I prefer this method of correction by means of several successive bandages to the articulating reduction bandages on account of its greater simplicity and practicability. The laxity of the articular ligaments, especially of the external ones, which is always associated with this treatment, must be looked upon as a disagreeable incident. Methods, therefore, by Which a correcting fracture of the lower end of the dia. physis is effected by osteoclasts are of much greater value. Kehler seeks to separate the epiphysis in this manner, aiding the separation by a sub cutaneous division of the thickened periosteum (epiphyseolysis).
Division of the bones with subsequent correction of position was most successful in fully developed genu valgum of older children. Mac Ewen's osteotorny, starting from a longitudinal incision at about the level of the internal condyle, separates the tissues clown to the bone, and the hone itself, transversely at the depth of the wound.
It is, of course, necessary to divide the bone which is most deformed, and the point of division must be as near the vertex of the curvature as possible.
This advice should guide us in most of our cases, but after division of one bone there always remains a slight corresponding deformity in the other articulating bone. In case both bonus arc involved to the same extent they must be treated alike, otherwise an overcorreetion of one bone is sufficient. Therefore a discussion of the seat of the deformity is eliminated, at least in regard to therapeutic measures.
The plane of division must be as near the vertex of the curvature as possible, and is located usually in the femoral diaithysis.
Brunn, therefore, removes the plane of the condyles and performs here a subcutaneous transverse osteotomy, starting from the external colt Lyle.
These considerations finally induced me—since 1000—to divide the diaphysis and epiphysis transversely along the cartilage. Fear was at first expressed that disturbances of growth would ensue. It was fortu nately soon dispersed. Out of 140 cases on which I operated not one showed any such disturbances whatever.
Recent investigations (Redinger) on rabbits proved that a delay in growth takes place only for a short time immediately after operation, but is made up again in about two years, owing to the rapid growth of a rabbit's bones. In a human being, therefore, where the rapidity of growth is twenty times less than in a rabbit, retardation must certainly prove slight. The delay of growth in a human being is thus not manifest. The insignificant operation is performed as follows: Mild ether narcosis. A narrow chisel with a transverse handle is driven into the limb parallel to the longitudinal axis in the region of the external condyle. Upon reaching the bone the periosteum is divided, the chisel turned transversely, and with gentle force pushed through the cartilaginous tissue, which is found quite easily, until it reaches the skin of the internal coudylc. In the same manner, by partly withdrawing the chisel the other cartilage and periosteum are divided. A layer is left untouched at the popliteal space on account of t he dangerous proximity of the popliteal artery. The chisel is now withdrawn entirely, the small wound is not sutured but bandaged, reduction is easily accomplished, and the cleft between bone and cartilage may be distinctly felt through the skin.
The duration of the operation is three or four minutes; five minutes suffice for operation on both sides. A plaster-of-Paris bandage is applied, and before it sets a cushion is placed between the knees; the lower ends of the cast are covered with gauze bandages.
The bandage remains in the overcorrecting position until it is firm. It is then turned into a permanent bandage and not interfered with for five or six weeks. During the last three weeks the child may walk around. After four weeks the bandage is shortened and the ankles freed.
Two weeks later the bandage is taken off entirely and eventually sup planted by light splints to be worn overnight. The latter consist of the longitudinal halves of the plaster cast. Lange employs similar splints made of celluloid from an overcorrecting model. In about ten (lays the knee flexion, which is at first painful, may be used without trouble. I never observed any permanent disturbance of locomotion arising from the knee.
I prefer this small and nearly bloodless operation to epiphyseolysis, because of the possibility of accurately determining the point of correc tion. It is superior to all other operations on the bone on account of the ease and rapidity with which it can be performed, and also because here the plane of division actually corresponds to the vertex of the curvature (see MacEwen).
The appropriate time for the different therapeutic measures may be stated as follows: Static corrective measures can be employed up to the fourth year with success.
Supinating supporters, correcting exercises and, in more pronounced cases, splints preceded by reducing bandages are required. The rigid splints are the hest (Thomas); those which are flexible in the region of the knee must have well-made articulations, otherwise the splint soon develops a deformity similar to that of the leg. The result must always be controlled by a drawing of the contours.
Should this treatment be insufficient, or for other reasons impossible, or in case the deformity is so marked as to produce a limitation of loco motion and a development of secondary deformities (deformity of t he tibia, flat-foot), the harmless little operation correcting the deformity in a radical manner must even be performed in early childhood.
This operation was of great benefit in many cases where social cir cumstances did not permit of a prolonged treatment and observation. It restored straight legs to the children and made them independent of the indolence or intelligence of parents, who always look upon a perma nent treatment in a very sceptical manner, as a rule not having time and sense enough to devote to such conditions.
The older the children the more necessary it becomes to turn from epiphyscotomy. In these cases the employment of hammer and chisel to divide the opposing bony structures appears sometimes inevitable. Thus far I have not observed any disadvantages of this method.
A later investigation of 140 cases operated on during the preceding ten years yielded the following results: Ninety per cent. permanently cured and the remainder decidedly improved. In one case only a mild distortion of the epiphysis backward was noticed and that was early corrected by the bloodless method. Not one case presented a shortening or any other disturbance of development.