Tenflon Transplantation in tna Treatment 
of Paralytic Deformities 
BY 
JOEL E. GOLDTHWAIT, M. D. 
SURGEON TO THE GOOD SAMARITAN HOSPITAL, ASSISTANT SURGEON TO 
THE CHILDREN’S HOSPITAL, ORTHOPEDIC SURGEON TO OUT- 
PATIENTS AT CARNEY HOSPITAL 
BOSTON 
Reprinted from, the Boston Medical and Surgical Journal 
of January g, iBg6 
BOSTON 
DAMRELL & UPHAM, PUBLISHERS 
No. 283 Washington Street 
1896 TENDON TRANSPLANTATION IN THE TREAT- 
MENT OF PARALYTIC DEFORMITIES.1 
Surgeon to the Good Samaritan Hospital, Assistant Surgeon to the 
Children’s Hospital, Orthopedic Surgeon to Out-Patients at Carney 
Hospital. 
JOEL E. GOLDTHWAIT, M.D., BOSTON, 
The purpose of this paper is to call attention to the 
possibility of furnishing better mechanical attach- 
ments for certain paralyzed or only partially paralyzed 
muscles, as a part of the treatment of paralytic de- 
formities. The same principles are to be employed in 
the treatment of deformities of other character; but 
it is my desire to confine this paper wholly to the con- 
sideration of the method as it is of use in the deform- 
ities which have resulted from some form of paralysis. 
When this work was commenced it was my belief 
that it was largely original, but upon a more careful 
perusal of the literature, recently made, 1 find that in 
1881 Nicoladoni operated upon a patient and attached 
one of the posterior peroneal tendons to the tendo- 
Achillis. Since then one or two other cases have been 
operated upon abroad, and there have been a few cases 
in this country. The operation, however, as it has 
been done, has never received public recognition and 
but one work on orthopedic surgery, with which I am 
familiar, even mentions it. Hoffa, in the last edition 
of his book, mentions Nicoladoni’s case almost without 
comment. 
From the cases which have come under my observa- 
tion, it seems to me that the operation deserves a much 
more prominent position than it has received, and that 
the method is capable of much broader use. The pro- 
cedure cannot, of course, cure a paralytic foot, neither 
is it to be applied to all cases of paralysis in which 
there is deformity; but in a certain limited number of 
cases the benefit to be derived from furnishing better 
attachments for the muscles is most marked. In cer- 
tain partial paralyses the power which remains in the 
1 Bead at the meeting of the American Orthopedic Association held 
in Chicago, September, 1895, and also at the Surgical Section of the 
Suffolk District Medical Society, November 6, 1895. 2 
unaffected muscles is a disadvantage rather than a 
benefit, as these muscles, having nothing to antagonize 
them, by their contraction pull the foot, or the part, 
out of its normal relation with the other parts; and 
after these normal relations are lost the deformity in- 
creases more easily and more rapidly. If in these 
cases some operation can be performed which will 
keep the bones and joints in more nearly their nor- 
mal relations, improvement results. A weak muscle 
cannot, of course, be made to do the work of a strong 
muscle, perfectly, but if this muscle, which has been 
working at a mechanical disadvantage and producing 
undesirable results, can be made to work in the right 
direction the patient is better off than formerly. The 
amount of improvement will depend upon the original 
condition, but all of the cases which have been oper- 
ated upon have been improved. It has been possible 
to substitute simple forms of apparatus for compli- 
cated ones, and in one or two cases to dispense with 
it entirely. The patients also walk better, the limp 
being less marked. 
Thus far the operations have been performed upon 
the feet, but there is no reason why the same principle 
should not be employed in other parts of the body. 
At the knee, undoubtedly, it could be employed to ad- 
vantage in a certain limited number of cases, and very 
possibly at some of the other articulations, although 
the best results are to be looked for in those portions 
of the body where the tendons are well formed and lie 
superficially. 
