Foot & Ankle International

In this retrospective study of 96 Mitchell first-metatarsal osteotomies performed on 69 patients with an average follow-up of 7 years, we found that more than 86% were completely satisfied and that the procedure was equally effective in all age groups. Excessive first metatarsal shortening, dorsiflexion of the osteotomy, and failure to correct the intermetatarsal angle to 10° or less correlated with poorer results. This study demonstrates a relationship between metatarsal shortening and osteotomy plan-tarflexion. Gait analysis demonstrated that these patients do not have normal foot mechanics postoperatively.

An analysis of nine replantations of completely amputated lower limbs is presented in this paper. Four cases were successful, including two at the level of the distal third of the tibia, one through the midfoot, and one at the proximal third of the tibia. The latter case involved the replantation of the shortened limb followed by a Syme's amputation of the foot to preserve a functional below-knee amputation level. In each successful case protective sensibility, bony union, and a stable stance and functional gait has been achieved, thereby eliminating a prosthetic requirement.

Four cases are presented of astragular arthrosis treated with substitution of the entire astragalus with a prosthesis identical in form to that bone. The four cases were due to severe fracture, avascular necrosis, and degenerative joint disease. One patient died of a heart attack 6 months after the operation, the other three cases, one of them with a 6-year follow-up, present a good result. The presentation is made to illustrate the clinical progress of treatment of talar arthroses.

Previous guidelines suggested that children age 2 to 6 years require a shoe size change every 1 to 2 months. Our study of foot growth in 112 children enrolled in a prospective treatment protocol for flatfoot demonstrates that children age 12 to 30 months will require shoe size change every two to three months but that foot growth slows over the subsequent four years, necessitating shoe size change only every 4 months in children up to 4 years of age and every 6 months in children from age 4 to 6 years.

Fifty-one arthrogrypotic feet have been treated and followed by the Pediatric Orthopaedic Unit, Tufts New England Medical Center, (1970–1980). Forty of the 51 feet presented as equinovarus with the residual divided among metatarsus adductus, vertical tali, and calcaneo-valgus. Equinovarus deformities are the most resistant in all cases. Corrective casts are applied for at least the first 3 months of life. Surgical procedures were then initiated with any evidence of lack of progression of treatment. Varus and equinus were treated by an extensive posterior and medial release. Lateral soft tissue releases in addition to calcaneocuboid fusion or cuboid osteotomy were necessary in 24 of the 70 operations. Recurrence rate has been a problem in the simple type of posterior release including only an Achilles tendon lengthening, and posterior capsulotomy of the ankle and subtalar joint. Tal-ectomy has been carried out in four feet and appears to be one type of reasonable salvage procedure in smaller children with recurrent varus. Treatment is difficult in these patients but a plantigrade foot should be achieved in all cases.

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.

The biomechanical evaluation of patients with painful heels has received only limited attention although the potential morbidity and disability associated with such an ailment can be severe. An objective analysis of the patient's foot function during gait can produce useful information to assess the underlying pathology. This method can also help to evaluate the efficacy of various existing treatment protocols. The impulse distribution based on foot-floor vertical reaction force and time under the hind-, mid-, and forefoot was determined in 32 normal subjects while walking in their usual street shoes. Variations related to shoe types were noted, with high heeled shoes causing the most significant deviations from normal.

The same technique was applied to 13 painful heel syndrome patients. Characteristic deviations from the normal impulse distribution were noted in these patients which provided the basis for differentiating the pathological condition between the patients with painful heel pads and those with plantar fasciitis. The effectiveness of using heel cups as a therapeutic device was also assessed. Although significant gait changes were not associated with the insertion of heel cups, they did seem to shift the foot-floor impulse forward from the heel region, which made them effective in patients afflicted with localized heel pain, but not in those with plantar fasciitis.

A retrospective study of 56 patients upon whom 76 inter-digital neuromas were excised was carefully evaluated. There were 53 females and 3 males, with an average age of 55 years. The main preoperative symptom was pain in the plantar aspect of the foot which was increased by walking and relieved by rest. The main preoperative physical finding was that of tenderness in the involved interspace. There were an equal number of interdigital neu-romas removed from the second and third interspace. Postoperatively 65% of patients still noted some local plantar tenderness, and 68% noted numbness in the interspace. Postoperatively 80% of the patients were subjectively improved.