THE OPERATIVE TREATMENT OF RESISTANT 
CLUB-FOOT. 
BY 
E. H. BRADFORD, M.D., 
BOSTON 
REPRINTED FROM THE 
TRANSACTIONS OF THE AMERICAN ORTHOPEDIC ASSOCIATION, 
1892. OPERATIVE TREATMENT OF RESISTANT 
CLUB-FOOT. 
By E. H. BRADFORD, M.D., 
BOSTON. -' " 
In presenting this paper, written on the subject of the treatment 
of resistant club-foot by means of radical operation, the statement 
should be made at the outset that it is not intended to advocate 
Fig. 1. 
Fig. 2. 
Imprint of foot of a child sixteen years 
old, treated when one year old for congen- 
ital club-foot. 
Imprint of normal foot. 
operative interference, even tenotomy, in all cases of club-foot, 
even of the congenital form. One of the most successful cases 2 
TREATMENT OF RESISTANT CLUB-FOOT. 
of congenital club-foot I am able to report was treated without 
any operative measures, even tenotomy. The result may be shown 
by the accompanying foot-print (Fig. 1). The drawings from pho- 
tographs have already been shown;1 but the foot-imprint is even 
more convincing than the photograph, and warrants the assertion 
that the feet are now perfectly normal in a child fifteen years of 
age treated without tenotomy when a year old. This can be seen 
by a comparison with the imprint of a normal foot (Fig. 2). 
Fig. 3. 
Drawn from photograph of a woman thirty-five years old, suffering from 
congenital club-foot. 
In this article, investigation will be limited to those cases which, 
either through previous neglect or bad treatment, or the obstinate 
nature of the deformity, have developed into the most persistent 
type of the distortion, resisting the simpler measures of treatment. 
In the 160 cases I have treated there has been no hesitation to per- 
form more radical operations, such as wedge-shaped exsection of the 
tarsus; though this method, as will be seen later, is at present not 
1 Transactions American Orthopedic Association, vol. i. E. H. BRADFORD. 
3 
advocated. While it is readily admitted that the successes of Drs. 
Taylor, Judson, and Shaffer have shown conclusively that club-foot 
can be in many instances satisfactorily corrected by means of me- 
chanical treatment alone, in advocating operative measures for the 
persistent cases the claim is made that in the severest and most 
resistant cases cure can be effected more- speedily, certainly, and 
Fig. 4. 
The foot one year after forcible correction. 
safely by proper radical operative measures than by simpler means. 
As Dr. Morton has well said, some cases of congenital club-foot 
are corrected without great difficulty and permanently cured, while 
in others the deformity is resistant, and there is a tendency to re- 
lapse ; and in treating of club-foot, in some instances time is of 
importance, and also the inefficiency or poverty of the parents has to 
be considered. Many resistant cases could be treated by mechan- 4 
TREATMENT OF RESISTANT CLUB-FOOT. 
ical means alone, provided the parents had sufficient persistency to 
continue the treatment for six months or a year or longer with daily 
or frequent visits; but where persistency and attention cannot be 
commanded, mechanical treatment becomes impossible, and these 
cases remain doomed to deformity unless some means can be devised 
which will enable the surgeon to cure in a short time. It is for 
this reason that operations on the bone, radical in character, are 
sometimes demanded which otherwise might have been avoided. 
The choice is between such methods as involve the least mutilation 
and give the best results in the speediest time. 
• Of these methods three deserve careful consideration : (1) Forci- 
ble correction, preceded by thorough division of the ligaments and 
tendons; (2) removal of the astragalus, an operation frequently 
performed on the European continent, and advocated lately by Dr. 
Morton, of Philadelphia ;1 (3) osteotomy of the neck of the os calcis 
and of the astragalus, preceded by careful division of the soft parts 
of the inner side of the foot. 
It is not proposed to consider the claims of wedge-shaped resec- 
tion of the tarsus, although this method has given good results. 
But anyone who has had experience with it will know that an 
unnecessary amount of bone is sacrificed where this method is 
relied upon. 
Forcible correction, combined with division of the shortened soft 
tissues accessible to the knife, will be found to be a method which in 
a large majority, even of the most resistant cases, will prove entirely 
satisfactory. It has the advantage of avoiding any unnecessary 
sacrifice of bony tissue, and has given excellent results. 
