Page Four P H Y S I O T H E R A P Y December, 1957. RECONSTRUCTIVE SURGERY IN POLIOM YELITIS by Mr. R. P. L a n c a s te r , F.R.C.S. A n a d d r e s s y i v e n a t S . A . S , l \ C o u n c i l M e e t i n g , E a s t L o n d o n , S e p t e m b e r , 19.S7. I feel h o n o u r e d . M a d a m C h a i r m a n , to be in vited t o read a P a p e r b e f o r e su c h a n a u g u s t b o d y as t h e S o u t h A f ri c a n Soci ety o f P h y s i o t h e r a p i s t s . H a v i n g , h o w e v e r , b ee n a n H o n o r a r y V ic e- P re si d en t o f t h e B o r d e r B r a n c h o f y o u r S o ci et y , I feel t h a t I a m o n e o f y ou . M o r e ov er . P h y s i o ­ t h e r a p i s t s a n d O r t h o p a e d i c S u r g e o n s w o r k t o g e t h e r as a t e a m a n d I a m glad t o sa y t h a t in E as t L o n d o n w e ar e h a p p i l y m a r r i e d . It is o nl y fit a n d p r o p e r t h a t t h e r e s h o u l d be a m a x i m u m a m o u n t o f c o - o p e r a t i o n b e t w e e n us a n d n o w h e r e is this t e a m sp irit s h o w n t o b e t t e r a d v a n t a g e , t h a n in t h e m a n a g e ­ m e n t a n d t r e a t m e n t o f ca s es o f P ol io m ye lit is . La st y ea r , we e x p e r i e n c e d a se ve re e p i d e m i c o f P o l io m ye lit is wh ich s t r a i n e d o u r r e s o u r c e s t o t h e m a x i m u m . I wish to pl ace on r e c o r d t h e ex ce ll en t w o r k c a r r i e d o u t in East L o n d o n a n d K i n g w i l l i a m s t o w n by all o u r P h y s i o t h e r a p i s t s . 1 a m g ra t e fu l f o r t h e c o - o p e r a t i o n 1 recei ved . T h e re co ve r y o f p a t i e n t s w i t h t h e m i n i m u m n u m b e r o f d e f o r m i t i e s is d u e t o th eir skill. P ol i o m y e l it i s is no t a n e w dise ase. It h as e xi s te d sinc e ea rl y civ il isa ti on , as b o r n e o u t by H i e r o g l y p h i c s c a r v e d in s t o n e o n t h e m o n u m e n t s a n d t e m p l e s o f a n c i e n t E g y p t. E n o r m o u s a d v a n c e s h a v e b e e n m a d e in t h e p r o p e r u n d e r ­ s t a n d i n g o f t h e dise ase in re cen t y e a r s a n d m o s t f o r t u n a t e l y , a m o d e o f c o n t r o l by v a c c i n a t i o n h a s b e e n ev o lv ed . V a r i o u s o b s e r v e r s in Br it ain . S o u t h A f ri c a a n d A m e r i c a feci t h a t a b o u t 8 0 % i m m u n i t y is c o n f e r r e d o n t h e p o p u l a t i o n by v a c c i n a t i o n . 1 his is m o s t g r at ify in g . P e r h a p s , o n e d a y , ev en m o r e ef fective c o n t r o l will be o b t a i n e d a n d t h e n P o l i o m y e ­ litis m a y j o i n t h e r a n k s o f o t h e r p l a g u e s t h a t o n c e ha v e b een , at least in t h e W e s t e r n civilised co u n t r i e s. P oliom yelitis m ay be said to have fo u r s ta g e s :— 1. T h e p r o d r o m a l st a ge , w h e n t h e in d i v i d u al is i n c u b a t i n g t h e dise ase. 2. T h e s t a g e o f a c u t e o n s e t , w h e n p ar al y sis ens ues . 3. T h e s t a g e o f co n v a l e s c e n c e , w h e n t h e a c u t e illness h a s su b s i d e d . 4. T h e st a g e o f r es id ua l paral ysis . W e , as P h y s i o t h e r a p i s t s a n d O r t h o p a e d i s t s , a r e c o n c e r n e d wit h t h e last t h r e e st ag es. O u r j o b is m a n i f o ld . W e m us t a l w a y s r e m e m b e r t h a t P o l i o m ye l it i s is a n e x h a u s t i n g a i l m e n t , p hy sic all y a n d ps yc ho lo g ic al ly a n d w e m u s t in o u r e n d e a ­ v o u r s t o i m p r o v e b o d y f u n c t i o n , be m i n d f u l o f t h e m e n t a l s t a l e o f p a t i e n t s a n d t h r o u g h o u t t r e a t m e n t , be ki n d , c o u r ­ t e o u s , c o n s i d e r a t e , p a t i e n t a n d e n c o u r a g i n g . T h e m o r a l e o f t h e p a t i e n t m u s t no t be a l l o w e d t o flag. T h o s e w h o h a v e e s c a p e d c o n t a c t with t h e c r i p p l e d , d o not a p p r e c i a t e t h e m e n t a l a n g u i s h t h e y suffer. S h a k e s p e a r e h a s c a p t u r e d th i s a n g u i s h in t h e m o n o l o g u e o f G l o u c e s t e r , w h e n in R i c h a r d III he e x c l a i m s — “ C h e a t e d o f f e a t u r e by d i s s e m b l i n g n a t u r e , D e f o r m e d , u n f in is h ed , s e n t b e f o r e my ti m e. I n t o thi s b r e a t h i n g w o r l d , s c ar c e h a l f m a d e up, A n d t h a t so lam el y a n d u n f a s h i o n a b l e , T h a t d o g s b a r k at m e as 1 halt by t h e m . ” A