Osteotomy and osteoclasis for deformities of the lower extremities

Preface

The author of this volume has had considerable experience both in the mechanical and in the operative treatment of the deformities considered in this book.

That there is a want of a concise treatise on osteotomy— one in which the methods of operating and the management of the wound and limb after section are considered — there can be no doubt. Whether the author has succeeded in this purpose the reader must determine.

Much time and reading have been devoted to its production, and he trusts that his labors have not been entirely in vain. Very free use has been made of Dr. Macewen's excellent work on Osteotomy, as well as of Campenon's thesis " Du redressement des membres par l'osteotomie," and for which the author desires to express his indebtedness.

He is also under great obligations to his friends Dr. W. T. Bull, Dr. V. P. Gibney, Dr. F. Lange, of this city, and to Dr. E. H. Bradford, of Boston, for vi PREFACE.

valuable assistance; to Dr. A. T. Cabot, of Boston, Dr. E. M. Moore, of Kochester, and Dr. K. H. Wharton, of Philadelphia, for the use of specimens and wood-cuts ; to the Librarian of the New York Hospital Library, and that of the Academy of Medicine, for aid in looking up references ; and to the publishers for the trouble they have taken to meet his views.

Chaeles T. Pooee.

5 West Thirtieth Street, New York, August i, 188JJ,.

Contents

CHAPTER PAGE

I. — The Relation between Rickets and Certain Deformities of the

Lower Limbs 1

Chapter I

Many of the deformities of the lower limbs whose treatment is considered in this volume have their origin in rickets. It has therefore been thought best to devote a short chapter to this disease, and to point out its connection with the subject under consideration.

Those who are connected with our large dispensaries are well aware of the prevalence of rickets among the ajyplicants for medical aid. Whether it is as common in this country as in certain parts of Europe is doubtful. It is not alone confined to the children of the middle and lower classes, but is met with among the offspring of the wealthy, not perhaps in its more advanced stages, yet sufficiently well marked to be easily recognized if its manifestations are carefully looked for. It is seen among children who have been brought up in the country as well as those who live in crowded cities, but to a much less extent. It is a disease that merits the careful attention not only of the surgeon, but of the general practitioner, in order that its results, in deformities of the long bones and changes in the shape of the chest and pelvis, may "be prevented. Kickets is not a disease of the bone alone, but is a constitutional affection, attacking the osseous structures in common with every other tissue of the body. It is essentially a disease of malnutrition. It may be congenital, but it usually first manifests itself in children from six months to three years of age. Bad air, improper food, and scanty clothing are its most prolific causes. Any child may become rickety, no matter how healthy it may have been at birth, if placed under any condition that interferes with its assimilative powers. It may be laid down as a rule that a healthy child, fed on good mother's milk, will never develop this disease. It is equally true that not every child who suffers from malnutrition will become rickety. Its beginning is insidious, with the ordinary symptoms of improper digestion. The little patient may be plump, but its muscles are flabby and its complexion pale and unhealthy ; large veins are distinctly seen through the pasty-looking skin. The bowels may be loose or confined, more often capricious, a day or two relaxed, then followed by a period of constipation ; the stools are white, curdy-looking, and extremely offensive ; the food is often passed through the alimentary canal undigested. Accompanying this derangement of the digestive apparatus there is profuse sweating of the head, neck, and upper part of the chest, worse at night. The moisture will be seen standing in large drops upon the forehead, and often runs down the face, and at night the pillow is drenched with it. While the head and neck are thus

RICKETS AND CERTAIN DEFORMITIES. 3

bathed in perspiration the abdomen and lower limbs are dry and hot. Another symptom is the desire of the child to keep cool at night. It constantly throws the clothes off from its feet and limbs, no matter how cold the temperature may be. The child soon loses its activity, and seems only happy when left alone. It will sit for hours almost motionless, is petulant, and cries on beino; moved. The desire to be let alone is due to tenderness, more or less marked, of the bones, so that any pressure on them is painful to the little one, and it dislikes to be handled.

