Arthur Steindler, MD, FACS, FICS (June 22, 1878 – July 21, 1959) was a towering intellectual architect of modern academic orthopaedic surgery, kinesiology, and reconstructive rehabilitation, celebrated for transforming orthopaedics from an empirical craft of braces and bone-setting into an exact quantitative science grounded in functional anatomy, biology, and vector biomechanics. As the founding Professor and Head of the Department of Orthopedic Surgery at the State University of Iowa (University of Iowa) for thirty-five years (1913/1915–1948), founder of the Children’s Hospital of Iowa, President of the American Orthopaedic Association (1932), President of the American Academy of Orthopaedic Surgeons, and founding member of the Orthopaedic Research Society, Steindler formulated landmark operative reconstructions—most notably the Steindler flexorplasty for paralytic flail elbow and Steindler subperiosteal stripping for rigid pes cavus deformity. Through his monumental treatises Mechanics of Normal and Pathological Locomotion in Man (1935) and Kinesiology of the Human Body Under Normal and Pathological Conditions (1955), he introduced the concepts of open and closed kinetic chains to musculoskeletal medicine and established quantitative gait kinetics, while cultivating the world-renowned “Iowa School” of orthopaedics that produced masters such as Ignacio Ponseti, Carroll Larson, Reginald Cooper, and Joseph Buckwalter.
| Biographical Milestone | Historical Record |
|---|---|
| Full Name & Honors | Arthur Steindler, MD, FACS, FICS; President of the American Orthopaedic Association (AOA, 1932); President of the American Academy of Orthopaedic Surgeons (AAOS); Founding Member of the Orthopaedic Research Society (ORS, 1954); Recipient of the American Medical Association Distinguished Service Award (1957); Honorary Fellow of the International College of Surgeons (FICS) |
| Lifespan & Era | June 22, 1878 – July 21, 1959 (Pioneering Era of Academic Orthopaedic Surgery, Biomechanics, and Reconstructive Rehabilitation) |
| Birthplace & Nationality | Graslitz, Bohemia (Austro-Hungarian Empire; now Kraslice, Czech Republic); Austrian-American |
| Primary Academic Affiliations | University of Vienna (MD 1902); State University of Iowa / University of Iowa College of Medicine (Founding Professor and Head of Department of Orthopedic Surgery, 1913/1915–1948; Professor Emeritus, 1948–1959); Children’s Hospital of Iowa (Founder and Chief Surgeon, 1915/1919–1948); Mercy Hospital, Iowa City (Senior Consulting Surgeon, 1948–1959); Rush Medical College & Home for Destitute Crippled Children, Chicago (1907–1910) |
| Hallmark Eponyms & Innovations | Steindler Flexorplasty (anterior transposition of flexor-pronator mass for flail elbow, 1918); Steindler Stripping (subperiosteal calcaneal release of plantar fascia and intrinsic muscles for pes cavus, 1920); Foundations of Kinesiology & Biomechanics (Open vs. Closed Kinetic Chains, 1935/1955); Steindler Procaine/Novocain Trigger-Point Infiltration Test for Low Back Pain (1938); Steindler Arthrodeses (Pantalar, Subtalar, and Wrist Arthrodesis); Founder of the “Iowa School” of Orthopaedics |
| Primary Subspecialties Impacted | Orthopaedic Biomechanics & Kinesiology, Pediatric Orthopaedics, Upper Extremity & Hand Reconstruction, Foot & Ankle Surgery, Spine & Lumbosacral Disorders, Neuromuscular Rehabilitation (Poliomyelitis & Brachial Plexus Palsies) |
1. The Shoulders of Giants: Historical Context & Significance
At the turn of the twentieth century, musculoskeletal medicine was trapped in an empirical, predominantly palliative epoch. Devastating epidemics of anterior poliomyelitis, intractable birth injuries such as Erb-Duchenne brachial plexus palsy, and congenital skeletal deformities swept across North America and Europe, leaving tens of thousands of children and young adults with flail, paralyzed extremities or rigid joint contractures. Contemporary orthopaedic practice offered little beyond passive containment: patients were encased for lifetimes within cumbersome steel calipers, spinal corsets, and heavy leather braces. Operative interventions were largely restricted to blind subcutaneous tenotomies or crude excisions that frequently substituted one disabling deformity for an even more destabilizing functional deficit. Muscle transfers and joint stabilizations were conducted on an ad-hoc, intuitive basis without an understanding of mechanical leverage, resting muscle tension, or vector kinematics.
