The Journal of

Bone & Joint Surgery

The Official Publication of the

American Orthopedic Association

and of the British Orthopaedic Association

Volume XX 1922

Under the Management of Dr. E. G. Brackett, Editor,

and Miss Lissner, Assistant Editor,

Boston, Massachusetts.

Y]> S<



Adams, Z. B. Treatment of congeni- ta] dislocation of hip as practised by Professor Denuce at Bordeaux, France. P. 523.

Allison, Nathaniel. Specialist in sur- gery and his viewpoint. P. 421.


Barrie, George. Hemorrhagic osteo- myelitis. P. 653.

Bennett, George E. Lengthening of quadriceps tendon. P. 279.

. Operation for hypertrophied

patella. P. 593.

Bernstein, Maurice A. Open reduc- tion of old congenital hip disloca- tion. P. 481.

Billington, R. Wallace. Tendon trans- plantation for musculospiral (radial) nerve injury. P. 538.

Boorstein, S. W. Cervical rib. P. 682.

British Orthopaedic Association. Dis- cussion on operative treatment of osteoarthritis of hip-joint. P. 137.

Brown, L. T. Beef bone in stabilizing operations of the spine. P. 711.

Calve, Jacques. Treatment of tuber- culosis of ankle in adult. P. 33.

Campiche, Paul, and Eaves, James. Note on malformation of carpus. P. 78.

Cofield, Robert B. Hypertrophic bone changes in tuberculous spondylitis. P. 332.

Cone, Sydney M. Pathology of ostei- tis deformans, Paget's disease. P. 751.

Cook, Robert J. Report of orthopae- dic examination of 1393 freshmen at Yale University. P. 247.

E Eaves, James, and Campiche, Paul.

Note on malformation of carpus.

P. 78. Elmer, Walter G. Substituting felt

for steel arch supports. P. 395.

Fitz-Simmons, Henry J. Simultane- ous hydrops of knees. P. 376.

Forbes, A. Mackenzie. Operative treatment of scoliosis. P. 446.

Gaenslen, F. J. Pain due to ilio-costal impingement. P. 705.

Gallie, W. E., and Le Mesurier, A. B. Clinical and experimental study of free transplantation of fascia and tendon. P. 600.

Gibbon, James W. Bone sarcoma. P. 512.

Gibson, Alexander. Painful, traumatic shoulder. P. 552.

Goldthwait, Joel E. "Flat hand" (manus planus) : its correction es- sential to normal function of hand. P. 469.


Haas, S. Spontaneous healing in- herent in transplanted bone. P. 209.

Henderson, Melvin S. Osteoma of cervical spine. P. 518.

Holland, C. Thurstan. Note on sac- ralization of fifth lumbar vertebra. P. 215.


Jones, Ellis. SubastragalorJ external dislocation. P. 325.

Kleinberg, S. Fracture of spine. P.

80. Kuth, J. R. Study of 208 cases of

lower back pain. P. 357.


Le Mesurier, A. B., and Gallie, W. E.

Clinical and experimental study of

free transplantation of fascia and

tendon. P. 600. Lewin, Philip. Osteitis deformans

(Paget's disease), with report of

three cases. P. 45. Lowman, C. L- Spinal pathology in

relation to ocular manifestations,

with report of cases. P. 580.


Masland, Harvey C Practical thoughts on bone pegs, bone screws, etc. P. 317.

Mayer, Leo. Treatment of paralytic flat feet. P. 39.

Mebane, Tom S. Chronic osteomye- litis secondary to compound frac- ture. P. 67.

Merrill, William Jackson. Davis method of reduction of congenital dislocation of hip-joint. P. 805.

Meyer, Arthur William. Further ob- servations upon use-destruction in joints. P. 491.

Miller, Edwin M. Congenital ankylo- sis of joints of hands and feet. P. 560.

Moore, Beveridge H. Case of spon- taneous fracture of transverse proc- ess of lumbar vertebra, due to tuber- culosis. P. 322.


Nutt, John Joseph. Further observa- tions on intra-perineural neurotomy in spastic conditions. P. 453.

Nutter, J. Appleton. On delayed un- ion and non-union of fractures. P. 104.

O'Ferrall, John Tolson. Low back pain Clinical study of cause. P. 384.

Oppenheimer, Edgar D. Early symp- toms of spinal cancer. P. 342.

Peabody, C. W. Unusual fractures. P. 459.

Robinson, Wilton H. Standard plas- ter bandage. P. 321.

Rogers, Mark H. Pathology of tu- berculosis of joints. P. 679.

Rosen, Neil G. Simplified method of measuring amplitude of motion in joints. P. 570.

Schulz, O. E. New method of oper- ative treatment of foot deformities. P. 219.

Schwartz, R. Plato. Mechanism of new plaster shell in treatment of Pott's disease in children, with lat- eral x-ray control. P. 789.

Shipley, Paul G. Studies on experi- mental rickets. P. 672.

Starr, Clarence L. Army experiences with tendon transference. P. 3.

Stewart, Steele F. Postoperative care of flexion contraction of hip. P. 548.

