Treatment of orthopedic

disorders

Orthopedic treatment
categories:

falls

into

three

1)No treatmentsimply reassurance or advice;

2)Non-operative treatment;
3)Operative treatment. In even case these three
possibilities of treatment should be considered
one by one in the order given. At least half of
the patients attending orthopedic out-patient
clinics (excluding cases of fracture) do not
require treatment: all that they need is
reassurance and advice. In many cases the sole
reason for the patient's attendance is that he
fears that he may have cancer, tuberculosis,
impending paralysis or other serious disease. If
he can be reassured that there is no evidence of
serious disease he goes away satisfied, and his
symptoms immediately become less disturbing.

If active treatment seems to be required

it is a good general principle that
whenever practicable a trial should be
given first to non-Operative measures;
though obviously there are occasions
when
early
or
indeed
immediate
operation
must
be
advised.
Most
orthopedic operations fall into the
category of 'luxury' rather than lifesaving procedures. Consequently the
patient should seldom be persuaded to
submit himself to operation: rather
should he have to persuade the surgeon
to undertake it. When one is undecided
whether
to
advise
conservative
treatment or operation it is wise always
to err on the side of non-intervention

METHODS OF NON-OPERATIVE
TREATMENT
1-Rest
Rest has been one of the mainstays of orthopedic
treatment. Complete rest demands recumbency in
bed or immobilization of the diseased part in
plaster. But by 'rest' the orthopedic surgeon does
not necessarily mean complete inactivity or
immobility. Often he means - no more than 'relative
rest', implying simply a reduction of accustomed
"activity and avoidance of strain. Indeed complete
rest is required much less often now than it was in
the past, because diseases for which rest was
previously important, such as poliomyelitis or
tuberculosis, can now be prevented or are more
readily amenable to specific remedies such as
antibacterial
agents.
Complete
rest
after
operations, formerly favored, has given place in
most cases to the earliest possible resumption of
activity.

2-Support
Rest and support often go together; but
there are occasions when support is needed
but not rest for example, to stabilize a joint
rendered insecure by muscle paralysis, or to
prevent the development of deformity.
When support is to be temporary it can be
provided by a cast or splint made from
plaster of Paris or from one of the newer
splinting materials. When it is to be
prolonged or permanent an individually
made surgical appliance,
or orthosis, is
required. Examples in common use are steelreinforced lumbar corsets, spinal braces,
cervical collars, wrist supports, walking
calipers, below-knee steels with ankle
straps, and devices to control drop foot.

3-Physiotherapy
Physiotherapy in its various forms occupies an
important place in the non-operativeand in the
post-operativetreatment
of
orthopedic
disabilities. Being easily prescribed, and entailing
no trouble to the surgeon, it is no doubt often
misused with the result that much treatment is
given that can have no beneficial effect, except
perhaps psychologically. Enlightened teaching and
a more scientific basis to practice has helped to
produce an awareness among physiotherapists of
the hazards as well as the merits of their art. This
has led to a correct emphasis being placed upon
the value in many conditions of active rather than
of passive treatment: in other words, of helping
the patient to help himself. This approach is
particularly rewarding in the rehabilitation of
patients after injury or after operation, and in
diseases such as poliomyelitis, cerebral palsy,
hemiplegia, and peripheral nerve palsies.

When it is used, physiotherapy should

be pursued thoroughly. Halfhearted
treatment at infrequent intervals is
unlikely to be helpful. Ideally it should
be practiced daily and the patient
should also be taught to treat
himself whenever possible, in addition
to-exercise regimes, physiotherapists
now have a wide range of electro
physical techniques available for the
treatment of both acute and chronic
disorders
of
the
musculoskeletal
system.

A-Active exercises. Exercise may be given for three

purposes:
To mobilize joints;
To strengthen muscles;
and
To improve coordination or balance. In mobilizing
exercises the patient's active efforts to move the
joint may be assisted by gentle pressure by the
physiotherapist's hand (assisted active exercises).
In muscle-strengthening exercises the patient is
encouraged to contract the weakened muscles
against
the
resistance
of
weights
or
springs, the resistance being increased as the
muscles
gain
power.
Exercises
to
improve
coordination are of particular importance in cerebral
palsy. Hydrotherapy. Hydrotherapy is a valuable
way of allowing active pain-free movements ' of all
joints in warm water. The warmth and buoyancy of
the water relieve muscle spasm and thus help to
reduce pain. Thus hydrotherapy may be particularly
useful in the treatment of rheumatoid polyarthritis.

