(Hohtmbta llmu^ratty m % (Uttg of 2few fork (Enllrgp of iphijHtrianB attb ^ttrgwms 3Frcm tlj? library, nf OII|ttrrl|Ui ffiarmalt M. 1. ^rtsf ttteb by ti?p HLxttrne (Elub nf Npw $nrk Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/osteotomyosteoclOOpoor OSTEOTOMY AND OSTEOCLASIS DEFORMITIES OP THE LOWER EXTREMITIES. BY CHARLES T. POOEE, M. D., SURGEON TO BT. MARY^ FREE HOSPITAL FOE CHILDREN, NEW YOEE! ; MEMBER OF THE NEW YORK SURGICAL SOCIETY, ETC. NEW YORK: D. APPLETON AND COMPANY, 1, 3, and 5 BOND STREET. 1884. Copyright, 1SS4, By D. APPLETON AND COMPANY. TO THE MEMORY OF MY UNCLE, CI1AELES N. TALBOT, Esq., THIS VOLUME IS DEDICATED, A3 A SLIGHT TRIBUTE OP AFFECTION, GRATITUDE, AND RESPECT. 374630 PREFACE. The author of this volume has had considerable experience both in the mechanical and in the opera- tive treatment of the deformities considered in this book. That there is a want of a concise treatise on oste- otomy — one in which the methods of operating and the management of the wound and limb after sec- tion are considered — there can be no doubt. Whether the author has succeeded in this purpose the reader must determine. Much time and reading have been devoted to its production, and he trusts that his labors have not been entirely in vain. Very free use has been made of Dr. Macewen's excellent work on Osteotomy, as well as of Campenon's thesis " Du redressement des membres par l'osteotomie," and for which the au- thor desires to express his indebtedness. He is also under great obligations to his friends Dr. W. T. Bull, Dr. V. P. Gibney, Dr. F. Lange, of this city, and to Dr. E. H. Bradford, of Boston, for v i PREFACE. valuable assistance; to Dr. A. T. Cabot, of Boston, Dr. E. M. Moore, of Kochester, and Dr. K. H. Whar- ton, of Philadelphia, for the use of specimens and wood-cuts ; to the Librarian of the New York Hos- pital Library, and that of the Academy of Medicine, for aid in looking up references ; and to the publish- ers for the trouble they have taken to meet his views. Chaeles T. Pooee. 5 West Thirtieth Street, New York, August i, 188JJ,. CONTENTS. CHAPTER PAGE I. — The Relation between Rickets and Certain Deformities of the Lower Limbs 1 II. — Osteotomy 11 III. — Osteotomy tor Deformities at the Dip Joint . . . .30 IV. — Genu Valgum ; its Etiology and Pathology . . . .TO V. — Osteotomy for Genu Valgum 94 VI.— Genu Varum. . . 12T VII. — Osteotomy for Anchylosis of the Knee Joint . . . .130 VIII. — Osteotomy for Tibial Curves 136 IX. — Osteoclasis 149 X. — Statistics after Osteotomies 170 Bibliography . . . . .'\ 1*75 Index „ 185 LIST OF ILLUSTRATIONS. FlaiTRE PAGE 1. Adams's Saw 14 2. Osteotome 17 3. " 17 4. " 17 5. 6. Method of ascertaining size of Wedge to be removed in Cuneiform Osteotomy 27 7. Sayre's Line of Section in Anchylosis of Hip Joint 3S 8. Volkmann's " " " 39 9. Adams's " " " 40 10. Gant's " , " " 41 11. Stephen Smith's " " " 42 12. Patient affected with Anchylosis of Hip Joint 63 13. Result after Osteotomy 64 14. Patient affected with Anchylosis of Hip Joint 66 15. Eesult after Osteotomy 67 17. Typical Case of Genu Valgum 71 18, 19. Outline of Ends of Femur in a Case of Genu Valgum 75 20. A Case of Genu Valgum complicated with other Curves 88 21. Ogston's Line of Section in Genu Valgum 96 22. Reeves's " " " " 97 23. Chiene's " " " " 98 24. Macewen's first " " " 98 25. " second " " " 103 26. 27. Outline of Condyles before and after Supra-condyloid Osteotomy. . . 113 28. Patient affected with Genu Valgum 120 29. Result after Osteotomy 121 30. 31. Patient affected with Genu Valgum 122 32. Result after Osteotomy 123 33. Patient affected with Genu Valgum 124 34. Result after Osteotomy 124 35. Patient affected with Genu Valgum 125 36. Result after Osteotomy 126 37. Case of Genu Varum 128 x LIST OF ILLUSTRATIONS. FIGURE PAGE 38. Case of Anterior Curvature of the Tibia 137 39. Patient affected with Bow-legs 147 40. Result after Osteotomy 147 41. Patient affected with marked antero-lateral curvature of the Tibia 148 42. Result after Cuneiform Osteotomy 148 43. Rizzoli's Osteoclast 155 44. Result after Osteoclasis with Taylor's Osteoclast. 158 45. Collin's Osteoclast 164 46. Robin's Osteoclast 165 47. Patient with Curvature of the Tibia 167 48. Result after Osteoclasis. 168 49. Patient with Curvature of the Tibia 168 50. Result after Osteoclasis 169 Plate I. — Dr. H. R. Wharton's case. Parts after Inter-trochanteric Oste- otomy — anterior view To face page 52 Plate II. — Dr. H. R. Wharton's case. Parts after Inter-trochanteric Oste- otomy — lateral view To face page 53 Plate III. — Dr. E. M. Moore's case. Parts after Inter-trochanteric Oste- otomy — anterior view To face page 55 Plate IV. — Dr. E. M. Moore's case. Parts after Inter-trochanteric Oste- otomy — lateral view ,To face page 56 Plate V. — Dr. A. T. Cabot's case. Parts after Supra-condyloid Oste- otomy To face page 112 OSTEOTOMY. CHAPTER I. THE EEL A TION EETWEEN EICEETS AND CEETAIN DEFORMI- TIES OF THE LOWER LIMES. Many of the deformities of the lower limbs whose treatment is considered in this volume have their origin in rickets. It has therefore been thought best to devote a short chapter to this disease, and to point out its connection with the subject under considera- tion. Those who are connected with our large dispen- saries are well aware of the prevalence of rickets among the ajyplicants for medical aid. Whether it is as common in this country as in certain parts of Europe is doubtful. It is not alone confined to the children of the middle and lower classes, but is met with among the offspring of the wealthy, not per- haps in its more advanced stages, yet sufficiently well marked to be easily recognized if its manifestations are carefully looked for. It is seen among children who have been brought up in the country as well as those who live in crowded cities, but to a much less extent. It is a disease that merits the careful atten- tion not only of the surgeon, but of the general prac- 2 OSTEOTOMY. titioner, in order that its results, in deformities of the long bones and changes in the shape of the chest and pelvis, may "be prevented. Kickets is not a dis- ease of the bone alone, but is a constitutional affec- tion, attacking the osseous structures in common with every other tissue of the body. It is essentially a disease of malnutrition. It may be congenital, but it usually first manifests itself in children from six months to three years of age. Bad air, improper food, and scanty clothing are its most prolific causes. Any child may become rickety, no matter how healthy it may have been at birth, if placed under any condi- tion that interferes with its assimilative powers. It may be laid down as a rule that a healthy child, fed on good mother's milk, will never develop this dis- ease. It is equally true that not every child who suffers from malnutrition will become rickety. Its beginning is insidious, with the ordinary symptoms of improper digestion. The little patient may be plump, but its muscles are flabby and its complexion pale and unhealthy ; large veins are distinctly seen through the pasty-looking skin. The bowels may be loose or confined, more often capricious, a day or two relaxed, then followed by a period of constipation ; the stools are white, curdy-looking, and extremely offensive ; the food is often passed through the ali- mentary canal undigested. Accompanying this de- rangement of the digestive apparatus there is profuse sweating of the head, neck, and upper part of the chest, worse at night. The moisture will be seen standing in large drops upon the forehead, and often runs down the face, and at night the pillow is drenched with it. While the head and neck are thus RICKETS AND CERTAIN DEFORMITIES. 3 bathed in perspiration the abdomen and lower limbs are dry and hot. Another symptom is the desire of the child to keep cool at night. It constantly throws the clothes off from its feet and limbs, no matter how cold the temperature may be. The child soon loses its activity, and seems only happy when left alone. It will sit for hours almost motionless, is petulant, and cries on beino; moved. The desire to be let alone is due to tenderness, more or less marked, of the bones, so that any pressure on them is painful to the little one, and it dislikes to be handled. Dentition in those affected with rickets is usually retarded, or, if the teeth have made their appearance, they soon become black and fall out, or are early at- tacked with caries. Jenuer states that if the ninth month passes without the appearance of a tooth, the cause should be carefully inquired into, and will al- most always be found in rickets. According to Eus- tace Smith, the symptoms of rickets seldom appear before the fourth, and usually not until the seventh month. Cases, however, occur in which the advent of the disease is delayed much longer. Jenner men- tions a girl of nine years of age in whom the symp- toms of rickets had just commenced. Enlargement of the spleen, liver, and of the lym- phatic glands in different portions of the body is a common accompaniment of this disorder. In some cases the patient is reduced to a skeleton, while in others, as mentioned before, it retains its plumpness. While the symptoms mentioned above are mani- festing themselves, changes are taking place in the bones, perhaps not more profound, yet more notice- able than in any other structure of the body. One 4 OSTEOTOMY. of the earliest of these is a beaded appearance at the sterno-costal junction and an enlargement of the epi- physes, especially those at the wrist-joint. If a child aifected with rickets be carefully examined, a line of nodules will be felt, and often seen, marking the point of junction between the ribs and the sternnm. This condition has been noticed in children suffering from rickets six weeks after birth. When this beading of the ribs is found, it is a positive proof of the exist- ence of this disease. There are also certain altera- tions in the occipital bone, often found at a very early stage of the disease in young children. Macnamara states that they are almost as constant a condition in this disease as the abnormalities of the ribs, but they are not as easily detected. If the occipital bone be carefully examined in young infants affected with this disease, there will often be felt several small, round, or oval soft spots, situated within the sutural mar- gins of the occipital and parietal bones. These spots are unossiiied portions of the structures from which the bone is produced. The number of these spots varies considerably. The occipital bone is often re- markably thin in cases of this disease, and the head has a peculiar elongated appearance, while the face in marked cases remains small. (Macnamara.) While these changes are going on, others of as marked a character are taking place in the ends and shaft of the long bones. The epiphyses become en- larged, and the shaft softened so that it is often bent, and the epiphyses may become twisted, according to the intensity of the disease and the force acting on the plastic bone. The condition of the bones varies with the stage and the intensity of the disease, and RICKETS AND CERTAIN DEFORMITIES. 5 whether the brunt of the changes falls upon the epiphyses or the diaphyses. At first the bones may be soft, so that they can be bent like cartilage ; later they become very hard and deformed. The pathological changes taking place in the bones are well described by Macnamara in his work " On Disease of the Bones and Joints." He says : " If a rickety bone be divided longitudinally during the first stage of rickets, the medulla filling the central canal and cancellated tissue will be found to be of a crimson color and jelly-like con- sistency, this soft medulla being especially abundant at the line of the junction between the diaphysis and epiphysis. The medulla of a child suffering from the first stage of rickets consists of a vast number of round cells, compound cells, and fat ; the adenoid tissue and vessels are normal in appear- ance ; in fact, the elements characteristic of healthy medulla are present in the bones of infants suffer- ing from this disease, but there is an imperfect for- mation of the calcareous skeleton of the bones, and in its place we find an excess of medullary tissue. . . . The malad} 7 , so far as the bones are con- cerned, depends on the deficiency of earthy matter contained in this hyaline matrix. If a section made through the epiphysis into the diaphysis be exam- ined during the first stage of the disease, there will be found at the line of ossification numerous villous- like processes of medulla, projecting, as it were, from the diaphysis into the epiphyseal cartilage. These processes, however, are not formed from the growth of the medulla of the diaphysis into the cartilage, but from a transformation of the cartilage-cells of q OSTEOTOMY. the epiphysis into medullary tissue at the normal line of ossification. The mass of the descendants of the cartilage-cell forming the processes referred to are incapable of producing healthy bone, in con- sequence of a deficiency of the bone-earth. So long as an infant is insufficiently supplied with, or is in- capable of assimilating, elements necessary to the cal- cification of the cartilage-cells, it is impossible that healthy bone can be produced." The changes in the shaft of the long bones, ac- cording to Virchow, " consist in the non-solidification of the fresh layers as they are formed, while the old layers of bone are consumed by normally progressive formation of medullary cavities. The periosteum is thickened and more adherent to the bone. Medul- lary spaces and vessels are met with where normally and properly not a single medullary cell and scarcely a single vessel ought to be found." During the height of the disease, when the changes in the bones are marked, they can be bent by the least possible force, and their spongy por- tions may be easily cut with a knife. In rickets the ligaments are often altered in their structure, so that they may become easily elongated, and thus permit lateral motion in joints in which normally it does not exist. However profound the changes in the bones may have been, as soon as the child begins to masticate and is able to assimilate proper nutriment, the vast number of bone-cells rapidly take up the earthy salts from the blood, and very dense bone is speedily produced, so that in a short time the bone may become very hard. Again, the process of sclerosis may be much slower, depending RICKETS AND CERTAIN DEFORMITIES. ? upon the power of the child to assimilate, and the quality of the food furnished. Rachitic changes in the osseous structure do not always take place in all the bones of the skeleton in equal degree, nor in every portion of an individual "bone. Thus soften- ing may be more marked at the epiphysis while in the shaft it is slight, or the shaft may show more advanced changes than the articular ends. The enlargement of the epiphyses is not an index of the changes in the shaft. The bone of one limb may be quite soft while that of the other is hard. I have met with this condition quite frequently in operating; one tibia has been found very easy to divide, while in the other section was difficult. The fibula has been found to be much harder than the tibia in the same limb. Perhaps the existence of different deformities may be due in part to this irregularity in the portion of the bone on which the intensity of the rachitic pro- cess falls. All writers on this disease divide it into a pre- liminary stage, one of softening and one of sclerosis. It is in the latter that the bone-cells take up from the blood the earthy matter that gives bone its hardness. It will be evident that this stage can not begin until the child is able to digest and assimi- late appropriate food. No rule can be laid down as to the length of time that the soft stage of rickets lasts, nor the rapidity with which the hardening may advance. Each case must be judged by itself. The general health, ruddy appearance, and firm con- dition of the muscles are the best guide. It may take many years in children of low vital powers for 2 8 OSTEOTOMY. the bones to become firm, while in others it may be accomplished in a few months. There is a condition described by some observers (Barlow, Page 1 ), as "acute rickets." It occurs in children under two years of age. There is profuse sweating about the head, changes in the epiphyses, and other symptoms usually found in rickets, to- gether with swelling and great tenderness of the lower extremities, due, it was supposed, to an effu- sion of blood under the periosteum and between the deeper muscular layers. Barlow considers it a combination of rickets and scurvy. By change of diet, fresh air, and compression of the limbs, recov- ery may take place rapidly. The age beyond which rickets is not developed is uncertain, but probably in the vast majority of cases not after the fifth year. Some writers consid- er that this disease may be developed between the twelfth and twentieth years ; that is, during the pe- riod of rapid growth. Mace wen is an advocate of this late appearance of rickets. But it is denied by the majority of writers. In the chapter on genu valgum the cases of Macew T en are given. I have never met with a case, and I think if they ever occur it must be exceptional. Deformities about the knee-joint are sometimes developed in persons from twelve to twenty years of age, but I think that their cause can be explained without attribut- ing them to rickets. In the cases that I have had the opportunity to examine there w 7 as absolutely no symptom of rickets except the bending of the bone at the ej:)iphyseal line. Most of the deformi- 1 "Brit. Med. Jour.," March 31, 1883, p. 619. RICKETS AND CERTAIN DEFORMITIES. 