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Osteotomies of the ankle and foot
The Foot (1993) 3, 46-48
Osteotomies of the ankle and foot J. Kirkup
Wedge excision of the lower femur to correct knee flexion contracture, pioneered by Barton of Philadelphia in 1837,’ signalled the introduction of a further operative technique fundamental to surgery of the locomotor system. Unlike subcutaneous tenotomy and joint excision, the acceptance of osteotomy was delayed for several decades, due to associated interoperative bone infection, morbidity and death. Nevertheless in 1853, Mayer of Wurzburg successfully corrected several knock-knee deformities by lower femoral and upper tibia1 osteotomies.’ It was left to Macewen of Glasgow to make osteotomy safe and routine, from 1878, by a rigorous antiseptic approach.3 Application to the foot was a later development, perhaps because of its particular bony anatomy and lack of angular deformity at any one site. Most foot osteotomies achieve correction by opening or closing a bony wedge, with the exception of linear overlap through the metatarsal shafts.
deflected upward and forward, and the weight pressure is placed upon the posterior instead of the inferior surface of the heel.” Meanwhile for structural varus of club foot, Phelps of New York recommended extensive soft tissue release, wedge resection of the calcaneum and osteotomy of the neck of the talus, in 1891.8 This was criticized by Elmslie of London in 1920 who nevertheless osteotomized the anterior calcaneum and if necessary the talar neck with or without lengthening of the tendo calcaneus.’ Calcaneal osteotomy was revived again in 1963 by Dwyer of Liverpool who inserted a wedge from the medial side: ‘. . . based upon the belief that the persistence of a small inverted heel in a club-foot is the essential factor in preventing complete correction and that it promotes relapse.“’
Recently, lateral wedges have been inserted for severe rheumatoid hindfoot valgus.
TIBIA AND FIBULA OTHER TARSAL BONES Correction of severe equinus was accomplished, by Berend of Berlin, in 1861 by osteotomy of the lower tibia and fibula, but only after 5 months of wound sepsis.4 Since, only sporadic supramalleolar correction has been undertaken, most recently for ankle joint valgus due to advanced rheumatoid arthritis.
In 1893 Stokes of Dublin reported correction of flat foot by talar osteotomy, removing a medial wedge from the neck of the bone” which Jones of Liverpool and Lovett of Harvard continued to recommend in 1929;” the hazard of talar necrosis is not mentioned. Most tarsal wedge osteotomies distal to the calcaneum and talus inevitably disturb joints and induce their fusion, even when the prime objective is correction of deformity rather than stabilization. To correct a severe flat foot, possibly due to tarsal synostosis, Golding-Bird of London excised the navicular and osteotomized the tarsus by transverse saw division in 1889.13 Lateral wedge tarsectomy for club foot, recommended by Davy of London in 1885 after 10 years experience, I4 has since proved the final remedy for persistent deformity, usually centred on the midtarsal joint. Dorsal tarsectomy at the same level corrects severe cavus deformity; this excision formed part of Jones of Liverpool’s operation for paralytic calcaneo-
CALCANEUM In 1883, Gleich of Vienna corrected structural foot valgus by an oblique osteotomy shifting the heel portion distally and medially.5 This was approved by Steindler of Iowa6 who in 1938, devised a rotation osteotomy of the calcaneum combined with tendo calcaneus lengthening for resistant painful spurs. He wrote: ‘The operative plan is to rotate the posterior process of the OS calcis so that its lowermost point is 46
Osteotomies of the ankle and foot
cavus in 1908.15 Wedge excisions centred at tarsometatarsal level avoid damaging the more mobile midtarsal joint although deformity is usually maximal at the latter.
