In antero-posterior curvature it is very often necessary to resort to a wedge shaped resection of bone; this is an operation of considerable gravity, and the utmost care must be taken to employ a reliable aseptic technique.
Hallux Valgus.
This is a displacement of the great toe outward; it is usually associated with enlargement of the bursa and tissues on the inner side of the metatarso-phalan geal joint. In its most marked condi tion the cause is usually rheumatic or rheumatoid in nature, although severe cases occur even when no other symp toms pointing to those affections exist.
From a clinical point of view, it is of importance to notice that the sheath of the flexor longus hallucis is bound down in the sole and behind the ankle by a dense fibrous covering, but in the upper part it is only surrounded by loose cellu lar tissue, and in this situation it is capable of great distension. Another cir cumstance of clinical importance is the existence of a communication between the sheath of the tendon of the tibialis anticus and the cuneo-metatarsal joint. Chemin (Comp. Rend. des Seances de la Soc. de Biol., '96).
—Conservative treatment may be tried with a small internal lateral splint of pasteboard to which the toe is drawn over by adhesive plaster or by means of a metal spring fastened to a sole-plate and made by the instrument maker. Radical treatment consists in excising the hypertrophied and inflamed tissues over the projecting part and removal of the head of the metatarsal bone. Care should be taken not to remove too much, or a flail-joint may be left and walking interfered with. For this reason it is preferable not to remove both articular surfaces. Osteotomy of the metacarpal bone has been done, but it is only effective in comparatively mild cases.
In hallux valgus removal of a portion of the head often fails to afford relief. Total resection of the joint does not overcome the deformity due to inward inclination of the metatarsal bone, and results in ankylosis, while tenotomy of the extensors of the great toe may be followed by suppression of the function of these muscles. Cuneiform resection of the metatarsal bone near its base, but in front of the insertion of tendon of peroneus muscle, recommended. Loison (Bull. et Mem. de In Soc. de Chic. de
Paris, No. 17, 1901).
Coxa Vara.
This is the name given to a condition in which the neck of the femur is so altered in relation to the shaft that the direction of the thigh is changed. The foot thus may be abnormally everted, and excessive adduction be present, produc ing a scissors-like deformity.
Twenty-two cases of coxa vara. It is In lie II more common than is supposed, and many eases are treated as cases of tubercular disease.
Coxa vara is to be detected only by physical examination. The points de veloped are: the trochanter is elevated, prominent, and displaced, as may be demonstrated by Nilaton's line and Bry ant's triangle, the actual shortening of the leg, and the peculiar and unequal limitation of the range of motion de pendent upon the deformity. In pro gressive cases the forced passive mo tion causes discomfort, and at times it may he resisted by voluntary and in voluntary contraction of the muscles. This is, however, unusual. There is com monly a certain amount of muscular atrophy, more marked in the thigh than in the leg, which corresponds to the donation and to the degree of the dis ability.
Cola yarn is probably the result of an inherited or acquired weakness, either of position or structure; it may be the im portant predisposing cause of the de formity. Exciting cause would be the instability of rapid growth, overstrain, overweight, and injury. Improper sur roundings, insufficient nourishment. or debility from any cause lessen the resistance of the bones as of other parts. but the presence of actual local disease is by no means necessary to explain the deformity. Whitman (N. Y. Med. Jour., Jan 21, '99).
In the presence of the positive find ings which present themselves in every case of infantile coxa vara, no one can deny the importance of rickets as an etiological factor in this condition. In the absence of any practical points in the etiology of the condition in the young adult one is obliged, theoretically at any rate, to accept the presence of some acute bone-softening process. Al though in the bulk of all cases this con dition may be justly considered one of kin to osteomalacia, yet there are a certain number of cases which point strongly to a true late rachitic process.