PHELPS’ METHOD FOR THE CURE OF CLUB-FOOT 
IX ADULTS. 
BY WM. E. WIRT, A. M., M. I)., PH. D. 
President of the Cleveland Medical Society; Professor of Orthopedic Surgery in the Medical De- 
partment of University of Wooster, etc. Formerly House Surgeon, Hospital for 
Ruptured and Crippied, New York City, N. Y. 
1 do not presume to present any radically new points regard- 
ing the usefulness of Phelps’ operation, especially to this Associa- 
tion, as I feel that the members of this organization are well ground- 
ed in the elements of the treatment of club-foot; yet I do believe 
that I can present some experience which may be of use to the gen- 
eral practitioner and the surgeon, whom we know have widely dif- 
ferent opinions on the subject of the treatment of this affection. 
Even this Association is not united in declaring for any given 
method of treating club-foot. Our ex-President, Dr. Steele, in his 
address, last year, called attention to this by the remark, that, “ if 
one simple plan of treating club-foot was always successful there 
would not be such a variety of methods suggested.” Let me fur- 
ther illustrate this diversity of opinion: In the Surgical Section of 
the Mississippi \ alley Medical Association at their last meeting 
(October, 1893), a surgeon of some prominence presented for the 
consideration of the Section, and advocated strongly, his new oper- 
ation for the cure of inveterate club-foot, which was a modified 
Chopart imputation. He claimed that in many of these cases he 
had failed to cure by all methods available, and further believed 
that this operation would give the best walking extremity obtainable. 
This is certainly an extreme view. The opposite extreme 
opinion was presented, in the discussion which followed, by a gen- 
tleman holding the chair of general surgery in one of our Western 
* Read before the American Orthopedic Association, May 30, 1894. 2 
CLUB-E’OOT IN ADULTS. 
colleges, who claimed that in his experience he had never seen a 
case requiring a cutting operation of any kind, but that he had 
deemed mechanical force under an anaesthetic plus the use of 
braces all-sufficient. 
I therefore feel that any experience which wfill tend to estab- 
lish an operation between the above extremes, which shall be satis- 
factory to the general profession in a given class of cases, is reason 
enough for its being recited. 
As to the question of Chopart operation or any modification of 
it for the relief of club-foot, 1 stated then, as 1 hold today, namely, 
that any amputation of a part of the foot for the relief of this con- 
dition is a stigma to surgery. The operation is not deserving of 
serious thought. In regard to the other extreme view, viz., that of 
attempting to cure all cases of club-foot by mechanical force (say 
tarsoclast) under an anesthetic, I would say that I have had some 
unfortunate experience, which has led me to avoid in certain cases 
carrying it to that extreme which is necessary in order to correct the 
deformity by this method alone. 
Case: I.—Oliver F. M., ten years old, with double congenital 
equino-varus, dislocation of left hip and imperfect action at both 
shoulders (the latisimus dorsi of both sides being short); also creak- 
ing motions at knee-joints; boy somewhat anaemic, circulation not 
very vigorous. Operated for cure of deformity of hand and both 
feet. I cut both tendines Achillis subcutaneouslv and fascia of sole 
of feet; also astragalo-scapdoid ligament. Used the Thomas tarso- 
clast with considerable force, finally getting the feet into good posi- 
tion, as shown by my notes in case-book. I saw the patient two 
hours after the operation, when the circulation had returned to all 
toes except great toe of the left foot. J gave orders to the house 
doctor that if the circulation did not return in a short time to cut 
down on the plaster dressing and relieve the tension. Two hours 
later (9 P. k.) 1 telephoned to the hospital, and was informed that CLUB-FOOT IN ADULTS. 
3 
the circulation had returned nicely to the great toe in question. I 
now think that that this was an incorrect report carelessly made. At 
8 o’clock the next morning I was called by telephone to come imme- 
diately to the hospital, as patient’s foot was in a bad condition. I 
immediately went to see him and found the toe of a dark-bluish 
color, the second toe in nearly the same condition, and on removing 
the plaster found a bleb on the inside of the arch of the foot two 
inches in width and nearly four inches long. At the position of 
this bleb sloughing subsequently took place. The lateral ligament 
of the great toe sloughed away, the tendon of the extensor proprius 
pollicis was exposed for about an inch, and also the bone at one or 
two points. The casting off of the slough and the suppurative 
process were very slow, keeping the boy confined to the house an 
extra month and a half. From the loss of the lateral ligament the 
toe was drawn out of position and an amputation of the toe was 
done. Ultimately I got a good result, the feet being perfectly 
straight, the boy walking very well. It is possible that had the 
plaster been removed the same evening of the operation the slough 
might not have taken place. Quite certain I am that had I fol- 
Jowed the suggestion of our worthy President, with whom 1 dis- 
cussed this case at our meeting in New York, and who advised the 
open incision, no such accident would have followed. 
Case II. (About six months after operating on Case I.)—Emma 
W., aged forty-four years, came to me for treatment. She was a 
maiden lady of marked subnormal cerebration, under size, being 
only about four and one-half feet tall, weighing probably about 
ninety pounds. She was anaemic, being about as colorless as any- 
one I have ever seen. Her hands were delicate and no larger than 
those of a child eight or ten years old. She had right equinus and 
left equino-varus from infantile paralysis. Being rather an unpro- 
mising subject I did not urge the operation, but spoke rather dis- 
couragingly of the possible outcome. But she declared that she 4 
CI.UB-FOOT IN ADULTS. 
had made up her mind to have an operation, no matter what hap- 
pened. 1 soon saw that she had a strong will if not backed by 
good judgment. Under an anesthetic I cut the tendo Achillis of 
left foot subcutaneously, also the fascia of sole, then by the Thomas 
torsoclast wrenched the foot into good shape, carrying it over as f«r 
as 1 desired, then put it up in plaster. 1 will here remark that her 
foot was as pliable as that of a child six years old or younger, and 
was carried into a position of valgus by the tarsoclast without the 
use of extreme force. Having had the former unpleasant experience 
and this being an unpromising case, I determined to watch the foot 
carefully myself. Soon the circulation seemed fairly good except 
in the great toe. In a little over an hour, finding that it still did 
not return in this toe, T cut through the plaster and sprung it anart. 
