Don't Throw Away the Cane W.P.blount

8/3/2019 Don't Throw Away the Cane W.P.blount

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Don't Throw Away the Cane *BY WALTEU P. BLOUNT, M.D., MILWAUKEE, WISCONSIN

As the causes of premature death are conquered one by one, man is given a longerlife in which to grow old gracefully. In the twilight years that his forefathers rarely knew,he needs help in seeing, hearing, chewing, and walking. Gradually we are coming to lookupon eye glasses, hearing devices, and dentures as welcome aids to gracious living ratherthan as the st igmata of senility. They should be accepted eagerly as components of a richerlife. The ('ane, too, should be restored to favor as a means of preventing fatigue and ahalting gait, rather than maligned as a sign of deterioration.

The use of the cane in order to prevent strain upon an ailing hip or knee is not generallyaeeepted. In the patient's mind there is a nice distinction between the permissible use of astick postoperatively and the adoption of this humble support for no other reason than therelief of a slight physical infirmity. A fat lady may waddle like a duek when she laboriouslywalks a few steps, but she resents the suggestion that she carry a cane. She would lookmuch better with a stick than with the limp; and with support she could walk enough toget some exereise. More walking would help with weight reduction. Bu t no! she is not readyfor a cane yet! The patient with residual disability after poliomyelitis and with a fatiguing,unsightly lureh needs a cane. Early degenerative hip disease may require no treatmentother than weight reduction and a stick in the opposite hand; however it takes an impres-sive orthopaedic surgeon to sell the idea.Pride is not always the major obstacle. There is no place for the stick in modernsociety. Man rarely walks. He rides in a car or a bus. The busses are crowded, and there isscarcely room in the modern car for the occupants to sit upright, without adding a stick.Your grandfather proudly rested his hands on the knob of a cane as he was driven behindgood horses. He stepped out briskly with his stick at the end of the ride. Now man mustlimp between busses without benefit of a cane.How our attitude toward the cane has changed! Earlies t man demonstrated his supe-riority to the beasts by carrying a stick in order to beat them off. The staff became a spear.The soldier leaned on the shaft when tired. The shepherd enjoyed the support of his crook.

The artist and the cartoonist have given us the history of the cane. In the Egyptiantombs of the Sixth Dynasty (2830 B. C.) the crude staff was illustrated. The stick graduallybecame a popular accessory that served many purposes. The nobleman struck at straydogs and cudgeled his slaves if they did not bow low enough. The cane became a symbolof power and aristocracy. Officialdom appeared with a mace or crosier. A jaunty stickwas carried by men and women alike at the race track and at the watering place.Following the publication in 1827 of the delightful medical biography, The Gold-Headed Cane, no well established doctor appeared in public without this symbol of hisprofession. The smooth polished stick was provided at the top with a hollow gold knob orerossbar eontaining aromatic vinegar. The man of seience held this to his nose so that thefumes might protect him from the exhalations of the sick person. The cane descended tothe doctor from Hermes or Mercurius, and, until our generation, it was as much a symbolof the healing ar t as was the caduceus. Now the doctor, as well as the patient, would rathersuffer great discomfort than the indignity of carrying a cane.

The advertisements of fifty years ago rarely depicted a stylish person without a cane.* Presidential Address read at the Annual Meeting of Th e American Academy of Orthopaedic Surgeons,Chicago, Illinois, January 30, 1956.

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696

RlfiNT

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tr ... ~ ' f

FIG. 1

I. o ~

W. P. BLOUNT

! / RIGHTfUll"'O..,

FIG. 2Fig. 1: When the patient stands, the weight of the body above the lowl'r l'xtrl'mities, 84. rl'sts equally onthe two normal hip joints. The statil ' force on each hip, indicated by a short arrow. R. is one-half of the totalsuperimposed weight. (From Pauwels &. Reproduced by permission of Ferdinand Enke \"erlag.)Fig. 2: (See also legend for Fig . 3.) Without moving the trunk or the pelvis the subject in Fig. 1 has liftedhis left lower extremity by flexing the hip and knee as though the left lower {'xtremity were in the swing phaseof walking. The weight of the left lower extremity is added to that of the torso. head, and arms, increasingthe total weight and moving the center of gravity of the body to the left to 85. The body weight that must beborne by the stationary right lower extremity is represented by the heavy line K. The abduetors of thestationary right hip must pull downward on the right side of the pelvis at B (vector M) strongly enough tosupport and to maintain In equilibrium the weight K. The force dO\\nward on the fulcrum at 0, the hip.is the sum of the vectors, M and K, expressed as R. The amounts of the downward pull by the abductors litB and the downward force at C are directly related to the relative length of the levers B to 0 and 0 to C.

l f B to 0 is one-third of 0 to C, the downward pull of the abductor muscles at B, expressed as .11, must bethree times the downward force at C, which is K, if the forces are to balance. The total pressure on the topof the femur, R, is the sum of M and K, or four times K. (From Pauwels.6 Reprodul'ed by permission ofFerdinand Enke Verlag.)A man was not fully dressed without his stick. Today only a few of the famous eharaetersin advertisements still carry canes.

