McGlamry■s Comprehensive Textbook

of Foot and Ankle Surgery, Volume 1 2

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McGLAMRY'S
SECTION IV: Lesser 31 Lapidus Bunionectomy:
Metatarsophalangeal Joint First Metatarsal-Cuneiform
.Artb.rod.esis •••••••••••••••••• 322
Defonnities LAWRENCE A. DIDOMENICO .AND
MARl WARGO-DORSEY
19 Plantar Plate Repair of the Second
Metatarsophalangeal Joint ••••••• 187 32 Juvenile Hallux Abducto Valgus
CRAIG A. CAMASTA
Defo:.rmity • • • • • • • • • • • • • • • • • • • 331
DONALD R. GREEN, KIERAN T. MAHAN, AND
20 Transverse Plane Digital TRACY L. KLlMAZ
Defornlities •••••••••••••••••• 202 33 Joint Salvage and Preservation
MICHAELS. DOWNEY, MICHAEL C. McGLAMBY,
AND SARAH A SPIZZIRRI
Surgical Techniques for
Hallux I.Jnlitus •••••••••••••••• 343
21 The Well Lesser Metatarsal ANNALISA. Y. CO, TIIOMAS J. CHANG, AND
Osteotomy • • • • • • • • • • • • • • • • • • • 224 CRAIG A. CAMASTA
RICHARD J. ZIRM
34 First Metatarsophalangeal
22 Central Rays: V Osteotomy, DFWO, Joint Arthroplasty • • • • • • • • • • • • • 362
Condylectomy • • • • • • • • • • • • • • • • 229 JOHN V. VANORE, WILLIAM G. MONTROSS,
Wll..LlAM D. FISHCO .AND JEFFREYS. BOBERG A. LOUIS JIMENEZ, AND JONNICA S. DOZIER
23 Tailor's Bunion Deformity ••••••• 235 35 First Metatarsophalangeal Joint
SEAN PATRICK DUNN AND JANE PONTIOUS .Artb.rod.esis • • • • • • • • • • • • • • • • • • 400
TIIOMAS P. SMITH AND .ALLISON J.A. MENKE
P.AllT m: FIRST~ HALLUX 36 Complications in Hallux Abducto
ABDUCTO VALGUS, AND Valgus Surgery (Excluding Hallux
BBLATBD DBFORMITIBS Varus) •••••••••••••••••••••• 417
MOllY A. JUDGE
24 Evaluation and Procedural Selection
in Hallux Valgus Surgery •••••••• 245 37 Hallux Varus ••••••••••••••••• 461
MOllY A. JUDGE
JE.PPREY S. BOBERG
25 Anatomic Dissection of the First
Metatarsophalangeal Joint for Hallux P.AllT IV: BEABFOOT
Valgus Surgery. • • • • • • • • • • • • • • • 250
JOHN A RUCH, CHARI...ES P. PEEBLES, .AND SECTION I: Midfoot and Heel
CLAIRE A. HOU.STROM
Surgery
26 Hallux Osteotomies • • • • • • • • • • • • 260
TIIOMAS P. SMl1H AND JARED L. MOON 38 Common Pedal Prominences ••••• 471
TIIO.MAS P. SMITH AND LESI.JE B. DOWI.JNG
27 Distal Metaphyseal Osteotomies in
Hallux Abducto Valgus Surgery ••• 279 39 Plauc1tar 1Eieel•••••••••••••••••• 4~4
TIIOMAS A. BROSKY ll .AND PATRICK B. HALL JEFFREYS. BOBERG, DAMIEN M. DAUPHINEE,
D. SCOT MALAY, AND WILI.JAM HARRIS IV
28 Proximal Osteotomies of the First
Metatarsal • • • • • • • • • • • • • • • • • • • 290 40 The Distal Tarsal Tunnel: First
ROBB A. MOT.HERSHliD Branch of the Lateral Plauc1tar
Nerve R.elease ••••••••••••••••• 505
29 Offset-V Osteotomy of the First
ROBERT M. GOECKER
Metatarsal Shaft in Hallux Abducto
Valgus •••••••••••••••••••••• 302 41 Plantar Foot Surgery ••••••••••• 513
GARY R. BAUERAND HAROLD W. VOGLER J. MICHAEL MILLER AND St.JHA:rr.. B. MASADEH

30 Z-Scarf Osteotomy ••••••••••••• 314 42 Pes Cavus Surgery ••••••••••••• 525

CHARLES J. GUDAS CRAIG A. CAMASTAAND .ANDREA D. CASS
SECTION II: Valgus Foot 56 Tarsometatarsal Arthrodesis •••••• 810
SHrnE JOHN, ALAN R. CATANZARITI,
Defonnity AND ROBERT W. .MENDICINO

43 Ankle Equinus • • • • • • • • • • • • • • • • 541 57 Trephine Arthrodesis at the

MICHAELS. DOWNEY AND JACLYN M. SCHWARTZ Midfoot • • • • • • • • • • • • • • • • • • • • • 820
ANNETI'.E D. FllJA'f.RAULT
44 Fle::dble Valgus Deformity ••••••• 585
KIERAN T. MAHAN AND K. PAUL FLANIGAN 58 Triple Arthrodesis • • • • • • • • • • • • • 824
JOHN A. RUCH, LOPA DALMIA,
45 Tarsal Coalition ••••••••••••••• 598 AND PATRICK B. HALL
MICHAELS. DOWNEY AND ALISON M. DBWATERS
46 Posterior Tibial Tendon 59 Subtalar Joint Arthrodesis • • • • • • • 843
MARKAHARDY
~otion •••••••••••••••••• 636
ALAN R. CATANZARITI, ROBERT W. MENDICINO, 60 Talonavicular Fusions ••••••••••• 851
AND MICHAEL P. MASKILL wn.LIAM D. FISHCO

47 Medial Column Fusion•••••••••• 670 61 Pantalar Arthrodesis ••••••••••• 855

lHOMAS J. CHANG TRAVIS A. MOTLEY AND BRIAN B. CARPENTER

48 Arthroereisis ••••••••••••••••• 675

DONAlD R. GRBBN AND :MITZI L WILilAMS
VOLUME TWO
P.All.T VII: SPECIAL SUB.GBllY:
PAB.T V: ANKLE CONDITIONS

49 Os Trigonum Surgery •••••••••• 691 SECTION I: Rhewnatoid Foot

MOLLY A. JUDGE and Ankle
50 Acute Ankle Conditions ••••••••• 702
62 Rheumatoid Rearfoot. • • • • • • • • • • 863
MARK A HARDY AND GINA A HILD
LINNIE V. RABJOHN AND DANIELJ. YARMEL
51 Old Syndesmotic Injuries •••••••• 710
63 Pan Metatarsal Head Resection ••• 876
BRIAN B. CARP.BNTE.RAND 'f.RAVIS A MOTLEY
DENNIS E. MARTIN
52 Ankle Bqlacem.ent Arthroplasty •• 717
JOHN M. SCHUBERTH, ]ER.O.ME K. STECK,
AND JEFFREY C. CHRISTENSEN
SECTION ll: Neurologic Disorders
53 Arthroscopy of the Ankle 64 Spasticity and Paralytic
~d F()()t •••••••••••••••••••• 757 Disorders • • • • • • • • • • • • • • • • • • • • 884
JEFFREY C. CHRISTENSEN, .MEAGAN M. JENNINGS, R. DAVID WARREN
AND JOHN J. STIENS'f.RA 65 Charcot-Marie-Tooth Disease ••••• 892
54 Osteochondroses of the Foot ROBERT M. GOECKE.R, ALAN S. BANKS,
~d Anlde • • • • • • • • • • • • • • • • • • • 780 MICHAELS. DOWNEY, AND RICHARD J. ZIRM
LAWRENCE M. FALLAT,
JEFFREY C. CHRISTENSEN, AND SECTION III: Peripheral Nerve
JACOB A. HORD
Surgery
PAB.T VI: .MIDFOOT JOINT
.All.THB.ODBSIS 66 General Entrapment Syndromes ••• 912
D. SCOT MALAY, E. DALTON McGLAMBY,
AND MARIJA UGRINICH
55 Principles of Arthrodesis •••••••• 803
SEAN PATRICK DUNN, JUSTIN T. MEYER., 67 Tarsal 1\umel Syndrome •••••••• 934
AND JOHN A RUCH MICHAELS. DOWNEY AND D.AN.IEL J. YARME.L
68 Complex Regional Pain Syndromes 78 Achilles Tendon Disorders •••••• 1I8I
and Related Disorders • • • • • • • • • • 950 JAMES L. lHOMAS
JEFFREY C. CHRISTENSEN 79 Plastic and Reconstructive
Surgery • • • • • • • • • • • • • • • • • • • • 1193
SECTION IV: Diabetic Foot TOD It STORM AND MICHAELS. LEE

69 Evaluation and Management of 80 Bone Anchors • • • • • • • • • • • • • • • I222

lHOMAS A. BROSKY ll, MICHAEL C. McGLAMRY,
the Diabetic Foot Wound •••••••• 986 AND MITZI L. Wll.LlAMS
JOHNS. STEINBERG AND PAUL J. KIM
70 Charcot Foot and Ankle 81 Interpositional Arthroplas'ty" of
Defornti'ty" • • • • • • • • • • • • • • • • • • 1008 the First Metatarsophalangeal
TIIOMAS M. ZGONIS, JOHN J. STAPLETON, Joint ...•••...••••...••••.. 1231
AND TIIOM.AS S. ROUKIS CHRISTOPHER P. HYERAND
JAYMES D. GRANATA
71 Amputations • • • • • • • • • • • • • • • • I 022
ROBERT P. TAYLOR, JAMES L. BOUCHARD, 82 Lateral Column Arthroplas'ty" • • • • I234
AND LINNlE V. RABJOHN lHOMAS J. CHANG

SECTION V: Congenital PAllT IX: SPECIAL SUB.GBllY:

Defonnities .MISCBLLANBOUS TOPICS

72 Bradtymetatarsia • • • • • • • • • • • • • I 036 83 External Fixation of Rearfoot

MICHBLLB L. BUTTERWORTH AND and Ankle Arthrodeses ••••••••• I24I
DENNIS E. MARTIN BRADLEY M LAMM
73 Metatarsus Adductus and Allied 84 Pun~eWounds ••••••••••••• I254
Disorders • • • • • • • • • • • • • • • • • • • 1056 STEPHEN V. COREY AND MICHElLE L.
PATRICKS. AGNEW BUTTERWORTII
7 4 Clubfoot • • • • • • • • • • • • • • • • • • • I 079 85 Lower Extremi'ty" Infections • • • • • 1267
LUKE D. CICCHlNELLI, DAVID J. GRANGER, .MARK A. KOSINSKI AND WARRENS. JOSEPH
TODD It GUNZY, TODD B. HADDON,
AND JORGE G. PENAGOS VASQUEZ
86 Osuotnyelitis •••••••••••••••• I287
LAWRENCE M. OLOFP AND GEOFFREY S. HEARD
75 Congenital Digital Deformities••• I097
75.1 Polydaa:yly 1097 87 Non~ .................. 1309
.ANNETTE D. Fn.IA'I'RA.ULT STEPHAN J. LAPOINTE
75.2 Mac:rodactyly II06 88 Orthobiologics ••••••••••••••• I322
THOMAS A. BROSKY ll
D. SCOT MALAY AND Wll..LlAM HARRIS IV
75.3 Ectrodactyly ll09
CORNELIUS M. DONOHUE 89 Eled:rical and Mechanical
75.4 Syndactyly lll7 Bone Growth Stimulation • • • • • • I333
CARL R. WAGRBICH, RENATO J. GIORGINI, MICHAELS. DOWNEY AND
TARA L. GIORGINI WEN-YIN CHOI WANG

PAllT VID: SPECIAL SUB.GBllY: 90 Nonosseous Injuries. • • • • • • • • • • 1350

KEmiD.COOK
SOFTTISSUB
76 Principles of Muscle-Tendon PAllT X: TUMOJlS
Surgery and Tendon Transfers • • • II27
STEPHEN J. Mll..LERAND MACK JAY GROVES IV 91 Skin Lesions ••••••••••••••••• I363
D. SCOT MALAY AND MAIUJA UGIUNICH
77 Peroneal Tendon Disorders ••••• I165
LAWRENCE A. DIDOMENICO 92 Soft Tissue Masses • • • • • • • • • • • • 1387
AND MICHELLE C. ANANIA MICHAELS. DOWNEY AND CHRISTA M GREDLEIN
 93 Bone Tumors of the Foot 104 Metatarsal Fractures. • • • • • • • • • 1646
and .Ankle ••••••••••••••••• 1413 .MICHAELS. LEE AND LINDA HO
LAWRENCE S. OSHER, BRYAN D. CAlDWELL, 105 Midfoot Fractures • • • • • • • • • • • 1662
AND lllLARBE B. Mll..LIR.ON
TRAVIS A. MOTLEY AND BRIAN B. CARPENTER
94 Surgical Management of Bone 106 Tarsometatarsal (Lisfranc)
Tumors in the Foot and .Ankle. • 1474 Joint Dislocation •••••••••••• 1677
HILARBE B. MILLIRON, JOSEPH A. PAVAZZO,
LAWRENCE A. DIDO.MENICO AND
AND B. HUDSON BERREY
DAWN Y. STEIN
95 Plantar Fibromatosis ••••••••• 1486 107 Calcaneal Fractures •••••••••• 1685
MICHAELS. DOWNEY AND
MEAGAN M. JENNINGS AND
RANDALL J. CONTENTO
JOHN M. SCHUBERTII

108 Talar Fractures. • • • • • • • • • • • • • 1707

JOHN M. SCHUBERTII, SHANNON M. RUSH, AND
PART XI: TJlAU.MA MEAGAN M. JENNINGS

SECTION I: Acute Trauma 109 Ankle Fractures • • • • • • • • • • • • • 1739

LAWRENCE M. FAU.AT, THOMAS J . .MERl:W.L,
ZEESHAN S. HUSAIN, AND I<J.'ITRA T. OWENS
96 Open Fractures • • • • • • • • • • • • • 1499
MARK A. HARDY AND JORDAN P. GROSSMAN 110 Pilon Fractures • • • • • • • • • • • • • 1765
GEORGES. GUMANN AND JUSTIN J. PLBMING
97 Complex Soft Tissue Injuries:
Degloving and Soft Tissue U>ss I l l Pediatric Foot and Ankle
. • Fra.ctu.res • • • • • • • • • • • • • • • • • • 1786
InJ'Urles ••••••••••••••••••• 1508
RYAN H. FITZGERALD AND JOHNS. STEINBERG EDWIN J. HARRIS

