The word talipes signifies some deformity of the foot and is quite
common in orthopedic practice, being found in nearly ten per cent
of the cases coming under this branch of the science. Club foot may
be classified into two types—the congenital and the acquired. The
congenital type is the most common and is due probably to abnormal
intrauterine pressure or to a perversion of normal intrauterine
development. The acquired type is due usually to injury or infantile
paralysis, but either joint disease or cerebral paralysis may be
the cause. The deformity presents six different forms with most
characteristic clinical pictures which, with the exception of talipes
planus I have taken up in the order of frequency.
[Illustration: Illustrating the more common types of talipes. A
combination of any may be present.]
=Talipes Equinovarus= is usually congenital and is the most common
type. It is characterized by inversion and torsion of the foot with
elevation of the heel. The weight is borne on the outer side of the
foot and in extreme cases upon the dorsum as well. Calluses are always
present which are red and painful upon the point where the greatest
weight is borne. The most common method of treating this condition
is to divide the tendo Achilles at a level with the malleoli. The
operation should be done aseptically and under complete anesthesia.
As an assistant raises the end of the foot so as to stretch the tendo
Achilles the surgeon enters the knife parallel to the border of the
tendon through the skin and tendon sheath into the tendon itself. Next
with a tenotome inserted into the incision and turned at right angles
to the tendon, the tendon is divided first on one-half then on the
other. Care should be taken to disturb the tendon sheath as little
as possible for it serves an important purpose in repair. When the
division is complete as indicated by the separation of the divided
ends, the tenotome is withdrawn and the minute opening in the skin,
from which there is only slight bleeding, is covered with aseptic
gauze. The foot is forced into dorsal flexion and if in severe cases
the deformity is not then corrected, the tendons on the outer side
of the foot may be shortened, while those on the inner side may be
lengthened in the same manner as the tendo Achilles. A plaster of Paris
cast is then applied well up to the knee with the foot in the over
corrected position, care being taken that no undue pressure is brought
upon the seat of operation, as this might interfere with the effusion
of plastic material. Personally I believe that functional use of the
limb and foot stimulate repair, and I always encourage the patient to
stand and walk after the discomfort of the operation has passed. At the
end of four weeks the space between the two cut ends will be filled
with new material and the cast can be removed, and in another month the
splice, which is somewhat larger and thicker than normal, should be
strong enough for use. In the course of a year the lengthened tendon is
perfectly normal.
=Talipes Equinus.=—In this type the patient walks on his toes with the
heel highly elevated, in the same position as the horse, and it will
be noticed that the foot has no dorsal flexion whatsoever. Infantile
paralysis affecting the anterior muscles of the leg is usually the
cause of this condition, though sometimes shortening of the leg
following knee joint disease, or fracture may lead to an adaptive
equinus which serves to make the limb of equal length for walking.
This type is by far the easiest to remedy, and the results following
operations are perfect. A simple division of the tendo Achilles is
made under anesthesia and a cast applied as above, in a position of
exaggerated dorsal flexion. Functional use of the limb after the cast
has been removed overcomes any stiffness that might occur and perfect
results are obtained in a short time, compared with the other types.
=Talipes Calcaneous.=—This is a condition in which the foot is held in
a position of dorsal flexion. The patient walks on the heel with an
inelastic gait because the spring of the foot is absent and the whole
weight is borne upon the os calcis. The best procedure in this type is
manipulative treatment into a position of plantar flexion to overcome
the contraction of the anterior muscles of the foot and leg, and bring
about contraction and shortening of the posterior muscles. A tenotomy
of the anterior tendons or an anesthetic is rarely indicated, though in
severe cases, a series of casts holding the foot in position of plantar
flexion may be necessary to secure good results. I have found it a help
to have a shoe with a heel prolongated backward, or a steel splint
laced to the leg to prevent the foot from upward motion.
=Talipes Valgus.=—This is a very uncommon type of deformity,
characterized by eversion of the foot. The patient walks on the inside
of the foot and, as a rule, experiences very little trouble. I find a
manipulative treatment is best for this condition, aided by braces.
=Talipes Cavus.=—This form is sometimes called “=hollow foot=” and is
very uncommon in this country. It is characterized by a markedly high
arch sometimes as in Chinese women to the extent that the anterior
part of the foot is approximated to the heel. The plantar fascia is
badly contracted and one can distinctly palpate the bands beneath the
skin. This condition is practically the same as the ordinary so-called
“=contracted foot=” except that it is much more exaggerated. The
ordinary high arch of today is usually the result of wearing too short
a shoe, and if painful, long last shoes, aided by manipulations, will
usually correct the trouble. In severe cases of contracted foot the
plantar fascia may be divided, under anesthesia and the arch brought
down and put in a cast, though this procedure is not very successful.
In case it is done the patient should be made to walk in two or three
weeks, as this helps materially to overcome the deformity and hasten
repair of the fascia.
=Talipes Planus.=—This condition is commonly known as “=flat foot=” and
is taken up in another part of this text. However, it is one of the
classifications of “club foot” and is far the most common type.
=Prognosis.=—These conditions never correct themselves and if
uncorrected usually get worse and the more severe types certainly
become obstinate malformations. In general the tendency to relapse
is strong, though if properly treated the results are excellent. In
infantile cases the time required for correction is relatively short,
but retentive appliances are needed for a longer time. The older
the cases and larger the foot the more difficult, of course, the
correction, but usually there is less danger of relapse. A perfect
correction, that is when the gait and attitude are normal, will never
relapse. I find it better to leave the fixation appliance on too long
than not long enough. Never remove a cast under four weeks except in
the cavus type, then apply a brace such as can be obtained from any
supply house for any type of case, for from one to three months longer.
The tendons involved in these conditions are so apparent that it is
almost impossible to make a mistake in the division of them. About
the only precaution necessary is to be assured that the tendon itself
is completely divided, but that the tendon sheath is only slightly
disturbed.