Orthopaediciq

Deformaties of the forefoot are the commonest abnormalities encountered in orthopaedic surgery.

A number of anatomically different deformities can slowly develop, and are differentiated conventially by terms such as “bunion”, “bunionette”, “claw toes”, “hammer toes”, “Morton’s neuroma”, “metatarsalgia”, “corns”, “calluses”, “hallux rigidus” and many more.

Many of these are demonstrated in this photograph. Notice two scars on each foot representing failed conventional surgery to bone,

One perception is that each of these deformaties is a distinct abnormality, and their management and various explainations of cause are offered as though they are independent of each other.

However they are all part of the same process, although one might appear earlier than another. A “bunion” might be treated successfully, only to be followed later by a “claw toe”, or a “neuroma” might be the first expression, to be later followed by other changes.

These deformities are mainly “age-related changes”, and develop progressively in most people as a factor of time. There is also a strong genetic component, and I have treated many families from great grand-mother to great grand-daughter. There appear to be different modes of genetic transmission, of which the commonest is mother to daughter, but other patterns have become apparent, including father to daughter, with a different anatomical presentation. There is also a gender bias towards the female, and although the typical changes do occur in males these are less frequent.

Diabetes, rheumatoid, and poor blood flow, as well as damage to muscle (sometimes via sport or dancing) appear to accelerate the changes of ageing.

“Primary” causes include a number of neurological conditions such as “hypertonic” changes (which typically appear in early adolescence) and poliomyelitis.

Finally there is a group in which “age related” changes compond the “primary” changes as the person ages.

Treatment. Conventionally orthopaedic surgeons, and for that matter, podiatric surgeons, have always considered that aligning the bones of the foot was the foundation on which correction of forefoot deformities was based. Therefore the bones are attacked surgically, and realigned. Whilst waiting for the bone fragments to heal these are held in place by pins, screws, plates or casts. Joints – often normal joints are excised, and the adjacent bones caused to join (“fused”) giving a stiff and (not always) straight toe.

This approach, to me, is irrational. There are no changes in the bones or joints. The deformities are produced entirely by contracting soft tissues. Bones, with only vary rare exceptions, cannot produce deformities.

Why, then, attack the bones? By so doing perfectly normal bone anatomy and perfectly normal joints are derranged or destroyed. Since bones take months, rather than weeks, to heal the convalescence is long  (and bone does not always heal!). Immobilisation in casts or splints for many weeks or months is necessary. Significant pain and convalescent incapacity occurs, and often a further surgery is fequired to remove the implanted plates and screws.

If surgery is required if is more rational to manage the prime cause, which is the soft tissue contraction. This is appealing since the foundation of the deformity is addressed. The complication rate is low  and recurrence is unheard of. Other benefits are the short convalescence, minimal pain (most people have no post operative pain), and minimal incapacity. The majority of patients walk out of hospital the same day, without needing casts, crutches, walking sticks, specialised footwear or wheelchairs.

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