In paralytic talipes varus as well as valgus we will be able to restore muscular equilibrium whenever sufficient sound muscle is left; otherwise we will have to prefer an arthrodesisIpius).
In paralysis of the quadriceps we can get good extension either by using the tensor fascias with a long strip of the fascia, or with the sar tori us (Schanz), or by pulling the flexors forward and se wing them on to the patella. Lange frequently uses in these cases, when the tendons are too short, a network of which will later be covered by connective tissue and thus take the place of the tendon.
Tenoplasty does not work very well in the hip-joint. Fortunately isolated paralyses in this region are rather rare. In extensive paralysis we will choose arthrodesis to prevent dislocation.
For paralysis of the abdominal muscles we recommend wearing an abdominal bandage (Fig. 179); this usually affects only parts of the muscles, because the nerve-supply is segmentary and comprises a num ber of segments. The nuclei for the iliopsoas muscle being near those for the oblique muscles, we will frequently observe paralysis of the ilio psoas accompanied by partial paresis of the abdominal wall.
In the upper limbs the conditions for tenoplasties are much more unfavorable; the most favorable is an isolated paralysis of the deltoid, which is a rather fre?ment form of paralysis (Fig. ISO).
Extensive union of part of the sound trapezius muscle to the tendon of the paralyzed deltoid muscle with elevation of the arm may bring back the function of this muscle under careful after-treatment; the pectoralis muscle may also be used for this purpose. In one case we even succeeded by union of the deltoid with part of the pectoralis at the height of the shoulder not only in restoring the function of the deltoid but also the lost rounding of the shoulder (Fig. 1S0).
In the upper trio and forearm we will find it very difficult to restore the fine complicated motions by peripheral muscular grafting, and nerve grafting will here prove far superior.
3. Operations on the Nerves (Nenroplasty) Though some of the older surgeons had reported good results from neuroplastiea, it is only recently that they have again been competing with other methods of conservative surgery.
It has been proved conclusively by animal experiments that we can succeed in supplying two peripheral nerve-ends with sufficient inner vation from one central nerve-end. This we can do in either of two
ways, either by grafting the central stump of a sound nerve (all or only part of it) on to a paralyzed nerve (central implantation) or by intro ducing the peripheral stump of a paralyzed nerve into the course of a sound one (peripheral implantation). Modifications of this arc possible in which the whole central stump of a less important nerve is united with the peripheral end of an important one in order to supply it with new nerve-impulses. It depends upon the case in hand which of these methods should be used.
We, personally, can look back upon a considerable number of successes with this method, and we feel, therefore, that we arc entitled to recommend it, for others also report successes in steadily increasing numbers.
In one ease of paralysis of the radial nerve, caused by intra partum fracture of the neck of the humerus, we succeeded in getting a perfect cure, after it had existed for twelve years, by a partial cen tral implantation of the median nerve, inside of eight months (Figs. ISIa, ISlb).
Several cases of poliomyelitic paralyses of the peroneus and axil la•is nerves showed recovery or at least improved function (Fig. 1S2).
For sonic reason which we can not yet explain the neurotization of seine of the muscles in the united groups may fail, but this can later be mended by tenoplasty.
The first principle, and one which we must always adhere to is nil nocere. We must never risk any of the sound material, and careful technic will avoid permanent postoperative defects.
This treatment, which attacks the pa ralysis more cent rally and which restores even complicated Inotions, is without doubt a great advance in the treatment of• paralysis. As mentioned before, we must not wait until the muscle is entirely dead. When the muscle has been failing for some months we should proceed with the neuroplasty. Spontaneous regeneration would take place in the course of the first six months at least by traces of contractions or by the persistence of the quantity and the quality of electrical irritability. (We must caution against over stretching of the muscle.) We can expect the appearance of the first motion about three months after the operation. The voluntary impulse will appear first and the electrical reaction later.