9 ties of the lower limb are developed during the period of rapid growth. They are met with first iu infantile life, when all the nutritive processes are at their height, and the child rapidly increases in weight and stature. This period, as a rule, does not extend beyond the seventh year. Then comes a time, extending from the seventh to the twelfth year, during which growth is much slower and de- formities are seldom developed. From the twelfth to the twentieth year is another period of growth and development during which the long bones rap- idly increase in length by the deposit of osseous material at their extremities, and which is finally completed by the consolidation of the epiphyses and diaphyses. In this period, again, certain deformi- ties, especially about the knee-joint, are developed in those who are compelled to labor hard and un- dergo fatigue. During the first period bending of the shaft of the long bones, with the consequent deformities, are common, while in the last period deformities having their origin near the joints are met with, and curva- tures of the shaft of the bones are seldom if ever seen. The connection between rickets and deformities of the bone is one of cause and effect. I do not think that the muscles exert an active influence, but that position and weight are the cause of the abnormal shape of the bones. In this very imperfect review of the symptoms of rickets, as it affects the bones of the extremities, noth- ing new is claimed, the object being simply to call at- tention to this most prolific cause of deformities. While the bones are soft, any abnormal change in 10 OSTEOTOMY. their shape can, and should, be corrected by appro- priate apparatus. But after sclerosis has taken place, or even is well advanced, orthopedic appliances will not correct. I am not a believer in the spontaneous cure of bending of the long bones. We often hear the advice given to mothers by members of the pro- fession not to submit these cases to treatment ; that the child will " outgrow " the malposition; and I wish to enter a protest against such advice, as it will only lead to disappointment. CHAPTER II. OSTEOTOMY. " Osteotomy," says Macewen, " in its broadest ac- ceptation, may be defined as a section of bone. It has, however, been regarded in a much more restrict- ed sense, the term being applied to such divisions of bone as have been proposed and undertaken for the relief of deformity, for the rectification of badly united fractures, and for the straightening of limbs affected with osseous anchylosis, which are fixed in a bad po- sition." (" Osteotomy," p. 37.) Section of the long bones for deformity had been proposed by many early writers on surgery, yet it does not appear to have been put in practice until 1815, when Le Mercier made a section of the tibia with a saw for a badly united fracture of that bone ; and in the following year Wasserfuhr practiced the same operation upon the femur. Barton, in 1826, per- formed an osteotomy just below the trochanter major for anchylosis with flexion of the thigh, through an open wound, the division being made with the saw. In 1834 Clemot removed a wedge-shaped piece of bone for the correction of an angular deformity of the femur. Portal, Ashley Cooper, Warren, of Boston, and others, performed similar operations. All sec- tions of bones prior to 1852 were performed through 12 OSTEOTOMY. an open wound. In that year Langenbeck made a division of the femur for anehylosis of the hip-joint by perforating the bone with a drill through a small wound in the soft parts, and then, introducing a nar- row saw, divided the bone. He gave to this opera- tion the name of subcutaneous osteotomy. In 1868 L. Stromeyer Little made use of a car- penter's chisel to divide the bone in a case of osseous anchylosis of the knee-joint, working through a small wound half an inch in length. In the following year Mr. William Adams performed the operation of sub- cutaneous section of the neck of the thigh-bone, known as Adams's operation. In 1875 Volkmann 1 operated antiseptically on two cases of anchylosis of the knee- joint, and in April of the same year Macewen per- formed a similar operation. Ogston, May 17, 1876, divided the internal condyle of the femur with a saw in a case of genu valgum, and Reeves 2 March 17, 1878, made a section of the internal condyle in Og- ston's line with an osteotome. And on February 2, 1878, Macewen first performed the operation above the condyle. Prior to 1875 all osteotomies were performed through an open wound, and were followed by sup- puration more or less profuse. In the earlier opera- tions no attempt was made to obtain primary union of the soft parts. Barton states that it was not de- sired. Langenbeck's operation does not seem to have been a great improvement upon those performed through an open wound, as deep-seated suppuration 1 "Edinb. Med. Jour.," March, 1875, p. 794. 2 " Brit. Med. Jour.," September, 21, 1378, p. 431. OSTEOTOMY. 13 is admitted to have frequently followed, and, as the only object in his method was to prevent such an occurrence, it failed in its object. Moreover, deep suppuration, with a small outlet for the discharge, is more productive of injury than suppuration in an open wound. It was, however, an advance toward a better method of operation — namely, the subcuta- neous way in which osteotomy is now performed, and, as such, merits a place in the history of osteoto- my. There was also at this time another revolu- tion taking place in surgical practice, which has con- tributed more to its advance within the last ten years than any one circumstance, and that was the method of treatment of wounds advocated by Mr. Lister. It was only on account of the safety which this method of wound management seemed to afford that surgeons felt justified in operating upon tissues, with which their predecessors considered it too hazardous to interfere. Although much of the technique of strict Listerism has been abandoned, yet its funda- mental principles have stood the test of time — namely, that on perfect cleanliness, thorough drain- age, and absolute rest, depend the best results in every operation. That osteotomy has obtained its place as a safe and justifiable procedure is due to the influence of Listerism. The instruments requisite for an osteotomy are few. It may be performed with a saw, chisel, or os- teotome. Mr. Adams's saw, which may be taken as a type of such instruments, he describes as follows : It is three eighths of an inch wide, with a cutting edge an inch and a half in length, at the end of a slender shank three inches long. He at first had a 14 OSTEOTOMY. straight handle, but later substituted a curved one, as being easier to grasp. The saw has a round, blunt end, in order not to injure the tissues behind the bone. (Fig. 1.) Dr. George F. Shrady, of this city, has modified Fig. 1. — Adams's Saw reduced one half, and the cutting edge. Adams's saw by making it more probe-pointed, and has an arrangement by means of a trochar and ca- nula, so that in introducing the saw all danger of any injury to the vessels and soft parts is obviated. OSTEOTOMY. 15 The instrument consists of first a trochar and ca- nula — the former is of the same size and shape as the saw. The canula has a fenestra corresponding in position to the teeth upon the saw. The method of using it is as follows : The trochar and canula are thrust down by the side of the bone to be di- vided — the instrument being held in such a position that the fenestrated portion of the canula shall rest upon the bone at the point of desired section ; the trochar is then withdrawn and is replaced by the saw ; the former is then removed, leaving the saw in position. After the bone has been sufficiently di- vided the canula is passed down over the saw and both are removed. It is claimed that with this instrument the dan- ger of injuring the soft parts is reduced to a mini- mum. I have never used it, but those who have speak well of it. The objections to the use of the saw in osteotomies are : It is harder to work, it takes a much longer time to make the section, there is more disturbance of the surrounding tissues, and, theoretically, the dust from the saw is liable to lead to suppuration, an objection that has not been sus- tained by practice. Wounds after the use of a saw heal kindly, and the bone-dust does not give any subsequent trouble. The method of using the saw for making section is as follows : An incision is made just large enough to easily admit the instrument down to and by the side of the bone to be divided. The saw is then passed down upon the knife as a guide, and the bone divided through the greater part of its thickness. The saw is then removed, a sponge damp- ened with carbolized water placed over the wound 16 OSTEOTOMY. to prevent the entrance of air, and the remainder of the bone fractured. The wound is to be treated in the same manner as one after an osteotomy performed with the chisel. In what experience I have had with the saw in tibial curves it has not seemed to me to be as good an instrument as the osteotome. It is more difficult to work, and it takes a much longer time to complete a section. Thus the time necessary to divide the neck of the femur varies from five to twenty-five minutes, and there is no doubt but that the soft parts are more or less lacerated by the teeth of the instru- ment. Shrady's saw may do away with this latter objection. A chain-saw has been used to make the section. Barwell has advocated its use within the past year. Osteotomy with an Osteotome. — There are two forms of cutting instruments of the chisel order — one having both planes gradually sloping down to a sharp cutting edge, the other made like a carpenter's chisel. To the former Macewen has given the name of osteotome, to distinguish it from the latter, which is properly a chisel. The osteotome is an instrument having its two flat surfaces gradually sloping down to a sharp cutting edge, like a long, slender wedge, resembling a knife-blade, being as thin as it ap- proaches the cutting surface as is safe. The accompanying cuts (Figs. 2 and 3) represent two views of an osteotome. They are reduced one half actual size. Fig. 2 shows the gradual slope of the flat surfaces, while Fig. 3 represents the latter. Fig. 4 is a smaller osteotome useful for division of the fibula and similar bones. OSTEOTOMY. 17 It should have a temper between that of a cold chisel and a carpenter's cutting tool, so that the edge will not be turned by the hardness of the bone, or so Fig. 2. Fig. 3. Vy brittle as to chip. It is well always to test the in- strument on a piece of hard bone, driving it in with a pretty strong blow with a mallet. If the edge is neither turned nor nicked, it is of a proper temper. The cutting edge should be very sharp. It should 18 OSTEOTOMY. be marked on the flat surface every half-inch from the edge, in order that the distance that the instru- ment has penetrated the bone may be known. A large handle is also of advantage, as it can be grasped more easily. The best width is half an inch. It is well to be provided with three osteotomes of the same width, but of different thickness, in order that, if the largest gets wedged, it may be withdrawn and replaced by the next smaller, to be again replaced by the third if it be found necessary. I also have an osteotome of the same shape, but only one quar- ter of an inch wide, for section of the fibula or any small bone. Most of the osteotomes found in instrument- stores are not made properly. They have a bulge just above the cutting edge, like a post-mortem chisel. In some trials made upon the cadaver with such an instrument it was found that the bone was invariably splintered at right angles to the line of desired section, the fracture extending several inches above or below the instrument. This was due to the thickness of the chisel just above its cutting edge acting too much like a wedge. The force required to drive such an instrument into the bone is much greater than with one made with straighter lines. An instrument properly made can be driven into the bone without turning from its direction. The mallet should be made heavier than those sold in necrosis cases. In fact, a good-sized carpen- ter's mallet is the best. A sand pillow, about six by eight inches square and three quarters filled with sand, and covered over with rubber cloth, complete the special outfit. OSTEOTOMY. 19 The chisel for performing a cuneiform osteotomy is shaped much like a carpenter's; half an inch is sufficient for its width. It should taper down more than the common necrosis chisel, and the beveled portion should not be too large. It should have a temper similar to the osteotome. Osteotomy is either linear or cuneiform. The for- mer is performed through a small wound, just large enough to easily admit the osteotome. The latter must be done through an open wound, and is there- fore not subcutaneous. The limb in either case, if possible, should be ren- dered bloodless by the use of an Esmarch bandage or any other method, as, especially in cuneiform sec- tions, it renders the operation much easier and does away with the constant use of the sponge. In regard to the use of Listerism, I am clearly of the opinion that it affords no additional safety, and I have long since abandoned its use. The method of management of the wound will be given in detail farther on. Simple Osteotomy. — The patient having been placed thoroughly under the influence of an anaes- thetic, the limb rendered bloodless if that is pos- sible, and the point of section decided upon, an in- cision is made with a sharp scalpel immediately down to the bone. Unless there are special reasons for so doing, the bone should not be reached by dis- secting down to it, but a quick, clean cut should be made. The line of the incision should be parallel with the line of the fiber of the muscles through which the wound passes. As a rule, this is parallel with the long axis of the limb. The place of in- 20 OSTEOTOMY. cision should be so planned as to avoid any artery or vein. The length of the wound should be only sufficient to easily admit the osteotome. This in- strument is then passed down upon the knife as a guide, and, when the former is well down upon the bone, the latter is withdrawn, and the osteotome is rotated so as to be at right angles with the long axis of the bone, and then driven in with pretty firm blows with the mallet. After each blow the in- strument is moved in a direction at right angles to the long axis of the bone — that is, in the line of the axis of the instrument — in order to keep it from be- coming wedged and to change the direction of the cut in the bone. It is also well, in bones of any width, to first divide the bone throughout its superficial surface, and then gradually to work from without inward through its width. Under no circumstance should the osteotome be used as a lever, as it will result in breaking the instrument. In some cases the bone may be divided in a fan-shaped manner by working in different directions from the point of first entrance. Divisions should be commenced with the largest osteotome, if the bone is of any size, as the femur or tibia, because after a time the instru- ment becomes wedged and is difficult to work. It can then be withdrawn and replaced by the next smaller, this to be again replaced by the third if necessary. Another reason is, that, by using the lar- gest first, the cut is made more V-shaped. When the osteotome has penetrated the hard, compact, bony tissue in the external portion, it will be felt to work more rapidly. When the external portion on the opposite side of the bone is reached, it will OSTEOTOMY. 21 be detected by the resistance in cutting. Then, as Macewen remarks, the osteotome acts as a probe as well as cutting instrument. During section the wound may be kept damp with carbolized water, but I do not think it essen- tial, nor do I place my instruments in any antiseptic solution before using. When the bone has been nearly divided, the osteotome is removed and the section completed by fracturing the remaining por- tion, a sponge wet with carbolized water being first placed over the wound and held firmly in place to prevent the entrance of air. The bone should have been sufficiently severed to make the fracture easy without the use of much force. If, however, it can not be broken without the use of too much force, the osteotome is re-entered and further section made. After fracture, the sponge is firmly secured over the wound with a few turns of a bandage, and then the Esmarch bandage removed. The limb is then left while the same operation is performed upon the other side. In case only one limb is to be operated upon, it is well to let the parts remain at rest for a few moments until the circulation in the limb has been re-established. The haemorrhage after an osteotomy is slight. I have never seen enough to cause any anxiety, although in a few cases there may be quite a free venous haemorrhage if the sponge has been removed too soon. There is, more- over, more blood oozing from the wound when the section has been made near the epiphysis of the tibia or when the bone is superficial. In deep osteotomies the blood is effused among the muscles, and does not come out of the wound unless pressed 22 OSTEOTOMY. out. I have once divided an artery of some size, to which reference will be made in another place. Management of the Wound. — On removing the sponge from over the wound, it will be found that the haemorrhage has almost ceased, but that blood can be forced up from its deeper portions, or will con- tinue to ooze if the bone be superficial. Macewen has advised that any piece of adipose or cellular tissue that may protrude from between the lips of the wound should be removed with a pair of curved scissors, as it will prove a source of irritation and prevent the closure of the wound by a blood-ciot. Experience has proved that this is an important point, and, from the neglect of this, failure to obtain rapid closure of the wound is almost always due. Macewen dresses the wound on strict Listerian prin- ciples. I do not think that there is any gain thereby. The method that has gained excellent results is as follows : In deep wounds, after removing any piece of tissue from between the lips of the wound, it may be washed out with some carbolized water of the strength of 1 to 40, and, after the parts are well dried, a strip of adhesive plaster, about half the width of the length of the wound, and long enough to pass one quarter of the way around the limb, is applied, pass- ing over the center of the wound, care being taken to bring the edges of the incision into perfect coap- tation. The object in only partially covering the incision is that, if there is any undue accumulation of blood, it can find vent through the portions of the wound not covered by the plaster, and thus prevent tension of the parts. The limb about the point of operation is now dusted over with iodoform diluted OSTEOTOMY. 23 with subnitrate of bismuth, and over this is jxlaced a small compress of cheese-cloth, two or three inches square and four or five layers thick. Or a compress of Lister's gauze may be used. If it is possible, a flannel bandage is applied from the ex- tremity to some distance above the point of section, and over this a plaster-of-Paris bandage (we are con- sidering osteotomies below the middle of the thigh). Before the plaster sets, the deformity should be cor- rected and held in the proper position until it has well hardened. I think it is well always to over- correct a little, for, as the bandage becomes loose, there is a tendency to lose a little of the correction. It will be found that, by the addition of some sul- phate of potash to the water in which the plaster-of- Paris bandages are soaked, they will harden much more rapidly. The bandage on the following day will be found more or less stained with blood from the oozing that has taken place, but it is of no consequence, and needs no attention. On the third day a fenestra should be cut over the seat of the wound, the compress re- moved, and the wound examined. An easy way to remove a small window is to make two cuts with a saw, at right angles to the long axis of the bone and about two inches apart, through the plaster, and then to unite their extremities by cuts with a strong knife. The square piece can then be lifted out, the flannel bandage cut, and through this opening the compress removed and the wound examined. The adhesive plaster need not be removed. If there is any oozing from the cut, a fresh piece of compress should be ap- plied, and the wound examined every day. If it is 3 24 OSTEOTOMY. dry, a little lint may be placed over it, and no fur- ther dressing is required. The result from this way of managing wounds has been eminently successful. In all but exceptional cases the incision has been found united on the third day, being represented by a mere line. Macewen's method aims at union by means of an organized clot. Of this method he says : 1 " During the first twenty- four hours the dressings ought to be looked at, in order to detect any appearance of blood-stains. If a stain of blood shows itself, the dressings must be removed. If there is no blood-stain during the first forty-eight hours, it is unlikely that any will after- ward appear. . . . The dressings are put on (strict Lister) in the operating-room, and not touched, unless blood appears, for a fortnight." Again, on page 175, in speaking of the organiza- tion of a blood-clot, he says : " The ordinary course which a wound healing by blood-clot takes may be described as follows: The blood is effused between the lips of the wound, and forms a clot. During the first few days a layer of translucent, yellowish mate- rial is often effused from the surface of the clot. This, however, is not constant. During the first week the blood-clot remains soft and moist ; then it becomes opaque round the margins, and by and by dries, the opacity and dryness gradually extending centripe- tally." Closing of a wound by a blood-clot takes ten or twelve days; by primary union, two or three days. With care to remove everything that may pro- trude from between the lips of the wound, primary 1 " Osteotomy," he. cit. OSTEOTOMY. 