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Experiences with intramedullary fixation in knee fusion
EXPERIENCES WITH INTRAMEDULLARY FIXATION IN KNEE FUSION JAMES K. STACK, M.D. Chicago, Illinois
T
HE intrameduIlary fixation principIe has been accepted in the treatment of certain fractures. It is natura1, then, that the inquiry should be made to determine its usefulness in other conditions. ChopchaI’ reported seven instances in six patients in which he used this method. The conditions were paraIysis of the limbs foIIowing poIiomyeIitis, two; rheumatoid arthritis, three; fibrosis ankyIosis with flexion deformity, two. A review of his work suggested that the method was a practica1 one, offered the patient many advantages so far as postoperative comfort and ambulation were concerned, and seemed to involve no unwarranted risk in either the earIy or Iate postoperative period. In this discussion of indications and contraindications he made the statement, “Of course intrameduIIary pinning of the knee is not possibIe in cases of inffammatorv diseases of the joint where arthrodesis is indicated. Here another technic has to be empIoyed.” Our first appIication of the method three years ago was in the fusion of a joint, painfu1 and greatIy impaired in function by a vaIgus deformity and instabiIity. This came about over a period of years and a number of traumas causing the joint to be of no use. The second instance, shortly after, was the fusion of a knee with severe hypertrophic changes. Ten years before this knee had been subjected to a joint dkbridement and it was serviceabIe for about eight years, after which gradual recurrence of pain, Iimited motion and instabiIity appeared. The postoperative course of these two patients after intrameduIIary fixation was so smooth and reIativeIy short that we were convinced of the merit of the method. During this period we had on the service an aduIt female with tubercuIosis of the right hip. In the course of a Brittain ischeofemora1 arthrodesis a Iarge tubercuIous abscess Iying in the distended inferior portion of the joint was entered at the time of osteotomy. The osteotomy site was flooded with pus and the open March,
1952
end of the meduIIary cana of the femur was exposed. Aspiration and cIeaning of the area were done but probabIy imperfectIy from the bacterioIogic standpoint. The operation was continued, the opening in the ischeum made, and a suitabIe tibia1 graft taken and driven across in the usua1 manner. The wound in the region of the hip and that of the Iower Ieg heaIed by primary intention. The bone transpIant was successfu1 and the patient went on to firm fusion without compIications. AI1 this was done under a heavy cover of peniciIIin and streptomycin, to which she showed no untoward reaction. This instance corroborates in a smaI1 way the numerous papers that have appeared in recent Iiterature stressing the point that streptomycin has brought about a new era in the management of skeIeta1 tubercuIosis. It has been accepted that with the use of this drug in adequate dosage and over the proper period of time, we are abIe to subject these patients to surgica1 procedures much earIier than in the past, and we are justified in using surgical measures that have been rejected as carrying unwarranted risk in the days before antibiotics were avaiIabIe. (Fig. I.) The Ktintscher nai1 was used for intrameduIIary fixation in tubercuIosis of the knee in six cases (TabIe I): two cases in which the disease was primariIy synovia1 with earIy bone invasion and no contractures; two cases in which both synovia1 and osseous invoIvement were present with contractures of 44 to 60 degrees; and two with synovia1 and osseous change but no contractures, as they had been previousIy treated by traction and pIaster fixation for rather long periods of time. AI1 the wounds in this tuberculosis group healed uneventfuIIy and in average time, and in each instance the knee went on to solid fusion. When the patient’s genera1 condition warranted, as judged by the temperature, body weight and sedimentation rate, a light cylinder cast was appIied from the upper thigh to the ankIe, and 291
Stack-IntrameduIIary
Fixation
in Knee
Fusion
FIG. I. A. W., typica case of tuberculosis of the knee with external rotation deformity; by the intermeduIIary nail method.
FIG. 2. H. W., typica Charcot series.
of the cases in the
later fused
weight-bearing was permitted with crutches or cane aid as the patient desired. In the hypertrophic arthritic group (TabIe II) no wound compIications were met and it was possible for them to be ambulatory somewhat sooner than those with tubercuIosis. In the Charcot group (TabIe III) the postoperative ambuIation time of the patients depended mostIy on the intensity of nervous system invoIvement. Those without a tabetic gait and no other joint invoIvement did about as we11as the hypertrophic patients, whiIe those with advanced cord changes or with other unstabIe joints were reIativeIy sIow. (Fig. 2.) The operation is done through a Iong median parapateIIar incision extending from just beIow the middIe of the thigh to the tibia1 tubercIe. We have not used a pneumatic cuff on the thigh because the buIk of the cuff prevents depression of the upper end of the Kiintscher nai1 when one attempts to insert it through the trap door of the femur in as near a paraIIe1 course to the femur as possible. A Iess buIky hemostatic device such as the Esmarck or Martin bandage couId probably be used. After the knee is open, the pateIIa is excised and a synovectomy is done if indicated. We usuaIIy did this in the tubercuIous and Charcot joints but not in the hypertrophic joints. The knee is then flexed sharply and the joint surfaces are resected and fitted. American
Journal
of Surgery
Stack-IntrameduIIary
Fixation TABLE
TUBERCULOSIS
Name
Sex, Race, Age
Side
Type
M. W.*
M, W, 5 I
Righ t
(3sseous and synoviat
J. G. M. L.t
h4, w,
21
M,
43
Righ t !same ‘ Left same
H. S.$
M, C, 32
Left
‘
A. W.5
F, C, 56
Righ t
!same
E.
M, W, 56
Righ t :same
Q.S
W,
same
293
I
-
-
Wound Healing
Fusion Time (mo.)
Primary
8
1‘racture
Primary Primary
4 7
I\lOtK I\Jone
Primary
6
1Irained from sinus not associated with
Primary
5
Iione
Primary
6
1Vane
Deformity
45O Aexion contracture None 3o” Aexion contracture None
Fusion
OF THE KNEE.
-
-
in Knee
Complications
of tibia at distal end of pin
wound three months postoperatively
- I
90° rotation contracture ,60” Aexion contracture H
-
-
-
* Fracture healed in normal time; it was caused by pressure of the pin against the anterior cortex. The tibia was very porotic from long disuse. t Also had clinical tubercuIosis of Iungs, spine and tendon sheaths of right wrist; died one year after the operation of miliary disease. $ AIso had tubercuIosis of right shouIder. $ Under treatment for pulmonary lesion.
TABLE ARTHRITIS
8Sex, Race,
Name
Side
Age
Left
M, W, 44
Traumatic
s. P.
