How can the modern orthopedic surgeon help the general practitioner in the treatment of chronic diseases?

HOW CAN THE MODERN ORTHOPEDIC SURGEON HELP THE GENERAL PRACTITIONER IN THE TREATMENT OF CHRONIC DISEASES? LEO MAYER, NEW YORK,

T

M.D.

(Received for publication Oct. 1, 1959)

N. Y.

0 avoid

the danger

of a boring

encyclopedic

type of paper and to make

my

contribution as practical as possible I am going to ask you, my readers, to listen to an imaginary conversation between an elderly physician with a large rural general lent

practice

training,

town.

The

has

and his young

passed

father

is eager

the

that there is a reversal

role of the aging

examinations

to get his son’s

eager to tell his dad the fascinating it happens

son, an orthopedic

his Board

Socrates,

story

point

elderly

who, after

has settled

excel-

in a nearby

of view and the son is equally

of up-to-date

of the Socratic the

surgeon

and

orthopedic

surgery.

Thus

method : the young man assumes

father

that

of the

inquiring

young

student. know,

FATHER.-YOU

I read my J.A.M.A. to fall behind.

every

I’m glad you’re

your knowledge SON.-Dad, with

have

of rickets

to

keep

up

is happening

with that

the

times.

I’m beginning to help me with

fun to work with you. my

Of course,

practice

includes

patients

I’m not referring

of every

to fractures

age,

and acute

we dis-

conditions.

first

thing

observed:

that

I must

tell

you

is something

is the marked

diminution

you

unquestionably

in the number

of cases

and scurvy.

FATHER.-I 50 years

since

the children.

eases but to chronic already

try

so much

going to be in the neighborhood

it will be great

SON.-The

I

but

of orthopedics.

FATHER.-Suppose, start

Son, week

should

ago rickets

say

an emphatic

was a common

YES.

disease.

When The

I began

farmers’

practicing

wives

didn’t

here know

anything about vitamin D. They rarely gave their babies orange juice and they were afraid of exposing them to the sun. Now that has changed. But even now, in the small towns, particularly among the Negroes and Italians, I find an occasional child with severe rachitic bowlegs and knock knees. SON.-Send such children to me. We can cure such deformities by osteotomies or, if the children

are young

enough,

by an osteoclasis.

FATHER.-What’s that? SON.-Fracturing the bones manually or with a special instrument called an osteoclast. Actually, in my residency I saw only a few such cases because Dr.

Hess’s

pioneer

work

on the prevention 470

of rickets

has had

such widespread

HOW CAN ORTHOPEDIST HEI>P GENERAL PRACTITIONER?

x2,m,er ‘8’ recognition

that

be treate’d

the disease

by means

It is, of course,

is a rarity.

of corrective

obvious

that

Milder

braces

the diet

cases

or plaster

must

of rickets of Paris

be carefully

can

to cry. His bleeding

made the diagnosis

controlled.

do you do with congenital

SoN.-There, diaper.

Dad,

to diaper

The

diaper

you have

a great

the babies

should

with

be carefully

folded

frog position.

of Bologna

dislocations ever,

late Dr. Putti

suspect

you

There’s

The

in northern

genitals

advantage

with a strip

metal

splint

is shallow

until the children vessels

to the femoral

is likely

to result

are best treated without

any anesthetic

FATHER.-HOW SON.-Please started

early.

braces teriorly. plaster often

clubfeet?

Most

of these

and

in severe

To reduce a Kirschner of Paris

slant

you had better

of permanent

easily and therefore

Then

usually

that

great

the blood

rough treatment

necrosis.

These

babies

by Hoke of Atlanta,

it can be slipped

danger

into the

of trauma.

