Table Of ContentMcGlamry's Forefoot Surgery
1st Edition
2004
Lippincott Williams & Wilkins
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10 9 8 7 6 5 4 3 2 1
Editors
Alan S. Banks D.P.M., F.A.C.F.A.S.
Director of Residency Training
Emory Northlake Regional Medical Center
Private Practice
Peachtree Podiatry Group, P.C.
Tucker, Georgia
Michael S. Downey D.P.M., F.A.C.F.A.S.
Chief
Division of Podiatric Surgery
Presbyterian Medical Center
University of Pennsylvania Health System
Professor and Immediate Past Chairman
Department of Surgery
Temple University School of Podiatric Medicine
Philadelphia, Pennsylvania
Dennis E. Martin D.P.M., F.A.C.F.A.S.
Departments of Podiatry and Orthopedics
Trident Regional Medical Center
North Charleston, South Carolina
Stephen J. Miller D.P.M., F.A.C.F.A.S.
Clinical Adjunct Faculty
Surgical Clinics
Temple University School of Podiatric Medicine
Philadelphia, Pennsylvania
Chief, Quality Assurance
Island Hospital
Anacortes, Washington
P.vii
Contributing Authors
Patrick S. Agnew D.P.M. Albert E. Burns D.P.M.
Podiatry Residency Director Professor
Eastern Virginia Medical School Department of Podiatric Surgery
President California College of Podiatric Medicine
American College of Foot and Ankle Pediatrics Past Chief and Staff
Norfolk, Virginia Department of Surgery
Pacific Coast Hospital
San Francisco, California
Robert G. Aguilar D.P.M.
Podiatry Section
Veteran's Administration Medical Center Craig A. Camasta D.P.M., F.A.C.F.A.S.
Augusta, Georgia
Faculty
The Podiatry Institute Tucker, Georgia Chief
Tzvi Bar-David D.P.M. Department of Surgery
Emory Park Medical Center
Lecturer
Lithia Springs, Georgia
Department of Orthopaedic Surgery
Columbia University College of Physicians and
Surgeons Bradley D. Castellano D.P.M.
Professional Associate
Section Chief of Podiatry
Department of Orthopaedic Surgery
Department of Surgery
New York Presbyterian Hospital-Columbia
Lee Memorial Hospital
Presbyterian Medical Center
Fort Myers, Florida
New York, New York
Alan R. Catanzariti D.P.M.
Gary R. Bauer D.P.M.
Department of Surgery Director
Temple University Podiatric Residency Training Program
School of Podiatric Medicine Department of Surgery
Philadelphia, Pennsylvania Division of Foot and Ankle Surgery
The Western Pennsylvania Hospital
Pittsburgh, Pennsylvania
Marc R. Bernbach D.P.M.
Community Faculty
Thomas J. Chang D.P.M.
Yale Primary Care Residency Program
Podiatric Section Past Professor and Chairman
Department of Surgery Department of Podiatric Surgery
Waterbury Hospital Health Center California College of Podiatric Medicine
Waterbury, Connecticut Chief of Podiatry
Department of Orthopedics
University of California, San Francisco—Mt. Zion
Edwin L. Blitch IV D.P.M.
Hospital
Private Practice San Francisco, California
Lowcountry Family Podiatry
North Charleston, South Carolina
P.viii
Luke D. Cicchinelli D.P.M. Paul M. Greenberg D.P.M.
Faculty Attending Surgeon
The Podiatry Institute Tucker, Georgia Chief Department of Surgery
Division of Podiatry St. Luke's—Roosevelt Hospital
Pitt County Memorial Hospital New York, New York
Greenville, North Carolina
Charles J. Gudas D.P.M.
Mary E. Crawford D.P.M., F.A.C.F.A.S. Bon Secours—St. Francis Hospital
Board of Advisors Charleston, South Carolina
Northwest Podiatric Foundation for Education
and Research, U.S.A. Louis A. Jimenez D.P.M.