M, W, 33
Right
1Rheumatoid
W. T.
M, W, 61
Right
1Hypertrophic
T. B.
M,W,5r
Left
Traumatic
c. H.t
M, W, 63
Left
t3Id
L. H.
P, C, 57
Right
-
Fusion Time (mo.1
Wound Healing
Symptoms
-
fracture pateIIa with infected repair and non union
Primary
Pain, quadriceps weakness, valgus deformity 15’ contracture limited Aexion, pain Pain, 10’ contracture Pain, limited motion, drainage from sinus tract Drainage, pain, Iimited motion
Transient
peroneal
nerve
palsy
Swelling, pain, weakness
-
5
-
Primary
3
None
Primary
5
None
Primary
6
None
Drainage continued but no extrusion took pIace Primary
6
None
8
None
-
* Nerve recovery at time fusion was complete. t Died nine months after operation of carcinoma of the bladder; two additiona
March, 1952
Complications
._
-_ H. c.*
Type
II
OF THE KNEE
cases since chart was compiled.
Stack-Intramedullary
194
Fixation
in Knee
Fusion
38 3c 3* FIG.3. FI. C., after resection of the joint, excision of the patella and trimming of the condyles; note the passage of the nai1 through the posterior part of the intercondylar notch and posterior dispIacement of the tibia to meet it. A, x-ray taken in the operating room; B and c, after fusion and removal of the nail. In upper ic) note that the trap door in the femur is stiI1 visibIe.
The proximal opening of the tibiaI meduIIary cana is then identified. A suitabIe rectanguIar opening is then made in the anterior surface of the femoraI shaft, Iarge enough to admit the pin and to aIIow the proximal end to be de-
tibia1 opening is pIaced opposite and the driving is continued far into the tibia1 meduIIary cavity. (Fig. 3.) While this is being done, counter pressure is made against the foot and attention is paid to the rotatory aIinement. The
TABLE III CHARCOTKNEE Name
Sex, Race, Age
Side
Wound HeaIing
Fusion
Primary
No
Right Primary
No
M, W, 63
Left
Primary
Yes
F, W, 64 F, W, 67 M. C, 48 M, W, 68 M, C, 54
Left
Primary Primary Primary Primary Primary
No NO No PossibIy Too earIy
HI. w.
M, C,
I. M.
F, C,
R. H. P. L. A. K. B. M.
48 46
Left
Right
Right Right Right -
Complications
?
Pin wandered distaIIy and joint disrupted seven months after operation; amputation was done and wound dehiscence made secondary dosure necessary Fracture of the nail at joint IeveI four months postoperativeIy; new and Ionger nai1 inserted which aIso fractured three months after insertion Fracture of femur at site of trap door; fracture heaIed as knee was fusing None None None None None up to time of writing
pressed. The entire extremity is then adducted to get more cIearance at the upper end of the pin and passage through the femur is started. When the pin appears at the intracondylar notch, the
anterior portions of the condyies are then trimmed and this canceIIous bone is packed into any surface inequaIities about the resected joint. The wound is closed in Iayers and a presAmerican
Journal
of Surgery
Stack-IntrameduIIary sure dressing apphed. A heavy posterior moId of pIaster during the immediate postoperative period and a watking cyhnder from the upper thigh to the ankle is used after the wound is healed and the sutures removed. If the knee is to be fused in fuII extension, as seemed particuIarIy desirabIe in the Charcot group of cases, the nail will emerge at the intracondyIar notch of the femur somewhat posterior to the centra1 point. This is due to the fact that one cannot depress the pin at its upper end sufficiently to cause it to be actually paraIIe1 with the femur, because of the interposition of the soft parts of the anterior thigh. With the naiI emerging posteriorIy, it wilt be necessary to displace the tibia somewhat posteriorIy in order to bring the opening of the meduhary canal of the tibia opposite the end of the pin. This position causes the femoraI condyIes to be unduIy prominent anteriorIy and this is one reason we have trimmed these down and removed the pateHa. We see no objection to the use of the canceIIous bone of the condyIes if free of disease as material to aid in the deveIopment of fusion. It is admitted that this procedure nar-
Fixation
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Fusion
FIG. 4. I. M., fracture of the naiI whiIe walking in a cylinder cast; it was removed and another nail inserted.
FIG. 5. R. H., fracture of the femur at site of entrance point of the nail; patient was placed in a single hip spica cast. Fracture healed and knee fused.
March,
I 932
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FIG. 6. Shows the tendency of the nail to wander proximahy; in no instance did a naiI wander distally.
rows the weight-bearing surfaces of the fused knee. Whether this has any significance in regard to future fracture complications remains to be seen. When the knee is fused in the optimum position of functional flexion, the insertion of the pin is much easier, the trap door in the femur is more distaI and the surfaces do not have to be narrowed as much as in the other instances. Kiintscher2 suggests the use of a long naiI (65 cm.) for the average thigh, driven from the femoral trochanter a11 the way through the femur and then across the knee into the tibia. This obviates the opening in the femoral shaft and has the advantage of not weakening the femur at the point of nail entrance in the Iower third. However, the method can be used only if the knee is to be ankylosed in complete extension, and in many instances this position is not desirable. We have used three types of pin, the cyIindrica1 curtain rod type with a IongitudinaI sIit for the guide, the diamond shape and the clover Ieaf type. We believe there is no choice among them for this particular work. (Figs. 4 to 7.) In concIusion, the method described utilizes the impaction principle which is desirable in arthrodesis because it permits early weightbearing with light cast protection and with complete freedom of motion in a11 but the affected joint. The time required for sohd bony fusion compares favorabIy with other methods.
FIG. 7. The nail lies in the interosseous space instead of the medullary canal of the tibia. No nerve or vascuIar comphcations occurred and it was allowed to remain until fusion of the knee was complete. It was then withdrawn through a small incision of the soft tissue at the distal end. REFERENCES I. CHOPCHAL.Intramedullary
pinning for arthrodesis of the knee joint. J. Bone EYJoint Surg., 30: Ig& 2. K~~NTSCHER, G. Eingurhrung in Die WarknageIung. J. internat. cbir., I I: xg3r. DISCUSSION
OF PAPERS
CAROTHERS PEDERSEN
AND AND
BY DRS.