“If I have seen further, it is by standing on the shoulders of giants.”
Sir Isaac Newton (1675) / Bernard of Chartres
Arthur Steindler fundamentally dismantled this empirical paradigm. Formed in the rigorous anatomical, pathological, and clinical crucible of the Second Vienna Medical School under Adolf Lorenz and Carl Nicoladoni, Steindler arrived in the United States with a revolutionary conviction: that the human musculoskeletal system is not a passive assembly of structural scaffolding, but a living, dynamic mechanical engine governed by immutable Newtonian physics, vector mechanics, and biological laws. He recognized that reconstructive surgery could succeed only if operative design adhered to precise mathematical principles of torque, joint moments, line of pull, and muscular work capacity.
Over a brilliant forty-year tenure at the University of Iowa, Steindler translated this philosophy into enduring surgical realities. In 1918, he published his eponymous flexorplasty, demonstrating that transposing the origin of the common flexor-pronator muscle mass proximally onto the anterior distal humerus could restore active, anti-gravity elbow flexion to an arm completely paralyzed by poliomyelitis or brachial plexus trauma. In 1920, he introduced Steindler stripping, providing an anatomical subperiosteal solution that unlocked rigid pes cavus deformities. Furthermore, by adapting the nineteenth-century kinematic mechanisms of German engineer Franz Reuleaux to human movement, Steindler authored the foundational treatises Mechanics of Normal and Pathological Locomotion in Man (1935) and Kinesiology of the Human Body Under Normal and Pathological Conditions (1955), introducing the fundamental clinical concepts of open and closed kinetic chains. In founding the “Iowa School” of orthopaedics and co-founding the Orthopaedic Research Society, Steindler erected the intellectual bridge connecting classical morphology to modern biomechanical engineering. Today, every surgeon who plans a tendon transfer, analyzes a pathological gait cycle, or balances a reconstructive joint arthrodesis stands squarely upon the shoulders of Arthur Steindler.
2. Early Life, Formative Education & Career Milestones
Education and Formative Surgical Training
Arthur Steindler was born on June 22, 1878, in Graslitz (now Kraslice), a picturesque industrial and musical town in the western Bohemia region of the Austro-Hungarian Empire. His father, Leopold Steindler, was a distinguished lawyer and legal magistrate who instilled in Arthur an enduring reverence for analytical discipline, scholarly precision, and humanistic culture. While Arthur was still a young boy, the family relocated to Vienna, the glittering intellectual, artistic, and medical metropolis of Central Europe. In Vienna, young Steindler was admitted to the celebrated Schottengymnasium, a prestigious classical gymnasium directed by Benedictine scholars. There he received a rigorous humanist education, mastering classical Latin, Greek, French, English, mathematics, and natural philosophy. Steindler also displayed a profound natural talent for music, becoming an accomplished cellist—a lifelong devotion that provided him balance and solace throughout decades of demanding surgical practice.
In 1896, Steindler matriculated at the University of Vienna Faculty of Medicine, then at the zenith of its international renown as the Second Vienna School of Medicine. In Vienna’s dissection halls and clinics, Steindler absorbed the uncompromising pathological and morphological rigor established by Carl von Rokitansky and Josef Hyrtl. He studied topographical human anatomy under Professor Emil Zuckerkandl, whose demanding dissections forged Steindler’s lifelong conviction that absolute anatomical mastery was the indispensable foundation of surgical innovation. He graduated with his Doctor of Medicine (MD) degree in 1902 at the age of twenty-four.
Following graduation, Steindler commenced postgraduate training in general surgery and orthopaedics in Vienna. He served as an assistant to Professor Adolf Lorenz (1854–1946), the undisputed worldwide master of “bloodless” orthopaedic surgery and non-operative manipulative reduction of congenital hip dislocation. From Lorenz, Steindler acquired extraordinary tactile sensitivity, conservative clinical restraint, and diagnostic mastery. Simultaneously, Steindler was profoundly influenced by Professor Carl Nicoladoni (1847–1902), the pioneering Austrian surgeon who in 1880 had performed the world’s first successful tendon transfer (transposing the peroneus longus tendon to the calcaneus to treat paralytic calcaneus deformity). Nicoladoni’s biological tendon transpositions captured Steindler’s imagination, igniting a lifelong commitment to dynamic muscle redistribution and the mechanical restoration of paralyzed extremities.
