Chapter XXXI (2)

Tuberculous disease of the joints is one of the most frequent of surgical lesions. It has produced characteristic appearances which have been known under the name of “scrofula of joints,” until a clearer recognition of the pathology of the condition led to the abandonment of the term scrofula. _Tumor albus_, or _white swelling_, was another term commonly applied to these lesions, because of the anemic appearance of the surface of the swollen joint.

_Tuberculous arthritis_ assumes different phases in proportion to the involvement of the different component structures of the joint. Some cases begin purely as a tuberculous synovitis, and may for a long time be limited to the synovial structures. Others begin within the spongy texture of the expanded joint ends of the long bones, the disease spreading from such foci and involving everything in the path which its products take in the effort to secure spontaneous evacuation, products of softening and infection travelling in the _direction of least resistance_.

It has been the writer’s custom to always follow Savory, in his suggestion to students to let their mental pictures of consumption of the lungs and pleuræ serve for illustration in similar disease of joints. Thus the cancellous bone structure much resembles the lung tissue in its spongy character. In both a capsule surrounds the mass of tubercle, and in each, by breaking down of its contents, a cavity is formed. Moreover, the pleura bears practically the same resemblance and relation to the lung and the chest wall that the synovialis does to the bone end and the joint cavity; as we may have pleuritis with phthisis, so we may have synovitis with tuberculous ostitis; and as adhesions tend to form in the pleural cavity, so also do they in the synovial cavity. Furthermore, in each case obliteration of deeper veins causes the more prominent appearance of the subcutaneous veins, and as tuberculous pleurisy often terminates in empyema, so does tuberculous hydrarthrosis often terminate in pyarthrosis, perhaps with fungous ulceration. In almost every feature, then, the progress and effect of tuberculosis in the lung and bone end may be likened to each other.

In some clinics bone and joint tuberculosis constitute nearly one-third of the total of cases treated. Joints of the lower limb are the ones most frequently involved in children, while in the adult those of the upper extremity are generally attacked. It is not often that more than one joint is involved at one time. The relation of traumatism to this disease has been frequently discussed, and is variously regarded. The disease is more common in those who are predisposed to it by environment or by heredity, in the latter case hereditary evidences usually being well marked. In such predisposed individuals, especially in the early years of life, severe injuries are usually promptly repaired, while the milder traumatisms, which are often frequent and to which too little attention is paid, seem often to so far lower tissue resistance as to favor an infection to which the individual is already favorably predisposed. The true position to take, then, would appear to be this, that _traumatisms rarely lead directly to joint tuberculosis, but only indirectly by affecting tissue susceptibility_.

Thus lesions which begin in the epiphyses lead to what is known as _osteopathic_ joint disease, while those which have their origin in the synovia give rise to the _arthropathic_ forms. The former are more common in children and the latter in adults (Fig. 202).

=Pathology.=--In regard to the pathology of these conditions it does not vary from that mentioned in the earlier portion of this work in connection with the general subject of Surgical Tuberculosis. The deposit of tubercle in the tissue whose resistance has been weakened is followed by the formation of granulation tissue, which, so long as the germs survive, tends to increase and to make room for itself at the expense of surrounding tissue. At the same time there occurs a tissue struggle by which the attempt is made to throw around an active focus a protecting barrier, which in soft tissues consists of condensed fibrous and connective tissue, and, in bone, of a sclerotic capsule, as though the intent were to imprison the disturbing cause, and, by completely enclosing it, effect protection. When this attempt at encapsulation is successful spontaneous recovery follows. It will be made successful, to some extent at least, by treatment whose most important local feature is physiological rest. On the other hand, when the attempt is unsuccessful and the barrier is transgressed by granulation tissue, the lesion will advance in the direction of least resistance, while its progress will be made known, especially as it approaches the surface, by very significant signs: adhesion of the overlying structures and finally of the skin, with purplish discoloration of the latter. Finally softening occurs with escape of granulation tissue, which, so soon as it is freed from pressure, will grow more luxuriantly and with more color, constituting the _fungous granulation tissue_, to which German pathologists so often allude, or so-called “proud flesh.” When this appears upon the surface it is soon infected with pyogenic organisms, breaks down, and an abscess cavity results, connecting with the original focus and its extensions. This may be so placed as to lie outside the joint capsule, which, in some respects, is fortunate for the patient. The joint function may then be compromised to only a minor degree.

Central sequestrum. (Ransohoff.)]

Often the direction of least resistance is toward the joint cavity, this fungous tissue loosening and perforating cartilage or periosteum before it enters the joint. Having penetrated it again it grows extensively until the cavity is distended, its rapidity of growth diminishing with the degree of pressure produced by its surroundings. This pressure will also make it less vascular, and when such a joint is opened it at first appears pale and anemic. In proportion as the joint distends it loses in motility, while should recovery occur spontaneously or as the result of treatment this tissue will to some extent disappear, to be replaced by adhesions by which pseudo-ankylosis is produced. The extent of the intra-articular involvement will cause obstruction to the deeper return circulation, and thus is brought about the prominence with which the subcutaneous veins appear. The degree of hydrarthrosis is apparently not limited except by the distensibility of the joint. In the articular or arthropathic forms there is always more or less synovial outpour.

