A CASE 
OF 
CARIES OF THE ANKLE, 
TREATED CONSERVATIVELY. 
BY 
CHARLES C. FOSTER, M.D., 
CAMBRIDGE, MASS. 
ORTHOPEDIST TO CAMBRIDGE HOSPITAL ; SURGEON FIFTH REGIMENT INFANTRY, M. V. M. 
REPRINTED FROM THE 
TRANSACTIONS OF THE AMERICAN ORTHOPEDIC ASSOCIATION, 
SEPTEMBER, 1889. A CASE 
OF 
CARIES OF THE ANKLE, 
TREATED CONSERVATIVELY. 
BY 
CHARLES C. FOSTER, M.D., 
CAMBRIDGE, MASS. 
ORTHOPEDIST TO CAMBRIDGE HOSPITAL ; SURGEON FIFTH REGIMENT INFANTRY, M. V. M. 
REPRINTED EROM THE 
TRANSACTIONS OF THE AMERICAN ORTHOPEDIC ASSOCIATION, 
SEPTEMBER, 1889. 
PHILADELPHIA: 
WM. J. DORNAN, PRINTER 
1 890. A CASE OF CARIES OF THE ANKLE, TREATED 
CONSERVATIVELY. 
By CHARLES C. FOSTER, M.D., 
CAMBRIDGE, MASS. 
So much has been said and written of late concerning the opera- 
tive treatment of caries of joints, that I fear the value of conserva- 
tive treatment in such cases is not fully appreciated; therefore I 
wish to present the following case as an example. It was treated at 
the Cambridge Hospital over a year ago. 
At the time of beginning treatment the patient, Mary D., was twelve 
years old. For seven or eight years she had had caries of the tarsus. 
Of late the disease varied in activity from time to time. A sinus would 
open, discharge for some months, then close. The whole tarsus was 
completely riddled. I counted seven distinct scars, and was told that 
many of them had discharged more than once. 
If I had attempted anything like a thorough removal of diseased 
bone by resection, which thoroughness seems to be now considered 
necessary to success, I think little or nothing would have been left 
between the os calcis and the phalanges. The best result then to be 
hoped for would have been a flail-joint; which I do not consider good, 
though some others appear to. 2 
CARIES OF THE ANKLE. 
When the disease was quiescent she could use the foot a little, but 
was often laid up by a fresh attack. 
It seemed to me that the disease had about run its course, and was 
ready to stop if given a fair chance; but that walking upon the foot in 
its present position, equinus, so ground the affected bones together as 
to keep up sufficient irritation to prevent this. 
Waiting for a period of quiescence, when all sinuses had been closed 
for ten days, I operated. 
The condition at the time was as follows: The disease had lasted 
seven or eight years, and was still active. The tarsus seemed com- 
pletely riddled, and showed scars of seven old sinuses, one of which 
had been discharging up to ten days before. The tibia was about one 
and a quarter inches shorter than its mate. The general health was 
fairly good. 
I divided the plantar fascia thoroughly ; also the abductor pollicis 
and ten do Achillis. I found the skin under the instep glued tightly 
to the bones by old adhesions, which I dissected up with the tenotome, 
subcutaneously. 
I made no attempt to force the foot into position, or to break down 
adhesions. I did not use plaster-of-Paris, but applied a steel shoe with 
simple up-and-down motion, exerting at first only very gentle pressure. 
From day to day the pressure was carefully increased ; the foot steadily 
yielding, and approaching a normal position. No pain worth men- 
tioning was caused at any time. Later passive motion was carefully 
used to improve the flexibility of the joint. 
Now the question came up: "How near normal position shall I 
bring that foot, to insure the greatest usefulness ? " 
The tibia on that side being one and a quarter inches short, I left 
the tendo Achillis about one-half an inch shorter than normal, trusting 
to the tilting of the pelvis to compensate for the remainder of the 
shortening. 
The heel of the shoe for the affected foot was built up one-half an 
inch. This was not a case in which I could expect a perfect result, 
but must make the most of what material I had; which is the sum and 
substance of conservative surgery. 
When the patient had regained some power in the foot, and some 
control over it, I let her begin to use it; at first simply standing upon 
both feet at once, then taking a step or two leaning on somebody's arm, 
and so on; still wearing the steel shoe. 
