REPRINTED EROM UNIVERSITY Medical Magazine. toirto uhocr tk «_s*»ce$ cr the alum* ano faculty of miokikj Of THE WPVtPS'TY Of FEARS'UVAHA EDITORIAL STAFF CAto'Ml CwkxvHm aimmaaa wwimku CONTENT* TNCX. •■00 a. rx>*jt n> SEPTEMBER, 1896 SOME FEATURES OF THE YEAR'S WORK IN ORTHOPEDIC SURGERY. (In the service of De Freest Willard, M.D.. at the I'niversity Hospital.)» , By JAMES J. WALSH, A.M., M.D., PHILADELPHIA. SOME FEATURES OF THE YEAR'S WORK IN ORTHOPEDIC SURGERY.1 [In the service of De Forest Willard, M.D.,1 at the University Hospital.] By James J. Walsh, A.M., M.D.,2 Philadelphia. Introduction. Orthopedia is of extreme interest to all surgeons.' Surgery was originally concerned so much with what have been called mutilating operations, necessary frequently, and essentially life-saving in aim, but still robbing the person of some part. The opportunity pre- sented to do work that leads to the correction and not the production of deformity, appeals strongly to the emotional side of the surgeon's nature. Orthopedic surgery, one is proud to say, owes much of its advance, in recent years, to the sterling work of Americans. The specialty itself is the only one, perhaps, in which the principal authorities and the main body of the literature are American. Much, however, remains yet to be done, not so much, perhaps, in the large cities as in the smaller towns throughout the country, where many a deformed child is dragging out a wearied existence that might be made much more livable if the general practitioner knew how to employ the usually simple mechanical and operative procedures and take the necessary after-care for the correction of the ordinary deformities. The trouble is, and always has been, that it is extremely hard to learn orthopedic surgery from books. Not that its operations require extremely delicate technique, nor that its post-operative methods are so complicated that they need careful drilling for their faithful accomplishment, but rather from just the opposite reasons. Operative procedures and corrective methods are, as a rule, so simple that it requires the conviction that comes from seeing to make one realize how effective they are in the correction of deformity. After simple tenotomies and the careful application of casts have placed club-feet in a position where they can be used well and easily if not over-gracefully, or have made possible the use of spastic muscles so that the child can walk that never walked before, then one realizes how much of power lies dormant in these simple measures. 1 A selection with some additions from " Notes on some Practical Work in Orthopedic Surgery," to which was awarded Professor Willard's Orthopedic prize. University of Pennsylvania, June, 1895. 2 The writer takes this occasion to thank Dr. James K. Young and Dr. Randolph Faries for sug- gestions and explanations very cordially given on a number of occasions. James J. Walsh. 2 Those of us who had the time and inclination were given such excellent opportunities in this line, in the wards of the University- Hospital, that it seemed that some notes on the more interesting of the many and varied cases under treatment might prove of general interest. It is with this idea that they are published. The important lesson of the year's work was, I think, if one were to sum it all up in a few words, that in orthopedic surgery it is not the dexterous, almost bloodless, performances of tenotomies, osteoto- mies, and even excisions that is the main thing, but that it is the careful, unremitting, well-directed after-treatment that assures suc- cess and secures permanent helpful reliable results. The notes a,re, of course, a reflection of this important lesson, and are concerned much more with the course of after-treatment than with the description of operative procedures. The year has been marked by a succession of interesting cases in most of the usual lines of orthopedic surgery, and the variety of these has made the clinical course eminently practical. Different phases of the same deformity requiring more and more operative measures for their relief, and varying forms of apparatus for their correction have followed one another or have been in the wards together, and have practically illustrated methods of procedure as no merely didactic teaching could. This has been especially true of talipes. I. Some Talipes Cases. Four equino-varus cases, selected from the number of those under treatment, illustrate very completely the extent to which operative procedures must be carried according to the age at which this defor- mity comes to the surgeon for correction. In cases of talipes it is well to commence mechanical and manip- ulative procedures as soon as the child is born, if possible. The tender age of a child instead of being an objection to this immediate correction is an encouragement. If taken when the tissues are soft and yielding during the first weeks of life, the deformed feet may be readily moulded into'proper shape, and easily directed in their growth in that position. Time only increases the deformity, and the gradual process of complete ossification makes correction harder and harder. If taken immediately after birth very little is usually necessary beyond forcible correction and careful attention, that the corrected position is main tained by suitable felt or metal splints, or better by plaster casts. In mild cases with careful attention a cure will be well advanced before the child is a year old, even without tenotomy. If the child Orthopedic Surgery. 