At present, attractive walking stieks can be purchased at only a very few smart shops.Beautiful canes are collector's items or dust catchers in storage attics. A patient rarelydisplays the ornamented cane which he inherited from some distinguish'd aneestor. Themodern varnished stick with a rubber tip is usually obtained from a brae' shop or drugstore. This utilitarian model is not esteemed as an accessory.To become popular again, the stick must be both beautiful and effieient. I t should

hang from the forearm in order to: free the hand, bu t it should remain within easy grasp.Canes might be sold like cars on the basis of novelty features. Hidden swords are nolonger permissible, bu t many ancient cane accessories could be revived. Flashlights, bottles, umbrellas, and even built-in radios would be useful. Beautiful plasties ('ould he ('omhined with the newer alloys in order to increase the sales appeal.Following a serious injury or anroperation on a hip, most patients of sixty or seYentyyears should continue the use of a" su"pport indefinitely in' order to protect the injured partfrom further insult. They would gladly do so were it not for vanity and for public opinion.The injUl"ed wOI"kman is not permitted to return to any job as long as he is using a support,

TIlE JOl'UXAJ. OF llOXE AX!> JOIXT Hl"UGEHY


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DON'T THROW A WA Y TH E CANE

FIG. :3Fig. 3: The forces operating at the hip arewell illustrated by the simple balance. In this

pair of drawings, as well as in Fig. 4 and in thediagrams of the hip, it is agreed that, for absolute accuracy in establishing a complete system according to the laws of physics, the forcesrepresented by the vector R should have thearrow pointing upward to represent the upward thrust of the femur. Throughout theseillustrations, this arrow has been reversed topoint downward in accordance with the orthopaedic concept of downward pressure on thehip, rather than upward pressure of the femuragainst the pelvis.Consider that the column which supports thisbalance has been provided with some kind of adevice for measunng the total weight which isresting on the fulcrum. In this series of drawings, the force designated by the letter AI,represents the force exerted by muscles to counterbalance the weight K. The total weight uponthe column of this balance must equal theweights at AI and K. For the sake of simplicity,the weight of the balance beam and i ts accessoryequipment will be disregarded. On the left,the superimposed weight R, which is equal totwo K, is divided equally at AI and K - the FIG 4perfectly balanced condition when the normal .

- - ~ C

human body is s t a n d i n ~ erect.In the same type of diagram on the right, the approximate hypothetical relationships are represented when one lever is shortened as in our last hip schema (Fig. 2). The lever arm, B to 0, isone-third the length of the lever arm 0 to C. In order to balance the weight K, it is now necessaryfor the weight AI to be three times the weight K in order to maintain equilibrium. This means thatthe center column supporting the balance beam must now ",;thstand pressure four times that of K.(Redrawn from Pauwels 7)Fig. 4: (See also legend for Fig. 3.) The lever B to 0 is one-sixth of the length of the lever 0 to C.

I t will now take six times the weight K applied at AI in order to balance the weight K. The weightR, supported by the column, will be the sum of M and K or seven times K. This represents diagrammatically what happens when the hip is in marked valgus position. (Redrawn from Pauwels 7)

697

so he abandons his cane while he still needs it. We must counteract this prejudice. Let usstart a movement to employ the cane carriers. We must educate the doctors, patients, employers, and the general public to turn back to the old order and to look upon the stick as agood friend. Here are some scientific reasons why it is needed.

