THE NECESSITY FOR EARLY CORRECTION 
IN CONGENITAL CLUB-FOOT.1 
H. AUGUSTUS WILSON,IVT.D., 
Clinical Professor of Orthopedic Surgery. 
GENTLEMEN: The cases brought before you 
this morning are of considerable interest, and 
I would like to have you try to place yourselves in 
the position, in which, as medical men, you must be 
placed when called upon to decide how to correct 
similar deformity, at what age it should be done, how 
long your efforts at correction should be continued, 
and what will be the condition of the feet in after life. 
The first patient, aged three months, is one with 
equino-varus, that was sent here by a graduate of the 
school. In the first place let us observe the position 
of the foot; it is the typical position of equino-varus, 
for the reason that there is present a compound variety 
of talipes. The inversion, or turning in, is very pro- 
nounced'; if the patient could walk it would do so 
upon the outer side of the foot. There is equinus, 
because the heel would not touch the ground in walk- 
ing, Both of these conditions being present in the 
same foot requires for its description a name which 
will designate the presence of the compound variety, 
and therefore it is called equino-varus. The question 
now arises as to the degree of severity of thb con- 
dition in this case, to determine the character of the 
remedial measures to be employed. By gentle press- 
ure I can completely overcome the varus, but I am 
unable to overcome the equinus. The tendo-achilles, 
or the gastrocnemius muscle is shortened, hence this 
difficulty. The articulating facet of the astragalus is 
dislocated from the natural position in contact with 
1 Delivered at the Jefferson Medical College Hospital. 2 
the tibia, and is decidedly prominent upon the out- 
side of the foot, and the astragalus itself is undoubt- 
edly malformed. Here, then, is the case before you ; 
now the question arises, What shall be done, and how 
soon shall the treatment be started ? Let us consider 
the arguments on both sides as to the earliest moment 
that correction would be advisable, and with that object 
in view, let us take as a basis the period at which the 
centers of ossification appear in the tarsal bones. 
That of the astragalus shows itself at the seventh 
month of foetal life, and it is the astragalus that in the 
large majority of cases of congenital club-foot is the 
principle, although not the only, disturbing factor. 
The os-calsis has two centers of ossification ; one of 
which appears at the same time as that of the astra- 
galus—the seventh month ; and the second, that for 
the great tuberosity, appears at the tenth year. The 
center for the scaphoid appears at the fourth year; 
for the cuboid, at birth ; and for the three cuneiform 
bones, between the first and third years. If these 
bones of the tarsus are in a deformed position at birth, 
what is the condition of the bones themselves at this 
time ? Are they ossified or cartilaginous ? All the 
bones of the tarsus are in a cartilaginous state at 
birth ; the centers of ossification of the astragalus 
and os-calsis only having appeared prior to this time, 
and that of the cuboid has just appeared. Accepting 
this, it would seem that the rational course to pursue, 
would be to correct the deformity at the earliest pos- 
sible moment, so that the process of ossification may 
go on in the proper manner, with the bones of the 
foot held in correct position, and it is therefore impor- 
tant to decide when that earliest possible moment is. 
Many surgeons urge that no case should be operated 
upon until the child is old enough to walk, at one or 
one and a half years. If we wait until then, however, 
we must know what the condition of the bones of the 
feet will be at that time. With the exception of the 3 
cuneiform bones, all have shown centers of ossification 
before that time, and the ossification has progressed 
in the deformed position in which they are held by 
any contracted soft tissues. This dry specimen shows 
a double congenital equino-varus in a still-born foetus, 
showing the malposition of all the tarsal bones. If 
these bones had ossified in the position in which they 
now are, this process would have gone on while they 
were in a deformed position, and as a result, at the 
age of one or one and a half years, if we should 
divide the tendons, the effect would be to simply re- 
arrange deformed bones, the period having elapsed 
when it was possible to materially alter their shape. 
