Operation for Wry Neck.—Subcutaneous section of the sterno-mastoid.—In what cases of wry neck is this operation suitable? In those only in which the muscles are the starting-point of the mischief. These are sometimes congenital, more frequently they commence in childhood. In cases where the distortion depends on disease of the cervical vertebræ, or is secondary to curvature of the spine, division of the muscle is worse than useless.
Operation.—A tenotomy knife, which should be sharp-pointed, narrow in the blade, with a blunt back, should be introduced through the skin a little to one side of the sternal portion of the affected muscle, passed along with its flat edge between the skin and the tendon, till it has fairly crossed the tendon; the blade should then be turned so that by a gradual sawing motion the edge may be made to divide the tendon about an inch above the sternum. A distinct snap will then be felt or heard, and the position of the head will be at once much improved. Exercise, warm bathing, and rubbing, will generally suffice to complete the cure, without it being necessary to call in the aid of the instrument-maker with his expensive apparatus.[166]
Operations for Club-Foot.—The following are the tendons which may require division in the cure of club-foot, and the operations for their division.
1. The tendo Achillis.—There are very few cases of true club-foot which can be successfully treated without division of the tendo Achillis. While in talipes equinis it is generally the only disturbing agent, in talipes varus and valgus it invariably increases and maintains the deformity, which the tibiales or peronei seem to originate.
Operation.—The foot being held at about a right angle with the leg, the operator should pinch up the skin over the tendon, introduce the knife flatwise, a little to one side of the tendon, till its point is nearly projecting at the other, then turn the edge on the tendon and cut inwards with a sawing motion till the tendon gives way with a distinct snap, and the foot can be completely flexed with ease.
Dr. Little[167] recommends that the tendon should be divided from before backwards. There is more risk by this method of wounding the skin, and thus losing the subcutaneous character of the operation.
Professor Pancoast[168] divides the inferior portion of the soleus muscle instead of the tendo Achillis.
2. Tibialis posticus.—Next in frequency and importance to that of the tendo Achillis, division of this tendon is much more difficult to perform. It may be performed either above or below the ankle.
(a.) Above the ankle.—The blade of a tenotomy knife should be entered perpendicularly at the posterior margin of the tibia, half an inch or an inch above the internal malleolus, so as to pass between the bone and the tendon of the tibialis posticus, the blade directed towards the latter; the assistant should now evert the foot, the operator pressing the blade against the tendon.[169]