98 Complications of Internal
F.txa.tion.
. ••••••••••••••••••• 1523 SECTION II: Repair of
JOHN V. VANORE AND WILIJAM G. MONTROSS Posttraumatic Injuries
99 Trauma to the Nail and Associated
Stru.ctu.res ••••••••••••••••• 1535
112 Neglected Calcaneal Fractures •• 1835
GEORGE T. LIU
D. SCOT MALAY AND ROBYN WINNER.
100 Management of Acute and Chronic 113 Ankle Malunions •••••••••••• 1849
BRADLEY M. LAMMAND JOHN E. HERZENBERG
Tendon Injury • • • • • • • • • • • • • • 1549
RYAN H. FITZGERALD 114 Supramalleolar Osteotomy ••••• 1874
SHANNON M. RUSH, AND JOHN M. SCHUBERTH
101 Achilles Tendon Trauma •••••• 1580
ALAN NG AND KEITH L. JACOBSON 115 Talar Avascular Necrosis •••••• 1890
CHRISTOPHER. F. HYERAND
102 Dislocations of the Foot WlUJ.AM T. DsCARBO
an.d .Ankle ••••••••••••••••• 1600
GRAHAM A. HAMILTON, LAWRENCE A. FORD, 116 Lisfranc Injuries. • • • • • • • • • • • • 1914
AND JOHANNA-MARIE RICHEY GEORGE P. W.ALLACB

103 Digital and Sesamoid 117 Fibular Lengthening • • • • • • • • • 1924

Fractures • • • • • • • • • • • • • • • • • • 1629 BYRON L. HUTCHINSON
MICHAELS. DOWNEY AND
GRETCHEN A LAWRENCE Inclc:::x. 1-1
Contributing Authors

Patriclt S. Agnew, DPM, FACFAS, Thomas A. Brosky II, DPM, Thomas ] • Chang, DPM, FACFAS
FACFAP FACFAS Faculty
Founder, Coastal Podiatry Group Faculty The Podiatry Institute
Virginia Beach, Virginia The Podiatry Institute Deatur, Gemgia
Past President, American College of Foot Attending Surgeon Clinical Professor and Pa.rt Chairman
and Ankle Pediatrics DeKalb Medical Center Depanment of Podiatric Surgery
Director, Podiatric Education Decatu~ Georgia Samuel Merritt School of
Eastern VIrginia Medical School Private Practice Podiatric Medicine
Norfolk, Vuginia Oakwood. Georgia Redwood Orthopedic Surgery Associates
Santa Rosa, California
Michelle C. Anania, DPM, FACFAS Michelle L. Butterworth, DPM,
Private Pn.ctice FACFAS Wcn-Ym Choi Wang, DPM,
An1tle and Foot Care Center:~~ Affiliate Member
.AACFAS
lbungato'WD, Ohio The Podiatry Institute
East Bay PhysidaDII Medical Group
Decatut; Georgia
Department of Podiatry
Alan S. Banks, DPM, FACFAS Private Practice
Advanced Wound Care Center
Faculty Pee Dee Foot Clinic
Sutter Delta Medical Center
The Podiatry Institute Kinptree, South Carolina
Antioch. c.illfornia
Deatur, Geagia
Private Pn.ctice Bryan D. Caldwell, DPM, MS
Village Podiatry Centers Professor and Dean Jeffrey C. Christensen, DPM,
Tucker, Georgia Clinical Educadon and Operations FACFAS
IWlt State University College of Pre.!ident and Founder
Podiatric Medicine Ankle and Foot Clinia Northwest
Gary R. Bauer, DPM Independence, Ohio
Associate Profe.olsor Emeritu.& Pa.rt Section Chliirman and
Department of Surgery Attending Surgeon
Temple University School of
Craig A. Camuta, DPM, FACFAS, Depanment of Orthopedia,
Podiatric Medicine
FACPS Podiatric Section
Philadelphia, Pennsylvania Faculty Swedish Medical Center
The Podiatry Institute Seattle, Washington
Decatut; Georgia
B. Hudaon Berrey, MD, FACS St. Joseph's Hospital
Profes.sor, Department of Atlanta, Georgia Luke D. Ciechinclli, DPM,
Orthopedic Surgery FACFAS
Chief, Sarcoma and Musculwkeletal Faculty
Brian B. Carpentao, DPM, FACFAS
Oncology The Podiatry Institute
Associate Professor
University of Florida Health Science Center Deatur, Gemgia
Department of Orthopedics
Jackaon'rille, Florida University of North Texas Health Private Pn.ctice
Science Center East Valley Foot and Ankle Speciiliat!
JeffreyS. Boberg, DPM, FACFAS Fon Worth. Texas Mesa, Arizona
Faculty
The Podiatry Institute Andrea D. Cast, DPM, AA.CFAS AnnaliJa Y. Co, DPM
Deatur, Geagia Faculty Faculty
Private Pn.ctice The Podiatry Institute
St. Louis, Missouri The Podiatry Institute
Decatu~ Georgia
Deatur, Gemgia
Private Practice Private Pn.ctice
Jamee L Bouchard, DPM, Smyrna, Georgia
Sacr.amento, California
FACFAS
Faculty Alan R. Catanzariti, DPM,
The Podiatry Institute FACFAS Randall J. Contento, DPM,
Deatur, Gemgia Affiliate Member .AACFAS
Private Pn.ctice The Podiatry Institute Private Pn.ctice
~enceriUe,Geo~ Decatut; Georgia Centnl Ohio Podiatty Group
The Western Pennsylvania Hospital Westeryille, Ohio
Philadelphia, Pennsylvania

X
 Contributing Authors xi

Keith D. Cook, DPM, FACFAS Cornelius M. Donohue, DPM Joseph A. Favazza, DPM
Director, Podiatric Medical Education Medical Director, Comprehensive Wound Assistant ProfeMOr
Unive.n ity Hospital Healing Center Department of Surgery
Unive.n ity of Medicine and Dentistry of Roxborough Memorial Hospital Ohio College of Podiatric Medicine
New Jersey Philadelphia, Pennsylvania Private Practice
Newark, New Jersey Twinsburg, Ohio
Leslie B. Dowling, DPM
Stephen V. Corey, DPM, FACFAS Faculty Danny R.. Fijalkowski, DPM
Faculty The Podiatry Institute Center for Podiatric Medicine
The Podiatry Institute Decatur, Georgia and Surgery
Decatur, Georgia Private Practice Belmont Community Hospital, a Division
Private Practice Waycross, Georgia of Wheeling Hospital
Pee Dee Foot Qinic Bellaire, Ohio
Kingstree, South Carolina Michael S. Downey, DPM,
FACFAS Annette D. Filiatrault, DPM, MS,
Timothy W. Crislip, DPM Faculty FACFAS
Private Practice The Podiatry Institute Faculty
Columbia Orthopaedic Group Decatur, Georgia The Podiatry Institute
Columbia, Missouri Clinical ProfeMOr and Former Chairman, Decatur, Georgia
Department of Surgery Private Practice
Lopa Dalmia, DPM Temple University School of Atlanta, Georgia
Faculty Podiatric Medicine
The Podiatry Inatitute Chief, Division of Podiatric Surgery William D. Fishco, DPM, MS,
Decatur, Georgia Penn PreJ~byterian Medical Center
.A&sociate Phyaician, Podiatric Surgery
FACFAS
Private Practice Faculty
Univenity of California Davis Ankle and Foot Medical Centers of the The Podiatry Institute
Health System Delaware Valley Decatur, Georgia
Citrus Heights, California Philadelphia, Pennsylvania Teaching Faculty
Maricopa Medical Center
Damien M. Dauphinee, DPM, J onnica S. Dozier, DPM Private Practice
FACFAS, FAENS, FACCWS, Staff Podiatrist Anthem, Arizona
CWS-P Carl Vinson Veterans Administration
Medical Director Medical Center Ryan H. Fitzgerald, DPM,
Center for Wound Healing and Dublin, Georgia AACFAS
Hyperbaric Medicine Private Practice
North Texas Hospital Sean Patrick Dunn, DPM Hess Orthopaedics and Sports Medicine
Denton, Texas Faculty Harrisonburg, Pennsylvania
The Podiatry Institute
William T. DeCarbo, DPM, Attending Surgeon K. Paul Flanigan, DPM,
AACFAS DeKalb Medical Center FACFAS
Fellowship Trained Foot and Decatur, Georgia Private Practice
Ankle Surgeon Staff Physician Portland Foot and Ankle
Faculty Northwest Georgia Medical Center Portland, Maine
Mountain Valley Foot and Ankle Gainemlle, Georgia
Reconstruction Fellowship Private Practice Justin J. Fleming, DPM,
The Orthopedic Group Oakwood, Georgia FACFAS
Pittsburgh, Pennsylvania Faculty
Cameron L. Eilts, DPM The Podiatry Institute
Alison M. DeWaters, DPM Faculty Decatur, Georgia
Private Practice The Podiatry Institute Chief, Foot and Ankle Service
Affiliated Foot and Ankle Center Decatur, Georgia Muscle, Bone and Joint Center
Howell, New Jersey Private Practice Director, Foot and Ankle Training
Sports Medicine Atlantic Orthopedics Aria Health System
Lawrence A. DiDomenico, DPM, Porumouth, New Hampshire Northwest Orthopedic Specialists
FACFAS Philadelphia, Pennsylvania
Adjunct ProfeMOr Lawrence M. Fallat, DPM,
Ohio College of Podiatric Medicine FACFAS Lawrence A. Ford, DPM,
Vwting ProfeMOr Clinical Assistant Professor FACFAS
Northeast Ohio Medical Univeraity Department of Family Practice Assistant Sul>Chief, Department of
Section Chief, Podiatric Medicine and Wayne State School of Medicine Orthopedics and Podiatric Surgery
Surgery Director, Podiatric Surgical Reaidency Kaiser Permanente
St. Elizabeth's Hospital Section Leader, Podiatry Program Director
Director, Reconstructive Rearfoot and Department of Surgery Kaiser San Francisco Bay Area Foot and
Ankle Surgical Fellowship Oakwood Hospital Ankle Residency
Ankle and Foot Care Centers Taylor, Michigan Oakland, California
Youngstown, Ohio
:x:ii Contributing Authon

R.m.ato J. Giorgini, DPM, Mack Jay Groves IV, DPM, William Harris IV, DPM,
FACFAS, FASPS, DABPS, FACFAS AACFAS
DABPO Facu1ty Private Practice
Section Chief, Podiatric Surgery The Podiatry Institute Lancaster, South Carolina
Director, Podiatric Medical Education Decatur, Georgia
Good Samaritan Medical Center St. Tammany Parish Hospital Geoffrey S. Heard, DPM
Professor, Division Surgical Sciences Covington, Louisiana Chairman, Podiatry Department
New York College of Podiatric Medicine Sequoia Hospital
Lindenhurst, New York Charles J. Gudas, DPM, FACFAS Redwood City, California
Private Practice Private Practice
Tara L. Giorgini, DPM, MD Charleston, South Carolina Belmont, California
Facu1ty
The Podiatry Institute George S. Gumann, DPM, John E. Herzenberg, MD, FRCSC
Decatur, Georgia
FACFAS Director, Pediatric Orthopedics
Casa di Cura Quisisana Director, International Center fur
Facu1ty
Rome, Italy Limb Lengthening
The Podiatry Institute
Decatur, Georgia Director, Limb Reconstruction Fellowship
Robert M. Goecker, DPM, Orthopedic Clinic Program
FACFAS Martin Army Hospital Rubin Institute for Advanced Orthopedics
Facu1ty Fort Benning, Georgia Sinai Hospital of Baltimore
The Podiatry Institute Clinical Professor, Department of
Decatur, Georgia Orthopaedics
Chief, Podiatric Foot and Ankle Surgery
Todd R. Gunzy, DPM, FACFAS
Affiliate Member University of Maryland School of Medicine
Sarasota Memorial Hospital Baltimore, Maryland
The Podiatry Institute
Private Practice
Decatur, Georgia
Sarasota, :florida
Director, Pediatric Foot and Ankle Medical Gina A. Hild, DPM
Mission Program PGYIII
ScanT. Grambart, DPM, Private Practice Kaiser Permanente, Cleveland Clinic
FACFAS Mesa, Arizona Foundation
Carle Physician Group Cleveland, Ohio
Carle Foundation Hospital
Clinical Instructor University of lliinois Todd B. Haddon, DPM, FACFAS
School of Medicine
Facu1ty Linda Ho, DPM
The Podiatry Institute Private Practice
Champaign, Dlinois
Decatur, Georgia Lorna Linda, California
Private Practice
Jaymes D. Granata, MD Mesa, Arizona Claire A. Hallstrom, DPM
Private Practice
Diplomate, American Board of
Lewis Center, Ohio
Patrick B. Hall, DPM Podiatric Surgery
Facu1ty Private Practice
David J. Granger, DPM, FACFAS The Podiatry Institute Ankle and Foot Center of Georgia
Orthopaedic and Spine Specialists Decatur, Georgia LaGrange, Georgia
York, Pennsylvania Bone and Joint Clinic of Baton Rouge
Baton Rouge, Louisiana Jacob A. Hord, DPM, AACFAS
Christa M. Gredlein, DPM, Facu1ty
FACFAS Graham A. Hamilton, DPM, Jewish Hospital Podiatry Residency
Private Practice Program
FACFAS
Baltimore, Maryland Louisville, Kentucky
Attending Surgeon
Department of Orthopedics and Private Practice
Donald R. Green, DPM, FACFAS Podiatric Surgery Shelbyville, Kentucky
Facu1ty Kaiser San Francisco Bay Area Foot and
The Podiatry Institute Ankle Residency Program Zeeshan S. Husain, DPM,
Decatur, Georgia Antioch, California FACFAS
Re.sidency Director Assistant Re.sidency Director
Scripps Mercy Kaiser Podiatric
Mark A. Hardy, DPM, FACFAS Podiatric Medicine and Surgery
Re.sidency Program Re.sidency
Staff
San Diego, California Detroit Medical Center
Ohio Pennanente Medical Group, Inc.
Clinical Professor Detroit, Michigan
Director, Cleveland Clinic Kaiser
California School of Podiatric Medicine
Permanente Foot and Ankle Residency
Oakland, California
Cleveland, Ohio Byron L. Hutchinson, DPM,
FACFAS
Jordan P. Grossman, DPM, Edwin J. Harris, DPM, FACFAS Program Director, Foot and
FACFAS Clinical Professor, Orthopaedics and Ankle Institute
Affiliate Member Rehabilitation St. Francis Hospital
The Podiatry Institute Loyola University Chicago, Stritch School Federal Way, Washington
Decatur, Georgia of Medicine Private Practice
Private Practice Chicago, lliinois Burien, Washington
Akron, Ohio
 Contributing Au.thon :x:iii

