THE PRESENT STATUS OE THE 
OPEN INCISION METHOD EOR 
TALIPES VARO-EQUINUS. 
BY 
A. M. PHELPS, M. D. 
Professor of Orthopedic Surgery, University of the City of New York; Professor 
of Orthopedic Surgery, Post-Graduate School and Hospital, New .York; 
Professor of Surgery, University of Vermont; Member of the New York 
Academy of Medicine, and the American Orthopedic Association, etc.; Visit- 
ing Surgeon to Charity Hospital. 
Read at the Tenth International Congress, Berlin. 
REPRINT FROM THE 
New England Medical Monthly. 
DANBURY, CONN.: 
THE DANBURY MEDICAL PRINTING COMPANY. 
1891. THE PRESENT STATUS OE THE 
OPEN INCISION METHOD FOR 
TALIPES VARO-EQUINUS. 
A. M. PHELPS, M. D. 
Professor of Orthopedic Surgery, University of the City of New York; Professor 
of Orthopedic Surgery, Post-Graduate School and Hospital, New York; 
Professor of Surgery, University of Vermont; Member of the New York 
Academy of Medicine, and the American Orthopedic Association, etc.; Visit- 
ing Surgeon to Charity Hospital. 
Read at the Tenth International Congress, Berlin. 
SINCE publishing my first paper, in 
1881, on the operation of open in- 
cision in club-foot, I have operated upon 
one hundred and sixty-one cases, which 
I desire to report upon at this meeting. 
At that time, and in a subsequent paper 
published in the "Transactions of the 
Eighth International Congress, Copen- 
hagen," my observations were not ex- 
tensive enough to enable me to speak 
with any degree of authority on the sub- 
ject. My convictions as to the advisa- 
bility of the method, however, were 
strong, and upon theoretical grounds, 
sustained by a limited number of cases, 
with results, I advised the operation. 
Mature experience now enables me to 
correct, or I might say more clearly de- 
fine, many points which at that time 
could not be made perfectly clear. I 
argued then for the operation. Now I 
desire to present a method which should 
govern all operative procedures in club- 
foot, giving to the operation its proper 
place in surgery. The difficulties which 
the profession have encountered have 
been the varied methods and operations 
which from time to time have been 
urged as the cure for all cases; and,only 
after a personal application of the 
method or operation urged,has the oper- 
ator discovered that his ship of anticipa- 
tion has been wrecked upon the rock of 
Fig. 1.-Shows not an uncommon result follow- 
ing- primary osteotomy. There has been a resection 
of the astragalus in one foot and cuneiform tarsec- 
tomy in the other. Photograph made of a case in 
the practice of an eminent European surgeon. 
experience. Primary osteotomy, astra- 
galus resection, cuneiform tarsectomy, 
open incision, and prolonged and inter- 
rupted traction with intricate machinery 6 
have all run the gauntlet of observation, 
and the roadside everywhere is strewn 
with lamentable failures. 
Why should this be so ? Simply that 
method, based upon some pathological 
fact and data of experience, has been 
ignored. 
I do not at this time care to discuss 
the etiology and pathology of talipes 
varo-equinus. Permit me to say, how- 
ever, that in all the pathological speci- 
mens which I have examined, the distor- 
tion of the soft part has been out of all 
proportion to the deformity of bone; 
and many specimens of severe deformity, 
which I have in my collection, show 
but slight bone-deformity, and that is 
confined chiefly to the neck of the astra- 
galus, while in other specimens the os 
calcis is also deformed. These distor- 
tions added to a great dislocation of the 
small bones of the tarsus, with changes 
in their articular surfaces, constitute the 
bone-deformity of talipes varo-equinus 
in a very large per cent, of cases occur- 
ring in children. Now, if these obser- 
vations are correct, and we can with 
perfect safety to foot and life divide ex- 
tensively soft parts, and secure useful 
feet in a short time, or as good results 
as can be obtained by any other method, 
are we justified in performing a primary 
osteotomy or resection of the astragalus *? 
Clearly not, for the results after primary 
bone operations are no better. Failures 
are common, and the mortality is about 
five per cent., whereas in operations on 
soft parts there is no mortality (see 
Fig. 1). 