LYONS, DAY,
SMITH,
QUIGLEY,
AND STACK
CHARLES S. VENABLE (San Antonio, Tex.): I want to comment on the report that Dr. Pedersen made on the subject of &ding grafts in fracture of the tibia, which I beIieve has been a forgotten child too Iong. I think it is one of the most important
American
Journal
of Sureerv
Stack-Intramedullary factors, particularIy in tibia1 fractures, if there has been a deIay, if there is a period when we have a delayed union, to get some fresh bone. I think a sIiding graft is one of the best answers we have ever had, provided we foIIow the precedent that is offered today by Dr. Pedersen in using a Iarge enough &ding graft, to take a11 the weight-bearing and a11 the resistance necessary during the period of heaIing. I wouId Iike to make the comment that a properly sized sIiding graft is a most vaIuabIe adjunct. It does not need hardware. Very often there may be a screw above or beIow, but for goodness sake, foIIow the doctor’s precept and make them Iarge enough. Apropos of fractures of the OS caIcis, we overIook the tension on the posterior segment at the attachment of the tendo-AchiIIes and the strong muscIes of the caIf of the Ieg. We waste a Iot of time trying to manipuIate and nail together or screw together and fix these fractures with the continued tension of the tendon of AchiIIes. I found a long time ago that if I wouId simpIy divide the tendo-AchiIIes by a Z incision (it wiI1 grow together again), you can then contro1 the fractures of the OS caIcis, particuIarIy in its posterior segment without resistance, and you do not have so much hardware in the foot, and IittIe, if any, permanent disabiIity. BARBARA STIMSON (Poughkeepsie, N. Y.): When Dr. QuigIey asked me to discuss his paper, I do not think he knew that I had the privilege of wearing a walking cast for about four weeks Iast summer for fractures of the metatarsaIs. I wouId Iike to say I agree with him whoIeheartedIy. I have had similar very bad results from aIIowing plated or screwed tibias to walk in a waIking iron, aIthough they seemed to be firmIy fixed, and I think one of the great problems he has brought out is the tendency for a11 patients in a walking cast to rotate the foot outward. I think a11 of you who have used waIking casts have been interested in the ingenuity of your patients in trying to cover their toes. Whether they wear ski-boots or a stocking or stockinette, they wouId Iike to have something to cover the toes. I was in the same situation. You want to protect your toes from being bumped as you walk around. I was going on vacation in Maine and I wanted to get out in the woods and I wanted to cover the rocks and pick blueberries. However, I did not quite see how I was going to do it. So I stopped at a friend’s moccasin shop on my way to Maine and, between us, we devised a moccasin-type toe to fit on the end of a waIking boot. I have tried it out on my patients and have found that it makes a great dea1 of difference in the way they walk. Their toes are protected and they are not afraid, therefore, to do the heeI-toe walk which they should do.
March, 1932
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297
Incidentally, the women patients Iike it very much because it is not a bad-Iooking shoe type. This is one that wiI1 fit any type of boot and either Ieg. It heIps prevent this rotation walk, as I say, and I speak feeIingIy because I have tried it. KELLOGG SPEED (Chicago, III.): The Canadians have contributed importantIy to the treatment of fractures of the calcaneus. I need onIy mention Fraser Curd, Sr., who believed that the fractured foot shouId be encased in a shoe, not aIways pIaster of Paris, as soon as possibIe, and weight-bearing shouId be inaugurated at once for the fuI1 amount, subIimina1 to unbearabIe pain, with no effort at reduction of any kind. Wilson’s fracture oration before the American College of Surgeons some years ago reviewed this whole subject very weI1, and GalIie’s bone grafting operation for squash fractures with painful subastragalar joint is known to al1 of us. FinaIIy, Harris’ monumental work on the foot, incIuding fractured OS calcis, was based on the recent study of recruits taken in the Canadian Army during World War II. The resuIts after any treatment of fractures of the caIcaneus may be interpreted from two standpoints: (I) the functiona return of the use of the foot based mainIy on the freedom from pain and the ability to wear an ordinary make shoe, with a wage-earning activity invoIved and (2) the cosmetic resuIt, incIuding the sweIIing and genera1 appearance aIong with some sort of acceptabIe x-ray examination so often required as a measure of cure in settling the compensation cases in the courts of many states in the United States instead of the resuIts of the cIinica1 examination of the functiona return and the abiIity to work which Dr. Carothers cared to stress. In Iooking at the shape of the caIcaneus, you cannot help but believe how impossibIe it is, once fractured, to moId or weld it into normal former shape; yet there are certain orthodox lines of treatment that may be required. In a case of an avuIsion fracture and tearing off of the posterior portion, it is doubtfu1 whether you couId get away with a Iarge fragment puIIed off and a gross deformity without some form of operative procedure. The OS caIcis is restored to norma shape by a very simpIe method, namely, passing a bone transpIant through both fragments for lixation. Also in the compIete crush fracture, with the distortion of the subastragaIar and other joints and the loose fragments in the hee1, we have terrific probIems. That is what Ieads to the pain. In the oId orthodox form, you and the genera1 practitioner may attempt to moId them into shape and yet the patient will often end up with a distortion and thickening, giving a painfu1 pressure under the maIIeoIus. I do not beIieve too much vaIue lies in the tuber angle. I do not adopt that as a criterion at all, but the spreading of the bone and the pressure under
298
Stack-IntrameduIIary
the malleoh can be seen. That distortion is really very worth whiIe attempting to correct. In the distortion, in the broken heeI as compared with the normaI, we see why we get that pressure. In some cases I have thinned that down by an operation, making the caIcaneus appear aImost Iike the normaI, and thus reIieving some of the symptoms. In the chronic painful subastragalar joint folIowing a heaIing of a compression fracture in which there has been no manipuration and perhaps the wearing of no support at any time and too early weight-bearing, if it is a severe fracture, we may adapt GaIIie’s method by inserting a transpIant through the taIus in this direction directed forward. It does not have to go a11 the way through the subastragaIar joint. After a few months, you get beginning union, filling in with bone, and the same hee1 four years later shows a compIete fusion of the joint and relief of the pain from the weight-bearing. ESLIE ASBURY (Cincinnati, 0.): I think Dr. Carothers has given us a very common sense method of handling fractures of the OS caIcis. It is reaIIy a revoIutionary return to first principIes. We have wandered tremendousIy in the treatment of fractures of the OS calcis and, aIthough Dr. Carothers’ method is unorthodox, it certainIy has worked out. I have seen a number of these cases and I know the resuIts are good. I have aIso used the method myself, with far better results than with the usua1 orthodox methods that we have been in the habit of using in the Iast ten or fifteen years. I think Dr. Quigley’s articIe iIIustrates we should never use waIking casts in fractures of the OS caIcis unti1 after about Jive weeks. I think in my use of waIking casts in these cases, the resuIts have been very bad, and I beIieve Dr. QuigIey showed us the reason. I think Dr. Stack’s paper, in which he described a case of successfu1 fusion of a Charcot joint, proved that we must be very carefu1 about weightbearing with our mechanical interna hxation gadgets. As to sIiding grafts, in thirty years’ use of no other method in the treatment of these cases, that is to say of non-union of the Iower third of the tibia, I have never seen it necessary to use interna fixation. I have never seen but two initia1 faiIures, and both of them obtained union with second operation. J. HUBER WAGNER (Pittsburgh, Pa.): I think I wouId be remiss if I did not say that I enjoyed the exceIIency of a11 of these papers, and the paper of Dr. QuigIey is timeIy. It is something I think we can a11 take home, give it a IittIe more thought, and probabIy a IittIe propagandizing among some of our younger coIIeagues who love to get their
