RDbSO So 8 Columbia Untoersrttp in tfje Cttp of i^eto ^orfe department of Hmrgerp Pull memorial funo TECHNIQUE OF OPERATIONS ON THE BONES, JOINTS, MUSCLES AND TENDONS THE MACMILLAN COMPANY NEW YORK • BOSTON • CHICAGO ■ DALUS ATLANTA • SAN FRANCISCO MACMILLAN & CO., Limited LONDON • BOMBAY • CALCUTTA MELBOURNE THE MACMILLAN CO. OF CANADA, Ltd. TORONTO TECHNIQUE OF OPERATIONS ON THE BONES, JOINTS, MUSCLES AND TENDONS BY ROBERT SOUTTER a.b., m.d. (harvard) assistant surgeon to the children's hospital, boston; surgeon-in-chief to the house of the good samaritan; surgeon to the long island hospital, boston; surgeon to the Massachusetts state hospital, canton; surgeon to the peabody home; instructor, harvard university medical school; fellow of american college of surgeons, american medical association, american orthopedic association, boston surgical society, etc. $>w fnrk THE MACMILLAN COMPANY 1917 All rights reserved Copyright, 1917 By THE MACMILLAN COMPANY Set up and electrotyped. Published September, 1917. Wo DR. E. H. BRADFORD Professor of Orthopedic Surgery, and Dean, Harvard University Medical School THIS VOLUME IS DEDICATED AS A TOKEN OF APPRECIATION OF HIS CLEAR-MINDED JUDGMENT, HIS HIGH SURGICAL SKILL AND PROFESSIONAL IDEALS, ALL OF WHICH HAVE BEEN A CONSTANT SOURCE OF INSPIRATION DURING THE INTI- MATE ASSOCIATION OF FIFTEEN YEARS PARTNERSHIP. Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/techniqueofoperaOOsout PREFACE This volume has been written at the request of many of my graduate students, including surgeons who have taken the courses at Harvard University Medical School and internes in the hospitals with which I am connected. The work contains only carefully tried-out methods which cover operations on the bones, joints, muscles and tendons, including muscle transplantations together with all the common operations for the cor- rection of deformities and some of the less usual ones. It is intended as a practical guide for advanced students, and for the surgeon who desires to select one of several tried-out methods for any special case. I have endeavored to give the important details of all procedures in order to freshen the surgeon's memory before operating. The history and origin of the operations is omitted for the sake of brevity. An at- tempt is made to give the more useful rather than to enumerate all operations that can be done. I have not planned to compile an ency- clopedia but to present a ready reference for the technique of the more practical operations on the upper and lower extremeties. The operative procedures, useful in infantile paralysis, are dealt with at length and the tried-out methods are here recommended rather than every possible operation. vu CONTENTS PART I— HIP CHAPTER I HIP OPERATIONS FOR CONGENITAL DEFORMITIES 1. Dislocation of the hip. Manipulation. Bloodless reduction. 2. Dislocation of the hip. Dr. Bradford's hip machine. 3. Dislocation of the hip. Post operative treatment. 4. Dislocation of the hip. Open operation. 5. Dislocation of the hip. Plaster of Paris. CHAPTER II HIP MUSCLE AND TENDON OPERATIONS. MUSCLE AND TENDON TRANSPLANTATION 6. Contracted soft tissues. Hip flexion. 7. Manipulation of the hip. 8. Transplantation of the hip flexors at the ilium. Fasciotomy at the hip.* 9. Fasciotomy to relieve flexion and abduction of the hip. 10. Application of plaster of Paris after fasciotomy or after osteotomy of the femur. CHAPTER III OTHER OPERATIONS IN CASES OF PARTIAL OR TOTAL PARALYSIS ABOUT THE HIP 11. Flail hip. 12. Operation for arthrodesis of the hip in paralytic conditions and in painful osteo-arthritic conditions. 13. Silk ligament at the hip for paralysis of the abductors. CHAPTER IV INCISION, PUNCTURE, ARTHROTOMY AT THE HIP 14. Incision for exposure of the ilium, Sprengel's incision. 15. Incision for exposure of the sacro-iliac joint. 16. Arthrotomy. 17. Arthrotomy of the hip. 18. Anterior incision. 19. Antero-lateral incision. 20. Antero-lateral incision with second part when more room is necessary. 21. Posterior incision. 22. U-shaped incision, Murphy, for arthroplasty. 23. Anterior U incision, Brackett. 24. Internal lateral incision. Adductor incision for the hip. * Soutter operation. ix K CONTENTS 25. Arthrotomy for fractures about the hip. 26. A method of treating overlapping fractures. 27. Fractures of lung standing still ununited or united with deformity prevent- ing function. 28. Fracture of the neck of the femur in the young or middle-aged. 29. Operation for Coxa vara. 30. Incision for exposure of the sciatic nerve. 31. Incision for the adductor magnus tendon in hip operations. 32. Incision for gluteal bursitis. 33. Tapping the hip joint. CHAPTER V OPERATIVE TREATMENT IN CASE OF HIP-JOINT ANKYLOSIS 34. Principle of arthroplasty. 35. Arthroplasty at the hip operation. 36. Operation for deformity at the hip with ankylosis. Hip flexion and adduc- tion with or without dislocation of the hip. 37. Subtrochanteric osteotomy, "Gant." 38. Operation for coxa vara with ankylosis of the hip. 39. Osteotomy at the neck of the femur. 40. Albee hip operation in osteo-arthritis. Arthrodesis. 41. Operation for separation of the epiphysis at the hip (see also fractures of the neck). 42. Adjusting legs of unequal length. CHAPTER VI OPERATIONS IN SUPPURATIVE CONDITIONS ABOUT THE HIP 43. Suppurative conditions about the hip. 44. Excisions of the hip in suppurative conditions. 45. Methods and principles of drainage in acute non-tubercular suppurative joint disease. 46. Acute arthritis of infancy. 47. Osteomylitis. PART II— KNEE CHAPTER I OPERATIONS FOR DEFORMITIES OF THE KNEE 48. Operative manipulation of the knee. 49. Operation for flexion deformity of the knee. 50. Operation of tendon lengthening to correct knee flexion. 51. Correction of subluxation of the tibia by manipulation, genuclasis. 52. Another method of correcting subluxation. 53. Operation for knock knee and bow leg. 54. Correction of flexion deformity of the knee by osteotomy of the femur. 55. Technique of osteotomy of the femur for flexion deformity of the knee. McCewen operation. CONTENTS xi 56. The application of plaster of Paris bandage after operation or manipulation of the knee. 57. Plaster of Paris for holding the knee. 58. A simple method for preventing rotation of a leg plaster. 59. Osgood operation for flexion deformity at the knee. CHAPTER II MUSCLE AND TENDON OPERATIONS. MUSCLE AND TENDON TRANSPLANTATIONS 60. Operation for rupture of the quadriceps extensor. 61. Muscle transplantation for paralysis of the anterior thigh muscles. 62. Transplantation of two hamstrings forward. 63. Operation for transplantation of the sartorius muscle for a weak or para- lyzed quadriceps. 64. Transplantation of the tensor fascia femoris to a weak or paralyzed quad- riceps. 65. Transplantation of the external hamstrings forward for a weak or paralyzed quadriceps. 66. Technique of muscle transplantation. 67. Muscle transplantation for paralysis of the anterior thigh muscles. 68. Plaster of Paris bandage following transplantation in the thigh. 69. Myotomy of the adductors and hamstring muscles for contracted muscles. 70. Operation for tenotomy of the hamstrings; tendon lengthening. 71. Myotomy in spastic paralysis. 72. Operation for myotomy of the internal hamstring. 73. Operation for removing a section from a muscle. 74. Operation for tenotomy of the adductor magnus tendon. CHAPTER III OPERATION IN CASES OF PARTIAL AND TOTAL PARALYSIS ABOUT JOINTS 75. Arthrodesis at the knee. 76. Operation for flail condition of the knee. 77. Bartow silk ligaments at the knee. CHAPTER IV INCISION, PUNCTURES AND ARTHROTOMY 78. Operation for a displaced semilunar cartilage. 79. Operation for torn crucial ligament. 80. Arthrotomy. 81. Arthrotomy at the knee. 82. Anterior median incision. Splitting the patella into lateral halves. 83. Posterior incision. 84. The bayonet incision at the knee. 85. Two lateral incisions at the knee. 86. The U-shaped incision at the knee. 87. Arthrotomy for fractures about the joints. 88. A method of treating overlapping fractures. xii CONTENTS 89. Fractures of long standing still ununited or united with deformity pre- venting function. 90. Fracture of the patella. 91. Fractures into the knee joint. 92. Operation for dislocation of the patella. 93. Tapping the knee joint. CHAPTER V SUPPURATIVE TREATMENT IN CASES OF JOINT ANKLYOSIS 94. Excision of the knee for ankylosis. 95. Arthroplasty for ankylosis of the knee. CHAPTER VI OPERATION IN SUPPURATIVE CONDITIONS 96. Suppurative conditions at the knee. 97. Osteomyelitis. 98. Excision of the knee in suppurative conditions. 98a. Methods and principles of drainage in acute non-tubercular suppurative joint disease. Knee, femur, tibia. PART III— FOOT AND ANKLE CHAPTER I OPERATION FOR DEFORMITIES 99. Manipulating the foot. 100. Manipulating the foot by means of apparatus. 101. Manipulating the foot by means of the Thomas Wrench. 102. Manipulating the foot by means of the Bradford Wrench. 103. Manipulating the foot by means of the Davis Wrench. 104. Operation for talipes varus and equino varus club foot. 105. Operation on the bone for extreme varus or equino varus (club foot opera- tion) congenital or acquired. 106. Operation for equino varus, congenital or acquired. Relieving the internal ligamentous attachments when the oscalsis is tilted. Dr. Ober's operation. 107. Application of plaster for varus or equino varus, club foot plaster. 108. The after-treatment of equino varus. 109. Operation for valgus, equino valgus, and calcaneo valgus. Flat foot. 110. Extreme valgus, calcaneo valgus, and equino valgus. 111. Bone operation for valgus, equino valgus or calcaneo valgus. 112. Operation for valgus with marked tilting of the oscalcis. 113. Plaster of Paris bandage for valgus. 114. Operation for arthrodesis of the astragalo-scaphoid joint for valgus, foot strain, and partial paralysis. 115. Operation for talipes calcaneous. CONTENTS xiii 116. Operation for pes cavus. 117. Deformities limiting the motion of the ankle joint following Potts fracture. 118. Hammer toe operation. Claw foot. 119. Hammer toe and claw foot. Contracted extensor longus digitorum. 120. Hammer toe and claw foot. Subcutaneous tenotomy of extensor longus digitorum near the head of the metatarsal. 121. Hammer toe and claw foot. Tenotomy of the extensor longus pollicis near the head of the metatarsal. Open tenotomy. 122. Hammer toe and claw foot. Operation for tenotomy or tendon lengthen- ing of the extensor longus digitorum tendon in the leg. 123. Hammer toe and claw foot. Operation on the bone. 124. Hammer toe and claw foot. Joint excision. 125. Operation for hallux valgus. CHAPTER II MUSCLE AND TENDON OPERATIONS. MUSCLE AND TENDON TRANSPLANTATION 126. General principles in simple tenotomies, tendon lengthening and tendon shortening. 127. Operation for tendon lengthening. 128. Operation for subcutaneous tenotomy of the tendo achilles. 129. Operation for talipes equinus. 130. After-treatment. 131. The plaster of Paris bandage for the foot after operation for talipes equinus. 132. Operation for tenotomy or tendon lengthening. Subcutaneous zig-zag tenotomy of the tendo-achilles. 133. The tenotome. 134. Operation for open tenotomy to relieve contracture of flexor longus digi- torum in the lower leg. 135. Subcutaneous tenotomy of the flexor longus digitorum at the base of the toes. 136. Subcutaneous tenotomy of the plantarfascia. 137. Operation for contracture of the tibialis posticus in the leg. 138. Tenotomy or tendon lengthening of the peroneii muscles. 139. Tenotomy or tendon lengthening of the tibialis anticus. 140. Tenotomy to relieve hammer toe (see hammer toe operation). 141. Tenotomy to relieve contracted extensor longus digitorum (see description under hammer toe) . 142. Subcutaneous tenotomy of extensor longus digitorum near the head of the metatarsal (see under hammer toe) . 143. Different forms of tenotomy to relieve contracted extensor longus digitorum in the lower leg (see description under hammer toe operation) . 144. Operation for tendon shortening. 145. Other methods of tendon shortening. 146. Operation for shortening the tendo achilles. 147. Operation for shortening the extensor longus digitorum. 148. Operation for a weak or paralysed tibialis anticus. Transplantation of the peroneii forward to give dorsal motion to the foot. Lange method. 149. Plaster of Paris, following muscle transplantation. 150. After-treatment, xiv CONTENTS 151. Operation for a weak or paralyzed tibialis anticus. Transplantation of the tibialis posticus forward to give dorsal motion to the foot. 152. Operation for a weak or paralyzed tibialis anticus. Transplantation of the flexor longus digitorum to give dorsal motion to the foot. 153. Operation for a weak or paralyzed tibialis anticus. Transferring the ex- tensor longus hallucis to reenforce the tibialis anticus in the lower third of the leg. 154. Operation for a weak or paralyzed tibialis anticus. Transplantation of the extensor longus hallucis to the tarsus. 155. Operation for a weak or paralyzed tibialis anticus. Transplantation of the extensor longus digitorum to the tarsus. 156. Operation for a weak or paralyzed tibialis anticus. Transplantation of the extensor longus digitorum to the tibialis anticus in the lower third of the leg. 157. Operation for a weak or paralyzed tibialis anticus. Transplantation of the extensor longus hallucis to the head of the metatarsal. 158. Operation for a weak or paralyzed tibialis anticus. Transplantation of the extensor longus digitorum. 159. Operation for a weak or paralyzed tibialis anticus. Transplantation of the extensor longus digitorum to the head of the metatarsal to give power to raise the foot. 160. Operation for paralysis of the tibialis anticus. Transplantation of one- half of the tendo achilles forward. 161. Operation for partial or total paralysis of the peroneii. Transplantation of one-half of the tendo achilles forward. 162. Operation for total or partial paralysis of the tibialis posticus. Transplan- tation of one-half of the tendo achilles. 163. Operation for transplantation of the flexor longus digitorum for partial paralysis of the tendo achilles. 16-1. Operation for transplantation of the tibialis posticus for partial paralysis of the tendo achilles. 165. Transplantation of peroneii to the tendo achilles. 166. Operation for paralysis of the great toe. Transplantation of its distal end to that of the tibialis anticus. 167. Operation for transplantation of the tibialis posticus to the tendo achilles. CHAPTER III OPERATION FOR PARTIAL AND TOTAL PARALYSIS ABOUT THE ANKLE 168. Astragalectomy and displacement of the foot backward for a flail or par- tially flail ankle or foot. 169. After-treatment. 170. Application of a plaster of Paris following an astragalectomy. 171. Operation for insertion of silk ligaments at the ankle. 172. Silk ligament operation at the ankle. Open method. 173. Silk ligament operation. Bradford's subcutaneous method. 174. Tendon fixation. Galli. 175. Tendon fixation for varus. 176. Tendon fixation for valgus. Dr. Galli's method. 177. Tendon fixation for calcaneous. Dr. Galli's method. CONTENTS xv 178. Fascia transplantation for toe drop. 179. Arthrodesis of the ankle for flail conditions at the ankle. CHAPTER IV INCISION, PUNCTURE AND ARTHROTOMY AT THE ANKLE 180. Arthrotomy. 181. Anterior external incision. 182. Posterior external incision. 183. Anterior internal incision. 184. Posterior internal incision. 185. Anterior median incision. 186. Circular incision for the exposure of the ankle joint. 187. Arthrotomy for fracture about the joints. 188. Osteotomy for deformity of the leg. 189. A method of treating overlapping fractures. 190. Fractures of long standing still ununited or united with deformity prevent- ing function. 191. Tapping at the ankle. CHAPTER V OPERATIVE TREATMENT IN CASES OF JOINT ANKYLOSIS 192. Arthroplasty for ankylosis of the tibio tarsal joint. 193. Arthroplasty operation. CHAPTER VI OPERATIONS IN SUPPURATIVE CONDITIONS OF THE FOOT AND ANKLE 194. Suppurative joint conditions about the ankle. 195. Disease of the oscalcis and tarsal bones. 196. Operation on the metatarsus and phalangeal bones and joints. 197. Operation in tuberculosis. 198. Osteomyelitis. 199. The Carrell-Dakin method. 200. Plastic operation for open wounds following osteomyelitis. 201. Methods and principles of drainage in acute non-tubercular suppurative joint disease. PART IV— SHOULDER CHAPTER I OPERATIONS FOR DISLOCATIONS AND DEFORMITIES 202. Manipulation of the shoulder joint to relieve contractures. 203. Operation to correct permanent inward rotation of the upper arm. 204. Osteotomy of the humerus to correct inward rotation of the shoulder. 205. Osteotomy for depressed acromium. 206. Muscle shortening. Operation for shortening the infra spinatus to correct inward rotation of the shoulder. xvi CONTENTS 207. Muscle lengthening to correct partial or total permanent inward rotation of the shoulder. 20S. Operation to correct inward rotation of the arm in obstetrical paralysis. Myotomy of the subscapulares and of the pectoralis muscles. Severe operation. 209. Operation to correct inward rotation of the arm in spastic paralysis. 210. Dislocation of the clavicle. 211. Partial dislocation of the shoulder due to paralysis, and in an obstetrical paralysis with or without depression of the acromion. 212. Partial dislocation of the shoulder in paralytic conditions. 213. Open operation in cases of irreducible dislocation of the shoulder. 214. Capsulorrahphy for dislocation of the shoulder. 215. Operation for recurrent dislocation of the shoulder. 216. Operation for congenital high position of the scapula or Sprengel's de- formity. 217. Application of plaster of Paris bandage for the shoulder. CHAPTER II MUSCLE AND TENDON OPERATIONS. MUSCLE AND TENDON TRANSPLANTATION 218. Operation for paralysis of the triceps, transplantation of the deltoid. 219. Operation for paralysis of the deltoid. Transplantation of the trapezius. 220. Operation for paralysis of the deltoid. Transplantation of the trapezius to part of the pectoralis major insertion. 221. Operation for paralysis of the deltoid. Pectoralis major transplantation. 222. Operation for paralysis of the biceps, transplantation of the triceps. CHAPTER III OPERATIONS IN PARTIAL AND TOTAL PARALYSIS ABOUT THE JOINT 223. Flail condition of the shoulder with partial or total dislocations of the shoulder due to paralysis. 224. Osteotomy for depressed acromion and capsulorrahphy. 225. Arthrodesis of the shoulder in paralytic conditions. 226. Bartow silk ligament at the shoulder in paralytic conditions. CHAPTER IV INCISION, PUNCTURE AND ARTHROTOMY 227. Arthrotomy. 228. Anterior incision. 229. Posterior incision. 230. Kocher incision. 231. Codman incision. 232. Fracture of the shoulder. 233. Fracture about the shoulder. 234. Arthrotomy for fractures about the shoulder joint. 235. A traction apparatus for fractures of the shoulder and the shaft of the humerus. 236. A method of treating overlapping fractures. CONTENTS xvii 237. Fractures of long standing still ununited or united with deformity prevent- ing function. 238. Tapping the shoulder joint. CHAPTER V OPERATIVE TREATMENT IN CASES OF JOINT ANKYLOSIS 239. Partial excision of the shoulder for ankylosis. 240. Excision of the shoulder to relieve ankylosis. 241. Arthroplasty for ankylosis of the shoulder. CHAPTER VI OPERATION IN SUPPURATIVE CONDITIONS 242. Osteomyelitis. 243. Suppurative conditions of the shoulder. 244. Excision of the shoulder in suppurative conditions. 245. Excision of the scapula in suppurative conditions. 246. Methods and principles of drainage in acute non-tubercular suppurative joint disease. Shoulder. PART V— ELBOW CHAPTER I OPERATION FOR DEFORMITIES AND DISLOCATION OF THE ELBOW 247. Dislocations of the elbow. 248. Manipulation of the elbow. 249. Plaster of Paris for the elbow. CHAPTER II MUSCLE AND TENDON OPERATIONS. MUSCLE AND TENDON TRANSPLANTATION 250. Transplantation of the triceps for paralysis of the biceps. (See also chap- ter on the shoulder and on the wrist.) CHAPTER III OPERATION IN CASES OF TOTAL OR PARTIAL PARALYSIS ABOUT THE ELBOW 251. Flail condition of the elbow. 252. Silk ligament at the elbow. 253. Fascia transplantation for flail conditions of the elbow. 254. Operation on the skin for a flail elbow. 255. Arthrodesis for a flail elbow. xviii CONTENTS CHAPTER IV INCISION, PUNCTURE, ARTHROTOMY AT THE ELBOW 256. Arthrotomy. 257. Posterior incision. 25S. External lateral incision. 259. Internal lateral incision. 260. Anterior incision for reaching the elbow joint. 261. Operations for fractures at the elbow. 262. A traction apparatus for fractures at the elbow. 263. A method of treating overlapping fractures. 26-4. Fractures of long standing still ununited or united with deformity prevent- ing function. 265. Irreducible dislocation and in multiple fractures of the elbow. 266. Overlapping fractures of both bones of the forearm. 267. Fracture of the olecranon. 268. Tapping the elbow joint. CHAPTER V ANKYLOSIS OF THE ELBOW 269. Excision or ankylosis for the elbow. 270. Synostosis at the elbow. 271. Arthroplasty for ankylosis at the elbow (general principles). 272. Arthroplasty for ankylosis of the elbow (technique). 273. Overhead sling for the arm following operation. CHAPTER VI OPERATION FOR SUPPURATIVE CONDITION 274. Suppurative conditions about the elbow. 275. Osteomyelitis. 276. Excision for suppuration. 277. Methods and principles of drainage in acute non-tubercular suppurative joint diseases. Elbow. PART VI— WRIST CHAPTER I DEFORMITIES AT THE WRIST 278. Operation for Madelung's deformity. 279. Club hand operation. 280. Contracted wrist and finger, operation. 281. Manipulation of the finger and wrist joints. CONTENTS xix CHAPTER II MUSCLE AND TENDON OPERATIONS. MUSCLE AND TENDON TRANSPLANTATION 282. Silk elongation for cut or short tendons. 283. Operation to give power to supinate the forearm in cases of paralysis of the supinators. Tubby operation. Transplantation of the pronator- radii-teres to give power of supination. 284. Transplantation in the forearm. 285. Operation for contracted or short extensors of the wrist and fingers. Ten- don lengthening. 286. Operation for contracted or short extensors of the wrist and fingers. Lengthening the muscles by a subperiosteal operation on the condyle. 287. Operation for contracted flexors of the wrist and fingers. Tendon length- ening. 288. Operation for contracted flexors of the wrist and fingers lengthening the muscles by a subperiosteal operation on the condyle. 289. Operation for shortening the long flexors of the wrist and fingers. Muscle and tendon shortening. 290. Operation for shortening the long extensor tendons of the wrist and fingers. Muscle and tendons shortening. 291. Operation for paralysis of the extensor longus pollicis or extensor longus digitorum. Transplantation of the palmaris longus. 292. Other transplantation in the forearm for paralysis of the extensor longus digitorum or the extensor longus pollicis. 293. Transplantations in the forearm for paralysis of the flexor longus digitorum ' and flexor longus pollicis. 294. Operation for paralysis of the flexor longus pollicis when the flexor carpi radialis is spared. 295. Operation for paralysis of the flexors of the wrist. Transplantation of the extensor carpi radialis and the flexor carpi ulnaris. 296. Nerve supply in the forearm. CHAPTER III INCISION, PUNCTURE AND ARTHROTOMT 297. Arthrotomy at the wrist. 298. Arthrotomy at the wrist. Ollier's incisions. 299. Posterior incision. 300. Arthrotomy at the wrist. Anterior incision. 301. Arthrotomy at the wrist. Radial incision. 302. Arthrotomy at the metacarpal and phalangeal joints. 303. Arthrotomy for fractures about the joints. 304. Fractures of long standing still ununited or united with deformity pre- venting function. ■ 305. Tapping the wrist joint. xx ' CONTENTS CHAPTER IV OPERATIVE TREATMENT IN CASES OF JOINT ANKYLOSIS 306. Arthroplasty. , 307. Arthroplasty in ankylosis of the wrist. 30S. Arthroplasty in ankylosis of the finger. CHAPTER V OPERATIONS IN SUPPURATIVE CONDITIONS 309. Suppurative conditions at the wrist. 310. Osteomyelitis near the wrist. 311. Excision of the wrist. 312. Operation for bone disease in the metacarpal or phalangeal bones or their joints. 313. Methods and principles of drainage in acute non-tubercular suppurative joint disease. PART VII CHAPTER I MISCELLANEOUS OPERATIONS 314. Torticollis operation. 315. Operation for tenosynovitis. 316. Bone grafting. 317. Operation on rachitic deformities. 318. Arthroplasty temperomaxillary joint. 319. Infantile paralysis. 320. Plastic operation on the spine for Potts disease. 321. Operation for obtaining ankylosis of the spine. Albee operation. 322. Operation for obtaining ankylosis of the spine. Hibbs operation. 323. The Carrell-Dakin technique for the treatment of suppurative cases, com- pound fractures, etc. CHAPTER II PLASTER AND BRACES 324. The application of plaster of Paris bandage. 325. Lacing a plaster of Paris. 326. Plaster of Paris bandage for the neck or the head, neck and thorax. Method of applying "Plaster Ropes." 327. A plaster of Paris jacket. 328. Plaster of Paris cuirass. 329. Plaster cuirass for the hip. 330. Plaster of Pars bandage for the hip. See also plaster cuirass for the hip and also congenital dislocation of the hip plaster. 331. Plaster of Paris for congenital dislocation of the hip. CONTENTS xxi 332. Application of a hip plaster of Paris after fasciotomy. Or after osteotomy of the hip or trochanter. 333. Retaining apparatus after operation on the hand. 334. Plaster of Paris bandage after operation on the knee. 335. The application of a plaster of Paris bandage after operation or manipula- tion of the knee. A simple method of preventing rotation of a leg plaster. Plaster holding the knee. 336. Plaster of Paris bandage after operation on the foot. 337. Application of plaster for varus, or equino varus. Club foot plaster. 338. Plaster of Paris bandage for valgus. 339. Plaster of Paris bandage after operation on the toes. CHAPTER III PREPARATION FOR OPERATION 340. Preparation of the skin for operation. 341. Preparation of the skin of the leg and foot for operation. 342. Preparation of the knee flexed at right angles for operation on the semilunar cartilage, etc. 343. Preparation of the skin of the arm for operation. 344. Preparation of the skin of the shoulder for operation. 345. Preparation of the skin of the elbow for operation. 346. Preparation of the skin of the hand and forearm for operation. 347. Preparation of the skin of the hip for operation. TECHNIQUE OF OPERATIONS ON THE BONES, JOINTS, MUSCLES AND TENDONS TECHNIQUE OF OPERATIONS PART I— HIP CHAPTER I OPERATIONS FOR CONGENITAL DISLOCATIONS AND DEFORMITIES OF THE HIP 1. Simple Manipulation for Congenital Dislocations of the Hip. — The manipulation of the hip for congenital dislocation of the hip where much force is necessary should never be done unless the patient has been walking on the leg at least three weeks. Where the manipulation is done in infants, if much force is required, it is better to wait until they can walk or creep satisfactorily. There is very much less chance of breaking the bone when it has been used in weight bearing for three weeks or more. For simple manipulation, the patient may be put lying on his face, the thigh over the side of the table. Pressure is put on the tro- chanter, with one hand the hip is flexed and gradually abducted with simultaneous pressure over the trochanter, pressing the head into the acetabulum. Second method The patient is placed on his back, assistants hold the pelvis by pressure on the anterior spines and pubic symphisis. The operator flexes the hip and abducts gently while he presses the trochanter upward, rotating the femur inward or outward as the case requires. When the head is in the acetabulum, the capsule and muscles should be stretched, forcing the head well into the socket until the femur can be brought parallel to a line passed through the anterior spines, and slightly beyond so that the knee will be above and posterior to it. When a dislocation of the hip is present, and the hip has been out for a long time and locomotion has been possible, the hip is often very difficult to replace. At times it will be necessary to do a fasciotomy at the hip (see section 9) to relieve the hip flexion and then reduce the hip. In difficult cases the Bradford congenital hip machine (see figures 1 to 3) will make the reduction possible or more simple. Whenever the surgeon. has a difficult case to reduce he should have this machine at hand. This apparatus is not effective in these cases because of traction, but in its varied methods of using leverage for reduction and after reduc- 1 TECHNIQUE OF OPERATIONS tion to assure a complete stretching of the capsule and other contracted tissues. Difficult cases that cannot ordinarily be relieved may be re- duced by this machine. Failing to reduce the hip by ordinary methods, the Bradford congenital hip machine is employed (see figures 1 to 3). 2. The use of Dr. Bradford's Congenital Hip Machine. — The patient is etherized and placed on his back on Dr. Bradford's congenital hip machine. The sacrum rests on the flat portion of the apparatus with the tuberosities of the ischii resting firmly against the up- rights. The pelvis is fixed by oval metal levers pressing on the anterior superior spines and pubic bone. The screws are tightened which hold these levers in place, firmly fixing the pelvis. While the patient is being placed in position, a legging is attached Fig. 1. Dr. Bradford's congenital hip ma- , ,1 r , t 11/ chine. A, Plate to be thumb screwed to a table, around the foot and ankle (pee B, Lever rod in position; used to press on the figures ep fig. 1). The traction trochanter and force it upward C, Lever rod. rod ( gee fig Ures dm fig. 1), is D, Traction rod. E, Traction legging, one for v f . j each leg. F, Perineum rods. H, rods to hold next placed in position and ex- iiium. J, Screw clamp to fasten to table, tension applied (see figure 3). L"^^^":^^ The hip is stretched in adduc- legging. N, S-hook to close the chain. P, Rings tion and hyperextension and in legging through which chain passes. S, The then in hyperextension and ab- holes to receive traction rods. j , • t~v • j.i_ i_ j. duction. During the hyperexten- sion and adduction, the surgeon rotates in and rotates out while the traction is in force. The joint is gently stretched and laxed, the operator applying force in a gradually increasing manner until con- siderable force is used and finally re- laxed entirely. In this manner a rhythmic application of force is kept up. No rough or forcible extension without a gradually increasing or gradually decreasing force should be Fig. 2. Patient on Bradford Con- emnloved Bv this method a mini- genital Hip machine - Dr - Bradford's empioyea. r»y mis mewioa a mini congenital hip mac hine (Front view). mum amount of trauma is caused. F. Perineum rods. H, Rods to hold ilium. A joint that at first will seem almost S - Holes for traction rods. J, Screw ., , , .n j.. . clamp to fasten to table. impossible to move will often give way and stretch down. Where the muscles are hard and firm it is an advantage not to overstretch as they all are useful in main- taining the hip in the acetabulum. When the lever (see figure c, fig. 1), is placed under the trochanter with the leg extended, the leg is gently abducted and the surgeon uses the lever to lift the head into place re- OPERATIONS FOR CONGENITAL DISLOCATIONS 3 during the application of traction. Sometimes this is sufficient for re- duction. As soon as the head is lifted over the rim of the acetabulum, the traction is removed. The operator flexes the hip in slight adduction, places the lever snugly under the trochanter, abducts and gently rotates in and out. As the head slides over the edge of the acetabulum more abduction is made, increasing the force as the operator assures him- self that the head is over the rim. Stretching should be continued until the capsule has been thoroughly pulled out and the head comes forward, filling the space under the artery. When the lever is in posi- tion holding the trochanter well forward the femur should be flexed and abducted, the line of the femur forced back so that the knee will be posterior to a line drawn through the anterior spines, and abducted above it (see figure 4). When dealing with marked anterior position of the neck it is often necessary to use the lever, not under the trochanter, but above it, press- ing the head downward, traction being applied at the same time that the lever is being used. During the application of plaster the position should be maintained by a skilled assistant in order that a dislocation at this time will be im- Fig. 3. Traction applied. H, Rods to hold ilium. F, Perineum rods. S, Hole for traction rod. D, Traction rod. E, Traction legging. The leg may be abducted hyperextended flexed or adducted and traction applied in the same way. possible. The plaster should include the pelvis, re-enforced in front and behind, holding firmly the tuberosity of the ischium and the great tro- chanter of the leg operated on. It should fit the thigh and leg and foot (see figures 12 to 14). The plaster is bivalved, which will allow the front to be removed easily for inspection of the leg. The patient is placed on a Bradford frame (see figures 8 to 11) , which makes it easy to move and carry him. The Bradford frame is elevated from the bed if the patient is put up in the Mueller position. Whether the Lorenz or modified frog position is used or the Mueller de- pends on the operator who will select the more stable position for the indi- vidual case. If possible the Mueller position should be adopted. With it inward rotation of the hip as seen in figures 13, 14 is obtained at the time of the operation, while with the Lorenz position, the hip is outwardly ro- tated and must be inwardly rotated during the convalescence. Dr. Brad- Fig. 4. A, A line connecting the an- terior spines looking at the patient from above. B, The abducted position of the femur with reference to the line A. C, A line connecting the anterior spines viewed from in front of the perineum. D, The line of the femur below the horizontal when the knee is depressed. TECHNIQUE OF OPERATIONS Fie 5. Plaster of Paris bandage ap- plied for double congenital dislocation of the hip, Lorenz position. A, Shows the plaster re-enforcement in front over the pubic bone, the re-enforcement is flat- tened in a plane at right angles to that at AA (see figure 6) . ford's machine- for the reduction of congenital hip has made it possible to reduce so many hips which otherwise would have to remain out that it has been found necessary to develop an after treatment especially adapted to difficult cases; difficult because they could not be reduced or difficult because they would not remain re- duced. 3. Post Operative Treatment. — The plaster is left in position for two months. At the end of one or two weeks an x-ray is taken to see the exact position of the hip. The front half of the plaster is removed for this purpose on the x-ray table. The patient remains on the Brad- ford frame. The front of the plaster is replaced and the patient put back to bed. After eight or ten weeks the plaster is cut away below the knee,, allowing the pa- tient to move the knee and ankle. At the end of the twelfth week, the front of the plaster is removed for a short time twice a day and the patient encouraged to kick the leg and lift the knee. The time is extended as the patient improves, until the patient is kicking the leg for about six or eight hours a day. As the muscles are seen to be strong, the patient is allowed to creep on the floor for twenty minutes twice a day with the front and back of the plaster firmly fastened. This time is gradually increased until the patient creeps six or eight hours a day. When the patient has been crawling with the plaster on for four hours a day and can do so fairly vig- orously, in renewing the plaster the leg is allowed to adduct as much as it will. When the muscles are not strong any renewal of the plaster should maintain the original abducted position. At the end of the fifth or seventh month the patient is allowed to creep without the plaster. The plas- ter is always re-applied at night until ,, .. . . i, A , ,i i c Fig. 8. Posterior view of Bradford the patient is well. At the end of frame showing lacing of c i oth on frame the ninth Or tenth month, the and opening for use of bed pan. Fig. 6. Shows the bridge like appearance of the plaster re-enforcement over the pubic bone as viewed from the front. Fig. 7. Posterior view in Muel ler position. A, Plaster re-enforce ment over the sacrum. ?<-?<. S 3f OPERATIONS FOR CONGENITAL DISLOCATIONS Fig. 9. Bradford frame. Showing method of elevating the frame by iron hooks to the head and foot of the bed. Fig. 10. Bradford frame elevated on boxes. patient is allowed to stand and walk for the first time. Then the hips will be found to be strong, evenly de- veloped and resistant to dislocation by any slight falls. The patient should be seen once a month for the following six months. After that once in three or four months until locomotion is perfect. With this form of after treatment the hips are not likely to dislocate. The muscles are firm and strong and the patient healthy. It has been found more advantageous than that form of after treatment which allows the patient to walk and bring the legs down by successive plasters. There is no danger of stiffness for motion is started early. There is almost no danger of disloca- tion as the muscles are made strong from the start and they all tend to hold the head in the acetabulum. In very strong patients, the abduc- tors and tissues on the outer side and above the femur will resist the adduc- tion and make walking awkward, sometimes for two Or three months. Fig. ll. Lorenz position in plaster Gentle stretching and massage are of vie wed from above the bed, the feet j . . ,1 • , • rro. ar id sacrum touch the bed. advantage at this time. There is no disadvantage in 'this provided there is good motion at the hip. These cases are less apt to dislocate than the ones which adduct readily. The ^!^______^ cases that adduct readily are the ones •n~^--2=====r, J C/ ^F wn ^ cn s ^ould be watched carefully. In *~~- ^ > """ both types of cases the walking becomes Jttis&szStoSx. nor r, 1 s radua " y - There is often a ro11 The plaster is split so that the front or slight limp when the patient is tired, half may be removed and replaced. The original position in plaster is main- tained until the muscles are strong and the patient is crawling at least four hours a day with the plaster on. When the patient can crawl vigorously, in renewing the plaster the leg is allowed to adduct as much as it will and a fresh plaster is applied with the leg adducted. If the leg will adduct completely it should be put up in an abducted position of fifteen ^ ste r T ^ e e ^ + iT ™j}°Zt *t! degrees. If the muscles are not strong in abducted. Mueller position in TECHNIQUE OF OPERATIONS reapplying the plaster the original position of abduction to ninety de- grees should be maintained. After six months, in renewing the plaster the leg may be allowed to come down straight if it will. The above method of after treat- ment has been used about eight years. It was developed at first by the writer for those cases that it was not pos- sible to successfully reduce without a machine for reduction, either be- cause they redislocated and showed no permanency of result or because they were too difficult to replace by hand or by hand assisted by a traction apparatus. In many, the detail of the after treatment Fig. 14. Mueller position in plaster viewed from the foot of the bed. The plaster is split so that the front may be removed and replaced. Fig. 15. Manipulation of the hip in the prone position. as described was the important factor in obtaining a permanent result. This treatment was adopted at first only for the difficult cases; now it is used by us for all cases. Among the early cases, three were put through this method of after treatment. The course was shortened to three months. They were all running about on their legs in that time. One dislocated. Time enough had not been allowed for shorten- ing of the capsule and growth of the bone. For this reason the time was extended to nine or ten months before allowing the patient to stand. The legs are stronger, less apt to dislocate and there is no stiffness. In the poliomyelitis case or paralytic dislocation the mus- cles are usually weak or en- tirely paralyzed, making it j. necessary m the majority of an d hyperextension. Fig. 16. Manipulation of the hip. Rotation out and hyperextension. OPERATIONS FOR CONGENITAL DISLOCATIONS 7 cases either to do an open operation and fasten the hip in the joint after reduction as above described or to do an arthrodesis at the hip in order to make it useful for weight bearing. When there is a great deal of twist in the neck of the femur, an os- teotomy of the neck or of the femur will relieve the twist. From experience it has been found that it is rarely necessary in younger cases to perform an osteotomy in thoroughly reduced heads where the after treatment is thorough. The torsion in time disappears. The twist in the neck forward will not interfere with the reduction but when it is present the surgeon should force the head well into the ace- tabulum and stretch the capsule completely so that it fits well around the head. 4. Open Operation for Dislocation of the Hip. — The open method for treatment of dislocation of the hip is adopted for the hip which otherwise could not be reduced or for the hip which will not remain reduced. After following the above method of treatment, when it is impossible to reduce a dislocation of the hip or when it will not remain in the socket after careful reduction and after treatment, an operation by incision becomes indicated. OPERATION Before preparing the skin for operation, the Bradford congenital hip machine is used and the hip reduced as described above. After cleansing and sterilizing the skin, sterile sheets should be placed around the leg in such a way that it may be manipulated in any position by an assistant. The operator stands outside of the leg to be operated on. An incision is made from the anterior superior spine to the upper edge of the great trochanter and then down along its anterior border. Other incisions may be preferred (see Arthrotomy at the Hip). The fascia lata and tensor fasciae femoris is retracted and the gluteus minimus removed from its insertion on the great trochanter and retracted upward and back- ward. The leg is forcibly abducted and outwardly rotated. The capsule is incised from above downward and from within outward, parallel to its fibers. The incision is carried down from the anterior inferior spine to the intra trochanteric line. The hip is reduced by flexing in adduc- tion, then outward rotation or inward rotation in abduction. A sterilized lever is placed under the trochanter and all resisting tissues are separated while the head is forced into place. If necessary the head is brought out into the wound and the acetabulum and head inspected. Any con- strictions of the capsule are cut, dividing them in a line with their fibers. After placing the head in the acetabulum, the capsule is shortened by mattress sutures made with heavy silk number fourteen or number sixteen or eighteen. The deep tissues are brought together with inter- rupted chromic catgut sutures number 00, the superficial tissues with interrupted chromic catgut sutures number 00, the skin with continuous 8 TECHNIQUE OF OPERATIONS chromic catgut sutures number 00. The hip is held in position by means of a plaster of Paris bandage in either a Mueller or Lorenz position (see figures 11 to 14), as described above. The after treatment varies in no way from that for congenital hip dislocation as described above. 5. Plaster of Paris for Congenital Dislocation of the Hip. — Follow- ing the operation for congenital dislocation of the hip a plaster of Paris bandage is applied as follows: stockinet or other suitable covering is applied to the pelvis and legs. Felt pads are applied over the anterior spines, over the top of the trochanter, under the sacrum and over the internal condyles of the femur. A well fitting plaster is then applied over the thighs and pelvis for a double case; or in a simple case over one thigh, with a few turns over the other, to prevent the pelvic portion from slipping up. Heavy plaster re-enforcement or plaster ropes are placed in front over the pelvic bone (see figures 5, 6, 7), along each thigh in front to prevent the breaking near the anterior spine. A similar re- enforcement is placed behind it on the sacrum and down the back of the thigh (see figures 6, 7). More plaster bandages are used to bind this re-enforcement to the rest of the plaster. The thigh of the dislocated hip or hips should be parallel to a line connecting the anterior superior spines and if possible the knees should be above this line and posterior to it. This will show good over-correction. The plaster should pull the trochanter down and hold it firmly. The tuberosity of the ischium should be held firmly and be well padded when the part of the plaster, including the pelvis and thigh and knee is harden- ing. Padding is applied to the lower leg and foot and the plaster con- tinued downward, the foot is held at right angles. It is important to maintain the desired position of the thigh and have the plaster harden immediately maintaining the Mueller or Lorenz posi- tion while completing the plaster down to the foot. The plaster should be split into an anterior and posterior half as shown in figures 12, 14, and laced as shown in figures 460 to 464. CHAPTER IJ. ! muscle transplantations: muscle and tendon operations about THE HIP 6. Operation for Manipulation of the Hip. Hip Flexion Due to Contracted Soft Tissues. — Hip contracture due to a short tensor fasciae femoris may be relieved when very slight by multiple subcuta- neous tenotomies of the fascia lata and sometimes by manipulation. Under ansesthesia the patient lying on his abdomen on a low table or couch (see figure 15), the operator holds the leg at the knee, another assistant presses with both hands over the buttock. The operator adducts (figure 16) the leg and hyperextencls. He combines the hyper- extension (figures 16, 17,) with inward rotation and with outward rotation alternately. The patient lying on his abdomen, the stretching may be varied by elevating the knee on hard pillows until the pelvis is well off of the table, the assistant pressing down on the buttock will stretch the resistant tissues at the hip. The patient lying on his back flexion abduction and rotation and a combination of these motions are used to limber the hip. Most of these cases of hip flexion even when they seem slight are difficult to correct, for it is almost impossible to prevent the tilting of the pelvis and curving of the lumbo sacral spine. For this reason the operator should be ready to do a fasciotomy when a simple manipulation has failed. If the patient is not very strong the fasciotomy should be resorted to at once as it is much shorter than a difficult manipulation at the hip. There is less damage and trauma and no shock when done quickly, see Fasciotomy, described elsewhere. 7. Manipulation of the Hip under an Anaesthetic for Flexion, Adduc- tion and Abduction Deformities. — If there is bony ankylosis it is useless to attempt manipulation; if the limitation of motion is in the capsule and the other soft parts, the result of manipulation is often very satisfactory. If the limitation of motion is considerable and of long standing, the muscles will often need to be lengthened as described in these pages under tendon or muscle lengthening, tenotomy, fasciotomy, etc. In addition to the muscle lengthening the joint capsule will need stretching; this can be done by manipulation. See also sections 36, 37. Manipulation of the joint is contra indicated if there has been tubercu- losis of the joint or recent disease. Manipulation is very apt to stir up the disease and in tuberculosis may even cause meningitis. When there has been no disease present for at least a year, it is safe to manipulate carefully. At the hip no great amount of force should be used if the limb has not been weight bearing for some time. The bone that has not 9 10 TECHNIQUE OF OPERATIONS borne weight is brittle and will easily fracture. If, in the x-ray, the head and neck and shaft show good heavy bone and weight bearing has been constant the danger of fracture will be diminished. Under anaesthesia the patient lying on his back, the operator adducts the hip as far as it will go, he then gently stretches and relaxes as it adducts further. This may be combined with inward rotation and then with outward rotation. After working in this manner to increase the adduction, he abducts the hip as far as it will go and then gently stretches and relaxes as he abducts further. This should be combined with rotation in and rotation out. The pelvis should be fixed by apparatus, a traction apparatus with a pull on both legs is a very satisfactory method of holding the pelvis. Assistants may hold the pelvis with their hands flexing the other thigh as far as it will go. Roughness should be avoided as it will cause unnecessary trauma and will give unnecessary pain and swelling after operation. The hip is next flexed forty-five degrees and rotated in and out as far as it will go and then stretched gently in inward and in outward rotation. This is repeated with the patient lying on his abdomen. The rotation should not be forced beyond thirty-five degrees. The adduction to thirty degrees, the abduction to forty-five degrees. The flexion to about ninety degrees and if it is difficult, even less. Abduction, flexion and hyperextension of twenty degrees, free and easy, are the motions that are the most useful. The operator should not attempt too much; if the hip will yield this much in difficult cases it is often possible to get other motions and more of these by gentle exercise in the after treat- ment provided the motion obtained is free and easy. To obtain a great radius of motion under anaesthesia and cause a great deal of trauma will net very little motion as an end result. The operator should content himself with the important motions and obtain these and the others as far as he can by gentle stretching and relaxing. It is surprising the amount that can be obtained by persistent stretch- ing in the different directions rather than by the use of overbearing force. While the patient lies on his abdomen, the hip is manipulated to in- crease the hyperextension by flexing the knee and by hyperextending the hip in adduction as well by hyperextending it in abduction. These motions are combined alternately with inward and with outward rota- tion. Traction is applied in bed following the manipulation. As the signs of local reaction subside the traction is gradually omitted and the patient gotten up walking on the other leg and swinging the manipulated leg ; exercise in bed should be done six or eight times a clay. As the leg acquires strength weight bearing is begun four to six steps, six or eight times a day and increased not too rapidly but as the local strength and reaction allows. If the patient has a little motion in all direc- tions these may be materially increased, especially in patients under forty. MUSCLE TRANSPLANTATIONS 11 8. Fasciotomy at the Hip. Transplantation of the Hip Flexors at the Ilium.* — The patient lies on his back. The skin preparation is made from the middle line of the abdomen in front, backward to the middle line behind, and around the whole leg to the knee. The leg is then enveloped in a sterile sheet up to the groin so that it may be manipulated during the operation. The operation is not one that involves any shock to the patient. It is indicated wherever the soft Fig. 18. Fasciotomy; transplantation of the hip flexors, line of incision. Fig. 19. Fasciotomy; transplantation of the hip flexors, incision of the tensor fascia femoris. tissues are contracted causing the back to arch when the patient stands. Such cases are often prevented from walking on account of the hip deformity which may be single or double. Cases with com- plete paralysis below the hips can be made to walk with apparatus if the arms are good enough to use crutches. With contracted hips it is additionally difficult or impossible. In these cases it is advisable to do the fasciotomy and allow the hips to be fully extended. OPERATION An incision is made parallel to the line of the femur one and one-half inches posterior to the anterior superior spine (see figure 18) extending two inches above and two inches below it. The subcutaneous tissues are dissected up and retracted throughout the length of the incision exposing the tough fibers of the fascia lata extending from the anterior superior spine to the top of the great trochanter (see figure 19). These fibers are incised from the anterior superior spine to the great trochanter (see figure 19). The dissection up to the present has been practically free from any but very superficial bleeding. A few of the superficial fibers of the underlying muscles are cut across. The anterior flap is- next retracted exposing the anterior superior spine (see figure 20). An osteotome is placed over the anterior superior spine and splits the periosteum, peeling it away from the crest, extending two inches back- ward to the inner and outer side. The osteotome is used to clear the top of the anterior superior spine of periosteum which peels readily from the sides of the crest. The periosteum is removed downward to below the anterior inferior spine (see figures 21, 22, 23). There is a little oozing from the periosteum but no bleeding if the surgeon is careful to keep the osteotome on the bone under the periosteum. When the crest has been cleared on both sides and below the anterior superior * Soutter operation. 12 TECHNIQUE OF OPERATIONS spine, a sponge may be used to push all of the soft tissues downward toward the knee. When this has been accomplished the patient is turned slightly on the other side, a sterile towel folded twice is placed over the buttock and the hip hyperextended, the finger of the operator in the wound pressing down the deep and superficial fibers which are found resistant. Very often the fascia, which is continuous with the abdominal fascia, is very much toughened and resists the hyperextension of the hip. When the hip has been satis- factorily hyperextended, the su- perficial fat which has not been Fig. 20. Fasciotomy; transplantation of Separated fl'Om the skill flap, is the hip flexors, subperiosteal removal of the drawn over the crest of the ilium tissues from the anterior and inferior spines, „ j „„< , • • -ji ■ . A 1 also from the sides of the erest of the ilium. and anterior spine with interrupted chromic catgut number 00. Only the fat and skin are sutured. When the operation is performed with an osteotome, in the manner described above, there is rarely any bleeding. It is very important in the after treatment that the head, shoulders and buttocks should rest on a level, being held in this way on a Bradford frame (see figures 24, 9, 10). The legs are hy- perextended backward below the frame. This position is more comfortably maintained by means of plaster of Paris ap- paratus extending from the nip- ple line tO the toes anteriorly, hip flexors, the tissues from the anterior superior and fl'Om the tOD of the Sa- s P me an< ^ below it pushed downward allowing , , , , L . . , , the leg to be lowered without causing lordosis. crum to the heels posteriorly (see figures 25 to 27). A large window should be cut over the abdomen from the ensiform to a little above the pubic bone. The plaster is re-enforced for this purpose as shown by the lines drawn on figures 28, 29. This position is maintained eight weeks. The patient is then gotten up gradually and encouraged to walk with a short light plaster and crutches. Later braces if necessary are applied and the hyperextended position used for two or three hours a day only. Fig. 22. Fasciotomy; transplantation of the A plaster shell and a Bradford hip flexors, the crest of the ilium exposed lat- f ra me is USed during the hours of hyperextension; this makes it possible to obtain the correct position each time (see figure 24). It is possible with this operation to relieve right angle contractures due to soft tissues. W T hen a partial or fibrinous ankylosis of the hip exists in connection with right angle flexion, this operation for relieving the soft tissues greatly simplifies the hip operation. In cases that have not walked for a long time on an ankylosed hip, there is great danger MUSCLE TRANSPLANTATIONS 13 of breaking the neck of the femur, during manipulation, the contracted soft tissues acting as a bow-string during manipulation. If on the other hand these are relieved by this operation, the hip joint may be manipulated or operated on more freely. In chronic conditions whether paralytic or not where the sitting or flexed hip position has been maintained over a long period of time, the flexion is difficult to overcome even by operative measures, for while we may hold the femur, it is almost impos- V / sible to hold the pelvis and spine from tilting forward j during the process of over correction. A flexed knee may be manip- ulated easily for it is possible to grip the tibia Fig. 23. Fasciot- omy ; transplantation of the hip flexors, showing the separa- tion of tissues. An- terior view, notice the separation of the periosteum from the bone. Fig. 24. Position of the patient on a Bradford frame after transplantation of the flexors at the ilium. Soutter operation. The hip operated on must be hy- perextended and adducted. and the femur. At the hip it is another matter; the pelvis is difficult to hold. This operation has been found of great value and the deformity is not apt to recur, for the length- ening of the muscles is definite and permanent. They are not cut across ; they retain their func- tion, reattaching themselves lower down. 9. Fasciotomy to Relieve Flex- ion and Abduction of the Hip. — See also sections 36, 37. When there is contraction of the hip flexors there is usually a short tensor fascia femoris which gives an abducted position of the hip. This is a common deformity in poliomyelitis. In spastic conditions and in cer- tain arthritic conditions when the FlG- 2 5. Posterior muscles shorten after long periods view of a plaster to view of a plaster to of contraction due to the disease hold both hips - hold both ^p 3 - or spasm, the adductors are more commonly shortened with the flexors. For this reason in spastic paralysis in addition to doing a fasciotomy or transplantation of the upper attachment of the flexors of the hip, it is necessary to do a myotomy of the adductors or of the inner hamstrings or both. 14 TECHNIQUE OF OPERATIONS r "When the position of hip flexion is due to old hip disease or arthritis, the adductors are usually short as well as the flexors of the hip. In this type of case there may be hip ankylosis either fibrous or bony. In relieving the attachment of the flexors at the ilium and transplant- ing them downward as described above, the adductors may be my'otom- ized or lengthened and the bone or joint deformity relieved at the same time. Each of these conditions is described under manipulation of the hip; osteotomy at the hip, sub- trochanteric osteotomy, myotomy, muscle and tendon lengthening and fasciotomy at the hip. See also sec- tions 36, 37. 10. Application of a Hip Plaster of Paris Bandage after Fasciotomy, or after Osteotomy at the Hip or Trochanter. — It may be as well to go into more de- tail as to the application of plaster. A loose ill-fitting plaster does not hold the patient or the bone. The sheet wadding should fit the leg snugly and the body perfectly. After the appli- cation, the outlines of the patient should be distinct and shapely. A pad of heavy felt is placed over the sacrum, another one over each anterior spine. A thin layer of felt covers the chest from the posterior Fig. 27. Side view axillary line laterally and of a plaster to hold rea ching down to the lower both hips. Notice , P .-. ., ml , . the opening over the edge of the ribs. The sheet abdomen and above wadding should be applied lavishly but firmly all over the patient but it should fit snugly. A large thick felt pad is placed over the tu- berosity of the ischium and the perineum of the affected side (see figures lines where the plaster should 30, 31). A long rope of plaster is first applied be re " enforced - Front view - over this felt, holding the felt against the tuberosity of the ischium. This plaster rope should be long enough to extend to the axilla in front and to the axilla behind (see figure 32). Its ends are held by a nurse during the application of the plaster around the back of the patient over the ropes (see figures 58 to 61) . This plaster rope should be used after os- teotomy or fractures at the hip. It is not necessary in simple correction the pelvis behind. After transplanta- tion of the hip flex- ors, this plaster is ap- plied with the hips hyperextended. Fig. 28. Plaster of Paris for both hips, showing by MUSCLE TRANSPLANTATIONS 15 of hip deformity. The plaster is then applied to the leg as far as the knee, the knee being well padded with felt in addition to the sheet wadding. The plaster should then be reinforced heavily in the front of the leg and hip, again over the pubic bone and front of the leg, again on the front up to the nipple. Additional reinforcement should be made on the side of the leg well posterior and extends up the side of the thorax. In a heavy person, each of these reinforcements should be one inch thick and two inches wide (see figures 28, 29) . Further reinforcement of the plaster is Fig. 30. Method of applying a plas- ter rope to the tuberosity of the ischium. (Note plaster rope X over felt padding. This is used to prevent a hip plaster from sliding upward. (See figure 31.) Fig. 29. Side view of plaster for both hips, showing by lines where the plas- ter should be re-en- forced. Fig. 31. Shows the plaster rope turned back and buried in the plaster. Fig. 32. Showing the plaster rope cov- ered with the rest of the plaster. made across the front of the chest, the sides of the abdomen and over the pubis (see figures 28) . The plaster is finished rapidly down from the axilla to the knee on the affected side and down about six inches on the opposite thigh. As soon "as the plaster has hardened the traction is removed gently from each leg. Sheet wadding is applied around the foot and ankle of the affected side and the plaster is completed from the toes to the knee. The plaster is cut out over the abdomen and behind as high as the lower end of the sacrum. The pelvic portion should be made very heavy. The patient should lie in bed with the buttocks rest- ing on the bed and the operated leg off of the side of the bed in order to 10 TECHNIQUE OF OPERATIONS maintain the hyperext ended position of the hip (see figure 24), unless he is placed on a Bradford frame held above the bed. If there is too much pressure on the chest, the leg is lowered. In this way there is no danger of loosing the hyperextended position of the leg. Plaster should be split, "bi-valved," on both sides of the leg and foot and tied with a wet gauze bandage or strapped with webbing straps or adhesive plaster. It is often necessary to use sedatives for the first five days, when the correction has been considerable. They should be given rather than withheld for pain or restlessness. After five days a well padded plaster will be perfectly comfortable. The patient lies on his back for five weeks and then is sat up in the original plaster. In sitting the good leg is flexed, the other reaches over the edge of the bed. At the end of the sixth or seventh week the patient is stood up a little at a time and finally at the end of the eighth or ninth week he walks on the good leg with crutches and assistance. The plaster is cut so that the knee por- tion may be removed posteriorly and allow a little motion here. When he is able to stand without showing any weakness, the plaster is re- moved and a light fresh plaster applied with the patient standing and holding on to his crutches. This position is preferable to one lying down when the plaster is to be used for locomotion. CHAPTER III OTHER OPERATIONS IN CASES OF PARTIAL OR TOTAL PARALYSIS ABOUT THE HIP 11. Operation for Partial or Total Paralysis of the Hip Muscles. Flail Hip. — When there is a total paralysis of the hip muscles, very extensive apparatus is necessary unless some operation can be done to insure the stability at the hip. An arthrodesis between the head and acetabulum or between the inner side of the trochanter and the pelvis and acetabulum may be done. The latter is preferable. No arthrodesis should be advised in small children and care should be taken not to injure the epiphysis in older children. An arthrodesis of the hip is very satisfactory. To obtain union, the operation requires some care. The inner side of the trochanter previously denuded is more apt to give good ankylosis than an attempted arthrodesis between the head and acetab- ulum. In extensive paralysis the bone repair is poor on account of the weak impoverished condition; the larger surface makes the union more probable. The operation is an easy one on account of the few muscle fibers in paralytic cases. After operation the hip should be pro- tected until weight bearing is satisfactory. Where the paralysis is partial, silk ligaments may be applied as described below to balance the strong muscles. When the paralysis is extensive they are not useful. 12. Operation for Arthrodesis of the Hip in Paralytic and in Osteo- Arthritic Conditions. — For a flail hip or a dislocated flail hip an arthro- desis is often done in order to make apparatus unnecessary. In osteo- arthritis it is done to relieve pain. See section 40. See figures 62-64. An incision is made, starting from the anterior superior spine and extending downward to the upper edge of the great trochanter and then down along its anterior border. Other incisions may be used (see Arthrotomy at the Hip). The tensor fascia femoris is separated from the gluteus minimus. The latter is detached from its insertion on the great trochanter. The leg is forcibly abducted. The capsule is incised from above downward and from within outward, parallel to its fibers. The incision is carried from close to the anterior inferior spine to the intra trochanteric line. The head is brought out into the wound and the acetabulum and head inspected. The capsule is removed at its distal attachment to the neck and trochanter by slowly rotating the hip inward and then outward. Three or four strands of heavy silk are placed in the detached edges of the tough capsular fibers, each strand quilted in and out of the capsule, two long ends for each strand. These are clamped and reattached later to the femur. The operator may now 17 18 TECHNIQUE OF OPERATIONS either denude the acetabulum of articular cartilage and the head of the femur likewise; or the acetabulum above and below is chiseled, making a long surface of denuded bone ready to receive the inner side of the denuded trochanter. Should the latter method be adopted, the head and neck of the femur are removed and a vertical wedge removed from the inner side of the femur, shaped to give abduction. This wedge may be one-half or three-fourths of an inch thick at the top and taper- ing to a sliver below. The exposed bone on the inner side of the femur should fit the denuded pelvic bone intimately. The operator should note the position of the patella in order to keep the femur in the proper position during the removal and fitting of the bony surfaces. The capsule of the joint having been partly saved, the four pair of heavy silk strands previously quilted into the capsule are now utilized and fasten the femur snugly to the pelvis, the muscles are brought tightly over this with kan- garoo tendon or double chromic catgut sutures number one, the skin with continuous chromic catgut suture number 00. A small gauze pad is placed over the wound, then sterile sheet wadding. A nail or a bone peg may be used to hold the trochanter to the pelvis. The plaster and after treatment is the same as that described follow- ing osteotomy of the femur for hip flexion. When an arthrodesis at the hip is done on account of muscular paral- ysis, if the abductors and the adductors are still strong, it is necessary often to lengthen or tenotomize or do a myotomy of these muscles de- pending on their condition. 13. Silk Ligaments at the Hip for Paralysis of the Abductors. — When the adductors are unopposed, walking is often very difficult in paralytic condition. An arthrodesis or silk ligament may be used to make apparatus unnecessary. The patient lies on his back, cushions or sand bags are placed under the buttock of the affected side holding the patient firmly and giving access to the posterior superior spine and allowing manipulation of the hip. Where the abductors of the hip are completely paralyzed and a flail condition of the hip is present, silk ligaments are placed from the crest of the ilium to the great trochanter. Incisions are made two inches long over the crest of the ilium and at right angles to it (see figure 33), at about ten different points. The bone is drilled, double strands of heavy braided silk number eighteen are inserted and looped through the crest of the ilium (see figure 34). Two strands will come from each insertion. Another incision is made vertically over the great trochanter extending one inch above and three inches downward over this bone. The eight or ten double silk strands which have been attached to the crest of the ilium are brought down by a tendon carrier, subcutaneously to the great trochanter. These strands are quilted into the fibrous tissues overlying the trochanter or the bone is drilled and . these silk strands inserted into three or four OTHER OPERATIONS IN PARALYSIS ABOUT THE HIP 19 drill holes and tied. Before these strands are tied, the leg should be abducted slightly in order to give good leverage to the strands and prevent adduction. The operator should notice the position of the patella and of the anterior spines, adjusting the leg according to these landmarks and tying the strands separately to maintain the desired position. In sitting, the patient abducts the leg slightly. If the leg is shorter than the other it should be held by the silk in a few more de- grees of abduction than if the legs were equal. The leg should be ab- ducted ten degrees more than the desired position in abduction; the degree depends on the amount of shortening. The deep tissues are Fig. 33. — Points of incision for silk ligaments at the hip. Lange. A, Crest incision. B, Trochanter incision. Fig. 34. — Silk ligaments applied in partial flail condi- tion of the hip, from the ilium to the trochanter. brought together with interrupted chromic catgut sutures number 00, the subcutaneous fat with interrupted chromic catgut sutures number 00. A plaster of Paris spica is applied from the nipple line (see figures 28, 29) down to the toes, maintaining the position of the hip with no strain on the ligaments for four or five months. After that time slight strains are allowed by removing the plaster for short in- tervals twice a day, gradually increasing as the case allows. The plaster of Paris bandage and apparatus, length of bed treatment, and other treatment is the same as that described after osteotomy for hip flexion. A leather spica may be substituted for the plaster after eight weeks. CHAPTER IV INCISION, PUNCTURE, ARTHROTOMY AT THE HIP 14. Exposure of the Ilium. Sprengel's Incision. — Sprengel's incision at the hip may be used for reaching the ilium in case of fracture or disease. The patient lies on the opposite side from that to be operated on. An incision is made along the crest of the ilium starting at the posterior superior spine extending forward to the anterior superior spine (see figure 35). All of the muscles are detached subperiosteally and peeled off of the crest. This incision is joined at its middle by a vertical one ex- tending down to the top of the great tro- chanter. The skin, fat, fascia, muscle and periosteum are all lifted in one layer and retracted downward and anteriorly and posteriorly from the bone, exposing the ilium and its crest. By means of a sharp osteotome the periosteum may be lifted from the inner side of the crest and expose the inner surface of the ilium. 15. Exposure of the Sacro-Iliac Joint. — To expose the sacro-iliac joint for disease, a curved incision is made, two or four inches forward of the posterior superior spine of the ilium and extending along the crest of the ilium backward and curving down- ward along the border of the sacrum (figure 36). A skin incision made extending one inch external to the border of the sacrum -Sprengel's incision -n 1 rj.uij.i- 1 along the crest of the ilium with a will be more comfortable to he on when vertical portion from its middle healing and will give as good exposure when down to the top of the trochanter. re tracted. If the surgeon prefers he may use a curved incision extending from a point one inch external to the third or fourth lumbar spinous process curving outward beyond the posterior spine of the ilium on the affected side and downward to the top of the coccyx. The incision is carried through the skin and fat in one layer. The flap is dissected back, exposing the fascia. The out- line of the sacrum is easily made out and the dissection continued as indicated. In disease of the bone in the sacro-iliac region the abscess may extend over the front of the sacrum as well as the side. It should be wiped out with gauze strips and the carious bone removed; small bits being 20 INCISION, PUNCTURE, ARTHROTOMY AT THE HIP 21 removed at a time. Tubes are placed from the surface to all the de- pendant portions; gauze is used to keep the soft tissues and skin well gaped for ten days after which the tubes are shortened and finally all removed in about ten days more, or sooner in mild cases. 16. Arthrotomy. — A knowledge of the important routes of approach to the joints will facilitate any joint exploration, the removal of foreign bodies, the repair of traumatic conditions, the adjustment of difficult fractures, the reduction of old and difficult dislocations, to mobilize joints where motion is partially or totally lost, and to restrict or stiffen the joint as in certain paralytic conditions, to relieve and thoroughly drain suppurative con- ditions; a knowledge of the important routes of approach to the joint is very important. For each case, the operator will select the incision best suited for the in- dividual condition. Each joint will be con- sidered separately but joint operations should never be hastily con- sidered , and should be avoided by anyone not familiar with the best surgical technique. In all operations on the joints, the incision should be made down to the synovial mem- brane and made large T , , c . jig. 6b. — Incision for reaching the sacroiliac articulation. enough before opening the synovial cavity. All bleeding should be stopped and the synovial membrane carefully opened. The joint structures should be tampered with as little as possible, the synovial membrane brought together sep- arately and the layers over it closed carefully in order not to disturb the function of the periarticular tissues. Unnecessary separation of the tissue layers is to be avoided. Tendons should be left in their sheath. Any lig- aments that must be cut should be loosened periosteal^, in order that they may be readily replaced. Early motion should be the rule, gentle at first, and gradually increased. 17. Arthrotomy at the Hip. — Arthrotomy at the hip is necessary sometimes for recent or old dislocations, for congenital dislocation of 22 TECHNIQUE OF OPERATIONS case. the hip, separation of the epiphysis, compound fractures, some simple fractures, acute arthritis of infancy, other suppurative conditions, hip disease, acetabular disease, to relieve ankylosis from various causes, for the purpose of arthroplasty, arthrodesis or excision. The surgeon will have to select the incision best suited to the necessities of the individual When a good view of the acetabulum is necessary, the antero- lateral incision has advantages. The anterior incision is often sufficient for the treatment of dislocations and for drainage. In suppurative cases an anterior incision or the first portion of the antero-lateral incision may be used, supplemented by a posterior incision. Wherever the condition is extensive and very acute, this incision should be supplemented also by an anterior incision. Where there is acetabular disease, the antero-lateral is preferable, supplemented by its second part when necessary. Whenever the suppurative condition is extremely severe and acute nothing but the most thorough drain- age should ever be attempted. For this purpose an anterior incision combined with an antero-lateral and a posterior will hip incision along give thorough drainage. It is a the outer border of cur i us fact that in suppurative con- the sartorius. i... r ±r. j. v 1 1 i_ 1 ditions ot the acetabulum and head the anterior incision is the one to close last and to discharge longest. For an arthroplasty, Dr. Murphy's U-shaped in- cision will give the most satisfactory exposure (see Arthroplasty at the Hip). In obscure joint derange- ment following injury, an antero-lateral will give the best view of the joint. In dislocation of the hip, an anterior incision or an antero-lateral incision may be used. In very difficult cases and cases of long standing the antero-lateral is preferable. 18. Anterior Incision (see figures 37, 38). — The incision begins one inch below the anterior superior spine, extends five inches downward between the sar- torious and the tensor fascia femoris following the outer border of the sartorious. The rectus is retracted inward and the tensor fascia femoris outward. The attachments of the sartorious, tensor fascia femoris and rectus femoris may be freed subperiosteally from the ilium as described under fasciotomy. This however will not be necessary in most instances. When the muscles are retracted the capsule is opened parallel to its fibers. Fig. 38. — Line of anterior incision. INCISION, PUNCTURE, ARTHltOTOMY AT THE HIP 23 19. Antero-lateral Incision (see figures 39, 40).— The incision is made from the anterior superior spine to the top of the great tro- chanter, then downward along the anterior border of the femur. The incision is made through the skin and fat down to the muscle fibers. The coarser fibers of the gluteus medius are recognized and separated from the finer fibers of the tensor fascia femoris; the two muscles are sep- arated by blunt dissection and retracted, exposing the capsule. If nec- essary the gluteus medius may be detached from its attachment to the trochanter. The capsule is incised in the lines of its fibers and retracted. Fig. 39.— Antero- lateral incision, from the anterior spine to the trochanter then downward along the femur separating the tensor fascia femoris gluteus medius. Fig. 40. — Antero-lateral in- cision. Lateral view. When more room is needed the an- tero-lateral incision is ex- tended backward along the dotted lines. Fig. 41. — A. Glutues medius; B, Tensor fascia femoris; C, Sar- torius; D, Quadri- ceps. All bleeding should be stopped before opening the synovial membrane. If it is necessary to inspect the acetabulum the femur is rotated out allowing the capsule to be detached from the femur subperiosteally as far inward as possible. The femur is next rotated inward while the capsule is being freed posteriorly. When this has been accomplished two to four silk strands are attached separately to the capsule along its detached margin. The ends of the silk are left long and clamped out- side the wound. This will facilitate retraction of the capsule and later recognition of its edges, when the operation is completed. If it is nec- essary to dislocate the head, the hip is flexed and abducted and out- wardly rotated, allowing the ligamentum teres to be cut. When the 24 TECHNIQUE OF OPERATIONS purpose of the operation is drainage, a pair of forceps or a sound can be used as an aid in making an opening posteriorly after the head is dislo- cated. As the blunt instrument protrudes under the skin, from within outward an incision is made over it, giving a point for posterior drainage. The antero-lateral incision is a very good one for dislocations as well as /, plastic operations. It is often supplemented by a y horizontal incision extending from the trochanter backward; see below. 20. Antero-lateral Incision with Second Part for more Extensive Exposure of the Hip (see figures 40, 41, 42).— The antero-lateral incision may be supple- mented b} r an incision about four inches long starting- two inches below the top of the trochanter directly backward from the first incision. This extends through the skin and fat. As the trochanter comes into view its top is removed by means of a sharp osteotome, or a Gigli saw, the operator being care- ful to leave enough bone so as not to weaken the neck. The Gigli blade is passed behind the top of the trochanter by means of a long heavy needle threaded with silk to which the saw chain is at- Fig 42-Antero- t fa d> lateral incision with horizontal incision. The gluteus mechus, the Anterior view. The p er if rmis, and gluteus cross line shows the • • j , 1 i 1 line of incision used minimus are detached and where more room is retracted upward, giving required. a g od exposure of the joint. Before detaching the trochanter, two double silk strands may be placed in the tendons of the gluteus medius and two in the fascia below so that in closing the wound the top of the trochanter may be readily re- placed by means of the silk sutures; or the bone may be drilled and sutures placed ready for use later when replacing the top of the trochanter. Some operators prefer From the junction of the pos- to nail the top of the trochanter into place terior and middle third of the ... ., .,i i • crest of the ilium to below the with a wire, nail or with a bone or ivory top of the trochanter . peg or bone screw. 21. Posterior Incision (see figure 43). — An incision is made ex- tending upward from the trochanter to the crest of the ilium, starting two inches below the top of the great trochanter to a point on the crest about three inches forward of the posterior superior spine. This in- INCISION, PUNCTURE, ARTHROTOMY AT THE HIP 25 cision is carried down through the skin and fat, exposing to the muscle layer. For simple drainage the muscle fibers of the gluteus maximus may be separated and some of the fibers cut. Or, the aponeurosis of the gluteus maximus is separated from the great trochanter, also some of the fibers of the gluteus minimus, and the muscles are retracted, exposing the capsule of the joint. This is separated parallel to its fibers. 22. U-Shaped Incision used by Dr. Murphy for Arthroplasty. — Dr. Murphy recommends a U-shaped incision for Arthroplasty at the hip, the sides of which are about five inches long and three inches apart. He starts above the trochanter and one inch behind. His incision extends two inches below the top of the trochanter. The trochanter should be in the centre of the U. This will give a piece of fascia lata four inches wide and five inches long to use as a flap. The anterior portion of the U starts two inches below and one inch anterior to the trochanter and extends up five inches in a straight line to the anterior superior spine of the ilium. The skin and fat and fascia are retracted up- ward, exposing the tro- chanter, the top Of Which is TT FlG : 44.-Anterior , • , i • , i U-mcision, from be- removed With its mUSCleS at- l ow the anterior su- tached, the operator being careful not to weaken the attachment of the neck in removing the top of the trochanter. 23. Anterior U-Incision (see figures 44, 45). — Dr. Brackett recommends the use of a U-shaped incision; the inner incision extends downward from just below the anterior superior spine five inches, keeping just external to the artery, then three to four inches across the leg and five inches upward anterior to the trochanter. The sartorius is recognized and retracted inward, with the rectus, the tensor fascia femoris out- ward. 24. Internal Lateral Incision. Adductor In- cision for Exposure of the Hip. — The hip is flexed ninety degrees, abducted ninety degrees and outwardly rotated ninety degrees. An incision five inches long is then made along the border of the adductor longus. The adductor longus is retracted in- ward and the pectineus outward. This incision is sometimes recom- mended in dislocations as it is the most direct route to the ilio femoral perior spine down- ward just outside the artery, then out- ward and upward along the trochanter. Brackett. Fig. 45.— Side view of U- shaped incision. (See fig- ure 44.) 26 TECHNIQUE OF OPERATIONS ligament which is often the obstacle preventing a successful reduction of the dislocation. 25. Arthrotomy for Fractures About the Hip. — The necessity of immediate operation in fracture about the joints depends, as in other fractures, on the acuteness of the local and general reaction. When these do not contra indicate immediate operation, certain fractures about the joint may require treatment by the open method. Among these are fractures of the patella, fracture of the olecranon, certain fractures of the surgical neck of tha humerus, and certain fractures of the neck of the femur, all compound fractures, even when the protrusion of the bone has been extremely slight, all fractures that cannot be main- tained, or where apposition is impossible, many fractures combined with dislocation, articular fractures with pieces locking or limiting the joint action. See figures 67 to 70. Where there is a great deal of trauma and in multiple fractures and in cases where there is a great deal of shock all that can be done is to immobilize the parts until a favorable time for operation. In selecting a suitable time for operation the surgeon must remember that when it is found necessary to operate on a fracture if there is no immediate contra indication, the sooner it is done the better. Where there is tremendous swelling the surgeon should always wait. All cases should be operated on that show no union after three months of good treatment. Methods of treating the" individual fracture cannot be considered in a limited space like this. The writer has described the routes of approach to the different joints and the technique of these. This will enable the surgeon from his knowledge of fractures to select the route best adapted for the individual treatment required and when necessary two or more incisions may be used. A knowledge of the technique will enable the surgeon to work rapidly in reaching the fracture on which he expects to spend time. 26. A Method of Treating Overlapping Fractures. — Where the bones overlap, an excellent method of treatment is one suggested to the writer many years ago by Dr. Edward Martin of Philadelphia. In the opera- tion when the surgeon has reached the fracture the ends are freed. A tough tape or webbing is used ten or twelve feet long and is sterilized. The two ends of the tape are tied together, a loop of the tape is placed over the distal end of the bone. The other end of the tape is thrown over the foot of the operating table, a thirty-five pound weight is attached to this by an assistant. In about five minutes the bones will be found to be separated at least one inch. The weight is then held up by a non-sterile assistant, the tape taken off of the end of the bone and clamped to the sheet on the operating table, so that it will not slip away while the surgeon works on the fracture. When the muscles are in fairly good tone or the overlapping of bone has been great, it will be found that the bones will overlap again in four or five minutes. A reapplication of the tape will separate the bones again for the same INCISION, PUNCTURE, ARTHROTOMY AT THE HIP 27 length of time. The end of the lower bone should not be cut or fresh- ened until all other procedures are done which require separation of the bone. When these have all been done the end of the bone over which the tape has been placed is freshened. After this the tape should not be placed on the end of the bone, but the two ends allowed to come to- gether and held by a clamp until the operation is complete. Very bad overlapping fractures have been treated in this way in fresh cases without the necessity of shortening the bone. In old fractures no more bone need be removed than is required by the conical condi- tion of the ends of the bone. 27. Fractures of Long Standing Still Ununited or United with Deformity, Preventing Function. — In fractures of long standing where there is a mild infection, conservative treatment should be tried first. When this has been tried free drainage should be established and at the same time the ends of the bone freshened up slightly. Unless the infection is marked, in many of these cases when the suppuration dis- appears, union has also taken place. In any case where there has been infection, no plastic operation should be performed until infection has been entirely absent for at least nine months; a year is safer. Where the infection is very mild and of long standing, during the process of treatment the patient may be allowed to walk on the other leg if the local reaction is not too great. Sometimes he may walk a little on the af- fected leg. It is of advantage in certain cases to use a Thomas knee splint to take some of the weight off of the affected leg, the patient being allowed to bear weight on the ball of the foot, the splint taking all the weight off of the heel. Where the x-ray shows conical ends of the bone it is practically useless to expect union without surgical interference. The Carrell-Dakin technique is advisable in infected cases. See section 323. 28. Fractures of the Neck of the Femur in the Young or Middle Aged. — In recent fractures of the neck of the femur, Dr. Whitman's technique is most satisfactory. Under anaesthesia, manual or mechan- ical traction is applied to both legs. The good leg is abducted to de- termine the amount of abduction possible. The fractured leg is pulled on and abducted while the surgeon presses on the trochanter, reducing the deformity and guiding the leg into extreme abduction and hyper- extension, and outward rotation is also corrected. A plaster of paris bandage is applied to the thorax, pelvis, thigh, leg and foot holding the hip in extreme hyperextension and extreme abduction; it should fit well. (See application of plaster for the hip and thorax.) A Bradford frame is used under the plaster. A well fitting plaster enables the patient to be moved after the first five days without disturbing the fracture. The bed may be lifted at the head to relieve any tendency to hypostatic con- gestion. The leg of the plaster rests off of the bed as described for plaster following osteotomy at the hip. The patient may be put on a bed rest at the end of two weeks, if necessary, the well leg remains on the bed; the leg in plaster is off of the side of the bed. The after treat- 28 TECHNIQUE OF OPERATIONS ment is otherwise the same as for osteotomy at the hip. The age of the patient must be considered. The results are very excellent. However, in the very feeble it may take one year before the patient is able to walk well, but then it is due to feebleness rather than lack of function. The hyperextensiori of the hip, the reduction of the deformity, the extreme abduction and correction of the outward rotation will favor good func- tion. In cases with osteoarthritis there is some danger of stiffness with any fracture. Fractures of the neck may be adjusted and nailed or bone pegged. In the old, the fracture is often impacted and should be dis- turbed as little as possible. The danger from pneumonia or hypo- static congestion is worse than the fracture. In younger subjects, an incision is made and the fracture adjusted. See figures 59 to 62. Trac- tion on the trochanter is made as described for overlapping fractures and the head and neck pegged, nailed, wired or grafted. The trochanter and neck are drilled and a tight prepared bone or other peg driven into the hole made by a drill the size of the peg and if possible tapered so that it may be driven tight.* The patient is put up in a long plaster spica from the nipple line to the toe and immobilized in bed for four to five weeks, and then gotten up with crutches and the spica cut off below the knee. Old fractures of the neck with an excursion of the trochanter may be adjusted by pulling down the leg as far as possible, then cutting the trochanter to fit the head or the denuded acetabulum. This gives a firm hip sometimes with forty to eighty degrees of motion, some- times very little motion. Walking is, however, much improved and later the other leg may be shortened if the dif- ference is great (see paragraph 42) . It should be remembered as pointed out by Whitman that full abduction and hyperextension is the best position for a recent fracture of the neck. 29. Coxa Vara. Operation. — In operations for Coxa Vara, an anterior or antero-lateral incision may be used unless a trochanteric operation is decided upon. This latter operation is the most satisfactory (see Subtrochanteric Osteotomy). 30. Incision for Exposure of the Sciatic Nerve.— An incision in the median line is made three inches long on the posterior aspect of the thigh beginning at the fold of the buttock divid- ing the lower fiber of the gluteus maximus and separating the tissues below this muscle by blunt dissection. The sciatic nerve can be felt with the finger. A full view of the nerve is obtained when the muscles are separated (figure 46). 31. Incision of the Adductor Magnus Tendon in Hip Opera- tions. — In manipulating a dislocated hip or a shortened leg due to * As described by Hawley. Fig. 46. — Incision for reach- ing the sciatic nerve. INCISION, PUNCTURE, ARTHROTOMY AT THE HIP 29 overlapping fracture of long standing, it is sometimes necessary in addition to having a traction machine and in addition to the opera- tion on the joint or the fracture, to gain length in the adductor magnus by a tenotomy of the tendon just above the internal condyle. The tendon may be felt here. An incision is made three-fourths of an inch long, the finger readily recognizes it, a director hooks it up and its fibers tenotomized directly across or by an oblique or zig-zag tenot- omy. One suture will close the incision. It is sometimes surprising the relief of tension obtained by this procedure (see figure 47) . 32. Operation for Gluteal Bursitis (see figure 48). — An incision is made three inches long over the great trochanter through the skin and Fig. 47. — A dductor magnus incision. Incision three-fourths of an inch long. Here the tendon can be hooked up and tenotomized. Fig. 48. — Incision for reaching the gluteal bursa. fat parallel to the femur. This is the most convenient incision for gluteal bursitis. The fascial portion of the gluteus maximus is raised and the bursa will be found under it. The bursa may be dissected out or incised and drained. 33. Tapping the Hip Joint.— The most scrupulous aseptic precau- tions are necessary both as to the preparation, and the protection, of the field of the operation. The trocar may be thrust just above the great trochanter from the side of the patient directly inward or the joint may be reached from the front external to the sartorius at the same level (see figures 49, 50). When the head or neck is reached the sharp point of the trocar may be withdrawn and the dull end used as a probe to locate the exact point 30 TECHNIQUE OF OPERATIONS before using the trocar point again. The neck is reached easily and then the head, further inward. The trocar point is then inserted and the joint tapped. When there is much effusion it is not difficult to ^*x I reach the joint. The skin is drawn to the side so that the hole in the skin and muscle will be out of line when the needle is removed. If fluid is to be withdrawn, and other solutions are to replace it, the amounts should be carefully measured. Two good graduated metal syringes are very useful. All of their parts should be tested beforehand. The trocar is Fig. 49.— Tapping made to enter the joint and then the hip from the j s connected with the syringe. As little air as possible should enter the joint. The trocar should be of large diameter as the fluid may be thick or flaky. When the patient is not anaesthetized for the operation it is often well to have a short flexible tube connect the trocar with the syringe. This should be fastened at both sides by silk ties so that it will not leak easily when pres- sure or suction is used. If the joint is to be washed out a definite amount of fluid is injected and the return measured in a sterilized measuring glass. Dr. Murphy uses a formalin glycerine solution as follows: — Liquor formaldehyde, 2% in glycerine, about ten drops of the formaldehyde to each ounce of glycerine. This acts very well in infectious synovitis. Fig- 50.— Tapping But it should not be used in arthritis deformans ^ SS, 01 ^ nor in old chronic arthritis. The tapping may be pom t one-half way done with ethyl chlorid or novocaine adreneline between the top of solution, 1%. The solution should be prepared * h ® artery? 