The principles and practice of modern surgery

by Roswell Park

Transplantation of a portion of the anterior tibial tendon, into the bone or into the opposed group of muscles. (After Vulpius.)

So far as technical considerations are concerned these operations should be performed only with the minutest attention to asepsis. When this has been secured a permanent dressing may be applied, the limb being left in the position most desired, and maintained there for several weeks. For this plaster of Paris makes the best support. The use of the rubber bandage will permit the operation to be bloodlessly made, by which it is greatly facilitated. If careful suturing be practised, there will be but little tendency to subsequent oozing or interference with repair. Fine discrimination is always needed in the matter of adjusting the length of tendon ends and the point of their fixation. A useless tendon which has been long stretched over a curved joint will have become elongated, and the tendon to be applied to it should be affixed farther down than would be otherwise necessary. The disposition of the upper portion of the useless tendon and muscle may also call for serious attention. It is rarely necessary to extirpate them. They are already atrophied, and to remove them would be to still further reduce the dimensions of the part. The excluded portions can thus be simply discarded. When there has been deformity with more or less pseudo-ankylosis the malposition should be forcibly redressed and the tendon grafting deferred until a subsequent time; the latter, to be successful, should be performed alone.

Incisions are usually made along and over the course of the tendons to be exposed, but not so close that the cutaneous scar can interfere with the tendon sheath. The lower end of a paralyzed muscle will appear very differently from that of one which is healthy; in the former instance the tissue will have lost its muscular character, and will be yellowish white and fatty. A fascia which has been stretched out of shape may be sutured in folds and will serve of itself to give support and shape to the part which is renewed.

The methods of uniting tendons are so numerous that they can be better estimated by a glance at the accompanying diagrams after Vulpius than by description ([Figs. 124] to [128]). It is not necessary to utilize all of the tendon of a healthy muscle, as it can be split and a portion diverted to its new function. It is not to be expected that tendons thus arranged will perfectly serve their purpose the first time they are used. There must elapse a period of education of the nerves and muscles whose relations are thus altered, and improvement in the use of the parts thus operated will accrue for months and even years. It is desirable that tendon surfaces thus applied to each other be made broad and extensive in order that their adhesion may be more firm.

Fig. 129

Showing methods of lengthening tendons. (Burrell.)

A modification of tendon grafting consists in implanting the tendon end into the periosteum instead of into some other tendon. There are various ways of making this implantation, either by simple suture or by boring into the bone or canalizing under a periosteal bridge. [Fig. 129] illustrates how the tendon of the tibialis anticus can be utilized in both ways. It will thus be seen that a tendon can be given either tendinous, periosteal, or osteal implantation. Tendons thus utilized rarely undergo necrosis or degeneration. So long as the possibility of infection be excluded almost anything can be done with these structures, in spite of their apparent lack of vascularity and vitality.

There are times when it is necessary to lengthen a tendon as well as to shorten it. [Fig. 129] illustrates methods by which both of these measures can be performed. Analogous methods have been practised with muscles themselves, although here the circumstances are different and nothing similar can be accomplished. Portions of the pectoralis major have been grafted into the biceps for paralysis of the latter.

Liberating the ring finger in musicians, by dividing the accessory tendons of the extensor communis digitorum, is an expedient suggested some years ago by Brinton. It is made by an incision less than a quarter of an inch long, through the skin and fascia, just below the carpal articulation of the metacarpal bone of the ring finger, and above the radial accessory slip, parallel with and on the radial aspect of the extensor tendon of that finger. The point of a narrow blunt-pointed bistoury is then inserted flatwise beneath the accessory slip down to a point just in front of the knuckles of the ring and middle fingers, where the blunt point should be felt beneath the skin. The bistoury is now turned upward, the middle finger strongly flexed, and the ring finger extended so as to make the slip tense when it is divided. The accessory slip on the other side of the extensor tendon is similarly divided through a distinct incision. Snug compression is made with a bandage over the wounds, with the thumb free, and after two days the patient is permitted to use the fingers in piano-playing in order to prevent reunion of cut surfaces.