Surgical Treatment Of Segmental Giantism Of The Foot
Edward T. Haslam, M.D.
My purpose in this article is to present an example of the operative technique we have found useful in a few patients with giantism or congenital hypertrophy limited to one or more rays of the foot, not associated with demonstrable neurofibromatosis, arteriovenous fistulae, or hemangiomatosis. In these patients the remainder of the extremity has been essentially normal, the reason for treatment being that the foot could not be fitted with a shoe. The case described here is merely an example, since none of the several patients whom I have seen with these conditions have had identical deformities.
The patient (G.C.) was admitted to Charity Hospital in New Orleans on April 3, 1964, at 22 months of age with the complaint of enlargement of the right foot, which prevented satisfactory shoe fitting. He had been delivered at home after an uncomplicated pregnancy with no history of maternal illness or ingestion of any medications, and was normal at birth except for enlargement of the third, fourth, and fifth toes and a moderate deformity of the second toe of the right foot. Three siblings were normal, and as far as was known, no other members of the family had experienced similar deformities. The patient had been healthy since birth, had walked at nine months of age, and otherwise exhibited normal development.
Physical examination revealed only that the right foot was grossly larger than the left, due partially to hypertrophy of the third, fourth, and fifth toes and partially to hypertrophy of the subcutaneous tissue corresponding to these three rays. These toes were functionless (Fig. 1 ), since the thickened plantar fat pad prevented them from coming into contact with the
ground, and the second toe was function-less because of its extended position.
On April 8, 1964, under general anesthesia and with the use of a pneumatic tourniquet, the third, fourth, and fifth toes were amputated, and the third metatarsal and excess skin and fat were removed. Outline for the tentative incisions were marked with methylene blue (Fig. 4 and 5 ). Additional plantar skin was removed just proximal to the second toe to correct the dorsiflexion deformity exhibited. Fig. 6 shows, the appearance of the foot after ablation of the lateral three toes and the third metatarsal shaft with appropriate defatting, A capsulot?my at the bases of the second and fourth metatarsals was carried out to allow partial obliteration of the dead space resulting from disarticulation and removal of the third metatarsal. The transverse intermetatarsal ligament was sutured with chromic catgut, the subcutaneous fascia was similarly closed, and the skin was closed with interrupted sutures of No.0000 silk (Fig. 7 and Fig. 8 ).
In keeping with our usual practice, we planned our operative incision to allow generous skin coverage and then removed any skin found to be superfluous. In defatting the sole of the foot, attention was given to preservation of blood supply. As visible arteries and veins were encountered, they were ligated and tied, and the circulation returned promptly to the first and second toes after the tourniquet was removed. No drains were used, and a posterior plaster splint was applied over a pressure dressing.
The patient's postoperative course was uneventful, and the sutures were removed on the 18th day following the operation. A small-sized area of the skin slough was present just lateral to the second toe, but this healed within four weeks postoperatively. X-rays taken five weeks postoperatively revealed that the condition of the foot was satisfactory (Fig. 9 ). The patient was fitted with mismated surgical shoes because of the swelling, and weight bearing was resumed.
He has been seen periodically from time to time, and when last seen in February 1966 had no complaints, was doing well, and was wearing mismated regular shoes. Unfortunately we have not been able to obtain current photographs of this patient. His gait is normal.
Satisfactory management of this condition involves an analysis of each individual case and modification of some basic principles of foot surgery. This applies particularly to the longitudinal plantar incision, which is necessary if an adequate amount of fat is to be removed and the width of the foot reduced to approximately the same size as the other. It is often impossible to match the foot sizes exactly, but this should be the surgeon's goal. The removal of the three lateral toes in this case did not impair function, since the toes were functionless anyway. Postoperatively the second toe was in a position to touch the floor and function, whereas preoperatively it was not. Therefore, although the surgery was ablative and destructive in one sense, it was really reconstructive in another.
This patient was operated on at 22 months of age, which was when we first encountered him. However, such surgery, in the absence of contraindications, would probably be better done at about the time that the child is establishing gait, when he is too young to be the object of his playmates' ridicule.
In addition to the case described, our experience has included a similar one involving the second, third, and fourth rays. This patient was treated by amputation of these toes and resection of the third metatarsal. A third patient had gross hypertrophy of the second ray and less marked hypertrophy of the third ray.
We are planning to review these cases after they have achieved skeletal maturity and hope to submit a more detailed report at that time. To date we have not found it necessary to do epiphyseal arrests to control leg length discrepancy in such patients, but the possibility should be kept in mind.
Edward T. Haslam, M.D. is associated with the Juvenile Amputee Clinic Crippled Children's Hospital New Orleans, Louisiana