Stone, Charles A. Amyatonia con- genita. Report of a case. P. 21.

Swaim, Loring T. Chronic arthritis. P. 426.


Whitman, Armitage. Astragalectomy and backward displacement of foot. Investigation of practical results. P. 266.

Wilson, John C. Reconstruction of internal lateral ligament of knee- joint. P. 129.

Wilson, Philip D. Early weight- bearing in treatment of amputa- tions of the lower limb. P. 224.



American Orthopedic Association, preliminary program. P. 209.

Amputations of lower limbs, Early weight-bearing in treatment of. Philip D. Wilson. P. 224.

Amyatonia congenita. Report of a case. Charles A. Stone. P. 21.

Ankylosis, Congenital, of joints of hands and feet. Edwin M. Miller. P. 560.

Arch supports, Substituting felt for steel. Walter G. Elmer. P. 395.

Arthritis, Chronic. Loring T. Swaim. P. 426.

Astragalectomy and backward dis- placement of feet. Investigation of practical results. Armitage Whit- man. P. 266.

B Back Pain, Low. Clinical study of cause. John Tolson O'Ferrall. P. 384.

-, Lower, Study of 208 cases of.

J. R. Kuth. P. 357.

Beef bone in stabilizing operations of the spine. L. T. Brown. P. 711.

Bone pegs, bone screws, etc., Prac- tical thoughts on. Harvey C. Mas- land. P. 317.

sarcoma. James W. Gibbon.

P. 512.

, transplanted, Spontaneous

healing inherent in. S. L. Haas. P. 209.

Book Review. Artificial limbs and amputation stumps. E. Muirhead Little, F.R.C.S. P. 855.

Carpus, Note on malformation of.

James Eaves and Paul Campiche.

P. 78. Cervical rib. S. W. Boorstein. P. 682. Congenital Hip Commission, Report

of. P. 821.


Bone sarcoma. George Barrie. P.

164. Tuberculosis in China. G. E. Brackett. P. 823.

Davis method of reduction of congen- ital dislocation of hip-joint. William Jackson Merrill. P. 805.

Dislocation, congenital, of hip, Treat- ment of, as practised by Professor Denuce at Bordeaux, France. Z. B. Adams. P. 523.

, congenital, of hip-joint, Davis

method of reduction of. William Jackson Merrill. P. 805.

-, subastragaloid external. Ellis

Jones. P. 325.

Flat feet, paralytic, Treatment of. Leo Mayer. P. 39.

"Flat hand" (manus planus): its cor- rection essential to normal function of hand. Joel E. Goldthwait. P. 469.

Flexion contraction of hip, Postoper- ative care of. Steele F. Stewart. P. 548.

Foot deformities, New method of op- erative treatment of. O. E. Schulz. P. 219.

Fracture, compound, Chronic osteo- myelitis secondary to. Tom S. Mebane. P. 67.

of spine. S. Kleinberg. P. 80.

, Spontaneous, of transverse

process of lumbar vertebra, due to tuberculosis. Beveridge H. Moore. P. 322.

Fractures, On delayed union and non- union of. J. Appleton Nutter. P. 104.

, Unusual. C. W. Peabody.

P. 459.


Hip dislocation, Open reduction of old congenital. Maurice A. Bern- stein. P. 481.


Hip-joint, Discussion on operative treatment of osteoarthritis of. Brit- ish Orthopaedic Association. P. 137.

, Postoperative care of flexion

contraction of. Steele F. Stewart. P. 548.

Hydrops, Simultaneous, of knees. Henry J. Fitz-Simmons. P. 376.

Hypertrophic bone changes in tuber- culous spondylitis. Robert B. Co- field. P. 332.

Ilio-Costal impingement, pain due to. F. J. Gaenslen. P. 705.

Plaster shell, new, Mechanics of, in treatment of Pott's disease in chil- dren, with lateral x-ray control. R. Plato Schwartz. P. 789.

Pott's disease in children, Mechanics of new plaster shell in treatment of, with lateral x-ray control. R. Plato Schwartz. P. 789.

Quadriceps tendon, Lengthening of. George E. Bennett. P. 279.

Joints, Simplified method of measur- ing amplitude of motion in. Neil G. Rosen. P. 570.

Knee-joint, Reconstruction of inter- nal lateral ligament of. John . C. Wilson. P. 129.


Neurotomy, intra-perineural, in spas- tic conditions, Further observations on. John Joseph Nutt. P. 453.

News notes. Pp. 166, 400, 613, 825.

Report of Congenital Hip Commis sion. P. 821.

Rickets, experimental, Studies on Paul G. Shipley. P. 672.

Sacralization of fifth lumbar vertebra, Note on. C. Thurstan Holland. P.


Scoliosis, Operative treatment of. A. Mackenzie Forbes. P. 446.

Orthopaedic examination of 1393 freshmen at Yale University, Re- port of. Robert J. Cook. P. 247.

Osteitis deformans (Paget's disease), Pathology of. Sydney M. Cone. P. 751.