The accompanying illustrations will serve to show the fact that 
in cases of the severest type the method is capable of giving satis- 
factory results without any sacrifice of bony tissue (Figs. 3, 4, 5, 6). 
This case has already been reported in the Revue d' Orthopedic, 
March 1, 1892. 
The foot-imprint represents the ultimate result three years after 
operation, and shows a sole of a foot entirely flat in walking, which 
three years before had been of the severest type of deformity, in a 
woman thirty-five years of age. A lever wrench was used in cor- 
1 Transactions of American Surgical Association, 1890, vol. viii. p. 71. E. H. BRADFORD. 
5 
rection previous to tenotomy having been done. Two sittings were 
required, as the skin tore on the inner side of the foot at the first, 
and it was thought advisable to delay complete rectification until a 
fortnight had passed after the first sitting. The patient was enabled 
to walk about with crutches two weeks after the second operation, 
and a splint was applied one month later. The patient began to 
walk with the splint and a cane about this time, and she is now 
Fig. 5. 
Foot one year after forcible correction.! 
able to walk about freely without any appliance. It is now four 
years after the operation. 
She suffered somewhat a year after the operation from the pain 
of flat-foot, the foot having been over-corrected, and the woman 
being stout and heavy. The cure may be considered complete and 
permanent. 
In regard to a choice between open incision and subcutaneous 
division of the soft parts preceding forcible correction, in a majority 
of cases I have employed the subcutaneous method, using a section 6 
TREATMENT OF RESISTANT CLUB-FOOT. 
of the insertion of the anterior and posterior tibialis anticus tendon 
and of the scapho-astragaleal ligaments, according to the method 
recommended by Drs. Parker and Shattock. After some practice 
with these methods, it has hitherto seemed to me that I have been 
able in a majority of cases to satisfactorily divide all of the soft 
tissues by subcutaneous division. The plantar fascia is divided 
first; the tenotome is then inserted on the inner edge of the foot, 
at a short distance below the internal malleolus, directly toward the 
Fig. 6. 
Sole-imprint of the same foot three years after forcible correction 
scaphoid ; it is then passed directly under the sole of the foot, hug- 
ging the bone, and drawn inward and forward, keeping close to the 
edge of the scaphoid as it joins the astragalus. The tenotome is 
then inserted on the outer side of the foot at the junction between 
the cuboid and the os calcis. After this the foot is forcibly cor- 
rected, such fibres as have not been thoroughly divided being 
stretched, and the tendo Achillis is divided with the tenotome. 
But in many cases during the past year I have operated by means 
of an open incision, introduced by Dr. Phelps; and I must frankly E. H. BRADFORD. 
7 
admit that the readiness with which everything is exposed, and the 
certainty with which everything can be divided, has led me to 
Fig. 7. 
Fig. 8. 
Congenital club-foot in a boy six years 
of age, drawn from a photograph. 
After forcible correction 
Fig. 10 
Fig. 9. 
Plaster-of-Paris imprint from a boy of 
eleven, after excision of astragalus for 
resistant club-foot. 
Drawn from photograph of 
foot of a boy of eleven, after 
osteotomy of neck of astraga- 
lus for club-foot. 8 
TREATMENT OF RESISTANT CLUB-FOOT. 
believe that, contrary to my previous opinion, the latter method is 
more thorough, and is to be preferred in resistant cases. There 
is one slight disadvantage, namely, the greater time needed for 
healing, as compared with that after subcutaneous division. The 
resulting scar is also an objection, though not a great one. In one 
case I have seen over-correction in a flat-foot follow too extensive 
section, but this can be avoided by proper judgment. 
Fig.11. 
Sole-imprint after removal of astragalus for club-foot, 
The case of forcible correction mentioned well represents what 
can be done in a great many club-feet of the severely resistant 
type by this method; but in some instances such perfection cannot 
be attained in this way; either the deformity is so great, or the 
undivided interosseous ligaments resist, that it is impossible to 
thoroughly over-correct. Repeated operation will in time stretch 
the contracted ligaments, but in some instances a satisfactory result 
is not gained. Example of this will be seen in the accompanying 
photographs (Figs. 7, 8). The deformity was of a very severe 
type ; one foot was entirely over-corrected; the left foot, however, 9 
E. H. BRADFORD. 
was nearly corrected, but not enough to prevent a relapse.1 In 
this instance a great deal of force was used, and two sittings were 
given ; but what appeared to be resistance at the joint between the 
cuboid and the os calcis was sufficiently strong to prevent bringing 
of the cuboid into an over-corrected position. The distortion at 
the astragalo-scaphoid articulation was satisfactorily corrected, but 
when the attempt was made to raise the outer edge of the foot at 
Fig. 12. 