B-Passive joint movements. The chief use of

passive movements, or 'mobilization', is to
preserve full mobility when the patient is
unable to move the joint activelythat is, when
the muscles are paralyzed or severed. They are
important in poliomyelitis and after nerve
injuriesespecially to preserve mobility in the
hand. Recently the use of machines to provide
continuous passive motion of joints after
operation or injury has become popular to
minimize complications and encourage healing
of articular cartilage.
Certain movements that are not under the
control of the patient may also be used
passively for treatment purposesnotably
distraction, which is commonly employed, for
instance, in the treatment of prolapsed cervical
disc and of certain other painful conditions of
the spinal column.

C-Electrical stimulation of muscles. If a muscle

has
its
nerve
supply
intact
electrical
stimulation
is
of
little
importance
in
increasing muscle strength: active exercises
are
generally
much
more
effective.
Nevertheless, electrotherapy does sometimes
have a place when used in conjunction with
exercisesfor example, in improving the
function of the intrinsic muscles of the foot, in
restoring activity to a quadriceps muscle that
has been inhibited after operation on the
knee, or in re-education after a tendon
transfer operation. Since the nerve supply is
intact the muscle may be stimulated through
its motor nerve by 'faradism' (that is, by
shocks of short duration (1 ms at 50 Hz)
induced by an electronic stimulator).

If the muscle is denervated (for instance,

after a peripheral nerve injury) it may be
stimulated electrically while recovery of
nerve function is awaited, in order to
retard the process of fibrosis that occurs
after about two years in any denervated
muscle. Such a muscle can be stimulated
only by 'galvanism'that is, by shocks of
relatively long duration (100-1000 ms at
frequency of 5-1.5 Hz) which stimulate
the muscle fibres directly, not through
its motor nerve. There is nothing to be
gained from prescribing this treatment if
recovery of nerve function within two
years cannot be hoped for.

D-Electro physical agents. These may be used to alter

the local temperature in the tissues by up to 10C,
either by the direct application of heating or cooling
agents, or by inducing an increase in temperature
with electromagnetic waves.
Local heat can be easily applied to the superficial
tissues with hot packs, infra-red lamps and paraffin
wax baths. The heat results in vasodilatation,
reduced, muscle spasm, and "decreased pain. Heating
effects can also be induced in deeper tissues,
including joints, by the use of short-wave and
microwave diathermy. The technique has the
additional
benefit
of
stimulating
circulatory
mechanisms and is particularly useful for joint
disorders including muscle and tendon tears,
hematoma, bursitis, and synovitis.
Ultrasound waves at about 1Q6 Hz can be projected as a
beam from a transducer to induce a heating effect in
deep tissues. They may also produce benefit from
their mechanical and chemical effects on collagen and
proteoglycans. Ultrasound is frequently used to
reduce post-traumatic hematoma, edema, and
adhesions" of joints and their associated soft tissues.

Cryotherapy by the application of ice or cold packs

may also be used to produce vasoconstriction
and to block pain pathways in the treatment of
acute traumatic and inflammatory swelling.
Interferential therapy and transcutaneous nerve
stimulation are now gaining popularity for the
treatment of chronic and intractable pain,
particularly when this is of sympathetic origin,
such as causalgia and reflex sympathetic
dystrophy. The interference effect uses two
differing
medium frequency alternating currents applied
simultaneously
through
two electrodes to
induce a current at the site of rheir interaction in
the
deep
tissues.
Transcutaneous
nerve
stimulation uses direct current pulses of
adjustable frequency to stimulate the larger
sensory
nerve fibers selectively and thereby to set up a
gate control mechanism blocking the activity
of the small fibers which conduct pain signals.

4-Local injections
The indications for local injections fall into two
.groups:
1)Osteoarthritis or-rheumatoid arthritis, in-which
the substance (usually hydrocortisone with or
without a local anaesthetic solution) is injected
directly into the affected joint with rigid aseptic
precautions; and
2)Extra-articular lesions of the type often ascribed
(for want of more precise knowledge) to chronic
strain,
as
exemplified
by
tennis
elbow,
tendonitis about the shoulder, and certain types
of back pain. The response depends upon the
nature of the basic lesion: permanent relief is
often gained in extra-articular lesions such as
tennis elbow, but in arthritis the benefit is often
no more than temporary, and repeated
injections are seldom to be recommended.

5-Drugs
Drugs
have
rather
a
small
place
in
orthopaedic practice. Those used may be
placed in seven categories: 1) antibacterial
agents; 2) analgesics; 3) sedatives; 4) antiinflammatory drugs; 5) hormone-like drugs; 6)
specific drugs; and 7) cytotoxic drugs.
Antibacterial
agents
are
of
immense
importance in infective lesions, especially in
acute osteomyelitis and acute pyogenic
arthritis. To be successful treatment must be
begun very early. These drugs are also of
definite value in certain chronic infections,
notably in tuberculosis.
Analgesics should be used as little as possible.
Many orthopaedic disorders are prolonged for
many weeks or months, and it is undesirable
to prescribe any but the mildest analgesics
continuously over long periods, except for
incurable malignant disease.

