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to the index-finger to replace the injured tendon. The extensor indicis proprius suffices, I have found, to extend the index-finger. A 4-inch incision lays bare the index-finger tendon of the extensor communis digitorum (see Fig. 126). second incision over the severed extensor tendon frees it from the scar tissue which usually holds it adherent to the bone. By means of a subcutaneous channel the substituting index tendon is transferred to its new position and sutured to the injured tendon by one of the methods above described.
After-treatment of Tendon Transplantations.-All tendon transplantations require an immobilizing splint which holds the extremity in such a position as to minimize the tension on the transplanted tendon. For this purpose the Jones splints may be used, the plaster-of-Paris dressing, or, as I prefer, the plaster-moulded splint. The latter saves expense and time, both in the application and in the removal. The duration of the immobilization depends upon the particular operation: when a tendon can be implanted directly into the bone, firm union has occurred, as determined by animal experiment, secondary operations on human beings and clinical experience, by the sixteenth day. After that time, the splint should be removed daily for active exercise of the transplanted tendon.
When the tendon cannot be attached to the bone but is sutured to another tendon, firm union does not occur as quickly. At least three weeks are required before healing has occurred. In the case of the operations for gunshot injuries to the tendons of the hands, the after-treatment is particularly difficult, since, by postponing exercise for three weeks, opportunity is given for the formation of adhesions to the scar tissue. Therefore, even at the risk of tearing the tendons apart, it is advisable to permit a little motion two weeks after the operation. When proper caution is used by surgeon and patient, the danger is slight.
In all cases, even after motion of the transplanted tendon is allowed, it must be carefully protected until it has acquired the strength of the normal. Thus, for transplantations of the tendons of the foot, a splint should be worn which holds the parts in the overco rected position: after transplantation of
the peroneus longus for paralytic flat-foot, an outside iron and Thomas shoe are used, after transplantation of the tibialis anticus for paralytic club-foot, an inner iron with a boot raised on the outer margin. Subsequent to operation on the hand corresponding splints, of metal or plaster, are readily devised to remove all strain from the transferred tendons.
Prognosis of Tendon Transplantation.-When a typical physiological operation can be performed, the operator should not be satisfied unless normal muscle balance is restored. In the presence of scar tissue, or if suture of tendon to tendon must be performed, the results are not as good. Then only about 60 to 70 per cent. of the normal range of motion can be expected.
Tenodesis.-Tenodesis or the fixation of tendons to bone is, particularly when combined with arthrodesis, an effective procedure in those cases to which tendon transplantations are not applicable. The following operations have given good results in my hands.
Tenodesis of the Extensor Tendons of the Index Finger Subsequent to Their Division.—The operation is indicated when, because of extensive scar tissue formation and infection, suture of the tendon is impossible. The interossei and lumbricals suffice to extend the distal phalanges, but the flexion of the proximal phalanx prevents effective use of the finger. By immobilizing it in the extended position the patient is enabled to use the finger for all forms of fine manual work.
Technic.-A 14-inch longitudinal incision exposes the extensor tendons as they pass over the metacarpophalangeal joint. They are freed from the surrounding tissue, divided 42 inch proximal to the joint and retracted downward so as to expose the joint. It is then denuded of cartilage with an appropriately shaped gouge. The proximal phalanx is held in the extended position and the extensor tendons firmly sutured to the traumatized periosteum and the metacarpal bone. In case it is impossible to secure firm mechanical fixation by these means, a small hole is drilled in the metacarpal bone and the tendons brought through this.
Subsequent to the operation the finger should be immobilized for three weeks and for two months thereafter a small
splint should be worn, holding the proximal phalanx in the extended position.
Tenodesis of the Extensor Tendons of the Wrist. This is applicable to gunshot injuries in which there has been very extensive loss of substance of all the muscles of the extensor surface of the forearm, with scar tissue formation extending down to the wrist, precluding the possibility of effective tendon transplantations.
Technic.—Two 14-inch longitudinal incisions, extending from the annular ligament upward, are made, the first over the extensor carpi radialis (longior and brevior), the second over the extensor carpi ulnaris. The tendons are freed, divided about 1 inch above the wrist and, with the hand in the hyperextended position, the tendons are drawn through holes drilled in the radius and ulna. The fixation must have sufficient mechanical security to hold the hand in the desired position. Splint for three weeks with the hand hyperextended, and for two months thereafter guard against flexion by a slight support which gives the fingers free play.
Tenodesis of the Extensor Tendons of the Foot in Cases of Footdrop Due to Paralysis of the External Popliteal Nerve.—Although I have had no experience with this operation the authority of Sir Robert Jones is sufficient to recommend it. For the technic the reader is referred to his "Notes on Military Orthopedics," page 23.
In cases of complete paralysis of the foot, I have employed tenodesis with excellent effect in conjunction with arthrodesis. All three extensor tendons are freed and drawn through channels bored through the crest of the tibia. The extensor longus digitorum and peroneus tertius are pulled very taut, so as to prevent the adduction of the anterior portion of the foot which so frequently follows arthrodesis.
In performing the arthrodesis two methods may be pursued.
1. Through two small lateral incisions on either side of the ankle joint, exposing the superior and the inferior surface of the astragalus, from which the cartilage is scraped with a sharp curette or with a gouge.
2. By the Albee method of enucleating the astragalus, denuding it of its cartilage and reinserting it.
Tenodesis of the Achilles Tendon for Paralysis of the Gastrocnemius and Soleus.—With this operation also I have had no personal experience, since I have preferred transplanting the flexor longus pollicis and peroneus longus tendons as substitutes for the paralyzed. Gallie, however, has been able to achieve excellent results by this method, so that it certainly should be considered as an important operative procedure. As in the previous tenodeses, the tendon should be implanted directly into the bone with sufficient tension to hold the foot in the corrected position. For further details the reader is referred to Dr. Gallie's description in the American Journal of Orthopedic Surgery, vol. xiv.
TREATMENT OF THE AMPUTATED
In the first portion of this book, no mention was made of amputations performed at the front since these are strictly surgical in nature. The usual operation is a simple oval or circular amputation, executed as rapidly as possible, with little thought of any result other than saving the patient's life. When these patients with a limb already amputated reach the base hospital, their further treatment should fall into the hands of some one versed not merely in surgical technic but in orthopedic principles and, above all, in the application of artificial limbs. The practice of turning the patient over to the manufacturer of artificial limbs as soon as the amputation wound has healed, is frequently responsible for much unnecessary suffering and many instances of poor function. Only by a rational harmonizing of surgical technic and orthopedic treatment with the brace-maker's art, can satisfactory results be achieved.
Preliminary Treatment of the Stump.-When the Amputation Wound is Still Unhealed.-It frequently occurs that by the time the patient has reached the base hospital the loose sutures applied at the time of the primary amputation have torn out, the skin flaps have retracted, and a large granulating area lies exposed. Attempt must be made to prevent further retraction of the skin. This is best done by applying a piece of stockinette to the stump after first painting it with some adhesive mixture, such as a solution of mastic. The free ends of the stockinette projecting below the stump are gathered
1 The solution of mastic is made as follows:
50; gtt. xx.