TENOTOMY.
For convenience' sake I group under this one head certain operations
used for the relief of distortion, in which muscles or tendons are
divided subcutaneously. Since the discovery of the principle by Delpech,
and the application of it by Stromeyer, Dieffenbach, Little, and
countless successors, it has been used for very many cases for which it
is totally inapplicable, _e.g._ for the division of the muscles of the
back in spinal curvature. Still there remain several deformities for the
relief of which subcutaneous tenotomy is a most important remedy; chief
among these are Wry Neck and Club-foot.
OPERATION FOR WRY NECK.--_Subcutaneous section of the
sterno-mastoid._--In what cases of wry neck is this operation suitable?
In those only in which the muscles are the starting-point of the
mischief. These are sometimes congenital, more frequently they commence
in childhood. In cases where the distortion depends on disease of the
cervical vertebræ, or is secondary to curvature of the spine, division
of the muscle is worse than useless.
_Operation._--A tenotomy knife, which should be sharp-pointed, narrow in
the blade, with a blunt back, should be introduced through the skin a
little to one side of the sternal portion of the affected muscle, passed
along with its flat edge between the skin and the tendon, till it has
fairly crossed the tendon; the blade should then be turned so that by a
gradual sawing motion the edge may be made to divide the tendon about an
inch above the sternum. A distinct snap will then be felt or heard, and
the position of the head will be at once much improved. Exercise, warm
bathing, and rubbing, will generally suffice to complete the cure,
without it being necessary to call in the aid of the instrument-maker
with his expensive apparatus.[166]
OPERATIONS FOR CLUB-FOOT.--The following are the tendons which _may_
require division in the cure of club-foot, and the operations for their
division.
1. _The tendo Achillis._--There are very few cases of true club-foot
which can be successfully treated without division of the tendo
Achillis. While in talipes equinis it is generally the only disturbing
agent, in talipes varus and valgus it invariably increases and maintains
the deformity, which the tibiales or peronei seem to originate.
_Operation._--The foot being held at about a right angle with the leg,
the operator should pinch up the skin over the tendon, introduce the
knife flatwise, a little to one side of the tendon, till its point is
nearly projecting at the other, then turn the edge on the tendon and cut
inwards with a sawing motion till the tendon gives way with a distinct
snap, and the foot can be completely flexed with ease.
Dr. Little[167] recommends that the tendon should be divided from
before backwards. There is more risk by this method of wounding the
skin, and thus losing the subcutaneous character of the operation.
Professor Pancoast[168] divides the inferior portion of the soleus
muscle instead of the tendo Achillis.
2. _Tibialis posticus._--Next in frequency and importance to that of the
tendo Achillis, division of this tendon is much more difficult to
perform. It may be performed either above or below the ankle.
(_a._) _Above the ankle._--The blade of a tenotomy knife should be
entered perpendicularly at the posterior margin of the tibia, half an
inch or an inch above the internal malleolus, so as to pass between the
bone and the tendon of the tibialis posticus, the blade directed towards
the latter; the assistant should now evert the foot, the operator
pressing the blade against the tendon.[169]
(_b._) _Below the ankle, close to the attachment to the scaphoid._ This
is the better position of the two when the position of the tendon can be
made out, which is not always the case, especially in cases of old
standing.
Raising the skin just over the astragalo-scaphoid joint, the knife
should be entered with its blade downwards, and across the tendon, and
should be made to cut on the bone, while an assistant everts the foot
till the tendon gives way with a distinct snap.
3. _Tibialis anticus_ may in like manner be divided either just above
the ankle, or at its insertion. When it requires division it can
generally be made so prominent as to render its division comparatively
easy.
4. _Peronei._--These do not often require division, cases of talipes
valgus being usually paralytic in character. If necessary they can be
cut as they cross the fibula.
5. _The plantar fascia_, may require division; when this is the case, it
is so prominent as to render the operation very easy, if conducted on
the principles mentioned above.
FOOTNOTES:
[166] Syme's _Pathology and Practice of Surgery_, p. 220.
[167] Holmes's _Surgery_, vol. iii. p. 573.
[168] Cross's _Surgery_, vol. ii. p. 273, 3d ed.
[169] Miller's _System of Surgery_, p. 1339; Holmes's _Surgery_, vol.
iii. p. 571.