Fixation
in Knee
Fusion
patients up the next day on a waIking spIint, rcgardIess. My primary purpose nova, however, is to bring to your attention that the essayists today, in discussing their cases, used the terms simpIe and compound fractures. As you know, there was adopted by the Fracture Committee of the American CoIlege about 1948 a resoIution attempting to give up the terms simpIe and compound for more distinctive and descriptive words, nameIy, open and cIosed fractures, when referring to what we used to caI1 simple and compound. The purpose was that we wouId use these terms foIlowing, I beIieve, the Enghsh custom I am sure the essayists are aware of the fact that this movement is afoot and it has been augmented by the American Orthopedic Association. I believe that in the future this society should give fuI1 support to the adoption of that terminology and the discussants or the essayists in the future shouId be carefu1 about this nomenclature. We should attempt to keep up with modern usage. FRASER N. GURD (MontreaI, Can.); There was one feature of Dr. QuigIey’s paper that I do not want to Iet go unmentioned. Early protected weight-bearing rather runs in my famiIy and the implication might be taken from his paper, aIthough I am sure it was not his intention, that in ankIe joint fractures the waIking cast beIow knee was very often bad treatment. I agree about the tibia and JibuIa and about the OS caIcis, provided ordinary judgment is used. However, in the ankIe joint fractures, my one pIea is not to forget the mechanism of reduction of the fracture, even weeks Iater. ManifestIy, if an external rotation fracture is put up in a walking cast in anything for forced interna rotation, it wiI1 slip. SimiIarIy, if a JibuIar flexion fracture is put up without pushing the foot into tibia1 flexion at the last moment before the pIaster dries, it, too, wil1 sIip when these torsion forces which he mentioned come into pIay. Again, in the tibia1 flexion fracture the original mechanism must be remembered and must be overcorrected at the time that the walking cast is put on, be it perhaps weeks later. I am not advocating that patients be up walking for a bimaIIeoIar fracture the next day, but I do beIieve that, after experience has shown that sufhcient gIuing of the fragments has occurred to make weight-bearing safe, provided these precautions of correction of the origina mechanism are taken at the time the cast is appIied, the uItimate end resuIt is very much better if the stimuIus of weightbearing is applied as early as possibIe to the bones and soft tissues about the ankIe joint. HENRY C. MARBLE (Boston, Mass.): I think Dr. Smith’s presentation makes it abundantIy
American Journal of Surgery
Stack-IntrameduIIary clear that he joins us in his dissatisfaction in the matter of intervertebral discs. We are dissatisfied (I) with the etiology or that conception of the etioIogy as to whether it is degenerative disease or whether it is the result of a single trauma; (2) with the diagnosis and a11 the factors being put together to make the diagnosis; (3) with the method, the indications for or against surgica1 operation, for or against conservative procedure, and (4) with the results. We are evaIuating these end resuIts. Dr. Aitken has written one paper, and I have aIso coIIaborated in a paper studying the end results. I might say for myself that I have never operated on an intervertebra1 disc and I never wiI1. They say the best umpire is the man who never pIayed basebalI; therefore, perhaps the best man to evamate these cases wouId be the man who never did one. We must have the evaIuation medical and not Iegal. When legal gentIemen get into medicine, they make exactly the same mess of medicine that doctors do when they try to get into Iaw. Hasn’t the time come for us to evaIuate these things on a pureIy medical basis and to let the IegaI side of it drop by the wayside? I must confess that I do not understand an evaIuation which is based upon a comparison of the Ioss of use of the arm for a disc which is in the Iumbar spine. That is the legal side of it. I think that one of the things which a society such as this might, with profit, do is to form a committee or to form some unit which couId standardize such a very vaIuabIe, such a very necessary study as this. In this way we are a11 taIking the same Ianguage, using the same methods, the same means, and the same yardstick of evaluation so that in the end we couId say, in a medica way, what we believe is the proper procedure both as to the etioIogy, diagnosis, procedure and evaIuation of end resuIts. CARLO SCUDERI (Chicago, III.): I wouId Iike to say a few words about Dr. Stack’s paper. It has been an excelIent presentation. I have had the opportunity of seeing some of these fiIms at the County HospitaI and he has taught me two very vaIuabIe points. One is that this type of arthrodesis is exceIIent. If you have adequate exposure, you can certainly get a good reapposition of the arthrodes-
March,
1952
Fixation
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299
ing surfaces and you can keep them in contact. You aIso can get these peopIe up and about much earlier without weight-bearing and practicalIy no pain once the wound is healed. The second thing that I Iearned from him was exempIifred in the case in which the pin did not go where the surgeon thought it was going. In the two cases that we have done we have Iearned to spend a IittIe time taking the anteroposterior and IateraI x-ray film in the operating room, before closing that wound up, to be sure the pin is in the medullary canaI. I do not Iike to disagree with an oIder man; but if I understood what Dr. VenabIe said, I want to voice one very strong objection. I heartiIy disapprove of the compIete section of the tendon of AchiIIes to treat a fracture of the OS calcis. We have other methods of positiona relaxation of the tendon of AchiIIes that may not be as complete as a complete section of the tendon surgicaIIy, but in the few cases I have tried to repair of acute Iaceration of the tendon of AchiIIes, I beIieve it is better if we do not do it surgicaIIy, as this produces an additiona serious source of disability. Whether or not Dr. VenabIe may have meant partial section, I do not know; but if he meant complete section of the tendon of Achilles, I want heartiIy to disagree with him. THOMAS B. QUIGLEY (cIosing): There is no basic disagreement, I think, between the essay and Dr. Curd’s remarks. What I was trying to say in perhaps a roundabout fashion is that there is no substitute for surgical judgment in the treatment of fractures beIow the knee. The name Gurd, as we a11 know, has been associated with surgical judgment in Iarge measure for very many years. RALPH G. CAROTHERS (cIosing): I wouId Iike to point out just one thing which I may not have stressed, and that is that we must forget these IateraI views and these angIes of BayIor and get down to what we see in the anteroposterior view in other words, what has happened to the bone IateraIIy. I have had the experience of aIIowing a patient to have no treatment when the OS caIcis on one side was very bad and the OS caIcis on the other side was apparentIy very sIightIy injured. That compression from side to side, I think, is necessary.