3 is permitted to walk upon the distorted foot, the pressure will exag- gerate the deformity and make it so serious as even to require muti- lating procedures later on. Consequently, if the foot has not been so corrected that it can be placed flat and squarely upon the floor when the walking age is reached, an operation must be no longer delayed. Tenotomy will accomplish as much in a few minutes in such cases as will apparatus in weeks, and save the child, besides, the constant annoyance of pressure for that time. It seems better in such cases to resort to this comparatively trivial measure rather than depend entirely on the corrective power of apparatus, which is slower and more painful in its effects. Where the deformity has been allowed to go uncorrected for some months tenotomies become absolutely necessary. The rule at the University, and in America generally, is to dress the foot after a tenotomy in at least a fully-corrected position, and it is even advised as a rule to have slight over-correction. Some ortho- pedists (not surgeons) abroad hesitate to separate the ends of ten- dons so much immediately after section fearing non-union. This fear is, however, unfounded. A series of experiments on animals, some years ago, in the Uni- versity laboratories demonstrated that nature always throws out suffi- cient material to fill the gap in a tendon, even though the ends may be separated three inches. The opposite custom of allowing the tendons to unite before securing correction practically renders the operation abortive, and tends to weaken the tendon on account of the deficiency of exuded plastic material. Very young children are not, of course, treated at the hospital, and our youngest case had been neglected for some months. Case I.-A child, aged 6 months. Deformity : pronounced equi- no-varus, congenital, and affecting both feet about equally. Simple tenotomies of the tendo-Achillis and tibialis anticus mus- cles were done and plaster casts carefully applied. As the child was to be away from observation, the mother not being able to stay long away from her distant home, it was necessary to be sure that the casts fitted properly, and that the child could not kick them off. It might seem a comparatively simple thing to be sure that the casts fulfilled these requirements, but any one who has tried to put casts on young children knows to the contrary. The chubby, rounded, infantile foot, with practically no heel, presents no prominent projections to aid in the retention of the cast, and then its extreme natural mobility before "it must hide in the prison cells of pride," and lose half the functions that nature intended it to have, gives it a range of wriggling movements far beyond expectation, and that some of the scientists 4 James J. Walsh. claim to be an atavistic reversion to an ancestor whose prehensible powers and proclivities are well known. It was only after the second cast had been applied to one foot and the third to the other that finally a satisfactory fit was obtained. The secret of success is to place the foot fully at a right angle with the leg and retain it there while the plaster bandage is applied, and to carry the cast above the knee slightly flexed. A tight or badly- applied bandage without thorough padding will cause injurious pressure and constant pain, and must be avoided, or sloughing will ensue. After six weeks apparatus was applied and manipulations were begun, and continued for some time. Case II.-Child, 16 months old, very pronounced equino-varus of both feet, congenital, with the deformity rendered more marked by efforts to use the limbs in the distorted positions. Here tenoto- mies of the tendo-Achillis and of both anterior and posterior tibials seemed the indication. These were done and the feet put up in casts. At the time of the operation attention was called to the unusual rigidity of the feet and the prominence of the astragali. It was impossible to make the latter slip back into place between the mal- leoli. It seemed unwise, however, to do a multilating tarsectomy on so young a child until all simpler means had been thoroughly tried and found unavailing. Twice the casts were renewed in the case, and every effort made for nearly three months to get the foot to retain the corrected posi- tion, but without success. Finally a Phelps's open incision was done, all structures that resisted correction being divided down to the bone. The wounds granulated very satisfactorily and healed uneventfully. The result was functionally a very good one, and the scar and furrow left after the operation were not so prominent as might have been expected. Walking apparatus was subsequently applied. Case III.