I still see quite a few. by plaster

But

to correction

occasionally

of equinus position

which

Clubfeet

are very

prone

of years

until

Jones

Achilles

capsule

of the OS calcis

the OS calcis

Sir Robert

a tight

the ankle

out for a number

correction.

send to me, because

It has been shown

devised

use

are not diagnosed

for treatment

wire into

the

a great

an abnormal

are amenable

cases

pelvis.

can be prevented

to me as soon as you can,

the equinus

dressing.

be carried

of the

of Czechoslovakia,

dislocations

using the method

such as the Denis-Browne.

be divided, serting

about

of

If, how-

and there’s

dislocation

Many

and with minimal

send those

the incidence

film

by Frejka

to the

but if you cover

of the head due to aseptic

traction,

called

of Haifa,

to pull the head down to the acetabulum. socket

x-ray

the roof shows

head can be ruptured

by gentle

enough

and

the dislocation.

in deformity

Teach an extra

such as the one used by Leffman

begin to walk. Those

be used in reducing

with

technique.

is minimal,

devised

the splinic even if the head is not dislocated. care must

an

of x-ray,

a complete

pillow splint

abduction

If the acetabulum

get

the danger

Frequently

patients.

is frequently

by this simple

to

bed he

C.

it will be thick

to what

of lead the danger

use of the rubber

or by a light

about

your

was able to reduce

markedly

be sure

nowadays

in early diagnosis.

by the early Israel.

very

a dislocation

a lot of talk

baby’s

Italy

to the

his

hemorrhages

wide apart

so that

corresponding

near

of vitamin

to help

legs held

hold the legs in wide abduction,

admitted

hip dislocations?

chance

the

splints.

And as for

subperiosteal

easy. And the cure was rapid with plenty

FATuER--What the mothers

gums and the characteristic

frequently

corrective

of children scurvy, I saw only one case among the thousands hospital. That child’s legs were so sensitive that if you came began

471

should of Paris tendon

must

Mayer

to recur

and

has advised into

treatment

the orthopedic

used to apply

must

be cut

can be incorporated surgeon

a critical

test,

be and posinthe

must is sure i.e., the

ability of the patient actively to evert the foot by means of the peroneal muscles. Even this test, however, is not always conclusive. It is advisable to continue the braces

even

after

the foot

mately normal form. FATXER.-Son, has any progress

use of special

shoes

and night

been

made

in solving

these deformities occur? SON -The most significant

has assumed the mystery

work has been done by a Hindu,

approxiof how

Dr. Duraiswami.

472

J.Chron. Dis

MAYER

While

in Liverpool

Johnson

with

Bryan

he demonstrated

stances

into the chick

deformities.

deformities. FATHER.--I measles

during

McFarland

the amazing

embryo.

Of course,

that

know,

June, 1961

and

effects

also

in Baltimore

of injecting

insulin

He was able to produce

does not mean

too,

that

her pregnancy

when

her baby

that

one

hip and spinal

patients

develops

into

for the Aid of Crippled

the cause of congenital

abnormalities.

which you may see, since it is rather

Children There

frequent:

We had at least 10 such cases in the hospital by a constriction enough

of the sheath

of your anatomy,

department sheath.

taught

Dad,

to locate

me how to cure

Naturally,

that

them:

you must be careful

is one little deformity my 3 years.

tendon. just

run close to the sheath.

One of our cases was bilateral.

when she saw her baby

using

all very well, Son,

serious

SON.-Now

you’re

let me congratulate of severe when

spinal

were

students

of tuberculosis

Hospital

in New York

pathetic

youngsters.

formities. their

methods

orthopedic

of them

made

chemotherapeutic

demonstrated sick patients.

Dr. David

Was

that

mother

a thumb.

But what are

My

filled

told

with

At the old Ruptured those

me that

long-standing and

ward was occupied

who lived developed

Crippled by these severe

Fusions

of the hip were also performed

a great

contribution

in high altitudes; But

attack,

Bosworth

“attendings”

were

First,

one of the main causes

de-

came in 1911 when Hibbs and Albee published

did the same at sea level.

recent

of the

I could talk for hours.

for reducing beds

died;

the spine.

in Leysin

effect of heliotherapy

and iproniazid.

seldom

practitioners

90 per cent of the children’s

of fusing

Rollier

and Calve tively

such a big field that

of the hips and spine. Many

portion

nerves of the thumb

normally!

to talk of curing

disease-tuberculosis. the

are caused

of the hip and the spine?

The first big step forward

cessfully. curative

opening

you general

hip and

they

cases

troubles

They

the tight

which

FaTHER.-That’s

in infants

of the thumb.