Academic Appointments and Clinical Leadership
In 1907, at the age of twenty-nine, Steindler made the momentous decision to emigrate to the United States. Arriving in Chicago, Illinois, he was appointed an assistant to Dr. John Ridlon at Rush Medical College and served as attending surgeon to the Home for Destitute Crippled Children. In Chicago, Steindler’s exceptional diagnostic acumen, surgical dexterity, and deep anatomical scholarship quickly attracted national attention. In 1910, Dr. William Jepson, Professor of Surgery at the State University of Iowa College of Medicine in Iowa City, recognized Steindler’s extraordinary potential and recruited him to establish an orthopaedic surgical service within the Department of Surgery.
Steindler found in Iowa an enormous, underserved rural population afflicted with crippling musculoskeletal diseases, including congenital clubfoot, developmental dysplasia of the hip, skeletal tuberculosis, and recurring epidemics of infantile paralysis (poliomyelitis). Demonstrating exceptional organizational vision, Steindler convinced university officials and state legislators that crippled children required comprehensive, specialized surgical care and prolonged physical rehabilitation. In 1915, the University of Iowa created an independent Department of Orthopedic Surgery—one of the earliest independent academic orthopaedic chairs in the United States—and appointed Arthur Steindler as its founding Professor and Head.
That same year, Steindler played an instrumental role in guiding the passage of the landmark Perkins Law (1915), followed by the Haskell-Klaus Law (1919), through the Iowa General Assembly. This historic public legislation committed state funds to transport and treat indigent crippled children at the university hospital free of charge. To accommodate the thousands of young patients arriving by train from across the Midwest, Steindler oversaw the design and construction of the Children’s Hospital of Iowa, which opened its doors in 1919. Under Steindler’s stewardship, the Children’s Hospital became an international center of clinical excellence, integrating surgical suites, convalescent wards, schoolrooms, a dedicated orthopaedic brace and instrument workshop, and the nation’s first specialized clinical kinesiology laboratory.
Steindler directed the Department of Orthopedic Surgery at Iowa for thirty-five years (1913/1915–1948). His daily morning clinical conferences, held at 7:30 AM, became legendary: house officers, fellows, and visiting surgeons from across the globe gathered as Steindler interrogated diagnostic findings, examined pathological gait kinematics, and illustrated vector mechanics on the blackboard. In 1932, his peers elected him President of the American Orthopaedic Association (AOA). He subsequently served as President of the American Academy of Orthopaedic Surgeons (AAOS), providing critical leadership in establishing residency accreditation and standardized educational curricula. In 1954, recognizing that modern orthopaedics required a dedicated scientific society for basic tissue biology and bioengineering, Steindler helped establish the Orthopaedic Research Society (ORS) as a founding member. In 1957, the American Medical Association awarded him its highest tribute, the AMA Distinguished Service Award.
Upon reaching the mandatory university retirement age of seventy in 1948, Steindler stepped down as department chair, succeeded by his illustrious pupil Carroll B. Larson. Retiring from academic administration, however, did not diminish his clinical energy. Across Iowa City at Mercy Hospital, Steindler established an active orthopaedic consulting practice and surgical clinic, continuing to operate, evaluate patients, conduct research, and instruct visiting fellows until his death on July 21, 1959, at the age of eighty-one.
Steindler’s greatest living monument was the “Iowa School” of orthopaedics. Operating in a rigorous “Master-to-Apprentice” tradition, he personally trained scores of academic leaders. Among his most celebrated trainees was Ignacio V. Ponseti (1914–2009), a Spanish physician and refugee whom Steindler welcomed to Iowa in 1941. Steindler recognized Ponseti’s exceptional biological insight, encouraging his basic histological research on skeletal dysplasia and the functional kinematics of clubfoot, which ultimately led to the worldwide adoption of the Ponseti method. Other renowned proteges included Carroll B. Larson, Reginald R. Cooper, and Joseph A. Buckwalter, creating an unbroken lineage of academic excellence that shaped modern orthopaedic surgery.
3. Core Orthopaedic Breakthroughs, Eponymous Signs & Innovations
Arthur Steindler’s scientific and operative legacy spans reconstructive upper extremity tendon transfers, pediatric foot and ankle surgery, the foundational laws of kinesiology, spine diagnostic methods, and joint arthrodesis. Rejecting empirical guesswork, Steindler evaluated every clinical deformity through the prism of functional anatomy and vector mechanics, formulating biological solutions that redistributed living dynamic forces to restore stable human locomotion and manual dexterity.