Christopher F. Hyer, DPM, MS, Paul J. Kim, DPM, FACFAS Geor~ T. Liu, DPM, FACFAS
FACFAS Associate Professor, Department of Assistant Professor
Fellowiliip Co-Director Plastic Surgery Depanment of Orthopaedic Surgery
Advanced Foot and Ankle Surgical Division of Wound Healing and Hyperbaric University of Texas Southwestern
Fellowiliip Medicine Medical Center
Orthopedic Foot and Ankle Center Georgetown University Hospital Parkland Memorial Hospital Level I
Westerville, Ohio Washington, District of Columbia Trauma Center
Dallas, Texas
Kcith L. Jacobson, DPM, Tracy L. Klim.az, DPM, AACFAS
FACFAS Private Practice Kieran T. Mahan, DPM, FACFAS
Committee Member Virginia Beach, Virginia Faculty
Highlands-Presbyterian St. Luke's The Podiatry Institute
Residency Program Constantine S. Kokenes, MD Decatur, Georgia
Advanced Orthopedic and Sports Medicine Depanment of Anesthesiology Associate Dean for Academic Affairs
Specialists DeKalb Medical Center Chair and Professor, Department of
Denver, Colorado Decatur, Georgia Podiatric Surgery
Temple University School of
Meagan M. Jennings, DPM, Mark A. Kosinski, DPM, FIDSA Podiatric Medicine
FACFAS Professor, Department of Medical Philadelphia, Pennsylvania
Depanment of Orthopedics and Podiatry Sciences
Palo Alto Medical Foundation New YOrk College of Podiatric Medicine D. Scot Malay, DPM, MSCE,
Chief of Podiatry New YOrk, New York FACFAS
El Camino Hospital Instructor, Department of Surgery Faculty
Mountain View, California New YOrk Medical College The Podiatry Institute
Valhallah, New York Decatur, Georgia
A. Louis Jimenez, DPM, FACFAS Director of Podiatric Research and
Faculty Bradley M. Lamm, DPM, FACFAS Staff Surgeon
The Podiatry Institute Head ofFoot and Ankle Surgery Penn Presbyterian Medical Center
Decatur, Georgia International Center for Private Practice
Program Director, Atlanta VAMC Podiatric Limb Lengthening Ankle and Foot Medical Centers of the
Residency Program Director, Foot and Ankle Deformity Delaware Valley
Past President, American College Foot and Correction Fellowship Philadelphia, Pennsylvania
Ankle Surgeons Rubin Institute for Advanced
Private Practice Orthopedics Dennis E. Martin, DPM, FACFAS
Gwinnett Foot, Ankle Leg Centers Sinai Hospital Faculty
Snellville, Georgia Baltimore, Maryland The Podiatry Institute
Decatur, Georgia
Shine John, DPM, AACFAS Adam S. Landsman, DPM, PhD, Private Practice
Foot Specialists FACFAS North Charleston, South Carolina
Cedar Park, Texas Assistant Professor of Surgery
Harvard Medical School Subail B. Masadeh, DPM, FACFAS
Warren S. Joseph, DPM, FIDSA Chief, Division of Podiatric Surgery Faculty
Consultant Cambridge Health Alliance American Health Network Fellowship
Lower Extremity Infectious Diseases Cambridge, Massachusetts Advanced Reconstructive Foot and
Roxborough Memorial Hospital Ankle Surgery
Philadelphia, Pennsylvania Stephan J. LaPointe, DPM, PhD, Private Practice
FACFAS Muncie, Indiana
Molly A. Judge, DPM, FACFAS Faculty
Director, Publications and Research The Podiatry Institute Michael P. Maskill, DPM
Podiatric Residency Program Decatur, Georgia Orthopaedic Associates of Kalamazoo
Cleveland Clinic Foundation-Kaiser Private Practice Depanment of Foot and Ankle Surgery
Permanente Foundation Rome, Georgia Kalamazoo, Michigan
Cleveland, Ohio
Adjunct Faculty Gretchen A. Lawrence, DPM, E. Dalton McGlamry, DPM, DSc
Ohio University and Colleges of AACFAS (Hon), DHL
Podiatric Medicine Private Practice Founding Member
Faculty Waynesville, North Carolina The Podiatry Institute
Graduate Medical Education Decatur, Georgia
Mercy Health Partners Michael S. Lee, DPM, FACFAS
Private Practice Adjunct Clinical Professor Michael C. McGlamry, DPM,
Toledo, Ohio Des Moines University FACFAS
Past President Faculty
CarlA. Kihm, DPM American College of Foot and The Podiatry Institute
Faculty Ankle Surgeons Decatur, Georgia
The Podiatry Institute Private Practice Private Practice
Decatur, Georgia Capital Orthopaedics and Sports Cumming, Georgia
Private Practice Medicine, PC
Douglasville, Geor gia Clive, Iowa
xiv Contributing Authon

Robert W. Mendicino, DPM, William G. Montross, DPM, Lawrence S. Osher, DPM

FACFAS FACFAS Professor, Department of
Foot and Ankle Surgery Attending Physician Podiatric Medicine
Pinnacle Orthopedic AMociates Denver Veterans Administration Hospital Ohio College of Podiatric Medicine
Salisbury, North Carolina Podiatric Residency Independence, Ohio
Denver, Colorado
Allison J.A. Menke, DPM, Assistant Clinical Professor Kittra T. Owens, DPM
Rocky Vista Osteopathic College Division Officer, Departtnent of
AACFAS Parker, Colorado Orthopedics
Faculty
Naval Hospital
The Podiatry Institute
Decatur, Georgia Jared L. Moon, DPM Camp Lejeune, North Carolina
Attending Surgeon Faculty
DeKalb Medical Center The Podiatry Institute Charles F. Peebles, DPM,
Decatur, Georgia Decatur, Georgia FACFAS
Private Practice Faculty
Chicago, lliinois The Podiatry Institute
Thomas J. Merrill, DPM,
FACFAS Decatur, Georgia
Faculty James H. Morgan Jr, DPM, Private Practice
The Podiatry Institute FACFAS, FAAPSM Atlanta, Georgia
Decatur, Georgia Faculty
Professor of Surgery The Podiatry Institute Jorge G. Penagos Vasquez, MD
Barry University School of Decatur, Georgia Chief, Department of Orthopaedic Surgery
Podiatric Medicine Private Practice and Foot and Ankle
Miami Shores, F1orida Mobile, Alabama Pediatric Foundation of Guatemala City
Residency Director Guatemala City, Guatemala
Mercy Hospital R.obb A. Mothenhed., DPM,
Miami, F1orida FACFAS Kcith D. Pfeifer, DPM
Faculty Assistant Residency Director
Amanda Meszaros, DPM, The Podiatry Institute Eisenhower Army Medical Center
FACFAS Decatur, Georgia Fort Gordon, Georgia
Co-Chair, Departtnent of Surgery AOA!umnus
Mercy Allen Hospital Departtnent of Orthopedics Jane Pontious, DPM, FACFAS
Private Practice University of Washington Faculty
Oberlin, Ohio Seattle, Washington The Podiatry Institute
Private Practice Decatur, Georgia
Winston-Salem, North Carolina Chair, Department of Surgery
Justin T. Meyer, DPM
Faculty Assistant Dean of Clinical Education
The Podiatry Institute Travis A. Motley, DPM, MS, Temple University School of
Decatur, Georgia FACFAS Podiatric Medicine
Private Practice AMociate Profe880r Philadelphia, Pennsylvania
Santa Barbara, California Departtnent of Orthopaedic Surgery
Bone and Joint Institute
Donald R. Powell, DPM
University of North Texas Health
Andrew J. Meyr, DPM, AACFAS Faculty
Science Center
Assistant Profei550r, Departtnent of The Podiatry Institute
Fort Worth, Texas
Podiatric Surgery Attending Surgeon
Temple University School of DeKalb Medical Center
Podiatric Medicine Aprajita Nakra, DPM, FACFAS Decatur, Georgia
Philadelphia, Pennsylvania Faculty
The Podiatry Institute
Decatur, Georgia Linnie V. Rabjohn, DPM,
J. Michael Miller, DPM, FACFAS FACFAS
Private Practice
Director of Fellowship Training
Phoenix and Gilbert, Arizona Private Practice
Foot and Ankle Reconstructive
Arlington/Mansfield Foot and
Surgical Service
Alan Ng, DPM, FACFAS Ankle Centers
American Health Network
Advanced Orthopedic and Sports Arlington, Texas
Indianapolis, Indiana
Medicine Specialists
Stephen J. Miller, DPM Residency Committee Highlands/ Johanna-Marie Richey, DPM, BBS
Presbyterian St. Luke's Medical Center Chief Resident
Faculty
Denver, Colorado Kaiser San Francisco Bay Area Foot and
The Podiatry Institute
Decatur, Georgia Ankle
Anacortes, Washington Lawrence M. Oloff, DPM San Francisco, California
Diplomate, American Board of
Podiatric Surgery
Hilaree B. Milliron, DPM
Sports Orthopedic and Rehabilitation
Private Practice
(SOAR) Medical Group
Jacksonville Beach, F1orida
Redwood City, California
 Contributing Autlwrs XV

Thomas S. Roukis, DPM, PhD, Sarah A. Spizzirri, DPM, AACFAS Marija U grinich, DPM, AACFAS
FACFAS Private Practice Staff Surgeon
Department of Orthopaedia Christie Clinic Penn Presbyterian Medical Center
Podiatry and Sporu Medicine Champaign, Illinois Private Practice
Gundenen Lutheran Medical Center Ankle and Foot Medical Centers of the
La Crosae, Wisconsin John J. Stapleton, DPM, FACFAS Delaware Valley
Foot and Ankle Surgery Philadelphia, Pennsylvania

John A. Ruch, DPM, FACFAS VSAS Orthopaedics

Chief of Podiatric Surgery John V. Vanore, DPM, FACFAS
Director of Medical Education
Leigh Valley Hospital Faculty
The Podiatry Institute The Podiatry Institute
Allentown, Pennsylvania
Attending Surgeon Decatur, Georgia
Clinical Assistant Professor of Surgery
DeKalb Medical Center
Penn State College of Medicine Private Practice
Decatur, Georgia Gadsden, Alabama
Private Practice Hershey, Pennsylvania
Village Podiatry Centers Harold W. Vogler, DPM, FACFAS
Tucker, Georgia Jerome: K. Steck, DPM, FACFAS
Private Practice Past Chairman, Department of Surgery
Southern Arizona Orthopedics Pennsylvania College of
Shannon M. Rnsh, DPM, FACFAS Tucson, Arizona Podiatric Medicine
Director, Silicon Valley Foot and Philadelphia, Pennsylvania
Ankle Fellowship Past Chairman, Section of Foot and
Palo Alto Medical Foundation
Dawn Y. Stein, DPM, CWS Ankle Surgery
Department of Podiatry Sarasota Memorial Hospital
Mountain View, California
Grove City Medical Center
Partner and Fellowship Director
Grove City, Pennsylvania
Sarasota Orthopedic Associates
Jay D. Ryan, DPM, AACFAS Sarasota, Florida
Faculty JohnS. Steinberg, DPM,
The Podiatry Institute FACFAS Carl R. Wagreich, DPM
Decatur, Georgia Associate Professor Associate Clinical Professor
Staff Physician Department of Plastic Surgery University of Southern California
Inova Fair&x Hospil31 Georgetown University School Los Angeles, California
Fairfax, Vrrginia of Medicine Residency Director
Program Director HealthSouth Surgery Center of South BayI
John M. Schuberth, DPM MedStar Washington Hospital Center Baja Project Surgical Residency Program
Faculty Podiatric Residency Torrance, California
The Podiatry Institute Co-Director, Center for Wound Healing Co-Director, Baja Project for
Decatur, Georgia MedStar Georgetown University Hospital Crippled Children
Chief, Foot and Ankle Surgery Washington, District of Columbia Mexicali, Mexico
Department of Orthopedic Surgery
Kaiser Foundation Hospital John J. Stienstra., DPM, George F. Wallace, DPM,
San Francisco, California FACFAS FACFAS
Department of Orthopedics Director, Podiatry Service
Jaclyn M. Schwartz, DPM The Permanente Medical Group Medical Director, Ambulatory Care Services
Senior Resident Union City, California University Hospital
DeKalb Medical Center University of Medicine and Dentistry of
Decatur, Georgia Tod R. Storm, DPM, FACFAS New jersey
Active Staff Newark, New jersey
Thomas F. Smith, DPM, FACFAS Bozeman Deaconess Hospital
Faculty Bozeman, Montana Marl Wargo-Dorsc:y, DPM,
The Podiatry Institute AACFAS
Decatur, Georgia Robert P. Taylor, DPM, FACFAS Private Practice
Chainnan, Podiatry Section Faculty The Ankle and Foot Care Centers
University Hospil31 The Podiatry Institute Boardman, Ohio
Podiatry Staff Decatur, Georgia
Charlie Norwood VAMC Adjunct Faculty R. David Warren, DPM,
Augusta, Georgia Department of Medicine FACFAS
Consultant Baylor Medical Center Private Practice
Eisenhower Army Medical Center Garland, Texas Arlington, Texas
FortGordon,Georgia Private Practice
Frisco, Texas Steven A. Weiskopf, DPM,
Joe T. Southerland, DPM, FACFAS FACFAS
Faculty James L. Thomas, DPM, Faculty
The Podiatry Institute FACFAS The Podiatry Institute
Decatur, Georgia Chief, Division of Foot and Ankle Decatur, Georgia
Private Practice Department of Orthopaedic Surgery Private Practice
Arlington/Mansfield Foot and University of Florida Woodstock, Georgia
Ankle Centers Jacksonville, Florida
Arlington, Texas
xvi Contributing Authon

