Finally, _amputation_ may be called for when other methods have failed, and the patient is unable to put the foot to the ground because of suppurating bursæ and ulceration of the skin. #Acquired Talipes Equino-varus.#--In the great majority of cases this condition results from anterior poliomyelitis. It especially affects the peronei and the extensors of the toes, and is unilateral. The patient is unable to dorsiflex and abduct the foot, which hangs with the toes pointed and the sole turned medially. At first the joints are flaccid, and the attitude can easily be corrected by manipulation. In course of time, however, the opposing muscles--those inserted into the tendo Achillis, the tibialis posterior, and the long flexors of the toes--become shortened, and there is secondary contraction of the plantar fascia and of the ligaments on the medial side of the foot, and the deformity is thus rendered permanent. The bones also are altered in their shape and mutual relations, the talus being rotated forwards so that a large portion of its trochlear surface protrudes from the tibio-fibular socket. The skin is cold and livid, and readily suffers from pressure sores. The whole limb is ill-developed, and may be shorter than its fellow, and the paralysed muscles are wasted and exhibit for a time the reaction of degeneration. A similar deformity may result from section of the peroneal (external popliteal) nerve, from the peroneal form of progressive muscular atrophy, and from peripheral neuritis. The _treatment_ of paralytic equino-varus, short of operation, has been referred to under anterior poliomyelitis (p. 242). If tendon transplantation is indicated, the tendon of the tibialis anterior is attached to the cuboid, and a strip of the tendo Achillis to the dorsal aspect of the tarsus. Jones displaces the tibialis anterior into the base of the fifth metatarsal. If the paralysis is widely distributed, and the joints are flail-like, it is better to ankylose the ankle and mid-tarsal joints. It may be necessary to divide in several places the plantar fascia and other structures that have undergone secondary shortening. As using the limb hastens the restoration of function, the child should be got on to his feet as soon as possible. The spastic form of talipes equino-varus is comparatively rare. The plantar flexors and invertors distort the foot into the equino-varus attitude. The heel is drawn up, the anterior part of the foot is adducted and inverted at the mid-tarsal joint. The muscles are tense and rigid, and the reflexes exaggerated. The condition is frequently bilateral, and is often associated with other deformities of the lower limb and with a characteristic spastic gait. Considerable improvement may be brought about by lengthening the tendons of the shortened muscles. In severe cases it may be necessary to resect a portion of the tarsus. The occurrence of #varus without equinus# is so exceptional as not to call for separate description.