1 aT Pou- twenty-four hours before it is used (Murphy). parts ligament. CHAPTER V OPERATIVE TREATMENT IN CASES OF HIP-JOINT ANKYLOSIS 34. Principle of Arthroplasty for Ankylosis of the Hip. — Ankylosis may be bony, cartilaginous or fibrous, it may be periarticular, liga- mentous and capsular, or extra articular, that is, skin scars, tendons, fascia, nerves and arteries. The form of ankylosis that exists will determine the treatment. A partial ankylosis at certain points had better not be treated by an arthroplasty. Age must be considered, also the general condition of the patient. When the ankylosis is bony, cartilaginous or fibrous, arthroplasty is indicated. When the condition is periarticular or extra articular, it may be treated by capsulotomy, tendon elongation, excision of exostoses, etc. Dr. Murphy lays stress on the following points: The principles of asepsis to the finest detail are absolutely essential. One not familiar with the best surgical technique should avoid arthroplastic operations. The exposure of the joint must be generous and careful. The excision of the ankylosis must be complete. The contracted capsular ligaments and soft parts must be freed and if necessary lengthened. The normal contour of the joint should be restored as near as possible. The operator should obtain a hyper-mobilization of the joint. The joint should be re-shaped to give stability. The inter-position of material to prevent reunion of the bone is necessary. The principle is to separate the bones and to interpose between them material to prevent ankylosis. The best material for this purpose is the human pedicle, composed of fat, muscle, fascia, or a combination of these. When this is not possible, a transplantation is made of fat and fascia from the trochanter bursa region or from the fascia lata. Material such as ivory, celluloid, silver are not good. Materials that will not absorb or that absorb too slowly are not desirable. During the operation the soft parts should be freely liberated. Attach the interposing flap to one bone only and cover it completely. Early motion, that is, at the end of five to seven days is necessary with or without gas or gas oxygen. Dr. Murphy records failures in arthroplasty as due to first, insuffi- cient and defective exsection of the capsule and ligaments, second, in- sufficient interposition of fat and fascia between the separated bony surfaces, third, infection, fourth, the sensitiveness to pain on motion after operation. Cases of primary tuberculosis and cases of recent infection that have 31 32 TECHNIQUE OF OPERATIONS subsided are not suitable cases for arthroplasty. In operating, in addi- tion to the usual protection of the field of operation, after the skin and fat have been incised, towels should be clamped to the edges of the skin. 35. Technique of Arthroplasty at the Hip. — Dr. Murphy recom- mends a U-shaped incision for Arthroplasty at the hip the sides of which are about five inches long and three inches apart. He starts one and one-half inches above the trochanter and one inch behind. The incision extends two inches below the top of the trochanter. The trochanter should be in the centre of the U. This will give a piece of fascia lata four inches wide and five inches long for use as a flap. The anterior portion of the U starts one inch below and one inch anterior to the trochanter and extends up five inches in a straight line to the anterior superior spine of the ilium. The skin and fat and fascia are retracted upward, exposing the trochanter, the top of which is removed with its muscles attached, the operator being careful not to weaken the attachment of the neck in removing the top of the trochanter. A large heavy needle threaded with silk is passed behind the top of the tro- chanter; to the silk is attached a chain saw. This is used to remove the top of the trochanter, the obturator and pyriformis muscles are de- tached and retracted. The capsule is separated subperiosteally from the neck of the femur, a number of silk sutures with long ends are placed in the capsule so that it may be easily recognized later on. The long ends are attached to clamps which help to hold the capsule retracted. The capsule should remain attached to the acetabulum. A curved chisel is used to separate the head from the acetabulum following the normal outlines of the joint, and extending inward one inch between the bones all around. Dr. Murphy's globular drill and cup-shaped endmill will smooth out the cavity and make a round shaped head of the femur. The flap of fascia and fat taken from under the skin are now placed inward and sutured to the remnant of the capsular ligament or may be covered over the whole head and neck of the femur. After replacing the head in the acetabulum, the capsule is sutured, the trochanter is replaced, the sep- arated obturator and pyriformis muscles are reattached. An eight or six pennyweight nail is used to hold the trochanter in place. The muscles are brought together with interrupted chronic catgut sutures number 00, the fat with interrupted chromic catgut sutures number 00, the skin with continuous chromic catgut sutures number 00. Buck's extension apparatus is applied with twenty pounds' weight holding the leg in an abducted position. The patient is kept in bed for seven to ten days with this apparatus. After this, passive motion in flexion is introduced depending on the amount of pain or motion. The passive motion is used daily. Lateral motions are begun later on. A removable splint or plaster is applied for three or four weeks and removed when a fair degree of motion is possible without pain or great discomfort. The patient is then allowed to get up with crutches and swing the leg. TREATMENT IN CASES OF HIP-JOINT ANKYLOSIS 33 36. Operation for Deformity at the Hip with Joint Ankylosis. Hip Flexion and Adduction with or without Dislocation of the Hip. Operation for Coxa Vara. — Where the tissues have been contracted about the hip over a long period of time and the hip not dislo- cated, there is sometimes a fibrous ankylosis at the hip which maintains the position of deformity even after an operation is done to relieve the contracture of the soft tissues. Often after dislocation a practical ankylosis exists. Where this ankylosis is very slight and not due to previous tuberculosis it is advisable to limber up the hip joint by manipulation as described in these pages elsewhere. When the ankylosis amounts practically to an arthrodesis or when an arthrodesis has been done and deformity of flexion and adduction have developed, it is often advisable to do a Gaunt or subtrochanteric os- teotomy and correct the deformity. Even when walking is possible with a flexed and adducted hip, there is a tremendous expenditure of energy due to the awkward and back strain- ing position; with this position there is often pain in the hip and back which eventually makes locomotion impossible. These conditions are relieved by straightening the leg and should not be left till the patient is disabled. When deformity and ankylosis exists the operation of choice is an osteot- omy. See figures 494 to 496. 37. Subtrochanteric Osteotomy, " Gant." — When under anaesthesia (for operation on the right hip) the patient is placed on the left side, the left hip and knee being flexed to add stability to the position. Sand bags and pillows are arranged about the chest to prevent the patient from rolling. The operator stands behind the patient, the skin being prepared and the operative field protected. The osteotome is introduced over the outer side of the trochanter subcutaneously with the blade parallel to the line of the femur about one or one and one-half inches below the top of the trochanter. When the periosteum is felt with the three, four and five cutting edge of the osteotome, the blade is turned so will be cut in sue- that it lies across the bone. The bone is cut across cession ^- slightly obliquely from without inward and downward, the operator cut- ting and then feeling, using the osteotome as a probe, then cutting what he feels with the osteotome. An open incision is of no advantage. The a » a - Fig. 51. — Diagram- matic cross section of bone. Shows inclin- ation of the osteo- tome when cutting the anterior bone surface and method of holding it inclined anteriorly. X 3 + Fig. 52.— Shows the method of cut- ting the bone in sec- tions on the anterior surface. Fig. 53.— Shows further cutting of the bone surface (sections 34 TECHNIQUE OF OPERATIONS bone is cut through on its anterior surface inward, then another portion is cut posterior to this, working from without inward, and so on backward until the bone is entirely cut (figures 57, 59). When the bone is cut through this can be determined by feeling with the osteotome, an as- sistant lifting the leg and gently abducting or rotating the femur. Crepitus is felt "when the bone is completely cut through. If a very little remains to be cut it will break readily as the femur is abducted and rotated. When the osteotome is with- drawn, no sutures are necessary. A sterile sheet wadding pad is placed over the small wound. The patient is placed on a traction machine after cutting Fig. 54. — Traction machine for operation on the hip or ^e bone but preferably femur holding the patient ready for plaster without change . , . . . of position. Traction rods in place. A, Rollers against Ior tne WilOle operation tuberosity of the ischium. B, Traction rod. Two like this, (see figures 54 to 59), C, Stand to hold pelvis off of the table. an( j fonfa Jgo-g nulled evenly so that the perineum rests firmly against the per- ineal rods. The left leg is tight- ened and then the right, the muscles being stretched down until good length is main- tained in the short leg and about forty de- grees of abduc- Fig. 55. — Traction machine parts. D, Leggings. Two like this. E, Pulleys. Two sets of double block pulleys. H, Disjointed traction rods. B, with thumb screws to hold inside rods. J, Rods that fit inside the traction rods. The stand for the thorax is similar to (C) only broader. tion with twenty-five degrees of hyperextension at the hip. This position is regulated and held by the traction apparatus during the application of the plaster, which should reach from the axilla to the tip of the toe of the affected leg. For 12 years the writer has used the apparatus illustrated here. Where a Hawley Table is available this should be used. The plas- ter extends a short distance down the opposite leg, and should maintain the hip operated on in an abducted position of forty-five degrees and hyperextended twenty-five degrees. When the plaster is completed a TREATMENT IN CASES OF HIP-JOINT ANKYLOSIS 35 window is cut over the abdomen and the plaster is removed from the back of the thorax down to the lumbar region and from the side fS> Fig. 56. — Traction machine for operation on the hip holding the patient ready for plaster without change of position. A, Rollers against tuberosity of the ischium. C, Stand to hold the pelvis off of the table. K, Extension used to clamp thorax and to clamp pelvic stand to table. There are four extension clamps like (K) . operated on as far as the crest of the ilium (see figures 25 to 29). This allows abduction and hy- perextension but not the reverse. The surgeon can as- sure himself of the abducted position by feeling the an- terior spines when the plaster is still soft, and as soon as the plaster is cut out he may put his hand through the window in the ab- dominal portion of the plaster and as- certain the position of the anterior superior spines in order to be certain that the abducted position has been maintained. The patient and plaster are placed on a Bradford frame and handled and moved on the frame. The patient is kept on his back for six weeks, after that he sits up in the Fig. 57.— Traction machine for operations on the hip hold- ing the patient ready for plaster without change of position, clamps holding it firmly to the table. A, Rollers against tuberosity of the ischium. C, Stand to hold pelvis off of the table. K, Extension used to clamp thorax stand and to clamp pelvic stand to table. M, Clamp. There are four like this. P, Shows extension clamping pelvic piece to table. 36 TECHNIQUE OF OPERATIONS plaster, on the edge of the bed, keep- ing the good leg in the bed, bending the good hip. In four days more he is allowed to stand on the good leg and encouraged to walk as soon as his strength allows. When he is able to keep his equilibrium for fif- Fig. 58. — To prevent slipping of the . .. . * . plaster. Method of applying plaster to teen minutes a lighter plaster is ap- tuberosity of the ischium by a plaster plied holding the pelvis and the leg rope (X) over felt padding, using traction above th knee Walking is en _ machine (see figure 57) . ° couraged on the operated leg in the seventh week. A leather spica should be used for about a year to pre- vent adduction. CURVED OSTEOTOMY AT THE BASE OF THE TROCHANTER Dr. Bracket? s Modification Instead of doing an oblique osteotomy, Dr. Hoffa and Dr. Brackett make an open incision anteriorly cutting the bone in a curve from Fig. 59. — Shows rope (X) pulled towards patient's shoulder. within outward and slide the bone in this curve into an abducted position. Removal of a Wedge of Bone If the operator prefers he may re- move a wedge of bone from the femur, close the gap and cause ab- duction and hy- perextension. The bone may be — sutured or wired or an in- lay bone graft used after os- teotonry. In the majority of cases a simple osteotomy is as good as any of the elaborate methods. In any event the result will depend on gaining and maintaining the position by an adequate well fitting plaster of Paris bandage. Fig. 60. — Shows the plaster applied over rope (X) and the ends turned down holding the pressure on the tuberosity of the is- chium. Fig. 61. — Represents the next stage with the plaster rope (X) buried in the plaster. TREATMENT IN CASES OF HIP- JOINT ANKYLOSIS 37 The reader is referred to other pages for the detail in applying a plaster of Paris after hip operations (see section 10). A good traction machine and a well applied plaster are essential for the best results after osteotomies whenever extreme deformity at the hip exists. 38. Operation for Coxa Vara with Ankylosis. — A subtrochanteric osteotomy as described above is the simplest and an effective way of correcting coxa vara. The removal of a wedge of bone from the tro- chanter is more complicated and rarely necessary. The after treatment is the same as in osteotomy at the trochanter. 39. Osteotomy at the Neck of the Femur. — Osteotomy at the neck of the femur to correct deformity here or for coxa vara is sometimes indicated. The neck is reached through an antero-lateral incision from the anterior spine to the top of the trochanter and then extending downward two or three inches along the front of the trochanter. The gluteus medius and tensor fascia femoris are separated and the neck is easily reached. A drill may be passed through the head of the femur and another through the trochanter. These are placed firmly in the bone and should be placed parallel to each other. The neck is cut with an osteotome and the leg put in the desired position. This operation should be done with the patient on a traction machine so that there will not be any over riding of the fragments. If necessary a bone peg is passed through the trochanter neck and head of the bone after correcting the deformity, the drill ends are now used to guide the position of the head and hold it into place while applying the bone graft or wire nail. The drill should be a little smaller than the nail or graft or a tapered bone peg may be used as suggested by Dr. Hawley. In most cases of deformity of the neck, an osteotomy through the trochanter will give the same result as to correction and will have the advantage of simplicity, also the bone is thick and heavy here, making good repair an assured factor. The operation is some distance from the joint so that it will be injured as little as possible. This operation should be done with a traction apparatus as described in these cases. The after treatment for osteotomy through the neck is the same as for osteotomy through the trochanter. 40. Albee Hip Operation in Osteo-arthritis for the Relief of Pain. Arthrodesis. — In osteo-arthritis at the hip, Dr. Albee has suggested a method of obtaining ankylosis by a partial excision in situ. This opera- tion is especially adapted to the adult arthritic case with severe pain and in no instance should it be used where there is active disease or when there has been tuberculosis or suppurative joint disease. An antero-lateral incision is made, the head exposed, but not dis- located, its upper and inner surface chiselled away (see figures 39 to 44) in situ, also the upper surface of the acetabulum remov- ing a quadrilateral piece of bone partly from the head and partly from the upper acetabulum. When this space closes the bone should be 38 TECHNIQUE OF OPERATIONS cut in such a way that the leg abducts, correcting any deformity in flexion or adduction. The operation may be done rapidly and the patient allowed up in two weeks with a protective splint, or plaster if the hip is sensitive. In order that motion of the hip may not return, activity of the patient but not of the hip is encouraged as early as possible. Weight bearing is allowed at the end of the fourth week. The activity of the patient is important as the operation is rarely necessary in those A Fig. 62.— Dr. Al- bee's operation out- line of bone to be removed from ace- tabulum and head of the femur. B Fig. 63.— Bone re- moved allowing ab- duction and full extension when the bony surfaces come together. Fig. 64. — Position favoring ankylosis. Fig. 65. — Method of drilling • the bone on either side. The dotted lines represent drill holes on the other side. Fig. 66. — Side view showing method of drilling the bone alternately on one side and the other. under fifty years of age, and then only as a means of relieving pain by causing ankylosis in a favorable position. See figures 62, 63, 64. 41. Operation for Separation of the Epiphysis at the Hip. — In separation of the head at the epiphysed line, the antero-lateral incision is the easiest method of approach when operation is indicated. In fractures of the neck or intra capsular fractures when operation is indicated, the antero-lateral incision is the most satisfactory. It may be necessary in these cases to insert a drill in the head of the bone and use the drill tip as a handle to control it while the fragments are TREATMENT IN CASES OF HIP-JOINT ANKYLOSIS 39 being adjusted. A bone graft or a peg or a long nail may be used to fix the fracture. See section 28. 42. Adjusting Legs of Unequal Length. — When the legs are very- unequal in length, the longer leg may be shortened. An incision four inches long is made laterally or anteriorally, separating the fibers of the muscles and exposing the femur at about its middle. The bone to be removed is marked above and below allowing the leg to be three-eighths or one-half inches longer than its fellow. The bone is cut with a Gigli saw or a sharp osteotome; the latter method requires less exposure and less disturbance of the tissues. The femur is cut through, then each end is brought out of the wound and sawed, the amount removed from each end carefully, measured by a sterile steel ruler. The bone sawed straight; or one end sawed wedge- shaped and the other like an inverted wedge to fit it; or each end may be cut like a long step so that they overlap and are held by a bone screw, suggested by Gallie, the bone drilled with a screw tap, which corresponds to the screw. A number 14 screw tap and screw are used. The bone is adjusted and sutures placed; coaptation splints are applied over sterile sheet wadding and a long plaster of Paris applied over this. The patient is kept in bed four or five weeks and is allowed to walk on the plaster, after that with crutches. When walking is easy the plaster is gradually omitted. CHAPTER VI OPERATIONS IN SUPPURATIVE CONDITIONS ABOUT THE HIP 43. Suppurative Conditions at the Hip Joint. — In suppurative conditions at the hip joint an anterior incision may be used. If the disease is extensive or very acute this should be combined with an ante- rior lateral incision and a posterior. A single incision is rarely enough. Tubes are placed to the joint from each incision; gauze is used to gap the corners and make them round. When the acetabulum is extensively diseased and the condition is progressively growing worse, the head should be dislocated and the acetabulum drained and a large opening made through it. The bone anterior to the acetabulum below the anterior spine may be chiselled away with the softened diseased parts of the acetabulum. While this may be indicated in adults, in children the worse cases of bone disease will often recover in time, following good drainage and without radical measures applied to the bone. In all cases good drainage should be established first and any radical measures applied to the bone should be reserved for those cases where good drainage is not sufficient. See section 323, Carrell-Dakin technique. 44. Excision of the Hip in Suppurative Conditions. — The hip is approached as described for arthrodesis (see section 12). The amount IV1 Fig. 67. — Heavy bent wire frame. Wire splint for fracture of the femur in infants. The frame is covered with canvas as de- Fig. 68. — Showing patient in position. scribed for the Bradford frame. The head f bone to be removed will depend ly ^ "fitJftSSSSl on the amount of disease present. 45. Methods and Principles of Drainage in Acute Non-tubercular -A small suppurative focus without virulence or active constitutional disturbance should be drained by a suitable incision, wiped out with gauze, a tube placed to its deepest part and the soft tissues gaped with gauze. 40 under the hips. legs lifting the hips very slightly off of the frame as shown in figure 68. Suppurative Joint Disease. Hip.- OPERATIONS IN SUPPURATIVE CONDITIONS 41 When there is a great deal of constitutional disturbance drainage and counter drainage should always be the rule; if the bone is involved this should be opened and counter opened as shown (figures 65, 66). The pus cavities in the soft tissues should be wiped out. No extensive bone operation should be done otherwise. The bone should be drained with tubes to the remote portions and the muscle, fat, and skin gaped by c z> Fig. 69. — Heavy bent wire frame holding the knees flexed. Fig. 70. — Bent wire frame for fracture of the femur in infants. The frame is made as described in 67. The leg wires are bent at the knee, three to five inches beyond the flexed gauze. These operations are done knee. Two soft folded towels (represented in quickly and should not be pro- black) one for each leg are placed behind the / / . . ^ upper third of the tibia and fastened to the longed, but efficient drainage and frame lifting the hips off of the frame. A counter drainage should be estab- lished unhesitatingly. It is rarely necessary to do more at this time. third and fourth soft folded towel is placed over the front of the lower third of each tibia to steady the leg and help hold the hips off of the frame. A fifth and sixth soft towel is If there is a marked sequestra P^ced above the knee and fastened to the - . . ■ i • i iii i frame. I he towels are marked in black. formation this should be removed, but this had better not be done at the time of instituting drainage when the patient is nearly exhausted from an acute process. Any future operation made necessary should give good drainage and the removal of the sequestra if separated. Any extensive non-tubercular suppurative bone disease about the hip should be drained by an antero-lateral and a posterior incision or by an anterior and a posterior or by all three. If the patient is very ill and the abscess not easily located an anterior, an antero-lateral and a poste- rior incision should be made very rapidly and good drainage established. The anterior is usually the last to close, in spite of the more dependent positions of the other two. In very ill cases the operation should be rapid with short anaesthesia but in these cases large incisions and always counter incisions should be insisted upon. Excision and removal of parts of the bone may be done later. Any chronic suppurating process should be well drained and counter drained, the pockets in the tissues well opened and wiped out and the diseased bone well drained. Large incisions should be made with tubes to all dependent parts and large gauze pads used gaping the wounds for at least ten days; after that the tubes and wicks are shortened. This method of treatment is usually very successful. It does not necessitate the constant reapplication of drains, so discomforting to the patient. Irrigations should not be used in the after treatment. The gauze should 42 TECHNIQUE OF OPERATIONS be placed around rather than over the wounds. The hip is held fixed by placing the patient on a Bradford frame with traction or by means of a plaster of Paris bandage or an old-fashioned Thomas hip splint. It should always be immobilized. See Carrell-Dakin Technique, sec- tion 323. 46. Acute Arthritis of Infancy. — The incision for drainage in acute arthritis of infancy is the antero-lateral incision without its second part. As soon as it is possible to make a diagnosis, an incision should be made down to the capsule in which a very minute incision is made and a tube introduced. Immediate drainage is all that is necessary in this condi- tion. This will relieve the tension in the capsule and render spontaneous dislocation unlikely. For tenderness or swelling of the hip due to sup- purative condition, following middle ear disease, scarlet fever or other acute infections, drainage is indicated as soon as a diagnosis can be made. Immobilization by sand bags with the patient on a Bradford frame is all that is necessary. In a few cases a wire splint may be used as shown in figures 68 to 70. 47. Osteomyelitis. — In osteomyelitis an operation should be done as early as possible after making the diagnosis. In sub-acute cases, in- cision and drainage is all that is necessary. Whenever incising for abscess, all the pockets should be opened and if the abscess is large, counter incisions are made at dependent portions. The pus pockets should be opened freely, wiped out with gauze, irrigated and wiped out again with gauze. Curetting should be avoided excepting for the re- moval of sinuses in the skin. In cases with sinuses it is often better to excise them. Perforated rubber tubing should be placed to drain the deepest portion of each pocket. The skin, fat and superficial muscle layers should be made to gap by means of gauze drains. At the end of ten days the gauze is removed and the tubes shortened. The tubes are gradually drawn out a little each day, or two, until not used. This method makes the repeated reapplication of drains and wicks unnecessary as the wound will gap of itself and close from the bottom if the surgeon has been careful to make large incisions. Where the periosteum is found destroyed or the pus under the peri- osteal layer, the bone should be opened by means of a large drill or a small gouge. Where this is necessary, the incisions should be large and a counter incision should be made on the other side of the bone with a hole made in the bone a little above or a little below the hole on the opposite side (figure 65). These holes in the bone should open up the medullary cavity. They should alternate on one side and the other as far up and down as the disease is suspected. When the abscess is very great and the bone involvement is large a number of good size holes should be made with a Burr drill or a curved gouge on both sides of the bone as shown in figure 66. The wound should be gaped widely; — the skin, fat and superficial muscle held wide open by large gauze drains. The tubes should reach from the surface to the deepest portions of the OPERATIONS IN SUPPURATIVE CONDITIONS 43 abscess cavity. Splints should always be applied to immobilize the limb. They should be placed so that they will not interfere with the dressing. In some instances it is better to apply the plaster with large windows and ropes or to use a Bradford frame and traction to give stability as shown in figure 453. The dressings should be done every day or twice a day, depending on the foul condition of the discharge. If the odor is excessive chlorinated soda dressing should be used diluted, 1 /i, V 3 or 1 / i U. S. P. strength. The gauze drains should remain for at least ten days without being disturbed. When removed granulations will be formed under them in such a way as to keep the wound open without applying drains. Irrigation may be used at the time of the operation and the wound thoroughly wiped out with gauze afterwards. No irrigation or probing or application of wicks will be necessary if the first drains are left in long enough. After the first ten days the tubes are shortened gradually until they are not needed. In severe cases where the patient is unconscious or delirious the bone should always be opened, three or four holes on either side made with a good size Burr drill or a gauge. In no case should the incision be made on one side of the leg only in severe cases. No tight packing should be used as this interferes with good drainage. Where sequestra have formed they should be removed. An x-ray should be taken whenever possible to determine the position of the disease (unless the case is ur- gent and an immediate x-ray is not obtainable). In cases of long standing that are sub-acute at the time of first exam- ination, where the bone is riddled with holes over an extremely long area, it is impossible often to remove the dead bone satisfactorily without removing all the bone. In these cases free incision down to the bone with frequent openings into the bone as described above, will allow the septic process to run its course and the sequestra to gradually separate. We have had some cases in which the lower third of both femora were riddled with holes and full of sequestra, the patient being in no condition for extensive operation, and yet not very ill. In these cases, however, if the surgeon had seen the patient in time an early operation would have prevented this extreme condition. Sometimes it is necessary to close a large open bone cavity which will not heal over. Where the process is distinctly septic no plastic operation should be done without first doing an operation to eliminate the septic condition. After that, part of the muscle may often be transferred over such a cavity after it is closed. In transferring a muscle over such a cavity it should be freely transplanted and held there without tension. The skin should be brought together over the muscle and the wound drained, as there is apt to be some inflammatory reaction. Where sequestra are present it is always desirable to remove them as soon as they have separated and the involucrum is strong enough to act as a support. Sequestra may be superficial or in the medullary cavity or both. Where there is a persistent sinus and a sequestrum is present, 44 TECHNIQUE OF OPERATIONS pus will continue to form until the sequestrum is removed. Cases dis- charging several years where a sequestrum is present may close in a few weeks after removal of the sequestrum. In closing a bone cavity its edges may be chiselled clean, then the bone incised a short distance from one edge and parallel to it, the incision is carried down to the medulla. This incision in the bone is widened by prying it open and forcing the bone together, closing the old cavity. This method of closing an old open bone cavity is sometimes satisfactory. For the treatment of suppurating conditions by the Carrell-Dakin tech- nique, see section 323. PART II— KNEE CHAPTER I OPERATIONS FOR DEFORMITIES OF THE KNEE Fig. 71. — Dr. Bradford's position for manipulation of the knee. The knee rests on a pillow. , 48. Operative Manipulation of the Knee. — In manipulation of the knee under anaesthesia the patient should lie on his face with a firm pillow (see figure 71), or sand bag under the lower end of the femur. Where there is very slight flexion of the knee due to contracture of the hamstrings, the operator will grasp the thigh near the tibia with the left hand and just below the middle of the calf with the right. An assist- ant holds the lower end of the femur and a second assistant steadies the buttock. In order not to break the femur or the tibia, the first assistant should hold the femur below the middle and the manipulator should hold the tibia above its middle. The joint is gently stretched and re- laxed, the operator applying force gently in a gradually increasing man- ner until considerable force is applied and then relaxing until very slight force is used and finally relaxing entirely. A rhythmic extension and flexion is kept up. No rough or forcible extension with- out a gradually increasing or gradually decreasing force should be employed. In this way a minimum amount of trauma is caused. A joint that at first will seem almost impossible to extend will often give way and straighten. 49. Operation for Flexion Deformity of the Knee. — Permanent flexion of the knee may exist with motion or without motion. When there is no motion the knee is ankylosed in a flexed position. When there is motion and permanent flexion, full extension is impossible. Complete flexion may also be im- possible. The treatment will of course depend on whether the deformity is 45 Fig. 72. — Dr. Goldthwait's genu- clast applied. A, Strap over the un- der end of femur. B, Pressure plate at upper end of tibia posteriorly. C, Strap over lower end of tibia an- teriorly. D, Lever end. 46 TECHNIQUE OF OPERATIONS easily corrected by gradual stretching under ether or whether these modes of treatment are undesirable because of the condition of previous disease or because of the resistant condition of the flexion. When no previous disease has existed if slight, the flexion is corrected by manip- ulation. Usually it is not necessary to lengthen or tenotomize the ham- strings (see in the pages tenotomy and myotomy of the hamstrings). When the condition is resistant or due to previous disease quiescent for a long time, especially if a fair degree of motion exists, an osteotomy and correction of the deformity is a very satisfactory procedure because of its ease and because of the result to the patient. This may be done when the examination and x-ray all show that the deformity is of long standing or was due to a diseased process that has subsided. Even if the motion is not limited by bony ankylosis, much trauma is necessary to forcibly straighten the deformity without osteotomy. The trauma from stretching and tearing will often give much swelling and a stiff knee may result. On the other hand, by an osteotomy all the joint motion present before operation is assured afterward with the leg straight. It is better to do an osteotomy, just above the adductor tu- bercle and straighten the knee. This is especially indicated if there is good motion in flexion beyond the permanent flexion. The knee should always be hyperextended a little after such an osteotomy. (See sec- tion 54.) In cases with from twenty-five to eighty degrees of permanent flex- ion with motion beyond this, there will be comparatively little trauma and a very good functional result from this operation. When con- siderable flexion exists, accompanied by subluxation, then a genuclast is often necessary to obtain the best results (see figure 72). Slight permanent flexion is sometimes due to a curled semilunar cartilage or in- flammatory changes due to injury of the Fig. 73.— Flexed knee with subluxa- cartilage. When this has existed for some time, force should not be used, but the inflammation allowed to subside or the cartilage removed com- pletely as described elsewhere in these pages. 50. Operation. — Tendon Lengthening to Correct Knee Flexion. — When the knee flexion is due entirely to short hamstring muscles these may be lengthened by one of the methods described under tendon lengthening either in the muscular or preferably in the tendonous parts of the muscle, the tendons being split diagonally or by the zig-zag method and sutured. In simple cases careful stretching under ether is all that is required. When the contracture is due to spastic rigidity of the flexors of the knee it is usually better to tenotomize the tendons by open method. If the contracture is of long standing, careful manipulation with or without genuclast may be necessary. If there is much joint ankylosis an osteotomy low down on the femur may be necessary as described in OPERATIONS FOR DEFORMITIES OF THE KNEE 47 these pages. When the tendons are lengthened and this is sufficient, the knee is held slightly hyperextended in plaster for six weeks, after that a caliper is used until locomotion is satisfactory. The caliper is gradually omitted as the leg becomes strong and the surgeon is able to assure himself that no recontracture is taking place. The muscles should be exercised in flexion and extension from the sixth week on. Usually the caliper is worn for two hours once a day to stretch out the tissues. If they tend to contract the daily time for wear- ing the splint is increased. 51. Correction of Subluxation of the Tibia by Manipulation. — If the subluxation of the tibia is very slight it may be corrected by manip- ulation at the same time as the permanent knee flexion. ' The patient is anaesthetized and turned over on his face. He is then drawn down so that the knee is at the edge of the table and a pillow Fig. 74. — A method of correcting Fig. 75. — Method of using the subluxation of the tibia by sheet trac- lower leg as a lever to correct sub- tion; sheets applied first stage. luxation of the tibia, second stage. is placed under the knee. An assistant holds the femur close to the knee and a second assistant holds his weight over the buttock. The operator flexes and extends the knee gently increasing the extension and forcing the tibia forward until the knee will slightly hyperextend. The patient is then turned over and a well padded and fitting plaster is applied as high as possible on the thigh and including the foot, holding the knee hyperextended. The plaster is split on either side and may be loosened if the swelling is great. The patient should be kept quiet for three days and in bed for a week, after that he is up if the swelling and local symptoms have subsided. He is then allowed to walk with the plaster. When walk- ing is easy a caliper splint is used during the day and a plaster at night. As the knee becomes strong without tendency to recontract, the caliper splint is omitted more and more and used only two hours a day for one year. If the knee tends to flex, the caliper will have to be worn longer each day. The plaster at night is omitted after the surgeon has assured himself that the knee does not recontract during the day. When the flexion and subluxation are considerable a genuclast should be used to correct the deformity. 48 TECHNIQUE OF OPERATIONS Manipulation of the Knee and Correction of Subluxation with Genuclast. — When there is subluxation of the tibia (see figure 73) the Goldthwait genuclast is used (see figure 72). This apparatus is applied with the knee flexed preferably at right angles. The deformity will sometimes decide the position of the knee. One strap rests over the end of the femur, a second strap is placed over the front and lower third of the tibia and a padded plate is forced by a twin screw against the upper end of the tibia. By increasing the pressure on the upper end of the tibia, subluxated tibia is brought forward; when this Fig. 76. — Method of maintaining hyperextension of the knee or other correction of deformities at the the knee during the application of plaster. is accomplished the genuclast is reapplied as follows : The strap which did rest under the lower end of the femur is now placed on the lower end of the femur anteriorly; the padded plate and the strap remain the same. The pressure is now reapplied on the upper end of the tibia and the genuclast used to straighten the knee until it is slightly hyperextended. A plaster of Paris is then ap- plied from the toes to the groin holding the knee slightly hyper- extended. In straightening a knee in plaster any pressure with the hand should be above the patella, not over it; forcing the patella on the bone is undesirable. It should be remembered also that any pres- sure or denting of the plaster remains as a prominence pressing into the patient. In correcting deformities at the knee it is important that sufficient correction should be done to obtain hyperextension of the knee easily maintained after the manipulation. This hyperextension should be so completely obtained that no force will be required in holding the knee in this position during the application of the plaster. After the operation the patient is kept quiet for about three weeks depending on the amount of swelling. After that he is allowed to walk on the leg a little each day. At the end of six weeks, as soon as he walks well with the plaster on the knee, a caliper splint is applied (figure 475), which should be used at first night and day or during the day and replaced by a plaster at night. At the end of three months the caliper splint which hyperextends the knee easily is omitted for part of each day. When the knee shows no tendency to recontract, the ap- paratus is omitted at night at first and then omitted entirely, ex- cepting for two hours each day. It should be used two hours each day at least one year. Recontracture often takes place very grad- ually and is not readily noticed. Any tendency to recurrence of the per- manent flexion at the knee should be treated by longer or continued OPERATIONS FOR DEFORMITIES OF THE KNEE 49 application of the caliper splint. Exercise should be used to strengthen the leg and aid in locomotion. In many cases where the permanent flexion at the knee has been pro- longed, especially when subluxation is extreme and has existed for many years, there is a fibrinous union of the upper end of the tibia to the femur. Often this can be overcome only by an open operation. In these cases two incisions should be made parallel to each other, one, one inch to the outer side and the other one inch to the inner side of the patella about five inches long. The adhesions are relieved. They are often found most resistant on the posterior part of the femur. When they are re- lieved the straightening of the knee is carried out as indicated above. Care should be taken not to cut the lateral ligaments. If necessary they may be removed subperiosteal^ from their attachments to the femur or tibia but not cut across. 52. Another Method of Correcting Subluxation. — In certain cases when it is necessary to straighten a knee and a genuclast is not available, two folded sheets will sometimes answer in correcting the subluxation (see figures 74 and 75). The patient lies on his abdomen; a twisted sheet is placed between his legs and drawn up tight against the tuberosity of the ischium. The ends extend one toward the shoulder in front and the other behind. They are brought together at the head of the operating table and a webbing strap is passed through the loop and then fastened to the head of the operating table. This prevents the patient from sliding down off of the operating table when the leg is being pulled. A second sheet is applied around the upper end of the tibia which is slightly flexed and carried down to the foot of the table (see figure 74). This second sheet is made fast and held by the first assistant. The operator flexes the knee, which motion forces the upper end of the tibia downward. The operator then extends the knee. The first assistant takes in the slack in the sheet to accommodate itself to the extended knee and as the operator flexes the knee again, the tibia is thus forced further into place. This process is repeated and a great deal of force may be used until the subluxation of the tibia is overcome. In cases where there is a partial ankylosis due to an old diseased process which has subsided, it is undesirable to use force in straightening the knee. It is also better not to do an arthroplasty. In these cases it is better to do an osteotomy through the femur, just above the adductor tubercle as described elsewhere in these pages. In some cases beside the flexion there is a knock knee or bow leg. Where the patient is young, it is possible to bend the leg at the epiphysis in the manipulation and to correct both the flexion and bowing at the same time. If this is unde- sirable an osteotomy is done and the correction made. 53. Operation for Knock Knee and Bow Leg. — For correction of knock knee and bowing at the knee, elaborate operations and removal of bone wedge are not frequently necessary. Where the patient is an adult and the knock knee or bow leg is over 50 TECHNIQUE OF OPERATIONS fifty degrees, a wedge of bone should be removed instead of doing an osteotomy. In other cases, excellent results are obtained by a simple osteotomy which is the operation of choice. This operation is not com- plicated and may be done rapidly. For bowing at the knee or knock knee, the operation on the bone is the same as that described for knee flexion. When there is bowing of the tibia and fibula a simple sub- cutaneous osteotomy of these bones with over-correction of the deformity is all that is usually required. If, however, the bowing is anterior or very acute, a small wedge of bone must be removed; the bone heals without being fastened together. A tenotomy of the tendon Achilles should always be done when the de- formity is in the lower leg. The after treatment is the same as for osteotomy at the knee. 54. Correction of Flexion Deformity of the Knee by Osteotomy of the Femur. — The patient lies on his back, the knee flexed at right angles; the operator stands on the side of the leg to be operated upon. A sand bag is placed under the knee, the adductor tubercle is felt through the skin. The osteotome is entered at the inner side of the leg just over the tubercle until it reaches the tubercle with the blade parallel to the femur. The operator prevents the slipping of the skin under the osteo- tome by placing the thumb and forefinger of the left hand on either side of the adductor tubercle, the thumb anterior, the index finger posterior. In stretching the skin with these fingers which are kept only a quarter of an inch apart, it is very easy for the osteotome to incise the tense skin without slipping. As soon as the periosteum can be felt by the cutting edge of the osteotome, the operator turns the cutting edge at right angles to the bone so that it will lie across the femur. The osteotomy should be done in the flat portion of the femur and not in the round position (figures 494 to 496). 55. Technique of Osteotomy of the Femur for Flexion Deformity of the Knee. — The knee should be flexed at right angles for the opera- tion in order to avoid the vessels and nerve close to the bone. The operator in using an osteotome should learn to cut and then to feel and then to cut what he feels with the osteotome, rapidly. In this way the osteotome is used as a probe, and as a cutting instrument. Some op- erators prefer to cut the anterior edge of the femur and then to place the osteotome back of this and cut another layer repeating the process layer by layer, progressing toward the back of the bone. The osteotome in cutting inclines forward and cuts the bone as marked in figures 52, 53. The osteotome inclines forward again and cuts next as shown in fig- ure 54. Cutting the bone close to the adductor tubercle prevents the antero-posterior deformity so often seen above the knee, when the osteotomy is done too high. The bone is in a better line than when the osteotomy is done low down. See figure 494. No suture is necessary in the small hole made by the osteotome. The knee is now straightened and the deformity corrected. If it is a bowing OPERATIONS FOR DEFORMITIES OF THE KNEE 51 at the knee, the leg should be put up in very slight knock knee. If the osteotomy is done for a knock knee, it should be put up in a very slight bow leg position. In all osteotomies, as soon as the bone is cut through, the leg should be held very carefully by an assistant and no jar allowed. Manipulation of the knee should not be done when an osteotomy is con- templated as it will add to the trauma and the motion which exists is apt to be lost in consequence. Sterile sheet wadding is placed around the leg at the region of the osteotomy and the whole leg covered with sheet wadding from the toes to the groin. A well fitting plaster is applied immediately and held in position until hard. 56. The Application of a Plaster of Paris Bandage After Operation or Manipulation of the Knee. — To facilitate the correction of knock knee or bow leg and at the same time to obtain a slight hyperextension of the knee during the application of plaster, the following method is of service in very muscular individuals or when much force is necessary. The leg having been covered with sheet wadding from the toes to the groin, a heavy felt pad is placed just above the knee, a double four inch bandage is spread over this pad and its four ends carried down to a leg or cross bar on the operating table and tied there (see figure 76). The operator can then slightly hyperextend the knee and correct the bowing or the knock knee during the application of the plaster (figures 77, 78). When the plaster has hardened the bandage is cut away from its attach- ment. In cases where correction of knee deformity has been done the plaster should extend high on the thigh. It should grasp both ends of each bone and fit the thigh well and fit the leg and foot well. Only in this way can the full correction be maintained. 57. Plaster for Holding the Knee. — The plaster should fit holding the upper and lower part of the femur and the upper and lower part of the tibia. The over-correction is maintained. In correcting bowing at the knee and knock knee, the plaster should be applied with the knee slightly hy- perextended. The plaster is applied from the toes to the groin and split on either side. 58. After Treat- ment and a Sim- ple Method of Preventing Rota- Fig. 77. — Plaster rope to prevent rotation of the plaster after tion Of a Leg fracture or operation on the leg. Lateral view. Plaster. — Plaster ropes are applied to prevent the rotation of the leg as shown in figures 77, 78. The patient should be disturbed as little as possible for the first five days, excepting for the use of the bed pan. He may be allowed to have a bed rest in two 52 TECHNIQUE OF OPERATIONS weeks and to sit up after the third week, depending on the case. Some cases are better in bed for five or six weeks. The leg should be kept quiet for about five weeks when the patient is allowed to get up and move around with crutches. At the end of the sixth week he is encouraged to bear weight on the leg. As soon as the patient can walk with the plaster easily it is removed for a part of each day Fig. 7S. — Plaster rope to prevent rotation of the plas- ter after operation. End view. and discarded as SOOn as Fig. 79.— Dr. Osgood's method of correcting knee possible, depending On the Aexion, removal of bone, A B, C, B' with coping strength of the leg. When no operation has been done on the bone, as soon as the reaction following the manipulation has subsided, the patient is allowed to sit up and then to walk. 59. Dr. Osgood's Method of Removing Bone for Flexion Deformity at the Knee. — Dr. Osgood has suggested a method of removing a wedge from the femur by means of a coping saw applied to the femur through two lateral incisions. A tracing of the x-ray before operation will help the operator to decide on the size and shape of the wedge to be removed (see figure 79 A, B, C, B'). A quadrilateral piece of bone is sawed out allowing correction of the knee flexion (see figure 79 A', B', C). The cut A-B is made three-fourths of an inch long, then B-C not through the posterior shell of bone. The saw blade is left at C. Another blade is inserted at B' and cuts toward C. The bone wedge is slid out and the posterior shell at C broken or bent as the leg is straightened. The after treatment is the same as for osteotomy above described. CHAPTER II MUSCLE AND TENDON OPERATIONS— MUSCLE AND TENDON TRANSPLANTATION 60. Operation for Rupture of the Quadriceps Extensor.— For rup- ture of the quadriceps a long median incision is made. The upper and lower ends of the muscle and its sheath are sutured with quilted silk sutures (see figure 218). The silk is pulled together approximating the edges of the lower muscle; interrupted chromic catgut sutures number 00 are used for the edges of the muscle, the silk being used to relieve the tension. It is impor- tant to suture the muscle sheath with interrupted catgut sutures number 00. The fat is brought to- gether with interrupted chromic catgut, the skin with continuous chromic catgut number 00. Large pro- tected wads of sheet wadding are placed over the muscle in addition to the circular layers. The leg is put up in plaster of Paris with the knee fully extended. The patient is placed in bed with a low bed rest and the leg elevated. Quiet in bed is necessary for about four weeks; a little more freedom may be allowed in the next two weeks. The plaster is removed after the sixth week. In patients over thirty, slight passive motions of the knee should be allowed daily Fig. after the third week in plaster. 61. Operation for Muscle Transplantation, Paraly- sis of the Anterior Thigh Muscles. — When a vigorous muscle is transplanted strong muscular action can usually be expected. In the choice of muscles to be transferred from the back of the leg forward, the sartorius and the inner hamstrings are preferable to the biceps. The biceps, however, may be trans- planted at the same time with one of the others. Before transplanting, any slight degree of flexion or knock knee is corrected by manipulation. When extreme knock knee or extreme flexion is present this should be corrected at a previous operation. At the time of operation the knee should hyperextend slightly without the use of force. When this is accomplished the transplantation may be done. 53 80.— Tendon carrier. Fig. 81. — Sartorius incision anterior; hamstring incision posterior. 54 TECHNIQUE OF OPERATIONS OPERATION A rubber bandage is applied from the toes to the groin, a tourniquet is applied high in the groin with the loose ends turned upward to allow the skin to be prepared very high. The patient is prepared with scrupulous care as to aseptic detail, the hip is flexed and abducted, Fig. 82. — Exposure of muscles. Fig. S3. — Muscle dis- sected up. Fig. 84. — Tendon carrier, reaching pos- teriorly for the ham- string tendon. The line over the patella shows the incision here, and over the tibia the second incision for in- sertion of the silk ten- don elongation. slightly; an incision is made starting one inch above and half an inch posterior to the internal condyle, the in- cision should be carried ver- Fig. 86. — Tendon tically through the skin and carrier passed up- su bcutaneous fat parallel to ward through the . . i j i subcutaneous tunnel, the femur and extend up- ward to the middle and upper thirds of the thigh. The muscles are examined to determine their relative strength. For practical purposes a totally paralyzed mus- cle will be gray, or grayish pink. A partially paralyzed muscle is pink, a strong muscle is red. At the lower portion of the wound the belly of the semi-membranosis Fig. 85. — Lateral view of the tendon carrier reaching for the hamstring tendon. MUSCLE AND TENDON OPERATIONS 55 is seen, then the tendon of the semi-membranosis and finally the tendon and muscle of the semi-tendonosis overlying the semi- membranosis. The semi-tendonosis and the gracilis have long thin tendons, and are chosen for transplantation rather than the semi- membranosis. When there is a paralysis involving the muscular action of the knee joint, it is undesirable to carry the dissection down below the condyle, for elaborate dissection at the side of the joint weakens it laterally. For this reason the skin is drawn downward and the tendon cut away as low as possible without being traced to its insertion beyond the joint line. The transplanted muscle (see figure 97) may be passed through a slit in the quadriceps tendon or muscle before being attached to the quad- riceps tendon and patella as described above. For the success of the operation further details are necessary. The surgeon should see that the portion of the silk hooked through the eye of the carrier is cut off later in order not to mutilate the silk that is to remain in the leg, either by bending or clamping it. Any injury to the silk which is to be left in the patient is undesirable. The surgeon should carefully test the silk and endeavor to break it with his hands at several points before quilting it through the tendon. The stitches in the tendon should be placed carefully and close together and not in the same line of cleavage. They should number about seven or eight on each side of the tendon. When there is little or no tendon, as in the case of the sartorius, "larger bites" through the muscle are neces- sary in order not to cut off the circulation of the muscle. In figures 93 and 95 the tendon protrudes through the lower incision and is quilted into the patella. The silk is tied here; another incision is made over the outer side of the upper end of the tibia one-half inch internal to the upper end of the fibula, curved and two inches long. The silk is quilted here into the periosteum and tied as shown in fig- ures 91 and 92. Fig. 87. — A, Retrac- tor preventing the in- folding of the fat while the muscle is drawn downward subcuta- neously to the patella. B, Silk extending to the tendon of the ham- string in the tunnel. Fig. 88.— Position of insertion of an in- ternal hamstring first into the patella, sec- ond to the outer tibia. 56 TECHNIQUE OF OPERATIONS At the thigh in transplanting a posterior muscle forward, the trans- planted muscle ma} r be attached directly to the quadriceps tendon and to the patella by the silk extension from the tendon (see figure 93). When the sartorius is transplanted it is attached to the quadriceps and then the silk is carried over the patella down directly in a straight line and inserted in the upper end of the tibia. The muscles are transplanted in the middle line above the patella. Below the patella the silk from an inner hamstring- is carried to the outer side of the tibia; that from an outer hamstring is carried to the inner side of the tibia. The knots tied three times in the silk are cut, leaving ends just long enough so that they will bend over and not stand up. They are also pressed firmly into the periosteum after being tied in order that they will lie The nee- as flat as possible. The mus- dle must enter the cle is dissected up to the mid- gleS 011 ^ right aU " dle 0f the thi g h - A l0n £ [ - tudinal incision is next made on the anterior and middle third of the thigh parallel to the femur down to the quadriceps muscle. The incision is retracted, a blunt dissector is used to make a tunnel backward connecting the anterior with the upper end of the posterior incisions. A long clamp or tendon carrier (see figure 80) is inserted into the tunnel (see figures 84, 86), anteriorly; it grasps the tendon of the semi-tendonosis and draws it forward out through the anterior incision (see figures 87, 88). In the case of the transplantation of the sartorius or of the gracilis, this tunnel should extend immediately under the fat and not through the paralyzed muscle there. A towel is placed on either side of the muscle while the heavy number eighteen braided silk is quilted up one side of the tendon and down the other (see figure 89) . The method of inserting silk is extremely important. The tendon fibers are easily split and tear readily. Each puncture of the needle should be made at right angles to the fibers of the tendon as shown in figure 90. Another incision is made parallel to the femur starting one inch below the upper edge of the patella, extending upward two and one-half inches directly over the centre of the patella. The incision is carried down Fig. 89.— Method of quilting silk into a tendon. MUSCLE AND TENDON OPERATIONS 57 through the superficial fascia and fat. A tendon carrier (see figure 80), is inserted at the patella incision making a broad tunnel in or below the subcutaneous fat connecting the two anterior incisions. The tendon carrier is passed upward in the tunnel to the upper thigh incision. The silk is passed through the eye of the carrier and pulled through the tunnel followed by the tendon and muscle. An assistant raises the lower end of the wound as shown in figure 88 to prevent inversion of the fat at this point while dragging the muscle through the tunnel. The trans- planted muscle is attached by mattrass sutures to the quadriceps tendon. Both muscles are scarified before placing the sutures. The muscle is also attached to the quadriceps muscle and tendon just above the patella. This is done with inter- rupted silk sutures. The quadriceps may be folded over the transplanted muscle or slit to receive it before applying the in- terrupted silk sutures. The silk ends from the transplanted tendon are threaded through peri- osteal needles (see fig- ure 281) and inserted by Fig quilted sutures into the patella (see figures 91 and 92) . The. silk is tied here and then passes subcuta- neously to the tibia. A small curved incision is made here and the silk quilted into the perios- teum over the tibia. The deep tissues are brought together with interrupted chromic catgut sutures number 00 care- fully covering the silk and the knot. The subcutaneous fat is brought together over this with interrupted chromic catgut sutures number 00, the skin with continuous chromic catgut sutures. About five or six layers of gauze one and one-half inches wide are laid over each incision extending one-half inches beyond at either end of the incision. Over this is placed sterile sheet wadding. See figures 234 to 236. See method of applying dressing under transplantation of peroneus forward, section number 147. 62. Transplantation of Two Hamstrings Forward. — When an outer as well as an inner hamstring is transplanted forward the process is the same. The two muscles are brought out of the anterior incision, one passes to it on the outer side of the leg, the other on the inner side. They 91. — Needle and insertion silk into the periosteum. -Quilted silk suture the periosteum and Fig. 93. — Insertion of silk into patella and into tibia. 58 TECHNIQUE OF OPERATIONS are both passed down the same tunnel to the patella and fastened to the quadriceps muscle or its tendon, both by mattrass sutures and then stitched to the patella. The silk from the inner muscle is cut from the start one inch or one and one-half inches shorter than the silk from the Fig. 94. — Closing anterior incisions. Fig. 95. — Diagram- matic representation of the transplantation of two hamstrings forward for paralysis of the quadriceps. Fig. 96. — Anterior incisions closed after transplanting two hamstrings to the patella and tibia for paralysis of the quad- riceps. outer muscles. In this way it may be dis- tinguished after being quilted into the patella and tied. The quilting in the patella is made separately (see figure 95) , for each strand. After insertion into the patella, the four strands are tied together after being tied in pairs. They are next inserted into the periosteum over the tibia, the two strands of silk from the outer hamstring to the inner side of the tibia, and the two strands of silk from the inner hamstring are carried to the outer side of the tibia. The strands are distinguished by their length as noted above. The knots are flattened and pressed firmly into the periosteum. The silk and knots are carefully covered with deep tissues, the subcutaneous tissues are brought together over this with interrupted chromic catgut sutures number 00, the skin with continuous chromic catgut sutures number 00. When the incisions are closed they appear as shown in figure 96. 63. Operation for Transplantation of the Sartorius Muscle for a Weak or Paralyzed Quadriceps. — In a transplantation of the sar- torius, this muscle when transplanted will easily reach the patella. It is usually sutured to the quadriceps tendon, the two muscles scarified first. Silk is quilted into the muscle as described for transplantation of the semi-tendinosus or the peroneus. The silk is carried down and in- MUSCLE AND TENDON OPERATIONS 59 serted into the patella and then into the tibia in the median line, otherwise the operation is the same as in transplantation of the semi-tendinosus forward. The sartorius is an easy muscle to trans- plant and when strong is always successful in its new position. 64. Transplantation of the Tensor Fascia Femo- ris, to a Weak or Para- lyzed Quadriceps. — The patient lies on his back, the operator stands on the side of the leg to be operated upon. An incision is made to the patella starting two inches below the anterior superior spine. The ten- sor fascia femoris muscle is exposed and a broad Fig. 98.— The para- lyzed quadriceps is folded in part over the transplanted muscle which is attached to the patella and again to the tibia. Fig. 97. — Passing the transplanted muscle through the quadriceps strip of fascia traced down and then attaching the to two inches above the silk extension to the patella. This is cut away pateUa and tibia ' below, dissected up, quilted up one side and down the other with silk, the fascia and muscle transferred inward entering a slit in the quadriceps tendon and being attached by quilted sutures to the quadriceps tendon and patella. The rest of the operation and after treatment differ in no way from that used in the transplantation of the semi-tendinosus. See section 61. 65. Transplantation of the External Hamstrings Forward, for a Weak or Paralyzed Quadriceps. — In transplanting the external ham- string, the biceps femorus, the short and long heads come together into one tendon. The incision for transplanting this tendon should be one or two inches from the median line. In transplanting this muscle for- ward it is better that the tunnel should pass through to the inner side of the vastus externus, for it is difficult to make the muscle reach. The tendon should be cut very low for the same reason. The pro- cedure otherwise is the same as for transplantation of the inner ham- string. 66. Technique of Muscle Transplantation.— In transplanting mus- cles or tendons from their position to take up the work of other muscles, it is important to weigh the strength of the paralyzed group, and deter- mine the strength of the muscles to be transplanted and the strength of the joint after removing this good muscle. If the joint stability is in any great degree affected by the transfer, this must in some way be 60 TECHNIQUE OF OPERATIONS compensated for and if it cannot be, the operator should consider the value of the transplantation with these facts in mind. At the time of operation, a red muscle will be a good one to transfer, a pink muscle may be of help in its new position but if it is a pinkish gray or fatty it will be useless when transplanted. The muscle to be transferred should be dissected up for at least one-half of its length from its insertion, carried forward or backward as the case may be, and then placed in a tunnel in a direct line for the desired new pull. The silk quilted into the tendon should extend some distance up the tendon in order not to be easily pulled out. The silk should be heavy number sixteen or number eighteen, braided. It should be tested to see if it will break before inserting it in the tendon. The silk can be made to reach any distance. In the process of repair it is covered completely by fibrous tissue which will strengthen it. The insertion of the silk into the perios- teum should be three or four quilted sutures for each strand (see figure 91, 92) , and then the ends are pulled tight one at a time, taking up the slack in the muscle and then tied three times, the end cut so that it will bend over. The knot is pressed into the underlying tissue using the handle of a pair of dressing forceps. The operator should assure himself that the transplanted muscle is pulled well down into its new position and is not caught by any constriction in the canal in which it has been placed. The insertion of the silk should be under a curved flap, the base of which overlies the knot. The silk should be covered by deep fascia or muscle when possible beside the skin and fat. No pressure should be allowed over the transplanted muscles or the incision. The dressings or plasters should be well padded for this purpose. 67. Muscle Transplantation for Paralysis of the Anterior Thigh Muscles. — One or more posterior thigh muscles may be transplanted forward to re-enforce a very weak quadriceps or to replace a paralyzed one. It must be borne in mind that the object of the transplantation is pri- marily to give stability to the knee. A very weak or paralyzed quadriceps is a constant menace to the patient. In walking he cannot lock the knee and be sure when trans- ferring the weight from the good leg to the affected leg that it may not give way under him. In walking he instinctively places the hand on the thigh to prevent the flexion of the knee as the weight is being trans- ferred to that leg. Stability in standing, the motions of stepping up and of stepping Fig. 99. — Roll of sheet wadding applied after tendon transplantation before applying the plaster. MUSCLE AND TENDON OPERATIONS 61 Fig -Sheet wadding being applied sheet wadding. of forward, as well as the extension of the knee are largely dependent on the quadriceps. When this muscle is absent, or deficient, one or more of the posterior thigh muscles may be transferred forward. While in transplantation none but good strong muscles should be used as a rule, in the case of the knee a weak muscle, when there are no others, will help give stability when trans- planted even if it is not strong enough to extend the knee with force. When such a transplant- ation is performed the patient or his relatives should realize the pur- pose of the operation in order not to expect more than the increased stability of the knee where such a weak muscle is used. 68. Plaster of Paris Bandage Following Trans- plantation in the Thigh. — A plaster of Paris bandage is applied from the toes to the groin and split on ei- ther side when dry enough. Fig. 101.— Sheet wadding rollers applied for plaster. The knee is held slightly After a tendon or muscle transplantation the plaster hyperextended. No pres- should extend as high as possible on the leg and include &me h M bg allowed on the foot. the knee cap or on the transplanted muscles. To avoid this a great deal of folded sheet wad- ding is laid over the anterior part of the thigh and patella before ap- plying the circular sheet wadding (see figures 99, 100, 101). The foot of the plaster should be ele- vated and always loosened but strapped at either side. While there is usu- ally much swelling there will be comparatively less if the operator avoids roughness in handling the tissues. After Treatment The patient is kept on his back for a week and then raised forty-five degrees on a bed rest for part of the time. When the swelling has sub- Fig. 102. — A plaster whether extending to the groin or the knee may be split at the sides so that it can be loosened or taken off. 62 TECHNIQUE OF OPERATIONS sided he may sit up in bed. He should not move much for two weeks; after that he may change his position frequently in bed. At the end of six weeks he is allowed to get out of bed in a chair or go-cart. At the end of eight weeks the plaster is changed and the patient walks with crutches on the other leg, gradually using the leg operated on. A caliper splint is used after the tenth week, replaced by the plaster at night. Muscle training and exercises are kept up for a year and a half at least. The knee is allowed to bend fifteen degrees at first but not more than forty-five degrees for a year; after that flexion is allowed just short of a right angle. Early stretching beyond a right angle weakens the muscle. 69. Myotomy of the Adductors and Hamstring Muscles. For Con- tracted Muscles. — When the adductor muscles and hamstrings are contracted and will not yield easily to gradual or forcible stretching under anaesthesia, they are better lengthened in the tendinous portion as described under tendon lengthening. The contraction may be due to disease, to injuries or to habit of position or abnormal tensions, and in spastic paralysis it is often necessary to throw the contracted spastic muscle temporarily out of commission. In this class of spastic cases a simple myotomy may be done. If it is necessary to put the muscle ab- solutely out of commission, in order that locomotion may be possible, either a transplantation of the muscle is made to where it will be more useful or a section from the muscle is removed. 70. Operation for Tenotomy of the Hamstrings or Tendon Length- ening. — This operation should never be done subcutaneously. A very small incision should be made over the outer and another over the inner side of the popliteal space. Each tendon is lifted out on a blunt dissector or grooved director and tenotomized, care being taken not to cut the nerves which are large. The surgeon may feel for each tendon, lift it and cut it in turn. The actual cutting of the tendon should be according to the rules laid down elsewhere in these pages under tenotomy and tendon lengthening (see section 127). The after treatment is the same as that laid down for myotomy of the hamstrings. See section 82. Sometimes a hasty operation is all that the patient will stand if he is weak or is bedridden. In this type of case the legs should be made straight and the muscles stretched enough at each joint simply to make standing and locomotion possible. The foot should never be forgotten. A good hip or patched up knee is not very useful if the foot cannot be used for standing. In a few cases one leg must be done at a time. In cases for myotomy when the patient is not strong enough to have one leg made good for weight bearing it is better to wait and strengthen the general condition by rest, exercise, hygiene, etc. 71. Myotomy in Spastic Paralysis. — A myotomy of the adductor or inner and outer hamstrings or of the peronei or the muscles of the leg or arm is performed in a similar way to that described under myotomy for the inner hamstrings. The surgeon should remember that tenotomy MUSCLE AND TENDON OPERATIONS 63 or tendon lengthening when applicable is preferable to myotomy except- ing in spastic paralysis and other paralysis when it is necessary to throw out of action muscles that are a hindrance to locomotion. Spastic cases not able to walk on account of the adduction of the thigh and flexion of the knee are greatly relieved by this operation. They may walk at first with difficulty and with apparatus only, but later will improve a great deal. 72. Operation for Myotomy of the Internal Hamstring. — A vertical incision four inches long is made on the inner and posterior aspect of the thigh at the junction of the middle and lower third down to the muscle layer. The semi-tendinosis is posterior and may be recognized by its long tendon, the semi-membranosis by its large bulk and low muscle fibers, the gracilis is forward of this with a long tendinous portion and the sartorius is a flat muscle, narrow and long with parallel edges; it has almost no tendon. The muscles selected for myotomy are taken in turn, the fibers are lifted on a director and cut a few at a time. This is repeated until the muscle is completely cut across. If the muscle is to be completely thrown out of commission, as in certain cross legged spastic conditions, a section one or two inches is cut out of each muscle as fol- lows. 73. Operation for Removing a Section from a Muscle. — In removing a section the muscle is cut twice. For the upper cut the muscle fibers are lifted on a director a few at a time as described above for a simple myot- omy. A second cut is made one or two inches below. The lower cut is made at once with scissors. When the muscle is very vascular it is transfixed in one or two places with a stab needle, double ligatures passed through interlocked, and tied as in tying pedicles. The muscle is then cut. A second cut is made one and one-half inches lower, the muscle tied off in the same way. The tying of a muscle before cutting is rarely necessary. The ends thus separated and tied are not apt to reunite. The subcutaneous fat is sutured with interrupted chromic catgut sutures number 00, the skin with continuous chromic catgut sutures number 00. No hemorrhage is likely even when large vascular muscles are cut across. The operator may prefer to turn back and suture the ends of the muscle myotomized. This will effectually prevent reunion. At the time of operating on the muscles, the joints should be limbered up allowing normal motion at the hip; the knees hyperextended slightly and flexed to a right angle. The ankle motion should also be investigated and made suitable for weight bearing and walking. In other words, the deformities and limitations of motion should be overcome. After Treatment The joint about which the myotomy is done should be immobilized by a plaster of Paris with the muscle held stretched out for eight weeks. When the plasters are removed, caliper splints should be used to keep the 64 TECHNIQUE OF OPERATIONS knees slightly hyperextended. The length of time necessary for the caliper splints depends on the tendency of the knee to contract. The splints are omitted a little and the time increased accordingly until they are worn each day one or two hours only. This is kept up for a year. The abduction is maintained part of each day by a wooden spreader between the braces. Any tendency to recontraction is followed by more vigorous use of the splints. The legs should be watched so that motion in abduction is easy and hyperextension of the knees possible without using force. 74. Operation for Tenotomy of the Adductor Magnus. — This tendon is easily felt just above the internal condyle of the femur. An incision is made one-half inch or one inch long just enough for the finger to feel the tendon (see figure 48), it is hooked up on a blunt dissector and tenotomized; one suture closes this incision. This operation is especially useful for contractures of the unopposed adductor; it is also useful in helping relax a difficult and shortened dislocated femur, or before per- forming an arthrodesis at the hip or to help overcome adduction for any reason. CHAPTER III OPERATION IN CASES OF PARTIAL AND TOTAL PARALYSIS 75. Arthrodesis at the Knee in Paralytic Conditions (See also Chapter II). — In infantile paralysis and other paralytic conditions elaborate operations and heavy apparatus are to be avoided whenever possible. When there is a complete paralysis of the muscles about both knee joints, especially when the hip muscles are good, it is often de- sirable to relieve the strain of carrying apparatus by stiffening one knee. The usual semilunar incision is to be avoided as should most of the cross incisions in paralytic conditions. The circulation and repair is naturally poor. In order to interfere as little as possible with the cir- culation, longitudinal incisions can be made on either side of the patella four or five inches long in order to allow easy retraction of the tissues. Very much less disturbance of the circulation is obtained by this method than by the usual semilunar incision. A bayonet incision is often pre- ferred in these cases. OPERATION A rubber bandage is applied from the toes to the groin and a tourniquet is applied here, the leg having been carefully prepared. Any deformity, such as flexion or bow leg or knock knee should be corrected. A bayonet incision or two parallel incisions are made four inches long, one, one inch from the outer border, and the other, one inch from the inner border of the patella (see figures 119 and 120). They should extend from the cross incision over the patella upward and downward two inches. The incisions are carried down to the bone, the soft tissues retracted exposing the knee joint (see section 92). The lateral ligaments are incised or detached subperiosteal^ and an osteotome is used to remove the articu- lar surface of the tibia or a saw when a large slice of bone is to be removed. The lower end of the femur is also shaved off with an osteotome, the two bony surfaces brought into firm apposition and sutured laterally and anteriorly by means of heavy silk or silver wire. Bone plates may be used, vanadium steel plates are easily bent and the surface of the bone should be cut with an osteotome to receive them so that their surface will lie flat. The under side of the patella may be cut away with an osteotome and mortised into a groove cut in the anterior surface of the tibia and femur, the patella being pulled down and firmly anchored to those bones by means of silk (see figures 103, 104, 105). This latter procedure is unnecessary 65 66 TECHNIQUE OF OPERATIONS when a bony arthrodesis has been done. It may be used as a substitute for the bone operation. A bone graft from the tibia will help lock the bones together. The graft is taken from the same leg, as recommended by Albee. In cases other than infantile paralysis an arthrodesis is done Fig. 103. — After excision or arthro- desis, silk ligaments applied to the patella, step I. Fig. 104. — After excision for arthrodesis, silk ligaments ap- plied to the patella, suture of patella tendon, step II. like an excision through an anterior semilunar incision. See elsewhere in these pages, excision of the knee. See section 97. 76. Operation for Flail Condition of the Knee. — When there is a paralysis of the muscles of the leg in extensive paralytic conditions not only is the knee flail because of the lack of power in the flexors and ex- tensors but the ligaments lack tone and are stretched out so that there is a lateral flail condition as well as an antero-posterior. For the slight conditions, the Bar- low silk ligaments are suffi- cient. For the very extreme cases an arthrodesis at the knee and a bone graft in addition is indicated. This eliminates elaborate appar- atus and allows the use of the leg without cumbersome braces. When the hip mus- cles are good the result is especially gratifying. Loco- motion becomes easy, the weight of apparatus is eliminated and the circulation in the leg becomes greatly improved. Fig. 105. — After exci- sion for arthrodesis, silk ligaments applied to the patella, wound closed, step III. Fig. 106. — View of popliteal space inci- sions for silk liga- ments. OPERATION IN CASES OF PARALYSIS 67 77. Operation for Inserting Bartow Silk Ligaments at the Knee in Paralytic Conditions. — The Bartow method of inserting silk ligament has proved of service especially at the knee and shoulder. The lig- aments are introduced intra-articularly going through the bone be- low, the joint and the bone above, then down in front of the bone, preferably through the capsule of the joint and in front of the bone below and tied. They may be inserted subcutaneously with- out incision, at the shoulder and at the front of the knee. At the back of the knee, however, it is better to make a small incision (see figures 108, 109 and 110) for the en- trance and exit of the special curved drill. This instrument con- sists of a handle (see figure 109), and a set of drills which are long and have different curves, the operator selecting the curve most adapted to the joint which he is operating upon. When there is no power of extension of the knee or when this power is Fig. 107. — View of popli- teal space, insertion of a pos- terior inner silk ligament. 1. Semi-tendonosis. 2. Semi- mem branosis. 3. Gracilis. 4. Inner head of gastrocnemius. 5. Femur. 6. Tibia. Fig. 108.— View of popliteal space, inser- tion of a posterior ex- ternal silk ligament. 1. Biceps. 2. Gastroc- nemius. 3. Femur. 4. Tibia. Fig. 109. — Bartow drill. The handle allows the drill to protrude slightly as it enters the bone. The drill handle slides back on the drill and is held by a thumb screw. The drills are made with different curves all fitting into the drill handle. so slight that it is impossible for the patient to use the knee satisfactorily without a splint, the Bartow silk ligament may be used instead of a brace. 68 TECHNIQUE OF OPERATIONS They will hold the knee firmly, sometimes allowing a little motion but not enough to give way when weight is applied to the leg. When there is a flail condition of the knee four or six ligaments may be applied, two anteriorly and two posteriorly. When the knee tends to hyperextend backward and there are muscles anteriorly, two posterior ligaments may be used. They will, however, limit the motion of the knee some- what. Where the muscles are weak this limitation is not undesirable. In selected cases the Bartow silk ligaments are most useful at the knee. OPERATION The leg having been cleaned, prepared and protected as for any joint operation, a Bartow drill (see figure 109), is entered one inch or one and Fig. 110. — Bartow silk ligament at the knee, in- sertion of the drill. The eye of the drill is threaded with silk. Fig. 111. — Bartow silk ligament at the knee, pos- terior ligament in place. Fig. 112. — Bartow silk liga- ment at the knee, insertion of drill. one-half inches from the middle of the tubercle of the tibia. The drill is pushed through the skin and bone at this point extending through the tuberosity of the tibia and upward (see figure 113), emerging at the top of the tibia into the joint; it next enters the lower surface of the femur and comes out anteriorly to the side of the patella. A piece of fine tough braided silk number 10 or linen thread is cut ten inches long, its two ends are threaded through the drill, the drill is withdrawn. This fine silk is used as a leader to draw the heavy silk through the bone. A num- ber 18 silk is threaded through the loop of the fine silk and drawn through the bone double. The drill is next introduced subcutaneously at the lower incision and made to protrude from the upper incision. The silk is threaded through it and brought down subcutaneously out through the lower skin incision (see figure 113). We now have the silk extending through the tuberosity of the tibia, emerging at the top of the tibia into the joint, into the lower end of the femur and out through the anterior OPERATION IN CASES OF PARALYSIS 69 surface of the femur and down subcutaneously in front of both bones (figure 113), to be tied in front of the tibia. In the same way a second parallel ligament is placed. There is then one to the outer and the other to the inner side of the patella. Where the knee joint is particularly relaxed, additional ligaments may be placed at the inner side and at the outer side of the knee joint and posteriorly (see figures 110 and 111). The knee is slightly hyperextended before tying the ligaments; they should be tied three times, double strands having been used for each ligament. The ends are cut about one-sixteenth of an inch long, the skin is lifted by means of forceps allowing the knot to slip below the skin and below the fat. The knot is compressed by means of a blunt in- strument, in order that it may not be too prominent under the skin. No sutures are necessary. Any other operation to be done on the hip or leg should be completed before tying the ligaments at the knee. No strain should be allowed on the new liga- ments after they are tied. When there is a ten- dency to hyperextension at the knee or when the knee joint is extensively relaxed, posterior liga- ments are applied in a similar way but at the posterior part of the tibia, and at the posterior part of the femur, a small incision above and a small incision below is made through which the drill is applied to the bone. Any lateral deformity or any permanent flexion should be corrected before inserting the liga- ments. An arthrodesis is preferable in very' heavy patients with extensive paralysis or in young patients with an extensive paralysis as the patient may be heavier later on. But when there is some joint stability or a little muscular power these ligaments are satisfactory. The after treatment consists of protection in plaster of Paris for eight weeks or longer; then a caliper splint is used until the patient is able to walk with confidence. The caliper then is at first worn loose, a little each day, then omitted a little each day until not needed. Fig. 113.— Bartow silk ligament at the knee, an- terior and posterior liga- ments in place. CHAPTER IV INCISION, PUNCTURES AND ARTHROTOMY 78. Operation for Displaced Semilunar Cartilage. — When operation is indicated for slight or considerable displacement of the semilunar carti- lage, one of several incisions may be used. An esmark is applied and a tourniquet. The leg should be prepared and the field of operation well protected, the knee flexed at right angle preferably off of the end of the operating table as suggested by Mr. Jones. The protecting sterile sheets should in- clude the foot and leg to above the calf. The upper / ^- — - sheets should extend down to a point two inches above the patella. The flexed knee hangs off of the operating table resting on a double sterile sheet which covers the other leg. After the skin incision, towels may be clamped to the edges of the retracted skin and a fresh knife and instruments used to com- plete the operation. A crecenteric incision (see fig- ures 114, 115) is made directly downward one-half inch for semilunar carti- to the inner side of the patella down to the tibia, lage, made with knee then curving at right angles along the upper edge of d- the tibia for two and one-half inches. The tissues are dissected up in one layer down to the tough fibrinous capsule for the full line of the incision. The flap is retracted inward and the fibers of the capsule incised leaving the synovial membrane unopened. Any bleeding points should be checked at this point. The synovial membrane is held up with a pair of forceps and nicked with a pair of scissors and then opened just above and parallel to the line of the tibia. This gives ready access to the semilunar cartilage. The inner semilunar cartilage is a little thicker through' than the external, it is elliptical in shape, while the external semilunar cartilage is not as thick through, and is circular and longer. If it is loose or turned up it should be lifted with a pair of forceps and a pair of blunt curved scissors used to dis- sect it from its underlying attachment as far posterior as possible, but in no case should the lateral ligament of the joints be cut to make the removal more complete. The joint should in no other way be interfered with. All but the most posterior portion of the carti- lage is removed. Any bleeding in the joint is checked by hot saline solu- tion on cotton pledgets; fine catgut or silk is used to close the synovial 70 Fig. 115. — Anterior view of semilunar cartilage incision. INCISION, PUNCTURES AND ARTHROTOMY 71 membrane. The joint capsule is brought together with interrupted chromic catgut sutures number 00, the skin, fat and fascia with inter- rupted chromic catgut number 00. A splint or plaster may be used for three days. After that no apparatus should be used. Small degrees of motion are encouraged after the fifth or seventh day. The patient is up on crutches at the end of two weeks, and weight bearing allowed at the end of the fourth week. The surgeon should be guided by the amount of swelling. When it is possible to handle the tissues care- fully at the time of operation surprisingly little reaction occurs from the operation. 79. Operation for Torn Crucial Ligaments at the Knee. — Injury and repair of crucial ligaments. The damage is readily detected when operating for deranged condition of the joint and any tear repaired with quilted silk sutures. The motion of the crucial is then tested with the knee flexed and extended. See figure 117. The anterior crucial ligament extends anteriorly from the inner to the outer side obliquely. The posterior crucial ligament extends from the outer side to the inner nearly vertically. The patient lies on his back, the operator stands on the side of the leg to be operated on. An esmark rubber bandage and tourniquet is applied, the skin having been prepared with scrupulous care as to aseptic detail, sterile sheets cover the upper third of the thigh and lower leg and foot from two inches below the tibial tubercle. An incision is made in the median line starting four inches above the patella and extending vertically downward in the median line to just below the adductor tubercle. The dissection is carried down in one layer through the skin and fat, the edges of which are dissected up and re- tracted. At this point the operator if he wishes may additionally pro- tect the incision by clamping sterile towels to the retracted edges of the skin and fat and use fresh instruments for completing the operation. The incision is made to the bone over the patella; the muscle and ten- don adjoining are separated in the median line above and below. A saw is used to separate the patella. When it is cut two-thirds through, the knee is then flexed and a chisel or osteotome is used to complete the separation. When the synovial membrane is opened above the patella, the operator carried the dissection upward, opening the joint cavity completely under the muscles laying bare the uppermost cul-de-sac. The patella ligament is split separating it into two lateral halves, also the sub-ligamentous fat; each half of the patella is now retracted and the knee flexed allowing a good view of the joint and the crucial ligaments. This incision will give a complete view of the synovial cavity ante- riorly. Any deranged condition having been remedied, the knee is straightened, the quadriceps entensor and the joint cavity beneath it are carefully brought together with chromic catgut sutures number 00 down to the patella. Silk or kangaroo tendon is used to bring the soft tissues together immediately at the upper end of the patella and imme- 72 TECHNIQUE OF OPERATIONS diately at the lower end of the patella. When for any reason these materials are undesirable or not available, chromic catgut sutures num- ber or 00 may be used. No sub-patella patella sutures are necessary; the halves of the patella are carefully adjusted and the sutures placed in the overlying fascia. Sometimes there is a little blood left in the joint but this will do no harm. As a rule washing with salt solution will re- move any that is present. Anj^ very small amount of free blood will not interfere with convalescence. The muscles and overlying tissues having been brought together with interrupted chromic catgut sutures number 00, the skin and fat are brought together with continuous chromic catgut sutures number 00. A posterior wire splint or a metal splint holding the knee very slightly flexed is applied and a plaster may be used over this. If a plaster is used it should be removed on the third or fifth day. Gentle motion is begun on the fifth or seventh day and as the patient progresses, he is encouraged to use the muscles and may be up with crutches at the end of ten to fourteen days. In the fourth week, he is encouraged to bear a little weight on the leg. 80. Arthrotomy. — A knowledge of the important routes of ap- proach to the joints will facilitate any joint exploration, the removal of foreign bodies, the repair of traumatic conditions, the adjustment of difficult fractures, the reduction of old and difficult dislocations, to mobilize joints where motion is partially or totally lost, and to restrict or stiffen the joint as in certain paralytic conditions, to relieve and thoroughly drain suppurative conditions; a knowledge of the important routes of approach to the joint is very important. For each case, the operator will select the incision best suited for the individual condition. Joint operations should never be hastily considered and should be avoided by any one not familiar with the best surgical technique. In all operations on the joints, the incision should be made down to the synovial membrane and large enough before opening the synovial cavity. All bleeding should be stopped and the synovia carefully opened. The joint structures should be tampered with as little as pos- sible, the synovial membrane brought carefully together and the layers over it closed in order not to disturb the function of the periarticular tissues. Unnecessary separation of the tissue layers is to be avoided. Any ligaments that must be cut should be loosened periosteally when possible, in order that they may be easily replaced. Early motion should be the rule, gentle at first, and gradually increased. 81. Arthrotomy at the Knee. — Arthrotomy at the knee is indicated for certain internal derangement, for the removal of foreign bodies or loose bodies, derangement of the semilunar cartilage, suppurative con- ditions, fractures, etc. For a good view of the joint and complete ex- ploration of the anterior cul-de-sacs an anterior median incision through the patella is the best. This will give an extensive view of the synovial pouches anteriorly, as well as all other anterior structures. The internal semilunar lateral incision is more useful for derangement of the inter- INCISION, PUNCTURES AND ARTHROTOMY 73 nal semilunar cartilage; the external is rarely deranged, an external semilunar will give ready access to the outer semilunar. This cartilage is rarely the cause of trouble. For plastic operation the two longitudinal antero-lateral incisions are generally preferred. For excision or arthro- desis the semilunar or "U" shaped incision is used. For drainage, numerous incisions have been recommended. The operator should not neglect the upper and lower parts of the synovial cavity anteriorly and the joint cavity behind in any extensive suppurative conditions. For displacement of the knee cap which is usually displaced outward, an antero-lateral incision will allow the tears in the capsule to be rem- edied and give access to the patella tendon which should be displaced as described in these pages elsewhere. For pre-patella bursitis a longitudinal incision just to the side of the bursa is used. For fractures of the patella a long median incision is made or a lateral just to the inner side of the patella but long enough through the skin and fat to allow retraction and complete exposure of the patella. 82. Anterior Median Incision. Splitting the Patella into Lateral Halves. — This incision is useful where a complete view is desired of the joint and its an- terior cul-de-sacs. It is useful for ob- scure internal de- rangement, for inspection and re- pair of the crucial ligaments, for the removal of loose bodies or pannus formation and for cleaning out the joint in septic con- ditions. It gives Fig. 116 a wide view of the knee and the most complete. This incision is not the best for reaching the semilunar cartilages. There is surprisingly little reaction following this operation. See figures 116, 117. The patient lies on his back, the operator stands on the side of the leg to be operated upon. An esmark rubber bandage and tourniquet is applied, the skin having been prepared with scrupulous care as to aseptic detail; sterile sheets cover the upper third of the thigh and lower leg and foot from two inches below the tibial tubercle. Occasionally the esmark and tourniquet may be omitted, if there is any reason for haste. An incision is made in the median line (see figure 114), starting from the patella and inclining slightly to the inner side, four inches upward. Anterior me- dian incision. Fig. 117. — Anterior median incision retracted, knee flexed showing view of crucial liga- ments. 