And, then, are we justified in treating 
a case by instrumental means for years, 
when a moment's work with the teno- 
tome or knife would shorten the period 
of treatment to as many weeks, with a 
result equally as good ? Certainly not 
if the patient will consent to an opera- 
tion. The tinkering and fooling with 
club-foot with traction machines, cover- 
ing over long periods of torture reckoned 
by years, with all its failures, brought 
orthopedics of the past into disrepute. 
The surgeon and patient became dis- 
gusted, and out of the chaos and wreck 
we saw methods devised which shortened 
Fig. 2.-(Phillipson). 
the period of treatment, and cured case& 
which chagrined the orthopedist on ac- 
count of his failures. These meth ods of 
mechanics, when carried to extremes, as 
we have all been obliged to witness, de- 
grade the orthopedic surgeon to the 
level of the chiropodist or mere instru- 
Fig. 3-Specimen in the College of Surgeons, 
London, showing Arrangement of Tendons in 
Varus. 
ment-maker, and one step farther carries 
him, with all his good intentions, within 
the vale of empiricism and quackery 7 
Again, on the other hand, the surgeon 
becomes impatient with all his cases and 
devises an operation. It proves service- 
able in many cases, fails in others, until 
he finds himself blindly following his 
operation and not a principle, mutilat- 
ing feet unnecessarily, and finally in 
disgust over failures, abandons his op- 
eration. 
A remedy for all this is a method, 
and nearly every operation ever devised 
will find its legitimate place in surgery. 
The method which I propose to gov- 
ern the management of club-foot, requir- 
ing operative work, is this: 
1. Exclude all cases which, by manip- 
ulation or force, can immediately, or in 
a reasonable length of time be cured; 
then the following rule should be fol- 
lowed: 
2. Cut the contracted parts as they 
first offer resistance, cutting in the order 
of those parts which first contracted 
when the deformity was produced. 
If the skin is not short, subcutaneous 
tenotomy in the sole of the foot will 
usually suffice. If the skin is short, an 
open incision one-fourth the distance 
across the foot can be made, beginning 
directly in front of the inner malleolus 
and carried down to the inner side of 
the astragalus (see Fig. 2). Through 
this incision the following tissues can 
be cut, if they offer strong resistance, in 
the order given: (a) Tenotomy of tibialis 
posticus (see Fig. 3); (Z>) division of ab- 
ductor pollicis (see Fig. 4); (c) division 
of plantar fascia through the wound; (d) 
division of flexor brevis muscle; (e) 
division of long flexors; (/*) division of 
deltoid ligament, all its branches (see 
Fig. 5). 
Fig. 5.-Incision under the Skin for the Ligament 
(Phillipson). 
3. Linear osteotomy through the neck 
of the astragalus (see Fig. 6). 
4. Resection of a wedge-shaped piece 
of bone from the body of the os calcis, 
the point meeting the linear osteotomy 
through the neck of astragalus. The 
foot will now swing to a straight position. 
(Fig. 6) 
This method of osteotomy is a correc- 
tion of my former paper, in which the 
cuneiform section was taken from the 
cuboid bone. 
In the management of club-foot it 
often becomes necessary for the opera- 
tor to apply more force than can be 
done by the hands, not only during the 
time of the operation, but in the subse- 
quent treatment of the foot as well. 
In nearly all cases of varo-equinus 
Fig. 4.-Specimen from the College of Surgeons, 
London, showing Muscles and Tendons in Varus. 
The operator will then proceed, after 
strong manipulation or force is applied 
with a club-foot machine or with the 
hands (see Figs. 7 and 8), to subcutan- 
eously divide, first the tendo-Achillis. 8 
there is a shortened condition of the 
ligamentous contraction posterior to the 
ankle-joint, and also an inward rotation 
of the os calcis. In such cases there is 
not sufficient power in the hand of the 
operator to overcome the ligamentous 
contraction. 
adjustable slide working upon the cross 
part of the bed piece. After having 
etherized the patient, he is placed in the 
machine with his leg flexed, as seen in 
Fig. 7. 