as Helal later otomies’.26
termed
them,
‘telescoping
47
oste-
PHALANGES METATARSALS
Distal osteotomy of the first metatarsal for hallux valgus was advocated by Reverdin of Geneva in 1881l6 and, undertaken about the same time by Barker of London at the suggestion of C. Hoar, one of his students,17 either with or without wedge excision. The procedure was greatly refined by Hohmann of Munich in 192318 and many variations have been designed since, including proximal osteotomy. Basal osteotomy of the first to fourth metatarsals for resistant metatarsus varus was undertaken by Lange of Munich in 195 1,I9 and of all five by Steytler and Van Der Walt of Stellenbosch in 1966;” in 1971 Berman and Gartiand of Philadelphia recommended dome-shaped osteotomies and temporary wire fixation of the first and fifth as the procedure of choice after 6 years of age.” Severe metatarsalgia was treated by Meisenbach of Buffalo in 1916 by transverse shaft osteotomies and dorsal tilt of the metatarsal heads (Figure).22 This was modified by Borggreve of Germany in 1949 who excised a dorsal wedge from the shaftz3 and, in 1968, Gagnon of Canada advocated the advantages of an oblique osteotomy near the base of the metatarsal.24 In 1975. Helal of London suggested better correction with an oblique osteotomy in the distal half of the central metatarsals and reported a series commencing in 1967; osteotomies of the first and fifth metatarsals were cut to displace towards the central three. 25 Early weight bearing was encouraged in order to leve! the tread by what were in effect floating osteotomies or,
Figure
For adolescent hallux rigidus, Kessel & Bonney of London recommended dorsal wedge excision osteotomy of the proximal phalangeal base of the hallux, in 1958.27 For terminal valgus of the hallux, Regnauld advocated excision osteotomy of the proximal phalanx close to the interphalangeal joint in 1974.2R
References 1. Barton J R. A new treatment in a case of anchylosis. Am J Med Sci 1837: 21: 332-340. 2. Mayer J A. Die osteotomie, ein neuer Beitrag zur operativen OrthopCdik. Illustr Med Zeit 1852: 2: l-28, 65-80. 3. Macewen W. On osteotomy for genu valgum, varum and ricketic curves. Lancet 1878: i: 449, ii: 911. 4. Berend H W. Application de I’ost&omie a l’orthopt-die. Gaz Hebdomaire de Med de Chir 1861: 8: 203. 5. Gleich A. Beitrag zur operativen plattfussbehandlung. Arch f Klin Chir 1883; 46: 358-362. 6. Steindler A. Orthopedic operations. Springfield: Thomas, 1940: 216. 7. Steindler A. Smith A R. Spurs of the OScalcis. S G Obs 1938; 66: 663. 8. Phelps A M. The present status of the open incision method for TVE. New Engl Med Mon 1891; 10: 217. 9. Elmslie J. The principles of treatment of congenitai tale-equino-varus. J Orthop S 1920; 2: 669-686. 10. Dwyer F C. The treatment of relapsed club foot by the insertion of a wedge into the calcaneum. J Bone Joint Surg 1963; 6lB: 67-75. 11. Stokes W. Remarks on flat foot. B M J 1894; ii: 1224-1226. 12. Jones R. Lovett R. Orthopedic surgery. Oxford: Milford, 1929: 629. 13. Golding-Bird C H. Operations on the tarsus in confirmed flat-foot. Lancet 1889; i: 677-678. 14. Davy R. Observations on the radical cure of clubfoot, Med Chir Trans 1885; 68: 139-145. 15. Jones R. An operation for paralytic calcaneo-cavus. Am J Orthop Surg 1908; 5: 371-376. 16. Reverdin J. De la dtviation en dehors du gros orteil et de son traitement chirurgical. Trans Int Med Congr London 1881; 2: 408. 17. Barker A E. An operation for hallux valgus. Lancet 1884; i: 665. 18. Hohmann G. ijber Hallux valgus und Spreifuss. Arch f Orth u UnfalI Chir 1923; 21: 525. 19. Lange M. Orthopidische-Chirurgische Operationslehre. Munchen: Bergmann. I95 I. 20. Steytler J C S, Van der Walt I D. Correction of resistant adduction of the forefoot m congenital clubfoot and congenital metatarsus varus by metatarsal osteotomy. Br J Surg 1966; 588-560. 21. Berman A, Gartland J J. Metatarsal osteotomy for the correction of the fore part of the foot in children. J Bone Joint Surg 1971; 53A: 498-506. 22 Meisenbach R 0. Painful anterior arch of the foot: an operation for its relief by means of raising the arch. Am J Orthop Surg 1916; 14: 206-211. 23 Borggreve J. Zur operativen Behandlung des kontrakten spreizfuss. Zeitsch f orthop und i Grenzengebiete 1949; 78: 581-582. 24 Gagnon P A. L’ost&otomie mbtatarsienne oblique
48 The Foot
25. 26.
27. 28.
dam le traitement chirurgical de la ktratose plantaire. Union Med Can 1968; 97: 32-36. Helal B. Metatarsal osteotomy for metatarsalgia. J Bone Joint Surg 1975; 57A: 187-192. Helal B, Greiss M. Telescoping osteotomy for pressure metatarsalgia. J Bone Joint S 1984; 66B: 213-217. Kessel L, Bonney G. Hallux rigidus in the adolescent. J Bone Joint Surg 19.58;40B: 668-673. Regnauld B. Techniques chirurgicales du pied. Paris: Masson, 1974: 13.