-Male, age io years. Deformity: talipes equino- varus in a marked degree, congenital, and never submitted to any treatment. A typical example of "reel feet," the turned-in feet being lifted over one another when he walked, as the spokes of a reel revolve now up now down when the instrument is put in motion. Both astragali projected very prominently on the dorsa of the feet, and it was very evident that it would be impossible to get them into their normal position between the malleoli. The usual conditions of pressure and counter-pressure being absent in such cases, the astraga- lus grows not in its normal shape but in a very distorted way. The indication is to remove the distorted astragalus and put the foot into a position where the other joints of the series at the ankle Orthopedic Surgery. 5 will have a chance to make up, as far as possible, for the impaired astragalo-tibio fibular articulation. Frequently, however, good ankle motion is secured in time. The removal of the normal astragalus, owing to the irregularity of its outline is, even on the cadaver, where there is no blood to obscure the site of operation, a task requiring extreme patience and care. In these cases with distorted astragali, where the ordinary anatomical lines of the bone do not serve as a guide, astragaloid excision makes a delicate test of operative skill and neatness. Both astragali were removed in this case at the clinic and the feet put up in gypsum casts in a slightly over-corrected position. The surgical course of the case after operation was uneventful. The casts were removed after three weeks and showed the cicatrix of an absolutely sterile wound that had healed by first intention. Fresh casts were put on, care being taken to maintain a well-corrected position of the foot. After this he was allowed to run around on the casts for four or five weeks, when he was given suitable braces. The position secured by the operative procedures was an excellent one, and the functional result very satisfactory. In time the braces and the gradual development of muscles improperly used up to this time will still further improve his condition. Case IV.-Girl, 14 years of age. Deformity: congenital equino- varus. The process of growth and the use of the feet in their faulty position have exaggerated the original deformity very much. Not only were the astragali very prominent, distorted, and misplaced, but the external malleoli, owing to the faulty application of pressure from walking in the deformed position, have become enlarged and mis- shapen. In this case, even after the excision of the astragali, it was found impossible to bring the feet into good positions owing to the serious deformity of the external malleoli. These were accordingly removed by a saw-section just about the level of the normal astragalo-tibio- fibular articulation. After the exsection the feet in slightly over-corrected positions were put up in plaster casts. These were removed after three weeks, and the incisions founo healed by first intention. Only a little serous exudation had stained the dressing, and that was perfectly sweet in odor and healthy. Considerable manipulation and interference with the incised tissues had been necessary for the excision of the astragali and the exsection of the malleoli, and some inflammatory reaction must have taken place, but thorough aseptic precautions had pre- vented this from going beyond the first stage, and under rest it had subsided practically without any symptoms. 6 James J. Walsh. Still further correction was secured in the new dressings which were put on, and after some time the patient was allowed to walk around in the casts. Not much improvement could be noticed in her walk at first, though now the feet were secured in correct positions, but when patients have for years been using their muscles in the abnormal way, necessitated by faulty position of the feet, there is necessarily a good deal of awkwardness when the attempt is made for the first time to use them as nature intended. After the removal of the casts, and the substitution of braces to secure proper correc- tion, this awkwardness in the use of the limbs began to pass off. It takes considerable time, however, to eradicate the faulty habits of years, and, as the patient's improvement was constant up to the time when she passed from observation, it was not too much to assure her that most of it would finally disappear. II. Deformities due to Nervous Diseases. Up to within very recent years it has not been considered of any avail to attempt to relieve by orthopedic measures any serious defor- mities due to nervous diseases. Such cases have been dismissed with the expression that as nature did not have the requisite nerve- force to supply the affected limbs, it was useless to try to benefit them by any surgical means. The neurologists have said of cerebral palsy the absence of cortical brain-cells is the cause of the spastic condition of the muscles, these cannot be supplied, of what