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Eight Principles of Forefoot Reconstruction
Sixth Principle
Relationships between forefoot, rear foot and lower limb
The sixth principle is to take into account the relationship between the forefoot and the rear- foot (and the lower limb). We emphasize this combination with three examples.
1) The gastrocnemius shortness (Fig. 45f1) has a close relationship with the forefoot, in most cases, by increasing the forefoot deformities so that the security in forefoot surgery is to per- form in the same session (or preferably few days before) the gastrocnemius release as required.
Sometimes the forefoot deformity, particularly overload (metatarsalgia) or claw toes deformity, have their main cause in the gastrocnemius shortness so that in this case, the forefoot sur-
Fig. 45f1 – Principle VI – Take into account the relationship between the rearfoot and the lower limb.
a) The gastrocnemius shortness (in all this figure, the same patient).
1. Severe forefoot deformity. 2. Same patient, left foot: Shortness of the gastrocnemius.
3 to 7. Postoperative aspects two months after metatarsal osteotomies (small shortening) and proximal gastrocnemius release. 3. The correction. 4, 5. On the corresponding foot, normal dorsal flexion (more than in the not operated right foot). 5. Plantar callosities have disappeared. 6. The patient can be on tiptoes and says that she feels better on this leg than on the right one.
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Fig. 45f2. Principle VI – Take into account the relationship between the rear foot and the lower limb.
b) Pes valgus.
Pictures from E. Toullec, Bordeaux.
Pes planus / valgus combined with hallux valgus deformity: Evan’s calcaneum osteotomy and scarf first metatarsal osteotomy with lateral shift and lowering. Pre and postoperative (months) aspects.
1, 2. Dorso-plantar clinical and radiological aspects.
3. The rear foot view.
4. Medial aspect.
5. Weight bearing sagittal X-rays, before removing the K-wire.
gery is limited and the main surgery is the gas- trocnemius release.
2) Pes valgus. In this case, the forefoot sur- gery is additional but very useful in achieving the correction. We met some significant cases of Evan’s calcaneum osteotomy combined with a scarf first metatarsal osteotomy with lowering.
3) In cavus foot (Fig. 45f3), the BRT basal metatarsal elevation osteotomy can be success- fully combined with a calcaneum osteotomy like the M. Myerson osteotomy, to offer an alterna- tive to the Lisfranc dorsal resection. This asso- ciation of extra-articular osteotomies was recently emphasized by J. Sammarco [107].
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Eight Principles of Forefoot Reconstruction
Fig. 45f3. Principle VI – Take into account the relationship between the rear foot and the lower limb.
c) Pes cavus.
As an alternative to the traditional Lisfranc osteotomy and according to other authors, like J. Sammarco, we think that the calcaneum osteotomy should be combined with the metatarsal basal osteotomy; so we use the BRT osteotomy.