Sedatives may be given if needed to promote

sleep, but as with analgesics the rule should be
to prescribe no more than is really necessary.
Anti-inflammatory drugs are those that damp
down the excessive inflammatory response that
may occur especially in rheumatoid arthritis and
related disorders, by inhibiting prostaglandin
formation.
Non-steroidal
anti-inflammatory
drugs are generally to be preferredespecially
in the first instanceand they are a mainstay in
the treatment of rheumatoid arthritis. Many of
these drugs also have an analgesic action. The
powerful steroids cortisone, prednisone and
their analogues should be used with extreme
caution
and
indeed
should
be
avoided
altogether whenever possible, because through
their side effects they may sometimes do more
harm than good.

Hormone-like drugs include the corticosteroids

noted
above,
and
sex
hormones
or
analogues used for the prevention of
osteoporosis in postmenopausal women, and
for the control of certain metastatic tumors
such as hormone-dependent breast and
prostatic tumors.
Specific drugs work well in certain special
diseases.-Examples are vitamin C for scurvy,
vitamin D for rickets and salicylates for the
arthritis of rheumatic fever.
Cytotoxic
drugs
form
the
basis
of
chemotherapy for malignant tumours. These
anti-cancer drugs include cyclophosphamide,
melphelan, vincristine and amethopterin.
They have serious side effects and are used
only under expert supervision.

6-Manipulation
Treatment by manipulation is practiced widely by
orthopedic surgeons and by others in allied
professions. Strictly, the term might legitimately be
used to include the passive movements, or
'mobilizations', that form part of the daily activities
of a physiotherapy department and which have
already been referred to above; but it is used here
in a more restricted sense, to describe passive
movements of joints, bones or soft tissues carried
out by the surgeonwith or without an anaesthetic,
and often forcefullyas a deliberate step in
treatment.
The subject will be considered under three general
headings:
Manipulation for correction of deformity;
Manipulation to improve the range of movements at
a stiff joints; and
Manipulation for relief of chronic pain in or about a
joint.

1-Manipulation for correction of deformity. In

this category manipulation has its most
obvious application in the reduction of
fractures and dislocations. It is also used to
overcome deformity from contracted or
short soft tissuesas, for example, in
congenital club foot. Yet another simple
example is the forcible subcutaneous
rupture and dispersal of a ganglion over the
dorsum of the wrist.
Technique. An anaesthetic may or may not be
required, according to the nature of the
condition that is being treated. In many
instancesas in manipulation for a fracture
or dislocationthe aim is to secure full
reduction at the one sitting; .but in resistant
deformities such as club foot repeated
manipulation may be required at intervals of
a week or so, a little further improvement
being gained each time.

Subsequent management. After manipulation for a

deformity that is liable to recuras in most cases
of displaced fracture and in chronic deformities of
jointsthe limb is usually immobilized on a splint
or in plaster to maintain the correction. In cases
of resistant deformity gradual yielding of the soft
tissue allows re-application of the splint in a more
favorable position each time it is changed.
2-Manipulation for joint stiffness. The type of case
mainly concerned here is that in which a. joint
shows serious limitation of movement after an
acute injuryusually a fracture of a limb bone.
'Frozen' shoulder (periarthritis) in its non-active
stage may also be included in this category. In
such cases the stiffness is caused by adhesions
either within the joint itself or, more often, in the
soft tissues about or near the joint. Forcible mani
pulation by the surgeon is not required very often
for stiffness of this type, because it will usually
respond gradually to treatment by active
exercises under the care of a physiotherapist,
combined with increasing use of the limb.

The joint that of most amenable to manipulation

is the knee. The shoulder and the joints of the
foot may also respond. Manipulation of the elbow
and of the joints of the hand may increase the
stiffness and should not be attempted.
Technique. Muscular relaxation should be secured
by anesthesia, supplemented if necessary by a
relaxant drug. Great force should not be used: it
is better to gain slight improvement by moderate
force and then to repeat the manipulation after
an interval. Excessive force may fracture a bone;
or it may cause fresh bleeding within the joint,
thereby aggravating the stiffness.
Subsequent management. Manipulation for joint
stiffness should always be followed by intensive
active exercises designed to retain the increased
range of movement.