To review the mechanics of the hip, let us start with a diagram' (Fig. 1) taken from themuch quoted, but little read, monograph of Pauwels, published in German in 1935.6I t represents the weight of the body above the lower extremities resting equally on thetwo normal hip joints. The sta tic force on each hip is one-half of the total superimposedVOL. 38-A. NO.3, ro:oi"E 1956


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698 W. P. BLOUNT

Fir;. 5 Fl(;. I)Fig. 5: The valgus hip represenwd schematically on the right.. The pull of the abductors at B is atth e elld of an abnormally short lever arm, B to 0, which is only olle-sixth of U to (' . Th(' pull downwardat B must be six times K in order to maintain equilihrium wh(,11 the left foot raised. The total pressureon the stationary right hip seven times K .Fig. I) : When there is a valgus deformity of the right hip, the patient actually reduces till' pressure 011t he head of the femur h ~ ' liAting th e trunk to th e right as she st.eps on the right foot. ThIS displa('('S

t.he center of gravity to tl](' right so as to require much less pull of the abdudor 1I11lseles 011 th e right, andeonseqllently mUl'h less foret 011 the head of the right femur."'eight, 01' less thall olle-third of the total body \\eight. :\Iuselps arc relaxed, alld I l l U , w h ~ pull is IlOt a factor.

In FigUl'e 2, olle must suppose that the same patient (fueing the reader with the rightside clearly marked) has lifted his left, lower extremity by flexillg the hip and kllee asthough the extremity were in the swing phase of walking. He hus not moved the trunk 01'pelvis. Th e weight of the left lower extremity is added to that of the torso, head, alldarms, increasing the total weight and moving the ccnter of gravity of the hody to the left.In this hypothetical and simplified schema. the actual foree that is exerted UPOIl the headof the right femUl' comprises not only this superimposed \\'eight, hut the total force that ismomentarily required to maintain th e halance of the peh'is as the left limh is lifted. Th eabductors of the stationary right hip must pull dowll\\"Urd on the right side of the peh'isstrongly enough to maintain equilibrium. Th e force dowllward 011 the hip is the sum of thevectors M and K. The amounts of the dowllward pull by the abductors alld the downward force of gravity are directly related to the relative length of the levers. If B to 0 isone-third of 0 to C, it is obvious that the downward pull of the abductor museles must 1)('three times the force of gravity in order to maintain balallce. Then the total pressme allthe head of the femur is four times that of the superimposed weight.

With th e use of a simple balance (Fig. 3), we can illustrate the mechallies of the forcesas they affect the load on the head of the femur. On the left is the perfectly balanced condi-

THE J O U R ~ A L OF B O ~ E AX U J O I ~ T Bl:RGERY


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DON'T THROW AWAY TH E CANE fl99

f -= - - - - i ' - - - - -1 w 1'"'1""1 /o ! ~ c .."'" =10.,

FIG. 7 FIG. 8Fig. 7: In this hip schema, the trunk is listed to the right. The center of gravity, 85, is shifted to theright. The lever arm, 0 to C, is reduced to less than the lever arm 0 to B. There 18 less pull required ofthe abduct or muscles than the actual body weight so that M is less than K. The total force, R, on thefemoral head is only slightly in excess of the superimposed weight. (From Pauwels '. Reproduced bypermission of Ferdinand Enke Verlag.)Fig. 8: In the subject studied in the companion Table I, without a stick, the force designated R is 385pounds. A cane used in the left hand supports the body weight, K, without requiring as much pull ofthe abductor muscles. The cane works through a long lever so that a moderate push on the stick greatlyrelieves the pressure on the hip. Here and in Table I, the:various lines labeled 1, 2, and 3 refer to rela-tionships in this average case with varying forces on the cane, while the levers remain constant in length.(From Pauwels 6. Reproduced by permission of Ferdinand Enke Verlag.)

R123

TABLE I(See Figure 8)

Pounds Pressureon Caneo203338

Pounds Pressureon Femoral Head38522011366

tion when the normal human body is standing erect and motionless; the superimposedweight is divided equally between the two hips. In the same type of diagram on the rightis represented the approximate hypothetical relationships when one lever is shortened, asin our last hip schema (Fig. 2).

In Figure 4, the relative length of the levers is shown even more unequal in order torepresent diagrammatically the situation with the hip in marked valgus position.The valgus hip is represented in a schematic drawing (Fig. 5). The pull of the abduc-tors is almost twice that if the angle of the femoral neck were normal.The foregoing is only a hypothetical analysis of forces. In actual life, the patient witha valgus hip limps (Fig. 6), and the force on the right hip is reduced. As weight is borneupon the right lower extremity, the trunk is shifted to the right with an abnormal list so

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700 W. P. IILOC:,\Tthat th e ('I'llter of /l:J"U\'ity is displaecd to th e right. Thl' result is thl' (haracteristic waddl('o(the fa t Illall or tlIP lilllp of th e mall with ('oxa \"lllg;a.