74 TECHNIQUE OF OPERATIONS The incision extends over the patella and below, in the median line, to just below the adductor tubercle. The dissection is carried down in one layer through the skin and fat, the edges of which are dissected up and retracted. At this point, the operator, if he wishes, may additionally protect the incision by clamping sterile towels to the retracted edges of the skin and fat and use fresh instruments for completing the operation. The surgeon may proceed in one of two ways. (A) Dissecting through the tendon above the patella, extending up- ward and inclining slightly to the inner side of the median line, then splitting the tendon below the median line before sawing the patella. (B) Or the tendon above and below the patella is split a little way before sawing the patella. With the leg straight the patella is sawed two-thirds through, the knee is now flexed forty-five degrees and a sharp osteotome used to complete the separation, then the tendon above is divided inclining to the inner side of the median line and the tendon below is split in the median line. A better exposure of the joint is possible if the patella is cut to the inner side of the median line as there is less mobility of the inner fragment (suggested by Dr. Brackett). When the synovial membrane is opened above the patella, the operator carries the dissection upward, opening the joint cavity completely under the muscles, laying bare the uppermost cul-de-sac. The knee is flexed ninety degrees and the patella retracted laterally. The patella ligament is split, separating it, also the sub-ligamentous fat. Each half of the patella is now retracted and the knee flexed allow- ing a good view of the joint and the crucial ligaments. The dissection of the tendon above should be carefully made so that it may be accurately approximated afterwards. The fat pad under the patella should be split in the median line, and its ligament on the inner side carefully adjusted when the sutures are placed, bringing the fat' pad together in its original position. Any deranged condition having been remedied, or loose body removed, the knee is straightened, the quadriceps extensor and the joint cavity beneath it are carefully brought together with chromic catgut sutures number 00 working from the patella upward. The joint should be handled as little as possible. Silk or kangaroo tendon is used to bring the soft tissues together immediately at the upper and lower end of the patella. When for any reason these materials are undesirable or not available, chromic catgut sutures number or 00 may be used. The halves of the patella are carefully adjusted and the sutures placed in the overlying fascia. No other patella sutures are necessary. Sometimes there is a little blood left in the joint. This will do no harm. As a rule, washing with salt solution will remove any that is present. Any very small amount of free blood will not interfere with convalescence. The muscles and overlying tissues are brought together with interrupted chromic catgut sutures number 00, the skin and fat brought together INCISION, PUNCTURES AND ARTHROTOMY 75 with continuous chromic catgut sutures number 00; a dry dressing is applied. A posterior wire splint, holding the knee very slightly flexed, is used and a plaster may be used over this. If the plaster is used, it should be removed on the fifth day. Gentle motion is begun on the fifth or seventh day by pressing with the hand in the popliteal space and raising the knee, letting the heel rest on the bed. As the patient pro- gresses, he is encouraged to use the muscles and may be up with crutches at the end of ten to fourteen days. In the fourth week, he is encouraged to bear a little weight on the leg. When there is restricted motion in the knee, it is sometimes impossible or difficult to flex the knee without injury. In these cases, the patella is separated with the knee straight. In the aged, or where the health is not good, when this operation is done for low grade painful suppurating conditions, it is often nec- essary to operate quickly and spend time in wiping out the cavity or in freeing it of foreign material. In these cases, the incision is made rapidly through the skin and fat as above described and dis- sected back only enough to recognize the tendons and to expose the patella. This is sawed rapidly two-thirds through. An osteotome is used to complete the separation. The upper synovial cavity is rapidly opened with a pair of blunt scissors curved on the flat side. The lower jaw of the scissors is entered into the joint above the patella and lifts the tendon and synovia, cutting it upward and extending slightly to the inner side of the median line. The tendon below is split through with the knife and the joint laid open completely. The knee is flexed at right angles. In these cases requiring haste, the joint is carefully treated. The important sutures are used, one or two in the sub-patella fat, a heavy one above and below the patella and a continuous chromic catgut suture 00 in the fibrous tissue over the patella. If there is time, the synovial cavity is closed slowly and carefully, — if not, it is sutured rapidly with the tendon by a continuous chromic catgut number 00. If drainage is necessary, tubes are placed into large punctures at the side of the joint made before the in- cision is closed. This rapid operation has been done in patients over sixty years of age. With a painful infected condition, requiring open operation, ultimate recovery is possible in some cases, ^ IG - . n 8- — Pos- with sixty to _ ninety _ degrees of motion. £^ e r a C^^g 83. Posterior Incision. — The posterior incision is in the median line used for loose bodies in the posterior part of the joint t £ re ? . mclies above or the removal of the exostosers, or for drainage when anterior and lateral drainage is not sufficient. A long vertical posterior median incision is made five inches long starting three inches above the joint line which may be felt in front. The incision is carried down 70 TECHNIQUE OF OPERATIONS through the skin and fat for the full length. A blunt instrument is then used separating the tissues between the outer side of the vessels and the biceps and outer head of the gastrocnemius. The tissues are then re- tracted and the synovial membrane opened. See figure 118. 84. The Bayonet Incision at the Knee. — This incision combines half the outer and half of an inner vertical incision with a cross incision over the patella or just below it. Whether the upper or the lower half is outward is a matter of choice. In order not to weaken the inner attachments of the patella to the tibia the upper portion of the bayonet in- cision had better be made one-half inch to the inner side of the patella starting three inches above the patella, extending across the patella one-half inch to its outer side and then downward three inches (see fig- ure 119). The cross incision is not made at right an- gles but inclines downward. In certain fractures and injuries this incision will be found of advantage. For a rapid excision in cases where the circulation is poor and the object of the excision is to obtain a stiff knee by grafting as well, this incision has many advantages. It is vertical and interferes very little with the circula- tion considering the size and the good exposure of the joint. The incision gives access to the tibia below, al- lowing a bone graft to be removed and placed across the excised joint, as suggested by Albee. 85. Two Lateral Incisions at the Knee (Fig. 120). — For exploratory arthrotomy or for suppurative con- ditions the median incision is preferable, but in cer- tain fractures or operations on the tibia and femur or on both bones, one or two lateral incisions are more practical than the anterior median incision. In certain suppurative conditions where the median in- cision has been used to expose the joint completely, two short lateral incisions may be used for the neces- sary persistent drainage after closing the anterior median. The lateral incision extends four to six inches on either side of the joint, one inch from the patella with their middle at the middle of the patella. These incisions are preferable for arthroplasty. A longitudinal incision is made four inches long, one inch to the inner side of the patella, starting two inches above the joint. The incision is carried down to the bone. All the tissues are lifted subperiosteal^ from the femur and from the tibia, allowing a free exposure as the incision Fig. 119.— I. U- shaped and Bayo- net incision at the knee. II. Bayonet incision; the up- right portions should be one-half or one inch outside or inside of the pa- tella. The horizon- tal portion may be over or just below the patella. Fig. 120. — Two lateral incisions at the knee. INCISION, PUNCTURES AND ARTHROTOMY 77 is retracted forward, and backward. A second incision is made ex- tending four inches above and three inches below the joint line and one inch to the outer side of the patella. 86. The U-Shaped Incision at the Knee (Fig. 119). — An outer incision is started three inches above the joint extending vertically downward one-half inch outside of the patella down to the level of the tubercle of the tibia and then horizontally across the tibia and extending vertically upward parallel to the first incision and one-half inch to the inner side of the patella extending to a point three inches above the joint. The incision is carried down to the bone if an excision is to be done. If the joint is to be opened and explored the incision is to be carried down to the capsule only. When the flap is retracted the synovial cavity is care- fully opened. 87. Arthrotomy for Fractures About the Joints. — The necessity of immediate operation in fracture about the joints depends, as in other fractures, on the acuteness of the local and general reaction. When these do not contra indicate immediate operation, certain fractures about the joint may require treatment by the open method. Among these are fractures of the patella, fracture of the olecranon and certain fractures of the surgical neck of the humerus and certain fractures of the neck of the femur, all compound fractures, even when the protrusion of the bone has been extremely slight, all fractures that cannot be maintained or where apposition is impossible, many fractures combined with dis- location, articular fractures with pieces locking or limiting the joint action. Where there is a great deal of trauma and in multiple fractures and in cases where there is a great deal of shock all that can be done is to im- mobilize the parts until a favorable time for operation. In selecting a suitable time for operation when it is found necessary to operate on a fracture if there is no immediate contra indication, the sooner it is done the better. Where there is tremendous swelling the surgeon should al- ways wait. All cases should be operated on that show no union after three months of good treatment. Methods of treating the individual fracture cannot be considered in a limited space like this. The writer has described the routes of approach to the different joints and the technique of these. This will enable the surgeon from his knowledge of fractures to select the route best adapted for the individual treatment required and when necessary two or more incisions may be used. A knowledge of the technique will enable the surgeon to work rapidly in reaching the fracture on which he expects to spend time. 88. A Method of Treating Overlapping Fractures. — Where the bones overlap, an excellent method of treatment is one suggested to the writer many years ago by Dr. Edward Martin of Philadelphia. In the opera- tion when the surgeon has reached the fracture the ends are freed. A tough tape or webbing is used ten or twelve feet long, sterilized. The 78 TECHNIQUE OF OPERATIONS two ends of the tape are tied together, a loop of the tape is placed over the distal end of the bone. The other end of the tape is thrown over the foot of the operating table, a thirty-five pound weight is attached to this by an assistant. In about five minutes the bones will be found to be separated at least one inch. The weight is then held up by a non-sterile assistant, the tape taken off of the end of the bone and clamped to the sheet on the operating table, so that it will not slip away while the surgeon works on the fracture. When the muscles are in fairly good tone or the overlapping of bone has been great, it will be found that the bones will overlap again in four or five minutes. A re- application of the tape will separate the bones again for the same length of time. The end of the lower bone should not be cut or freshened until all other procedures are done which require separation of the bone. When these have all been done the end of the bone over which the tape has been placed is freshened. After this the tape should not be placed on the end of the bone, unless it is very necessary, but the two ends allowed to come together and held by a clamp until the operation is complete. Very bad overlapping fractures have been treated in this way in fresh cases without the necessity of shortening the bone. In old fractures no more bone need be removed than is required by the conical condition of the ends of the bone. 89. Fractures of Long Standing Still Ununited or United with De- formity, Preventing Function. — In fractures of long standing where there is a mild infection, conservative treatment should be tried first. When this has been tried free drainage should be established and at the same time the ends of the bone freshened up slightly. Unless the infection is marked, in many of these cases when the infection disappears, union has also taken place. In any case where there has been infection, no plastic operation should be used until the infection has been entirely absent for at least nine months, a year is safer. Where the in- fection is very mild and of long standing, during the process of treatment the patient may be allowed to walk on the other leg if the local reaction is not too great. Sometimes he may walk a little on the affected leg. It is of advantage in certain cases to use a Thomas splint to take some of the weight off of the affected leg, the patient being allowed to bear weight on the ball of the foot, the splint taking all the weight off of the heel. Where the x-ray shows conical bone ends it is practically useless to expect union without surgical interference. 90. Fracture of the Patella. — Fractures of the patella usually re- quire treatment by the open method. Where the fracture is not com- pound the joint should be disturbed as little as possible, the fragments adjusted and sutured, if possible, by absorbable material. The suturing of the patella may require drilling the bone. The drill holes should not be made through to the under surface of the patella but from the fracture to the front of the patella. Multiple irregular fractures are often INCISION, PUNCTURES AND ARTHROTOMY 79 very difficult to treat. Too perfect adjustment at the expense of exces- sive manipulation is not desirable in extremely difficult cases. A simple transverse fracture may be sutured with kangaroo through the perios- teum and overlying fibrous tissues. The knee should be kept straight in plaster three weeks and then gentle passive motion without force is instituted daily, allowing the heel to rest on the bed while the knee is being slightly flexed, and the plaster reapplied afterwards. The plaster is removed a part of each day after the fourth week and gradually omitted entirely. The patient walks on the leg with the plaster and crutches in four weeks. 91. Fractures into the Knee Joint.— Fractures and oblique frac- tures into the knee joint will often require open operation and adjust- ment of the fragments. Bone grafts, plates or phospho bronze or silver wire may need to be used. The lower end of the femur is accessible from the sides through vertical incisions just anterior to the condyles posterior enough to avoid opening the joint capsule. The upper tibia is reacted by anterior incisions. 92. Operation for Dislocation of the Patella. — When the patella is excessively loose and dislocates easily, the simplest operation is that described by Dr. Goldthwait "splitting" the patella tendon. The dis- placement of the patella is usually outward. It reduces itself but has torn the inner capsule which becomes stretched, giving a predisposition to future dislocation. OPERATION An esmark and tourniquet is applied, the usual preparation and protection of the field of operation is used. An incision is made three inches long to the inner side of the median line extending from the middle of the patella downward. The skin and subcutaneous tissues are re- tracted in one piece exposing the patella tendon. This is raised on a blunt instrument and slit longitudinally; the outer half is detached subperiosteally, slid under the inner half and reattached by quilted sutures to the periosteum to the inner side. The deep tissues are brought together with interrupted chromic catgut sutures number 00, the subcutaneous fat with interrupted chromic catgut sutures number 00, the skin with continuous chromic catgut sutures number 00. A small dressing is applied and a plaster of Paris bandage from the toes to the groin. It is split on both sides. Slight knee flexion is allowed in six weeks; walking with the plaster on in eight weeks. The plaster is gradually omitted after that. 93. Tapping the Knee Joint. — The most scrupulous aseptic pre- cautions are necessary both as to the preparation and the protection of the field of the operation. The knee may be tapped under the vastus internus, the vastus externus or posterior to the outer border of the patella. The operator uses the other hand or has an assistant press the 80 TECHNIQUE OF OPERATIONS swelling from the other side of the joint. This makes it easier to insert the trocar. It may be advisable to wash out each joint pocket separately. When there is much effusion it is not difficult to reach the joint. The skin is drawn to the side so that the hole in the skin and muscle will be out of line when the needle is removed. If fluid is to be drawn, and other solutions are to replace it, the amounts should be carefully measured. Two good graduated metal syringes are used, one used to aspirate, one to inject. All of their parts should be tested beforehand. The trocar is made to enter the joint and then is connected with the syringe. As little air as possible should enter the joint. The trocar should be of large diameter as the fluid may be thick or flaky. When the patient is not anaesthetized for the operation it is often well to have a short flexible tube connect the trocar with the syringe. This should be fastened at both ends by silk ties so that it will not leak easily when pressure or suction is used. If the joint is to be washed out a definite amount of fluid is injected and the return measured in a sterilized measuring glass. When the process is complete the amount of fluid left in the knee joint should not exceed one and a half ounces. This amount will not cause pain or too much distension in an adult knee. Dr. Murphy uses a formalin glycerine solution as follows: — Liquor formaldehyde 2% in glycerine, about ten drops of the formaldehyde to each ounce of glycerine. This acts very well in infectious synovitis. But it should not be used in arthritis deformans nor in old chronic arthritis. The tapping may be done with ethyl chlorid or novocaine adreneline solution, 1%. The solution should be prepared twenty-four hours before it is used. CHAPTER V OPERATIVE TREATMENT IN CASES OF JOINT ANKYLOSIS 94. Excision of the Knee to Obtain Ankylosis. — An esmark rubber bandage is applied from the toes to the groin and a tourniquet applied at the upper part of the thigh. The esmark is removed, the skin of the leg prepared for operation, and the leg protected with sterile sheets. A bayonet incision (see section 84), or a U-shaped incision, is made starting two inches above the joint and one inch to the side of the patella extending vertically downward to the level of the tuberosity of the tibia, then horizontally across the tibia, and up on the side, one inch from the patella to a point one and one-half inches above the joint. The sides of the "U" should be parallel, and about one inch from the edges of the patella. The incision is carried down to the bone and the flap dissected up rapidly in one piece. The ligamentum patellae is cut across or the patella may be sawed through; the soft tissues are dissected up from the femur. The tissues are removed from the bone preferably with the periosteum. The tibia is likewise exposed preferably sub- periosteally and the tissues retracted. Any disease of the soft tissues is now cleaned away. The knee is next flexed acutely, the crucial liga- ments cut and the joint surface brought into view. The lower end of the femur is brought forward by displacing the tibia backward, the soft tissues removed subperiosteally from its posterior surface. The upper end of the tibia is next brought forward by displacing the femur back- ward, the knee being flexed. The soft tissues are removed subperios- teally from the back of the tibia. There is no danger of injuring the nerve and vessels by this subperiosteal method. The operator should work carefully but rapidly. A thin slice is removed from each bone in such a way that when the bone surface will be brought together the knee will be flexed ten or fifteen degrees. The bones are held perpendicular to the table while the saw is being used, usually the tibia first. In children the epiphysial line should be avoided. Save as much bone as possible. The bones should be placed in line as viewed from the front and in 10 degrees of flexion. When the operation is one for disease of the bone the diseased focuses are cut out with an osteotome or chisel in the healthy bone around the diseased cavity, the cavity is chiselled out carefully, and all the disease removed. It is better not to use a curette for this purpose. The slice of bone removed from the tibia or femur need not be thick if the cavities are chiselled out. There is very little shortening of the leg by this method. When the operation is done not for disease but to stiffen the knee, 81 82 TECHNIQUE OF OPERATIONS only a very small slice is removed from each bone. After removal of bhe bone, the tissues are washed with hot saline solution and the tour- niquet loosened to allow any bleeding points to be caught and tied. When it is necessary to remove a good deal of bone with the saw, the tissues must be .very completely dissected away subperiosteally from the front and back of the tibia as well as from back and front of the femur so that they may be retracted allowing fully an inch of the bone to protrude denuded of periosteum. In fitting the bones together, any tendency to bow leg or knock knee should be corrected. The operator should repeatedly notice the position of the foot and the direction which it is pointing before he removes the bone from the tibia, as it is very easy for the tibia to be inwardly or outwardly rotated during the operation. The bones are placed in apposition and may be held there by bone graft from the same leg by bone plates by kangaroo or silver wire sutures. The bone ap- position should be very perfect and the bones held firmly together in order that perfect union will be obtained. The operation should be done without any unnecessary waste of time. The deep tissues and periosteum are brought together with interrupted chromic catgut sutures number 00, the deep tissues with interrupted chromic catgut sutures number 00. A posterior metal or wire splint properly padded and bent to the desired angle made ready before the operation is now applied directly to the leg. A plaster of Paris is applied over this includ- ing the foot and extending well up into the groin. This should remain in position for at least four weeks. The dressing is inspected through a window cut in the plaster. Weight bearing is allowed in the fifth or sixth week if there is no disease and very little reaction at that time. When the operation is done to remove disease there is often too much reaction for weight bearing for a long time after the patient is allowed to be up and about. In the severe cases there is sometimes sinus formation but the ultimate healing occurs in a much shorter time than if the operation were not done. In these cases, weight bearing will not be tolerated so early. Excision of the knee is rarely necessary after injury. Where there is flexion deformity, a McEwen osteotomy is preferable to any operation on the joint. This is especially so if there is any motion in the joint. Excision or erasion of the knee joint may be used in paralytic cases to give a stiff knee when there is no power in the muscles. Before doing an excision for disease of the bone, conservative treatment and drainage should be tried first. It has been recommended to transfer the posterior muscles to the side of the knee to prevent any tendency to flexion or subluxation. This should not be necessary and will prolong the operation which is usually done on patients with lowered local or general conditions or both. 95. Arthroplasty for Ankylosis of the Knee. — Ankylosis may be bony, cartilaginous or fibrinous, it may be periarticular, ligamentous OPERATIVE TREATMENT OF JOINT ANKYLOSIS 83 and capsular, or extra articular, that is, skin scars, tendons, fascia, nerves and arteries. The form of ankylosis that exists will determine the treatment. A partial ankylosis at certain points had better not be treated by an arthroplasty. Age must be considered, also the general condition of the patient. When the ankylosis is bony, cartilaginous or fibrinous, arthroplasty is indicated. When the condition is periarticular or extra articular, it may be treated by capsulotomy, tendon elongation, excision of exostosies, etc. Dr. Murphy lays stress on the following points: — The principles of asepsis to the finest detail are absolutely essential. One not familiar with the best surgical technique should avoid arthroplastic operations. The exposure of the joint must be generous and complete. The con- tracted capsular ligaments and soft parts must be freed and if necessary lengthened. The normal contour of the joint should be restored as near as possible. The operator should obtain a hyper-mobilization of the joint. The joint should be re-shaped to give stability. The inter- position of material to prevent reunion of the bone is necessary. The principle is to separate the bones and to interpose between them material to prevent ankylosis. The best material for this purpose is the human pedicle composed of fat, muscle, fascia or a combination of these. When this is not possible, a transplantation is made of fat and fascia from the trochanter bursa region or from the fascia lata. Materials such as ivory, celluloid or silver are not good. Materials that will not absorb or that absorb too slowly are not desirable. During the operation the soft parts should be freely liberated. Attach the interposing flap to one bone only and cover it completely. Early motion, that is, at the end of five to seven days, is necessary with or without gas or gas and oxygen. Dr. Murphy records failures in arthroplasty as due to first, insufficient and defective exsection of the capsule and ligaments, second, insufficient interposition of fat and fascia between the separated bony surfaces, third, infection, fourth, the sensitiveness to pain on motion after opera- tion. Cases of primary tuberculosis and cases of recent infection that have subsided are not suitable cases for arthroplasty. In operation, in addi- tion to the usual protection of the field of operation, after the skin and fat have been incised, towels should be clamped to the edges of the skin as an extra protection. The knee is the least favorable joint for arthroplasty. Operations on the knee are very difficult because of numerous factors. Among these are the peculiarity of the joint and the fact that not only motion must be obtained, but good weight bearing qualities. There must be firmness and yet free use. For this reason if the ankylosis is only partial and the knee is permanently flexed it is better in these cases to do a McEwen osteotomy above the abductor tubercle as described elsewhere in. tbrs? 84 TECHNIQUE OF OPERATIONS pages and in this way straighten the knee without trauma and give the patient a straight leg with the benefit of the motion which he had before the operation (see Osteotomy at the Knee, section 54). When the ankylosis is complete and requires an arthroplasty (see General Considerations in Arthroplasty), the following operation is described as outlined by Dr. Murphy. OPERATION The patient lies on his back, the operator stands on the side of the leg to be operated upon. The field of operation is properly protected and the leg below the knee so covered by sheets that the knee may be manipulated without disturbing the protection. A longitudinal incision is made four inches long, one inch to the inner side of the patella, starting two inches above the joint. The incision is carried down to the bone. All the tissues are lifted subperiosteally from the femur and from the tibia, allowing a free exposure as the in- cision is retracted forward, and backward. A second incision is made extending four inches above and three inches below the joint line and one inch to the outer side of the patella. The subperiosteal dissection is continued around to the outer and anterior side of the femur and tibia. The posterior part of the joint is not disturbed; a curved chisel is used to separate the two bones and give them the normal contours. A cavity is made in the tibia to receive each condyle and deep enough to permit extension. An exaggerated intracondylar notch and ridge are made. A " U " shaped incision may be used instead of the lateral, the sides of which are either side of the patella, extending one inch above the top of the patella, and going down and curved one inch below the patella. The skin and fascia flap are made carefully without disturbing the pre-patella bursa; the base of the flap is upward. A pedicle flap is made from the vastus internus and another from the vastus externus. These are placed over the condyles and between the patella and the condyles. If the operator prefers, he may use two rectangular flaps two and one- half inches by three and one-half inches, composed of the capsule and the subcutaneous fat with a base downward attached to the tuberosity of the tibia below the line of joint. This will include all the lateral capsule, fat and fascia. As to the choice of incisions, the two lateral incisions are preferable to the " U " shaped. The pedicles for arthroplasty at the knee may be taken from the vastus internus and externus as described above with the pedicle up- ward, or the fascia over the muscles may be split from above downward into two parts and folded over the joint and joined at the middle of the joint and under the patella. The flaps are separated with a blunt in- OPERATIVE TREATMENT OF JOINT ANKYLOSIS 85 strument from the overlying skin and fat and folded in between the bones. If the patella has been adherent it may be rotated one hundred and eighty degrees without disturbing the pre-patella bursa. The upper end of the patella may need to be trimmed with bone forceps to render it smooth and level before it is turned. When the vasti are used in this instance, the vastus internus and the vastus externus are sutured to the opposite sides of the quadriceps from which they are freed. This attachment will prevent the slipping of the patella. Baer has used successfully chromicized pig's bladder prepared for arthroplasty. Free fascia flap The operator may choose to cover the under side of the patella and the whole of the articular surface with a free fascia graft taken from the fascia lata. This is attached without rotating the patella. The flaps are sutured to the patella ligament and to each other in the median line. They are then sutured to the posterior capsule which has not been dis- turbed and should cover the tibia completely. When a free fascial trans- plant is used, it should be at least three and one-half by five inches. It should extend up under the patella. A carpenter and cabinet maker chisel, curved and straight, will give the best tools for shaping the joint. The normal outlines will tend to prevent luxation. The operator should be sure that the line of the leg is straight, and should remove sufficient amount of bone so that pressure between the bones will not cause ne- crosis of the transplanted flap. A wire splint or a Buck's extension with twelve pounds' weight is used after operation. Active and passive motions should be begun early. The patient is kept in bed for seven to ten days with this apparatus. CHAPTER VI OPERATION IN SUPPURATIVE CONDITIONS 96. Suppurative Conditions at the Knee. — In suppurative condi- tions at the knee joint if it is necessary to expose and wipe out the whole joint an anterior median incision will allow the most complete inspec- tion, irrigation and wiping out the cavity. When this incision is closed the pouches on either side and above the patella should be drained by punctures two inches long. Drains on either side of the patella may be used but should be avoided if the others are likely to prove sufficient. At the time of operation two lateral incisions may be necessary in those cases that require thorough irrigation, and tubes are inserted laterally. The important parts of the capsule are very little injured by the median incision with lateral drainage and the operation is just as quick and much more thorough than by two lateral incisions. If the patient will not stand a complete operation, two incisions are made vertically on either side of the patella for drainage only, tubes are placed to each joint pocket and gauze is used to gap the angles of the in- cisions. These remain for ten days and then are shortened. See last half of section 82. A plaster of Paris bandage is applied with large windows as shown in figure 449. Plaster ropes are used to connect two plaster cuffs, one at the thigh, the other on the calf of the leg. Large wads of sheet wadding are placed about the joint to hold the plaster ropes while they are being- applied. When the plaster is cut away exposing the plaster ropes the extra sheet wadding is removed leaving the joint exposed for inspection and drainage. See Carrell method, section 323. 97. Osteomyelitis. — In osteomyelitis an operation should be done as early as possible after making the diagnosis. In sub-acute cases, incision and drainage are all that is necessary. Whenever incising for abscess all the pockets should be opened and if the abscess is large, counter incisions are made at dependent places. The pus pocket should be opened freely, wiped out with gauze, irrigated and wiped out again with gauze. Curetting should be avoided excepting for the removal of sinuses in the skin and in cases of sinuses it is often better to excise them. Perforated rubber tubing should be placed to drain the deepest portions of the pockets. The skin, fat and superficial muscle layers should be made to gap by means of gauze drains. At the end of ten days the gauze is removed and the tubes shortened. The tubes are gradually drawn out a little each day or two until not used. This method makes the repeated reapplication of drains and wicks 86 OPERATION IN SUPPURATIVE CONDITIONS 87 unnecessary as the wound will gap of itself and close from the bottom if the surgeon has been careful to make large incisions. Where the periosteum is found destroyed or the pus under the perios- teal layer, the bone should be opened by means of a large drill or a small gouge. Where this is necessary, the incisions should be large and the counter incision should be made on the other side of the bone with a hole made in the bone a little above or a little below the hole on the opposite side (figure 65). These holes in the bone should open up the medullary cavity. They should alternate on one side and the other as far up and down as the disease is suspected. When the abscess is very great and the bone involvement is large, a number of good sized holes should be made with a Burr drill or a curved gouge on both sides of the bone as shown in figure 66. The wound should be gaped widely; — the skin, fat and superficial muscle held open by large gauze drains. The tubes should reach from the surface to the deepest portions of the abscess cavity. Splints should always be applied to immobilize the Limb. They should be placed so that they will not interfere with the dressing. In some instances it is better to apply plaster with large windows and ropes to give stability as shown in figure 449. The dressing should be done every day or twice a day, depending on the foul condition of the discharge. If the odor is excessive; chlorinated soda dressing should be used diluted 72, 1 jz or 1 j i the U. S. P. strength. The gauze drains should be left for at least ten days without being disturbed. When removed, granulations will be formed under them in such a way as to keep the wound open without applying the drains. Irrigation may be used at the time of operation and the wound thoroughly wiped out with gauze afterward. No irrigation or probing or application of wicks will be necessary if the first drain is left in long enough. After the first ten days the tubes are shortened up gradually until they are not needed. Much may be expected in the future from the Carrell-Dakin solution and technique. See section 323. In severe cases where the patient is unconscious or delirious, the bone should be always open, three or four holes on either side made with a good size Burr drill. In no case should the incision be made only on one side of the leg in severe cases. No tight packing should be used as this interferes with good drainage. Where sequestra have formed they should be removed. An x-ray should be taken whenever possible to determine the position of the disease (unless the case is urgent and an immediate x-ray is not obtainable). In cases of long standing that are sub-acute at the first examination, where the bone is riddled with holes over an extremely long area, it is impossible often to remove the dead bone satisfactorily without removing all the bone. In these cases free incision down to the bone with frequent openings into the bone as described above, will allow the septic process to run its course and the sequestra to gradually separate. We have had 88 TECHNIQUE OF OPERATIONS some cases in which the lower third of both femora were riddled with holes and full of sequestra, the patient being in no condition for extensive operation, and yet not very ill. In these cases, however, if the surgeon had seen the patient in time an early operation would have prevented this extreme condition. Sometimes it is necessary to close a large bone cavity which will not heal over. Where the process is distinctly septic no plastic operation should be done without first doing an operation to eliminate the septic condition. After that part of the muscle may often be transferred over such a cavity after it is closed. In transferring a muscle over such a cavity it should be freely transplanted and held there without tension. The skin should be brought together over the muscle and the wound drained, as there is apt to be inflammatory disturbance. Where sequestra are present it is always desirable to remove them as soon as they have separated and the involucrum is strong enough to act as a support. Sequestra may be superficial or in the medullary cavity or both. Where there is a persistent sinus and a sequestrum is present, pus will continue to form until the sequestrum is removed. Cases dis- charging several years where a sequestrum is present may close in a few weeks after removal of the sequestrum. In closing a bone cavity its edges may be chiselled clean and then the bone incised a short distance from one edge and parallel to it, the in- cision is carried down to the medulla, the incision in the bone is widened by prying it open and forcing the bone together closing the old cavity. This is sometimes a satisfactory method of closing an old open bone cavity which has sclerozed edges. 98. Excision of the Knee in Suppurative Conditions. — When an excision of the knee is indicated on account of the failure of conservative methods and the case is growing progressively worse in spite of good drainage, the operation is performed as rapidly as possible in order to diminish the shock due to a prolonged operation. The technique is the same as that described under excision and ar- throdesis when the tibia and femur are sawed across. The diseased cavities in the bone should be removed with a chisel or an osteotome, cutting them out wholly in the healthy bone. There will be just as good repair and less shortening by this method. Before placing the bones in apposition to obtain ankylosis, small holes should be drilled from the anterior or lateral surface of each bone to the cavities chiselled out if they are deep. This will insure good drainage. Drains should be used in all suppurative conditions. The joint should be immobilized after opera- tions on the knee joint or its vicinity. 98a. Methods and Principles of Drainage in Acute Non-tubercular Suppurative Joint Disease. Knee, femur, tibia. — A small suppurative focus without virulence or active constitutional disturbance should be drained by a suitable incision wiped out with gauze, a tube placed to its deepest part and the soft tissues gaped with gauze. OPERATION IN SUPPURATIVE CONDITIONS 89 When there is a great deal of constitutional disturbance drainage and counter drainage should always be the rule. If the bone is involved this should be opened and counter opened as shown in figure 66. The pus cavities in the soft tissues should be wiped out. No extensive bone operation should be done otherwise. The bone should be drained with tubes to the remote portions and the muscle, fat and skin gaped by gauze. The operation is done quickly and should not be prolonged, but efficient drainage and counter drainage should be established un- hesitatingly. It is rarely necessary to do more at this time. If there is a marked sequestra formation this should be removed, but this had better not be done at the time of instituting drainage when the patient is nearly exhausted from an acute process. Any future operation made necessary should give good drainage and the removal of the sequestra if present and separated. Any extensive non-tubercular suppurating bone disease about the knee, tibia or femur shaft should be drained by two long lateral incisions. If the patient is very ill and the bone abscess not readily located, long incisions with large drill holes alternating in the bone should be made (figure 66). This should be done very rapidly and good drainage estab- lished. In any chronic suppurating process the pockets in the tissues should be well opened and wiped out and the diseased bone well drained and counterdrained. Large incisions should be made with tubes to all de- pendent parts and large gauze pads used, gaping the wounds for at least ten days and then the tubes and wicks shortened. This method of treatment is usually very successful. It does not necessitate the constant reapplication of drains, so discomforting to the patient. Ir- rigations should not be used in the after treatment unless the Carrell- Dakin method is used. The gauze should be placed around rather than over the wounds. The knee should be immobilized after opera- tions on the joint or its vicinity. PART III— FOOT AND ANKLE CHAPTER I OPERATION FOR DEFORMITIES 99. Manipulating the Foot. — The patient is anaesthetized. Usually in manipulating the foot, the patient lies on his back, the foot is flexed and extended, adducted, abducted or pronated and supinated. Dr. Bradford has suggested a very convenient method of manipu- lating the foot. The patient lies on his abdomen (see figure 169), with the knee flexed. The table should be low; if not the opera- tor may stand on a box or stool ; a pillow is placed under the knee. One or two assistants hold the leg above the ankle, the operator grasps the ball of the foot in both hands. This method is especially effective as the operator's weight is above the foot, adding many pounds to the strength of his hands. The power of the hands Or foot FlG - 121.— Thomas wrench applied to the scaph- oid and metatarsus. wrench is. applied more directly to the joints of the foot without motion of the leg. The peronei be stretched, the anticus, and pos- and the tendo should tibialis ticus Achilles; the terminal Fig. 122.— Thomas wrench applied to force the front phalanges of the toes of the foot down or up. flexed, then the proximal phalanges, then the metatarsophalangeal joints flexed and extended with the foot at first in dorsal flexion and later with the foot in equinus. The operator assures himself that the motions of all the toes and the foot joints are normal. The foot is stretched with the hand or with one of the foot wrenches. 100. Manipulation of the Foot by Means of Apparatus. — When it is necessary to correct deformities of the foot, and do a tenotomy of the 91 92 TECHNIQUE OF OPERATIONS Thomas wrench to correct equinus. ally increas- ing manner until consid- erable force is applied and then re- laxing until very slight force is used and finally relaxing en- tirely. In this manner a rhythmic tendo Achilles, the ten- otomy of the tendo Achilles should be per- formed last. Stretch- ing of the foot is best performed with the tendo Achilles intact. The joint is gently stretched and relaxed, the operator applying force gently in a gradu- Fig. 125. Fig. 124. — The Thomas wrench, used in manipulating the foot before or after operations on the foot. The wrench is nickeled and may be sterilized. The jaws that hold the foot are removable and vary in shapes (see figure 125) to fit the deformities; and to fit children's or adults' feet. By stretching with it a much less extensive operation is necessary. stretching is kept up. No rough or forci- ble motion with- out a gradually increasing and gradually de- creasing force should be em- ployed. A joint that at first will seem almost im- possible to move will often give way and straighten. When the front of the foot and other deformi- ties are satis- factorily cor- -Thomas wrench, actual size of head of wrench; jaws fit in the squares. OPERATION FOR DEFORMITIES 93 94 TECHNIQUE OF OPERATIONS Fig. 130. — Thomas wrench applied to the metatarsus and cuboid. Fig. 131. — Thomas wrench applied to the astragalus and cuboid. Fig. 132. — Thomas wrench to limber the tarsus at the cuboid. c_z_ Fig. 133. — Thomas wrench applied to correct varus. OPERATION FOR DEFORMITIES 95 CZ Fig. 134. — Thomas wrench rected, then the tendo Achilles may be tenoto- mized if necessary. 101. Manipulating the Foot by Means of the Thomas Wrench. — A very convenient wrench for manipulating the foot is known as the Thomas Wrench, represented in figure 124. It is a large monkey wrench fifteen inches long. The wrench a £ e d d t0 the scaphoid and has two arms which grasp the foot. These arms are six inches long. The exact length and dimension of these jaws are out- lined in figures 124 to 129. They vary in size and contour and may be applied to the wrench in order to fit a large or a small foot. In the use of force to correct deformity, slight pressure is applied by means of the wrench and then the force relaxed. Slight pressure is again brought to bear by means of the wrench and then relaxed. With a rhythmic ap- plication of force, and then relaxation, the blood en- ters the stretch- ing tissues and Fig. 135 — Dr. Brad- there is less dan- *° rd ' s ? lub foot wrench. ~ , . By using this wrench ger Of tearing before r after opera- them at any one ting on the foot a much point. Consid- j^s extensive operation - , , j. ls necessary. 1 he mid- erable force die section slides, ad- may be applied Justing itself to the size • . i • of the foot. in this way, with less swelling after a forcible manipulation than if the parts are handled roughly. The stretching of a deformity should be slow and not violent. In applying the various Fig. 137.— Single mechanical foot stretchers, an ex- t"f^ S ,^r treme deformity which gives way very little at first will often yield ■i entirely if the operator is patient. Figures 121 to 134 represent the Fig. 138.— Removable end of many methods of applying the tZZSt -!* a" in Th °™s wrench to the foot. an ordinary instrument sterilizer. After any foot operation the Fig. 136. — The great toe metatarsal hold used for the left foot, the other for the right; this one is detached, the other is in place. (See fig- ure 135). c 96 TECHNIQUE OF OPERATIONS wrench will help complete the correction of the deformity and make more extensive operations unnecessary. These wrenches are especially Fig. 139. — Dr. Bradford's club foot wrench applied, to raise the cuboid and abduct the foot. useful in obtaining the normal range of motion in the foot before other operations. 102. Manipulation of the Foot by Means of the Bradford Wrench.— Figures 145 to 150 represent one of Dr. Bradford's club foot wrenches Fig. 140. — Dr. Bradford's club foot wrench, external view from above. to correct deformity in the foot and ankle. While designed to correct club foot it readily adapts itself to the correction of the other foot de- formities and to limber up the joints of the ankle and foot. OPERATION FOR DEFORMITIES 97 Fig. 141. — Dr. Bradford's club foot wrench, external view from below. Fig. 142. — Dr. Bradford's club foot wrench, internal plantar view. Fig. 143. — Dr. Bradford's club foot wrench, internal view from above. 98 TECHNIQUE OF OPERATIONS Pig. 144. — Dr. Bradford's club foot wrench. Fig. 145. — Another of Dr. Bradford's club foot wrenches taken apart; by using this wrench before or after operating, a much less extensive operation is necessary. A is applied to the bar C at A. B is applied to the bar C at B. The bar C is first applied to the hole C. The hook D is applied to the hole D. (See illustrations 146 to 150.) OPERATION FOR DEFORMITIES 99 Pig. 147. — Dr. Bradford's other club foot wrench applied to the foot. External view. Fig. 146. — Dr. Bradford's other club foot wrench applied to the foot. Plantar view. Fig. 148. — Dr. Bradford's other club foot wrench ap- plied to the foot. Internal and plantar view. They will also be useful in increasing the flexibility in the joints of the foot and ankle. Another wrench of Dr. Bradford's (see figures 135 to 144) is used to cor- rect the deformities of the foot. This wrench is useful to limber up the foot and help correct the ankle and foot deformities. 103. Manipulation of the Foot by Means of Dr. Davis Wire Foot Wrench. — Dr. Gwilym Davis' wire foot wrench (see figures 151-155), is used to correct deformities of the foot. 104. Operation for Talipes Varus, and Equino Varus, Club Foot. — A varus or equino varus (see figures 160-161) may be slight or extreme. Fig. 149. — Dr. Bradford's other club foot wrench applied to the foot. Dorsal view. 100 TECHNIQUE OF OPERATIONS Fig. 151.— Dr. Davis' wire foot stretcher applied, plantar view. It consists of a heavy inflexible iron wire and two webbing straps. Dimensions of the wrench. Length = 19}/£ inches. Width = 5 inches. Diameter of wire = 3 /s inches. Cross piece length = 7J^ inches. Distance between ends of cross piece = 5 inches. Fig. 150. — Dr. Bradford's other club foot wrench ap- plied to the foot. Dorsal view with force applied. It may be due to over-strong tibialis posticus or anticus and long flexor of the toe tendons with weak peronei; or it may be due to relaxed peronei with not over-strong muscles on the in- side of the foot, or the muscle may be paralyzed and the deformity due to lack of foot balance, or to uneven bony overgrowth, or lack of growth. In some cases the deformity is acquired at the time when the patient begins to recover from a paralysis. After operation sometimes the weak muscles are made as strong as ever if the foot is overcorrected, and put in a position of valgus, followed by muscle training. When the cor- rection of a varus or e q u i n o-varus cannot be main- tained after proper relaxation of the contracted tissues and training of the peroneii, it may be necessary to trans- plant the tibialis anticus or the long toe extensors to the middle of the midtarsus region. This often is suf- ficient in slight Fig. 152. — Dr. Davis' wire foot stretcher applied. Internal view. Fig. 153.— Doctor Davis' wire foot stretcher applied. Dorsal view. OPERATION FOR DEFORMITIES 101 Fig. 154.— Dr. Davis' varus cases where the lateral stability of the foot is otherwise good. In a case where the posterior tibial muscles and the long flexors of the toes are extremely strong, the anterior tibial muscle must be put fur- ther to the outer side or one of the strong muscles transplanted forward and outward to balance it. Before transplanting, the normal motion of the joint must be restored. Any tendency of equinus must be overcome by stretching and by a teno- tomy. No transplantation should be performed unless the action of the ankle is free and the de- formities overcome. Where the long flexor of the toes is extremely good, this muscle may be transplanted forward to restore the balance of the foot. (For a description of the transplanta- tion of the long flexor of the toe forward, or of the tibialis posticus forward, the reader is re- ferred to subsequent pages.) In transplanting the long toe flexor, or the tibialis posticus forward, it should be remembered ™ ire fo °t stretcher applied. . . , .! • • , i ... , External view. not to weaken the joint by incisions around the malleoli. The tibialis posticus lies anterior to the flexor longus digitorum, but these tendons are best dif- ferentiated by pulling on the tendon, and noticing the flexion of the toes in the case of the long flexor. The tibialis posticus lies anterior, and the flexor longus digitorum Fig. 155.— Dr. Davis' wire nex + the posterior tibial artery and the foot stretcher applied to the j • mi i • patient in Dr. Bradford's posi- nerves are posterior. There are also two tion, for manipulation of the small plantar cutaneous nerves. foot - In cases in which the varus is extreme and due to position rather than to muscle pull, especially when the muscles are weak, after correcting the deformity by man- ipulation and teno- tomies, silk liga- ments may be used for one or two years to maintain stabil- ity of the ankle. In children over seven Or eight years Fig. 156. — Plaster split at the sides with plaster rope flattened Old, and in adults to prevent rotation of the leg. Side view. where the ankle is very much relaxed (the so-called "dangle foot") an astragalectomy with displacement of the foot backward is advisable. This will give good lateral stability without a stiff joint. Where silk liga- 102 TECHNIQUE OF OPERATIONS ments are used as a temporary means of retaining the foot, Dr. Bradford's operation for subcutaneous silk ligament is simple (see section 173) and preferable to the method by open incision. An open or closed operation, cutting all resistant tissues on the inner side of the foot called the Phelps operation, should not be done. There are much better and less mutilating operations to correct varus or equino varus. 105. Operation on the bone for Extreme Varus, or Equino Varus (club foot operation) Congenital or Acquired. — The following operations are Fig. 157. — End view of figure 156. Fig. 158. — Method of spreading a wet three inch gauze bandage and tying a split plaster. indicated in congenital club foot as well as in the infantile and acquired forms, depending on the degree of deformity. When it is extreme, it Fig. 160. — Equino varus. Club foot. Plantar view. k Fig. 159. — Equinus. is often necessary to take a small wedge from the forward end of the os- calcis and sometimes from the astragalus to obtain complete over-correction of the deformity. In the paralytic club foot it is not necessary to overcorrect to the same extent that it is necessary in the congenital, but a slight over-correction should always be made. If the deformity is extreme, how- ever, the over-correction should be proportionate. fkj. i6i.— Equino When after manipulation and tenotomy of the varus. Club foot, plantar fascia a complete over-correction is not ob- atera view * tained, without force, a small wedge of bone is removed from the astragalus and os-calcis (see shaded portion, figure 163). This is done through an incision anterior to the tip of the fibula and ex- tending towards the prominence at the base of the fifth metatarsal. The incision is carried down to the bone, the tendons and muscles OPERATION FOR DEFORMITIES 103 retracted, exposing the prominent portion of the astragalus. A small wedge is removed from this bone in such a way that the closing of the gap will allow the foot to dorsally flex. The osteotome should enter the bone some distance from the tibia in order that the callus from bone healing will not interfere with the motion of the ankle joint. See figure 494. Should the eversion be difficult to obtain, a small wedge is taken out of the forward end of the os-calcis, allowing the foot to evert. A Fig. 162. — Calcaneous. Fig. 163. — Shaded portion of bone must sometimes be removed in extreme club foot deformity. The size of the wedge and its shape will vary with the deformity. small wedge of bone should be removed and then more as the case re- quires, though an operator familiar with bone operations for club foot may often judge the right amount from the start. Where much tilting of the os-calcis accompanies an equino varus, Dr. Ober has suggested the loosening of the ligaments from the internal malleolus allowing the over- correction of the tilt of the os-calcis during the correction of the deform- Fig. 164. — Incision two inches above the tip of the malleolus curving down- ward and forward. Fig. 165. — The regular line marks the malleolus, the irregular line indicates the raised periosteum. The tendon is below. ity at the front of the foot. This latter operation is often sufficient without removing bone. 106. Operation for Equino Varus, Congenital or Acquired. Reliev- ing the Internal Ligamentous Attachments when the Os-calcis is Tilted or Rotated in and under. Dr. Ober's Operation. — The foot is pre- pared in the usual way, the patient lies on his back, a sand bag is placed under the foot, the operator stands on the outer side of the right foot, 104 TECHNIQUE OF OPERATIONS an assistant holds the ball of the foot while the incision is being made. Before making an incision, the foot is manipulated and stretched as described under Manipulation. An incision is made on the inner side of the tibia from a point V/i t° 2 inches above the internal malleolus, curving downward and forward to the scaphoid (see figure 164). The [incision is curved slightly; it is carried down to the bone, its edges re- • tracted exposing the periosteum over the internal malleolus (see figure 165). This periosteum is incised across one inch above its tip, and on either side of the tip, the periosteum is raised in one piece from the flat surface of the bone, the irregular line marks the raised periosteum (figure 166), the anterior and posterior surfaces continuously with the Fig. 166. — The osteotome raises the periosteum and ligaments subperiostially extending anteriorly. Fig. 167. — The osteotome raises the peri- osteum and ligaments subperiosteally below the malleolus. ligaments, and on either side of the malleolus (see figures 167 to 170). An osteotome is used to lift the attachment of the ligaments free from the malleolus continuously with the periosteum. The lifting of the perios- teum and ligaments is continued to the ligaments of the astragalus and os-calcis, the astragalus and scaphoid allowing the foot to swing freely outward. The raised periosteum on the tibia is drawn downward as the deformity is corrected. The internal lateral ligament is freed to- gether with the anterior ligament, the dorsal astragaloscaphoid liga- ment, and the attachment at the scaphoid tubercle. The foot is then manipulated and the amount of overcorrection estimated. It is suffi- cient if the tilt in the os-calcis is overcorrected and the cuboid goes well up into place, and if the dorsal motion to the foot and eversion of the front part of the foot is easy to obtain. The tendo Achilles is ten- otomized last (see previous chapter on Tenotomy of the Tendo Achilles). This tenotomy is done last as it is necessary for it to hold the os-calcis during the correction of the deformity. If sufficient correction is not obtained by freeing the ligaments the operator will use the Thomas OPERATION FOR DEFORMITIES 105 wrench (see figure 124), or the Bradford wrench (see figures 135 and 145) before and after cutting the tendo Achilles; the periosteum is not sutured. The deep tissues are brought together over the bone by interrupted chro- mic catgut sutures number 00, the subcutaneous tissues with interrupted chromic catgut sutures number 00, and the skin with continuous chromic catgut sutures number 00. A very Fig. 170.— Plantar view. The irregular line indicates the tissues raised subperiosteally from the tarsus. Fig. 169. — Lateral view. " The ir- Fig. 168. — The osteotome extending regular line indicates the tissues backward subperiosteally under the liga- raised subperiosteally from the tar- ments and tendons. sus. small amount of gauze is placed over the wound, only about four thin lay- ers, extending one-half inch either side and beyond the ends of the incision in order to have no lumps. Sterile sheet wadding is next applied to fit the foot snugly so that the outlines of the leg and foot are shapely and the amount of correction easily estimated. A plas- ter of Paris bandage is applied from the toes to the groin With the knee foot cuff of the plaster bandage with only bent. (For details of this plaster, tw .° heel tur ns to hold it on. CD, Leg and 11 \ thigh cuff. When these cuffs have har- See DeiOW.; ... . dened the foot is held over-corrected, the It will be noticed in this Operation plaster then is completed by uniting the that the operator raises the perios- two cuffs - teum from the inner side of the internal malleolus, a strip 1 or 13^ inches long, 2 inches in adults and as broad as the malleolus. As this is raised from the bone with an osteotome, it is lifted continuously with 106 TECHNIQUE OF OPERATIONS the ligaments and periosteum below for at least an inch below the tip of the malleolus. The periosteum anteriorly is raised from the tip of the malleolus continuously with the ligaments and periosteum over the bones for at least an inch forward and downward. Posteriorly the same process is repeated, the osteotome dipping behind the tendon sheath and lifting them with the periosteum below them (see figures 1G9, 170). 107. Application of Plaster for Varus or Equino Varus, Club Foot Plaster. — Some care is necessary in applying a plaster to the foot for correction of bone deformity; a liberal amount of well fitting sheet wadding is applied then. About eight layers of plaster of Paris bandage are applied around the ball of the foot and metatarsals, two la3 r ers only around the heel to prevent this cuff from slipping off. This is allowed to harden while the plaster is applied to the thigh and leg with the knee flexed eighty degrees. When these two portions are hard, the patient is turned over on his abdomen and a pillow is placed under the knee. The operator holds the foot overcorrected (see figure 171), while an assistant joins the two portions of the plaster, Fig. 172T— After I n this way there is no cramping of the toes which operation a club foot are held flat and the plaster is applied to the de- should be held in formity w hile it is held corrected. If the operation plaster well abducted . , , P .,, ., dorsaiiy flexed and has been thoroughly done, the foot will easily over- with the cuboid ele- correct without force. Good overcorrection of the deformity is a sure method of preventing pressure sores and discomfort from the plaster. The position of overcorrection of the foot in plaster is important. A vertical line through the mid- dle of the lower leg is drawn on the plaster. This line should be determined by an imaginary plane passed through the femur and tibia. The foot should be abducted fifty degrees from this plane. It should be dorsaiiy flexed about twenty-five degrees, the cu- boid being raised more than the rest of the foot (see figure 172). 108. The After Treatment of Equino Varus.— The patient should wear a plaster for six or eight weeks with the knee flexed forty-five degrees to eighty de- grees and maintaining extreme overcorrection (see figure 172). At the end of this time a lighter plaster is applied with the knee flexed only twenty degrees. The patient is allowed to walk on the plaster. Wooden, felt or plaster wedges are applied to the wedged to make sole of the plaster to aid in locomotion. When walk- talking more easy, ing is good, a wedged shoe (see figure 173) and brace, or simply the wedged shoe is worn. Exercises for all the muscles become part of Fig. 173.— Wedged shoe. When an over- corrected position is to be maintained, the brace is bent, the heel of the shoe is broadened and OPERATION FOR DEFORMITIES 107 the after treatment with manual overstretching of the deformity daily. 109. Methods of Obtaining Stability at the Ankle and Foot. Opera- tion for Valgus, Equino Valgus and Calcaneo Valgus. Flat foot. — The following operation is also used for congenital and acquired flat foot. Equino valgus, calcaneo valgus and flat foot, valgus (figures 175, 176). In some paralytic and congenital valgus deformities the tibialis anticus and tibialis posticus, and long flexors of the toes are either paralyzed or very much weakened, or proportionally weaker than their opponents. In some cases the muscles are all weak and the deformity is due to attitude or bony growth. In these conditions the peronei muscles are sometimes found very strongly contracted, so that they seem powerless. To restore a balance of the foot, first the deformities should be overcorrected by operation unless they are very slight and the muscles trained and given the best possible chance to develop under orthopedic treatment. In paralytic cases where the peronei are strong and the patient cannot raise the foot, a transplantation of the peronei forward is often advisable. When this is decided upon the muscles are transplanted as described elsewhere under muscle transplantation. The position of insertion of the tendon will depend on the position and strength of the other good muscles. In extreme valgus the internal cuneiform, or scaphoid, may be selected as the best position for inser- tion; in some other deformities the middle or outer cuneiform. Where there is good lateral stability at the ankle, the tendon should be put in about the middle of the foot. Where there is a marked lack of stability at the ankle joint an astragalectomy with displacement of the foot backward gives an extremely good foot without stiffening the ankle and to this a transplantation of the peronei forward may be done to great advantage. Where the extensors of the toes are extremely active, and this is often the case in paralytic cases where the peronei are spared, there is often a marked hammer toe due to the con- tracture of the extensors of the toes which are stretched upward as they are constantly used in rais- ing the foot. Where there is a hammer toe, it is well in the case of the great toe to transplant the tendon of the great toe into the head of the metatarsal, and also to use the other long extensor of the toes either in the same way, or better still to attach them- to the tarsus and cut them away below. 110. Extreme Valgus, Calcaneo Valgus, and Equino FlG \ } 74 •- Val s us ■xt , Tj.,, , , , t with hammer toes. Valgus. — It there are no muscles to transplant any one of the above methods of correction may be selected. For a very hopeless flail ankle an astragalectomy and displacement of the foot backward is the operation of choice. When it is possible to transplant a muscle to a 108 TECHNIQUE OF OPERATIONS position of greater usefulness it should be done in addition to correcting the valgus. When a valgus has existed for a long time uncorrected and there is often much bony change similar to that seen in congenital valgus cases, a wedge of bone may be removed from the scaphoid and adjoining bones further outward, the closing of the gap correcting the abducted and flattened foot. When the os-calcis tilts markedly, the external ligaments may be loosened subperiostically from the external malleolus, and from the os-calcis subperiosteal^ as described below, allowing the bone to swing under the astragalus and tibia. The correction of valgus is usually possible by manipulation with the hands or by one of the wrenches described for manipulation of the foot. The foot should be made limber in all normal directions and the valgus overcome. Fig. 175. — Valgus, When the condition is extreme, and has existed since the onset of a paralysis, the correction should be made by operation and the tibial muscles allowed to regain strength. When this does not occur or if they are found to be definitely paralyzed or extremely weak, after attempts to train and develop them, a trans- plantation of other muscles forward may be made. The correction of valgus due to deformity of the bone is best done by removing a wedge from the scaphoid, or if the ankle is flail, by an astragalectomy, or both tibialis tendons may be inserted into grooves in the tibia anteriorly and posteriorly and buried there to act as internal ligaments prevent- ing valgus (see Artificial Ligaments). 111. Bone Operation for Valgus or Equino Valgus or Calcaneo Valgus. — The patient lies on his back, the knee outwardly rotated, a rubber bandage is applied to evasculate the foot and leg and a tourniquet is applied below the knee, the foot resting on a sand bag. The operator stands on the side of the leg to be operated on. An incision is made one-half inch anterior and one- half inch below the internal malleolus extending for- ward to the first metatarsal. The incision is carried down to the bone, the tissues dissected up, retracted in one layer exposing the scaphoid; the tibialis tendons Fig. 176. — Valgus, are retracted and carefully protected from injury. A latera view, wedge of bone is removed from the scaphoid and the adjoining bones, if necessary, to allow the foot to swing in, as the gap closes. The perios- teum is tough at the inner side of the foot, making it easy to place sutures to hold the bones together. The deep and superficial tis- sues are brought together with interrupted chromic catgut sutures number 00, the skin with continuous chromic catgut sutures num- ber 00. OPERATION FOR DEFORMITIES 109 If the deformity is largely clue to a tilted os-calcis, the following operation will be useful. 112. Operation for Valgus with Marked Tilting of the Os-calcis. — The patient lies on his back, the operator stands on the side of the leg to be operated on, a rubber bandage and tourniquet are applied. A curved incision, two and one-half inches long is made one inch above the tip of the external malleolus, extending forward and down- ward to the cuboid. The skin and subcutaneous tissues are dissected up exposing the malleolus. An osteotome is used to free its ligaments subperiosteally from the outer, inner, posterior and anterior surface, also the attachments of these ligaments to the os-calcis and astragalus; all are freed subperiosteally. This will usually allow the foot and os-calcis to be brought into position either manually or by wrenches. If not the astragalo calcaneous ligament is separated subperiosteally by means of an osteotome inserted between these bones. The attachment here is very extensive, the separation should be done with care in order to cut all the fibers, the operator feeling for each soft attachment and cutting it, injuring the bone as little as possible. The foot wrenches (figures 123 to 155) will aid the operator to complete the overcorrec- tion. If sufficient overcorrection cannot be obtained by this process, the operator should remove a wedge of bone as described for valgus. 113. Plaster of Paris Bandage for Valgus. — A plaster of Paris band- age is applied from the toes to the groin with the knee bent, as follows : a liberal quantity of well fitting sheet wadding is applied to the foot and leg, an extra amount being placed on the heel. Eight turns of plaster bandage are placed over the ball of the foot and around the metatarsals in front. Only one or two turns are made around the heel to hold the cuff on. The cuff is allowed to harden while the plaster is put on from above the ankle to the groin with the knee bent. When this has har- dened the patient is turned over on his abdomen, the knee rests on a cushion, the operator holds the ball of the foot in a dorsal position and adducts it, correcting the deformity while the plaster is completed be- tween the foot cuff and the leg. The heel should not be allowed to be dented or to rest on the table or bed. After an extensive operation, the patient is kept quiet for three weeks. After that he is allowed to sit in a chair. At the end of the fourth week he walks on the other foot, using crutches. Weight-bearing is allowed in the eighth week, depend- ing on the case; always with the plaster at first. After the eighth week the knee may be flexed twenty degrees only. In infantile paralysis, as in congenital valgus, overcorrection is made with the feet in marked adduction so that they interfere in walking. This is maintained at least six months. Walking is made possible by wooden or plaster wedges under the sole of the plaster. When a transplantation is done at the same time, the rules laid down for transplantation must be observed; when tenotomies alone, or mechanical wrenching, these conditions will govern the after treatment. 110 TECHNIQUE OF OPERATIONS Rules for after treatment in these cases are laid down under transplan- tation, tenotomy, use of foot wrenches, etc. This arrangement of the plaster is important in most operations on the foot. A window is cut in the plaster over the point of operation to allow inspection of the incision. The plaster should be split on both sides so that it may be loosened or removed. The patient is allowed to walk on the foot at the end of six weeks with the plaster on. When the patient is able to walk easily with the plaster it may be re- moved for a few steps two or three times a day until walking is easy without the plaster. . When this has been accomplished the plaster is omitted. The leg and foot should be exercised and the muscles trained. 114. Operation for Arthrodesis of the Astragalo-scaphoid Joint, for Valgus Foot Strain and Partial Paralysis. — This operation is done for weakness or partial paralysis of the plantar muscles. Sometimes when one or both tibials are weak, allowing the foot to sag and causing a strain at this joint, there is often an intermittent pain. The patient lies on his back. For operation on the right foot, a pillow is placed under the right knee, flexing it to about thirty degrees, the operator stands on the same side as the foot to be operated on. A sand bag is placed under the ankle and foot. An incision is made one-half inch forward and one-half inch below the internal malleolus, two inches long, extending forward almost to the head of the first metatarsal. The incision is carried down to the bone. The anterior tibial and posterior tendons are avoided and retracted. A small osteotome is used to remove the cartilage from the forward end of the astragalus and from the adjoining scaphoid. The denuded bony surfaces are made to fit smoothly and the foot is adducted, forcing the bones together. The position of the foot in the plaster will hold the bones together. The bones may be drilled and a kangaroo, or double chromic catgut suture, used to fasten the bones into firm apposition. The deep tissues are brought together with interrupted catgut sutures number 00, the skin with continuous chromic catgut sutures number 00. The foot would be put up in a good position for weight-bearing plus a slight overcorrection in adduction and in about twenty-five degrees of dorsal flexion. The position should be one useful in walking. A plaster of Paris bandage is applied from the toes to the middle of the thigh with the knee slightly bent. It is important that the knee should be bent in order that the plaster will not rotate on the leg. 115. Operation for Talipes Calcaneous. — Where the tibialis anticus is very strong and there is a calcaneous deformity, due to complete paral- ysis of the muscles to the tendo Achilles one of the peronei muscles or the toe flexors, or posterior tibial, may be transplanted backward to the tendo Achilles. The muscle selected will depend on the deformity. If there is a tendency to valgus with the calcaneous (see figure 159), one of the outer muscles should be used ; if there is a tendency to varus one of the inner tendons should be used. In some cases the tibialis an- OPERATION FOR DEFORMITIES 111 ticus or the long toe extensors or both must be put to the middle or slightly to the outer side of the middle of the tarsus in order to make up for the muscle transplanted backward. Very often an astragalectomy is necessary with or without transplantation of muscles. Tendon fixa- tion of the tendo Achilles as described by Dr. Galli may be used. Short- ening of the tendo Achilles is not to be recommended. Dr. Galli's tendon fixation gives added life to the paralyzed tendon from the cortex of the bone. Shortening a paralyzed tendo Achilles is of temporary value only, for it will stretch again. Operation for Astragalectomy and Displacement of the Foot Back- ward (see under Flail Ankle) section 168. Operation for Silk Ligaments at the Ankle (see under Flail Ankle) section 171. Operation for Tendon Fixation at the Ankle (see under Flail Ankle) section 174. Operation for Arthrodesis at the Ankle (see under Flail Ankle) section 199. 116. Operation for Pes Cavus. — The pain in pes cavus is most fre- quently due to the flexed position of the toes, lack of upward motion of the foot and lack of spring due to the contracture. The toes may be corrected by an operation on the ten- Fig. 1S5. — Incision Fig. 186.— Shaded toe. The adjust- f° r reacmn S the phalan- line indicates bone ^ r x i_ geal bones or joints. removal. mentoithe Fig. 187.— Shaded line indicates joint removal. shortened tissues is immediate and without cutting them. The opera- tor must never overlook the deformity of the joint above and below the main deformity. OPERATION FOR DEFORMITIES 115 119. Hammer Toe and Clawfoot. Contracted Extensor Longus Digitorum and Hammer Toe Deformity (sec figures 182 to 187;. — When a hammer toe is of long standing, an operation is usually done to relieve the contracted tendon which extends the phalanx on the meta- tarsal. When the cause of extension of the phalanx is due to the con- stant use of the extensor of the toe to raise the foot in walking, it is advisable to insert these tendons, either into the tarsus higher up or into the head of the metatarsal bones and completely separate the tendons below from the toe. 120. Hammer Toe and Clawfoot. Subcutaneous Tenotomy of Extensor Longus Digitorum near the Head of the Metatarsal. — Where the extensor contraction is very slight but needs opera- tion, a subcutaneous tenotomy of the extensors of the toes may be done as shown in figure 188. The opera- tor feels for the tendon with the finger of the right hand, enters the skin vertically, to one side of the tendon, lifts the skin with the side or the dull edge of the tenotome, and slides it under the skin over the tendon. The blade is inserted on the side of the tendon beyond. The operator puts the tendon on a stretch by flexing the toe and the tendon is cut across with a gentle sawing motion. The cutting of the tendon gives the same sensation as the cutting of celery. When the tendon is completely cut across there is a snap and the toe will be relaxed. When there is very Fig. 188— Subcu- siight hammer toe and no t ane o us tenotomy of , • , i i , i the toe extensor. change in the capsule, the operation may be done with ethyl chloride anaesthesia. 121. Hammer Toe and Clawfoot. Tenot- omy of the Extensor Longus Pollicis near the Head of the Metatarsal. Open Tenot- omy. — Two longitudinal incisions are made (see figures 189, 305), one over and parallel to the second metatarsal, and the other over and parallel to the fourth metatarsal; Fig. 189.— Open operation through these incisions by retracting to for tenotomy of the contracted one s [^ e and then to the other all the long toe extensors. ■, -i ■, 1 ■, , ■ ■, tendons are easily reached and tenotomized without injuring other tissues. Tenotomies of the capsules are usu- ally necessary and manipulation and stretching of the toe at each joint. 116 TECHNIQUE OF OPERATIONS 122. Hammer Toe and Clawfoot. Operation for Tenotomy or Ten- don Lengthening the Extensor Longus Digitorum Tendons in the Leg. — The patient lies on his back, the operator stands on the side of the leg to be operated on An incision is made two inches long over the front and lower third of the leg through the skin and fat. The skin and subcutaneous fat are retracted and the anterior tendons are exposed. Lifting each tendon on a blunt instrument will give sufficient pull to show to which toe it extends. Each extensor tendon may be cut with a tenotome halfway through on one side and halfway through on the other at a different level, pulled down and sutured as described elsewhere for tenotomy of the tendo Achilles (see figures 216 to 217), or one of the other methods of tendon lengthening should be used, described elsewhere in these pages under tendon lengthening (section 127) After a simple tenotomy, the foot is put up in a plaster of Paris band- age in an equinus position for about a week, then brought up to right angles. The patient is then allowed to walk with the plaster after the third week. After that the plaster may be removed part of each day and rapidly discarded. After a tendon lengthening the patient should not walk on the foot for seven or eight weeks. At first he walks a little with the plaster on. The length of time is gradually increased and the plaster omitted a little each day until walking has become easy. This operation will rarely be needed, for where the extensor tendons have become excessively strong and consequently short, it is better to put them into the tarsus and use them to raise the foot rather than to lengthen them. 123. Hammer Toe and Clawfoot. Operation on the Bone (see figures 185, 187). — An incision three-fourths of an inch long is made to the inner or outer side of the dorsal tendon down to the bone. The incision through the skin and fat should be made in one layer in order to keep the flaps as thick as possible. If the toe shows pressure from the shoe more on one side than FlG 190 Hpi^ster digit ^ Ge other, the side showing the least pressure for maintaining correction should be chosen for the incision. The incision a ^° e p r erationsontnetoes is made as snown in fi gure 185. It is carried down to the bone, the periosteum of the proxi- mal end of the phalanx cut through and then lifted by means of a small sharp osteotome. The tissues must be freed subperiosteally before the bone can be removed. This subperiosteal dissection is made with a small sharp osteotome which minimizes the injury to all the soft parts. A small portion of this bone is removed enough to allow the joint to be overcorrected without force (see shaded portion of figure 186). The joint should be perfectly loose and able to flex or extend after removing the bone. At the time of the operation, it is almost always necessary to relieve the extended position of the joint above the one flexed and OPERATION FOR DEFORMITIES 117 often a tenotomy of the extensor tendons, or capsule of the joint above, is necessary. When the tenotomies are necessary besides the bone operation the reader is referred to the descrip- . t tion of tenotomy of these tendons. If the operator chooses to excise the joint instead of removing the bone from the proximal end of the second phalanx alone, he operates as follows. 124 Hammer Toe Operation and Claw- foot. Joint Excision. — An incision is made as Fig. 192. — Splints for holding the toes. Multiple bent copper wire rectangles applied to ankle cuff and foot cuff and held by ad- hesive bands. Fig 191.— Splints for in the previous opera- holding the toes, sheet tion (see figure 187), wadding cuff and bandage , v , , /,i over ankle and foot. down to the bone (the incision need not be more than three-fourths of an inch long). The periosteum is incised by means of a small sharp osteotome; it is raised and an excision of the joint performed by subperiosteal^ cutting the distal end of the proximal phalanx and the proximal end of the second phalanx. Enough bone is removed to allow very free exten- sion and flexion of the joint. It is usually necessary, in a hammer toe operation, to do a tenotomy of the extensor of the joint just above, and sometimes of the capsule of that joint to allow easy flexion at that point (see Operation on Extensor Tendons of the Toes, section 154). The subcutaneous tissues may be brought together with interrupted chromic catgut sutures number 00 and the skin with continuous chro- mic catgut sutures number 00. A wire splint (see figures 191 to 194) with adhesive or a wooden plantar splint, well padded, is applied to the whole foot and toes operated on and a plaster of Paris bandage over this, a special plaster rope or finger is applied beyond each toe (see figure 190). When ; • , j —Post i- * ne °P era tor has handled the toe gently there is practi- erative hammer toe cally no swelling after five days. The patient should splint. A, Represents ^g taught to passively hyperextend and stretch bent e to W hyperextend the toes where they were flexed and to flex the the toe. b, Felt pad metacarpo phalangeal joints which were extended. ST d the toe PereXtend " This is d ° ne five t0 ten tlmeS ' f0Ur tlmeS a day * The patient walks with the plaster in two weeks. The toe should be given freedom in a moccasin after that for two or three weeks, then a very broad shoe used. The stretching exercises are kept up by the patient twice daily for eight weeks. The treatment must vary for the individual case. 118 TECHNIQUE OF OPERATIONS Callouses under the ball of the foot are usually due to a contracted condition of the overlying joint which nature protects by callouses. To overcome a callous which is often painful it is necessary to overcome the extension of the toe and flexion of the phalanx or both as the case may be. When the deformities are overcome, the callous may be treated and will gradually disappear. 125. Operation for Hallux Valgus. — Hallux Valgus often accom- panies other deformities. Where the hallux valgus deformity is not extreme, a tenotomy, preferably a zigzag, of the extensor of the great toe may be done and an osteotomy performed through the base of the head of the metatarsal (see figures 195, 196). A longitudinal incision is made one inch long to the inner side of the tendon of the great toe over the head of the metatarsal (figure 197). The incision is carried down to the bone, an osteotomy is performed through the head of the bone (figure 195), and the deformity over- corrected at the point of osteotomy. An osteotomy requires a very small incision. Fig. 194. — A d h e s i v e bands holding wire and foot and ankle cuffs. Splints for holding the toes. Fig. 195. — Osteotomy for hallux valgus. Fig. 196. — Wedge of bone removed for hallux valgus. No dissection of the tissues from the bone is necessary, excepting im- mediately at the point of incision. This will give little swelling and good correction. It should be done close to the joint. The subcutaneous tis- sues are brought together with interrupted chromic catgut sutures num- ber 00, the skin with continuous chromic catgut sutures number 00. A wooden plantar splint is applied (figure 198) to hold the toe in overcorrec- tion. This splint should be made before the operation from a tracing of the foot (see figure 200) . It is applied as shown in figure 199. A plaster is applied from the middle of the calf to the toe holding the foot at right angles over the splint. The plaster is split on either side so that the top may be removed and the dressing inspected without disturbing the position of the foot and toe. If one foot alone has been operated upon the patient may walk freely on the other foot as soon as the swelling has disappeared and the wound has entirely healed but not sooner than ten days. A child is kept in bed two weeks but he may OPERATION FOR DEFORMITIES 119 be allowed to sit up in bed. No walking on the foot should be allowed until the fifth week. The metatarsal head may be cut by a chain saw, applied around the head of the metatarsal by means of a special in- strument devised by Dr. Osgood. Sometimes a wedge of bone is removed to allow correction of the toe. For removing a wedge of bone the same incisions are used, a small wedge Fig. 197.— Shaded portion of bone re- moved from the dor- sal but not the plan- tar surface of the metatarsal for hallux valgus. Fig. 198. —Post operative plantar wooden splint for hallux valgus, show- ing correction (see figure 200). Fig. 199. — Plas- ter applied over plantar splint fol- lowing hallux valgus operation. of bone is cut with an osteotome from the base of the head of the meta- tarsal (see figure 196) , or the bone may be removed from the upper and outer side of the head of the metatarsal (see figure 197), leaving the weight-bearing portion of the metatarsal on the plantar surface. This should never be removed. Most cases do well with almost any operation carefully done. The cases that do badly and are crip- pled afterward are those where the head of the bone has been removed or else the weight-bearing portion of the bone interfered FlG - 200.— The striped fines .,, outline the application of the Wltn. adhesive to the splint to hold Any small exostoses on the tip of the meta- the toe adducted. Padding is tarsal may be removed with an osteotome. put over the toe first ' Patients with osteo-arthritis and those with infectious arthritis may get a stiff joint following this operation. It is to be avoided there- fore in these cases. CHAPTER II MUSCLE AND TENDON OPERATIONS — MUSCLE AND TENDON TRANSPLANTATION 126. General Principles in Simple Tenotomies, Tendon Lengthening and Tendon Shortening. — A tenotomy is a simple way of relieving the tension due to a short tendon. Regeneration of a tendon is extremely good, especially the regeneration of certain tendons like that of the tendo Achilles. Subcutaneous tenotomy should not be performed where there are important blood vessels, or nerves, which might be accidentally cut during the operation. In tenotomizing a tendon it is important not to cut the whole of the sheath at the point of tenotomy. Experimentally it has been shown by Dr. Sever and others that regeneration of a tendon is favored by the presence of part of the tendon sheath. Where the sheath is entirely cut across, regener- ation between the ends of the tendon is apt to be wholly by scar tissue. When some of the sheath remains, the tendon itself regenerates. A tenotomy is such a simple opera- tion that when tenotomy of the tendo Achilles has been described there will be no need of describing the operation for other tendons. 127. Open Operation for Tendon Fig. 201.— Zig-zag Lengthening. — The skin and fat are tenotomy of the incised and retracted exposing the tendon. A slit one-half inch long is made parallel to the tendon fibers vertically through its middle, and the slit connected with one at right angles at each end, one on the out- side of the tendon at one end, the other on the inside of the tendon at the other end (see figures 201, 202). The ends are sutured or left free. The tendon may be slit diagonally from front to back, or diagonally from side to side with or without suture of its ends. The tendon sheath is closed loosely over the tendon. The subcutaneous fat and skin are brought together with interrupted chromic catgut sutures number 00. For conditions other than poliomyelitis and sometimes in poliomy- 120 tendo Achilles good method. Fig. 202. The ten- don drawn out. MUSCLE AND TENDON OPERATIONS 121 elitis, if the deformity has been of long standing, or due to a fracture or dislocation, it must be remembered that there are probably other tissues maintaining the deformity beside the tendons. If these are bone, more ex- tensive operations will be necessary. If the deform- ity is due to fibrinous adhesions or due to con- tractures of the soft tis- sues only, manipulation and stretching should ac- FlG - 203 - X marks point for inserting tenotome - company the tenotomy. The operator should have some form of foot stretcher on hand, such as the Thomas wrench or one of Dr. Bradford's club foot wrenches or Dr. Davis' foot stretcher. In the case of spastic condition of the muscle, a tenotomy is often unnecessary to correct any equinus that is present. Should tenotomy of the tendo Achilles be done in spastic paralysis, the foot must be brought to a right angle position in from three to five days after operation. In cases of spastic paralysis in which a tenotomy has been per- formed, the foot is put up at first in five degrees or ten degrees of dorsal flexion rather than more. Spastic muscles at the ankle do not accommodate themselves readily to an over-stretched position. When the Fig. 204. — Inser- tion of tenotome un- der the skin across the tendon. Fig. 205.- -Cutting the inner half of the tendo Achilles at a higher level. tendon to be lengthened overlies the belly of the muscle in part of its course, the tendon may be lengthened here. The skin incision should be to one side of the line of the tendon and when closed the fat brought over the tendons and carefully sutured. The tendons should be handled as little as possible and not injured by hard forceps or by clamping. Any ends of tendons that are to be cut away may be clamped. 122 TECHNIQUE OF OPERATIONS In subcutaneous tenotomy of the tendo Achilles (figures 203 to 206) it may be incised posteriorly or laterally, cutting away from the skin. Cutting the skin is apt to cause small adhesions which may be avoided by cutting away from it. An open incision and lengthening of the tendo Achilles is here de- scribed, as it is sometimes necessary. It is an unnecessary operation in the majority of cases, especially when it is done in connection with other operations which is ver}' often the case. A subcutaneous tenotomy of the tendo Achilles may be done in a minute which does not prolong the operation to any degree. In the case of other tendons, open length- Fig. 206. — Cutting the outer half of the tendo Achilles at a lower level. When the tendon is stretched a zig- zag subcutaneous tenotomy results. (See figure 201.) ening may be advisable and is often the operation of choice. A subcutaneous tenotomy is preferable for the Achilles tendon even when there are scars of previous tenotomies. No danger of non-union need be feared. In a large clinic where thousands of tenotomies have been done, lack of union following tenotomy has almost never been seen. Occasionally a writer reports a non- union of the tendo Achilles. In hospitals this opera- " FlG . 2 07.— Teno- tion is apt to be delegated to those less skilled in tomy across the operating. In spite of this the cases of non-union are £gst method* the few. A non-union, we are led to believe, is due to the complete cutting of the sheath combined with careless after treatment. Tenotomy of the tendo Achilles is usually performed to relieve equinus, or to allow more upward motion of the foot. More detail in the tech- nique of tenotomy is given below. 128. Operation for Subcutaneous Tenotomy of the Left Tendo Achilles (figure 207). — The surgeon holds the ball of the foot in the left hand. By pressure he is able to tighten or loosen the tendo Achilles. The tenotome is passed vertically through the skin. The tenotome should enter the skin some distance from the tendon (see figure 203), point X. The tendon having pierced the skin, the tendo Achilles is relaxed. The blade of the knife is passed under the skin and over the tendon until it has crossed to the other side. The MUSCLE AND TENDON OPERATIONS 123 blade is then turned down on the tendon (see figures 204 to 206). The surgeon tightens the tendon with the left hand by pressure on the ball of the foot during the cutting. The last part of the tendon is torn by the tension. This saves part of the tendon sheath. The tenotome by a gentle sawing motion gradually cuts through the tendon. The cutting gives the same sensation as when celery is cut through. The tendon is stretched and the foot brought up, over-correcting the equinus. In all cases where the tendo Achilles is tenotomized the foot should be held afterward in a firm plaster of Paris bandage extending from the toes to the knee for from five to six weeks. The foot should be dorsally flexed at least twenty degrees from the right angle. Walking on the foot is allowed with the plaster in four weeks from the time of operation. 129. Operation for Talipes Equinus (see figure 159). — The position of equinus is often due to a simple contracture of the tendo Achilles readily relieved by a tenotomy. When complicated by a contracture of the other posterior tendons on both sides and the capsule and joint ligaments, stretching by means of one of the wrenches described in another chapter may be used. A tenotomy of the tendo Achilles is usually sufficient to correct the deformity when it is simple. AFTER TREATMENT 130. Following the tenotomy, a plaster of Paris bandage is applied from the toes to below the knee; the patient may walk on the unaffected leg using crutches. It is better to remain quiet for the first five days. In the case of children, they should remain in bed for one week. It is not necessary after the first twenty-four hours that they should remain at a hospital. Where much force has been used or where it has been neces- sary to use wrenches, the patient had better be in a hospital until all swelling has subsided. Walking on the foot with the plaster is allowed after the fifth week a little at first. A wooden plaster, or felt wedge is put under the ball of the foot until the foot is brought down to right angles. The plaster is gradually omitted as walking improves. In most instances the equinus is only part of one of the many de- formities of the foot described below. 131. The Plaster of Paris Bandage for the Foot After Operation for Talipes Equinus. — Following a tenotomy of the tendo Achilles, the foot should be put up in a plaster of Paris dressing with plenty of well fitting padding. There should be a great deal of sheet wadding or other padding about the heel to prevent pressure here. When the surgeon has applied as much sheet wadding as he thinks necessary he should apply as much again on the heel to be sure to protect it. While the plaster is drying, no pressure should be allowed to dent the plaster, particularly at the heel. A pillow is placed under the calf of the leg reaching almost to the heel, keeping it off of the table or bed. The plaster should not bend the toes over the dorsum of the foot, but hold the whole foot evenly raised, the toes flat in line with the ball of the foot. 124 TECHNIQUE OF OPERATIONS A - / \ As soon as the plaster is dry it should be split on both sides. It may be strapped on (see figure 156) or held by means of a wet gauze bandage (see figure 158), which should be kept broad and from curling at its edges on the back of the plaster and at the side, and come together only where it is tied. Such a bandage will not slip or curl; the top of the plaster will be held securely. Should an open operation be necessary, a careful dissection is made down to the tendon, the skin and subcutaneous incision should be to one side of the tendon and not overlying it. When the tissues have been retracted exposing the tendon, it is tenotomized either directly across (figure 207), or it is tenotomized diagonally, or it may be tenot- omized above on one side, and below on the other side (see figure 202), and the tendon drawn out. Elaborate methods of tenotomy are unnecessary as they simply increase the chances of adhesions with- out increasing the efficiency of the tendon. 