REPORT OF A CASE 
OF 
WLADIMIROFF-MIKULICZ OSTEOPLASTIC 
RESECTION OF THE FOOT. 
BY 
WILLIAM BARTON HOPKINS, M.D., 
SURGEON TO THE EPISCOPAL HOSPITAL, PHILADELPHIA. 
EXTRACTED FROM THE 
TRANSACTIONS OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA, 
NOVEMBER 2, 1887. 
PHILADELPHIA: 
WM. J. DORNAN, PRINTER. 
1888. REPORT OF A CASE 
OF 
WLADIMIROFF- MIKULICZ OSTEOPLASTIC 
RESECTION OF THE FOOT. 
BY 
WILLIAM BARTON HOPKINS, M.D., 
SURGEON TO THE EPISCOPAL HOSPITAL, PHILADELPHIA. 
EXTRACTED EROM THE 
TRANSACTIONS OE THE COLLEGE OF PHYSICIANS OF PHILADELPHIA, 
NOVEMBER 2, 1887. 
PHILADELPHIA 
WM. J. DORNAN, PRINTER 
188 8. REPORT 
OF A 
CASE OF WLADIMIROFF-MIKULICZ 
OSTEOPLASTIC RESECTION OF THE FOOT. 
By 
WILLIAM BARTON HOPKINS, M.D., 
SURGEON TO THE EPISCOPAL HOSPITAL, PHILADELPHIA. 
[Read November 2, 1887.] 
The operation which is the subject of this report was 
originally designed by a Russian, Dr. W. D. Wladimiroff, 
in 1871, but as he published the account of it in his 
own language, it was not known out of Russia until 
nine years afterward. In 1880 Dr. John Mikulicz, of 
Vienna, performed the same operation and published it 
as his own device, not knowing that it had ever been 
done before. 
Wladimiroff called it the operation for the production 
of artificial pes equinus; Mikulicz, the osteoplastic 
resection of the foot. The toe-stump operation would 
probably still better distinguish it. It consists essen- 
tially in removing the entire heel and ankle-joint and 
applying what remains of the foot to the leg in a position 
of pes equinus (Fig. 1), so that the patient walks on his 2 
HOPKINS, 
toes. The conditions for which it has been performed 
are (1) caries of the larger tarsal bones, and (2) exten- 
sive loss of the tissues about the heel, either from 
disease or injury. For the relief of the former it has 
been almost exclusively practised, and a number of 
excellent results have been obtained, though there is, of 
course, the risk of the disease attacking the remaining 
Fig. 1. 
Artificial pes equinus. 
bones and causing relapse. To the latter class of cases, 
though of these there are as yet but few examples, it 
will probably prove more particularly applicable, as in 
them the tissues involved preclude the conservative 
operations of Chopart, Pirogoff, and Syme, and leave no 
alternative but amputation of the leg. Should further 
experience confirm the observations so far made, that 
this operation is followed by decidedly better functional 
results than amputation, its future scope will probably 
include many cases of railroad, gunshot, and the like 
injuries, where the parts destroyed correspond with 
those which by it are removed. 
There have been twenty-one cases recorded within 
the past seven years. Most of these have been sue- WLADIMIR0FF-M1KULICZ OPERATION. 
3 
cessful, and most of them for caries. The case reported 
this evening is only the second in which the operation 
has been done for injury of the tissues about the heel. 
The patient's history is as follows: 
Wm. D., aged thirty-seven, born in Scotland, a strong, 
healthy man, was admitted to the Episcopal Hospital, 
November 16, 1886. Two months before his admission he 
had been run over by a freight car. The wheel had passed 
over his left foot, tearing away the tissues of the heel down 
to the bone, laying bare the extensor tendons of the toes, and 
leaving an isthmus of sound integument upon the dorsum of 
the foot not wider, according to the patient's recollection, than 
an inch and a half. During his stay in the hospital of nearly 
four months, the ulcer, for which he was admitted, obstinately 
refused to heal. Its cicatricial border having advanced to the 
utmost limit of its tensile strength, would repeatedly break 
down, so that all efforts to facilitate healing failed. The accom- 
panying cut (Fig. 2), taken from a photograph of the foot at the 
Fig. 2. 
