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CHAPTER 31
previously carried out the vertical technique but the Z-form has become the most
popular. For the suture of the edges of the divided tendon, either finest silk or stainless
steel sutures are used. Great care must be taken when applying the dressing and well
padded splint that the position of the feet at 85-90° angle is maintained and pressure to
heels must be strictly avoided during the following weeks. Standing and walking should,
normally, not commence before three weeks after operation. It is then the task of the
physiotherapist and the patient to ensure full weight-bearing on the whole plantar
surface of the feet.
Tendon transplantations for the correction of severe spastic pes equino-varus, by
transferring part or the whole of the tibialis anterior tendon on to the extensor digitorum
or, in cases of severe spastic equino-valgus, transferring the peroneal tendons on to the
extensor digitorum, have rarely been necessary.
In the past resection of two-thirds of the branches of the gastrocnemius muscle, the
dorsal branch of the soleus and the innervation of the toeflexors (StoffePs operation) has
been used for elimination of the increased plantar flexion reflex activity and contractures.
However, this operation has had only temporary effects, and the end results have been as
disappointing as the selective resection of the spinal roots.
(b)
Resection and/or elongation of knee-flexors
Prolonged approximation of the knee-flexors during the stage of spinal shock by keeping
the legs in semi-flexion often leads to tendinous contractures and in increased flexor
spasms once reflex automatism has developed. Unless the contractures can be overcome
by conservative means (see chapter on Physiotherapy), resection of inner hamstring
tendons with or without elongation of the biceps femoris has to be performed to restore
standing and walking.
(c)
Resection of the obturator nerve and myotomy of the ilio-psoas
The most incapacitating part of the reflex flexion synergy are violent hip flexor and adduc
tor spasms, often resulting in contractures if not counteracted from the beginning. These
complications not only make standing and walking impossible but greatly interfere with
the sexual activity of paraplegics and tetraplegics, especially those with incomplete
lesions where potency and fertility is preserved. If adductor spasms are predominant,
the intrapelvic, extraperitoneal resection of the obturator nerve, as introduced by Selig
(1914), is the method of choice, and in our material has proved the most effective treat
ment of this complication. Fig. 217 shows the effect of this operation in a severe though
incomplete transverse lesion below T5 with profound adductor spasms which not only
made walking most difficult but also greatly interfered with sexual intercourse. Following
bilateral intrapelvic obturator resection walking capability greatly improved, and the
patient was able to carry out his marital activities with full satisfaction to his wife and
himself. This method is infinitely preferable to the subinguinal, extrapelvic resection,
as the obturator nerve has already branched off into its peripheral ramifications, nor has
myotomy of the adductors proved a suitable method in these cases. Crushing or only
partial resection of the obturator, which is still recommended (Griffith, 1969), has
