OPERATIVE TREATMENT 1. Joints 13y eliminating the joints (resections) we change the infirm pendu lous limb into a solid prop. Arthrodesis in the foot and the knee-joint transforms useless limbs into useful ones (Albert). But we must be careful not to sacrifice the epiphysis in the youthful bones, so that the leg, which anyhow remains backward in growth from non-use, is not shortened still further. As we usually have to work within the cartilage we cannot expect the same solid union as in adults, and in order to avoid secondary curvatures after arthrodesis, we either postpone this until later, or we let the patient wear fixation and supporting apparatus for a long time afterward. These will permit the use of weights and at the same time prevent curvatures (Jones). The putting on of the weight must be permitted as a preventive for atrophy.
We have-thus frequently succeeded in paralyses of the lower limb in ridding the patient of his crutches and apparatus (Fig. 17Sb).
Even the latest writers (Vulpius, Bade) prefer arthrodesis to com plicated and problematical tendon operations for the extensive paralyses in the lower limbs, and that justly, especially in those eases in which the weakened muscle or insufficient after-treatment and unintelligent surroundings would make the result doubtful. The nailing of the young bone (according to Bade-Lexer) is a real advance; in this method we stiffen the joints almost subcutaneously without opening them by driving in ivory pegs through the parts forming the joint.
- 2. Operations on the Tendons and Muscles Nicoladoni taught us how to use the active muscles for the substi tution of the paralyzed ones, and his method has been developed to a wonderful degree. Every paralysis was treated by tendon-grafting, and even when only one muscle was preserved it was split in two and thus made into its own antagonist, and we then expected a dissociation of the motions in the muscle itself. This polypragmasia naturally made the pendulum swing too much in the other direction—a consequence of abusing this excellent method.
We owe to Hoffa and others the working out of the methods now in use and their limitation.
The method of grafting now accepted is divided into the grafting of tendon upon tendon (Vulpius) and into forming a new insertion for the muscle by se wing the tendon to the periostemn and bone (periosteal method, Lange). Each given case will tell us which method is preferable.
For instance, if we can unite the peripheral tendon of the til,ialis muscle, which is paralyzed, with the fleshy part of the extensor digito ruin, then we will tint orally do it ; but it is entirely difTerent if we have extensive paralyses and little muscle preserved for a simple mechanism and we cannot make use of the points of insertion which had been serving for the finer complicated motions.
In such a case careful considera tion, clear mechanical understand ing and wide experience will show us the way.
As far as possible only equi functional muscles should be used for subst it ut ion, for when using the antagonists we can expect less of function than of muscular stability.
In the hands of the expert any one of the following methods can give the desired result and will supply us with unlitnited resources: tendon-splitting, t endon :graft ing, grafting the end of a paralyzed ten don upon a sound muscle, union of a less important sound muscle with the tendon of an indispensable muscle (Vulpius), periosteal fasten ing (Lange), lengthening by tenot omy or accordion tenoplasty, sub stitution of silk tendons. etc.
We will always have to pay special attention to obtain muscular equilibrium, though with lessened strength and simplified mechanism. Only thus will we be able to pre vent the return of the deformity.
The after-treatment is one of the most important factors. Even when we form the new tendon we will have to consider the possibility of adhesions of the tendon to the neighboring tissues (interposition of fat). Careful early motions must aid in this. But we must avoid all overstretching of the muscle, because it can work only under a certain tension. After sufficient resistance to weight has developed, then we can permit the free use of the muscles.