3-Manipulation for relief of chronic pain. In

this third category of case treatment by
manipulation
is
somewhat
empirical,
because in many instances it is impossible
to determine precisely the nature of the
underlying pathology, and consequently the
way in which manipulation acts is a matter
of conjecture. Manipulation is used in such
cases simply because previous experience
has proved that it is often successful.
The painful conditions that respond best to
manipulation are chronic strains, especially
of the tarsal joints, the joints of the spinal
column, and the sacro-iliac joints. A chronic
strain may be the consequence of an acute
injury that has not been followed by
complete resolution, or it may be caused by
long-continued mechanical overstrain.

It is generally surmised that adhesions

are present that prevent the extremes
of joint movement (even though a
restriction of movement may not be
obvious clinically), that these adhesions
are painful when stretched, and that the
effect of manipulation is to rupture
them. An alternative explanation that is
advanced in certain cases is that there
is a minor displacement of the joint
surfaces
or
of
an
intra-articular
structure (even though this can seldom
be demonstrated radiologically), and
that the effect of manipulation is to
restore normal apposition.

Technique.Manipulation for relief of pain

from chronic strain consists in putting the
affected joint or joints forcibly through a
full range of movement, usually while the
patient
is
fully
relaxed
under
an
anaesthetic but sometimes without an
anaesthetic. Steady longitudinal distraction
of the joint is often a useful preliminary to
the forcing of the extreme range.
Subsequent management. The manipulation
should
usually
be
followed
by
physiotherapy to maintain the function of
the joint. It may be repeated after an
interval if initial improvement does not
progress to complete cure.

Dangers and safeguards in treatment by

manipulation. Manipulation may do harm if
it is undertaken for the stiffness of
inflammatory arthritis in an active stage, or
if a tumor or other destructive disease
exists close to the joint. It is also
inadvisable in cases of acute back pain due
to prolapsed intervertebral disc, because it
may cause further extrusion of disc
material. This emphasizes the importance of
careful clinical and radiological examination
supplemented' when necessary by other
investigations such as determination of the
erythrocytesedimentation
rate,
radioisotope scanning, radiculography or
magnetic
resonance
imagingbefore
treatment is begun. It must be emphasized
again that manipulation is of no value for
stiffness of the metacarpo-phalangeal joints
and interphalangeal joints of the hand.

During the manipulation itself

care must be taken to avoid
disasters such as the fracture of a
bone or massive displacement of an
intervertebral disc. It is well known
that a fracture "
especially of the
patella or humerus may be caused
easily by injudicious manipulations.
This risk is greatly" increased if the
bone is already weak from the
osteoporosis of disuse or from other
rarefying disease.

7-Radiotherapy
Radiotherapyby x-rays or by the gamma rays
of radio-active substances may be used for
certain benign conditions or for malignant
disease. Because of its possible ill effects
particularly the risk of inducing malignant
change it should be advised only with caution
for benign lesions, but its use may rarely be
justified in the treatment of recalcitrant
ankylosing spondylitis and in cases of giantcell tumor of bone that are unsuitable for local
excision. In malignant disease radiotherapy is
occasionally curative but more often palliative.
In conditions such as malignant bone tumors,
for which a tumor dose in the range of 50006000 centiGray may be required, only the
penetrating rays produced by a super-voltage
x-ray plant or by a radioactive cobalt unit
should be used. With such apparatus a high
dose can be delivered to the tumor with the
least possible damage to the skin.

OPERATIVE TREATMENT
The chief essential of any operation is that it
should not make the patient worse than he
was before he submitted to it. This is so
obvious that the statement may sound almost
absurd. Yet it is unfortunately true that a
disturbing number of operations carried out
for orthopedic conditions do in fact cause
more harm than good for one reason or
another. Hence the selection of cases for
operation, the choice of the most appropriate
operation
in
given
circumstances,
the
technical performance of the operation, and
the post-operative management are matters of
the highest importance, and they call for a
high degree of judgment and skill. Herein lies
much of the fascination of orthopedic surgery.
A detailed account of operative techniques is
unnecessary here. All that is required is a brief
mention of the more important operations.

1-Synovectomy:
Synovectomy is the operation for removal
of the inflamed lining of a joint, while
leaving the capsule intact. It may be of
value in some types of chronic infective
arthritis as well as in early rheumatoid
arthritis. Because of the difficulty in
gaining
anatomical
access,
it
is
necessarily a subtotal procedure; but it
may nevertheless afford worthwhile relief
by reducing local pain and swelling. There
is no clear evidence that it protects the
articular cartilage from further damage;
but the removal of a large part of this
invasive ' granulation tissue or pannus
may be of benefit by reducing the
production" of proteolytic enzymes.