I contend that it is not rational to wait until, the 
doubtful assistance of walking can be secured, because 
I believe that it is clearly proven that the earliest 
moment at which you correct the deformed foot, the 
more satisfactory will be the ultimate result. This 
ultimate result, however, depends upon the complete- 
ness of the first correction, and as well, upon the 
efficiency of the maintenance of the corrected position 
and the establishment of correlation of muscular 
forces. Relapses are the inevitable result of in- 
efficiency on the part of those having the care or 
direction of the institution of remedial measures, and 
one of the prominent factors in these cases, I have 
found to be incomplete early correction. 
The incompleteness of the early correction depended, 
in some instances, upon the late period at which cor- 
rection was attempted, for I am abundantly satisfied 
that the best ultimate results I have had, have been 
in cases where complete correction was accomplished 
in the first month, and persistent efforts maintained. 
In many of these cases I have found an entire absence 
of those signs of muscle atrophy which are so con- 
spicuous in, I believe I am right in saying, neglected 
cases. Now, shall we take a child at the age of one 
month, or less, and divide the tendons or other con- 4 
traded soft tissues, or shall we confine our efforts 
entirely to manipulation and the employment restrain- 
ing apparatus until a later period in the child’s life ? 
I know that there are those who advocate postponing 
operation until a later period, since in some cases 
manipulation alone wdll apparently elongate the con- 
tracted tendons. While it is improper to say that in 
all cases operative procedure should be resorted to, I 
firmly believe that the rule should be adopted, and, 
without exception, that complete correction should 
be accomplished at the earliest possible moment, and 
that this correction should be accomplished by the 
employment of ever}’- rational means, let it be oper- 
ative, mechanical, manipulative, or gymnastic, but 
it must be complete to be effective. 
I believe that the soft bones of the tarsus will alter 
their shapes as they are squeezed and compressed by 
force, and leave the shortened tendons as much con- 
tracted as they were before, because we know that 
tendons rarely, if ever, yield, except by tearing, while 
cartilaginous bones, not yet ossified, will yield to 
pressure. I believe that you will find, on making an 
examination of such a foot, no elongation of the ten- 
dons, but an altered external appearance of the foot, 
due to the softened condition of the bones, their be- 
ing squeezed into an external appearance of correc- 
tion. I believe, therefore, that at the earliest pos- 
sible moment we should employ any method which 
will be necessary to correct the deformity, and which 
will prevent a return to the deformed condition. It 
is a very unusual thing to have the opportunity of 
making a post-mortem examination in the age of 
early infancy, in a condition of congenital club-foot, 
whether it has had proper, or improper, attempts at 
partial or complete correction. lam inclined to be- 
lieve that the malformation of the tarsal bones, seen 
in adult specimens, is often produced by the charac- 
ter of the manipulative force that was applied in early 5 
infancy, and that this would not have occurred had 
complete division of contracted soft tissues been made 
at the proper time, 
I told you earlier in the course, that it was neces- 
sary, for convenience of study, to divide your cases 
of club-foot into three arbitrary divisions: the first 
variety including those in which the deformity is 
easily corrected, and the foot easily maintained in the 
correct position ; the second variety is that in which 
the deformity can be corrected, but with difficulty, 
and immediately returns upon cessation of restrain- 
ing force ; and the third variety is that in which it is 
impossible to correct the deformity without recourse 
to surgical or powerful mechanical measures. This 
second child has one foot in a mild form of equino- 
varus. You will notice how easily the deformity can 
be corrected, and how easily it is maintained in the 
correct position. There are no contracted tendons in 
this case, and it has been impossible to find dimin- 
ished activity in any muscle. The displacement of 
the tarsal bones is slight, especially of the astragalus, 
and this is easily effaced. Here it would be mark- 
edly improper to perform any surgical operation, for 
there is nothing to operate upon, no contracted soft 
tissues to cut. 
The child I had before you first affords an illustra- 
tion of the third variety in which the varus only 
could be overcome, the equinus not yielding, and I 
bring her before you again to emphasize another point. 
Shall we proceed, by force alone, to try to overcome 
the deformity ? I have already explained the disad- 
vantages of such a procedure, and will demonstrate 
the procedure that I consider essential. This morn- 
ing I shall proceed to divide the tendo achilles, for 
the reason that that is one factor in the foot which 
maintains the deformity and prevents a correction. 