Mitzi L. Willianu, DPM, FACFAS Jon M. Wilson Jr, DPM, AACFAS Thomas M. Zgonis, DPM,
'\bung Affiliate Member Department of Surgery FACFAS
The Podiatry Institute St. Tammany Parish Hospital Associate Profe.ssor, Department of
Decatur, Georgia Lakeview Regional Medical Center Orthopaedics
Attending Surgeon Covington, Louisiana Division Chief, Externship
San Francisco Bay Area Foot and Ankle Fellowship Program Director
Residency Program Robyn Wmner, DPM Universitr of Texas Health Science Center
Department of Orthopedics and Private Practice San Antonio, Texas
Podiatric Surgery Seattle, ~asbington
Kaiser Permanente Hospital Richard J. Zirm, DPM
Oakland, California
Daniel J. Yarmd, DPM, AACFAS, Facultr
AAPWCA The Podiatry Institute
Jason J. Willis, DPM, AACFAS Private Practice and Attending Facultr Decatur, Georgia
Attending Podiatrist Pinnacle Health Hospitals Department of Surgery
Foot Centers of Texas Harrisburg, Pennsylvania Southwest General Health Center
Methodist Sugar Land Hospital Private Practice
Sugar Land, Texas Cleveland, Ohio
Foreword

The fourth edition of MtGlmnry's Comprilunsive To:tbooll. ofFoot perioperative management, which includes the various aspects
and AnA:le SurF'J has ~n written to meet the current need that one encounters in foot and ankte surgery. The next 50
for a comprehensive work on foot and ankle surgery, not only chapters follow guidelines of anatomical sites where foot and
for podiatric surgeons but also for orthopaedic foot and ankle ankle surgery is performed, beginning with nail surgery and
surgeons, who are making valuable contributions to this field. concluding with midfoot and hindfoot arthrodesis. The section
Foot and ankle surgery has evolved at a rapid pace over the on first ray, hallux abducto valgus, and related deformities is
past 80 yeara. Not until an understanding of foot and ankle especially noteworthy, with 14 chapters on the subject cover-
biomecl\anics and the principles of AO-ASIF were materially ing virtually every aspect of contemporary correction of bun-
refined was this surgery practiced with precision. Prior to that ion deformities and their complications. This is true as well for
time, functional arthroplasty and fusion dominated the field. the section on trauma, with 18 comprehensive chapters on the
Orthopaedic companies assisted in that revolution with the subject.
development of unique designs of internal and external fixa. This book is designed to be a use11-friendly and clinically ret-
tion that brought the surgical results into a functional cure evant text on common foot and ankle surgery procedures. A3.
rather than a palliative "fix." the discipline becomes more and more sophisticated, it is obvi-
In concert with this revolution, E. Dalton McGlamry, DPM, ous that the technical component of operative intervention is
founded the Podiatry Institute in Atlanta and soon thereafter critical to clinical success or failure. Therefore, there continues
edited the text Ftt.tttlamm.tals ofFoot Surgery and the first edition to be an important need to understand the technical aspects of
of TM Comprthtm.ri:ue Textboolr. aJ Foat Stt.rgtry. Dr. McGlamry was foot and ankle surgery. Many pearls of wisdom are detailed by
a great inspiration to all podiatric surgeons, and his legacy has the authors in order to deal with the multiple potential pitfalls
been carried on by many of his residents and colleagues. seen in patients with complex foot and ankle deformities.
This two>rolume edition of McGIDmry 's Comfmhensive Thaboolt I have often said that "surgery is both a science and an art,
of Foo' and AnAlt Stt.rgr:ry, edited by Joe T. Southerland, DPM, but foot and ankle surgery may be more art than science." This
and assisted by 151 authors, consists of 117 chapters and more text should prove to be the resource of choice for modern foot
than 1,900 pages and is worthy of comparison with Campbtll's and ankle surgery care over the next several years. It will serve
Opt:rative OrtlwjNuli.cs. Virtually every aspect of foot and ankle those who are novices in the field who wish to concentrate on
surgery has been covered, from ingrown nails to total ankle principles, those experienced surgeons who wish to fine-tune
arthroplasty and hybrid external fixation. their approach, and everyone in between.
To overcome the widespread conception of foot and ankle
surgery as a purely mechanical equation, an e.ffort is made in Lowtll Scott Wal, St; DPM
the first section of this text to correlate the technical princi- WalFDOt andAnAI.e IruUtuu
ples used in this subspecialty. This is followed by a section on Des PWinu, .llmwis
Preface

It is with great pleasure that we present the fourth edition of textbook has been printed in full color throughout, greatly clar-
MeGlmnry's Comjmi&Muive Tmlxxile ofFoot and AnA:le Su'l'{lfi"Jo The ifying the appearance of disorders, diagnostic signs, and surgi-
goal of this text, as always, is to help students build a good foun- c.allandmarks and bringing the operative steps to life.
dation, to help residents develop their skills, and to help Slll'- As the lead editor, I extend my gratitude to the S&tion edi-
geons hone their teclmique. tors for their work in helping make this a reality. However,
Like the three previous editions, this book encompasses all most appreciated are the authors, without whom a book of this
faceta of foot and ankle surgery. This edition, however, places sort cannot exist. Amid the responsibilities of practice, teach-
greater emphasis on an instructional approach so as to better ing, and family lives, they were able to find the time needed to
help the surgeon, resident, or student SIN! how the procedures write these chapters. Unfortunately, this edition is missing one
are done. It has been completely reorganized to present con- esteemed author, Gerard V. 'fu, who passed away unexpectedly
tent in a more logic.al fashion. Divided into 12 parts across 2 in 2005.
volumes, it begins with basics such as biomaterials and pain It has been a several-year journey since we started work on
management and moves through anatomic locations, physi· this book, and I am very proud to be a part of it. It is my hope
ologk conditions, special surgery, tumors, and trauma. This that it delivers what we set out to do.
fourth edition has dozens more chapters and contributors
than earlier volumes, making it the most truly comprehensive
~ve Tmboolr. so far. In addition, for the first time, the
Introduction

& the dir~tor of Medical Education of the Podiatry Institute, I n~ssary to complete even a single article. That the dedicated
am proud to provide the Introduction for the fourth edition of faculty of the Podiatry Institute have stuck together for over
McGlmnry's Comfmhmsi:ve Textbook. ofFoot tmdA.nAlt Su.rgtry. 40 years and overseen the publication of a major textbook on
This textbook is the ongoing testament to the life passion foot and ankle surgery through four editions is a remarkable
of E. Dalton McGlamry, DPM. This ambitious project was con- feat. One of our dearest members, the late Gerard Vmcent 'fu,
ceived SO years ago under the direction of Dr. McGlamry. The deserves special mention. His many contributions to podiatric
supporting staff included graduates of the original Doctor's education, his drive and energy, his integrity, his love of the
Hospital Podiatric Residency and many other highly talented profession, and his commitment to colleagues and friends have
and dedicated educators in the podiatric profession. inspired and always will inspire us.
The first edition, called simply Ctmt.prthmsivt Textbook. ofFtJIJt The contributing authors for this textbook throughout its
Su.rgt:ry, took several years to compile and edit and was pub- lifespan so far are too many to mention individually, but with-
lished in 1987. It could not have been completed without the out each and every one of them those editions could not have
tireless support of Dalton's wife, Bed.y, who served the unenvi- been completed. I would like to recognize and salute each of
able roll as authors' editor. The second edition was produced the individuals who once again have sacrificed their personal
in 1992 under the guidance of editors Dalton McGlamry, Alan time and energy to perpetuate this information.
Banks, and Michael Downey. The third edition was released in The completion of this edition of MtGWmry ~ Cnm.JmlwMw
2001 with Alan Banks, Michael Downey, Dennis Martin, and Textboolc ofFoot tmd A.nkl.e Surgery could not have been possible
Steve Miller serving as editors. You now hold the fourth edition. without the tireless efforts of Mr. Dan Vickers, the ex~utive
Our many thanks are owed to editors Joe Southerland, Jeffrey director of the Podiatry Institute. It has been Dan's commit-
Boberg, Michael Downey, Aprajita Nakra, and Linnie Rabjohn ment and support to the project, to the institute, and to each of
for their countless hours of work. us that has kept us on track to reach our goal once again.
Anyone who has attempted to produce a scientific paper
knows the many hours of commitment and effort that are John A. Ruch, DPM
Basics
 SECTION
Technicsl Principles I
CHAPTER
D. Scot Malay

l Robyn Winner

Instrumentation
Surgical instrumentation is highly specialized, and it has been instruments is also beneficial with respect to instrument
said that there is a tool for every maneuver. In many instances, performance and durability. High-quality surgical scissors,
multiple instruments serve the same function, and each sur- for instance, have finger rings and handles made of 300 series
geon develops his or her own preferences. All foot and ankle alloy, blades made of 400 series alloy, and tungsten-carbide
surgeons should familiarize themselves with the basic set of blade edge inserts.
podiatric surgical instruments. A thorough understanding of
the design and proper use of the basic tools enable the surgeon
to operate with comfort and proficiency. SURGICAL BLADES
The scalpel is the instrument of choice for precise, atraumatic
METALLURGY AND MANUFACTURING division of tissue. The scalpel consists of a handle portion and
a blade portion. BLades may be detachable and thereby replace-
High-quality surgical instruments are typically made of austen- able, or the scalpel may consist of a solid piece of steel that
itic (300 series) or martensitic (400 series) stainless steel. These requires periodic sharpening of the blade. The handle portion
iron-baaed alloys contain carbon, chromium, nickel, and molyb- of the scalpel may differ in size. The no. 8 handle is most com-
denum as essential elements in their production. The presence monly used for foot and ankle surgery (Fig. 1.2). The handle
of carbon makes the steel extremely hard, whereas chromium should have an engyaved metric scale on one side. The scalpel
primarily allows resistance to corrosion. The formation ofa pu- can be held between the thumb and third finger, with the index
sive layer ofchromium oxide on the surface of the alloy imparts finger placed along the back of the blade. This is referred to as
corrosion resistance. Corrosion-resistant alloys, when properly the pencil grip and is used in foot and ankle surgery because
manufactured, are capable of replenishing the inert chromium it provides excellent control for making precise incisions
oxide layer after mechanical disruption. Repassivation spon- (Fig. 1.3). When it is held in the reverse fashion, the scalpel han-
taneously occurs when exposed chromium within the alloy dle may also be used to assist in separating the subcutaneous
cowlently bonds with oxygen from the aqueous environment tissue from the deeper layers. This is commonly performed in
of the tissue fluids. The presence of the other elements in the the reflection of the subcutaneous tissue from the medial aspect
molecular configuration of the stainless steel allows the manu- of the first metatarsophalangeal joint in hallux abducto valgus
facturer to manipulate the alloy's ductility, malleability, tough- surgery (Fig. 1.4).
ness, and corrosion resistance further. When extreme hardness Scalpel blades are also available in various sizes and shapes
is required for a specific component of the surgical instrument, (Fig. 1.5). Blades are constructed of high-quality surgical steel,
such as the grasping surface of a needle holder, a tungsten-call- with the cutting edge honed to a width of approximately
bide insert is often used (Fig. 1.1). 0.015 inch. The scalpel blade is designed strictly for incising
The most useful implantable alloy, austenitic stainless tissues, and the belly of the blade should be used as the pri-
steel, is designated in manufacturing terms as 800 series alloy mary cutting edge. Scalpel blades should not be used for pry-
or, more specifically, 816LVM. Austenitic stainless steel offers ing because they may easily break within the wound. Reversing
superior corrosion resistance, malleability, and ductility in the instrument and prying or bluntly separating with the han-
comparison with the harder martensitic (400 series) steel dle portion of the scalpel may be useful. Separate blades are
alloys. Austenitic stainless steel is ideal for the production of usually used for incising the skin and deeper tissues. The broad
metallic implants, such as screws, plates, pins, and other fixa. no. 10 blade functions well as the skin knife in most cases,
tion devices, because of the alloy's ability to resist corrosion. although the smaller no. 15 blade may be desirable for mak-
Austenitic alloys are also used to manufacture forceps and ing precise skin incisions on the digits. The no. 15 blade is also
retractors in which resilience is a necessary property of the most commonly used as the deep knife. The no. 11, or bayonet,
instrumenL Martensitic alloys are used to manufacture cut- blade is useful for performing open Z-plasty tenotomy, as well
ting instruments that must maintain sharp edges and accu- as incising superficial abscesses for drainage. Some surgeons
rate jaw alignment, such as osteotomes, scissors, curettes, find the smaller Beaver blades (nos. 64, 67, and 81) and match-
and rongeurs. The combination of austenitic and martensitic ing handle useful for digital arthroplasty as well as for nail plate
alloys for specific component parts of high-quality surgical and bed incisions.

3
Figm.'e 1.1 Needle driver with a tungmm-carbide imert.

Figutc 1.2 A Do. ~ scalpel handle with an engraved metric B<:ale.

Figa.re 1.4 The reverse end of the l!CIIlpel may be wed to help sepa-
rate the subcutaneous tis!ue from deeper layers.

Figaa.'e 1.3 The pencil grip may be used to hold d:le l!CIIlpel handle.

SCISSORS
Besides the scalpel, scissors are the instruments most commonly
used for tissue dissection (Figs.1.6and 1.7). Scissors also serve as
the general-purpose instrument for cutting sutures, bandages,
and other materiala. Tissue scissors are finely constructed of sur-
gical s~l and are of lighter weight compared with the heavier
suture cutting and utility scisaora. Diasecting scisaora are designed FJgare 1.5 Surgical blade.! (top to bottom): DO. 10, no. 11, DO. 15,
to cut soft tissues only and should not be used to cut other mate- and no. 62 on a minihandle.
rials. These instruments are best grasped with the thumb and
ring fingers in the finger rings, with the index finger stabilizing
the hinge region of the sci.uors and the middle and little fingers surface, whereas curved blades aid in deeper dissection. The
on either &ide of the lesser digital finger ring (Fig. 1.8). curved design of dissecting scissors enhances visualization of
The blunt tips of dissecting sciMors are best used for spread- the cutting field, improves directional mobility, and readily
ing and cutting tissues, and thumb forceps are usually held in allows tissue separation along smooth curves. Heavier blunt-
the contralateral hand to manipulate tissues. The blades of the tipped Mayo scissors are used for cutting thick bands of fascia
scissors should not be closed without first visualizing the tips. and ligament; they are available with either straight or curved
Tungsten-carbide blade inserts prolong the maintenance of blades. The lighter Metzenbaum scissors have narrow, slightly
a &harp cutting edge. Straight blades are used near the wound curved, blunt-tipped blades that are ideal for subcutaneous
 Figm.'e 1.6 Mettenbaum acillsor:~~.

disa&tion and cutting lighter fascial and capsular structures.