The head of our orthopedic

divide

not to cut the sensory its thumb

and studies

I hope you remember

happy

you doing about

Foundation

a flexion contracture during

I don’t

in their far-reaching

of the flexor longus pollicis;

these

German

to be born deaf or blind.

can do much about that. suppose you “orthopods” SON.-NO, we cannot. But we are supporting the National also the Association

Bob sub-

we know how to prevent

of my

is likely

clubfeet,

with

and other

by

at Berck-Plage

more important

suc-

demonstrating in France,

the Calot

has been the compara-

first by streptomycin,

at the Sea View Hospital

then

by isoniazid

in New York

has

the amazing effects of these drugs in a large series of desperately His success has revolutionized the method of treatment. It is now

necessary

to fuse either

the hip or the spine.

Instead,

we can attack

the

focus, excise the diseased bone, implant the appropriate chemical, and expect the wounds to heal per primam. DeRoy and Fisher of Pittsburgh have published papers on a convincing series of spinal cases. In Israel, where there is much tuberculosis among the impoverished immigrants, Dr. Seidenmann has had similar results. So, if you see a case of bone tuberculosis send me the patient. I’m not yet able to match Dave Bosworth, but he has taught me enough to help your patient. There’s a much larger group of patients who will consult you, Dad, because

Volume 13 Number 6

HOW

CAN ORTHOPEDIST

HELP GENERAL

PRACTITIONER?

473

of a hip limp, not due to tuberculosis. Those in the younger age group, 6 to 10 years, are usually suffering from Calve-Perthes disease; in the older group, 11 to 14, from slipping of the femoral epiphysis. Both require expert orthopedic attention. In Calve-Perthes disease there is an aseptic necrosis of the femoral head and the metaphysis. Why it occurs we do not know, but we do know that during the cycle of the disease, which lasts about 3 years, the softened bone must be protected from weightbearing. Operations have been tried, but without much effect. In slipped epiphysis, on the other hand, operation is of the greatest value. This consists in fixing the head to the neck either by an appropriate nail, by long screws, or by a bone graft. The results are brilliant. The patients are cured and may socln resume normal activity. Delay, however, invites disaster; the head may slip so far as to cause a serious deformity. So don’t wait; better send the patient by ambulance, if he lives at a distance. FATHER.-Thanks, Son. I’ll try to remember your warning. Tell me now a little about scoliosis. SON.-That’s another big topic. The subject is still controversial, but great advances have been made. One of my teachers, who worked in Germany before World War I, told me a little story to illustrate the defeatist attitude of that timeand remember that Germany was then in the forefront of orthopedic development. He asked a noted German orthopedic professor how long he would treat a case of scoliosis. The answer was, “Till the bill amounts to 500 marks.” Now the defeatist spirit has been replaced by one of hopeful confidence. The pioneer work of Russell Hibbs, continued by his pupil, J. C. Risser, by John Cobb, J. H. Moe, and others who relied on spinal fusion, and the conservative efforts of the Milwaukee school, headed by Walter Blount, have enabled us to straighten many a crooked back. The way is long, arduous, and expensive, but the results are encouraging. I hope Dad, that you will educate your patients to watch the backs of their children and send them to me before the curve has become fixed. FATHER.-we’ve been so busy talking about bones that we haven’t said a word thus far about paralyses. I’m glad to tell you that in these last years, since I’ve been injecting the Salk vaccine, I have seen only 2 new cases of polio, and both were mild. There are, however, still a number of my patients suffering from paralytic deformities. What should I do with them? %x.--Send them to me. The surgical correction of such deformities is one of the most fascinating fields of orthopedic surgery. By means of tendon transplants, joint fusions, and other plastic procedures we can improve almost every case. I want to tell you about one of my fellow residents who developed polio as a sequence of volunteering to fight an epidemic in North Carolina. His right arm became useless because of a paralysis of the elbow and shoulder muscles. One of Iour “attendings” did a Steindler tendon transplant at the elbow and a fusion of the shoulder. The result was a strong arm with which the young doctor was ablce to resume operating, apply plaster dressings, swim, and play tennis. Another case made a deep impression on me because of the dramatic cure of a pelvic obliquity which caused a discrepancy in leg length of 4 inches. The patient, a young woman, was able to discard her brace and high shoe and her limp almost

474

J. Chron. Dis. June, 1961

MAYER

disappeared.

Other

instruction

patients

do

not

require

operations,

but

need

and a useful member Can you say a hopeful

more

intensively

spastic

type,

tremor.

About

Naturally,

troubled

word about

and no, Dad.