The slide, 14, is adjusted to prevent 
the leg from slipping, The straps 10, 
11 and 12 hold the leg in a firm position 
on the bed piece; 16 is a fulcrum, into 
which the end of the lever, 1, is inserted 
for the purpose of making the pressure 
upon the os calcis by means of the pad. 
4, 5 is the adjustable fulcrum into which 
the end of the other lever is inserted. 
The foot is attached to this lever by 
means of straps 7, 8, and 9, Fig. 7, and 
5, 6 and 7, Fig. 8. The straps, 5 and 6, 
are attached to the nuts, 4, 4, by turn- 
ing the screws, 2, 2, which are held in the 
proper position by the framework, 3. 
Any amount of force can be applied 
to the heel and instep. The jack can be 
adjusted to the lever as seen in Fig. 7, 
the strap, 7, passing around the foot as 
Os. 
Calcis. 
Neck of astragalus. 
Fig. 6. 
To fulfill all of these requirements, I 
have devised a machine which will be 
found invaluable. It can be used in the 
class of cases above indicated, and also 
for the purpose of placing the foot in 
the proper position before the applica- 
tion of the water-glass shoe and plaster- 
of-Paris dressing, or the application of 
any form of apparatus. 
Fig. 7. 
It consists of a combination of levers 
and screws so adjusted as to apply the 
force in the proper direction, varying 
from a single pound to one ton in force. 
The bed-piece (Fig. 7) is fastened to a 
table by means of a clamp, 15; 14 is an 
seen in Fig. 8, secures the toes firmly. 
The operator and his assistant turn up 
the screws, applying any amount of 
force required. The operator now, with 
his canting lever, 3, in his hand, flexes 
and rotates the foot, breaking it across 9 
the adjustable fulcrum, 6, while his as- 
sistant holds the heel firmly with the 
other lever. As flexing force is applied 
by the large lever, the leg is prevented 
from slipping by the adjustable slide, 14. 
The machine will not only be found 
invaluable in all cases of club-foot, but 
more particularly so in those severe 
forms of club-foot requiring operation. 
The operator from time to time can ad- 
just the machine and apply any amount 
of force, breaking ligaments which he 
would find difficult or impossible to cut. 
In the after-treatment of club-foot it will 
be found most useful. 
The operator should not cease operat- 
ing until the foot is super-corrected, 
otherwise a relapse may be looked for, 
beginning with manipulation, either 
with the hand or the club-foot machine, 
or both, and concluding, if necessary, 
foot is straight, and guesses that he can 
correct the deformity left by proper 
after-treatment, which, as a rule, he can- 
not do. 
Another source of failure is bad dress- 
ing. The desire to use some pet splint, 
or devise some new scheme, accounts 
for the disappointment with results. 
Failing to super-correct by operation 
and some worthless wood or metal splint, 
so adjusted as to make undue pressure 
upon the resisting foot, produce slough- 
ing or even gangrene. When the foot 
has been once super-corrected, it will 
then rest in proper dressings without re- 
sistance or pressure, and sloughing is 
never seen. 
THE OPERATION. 
Prepare the foot by scrubbing, scrap- 
ing, and antisepticizing with bichloride 
of mercury solution, 1 to 1,000 the night 
before. Carefully see that every detail 
of antiseptic surgery is followed at the 
time of operating. Then cleanse the foot 
with iodoform, 1 part; ether sulph., 8 
parts. Apply the Esmarch bandage. 
Keep up a constant irrigation with 
bichloride solution, 1 to 2,000 during 
the operation. After strong manipula- 
tion, either manual or instrumental, and 
subcutaneous tenotomy, make the open 
incision already described in Fig, 2, cut 
in the order already suggested. Use 
strong force after each tissue cut. 
Nothing will be gained by dividing soft 
Sparts more extensively than suggested 
above. If the foot still resists and can- 
not be placed in a super-corrected posi- 
tion, linear osteotomy, and finally cunei- 
form resection should be done (see Fig. 
6). In two cases, in adults, I found it 
'necessary to remove both cuboid and 
scaphoid bones. Open incision in chil- 
dren under one year of age I have never 
found necessary. 