132. Subcutaneous Zigzag Tenotomy of the Tendo Achilles. — A tenotome is entered through the skin as described above (point X, figures 203 to 207). The operator holds the foot as in the case of the straight tenotomy. The preparation is the same. The ob- ject of the tenotomy is to cut the tendon at the points seen in figure 201 and then to tear the tendon. The tendon sheath is not cut on both sides at the same level (see figure 202). The surgeon holds the ball of the foot in the left hand, the tenotome is en- tered vertically through the skin at a point a short distance from the tendon (see figure 203) point X. The surgeon relaxes the tendon, the tenotome passes under the skin to the opposite side of the tendon, making the cut at figure 205; it is next drawn a lit- tle one side and lowered and the cut (figure 206) is made. The operator may prefer to cut the tendon diago- nally from front to back or diagonally from side to side, subcutaneously. tome. ' Narrow blade Figure 206 represents the position of the tenotome and long narrow in making the incision on the outer side of the tendo blunt collar. Achilles. After the tendon is cut halfway through on the outer side, it should be cut halfway through on the inner side, at a level one-half an inch lower. In changing the position of the tenotome the surgeon relaxes the pressure on the ball of the foot so that the tendo Achilles is relaxed, allowing the tenotome to be brought easily into position. A tenotomy may be performed at almost any level. It is better, however, to operate on or MUSCLE AND TENDON OPERATIONS 125 near the round portion rather than the flat portion of the ten- don. 133. The Tenotome.— Figure 208 will show the proper shape of the tenotome and figure 209, the kind of tenotome usually found at instrument stores. The blade of a good tenotome is very small, one-quarter or three-eighths of an inch long and one-eighth to one-sixteenth of an inch in diameter. The neck should be strong and not sharp, and long enough to allow the blade to extend some distance inward but not so weak in the neck that it will break or bend. 134. Operation for Open Tenotomy to Relieve Contracture of Flexor Longus Digitorum in the Lower Leg. — When this deformity accompanies ex- tension of the metatarso phalangeal joint, the reader is referred to a fuller description under Hammer Toe. As the patient lies on his back, the operator stands on the same side as the leg to be oper- ated on. An incision is made one-half inch directly pos- terior to the internal malleolus and two inches long, through the skin and subcutaneous fat. This is dissected up and retracted exposing the tendons, a blunt dissec- tor raises the flexed tendon of the toes which the sur- geon assures himself he has by pulling on the blunt dis- sector thereby to ° large - contracting the toes. A zigzag 3 q tenotomy or a tendon lengthening Fig. 210.— Tendon lengthening in the belly may be done according to any of the muscle, a zigzag tenotomy may be f t h e methods described under done here. (See figure 201.) , , , rT ^ 1 tendon lengthening. The sub- cutaneous tissues are brought together with interrupted chromic catgut sutures number 00, the skin with continuous chromic catgut sutures number 00. A well padded plaster of Paris bandage is applied holding the feet dorsally flexed and the toes extended by "digit ropes" in the Fig. 209. — Teno- tome usually to be found for sale. The blade is too long and 126 TECHNIQUE OF OPERATIONS plaster (see figure 190). The case is allowed to walk after the fifth week with plaster. At the end of eight weeks if the patient can walk well the cast is gradually omitted. 135. Subcutaneous Tenotomy of the Flexor Longus Digitorum at the Base of the Toe. — A subcutaneous tenotomy of the tendons of the toes may be made at the base of each toe or at the toe under the second phalanx. The tenotome is inserted in each case to the side of the tightened tendon which may be felt as the toe is held extended. As the teno- tome is slid over the tendon the toe should be relaxed. When the blade reaches the farther end of the tendon the toe is extended allowing the rigid tendon to come in contact with the blade. The tendon is then cut across by a gentle sawing motion. As the fibers are cut they give the sensation of cutting celery. The foot is put up in plaster with toe portion hyperex- tending the toes. This remains on three or four weeks. The after treatment will consist of extending the toes daily. When the operation of extending the flexed tendons of the toes is done for hammer toe, the extended metacarpal phalanx joint must be cor- rected as well as the flexed phalangeal joint beyond, otherwise the operation is but half done. A toe splint (see figures 190 to 194), the toe wire bent to correct the deformity or foot plaster should flex the metacarpo phalangeal joint and extend the phalanges. In severe cases, apparatus should be worn constantly for six or eight weeks and gradually omitted after that. Exercises and stretching of the toes should be done daily for about a year; otherwise the tendons may con- tract. Apparatus in severe cases should be used an hour daily for a year. 136. Subcutaneous Tenotomy of the Plantar Fascia. (Subcutaneous Tenotomy of the Left Plantar Fascia) (figures 211 and 212). — In doing a tenotomy the shape of the tenotome is impor- tant. It should have a narrow blade about three- eighths of an inch long, such as is shown in fig- ure 208. The operator holds the ball of the foot in the left hand and enters the tenotome 12.— Pass perpendicularly through the skin at a point X tenotome between the skin in figure 211. The skin is lifted by the blunt part and the plantar fascia - of the tenotome while the tenotome passes between the skin and the plan- tar fascia (figure 212), the operator being careful not to cut the under sur- face of the skin across the foot. The surgeon should feel carefully with Fig. 211.— Tenot- omy of the plantar fascia. X; points of entrance for the ten- otome. MUSCLE AND TENDON OPERATIONS 127 the fingers of the right hand for the fibers which he wishes to relieve. By a gentle sawing motion' of the blade of the knife, the plantar fascia is cut across; the cutting of its fibers gives very much the same sensation as that of cutting celery. The fibers are all cut across one after another without penetrating deeply into the tissues. If the surgeon feels with his knife while he is cutting, there is no danger of extending deeply beyond the fibers of the fascia. Before withdrawing the knife the surgeon should feel for any fibers that remain uncut. It is distinctly advisable not to cut the skin, for in subsequent stretching of the foot later it is apt to be torn. The deep tendons should also be avoided. Occasionally there is some bleeding due to the cutting of small vessels. This usually does not amount to anything and requires no special treatment. Gentle pressure with the fingers is sometimes necessary when the bleeding is excessive. 'This condition is rare. Tenotomy of the plantar fascia is usually done in connection with other operations to correct deformity. It is often necessary in operations for the cor- rection of equino varus, varus, equinus and cavus. 137. Operation for Contracture of the Tibialis Posticus in the Leg. — The tendon is reached as described for the flexor longus digitorum pos- terior to the malleolus, or it may be tenotomized in the foot below the malleolus. This operation is almost never required excepting in spastic paralysis with extreme deformity. 138. Tenotomy or Tendon Lengthening of the Peroneii Muscles. — In the case of the peroneii muscles, it is better if cutting them subcuta- neously, to select a point a little forward and below the internal mal- leolus. The operator strongly adducts the foot, feels the tendon with the forefinger of the right hand, while he holds the tenotome between the thumb and forefinger of the same hand. When the tenotomy of the peroneii is indicated it may be done subcutaneously as in elongating any tendon as described in these pages under tenotomy of the tendo Achilles. If the tendons are to be tenotomized back of the internal malleolus, a small incision should be made; the tendons lifted out on a blunt dis- sector, or director, and cut across. While this operation is desirable in certain spastic conditions and some cases of extreme flat foot and may be found necessary in certain infantile paralysis cases, it is usually better to transplant these muscles if they are strong and make them useful for either extending or flexing the foot, depending on which motion is lacking. Tendon lengthening should be done in the lower middle third of the leg; for detail, see tendon lengthening, section 127. 139. Tenotomy or Tendon Lengthening of the Tibialis Anticus. — Tenotomy of the tibialis anticus may be done subcutaneously at the inner side of the foot where it is easily felt when contracted. Its prom- inence may be exaggerated by abducting and pronating the foot. It is rarely indicated 128 TECHNIQUE OF OPERATIONS The rules for lengthening the tibialis anticus and its tenotomy are the same as those described in these pages under tenotomy and tendon lengthening. 140. Tenotomy to Relieve Hammer Toe (see Hammer Toe Oper- ation. See section 118 to 124). 141. Tenotomy to Relieve Contracted Extensor Longus Digitorum (see Description under Hammer Toe Operation). 142. Subcutaneous Tenotomy of Extensor Longus Digitorum near the Head of the Metatarsal (see Description made under Hammer Toe. Section 118 to 124). 143. Different Forms of Tenotomy to Relieve Contracted Extensor Longus Digitorum in the Lower Leg (see Description under Hammer Toe Operation 118 to 124.) 144. Operation for Tendon Shortening. — A tendon may be short- ened in many different ways. A tendon extending into a muscle is shortened over the belly of the muscle (see figure 213, 214), or the tendon may be shortened below the muscle (see figures 217, 218). Two incisions are made across the tendon at right angles to its fibers and one and one-half inches apart, extending halfway through, one on the inner side \ I \ -'/ an d one on the outer side of [f vH 1 / ^ e tendon. A third incision connects these two by splitting the tendon parallel to its fibers (figure 213). If it is necessary to shorten the tendon a quarter of an inch, a quarter of an inch is cut away from the end of the narrow portion of each end, as shown by the shaded marks in figure 217. The ten- don is sutured as shown in figure 218. 145. Other Methods of Ten- don Shortening. — The tendon may be overlapped as seen in figure 216, or it is tucked and stitched (see figures 219 and 220), or it is reefed by a quilted silk suture (see figures 218 to 222). When there is to be much strain, quilted silk sutures as suggested by Pro- fessor Lange should be used from one tendon and into the other after whatever method of shortening used. Additional mattrass sutures may be used beside. Fig. 213.— Tendon shortening in the belly of the muscle. Shaded portion is re- moved and the space closed as shown in figure 214. Fig. 214. — Ten- don shortening su- tures in place. (See figure 213.) MUSCLE AND TENDON OPERATIONS 129 146. Operation for Shortening the Tendo Achilles. — The patient lies face downward, the feet extend beyond the end of the operating table, or by means of a large sand bag under the lower third of the tibia, the foot is elevated allowing easy motion of the ankle in flexion and ex- tension without touching the operating table. The operator stands on the same side as the foot to be operated on. An incision is made two and one-half inches long parallel to, and one- half an inch to the side of, the tendo Achilles. Dissection is made in one layer down to the tendo Achilles sheath. Its sheath is opened longi- tudinally exposing the tendon. This is cut and overlapped (see figures 215 to 222), or tucked and stitched or reefed by quilted silk sutures. In this latter instance, the tendon shortens to the tension of the silk. Fig. 215. — Cutting the tendon. Fig. 216.— Slitting and reefing a zigzag tenotomy. The shortening desired is marked in shadow. Fig. 217.— Tendon shortened and su- tured, completed. Fig. 218.— Reefing with quilted sutures. Cutting and overlap- ping the tendon. The sheath is closed by small catgut sutures, the retracted skin and fat allowed to slip in position and closed by interrupted chromic catgut sutures number 00, the skin with continuous chromic catgut sutures number 00. Plenty of sheet wadding is applied over a very small gauze dry dressing. The heel is protected by three or four extra thick- nesses of sheet wadding. A plaster of Paris dressing is applied snugly, holding the foot in an equinus position. The patient is allowed to walk on the foot in four weeks with the plaster on and a block under the heel. In seven weeks the plaster is gradually discarded. 147. Operation for Shortening the Extensor Longus Digitorum. — The patient lies on his back, the operator stands on the side of the leg to be operated on. An incision is made two inches long, through the skin and fat over the front and lower third of the leg. The skin and subcutaneous fat are retracted exposing the extensor tendons. Lifting each tendon on a 130 TECHNIQUE OF OPERATIONS blunt instrument will give sufficient pull to show to which toe it extends. Each extensor tendon is shortened by one of the methods described in these pages under Tendon Shortening. The foot is put up in plaster Fig. 219. — Tuck- ing and reefing, slit- ting the tendon be- fore suture. Fig. 220. — Tuck- ing and reefing with- out cutting the ten- don. Fig. 221. — Quilted suture applied. in marked dorsal flexion. The patient walks for two weeks with the plaster. After six weeks the plaster is discarded as rapidly as possible. The operation is necessary only in cases with contracture of the flexors or of the joint that has existed for a long time. The flexors will often have to be lengthened or tenotomized. 148. Lange Method. Operation for a Weak or Paralyzed Tibialis Anticus. Transplantation of the Peroneii Mus- cles Forward to Give Dorsal Motion to the Foot. — The patient lies on his -Quilted suture reef pulled back, a sand bag under the ankle; the operator stands on the same side of the table as the leg to be operated on. A rubber bandage is applied from the toes to just above the knee where a tourniquet is applied over a towel. The leg is prepared with scrupulous care as to aseptic detail. An incision is made one inch above and one-half an inch posterior to the tip of the external malleolus extending upward to the middle of the leg parallel to the fibula (figure 223) . An incision extending around the external malleolus and close to the bone is undesirable as the scar is sometimes painful to the patient later on. The strong fibrinous sheath Fig. 222.- MUSCLE AND TENDON OPERATIONS 131 and rectaculum about the malleolus should not be opened or cut. In this way the joint will not be weakened unnecessarily. The incision is carried down to the peronei muscles which should be examined before transplanting. If red they will be vigorous and very good for trans- planting, if pink they will not be quite as serviceable, if gray or grayish pink they will not be useful for trans- plantation. The lower end of the incision is pulled downward by a hooked retractor, allowing access to the tendons below the incisions (figure 224) . Fre- FlG " 223 -- Illcisiotl f or reachin S the peroneii muscles. quently both the long and short peronei are transplanted at the same time. They are cut be- low as shown in fig- ure 225, the detached ends held in a heme- static. The clamped tip is cut away later. The operator dissects the muscles from the bone with a scapel until a good line of cleavage is reached, then he may continue the dissecting, using a sponge. He should avoid injuring the branch from the external popliteal nerve which lies near the bone Fig. 224. — Retraction of wound below, exposing peroneii tendons, below the incision. Fig. 225. — Cutting the peroneii tendons. anterior to these muscles and is apt to be rolled up in the separated muscle sheath as it folds over it. Next an incision two inches long is made over the anterior and middle aspect of the leg down to the fibers of the tibialis anticus. A subcutaneous tunnel is made under the fat 132 TECHNIQUE OF OPERATIONS connecting this incision with the upper end of the first, a long clamp or tendon carrier is passed through the tunnel backward grasping the peronei tendons, bringing them forward as shown in figure 226. Sterile Fig. 226. — Pulling the peronei tendons forward out through the anterior incision. towels are placed above and below this mus- cle as it protrudes through the anterior in- cisions while heavy number eighteen silk is quilted up one side of the tendon and down the other side as shown in figure 227. The silk should be pulled and tested to see that it is strong before inserting it into the tendon. The tendon quilting should be done very carefully. The needle is passed vertically through the tendon as shown in figure 227 in order not to tear the tendon fibers. The nee- dle is not inserted twice in exactly the same line as this favors splitting of the tendon. About eight stitches should be made in this way on either side of the tendon. The muscle and silk are now turned upward and covered with a sterile towel while the tun- nel is made in or under the subcutaneous fat down to the midtarsus region. The point of insertion in the tarsus is determined by the de- Fig. 227. — Method of f orm ity and the unparalyzed muscles remaining. quilting the silk into the ten- „,. {■,».■, . , , i i j ,1 don, and method of placing The pull of the transplanted muscle and those needle at right angles to the remaining should bring the foot up with an the d sUk. fibreS WhGn inserting even degree of pronation and supination. If the tibialis anticus is paralyzed, the insertion is placed about the middle of the midtarsus. If this muscle is present to a slight degree, insertion may be placed further to the outer side. MUSCLE AND TENDON OPERATIONS 133 The point of insertion having been selected, a curved flap is made 80 that its base overlies (see figure 226) the point at which the silk is to be inserted. The flap should take with it in one layer, the sub- cutaneous fat and fascia. It should be slightly curved and laid out not to cut off the circulation at its proximal end. By means of a tendon carrier (figure 228), a tunnel is made in the subcutaneous Fig. 228. — Tunnel from the foot to the anterior leg incision method of retracting the lower end of the anterior leg incision to prevent inversion of the subcutaneous tissues while drawing the muscle downward. fat connecting the anterior leg incision with the foot incision. A long tendon carrier (see figure 230) is passed from the foot incision up- ward, or the reverse; the silk is threaded in the eye of the carrier. The lower end of the incision on the front of the leg is held raised by means of a retractor as shown in figure 228 to prevent inversion of the fat while the muscles and tendons are drawn downward. If the trans- Fig. 229. — Quilting of the silk tendon extension into the periosteum of the tarsus. plantation is done in an adult with very long legs, it is sometimes neces- sary to have an opening in the front of the leg halfway between the upper incision and the foot. The silk, the tendon and muscle are then pulled down to this incision and then to the foot. The silk, the tendon and muscle are drawn through the tunnel and the silk pro- trudes at the tarsal incision as shown in figures 228 and 229. The 131 Tl '( UNIQUE OF OPERATIONS silk is next inserted into the periosteum of the tarsus by quilted su- tures (see figures 231, 232, 281). The operator is careful that the part of the silk in the eye of the needle or any part clamped is the part to be cut away later. The silk to remain in the patient should not be clamped ' nor put through the eye of the needle. Before tying, each strand is pulled upon so that it will be tense, holding the foot in a position of slight dorsal flexion. The operator should assure himself that the muscle is not caught at any one point in the tunnel and that it will slide freely as far as it will, before inserting the silk into the periosteum of the foot, otherwise there may be relaxation of the silk during convalescence. When the silk is tied, it should hold the foot above the desired position. After being tied three times, the knot is pressed into fVWl U / Fig. 231. — Needle and silk being inserted into the periosteum. Fig. 232. — Silk quilted into the periosteum. the periosteum so that it will lie flat. It is then covered over by the muscle fibers or tendons in the foot. The deep tis- *^ sues are brought "> together with inter- rupted chromic cat- gut sutures number 00, the subcuta- neous fat with in- terrupted -chromic catgut sutures num- ber 00, the skin with continuous chromic catgut sutures num- ber 00. Six layers ^ig. ^33. — Method of applying force f i j with the finger close to the needle, while OI gauze are placed mser t mg the needle into the periosteum Over each WOUnd ex- or bone to avoid breaking the needle. Fig. 230. - Tendon tending One-half No Pressure is used to twist the handle D , , , of the needle holder. earner. mc \ 1 beyond the ends of incisions and about one inch or one and one-half inches broad. 149. Plaster of Paris. — This size dressing facilitates inspection later on without interfering with the plaster. A large fold or roll of MUSCLE AND TENDON OPERATIONS 135 loose sterile sheet wadding is placed over the front of the leg to prevent pressure on the transplanted muscle (see figures 234 to 235): over this sheet wadding rollers are placed before applying the plaster of Paris bandage. The plaster of Paris bandage should reach from the toes to the groin with the foot slightly overcorrected, relaxing the tendon and silk. The plaster is split on each side allowing the front to be lifted or removed for inspection of the dressing. The foot should be manipulated, before operating so that its action is free and normal in all directions. If the tendo Achilles is short this must be relieved before doing any transplantation to the front of the foot. When this has been ac- complished then a tendon transplantation may be performed. A strong ten- don Achilles should be tenotomized when muscles are transplanted to the front of the foot. When FlG 234 _ Roll of sheet wadding applied after ten . there IS much Swelling don transplantation to prevent pressure of the plaster after the Operation the over the transplanted muscle. front of the plaster is raised allowing one-half inch gap on both sides of the plaster from the toes to the upper thigh. If necessary the sheet wad- ding roll on the front of the leg is removed and the sheet wadding split along FlG - 235 - — Sheet wadding rollers being applied over the whole front of the leg, the large sheet wadding roll. the skin from groin. exposing the toes to the This will prevent any con- striction from bands of sheet wadding. This need not be done unless there is much swelling. There is usually considerable swelling after a muscle Fig. 236. — bheet wadding rollers applied ready for . ° . _ .„ plaster. After muscle transplantation the whole leg and transplantation. It Will foot should be included in the plaster. be very much less if the operator handles the tissues carefully and avoids all roughness in the manipulation of the joints and transplanted tissues. Unnecessary roughness is especially to be avoided in making the subcutaneous 13G TECHNIQUE OF OPERATIONS tunnels. The incisions may be inspected on the fifth or seventh or tenth day and fresh dressing applied. If there is the slightest moisture, an alcohol dressing is applied and repeated in two days; after that the dressing should be dry (see healing of wounds in infantile cases under general consideration). 150. After Treatment. — The patient should be encouraged to move as little as possible for the first five days; pillows are allowed then, raising the pal lent forty-five degrees. He may turn on his side at the end of ten days. At that time a bed rest is allowed. The patient is kept very quiet for six weeks. After that he is allowed to be in a go-cart or in a wheel chair. He walks with crutches in the eighth week. Weight-bearing with the plaster is allowed after the eighth week. Fig 237.— A method of splitting a plaster of Paris yfam wa lking is easy bandage; webbing straps hold the plaster together. A . , , . ° , plaster to the groin should be used after muscle trans- WltU tUe plaster, a Snort plantation. caliper is used with a double ankle stop. The braces are used during the day, a plaster of Paris at night holding the foot at right angles. Special exer- cises and muscle training are started the seventh week after operation and continued for a year at least. Great care should be taken not to stretch the foot downward for about a year. The shoe and stocking should be removed with an upward and not downward pull. Much may be expected from the transplantation of the peronei muscles, especially when they are red and large. Great care should be used in selecting the insertion with reference to the deformity and the pull of the muscles that will exist after transplantation. The peronei or any other muscle should not be transplanted to give power to raise the foot without doing something to give good lateral stability at the ankle joint if this is flail or very weak (see operations for flail ankle). A muscle when carefully transplanted will give strength where it is placed and take up the new motion, but it must not be expected to give strength and lateral stability besides. Any joint deficiency must be compensated for either before or at the time of transplanting. In any transplantation, one-half of the lower end of the tendon to be trans- Fig. 238. — Plaster of Paris bandage, split and held with a three inch gauze bandage wet and placed at intervals. MUSCLE AND TENDON OPERATIONS 137 planted may be left, and a tendon fixation done with it (see Tendon Fixation). The principles for joint stability considered under the different de- formities are applicable in connection with the various transplantations. • Sections 109 and 110. Whenever transplanting a muscle or tendon when it will reach the bone, it can be placed in a groove under the periosteum as recommended by Dr. Vulpius. When it will not reach, silk elongation is most satisfactory. 151. Operation for a Weak or Paralyzed Tibialis Anticus. Trans- plantation of the Tibialis Posticus Forward to give Dorsal Motion to the Foot. — The patient lies on his back with his leg outwardly rotated, a sand bag or heavy pillow may be placed under the buttock of the opposite side; the operator stands on the same side as the leg to be operated on. OPERATION An incision is made parallel to the tibia extending one inch above and one-half inch posterior to the internal malleolus, extending up to the middle of the leg and down to the muscle layer. The tibialis posticus tendon is lifted on a blunt dissector. It may be distinguished from the long flexor of the toe as the latter will contract the toes when forcibly lifted on the blunt dissector. An assistant holds the incision retracted downward while the tibialis posticus tendon is drawn up and cut away below. The tendon tip is held in the hemastatic, the compressed part is cut away later. The tendon and muscle are dissected up to the middle of the leg. An incision is made over the front and middle of the tibia, a tunnel is made from the upper end of the first incision subcutaneously to the incision on the anterior part of the leg. A tendon carrier or long clamp is passed from the anterior incision backward, grasps the tip of the tibialis posticus tendon, draws it forward followed by its muscle. Sterile towels are placed above and below the muscle, while silk is quilted up one side and down the other side as shown in figure 227. In in- serting the needle through the tendon it should be passed vertically through in order not to tear the fibers as shown in figure 227. The muscle and silk are turned upward and covered with a sterile towel while a tunnel is made in or under the subcutaneous fat down to the mid- tarsus region. The point of insertion in the midtarsus is determined by the unparalyzed muscles remaining. If the tibialis anticus is paratyzed, the insertion may be made about the middle of the midtarsus at B, figure 247. If this muscle is present to a slight degree, insertion may be made further to the outer side (C, figure 247). The point of insertion having been selected, a curved flap is made so that its base overlies the point at which the silk is to be inserted (figure 226). The flap should take with it in one layer the subcutaneous fat and fascia and extend to the layer of the tendons and muscles. Its curve should be slight and laid out not to cut off the circulation at its proximal end. A subcuta- 138 TECHNIQUE OF OPERATIONS neous tunnel is made by means of a tendon carrier (see figure 230), from the incision at the front of the leg to the incision in the foot. The lower end of the upper incision is carefully held up by means of a retrac- tor (figure 228) to prevent inversion of the fat while the muscles and tendons are drawn downward. The muscle is drawn through the tunnel and the silk protrudes through the incision at the tarsus as shown in figure 229. The silk is quilted in the periosteum as shown in figures 231 and 232. Before tying, each strand is pulled upon so that it will be tense, holding the foot in a position of very slight dorsal flexion. The operator should assure himself that the muscle is not caught at any one point in the tunnel and that it will slide freely as far as it will go before inserting the silk in the periosteum of the foot, otherwise there may be relaxation of the silk during the convalescence. When the silk is tied the foot should be held in the desired position in slight dorsal flexion. After being tied the knot is pressed flat and covered over by the muscle fibers or tendons in the foot, then the deep tissues are brought together with interrupted chromic catgut sutures number 00, the subcutaneous fat with interrupted chromic sutures number 00, and the skin with continuous chromic catgut sutures num- ber 00. Six layers of gauze are placed over each wound extending one- half inch beyond the ends of incision and about one inch or one and one- half inches broad. This size dressing facilitates the inspection of the wound later on without interfering with the plaster. Sterile sheet wadding should be applied with a large fold or roll of loose sheet wadding over the front of the leg to prevent pressure from the plaster on the transplanted muscle (see figures 234 to 236) . After this sheet wadding rollers are applied; a plaster of Paris bandage is next applied from the toes to the groin with the foot slightly overcorrected, relaxing the tendon and silk. Before operation for transplantation forward at the ankle, if the tendo Achilles is extremely strong it is well to do a tenotomy. The foot should be manipulated so that its action is free and normal in all direc- tions. When this has been accomplished a tendon transplantation may be performed. The after care in this operation is the same as that laid down for transplantation of the peronei muscles forward. In using the tibialis posticus for transplantation it may be well to slit the tendon longitudinally and take half of the tendon with the whole muscle for transplantation as described above. The half of the tendon remaining attached below can be used to fix the joint as described under tendon fixation. This will prevent pronation and weakening of the joint laterally. The rules that govern joint stability should be observed as described under transplantation of the peronei muscles and as de- scribed under the various foot deformities. Sections 109 and 110. 152. Operation for a Weak or Paralyzed Tibialis Anticus. Trans- plantation of the Flexor Longus Digitorum to Give Dorsal Motion to the Foot. — This operation differs in no way from the transplantation MUSCLE AND TENDON OPERATIONS 139 of the tibialis posticus forward excepting in the use of the long flexor of the toes instead of the tibialis posticus. The operative consideration and the after care are the same. 153. Operation for a Weak or Paralyzed Tibialis Anticus. Trans- ferring the Extensor Longus Hallucis to Re-enforce the Tibialis An- ticus in the Lower Third of the Leg. — The patient lies on his back, the operator stands on the side of the leg to be operated on. An incision is made two inches long through the skin and fat over the front and lower third of the leg. The skin and subcutaneous fat are re- tracted and the extensor tendons are exposed. Lifting each tendon on a Fig. 239.— Expos- ure of the tibialis anticus and extensor longus hallucis in the lower third of the leg. Fig. 240.— The ex- tensor longus hallu- cis transferred to re- enforce the tibialis anticus in the lower third of the leg. (See figure 239.) Fig. 241.— The ex- tensor longus hallu- cis sutured after being transferred to> the tibialis anticus. blunt instrument will give sufficient pull to show to which toe it extends. The extensor of the great toe is isolated and cut, the proximal end is placed through a slit in the tibialis anticus tendon and pulled into the slit until it relaxes, the tibialis muscle slightly above the slit. Quilted sutures are then used to unite both tendons; either mattrass sutures or quilted sutures are used (see figures 239 to 241). The wound is closed up in slight dorsal flexion, relieving the strain on the transplanted muscle. After six weeks the patient walks for two weeks with the plaster, after that it is removed gradually. When the tibialis anticus is nearly completely paralyzed, a short caliper brace with a double stop at the ankle is worn for about a year during the day and a plaster or posterior wire splint is worn at night. The latter reaches from the toes to below 140 TECHNIQUE OF OPERATIONS the knee. Muscle training and special exercise should be done for a year or more. 154. Operation for Transplantation of the Extensor Longus Hallucis to the Tarsus for Weak or Paralyzed Tibialis Anticus. — A transplanta- tion of the extensor longus hallucis may be done to the tarsus, to the metatarsal or in the lower third of the leg to the tibialis anticus. This operation is often done in addition to transplanting other muscles such as the peroneii forward. Besides giving added power to raise the foot, it will decrease the tendency to hammer toe when this is developing. Fig. 242. — Incision on the dorsum of the foot exposing the ex- tensor tendons. Fig. 243. — Silk quilted into the ex- tensor longus hallucis which is ready to be placed into the slit tibialis anticus ten- don. Fig. 244. — Inser- tion of the extensor longus hallucis into the slit tibialis anti- cus tendon. Operation for a Weak or Paralyzed Tibialis Anticus. Transplant- ation of the Extensor Longus Hallucis to the Tendon in the Foot. — An incision is made over dorsum of the foot, the tendon is cut away from the toe at the dorsum of the foot, silk is quilted up one side and down the other of the tendon and the tendon fastened into the perios- teum of the bone by means of this silk which is quilted into the perios- teum (see figures 242 to 244). The operative technique, the operative considerations, and the after treatment are all similar to that considered under transplantation of the peroneii forward and under deformities of the foot and ankle. Sections 151, 109, 110. 155. Transplantation of the Extensor Longus Digitorum to the Tarsus to Raise the Foot; for a Weak or Paralyzed Tibialis Anticus.— The patient lies on his back, the operator stands on the same side as the leg to be operated on, a sand bag is placed under the ankle. A longitudinal incision is made over the dorsum of the foot from the base of the third metatarsal to the annular ligament (figure 258). The extensor tendons of the four outer toes are cut away as low down as possible. The foot is brought up to a dorsal position twenty degrees from a right angle. The tendons are cut long enough so that when attached to the periosteum of the tarsal bones they will hold the foot MUSCLE AND TENDON OPERATIONS 141 in position. The silk is quilted up one side and down the other side of the tendons as shown in figure 227. This quilting must be done high on the tendons as the operator will see. This may be done in pairs or all four tendons may be quilted at the same time. The lower end of the silk is quilted into the periosteum overlying the tarsal bones (see figure 232). The point selected for the insertion of this silk into the tarsus will depend largely on the deformity and the muscles that are paralyzed (see General Considerations in Muscle Transplantation and Foot De- formities). Sections 109, 110. If the tibialis posticus is strong, these tendons may be transplanted outward to re-enforce the action of the peroneii muscles. If the tibialis anticus is paralyzed, and the Fig. 245. — Inser- tion of quilted silk sutures into the cut tendons of the tibia- lis anticus and the extensor longus hal- lucis. Fig. 246. — Inser- tion of the tendons by quilted silk su- tures into the perios- teum at the middle of the tarsus. Fig. 247.— Points of insertion in the tarsus for tendons or silk liga- ments. tibialis posticus is gone, these tendons should be transplanted to the inner side of the foot to raise the foot (see figures 245-246) and counter-balance the peroneii muscles. If the peroneii and tibialis anticus and tibialis posticus are all gone, it will be of advantage to attach these tendons in the middle of the foot or to place two to the outer side and two to the inner side. The me- chanical action of the foot before transplantation should be observed and also the relative strength of the muscles to be transferred. The operative consideration and after treatment are similar to that described for transplantation of the peroneii forward. If the tendo Achilles is short, this must be relieved before any transplantation to the front of the foot. 156. Operation for a Weak or Paralyzed Tibialis Anticus. Trans- plantation of the Extensor Longus Digitorum to the Tibialis Anticus in the Lower Third of the Leg. — The extensor longus digitorum may be transplanted to the tibialis anticus tendon. An incision two and one- half inches long is made on the anterior aspect of the lower third of the tibia and parallel to it. 142 TECHNIQUE OF OPERATIONS The extensor tendons are drawn up and cut away below. A slit is made in the tibialis anticus tendon. The detail of this operation and the after treatment is the same as that described for the transplantation of the extensor longus hallucis into the tendon of the tibialis anticus. See section 153. 157. Transplantation of the Extensor Longus Hal- lucis to the Head of the Metatarsal. — This may be done by an incision over the dorsum of the foot two inches long extending from the joint upward. The dissection is carried down to the tendon, the incision is stretched downward by retractors and the tendon cut away below. As it is held up it is slit with a tenotome Fig. 248. — The extensor longus hal- lucis transferred to re-enforce the long extensor tendons of the toes. Fig. 251. — Split tendon passed through the bone. The second silk wormgut leader ready to carry the other end of the ten- don through the bone in the opposite direction. Fig. 249.— Drilling the head of the metatarsal; cut and split extensor tendon. (Silk wormgut leader doubled and placed in the drill end). Fig. 252. — Both ends of the split ten- don passed through the bone. Fig. 250.— Two silk wormgut leaders, one looped into the first which protrudes through the drill hole in the bone. Slit tendon ready to be pulled through the bone. Fig. 253. — Suture of the tendon ends to the unsplit portion of the tendon. (figure 249). The head of the metatarsal is drilled in its end. The two ends of a piece of silk wormgut are threaded through this hole (see MUSCLE AND TENDON OPERATIONS 143 figure 250), and drawn through the bone. The loop acts as a leader to draw the split tendon through the bone (figure 251). The operator should be careful to use a large size drill in order that the hole will be large enough to allow the tendon to be drawn through easily. A second loop of silk wormgut is passed through the first loop and drawn through the bone with one end of the slit tendon (figure 250). As the end of the tendon emerges from the other side of the bone it is grasped at its end by a small hemastatic and pulled tightly. The clamped tip is cut away later. The projecting loop of silk wormgut which has just been pulled through with the tendon is now ready to receive the other end of the slit tendon (see figure 251). This end is pulled through the bone in an opposite direction from its fellow (see figure 252). An assistant holds the foot in dorsal flexion during the application of the tendon to the bone. The two tendon ends are drawn tight and Fig. 2 5 4. — A method of suturing Fig. 255.— Method , * IG - ^ 5fc V~Tu £ the tendon to the of using silk sutures loop passed through capsule and perios- to hold the split ten- * he h f ad of the met u a " teum with silk. don. * arsal rec f lves * he tendon; it is then folded over the dorsum of the metatarsus where they turned over and su- meet (see figure 253) , and are sutured together with *"e 6 257 ) ' interrupted chromic catgut sutures number 00 and at the same time sutured to the tendon from which they come above its division (see figure 253). The deep tissues are brought together over them with interrupted chromic catgut sutures number 00, the subcutaneous fat with interrupted chromic catgut sutures number 00, the skin with continuous chromic catgut sutures number 00. Other methods of suture are suggested in figures 254, 255, 257. In judging the tension on the tendon of the transplanted extensor hallucis, the operator should see that it maintains the foot at a right angle before the sutures are placed. A plaster well padded with sheet wadding is applied from the toes to the knee. The patient is allowed to walk with the plaster at the end of the third week if no other operation has been done. The muscles should be trained and exercised. The after care otherwise is the same as that for transplantation of the peroneii. 144 TECHNIQUE OF OPERATIONS 158. Transplantation of the Extensor Longus Digitorum in Paralysis of the Tibialis Anticus or when the Tibialis Anticus is very Weak. — The extensor longus digitorum is very useful for transplantation to give power to raise the foot when the tibialis anticus is weak or paralyzed. This transplantation may be used in addition to other A Fig. 257.— Suture of the tendon passed over the silk loop. (See figure 250.) transplantations of muscles placed forward, especially Owhen these muscles are strong and are causing de- formity. When the patient is raising the foot largely by the power of the external longus digitorum as is often the case in paralysis of the tibialis anticus, and other paralyses, a hammer toe and claw foot is de- veloping either from the strong action of the long extensors of the toes or from the weak opponents or both. In this instance a transplantation is doubly useful. The tendons may be transplanted to the tarsus altogether or in pairs, they may be transplanted to the head of the metatarsals or they may be inserted into the tibialis anticus tendon in the lower third of the leg. The consideration of the insertion of transplanted tendons is discussed separately (see sections 109, 110) under transplantation of the peroneii and under the various deformities of the ankle and foot (see also Hammer Toe, sections 118 to 124). Persistent extension of the toes gives a permanent deformity, and causes a callous under the ball of the toes sooner or later. 159. Transplantation of the Extensor Longus Digitorum to the Head of the Metatarsal to give Power to Raise the Foot. — The extensor longus digitorum tendons may each be put into the head of its metatarsals as already described for the extensor longus hallucis. Section 158. The after treatment is the same as for trans- plantation of the peroneii muscles forward. 160. Operation for Paralysis of the Tibialis Anticus. Transplantation of One-half of the Tendo Achilles Forward. — One-half of the of the foot. 1. Extensor tendo Achilles may be brought forward with brevis. 2. Extensor longus. , 1( . « .. t i , i , j . , ,r 3. Extensor hallucis. one-halt of its muscle and transplanted into the 4 _ Tibialis anticus. A, B, tibialis anticus tendon or into the tarsus as de- and C are good points for scribed for the tibialis posticus forward. With the silk insertion, under the . c . , . muscles, whenever possible. this operation a tendon fixation may be done with one-half of the tibialis anticus and one-half of the tibialis posticus. The after treatment is the same as for transplantation of the tibialis posticus forward. MUSCLE AND TENDON OPERATIONS 145 161. Operation for Partial or Total Paralysis of the Peroneii. Trans- plantation of one-half of the Tendo Achilles Forward. — When the peroneii are paralyzed or very weak and there is no other better procedure to restore the usefulness of the foot, if the tendo Achilles is extremely strong, this tendon may be slit upward from the os-calcis and one-half of the tendon and muscle transplanted forward. An incision is made one-half way between the external malleolus and the outer edge of the tendo Achilles extending upward to the middle of the leg. The incision is dissected up and retracted exposing the tendo Achilles and its muscle and the peroneii tendons with their muscles. The outer half of the Achilles tendon is cut away below at the os-calcis and dissected up and carried forward and attached to the peroneii ten- dons, as follows; the tendon is drawn down along the peroneii and in- serted through the slit made in the peroneii; a silk suture is first quilted into the half Achilles tendon. This silk is quilted into the peroneii tendons holding the foot in slight equinus valgus. The deep sutures are brought together with interrupted chromic catgut sutures number 00, the subcutaneous fat with interrupted chromic catgut sutures number 00, the skin with continuous chromic catgut sutures number 00. A plaster of Paris bandage is applied from the toes to the groin. In selected cases this procedure will correct a slight varus and give power to abduct the foot. The after treatment is the same as prescribed for transplantation of the peroneii forward, excepting that the foot is put up in an equino valgus and held there by a plaster for six weeks, later a brace is used and the heel and shoe built up to maintain this position for about six months. After that the foot is put up in this extreme position a short time each day. 162. Operation for Total or Partial Paralysis of the Tibialis Posticus. Trans- plantation of one-half of the Tendo Achilles. — One- half of the tendo Achilles is transplanted forward, into the tibialis posticus, done . FlG - 259 - — Inci - on the inner side of the leg bXeeTthf tendo F^T 2 60.-The , as described for paralysis Achilles and the neii muscles dissected up of the peroneii tendons. peroneii tendons. and quilted with silk. The post operative treatment is the same ; the foot, however, should be put up in a position of equino varus. With this operation one-half of the tibialis posticus may be attached to the internal malleolus (see Tendon Fixation for Valgus). 146 TECHNIQUE OF OPERATIONS 163. Operation for Transplantation of the Flexor Longus Digitorum for a Weak Tendo Achilles. — This operation is identical with the operation for transplantation of the tibialis posticus excepting that the long flexor digitorum tendon is used. It is readily recognized by the surgeon; as he raises the tendon on a blunt dissector it will cause the toes to contract. The after treatment is the same as that for transplantation of the peroneii. 164. Operation for Transplantation of the Tibialis Posticus for a Weak Tendo Achilles. — The tibialis posticus tendon may be sub- stituted for the flexor longus digitorum in the above operation. 165. Transplantation of Peroneii to the Tendo Achilles. — Where the tendo Achilles is weak or paralyzed, one or both of the peroneii tendons may be transplanted backward (see figures 259 to 261), and passed through a slit in the tendo Achilles and attached to it by quilted silk sutures. The distal ends of the peroneii tendons, one or both or part of one or both, are attached to the mal- leolus (see Tendon Fixation). This transplantation is often done in case of calcaneous at the same time that an astragalectomy is done with displacement of the foot backward. See section 168. When the tibialis posticus is paralyzed one of the peroneii may be transferred to it; it is transplanted into the posterior tibial tendon back of the internal malleolus. The line of the muscle is changed at the middle of the calf. The transplanted tendon is quilted with silk in the usual way, then passed through a slit in the tibialis posticus tendon and the silk quilted and tied in this tendon. The inner half of the tendo Achilles and its muscle may be used for Fig. 261. -- The the same purpose as described for the transfer of its ES the*" Lndo ™ tCT half t0 the P« 0ndi - Achilles and fastened 166. Operation for Paralysis of Extensor of the with -silk sutures. G rea t Toe. (Transplantation of its Distal End to that of the Tibialis Anticus). — The patient lies on his back, the opera- tor stands on the side of the leg to be operated on. An incision is made two inches long through the skin and fat over the anterior lower third of the leg. The skin and subcutaneous fat are retracted and the extensor tendons are exposed. Lifting each tendon on a blunt instrument will give sufficient pull to show to which toe it extends. The distal end of the extensor tendon of the great toe is isolated and sutured through a slit made in the tibialis anticus. The degree of tension should be carefully estimated in order not to cause a hammer toe. The tension should be a little less than that of the tibialis tendons. A plaster is applied with the foot at right angles. After three or four weeks the MUSCLE AND TENDON OPERATIONS 147 patient walks on the foot with the plaster. After that it is gradually omitted as walking improves. 167. Operation for Transplantation of the Tibialis Posticus to the Tendo Achilles. — The patient lies on his back, with his leg outwardly rotated, a sand bag or heavy pillow may be placed under the buttock of the opposite side. The operator stands on the same side of the table as the leg to be operated on. OPERATION An incision is made parallel to the tibia extending one inch above and one-half an inch posterior to the internal malleolus, extending up to the middle and upper third of the leg. The tibialis posticus tendon is isolated and held on a blunt dissector. It may be distinguished from the long flexor of the toe as the latter will contract the toes when lifted on a blunt dissector. An assistant holds the incision retracted down- ward by a hooked retractor and the tibialis posticus tendon is cut away low down, unless half of it is to be attached to the internal malleolus (see Tendon Fixation for Valgus) . The tendon and muscles are dissected up to the middle of the leg. Two sterile towels are placed about the tibialis posticus muscle, one above and the other below. The tendon tip is held by the hemastatic while the operator quilts silk up one side and down the other (see figure 227). The silk is carefully tested before inserting it into the tendon, a heavy number sixteen or number eighteen braided silk is used. The incision is next retracted exposing the tendo Achilles extending downward from the junction of the middle and lower third of the leg. The tendon of the tibialis posticus is placed through a slit in the tendo Achilles and sutured there by means of quilted silk sutures as shown in figure 261. The operation is sometimes done in connection with an astragalectomy when there is paralysis of the poste- rior muscles. The plaster and after treatment is the same as that for transplantation of the peroneii muscles, excepting that the foot is put in a few degrees of equinus. A plaster or wooden heel is used for early locomotion with the plaster on. CHAPTER III OPERATION IN CASES OF PARTIAL OR TOTAL PARALYSIS ABOUT THE ankle. (See also Chapter II) 168. Astragalectomy and Displacement of the Foot Backward for Flail, Partially Flail or Foot Operation. — (Devised by Dr. Whitman). operation The patient lies on his back, the operator stands on the same side of the table as the ankle to be operated on. One of two incisions may be used; either an incision starting posterior to the external malleolus and one inch above it sweep- Fig. 262.— The usual in- cision for removal of the astragalus and for opera- tions on the ankle joint. Circular incision. Fig 263. — Anterior external incision used for astraga- lectomy in paralytic cases when the sub-periosteal method of elevating the tissues is employed. ing around anteriorly in a circle to the middle of the tarsus and then curving downward to the base of the second or third metatarsal (see figure 262), or a vertical incision (see figures 263, 264) is made two and one-half inches long anterior to the external malleolus and extending downward to the inner side of the peroneii tendons. In infantile paralysis where the object of the operation is to give stability at the joint and to interfere as little as possible with the circulation in a patient where the circulation is none too good, the operator prefers the second incision which disturbs the circulation much less. In using this incision it is possible to do the operation in thirteen minutes including very extensive attention to the tibia and both malleoli. The incision in no way hampers the operator as soon as he understands how to remove the astragalus. The incision extends down to the bone, is made vertically 23^ inches 148 OPERATION IN CASES OF PARALYSIS ABOUT THE ANKLE 149 long anterior to the external malleolus curving slightly anterior to the peroneii tendons, the surgeon using the scalpel. The posterior edge of the incision is retracted slightly (see figure 265). The operator uses an osteotome on the external malleolus to remove the attachment of the Fig. 264. — Incision anterior to the peroneii tendons in the foot. Fig. 265. — Retraction of skin and fat. Fig. 266. — Subperiosteal re- moval of tissues from the anterior surface of external malleolus. 1 * ^3 Fig. 267.— 1, Oscalcis. 2, tragalus. 3, Cuboid. As- Fig. 268.— De- taching the peri- osteum and tis- sues from the external malleo- 1 u s, subperios- teally. lateral ligament subperiosteally (figures 266 to 270). He removes all the tissues subperiosteally from the under side, the back and inner side and the front of the lower fibula for one inch or more (see figure 268). The an- terior edge of the incision is next retracted (see figure 269). The osteotome lifts the tissues from the bone well forward. The neck of the astragalus is cut as far forward as possible (figures 270, 271). The bone here is cut completely across. The osteotome is withdrawn 150 TECHNIQUE OF OPERATIONS and placed above the astragalus on its tibial articular surface as far in- ward as possible (figure 271). The foot is adducted for this purpose. The bone is cut vertically clown and back leaving a narrow flat disk close to the internal malleolus. There is now beside this disk two other pieces of the astragalus. A large piece close to the external malleolus and a small knob forward of the neck (see figure 271). The outer portion of the astragalus is Fig. 269.— Show- ing relative position of the tibia, fibula and astragalus. Fig. 270. — Astragalus. ., , . ... , „ , .. Fig. 271. — Lower line, os- easily removed and will be found most adherent teotome cutting the neck of On its Under Surface. The Operator at this the astragalus, as far forward point may dislocate the foot inward as seen ZESteStS.'tZS. in figure 272, or he may remove first the inner lus, from above downward, at disk-like portion of the astragalus from its at- the inner side - close t0 the tachment to the internal malleolus. The lower end of the astragalus beyond the neck is very easy to remove as it has practically no attachments, if the first osteotomy is done for- ward enough. When the astragalus has been removed completely the foot is dis- placed inward exposing both malleoli (see figure 272). The tissues are dis- sected subperiosteal^ with an osteotome from the posterior surface of the fibula; extending inward, they are removed subperiosteally from the posterior sur- face of the tibia for an inch upward and from the posterior, anterior, and outer surface of the internal malleolus. If these tissues are not carefully removed sment of the the foot will not displace backward as it should and an eversion of the foot will be present which is undesirable in para- lytic cases, especially when the muscles that lock the knee are weak or com- pletely paratyzed. The operator replaces the foot and dislocates it backward. He uses his finger through the wound to see if any tissues Fig. foot inward, after removal of the as tragalus giving full access to the tibia and the malleoli, anteriorly and posteriorly. OPERATION IN CASES OF PARALYSIS ABOUT THE ANKLE 151 resist making a perfect dislocation backward. It should be remem- bered that the external malleolus is further posterior in the foot than the internal. This relation should to a certain degree be present in order that the foot shall not be everted. If the tissues have not been removed subperiostially from the fibula, tibia and tarsus as described above, it will be necessary to shave off the inner surface of each malleolus and the tarsus against which these malleoli rest. The deep tissues are brought together sealing the bony cavity com- pletely with interrupted chromic catgut sutures num- ber 00, the subcutaneous fat with interrupted chromic catgut sutures number 00, the skin with continuous chromic catgut sutures number 00. A small dressing is placed over the wound consisting of five thicknesses of gauze one inch broad and extending one-half inch beyond either edge of the wound. Sterile sheet wad- ding is put around the foot over this. The leg is well padded with sheet padding and a plaster of Paris bandage applied from the toes to the groin. In cases of calcaneous, the foot is put up in an Fig. 273.— Astrag- equinilS position. alectomy and dis- \ . , „ placement of the In cases without calcaneous deformity, it may be foot backward giv- put up in an equinus position for a short time and } n s a fullness at the then brought to a right angle or it may be put up at internal malleol us- . right angles at the time of the operation. When a tendon transplanta- tion is done to the front of the foot, the foot is put up at right angles. By dissecting the tissues up subperiosteal^ they reattach- themselves readily and firmly, yet without causing a stiff joint. The ultimate re- sult of astragalectomies with displacement of the foot backward is very good. The patient may expect from one to two-thirds of the normal motion, sometimes more, and absolute lateral stability. 169. After Treatment. — By using the subperiosteal dissection, the after treatment may be the same as that employed for a Potts fracture at the ankle. The patient is allowed to walk with a plaster at the end of six weeks and with a paralytic at the end of four or five months, all apparatus may be omitted. In growing chil- dren it is important to broaden the heel or to wear apparatus for a year to prevent the foot turning one way or the other as the bones grow. The shoes should be kept repaired constantly. An astragalectomy and displacement of the foot backward may be done in connection with transplantation of any strong muscles to take the place of weak ones. The transplantation may be done at the same time as the astragalectomy; the bone operation precedes the transplan- tation. The peroneii are often used in this way to re-enforce the muscle of the front of the foot or to re-enforce the muscles on the back. Other muscles may be used instead of the peroneii for the same purpose. These 152 TECHNIQUE OF OPERATIONS transplantations arc done as described elsewhere in these pages; the insertion of the tendons will be further forward at the tarsus on account of the displacement of the foot backward. The original plaster should not be changed until the sixth week. This assures good displacement of the foot. If the plaster is poorly applied the foot will slip forward. This may be corrected under an anaesthetic, never without, at the end of the first week. 170. Application of Plaster Following Astragalectomy. — As the foot is being placed in a special position it is important that the operator who has manipulated the foot at the time of operation should hold the foot at the time of the application of the plaster, in order to be sure that he is fitting the foot to the tibia as he has planned it. For the same reason some detail as to the method of application of the plaster will not be out of place. The foot having been well protected with well fitting sheet wadding, especially the heel, a cuff of plaster of Paris bandage is put on six or eight layers on the lower end of the tibia and another cuff of about eight layers of plaster around the ball of the foot. When these are hard the operator places the foot in the desired position, manipulates it gently to assure himself that the position is the one he wishes and that the ankle motion is smooth and free. He holds the foot by the cuff of plaster with his right hand and the cuff around the tibia with his left. The assistant finishes the plaster connecting the two cuffs. When this third portion of the plaster has hardened, the posi- tion of the foot is fairly assured. A well fitting plaster over the rest of the leg is applied, extending to the groin. 171. Operation for Insertion of Silk Ligaments at the Ankle. — Silk ligaments at the ankle are useful to maintain lateral stability and prevent toe drop in adults and children as a permanent measure in para- lytic conditions. They may be used in children for the same purpose as a temporary measure during the recovery of the muscles. They are useful as per- manent ligaments to prevent toe drop and to increase the lateral stability when the ankle is not flail, but weak. This is especially the case when the anterior muscles are paralyzed and there is very little power in the posterior muscles. They are useful in this instance in adults and in children. The silk ligament is not of value to maintain lateral stability when op- posed to strong muscles, or for a flail ankle. In suitable cases they will make braces unnecessary at the ankle and will give sufficient stability here for weight-bearing. In adults at the ankle they may be applied directly to the bone above and to the bones of the foot be- low (see figure 279). Where they are to be used temporarily in children, they may also be applied to the bone above and the bone below. When, Fig. 274.— Perios- teum incised, for the insertion of silk liga- ments. OPERATION IN CASES OF PARALYSIS ABOUT THE ANKLE 153 however, they are used in children to remain permanently, the upper at- tachment should be made to the everted edges of the periosteum as de- Fig. 275.. — Inci- sions for the inser- tion of silk ligaments in the lower third of the leg and at the tarsus. Fig. 276.— Method of elevating the edges of the everted periosteum prepara- tory to the insertion of silk ligaments. Fig. 277. — The silk quilted up one side and down the other of the everted periosteum ; a second strand being tied into the first silk, to give four ends. (See next figure) . scribed below (see figure 277) , in order to allow further growth without relative contracture. 172. Silk Ligament Operation at the Ankle. Open Method. — The patient lies on his back, the operator stands to the outer side of the ankle to be operated on. An incision is made over the anterior and lower third of the tibia two inches long down to the periosteum (see fig- ures 274, 275). This is incised, its edges everted (see figure 276) , silk is quilted up one side and down the other (see fig- ure 277). The second piece of silk is _ F ; G n 278 \Tu Method J of 1 , t ^ ng i he ' -n • i -i • • first silk and the second silk together tied to the Silk m the periosteum giving to give four strands. The first is in- f Our Strands (figures 278 and 279). The serted into the periosteum. A, First point of insertion in the foot is next ^^silk" §!" t Selected with a View to gOOd leverage and strand tied. D, The second strand balance. A curved incision is made over ^ed giving four strands for inser- ., ■ i • j i <• ■ i <■• . • tion m the periosteum of the tarsus. the points in the toot chosen tor insertion, one to the outer side, the other to the inner side (see figure 275). The silk is carried subcutaneously from the leg to the foot incision (see 154 TECHNIQUE OF OPERATIONS figure 280). At the cuboid and dorsal cuneo-cuboid ligaments, the silk is quilted through the periosteum as described for transplanting the peroneii. On the inner side of the foot a curved incision is made over the scaphoid and internal cuneiform, the silk is carried subcutaneously from the anterior incision in the leg to this incision and there inserted by quilted sutures (figure 232). The knots are pressed down and flattened after three ties. The muscle fibers of the short ex- tensor digitorum are retracted be- fore insertion of the silk in the periosteum and become useful cover- ing for the knot and silk at its inser- tion on the outer side of the foot. On the inner side the tendons may be used. The deep fascia is brought together over this with interrupted chromic catgut su- tures number 00, the subcutaneous tissues with in- terrupted chromic catgut sutures Fig. 279.— Second strand tied to the first, giving four strands, two for each side of the foot. Fig. 280. — Ten- don carrier used to draw the silk down to the tarsus. Fig. 281.— Perios- teal needle, short, round, not brittle, with a large eye; the needle is flat- tened at the eye. number 00, the skin with continuous chromic catgut sutures number 00. Before tying these ligaments each silk strand is pulled firmly through its periosteal insertion so that it will firmly hold the foot in very slightly overcorrected position. When the tendo Achilles is resistant or its muscles are strong, it is advisable to stretch the foot well upward and do a tenotomy of the Achilles tendon before inserting the silk. All deform- ities of the ankle and all restrictions of motion should be overcorrected before inserting the silk; — when the deformities are considerable they should be corrected at a previous opera- FlG - 282. — Short needle .. * m, P . * , , , n -i i • li v holder, forcing the needle tion. The foot should be flexible m all direc- thr0U g h the periosteum; pres- tions at the time of applying the artificial sure is applied on the needle liffampnts holder close to the needle, but ° ' . . . . no twisting force should be The needles used for periosteal insertion use d in order not to break the are shown in figure 281. In forcing the needle, needle through the periosteum and superficial part of the bone, a heavy hemastatic is very useful. The pressure exerted by the surgeon should OPERATION IN CASES OF PARALYSIS ABOUT THE ANKLE 155 not be applied at the handle of the hcmastatic but near the needle with the finger or thumb of the left hand on the hemastatic as shown in figure 282. 173. Silk Ligament Operation. — Dr. Bradford's subcutaneous method. Subcutaneous silk ligaments may be applied rapidly with very Fig. 283. ments. "-iw m.^ Fig. 284.-Drill Fig. 285. -Silk ing the tibia and with silk wormgut wormgut leader used Fig. 286. — Silk tarsus for silk hga- leader inserted into to carry the silk passed through the the end of the drill. through the tibia; drill tibia, tendon carrier inserted through the from the outer side of tarsus. Silk wormgut the foot, to the outer leader passed through side of the leg, receiv- the eye of the drill. ing the silk. little disturbance to the tissues. The point in the lower third of the tibia is selected (figure 283), the skin over the bone is slid backward; a drill with an eye in its end is passed through the skin and tibia (figure 284); as it protrudes from the bone on the other side of the leg, the skin is slid forward and the drill pushed through it. In this ; n way the hole in the skin and in the through the tibia carrier completing the D0n 6 Will be Out of line. The tWO d °T t t0 b th d leg ' silk insertion- en ds of a piece of silk wormgut are through the tarsus P ass ed through the eyes in the drill and withdrawn by means of a silk with it (figure 285). The loop in the silkworm gut is wormgut leader. i e ^. protruding on one side of the leg, the two ends at the other side. The exit of the drill in the skin is made at a different level to the bone exit. This is done by pulling the skin to one side of the bone before the drill perforates it as described above. The tarsal bones are drilled in a similar way (figures 283 and 285). As the drill is withdrawn a guide of double silkworm gut is pulled through the bone 156 TECHNIQUE OF OPERATIONS so that the loop protrudes at one side of the foot and the two ends pro- trude at the other side. A double strand of heavy braided silk number 16 or 18 is carried through the tibia bones by means of the silkworm gut guide. A carrier is introduced at the skin puncture at the side of the tibia (see figure 286). This guide is carried up subcutaneously and brought out through the skin hole above (figure 286). The silk is passed through the eye of the carrier and drawn downward (figure 287). This silk is next passed through the loop of the silkworm gut and drawn through the tarsus. The carrier is next inserted to the inner side of the tibia through the skin and carried downward subcutaneously so that it protrudes below at the midtarsal region. The silk here is passed through the eye of the carrier and drawn upward subcutaneously so that both ends of the silk now protrude from the same hole above (figures 288, 289). The ligaments are drawn tight and the foot elevated. The silk is then tied and the ends cut; the skin is drawn outward over the knot which now slides through the tissues and lies close to the bone. The skin perforation being at a different level from that of the drill hole in Fig. 289.— Silk just before tying. Fig. 290.— Silk lig- aments. Silk in- serted from the tibia the bone, no sutures S^nSSL* ^ are necessary. The foot vent toe drop. should be held in a very slight overcorrection by „ ^ f 1 i _Tend ^ 1 °, f th ! ,.,,.. . ,. J peroneus longus displaced the silk ligament. Plaster is applied holding the forward, and sutured in a foot so that no strain comes on the silk ligament. e roove in the bone. 174. Tendon Fixation. — In the use of tendon fixation, advocated and improved by Dr. Galli, slight overcorrection of the deformity should be made. Either the whole of the tendon may be cut away above and the distal end put in a groove in the bone to grow and be nourished there by the bone and periosteum to which it becomes attached, or instead of using the whole of the tendon the tendon is split and one-half left in- tact; the other half cut and its distal end used for tendon fixation. In this way any tendency of the muscle to regenerate will be safeguarded. OPERATION IN CASES OF PARALYSIS ABOUT THE ANKLE 157 This method of tendon fixation is not recommended where there is extreme deformity or where the tendon fixation would be opposed to strong muscles or for total flail conditions of the ankle. 175. Tendon Fixation for Varus. Dr. Galli's method. When the peroneii are paralyzed and tendon fixation is decided upon, a vertical incision is made on the outer aspect of the lower end of the fibula. The skin is retracted exposing the fibula three inches from the tip of the bone. "With a periosteal elevator, the periosteum is raised one-eighth of an inch or more on either side of the incision and in the case of the epiphy- sis or epiphyseal cartilage, the perichondrium and a flake of cartilage are raised with a knife. ..." With a gouge a groove is made two and one-half inches long and one-eighth of an inch wide, to receive the peroneii tendons. The tendon, denuded of its tendon sheath, is placed in the groove. The tendon does not attach itself to the bone but slides if the sheath is not re- moved. The foot is brought around in the posi- tion desired, the tendon pulled tight and fastened to the periosteum by a silk suture. It is also fastened below by a silk suture which prevents it from slipping; its upper end may be turned down. The peroneus longus is displaced forward before being placed in this groove on the front of the fibula (see figure 291). The peroneus brevis is al- lowed to remain under the external malleolus and placed in a groove on the posterior aspect of the fibula (see figure 292) . The periosteum is ele- peroneus longus displaced vated, a groove two and one-half inches long forward and inserted in a , . , , , c . , . , . , i groove in the bone. and an eighth of an inch wide is made on the posterior aspect of the fibula to receive this tendon. The tendon is denuded of its sheath, placed in the groove, the periosteum brought together over it, the tendon doubled over at the top, having first been pulled tightly and sutured at the upper end of the tunnel and at the lower end of the tunnel with one or two silk sutures. 176. Tendon Fixation for Valgus. — Dr. Galli's method. Where there is marked valgus and the tibialis anticus is completely paralyzed, an incision is made on the anterior and inner aspect of the lower end of the tibia down to the tibialis anticus. A groove is made in the lower end of the tibia similar to that in the fibula (see figures 291 and 292), one-eighth of an inch wide and two and one-half inches long. The tendon of the tibialis anticus is denuded of its sheath, and drawn into the groove. The periosteum is brought together over this, the ten- don is turned over at the top and sutured with one or more silk sutures, at the upper and lower ends of the tunnel. A tunnel should of Fig. 292. — Tendon the peroneius brevis in- serted in a groove in the bone posteriorly. The 158 TECHNIQUE OF OPERATIONS be made in a similar way for the tibialis posticus on the inner side of the tibia. 177. Tendon Fixation for Calcaneous. — Dr. Galli's method. In cases of calcaneous, an incision is made along the whole length of the tendo Achilles. The sheath is split throughout the length of the incision and the tendon exposed. It is freed from its attachments to the sheath and retracted inward so as to expose the fibrinous covering of the deep muscles of the leg. A vertical incision is made through this sheath (which is the intermuscular septum between the deep and superficial layers of the flexor muscles of the leg) and the long flexor longus hallucis comes into view. This muscle is then retracted inward, exposing the posterior surface of the shaft and lower extremity of the tibia. About three inches of the tibia is exposed. A vertical incision is made through the periosteum. A large gouge is used to open up the medullaiy cavity of the bone. This trough receives the tendo Achilles and the periosteum is closed in over it. If the leg is short the patient is put up in slight equinus, if not the tendon is held with the foot at right angles. In some Fig. 293. — Tibia drilled, silk wormgut leader placed in eye of drill. cases a tendon fixa- tion of one-half the tendon has been used and the other half al- lowed to remain at- tached to its muscle, limited. Fixation in transplantation. Fig. 294.— Silk worm- gut leader loop ready to draw a second silk worm- gut leader through the tibia, and with it the rolled end of the fascia. The drill is passed through the tarsus and receives a silk wormgut leader here. Fig. 295.— The fascia is drawn through the bone by the first silk wormgut leader and with it the second silk wormgut guide which is used to draw the second end of the fascia through the tibia. In this way only the deforming part of the motion is plaster of Paris is used as described for tendon OPERATION IN CASES OF PARALYSIS ABOUT THE ANKLE 159 178. Fascia Transplantation for Toe Drop. — The patient lies on his back, the operator stands on the same side of the table as the leg to be operated on. An incision is made three inches long over the front of the lower third of the tibia down to the bone, the tissues are retracted, the bone drilled with a large drill made with an eye in its end. A double strand of silkworm gut is passed through the drill to act as a guide (see Operation for Silk Ligament and figure 293). A second incision is made longitudinally and centrally over the midtarsal region and car- ried down to the bone; the edges are retracted and the bone exposed with its overlying periosteum. An incision is made five or six inches long in the unparalyzed leg on the outer side of the middle of the thigh through the skin and fat down to the fascia lata. A piece of fascia may be removed much longer and broader than the incision by retracting up, then down and then laterally. The amount selected should be estimated by measuring with a probe. The fascia removed should be not less than two inches wider and two inches longer than the length necessary to go through both bone holes and cover the distance between. The fascia is slit at each end (see figure 294), the ends are then rolled. The roll- ing makes the fascia tougher, the upper ends are drawn through the hole drilled in the tibia, then over- lapped and su- tured with inter- r u p t e d chromic catgut sutures number 00 (see figure 295). The fascia is carried in a subcutaneous tunnel made just below the fat to the lower incision the foot (see m Fig. 296. — Both upper ends of the fascia are passed through the tibia and sutured ; both lower ends of the fascia are passed through the tarsus ready for suture. Fig. 2 9 7. —A method of suturing the fascia with silk to the tibia and to the tarsus by quilted sutures. Fig. 298. — The fascia sutured to the tibia and to the tar- sus. figure 296). Or it is sutured to the periosteum by quilted silk sutures (see figure 297), or the bones of the foot may be drilled and the fascia inserted in the same way as in the tibia. If the operator prefers, he may slit the periosteum of the tibia longitu- 100 TECHNIQUE OF OPERATIONS I dinally, its edges then everted (see figures 297 to 299), and the fascia tucked under the periosteum and stitched here with silk number twelve or number fourteen. At the foot two grooves may be made in the bone with an osteotome, the ends of the fascia tucked each in his groove and the periosteum drawn tightly over the stitches extending through the transplanted fascia. Before attaching the fascia firmly the foot should be brought to a position of fifteen or twenty degrees of dorsal flexion and be held here by the fascia. The deep tissues are brought together with interrupted chromic catgut sutures number 00, the skin with con- tinuous chromic catgut sutures number 00. A dress- ing of four thicknesses of gauze, extending one-half an inch beyond is placed over the wound, then sterile sheet wadding. A plaster of Paris bandage is applied over this from the toes to the groin, care being taken to protect the heel to prevent pressure and tension on the transplanted fascia. The plaster is split on either side to allow removal of the front half for inspection of the incision. The plaster remains for eight weeks, the patient being allowed to walk with the plaster a little after the first six weeks; when walking becomes easy a short caliper with a double stop at the ankle is used during the day and the plaster at night to prevent toe drop for one year at least. 179. Arthrodesis for Flail Condition of the Ankle. — For arthrodesis at the ankle an incision is made starting one-half an inch posterior to the ex- ternal malleolus and one inch above. This sweeps around over the fibula and forward to the middle of the front of the foot and then down to the base of the second and third metatarsal. The soft tissues are retracted and the periosteum removed from the ex- ternal malleolus with its ligaments with an osteotome. The foot is dislo- cated outward, a thin layer of bone is cut from the top of the tibia and the internal aspects of both malleoli are likewise denuded of periosteum. The surface of the astragalus should fit the bony surface of the tibia and fibula, and wherever they come in contact the bone should be exposed. The foot is replaced and the bones held together by heavy chromic catgut sutures number 1 or kangaroo tendon sutures. The deep tissues are brought together with interrupted chromic catgut sutures number 00, the super- ficial fat with interrupted chromic catgut sutures number 00, the skin with continuous chromic catgut. A very small gauze dressing is applied over the incision; sterile sheet wadding over this. A plaster of Paris bandage is applied from the toes to the groin with the knee slightly bent, the foot being held at right angles. This plaster should be worn without weight bearing for about six weeks; after that a light plaster applied from the knee downward and the patient en- FlG 299. — Incisions closed. OPERATION IN CASES OF PARALYSIS ABOUT THE ANKLE 161 couraged to walk. At the end of ten weeks he may walk without support. There are so many better operations than arthrodesis at the ankle that there are very few conditions for which it may be recommended. A totally flail ankle, known as "dangel foot" can be made serviceable with excellent lateral stability and yet up and down motion by means of an astragalectomy and displacement of the foot backward which is preferable to any operation which would stiffen the joint. More- over, in cases where the joint is not extremely loose, silk ligaments or ligaments made out of the tendons around the ankle as advocated by Dr. Galli, are distinctly preferable to a stiff ankle from arthrodesis. In walking, arthrodesis causes an awkward motion of the foot, the leg being held outwardly rotated. When the ankle is perfectly stiff by an arthrodesis, the patient walks as if he had a painful flat foot. As the front of the foot will not come up, the toe must be everted in order to make walking easy. CHAPTER IV INCISION, PUNCTURE AND ARTHROTOMY 180. Arthrotomy. — A knowledge of the important routes of ap- proach to the joints will facilitate any joint exploration, the removal of foreign bodies, the repair of traumatic conditions, the adjustment of difficult fractures, the reduction of old and difficult dislocations, the mobilization of joints where motion is partially or totally lost, and stiffening the joint as in certain paralytic conditions, to relieving and thoroughly draining suppurative conditions; a knowledge of the important routes of approach to the joint is very important. For each case, the operator will select the incision best suited for the individual condition. Each joint will be considered separately in other chapters. In all operations on the joints, the incision should be made down to the synovial membrane and made large enough before opening the synovial cavity. All bleeding should be stopped and the synovial membrane carefully opened. The joint structures should be tampered with as little as possible, the synovial membrane brought together care- fully and the layers over it closed in order not to disturb the function . of the peri-articular tissues. Unnecessary sepa- / | ration of the tissue layers is to be avoided. Tendons should be left in their sheath. Any ligaments that must be cut should be loosened periostically, in order that they may be readily replaced. Early motion should be the rule, gentle at first, and gradually increased. Joint operations should never be hastily considered and should be avoided by anyone not familiar with the best surgical technique. 181. Anterior External Incision (figure 300). — At the ankle a curved incision may be made starting two and one-half inches above the ex- ternal malleolus extending along the anterior border of the fibula, curving downward and forward just above the peroneii tendons to the cuboid. The tibia-tarsal joint line is a little over an inch above the tip of the fibula. 182. Posterior External Incision (figure 300). — An external incision may be made halfway between the external malleolus and the outer edge of the tendo Achilles, starting two and one-half inches above the malleolus extending downward parallel to the fibula and curving forward three-fourths of an inch below the tip of the external malleolus. 162 Fig. 300. nal incision, ternal incision Anterior exter- Posterior ex- INCISION, PUNCTURE AND ARTHROTOMY 163 Fig. 301. — Anterior inter- Posterior in- 183. Anterior Internal Incision (figure 301). — An incision may be made along the anterior border of the tibia starting two inches above the internal malleolus. This incision is carried downward and forward to the tubercle of the scaphoid. Any of these incisions may be carried further forward for operation on the tarsus. 184. Posterior Internal Incision (figure 301) . — An internal incision may be made halfway between the tendo Achilles and the internal malleolus starting two inches above it and ex- tending downward and curving forward one inch below the internal malleolus. These in- cisions will give access to the os-calcis and the posterior part of the ankle joint. An incision close to the peroneii or posterior tibial tendons and very close to the bone at the malleolus is very undesirable as the scar often becomes ad- herent to the bone which gives discomfort and pain later on. The two posterior incisions may be joined by an incision continued around over nai incision the os-calcis and extending from three-fourths of ternal "Vision. an inch below the external to three-fourths of an inch below the internal malleolus. This may be done without carrying the lateral incisions up- ward or in addition to the lateral incisions extended upward. In view of the fact that the two posterior incisions above described give ready -. access when used together to the os-calcis in cases of \ fracture or of extensive disease, it is better not to use the horizontal incision over the os-calcis as the scar is often painful later on and it rubs against the shoe. For fractures these incisions give ready access to any part of the tissues. For disease of the os- calcis they should be combined; the two posterior are sufficient unless the disease extends far forward and involves the astragalus. In this instance an an- terior median incision with the two posterior will give all the room that is necessary for removal of bone or sequestra and for good drainage. 185. Anterior Median Incision (see figure 302) .— An interior median incision is made two inches above the joint line and extends vertically downward over the midtarsus just external to the extensor of the great toe to the base of the third metatarsal. It may be made over the middle or outer third of the foot. Plantar incisions should be avoided; the incision to the sole should be at one or both sides of the foot; there are of course exceptional cases of foreign bodies. Fig. 302. — Anterior median incision. 104 TECHNIQUE OF OPERATIONS 186. Circular Incision for the Exposure of the Ankle Joint. (See Figs. 303 and 30-4.) — An incision is made one inch above the external malleolus starting halfway between the fibula and the tendo Achilles and extending forward and slightly downward to the front and middle of the tarsus, then curving directly downward to the base or middle of the third metatarsal. The tissues may be lifted subperiosteally, the tendons retracted in the tissues, allowing the edges of the incision to be raised for an inch Fig. 303. — Incision for removal of the astragalus or for a com- plete inspection of the ankle joint by displacing the foot outward. (See figure 304.) either way, the ligaments about the ex- FlG 30 4.— Displacement of the foot temal malleolus are Separated Off the outward after incision for inspection anterior internal and posterior as well of the ankle - < See & ^ Te 303 >- as the external surface of the fibula, allowing the foot to be dislocated inward as shown in figure 304. This gives an excellent view of the tibio tarsal joint, the astragalus and the upper portion of the tarsus. It is usually not necessary to cut the tendons to dislocate the foot. The foot should be carefully replaced and the deep tissues as well as the skin sutured. The external ligaments if detached subperiosteally from the fibula will reunite without suture. It will be remembered that they are lifted from the outer side of the malleolus with the skin and fat and periosteum. After operation the foot is held in plaster dorsally flexed thirty degrees. 187. Arthrotomy for Fractures About the Joints. — The necessity of immediate operation in fractures about the joints depends, as in other fractures, on the acuteness of the local and general reaction. When these do not contra indicate immediate operation, certain fractures about the joints may require treatment by the open method. Among these are fractures of the patella, fractures of the olecranon and certain fractures of the surgical neck of the humerus and certain fractures of the neck of the femur, all compound fractures, even when the protrusion of the bone has been extremely slight, all fractures that cannot be re- duced by manipulation or in which the correction cannot be main- tained or where apposition is impossible, many fractures combined with dislocation, articular fractures with pieces locking or limiting the joint action. INCISION, PUNCTURE AND ARTHROTOMY 165 Where there is a great deal of trauma and in multiple fractures and in cases where there is a great deal of shock, all that can be done is to im- mobilize the parts until a favorable time for operation. In selecting a suitable time for operation, when it is found necessary to operate on a fracture if there is no immediate contra indication, the sooner it is done the better. Where there is extreme swelling the surgeon should always wait. All cases should be operated on that show no union after three months of good treatment. Methods of treating the individual fracture cannot be considered in a limited space like this. The writer has described the routes of approach to the different joints and the technique of these. This will enable the surgeon from his knowledge of fractures to select the route best adapted for the individual treatment required and when necessary two or more incisions may be used. A knowledge of the technique will enable the surgeon to work rapidly in reaching the fracture on which he expects to spend time. 188. — The bones of the leg are readily reached and cut with an osteo- tome in the case of deformity from fractures. The fresh fractures that require open operation are also readily reached. It is important in frac- tures about the ankle to note the position of the foot with reference to the patella and anterior spine. The great toe should be in a line with the inner border of the patella and the anterior superior spine. The bone should be otherwise aligned and the foot not allowed to drop back. If this takes place the patient loses the dorsal motion of the foot, so important for any form of activity. Anterior bowing at the point of fracture is apt to take place and evertion of the foot. These must be prevented especially in low fractures of both bones. If the malleoli are fractured, the foot will displace backward. To prevent this, the foot should be dorsally flexed as described by Cotton. In almost all ankle fractures, the foot should be dorsally flexed from twenty to forty-five degrees, depending on the case. In bowing and deformity from old fractures after cutting the bone, a tenotomy of the tendo Achilles is usually necesssary to allow free overcorrection of the fracture. 189. A Method of Treating Overlapping Fractures. — Where the bones overlap, an excellent method of treatment is one suggested to the writer many years ago by Dr. Edward Martin of Philadelphia. In the operation when the surgeon has reached the fracture the ends are freed. A tough tape or webbing is used ten or twelve feet long, sterilized. The two ends of the tape are tied together, a loop of the tape is placed over the distal end of the bone. The other end of the tape is thrown over the foot of the operating table, a thirty-five pound weight is attached to this by an assistant. In about five minutes the bones will be found to be separated at least one inch. The weight is then held up by a y non- sterile assistant, the tape taken off of the end of the bone and clamped to the sheet on the operating table, so that it will not slip away while the surgeon works on the fracture. When the muscles are in fairly 166 TECHNIQUE OF OPERATIONS good tone or the overlapping of bone has been great, it will be found that the bones will overlap again in four or five minutes. A reappliea- tion of the tape will separate the bones again for the same length of time. The end of the lower bone should not be cut or freshened until all other procedures are done which require separation of the bones. When these have all been done the end of the bone over which the tape has been placed is freshened. After this the tape should not be placed on the end of the bone, unless it is very necessary, but the two ends al- lowed .to come together and held by a clamp until the operation is com- plete. Very bad overlapping fractures have been treated in this way in fresh cases without the necessity of shortening the bone. In old frac- tures no more bone need be removed than is required by the conical condition of the ends of the bone. 190. Fractures of Long Standing Still Ununited or United with Deformity, Preventing Function. — In fractures of long standing where there is a mild infection, conservative treatment should be tried first. When this has been tried free drainage should be established and at the same time the ends of the bone freshened up slightly. Unless the infection is marked, in many of these cases when the suppuration disappears, union has also taken place. In any case where there has been infection, no plastic operation should be used until the infection has been entirely absent for at least nine months — a year is safer. Where the infec- tion is very mild and of long standing, during the process of treatment the patient may be allowed to walk on the other leg if the local reaction is not too great. Sometimes he may walk a little on the affected leg. It is of advantage in certain cases to use a Thomas splint to take some of the weight off of the affected leg, the patient being allowed to bear weight on the ball of the foot, the splint taking all the weight off of the heel. Where the x-ray shows conical ends of the bone it is practically useless to expect union without surgical interference. 191. Tapping the Ankle. — The most scrupulous aseptic precautions are necessary both as to the preparation and the protection of the field of operation. When there is effusion the joint is readily reached with a trocar either anterior to the external or internal malleolus and just posterior to the tendon sheaths. The skin is drawn to the side so that the hole in the skin and muscle will be out of line when the needle is removed. If fluid is to be drawn, and other solutions are to replace it, the amounts should be carefully measured. Two good graduated metal syringes are very useful. All of their parts should be tested beforehand. The trocar is made to enter the joint and then is connected with the syringe. As little air as possible should enter the joint. The trocar should be of large diameter as the fluid may be thick or flaky. When the patient is not anaesthetized for the operation it is often well to have a short flex- ible tube connect the trocar with the syringe. This should be fastened INCISION, PUNCTURE AND ARTHROTOMY 167 at both ends by silk ties so that it will not leak easily when pressure or ■ suction is used. If the joint is to be washed out a definite amount of fluid is injected and the return measured in a sterilized measuring glass. The tibio-tarsal joint is about one and one-fourth inches above the external malleolus. Dr. Murphy uses a formalin glycerine solution as follows : — Liquor formaldehyde, 2% in glycerine. About ten drops of formaldehyde to each ounce of glycerine. This acts very well in infectious synovitis. But it should not be used in arthritis deformans nor in old chronic arthritis. The solution should be prepared twenty-four hours before it is used (Murphy). The tapping may be done with ethyl chlorid or novocaine adreneline solution, 1%. CHAPTER V OPERATIVE TREATMENT IN CASES OF JOINT ANKYLOSIS 192. Arthroplasty for Ankylosis. — Ankylosis may be bony, car- tilaginous or fibrinous, it may be periarticular, ligamentous and cap- sular, or extra articular, that is, skin scars, tendons, fascia, nerves and arteries. The form of ankylosis that exists will determine the treatment. A partial ankylosis at certain points had better not be treated by an ar- throplasty. Age must be considered, also the general condition of the patient. When the ankylosis is bony, cartilaginous or fibrinous, arthroplasty is indicated. When the condition is periarticular or extra articular, it may be treated by capsulotomy, tendon elongation, excision of exostoses, etc. Dr. Murphy lays stress on the following points: — The principles of asepsis to the finest detail are absolutely essential. One not familiar with the best surgical technique should avoid arthroplasty operations. The exposure of the joint must be generous and careful. The excision of the ankylosis must be complete. The contracted capsular ligaments and soft parts must be freed and if necessary lengthened. The normal contour of the joint should be restored as near as possible. The operator should obtain a hyper-mobilization of the joint. The joint should be re-shaped to give stability. The inter-position of material to prevent reunion of the bone is necessary. The principle is to separate the bones and to interpose between them material to prevent ankylosis. The best material for this purpose is the human pedicle, composed of fat, muscle, fascia, or a combination of these. When this is not possible, a transplantation is made of fat and fascia from the trochanter bursa region or from the fascia lata. Material such as ivory, celluloid, silver are not good. Materials that will not absorb or that absorb too slowly are not desirable. During the operation the soft parts should be freely liberated. Attach the interposing flap to one bone only and cover it completely. Early motion, that is, at the end of five to seven days is necessary with or without gas or gas oxygen. Dr. Murphy records failures in arthroplasty as due to first, insufficient and defective exsection of the capsule and ligaments, second, insufficient interposition of fat and fascia between the separated bony surfaces, third, infection, fourth, the sensitiveness of pain on motion after opera- tion. Cases of primary tuberculosis and cases of recent infection that have 168 OPERATIVE TREATMENT IN JOINT ANKYLOSIS 169 subsided are not suitable cases for arthroplasty. In operation, in addi- tion to the usual protection of the field of operation, after the skin and fat have been incised, towels should be clamped to the edges of the skin as an extra protection. 