The cases to be selected for the operation are those 
in which one group of muscles has been destroyed, 
leaving the antagonizing or accessory muscles little if 
any impaired. This condition, if not treated, results 
in a definite deformity, simply from the muscular ac- 
tivity ; and this becomes more marked as the age of 
the patient increases, partly because of the greater 
weight to be borne and partly because of the greater 
strength of the non-paralyzed muscles. In certain 
cases, as the deformity develops and increases, the me- 
chanics of motion changes, so that the relation of the 
power to the fulcrum, and the fulcrum to the weight, 
or the portion moved, is entirely unlike the original 
condition. This is true in certain deformities at the 
knee, but is best demonstrated in the cases of infantile 3 
paralysis, in which all of the posterior muscles of the 
calf are paralyzed with the exception of the two pe- 
roneals. The action of these muscles normally is to 
extend the foot at the ankle, and to abduct, or turn out, 
the front part of the foot, the fulcrum being the pos- 
terior edge of the outer malleolus. There being no 
power in the gastrocnemius or in the muscles at the 
inner side of the back of the leg to control the pero- 
neal muscles, their action gradually stretches the inter- 
nal lateral ligaments and the whole foot is drawn 
outwards. The internal malleolus becomes more 
prominent while the outer malleolus is less so, owing 
to the turning out of the foot. Mechanically this 
places the outer malleolus, or the fulcrum over which 
the peroneal tendons act, distinctly inside the line of 
motion. As the result of this the tendons are gradu- 
ally drawn outward until they slip over the posterior 
edge of the malleolus, and finally rest upon its outer 
surface, and in cases of long standing well toward the 
anterior edge. This position of the tendons is very 
well shown in Fig. 20, made from a photograph 
taken while the patient was attempting to extend the 
foot. 
With the tendons in this position, the action of the 
muscles causes flexion and abduction, instead of ex- 
tension and abduction of the foot as is normal. Fig. 
1 is from a photograph taken with the patient attempt- 
ing to extend the feet. The right foot, which is not 4 
paralyzed, is extended normally, while the left is ac- 
tually flexed as well as abducted. In this case all of 
the posterior muscles were paralyzed except the per- 
oneus longus and brevis, and these tendons instead of 
being behind the malleolus were on the outer side near 
the anterior edge. It is evident that in such a con- 
dition the active muscles do harm rather than good, as 
their action draws the foot into the worst possible 
position for use in standing or walking. 
The best place for these active muscles to be 
attached would be on the inner side and directly be- 
hind the foot, as in this position the foot can be ex- 
tended and the arch supported, or, in other words, the 
power is applied to the best mechanical advantage. 
In paralysis of the anterior muscles of the leg, if 
the paralysis is partial, those on the inner side are 
much more often affected, so that dorsal flexion of 
the foot is performed by the outer muscles, the ex- 
tensor communis digitorum and the peroneus tertius. 
The result of this is that the foot is not simply 
flexed, but is flexed and abducted. This is shown 
in Fig. 2 and also in Fig. 19, in both of which the 
attempt at flexion was being made. In Fig. 2 the 
right foot is simply flexed while the left foot, the one 
that is paralyzed, is drawn up and out. 
The absence of the anterior tibial, or the muscular 
power which is normally applied to the inner side of 
the foot in front, is noticed also in the action of the 
posterior muscles, and instead of simple extension at 
the ankle, extension and abduction also is the result, 
there being nothing in front on the inner side to steady 5 
or control the muscles behind. Fig. 3 was taken with 
the patient extending the feet as much as possible. 
The right foot is extended, and if anything, is turned 
in slightly, while the left foot is turned out as well as 
extended. This absence of the anterior tibial muscle 
in walking or standing results, from the position in 
which the foot is placed, in a gradual giving way of 
the arch, and a flat-foot of a greater or less degree. 
Fig. 15 illustrates an extreme type of this condition. 
It is obvious that, in such a case, if the active muscles 
could be attached to the inner side of the foot the 
usefulness would be greatly increased. 
The following cases are reported with considerable 6 
detail, as illustrative of the principles which have been 
expressed. Only those cases are reported which were 
operated upon at least three months ago, as the immedi- 
ate results are of less value. 
Case I. A young woman, nineteen years old, came 
to the Carney Hospital in October, 1894, for treatment 
of the left foot. When nine months old she had an 
attack of infantile paralysis which involved the left foot. 
Walking has always been difficult, but of late, owing 
apparently to her increased weight, there has been 
considerable pain referred to the inner side of the foot, 
under the inner malleolus. It was because of this pain 
that she sought treatment. 
The left leg was an inch shorter than the right; 
there was marked atrophy of the calf; and the foot 
was in the position of most extreme calcaneo-valgus. 
In walking, the weight was borne upon the inner edge 
of the heel, the anterior portion of the foot being 
turned outwards fully forty degrees with the normal 
axis of the ankle-joint. The posterior muscles were 
all paralyzed, with the exception of theperoneus longus 
and brevis, and the tendons of these muscles were 
on the outer surface of the malleolus. The anterior 7 
muscles were practically uormal, and having no pos 
terior muscles to antagonize them, their contraction 
caused such extreme flexion that the dorsum of the 
foot rested against the anterior surface of the leg. 