, with report of three cases.

Philip Lewin. P. 45.

Osteoarthritis of hip-joint, Discussion on operative treatment of. British Orthopaedic Association. P. 137.

Osteoma of cervical spine. Melvin S. Henderson. P. 518.

Osteomyelitis, Chronic, secondary to compound fracture. Tom S. Me- bane. P. 67.

, Hemorrhagic. George Barrie.

P. 653.

Shoulder, Painful traumatic. Alexan- der Gibson. P. 552.

Shriners hospitals for crippled chil- dren. P. 135.

Specialist in surgery and his view- point. Nathaniel Allison. P. 421.

Spinal cancer, Early symptoms of. Edgar D. Oppenheimer. P. 342.

pathology in relation to ocular

manifestations, with report of cases, C. L. Lowman. P.' 580.

Spine, Beef bone in stabilizing opera- tions of. L. T. Brown. P. 711.

Paralytic flat feet, Treatment of. Leo

Mayer. P. 39. Patella, hypertrophied, Operation for.

George E. Bennett. P. 593. Plaster bandage, Standard. Wilton H.

Robinson. P. 321.

-, Fracture of. S. Kleinberg.

P. 80.

Spondylitis, tuberculous, Hypertro- phic bone changes in. Robert B. Cofield. P. 332.


Tendon transference, Army experi- ences with. Clarence L. Starr. P. 3.

transplantation for musculospi-

ral (radial) nerve injury. R. Wal- lace Billington. P. 538.

Transplantation, free, of fascia and tendon, Clinical and experimental study of. W. E. Gallie and A. B. Le Mesurier. P. 600.

Tuberculosis of ankle in adult, Treat- ment of. Jacques Calve. P. 33.

Tuberculosis of joints, Pathology of. Mark H. Rogers. P. 679.

U Use-destruction in joints, Further ob- servations upon. Arthur William Meyer. P. 491.

Yale University, Report of orthopae- dic examination of 1393 freshmen of. Robert J. Cook. P. 247.



Acromegaly, Relation of, to thyroid disease, with statistical study. J. M. Anders and H. M. Jameson. P. 638.

Amebiasis of bones. Charles A. Ko- foid and Olive Swezey. P. 835.

Amputations at shoulder and at hip. H. Littlewood. P. 631.

Ankylosis, bony, of knee-joint, Mobi- lization of. Charles Ogilvy. P. 411.

Arthritis, Chronic. Leonard W. Ely. P. 624.

-, chronic, Amoeba as cause of

second great type of. Leonard W. Ely, Alfred C. Reed and Harry A. Wyckoff. P. 625.

-, chronic, Treatment of, with

special reference to end-results. Walter L. Bierring. P. 624.

deformans as deficiency dis-

ease. G. C. Belcher. P. 623.

deformans juvenilis of hip,

Case of. Yvernault. P. 838.

deformans, Operative treat-

ment of. A. Wollenberg. P. 836. gonorrheal, Treatment of, by

injection of joint fluid. H. Dufour, J. Thiers, and Alexewsky. P. 626. Infectious, of spine. Sigmund

Epstein. P. 626.

-, Rheumatoid. N. Davies. P.


-, Rheumatoid, due to infection of nasal accessory sinuses. P. Watson-Williams. P. 626.

Treatment of. Arthur F.

Chace and Victor C. Myers. P. 201. Arthoplasty of elbow-joint. Harold C. Bean. P. 630.


Bertolotti's syndrome; Contribution to knowledge of. Armando Alba- nese. P. 641.

Bone, Action of radium on tumors of. Isaac Levin. P. 407.

Bone development, Biology of, in relation to bone transplantation. Philip William Nathan. P. 178.

, Function in relation to trans- plantation of. S. L. Haas. P. 174. graft, Certain fundamental

laws underlying surgical use of. F. H. Albee. P. 173.

plate for use in fractures close

to joints or to epiphyses. W. H. Byford. P. 619.

repair, Some factors in. Wil-

liam Seaman Bainbridge. P. 410.

Bursa, subacromial, Case of ossifica- tion of. Coulomb. P. 854.

Bursitis calcarea of the epicondylus externus humeri; contribution to pathogenesis of epicondylitis. J. Schmitt. P. 204.

, retrocalcanean, Diagnostic and

therapeutic point in. A. L. Nielson. P. 203.

Carpus, Traumatology of. A. H. Bizarro. P. 838.

Cervical rib, with report of two cases. Paul C. Colonna. P. 627.

ribs: with special reference to

surgical treatment. Alfred S. Tay- lor. P. 628.

Chronic patient, Challenge of, to med- ical profession. Joel E. Goldthwait. P. 415.

Cineplastic surgery of upper extremi- ty. F. M. Cadenat. P. 176.

Circulatory disturbances of feet. Emil S. Geist. P. 646.

Club-foot operation. Gaugele. P. 831.

, Treatment of neglected cases

of. A. Paynter Noall. P. 406.

Contractures, arthrogenetic, of knee, Treatment of, with partial alcoholi- zation of sciatic nerve. Dario Maragliano. P. 632.