Hallmark Anatomical, Diagnostic and Operative Contributions
- Steindler Flexorplasty (1918): In his classic 1918 treatise in the Journal of the American Medical Association, “Orthopedic operations on the hand,” Steindler introduced his transformative reconstructive muscle transposition for flail elbow paralysis resulting from anterior poliomyelitis or upper brachial plexus injuries (Erb-Duchenne palsy). In patients retaining active forearm flexors and pronators but completely lacking biceps brachii and brachialis function, the arm hangs limp and useless at the side. Steindler recognized that the common flexor-pronator mass (pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis, and flexor carpi ulnaris) arises from the medial epicondyle of the humerus, lying directly on the transverse axis of elbow rotation. By detaching this muscular origin with an osteoperiosteal bone wafer and transposing it 4 to 5 cm proximally onto the anterior surface of the distal humeral shaft, Steindler lengthened its moment arm. This converted forearm muscles that previously acted merely as wrist flexors into powerful active elbow flexors, restoring functional anti-gravity flexion (often against 1 to 2 kg of resistance) and enabling patients to feed themselves and touch their head and face.
- Steindler Stripping of the Plantar Fascia (1920): Addressing the rigid, agonizing hollow claw foot deformity (pes cavus) seen in poliomyelitis, Charcot-Marie-Tooth disease, Friedreich’s ataxia, and idiopathic contractures, Steindler published his definitive operative technique in Archives of Surgery (1921), “The treatment of pes cavus (hollow claw foot).” Rather than performing partial percutaneous fasciotomies that failed to release deep muscular contractures and led to rapid relapse, Steindler devised a radical subperiosteal stripping. Through a curved medial incision over the calcaneus, he meticulously entered the plane between the abductor hallucis and the osseous calcaneal tuberosity. Using a sharp periosteal elevator, he stripped the central, medial, and lateral bands of the plantar aponeurosis, along with the fleshy origins of the flexor digitorum brevis, abductor hallucis, and abductor digiti minimi, completely off the plantar surface of the calcaneus forward to the calcaneocuboid and talonavicular joints. This completely uncoupled the locked longitudinal arch, permitting the rigid hindfoot and midfoot to flatten under physiological load.
- Pioneering Treatises on Kinesiology and Biomechanics (1935, 1955): Steindler was the undisputed pioneer of quantitative orthopaedic kinesiology in North America. In his landmark monographs Mechanics of Normal and Pathological Locomotion in Man (1935) and Kinesiology of the Human Body Under Normal and Pathological Conditions (1955), he adapted Franz Reuleaux’s kinematic engineering theorems to human biology, introducing the enduring concepts of Open Kinetic Chains (OKC) and Closed Kinetic Chains (CKC). He established mathematical methodologies to calculate center-of-gravity trajectories, ground reaction force vectors, inertia moments, and joint mechanical efficiency during normal and pathological human gait, transforming orthopaedics from a purely morphological specialty into a quantitative physical science.
- Steindler Procaine/Novocain Trigger-Point Test for Low Back Pain (1938): In a landmark 1938 study in JAMA co-authored with J. Vernon Luck (“Differential diagnosis of pain low in the back: Allocation of the source of pain by the procaine hydrochloride method”), Steindler was among the first in modern medicine to introduce and define the term “trigger point” in musculoskeletal pathology. To differentiate primary lumbosacral myofascial tears and ligamentous sprains from true radicular compression caused by herniated intervertebral discs or spinal tumors, Steindler developed a selective local anesthetic infiltration test. Infiltrating localized tender myofascial nodules (over the posterior superior iliac spine, sacroiliac ligaments, or erector spinae) with 5 to 10 mL of 1% procaine (Novocain), he demonstrated that if local back pain, protective muscle spasm, and radiating pseudosciatica immediately vanished, the pathology was proven to be referred myofascial pain arising from peripheral musculoskeletal structures rather than primary nerve root compression.
