Reprint from The Nashville Journal of Medicine and Surgery, 
July, 1895. 
PHELP'S OPERATION FOR CLUB-FOOT.* 
/ 
BY CHARLES 8. BRIGGS, A.M., M.D., 
Professor of Surgery in the Medical Department of the University of 
Nashville. 
Probably no deformity in the domain of orthopedic surgery 
has been so thoroughly studied, or called forth so many elaborate 
papers, or had such an infinite variety of ingenius apparatus for 
its correction as the very common congenital defect, club-foot. 
With all the advantages of centuries of accumulated wisdom 
and experience, the treatment of that condition is still a vexed 
question. 
Every surgeon of any experience in orthopedic surgery must 
confess to not infrequent disappointment in the treatment of 
club-foot. Even when treatment Is instituted soon after birth, 
at which time it is universally acknowledged the prospects for 
correction are the best, by tenotomy of shortened tendons, by 
the employment of retentive apparatus and an intelligent after 
treatment, the remote results are at best only an improvement, 
not a full restoration of the symmetry of the part. 
It is readily conceded that in order to obtain the best results, 
treatment of club-foot promises most when undertaken early, 
before the bones have become fully formed, that is before the 
sixth year. Just before or after puberty the tarsal bones in club- 
foot are misshapen and held in abnormal relations to each other, 
and no ordinary treatment can hope to restore them. In such 
cases, in order to bring about a restoration of the axis of the 
the foot, a mutilating operation, such as tarsectomy or excision 
*Read before the Middle 'Tennessee Medical Society, at Columbia, 
Tenn. April 16, 1895. 2 
of certain bones of the tarsus must be done, which necessitates 
shortening of the foot. 
As to the best method of treatment of club-foot, it will be 
readily admitted that no one procedure is applicable to all cases. 
The surgeon must be governed in his choice of operation by the 
age of the patient, the extent of the deformity, the resistance 
of structures involved, and various other circumstances. The 
routinist is sure to meet with failure more frequently than with 
success. The object of treatment is to correct the faulty posi- 
tion of the foot and to prevent relapse until such time that the 
foot will be in a proper position for walking, and be maintained 
so by muscular action without the aid of a retentive brace. 
The perpetuation of club-foot is due to the fact that the 
structures on one side of the limb are abnormally shortened, 
while those of the other side are abnormally elongated. A cure 
can not be effected until equalization of all the structures can 
be brought about. It is not enough to correct the mal-position 
by any of the various methods in vogue, as manipulation, forci- 
ble replacement manual or instrumental, subcutaneous section 
of all the contracted structures, the open incision of these parts, 
or tarsectomy. This is but the initial step towards cure. Were 
the treatment to proceed no further than this, relapse would be 
certain in every case. The super-elongated structures fail to 
maintain the correction, and the foot rapidly resumes its former 
vicious position. 
It is more than likely that most failures after all methods of 
treatment are due to defective after-treatment; in other words, to 
the failure to maintain the corrected, or over-corrected foot in 
position by mechanical aids until well balanced antagonism of 
the opposing groups of muscles is secured, so that they may act 
coordinately in locomotion. 
Then what method of treatment is best adapted to the largest 
number of cases of club-foot in all conditions? 
Manipulation and massage is applicable to mild cases only, 
and to be successful must be commenced soon after birth, and be 
systematically and perseveringly followed up for months, supple- 
mented by maintenance of the foot in the corrected position by 
means of plasters, bandages, splints, or braces. Forcible re- 
placement must be done under an anesthetic. In this form of 3 
treatment the rectification of the deformity is accomplished by 
manual or instrumental force, a procedure which entails neces- 
sary laceration of the contracted parts, and frequently, in ex- 
treme cases, of even the shortened skin on the inner border of the 
foot. Extensive contusion with sloughing of the injured parts 
occasionally complicates this form of treatment. This proce- 
dure requires, for its successful accomplishment, an educated 
touch and good judgment. No doubt in skillful hands, cures 
can be effected by this treatment, but it is not a method that will 
recommend itself for general adoption. 