Traumatic ulcer of the heel. 
time of the operation, shows accurately the position of the 
ulcer and cicatrix on the outer side. On the inner side the 4 
HOPKINS, 
ulcer did not extend quite so far forward. The operation was 
performed with proper antiseptic precautions, March 8,1887. 
The patient, after etherization, was placed upon his abdomen ; 
the sound leg was flexed upon the thigh and held out of the 
way by an assistant. The injured foot having been cleansed, 
was elevated upon a block placed beneath the rubber cloth 
and a constant stream of sublimate solution from the irrigator 
directed upon it during the two hours and three-quarters 
occupied by the operation. 
The first step consisted in dissecting out the posterior tibial 
nerve. An incision started behind the inner malleolus was 
carried obliquely downward and forward below it to a point 
below Chopart's joint. The nerve was found to be so deeply 
imbedded in newly formed, very dense fibrous tissue, that it 
was dissected out with some difficulty. It was then divided 
at the upper and lower angles of the wound, about two inches 
of its length being removed. 
The second step in the operation consisted in forming the 
flaps. These had to be slightly modified by the form of the 
ulcer, in order that their edges should consist of moderately 
healthy skin; in most respects, however, the limits of the ulcer 
corresponded with rather remarkable accuracy to the pre- 
scribed lines of incision. The first incision was carried across 
the sole of the foot, down to the bone, from the tubercle of 
the scaphoid on the inside to a point a finger's breadth behind 
the base of the fifth metatarsal bone on the outside; and the 
second straight across the back of the ankle half an inch 
above the os calcis, from the external angle of the sole incision 
to the upper angle of the tibial nerve incision. 
The third step consisted in the resection of the astragalus 
and os calcis, and the shaving off of the lower ends of the 
tibia and fibula and posterior surfaces of the scaphoid and 
cuboid. Disarticulation of the astragalus at the ankle-joint 
was done from behind forward; of the os calcis at its cuboid 
joint, and the astragalus at its scaphoid joint from below 
upward. Due care was taken not to injure the dorsalis pedis 
during the last-mentioned disarticulation, as the position of WLADIMIROFF-MIKULICZ OPERATION. 
5 
the ulcer necessitated the division and ligation of the posterior 
tibial artery in forming the flaps. 
The last step in the operation included the approximation 
of the bones, divided nerve and tendon ends, and the closure 
and dressing of the wound. 
With the view of obtaining more perfect fixation of the 
tarsus to the tibia and fibula than has heretofore been found 
possible, two sterilized bone dowels were placed in holes 
drilled into the lower extremity of the tibia at points which 
corresponded as nearly as possible to the centres of the pre- 
senting surfaces of the scaphoid and cuboid; the insertion of 
their projecting points into these bones being deferred until 
the final adjustment of the parts. A very fine catgut suture 
was so placed in the divided and retrenched ends of the pos- 
terior tibial nerve as to bring these ends into very accurate 
apposition without undue pressure. The slack, however, was 
not yet taken up. In like manner sutures of stronger gut 
were introduced into the divided and retrenched ends of the 
tendon of the peroneus longus, about three inches of which 
were excised, and into the divided end of the tendo-Achillis, 
and the edge of the plantar fascia exposed in the lower flap. 
These sutures were all allowed to remain slack until the foot 
should be brought into its new position. Moderate pressure 
was sufficient to accomplish this and to impale the tarsal bones 
upon the sharp-pointed dowels. With the foot firmly retained 
in this position, the extremities of the nerve were brought 
accurately together and sutured. The tendon of the peroneus 
longus was likewise sutured and the terminal extremity of the 
tendo-Achillis stitched to the edge of the plantar fascia. The 
introduction of drainage catgut and suturing the skin flaps 
with catgut completed the approximation of the parts. A 
dressing of gauze, iodoform, and sublimate cotton was applied 
and the limb was placed upon a straight posterior splint. The 
latter was in three days substituted by a plaster-of-Paris double 
dressing, the foot and leg sections being connected by an iron 
bracket anteriorly in order to leave ample room for washing 
and dressing the wound. Five weeks later a small ulcer 6 
HOPKINS, 
remained, but union of the deeper parts was complete and 
consolidation of the tarsal and leg bones was found to have 
begun. The patient at this time complained of tingling in 
the toes accompanied by occasional shooting pains, and there 
was partial anaesthesia of the sole of the foot. Sensation 
gradually returned, and is now restored except over a very 
limited area. 
