Orthopaedic Surgery

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ORTHOPAEDIC SURGERY. - The branch of surgery known as Orthopaedic (Gr. c5pOos, straight, and rrais, child) has long out grown its etymological meaning. It now deals with the adult as well as the child. Until comparatively recently it embraced only congenital deformities of children, lateral curvature, acquired deformities of the feet, deformities due to rickets and infantile paralysis, and to certain types of ankylosis. More recently it has included tubercular and other infective diseases of joints, both in children and in adults. The experiences of the World War of 1914-8 considerably broadened its definition, and revealed the fact that the teaching of orthopaedic surgery had been very deficient - more particularly in the treatment of injuries of the extremities. Visits to command depots and certain military hospitals convinced the British authorities of the necessity of starting a series of large hospitals all over the British Isles; these were first called " orthopaedic centres " and later " special military surgical centres." They were situated in London, Liverpool, Manchester, Leeds, Newcastle, Oxford, Reading, Cardiff, Bristol, Bath, Edinburgh, Glasgow, Aberdeen, Dublin and Belfast. These hospitals were staffed by men trained in orthopaedic surgery, by general surgeons and neurologists, and were equipped with every modern facility for the practice of reconstructive surgery, including physiotherapy departments, gymnasia and vocational curative workshops. The group of cases treated at the orthopaedic centres consisted of: - fractures (recent, malunited and ununited); paralyses due to injury of the peripheral nerves; paralyses due to injuries of the central nervous system; diseases, derangements and disabilities of joints, including the spine; deformities due to the contractions of scars and to injuries of muscles; functional diseases requiring reeducation. Later, limbfitting centres were attached to several of these hospitals.

The wisdom of creating these centres was soon apparent. Derelicts poured in from all parts of the country, and soldiers who had been discharged with deformity were readmitted for treatment. The value of segregating cases in masses under surgeons specially trained for the work was clearly demonstrated. The experiment started in Liverpool with 250 beds, and the expansion was so rapid that in less than 12 months 21,000 beds were under orthopaedic control.

After the war there was a movement in all parts of Great Britain to improve the training in orthopaedic surgery, and to increase in scope and number the special departments attached to universities and medical schools, and to simplify and make more thorough the treatment of fractures. The fact that 50% o of the wounded in the war of 1914-8 received injuries resulting in impairment of locomotor function and usefulness of limbs, brought the importance of orthopaedic principles and methods of treatment into great prominence.

Orthopaedic surgery may now be said to include: - (a) Congenital and acquired deformities of the spine and extremities; (b) infantile paralysis after the acute stage; (c) the deformities of adult paralysis; (d) stiff and ankylosed joints; (e) torticollis (" wry-neck "); (f) diseases of joints and disabilities, such as rupture of crucial ligaments, injuries to semilunar cartilage, snapping hip, slipping patella, and those conditions which are included under the aggressive title of " bonesetting." The war enabled surgeons to formulate conclusions based on the observation of large groups of cases, and to obtain information likely to be of great value when dealing with industrial cases. The suture of divided peripheral nerves will serve as an example. In pre-war days, an experienced surgeon in the course of a life-time rarely saw more than 20 cases. During the war many surgeons sutured over 500 nerves, and the successful issue was due largely to the experiences gained by orthopaedic surgeons in the treatment of the paralysis of infants. From the nature of the injuries and the prolonged suppuration that followed, operation often had to be postponed for many months, and only after the removal of all cicatricial tissue was it safe to operate owing to what is called latent sepsis. Germs which remained quiescent, when disturbed by the knife assumed activity - often of a very virulent type. In other cases, muscle had to be freed and developed, and diseased areas of bone drastically extirpated before a nerve could be sutured. These operations required great delicacy and judgment. It was found by experience that in most cases it was possible to bring the nerve-ends together even after the destruction of a considerable area. This was sometimes effected by posturing the joints in order to lessen tension. In other cases the nerves were transposed from their bed and made to take a shorter course. In other instances the operation was done in stages in order gradually to stretch the nerve. Many methods which were formerly used to protect the injured nerve from injury during healing by adhesions were discarded in favour of surrounding the sutured ends by living tissue. Nerve grafting - i.e. utilizing a portion of a cutaneous nerve to bridge the gap in a motor nerve, proved a failure. Equally abortive were all attempts at grafting foreign material, nerve anastomosis, and the turning down of flaps. The great lesson learnt was that end-to-end suture is the only method to adopt in the immediate future.