The fine cutting blades of the lightweight iris scissors are suited
only for delicate tissue dissection, and careful manipulation of
the sharp tips of this instrument is necessary. The short, broad-
blade, colla:Nnd-crown, or Sistrunk, scissors are occasionally
used for accurate dissection of osseous structures such as sesa-
moid bones. Figm.'e 1.8 Grasping the aci.!sora.
Suture scissors usually have straight blades with blunt tips
that reduce the chance of inadvertent injury to nearby tissues.
When deep sutures are cut, the tips of the scissors are placed HEMOSTATIC FORCEPS
about the suture and the blades are slid down to the level of the
knot; they are turned approximately 25 degrees, and, with the Hemostats are hinged instruments composed of a set ofjaws, fin.
tips in full view, the scissors are closed. In cutting deep sutures ger rings, and a loc.king mecl\anism (Fig. 1.9). They are the pri·
that are under a large amount of tension, a small tag of suture mary means of acquiring hemostasis during anatomic dissection
should be left above the knot. A larger tag is left when one is and are also useful fur bluntly spreading tissues. Many types of
cutting skin sutures that will be removed later. Often, general hemostatic forceps are av.ailahle, and those most commonly used
utility scissors, which come in various sizes, are used for cutting in foot surgery include the mosquito (Halsted), Crile, and Kelly
sutures. Stainless steel monofilament wire sutures are cut with designs. Hemostaticjaws are straight or curved, with lle!Tations that
wire-cutting scissors. run either perpendicular or parallel to the long axis of the jaws.
Bandage scissors are designed with a flat, plow-like lower The .furceps close with force about the vessel and lock and thereby
blade tip that protects the patient from inadvertent injury dur- crush the contained tissue that will be ligated. H the clamped po~~o
ing bandage removal. Ideally, a wound should be undressed tion ofve&'Jel is to remain functional, such as in vascular reconstruc-
without cutting the deep layers of the bandage. All house staff tion, a noncrusbing or controlled-closure hemostat must be used.
members and medical students should carry, and have readily Hemostatic metal clips may also be used to obtain ~~&ure ligation
available, a clean, sharp pair of bandage scissors. of ves.sels in sites that are poorly accessible with hand ties.

Figm.'e 1.7 Scillsora (left, top to bottom, dlen right, top to bottom.): ban~, wire-cutting, Mettenbaum,
crown-and-collar or Simunk, irU, and Mayo.
F.igure 1.9 Halated (mosquito) hemostatic forceps.

THU.'MB FORCEPS
F.lgu.re 1.11 Assorted tn.ction forcep (top to bottom): Backhaua
Thumb forceps consist of two pieas of surgical steel attached
towel clamp, phalangeal forceps, Lewin, sesamoid clamp, Kocher, and
at one end, and they are used to pick up or grasp tissues Alli.a clamp.
(Fig. 1.10). The forceps are held among the thumb, middle
finger, and index finger of either hand. The tips may be flat or
have teeth or tine serrations, and they vary in width. Forceps each jaw typically has teeth, or a single sharp point, that pro-
with teeth (Brown-Adson, rat-tooth or one-two) are usually nar- vides traction without undue pressure or crushing force.
row and allow the surgeon to hold structures securely while a The Backhaus towel clamp provides a double-sharp set of
minimum of tension is applied. Flat-tipped or finely serrated jaws and is used for draping the operative field and, occasion·
narrow forceps (atraumatic forceps) are used to delicately ally, for grasping bone. The Allis clamp is available with narrow
grasp vital structures, to pull sutures and needles, and, with or wide jaws, each jaw composed of opposing serrated edges
great care, to manipulate skin during closure. The one-two or short teeth. These are effective for grasping and retracting
(rat-tooth) pickup is frequently used for skin closure, depend- fascia and the subcutaneous layer, and they are occ:asionally
ing on the surgeon's preference. The wide-tipped Russian for>- used for clamping towels while draping. Kocher forceps have
ceps are excellent for delicate manipulation of deep tiSIIUes in two long-blade jaws displaying transverse serrations with oppos-
the hindfoot and ankle. Wide-tipped atraumatic forceps (Potta- ing sharp, interlocking teeth at the tips. These are useful for
Smith) may also be useful for the application and removal of placing traction on heavy fascia, although care must be taken
surgical dressings. to avoid crwibing the contained tissues. Uterine packing for-
ceps have gently curved, long jaws that make them ideal for
transferring tendons along tendon sheaths during myoplastic
TRACTION FORCEPS reconstruction. The sesamoid clamp and phalangeal forceps
are specifically designed for grasping small ossides and bony
Traction forceps are of heavier construction than hemostats fragments. The sponge clamp has two opposing circular jaws
and consist of a locking meihanism and finger rings, as well with transverse serrations used to hold a folded gauze sponge
as jaws for grasping tissues (Fig. 1.11). The grasping portion of during preparation or blotting of the surgical area (Fig.l.l2).

. -- ~

Flgaft 1.10 Assorted thumb forceps (top to botmm): one-two or F.lgu.re 1.U Top to bottom: uterine packing forcep, tendon-pass-
rat-tooth, Brown-Ad.ron, and atra.wnatic. ing foru:pa, and sponge clamp.
RETRACTORS
Retractors are used to hold tissues aside, thereby increasing
exposure and protecting vital structures. The blade portion of
the retractor may be fixed or malleable, and the retractor it!elf
may be handheld or self:.retaining. Handheld retractors enable
the as.sistantto control the force with which tissues are held and to
release tension intermittently as necessary (Figs. 1.13 and 1.14).
Conversely, self:.retaining retractors free the assistant to perform
duties that may expedite the procedure (Figs. 1.15 to 1.17).

FJgo.re 1.16 The Weitlaner retractnr ia particularly helpful in di.uec-

tion of the fint intennetatamil apace for the repair of hallux ahducto
valgus deformity.
Pigutc 1.13 Handheld retractor& (top to bottom): double-prong
skin hook&. Senn, and R.agnell.

Piga.re 1.14 The Senn rettactor (seen domilly) worb well when tilt-
sue need! to be pulled apart to provide visualization of deeper structure.!~. FJgure 1.17 The small lamina spreader.
The Seeburger malleable retractor (seen pbmt:arly) ill helpful in reflea-
ing and holding tissue around a comer or exposed ugion of bone.

Selfretaining retractors should be gently set and intermittently

released during long procedures in an effort to avoid tissue
neaosis or excessive retraction trauma. Large handheld retrac-
tors such as the Army-Navy devices are helpful in providing full
exposure when disse(:tion is performed in the rearfoot and
ankle area (Fig. 1.18).
A selfretaining retractor with many applications in recon-
structive foot and ankle surgery, the Weinraub Joint and
Calcaneal Spreader (Innomed, Savannah, GA) (Fig. 1.19)
employs two pins that are affixed to the selected osseous seg-
ments to be separated (or compressed) via cylindrical sleeves
on either side of the retractor's hinged arms, thereby stabiliz..
ing the instrument and preventing descent into the surgical
site (Fig. 1.20). This particular retractor, or one with a simi-
lar design, can be used to enhance exposure and to facilitate
Plgaft 1.15 The three-two Weidaner self-l'etaining retractor (top) access to many joints, particularly those deep in the hindfoot,
and dle digital self-l'etaining or Holzheimer retractor. for resection and preparation for fusion.
 PERIOSTEAL ELEVATORS
Periosteal elevators are used to separate periosteum from under-
lying bone and, occasionally, to provide leverage for retracting
deep fascia, ligaments, and periosteum (Fig. 1.21). These insttu·
ments have smooth, broad blades that vary in sharpness. The
Freer elevator is ideal for refleding periostewn from the shaft of
a metatarsal. One end of the Freer elevator is semisharp, whereas
the other is blunL The Sayre elevator has a short, heavy, rounded
blade frequently used to distract the sesamoid apparatus from
the first metatarsal head. In other circumstances, it works well
PJgurc 1.18 Top to bou.xm: Large malleable ribbon retractor, .Army- to pry apart and separate ossecus segments. Key elevators are
Navy or rightoQDgle, and Volknwm rake.
excellent for rapidly reflecting periosteum from glabrous bony
surfaces, as are the narrow-blade and broad-blade Langenh«k
elevators. Crego elevators expedite periosteal reflection around
curved surfaces such as the talar neck and posterior aspect of
the calcaneus and are essential in performing triple arthrodesis
and other hindfoot procedures (Fig. 1.22).

OSTEOTOMES, CmSELS, GOUGES,

AND MALLETS
Osteotomes (Lambotte) and chisels are used to resect promi-
nent portions of bone, and the cutting edge of these instru-
ments must be periodically sharpened to ensure proper
function. Osteotomes differ from chisels in that both surfaces
of an osteotome taper to form a fine cutting edge, whereas one
surface ofa chisel tapers to meet the opposite flat surface at the
cutting edge (1) (Fig. 1.23).

'

P.igurc 1.19 The WeiDraub retractor.

P.igure 1.21 Periosteal elevator& (top to boctom): Freer, Sayre, and

Key.

Flgaft 1.20 The Weinnub retractor affixed to joint margins via

0.045-inch K-wires and wed to distract the osseous .!egmenta. Flgaft 1.22 Crego peri.o.rt.ea1 elevatora.
F.igure 1.23 Chi&eJ. (COp) and osteotome (bouom).

F.igu.re 1.26 Top co botco:m: Bone-cutting forceps (double-action),

straight rongeur (double4Ction), and curved rongeur (single-hinge).

BONE-CUTTING FORCEPS AND

RONGEURS
Bone-cutting forceps and rongeurs are used to incise
through and reduce bone or to resect cartilaginous surfaces.
Instruments used for osseous work (Fig. 1.26) are frequently
of the multihinge design and function on the SO<alled double-
action principle. This increases mecllanical advantage, reduces
operator strain, and provides increased accuracy. Double-action
bone-cutting forceps have straight or slightly curved jaws that
F.igu.re 1.24 Mallet (COp) andmaighto.rteotome (bottom). are ideal for transecting phalanges and other small-diameter
portions of bone. Rongeurs have strong, heavily constructed
opposing jaws, each of which is scooped out like the tip of a
curette. Rongeur jaw designs include broad or narrow (needle-
nose rongeurs) and straight or curved. The sharp cutting edges
of the rongeur are ideal for reducing bony prominences, such
as spurs and spicules, as well as sharp edges.

TREPHINES AND CURE'ITES

FJga.re 1.26 McGlamry metatamd elevator. Trephines display a circular cutting edge at the tip of a hol-
low tube that enables the operator to remove plugs of bone
neatly for biopsy, graft procurement, or osseous reduction
(Figs. 1.27 and 1.28). Aasorted trephines and correspond-
ing obturators should be available. A small modified tre-
Ostectomes and chisels are held firmly in one hand and phine, known as a plug cutter, may also be used to remove
are driven with deliberate, repetitive blows from the smgical
malleL Mallets are available with stainless steel heads, as well
as heads capped with synthetic polymers for quieting the blow
and enhancing control. The small and medium-sized mallets
are best suited for podiatric surgery (Fig. 1.24).
Gouges are similar to chisels; however, the cutting edge
is curved. These instruments come in various widths and
are useful in smoothing curved surfaces and rounding flat
surfaces of bone. Gouges may also be used to free meta-
tarsal heads from surrounding soft tissue structures. The
McGlamry metatarsal elevator is a specialized gouge with
a broad, curved, scoop-like blade set on a curved handle
(Fig. 1.25). This instrument is ideal for freeing metatarsal
heads from adherent soft tissues, for exposing the plantar
surface of the head for observation, and for releasing an
adherent flexor plate. Flgaft 1.27 Obtum.or (COp) and trephine (boUo:m.).
 BONE-HOLDING CLAMPS AND
REDUCTION FORCEPS
Clamps used to grasp bone or to hold bony fragments together
are of heavy construction and are capable of applying large
amounts of pressure. Some bone clamps and reduction fOJ.'o
ceps have a hinge with a locking ratchet, whereas others close
on tightening of a locking nut. Small fragments of bone and
small ossicles such as sesamoids or phalanges may be grasped
and manipulated with sesamoid and phalangeal clamps
(Fig. 1.31). The double-sharp and alligator bone reduction
forceps are ideally suited for reducing and maintaining small
and medium-sized fragments (Fig. 1.32). Larger fragments
encountered in hindfoot and ankle fractures require heavier
reduction forceps such as the Lewin, "baby" Lane, Lowman,
and Verbrugge (Fig. U~3).

Figw.'e 1.28 The trephine may be used in joint fu.!ion. Bone baa RASPS
been removed in 1he lint metataraocuneifonn joint. The defecu will be
replaced with bone graft to effect fusion.
Rasps are used to reduce and smooth bony surfaces (Fig. 1.34);
they are usually employed after a bony prominence has been
grossly reduced by means of an osteotome and mallet, ron-
geur, or power saw. The cutting surface of a rasp presents ser-
.s rations of fine teeth running in a parallel or crosscut pattern
(Fig. 1.35). The Bell rasp is double-ended with two small ellip-
tic rasping surfaces. The Joseph nasal rasp, also known as the
beave~~otail rasp, has a single, long, elliptic cutting surface with
a double crosscut pattern for fine smoothing of broad surfaces.
The Mala and Parkes rasps each present a single, coarse cutting
surface ideal for rapid reduction of large ossecus prominences.
Rasping surfaces are also available for r«iprocating power
F.igurc 1.29 CuretteJJ: dermal (top) and Cobb (bouo.m). instrumentation. A stainless steel wire brush should be avail-
able for periodic intraoperative cleansing of the rasp surface.