Subcutaneous section combined with forcible correction, is a 
favorite method with many surgeons. In fact it may be regarded 
as orthodox treatment to divide the tendo Achillis in every case 
that presents and without further effort at rectification than may 
be obtained by bringing down the heel, to adjust a club-foot 
shoe, relying upon the support it gives for the further correction 
of the deformity, or putting the foot up in plaster of Paris 
bandage until a brace can be adjusted. Can it be surprising 
that relapse in cases so treated is the rule, cure the exception? 
More radical operators divide subcutaneously net only the 
tendo-Achillis, but also all the contracted structures on the con- 
cave border of the foot, and at the same time force the foot into 
an over-corrected position. Proper retentive apparatus is after- 
wards adjusted to maintain the rectification. There can be no 
doubt but that numerous successes are obtained by this proce- 
dure. The objection to this method is that it requires for the 
subcutaneous division of such structures more than average skill, 
and that in many cases no amount of dexterity will enable the 
operator to divide all the contracted parts. 
As regards excision of the bones of the tarsus, or tarsectomy, 
according to the conditions present the astragalus or the cuboid 
or the calcaneum, in whole or in part, is removed, or without 
regard to any particular bone, a V-shaped section of the bones 
forming the convexity on the outer border is excised. This is a 
procedure which should be reserved for cases not amenable to 
treatment by other less mutilating methods. 
As an operation for the relief of club-foot which commends 
itself for simplicity, thoroughness, efficacy, and safety, the open 
incision, or Phelp's operation, is in my opinion the' best. The 
fact that it is applicable to talipes of nearly every age and con- 4 
dition, is a strong argument in its favor. It yields excellent re- 
sults, both in infancy and in more advanced years. Performed 
antiseptically, it is practically as safe as subcutaneous section of 
the contractures, while the tissues in the open wound can be 
more effectually dealt with. In the open wound, contracting 
bands which could never be reached by the subcutaneous cut, 
can be readily divided. 
"Blind surgery is bad surgery," and subcutaneous tenotomy 
is necessarily blind surgery. 
In these day of aseptic surgery, the superior advantages of 
subcutaneous operations no longer exist. The mortality rate of 
the open treatment of talipes is encouragingly small. Phelp 
reports two hundred operations without a single death, and sta- 
tistics from other sources are equally as good. 
In performingPhelp's operation, if thorough division of all the 
contracted structures fails to bring about complete rectification, 
forcible replacement may succeed, and in the event of failure 
even then, excision of the astragalus or other bones may be re- 
sorted to as supplementary to the operation. The widely-gaping 
wound fills rapidly with granulations which organize into scar 
tissue with some tendency to contraction, but the contraction is 
rarely sufficient to reproduce the original deformity. The skin 
on the inner side of the foot in talipes is shortened and is as 
great an element in the make up of the deformity as contraction 
of the deeper structures. The necessity for its division is as 
great as for that of the tendons. Another advantage of the 
open incision is that it lengthens the inner border of the foot. 
The operation is a simple one, and is performed as follows: 
The foot and leg are prepared by thorough scrubbing with 
sublimated solution and an antiseptic dressing applied some hours 
before the operation. An anesthetic having been administered, 
the first step in the operation is the subcutaneous division of the 
tendo Achillis. This having been done and the heel brought 
down and the amount of resistance ascertained by forcible manip- 
ulation, a free vertical incision is made on the inner border of 
the foot from near the middle of the instep to the sole. The 
incision is placed about midway between the internal malleolus 
and the base of the first metarsal bone. It should be carried 
just posterior to the scaphoid tubercle, but in varus this process 
can very rarely be felt. The vertical crease in the skin, which 5 
represents the line of greatest contraction and which passes just 
behind the tubercle of the scaphoid, may serve as a guide for 
the incision. The cut is rapidly deepened, and each contracted 
tissue divided as it presents until the astragalo-scaphoid joint is 
opened. The foot now being brought forcibly straight, the tip 
of the finger in the wound can ascertain whether contractures 
persist, and the knife applied where needed. Usually there is 
divided in the incision the internal saphenous vein, the tibialis 
anticus, tibialis posticus, plantar fascia, abductor pollicis, flexor 
brevis digitorum, some of the fibres of the flexor longus digito- 
rum, and, as happened in one of my cases, the tendon of the 
peroneus longus. The internal plantar artery is divided, but its 
division is not attended with any serious consequences. Even 
if the main artery, the external plantar, is wounded, the foot 
will be amply supplied by the dorsalis pedis. The deltoid liga- 
ment is usually an important constricting tissue. This having been 
divided, the astragalo-scaphoid joint is opened and its ligament 
out. In extreme cases, the calcaneo-cuboid ligament requires 
division. Divide every structure which stands in the way of 
full correction should be the rule. Hemorrhage is generally 
slight. 