T
HE intrameduIlary fixation principIe has been accepted in the treatment of certain fractures. It is natura1, then, that the inquiry should be made to determine its usefulness in other conditions. ChopchaI’ reported seven instances in six patients in which he used this method. The conditions were paraIysis of the limbs foIIowing poIiomyeIitis, two; rheumatoid arthritis, three; fibrosis ankyIosis with flexion deformity, two. A review of his work suggested that the method was a practica1 one, offered the patient many advantages so far as postoperative comfort and ambulation were concerned, and seemed to involve no unwarranted risk in either the earIy or Iate postoperative period. In this discussion of indications and contraindications he made the statement, “Of course intrameduIIary pinning of the knee is not possibIe in cases of inffammatorv diseases of the joint where arthrodesis is indicated. Here another technic has to be empIoyed.” Our first appIication of the method three years ago was in the fusion of a joint, painfu1 and greatIy impaired in function by a vaIgus deformity and instabiIity. This came about over a period of years and a number of traumas causing the joint to be of no use. The second instance, shortly after, was the fusion of a knee with severe hypertrophic changes. Ten years before this knee had been subjected to a joint dkbridement and it was serviceabIe for about eight years, after which gradual recurrence of pain, Iimited motion and instabiIity appeared. The postoperative course of these two patients after intrameduIIary fixation was so smooth and reIativeIy short that we were convinced of the merit of the method. During this period we had on the service an aduIt female with tubercuIosis of the right hip. In the course of a Brittain ischeofemora1 arthrodesis a Iarge tubercuIous abscess Iying in the distended inferior portion of the joint was entered at the time of osteotomy. The osteotomy site was flooded with pus and the open March,
1952
end of the meduIIary cana of the femur was exposed. Aspiration and cIeaning of the area were done but probabIy imperfectIy from the bacterioIogic standpoint. The operation was continued, the opening in the ischeum made, and a suitabIe tibia1 graft taken and driven across in the usua1 manner. The wound in the region of the hip and that of the Iower Ieg heaIed by primary intention. The bone transpIant was successfu1 and the patient went on to firm fusion without compIications. AI1 this was done under a heavy cover of peniciIIin and streptomycin, to which she showed no untoward reaction. This instance corroborates in a smaI1 way the numerous papers that have appeared in recent Iiterature stressing the point that streptomycin has brought about a new era in the management of skeIeta1 tubercuIosis. It has been accepted that with the use of this drug in adequate dosage and over the proper period of time, we are abIe to subject these patients to surgica1 procedures much earIier than in the past, and we are justified in using surgical measures that have been rejected as carrying unwarranted risk in the days before antibiotics were avaiIabIe. (Fig. I.) The Ktintscher nai1 was used for intrameduIIary fixation in tubercuIosis of the knee in six cases (TabIe I): two cases in which the disease was primariIy synovia1 with earIy bone invasion and no contractures; two cases in which both synovia1 and osseous invoIvement were present with contractures of 44 to 60 degrees; and two with synovia1 and osseous change but no contractures, as they had been previousIy treated by traction and pIaster fixation for rather long periods of time. AI1 the wounds in this tuberculosis group healed uneventfuIIy and in average time, and in each instance the knee went on to solid fusion. When the patient’s genera1 condition warranted, as judged by the temperature, body weight and sedimentation rate, a light cylinder cast was appIied from the upper thigh to the ankIe, and 291
Stack-IntrameduIIary
Fixation
in Knee
Fusion
FIG. I. A. W., typica case of tuberculosis of the knee with external rotation deformity; by the intermeduIIary nail method.
FIG. 2. H. W., typica Charcot series.
of the cases in the
later fused
weight-bearing was permitted with crutches or cane aid as the patient desired. In the hypertrophic arthritic group (TabIe II) no wound compIications were met and it was possible for them to be ambulatory somewhat sooner than those with tubercuIosis. In the Charcot group (TabIe III) the postoperative ambuIation time of the patients depended mostIy on the intensity of nervous system invoIvement. Those without a tabetic gait and no other joint invoIvement did about as we11as the hypertrophic patients, whiIe those with advanced cord changes or with other unstabIe joints were reIativeIy sIow. (Fig. 2.) The operation is done through a Iong median parapateIIar incision extending from just beIow the middIe of the thigh to the tibia1 tubercIe. We have not used a pneumatic cuff on the thigh because the buIk of the cuff prevents depression of the upper end of the Kiintscher nai1 when one attempts to insert it through the trap door of the femur in as near a paraIIe1 course to the femur as possible. A Iess buIky hemostatic device such as the Esmarck or Martin bandage couId probably be used. After the knee is open, the pateIIa is excised and a synovectomy is done if indicated. We usuaIIy did this in the tubercuIous and Charcot joints but not in the hypertrophic joints. The knee is then flexed sharply and the joint surfaces are resected and fitted. American
Journal
of Surgery
Stack-IntrameduIIary
Fixation TABLE
TUBERCULOSIS
Name
Sex, Race, Age
Side
Type
M. W.*
M, W, 5 I
Righ t
(3sseous and synoviat
J. G. M. L.t
h4, w,
21
M,
43
Righ t !same ‘ Left same
H. S.$
M, C, 32
Left
‘
A. W.5
F, C, 56
Righ t
!same
E.
M, W, 56
Righ t :same
Q.S
W,
same
293
I
-
-
Wound Healing
Fusion Time (mo.)
Primary
8
1‘racture
Primary Primary
4 7
I\lOtK I\Jone
Primary
6
1Irained from sinus not associated with
Primary
5
Iione
Primary
6
1Vane
Deformity
45O Aexion contracture None 3o” Aexion contracture None
Fusion
OF THE KNEE.
-
-
in Knee
Complications
of tibia at distal end of pin
wound three months postoperatively
- I
90° rotation contracture ,60” Aexion contracture H
-
-
-
* Fracture healed in normal time; it was caused by pressure of the pin against the anterior cortex. The tibia was very porotic from long disuse. t Also had clinical tubercuIosis of Iungs, spine and tendon sheaths of right wrist; died one year after the operation of miliary disease. $ AIso had tubercuIosis of right shouIder. $ Under treatment for pulmonary lesion.
TABLE ARTHRITIS
8Sex, Race,
Name
Side
Age
Left
M, W, 44
Traumatic
s. P.