The patient comes from a distance, and the parents 
wish us to perform the operation and send the child 6 
home at once. I shall operate, however, and keep 
the child for a week, and then demand that the child be 
brought to us every two weeks, to enable us to keep 
an oversight of the case. This is an ordinary expe- 
rience, for it is curiously deemed a trivial thing to 
correct a club-foot in a baby, and that simple division 
of the tendo achilles is the cure. In reality, the first 
correction, no matter by what means accomplished, 
is but means to an end. It is not only correcting the 
appearance of the deformity, but it is the correction 
of the mechanical defect so that the mechanical func- 
tions may be re established. 
The successful accomplishment of a cure of club- 
foot depends upon the efficiency of all three legs of a 
tripod, as it were, correction, maintenance of the cor- 
rect position, and the establishment of correlation of 
muscular forces. And upon the tripod depends the 
efficiency of the treatment. I always insist that the 
patients, after the primary operation, shall come un- 
der my observation again at a period of not over one 
month, and that not more than a month shall elapse 
without a critical inspection, that the progress may 
be watched, to avoid neglect. If plaster of Paris is 
left on for any considerable length of time, an atro- 
phy of the muscles of the leg must necessarily follow 
from disuse. The muscles in these congenital cases 
are usually perfectly normal at birth, but are induced 
to become atrophied by the means resorted to, to over- 
come the deformity. After taking the plaster of Paris 
off, we shall, in this case apply an apparatus permit- 
ting full free motion of the ankle, but holding the 
foot in natural position. I shall also instruct the 
mother how to manipulate the foot, so as to prevent 
atrophy of the muscles, by encouraging muscular de- 
velopment. The production of muscular atrophy, 
which is such a serious obstacle to correction of club- 
foot after infancy, is a profoundly interesting subject, 
and I have but to refer you to Chinese ladies’ feet for 7 
evidence of what is too often done with club feet. 
The long continued use of plaster of Paris, or me- 
chanical apparatus of any kind that does not provide 
free ankle motion, will accomplish, just as success- 
fully as the binder, a muscle atrophy. This muscle 
atrophy is, in turn, followed by atrophy of bones, not 
only in their diameter, but in their length as well. 
The natural tendency of a congenital club-foot is 
towards atrophy from disuse, and, therefore, we are 
warranted in resorting to every means to avoid its oc- 
currence. 
If the plantar fascia in this case is so tight or con- 
tracted as to hold the foot in the incorrect position, 
we shall divide that, in addition to the achilles. The 
same thing holds true with reference to the flexors of 
the toes, if I find them unduly shortened. In brief, 
divide with a clean cut all soft tissues that restrain 
perfect correction, for unless you do this, you are sure 
to have an incomplete correction. In performing the 
operation, I put the foot first into a stretched position 
and then mark with my thumb nail a point sufficiently 
far from the tendon, say one-fourth of an inch, where 
I insert my knife. The point at which the division 
of the tendon-achilles is preferably made, is just above 
the attachment of the tendon to the os calsis. It is 
simply a matter of choice whether I cut from within, 
outward, or from without inward. You can now 
see the degree of separation of the two ends of the 
tendon. There is a space here of fully three quarters 
of an inch, which permits of elongation of the tendon 
to that extent. I apply collodion over the wound, to 
hermetically seal it, to prevent any contact with the 
atmosphere and septic germs, and therein lies the ad- 
vantage of the subcutaneous method, namely the 
avoidance of the risk of suppuration. Notwithstand- 
ing the greatest care, however, there is always danger 
of infection taking place, no matter whether an open 
wound is made or the operation is done subcutane- 8 
ously. The subcutaneous method has the least risk, 
in that only a minute puncture is made, with imme- 
diate closure of the wound. I always prefer the open 
method, for it is far more skilful and accurate, and 
avoids the necessity of cutting other tissues than the 
tendon to be divided. 
The length of time required for a tendon to unite, is 
from one to two weeks, and at the end of three weeks 
the new formed structure is as strong as any other part 
of the tendon. Immediately after tenotomy the foot 
should be placed in an over-corrected position, so as 
to separate the divided ends of the tendon as much as 
may be required, depending upon muscle contraction 
to shorten it when necessary. The method of putting 
the foot into the deformed position, or in only a par- 
tially corrected position, should not be observed, be- 
cause it will be necessary to stretch something later, 
or re-divide the tendon. To stretch this newly 
formed tissue is to weaken it by making it attenuated. 