Director of Education and Residency Training Faculty
Northwest Podiatric Surgical Residency Program The Podiatry Institute
Swedish Medical Center Department of Podiatry
Seattle, Washington Emory Northlake Regional Medical Center
Tucker, Georgia
Gary L. Dockery D.P.M., F.A.C.F.A.S. Residency Instructor
Founder and Scientific Chairman Department of Podiatry
Northwest Podiatric Foundation for Education Atlanta VA Medical Center
and Research, U.S.A. Decatur, Georgia
Seattle, Washington
Sonya Kurichh D.P.M.
Michael S. Downey D.P.M., F.A.C.F.A.S. Resident
Chief Podiatry Section
Division of Podiatric Surgery Veteran's Administration Medical Center
Presbyterian Medical Center Augusta, Georgia
University of Pennsylvania Health System
Professor and Immediate Past Chairman Scot D. Malay D.P.M., F.A.C.F.A.S.
Department of Surgery Director
Temple University School of Podiatric Medicine Resident Research
Philadelphia, Pennsylvania Presbyterian Medical Center
University of Pennsylvania Health System
William D. Fishco M.S., D.P.M. Philadelphia, Pennsylvania
Faculty
The Podiatry Institute Tucker, Georgia Private Dennis E. Martin D.P.M., F.A.C.F.A.S.
Practice Departments of Podiatry and Orthopedics
Flagstaff, Arizona Trident Regional Medical Center
North Charleston, South Carolina
Donald R. Green D.P.M.
Clinical Assistant Professor Dalton E. McGlamry D.P.M., F.A.C.F.A.S.,
Department of Orthopedics D.SC.(HON.), D.H.L.
University of California, San Diego Medical Peachtree Podiatry Group, P.C.
Center Founding Member
Podiatric Residency Director The Podiatry Institute
Department of Surgery Tucker, Georgia
Scripps Mercy Medical Center
Michael C. McGlamry D.P.M., F.A.C.F.A.S.
San Diego, California
Staff
Department of Surgery
North Florida Regional Medical Center
Gainesville, Florida
P.ix
Stephanie Comer Merritt D.P.M. Department of Podiatry
Private Practice Emory Northlake Regional Medical Center
Roswell, Georgia Tucker, Georgia
Stephen J. Miller D.P.M., F.A.C.F.A.S. Molly Schnirring-Judge D.P.M.
Clinical Adjunct Faculty Director
Surgical Clinics Externship Program
Temple University School of Podiatric Medicine Section of Podiatric Surgery
Philadelphia, Pennsylvania St. Vincent Charity Hospital
Chief, Quality Assurance Cleveland, Ohio
Island Hospital Staff Surgeon
Anacortes, Washington Department of Surgery
Editorial Advisor St. Charles Hospital
Journal of the American Podiatric Medical Oregon, Ohio
Association
Bethesda, Maryland Carolyn J. Sharrock-Maher D.P.M.
Resident in Podiatric Surgery
Robb A. Mothershed D.P.M. Department of Surgery
Faculty Saint Francis Hospital and Medical Center
The Podiatry Institute Tucker, Georgia AO Hartford, Connecticut
Alumni Department of Orthopedics
University of Washington Jeffrey E. Shook D.P.M.
Seattle, Washington Residency Director
Private Practice Huntington Podiatric Surgical Program
Winston-Salem, North Carolina St. Mary's Hospital
Huntington, West Virginia
Aprajita Nakra D.P.M.
Private Practice Thomas F. Smith D.P.M.
Mesa, Arizona Faculty and Board Member
The Podiatry Institute
Charles F. Peebles D.P.M. Tucker, Georgia
Faculty Residency Director, Podiatry Service
The Podiatry Institute Tucker, Georgia Private Department of Surgery
Practice Dwight David Eisenhower Army Medical Center
Ft. Walton Beach, Florida Fort Gordon, Georgia
Chief, Podiatry Section
Keith D. Pfeifer D.P.M. Department of Surgery
Staff Podiatrist University Hospital
Dwight David Eisenhower Army Medical Center Augusta, Georgia
Fort Gordon, Georgia
Joe T. Southerland D.P.M., F.A.C.F.A.S.