The Dressings.-Sponge out the 
wound, then apply, 1, Lister's protec- 
tive, not rubber tissue; 2, antiseptic 
gauze, large quantity; 3, antiseptic 
bandage; 4, absorbent cotton to knee; 5, 
over all a plaster-of-Paris bandage, hold- 
Fig. 8. 
with extensive osteotomy, pursuing the 
order of procedure as recommended 
above. Failures occur because the op- 
erator concludes his work before the 10 
ing the foot in the super-corrected posi- 
tion, until the plaster sets; avoid making 
pressure either by dressings or twisting 
the foot too far outward; 6, remove the 
Esmarch bandage; 7, sling the foot to a 
nearly perpendicular position for six 
hours or longer. Organization of blood- 
clot usually occurs, but it is not essential 
to a good result. 
series of cases and of those which I have 
compiled will be found in the table on 
pages 224-225. 
Fig. 10.-(Gerster). 
In conclusion, equino-varus, after any 
operation, or mechanical treatment, is 
quite likely to relapse. For months, and 
even years, the surgeon will need to care- 
fully look after many of his patients. I 
have seen relapses following mechanical 
treatment which have been carried out for 
years, in every form of osteotomy, and 
Fig. 9. 
My last cases were dressed as indi- 
cated, but the wound was filled writli 
chopped-up fine cat-gut. Organization 
was perfect in each case. Fig. 9 shows 
scarring in a foot four weeks after the 
operation. Fig. 10 shows position of 
scar and appearance of the foot at the 
fourth week; Figs. 11 and 12 the condi- 
tion before and three weeks after the 
operation; Figs. 13 and 14, the deform- 
ity and method of after-treatment by 
means of hooks and plasters one year 
after. 
After-treatment.-The plaster-of-Paris 
shoe; water-glass shoe and the hooks 
and plasters answer well. The hooks 
and plasters are well adapted to children 
over two years of age. Fig. 14 re- 
presents the plaster and hooks as ap- 
plied to the feet, the bandages removed. 
The upper hook connects with a belt 
above the hips by means of a tape, 
which tape is secured to the side of the 
leg at the knee w ith a strap. The lac- 
ings between the hooks hold the foot in 
the normal position. The results ofjny 
Fig. 11. 
more particularly excision of the astra- 
galus. In my travels through Germany 
I made casts of feet which had relapsed 
after these osteotomies in the hands of 
some of the most eminent and distin- 
guished German surgeons, and the same 11 
observations are to be made in every 
country. An operation only straightens 
the feet; when this has been accom- 
plished, the treatment (and not until 
then can treatment be said to begin) is 
only commenced. The slight twist in 
the neck of the astragalus will not be 
found a serious obstacle in the way of 
cure, unless excessive, in which class of 
cases it should have been divided with a 
chisel at the time of operating. 
What are the limits of the application 
of this operation? 1. Eliminate all 
cases which by the hand can easily be 
placed in a normal position; 2, eliminate 
all of those cases which can by subcu- 
taneous tenotomy be perfectly relieved 
with accompanying proper after-manage- 
ment. Then open incision will find its 
legitimate place in surgery. 
What are the advantages of the oper- 
ation ? 1, Cutting parts as they offer 
always short, and from its intimate con- 
nection with the plantar fascia would 
defeat the object of the operation), the 
operator can ascertain the amount of 
the deformity of the bones, and if any 
considerable amount exists it can be 
easily remedied with a chisel; 5, it re- 
stores the foot to its natural length by 
lengthening the shortened side; 6? it 
makes the surgeon master of the situa- 
tion ; he advances step by step in a proper 
order, and need not stop or retreat until 
the deformity is overcome,beginning with 
manipulation and subcutaneous tenot- 
omy, and ending with osteotomy, if 
necessary. 
I desire to say that osteotomy should 
not be resorted to as a primary operation, 
and not until after the contracted soft 
parts have been lengthened, for the rea- 
son that in primary osteotomy the bones 
of the foot must be shortened in propor- 
Fig. 13. 