l t h o u g h t h e O r t h o p a e d i c S u r g e o n is r e s p o n s i b l e fo r t h e d i r e c t i o n o f st a g e s 2, 3 a n d 4, t h e P h y s i o t h e r a p i s t is t h e o n e m o s t in t i m at el y c o n c e r n e d w it h t h e a c t u a l m a n a g e m e n t a n d t r e a t m e n t o f t h e case. In s t a g e 4, h o w e v e r , w h e n t h e r es id ua l st a g e o f t h e dise ase h a s b ee n well e s t a b l is h e d a n d i m p r o v e m e n t in m u sc le p o w e r c a n n o lo n g e r be e x p e c t e d f r o m c o n s e r v a t i v e t r e a t m e n t , su rg ica l m e a s u r e s s h o u l d b e c o n t e m p l a t e d . T h i s s t a g e is Fig. I A za r i a l K h o k h o t h o — Po li o (Be fo re tr e a t m e n t ). s e l d o m r e a c h e d b e f o r e t w o ye ar s h a v e e l a p s e d f o l lo w in g t he o n s e t o f par aly sis . P ri or t o t h a t , d e f o r m i t i e s m a y ar is e if. t r e a t m e n t is ne gl ec te d. In thi s case, s u r g e r y m a y oc c a s i o n a l !) ! be nec es sa ry t o relieve t h e o v e r s t r e t c h i n g o f t h e p ar a l y se d o r w e a k e n e d m usc les . In t h e t i m e at m y d is po s al , it is q u i t e i m p o s s i b l e t o r u n t h r o u g h t h e g a m u t o f O r t h o p a e d i c p r o c e d u r e s wh ich m a y be r e q u i r e d fo r r e h a b i l i t a t i o n o f p a t i e n t s su f f e r i n g f o r m P o l i o ­ myelitis. It m u s t suffice f o r m e t o o u t l i n e t h e b r o a d pr in ci pa ls o f r e c o n s t r u c t i v e s u r g e r y a n d t h e r e b y s h o w w h a t c a n be d o n e fo r t h e s e p ati en ts. D eform ities. D e f o r m i t y m a y re su lt f r o m t h e effects o f gr av it y , fa ulty p o s t u r e , u n r el ie ve d m u sc le s p a s m o r m u s c le i m b a l a n c e . W i t h skille d n u r s i n g a n d c o r r e c t P h y s i o t h e r a p y , d e f o r m i t i e s s h o u l d ra re ly o c c u r , at an y r a t e in t h e lim bs. S p l i n t s s h o u l d be utilised w h e r e nec es sa ry a n d j o i n t s m u s t be p u t t h r o u g h t h e i r full r a n g e o f m o v e m e n t w h e n s p a s m ha s su b s i d e d , a i d e d , if n ec es sa ry , by w a r m t h , ho t b a t h s o r ev en by t h e use o f a n t i - s p a s m o d i c d ru gs. I wis h t o d r a w y o u r a t t e n t i o n t o t h e d e f o r m i n g f or ce o f t h e lli o -ti bi al b a n d . As y o u . n o d o u b t , r e m e m b e r , thi s b a n d ar is es f r o m t h e cr es t o f t h e Ilium. O n t h e l at er al as p ec t o f t h e t hi gh , it is c o n t i n u o u s w i t h t h e l at er al i n t e r - m u s c u l a r s e p t u m a n d h e n c e is a t t a c h e d t o t h e f e m u r , at it’s l o w e r en d, R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) December, 1957. ______________________ P H Y S I O T H E R A P Y Pa ge Five F ig. II A z a ria l K h o k h o th o — P o lio ( a fte r tre a tm e n t). it is i n se rt ed in to th e o u t e r s i d e o f t h e ti bia. If t h e r e is s p a s m o f t h e bi ceps. G l u t e i a n d T e n s o r F as c i a F e m o r i s a n d a c o m p l e t e r a n g e o f pas sive m o v e m e n t o f t h e h i p a n d k n e e is no t m a i n t a i n e d , flexion, a b d u c t i o n a n d e x t e r n a l r o t a t i o n c o n t r a c t u r e o f t h e hip m a y arise, g e n u v a l g u m a n d flexion c o n t r a c t u r e o f t h e k n ee , e x t e r n a l t o r ti o n o f t h e tib ia a n d fe m u r a n d lastly, pelvic o b l i q u i t y w i t h scoliosis. In a flail leg, gr avi ty t e n d s t o ex t er n al l y r o t a t e th e leg. T o p r e v e n t this, 1 m a k e a light p l a s te r splin t e x t e n d i n g from t h e th ig h t o t h e t o es w it h a t r a n s v e r s e b ar at t h e heel whi ch p r e v e n t s t h e limb f r o m ro lling ou t. If d e f o r m i t i e s a r e r ec en t , c o n s e r v a ti v e m e a s u r e s , su c h as, spl in ti n g , t r a c t i o n o r m a n i p u l a t i o n m a y relieve t h e m . If so ft tissu es a r e c o n t r a c t e d , t e n o t o m i e s , t e n d o n l e n g t h e n i n g p r o c e d u r e s , f a s c i o t o m y a n d c a p s u l o t o m y m a y be n ee d ed . W h e n d e f o r m i t i e s a r e l o n g s t a n d i n g , t h e b o n e s m a y be a l t e r e d in c o n t o u r a n d o s t e o t o m i e s will be r e q u i r e d . Operative M easures. O p e r a t i v e m e a s u r e s fo r t h e r es id u al st a g e o f P ol io m ye lit is a r e d e s i g n e d . 