The consists in wearing shoes with the outer side of the soles raised. Celluloid plates with an elevation of at least cm. can he worn inside of the shoe to which a splint is attached which serves to pronate the foot when the shoe is laced. In order to prevent the heel slipping, I use an appliance around the heel consisting of four straps which pass through four holes in the shoe near the heel and fasten around the ankle (sec Fracture of femur).
Elastic bands are applied from the side of the shoe backwards and upwards to the opposite hip in cases of continued inward rotation of the hip. A splint apparatus could also be used and adjusted so as to bring about forcibly an outward rotation with the aid of a pelvic truss.
I never made use of mechanical appliances such as the osteoclasts of Lorenz, Schulze, or Thomas to correct these deformities, because I believe that it is possible to treat successfully any degree of club-foot in children without such procedure. The bloodless method of redresse ment, including tenotomy and fasciotomy, has always proved entirely satisfactory to me and the severer operations are unnecessary in children.
If for any reason early treatment is impossible I postpone the plaster-of-Paris treatment until after the sixth month. This is in con formity with the views of other authors, as it enables the child to walk on its feet immediately after the treatment is finished, so that the weight of the body assists in further correcting the deformity. When the cor rection is made at an earlier period a prolonged after-treatment is neces sary, which in most cases cannot be carried out.
The treatment may be discontinued when the child is able to walk on the sole of the foot with the toes everted and actively to pronate and dorsi-flex the foot.
Relapses occur especially in the out-patient department on account of the dependence of such eases on external conditions and influences.
Irregularity in applying the treatment and careless nursing inevitably cause relapses. It is therefore necessary to keep patients under observa tion at least 011P0 every two years, and perform subsequent operations, if occasion arises, before the deformity grows too old.
The fixation of so-called "rebellious" club-feet, which easily incline to relapses, is best accomplished by performing a tenoplastic operation. This consists in shortening the pronating muscles and making a peri osteal transplantation of the insertion of the tibialis anticus muscle on the external border of the foot.
Among the many operations performed to correct this deformity Phelps's division of the soft tissues and Codivilla's combination of division of soft tissue and tendon transp'.antation may be mentioned. There are a number of bone operations which change the position of the foot by osteotomy or removing some bony tissue at the outer border of the foot (enucleation, resection, wedge incision).
The treatment of acquired club-foot depends on the condition which brought about the deformity. The removal of cicatrical tissue by means of skin grafting and the reinstatement of active muscular contractions in paralysis may be employed. The latter can be accomplished by resusci tating the paralyzed muscle by nerve transplantation, or by transplanting the muscular insertion so as to give the desired direction of motion.
The treatment with apparatus should be confined solely to inoper able cases or used as an aid in the after-treatment. It consists in the application of hollow splint braces to support the foot in the corrected position and the use of elastic bands to check certain motions and to replace lost muscular power and activity.