Surgery, with Special Reference to Podiatry

by Maximilian Stern; Edward Adams

Pathology. The displacement outward (which reaches 30 to 40 degrees in the average case and may reach 90 degrees) of the phalangeal part of the great-toe joint, uncovers the inner part of the head of the metartarsal bone, and here the cartilage degenerates, and the bone becomes condensed at its outer part. The inner lateral ligament is lengthened and thickened and the sesamoid bones become displaced outward and are often thickened.

Under the skin, at the inner and prominent aspect of the foot, is to be found a bursa, which is liable to inflammation under pressure, and is known as a bunion. The inflammation in this sac may extend to the joint and thus disintegrate it.

Symptoms. The toe is displaced outward and a reddened and shiny condition of the thickened skin exists over the inner prominence and perhaps over the top of the toe joint. The great toe if seriously displaced, must lie over or under the other toes, the former being the more common position. In other cases the second toe may be crowded up as a hammertoe. The joint is painful and the inner toes, being crowded to the outer side of the foot, are the seat of corns and callosities. Flat foot is frequently associated with this condition.

Treatment. In mild cases, the stocking should be split to allow a separate stall for the great toe, and broad toed boots should be worn. If flat foot exists, a support should be supplied for its aid in restoring the position of the great toe. In severe cases, nothing short of an operation is likely to be of value. A toe-post may be worn for a time in mild cases.

Amputation of the head of the metatarsal bone gives uniformly good results.

The toe is straightened and flexible; ankylosis with this operation does not occur.

In operations for hallux valgus there are two distinct purposes acting as determining factors in making a choice in a given case as to which is indicated. These are: (1)the radical operation for the correction of the deformity, and (2)the palliative operation for the alleviation of symptoms by the removal of the hypertrophied portion of the metatarsal head which is exposed to pressure. Among operations in the first mentioned class, the one known as the Mayo operation is, in all probability, the best. The entire head of the metatarsal is amputated, and the bursa is turned in over the cut end of bone, to diminish the amount of shortening and to prevent ankylosis of the joint. This latter consideration, however, is an unnecessary one, for in operations within this joint, ankylosis does not occur when the synovial surface of the phalanx is left undisturbed, even when the bursa is not employed as an intervening pad.

In the other class of operations for the relief of symptoms, no attempt is made to straighten the toe. A wedge-shaped piece of the exostosis is removed, against which pressure has caused symptoms.

A palliative operation devised by Dr. Robert T. Morris of this city, is one easy of accomplishment and serves every purpose where a radical operation is interdicted. It is known as the “button-hole” operation because of the fact that only a small incision is made immediately above the protuberant bone through which a sharp chisel is inserted, cutting off the offending “button” of bone.

An operation which in the hands of the authors has proven of distinct value, and which has probably not been previously described eliminates both the deformity and its painful symptoms. This operation which is described below, is less severe than other radical operations and not very much more so than the usual palliative ones.