use will it be to do tenotomies and set the limbs in correct positions ; after union the spasm will inevitably recur, and with it the deformity. Of late, despite the conclusiveness of this a priori reasoning, patients deformed from nervous disease have been operated upon and with very gratifying success. Americans first attempted this line of work, and it is to them that is due the entire credit of its success. Such distinguished au- thorities as Hoffa, in Germany, and Redard, in France, attribute the initiative in this matter to Professor Willard, and further state that he is constantly widening the limits of benefit which orthopedic sur- geons can accomplish for this class of cases. When once muscles are put in a position in which they can exer- cise their function normally, the very exercise of this function seems to react on the nerves that supply them, and give them additional vigor. Nerve-centres cannot be supplied, but those that exist can be trained to do all the work of which they are possibly capable, and so supply the place of absent or atrophic cells. In cerebral palsy the relief of the spastic contraction of the mus- cles, when the limbs are put in proper position after tenotomies, Orthopedic Surgery. 7 very soon shows itself in an improvement of all the vital nerve forces. Even the intellectual condition of the patient, never very high, begins very soon to show decided improvement. Hope, confi- dence, and courage become visible upon the countenance and replace the stolidity so common before ; the association with those of their own age, the seeing of friends, the coming in contact with those out- sideuof the immediate family instead of the state of segregation and almost solitude to which they were condemned before, has a great deal to do with this. Environment has much to do with the inflow of ideas, and even a normal child placed under similarly restricted surroundings would fail to develop to its limits. But there is un- doubtedly another etiological factor present. It is as if the contin- uous spasm of the muscles had been consuming vital nervous energy which now, that the spasm is relieved, has an opportunity to exert itself to some good purpose along other lines. The explanation may seem rather theoretical, but there has been without doubt, while the spastic condition existed, a continuous stream of nerve impulses being sent down to the contracted muscles and to no purpose. This has been a drain on the already not superabundant nerve- force that has been felt by the whole organism. The relief of the condition has consequently led to a general improvement of the nervous condition, and this is easily reflected in the intellectual faculties. Two of the cases of cerebral palsy treated have been interesting from the inveteracy of the condition, the helplessness of the patients, and the relief afforded. Case I.-Girl, aged 13 years. Spastic cerebral palsy. She practically had never walked, though she had learned to drag her- self around on a pair of crutches with her toes only touching the floor. Contracture existed at the ankle due to spasm of the gatroc- nemius and soleus, the foot being in equinus. There was contracture also at the knee, from spasm of the biceps, semitendinosus, semi- membranous and sartorius, the hamstrings standing out prominently beneath the stretched skin. Contractures at the hip were also present, due mainly to spasm of the adductors causing a tendency to adduction, and giving the scis- sors gait so typical of the affection. The history of the case is a type of this class. A first child, born at seven months, always extremely delicate, cut her teeth late, the first after she was a year old, did not sit up alone until she was over 3 years old, and did not begin to talk until she was nearly 5. Everything points to lack of cerebral development, or should we say lack of cerebral cells to undergo development. It is the lat- 8 Janies J. Walsh. ter expression that is the favorite one with the neurologist, and con- stitutes the reason usually given for non-interference in these cases. The operative procedures in a case of this kind are of the sim- plest. The tendons of all muscles that resist the reposition of the limb into its normal shape are cut. Casts are then applied to keep the limbs straight and resist the tendency to spasmodic contrac- ture that will recur as soon as the tendons have united again. At the hip this tendency is overcome by the weight of the casts on the limbs which are carried up as high as comfort and a due regard for cleanliness will permit. The tendency to contraction of the adductors, so typical a de- formity in these cases and the cause of the scissors-like movement when progression is attempted, is overcome by keeping the limbs stiffened by the plaster casts widely separated until the fibrous band in the divided adductors has been fully deposited. The dressings can usually be allowed to remain for four to six weeks, when they will probably have to be renewed, first being sure, by placing the patient face downward, that sufficient correction