Coraco-clavicular articulation, Three cases of, observed in living. F. Frasseto. P. 184.

Coxa vara. Rene Bloch. P. 847.


Coxalgia, Tuberculous, in adult: dry caries of hip. Maurice Patel. P. 401.


Dislocation, complete, irreducible, con- genital, of patella, Operation for. Albert Mouchet and Jacques Du- rand. P. 841.

Dislocations and fracture-dislocations occurring at the acromio-clavicular articulation. R. W. McNealy. P. 622.

Dupuytren's contracture, End-results of operation for. A. Bruce Gill. P. 851.

Elbow, Observations based on study

of injury to. Isidore Cohn. P. 191. Epicondylitis of athletes. Tavernier.

P. 845. Equino varus in new-born, Method of

prolonged retention in treatment of.

Lucien Michel. P. 832.

Feet, Injuries of. U. V. Portmann and F. C. Warnshuis. P. 190.

Finger nails, Changes in, after rheu- matic fever and tuberculosis. Wil- liam H. Rosenau. P. 852.

Fingers, Stiff. F. J. Cotton and E. J. Sawyer. P. 630.

Fracture and dislocation of cervical vertebrae without paralysis. W. E. Hartshorn. P. 621.

of clavicle, Treatment of, by

continuous traction. Burian. P. 618.

of neck of femur. S. Klein-

berg. P. 403.

of scaphoid of foot. A. Rosen-

berg. P. 403.

Fractures, certain, of femur, humerus, and forearm, Operative treatment of. E. W. Ryerson. P. 842.

, false, of femoral neck, Diag- nosis of. Bloch. P. 618.

-, metatarsophalangeal, Report of

twenty-seven cases. A. G. Bolduc. P. 839.

-, Mechanics of. Fractures from

shearing forces. C. Ghillini. P. 620.

near joints, Management of.

P. H. Kreuscher. P. 621.

of bones, Certain problems

Fractures of forearm, Mechanics and treatment of. Paul B. Magnuson. P. 841.

of long bones, Influence of

physical therapy in reducing time of disability in. Jonathan M. Wain- wright. P. 405.

of metacarpals and phalanges

of fingers, Treatment of. R. D Wheeler. P. 623.

-, Old os calcis. Fred J. Cotton

P. 402.

Pathological. E. A. Codman.

P. 839.

Physiotherapy in after-care of.

H. E. Stewart. P. 842.

recent, Treatment of. Frank

E. Peckham. P. 842. Fragilitas ossium. Edgar A. Vander Veer and Arthur M. Dickinson. P. 408.

Ganglion of wrist region. H. P. H.

Galloway. P. 407. Genu valgum, Origin of, from pes

valgus. Elizabeth E. Schmidt. P.

189. Gout, Humoral syndrome of. A.

Chauffard. P. 847.

H Hip, Anatomic evolution of, after re- duction of congenital luxations. Broca and d'Intignano. P. 413. dislocation, Retention of diffi- cult cases of, by intracapsular injec- tions of alcohol. H. Graetz. P. 192.

joint, Case of bilateral disloca-

concerning. Charles M. Scudder. P. 404.

tion of. Walter G. Stern. P. 190. Hydrarthrosis, Intermittent. A. L.

Nielson. P. 639. Hypophysis, Congenital deformities

and anomalies of, in a twin. Nino

Samaja. P. 627.

Infectious arthritis, Chronic: statisti- cal report with end-results. Frank Billings, George H. Cole, and Wil- liam S. Hibbs. P. 834.

Intermittent claudication due to car- diac hypoplasia. Serko. P. 852.


Joints, Research on development of. Giulio Faldino. P. 644.



Knee, Permanent results of operation on semilunar cartilages of. . Bau- mann. P. 178.

Kohler's disease. George I. Bauman. P. 180.

Lengthening, Experimental, of limbs.

O. Nuzzi. P. 634. Loose bodies in joints. A. G. T.

Fisher. P. 201.

M Madelung's deformity of wrist.

Brandes. P. 830. Mobilization, Methodic, in treatment

of articular affections. Kouindjy.

P. 630. Myositis ossificans, traumatic, Case of.

S. L. Bhatia. P. 842. Myxoma, Joint. G. Bolognesi. P.


N Nerve injuries, Treatment of irrepa- rable. R. E. Harris. P. 412.

Orthopaedic surgery, Report of prog- ress in. M. N. Smith-Petersen. P. 853.

Osteitis deformans, Fracture in. J. Anderson Smith. P. 844.

fibrosa of os calcis as cause of

typical calcaneitis. H. J. Bettman. P. 846.

Traumatic, of wrist. Mark H.

Rogers. P. 844. Osteo-arthropathy, late hereditary

syphilitic, Contribution to study of.

Miginiac and Cadenat. P. 837. Osteochondritis deformans juvenilis

of hip. Lance, Andrieu and Cap-

pelle. P. 848. , Infantile deforming, of upper

femoral epiphysis. Feutelais. P.


of hip, Atypical forms of.