Later I put her into a properly made pair of leather lace-boots; the 
one for the affected foot having a raised heel, a steel shank, and some CHARLES C. FOSTER. 
3 
building up under the instep to support it. She has worn such ever 
since. 
All this time she was being taught to walk; that is, if she used her 
foot clumsily, or walked with a " dot-and-go-one " gait, she was cau- 
tioned and made to do better. This training is very important in all 
foot cases; it is a good deal of trouble for the surgeon and for the 
parents, but if thoroughly carried out it pays well in the end. 
At first the leather shoes were worn only a short time daily; this 
time was gradually increased, the steel shoe being for some time longer 
worn at night as a precaution. When at last this was given up all 
treatment was finished. 
From the day of operation until now there has not been a single 
check or an unfavorable symptom. 
The foot is now surprisingly well shaped ; its motion is excellent, 
and it is under perfect control. The patient walks strongly, easily and 
smoothly, never complaining, even when questioned, of pain or fatigue. 
Such treatment is not so quick, so easy or so striking as a success- 
ful resection. The progress is slow. It takes a great deal of the 
surgeon's and of the parents' time and personal attention. But I 
claim that in this case, and in many others, the final result will repay 
the extra trouble. 
In the cases of resection that I have examined the foot has seemed 
to me rather clumsy and with but little motion. The patient has 
little or no control over it. Consequently the patient instead of 
walking with a natural " heel-and-toe " action, must stump upon it. 
Often for a long time they complain of some pain in the foot if too 
freely used. 
This is very natural, for in an average case the entire articulation 
with the leg, consisting of the astragalus and the tips of the tibia and 
fibula, is removed, leaving the weight of the body to be borne by the 
ends of the long bones resting directly upon the os calcis, probably 
also upon the scaphoid and cuboid. A pretty firm union is formed, 
but there is no true articulation. The whole arch of the tarsus is 
undoubtedly weakened. 
From the mobility of an ankle successfully treated by conservative 
methods it seems to me that the repair of the articulation must be 
more thorough than one would expect from the study of pathological 
specimens. Indeed, all caries of bone has a stronger tendency toward 
self-limitation and repair than many of us realize. The reparative 4 
CARIES OF THE ANKLE. 
power of periosteum, of cartilage, and of synovial membrane seems to 
be less, but it may be greater than we suppose. Well-treated cases 
do not often appear among pathological specimens. 
I believe few surgeons claim that the result of resection is any 
better than that of conservatism when successful. But they consider 
the results of resection far more certain. There I differ from them, 
if the conservatism be properly and thoroughly carried out. The 
avoidance of suffering is another plea for resection. In well-treated 
cases there is usually but little pain. The dangers and difficulties of 
prolonged confinement are often exaggerated. Children among good 
surroundings and with proper care thrive surprisingly in confinement. 
The long time necessary for a cure, and the amount of attention, 
both of the surgeon and of the parents, are often considered insuper- 
able obstacles. Yet I have never met parents, whose position in 
society was comfortable, who were not willing to meet the surgeon 
more than half-way, and to do all that he asked. If the surgeon 
himself have not the patience to put such a case through, he should 
not make orthopedics his specialty. 
I have been the pupil and the assistant of Buckminster Brown, and 
have seen in his practice what can be accomplished by such methods. 
I do not claim that all cases should be treated conservatively. I 
do not wish to condemn resection, but only to restrict its use. 
Dr. Henry J. Bigelow used to divide club-feet into two classes. 
" One class," he said, " can pay for treatment, and is cured; the 
other cannot pay, and is incurable.'' We have advanced a stage 
beyond this standpoint and can now give either class a serviceable 
limb; but the paying class can still command an excellence in the 
final result from which the poor patient is debarred by bad surround- 
ings and lack of attention, and the hospital patient by lack of time. 
For all such cases resection is the method, insuring them, as it 
does, a serviceable limb. But for the little girl destined to grow up 
a society belle, more is demanded. Her time in childhood is of little 
value, and should be sacrificed without hesitation, if by so doing the 
final result can be improved. The surgeon should labor to secure 
the very best possible result, the most finished, the most polished, so 
to speak. And I claim that such a result is most likely to be secured 
by intelligent, painstaking conservatism. 
The cut shows the cast taken before treatment was begun, and 
the foot as it appears eighteen months after treatment was completed.