Club-Foot 503 



This operation should not be undertaken, however, until the gym- 

 nastic exercises have had a prolonged and patient trial. 



Talipes (talus, ankle ; pes, foot), because, in the commonest variety 

 of club-foot, the patient walks on 

 the outer side of the ankle this 

 variety is equino-varus, the 

 heel, or heels, being drawn up 

 (as in cquus\ and the soles being 

 turned inwards towards each 

 other, varits. 



Before birth the feet are nor- 

 mally in this position, in order 

 that the embryo may be packed 

 in the smallest space ; the com- 

 pression of the uterine wall, in all 

 probability, causes the arrange- 

 ment. If, after birth, their posi- 

 tion be not improved by development, the retaining bands become 

 permanently shortened and the bones misshaped. 



The structures which may require division in talipes equino-varus 

 are the tendo Achillis (and in slight deformity this may suffice), the 

 tibialis anticus, tibialis posticus, and flexor longus digitorum ; the 

 anterior part of the deltoid ligament, which is holding back the tuber- 

 osity of the scaphoid bone ; the inner part of the plantar fascia, and 

 possibly also the abductor hallucis. Indeed, every structure is to 

 be divided until the foot can be placed in the proper position. After 

 this it is fixed in a gypsum case till the wounds are soundly healed, 

 then massage is employed. There need be no anxiety about the non- 

 union of widely sundered tendon-ends, so long as they are not divided 

 in their synwial sheath. At the present day the tendons are divided 

 by a free incision in the sole, rather than above the malleoli, where 

 they lie in synovial sheaths and in the neighbourhood of important 

 vessels. 



The tendon of Achilles is divided from before backwards an inch 

 above its insertion ; the tibialis anticus is divided from the outer (the 

 arterial side) just below and in front of the inner malleolus. The 

 tibialis posticus is divided between the tip of the inner malleolus 

 and the tuberosity of the scaphoid, and here also the anterior part of 

 the deltoid ligament may be severed. The other bands are cut 

 wherever they can be felt firm and resisting beneath the skin, and, as 

 remarked above, by a free incision, so that the surgeon may see wha: 

 he is doing ; subcutaneous tenotomy is often disappointing. 



The flexor longus digitorum rarely needs section. 



In the adult a wedge of bone has occasionally to be removed from 

 the upper and inner part of the tarsus, before the man can become a 

 plantigrade, or, better still, the astragalus is excised, as advised by Lund. 