Nove-Josserand. P. 853.

of hip, or coxa plana. F. Calot

and H. Colleu. P. 416.

of ribs following typhus fever

and its treatment by injections of iodine. Nadine Dobrovolskaia. P. 643. Osteochondromata, Multiple. Bernard Pierre Widmann. P. 205.

Osteomata of brachial triceps. Mas-

sart. P. 636. Osteomyelitis, Acute. A. Cohn. P.

643. , Clinical study of pathology of.

A. Gibson. P. 409.

Hemorrhagic. Ernest H. Ar-

nold. P. 409.

of adolescent long bones,

Growth problems following. Kel- logg Speed. P. 850.

-, Sclerosing non-suppurative, as

described by- Garre. S. Fosdick Jones. P. 179. Osteotomy, Results of supra-condylar, in flexion contractures of knee- joint. L. Aubrey. P. 175.

Paget's disease. Babonneix, Denoy- elle, and Perisson. P. 638.

Paralysis, Birth. H. Piatt. P. 406.

, Deltoid, and arthrodesis of

shoulder-joint. George F. Straub. P. 834. .

in children due to bite of wood-

ticks. P. D. McCormack. P. 198. plexus, of new-born, Etiology

of. Weil. P. 199.

-, Postdiphtheritic. T. J. Elter-

ich. P. 833.

Patella bipartita. Hans Blencke. P. 830.

Pelvic muscles, shortened, Some ob- servations on static influence of. John Joseph Nutt. P. 203.

Pelvis, Leveling (balancing), in cases of inequality of length of legs, with description of pathognomonic sign. Philip Lewin. P. 631.

Pes adductus, congenital, Contribu- tion to pathology and therapy of. W. Jareschy. P. 186.

Poliomyelitis, Diagnosis, prognosis, and early treatment of. Robert W. Lovett. P. 833.

Postoperative treatment in certain surgical procedures on upper ex- tremity. Arthur Steindler. P. 635.

Pott's disease, Hysterical. Feutelais. P. 846.

Pseudo-coxalgia (osteochondritis de- formans juvenilis coxae: quiet hip disease). Harry Piatt. P. 639.

Pseudo-paraplegia resulting from double tabetic arthropathy of hips. Andre L6ri and Lerond. P. 647.


Rachitic deformities of thorax, Etio- logical treatment of. R. Boeckh. P, 187,

Radiographing spine and pelvis, The- sis upon subject of. H. J. Suggars. P. 853.

Radius, Dislocation of, forward at in- ferior radio-ulnar joint. L. Rogers. P. 191.

Raynaud's disease, Treatment of, with thyroid extract. Edwin W. Hirsch. P. 408.

Rheumatoid arthritis, Two cases of. A. Mackenzie Forbes. P. 835.

Rickets, Etiology of. G. Bruton Sweet. P. 409.

, Experimental, in rats. V.

Korenchevsky. P. 848.

Roentgen-ray therapy in chronic dis- eases of bones, joints, and tendons. Herman B. Philips and Harry Finklestein. P. 181.

Sacro-iliac joint, Dislocation of. Alex- ander Gibson. P. 190.

Sacro-iliac sprain- E. D. Martin. P. 622.

Sarcoma of long bones. H. W. Mey- erding. P. 637.

Scaphoid bone of foot, Isolated dis- ease of. A. S. Risser. P. 641.

Schlatter's disease and frequent symp- toms of late rickets. Bernard Hin- richs. P. 188.

Sciatica, Treatment of so-called. J. A. Nutter. P. 851.

Scoliosis, Is operative treatment of, possible? H. Hoessly. P. 183.

; , Result of extensive rib resec- tion on concave side in severe. Fritz Lange. P. 182.

structural, Treatment of. at

Massachusetts General Hospital. Armin Klein. P. 646.

-, Treatment of sharp costal

gibbosity in, by open operation as supplement to orthopaedic treat- ment. Gaudier and Swynghedauw P. 181.

Semilunar cartilage of knee, Note on injuries to. James Eaves and Pau! Campiche. P. 405.

Shoulder, congenita] elevated, Opera- tive treatment of, according to Koe- nig. Grauhan. P. 831.

Shoulder-joint, Diagnosis and treat- ment of some common injuries of. Robert W. Lovett. P. 844.

-, Observations on normally de-

veloping. Isidore Cohn. P. 415.

Spina bifida occulta, Progressive foot deformities in. L. Roeren. P. 184.

Spine and ribs, Congenital anatomic defects of. James Warren Sever. P. 832.

Subacromial luxation, Bilateral, of humerus by muscular action in epi- lepsy. Costantini. P. 619.

Tarsal scaphoid, Disease of, in young children. Abrahamsen. P. 180.

Tennis elbow. L. Cooke. P. 842.

Thumb, Plastic substitution of. Per- thes. P. 174.

Tibial tubercle, Two unusual cases of injury to. James Warren Sever. P. 622.

Tuberculosis, joint, Early diagnosis and treatment of. J. T. O'Ferrall. P. 616.

of patella, Extra-articular. G.