1. T o c o r r e c t d e f o r m i t i e s i n c l u d i n g d i sc re p en c ie s in leg lengt hs, 2. T o re -e sta b li sh m u s c le po w er . 3. T o stab ili se r el ax ed o r flail j o i n t s. B e fo re o p e r a t i o n is u n d e r t a k e n , th e S u r g e o n m u s t a n t i c i ­ pa t e t h e po ss ib le effect o f a c o n t e m p l a t e d p r o c e d u r e a n d a m e n t a l pi c t u r e o f t h e p o s t - o p e r a t i v e c o n d i t i o n o f t h e p at i en t m u st be c r e a t e d . It is n o t e n o u g h for o n e t o say t h a t b e c a u s e the pa t i en t h as a specific d e f o r m i t y t h a t a s t a n d a r d o p e r a t i v e p r o c e d u r e s h o u l d be u n d e r t a k e n t o rectify it. F o r in st a n c e , l e n g t h e n i n g t h c T e n d o A c hi ll es is g o o d policy fo r a n e q u i n u s fo o t , bu t a p a t i e n t wi th par aly sis o f t h e Q u a d r i c e p s w h o has an e q u i n u s d e f o r m i t y o f th e f o ot m a y be a b l e t o get a r o u n d r e a s o n a b l y well, i f he ha s a p o w e r fu l G a s t r o c n e m i u s which is a b l e t o sta bi li s e t h e k n e e t h r o u g h t h e o r i g in s o f th e musc le f r o m t h e f e m o r a l co n dy le s . If t h e T e n d o A chi ll es is l e n g t h ­ e n e d in su c h a p a t i e n t , he m a y n o lo n g er b e a b l e to wa lk u n a i d e d a n d a c a l i p e r m a y h a v e t o be p r es cr ib ed . T en d o n T ra n s p la n ta tio n . T e n d o n t r a n s p l a n t a t i o n o r t r a n s p o s i t i o n is t h e m o s t useful t o r es t o r e a lost f u n c t i o n a l ca p a c it y . C a r e f u l j u d g e m e n t m u st be ex er cis ed , in t h e s e le ct io n o f t h e t e n d o n used f o r t r a n s ­ fere nce . C e r t a i n p o s t u l a t e s m u st be m a d e . 1. T h e t e n d o n m u st ha v e a d e q u a t e po w er . 2. It m u st be i ns e rt ed in a c o m p a r a t i v e l y direct line, f ro m its ori gin t o its in sertion. 3. It m u st lie in a s h e a t h o r in fat to p e r m i t co rre ct gliding. 4. T h e r e m u s t be n o d e f o r m i t y o f t h e j o i n t o v e r w hi ch the n e w t r a n s p l a n t passes. 5. T h e t e n d o n m u st be u n d e r co r re c t te n s io n . 1 wish to i ll us tr at e t h e use o f th i s t y p e o f o p e r a t i o n by a few e x a m p l e s . C law ed Toes. F irstly , it is a use ful p r o c e d u r e in t h e t r e a t m e n t o f clawed t oes. C l a w e d t o es a r e d u e to o v e r a c t i o n o f t h e L o n g E x t e n s o r s o r w e a k n e ss o r pa ra ly sis o f t h e F l e x o r s o r In t ri n s ic m uscles o f t h e toes. T h e o p e r a t i o n w h i c h I c a r r y o u t c o ns is ts o f m a k i n g inci sio ns o v e r t h e d o r s a l a s p e c t o f t h e to es , ac ro ss th e m e t a t a r s o - p h a l a n g e a l j o i n t s , di vi di ng t h e i n se rti on o f t h e L o n g E x t e n s o r t e n d o n s fr o m t h e p h a l a n g e s a n d f re e in g t h e t e n d o n s ba ck t o t h e reg ion o f t h e m e t a t a r s a l neck s. A h o le is t h e n drilled t h r o u g h t h e nec k o f ea ch m e t a t a r s a l , t h e t e n d o n is pa ss ed t h r o u g h t h e h ol e a n d s u t u r e d to itself, t h e foo t being k e p t at a right a n g l e a n d t h e t e n d o n be in g pu ll ed t h r o u g h t h e h o l e u n d e r te n s io n . T h e i n t e r p h a l a n g e a l j o i n t s ar e a r t h r o d e s e d by excis ion o f t h e ca r t i l ag e a n d fixing t he p h a l a n g e s wi th s h o r t len g t h s o f K i r s c h n e r wi re. T h e f oo t is p la ce d in a p a d d e d P l as t er o f P ar is cast w h ic h is m a i n t a i n e d for a b o u t a m o n t h , w h e n th e wir es a r e r e m o v e d f r o m t h e toes. P h y s i o t h e r a p y is t h e n i n s t it u te d . T h e L o n g E x te n s o r t e n d o n s act as a slin g w hi ch pull u p t h e m e t a t a r s a l s , r e ­ c r e a t i n g a t r a n s v e r s e ar ch. D ropped Foot. In a d r o p f oo t d e f o r m i t y d u e t o p ar al y sis o f t h e T ib ia li s A n t e r i o r , if t h e T ib i al i s P o s t e r i o r is p o w e r fu l , I t r a n s p o s e the t h e i n s e rt i o n o f this muscle. 