Le t s(,p what h a p l ) ( , l I ~ ill 0111" hip ~ ( ' I t e m a whcll th e patipllt limps (Fig , 7), \\"ith tlIPtrullk listillg; to tlIP right. tl\(' ('plltpr of gra\'ity ~ h i f t ( ' d to tl\(, right. TI\('lp\"('r ann () to ( '

FI


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DO!,;'T THROW AWAY TH E CANE

FIG.9-DRoentgenogram made on December 7, 1955. Avascular necrosis appearedtwo and one-half years after the fracture, and two years after the patient hadahandoned crutches. With the use of crutches for one year, the head was revascularized . Roentgenogram shows the appearance of the hip five years aftcrhealing of the fracture. She uses a cane in the right hand. There has been noehange in the last two years. Hip motions are only slightly restricted. There isdiscomfort with changes of weather or overactivity.

iOl

is reduced to'less than the lever arm 0 to B, and less pull of the abductor muscles is requiredthan that which would be required by the actual body weight. The total force on thefemoral head is only slightly in excess of the superimposed weight.

The response to pain in the hip is similar; the result is an antalgic limp. The torsolists to the affected side when weight is borne on this hip in order to reduce the downwardforce on the femoral head and thus to reduce the pain. In our diagram, if the list is exaggerated enough to shift the weight so that K coincides with R, no pull at all is necessaryon the abductor muscles. This type of limp is familiar in the patient with completelyparalyzed abductor muscles.Limping, as a means of relieving stress on a hip, may be tolerated in an energeticchild, bu t it is not a desirable gait for an adult. Constant lurching of the torso is fatiguing;it produces excessive strain on the lumbar spine and causes backache. Above all, it is unsightly. The patient does not want to limp! In his sporadic attempts to reduce the lurch,the patient with a normal femoral angle repeatedly increases the pressure on the femoralhead up to four times that of the body weight. The man with a valgus femoral neck applieseven more force with each step. Rapid deterioration of the hip is inevitable.

The patient of the wise orthopaedic surgeon walks with crutches for six months aftera fracture of the neck of the femur. He uses a stick for a longer time - the wiser the doctor, the longer the time. If his medical adviser, his physical therapist, his friends, and hisVOL . 38-A. ;>;0. 3. Jl';>;E 1956


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702 W. P. nLOUXTpride finally drive him to abandon the cane while he still needs one, he limps. He limps ina subconscious effort to reduce the stra in on a weakened hip. If there is free motion at thejoint, he lists to the same side in order to reduee the pressurl' on the top of the femoralhead, as we h a n ~ just shown. I f there is restricted motion. h(' C'lUIIlOt shift his body weightbu t he hurries to remove the weight from the painful hip joint. When his pride makes himreduee the limp to a minimum, the excessive force pressing on the aging hip takes its tollin producing degenerative changes. He should not have thrown away the stick.As Pauwels has showll so well (Fig. 8), the use of a cane in the left hand reduces thepressure on the right femoral head without the need for limping. The support afforded bythe stick greatly lessens the pull required of the abductor muscles in helping to support thebody weight. The cane works through a long lever, so that a moderate push on the stickgreatly relieves the strain on the hip. The relative forces are shown in Table I. Pauwelsestimated that during the stance phase of walking, without the support of a eane, an average person exerts a static force of 385 pounds on the stationary hip. This weight can bereduced to 220 pounds by pushing down on a stick with the opposite hand the equivalentof 20 pounds. The cane is really an efficient mechanieal de\iee.Trochanteric fractures, as well as subeapital fl'actures, will heal more promptly ifreduced in some degree of valgus (Fig. 9-A). So far as it goes, this prin('iple is a good one.With secure internal fixation (Fig. 9-B), a woman, forty-six years old, walked with crutehessoon after the operation. Reduction and fixation were satisfaetory as seen in the lateralroentgenogram (Fig. 9-C). In the valgus position, bony union was prompt , and there waslittle danger of coxa vara.

