Treatment of orthopaedic disorders

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Treatment of orthopedic disorders
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• Orthopedic treatment falls into three categories
  
• No treatmentsimply reassurance or advice
• Non-operative treatment
• 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.

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• 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 life-saving 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

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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.

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• 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 steel-reinforced
  lumbar corsets, spinal braces, cervical collars,
  wrist supports, walking calipers, below-knee
  steels with ankle straps, and devices to control
  drop foot.

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• 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.

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• 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 treathimself
  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.

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• 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
  orsprings, 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.

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• 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.

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• 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).

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• 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.

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• 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.

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• 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
  thetreatment of chronic and intractable pain,
  particularly when this is of sympathetic
  origin,such as causalgia and reflex sympathetic
  dystrophy. The interference effect uses two
  differingmedium frequency alternating currents
  applied simultaneously through two electrodes
  toinduce a current at the site of rheir
  interaction in the deep tissues. Transcutaneous
  nervestimulation uses direct current pulses of
  adjustable frequency to stimulate the larger
  sensorynerve fibers selectively and thereby to
  set up a gate control mechanism blocking the
  activityof the small fibers which conduct pain
  signals.

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• 4-Local injections
• The indications for local injections fall into
  two .groups
• 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
• 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.

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• 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) anti-inflammatory
  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.

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• 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.

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• 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.

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• 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.

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• 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.

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• 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 manipulation 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.

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• 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.

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• 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.

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• 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.

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• 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.

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• 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
  erythrocyte- sedimentation 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.

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• 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.

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• 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 effectsparticularly
  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 giant-cell 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 5000-6000 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.

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• 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.

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• 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.

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• 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
• To correct excessive angulation, bowing or
  rotation of a long bone
• To permit angulations of a bone in. order to
  compensate for mal-alignment at a joint
• 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
• 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).

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• 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.

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• 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.

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Fig.isThree-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 tuberosity. 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 arthrodesis' by
ilio-femoral graft. 3. Extra-articular
arthrodesis by ischio-femoral graft. The methods
may be combined
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• Indications.
• Arthrodesis is indicated mainly in the
  following conditions
• Advanced osteoarthritis or rheumatoid arthritis
  with disabling pain, especially when confined to
  a single joint
• Quiescent tuberculous arthritis with destruction
  of the joint surfaces, to eliminate risk of
  recrudescence and to prevent deformity
• Instability from muscle paralysis, as after
  poliomyelitis
• For permanent correction of deformity, as in
  hammer toe.

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• Methods of arthrodesis. Arthrodesis may be
  intra-articular 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.

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• 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.

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• 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.

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• Methods of arthroplasty. Three methods are in
  general use
• Excision arthroplasty
• Half-joint replacement arthroplasty and
• 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.

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• Half-joint replacement arthroplasty (hemi-
  arthroplasty). 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.

41
Fig. 17 Fig. 18 Fig.19 Three methods of
arthroplasty, as_exemplified at the hip. Figure
17 Excision arthroplasty. Note the interposed
soft tissue. Figure 18Half-joint 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'.
42

• 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.

43

• 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, metacarpo-phalatigeal
  joints and metatarsophalangeal -joints'. A
  disadvantagewhich applies also to half-joint
  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.

44

• 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.

45

• 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.

46

• 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 21Cancellous grafts used to
  fill a cavity in a bone.

47

• 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
  graftas 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.

48

• 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.

49

• Indications. Bone grafts are used mainly in three
  types of case
• in cases of ununited fracture, to promote union
• in arthrodesis of joints, either to supplement an
  intra-articular arthrodesis or to promote
  extraarticular fusion (see p. 29)
• 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).

50

• 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).

51

• 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).

52

• Indications.
• Tendon transfers "have their main application
  in three groups of conditions
• 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
• in cases of deformity from muscle imbalance, to
  maintain correction by switching healthy muscles
  to restore proper balance and
• 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.

53

• 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 transferspronator 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).

54
Transfer of extensor indici to replace a
rupturedextensor pollicis longus. This transfer
is to bepreferred to direct suture when the ends
of theruptured tendon are frayed.
55

• 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.

56

• 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
• Leg lengthening
• Leg shortening and
• Arrest of epiphysial growth.

57

• 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.

58

• 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.

59

• 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.

60

• 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.