1 d o so by first m a k i n g a n incision o v e r its i n s e rt i o n i n t o t he n av i c u l a r a n d free it with spe cia l t e n d o n s t r i p p e r s a s far as t h e m ed ia l m al le ol us . I t h e n m a k e a s e c o n d incision o v e r t h e a n t e r i o r su r f a c e o f t h e l o w e r t h i r d o f t h e lo w er leg a n d w o r k m y w a y b e tw ee n t h e tib ia a n d fibu la till I re ach t h e i n t e r o s s e o u s m e m b r a n e w h ic h I incise. T h e t e n d o n o f t h e T ib i al i s P o s t e r i o r , wh ich a s y o u r e m e m b e r lies in t he p o s t e r i o r c o m p a r t m e n t o f t h e leg, is f o u n d a n d t h e n b r o u g h t t h r o u g h t h e o p e n i n g in t he i n t e r o s s e o u s m e m b r a n e to t h e a n t e r i o r c o m p a r t m e n t o f t he leg. A t h i r d incision is t h e n m a d e o n t h e d o r s u m o f t h e foot t o w a r d s it's m e d i a l a s p e c t a n d t h e s h e a t h o f t h e t e n d o n o f t h e T ib ia li s A n t e r i o r is o p e n e d . U s in g t e n d o n t r a n s p l a n t ­ a t i o n force ps, 1 insert this in to t h e s h e a t h o f t h e Tibi ali s A n t e r i o r till it e m e r g e s at th e se c o n d incision. T h e en d o f th e t e n d o n o f t h e T ibialis P o st e r i o r is n o w g r a s p e d a n d d r a w n d o w n t h r o u g h t h e s h e a t h , e m e r g i n g at t h e d o r s u m o f t he foot. A ho le is m a d e t h r o u g h o n e o f t h e b o n e s in t h e a r e a an d th e t e n d o n is n o w p a s s e d t h r o u g h thi s a n d s u t u r e d b a c k on itself wi th t h e f o o t in dor si- fle xi on a n d slight i nv er sio n. A R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page Six P H Y S I O T H E R A P Y December, 1957. p l a s te r ca s t is a p p l i e d t o t h e f oo t a n d l o w e r leg a n d m a i n ­ t a i n e d f o r a b o u t a m o n t h . A t t h e e n d o f this p e r i o d , t h e p a t i e n t is re fe rr ed b ac k t o t h e P h y s i o t h e r a p i s t fo r r e - e d u c a t i o n o f t h e t r a n s p l a n t . In ad d i t i o n t o exer cis e, F a r a d i c s t i m u l a t i o n is o ft en n ec es sa ry. If t h e t r a n s p l a n t is o f n o r m a l s t r e n g t h o r n e a r n o r m a l , t h e p a t i e n t is fully a b l e t o dorsi fl ex t h e f o o t a n d a ls o t o in vert it. P aralysed Quadriceps. A n o p e r a t i o n w hi ch o f t e n p r ov es m o st useful is t r a n s ­ p l a n t a t i o n o f o n e o f t h e H a m s t r i n g s in to t h e Q u a d r i c e p s , w h e n t h a t m us c le is p a r a l y s e d , in o r d e r t o give i ncr eas ed sta bi li ty t o t h e kn ee. If t h e H a m s t r i n g s a r e well d e v e l o p e d , utilising o n ly t h e Biceps F e m o r i s is e n o u g h . If b o t h t h e S e m i - t e n d o n o s u s a n d t h e Biceps a r e ut ilised a n d t h e G a s - t r o c n e m i i a r e n o t well d e v e l o p e d , g e n u r e c u r v a t u m will arise. Paralysed Biceps. Lastly, a n e x a m p l e in t h e a r m . W h e n t h e Biceps is p a r a ­ lysed a n d t h e p a t i e n t h as well d e v e l o p e d wrist a n d finger flexors, S t e i n d l e r ' s o p e r a t i o n is m o s t useful. T h i s c on s is ts in t r a n s f e r r i n g t h e o r i g in o f t h e F l e x o r s o f t h e wrist a n d fingers t o g e t h e r w i t h a sm all flake o f b o n e t o t h e u p p e r p o r t i o n o f t h e s u p r a - c o n d y l a r ridg e a n d fixing t h e f r a g m e n t o f b o n e t o t h e h u m e r u s . T h e F l e x o r s n o w ar ise a b o v e t h e elb ow j o i n t a n d p a s s in f r o n t o f it. H e n c e t h e y m u s t flex t h e jo in t. T e n o to m ie s ar.d F a sc io to m y . T e n o t o m i e s a n d f a s c i o t o m y a r e f re q u e n tl y c a r r ie d o u t in c o n j u n c t i o n wi th o t h e r o p e r a t i o n s . E x a m p le 1: In p e s ca v u s , S t e i n d l e r ' s o p e r a t i o n o f st r i p p i n g t h e p l a n t a r s t r u c t u r e s o f f th e os calcis is o f t e n d o n e in c o m ­ b i n a t i o n w i t h a w e d g e t a r s e c t o m y . E x a m p l e 2 : I h a v e a l r e a d y re fe rr ed t o c o n t r a c t u r e o f the Ilio-tibial b a n d a n d t he G l u t e i w h ic h will give rise t o flexion a n d a b d u c t i o n d e f o r m i t y o f t h e hip. A n ex cel len t m e t h o d o f c o r r e c t i n g thi s d e f o r m i t y is by c a r r y i n g o u t S o u lie r's F asciotom y. T h i s c o n s i st s o f m a k i n g a n incis ion a l o n g t h e a n t e r i o r p o r t i o n o f t h e cre st o f t h e I liu m , d iv id in g th e S a r t o r i u s at it ’s i ns e rti o n a n d s t r i p p i n g o f f all t h e A b d u c t o r s fr o m t h e cre st o f t h e I liu m , w o r k i n g o n e ’s w a y d o w n t o t h e R e c t u s F e m o r i s a n d if ne ce s sa ry , even o p e n i n g i n t o th e c a p s u l e o f th e hi p j o i n t itself. T o c o m p l e t e t h e p r o c e d u r e a n d t o p r e v e n t t h e p r o m i n a n c e o f t h e Iliac b o n e , t h e cre st o f th e Ilium itself is f re q u e n tl y ex er cis ed . 