i66

THEORTHOPAEDIC REHABILITATION OF A PATIENTAFTER EXCISION OF A CEREBRAL TUMOUR

By WYLIE MCKISSOCK, O.B.E., M.S., and K. I. NISSEN, F.R.C.S.

The decision to attempt the salvage of a patientleft with severe deformities from spastic paralysisis seldom made easily. It is difficult to predict thegain in function, the surgical procedures may needto be major and multiple, and re-education mustbe patient and prolonged. On the other hand, animportant consideration is the chance of releasingan attendant, often a near relative, from thebondage of constant care. The case reportedhere is a good example of the problems sometimesencountered.

HistoryThe patient is a man aged 32 years. In 1924

at the age of six, Sir Percy Sargent explored butwas unable to remove a gliomatous cyst of theright parietal region which had been causingsymptoms for two years. After the operation hewas left with extensive weakness on the left sideand a squint, but he continued his education and

FIG. ia..Aradiograph taken before the second opera-tion, showing the bone flap of the operation by SirPercy-Sargent and calcification in the gliomatouscyst.

finally entered the Civil Service in I94i at theage of 24. Two years later he had the first of fourfainting attacks, each with loss of consciousnessfor a few minutes. All the attacks occurred inthe morning; they were preceded by momentarydizziness and followed by extension of the headand neck. There were no headaches and eachtime he was able to return to work the next day.The weakness Qf the left side did not increaseafter any attack.Apart from the stationary left side, the main

findings in I944 were radiological. There was anold right parietal skull defect, mostly covered bynew bone formation, and a large calcified tumourin the right temporal lobe originating from quite anarrow stalk in the middle of the fossa and extend-ing well into the parietal region (Fig. ia). In theupper part was a cyst 6 cm. in diameter.

In October I944 the large cystic tumour wasexcised at the Atkinson Morley Hospital. Severe

FIG. ib.-A radiograph taken after the second opera-tion, showing the extensive bone flap, and the silverclips use I to control haemorrhage from the tem-poral fossa and from the choroid plexus.

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March 1950 McKISSOCK and NISSEN: Orthopaedic- Rehabilitation of a Patienit 16

FIGzaN rdigrah f te ef ar bfor oeraio sowig he axmumdereeofx.lunar.exenionofthelbow ad of dosiflexon.of.te.wris

Fmzb A radiograph ~taeafesetooftebcpanbrcilsatumuceangoe'rhodisfthe wri Theradus and uintentioally theulna ar sondy.uedwihth.cra.boe

arterial bleeding from the deep surface of thetemporal lobe was controlled by silver clips. Thetumour had invaded the inner wall of the temporalhorn, the trigone, and the lateral wall of theventricle. The temporal part of the choroid plexuswas divided between silver clips and removed.The enormous cavity left after excision of thetumour led to collapse of the entire hemisphere andthe brain fell away from the cranium for 2 to 3 cm.The whole space was filled with saline and thedural flap was closed in the usual manner. Thebone flap was replaced after a moderate decom-pression at the base.For several weeks the post-operative state was

extremely grave and it was doubted whether the

patient would ever rouse from his state of stupor.After five months, however, he could mutter afew words and move the right arm. After oneyear he was talking freely, and was again continent;four deep pressure sores were healing, but severecontractures had developed in the left arm and inboth legs. He was now being cared for at homeentirely by his widowed mother, an air-raidwarden; he spent part of each day in a chair, buthad often been alone at night during the bombingraids. After two years he was so alert and co-operative that he was referred to an orthopaediccentre, but all attempts to correct the deformitiesof the legs by physical means failed, and he wasreturned to his upstair bedroom off Streatham Hill.

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i68 POSTGRADUATE MEDICAL JOURNAL March 1950-

FIG. 3.-A radiograph before operation showing dislocation of the left hip and abduction deformity of the right hip,Both trochanters have been eroded from pressure sores. The right lesser trochanter is seen in full profile,indicating a marked degree of external rotation.