2-Osteotomy
Osteotomy is the operation of cutting a bone or creating
a surgical fracture. It has almost supplanted osteoclasis
(forcible hending or incomplete "breaking of a bone),
which-formerly was often used to-correct deformities of
the long bones in children with rickets and which may
still be suitable occasionally for that purpose.
Indications. The general indications for osteotomy are as
follows:
1)To correct excessive angulation, bowing or rotation of a
long bone;
2) To permit angulations of a bone in. order to compensate
for mal-alignment at a joint;
3) To permit elongation or shortening of a bone in the
lower limb in order to correct a discrepancy of length
between the two sides. In addition, there are certain
special indications for osteotomy at the upper end of the
femur, as follows:
4)To improve stability at the hip by altering the line of
weight
transmission (abduction osteotomy, p. 301); and 5) to
relieve the pain of an osteoarthritic hip (displacement
osteotomy, p. 310).

Technique. If the bone is relatively soft (as in

children) it may. be divided simply with an
osteotome or, in the case of a thin bone, by
bone-cutting forceps. The strong cortex of the
major long bones in an adult is not easily
divided in that way because it tends to
splinter; so most surgeons weaken the bone by
making multiple drill holes before applying the
osteotome, or, alternatively, they use a
powered saw or a high-speed dental burr.
When the bone has been divided and the
necessary
correction
made
it
is
often
convenient to fix the fragments with a plate,
nail-plate, or medullary nail: this may allow
external splintage to be dispensed with. If
internal fixation is not used the fragments may
be immobilised by an external fixator; or they
may be held in position by a suitable splint or
plaster until union has occurred.

3-Arthrodesis
The operation of arthrodesis, or joint
fusion, is still widely used, though
since
the
advent
of
reliable
techniques of joint reconstruction, or
arthroplasty, it is used less frequently
than in the past for the major limb
joints. The disability from a single
stiff joint is usually slight, and
patients readily adapt themselves to
it. Even when two or three joints are
fused function may be surprisingly
good, depending upon the particular
joints affected.

Fig.is
Three-methods of arthrodesis of the~ shoulder.
1. Intra-articular arthrodesis with fixation by a
nail. 2. Extraarticular arthrodesis: acromion
turned down into a slot in the greater tuber
osity. 3. Extra-articular arthrodesis: strut graft
between humerus and scapula. Combinations
of
the
methods
may
be
used.

Three methods of arthrodesis

of the hip. 1. Intra-articyiar
arthrodesis with fixation by a
nail 2. Extra-articular arthro
desis' by ilio-femoral graft. 3.
Extra-articular arthrodesis by

Indications.
Arthrodesis is indicated mainly in the
following conditions:
1)Advanced osteoarthritis or rheumatoid
arthritis with disabling pain, especially
when confined to a single joint;
2) Quiescent tuberculous arthritis with
destruction of the joint surfaces, to
eliminate risk of recrudescence and to
prevent deformity;
3) Instability from muscle paralysis, as
after poliomyelitis;
4)For permanent correction of deformity,
as in hammer toe.

Methods of arthrodesis. Arthrodesis may be intraarticular or extra-articular, or the two may be

combined. In intra-articular arthrodesis the joint
is opened and the bone ends are displayed. The
articular cartilage (or what remains of it) is
removed so that raw bone is exposed. The joint
is
placed
in
the
desired
position
and
immobilized, usually by metallic internal fixation
as well as by a plaster-of-Paris splint, until
clinical tests and radiographs show sound bony
fusion.
In extra-articular arthrodesis the joint itself is left
undisturbed (though it may be immobilized by a
nail or screw), but it is 'by-passed' by securing
bone-to-bone fusion outside the joint, usually
through the medium of a bone graft. The method
is applicable mainly to the spine, shoulder, and
hip. It has a theoretical advantage in cases of
infective joint disease, because any risk of
reactivating or disseminating the infection by
opening the joint is avoided.

Position for arthrodesis.

The best position for

arthrodesis should not be regarded as rigidly
established for each joint: variations may be
appropriate and desirable in individual casesfor
instance, to conform to the requirements of the
patient's work. The following is only a general guide.
Shoulder: 30 degrees of abduction and flexion, with
40 degrees of medial rotation. Elbow: If only one
elbow is affected, 75 degrees of flexion from the fully
extended position (or according to the requirements
of the patient's work). If both elbows are affected,
one should be in flexion 10 degrees above the right
angle and the other about 20 degrees below the right
angle. If forearm rotation is lost the most useful
position of the forearm is in 10 degrees of pronation.
Wrist: Extended 20 degrees. Metacarpophalangeal
joints: Flexed 35 degrees. Interphalangeal joints:
Semiflexed. Hip: About 15 degrees of flexion; . no
abduction or adduction. Knee: About 20 degrees of
flexion. Ankle: In men, right angle; in women, 15-25
degrees of plantarflexion, according to accustomed
height of heel. Metatarsophalangeal joint of big toe:
Slight extension, depending upon the accustomed
height of shoe heel.