1 t h e n m a k e use o f the D a m e A gnes HunI m e thod o f c o r r e c t in g flexion d e f o rm i t y , by a p p l y i n g a P l as t er o f P ar is sp ic a to t h e o p p o s i t e leg, t h e hi p o n this side be i n g flexed wi th a vi ew t o fla tte n in g t he l u m b a r spine . T h e o p e r a t e d h i p is t h e n pl a c e d in a T h o m a s sp li nt w h ic h is g r a d u a l l y lo w er ed , until all t h e ti ssues in t h e f r o n t o f t h e hip a r e t h o r o u g h l y st r e t c h e d w h e n t h e pl as te r spica is r e m o v e d f r o m t h e o p p o s i t e leg. W e c a r r y o u t l ar ge n u m b e r s o f th es e o p e r a t i o n s ever y ye ar o n t h e B a n tu a n d c o n v e r t m a n y o f th e s e p a t i e n t s in to useful a n d ere ct ci t i ze n s w h e r e b e f o r e th ey w er e e i t h e r b e d - ri d d e n o r c r a w l e d a b o u t t h e i r kias o n h a n d s a n d knees. (See p h o t o g r a p h s ) . S ta b ilis a tio n o f J o in ts . T h e p u r p o s e o f f oo t sta b il i s at i o n in Poli om yel iti s is to c a u s e a r e d u c t i o n in t h e n u m b e r o f j o i n t s w hi ch w e a k o r p a r a l y s e d m u s t c o n t r o l . T h e o p e r a t i o n o f f oo t sta bi li sa ti o n s h o u l d no t be u n d e r t a k e n b e f o r e t h e ag e o f 10 as t he tarsal b o n e s co n s i st ch i e f l y o f c a r t i l a g e a n d t h e r e is relatively little c a n c e ll o u s b o n e t o e n s u r e fu sio n . F u r t h e r m o r e , g r o w t h d i s t u r b a n c e m a y o c c u r if t h e o p e r a t i o n is u n d e r t a k e n at to o ea r l y a n age. T h e r e a r e dif fer ent t y p e s o f f o ot sta bi li si ng o p e r a t i o n s d e p e n d i n g u p o n t h e m us cle b a l a n c e o f th e a n k l e a n d t h e foot. R yerson's Triple Arthrodesis. F o r i ns ta n c e, if t h e d o r si f le x o rs a n d p l a n t a r fl e x o r s ar e e q u a l l y d e v e l o p e d a n d t h e r e is l at er al instabi li ty d u e to para ly sis o f t h e in v e r t o r s a n d e v e r t o rs , R yerson's Triple A rthrodesis is d o n e . T h i s c o n s i st s in e r a s i n g t h e a r t i c u l a r c a r t i l a g e b e t w e e n t h e t a l u s a n d os calcis, b e t w e e n t h e talus a n d n a vi cu la r a n d b e t w e e n t h e os calcis a n d c u b o i d . D unn's Arthrodesis. If, ho w e v e r , t h e c a l f is w ea k , it is b e t t e r t o c a r r y ou t D unn's A rthrodesis w hi ch co n s is ts in r e m o v a l o f t h e sc a p h o i d b o n e itself p e r m i t t i n g t h e ta lu s a n d h en ce t h e a n k l e j o i n t to be b r o u g h t n e a r e r t o t h e c e n t r e o f t h e foot. T h i s p r o c e d u r e a l l o w s a rela tive l e n g t h e n i n g o f t h e p o s t e r i o r lever a r m of th e foo t a n d h e n c e t h e w e a k e n e d c a l f m us c le pu t t o a g r e a t e r m e c h a n i c a l a d v a n t a g e . A sa tis fa ct o ril y s t a bi li s ed f o o t s h o u l d l o ok n a t u r a l in sh o e s, s h o u l d n o t i nve rt o r ev er t o n w a l k i n g a n d a b r a c e to c o n t r o l t h e foo t s h o u l d n o t b e neces sa ry. Arthrodesis o f Knee. If a k n e e is flail a n d n o m u s c le s a r e a v a i l a b l e fo r t e n d o r t r a n s f e r e n c e , e i t h e r a c a l i p e r o r a n a r t h r o d e s i s o f t he kn ee j o i n t is i n d ic at ed . In c h i l d r e n it is a l w a y s bes t t o use a cal ip er , at a n y ra te, unt il t h e y h a v e r e a c h e d a fairly m a t u r e age . In t h e a d u l t B a n tu , espe cia ll y t h o s e w h o live in t h e ' . B u n d u , " a r t h r o d e s i s is o f t e n a wise p r o c e d u r e , for, if t h e p a t i e n t isf given a c al ip er , he f re q u e n tl y d o c s no t w e a r it, or , it is a l w a y s " b r e a k i n g d o w n . T h e o p e r a t i o n w hi ch I n o w us e es clusively c o n s i s t s in ex cis in g t h e a r t i c u l a r c a r t i l a g e a n d e x p o s i n g t h e c a n c e ll o u s b o n e . If t h e r e is a d e f o r m i t y o f t h e k n ee , e n o u g h b o n e is r e m o v e d t o c o r r e c t this a n d o n o cc as i o n s, a l e n g t h e n i n g o f t h e H a m s t r i n g t e n d o n is a ls o d o n e . T h e k n e e is pu t up in a b o u t 15 d e g r e e s o f flexion a n d a C h a r n l e y - K e y sp li nt is utilised. T h i s c o n s i st s o f t h e i n t r o d u c t i o n o f S t e i n m a n Pin s t h r o u g h t h e f e m u r a n d t h e ti bi a, t h e e n d s o f t h e Pin s f F ig. I l l W ilso n B ingiw e— P o lio W a lk s on a ll fo u rs. G ro ss d e fo rm itie s o f b o th hips— B e fo re T re a tm e n t. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) December, 1957. ___________ P H Y S I O T H E R A P Y ____________ Page Seven bein g a t t a c h e d by te le s co p ic t u b e s w h ic h o n ti g h t en i n g t h e r a w o p p o s i n g su r f a c e s o f t h e b o n e s ca us es c o m p r e s s i o n a n d , t h e r e fo r e , m o r e r a p i d un i o n . A l t h o u g h we r e m o v e t h e splint jn a m o n t h a n d k e e p t h e p a t i e n t in p l a s te r u p to t h r e e m o n t h s , it h as be en s h o w n t h a t m a n y o f th e s e k n e e s a r e clinically solid at t h e e n d o f a m o n t h . Stabilisation o f Hip. In th e case o f t h e flail hip w hi ch is n o t spl in ted a n d in whi ch fa ul ty p o s t u r e s a r e a l l o w e d t o d ev el o p , t h e leg m ay c o m e i n t o m a r k e d a d d u c t i o n a n d wi th t h e st r e t c h i n g o f th e j o in t c a p s u l e a n d s u r r o u n d i n g musc les, a p a t h o l o g i c a l p o s ­ te r io r d i s l o c a ti o n o f th e hi p oc cu rs. A n exce llent way o f giving sta bi li ty t o t h e hi p is t o ca r r y o u t a s u b - t r o c h a n t e r i c o s t e o t o m y o f t h e f e m u r, t h e di sl o ca ti o n first bein g r ed uc ed by a b d u c t i o n o f t h e leg. T h e sh a ft o f t h e f e m u r is then b r o u g h t d o w n t o t h e n e u t r a l p o s it io n a n d t h e t w o fr a g m e n t s , t he u p p e r still b e i n g held in a n a b d u c t e d po si ti on , a r e then fixed b y a m et al p lat e. A P l as t er o f Paris spica is ap p l i e d until u n i o n is c o m p l e t e . Scoliosis. I h av e a l r e a d y re fe rr e d t o t h e tilt o f t h e pelvis o cc a s i o n e d by c o n t r a c t u r e o f t h e llio-t ib ial b a n d a n d h o w f r eq ue n tl y S o u lie r's f a s c i o t o m y will c o r r e c t this. If t h e scoliosis per sis ts in sp it e o f thi s m e a s u r e , it will b e f r eq ue n tl y fo u n d t o d i s a p p e a r w h e n t h e leg is a b d u c t e d . T h e m e t h o d t h a t we a d o p t to c o r r e c t t h e scoliosis is t o first sc re e n t h e t r u n k a n d hips in t h e X - r a y D e p a r t m e n t t o as c e r ta in t h e d eg r ee o f a b d u c t i o n o f t h e hip t h a t is ne ce ss a ry to co r re c t t h e scoliosis. H a v i n g a s c e r t a i n e d t h e a n g l e o f a b d u c t i o n o f t he hip ne ce ss a ry t o c o r re s t t h e scoliosis, a s u b - t r o c h a n t e r i c o s t e o t o m y is c a r r i e d o u t , a w e d g e o f b o n e being r e m o v e d fr o m t h e m ed ia l a s p e c t o f th e f e m u r e q u a l to t h e d e g r e e o f a b d u c t i o n o f t h e hip. T h e f r a g m e n t s a r e t h e n p la te d in thi s po sit io n. E xce ll ent re sul ts h a v e b ee n o b t a i n e d by this m ea s u re . Arthrodesis o f Shoulder. In a flail s h o u l d e r , a r t h r o d e s i s is u n d e r t a k e n p r o v i d e d th e T r a p e z i u s is n o t p a r a l y se d . O n e o f th e f u n c t i o n s o f th e T r a p e z i u s is t o c a u s e r o t a t i o n o f t h e sc a p u l a a n d he n ce , if t h er e is b o n y f u si o n be t w e e n t h e h u m e r u s a n d t h e s c a p u l a , active c o n t r a c t i o n o f t h e T r a p e z i u s will al l o w a b d u c t i o n o f t h e a r m to o cc u r . If, in a d d i t i o n t o t h e flail s h o u l d e r , th e Biceps is n o t s t r o n g e n o u g h t o flex t h e f o r e a r m a ga in s t gravity, w h e n a r t h r o d e s i s is c a r r ie d o u t , t h e a r m s h o u l d b e p u t u p in a few d e g r e e s o f i n t e r n a l r o t a t i o n , so t h a t w h e n it is a b d u c t e d , g r av it y will assist t h e Biceps in flexing th e e l b o w a n d p e r m i t t h e h a n d t o be p l a c e d o p p o s i t e t h e m o u t h . If t h e Biceps is c o m p l e t e l y p a r a l y s e d a n d t h e F l e x o r s o f t h e wrist a n d fingers a r e p ow er fu ll y d e v e l o p e d , t h e y c a n b e s h i f t e d pr o x i m a ll y as in S t e i n d l e r ' s O p e r a t i o n t o pa s s in f r o n t o f t h e e l b