FLAT

A PRELIMINARY REPORT
B. S. From
JONES,

FOOT
AN OPERATION
SOUTH

OF
CAPE

FOR
AFRICA

SEVERE

CASES

TOWN,

the Princess

Alice

Orthopaedic

Hospital,

Cape

Town

The pathogenesis of flat foot and its operative correction for severe cases are reviewed. The importance of the medial plantar fascia in maintaining the sfructural integrity of the foot is emphasised. Reinforcement of an incompetent plantar fascia by separating the inner half of the calcaneal tendon and attaching it to the neck of the first metatarsal has given results in three patients that were satisfactory at two, six and seven years later.
It is now generally accepted that the integrity of the longitudinal arch and the stability of the weight-bearing foot are derived mainly from the intrinsic structural strength, materially maintained both bony and ligamentous, dependent on muscle action. that under defined conditions assumes that the same the loaded and are not Rose (1962) a particular posture, and foot can, at The young childhood will eventually produce this undesirable cause state,

and this is believed flat foot.

to be the common

of structural

PREVENTION
child will

OF
inevitably

FLAT
outgrow

FOOT
the postural

foot under load always Jones (1941) demonstrated

any rate for a short time, support thrice without structural failure. it is therefore overloading in adult life as a result, obesity although or pregnancy such crises is a significant of excessive in the already normal foot. stress

the body weight doubted whether for instance, of cause may of flat foot, precipitate or, indeed,

determinants ofits pronated feet, and to prevent the latter from graduating to a state of structural collapse it is merely necessary, during the interim period, to protect the ing integrity of the weight-bearing medial plantar in pronation. structures by preventThe Helfet heelseat the vertical body laterally against acts into both

symptoms of foot strain even in the structurally

flat foot

purports weight

to achieve this into a horizontal

by converting force directed

On the other hand pronated feet are of common occurrence in early childhood, at which time joint flexibility, as in the metacarpo-phalangeal joints or elbows, is usually greater than at later ages. The feet may well share in this the pronated laxity, and feet of this to such age-group structural may immaturity reasonably be

sustentaculum and talus, while the Schwartz meniscus as a wedge to prevent the calcaneus from rolling valgus at the calcaneo-contact joint (Rose 1958); supports too often lack the strength Rose medial and rigidity breakage or distortion. while a raise under the ineffective, metatarsal the heel simplest raise in association head it does expedient until such neutral, of such

to resist

(1962) demonstrated that, part of the heel is in itself

attributed. The condition is often associated with postural knock-knee, and yet a supinated foot with an inverted heel is the normal concomitant of genu valgum, as, for example, that of rachitic be surmised that the pronated counter-thrust surface, is the knock-knee. Under usually normal passive windlass cause degree index plete other merely irreparably
B. S. Jones,

with a raise under the first correct the pronated foot. Thus is to prescribe a medial sole and foot as a structurally mature

time

origin. foot,

It may therefore by realigning the calcaneo-contact of the postural such feet can, and

and a normal, In the absence

weight-bearing a precautionary

habit is acquired. measure adopted will go flat foot. or experienced as military through In most only service,

from cause

the ground at the of the development circumstances structural Standing maturity on the

from the earliest life with a varying patients symptoms times during

age, many patients degree of structural are absent, trivial such stress,

favourable

ofexceptional

do, achieve posture. extension action

and a more or less ball of the foot or virtue (Hicks of the 1954), The is an

and are then relieved by the appropriate shoe alteration. Thus, operative measures for the correction of structural flat foot are reserved cannot be controlled more or less disabling anticipated. for cases so severe that the pronation by a medial shoe raise, and when symptoms are present or to be

of the big toe will, by of the strong plantar fascia

the heel to invert and restore to which this phenomenon of the absence medial integrity indicates plantar and Prolonged,
M.Ch.Orth.,

the visible arch. can be elicited fascia, stretching The foot but and

of the

plantar

its com-

irreversible structures. pronated

of this and is no longer and in

Princess

CURRENT
Bringing contact
Alice

OPERATIVE
heel and the counter-force

PROCEDURES
at the subtalar
Retreat, Cape

immature flat.
M.D.,

structurally weight-bearing
Senior Specialist,

the joint
Orthopaedic

calcaneoaxis by

pronated
F.R.C.S.E.,

medially

in relation
White

to the
Road,

Hospital,

Town,

South
VOL.

