REPORT OF THE VISIT OF THE 1957 AMERICAN AND CANADIAN TRAVELING FELLOWS TO GREAT BRITAIN

¹ NEW YORK, N. Y.

Needless to say it is impossible to reduce such a magnificent experience to a few printed pages. Space does not permit other than a brief summary of the events and places visited.

In Britain we found the orthopaedic problems were essentially the same as in America. While the approach to these problems may at times differ from ours, the results, in some seem to be better, while in others they were perhaps not as satisfactory.

Tuberculosis is somewhat more prevalent, but as in the United States and Canada, a definite decline in frequency is noted. There is a great tendency to drain abscesses and remove necrotic débris with antibiotic treatment. In spinal lesions this is done by a costotransversectomy, or by an anterolateral approach. The patient is kept recumbent until stability occurs anteriorly. Posterior fusion is advocated only when the spine is markedly unstable. However, we feel that primary posterior fusions can and do give good results.

Joint tuberculosis, if seen early, is treated conservatively with antibiotics in an attempt to preserve function. If the joint has been destroyed, a fusion is done. This is a concept which is held by many on both sides of the Atlantic.

The acrylic Judet prosthesis, at one time widely accepted, has proved to be unsatisfactory in Britain. We saw few prostheses of any type, probably due to the bitter experience with the Judet. Cups too were generally believed to be unsatisfactory. The British, in search of a means of solving the problem, have resorted to fusions, Girdlestone operations, and the McMurray osteotomy. The results of the latter procedure were some of the most impressive seen on the tour. The procedure is only done for the relief of pain, and for the most part in osteo-arthritis of the hip. There is no unanimity of opinion as to why it is successful. It would appear that the only common denominator is division of the femur. Some have used internal fixation, and some not. Unlike the patients treated with the insertion of a prosthesis, these patients improve with time. Long-term unselected follow-ups were shown in more than one institution. In some instances the joint space, on the roentgenograms, appeared to re-form.

When we were first presented with the McMurray osteotomy we were skeptical as to its value. As time went on we were able to question and examine more patients on whom this had been done. We then became more impressed with its place as a pain relieving procedure.

Traumatic paraplegia is treated by open reduction of the dislocated facets to relieve any cord pressure, and by plate stabilization. This allows early mobilization and is followed directly by early and constant physical therapy. Spine fusion is rarely done at the time of open reduction. The experience of both Mr. Meurig Williams at Cardiff and the group at Lodge Moor Paraplegic Center is that in the majority of instances spontaneous interbody fusion will occur. The results, in spite of adequate care, are generally poor. Laminectomy is felt to be rarely, if ever, indicated.

Congenital dislocation of the hip, if seen before the child is eighteen months old, is managed by abduction. In older children open procedures are generally resorted to. Arthrograms are popular to determine the position of the limbus, which is resected if it blocks reduction. Derotational osteotomy is frequently used.

Joint arthrodeses are performed by a variety of techniques with the exception of knee fusions which are almost invariably done by means of compression.

In Britain, tendon transfers seemed popular. In the foot they are used to prevent deformity pending bone stabilization if such proves necessary. Weakened muscles are sometimes transferred. In the upper extremity it is felt better to use normal muscles for the purpose. In some instances it appeared that a primary bone stabilization might have given a more satisfactory result.

Leg lengthening procedures were shown to us in more than one hospital. Considerable length was gained but in some patients there were complications.

We saw numerous operations aimed at correcting foot deformities. One of these, the Dwyer procedure, is for correction of varus or valgus heel. It consists of an osteotomy through the calcaneus. Several good result of this procedure were shown. Relapsing club feet, refractory to plaster-cast correction, were managed by a medial release and tendon transplants, usually tibialis posterior through the interosseous membrane, or a lateral transplant of the tibialis anterior. Mr. Dilwyn Evans of Cardiff combines this with a calcaneocuboid fusion.

The problem of mobile claw toes in children was managed in some centers by a transfer of the long flexors to the dorsal extensor expansions. The results were impressive.

We were introduced to a procedure known as the "ten-toe-ectomy" designed for painful and uncorrectable claw toes. As the name implies it consists of amputation of all ten toes. The shoes are fitted with an insert postoperatively to take the place of the amputated digits. It appeared to be a rather radical way to handle this problem, but the patients we saw on whom it was done were satisfied.

Hallux valgus is treated by a Kellar procedure or by fusion of the metacarpophalangeal joint using catgut sutures for fixation or a screw across the joint.

In conclusion, we extend our most sincere thanks to Thc American Orthopaedic Association and The Canadian Orthopaedic Association for sending us. Selection as a traveling fellow imposes an honor, and a responsibility that we cannot adequately define. The memories of the trip will always be with us. New British acquaintances have quickly become old friends. With the passage of time the value of this period of study will be of even greater importance to each of us.

Our British hosts were magnificent, and could have given no more cordial reception, nor could they have shown greater hospitality. To each of them we express our deepest thanks.

The program as presented could not have been improved upon. The careful planning, the many centers visited, allowed us to see a cross section of orthopaedic surgery in Britain. Two men were extremely helpful, Mr. Philip Wiles, the President of The British Orthopaedic Association, and Mr. J. I. P. James, the Secretary, who worked together to organize a magnificent itinerary.

We sincerely hope that the Traveling Fellowship continues, and we shall do our utmost to propagate the information gathered in Britain.

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