25 union should be obtained in all cases. The simpli- city with which the plan advocated in these pages can be carried out is in contrast to that of Mace wen. Since adopting this method, I have performed over sixty linear osteotomies. In all but three cases the wound was united on the third day. Failure to ob- tain primary union was in two cases due to the fact that the wound was not properly cared for. In the third no reason can be assigned. It is evident that the earlier the wound closes the less is the liability of any accident, and the closer will the reparative process in the bone follow the course of a simple fracture. I believe that the suc- cess of an osteotomy depends more upon the man- agement of the small incision than upon any detail in the section of the bone, and that the neglect to remove any tissue that protrudes between the lips of the incision is the cause above all others of suppura- tion. The temperature after an osteotomy seldom rises above 100° R, and in the majority of cases does not get above normal. In a few patients I have seen a temperature of 102° or 103° F. without any assignable cause, the wound pursuing a perfectly normal course. As a rule, however, a registration of the mercury above 100° after the third day demands a careful inspection of the wound, as it may denote suppuration. The temperature in children often rises rapidly, and has as sudden fall without any serious import. A temperature of 103° the day after an osteotomy in an excitable child has been met with, yet the wound, on inspection, appeared perfect- ly normal, and primary union was obtained. Again, 26 OSTEOTOMY. I Lave seen quite a large abscess in the soft parts, of which the thermometer gave not the slightest indi- cation. So the thermometer is not an infallible guide as to the presence of pus. The pain after an osteotomy is generally slight. I have seen a child, two hours after an osteotomy of both tibia, sitting up in bed and playing with her toys as though nothing had been done. But, as a rule, a small dose of some anodyne is required the first night. The first dressing (plaster splint) can usually be left on until firm union has taken place and the pa- tient is well enough to be up and about. Cuneiform Osteotomy. — In anterior curvatures of the tibia, and in angular deformities of the long bones, a wedge of bone has often to be removed. For this purpose a chisel, and not an osteotome, is used, and the operation is through an open wound. An Esmarch bandage having been applied, an in- cision is made parallel to the long axis of the limb, directly down to the bone at the point of greatest curvature, long enough to give plenty of room, which will be found, in the deepest portion of the wound, to be a little longer than the width of the wedge to be removed. If the bone is covered with much muscular tissue, the incision in the skin will have to be somewhat longer. The periosteum is di- vided in the same line as the incision in the soft parts, and is of the same length. Another short in- cision at right angles to the first at about its middle is often an advantage. The periosteum is then sepa- rated from the bone well down on either side. The exact size of the wedge to be removed should be ac- curately ascertained before beginning the operation. OSTEOTOMY. 27 A ready way is to take a narrow piece of lead and mold it to the curvature of the bone. This can be traced upon a piece of paper or card-board, and a line drawn parallel to it at a distance equal to the thickness of the bone. By cutting this out you have a pattern of the outline of the bone. Now cut this in two at the point of greatest curvature, and, by placing one piece over the other until the line of the upper border is straight, the amount that one over- laps the other will represent the size of the wedge to be removed. Fig. 5. Fig. 6. Figs. 5 and 6 are reduced from the pattern of a case of anterior curvature of the tibia. Fig. 5 shows the amount of deformity, and the dotted lines in Fig. 6 the size of the wedge of bone to be removed, in order to correct the deformity. In the beginning a much smaller wedge should be removed than is required, by cutting with the flat side of the chisel toward the part of the bone to be left. This can be increased by chips or shavings removed alternately from either side, and gradually increasing in depth. By keeping the chisel inside of the periosteum, there will be no danger of injuring 28 OSTEOTOMY. the soft parts on either side of the bone. The apex of the wedge should extend well into the compact tissue on the opposite side of the bone. When this point has been reached and the whole width of the bone included in the wedge, the section can be com- pleted by driving an osteotome directly backward from the apex of the cuneiform section. If the V- shaped piece has been accurately calculated, the two opposite surfaces will come into apposition, and the deformity just corrected. During the operation, care should be taken to remove all the shavings of bone. A sponge wet with carbolized water is placed over the wound and the Esmarch bandage removed. The haemorrhage from a cuneiform is much greater than that from a linear osteotomy. After the circulation has become re-established in the limb the sponge is removed, and any vessel that may cause trouble se- cured with carbolized gut. The edges of the perios- teum are to be approximated with antiseptic liga- tures. If the bone is subcutaneous, and if it is pos- sible, a counter-opening should be made opposite the apex of the wedge, and carbolized horse-hair passed from this through the operation wound. The lips of the wound should then be brought into perfect co- aptation with carbolized gut, the horse-hair being brought out at one corner. Over the line of inci- sion iodoform is dusted, and then a small compress applied sufficient to cover the wound, and over this again a flannel bandage and plaster-of-Paris splint, if in a position where such a dressing is applicable. On the second day a fenestra is to be cut, the com- press removed, and the horse-hair is taken out piece by piece. This is easily done without giving the OSTEOTOMY. 20 patient any pain. A fresh compress is applied, and over this a bandage to keep it in place. The reason why a counter-opening is advocated is because in a certain class of cases, where the bone is superficial, on account of the increased amount of haemorrhage there is liable to be too much tension of the skin, thus preventing primary union. Before I adopted this plan I invariably had suppuration, but since its adoption have secured primary union in every case. In correcting after a cuneiform osteotomy great care should be taken that no portion of tissue gets between the ends of the bone. Should such an acci- dent happen, suppuration will be sure to follow. I think that many cases of suppuration after this operation are due to this accident. An argument has been frequently used against osteotomies, that in performing them compound frac- tures are produced, and as compound fractures are exceedingly dangerous, therefore osteotomies are ex- ceedingly dangerous operations. In only one respect can an osteotomy be classed with a compound frac- ture, and that is that in both there is a communica- tion between the ends of the bone and the air; but the bone is reached in the former by a clean-cut wound without any disturbance of the soft parts ; in the lat- ter the wound is a contused and lacerated one, caused either by the ends of the fractured bone, or by the violence causing the injury. The danger from a com- pound fracture is not the simple fact that there is a communication with the bone, but that the soft parts are torn and lacerated, and herein arises the danger. Osteotomy should be classed as simple fracture. CHAPTEE III. OSTEOTOMY FOR DEFORMITIES AT THE HIP JOINT. Deformities at the hip joint which may be re- lieved by an osteotomy may be considered under four heads, namely : 1. After hip-joint disease. 2. After rheumatism. 3. After unreduced dislocation. 4. After fractures united at an angle. The great majority of deformities of this joint fol- low coxalgia. There are but few persons who have had suppurative disease of this articulation who re- cover with motion, and many in whom there have been no signs of abscess, yet the joint remains stiff, with an amount of flexion and adduction which in- terferes much with locomotion. Or there may be some movement, yet, on account of the contraction of the psoas and iliacus, and the adductors, the limb is flexed and adducted on the pelvis at an angle too great for easy locomotion. The foot can not be planted firmly on the ground even with the greatest latitude of motion at the lower lumbar vertebrae, the gait being awkward and labored. It becomes a ques- tion whether by an operation any improvement can be obtained. DEFORMITIES AT THE HIP JOINT. 31 An anchylosed Lip joint, in which the limb is held in a perfectly straight line with the long axis of the body, is a useful one for walking or standing, but is more of a deformity in any other position of the body than one fixed at a right angle to the pelvis. In the former case the person can not sit down with any degree of comfort, or put on his shoes, whereas in the latter, by the aid of proper orthopedic appli- ances, not only is the sitting posture comfortable, but locomotion can be performed with considerable facili- ty. It therefore becomes an interesting question at what angle an anchylosed hip should be placed so as to be a compromise, as it were, between the two positions, and give the patient the greatest amount of use ; that is, easy walking and comfort in the sit- ting posture. I think that an angle of 125° with the transverse axis of the pelvis when in an erect posi- tion gives this. It permits of comfortable locomo- tion, ease in sitting, and ability to put on his shoes. This, then, taken as a standard, enables us to dis- cuss the question of correcting any marked deviation on either side of this line. The angle of deviation is obtained by standing the patient erect and bring- ing up the thigh until the lordosis is obliterated, or, in other words, until the pelvis assumes its normal position. The deformity after hip-joint disease is due, first, to contraction of the psoas and iliacus muscles, caus- ing flexion and rotation of the limb ; second, to the action of the adductors, drawing the thigh toward the median line. This is accompanied or followed by tilting of the pelvis upward on the diseased side in order to bring the limb more in a line with the 32 OSTEOTOMY. long axis of the body, and thus prevent it from cross- ing over the sound one. It is a compensatory, not pathological, position. In the early stage of this af- fection the apparent shortening is due to this tilt- ing of the pelvis. Later, in those cases in which changes take place in the head and acetabulum, there is actual shortening of the limb. The absorption more or less of the head of the femur, and the higher plane occupied by the trochan- ter, due partly to the above-mentioned change and partly to elongation of the acetabulum in its upper or posterior diameter, increases in no small degree the deformity and the amount of shortening of the limb. The difficulty in walking is not due so much to the shortening and flexion as to the adduction of the limb, whether the anchylosis be bony or fibrous. The characteristic awkward gait of a patient who has recovered from a coxalgia with anchylosis is due to the tilting upward of the pelvis on the diseased side. In time other muscles become shortened, and add another element to the problem of correction. The muscles chiefly at fault are the psoas and iliacus, and the adductors; and, even when the de- formity is corrected by any operation above the in- sertion of the former, the question still remains, How can we elongate them ? From their origin and inser- tion being movable, it is impossible to apply any force in order to lengthen them. When extension is applied to the thigh the lumbar vertebrse, arch for- ward (lordosis), and when the lordosis is obliterated the thigh is flexed more or less, being carried forward by the pelvis. DEFORMITIES A T THE HIP JOINT. 33 In those cases in which anchylosis does not take place there may be motion in the direction of far- ther flexion, but extension beyond a certain point is impossible ; and, although the thigh can be brought down so that the foot can be planted flat on the ground, it is not from further extension, but is ac- complished by bending inward of the lumber spine, due to the same shortening of the muscles inserted into the trochanter minor. In this class of cases walking is almost as difficult as in those where the joint is fixed. In cases where suppuration has been extensive the soft parts about the region of the hip joint are often infiltrated with cicatricial tissue which binds the skin to the bone. In anchylosis following rheumatic inflammation the condition of the parts is entirely different ; the head and neck are intact, the bone is not infiltrated with inflammatory products of low vitality. It may be increased in hardness, but the parts retain their normal relations, the neck is not shortened, the an- chylosis is usually bony, the soft parts are normal, and the psoas and iliacus are not as much of an ele- ment in causing the deformity. It is clue more to position, while in hip-joint disease it is the active contraction of the muscles that causes the deformity. In this disease the limb may be fixed in a straight line with the body, a condition very seldom, if ever, met with after coxalgia. In rheumatoid arthritis the joint may be sur- rounded by irregular bony growth, while the bone itself is very compact and hard, like ivory. Deformities due to unreduced dislocations are not 34 OSTEOTOMY. of frequent occurrence. The dislocation may be trau- matic, or pathological. The latter may occur during the course of hip- joint disease, but I do not think that they are as common as some writers would lead us to suppose. It may occur during the course of some debilitating disease, as typhoid fever. 1 I have seen one taking place upon the dorsum of the ilium during an at tack of acute polyarticular rheumatism, complicated with serious heart trouble. Burns 2 reports a simi- lar case. In cases of dislocation in hip-joint disease the head is often found much altered. Malpositions of the femur after fracture are some- times met with, and should be included in this class. In all of these cases (fracture of the femur ex- cluded, unless they occur very high up) one of the chief obstacles to the correction of the deformity and causing the difficulty in walking is the contraction of the adductors. Flexion alone is not the chief cause of the trouble. It is the adduction of the limb ; and, even if the dislocation is reduced, the muscles carry the limb inward, and must be cut in order to afford relief. There is a well-grounded opinion among practical surgeons that any attempt to correct deformities at the hip joint after suppurative coxalgia, or to regain motion in this articulation, should not be entertained. My own experience has been anything but encourag- ing. Two cases in which I made the attempt resulted in rekindling a disease in the joints that had shown no symptom for several years, and which, in one, ended in the death of the patient. 1 Rawdon, " Liverpool Med.-Chir. Jour.," 1882, p. 22. 2 " Centralbl.," 18*79, p. 691. DEFORMITIES AT THE EIP JOINT. 35 Morton, of Philadelphia, has had a similar unfor- tunate experience. The records of many hospital surgeons show simi- lar results. It is true that in a few cases the opera- tion of forcibly straightening has been followed by success. Gay reported such a case at the meeting of the American Medical Association, 1882, in which the neck was fractured and an improved position obtained. Mr. Broadhurst ' also advocates forcible straightening, and claims remarkable success. But the cases are so carelessly reported that it is impos- sible to form any opinion of the results. I am decid- edly of the opinion that under no circumstances should a hip joint that has been the seat of sup- purative coxalgia be forcibly straightened. It is a dangerous operation, and is unwarrantable. The position of the trochanter on the diseased side may be taken as an index of the amount of alteration in the head and neck of the femur. If it is hio;her than on the sound side, the position of the foot being normal, the change must be due, in the vast majori- ty of cases, to absorption of the head and neck ; and the more the upper border of the trochanter major is above Nelaton's line, the more profound must be the alteration in the upper part of the femur. Shortening of the limb, that is, the measurement from the anterior-superior spine of the ilium to the internal malleolus is not as reliable a guide as to the condition of the neck as the position of the trochan- ter, because the whole limb may be atrophied from disease without any marked change in the neck. 1 "On Anchylosis," London, 1881. 36 OSTEOTOMY. Histoey. — In 1826, Rhea Barton 1 devised and carried out the following operation for anchylosis of the hip joint at a right angle subsequent to in- flammation of that articulation : The patient was a sailor twenty-one years of age. The limb was flexed at a right angle, rotated inward, and ad- ducted. A straight incision was made parallel to the long axis of the limb at the upper portion of the thigh, and a short transverse one at the point of in- tended section. The bone was divided with a nar- row saw just above the trochanter minor. No ves- sels were ligated. Primary union was not desired. The operation was completed in seven minutes. Passive motion was commenced on the twentieth day, and repeated at intervals of several days. At the time of discharge, two months after the opera- tion, the patient was able to execute " every move- ment which the limb originally possessed." He had a movable joint for six years, when he became dissi- pated, the new joint gradually became stiff, and at post-mortem examination the artificial joint was found anchylosed. 2 Rodger, 3 in 1830, removed a wedge-shaped piece of bone above the trochanter minor from a man forty- seven years of age, for anchylosis of the hip joint, at a right angle, with marked adduction. Clemot, 4 in 1834, removed a wedge-shaped piece from the femur of a child four years of age for a deformity follow- ing hip-joint disease. 1 " North Am. Med. and Surg. Jour.," 1827, vol. iii, p. 279. 2 " Am. Jour. Med. Sci.," 1837, vol. xxi, p. 333. 3 " N. Y. Jour. Med. and Surg.," 1840, p. 240. 4 "Gaz. Med. de Paris," 1836, p. 347. DEFORMITIES AT TEE HIP JOINT. 37 Maisonneuve ' made a section between the tro- chanters. Mayer first proposed an osteotomy for old dislo- cation, and Broadhurst, in 1862, divided the neck of the femur for anchylosis with deformity following hip-joint disease. 