SUPRAMALLEOLAR OSTEOTOMY FOR OUTWARD DEVIATION OF THE FOOT, SUBSEQUENT TO POTT'S FRACTURE HEALED UP IN A BAD POSITION *

THE operation of osteotomy, introduced into surgery as a means of correcting deviations in the shape and direction of the extremities in cases in which this deviation was an essential hindrance to the use of the limb thus affected, was first systematized by von Langenbeck in 1852 for ankylosis in false position of the hip- and knee-joints.

The operation was performed according to the so-called subcutaneous method, that is, through the smallest possible opening in the skin a fine saw was passed in upon the bone, and this cut through, the false position corrected, and the cut surfaces of the bone left to unite in the same way as in a common fracture. The small opening in the skin had for its object the prevention of suppuration. The subcutaneous operation of tenotomy has the same object. These precautions were natural and necessary prior to the advent of antiseptic operating and dressing.

A step in advance was made by Gross, of Philadelphia, in 1861, who rendered the operation more easy of performance by substituting the chisel for the saw.

Since this period, that is, for the last twenty years, osteotomy has been a common operation for the correction of the various deviations of the bones of the extremities arising from rachitis, ankylosis of the joints, fracture healed up in a bad position, or from any other cause.

Even before the Lister method was known in surgery and employed in osteotomy relatively little danger was connected with the operation. In most of the cases operated upon the limbs healed in a correct position, just as they would after a common subcutaneous fracture; but sometimes suppuration would set in, and even erysipelas and pyemia could not be entirely excluded.

The fear of these complications deterred the profession in general from recommending or making use of the operation in all cases in which it would prove of essential benefit, and, we may say, limited the operation to those cases in which it was imperatively necessary.

The antiseptic method of operating and dressing has done away with this drawback in the indications for the operation, and at the same time has rendered the so-called subcutaneous operation unnecessary. We are now able to cut without fear through the soft parts covering *Medical News, 1882, vol. xl, pp. 398, 427. 289

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the bone to be divided, making as large an incision as is necessary to cut through the osseous tissue with ease and safety. Through this opening we can make an incision in the periosteum, denude as much of the surface of the bone as is necessary, cut out by means of saw, chisel, and hammer a piece of bone of the exact size and shape we require, unite the osseous surfaces with silver sutures if we deem it advisable, and, in fact, operate with perfect safety and security, allowing sufficient time for all the details of the operation, because we know that we are protected by antiseptic precautions, by which the healing by first intention of a wound, whether large or small, is accomplished with equal rapidity and safety.

We must bear in mind, however, that this wider field in the indications for the operation which has been opened up by the Lister method at the same time places an increased amount of responsibility upon the operator, since he now is held responsible for all septic accidents which might occur subsequent to the operation.

When all antiseptic precautions are taken, down to the most minute details, during the operation and in the course of the after-treatment, and carried through systematically, there can be no more danger than in subcutaneous osteotomy.

It was with this conviction that I did not hesitate to extend the employment of osteotomy to cases of false position of the foot following Pott's fracture. In these cases there is no vital indication for the operation, as such patients are able to limp about, with or without the use of a cane; but the deviation of the foot impairs their walking so considerably that a large number, particularly of the lower class of the people, are thereby unable to earn a living, as many of them cannot learn or work at a trade in which walking or the free use of the lower extremities does not play an important part.

The following cases will show that supramalleolar osteotomy can be performed in such cases, not only without danger to the patient's life, but with the result of completely restoring the usefulness of the foot, so as to enable him to walk just as well as before the fracture and subsequent deviation had taken place.

CASE I.-Outward deviation of left foot, subsequent to compound comminuted Pott's fracture in a syphilitic individual. Supramalleolar osteotomy, followed by suppuration. Union in eight weeks. Out of bed in nine weeks. Able to bear weight on foot in eleven weeks. Open sinuses for more than a year. Subsequent complete recovery, with perfect ease in walking.

Henry H., a clerk thirty-eight years of age, was admitted to Cook County Hospital June 16, 1879. The patient had syphilis some years ago, but with this exception had been always healthy, until eighteen months previous to his entrance to the hospital, when, in St. Louis, Mo., he received an injury which caused a compound comminuted fracture and dislocation of the left ankle-joint. He was treated for five months in a hospital in St. Louis, and at the end of that time was able to walk about with a cane. On account of an outward deviation of the foot, however, walking was painful, and could be endured for only a very short time. In June an abscess formed around the internal malleolus, which was opened on admission and some pus evacuated. No denuded bone could be felt through the wound.

