes Planovalgus.- 16.5 Paralytic Pes Planovalgus.- 16.5.1 Poliomyelitis.- 16.5.2 Pes Planovalgus from Medial Popliteal Nerve Lesions.- 16.5.3 Flaccid Hemiplegia.- 16.5.4 Paralytic Pes Planovalgus from Spina Bifida.- 16.6 Spastic Flat Foot.- 16.6.1 Treatment.- 17 Disorders of the Toes.- 17.1 Nail Plate.- 17.1.1 Ingrown Toenail.- 17.1.2 Provence Nail.- 17.1.3 Spatulate Deformity.- 17.1.4 Onychodystrophy.- 17.1.5 Onychomycosis.- 17.2 Nail Bed.- 17.2.1 Subungual Exostosis.- 17.2.2 Subungual Chondroma.- 17.2.3 Angioneuromyoma.- 17.2.4 Subungual Corn.- 17.2.5 Subungual Haematoma.- 17.3 Nail Fold.- 17.3.1 Nail Fold Corn.- 17.3.2 Koenen Tumour.- 17.3.3 Para-Ungual Verruca.- 17.4 Skin.- 17.4.1 Digital Corn.- 17.4.2 Digital Verruca.- 17.4.3 Chilblain.- 17.5 Joints.- 17.5.1 Clawing of Great Toe.- 17.5.2 Clawing of Lesser Toe.- 17.5.3 Transverse Deformities: Clinodactyly.- 17.5.4 Dislocation.- 17.5.5 Osteochondral Fractures.- 17.6 Summary of Operative Procedures.- 18 Disorders of the Great Toe.- 18.1 Hallux Valgus.- 18.1.1 Description.- 18.1.2 Clinical Features.- 18.1.3 Treatment.- 18.1.4 Metatarsal Osteotomy.- 18.2 Hallux Varus.- 18.2.1 Description.- 18.2.2 Clinical Features.- 18.2.3 Treatment.- 18.3 Hallux Flexus.- 18.3.1 Description.- 18.3.2 Clinical Features.- 18.3.3 Treatment.- 18.4 Hallux Extensus and Hallux Erectus.- 18.4.1 Idiopathic Hallux Extensus.- 18.4.2 Iatrogenic Hallux Erectus.- 19 Quintus Varus.- 19.1 Description.- 19.2 Clinical Features.- 19.3 Treatment.- 20 Tarsalgia.- 20.1 Integument.- 20.1.1 Skin.- 20.1.2 Subcutaneous Tissue.- 20.1.3 Aponeurosis.- 20.2 Tendons and Tendon Sheaths.- 20.2.1 Partial Rupture.- 20.2.2 Tendinitis at Insertions.- 20.2.3 Stenosing Tenosynovitis.- 20.3 Capsules and Ligaments.- 20.4 Joints.- 20.4.1 Arthrosis.- 20.4.2 Specific Arthritides.- 20.5 Bones.- 20.5.1 Post-Traumatic Tarsalgia.- 20.5.2 Aseptic Necrosis of Talus.- 20.5.3 Solitary Cyst of Calcaneum.- 20.5.4 Retrocalcaneal Tarsalgia.- 20.6 Postural Tarsalgia.- 20.6.1 Extrinsic Causes.- 20.6.2 Intrinsic Conditions.- 20.7 Sites of Tarsalgia.- III Trauma and Arthrosis.- 21 Ligamentous Injuries of Ankle and Hindfoot.- 21.1 Classification.- 21.1.1 Eversion Injuries.- 21.1.2 Inversion Injuries.- 21.1.3 Pure Abduction Injuries.- 21.1.4 Pure Adduction Injuries.- 21.1.5 Plantarflexion Injuries.- 21.1.6 Dorsiflexion Injuries.- 21.2 Clinical Features.- 21.2.1 Severity.- 21.2.2 Pain.- 21.2.3 Swelling.- 21.2.4 Loss of Function.- 21.2.5 Talar Instability.- 21.3 Radiography.- 21.4 Treatment.- 21.4.1 Minor Injuries.- 21.4.2 Major Injuries.- 21.5 Late Complications.- 21.5.1 Functional Sequelae.- 21.5.2 Ligamentous Laxity with Subluxation of Talus.- 21.5.3 Vasomotor Conditions.- 21.5.4 Joint Complications.- 22 Post-Traumatic Osteoarthrosis.- 22.1 Toes.- 22.1.1 Etiology.- 22.1.2 Clinical Features.- 22.1.3 Treatment.- 22.2 Metatarsophalangeal Joints.- 22.2.1 Etiology.- 22.2.2 Clinical Features.- 22.2.3 Treatment.- 22.3 Complications of Metatarsal Fracture.- 22.4 Lisfranc Joint Line.- 22.5 Midtarsal Region.- 22.6 Tarsus.