SON.-Yes

disease

Dr. Winthrop

and has divided

children

with

cerebral

Phelps of Baltimore

athetosis,

of the patients

it is the mentally

my

it into different

there are cases showing one-third

by

normal

groups.

ataxia,

has studied Besides

rigidities,

with

insists on the value

mild

spasticity

who

seen he is losing out to such men as Eggers of Galveston,

the dramatic

results of various

of tight structures, formed

arthrodeses,

for the special

and hundreds

of patients

cases of spastic I’m sure I’ve

Silver of Providence,

operations

study

of cerebral

are receiving

equinus,

palsy;

Even

Texas,

lengthening,

Bill

divisions

A new society

yearly

meetings

treatment.

or scissors

to help them.

the best but from

who have demonstrated

procedures.

constructive

knee contractures,

learnt enough

treatment,

such as tendon

and other plastic

impairment.

have

what I’ve

and Carroll

of nonoperative

the

the usual

and congenital

have some degree of mental

Dr. Phelps

of New York,

palsy.

them?

prognosis.

been

and

of his community. really

FATHER.-I’m

Cooper

braces

in how to use them. Our aim with each one is to make him independent

gait,

the difficult

has

are held,

If you have any send them

to me;

hand cases can be

improved. FaTHER.-That ways

in which

sounds encouraging.

an orthopedic

our talk were to stop

fines itself to children

the orthopedic Gibney

an American

straight,

hospital,

cases that even to you.

But

surgery

no longer

You know that Andre,

and until the beginning

the old Hospital

con-

the father

from two Greek words pais (a child) of the twentieth

century

did little more than try to make the child straight. the first to introduce

if

I hope

my adult cases.

for orthopedic

the word orthopaedia

surgeon

was, I think,

to go ahead,

as it did at its beginning.

coined

and orthos, meaning

I’d feel grateful

for I want to learn about

I want

course

of our specialty,

In fact, Son, you have told me so many can help my pediatric

right here and now,

we can go ahead talking SON.-of

surgeon

an orthopedic

for Ruptured

ward

Virgil

for adults

and Crippled

into

in New York.

Now that the orthopedic surgeon has taken over the treatment of fractures and other traumas of the extremities, his practice has become more and more devoted to adults. an old-time

But that is a phase of our work which practitioner,

know very

well which

needs no elaboration. accident

and when you have to call for help. I want to discuss disease who probably

represent

the largest percentage

You,

as

cases you can manage

the patients

with chronic

of your practice.

Actually,

the orthopedic surgeon cannot contribute much to the treatment of the patients with cardiovascular disease who fill your waiting room. But I want to call your attention

to the statement

recently

issued

by the National

Health

Committee

prepared by eight eminent physicians regarding the factors which predispose an individual to arteriosclerosis, heart attack, and stroke. One of the five factors was overweight. We orthopedists are greatly interested in suitable exercises to help reduce obesity. Maybe you think that exercises would be injurious to the arteriosclerotic individual, but then you would be at variance with these doctors, five of whom were past presidents of the American Heart Association, who held

Volume13 Number6

475

HOW CAN ORTHOPEDIST HELP GENERAL PRACTITIONER?

that moderate physical activity tended to lessen the hazards of arteriosclerosis. If a cerebral accident occurs and the patient survives, the resultant hemiplegia can be made amenable cated;

t’races

Achilles which

may

tendon draws

to orthopedic

may

into

and Rehabilitation

right

excellent

away

given

tendon about

a month,

operatic’n.

the tibialis

yes.

Very

but

very worrisome difficult

for

the

men

In general nowadays toms of degeneration

.bypressure

caused without

traction

once

considered

ideas

have

about

patients

been

tendon

border

of the

Medicine

treated

with

an old disease.

a

I can

who would probably

Can you lengthen

be

the Achilles

at one sitting?

may

be allowed

in plaster

removal

and

the

of the plaster. backache.

controversy

should

for

after

who I know have

or recurrent

orthopedist treatment

of Paris

out of bed 2 weeks

after

with chronic the

anticus

They

rages

be conservative

been

are also

high

among

or operative.

the cases fall into two groups: first, those with definite sympof the intervertebral disc usually accompanied by leg pain of the extruded

discal symptoms.

after

cases

leg is immobilized

immediately

trained

whether

new

are indithe short

of Physical

with you a group of patients

to you-those

cases

experier.ced

are begun

to discuss

tibialis

to the outer

At the Institute

you suggest.