The fallacy in the proposition is this. The position of valgus that ensures rapid healingalso reduces the lateral lever in the system of forces that ha\'e been discussed and greatlyincreases the pressure that is brought to bear on the hip as soon as cane or erutches arediscarded. A very high percentage of trochanteric fractures that heal in valgus result inavascular necrosis of the femoral head (Fig. 9-D) , a rare complieation if this fractureheals with the normal amount of varus, that is, with an abductor lever arm of normallength. In the case illustrated, pain and limp appeared several years after the fracture. Thepatient walked with crutches for one year, and the symptoms disappeared. There was noappreciable change as seen in roentgenograms in two years. An arthroplasty was suggestedelsewhere and may be desirable in the future. Howe\'er, with a ('ane she has no pain anddoes not limp. Hip motion is only slightly restrieted. She should not throwaway the cane!COllsider the seventy-year-old grandmother who is being treated for an impactedfracture of the neck of the femur in valgus position or the seventy-three-year-old lady witharthritis and a vertical fracture of the neck of the femur whose right hip is shown in FigurelO-A. We obtained satisfactory reduction and valgus position by simultaneous osteotomy,closed reduction, and fixation with Moore pins (Fig. 1O-B)2. I f either of these ladies knewof the likelihood of avascular necrosis developing, neither would abandon the supportwhich offers some assurance of preserving the funetion of the hip; neither would throwaway the cane.

At first the patient is timid about abandoning support. An optimistie prognosis fromthe orthopaedic surgeon encourages him to get rid of his eane. The do(,tor wants to pro\'ethe sueeess of his treatment to the critical world and the patient is inspired to show that heis wholly well again by discarding all support. I f the patient is thirty or forty, he shouldstrive for rapid complete reeovery; if he is sixty 01' seventy, he should adopt a eane untilseveral years' observation have proved that the cireulation of the femoral head has beenwholly re-established. Giving up the stick should not be used as a proof of reeovery.

The doetor says to the patient, "You may discontinue the cane as soon as you feelstrong enough". Xo one asks if the femoral head is strong enough; often it is not. Theroentgenogl'am may give e\'idenee of good healing; bu t doctor, treat the patient, not thepicture. The hip may hold out for a year or two and then give up; degClH'l'ative changesTHE JOURXAL OF BOXE AXD Jor:o..-r SURGERY


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J)O:'\ ''I' THROW .\ WA Y TH E ('.\:'\1':

I, S.

Fu;. 1O-A FIG. 10-131O-A: I. ::i. Roentgenogram made October 22, 1!J-I3, shows vertical fracture of the nel'k of thefemur in a female, age seventy-three, with generalized atrophic arthritis of moderate grade. ~ i m u l talJ('ous osteotomy, closed reduction, and fixation with :\Ioore pins were indicated in order to assureprompt healing and an ultimate good functional result.

Fil!: . 10-13: Roentgenogram made April 10, 19-16, two an d one-half years after the roentgenogramseen in Fig. 1O-A. The fracture had been reduced and immobilized by two Moore pins. The osteotomyhad hl'l'n ~ e c u r l ' d by a blade-plate which penetrated the fracture site. :\ 0 avascular necrosis developl'd .(Figs. IO-A and 100B are reproduced by permission from IflNlruc/OflU/ COllrse L e ( ' l l l r e of Th e Amel'ican Aeudemy of Orthopaedic Surgeons, W52, Vol. IX, p. 23.)

supervene. Most surgeons insist that a patient with a hip fracture walk with crutches forsix to nine months. But is that long enough? Th e avascular necroses come on one to fiveyears later. Why'!

Have any surgeons seen avascular necrosis with sequestration and deformity developin a patient who still walked with crutches? Stimulated by the brilliant research and thead viee of 0111' late Honorary :\Iemher, Dallas Phemister, I have insisted upon two yearsor more of ('l'Utch-walking for sewral patients with early avascular necrosis. Adequatecirculation was re-established in most of th e femoral heads. Perhaps prolonged supportwould redllee the incidence of this eomplication. I t is worth trying! The prevention ofavaseular ne('I 'osis is much more desirable than an attempted cure. Why throwaway theeane'!

The use of an artificia l femoral head is justifiable only in patients who have a relativelyshort life expel'tancy. Even in this group, most patients should prolong the usefulness ofthe endoprosthesis by the permanent use of a stick in the opposite hand. Th e surgeonshould tell the patient frankly, "This makeshift hip is good for five years if you are enoughof an a('rohat to \\'alk \\'ithout a ('ane; it is good for ten years if you are smart enough to('ut down on the stress that you put on this artificial joint." My figures are subjeet to revision \\'hen further ('linieal research has shown how long the average endoprosthesis willfunetion satisfaetorily.

