OPERATIONS FOR CLUB-FOOT.--The following are the tendons which _may_ require division in the cure of club-foot, and the operations for their division. 1. _The tendo Achillis._--There are very few cases of true club-foot which can be successfully treated without division of the tendo Achillis. While in talipes equinis it is generally the only disturbing agent, in talipes varus and valgus it invariably increases and maintains the deformity, which the tibiales or peronei seem to originate. _Operation._--The foot being held at about a right angle with the leg, the operator should pinch up the skin over the tendon, introduce the knife flatwise, a little to one side of the tendon, till its point is nearly projecting at the other, then turn the edge on the tendon and cut inwards with a sawing motion till the tendon gives way with a distinct snap, and the foot can be completely flexed with ease. Dr. Little[167] recommends that the tendon should be divided from before backwards. There is more risk by this method of wounding the skin, and thus losing the subcutaneous character of the operation. Professor Pancoast[168] divides the inferior portion of the soleus muscle instead of the tendo Achillis. 2. _Tibialis posticus._--Next in frequency and importance to that of the tendo Achillis, division of this tendon is much more difficult to perform. It may be performed either above or below the ankle. (_a._) _Above the ankle._--The blade of a tenotomy knife should be entered perpendicularly at the posterior margin of the tibia, half an inch or an inch above the internal malleolus, so as to pass between the bone and the tendon of the tibialis posticus, the blade directed towards the latter; the assistant should now evert the foot, the operator pressing the blade against the tendon.[169] (_b._) _Below the ankle, close to the attachment to the scaphoid._ This is the better position of the two when the position of the tendon can be made out, which is not always the case, especially in cases of old standing. Raising the skin just over the astragalo-scaphoid joint, the knife should be entered with its blade downwards, and across the tendon, and should be made to cut on the bone, while an assistant everts the foot till the tendon gives way with a distinct snap. 3. _Tibialis anticus_ may in like manner be divided either just above the ankle, or at its insertion. When it requires division it can generally be made so prominent as to render its division comparatively easy. 4. _Peronei._--These do not often require division, cases of talipes valgus being usually paralytic in character. If necessary they can be cut as they cross the fibula. 5. _The plantar fascia_, may require division; when this is the case, it is so prominent as to render the operation very easy, if conducted on the principles mentioned above. FOOTNOTES: [166] Syme's _Pathology and Practice of Surgery_, p. 220. [167] Holmes's _Surgery_, vol. iii. p. 573.