- 22.7 The Ankle.- 22.7.1 Ligamentous Injuries.- 22.7.2 Dorsiflexion Injuries.- 22.7.3 Contracture of Ankle Joint Without Joint Surface Involvement.- 22.7.4 Fractures of Malleoli.- 22.7.5 Avascular Necrosis of Talus and Osteochondritis Dissecans.- 23 Hallux Rigidus.- 23.1 Description.- 23.1.1 Bone.- 23.1.2 Cartilage.- 23.1.3 Periosteum.- 23.1.4 Capsule.- 23.2 Etiology.- 23.3 Clinical Features.- 23.3.1 First Degree.- 23.3.2 Second Degree.- 23.3.3 Third Degree.- 23.4 Treatment.- 23.4.1 Conservative.- 23.4.2 Operative.- 24 Freiberg-Kohler Avascular Necrosis.- 24.1 Etiology.- 24.2 Clinical Features.- 24.3 Treatment.- 24.3.1 Conservative.- 24.3.2 Surgical.- 25 Consequences of Failed Operative Treatment in the Antetarsus.- 25.1 Keller-Brandes and Lelievire Arthroplasties.- 25.2 Peg Implant Arthroplasties.- 25.3 McBride and Schede Procedures.- 25.4 Hueter-Mayo Amputation of First Metatarsal Head.- 25.4.1 Intact Phalangeal Base with Normal Articular Cartilage.- 25.4.2 Damaged Cartilaginous Surface of Phalangeal Base.- 25.4.3 Gross Resection of Metatarsal Head.- 25.5 Metatarsophalangeal Complications of Lesser Toes.- 25.6 Resection of Metatarsal Heads of Lesser Toes.- 25.7 Hohmann-Wallet Procedure.- IV Congenital Abnormalities.- 26 Congenital Displacements.- 26.1 Pes Talus.- 26.1.1 Etiology.- 26.1.2 Clinical Features.- 26.1.3 Treatment.- 26.2 Pes Valgus.- 26.2.1 Description.- 26.2.2 Treatment.- 26.3 Pes Varus.- 26.3.1 Description.- 26.3.2 Treatment.- 26.4 PesAdductus.- 26.4.1 Description.- 26.4.2 Clinical Features.- 26.4.3 Treatment.- 26.5 Pes Equinovarus.- 26.5.1 Etiology and Description.- 26.5.2 Clinical Features.- 26.5.3 Treatment.- 26.5.4 Treatment of Relapsed Pes Equinovarus.- 26.6 Congenital Vertical Talus (Convex Planovalgus Foot).- 26.6.1 Description.- 26.6.2 Etiology.- 26.6.3 Clinical Features.- 26.6.4 Treatment.- 27 Congenital Malformations.- 27.1 Aplasia.- 27.2 Hypoplasia.- 27.3 Hyperplasia.- 27.4 Polyplasia.- 27.5 Symplasia.- 27.5.1 Cutaneous Syndactyly.- 27.5.2 Osteocutaneous Syndactyly.- 27.5.3 Synostosis.- 27.6 Clinodactyly.- 27.7 Camptodactyly.- 27.8 Hallux Varus.- 28 Os Intermetatarseum.- V Trophic Disorders.- 29 Plantalgias of Vascular Origin.- 29.1 Venous Insufficiency.- 29.2 Arterial Insufficiency.- 29.2.1 Raynaud's Disease.- 29.2.2 Arteritis.- 29.2.3 Erythema Pernio.- 30 Neurodystrophic Metatarsalgia.- 30.1 Etiology.- 30.2 Clinical Features.- 30.2.1 Onset.- 30.2.2 Established Condition.- 30.2.3 Phase of Recovery.- 30.3 Atypical Forms.- 30.4 Differential Diagnosis.- 30.5 Treatment.- 31 Perforating Plantar Ulcer.- 31.1 Etiology.- 31.2 Clinical Features.- 31.3 Diagnosis.- 31.3.1 Past Medical History.- 31.3.2 Morphological Abnormalities of Foot.- 31.3.3 Vascular Supply.- 31.3.4 Laboratory Tests.- 31.3.5 Neurological Examination.- 31.3.6 Joint Involvement.- 31.3.7 Differential Diagnosis.- 31.3.8 Trophic Disorders.- 31.3.9 Postural Disorders of Foot.- 31.4 Treatment.- 31.4.1 Local Treatment.- 31.4.2 General Medical Treatment.- 31.4.3 Surgical Management.- 31.4.4 Orthopaedic Insoles.