TreatmentFour years after the second brain operation the

patient was admitted to the country branch of theRoyal National Orthopaedic Hospital, where hewas to remain as an in-patient for a year. At firstsight the possibility of his ever walking againappeared remote. Though the right arm waspowerful, the left arm was wasted and contractedat the elbow and wrist, rather like the wing of aplucked fowl (Fig. 2a). The left leg was almostcompletely paralysed, with the hip dislocated andthe femur internally rotated, flexed and adducted(Fig. 3); the knee was moderately flexed, and thefoot was in the equino-varus position. The rightleg, less completely paralysed, had been pushedinto abduction by the left, and was externallyrotated and flexed; the knee showed a flexioncontracture of 300, but the foot, apart froma deep old pressure sore caused by the oppositeheel, was in good shape. There were also healed

sores adherent to bone over each great trochanter,one ischial tuberosity, and the dorsum of the rightfoot. The patient was somewhat obese. On thecredit side, however, there were intelligent co-opera-tion, a splendid right arm and an optimistic mother.The order of the seven reconstructive pro-

cedures considered necessary for the three limbswas first decided upon, and in the event, except fortemporary setbacks at the left wrist and right hip,the order was adhered to. It was argued that asthe prospect of walking depended on obtainingcrutch support from both arms, the left arm shouldbe made fit for this purpose by bringing it downto a right angle at the elbow, with the wriststraight. In this position a crutch with a gutter topand a bicycle handle-grip set to the angle of thepalm can be used to advantage even when theonly useful power in the arm is in the shouldermuscles (Fig. 5b). Two operations were neededfor the left arm:-

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FIG. 4. A radiograph talien after Batchelor's operation on the left hip, and osteotomy of the right femur (the platehaving been removed). The angulation of the remaining plate appears diminished owing to some external rotationof the left leg.

I. Reduction of the flexion contracture of theelbow. A broad V-shaped incision was made inthe contracted skin over the front of the joint toallow elongation of the skin and suturing in theshape of a Y. The biceps tendon and all fibres ofbrachialis anticus were transected. This allowedthe forearm to extend to just below the rightangle, which position was maintained by plaster-of-Paris. The wound took four weeks to healsoundly. End-result: This degree of correctionhas been maintained. The brachio-radialis musclenow provides sufficient flexor tone to balance thetriceps.

a. Arthrodesis of wirst ('gouge' technique). Thetendons of the deforming muscles flexor carpiradialis and ulnaris were first divided. A 4-in.mid-line dorsal incision was made over the wrist,and the atrophied extensor tendons were freelymobilized to allow retraction to one side or theother. The distal inch of the ulna was excised in

the hope of retaining some range of rotation of theforearm. The lower end of the radius was nextbared and fashioned into a gouge with the bevelledside forwards. Both rows of carpal bones werethen split in halves in a curved fashion, and thegouge of cancellous bone of the radius was wellimpacted into them. This left the wrist straight,and a full-arm padded plaster was applied.Despite elevation and ice bags, the post-operativeswelling was much greater than usual, and bycausing pressure against the cast, disimpacted theradius from the carpus. A month later this wascorrected and good impaction was maintained forthree months, by which time sound fusion hadoccurred (Fig. 2b). The lower end of the ulna,however, also shared in the fusion; this meant afixed position of rotation of the forearm, a matterof little moment and possibly an advantage in acase such as this. End-result: The left arm is nowa limb of some practical value. With the special

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comfortable sitting. Note the healed pressuresores over the great trochanter and on the dorsumof the right foot.

crutch strapped on, the patient can stand alone;with it off, he can use the fist for steadying objects,and even has some weak returning power of grasp.

Treatment of the Left LegWith the surgical programme for the arm well

in hand, and with the knowledge that shortanaesthetics at least were well tolerated, the majorprocedures for the lower limbs could begin.Obviously the adducted left leg had to be restoredto a vertical position where it could act as a propand where it would allow room for the correctionof the abducted left leg. The spastic and con-tracted adductor muscles needed to be dealt withfirst, and then some type of arthroplasty had tobe performed on the dislocated hip in order torestore sufficient movement to allow both sittingand standing positions. For this type of case,Batchelor's two-stage pseudarthrosis,1 so well

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FIG. 5b.-The patient standing with the aid of aspecial crutch incorporating a padded gutter-splintfor the arm, and a bicycle-grip set to suit the palm.The scars of the tibial pins are visible. The leftshoe has been raised 2 in. (The squint is due onthe right side to complete paralysis of all musclesexcept the external rectus, and on the left, toparesis of the intemal, superior and inferior recti.)

described in a previous number of this Journal,was the obvious choice.