NEEDLE HOLDERS
Needle holders consist of finger rings, a locking m«ha-
nism, and jaws and come in a wide variety of sizes and shapes
(Fig. 1.36). The individual surgeon picks the design that he or

F.igurc 1.30 Ringed (uterine) curette.

surrounding bone from the tip of a buried fixation wire or

pin and thereby to expedite removal of the wire or pin when-
ever retrieval is ne<essary.
Curettes conaist of a curved, scoop-like blade on a handle
(Fig. 1.29). Heavy curettes are used for reducing rough bony
surfaces and for gouging into broad areas of bone. They are
also useful for debriding infected or necrotic bone. Dermal
curettes, conversely, are of lighter construction and are used
for debridement of soft tissues as well as nail beds and grooves.
runged (uterine) curette& are unique in that the shaft of the
instrument is malleable, so the cutting portion of the instru-
ment can be placed in areas that are difficult to reach such as
the lateral portion of the talonavicular joint when arthrodesis is
performed (Fig.l.30). Flgme 1.31 Philangeal (top) and .~esamoid (bottom) clamp.
Pigutc 1.32 Bone reduction forceps (left to
riFt): Lewin, .ASIF double.sharp, ASIF "alliga-
tor" small fragment, ASIF small plate forceps,
and ASIF small fragment self-centering damp.

FJga.re 1.34 Ra!ping insttumentll (top to bottom):Joseph IWIBlrli!p

(beaver-ail), Maltz rasp, Podiatty Institute l'li!P• and Bell rasp.
Piguft 1.33 Large fragment reduction forceps (top to bottom.): Ve~~<
brugge, Lowman, and "baby" Lane.

she prefers for each specific task. Long-handled needle hold-

ers are used for closing deeper layers, whereas shorter designs
are used superficially. Jaw designs vary from smooth, to crosscut
or parallel serrations, to channeled jaws for holding specific
needles and those modified for twisting wires. Needle holders
with heavy jaws are used to hold large needles, and 'llict vma.
Tungaten<arbide jaw insens greatly enhance instrument func-
tion and durability. hamples of commonly used needle hold-
ers include Mayo-Hegar, Sarot, Ryder, and Halsey devices.

POWER INSTRUMENTATION
Practically any aspect of osseous surgery may be perfOrmed with
power instrumentation. Power saws, both oscillating and recipro-
cating, drills, burs, rasps, wire drivers, osteotomes, and screwd:riv-
ers are commercially available. Power sources may be pneumatic
or electrical (alternating or direct current). Power instrumenta-
tion varies with respect to size, strength, maneuverability, preci-
sion, durability, method of sterilization, and care. The decision F.igure 1.35 Comparison of a'OII8Cilt (left) and parallekut (right)
regarding which set to use varies with the surgical &i.te and the r.uping surfat;e&.
 FJgure 1.38 Malleable Fruier-tip auction catheter.

steel wire sutures (20, 22, 24, 26, 28, and !0 gauge), Kirschner
wires (K-wires), and Steinmann pins in a variety of sizes, both
threaded and smooth, with tips varying from tapered to tro·
car or bayonet for easy penetration of hard cortic.al bone.
These may be used to fixate bony fragments by direct pinning
or intramedullary nailing, as well as providing anchoring for
skeletal traction. Various specialized wire twisters are avail-
able. A handheld wire bender, a standard wire cutter or a
Pigutc 1.36 .A&sorted n«dle holder&. flush wire cutter, a pair of needl~nose pliers (singl~ or dou-
ble-action), and a small plug cutter are also recommended
surgeon's preference. The electtosurgical cleaning ("scratch") (Fig. 1.87).
pad can also be used to refine the cutting edges of some instru-
ments, as suggested by Kubiak et al (2). Its coarse surface, sy.nth~
sized from aluminum oxide and rooted in epoxy, may be used to SUCTION APPARATUS
refinish coarse irregularities on instruments made of soft metals,
some stainless steel instruments, and even titanium. The authors A continuous suction source is helpful in some podiatric SW'-
have used this intraoperatively to restore the rims of drill sleeves gical cases. The amount of suction should be variable and
damaged and deformed from repeated use. controlled by the assistant operating the suction catheter. The
malleable Frazier-tip suction catheter (Fig. 1.~8) is ideal for use
in foot and ankle surgery, whereas suction catheters of a larger
INSTRUMENTS FOR FIXATION OF BONE size may be necessary in the leg.
AND OTHER. TISSUES
Fixation of bony fragments may be obtained in many ways. CONCLUSION
Osseous fixation is best obtained by following standard tech-
niques of osteosynthesis. Fixation devices include stainless Obviously, the wide variety of surgical needs mandates the avail·
ability of a large array of instrumentation (3). Not every instru·
ment is needed for every case, and for this reason the basic
inatruments are divided into a forefoot pack and a rearfoot or
ankle pack. The forefoot pack supplies inatrumentation for a
typical bilateral forefoot case. For hindfoot surgery, the rearfoot
or ankle pack is opened along with the forefoot pack. Division
of instrumentation into reduced sets also allows more efficient
sterilization and storage. Instruments that may be needed at
any time, regardless of surgical site, are packed separately. Basic
inatrument packs for specific surgical application include the
following:
I. Forefoot pack
A. Blade handles
1. No. 8 scalpel handle (six)
2. Long and short Beaver handles (one each)
B. Scissors
1. Iris, small (one)
2. Crown and collar (one)
8. Curved and straight Mayo (one each)
Flgaft 1.37 Flush pin .et conai.su of a double-action flush pin cutter
4. Metzenbaum (two)
(top) designed to cut K-wirea flush with bone to facilitate burying af 5. Large utility (two)
wires. It also contains a arruiU plug cutter (middle) and double-action 6. Lister bandage (two)
needle-no.e pliers (boUom) for retrieval of buried wires. 7. Monofilament wire cutter (one)
 Oiaptt!T 1 • Instrumentation 13

C. Hemostatic forceps B. Periosteal elevators

1. Curved and straight mosquito (12 and four, respectively) 1. Key (one set)
2. Curved and straight Crile (two each) 2. Crego (one set)
3. Curved and straight Kelly (two each) C. Osteotomes, gouges, mallets
D. Thumb forceps 1. Large osteotomes (one set)
1. Brown-Adson (four) 2. Gouges (one set)
2. Rat-tooth (one-two pickup) (two) 3. Large surgical mallet (one)
3. Atraumatic (two) D. Bone<utting forceps and rongeurs
4. Large toothed (two) 1. Large double-action bone-cutting
5. Large atraumatic (two) forceps (one)
E. Traction forceps 2. Large double-action rongeur (one)
1. Backhaus towel clamp (six) 3. K.errison rongeur (two)
2. Allis damp, large and small (two each) E. Curettes and trephines
3. Kocher (two) 1. Bone curettes (one set)
4. Sesamoid damp (one) 2. Trephines (one set)
5. Phalangeal forceps (one) F. Miscellaneous
6. Sponge clamp (one) 1. Blount staple holder, driver, puller
F. Retractors (one set)
1. Digital self-retaining (one) 2. Large pin cutter (one)
2. Weitlaner three-two and four-three (two and one, III. Minor surgical pack
respectively) A. Blade handles: no. 3 scalpel handle (two)
3. Skin hooks, single- and double-prong (two and four, B. Scissors
respectively) 1. Iris (one)
4. Ragnell (four) 2. Crown and collar (one)
5. Senn (four) 3. Curved and straight Mayo (one each)
6. Seeburger (two) 4. Metzenbaum (one)
7. Mini-Hohmann (four) 5. Utility scissors (one)
8. Rakes (four-prong, sharp) (two) C. Hemostatic forceps
9. Army-Navy (two) 1. Curved and straight mosquito (four and two,
10. Malleable ribbon (two) respectively)
G. Periosteal elevators 2. Curved and straight Crile (one each)
1. Freer (four) 3. Curved and straight Kelly (one each)
2. Langenbeck, narrow and broad (one each) D. Thumbforceps
3. Sayre (one) 1. Brown-Adson (one)
H. Osteotomes, chisels, mallets 2. Rat-tooth (one-two pickup) (one)
1. Lambotte osteotomes (2 to 22 mm) (one each) 3. Atraumatic (one)
2. Curved osteotome (8 mm) (one) E. Traction forceps
3. US Army no. 18 chisel (one) 1. Backhaus towel clamps (two)
4. Medium-sized surgical mallet (one) 2. Allis clamp (two)
I. Bone-cutting forceps, rongeurs F. Retractors
1. Double-action bone<utting forceps (one) 1. Digital self-retaining (one)
2. Large and small curved double-action rongeurs (one 2. Weitlaner three-two (one)
each) 3. Skin hooks, double-prong (two)
3. Needle-nose rongeur (one) 4. Senn (two)
J. Bone-holding clamps: Lewin (one) 5. Seeburger (two)
K. Rasps and wire brush G. Periosteal elevators: Freer (two)
1. Bell rasp (two) H. Rasps
2. Joseph nasal (beaver-tail) (two) 1. Bell (one)
3. Maltz and Parkes (one each) 2.Joseph nasal (one)
4. Wire brush (one) I. Needle holders: large and small (one each)
L. Needle holders: assorted sizes and jaw configurations J. Miscellaneous
depending on surgeon's preference 1. Large bone curette (one)
M. Miscellaneous 2. Straight nail nipper (one)
1. Ruler (stainless steel) 3. Curved tissue nipper (one)
2. Flush wire cutter (one) 4 . Glass medicine cup (one)
3. Wire bender (one) 5. Stainless steel bowl (3-inch diameter) (one)
4. Double-action needle-nose pliers (two) 6. Bandages
5. Small plug cutter (one) a. 4 x 4 inch gauze (10)
II. Rearfoot or ankle pack b. 2- and 3-inch Kling (one each)
A. Retractors IV. Nail surgical pack
1. Large ribbon (two) A. Blade handles
2. Large rakes (two) 1. No.3 scalpel blade (one)
3. Lamina spreader (one) 2. Beaver blade handle (one)
14 Part I • Basics Section I • Technical Principles

B. Scissors and nippers 3. Nail nipper (one)

I. Iris (one) 4. Tissue nipper (one)
2. Utility (one) C. Hemostatic forceps: curved and straight mosquito (one
3. Large and small nail nippers (one) each)
4. English anvil nail nipper (one) D. Thumb forceps
C. Hemostatic forceps 1. Brown-Adson (one)
I. Straight mosquito (two) 2. Atraumatic (one)
2. Straight Kelly (one) E. Elevators and curettes
D. Thumb forceps: Brown-Adson (one) 1. Freer (one)
E. Elevators and curettes 2. Medium sized dermal and bone curette (one each)
I. Freer (two) F. Miscellaneous bandages
2. Nail-plate elevator, large and small (one each) 1. 4 x 4 inch gauze (10)
3. Medium-sized dermal and bone curette 2. 2-inch Kling (one)
(one each) VI. Podiatry dressing pack
F. Needle holder: small (Mayo-Hegar jaw) (one) A 4 x 4 inch gauze (10)
G. Miscellaneous B. Kling
I. Glass medicine cup (one) 1. 2-inch (one)
2. Cotton-tip applicators (IO) 2. 3-inch (one)
3. Bandages C. Tube gauze (2 5/8 x 36 inch) (one)
a. 2 x 2 inch and 4 x 4 inch gauze (10 and six,
respectively) REFERENCES
b. 2-inch Kling (one)
V. illcer or wound debridement pack 1. EdmoruonAS, Crenoh2wAH, edo. c-pbill's~ ~.6th ed. St. LoW., MO: CV
A. Blade handles: no. 3 scalpel handle (two) Mooby, 1980:1-20.
B. Scissors and nippers 2. Kubiak EN, Hildebrandt R, Ego! KA, ct al.lntraoperotive imtrumcnt n:pairu.ing an clec-
troauterypad.JOrfAop Th>1ooa2004;18:2M-2!7.
1. Iris (one) ~- Nealon TF. l'tu&ddount.Jl .!iills ;, ..,.,...,, ~nl ed. Philadelphia, PA: WB Saund.en,
2. Utility (one) 1979:12-24.
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 DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI

Newala, too, suffers from the distance of its water-supply—at least

the Newala of to-day does; there was once another Newala in a lovely
valley at the foot of the plateau. I visited it and found scarcely a trace
of houses, only a Christian cemetery, with the graves of several
missionaries and their converts, remaining as a monument of its
former glories. But the surroundings are wonderfully beautiful. A
thick grove of splendid mango-trees closes in the weather-worn
crosses and headstones; behind them, combining the useful and the
agreeable, is a whole plantation of lemon-trees covered with ripe
fruit; not the small African kind, but a much larger and also juicier
imported variety, which drops into the hands of the passing traveller,
without calling for any exertion on his part. Old Newala is now under
the jurisdiction of the native pastor, Daudi, at Chingulungulu, who,
as I am on very friendly terms with him, allows me, as a matter of
course, the use of this lemon-grove during my stay at Newala.
 FEET MUTILATED BY THE RAVAGES OF THE “JIGGER”
(Sarcopsylla penetrans)