I believe I have never known a tendon to fail to unite, 
although great separation of the divided end has, in 
some cases, taken place. 
Now the question arises in the application of our 
maintenance apparatus of plaster of Paris, what is 
the object to be accomplished by its use? In the 
first place, to mould the foot into a proper position 
and force the tarsal bones to occupy positions ap- 
proaching the normal. The foot is now in an over- 
corrected position, being extended to less than a right 
angle and slightly everted, and the plaster of Paris 
will hold it in this position. In about two weeks the 
tendon will be strongly united, and enable us to be- 
gin our manipulation. Then will be the time to ap- 
ply our steel maintenance apparatus, and it must be 
prescribed with a definite object. That object is, I 
am sure, now clear to you, and I will therefore indi- 
cate its essential features, A free ankle joint, ob- 
tained by having that part which is attached to the 9 
sole of the shoe, joined to the upright lateral leg bars, 
at a point above the tip of the malleolus. Just below 
the knee a semi circular band holds the upright bars 
in proper position, and is strapped and buckled in 
front. There must be nothing, whatever, to prevent 
free motion of the ankle in the natural hinge motion. 
It is often expedient to use elastic traction as a means 
of maintenance, and where this is sufficient and is 
desired, it can easily be accomplished with the use of 
elastic rubber bands, held in place by adhesive plas- 
ter. I never like to leave the plaster of Paris on 
longer than three weeks altogether, because its use is 
not beneficial, and its long continuance sure to be 
prejudicial. The child being under ether, I have no 
hesitancy in using as great force as may be necessary 
to overcorrect the foot. 
There is danger to be avoided in the use of plaster 
of Paris, to which I must direct your attention, for it 
has occurred, or been threatened sufficiently often, to 
be a warning of the possibility of its occurrence. I 
refer to the possibility of constriction and strangula- 
tion, and the possible production of gangrene. There 
need be no fear of this if you carefully instruct the 
mother to frequently observe the condition of the cir- 
culation, by pressing upon the toes, and observing if 
the pink flush follows the white appearance produced 
by the finger. To make this possible you must, of 
course, leave the toes uncovered, and it should be a 
rule never to cover an entire extremity, because you 
want to know what is going on there. Should the 
mother notice any apparent interference with the cir- 
culation, she can call your attention to it, and you 
can, if necessary, remove the cast and reapply it. 
Plaster of Paris always contracts in setting, and a 
knowledge of this will prevent the application being 
made too tight. 
The length of time required to accomplish a full 
and complete correction of a congenital club-foot is the same as that required to form the foot of a normal 
child. Not until a child is ten or twelve years old 
does a foot possess the normal mechanical conditions 
necessary for its full usefulness. All babies are flat- 
footed, many are naturally pigeon-toed, but all of 
these conditions pass off where there is a natural ten- 
dency to do so. 
The same thing may be said of a child born with 
a club-foot, certainly in the milder forms, that until 
the age of ten or twelve years, the correction must be 
maintained mechanically, and efforts must constantly 
be made to develop the muscular system. 
That which in the normal child prevents the foot from 
becoming deformed, although it may be placed tem- 
porarily in a deformed position, is the correlation of 
muscular forces, and this must and can be established 
in cases of club-foot that are corrected sufficiently 
early. You must avoid the absurdity of resorting to 
gymnastic forms of treatment, and at the same time 
destroying its efficiency, by the use of mechanical 
restraining apparatus, that not only prevents the re- 
production of the deformity, but at the same time re- 
strains all motion. Thus I have seen rigid plaster of 
Paris in constant use in cases where it was removed 
every day for half an hour, and during that time, de- 
velopment methods employed. To accomplish a com- 
plete recovery, there must be an understanding of the 
mechanical functions to be recovered, and this is ap- 
parently absent in those who simply cut tendons and 
allow the case to relapse by neglect, or who consider 
braces to be curative.