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74 American Journal of Surgery Section of Orthopedic Surgery JULY, ,927 I can see cIearIy where in a number of cases of equinus we were somewhat at sea as to what to do, I know now that we shouId have used the bone-bIock operation. In the future I shah be very enthusiastic about it. DR. ROBERT HUMPHRIES: I think I am the onIy one here who has done this bone-bIock operation, and have seen a number of cases foIIowed with very good results. There is no pain and it has heId up the foot very satis- factoriIy for periods of two or three years after I have used it. I have had no such proofs as Dr. CampbeII, but my own observations have been very satisfactory. DR. CAMPBELL (cIosing): I thank you for your IiberaI discussion particuIarIy at this Iate hour. I shaI1 not go into detaiIs because of it, but in answer to Dr. Mayer, I fee1 that in connection with transpIanting of tendons, wherever you use .a tendon to Iift up the foot, you may get very exceIIent resuIts that may be permanent in many cases, but we have seen a number of cases which acted beautifuIIy for one or two years or for quite a whiIe, but ten years Iater, after constantIy bearing weight and being used, the muscIe became stretched, because that is more than any transpIanted muscIe can reaIIy accompIish. The bone-bIock operation forms a permanent bony process with Iimited pIantar Aexion. It is not necessary to have fuI1 pIantar ffexion in this case. In answer to Dr. KIeinberg, in a case of equinus, I Iengthen the hee1 cord where it is tight, and if it is rigid, I do it at the same time as I make the bone-block. I aIways Iengthen where there is the sIightest contracture of tendon. As to caIcaneus I tried the operation in five or six cases and found it an absoIute faiIure. You ask about other deformities of the feet. When- ever I have to dea1 with an equinus, whether vaIgus or varus, I use bone-bIock. If bone is excised from the forefoot it is denuded of cartiIage, and this removed cartiIage is pIaced in mosaic fashion to cover the posterior, inner and outer aspects of the pyramid to prevent adhesion to the surrounding structures. You can puI1 it off with a knife, or you can shave it off. This step, however, is by no means essen- tia1, as resuIts are as good when bone is obtain- ed from eIsewhere free of cartiIage. Regarding the question of pain, shouId pain persist, we couId remove a portion of the new process. I have had to do it in but one case out of the 162 that have been mentioned here. PRESENTATION OF CASES RECURRENT DISLOCATION OF THE PATELLA. OPERATION SAMUEL A. JAHSS, M.D. (By invitation) This gir1, aged sixteen, came to the HospitaI for Joint Diseases in August, 1926. In June, 1926, while running, she feIt something snap in her right knee. She couId not bend her knee aIthough the entire phenomenon was not accom- panied by much pain. She saw that the right knee was much broader than the Ieft, and she aIso noticed something sticking out on the side of the joint (external). She straightened her knee, and this protrusion snapped back into pIace, without manipuIation. This occurred two or three times a week for about eight weeks. (June to August.) She was operated upon August 18, 1926, by the AIbee modification of the Jones operation in which the trochIear surface of the externa1 condyIe was osteotomized and a trianguIar bone graft (from the tibia) was inserted into the space between the fragments of the condyIe in order to raise the trochIear surface and prevent dis- Iocation from taking place. This procedure is recommended in cases where the externa1 con- dyIe is much fIatter than the interna one, a condition present in the congenita1 type of case. AIthough the transposition of part or the whoIe of the Iigamentum pateIIae is advised (A. G. T. Fisher) in cases that are not congeni- ta1 (in which group the present case beIonged), this procedure was not foIIowed because recurrences are reported quite often when the soft structure operation aIone is performed. The resuIt has been most satisfactory. The patient has a norma range of motion and has had no recurrence since the operation, a period of seven months. BILATERAL COXA VARA OF UNKNOWN ORIGIN JOSEPH G. WISHNEK, M.D. (By invitation) N. D., aged seven years, was admitted to the HospitaI for Joint Diseases in May, 1926, on the service of Dr. Leo Mayer. She had been sent there by the schoo1 doctor who, in the routine examination when the chiId first entered school, discovered peculiarity in waIk-

Bilateral coxa vara of unknown origin

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74 American Journal of Surgery Section of Orthopedic Surgery JULY, ,927

I can see cIearIy where in a number of cases of equinus we were somewhat at sea as to what to do, I know now that we shouId have used the bone-bIock operation. In the future I shah be very enthusiastic about it.