He left the hospital at his own request August 10th, the wound not yet being healed, but returned September 1st, suffering with increased swelling and pain, and was placed under my care.

Examination.-Patient is unable to walk on account of pain in the region of the left ankle-joint, at which point is found a Pott's fracture healed in a bad position, with outward deviation of the foot. The internal malleolus is very prominent, considerably enlarged, and covered on its inner surface with a layer of adherent cicatricial tissue. Above and exterior to the external malleolus is an irregularly shaped ulcer, about 3/4 inch in diameter, with quite abrupt edges and an uneven floor, covered with grayish-red, discolored granulations, and secreting a large amount of thin, grayish pus. The surrounding skin is dark red, swollen, and tender.

The deformity of the foot (shown in Fig. 31) is the real cause of his inability to walk, as the line of gravity of the limb falls internal to the foot, or, in other words, the foot is in a position of dislocation outside of the line

of gravity; that is, the line of gravity of the foot forms an angle with the line of gravity of the limb, which opens outward, and in which the apex of the angle corresponds to the base of the internal malleolus, the seat of the old Pott's fracture.

To remedy this deformity-after careful investigation upon the cadaver as to the best method of performing osteotomy in such cases -I devised the following operation:

A

September 12th: I operated, assisted by Dr. Sawyers, and in the presence of Drs. Gunn, Isham, Jacobson, and Lee. The patient was anesthetized with ether. A transverse semilunar incision was made over the inner surface of the inferior extremity of the tibia, 2 inches above the apex of the internal malleolus, through the skin and subcutaneous tissue, being careful not to open the sheaths of the tendons of the anterior and posterior tibialis muscles. transverse incision was then made through the periosteum, and a short longitudinal incision on either end of this. The two flaps of periosteum were separated from the bone with a gouge, and a base 34 inch in width was marked out with a saw, for a wedge-shaped piece of bone, which was cut out by means of hammer and chisel, the point of the wedge being at the external border of the tibia. The attempt was now made to reduce the deformity by taking the foot in the right hand and bending it over the knee. While reducing this deformity the fibula fractured at about 1 inch below the cut through the tibia, and the upper fragment of the external malleolus broke out through the ulcer described above, thus making a compound complicated fracture which extended into the ankle-joint. The external malleolus was the seat of a diffuse osteoporotic osteitis, and consequently the osseous tissue at this point was very fragile. The remaining part of the diseased malleolus was now removed, the cut surfaces of the tibia approximated and secured by strong silver wire sutures, a drainage-tube inserted, the wound closed by sutures, and a Lister dressing applied.

The leg was then placed in an apparatus devised for the purpose, which consisted of a padded leather band around the upper part of the calf, which contained a heavy steel bar that came down on the external side of the foot, bearing a foot-piece, which was

inverted and kept in place by a strap on the inner aspect of the leg. The steel bar, when passing over the external malleolus, was bent out so as to permit the application of Lister dressings around the ankle-joint without removing the apparatus. The band was secured around the leg by leather straps and buckles, and the foot fixed to the foot-piece by roller bandages. The whole apparatus was suspended in a Hodgen's anterior splint. September 13th: A little hemorrhage occurred during the night, with some pain. September 14th: Wound dressed; no suppuration.

September 16th: Wound dressed; very little suppuration, but considerable pain. Applied ice-bag over the dressing.

October 8th: For the last two weeks he has had no pain. The wounds, over both the tibia and the fibula, are granulating somewhat luxuriously. Touched with nitrate of silver.

October 18th: Wound dressed. Foot seems to be turned inward a little too much. A compress and bandage was, therefore, applied to correct the position, but this caused the patient so much pain that it was discontinued.

October 22d: Wound dressed. The wound seems to have come to a standstill as regards healing, being covered with soft, pulpy, jelly-like granulations, which were cauterized thoroughly with silver nitrate.

October 23d: A small piece of dead bone came out from the wound over the external malleolus.

October 26th: The splint was removed, in order to be used as a pattern in making a splint for a patient upon whom Dr. Gunn was about to perform a similar operation for the same deformity. The leg was placed in a Hodgen's splint.

