CLUB FOOT.
Congenital club foot is commonly of the equino-varus type, and the deformity can be effectually dealt with when not severe without any cut ting operation. A few days after birth systematic manipulations of the distorted foot should be patiently and perseveringly undertaken by a trained nurse. The anterior portion of the foot being grasped by one hand and the heel by the other, the sole is everted and the foot turned outwards and held for a few moments in this position, the operation being repeated many times till the greatest degree of correction is obtained.
Then by flexing the foot upon the leg the tendo Achillis and its muscles are stretched in a similar manner, after which both manipulations may be combined and the muscles of the limb carefully massaged, these operations being carried out many times each day.
After some degree of correction of the deformity has been achieved for several weeks by these means, splints may be utilised; a padded poro plastic, malleable iron or aluminium splint with a foot-piece should be applied after bending it or moulding it to the position of the limb, whilst the latter is firmly held in the best corrected position without causing pain and a bandage is applied. Several times during the day the splint is to be removed and the manipulations and massage with douching repeated, the apparatus being from time to time further bent or remoulded as the deformity becomes less, and it may be kept on at night. By persisting with this treatment, in all mild cases the deformity may be so reduced that when the child commences to put its feet upon the ground the tendency of the foot to regain its abnormal position may have disappeared and walking movements will further advance the cure, but still great attention must he given to prevent relapse and a splint must be applied at night and so bandaged as to cause rotation outwards of the leg in order to correct the tendency of the toes to turn inwards. A walking boot with steel supports is also usually necessary for a time.
In severe cases the correction of the distortion cannot he effected by manipulation with the hands, and then tenotomy under anesthesia must be resorted to, and the deformity overcorrected by forcibly twisting the footinto its normal position. The best practice is to first cut the structures
which produce the varus distortion—viz., the tendon of the tibialis anticus, the plantar fascia, a portion of the internal ligament of the ankle-joint and sometimes the tendon of the posterior tibial muscle. The foot is manipulated until the varus deformity is overcorrected. Tenotomy of the tendo Achillis is now carried out and the equinus position overcorrected. The foot is then put in plaster in the overcorrected position and not disturbed unless for special reasons for 3 to 4 weeks. At the end of this time the plaster is removed and either reapplied or reapplied after further manipulation. The repetition of this treatment over several months will usually result in cure of the deformity. To prevent recurrence it will be sufficient to allow special boots, if necessary fitted with iron supports, to be worn by day and Jones' club-foot splints at night. Mechanical appliances may be usOid for control of deformities, but not for their cure.
In very severe cases where the distortion cannot be remedied by the above measures and in relapsing cases Phelp's operation of dividing all the constricting structures by an open incision down to the hone on the Inner side of the foot has been practised.
When the bones in neglected cases have become deformed, the operation of tarsectoiny is advocated, by which a wedge-shaped mass of bone con sisting of portions of the astragalus, cuboid, scaphoid and os calcis is removed or Lund's astragalectomy must be used. It is the best operative measure where manipulation and tenotomy fail. Ogston's alternative plan has found favour; this consists in cutting down upon the tarsus and gouging out the osseous nucleus of the astragalus, anterior part of the calcis and cuhoid, leaving behind their cartilaginous shells.