4-Arthroplasty
Arthroplasty is the operation for construction of a
new movable joint. It is not applicable to every
joint: in practice, its use is mainly confined to the
hip, the knee, the shoulder, the elbow, certain joints
in the hand, and the metatarso-phalangeal joints in
the foot.
Indications. The indications for arthroplasty vary with
the particular joint affected and the degree of
disability. Broadly, it has a use in the following
conditions:
1) Advanced osteoarthritis or rheumatoid arthritis with disabling pain, especially in-the hip, knee,
shoulder, elbow, hand and metatai'so-phaiangeal
joints;
2)
Quiescent
destructive
tuberculous
arthritis
especially of the elbow or hip;
3) For the-'correction of certain types ef deformity
(especially hallux valgus);
4) Certain ununited fractures of the neck of the femur.
It will be realised that in several of these conditions
arthroplasty is an alternative to arthrodesis.

Methods of arthroplasty. Three methods are in

general use:
1)Excision arthroplasty;
2)Half-joint replacement arthroplasty; and
3)Total replacement arthroplasty. Each has its
merits, disadvantages and special applications.
Excision arthroplasty. In this method one or both of
the articular ends of the bones are simply excised,
so that a gapis created between them. The gap
fills with fibrous tissue, or a pad of muscle or
other soft tissue may be sewn in between the
bones. By virtue of its flexibility the interposed
tissue allows a reasonable range of movement,
but the joint often lacks stability. Excision
arthroplasty is used most commonly at the
metatarso-phalangeal joint of the big toe, in the
treatment of hallux valgus and hallux rigidus
(Keller's operation). It is also commonly used at
the hip, usually as a salvage operation after failed
replacement arthroplasty. It is used occasionally
at the elbow, the shoulder, and certain of the
small joints of the hands and feet.

Half-joint replacement arthroplasty (hemiarthroplasty). In half joint replacement

arthroplasty only one of the articulating
surfaces is removed and replaced by a
prosthesis of similar shape. The prosthesis is
usually made from metal. When .appropriate
it may be fixed into the recipient bone with
acrylic filling compound or 'cement'. The
opposing, normal articulating surface is left
undisturbed. The technique has its main
application at the hip, where prosthetic
replacement of the head and neck of the
femur is commonly practised for femoral neck
fracture in the elderly (Fig. 18). It has rather
a limited use elsewhere, examples being the
replacement of the head of the radius after
certain types of fracture, and replacement of
the lunate bone in Kienbock's disease.

arthroplasty, as_exemplified at the hip. Figure 17 Excision

arthroplasty. Note the interposed soft tissue. Figure 18Halfjoint replacement arthroplasty: [he femoral head is replaced
by a metal prosthesis. Figure 19Total replacement
arthroplasty. The femoral head is replaced by a metal
prosthesis and the acetabulum by a plastic socket. Both
components may be held in place by acrylic filling compound
or
'cement'.

Total replacement arthroplasty. In this

technique both of the opposed
articulating surfaces are excised and
replaced by prosthetic components
(Fig. 19). In the larger joints one of
the components is usually of metal
and the other of high density
polyethylene, and it is usual for both
components to be held in place by
acrylic 'cement'. In small joints such
as the metacarpophalangeal joints a
flexible one-piece prosthesis made
from silicone rubber may be used.

Total
replacement
arthroplasty
has
proved very successful at the hip and to a
lesser extent at the knee. It has been
extended, so far with only moderate
success, to many other joints including
the shoulder, elbow, ankle, metacarpophalatigeal
joints
and
metatarsophalangeal
-joints'.
A
disadvantagewhich applies also to halfjoint replacement arthroplastyis that
there is a tendency for the prosthesis to
work loose after a variable time that
cannot.be predicted.
A
well
fitted
replacement joint may, however, give
good service for many years, especially in
the case of the hip.

5-Bone grafting operations

Bone grafts are usually obtained from
another
part
of
the
patient's
body
(autogenous grafts or autografts). If it is
impracticable or undesirable to take bone
from the patient's own body, grafts from
another human subject may be used
(allografts,
-homogenous
grafts
or
homografts). These must be stored frozen
under aseptic conditions until they have been
proved to be free from transmissible
infection, including HIV and other dangerous
viral infections. For bone from living donors
(mainly femoral heads removed during hip
replacement operations) this necessitates
retesting after six to nine months to ensure
that the donor was not incubating infectious
disease at the time of removal of the bone.
Cadaveric bone sterilised by irradiation is
sometimes used and is increasingly available
from large tissue banks.