Africa.
57-B, No. 3, AUGUST

1975

279

280 open process wedge elevation and of the Hill posterior by calcaneal oblique,

B. S. JONES

articular lateral and

(Baker

1964),

in the angle between the calcaneal so some structural improvement in its Rose (1962) characteristic pointed out that weight-bearing

axis in the

and the floor and longitudinal arch. foot tarsothe the the

open wedge osteotomy of the calcaneus (Lord 1923; Dwyer 1961 ; Silver, Simon, Spindell, Lichtman and Scala 1967) or by medial displacement osteotomy (Koutsougiannis 1971) have given gratifying results in mild or moderate cases. With the valgus heel corrected, weightbearing in pronation load from the medial relief of the symptoms do not procedures is discouraged by diversion of the plantar structures, with consequent of achieve foot any strain. material However, structural these im-

with a particular position the

metatarsal limitation posture

joints are always fully extended and that of their extension is a determinant of adopted. Thus a raise under the head of sole discourages pronation, whereas alone fails. To correct the

first metatarsal raise of the

a medial pronated

foot permanently must be achieved. towards the end metatarsal joint recting moderate, the below more severe is suitable.

some alteration in the skeletal structure On this principle it was found that, of growth, in plantar mobile cases for fusion flexion flat foot, which of the first cuneiform was successful in corthough inadequate for the operation described

provement in the longitudinal arch, and are inadequate for the more severe cases of mobile flat foot. Attempts at structural improvement and stabilisation of the arch have not been entirely satisfactory. Hoke (1931) position. part give act. the the fused He the naviculo-cuneiform credited the muscles the arch more stable found that joint with in the correct an important

in maintaining a longer and Jack (1953)

and believed this fusion to lever on which they might this procedure reconstituted restricted (1967), to in a 50 per of tarsal

THE The principle-Hicks

of the medial in preserving

OPERATION (1954) pointed out the great strength

arch only if radiographic naviculo-cuneiform joint, follow-up results in many. the originator and plantar medially but

collapse was but Seymour cases, with development

plantar fascia and stressed the integrity of the longitudinal

its importance arch, which

nineteen-year

of Jacks

reported

cent of unsatisfactory degenerative change Gleich (1893), removed a medial bringing the heel

he described as a truss system, the tie of which is represented by the plantar fascia. The windlass action of the latter, which he described and the clinical demonstration of which has already been mentioned, renders the tie of this truss system adjustable in length. Permanent stretching or disruption of the plantar fascia is a major factor

of calcaneal osteotomy, based wedge, not only advancing it with increase

FIG.

3 of the left foot before treatment.

FIG. Figure

4 2-Radiograph of the

FIG.

5 Figures 3 to 5-

Case

1.

Figure

1-Radiograph

ainil

photographs

of the patient

weight-bearing

six years
THE

after

left foot after operation. OF BONE

operation.

JOURNAL

AND

JOINT

SURGERY

FLAT

FOOT

281 attached to the calcaneus at its lower end. Skin and

in the establishment object of the operation this fascia by the Because of the bone, because fascia. ing the

of a structurally flat about to be described medial half of the

foot, and the is to replace tendon. phalanx metatarsal adjustable plantar

left

calcaneal

fat are undercut and aspect of the calcaneus.

the tendon is frxed, big toe, but to the the tie so provided the windlass it lacks

not to the proximal neck of the first is fixed action and is not of the normal

over the medial

aspect

separated from the infero-medial A second small incision is made of the neck of the first metatarsal

bone and a hole is drilled through it. A Kochers forceps is insinuated subcutaneously from this incision to emerge at the lower end of the first incision. The separated upper grasped end of the medial in the Kochers Here the and position. strip forceps of calcaneal and drawn tendon out at is the

The procedure-Through
distally tendon to the is split medial sagittally

a stocking-seam
side into of the two

incision
calcaneal halves. The

deviattendon, upper is

second incision. is passed through metatarsal in the bone corrected

the rolled-up fascial prolongation drill hole in the neck of the first sutured The to itself wounds with are the arch held and a closed

end of the medial half, including over the muscle belly, is divided

its fascial from the

prolongation muscle but

h of

the

right

t-bearing

two years

foot before treatment. after operation.

Figure

8-Clinical

photograph

to

ration.
peration. years
VOL. 57-B, No. 3, AUGUST 1975 after

ograph of the right foot 12 and 13-Clinical photographs

five years after operation. of the right foot bearing

operation.