193. Tibia-Tarsal Arthroplasty. — An incision is made one inch above the external malleolus starting halfway between the fibula and the tendo Achilles extending forward and slightly downward to the front and middle of the tarsus, then curving directly downward to the base or middle of the third metatarsal. The tissues may be lifted subperiosteal^, allowing the edges of the incision to be raised an inch either way. The tendons are retracted with the tissues. The ligaments about the external malleolus are separated off the anterior internal and posterior as well as the external surface of the fibula, the joint line is made with a chisel or osteotome allowing the foot to be dislocated inward as shown in figure 304, the periosteum is peeled back from the tibia for one inch anteriorly and posteriorly. A piece of fascia three by five inches or larger is removed from the outer surface of the fascia lata. This is placed over the front, the under side and the posterior surface of the tibia. When the fascia is sutured in place the foot is replaced. The deep tissues as well as the skin and fat are brought together with sutures. As the periosteum was raised from the external malleolus, one inch above its tip and stripped downward with the external lateral ligament, the latter will unite without suture. A carefully applied plaster of Paris bandage is used holding the foot dorsally flexed thirty degrees. CHAPTER VI OPERATIONS IN SUPPURATIVE CONDITIONS 194. Suppurative Joint Conditions about the Ankle. (See Carrell- Dakin technique, section 323.) — In suppurative conditions about the ankle joint, openings and counter openings should be used in severe cases; in milder conditions a single incision is rarely sufficient. One of the lateral incisions should be used as indicated by the swelling. When the focus is located another incision is made on the opposite side of the joint or anteriorly or both, as the case requires. 195. Disease of the Os-calcis and Tarsal Bones. — In disease of the os-calcis and tarsal bones when the condition is acute, drainage with opening of the bone is indicated. When the focus is located, the foot should be drained on both sides and if necessary anteriorly. If the disease is sub-acute and of long standing and has not yielded to conserv- ative methods or to through drainage, the focus as indicated by an x-ray should be chiselled out by cutting in the good bone around the focus and removing the whole disease. Drainage is established on both sides and anteriorly in some cases, if necessary. The cavities are irri- gated with salt solution and wiped out with gauze strips. The soft tissues are gaped with gauze in the corners to keep them wide, tubes are placed extending to the cavities. The foot is held in a plaster with plaster ropes to allow large windows for dressing (figures 451 to 456). The method of application should be carefully planned to give immobilization without having the plaster heavy. The wicks and tubes are shortened after the tenth day, then removed. By this method no further wicks need be applied as the wounds made large in the first place become round in shape and close slowly. The whole of the os-calcis or any other bones of the tarsus may be removed leaving the periosteum and a small shell of bone. The whole will reform in about six months, allowing some weight-bearing with the plaster. When weight-bearing is painless, the plaster is gradually omitted. A small sinus may last for six months more, sometimes it will close in three months. The foul original condition and the pain will be eliminated by the operation and a good foot for function will re- sult ultimately. 196. Operations on the Metatarsal and Phalangeal Bones and Joints. (See Fig. 305.) — To reach the joints or small bones of the foot a dorsal incision or two dorsal incisions may be made between the line of the artery and the line of the tendon. The skin incision should be made down to the bone without separating the fat and other tissues. 170 OPERATIONS IN SUPPURATIVE CONDITIONS 171 In other words, the periosteum is raised from the bone without expos- ing the structures between it and the skin. This raising of the peri- osteum is made with a long handled, very small osteotome, the osteo- tome being used as soon as the knife has reached the bone. When the periosteum is raised, small dull hooks or re- tractors are then used to hold the tissues and expose the bone or joint. In a similar man- ner the metatarsals are exposed. 197. Operation in Tuberculosis of the Tarsus. — An esmark rubber bandage is ap- plied to the foot and leg up to the middle of the calf and a tourniquet is applied above this. In tuberculosis of the os-calcis, a posterior lateral incision is made on either side of the os-calcis one-half inch posterior to each mal- leolus extending down and curving forward. The incision is carried down to the bone; the tissues are dissected up subperiosteally. The incisions are retracted well, exposing the bone. The diseased bone will come into view, a chisel fig. 305. — incisions for is used in the healthy bone around it, chiselling reaching the bones and joints away a small portion of the healthy bone "Lt^eTiods™ *""* around the focus. The bone is chiselled away and the diseased bone can be removed readily. When all the disease has been removed in this way by cutting through the healthy bone,, the cavity is wiped out with strips of gauze until they come out perfectly clean. It is then irrigated with salt solution, then wiped out again with long strips of gauze. As a rule it is better not to use a» curette in bone disease. The edges of the wound are gaped by rolled gauze sponges. The foot is held in slight dorsal flexion by means of a plaster of Paris bandage, extending from the toes to the knee. In "ex- tensive cases, a plaster should extend to the groin. The plaster is applied with plaster ropes (see figures 451 to 456) so that the dressing may be done without soiling the plaster or interfering with the position of the foot. At the end of six weeks the plaster is changed, and a great deal of new bone will have formed. In ten weeks there will be almost no discharge. A small sinus may persist for six months or longer. The pain and foul condition of the wound will disappear usually ten to fourteen days after the operation. The patient is up in three weeks and may walk on the foot with the plaster and crutches after twelve weeks. OPERATION IN TUBERCULOSIS OF THE BONE In tuberculosis of the bone in the foot and hand with or without abscess, operation on the diseased bone is to be avoided. When conservative methods have failed complete drainage and counter 172 TECHNIQUE OF OPERATIONS drainage is indicated with an opening made in the bone. But large abscesses will often absorb and give less constitutional symp- toms when allowed to absorb than when the infection becomes mixed following operative procedures. When it is necessary to open these abscesses . because they are about to break or because of the condition of the patient they should have drainage and counter drainage, the cavities wiped out and washed out and again wiped out. After this tubes are placed to all dependent parts of the abscess cavity and gauze used to gap the angles of the incision. These tubes and gauze wicks are left in place ten days and then gradually shortened, no injection should be used, nor any irrigation after opera- tion. The reapplication of wicks will probably be unnecessary if the incisions are large enough. In tuberculosis of the bone it is rarely necessary to do more than drain and counter drain the abscesses, sometimes drain the bone cavity. It is better not to attempt to excise the disease excepting in extremely severe cases. The small focus will do better without being excised, the large ones may come to extensive operation and excision. See sec- tion 212. In draining a psoas abscess it is better in every case to drain the lumbar region as well as the abdomen or the groin. When the abdomen or groin is opened at the point of swelling, a large urethral sound is care- fully opened here and made to protrude behind, the operator cuts down on the sound behind, giving posterior drainage. The rule for a posterior counter opening in a psoas abscess should always be followed; the duration is shorter and the drainage more satisfactory. 198. Osteomyelitis. — In osteomyelitis an operation should be done as early as possible after making the diagnosis. In sub-acute cases, incision and drainage are all that is necessary. Whenever incising for abscess all the pockets should be opened and if the abscess is large, counter incisions are made at dependent portions. The pus pocket should be opened freely, wiped out with gauze, irrigated and wiped out again with gauze. Curetting should be avoided excepting for the re- moval of sinuses in the skin and in cases of sinuses it is often better to excise them. Perforated rubber tubing should be placed to drain the deepest portions of the pockets. The skin, fat and superficial muscle layers should be made to gap by means of gauze drains. At the end of ten days the gauze is removed and the tubes shortened. The tubes are gradually drawn out a little each day or two until not used. This method makes the repeated reapplication of drains and wicks unnecessary as the wound will gap of itself and close from the bottom if the surgeon has been careful to make large incisions. Where the periosteum is found destroyed or the pus under the perios- OPERATIONS IN SUPPURATIVE CONDITIONS 173 teal layer, the bone should be opened by means of a large drill or a small gouge. Where this is necessary, the incisions should be large and the counter incision should be made on the other side of the bone with a hole made in the bone a little above or a little below the hole on the opposite side (figure 66). These holes in the bone should open up the medullary cavity. They should alternate on one side and the other as far up and down as the disease is suspected. When the abscess is very great and the bone involvement is large a number of good sized holes should be made with a Burr drill or a curved gouge on both sides of the bone as shown in figure 67. The wound should be gaped widely; — the skin, fat and superficial muscle held open by large gauze drains. The tubes should reach from the surface to the deepest portions of the abscess cavity. Splints should always be applied to immob- ilize the limb. They should be placed so that they will not inter- fere with the dressing. In some instances it is better to apply plaster with large windows and ropes to give stability as shown in figures 451 to 456. The dressing should be done every day or twice a day, de- pending on the foul condition of the discharge. If the odor is excessive, chlorinated soda dressing should be used diluted, using it 1 / 2 , l jz or l ji the U. S. P. strength. The gauze drains should be left for at least ten days without being disturbed. When removed granulations will be formed under them in such a way as to keep the wound open without applying the drains. Irrigation may be used at the time of operation and the wound thoroughly wiped out with gauze afterward. No irriga- tion or probing or application of wicks will be necessary if the first drains are left in long enough. After the first ten days the tubes are shortened up gradually until they are not needed. In severe cases where the patient is unconscious or delirious, the bone should always be opened, three or four holes on either side made with a good sized Burr drill or a gauge. In no case should the incision be made only on one side of the leg in severe cases. No tight packing should be used as this interferes with good drainage. Where sequestra have formed they should be removed. An x-ray should be taken whenever possible to determine the position of the disease, (unless the case is ur- gent and an immediate x-ray is not obtainable). In cases of long standing that are sub-acute at the first examination, where the bone is riddled with holes over an extremely long area, it is impossible often to remove the dead bone satisfactorily without remov- ing all the bone. In these cases free incision down to the bone with frequent openings into the bone as described above, will allow the septic process to run its course and the sequestra to gradually separate. We have had some cases in which the lower third of both femora were riddled with holes and full of sequestra, the patient being in no condition for extensive operation, and yet not very ill. In these cases, however, if the surgeon has seen the patient in time an early operation would have prevented this extreme condition. 174 TECHNIQUE OF OPERATIONS 199. The Carrell-Dakin Method of Treating Pus Cavities —Much may be expected from this method in the future treatment of suppurative conditions. See section 323. Sometimes it is necessary to close a large bone cavity which will not heal over. "Where the process is distinctly septic no plastic operation should be done without first doing an operation to eliminate the infectious condition. - After that part of the muscle may often be transferred over such a cavity after it is closed. In transferring a muscle over such a cavity it should be freely transplanted and held there without tension. The skin should be brought together over the muscle and the wound drained as there is apt to be some inflammatory disturbance. Where sequestra are present it is always desirable to remove them as soon as they have separated and the involucrum is strong enough to act as a support. Sequestra may be superficial or in the mellullary cavity or both. Where there is a persistent sinus and a sequestrum is present, pus will continue to form until the sequestrum is removed, Cases discharging several years where sequestrum is present may close in a few weeks after removal of the sequestrum. 200. Plastic Operation for Open Wounds Following Osteomyelitis. — In cases of chronic osteomyelitis when the disease has practically sub- sided and the bone has remained gaping for a long time, it is sometimes very difficult to secure a closing of the wound. Not only the skin and soft tissues, but the bone edges are sclerosed. Various operations have been devised to promote healing. The following method is very useful. Although used for a long time the writer has not been able to find the physician responsible for the idea. An incision is made to one side of the gaping wound down to the periosteum. This is lifted from the bone for the full length of the inci- sion which should be a little longer than the gaping wound in the bone. A groove is cut in the healthy bone all the way for the full line of incision and down to the medullary cavity. When this has been done a sclerosed portion of the gaping bone should be excised completely down to the medulla. This leaves a long free piece of bone between this gaping wound and the groove. This bone is displaced toward the gap in the bone, completely closing it. The skin is brought together loosely over this and completely together in certain places. The gap will now be in the healthy bone which will gradually close after the patient recovers from the local reaction due to the operation. In all these cases there is usually a slight septic reaction following the closure of the infected surfaces. 201. Methods and Principles of Drainage in Acute Non-tubercular Suppurative Joint Disease. Ankle and Foot. — A small suppurative focus without virulence or active constitutional disturbance should be drained by a suitable incision, wiped out with gauze, a tube placed to its deepest part and the soft tissues gaped with gauze. When there is a great deal of constitutional disturbance, drainage and OPERATIONS IN SUPPURATIVE CONDITIONS 175 counter drainage should always be the rule; if the bone is involved this should be opened and counteropened as shown. The pus cavities in the soft tissues should be wiped out. No extensive bone opera- tion should be done otherwise. The bone should be drained with tubes to the remote portions and the muscle, fat and skin gaped by gauze. These operations are done quickly and should not be prolonged, but efficient drainage and counter drainage should be established unhesi- tatingly. It is rarely necessary to do more at this time. If there is a marked sequestra formation this should be removed, but this had bet- ter not be done at the time of instituting drainage when the patient is nearly exhausted from an acute process. Any future operation made necessary should give good drainage and the removal of the sequestra if present and separated. See section 323. Any extensive non-tubercular suppurating bone disease about the ankle should be drained by two lateral anterior or two posterior incisions and, if necessary, an anterior median. If the patient is very ill and the bone abscess not readily located the tissues are opened down to the bone. This should be done very rapidly and good drainage established. Any chronic suppurating process should be well drained and counter drained, the pockets in the tissues well opened and wiped out and the diseased bone well drained in the same way. PART IV-SHOULDER CHAPTER I OPERATIONS FOR DISLOCATIONS AND DEFORMITIES 202. Manipulation of the Shoulder Joint to Relieve Contractures. — It is important not to manipulate a joint where there is disease, or severe injury. Obtaining motion under an anaesthetic should be done only in cases with limited motion where there is no disease and where the limitation of motion is due entirely to extra articular adhesions or mus- cular contractures or very slight articular adhesions. In manipulation of the shoulder to relieve contractures the normal motion of the joint should be remembered (see figures 306 to 313). The Fig. 306, — Neu- tral position as to rotation when the line between con- dyles of the hu- merus is parallel to a line between the anterior superior spines of the ilium. Fig. 307.— Outward rotation of the shoul- der. Fig. 309. — Ab- Fig. 308. — Ab- duction of the shoul- duction of the shoul- der with outward der. rotation. stretching of the resisting tissues is made gradually, then relaxing, the force being applied gently and in- creased to a climax then gradually decreased until there is complete relaxation. The blood is thus allowed to enter and the tissues give way and stretch with less tearing and less trauma. A fair amount of normal action in all directions should be obtained at the shoulder before any operation on the muscles; such as a muscle transplantation, is done. A fair radius of shoulder motion is present when the fingers will reach the opposite scapula, the forearm passing in front of the face and the hand over the shoulder to the scapula; second, the arm passing behind the waist and upward to the scapula; third, the arm passing behind the head and neck and down to the scapula. Outward rotation of the shoulder is very important. It is easily lost and often difficult to obtain. If the elbow is held to the side and flexed at right angles, the shoulder should outwardly rotate (varying with the 177 178 TECHNIQUE OF OPERATIONS individual) to at least sixty degrees from a position with the forearm pointing to the front, the inward rotation including some motion of the scapula might reach one hundred and twenty degrees. The humerus will extend forward and upward pointing fifteen degrees or more back from the perpendicular in standing, including some motion of the scapula. The abduction (with a neutral position as to rotation) extends to about a right angle from the side; after that the scapula moves as the elbow is raised, unless the shoulder is outwardly rotated. When this outward rotation has taken place the arm may be abducted and raised further until the humerus is perpendicular in standing. The amount of adduction varies and may be estimated at about thirty degrees, vary- ing in the individual; combined motions are also possible. Extension backward varies from thirty degrees to forty-five degrees. The operator Fig. 310.— Inward rotation of the shoulder, the fore- arm lies across the body. Fig. 3 13. — Ex- Fig. 312. — Out- treme abduction of ward rotation of the the shoulder possible shoulder and ninety with the humerus degrees of abduction, outwardly rotated. Fig. 311.— Abduc- tion of the shoulder with neutral position as to rotation. No further abduction is possible without moving the scapula unless the shoulder is should try each motion and gradu- outwardiy rotated. ally stre tch until each motion is possible, holding the arm just below the flexed elbow and remembering the tremendous leverage possible. An arm that has been out of commission for some time will have a very brittle bone. Manipulation in such cases should be done with care. The joint is gently stretched and relaxed, the operator applying force gently in a gradually increasing manner until considerable force is ap- plied and finally relaxing entirely. In this manner a rhythmic extension and flexion is kept up. No rough or forcible extension without a grad- ually increasing or gradually decreasing force should be employed. By this method a minimum amount of trauma will be caused and a joint that at first seems almost impossible to move will often move consider- ably. ^ After obtaining the normal motion of the shoulder as completely as possible by manipulation, the arm is put up either straight up above the head and with the elbow slightly bent, or it is put up with the elbow a little above the shoulder. This position is maintained by a wire splint (see figures 314, 315), or a plaster of Paris bandage including the arm and thorax (see figures 316, 317, 318). After two to four weeks the arm OPERATIONS FOR DISLOCATIONS AND DEFORMITIES 179 is lowered, depending on the swelling. If the arm is not put up straight above the head and outwardly rotated, the next best position is that of outward rotation and abduction, so that the humerus is forty-five degrees beyond right angle in abduction. It is held this way about two Fig. 314. — Wire arm shelf applied after shoul- der operations. (It may- be raised or lowered by bending the wire.) Fig. 315. — Wire arm shelf, showing straps for the thorax and for the arm. Fig. 316. — Plaster applied after shoulder operations in a posi- to four weeks, a longer time if there is much tion of abduction and it -»«- i it i- -lii outward rotation. swelling. Much swelling may be avoided by care in manipulation, force may be used but not roughness. An ice bag is of service applied immediately after the operation if the stretching has been difficult. In quiescent arthritic cases this should always be done. After' the first two weeks if there is no swelling, the arm is lowered so that the humerus is horizontal, i. e., ninety degrees of abduction and forty-five degrees of outward rotation, the forearm with the elbow at right angles. This position is maintained by a wire splint in the form of a shelf (see figures 314 and 315). The wire is bent and lowered as the case improves. The arm is strapped to it allowing the use of the elbow, wrist and hand without removing the shelf. As the patient learns to exercise the muscles of the fingers, forearm and upper arm on the shelf, he is able later to lift the arm above the shelf. With improvement in strength the shelf is lowered ,. Fl , G - 317.— Plaster ap- i„£fj.j -j.j !?ti.l- i phed after shoulder op- to fifty degrees or sixty degrees of abduction and erations in a position of used this way for six to ten months depending on ninety degrees abduction the strength of the arm. Much of the exercise a ° ^ a e t ^ al position a3 each day should be done with the humerus held abducted sixty degrees and resting on such a shelf or table dur- ing the exercise. Later the exercise is repeated daily without the shelf. 180 TECHNIQUE OF OPERATIONS 203. Operations to Correct Permanent Inward Rotation of the Upper Arm. — Inward rotation of the shoulder, when not due to a joint condition, is caused by a relaxed condition of the posterior out- ward rotators of the shoulder or a tense condition of the inward rota- tors. This may be actual, as in spastic cases, or comparative as in infantile paralysis. Sometimes with the primary cause there co- exists adhesions and tissue short- ening and sometimes depression of the acromium that must be taken into account. When there is a bony change that prevents correc- tion of the deformity it will usually appear on palpation or in the x-ray or both. In slight cases, the outward rota- tion may be secured by reefing the posterior capsule which practically tightens up the infra-spinatus mus- cle. If this muscle is good the benefit will be more than tem- porary. Where the contracture is extreme, this will not be sufficient. The condition may also be re- lieved by lengthening the attach- ment of the pectoralis major, which is slit and overlapped as described elsewhere in these pages or by an osteotomy through the upper or lower third of the humerus, the lower fragment being outwardly rotated and allowed to heal in this position. In the obstetrical paralysis cases and certain spastic cases the best results are obtained by a myotomy of the pectoral and Fig. 318.— Plaster cuirass used after opera- f the Sllbscapularis suggested by tion on the shoulder. ^ g^. ^ ^ ^^ ^ scapula to flatten into position. Often an osteotomy of the acromium is necessary beside. 204. Osteotomy of the Humerus to Correct Inward Rotation of the Shoulder. — The patient lies on his back, being placed close to the opposite edge of the operating table. The operator stands on the side of the arm to be operated on. The assistant stands to his right holding the forearm with flexion at the elbow. See figures 494-496. OPERATIONS FOR DISLOCATIONS AND DEFORMITIES 181 An incision is made one inch long, just above the junction of the upper and middle third of the outer aspect of the upper arm, or in the upper part of the lower third. The skin is incised and retracted; the fat and the muscle fibers are separated by a blunt dissector, and retracted, ex- Fig. 319. — Double many tail swathe used behind the plaster cuirass. posing the bone. A very small incision is 11 ,i , • a j. -j. ■ Fig. 320. — Manner of com- all that is necessary. An osteotome is ap- bining the plaster in front with plied to the bone the double many tail swathe be- fsee fiffure 321 ) mnd an< ^ with the plaster arm f, . ... i above. Notice the plaster rope -Before CUttmg the used to re-enforce the plaster bone COmpletelv and incorporated in its deep through, the sur- layers- geon assures himself that his assistant is steadying the elbow and forearm in order to allow practically no displacement and no trauma when the bone is cut through. After completing the cut in the bone, the wound is closed by one or two deep catgut sutures, number 00, including the skin. Five layers of gauze just covering the incision are ap- plied as a dressing, over this rollers of sterile sheet wadding. The sterile sheet wadding rollers are applied gently and carefully in order to prevent any jarring or displacement of the bone. Coaptation splints are next applied as seen in figure 322. When the coaptation splints are snugly fastened, the FlG ' 321 th^ hum t eru e CUttinS arm is next S entl y rotated outward about thirty degrees. This thirty degrees is esti- mated from a position in which the forearm points to the front with the elbow at the side. A plaster of Paris bandage is applied holding the arm and forearm at right angles (see figure 323). Over this a snug swathe is applied holding the plaster at the shoulder and the elbow to the side (see figure 324). An internal angular splint over the coaptation splint, 182 TECHNIQUE OF OPERATIONS a shoulder cap, an axillary pad, a swathe in- cluding the chest and affected arm may be sub- stituted for the plaster, the outward rotation of the shoulder in this instance is maintained by Fig. 323. — A plaster of Paris bandage and axillary pad applied over the coaptation splints. Fig. 322.— Sheet wadding applied without disturbing the arm. Coaptation splints applied before disturbing the cut bone. Fig. 324. — Swathe applied over the thorax and arm. the use of adhesive straps looped around the fore- arm over the apparatus and over the outside of the swathe instead of being placed on the skin. Two adhesive straps are applied separately extending from the shoulder to the back and two straps applied separately from the shoulder to the front of the chest, and two from the elbow, one in front, and one behind the thorax. Excellent results are obtained from this operation. Fig. 325. — Splint and belt to prevent inward rotation of the shoulder, showing ex- tension of the elbow. There is no limitation of flexion or extension of the elbow. OPERATIONS FOR DISLOCATIONS AND DEFORMITIES 183 The pain suffered is practically nothing if the dressing is comfortably applied. There is little or no swelling. After treatment The patient should be kept in bed about ten days using a low bed rest constantly. The bed rest is raised for meals after the first week. C 0$M Fig. 328.— Splint and belt to pre- vent inward rotation of the shoulder. A, Plate to prevent inward rotation. B, Joint allowing flexion and exten- sion of the elbow and outward rota- tion of the shoulder. C, Leather cuff for upper arm. D, Leather cuff for forearm. E, Belt. Fig. 326.— Splint and belt to prevent in- ward rotation of the shoulder, showing out- ward rotation of the shoulder. Fig. 327.— Splint and belt to prevent in- ward rotation of the shoulder, with the shoulder rotated to a neutral position. Fig. 329.— Splint and belt to prevent inward rotation of the shoulder, inner view. The outward rotation is maintained for six or eight weeks allowing use of the hand in the third week. The apparatus is removed a little each day after the sixth week. If the union is soft the apparatus should remain longer. After the eighth week the apparatus is worn part of each day and a belt apparatus maintains the outward rotation of the shoulder and allows the use of the arm and hand. It consists of a metal semicircle fastened to a belt preventing the inward rotation of the shoulder (see figures 325, 326, 327, 328 and 329). The humerus is fastened by a cuff to the belt pre- venting abduction of the arm. A wrist cuff is attached to a metal arm which strikes the aluminum semicircle and checks inward rotation. This apparatus is worn for the whole or part of the day over the clothes. In extreme cases, apparatus is necessary for a year, muscle stretching 1S4 TECHNIQUE OF OPERATIONS and muscle training should be done twice daily as long as there is any tendency of the muscles to recontract. 205. Osteotomy for a Depressed Acromium. — When the acromium is depressed in certain paralytic conditions of the shoulder and in children with total or partial dislocation of the shoulder of long stand- ing, the head of the humerus will be found slightly out of place and a limitation of motion caused from the deformity of the acromium. This turning over is demonstrable by the x-ray but may be easily felt. An osteotome is used to incise the skin one and one-half inches from the tip of the acromium, a subcutaneous osteotomy of the acro- mium, is done, allowing the depression to be corrected and the humerus to slide Fig. 330. — Deltoid fibers retracted showing fatty layers over the cap- sule. Fig. 331. — Sutures quilted into the capsule. into place. . The incision may need one suture. The shoulder is held out- wardly rotated ninety degrees and abducted ninety degrees for six weeks. During the healing of the fracture, other treatment is sometimes necessary when the condition accompanies ob- stetrical or infantile paralysis. 206. Muscle Shortening. Opera- tion for Shortening the Infra Spinatus to Correct Inward Rotation of the Shoulder. — The patient lies on his back, a hard pillow Or sand bag lifts FlG - 332 —Capsule drawn tight after ., . , . -ip,! ,i jij rotating the shoulder outward. the right side ot the thorax so that the scapula does not touch. After stretching the shoulder in outward rotation, sterile protection is used leaving the shoulder exposed above and posteriorly as well as laterally and anteriorly. An incision three inches long is made through the skin and fat from the tip of the acromium backward and outward parallel to the outer fibers of the deltoid (figure 330) ; the deltoid fibers are next separated with a OPERATIONS FOR DISLOCATIONS AND DEFORMITIES 185 blunt dissector exposing the thin fatty layer over the capsule; this is followed downward. A double set of mattrass sutures are quilted into the capsule and infra spinatus tendon which is continuous with it (figure 331). The shoulder is outwardly rotated as far as possible and each of the sutures tightened and tied (figure 332), maintaining the outward rotation. The arm is held in an outwardly rotated position by means of plaster of Paris or a wire splint (see figures 314 to 317). This operation is recommended by Professor Vulpius and others for persistent inward rotation of the shoulder (see Osteotomy). Section 204. 207. Muscle Lengthening to Correct Partial or Total Permanent Rotation of the Shoulder. — When the inward rotation of the shoulder is due to the short or contracted pectoral muscle the subscapularis will usually be found short also. This may be demonstrated by out- wardly rotating the humerus. When this is performed the axillary border of the scapula will come forward. The latter may be cut across at its attachment or, as recommended by Dr. Sever, away from the capsule. The lengthening of the pectoralis muscle should be done in its outer portion. The fibers are cut across diagonally and sutured, or in a dentated manner as shown in figures 201, 202 and then sutured. The humerus should be placed in a position of ninety degrees of abduction and ninety degrees of outward rotation and held there for six weeks (see figure 316). After the third week the arm is put on a wire splint (see figures 314 and 315) and passive motion applied twice a day. After six weeks the arm is used on a shelf holding it adducted sixty degrees. The position of extreme outward rotation should be maintained for six or eight weeks, allowing the use of the wrist and hand after the first week. At the end of six weeks the apparatus is re- moved twice daily for twenty minutes. The time is extended every three days until it is removed six hours a day. After that the splint is used, maintaining extreme outward rotation for two hours daily for a year. Exercises and muscle training, especially in outward rotation, should be done for several years, depending on the tendency of the deformity to recur. 208. Operation for Inward Rotation of the Shoulder in Obstetrical Paralysis and other Conditions. Myotomy of the Subscapulars and of the Pectoralis Muscles. Dr. Sever's Operation. — In inward rota- tion of the shoulder due to obstetrical paralysis a certain number of cases cannot be benefited by conservative treatment. It is necessary to myotomize the pectoralis major and subscapularis muscles. When this is done the tendency to round shoulders and paralysis of all other muscles of the shoulder due to the contracture can often be prevented. The scapula fits back into place and the other muscles develop often to a surprising degree. After cutting the pectoralis major the surgeon may feel that he has done enough, but he will find that in outwardly rotating the humerus the scapula will come forward into the axilla. After cutting the subscapularis this will not take place. 186 TECHNIQUE OF OPERATIONS This operation may be done also in cases of cerebral paralysis that have the deformity. The arm is abducted and outwardly rotated. An incision is made from the acromium downward and outward between the deltoid and the pectoralis major muscles. When these muscles have been separated with a blunt dissector the fibers of the pectoral are lifted on a director and cut across, unless the operator decides to lengthen them as described else- where in these pages. The under fibers of the pectoralis tendon are tough and fibrous. These should be cut as well as the muscle fibers. The shoulder should now easily rotate outward, but if the operator stops here he will find that a troublesome inclination forward of the scapula will persist when the child grows older. The outer border of the scapula and its angle will be found to come forward into the axilla as the shoulder is outwardly rotated. To avoid this Dr. Sever has suggested cutting the subscapularis in its tendon away from the cap- sule. The humerus is outwardly rotated, bringing the subscapularis tendon into view, it is attached high up in the inner border of the bicipital groove and is continuous with the fibers of the capsule. At this point a few muscular fibers extend here almost to the bicipital groove. The writer has incised the fibers here at the outer edge of the bicipital groove. This should not be done until the tendon has been traced to its attachment here. When it is cut the humerus may be outwardly rotated without bringing the scapula forward into the axilla. The deep and superficial tissues are closed with interrupted catgut, the skin with continuous catgut sutures. The shoulder is held ab- ducted ninety degrees; outwardly rotated ninety degrees with the elbow at right angles. A plaster is applied as shown in figure 316, including the thorax and arm. The plaster is bivalved so that the upper por- tion of the shoulder and arm plaster is removable, allowing the arm to slide out and be manipulated after the second week; in three or four weeks a wire splint is used (see figures 314, 316), allowing the arm to be used and manipulated so that there will be no danger of stiffness. At the end of three months the shoulder shelf is gradually discarded, being used two hours a day for one year after that. This operation by relieving the strongly contracted muscles in ob- stetrical paralysis will allow the arm to grow in strength and usefulness, which is not possible otherwise. The muscles and use of the arm must be trained daily. 209. Operation for Inward Rotation of the Arm in Spastic Paralysis. — In certain spastic paralysis cases the inward rotation of the shoulder is very similar to that seen in obstetrical paralysis. In these cases it is often of advantage to cut the pectoral and the subscapularis muscles to allow free outward rotation of the shoulder without causing the outer border of the scapula to move forward into the axilla. The operation is described in these pages for obstetrical paralysis. The after treatment is the same. See sections 207, 208. OPERATIONS FOR DISLOCATIONS AND DEFORMITIES 187 210. Dislocation of the Clavicle. — A dislocation of the clavicle of long standing will require an incision along the end dislocated, often the sternal end. A sand bag is placed between the shoulder blades and the chest held well up, expanded over pillows, with the head held back. This position is obtained before operation. The clavicle is exposed and the end loosened up subperiosteally, the shoulder hyperextended and the clavicles will readily slip in place. If the loosening of the tissues does not complete reduction a small por- tion of bone is removed. The bone is freshened and drilled before re- duction and held in place by heavy silk or by silver wire. A Sayre apparatus is applied as for fracture of the clavicle or a plaster of Paris jacket or posterior shell is used or a Sayre clavicle brace. The treatment is the same as for fracture of the clavicle. 211. Partial Dislocation of the Shoulder due to Paralysis, often in Obstetrical Paralysis with or without Depression of the Acromium. — In dislocation of the shoulder due to paralysis of the muscles, the capsule must often be reefed, the shoulder outwardly rotated and ab- ducted ninety degrees and held on a wire shelf while the partly paralyzed muscles are relieved of strain and weight-bearing and are exercised in this position for months. Good action of the shoulder is often prevented and the dislocation maintained by a depression of the acromium, this with the long capsule favor the dislocation. The depressed acromium is cut across at the root by an osteotome and the capsule reefed by quilted sutures. The arm is then held as above described for five weeks during the healing of the fracture and afterward as long as it is necessary to allow the muscles to be- come strong. See sections 205, 214. 212. Partial Dislocations of the Shoul- der in Paralytic Conditions. — In condi- tions of partial dislocation of the shoulder in obstetrical paralysis and other paralytic conditions of the deltoid, the capsule is abnormally long allowing a displacement of the humerus. The dislocation may be replaced and a few quilted sutures stitched into the cap- sule in such a way as to pucker the cap- sule and shorten it (see figure 333) . See section 214. This will suffice unless the dislocation is of long standing and the acromium has become depressed in which case this de- FlG - 333.— Capsulorrhapy. formity should be remedied at the same time by an osteotomy. See section 205. 18S TECHNIQUE OF OPERATIONS 213. Open Operation in Cases of Irreducible Dislocation of the Shoulder. — A dislocation of the shoulder should be reduced by the usual manipulation; when it does not yield to this as in certain recent and in dislocations of long standing the open operation is indicated. An anterior incision or a Kocher incision may be used, preferably the anterior enlarged as described under arthrotomy. In any so-called irreducible dislocation, the operator may make an attempt to reduce the dislocation by the usual methods before using the open operation; when there is evidence of adhesions or the dis- location is of long standing, after a well applied attempt an operation should be resorted to at once, in order to save time and not exhaust the patient. Extensive manipulations, especially in the old, are unde- sirable when an open operation is probable. In some cases an excision is necessary either because reduction is impossible or the head is held too tightly by the contracted tissues. In dislocations of long standing where the joint cavity and head are in- jured and where reduction without tension may be effected an excision is not indicated. Generally if the bone adjoining the head is well cleared subperiosteal^ an excision may be avoided. A subglenoid dislocation of five years' stand- ing may be reduced by this method without excision. The Burrell incision (figure 362) is a very useful one for these cases. It is necessary in these cases after opening the glenoid cavity which will be found much retracted, to replace the head and overlap the muscles in such a way as to complete the capsule where it is lacking. In some cases the very much lengthened muscles must be allowed to contract. For this purpose the elbows and forearm should be well padded and held by adhesive plaster straps to the opposite shoulder so that no weight will come on the sutured capsule and the muscles. The relief of pain following the operation is usually immediate. 214. Capsulorrhapy for Dislocation of the Shoulder in Paralytic Conditions. — The dislocation in paralytic conditions, when it is not traumatic, is usually due to a long relaxed capsule. The lack of muscle and tissue tone has allowed the capsule to be dragged out until it is too long. An incision is made parallel to the inner border of the deltoid and one- half inch from it. The deltoid fibers are separated and the capsule is exposed, the arm is outwardly rotated ninety degrees and abducted ninety degrees, two or three sets of quilted sutures are placed in the capsule in such a way as to pucker it and as the sutures are drawn and tied this will remedy the lax condition. The arm is held on a wire shelf and the muscles exercised and strengthened on it for six to ten months depending on the amount of paralysis. 215. Operation for Recurrent Dislocation of the Shoulder. — In recurrent dislocation of the shoulder an incision is made between the pectoralis major and the deltoid extending inward one-half inch below OPERATIONS FOR DISLOCATIONS AND DEFORMITIES 189 the clavicle. The joint is reached and the tear in the capsule located by a complete exposure of the joint. When the capsule is not easily- closed, silk may be quilted across or the capsule released from the humerus subperiosteally and the tear is sutured with silk. The suture should not limit motion in outward rotation; for this reason the humerus is outwardly rotated while the sutures are being placed. No motion in abduction of the shoulder should be allowed for at least four weeks. But slight motions are allowed in other directions especially in outward rotation after the tenth day. 216. Operation for Congenital High Position of the Scapula or Sprengel's Deformity. — An incision is made along the vertebral border of the scapula down to the bone; as the edge of the scapula is reached an osteotome is used to lift the muscles subperiosteally from its inner border upward and the muscles from the upper border. That part of the scapula above the spine which is often folded over should be chiselled away and removed. When the muscles are detached subperiosteally from the under side and upper end of the scapula by a subperiosteal dissection, using a long handled osteotome, the scapula will be released and may be depressed and if necessary held in position to the rib by a long chromic catgut suture number one. A plaster of Paris bandage is used to hold the arm and thorax. 217. Application of Plaster of Paris Bandage to the Shoulder. — In applying the plaster of Paris bandage to the shoulder, the plaster should be low on the side of the chest of the affected shoulder; it should be very narrow and high on the chest under the opposite shoulder. It may reach over both shoulder or include only the affected or the well shoulder but it should include the humerus and forearm of the affected side (see figures 316, 317). There should be a good deal of padding low down on the chest below the axilla of the affected side, also about the elbow and axilla. The elbow is usually held at right angles in order to maintain the necessary rotation. The plaster is halved so that the upper portion may be re- moved from the arm and forearm allowing the shoulder to be inspected or manipulated. The chest portion of the plaster is bivalved so that the front or back may be removed. This part of the plaster can be laced as shown in figures 436 to 440. CHAPTER II MUSCLE AND TENDON OPERATIONS. -MUSCLE AND TENDON TRANSPLANTATION. 218. Operation for Paralysis of the Triceps, Transplantation of the Deltoid. — When the triceps is paralyzed and the deltoid remains good, a long vertical incision is made over the outer border of the deltoid down to the junction of the middle and lower third of the arm. The incision is made in the outer third of the posterior aspect of the upper arm. Fig. 334. — Triceps dissected up. The tissues are retracted exposing the deltoid. One-half or two- thirds of the upper fibers of the triceps are removed from their attachment and attached to the posterior half of the deltoid which is freed as low as possible. The upper end of the triceps is de- tached from the humerus. The fibers are scarified superficially on Fig. 335. — Split deltoid transplantation to the paralyzed triceps. both sides. The posterior half of the deltoid muscle to be trans- planted is divided into two halves (see figures 334 and 335). The fibers of the triceps are quilted with silk, quilted sutures are placed in each part of the slit deltoid, one set in each half that has been divided. The slit in the deltoid receives the triceps, one-half going anterior, the other posterior. The muscles are held together by these 190 MUSCLE AND TENDON OPERATIONS 191 quilted silk sutures and other mattrass sutures. The deltoid muscle is superficially scarified before being attached to the triceps. A plaster or wire splint is applied holding the elbow straight or in a few degrees of flexion and a large wedge pad in the axilla; a swathe is applied including the arm and thorax. A window is cut over the posterior part of the plaster which allows inspection of the incision. The after treatment r Fig. 336. — Incision over the trapezius and deltoid. Fig. 337.- — Part of the trapezius cut from its insertion and dissected up. consists of absolute rest for two weeks in bed on an incline with a low bed rest. The arm is kept extended six weeks and gradually flexed but not more than twenty degrees beyond a right angle position for over six months. Muscle training and ex- ercises at home should be employed daily for at least a year. 219. Transplantation of the Trapezius to the Deltoid for Paralysis of the Del- toid. — In operation on the right shoulder, the patient lies on his back with a large sand bag or hard pillow under the right shoulder so that the shoulder and scapula are held off of the operating table. The operator stands above the shoulder. A • • • j i J.T- j r Fig. 338. — The upper arm ab- An incision is made along the edge of ducted and outwardl £ rotated t0 the trapezius to the acromion process. The allow the insertion of the trapezius skin and fat are dissected in one layer and mto the delt0ld - retracted, exposing the trapezius muscle (see figures 336 to 341). Part of its clavicular and scapula insertion is dissected up and carried outward to the deltoid. Before insertion, both the deltoid and the trapezius muscle fibers are scarified superficially. The trapezius is quilted up one side and down the other with silk sutures and attached to the upper 192 TECHNIQUE OF OPERATIONS end of the deltoid which is freed and the silk is quilted into it. Mattress sutures are also placed into the overlapping muscles. The shoulder should be flexed and raised (figure 316). The elbow is at the height of Fig. 339. — The trapezius su- tured to the deltoid and then the paralyzed deltoid sutured over- lapping the trapezius. Fiq. 340. — Suture of the subcu- taneous tissues. the shoulder and held in this way during and after the transplantation. The deep tissues are brought together with interrupted chromic catgut sutures number 00, the skin with con- tinuous chromic catgut sutures number 00. The abduction is ninety degrees, the outward rotation forty-five degrees. The position is maintained as seen in fig- ure 317, by a plaster of Paris bandage extend- ing over the chest and arm. A wire splint replaces the plaster at the end of two weeks. The plaster is preferable at the time of the operation as it will be more comfortable and allow less motion. The after treatment is the same as that prescribed for transplantation of the trape- zius to half of the pectoralis major. See sec- tion 241. 220. Operation for Paralysis of the Del- sutures. toid. Transplantation of the Trapezius to Part of the Pectoralis Major Insertion. — To transplant the trapezius to half of the insertion of the pectoralis major, the patient lies on his back, the operator stands on the side on which the operation is to be done. An incision is made one inch above the lower edge of the pectoralis Fig. 341. — Incision sutured with continuous or interrupted MUSCLE AND TENDON OPERATIONS major and parallel to it. The incision extends from the humerus four inches inward through the skin and subcutaneous fat. These are re- tracted. A broad portion of the lower edge of the muscle is detached from the rest of the muscle; the fibers are separated from within out- ward (see figures 342, 343). When the tendon is reached it is slit longi- tudinally. The muscle thus separated is reflected upward toward the shoulder; it is still attached to the humerus by one-half of the tendon. Fig. 342. — Exposure of the pec- toralis major. Fig. 343.— One-half of the pec- toralis major ready to be attached to a portion of the trapezius. Fig. 344. — Posterior view, posure of the trapezius. Fig. 345. — Posterior view. The trapezius cut Ex- away from its insertion, ready for silk su- tures. The separated muscle is raised, and a towel placed on the arm above and another below while two or three sets of quilted silk sutures are inserted into its fibers. The breakage of the silk should be tested before inserting it into the muscle. A second incision is made along the anterior border of the trapezius (figures 344, 345). Part of the scapula and clavicular fibers are dissected up, the separated muscle is raised, a towel placed above and another below, while three sets of silk sutures are quilted into it. The superficial fibers of the pectoral and trapezius muscle are scarified. 194 TECHNIQUE OF OPERATIONS A broad tunnel is made below the subcutaneous fat connecting the shoulder and pectoral incisions subcutaneously (figure 346). The pectoral and trapezius muscles are introduced and retracted allowing the muscles to be sutured together (figure 347). The muscles may be slit into three portions so that in- overlapping, two tails of one muscle will go forward and one posterior while two tails of the other muscle will go posteriorly and one forward (figure 348). The muscles are sutured together and the quilted silk sutures already placed are ex- Fig. 346. — Intermediate silk and sub- cutaneous tissue raised allowing the trape- zius and pectoralis to be approximated. Fig. 347. — Another method of attaching the trapezius to the pectoralis; scarification and interrupted sutures. Fig. 348. — The split trape- zius receives the pectoralis muscle and is fastened to it by quilted sutures. AlM^ Fig. 349. — Both incisions are closed with inter- rupted or continuous sutures. tended from one muscle to the other and quilted in such a way that the silk coming from the pectoral is quilted into the trapezius. Additional mattress sutures are added if necessary. The muscle circulation must not be cut off by too many sutures. The deep tissues are brought together with interrupted chromic catgut sutures number 00, the sub- cutaneous fat with interrupted chromic catgut sutures number 00, the skin with continuous chromic catgut sutures. A plaster of Paris MUSCLE AND TENDON OPERATIONS 195 dressing is applied holding the arm raised above the head, as seen in figures 316 and 317. This position is maintained for about three weeks, after that the arm is gradually brought down and the plaster replaced by a wire splint (see figures 314 and 315). A wire shelf (figure 314), will replace the ordinary plaster at the end of two months. This should be used for nine months or a year, holding the arm in sixty degrees of abduction, the elbow not being allowed to drop below an ab- ducted position of fifty degrees. The hand and forearm may be used on the shelf. Stretching, muscle training and exercises should be done daily until the muscles are sufficiently strong and serviceable. 221. Pectoralis Major Transplantation, for Paralysis of the Deltoid. — Dr. Legg recommends an incision one inch below the sternal end of the clavicle extending outward one inch below the clavicle and parallel Fig. 350. — Exposure of the pectoralis major. The sternal end dissected up and turned back to cover the deltoid and the shoulder. to it (see figure 350). The incision is continued along the anterior border of the deltoid almost to the deltoid tubercle. The skin and superficial fat are reflected outward, the sternal origin of the pectoralis major is reflexed outward with the inner two thirds of the clavicular origin, avoiding the nerves which enter just below the outer third of the clavicle. The lower border of the pectoral is freed from its insertion (figure 351). The lower sternal origin is to be laid over the clavicle and extends back over the shoulder. It will fill well the space over the flattened paralyzed muscles. An incision is now made along the spine of the scapula extending from the base of the spine outward to join the first incision. The skin and subcutaneous fat are reflected downward and upward exposing part of the trapezius. The dissected origin of the pectoralis major is now turned outward so that it lies over the scapula, the sternal portion of its origin is inserted with silk into the periosteum along the spine of the scapula. The clavicular portion and the upper sternal portion is 196 TECHNIQUE OF OPERATIONS inserted into the substance of the trapezius muscle. The subcutaneous fat is brought together with interrupted chromic catgut number 00, the skin with continuous chromic catgut number 00. The arm is placed in a position of ninety degrees of abduction and held there by means of a plaster of Paris bandage or a wire splint made for the purpose. The Fig. 351. — Pectoralis major reflected over the shoul- der and attached to the spine of the scapula to become useful in raising the arm. after treatment is the same as that described under transplantation of the trapezius and one-half of the pectoralis major insertion. 222. Operation for Paralysis of the Biceps, Trans- plantation of the Triceps. — The patient lies on his left side for transplantation on the right arm with F large pillows or sand bags to steady him. The f the triceps, operator stands behind the arm to be operated on. An incision is made in the outer third of the posterior aspect of the upper arm, extending from the upper and middle thirds down to just below the external condyle (figure 352). The incision is carried down to the muscle, the skin and fat are retracted exposing the outer edge of the triceps and its tendon. The outer third of the tendon is detached below the elbow and dissected upward to one and one-half inches above the joint (see figures 353 and 354). At this point the outer half of the muscle is divided and its muscle fibers separated to almost the junction of the upper and middle thirds of the arm. A second incision is made anteriorly in the middle third of the upper arm down to the biceps. The incision is then carried downward to the bicipital fascia on the front of the forearm. A subcutaneous tunnel is made under the fat connect- ing the upper ends of these two incisions, a tendon carrier or clamp is passed from the anterior incision backward. The triceps tendon is grasped and drawn forward out of the anterior incision (figure 354). Number eighteen braided silk is quilted up one side of the tendon and down the other (figure 355). At this point one of four methods may be adopted, either the biceps is scarified superficially, the triceps also, the MUSCLE AND TENDON OPERATIONS 197 two placed in apposition and sutured, the quilted end of the triceps is inserted and fastened to the bicipital fascia below the elbow; or second, the biceps may be lifted on a blunt dissector, its fibers separated longi- tudinally, the triceps passed through the slit and its end carried down to the bicipital fascia (figure 355) where it is sutured, other mattress su- tures being placed to hold the muscles in apposition ; or third, the triceps may be passed through a slit in the biceps in the middle of the upper arm and again through a second slit lower down and sutured in the same way; Fig. 353.— The tri- ceps split and one half to be trans- planted forward. Fig. 354. — One half of the triceps drawn forward through the tunnel. Fig. 355. — One half of the triceps C drawn forward and sutured to the biceps D, quilted silk exten- sion to the bicipital fascia B. or fourth, the biceps may be cut away bodily at the middle of the upper arm and attached to the triceps by interrupted chromic catgut mattress sutures wherever necessary. The end of the triceps in all cases should be attached below the bicipital fascia, by means of silk as described above. The arm is put up in a plaster of Paris bandage or a posterior wire splint with the elbow flexed to forty-five degrees more than right angle. Right angle flexion should be maintained at least nine months, allow- ing the use of the forearm and hand and allowing motion in flexion at the elbow but not extension beyond the right angle position. Muscle train- ing and exercises should be done daily for a year or more, depending on the case. CHAPTER III OPERATIONS IN PARTIAL AND TOTAL PARALYSIS 223. Flail Conditions of the Shoulder and Partial or Total Disloca- tions of the Shoulder Due to Paralysis. — In paralysis of the shoulder the deltoid ma}' be partially or completely paralyzed. See also Chap- ter II. When a flail condition has existed for a long time, especially when it has existed from infancy, there is often a dislocation and a rounding down of the acromion process over the shoulder. When a transplanta- tion or capsulorrhaphy is advisable here, it is sometimes necessary to do an osteotomy of the acromion to allow the shoulder to be relaxed. The curved acromion will often interfere with the normal motion of the joint. 224. Operation for Depression of the Acromion over the Head of the Humerus and Capsulorrhaphy. — For operation on the right shoulder, the right side of the patient is elevated by sand bags or hard cushions under the right thorax from the angle of the scapula downward. The shoulder and upper three-fourths of the scapula are held well off of the table. The cushions should be placed to insure a firm position of the patient so that neither he nor they will slide during the operation and manipulation of the arm. The operator stands above the shoulder with his left side toward the head of the patient and traces the curving acromion with his left hand. An incision is made down to the bone three-fourths of an inch long and about one and one-half inches from the tip of the acromion. An osteotome is used to cut the bone. The acromion process is very readily reached and cut, through an extremely small incision. A second incision is made over the anterior aspect of the humerus about one-half inch from the anterior border of the deltoid and parallel to its fibers. See figure 356. The incision is carried through the deltoid fibers separating them with a blunt instrument. The joint capsule is readily reached and reefed by inserting three or four heavy silk quilted sutures (see figure 333). These are tightened and tied holding the head of the humerus close to the glenoid. They should not interfere with motion. The deep tissues are brought together with interrupted chromic catgut sutures number 00 and the subcutaneous tissues with interrupted chromic catgut sutures number 00, the skin with interrupted horse hair, or subcutaneous or continuous chromic catgut sutures number 00. The shoulder should be held abducted to right angle and outwardly rotated about sixty degrees (see figure 316). A plaster dressing is applied over the op- posite shoulder and the chest and including the arm and hand, allow- 198 OPERATIONS IN PARTIAL AND TOTAL PARALYSIS 199 ing free play of the fingers and thumb. A wire splint is sometimes used instead of the plaster (see figures 314 and 315). The arm is kept in this position six or eight weeks. After that the treatment is the same as that described under transplantation of the trapezius. 225. Arthrodesis of the Shoulder in Paralytic Conditions. — In paralytic cases, the object of this operation is to take advantage of the good muscles attached to the scapula and use them to control and raise the shoulder. This is accomplished by placing the arm in an abducted position and fixing it to the scapula. For operation on the right shoulder, the right side of the patient is elevated by sand bags or hard cushions under the right thorax from the angle of the scapula downward. The shoulder and upper three-fourths of the scapula are held well off of the table. The cushions should be Fig. 356.— Retracted del- toid exposing the joint cap- sule. Fig. 357. — Tendon of the biceps displaced inward, head of the humerus dislocated ex- posing the glenoid. 1, Acromion. 2, Cora- coid. 3, Tendon of biceps, behind it the glenoid. placed to insure a firm position of the patient so that neither he nor they will slide during the operation and manipulation of the arm. An anterior incision is made from the space halfway between the acro- mion and coracoid process down the arm parallel to the bicipital groove almost as far down as the insertion of the deltoid. The incision is carried through the deltoid, its fibers being separated with a blunt instrument a short distance from its inner border, the muscle fibers are retracted, the bicipital groove is located, the joint capsule opened here (figure 356). The tendon of the biceps is exposed and raised from its groove and displaced inwardly over the head of the humerus. This is facilitated by rotation of the arm. The capsule is elevated and dis- sected free from the humerus close to the bone (this may be done sub- periosteally with an osteotome). The arm is manipulated and rotated to aid the dissection, allowing the capsule to be dissected from the humerus by rotating inward and outward. The head is displaced well forward allowing free access to the glenoid cavity (see figure 357). 200 TECHNIQUE OF OPERATIONS Three or four quilled silk sutures are placed separately into the freed capsule so that both ends from each strand quilted in are firmly attached to the capsule and used to hold it retracted and later aid in finding the edges for suture. The glenoid surface is denuded to the bone. The surface of the head of the humerus coming in contact with the joint should then be removed so that the head of the humerus and denuded glenoid will be in smooth flat contact assuring a complete ankylosis between the scapula and the head of the humerus with the arm placed in a position of about seventy degrees of abduction. These bones may be drilled and fastened together with heavy silk sutures. Other silk sutures may be placed through the acromion and the tuberosity of the humerus. The arm should be abducted about twenty degrees more than the final position desired. When the silk is tied the humerus should be held firmly to the bone in the desired abducted position. The capsule sutures already placed are brought together and tied, holding the bone firmly in place. The deep tissues are brought together with interrupted chromic catgut sutures number 00, the sub- cutaneous fat with interrupted chromic catgut sutures number 00, the skin with continuous chromic catgut sutures number 00. The shoulder is held firmly in this position by a well fitting plaster of Paris bandage padded throughout. Extra padding is placed under the elbow over the shoulder and over the thorax in the axillary line. A small window is cut for inspection of the incision without disturb- ing the plaster. The arm is held in plaster six weeks. The patient is kept in bed for two weeks. Motions of the hand and wrist are en- couraged after the second week. After the sixth week, a wire shelf (see figures 314 and 315) is used bent down to maintain the desired abduction, about seventy degrees. This allows the use of the arm, fore- arm and hand and abduction of the shoulder but prevents adduction. Exercises and muscle training should be used in connection with the splint for at least a year. After that the splint is used two hours a clay, depending on the strength of the scapula muscles. The object of the operation is to take advantage of the scapula to raise the arm when the shoulder muscles are paralyzed. 226. Bartow Silk Ligaments at the Shoulder in Paralytic Conditions. — At the shoulder when there is a complete paralysis of the deltoid and it is inadvisable to do a transplantation, the Bartow silk ligaments may be used to hold the shoulder to the scapula. They will also hold the head of the humerus close to the acromion and allow better use of the muscles when there is a partial paralysis. OPERATION An assistant holds the humerus close to the acromion in a neutral position as to rotation, the elbow being flexed at right angles ; the fore- arm points directly forward. The Bartow drill described above is in- serted through the acromion from above downward and outward. The OPERATIONS IN PARTIAL AND TOTAL PARALYSIS 201 drill should protrude through the handle a very little. As it cuts the bone the handle is placed one-half to three-fourths inches further back, keeping the handle as low as possible on the drill. The drill is passed through the head of the humerus and out at the side. As it protrudes through the skin a heavy number eighteen silk is threaded through the eye in the drill and drawn through the skin on the top of the shoulder. The drill is next passed downward subcutaneously through the joint capsule if possible and protrudes through the opening in the skin below. The silk is removed from the drill, the drill withdrawn, leaving both ends of silk protruding through the lower hole in the skin. The humerus is placed in the desired position close to the acromion, the silk is tied tightly three times, the ends cut and allowed to recede through the hole in the skin and fat. The after treatment is the same as that described in these pages for arthrodesis of the shoulder. See section 225. CHAPTER IV INCISION PUNCTURE AND ARTHROTOMY 227. Arthrotomy. — A knowledge of the important routes of approach to the joints will facilitate any joint exploration, the removal of foreign bodies, the repair of traumatic conditions, the adjustment of difficult fractures, the reduction of old and difficult dislocations, mobilization of joints where motion is partially or totally lost, and stiffening the joint as in certain paralytic conditions, treatment and drainage of suppura- tive conditions; a knowledge of the important routes of approach to the joint is very important. For each case, the operator will select the incision best suited for the individual condition. Each joint will be considered separately in its chapter. In all operations on the joints, the incision should be made down to the synovial membrane and made large enough before opening the syn- ovial cavity. All bleeding should be stopped and the synovial mem- brane carefully opened. The joint structures should be tampered with as little as possible, the synovial membrane brought together carefully and the layers over it closed in order not to disturb the function of the periarticular tissues. Unnecessary separation of the tissue layers is to be avoided. Tendons should be left in their sheath. Any ligaments that must be cut should be loosened subperiosteal^, in order that they may be readily replaced. Early motion should be the rule, gentle at first, and gradually increased. The shoulder joint is readily opened or punctured for diagnostic purposes but joint operations should never be hastily considered and should be avoided by anyone not familiar with the best surgical tech- nique. Arthrotomy of the shoulder is necessary sometimes for bursitis, some- times for the rupture of the supra-spinatus, sometimes on account of disease, sometimes for exploration, in cases of obscure internal derange- ment of the joint, or for removal of a foreign body, dislocation, fracture, for acute infections or suppuration. Incision in the overlying tissues should be made to one side of the line of incision in the capsule. All bleeding should be stopped before opening the synovial cavity. The latter should be opened carefully and the cavity itself interfered with as little as possible, avoiding rough and sharp instruments. For reefing the capsule, the anterior incision is often the best, but the posterior may be used. For drainage, the operator may choose the anterior route or the posterior, or both. In any extensive suppurative condition, the joints should be thoroughly drained. At times an anterior 202 INCISION, PUNCTURE AND ARTHROTOMY 203 incision with a puncture posteriorly will give sufficient drainage. This is especially so in the case of suppurative bone conditions. 228. Anterior Incision. (See Fig. 358.) — An incision is made from one-half inch below the acromion downward parallel to the deltoid muscle and slightly external to its innermost border. The incision is made three or four inches long. A layer of delicate fat is reached be- fore opening the joint cavity. The sub-acromion bursa will be found under the deltoid andacromion (see figure 358). When more room is necessary When it is necessary to have more room than is afforded by this in- cision, it is extended downward, but if very much room is needed it is better to make a second incision joining the first one-half inch below the acromion, extending inward one inch below and parallel to the clavicle, separating a few of the deltoid fibers (see figure 359) . This extra incision is not often necessary but it is very useful in difficult frac- tures and dislocations. The synovial cavity is opened in the line of the bicipital groove which is easily felt with the finger. A director is placed in the groove and the capsule opened on it. If it is necessary to have a full view of the head of the humerus, the tendon of the biceps is lifted from its groove with a blunt dissector and displaced inward. The shoulder is rotated inward, then outward slowly giving access to the restricting por- tions of the capsule which are removed subperiosteal^ parallel to the del- to allow the head to be toidfibres - turned out through the incision by adducting the arm a very good view of the head and glenoid. The anterior route is a simple and very useful route of approach for operations on the capsule, for excision, arthrodesis, and certain fractures. When the purpose of operation is accomplished, the head is replaced, the biceps tendon placed in its groove and the overlying tissues sutured layer by layer with interrupted chromic catgut sutures number 00. 229. Posterior Incision. — An incision is made starting one-half inch posterior to the tip of the acromion downward parallel to and one- half inch from the posterior border of the deltoid (figure 361). The Fig. 358. — An- terior incision start- ing one inch below the acromion and extending downward Fig. 359. — An- terior incision with extension one half an inch below the acro- mion extending in- ward parallel to the clavicle. , This will allow 204 TECHNIQUE OF OPERATIONS incision is carried through the skin and fat for about three inches. The deltoid fibers are separated with a blunt instrument, the fat overlying the synovial membrane is carefully opened and finally the synovial membrane is lifted with forceps and incised. 230. Kocher Incision. — This incision is carried from the acromio- clavicular joint along the upper border of the acromion and the spine of the scapula to its root. From this point, the middle of the spine, it is curved downward and forward to the posterior fold of the axilla (figure 360). The acromio-clavicular joint is cut across or preferably the fibers of the acromion legament are detached subperiosteally from the acromion. The finger or a blunt dissector separates the deltoid from the underlying tissues. The muscles are separated subperiosteally from the upper and lower border of the spine of the scapula. The acromion is J Fig. 360. — Kocher incision from the acromio-clavicular joint back- ward to the root of the spine of the scapula and then downward and outward to the posterior axillary- line. chiselled through and is re- , , j ~ j • , i ,i Fig. 361. — Codman incision between the acromio- tracted tor ward Wltn tne clavicular joint extending forward, separating the deltoid. The Operator deltoid anteriorly parallel to its fibers and backward should take care not to in- P ara ^ e ^ to the posterior margin of the deltoid. The . ' , posterior portion corresponds to the posterior incision. jure the supra-scapula nerve which passes under the muscles from above to below the spine into the infra-spinatus fossa. A hole is drilled through the acromion and another through the spine before separating the latter with a chisel. Sutures are placed through these holes before separating the acromion with the chisel. This enables them to be replaced easily afterward, the head of the humerus and glenoid fossa are fully exposed, after lifting the bicipital tendon from the groove and displacing it inward. 231. Codman Incision. — The saber cut Codman incision is made over the acromio-clavicular joint extending forward and backward along the anterior and posterior border of the deltoid (figure 361). The incision is continued along the spine of the scapula to its root. The acromion is separated from the spine by means of an osteotome or by a gigli saw. The acromion is first detached from the clavicle anteriorly. It is displaced forward with its deltoid attachment exposing the glenoid and the humerus. INCISION, PUNCTURE AND ARTHROTOMY 205 Fig. 362. — Burrell incision. The arm is abducted. The incision separates the pectoral from the deltoid extending in- ward below the clavicle one or two inches. This incision may be used for fractures or dislocations or for explora- tion of the shoulder joint. After operation the shoulder should be held by a long axillary pad or by means of a wire or plaster splint holding the arm extended straight above the head or abducted ninety degrees and outwardly rotated forty-five degrees to ninety degrees, depending on the case. Motion in outward rotation is very easily lost and very important for future func- tion. During convalescence motion in the joint is encouraged early without changing the position of abduction and outward rotation on the splint. When small arcs of motion are suc- cessfully obtained without much dis- comfort more motion is allowed. Ex- ercises are done often during the day but a very little at a time at first. After ten days there should be a marked increase in the ease and in the arc of motion. 232. Fractures of the Shoulder, — A fracture through the surgical or anatomical neck or head or tuberosity with or without dislocation will very frequently require treatment by the open method. The bone is easily reached by the usual shoulder incisions. As these fractures are difficult to treat no attempt at reduction should be made until a careful diagnosis is obtained from an x-ray. There is no necessity for haste. If necessary, the operation may be delayed several days for the sake of good x-rays. The surgeon having assured himself of the exact condition of the bone, the fracture is adjusted and plated or wired or bone grafted as the case requires. See sections 261, 262. The arm should be held to the side, the forearm pointing forward, with a large or small trian- gular pad in the axilla, coaptation splints, a shoulder cap, an internal an- gular elbow splint, a body swathe holding the arm to the side, and the patient kept in bed on a bed rest, the elbow unsupported in order to allow its weight to act on the lower fragment in preventing over-riding. When the fracture has healed, if the original trauma has been great, it may be necessary to abduct and outwardfy rotate the shoulder and hold it on a wire splint and exercise it in this position and later on a wire shelf abducted ninety degrees. The shelf is gradually lowered as the deltoid and other shoulder muscles acquire strength. Motion is nec- essary after the third or fourth week. Long immobilization must be avoided. 233. Fractures About the Shoulder. — When it is necessary to operate on shoulder fractures they are usually reached through a simple anterior incision or an enlarged anterior incision. For posterior frac- 206 TECHNIQUE OF OPERATIONS tures or fracture of the tuberosity the Kocher incision may be used. For small fractures of the tuberosity a simple posterior incision is often sufficient. Fractures of the surgical neck are reached by an anterior incision, the head may be drilled and held by the drill during the adjustment of the fracture. In. difficult cases both an anterior and a posterior incision may be necessary. A most complete exposure is obtained by a Kocher incision or a Codman incision. 234. Arthrotomy for Fractures about the Shoulder Joint. — The necessity of immediate operation in fractures about the joints depends, as in other fractures, on the acuteness of the local and general reaction. When these do not contra indicate immediate operation, certain frac- tures about the joints may require treatment by the open method. Among these are fractures of the patella, fractures of the olecranon and certain fractures of the surgical neck of the humerus, fractures and dislocations combined and certain fractures of the neck of the femur, all compound fractures, even when the protrusion of the bone has been extremely slight, all fractures that cannot be reduced by manipulation or in which the correction cannot be maintained or where apposition is impossible, many fractures combined with dislocation, articular frac- tures with pieces locking or limiting the joint action. Where there is a great deal of trauma and in multiple fractures and in cases where there is a great deal of shock all that can be done is to immobilize the parts until a favorable time for operation. In selecting a suitable time for operation when it is found necessary to operate on a fracture if there is no immediate contra indication, the sooner it is done the better. When there is tremendous swelling one should always wait. All cases should be operated on that show no union after three months of good treatment. Methods of treating the individual fracture cannot be considered in a limited space like this. The writer has described the routes of approach to the different joints and the technique of these. This will enable the surgeon from his knowledge of fractures to select the route best adapted for the individual treatment required and when necessary two or more incisions may be used. A knowledge of the technique will enable the surgeon to work rapidly in reaching the fracture on which he expects to spend time. See section 232. 235. A Traction Apparatus for Fractures of the Shoulder and the Shaft of the Humerus. — When traction is of advantage, the same apparatus may be used for fractures at the shoulder and for fractures of the shaft of the humerus that is described under fracture at the elbow. Section 262. 236. A Method of Treating Overlapping Fractures. — Where the bones overlap, an excellent method of treatment is one suggested to the INCISION, PUNCTURE AND ARTHROTOMY 207 writer many 3 r ears ago by Dr. Edward Martin of Philadelphia. In the operation when the surgeon has reached the fracture the ends are freed. A tough tape or webbing is used ten or twelve feet long, sterilized. The two ends of the tape are tied together, a loop of the tape is placed over the distal end of the bone. The other end of the tape is thrown over the foot of the operating table, a thirty-five pound weight is at- tached to this by an assistant. In about five minutes the bones will be found to be separated at least one inch. The weight is then held up by a non-sterile assistant, the tape taken off of the end of the bone and clamped to the sheet on the operating table, so that it will not slip away while the surgeon works on the fracture. When the muscles are in fairly good tone or the overlapping of bone has been great, it will be found that the bones will overlap again in four or five minutes. A reapplication of the tape will separate the bones again for the same length of time. The end of the lower bone should not be cut or freshened until all other procedures are done which require separation of the bone. When these have all been done the end of the bone over which the tape has been placed is freshened. After this the tape should not be placed on the end of the bone, unless it is very necessary but the two ends allowed to come together and held by a clamp until the operation is complete. Very bad overlapping fractures have been treated in this way in fresh cases without the necessity of shortening the bone. In old fractures no more bone need be removed than is required by the conical condition of the ends. See section 232. 237. Fractures of Long Standing Still Ununited or United with Deformity, Preventing Function. — In fractures of long standing where there is a mild infection, conservative treatment should be tried first. When this has been tried free drainage should be established and at the same time the ends of the bone freshened up slightly. Unless the infection is marked, in many of these cases when the suppuration dis- appears, union has also taken place. In any case where there has been in- fection, no plastic operation should be used until the infection has been entirely absent for at least nine months, a year is safer. Where the infec- tion is very mild and of long standing, during the process of treatment the patient may be allowed to walk on the other leg if the local reaction is not too great. Sometimes he may walk a little on the affected leg. It is of advantage in certain cases to use a Thomas splint to take some of the weight off of the affected leg, the patient being allowed to bear weight on the ball of the foot, the splint taking all the weight off of the heel. Where the x-ray shows conical ends of the bone it is practically useless to expect union without surgical interference. 238. Tapping the Shoulder Joint. — The most scrupulous aseptic precautions are necessary both as to the preparation and the protection of the field of the operation. It is rarely necessary to tap the shoulder joint. When there is much swelling, the synovial cavity is more readily reached. It is tapped ex- 208 TECHNIQUE OF OPERATIONS ternaJly just anterior to the acromion halfway between it and the most anterior portion of the deltoid, obliquely down and back. The sub- deltoid and subacromial bursa must not be forgotten. The tapping may be done with ethyl chlorid or novocaine adreneline solution, 1%. When there is much effusion it is not difficult to reach the joint. The skin is drawn to. the side so that the hole in the skin and muscle will be out of line when the needle is removed. If fluid is to be drawn, and other solutions are to replace it, the amounts should be carefully measured. Two good graduated metal S}Tinges are very useful. All of their parts should be tested beforehand. The trocar is made to enter the joint and then is connected with the syringe. As little air as possible should enter the joint. The trocar should be of large diameter as the fluid may be thick or flaky. When the patient is not anaesthetized for the operation it is often well to have a short flexible tube connect the trocar with the syringe. This should be fastened at both ends by silk ties so that it will not leak easily when pressure or suction is used. If the joint is to be washed out a definite amount of fluid is injected and the return measured in a sterilized measuring glass. Dr. Murphy uses a formalin glycerine solution as follows: — Liquor formaldehyde 2% in glycerine, about ten drops of the formaldehyde to each ounce of glycerine. This acts very well in infectious synovitis. But it should not be used in arthritis deformans nor in old chronic arthritis. The tapping may be done with ethyl chlorid or novocaine adreneline solution, 1%. The solution should be prepared twenty-four hours before it is used (Murphy). CHAPTER V OPERATIVE TREATMENT IN CASES OF JOINT ANKYLOSIS 239. Partial Excision of the Shoulder for Ankylosis. — When there is ankylosis of the shoulder, a partial excision may be done. The opera- tion is the same as that described here under Excision, with this excep- tion: — that only enough of the bone is removed to allow free motion. The attachment of the infra spinatus and the deltoid should be carefully replaced and the arm held abducted ninety degrees and outwardly rotated ninety degrees. This position is maintained until the tone of the muscles is partly recovered by exercising in this position. 240. Excision of the Shoulder to Relieve Ankylosis. — When the shoulder is ankylosed an arthroplasty is the operation of choice. When there has been no disease for at least a year and if the condition was not originally tubercular, a partial incision may be done, allowing a loose joint with motion. The operation is performed as described for excision, the head is re- moved, the sharp bony edges are removed and the arm placed in a posi- tion of ninety degrees outward rotation and ninety degrees of abduc- tion in plaster. In three weeks a wire splint is used and exercise and motion are encouraged on this wire shelf splint for four months. The arm is held there in a position of ninety degrees of abduction and in a neutral position as to rotation until the shoulder muscles have acquired strength. 241. Arthroplasty for Ankylosis of the Shoulder. — Ankylosis may be bony, cartilaginous or fibrinous, it may be periarticular, ligamentous and capsular, or extra articular, that is, skin scars, tendons, fascia, nerves and arteries. The form of ankylosis that exists will determine the treatment. A partial ankylosis at certain joints had better not be treated by an arthroplasty. Age must be considered, also the general condition of the patient. When the ankylosis is bony, cartilaginous or fibrinous, arthroplasty is indicated. When the condition is periarticular or extra articular, it may be treated by capsulotomy, tendon elongation, excision of exostoses, etc. Dr. Murphy lays stress on the following points: — The principles of asepsis to the finest detail are absolutely essential. One not familiar with the best surgical technique should avoid arthroplastic operations. The exposure of the joint must be generous and careful. The excision of the ankylosis must be complete. The contracted capsular ligaments and soft parts must be freed and if necessary lengthened. The normal 209 210 TECHNIQUE OF OPERATIONS contour of the joint should be restored as nearly as possible. The operator should obtain a hyper-mobilization of the joint. The joint should be re-shaped to give stability. The inter-position of material to prevent reunion of the bone is necessary. The principle is to separate the bones and to interpose between them material to prevent bony union. The best material for this purpose is a pedicle flap composed of fat, muscle, fascia, or a combination of these. When this is not possible, a transplantation is made of fat and fascia from the trochanter bursa region or from the fascia lata. Materials such as ivory, celluloid, silver are not especially good. Materials that will not absorb or that absorb too slowly are not desir- able. During the operation the soft parts should be freely liberated. At- tach the interposing flap to one bone only and cover it completely. Early motion, that is, active or passive, at the end of five to seven days is necessary with or without gas or gas oxygen. Dr. Murphy records failures in arthroplasty as due to first, insufficient and defective exsection of the capsule and ligaments, second, insufficient interposition of fat and fascia between the separated bony surfaces, third, infection, fourth, the sensitiveness of pain on motion after opera- tion. Cases of primary tuberculosis and cases of recent infection that have subsided are not suitable cases for arthroplasty. In operation, in addi- tion to the usual protection of the field of operation, after the skin and fat have been incised, towels should be clamped to the edges of the skin as an extra protection. The patient lies on his back with a hard pillow or sand bag under the middle of the back and scapular to hold the shoulder off of the operating table. The operator stands on the side of the shoulder to be operated on. Dr. Murphy uses an incision starting one-half inch below the acro- mion downward parallel to the fibers of the deltoid and one-half inch from its internal margin. The incision extends four inches downward through the skin and fat to the muscle. A transverse incision is made at right angles across the chest over the middle of the pectoralis major. The fibers of the deltoid are separated with a blunt dissector, the shoul- der is rotated so that the bicipital groove comes in the line of incision. The blunt dissector is slid under the capsule in this groove. The cap- sule is cut on the director up to the acromion. The capsule is removed subperiosteal^ from the humerus as far as possible anteriorly and in- ward and outwardly and backward. Long silk sutures may be placed in the capsule to hold it retracted so that it may easily be recognized later on. The tendon of the biceps is lifted on a blunt dissector and displaced inward. The head of the humerus is separated from the glenoid with a curbed chisel and rounded, following the original ana- tomical lines as nearly as possible. A flap of fat, aponeurosis and muscle OPERATIVE TREATMENT IN JOINT ANKYLOSIS 211 is taken from the middle of the pectoralis major. Dr. Murphy advises a flap four and one-half inches by three and one-half inches out of the middle of the pectoralis major. The pedicle is left attached to the humerus and should be large enough to completely cover the bony surface. The head of the humerus is placed against the glenoid which has been smoothed. Over the head is stretched the fat, aponeurosis and muscle flap. These have been firmly sutured so that they will re- main around the head. The capsule is now fastened to the humerus with interrupted chromic catgut sutures number 00, the muscles are attached with interrupted chromic catgut sutures number 00, the fat brought together with interrupted chromic catgut sutures, the skin with continuous chromic catgut sutures. The under surface of the pectoralis major muscle is freed with a blunt dissector so that its fibers can be brought together wherever there is a gap in the tendon or muscle. The skin and fat are brought together with interrupted chromic catgut sutures. If the surgeon prefers to use the deltoid instead of the pectoral, an incision is made four inches long below the clavicle passing external to the deltoid fibers, between the deltoid and pectoral. This will, expose the joint completely if the directions are followed as above. After freeing and shaping the bone, the deltoid is cut transversely and a piece interposed four inches wide between the head and the glenoid. It has been suggested by Dr. Coville to remove a piece from the sur- gical neck and give motion at this point by interposition of the deltoid. This he reports as a practical operation. After arthroplasty of the shoulder the weight of the arm should be lifted from the shoulder by a wire splint holding the arm in an abducted and outwardly rotated position (see figures 311, 312). Motion is begun with the arm still on the splint at the end of a week or ten days. "When motion is possible without pain or discomfort it is increased and the splint lowered as soon as the shoulder is strong enough, which will not be before the fourth to the sixth week. CHAPTER VI OPERATION IN SUPPURATIVE CONDITIONS 242. Osteomyelitis. — In osteomyelitis an operation should be done as early as possible after making the diagnosis. In sub-acute cases, incision and drainage are all that is necessary. Whenever incising for abscess all the pockets should be opened and if the abscess is large, coun- ter incisions are made at dependent portions. The pus pocket should be opened freely, wiped out with gauze, irrigated and wiped out again with gauze. Curetting should be avoided excepting for the removal of sinuses in the skin and in cases of sinuses it is often better to excise them. Perforated rubber tubing should be placed to drain the deepest portions of the pockets. The skin, fat and superficial muscle layers should be made to gap by means of gauze drains. At the end of ten days the gauze is removed and the tubes shortened. The tubes are gradually drawn out a little each day or two until not used. This method makes the repeated reapplication of drains and wicks unneces- sary as the wound will gap of itself and close from the bottom if the surgeon has been careful to make large incisions. Where the periosteum is found destroj^ed or the pus under the perios- teal layer, the bone should be opened by means of a large drill or a small gouge. Where this is necessary, the incisions should be large and the counter incision should be made on the other side of the bone with a hole made in the bone a little above or below the hole on the opposite side (figure 66). These holes in the bone should open up the medullary cavity. They should alternate on one side and the other as far up and down as the disease is suspected. When the abscess is very great and the bone involvement is large a number of good sized holes should be made with a Burr drill or a curved gouge on both sides of the bone as shown in figure 67. The wound should be gaped widely; — the skin, fat and superficial muscle held open by large gauze drains. The tubes should reach from the surface to the deepest portions of the abscess cavity. Splints should always be applied to immobilize the limb. They should be placed so that they will not interfere with the dress- ing. In some instances it is better to apply plaster with large windows and ropes to give stability as shown in figures 459-460. The dressing should be done every day or twice a day, depending on the foul condition of the discharge. If the odor is excessive, chlorinated soda dressing should be used diluted, using it V2, l lz, or 1 / i the U. S. P. strength. The gauze drains should be left for at least ten days without being dis- turbed. When removed, granulations will be formed under them in such 212 OPERATION IN SUPPURATIVE CONDITIONS 213 a way as to keep the wound open without applying the drains. Irriga- tion may be used at the time of operation and the wound thoroughly wiped out with gauze afterward. No irrigation or probing or application of wicks will be necessary if the first drain is left in long enough. After the first ten days the tubes are shortened up gradually until they are not needed. See Carrell-Dakin technique, section 323. In severe cases where the patient is unconscious or delirious, the bone should always be opened, three or four holes on either side made with a gauge or good sized Burr drill. In no case should the incision be made only on one side of the leg in severe cases. No tight packing should be used as this interferes with good drainage. Where sequestra have formed they should be removed. An x-ray should be taken whenever possible to determine the position of the disease (unless the case is ur- gent and an immediate x-ray is not obtainable). In cases of long standing that are sub-acute at the first examination, where the bone is riddled with holes over an extremely long area, it is impossible often to remove the dead bone satisfactorily without re- moving all the bone. In these cases free incision down to the bone with frequent openings into the bone as described above, will allow the septic process to run its course and the sequestra to gradually separate. We have had some cases in which the lower third of both femora were riddled with holes and full of sequestra, the patient being in no condition for extensive operation, and yet not very ill. In these cases, however, if the surgeon had seen the patient in time an early operation would have prevented this extreme condition. Sometimes it is necessary to close a large bone cavity which will not heal over. Where the process is distinctly septic no plastic operation should be done without first doing an operation to eliminate the septic condition. After that, part of the muscle may often be transferred over such a cavity after it is closed. In transferring a muscle over such a cavity it should be freely transplanted and held there without tension. The skin should be brought together over the muscle and the wound drained, as there is apt to be inflammatory disturbance. Where sequestra are present it is always desirable to remove them as soon as they have separated and the involucrum is strong enough to act as a support. Sequestra may be superficial or in the medullary cavity or both. Where there is a persistent sinus and a sequestrum is present, pus will continue to form until the sequestrum is removed. Cases dis- charging several years where sequestrum is present may close in a few weeks after removal of the sequestrum. In closing a bone cavity its edges may be chiselled clean and then the bone incised a short distance from one edge and parallel to it, the incision is carried down to the medulla, the incision in the bone is widened by prying it open and forcing the bone together, closing the old cavity. This is sometimes a satisfactory method of closing an old open bone cavity which has schlerosed edges. 