Tendon Resection Research Articles

Treatment of Severe Rigid Contractures of Cerebral Palsied Upper Limbs

Flexion contractures caused by cerebral palsy in adult patients can become so rigid and so severe that skin breakdown and infection on the flexor surfaces of the palm and elbow can result. In 11 such patients we have utilized tendon resections, ray amputations, elbow resection arthroplasties and other techniques to correct deformities. Because improvement of hygiene and not functional rehabilitation was the goal in these patients, these aggressive measures could be utilized more freely than usual without fear of jeopardizing the patient's ability to use the hand post-operatively. Treatment of combined intrinsic and extrinsic contracture usually required resection of the sublimi and metacarpal head resection. Thumb-in-palm deformities were difficult to correct and required osteotomies of the first metacarpal or greater multangular resection. Elbow resection was useful in correcting flexion deformities of that joint but deformity recurred unless the biceps tendon was released as part of the procedure.

The Surgical Management of Chronic Tophaceous Gout

In 10 per cent of patients with gout, tophi form; these may destroy skin, tendons, ligaments, and the skeletal structures. Since the disease may ultimately disable the musculoskeletal system, if improperly treated, the management of these patients should be the combined responsibility of the internist and the orthopaedic surgeon. [See figure in the PDF file] Early diagnosis and prompt treatment can prevent severe crippling. In patients in whom the disease has been neglected tophaceous destruction of musculoskeletal structures may be helped by carefully selected surgical procedures. The pathological process is one of invasion and destruction of skin, ligament, tendon, cartilage, and bone by deposition of urates. This process is accompanied by an acute or chronic inflammatory response at the site of involvement. Lesions may be encapsulated in bursae and subcutaneous tissue and infiltrative in skin, tendon, and bone. Tophi may form rapidly or slowly and physical properties vary from semiliquid to inspissated, chalk-like deposits. The distribution of lesions is primarily distal in the extremities with a predilection for the extensor surfaces. Blood vessels may be involved in the process to a moderate degree, but nerves and muscles are apparently affected by pressure phenomena rather than invasion or deposition of urates. We believe surgical intervention is warranted in the following conditions found in chronic tophaceous gout: (1) when tophi are unsightly: (2) when tophi are painful; (3) when tophi interfere with tendon function; (4) wherm tophi threaten to cause skin necrosis and ulceration; (5) when tophi have ulcerated or sinuses are present: (6) when tophi encroach upon nerves causing symptoms of compression; (7) when joints are being destroyed and are painful; and (8) when the total amount of urates in the body can be lowered by excision of readily accessible large tophi. Sodium urate and uric acid seem to possess bacteriostatic properties so that sepsis is usually mild and well localized when present. Circulation may be impaired by tophi when distension of the tissues is marked, although the skin survives remarkably well until late in the process. Arteriosclerosis is commonly present in the lower extremities in the older patients. These factors demand specialized surgical technique. The pneumatic tourniquet may be used in the upper extremity, but should be used cautiously in the lower extremity. Local tourniquets should not be used about fingers or toes. General anaesthesia is preferable to local anaesthesia except for minor excisions of superficial tophi. Distension of tissues with the local anaesthetic agent may impair the blood supply and cause necrosis of skin. Incisions in general should parallel the blood supply of the part. Counter-incisions in the fingers and toes should be avoided as necrosis of the intervening skin may result. Sharp dissection is preferred when it is feasible, but curettage may be done in infiltrative lesions to remove the maximum amount of urates while preserving essential structures. Gentle handling of tissues is necessary to preserve the blood supply. Wounds should be irrigated to prevent necrosis of tissue from drying and to mechanically aid in removal of the tophi. Resection of joints, arthroplasty, and arthrodesis of painful joints may lessen pain and improve function to a limited degree. Curettage or partial resection of tendons may help preserve function. Skin-grafting may hasten healing of ulcerated lesions after removal of the gouty deposits when granulation tissue appears. Infection is not a serious problem and the general principles of treating infections apply to gout with addition of the medical management peculiar to gout. Minimal suturing of wounds is advisable in order to preserve blood supply and to allow escape of liquified deposits following surgery when removal of the tophus is incomplete. Pressure dressings and splints minimize dead space, help prevent hematomata, and put the parts at rest so that healing may occur. Prolonged splinting is to be avoided as ankylosis may occur. Amputation of toes may be necessary, but every effort should be made to preserve the fingers. A definite plan of preoperative and postoperative medical management helps to prevent complications and acute attacks following surgery.