- Reconstructive Joint Arthrodesis Paradigms: In treating severe, unstable flail extremities following poliomyelitis, Steindler perfected biological stabilization techniques, including pantalar arthrodesis (combining tibiotalar, subtalar, and talonavicular-calcaneocuboid fusion to convert a flail, useless foot into a stable, painless bipedal weight-bearing platform), subtalar arthrodesis, and wrist fusion using autogenous corticocancellous bone struts, establishing stability upon which distal functional tendon transfers could safely act.
- Founding the Orthopaedic Research Society (1954): Recognizing that surgical technique must constantly be validated and refreshed by basic biological, histological, and engineering research, Steindler served as a primary founding catalyst of the Orthopaedic Research Society (ORS) in 1954, institutionalizing the symbiotic relationship between clinical orthopaedic surgery and basic laboratory science.
Biomechanical Principles: Dynamic Muscle Transfers, Plantar Fascial Vectors, and Joint Kinematics
The genius of Arthur Steindler lay in his capacity to express complex clinical deformities in terms of rigorous vector physics, rotational torque, and kinematic constraints. Nowhere is this clearer than in his analyses of the flail elbow, rigid pes cavus, and kinetic chain linkages.
In the normal upper extremity, active elbow flexion is powered by the biceps brachii, brachialis, and brachioradialis muscles, generating a robust flexor moment across the humeroulnar and humeroradial articulations. When poliomyelitis anterior horn cell destruction or high brachial plexus injury denervates these primary flexors, the limb hangs flail. Although the forearm flexor-pronator group (pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis, and flexor carpi ulnaris) remains functional (innervated by median and ulnar roots from C7–T1), these muscles cannot flex the elbow under normal anatomical conditions. Because their common origin lies on the medial epicondyle of the humerus—which is positioned almost exactly along the transverse flexion-extension axis of the elbow—the perpendicular distance (moment arm, d) from their line of action to the joint center of rotation is negligible (approaching zero). Consequently, by the torque formula:
M = F × d
where M is the flexor moment, F is contractile muscle force, and d is the moment arm, the rotational moment generated across the humeroulnar joint is practically zero. Contraction of the forearm muscles produces only pronation of the radius and acute flexion of the wrist and digits.
Steindler’s flexorplasty ingeniously altered this vector geometry. By mobilizing the common flexor-pronator origin from the medial epicondyle and shifting it 4 to 5 cm proximally onto the anterior surface of the distal humeral shaft, Steindler radically transformed its line of action. In this new anterior and proximal location, the moment arm (d) relative to the elbow flexion axis is expanded from near zero to approximately 2.5 to 3.5 cm. When the patient fires the transferred muscle group, the generated muscle tension (F) acts across this substantial mechanical moment arm, producing robust active elbow flexion torque. This enables the patient to achieve 90 to 120 degrees of active elbow flexion against gravity.
Steindler recognized, however, the kinematic trade-offs inherent in this transfer, a phenomenon now celebrated as the “Steindler effect.” Because the transferred muscles retain their distal insertions into the carpal bones and phalanges, their contraction to flex the elbow simultaneously generates strong wrist and finger flexion and forearm pronation. To initiate elbow flexion, the patient must first make a fist and flex the wrist. If the patient possesses active wrist extensors (extensor carpi radialis longus and brevis, innervated by the radial nerve), these muscles fire synergistically to stabilize the wrist in neutral or slight dorsiflexion, preventing wrist collapse and optimizing the power of the flexorplasty. Conversely, in patients who lack functional wrist extensors, the wrist drops into acute hyperflexion, dissipating contractile excursion. Steindler solved this clinical problem by demonstrating that performing a concurrent or staged wrist arthrodesis eliminates the wrist flexion drop, locking the distal kinetic segment and channeling 100% of the muscular force directly into active elbow flexion.
In pes cavus, Steindler addressed a pathological closed kinetic chain deformity. The human foot functions as a dynamic triangular truss: the calcaneus represents the posterior pillar, the metatarsal heads represent the anterior pillar, and the plantar aponeurosis and intrinsic musculature form the tensile tie-rod (chord) spanning the base. In neuromuscular conditions such as Charcot-Marie-Tooth disease or poliomyelitis, muscle imbalance—specifically weakness of the anterior tibialis coupled with an unopposed, hyperactive peroneus longus and intrinsic flexor hypertonia—depresses the first metatarsal head and foreshortens the plantar tie-rod. As the plantar fascia, flexor digitorum brevis, and abductor hallucis contract into dense, unyielding fibrous cords, they pull the calcaneal tuberosity and metatarsal heads closer together, acutely elevating the longitudinal arch. With every step in the stance phase (closed kinetic chain), body weight drives down through the talus, but the contracted plantar chord refuses to elongate, locking the midfoot and hindfoot in rigid supination and forcing the heel into secondary varus.