Two hours later, still finding imperfect circulation, I took off the 
plaster entirely, liiven then the circulation of the skin did not 
not return over a large area on the inside of foot, toe and heel. 1 
am convinced that in this case the sloughing was due to the stretch- 
ing of the skin pure and simple. This is proven by sloughing tak- 
ing place on the heel where there was no pressure whatever either 
by tarsoclast or plaster-of-paris. Ilad I done the open-incision 
operation in this case, as I certainly would do now, T feel reasona- 
bly sure that healing would have taken place in a month to six 
weeks instead of having to wait for the tedious healing of an exten- 
sive slouch. 
In contrast to the above-mentioned case, I desire to report 
Phelps1 operation on a girl nearly nineteen years old. 
Case ! IT.—Acldie P., aged nineteen years, of Pottsville, Pa. 
Double congenital equino-varus. When a few months old an oper- 
ation was performed on both feet; she wore braces until the age of 
five years. Both feet were still badly deformed. She was then 
taken to Buffalo and again had both feet operated upon without 
much improvement. At home, by the use of braces, massage, CLUB-FOOT IX ADULTS. 
5 
manual force, and plaster, the left foot was nearly cured, and there 
only remained at the time of my examination some shortening of 
tendo Achillis which permitted the foot to flex to just a right angle. 
The patient was satisfied with this foot, and only wished for correc- 
tion of deformity of the other (right) foot. The right foot could 
not be flexed to less than 110y; there was marked cavus and varus 
of moderate severity. Under an anesthetic 1 cut the tendo Achillis 
subcutaneously, and after some minutes’ trial found that 1 could not 
get the heel down, so I made an open incision over the tendon, 
cutting as much of the posterior heel ligament as I could reach, in- 
sertinor the blade of the knife over an inch below the level of the 
skin. Considerable hemorrhage followed the last deep cut, and for 
a time I thought I had severed the posterior tibial artery, but by 
packing the wound the hemorrhage was soon stopped, and from the 
lack at any time of interference in the circulation of the foot I was 
led to believe that it was the internal calcanean, which 1 think 1 
have cut on several occasions. Having gotten the heel down satis- 
factorily T made the open incision from a point about an inch in 
front of the anterior part of the inner malleolus straight downward 
to about half across the sole of the foot; cut through everything, 
including astragalo-scaphoid ligament. I then applied the wrench; 
but with all the power I could use was unable to get the foot into 
satisfactory position, so again applied the knife, cutting more liga- 
mentous tissue. On a second application of the tarsocrast I was 
able to bring the foot into entirely satisfactory position ; the 
wound gaped about an inch and was lightly packed with gauze 
and the foot fixed in plaster-of-paris. Wound filled slowly but 
perfectly. She wore a brace about four months as a precaution, 
but I hardly think that it was necessary. May 18, 1894, 1 re- 
ceived a photograph and a letter saying that the foot is per- 
fectly straight, that she wears the same sized shoe as on the other 
foot, that she can walk a long distance without tiring, and that there 6 
CLUB-FOOT IN ADULTS. 
is no disposition for the foot to turn in. In other words, it is about 
as nearly a perfect result as one would wish, and this in a young 
lady nineteen years old. 
Case IV.—Two years and a half ago I removed a wedge 
formed of parts of the os calcis and cuboid, after finding that 1 
could not straighten by tentomies and tarsoclasis in the case of a 
girl about twelve years old, upon whom six previous operations 
(tenotomies) had been performed by three different surgeons. I got 
a perfect result as far as position of the foot is concerned, and the 
girl walks without limp; but we have here, as after all operations 
where a wedge is removed, a foot somewhat smaller than the other 
one; and there is also some flat-foot existing. This is another case 
in which I would now make an open incision. 
The question now arising in the discussion of this problem is, 
What are the possibilities of the open incision plus other more rad- 
ical measures in adult club-feet ? My belief in the matter is, viz., 
that by tenotomies, the open incision, the removal of a tarsal wedge, 
and the removal, sometimes, of the astragalus, the feet in the worst 
cases will be brought to the front; not that the feet in the severer 
forms found in adults will be perfect, but, though lacking much 
motion at the ankle, and the elasticity and form of the arch being 
gone, and perhaps somewhat misshapen, yet will they be so much 
superior to the condition in which we find them that the propriety 
of the above described operation cannot be questioned. 
To the assertion that Chopart’s amputation is indicated, 1 ven- 
ture to say that but few if any will assent; and 1 dare say that 
none will claim that tenotomies with tarsoclasis will cure the worst 
cases. 
Conclusion.—From my experience and observation I am led 
to draw the following conclusions: The skin in the case of some 
adults and older children will not stand the amount of stretching 
necessary to bring the foot into good position, but sloughing will CLUB-FOOT IN ADULTS. 
7 
take place. Therefore in these cases tenotomies and tarsoclasis 
will be unsatisfactory, though sufficient to correct the deformity. 
Tenotomy of the tendo Achillis, and in some cases section of 
the heel ligaments, the open incision on the concave side of the foot 
and the use of tarsoclasis will cure many of these adult club-feet. 
In the worst cases, in addition to the above, removal of a tarsal 
wedge or the removal of the astragalus, or both, may be required 
before the deformity can be overcome.