Dentition in those affected with rickets is usually retarded, or, if the teeth have made their appearance, they soon become black and fall out, or are early attacked with caries. Jenuer states that if the ninth month passes without the appearance of a tooth, the cause should be carefully inquired into, and will almost always be found in rickets. According to Eustace Smith, the symptoms of rickets seldom appear before the fourth, and usually not until the seventh month. Cases, however, occur in which the advent of the disease is delayed much longer. Jenner mentions a girl of nine years of age in whom the symptoms of rickets had just commenced.

Enlargement of the spleen, liver, and of the lymphatic glands in different portions of the body is a common accompaniment of this disorder. In some cases the patient is reduced to a skeleton, while in others, as mentioned before, it retains its plumpness.

While the symptoms mentioned above are manifesting themselves, changes are taking place in the bones, perhaps not more profound, yet more noticeable than in any other structure of the body. One of the earliest of these is a beaded appearance at the sterno-costal junction and an enlargement of the epiphyses, especially those at the wrist-joint. If a child aifected with rickets be carefully examined, a line of nodules will be felt, and often seen, marking the point of junction between the ribs and the sternnm. This condition has been noticed in children suffering from rickets six weeks after birth. When this beading of the ribs is found, it is a positive proof of the existence of this disease. There are also certain alterations in the occipital bone, often found at a very early stage of the disease in young children. Macnamara states that they are almost as constant a condition in this disease as the abnormalities of the ribs, but they are not as easily detected. If the occipital bone be carefully examined in young infants affected with this disease, there will often be felt several small, round, or oval soft spots, situated within the sutural margins of the occipital and parietal bones. These spots are unossiiied portions of the structures from which the bone is produced. The number of these spots varies considerably. The occipital bone is often remarkably thin in cases of this disease, and the head has a peculiar elongated appearance, while the face in marked cases remains small. (Macnamara.)

While these changes are going on, others of as marked a character are taking place in the ends and shaft of the long bones. The epiphyses become enlarged, and the shaft softened so that it is often bent, and the epiphyses may become twisted, according to the intensity of the disease and the force acting on the plastic bone. The condition of the bones varies with the stage and the intensity of the disease, and

RICKETS AND CERTAIN DEFORMITIES. 5

whether the brunt of the changes falls upon the epiphyses or the diaphyses. At first the bones may be soft, so that they can be bent like cartilage ; later they become very hard and deformed.

The pathological changes taking place in the bones are well described by Macnamara in his work " On Disease of the Bones and Joints." He says : " If a rickety bone be divided longitudinally during the first stage of rickets, the medulla filling the central canal and cancellated tissue will be found to be of a crimson color and jelly-like consistency, this soft medulla being especially abundant at the line of the junction between the diaphysis and epiphysis. The medulla of a child suffering from the first stage of rickets consists of a vast number of round cells, compound cells, and fat ; the adenoid tissue and vessels are normal in appearance ; in fact, the elements characteristic of healthy medulla are present in the bones of infants suffering from this disease, but there is an imperfect formation of the calcareous skeleton of the bones, and in its place we find an excess of medullary tissue. . . . The malad}7, so far as the bones are concerned, depends on the deficiency of earthy matter contained in this hyaline matrix. If a section made through the epiphysis into the diaphysis be examined during the first stage of the disease, there will be found at the line of ossification numerous villouslike processes of medulla, projecting, as it were, from the diaphysis into the epiphyseal cartilage. These processes, however, are not formed from the growth of the medulla of the diaphysis into the cartilage, but from a transformation of the cartilage-cells of q OSTEOTOMY.

the epiphysis into medullary tissue at the normal line of ossification. The mass of the descendants of the cartilage-cell forming the processes referred to are incapable of producing healthy bone, in consequence of a deficiency of the bone-earth. So long as an infant is insufficiently supplied with, or is incapable of assimilating, elements necessary to the calcification of the cartilage-cells, it is impossible that healthy bone can be produced."