o w a n d t h u s flex it. A n a l t e r n a t i v e p r o c e d u r e is to utilise t h e s te rn al fibres o f t h e P e c t o r a l i s M a j o r w hi ch a r e t r a n s p l a n t e d in to t h e Biceps itself. If o n e is u n a b l e to m a k e use o f t h e P e c t o r a l i s M a j o r a n d t he F l e x o r s o f t h e f o e r a r m a r e no t c o n s i d e r e d t o b e suffi­ ciently s t r o n g e n o u g h to flex t h e el b o w , c o n s i d e r a t i o n c a n be given to t h e in g e n i o u s o p e r a t i o n de vi se d by Bunnell w h e r e b y t h e s t e r n o - m a s t o i d is t r a n s f e r r e d in to t h e Biceps. T he m u s c le is d e t a c h e d fr o m t h e s t e r n u m a n d t h e clavicle a n d e l o n g a t e d , by s u t u r i n g a s t r i p o f fascia lat a t o it, so t h a t it c a n be m a d e t o pas s via a s u b c u t a n e o u s t u n n e l t o t h e t e n d o n o f t h e Biceps in t h e re gi on o f t h e el b o w . By r o t a t i o n o f t h e h e a d a n d n ec k t h e f o r e a r m ca n be flexed. I h a v e a ls o u n d e r t a k e n o n e su ch o p e r a t i o n , bu t a l t h o u g h t h e n e w t e n d o n c o u l d be d e f i n a t e l y felt a n d se en t o c o n t r a c t , I d i d no t p l a c e e n o u g h t e n s i o n o n t h e s t e r n o m a s t o i d itself t o e n a b l e it t o flex t h e e l b o w j o i n t . T h e pa t i en t , a C o l o u r e d a d u l t , r e f u s e d t o let m e r e - o p e r a t e e x c l a i m i n g : — “ W a t sal dit he lp , D o k t o r , as ek m y k o p d r a a i o m m y e l m b o o g te laat buig. Ek sal nie ’n s ta at we es o m te s ie n w at ek d o e n n i e. ” Fig. IV W ilso n B ingiw e— A fte r T re a tm e n t. A rthrodesis o f Elbow an d Wrist. In st ab i l i t y o f t h e e l b o w a n d wrist a r e bes t dea lt wit h by a r t h r o d e s i s if n o t e n d o n s a r e a v a i l a b l e fo r t r a n s p l a n t . T h e e l b o w s h o u l d be pu t u p at a b o u t 120 d e g r e e s a n d t h e wrist in a b o u t 10 d e g r e e s o f dor sif lex io n. T h e s e a r e t h e po si t i o n s for o p t i m u m f u n c t i o n . L eg L en g th e n in g a n d L eg S h o rte n in g , If t h e r e is m o r e t h a n 2 in che s o f s h o r t e n i n g in a d o l e s c e n c e o r y o u n g a d u l t s, c o n s i d e r a t i o n m a y be giv en to leg l en gh t- e n in g, b u t it s h o u l d be p o i n t e d o u t t h a t t h e o p e r a t i o n m a y be a f o r m i d a b l e p r o c e d u r e , espec ial ly if t h e f e m u r is b ei n g l e n g t h e n e d a n d a w h o l e series o f c o m p l i c a t i o n s h a v e t o be c o n s i d e r e d . 1. D e f o r m i t i e s o f t h e fo o t , su c h as, va lg us a n d e q u i n u s m a y ar ise . T h e s e a r e d u e t o fa il ure o f t h e soft p a r t s to l e n g t h e n p r o p o r t i o n a t e l y t o t h e bo ne s . 2. D e f o r m i t i e s o f t h e k n e e — g en u v a l g u m a n d flexion c o n t r a c t u r e . 3. Stiffness o f t h e a n k l e d u e t o t h e t r e m e n d o u s pr es s ur e o n t h e a r t i c u l a r s u r f a c e s c a u s i n g t r a u m a t i c a r th ri ti s. 4. B o w i n g o f f r a g m e n t s wi th m a l - u n i o n o r n o n - u n i o n . R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page Eight P H Y S I O T H E R A P Y December, 1957. 5. N e r v e c o m p lic a tio n s , s u c h a s, p a ra ly s is o f m u sc le s o r lo ss o f s e n s a tio n d u e t o o v e r -s tre tc h in g o f t h e n e rv e s. 6. D is tu r b a n c e s o f c ir c u la tio n c a u s in g o e d e m a o r e v e n , o c c a s io n a lly , g a n g r e n e o f a p a r t o f a lim b . 7. B o n e I n fe c tio n . M a n y su r g e o n s , t h e r e fo r e , p r e fe r to s h o r t e n t h e le g b y r e -s e c tio n o f b o n e o r b y e p ip h y s e a l a rre s t. I n C a p e T o w n , B e ll h a s e v o lv e d a n in te r e s tin g o p e r a tio n f o r e q u a lis a tio n o f le g le n g th s . H e o p e r a te s o n b o th fe m o ra , o s te o to m is in g t h e s h o r te n e d b o n e a n d r e m o v in g a c o m p le te se c tio n o f t h e o p p o s i t e f e m u r r o u g h ly e q u a l t o t h e a m o u n t o f s h o r te n in g in t h e o t h e r leg . T h is s e g m e n t o f b o n e is le ft in s itu u n d e r t h e m u sc le s, w h ile t h e m a in f ra g m e n ts a r e h e ld t o g e t h e r b y a K u n t s c h e r N a il u n til th e y h a v e u n ite d . I n t h e in te r im , tr a c tio n is a p p lie d to t h e o s te o to m is