Fig. 13. 
Drawn from photograph after removal of 
astragalus of left foot for club-foot. 
Drawn from photograph after removal 
of astragalus of left foot. 
the same time that the front of the foot was turned up and brought 
up, an amount of resistance was encountered which could not be 
corrected by force. It formerly appeared to me that this was due 
to the strength of ligamentous bands uniting the important tarsal 
bones, and that if sufficient force were applied the difficulty could 
be overcome. 
i The patient died of diphtheria before an operation for complete correction of the 
left foot could be undertaken. 10 
TREATMENT OF RESISTANT CLUB-FOOT. 
I am unable to state in how large a percentage of cases complete 
correction by means of force is possible. In a large number of 
cases this is true, but experience has shown me, in the one hundred 
and sixty cases which have come under my care, that in five, re- 
lapses have occurred after satisfactory over-correction by force, as 
in the case just mentioned. In most of the cases the feet were 
small, the children being very young. I had explained this on 
Fig. 14. 
Drawn from, photograph after removal of astragalus. 
the supposition that owing to the elasticity of the bones in the 
feet of children, the force could not be applied in such a way as to 
rupture or stretch the contracted ligaments. It also seemed prob- 
able that in some instances deformity of bone was the impediment; 
and for this reason I have in the last year excised the astragalus in 
five cases, in the belief that the astragalus was the bone chiefly 
affected, and because excellent results were reported as following 
this operation, especially in the interesting article by Dr. Morton. 
The results in five cases operated upon by me in this way are 11 
E. H. BRADFORD. 
given below. The operation is itself a simple one. An'Esmarch 
bandage is applied, and an incision made on the outer side of the 
foot, beginning a little above the external malleolus, and curving 
forward and reaching to slightly beyond the head of the metatarsal. 
After dissecting back the flaps by cross incisions, the astragalus is 
separated from the scaphoid, the tibia and fibula, and, after forcibly 
twisting the foot, from the os calcis. Some difficulty is often 
encountered in dividing the strong ligament between the astragalus 
Fig. 15. 
Sole-imprint of a case of club-foot corrected by tenotomy with inversion 
of the foot without contraction. 
and os calcis, but after the use of some care this ligament is divided, 
and the astragalus is removed. A counter-opening is sometimes 
made on the inner side of the foot; the wound through the 
skin is stitched; and after removal of the Esmarch bandage, the 
wound is dressed aseptically and the foot placed iu a corrected 
position, and fixed by means of a plaster bandage applied over a 
large aseptic dressing. The foot can, after operation, be placed 
without difficulty in the proper position, and if proper care is used 
in asepsis, no evil effects follow the operation, and the wound 12 
TREATMENT OF RESISTANT CLUB-FOOT. 
should heal well. After three weeks the plaster bandage is re- 
moved, an appliance put on, and later the patient allowed to 
walk. The result is a useful and often an excellent foot, cor- 
recting appliances are not required after the ankle regains strength, 
that is, in from two to three months. 
Fig. 16. 
Drawn from specimen of adult club-foot. 
The results after this operation are shown in the accompanying 
pictures. It will not be found, however, that the results are 
entirely perfect, and it must be admitted that the removal of so 
large and important a bone as the astragalus is in itself a mutila- 
tion which it is desirable to avoid if as good result can be obtained 
in other ways. An examination of the imprints of the sole in all 
the cases showed that a slight inversion still remains. This gives 
a result which, although satisfactory in that the resulting feet are 
not noticeably deformed and are useful, cannot be regarded as per- 
fect, and perfection is what should be aimed at. This may be seen 
in the tracing of the feet shown in the accompanying illustrations. 
If the sole of a normal foot be examined, it will be noticed that a 
line drawn through the middle of the sole is a straight one. In 
the cases of club-foot after removal of the astragalus, it will often 
be seen that the median line in front of the medio-tarsal articulation 
forms an angle with the median line posterior to that articulation. 