The

the patients

Exercises

Now I want

overactive

of these

anticus

easily.

and massage

leg; even better,

be shifted

of old hemiplegic

for the operation

and transfer

SON-Oh,

many

me some

of a couple

candidates

the

can

into eversion.

in New York

fair degree of success. FATHER.-You’ve

and

inversion

its action

Exercises

the paralyzed

be lengthened

the foot

foot so as to convert

think

treatment.

be used to support

disc against

a lumbar

In the first group, if symptoms

has been

applied,

painful

and

a myelogram

dangerous,

should

can

now

nerve;

second,

do not subside be performed.

be considered

those

promptly This

test,

innocuous

if

done by an experienced surgeon. It is valuable both in confirmation of the diagnosis of herniated disc and in deciding the level of the involved disc or discs. Remember, been

Dad,

proved

companied hospital,

frequently

the removal by a fusion

where

combination occasional

that

I had

of fusion case.

Both

several

of the disc

of the adjacent my residency, with

is indicated. vertebrae half

disc removal;

groups

seemed

discs are involved. Whether is another

If a herniation this

should

be ac-

moot subject.

In the

the attending

surgeons

believed

the other

reserved

fusion

satisfied

with

half their

has

results.

in a

for the

I, myself,

have

not as yet had sufficient experience to reach a final decision but I find that my patients, are getting along well without fusion and I can get them out of bed 10 days after the laminectomy and disc removal. The decide

other

group

lvhether

traumatic,

the

visceral,

manifestations. The general practitioner, as the cause

of cases,

those

symptoms or anatomic treatment, can usually

of backache.

Since

are

without due

disc symptoms,

to postural

abnormalities,

defects,

neoplasms,

require arthritis, or

analysis

to

repeated

psychoneurotic

of course, varies with the etiology. You, as a spot the patient with a fixed retroverted uterus you take

x-ray

films you will also recognize

at

once the occasional case of spondylolisthesis. Incidentally, not all of these require fusion; some do very well with a good corset. Once in a blue moon you may see a spinal. neoplasm. At our hospital we had 3 cases of osteoid osteoma causing

J. Chron. Dis. June, 1961

MAYER

476 backache.

They

to operate

upon successfully,

are difficult

as if by magic.

You

can readily

nosis and treatment. FATHER.-Having the difficulties

had

quite but

seem to be. If my back

for backache

I try to determine

in the roentgenogram is removed

a little

backache

Fusion

I am fully

5 years.

the cause of the back

of

as you

a visit from me, but I

but I haven’t

In treating

pain. This

aware

by the problem

used to be very popular

the past

field this is for diag-

myself

I am not as fascinated

gets to be too bad you can expect

during

and also difficult

the pain will disappear

see, Dad, what a fascinating

you mention,

do not want a fusion. SON.-Don’t worry. a fusion

to diagnose

but if the osteoma

backs

performed

conservatively

is frequently

postural

or due

to arthritis,

the kind of work, the bed, or some other detail in the life of the patient. and chemotherapy, including local injections I use appropriate braces, exercises,

of hydrocortisone tients

in pinpoint

in the hospital

Very

few branches

treatment

areas

of sensitivity.

for a preliminary of my work

of painful

backs,

FATHER.-while

period

require

as much

you’re

on the subject

of the intervertebral are promptly support ation

of backs,

changes.

The

who came disturbance

of the offending

trolling

his bow.

if the lesion to me because Fortunately,

condition completely. FATHER.-I had SoN.-Possibly shoulders quently is visible

are the

with subsequent in the x-ray,

disc;

the neck.

to the

has been that by trauma,

surgeons

pleased

cervical

symptoms

favor

approach

early

may

others explor-

be anteroof injection

I remember

and paresthesia

cervical

many

by the results

localized.

I

may be a herniation

use of a well-fitted

the surgical

can be sharply

one noted

of the right

thumb.

was so marked that he had great difficulty in cona single injection of hydrocortisone relieved the hydrocortisone

shoulders,

that’s result

progressive

of numbness

no idea

I have tried it for painful

localized

spine there

cases are caused

I have been much

of sensation

usually

cases my experience

of the most

pa-

bed rest.

as the nonoperative

tell me about

and the subsequent

of the chronic

as well as posterior.

of hydrocortisone cellist

In most

Some

are

to put

most cases can be helped.