The changes in the shaft of the long bones, according to Virchow, " consist in the non-solidification of the fresh layers as they are formed, while the old layers of bone are consumed by normally progressive formation of medullary cavities. The periosteum is thickened and more adherent to the bone. Medullary spaces and vessels are met with where normally and properly not a single medullary cell and scarcely a single vessel ought to be found."

During the height of the disease, when the changes in the bones are marked, they can be bent by the least possible force, and their spongy portions may be easily cut with a knife. In rickets the ligaments are often altered in their structure, so that they may become easily elongated, and thus permit lateral motion in joints in which normally it does not exist. However profound the changes in the bones may have been, as soon as the child begins to masticate and is able to assimilate proper nutriment, the vast number of bone-cells rapidly take up the earthy salts from the blood, and very dense bone is speedily produced, so that in a short time the bone may become very hard. Again, the process of sclerosis may be much slower, depending

RICKETS AND CERTAIN DEFORMITIES. ?

upon the power of the child to assimilate, and the quality of the food furnished. Rachitic changes in the osseous structure do not always take place in all the bones of the skeleton in equal degree, nor in every portion of an individual "bone. Thus softening may be more marked at the epiphysis while in the shaft it is slight, or the shaft may show more advanced changes than the articular ends. The enlargement of the epiphyses is not an index of the changes in the shaft. The bone of one limb may be quite soft while that of the other is hard. I have met with this condition quite frequently in operating; one tibia has been found very easy to divide, while in the other section was difficult. The fibula has been found to be much harder than the tibia in the same limb.

Perhaps the existence of different deformities may be due in part to this irregularity in the portion of the bone on which the intensity of the rachitic process falls.

All writers on this disease divide it into a preliminary stage, one of softening and one of sclerosis. It is in the latter that the bone-cells take up from the blood the earthy matter that gives bone its hardness. It will be evident that this stage can not begin until the child is able to digest and assimilate appropriate food. No rule can be laid down as to the length of time that the soft stage of rickets lasts, nor the rapidity with which the hardening may advance. Each case must be judged by itself. The general health, ruddy appearance, and firm condition of the muscles are the best guide. It may take many years in children of low vital powers for 2 the bones to become firm, while in others it may be accomplished in a few months.

There is a condition described by some observers (Barlow, Page1), as "acute rickets." It occurs in children under two years of age. There is profuse sweating about the head, changes in the epiphyses, and other symptoms usually found in rickets, together with swelling and great tenderness of the lower extremities, due, it was supposed, to an effusion of blood under the periosteum and between the deeper muscular layers. Barlow considers it a combination of rickets and scurvy. By change of diet, fresh air, and compression of the limbs, recovery may take place rapidly.

The age beyond which rickets is not developed is uncertain, but probably in the vast majority of cases not after the fifth year. Some writers consider that this disease may be developed between the twelfth and twentieth years ; that is, during the period of rapid growth. Mace wen is an advocate of this late appearance of rickets. But it is denied by the majority of writers. In the chapter on genu valgum the cases of MacewTen are given. I have never met with a case, and I think if they ever occur it must be exceptional. Deformities about the knee-joint are sometimes developed in persons from twelve to twenty years of age, but I think that their cause can be explained without attributing them to rickets. In the cases that I have had the opportunity to examine there w7as absolutely no symptom of rickets except the bending of the bone at the ej:)iphyseal line. Most of the deformi-

RICKETS AND CERTAIN DEFORMITIES. 9

ties of the lower limb are developed during the period of rapid growth. They are met with first iu infantile life, when all the nutritive processes are at their height, and the child rapidly increases in weight and stature. This period, as a rule, does not extend beyond the seventh year. Then comes a time, extending from the seventh to the twelfth year, during which growth is much slower and deformities are seldom developed. From the twelfth to the twentieth year is another period of growth and development during which the long bones rapidly increase in length by the deposit of osseous material at their extremities, and which is finally completed by the consolidation of the epiphyses and diaphyses. In this period, again, certain deformities, especially about the knee-joint, are developed in those who are compelled to labor hard and undergo fatigue.