DR. ROBERT HUMPHRIES: I think I am the onIy one here who has done this bone-bIock operation, and have seen a number of cases foIIowed with very good results. There is no pain and it has heId up the foot very satis- factoriIy for periods of two or three years after I have used it. I have had no such proofs as Dr. CampbeII, but my own observations have been very satisfactory.

DR. CAMPBELL (cIosing): I thank you for your IiberaI discussion particuIarIy at this Iate hour. I shaI1 not go into detaiIs because of it, but in answer to Dr. Mayer, I fee1 that in connection with transpIanting of tendons, wherever you use .a tendon to Iift up the foot, you may get very exceIIent resuIts that may be permanent in many cases, but we have seen a number of cases which acted beautifuIIy for one or two years or for quite a whiIe, but ten years Iater, after constantIy bearing weight and being used, the muscIe became stretched, because that is more than any transpIanted muscIe can reaIIy accompIish. The bone-bIock operation forms a permanent bony process with Iimited pIantar Aexion. It is not necessary to have fuI1 pIantar ffexion in this case. In answer to Dr. KIeinberg, in a case of equinus, I Iengthen the hee1 cord where it is tight, and if it is rigid, I do it at the same time as I make the bone-block. I aIways Iengthen where there is the sIightest contracture of tendon. As to caIcaneus I tried the operation in five or six cases and found it an absoIute faiIure. You ask about other deformities of the feet. When- ever I have to dea1 with an equinus, whether vaIgus or varus, I use bone-bIock. If bone is excised from the forefoot it is denuded of cartiIage, and this removed cartiIage is pIaced in mosaic fashion to cover the posterior, inner and outer aspects of the pyramid to prevent adhesion to the surrounding structures. You can puI1 it off with a knife, or you can shave it off. This step, however, is by no means essen- tia1, as resuIts are as good when bone is obtain- ed from eIsewhere free of cartiIage. Regarding the question of pain, shouId pain persist, we couId remove a portion of the new process. I have had to do it in but one case out of the 162 that have been mentioned here.

PRESENTATION OF CASES

RECURRENT DISLOCATION OF THE PATELLA. OPERATION

SAMUEL A. JAHSS, M.D.

(By invitation)

This gir1, aged sixteen, came to the HospitaI for Joint Diseases in August, 1926. In June, 1926, while running, she feIt something snap in her right knee. She couId not bend her knee aIthough the entire phenomenon was not accom- panied by much pain. She saw that the right knee was much broader than the Ieft, and she aIso noticed something sticking out on the side of the joint (external). She straightened her knee, and this protrusion snapped back into pIace, without manipuIation. This occurred two or three times a week for about eight weeks. (June to August.)

She was operated upon August 18, 1926, by the AIbee modification of the Jones operation in which the trochIear surface of the externa1 condyIe was osteotomized and a trianguIar bone graft (from the tibia) was inserted into the space between the fragments of the condyIe in order to raise the trochIear surface and prevent dis- Iocation from taking place. This procedure is recommended in cases where the externa1 con- dyIe is much fIatter than the interna one, a condition present in the congenita1 type of case. AIthough the transposition of part or the whoIe of the Iigamentum pateIIae is advised (A. G. T. Fisher) in cases that are not congeni- ta1 (in which group the present case beIonged), this procedure was not foIIowed because recurrences are reported quite often when the soft structure operation aIone is performed. The resuIt has been most satisfactory. The patient has a norma range of motion and has had no recurrence since the operation, a period of seven months.