Jean. P. 401.

of upper extremity. Giovanni

Valtancoli. P. 616.

so-called surgical, Conserva-

tive treatment of. A. Bier. P. 195.

, Statistics of bone and joint,

in last five years. L. Frosch. P. 192.

-, surgical, Operative treatment

of. F. Koenig. P. 194.

Tuberculous spondylitis, Operative treatment of. Bachlaender. P. 850.

Whitman abduction splints, Mechani- cal device to facilitate handling of

« patients in. O. F. Schussler. P. 622.

Writers' cramp: its cause and cure W. H. Bates. P. 414.

Vol. IV, No. 1 JANUARY, 1922 £*; .,

The Journa Bone & Joint Sur



In civilian practice previous to the recent Great War, attempts at restoration of function by muscle transference had been very largely limited to the lower extremity.

This was probably due to the fact that all movements of the upper extremity, particularly in the forearm and hand, are so complicated and exact, and the muscles controlling these movements so numerous, that it did not appear feasible so to adjust the transferred muscles that these finer and essential movements might be preserved. The war, how- ever, brought the surgeon face to face with a problem never before encountered in any such wholesale fashion, and when the great group of cases presented themselves with deformed and disabled limbs due to irreparable nerve injuries, necessity proved the stimulus required and for the most part these disabilities have been overcome, and use- less members have been changed to functioning ones more or less perfect.

In some cases the end-results, so far as the restoration of function is concerned, are so nearly perfect that one feels that so good a sub- stitute has been provided in such irreparable peripheral nerve lesions as to make it a matter of small concern if a purely motor nerve were restored or not.

The function of a limb also may be often restored in eight or ten weeks by muscle transference which could not be procured, if nerve suture were successful, in less than twelve to eighteen months.


action depending upon ^ je— ^ nc^ pow is - so successfully met as wher- fa £ range^ ^ ^ ^ rf ^ without great power. For this rea*° „,ccessM than the reverse.

forearm to the extensor group is much ^ore "™ nearly so, due to

Loss of function of the hand -«£££££££ comparatively loss of balance, even though teP^ rf ^ forearm

small group of muscles and ^P**™* exemplified in

remain active and capable of j™ctl^ -x or terior inter-

sible to use

due to the lack of balance.

due to the lack ot balance. -ttfflrrot a redistribution

he secured. That these principles are n t f nil ' ™"££^ several

^ Tot; - PO^muXhaving similar action to the ones they ar\o replace should be' used, mile it is perfectly true that a muscK havng a'diametrieally opposite action to the one it is to repln e may be transferred and trained to functionate automatically in its new LpS, yet it is obvious that a much shorter period of training will be necessary and a better nltimate function will be obtained, if one of sim- ilar action is transferred. For example, one of the extensors of the wrist, the extensor carpi radialis longior, may be transferred to the long ex- tensor of the thumb and learn to perform the function of a thnmb extensor in a very few weeks, whereas a flexor of the wrist so trans- ferred, will require a long period of patient training.

2 If only a portion of a tendon is to be transferred «t must have the' same action as the muscle it is to replace. Using the preceding example it is perfectly feasible to transfer half of the tendon of the


extensor carpi radialis longior to the long extensor of the thumb and obtain good results. On the other hand it is hopeless to expect to transfer half of the flexor of the wrist, say the flexor carpi radialis to the extensor of the thumb and expect any results. That would be asking a muscle to perform two opposing actions at the same time, yet this very operation is described in a recent paper and good re- sults are reported. An even more gross impossibility is reported in another paper where a section of the tendo Achillis is split from its outer side and carried forward to an insertion into the peroneus longus and a second section taken from the inner side similarly carried for- ward to the tibialis anticus, the remaining section remaining attached to its normal insertion into the os calcis. A stabilized or balanced foot is reported. This is obviously incorrect and serves no other pur- pose than to bring a good operation into disrepute by asking it to do the impossible.

3. The line of pull should be as straight as possible for mechan- ically the muscle will work more efficiently if the line between its origin and its new insertion is a straight line. This necessitates long incisions and care to see that the tendon, which winds obliquely around the arm, for instance, is not widely deviated by any hindering structures.

4. The fixation of the transferred muscle should be with a good deal of tension. This will take up any slack due to straightening out of the line of pull when such line has not been perfectly straight at time of operation. It also allows for a little slipping which often takes place at the point of fixation. The position of the member to be con- trolled therefrom should be one of considerable over-correction when the transfer is made.

Our lack of experience in earlier cases showed poorer results, due to neglect of this principle, than the later cases where it was carefully observed.

5. Any deformity due to contraction of tissues should be overcome before transfer of muscles is attempted. A group of cases has been seen by the writer, in which the best results were not obtained be- cause of failure to secure the necessary correction of deformity before operation for tendon transference.

6. Tendons may be transferred to a new position by utilizing the sheath of the muscle to be replaced and threading the new tendon down the sheath, but for the most part transferred tendons should run in the fatty subcutaneous tissue.