Regeneration of tendons. Przewalski (Orth. and Traum., 1928, vol. 5-6)

The author performed experiments with Achilles tendon resection in dogs, and it turned out that in those cases where the tendon sheath was preserved, the defect was repaired by tendon regeneration. In contrast, in the absence of the tendon sheath, the defect was replaced by connective tissue.

Electrical responses of extensor muscles during postural (myotatic) contraction

Liddell and Sherrington (22) have observed that an anti-gravity muscle of decerebrate and thalamic animals responds to relatively slow stretches by active contraction, and it has been concluded that these myotatic reflexes are in large measure responsible for the postural tonus of muscles (29). As the behaviour of the electrical responses during such stretch reflexes has not been previously examined, we have obtained simultaneous mechanical and electrical records of the responses of the quadriceps extensor of cats to stretching, and we propose in this communication to describe the results.Method. —A myograph of high natural frequency (1,600 per second) in the same optical system as the galvanometer has been employed as previously described (13, 15, 17). Two silver pins coated with chloride have been used as leads, one inserted into the tendon, the other inserted into the belly of rectus femoris. The falling table described by Liddell and Sherrington (22) has been used for slow stretches. Cats decerebrated under deep anæsthesia by the trephine method and allowed to recover have been used throughout. All muscles (except the one used) of both hind limbs were immobilised by nerve section and resection of tendons. The knee-jerks studied were usually elicited by tapping the tendon with the finger, but sometimes also by tapping the table, which, although heavy and rigid, yielded probably 1/40 mm., thereby stretching the muscle and eliciting the reflex.

TENDON ADVANCEMENT AND TENDON RETROPLACEMENT.

Reference is here made to advancement of tendons as distinguished from tendon resection or tendon shortening. In the latter two, the stump of the partially severed tendon furnishes the point of attachment of the portion to be brought forward. Not so, however, in tendon advancement. This operation is required as a remedy for strabismus, insufficiencies, and for the results of old operations excessive in their effects. Tendon retroplacement is here recommended as a control procedure, in connection with complete tenotomy, and is to be practiced at the time and as a part of the original operation. It may as well be said at once that in the opinion of the writer, the operation for tendon advancement, as described by Stevens and performed with the singularly delicate instruments which he has given us, may be substituted with advantage for all other operations heretofore described. The small conjunctival opening with its minimum

WESTMINSTER HOSPITAL.: SECONDARY SUTURE OF THE PATELLA, WITH RESECTION OF THE QUADRICEPS EXTENSOR TENDON

WESTMINSTER HOSPITAL.: SECONDARY SUTURE OF THE PATELLA, WITH RESECTION OF THE QUADRICEPS EXTENSOR TENDON

AMPUTATION BELOW THE KNEE-JOINT IN PREFERENCE TO BRISMENT FORCE IN CERTAIN CASES OF DEFORMITY WITH ANCHYLOSIS. ILLUSTRATED BY TWO CASES.

[Read in the Section on Surgery and Anatomy, June, 1883.] Gentlemen: In all chronic inflammations of the knee-joint, such as strumous synovitis, white swelling, fungus articuli, etc., there is a reflex muscular contraction, which, unless prevented or overcome by persistent extension and counter-extension during the progress of the disease, will result in more or less serious deformity, generally a partial or incomplete sub-luxation backward with outward rotation, in which position it may be anchylosed by fibrous adhesions, false anchylosis, or by bony fusion, true anchylosis. In all cases where the disease has entirely subsided, leaving this deformity, if it is possible to separate the patella from its adhesions with the femur, and if there is any movement whatever between the tibia and the femur, it is easier to resort to brisment forcé, even if it be necessary to make subcutaneous resection of the hamstring tendons in order that the leg