As in the lumbar

by traction

Many

and removal

lateral

disc.

relieved

or collar.

by arthritic

plexus.

I have

or of simple

ingenuity

but, with persistence

guess you consider that part of the back. SON.-Of course, but the symptoms spine and the cervical

Frequently

of traction

true,

but

I’m

of microscopic tendonitis

could

but I’m afraid sure tears

I could of the

and deposition

try to hit the deposit

be used

for

my technique teach

you.

supraspinatus

of calcium.

with the needle.

that Most

painful

tendon,

If a calcium Inject

purpose.

is not too good. fre-

deposit

first 3 or 4 C.C.

of procaine solution or a similar local anesthetic, then 1 C.C. of hydrocortisone solution. Often this is followed by a painful reaction lasting a few hours, but then the pain and muscle spasm begin to subside. If no calcium deposit is visible aim the needle at the most sensitive point and inject close to the humerus. Usually 4 or 5 injections are sufficient to cure. Occasionally there will be a resistant case which will require open operation for removal of a calcium deposit. Of course there are other cases due to involvement of the long head of the biceps. FATHER.-DO you realize, Son, that we’ve been chatting for over an hour

Volume

13

Number

6

HOW CAN ORTHOPEDIST

and I haven’t those

with

yet heard

chronic

in my practice

GENERAL

a word from you about

arthritis.

I wonder

and how troublesome was coming

SON.-1

HELP

a large group

whether

you realize

they can be both

to them

next.

Of course,

their

medical

treatment

than

I do. I’m sure that

with

the corticosteroids

and

that

effects.

I usually

has become I confine

work

pain may be a torn meniscus and

of the synovial in the

fusion.

Some

of Boston been

more

The

the best

‘is not easily and Dr.

operation.

answered.

Larsen

is similar.

Mr.

in Iowa

the Smith-Petersen

City

If, however,

Vitallium

have

arthritic source

may joint

be done,

cartilage,

notably

for years

of

If the degener-

Dr.

are

a

Kuhns

have

not

particularly

fusion.

If the process

Alexander

The

fat pad. of the

side

the field

but my attempts

suffered

about

fine results

the main

a synovectomy

material;

have

more

of new drugs.

cases.

with arthroplasty,

after a successful

At the hip the problem is, I think,

who

number

selected

ulceration

are

of the disturbing

In the knee

extensive,

as interposition

patients

you know

retropatellar

marked

had good results

who uses nylon to the surgeon

with

there

and to me.

to help me since

in the

by operation. is very

cases

men have

encouraging.

grateful

membrane

severe

Dad,

are such a confusing

or an inflamed

of my patients-

how many

you have had some

also seen some

to surgery

be helped

477

to themselves

in rheumatology

and there

my orthopedic

knee and hip can often ation

you’ve

call in a specialist

so complicated

PRACTITIONER?

both

is confined

to one hip, fusion

hips are involved

Law in London,

demonstrated

remarkably

cup, but few others

the question

Dr. Aufranc

in Boston,

good

results

with

have been able to achieve

the

same degree of exquisite technique which they possess. The insertion of prosthetic appliances, either of metal or plastic material, though hailed at first as the perfect which

:solution, consists

from pan

but leaves

Scaglietti

not

we must we stop

many

permanent

cures.

of the head and angulational

resects

with a limp. The

the enlarged

try to learn

the best results

Before

given

the patient

who simply

to me that it gives

has

of resection

Milch

operation, gives

relief

same holds for the method head.

Consequently,

how to do the Smith-Petersen

in the bilateral

this long talk

femoral

The

osteotomy,

of

it seems

operation

since

cases.

I must

tell

you about

my experience

with

a

few cases of gouty tophi located

in the hand and foot. Some of these had ulcerated

through

and were causing

the skin, were infected,

lying bone was involved. the involved

bone,

I treated

packing,

these

much pain. In some the under-

with excision

and local antibiotics.

of the tophi,

All of them

healed

curettage

of

remarkably

well. FATHER.-Son, will

be glad

you

you became

have

taught

an orthopedic

me

a lot. surgeon.

1 am

sure

many

of my

patients