Fig. 12. 
resistance in their respective order pre- 
vents the operator from needlessly cut- 
ting tissue not deformed by contraction; 
2, after the subcutaneous tenotomy of 
the tendo-Achillis the tibialis posticus 
tendon is easily cut, through an open 
wound, near its attachment to the 
scaphoid, ligamentous contraction at 
this point can also be divided; 3, 
through this open wound contracted 
parts can be extensively cut without 
wounding the plantar arteries or nerves; 
4, after all contracted soft parts have 
been divided, including the skin, (which 
by the way, in this class of cases is 
tion to the amount of shortening of the 
soft parts; and in a vast majority of 
cases of this form of intractable club-foot 
Fig. 14. 12 
Number. 
Age. 
Form. 
Wound 
healed 
in- 
Duration of 
after-treatment. 
Result after 4 
months. 
: Previously op- 
erated on by- 
Blood-clot or- 
ganization. 
Remarks. 
1 
4 yrs 
Doub. 
4 weeks 
11 yrs 
Perfect 
Tenotomy 
A case of true congenital paralytic talipes varo- 
2 
3 " 
44 
" 
1 " 
Relapse 
u 
equinus. 
Relapse from neglect. 
3 
4 
8 " 
Sing. 
4 
4 
9 44 
Perfect 
Mechanics 
Tenotomy 
Wore braces five j 
5 
0 
7 
5 " 
14 mos 
13 yrs 
Doub. 
4 
" 
4 
3 " 
3 " 
4 mos 
44 
Linear osteotomy. 
8 
9 
1(1 
9 " 
12 " 
8 " 
« 
1 " 
44 
« 
Linear osteotomy. 
" " and cuneiform resection. 
11 
15 " 
44 
4 
i " 
*4 
44 
12 
17 " 
44 
5 
i *■ 
Yes 
44 4i 44 44 44 
13 
10 " 
44 
3% " 
1 " 
** 
Mechanics 
44 
For four years wore braces. 
14 
7 
44 
4 " 
44 
44 
15 
19 " 
5 
6 mos 
•• 
Tenotomy 
Non-congenital. 
16 
6 " 
** 
4 
1 yr 
*• 
•• 
17 
9 " 
44 
4 
6 mos 
** 
•• 
18 
44 
3 " 
2 yrs 
** 
44 
44 
19 
5 " 
Sing. 
4 
2 " 
* 
Plas. Paris 
•• 
Relapse after one year; neglect. 
2(1 
4 " 
4 
1 " 
** 
Tenotomy 
44 
21 
7 " 
44 
4 
1H" 
1 " 
Fair 
No 
Parents neglected him; poOr. 
22 
o 44 
Doub. 
3*4 " 
Perfect 
Yes 
23 
6 " 
44 
4 
8 mos 
44 
Tenotomy 
44 
Fon-congenital. 
24 
9 " 
44 
4 
6 " 
»* 
44 
25 
8 " 
44 
4 
lyr 
1 " 
Good 
•• 
44 
26 
3 " 
44 
" 
3 
Perfect 
•* 
No 
Partial relapse after one year. 
27 
5 4w 
Sing. 
2 yrs 
44 
»» 
Yes 
28 
1% " 
Doub. 
3 
• 4 
•4 
29 
13 " 
Sing. 
•) 
1 yr 
44 
Tenotomy 
*4 
30 
18 " 
6 
6 mos 
Good 
Mechanics 
*4 
Club-foot shoes for fifteen years. 
31 
10 " 
Doub. 
4 
1 yr 
Perfect 
Tenotomy 
** 
Linear osteotomy. 
32 
9 " 
44 
5 
6 mos 
44 
33 
35 
44 
3Jx> " 
lyr 
*4 
Tenotomy 
No 
34 
22 " 
Sing. 
5 
4 mos 
Good 
Yes 
Linear and cuneiform osteotomy. 
35 
" 
Doub. 
4 
2 yrs 
Perfect 
Tenotomy 
4' 
Linear and cuneiform osteotomy, removal 
36 
31 " 
Sing. 
5 
6 in os 
44 
4* 
37 
9 " 
Doub. 
4 
1 yr 
44 
44 
No 
cuboid and scaphoid. 