M, W, 33
Right
1Rheumatoid
W. T.
M, W, 61
Right
1Hypertrophic
T. B.
M,W,5r
Left
Traumatic
c. H.t
M, W, 63
Left
t3Id
L. H.
P, C, 57
Right
-
Fusion Time (mo.1
Wound Healing
Symptoms
-
fracture pateIIa with infected repair and non union
Primary
Pain, quadriceps weakness, valgus deformity 15’ contracture limited Aexion, pain Pain, 10’ contracture Pain, limited motion, drainage from sinus tract Drainage, pain, Iimited motion
Transient
peroneal
nerve
palsy
Swelling, pain, weakness
-
5
-
Primary
3
None
Primary
5
None
Primary
6
None
Drainage continued but no extrusion took pIace Primary
6
None
8
None
-
* Nerve recovery at time fusion was complete. t Died nine months after operation of carcinoma of the bladder; two additiona
March, 1952
Complications
._
-_ H. c.*
Type
II
OF THE KNEE
cases since chart was compiled.
Stack-Intramedullary
194
Fixation
in Knee
Fusion
38 3c 3* FIG.3. FI. C., after resection of the joint, excision of the patella and trimming of the condyles; note the passage of the nai1 through the posterior part of the intercondylar notch and posterior dispIacement of the tibia to meet it. A, x-ray taken in the operating room; B and c, after fusion and removal of the nail. In upper ic) note that the trap door in the femur is stiI1 visibIe.
The proximal opening of the tibiaI meduIIary cana is then identified. A suitabIe rectanguIar opening is then made in the anterior surface of the femoraI shaft, Iarge enough to admit the pin and to aIIow the proximal end to be de-
tibia1 opening is pIaced opposite and the driving is continued far into the tibia1 meduIIary cavity. (Fig. 3.) While this is being done, counter pressure is made against the foot and attention is paid to the rotatory aIinement. The
TABLE III CHARCOTKNEE Name
Sex, Race, Age
Side
Wound HeaIing
Fusion
Primary
No
Right Primary
No
M, W, 63
Left
Primary
Yes
F, W, 64 F, W, 67 M. C, 48 M, W, 68 M, C, 54
Left
Primary Primary Primary Primary Primary
No NO No PossibIy Too earIy
HI. w.
M, C,
I. M.
F, C,
R. H. P. L. A. K. B. M.
48 46
Left
Right
Right Right Right -
Complications
?
Pin wandered distaIIy and joint disrupted seven months after operation; amputation was done and wound dehiscence made secondary dosure necessary Fracture of the nail at joint IeveI four months postoperativeIy; new and Ionger nai1 inserted which aIso fractured three months after insertion Fracture of femur at site of trap door; fracture heaIed as knee was fusing None None None None None up to time of writing
pressed. The entire extremity is then adducted to get more cIearance at the upper end of the pin and passage through the femur is started. When the pin appears at the intracondylar notch, the
anterior portions of the condyies are then trimmed and this canceIIous bone is packed into any surface inequaIities about the resected joint. The wound is closed in Iayers and a presAmerican
Journal
of Surgery
Stack-IntrameduIIary sure dressing apphed. A heavy posterior moId of pIaster during the immediate postoperative period and a watking cyhnder from the upper thigh to the ankle is used after the wound is healed and the sutures removed. If the knee is to be fused in fuII extension, as seemed particuIarIy desirabIe in the Charcot group of cases, the nail will emerge at the intracondyIar notch of the femur somewhat posterior to the centra1 point. This is due to the fact that one cannot depress the pin at its upper end sufficiently to cause it to be actually paraIIe1 with the femur, because of the interposition of the soft parts of the anterior thigh. With the naiI emerging posteriorIy, it wilt be necessary to displace the tibia somewhat posteriorIy in order to bring the opening of the meduhary canal of the tibia opposite the end of the pin. This position causes the femoraI condyIes to be unduIy prominent anteriorIy and this is one reason we have trimmed these down and removed the pateHa. We see no objection to the use of the canceIIous bone of the condyIes if free of disease as material to aid in the deveIopment of fusion. It is admitted that this procedure nar-
Fixation
in Knee
Fusion
FIG. 4. I. M., fracture of the naiI whiIe walking in a cylinder cast; it was removed and another nail inserted.
FIG. 5. R. H., fracture of the femur at site of entrance point of the nail; patient was placed in a single hip spica cast. Fracture healed and knee fused.
March,
I 932
295
Stack-IntramedulIary
Fixation
in Knee
Fusion
FIG. 6. Shows the tendency of the nail to wander proximahy; in no instance did a naiI wander distally.
rows the weight-bearing surfaces of the fused knee. Whether this has any significance in regard to future fracture complications remains to be seen. When the knee is fused in the optimum position of functional flexion, the insertion of the pin is much easier, the trap door in the femur is more distaI and the surfaces do not have to be narrowed as much as in the other instances. Kiintscher2 suggests the use of a long naiI (65 cm.) for the average thigh, driven from the femoral trochanter a11 the way through the femur and then across the knee into the tibia. This obviates the opening in the femoral shaft and has the advantage of not weakening the femur at the point of nail entrance in the Iower third. However, the method can be used only if the knee is to be ankylosed in complete extension, and in many instances this position is not desirable. We have used three types of pin, the cyIindrica1 curtain rod type with a IongitudinaI sIit for the guide, the diamond shape and the clover Ieaf type. We believe there is no choice among them for this particular work. (Figs. 4 to 7.) In concIusion, the method described utilizes the impaction principle which is desirable in arthrodesis because it permits early weightbearing with light cast protection and with complete freedom of motion in a11 but the affected joint. The time required for sohd bony fusion compares favorabIy with other methods.
FIG. 7. The nail lies in the interosseous space instead of the medullary canal of the tibia. No nerve or vascuIar comphcations occurred and it was allowed to remain until fusion of the knee was complete. It was then withdrawn through a small incision of the soft tissue at the distal end. REFERENCES I. CHOPCHAL.Intramedullary
pinning for arthrodesis of the knee joint. J. Bone EYJoint Surg., 30: Ig& 2. K~~NTSCHER, G. Eingurhrung in Die WarknageIung. J. internat. cbir., I I: xg3r. DISCUSSION
OF PAPERS
CAROTHERS PEDERSEN
AND AND
BY DRS.