Bleeding points can be secured by hemostatic forceps, as they 
show in the progress of the operation. Ligatures may be ap- 
plied when found necessary. After the bleeding has ceased, the 
wound is thoroughly irrigated and the widely-gaping wound 
loosely packed with iodoform gauze to the level of the surface, 
the foot being held during the entire dressing in an over-cor- 
rected position. The foot is then enveloped in mercuric gauze 
and a smooth layer of absorbent cotton and a flannel bandage 
applied from the toes to the knee. Two splints, each made of 
eight or ten thicknesses of ribbed crinoline, are shaped to the 
sides of the leg and foot, soaked in a mixture of plaster of Paris, 
and applied to the limb, taking care to leave an interval between 
the edges in front. These are held in place by a wetted crino- 
line bandage. The foot is held in position of over-correction 
until the plaster has hardened, care being taken that pressure is 
not so directed as to cause indentations on the inner surface of 
the splints. If the plaster is slow in setting, I have found it 
convenient to adjust a thin wooden splint cut of proper shape to 
the outside of the foot and leg held in place by a bandage. The 6 
oes should be left exposed so as to judge of the circulation in 
the foot. This dressing is not disturbed, unless some accident 
occurs, for two or three weeks when the splints are taken off, the 
packing removed, the wound thoroughly irrigated, and a similar 
dressing applied. The gap fills with granulations very rap- 
idly, and is level with the surface in four or five weeks. The 
patient is permitted to walk about on the gypsum boot as soon 
as it has hardened sufficiently. When the wound has cicatrized, 
a light retentive brace, sufficient to overcome tendency to recon- 
traction, should be worn, and the patient is encouraged to walk 
as much as possible, thus training the muscles to act with the 
foot in the correct position. As soon as there is no tendency for 
the toes to turn inwards with the heel upon the ground in walk- 
ing, the brace may be dispensed with. 
In my own experience in the treatment of talipes varus, I 
confess to a greater number of failures than cures in cases in which 
I resorted to the orthodox treatment of tenotomy and club-foot 
appliances. These failures may be attributed in great part to 
inefficient after-treatment, which in the majority of cases is left 
for the parents or attendants to carry out. The surgeon, how- 
ever, gets the blame for all failures. Since adopting Phelp's 
operation, which I have now performed a number of times, in 
patients ranging from six weeks to ten years of age, I am en- 
couraged to believe that failure will be the exception, and not 
the rule, as heretofore. I have obtained good results in every 
case, and not an untoward symptom has ever manifested itself. 
While in my opinion the operation is demanded in inveterate 
and extreme cases of club-foot in children past the age of in- 
fancy, I can see no valid objection to its performance in the early 
weeks of infancy. 
Phelp's operation has the following points of excellence over 
other methods: 
First. It is applicable to all conditions and ages of club-foot. 
Second. It is safe and is easily performed. 
Third. It is effectual in that the contractures are freely ex- 
posed and can, therefore, be unerringly dealt with. 
Fourth. It involves no mutilation of the foot, which is 
lengthened rather than shortened, as in tarsectomy. 
Fifth. Relapses are less liable to occur than after the employ- 
ment of other methods.