During the first period bending of the shaft of the long bones, with the consequent deformities, are common, while in the last period deformities having their origin near the joints are met with, and curvatures of the shaft of the bones are seldom if ever seen.

The connection between rickets and deformities of the bone is one of cause and effect. I do not think that the muscles exert an active influence, but that position and weight are the cause of the abnormal shape of the bones.

In this very imperfect review of the symptoms of rickets, as it affects the bones of the extremities, nothing new is claimed, the object being simply to call attention to this most prolific cause of deformities.

While the bones are soft, any abnormal change in their shape can, and should, be corrected by appropriate apparatus. But after sclerosis has taken place, or even is well advanced, orthopedic appliances will not correct. I am not a believer in the spontaneous cure of bending of the long bones. We often hear the advice given to mothers by members of the profession not to submit these cases to treatment ; that the child will " outgrow " the malposition; and I wish to enter a protest against such advice, as it will only lead to disappointment.

Chapter II. Osteotomy

" Osteotomy," says Macewen, " in its broadest acceptation, may be defined as a section of bone. It has, however, been regarded in a much more restricted sense, the term being applied to such divisions of bone as have been proposed and undertaken for the relief of deformity, for the rectification of badly united fractures, and for the straightening of limbs affected with osseous anchylosis, which are fixed in a bad position." (" Osteotomy," p. 37.)

Section of the long bones for deformity had been proposed by many early writers on surgery, yet it does not appear to have been put in practice until 1815, when Le Mercier made a section of the tibia with a saw for a badly united fracture of that bone ; and in the following year Wasserfuhr practiced the same operation upon the femur. Barton, in 1826, performed an osteotomy just below the trochanter major for anchylosis with flexion of the thigh, through an open wound, the division being made with the saw. In 1834 Clemot removed a wedge-shaped piece of bone for the correction of an angular deformity of the femur. Portal, Ashley Cooper, Warren, of Boston, and others, performed similar operations. All sections of bones prior to 1852 were performed through an open wound. In that year Langenbeck made a division of the femur for anehylosis of the hip-joint by perforating the bone with a drill through a small wound in the soft parts, and then, introducing a narrow saw, divided the bone. He gave to this operation the name of subcutaneous osteotomy.

In 1868 L. Stromeyer Little made use of a carpenter's chisel to divide the bone in a case of osseous anchylosis of the knee-joint, working through a small wound half an inch in length. In the following year Mr. William Adams performed the operation of subcutaneous section of the neck of the thigh-bone, known as Adams's operation. In 1875 Volkmann1 operated antiseptically on two cases of anchylosis of the knee-joint, and in April of the same year Macewen performed a similar operation. Ogston, May 17, 1876, divided the internal condyle of the femur with a saw in a case of genu valgum, and Reeves 2 March 17, 1878, made a section of the internal condyle in Ogston's line with an osteotome. And on February 2, 1878, Macewen first performed the operation above the condyle.

Prior to 1875 all osteotomies were performed through an open wound, and were followed by suppuration more or less profuse. In the earlier operations no attempt was made to obtain primary union of the soft parts. Barton states that it was not desired.

Langenbeck's operation does not seem to have been a great improvement upon those performed through an open wound, as deep-seated suppuration

1 "Edinb. Med. Jour.," March, 1875, p. 794.

2 " Brit. Med. Jour.," September, 21, 1378, p. 431.

is admitted to have frequently followed, and, as the only object in his method was to prevent such an occurrence, it failed in its object. Moreover, deep suppuration, with a small outlet for the discharge, is more productive of injury than suppuration in an open wound. It was, however, an advance toward a better method of operation — namely, the subcutaneous way in which osteotomy is now performed, and, as such, merits a place in the history of osteotomy. There was also at this time another revolution taking place in surgical practice, which has contributed more to its advance within the last ten years than any one circumstance, and that was the method of treatment of wounds advocated by Mr. Lister.