2 All of these operations were made through an open wound, and the section made with a saw. In 1862 Dr. Lewis A. Sayre 3 made a section of the femur just above the trochanter minor and removed a " semicircular piece of bone with its concavity down- ward" and rounded off the upper portion of the lower fragment so as to be received into this cup- shaped depression, and thus aid in establishing an' artificial joint. The first patient operated upon in this manner is reported " cured " with a movable joint at the point of operation. He repeated the same operation later upon another patient, but she died of tuberculosis before a sufficient time had elapsed to establish good and useful motion. In both of these cases there was necrosis of a portion of the bone : in the first, two pieces that " seem to be exfoliated from the lower fragment " : in the second, "two pieces about the size of a pin's head." In the last case, at post-mortem examination the structures of a new joint are reported to have been found. (Fig. 7 shows the line of Sayre's section.) Walter 4 repeated Sayre's operation for anchylosis of both hip joints. After considerable suppuration, 1 "Gaz. Med. de Paris," 184V, p. 935. 2 " Lancet," 1862, vol. i, p. 326. 8 " N. Y. Med. Jour.," January, 1869, p. 337. 4 "Arch. Clin. Surg.," August, 18*76, p. 60. 38 OSTEOTOMY. the patient is reported as having only limited motion at the new articulation, with a history of a tendency to become stiff. In 1863 Weinlechner performed a section through the neck with a chisel. Langen- beck, in 1852, corrected deform- ities in the hip joint by divid- ing the bone with a narrow saw, passed into the bone through a small perforation made with a drill. Suppuration followed in all the cases operated on. Mr. Adams, in 1869, first divided the neck of the femur through a small wound, and gave to the operation the name of subcuta- neous osteotomy. Since that date sections of the femur for deformity have been performed by surgeons both on the conti- nent and in this country. Volkmann 1 removed a wedge-shaped piece of bone from below the trochanter major in order to correct the adduction in bony anchylosis (Fig. 8). Later 2 he substituted an excision of the joint with a chisel and gouge, a linear osteotomy being first performed, and then the head and neck removed in small pieces. He reports six patients operated upon with good results in regard to the re-establishment at the new articulation. The three points at which section has been made 1 " Centralbl. fur Chirurg.," 1874. No. 1, p. 1. 2 " Centralbl. fiir Chirurg., 1880, No. 5. Fig. 7. — Sayre's line of sec- tion. DEFORMITIES AT THE HIP JOINT. 39 on the femur are through the neck, between the trochanters, and below the trochanter minor. Maisonneuve, in 1847, divided the neck of the femur through an open wound, 1 and Weinlechner in 1863. But to Mr. Adams is due the credit of devising an ope- ration through a very small wound and reducing the risks of suppu- ration to a minimum. The instru- ments used were a long tenotomy- knife and a very small saw* (Fig. 1), three eighths of an inch wide, with a cutting edge one inch and a half in length, at the end of a slender shank three inches long. The details of the operation are as follows : The tenotomy-knife is entered a little above the top of the great trochanter and car- ried straight down to the neck of the thigh-bone. The muscles are divided and the capsular ligament freely opened. Withdrawing the knife, the small saw is carried along the track made straight down to the bone, which is then divided from before backward, and at right angles to the long axis of the neck. After the division is completed (Fig. 9), those muscles that prevent the limb being brought into the desired position are divided and the limb put up in a straight position. He simply covers the wound with a compress held in position by a piece of ad- hesive plaster. 1 " Gaz. de Hop.," 1849, p. 64. Fig. 8. — Volkmann's line of section. 40 OSTEOTOMY. Goldino-.Bird substituted a chisel for the saw. 1 Stokes 2 divided the neck with an osteotome in Adams's line. Operations between the trochanters have been performed by Barton and Maisonneuve and Sayre through an open wound, division of the bone being made with a saw. Later, sections have been made through a small wound with the osteotome. But few cases have been reported. The operation is performed like any simple osteotomy. Cuneiform section between the trochanters has been more frequently per- formed. They seem to be adapted to those cases of marked adduction. Mr. Barwell 3 divided the femur just above the trochanter minor with a chain-saw, and a strict antiseptic method, argu- ing that a section below the trochanter minor would pro- duce too much shortening, equal in amount to the distance from the head to the point below the trochanter — from two to three inches. The wound healed by first intention; a firm union was established in thirty-three days. Mr. Gant 4 made a section with an osteotome of Fig. 9. — Adams's line of section. 1 " Guy's Hospital Report," 187V, p. 278. 2 " Brit. Med. Jour.," April 8, 1882, p. 505. 3 "Brit. Med. Jour.," May 29, 1880, p. 812. 4 " Lancet," December, 1872, p. 881. DEFORMITIES A T THE HIP JOINT. 41 the shaft of the femur below the trochanter minor for deformity at the hip joint (Fig. 10). He advo- cated it for anatomical reasons : that the resistance of the psoas and iliacus was set free, and on the pathological grounds in that the section was made through healthy bone, or rather at a greater dis- tance from the point of disease after coxalgia, and thus the operation was not as liable to rekindle the joint trouble. Lately, Dr. Stephen Smith 1 performed the following opera- tion for anchylosis of the hip- joint at a right angle : With a Shrady's saw he made two par- tial sections of the femur just below the trochanter minor — one from its posterior and one from its anterior aspect — half an inch apart, and then fractur- ing the intervening portion of bone, thus making a half tenon Fig. 10.— Gant'siineofsec- and mortise, the object being to prevent any tendency to displacement of lower fragment so as to endanger non-union. After placing the bone in position, the two fragments would as- sume the relations exhibited in Fig-. 11. The patient recovered after evacuation of a large abscess, extending from the point of operation nearly down to the knee. Adams's operation can only be performed when the neck of the bone is present. It is therefore only 1 "Med. Record," Jnne 2, 1883, p. 589. 42 OSTEOTOMY. applicable to cases of anchylosis following rheuma- tism, and possibly those cases of recovery from hip joint disease in which there has been but slight destruction of these parts with bony anchylo- sis. But it is a serious question whether cases of deformity after suppurative coxalgia should ever be submitted to the operation. In the vast majority of cases the section would be through bone infiltrated with inflammatory products of low vitality. The incision, to gain access to the neck, would frequently have to be made through tissue that had been riddled with abscesses, and with the skin often bound down to the bone, and even after a sec- tion it would be very difficult to bring the limb down. Adams's operation is not applicable to cases where the psoas and the iliacus are greatly shortened, and this occurs more often after hip- joint disease than after anchylosis following any other condition. Cases of unreduced traumatic dislocation offer a much better chance. In regard to the class of cases that are suited to the operation, Mr. Adams justly states " that those cases are best adapted to this operation in which there is but slight destruction of Fig. 11. — Smith's line of section. DEFORMITIES A T THE HIP JOINT. 43 the head and neck, and in which there is bony an- chylosis, and that cases of anchylosis after rheumatic inflammation are the most favorable ; those after sup- purative coxalgia the least so." In regard to operations between the trochanters the section is made farther away from the seat of disease in cases of deformity after suppurative coxal- gia, and it also permits of a wedge-shaped piece of bone to be removed, if so desired, in cases of marked adduction. Yet, as the point of division is above the insertion of the psoas and iliacus, there is a doubt whether the deformity is as easily overcome as in section below that point. If the object of an opera- tion is to obtain useful motion in addition to the correction of the deformity, there is no question but that the nearer the division is made to the true axis of motion the better. But useful motion after an osteotomy, be it linear, cuneiform, or elliptic, is rarely obtained, no matter where the section is made. Mo- tion has been obtained in some cases, but they are exceptional I do not think that an inter- trochan- teric operation is the best for deformity after joint disease. It is too near the point of old disease, and it does not free the muscles inserted into the trochan- ter minor. It is, however, a good operation vvhen the bone is healthy ; the operation below the trochan- ter minor is the one to perform after hip-joint dis- ease. Mr. Gant * thus very concisely states the ques- tion when section should be performed below and when above the trochanter minor. 1. "When in consequence of continued disease of the hip joint the head of the femur has disappeared, 1 "Brit. Med. Jour.," October 18, 1879, p. 606. 44: OSTEOTOMY. leaving only a stunted nodule of bone, representing the neck above the trochanter, in such a case the operation of section in the femoral neck can not be performed, there being no neck to divide. This ad- vanced degree of destruction may be ascertained by careful measurement of the femur compared with the other. Even when supra-trochanteric section is prac- ticable the state of the neck may render this opera- tion abortive. The seat of the operation will be in an almost carious portion of bone which is unfit to yield a fibrous union, or possibly atrophy or ne- crosis of the upper portion of the neck may ensue by cutting off vascular supply from bone already devitalized. 2. " Another class of cases inappropriate for Adams's operation is when, the anchylosis having re- sulted from rheumatic arthritis, there is an exuberant deposit of new bone, forming hard nodules or spicu- le around the femoral neck, itself entire. The thick- ening and induration existing will resist any justifi- able attempts to divide the bone in this situation. " In cases, however, of deformity after acute trau- matic inflammation of the hip, a high section is justi- fiable. STATISTICS. Sections through, the Neck (68 cases). — In 17 the deformity was due to rheumatism; in 27 it followed hip-joint disease ; in 7 to unreduced dislocations, path- ological and traumatic ; in 1 to osteo-myelitis of the femur ; and in 16 no cause was assigned. In 3 of the patients both hips were anchylosed. The bone was divided with a saw in 40 cases, in 15 with an osteo- DEFORMITIES AT THE HIP JOINT. 45 tome, and in 12 the instrument is not mentioned. In 13 cases, suppuration followed the operation. In 8 — Golding-Bird, 1 Croft, 2 Servais, 3 Billroth, 4 Willetts, 6 Adams, 6 Holmes, 7 a case mentioned by Wharton 8 and Shaffer 9 — it was excessive. In 3 — Maunder 10 2 cases, Adams " — it was slight, and in one Hutchinson I2 an abscess formed at the seat of section, but not con- nected with the bone four months after the opera- tion. In three cases there was more or less necrosis following the operation (Golding-Bird, Servais, and Billroth). Six deaths have been reported: One by Croft, from pyaemia, due to extensive suppuration and ca- ries of the head of the femur. The deformity was due to hip-joint disease. One by Billroth, from pyae- mia, four months after the operation, the deformity following hip-joint disease. One by Willetts, where extensive suppuration and caries of the head followed the section, and for which amputation at the hip joint was performed, the patient dying within twenty-four hours. One by Adams, eight months later, from tu- berculosis. One by Holmes, from exhaustion due to long and extensive suppuration. And one by Shaffer, from relapse of the joint disease, followed by exten- sive suppuration and death, two years and a half after the operation. A percentage of 8*82 +• It should be stated, however, in justice to the last operator, 1 " Guy's Hosp. Rep.," N. S., vol. xxii, p. 275. 2 Adams, "Trans. Med. Chir. Soc," vol. Ix, p. 1. 3 " Rev. de Chir.," Dec, 1881, p. 1043. 4 Langenbeck's " Archiv.," vol. xviii. 5 Adams's Table, loc. cit. « Loc. cit. "> " Lancet," Oct. 14, 1876, p. 535. 8 "Am. Jour. Med. Sci.," April, 1883, p. 101. 9 " Annals Anat. and Surg.," Dec, 1883, p. 243. J0 " Lancet," March 25, 1876, p. 476. " Adams's Table, loc. cit. 12 "Brit. Med Jour.," March 4, 1882, p. 298. 46 OSTEOTOMY. that, had he been permitted to excise the joint after suppuration had taken place, the fatal result might not have followed. In those patients in whom recovery took place bony union was reported in "fifteen cases. Fifteen are reported to have some motion at the point of section at the time of dismissal. Nineteen were dis- charged cured, one improved, one with limb flexed at angle of 150°, and in four the deformity after a time returned. In regard to motion, in the majority of the cases it was only slight. In two patients of Lund's, in whom there had existed anchylosis of both hip joints, free motion is reported in one, fourteen and sixteen months, the other six and nine months after the operation, the section of the two limbs having been performed at different dates. In Sands's case fair mo- tion was obtained, and, I am informed, lasted for sev- eral years, but the false joint gradually became stiff and firmly anchylosed. In the remaining cases the motion was in time lost and the limbs became stiff. The deformity in sixty-one cases consisted of flexion and adduction, and in seven limbs the anchy- losis was in a straight position. Sections below the Neck (Linear), 64 cases. — The deformity was due to hip-joint disease in 39 cases ; to abscess of the hip joint after confinement, 1 ; rheumatism, 2 ; to injury, 1 ; in 21 cases the cause was •not mentioned. The section was made between the trochanters in 10 ; below, in 52 ; in 2 cases the point of operation is not mentioned. Only 11 operations were per- formed under strict antiseptic methods (Lister). DEFORMITIES AT TEE HIP JOINT. 47 The result was : Cured with firm anchylosis 52 Cured with motion 2 Result not satisfactory 1 Improved 3 Died G Total G4 The cause of death was, one reported by Borchers, 1 due to relapse of the joiut disease ; one by Billroth, 3 from extensive suppuration nine weeks after the op- eration ; one by Billroth, 3 pyaemia, seventh day ; one by Bryant, 4 from pyaemia, thirty-six days after an op- eration for deformity of both hip joints, due to exten- sive suppuration from bed-sores ; one by Porter, 5 from exhaustion due to suppuration above the point of operation four months later, and one by Margary, 6 from collapse on the day of the operation after a Volkmann cuneiform and linear osteotomy of the tibia — a mortality of 9'37 + per cent. Suppuration is reported to have occurred in 12 cases : Borchers, 7 Stephen Smith, 6 Hamilton, 9 Maun- der, 10 two cases ; Rodgers, 11 Maisonneuve, 12 Billroth, 13 Porter," Margary, 15 Croft, 16 Moore. 17 1 " Med. Record," May 19, 1883, p. 541. 2 "Arch, fur klin. Chirurg.," 1882, p. 60. 3 " Chirurg. Klin. Wien.," 1871-'76, p. 543. 4 " Lancet, " Dec. 22, 1877, p. 917. 5 "Boston Med. and Surg. Jour.," April 18, 1878, p. 505. 6 " L'Osteotomie," Campenon. I Loc. cit. 8 " Med. Record," June 2, 1883, p. 589. 9 "Ohio Med. Recorder," Aug., 1877, p. 97. 10 "Trans. Clin. Soc," London, vol. ix, p. 160. II "New York Med. and Surg. Jour.," 1840, vol. ii, p. 238. 12 "Gaz. Med. de Paris," 1847, p. 935. 13 "Ziiricher Berichter," s. 552. 14 Loc cit. I5 " L'Osteotomie," Campenon. 16 "Trans. Clin. Soc," London, 1877, p. 93. 17 "Trans. Am. Surg. Association," vol. i, p. 111. 48 OSTEOTOMY. In Hamilton's, Roclgers's, Maisonneuve's, and Moore's cases, the operation was performed through a large wound, and before the subcutaneous method was adopted. In three patients there existed anchy- losis of both hips. (Bryant, Ashhurst, and Hutchi- son, of Brooklyn.) Cuneiform Sections. — Of these, 35 cases have been collected. Of these, in 27 the section was made be- tween the trochanters ; in 5 the section was made be- low the trochanter minor ; in 3 the location was not stated — 35. Of these, 28 recovered and 5 died. In 1 the result is not stated, and 1 is reported some years later as being in no better condition than be- fore the operation. In 9 cases suppuration is reported to have taken place, and in 22 no information is given with regard to this point. In 3, more or less necrosis is men- tioned. The cause of death was as follows : One reported by Weber, 1 from Bright's disease; one by Ders, s from exhaustive and excessive suppuration ; one by Knorr, 3 from amyloid degeneration ; one by Sayre, 4 from tuberculosis; and one by Lesrink, 6 from em- bolism — a mortality of 14"31. There are reported 3 cases cured with motion; 21 cured, 1 improved, and 2 cured with anchy- losis in a straight line. Three cases, from their subsequent history, can not be put down as suc- cessful. Taking the whole number of cases analyzed of 1 Rosmanit's Statistics, he. cit. 2 Rosmanit's Statistics. 3 Langenbeck's "Arch.," Bd. v., s. 479. 4 "New York. Med. Jour.," January, 1869, p. 348. 5 Rosmanit's Statistics, loc. cit. DEFORMITIES AT THE HIP JOINT. 49 osteotomy about the upper end of the femur, we find: Cured. Died. Failures. 68 sections through the neck 56 6 G 64 sections below the trochanters (linear) 54 6 4 35 sections, cuneiform 28 2 138 17 12 167 giving a mortality of 10 - 18. It is also found that, of the fatal cases, twelve occurred prior to 1877, and only five after that date, the cases being very nearly equal in number in these two periods. I think, therefore, that these tables taken alone are misleading in regard to the death-rate, which they make to appear much higher than it really is under the present method of management of wounds. It would appear that the fatal cases were most numer- ous in the earlier history of the operation, before ex- perience had demonstrated what class of cases were proper ones for operation. For instance, in the fatal case of Mr. Croft, Mr. Adams, although at the time advising the operation, states later that his opinion was wrong. Other cases of deformity after hip-joint disease were subjected to an operation at too early a date after the acute symptoms had subsided, or the section was made too high. Another cause of the increased mortality was the improper method of operation. Many of the -earlier sections were performed through large wounds, and extensive dissections were often made to reach the bone. Osteotomy, as well as other operations which have suddenly become popularized, as it were, has suffered from a want of a clear understanding of the cases 50 OSTEOTOMY. suited for section and the faulty methods adopted, and the earlier operations have always contrib- uted the greatest number of fatal and unrelieved cases. In regard to the question, What operation should be performed % as mentioned before, cases of deformi- ties following coxalgia are the most unfavorable for section through the neck, and, as a rule, the more severe the joint trouble has been, the farther from the articulation should the section be made. The ex- istence of a neck is an absolute necessity in Adams's operation. The amount of real shortening is an index of the extent of its destruction in all cases, disloca- tions being excluded. It should also not be for- gotten that in this class of cases an Adams may fail to correct, or the deformity may return. This has happened in at least four patients, and a sec- tion below the trochanter minor had to be per- formed. Whether an operation above or below the tro- chanter minor will be the best, depends upon the amount of shortening of the muscles inserted at that point, and the extent of the disease that has existed in the hip joint. If there is marked contraction, a section above the trochanter minor will not, as a rule, correct the deformity. Whether a simple or cuneiform osteotomy should be performed is, in my opinion, of little moment. The latter has been advocated in deformities accompanied by marked adduction of the limb. I think that a linear section will accomplish as much as a cuneiform. There will, of course, be a larger gap to be filled with new bone on the inner side than where a wedge of DEFORMITIES AT THE HIP JOINT. 