BONES JOINTS ORTHOPJEDIC.
Changes in the Surgical Technique of Joint Opera-4 tions. Joint operations deal with either infected or non-infected articulations. The former category embraces operations for traumatism of joints (resec tions), removal of bullets, foreign bodies, fragments of fractured bone, floating cartilage, resection for tuberculosis, neoplasm and deformity. As a prototype for such operations, the knee is chosen, wherefore fracture of patella is included.
Since the maintenance of joint function is the chief desider atum, a rigid asepsis must be guaranteed. This can only be at tained by conducting the operation instrumentally, to the entire exclusion of any contact of the fingers with the wound, by em ploying the constrictor to render parts bloodless, as thereby sponge-contact of the wound is obviated, and in addition the operation is easier technically. Finally, by doing away with the irrigation with carbolic and sublimate solutions drainage can be dispensed with, and limited merely to resections where the secre tion in the first days has to be carried off.
In his experience, Koenig found the X-rays of little value in the diagnosis of foreign bodies, floating cartilage, and neo plasms of soft parts of joints.
As to infected joints, while not belittling arthrotomy with continuous irrigations, it is, in rebellious staphylococcus and streptococcus joints, often possible by multiple counter incisions into the joint and a free exposure of all the pockets to avoid amputation.
In the phlegmonous variety of gonorrhoeal arthritis, with scant effusion into the joint, but much infiltration into the peri articular tissues the whole course is cut short by extensive in cisions, pain being markedly diminished, and some motion of the joint preserved. If, notwithstanding extensive lateral incisions into knee-joint, fever and discharge persist, threatening a pymmic condition, a transverse incision above the patella dividing the tendon is justified to save life and limb.
In coxitis deformans, attended with marked deformity and outgrowth of osteophytes, a resection of femoral head is recom mended.
In the discussion, Schede claimed that he could bring about a cure in most instances by antiseptic irrigations, provided the capsule and periarticular tissues are yet intact. In reply, Koenig admits this to be his point of view also, save in extreme instances, strongly suggesting amputation, when he recommends extensive incisions. Verhandlungen der deutschen Gesellschaft far Chi rurgie, XXIX Congress.
The Initial Stages of Coxa The author reasons by analogy from the state of affairs in scoliosis that coxa vara must also have a preliminary state of development. As a matter of fact, he finds that it shows itself at the age of fourteen, most frequently in males, unlike the preponderance of females in scoliosis. This discrepancy, he thinks, is only apparent, and is accounted for by the fact that only the males present themselves with advanced objective phenomena, since the females are not exposed to the severer insults as the male in the pursuit of his duties, and because the former soon yield, on the advent of any disquieting symptoms of locomotion. Consequently, in females the disease hardly gets beyond the initial stage.
From eight instances, all females, ages ranging from seven to seventeen years, the author has projected a picture of incipient coxa vara—characterized by bilateral limping, attended with pains radiating to knee when standing, disappearing in the recumbent position. No starting pains, no spasms, motion limited only in one or two directions, viz., abduction and external rotation, slight atrophy of the hip muscles. With all of these there is as yet no elevation of the trochanter major, and that very slightly, if at all. Other closely allied diseases of the hip are ruled out for the want of the usually associated phenomena. Since so little can be done in the well developed case of coxa vara adolescen tium, great stress is laid on the recognition of coxa vara before objective deformity has set in, i.e., at puberty, when by slight correction the properly directed statical forces can alone prevent the onset of deformity. Zeitschrift fiir Orthopiidische Chirurgic, Band viii, Heft i.
Periosteal Tendon Implantation. This operation was first instituted by Drobnik, the originator of tendon anastomosis, who, after a single un successful application of it, abandoned the procedure. Lange was prompted to revive the method because his observation in ordinary tendon implantations taught him that the peripheral tendon stump, atrophic as it often is, subsequently stretched when joined to a slip of some active muscle, thus curtailing its efficiency. To obviate this, a tendon with muscle attached was longitudinally bisected, severed at its bony insertion, and this half implanted anew into the periosteum of some other bone. Such a procedure was applied to a lad of seven years, who at the age of two years had a poliomyelitis, which left the peronei and the extensor communis digitorum paralyzed. The antagonistic tibialis anticus caused a club-foot. After redressement of the foot in narcosis, at the same sitting the tibialis anticus was split and its external half separated from its original. Insertion was car ried subcutaneously outward and implanted into the cuboid. Ten months later the function of the foot was restored to normal. At first it was difficult to bring the slip of the tibialis anticus to con tract independently of its parent half, but by passive and active exercises this was accomplished.
In a second that of a female, aged twelve years, paraly sis of the gastrocnemius following poliomyelitis caused pes calcaneus. This, still further complicated by paralysis of the tibialis anticus, added a valgus position to the foot. The most potent muscle, the peronxus longus, was severed from its inser tion, passed between the fibres of the tendo Achilles, and inserted into the menial surface of the os calcis. Thereby the plantar flexion was obtained, the foot turned inward, and the inner border of the foot raised. Finally, this method was applied in a case of quadriceps extensor paralysis after poliomyelitis. The semimem branosus and semitendinosus were severed at their insertion into the tibia and fibula respectively. They were then made to pass forward subcutaneously, overlapping each other about two fingers' breadth above the patella. From this muscular loop two stout silk strands were passed over the patella subcutaneously to be inserted into the head of the periosteum of tibia. These silk strands were intended to form irritating centres about which con nective tissue would form so as to bridge the interval between the loop of muscles above and the tibia below (used successfully by Gluck and Kiimmel). Eight weeks later extension of leg was possible while lying on the side, but it could only be partially maintained in the horizontal position, while standing without any mechanical support was the most marked gain. Six months later the new-formed connective tissue tendon is as thick as a lead pencil and extension can be carried to forty-five degrees in hori zontal position. Of two other cases likewise operated, one ap proached the absolute normal function of extension, the other could only be extended to forty-five degrees. Zeitschrift fir Or thopiidische Chirurgie, Band viii, Heft I.