LYONS, DAY,
SMITH,
QUIGLEY,
AND STACK
CHARLES S. VENABLE (San Antonio, Tex.): I want to comment on the report that Dr. Pedersen made on the subject of &ding grafts in fracture of the tibia, which I beIieve has been a forgotten child too Iong. I think it is one of the most important
American
Journal
of Sureerv
Stack-Intramedullary factors, particularIy in tibia1 fractures, if there has been a deIay, if there is a period when we have a delayed union, to get some fresh bone. I think a sIiding graft is one of the best answers we have ever had, provided we foIIow the precedent that is offered today by Dr. Pedersen in using a Iarge enough &ding graft, to take a11 the weight-bearing and a11 the resistance necessary during the period of heaIing. I wouId Iike to make the comment that a properly sized sIiding graft is a most vaIuabIe adjunct. It does not need hardware. Very often there may be a screw above or beIow, but for goodness sake, foIIow the doctor’s precept and make them Iarge enough. Apropos of fractures of the OS caIcis, we overIook the tension on the posterior segment at the attachment of the tendo-AchiIIes and the strong muscIes of the caIf of the Ieg. We waste a Iot of time trying to manipuIate and nail together or screw together and fix these fractures with the continued tension of the tendon of AchiIIes. I found a long time ago that if I wouId simpIy divide the tendo-AchiIIes by a Z incision (it wiI1 grow together again), you can then contro1 the fractures of the OS caIcis, particuIarIy in its posterior segment without resistance, and you do not have so much hardware in the foot, and IittIe, if any, permanent disabiIity. BARBARA STIMSON (Poughkeepsie, N. Y.): When Dr. QuigIey asked me to discuss his paper, I do not think he knew that I had the privilege of wearing a walking cast for about four weeks Iast summer for fractures of the metatarsaIs. I wouId Iike to say I agree with him whoIeheartedIy. I have had similar very bad results from aIIowing plated or screwed tibias to walk in a waIking iron, aIthough they seemed to be firmIy fixed, and I think one of the great problems he has brought out is the tendency for a11 patients in a walking cast to rotate the foot outward. I think a11 of you who have used waIking casts have been interested in the ingenuity of your patients in trying to cover their toes. Whether they wear ski-boots or a stocking or stockinette, they wouId Iike to have something to cover the toes. I was in the same situation. You want to protect your toes from being bumped as you walk around. I was going on vacation in Maine and I wanted to get out in the woods and I wanted to cover the rocks and pick blueberries. However, I did not quite see how I was going to do it. So I stopped at a friend’s moccasin shop on my way to Maine and, between us, we devised a moccasin-type toe to fit on the end of a waIking boot. I have tried it out on my patients and have found that it makes a great dea1 of difference in the way they walk. Their toes are protected and they are not afraid, therefore, to do the heeI-toe walk which they should do.
March, 1932
Fixation
in Knee
Fusion
297
Incidentally, the women patients Iike it very much because it is not a bad-Iooking shoe type. This is one that wiI1 fit any type of boot and either Ieg. It heIps prevent this rotation walk, as I say, and I speak feeIingIy because I have tried it. KELLOGG SPEED (Chicago, III.): The Canadians have contributed importantIy to the treatment of fractures of the calcaneus. I need onIy mention Fraser Curd, Sr., who believed that the fractured foot shouId be encased in a shoe, not aIways pIaster of Paris, as soon as possibIe, and weight-bearing shouId be inaugurated at once for the fuI1 amount, subIimina1 to unbearabIe pain, with no effort at reduction of any kind. Wilson’s fracture oration before the American College of Surgeons some years ago reviewed this whole subject very weI1, and GalIie’s bone grafting operation for squash fractures with painful subastragalar joint is known to al1 of us. FinaIIy, Harris’ monumental work on the foot, incIuding fractured OS calcis, was based on the recent study of recruits taken in the Canadian Army during World War II. The resuIts after any treatment of fractures of the caIcaneus may be interpreted from two standpoints: (I) the functiona return of the use of the foot based mainIy on the freedom from pain and the ability to wear an ordinary make shoe, with a wage-earning activity invoIved and (2) the cosmetic resuIt, incIuding the sweIIing and genera1 appearance aIong with some sort of acceptabIe x-ray examination so often required as a measure of cure in settling the compensation cases in the courts of many states in the United States instead of the resuIts of the cIinica1 examination of the functiona return and the abiIity to work which Dr. Carothers cared to stress. In Iooking at the shape of the caIcaneus, you cannot help but believe how impossibIe it is, once fractured, to moId or weld it into normal former shape; yet there are certain orthodox lines of treatment that may be required. In a case of an avuIsion fracture and tearing off of the posterior portion, it is doubtfu1 whether you couId get away with a Iarge fragment puIIed off and a gross deformity without some form of operative procedure. The OS caIcis is restored to norma shape by a very simpIe method, namely, passing a bone transpIant through both fragments for lixation. Also in the compIete crush fracture, with the distortion of the subastragaIar and other joints and the loose fragments in the hee1, we have terrific probIems. That is what Ieads to the pain. In the oId orthodox form, you and the genera1 practitioner may attempt to moId them into shape and yet the patient will often end up with a distortion and thickening, giving a painfu1 pressure under the maIIeoIus. I do not beIieve too much vaIue lies in the tuber angle. I do not adopt that as a criterion at all, but the spreading of the bone and the pressure under
298
Stack-IntrameduIIary
the malleoh can be seen. That distortion is really very worth whiIe attempting to correct. In the distortion, in the broken heeI as compared with the normaI, we see why we get that pressure. In some cases I have thinned that down by an operation, making the caIcaneus appear aImost Iike the normaI, and thus reIieving some of the symptoms. In the chronic painful subastragalar joint folIowing a heaIing of a compression fracture in which there has been no manipuration and perhaps the wearing of no support at any time and too early weight-bearing, if it is a severe fracture, we may adapt GaIIie’s method by inserting a transpIant through the taIus in this direction directed forward. It does not have to go a11 the way through the subastragaIar joint. After a few months, you get beginning union, filling in with bone, and the same hee1 four years later shows a compIete fusion of the joint and relief of the pain from the weight-bearing. ESLIE ASBURY (Cincinnati, 0.): I think Dr. Carothers has given us a very common sense method of handling fractures of the OS caIcis. It is reaIIy a revoIutionary return to first principIes. We have wandered tremendousIy in the treatment of fractures of the OS calcis and, aIthough Dr. Carothers’ method is unorthodox, it certainIy has worked out. I have seen a number of these cases and I know the resuIts are good. I have aIso used the method myself, with far better results than with the usua1 orthodox methods that we have been in the habit of using in the Iast ten or fifteen years. I think Dr. Quigley’s articIe iIIustrates we should never use waIking casts in fractures of the OS caIcis unti1 after about Jive weeks. I think in my use of waIking casts in these cases, the resuIts have been very bad, and I beIieve Dr. QuigIey showed us the reason. I think Dr. Stack’s paper, in which he described a case of successfu1 fusion of a Charcot joint, proved that we must be very carefu1 about weightbearing with our mechanical interna hxation gadgets. As to sIiding grafts, in thirty years’ use of no other method in the treatment of these cases, that is to say of non-union of the Iower third of the tibia, I have never seen it necessary to use interna fixation. I have never seen but two initia1 faiIures, and both of them obtained union with second operation. J. HUBER WAGNER (Pittsburgh, Pa.): I think I wouId be remiss if I did not say that I enjoyed the exceIIency of a11 of these papers, and the paper of Dr. QuigIey is timeIy. It is something I think we can a11 take home, give it a IittIe more thought, and probabIy a IittIe propagandizing among some of our younger coIIeagues who love to get their