of the tendency to spasmodic contraction at the hips is being overcome, and taking careful precautions in the application of the second set of casts. After about three months braces are to be fitted. These have a lock-joint at the knee, and are carried well up the limb on the inside and to a band around the waist on the outside. They need to be padded at the knee and ankle, and are fastened to a pair of shoes so arranged as to overcome any deformity of the foot itself. They keep the limbs absolutely rigid and are an essential part of the treatment, the patient meanwhile using crutches until the tendency to spasmodic contraction, which may take a year or more, has passed away. These are the details of the procedures employed in the girl's case1 just mentioned, and also in the case of a boy who came with spastic palsy. Case II.-Boy, of 8 years, who had never walked. His only mode of locomotion was on his hands and knees, his hands being firmly fixed some distance in front of him he then dragged the rest of the body forward. His lower limbs were so contracted that he was able to use them but little even in this mode of progression. Yet, as is the rule in these cases, they were not atrophied. The muscles were rounded and full, but soft and flabby from want of exercise. 1 I saw this case (December, 1895) about a year after beginning treatment. She still uses crutches, but is able to move around easier, though she had never walked before. What surprises her friends is the wonderful improvement that has taken place in her mental condition since she was operated upon. Orthopedic Surgery. 9 After tenotomies and casts for some months he was put on his feet with braces and crutches, and at last accounts was improving in his walk, and brightening up in intelligence. Progressive Muscular Atrophy.-One very severe case in which the atrophic process had ceased for some time was under treatment, and was decidedly benefited as far as locomotion was concerned. Case III.-The patient, a man of 35 years, had suffered some years ago from progressive muscular atrophy, which had involved the arms completely and the legs partially when its progress stopped, at least for a time. There had been no further evidence of the advance of the disease for more than a year when he came to the hospital. As a result, perhaps of the disease but mostly of faulty position in bed, contractures of the muscles had ensued, and the hip and knee on both sides could not be straightened. The wasting of the muscles had been quite extensive, and it looked hopeless to attempt to help him by surgical interference. The tendons at the knee and hip were cut, however, the limbs put in cor- rected positions in casts, and after five weeks he was fitted with braces. These were made strong so as to be a firm support to the body, for the atrophied legs could perform little of their normal func- tion and were mainly useful as something to which to attach the apparatus. With the aid of a pair of crutches he was able to walk, though not very well, for his arms had shared in the atrophic process and he was unable to aid himself as one normally would. He left, however, feeling that his condition was much better than his abso- lutely bedridden condition before, and rejoiced that he was able to get out of his room to move about. III. Deformities arising from Tubercular Joint-Disease. Anchylosis of hip and knee in bad position are frequently neglected. The dread of lightingup again the tuberculous process that had already worked such havoc to the joint-structures, of perhaps fanning into a new flame a focus that nature had encapsulated for her protection, has often deterred surgeons from attempting to put the limbs in a better position. Osteotomies at or near the original seat of disease, after long quiescence or wedge-shaped excisions, are the favorite operations for correcting these resultant deformities, and usually give satisfactory results. Now, however, forcible straightening is frequently employed after the disease has been dormant for some time, the adhesions between joint surfaces being gradually and gently broken up under ether and the limb placed in good position. Where the deformity is 10 James J. Walsh. great this is not all done at one time, but a certain amount of cor- rection attained the first time and then the patient put to bed, kept perfectly quiet by means of sand-bags and extension, or by a plaster- coat, and his condition carefully watched for any inflammatory reac- tion that may result from the manipulations. If the reaction as indicated by local inflammatory symptoms and the pulse and temperature are marked, any further attempt at correc- tion is deferred for a considerable time, otherwise, as soon as the local tenderness subsides, further correction is secured. Two cases out of a number in the ward during the year illustrate the success of this method of treatment. Case I.