I f one must usc a substitute for the upper end of the fCllllll', the normal length of thefemoral nc('k should he pl'escrved, if possible, so that the abdudors will work effi('icntly.When thc ahdul'tor lever arm is reduced because of a short neck or because of valgusVOL. 38-"'. xo. 3. Jl ':- ;E 1956


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704 w. P. DLOU:-IT

Degenerative Arthrosis

McMurray withInternal Fixation

FH ;, 11Th e technique of the displacement (:\I(':\lurra.,') osteotom. with ~ \ r a i f , ! : h t "blade-plate fixation . A flexion deformit." of 15 dpgrees, adduction of 2;) g r e l ~

al)(1 outward rotation of 10 degrees can he correckd without bcndinf,!: the IIladeplate and without using one wit h angulation in t hI' sagit tal plane. I ' t he proximalend of t.he femur is lIormally dl'nse, no exterual fixation is J ] e ( ' ( ' ~ s a r y(Fig. II is reproduced by permissioJ] from l l l ~ t / ' l l r t i ( } n a l C O l l r ~ c Lectllres ofTh e Allleri"un Aeademy of Orthopuedic Surgeons, 1!J52, Vol. 1'\, p, 2 : ~ , )

position, the additional strain on the artifieial hip joint must 1)(' rI,lien,d h ~ ' the use of astick. I f the bone is ahnormally soft or if the shaft of the endoprost Iwsis is loose, all "urgeon"will agree that th e use of a cane i" neeessary. Is it no t wi"e. thereforI'. to proteet mo"t freshlyinserted endoprosthe"es from the start, before eomplication" apppar'!

I should rather he rememhered as a thoughtful surgpon I han a" a hold one. I suhmitthat a \\'ell planned sequence of lesser operations with long inter\'als hetween, and the w;('of a cane as needed. may pro\'e hetter for th e patienl and pro(hw( i\'e of a more desirahleend result than somp more heroic surgical procedllrl'. Th('l'p i:-: a (,IHlen('y among orthopaedic surgeon" to ex(,hange simple methods for dramati( (rpulment that will not requirpth e use of th e eane. Th e surgeon looks for a single, definiti\e. hrid!!:p-hurning operation that\\'ill cure t he patient eompletely for t he rest of his life. Too often. t his goal is not reached.Th e patient stillnC'eds the stiek (or e\'en crutehes) after this heroi(' operation. I f a satisfa(tory arthroplasty or reconstruetion operation i" performed, how much hetter it wouldbe for most patients to urge th e continued use of a ('ane ill order to preSl'ITe th e funetiollof the reshaped bone by taking the strain off th e hip for ~ e a r s . no t for months o n l ~ ' .

Degenerati\'e arthrosis of a single hip is a good example of what I am talking about. AsT H E JOVRXAL OF "O X -: AX O JO[XT ti l' Rl ;ERY


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DON'T THROW A WA Y TH E C,D,E 705t he ar ticular eartilage wears out. nature gradually produces marginal osteophytes andfibrous periarthritis that stiffens the joint. The hip that is ankylosed by nature is pulledinexorably into deformity long before motion in flexion is much limited. The patient cansit ( ' o m f o r t a h l ~ . hut whm 11


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,00 W , 1', I IL() \ 'XT

Fij,(, I:l-A: H, '1' . a ilia f ' , aj,(f' fifty-t\\,o , HOf'lItj,(f'lIoj,(ralll lIIadf' :'I I:t ,I' II , 1 ~ I , ~ : I , :,hol\"l'd alll'allf'f,d df'j,((,IIf'rativ(' arthrosis of till' rij,(ht hip, Th('rf' wa s lIIark('d r('strif' tioll of 1II0tion an d thf'rp was 0111,1' 20d('gTf'('s of flf'xioll , TIII'rf ' wa s al l '1!ldtlf'tioll'f'x\t'rllal rotatioll d('forlllity, This hi p suita)'lf' for arthr o d f ' s i ~ , '1'1](' IUllIhar ~ p i n f ' ha d j,(raduall,I' hf'f'ollw a f ' f ' u ~ t o l l l ( ' d to illf'rf'a:'f'd dell lanlk

Fij,(, I:l-B: A TUelltj,(f'noj,(TaIll llIadf' .Jul,I ' 22, 1 ~ 1 . ' j : l , tll'O m O l l t h ~ aftf'r a pill-alid-do\l'f'1 a r t h r o d l ' s i ~ , TIll'hi p ha s heell hrought illto fl('xioll of:m d('j,(rf'(''' , II('utral ahdtlf'tion-adduetioll, an d 1(,,,, f'xtprrral rotatioll ,In this po"itioll, thf' hi p w a ~ nailf'd s o l i d l ~ ' and tw o j , ( r a f t ~ from th(' h011l' hank 1\"1 'f f dril'( '11 'If'ro,, till'joillt lim' , This I\":lS dOll(' throuj,(h a Iatl'ral approaf'il Il'ithout op('lIillj,( til(' hip joillt.

