Forefoot Reconstruction

Dr. Barouk is well known for his development of surgical techniques for the management of forefoot disorders, and the second edition of his book, “Forefoot Reconstruction”, provides insight into his thinking and approach to the management of these sometimes complex problems. The book is copiously illustrated with clinical images, radiographs and diagrams explaining his surgical techniques, and text is kept to a minimum, making it easy to read. Included with the book are two CDs, the smaller containing copyright-free illustrations of the operative procedures, and the larger showing audiovisual presentations of the procedures, which worked smoothly with QuickTime Player 6 (included on the disk).

The book is divided into four main sections. The first describes the various surgical techniques used. Osteotomies are described in detail, indicating their historical development, how they can be adapted for particular clinical circumstances, and the problems and disadvantages associated with them giving guidance as to how these may be avoided. Soft tissue procedures are also covered and there is particular emphasis on equinus contracture as a factor in forefoot pathologies. There are short reviews of the use of memory staples, in the fixation of osteotomies and fusions, and button spacers in damaged joints, but the emphasis thoughout the book is on preservation of joints and, by use of metatarsal shortening and “decompression” of joints, Dr. Barouk's use of these in the forefoot has declined.

The second section considers the main deformities affecting the forefoot from hallux valgus and lesser toe deformities to MTP dislocations, transverse plane deformities and the rheumatoid forefoot, and how the operative techniques described in the first section can be used. There is emphasis on obtaining uniformity of the height of the metatarsal heads, to “correct” their lengths so that they approximate to the ideal relative lengths as defined by Maestro et al. [1], and to shorten metatarsals to decompress arthritic joints. Dr. Barouk shows us his application of the various operative procedures in common problems, taking us progressively through to the more complex disorders of the forefoot.

Section 3 covers the patient management process from pre-operative evaluation, surgery, to post-operative care. The procedure for the standard radiographs is described leading to the pre-operative plan. Dr. Barouk shows us the surgical instruments he uses and describes the surgical implants, many of which he has developed himself. When it comes to post-operative care he stresses the importance of swelling reduction by elevation, early ambulation in protective and weight relieving footwear, close surgeon supervision of care, and patient participation in rehabilitation by use of stretching exercises and strapping.

In the final section, Dr. Barouk defines his “Eight Principles in Forefoot Reconstruction”. This is a summary of the preceding sections in the book. The last of these principles is to “obtain a foot which fits into elegant shoes”, which, if the reader had not already appreciated, indicates the importance of cosmesis in Dr. Barouk's approach to correction of forefoot deformity.

The value of a new book can be measured in a number of ways. Certainly for ease of reading and reference to surgical techniques it scores highly, with a very visual approach to their description. From the scientific point of view, however, it is lacking. There is no detailed presentation of patients’ pre-operative symptoms, deformities and outcomes, and so comparison with other studies is not possible [2], [3], [4]. Discussion of alternative management options is superficial and limited, and although there are 131 references listed in the bibliography, very few of them are directly quoted in the text (and many of the reference numbers given are incorrect), making it difficult for the reader to investigate the author's claims further. In the forward, Dr. Barouk states that “this book is not based on any theory, but is rather a direct result of my day-to-day current practice of forefoot surgery”. As a consequence, there is no consideration of the mechanisms that control the foot in its functions of standing and walking, and how these mechanisms might be affected by his surgical interventions. The book therefore represents the opinion of one very eminent orthopaedic surgeon, but the reader should be aware that there are many other opinions and approaches to the management of forefoot disorders. Dr. Barouk, in his acknowledgements, refers to the “French flavour” of his English. This leads to some mild ambiguities in the text. It also leaves me with the impression that this book, and his approach to the foot, is more about art than science.