214 TECHNIQUE OF OPERATIONS 243. Suppurative Conditions of the Shoulder. — In suppurative conditions about the shoulder joint an anterior incision through the deltoid fibers is a convenient route of approach. This will usually have to be supplemented by a posterior opening and sometimes by one in the axilla. The joint is then washed out thoroughly before replacing the head, the abscess cavhy r is well wiped out with gauze and drains applied. The angles of the wound are held apart by rolls of gauze and tubes are placed to the depth of the suppurating cavities. If the disease is extensive or there is to be prolonged drainage or in cases where disease is extremely virulent, the operator should use large anterior and posterior incisions, keeping them well open with sponges in addition to the tubes inserted to the deep pockets. Where there is extreme suppuration, a wire splint is preferable to a plaster unless the latter is applied with large windows and ropes as shown in figures 459, 460. See the Carrell-Dakin technique, section 323. 244. Excision of the Shoulder in Suppurative Conditions. — An ex- cision of the shoulder may be indicated in certain cases of tuberculosis of the joint, in cases of extensive suppuration, for certain compound fractures, for irreducible dislocations sometimes, for ankylosis, etc. The patient lies on his back, a sand bag or hard pillow is placed under the middle of the back to raise the shoulder well off of the operating table. The operator stands on the same side of the patient as the arm to be operated on; the field is protected in such a way that the arm and hand protected in a sterile sheet, may be manipulated into any position. OPERATION An incision is made one-half inch below the acromion extending down- ward parallel to the fibers of the deltoid and one-half inch to the outer side of its anterior inner margin. The incision is carried down four inches through the skin and fat to the muscle. The muscle fibers are next separated with a blunt instrument for the whole length of the incision. When the deltoid is retracted the operator will easily detect the bicipital groove with his finger and make an incision down to it by passing a director in the groove and cutting the capsule on the director up to the acromion. If the excision is done to obtain ankylosis as in paralytic conditions or to obtain motion in cases of ankylosis either from injury, old disease, or fracture, the operator will not need to remove much bone. When, how- ever, a great deal of bone must be removed on account of extensive dis- ease, it will be necessary to detach some of the important muscles. The tendon of the biceps will be lifted from its groove on a blunt dissector and displaced inward, while the shoulder is rotated slowly inward and then outward during the process of freeing the capsule subperiosteal^ and also the attachment of the supra and infra spinatus and teres minor from the great tuberosity. The sub-scapularis teres major ex- OPERATION IN SUPPURATIVE CONDITIONS 215 tend to the lesser tuberosity. This relieves at the same time the cor- raco-humeral ligament. The head is now easily brought out of the wound and the necessary bone sawed off below the cartilage line. The axillary nerve and circum- flex artery must be remembered. With care they will not come into view. In children the epiphyseal line should be preserved. After re- moving the necessary amount of bone, rongeurs are used to remove the sharp edges of the bone. The glenoid cavity is inspected and any dis- eased portion removed with a chisel, not with a curette. Unless the disease is extremely slight, posterior drainage should be secured by a posterior opening. A pair of forceps is pushed through the tissues and made to protrude posteriorly. As they protrude, a one and one-half inch incision is made. If, however, the operation is done to obtain ankylosis, or to give motion, no drainage is necessary and the incision is closed completely. The capsule which was detached is brought down to the humerus and sutured anteriorly and posteriorly with kangaroo or chromic catgut sutures number one, the muscles with chromic catgut sutures number 00, the fat also; the skin with continuous chromic catgut sutures number 00. When drainage is necessary, the edges of the wound and the pos- terior incision are gaped by means of round wads of gauze, extending through the skin, fat and superficial muscle, tube drains are placed between and extend to the deepest portions of the wound. The arm should be held in an abducted position of not less than forty-five degrees, a large pad being placed under the elbow so that it may be held strapped up to allow good healing of the approximate soft tissues. When the operation is done to obtain motion, the shoulder is held abducted ninety degrees and outwardly rotated sixty degrees on a wire splint or in plaster (see figures 314 to 317). When the operation is done to obtain ankylosis as in certain paralytic conditions in order that the scapula muscles may be used to control the actions of the humerus, the arm is abducted about seventy degrees and held firmly (see Arthrodesis of the Shoulder). 245. Excision of the Scapula in Suppurative Conditions. — The patient lies on the opposite side of the body in a semi-prone position. An incision is made over the posterior inner border of the scapula. This is joined by a second incision extending along the spine of the scap- ula to the tip of the acromion. An osteotome is used to remove the muscles subperiosteally from the inner border of the scapula extending upward along the upper border. The operator will next work from the inferior angle upward along the axillary border and the under side of the scapula. An osteotome is used to remove subperiosteally the trape- zius, the supra and infra spinatus muscles working from within, outward. The acromion is chiselled through with an osteotome, freeing it from the spine of the scapula, the corracoid is freed at its base with an osteotome. 216 TECHNIQUE OF OPERATIONS The supra scapular nerve should be avoided. Several small arteries will have to be ligated. When the inner and outer portions of the scapula are cleared from below upward, the scapula is lifted by its lower angle so that the anterior surfaces may be cleared of the sub-scapular muscle and serratus. All that remains after this are the attachments of the capsule and omohyoid muscle. The circumflex artery and transverse arteiy of the scapula may give some bleeding. The supra scapular nerve accompanies the transverse scapular artery. When possible the joint should be left. The shock from this operation is very much less than that of removing the arm and blade. W 7 henever this limited operation may be done it is preferable for this reason to a complete removal of the arm and scapula. After removal of the scapula the joint may be attached to the clavicle. If the operation is done for disease, drainage will be necessary at the dependent portions of the incision. The edges of the incision may be opened or gaped with round gauze pads extending through the skin, fat, and superficial muscle. Tubes are placed between these to the deepest portion of the cavity. The weight of the arm and shoulder is borne on a wire shoulder shelf (see figures 314 and 315), holding the arm abducted ninety degrees and outwardly rotated sixty degrees. Motion of the forearm, wrist and fingers is encouraged on the shelf after ten days. As the arm acquires strength, the shelf is lowered gradually and motions of the arm, active and passive, are encouraged without the shelf. 246. Methods and Principles of Drainage in Acute Non-tubercular Suppurative Joint Disease. Shoulder. — A small suppurative focus without virulence or active constitutional disturbance should be drained by a suitable incision wiped out with gauze, a tube placed to its deepest part and the soft tissues gaped with gauze. When there is a great deal of constitutional disturbance drainage and counter drainage should always be the rule; if the bone is involved this should be opened and counter opened as shown (see figure 66). The pus cavities in the soft tissues should be wiped out. No extensive bone operation should be done otherwise. The bone should be drained with tubes to the remote portions and the muscle, fat, and skin gaped by gauze. These operations are done quickly and should not be prolonged, but efficient drainage and counter drainage should be established unhesi- tatingly. It is rarely necessary to do more at this time. If there is a marked sequestra formation this should be removed, but this had bet- ter not be done at the time of instituting drainage when the patient is nearly exhausted from an acute process. Any future operation made necessary should give good drainage and the removal of the sequestra if present and separated. See the Carrell-Dakin technique, section 323. PART V— ELBOW CHAPTER I OPERATION FOR DEFORMITIES AND DISLOCATION OF THE ELBOW 247. Dislocations of the Elbow. — Dislocations of the elbow should be treated early. The bones may be reached by two lateral incisions each four inches long, or by a posterior incision internal to the olecranon five inches long with an external lateral just anterior to the condyle over the radial joint and extending upward four inches. Dislocations of long standing are difficult to replace and may require an excision or arthroplasty. Each case will differ more or less but any case unreduced after six weeks is apt to have pretty substantial adhe- sions, rendering reduction difficult or impossible. When accurate re- placement is impossible an arthroplasty or excision should be done without delay. The surgeon should avoid rough manipulation in at- tempting reduction as this will complicate the recovery from the opera- tion which he adopts later. If an open operation is necessary, the bones are brought into view and the tissues lifted from the bone. The soft tissues are separated en masse from the capsule fairly completely, keeping close to the bone subperios- teally as described under excision of the elbow, (see Excision, sections 269, 276). Instead of removing any bone the joint must be replaced accu- rately. The elbow is put up at right angles for ten days and then flexed to forty-five degrees from the right angle. Passive motion is begun gently after the first seven or ten days. 248. Manipulation of the Elbow Joint. — In manipulation for flexi- bility of the elbow, the motion in flexion and extension should be done with the forearm pronated and with the forearm supinated. The mo- tions of the radius at the elbow should be tested in supination and in pronation with the elbow extended with the elbow flexed and with the elbow at right angle. The flexion and extension of the wrist is manipulated in a pronated position and in a supinated position; the adduction and abduction of the wrist in a pronated position and in a supinated position and so on. In manipulating for the flexibility of the fingers the wrist should be flexed, then extended for each manipulation. The manipulation should be done with the forearm pronated and repeated with it supinated. The normal motion of the joint should be remembered. The stretch- ing of the resisting tissues made gradually with a rhythmic stretching and relaxing, the force being applied gently and increased to a climax and 217 218 TECHNIQUE OF OPERATIONS gradually decreased until there is complete relaxation. The joint is stretched and relaxed, the operator applying force in a gradually in- creasing manner until considerable force is applied and then relaxing until very slight force is used and finally relaxing entirely. In this manner a rhythmic extension and flexion is kept up. No rough or forcible extension without a gradually increasing or gradually decreasing force should be employed. By this method a minimum amount of trauma is caused. Forcible pumping motions are to be avoided. A joint that at first will seem almost impossible to move will often give way. Be- fore any extensive operation, a fairly normal action in all normal direc- tions should be obtained. 249. Plaster of Paris for the Elbow. — A plaster of Paris at the elbow may be put on with the arm straight or with the elbow flexed at any angle. The palm of the hand and the space to the outer side of the second metacarpal should be well padded so that the plaster may be carried between the thumb and index finger over the second metacarpal but not in such a way as to interfere with the motion of the thumb and index finger or the other fingers. This hand portion of plaster will maintain the desired pronation or supination of the forearm. The wrist and elbow should be very well padded, but the plaster should fit the humerus from end to end and the forearm from end to end. CHAPTER II MUSCLE AND TENDON OPERATIONS. MUSCLE AND TENDON TRANSPLANTATION 250. Transplantation of the Triceps for Paralysis of the Biceps. — — When the biceps is paralyzed and the triceps is good and strong, the outer half of this muscle may be transplanted into the paralyzed biceps as follows. OPERATION An incision is made over the back of the upper arm starting at the junction of the middle and upper third extending downward over the olecranon. The skin and fat are retracted exposing the outer third of the tendon of the triceps. This is divided and dissected from the bone to the above olecranon, here it is expanded into half of the triceps muscle. The outer half of tri- ceps is dissected up to a little above the middle of the arm. An incision is now made over the front and middle of the biceps down to this muscle, this is split with a blunt dissector and a tunnel made extending backward to the posterior in- cision. A tendon carrier or clamp is passed backward through the tunnel, grasps the tendon of the triceps bringing it forward through the opening of the biceps. Silk is now quilted up one side and down the other of the triceps tendon. An incision is now made over the front of the elbow extending over the inner side of the biceps tendon and to its fascial ex- pansion below. The incision should expose the lower end of the biceps muscle as well. A subcutaneous tunnel is now made below the fat con- necting the two anterior incisions. A tendon carrier is now passed up- ward from the lower to the upper incision and brings with it the silk and tricep tendon. The silk is now quilted into the bicep tendon and fascia and the lower end of the biceps muscle sutured to the tricep, the elbow being flexed twenty degrees beyond a right angle. The deep tissues and fat are sutured with interrupted catgut sutures, the skin with chromic catgut number 00. A plaster of Paris bandage is applied holding the elbow flexed slightly more than a right angle. Fig. 363. — Humerus drilled, leader of silk worm- gut placed in drill eye. 219 CHAPTER III OPERATION IN CASES OF TOTAL OR PARTIAL PARALYSIS 251. Flail Condition of the Elbow. — When a flail condition of the elbow exists, silk ligaments may be used to hold the joint at right angles or an arthrodesis may be done, otherwise it will be necessary to use a brace to hold the elbow at right angles in order that the hand may be used. An apparatus is often sufficient and very comfortable. 252. Silk Ligament at the Elbow. — If silk ligaments are to be used they are inserted as described for the ankle (see also figures 363 to 368). 253. Fascia Transplantation for Flail Condition of the Elbow. — OPERATION An incision is made three inches long over the anterior lower third of the humerus, and extending through the skin and fat. What Fig. 364. — Silk wormgut drawn through the humerus. Drill used to draw silk subcuta- neously to the forearm. Fig. 365.— Drill passed through the ulna. Silk from the humerus threaded through the silk wormgut leader. Fig. 366. — Silk protruded from the forearm, one has passed through the ulna, the other comes from the humerus. Fig. 367. — Diagram of silk ligaments in paralysis at the elbow. remains of the atrophied fibers of the biceps and brachealus anticus fibers are separated by a blunt dissector and retracted exposing the bone. A large hole is drilled in the humerus through the anterior third of the bone and a silk wormgut guide (figure 363), passed through the 220 OPERATION IN CASES OF TOTAL OR PARTIAL PARALYSIS 221 bone by means of the drill which should be made with an eye. A second incision is made four inches long over the middle of the upper half of the forearm through the skin and subcutaneous fat. The atrophied muscles are easily separated and the ulnar bone exposed and drilled. A silk wormgut guide is passed through the bone. Removal of fascia from the fascia lata An incision five or six inches long is made on the middle and outer aspect of the thigh down to the fascia lata; by retracting the skin and fat which is very elastic, a piece of fascia broader and longer than the incision may be obtained. The amount necessary should be care- fully measured by a probe and an extra two inches allowed. The fascia removed is slit at each end and its edges rolled (figure 294). A tunnel is , . . , i c , Fig. 368. — Incisions closed. made in the subcutaneous fat con- necting the two arm incisions, the fascia passed through this and its ends (figure 295), passed through the bone above; the lower ends through the bone below. The ends are overlapped and sutured with interrupted chromic catgut sutures number 00 (figure 296). If the operator pre- fers, these ends are sutured to the deep fascia or to silk passed through the bone (figure 297). The elbow should be flexed fifteen degrees be- yond what is desired so that the fascia will hold it flexed slightly more than right angles. There will be a stretching of about twenty-five de- grees in time. After treatment A posterior wire splint or plaster of Paris bandage is applied holding the elbow in sufficient flexion to take all tension off of the fascia. A large roll of loose cotton is placed over the front of the arm and arranged as in tendon operation on the leg. The original position should be main- tained eight weeks. If a plaster of Paris bandage is used the front half may be removed and a gauze bandage applied to hold on the posterior half. In this way the wound may be inspected readily. After six weeks the weight of the forearm is allowed to pull on the fascia from five to fifteen minutes twice a day in increasing doses. Then later four times increasing every third day, until the forearm is carried without apparatus two hours at a time. After this the strain of holding the forearm is increased rapidly. 254. Operation on the Skin for a Flail Elbow, (Mr. Jones' operation) . — The patient lies on his back, the extended arm is placed on a table. An incision is made diamond shaped through the skin and fat and sub- cutaneous tissue over the front of the arm, the skin removed and sutured so that the upper and lower angles of the diamond come in contact 2 .'2 TECHNIQUE OF OPERATIONS with each other, holding the arm at flexion twenty degiees more than right angles. Before incising the skin, a heavy piece of silk is passed through the skin (see figures 359, 360), at the selected upper angle and another at the selected lower angle of the diamond. These are brought together so that the operator may judge the amount of stretching that will take place when the weight of the forearm is allowed to come on the skin. When this is determined, a diamond shaped piece of skin is marked out with its upper end on the anterior aspect of the lower third of the upper arm and the lower angle of the diamond will be in the upper third of the forearm. These points will have been determined by the silk inserted in the skin and made to hold the arm in the desired position before incis- ing the skin. This will decide the proper distance between the upper Fig. 369. — Diamond shaped skin incision; the outer edges are approximated and then the inner edges approximated. Fig. 370. — Edges of the dia- mond are brought together. and lower ends of the diamond. The test will also determine the shape of the diamond. The operator will remove less skin than is required. More is then removed to hold the elbow flexed twenty degrees beyond right angle. After treatment A plaster of Paris bandage or posterior wire splint will relieve tension on the skin until it is healed. This should remain for eight weeks. It is then removed fifteen minutes twice daily, later four times a day and increased every three days until the patient has the motion of the fore- arm without the splint for two hours twice daily; after that the progress is more rapid. 255. Arthrodesis of a Flail Elbow.— If a rubber bandage and tourni- quet are to be used, the surgeon should have the tourniquet put on care- fully and not too tight and have it removed as early as possible. A towel should be put under the tourniquet. The patient lies on his back, the arm across his thorax. The operator stands on the same side as the arm to be operated on. A posterior inci- OPERATION IN CASES OF TOTAL OR PARTIAL PARALYSIS 223 sion, four inches long is made, starting two inches above the tip of the olecranon and extending vertically downward to the triceps. The fibers of the triceps are separated carefully and a subperiosteal dissection is made, exposing the sides and back of the humerus and of the ulna. The joint capsule is opened, the olecranon is chiselled off with an osteotome through the middle of the sigmoid cavity and the end dis- placed upwards; the joint is denuded of cartilage and roughened. The trochlea surface may be split from below upwards, the edge of the osteotome being parallel to the intracondylar line. The broadening of the trochlea surface and the roughening of the bone in consequence favors ankylosis. The olecranon is held in place by suturing the periosteum or by silver wire. The separated olecranon may be fastened to the hu- merus by silk or silver wire preventing extension of the arm. The deep tissues are carefully brought together with interrupted chromic catgut sutures number 00, the triceps likewise, the subcutaneous fat with in- terrupted chromic catgut sutures number 00, the skin with continuous chromic catgut sutures number 00. The arm should be put up extended fifteen degrees or twenty degrees from a right angle position and held here by a firm plaster of Paris bandage with windows for the inspection of the incisions. In most instances apparatus is preferable to an opera- tion when a flail elbow exists. It is well to remember that the surgeon is not always gratified when attempting to get ankylosis at the elbow, though under other circumstances a stiff elbow is not uncommon. CHAPTER IV INCISION, PUNCTURE AND ARTHROTOMY 256. Artnrotomy. — A knowledge of the important routes of ap- proach to the joints will facilitate any joint exploration, the removal of foreign bodies, the repair of traumatic conditions, the adjustment of difficult fractures, the reduction of old and difficult dislocations, the mobilization of joints where motion is partially or totally lost, and the stiffening of the joint as in certain paralytic conditions, the treatment and drainage of suppurative conditions; a knowledge of the important routes of approach to the joint is very important. For each case, the operator will select the incision best suited for the individual condition. Each joint will be considered separately in other chapters. In all operations on the joints, the incision should be made down to the synovial cavity. All bleeding should be stopped and the synovial membrane carefully opened. The joint structures should be tampered with as little as possible, the synovial membrane brought together carefully and the layers over it closed in order not to disturb the func- tion of the periarticular tissues. Unnecessary separation of the tissue layers is to be avoided. Tendons should be left in their sheath. Any ligaments that must be cut should be loosened periosteally, in order that they may be readily replaced. Early motion should be the rule, gentle at first, and gradually increased. Joint operations should never be hastily considered and should be avoided by anyone not familiar with the best surgical technique. In exploratory operations at the elbow, erasions, excisions, or arthro- desis, or dislocations, for draining suppurative conditions, either the posterior or the external-lateral supplemented at the same time by an internal incision are the routes preferred. The operator stands on the side of the arm to be operated upon. The arm is placed across the patient's thorax. The incision is made four inches long starting two inches above the tip of the olecranon and slightly to the outer side of the middle line. The fibers of the triceps are divided carefully in the line of the incision. The dissection is car- ried down to the bone and through the periosteum. By means of a long handled osteotome or a sharp periosteum elevator the periosteum is removed, working to the outer side, clearing the condyle from above downward. 257. Posterior Incision (see figure 371). — The posterior incision is made vertically to the outer side of the olecranon or to the inner side. The outer incision is preferable for excision, arthroplasty, fractures of the olecranon, of the outer condyle, and exploratory operations on the 224 INCISION, PUNCTURE AND ARTHROTOMY 225 joint. For dislocations, the incision may be made to the inner side of the olecranon and be supplemented by an external incision over the con- dyle slightly anterior. Some surgeons prefer two lateral incisions for dislocations and for arthroplasty. The anterior incision is a more hazardous route than the lateral or the posterior and is rarely necessary. The anterior route follows the outer edge of the biceps tendon down to the capsule. The posterior incision begins two inches above the olecranon and extends vertically downward about four inches. It is made to the outer side of the olecranon. The dissection is carried down to the bone. The periosteum is incised and the tissues lifted with it. A long handled osteotome is used for this purpose or a sharp periosteal elevator with a good handle. The periosteum is started at the upper end of the incision and raised, working downward until the lower end of the incision is reached; the operator then works at that end and goes upward and outward, raising the periosteum from the bone until the Fig. 371. — Posterior in- outer Condyle is cleared. The Surgeon should cision along the inner side of • i r £ ,1 • j the olecranon extending four avoid roughness in forcing up the periosteum. i nc hes above and four inches The work at this point is largely one of dili- below the joint, gence. The outer condyle is cleared first then the inner condyle (see Excision, section 276). 258. External Lateral Incision (see figure 372). — This incision is made parallel to the bone extending over the head of the radius and upward five inches, just anterior to the condyle. The dissection is made care- fully down to the bone, the radial joint opened if neces- sary and the per- iosteum raised from the condyle starting over the Fig. 372.— External lateral incision head of the over the condyle and head of the radius working radms - upward and for- ward until the upper end of the incision is incision just posterior to reached. The operator raises the periosteum the internal condyle. here, then works gradually downward and then upward lifting all the tissues subperiosteally; after clearing the bone anteriorly he may clear off the periosteum posteriorly, depending on the exposure necessary. 259. Internal Lateral Incision (see figure 373). — This incision is made four inches long extending two inches above and two inches below Fig. 373.— Internal lateral 220 TECHNIQUE OF OPERATIONS the condyle and slightly posterior to it. The position of the ulnar nerve must be remembered. The periosteum is lifted under it so that it is not seen during the process of lifting the periosteum. The operator clears the condyle as far as necessary anteriorly and then posteriorly. 260. Anterior Incision for Reaching the Elbow Joint. — This incision is rarely necessary and is not as practical as the posterior or lateral. It is made to the outer side of the tendon of the biceps, following down through the bicipital fascia. A blunt dissector is used to separate the tissue below this until the capsule is reached (see figure 374). 261. Operations for Fractures at the Elbow. — Operations, when necessary, for fractures at the elbow, should be done as early as possible. In all compound fractures where the condition of the patient allows, the compound wound should be opened up and thoroughly cleansed. If opening up the compound wound does not give a good approach for treatment of the fracture, one of the above incisions may be utilized in addition. Quantities of irrigation with sterile water or sterile salt solution together with wiping out of the wound with gauze strips will usually be sufficient to give a first intention healing. The operator will have to select the incision best suited for the individual fracture. It is important to re- rior incision" along member that there will be better healing with a long the outer side of the vertical incision than with a transverse incision. The bicipital fascia. tissues should not be separated in layers but be kept together on either side of the incision. No method should be adopted that will increase the amount of repair necessary or interfere unduly with the circulation. Plenty of room is, however, necessary. If the swelling is great, it will be difficult to put the fracture up at an acute angle to the desirable position which assures the proper adjustment of the fragments. It is often better for this reason not to operate until the swelling has subsided; in the meantime the elbow is immobilized at right angles. The necessity of immediate operation in fractures about the joints depends, as in other fractures, on the acuteness of the local and gen- eral reaction. When these do not contra indicate immediate opera- tion, certain fractures about the joints may require treatment by the open method. Among these are fractures of the patella, fractures of the olecranon and certain fractures of the surgical neck of the hu- merus and certain fractures of the neck of the femur, all compound fractures, even when the protrusion of the bone has been extremely slight, all fractures that cannot be reduced by manipulation or in which the correction cannot be maintained or where apposition is impossible, INCISION, PUNCTURE AND ARTHROTOMY 227 many fractures combined with dislocation, articular fractures with pieces locking or limiting the joint action. Where there is a great deal of trauma and in multiple fractures and in cases where there is a great deal of shock all that can be done is to im- mobilize the parts until a favorable time for operation. In selecting a suitable time for operation the surgeon must remember that when it is found necessary to operate on a fracture if there is no immediate contra indication, the sooner it is done the better. Where there is tremendous swelling one should always wait. All cases should be operated on that show no union after three months of good treatment. Fig. 375. — Portable traction -pa apparatus applied for fractures -*-^ of the upper extremity. A, Can- vas belt. B, Rod which can be taken apart. C, Two double block pulleys. E, Broad web- bing, doubled and passed around the flexed forearm over a pad (H). J, Traction rod hooked to canvas belt. 262. A Traction Apparatus for Fractures at the Elbow (see figures 375 to 379). Note. — (This apparatus may be used for fractures of the shoulder and fractures of the shaft of the humerus.) In fractures and dislocations of the elbow and the lower end of the humerus, when the displacement is very marked, replacement is diffi- cult without a good deal of injury to the tissues. The following apparatus has been found of service in that it minimizes the trauma of reduction. It makes the alignment of a fracture a matter of regulated precision. The apparatus may be used in open operations and in reducing a fracture or dislocation without incision ; it may be used in fractures of the elbow, humerus and shoulder whenever traction is 228 TECHNIQUE OF OPERATIONS an advantage with or without incision to adjust the fractures to wire, bone plate, or bone graft. The apparatus consists of a canvas belt (see figure A), two double two inch block pulleys (see figure C), and a rod five feet long and three-fourths of an inch in diameter (see figure B), bent at both ends with a hook at each tip. This rod is made in three sections so that it may be easily carried. For use without incision (See figure 375.) A canvas belt is placed around the patient's thorax high up under the axilla. This serves to hold one end of the rod making traction on the arm as follows: — the patient is anaesthetized and lies on the operating table or bed, the traction rod is placed over the front of the chest (see fig- ure B). One end is hooked to the canvas belt at the side opposite the fracture (see figure J). The other end extends nearly four feet from the side of the operating table. A heavy pad (see figure H) consisting of one or two pillow cases folded, is placed over the upper end of the forearm. Around this is placed a webbing strap, doubled (see fig- ure E) . Pulleys are attached from the free end of the traction rod to the webbing around the upper end of the flexed forearm. Traction is then ap- plied with the elbow flexed at right angles. When the overlapping is corrected, traction is maintained while the surgeon moves the frag- ments forward or back or laterally, as the case requires. The traction can be increased or di- minished easily and gradually without jarring the parts. The perfect control is effected by two two-inch double block pulleys (see figure C). Single block pulleys are not satisfactory. The surgeon manipulates the bones while he directs the assistant managing the traction. A pull of one inch on the rope will move the fragments one- fourth of an inch, transverse supracondylar When the fracture or dislocation is adjusted, the fractures. 2a, 2b, oblique webbing on the upper forearm- is moved to the f £T*c£?of S ttene?£' wrist while the elbow is S reased or Powdered if necessary. The webbing is then replaced over its pad and the final adjustment made by applying traction again. The elbow is then flexed to an acute angle or put in a position selected by the surgeon and held there by him while the retentive dressing is applied. When traction is released the surgeon maintains his hold on the arm, the webbing on the forearm of the patient is removed by sliding it up over the wrist and hand to the forearm of the surgeon or it may be unbuckled and INCISION, PUNCTURE AND ARTHROTOMY 229 removed if no longer needed. This apparatus, in connection with a trac- tion machine for operations on the leg, was devised about twelve years ago by the writer. It should be noted that while making traction the forearm strap must not slide off the pad nor the elbow allowed to become acutely flexed. Use of the apparatus for open operations On fractures or dislocation of the elbow (See figures 377, 378.) Note. — (This apparatus can be used in fractures of the shoulder and shaft.) This apparatus is used as described above when an open operation is necessary. In order not to interfere with the asepsis of the operation, the traction rod is placed across the operating table covered with a pil- low and the patient placed over the pillow. This places the rod behind Fig. 377. — Represents the apparatus ready to be covered with sterile sheets for open operations, the arm, arm pad and webbing (A) being sterilized. the patient instead of in front, its end protruding at the side of the oper- ating table nearly four feet. One end of the traction belt is hooked to the canvas belt as described above. The arm and hand are cleaned up, made sterile, and protected as usual with sterile sheets. The folded pillow case or small sheet which is to be used as a pad on the forearm is sterilized beforehand. The webbing for traction on the forearm is also sterilized. This webbing should extend at least a foot from the elbow after being doubled and looped over the padded forearm. The loop of webbing is next attached to the pulley and covered by a sterile sheet pinned to it and clamped so that the webbing touching the pulley and the pulley cannot be exposed during the application and removal of traction while operating. This sterile sheet protection allows the operator to remove completely and re-apply the loop of webbing from the forearm without disturbing the asepsis. The traction rod and pa- tient are protected by sterile sheets (see figure 378). Traction may be applied and released during the operation without exposure of any non- sterile material. 230 TECHNIQUE OF OPERATIONS Where the trauma, due to the accident, has been great, it is better in the case of certain fractures to wait from five to seven days to allow the swelling to subside before replacing the fracture. The fracture is immobilized during the interval. It is of advantage in these cases, where the displacement is great, in replacing the fracture, to cause as little trauma and consequent after swelling as possible, following the reduc- tion. This apparatus is especially valuable for this purpose. When the fragments are finally adjusted, this method is sufficiently free from trauma to cause little and in some cases practically no additional swell- ing following its use. Most fractures of the elbow, excepting fractures of the olecranon, are best held with the elbow at an acute angle. This position is not always a desirable one at the time of injury on account of the swelling. Over- lapping bones, with lateral and antero-posterior displacement at the Fig. 378. — Represents the apparatus covered with sterile sheets, represented by cross lines. Traction at (K) is made by a non-sterile assistant. The sterilized webbing (A) can be removed from the arm and replaced. elbow, are difficult to replace without causing a good deal of swelling which, if it occurs, may make it necessary to abandon the acute flexion position so desirable in many elbow fractures. By means of this apparatus, used when the swelling has largely sub- sided, there need be very little additional swelling following reduction, making the use of the acutely flexed position comparatively free from danger and free from acute pain. The adjustment is under perfect control making very perfect reduction possible. Methods of treating the individual fracture cannot be considered in a limited space like this. The writer has described the routes of ap- proach to the different joints and the technique of these. This will en- able the surgeon from his knowledge of fractures to select the route best adapted for the individual treatment required and when necessary two or more incisions may be used. A knowledge of the technique will en- able the surgeon to work rapidly in reaching the fracture on which he expects to spend time. INCISION, PUNCTURE AND ARTHROTOMY 231 263. A Method of Treating Overlapping Fractures.— Where the bones overlap, an excellent method of treatment is one suggested to the writer many years ago by Dr. Edward Martin of Philadelphia. In the operation when the surgeon has reached the fracture the bone is freed. A tough tape or webbing is used ten or twelve feet long, sterilized. The two ends of the tape are tied together, a loop of the tape is placed over the distal end of the bone. The other end of the tape is thrown over the foot of the operating table, a thirty-five pound weight is attached to this by an assistant. In about five minutes the bones will be found to be separated at least one inch. The weight is then held up by a non-sterile assistant, the tape taken off of the end of the bone and clamped to the sheet on the operating table, so that it will not slip away while the surgeon works on the fracture. When the muscles are in fairly good tone or the overlapping of bone has been great, it will be found that the bones will overlap again in four or five minutes. A reapplication of the tape will separate the bones again for the same length of time. The end of the lower bone should not be cut or freshened until all other procedures are done which require separa- tion of the bone. When these have all been done the end of the bone over which the tape has been placed is freshened. After this the tape should not be placed on the end of the bone unless it is very nec- essary, but the two ends allowed to come together and held by a clamp until the operation is complete. Very bad overlapping fractures have been treated in this way in fresh cases without the necessity of shortening the bone. In old fractures no more bone need be removed than is required by the conical condition of the ends of the bone. 264. Fractures of Long Standing Still Unu- nited or United with Deformity, Preventing Function. — In fractures of long standing where there is a mild infection conservative treatment should be tried first. When this has been tried free drainage should be established and at the same time the ends of the bone freshened up slightly. Unless the infection is marked, in many of these cases when the suppuration dis- appears, union has also taken place. In any case where there has been infection, no plastic operation should be used until the infection has been entirely absent for at least nine months, a year is safer. Where the infec- tion is very mild and of long standing, during the process of treatment the patient may be allowed to walk on the other leg if the local reaction is not too great. Sometimes he may walk a little on the affected leg. Fig. 379. — These fractures may be treated by the traction appara- tus (see figure 377) , with or without open incision. 232 TECHNIQUE OF OPERATIONS It is of advantage in certain cases to use a Thomas splint to take some of the weight off of the affected leg, the patient being allowed to bear weight on the ball of the foot, the splint taking all the weight off of the heel. Where the x-ray shows conical ends of the bones it is practically useless to expect union, without surgical interference. If there is much swelling in fractures about the elbow, the arm may need to be held at right angles until it has subsided, but as a rule the acute flexion assures correction of the displaced fragments. When they are not readily re- placed, an open incision is made to the bone. The surgeon chooses the incision best adapted to the fracture and goes down through the peri- osteum exposing the bone subperiosteally and adjusting the fragments when the bone is well exposed. 265. Irreducible Dislocation and in Multiple Fractures of the Elbow. — After severe injuries with multiple fractures at the elbow and in ir- reducible dislocations of the elbow, it is often necessary to do an excision or an arthroplasty in those cases that do not yield to the usual methods of conservative treatment. See sections 289 and 292. 266. Overlapping Fractures of Both Bones of the Forearm. — When there is a fracture of both bones of the forearm, it is often possible to ob- tain good apposition without an incision. However, the overlapping fracture is a very difficult one to reduce and to hold after reduction. When treated by the open method, it requires the greatest care and pre- cision. One bone is apt to displace while the other is being adjusted. To avoid this, the method of reduction is described with some detail. When a satisfactory reduction is not obtained shortly after the acci- dent, an incision is almost always necessary. If the fracture is fairly re- cent, that is to say, within three weeks, good union may be expected after reduction. An incision is made for each bone separately, the skin and fat separated in one layer. It is made at the side of the arm in order not to be pressed on by the splints. The overlapping bones should be treated as described elsewhere, for overlapping fractures. The tape placed on the ends of the bone will readily separate them with a min- imum amount of trauma. Each bone should be placed in position. Following this, sutures are placed through the skin and fat without closing the wound. These sutures are not tied. The long suture ends are clamped and held aside so that the fractures may be readily in- spected. One assistant holds the wrist, and another the elbow, while the surgeon takes a final view of one fracture, and then the other. If nec- essary, the surgeon should re-adjust the fracture before closing the in- cisions, the arm is held steadily by the two assistants, while the sutures are being tied and other superficial sutures are placed without moving the arm. They do not relax their hold until the splints and bandages are applied. Sterile sheet wadding is placed evenly around the arm. The anterior and posterior splints are applied without disturbing the fracture. An internal angular splint is applied or else a plaster of Paris INCISION, PUNCTURE AND ARTHROTOMY 233 bandage to immobilize the elbow. The plaster should be put around the two forearm splints but later half of it cut away below the splints, This allows the elbow and the splints to be inspected. After in- spection, the elbow is flexed again, and the two splints slide into place in the plaster and are bandaged there. In judging the ten- sion of the splints the surgeon presses the splints together at the points where the adhesive is placed. If the adhesive will wrinkle slightly it is not too tight. The splints should fit the arm per- fectly at the side and have ten to twelve thicknesses of sheet wadding. No foreign substance as a rule need be used to hold the bones, unless the fracture is of long standing, in which case it is better to use a bone graft than bone plates for one bone at least. The bones are chiselled apart and the ends fastened. Where the tape method of treating over- lapping fractures is used it is not necessary to shorten the bone unless the fracture is old and the x-ray shows that the ends are conical. (See sections 262, 263.) Following the operation, the fracture should be viewed at the end of five days and then every second or third day by removing the posterior splint ; any tendency to bowing should be ad- justed by small pads. Otherwise the fracture is treated like a simple fracture of both bones. 267. Fractures of the Olecranon. — When a fracture of the olecranon is treated by a splint holding the arm straight, it may heal without surgical interference. It should be operated on early if the fragments cannot be easily replaced or if they have been separated a week or more. If left any length of time the fragments are apt to heal and the ends will not fit as well. A "U" shaped incision or a long posterior incision is used to the outer side of the fracture through the skin and fat. These are retracted and the incision carried down to the bone in the median line. Any clot is wiped out. The fractured ends are brought together and fitted, then the bone is drilled. The drill is inserted through one fragment; as the tip protrudes the fragments are put together. The drill point is made to mark the point of entry in the second fragment. The drill is then withdrawn from the first fragment and is used at the marked point to drill the second fragment. Kangaroo, phospho bronze or silver wire may be used to fasten the fragments together perferably at first. The arm is put up straight and flexed slightly at the end of ten days, the flexion is increased gradually, until it reaches a right angle in three weeks. At the end of six weeks if it will not flex forty-five degrees beyond the right angle, it should be manipulated gently under an anaes- thetic and placed in an acute angle and held by adhesive or a figure of eight bandage for a few days. As long as the thumb can reach the shoulder, the arm may be allowed more extension. Should it become difficult to reach the shoulder, with the thumb, the adhesive is tempo- rarily shortened preventing extension beyond a point from which this flexion is easy. 234 TECHNIQUE OF OPERATIONS 268. Tapping the Elbow Joint. — The most scrupulous aseptic pre- cautions are necessary both as to the preparation and the protection of the field of the operation. The elbow is flexed at right angles, the trocar enters the joint just anterior to the external condyle above the head of the radius. The proc- ess is rendered easier when there is much swelling. An assistant or the operator presses on the joint anteriorly to make the joint as full as pos- sible at the point of tapping. The elbow being fully flexed, the joint may be tapped above the olecranon. Local anaesthesia may be sufficient but the use of gas or primary ansesthesis is preferable if any injections are to be made. When there is much effusion it is not difficult to reach the joint. The skin is drawn to the side so that the hole in the skin and muscle will be out of line when the needle is removed. If fluid is to be drawn, and other solutions are to replace it, the amounts should be carefully measured. Two good graduated metal syringes are very useful. All of their parts should be tested beforehand. The trocar is made to enter the joint and then is connected with the syringe. As little air as possible should enter the joint. The trocar should be of large diameter as the fluid may be thick or flaky. When the patient is not anaesthetized for the opera- tion it is often well to have a short flexible tube connect the trocar with the syringe. This should be fastened at both ends by silk ties so that it will not leak easily when pressure or suction is used. If the joint is to be washed out a definite amount of fluid is injected and the return measured in a sterilized measuring glass. Dr. Murphy uses a formalin glycerine solution as follows: — Liquor formaldehyde 2% in glycerine, about ten drops of the formaldehyde to each ounce of glycerine. This acts very well in infectious synovitis, but it should not be used in arthritis deformans nor in chronic arthritis. The tapping may be done with ethyl chlorid or novocaine adreneline solution 1%. The solution should be prepared twenty-four hours before it is used (Murphy). CHAPTER V OPERATION IN CASES OF ANKYLOSIS OF THE ELBOW 269. Excision or Ankylosis for the Elbow. — Ankylosis of the elbow may be congenital or as a result of trauma or suppurative arthritis. These may be of bone origin, articular, or periarticular, causing thick- ening or scar formation. Ankylosis may be caused by injuries and frac- tures, irreducible fractures or dislocations of the humero-radial or of the humero-ulnar joint. Excision or arthroplasty is indicated for ankylosis from whatever cause which does not yield to conservative measures, provided no disease has existed for over a year. When tuberculosis has existed, an arthro- plasty is not as good an operation as an excision; neither should be done unless some muscular power is present. In some cases when there is power this may develop and an operation done when the muscle seems strong enough for future function. For ankylosis of the radial joint, an excision of the head of the radius is possible through a very small incision. The bone is removed by a small osteotome and a fat and fascia flap or a muscular flap turned in between the bones. See section 276. 270. Synostosis at the Elbow. — A synostosis of the bones of the forearm, either congenital or acquired, is often difficult to treat. The operator should make long incisions that will gape easily. The dissec- tion should be made to the bone carefully without separating the layers on either side of the incision. In this way a minimum amount of injury is possible to the tendons and other important structures and the condi- tion will be readily exposed and dealt with without injury to the soft tissues. 271. Arthroplasty for Ankylosis at the Elbow. — Ankylosis may be bony, cartilaginous or fibrinous, it may be periarticular, ligamentous and capsular, or extra articular, that is, skin scars, tendons, fascia, nerves and arteries. The form of ankylosis that exists will determine the treatment. A partial ankylosis at certain points had better not be treated by an ar- throplasty. Age must be considered, also the general condition of the patient. When the ankylosis is bony, cartilaginous or fibrinous, arthroplasty is indicated. When the condition is periarticular or extra articular, it may be treated by capsulotomy, tendon elongation, excision of exostosies, etc. Dr. Murphy lays stress on the following points: — The principles of asepsis to the finest detail are absolutely essential. One not familiar 235 236 TECHNIQUE OF OPERATIONS with the best surgical technique should avoid arthroplasty operations. The exposure of the joint must be generous and complete. The con- tracted capsular ligaments and soft parts must be freed and if necessary lengthened. The normal contour of the joint should be restored as near as possible. The operator should obtain a hyper-mobilization of the joint. The joint should be re-shaped to give stability. The inter- position of material to prevent reunion of the bone is necessary. The principle is to separate the bones and to interpose between them material to prevent ankylosis. The best material for this purpose is the human pedicle composed of fat, muscle, fascia or a combination of these. When this is not possible, a transplantation is made of fat and fascia from the trochanter bursa region or from the fascia lata. Material such as ivory, celluloid, silver are not good. Materials that will not absorb or that absorb too slowly are not desirable. During the operation the soft parts should be freely liberated. Attach the interposing flap to one bone only and cover it completely. Early motion, that is, at the end of five to seven days is necessary with or without gas or gas and oxygen. Dr. Murphy records failures in arthroplasty as due to first, insufficient and defective exsection of the capsule and ligaments, second, insufficient interposition of fat and fascia between the separated bony surfaces, third, infection, fourth, the sensitiveness to pain or motion after opera- tion. Cases of primary tuberculois and cases of recent infection that have subsided are not suitable cases for arthroplasty. In operation, in addi- tion to the usual protection of the field of operation, after the skin and fat have been incised, towels should be clamped to the edges of the skin as an extra protection. 272. Arthroplasty for Ankylosis at the Elbow. — The patient lies on his back, the operator stands on the side of the arm to be operated on. The shoulder is adducted and flexed and inwardly rotated. An incision is made six inches long with its middle at the olecranon. Two lateral are preferable, one may be sufficient. In any extensive injury which has caused the ankylosis, the operator may either stick very closely to the bone and avoid seeing the ulnar nerve or he may find the ulnar nerve and free it. Whenever the scar tissue does not extend to the bone, and is not great, it is better to stick close to the bone and not see the nerve. After freeing the humerus and ulna as described in these pages for an Excision (see Operation for Excision), the bones are separated as there described, the olecranon will have to be sacrificed as it will interfere with the plastic operation. After shaping the hu- merus and ulna so that they conform to the normal joint outlines, a flap is taken from the uponurosis of the supinator longus and interposed be- tween the bones or the operator may prefer to use a portion of the fat and fascia on the inner side of the arm. In either case the base of the flap is directed upward. The flap should reach completely across the' OPERATION IN ANKYLOSIS OF THE ELBOW 237 joint and be wide enough to cover it. If there is an ankylosis as is often the case, between the radius and the lesser sigmoid cavity, a portion of the bone must be removed here and muscle interposed. When the ulnar nerve has been found to be fastened down firmly with scar tissue to the bone and when any extensive dissection has been necessary to free it, it should be replaced in its groove at the end of the operation well sur- rounded with fat. The arm should be held in a right angle position for about a week and motion begun after that a little twice a day. In ten days apparatus is removed and a sling worn. Where the operation has been carefully done, it is usually necessary to gain flexion rather than extension. In the after treatment the operator should work to gain flexion first. When the extended and abducted thumb can touch the humerus, this motion should be preserved while motion in extension is being encour- aged. The further treatment depends on exercises, and physical therapy such as baking and massage. 273. Overhead Sling for the Arm Following Operation. — The arm may be held vertically or horizontally by an overhead sling. A long stick of wood like a broom handle is attached in a vertical position to the post at the foot of the bed. The upper end should be about five or six feet from the floor, another is placed at the middle of the head of the bed in the same way. A light window cord is drawn tightly between the ends of the two sticks, the arm is held off of the bed by a bandage attached to the rope. The suspended arm should be placed in a com- fortable position. CHAPTER VI OPERATION FOR SUPPURATIVE CONDITIONS 274. Suppurative Conditions, about the Elbow. — A posterior inci- sion either side of the olecranon, avoiding the ulnar nerve, combined with a lateral, just anterior to the external condyle, to drain the radial joint will be sufficient for the majority of extensive suppurative conditions. At the elbow it is important in extensive joint suppuration to open anteriorly as well as posteriorly and not forget the radial joint. See Carrell-Dakin Technique, section 323. The principles otherwise are the same as those laid down for other joints. 275. Osteomyelitis. — In osteomyelitis an operation should be done as early as possible after making the diagnosis. In sub-acute cases, incision and drainage are all that is necessary. Whenever incising for abscess all the pockets should be opened and if the abscess is large, counter incisions are made at dependent portions. The pus pocket should be opened freely, wiped out with gauze, irrigated and wiped out again with gauze. Curetting should be avoided excepting for the re- moval of sinuses in the skin and in cases of sinuses it is often better to excise them. Perforated rubber tubing should be placed to drain the deepest portion of each pocket. The skin, fat and superficial muscle layers should be made to gap by means of gauze drains. At the end of ten days the gauze is removed and the tubes shortened. The tubes are gradually drawn out a little each day or two until not used. This method makes the repeated reapplication of drains and wicks unneces- sary as the wound will gap of itself and close from the bottom if the surgeon has been careful to make large incisions. Where the periosteum is found destroyed or there is pus under the peri- osteal layer, the bone should be opened by means of a large drill or a small gouge. Where this is necessary, the incisions should be large and a counter incision should be made on the other side of the bone with a hole made in the bone a little above or below the hole on the opposite side (figure 66) . These holes in the bone should open up the medullary cavity. They should alternate on one side and the other as far up and down as the disease is suspected. When the abscess is very great and the bone involvement is large a number of good sized holes should be made with a Burr drill or a curved gouge on both sides of the bone as shown in figure 67. The wound should be gaped widely; — the skin, fat and superficial muscle held wide open by large gauze drains. The tubes should reach from the surface to the deepest portions of the ab- scess cavity. Splints should always be applied to immobilize the limb. 238 OPERATION FOR SUPPURATIVE CONDITIONS 230 They should be placed so that they will not interfere with the dressing. In some instances it is better to apply a plaster with large windows and ropes to give stability as shown in figures 450 to 460. The dress- ings should be done every day or twice a day, depending on the foul condition of the discharge. If the odor is excessive chlorinated soda dressing should be used diluted, 1 /z, ] /-3 or 1 / i the U. S. P. strength. The gauze drains should remain for at least ten days without being disturbed. When removed granulations will be formed under them in such a way as to keep the wound open without applying drains. Irrigation may be used at the time of the operation and the wound thoroughly wiped out with gauze afterwards. No irrigation or probing or application of wicks will be necessary if the first drains are left in long enough. After the first ten days the tubes are shortened gradually until they are not needed. In severe cases where the patient is unconscious or delirious the bone should always be opened, three or four holes on either side made with a good sized Burr drill or gouge. In severe cases the incision should be made on both sides of the leg always. No tight packing should be used as this interferes with good drainage. Where sequestra have formed they should be removed. An x-ray should be taken whenever possible to determine the position of the disease (unless the case is ur- gent and an immediate x-ray is not obtainable). In cases of long standing that are sub-acute at the time of first exam- ination, where the bone is riddled with holes over an extremely long area, it is impossible often to remove the dead bone satisfactorily with- out removing all the bone. In these cases free incision down to the bone with frequent openings into the bone as described above, will allow the infection to run its course and the sequestra to gradually separate. We have had some cases in which the lower third of both femora were riddled with holes and full of sequestra, the patient being in no condition for extensive operation, and yet not very ill. In these cases, however, if the surgeon had seen the patient in time an early operation would have prevented this extreme condition. Sometimes it is necessary to close a large open bone cavity which will not heal over. Where the process is distinctly infected no plastic operation should be done without first doing an operation to eliminate the infection. After that, part of the muscle may often be trans- ferred over such a cavity to close it. In transferring a muscle over such a cavity it should be freely transplanted and held there without ten- sion. The skin should be brought together over the muscle and the wound drained. Where sequestra are present it is always desirable to remove them as soon as they have separated and the involucrum is strong enough to act as a support. Sequestra may be superficial or in the medullary cavitj 7 or both. Where there is a persistent sinus and a sequestrum is present, pus will continue to form until the sequestrum is removed. Cases 240 TECHNIQUE OF OPERATIONS discharging several years where a sequestrum is present may close in a few weeks after removal of the sequestrum. To close a bone cavity its edges may be chiselled clean, then the bone incised a short distance from one edge and parallel to it, the incision is carried down to the medulla, the incision in the bone is widened by prying it open and forcing the bone together and closing the old cavity. This is sometimes a satisfactory method of closing an old open bone cavity which has sclerosed edges. See Carrell-Dakin technique, sec- tion 323. 276. Excision of the Elbow for Suppuration. (See Fig. 371.) — An incision is made starting two or three inches above the olecranon and to its outer side extending vertically downward two or three inches below it. The skin and fat are separated and the triceps muscle fibers separated down to the bone. The periosteum is incised and peeled off the outer condyle of the humerus above and downward to the ole- cranon and off of this and the ulna extending outward so that the whole of the external condyle is exposed subperiosteally. After this, the in- ternal condyle is cleared in the same way, a long handled osteotome being used for the purpose. The ulnar nerve must be avoided; it is per- fectly safe if the operator will stick below the periosteum, it will not come into view. The olecranon is chiselled off the joint opened. The humerus is cleared next anteriorly and laterally. In case of ankylosis it is sometimes easier to clear the ulna and radius. When the joint is separated it is easy to keep up the subperiosteal dissection by bringing the humerus out of the wound and then the ulna and radius. The diseased bone is removed with a saw just at the upper part of the condyles removing one-half inch from the condyles (see figure 380) and just through the base of the head of the radius removing the head of the radius and the ulna at the same level (see figure 380) ; this should be removed with a saw. Fig. 380. — Excision of Rongeurs are used to remove the sharp edge of the elbow, line marking the the bone, any further disease is cut out with a bone to be removed. chisel? cutt i ng t h e healthy bone around it. Enough bone should be removed with the saw to allow very free mobility of the joint. The disease in the soft tissues is dissected out completely. The triceps and all the tissues have remained unexposed between the periosteum and the skin. They are now brought together and carefully sutured. The periosteum and the muscles, the fat and the skin layer by layer, covering the end of the radius with muscle to prevent adhesions. A puncture is made one inch long over the other side of the joint where the head of the radius was situated. This and a similar internal poste- OPERATION FOR SUPPURATIVE CONDITIONS 241 rior drainage point is usually sufficient in suppurative cases. The triceps will repair and be ready for future usefulness. The elbow is immobilized at right angles in plaster and the elbow may be suspended by a bandage to an overhead trolley, held there after operation. Later the elbow is acutely flexed. Pronation and supination and flexion are begun a little on the tenth day. The arm should be allowed to flex but no extension beyond a right angle allowed until the muscles are strong enough to flex completely and extend easily to a right angled position. 277. Methods and Principles of Drainage in Acute Non-tubercular Suppurative Joint Disease. Elbow. — A small suppurative focus with- out virulence or active constitutional disturbance should be drained by a suitable incision wiped out with gauze, a tube placed to its deepest part and the soft tissues gaped with gauze. See section 323. When there is a great deal of constitutional disturbance drainage and counter drainage should always be the rule; if the bone is involved this should be opened and counter opened (figure 66) . The pus cavities in the soft tissues should be wiped out. No extensive bone operation should be done otherwise. The bone should be drained with tubes to the remote portions and the muscle, fat and skin gaped by gauze. These operations are done quickly and should not be prolonged, but efficient drainage and counter drainage should be established unhesi- tatingly. It is rarely necessary to do more at this time. If there is a marked sequestra formation this should be removed, but this had bet- ter not be done at the time of instituting drainage when the patient is nearly exhausted from an acute process. Any future operation made necessary should give good drainage and the removal of the sequestra if present and separated. The joint should be immobilized. Any extensive non-tubercular suppurative bone disease about the elbow should be drained by a posterior and an antero-lateral external incision or by both of these and an internal lateral. If the patient is very ill and the abscess in the bone not easily located, large incisions are made to the bone and the bone drilled or not, as the case demands. The operation should be done very rapidly and good drainage estab- lished. For chronic suppuration or tuberculosis an excision is often in- dicated when conservative treatment has been unsuccessful. PART VI— WRIST AND BAND CHAPTER I DEFORMITIES OF THE WRIST AND HAND 278. Operation for Madelung's Deformity. — An incision is made down to the bones of the carpus and projecting bone, the bones are exposed subperiosteal^ and enough of the carpus removed to allow the prominent bone to slip into place. The incisions are closed, the tendons retracted without disturbing them in the tissues. A plaster and then a leather should be worn for about three months. This apparatus should allow the use of the fingers and hand but im- mobilize the wrist. The carpal joints beyond the wrist will increase in motion and make up for some of the restriction of motion which follows the operation. 279. Club Hand Operation. — When the deformity is due to absence of one of the bones of the forearm, a longitudinal incision is made over the remaining bone; the latter is split to receive the carpus. The carpus is prepared by slanting its lateral edges without narrowing it any more than is absolutely necessary. The bone and carpus are sutured and the tissue closed, the arm and hand being held in a plaster allowing the use of the fingers and hand. As these grow strong the support is grad- ually omitted after the third or fourth month. The carpus usually becomes very flexible allowing about one-third of the normal wrist flexion and extension. When both bones are present bony union by graft or splitting the radius is usually necessary to prevent recurrence of the deformity of the wrist. 280. Contracted Wrist and Finger Operation. — When the wrist and fingers are contracted if there is no disease present, the wrist may be manipulated so that it will extend, flex, adduct and abduct in a pronated, in a supinated position, and halfway between the two. It is sometimes necessary to lengthen the tendons of the contracted muscles as described in these pages. Where there is much scar tissue in the palm of the hand or wrist it may be necessary to excise this and to transplant a flap from the abdomen. To do this a sterile cloth is cut the size of the flap de- sired. The hand is placed over the abdomen in a comfortable position without strain on the shoulder, elbow or wrist. The site of the skin is selected, the cloth pattern is laid over it and the outline marked one- half inch larger than is necessary all around. The flap is dissected up, leaving two broad attachments. The hand is placed in position and the flap adjusted but not finally sutured. The hand is withdrawn. 243 244 TECHNIQUE OF OPERATIONS If necessary one of the broad attachments may be cut away or they may both be left. The skin edges from which the flap was cut are now lifted with the fat and freed well from four to six inches separating the fat from the underlying fascia. This will allow the skin to be brought to- gether without tension under the lifted flap. Mattress sutures over gauze or over rubber tubing are used to hold the edges without tension; the skin and fat are sutured. The hand is now placed in posi- tion over this and the flap sutured to it as planned. The upper arm and forearm are separated from the body by sterile towels and padding, a swathe is placed over this leaving the hand and flap exposed, adhesive plaster is placed outside the swathe about three strips three inches broad, this will hold the arm in place. To return to the hand, before the dressing is applied any surfaces of skin that come in contact, should be separated by an intervening layer of cotton cloth, sterilized. This is placed between the palm and the skin of the abdomen. The flap should be sutured carefully allow- ing no granulating areas excepting at the pedicle attachment. If the flap is large its edges may be brought together making a cylinder, where it leaves the abdomen. This may be done before finally placing the hand in position. In eight days the hand with the graft is cut away from the abdomen. The abdominal skin will be healed excepting a small opening which is closed. The skin edges are freshened before suture. When the contracture is of the finger only, this may be congenital or acquired. A rectangular palmar skin flap is usually better than a V- shaped one though sometimes a V-shaped one is preferable. When it is necessary to place a wolf graft from the arm or leg, a square end skin incision is preferable. The skin flap slides down and the tendon stretched or lengthened. After operation for flexion of the finger, the wrist should be held flexed by means of a dorsal wire or aluminium splint on the hand and forearm and the fingers held extended. The splint is used constantly for three weeks and part of each day, after that for at least six months. 281. Manipulation of the Finger and Wrist Joints. — The flexion and extension of the wrist are manipulated in a pronated position and in a supinated position; the adduction and abduction of the wrist in a pro- nated position and so on. In manipulating for flexibility of the fingers, the wrist should be flexed, then extended for each manipulation. The manipulation should be done with the forearm pronated and repeated with it supinated. The normal motion of the joint should be remembered. The stretch- ing of the resisting tissues made gradually with a rhythmic stretching and relaxing, the force being applied gently and increased to a climax and gradually decreased until there is complete relaxation. The joint is stretched and relaxed, the operator applying force in a gradually increasing manner until considerable force is applied and then relaxing DEFORMITIES OF THE WRIST AND HAND 245 until very slight force is used and finally relaxing entirely. In this man- ner a rhythmic extension and flexion are kept up. No rough or forcible extension without a gradually increasing or gradually decreasing force should be employed. By this method a minimum amount of trauma is caused. Forcible pumping motions are to be avoided. A joint that at first will seem almost impossible to move will often yield. Before any extensive muscle or tendon operation, a fairly normal action in all di- rections should be obtained. CHAPTER II MUSCLE AND TENDON OPERATIONS. MUSCLE AND TENDON TRANSPLANTATION F i o. -Silk 282. Silk Elongation for Cut or Short Tendons in the Finger. — When a tendon in the finger is cut or hopelessly involved in scar contractures it is often simpler to elongate with silk as described below rather than to dissect up the tissues and separate out the tendon from a large mass of scar tissue to which . it will readily adhere again. This is especially the don at the finger case when the tendon has been cut and injured in tip - several places. OPERATION A small incision is made three-quarters to one inch long on the palmar surface of the finger (see figure 381), a number fourteen silk is quilted into the fibrous sheath about the tendon. A second incision is made in the front of the wrist above the carpal bones, a long probe or director with a hole in its end is passed from the finger to the wrist subcutaneously. A silk guide is passed through the e} r e in the probe and the silk withdrawn with this guide or directly with the probe. The number four- teen silk now reaches the wrist. The incision in the finger is closed with interrupted chromic catgut number 00 or with horse hair. The flexor tendons in the wrist are exposed and the proper one located by pulling on the others which extend to the fingers. The silk is now quilted into the tendon (see figures 382, 383), which is cut away so that it will be free from its distal attachment, unless one of the free tendons to one of the other fingers is used. In this in- Fig. 382.— Silk quilted into the tendon is drawn to the lower Stance the two fingers must be forearm by means of expected to flex simultaneously. a tendon carrier. The deep fascia is brought together with interrupted chromic catgut number 00, the subcutaneous fat with interrupted chromic catgut number 00, the skin with continuous chromic catgut number 00. 246 Fig. 383. — Silk quilted into the ten- don at the wrist and then tied to the silk from the finger. MUSCLE AND TENDON OPERATIONS 247 The finger and wrist are immobilized for two weeks, after that slight motion is allowed under supervision of the surgeon for three weeks more. After that the splints are removed and the muscles trained. 283. Operation to give Power to Supinate the Forearm in Cases of Paralysis of the Supinators. Tubby Operation. Transplanta- tion of the Pronator-radii-teres to give Power of Supina- tion. — The transplantation of the pronator-radii-teres is done for a persistent or marked tendency to continuous pronation often present in spastic cerebral par- alysis and sometimes in infantile paralysis and obstetrical cases. Dr. Tubby advised the trans- plantation of the pronator-radii- teres in these cases converting the muscle into a supinator. An esmark and tourniquet, if used, should be applied carefully by an experienced person. The arm is bandaged with a rubber bandage from the finger tips to the middle of the upper arm. Here a towel is applied under the forearm is pronated tourniquet which should be ap- the^upinXr? 8 ° f plied with great care and not too tightly. As soon as the important part of the operation is over, the tourniquet should be removed as tourniquets on the arm are undesirable for any length of time. Fig. 384. — Inci- sion for transplanta- tion of the pronator- radii-teres when the Fig. 385.— Tis- sues and superficial muscles retracted to show the oblique fi- bers of the pronator- radii-teres. OPERATION ON THE RIGHT ARM The operator stands on the outer side of the forearm which is held supinated. An incision is made (figure 384) on the outer third of the fore- arm down to the muscle layer, the main portion of the muscular fibers of the pronator-radii-teres extend across the arm above the junction of the upper and middle thirds (see figure 385). The tendinous portion is. largely in the middle portion of the forearm. To find the muscle easily, the incision should be made in the outer third of the forearm with its middle corresponding to the junction of the upper and middle thirds. When carried down to the muscle layer, the incision should expose the supinator longus (figures 386 to 388); this is retracted outward, ex- posing the pronator-radii-teres, extending obliquely from the internal condyle to the middle of the radius. It is the only oblique muscle here. If the operator experiences any difficulty in finding the pronator-radii- 248 TECHNIQUE OF OPERATIONS teres, he may expose the anterior surface of the radius. If he traces this upward, he will come across the oblique attachment of the pronator. In dissecting this attachment from the bone, the operator should work from above downward. The fibrinous attachment is intimately con- nected with the periosteum which is very much coarsened; in dissecting the insertion subperiosteal^' from above downward it is possible Fig. 386. — Retrac- tors expose the oblique muscle fibres of the pronator-radii- teres. Fig. 387. — Fur- ther retraction ex- posing the attach- ment of the prona- tor-radii-teres along the radius. Fig. 388. — Tendon carrier or clamp passing forward to grasp the tendon and draw it out of the posterior incision. to obtain a very much longer tendon which will reach easily around the radius (see figures 389 to 394). The flexor longus pollicis and sublimis digitorum lie under the pronator-radii-teres. The pronator ten- don is dissected up, a blunt dissector is used to separate the inter- osseous membrane between the bones close to the radius. As the blunt dissector comes to the surface posteriorly, a small incision is made over it allowing it to protrude through the skin. A long clamp or tendon carrier is entered here and protrudes through the anterior inci- sion passing to the inner side of the radius. It grasps the tendon of the pronator and draws it out posteriorly, a towel is placed above and another below the muscle while silk is quilted up one side and down the other of the tendon, as described under transplantation of the peroneii. A long clamp is now inserted into the anterior incision extending back- ward along the outer side of the radius. It protrudes through the pos- terior incision, grasps the silk and draws it forward followed by the MUSCLE AND TENDON OPERATIONS 249 tendon on the outer side of the radius. The new insertion of the pronator- radii-teres is selected slightly above its previous insertion. The bone is drilled here (figure 390), the forearm being placed in a position one-half way between pronation and supination. The bone is drilled antero- posteriorly (see figures 391, 392). Two ends of silkworm gut are pulled through this drill hole to be used as a leader in introducing the silk from the tendon. The loop of silkworm gut should protrude anteriorly (see figure 394). The silk from the tendon is drawn through (see figure 394), and protrudes at the posterior incision. A tendon carrier or long carrier is passed into the anterior incision to the inner side of the radii and pro- trudes from the posterior incision. The silk is grasped by it and pulled forward. One end is passed under the silk where it enters the drill hole. The arm should be F i g. 3 8 9.— The pronator-radii -teres protrudes backward and is then drawn forward to the outer side of the radius. Fig. 390. — Diagram of the radius and ulna, the former being pieced by a drill. A silk wormgut leader is being passed through the drill eye. Fig. 391. — The silk from the tendon extends to the inner side then posterior and enters the bone posteriorly when the arm is pro- nated. supinated forcibly before tying the silk. The muscle should hold the arm in a supinated position. An assistant maintains this posi- tion while the muscle is drawn tight and the silk tied three times. The knot is pressed flat. The subcutaneous tissues are brought together with interrupted chromic catgut sutures number 00, and the skin with continuous chromic catgut sutures number 00. A plaster of Paris bandage is applied (see figure 395) with the forearm held in a supinated position. The thumb and fingers should be per- fectly free, a small plaster rope being applied over the palm of the hand which is well padded. The plaster should be split on both sides of the arm and windows cut over each incision to allow inspection of the wound without removing the apparatus. If there is much swelling the plaster may be loosened at either side or the front half removed. The patient 250 TECHNIQUE OF OPERATIONS is kept in bed at least five days. Moving about increases the swelling. Where the surgeon is careful and gentle in the manipulation of the mus- cles and subcutaneous tissues, the swelling will be correspondingly less. The wounds should be dressed on the fifth and seventh days with gauze wet with alcohol. After that the wounds are dressed every second or fourth day with a dry dressing. The supinated position of the forearm should be main- tained from four to six months. After that a light apparatus, such as a plaster or leather or wire splint (figure 401), is worn maintaining extreme supination Fig. 892.— As the arm is supinated the silk from the tendon enters the bone from the inner side, be- tween the bones, and is tied as shown in this, and the next figure. Fig. 393.— R, Radius. U, Ulna. When the fore- arm is supinated the silk enters the bone at the inner side of the radius, protrudes outward, ex- tending posteriorly and comes up to the inner side where it is tied. Fig. 394.— Prona- tor-radii-teres held to the bone by silk. for six or eight hours each day. Muscle training and daily stretching should be begun after the sixth week and continued for a year at least. The use of the extremely supinated position daily by means of a splint will vary according to the control of the arm and the tendency to pronate. This should be watched and the splint used accordingly. 284. Muscle Transplantation in the Forearm. — In transplantation for paralysis of the extensors of the wrist and fingers the different methods are given below. The operator will have to select the muscles spared in the individual case. A gray or grayish pink muscle will not be suitable for transplantation. A pinkish red should not be selected if a better one is available. The wrist flexors and extensors may be used for paralysis of the extensors of the fingers or for the paralysis of the flexors of the finger as described below. The strong muscles must often be lengthened or stretched out before it is safe to transplant. This must be determined by the individual case. 285. Operation for Contracted or Short Extensors of the Wrist and Fingers ; Tendon Lengthening. — The patient lies on his back, the arm rests on a table, the operator stands on one side, the assistant on the other. An incision is made three or four inches long over the middle third of MUSCLE AND TENDON OPERATIONS 251 the forearm down to the muscles. The tendons are carefully lifted with a blunt dissector to assure the operator of the exact function of each and to which finger it extends. The lengthening should be done in the d Fig. 396.— The tendon to be length- ened. Fig. 397. — The tendon cut either straight across or zig- zag (see figure 399). Fig. 395. — Plaster of Paris with the elbow straight, the forearm supi- nated and a long piece of wood incor- porated in the plaster at right angles to the arm extending across the patient's lap and preventing pronation of the arm. tendon on the belly of the mus- cle according to one of the methods described under tendon lengthening. (See section 126). Each tendon should be noted previous to operation and the required amount of shortening or lengthening estimated for each tendon. At the time of opera- tion the surgeon pulls on the Fig. 399.— Zig-zag tenotomy. tendon and recognizes it from its FlG - 398. — Tendon ,• ,-, • , r lengthened. action on the wrist or finger. Each one is lengthened as planned before operation (see figures 396 to 399). The deep tissues are brought together with interrupted chromic catgut sutures number 00, the subcutaneous tissues with interrupted chromic catgut sutures number 00, the skin with continuous chromic cat- gut sutures number 00. A small dressing, four or five layers of gauze, 252 TECHNIQUE OF OPERATIONS one inch wide are placed on the wound and extending one-half inch be- 3 T ond the incision at each end. Sterile sheet wadding is applied over this. A wire or aluminum splint (see figures 400 to 402) or plaster of Paris bandage is applied holding the elbow at right angles and the fingers and wrist flexed after an operation on the extensors and hold- ing the wrist arid fingers extended after an operation on the flexors. In cases with deformity that is extreme and of long standing, when the flexors are lengthened the extensors must be shortened and vice versa. Fig. 400. — Plaster ap- plied allowing the use of the fingers, or extended holding wrist flexed or ex- tended with the elbow flexed when pronation and supination must be con- trolled. Fig. 401. — Plaster of Paris bandage holding the wrist and fingers flexed; a similar plaster is used when extension of the wrist and fingers is required. Fig. 402. — Aluminum splint to hold the wrist and fingers flexed. A, Elbow portion which is strapped on with tapes. B, Forearm, wrist and finger por- tion holding the wrist and fin- gers flexed. C, Tape which is wound between the finger por- tion of the splint and over the wrist to hold the splint in place. D, End view of the finger portion of splint, showing the attachment at X of tape C. A splint for extension of the fingers is made in a similar way. The operator must decide on the value of the muscles and act accord- ingly. The post-operative treatment is the same as that laid down under the transplantation of the palmaris longus. 286. Operation for Contracted or Short Extensors of the Wrist and Fingers. Lengthening the Muscles by a Subperiosteal Operation at the Condyle. — Contractures of the fingers and wrist, due to shortening of the long extensors of the wrist and the fingers should be overcome by carefully applied splints. When the deformity is extreme this is not always possible. When stretching and manipulation have been per- formed in a careful and accurate manner over a considerable period of time, additional length for the extensor tendon may be obtained by MUSCLE AND TENDON OPERATIONS 253 loosening the attachment of these muscles at the elbow. This opera- tion is very satisfactory when the tendons are evenly contracted. OPERATION AT THE CONDYLE The patient lies on his back, the arm is laid across the thorax. The operator stands on the same side of the operating table as the arm to be operated on. When the exten- sors are contracted, an incision two and one-half inches long is made over the outer condyle of the arm down to the bone. The muscles are detached subperios- teally from the external condyle by means of a small osteo- tome; the detached muscles are pushed downward until the fin- gers can be completely flexed. Post-operative treatment An apparatus should be worn after the operation continuously for eight weeks and for part of each day after that, depending on the tendency of the muscles tions"tobe removed to recontract. are here shaded. Fig. 403. — Ten- don shortening, por- Fig. 404.— Suture of shortened tendons. Operation on the belly of the muscle for lengthening the long extensors of the wrist and fingers An incision is sometimes made over the contracted muscles and a few fibers cut at different points in the belly of the muscle to allow it to stretch down. The tendons may be cut and lengthened in the belly of the muscle (figures 396 to 398). Lengthening at the condyle or in the tendon over the muscles are the better procedures. Post-operative treatment Extreme overcorrection should be maintained at the time of opera- tion. It is often necessary to manipulate the finger and wrist joint after a deformity of long standing. Each joint should be carefully manipulated. Contracted fibers will yield with very little reaction to gradual force frequently relaxed. The relaxing of force and repeated stretching should be done without roughness until the joint yields. Weak muscles cannot be expected to gain until their strong opponents and the tissues limiting motion are all overstretched. At times in addi- tion to lengthening the extensors it is necessary to shorten the flexors as described elsewhere in these pages. 254 TECHNIQUE OF OPERATIONS 287. Operation for Contracted Flexors of the Wrist and Fingers. Tendon Lengthening. — The incision is made over the flexors and the tendons lengthened as described for lengthening the contracted tendons of the exi elisors (figures 396 to 398). 288. Operation for Contracted Flexors of the Wrist and Fingers, Lengthening the Muscles by a Subperiosteal Operation at the Con- dyle. — This operation is done at the internal condyle in a similar way to that described for contracted extensors of the forearm performed at the external condjde. See section 386. After operation the elbow is held at right angles, the wrist and fingers are put up in a position of extreme extension. Otherwise the post- operative treatment is the same as that for contracted extensors. It is sometimes necessary to shorten the extensors as well as to lengthen the flexors. The operator should see that the finger, wrist and elbow joints will bend normally to allow use after correcting the condition. 289. Operation for Shortening the Long Flexors of the Wrist and Fingers. Muscle and Tendon Shortening. — The patient lies on his back, the arm rests on a table. In operation on the right arm, the opera- tor stands facing the external condyle of the humerus. The assistant stands between the body and the arm. For the left forearm, the posi- tions are reversed. OPEEATION A longitudinal incision three inches long is made over the middle of the forearm at the junction of the middle and lower third. It should extend through the skin and fat which are dissected up in one layer. When the tendons are reached, any one of the methods described under tendon shortening may be used. Each tendon should be noted previous to operation and the required amount of shortening or lengthen- ing estimated for each tendon. At the time of operation, the surgeon pulls on the tendon and recognizes it from its action on the wrist or finger. Each one is shortened as planned before operation. The shortening is done either in the tendon overlying the muscle or below the muscle (figures 403, 404) . When the operation is completed a small piece of gauze four or five layers thick is placed over the wound, extend- ing a half inch beyond at either end and one inch broad. Sterile sheet wadding is placed over this and the arm and hand are held flexed by a wire or aluminum splint holding the wrist flexed, or a plaster of Paris dressing. The front half of the plaster may be removed. A gauze bandage is then applied after removing the front half of the plaster. This opera- tion is recommended when the opposing muscles have stretched out the flexors. To assure a permanent result the strong extensors should be stretched out daily. In extreme cases, the extensors should be length- ened at the time of operation (figures 396 to 398). MUSCLE AND TENDON OPERATIONS 255 After treatment A splint is worn constantly for two months after the operation. After that the splint is removed more and more; finally being used only two hours daily for one or two years, depending on the tendency of the deformity to recur. Exercises and muscle training should be light at first and continued at least as long as the splint is thought necessary. In most cases the arm should be exercised for several years after the splint is discarded. 290. Operation for Shortening the Long Extensor Tendons of the Wrist and Fingers. Muscle and Tendon Shortening. — The patient lies on his back, an assistant holds the flexed elbow on a table, the opera- tor sits facing the posterior surface of the forearm and makes an incision three inches long in the lower half through the skin and fat exposing the tendons. The tendons may be shortened in the muscle or below it (see Tendon Shortening). The detail of the operation of tendon shortening is now similar to that described for shortening the long flexors of the fingers. (Section 289.) Each tendon should be noted previous to operation and the required amount of shortening or lengthening estimated for each tendon. At the time of operation the surgeon pulls on the tendon and recognizes it from its action on the wrist and finger. Each one is shortened as planned before operation. Post-operative treatment After the operation a plaster or wire or an aluminum splint is applied, holding the elbow at right angles and the wrist and fingers fully ex- tended. In extreme cases it may be necessary to lengthen the flexors. The success of the operation depends on the same treatment and after care laid down for the post-operative care in shortening the flexor ten- dons of the forearm. 291. Operation for Paralysis of the Extensor Longus Pollicis or Extensor Longus Digitorum. Transplantation of the Palmaris Longus. —Where the extensors of the fingers are paralyzed the palmaris longus is exposed by an anterior incision, its tendon freed below; the muscle dissected up to the middle of the forearm where a blunt dissector is used to separate the muscles, and the interosseous membrane. As the blunt dissector is made to protrude posteriorly, an incision is made through the skin over it, a tendon carrier or long clamp is passed for- ward from the posterior to the anterior incision and the tendon grasped and drawn out posteriorly. A towel is placed above and another below the tendon, while silk is quilted up one side and down the other. The posterior incision is extended downward and the paralyzed tendons ex- posed, the surgeon pulling on each one to assure himself to which joints they go. The tendon of the palmaris is attached by its silk, quilted into the extensor tendons on the back of the forearm, with or 256 TECHNIQUE OF OPERATIONS without passing it through a slit in the paralyzed extensors; these are all quilted with the silk from the palmaris tendon. (See figures 408, 409). The muscle transplanted should hold the fingers slightly extended. The method of applying the silk is described under transplantation of the peroneii. Section 148. After treatment After operation, a wire or aluminum splint or plaster is worn stretch- ing out the strong muscles and relaxing the transplanted and weak muscles. The splint should immobilize the elbow, wrist and fingers for three weeks. After that finger motions are encouraged each day. The splint is worn for six weeks and omitted a little at a time. After that muscle training and exercise are started before the eighth week. The splint is gradually omitted except for two to four hours a day, depending on the tendency of the strong muscles to recontract. The rules for lengthening tendons and muscles are given elsewhere in these pages, should it be necessary to readjust other tendons in addition to trans- planting. 292. Other Transplantations in the Forearm, for Paralysis of the Extensor Longus Digitorum or the Extensor Longus Pollicis. — At the wrist, the flexor carpi ulnaris and the flexor carpi radialis, the palmaris longus and in some cases the extensor carpi radialis, when spared, may be transplanted to take the place of the extensors of the fingers or thumb in a manner already de- scribed for the transplantation of the palmaris longus. 293. Transplantations in the Forearm for Paralysis of the Flexor Longus Digitorum and Flexor Longus Pollicis. — In paralysis of the flexor longus digitorum and flexor longus pollicis, the extensor carpi ulnaris, or the extensor carpi radialis and the flexor carpi ulnaris one or two may be brought forward and inserted into the flexors of the fingers or thumb as described for the transplantation of the palmaris longus backward. 294. Operation for Paralysis of the Flexor Longus Pollicis when the Flexor Carpi Radialis is Spared. — The flexor carpi radialis may be used (see figures 405 to 407) for paralysis of the flexor longus pollicis and transplanted as described for transplantation of the palmaris longus. Fig. 405. — Incision for paralysis of the flexor longus pollicis when the flexor carpi radialis is spared. A, Median nerve. B, Flexor carpi radialis. C, Flexor longus pollicis. MUSCLE AND TENDON OPERATIONS 257 295. Operation for Paralysis of the Flexors of the Wrist, Trans- plantation of the Extensor Carpi Radialis and the Flexor Carpi Ulnaris. —The extensor carpi ulnaris or extensor carpi radialis may be trans- planted forward as described for the palmaris longus when transplanted backward. 