ORTHOPEDIC SURGERY.
Definition. — Orthopaedics is that branch of surgery which relates to the prevention and correction of deformities. Although it is difficult to draw a sharp line between cases that enter into the field of orthopedic surgery and those that do not, it is generally conceded that true orthopmdic cases are those which require some mechanical appli ances in their treatment.
Club-foot.
General Considerations and Varieties.
—Club-foot is the name applied to a condition of the foot in which it is more or less deformed and displaced from its normal position. The displacement of the foot is in the direction of a normal movement; thus, it may be inward, when it is called pes yams; outward, when it is called pes valgus; flexed teriorly, constituting pes calcaneus; and entended, causing walking on the toes, when it is called pes equinus. The dis tortion may be a compound instead of a simple one, producing an eguino-varus or eguino-valgus. Usually the affection is congenital, but not rarely it is ac quired; in such cases paralysis plays an important part.
The most common form is equino yarus, in which the foot is raised at the heel and the sole turned inward. narily the diagnosis is easy, but a wrong course is not infrequently pursued, hardly on account of the difficulty in recognizing the condition, but rather be cause the parents and even occasionally the physician do not appreciate the necessity of instituting treatment at once. In congenital cases treatment can be carried on with advantage almost from the moment of birth, yet it is not seldom that the importance of under taking treatment is only appreciated when the child attempts to walk, eight months to a year and even later. The dif ference between the acquired and congen ital forms should be carefully estab lished, as it influences both prognosis and treatment. In the congenital form, for instance, the muscles of the length ened tendons are not paralyzed, but merely disabled by their abnormal posi tion. When, therefore, the faulty posi tion is corrected, the muscles will re sume their functions, and the prognosis as regards an ultimate good result, and even complete cure, is excellent.
Again, in the acquired form paralysis of one set of muscles is usually more or less complete, and as this is often per manent it is obvious that in many cases a cure cannot be expected, and the best that can be done is to improve the func tion and appearance of the part. Oper ative measures are to be undertaken only with the greatest care. It is evident that if tenotomy is performed on the con tracted muscles the limb is left helpless, as both sets of muscles are disabled.
I. The prognosis in ordinary non-para lytic club-foot is good.
2. In children the restoration of form should be perfect, and function should closely approximate the normal.
3. Restrictive methods, either by dress ings or apparatus, should be as little employed as possible.
4. Persistent manipulation improves function and development.
5. Operative treatment must he thor ough. No part of the correction of de formity should he left, hoping that me chanical means will complete the work.
C. Intelligent and long-continued after treatment is essential to a final good re sult. Properly-constructed boots should be worn, and the foot retained in the cor rected position at night.
7. Age is no bar to successful treat ment. Eminently satisfactory results may be obtained in adult life. Even in the case of adults the more heroic methods of operation in many cases are not called for.
S. The prognosis in paralytic eases will vary according to the nature and degree of paralysis. McKenzie (Canada Jour. of Med. and Surg., May, '99).
Experience based upon sixteen hun dred and fifty operations suggests that all cases should be operated on after the fourth month where there is shortened skin and ligaments, and the open incis ion should always be employed. Pro longed medical treatment extending over months and years, while it may effect improvement, yet it only displaces the simplest and most certain way of deal ing with these eases. An operation for elub-foot should never be considered finished until the foot is placed in an overeorreeted position with the foot flexed upon the leg and the heel promi nent, so that it first strikes the ground in walking. Club-foot shoes of all kinds discarded and replaced by plaster of Paris or adhesive plaster to maintain the foot in an overcorrected position. Post-operative treatment is very impor tant; indeed, the treatment of these eases may be said to just begin with the operation. Osteoclasis should be per formed in all cases where there is an in ward twist of the tibia; otherwise they will relapse. Bone operations should never be done prematurely. Open incis ion should supplement all cases of sub cutaneous tenotomy when it fails to overcorrect. Short tendons and liga ments should be cut, and not stretched, as the latter deforms the foot. A ease cannot be said to be cured and free from danger of relapse until the heel strikes the ground first in walking. A. M.