7. In the lower extremity it is a common experience that tendons transferred should he inserted into bone or periosteum. In the upper extremity the attachment of tendon to tendon has been quite satisfactory.

8. Care should be taken to adequately fix tendon to tendon, as a good many cases have failed and required subsequent reoperation be- cause the union has slipped. In our experience the recipient tendon should be slit, the transferred tendon denuded of its sheath by scraping thoroughly, and macerating somewhat, by Kocher forceps. This tendon is then threaded through the slit in the recipient tendon or tendons, sutured in two places and either buried in it or turned back and stitched to itself.

The suture material we have found most satisfactory is linen, and in no case have we had any infection which could be traced to this cause and in no case have the sutures been extruded.

Catgut will not stand the strain of attempted movement at the end of three weeks as seems essential to get best results.

9. The limb must be placed in a splint, preferably of plaster of Paris, and all motion, which would strain the suture linen, prevented for three weeks. Then a removable splint is substituted and removed daily for training.

The training should be in the hands of an expert who has a thor- ough knowledge of anatomy and who has seen the operation performed, so as to be able to appreciate the aims of the surgeon. At the end of two months all splints may be discarded.

By far the greatest number of cases of muscle transference in the army has been for irreparable injury of the musculo-spiral nerve. The best results have also been obtained in this injury, probably because this nerve is for the most part a purely motor nerve and the remain- ing disability from anaesthesia is negligible, and partly because the power required to overcome the disability is really only that necessary to overcome gravity. The technique of operation for this disability will serve as illustrative of all. The object of operation is to restore the extensor function of the thumb, wrist, and fingers.

The arm is prepared in the usual way and painted with iodine from above the elbow to the finger tips. The whole forearm is left exposed by the draping. An incision about five inches long is first made on the palmar aspect of the forearm between the tendons of the flexor carpi radialis and the palmaris longus ending at the wrist The exposed tendons are carefully freed from their sheaths well up to the middle of the forearm. To avoid injury to the tendons they are


only handled at the points of their insertion. The tendons are then divided at their insertion and the skin edges clipped together. A long incision, seven or eight inches long, is made on the dorsal aspect of the forearm following a line from the external condyle of the humerus to the styloid process of the radius with the hand prone. The incision ends in a slight hook at its lower end to thoroughly expose the ex- tensor tendons of the thumb. This incision is made through the skin and deep fascia, exposing the muscles. All haemorrhage should be controlled by clipping superficial veins, and if this is thoroughly done no further bleeding of moment will be encountered. We believe bet- ter results are obtained if no tourniquet is used, and of course one eliminates the danger of temporary paralysis from pressure. If this incision is properly placed, it immediately overlies the septum between the radial extensors of the wrist and the extensor communis digitorum. With sponge pressure or blunt dissection the bellies of these muscles ere separated down to the radius at the upper end of the incision. This exposes directly the oblique insertion of the pronator radii teres into the outer surface of the radius.

This insertion is completely freed with a periosteal elevator taking the periosteum with it. By blunt dissection it should be determined that this muscle insertion is absolutely free, otherwise it will not act freely in its new capacity.

The extensors carpi radialis longior and brevior are stabbed and the freed end of the pronator teres is threaded through from the deep surface and its periosteal ending sutured to the aponeurotic sur- face of these muscles. The tag ends should be buried by a Lembert type of suture so as to leave the surface smooth. The tendons of the common extensor to the fingers are freed from their sheath above the annular ligament and the separate sheath of the extensor minimi digiti opened so as to bring all four tendons together. The three ex- tensors of the thumb are next exposed as they pass obliquely around the lower end of the radius. The long extensor of the thumb is lifted from its separate tunnel and brought alongside the extensor ossis metacarpi and the primary extensor of the thumb. Next, the fat of the subcutaneous tissue is tunnelled obliquely between the upper end of the palmar incision and the lower end of the dorsal incision, and the flexors are brought through this tunnel so as to give a straight, pull. The three exposed extensors of the thumb are slit and the pal- maris longus, after being denuded of sheath and all areolar tissue, is threaded through all three, and stitched to each in order, with suffi- cient tension to keep the thumb extended.


The four common extensor tendons are similarly slit and the pre- pared flexor carpi radialis threaded through, suturing securely when it passes through each slit. The end of the transferred tendon may be buried in the extensor minimi digiti or turned back on itself and stitched to each tendon in turn and then to itself. The fingers and wrist must be kept in position of hyperextension during this proced- ure. No attempt is made to suture the fascia on either surface of the arm, but an attempt is made to cover exposed sutures of tendons with the subcutaneous fat by bringing skin edges together with a subcutane- ous suture. A plaster of Paris splint is put on over a sufficient dress- ing and left for three weeks.

In all, about three hundred cases have been operated upon 'by tendon transference, for various disabilities, in the Dominion Orthopaedic Hos- pital, Toronto. The general impression formed as to results is that they are nearly perfect in the great majority of cases, and where the results are only fair it is usually due to the fact that limited move- ments of joints have not been entirely overcome, or that the tendon fixation has slipped. In other words, the failure to secure perfect iesult is, in nearly all instances, due to a fault which might have been overcome.