- 31.4.5 Rehabilitation.- 31.5 Specific Neurological Diseases.- 31.5.1 Bureau-Barriere Disease.- 31.5.2 Tabes Dorsalis.- 31.5.3 Thevenard's Disease.- 31.5.4 Syringomyelia.- 32 Diabetes Mellitus.- 32.1 Etiology.- 32.2 Clinical Features.- 32.3 Treatment.- VI Entrapment Syndromes.- 33 Tarsal Tunnel Syndrome.- 33.1 Etiology.- 33.2 Clinical Features.- 33.2.1 Neurological Disorders.- 33.2.2 Vascular Impairment.- 33.2.3 Trophic Disorders.- 33.2.4 Clinical Forms.- 33.3 Paraclinical Examination.- 33.4 Treatment.- 33.4.1 Conservative.- 33.4.2 Operative.- 34 Sinus Tarsi Syndrome.- 34.1 Anatomy and Etiology.- 34.2 Clinical Features.- 34.3 Treatment.- 34.3.1 Conservative.- 34.3.2 Operative.- 35 Morton Neuralgia.- 35.1 Anatomy and Etiology.- 35.2 Clinical Features.- 35.3 Treatment.- 35.3.1 Conservative.- 35.3.2 Operative.- VII Rheumatic Diseases.- 36 Rheumatoid Arthritis.- 36.1 Clinical Features.- 36.2 Radiography.- 36.3 Laboratory Investigations.- 36.4 Treatment.- 36.4.1 General Measures.- 36.4.2 Medical.- 36.4.3 Orthotic.- 36.4.4 Operative.- 37 Ankylosing Spondylitis.- 37.1 Clinical Features.- 37.2 Treatment.- 37.2.1 General.- 37.2.2 Insoles.- 37.2.3 Operative.- 38 Psoriatic Arthritis.- 38.1 Clinical Features.- 38.1.1 Cutaneous Manifestations.- 38.1.2 Nail Lesions.- 38.1.3 Osteoarticular Involvement.- 38.2 Treatment.- 38.2.1 Medical.- 38.2.2 Insoles.- 38.2.3 Operative.- 39 Gout.- 39.1 Acute Gout.- 39.1.1 Clinical Features.- 39.1.2 Treatment.- 39.2 Chronic Gout.- 39.2.1 Clinical Features.- 39.2.2 Treatment.- VIII Treatment.- 40 Insoles.- 40.1 Mode of Action.- 40.1.1 Corrective Elements.- 40.1.2 Supportive Elements.- 40.1.3 Relaxing and Load-Relieving Elements.- 40.1.4 Compensating Elements.- 40.2 Therapeutic Indications.- 40.2.1 Corrective Insoles.- 40.2.2 Compensating Supportive Antalgic Insoles.- 40.2.3 Supporting Compensating Insoles for Extrinsic Displacements.- 40.2.4 Load-Reducing Insoles.- 40.2.5 Special Supportive Insoles.- 41 Instrumentation, Technique, and Surgical Approach.- 41.1 Instrumentation.- 41.2 General Technique.- 41.3 Surgical Approaches.- 41.3.1 Great Toe.- 41.3.2 Lesser Toes.- 41.3.3 Forefoot.- 41.3.4 Tarsometatarsal Joints.- 41.3.5 Midtarsal Incisions.- 41.3.6 Tarsal Incisions.- 41.3.7 Ankle Joint.- 41.3.8 Tendons.- 41.3.9 Heel.- 41.3.10Cutaneous Lesions.- 42 Corrective Operations for Painful Syndromes of the Forefoot.- 42.1 Metatarsal Realignment.- 42.1.1 Indications.- 42.1.2 Technique.- 42.2 Trapezoidal Osteotomy.- 42.2.1 Indications.- 42.2.2 Technique.- 42.3 Head-Shaft Enclavement.- 42.3.1 Indications.- 42.3.2 Technique.- 42.4 Metatarsophalangeal Interposition Cup Arthroplasty.- 42.4.1 Indications.- 42.4.2 Technique.- 42.5 Prosthetic Replacement of Metatarsal Head.- 42.5.1 Indications.- 42.5.2 Technique.- 42.6 Elongation of First Metatarsal for Congenital or Acquired Shortness.- 42.6.1 Indications.- 42.6.2 Technique.- 42.7 V-Osteotomy of Metatarsals.- 42.7.1 Indications.- 42.7.2 Technique.- 43 Afterword.- 44 Historical Bibliography.- 45 References.- 46 Subject Index.