In the treatment of paralyses of the arm and the knee, there is no essential difference between the American and the German orthopaedic schools. In paralyses of the hip, the Germans stress the transplantation of muscles to replace the paralyzed ones, since the patients by this means regain control of the hip joint and learn to walk with more stability and for a greater distance. In America, apparently few operations of this type have been performed. For the paralyses of the foot there are, however, very marked differences of opinion.
From the eighth to the fourteenth years, I avoid bone and joint operations with the exception of Putti's partial arthrodesis and my own connective-tissue arthrodesis of the upper ankle joint, but correct the deformity of the foot by thorough manipulation and then take great pains to reestablish muscle balance by means of tendon transplantation. Such a plan of treatment can be successful only after careful treatment with apparatus carried out for one or two years.
Our method seems to have three advantages over the astragalectomy:
1. The foot is not deformed by the operation, but maintains its normal structure.
2. Redressment and tendon transplantations are less dangerous procedures than astragalectomy. Bone and joint operations are seldom necessary up to the fifteenth year in patients who have been treated by my method.
3. The most important motion of the normal foot is retained; therefore this type of foot is far superior to the stiff foot when tested by demands of social life such as dancing, tennis, and mountain climbing.
If one reckons the usefulness of the normal foot at 100 per cent., then one is able to secure by redressment and tendon transplantations, sixty to eighty per cent. of normal. The usefulness of a foot after astragalectomy I should rate, with reference to demands of social life, at thirty to forty per cent. If it is possible, therefore, to carry out the necessary after-treatment with apparatus, one ought to favor the German method. Only when for economic reasons the after-treatment cannot be effectively carried out, is astragalectomy indicated, because it is the most rapid and economical method of stabilizing the foot.
From the fifteenth year on, operations on the bones and joints are indicated in cases of severe paralyses to correct the deformity of the foot and to stabilize relaxed joints.
If the patient stresses the importance of having a foot which is capable of responding to the demands of social life, then one should try to preserve active supination and pronation, provided five powerful muscles can be utilized for transplantation. In all severe paralyses, one should combine the arthrodesing of the subastragaloid joint with tendon transplantation, a combination which was first developed in systematic fashion by American orthopaedic surgeons. In Germany, this American method has been adopted, and I do not question that it will be used more and more frequently in patients of fifteen years of age.
If American orthopaedic surgeons were to limit as far as possible the astragalectomy in children under fourteen years of age, and stress the importance of tendon transplantations, unanimity could be reached in the surgery of paralytic deformities and the number of paralyzed feet which could meet the demands not only of daily labor but of social life would be much greater than at present.