The patient was admitted to the hospital and the fol- 
lowing operation performed (Fig. 4). An oblique 
incision, four inches long, was made so that it crossed 
the tendo-Achillis about one inch above its insertion 
into the os calcis. Through this wound the peroneal 
tendons c and d, were exposed and divided at about 
the lower edge of the malleolus. The tendo-Achillis 
(a) was then freed, and the tendon of the peroneus 
brevis (d) was passed under this and attached to the 
tendon of the flexer longus pollicis (b). The tendon 
of the peroneus longus (c) was then attached to the 
tendo-Achillis (a), after which the wound was closed 
and a plaster-of-Paris bandage applied, holding the 
foot extended in order to relieve the strain, as much as 
possible, from the sutured tendons. 
The wound so that fully six weeks were 
required for the healing, after which the patient was 
allowed to walk about without apparatus. One month 
later, because of the tendency to pronation, a valgus 
plate, was applied, and this has been worn since. 
The result in this case is best shown by the illustra- 8 
tions. Fig. 5 shows the position as the weight is 
borne, the turning out of the foot being entirely cor- 
rected. The extreme flexion has been controlled, only 
that which is shown in Fig. 6 being possible. Exten- 
sion is possible, as is shown in Fig. 7, contrasted with 
absolutely no power of extension before the operation. 
The improvement in the tread of the foot is strikingly 
shown by the boots worn before and since the opera- 
tion. Fig. Bis from a photograph of a boot which was 
worn by the patient previous to the operation. Fig. 9 
is from the boot which was worn for several months 
after the operation. The difference in the line of the 
heel is very striking. Without the operation it would 
have been necessary for the patient to wear an ex- 
pensive apparatus probably for the rest of her life. As 
the result of the operation she is able to get along with 
a simple valgus plate, and with this she has been doing 
general housework for the past eight months, entirely 
free from pain or other symptoms. 
Case 11. A boy about thirteen years of age. When 
two years old he was paralyzed, the right lower leg and 9 
foot being the parts affected. All of the posterior 
muscles were destroyed, with the exception of the two 
peronei, and all of the anterior muscles except the 
peroneus tertius aud the extensor communis digitorum. 
As the result of this, all the power being applied at 
the outer side of the foot, and the posterior tendons 
being out of place, as described in the previous case, the 
foot was in the position of calcaneo valgus. Walking 
without a crutch or an apparatus extending to the knee 
was practically impossible. 
The patient was admitted to the Children’s Hospital, 
and through the kindness of Dr. Burrell I was per- 
mitted to operate upon him. The first operation, which 
was performed about three and one-half months ago, 
was practically the same as that described in Case I. 10 
Two weeks after this a second operation (Fig. 10) 
was performed, this time upon the anterior tendons, in 
the endeavor to furnish some muscular attachment at 
the inner side of the foot. An oblique incision was 
made across the front of the leg just above the ankle- 
joint, and the tendons carefully separated. The tendon 
of the peroneus tertius (h) and the outer segment (c) of 
the tendon of the common extensor (d) were then di- 
vided as low down as possible and attached to the ten- 
don of the anterior tibial (a) muscle. The wound was 
then treated as in the other cases, sutured without drain- 
age, and the foot done up in plaster-of-Paris for two 
weeks’ time, after which moderate motion was allowed, 
the patient being permitted to walk at the end of the 
third week. 
The result in this case is very good, the extreme 
valgus has been corrected, and a simple valgus plate 
gives all the support that is needed. The amount of 
voluntary flexion and extension is shown in Figs. 11 
and 12. Before the operation there was no power of 
extension. It is also to be noticed that the motions 
are pure flexion and extension, the valgus being entirely 
corrected. Fig. 13 shows the foot with the weight 
borne before the operation. 
Case 111. A boy, twelve years of age, entered the 
Children’s Hospital in August last, in Dr. Cushing’s 11 
service, and it was through his kindness that I was 
permitted to take charge of the case. 
There was a marked valgus of the left foot resulting 
from an attack of infantile paralysis when two years 
of age. There was no contraction of the anterior 
tibial muscle and hut slight response with the extensor 
longus pollicis. The other anterior muscles were nor- 
mal, and the posterior muscles were normal except 
that there was a moderate amount of contraction of 
the tendo-Achilles, evidently due to the weakness of 
the anterior antagonizing muscles. On any attempt 
at flexion, the foot was drawn up and out, due to the 
point of attachment of the active muscles, at the outer 
portion of the foot. 
