Manual of Surgery Volume Second: Extremities—Head—Neck. Sixth Edition.

by Alexis Thomson; Alexander Miles

In extreme cases, the supinated foot forms an acute angle with the leg, and there is frequently a deep transverse depression across the sole, the result of contraction of the plantar fascia—a feature which is distinctive of the congenital form of club-foot.

In children who have walked, the deformity becomes aggravated. The dorsum of the foot is markedly uneven, partly because of the prominence of the individual tarsal bones, and especially of the head of the talus and greater process of the calcaneus, and partly because of a depression over the neck of the talus. Instead of resting on its lateral border, the foot may finally rest on the dorsum, the sole looking upwards and backwards. While the skin over the heel remains comparatively thin and delicate, that covering the lateral border and dorsum of the foot becomes the seat of callosities, beneath which adventitious bursæ are formed. These bursæ are liable to become inflamed, and are then a source of great suffering, and if they suppurate may cause persistent sinuses. The muscles of the leg and foot, although not paralysed, undergo atrophy from disuse. In walking, the patient lifts one foot over the other in an ungainly and laborious manner, without any spring, as if walking on stilts.

In adults, these features are further aggravated, and there are permanent changes in the bones ([Fig. 144]).

Fig. 144.—Congenital Talipes Equino-varus in a man æt. 24; seen from behind.

Treatment.—This should be commenced as soon as the viability of the infant is beyond question, as the younger the patient the more easily and completely is the deformity rectified. Manipulations to correct the deformity should be carried out twice or thrice daily, and the limbs are also massaged and douched. At the end of two or three months, assistance may be derived from the use of a simple lateral poroplastic or aluminium splint with a foot-piece, or more simply by a strip of rubber plaster. The foot is held in the over-corrected attitude and the plaster is applied so as to maintain this attitude. If this regime is systematically persevered with from within a few days after birth, by the time the child begins to walk the sole can be brought into contact with the ground, and the weight of the body will aid in correcting the deformity. If the equinus element resists correction, the tendo Achillis should be lengthened.

The turning in of the toes may be overcome by strapping the feet at night to a wooden board with the whole lower limb rotated laterally so that the toes of each foot point directly outwards. On account of the tendency towards relapse, the manipulations and massage must be persevered with for at least a year.

Tenotomy and Forcible Correction under Anæsthesia.—In more severe cases we have to deal not only with the contracted soft parts, but with changes in the bones resulting from their having grown in adaptation to the deformed attitude. The majority of surgeons defer operative measures until the child is about a year old.

The soft parts to be divided are the tendo Achillis, the medial and posterior ligaments of the ankle, the plantar fascia, the calcaneo-navicular ligaments, and the tibialis posterior tendon. The varus deformity may then be corrected by laying the foot on its lateral side on a padded triangular wooden block, and pressing forcibly on the anterior and posterior ends of the foot so as to undo the curve on its medial side and allow of abduction of the foot; this is usually attended with cracking as the shortened ligaments give way. The equinus element is next dealt with by forcibly dorsiflexing the foot until the deformity is over-corrected. If it is preferred to correct the deformity in stages instead of at one sitting, the equinus element is left to the last. In older children, the strength of the hands is usually insufficient to stretch the tissues, and mechanical wrenches may be employed, such as those devised by Thomas, Bradford, or Lorenz.