MEMOIRS.

CLUB-FOOT.*

BY BART E. MCKENZIE, B. A., M. D., TORONTO, ONTARIO.

SURGEON TO THE TORONTO ORTHOPEDIC HOSPITAL; ORTHOPEDIC SURGEON TO GRACE HOSPITAL; ASSOCIATE PROFESSOR OF CLINICAL SURGERY IN THE ONTARIO College FOR WOMEN.

[PUBLISHED IN The Physician and Surgeon EXCLUSIVELY)

IN speaking upon the subject of club-foot I shall refer especially to the congenital deformity which is known as talipes equino-varus. There are many deformities of the foot and sometimes the word club-foot is used to signify varieties other than that just named. For example, osteomyelitis affecting the tibia has, in some instances, interfered with its growth at the lower end, permitting the shortened tibia and growing fibula to push the foot inward so that the weight of the body transmitted through the leg would naturally tend to reach the ground at the outer side of the foot. Simple equinus arising more commonly from some form of paralysis, the heel being drawn upward to a varying extent, is sometimes spoken of as club-foot. Even the condition of the foot which is more properly and commonly known as flat-foot is sometimes spoken of under the name designated above. At this time, however, I shall confine my remarks wholly to the consideration of equino-varus, which is the true club-foot.

In order to treat club-foot properly and with a reasonable prospect of success, we must thoroughly understand the normal architecture of the foot and the varying pathologic anatomy which is found present in clubfoot. In the mechanism of the foot it is proper to speak of three arches, two of which are commonly described in the works on anatomy, the third of which, however, is of more importance than the others in the consideration of our subject. The first is the longitudinal arch, the heel being . a single posterior pier while the heads of the metatarsal bones present a compound pier in front. The second arch exists under the metatarsal bones and is transverse. The third is seen clearly only when the two feet are considered together. The piers of the arch are found at the outer borders of the feet, and it is incomplete in either foot alone; that is to say, considering only one foot, the outer end of the arch is supported upon the ground at the outer border while the inner extremity of the segment which is seen in one foot has no direct mechanical support. The segment terminates at the inner border of the foot and does not come into contact with the ground. The maintenance of the extremity of this segment in a normal position has much to do with the elasticity and gracefulness of the foot. The necessary support to so maintain it is found in the muscles which are inserted at or pass under the inner border.

When the end of this incomplete arch is unduly depressed it gives us

*Read before the NORTHEASTERN DISTRICT MEDICAL SOCIETY OF MICHIGAN at its Port Huron meeting.

a form of flat-foot; when the balance of the foot is lost by its elevation so that the foot is thrown more toward the outer border, we have a degree of club-foot. The parts moving upon each other at any joint should be maintained in even balance. For example: the extensors at the knee may be so weak that the hamstrings do not permit of an even balance but cause habitual flexion, and in time contracture of these hamstrings will occur and permanent flexion at the knee will result; or, on the other hand, the hamstrings may be so disabled that flexion cannot be effected. In a similar manner at the foot, all varieties of motion which are normal to the

foot should be capable of performance. If, for causes which were prenatal, the structures which draw the foot inward and the heel upward have become so shortened that the foot is thrown upon its outer border, even tending to roll over till the dorsum of the foot comes into contact with the ground, we have a compound deformity. (See Figure I.)

It is necessary to have a clear understanding of the elements which make up the final and resulting deformity and disabilty. First let us look at the foot per se as if it were disarticulated at the ankle-joint. It will be seen that the anterior part of the foot curves inward so that the inner

(See

border is shortened and the outer border is relatively lengthened. Figures II and III, for comparison.) The longitudinal arch too, in most cases, is greatly shortened, the plantar ligament, the plantar fascia, tibialis posticus, flexor longus digitorum, flexor longus hallucis, the calcaneoscaphoid ligament and other structures at the plantar surface and inner border are unduly short and present great resistance when an effort is made to place the anterior part of the foot in normal line with the posterior. Even the bones toward the inner and plantar aspect of the foot are shorter and smaller, and present a more concave appearance than normal. Exactly the opposite conditions prevail at the outer border and dorsum of the foot, namely, the muscular, ligamentous, fascial, and osseous structures are relatively lengthened, and the appearance is more convex than normal. In the consideration of the treatment of club-foot the deformity just described should be considered alone and apart from that to which I am about to refer.