The water-supply of New Newala is in the bottom of the valley,

some 1,600 feet lower down. The way is not only long and fatiguing,
but the water, when we get it, is thoroughly bad. We are suffering not
only from this, but from the fact that the arrangements at Newala are
nothing short of luxurious. We have a separate kitchen—a hut built
against the boma palisade on the right of the baraza, the interior of
which is not visible from our usual position. Our two cooks were not
long in finding this out, and they consequently do—or rather neglect
to do—what they please. In any case they do not seem to be very
particular about the boiling of our drinking-water—at least I can
attribute to no other cause certain attacks of a dysenteric nature,
from which both Knudsen and I have suffered for some time. If a
man like Omari has to be left unwatched for a moment, he is capable
of anything. Besides this complaint, we are inconvenienced by the
state of our nails, which have become as hard as glass, and crack on
the slightest provocation, and I have the additional infliction of
pimples all over me. As if all this were not enough, we have also, for
the last week been waging war against the jigger, who has found his
Eldorado in the hot sand of the Makonde plateau. Our men are seen
all day long—whenever their chronic colds and the dysentery likewise
raging among them permit—occupied in removing this scourge of
Africa from their feet and trying to prevent the disastrous
consequences of its presence. It is quite common to see natives of
this place with one or two toes missing; many have lost all their toes,
or even the whole front part of the foot, so that a well-formed leg
ends in a shapeless stump. These ravages are caused by the female of
Sarcopsylla penetrans, which bores its way under the skin and there
develops an egg-sac the size of a pea. In all books on the subject, it is
stated that one’s attention is called to the presence of this parasite by
an intolerable itching. This agrees very well with my experience, so
far as the softer parts of the sole, the spaces between and under the
toes, and the side of the foot are concerned, but if the creature
penetrates through the harder parts of the heel or ball of the foot, it
may escape even the most careful search till it has reached maturity.
Then there is no time to be lost, if the horrible ulceration, of which
we see cases by the dozen every day, is to be prevented. It is much
easier, by the way, to discover the insect on the white skin of a
European than on that of a native, on which the dark speck scarcely
shows. The four or five jiggers which, in spite of the fact that I
constantly wore high laced boots, chose my feet to settle in, were
taken out for me by the all-accomplished Knudsen, after which I
thought it advisable to wash out the cavities with corrosive
sublimate. The natives have a different sort of disinfectant—they fill
the hole with scraped roots. In a tiny Makua village on the slope of
the plateau south of Newala, we saw an old woman who had filled all
the spaces under her toe-nails with powdered roots by way of
prophylactic treatment. What will be the result, if any, who can say?
The rest of the many trifling ills which trouble our existence are
really more comic than serious. In the absence of anything else to
smoke, Knudsen and I at last opened a box of cigars procured from
the Indian store-keeper at Lindi, and tried them, with the most
distressing results. Whether they contain opium or some other
narcotic, neither of us can say, but after the tenth puff we were both
“off,” three-quarters stupefied and unspeakably wretched. Slowly we
recovered—and what happened next? Half-an-hour later we were
once more smoking these poisonous concoctions—so insatiable is the
craving for tobacco in the tropics.
Even my present attacks of fever scarcely deserve to be taken
seriously. I have had no less than three here at Newala, all of which
have run their course in an incredibly short time. In the early
afternoon, I am busy with my old natives, asking questions and
making notes. The strong midday coffee has stimulated my spirits to
an extraordinary degree, the brain is active and vigorous, and work
progresses rapidly, while a pleasant warmth pervades the whole
body. Suddenly this gives place to a violent chill, forcing me to put on
my overcoat, though it is only half-past three and the afternoon sun
is at its hottest. Now the brain no longer works with such acuteness
and logical precision; more especially does it fail me in trying to
establish the syntax of the difficult Makua language on which I have
ventured, as if I had not enough to do without it. Under the
circumstances it seems advisable to take my temperature, and I do
so, to save trouble, without leaving my seat, and while going on with
my work. On examination, I find it to be 101·48°. My tutors are
abruptly dismissed and my bed set up in the baraza; a few minutes
later I am in it and treating myself internally with hot water and
lemon-juice.
Three hours later, the thermometer marks nearly 104°, and I make
them carry me back into the tent, bed and all, as I am now perspiring
heavily, and exposure to the cold wind just beginning to blow might
mean a fatal chill. I lie still for a little while, and then find, to my
great relief, that the temperature is not rising, but rather falling. This
is about 7.30 p.m. At 8 p.m. I find, to my unbounded astonishment,
that it has fallen below 98·6°, and I feel perfectly well. I read for an
hour or two, and could very well enjoy a smoke, if I had the
wherewithal—Indian cigars being out of the question.
Having no medical training, I am at a loss to account for this state
of things. It is impossible that these transitory attacks of high fever
should be malarial; it seems more probable that they are due to a
kind of sunstroke. On consulting my note-book, I become more and
more inclined to think this is the case, for these attacks regularly
follow extreme fatigue and long exposure to strong sunshine. They at
least have the advantage of being only short interruptions to my
work, as on the following morning I am always quite fresh and fit.
My treasure of a cook is suffering from an enormous hydrocele which
makes it difficult for him to get up, and Moritz is obliged to keep in
the dark on account of his inflamed eyes. Knudsen’s cook, a raw boy
from somewhere in the bush, knows still less of cooking than Omari;
consequently Nils Knudsen himself has been promoted to the vacant
post. Finding that we had come to the end of our supplies, he began
by sending to Chingulungulu for the four sucking-pigs which we had
bought from Matola and temporarily left in his charge; and when
they came up, neatly packed in a large crate, he callously slaughtered
the biggest of them. The first joint we were thoughtless enough to
entrust for roasting to Knudsen’s mshenzi cook, and it was
consequently uneatable; but we made the rest of the animal into a
jelly which we ate with great relish after weeks of underfeeding,
consuming incredible helpings of it at both midday and evening
meals. The only drawback is a certain want of variety in the tinned
vegetables. Dr. Jäger, to whom the Geographical Commission
entrusted the provisioning of the expeditions—mine as well as his
own—because he had more time on his hands than the rest of us,
seems to have laid in a huge stock of Teltow turnips,[46] an article of
food which is all very well for occasional use, but which quickly palls
when set before one every day; and we seem to have no other tins
left. There is no help for it—we must put up with the turnips; but I
am certain that, once I am home again, I shall not touch them for ten
years to come.
Amid all these minor evils, which, after all, go to make up the
genuine flavour of Africa, there is at least one cheering touch:
Knudsen has, with the dexterity of a skilled mechanic, repaired my 9
× 12 cm. camera, at least so far that I can use it with a little care.
How, in the absence of finger-nails, he was able to accomplish such a
ticklish piece of work, having no tool but a clumsy screw-driver for
taking to pieces and putting together again the complicated
mechanism of the instantaneous shutter, is still a mystery to me; but
he did it successfully. The loss of his finger-nails shows him in a light
contrasting curiously enough with the intelligence evinced by the
above operation; though, after all, it is scarcely surprising after his
ten years’ residence in the bush. One day, at Lindi, he had occasion
to wash a dog, which must have been in need of very thorough
cleansing, for the bottle handed to our friend for the purpose had an
extremely strong smell. Having performed his task in the most
conscientious manner, he perceived with some surprise that the dog
did not appear much the better for it, and was further surprised by
finding his own nails ulcerating away in the course of the next few
days. “How was I to know that carbolic acid has to be diluted?” he
mutters indignantly, from time to time, with a troubled gaze at his
mutilated finger-tips.
 Since we came to Newala we have been making excursions in all
directions through the surrounding country, in accordance with old
habit, and also because the akida Sefu did not get together the tribal
elders from whom I wanted information so speedily as he had
promised. There is, however, no harm done, as, even if seen only
from the outside, the country and people are interesting enough.
The Makonde plateau is like a large rectangular table rounded off
at the corners. Measured from the Indian Ocean to Newala, it is
about seventy-five miles long, and between the Rovuma and the
Lukuledi it averages fifty miles in breadth, so that its superficial area
is about two-thirds of that of the kingdom of Saxony. The surface,
however, is not level, but uniformly inclined from its south-western
edge to the ocean. From the upper edge, on which Newala lies, the
eye ranges for many miles east and north-east, without encountering
any obstacle, over the Makonde bush. It is a green sea, from which
here and there thick clouds of smoke rise, to show that it, too, is
inhabited by men who carry on their tillage like so many other
primitive peoples, by cutting down and burning the bush, and
manuring with the ashes. Even in the radiant light of a tropical day
such a fire is a grand sight.
Much less effective is the impression produced just now by the
great western plain as seen from the edge of the plateau. As often as
time permits, I stroll along this edge, sometimes in one direction,
sometimes in another, in the hope of finding the air clear enough to
let me enjoy the view; but I have always been disappointed.
Wherever one looks, clouds of smoke rise from the burning bush,
and the air is full of smoke and vapour. It is a pity, for under more
favourable circumstances the panorama of the whole country up to
the distant Majeje hills must be truly magnificent. It is of little use
taking photographs now, and an outline sketch gives a very poor idea
of the scenery. In one of these excursions I went out of my way to
make a personal attempt on the Makonde bush. The present edge of
the plateau is the result of a far-reaching process of destruction
through erosion and denudation. The Makonde strata are
everywhere cut into by ravines, which, though short, are hundreds of
yards in depth. In consequence of the loose stratification of these
beds, not only are the walls of these ravines nearly vertical, but their
upper end is closed by an equally steep escarpment, so that the
western edge of the Makonde plateau is hemmed in by a series of
deep, basin-like valleys. In order to get from one side of such a ravine
to the other, I cut my way through the bush with a dozen of my men.
It was a very open part, with more grass than scrub, but even so the
short stretch of less than two hundred yards was very hard work; at
the end of it the men’s calicoes were in rags and they themselves
bleeding from hundreds of scratches, while even our strong khaki
suits had not escaped scatheless.

NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR

MAHUTA

I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
 The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.

MAKONDE LOCK AND KEY AT JUMBE CHAURO

 This is the general way of closing a house. The Makonde at Jumbe
Chauro, however, have a much more complicated, solid and original
one. Here, too, the door is as already described, except that there is
only one post on the inside, standing by itself about six inches from
one side of the doorway. Opposite this post is a hole in the wall just
large enough to admit a man’s arm. The door is closed inside by a
large wooden bolt passing through a hole in this post and pressing
with its free end against the door. The other end has three holes into
which fit three pegs running in vertical grooves inside the post. The
door is opened with a wooden key about a foot long, somewhat
curved and sloped off at the butt; the other end has three pegs
corresponding to the holes, in the bolt, so that, when it is thrust
through the hole in the wall and inserted into the rectangular
opening in the post, the pegs can be lifted and the bolt drawn out.[50]

MODE OF INSERTING THE KEY

With no small pride first one householder and then a second

showed me on the spot the action of this greatest invention of the
Makonde Highlands. To both with an admiring exclamation of
“Vizuri sana!” (“Very fine!”). I expressed the wish to take back these
marvels with me to Ulaya, to show the Wazungu what clever fellows
the Makonde are. Scarcely five minutes after my return to camp at
Newala, the two men came up sweating under the weight of two
heavy logs which they laid down at my feet, handing over at the same
time the keys of the fallen fortress. Arguing, logically enough, that if
the key was wanted, the lock would be wanted with it, they had taken
their axes and chopped down the posts—as it never occurred to them
to dig them out of the ground and so bring them intact. Thus I have
two badly damaged specimens, and the owners, instead of praise,
come in for a blowing-up.
The Makua huts in the environs of Newala are especially
miserable; their more than slovenly construction reminds one of the
temporary erections of the Makua at Hatia’s, though the people here
have not been concerned in a war. It must therefore be due to
congenital idleness, or else to the absence of a powerful chief. Even
the baraza at Mlipa’s, a short hour’s walk south-east of Newala,
shares in this general neglect. While public buildings in this country
are usually looked after more or less carefully, this is in evident
danger of being blown over by the first strong easterly gale. The only
attractive object in this whole district is the grave of the late chief
Mlipa. I visited it in the morning, while the sun was still trying with
partial success to break through the rolling mists, and the circular
grove of tall euphorbias, which, with a broken pot, is all that marks
the old king’s resting-place, impressed one with a touch of pathos.
Even my very materially-minded carriers seemed to feel something
of the sort, for instead of their usual ribald songs, they chanted
solemnly, as we marched on through the dense green of the Makonde
bush:—
 “We shall arrive with the great master; we stand in a row and have
no fear about getting our food and our money from the Serkali (the
Government). We are not afraid; we are going along with the great
master, the lion; we are going down to the coast and back.”
With regard to the characteristic features of the various tribes here
on the western edge of the plateau, I can arrive at no other
conclusion than the one already come to in the plain, viz., that it is
impossible for anyone but a trained anthropologist to assign any
given individual at once to his proper tribe. In fact, I think that even
an anthropological specialist, after the most careful examination,
might find it a difficult task to decide. The whole congeries of peoples
collected in the region bounded on the west by the great Central
African rift, Tanganyika and Nyasa, and on the east by the Indian
Ocean, are closely related to each other—some of their languages are
only distinguished from one another as dialects of the same speech,
and no doubt all the tribes present the same shape of skull and
structure of skeleton. Thus, surely, there can be no very striking
differences in outward appearance.
 Even did such exist, I should have no time
to concern myself with them, for day after day,
I have to see or hear, as the case may be—in
any case to grasp and record—an
extraordinary number of ethnographic
phenomena. I am almost disposed to think it
fortunate that some departments of inquiry, at
least, are barred by external circumstances.
Chief among these is the subject of iron-
working. We are apt to think of Africa as a
country where iron ore is everywhere, so to
speak, to be picked up by the roadside, and
where it would be quite surprising if the
inhabitants had not learnt to smelt the
material ready to their hand. In fact, the
knowledge of this art ranges all over the
continent, from the Kabyles in the north to the
Kafirs in the south. Here between the Rovuma
and the Lukuledi the conditions are not so
favourable. According to the statements of the
Makonde, neither ironstone nor any other
form of iron ore is known to them. They have
not therefore advanced to the art of smelting
the metal, but have hitherto bought all their
THE ANCESTRESS OF
THE MAKONDE
iron implements from neighbouring tribes.
Even in the plain the inhabitants are not much
better off. Only one man now living is said to
understand the art of smelting iron. This old fundi lives close to
Huwe, that isolated, steep-sided block of granite which rises out of
the green solitude between Masasi and Chingulungulu, and whose
jagged and splintered top meets the traveller’s eye everywhere. While
still at Masasi I wished to see this man at work, but was told that,
frightened by the rising, he had retired across the Rovuma, though
he would soon return. All subsequent inquiries as to whether the
fundi had come back met with the genuine African answer, “Bado”
(“Not yet”).
 BRAZIER