Non-congenital. 
38 
4 " 
" 
44 
*4 
Yes 
Relapse after one year from bad neglect. 
39 
3 " 
*• 
4 
3 mos 
44 
44 
*4 
40 
5 " 
Sing. 
u 
" 
4 " 
44 
*4 
44 
But relapsed after one year, from bad manage- 
41 
2 " 
4 " 
6 " 
4* 
** 
44 
42 
3 " 
44 
4 " 
7 " 
44 
44 
44 
ment. 
43 
n 
Doub. 
4 
lyr 
Good 
No 
44 
8 " 
44 
3 
6 mos 
»* 
»• 
Relapsed from neglect, one year later. 
45 
3 " 
4 
3 " 
44 
Mechanics 
Yes 
46 
12 " 
44 
5 
4 " 
I 'erfect 
44 
47 
16 " 
44 
6 
6 " 
Good 
44 
Linear osteotomy, cuneiform resection. 
48 
4 " 
44 
% " 
lyr 
44 
44 
49 
5 " 
44 
4 
4 mos 
Perfect 
Tenotomy 
44 
50 
13 " 
n 41 
6 " 
44 
Non-coflgenital. 
51 
11 " 
Sing. 
4 
1 yr 
44 
44 
4* 
a? 
53 
9 " 
8 " 
Doub. 
5 
4 
2 mos 
3 " 
Good 
Tenotomy 
Yes 
54 
5 " 
44 
" 
4 " 
Perfect 
4* 
55 
~ 44 
44 
4 
5 " 
44 
** 
Non-congenital. 
56 
z 
44 
4 
3 " 
4* 
Tenotomy 
No 
57 
3 " 
44 
5 
4 " 
44 
Yes 
58 
7 
Sing. 
4 
8 " 
Good 
44 
Relapse partial after one year, from neglect. 
59 
44 
4 
I yr 
•4 
44 
60 
z 
*4 
" 
6 mos 
'4 
Tenotomy 
44 
61 
5 
D oub. 
4 
1 yr 
Perfect 
44 
62 
16 " 
6 
4 mos 
Good 
*4 
44 
Linear osteotomy. 
63 
9 " 
44 
4 
2 " 
44 
No 
64 
11 " 
Sing. 
•5 
3 
44 
Tenotomy 
Yes 
Linear osteotomy. 
55 
21 " 
7 
6 " 
44 
44 
Linear osteotomy, cuneiform resection, re- 
66 
4 " 
Doub. 
4 
lyr 
Perfect 
Yes 
moval cuboid and scaphoid; slough from tight 
dressing. 
67 
8 " 
5 
4 mos 
44 
44 
Linear osteotomy. 
68 
7 ** 
44 
•) 
3 " 
*4 
4 • 
44 
69 
4 " 
44 
4 
\ 4* 
44 
44 
44 
70 
4 " 
Sing. 
4 
8 " 
44 
44 
44 
Linear osteotomy. 
71 
7 
D oub. 
4 
lyr 
Good 
44 
44 
Relapse after one year from neglect. 
72 
6 " 
'4 
4 
3 mos 
44 
44 
Partial relapse from neglect. 
73 
9 " 
*4 
5 
4 " 
*4 
44 
74 
13 mos 
44 
4 
6 " 
Perfect 
Tenotomy 
*4 
75 
17 yrs 
5 " 
Sing. 
6 
4 " 
Good 
44 
Linear osteotomy, cuneiform resection. 
76 
Doub. 
X 4 4 
8 " 
4* 
44 
No 
8 " 
*4 
O 
1 yr 
4* 
*4 
78 
12 " 
*4 
6 mos 
Perfect 
Tenotomy 
Yes 
Linear osteotomy. 
79 
3 " 
44 
4 
4 " 13 
Number. 
Age. 
Form. 
W ound 
healed 
in- 
Duration of 
after-treatment 
Result after 4 
months. 
Previously op- 
erated on by- 
Blood-clot or- 
ganization. 
Remarks. 
80 
5 yrs. 
D oub. 
4 weeks. 