BILATERAL COXA VARA OF UNKNOWN ORIGIN

JOSEPH G. WISHNEK, M.D.

(By invitation)

N. D., aged seven years, was admitted to the HospitaI for Joint Diseases in May, 1926, on the service of Dr. Leo Mayer. She had been sent there by the schoo1 doctor who, in the routine examination when the chiId first entered school, discovered peculiarity in waIk-

NEW SERIES VOL. III, No. I Section of Orthopedic Surgery American journal of surgerJ, 75

ing and limitation of motion at the hips. She degrees, and there was Ilexion contracture of is the seventh child of her mother, and was 13 degrees at both hips. All other motion at the delivered at term as a normal head presentation hip was normaI. Wassermann reaction negative. without any difficulty. She weighed ten pounds AIthough our first impression was that the at birth. During her infancy she was breast-fed condition was one of congenita1 disIocation of and bottle-fed. The First tooth appeared at seven the hips, limitation of abduction and ffexion months. She began to walk at eight months. contracture established the diagnosis of biIatera1 She taIked when one year old. There was at no coxa vara. time during her infancy any sign or symptom The roentgenogram (Fig. I) shows coxa vara of rickets. There were none of the acute infec- with pecuIiar disturbance at both upper femoraI tious diseases of childhood unti1 the age of epiphyses. There is an interruption in the three, when she had a miId pertussis, and at six continuity of the neck, but the periosteum at when she had varicella. The mother states the lower border is still intact. The etioIogy is

FIG. I. BiIateraI coxa vara due to giving-way of neck. Loss of continuity except at Iower border.

that the baby walked normaIly, that is Iike all other children, until she was three years old. During this time she fell frequently but not severeIy. The mother attributed the frequent falling to Iack of proper attention and not to any iIIness or abnormaIity. At no time was the chiId laid up or disabIed. When three years oId there began peculiarity in waIking, and at that time the mother recalls the baby did compIain of occasiona fatigue. StiII no medica aid was sought because the parents thought the gait onIy sIightIy abnorma1, and hoped it wouId improve with time. When the chiId entered schoo1 at the age of six the school physician discovered the real state of affairs.

Examination on admission showed a marked Iordosis with the waddling gait so characteris- tic of biIatera1 congenita1 hip disIocation. Both trochanters were high but on the same IeveI. The Iower extremities were of equa1 length. Abduction of both Iegs was limited at five

FIG. 2. BiIateraI wedge osteotomy through greater trochanter correcting coxa vara.

not quite clear. This case corresponds very cIoseIy with severa described bv R. G. EImsIie as idiopathic coxa vara of the-infantile type, with fibrous intersection at the neck. In his cases, the onset was Iikewise insidious, the age was between three and six, and a11 had Iordosis and flexion contracture at the hips. The roent- gen-ray pictures were exact replicas of the one in this case. Mr. EImsIie, however, after con- siderabIe pathologica and anatomica work could not arrive at a definite causative factor. He suspected a maldevelopment in the upper epiphysis of the femur with weight-bearing as the deciding factor. In our case, there was no trauma at birth and rickets was ruled out. It is possibIe that the frequently repeated injuries during the first three years were suff~- cient to cause this downward dispIacement of the head and neck, a weak or undeveIoped neck being a predisposing factor. After this, the body weight was sufficient to cause further

76 American Journd of Surgery 1 Section of Orthopedic Surgery JUI.Y, ,927

downward dispIacement of the head and neck. Since bone deveIopment begins and proceeds from the Iower part of the neck, here the periosteum and a thin layer of bone may remain intact. This type is to be differentiated from the congenita1 type of coxa vara which is evident as soon as the chiId begins to waIk. In these cases there is no abnormaIity in the deveIopment of the neck of the femur. In the infantiIe type, the so-caIIed fibrous intersection of the neck has been demonstrated by R. Jones and EImsIie, and the specimens they have show the presence of other congenita1 abnor- maIities. In rickets, the roentgenogram is entireIy different. There is a bowing of the whoIe neck aIong with an antero-externa1 bowing of the upper end of the femur. AIso in these cases there is usuaIIy no Iimitation of motion at the hip.

