Foot & Ankle International

In a 2-year period, 17 patients presented with 25 highly symptomatic neuromas which followed routine orthopaedic procedures on the dorsum of the foot. Most of the neuromas followed incisions made on the dorsomedial two-thirds or so of the midfoot. Three of the patients who refused surgery and were treated nonoperatively had mediocre results. Fourteen patients underwent surgery. Two early cases underwent neurolysis of spindle neuromas with satisfactory results but with some persistent pain and dysfunction. Spindle and bulb neuromas in the remaining 12 patients were widely excised with highly satisfactory results in 10 and unsatisfactory results in two. A functional anatomic study was carried out to determine the area of sensation supplied by the deep peroneal nerve. The results of this study along with a review of anatomical references was used to diagram the sensory distribution to the dorsum of the foot. These diagrams proved helpful in making accurate anatomic diagnoses of the nerves involved with neuromas prior to treatment. The incidence of incisional neuromas is higher than anticipated, and the disability from them can be as severe as those reported in the hand and wrist. Proper diagnosis and treatment are essential to relieve this disability.

In 6 years through 1982, the authors performed 34 operative cases in 26 patients with recalcitrant heel pain. The operative procedure involves an isolated neurolysis of the mixed nerve supplying the abductor digiti qpinti muscle as it passes beneath the abductor hallucis muscle and beneath the medial ridge of the calcaneus. The deep fascia of the abductor hallucis muscle is released routinely, and an impinging heel spur or tight plantar fascia is partially removed or released if it is causing entrapment of the nerve. The biomechanical pathogenesis of heel pain in relation to pes planus and pes cavus predisposing to an entrapment neuropathy is described, and the anatomy of the heel in relation to the nerve distribution is clarified and well illustrated.

Of the 34 operated heels, 32 had good results and two had poor results. Heel pain can cause total disability in the working population and may jeopardize one's employment or professional athletic career. The authors believe operative treatment has a place in the care of recalcitrant heel pain and that an entrapment neuropathy is an etiological factor in heel pain.

Sixteen patients with duplication of the hallux were reviewed. Follow-up averaged 21 years. Duplication may be classified into three groups: simple hallucal duplication, a transitional type with a short thick first metatarsal, and complete first ray duplication. Routine removal of the most medial hallux or ray is to be avoided. Careful preoperative assessment is necessary to compare hallucal function, cosmesis, and metatarsal weightbearing. Surgery should also correct the associated congenital hallux varus. Surgical complications include functionless hallucis from inappropriate selection and medial soft tissue contractures with either recurrence of the hallux varus or the gradual development of a hallux varus interphalangeus.

The results of 59 surgical procedures for correction of spastic equinovarus deformity of the foot using the split anterior tibial tendon (SPLATT) were reviewed in 54 adults with traumatic head injury. The mean time of follow-up was 49.7 months. Thirty-nine individuals had hemiplegic involvement, three had triplegic involvement, and 12 were quadriplegic. Evaluation of the patterns of lower extremity muscle activity preoperatively by dynamic electromyography in 33 patients showed no significant difference from that seen in the hemiplegic stroke population, namely, spastic calf muscles with overactive toe flexors and anterior tibial muscle. At follow-up all feet were in a plantigrade position. The only complication was a superficial skin slough on the dorsum of the foot which healed uneventfully. Postoperatively, 18 extremities (31%) were brace-free. Forty-one extremities required support because of calf weakness, ataxia, or proprioceptive deficits. Of the 15 patients who were nonambulatory prior to surgery, nine (60%) became ambulatory. At follow-up 36 patients (67%) were independent ambulators, four (7%) required supervision assistance, two (4%) required standby assistance, and six (11%) required minimal assistance. The six individuals (11%) who remained maximally assisted or nonambulatory had improved wheelchair positioning and shoe wear. These results show that the split anterior tibial tendon transfer is a safe and effective procedure for the head trauma patient since it corrects the equinovarus deformity, allowing for improved shoe wear and wheelchair positioning in the nonambulatory individual and improved ambulation with decreased brace wear in the more functional patient.

An osteotomy of the lateral malleolus for rerouting the peroneal tendons in cases of acute or recurrent dislocation is described. This technique, which does not compromise the stability of the ankle joint or the excursion of the peroneal tendons, allows an early return to full activity with no loss of function.

A case of painful calcification within a sesamoid bursa of the great toe is presented. This may be the first description of painful calcification of this site.