A very remarkable adaptation of orthopaedic experience to injuries of the war was the transplantation of tendons in conditions of irreparable injury to the nerve. This was most useful in the cases where the musculospiral nerve was so destroyed as to render suture impossible. As a result of this injury the function of the hand was greatly impaired. The musculospiral nerve governs the motion of all the muscles which extend the wrist and the fingers. Destruction of the nerve paralysed all the muscles, and the victim, if he wished to extend the wrist and fingers, had to do it by using the other hand. Orthopaedic surgeons had been accustomed for many years to utilize any spare active muscles, in cases of infantile paralysis, in order to take the place and assume the action of the muscles which were paralysed. For instance, a muscle group whose function was to evert the foot (peronei), if found paralysed, would be replaced by one of the invertors of the foot (tibialis anticus). This muscle would be dissected from its insertion halfway to its origin, and taken from the inner side of the foot and planted into the bone on the outer side. The child would then be trained to use the muscle so that when it acted it would assume the function of the paralysed muscle. This principle was adopted on a very large scale in all the orthopaedic centres to supply a remedy for the paralysed extensors of the wrist and hand. Certain muscles would be taken from the front of the forearm, one of which would be attached to the paralysed thumb, another to the extensors of the wrist, and another to the various extensors of the fingers. In this way, some hundreds of cases experienced a complete restoration of the function of the hand.

The influence of physiology or psychology as it affects the transplanted muscle deserves comment. It is very difficult to explain how a muscle which has always acted as an invertor should respond to a command to evert. After a little education, however, the will becomes the master of the situation, and the transplanted tendons display an admirable functional adaptation. A few soldiers suffered from the destruction of the obdurator nerve with a resulting paralysis of the quadriceps - a muscle whose function it is to extend the leg. In order to regain that function, two of the muscles from behind the knee are brought to the front of the thigh and fastened into the kneecap to replace the quadriceps. In this way again, muscles, which normally bend the knee, take up a new action and straighten it.

Another orthopaedic principle derived from the treatment of infantile paralysis and utilized for war injuries is known as tendon fixation. An example can be given by an irreparable injury of the sciatic nerve. All the muscles below the knee are paralysed. There are therefore none that can be transplanted, and the foot remains flail. In such cases, the paralysed tendons are utilized to sling the foot to the bones of the lower leg. Certain tendons in front of the foot are cut below their origin and fixed in a tunnel bored into the bone, while the tendo Achillis at the back is treated in a similar manner. The foot is thus slung into a good carrying position, and cumbersome braces discarded.

The history of damaged joints is hardly less interesting. The wounds of the tear were often so extensive that joints were not only destroyed but large pieces of bone were carried awa y, so that the arm or leg dangled in flail fashion. As an example, the case of the shoulder will serve to illustrate our procedure in dealing with other joints. The arm lies limp at the side - there is no power to lift, laterally deflect or rotate it. Experience in treating infantile paralysis in children has supplied an idea by which the limb can be made useful. The procedure is known as arthrodesis. Although the arm cannot move, the shoulder-blade can. The surgeon attaches the bone of the arm (humerus) to the shoulder-blade and allows both bones to become united. The arm is fixed in the most useful position in relation to the shoulder-blade; the muscles which hitherto only moved the shoulder-blade will now move the arm also. By this device the patient is able to feed himself, lift his arm from his side, put his hand in his pocket and perform many useful functions.

Again, the orthopaedic surgeon may have to deal with a stiff or ankylosed joint. In the case of the hip, shoulder or elbow, there are at his command methods to mobilize them by forming new joints. The hip-joint will serve as an example. The destroyed joint is cut down upon, the socket reconstructed, the head of the thigh-bone reshaped, and soft muscular and fascial tissue utilized as a buffer between the bones in order to imitate nature. The war has brought about the perfection of such methods, enabling flail joints to be stiffened, and mobilizing those which are ankylosed.

Bone grafting has been much simplified, and has been largely used in the surgery of the jaws and in ununited fractures of every kind. Gaps of four and five inches have been remedied by this means, and certain technical details have been perfected which have given the transplanted bone greater viability. It has been most useful in fractures below the knee and in the forearm. Cases are on record where the graft has been broken and has united again, as in the case of a simple fracture. Grafts have also lived in the presence of suppuration. The shin-bone (tibia) is the favourite quarry from which the grafted bone is taken. A point of great interest is that the grafted bone often develops until it assumes the thickness and contour of the bone which it supplants.