Three months after the operation, under ether, the toes were 
extended to a right angle; to accomplish which moderate force 
only was required. Since then there has been nothing to note. 
The limb continues to gain in strength and the patient can 
Fig. 3. 
Appearance of the foot after the operation. 
now, with a cane, walk four miles a day. He has had the 
braced shoe which he wears but two weeks, and has, therefore, 
not yet had time to become thoroughly accustomed to it. He 
walks well without a cane, while with one, when not fatigued, 
he shows hardly a limp. This cut (Fig. 3) represents the limb 
after the operation, and was engraved from a photograph on 
the block. 
Two modifications of the operation, as practised in 
this case, deserve mention, namely: the employment of WLADIMIROFF-MIKULICZ OPERATION. 
7 
bone pegs or dowels to fix the tarsal bones to the tibia, 
and the suturing of the divided and retrenched tendons. 
The dowels provided proved rather too light to make 
the joint firm and immovable, but they were neverthe- 
less used, as heavier ones were not at hand. Perfect 
fixation of the tarsus and leg at the outset, by lessen- 
ing suppuration, by promoting early bony union, and 
by obviating the necessity of such carefully applied 
outside support, would seem to be an important factor 
in the after-treatment of the operation. The dowels 
should be three-sixteenths of an inch in diameter and 
three inches in length. They may be sunk two inches 
in the tibia and one inch in the tarsus. Holes need not 
be drilled for them in the latter, as their sharp points 
readily penetrate the cancellated structure of these 
bones. Uniting the severed tendons has, without 
doubt, added to the function of the foot in this case. 
Though suggested in The Medical News editorially, it 
does not appear to have been attempted before. The 
plantar fascia was chosen as a strong accessible point to 
which to attach the tendo-Achillis, instead of the tarsal 
periosteum, as suggested in The Medical News. 
Within the narrow limits of motion which now remain, 
the patient can flex, as well as extend the foot. The 
motion is partly tarso-metatarsal, and partly tarso- 
tibial. The latter is diminishing, and the braced boot 
which he wears may probably be cast aside within one 
year. 
The following table includes, it is believed, all the 
operations which have been performed, with the excep- 
tion of five Russian cases reported incidentally by 
Sklifossowsky. The first nineteen cases are taken from 
the table of Zesas, Arc/zwfur Idinische Chirurgie, 1886, 
Bd. 33. 8 
HOPKINS, 
No. 
Operator. 
Year. 
Age. 
Cause. 
Result. 
Authority. 
Remarks. 
1 
Wladimiroff, 
1871 
15 
Caries. 
Recovery. 
Aus den Arbeiten der Gesell- 
schaft der Aerzte der Stadt 
Kasan, 1872. 
Patient walked very well without cane. 
2 
Mikulicz, 
1880 
23 
Syphilitic 
ulcer. 
Recovery. 
Archiv fur klin. Chirurgie, 
Bd. 26. 
At the end of four months patient walked 
with cane and boot, while in eighteen 
months did hard work, and could walk 
one hour. 
3 
Socin, 
1881 
22 
Caries. 
Recovery. 
Jahresbericht fiber die chir- 
urgische Abtheilung das 
Spitales zu Basel, 1881-82 
After two months used cane and worked 
in the field; no relapse after two years. 
4 
Mikulicz, 
1881 
27 
Caries. 
Recovery. 
Centralblatt fur Chirurgie, 
1884. 
Patient, with boot, could walk quite far, 
but without it had to use a cane; six 
months afterward died of pulmonary 
tuberculosis. 