The operation (Fig. 14), which was performed over 
three months ago, consisted in exposing the anterior 
tendons as was done in Case 11, and then instead of 
attaching the peroneus tertius (b) to the anterior tibial 12 
(a), the anterior tibial (a) tendon was split and at- 
tached to the peroneus tertius (5). This seems to me 
to be a better operation, as none of the attachments 
of the active muscles are sacrificed, but instead another 
attachment for these muscles is made. 
The result in this case is most satisfactory ; the val- 
gus and abduction of the foot, which was so marked 
before the operation (Fig. 15), has been entirely cor- 
rected, and even when all the weight is borne upon 
the foot, the arch is high and there is no tendency to 
the old flat-foot. Figs. 16 and 17 were both taken 13 
with the right foot raised so that all of the weight was 
supported. The contrast between this and the condi- 
tion before the operation (Fig. 15), in which only half 
the weight was supported, is very striking. 
No apparatus whatever has been wornjsince the op- 
eration, and the child walks with the foot straight for- 
ward. On voluntary*flexion the foot is drawn up per- 
fectly straight (Fig. 18), in contrast to the flexion and 
abduction which was present before the operation 
(Fig. 19). 
Case IV. A girl, ten years of age, whom I saw at 
the Children’s Hospital, and later operated upon, 
through the kindness of Dr. Bradford. Both legs 
were paralyzed, the right completely, and the left par- 14 
tially. In the left leg all of the posterior muscles were 
destroyed with the exception of the peroneals, and the 
position of these tendons was on the outer side of the 
malleolus, as has been described and as is shown in 
Fig. 20. The anterior muscles were weak, but all 
showed some contraction. From the position of 
the peroneal tendons, however, simple flexion of the 
foot was impossible, it being drawn up and out as is 
shown in Fig. 21. 
The operation, which was performed about three 
months ago, was the same as in the first case (Fig. 4). 
The result in this case is best shown by the photo- 15 
graphs. Fig. 22 shows the position of the foot with 
the weight borne, Fig. 23 shows the voluntary exten- 
sion, to be contrasted with the condition before the 
operation, Fig. 20, and Fig. 24 shows the amount of 
voluntary flexion to be contrasted with Fig. 21. 
A valgus plate is all that is necessary to keep the 
foot in the proper position. 
The method of attaching the tendons is of great 
importance, and unless they are firmly joined the ben- 
efit of the operation is lost. Tendons do not unite as 
readily as other tissues, so that it is desirable to offer 
as large a surface for adhesion as is possible. The fol- 
lowing method has proved very satisfactory, a method, 
which, I think, has not been used before. The tendon 
to which the attachment is to be made is split, and the 
end of the severed tendon, after it has been scored 
across to make the surface rough, is drawn through 
this slit and held by two quilted sutures. In this way 
both sides of the severed tendon become attached ; and, 
to offer a etill greater area for adhesion, the sutures are 16 
so placed that when tightened the outer tendon is 
spread out. The arrangement of the sutures is shown 
in Fig. 25. The outermost suture is passed through 
both tendons and tied. The other is passed through 
the outer portion of the split tendon, then through the 
free tendon, from an eighth to a quarter of an inch 
away from the edge of the first tendon, then through 
the posterior portion of the split tendon and then back 
in the same way. When this suture is tied it spreads 
the outer tendon as is shown in Fig. 26. Fine silk 
was the material used for the sutures. 
CONCLUSION. 
The purpose of the paper is to show the possibility 
of furnishing better mechanical attachments for the 
non-paralyzed muscles in the treatment of paralytic 
deformities. 
The best results are to be looked for in the cases in 
which one group of muscles is paralyzed, leaving the 
antagonizing or accessory group unimpaired. Much 
of the deformity is due to the action of these muscles 
without the control of the other group. 
Four cases are reported after at least three months 
since the operation. The first case, that of an adult, 
was operated upon over a year ago. In all there has 
been a marked improvement. In three cases the pero- 
ueus longus was attached to the tendo-Achillis and 
the peroueus brevis to the flexor longus pollicis. In 
two cases the anterior tibial tendon was attached to 
the peroneus tertius. 
The tendons were attached by splitting one and 
drawing the other through this and suturing them with 
quilted sutures. S. J. PARKHILL & CO., PRINTERS 
BOSTON