Excisions of the Tarsus and Osteoplastic Excision of the Heel.
—Removal of the tarsal bones is confined usually to cases of tuberculous disease, and may be performed by a variety of methods. Thus the tissues of the sole of the foot may be divided transversely by an incision carried from the tubercle of the scaphoid beneath the sole and across to a point one inch behind the base of the metatarsal. Through this, access can be made to the inferior surface of the tarsus. Conversely the upper portion may be exposed by a similar transverse incision across the dorsum of the foot, by lateral incisions, or by a combination of both. It is seldom necessary to divide the tendons, it being nearly always possible to gather them into a group and lift them out, while the bones are attacked with a sharp spoon or a chisel.
Occasionally the calcis becomes involved in cancerous or tuberculous disease and it would appear that removal of the heel proper would be all that is required. To meet these indications Wladimirov, in 1871, and Mikulicz, in 1880, independently devised a method by which the ankle-joint may be opened and as much of the heel and adjoining tarsus as necessary removed, the foot being later fixed in the extreme equinus position. This is referred to as osteoplastic excision or amputation of the heel. [Fig. 222] illustrates the line of incision, which extends from the tubercle of the scaphoid beneath the heel to a point on the opposite side, then obliquely upward and backward to the base of each malleolus, and then transversely and posteriorly, thus including within its line the region of the heel. These incisions extend to the bone, the ankle-joint is opened posteriorly, the lateral ligaments divided, the lower extremities of the tibia and fibula removed with a saw, the astragalus and calcis separated from their attachments, and the posterior articular surfaces of the scaphoid and cuboid also removed. The lines of division of bone are indicated by dotted lines in [Fig. 222]. Thus the lower ends of the leg bones are brought into contact with the upper end of the divided tarsus by straightening the foot in the extreme equinus position and maintaining this position with wire sutures or bone or metal pins.
Fig. 221
König’s incision for excision of the ankle.
Fig. 222
Osteoplastic excision of the foot. (Mikulicz.)
The cases in which this method is of use are rare, but when indicated it has usually given satisfactory results. It is a substitute for amputation of the leg, and it is often an open question as to which will give the most satisfactory result. It has probably not been practised a hundred times.