It was only on account of the safety which this method of wound management seemed to afford that surgeons felt justified in operating upon tissues, with which their predecessors considered it too hazardous to interfere. Although much of the technique of strict Listerism has been abandoned, yet its fundamental principles have stood the test of time — namely, that on perfect cleanliness, thorough drainage, and absolute rest, depend the best results in every operation. That osteotomy has obtained its place as a safe and justifiable procedure is due to the influence of Listerism.

The instruments requisite for an osteotomy are few. It may be performed with a saw, chisel, or osteotome. Mr. Adams's saw, which may be taken as a type of such instruments, he describes as follows : It is three eighths of an inch wide, with a cutting edge an inch and a half in length, at the end of a slender shank three inches long. He at first had a

OSTEOTOMY.

straight handle, but later substituted a curved one, as being easier to grasp. The saw has a round, blunt end, in order not to injure the tissues behind the bone. (Fig. 1.)

Dr. George F. Shrady, of this city, has modified

Fig. 1. — Adams's Saw reduced one half, and the cutting edge.

Adams's saw by making it more probe-pointed, and has an arrangement by means of a trochar and canula, so that in introducing the saw all danger of any injury to the vessels and soft parts is obviated.

The instrument consists of first a trochar and canula — the former is of the same size and shape as the saw. The canula has a fenestra corresponding in position to the teeth upon the saw. The method of using it is as follows : The trochar and canula are thrust down by the side of the bone to be divided— the instrument being held in such a position that the fenestrated portion of the canula shall rest upon the bone at the point of desired section ; the trochar is then withdrawn and is replaced by the saw ; the former is then removed, leaving the saw in position. After the bone has been sufficiently divided the canula is passed down over the saw and both are removed.

It is claimed that with this instrument the danger of injuring the soft parts is reduced to a minimum. I have never used it, but those who have speak well of it. The objections to the use of the saw in osteotomies are : It is harder to work, it takes a much longer time to make the section, there is more disturbance of the surrounding tissues, and, theoretically, the dust from the saw is liable to lead to suppuration, an objection that has not been sustained by practice. Wounds after the use of a saw heal kindly, and the bone-dust does not give any subsequent trouble. The method of using the saw for making section is as follows : An incision is made just large enough to easily admit the instrument down to and by the side of the bone to be divided. The saw is then passed down upon the knife as a guide, and the bone divided through the greater part of its thickness. The saw is then removed, a sponge dampened with carbolized water placed over the wound to prevent the entrance of air, and the remainder of the bone fractured. The wound is to be treated in the same manner as one after an osteotomy performed with the chisel.

In what experience I have had with the saw in tibial curves it has not seemed to me to be as good an instrument as the osteotome. It is more difficult to work, and it takes a much longer time to complete a section. Thus the time necessary to divide the neck of the femur varies from five to twenty-five minutes, and there is no doubt but that the soft parts are more or less lacerated by the teeth of the instrument. Shrady's saw may do away with this latter objection.

A chain-saw has been used to make the section. Barwell has advocated its use within the past year.

Osteotomy with an Osteotome. — There are two forms of cutting instruments of the chisel order — one having both planes gradually sloping down to a sharp cutting edge, the other made like a carpenter's chisel. To the former Macewen has given the name of osteotome, to distinguish it from the latter, which is properly a chisel. The osteotome is an instrument having its two flat surfaces gradually sloping down to a sharp cutting edge, like a long, slender wedge, resembling a knife-blade, being as thin as it approaches the cutting surface as is safe.

The accompanying cuts (Figs. 2 and 3) represent two views of an osteotome. They are reduced one half actual size. Fig. 2 shows the gradual slope of the flat surfaces, while Fig. 3 represents the latter. Fig. 4 is a smaller osteotome useful for division of the fibula and similar bones.

OSTEOTOMY.

It should have a temper between that of a cold chisel and a carpenter's cutting tool, so that the edge will not be turned by the hardness of the bone, or so

Fig. 2.

Fig. 3.

