TALIPES EQUINO-VAKUS. 153 



may still act as a point from which manipulation may be under- 

 taken to cure the varus. 



The place at which division of the three tendons should be 

 carried out must be carefully noticed. The tibialis anticus may 

 be conveniently divided close above its insertion into the inner 

 and plantar aspect of the internal cuneiform and base of the first 

 metatarsal and therefore below the ankle joint. The tibialis 

 posticus can be satisfactorily attacked immediately behind the 

 internal border of the tibia, at the base of the internal malleolus. 

 The tenotome placed between the bone and the tendon cuts, 

 backwards and inwards, and may easily at the same time divide 

 the flexor longus digitorum. There is not the least disadvantage 

 in so doing, provided the knife does not go further and injure the 

 posterior tibial artery immediately posterior to the tendon of 

 the long flexor of the toes. Behind this again will be found the 

 posterior tibial nerve and posterior to it the flexor longus hallucis 

 tendon ; but none of these structures should ever really be in 

 danger in tenotomy of the posterior tibial tendon. 



The section of the tendo Achillis is best performed where that 

 structure is rounded, namely, a little below the level of the tip 

 of the internal malleolus. A puncture is made with a sharp 

 tenotome from the inner side in front of the tendon, care being 

 taken not to insert the point of the instrument into the substance 

 of the tendon, which is decidedly thick at this spot. A blunt 

 tenotome is then introduced, and its cutting edge directed 

 towards the anterior surface of the tendon. Whilst the last 

 fibres are being divided, and particularly the moment when they 

 give way and the foot is released, the skin lying posterior to the 

 tendon is very apt to be cut through, an accident which may lead 

 to disastrous results. 



Even after the division of these tendons it may be found that 

 full correction is impossible, mainly owing to the contraction 

 of other tissues on the inner side of the foot, including skin, 

 fascia, the abductor hallucis and even the ligaments. It may, 

 therefore, become necessary to divide all these constricting 

 structures down to the bones themselves, but as a rule such 