296. Nerve Supply in the Forearm. — As an additional guide in paralytic cases the following summary of the nerve supply may be of Fig. 406.— B, The flexor carpi radialis is split and retracted. C, The flexor longus pollicis is cut away and its distal end quilted with silk. Fig. 407. — The flexor longus pollicis (C) is passed through the flexor carpi radialis. Quilted sutures unite the tendons. The flexor carpi radialis is cut across to allow free action of the thumb. Fig. 408. —Silk tendon elongation to replace a cut or ad- herent tendon. The needle should pierce the tendon at right angles in applying the silk. help. The operator should get a strong voluntary reaction in any muscle he intends to transplant. Without good control the muscle will be of little value. Sometimes it is necessary to train the muscles to the proper strength. At the time of operation the muscle to be trans- planted, to be satisfactory, should be a good red color even when a tourniquet is applied. The pronator and flexor muscles of the forearm receive their nerves mostly from the median, only one, the flexor carpi ulnaris, being wholly and another, the flexor profundus digitorum, in part supplied from the ulnar nerve by branches entering them near the elbow. The pronator radii teres, flexor carpi radialis, palmaris longus, and the condylo-ulnar 258 TECHNIQUE OF OPERATIONS Fig. 409. Silk applied to the ten- anatomy), don. head of the flexor sublimis digitorum receive branches from the median in the neighborhood of the elbow, while the radial head and the index finger belly of the flexor sublimis have separate twigs from the same trunk. The flexor longus pollicis, pronator quadratus and outer half of the flexor profundis digi- torum are supplied by the anterior interosseous branch of the median. The outer two lumbricales are innervated by the median and the inner two by the ulnar (Quain's anatomy). The anconeus, supinator longus and extensor carpi radialis longior receive branches from the musculo- spiral nerve, the remaining muscles of this group are supplied by the posterior interosseous division of that trunk, the offsets for the extensor carpi radialis brevior and supinator brevis arising from the nerve before it pierces the matter muscle, while those, for the extensors of the digits, both superficial and deep as well as the extensor carpi ulnaris are given off after it appears on the back of the forearm (Quain's CHAPTER III INCISION PUNCTURE AND ARTHROTOMY 297. Arthrotomy at the Wrist. — A knowledge of the important routes of approach to the joints will facilitate any joint exploration, the removal of foreign bodies, the repair of traumatic conditions, the ad- justment of difficult fractures, the reduction of old and difficult disloca- tions, the mobilization of joints where motion is partially or totally lost, and the stiffening of the joint as in certain paralytic conditions, the treatment and drainage of suppurative conditions; a knowledge of the important routes of approach to the joint is very important. For each case, the operator will select the incision best suited for the individual condition. Each joint will be considered separately in other chapters. The incision should be made down to the synovial cavity. All bleed- ing should be stopped and the synovial membrane carefully opened. The joint structures should be tampered with as little as possible, the synovial membrane brought together carefully and the layers over it closed in order not to disturb the function of the periarticular tissues. Unnecessary separation of the tissue layers is to be avoided. Tendons should be left in their sheath. Any ligaments that must be cut should be loosened periosteally, in order that they may be readily replaced. Early motion should be the rule, gentle at first, and gradually increased. Arthrotomy at the wrist is done for deformity, congenital or acquired, compound fractures, ankylosis following injury or disease and suppura- tive conditions. Joint operations should never be hastily considered and should be avoided by anyone not familiar with the best surgical technique. When it is necessary to have free access to the bones on account of fracture, deformity or suppurative disease, less injury is done to the soft parts if the operator will use an anterior and a posterior incision at the same time rather than a single incision. It must be remembered that any operation at the wrist may involve serious injury or adhesion or even sloughing of the tendons which later may interfere seriously with the action of the fingers. This can be avoided by sufficiently long- incisions to allow easy retraction of the tendons undisturbed in their sheath with the underlying periosteum still attached. The posterior annular ligament must be incised. With one finger through the an- terior and another through the posterior incision it is possible to manipu- late or remove the bones without roughness and trauma. The amount of swelling, pain and injury from the operation will be correspondingly less. For exploratory operation on the wrist, the anterior or the posterior 259 260 TECHNIQUE OF OPERATIONS incision may be used, or both. The posterior is preferable where only one is to be used. It extends from between the styloids to the second or third metacarpal. For purposes of drainage, an anterior and posterior incision should be made and sometimes a radial or lateral, depending on the extent of the disease or injury. An x-ray will help determine. For simple irreducible fractures, compound fractures, dislocation or internal displacement demanding operative intervention, the anterior and posterior incisions should be used unless one is sufficient, but for suppuration at the wrist two or more incisions are necessary. When removal of one or more bones is necessary as in tuberculosis, a better result as to function is obtained when all the bones are removed with perhaps the exception of the pisiform and perhaps the trapezius, the unciform process of the unciform may be left. Even when only one bone is diseased there is less danger of stiffness by a complete excision. There is never abnormal mobility if the operation is done subperiosteal^ even though all the carpal bones are removed. 298. Arthrotomy at the Wrist. Ollier's Incisions. — Oilier advises three incisions for suppurative conditions, an anterior lateral, a posterior and a small external for drainage when necessary. The arm is evasculated by an esmark and tourniquet (the tourniquet is applied over a towel for a short time only). The skin having been carefully prepared and the field of operation protected, the arm rests on a small table to one side of the operating table. The operator sits facing the side of the table, his assistant faces him. The arm is pronated and rests on a sand bag. 299. Posterior Incision. — An incision is made midway between the styloids starting one inch above them and extending vertically downward through the posterior annular liga- ment to the middle of the second metatarsal along the outer side of the extensor indicis. The dissection is carried down to the perios- Starting 0S onT inch teum, the extensor indicis is to be retracted inward and the extensor secondi internodii out- ward. The extensor carpi radialis longus and brevis should be spared and detached sub- tensor indicis to the middle periosteally (see figure 410). of the second metacarpal. 300 Arthrotomy of the Wrist. Anterior Incision. — A palmar incision is made over the radial border of the ulna starting one inch above the styloid process and extending to the base of the fifth metacarpal, leaving the flexor carpi ulnaris to the inner side. This incision is carried down to the periosteum (fig- ure 411). sion. starting one above the styloids and pass- ing through the middle of a line connecting them along the outer border of the ex- INCISION, PUNCTURE AND ARTHROTOMY 261 301. Radial Incision. — A third incision is now made when necessary (see figure 411), one inch long over the styloid process of the radius; it is carried down to the bone and made before removing the carpus. For complete drainage, for tuberculous or purulent disease, three inci- sions are made. The operation is continued as the case requires. For adjustment of fractures, correction of deformity or excision, where there is no active disease the posterior and anterior are all that are necessary. 302. Arthrotomy at the Metacarpal and Phalangeal Joints. Operations on the Long Bones of the Finger and Hand. — The finger joints are best reached by one or two dorsal incisions between the tendon and the artery. When necessary a palmar incision similarly Fig. 411. — Anterior incision. Starting one inch above the styloid along the radial border of the ulna to the base of the situated is made, but m view of the tendency mh meUearpal ' the nex0 r to SCar contracture it is better to have the in- carpi ulnaris to the inner side. Cision on the dorsum. (See figures 412, Tn e . radi . al or external lateral incision is made over the sty- 41o.) loid of the radius for one or The incision is made with a scalpel down one and one-half inches. to the bone through the periosteum. A long handled small osteotome is then used to raise the periosteum exposing the joint and the bone, above and below, without disturbing the structures between the perios- teum and the skin. Hooks or small retractors are used, exposing the bone or joint. When the joint is subluxated, the ligaments may be relieved subperiosteally and the joint replaced. In some instances it is necessary to excise a portion of the bone as described for hammer toe. The long bones of the hand and finger are reached in the same way. 303. Arthrotomy for Fractures about the Joints. — The necessity of immediate operation in fractures about the joints depends, as in other fractures, on the acuteness of the local and general reaction. When these do not contra indicate immediate opera- tion, certain fractures about the joints may require treatment by the open method. Among these are Fig. 412. — Incision ,, j » , , , , , ~ . , , for arthrotomy at the a ^ compound fractures, even when the protrusion of metacarpophalangeal the bone has been extremely slight, all fractures Jolnt * that cannot be reduced by manipulation or in which the correction cannot be maintained or Avhere apposition is impossible, many fractures combined with dislocation, articular fractures with pieces locking or limiting the joint action. Where there is a great deal of trauma, and in multiple fractures, and in cases where there is a great deal of shock, all that can be done is to 202 TECHNIQUE OF OPERATIONS immobilize the parts until a favorable time for operation. In selecting a suitable time for operation when it is found necessary to operate on a fracture it' there is no immediate contra indication, the sooner it is done the better. Where there is tremendous swelling the surgeon should always wait. All cases should be operated on that show no union after three months of good treat- ment. Methods of treating the individual fracture cannot be considered in a limited space like this. The writer has described the routes of approach to the different joints and the technique of these. This will enable the surgeon from his knowledge of fractures to select Fiq. 413. — inci- ^ ne rou t e best adapted for the individual treatment sion for arthrotomy, required and when necessary two or more incisions phalangeal jomt. ma y ^ e use( j # a knowledge of the technique will enable the surgeon to work rapidly in reaching the fracture on which he expects to spend time. 304. Fractures of Long Standing Still Ununited or United with Deformity, Preventing Function. Fractures near or of the Carpus. — Deformity from fractures at the wrist may be corrected by an osteotomy of one or both bones as the case requires. An incision is made as for exci- sion of the wrist or at the side separately for each bone. The bones are cut through by means of an osteotome, and the case treated as if it were a fresh fracture by well fitting anterior and posterior splints. When there is deformity low down and the fracture is under three weeks old, it is usually possible to manipulate the fracture, and correct the deform- ity without an open incision. The treatment of fracture of both bones by the open method is described elsewhere in these pages. The Thomas wrench as described in these pages, may be used to manipulate the wrist. This has been suggested by Dr. Stone.* Separation of the epiphysis with deformity may be corrected by means of a Thomas wrench, if the fracture is three weeks old. Occasionally it is possible to correct frac- tures, when they are five weeks old, when the union is soft. The surgeon should be careful to avoid trauma in manipulating the fracture. It is bet- ter to cut the bone with an osteotome and avoid trauma, than to manipu- late to such an extent, with force, as to cause a great deal of swelling. In injury of the carpus, the bone most commonly fractured is the sca- phoid. The semiluna may be displaced with or without fractures of the scaphoid. In fractures of the scaphoid, the fracture heals without giving any trouble. Occasionally there is displacement of one of these bones or of a fragment. Where there is displacement, sometimes it is impos- sible to manipulate the fragment into position. When this is the case, an incision is made and the displaced fragment removed. Oc- casionally the whole bone should be removed. An excellent result * Dr. J. S. Stone, Boston. INCISION, PUNCTURE AND ARTHROTOMY 263 follows the operation. Fracture of the scaphoid will limit motion in extension of the wrist without limiting flexion to any great extent. Displacement of the semilunar bone may require removal of this hone to obtain good function of the wrist, when after long immobilization function is still impaired. In any case where there has been infection, no plastic operation should be used until the infection has been entirely absent for at least nine months. A year is safer. Where the infection is very mild and of long standing, during the process of treatment the patient may be allowed to use the arm if the local reaction is not too great. It is of ad- vantage in certain cases to use a wire or leather splint to take some of the strain. Where the x-ray shows conical ends of the bone it is practi- cally useless to expect union without surgical interference. 305. Tapping the Wrist Joint. — The most scrupulous aseptic pre- cautions are necessary both as to the preparation and the protection of the field of the operation. The forearm is pronated and the joint tapped at the styloid process of the ulna between it and the long extensor tendons, or at the level of the styloid of the radius between the extensor longus indicis and extensor longus pollicis. The tapping may be done under local anaesthesia. When there is much effusion it is not difficult to reach the joint. If fluid is to be drawn, and other solutions are to replace it, the amounts should be carefully measured. Two good graduated metal syringes are very useful. All of their parts should be tested before- hand. The trocar is made to enter the joint and then is connected with the syringe. As little air as possible should enter the joint. The trocar should be of large diameter as the fluid may be thick or flaky. When the patient is not anaesthetized for the operation it is often well to have a short flexible tube connect the trocar with the syringe. This should be fastened at both ends by silk ties so that it will not leak easily when pressure or suction is used. If the joint is to be washed out a definite amount of fluid is injected and the return meas- ured in a sterilized measuring glass. Dr. Murphy uses a formalin glycerine solution as follows: liquor for- maldehyde 2% in glycerine, about ten drops of the formaldehyde to each ounce of glycerine. This acts very well in infectious synovitis. But it should not be used in arthritis deformans nor in old chronic arthritis. The tapping may be done with ethyl chlorid or novocaine adreneline solution, 1%. The solution should be prepared twenty-four hours before it is used (Murphy). CHAPTER IV OPERATIVE TREATMENT IN CASES OF JOINT ANKYLOSIS 306. Arthroplasty. — Ankylosis may be bony, cartilaginous or fibrinous, it may be periarticular, ligamentous and capsular, or extra articular, that is, skin scars, tendons, fascia, nerves and arteries. The form of ankylosis that exists will determine the treatment. A partial ankylosis at certain points had better not be treated by an arthroplasty. Age must be considered, also the general condition of the patient. When the ankylosis is bony, cartilaginous or fibrinous, arthroplasty is indicated. When the condition is periarticular or extra articular, it may be treated by capsulotomy, tendon elongation, excision of exostosies, etc. Dr. Murphy lays stress on the following points: — The principles of asepsis to the finest detail are absolutely essential. One not familiar with the best surgical technique should avoid arthroplasty operations. The exposure of the joint must be generous and complete. The con- tracted capsular ligaments and soft parts must be freed and if necessary lengthened. The normal contour of the joint should be restored as nearly as possible. The operator should obtain a hyper-mobilization of the joint. The joint should be reshaped to give stability. The inter- position of material to prevent reunion of the bone is necessary. The principle is to separate the bones and to interpose between them material to prevent ankylosis. The best material for this purpose is the human pedicle composed of fat, muscle, fascia or a combination of these. When this is not possible, a transplantation is made of fat and fascia from the trochanter bursa region or from the fascia lata. Materials such as ivory, celluloid, silver are not good. Materials that will not absorb or that absorb too slowly are not desirable. During the operation the soft parts should be freely liberated. Attach the interposing flap to one bone only and cover it completely. Early motion, that is, at the end of five to seven days is necessary with or without gas or gas and oxygen. Dr. Murphy records failures in arthroplasty as due to first, insufficient and defective exsection of the capsule and ligaments, second, insufficient interposition of fat and fascia between the separated bony surfaces, third, infection, fourth, the sensitiveness to pain on motion after opera- tion. Cases of primary tuberculosis and cases of recent infection that have subsided are not suitable cases for arthroplasty. In operation, in addi- tion to the usual protection of the field of operation, after the skin and 264 OPERATIVE TREATMENT IN JOINT ANKYLOSIS 265 fat have been incised, towels should be clamped to the edges of the skin as an extra protection. 307. Arthroplasty in Ankylosis of the Wrist. — In ankylosis of the wrist very good motion and function are possible by a complete incision of all the carpal bones as described (see Excision of the Wrist). The function is usually so good that an arthroplasty is uncalled for at this joint. A stiff wrist should not be interfered with in cases of chronic rheu- matism where the fingers and other joints in the arm are affected by rheumatism unless it is badly deformed or unless the patient is very healthy and the rheumatism has entirely subsided. Where the disease is of an infectious or tubercular nature and in the wrist only and where the patient is in good health, an excision at the wrist may be done to relieve the ankylosis. 308. Arthroplasty for Ankylosis of the Finger. — A dorsal incision is made just to the side of the tendon between it and the artery; usually two dorsal incisions are necessary: They are carried carefully down through the periosteum, a long handled small osteotome is used to raise the periosteum completely from the two bones without disturbing the tissues between the periosteum and the skin. The lateral ligaments of the joint are removed in a similar way. The necessary bone is removed to allow easy motion of the joint. The bones are shaped as nearly as possible to conform to the natural shape of the joint. A flap of fascia is cut from the thigh and placed over the end of the bones and sutured to one bone overlapping its end. The finger fibrous tissue may be used for the same purpose. There is less disturbance of the mechanism of the fingers by diminishing the dissection and using fascia lata. The incisions are closed with chromic catgut number 00. Enough bone should be removed to allow easy motion. There should be very little disturbance of the other tissues. The finger, hand and wrist are immobilized on a palmar splint ex- tending to the elbow. Gentle passive motion is allowed after seven to ten days, depending on the amount of pain and swelling. CHAPTER V . OPERATION IN SUPPURATIVE CONDITIONS 309. Suppurative Condition at the Wrist. — When the condition at the wrist is one of severe acute suppuration, the anterior and posterior with the radial incision should be used, the disease well drained, the abscess cavity washed with salt solution and wiped out with gauze strips. When necessary the bone is incised and cleaned out with a chisel or osteotome. After operation the incisions are kept wide at the corners with gauze and tubes placed between them. A stiff wrist often results from suppurative conditions. Motion is always obtainable by operative measures unless the tendons are exten- sively involved in the adhesions. A constantly painful and weak wrist is disabling when due to chronic suppuration. Drainage followed by an excision or an excision from the first is justifiable and gives a very excellent result when carefully done. Any very acute suppurative con- dition should be allowed to subside after drainage and an excision then done will give promise of excellent wrist motion. If the condition is sub-acute the disease may be removed and an excision done at the same time. The joint should be immobilized and the fingers allowed to have free motion. See Carrell-Dakin Technique, section 323. 310. Osteomyelitis at the Wrist. — In osteomyelitis an operation should be done as early as possible after making the diagnosis. In sub- acute cases, incision and drainage are all that is necessary. Whenever incising for abscess all the pockets should be opened and if the abscess is large, counter incisions are made at dependent portions. The pus pocket should be opened freely, wiped out with gauze, irrigated and wiped out again with gauze. Curetting should be avoided excepting for the removal of sinuses in the skin, and in cases of sinuses it is often better to excise them. Perforated rubber tubing should be placed to drain the deepest portion of each pocket. The skin, fat and superficial muscle layers should be made to gap by means of gauze drains. At the end of ten days the gauze is removed and the tubes shortened. The tubes are gradually drawn out a little each day or two until not used. This method makes the repeated reapplication of drains and wicks unnecessary as the wound will gap of itself and close from the bottom if the surgeon has been careful to make large incisions. Where this is necessary, the incisions should be large and a counter incision should be made on the other side of the bone with a hole made in the bone. Splints should always be applied to immobilize the limb. They should be placed so that they will not interfere with the dressing. In some instances it is better to apply a plaster with 266 OPERATION IN SUPPURATIVE CONDITIONS 267 large windows and ropes to give stability. The dressings should be done every day or twice a day, depending on the foul condition of the discharge. If the odor is excessive chlorinated soda dress- ing should be used diluted, using it x \i, '/s, l fi the U. S. P. strength. The gauze drains should remain for at least ten days without being dis- turbed. When removed granulations will be formed under them in such a way as to keep the wound open without applying drains. Irrigation may be used at the time of the operation and the wound thoroughly wiped out with gauze afterwards. No irrigation or probing or applica- tion of wicks will be necessary if the first drains are left in long enough. After the first ten days the tubes are shortened gradually until they are not needed. See section 323. In severe cases where the patient is unconscious or delirious the bone should always be opened. No tight packing should be used, as this interferes with good drainage. Where sequestra have formed they should be removed. An x-ray should be taken whenever possible to determine the position of the disease (unless the case is urgent and an immediate x-ray is not obtainable). In cases of long standing that are sub-acute at the time of first exami- nation, where the bone is riddled with holes over an extremely long area, it is impossible often to remove the dead bone satisfactorily without removing all the bone. In these cases free incision down to the bone with frequent openings into the bone as described above, will allow the septic process to run its course and the sequestra to gradually separate. Where sequestra are present it is always desirable to remove them as soon as they have separated, provided the involucrum is strong enough to act as a support. Sequestra may be superficial or in the medullary cavity or both. Where there is a persistent sinus and a sequestrum is present, pus will continue to form until the sequestrum is removed. Cases discharging several years where a sequestrum is present may close in a few weeks after removal of the sequestrum. See Carrell-Dakin Technique, section 323. 311. Excision of the Wrist.— When removal of one or more bones' is necessary as in tuberculosis, a better result as to function is obtained when all the bones are removed with perhaps the exception of the pisiform and perhaps the trapezius; the unciform process of the unciform may be left. Even when only one bone is diseased there is less danger of stiffness by a complete excision. There is never abnormal mobility if the operation is done subperiosteally even though all the carpal bones are removed. An excision of the wrist will give a useful wrist with one or two-thirds or more of the normal flexion and extension. When the op- eration is done for a stiff wrist due to deformity, old fracture or inflamma- tion that has subsided, very excellent results as to function are possible if the operator is careful to minimize the trauma in gentle handling of tissues, to use long incisions so that retraction is possible without separa- tion of the delicate structures. Any adhesions that limit motion of the 26S TECHNIQUE OF OPERATIONS tendons should be noted before operation and the fingers manipulated but not roughly to relieve this. If excision is decided upon no rough handling or breaking up of adhesions should be done at the time of operation. The removal of the carpus will relieve many of the adhesions and make extensive manipulation unnecessary. After the operation the action of all the joints of the fingers must be noted and the fingers manipulated so that their action will be unrestricted. When the operation is done for suppurative conditions, conservative treatment should be tried first unless the disease is acute or of long standing, or extremely painful and conservative treatment has proved ineffective. OPERATION (Excision of the wrist) Ollier's incision Oilier advises three incisions for suppurative conditions, an anterior lateral, a posterior and a small external for drainage when necessary. The arm is evasculated by an esmark and tourniquet (the tourniquet is applied over a towel for a short time only). The skin having been carefully prepared and the field of operation protected, the arm rests on a small table to one side of the operating table. The operator sits facing the side of the table, his assistant faces him. The arm is pronated and rests on a sand bag. Posterior incision An incision is made midway between the styloids starting one inch above them and extending vertically downward through the posterior annular ligament to the middle of the second metatarsal along the outer side of the extensor indicis. The dissection is carried down to the peri- osteum, the extensor indicis is to be retracted inward and the extensor secondi internodii outward. The extensor carpi raclialis longus and brevis should be spared and detached subperiosteal^ (see figure 410). Anterior incision A palmar incision is made over the radial border of the ulna starting one inch above the styloid process and extending to the base of the fifth metatarsal, leaving the flexor carpi ulnaris to the inner side. This inci- sion is carried down to the periosteum (figure 411). (Excision of the wrist) radial incision A third incision is now made when necessary (see figure 411), one inch long over the styloid process of the radius; it is carried down to the bone and made before removing the carpus. For complete drainage for tuberculous or purulent disease, three incisions are made. The operation is continued as the case requires. For adjustment of fractures, correction of deformity or excision, where OPERATION IN SUPPURATIVE CONDITIONS 269 there is no active disease the posterior and anterior are all that are necessary. The operator carries each incision described above in turn through the periosteum to the bone. Lifting the periosteum with a small long handled osteotome. It is to be retracted, leaving the surface of the bones uncovered of periosteum and the tendons and their sheath un- touched. Wide separation of the overlying tissues en masse with the periosteum is necessary. The surgeon is now ready for the third step, the removal of one bone after another. After removal or adjustment of the bones, the surgeon has the tourni- quet removed. The deep tissues and periosteum are brought together with interrupted chromic catgut sutures number 00, the subcutaneous fat with interrupted chromic catgut sutures number 00, the skin with continuous chromic catgut sutures or horsehair. When suppurative disease is present the bones are removed, preferably with a small long handled osteotome. This instrument is used to separate the bones from the periosteum. The interosseous periosteum is removed with the bones leaving one large cleaned out cavity. This is wiped out with sponges and washed with salt solution when there is much suppuration. The ends of the metacarpal, the ulna and radius are inspected and any dis- ease here removed. The styloids should be left in all cases even when other bone must be removed. Excision of the wrist In case of children where there is good bone and then suppuration beyond it in the epiphysis, the diseased bone is wiped with a sponge and an extra incision made directly over it to give immediate drainage, but the epiphysis should be left unharmed, the surgeon depending on good drainage to the epiphysis. The diseased bone is not removed at this point. The tendons, sheaths and ligaments should be untouched with their contiguous periosteum. If, however, the disease has penetrated to these tissues, it should be dissected away carefully. After completely clearing out the whole cavity it is washed out with salt solution and sponged out with gauze strips. After inspection, if the whole cavity is satisfactorily cleaned out, the tourniquet is removed. Large wads of gauze are made to gap the wounds at their corners and drainage tubes placed between. The third incision is used for drainage in suppura- tive cases only as described above. After treatment The tubes and gauze remain for eight to ten days and can then be safely removed and no other drains inserted. After operation a wire splint or plaster is applied holding the hand, forearm and upper arm firmly; the elbow at right angles. It should be applied so that inspec- tion and all soiled dressing can be changed without disturbing the splint. 270 TECHNIQUE OF OPERATIONS The windows in the plaster or open places in the splint should leave a margin of healthy skin beyond the incision at either end so that the splint can be kept clean. The splint should allow free motion of the fingers at the metatarsal phalangeal joints and beyond. Active motion of the fingers is encouraged on the fourth day and gentle passive motion if the active motion is not satisfactory. The splint is removed a little each day after the eighth week unless the suppuration is severe. In non-suppurative cases the splint is removed about the fifth week a little at a time until the muscles are strong enough to support the wrist. 312. Operation for Bone Disease in the Metacarpal or Phalangeal Bones or their Joints. — An incision is made on the dorsum of the finger between the tendon line and the artery (figures 423 and 424). The incision is made with the scalpel carefully down through the perios- teum. A small long handled osteotome is used to raise the periosteum from the bone. This is retracted without disturbing the structures between the periosteum and the skin. In children the epiphysis should be interfered with as little as possible, a quadrilateral door is taken out of the shaft of the bone not extending to the epiphysis in children even when it is diseased. The cavity is wiped out, a tube or rubber drain in- serted, and gauze is used to gap the soft tissues. These drains are left ten days, the dressing done after the operation or the third or fourth day and as often as necessary without disturbing the drains. These are shortened after the tenth day and later omitted. By this method the sinus will remain open without reapplying drains. The forearm, wrist and fingers are held on a splint for a week or ten days; after that the unaffected fingers should be allowed freedom and the patient encouraged to use them. In some cases there is a swelling at the base of the wrist on the palmar side; in these cases and when the dorsum of the hand is swollen, there is a palmar abscess which will have to be drained especially if the patient is acutely ill. If there is no great virulence, but the hand is swollen, the wrist and forearm may be opened as well as the finger. The operator must be guided by the presence of pus, the general and local reaction. In any acute process daily soaks in antiseptic solution will be indicated for the whole arm and hand, with or without poultices, the old flaxseed poultices are usually the best unless they irritate the skin. The treatment of the metacarpal bone is the same as that laid out for the phalangeal bones. The axillary glands should be examined. 313. Methods and Principles of Drainage in Acute Non-tubercular Suppurative Joint Disease. Wrist and Hand — A small suppurative focus without virulence or active constitutional disturbance should be drained by a suitable incision wiped out with gauze, a tube placed to its deepest part and the soft tissues gaped with gauze. When there is a great deal of constitutional disturbance drainage and counter drainage should always be the rule. If the bone is involved this should be opened. The pus cavities in the soft tissues should be OPERATION IN SUPPURATIVE CONDITIONS 271 wiped out. No extensive bone operation should be done otherwise. The bone should be drained with tubes to the remote portions and the muscle, fat and skin gaped by gauze. These operations are done quickly and should not be prolonged, but efficient drainage and counter drainage should be established unhesitatingly. The joint is immobilized and the fingers left free after all operations for suppurative conditions of the bone or joint near the wrist when possible. In any extensive non-tubercular suppurating bone disease about the wrist or hand anterior and posterior incisions should be made at the wrist and on the back of the hand and back of the fingers when neces- sary. If the patient is very ill the operation should be done very rap- idly and good drainage established. See Carrell-Dakin Technique, section 323. PART VII— MISCELLANEOUS OPERATIONS CHAPTER I MISCELLANEOUS OPERATIONS 314. Torticollis Operation. (Figures 414 to 418.) — The patient lies on his back with a sand bag or hard pillow under his shoulders so there is slight tension on the sternocleidomastoid muscles. The tense muscle should be carefully noted before the patient is anaesthetized so that there will be no doubt as to which side is to be operated on. Under anaesthesia it is often impossible to tell which muscles are contracted. The head Fig. 414. — The two portions of the sternocleidomastoid are ex- posed. The skin incision should be very small and stretched inward Fig. 415.— A few muscle fibers at a and outward to reach both portions time are divided on a director, of the muscles. (See figures 218, 219.) and thorax and shoulder are properly covered to protect the field of operation. An incision may be made one and one-half inches above the clavicle and parallel to it just above the clavicle or just below the clavicle. When operating on a boy the incision over the clavicle is very service- able. In operating on a girl an incision that will be covered by a neck- lace or a neck band is often preferred. For this reason an incision higher up is sometimes chosen. The skin in this region is very elastic and can be drawn up and down laterally without difficulty. For this reason the incision need not be more than three-fourths of an inch long. If the incision is made over the clavicle it is started an inch from the 273 274 TECHNIQUE OF OPERATIONS sternal end of the clavicle and extends three-fourths of an inch outward. The incision is retracted inward while the operator separates the fibers of the inner end of the sternocleidomastoid and its sheath. The incision is gradually drawn outward as the outer fibers of the sheath and muscle are cut. A director is used to lift a few fibers of the muscle at a time in order to avoid unnecessary bleeding. Very rarely there is a moderately large vessel in the sternomastoid which bleeds after the muscle drops back in the wound. The operator should be careful not to miss these vessels, remembering that when the muscle fibers are lifted on a director they are tense and bleeding will not occur until after the fibers are re- laxed. As the posterior sheath of the muscle is reached, the operator Fig. 416. — Both portions of the muscle and its sheath must be com- pletely divided. Fig. 417. — On the neck a small incision can be pulled to one side and then moved to the other, ex- posing small portions of the muscle at a time. In this figure the incision is moved outward, in the next figure inward. should take care not to injure the carotid sheath. The jugular sheath is not readily distinguished from the layers of fascia. If the muscle is very vascular it may be tied off and the fibers cut afterwards. Should any extensive oozing occur, packing with gauze strips for five or ten minutes is usually all that is necessary. When the operation is complete the operator should see that no fibers of the sheath and the muscle are left. He should put his finger in the wound and trace the anterior edge of the clavicle, the upper edge, and the posterior edge, looking for uncut fibers from the interclavicular notch outward. The fibers most com- monly overlooked are superficial ones immediately under the skin and fat. These are more often neglected while the attention is concentrated on the deeper portions of the muscle. The string-like fibers that are sometimes overlooked do not materially interfere with the correction of the deformity when the operation is otherwise well done; they do interfere more or less with the cosmetic effect afterward. Suture. — The subcutaneous fat is brought together with interrupted chromic catgut MISCELLANEOUS OPERATIONS 275 sutures firmly enough so that there will be no tension on the over- lying skin. The skin is brought together with a subcutaneous suture and painted with compound tincture of benzoin, not, however, if iodine was used. Four layers of gauze a little longer than the incision and an inch wide are placed over the incision and painted with com- pound tincture of benzoin. This practically seals the wound before it is healed. The dressing may be inspected at the end of the fifth day. In cases of spasmodic torticollis, a portion of the sternocleidomastoid is often removed instead of cutting it across. Tillaux and Lange prefer cutting the sternocleidomastoid close to the mastoid process. When an operation is done here the incision is made over the mastoid process, the muscle should be cut close to the bone. The after treatment is the same with this exception, that the correction Fig. 418. — The incision is moved inward; in the figure pre- ceding it is moved outward, ex- posing each part of the muscle. Fig. 419. — Showing a method of overlapping a stretched out mus- cle. of the head should not be undertaken until the fourth or fifth day of convalescence; moreover, the correction should be gradually increased every second day as there is often too much strain on the pneumogastric nerve if overcorrection is instituted at once. The success of the operation in congenital torticollis depends first on thoroughness, making sure that no fibers of the muscle of the sheath are left uncut; second, maintaining an overcorrected position of the head after operation for nine or ten months. The first four to six weeks a plaster of Paris is used, later a well fitting brace maintaining overcorrec- tion. This apparatus is not uncomfortable as soon as the patient gets used to wearing it. The plaster (figures 420, 422), should include the head and thorax; the ears and top of the head should always be left out. In order to maintain the position of the head, the chin, the occiput and forehead must be held. After operations on the right sternocleido- mastoid, the chin should be turned to the right. The left ear should be depressed toward the left shoulder and the cervical spine should be left 276 TECHNIQUE OF OPERATIONS in a straight position otherwise. After operations on the left muscle the position is reversed. 315. Operation for Tenosynovitis. — When a tenosynovitis has not responded to conservative treatment it is sometimes necessary to oper- ate, especially when it is tubercular. Incision and drainage are not sufficient. The tendon sheath must be completely exposed by a gener- ous incision, and carefully dissected away from the tendon throughout its entire length. The tendon may be covered with sterile vaseline and replaced and the skin closed so that the tendon will not adhere to it. Fat or fascia may be used to pre- vent adhesions. This is the only operative measure that gives complete satisfaction in extensive cases. Fig. 420.— Torticollis plaster. The chest por- tion is applied over sheet wadding. The shoulder "plaster ropes" are ap- plied over felt. The chin, head, occiput and forehead portions are applied over felt. The shoulder rope is turned back while it is soft. (See figures 421 and 422.) Fig. 421.— The body and head portions are connected by plaster ropes while they are wet. Plaster bandages are folded over them and incorporated into the plaster. (See fig- ure 422.) Fig. 422.— When the plaster is finished, the portion over the top of the head is cut away, allowing the head to be taken care of, the ears should be free, the plas- ter should be light. Small local conditions may be excised, removing a small portion of the sheath above and below. The part should be immobilized for about a week and then motion of the tendon encouraged six or eight times a day, and the immobilization reapplied. 316. Bone Grafting. — In considering bone grafting, the operator should remember certain things which underlie the success of this opera- tion. Absolute asepis to the smallest detail is essential. The bone to be grafted should be completely prepared before cutting the graft. The graft should fit snugly and be held in place by sutures or pegs. Whatever shape and type of graft and for whatever purposes used, the human graft either from the patient or another patient is better than a graft taken from an animal. The graft should have a good bony con- tact at each end with the medulla of the bone to which it is attached. MISCELLANEOUS OPERATIONS 277 Both ends of the graft beyond the bridge should have as long a surface of contact as possible. Whenever possible this surface of contact should be at least two inches. When the tissues about the bone to be grafted are very debilitated or the soft parts very sclerosed from extensive scar formation or injury as in certain old ununited fractures, the fibrinous union between the ends is not removed except where the trough is made for the graft inlay. There will be much less disturb- ance of the tissue by this method and the repair in the extremely de- bilitated will be better than if the bones had been completely cleared on all sides. When operating on healthy ununited fractures, large dissections may be done if necessary with impunity. With the debilitated and in the presence of extensive sclerosed tissues a minimum amount of trauma should be caused. (See Hibbs operation and Albee opera- tion.) In these cases the bone to be operated on is uncovered by a flap of fat and skin, the incision of which is some distance from the bone. When the flap is turned back the deeper tissues are incised directly over the bone in another line under the flap. Too much cannot be urged in favor of the large and long graft. Small, short grafts should be used as infre- quently as possible. If there has been any inflammatory process with infection, no operation for bone grafting should be done until nine months or a year after the disappearance of all symptoms of inflammation. Method of suturing the graft in place is illustrated (see figure 423). The graft may be pegged with small bone pegs or by means of bone screws filling a tap drilled in the bone cortex. 317. Operation for Rachitic Deformities. — In operating for bone deformities in rickets, an x-ray should be used to determine the advis- ability of operating; where the epiphysis show a fringy indefinite outline it is better to defer the operation. When the epiphyseal line is clear in the x-ray, the deformities may be corrected by osteotomy as described in these pages. Immobilization of the cut bone should be very perfect, the deformity over corrected. After six weeks of bed and plaster of Paris bandages the patient is allowed to walk with the plaster on. When the rickets is still active, general hygiene, orange juice and anti-rachitic Fig. 423. — Diagram showing inlay bone graft. A, The graft in place held by catgut or kangaroo sutures. B, Bone graft showing grooves for the suture. C, A cross section of bone showing drill holes for suture and method of applying the sutures. D, Cross section of bone showing graft in shaded lines and the sutures holding it. 278 TECHNIQUE OF OPERATIONS diet should be prescribed. The apparatus to maintain correction of the deformity should be worn for about a year. Activity should be en- couraged but with two to four hours of rest, daily, depending on the active condition of the rickets and depending on the strength of the child. 318. Arthroplasty of the Tempomaxillary Joint. — Ankylosis at the tempomaxillary joint as pointed out by Dr. Murphy may be articular or extra articular. An incision is made above the zygoma and parallel to it down to the fascia and not through it. An incision is made from the posterior region of the ascending ramus displacing the parotid and facial nerves without injuring them. The vertical portion of the incision is one or two inches long from the lower margin of the zygoma straight up into the hair, passing in front of the ear. When the bone has been freed and a small portion removed a flap is taken from the temporal fascia and interposed between the divided surfaces. The coronoid may be found ankylosed to the skull in addition to ankylosis of the temporo-mandibular joint. This must be relieved by osteotomy and interposition of fascia to prevent bony union. 319. Infantile Paralysis. — Operations in infantile paralysis are for- tunately not necessary in the majority of cases; very slight cases may be improved by muscle training and development exercises. The object of all treatment is to secure strength and stability at each joint about which paralyzed or partially paralyzed muscles play. To secure this, the joint must be made stable and firm and the muscles equalized or balanced. While it is true that the majority of poliomyelitis cases do not require operation, there are a selected few of the mild cases that are greatly benefited by it. As there may be a partial paralysis in the individual muscle, or there may be a total paralysis of one or all of the muscles, the deformities and disabilities are correspondingly numerous giving an infinite variety of possibilities in the operative treatment. A selection of the operation must be based on a careful observation of the individual case. Care should be taken early in the disease to develop the muscle and prevent deformity. In neglected cases or cases where the muscles have developed unevenly, deformity and contractures are often present; these must be corrected and the muscles brought to as high a state of efficiency as possible, then operations to improve stability of the joint, to improve motion of the joint, and to improve locomotion as a whole, are advisable. In infantile paralysis, no operation should be considered early in the disease and no operation (excepting those to relieve deformities and contractures) should be done until the second or third year after the onset of the disease. Deformities should be corrected by operation or otherwise as early as possible in order to allow the tissues to re- cover, then the muscles and tissues should be brought to as high a state of function as possible. When deformities and contractures have existed and are relieved by MISCELLANEOUS OPERATIONS 279 operation there will be much gain in the strength and the development of the limb. Deformities and contractures that are extreme when re- lieved will often allow the muscles to gain a great deal, especially if the surgeon understands the training of muscles in paralytic conditions. Slight deformities left uncorrected often impede the recovery of partly paralyzed muscles. The operations which are undertaken to increase the usefulness of the leg should never be done until deformities have been relieved and the muscles trained. The question as to which operation is most appropriate for the individual case is a matter largely of judg- ment. Operations will relieve disability, aid in locomotion and give better function and often make braces unnecessary. The operations are considered in the different chapters ac- cording to the joint affected by the paralysis. Fig. 424. — Skin and fat incision for plastic operation on the spine or for lamenectomy. The ends of the incision do not cross the median line. 320. Plastic Operation on the Spine for Potts Disease. — A plastic operation on the spine to fix the spine in Potts disease has been a valuable contribu- tion to the treatment in many cases. There is very little choice between Dr. Hibb's and Dr. Albee's operation as to the ultimate result. In the i _. f +\ I |... , p. Fig. 425. — After retracting the skin and fat, nanas 01 tne less Skilled, Dr. ^he i nc i s i n is made in the median line or slightly Albee's Operation is a simpler to the side through the ligament, the spines and onp the interspinous ligament. Albee operation. When there are signs of paralysis in the leg, neither of these operations should be done until the spine has been hyperextended and undergone treatment to relieve the pressure on the spinal cord. When the nec- essary relief has been obtained and the muscular strength has been re- turned in the legs, the operator then may select the operation best suited to the individual case. In children that live near enough to report for observation, brace and jacket treatment are preferable to the opera- tion. Where the deformity is increasing or the children are apt to be neglected or live so far off that they cannot report frequently enough for observation, then a plastic operation on the spine is often advisable. In adults an operation is preferable to jacket or brace treatment as it materially shortens the disability and the course of disease and enables the 280 TECHNIQUE OF OPERATIONS patient to go to work in a comparatively short time. In children, appara- tus treatment will not interfere with their going to school and being per- fectly well. In adults the discouragement and debility following the lack of work is so discouraging that an early operation should be done especially if there is no paralysis. Where paralysis is beginning, re- cumbent treatment should be used until recovery has been made and then an operation performed. 321. Operation for Obtaining Ankylosis of the Spine. Albee Operation. — The patient is brought into the operating room on a Bradford frame, lying in a posterior plaster shell which has been made sev- eral days before and which holds the spine in the posi- tion which the operator wishes the spine to be after operation. This plaster should not only have been made several days before Fig. 426. — The spines and inter-spinous ligaments are b u £ s h ou ] c | b e tried On and split. Albee operation. found to be comfortable before using it at the time of opera- tion. The patient is put on the operating table and when anaesthetized is turned on his abdomen. The surgeon marks lightly on the skin with a scalpel the upward and the lower limit of the spine to be immobilized. An incision is made slightly Fig. 427.— A probe is used to measure the above and extending slightly shape and length of the desired graft. Albee below these marks. The incision °P eration - should be one-half inch to the side of the spinous processes and parallel to them. It is carried vertically through the skin and sub- cutaneous fat. This is retracted exposing the spinous process (see figure 424). These are incised through their middle with an osteotome so that they are split continuously with the spinous and inter-spinous ligaments (see figures 425 to 427). When the space between the bone and inter-spinous ligaments is completed and retracted, the operator uses a probe to measure the length of the graft necessary and bends the probe to the shape of the cavity. The back is covered with a sterile towel. The knee is flexed about 35 degrees beyond right angle and the ankle held by an assistant. An incision is made 1" to the outer side of the ridge of the tibia. The incision is made rapidly through the skin and fat down to the tibialis MISCELLANEOUS OPERATIONS 281 anticus muscle. The skin and fat are dissected up rapidly exposing the tibia. The length and shape of the graft is again measured with a flexi- ble probe deep down in the incision through the spinous process. The operator places the probe on the periosteum of the tibia and cuts an out- line on the periosteum corresponding to the curve and length of the graft desired. It is as well to cut the graft about 1" longer than is necessary. The graft is cut by a mechanical saw or a sharp osteotome. Just before removing the graft from the bone, the operator uncovers the incision over the spine and makes sure that it is ready to receive the graft from A £ Fig. 429. — Method of sawing Fig. 428. — The graft is placed between the split bone and the split ligaments. the tibia (see figures 427 and 428). The graft is then placed between the split spinous processes for the full length of the incision. By cross cuts in the graft (see figure 429), it may be curved to fit any angle. The periosteum is sutured firmly over the graft with interrupted chromic catgut sutures number 1 or kangaroo tendon (see fig- ure 430). The operator should SUture one slots in a graft used when neces- end and work np toward the other. The S&Tl'sSSS'fb. *S periosteum should not be everted or inverted sawed through. B, Shows the as is often the case. When the periosteum possibility of bending the graft , , , , i , , , . so that it will fit. and muscle layers have been brought to- gether with interrupted chromic catgut, the muscles on either side may be folded over and held by interrupted chromic catgut sutures number over this, the fat is sutured with interrupted chromic catgut and the skin with continuous chromic catgut. When the skin is closed, two large pads of sterile sheet wadding are placed one on each side of the incision (see figure 431). A small strip of sheet wadding is placed over the pads. The plaster shell is now placed on top of the patient, the padding well adjusted, a swathe is placed under the patient and passed around the plaster shell holding it firmly in place. The patient is then rolled on his back with the plaster shell in place. A Bradford frame is brought to the side of the operating table on a truck. The patient should be disturbed as little as possible for five days. In using the bed _ >vj TECHNIQUE OF OPERATIONS pan, the Bradford frame may be raised without disturbing the patient in the shell. As a rule no dressing is necessary until the third or fourth week. In some instances a window is cut out in the posterior shell at the time it is made to allow dressing without disturbing the patient. At i he end of six weeks a plaster jacket or a brace is applied and the patient allowed to sit up in bed. The patient is gradually gotten up and allowed to walk. At the end of six months the ap- paratus may be discarded. 322. Operation for Obtain- ing Ankylosis of the Spine. Hibbs Operation. — The pa- tient is brought into the operating room on a Brad- Fig. 430.— Sutures are placed holding the graft ford frame lying in a posterior ?ew;;^, o tld;;i!^f;™ti"plr 3areplaced p^ ** •»** has been made several days before and which holds the spine in the position which the operator wishes the spine to be after the operation. This plaster should not only have been made sev- eral days before but should be tried on and found to be com- fortable before using it at the time of operation. The patient is put on the operating table and when anaesthetized is turned on his abdomen. The Fig. 431. — Folded sterile sheet pads are placed on either side of the incision. surgeon marks lightly on the skin with a scalpel the upward and the lower limit of the spine to be immobilized. An incision is made slightly above and extending slightly below these marks. The incision should be carried vertically through the skin and subcutaneous fat one-half inch to the side of the spinous processes and parallel to them. This is retracted ; the operator now incises the perios- teum over the spinous process down to the tips of the bone from one end of the incision to the other. This incision is carried through the inter- spinous ligament continuously with the periosteum which is to be re- moved from either side of the spinous process. In other words, the peri- osteum is removed from the tip of the spinous process down on either side of the process continuously with half of the inter-spinous liga- ments. The periosteum on the upper and under surface of the spinous process is removed at the same time. The dissection is carried well forward freeing the lamina on both sides. The operation is done satis- factorily when the operator can clear the periosteum on both sides con- MISCELLANEOUS OPERATIONS 283 tinuously with the ligaments, separating the periosteum from the liga- ments hardly at all. The tip of each spinous process is carefully inspected to see that it is denuded of periosteum. The under side and the upper side of the spinous process are also carefully inspected and cleared again, if necessary, of any remaining bits of periosteum. The lateral articulations are curetted. The spinous processes are then cut at their bases and bent down so that the tip of each spinous process above touches the cut base of the spinous process below (see figure 432) . There is then a continuous bony ridge made by the touching of the cut base of one spine and the fresh tip of the next process from one end of the incision to the other. Small portions of the lamina which have been denuded of periosteum may be split off and folded across to the lamina above and below. The periosteum and ligaments which were removed en masse from the two sides of the spinous process are now brought together covering the bone completely. Heavy chromic (JUls) Fig. 432, -Method of cutting and overlapping the spinous processes. Hibbs operation. catgut sutures or kangaroo sutures are used to bring these tissues to- gether. The deep tissues are brought together with interrupted chro- mic catgut sutures number 00, the subcutaneous fat with interrupted chromic catgut sutures number 00, the skin with continuous chromic catgut. Certain precautions are necessary in this operation. There is a good deal of ooze from the bone but practically no bleeding of any consequence if the operator is careful to make his dissection with a large and a small osteotome so that the work is done subperiosteally. The operator should clear one side of the spine working from above downward or from below upward and then clear the other side. In doing this as he goes downward large strips are packed between the periosteum and the denuded spine. This will stop the bone ooze. The operator denudes the spinous process with the ligaments attached to the periosteum all in one piece. Strips are packed and then he works down- ward to the end and then he works upward packing the space he leaves, and uncovering the way he is going, working off the periosteum and the ligaments deeper and further forward. With each succeeding step the operator will see more clearly the outlines of the spines and lami- nae. Having cleared one side of the spine well forward, the sperator 284 TECHNIQUE OF OPERATIONS parks the space between the periosteum and the spine with strips and works on the other side of the spine. In bringing together the periosteum over the bent down spinous processes, the periosteum and muscles, es- pecially in adults where they are large, will be found to be rolled in. It is important to unroll the mass of periosteum and muscles to which it is attached before placing the sutures in order to be sure that the removed periosteum comes again in contact with the bone. When the skin is closed two large pads of sterile sheet wadding are placed one on each side of the incision (see figure 431). A small strip of sheet wadding is placed over these pads, the plaster shell is now placed on top of the patient, the padding well adjusted, a swathe is placed under the patient and passed around the plaster shell holding it firmly in place. A Bradford frame is brought to the side of the operating table on a truck, the patient and shell are rolled over so that the patient lies in the shell on the frame. The patient should be disturbed as little as possible for five days. In using the bed pan, the Bradford frame may be raised without disturbing the patient in the shell. As a rule no dressing is necessary until the third or fourth week. In some instances a window is cut out in the posterior shell when it is made to allow dressing the wound without disturbing the patient. At the end of six weeks a plaster jacket or a brace is applied and the patient allowed to sit up in bed. The patient is gradually gotten up and allowed to walk. At the end of six months the apparatus may be discarded. 323. The Carrell-Dakin Technique for the Treatment of Suppura- tive Cases, Compound Fractures, Etc. The use of the Dakin solution (Desfresne modification) has improved remarkably in the method of treating not only deep but superficial suppuration both recent and advanced. Recent wounds may be sterilized; pus cavi- ties and old infected compound fractures are made clean in a very short time. Superficial pus cavities are clean enough for suture in from four to fifteen days. Deep-seated, badly infected wounds or extensive neglected compound fractures requiring amputation may be rendered clean and healthy in from fifteen to twenty-five days without amputation. In seven days there is usually a very marked improvement. A record of the severity of the infection is made by making smears from various parts of the wound. These are taken daily, stained with any stain such as methylin blue put under a one- twelfth oil emersion. The bacteria are counted regardless of kind. They are at first innumerable. In seven days they are usually tremen- dously reduced. When they amount to two or three organisms to four or five fields and remain so for five days, the wound may be sutured and heals by first intention. This is the result in the worst of war wounds treated by this method. Death, amputation and prolonged suffering are all greatly reduced. All surgeons should become familiar not with the principles but the exact detail of this technique. The result in any given case, it is estimated, is that the solution counts 20 MISCELLANEOUS OPERATIONS 285 per cent and observance of the technique 80 per cent. The detail is most important, first in the making and preserving of the solution; second, in the treatment of the wound, making large open cavities which can be dressed advantageously by this method following the removal of all foreign material or destroyed tissues excepting bone; third, the technique in the care of the skin about the wound, and of the wound itself; and fourth, the closure of the wound, whenever possible, at the proper time. Cases that would require from three to six months to heal can be healed in from four to six weeks, often in much less time. (a) The Dakin Solution * (Desfresne Modification). The solution is made up of sodium hypochlorite free from caustic alkali containing 0.45 to 0.50 per cent hypochlorite. Under 0.45 per cent is too weak. Above 0.50 per cent is irritating. It must not be heated, not placed with alcohol, not used in the eye, nor intravenously. (b) Preparation of the solution. With chloride of lime (bleaching powder) having 25 per cent of active chlorine, to make 10 litres of solution; the quantities are as follows: — 200 grams chloride of lime 25 per cent active chlorine 100 grams sodium carbonate dry (soda of Solway) 80 grams sodium bicarbonate, dry. These ingredients are put in a 12-litre flask as follows : — 5 litres of water and 200 grams of chloride of lime, shake vigorously until no parts float and all is dissolved; leave from six to twelve hours. At the same time dissolve in 5 litres of ordinary cold water the car- bonate and bicarbonate of soda. Let this stand from six to twelve hours. After twelve hours the soda solution is poured into the solution of chloride of lime; shake vigorously a few minutes. Allow the cal- cium carbonate to be precipitated ; in half an hour, siphon the liquid and filter it with a double blotting paper, to obtain a good clear liquid. The stock solution is kept in blue and brown bottles well corked. It should be kept tight, kept cool and in the dark. (c) Testing the chloride of lime for chlorine. This must be done every time a new product is received. To deter- mine the active chlorine in the bleaching powder, titration of the chlo- ride of lime must be done. Take small quantities from different parts of the jar of bleaching powder, weigh out 20 grams, mix in one litre of tap water, leave in contact a few hours; Take 10 cu. c. m. of the clear liquid, add to it 10 cu. c. m. of a 10 per cent solution of potassium iodide 2 cu. c. m. of acetic acid. * Surgery, Gynaecology and Obstetrics, Volume XXIV, Number three, March, 1917, page 255. Dr. Sherman's article has been freely quoted in obtaining the data for the solution. 286 TECHNIQUE OF OPERATIONS Put into this mixture, drop by drop, a decinormal solution of hyposul- phite (2.48 per cent) until decolorized. The number N of cu. c. m. of this solution used multiplied by 1775 will give the weight N of active chlorine contained in 100 grams of the speci- men of chloride of lime. (d) Making the. solution with other chloride of lime than that contain- ing 25 per cent of chlorine. It will be necessary to reduce or enlarge the proportion contained in the preparation. This is done by multiplying the three numbers, above mentioned, 200, 100 and 80 by the factor 25 N, in which N repre- sents the weight of the active chlorine per cent in 100 grams of the chloride of lime used. (e) Testing the Dakin solution for the amount of hypochlorite of soda it contains. Titration of the Dakin solution: — measure 10 cu. c. in. of the solution add 20 cu. cm. of potassium iodide 10 per cent solution 20 cu. c. m. of potassium iodide 10 per cent solution 2 cu. c. m. of acetic acid Drop by drop add a decinormal solution of sodium hyposulphite until decolorized. The number of cu. c. m. used multiplied by 0.03725 will give the weight of the hypochlorite of soda contained in 100 cu. c. m. of the solution. It should contain from 0.45 to 0.50 per cent of hypochlorite of soda. Under 0.45 per cent it is too weak, over 0.50 per cent it is irritating or burns the skin. (f) Testing the alkalinity of the Dakin solution. Pour 20 cu. c. m. of the solution and drop on the surface of the liquid a few centigrams of powdered phenol phthalein. The correct solution does not give any color. Lebarrague's solution and Eau de Javel will give an intense red color, showing in these two solutions the presence of caustic alkali. (g) Difficulties of the Dakin solution. Unstableness of the bleaching lime varying in active chlorine from 15 per cent to 37 per cent which gives some trouble in making the solu- tion. Much of the sodium bicarbonate is really sodium carbonate, making it difficult to neutralize the solution. If it is alkaline or caustic it will burn the skin and irritate the tissues. It must be neutralized by sodium bicarbonate. It must be frequently and thoroughly tested on account of its unstableness and tendency to become caustic. It must be from 0.45 to 0.50 per cent hypochlorite; — more makes it burn and irritate, less makes it too weak. (h) Solutions similar to the Dakin solution, — more stable but not yet proved to be as good. Chloramine (Boots) and chlorazene (Abbott) — paratoluene sodium MISCELLANEOUS OPERATIONS 287 sulpho chloramide. This contains chemically combined chlorine acting similarly to Dakin's solution. It is more stable and will perhaps be found more satisfactory where there is no facility for making the Dakin solution, or in hot climates, (i) First aid dressing of the wound. The skin should be painted with iodine, 3-}4 per cent, at the trenches, or where wounded. The Dakin solution should be injected into any small wound. If wide or open, the wound should be packed loosely with gauze and filled with the Dakin solution, (j) Operation. — Preparation of the wound for treat- ment. As soon as the condition of the patient allows he is anesthetized. Free incisions and explorations are made for foreign bodies of all wounds as early as pos- sible. X-rays are taken beforehand, if possible. The shell tracts are opened and any devitalized tissue excised. Carrell tubes (see figure 434) are placed to the bottom of the cavities; gauze is placed loosely be- tween the tubes. The solution is injected into the fig. wound to see the amount necessary to fill the cavity for containing Carreil- with the gauze in place. The surgeon should see that £££ stoker. 11 ^ it flows readily to all parts. The actual contact of the solution with all of the tissues is vital to its success. More- over, the wounds should be made so large and accessible to every part that, not only the tubes, but the gauze may be removed every twenty-four hours and fresh gauze, or gauze and tubes easily replaced to the remotest corner with little pain, using dressing forceps only. The strictest asepsis is essential in dressing the wounds. Over the dressing is placed a non- absorbent cotton pad but before this, gauze saturated in liquid vaseline, and sterilized, is placed on the skin around the wound. This is done to protect the bed and clothing from the bleaching and destruction of the chlorine. The whole leg is bandaged with non-absorbent cotton, or Turkish toweling, (k) Dressing and after care. Every two hours night and day the wound is saturated with the solu- tion. The amount used is carefully noted on the graduated vessel at the head of the bed. The necessary amount is noted and prescribed. The dressing should be saturated, as noted at the time of operation. If there is pain the vessel should be lowered. When the dressing is done, the gauze is changed and fresh sterile gauze is placed in the wound around the tubes. The gauze is placed loosely and must not occlude the tubes, or press or bend them. It should not be dragged on the skin, or touched with the hands; for this reason the wound must be made very large and wide open at the time of operation. The remotest corners must be carefully cared for and the tubes arranged to reach 288 TECHNIQUE OF OPERATIONS every part of the cavity. In large, or small, superficial wounds, the tubes are laid lengthwise. Either dressing or artery forceps may be used, but the hands should not touch the wound, gauze or any material. When the tubes and gauze arc arranged in the wound, a measured amount of the Dakin solution is allowed to saturate the wound and the amounted noted. The skin is cleaned with ether, a neutral sodium oleate is applied over' the skin, followed by sponging with the Dakin solution, and then the sterile gauze containing vaseline is applied over it around the wound. Over this is placed the chy non-absorbent cotton about 3 c. m. in thinkness. The dressing is done ever3 r twenty-four hours but in emergency, may go two or three days. The saturation with the Dakin solution must be continued every two hours, night and day. The intermittent satu- ration seems to be more satisfactory than a constant drip. It takes at least two weeks to master the details of this technique. Re-infection is easy, and may come from lack of care of the skin, or the failure to observe any detail. (1) [Microscopic examination of wound smears. A one-twelfth oil emersion is used. Smears are prepared in the usual way and stained with almost any simple stain. For the first six days enormous numbers of organisms are present and enormous numbers of polymorphonuclear leucocytes. After the seventh day, the organisms decrease markedly, small mononuclears appear instead of the poly- morphonuclears. The appearance of macrophages after the tenth or eleventh day is considered a very good sign. The bacteria constantly decrease, the cocci remaining the longest. When there are but two or three bacteria in five fields and this condition persists for five clays con- secutively the wound may be sutured and heals by first intention. It is said to be safe to do a bone graft two weeks after the wound is healed. It is probably better to wait two months. The solution is non-toxic regardless of the amount used, it will abort infection, and control well established suppuration. Its success de- pends upon the Carrell detail, (m) The apparatus and material neces- sary. (See Figs. 433 to 435.) (1) A vessel for containing the solution. The vessel is suspended three feet above Fig. 434,-RubbeT tubes~from the patient. It should be graduated and the wound are attached to a glass empty not at the side but at the bottom, distributor. s0 t h a t it may all be emptied. It should be closed with a rubber cork through which a glass thistle (E, figure No. 433) is fitted, with sterile cotton in its end. In this way the air may enter but no chlorine is apt to escape. (2) The tubing should be pure gum rubber to withstand the chemical action of the solution, five millimeters in diameter, one millimeter thick, making the internal diameter three millimeters. It is cut from 15 MISCELLANEOUS OPERATIONS 281) to 25 c. m. long. The tubes should be good enough rubber so that it may be tied with pagenstecher at its distal end and not leak. The tube is perforated at its distal end with a leather punch through both walls at once. The holes should be every l->^ millimeter, six to ten pairs of punctures in all. The holes at one level are at right angles to those above and below. All of the plugs should be removed. (3) A glass drip (C, figure No. 433) similar to that used for rectal salt solution is fastened to the rubber outlet pipe from the Dakin solu- tion. This should be six millimeters in diameter. (4) Distributors of glass (A & B, figure No. 435) so that one, two or four tubes may be attached to each distributor. The distributors are attached to the numerous tubes in the wound, one end being reserved for the supply tube to which the glass a __. drip is attached with a regulator clamp above it. The u A bottle is placed three feet above the patient. « r— i~n^ (5) A regulator clamp attached above the glass U Li LI U drip. (D, figure No. 433.) FlG - 435. -Other (6) Gauze soaked in liquid vaseline and sterilized; tributors wfth^woor then cool. This is used around the skin to prevent three or more open- leaks. ings - (7) Sterile gauze to pack lightly in the wound and to use in the dress- ing. (8) Non-absorbent cotton to envelop the limb and to place over the sterile gauze used in the dressing. (9) Ether to wash the skin about the wound. CHAPTER II PLASTER OF PARIS AND BRACES i 324. The Application of Plaster of Paris Bandage. — Plaster of Paris bandages, three, four and five inches wide are more useful than any other sizes. While applying a plaster the water should be frequently changed, a bucket full for every eight plasters. The water becomes super-saturated after that. Sheet wadding rollers should be made three or four inches broad and rolled one thickness at a time. In this way they may be placed in close position to the patient and rolled snugly, making the outlines of the body distinct. This is essential in dealing with deformities. It is impos- sible to apply a well fitting plaster over carelessly ap- plied sheet wadding. The leg should look like a leg, the arm like an arm after the application of sheet wad- ding. A liberal amount of snugly fitting sheet wadding should be used. A plaster of Paris bandage should be light, re-enforced when necessary at certain places. Deformities and contractures should be over stretched and the joints returned so nearly to normal at the end of the operation that no force will be necessary during the application of the plaster. Heavy plasters are necessary after operations on the hip in heavy patients to allow them to be moved without breaking the plas- ter. Such plasters should be heavy where they are apt to break; the re-enforcement is made by plaster ropes. In making plaster ropes, the end of the soaked plas- ter bandage is held in one hand and the bandage un- rolled to the length desired. This length is measured off repeatedly over and over until the bandage is The operator holds between his hands the This is Fig. 4 3 6. — A method of lacing a plaster of Paris jacket or leg plaster. Holes are made one or one-half inches to Used Up two inches from the plaster bandage unrolled the length desired r passed through his closed hand and squeezed firmly to- gether into the shape of a rope. In doing this all parts of this plaster bandage come firmly in contact. The rope is then applied while it is soft and pliable to the plaster on the patient at the point where re- needed. The operator flattens the rope into the three inches apart. Raw hide or heavy cord is passed through the loops. (See figures 461 to 464.) enforcement is plaster leaving it round wherever it is used to bridge over a space. Plaster bandages are applied over the rope, incorporating it in the plaster. The plaster should be split on both sides shortly after the 290 PLASTER OF PARIS AND BRACES 291 Fig. 437. — Another heavy cord is run Fig. 438. — Both cords are tightened and tied at each end. operation and strapped on with webbing straps and buckles or with adhesive straps or tied with a wet bandage. A window should be cut over the incision to allow it to be inspected without disturbing the plaster. Plaster ropes may be used to re-enforce where large windows are necessary (see fig- ures 450 to 460). If there is much swelling, the plaster is loosened and the front half lifted so that the finger may be passed between the halves from one end of the plaster to the other on the sides. If there is still much swelling, the front of the plaster is removed and the sheet wadding opened, ex- posing the skin along the whole length of the limb. A well padded plaster is comfortable. There should be no pain ex- cepting that coming from the through the loops of "trip first cord operation. Bone operations are rendered very much less painful if the surgeon is careful in the manipulation of the bone and avoids being rough when force is necessary. 325. Lacing a Plaster. — When a plaster is to be re- moved and reapplied, a temporary method of lacing the plaster has been found very convenient (see fig- ures 436 to 440). The plaster is removed, holes are made with a big awl two or three inches apart one or two inches from the edge of the plaster. The holes should be made one-fourth inch in di- ameter so that an ordinary shoe lacing can be passed through the hole, double. A long cord or lacing is placed on the under side of the plaster (see fig- ure 436) and loops from it Fig. 440.— A lacing passed up through each hole, is used from side to A second lacing is passed down the outside of the plaster through the loops. The under lacing is then pulled tight holding the outside lacing which is also stretched tight (see figures 438 and 439). The lacings are tied together at the ends of the plaster; a set of holes and two lacings have been Fig. 439. — The cord between the holes is tight but loosens enough to act as a loop for the lacing. (See fig- ure 440) . side to hold the plas- ter together. 292 TECHNIQUE OF OPERATIONS r applied along each edge. When the plaster is reapplied there will be a loop of lacing every two inches along each edge. The loops are used as eyelets, an ordinary lacing passed through them holding the plaster together (see figure 440). 326. Plaster of Paris Bandage for Neck or Head, Neck and Thorax. Method of Applying "Plaster Ropes" (see figures 420 to 422). — In applying a plaster of Paris for the head, neck and thorax, a light plaster should be put on the thorax and another on the head in the following way: — sheet wadding and a stockinet cover the head and neck except the face, a band of plaster connects the forehead with the occiput, another band goes in front of the ear under the chin and over the top of the head. A thickness of felt is placed under each band. The plaster should avoid the ears. The thorax is covered with sheet wadding, and felt straps three inches broad and twenty inches long over each shoulder. Over each of these is placed a flattened plaster rope. A light plaster is then put on the thorax, the plaster ropes are flattened and included in the plaster. The four ends are turned up and looped into the thorax plaster as it is applied; the head is now held in the desired position, a plaster rope is placed on each side extending from the front of the thorax up over the shoulder rope connecting with the plaster in front of the ear. A third extra heavy rope extends •aciS' 44 N^the from the P laster on the °™ ] 'P llt to tne middle of the window over the ab- back or to the back of a shoulder strip. These ropes domen, the back of should be flattened on the thorax. They are made S'thrboltoS'ofihf as lon g as necessary and one inch by one and one- sacrum. Under the half inches broad; the double rope behind is twice arm, the plaster cut £his size Trto^lLfZ The ropes are applied when soft and rubbed well posterior axillary into a round shape. They are flattened wherever they line. The jacket is are in con t ac t with plaster. The round part of the vertical at the an- . , -,iiji i i_ • u tenor axillary line ropes may be covered over with plaster bandages which and extends straight are placed over them and extend downward to the up to the clavicle. main part of the plagter> 327. A Plaster of Paris Jacket. — When a plaster is applied to hold the spine, a thick undershirt is worn. The anterior spines and the crest of the ilium should be well padded with felt, also the sacrum and the front of the chest and axilla. The plaster is applied over this and re-enforced so that a large window may be cut over the abdomen (see figure 441). The plaster may be slit on the two sides and laced as described above (see figures 436 to 440), or it may be slit in front and laced here. If the plaster is to be laced at the two sides, in cutting the plaster two angular cuts should be made on each PLASTER OF PARIS AND BRACES 293 side (see figure 461) in order that the sides will fit and the plaster not twist. The top of the plaster should reach as high as the collar bone in the middle and in front of the shoulder; large cuts are made at the side for the arm so that it is not held up by the plaster. Below, it should cover the whole of the sacrum behind so that in sitting upright it is one inch off of the chair. In front it covers the anterior superior spine about one inch and is cut up to allow right angle flexion of the hip. 328. The Plaster Cuirass. — Where an operation is performed on the shoulder or hip in a very heavy person, the body portion of the plaster may be applied with a double swathe posterior and a plaster of Paris bandage, anterior. This plaster is continuous with the leg or arm as the case may be and holds the hip or shoulder. Plaster cuirass for the shoulder (figures 318, 319, 320) The arm is abducted and outwardly rotated, a double swathe of un- bleached cotton passed under the thorax; this is slid up so that it will reach a little higher than the clavicle. The swathe is torn at the side mak- ing about eight many tails (see figure 319) each one and one-half inches to two inches broad. They should be torn to the posterior axillary line on either side. As the swathe is doubled the tails are double making eight pairs of tails. Sheet wadding is placed over the chest and shoulders and around the arm and hand. A heavy sheet wadding pad six inches broad is placed on either side of the chest from the axilla down. The plaster of Paris is applied over the thorax in two layers, the third layer reaches over the side of the thorax and is caught by a double many tail near the posterior axillary line, the plaster bandage loop resting on the thick sheet wadding pad. The plaster bandage is carried to the oppo- site side and is caught there in like manner; the bandage is carried over the thorax, being caught on one side and the other, until it has been looped all the way down on each side, around each of the double tails. The plaster is applied and re-enforced on the front of the thorax. It is then looped again around the many tails on either side. Two layers of plaster of Paris are placed on the arm and shoulder and two heavy ropes of plaster are made one inch thick and two inches broad. These are put along the arm together and reach over the thorax where they are divided like an inverted Y (figure 320) one down the front of the chest, the other diagonally. These ropes are flattened into the plaster. More plaster is put over the arm and hand and thorax, finishing the plaster. When the plaster is complete, each many tail is pulled through its plaster loop (consisting of three or four turns of plaster). In tins way the posterior cloth is made tight and smooth. The two upper tails are placed too high to be incorporated in the plaster at the side. They are brought over the shoulder, two double tails, over each shoulder and incorporated in loops of plaster at the top 294 TECHNIQUE OF OPERATIONS during the application of the thoracic part. These tails are now tight- ened and tied to each other, two on the right and two on the left. At the side when the swathe tails have all been tightened on the right, the upper two are tied to one from the next plaster loop, the other is tied to one from the next loop below and so on until finally the lower one from the last loop but one is tied to the two from the last loop. On the left side the tails are now tightened, drawing the cloth smoothly behind. The tails are tied as described above. In this way one-half of each tail goes up, the other half down to be tied to half of the next tail. The last tail at the top and the last at the bottom are not divided. 329. Plaster Cuirass for the Hip (see figures 318 to 320).— The thoracic, abdominal and pelvic portion of the plaster is applied as de- scribed for the shoulder. The double swathe made of unbleached or tough cotton reaches over the buttock upward to the nipple line. The plaster is re-enforced on either side of the abdomen and also across the thorax and across the pubic bone, so that a large window may be cut over the abdomen without weakening the plaster. When two layers of the leg plaster are applied, four heavy plaster ropes are made, one inch by two inches broad and two feet long; one reaching from the side and nipple line, one from the middle front of the thigh to the waist, and another curving over the pubic bone, a fourth from the middle of the thigh in front to the extreme side of the plaster and reaching to the waist. These ropes are flattened and moulded into the underlying plaster. More layers of plaster are then put on the body plaster and leg plaster until it is completed. These re-enforcements should be placed so that windows can be made in the plaster allowing the incisions to be dressed without disturbing the plaster. The leg portion is split at either side down to the toes. The plaster is not only useful for fasciotomies at the hip and opera- tions on the shoulder or hip in infantile paralysis but in many other or- thopedic conditions. In impacted fracture in old people the cuirass may be applied without disturbing the patient lying in bed. The double cloth is passed under the body ; the leg gently abducted and held there, moving the patient just enough to have the leg off of the bed. One assistant holding the leg or arm is all that is necessary for the application of this form of plaster. When a spica board and many assistants are not available, it will be found a very convenient form of plaster, especially when the patient is heavy. For any one used to handling plaster of Paris it is easy to apply. 330. Plaster of Paris Bandage for the Hip. (See figure 450; see also Plaster Cuirass for the Hip, and Congenital Dislocation of the Hip Plaster). — In the application of a short plaster spica the anterior spines should be well padded and also the sacrum. In lying down it is difficult to be comfortable unless there is plenty of padding over the sacrum. A heavy felt pad should be used here. About twelve folds of sheet wadding are equal to a good felt pad. PLASTER OF PARIS AND BRACES 295 Where an operation has been done on the hip it is better to in- clude the thorax and the leg and foot (see figures 27 to 29). In ap- plying a plaster to the thorax and leg there should be felt pads over the anterior spines and sacrum in addition to the usual sheet wadding which is applied from the toe to the axilla. The plaster should fit snugly and be re-enforced over the pubic bone, over the back of the hip double, over the front of the thigh and hip and pubic bone and finally on either side and above the abdomen. These re-enforcements consist of one plaster rope one and one-half inches by one inch wide. A large window is cut over the abdomen in order that there shall be no pressure here. The plaster is split at each side and held together by adhesive or webbing straps. A short hip plaster for walking may be applied later on. This includes the pelvis and the leg as far as the knee. This should be well padded and may be made to lace on both sides of the leg and both of the pelvis as described above (figures 436 to 440). When a hip plaster is applied to hold abduction or flexion or hyperex- tension, it is important that a few turns be taken around the thigh of the opposite leg to make sure that the pelvic portion cannot ride up on that side. After ten days or later when the patient begins to sit up this portion of the plaster is removed. 331. Plaster of Paris for Congenital Dislocation of the Hip. — Fol- lowing the operation for congenital dislocation of the hip a plaster of Paris bandage is applied as follows : — stockinet or other suitable cover- ing is applied to the pelvis and the legs. Felt pads are applied over the anterior spines, over the top of the trochanter, under the sacrum and over the internal condyles of the femur. A well fitting plaster is then applied over the thighs and pelvis for a double case or in a single case over one thigh with a few turns over the other to prevent the pelvic portion from slipping up. Heavy plaster re-enforcement or plaster ropes are placed in front over the pelvic bone (see figures 5 to 7) along each thigh and in front to prevent the breaking near the anterior spine. A similar re-enforcement is placed behind it on the sacrum and down the back of the thigh (figures 11 to 14). More plaster bandages are used to bind this re-enforcement to the rest of the plaster. The thigh of the dislocated hip or hips should be parallel to a line connecting the anterior spines and if possible the knees should be above this line and posterior to it. This will show good overcorrection. The plaster should pull the trochanter down and hold it firmly. The tuberosity of the ischium should be held firmly and be well padded. When the part of the plaster, including the pelvis and thigh and knee, is harden- ing, padding is applied to the lower leg and foot and the plaster con- tinued downward, the foot being held at right angles. It is important to maintain the desired position of the thigh and have the plaster harden immediately, maintaining the Mueller or Lorenz position while completing the plaster down to the foot. The plaster 296 TECHNIQUE OF OPERATIONS should be split into an anterior and posterior half as shown in figures 11 to 14, and laced as shown in figures 436 to 440. 332. Application of a Hip Plaster of Paris after Fasciotomy. Or After Osteotomy of the Hip or Trochanter. — It may be as well to go more into detail as to the application of plaster. A loose ill-fitting plaster does not hold the patient or the bone. The sheet wadding should fit the leg snugly and the body perfectly. After the application, the outlines of the patient should be distinct and shapely. A pad of heavy felt is placed over the sacrum, another one over each anterior spine. A thin layer of felt covers the chest from the posterior axillary line laterally and reaching down to the lower edge of the ribs. The sheet wadding should be applied lavishly but firmly all over the patient and it should fit snugly. A large thick felt pad is placed over the tuberosity of the ischium and the perineum of the affected side (see figure 30). A long rope of plaster is applied over this felt holding the felt against the tuber- osity of the ischium. This plaster rope should be long enough to ex- tend to the axilla in front, to the axilla behind (see figures 59 and 60) . Its ends are held by a nurse during the application of the plaster to the back. Tins plaster rope should be used after osteotomy or fractures at the hip. The plaster is then applied to the leg as far as the knee, the knee being well padded with felt in addition to the sheet wadding. The plaster should then be re-enforced heavily in the front of the leg and hip, again over the pubic bone and front of the leg, again on the front up to the nipple. Additional re-enforcement should be made on the side of the leg well posterior and extends well up to the thorax. In a heavy person each of these re-enforce- ments should be one inch thick and two inches wide (see figure 28). Further re-enforcement of plaster is made across the front of the chest, the sides of the abdomen and over the pubis, marked by lines (see figures 28 and 29) . The plaster is finished rapidly down from the axilla to the knee on the unaffected side and down about six inches on the opposite thigh. As soon as the plaster has hardened the traction is removed gently from each leg. Sheet wadding is applied around the foot and ankle on the affected side and the plaster is completed from the toes to the knees. The plaster is cut out over the abdomen and behind as high as the upper sacrum. The pelvic portion should be very heavy. The patient should lie in bed with the buttocks resting on the bed and the operated leg off of the side on the bed in order to maintain the hyperextended position of the hip, unless he is placed on a Brad- ford frame held above the bed. If there is too much pressure on the chest, the leg is lowered. In this way there is no danger of losing the hyperextended position of the leg. Plasters should be split, "bi-valved," on both sides of the leg and foot and tied with a wet bandage or strapped with webbing straps or adhesive. It is often necessary to use sedatives for the first five days, when the correction has been considerable. They should be given rather than withheld for pain or restlessness. After PLASTER OF PARIS AND BRACES 297 five days a well padded plaster will be perfectly comfortable. The patient lies on his back for five weeks and then is sat up in the original plaster. In sitting, the good leg is flexed, the other reaches over the edge of the bed. At the end of the sixth or seventh week the patient is stood up a little at a time and finally at the end of the eighth or ninth week he walks on the good leg with crutches and assistance. The plaster is cut so that the knee portion may be removed posteriorly and allow a little motion here. When he is able to stand without showing any weakness, the plaster is removed and a light plaster applied with Fig. 442.- -Side view of apparatus applied without elastic bands. IP Fig. 443. — Elastic straps applied to the hooks of the apparatus to overcorrect finger flexion, side view. Fig. 444. — Dorsal view of post-operative ap- paratus to correct finger flexion. (Note attachment of elastic bands from each finger to the wrist). Fig. 445. — A finger splint for stretching in hyper extension the metaearpo-phalangeal or for the phalangeal joint. The cord reaches around the upper arm. (See fig- ure 446). the patient standing and holding on to his crutches. This position is pref- erable to one lying down when the plaster is to be used for locomotion. 333. Retaining Apparatus after Operation on the Hand (442 to 446) . — In claw hand and deformities of the finger the same plaster apparatus may be used as described for hammer toe. In the case of a hand, it is more convenient to use a wire splint or aluminum splint with a point for each finger bent to correct the deformity, the wrist should be flexed or ex- tended and it should always include the flexed elbow in order to maintain good position of the hand and wrist. For hyperextension of the fingers and wrist, the palm of the hand is usually placed upward, the splint on the palm of the hand. For flexion of the fingers and wrist the palm is placed downward, the splint on the back of the hand. This will 298 TECHNIQUE OF OPERATIONS necessarily vary according to the condition. It is usually convenient to have the elbow part of the splint separate from the wrist and hand splint. The former is applied to the arm and forearm, the latter over- laps the former about four inches in the forearm. The hand and finger Fig. 446.