Fixation
in Knee
Fusion
patients up the next day on a waIking spIint, rcgardIess. My primary purpose nova, however, is to bring to your attention that the essayists today, in discussing their cases, used the terms simpIe and compound fractures. As you know, there was adopted by the Fracture Committee of the American CoIlege about 1948 a resoIution attempting to give up the terms simpIe and compound for more distinctive and descriptive words, nameIy, open and cIosed fractures, when referring to what we used to caI1 simple and compound. The purpose was that we wouId use these terms foIlowing, I beIieve, the Enghsh custom I am sure the essayists are aware of the fact that this movement is afoot and it has been augmented by the American Orthopedic Association. I believe that in the future this society should give fuI1 support to the adoption of that terminology and the discussants or the essayists in the future shouId be carefu1 about this nomenclature. We should attempt to keep up with modern usage. FRASER N. GURD (MontreaI, Can.); There was one feature of Dr. QuigIey’s paper that I do not want to Iet go unmentioned. Early protected weight-bearing rather runs in my famiIy and the implication might be taken from his paper, aIthough I am sure it was not his intention, that in ankIe joint fractures the waIking cast beIow knee was very often bad treatment. I agree about the tibia and JibuIa and about the OS caIcis, provided ordinary judgment is used. However, in the ankIe joint fractures, my one pIea is not to forget the mechanism of reduction of the fracture, even weeks Iater. ManifestIy, if an external rotation fracture is put up in a walking cast in anything for forced interna rotation, it wiI1 slip. SimiIarIy, if a JibuIar flexion fracture is put up without pushing the foot into tibia1 flexion at the last moment before the pIaster dries, it, too, wil1 sIip when these torsion forces which he mentioned come into pIay. Again, in the tibia1 flexion fracture the original mechanism must be remembered and must be overcorrected at the time that the walking cast is put on, be it perhaps weeks later. I am not advocating that patients be up walking for a bimaIIeoIar fracture the next day, but I do beIieve that, after experience has shown that sufhcient gIuing of the fragments has occurred to make weight-bearing safe, provided these precautions of correction of the origina mechanism are taken at the time the cast is appIied, the uItimate end resuIt is very much better if the stimuIus of weightbearing is applied as early as possibIe to the bones and soft tissues about the ankIe joint. HENRY C. MARBLE (Boston, Mass.): I think Dr. Smith’s presentation makes it abundantIy
American Journal of Surgery
Stack-IntrameduIIary clear that he joins us in his dissatisfaction in the matter of intervertebral discs. We are dissatisfied (I) with the etiology or that conception of the etioIogy as to whether it is degenerative disease or whether it is the result of a single trauma; (2) with the diagnosis and a11 the factors being put together to make the diagnosis; (3) with the method, the indications for or against surgica1 operation, for or against conservative procedure, and (4) with the results. We are evaIuating these end resuIts. Dr. Aitken has written one paper, and I have aIso coIIaborated in a paper studying the end results. I might say for myself that I have never operated on an intervertebra1 disc and I never wiI1. They say the best umpire is the man who never pIayed basebalI; therefore, perhaps the best man to evamate these cases wouId be the man who never did one. We must have the evaIuation medical and not Iegal. When legal gentIemen get into medicine, they make exactly the same mess of medicine that doctors do when they try to get into Iaw. Hasn’t the time come for us to evaIuate these things on a pureIy medical basis and to let the IegaI side of it drop by the wayside? I must confess that I do not understand an evaIuation which is based upon a comparison of the Ioss of use of the arm for a disc which is in the Iumbar spine. That is the legal side of it. I think that one of the things which a society such as this might, with profit, do is to form a committee or to form some unit which couId standardize such a very vaIuabIe, such a very necessary study as this. In this way we are a11 taIking the same Ianguage, using the same methods, the same means, and the same yardstick of evaluation so that in the end we couId say, in a medica way, what we believe is the proper procedure both as to the etioIogy, diagnosis, procedure and evaIuation of end resuIts. CARLO SCUDERI (Chicago, III.): I wouId Iike to say a few words about Dr. Stack’s paper. It has been an excelIent presentation. I have had the opportunity of seeing some of these fiIms at the County HospitaI and he has taught me two very vaIuabIe points. One is that this type of arthrodesis is exceIIent. If you have adequate exposure, you can certainly get a good reapposition of the arthrodes-
March,
1952
Fixation
in Knee
Fusion
299
ing surfaces and you can keep them in contact. You aIso can get these peopIe up and about much earlier without weight-bearing and practicalIy no pain once the wound is healed. The second thing that I Iearned from him was exempIifred in the case in which the pin did not go where the surgeon thought it was going. In the two cases that we have done we have Iearned to spend a IittIe time taking the anteroposterior and IateraI x-ray film in the operating room, before closing that wound up, to be sure the pin is in the medullary canaI. I do not Iike to disagree with an oIder man; but if I understood what Dr. VenabIe said, I want to voice one very strong objection. I heartiIy disapprove of the compIete section of the tendon of AchiIIes to treat a fracture of the OS calcis. We have other methods of positiona relaxation of the tendon of AchiIIes that may not be as complete as a complete section of the tendon surgicaIIy, but in the few cases I have tried to repair of acute Iaceration of the tendon of AchiIIes, I beIieve it is better if we do not do it surgicaIIy, as this produces an additiona serious source of disability. Whether or not Dr. VenabIe may have meant partial section, I do not know; but if he meant complete section of the tendon of Achilles, I want heartiIy to disagree with him. THOMAS B. QUIGLEY (cIosing): There is no basic disagreement, I think, between the essay and Dr. Curd’s remarks. What I was trying to say in perhaps a roundabout fashion is that there is no substitute for surgical judgment in the treatment of fractures beIow the knee. The name Gurd, as we a11 know, has been associated with surgical judgment in Iarge measure for very many years. RALPH G. CAROTHERS (cIosing): I wouId Iike to point out just one thing which I may not have stressed, and that is that we must forget these IateraI views and these angIes of BayIor and get down to what we see in the anteroposterior view in other words, what has happened to the bone IateraIIy. I have had the experience of aIIowing a patient to have no treatment when the OS caIcis on one side was very bad and the OS caIcis on the other side was apparentIy very sIightIy injured. That compression from side to side, I think, is necessary.