3. Obturator neurectomy and tenotomy of ad-ductors of left hip. Through a median suprapubicincision, and with some difficulty due to massesof retroperitoneal fat, the obturator nerve wasfound near the obturator foramen and divided.The adductor tendons were divided subcutaneouslyclose to the pubis, and most of the adduction con-tracture was reduced by guarded manipulationof the femur. This position was maintainedsimply by putting a sling round each knee andtying them to the sides of the bed.

4. First stage of Batchelor's operation. The lefthip joint was exposed by the anterior (Smith-Petersen) approach, and the head and neck of thefemur were excised. It was then possible toabduct the leg, and the fixed flexion deformityalmost disappeared. Post-operatively, skeletal

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.March 1950 McKISSOCK and NISSEN: Orthopaedic Rehabilitation of a Patient I71

traction was secured with a Steinmann's pinthrough the tibial tuberosity, and a system ofstirrups and pulleys which allowed free swingingmovement from the overhead beam.2 To avoidany recurrence of fixed flexion the patient wasnursed flat on the bed for half of each day. Afterfour weeks there was a range of assisted activemovement which was surprisingly good in view ofthe previous absence of voluntary movement atthe hip.

5. Second stage of Batchelor's operation. Thiswas performed with the patient lying prone on theoperating table, which was broken at the level ofthe hips by some 200 in order to relax the psoasmuscles. The subtrochanteric osteotomy, with aspike on the distal fragment, was made in theusual way and fixed with a six-hole plate angledabout 30°. In this way a plaster spica was avoided,and with skeletal traction as before, swingingmovements were again started after four or fivedays. Radiographs showed sound bonv union ateight weeks as usual. End-result: The presentrange of flexion is from 5' to 8o0; adduction andabduction are each 200; but some fixed externalrotation has developed from the pull of the psoas,the action of which on the lesser trochanter, nowthat the head and neck are missing, is very similarto that of the normal biceps muscle on thetuberosity of the radius.

Treatment of the Right LegAttention was next paid to the right leg, first to

the flexed knee, and then to the hip, which was re-maining widely abducted despite the departure ofthe left leg to the neutral position.

6. Tenotomy of the right hamstrings. Thetendons of all the hamstrings were divided throughtwo short vertical incisions just above the knee.With firm pressure, most of the flexion deformitywas corrected and a long plaster was applied. Atthe same time the equino-varus deformity of theleft foot was treated by manipulation and plaster, aprocedure later repeated twice.

7. Plated osteotomy of right femur. The upperthird of the femur was exposed through an in-cision which encroached on the fibrous scar of anold pressure sore adherent to the trochanter.After section of the upper shaft and correction ofthe triple deformity of abduction, external rota-tion and flexion, a plate was twisted to fit theavailable bone surfaces, and fixed with six screws.Tibial traction was again applied, and both legswere in a normal attitude.The second setb& c' to the programme was now

encountered. A low-grade infection developed,most probably owing to the extension of the in-cision into the region of the old pressure sore.

FIG. 6.-A photograph taken six months after dischargefrom hospital. The persistent lean to the left iswell shown. Standing would obviously be im-possible without support from the crutch on thebadly paralysed left arm. The picture emphasizesthe importance of an 'all-or-nothing' programmein cases of this type.

Fortunately bone union was rapid and appearedcomplete after eight weeks. The plate was thenremoved and the incision healed by first intention.End-result: The range of movement is as good asthat of the right hip.

ProgressTen months after admission, exercises in the

warm pool were commenced. These went well,but when crutches were first used, the degree ofimpairment of balance became apparent from theconstant pitch of the trunk over to the left side(Fig. 6). This has made rising from a chairwithout aid a serious difficulty.

Six months after discharge from hospital, thepatient is up all day, dresses himself, manages histoilet, and can walk with crutches. A sympathetichousing manager has found a bungalow with agarden. There is talk of a motor chair and clericalwork, while his mother, free from the burden shecarried for four years, is a changed woman.

AcknowledgmentsThe clinical photographs and prints of radio-

graphs are the work of Mr. R. J. Whitley at theInstitute of Orthopaedics.

REFERENCES

i. BATCHELOR, J. S. (I948), Postgrad. Mled. Youir., 24, 241.2. NISSEN, K. I. (1949), Proc. Rov. SNoc. Med. (.Section

Orthopaedics), November, in press.

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