Grafts
obtained
from
animals
(xenografts, heterogenous grafts or
hetero-grafts) may be applicable if
they are specially treated to reduce
their antigenic properties. At some
centres limited use is still made of
such bone . (chiefly bovine) prepared
commercially in sterile packs, but it
has been shown to be far inferior to
the patient's own bone and cannot
be
relied
upon
to
become
incorporated with the host bone.

Figs
20
and
21
Examples of bone
grafting
techniques. Figure
20Cortical
slab
graft held by four
screws, as used to
bridge an ununited
fracture. Figure 21
Cancellous grafts
used to fill a cavity
in a bone.

Bone transferred as a free autograft from one

site to another does not survive wholly in a
living state. For the most part the bone xells
die, although a proportion may possibly
survive, especially in cancellous bone The
purpose of the graft;as of allografts and
heterograftsis mainly to serve as a
scaffolding or temporary .bridge upon -which
new bone is laid down, it also provides an
osteogenic stimulus to the host cells from the
bone morphogenic proteins released from the
non-cellular bone matrix. Thus the whole of a
graft is eventually replaced by new living
bone. This process of replacement is
dependent upon adequate revascularisation
of the graft; so a graft that lies in a highly
vascular bed is more likely to succeed than
one that is surrounded by relatively ischemic
tissue.

With refinements in the technique

of micro vascular surgery it is now
possible to transfer bone with its
soft-tissue coverings on a vascular
pedicle to a distant recipient site,
with immediate anastomosis of its
nutrient vessels to those in the new
bed. Such living grafts are found to
become incorporated rapidly. This
recent advance in grafting technique
is valuable in major reconstructive
procedures after extensive loss of
bone and soft tissue.

Indications. Bone grafts are used mainly in

three types of case:
1)in cases of ununited fracture, to promote
union;
2)in arthrodesis of joints, either to supplement
an intra-articular arthrodesis or to promote
extraarticular fusion (see p. 29);
3) to fill a defect or cavity in a bone.
Technique. Autogenous bone for grafting may
be obtained as a solid slab, or it may be used
in the form of multiple slivers or strips, or of
small chips.
Slab grafts. A slab graft is usually obtained
from strong cortical bone: the subcutaneous
part of the tibia is a common site. The graft is
fixed to the recipient bone either by screws
or by inlaying. Such a graft serves as an
internal splint as well as providing a
framework for the growth of new bone (Fig.
20).

Strip grafts. Sliver or strip grafts are

generally obtained from spongy cancellous
bone especially from the crest of the
ilium. They are used commonly for
ununited fractures. They are laid about the
fracture, deep to the periosteum, and are
held in place by suture of the soft tissues
over them (Phemister 1947).
Chip grafts. These also are preferably
obtained from cancellous bone. They serve
the same purposes as sliver grafts butare
smaller pieces of bone. The chips are
packed firmly into, or around, the recipient
bone and are held in place simply by
suture of the soft tissues over them (Fig.
21).

6-Tendon transfer operations

In the operation of tendon transfer, or tendon
transplant, the insertion of a healthy
functioning muscle is moved to a new site, so
that the muscle henceforth has a different
action. In this way the function of a paralysed
or severed muscle can be taken over by one
that is intact. In properly selected cases there
need be no noticeable loss of power in the
former sphere of action of the transferred
muscle, because there is often considerable
duplication or overlap'in the function of
individual muscles. Thus a tendon of flexor
digitorum superficialis may be transferred to
a new site without "appreciably impairing the
power of finger flexion, which can be
adequately
controlled
by
the
flexor
profundus. Similarly the extensor indicis can
be spared for a new function without
seriously interfering with the power of
extension of the index finger (Fig. -22).

Indications.
Tendon transfers "have their main application in
three groups of conditions:
1)in cases of muscle paralysis, to restore or improve
active control'of a joint by-re-routing a healthy
muscle to act in place of a paralysed one;
2)in cases of deformity from muscle imbalance, to
maintain correction by switching healthy muscles
to restore proper balance; and
3)in -cases of "ruptured or cut tendon, "when direct
suture of the ends is~ impracticable.
Technique. The tendon to be transferred is divided
at an appropriate point, re-routed in the direction
of its new action, and secured to its new insertion.
If it is to be inserted into ' bone it is passed
through a drill hole and held by suturing back on
itself or by suturing to the periosteum or soft
tissues on the deep aspect of the bone. If it is to
be united to a tendon stump the junction may be
secured by end-to-end suture or, preferably, by
interlacing the tendons one through the other and
transfixing them with mattress sutures.