282 padded, after months below-knee operation unprotected plaster cast plaster is applied. is applied, is allowed.
Six

B. S. JONES

weeks at three

less,
Case

with

a well-formed

arch

and

a neutral

heel

(Figs.

a walking

and

1 to 5).

weight-bearing

2-A
1967 with

coloured
the right

boy
nail-patella foot

aged
with

five

years

was
and at the

admitted
a severe midtarsal

in

syndrome a break replacement last seen two

rocker-bottom

CASE
So far the operation in three patients, pathological factor degree gratifying procedure mobile flat of deformity. result over will indeed foot.

REPORTS

joint. fascia

A calcaneal tendon was done and, when

of the plantar years later, the

has been done on only three feet in all of whom some exceptional contributed to an unusually severe The maintenance in all three of a several years suggests give lasting correction that this of severe,

foot, though hypermobility

6

still flat, had a neutral and no rocker-bottom

heel, no midtarsal deformity (Figs.

to 8).

3-A coloured boy was first seen in 1964 at the age of five and a half years with severe pes plano-valgus associated with excessive laxity of wrists and fingers, 5
Case

Case 1-A coloured girl was first seen in 1965 at the age of ten, with slight congenital hypertrophy of the left lower limb and bilateral rocker-bottom feet, very severe on the left side. Irons and T-straps and in were 1967 worn for two years tendon without improvement, a calcaneal

degrees of genu recurvatum and calcaneus For nearly three years he was treated, sole fascia the was and was right heel raises, later In last heel with 1967 seen neutral irons the tendon

hypermobility. first with medial and T-straps, transplant later, the but plantar on foot defective

without

improvement.
replaced side and, when the

by a calcaneal

six years

replacement side. Seven

of the plantar fascia was done on the left years later in 1974 the left foot was symptom-

symptomless,

both clinically

and radiographically

and the arch restored (Figs. 9 to 13).

REFERENCES
Baker, L. D., and Hill, L. M. (1964) Foot alignment in the cerebral palsy patient. Journal ofBone and Joint Surgery, 46-A, 1-15. Dwyer, F. C. (1961) Osteotomy of the calcaneum in the treatment of grossly everted feet with special reference to cerebral palsy. In Huiti#{232}meCongr#{234}s Internationale de Chirurgie orthop#{233}dique, New York, 4-9 Septembre 1960. Soci#{233}t#{233} Internationale de Chirurgie orthop#{233}dique et de Traumatologie, pp. 892-897. Brussels: Imprimerie des Sciences. Gleich, A. (1893) Beitrag zur operativen Plattfussbehandiung. Archivfur klinische Chirurgie, 46, 358-362. Hicks, J. H. (1954) The mechanics of the foot. II. The plantar aponeurosis and the arch. Journal ofAnatomy, 88, 25-30. Hoke, M. (1931) An operation for the correction of extremely relaxed flat feet. Journal of Bone and Joint Surgery, 13, 773-783. Jack, E. A. (1953) Naviculo-cuneiform fusion in treatment of flat foot. Journal ofBone and Joint Surgery, 35-B, 75-82. Jones, R. L. (1941) The human foot. An experimental study of its mechanics, and the role of its muscles and ligaments in the support of the arch. American Journal ofAnatomy, 68, 1-39. Koutsougiannis, E. (1971) Treatment of mobile flat foot by displacement osteotomy of calcaneus. Journal of Bone and Joint Surgery, 53-B, 96-100. Lord, J. P. (1923) Correction of extreme flatfoot. Value of osteotomy of os calcis and inward displacement of posterior fragment (Gleich operation). Journal ofthe American Medical Association, 81, 1502-1506. Rose, G. K. (1958) Correction of the pronated foot. Journal ofBone andJoint Surgery, 40-B, 674-683. Rose, G. K. (1962) Correction of the pronated foot. Journal ofBone andJoint Surgery, 44-B, 642-647. Seymour, N. (1967) The late results of naviculo-cuneiform fusion. Journal ofBone and Joint Surgery, 49-B, 558-559. Silver, C. M., Simon, S. D., Spindefl, E., Lltchman, H. M., and Scala, M. (1967) Calcaneal osteotomy for valgus and varus deformities of the foot in cerebral palsy. Journal ofBone and Joint Surgery, 49-A, 232-246.

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