-A boy of 12 years, in whom, five years ago, there had been severe tuberculous arthritis of the hip that had gone on to sup- puration and the production of two sinuses, the cicatrices of which are very evident. The disease had gradually passed off, leaving the joint anchylosed in aposition of flexion to 100 degrees together with adduction. Under ether the adhesions were cautiously broken up. Some of the deformity in these cases is always due to the inflammatory thick- ening of structures about the joint, and these must be made to yield and to accommodate themselves to the proper position of the bones. Not much force was employed the first time, and after correction was evident the patient was put to bed with fixation to note the result. Nothing untoward was observed, and at a clinic three weeks later the limb was put into good position, and then retained there by suita- ble splints and sand-bags. The final result was functionally excellent, and the boy went out with a much more useful limb than he had had before. Case II was that of a little girl of 8 years, whose history might well have discouraged surgical interference. Her father had died of tubercular phthisis, and during his last year of life the child had been almost constantly with him. At years she had developed " sore eyes," and the mother's description of the chronic course of the dis- ease and its recurrence so often after apparent cure left no doubt that the trouble had been phlyctenular conjunctivitis or worse, and tubercular in origin. The child had, when she came under treatment, the pale, delicate, anemic countenance of what is sometimes called the scrofulous diathesis. When between 4 and 5 years coxitis devel. oped, and later tubercular arthritis of the knee. Neither of them had gone on to the formation of sinuses, but both had led to anchy- losis of the respective joints. Here, too, the adhesions and constric- tions around the joints were carefully broken up at two clinics and the limb placed in good position with thorough fixation. After about Orthopedic Surgery. 11 twelve weeks the little girl was ready to go out. There was only three-quarters of an inch difference in the length of the two limbs. Though, of course, the functions of the joints had been destroyed and the limb was anchylosed. Spinal Caries.-Two interesting cases of caries of the spine illustrate some of the unusual features of that affection. Both patients had complete paraplegia, and one of them had in addition complete anesthesia of both limbs from the hips down. In both the disease was located in the mid-dorsal region. In neither was it very extensive, at least it did not produce nearly the amount of deformity that some of the cases treated during the year had exhibited, though the latter had none of the serious paralytic symptoms of the two cases under consideration. Case I.-The paraplegic was a little Italian boy of about years, fat and well nourished, There was more deformity in his case than in the other. He had completely lost the use of his limbs. Gradually motion returned under rest in bed, with extension and counter-extension, perfect fixation by means of a cast, and daily applications of massage and electricity, just enough current being used to excite contractions in the muscles and yet not give pain. After about five months he was able to be up and around the wards, and a month later, though still wearing a cast, was allowed to go home, practically able to walk as well as ever. Case II was a more serious one, sensation and motion being both completely lost. In this case, besides the cast, weights were applied to the legs and extension secured by padded straps beneath the chin and occiput and fastened to the head of the bed. These straps were left to the patient's own control, and when they became too irksome he was allowed to remove them and rest for awhile. Here, too, but much more slowly, recovery gradually took place. Sensation by degrees returned and stole slowly down the limbs. Only from week to week could it be noticed that the line of sensitiveness was lower down than before. At the end of eight months sensation had almost entirely returned, but motion was only beginning to come back. At the end of the year there had been marked improvement, but he was still unable to walk.1 In this case the kyphosis, evidencing the extent of the disease and the number of vertebrae affected, was only comparatively slight. Acute angulation of the canal rarely produces paraplegia and paresthesia, though it might be expected' to do so from the gross morbid appearance post-mortem. Here with paralytic conditions 1 One year later he could sit up well with the support of head extension attached to an over- hanging arm, control of bladder and rectum had returned, and motion was slowly returning. 12 James J. Walsh. absolute there was absent any evidence of such a factor in the etiology of these symptoms. Removal of the laminae to secure release of injurious pressure upon the cord has been done in a number of cases, but the results have not been permanently satisfactory. These cases of spinal para- plegia, as a rule, recover, showing that the tubercular deposit within the canal may be absorbed and permit restoration of cord functions.