FIf;, I:l-CFij,( , I:l-(': III till' latf'ral TOf'ntl!('lIoj,(ralll, lIIade 011 : ' I 1 : t ~ ' I!I, 1!I,):3 thf' pillS ar . ~ h o w l I to I .. II'id . I,I' disI)('rsf'd , j,(ivilll! f'xtn'IlI({I' Sf'I'ur(' fixatiOiI. \\"ith a hip of al'f'raj,( ' 1.0111' df'lI'itl', no ('xtf'rllal tixatioll is1I('I'f'"ar,1". At th e p r f ' ~ e l l t tilllf', 011.. IlJassiv(' hOIllOj,(l'IIflU" j,(raft f'lllploYf'd at thl' illff'rior lIIarj,(ill of till'II('('k, togf'tlH'r with fivf' or ~ i x OIIf'-f'ighth-illf'h pillS sprl'ad out ill till' sUIH'rior an d postprior porli,"'softil(' a('e\.abululII , '1'1", op('ralioll is s a l i ~ f a l ' l f l r , I ' , ('I'f'II without tllf' j,(raft. IIlII fusioll is sloll'f'r ill 1"'I'omillJ.(

solid, The IIwlhod should 110/1 ... f'lIIplo,\"I 'd if thf'r( ' is mo r . thall :1O df'j,(rl'('s of motioll,Fi g , \:l-D : HO('lItj,(f'IIoj,(rallllllafl(, 011 ()f'\,ol'f'r 28, I ! ;');) , 111"0 :v'('ars aflf'r fllsilln IIp .ralillll, l 'nilln III' 1IIf 'hi p w a ~ solid an d t II(' grafts w . rf' wf'1I illl'orporal(,d, Th . rf' W' l ' no rf"1


14/15

DOX'T THROW AWAY TH E CANE 707increased strain on both the ailing hip and the low back. He cannot list over in an antalgiclimp, so he hurries to remove the weight from the painful hip.

A cane and an anodyne may be all that are necessary to keep him going until anarthrodesis is indiC'ated, as I shall point out later. He may need a neurectomy or physicaltherapy or both, and probably he should reduce his weight. But if the pain and the deformit y are exeessive, how logical it is to perform a displacement osteotomy of the femur nearthe hip joint (Fig. 11). This operation eorrects the deformity and thus relieves the paincaused by strain on the hip and the low back. Weight is borne on the distal segment 5, sothat there is less pressure on the joint and greatly increased stability. Motion in flexionis preserved.

The same eut of the osteotome that corrects the mechanics of the hip relieves thearthritie aehe, as was observed by J. Forbes Mackenzie of Melbourne, Australia, twentyyears ago. He showed that drilling, 01' cutting a hole in the cortex of the bone neal' the hipor knee joint, relieved the pain of osteo-arthritis, often for many years. Since Maekenzie'sobservation, numerous new operations have been done for the relief of pain and disability.:\fany of the more compliC'ated have depended for their temporary success on the simplefact that the cortex of the bone is cut near the joint.B. H., a fifty-year-old female had a hip that was suitable for displacement osteotomy(Fig. 12-A). The Trendelenberg sign was positive on the right, and the patient eould notwalk fifty feet without severe pain (Fig. 12-B). Internal fixation of the osteotomizedfemur allowed prompt el'UtC'h-walking with partial weight-bearing. Flexion was preservedso that the patient eould sit. Regained extension and abduction permitted erect standingand walking. Proper alignment as shown in the lateral roentgenogram (Fig. 12-C) isimportant. B. H. is well satisfied after ten years. There has been no significant change asseen in the roentgenograms. She does not tire with normal walking, and she says that shehas no pain. She scarcely limps. She promises to use a cane if pain returns. I should liketo have her use one now.

