Another form of splint, instead of the ordinary right-angled gutter-splint above mentioned, consists of a foot-piece cut in the shape of the foot and made out of quarter-inch-thick board. To this is fastened an iron upright which goes up alongside the leg, and encircles it half way around just below the knee. The foot is firmly strapped to the foot-piece by means of adhesive plaster and covered with a bandage, which is carried up to the knee. The iron upright is then bent backward and its upper part hooked around the back of the leg, and the whole covered with the remaining por tion of the bandage. This is to be changed every few clays, and if the ad hesive plaster causes soreness of the foot the latter is to be first covered by a band age and then strapped with the adhesive plaster to the foot-piece. Recently I have modified this splint by inserting a joint at the ankle and fastening the up right to the foot-board by means of a hinge-joint. The iron goes up the inner side of the leg and a light rubber tube passes from the outer side of the iron upright at the knee to the outer side of the foot-board well forward. By its con stant traction the elastic tends to correct the deformity.
The question of tenotomy will arise. In very young infants it is better not to resort to tenotomy at once. In many cases after a few weeks' treatment it will be found unnecessary. In some infants the deformity is so firm and resistant as to make it practically impossible to keep the braces or splints on or to bring down the heel. In these cases no hesitation should be felt in resorting to tenotomy. Usually a tenotomy of the tendo Achillis will be sufficient. In older and more re bellious cases tenotomy -of the anterior and posterior tibials in addition to the tendo Achillis will be required. Also at times the contracted plantar fascia should be divided.
When the child attempts to walk, a walking-shoe should be ordered. This is similar to the night-shoe, except that it is made stronger and more suitable to stand the wear and tear of continued use.
As cases grow older so do the diffi culties of treatment increase: The feet should be put up in plaster of Paris and held as nearly as possible in the cor rected position until the plaster sets. After a few weeks' trial, if satisfactory progress is not made, tenotomy should be performed and the plaster reapplied until later on walking-shoes may be worn.
In still more severe cases more radical procedures are sometimes demanded. Of these the open section of the tissues of the inner side and sole of the foot as advised by A. M. Phelps may be tried.
The cases of excision of the astragalus alone for equino-varus which have come under my notice have not seemed to me to be satisfactory. In those cases in which it brought the foot into fairly good position less radical measures would probably have been sufficient, while in the bad cases the deformity per sisted, even after the bone had been re moved. This is only to be expected be cause in equino-varus both the inner and outer arches are disturbed, while removal of the astragalus simply affects the inner arch.
In the most severe cases, those vary ing in age from six years to adult life, I have resorted to wedge-shaped resection. This is done by making an incision over the cuboid and anterior part of the cal caneum and then gouging out the bone clear across the tarsus. The parts re moved consist of the anterior part of the calcaneum and astragalus and either the whole or part of the cuboid, scaphoid, and the three cuneiform bones.
Procedure advocated for treating talipes, by which opening the joints of the tarsus avoided. The bony parts are first divided in a line a little behind the line of incision in Chopart's operation, and then in a line through the cuboid and three cuneiform bones. The skele ton of the foot is then in three distinct pieces, and can be molded into what ever shape is required. McCormick (New Zealand Med. Jour., Jan., '93).
All feet at any age after the fourth month with shortened skin and liga ments should be operated on by open in cision. The operation is not completed until the foot is placed in the super corrected position, flexed upon the leg and the heel prominent so that it strikes the ground in walking before the an terior segment of the foot does. Club foot shoes should be discarded for mass age and manipulation, accompanied with fixation of the foot in the supercorrected position by a plaster-of-Paris shoe or ad hesive plaster. Treatment begins imme diately after the operation is completed. Osteoclasis should be performed in all cases of inward twist of the tibia, or a relapse may be looked for. Bone opera tions should never be performed pri marily. Tendons and ligaments should be cut, and not stretched. No case is cured until the heel strikes the ground first in walking. Open incision should never be performed unless the skin re sists and will not stretch sufficient to allow the supercorrective and the proper unfolding of the foot. The weight of the body falling upon any club-shoe or brace nullifies the action of the apparatus. Phelps (Brit. Med. Jour., Oct. 20, 1900).