51 bone has been removed. Theoretically, the latter may appear to be the better plan, but practically it makes no difference. The length of the incision, and the fact that a cuneiform osteotomy must be made through a large wound, does not add to the risk, provided the wound is treated properly. A division of the femur performed after the method advocated by Dr. Stephen Smith has no advantage, I think, over a simple osteotomy. The tendency for the lower fragment to slip is not great ; at least there has been no record, except in one case, of such an accident, which the tenon and mortise plan did not prevent in the case reported. The operation has the theoretical objection of causing greater disturbance of the soft parts, and makes two partial sections of the bone. The abscess complicating the case should be attributed not to the operation, but to the lack of drainage. Volkmann's excision of the hip joint by means of a chisel, as a substitute for " osteotomacia-subtro- chanterica," has had but few advocates, both on ac- count of the difficulty and tediousness of the opera- tion, and the fact that but few cases are appropriate for the operation. The object aimed at is to obtain a movable articulation. The question when an osteotomy should be per- formed is one not easy to answer. The liability of strumous joints to take on a new inflammatory ac- tion, from apparently slight injury, even some time after all symptoms of former trouble have disap- peared, would indicate that some months should elapse after a " cure " before an attempt should be made to correct any malposition. Any pain about 52 OSTEOTOMY. the articulation should be a counter-indication against an operation. There have been but two recorded post-mor- tem examinations after an osteotomy at the upper end of the femur, one by Dr. E. M. Moore, of Roch- ester, and one by Dr. H. R. Wharton, of Philadel- phia. Dr. Wharton's case occurred in a patient nine years of age, who had suffered from hip-joint disease, and had recovered with the limb flexed at a right angle, with rotation outward and adduction. On No- vember 25, 1882, Dr. H. R. Wharton made a subcu- taneous section of the right femur below the lesser trochanter with a saw, which allowed the limb to be brought down into a good position ; the usual dress- ings were applied, and in March, 1880, the patient was walking about the ward with the aid of a hio-h shoe. 1 Some months later a swelling; was noticed in the neighborhood of the great trochanter ; this proved to be an abscess and was opened. From this time the patient grew rapidly worse, and finally died, Au- gust 15, 1883, from exhaustion. The fatal issue had no connection with the operation, but was due to a fall. The specimen consists of the head, neck, and a portion of the shaft of the femur (Plates I and II). The head is denuded of cartilage, but otherwise does not show evidence of much disease. The section was made from a point midway between the tro- chanter major and minor downward and inward (d c, Plate I), so that the separation took place, as nearly as can be judged, in a line from this point 1 " Am. Jour. Med. Sci.," July, 1883, p. 103. PLATE I. Dr. H. E. Wharton's case— the parts after an intertrochanteric operation, anterior view. PLATE II. Dr. II. R. Wharton's case— the parts after an intertrochanteric operation, lateral view. DEFORMITIES AT TEE HIP JOINT. 53 through the middle of the trochanter minor. There had been a sliding inward of the lower fragment, which has left a corresponding portion of the cut surface on the upper fragment b (Plate I), and also seen at b (Plate II), and a twisting outward on its longitudinal axis. The sloping projection (a, Plate I) is not due entirely to the displacement inward of the lower fragment, but in part to the rotation men- tioned above. As the femur is much shorter in its antero-posterior than in its lateral diameter at this point, there would naturally be some projection when the lower portion was rotated outward to overcome the malposition due to the disease. From an examination of the cut, it is evident that the de- formity has been corrected. The nature and amount of the correction are seen in Plate II. At the time of the operation there was left a V-shaped gap on the anterior aspect of the femur at the point of section ; this has been filled up by new bone (a a, Plate II). It will be noticed that the outer line of the bone slopes inward, due to the sliding in this di- rection. A careful study of this specimen shows the nature of the deformity after an osteotomy ; it also shows how little is the shortening due to the operation. The displacement inward may have been due to the fact that the attachment of the psoas and iliacus were not entirely freed because the section was not made below the trochanter minor, but through it, and these muscles had drawn the lower fragment in- ward. Dr. Moore's patient was an adult, in whom there existed a dislocation of the head of the femur on to 54 OSTEOTOMY. the ilium, just above the upper portion of the lip of the acetabulum. The dislocation was primarily back- ward on to the dorsum ilii, but by manipulation it had been thrown into the position mentioned above, with the head forward, just behind the anterior- superior spine of the ilium (a, Plate IV), and all at- tempts to dislodge it from this position failed. The foot pointed directly outward, at right angles to its normal position, and the limb was hyperextended, so that walking was extremely difficult. There was shortening of two inches and a half. An attempt was made to divide with a tenotome the bands that were supposed to prevent reduction, but the knife encoun- tered bone that seemed to surround the head and hold it in its abnormal position. An incision was then made down upon the intertrochanteric portion of the femur on its lateral aspect, and the bone divided with a metacarpal saw above the trochanter minor. After section, the limb was rotated inward, so as to bring the foot into its normal position, and extension by means of a weight of fifteen pounds applied, the object being to obtain a joint at the point of section. Passive motion was com- menced early, but, notwithstanding persistent efforts, bony union was established, the shortening of the limb being; reduced from two inches and a half to one inch. There was considerable suppuration, last- ing some months, but finally ceased under the use of antisyphilitic treatment, the patient exhibiting a specific eruption. For some time he was able to get about comfortably with the aid of a cane. He died two years later from phthisis. Plates III and IV are from photographs of the specimen kindly furnished PLATE III. % Dr. E. M. Moore's ca^e— the parts after an intertrochanteric operation, anterior view. DEFORMITIES A T THE HIP JOINT. 55 by Dr. Moore. Plate III is an anterior and Plate IV a lateral view of the specimen. The head is dislocated and is seen (a, Plate IV) just behind the anterior-superior spine ; the trochan- ter, covered in this situation with a shell of new bone, is posterior (&). The section was made mid- way between the trochanters, in a direction from without inward and a little downward, to a point just above the trochanter minor. The head is per- fectly healthy. It is held firmly in its new position by a deposit of new bone (&, Plates III and IV), which covers it, except at one point (#, Plates III and IV) and the upper portion of the trochanter, and is con- tinuous anteriorly below with the mass of new bone below the head, to be presently described, while above and in front of the head it is blended with the ilium (<7, Plates III and IV). There is an enormous mass of bone, irregular in shape and perforated by many foramina, which springs from the anterior portion of the shaft from a point one inch and a half below the level of the trochanter minor (d, Plate IV) and extends upward and forward to a point on the ilium just below the situation of the head, where it is blended with the shell of bone covering the head (atient dying, six weeks after section, of typhoid fever. He says : " In this figure the inner side of the bone 1 "Boston Med. and Surg. Jour.," February 16, 1883, p. 154. 112 OSTEOTOMY. upon which the chisel was entered is to the right. At c we have the line of the epiphysis; three fourths of an inch above this is the line of division. On the outer side of the bone the line of the shaft is pretty well preserved. On the inner side a consider- able displacement has occurred. The compact wall of the shaft has been driven down into the cancel- lated tissue at the point a. The tissue in the middle of the shaft, on the other hand, was less resistant than the more densely cancellated tissue below, so that the center of the lower fragment is impacted into the upper. A very firm locking is the conse- quence, and this, no doubt, greatly facilitated rapid recovery. That there has been but slight reaction in the parts above is shown by the absence of callus. The only true callus formation is seen at b t where a little new bone has been thrown out over the free end of the lower fragment ; besides this there is only a very thin layer of new bone under the periosteum on the outer side." 1 Results. — As to the limb. The object of a subcon- dyloid (Mace wen's) operation is to make a wedge- shaped incision into the lower end of the femur, just above the epiphysis, extending from within outward, the apex of the wedge penetrating the compact os- seous structure on the outer aspect of the bone. By the use of the largest osteotome at the beginning, and only replacing it with the next smaller when it is ab- solutely necessary, on account of the instrument be- coming wedged, the cut in the bone is made wider, not by any loss of substance, but by condensation of the bone on either side the instrument. In cases of 1 "Boston Med. and Surg. Jour.," 1882, vol. cvi, p. 155. PLATE V. Dr. A. T. Cabot's case— the parts after a supra-condyloid operation. OSTEOTOMY FOR GENU VALGUM. 113 knock-knee where the deformity is not very great, in bending the leg inward the two opposite surfaces of this V-shaped cut come into apposition, and just cor- rect the malposition of the leg. ~No re-entering angle is left on the outer aspect of the femur. If, however, the deformity is great, there will exist a re-entering angle opposite the point of section on the external aspect of the bone. This, as has been proved by post- mortem examination, will till up with new bone, the same as after a simple fracture. The effect on the bone, as a whole, is to compensate for the curve with its convexity inward, by a sharp bend hav- ing its angle at the lower end of the bone. In Fig. 26. Fig. 27. those cases where the deformity is due to a change in the shape of the condyle, where it is depressed either by growth or by the abnormal deposit of bone just above it, the result of the operation is practically to remove a wedge-shaped piece of bone, and thus raise the plane of the condyle. That there is an actual change in the plane of the two condyles after a supra-con dyloid operation is demonstrated in Figs. 26 and 27. They are reduced from tracings of the 114 OSTEOTOMY. lower end of the femur before and after the opera- tion. The cut marked E is from the right, that marked L from the left limb; the star indicates the internal condyle, the heavy line the contour of the parts before, the dotted line after the section. It will be noticed that the two condyles after the op- eration are upon the same plane. The distance be- tween the two lines is the amount of correction gained by the operation. It is true that the cor- rection in some cases is not at the real point of de- formity, yet practically it is perfect as far as the posi- tion of the tibia is concerned, and this is the real deformity. Suppuration. — In a carefully performed osteoto- my, suppuration of any amount is rarely met. In my own experience, after a supra-con dyloid operation, suppuration has occurred in four limbs only. In three it evidently had its starting-point in a piece of tissue that protruded from between the lips of the wound, and was irritated by the dressing. On re- moving the compress from over the wound, the pus flowed out, proving that the pad, hardened with blood, prevented its escape. The application of a large compress in the course of the abscess was soon followed by a cure. The other abscess I can assign no cause for. It was small, and gave no trouble. In two of these cases the thermometer gave no indica- tion of the presence of matter, the temperature being normal the whole time. STATISTICS. Of six hundred and twenty-two cases of Mac- e wen's operations (section above the condyles), as OSTEOTOMY FOR GENU VALGUM. H5 far as can be ascertained, there have been but three fatal cases reported that could in any way be at- tributed to the operation. One was a case reported by Dunlap, where death was due to septicaemia sec- ondary to a cellulitis of the thigh due to improper dressing; one, by Bull, was probably the result of carbolic-acid poisoning. Langton ' reports a case in which he performed a Macewen's operation on the right femur of a patient nineteen years of age. Not much bleeding occurred at the time of the operation, but in the evening the dressings (Lister) w r ere filled with blood ; they were removed for the same cause daily during the next four days, and then a drainage- tube inserted. Ten days later the patient lost six ounces of blood; as the haemorrhage continued, the wound was enlarged. The end of the lower frag- ment was found posteriorly, and from it projected a sharp spicula of bone. The ends of the fragments were excised and the popliteal artery exposed. It was then found that there was a small hole on its anterior aspect of the size of the splinter of bone. The artery was ligated above and below the point of puncture. The next day the leg became gangre- nous, and an amputation was performed two inches above the end of the upper fragment. The patient died the same evening. McGrill 2 reports a case in which, during a supra-condyloid operation, the pop- liteal artery was completely divided transversely, the vessel was exposed, and both ends ligated with anti- septic catgut. The patient made a good recovery, the deformity being relieved. 1 " Lancet," March 29, 1884, p. 564. 2 "Lancet," May 17, 1884, p. 891. 116 OSTEOTOMY. In two cases the an&stomotica magna has been di- vided during a Maeewen's operation — once by Ger- ster ' and once by Marsh. 2 In both of these cases the point of the incision in the skin was determined by Maeewen's rule, and the limb was operated upon with the leg in an extended position. There have been other deaths reported, viz. : from diphtheria, meningitis, pneumonia, and uraemia ; but they should not be attributed to the operation. It is claimed by Macewen, and I think justly, that Dunlap's operation was not a strictly supra-con dyloid section according to his method. It was performed with a chisel, and not an osteotome, "and the line of the section was zigzag." 3 But as the fatal issue was not due to anything about the wound, but to an error in dressing, even this case should not be charged to the operation. Bull's case of carbolic- acid poisoning is excluded on the same ground. There has, therefore, been but one death recorded from the operation. In thirty cases the section was made from the outside. In twenty-seven of these the bone was divided with a saw ; in the other cases an osteotome was used. In eleven cases section was made with a saw in Maeewen's line. In none of these did sup- puration occur. There have been ten. cases recorded in which suppuration has occurred after a supra-con- dyloid operation, and in none of these did the pus communicate with the bone. There have no doubt been many other cases in which it has occurred, but no record has been made of the fact. 1 "N. Y. Med. Jour.," February 23, 1884, p. 227. s "Brit. Med. Jour.," April 5, 1884, p. 665. 3 Private note. OSTEOTOMY FOR GENU VALGUM. H7 In one case (Taylor 1 ) there was some effusion into the joint a day or two after the operation. Weir also reported a case where this took place some weeks after the operation, when the patient began to use this limb. In the latter case it is probable that the effusion was due to over-exercise. In two cases considerable stiff- ness persisted for some time (Wright, 2 Rabagliati 3 ). In one case the deformity returned, and Ogston's operation was performed with a good result. In this case the section was made from the outside ; the pa- tient may possibly have been permitted to go about before the new bony deposit had become well con- solidated, and the deformity thus reproduced. In one case the joint was fractured into during the sec- tion (Rabagliati 4 ). The patient recovered, but with restricted motion in the joint. This is the only case in which this accident has ever been reported. It may have been due to the rise of an osteotome of too great thickness, and driving it after it had be- come tightly wedged. Ogston's Operation. — Out of one hundred and ten cases, only two are reported to have died — one from septic pneumonia (Baker), and one from uraemia (Thiersch), six weeks after the section. The latter can not be attributed to the operation. Suppuration is reported by Jones, Schonborn, Sonnenburg, and Margary. In three cases it was con- siderable. In one it involved the joint, necessitat- ing many incisions and drainage. In one case a trou- blesome synovitis persisted for some time (Callen- 1 "Brit. Med. Jour.," April 7, 187Y, p. 429. i Loc. tit. a Loc. pit. 4 "Brit. Med. Jour.," November 24, 1883, p. 1006. 118 OSTEOTOMY. der). In almost all cases there was more or less effusion for a few days. Three patients recovered with complete ankylosis, and one of them with the limb flexed at a right angle, while in four there ex- isted for many months marked stiffness of the knee joint. Acute pain in the knee joint, lasting several days, seemed to have been not an infrequent occur- rence. In one case the saw broke, and was left in the bone. No complication followed. Reeved s Linear Section with Chisel in Ogston's Line. — In thirty-seven cases, of which record can be found, the ultimate result has been good in all ex- cept one (Haward), where the chisel broke in the condyle, and was extracted. Swelling of the knee and thigh followed, with free suppuration, and after recovery the limb was straight while the patient was lying down, but, when any weight was brought to bear upon it, it bent inward. Besides the above case, suppuration has been reported in three others (Holmes, Sterling, and Briddon). Baker 1 states that he has collected fifty-seven cases of Reeves's opera- tions. In one case there was effusion into the knee joint. BarweIVs Linear Section of Femur and Tibia. — In twenty cases, recovery is reported as having taken place in all. Suppuration from the femoral wound occurred in one case, a slight synovitis in one, and the external lateral ligament was ruptured once 2 during the operation. In most of these cases the tibial section was made from three weeks to three 1 " Brit. Med. Jour.," 18*79, vol. ii, p. 3. 