In such patients, there is ample hip motion in flexion in order to prevent furtherstrain of the low baek. I f the motion is slowly lost over the years, the lumbar spine isgradually aceustomed to increased demands. r sually the patient thinks that he sits wellbeeause he bends at the hip. He is surprised later when he is informed that he has only 20degrees of actual flexion of the hip joint. He has been sitting by flexing his lumbar spine.In the patient who has been earried along with a cane and conservative treatment(Fig. 13-A), or in the patient who has had a previous displacement osteotomy, enoughpain may gradually de\'elop in the stiffening hip to justify surgery. I f there is only onejoint invoh'ed, he may at this time be offered an arthrodesis. 2 With motion almost gone,a permanent cure is ohtained by means of pin-and-dowel fixation of the unopened hipjoint.Desirable flexion of about 30 degrees is maintained. The hip is brought into less external rotation and into neutral abduetion or is left in slight adduction, if the legs are of equallength. The aching is again relieved, aceording to Maekenzie's principle, and is permanently eliminated by obliterating motion (Fig. 13-B). The pins should be widely dispersedas seen in the lateral roentgenogram (Fig. 13-C). External support is unneC'essary with

hone of a\'erage density.R. T. left the hospital on el'Utehes after two weeks. The hip was fused solidly in fivemonths, but he used a support for two months longer. The appearanC'e of the hip two yearsInter is shown in Figll1'C' 13-D.The lumhnr spin!' was alrC'ndy limbC'I' iwcausC' of the gradually inereasing demands

put upon it hy the stiffening hip joint. ThC're was little postoperative haeka('he and thepatient was umbulatory with ('mtr'hC's soon ufter the operation. Free motion of the knee,whieh wus mlwh more important than motion at the hip, was maintained heeuuse the useof a east was avoided. He was left with good function and freedom from pain. He has theVOl.. 38-A. :-.00. 3. JUXE 1956


15/15

708 W. P. BLOUNTendurance which only an arthrodesis can provide. A cane is unnecessary. Even if this hadbeen his second operation, the patient would have been hospitalized for a total of not morethan four or five weeks.A pin-and-dowel fusion does not work well when there is free motion. An attempt toarthrodese the hip ten years previously would have required an extensive arthrotomy withexternal fixation of the knee and baek, as well as of the hip, for a prolonged period. Afterthis enforced rest, the lumbar spine would have been called upon suddenly for activityfar beyond any previous motion of these rusty vertebral joints. Pain in the low backwould have been inevitable.Arthrodesis of the hip, one of the most valuable procedures for the relief of disease,pain, or disability of the hip has fallen into disrepute in adults because of subsequent backpain in poorly selected cases. I f the operative procedures are taken in logical sequence,with intermittent use of a cane, nature will help with the treatment, and arthrodesis of thehip need not be limited to children and to young adults.Lest you think that I am just reminiscing about old-fashioned operations, let meremind you that medicine as a whole has advanced more in the last fifty years than in allpreceding historic time. This is eertainly true for the specialty of orthopaedics. I t is withthe greatest satisfartion that I review the most welcome changes that have occurred in mybrief span: better treatment of fractures, par ticularly of the femur, the humerus, the spine,and the ealeaneus, t remendous reduetion of the incidence of osteomyelitis and bone tubereulosis, the diagnosis and treatment of the protruded intervertebral disc as a cause forintractable baek pain and sciatica, the use of endoprostheses in selected hip disorders, andnow a successful campaign against poliomyelitis.

In the near future, I look for a substantial reduction in the number of eongenital deformities and in the incidence of cerebral palsy and traffic and industrial accidents. Inequalities of leg length will be controlled from the time of their appearance. Most scolioses willbe prevented, and the few remaining will be intelligently and effectively treated by theaverage orthopaedic surgeon. The Orthopaedic Research and Education Foundation,with the help of all of us, will have a significant part in achieving these and other gains.I hope that the next decade will see the elimination of avoidable complications in thefractures of childhood-the complications that are due to the lack of unders tanding of theeffeet of growth on fraeture healing and of fracture healing on growth. This implies theknowledge that frar tures in ehildren are different. Finally I hope, that in our progressivelymore rtopian existence, a glorified cane will regain some of its previous popularity and willassume its proper role in the intelligent prevention and follow-up care of many orthopaedicconditions. The fallary of our generation, "You don't need a cane", will be supplanted bythe slogan, "Don't throwaway the cane".

REFEREXCES1. BLOl"NT, W. P. : Bladl'-Plute Internal Fixation for High Femoral ( ) ~ t ( ' o t ( ) m i ( ' ~ . J. Bonl' and Joint Surg.,

25: 319-339, Apr. !!lola.2. BLOU:O;T, W. P. : Proximal Osteotomil's of the Femur. In Instructional COUfl

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Don't Throw Away the Cane W.P.blount