In well-marked and in resistive cases an anesthetic should be given, while by the use of sufficient force, which may be relatively great, but which should be gently applied, the resisting tissues are so stretched, if necessary to the point of something yielding, that but slight pressure is required to hold the foot in an overcorrected position. When the knife is required the tendo Achillis should always, and the plantar tendons and fasciæ usually, be subcutaneously divided, under aseptic precautions. The foot is then enveloped in suitable dressings and put up in overcorrected position for two or three days, in a rigid dressing at first of starch, but after this in plaster of Paris; this is the writer’s plan of procedure. The insertion of the point of the tenotome sufficiently deep to divide all resistive ligaments and tissues (e. g., the astragaloscaphoid or the calcaneocuboid) nowise complicates this method, but makes it more efficient.
Cases which are resistant are best submitted at once to open operation (that is, after vigorous stretching of the contracted tissues), always under strict asepsis. After decades of milder ineffectual methods it remained for A. M. Phelps, of New York, to show the benefits of this method by which all contracted tissues on the concave aspect of the foot are exposed and divided. Incision is made here from the top of the inner malleolus to the inside of the first tarsometatarsal joint. With a little care the artery can be avoided, but I have never seen any harm come from its division. Everything which proves resistant is divided, even the inner osseous ligaments. Sometimes the incisions can be made in wedge-shape, or obliquely, so that the wound does not remain so widely open. No attempt is made to close this wound. The operation may be done bloodlessly, under the Martin rubber bandage, but whether this be used or not any vessel which can be recognized as such should be tied; otherwise the wound is snugly packed with gauze (upon which I like to use Peru balsam). An ample surgical dressing is applied over it. This is covered with gutta-percha tissue, to prevent too free access of air to the blood which will ooze into the dressing, and the whole is then covered with a starch bandage, in overcorrected position; this is left, according to circumstances, for from three days to a week—the longer the better. Then everything is removed, fresh gauze placed in the wound, which will be found already largely filled up; fresh dressings are applied, and the foot put up in plaster of Paris, with or without a fenestrum or any provision by which the region of the wound may be easily uncovered for necessary renewal of dressing.
It is in the most pronounced types of cases only, with marked bone deformity, or those in which previous operations have failed, that the still more radical division or removal of some part of the tarsus is necessary. As to this no universal rule can be applied save this: take out sufficient to correct deformity. In some cases it will be sufficient to excise the astragalus (astragalectomy). In other cases it is better to remove a wedge-shaped piece of the tarsus, without reference to the name of the bones attacked (tarsectomy). I have never found it necessary to touch the external malleolus, though this has been suggested, nor to do osteotomy of the calcis or of the leg bones above the ankle, as a few have done.
Fig. 263
Park’s club foot brace.
These operations are usually practised, after a preliminary stretching, through a curved incision on the outer aspect of the foot, through which, at the same time, the thickened bursæ may be removed, or the callosities included in the incision. The chief convexity of the incision should be over the os calcis at its anterior portion. As the dissection is made the tendons are drawn aside and spared. If it be necessary to divide one or more of them it should be re-united later. According to the density of the structures a strong knife may be used, and strong scissors, or an osteotome manipulated either by hand or with the hammer. After sufficient V-shaped or wedge-shaped bone has been removed the defect should be held together, if practicable, by buried tendon sutures or wire; it is rarely necessary to use drainage. The external wound may be loosely closed with buried sutures, a suitable dressing applied, and the foot put up in a rigid splint; this should permit of removal, or at least inspection of the wound after a few days, for renewal of those dressings which are saturated with blood and for application of new dressings. After this the foot and leg should be put up in overcorrected position in plaster of Paris.
In aggravated cases of club-foot Wilson believes combined operation to give better functional results than can be obtained by any other method. The astragaloscaphoid joint is exposed by an incision over the prominence of the scaphoid, and, being cleared, is opened with chisel or bone forceps, while sufficient of the articular surfaces is removed to destroy them as such and to take out a sufficiently large wedge-shaped piece from either bone so that the desired arch of the foot is restored, or even exaggerated. Then the tendon of the extensor proprius hallucis is exposed and divided just above the great toe, the upper end of the tendon being drawn out through the first incision. To this end is attached a strong silk ligature. The scaphoid is then perforated with a bone drill at some distance from its superficial aspect and at such an angle, with the foot in correct position, that the canal thus made shall be in line with the action of the tendon. The drill is then withdrawn and the tendon passed through the opening by means of its attached silk. One inch beyond the bony canal the tendon is cut off and split in halves, each half being turned in opposite direction and fastened to the periosteum of the scaphoid with fine silk, while the foot is held in overcorrected position, so that the tendon is sewed in its new place under moderate tension. The foot is then dressed in this overcorrected position in plaster of Paris, the splint extending nearly to the knee, and the wound area being exposed by a fenestrum cut in the splint before it is hard.
The location of the incision over the dorsum or outer aspect of the foot may be varied to suit the needs of the case and the method of the attack. In a general way a flap of soft tissues is raised and tendons, so far as possible, are held outward. This is usually practicable, and it is rarely necessary to divide the latter. After operation of any type and recovery from the same it will be necessary for a long time to have the patient wear a corrective appliance. This should be applied as early as possible, and should be worn continuously, i. e., night and day; inasmuch as growth is continuous there should also be continued correctional influences. Many types of apparatus have been devised. That which the writer has found effective and has adopted for a number of years is illustrated in [Fig. 263]. It may be made single or double, as occasion requires. A part of the appliance is a spiral spring and a provision for a constant outward pressure is made upon the foot, by which inversion is more easily overcome, as well as any inward spiral twist of the bones of the leg. No such apparatus can be made effective unless connected suitably with a waist-band. This is, therefore, included in the shoe shown in [Fig. 263]. Furthermore the appliance should be so made as to permit adjustment commensurate with the rapid growth of the patient, and in order that it need not be too often renewed. Some degree of mechanical ability is required for its application and management. The principles are, however, easily mastered and most parents can soon learn to manage it.