No branch of surgery has been so much advanced by the war as fractures. Before the war, the treatment of fractures in England was little less than a reproach. Fractures of the femur, unless operated upon, generally displayed a shortening of about two inches. This was largely due to faulty education of the student, and the early evacuation of fractures from hospital wards. There was usually no considered after-treatment. Few surgeons knew the uses of the Thomas splint which, for simplicity and efficacy, surpassed any appliance in any of the armies. There was no effort in the first stage of the war to standardize this splint or to segregate fractures. This resulted in a great mortality, and filled the orthopaedic centres with appalling deformities. Fractures of the femur will serve as an example. In the early phases of the war the mortality from these fractures was 80%. Later, when fractures were segregated at the base and the Thomas splint applied in the firing line, this mortality was reduced to 20%. The standardization of the Thomas splint, the education of men in its use, and its application on the field of battle, secured for the fracture immobilization and simplified treatment; it minimized shock, and it prevented the perforation of vessels by securing the alignment of the broken ends. Its use had to be understood from the field to the base hospitals, for continuity of treatment was imperative. At the base hospital it might be necessary to apply modifications in more leisurely fashion. At a later date these fractures were admitted directly into orthopaedic centres, and, as a result of investigation, it was found that out of several hundreds of cases the average shortening did not exceed half an inch. These results in the British army were incomparably better than those in any of the other armies. The important lessons learnt from these experiences are: The necessity of better training of students, the standardization of the most efficient splints, the segregation of cases under men versed in mechanical principles, and the securing of efficient orthopaedic after-care in order to obtain function.

Further experiences gained in orthopaedic hospitals included the radical treatment of the chronic sinuses leading to diseased bone. Instead of simple procedures to remove dead bone, a very extensive operation was generally performed. All unsound bone, not merely dead bone, was removed, and the edges of the large cavities bevelled down in order that the soft tissues might fill the cavity. This thorough treatment often reduced healing to weeks instead of years. Malunited fractures again formed a large group in the orthopaedic centres. Surgery has now sufficiently advanced that, under favourable conditions, deformity should not occur. The orthopaedic teaching emphasizes the fact that good function is its end and any operation performed should have this as its aim. Aesthetic and other objects are of minor importance. Correct alignment is the most important factor governing success. Unless this be secured erroneous deflection of body weight upon the joints above and below the fracture results.

A meticulous end-to-end union with a lateral deviation is not so successful as even a little over-riding accompanied by a good alignment. Many hundreds of fractures which violated this axiom were rebroken and the limb reconstructed. Surgeons were often able to lengthen the limb by five inches or more.

Orthopaedic surgery emphasizes the after-treatment of all these chronic cases. All joints have to be kept mobile, muscle-wasting hindered, reeducation courses attended, and all the modern advantages of physiotherapy utilized.

Artificial Limbs

In the early stage of the war it was found very difficult to keep up any adequate supply of artificial limbs. All the English limb-making firms suffered from the fact that their staffs were at the front. The authorities were so firm that it was impossible to recall them, although the shortage of limbs had become appalling. An exhibition, to which all limb-makers were invited, was held at Roehampton House, and artificial limbs were sent by both English and foreign makers. The Americans, however, were alone prepared to start work with full staffs, so that the bulk of limbs supplied were of the American pattern, and were made in ever-increasing numbers on the hospital grounds.

They were strong and very reliable, and, at that time, they represented all that was best and up-to-date. Later, in 1919, a parliamentary committee was constituted in England to study the question of standardizing limbs in order to lessen the cost and expedite production. After much deliberation they fixed upon certain standardized patterns suited to the more frequent sites of amputation. They were based upon the most reliable features of both the American and English types. They were manufactured in wood and leather with steel joints, and, although on the whole satisfactory, complaints were often made that they were too heavy. In consequence, a standardized leg has been in course of being perfected, which combines lightness with durability, and the weight of which will not be more than four or five pounds. There can be no doubt that artificial limbs for high-up amputations had previously been far too heavy, and the introduction of a light metal or wooden splint will supply a reasonable demand.