Steindler demonstrated that a simple transverse fasciotomy was mechanically inadequate because it divided only the central aponeurotic band, leaving the deep intermuscular septa, long plantar ligament attachments, and short flexor origins intact. His subperiosteal stripping technique released the entire complex off the calcaneal tuberosity down to bare cortical bone. By detaching the origin of the tie-rod from its posterior osseous anchor, the tensile restraint across the base of the arch was completely abolished. Under intraoperative manual pressure or postoperative weight-bearing in plaster, the triangular truss could flatten, the calcaneus returned to a neutral sagittal alignment, and forefoot pronation was restored.
Finally, Steindler’s conceptualization of Open Kinetic Chains (OKC) and Closed Kinetic Chains (CKC) provided orthopaedics with a universal biomechanical language. Adapting Franz Reuleaux’s engineering definitions, Steindler defined an open kinetic chain as a series of connected joint links in which the terminal (distal) segment moves freely in space without external resistance (such as the swing phase of walking or reaching with the hand). In an open chain, joint motions can occur independently of one another. In contrast, a closed kinetic chain exists whenever the distal segment meets substantial external resistance or is fixed to a surface (such as the foot planted on the ground during the stance phase of gait or hands bearing weight during a push-up). In a closed chain, motion at any single joint forces compensatory, coupled motions across every proximal and distal joint throughout the entire extremity. Steindler showed that pathological gaits—such as the Trendelenburg pelvic drop, the gluteus maximus extensor lurch, or the quadriceps-avoidance gait—are predictable, closed-chain mechanical adaptations designed to shift the body’s center of gravity and minimize muscular torque requirements across painful or paralyzed joints.
4. Master Class Pro-Tip
Achieving predictable, anti-gravity elbow flexion with the Steindler flexorplasty demands strict adherence to preoperative muscle grading, absolute neurovascular protection, and precise anatomical fixation of the common flexor-pronator mass to the anterior distal humerus. Success hinges upon three non-negotiable operative principles: avoiding injury to the ulnar nerve, preserving the medial collateral ligament of the elbow, and securing the transferred origin under physiological tension.
Carefully confirm preoperatively that the patient has at least Medical Research Council (MRC) Grade 4 strength in the wrist flexors and pronator teres; transferring a weak muscle group (Grade 3 or less) will fail to achieve anti-gravity elbow flexion. Position the patient supine with the operative arm abducted on an arm board under pneumatic tourniquet control. Make an 8 to 10 cm lazy-S incision along the medial aspect of the elbow, centering the midportion of the incision slightly anterior to the medial epicondyle to avoid a straight flexion crease contracture.
Before touching the flexor origin, locate, neurolyse, and safely mobilize the ulnar nerve in the cubital tunnel posterior to the medial epicondyle. Tag the nerve gently with a soft vessel loop. The ulnar nerve must be routinely transposed subcutaneously anterior to the medial epicondyle during closure; failure to anteriorly transpose the nerve risks acute traction neuropathy or late tardy ulnar palsy when the flexor-pronator mass is transferred proximally.
Expose the common flexor-pronator tendon origin at the medial epicondyle. With a fine osteotome, harvest the origin with a thin wafer of cortical bone (approximately 1.0 × 1.5 cm and 2 mm thick) rather than dissecting sharply through tendon substance. Incorporating this cortical bone wafer preserves the structural integrity of the tendon insertion, allows bone-to-bone healing, and facilitates rigid screw or transosseous suture fixation. Proceed with extreme caution during the deep dissection: do not extend the osteotomy too deep into the epicondylar base, and carefully identify and preserve the anterior bundle of the medial (ulnar) collateral ligament (MCL). Inadvertent detachment or transection of the anterior MCL bundle creates catastrophic valgus instability of the elbow joint.
Mobilize the flexor-pronator muscle belly distally along the anterior forearm for approximately 5 to 7 cm, gently releasing deep fascial bands between the flexor mass and the ulna. Exercise extreme vigilance during this distal mobilization: identify and protect the motor branches of the median nerve entering the deep surfaces of the pronator teres and flexor carpi radialis, and preserve the anterior interosseous nerve. Insufficient distal mobilization will restrict proximal transposition and generate excessive passive tension, leading to ischemic necrosis of the muscle belly.