Treatment consisted in cuneiform osteo- tomies through the greater trochanter and correction of the ffexion contracture at the hips (Fig. 2). The chiId can now abduct to 45 degrees. The Iordosis is onIy partiaIIy corrected but is now being treated with exercises: There has been an increase of one-haIf inch in the Iength of both Iower extremities. The height of the chiId has increased three-quarters of an inch. Her genera1 appearance is suspicious of a thyroid or muItipIe endocrine gIand disturbance. For this reason, we have prescribed thyroid extract , >$, three times a day for the past eight months. Whether the endocrine disturbance is a factor in this case I cannot say. Roentgeno- grams of other joints and Iong bones show nothing abnorma1.

BIFURCATION OPERATION

(THREE CASES)

WALTER I. GALLAND, ‘M.D.

CASE I. M. S., aged eIeven years. Infectious epiphysitis at the head of the right femur at the age of three years compIeteIy destroying the head and neck of the femur. Admitted to the HospitaI for Joint Diseases September 18, 1925. Chief compIaint, Iimp and shortening of the right Iower extremity. On admission had a severe right hip Iimp. This hip was in 30 degrees of Aexion contracture. There- was a shortening of 246 inches of the right Iower extremity which was extremeIy atrophic, a “match-stick Ieg” due to disease. On Septem- ber 14, 1925, a Soutter fasciotomy was

performed, and the hexion contracture was cor- rected. The chiId was then pIaced in suspen- sion-traction and the shortening was reduced about 3/4 of an inch. On ApriI I, 1925, the bifurcation operation was performed through a five-inch incision beginning at the tip of the greater trochanter, and extending down the antero-IateraI aspect of the thigh. The femur was exposed and divided obIiqueIy with an osteotome at the IeveI of the Iesser trochanter. The upper end of the Iower fragment was dis- located into the acetabuIar region by abducting the extremity and guiding the fragment into position with the forefinger. The trochanteric fragment was adducted by digita pressure. The extremity was pIaced in a pIaster spica to the toes with the hip in IO degrees of flexion and slight externa1 rotation and 40 degrees of abduction. There was no postoperative shock. Weight-bearing was permitted in pIaster after four weeks. The spica was shortened to the knee after six weeks, and remova I I weeks after the operation. The hip now functions painIessIy. There is I inch of shortening; ffexion is free to go degrees, abduction to 40 degrees. Rotation is moderateIy free.

CASE II. Mrs. A. M., aged fifty-four years. Admitted to the HospitaI for Jomt Diseases, October 12, 1926. Chief compIaint, pain in left hip. The Ieft Iower extremity was heId in external rotation. The extremity showed an actual shortening of 144 inches. FIexion was Iimited to 15 degrees on account of pain, abduc- tion limited to 30 degrees. The greater tro- chanter was eIevated above Ntlaton’s Iine. SIiding motion of the femur was present. Roentgenogram showed ununited fracture of the neck of the Ieft femur. The patient was placed in preIiminary suspension-traction, and the shortening was somewhat reduced. She was in poor physica condition on admission and was not considered a good operative risk. A Iarge mass was present in the right iIiac region-a poIycystic kidney.

Operation, November 4, 1926: The Ieft femur was bifurcated through a six inch inci- sion beginning at the tip of the great trochanter as in Case I. The osteotome was directed upward and inward into the Iesser trochanter from a point four fingers beIow the tip of the greater trochanter. The upper end of theIower fragment was disIocated and guided with the forehnger into position just beIow the “chin” of the head of the femur. The trochanteric