This, which is not to be seen in a normal foot, is evidently due to 
the obliquity of the anterior facet of the os calcis, normally at 
right angles to the long axis of the foot, as it is well known from E. H. BRADFORD. 
13 
pathological specimens that this obliquity exists in a certain number 
of cases. A picture of the sole of what may be termed a perfect 
result is seen in the accompanying photograph (Fig. 10). 
In two of the five cases of excision of the astragalus I have 
done, the deformity was in both feet; in the others the deformity 
was of one. In all the cases the deformity was congenital, and 
had been treated with care before. Two of the cases had been 
Fig. 17. 
Fig. 18. 
Imprint left foot, congenital club-foot, 
before operation. 
Imprint right foot before operation. 
treated by me, and had relapsed later; and they were earlier cases 
where the details of treatment were not as thoroughly understood 
by myself as later experience has taught. One was a boy ot 
twelve; the second was a boy of ten, double deformity; the third, 
a boy of six; the fourth, a boy of ten ; and the fifth, a girl of ten. 
The results were satisfactory. 
In all of these cases the slight obliquity inward of the anterior 
portion of the feet was noticed, marring the perfection of the 
result, though in no way preventing the usefulness of the foot or 14 
TREATMENT OF RESISTANT CLUB-FOOT. 
the activity of the child. This is indicated by the sole-impression 
of the imprint of the foot of Case II. (Fig. 11). In Case V., some 
twisting of the foot remains, as is seen by the illustrations (Figs. 
12, 13). The astragalus was removed without difficulty. The 
wound healed; and the patient was soon able to walk about freely, 
with motion at her new ankle-joint. Judging from external ap- 
pearances and the history of the case, it is evident that some internal 
Fig. 19. 
Fig. 20. 
Imprint left foot after operation. 
Imprint right foot after operation- 
osteotomy of neck of astragalus and 
os calcis. 
and anterior obliquity at the articulation of the os calcis must be 
present, for after removal of the astragalus the inward inversion 
of the front of the foot should disappear, unless some other cause 
than the distortion of the astragalus was present (Fig. 14.) 
If the removal of the astragalus is not sufficient for complete 
correction, it is evident that the deformity exists also elsewhere, 
and the obliquity in the facet of the head of the os calcis suggests 
itself as a cause of the continuance of the distortion. This obliquity 15 
E. H. BRADFORD. 
of the os calcis is demonstrated by the accompanying footprint, 
which shows the footprint of a case of congenital club-foot, treated 
Fig. 21. 
Drawn from photograph before operation in boy of twelve 
Fig. 22. 
From photograph after operation in boy of twelve-osteotomy of neck of astragalus 
and os calcis. 
by mechanical stretching and tenotomy of the tendo Achillis (Fig. 
15). The deformity is entirely corrected, as far as can be demon- 16 
TREATMENT OF RESISTANT CLUB-FOOT. 
strated by complete flexibility and excellence in gait. There are 
at present no contractions either in the tendo Achillis, plantar 
fascia, or in any part of the foot. The foot can be placed readily 
in an over-corrected position. The child walks about without 
apparatus, which has been discarded for several years. There is a 
tendency, however, for the child to toe in, especially when running, 
and the footprint indicates that the anterior part of the foot turns 
to the inside. This appears to be due to the obliquity in the 
articulation of the facet of the os calcis. The [same condition is 
Fig. 23. 
Drawn from photograph after operation 
seen in the photograph from the dissection in the Warren Museum 
(Fig. 16), and even better in a specimen of adult congenital club- 
foot prepared by Dr. Goldthwait. 
On examination of this specimen, it will be clearly seen that the 
obstacles to the correction of this deformity do not lie alone in the 
distortion of the astragalus, nor in the ligamentous tissues which 
bind the scaphoid to the astragalus. After these may be removed, 
there remain evidences of distortion in the os calcis at its junction 
with the cuboid. The articulated surface of the os calcis, as it lies 
in contact with the cuboid, is oblique relative to the axis of the 
foot, rather than at right angles to this axis. It is manifest that E. H. BRADFORD. 
17 
in this individual case it would be impossible to entirely replace 
the cuboid in the proper position in relation to the os calcis simply 
by a division of the soft parts on the inner side of the foot, and 
also that after removal of the astragalus all the osseous obstacle to 
correction is not removed. 