The author John R. Kirkup Weston Hill 1 Weston Park East Bath BAl 2XA UK
Osteotomies of the ankle and foot J. Kirkup
Wedge excision of the lower femur to correct knee flexion contracture, pioneered by Barton of Philadelphia in 1837,’ signalled the introduction of a further operative technique fundamental to surgery of the locomotor system. Unlike subcutaneous tenotomy and joint excision, the acceptance of osteotomy was delayed for several decades, due to associated interoperative bone infection, morbidity and death. Nevertheless in 1853, Mayer of Wurzburg successfully corrected several knock-knee deformities by lower femoral and upper tibia1 osteotomies.’ It was left to Macewen of Glasgow to make osteotomy safe and routine, from 1878, by a rigorous antiseptic approach.3 Application to the foot was a later development, perhaps because of its particular bony anatomy and lack of angular deformity at any one site. Most foot osteotomies achieve correction by opening or closing a bony wedge, with the exception of linear overlap through the metatarsal shafts.
deflected upward and forward, and the weight pressure is placed upon the posterior instead of the inferior surface of the heel.” Meanwhile for structural varus of club foot, Phelps of New York recommended extensive soft tissue release, wedge resection of the calcaneum and osteotomy of the neck of the talus, in 1891.8 This was criticized by Elmslie of London in 1920 who nevertheless osteotomized the anterior calcaneum and if necessary the talar neck with or without lengthening of the tendo calcaneus.’ Calcaneal osteotomy was revived again in 1963 by Dwyer of Liverpool who inserted a wedge from the medial side: ‘. . . based upon the belief that the persistence of a small inverted heel in a club-foot is the essential factor in preventing complete correction and that it promotes relapse.“’
Recently, lateral wedges have been inserted for severe rheumatoid hindfoot valgus.
TIBIA AND FIBULA OTHER TARSAL BONES Correction of severe equinus was accomplished, by Berend of Berlin, in 1861 by osteotomy of the lower tibia and fibula, but only after 5 months of wound sepsis.4 Since, only sporadic supramalleolar correction has been undertaken, most recently for ankle joint valgus due to advanced rheumatoid arthritis.
In 1893 Stokes of Dublin reported correction of flat foot by talar osteotomy, removing a medial wedge from the neck of the bone” which Jones of Liverpool and Lovett of Harvard continued to recommend in 1929;” the hazard of talar necrosis is not mentioned. Most tarsal wedge osteotomies distal to the calcaneum and talus inevitably disturb joints and induce their fusion, even when the prime objective is correction of deformity rather than stabilization. To correct a severe flat foot, possibly due to tarsal synostosis, Golding-Bird of London excised the navicular and osteotomized the tarsus by transverse saw division in 1889.13 Lateral wedge tarsectomy for club foot, recommended by Davy of London in 1885 after 10 years experience, I4 has since proved the final remedy for persistent deformity, usually centred on the midtarsal joint. Dorsal tarsectomy at the same level corrects severe cavus deformity; this excision formed part of Jones of Liverpool’s operation for paralytic calcaneo-
CALCANEUM In 1883, Gleich of Vienna corrected structural foot valgus by an oblique osteotomy shifting the heel portion distally and medially.5 This was approved by Steindler of Iowa6 who in 1938, devised a rotation osteotomy of the calcaneum combined with tendo calcaneus lengthening for resistant painful spurs. He wrote: ‘The operative plan is to rotate the posterior process of the OS calcis so that its lowermost point is 46
Osteotomies of the ankle and foot
cavus in 1908.15 Wedge excisions centred at tarsometatarsal level avoid damaging the more mobile midtarsal joint although deformity is usually maximal at the latter.