Prepare the recipient site on the anterior surface of the distal humerus, 4 to 5 cm proximal to the articular joint line and slightly lateral to the anatomical midline of the shaft. Decorticate a matching cortical trough in the anterior humerus down to bleeding cancellous bone. With the elbow flexed to 90 degrees and the forearm held in full pronation, advance the bone wafer into the trough. Secure the wafer rigidly using a 3.5-mm cortical lag screw with a washer, or heavy nonabsorbable sutures passed through drill holes in the humeral cortices. Verifying stability under dynamic motion is crucial: ensure that passive elbow extension to 45 degrees does not pull the bone wafer out of its bed, and confirm that active tension is fully restored.
Transpose the tagged ulnar nerve anterior to the epicondylar bed into a subcutaneous pocket, closing the overlying fascia loosely to avoid compression. Close the skin in layers without dead space and place the arm in a well-padded posterior plaster splint holding the elbow in 90 to 100 degrees of flexion and the forearm in full pronation. Maintain rigid immobilization for 4 to 6 weeks to permit complete osseous consolidation of the bone wafer before initiating active, gravity-eliminated flexion rehabilitation.
Master Class Surgical Pearl: The Steindler Flexorplasty for Paralytic Elbow Flexion Loss
5. Primary Landmark Publications & Bibliography
The foundational contributions of Arthur Steindler are preserved in these original landmark monographs and peer-reviewed surgical literature:
- Steindler A. Orthopedic operations on the hand. JAMA. 1918;71(16):1288-1291. doi:10.1001/jama.1918.02600420030009. [DOI]
- Steindler A. The treatment of pes cavus (hollow claw foot). Arch Surg. 1921;2(2):325-337. doi:10.1001/archsurg.1921.01110050143007. [DOI]
- Steindler A. Mechanics of Normal and Pathological Locomotion in Man. Springfield, IL: Charles C Thomas; 1935. doi:10.1111/j.1746-1561.1936.tb08847.x. [DOI]
- Steindler A. Kinesiology of the Human Body Under Normal and Pathological Conditions. Springfield, IL: Charles C Thomas; 1955.
- Steindler A, Luck JV. Differential diagnosis of pain low in the back: Allocation of the source of pain by the procaine hydrochloride method. JAMA. 1938;110(2):106-113. doi:10.1001/jama.1938.02790020020007. [DOI]
- Steindler A. The tabetic arthropathies. JAMA. 1931;96(4):250-256. doi:10.1001/jama.1931.02720300020005. [DOI]
- Steindler A. On the clinical significance of the antalgic position and restriction of motion in cases of low back pain and sciatic radiation. Proc R Soc Med. 1954;47(12):1069-1073. doi:10.1177/003591575404701213. [DOI] [PubMed]
- Ponseti IV. Arthur Steindler. J Bone Joint Surg Am. 1959;41(8):1535-1538. doi:10.2106/00004623-195941080-00017. [DOI]
- Buckwalter JA, Brand RA. Arthur Steindler and orthopaedic research. J Orthop Res. 1999;17(1):1-4. doi:10.1002/jor.1100170102. [DOI]
- Mostofi SB. Arthur Steindler 1878–1959. In: Mostofi SB, ed. Who’s Who in Orthopedics. London: Springer; 2005:319-322. doi:10.1007/1-84628-070-2_244. [DOI]
6. Biographical Provenance & Acknowledgments
This historical biography was synthesized for the OrthopaedicsOne Knowledge Network as part of A Who’s Who of Orthopaedics, adapted and expanded from the foundational biographical directory Who’s Who in Orthopedics (Springer-Verlag London) edited by Seyed B. Mostofi, BSc, MBBS, FRCS (Ed).
Last Updated on September 29, 2026
🔗 Knowledge Graph & Clinical Correlates
OrthopaedicsOne Living Semantic Network💼 Practice Management & Professional Operations
- Winthrop M. Phelps History of Orthopaedics
- Willis Cohoon Campbell History of Orthopaedics
- William Waugh History of Orthopaedics
- William Ward Plummer History of Orthopaedics
- William Thomas Gordon Pugh History of Orthopaedics
- William Stewart Halsted History of Orthopaedics
- William Stevenson Baer History of Orthopaedics
- William Morant Baker History of Orthopaedics