— Method of applying the string around the upper a r m when using the splint. (See figure 445). Fig. 447. — Method of splitting a plaster of Paris applied to the leg, allowing the front half or the posterior half to be re- moved. There is a window cut when necessary to allow in- spection of the dressing. There is a plaster rope flattened so that the leg will not rotate. The plaster is held together with webbing straps. A knee plaster should reach high on the thigh. (See figure 448.) part is applied and then brought into position and strapped to the elbow splint. In difficult cases this method of application has been found very satisfactory. 334. Plaster of Paris Bandage after Operation on the Knee. — In the application of a plaster to the knee after operation for correction of deformity, the sheet wadding should fit perfectly. The plaster should reach high in the groin in order to get a grip on the upper end of the femur, the plaster should hold the lower end of the femur snugly, also the upper and lower end of the tibia and the foot and ankle. If the plaster does not resemble the shape of the leg after its application there is apt to be more or less motion at the knee which may interfere with the result of the operation. The knee should always be bent a little backward, and a little hyperex- tended during the application of the plaster. Fig. 448. — End view of plas- ter (figure 447). Notice that the heel is held off of the table. A plaster rope flattened pre- formities at the knee. In straightening the knee, pressure should be made above and Pressure on the patella maintained by the plaster may cause it to be adherent. The foot and ankle are included in the plaster whenever the knee is sensitive or the operation has been extensive. A plaster rope is applied around the finished plaster (see leg in bed unnecessary. not over the knee cap. PLASTER OF PARIS AND BRACES 299 figures 447 and 448) extending on either side of the plaster preventing the leg from rotating on the table or bed. This rope may be placed at the calf. When the knee is exquisitely tender, the plaster should in- clude the joint above as well as the joint below. The plaster is split at the sides and held together with webbing or adhesive straps or a wet bandage (see figures 156 to 158). Windows are cut for inspection of the dressing without disturbing the joints. Extremely large windows may be provided for by re-enforcement with plaster rope (see figure 449). Fig. 449. — Method of applying a plaster exposing the knee for extensive dressings but immobilizing it com- pletely. The re-en- forced portions of the plaster across the knee are plaster ropes in- corporated in the leg and in the thigh plas- ter. Fig. 450. — Method of immobilizing the hip and allowing it ex- posed completely when extensive dressings are necessary. The plaster ropes are placed some distance from the skin and join the pelvis with the leg portion of the plaster. Fig. 451. — A method of applying plaster and maintaining position of the foot but allowing the heel and ankle to be exposed for dressing. (See figure 452.) 335. The Application of a Plaster of Paris Bandage after Operation or Manipulation of the Knee. — To facilitate the correction of knock knee or bow leg and at the same time to obtain a slight hyperextension of the knee during the application of plaster, the following method is of service in very muscular individuals or when much force is necessary. The leg having been covered with sheet wadding from the toes to the groin, a heavy felt pad is placed just above the knee, a double four inch bandage is spread over this pad and its four ends carried down to a leg or cross bar on the operating table and tied there (see figure 76). The operator can then slightly hyperextend the knee and correct bowing or the knock knee during the application of the plaster. When the plaster has hardened the bandage is cut away from its attachment. In cases where correction of the knee deformity has been done the plaster should extend high on the thigh. It should grasp both 300 TECHNIQUE OF OPERATIONS Fig. 452.— Plantar view of figure 451. The lined portion is a padded wooden splint. The white is a plaster and extends beyond the heel. Dotted line marks the heel. ends of each bone and fit the thigh well and fit the leg and foot well. Only in this way can the full correc- tion be main- tained. A Simple Method of Pre- venting Rota- tion of a Leg Plaster. — Plas- ter ropes are ap- plied to prevent the rotation of the leg as shown in figures 447 and 448. 336. Plaster of Paris Band- age after Oper- ation on the Foot. — In the application of a plaster for hold- ing the foot, it without cramping Fig. 453. — Front view of plaster (fig- ures 451, 452). The plaster may reach to the knee or above the knee. For a very complete fixation it should reach above, the knee being flexed slightly to prevent rotation of the plas- ter. Fig. 454.— Plaster of Paris applied with a padded wooden sole splint and "plaster ropes" acting as a cage and holding the foot at right angles. This is useful for ex- tensive dressings. Fig. 455. — An arrangement for exposing the front of the foot for dressings and maintaining posi- tion of the ankle by means of plaster of Paris. Fig. 456.— Plantar view for either fig- ure 454 or 455. Dot- ted lines show the "plaster ropes" as they extend into the plaster. is important to hold the ball of the foot firmly the toes. A small strip of cotton may be placed PLASTER OF PARIS AND BRACES 301 between the toes and folded back over the foot. It is removed after the plaster is hard. This will give room for the toes. In using pressure on the ball of the foot, for correction during the application of a plaster, the surgeon should not extend the toes at the head of the metatarsal. The heel should be padded well; pressing the plaster into the heel should be avoided. Pressure over the dorsum of the foot near the tibia should be avoided, either directly with the hand or forcing 3 in the plaster during the correction of deformity. When correction is made the plaster is apt to wrinkle here and cause a slough unless the surgeon is careful to get his correction and then apply the plaster. If the plaster is applied first and the correction ob- tained afterward the wrinkling of the V "TT" Fig. 457. — Dr. Bradford's position for manipulation of the foot. This position is used during the application of the plas- ter bandage following operation on the foot. The plaster is put on the foot from A to B; only two turns around the heel to hold this "foot-cuff" on. The knee is Fig. 458. — Position flexed and a plaster put on from D to C. of the foot following When these portions of the plaster have club foot operation. Fig. 459. — Shoulder hardened the foot is held in position and The foot is abducted, plaster with plaster ropes the plaster is finished uniting the foot and dorsally flexed and used when extensive leg portions. the cuboid raised. dressings are necessary. plaster is apt to result. Methods of holding deformities during the application of a plaster have been given for this purpose after each operation. In applying a plaster to the foot after correction of a de- formity, when the knee is normal the plaster is applied with the knee slightly bent to prevent the rotation of the plaster on the leg. When the condition or an operation on the knee will not allow this position, a plaster rope included in the plaster can be used to prevent rotation. It extends out at either side preventing rotation of the leg in bed (see figure 447). It may be necessary to apply the plaster around the pelvis to prevent the plaster from twisting if the knee must be kept straight. This should be avoided when possible as it complicates the care of the patient in bed. See figures 451 to 456. 302 TECHNIQUE OF OPERATIONS 837. Application of Plaster for Varus or Equino Varus, Club Foot Plaster. — Some care is necessary in applying a plaster to the foot for correction of bone deformity. A liberal quantity of well fitting sheet wadding is applied to the foot and leg, an extra amount being placed over the heel and between the toes. About eight layers of plaster band- age are applied around the ball of the foot and metatarsals, two layers only around the heel to prevent this cuff from slipping off. This is allowed to harden while the plaster is applied to the thigh and leg with Fig. 461. — Method of splitting a plaster with two or more jogs so that the two halves are accurately placed together. This jogging of the plaster may be done for jackets as well as for other plasters. JL Fig. 460. — Shoulder plaster used when exten- sive dressings are neces- sary. Fig. 462. Plaster knife. These plaster knives are made the knee flexed eighty to cut leather; they may be obtained by the dozen at less decrees When these two *^ an * en cent s apiece. It is easy to cut with the point ° . , i,i without endangering the patient. portions are hard, the patient is turned over on his abdomen and a pillow is placed under the knee. The operator holds the foot overcorrected (see figures 457 and 458) while an assistant joins the two portions of the plaster. In this way there is no cramping of the toes which are held flat and the plaster is applied to the deformity which is held corrected. If the operation has been thoroughly done the foot will easily overcorrect without force. Good overcorrection of the deformity is a sure method of preventing pressure sores and discomfort from the plaster. The position of over- correction of the foot in plaster is important. A vertical line through the middle of the lower leg is drawn on the plaster. This line should be determined by an imaginary plane passed through the femur and tibia. The foot should be abducted fifty degrees from this plane. It should be dorsally flexed about twenty-five degrees, the cuboid being raised more than the rest of the foot (see figures 457 and 458). PLASTER OF PARIS AND BRACES 30.- 338. Plaster of Paris Bandage for Valgus.— A plaster of Paris bandage is applied from the toes to the groin with the knee bent, as follows: a liberal quantity of well fitting sheet wadding is applied to the foot and leg, an extra amount being placed on the heel and between the toes. Eight turns of the plaster bandage are placed over the ball of the foot and around the metatarsals in front. Only one or two turns are made around the heel to hold the cuff on. The cuff is allowed to harden while the plaster is put on from above the ankle to the groin with the knee bent. When this has hardened the patient is turned over on his ab- domen, the knee rests on a cushion, the operator holds the ball of the foot in a dorsal position and adducts it, correcting the deformity while the plaster is com- pleted between the foot cuff and the leg. The heel should not be allowed to be dented or to rest on the table or bed. After an ex- Fig. 463.— Poste- rior view of plaster shell showing the method of cutting out a lozenge-shaped piece of plaster to allow the shell to be hyper extended at any point selected by the surgeon. Sometimes it is bet- ter to cut out trian- gular pieces as shown in figure 464. After bending the plaster it is re-enforced by heavy plaster ropes as shown in the dot- ted lines. Fig. 464. — When the plaster of Paris shell is made on the patient it must be hyperextended often at the point selected by the surgeon. Triangular pieces are cut out at either side of the plaster or a lozenge piece is cut out of the middle as shown in figure 463. This allows the bending of the plas- ter. It is then re- enforced as shown by the dotted lines and the shell com- pleted as shown in figure 465. Fig. 465. — Posterior plaster shell for maintaining position of the spine in recumbency. This shell will not rotate. J^> Fig. 466. — Cross section of plas- ter shell, showing the plaster por- tion resting on the table preventing rotation. tensive operation, the patient is kept quiet for three weeks. After that he is allowed to sit in a chair. At the end of the fourth week he walks on the other foot using crutches. Weight-bearing is allowed in the eighth week depending on the case; always with the plaster at first. After the eighth week the knee may be flexed twenty degrees only. In infantile paralysis, as in congenital valgus, overcorrection is made with the feet in marked adduction so that they interfere in walking. This is maintained for at least six months. Walking is made possible by wooden or plaster wedges under the sole of the plaster. 304 TECHNIQUE OF OPERATIONS Fig. 467. — This board with a pelvic rest is fastened to any table and is used to support the sacrum during the application of a pelvic plaster. Fig. 46S. — A box used to support the thorax of a patient during the application of a pelvic plaster. Fig. 469. — Portable Goldwait frame for the application of plaster jackets. 339. Plaster of Paris after Operation on the Toes. — There is some difficulty in maintaining the overcorrec- tion of hammer toe in a comfortable manner without interfering with the circula- tion. In the first place, as in the case of any deformity, the overcorrection after operation should be so complete that the toe may be put in any Fig. 470. — Posterior view of modified Taylor back brace. The U piece should be broad and ex- tends down almost to the tuberosity of the ischium at the side. Its top should be broader than the posterior supe- rior spines; the uprights rest on the transverse processes, the cross bars help to immobilize. Fig. 471. — Shows the front view of the two leather or canvas aprons used to hold the Taylor brace in place. position without force or ten sion. A well fitting plaster is then applied to the ankle and ball of the foot, often the leg is included. Incorporated in the dorsal part of the plaster are five digit-like pro- PLASTER OF PARIS AND BRACES 305 Fig. 472. — Side view of the straps and the Taylor back brace. Fig. 473. — Brad- ford abduction splint and high sole. Back view. jections made of plaster bandages moulded to protrude beyond the toes (see figures 190 to 194). When they have hardened a pad is placed under each projection, holding its metatarso- phalangeal joint flexed; a felt pad is then placed under the ball of each toe and a gauze bandage is looped around the toe and felt pad draw- ing it up to its plaster digit, holding the phalangeal joint hyperextended (see figure 190). A similar plaster may be used for the hand when a wire or aluminum is not available. The splint is preferable for the fingers. This method of applying plaster is perfectly comfortable if the opera- tion is done completely so that no force is necessary to hold the over- correction. Fig. 474.— Bradford abduction splint and high sole, front view. This splint is practi- cally a Thomas knee splint with one-half of a Thomas ring on the opposite side, the two connected by a pubic iron in the shape of a horse shoe. This pubic portion is from two to three inches broad. The measurement of the Thomas knee splint is otherwise the same. CHAPTER III PREPARATION FOR OPERATION Fig. 475. — Long caliper splint used to im- mobilize the knee and ankle with two leather anterior bands, one to hold the upper end of the tibia, the other the lower end of the femur. One or both of these may be used, depending on the use of the brace. If an operation has been done above the patella, it is better to use the lower band only. If an operation has been done below the patella it is better to use the upper one only. Where the splint is used and no operation has been done in front of the knee, an ordinary knee band, as shown in figure 476 may be used instead of these two anterior bands. This splint fits into a socket attached to a shoe. It reaches from one and one-half inches below the fold of the buttock to the sole of the foot. The uprights follow the outline of the leg. A tracing is taken of the leg for this purpose. This splint may be made with a joint at the knee which locks or allows varying degrees of motion. (See figure 478). Fig. 476. — This is a knee cap which fits over the patella and is used to keep the knee straight when used with a long cali- per splint. (See figure 495.) ra Fig. 477. — Short caliper splint used to immobilize the ankle. This splint fits into a socket attached to a shoe. This splint reaches from the tuberosity of the tibia to the sole of the foot. (See figure 478). Fig. 478. — The caliper splint (see fig- ures 475 and 477) may be arranged at its lower end with a caliper stirrup as shown above. This allows the splint to be fas- tened to the shoe by means of straps in- stead of having a socket made in the shoe for the purpose of holding the splint. One strap goes over the midtarsus, the other over the heel of the shoe. 340. Preparation for Operation. — In the preparation of the patient for operation the skin must be clean and free from irritation. If iodine is to be used, the surface should not be bandaged tightly beforehand. Soap and water should not be used for at least twenty-four hours before iodine. For shaving previous to the use of iodine, a paste of water and talcum powder or plain water is used, the application of 3 3^% tincture of 306 PREPARATION FOR OPERATION 307 iodine will be sufficient for the preparation of a fairly clean skin. Where it is necessary to use soap and water it is not advisable on the chronic debilitated patient to follow this with tincture of iodine. When Fig. 479. — Method of re-enforcing the boot to immobilize the ankle. A piece of sole leather (dotted portion) is stitched inside of the shoe, on both sides of the ankle. A hole is cut in the sole leather where the mal- leolus rests. Fig. 482. Fig. 4 8 0. — Posterior view of a short caliper splint applied to hold the ankle in an over corrected position. Notice the wedge under the shoe and the extension of the wedge laterally. The caliper is jr IG . 483.— Method of holding the leg when the bent to maintain the over s kj n f t h e f 00 t and ankle are being prepared for corrected position desired. operation. it is necessary to use soap and water the part is thoroughly scrubbed with water and green soap on a gauze sponge. The skin is first shaved, cleaned with soap and water, the soap is then entirely washed off with fresh water and the skin thoroughly scrubbed with a 70% solution of alcohol or with Harrington's * or some other solution on a gauze sponge. * (Harrington solution) Bichloride of Mercury 1 5-10 grams Hydrochloric Acid 100 cc Glycerine 100 cc Alcohol 1200 cc Distilled water 2000 cc 308 TECHNIQUE OF OPERATIONS Fig. 485. ■A sterile towel is put on the sterilized skin above. The alcohol should be used very freely from a basin sterilized by boiling and the scrubbing systematically done. When there is to be much manipulation at the time of operation, the iodine preparation should not be used, any friction over iodine will cause blistering of the skin. In "cleaning up" a patient and in placing the protective towels and sheets, etc., the assistants should be trained to be systematic and rapid; one space should be taken up after another and done thor- oughly. There should be no waste of time or delays, a nurse should be ready with each covering for the patient, Fig. 4S4.— The skin is sterilized from M to N. handing it promptly to the assistant in the order it is expected. In "cleaning up" a leg or an arm the following method may be used : 341. Preparation of the Leg and Foot for Opera- tion. — The hair is shaved the day before, using no soap if an iodine preparation is to be used. When iodine is not used the upper end of the leg is cleaned by the nurse, starting at the front of the upper end of the thigh (see figure 481), a section of the leg is scrubbed from (a-b) to (c-d) on the outer side and then back from (c-d) to (a-b). Another section is next cleaned on the inner side from (a-b) to (c-d) and then back from (c-d) to (a-b). This process is repeated twice. The nurse next cleans in a similar way the next section of the leg which overlaps the first section and extends from a-prime, b-prime, c-prime, d-prime. In the same way the third section is made to overlap the second and a fourth section overlaps the third and so on down the leg (see figure 482) . In this way the leg is cleaned com- pletely first with soap and water and second with the antiseptic solution desired. Additional cleansing may be used at the regions where the incisions are to be made. When the foot is to be prepared a nurse holds the leg just below the knee as seen in figure 483. When the foot is thoroughly cleaned it is held by a sterile nurse with a sterile towel. The leg is then cleaned up from below up- ward, using one section after another as demonstrated in figure 482. When the leg is thoroughly cleansed it is still held by a clean assist- ant while a sterile sheet is applied over the operating table, under the leg, second, a sterile towel is wound around the cleaned skin, high up on the leg to mark the sterile limit (figure 485). This towel overlaps the sterilized skin and is clamped or tied so that it will not expose the non- sterile skin. A sheet is placed over the patient and the upper leg, covering PREPARATION FOR OPERATION 309 it below the towel which has just been mentioned and clamped around it. The patient is then ready for operation. One or more sand bags are use- ful in an operation on the leg, arm and foot. A sterile sheet doubled is placed on a sterilized table, a sand bag placed on it, the sheet is folded over it several times and the edges turned in. The sand bag may- then be handled by the operator and his assistants. When a middle por- tion of the leg is to be operated upon, as for instance the knee, the leg may be prepared in the manner described above from the points Fig. 486.— A sterile sheet is put on the operating table, fm-n) (figure 484) a another over it. The foot is placed on the second sheet. V - -i •/ . (See figure 487.) non-s t e r i 1 e assistant holding the foot so that the leg is off of the side of the oper- ating table and easily cleaned on all sides. When the leg is surgically clean, a doubled sterile sheet is placed on the oper- ating table while the leg is held up, second, Fig. 487.— The sterile sheet covers the lower part of the tn ® st p nle towel IS sterilized skin (figure 484) and the foot around which it is rolled JUSt below the folded and tied. (See figure 488.) point cleaned Up above the knee (m) and another just above the point cleaned up below the knee (n); third (see figure 490) a doubled sheet is laid over the patient, and the leg and upper leg towel. A sheet is placed on the operating table (see figure 486). The nurse lays the foot and presses it in place on this sterile sheet and wraps it around the leg as in figures 487, 490. The loose end beyond the toes is folded back over the foot. This is tied with a strip over the foot, around the ankle and around the leg. Instead of using strips, a towel folded five or six inches broad and rolled may be bandaged around the foot and ankle to hold the sheet in place. This will give firmness and keep the sheet from slipping during manipulation of the leg (see figures 491 and 492). The advantage of using a sheet to envelop the lower leg and foot is, first, the saving of time as it is not necessary to prepare this great 310 TECHNIQUE OF OPERATIONS extent of skin and second, the operator is able to manipulate the leg which is protected in a sterile sheet. 342. Preparation of the Knee Flexed at Right Angles for Operation on the Semilunar Cartilage, etc. — The knee is prepared and protected as described above. Sterile sheets include the leg above and below the knee and the foot. The end of the operating table is let down and the patient's leg allowed to flex at right angles off of the end of the table. Sterile sheets protect the leg from the tableleaf and hang from the operat- ing table almost to the floor. The surgeon may stand or may sit in front of the knee and rests the foot on a sterile sheet placed in his lap over his gown. Assist- ants stand on either side of the knee. 343. Preparation of the Arm for Opera- tion. — When the elbow or arm near it is to be operated on, the prepa- Fig. 4SS.— The foot and leg are now well covered with ration is similar to that sterile sheets which cannot slip in manipulation of the described for the mid- leg. (See figure 489.) die of the leg. For the forearm or hand the preparation is used as described for the leg and foot. 344. Preparation of the Shoulder for Op- eration (see figure 493). — In operation on the shoulder the prep- aration should be made from the middle Fig. 489.— A double sheet is now placed over the upper line On the thorax an- sterile towel and clamped. (See figure 490.) terior to the middle line posterior, and as far down as the waist. The arm is prepared to the elbow. In the preparation of the shoulder and outer scapula region the patient lies on his back with hard pillows or sand bags or sawdust bags holding the pelvis rotated forward forty-five degrees. A large sand bag beneath the shoulder blades holds the posterior deltoid region six inches off of the operating table. As soon as the patient is anaesthetized he is placed on these cushions. If the right side is to be operated upon he is then rolled well over on the left side to give access to the back. The scapula and trapezius region are cleaned with sterilizing solution to the median line, also the shoulder and arm to below the elbow. The front of the chest is sterilized to the median line and to below the nipple, lower if necessary. A double sterile PREPARATION FOR OPERATION 311 Fig. 490. Fig. 491. — The knee is now ready for operation. (See figure 492). Fig. 492.— The sheet on the foot and lower leg may be fastened with towels as shown in figure. Fig. 493.— In operations on the shoulder a sand or sawdust pillow is placed to the inner side of the scapula. The shoulder !l ne f *i!f Slde ° f the °P eratin g table. This position makes the shoulder accessible in front and behind without changing the position of the patient during the operation. Fig. 494. — The osteo- tome on the market; side view of its blade, as it should not be; there should be no sudden shoulder near its cutting edge. The sur- geon should be able to feel with the end of the osteo- tome; any sudden curve or shoulder is a disadvantage. (See figure 496.) U Fig. 495.— The fiat side. An osteotome should have a large handle so that it may easily be controlled. Its sides should not flare too much. 312 TECHNIQUE OF OPERATIONS sheet is placed under the scapula and thorax over the sand bags, the patient is then allowed to roll back into the position at first described. The hand which is not sterilized is still being held by a non-sterile nurse. A sterile sheet doubled covers the head and neck. It is caught above the shoulder by clamps to the sheet on the table. Another sheet doubled reaches from the neck across the chest above the nipple continuing off of the operating table. This sheet is clamped to the second sheet at the neck and to the first sheet at the side of the operating table. A fourth sheet doubled is placed over the rest of the abdomen and legs, covering the patient and the operating table completely. The non-sterile hand and forearm is still held by an assistant. A doubled sterile sheet is placed over the thorax just below the shoulder. The non-sterile assistant places the hand, forearm and elbow firmly on this sheet and steadies it by the non-sterile part until a clean assistant grasps the sterile arm above the elbow and steadies it while the sheet isfolded from without inward over the arm and hand. The inner part of the sheet is then folded over. The end of the folded sheet beyond the fingers is turned back over the hand. Two towels folded five or six inches broad and rolled are now used. One is bandaged about the wrist holding the turned over end of the sheet, the other is bandaged about the elbow holding the sterile sheet well above the elbow. These towels are pinned or clamped. Gauze strips may be used instead of the towels. The folded flat towel holds the sheet firmly and has body enough to prevent slipping. 345. Preparation of the Elbow for Operation. — In the preparation of the elbow for operation, the patient lies on his back, a non-sterile nurse holds the hand of the arm to be operated upon. The arm is cleaned from the wrist to the axilla in a manner described for cleaning the leg. A sterile towel already folded, four to six inches broad and rolled is applied around the upper arm. If it is necessary to operate high on the upper arm, the shoulder and axilla are prepared and a small sheet or double towel is looped around the shoulder as shown in figure 493. A sterile assistant now holds the arm just below the elbow. The operating table is now covered with ster- ile sheets, a large towel doubled is placed on the operating table. The assistant places the hand and lower third of the forearm on it. The towel should be large enough to fold around the hand at least three times. When folded the end extending beyond the fingers is doubled over the hand. One of two methods may be used, either a strip is placed around the hand and tied and another around the wrist and tied, holding the towel in place, or a towel previously folded four to six inches broad and rolled is bandaged to hold on the towel, covering the wrist and hand. The towel is clamped or pinned in place. The arm is now placed across the thorax or on the operating table or on a small table or on a shelf covered with a doubled sterile sheet. 346. Preparation of the Hand and Forearm for Operation. — If the hand is to be operated on, a non-sterile nurse holds the arm PREPARATION FOR OPERATION 313 firmly with both her hands just below the elbow, the patient's fingers and hand and arm are cleaned up to the forearm without disturbing the holder of the arm. A sterile towel previously folded, four to six inches broad and rolled, is bandaged firmly above the wrist and clamped. The Fig. 496. — Side view of an osteotome show- ing the gradual slant without any bulge near the cutting edge. Pig. 49 9. —The straps are next crossed under the foot. Fig. 497.— Dr. Hay- ward Cushing's knot for temporary traction during an operation. The tendo achilles and foot are padded with heavy pads such as saddle felt; then a heavy webbing strap is applied first to the back of the leg. Fig. 500. —After crossing under the foot they are brought up on the sides of the foot and looped through the first part of the web- bing. Fig. 498.— The strap is crossed over the tar- sus which is well pad- ded. Fig. 501. — When the straps are pulled tight a side view shows the pull near the mal- leoli preventing con- striction of the ankle during the application of force. hand is placed on a sterile table, a sheet doubled covers the arm from the wrist over the sterile towel. For operations on the forearm, the preparation is similar. 347. Preparation of the Hip for Operation. — In the preparation for the right hip, the patient is placed on his left side close to the left edge of the operating table; the foot is held by a non-sterile as- sistant, the leg is prepared on all sides from below the knee to the perineum as described above. The assistant holds the foot high enough to afford easy access to all parts of the leg. The body is prepared from 314 TECHNIQUE OF OPERATIONS the waist down to the leg, extending beyond the median line in front and behind. Four sterile sheets are now used on the patient, a fifth on the leg. When the patient is clean a doubled sterile sheet is placed on the operating table behind the patient; the patient is turned back over it. The leg is still held up off of the operating table by the non-sterile assist- ant. A sheet is placed under it over the non-sterile leg and operating Fig. 502. — Plantar view showing crossing of straps. table. A sterile sheet doubled is placed under the clean leg, close to the perineum and up over the ab- domen, another covers the patient and table above the anterior Fig. 503. — The straps are tied together under the foot making a hook to which traction may be applied. When much traction is necessary the usual ordinary webbing may be used if three thicknesses are used folded together and used to- gether. Fig. 504.— Method of padding before applying the straps for traction (see fig- ure 503) . Heavy saddle felt ( z /i of aa inch thick) is used cut four inches broad and thirty inches long. It is folded over the tendo achilles and front of the foot; the padding may advantageously include the sole of the foot. spines. These are all clamped where they cross each other. The whole table and other leg are now covered with the fourth sterile sheet. A fifth doubled sheet is placed on the operating table to receive the foot of the cleaned leg which is placed firmly on it by the non-sterile assistant and held until it is steadied by the clean assistant, grasping the thigh while the outer edge of the sterile sheet is folded inward over the leg and foot. The inner part of the sheet is then folded around the leg. At the foot, the sheet beyond the toes is folded back over the foot; a towel previously folded four to six inches broad and rolled is bandaged and clamped around the foot and ankle to hold the sheet in place. Another towel like this is applied above the knee to hold the upper end of the sheet in place. This pre- vents any possibility of disturbing the protection during manipulation of the leg. INDEX The author will be glad to know of any methods or practical points that have been of value to surgeons in operations on bones, joints, muscles and tendons. Any suggestions will be welcomed. All numbers refer to paragraphs unless figures are mentioned A Abducted hip, see hip deformity Achilles tendon, lengthening, 127 " " shortening, 146 " " tenotomy, 132 Acromion depressed, 205, 224 " in obstetrical paralysis, 208, 211 " osteotomy for, 205," 224 " shoulder dislocation with, 205-211, 224 Acute arthritis of infancy, 46 Adducted hip, see hip deformity Adductor incision at the hip, 24, 31 " magnus tenotomy, 31 " myotomy, 69 Adjusting the length of the legs, 42 After-treatment, see under each operation Albee bone grafting, the spine, 321 " hip operation for osteo-arthritis, 40 " operation for ankylosing of the spine, 320 Ankle, ankylosis of; arthroplasty, 192, 193 " ankylosis; astragalectomy, 168, 192 ". arthrodesis, 179 " arthrotomy, 180 anterior external incision, 181 " " anterior internal incision, 183 " anterior median incision, 185 " circular incision, 186 " Kocher incision, 186 " metatarsal incision, 196 " posterior external incision, 182 " posterior internal incision, 184 " arthroplasty, 192-193 " astragalectomy, 168 " Bradford silk ligament, 173 " bone operation for cavus, 116 for club foot, 105 " " " for valgus, 110-111 " " " for varus, 104, 105, 106 " calcaneus, 115 " calliper splint, fig. 477 " circular incision, 186 " claw foot, 118-124 " club foot, 104-108 315 316 INDEX Ankle, contracted tendons, 118-124 toes, 11S-124 " dangle foot, 1GS, 179 " deformities, see varus, valgus, cavus, equmus, see Part III, Chapters I— III " " equinus, 117, 129 " • " equino valgus, 109-114 " , equino varus, 104-108 " excision, 168, 195, 197 " flail, 179 " flat foot, 109-114 " fracture, 117, 187-190 " hammer toe, claw foot, 118-124 " hallux valgus and foot deformity, 125 " incision, see Incisions, 1S1-186, Part. Ill, Chapter IV " infantile paralysis, see deformities, paralysis, transplantation " joint, tibio-tarsal, complete exposure for, 186 " manipulation with Bradford wrench, 102 " " " club foot wrench, 101-103 " " " Davis wrench, 103 " " " flat foot wrench, 101, 103 " " " Thomas wrench, 101 " muscle transplantations in, see paralysis, muscle transplantation " Ober operation for club foot, 106 " osteomyelitis, 198, 323 " paralytic conditions of, 151-164, 166 " plaster of Paris for, Figs. 451-456, see under each operation " poliomyelitis, see deformities, paralysis " posterior external incision, 182 " " internal incision, 183 " Potts fracture deformity, 117 " preparation of the skin for operation, 341 " puncture of the ankle joint, 191 " silk ligaments, subcutaneous method, 173 " " " by open method, 172 " supports, figs. 477, 479, 4S0 " suppurative conditions, 194-201, 323 " tapping of, 191 " tendon fixation, 174 " lengthening, 138, 139, 140 " " shortening, 144-148 " " transplantation, see muscle transplantation, paralysis " tuberculosis, 197 " valgus, 109-113 " varus, 104-109 " weak, 171, 172, 173, Chapter III " wrenches, Bradford, 102 club foot, 101-103 Davis, 103 flat foot, 101, 103 Thomas, 101 Ankylosis of the ankle, Section III, Chapter V " " " arthroplasty, 192 " " " " equinus position, operation for, 117, 129 " " " elbow, Part V, Chapter V " " " " arthroplasty, 271-272 " " " " excision, 269 INDEX 317 Ankylosis of the finger, arthroplasty, 308 " " " hip, 34 " " " " arthroplasty, 35 " " " " Gant operation in cases of, 37 " " " " excision for, 44 " " " " osteotomy, in cases of, 39 " " " jaw, arthroplasty, 318 " " " knee, Chapter V, also 94 " " " arthroplasty, 95 " " shoulder, Part IV, Chapter V " " " " arthroplasty for, 241 " " " " excision for, 239-240 " " " spine, by Albee operation, 321 " " " " by bone graft, 320 " " " " by Hibbs operation, 316, 322 " " " " by plastic operation on the, 320 " " " wrist, Part VI, Chapter IV " " " " arthroplasty, 307 " " " " excision for, 311 Apparatus after operation, see under each operation " " " see also plaster of Paris Apparatus for ankle, caliper splint, Fig. 477 " back, brace, Figs. 470-472 " Bradford frame, Figs. 8, 9, 10, 24 " " caliper splint, long and short, Figs. 475-478 " Carrell technique, 323M " " Carrell-Dakin technique, 323 " " congenital hip machine, Figs. 1-3 " " extension or flexion of the fingers, Fig. 402 " " finger, Figs. 442, 446 " " " after operation on the, 333 " " fracture of the femur in infants, Figs. 67-70 " " hallux valgus, Figs. 198-200 " " hand, after operation on the, 333 " "hip splint, Figs. 473-474 " " " traction apparatus for use during the operation, Figs. 54-61 " " knee caliper splint, Fig. 475 " " manipulating the foot, 100 " " preventing inward rotation of the forearm, Fig. 395 " shoulder shelf, Figs. 314, 315 " " toes, Figs. 190-194 " " traction during operation on the leg or arm, 235, Figs. 55, 61 " " " on the arm, 262 " " " on the elbow, 262 " " " on the leg, Figs. 54, 57 on the shoulder, 235 " " wrist, after operation on the, 323 Arm, see shoulder, elbow, wrist, hand " operation, overhead sling after, 273 " preparation of the skin for operation, 343 " traction apparatus for fractures, 235 Arthritis of infancy, acute, 46 Arthrodesis of the ankle, 179, see astragalectomy, silk ligaments " " elbow, 255 " " " silk ligaments, 252 " " flail ankle, 179 318 INDEX Arthrodesis of the hip, 12-40 silk ligaments, 13 " " knee, 75 " " " silk ligaments, 77 " " osteo-arthritis of the hip, 12 " " paralytic conditions, see under each joint " " shoulder, 225 " " silk ligament for, see silk ligaments " " " tibio-tarsal, 179 " ankle, 192 astragalo-scaphoid, 114 " elbow, 271-272 " finger, 308 " hand, 306-308 " hip, 34, 35 " Murphy, 34, 35 " knee, 95 Murphy principles, see under each joint phalangeal, 308 " shoulder, 241 " wrist, 306-308 tempomaxillary, 318 " tibio-tarsal, 179 Arthrotomy, Ankle, 181-186 " anterior median incision, 185 " circular incision, 186 " external anterior incision, 181 " posterior incision, 182 " internal anterior incision, 183 posterior incision, 184 " Kocher incision, 186 " tarsal incision, 181-186 " and foot, Part III, Chapter IV Carpal, 298-301 " anterior incision, 300 " external incision, 301 " Oilier incision, 298 " posterior incision, 299 " radial incision, 301 Elbow, Part V, Chapter IV, 256-260 " anterior incision, 260 " external incision, 258 " internal incision, 259 " posterior incision, 257 " radial incision, 258 " Finger, 302 Foot, 180-187 " anterior incision, 185 " circular incision, 186 " external anterior incision, 181 posterior incision, 182 " Kocher incision, 186 " metatarsal incision, 196 " phalangeal incision, 196 " " tarsal incision, 181-186 Hand, 302 INDEX 319 Arthrotomy, Hand, anterior incision, 300 " " carpal incision, 298-301 » " external incision, 301 " " metacarpal incision, 302 " " Oilier incision, 298 " " phalangeal incision, 302 " " posterior incision, 299 " " radial incision, 301 " Hip, anterior incision, 18 " " adductor incision, 24 " " anterior "U" shaped incision, 23 « " Brackett antero-lateral incision, 19 u " " " " with enlargement, 20 " " Murphy incision, 22 " " posterior incision, 21 " " Sprengel's incision, 14 " Knee, see Chapter IV " " anterior median incision, 82 " " bayonet incision, 84 " " cartilage semilunar incision, 78 " " crucial ligaments, incision, 85 " " lateral incision, 85 " " median incision, 82 " " posterior incision, 83 " " semilunar cartilage, incision, 78 " " " U " shaped incision, 86 " Metacarpal bones, 302 " Phalangeal incision, 302 " Sacro-iliac joint incision, 15 " Semilunar cartilage incision, 78 Shoulder, 228, 231, Part IV, Chapter IV " " anterior incision, 228 " " Burrell incision, 213 " " Codman incision, 231 " " Kocher incision, 230 " " posterior incision, 229 Wrist, 297, 303, Part VI, Chapter III " " anterior incision, 300 " " external incision, 301 " " metacarpal incision, 302 " " Ollier's incision, 298 " " posterior incision, 299 " " radial incision, 301 Astragalectomy, for dangle foot, 168 for flail ankle, 168 " displacement of foot backward, 168 " for paralytic cases, 168-170 " plaster of Paris for, 170 Astragalo-scaphoid arthrodesis, 114 Astragalus, see astragalectomy " bone operation, see club foot, pes cavus, Jones operation " drainage in suppurative conditions, 194, 323 " circular incision for astragalectomy, 186 " lateral incision for astragalectomy, 168 " suppurative conditions of, 194, 323 " tuberculosis of, 197 320 INDEX B Back brace, Figs. 470-472 Bacterial examination, Carroll technique, 323L Baer's chromicized pig's bladder for arthroplasty, 95 Bartow drill for silk ligaments, Fig. 109 " silk ligament at the knee, 77 " " " " " shoulder, 226 Bayonet incision at the knee, 84 Biceps femoris, sec hamstring " myotomy of, 69 " paralysis of, transplantation of the triceps, 250 " transplantation of, 61-67 Bloodless operation for congenital hip, 1-2 " reduction of congenital hip, 1 Bow leg, 53, 317 " " operation, 53 Bowing from rickets, 317 Bone graft for, 316 " " fractures, see fractures " " knee ankylosis, 94, 95 " " operation on the spine, Albee, 321 " " spinal ankylosis, 321, 322 " " ununited fractures, see fractures Bone operations, see deformities, osteotomy, bone graft, suppurative conditions Brackett's curved osteotomy, 39 " "U" shape incision at hip, 23 Bradford's club foot wrench, Figs. 145, 150, also 135-141 congenital hip machine, 2 congenital hip machine, Figs. 1-3 frame, Figs. 8-10-9-24 hip machine, 2 " splint, 474 subcutaneous method of silk ligaments, 173 wrench for manipulation of the foot, 102 Burrell incision in dislocation of shoulder, Fig. 362, § 213 c Caliper splints, Figs. 475-478 Carrell-Dakin apparatus, 323M " " bacterial test, 323L " " first aid dressing, 3231 " " microscopic examination, 323L " " operative preparation, 323 J " solution, 323A " technique, 3231, J, K " " wound dressing, 323K " " " preparation, 323 J Club foot, 106-113 " " after-treatment, 108 " " Bradford wrench for, 102 " " bone operation, 105 " " Davis wrench for, 103 " " excision of bone, 105 " " operations, 104-107 " " plaster of Paris for, Figs. 457, 458, § 107 INDEX 321 Club foot, position for, 107 " " Thomas wrench for, 101 " " wrenches, 100-103 " " wrench, Bradford, § 102, Figs. 145-150, also Figs. 135-141 " " " Davis, 103 " " " Thomas, 101 Codman incision at the shoulder, 231 Compound fractures, see fractures, suppurative conditions Congenital dislocation of the hip, Part I, Chapter I " " " " " after-treatment, 3 " " " " " apparatus for, Figs. 1-3 " " " " " bloodless reduction, 1 " " " " " Bradford hip machine, 2 " " " " " " frame for, 3 " " " " " " method, 3 " " " " " Lorenz position for, Figs. 11-12 " " " " " machine for reducing, Figs. 1-3 " " " " " method of treatment, 1 " " " " " Mueller position for, 13-14 " " " '" " open operation, 4 " " " " " Plaster of Paris for, 5 Congenital hip, see congenital dislocation of, hip Contracted ankle, see deformities of the " extensors of the fingers, see tendon lengthening " extensors of the wrist, see tendon lengthening finger, 280 " " manipulation, 281 " flexors of the fingers, tendon lengthening, subperiosteally at the condyle, 288 " flexors of the wrist, tendon lengthening, subperiosteally at the condyle, 288 " hip, 8 " " ankylosed, 38 " knee, see knee flexion " shoulder, manipulation for, 202 " muscles, myotomy for, 69-70 " tendons, see tendon lengthening " wrist, 280' Coxa vara, 29 Crucial ligaments, operation for repair of, 79 Cuirass, plaster of Paris for the hip and for the shoulder, 318, 320, 328, 329 . Curved osteotomy at the hip, 37 Cushing knot for leg traction, Figs. 497-504 Cut tendon of the finger, 282 D Dakin-Carrell, see Carrell-Dakin, 323 Dakin solution, see also Carrell-Dakin, 323 " " chlorine test for, 323 difficulties of, 323G " lime, test for chlorine in, 323C, 323D " " making solution, 323B " " solution formula, 323 A " " " preparation, 323B test for, 323E " " test for Dakin solution, 323E 322 INDEX Dakiu solution, test for chlorine in lime, 323C " " " " " " Dakin solution, 323E Dangle foot, 16S Davis club foot wrench, 103 " foot wrench, for manipulation of the foot, 103 Deformity, ankle, sec ankle deformity elbow, see elbow deformity femur, see femur deformity finger, see finger deformity foot, see foot deformity hand, see hand deformity hip, see hip deformity humerus, see humerus deformity infantile paralysis, see paralysis deformity knee, see knee deformity poliomyelitis, see elbow, foot, hand, hip, knee and wrist rachitic, see rickets deformity rickets, 317 " bow leg, see bow leg deformity " knock knee, see knock knee deformity shoulder, see shoulder deformity tibia, see tibia deformity toe, see toe deformity wrist, see wrist deformity Dislocation, clavicle, 210 elbow, Part V, Chapter I, also 247, 265 elbow, irreducible, 265 hip, congenital, Part I, Chapter I, also see congenital dislocation of the hip hip, congenital, plaster of Paris, 331 patella, 92 shoulder, Part IV, Chapter I " capsulorrahphy, 214 " irreducible, 213 " in obstetrical paralysis, 211 " recurrent, 215 Displacement of the foot backward, astragalectomy, 168 Displaced semilunar cartilage, 78 Drill, Bartow, Fig. 109 E Elbow ankylosis, 269, also Part V, Chapter V " " arthroplasty for, 271, 272 " " excision for, 269 " anterior incision, 260 " arthrodesis, 255 " arthroplasty, 271, 272 " arthrotomy, Part V, Chapter IV, 256-260 " " anterior incision, 260 " " external incision, 258 " " internal incision, 259 " " posterior incision, 257 " " radial incision, 258 " deformity, Part V, Chapter I, see ankylosis, 269, see dislocation, 247 " " from fracture, see fractures, 261-267 INDEX 323 Elbow deformity, manipulation for, 248 " " see osteotomy, 204 " dislocation, Part V, Chapter I " " irreducible, 265 " excision for ankylosis of, 269 " " " suppurative conditions, 276 " external lateral incision, 258 " fascia transplantation, 253 " flail, 251, 252-253 " " arthrodesis, 255 " " silk ligaments for, 252 " fracture, 261-267 " " both arms, 266 deformity, 261-267 " " of the olecranon, 267 " " overlapping, 266 " " traction apparatus for, 262 " " ununited, 264 " incision, anterior incision, 260 " " external incision, 258 " " internal incision, 259 " " posterior incision, 257 " " radial incision, 258 " infantile paralysis, see deformities, flail elbow, muscle transplantation, paraly- sis " internal lateral incision, 259 " Jones operation, 254 " manipulation, 248 " multiple fractures, 265 " muscle transplantation, see paralysis, muscle transplantation " operation, overhead sling, 273 " osteomyelitis, 275, 323, also see suppurative conditions at the elbow " overhead sling in operations on the, 273 " overlapping fracture, 263 " paralysis, see paralysis, muscle transplantation, also 251-253 " plaster of Paris for, 249 " poliomyelitis, see deformities, flail elbow, muscle transplantation, paralysis " posterior incision, 257 " preparation of the skin for operation, 345 " puncture, 268 " silk ligaments, 252 " skin operation, 254 " skin preparation for operation, 345 " sling overhead in operations on, 273 " subluxation, 247, 262-265, see fracture " suppurative conditions, 323, also Part V, Chapter V, also 274-277 " synostosis, 270 " tapping, 268 " tendon transplantation, see muscle transplantation " traction apparatus for operations on or fractures of, 262 " tuberculosis, excision for, 276 " ununited fractures, 264 Elongation of the tendon in the finger, 282 Equino valgus, 109, 114 " " bone operation for, 111 " " Bradford wrench for manipulation of, 102 324 INDEX Equino valgus, Davis wrench for manipulation of, 103 " Thomas wrench for manipulation of, 101 " " manipulation, 99 " " plaster for, 113 " " position for, 113 " Thomas wrench for, 101 " " tilting of the oscalcis in, 112 " wrenches for, 101, 102, 103 " varus, 106 " " after-treatment, 108 " " bone operation for, 105 " Bradford wrenches for, Fig. 102 " " Davis wrench for, 103 " " manipulation for, 99 " Ober operation for, 106 " " operations for, 104, 105, 106 " " plaster of Paris for, 337 " position for, 113 " " Thomas wrench for, 101 Equinus, 117, see manipulation of the foot " fascia transplantation, 178 " fractures, old, with equinus, 117, 129 " operation, 129 " plaster of Paris bandage, 131 " silk ligaments for, 171, 172, 173 " wrenches for, 101-103 Excision for elbow ankylosis, 269 " " " suppurative conditions of, 274 " " " tuberculosis of, 276 " hip, 44 " " "in suppurative conditions, 12-45, 323 " " " partial, in osteo-arthritis, painful, 40 " " knee to obtain ankylosis, 94 " shoulder, 239-240 " in suppurative conditions, 244 " wrist, 311 " " after-treatment, 311 " " " ankylosis, 311 " " " anterior and posterior excision, 311 " Ollier's method, 311 " " " in suppurative conditions, 309, 310, 311 Exposure of the joints, see arthrotomy Extensor, finger, tendon shortening, 290 " contracted, tendon lengthening, 285 " lengthening by subperiosteal operation at the condyle, 286 longus digitorum contracture, 119, 120, 121 " " " operation, 119, 120, 121 shortened, 119, 120, 121 tenotomy, 119, 120, 121 " " transplantation, 292 " pollicis transplantation, 292 wrist, contracted, tendon lengthening, 285 " " tendon shortening, 290 External incisions, see arthrotomy INDEX 325 F Fascia transplantation, ankle for equinus, 178 " " elbow, 253 " " equinus, 178 " " toe drop, 178 " removal from the thigh, 253 Fasciotomy, hip, 8 " plaster of Paris after, 332 Femur bowing, 188, 53, 55 " deformity, 53, see hip, deformity of the, see knee deformity " fractures, 25-28 " " overlapping, 26 " length adjustment, 42 " osteomyelitis, 43, 44, 45, 46, 47, 323 " osteotomy for bowing, 188 Gant, 37 " " for hip deformity, 37 " " for knee deformity, 55 " " McCewen, 55 Fibula, 189 " bowing, 53, 188 " deformity, 188 " fractures, 190 " " overlapping, 189 " osteomyelitis, 198 " osteotomy, 188 " suppurative conditions, 194 Finger ankylosis, arthroplasty for, 308 " apparatus, Figs. 442, 446 " " after operation, 333 " arthrotomy, 302 " contracted, 280 " contracted, manipulation, 281 " flexors, contracted, tendon lengthening subperiosteal^/ at the condyle, 288 " fracture, 303-304 " " ununited, 304 " incision, 302 " manipulation, 281 " retaining apparatus, 323, Figs. 442-446 " silk elongation for cut tendon, 282 " suppurative bone disease, 309 " tendon cut, silk elongation, 282 First aid dressing, Carrell method, 3231 Flail ankle, 168, also see Chapter III " " arthrodesis for, 179 " " astragalectomy for, 168 " muscle transplantation for, 168 " silk ligaments for, 171, 172, 173 " " tendon transplantation for, 168 " elbow, 251, 252, 253, 254, 255, also Part V, Chapter III " " arthrodesis for, 255 " " silk ligaments for, 252 " hip, 8-10 " " arthrodesis for, 12 " " silk ligaments for, 13 326 INDEX Flail knee, 75, 76, 77 " " arthrodesis for, 75 " " patella, fixation for, 76 " " silk ligaments for, 77 ' shoulder, 223 " arthrodesis for, 225 " silk ligaments for, 226 carsus, astragalo-scaphoid arthrodesis for, 114 Flat foot, 109-114 " " bone operation for, 111 " " Bradford wrench for, 102 " " Davis wrench for, 103 " " excision of bone for, 111 " " manipulation of, 99 " " plaster of Paris for, 113 " " position for, 113 " " tilting of the oscalcis, operation for, 112 " " Thomas wrench for, 101 " " WTench for, 100 Flexed hip, bone operation for, 37 " " fasciotomy for, 8 " " Gant operation for, 37 " " manipulation for, 7 " " osteotomy for, 39 " " Soutter operation for, 8 " " transplantation of hip flexors for, 8 " knee, bone operation for, 54 " " genuclast for, 51 " " manipulation for, 48 " " myotomy for, 71 " " osteotomy for, 54 " " tenotomy for, 70-74 Flexor of fingers contracted, tendon lengthening subperiosteally at the condyle, 288 " " finger, tendon lengthening, 287 " " " " shortening, 289 " " wrist, contracted, tendon lengthening subperiosteally at the condyle, 288 " " " tendon lengthening, 287 " " " " shortening, 289 Foot, ankylosis of; arthroplasty, 192 " ankylosis; astragalectomy, 168 " arthrodesis, 179 " arthrotomy, 180-187 " arthrotomy, anterior external incision, 181 " " " internal incision, 183 " " " median incision, 185 " " circular incision, 186 " " Kocher incision, 186 " " metacarpal incision, 302 " " posterior external incision, 182 " " posterior internal incision, 184 " arthroplasty, 192 " astragalectomy, 168 " Bradford silk ligament, 173 " bone operation for cavus, 116 " bone operation for club foot, 105 "" " " valgus, 111 INDEX 327 Foot, bone operation for varus, 105 " calcaneus, 115 " caliper splint, Fig. 477 " circular incision, 186 " claw foot, 118-124 " club foot, 104-108 " contracted tendons, 118-124 " contracted toes, claw foot, 118-124 " dangle, 168, 179 " deformities, see varus, valgus, cavus, equinus, see Part III, Chapters I-III " " equinus, 117, 129 " " equino valgus, 109, 114 " " varus, 104, 105, 106, 107, 108 " excision, 168, 195, 197 " flail, 179 " flat foot, 109-114 " fracture, 117, 187-190 " hammer toe, claw foot, 118, 124 " hallux valgus and foot deformity, 125 " incision, see arthrotomy " infantile paralysis, see deformities, paralysis, transplantation " joint, tibio- tarsal, complete exposure for, 186 " manipulation with Bradford wrench, 102 " " " club foot wrench, 101-103 " " " Davis wrench, 103 " " " flat foot wrench, 101, 103 " " " Thomas wrench, 101 " muscle transplantations, in, see paralysis, muscle transplantation " Ober operation for club foot, 106 " osteomyelitis, 198, 323 " paralytic conditions of, 151-164, 166 " plaster of Paris for, Figs. 451-456, see under each operation " poliomyelitis, see deformities, paralysis " posterior external incision, 182 " posterior internal incision, 183 " Potts fracture deformity, 117 " preparation of the skin for operation, 341 " puncture of the ankle joint, 191 " silk ligaments, subcutaneous method, 173 " " " by open method, 172 " supports, Figs. 477, 479, 480 " suppurative conditions, 194-201, 323 " tapping of, 191 " tendon fixation, 174 " " lengthening, 138-140 " " shortening, 144, 148 " " transplantation, see muscle transplantation, see paralysis " tuberculosis, 197 " valgus, 109-113 " varus, 104-109 " weak, 171, 172, 173, Chapter III " wrenches, Bradford, 102 club foot, 101-103 " " Davis, 103 flat foot, 101, 103 " " Thomas, 101 328 INDEX Forearm, apparatus to prevent inward rotation, Fig. 395 " bowing of, 317 " deformity of, 317 " fractures of, 261 " fractures of both bones overlapping, 266 " muscle transplantation in the, 284 Formaldehyde glycerine solution for injection into the joint, 33 Fracture, ankle, 117, also 187-190 " bones both of the forearm, 266 " carpus, 304 " compound, see suppurative conditions " deformity from, see each joint, each bone elbow, 261-267 " multiple, 265 " " traction apparatus for, 262 femur, 25-28 " " in infants, apparatus for, Figs. 67-70 " " neck, plaster of Paris cuirass for, 329 " " overlapping, 26 " " traction apparatus for, 37, Figs. 54-57 fibula, 190 " fibula, overlapping, 189 " finger, 303-304 foot, in the, 187-190 " forearm, both bones, 266 hand, 303-304 hip, 25, 26, 27, 28 " " compound, 27 " " at the neck, 28 " " ununited, 27 " " plaster of Paris cuirass, for, 329 " " traction apparatus for, 37, Figs. 54, 57 humerus, 232, 233 " " overlapping, 263 " " traction apparatus for, 235, also 262 " " ununited, 237 " knee cap, 90 " knee joint, 91 leg, 190 " neck of the femur, plaster of Paris cuirass for, 329 " neck of the femur, 28 " olecranon, 267 " patella, 90 radius, 266 shoulder, 232-237 " " traction apparatus for, 235, also Figs. 375, 378 shoulder, 237 tibia, 189 " ulna, 266 " Whitman treatment for fracture femoral neck, 28 " wrist, 303-304 Frame, Bradford, Figs. 8, 9, 10, 24 " portable for jackets, plaster of Paris, Fig. 469 INDEX 329 G Galli tendon fixation, 174, 175, 176, 177 Gant operation at the hip, 37 General considerations, infantile paralysis, 319 Genuclast, Fig. 72 Goldthwait, 51, also Fig. 72 " for subluxation of the knee, 51 Gluteal bursitis, incision for, 32 Glycerine formaldehyde antiseptic injection, 33 Goldthwait genuclast, 51, also Fig. 72 Gracillis myotomy, 69 " transplantation, see muscle transplantation, see hamstring H Hallux valgus, 125 " " after-treatment, 125 Hammer toe, 118-124 " " bone operation for, 123 " " excision of the joint for, 124 " tendon operation for, 119, 120, 122 Hamstring muscles transplantation forward, 61-62 " " transplantation, see muscle transplantation " tenotomy, 69-70 Hand ankylosis, arthroplasty for, 307 " excision for, 311 anterior incision, 300 apparatus after operation on, 333 arthroplasty for ankylosis, 307 arthrotomy, 297-302 " anterior incision, 300 " external incision, 301 " metacarpal incision, 302 " Oilier incision, 298 " posterior incision, 299 " radial incision, 301 club hand, 279 congenital deformity, 278-280 contracted fingers, 280 " tendons, 281, 282, 285, 286-288 " wrist, 280 cut tendons, 282 deformity, Part VI, Chapter I club hand, 279 " Madelung, 278 " pronation, 283 " Tubby operation for, 283 " wrist manipulation for, 281 dislocation, 278 excision of the carpus, 311 excision for ankylosis, 306-308, 311 excision in suppurative conditions, 311 external incision, 301 flexed, 280 flexors contracted, tendon lengthening subperiosteally at the condyle, 288 fractures, carpal, 303-304 330 INDEX Hand incisions, anterior, 300 " external, 301 " metacarpal, 302 " Oilier, 298 " phalangeal, 302 " posterior, 299 radial, 301 infantile paralysis, see deformities, muscle transplantation, deformities muscle and tendon operations manipulation for the, 2S1 Madelung deformity, 278 osteomyelitis, Part VI, Chapter V, 323 poliomyelitis, see paralysis, deformities, muscle transplantation preparation of the skin for operation, 346 pronation deformity, 283 pronation deformity, muscle transplantation, Tubby operation for, 283 puncture, 305 retaining apparatus, 333 rachitic deformity, 317 . silk extension for cut tendons, 282 suppurative conditions, Part VI, Chapter V, 323 tendon elongation, 287 tendon lengthening, 285, 287 tapping the, 305 tendon shortening, 289, 290 tendon silk extension, 282" tendons cut, 282 Tubby operation for pronation of the, 283 tuberculosis, see suppurative conditions Hawley table, 37 Head, plaster of Paris bandage for, 326 Hibbs operation for obtaining ankylosis of the spine, 320 High scapula, 216 Hip abduction and flexion deformity, 6, 7, 36, 37 " adduction and flexion deformity, 6, 7, 36, 37 " ankylosis of, 34-37 " " with flexion and adduction, 36 " arthritis in infancy, acute, 46 " arthrodesis, 40 " arthroplasty, 34 " arthrotomy, adductor incision, 24 " " anterior incision, 18 " " antero-lateral incision, 19 " " anterior "U" incision, 23 " " Brackett incision, 23 " " Murphy incision, 22 " " posterior incision, 21 " " Sprengel's incision, 14 " Bradford congenital hip operation, 2 " machine, 2 " coxa vara, 29, 38 " deformity, see subluxation, flexion, dislocation, abduction, adduction, coxa vara, " bowing and fracture. " dislocation, congenital, 1 " " bloodless operation, 1 " " open operation, 4 INDEX 331 Hip dislocation, plaster of Paris for, 5 " epiphysis, separation, 41 excision, 44 fasciotomy, 8 flail, 11 flexion, 6, 7, 8, also see Soutter's operation " with abduction, 36 " " ankylosis, 36 " " dislocation, 36, also see congenital hip " without dislocation, 36 " due to contracted soft tissues, 6 " operation, 37 flexors transplanted, see transplantation of hip flexors, 8 fracture, 25, 26, 27, 28 " of the neck, 28 Gant operation, 37 neck, 28 overlapping, 26 ununited, 27 incision, adductor, 31 " anterior, 18 " antero-lateral, 19 " antero-lateral with enlargement, 20 " anterior "U" shape, 23 " Brackett's "U," 23 " internal, 24 " posterior, 21 " "U" shape, 22 " Sprengel's, 14 Hip joint, tapping, 33 machine, 2 Bradford, 2 " for traction during operations on the hip or leg, 2 " congenital, Figs. 1-3 " for traction, during operation, 2 manipulation, 6 muscle transplant hip flexors, 8 myotomy for spastic contractures, 71-73 operation, tense adductor magnus, 31 osteo-arthritis, 40 osteomyelitis, 323, 47 osteotomy at the neck, 39 " subtrochanteric, 37 plaster of Paris, 330 plaster of Paris for congenital, 331 " " " after fasciotomy, 332 " " " after osteotomy, 10 " " " after transplantation of the hip flexors, 8 " " " cuirass, 329 preparation of the skin for operation, 347 rickets, 29 silk ligaments, 13 Soutter operation, 8 splint, Figs. 473, 474 suppurative conditions, 43, 44, 45, 46, 47, also 323 tendon transplantation see muscle transplantation 332 INDEX Hip traction during operations, Fig. 55-61 " " apparatus, Figs. 55-61 " transplantation of the hip flexors at the ilium, Hoffa's curved bsteotomyj 37 Hollow foot, 116 Humerus deformity from fracture, 237 " dislocation, 210 " excision of the elbow, 269-276 " " shoulder, 239, 240 fracture deformity, 204, 232, 233 " " elbow, 264 " " overlapping, 263 " ununited, 264 " " supracondylar, 261-262 " " traction apparatus for, 235, 262 " inward rotation, 203 " osteotomy for inward rotation, 204 " " " deformity, 204 " osteomyelitis, 242-244 " overlapping fracture, 236 " plaster of Paris for, 217 " " " " cuirass for, 328 " suppurative conditions, 243, 323 wire shelf for, Figs. 314, 315 Ilium exposure, 14 Incision, 14 ankle, 181-186 " " anterior median, 185 " " circular, 186 " " external anterior, 181 " " " posterior, 182 " " internal anterior, 183 " " " posterior, 184 " Kocher, 186 " " tarsal, 181-185 " " and foot, Part III, Chapter IV carpal, 298-301 " " anterior, 300 " " external, 301 " Oilier, 298 " " posterior, 299 " radial, 301 " elbow, Part V, Chapter IV, 256-260 ■ " " anterior, 260 " " external, 258 " internal, 259 " " posterior, 257 " " radial, 258 finger, 302 " foot, 181-186 " " anterior, 181 " " circular, 186 " " external anterior, 181, 183 " " " posterior, 182, 184 INDEX 333 Incision, foot, Kocher, 186 " metatarsal, 196 " phalangeal, 196 " tarsal, 181-185 hand, 302 " anterior, 300 " carpal, 298-301 " external, 301 " metacarpal, 302 " Oilier, 298 " phalangeal, 302 " posterior, 299 " radial, 301 hip, anterior, 18 " adductor, 24 " anterior "U" shaped, 23 " Brackett antero-lateral, 19 " " " " with enlargement, 20 " Murphy, 22 " posterior, 21 " Sprengel's, 14 knee, see Chapter IV " anterior median, 82 " bayonet, 84 " cartilage semilunar, 78 " crucial ligaments, 79 " lateral, 85 " median, 82 " posterior, 83 " semilunar cartilage, 78 " "U" shaped, 86 metacarpal bones, 302 phalangeal, 302 sacro-iliac joint, 15 semilunar cartilage, 78 shoulder, 228, 231, Part IV, Chapter IV anterior, 228 Burrell, 213 Codman, 231 Kocher, 230 posterior, 229 i it, 297, 303, Part VI, Chapter III anterior, 300 external, 301 metacarpal, 302 Ollier's, 298 posterior, 299 radial, 301 Infantile paralysis, 319 and under each joint, see muscle transplantation, see muscle and tendon operations Infra spinatus shortening, 206 Instruments, Bartow drill, Fig. 109 " Bradford foot wrench, 102 club foot wrench, 101, 102, 103 " " " Bradford, 102 " " " Davis, 103 334 INDEX Instruments, club foot wrench, Thomas, 101 Davis foot wrench, 103 foot wrench, Figs. 121-154 genuclast, Fig. 72 " Goldthwait, Fig. 72 Goldthwait genuclast, Fig. 72 needle for subperiosteal insertion of silk, 91 osteotome, good and poor, Figs. 494-496 periosteal needle, Figs. 91, 281 tendon carrier, Fig. 80, also Fig. 230 tenotome, good and poor, Figs. 208-209 Thomas foot wrench, Figs. 121-131 Inward rotation, shoulder due to spastic paralysis, 209 " " " muscle lengthening, 207 " " " muscle shortening, 206 " " " obstetrical paralysis, 208 " " " obstetrical, see obstetrical paralysis " " " operation for, 203 " " " osteotomy for, 204 " " " Sever's operation, 208 Irreducible dislocation elbow, 265, also see dislocation " " shoulder, 213, also see dislocation Jacket, plaster of Paris, 327 " " " " portable frame for, Fig. 469 Jaw ankylosis, arthroplasty, 318 Joint, see ankle, elbow, hip, knee, shoulder, wrist " antiseptic injection, 33 Jones operation at the elbow, 254 " operation, 116 E Knee ankylosis, Chapter V " arthroplasty, 95 " arthrodesis for, 75 " arthrotomy, Chapter IV, §§ 80, 81 " anterior median, 82 " bayonet, 84 " crucial ligament for, 79 " lateral, 85 " median, 82 " posterior, 83 " semilunar for, 78 " "U" incision, 86 " Bartow silk hgament for, 77 " caliper sphnt, Figs. 475-476 " crucial ligament, 79 " fractures, patella, 90 " " overlapping of femur or tibia, 88 " ununited, 89 " deformity, 55, also Chapter I " correction with genuclast, 51 " " osteotomy, 54 " tendon lengthening, 50 INDEX .335 Knee dislocation patella, 92 excision for, 94, 98 exposure, "U" shape incision, 86 flail, 75 flexion, 48 also 51 " correction with genuclast, 51 " deformity, Osgood's operation, 59 " tendon lengthening, 50 • " osteotomy, 54 incision, see arthrotomy " adductor tendon for, 31 internal derangement, 79, also see arthrotomy joint fractures, 91 joint puncture, 93 joint tapping, 93 manipulation, 48 muscle transplantation, see paralysis, muscle transplantation muscle rupture, 60 myotomy, 69-71 osteomyelitis, 97, 98, 99, also 323 operative preparation of the skin, 342 osteotomy for, 54, 55 patella dislocation, 92 plaster of Paris after manipulation, 335 " " " preventing rotation, 58 " " " after operation, 334 preparation of the skin for operation, 341-342 rachitic deformities, 53 semilunar cartilage, 73 silk ligaments, 77 subluxation, 51 " manipulation, 51-52 " genuclast for, 51 suppurative conditions, 96, 97, 98, 99, also 323 suppurative conditions and osteomyelitis, 323 tendon transplantation, see muscle transplantation tenotomy, 70, 74 Knife for plaster of Paris, Fig. 462 Knock knee, 53 " " operation, 53 Knot for leg traction, Figs. 497, 504 Kocher incision at ankle, 186 " " " shoulder, 230 L Lacing of a plaster of Paris, 325 Lange method of muscle and tendon transplantation, 148 Leg, plaster of Paris for, Fig. 461 " preparation of the skin for operation, 341 " traction apparatus for operations on the, 37 M Machine for congenital dislocation of the hip, Bradford, 2 Madelung's deformity, 278 Manipulation, elbow, 248 " finger, 281 330 INDEX Manipulation, foot, 99 " " apparatus for, 100 " Bradford wrench for, 102 " " Davis wrench for, 103 " " deformity, 99 " " Thomas wrench, 101 " " plaster of Paris following, 107 " hand, plaster of Paris following, 281 " hip, under anaesthesia, 7 knee,4S-50 " " plaster of Paris following, 57, 335 " " subluxation for, 51-52 " shoulder joint, 202 " wrist, 281 Martin's traction in overlapping fractures at the arm, 236 « u it « « << « | egj jgg " " " " " " thigh, 26 Metacarpal and phalangeal ankyloss, 308 " arthroplasty, 308 arthrotomy, 302 " bone incision, 302 " contracted tendon, 382 " cut tendon, 382 " incision, 302 " joint incision, 302 " silk tendon elongation, 382 " tendon elongation, 382 Metatarsal suppurative conditions, 312 " and phalangeal ankylosis, 123, 124 arthrotomy, 196 bone incision, 196 contracted tendon, 119, 121 cut tendon, 382 deformity, 118-124 excision, 124 osteotomy, 123 oste-ectomy, 124 silk tendon elongation, 382 suppurative conditions, 196 tendon elongation, 382 Motions of the shoulder, normal, 202 Multiple suppurative conditions, 312 Murphy's arthroplasty at the elbow, 271, 272 " " hip, 34, 35 " " knee, 95 " " shoulder, 241 " solution for antiseptic injection into the joint, 93 " "TJ" shaped incision at the hip, 22 Muscle insertion, Vulpius, 150 " operations, see muscle transplantation, tendon lengthening and muscle shortening Muscle operations at the elbow, Part V, Chapter II " " finger, Part VI, Chapter II " " foot, Part III, Chapter II " " " hip, Part I, Chapter II " " knee, Part II, Chapter II INDEX 337 Muscle operations at the wrist, Part VI, Chapter II " rupture, 60 " section removed from, 73 " shortening, infra spinatus, 206 " " inward rotation of the shoulder, 206, 207 " " leg, in the, 144 " " long flexors of the fingers, 289 " " long flexors of the wrist, 290 " transplantations, biceps, paralysis, 250 " " elbow, paralysis, Part V, Chapter II " " of the extensor carpi radialis, for paralysis of the flexors, 295 " " of the extensor longus digitorum, 155, 156, 158, 159 " " " " " " " to the heads of the metatarsal, 157, 159 " and tendon transplantations of the extensor longus digitorum in the lower third of the leg, 156 Muscle and tendon transplantations of the extensor longus digitorum to the tarsus, 155 Muscle and tendon transplantations of the extensor longus digitorum to the metatar- sal heads, 159 Muscle and tendon transplantations of the extensor longus hallucis, 153, 154, 157 Muscle and tendon transplantations of the extensor longus hallucis to the heads of the metatarsal, 157 Muscle and tendon transplantation of the extensor longus hallucis in the lower third of the leg, 153 Muscle and tendon transplantation of the extensor longus hallucis to the tarsus, 154 " " " " " " external hamstring, 65 " " " " " finger paralysis, 282 " " " cut tendon, 282 " " " " " " flexor carpi radialis for paralysis of the flexor longus pollicis, 294 Muscle and tendon transplantations of the flexor carpi ulnaris for paralysis of the flexors of the wrist, 295 Muscle and tendon transplantations of the flexor longus digitorum, 152 " " " " " " " " " to the tendo Achilles, 163 Muscle and tendon transplantations in the forearm, 284 " " " " " nerve supply, 292, 296 " " " " " " " for paralysis in the extensor longus pollicis, 292 Muscle and tendon transplantations of the gracillis, 61-67 " " " " " " hamstring muscles forward to the quad- riceps, 61-62 Muscle and tendon transplantations at the hip, Chapter II, Part I " " " " of " " flexors at the ilium, 8 " " " " at the ilium, 8 " " knee, Chapter II, Part II " " " " " Lange method, 148 " " " " nerve supply in the forearm, 292, 296 " " " " of the palmaris longus, 291 " " " " " " for paralysis of the ex- tensor pollicis, 291 " " " " for paralysis of the fingers, 284 " " " " in paralysis of the tibialis anticus, 148-160 " " " " of part of the tibialis anticus to the extensor of the great toe, 166 338 INDEX Muscle and tendon transplantations of the pectoralis major for paralysis of the del- toid, 221 Muscle and tendon transplantations of the pectoralis major to the trapezius, 220 " " " " " peroneii, 148 " " " " " " to the front of the foot, 148 " " " " " " Lange method, 148 " " " " " " " post-operative plaster, 149 " ' " " " " to the tendo Achilles, 165 " " " " " tenotomy of the, 138 " " " " sartorius, 61, 63, 67 " " " " " " semi-membranosis, 61-67 " " " " " " semi-tendonosis, 61-67 " ■ « " at the shoulder, Part IV, Chapter II " of the tendo Achilles forward, 161-162 " " " " one-half forward, 160, 161, 162 " " " " of the tensor fascia-femoris, 61-67 at " thigh, 61 " " " " of " " plaster of Paris, 68 " " " " " " tibialis anticus, paralysis, 148-160 " " " " " " " " in paralysis of the exten- sor hallucis, 166 " " " " of the tibialis posticus, 151, also 167 " " " " " " . " forward, 151 " " " " " to the tendo Achilles, 164 " for toe drop fascia, 178 " " " " of the trapezius to the deltoid, 219 ,( " " " " " " " pectoralis major, 220 " " triceps, 250 " " " " " " " to the biceps, 250 " " " " two hamstrings forward in the thigh, 62 " " " " " " wrist, 284, also Part VI, Chapter II, see deformities, muscle and tendon operations under each joint, paralysis Myotomy, adductors, of the, 69 " hamstrings, of the, 69 " in obstetrical paralysis, 208 " in spastic paralysis, 71 N Neck deformity, see wry neck, torticollis " of the femur, fracture, 28 " " " " osteotomy for, 39 " " " " fracture or osteotomy, plaster of Paris' bandage for, 326 Nerve, sciatic incision for, 30 " supply of the muscles of the forearm, 296 Normal motions of the shoulder, 202 o Ober operation for club foot, 106 Obstetrical paralysis, 208 " " Sever operation, 208 " " depression of the acromion, 211, see shoulder inward rotation INDEX 339 Olecranon fracture, 267 Ollier's incision at the wrist, 298 " method of excision at the wrist, 311 Operations in infantile paralysis, general considerations, 319, see muscle and tendon operation, deformities Operations in the neck, wry neck, 314 Oscalcis, disease of the, 195 " tilting in club foot, 104, 105, 106, 107 " " " flat foot, 112 " " " valgus, 112 Osgood's instrument in hallux valgus, 125 Osgood operation at the knee, 59 Oste-ectomy, see deformities Osteo-arthritis at the hip, arthrodesis for, 40 Osteomyelitis, see suppurative conditions of the hip, knee, ankle, shoulder, elbow and wrist, also 323 Osteomyelitis, ankle, 198, 323 " elbow, 275, 323, see suppurative conditions at the elbow " fibula, 97, 98, 99, 323 hip, 43, 44, 45, also 323 " humerus, 242-244, 323 " knee, 97, 98, 99, also 323 " plastic operation for closing wounds from, 200 radius, see suppurative conditions about the elbow, also sections 275, 323 " shoulder, 242-244, also 323 " suppurative conditions at the hip, 323, see under each joint " tibia, 97, 98, 99, also 323 " ulna, see suppurative conditions about the elbow, also 275, 323 " wrist, Part VI, Chapter V, also 323 Osteotome, good and poor, Figs. 494-498 Osteotomy, 188 " for anterior bow legs, 53 " bow leg, 53 " coxa vara, 29 " " depressed acromion, 205 " " femur, 55 " " flexion deformity of the hip, 6, 8, 37 " " flexion deformity of the knee, 54 " " hallux valgus, 125 " hip, 37 " " hip, plaster of Paris after, 332 " " inward rotation of the shoulder, 204 " " knee deformity, 55 " " knock knee, 53 " " metatarsal, 123 " " neck of the femur, 39 " " shoulder inward rotation, 204 " " subtrochanteric, 37 " " trochanteric, 36 Overhead sling after operation on the arm, 273 Overlapping fractures of both bones of the forearm, 266 " " " elbow, 263 " " " hip, method of treating, 26 " humerus, 263 " " " shoulder, 236 340 INDEX Paralysis of the abductors, silk ligaments at the hip for, 13 • ankle, 168, 171, 174, see Chapter III ' anterior thigh muscles, 61-67 ' biceps; transplantation of the triceps, 222, also 251 ' deltoid; transplantation of the pectoralis major, 221 ' " " " " " " " to the trapezius, 220 " " to the trapezius, 219 ' " " of the trapezius to part of the pectoralis major, 220 ' elbow, 222, 251, Part V, Chapter III, also 251, 252, 253 ' extensor of the great toe; transplantation for, 166 ' " longus digitorum; transplantation for, 292 ' " " " " of the palmaris longus, 291 " " " " for, 292 ' " " " " of the palmaris longus, 291 ' flexor longus digitorum, muscle transplantation for, 293 ' " " pollicis, muscle transplantation for, 293 '•' " " " when the flexor carpi radialis is spared, 294 ' flexors of the wrist, transplantation of the extensor carpi radialis, 295 ;< " " " " transplantation of the flexor carpi ulnaris, 295 :< foot, astragalo-scaphoid arthrodesis for, 114 ' hip, 11-12 ' " abductors, silk ligament for, 13 ' " arthrodesis for, 12 ' " fasciotomy, 8 :< " silk ligaments for, 13 ' " Soutter operation, 8 " " transplantation of the hip flexors, 8 : ' knee, 77 ' " arthrodesis, 75 " " Bartow silk ligament for, 77 ; ' " silk ligaments, 77 " " operations for, Part II, Chapter III " " hamstring transplantation, 61, 62 " " sartorius transplantation, 63 " " tensor fascia femoris transplantation, 64 " peroneii, transplantation of one-half of the tendo Achilles, 161 " quadriceps, muscle transplantation, 61 " " hamstring transplantation, 61, 62 " " sartorius transplantation, 63 " " tensor fascia femoris transplantation, 64 " shoulder, 218, 222, also see Chapter III, Section IV " " arthrodesis for, 225 " " with depressed acromion, 224 dislocation, 214 " " silk ligaments for, 226 " " transplantation of the pectoral, 220 " " " " " trapezius, 219 " " see deltoid paralysis " tendo Achilles, transplantation of the flexor longus digitorum, 163 " " " " " " peroneii, 165 " " " " " tibialis posticus, 164, 167 INDEX 341 Paralysis of the tibialis anticus, muscle transplantation for, 148-160 " " " " " transplantation of the extensor hallucis, 157 " " " " " " " " digitorum, 156 " " " " " " " peroneii, 165 " " " " " " " " tibialis posticus, 151 " " " " " " " " tendo Achilles, 160 " " " " " " of one-half of the tendo Achilles forward, 162, see also under deformities of each joint due to paralysis Paralysis spastic, myotomy for, 69, 71 Paralytic dislocation of the ankle, see flail ankle " " " hip, see arthrodesis, silk ligament " " " " knee, see arthrodesis, silk ligament " " " " shoulder, partial dislocation of, 211-212, also 223 Patella dislocation, 92 " fracture, 90 Pectoralis muscle, tenotomy, 208 Periosteal needle, Figs. 91, 281 Peroneii transplantation, 148 " after treatment, 150 " Lange method, 148 " post-operative plaster, 149 " tenotomy of the, 138 Pes cavus, 116 Phalangeal, see metacarpal, metatarsal Pig's bladder for arthroplasty, 95 Plaster of Paris, Albee operation, see plaster shell " " " ankle, Figs. 451-456 " " " ankylosis of the spine operation, see plaster shell " " " astragalectomy, 170 " " " calcaneus, 338 " " " calcaneo varus, 337 " " " " valgus, 338 " " " club foot, 337 also Figs. 457-458 " " " cuirass, Figs. 318, 320 " " " deformities of the foot, 121, also see chapter on deformities of the foot " " " elbow, 249 " " " for equino varus, 337 " " " " equino valgus, 338 " " " " equinus, 131 " " " "flat foot, 338 " " " " fasciotomy, 332 " " " " fracture of the hip, 37, 329 " " " " " " both bones of the forearm, 266 " " following operations, see under each operation " " " " foot, 457-458 " " " " " deformities, 457-458 " " " " " manipulation, 131 " " " " " operations, 131, also 336 " " " " Gant operation, 10 " " " "hip, Section 330 also Fig. 450 " " " " " congenital dislocation, 5 " " " hip, congenital dislocation in the after treatment, 3 " " " " dislocation, 5 " " " " in infantile paralysis, 10 " " " head, 326 " " " Hibbs operation, see plaster shell 342 INDEX Plaster of Paris jacket, 327 " " " " portable frame for, Fig. 469 " " " knee, 56-57 " " " " manipulation, 56, also 335 " " " " operation, 56, also 334 " " " knife, for, Fig. 462 " " " lacing method of, 325 " " " leg, Fig. 461, also Section 335 " " " method of lacing, 325 " " " method of preventing rotation, 58 " " " muscle transplantation of the hip flexors, 8-10, 332 " " " " " in the thigh, 68 " " " neck, 326 " " " ropes, 326 " " " posterior shell, 463 " " " sheU, Figs. 463^66 " " " " posterior, Fig. 463 " " " shoulder, 217, also 328, Figs. 459-460 " " " spica board, Figs. 467-468 " " " Soutter operation, 332 " " " spine, see posterior shell, jacket " " " thigh, muscle transplantation, 68 " " " thorax, 326 " " " toe operation, 339 " " " trochanter operation, 10 " " " varus, 337 " " " valgus, 338 " " " see also under each operation Plastic operation on the spine, 320 " Albee, 321 " Hibbs, 322 Poliomyelitis, see deformities, muscle and tendon operations, muscle transplantation " general considerations, 319 " " principles, 319 Post-operative treatment, see under each operation Posterior incisions, see incisions " plaster shell, Fig. 463 Potts disease, operation on the spine, 320, 321, 322 " fracture deformity, 117 Preparation of the skin for operation, 340, see Part VII, Chapter III, also 340-347 " " " " " arm, 343 " " " " " elbow, 345 " " " " " foot, 341 " " " " " forearm, 346 " " " " " hand, 346 " " " " " hip, 347 " " " " " knee, 341-342 " " " " " leg, 341 " " " " " shoulder, 344 " " " " " thigh, 347 Puncture, ankle, Part III, Chapter IV, also 191 " elbow, 268 hip, 33 " knee joint, Part II, Chapter IV, also Section 93 " shoulder, Part IV, Chapter IV, 238 " wrist, 305 INDEX 343 Q Quadriceps rupture, 60 R Rachitic deformity, 317, see osteotomy, rickets, 317 Radius bowing, 266 " deformity, 266 " fracture of both bones, 263, 266 " " overlapping, 263, 266 " osteomyelitis of, see suppurative conditions about the elbow, also 275 " suppurative conditions, 275 " synostosis, 270 Recumbent frame, Figs. 8, 9, 10, 24 Retaining apparatus for the hand post operative, 333 " " " " wrist post operative, 333 Ruptured muscle, 60 " quadriceps, 60 S Sacro-iliac joint, 15 " " incision, 15 Sartorius muscle transplanted, 65 Scapula deformity, 216 " suppurative conditions, 45, also 323 Sciatic nerve, incision for exposure, 30 Semilunar cartilage, incision for exposure of, 78 Semimembranosis, see hamstring " myotomy, 69 " " transplantation, 61-67 Semitendonosis, see hamstring " myotomy, 69 " " transplantation, 61-67 S'ever's operation, 208 Silk elongation for cut tendon in the hand or finger, 282 " " short tendon in the hand or finger, 282 " ligaments, 13, 77, 171, 172, 173, 226 ankle, 171, 172, 173 hip, 13 " " knee, Bartow, 77 " open method, 172 " " in paralysis at the knee, 77 paralysis of the shoulder, 226 " shoulder, 226 subcutaneous method, 173 " " for toe drop, 171, 172, 173 " " for weak ankle, 171, 172, 173 Skin operation, for flail elbow, 254 " at the elbow, Jones operation, 254 " preparation for operation, 347 arm, 343 elbow, 345 foot, 341 hand, 346 knee, 341-342 leg, 341 shoulder, 344 Shell, plaster of Paris, Figs. 463, 466 344 INDEX Shoe stiffening, Fig. 479 Short tendon of the finger, 2S2 Shoulder, acromion depressed, 224 ankylosis, arthroplasty for, 241 anterior incision, 228 arthrodesis, 225 arthroplasty, 241 arthrotomy, anterior incision, 228 enlarged, 229 Burrell " 213 Codtnan " 231 Kocher " 230 " posterior " 229 Bartow silk ligament for, 226 capsulorrahphy, 214, also 224 deformity from fracture, 237 depressed acromion, 224 dislocation, irreducible, 213, also 215 " and depressed acromion, 211, 224 " paralytic, 212, also 223 partial, 212 excision, 239-240 " partial, 239 excisions in suppurative conditions, 244 flail shoulder, 223 fractures, 232-237 " deformities, 237 " humerus, 232-237 " overlapping, 236 " ununited, 237 fracture, traction apparatus for, Figs. 375, 378 " ununited, 237 incision, 228-231 Codman, 231 Kocher, 230 infantile paralysis of, see deformities, muscle transplantation, paralysis inward rotation of the, muscle lengthening for, 207 " " " shortening for, 206 " " myotomy for, 207-209 " " " " obstetrical paralysis cases, 208 " " " " osteotomy for, 204 " " " " Sever operation for, 208 manipulation of, 202 muscle lengthening for inward rotation of, 207 " operations, Part IV, Chapter II " shortening for inward rotation of, 206 " transplantation, see under paralysis and under muscle transplanta- tion myotomy for inward rotation, 207-209 obstetrical paralysis with inward rotation of the, 208 osteotomy of the acromion, 205 ; " " " humerus, 204 " for inward rotation, 204 osteomyelitis, 242-244, also 323 paralysis, arthrodesis, 225 plaster of Paris for, 217, also 328, Figs. 459-460 INDEX 345 Shoulder, poliomyelitis, see deformity, paralysis, muscle transplantation " posterior incision, 229 " rotation in, of the; muscle lengthening for, 207 " " " " " " shortening for, 206 " " " v« " myotomy for, 207-209 " " " " " obstetrical paralysis cases, 208 " • " " " " osteotomy for, 204 " " " " " Sever operation for, 208 " Sever operation for the, Figs. 314, 315 " silk ligaments, 226 " splint of wire for, Figs. 314, 315 " suppurative conditions, 242, 244, also 323 " tapping, 238 " tendon operations, Part IV, Chapter II " " transplantation, Part IV, Chapter II " traction apparatus for, 235 wire shelf for, Figs. 314, 315 Solution for Carrell technique, 323 " " Dakin technique, 323 " " injection into the joint; Murphy's, 238 Soutter operation, transplantation of the hip flexors, 8 Spastic, myotomy, 69-70 " paralysis, 71-73 " " fasciotomy for, 8 " " myotomy for, 71 " " inward rotation of the shoulder for, 209 " " tendon lengthening for, 127 tenotomy for, 33, 71, 127, 283 Spica board for plaster of Paris, Figs. 463, 467, 468 Spinal ankylosis, Hibbs operation, 322 " operation, after treatment, 322 " tuberculosis: operative ankylosis of the spine for, 321, 322 Spine operative to obtain ankylosis for, 320, 321, 322 " " Albee operation, 320-321 " " " " Hibbs operation, 320-322 Spint, see apparatus Splitting the patella laterally, 82 Sprengle's deformity, 216 " incision for exposure of the ilium, 14 Stiff ankle following Potts fracture, 117 Subcutaneous tenotomy, 132 " " of the tendo Achilles, 128 also 132 Subluxation of the knee, 51 " " " " correction with genuclast, 51 " " " manipulation for, 51-52 " " " tibia operative treatment, 51 Subperiosteal club foot operation, 106 flat foot operation, 112 lengthening of the hip flexors, 8 operation for tendon lengthening in the forearm, 286 " on the elbow, 272, 276 " " wrist, 307, 311 " tendon insertion, Vulpius, 150 Subscapulars tenotomy, 208 Subtrochanteric osteotomy at the hip, 37 Support for the ankle, see braces and Figs. 477, 479, 480 346 INDEX Suppurative conditions, 323, see also under each joint " " of the ankle, 194-201, also 323 " " " bone, 323, see also under each joint " " " Carrcll-Dakin technique, 323 " " " compound fractures, see under each bone and 323 " " " " elbow, 274-277 and 323 " " fingers, 312 " " foot, 194, 201, 323 " " " " hand, 309, 311, 323 11 " " " hip, 43, 44, 45, also 323 " " " " knee, 96, 97, 98, 99, also 323 " " " " metatarsal, 196 " " " " oscalcis, 195 " " " phalanges of the foot, 196 " " " " scapula, 245, also 323 " " " " shoulder, 242-244, also 323 " " tarsus, 195 " " toes, 196 " " " " wrist, 309, 310, also 323 " " " " wrist, excision, 311 Suppurating wounds, Carrell operative method of preparation, 323J Synostosis of the elbow, 270 Tapping the ankle, 191 " " elbow joint, 268 " " hip joint, 33 " " knee joint, 93 " " shoulder, 238, also Part IV, Chapter IV " " tarsus, 195 " " wrist joint, 305 Tarsal, tuberculosis, 197 Tarsus, bone operation, see pes cavus, club foot and valgus " suppurative conditions, 195 and 323 Tendo Achilles, see under muscle transplantation, deformity, paralysis " " shortening, 146 " " subcutaneous tenotomy, 128, 132 " " zig-zag tenotomy, 132 Tendon carrier, Fig. 80, also 230 " cut, of the finger, 282 " " silk elongation, 282 " fixation, 174, 175, 176, 177 " ankle, 174-177 " " calcaneus, 177 " Galli, 174-177 " " valgus, 176 " " varus, 175 " elongation in the finger, 282 " insertion, Vulpius, 150 " lengthening, 126-133 extensors of the fingers, 285 " " • " " " wrist, 285 " " flexors of the fingers, 287-288 " " " wrist, 287-288 " " hamstring, 69-70 " " knee, 50 INDEX 347 Tendon lengthening, knee flexed, 50 " " open operation for, 127 " " peroneii, 138 " " in spastic paralysis, 71-73, 127, 283 " " subperiosteal operation at the elbow, 286 " " tenotomy, 127-132 " thigh, 69-70 " " tibialis anticus, 139 " " " posticus, 137 " operations, see Chapter II, deformities, paralysis, transplantation, tendon fixation, silk tendons Tendon operations, elbow, Part V, Chapter II " " finger, Part VI, Chapter II " " foot, Part III, Chapter II " hip, Part I, Chapter II " " knee, Part II, Chapter II " " tenosynovitis, 315 " " wrist, Part VI, Chapter II " shortening, see tendon operations Achilles tendon, 146 " " extensors of the fingers, 290 " " extensor longus digitorum, 147 " " extensors of the wrist, 290 " " flexors of the fingers, 289 " " " " " wrist, 289 " " leg, 144-145 " " long flexors of the fingers, 289 « " « « " " wrist, 289 " tendo Achilles, 146 Tenotome, the, 133, also Figs. 208-209 " bad, 133 " good, 133 " " selection of, 133 Tenosynovitis, 315 Tenotomy, see deformities, see paralysis " adductor magnus, of the, 74 " extensor longus digitorum, of the, 119-121 " general principles of, 126-133 " hamstrings, of the, 69-70 " hammer toe, 118-124 " lengthening a tendon, 128 " obstetrical paralysis for, 208 " open, for short flexor longus digitorum in the leg, 134 " pectoralis muscle, of the, 208 " peroneii, 138 " planta fascia, 136 " spastic paralysis, 71, 73, 127, 283 " subcutaneous at base of the toes, 135 " subscapularis, 208 " tibialis anticus, 139 " " posticus, 137 " "toe deformity, 118-124 Testing Carrell solution, 323E " chloride of lime for chlorine, 323C " Dakin solution, 323E Tempo-maxillafy arthroplasty, 318 34S INDEX Thomas club foot wrench, 101 " wrench, Figs. 121-130 " " manipulation of the foot, 101 Thorax, plaster of Paris bandage for, 326 Tibia bowing, 53 " deformity, 53 " fracture, 117 fracture overlapping, 189 " osteotomy, 53 " subluxation, 51 " suppurative conditions, 194, 323 Tibialis posticus, tenotomy, 137 Tibio-tarsal arthrodesis, 179 " " arthroplasty, 193 " " flail joint, see astragalectomy Tilting of the oscalcis in club foot, 104-107, 112 Toe, apparatus for the, Figs. 190-193 " ankylosis, see hammer toe " arthroplasty, see finger arthroplasty, hammer toe operation " arthrotomy, 125 " contracted, 118-124 " deformity, 124 " " excision of the joint, 124 " hallux valgus, 125 " hammer toe, 118-124 " " bone operation for, 123 " " excision for, 124 " manipulation, 99, 118 " " tenotomy operation for, 120, 121, 122 " drop, silk ligaments for, 171-173 " plaster of Paris, after operation, 339 Torticollis, myotomy, 314 " plaster of Paris, 326 Traction apparatus for operations on, Figs. 54-61 " " arm, 262 " " " congenital hip, 2 " elbow, 262 " " " fractures of the elbow, 262 " " " " " " femur, Figs. 54-57 " " hip, 37, Figs. 54-57 " " " " " " humerus, 235 " " " " " knee, Figs. 54-57 " " shoulder, 235, Figs. 375-378 " " tibia, Figs. 54-57 " hip, 37, Figs, 54, 55, 56, 57 " " " humerus, 235 " leg, Figs. 54-57 " shoulder, 235 " machine, see traction apparatus Treatment of overlapping fractures, see fractures Tuberculosis of the, see suppurative conditions " " ankle and foot, 197 " " " elbow, excision, 276 " " " hand, see suppurative conditions of the wrist " " " spine operation for obtaining ankylosis, 321, 322 " " " wrist, see suppurative conditions of the wrist, excision INDEX 349 U "U" shaped incision anterior, at the hip, 23 " at the hip, 22 " " " knee, 86 Ulna bowing, 317 " deformity, 317 " fracture, overlapping, 266 " osteotomy, see osteotomy for bow legs, 53 " suppurative, 274-277 Ununited fractures, see fractures V Valgus, 109-114 " after treatment, for, 113 " astragalo-scaphoid, arthrodesis, 114 " bone operation for, 111 " manipulation, see deformity, paralysis, muscle transplantation " plaster for, 113, see foot wrenches " plaster of Paris bandage after operation, 338 " tendon fixation, 176 " tilting of the oscalcis in, 112 " transplantation of the peroneii, 148 Varus, see deformities, manipulation of the foot, foot wrenches, paralysis, muscle transplantation, also 104-108 " after treatment, 108 " application of plaster, 107 " bone operation for, 105 " operations for, 104-107 " plaster of Paris for, 337 " tendon fixation, 175 Vulpius, subperiosteal tendon insertion, 150 W Whitman's operation, 168, also see astragalectomy " treatment of fracture of the neck of the femur, 28 Wrench for club foot, Bradford's, Figs. 145, 150, also 135-141 " Bradford's for foot manipulation, 102 " Davis' for foot manipulation, 103 " Thomas for foot manipulation, Figs. 121-134 Wrist, ankylosis, arthroplasty for, 307 " " excision for, 311 " anterior incision, 300 " apparatus after operation, on, 333 " arthroplasty for ankylosis, 307 " arthrotomy, 297-304 " " anterior incision, 300 " " external incision, 301 " " metacarpal incision, 302 " " Oilier incision, 298 " " posterior incision, 299 " " radial incision, 301 " club hand, 279 " congenital deformity, 278-280 " contracted fingers, 280 " tendons, 280 wrist, 280 350 INDEX Wrist, cut tendons, 2S2 " deformity, Part VI, Chapter I " " club hand, 279 " " Madelung, 27S " " pronation, 2S3 " " Tubby operation for, 283 " " wrist manipulation for, 281 " dislocation, 278 " excision of the carpus, 311 " " for ankylosis, 311 " " in suppurative conditions, 311 " external incision, 301 " flexed, 2S0 " flexors contracted tendon lengthening subperiosteal^ at the condyle, 288 " fractures, carpal, 303-304 " incisions, anterior, 300 " " external, 301 " " metacarpal, 302 " Oilier, 298 phalangeal, 302 " " posterior, 299 radial, 301 " infantile paralysis, see deformities, muscle transplantation, deformities, muscle and tendon operations Wrist, manipulation for the, 281 " Madelung deformity, 278 " osteomyelitis, Part VI, Chapter V, 323 " poliomyelitis, see paralysis, deformities, muscle transplantation " preparation of the skin for operation, 346 " pronation deformity, 283 " pronation deformity, muscle transplantation, Tubby operation for, 283 " puncture, 305 " retaining apparatus, 333 " ricketic deformity, 317 " silk extension for cut tendons, 282 " suppurative conditions, Part VI, Chapter V, 323 " tendon elongation, 282 " " lengthening, 285 " tapping the, 305 " " shortening, 289-290 " " silk extension, 282 " tendons cut, 282 " Tubby operation for pronation of the, 283 " tuberculosis, see suppurative conditions " wry neck, 314 Printed in the United States of America r I ^HE following pages contain advertisements of a few of the Macmillan books on kindred subjects. Deformities, Including Diseases of the Bones and Joints A Text-Book of Orthopedic Surgery. Second edition BY A. H. TUBBY, M.S., Lond., F.R.C.S., Eng., Surgeon in Charge Orthopedic Department, Westminster Hospital; Lecturer on Clinical and Orthopedic Surgery in the Medical College Illustrated by 70 -plates and over 1,700 figures, of which nearly 400 are original, and by notes of 54 cases 2 vols., 8vo, $13.00 Immense progress has been made lately in Orthopedic Surgery. New methods of treatment, based on clearer con- ceptions of pathogenesis and rendered possible by recent advances in technique, have come into vogue, and in a measure have supplanted the older ones. Many recent de- velopments have made it desirable to bring out a work which should be absolutely up to date, since there is no recent English work covering the subject thoroughly. The work has, therefore, been entirely rewritten and a definite plan, long under consideration, has been carefully followed. This plan provides for the grouping and arrange- ment of the various subjects on etiological and pathological bases, in preference to the less scientific regional classifica- tion, adopted in the first edition. Thus, one section is now devoted to deformities of congenital origin, another to those arising from static conditions, a third to paralytic deformi- ties, and so on, the subject being completed in ten sections. THE MACMILLAN COMPANY Publishers 64-66 Fifth Avenue New York Modern Methods in the Surgery of Paralyses "With special Reference to Muscle-Grafting, Tendon-Transplantation, and Arthrodesis BY A. H. TUBBY, M.S., F.R.C.S., and ROBERT JONES, F.R.C.S.E., Honorary Surgeon to the Royal Southern Hospital, Liverpool Illustrated by 93 figures and 58 cases Extra Crown, Svo. Cloth, 325 pp., ill., index, $3.50 Lancet. — "The work before us deals with these methods of treatment (tendon transplantation and arthrodesis) and describes the conditions for which they are suitable and the mode of their application, and we may say that the descrip- tions are clear and accurate. The authors do not bestow extravagant praise on the methods which they advocate, but they point out any disadvantages that may exist with regard to the application of these methods in any individual case. The book also contains a description of infantile paralysis, and the chief other diseases in which paralysis may need to be treated, and this account may enable the surgeon to anticipate and thus to prevent the deformities which otherwise might occur. Altogether we can commend highly this little treatise." THE MACMILLAN COMPANY Publishers 64-66 Fifth Avenue New York Radiography, X-Ray Therapeutics, and Ra- dium Therapy A Handbook for Students and Practitioners BY ROBERT KNOX, M.D. (Edin.), M.R.C.S. (Eng.), L.R.C.P. (Lond.), Hon. Radiographer, King's College Hospital; Director, Electrical and Radiothera- peutic Department, Cancer Hospital, London; Hon. Radiographer, Great Northern Central Hospital, London. Profusely illustrated. Cloth, 8vo, 406 pp., $8.00 Adopted by the United States Army and Navy. This work is intended to give the student and practi- tioner in a compact form as much information as possible relating to Radiography, Radiotherapeutics, and Radium Therapy. The book is thoroughly practical, the aim of the author being to put into the hands of the beginner, in a condensed and useful form, the information necessary to enable him to understand, and then to use, his apparatus. Embracing, as it does, a comparatively new subject, much of the work is original. The section on Radiography deals with principles, form of apparatus, technique of application, manipulation, and diagnosis. In the selection of illustrations, the practical aspects of the work have been kept well in mind. The section on Radiotherapeutics is very practical. Methods of treatment are given in detail, in order that readers may thoroughly grasp the principles of this com- paratively new therapeutic agent. The section on Radium has been purposely enlarged in order that the reader may gain a working knowledge of this important agent. The chapter on Therapeutics will guide the reader regarding the type of case in which Radium may ^be useful, and the author goes fully into the important ques- tion of dosage. A chapter on the Physics of Radium has been included from the pen of Mr. C. E. S. PhiUips, F.R.S.Ed. THE MACMILLAN COMPANY Publishers 64-66 Fifth Avenue New York Tuberculosis of the Bones and Joints in Children BY JOHN FRASER, M.D., F.R.C.S.E., Ch.M., Assistant Surgeon, Royal Hospital for Sick Children, Edinburgh With 51 full page plates (2 in color) and 164 figures in the text Royal Svo, 352 pp., index, -$4.50 Tuberculous Disease of the Bones and Joints is in large measure a disease of children, and as a result of the dis- astrous consequences which so often follow its course, it is one of the most important of the various forms of Tuber- culosis. This work deals fully with the condition. The more recent investigations on the Etiology are fully dis- cussed, the Pathology is a special feature, and much of the material in this relation is original. Diagnosis, Prognosis and Treatment are fully discussed. Special attention has been paid to the making and fitting of the various splints. Dr. Fraser is well known to American physicians through his various magazine contributions and lectures. His book is without doubt one of the most important publications that has yet appeared on this subject. THE MACMILLAN COMPANY Publishers 64-66 Fifth Avenue New York COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or by special ar- rangement with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE \l: C2BI1 140IMI00 Scrv-ht eR So 8 COLUMBIA UNIVERSITY LIBRARIES (hsl stx) RD 680 So8 C.1 Technique of operations on the bones 2002279452