Some consolation was afforded me by a brassfounder, whom I

came across in the bush near Akundonde’s. This man is the favourite
of women, and therefore no doubt of the gods; he welds the glittering
brass rods purchased at the coast into those massive, heavy rings
which, on the wrists and ankles of the local fair ones, continually give
me fresh food for admiration. Like every decent master-craftsman he
had all his tools with him, consisting of a pair of bellows, three
crucibles and a hammer—nothing more, apparently. He was quite
willing to show his skill, and in a twinkling had fixed his bellows on
the ground. They are simply two goat-skins, taken off whole, the four
legs being closed by knots, while the upper opening, intended to
admit the air, is kept stretched by two pieces of wood. At the lower
end of the skin a smaller opening is left into which a wooden tube is
stuck. The fundi has quickly borrowed a heap of wood-embers from
the nearest hut; he then fixes the free ends of the two tubes into an
earthen pipe, and clamps them to the ground by means of a bent
piece of wood. Now he fills one of his small clay crucibles, the dross
on which shows that they have been long in use, with the yellow
material, places it in the midst of the embers, which, at present are
only faintly glimmering, and begins his work. In quick alternation
the smith’s two hands move up and down with the open ends of the
bellows; as he raises his hand he holds the slit wide open, so as to let
the air enter the skin bag unhindered. In pressing it down he closes
the bag, and the air puffs through the bamboo tube and clay pipe into
the fire, which quickly burns up. The smith, however, does not keep
on with this work, but beckons to another man, who relieves him at
the bellows, while he takes some more tools out of a large skin pouch
carried on his back. I look on in wonder as, with a smooth round
stick about the thickness of a finger, he bores a few vertical holes into
the clean sand of the soil. This should not be difficult, yet the man
seems to be taking great pains over it. Then he fastens down to the
ground, with a couple of wooden clamps, a neat little trough made by
splitting a joint of bamboo in half, so that the ends are closed by the
two knots. At last the yellow metal has attained the right consistency,
and the fundi lifts the crucible from the fire by means of two sticks
split at the end to serve as tongs. A short swift turn to the left—a
tilting of the crucible—and the molten brass, hissing and giving forth
clouds of smoke, flows first into the bamboo mould and then into the
holes in the ground.
The technique of this backwoods craftsman may not be very far
advanced, but it cannot be denied that he knows how to obtain an
adequate result by the simplest means. The ladies of highest rank in
this country—that is to say, those who can afford it, wear two kinds
of these massive brass rings, one cylindrical, the other semicircular
in section. The latter are cast in the most ingenious way in the
bamboo mould, the former in the circular hole in the sand. It is quite
a simple matter for the fundi to fit these bars to the limbs of his fair
customers; with a few light strokes of his hammer he bends the
pliable brass round arm or ankle without further inconvenience to
the wearer.
SHAPING THE POT

SMOOTHING WITH MAIZE-COB

CUTTING THE EDGE

 FINISHING THE BOTTOM

LAST SMOOTHING BEFORE

BURNING

FIRING THE BRUSH-PILE

 LIGHTING THE FARTHER SIDE OF
THE PILE

TURNING THE RED-HOT VESSEL

NYASA WOMAN MAKING POTS AT MASASI

Pottery is an art which must always and everywhere excite the
interest of the student, just because it is so intimately connected with
the development of human culture, and because its relics are one of
the principal factors in the reconstruction of our own condition in
prehistoric times. I shall always remember with pleasure the two or
three afternoons at Masasi when Salim Matola’s mother, a slightly-
built, graceful, pleasant-looking woman, explained to me with
touching patience, by means of concrete illustrations, the ceramic art
of her people. The only implements for this primitive process were a
lump of clay in her left hand, and in the right a calabash containing
the following valuables: the fragment of a maize-cob stripped of all
its grains, a smooth, oval pebble, about the size of a pigeon’s egg, a
few chips of gourd-shell, a bamboo splinter about the length of one’s
hand, a small shell, and a bunch of some herb resembling spinach.
 Nothing more. The woman scraped with the
shell a round, shallow hole in the soft, fine
sand of the soil, and, when an active young
girl had filled the calabash with water for her,
she began to knead the clay. As if by magic it
gradually assumed the shape of a rough but
already well-shaped vessel, which only wanted
a little touching up with the instruments
before mentioned. I looked out with the
MAKUA WOMAN closest attention for any indication of the use
MAKING A POT. of the potter’s wheel, in however rudimentary
SHOWS THE a form, but no—hapana (there is none). The
BEGINNINGS OF THE embryo pot stood firmly in its little
POTTER’S WHEEL
depression, and the woman walked round it in
a stooping posture, whether she was removing
small stones or similar foreign bodies with the maize-cob, smoothing
the inner or outer surface with the splinter of bamboo, or later, after
letting it dry for a day, pricking in the ornamentation with a pointed
bit of gourd-shell, or working out the bottom, or cutting the edge
with a sharp bamboo knife, or giving the last touches to the finished
vessel. This occupation of the women is infinitely toilsome, but it is
without doubt an accurate reproduction of the process in use among
our ancestors of the Neolithic and Bronze ages.
There is no doubt that the invention of pottery, an item in human
progress whose importance cannot be over-estimated, is due to
women. Rough, coarse and unfeeling, the men of the horde range
over the countryside. When the united cunning of the hunters has
succeeded in killing the game; not one of them thinks of carrying
home the spoil. A bright fire, kindled by a vigorous wielding of the
drill, is crackling beside them; the animal has been cleaned and cut
up secundum artem, and, after a slight singeing, will soon disappear
under their sharp teeth; no one all this time giving a single thought
to wife or child.
To what shifts, on the other hand, the primitive wife, and still more
the primitive mother, was put! Not even prehistoric stomachs could
endure an unvarying diet of raw food. Something or other suggested
the beneficial effect of hot water on the majority of approved but
indigestible dishes. Perhaps a neighbour had tried holding the hard
roots or tubers over the fire in a calabash filled with water—or maybe
an ostrich-egg-shell, or a hastily improvised vessel of bark. They
became much softer and more palatable than they had previously
been; but, unfortunately, the vessel could not stand the fire and got
charred on the outside. That can be remedied, thought our
ancestress, and plastered a layer of wet clay round a similar vessel.
This is an improvement; the cooking utensil remains uninjured, but
the heat of the fire has shrunk it, so that it is loose in its shell. The
next step is to detach it, so, with a firm grip and a jerk, shell and
kernel are separated, and pottery is invented. Perhaps, however, the
discovery which led to an intelligent use of the burnt-clay shell, was
made in a slightly different way. Ostrich-eggs and calabashes are not
to be found in every part of the world, but everywhere mankind has
arrived at the art of making baskets out of pliant materials, such as
bark, bast, strips of palm-leaf, supple twigs, etc. Our inventor has no
water-tight vessel provided by nature. “Never mind, let us line the
basket with clay.” This answers the purpose, but alas! the basket gets
burnt over the blazing fire, the woman watches the process of
cooking with increasing uneasiness, fearing a leak, but no leak
appears. The food, done to a turn, is eaten with peculiar relish; and
the cooking-vessel is examined, half in curiosity, half in satisfaction
at the result. The plastic clay is now hard as stone, and at the same
time looks exceedingly well, for the neat plaiting of the burnt basket
is traced all over it in a pretty pattern. Thus, simultaneously with
pottery, its ornamentation was invented.
Primitive woman has another claim to respect. It was the man,
roving abroad, who invented the art of producing fire at will, but the
woman, unable to imitate him in this, has been a Vestal from the
earliest times. Nothing gives so much trouble as the keeping alight of
the smouldering brand, and, above all, when all the men are absent
from the camp. Heavy rain-clouds gather, already the first large
drops are falling, the first gusts of the storm rage over the plain. The
little flame, a greater anxiety to the woman than her own children,
flickers unsteadily in the blast. What is to be done? A sudden thought
occurs to her, and in an instant she has constructed a primitive hut
out of strips of bark, to protect the flame against rain and wind.
This, or something very like it, was the way in which the principle
of the house was discovered; and even the most hardened misogynist
cannot fairly refuse a woman the credit of it. The protection of the
hearth-fire from the weather is the germ from which the human
dwelling was evolved. Men had little, if any share, in this forward
step, and that only at a late stage. Even at the present day, the
plastering of the housewall with clay and the manufacture of pottery
are exclusively the women’s business. These are two very significant
survivals. Our European kitchen-garden, too, is originally a woman’s
invention, and the hoe, the primitive instrument of agriculture, is,
characteristically enough, still used in this department. But the
noblest achievement which we owe to the other sex is unquestionably
the art of cookery. Roasting alone—the oldest process—is one for
which men took the hint (a very obvious one) from nature. It must
have been suggested by the scorched carcase of some animal
overtaken by the destructive forest-fires. But boiling—the process of
improving organic substances by the help of water heated to boiling-
point—is a much later discovery. It is so recent that it has not even
yet penetrated to all parts of the world. The Polynesians understand
how to steam food, that is, to cook it, neatly wrapped in leaves, in a
hole in the earth between hot stones, the air being excluded, and
(sometimes) a few drops of water sprinkled on the stones; but they
do not understand boiling.
To come back from this digression, we find that the slender Nyasa
woman has, after once more carefully examining the finished pot,
put it aside in the shade to dry. On the following day she sends me
word by her son, Salim Matola, who is always on hand, that she is
going to do the burning, and, on coming out of my house, I find her
already hard at work. She has spread on the ground a layer of very
dry sticks, about as thick as one’s thumb, has laid the pot (now of a
yellowish-grey colour) on them, and is piling brushwood round it.
My faithful Pesa mbili, the mnyampara, who has been standing by,
most obligingly, with a lighted stick, now hands it to her. Both of
them, blowing steadily, light the pile on the lee side, and, when the
flame begins to catch, on the weather side also. Soon the whole is in a
blaze, but the dry fuel is quickly consumed and the fire dies down, so
that we see the red-hot vessel rising from the ashes. The woman
turns it continually with a long stick, sometimes one way and
sometimes another, so that it may be evenly heated all over. In
twenty minutes she rolls it out of the ash-heap, takes up the bundle
of spinach, which has been lying for two days in a jar of water, and
sprinkles the red-hot clay with it. The places where the drops fall are
marked by black spots on the uniform reddish-brown surface. With a
sigh of relief, and with visible satisfaction, the woman rises to an
erect position; she is standing just in a line between me and the fire,
from which a cloud of smoke is just rising: I press the ball of my
camera, the shutter clicks—the apotheosis is achieved! Like a
priestess, representative of her inventive sex, the graceful woman
stands: at her feet the hearth-fire she has given us beside her the
invention she has devised for us, in the background the home she has
built for us.
At Newala, also, I have had the manufacture of pottery carried on
in my presence. Technically the process is better than that already
described, for here we find the beginnings of the potter’s wheel,
which does not seem to exist in the plains; at least I have seen
nothing of the sort. The artist, a frightfully stupid Makua woman, did
not make a depression in the ground to receive the pot she was about
to shape, but used instead a large potsherd. Otherwise, she went to
work in much the same way as Salim’s mother, except that she saved
herself the trouble of walking round and round her work by squatting
at her ease and letting the pot and potsherd rotate round her; this is
surely the first step towards a machine. But it does not follow that
the pot was improved by the process. It is true that it was beautifully
rounded and presented a very creditable appearance when finished,
but the numerous large and small vessels which I have seen, and, in
part, collected, in the “less advanced” districts, are no less so. We
moderns imagine that instruments of precision are necessary to
produce excellent results. Go to the prehistoric collections of our
museums and look at the pots, urns and bowls of our ancestors in the
dim ages of the past, and you will at once perceive your error.
MAKING LONGITUDINAL CUT IN
BARK

DRAWING THE BARK OFF THE LOG

REMOVING THE OUTER BARK

 BEATING THE BARK

WORKING THE BARK-CLOTH AFTER BEATING, TO MAKE IT

SOFT

MANUFACTURE OF BARK-CLOTH AT NEWALA

To-day, nearly the whole population of German East Africa is
clothed in imported calico. This was not always the case; even now in
some parts of the north dressed skins are still the prevailing wear,
and in the north-western districts—east and north of Lake
Tanganyika—lies a zone where bark-cloth has not yet been
superseded. Probably not many generations have passed since such
bark fabrics and kilts of skins were the only clothing even in the
south. Even to-day, large quantities of this bright-red or drab
material are still to be found; but if we wish to see it, we must look in
the granaries and on the drying stages inside the native huts, where
it serves less ambitious uses as wrappings for those seeds and fruits
which require to be packed with special care. The salt produced at
Masasi, too, is packed for transport to a distance in large sheets of
bark-cloth. Wherever I found it in any degree possible, I studied the
process of making this cloth. The native requisitioned for the
purpose arrived, carrying a log between two and three yards long and
as thick as his thigh, and nothing else except a curiously-shaped
mallet and the usual long, sharp and pointed knife which all men and
boys wear in a belt at their backs without a sheath—horribile dictu!
[51]
Silently he squats down before me, and with two rapid cuts has
drawn a couple of circles round the log some two yards apart, and
slits the bark lengthwise between them with the point of his knife.
With evident care, he then scrapes off the outer rind all round the
log, so that in a quarter of an hour the inner red layer of the bark
shows up brightly-coloured between the two untouched ends. With
some trouble and much caution, he now loosens the bark at one end,
and opens the cylinder. He then stands up, takes hold of the free
edge with both hands, and turning it inside out, slowly but steadily
pulls it off in one piece. Now comes the troublesome work of
scraping all superfluous particles of outer bark from the outside of
the long, narrow piece of material, while the inner side is carefully
scrutinised for defective spots. At last it is ready for beating. Having
signalled to a friend, who immediately places a bowl of water beside
him, the artificer damps his sheet of bark all over, seizes his mallet,
lays one end of the stuff on the smoothest spot of the log, and
hammers away slowly but continuously. “Very simple!” I think to
myself. “Why, I could do that, too!”—but I am forced to change my
opinions a little later on; for the beating is quite an art, if the fabric is
not to be beaten to pieces. To prevent the breaking of the fibres, the
stuff is several times folded across, so as to interpose several
thicknesses between the mallet and the block. At last the required
state is reached, and the fundi seizes the sheet, still folded, by both
ends, and wrings it out, or calls an assistant to take one end while he
holds the other. The cloth produced in this way is not nearly so fine
and uniform in texture as the famous Uganda bark-cloth, but it is
quite soft, and, above all, cheap.
Now, too, I examine the mallet. My craftsman has been using the
simpler but better form of this implement, a conical block of some
hard wood, its base—the striking surface—being scored across and
across with more or less deeply-cut grooves, and the handle stuck
into a hole in the middle. The other and earlier form of mallet is
shaped in the same way, but the head is fastened by an ingenious
network of bark strips into the split bamboo serving as a handle. The
observation so often made, that ancient customs persist longest in
connection with religious ceremonies and in the life of children, here
finds confirmation. As we shall soon see, bark-cloth is still worn
during the unyago,[52] having been prepared with special solemn
ceremonies; and many a mother, if she has no other garment handy,
will still put her little one into a kilt of bark-cloth, which, after all,
looks better, besides being more in keeping with its African
surroundings, than the ridiculous bit of print from Ulaya.
MAKUA WOMEN