Jane Pontious D.P.M. Faculty
Associate Professor The Podiatry Institute Tucker, Georgia Private
Department of Surgery Practice
Temple University School of Podiatric Medicine Arlington Podiatry
Philadelphia, Pennsylvania Arlington, Texas
John A. Ruch D.P.M., F.A.C.F.A.S. Claire A. Sun D.P.M.
Director Resident
Medical Education Department of Podiatric Surgery
The Podiatry Institute Emory Northlake Regional Medical Center
Staff Tucker, Georgia
P.x
John V. Vanore D.P.M.
Medical Staff
Department of Surgery
Riverview Regional Medical Center
Private Practice
Gadsden, Alabama
Harold W. Vogler D.P.M., F.A.C.F.A.S.
Research Fellow
Laboratory of Functional Anatomy and
Biomechanics
University of Copenhagen, Panum Institute
Copenhagen, Denmark
Section of Foot Surgery
Sarasota Memorial Hospital
Sarasota Orthopedic Associates
Sarasota, Florida
Carl R. Wagreich D.P.M.
Co-Director
Baja Project for Crippled Children
Mexicali, Mexico
Director of Residency Education
Department of Podiatric Surgery
Healthsouth Surgery Center of South Bay
Torrance, California
Gerard V. Yu D.P.M.
Senior Clinical Instructor
Department of Family Practice
Case Western Reserve University School of
Medicine
Director, Podiatric Medical Education
Section of Podiatry
Division of Orthopedic Surgery
Department of Surgery
St. Vincent Charity Hospital
Cleveland, Ohio
P.xi
Preface
McGlamry's Forefoot Surgery consists of a compilation of the most popular chapters from the third edition of McGlamry's Comprehensive
Textbook of Foot and Ankle Surgery. We are providing this information in a separate format in response to requests from foot and ankle
surgeons both here and abroad who are interested primarily in forefoot surgery. The interest in foot surgery is rapidly expanding
throughout many areas of the world, and with that, there is a growing need for readily available material that will assist in the
development of knowledge and skills for the management of the more common conditions of foot surgery. The chapters in this volume are
taken without alteration from the more comprehensive reference book. The editors hope that providing this version of the material will
lead to improved treatment of common foot problems.
Contents
Preface
Editors
Contributing Authors
Contents
Chapter 1 Nails
Chapter 2 Morton's Neuroma
Chapter 3 Lesser Ray Deformities
Chapter 4 Implants
Chapter 5 Introduction and Evaluation of Hallux Abducto Valgus
Chapter 6 Anatomic Dissection of the First Metatarsophalangeal Joint for Hallux Valgus Surgery
Chapter 7 Distal Metaphyseal Osteotomies in Hallux Abducto Valgus Surgery
Chapter 8 Proximal Procedures of the First Ray
Chapter 9 Osteotomies of the First Metatarsal Shaft in Hallux Abducto Valgus
Chapter 10 Arthrodesis of the First Metatarsophalangeal Joint
Chapter 11 Juvenile Hallux Abducto Valgus Deformity
Chapter 12 Traditional Procedures for the Repair of Hallux Abducto Valgus
Chapter 13 Surgical Procedures of the Hallux
Chapter 14 Complications of Hallux Abducto Valgus Surgery
Chapter 15 Hallux Limitus and Hallux Rigidus
Chapter 16 Metatarsus Adductus and Allied Disorders
Chapter 17 Congenital Deformities
Chapter 18 Trauma to the Nail and Associated Structures
Chapter 19 Dislocations
Chapter 20 Digital and Sesamoid Fractures
Chapter 21 Callus Distraction Principles and Indications
Subject Index
P.1
Chapter 1
Nails
Gary L. Dockery
The toenail is a specialized keratinized appendage with a primary function of protection for the distal phalanx. It is capable of only a
limited number of pathologic responses, many of which are reviewed in this chapter.