2 Margary, Caiapenon, loc. cit. OSTEOTOMY FOR GENU VALGUM. H9 months after the femoral ; in a few, however, both sections were performed on the same day. Linear Osteotomy of the Tibia (Billroth). — Of thirty-one limbs on which this operation was per- formed, in thirty firm union was established. In one case a slight synovitis is reported, lasting six weeks. In one case there was high temperature and great pain, followed by gangrene of the foot, neces- sitating an amputation at the lower third of the leg (Margary). Cuneiform Osteotomy of the Tibia (Mayer and Schecle). — In twenty-two limbs submitted to this operation, recovery took place in all ; in one case osteomyelitis and suppuration followed the opera- tion. Cuneiform Osteotomy at loiver end of Femur (Chiene and Macewen). — In fourteen cases, there was one death from suppuration and erysipelas. At the time of death the bones were united. A good recov- ery is reported in the remaining cases. In osteotomies for the relief of genu valgum there have been only three deaths that were due to the op- eration. Suppuration is reported to have occurred in nineteen limbs. In five cases the joint was stiff to a greater or less degree, in four firm ankylosis took place, and in two amputation had to be per- formed on account of gangrene of the foot. In nine limbs the result was only an improvement. ILLUSTRATIVE CASES. Case I. — Anna A., four and a half years of age, was admitted into St. Mary's Hospital in February, 9 120 OSTEOTOMY. 1881. She lias enlarged epiphyses, and gives a clear history of rickets. Macewen's supra - condyloid operation was per- formed on both femora March 17, 1881. The limbs were immediately put up in a plaster-of-Paris band- age. A fenestra was cut over the seat of the wounds on the 19th, at which time they were found to have closed, the point of incision being represented by a fine line only. On April 16th the splints were re- moved. Union firm. Fig. 28 is from a photograph taken at time of ad- mission; Fig. 29 at date of discharge. Case II. — George R., colored, aged six years, came Fig. 28. under my care in April, 1882. He shows marked rachitic changes in all the long bones. The femurs have an anterior curvature, both internal condyles are much depressed, and there is an acute bend out- ward just below the epiphysis of the tibia. There OSTEOTOMY FOR GENU VALGUM. 121 is also an anterior curvature of the bones of the legs. Figs. 30 and 31 are from photographs, and are a good illustration of a marked case of rachitic curvature. Walking is very difficult. There is considerable re- laxation of the ligaments. On May 1, 1882, I performed Macewen's opera- tion upon the right femur, and a linear osteotomy on Fig. 29. the left tibia just below the tubercle. The femoral wound closed, but from the tibial there was some slight suppuration. By these operations considerable improvement was obtained. In October, 1882, the same operation was done on the left femur, and a linear osteotomy on the right tibia and fibula. The limbs were apparently brought into good posi- tion. The bones were neither hard nor soft. There was an abscess in connection with the femoral wound which burrowed up under the splint, and was opened on the lateral aspect of the thigh above the plaster- 122 OSTEOTOMY. of-Paris bandage. The operation-wound had closed. After evacuating the matter, the abscess cavity con- Fig. 30. Fig. 31. OSTEOTOMY FOR GENU VALGUM. 123 tracted down and the discharge ceased. On remov- ing the splints, the deformity was found to still per- sist, but in a much less degree. During the winter and spring an attempt was made to correct what re- mained of the deformity with splints, but, owing to the relaxed condition of the ligaments, it was im- possible to gain any improvement. During the past summer he was down at the sea-side, where he greatly improved in every respect except the curvature of the bones. In October, 1883, I made a cuneiform osteotomy Fig. 32. of both tibiaa from the inside, just below the level of the tubercle. Sufficient bone was removed to allow the tibia to be brought into a straight line with the femur. The wounds were treated in the usual man- ner, and horse-hair drainage used. The following day it was removed. There has not been a particle of suppuration. In November, 1883, the splints were removed. Fig. 32 shows his present condition. 124 OSTEOTOMY. There is still a marked anterior curvature of the shaft of the tibia. This case illustrates one of the worst deformities Fig. 33. Fig. Si. OSTEOTOMY FOR GENU VALGUM. 125 I have ever attempted to treat, and is used not so much to exhibit a perfect correction as to show what may be accomplished in so unpromising a case. Case III. — Lillie B., four years of age, has genu valgum of rachitic origin in right limb, due to a depression of the plane of the internal condyle and Fig. 35. some elevation of the inner head of the tibia. Fig. 33 is from a photograph, and shows the extent of the deformity. On March 14, 1881, a supra-con dyloid operation was performed. On examination of the wound on the seventh day, it was found to be represented by a fine line. April 15th the plaster-of- Paris splint was re- moved, and correction was found to be perfect. Fig. 34 shows the condition of the limb at time of dis- charge from the hospital. 120 OSTEOTOMY, Case IV. — W. S., fourteen years of age, was ad- mitted into St. Mary's Hospital in February, 1881. He is very small for his age, has misshapen chest and k&sfe? Fig. SG. other rachitic deformities, together with genu valgum. The ligaments of the knee joint are relaxed. . Fig. 35 is from a photograph taken shortly after admission, and shows the amount of the deformity. On February 25, 1881, Macewen's supra-condy- loid osteotomy was performed upon both limbs, and immediately put in plaster -of- Paris splints. The wounds were found closed on the 27th, and the splints were removed on the 7th of April, at which time consolidation between the fragments was firm. Fig. 36 is from a photograph taken after he left the hospital. CHAPTER VI. GENU VARUM. Genu Varum lias been described by some writers on deformities as the reverse of genu valgum, and that the pathological changes found in the former are similar to those met with in the latter, except that they occupy the opposite side of the limb. This is an error, at least in the vast majority of cases. The deformity in genu varum seldom has that angular appearance so characteristic of knock knee. The whole limb from the trochanter to just above the malleolus forms a long curve, the femur and tibia apparently being equally involved, whose greatest convexity is at the knee joint. There are, however, a few cases that present an angular appearance at the knee joint. I have met one case in which the deformity was due to a lengthening of the ex- ternal condyle, resembling the condition often found in knock knee. Reeves 1 reports a case of hyper- trophy of the external condyle. Genu varum of a marked degree is not as common a deformity as genu valgum, nor are all cases of apparent bowing outward of the limb to be classed as cases of this deformity. Many examples of uncomplicated cur- vature of the tibia present an appearance of genu 1 " Trans. Clin. Soc," London, 1879, p. 32. 128 OSTEOTOMY. varum, but, on correcting the tibial curve, the whole deformity is removed, thus proving that the femur was not involved. Fig. 37 illustrates this. In other examples there may be a slight bending of the femur. Again, a curvature of the thigh may not be observed until the tibial curve has been corrected. Genu varum may be present in one limb and genu valgum in the other. This deformity may be com- plicated by other curvatures of the bones of the leg. Fig. 37. The cause of genu varum is rickets, and in the majority of cases the femoral is secondary to the tibial curve. Patients affected with genu varum to any marked degree walk in an awkward manner, but there is not as much pain from this deformity as from genu valgum. The elements going to form this deformity being so variable, no strict rule can be laid down as to its GENU VARUM. 129 management. The same remarks that were made with regard to the mechanical treatment of knock knee apply with equal force to cases of genu varum. When an operation is called for, it will often be found that a correction of the most marked curve, which is generally the tibial, will remove, or almost remove, the deformity, so that no other section is called for. An osteotomy should be performed at the point of greatest curvature in each bone, and the bone in which the most marked bend exists should always be divided first. In marked cases, several osteotomies are necessary to entirely correct. Theoretically, the section should be made of the tibia from without inward ; but, on account of the difficulty of getting at the bone on its outer aspect, and the vessels in close proximity to it in this situa- tion, it is not practical, and its division is made from before backward. The fibula should always be divided first. Section of the femur is best made from the outside. CHAPTEE VII. OSTEOTOMY FOB ANKYLOSIS OF THE KNEE JOINT. Osteotomy for ankylosis of the knee joint was first performed by J. Rhea Barton, 1 who made a cuneiform section of the femur at its lower extremity. The late Gurdon Buck, in 1844, modified Barton's operation by including the ends of the femur and tibia together with the patella in the wedge. Since then other operations have been performed. They can be best considered under — 1. Operations upon the femur. 2. Operations upon the tibia. 3. Operations upon the femur and tibia. 4. Operations upon the joint itself. 1. Operations 'upon the Femur. — Barton's opera- tion, performed in 1835, for bony ankylosis of the knee joint at a right angle, consisted in removing a V-shaped piece of bone, base forward, from just above the condyle of the femur, in the following manner: The bone was reached by an angular- shaped flap, base outward, made just above the con- dyles, and a V-shaped piece of bone then removed, the apex not extending entirely through the thick- ness of the shaft. The section was made with a 1 "Am. Jour. Med. Sciences," 1837, vol. xxi, p. 332. ANKYLOSIS OF TEE KNEE JOINT. 131 saw, and the remaining portion of the shaft frac- tured by bending the \eg. The line of incision was closed by sutures and adhesive plaster, and the limb placed upon a double inclined plane. After some days the leg was gradually brought up into a straight line with the femur. The object in not immediately correcting the deformity was that the rousfh ends of the divided bone mi«:ht become rounded off by inflammatory action. Quite a num- ber of patients have been operated upon by Bar- ton's method, but modified by the immediate instead of the gradual correction of the deformity. Kilgarriff, 1 in a case of ankylosis at a right angle following extensive injury to the knee, slightly modified Barton's operation by making a complete section of the bone. His reasons for this mode of operating were that the skin over the knee had been entirely replaced by cicatricial tissue, and he desired to remove more bone than a strict Barton's opera- tion would accomplish. Schillbach is reported by Heyfelder (p. 108) to have made a complete resec- tion with a chain-saw of a wedge-shaped segment of the femur. Pancoast 2 operated upon the shaft by perforating the bone in different directions in the line of desired fracture with a gimlet through a small wound, and then breaking the bone. An ab- scess formed at the seat of operation, but eventually the patient made a good recovery, the limb being nearly in a straight position. In the following year Brainard, of Chicago, operated upon the condyles, the bone at this point being perforated by an instru- 1 "Dub. Med. Jour.," March, 1880, p. 189. 2 "Med. and Surg. Reporter," March 5, 1859, p. 408. 132 OSTEOTOMY. merit devised for this purpose. He was unable at the time to fracture the bone, but some days later, after innarnniatory action had been set up, the bone easily gave way. Stephen Smith ' attempted to per- form Brainard's operation, but was unable to fracture the bone, even after inflammatory action had lasted for some time. Langenbeck, in 1862, practiced subcutaneous osteotomy above the condyles by means of his per- forator and small saw, but the operation can not be considered a strict subcutaneous one as such sections are now peformed. Barwell 2 performed a linear osteotomy with a chisel, two inches above the lower end of the femur, for the correction of angular ankylosis at the knee joint, with excellent results. A few months later Macewen, in April, 1875, operated antiseptically in a knee joint in a similar manner. 2. Operations upon the Tibia. — Wahl, of St. Peters- burg, in 1877 performed a cuneiform osteotomy upon the tibia just below the tubercle for the relief of a knee ankylosed at a right angle. The operation was followed by suppuration and necrosis. Margary repeated this operation, but with better success. It does not seem to have been a favorite operation, and has had but few advocates. 3. Operations upon the Femur and Tibia. — This includes cuneiform excision of the ankylosed joint and linear osteotomy of both bones. Buck, 3 in 1844, modified Barton's operation by removing a wedge- 1 "Am. Med. Times," 1860, vol. i, p. 310. 2 "Brit. Med. Jour.," April 28, 1878, p. 807. 3 "Am. Jour. Med. Sciences.," October, 1S45, p. 277. ANKYLOSIS OF THE KNEE JOINT. 133 shaped piece, which included the articular ends of the femur and tibia, together with the patella, and immediately rectifying the position of the leg. The apex of the V-shaped section did not reach the pos- terior portion of the bones, a bridge of bone being left, which was fractured. The object in this was to obviate any danger of injury to the popliteal vessels. The operation is really an excision of an ankylosed joint. It has been adopted in the vast majority of cases of bony ankylosis of the knee joint at an angle, and records of its success are scattered through the medical journals since the day of its first performance. Eutriken l deviated from Buck's operation in that lie included the whole thickness of the bones in the section on account of the marked contraction of the tissues behind the joint, requiring the removal of more bone than was possible by Buck's section. The same end, however, could have been accomplished by making the cuts as designed by the first operator, and then removing additional pieces until the nec- essary amount of bone had been removed. Buck's operation is certainly a safer one in that the vessels are protected by a bridge of bone from the saw. In marked cases of deformity at the knee joint submitted to a linear osteotomy, most operators have advised and practiced two sections: one at the lower end of the' femur, by which half of the desired cor- rection was obtained, and later a division of the tibia just below the tubercle, by which the remainder of the deformity was removed. The advantage of this operation is that the shortening of the limb is not increased, while, on the other hand, it leaves the 1 " The Clinic," March 12, 1876. 134 OSTEOTOMY. joint prominent and misshapen. Time will, how- ever, diminish this deformity to some extent. In correcting after a linear osteotomy there is an enter- ing angle left on the posterior aspect of the bone, its size varying with the amount of correction made. This in time is obliterated by the formation of new bone. There have been two operations performed upon the joint itself, in order to break up the bony bands between the bones. In 1861 Gross 1 per- formed a subcutaneous operation by entering the joint itself with a perforator and after dividing or breaking up all adhesions, placed the limb in the desired position, the operation being performed through an incision one half an inch long. He re- ports six successes out of seven patients operated upon. Stromeyer Little, 2 in 18G8, divided the uniting bands between the femur and tibia, in a case of bony ankylosis of the knee joint, with a carpenter's chisel, one fourth of an inch wide, through a small incision, and then brought the leg into a straight position. The wound closed without suppuration by the sixth day. Dr. H. B. Sands, of this city, has, I believe, performed a similar operation. Of these operations for correcting ankylosis of the knee joint at an angle, that of Buck (cuneiform osteotomy), removing a V-shaped piece from above the joint, and linear osteotomy of the femur and tibia, are mainly prac- ticed. Buck's operation does not properly belong to osteotomies, but rather to excision. Linear osteotomy for angular deformity at the ^'System of Surgery," 1882, vol. i, p. 1096. 2 " Medico-Chir. Trans.," vol. iv, p. 247. ANKYLOSIS OF THE KNEE JOINT. 135 knee joint is performed as follows : The limb should be rendered bloodless, and a small incision made by the side of the rectus tendon, at a point a finger's breadth above the upper portion of the external condyle, of sufficient length to admit the osteotome. This latter instrument is then passed down upon the knife as a guide, and the femur divided as in other osteotomies until it can be easily fractured. If the deformity is great, it is well to make in addi- tion a section of the tibia just below the tubercle, and divide the amount of correction between the two bones. Barwell makes the section of the tibia two weeks later, while Macewen operates upon both bones upon the same day. The nearer to the joint the section is made, the less will the knee project after the correction is made. In time, however, the deformity is diminished by rounding off and filling up any projection and depression, so that in a year after the operation the appearance of the limb has greatly improved. The shortening of the limb is less than after a cuneiform osteotomy. Macewen reports no shortening in some of liis cases. The only accident after a linear osteotomy that I have seen mentioned is gangrene from compression of the popliteal vessels from the acuteness of the bend after straightening the limb. I have never performed the operation of simply dividing the bone. I think that a Buck's operation is the safer and better. 10 CHAPTER VIII. OSTEOTOMY FOB TIBIAL CURVES. Tibial curves may be studied under three condi- tions: rachitic, traumatic, and pathological. As in other deformities of the long bones, the vast majority of cases of bending of the bones of the legs are in- cluded in the first class. Rachitic curvature of the tibia and fibula belong to the earlier manifestations of this disease, and usually begin before the third year. Their cause is mechanical — standing ; sitting with their feet bent under, or cross-legged, a very common position for a child affected with rickets to assume; sometimes the way in which they are carried by their nurse is a factor in the production of these deformities ; in fact, almost any position will produce a curvature of these bones in a young child affected with rickets. I have never been able to sat- isfy myself that the muscles of the limb were an active element in their production. Curvatures of the tibia may be lateral, anterior, or antero-lateral. The bending may be confined to the lower third of the bone, just above the malleolus, where a sharp, almost angular curve may be found ; it may involve the whole bone, from just below the upper epiphysis to the malleoli, or there may be a OSTEOTOMY FOR TIBIAL CURVES. 