October 29th: Another small piece of dead bone was taken out. The patient has had some diarrhea. The wounds showed no tendency to heal, and were covered with a thick, grayish, croupous exudate. Cauterized with silver nitrate.

November 5th: The wound is looking better, and the silver wire is removed. November 12th: Removed the frame and suspension apparatus, and the limb was placed in a fracture-box.

December 4th: For the last two days the patient has had pain around the external malleolus, behind which was a small abscess, which was opened and washed out.

December 11th: On account of the discharge the wound has to be dressed every day. December 15th: The discharge ceased, and the patient got up and walked about a little on crutches.

December 25th: Is up most of the day, and can walk a few steps without crutches. Two sinuses lead to the denuded bone.

January 17, 1880: All the sinuses are nearly closed, but there is still some swelling. January 23d: A small abscess opened, through which a probe can be passed in deep within the bones.

March 1st: The wound is healing up on both sides with very little discharge. April 2d: A discharging sinus from the cavity within the tibia was cauterized, three small fragments of bone extracted, the cavity filled with boric acid, and a drainagetube inserted.

March 15, 1881: The last of the superficial ulcers healed, and the position of the foot was straight (as is shown in Fig. 32). The tendo Achillis is in the usual straight line, and upon bearing the weight of the body on the foot no deviation is noticeable. The patient walks two to three miles without inconvenience and without the use of a cane. The inferior extremity of the tibia is still somewhat enlarged, and there is some tenderness on pressure on its surface.

May 7th: From time to time superficial ulcerations have formed, not upon the cicatricial tissue of the wounds of operation, but below this, on the cicatrix of the original wound caused by the compound fracture. Mobility in the ankle-joint is still somewhat limited, but this does not prevent him from walking without a cane and without limping.

As far as the bones operated upon are concerned, the final result of the operation is perfect, but the long convalescence in the case is an exception, and was due to the specific chronic disease in the bones operated upon.

In uncomplicated cases, in which the patient's health is good and the osseous tissue at the seat of the operation normal, the time for the healing of the cut surfaces of the bones and the osteotomy wound will not greatly exceed the usual limited number of weeks required for the recovery from a common subcutaneous Pott's fracture. This I intend to show by the following cases:

CASE II.-Outward deviation of left foot subsequent to Pott's fracture. Operation four months later. Aseptic course without suppuration. Eight days later, drainage-tubes removed. Perfect osseous union in four weeks. Complete recovery. (Fenger, Chicago, 1880.)

John B., Irish, aged thirty-eight, a painter, was admitted to Cook County Hospital July 14, 1880. He had previously had good health. On April 15th he was seated beside a tree, eating dinner, and got up suddenly; in so doing he put his left foot into his dinner pail; his right foot slipped, throwing his weight on the left foot, which turned outward and upward, causing him much pain. A physician was called, who pronounced the injury a fracture. At this time the foot was turned outward and upward until it was nearly at right angles with the leg. It was placed in loose dressings for a week, after which a starch bandage was applied, which was continued for four weeks. The patient remained in bed for more than four weeks, and was then allowed to be up on crutches, but was not yet able to bear his weight on the foot. Consequently, four and one-half months after the receipt of the injury, the patient entered Cook County Hospital and was placed in my care.

On admission the patient was unable to walk without the aid of a cane. He could not bear weight on the foot without intense pain. The same deformity existed which has already been illustrated in Case I; that is, the foot was in a position of outward subluxation; the line of gravity of the limb, instead of being continuous with the line of gravity of the foot, formed, with the latter, an angle of from 30 to 35 degrees, the apex of the angle being at the base of the internal malleolus.

August 13th: The patient having been anesthetized with ether, I proceeded to perform osteotomy, following the same plan devised in Case I, namely, a transverse incision was made across the lower extremity of the internal surface of the tibia, about 13⁄44 inches above the apex of the internal malleolus. The skin, subcutaneous tissue, and periosteum were divided, the periosteal incision being in the shape of an H, having an elongated cross-bar. The two narrow flaps of periosteum were now loosened from the bone. A narrow retractor was inserted between the periosteum and the bone, so as to avoid opening the sheath of the tendons of the tibialis anticus and posticus. Two parallel transverse