Vy brittle as to chip. It is well always to test the instrument on a piece of hard bone, driving it in with a pretty strong blow with a mallet. If the edge is neither turned nor nicked, it is of a proper temper. The cutting edge should be very sharp. It should be marked on the flat surface every half-inch from the edge, in order that the distance that the instrument has penetrated the bone may be known. A large handle is also of advantage, as it can be grasped more easily. The best width is half an inch. It is well to be provided with three osteotomes of the same width, but of different thickness, in order that, if the largest gets wedged, it may be withdrawn and replaced by the next smaller, to be again replaced by the third if it be found necessary. I also have an osteotome of the same shape, but only one quarter of an inch wide, for section of the fibula or any small bone.

Most of the osteotomes found in instrumentstores are not made properly. They have a bulge just above the cutting edge, like a post-mortem chisel. In some trials made upon the cadaver with such an instrument it was found that the bone was invariably splintered at right angles to the line of desired section, the fracture extending several inches above or below the instrument. This was due to the thickness of the chisel just above its cutting edge acting too much like a wedge. The force required to drive such an instrument into the bone is much greater than with one made with straighter lines.

An instrument properly made can be driven into the bone without turning from its direction.

The mallet should be made heavier than those sold in necrosis cases. In fact, a good-sized carpenter's mallet is the best. A sand pillow, about six by eight inches square and three quarters filled with sand, and covered over with rubber cloth, complete the special outfit.

The chisel for performing a cuneiform osteotomy is shaped much like a carpenter's; half an inch is sufficient for its width. It should taper down more than the common necrosis chisel, and the beveled portion should not be too large. It should have a temper similar to the osteotome.

Osteotomy is either linear or cuneiform. The former is performed through a small wound, just large enough to easily admit the osteotome. The latter must be done through an open wound, and is therefore not subcutaneous.

The limb in either case, if possible, should be rendered bloodless by the use of an Esmarch bandage or any other method, as, especially in cuneiform sections, it renders the operation much easier and does away with the constant use of the sponge.

In regard to the use of Listerism, I am clearly of the opinion that it affords no additional safety, and I have long since abandoned its use. The method of management of the wound will be given in detail farther on.

Simple Osteotomy. — The patient having been placed thoroughly under the influence of an anaesthetic, the limb rendered bloodless if that is possible, and the point of section decided upon, an incision is made with a sharp scalpel immediately down to the bone. Unless there are special reasons for so doing, the bone should not be reached by dissecting down to it, but a quick, clean cut should be made. The line of the incision should be parallel with the line of the fiber of the muscles through which the wound passes. As a rule, this is parallel with the long axis of the limb. The place of incision should be so planned as to avoid any artery or vein. The length of the wound should be only sufficient to easily admit the osteotome. This instrument is then passed down upon the knife as a guide, and, when the former is well down upon the bone, the latter is withdrawn, and the osteotome is rotated so as to be at right angles with the long axis of the bone, and then driven in with pretty firm blows with the mallet. After each blow the instrument is moved in a direction at right angles to the long axis of the bone — that is, in the line of the axis of the instrument — in order to keep it from becoming wedged and to change the direction of the cut in the bone. It is also well, in bones of any width, to first divide the bone throughout its superficial surface, and then gradually to work from without inward through its width. Under no circumstance should the osteotome be used as a lever, as it will result in breaking the instrument. In some cases the bone may be divided in a fan-shaped manner by working in different directions from the point of first entrance. Divisions should be commenced with the largest osteotome, if the bone is of any size, as the femur or tibia, because after a time the instrument becomes wedged and is difficult to work. It can then be withdrawn and replaced by the next smaller, this to be again replaced by the third if necessary. Another reason is, that, by using the largest first, the cut is made more V-shaped. When the osteotome has penetrated the hard, compact, bony tissue in the external portion, it will be felt to work more rapidly. When the external portion on the opposite side of the bone is reached, it will be detected by the resistance in cutting. Then, as Macewen remarks, the osteotome acts as a probe as well as cutting instrument.