137 sharp, short curvature at its lower third, and then a long one above, or the bone may have only one long anterior curve. In marked cases the tibia is often flattened from before backward, or from side to side. In the latter cases the spine is much sharper and seems more prominent. In anterior curvatures the bone is often elongated on its anterior border, and overhangs the foot (as in Fig. 38). Lateral curva- Fig. 38. ture of the tibia and fibula with that of the femur, form genu varum. Traumatic deformities of these bones have their origin in fractures, which, for one reason or another, have been allowed to unite at an angle. To this class belong intra-uterine fractures. These are almost always angular ; some few cases of simple bending are reported. Deformities from this cause are not as frequently met with as formerly, owing to improved methods of treating these injuries. The greater por- tion occupy the middle third, and next in frequency 138 OSTEOTOMY. we find malposition of the foot, due to fracture of the lower portion of the fibula and a chipping off of the internal malleolus (Pott's fracture), the foot being turned outward. Thus, in seventy-four cases, fifty-one occurred in the middle third and twenty- three in the lower portion of the limb. Operations for the correction of vicious union of the tibia and fibula above the lower portion may be resolved into three — a simple section, a cuneiform section, and an excision of the ends of the fragments after a simple division. Of simple section nine cases are reported, twenty-six of cuneiform excision, and fifteen of an excision of the ends of the bones after a linear section. Of the first class, suppuration is reported in ten cases ; one patient died — no cause assigned ; and six were cured — no mention of the formation of pus being made. Of cuneiform osteotomies, in nine patients suppu- ration is reported, two died from pyaemia; in two the limb was amputated subsequently ; in one the femoral artery was ligated to control haemorrhage; and thirteen are reported " cured " — no mention be- ing made of suppuration. Of re-excision of the ends of the bone after a simple division, in six cases suppuration is reported ; one patient died from pyaemia; in one the limb was amputated some time after the operation for non- union ; and in six no accident is reported. There have been three operations performed for the correction of the malposition of the foot after a Pott's fracture — namely, an excision of the lower end of the tibia, with a division or osteoclasis of the fibula; an excision of the internal malleolus, with OSTEOTOMY FOR TIBIAL CURVES. 139 fracture of the fibula ; a cuneiform osteotomy, base inward, on the inner aspect of the tibia, and a linear section, or simple fracture of the fibula. The latter operation has lately been performed by Fen- ger, 1 of Chicago. The result of these operations has been to bring the foot inward and so to allow its axis to correspond with that of the knee and hip joint. Of twenty-three patients on whom these operations have been performed, in twenty-two re- covery took place, with a useful foot, and one died on the tenth day from purulent infection. In five of these suppuration is reported to have occurred ; in two, however, it was only slight. In some of the cases the ends of the bones have been wired together, but recovery does not seem to have been any more perfect than in those in which this was not done. It is probable that suppuration occurred in more cases than those given above, as the majority of cases were operated upon before the present methods of operating and management of wounds were adopted. In 1861, Berend, of Berlin, 3 reported a case of marked deformity after a fracture, with ankylosis of the ankle joint, in which he performed a cuneiform osteotomy at the lower portion of the tibia with good result. Billroth 3 reports a similar case. Pathological. — In this class are included those cases of bending of the bone from local diseases — as inflammation of bone. Schede reports the case of a girl with congenital syphilis who had had a chronic periostitis of the tibia for nine years, with 1 " Med. News," April 15 and 22, 1882. 2 Campenon, loc. cit., p. 186. 3 " Wien. med. Wochenschrift," 1881, p. 414. 140 OSTEOTOMY. elongation of the bone, eight to nine centimetres, the fibula not being affected. The tibia was curved, with its convexity inward. Willitts * mentions a case in which the tibia was bent at an acute angle outward, following necrosis of the outer portion of the shaft, near the epiphysis. Similar cases may be found scattered through medical literature. These deformities are due to an increased growth of a portion or the whole of the bone, and consequent bending due to the unequal growth of the fibula. It is met only among children and adolescents. It is rather a common belief among parents, and to some degree among physicians, that children af- fected with these curves of the bones of the leg will outgrow the deformity, and that all local treatment is uncalled for. It does not seem possible, while a child is running about, that any real obliteration of these curvatures could take place. They may, and certainly do, in some cases, undergo a relative change ; the bone increases in length and thickness, while the curve remains the same size as at first, so that it is relatively smaller and less marked in later years. This is especially true of short, sharp curves at the lower end of the tibia. In later years these are apparently smaller and less observable. Long anterior curves do not show the same tendency to become obliterated. They seldom, if ever, diminish, and, when the limbs are uncovered, will always be noticeable. Treatment. — The same remarks are applicable to curvatures of the bones of the legs due to rickets as to the deformities of other long bones of similar 1 "Brit. Med. Jour.," February 1, 18*79, p. 151. OSTEOTOMY FOR TIBIAL CURVES. 141 origin. "While the bone is soft, lateral bending of the limb may be straightened by splints ; but, after they have become hard, mechanical treatment is useless. Anterior curvatures are not suitable for mechanical treatment, for the reason that pressure can not be applied over the crest of the tibia, the sharp edge of the bone cutting through the skin. It is true that in catalogues of instrument-makers, and in some works on surgery, braces are figured for application over the crest of the tibia to correct anterior curvatures ; but they are entirely useless. When the bones are only moderately sclerosed, time may be gained by putting the patient under ether and forcibly straightening the limb, and then putting it up in plaster of Paris. Mr. Howard Marsh speaks well of this plan. I have adopted it in some cases, and think it an advantage. After the bones have become bard, osteotomy or osteoclasis must be performed. The latter method will be treated of in another chapter. Osteotomy for bow-legs may be either linear or cuneiform. All lateral and anterior curvatures of slight degree may be corrected by a linear osteotomy ; anterior curves of marked degree by a cuneiform section. Osteotomy for these deformities should be made at the point of greatest curvature. In all cases the fibula should be divided first, using a small osteotome, because the bone is difficult to steady after the tibia has been fractured, and in cuneiform sections the less the parts about the tibia are disturbed the better. It will be found easier to make the section of the fibula upward and inward. In performing the tibial section, the incision should be made down upon the crest at the 142 OSTEOTOMY. point of greatest curvature parallel to the long axis of the bone, the instrument introduced and rotated so as to be at right angles with its line of entrance. It is best to begin to divide from the crest inward. Care should be taken that the edge of the osteotome does not extend beyond the outer border of the crest, as the anterior tibial artery may be nearer to the bone than normal, and is liable to be divided. I had this accident happen to me in my first case. After the bone has been divided through about two thirds of its thickness, the section can be completed by fracture. The wounds are to be treated in the manner pointed out on page 22. I think it well to make a counter-opening on the inner side of the leg and pass horse-hair through for the purpose of preventing any accumulation of blood separating the edges of the wound. The tibia being superficial, there is not as much room for the effused blood as in bones better covered with muscles, and I have always found that it is liable to force the line of in- cision open. In simple lateral curves the thinnest osteotome should be used, as the cut in the bone should be as narrow as possible. Cuneiform, Osteotomy. — Anterior curvatures, if marked, are best corrected by the removal of a wedge- shaped piece of bone. The more angular the deformi- ty, the less will linear section correct. A counter- opening should always be made on the inner aspect of the leg, opposite a point corresponding to the apex of the wedge, and carbolized horse-hair be passed through the cut and out of the operation wound. An easy way to accomplish this is to pass a pair of dressing forceps (closed) down, through, and below the OSTEOTOMY FOR TIBIAL CURVES. U3 divided bone, and, by a twisting motion, force the end beneath the skin at the point where it is intended to make the counter-opening. The blades are sepa- rated and the skin divided between them. The horse-hair is then caught in, and the forceps drawn up through the original incision. The edges of the cut on the anterior aspect of the leg are to be united with antiseptic gut, and over this a small compress, the wound having been first washed out with some antiseptic. I have used iodoform, dusted over the wound, but any similar method of wound-dressing may be adopted. The whole limb and lower portion of the thigh is then incased in a plaster-of-Paris splint. Before this becomes hard the limb is put into the desired position. It is well to over-correct a little, as after a time the plaster splint becomes loose and allows the position of the limb to be altered. In this class of cases a tenotomy of the tendo Achillis is often necessary. The horse-hair should be removed upon the second day through a fenestra cut over the situa- tion of the wound. Its removal causes no pain. The method of performing a cuneiform osteotomy has been given with much detail, because I am satis- fied, from personal experience, that its success — that is, primary union of the wound — depends much more upon the manner of dressing than upon the way in which the section of the bone is performed. In the first five cases, eight limbs, in which I removed a wedge-shaped piece for anterior curvature of the tibia, suppuration, more or less extensive, occurred in all the limbs. On examination of the wound on the second day, blood was found to have been effused and to have burrowed up under the skin to a con- 144 OSTEOTOMY. siderable distance. The edges of the wound were separated by the blood, and, notwithstanding the use of strict antiseptic precautions in some cases, suppu- ration invariably followed, and in one or two cases counter-openings had to be made. Drainage from the wound itself did not seem to obviate the diffi- culty. Since I have adopted the plan mentioned above the course of the wound has been similar to those after a simple osteotomy. I have never seen a drop of pus. In one case I removed a wedge-shaped piece of bone from the inner side of the tibia just below the epiphysis in order to correct an angular deformity at that point; the wound closed by pri- mary union. The pinching of a piece of muscular and cellular tissue between the fragments may cause suppuration. The haemorrhage following a cuneiform osteotomy is much greater than after a simple section of the bone. Other things being equal, I think that sup- puration is more liable to follow an osteotomy, be it either linear or cuneiform, of a bone that is subcu- taneous, than of one that is well covered with mus- cles, and I attribute this to the fact that in the former case any great accumulation of blood is sure to cause tension on the wound and prevent primary union. Therefore, the more subcutaneous the bone, the greater is the necessity for a counter-opening and good drainage. Complications. — There have been two deaths re- ported after an osteotomy of the tibia and fibula, one by Muralt 1 in a young girl who died, some days after the date of the operation, from diarrhoea The 'Boeckel's Tables. OSTEOTOMY FOR TIBIAL CURVES. 145 autopsy revealed nothing to account for the fatal result. Gould x reports a fatal case in a healthy boy, eight years of age, death being due to carbolic-acid poisoning thirty-six and a half hours after the opera- tion. In neither of these cases can the fatal result be attributed to the operation itself. In two hundred and fifteen cases of osteotomy tabulated by Bceckel and Campenon, an excessive haemorrhage occurred in four, in forty-one suppura- tion took place, and in fifteen a limited necrosis of a portion of the cut surface is reported. Volkmann 2 mentions a case in which he amputated a limb on ac- count of an enchondroma, having its origin at the point of section. I have lost two patients from inter-current disease after firm union had taken place, the fatal issue being in no way connected with the op- eration : one from diphtheria, and one from meningitis. In regard to the liability of the deformity to return after an osteotomy, in one case only have I seen it, and that was in a boy five years of age, on whom a linear osteotomy was performed on both limbs for lateral curvature of the tibia. He was an inmate of an asylum. The bones were quite hard. He was discharged with limb straight and union firm. Five months later he was returned to the hospital with an angular anterior deformity at point of section, with the statement that it had only re- cently appeared. The boy at the time of re-admis- sion was in poor condition. It would seem probable that the angular deformity was due to softening of the callus, owing to improper food, and not to bend- 1 " Brit. Med. Jour.," May 28, 1881, p. 850. 2 " Berl. klin. Wocheu.," 1877, No. 40, p. 591. 146 OSTEOTOMY. ing from a soft condition of the bones. Billroth re- ports one case, of a child four years of age, in whom the deformity (lateral curvature of the tibia) re- turned after some months. ILLUSTEATIVE CASES. Case I. — M. P., four years of age, was admitted into St. Mary's Hospital, January, 1879, with a marked antero-lateral curvature of both limbs, of ra- chitic origin, most marked at their lower third. In February a linear osteotomy was performed upon both tibiae, a section of the fibulae having been first done. A counter-opening was made on the inner aspect of the limb, and carbolized horse-hair passed through. The limbs were put upon a tem- porary splint, and, after the wound had closed, a plaster-of-Paris dressing was applied. This was kept on until consolidation had taken place, when she was allowed to get up and use her limb. Figs. 39 and 40 are from photographs taken be- fore and after section. Case IT. — G. H., four years of age, was admitted into St. Mary's Hospital, in 1882, with a marked curvature of the bones of both legs at their lower third. The bones have a lateral, with a marked anterior bend, so that the crest of the tibia over- hangs the ankle joint. In February osteoclasis was performed upon both limbs, but only the lateral curve could be corrected. The limbs were imme- diately put up in plaster of Paris in a straight posi- tion as regards the lateral bend. In May a cuneiform osteotomy was performed upon both tibiae, and a linear on the fibulae, counter-openings were made, OSTEOTOMY FOR TIBIAL CURVES. 147 carbolized horse-Lair passed, and the lips of the tibial wounds were united with carbolized catgut. On the following day the horse-hairs were removed. The Fig. 39. Fig. 40. 14S OSTEOTOMY. wounds healed by primary union. The temperature was never above 99°. In four weeks the splints Fig. 41. Fig. 42. were removed, and the union was found to be firm. Figs. 41 and 42 show the deformity, and correction obtained. CHAPTER IX. OSTEOCLASIS. The correction of deformities of the long bone by fracture is an old operation, and its history dates back to the time of Hippocrates. Osteoclasis may be either manual or instrumental. Cases appropriate to the former procedure are de- formities after fracture and bending of the long bone, in the one before union is firmly established, and in the other while the bones are in a pliable condition. In this class should be included cases of fibrous, and some of bony ankylosis of joints — and "redresse- merit brusque." To instrumental osteoclasis is ap- plicable all cases of deformity after fracture and curvature of the long bones, where perfect consolida- tion in the one and sclerosis in the other has taken place. The cases that can be corrected by manual os- teoclasis are comparatively few, and even in those in which it is possible to correct without the use of an apparatus for the application of power, the latter is better, on account of the precision with which the point of rupture can be determined. Fracture, or bending of the bones of the legs, even in quite young children, is more difficult than is supposed. 150 OSTEOTOMY. To the operation by means of an osteoclast belong the vast majority of cas.es of deformities. Osteoclasis without an instrument requires but a brief notice. The cases to which it is applicable are so apparent that their recapitulation would be use- less except for the correction of certain deformities at the knee joint. I refer to genu valgum and genu varum. Although redressement brusque does not belong to the same category as forcible correction of fracture, yet its consideration in connection with osteoclasis seems approj3riate. The method was first advocated for rachitic curvature by Guerin * in 1 848 ; later, M. Delore, of Lyons, applied this procedure to genu valgum and genu varum. It has been a favorite operation among the surgeons of the French school, while osteotomy has had its chief advocates in Eng- land and Germany. The object of Delore in redressement brusque was to cause a partial diastasis between the diaphysis and epiphysis at the lower portion of the femur, and then to slide the epiphysis together with the tibia inward, and thus correct the deformity. Delore's method of operating is as follows: The patient, being fully under the influence of an anaesthetic, is placed on the side on which the limb to be operated uj)on is situ- ated, with the external malleolus and the upper por- tion of the thigh resting firmly on the table. Then, by sudden and repeated applications of force by means of the hand placed on the apex formed by the deformity, the knee is forced outward until the leg assumes its normal relation to the thigh. The opera- tion is performed slowly and progressively, the time 1 " Gaz. Med. de Paris," 1848, p. 743. OSTEOCLASIS. 