It has been difficult to get a final report in a great many of these cases, but the attached report shows end-results in 52 cases in which a recent examination was possible.

The results collected are seen to be after periods varying from three months to 2% years.

They are summarized as follows : Excellent, 29 ; good, 15 ; fair, 7 ; fail- ure, 1. Total, 52.

In results classed as excellent the patients are able to perform any function which they could before the injury, with the exception of having somewhat lessened power.

In results classed as good, function is restored but movements are not quite as free as normal and power somewhat lessened.

In results classed fair, a great improvement is obtained, but motion is restricted and power limited.

Only one failure is noted, case of Lieut. F., and the report shows that a number of other factors enter into this result.

The metacarpophalangeal joint and all the tendons to the thumb were injured and an attempt was made to establish both flexion and extension.


Pron. Teres to Ext. Carp. Rad. L. and B.

Flex. Carp. Had. to Ext. Dig. Com.

Palm. Long, to

Thumb tendons.

Fig. 1.— Diagram of the operation of tendon transference for irreparable

culospiral injuries.



Note. Under "Type of Operation" the term "Complete trans- ference" means a transfer as follows: Pronator Teres to Ext. Carp. Rad. L. & B.; Palm. Long, to Abduct. Poll. Long., Ext. Poll. Brev.; Flex. Carp. Rad. to Ext. Poll. Long., Ext. Dig. Com.

Number 91178: Rank Gunner. Type of Injury Irreparable mus- culo spiral lesion, Rt. Type of Operation Complete transference. No Palm. Long., hence Flex. Carp. Rad. split. End-Results 2% years after operation, functional result excellent. Has worked as a carter since discharge without having to stop work. Anatomical result fair. Can extend hand from full flexion to 180°. Can fully extend fingers when wrist is at 180°. Can abduct thumb clear of wrist. Movements are free and strong. (See Fig. 2)

Fig. 2.— Case No. 91178.

Number 10916: Rank Private. Type of Injury Irreparable mus- culo spiral lesion, Rt. Type of Operation Complete transference. End-Results— 2y2 years after operation, functional result excellent. Uses hand for everything. Drives a car. States that function is per- fect. Anatomically, Can extend wrist from full flexion to 210°. Does not extend the fingers well. These remain flexed on hand at an angle of about 150°. Thumb just clears the carpus. Wrist-drop is perma- nently cured.



Number 663144: Rank Private. Type of Injury Irreparable musculo spiral lesion, Lt. Type of Operation Complete transference. End-Results 2% years after operation. Functional result excellent. Uses arm for everything, including heavy work. Spent some time as a laborer grinding rail joints. Anatomically Can extend wrist from full flexion to 210°. Can extend fingers separately from wrist. Thumb clears hand.

Fig. 3.— Case No. 291383.

Number 407716: Rank Sergeant. Type of Injury Irreparable M. S. lesion, Lt. Gas gangrene with extensive adhesions of tendons to sheaths. Type of Operation Complete transference. End-Results 2% years after operation. An astonishingly perfect result. Hand is quite as useful as before injury. Strength only is subnormal and that slightly. Can extend wrist from 150° to 210°. Can extend fin- gers fully with wrist at extreme of extension. Can abduct thumb well. It is hard to tell the hand from normal.


Number 745202: Bank Private. Type of Injury— Irreparable muse, spiral lesion. Type of Operation—Complete transference. Palm. Long, absent. Flex. Carp. Rad. split. End-Results Three months after operation. Fair result. Extends fingers to straight line. Ab- duct thumb well. Extends wrist 20°.

Number 192480: Bank Private. Type of Injury Irreparable muse, spiral lesion, Lt. Type of Operation— Complete transference. End-Results 13 months after operation. Result is not very good. Operation was hampered by numerous and extensive limitations of movements of shoulder, elbow and wrist. Range of movement of wrist small. A. G. F., 155. A. G. E., 180. Thumb just clears hand. Marked limitations of movements of fingers.

Number 291383: Rank Private. Type of Injury Irreparable muse, spiral lesion, Lt. Type of Operation Complete transference. End-Results 3 months after operation. Excellent result. All move- ments of left hand normal in range but subnormal in strength. A. G. P.. wrist, 145. A. G. E., 213°. Extends fingers well and abducts thumb. (See Fig. 3)

Number 445761 : Rank Private. Type of Injury Irreparable muse, spiral lesion, Lt. Type of Operation Complete transference. End-Results 2 years after operation. Excellent functional result. Has worked continuously since discharge. Hospital orderly. Ana- tomically— Can extend wrist from full flexion to 180°. Cannot get be- yond this. Fingers can be maintained in full extension when wrist is at 180°. Thumb is abducted well.

Number 709874: Rank Private. Type of Injury Irreparable muse, spiral lesion, Lt. Type of Operation Complete transference. Palm. Long, absent. Hence Flex. Carp. Rad. split. Because of fail- ure to develop extension of wrist, the wound was