It can be said without entering into any technical details that, as an artificial limb has to transmit the weight of the body to the ground, it should be stable, painless, and permit the patient to walk in a natural, easy manner. The weight of the body in certain cases is carried directly on to the artificial limb through the end of the stump (end-bearing). In other cases a portion only of the weight is carried through the end of the stump - the rest of the weight being distributed through other anatomical points (partial end-bearing). Sometimes it is transmitted through the bony points about the joint above the amputation - i.e. round the hip-joint in cases of amputation through the thigh (ischial bearing). The complete end-bearing distribution of weight is the ideal condition, but can only rarely be secured. It is best exemplified in a Symes' amputation which is performed when the front part of the foot is removed and the skin over the heel forms the flap. The skin has to be thick and the end of the bone expanded, otherwise ulceration may result.

While artificial legs have on the whole given very general satisfaction, artificial arms have been very disappointing. The leg is comparatively a simple proposition - it merely has to bear weight and perform the act of walking. The arm, on the contrary, is expected to perform diverse and complex acts. Too many arms have been merely ornamental, and have been discarded early, only to be worn for aesthetic reasons. When the war broke out only very primitive types of arms existed. They consisted of a bucket, a hinge automatically locking elbow and a dummy hand, which could be taken off and replaced by a hook or a ring. Later, certain arms were introduced which displayed great inventive ingenuity. These limbs were worked by certain movements of the body assisted by the stump. In an amputation above the elbow, for instance, the forearm could be fixed and supinated and the fingers opened and closed. They were, however, not a success owing to their weight and complexity, and the movements were not those which could prove useful in daily life. Mechanical arms of various types followed, some of which have proved useful. They are included in the class known as the " worker's arm," and consist of an apparatus where the external shape of the arm is sacrificed to utility. Various tools and other mechanical devices are attached to the end of the arm and, with training, patients are able to do very useful work. It must be admitted, however, that fully two-thirds of the men have discarded their artificial arms. Doubtless, with encouragement and better and more prolonged training, men would obtain much more satisfaction from their artificial limbs.

Temporary limbs have been employed regularly in Great Britain for the lower limbs in order to bring the leg into action at the first available moment to exercise the muscles of the stump, to avoid the evil of crutches and to allow the shrinkage of the stump to take place - an essential preliminary to the final fitting of a bucket. The bucket is usually made of plaster of Paris, moulded very accurately in order that shrinking may take place from pressure. Many excellent fibre temporary or peg legs were made by amateurs and supplied by the Red Cross Society.

The Belgians and French used temporary arms in order to keep the muscles active and the joints mobile from the time the stump healed. Schools were started in order to teach the men their possibilities and limitations. In England, owing to rapid evacuation, very little time was spent in training men to adapt their arms to their own special trades. This is perhaps one of the main reasons of failure.

One of the most interesting developments in connexion with amputations has been the so-called operation of cinematization of amputation stumps. A considerable length of muscle is preserved at the time of the amputation, and the opposing groups are separated and covered with skin. By exercise these rival groups can be trained to retract often two inches, and can thus be utilized to work an artificial hand by direct volition. Experiments are being continued and the prospects are encouraging.

Deformities

The aim of the modern orthopaedic surgeon is to prevent the occurrence of deformity, and to insist upon early treatment. In the case of children there are four groups of cripples. They consist of (a) surgical tuberculosis; (b) rickets; (c) congenital deformities; (d) deformities due to injuries and infections of bone. Rickets and surgical tuberculosis account for nearly 50% of the deformities of children, while congenital deformities and infantile paralysis will account for the remaining cases. In the group of surgical tuberculosis are included spinal caries and diseases of the various joints. Amongst the rickety cases are found knock-knee, bow-legs, spinal deviations, flat-feet, deformities of hip, etc. Amongst the congenital group there are the various types of club-feet, wry-neck and allied affections.

Most of the deformities due to these various conditions may be altogether prevented, and the cases grouped under tuberculosis and rickets should in time be eradicated, given reasonable State facilities. In the prevention of tuberculosis nothing is more important than the provision of milk free from tubercle bacilli. Until the menace of cattle affected with tubercle is removed, one of the chief origins of infection will persist. The etiology of rickets is sufficiently known to merit some organized method of control. Recent investigations with regard to vitamine have served to confirm the belief that it is largely a dietetic disease intensified by insanitary conditions. With a better education of the student as to the origin of deformities, many of the dangers of rickets would be eradicated, such as the evils of superincumbent body-weight as applied to soft bone.

Orthopaedic surgery is largely the surgery of the extremities, and the aim of the surgeon is the removal of disability. He effects this by a scientific application of the lessons to be learnt from anatomy, physiology, pathology and mechanics. In his reconstructive efforts he places the restoration of form as secondary to the restoration of function. (R. Jo.)

Categories: NOS-OYA | Anatomy