151 required to obtain restitution varying from five minutes to half an hour. In young children only a very moderate pressure is required, while in persons of eighteen or twenty years great force is necessary. M. Taillaux operates by placing the patient upon the opposite side, resting the knee upon a cushion, and, using the leg as a lever, forces the lower limb into the desired position. The deformity gives way with a series of cracks. The lesions produced by this op- eration differ somewhat in different cases. Yet they are all of a serious nature, and are accompanied at least by effusion into the joint, and often by inflam- mation. In a patient of Delore's who died of measles twenty days after a redressement brusque for genu valgum, it was found that the lower epiphysis of the femur had been partially detached; there was considerable ecchymosis under the periosteum on the anterior aspect of the femur; the external portion of the epiphysis of the tibia had been loosened, and the end of the fibula torn off and dragged upward by the external lateral ligament. Frequently the inter- nal condyle of the femur or inner head of the tibia is flattened or crushed in by the amount of force employed, while the periosteum is torn and detached. In older subjects, fracture of the shaft has been pro- duced, or rupture of the external lateral ligament. Inflammation of the knee, more or less intense, has followed the operation. Notwithstanding the appa- rently severe nature of the immediate effects of the operation, in two hundred and fifty limbs operated upon by Delore he reports no accident ; and states that in about one year all traces of the operation have disappeared. But even then the patient has to 11 152 OSTEOTOMY. be kept under observation many months, and a re- turn of the deformity is by no means exceptional. Serious inflammation of the joint and suppurative periostitis of the shaft of the femur have been re- ported. Delore has operated chiefly upon children. It is reported that the injury to the ends of the bones entering into the formation of the knee joint has not been followed by arrest of development in the limb. It would appear that the nearer the pa- tient approached adult life, the more serious and dif- ficult the operation is. Hedressement brusque for genu valgum has had but few, if any, advocates in this country. That it has not been more frequently followed by serious joint disease with disorganization of the articulation is a matter of surprise. Perhaps the explanation is that the operation has only been performed in selected cases, on patients who were in good health and with no predisposition to tubercular affections. The fact that the exact nature of the lesions produced in any single case are so uncertain, and the time necessary to regain use of the joint so long, has de- terred most surgeons from adopting this operation ; and now that a much better and more precise method of correcting genu valgum and genu varum has been devised in osteotomy, it is probable that redressement brusque is an operation of the past. Rushton Parker 1 has reported some cases of cur- vature of the femur and genu valgum treated by osteoclasis of that bone. His method is as follows : The knee joint was fixed in an extended position by means of well-padded iron splints, enveloping the 1 "Med. Times and Gaz.," December 29, 1S83. OSTEOCLASIS. 153 upper half of the leg and the lower portion of the thigh, so that the part of the limb below the curve or desired point of fracture should be perfectly im- movable and serve as a lever. The thigh was then laid on its outer side, the upper part being held firmly down on the table, the point of desired frac- ture just on the edge, and the rest of the limb pro- jecting beyond. Then, by using the latter portion of the limb as a lever, fracture was readily produced at the desired point. He mentions a troublesome syno- vitis of the knee joint in one of his cases as a result of the operation. Rupture of ankylosed joints is a serious opera- tion. Its dangers, however, are different for different articulations, and vary with the nature of the uniting medium. In joints presenting extensive bony sur- faces, and in which bony union has taken place, forci- ble rupture is a grave operation. It is often impos- sible to cause a separation between the bones, and fracture may take place at a point on either side of the joint and produce a deformity in no way an im- provement on the one it was sought to relieve. It is not a safe operation for bony, and is a very question- able one in fibrous, ankylosis of the hip joint. In the former case the enormous power, when the pelvis is fixed, that can be brought; to bear upon the upper end of the femur will certainly produce a fracture if the attempt is persisted in, but at what point depends upon where the bone is the weakest. In fibrous ankylosis after suppurative coxalgia, as said before, it is too hazardous an operation. In the knee joint excellent results have followed forcible rupture, and, if the band be fibrous, some useful motion is 154 OSTEOTOMY. often obtained. It is not entirely devoid of danger to the popliteal nerve and vessels behind the joint, injury to which has been recorded. When there is much cicatrical tissue behind the articulation, the danger that the important structures in that situa- tion maybe torn is not slight if persistent force is employed. It is questionable whether an osteotomy would not be a better and safer operation in this class of cases, be it linear or cuneiform. In this case, however, a movable joint is not a possibility. It should be stated, however, that in ankylosis of the hip joint after disease, excellent results from forci- ble fracture have been recorded by M. Broca, ' Labo- rie, 2 Tillaux, 3 and by other surgeons in England and in this country. Yet its dangers, especially after coxalgia, are by no means slight. Disastrous results have been too common, and its results compare very unfavorably with those of osteotomy. Osteoclasis by means of an apparatus by which considerable power can be applied has been ad- vocated by all writers upon surgery, and many instruments have been devised for this purpose. The earlier operations were restricted to the correc- tion of fractures of the long bone united at an angle, but later surgeons have extended the operation to deformities of the limbs due to other causes. Busch, Louvier, Maisonneuve, and others, have invented in- struments for the purpose. In 1846, Bizzoli devised an osteoclast, which, with some modification, is still used. Its introduction into this country is due to 1 " Bull, de la soc. de chir.," Paris, vol. i, 1860, p. 243. ^Ibid., p. 235. 3 Ibid., 18*75, p. 353. OSTEOCLASIS. 155 Dr. A. T. Cabot, of Boston. 1 It consists (Fig. 43) of a heavy bar, fifteen inches long, one inch wide, and three eighths of an inch thick, being much thicker in the center, which is pierced for the female portion of a screw. Into this is fitted a round steel bar, one half an inch in diameter, on which is cut a thread corre- sponding to the nut on the long bar, and furnished at its upper portion with a handle ; and at its lower Fig. 43. extremity is a strong, well -padded steel plate or crutch, forming a segment of a circle. The portion of steel forming the male part of the screw turns in a socket on the upper side of this crutch. Two steel rings, five inches in diameter, one inch wide, and one fourth of an inch thick, having at their upper por- tion a slot into which the large bar slides, and to which they are fixed in any desired position by bind- 1 page 333. Barwell, R. Brit. Med. Jour., May 29, 1880, page 812. Lancet, 1880, vol. i, page 837. A Treatise on Disease of Joints, 2d ed., 1881, page 564. 180 OSTEOTOMY. Boeckel, J. Rev. de Chirg., June 10, 1882, page 480. Broadhurst, B. E. On Ankylosis, 1881, page 89. Brit. Med. Jour., Feb. 3, 1877, page 135. Lancet, 1862, vol. i, page 326. Cases of Subcutaneous Section of the Neck of the Thigh- Bone. Trans. Clin. Soc, Lond., vol. x, 1877, page 91. Broome, G. A. Trans. Med. Assoc, of Missouri, 1877, page 34. Borchers. N. Y. Med. Record, May 19, 1883, page 541. Bull, W. T. N. Y. Med. Jour., Jan. 26, 1884, page 103. Bryant, T. Lancet, Nov. 10, 1877, page 686. Lancet, Nov. 17, 1877, page 724. Lancet, Dec. 22, 1877, page 917. Berend. Gaz. hebd., 1862, page 284. Billroth, Th. Chirurgische klinik Wien., 1871-76, page 543. Cameron. Glas. Med. Jour., 1879, vol. xii, page 305. Carmalt, W. H. N. Y. Med. Jour., June 7, 1884, page 646. Clemot. Gaz. med. de Paris, 1836, page 347. Conner, P. S. Cin. Lancet and Clinic, July 6, 1878, page 1. Croft. Trans. Clin. Soc, London, 1877, vol. x, page 94 ; and Brit. Med. Jour., Feb. 3, 1877, page 135. Davy, R. Lancet, Nov. 15, 1879, page 732. Devecchi, P. The Western Lancet, Sept. and Nov., 1881, pages 289 and 385. Fagan, J. Dub. Med. Jour., Dec, 1879, page 444. Gant, F. J. Lancet, Dec 21, 1872, page 881. Brit. Med. Jour., July 1, 1876, page 28. Brit. Med. Jour., Oct. 18, 1879, page 606. Goldie, R. W. Brit. Med. Jour., 1883, vol. i, page 155. Golding-Bird, C. H. Guy's Hospt. Rep., N. S., vol. xxii, 1877, page 275. Hamilton, J. W. Ohio Med. Recorder, Aug., 1877, page 97. Hodges, H. L. Med. and Surg. Reporter (Phila.), May 4, 1878, page 341. Holmes, T. Lancet, Oct. 14, 1876, page 536. Hutchison, J. C. Proc Med. Soc, Kings County, 1878, page 259. Am. Jour. Med. Scien., 1883, vol. clxx, page 409. Hutchinson, J. Brit. Med. Jour., March 4, 1882, page 298. Jordan, F. Brit. Med. Jour., Dec. 24, 1870, page 676. Keetley, C. B. Brit. Med. Jour., Feb. 9, 1884, page 261. BIBLIOGRAPHY. 181 Lund, E. Brit. Med. Jour., Jan. 29, 1876, page 128. Macewen, W. Glas. Med. Jour., Oct., 1879, page 305. Maisonneuve. Gaz. med. de Paris, 1847, page 935. Gaz. de Hop., 1849, page 64. Marsh, H. Brit. Med. Jour., April 5, 1884, page 665. Maunder, C. F. Brit. Med. Jour., Nov. 4, 1876, page 605. Lancet, July 11, 1874, page 65. Lancet, March 25, 1876, page 476. Lancet, Oct. 28, 1876, page 609. Trans. Clin. Soc., London, vol. ix, 1876, page 160. Brit. Med. Jour., May 20, 1876, page 644. Brit. Med. Jour., Dec. 8, 1877, page 804. Moore, E. M. Trans. Am. Surg. Assoc, vol. i, 1880-'83, p. 111. Morton. Phila. Med. Times, 1881, vol. xii, page 219. Norton, A. T. Lancet, 1879, vol. i, page 264. Novari, G. F. Arch. Ortopedia, Jan., 1884, page 46. Porter. Bost. Med. and Surg. Jour., April 18, 1878, page 505. Post, A. G. Annals of Anat. and Surg., Jan., 1883, page 30. Parker, R. W. Brit. Med. Jour., Oct. 18, 1879, page 611. Rosmanit, J. Zur operativen Behandlung der schiveren For- men von Contracturen und Anchylosen im Huftgelenk. Arch, fur klin. Chirg., 1882, vol. xxviii, page 1. Rawdon, H. G. Liverpool Med. Ghir. Jour., 1881, page 187. Liverpool Med. Chir. Jour., Jan., 1882, page 23. Rodgers, J. K. N. Y. Jour. Med. and Surg., 1840, vol. ii, page 238. Sands, H. B. N. Y. Med. Jour., 1873, vol. xviii, page 609. Sayre, L. A. N. Y. Med. Jour., Jan., 1869, page 337. Shaffer, N. M. Annals Anat. and Surg., Dec, 1883, page 243. Servais. Rev. de chirg., Dec, 1881, page 1043 ; and Bull, Acad. roy. de med. de Belgique, 1881, vol. xv, page 465. Smith, Stephen. N. Y. Med. Record, June 2, 1883, page 589. Stokes. Brit. Med. Jour., April 8, 1882, page 505. Van Der Veer. Annals Anat. and Surg., Oct., 1883, page 161. Volkmann, R. Centralbl. fur Chirurg, 1874. Centralbl. fur Chirurg, 1880, No. 5, page 64. Wharton, H. R. Am. Jour. Med. Scien., 1883, No. clxxi, page 101. Med. Times (Phila.), Oct. 20, 1883, page 427. Walter, A. G. Arch. Clin. Surg. (N. Y.), 1876, page 60. 182 OSTEOTOMY. TIBIAL CURVES. Alexander. Liverpool Med. Cbir. Jour., 1881, page 191. Brainard. Chicago Med. Jour., 1859, vol. ii, page 5. Boeekel, J. Gaz. Med. de Strasb., 1879, 3 s., vol. viii, page 42, 53, 65, 82, 94, 108. Chavasse, T. F. Brit. Med. Jour., July 30, 1881, page 158. Gibney, V. S. Maryland Med. Jour., 1879, vol. v, page 15. Guerin. Bull, de l'Academie Med., April, 1876. Haward. St. George's Hosp. Rep., 1877-78, vol. ix, page 133. Jones, T. Brit. Med. Jour., Oct. 18, 1879, page 613. Marsb, H. Med. Cbir. Trans., vol. Ixviii, 1874. Pean. Redressement des os des jambes cbez. una dolescent. Paris med., 1879, 2 s., vol. v, page 17. Ruess, L. J. M. De l'Osteotomie dans corbure racbitique des os These de Paris, 1878, No. 90. Whitson, J. Brit. Med. Jour., April 22, 1882, page 577. OSTEOCLASIS. Aysaquer, P. Du redressement des courbures racbitique des membres infereurs cbez les enfants par osteoclasis. Tbese de Paris, 1879, No. 82. Berry W. Med. Press and Circ, Sept. 12, 1883, page 219. Bertbet L. Appareils pour les redressement articulaires. Rev. mens, de mal de l'enfants, Paris, 1884 vol. ii, page 29. Jour. gen. de therap., Jan. 15, 1880, page 40. Bracbini A. Sperimentali Firenze, 1882, page 42. Bradford, E. H. Bost. Med. and Surg. Jour., 1881, vol. cv, page 444. Braye. Du genu valgum et de son redressement par l'appareil. Collin, Tbese de Paris, 1880, No. 472. Cabot, A. T. Bost. Med. and Surg. Jour., 1879, vol. ci, page 217. Delore, X. Du mecanisme du genou en dedans et de son traite- ment par le decollement des epiphyses, Lyon, 1874. / Delarue, V. Du redressement du genu valgum par l'osteoclasie. Tbese de Paris, No. 184, 1884. De Sante. Arcb. gen. de m6d., 1879, vol. i, page 719. Farabeuf. Gaz. des Hopt., 1879, page 1198 ; 1880, page 13. Fifield. Med. News (Philadelphia), 1883, vol. xlvii, page 414. OSTEOCLASIS. 1S3 Gillette. Genu valgum : osteoclasie (Collin). Bull, et men. de la soc. de chir., Paris, 1883, N. S., vol. ix, page 920. Guers, A. Traitement du genu en dedans chez l'adolescent par un nouvel appareil. These Lyon, 1881, No. 83. Guillon, G. Appareil pour le redressement d'un femur vicieu- sement consolidi. In his. oeuvres cher et m6d., Paris, 1879, page 137. Horand, M. Lyon m6d., Jan. 6, 1884, page 16. Leveque. Union med. et scient. du nord est Reims, 1883, vii, page 157. Le Dentu. Bull, et men. de la soc. de chirg., Paris, 1880, N. S., vol. vi, page 419. Menard, V. Redressement brusque du genu valgum. Rev. de chirg., 1881, page 727. Molliere. Lyon med., Dec. 23, 1883, page 549. Nepveu. Arch. gen. de med., 1875, vol. ii, page 332. Parker, R. Med. Times and Gaz., 1883, vol. ii, page 738. Polaillon. Genu valgum opere par l'osteoclasie (Collin). Bull, et men. de la soc. de chirg., Paris, 1883, N. S., vol. ix, page 885. Porter. Bost. Med. and Surg. Jour., April 14, 1879, page 217. Ribera, J. Rev. de enferno de niflos. Madrid, 1883, vol. i, page 211. Robin V. Lyon med., 1883, vol. xliii, page 44. Lyon med., 1882, vol. xxxix, pages 449, 487. Taylor C. F. K Y. Med. Record, April 21, 1877, page 241. Terrillon. Nouvel appareil pour le redressement des position vicieuse de la cuisse sur le bassin. Bull. gen. de therap., 1882, vol. cii, page 241. Vallin. Redressement manuel dans les deviation rachitique du membres infereur. Rev. mens, de mal. de l'enfant, 1884, vol. ii, page 19. 13 INDEX Adams's operation through the neck of the thigh, 39. Adams's saw, 14. Accidents after osteotomies about the hip joint, 60. Age at which rachitic deformities are developed, 8. Angle, proper one for limb after oste- otomy for deformities at the hip joint, 31. Anchylosis of hip joint after rheuma- tism, 33. of hip joint, 30. of knee joint, 130. Anchvlosed joints, forcible rupture of, " 153. Bandages, plaster-of-Paris, 22, 28, 60, 106, 143. Barwell's operation for anchylosis of the hip joint, 40. operations for genu valgum, 102. Barton, J. R. Osteotomy for anchylosis of hip joint, 36. Barton's operation for anchylosis of knee joint, 130. Biceps, contraction of, in genu valgum, 87. Buck, Gurdon. Operation for anchy- losed knee, 132. Cabot, Dr. A. T. Case of osteoclasis, 161. Case of osteotomy, 111. Cases of osteotomy for anchylosis at the hip joint, 63. of genu valgum adolescentium, 80. appropriate for osteoclasis, 162. of genu valgum appropriate for an osteotomy, 108. Chiene's operation for genu valgum, 97. Chisel for osteotomy, 19. Collin's osteoclast, 164. Condyle, internal position of, in genu valgum, 75. external atrophy of, 77. Death after osteotomies, 45, 119, 144. Deaths after osteotomies about hip joint, 49. Deaths after osteotomies about knee, 116. Delore. Redressement brusque, 150. Elbow joint, osteotomy for anchylosis of, 174. Fifield's case of non-union after osteo- clasis, 160. Gant's operation for anchylosis at hip, 40. Genu valgum adolescentium, 80. cause of, 73. etiology of, 78. due to traumatism, 84. femoral, 74. uncomplicated example of, 71. history of operations for, 94. infantile, 78. partial excision of knee joint for, 93. double osteotomy for, 102. cases appropriate for osteotomy, 108. Barwell's operation for, 102. Chiene's operation for, 97. Macewen's first operation for, 98. Macewen's second operation, 102, 105. MacCormac's operation for, 103. Ogston's operation for, 95. Reeves's operation for, 96. mode of performing supra-condyloid osteotomy,. 105. 186 INDEX. Genu valgum, mechanical treatment of, 88. defect, in all operations upon the condyle, 100. tibial, 77. theories of cause of, 73. statistics after osteotomy, 114. osteotomy for, 94. Genu varum, 127. Gross's operation for anchylosed knee joint, 184. Haemorrhage after osteotomy for genu valgum, 115. Hip joint, deformities at, their cause, 30 deformities of, after hip-joint dis- ease, 31. deformities of, after dislocation, 33. deformities of, after fracture, 34. deformities of. What operation should be performed ? 50. Humerus, osteotomy of, for deformity, 174. Instrument required for osteotomy, 14. Knee joint, anchylosis of , osteotomy for, 130. Langton's case of supra-condyloid oste- otomy, wound of popliteal ar- tery, 115. Langenbeck's operation, 12. Ligaments, condition of, in genu val- gum, 78. Limb, management of, after osteotomy, 22, 28, 67, 106, 142. Listerism and osteotomy, 13, 19. Little's operation for anchylosis of knee joint, 134. Macewen's first operation for genu val- gum, 98. second operation for genu valgum, 102. MacCormac's operation for genu val- gum, 103. McGill's case of division of popliteal artery in supra-condyloid oste- otomy, 115. Macnamara on rickety bones, 5. Maisonneuve's operation through the neck, 39. Mechanical treatment of genu valgum, one cause of the failure of, 88. Method of management of limb after an osteotomy about the hip joint, 67. Mid-femoral osteotomy for genu val- gum, 103. Moore, Dr. E. M. Case of osteotomy at the hip, 52. Mortality after osteotomy, 173. Motion after osteotomies about the hip joint, 57. Occipital bone, alterations in, 4. Ogston's operation for genu valgum, 95. Osteotome, description of, 16. manner of using, 19. Osteoclasis, 149. for rachitic curvature of the bones of the legs, 157. for tibial curvatures, 157. for deformities of the long bone after fracture, 156. Osteoclast, Collin's, 164. Rozzoli's, 154. Robin's, 165. Osteotomy, definition of, 11. instruments for, 14. history of, 12. method of performing, 19. subcutaneous, 19. by open wound, 26. cuneiform, 26. for deformity at the hip joint, his- tory of, 36. at hip joint, when it should be per- formed, 51. of the femur for deformities due to vicious union after fracture, 61. linear, for anchylosis of knee joint, 134. of neck of femur, 39. inter-trochanteric, 38. below trochanter minor, 40, 43. for deformity of the knee joint, 130. for deformities after fracture of the bones of the leg, 138. for genu valgum, 94. cuneiform, of the tibia. 142. for curvature of the tibia and fibula, 136. for genu valgum, suppuration after, 114. for deformity of the humerus, 174. for deformity of the elbow, 174. for deformity of the radius, 174. Pain after osteotomies, 26. Parker, Rushton, osteoclasis, 152. Post's, Dr. A. C, fatal case after oste- otomy, 60. INDEX. 187 Radius, osteotomy of, for deformity, 174. Redressernent brusque, 150. Reeves's operation for genu valgum, 96. mid-femoral operation for genu val- gum, 103. Rickets not confined to children of the poor, 2. symptoms of, 2. its relation to deformities, 2. acute, 8. Rizzoli's osteoclast, 154. Robin's osteoclast, 165. Rodger's, J. K., operation for defor- mity at hip joint, 36. Sands, Dr. H. B., on motion after os- teotomy about the hip joint, 58. Statistics of osteotomies about the hip joint, 44. of osteotomies, personal, 1*70. of operations upon the tibia, 145. of osteotomies, general, 173. Shrady saw, 15. Saw, Adams's, 14. Shrady's, 14. objections to, 15. Sayre's, L. A., line of section between the trochanters, 37. Servais. Case of osteotomy, 61. Smith's, Stephen, operation for de- formity at the hip joint, 41. Suppuration after osteotomies, CO, 114, 170. Taylor's, Dr. C. T., osteoclast, 150. Temperature after osteotomy, 25. Tibial spines, 83. Tibia and fibula, curvature of, 136. osteotomy for deformities after frac- ture of, 137. Volkmann. Operation between the tro- chanters, 38. Wedge, method of removing one, 27. method of determining size of, in cuneiform osteotomy, 27. Wharton's, Dr. H. R., case of osteoto- my of the hip, 62. Wound, Macewen's method of manage- ment of, 24. management of, after ostcotomv, 22. A DICTIONARY OF MEDICINE, INCLUDING GENERAL PATHOLOGY, GENERAL THERAPEUTICS, HYGIENE, AND THE DISEASES PECULIAR TO WOMEN AND CHILDREN. BY VARIOUS WRITERS. EDITED BY RICHARD QUAIN, M. D., F. R. S., Fellow of the Royal College of Physicians, and Physician to the Hospital for Diseases of the Chest, at Brompton, etc. In one large 8vo volume of 1,834 pages with 138 Illustrations. Half morocco, price, $8.00. Sold only by Subscription. 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