as Helal later otomies’.26
termed
them,
‘telescoping
47
oste-
PHALANGES METATARSALS
Distal osteotomy of the first metatarsal for hallux valgus was advocated by Reverdin of Geneva in 1881l6 and, undertaken about the same time by Barker of London at the suggestion of C. Hoar, one of his students,17 either with or without wedge excision. The procedure was greatly refined by Hohmann of Munich in 192318 and many variations have been designed since, including proximal osteotomy. Basal osteotomy of the first to fourth metatarsals for resistant metatarsus varus was undertaken by Lange of Munich in 195 1,I9 and of all five by Steytler and Van Der Walt of Stellenbosch in 1966;” in 1971 Berman and Gartiand of Philadelphia recommended dome-shaped osteotomies and temporary wire fixation of the first and fifth as the procedure of choice after 6 years of age.” Severe metatarsalgia was treated by Meisenbach of Buffalo in 1916 by transverse shaft osteotomies and dorsal tilt of the metatarsal heads (Figure).22 This was modified by Borggreve of Germany in 1949 who excised a dorsal wedge from the shaftz3 and, in 1968, Gagnon of Canada advocated the advantages of an oblique osteotomy near the base of the metatarsal.24 In 1975. Helal of London suggested better correction with an oblique osteotomy in the distal half of the central metatarsals and reported a series commencing in 1967; osteotomies of the first and fifth metatarsals were cut to displace towards the central three. 25 Early weight bearing was encouraged in order to leve! the tread by what were in effect floating osteotomies or,
Figure
For adolescent hallux rigidus, Kessel & Bonney of London recommended dorsal wedge excision osteotomy of the proximal phalangeal base of the hallux, in 1958.27 For terminal valgus of the hallux, Regnauld advocated excision osteotomy of the proximal phalanx close to the interphalangeal joint in 1974.2R
References 1. Barton J R. A new treatment in a case of anchylosis. Am J Med Sci 1837: 21: 332-340. 2. Mayer J A. Die osteotomie, ein neuer Beitrag zur operativen OrthopCdik. Illustr Med Zeit 1852: 2: l-28, 65-80. 3. Macewen W. On osteotomy for genu valgum, varum and ricketic curves. Lancet 1878: i: 449, ii: 911. 4. Berend H W. Application de I’ost&omie a l’orthopt-die. Gaz Hebdomaire de Med de Chir 1861: 8: 203. 5. Gleich A. Beitrag zur operativen plattfussbehandlung. Arch f Klin Chir 1883; 46: 358-362. 6. Steindler A. Orthopedic operations. Springfield: Thomas, 1940: 216. 7. Steindler A. Smith A R. Spurs of the OScalcis. S G Obs 1938; 66: 663. 8. Phelps A M. The present status of the open incision method for TVE. New Engl Med Mon 1891; 10: 217. 9. Elmslie J. The principles of treatment of congenitai tale-equino-varus. J Orthop S 1920; 2: 669-686. 10. Dwyer F C. The treatment of relapsed club foot by the insertion of a wedge into the calcaneum. J Bone Joint Surg 1963; 6lB: 67-75. 11. Stokes W. Remarks on flat foot. B M J 1894; ii: 1224-1226. 12. Jones R. Lovett R. Orthopedic surgery. Oxford: Milford, 1929: 629. 13. Golding-Bird C H. Operations on the tarsus in confirmed flat-foot. Lancet 1889; i: 677-678. 14. Davy R. Observations on the radical cure of clubfoot, Med Chir Trans 1885; 68: 139-145. 15. Jones R. An operation for paralytic calcaneo-cavus. Am J Orthop Surg 1908; 5: 371-376. 16. Reverdin J. De la dtviation en dehors du gros orteil et de son traitement chirurgical. Trans Int Med Congr London 1881; 2: 408. 17. Barker A E. An operation for hallux valgus. Lancet 1884; i: 665. 18. Hohmann G. ijber Hallux valgus und Spreifuss. Arch f Orth u UnfalI Chir 1923; 21: 525. 19. Lange M. Orthopidische-Chirurgische Operationslehre. Munchen: Bergmann. I95 I. 20. Steytler J C S, Van der Walt I D. Correction of resistant adduction of the forefoot m congenital clubfoot and congenital metatarsus varus by metatarsal osteotomy. Br J Surg 1966; 588-560. 21. Berman A, Gartland J J. Metatarsal osteotomy for the correction of the fore part of the foot in children. J Bone Joint Surg 1971; 53A: 498-506. 22 Meisenbach R 0. Painful anterior arch of the foot: an operation for its relief by means of raising the arch. Am J Orthop Surg 1916; 14: 206-211. 23 Borggreve J. Zur operativen Behandlung des kontrakten spreizfuss. Zeitsch f orthop und i Grenzengebiete 1949; 78: 581-582. 24 Gagnon P A. L’ost&otomie mbtatarsienne oblique
48 The Foot
25. 26.
27. 28.
dam le traitement chirurgical de la ktratose plantaire. Union Med Can 1968; 97: 32-36. Helal B. Metatarsal osteotomy for metatarsalgia. J Bone Joint Surg 1975; 57A: 187-192. Helal B, Greiss M. Telescoping osteotomy for pressure metatarsalgia. J Bone Joint S 1984; 66B: 213-217. Kessel L, Bonney G. Hallux rigidus in the adolescent. J Bone Joint Surg 19.58;40B: 668-673. Regnauld B. Techniques chirurgicales du pied. Paris: Masson, 1974: 13.
The author John R. Kirkup Weston Hill 1 Weston Park East Bath BAl 2XA UK