e d a n d s h o r te n e d lim b , b y s k e le ta l t r a c tio n . W h e n t h e f ra g m e n ts a r e d is tr a c te d to t h e r e q u ire d a m o u n t, t h e p a t i e n t is r e ­ s u b je c te d to su r g e r y , t h e se c tio n o f t h e b o n e in th e o p p o s ite le g is re m o v e d a n d tr a n s f e r r e d t o fill t h e g a p b e tw e e n th e d i s tr a c te d f ra g m e n ts o f t h e e ffe c te d fe m u r. T h e th r e e f ra g m e n ts a r e n o w h e ld in p o s itio n , by t h e in s e rtio n o f a K u n ts c h e r N a il. I h a v e n o t u n d e r t a k e n o n e o f th e s e o p e r ­ a tio n s m y se lf, b u t h a v e s e e n t h e e n d r e s u lts o f t h r e e o f B e ll’s c a s e s a n d h a v e b e e n m o s t im p re s s e d b y th is in g e n io u s m e th o d o f e q u a lis in g t h e le g le n g th s . N o a t t e m p t s h o u ld b e m a d e t o le n g th e n a lim b i f t h e d is c re p e n c y in le g l e n g th is s u c h t h a t it is k n o w n in a d v a n c e t h a t e v e n a f t e r t h e p r o c e d u r e is c o m p le te , t h e r e w ill still b e so m u c h d is p a r ity t h a t a n a p p lia n c e w ill n e v e r-th e -le s s b e n e c e s s a ry . S h o r te n in g a n o r m a l lim b b y re s e c tio n o r e p y p h y s e a l a r r e s t, h o w e v e r , m u s t n o t b e lig h tly u n d e r t a k e n f o r, in s p ite o f e v e ry c a re , th e r e is still t h e e v e r p r e s e n t risk o f in fe c tio n o f b o n e a n d i f th is s h o u ld in su e , t h e e n d re s u lts m ig h t w ell b e d is a s te r o u s . I f e p ip h y s e a l s ta p lin g is u n d e r t a k e n in a c h ild w h o is u n a b l e to m a k e a d e c is io n f o r h im se lf, t h e p r o b le m s h o u ld b e th o r o u g h ly d is c u sse d w ith t h e p a r e n t s a n d th e p r o s a n d c o n s o f l e n g th e n in g a s o p p o s e d to s h o r te n in g m u st b e ra is e d a n d t h e p o te n tia l c o m p lic a tio n s p o in te d o u t. Osteotomies o f Bone. O s te o to m ie s o f b o n e f o r t h e c o r r e c tio n o f d e f o rm ity a re f re q u e n tly u n d e r t a k e n . I h a v e a lr e a d y m e n tio n e d o n e o r tw o e x a m p le s . S u p r a - c o n d y la r o s te o to m y o f t h e f e m u r f o r g e n u v a lg u m a n d w e d g e ta r s e c to m y f o r c a v u s , v a r u s a n d v a lg u s d e f o rm itie s o f t h e f o o t a r e f r e q u e n tly u n d e r ta k e n . T h e s e o p e r a t i o n s a r e u su a lly e x tr e m e ly su c c e ssfu l. Conclusion. I h a v e s p o k e n f o r lo n g e n o u g h a n d in m y t a l k h a v e o n ly m e n tio n e d a few o f t h e m a n y te c h n ic a l p r o c e d u r e s u n d e r ta k e n t o c o r r e c t d e f o rm itie s w h ic h h a v e a ris e n a n d t o im p ro v e th e f u n c tio n o f a lim b . T h e s u b je c t is t o o v a s t a n d I h a v e o n ly s k im m e d t h r o u g h s o m e o f t h e p r o b le m s a s e n c o u n te r e d in t h e e x tr e m itie s , h a v in g la rg e ly ig n o r e d t h e v a r ie d a n d h ig h ly c o m p lic a te d p r o b le m s m e t w ith in t h e t r u n k — p ro b le m s , s u c h a s, sc o lio s is. N o r h a v e I d e a lt w ith t h e p r o c e d u r e s f o r t h e h a n d s . T h e p u r p o s e o f t h e p a p e r , h o w e v e r, is to sh o w w h a t c a n b e d o n e b y s u rg ic a l r e - c o n s tr u c tio n , f o r th o se p a t i e n t s w h o a r e se v e rly d is a b le d b y P o lio m y e litis . By r e s tr ic tin g h is w o r k e n tir e ly t o t h e h a n d lin g o f P o lio m y e litis p a tie n ts , a n O r t h o p a e d i c S u rg e o n c a n g a in su ffic ie n t e x ­ p e r ie n c e in a lm o s t all t h e s u rg ic a l p r o c e d u r e s d e a l t w ith in t h e w h o le field o f O r th o p a e d ic s . T r e a t m e n t is u s u a lly p r o lo n g e d , tim e -c o n s u m im g a n d e x a c tin g , b u t w h a t g r e a t e r re w a r d c a n a m a n h a v e t h a n w h e n a c h ild w h o h a s b e e n u n d e r h is c a r e f o r m o n th s o r y e a r s a n d w h o h a s b e e n s u b je c te d t o m a n y o p e r a tio n s , s tr e tc h e s o u t h is h a n d to t h e s u r g e o n a n d sa y s, “ D o c to r , y o u h a v e m a d e m e w a lk .” P hotographs lent b y k in d perm ission o f " T h e E a st London Cam era S h o p .” ADVERTISING SPACE AVAILABLE A p p ly : Hon. Treasurer: Mrs. M. Levy, 105, Acacia Road, Blackheath - Johannesburg. \ R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )