496 



THE INFERIOR EXTREMITY 



inserted at the cubo-metatarsal joint and carried medially 

 through the cuneiform bones to the medial border of the foot. 

 Thereafter the wedge is removed; and if sufficient bone has been 

 resected, the two portions of the foot can be brought together 

 without any stretching of soft parts. 



In order to correct the " in-toeing/' the abductor hallucis 

 (p. 491) may be excised through a linear incision on the medial 

 side of the foot. Division or lengthening of the tendo calcaneus 

 (p. 475) completes the operation. 



It must be remembered that many of the muscles which are 

 involved at first in acute anterior poliomyelitis may subsequently 

 recover ; and on this account steps must be taken to prevent 

 the temporarily paralysed muscles from being overstretched by 

 their unaffected antagonists. Deformities which result from 

 the permanent paralysis of some muscle or muscles may be 

 diminished by operative treatment. 



Arthrodesis is restricted to cases of widespread paralysis 

 with flail joints. 



When the paralysis is more limited; nerve-anastomosis, a 

 practice as yet in process of development; or tendon trans- 

 plantation, may be carried out. In the latter operation; either 

 the whole or part of the tendon of an unaffected muscle may be 

 transplanted into the tendon of one of the paralysed muscles, 

 or it may be inserted subperiosteally to a fresh attachment so 

 as to restore the muscular balance of the foot. 



The following table shows the position in which tenotomy 

 of the various tendons can be carried out most conveniently : 



Tendon. 



Position of Incision. 



Tibialis Anterior. 

 Tibialis Posterior. 

 Tendo Calcaneus. 



Peronsei (Longus and 



Brevis). 

 Extensor Hallucis Longus. 



Extensor Digitorum Longus 

 and Peronaeus Tertius. 



At lateral side of tendon, just anterior to 



the tuberosity of the navicular. 

 At medial side of tendon, proximal to the 



medial malleolus. 

 i inches (in the child, inch) proximal to 



its insertion. 

 At lateral side of tendons proximal to tip 



of lateral malleolus. 

 At lateral side of tendon (to avoid injuring 



the dorsalis pedis), and opposite the 



tuberosity of the navicular. 

 At medial side of tendons (to avoid injuring 



the anterior tibial vessels), either at the 



ankle-joint or one inch proximal to it. 