Fig. 24. 
Drawn from casts before operation in a boy of ten with 
congenital club-foot. 
The method of procedure for attacking the projection of the os 
calcis is a simple one. An incision should be made, starting below 
the external malleolus with convevity upward reaching to the pro- 
jecting head of the astragalus, and passing downward toward the 
outer side of the foot toward the sole. This flap should be drawn 
down by means of hooks, and the neck of the os calcis laid bare. 
An osteotome can be inserted a short distance from the line of the 
cartilage, and the wedge-shaped piece of bone removed from the 
neck. The foot can be forcibly corrected with but little force if 
the contractions of the soft parts on the inside of the foot have 
been stretched or divided. If, however, there is, as often occurs, 
also resistance at the astragalus, the upper portion of the skin 
above the incision can bo retracted, and the neck of the astragalus 18 
TREATMENT OF RESISTANT CLUB-FOOT. 
easily seen, an osteotome inserted, and either the astragalus divided 
by a linear osteotomy or a wedge-shape piece removed. The 
operation can be done very readily and with but little mutilation 
of the foot. 
I have operated in this way in three cases of double congenital 
club-foot with satisfactory results in the past year. The accom- 
panying photographs and imprints indicate the results. They were 
taken (Figs. 17,18, 19, 20, 21, 22, 23, 24, 25) some time after the 
operation, proving the ultimate result to be satisfactory. Nothing 
Fig. 25. 
Drawn from photograph after operation-double osteotomy of neck of astragalus 
and os calcis. 
of particular interest in the history of either case is to be recorded, 
except that in the first case open incision was done on one foot, and 
osteotomy of the neck of the os calcis and the astragalus were done 
upon the other foot with tenotomy, but without open incision on 
the inner side of the foot. The result, as indicated by the tracing, 
would appear to show that the open incision without osteotomy 
gave a more satisfactory result than osteotomy following subcutaneous 
tenotomy. This is, perhaps, due to the fact that the foot on which E. H. BRADFORD. 
19 
osteotomy was done was the more severely deformed of the two. 
But it may suggest also the fact, which I have found in other 
instances, that subcutaneous incision does not divide as thoroughly 
as an open incision. In several instances I have divided by means 
of subcutaneous tenotomy as thoroughly as I was able to do, and 
I have subsequently cut down by an open incision to see if I had 
left any tissues undivided; and I have satisfied myself that, with 
the tenotome in the foot, fibres may be left undivided by subcu- 
Fig. 26. 
Sole-imprint after osteotomy of neck of os calcis and astragalus. 
taneous division which can be only discovered by open incision, as 
is the case in subcutaneous division of the insertion of the sterno- 
cleido mastoid. 
In the second case (Figs. 24, 25) the result was entirely satis- 
factory, and both were operated upon by osteotomy of the neck of 
the astragalus and of the os calcis. In previous cases I have 
attempted to osteotomize the neck of the os calcis without thorough 
division of the plantar fascia in inner ligaments. They were 
earlier cases, and the operation was not done with precision or with 
the carrying out of the details already mentioned; and they may 20 
TREATMENT OF RESISTANT CLUB-FOOT. 
be fairly considered experimental cases. Although the deformity 
was corrected satisfactorily and useful feet resulted, yet the greatest 
possible perfection was not gained, as is shown in the accompany- 
ing footprint (Fig. 26), which, it will be seen, though that of a 
useful foot, and in result to be compared with that after enucleation 
of the astragalus, yet is not so excellent as in the best cases. 
In conclusion, it can be said that not only is club-foot of the 
most persistent variety entirely and completely curable, but also 
that in many cases the milder means are sufficient. It is, however, 
demonstrable that in a certain number of cases osseous deformity 
of the neck of the astragalus and os calcis exists; and where this 
exists, the perfect correction can be made with but little mutilation 
of the bone, by either a linear osteotomy of the neck of the os 
calcis and of the astragalus, or the removal from the neck of 
either or both a small wedge of bone, if this is preceded by thor- 
ough division or stretching of the contracted soft parts. Thorough 
lengthening of the contracted ligaments and fasciae, as well as 
tendons, either by stretching or tenotomy or open incision, is essen- 
tial for a perfect result; if this is not done a less perfect result is 
obtained.