5 
Sklifossowsky, 
1882 
30 
Caries. 
Recovery. 
Bull, de la Societe de Chir- 
urgie de Moskou, 1882. 
Patient did well. 
6 
Haberern, 
1882 
18 
Caries. 
Relapse. 
Verhandl. der Deutschen 
Gesellschaft fur Chirurgie, 
1884. 
Amputation of the leg, after five months, 
from which he recovered. 
7 
Mikulicz, 
1883 
16 
Caries. 
Recovery. 
Centralblatt fur Chirurgie, 
1884. 
Patient walked in six months with boot; 
without it had to use a cane, 
Patient died in eight months of what 
appeared to be pulmonary tuberculosis 
8 
Lauenstein, 
1883 
32 
Caries. 
Recovery. 
Ibid. 
9 
Lauenstein, 
1883 
25 
Caries.. 
Recovery. 
Ibid. 
Patient could walk four hours at a time, 
and without boot could step firmly 
upon his foot. 
10 
Mikulicz, 
1883 
? 
Caries. 
Recovery. 
Verhandl. der Deutschen 
Gesellschaft fur Chirurgie, 
1884. 
Patient walked well with cane. 
11 
Roser, 
? 
? 
Caries. 
Recovery. 
Fischer: Deutsche Zeitschrift 
fur Chirurgie, xxiii. S. 164. 
Functional result excellent. 
Table of Operations. WLADIMIROFF-MIKULICZ OPERATION. 
9 
No. 
Operator. 
Year. 
Age. 
Cause. 
Result. 
Authority. 
Remarks. 
12 
Kummell, 
1884 
38 
Caries. 
Relapse. 
Centralblatt fur Chirurgie, 
1885. 
After four months resection of the rest of 
the tarsus, part of the metatarsus, and 
a portion of the tibia and fibula. 
13 
Scbattauer, 
? 
10 
Caries. 
Recovery. 
Ibid. 
Patient, with boot, could walk many 
hours without fatigue. 
14 
Renssen, 
(Ranke's 
Clinic.) 
1884 
? 
Deformity re- 
sulting from 
fracture. 
Recovery. 
Ibid. 
Seven and a half months after operation 
patient walked well with boot; 3| cm. 
shortening. 
15 
Schattauer, 
1884 
9 
Caries. 
Relapse. 
Ibid. 
Five weeks after the operation amputa- 
tion of the leg; recovered. 
16 
Fischer, 
1884 
18 
Caries. 
Relapse. 
Deutsche Zeitschrift fur 
Chirurgie, xxiii. 1 u. 2 
Heft. 
Resection of second and third cuneiform 
bones and remainder of cuboid ; re- 
covered. At the end of a year patient 
walked well with boot and cane ; could 
go up stairs. 
17 
Niehans, 
? 
50 
Injury of 
heel. 
Recovery. 
Very good functional result. Without 
boot or cane became easily fatigued. 
18 
Srodina, 
1885 
20 
Caries. 
Gangrene. 
Centralblatt fur Chirurgie, 
1886, No. 3. 
Amputation at the lower third of the 
leg. 
19 
Sordina, 
1885 
11 
Caries. 
Recovery. 
Ibid. 
Very good result. 
20 
Gutsch, 
1886 
13 
Caries. 
Recovery. 
Archiv fur klin. Chirurgie, 
Bd. 34, 1836. 
Resection included parts of all the cunei- 
form bones and seven centimetres of 
the tibia and fibula; function com- 
pletely restored. 
21 
Fenger, 
1886 
29 
Caries. 
Recovery. 
Journal of the Amer. Med. 
Association vol. viii., Jan. 
1887. 
Fifteen months after the operation can 
walk without boot and cane, and bear 
the whole weight on the foot; solid 
ankylosis ; lengthening 5 cm. 
After eight months can walk four miles 
with cane and boot; limited motion un- 
der voluntary control in flexion as well 
as extension; about f in. lengthening. 
22 
Hopkins, 
1887 
37 
Traumatic 
ulcer. 
Recovery. 
*