1. Stability was obtained in all the cases attempted. Although the functional result was good in twenty cases and fair in five, the mechanical position in which the arthrodeses took place was good in only six cases, fair in six, and bad in fifteen. This means that more attention should be paid to the position in which the joints to be arthrodesed are put in at the time of the operation, or that the first position be corrected as soon as it is found to be unsatisfactory.
2. The relation of the vertical axis of the os calcis to the axis of the tibia was found to be straight in six cases, in valgus in six, and in varus in fifteen cases. Although the functional result was good in nineteen and fair in six, the mechanical result was good in only four cases, fair in eight, and bad in fifteen. As said above, when there was a varus or a valgus position without weight-bearing, there was a tendency for this faulty position to increase with weight-bearing. The importance of obtaining the straight position must therefore be remembered at the time of the operation.
3. The shape of the foot as judged by the relation of the forefoot to the posterior foot. Our results showed that only one foot was straight, eighteen were in varus, six in valgus, and one in cavus. From the functional side, however, eighteen were good and eight fair; from the mechanical side, three were good, seven were fair, and fifteen were bad.
4. Torsion of the tibia. This condition, as shown by the backward displacement of the fibula on the tibia, was found to be normal in ten cases, moderate in ten, and extreme in seven. This was measured roughly with a goniometer. The relation was considered normal if the lower end of the fibula was 20-30 degrees behind the plane of the tibial condyles; moderate if 30-50 degrees; and extreme if 50-70 degrees. The functional result was found to be good in the normal cases seven times, and in those cases with a moderate backward displacement seven times, and fair in three times each. In the cases with the extreme backward displacement the functional result was good in four and fair in three cases. The mechanical result was good in the normal cases in two, fair in two, and bad in six. In the moderate conditions it was good in one, fair in two, and bad in seven. In the extreme cases it was good in one, fair in two, and bad in four cases. From this it would seem that the amount of tibial torsion present was of not much importance, at least from the functional point of view.
5. A comparison of the deformities before operation and the result after operation brought out the following: In four equino valgus cases the functional result was good in three and fair in one case. The mechanical result was good in one, fair in one, and bad in two cases. In sixteen equino varus cases the functional result was good in ten, fair in six. The mechanical result was good in two, fair in two, and bad in twelve cases. In four cases of varus with cavus the functional result was good in three and fair in one, while the mechanical result was good in one, fair in two, and bad in one.
6. The functional result or the patients' opinion of the condition showed that nineteen, or 70%, considered their result good, and eight, or 30%, considered their result fair. None of them thought they were worse.
7. The mechanical result as judged by a combination of all the above examinations taken together showed that five, or 18%, were good; six, or 22%, were fair, and sixteen, or 59%, were bad.
8. Suggestions for treatment:
Greater care should be taken at the time of the operation to insure the foot being put into the best mechanical alignment possible. It should be possible to get the os calcis into a straight position if the operation is done properly. It may not and very often will not be possible to get the fore-foot in the proper relation to the posterior foot at the first operation, but it is the duty of the surgeon to see that this relationship is established before the patient is discharged from his care. This should be possible to accomplish by manipulation or corrective plasters if it is done within six to eight weeks after the first operation and it should always be done.
As orthopaedic surgeons we should not be satisfied with pleasing the patients by making them better than they were before. We should be satisfied only by doing an operation and following up the after-treatment in such a way that the patient gets a result that is mechanically as perfect as possible. In this kind of work anything less than this means that we have not lived up to the standards which we should always have before us.
(C) 1924 All Rights Reserved.The Journal of Bone and Joint Surgery, Inc.