4 
6 mos 
Perfect 
44 
Tenotomy 
Yes 
81 
3 " 
•• 
3 " 
44 
82 
6 " 
•• 
5 
4 " 
44 
** 
N on-congenital. 
83 
8 " 
Sing. 
5 44 
lyr 
** 
•• 
44 
84 
3 " 
Doub. 
4 
3 mos 
Good 
Mechanics 
44 
Club-foot shoe. 
85 
10 " 
44 
8 
4 " 
44 
Sloughing from tight dressing. 
86 
44 
4 " 
2 yrs 
Perfect 
Tenotomy 
•• 
87 
« 
5 44 
1 yr 
88 
Q 41 
" 
6 mos 
Tenotomy 
No 
89 
6 44 
4 
4 " 
• • 
Yes 
90 
16 " 
Sing. 
6 
6 " 
44 
44 
44 
Linear osteotomy. 
91 
9 " 
4 
3 " 
44 
** 
44 
Cat-gut dressing in wound. 
92 
4 " 
Doub. 
4 
4 " 
44 
44 
93 
6 " 
Sing. 
5 44 
4 " 
44 
44 44 44 
The word " Perfect " used in the above report signifies a straight and useful foot, either toeing straight 
ahead or out, with normal functions fairly well preserved. 
The words " Good " and " Fair " signify intoeing of foot, with congenital defect either in the ankle- 
joint, tibia, or muscles, but useful feet, walking on plantar surface. 
it will be found unnecessary after the 
steps which I have detailed have been 
taken. And certainly no operator can 
determine the amount of deformity in 
the bones until he has relieved all the 
contracted soft parts, and a slight de- 
formity in the bones had better be left 
than to resort to an extensive osteotomy. 
To summarize: In 93 cases there were 
161 operations performed, the average 
age being six and a half years, the aver- 
age time of healing of the primary 
wound was four weeks, there were 117 
cases of blood-clot organization, 4 cat- 
gut, and 19 failures in J 40 cases. 
The duration of after-treatment was 
ten months. On the fourth month after 
operating the feet were all straight. 
Out of the 140 cases traced after one 
year, 10 cases were found relapsed, or 
partially so, from neglect. * I will say 
that relapses, when they occur, take 
place during the first year after the op- 
eration as a general rule. 
There were performed 10 linear osteo- 
tomies, 5 linear osteotomies with cunei- 
form resection from os calcis or cuboid, 
and 2 linear or cuneiform osteotomies, 
together with removal of both cuboid 
and scaphoid bones, making in all 17 
osteotomies. 
These results vary but little from 
Dr. Kaptyn's, of Abcande, Amsterdam, 
who has kindly furnished me with the 
statistics of 42 operations in 36 cases 
in Holland. In this series 34 were very 
good, 1 materially improved, fair results 
in 6, and 1 still under treatment. In 
other words good results were obtained in 
36 feet, with useful feet in all the others,, 
except 1, which is unknown. 
I find in looking over the literature on 
the subject, the following reported cases: 
Hoffe,6;Schede, 20; Nunchen, 13; Oliva, 
6; Postempski, 1; Schreiber, 11; Lowen- 
stein, 2; Jones, 10; Roman 3; Giordane, 
1; Motta, 7; Volkman, 21; Kirmison and 
Rochard, 7; Ambrose, 1; Phillipson, 3; 
Levy, 9; Kaptyn, 42; Post, 2; Hamburg 
Medical, 1884,12; Kingston, 4; the writ- 
er, 161, making in all 342. (This includes 
the cases of Professor Tilanus, Professor 
Korteweg, Dr. Konwer, Professor Ster- 
son, Van der Hoeren, Dr. Dunnewold). 
All the cases at the time of reporting 
upon them were good results. In no 
case did I find a sensitive scar, a flat 
foot, or paralysis following the operation. 
No considerable atrophy of the muscles 
of the limb followed the operation in 
any case; the motion of the toes was pre- 
served in nearly all the cases. In those 
with loss of flexion of toes, locomotion 
seemed to be as perfect. 
In my series, one hundred and forty- 
one cases had already run the gauntlet 
of tenotomy and instrumental treatment, 
with a relapse in each case.