Unlike skin and hair, the nail does not shed or desquamate and is not cyclic. Nails are hard because of a relative lack of water content as
compared with the stratum corneum (1 ). Water flux across the nail is ten times that across skin; however, the nail plate is unable to hold
water because of its low (less than 5% by weight) lipid content (2 ). Moreover, the relatively high sulfur content in nails, predominantly in
the form of cystine, appears to contribute to their hardness. Nails are 9.4% cystine by weight compared with 1% in callus (3 ).
Because the nail is hard and does not desquamate, many of the conditions involving the nails become more difficult to treat either with
medication or by surgical means. A thorough knowledge of the properties of the nail and its surrounding anatomic structures increases the
effectiveness of all treatment programs and enables the physician to provide better cosmetic results (4 ).
ANATOMY
The nail consists of a nail plate and the supporting tissues surrounding it (Fig. 1 ). Nail growth appears to be continuous, with little change
in the overall rate. Toenails extend distally approximately 0.03 to 0.05 mm a day. The thickness of the toenail is between 0.05 and 1.0 mm.
The toenail is set on the dorsal surface of the distal end of the toes in grooves that are referred to as the lateral and proximal nail grooves
(Fig. 2 ). The grooves are covered by corresponding folds, the lateral and proximal nail folds. The nail plate itself appears translucent in
areas where it is not attached to the underlying nail bed. The areas that are attached to the underlying adherent and vascular nail bed
appear pink as the result of the transmission of color from this area.
Many digits display a white semicircular lunula at the proximal end of the nail plate, which is the topographic marker of the nail matrix.
The lunula represents the junction point between the nail matrix and the nail bed. The nail matrix, which synthesizes the nail plate
substance, extends proximally under the nail fold about 5 to 10 mm in depth. The region underlying the free edge of the nail plate distal to
the nail bed and proximal to the epidermis of the tip of the digit is the hyponychium. Overlapping the matrix of the nail is the proximal
nail fold, the stratum corneum of which is prolonged distally as a thin, cuticular fold, the eponychium. Below the nail lies the germinative
zone that, together with the subjacent corium, forms the nail bed (5 ).
Circulation to the nail is supplied by two arterial arches derived from the two digital arteries. The digital arteries course laterally on the
digits and give off multiple small dorsal branches into the pulp space of the distal phalanx. These dorsal branches, in turn, divide to form
the distal and proximal arches (Fig. 3 ). An additional branch leaves the digital artery at the midportion of the middle phalanx and does not
enter the pulp space but courses over the distal interphalangeal joint space. This serves the proximal matrix and provides the corollary
circulation (6 ).
The hallux receives its innervation from four nerves: (a) a digital branch of the deep peroneal that supplies the lateral dorsal area, (b) the
medial dorsal cutaneous nerve, (c) the lateral common digital nerve from the medial plantar nerve that supplies the lateral plantar area,
and (d) the medial digital nerve from the medial plantar nerve that supplies the medial plantar area of the hallux (7 ) (Fig. 4 ).
Because of the orientation of the matrix cells in a forward position and because of pressure exerted by the posterior nail fold, the nail
grows forward and flat rather than upward. If a portion of the nail matrix is rearranged because of injury or surgery, or if it is grafted on
the skin away from the nail fold, it will produce a nail that projects straight up from its surface (8 ). If the nail is completely removed, the
upward pressure will force the distal nail bed to bend and elevate upward, causing a deformation of the distal nail bed. As the new nail
begins to grow out, it approaches the end of the toe only to meet this soft tissue wall, which tends to bulge the soft tissues upward around
the distal part of the new nail, and the result is the creation of an ingrown or clubbed nail (9 ) (Fig. 5 ).