Assuming that the foot per se is duly corrected and normal, and that none of the conditions above described are present, it might still be a fact that the relation of the foot to the leg is wrong, namely, that the heel is unduly drawn upward and maintained by short calf muscles so that it is impossible to bring the foot into a normal relation to the leg. The in-turning of the foot described before is known as varus; that which we are now considering is equinus. In this latter the anterior part of the articular surface of the astragalus which should normally come in between the malleoli is often unduly wide, so that it cannot readily be forced back into its place. The anterior structures are relatively lengthened and powerless to produce dorsi-flexion, while the calf muscles, terminating in the tendo Achillis and inserted at the posterior end of the os calcis, are shortened. To lose sight of the distinctive features of each part of this complex deformity is to let go of the first principles of successful treatment. In the great majority of patients the complete and satisfactory rectification of the part first described, namely, the varus, is much the more difficult. The practice, which is so common, of cutting the tendo Achillis and bringing the heel down so as to rectify at first the relation of the foot to the leg is to place an insuperable obstacle in the way of obtaining a satisfactory result. Let us assume that the heel has been brought down as just referred to, and the relation of the foot to the leg has been made normal. Now the main axis of the foot is at right angle to the axis of the leg, but the distortion of the foot in itself still exists. It will be seen that if an attempt be made to correct the varus under these circumstances the forcible pulling of the anterior part of the foot outward is like turning a crank, the foot being the crank proper and the leg the axis about which the turning takes place. On the other hand, before the heel has been brought down it will be seen that the anterior part of the leg and the dorsum of the foot are practically in the same plane, and if an attempt now be made

to rectify the varus by pulling the anterior part of the foot outward we have a long lever, the foot in the vicinity of the external malleolus being a fulcrum over which prying may be done, while the foot anterior to that is one end of the lever and the leg the other. A little careful attention to this point will at once show the wonderful mechanical advantage there is in correcting, first, the varus. There is no disadvantage in leaving the correction of the equinus to a later time.

The principles of treatment will be the same whether in the adult or child.

The question is sometimes asked, What is the proper time at which to commence treatment. Attention should be given to the case from the earliest days of infancy. For the first year, or certainly for the first eight or nine months, the attention, however, should be given by the nurse or mother, under the direction of the surgeon. The treatment should be

manipulation of the foot and leg, an effort being made to correct or overcorrect with the hand the distortion before referred to, giving most attention to turning the foot outward, so as to rectify the varus. Unfortunately, the practice is common to encase the foot in some sort of restrictive appliance, plaster of Paris, club-foot shoes, et cetera. The application of such tends to interfere with the development of a foot and leg, which in all cases comes short of normal completeness. Massage and manipulation, as just described, on the other hand, will tend to favor the more complete development of the leg and foot. Even if correction were fully made within the first year it cannot be maintained without the use of mechanical means. Nature's method of retaining the corrected foot in position is found in its normal function in walking; hence it is not important that complete correction be effected until the time comes when the child can bear and carry about his own weight. When the time comes for the surgeon's active interference, the steps to be taken will depend much upon the resistance offered by the foot. In a considerable number of instances in which manipulation by the nurse or mother, as above described, has been intelligently carried out, the surgeon will find it sufficient to correct the foot by his hand, and to fully rectify its deformity and to maintain the correction by some fixed dressing, of which plaster of Paris is the best. Sometimes this may be done with one dressing. More commonly several

dressings are required.

Assuming always that the deformity of the foot per se has been overcorrected, attention should be given to the rectification of the equinus. Very seldom can this be wisely done without section of the tendo Achillis. No hesitation need be felt in making complete section of the tendo Achillis, or any other tendon. The foot is then placed in an over-corrected position so that the plantar surface of the foot shall be at an angle of eighty degrees or thereabouts with the legs.

Assuming that the first steps are not so easily accomplished, certain structures may be felt digitally, which offer marked resistance to our efforts. Of these I find the plantar fascia the most notable, and that which I generally cut first when cutting is found necessary. Following this, the tibialis posticus tendon offers most opposition. Then there is the internal lateral ligament, and often the long plantar ligament. It is exceedingly uncommon to find the tibialis anticus offering any effectual resistance. This is due to the fact that, while the in-turning of the foot would point to a short tibialis anticus muscle, yet the condition of equinus would indicate lengthening of this muscle. After section of any or all of the structures just named, the foot, whether that of an infant, a child, or an adult, can, in large measure, be placed in normal shape. It is not uncommon to find, when the foot has been partially corrected, that the skin offers definite obstruction to further replacement. At this time I desist from further correction and apply my fixed dressing. When this has been left