Examples.
1) In a case of paralysis of the radial nerve, with
loss of active extension of the wrist, fingers and
thumb, function may be restored by the
following tendon transfers:pronator teres is
transferred to extensor carpiradialis brevis;
flexor carpi ulnaris is transferred to extensor
digitorum and extensor pollicis longus; and
palmaris longus is transferred to abductor
pollicis longus.
2) In a case of congenital talipes equino-varus ,
transfer of the tendon of the tibialis anterior or
tibialis posterior to the outer side of the foot will
help to prevent recurrence of the deformity.
3) In a case of rupture of the extensor pollicis
longus, with extensive fraying of the tendon,
direct repair may be impracticable. Function may
be restored by transfer of the extensor indicis to
the extensor pollicis longus (Fig. 22).

Transfer
extensor
preferred
ruptured

of
extensor
indici;
to
replace
a
pollicis
longus.
This
transfer
is
to
direct
suture
when
the
ends
tendon

are

ruptured
to
be
of
the
frayed

7-Tendon grafting operations

In tendon grafting a length of free tendon is
used
to
bridge
a
gap
between
"the severed ends of the recipient tendon.
Indications. The chief use of free tendon
grafts is in the reconstruction of flexor
tendons severed and adherent In the
fibrous digital sheaths of the hand (p. 275).
Technique. The free tendon graft is usually
obtained from the palmaris longus or from
one of the toe extensors at the dorsum of
the foot. The original, adherent tendon is
removed. Proximally, the graft is joined to
the recipient tendon by sutures of stainless
steel wire. Distally, it maybe secured to the
distal stump of the recipient tendon or it
may be attached directly to bone "through
a drill hole.

8-Equalization of leg length

If a patient's legs are of markedly
unequal length, as in- certain cases
of congenital anomaly, previous
poliomyelitis, or" damage to a
growths epiphysis, the discrepancy
may be reduced or eliminated by
operation. The methods available
are:
1)Leg lengthening;
2)Leg shortening;
and
3)Arrest of epiphysial growth.

Leg lengthening is suitable mainly for children.

It is achieved by dividing the appropriate bone
(usually the tibia, sometimes the femur) and
then gradually elongating the limb in a special
screw-distraction apparatus at the rate of
about 2 millimetres a day. A maximum of about
5 centimetres may be gained. The procedure is
time-consuming and trying for the patient, and
should be reserved for carefully selected cases
in which the discrepancy in length is marked.
A more recent innovation is the technique of
bone transport, in which a length of the
diaphysis is moved slowly downwards to fill a
gap, while new bone forms to fill in the space
created by its advancement. These techniques
have been facilitated by the introduction of the
ring frame distractor of Ilizarov, which allows
correction
of
angulation
as
well
as
lengthening.

Leg shortening, by removing an appropriate

length from the shaft of the longer femur or
tibia, is less hazardous but not to be
undertaken lightly because it disturbs a limb
that was previously normal. In a patient who
is fairly tall, and especially in adults, it is
often preferable to leg lengthening.
Arrest of epiphysial growth (on the longer
side) is applicable only to children with
considerable growth still to come. It entails
either destruction, or bridging by bone grafts
or by metal staples, of the lower femoral
epiphysis or of the upper tibial epiphysis, or
both. The correction to be expected depends
upon the amount of growth still to come from
the corresponding epiphysis of the opposite
(shorter) leg, which depends in turn upon the
age at which the operation is undertaken,
and upon the nature of the abnormality that
is responsible for the shortening.

9-Biopsy
Biopsy is the operation of taking a specimen of
living tissue for histological, electron-microscopic
or other examination in order to elucidate the
nature of a disease. Very, often it is done as a
final step in the diagnosis and staging of a tumor.
Two techniques of biopsy are available:
1) needle biopsy, in which a core of tissue is
extracted by a special hollow needle; and
2) open biopsy. Except in certain situations open
biopsy is usually to be preferred despite a
theoretically greater risk of tumor dissemination,
because it is more likely to yield a representative
specimen. Nevertheless needle biopsy has an
important place, and with improvements in
technique its application has been widened,
though diagnostic accuracy still does not exceed
70 per cent.

The main essentials in a biopsy

operation are:
1) that an adequate and
representative piece of tissue be
obtained; and
2) that the incision be so placed that
it does not prejudice the success of a
subsequent operation for total
eradication of the tumorespecially
in malignant disease. The scar must
be so placed that it is conveniently
included in the block of tissue to be
excised.