Tuberculous panarthritis. (Ransohoff.)]

To the condition already described may be added the destruction produced by suppuration, infection occurring either through the circulation, as is quite possible, or through some trifling surface abrasion. In more chronic cases _caseation_ may occur, especially in bone foci. Finally, as the result of a combination of morbid processes, there is produced more or less complete disorganization, all of which is summed up in the term _tuberculous panarthritis_. To that condition in which the articular surfaces are more or less studded with fungous patches the term _pannus of the joint_ is often applied. To reiterate, then, as between a chronic hydrarthrosis and a destructive panarthritis, perhaps even with necrosis of epiphyses, it is but a difference of degree and of combination of infectious processes (Figs. 203, 204, 205 and 206).

Among the other consequences of panarthritis may be the formation of _sequestra_ in or near the epiphyses, and such destruction as shall lead to _pathological dislocation_, the latter being well illustrated in Figs. 204 and 207. This dislocation is always the result of the pull of muscles thrown into that condition of reflex spasm which is a characteristic feature of this disease. It appears conspicuously at the knee, usually as a backward subluxation (Fig. 207), and at the hip as an upward dislocation, sometimes with more or less apparent migration of the acetabulum. Another consequence of tuberculous hydrarthrosis, which frequently persists even long after the subsidence of the acute stage of the disease, is the occurrence within the joint cavity of _rice-grain_ or _melon-seed bodies_, for whose presence it is not easy to account. The generally received explanation is that they are the result of fibrinous outpour, whose fluid portions have been absorbed, while the remaining nearly pure fibrin is broken up into particles and rounded off by attrition during the movements of the joint. They may accumulate in astonishing amount, thus stamping the disease as having a chronic rather than an acute character. After a time they provoke a fresh outpour of fluid, as a result of the irritation which they produce. This fluid is at first usually clear serum, but becomes turbid or seropyoid, and, if infected, becomes pure pus, in which the rice-grain bodies are dissolved or disintegrated.

Bony ankylosis of knee. (Ransohoff.)]

Section of bony ankylosis of hip. (Original.)]

Tuberculous panarthritis, illustrating various types of degeneration and destruction. (Lexer.)]

_Recovery is possible_ in many cases when the lesions have not advanced too far. It is rarely ideal, and usually leaves some evidence of its existence in limitation of motion, thickening, or other recognizable symptom. Constitutional as well as local measures have much to do with bringing about this result. It is for this reason that it is so essential to take tuberculous-joint patients out of the environment in which ordinarily they live and get them outdoors, exposed to sunlight and benefited by the best of nutrition. _Rest, oxygen, and hypernutrition_ are the three best general measures for combating these conditions. When recovery does occur it is by the death of all active germs, the absorption to varying extent of disease products, including granulation tissue, and the organization into fibrous and cicatricial tissue of the unabsorbed residue. No tissue which has been actually disorganized is completely restored. The best that can be hoped for is substitution of fibrous or cicatricial tissue. Function may be more or less completely regained. This will depend largely upon how early treatment is instituted. In general it may be said that there is always hope for tuberculous joints _if suitable treatment be instituted early and if the environment can be made satisfactory_. Unfortunately this is not often possible, and the best that can be hoped for is subsidence of disease at the expense of more or less ankylosis, perhaps deformity, while, at the worst, there may be loss of joint if not of life. It might be misinterpreted should it be said that there is one kind of treatment for the wealthy and another for the poor, yet so much does depend upon what the patient or the parents can afford in the way of change of surroundings that the whole plan of treatment often depends upon the patient’s circumstances. Radical measures may therefore be deemed best in those who cannot afford long delay and temporization, while at other times expensive apparatus and change of residence may bring about the desired result.

_The general appearance of a tuberculous joint_ is one of manifest enlargement which is made more conspicuous by wasting of the limb above and below. Nevertheless by actual measurement it will usually be found to have a greater circumference than its fellow of the opposite side. Its covering skin is pale and often glistening, with prominent veins, while in proportion to the distention by fluid there will be more or less distinct fluctuation. When the joint is evidently distended and does not fluctuate the inference is that it is filled with granulation tissue. There will also be marked thickening of all the articular coverings, the synovial membrane itself being often as thick as sole leather. At points where perforation may threaten there may be dimpling and retraction of the skin, with fixation and discoloration.

=Symptoms.=--_Tuberculous joint disease is characterized especially by loss of function, muscle spasm, muscle atrophy, pain and tenderness_ of rather significant character, and the other joint features already mentioned. _Loss of function_ may be partial or complete. It depends on the amount of tenderness and the deformity already produced by muscle spasm. Motility is more or less restricted even under an anesthetic. This is induced by actual limitation of motion by products of exudation, by muscle spasm and wasting, and by the involuntary shrinking of the patient when tender joint surfaces are pressed against each other.

Backward displacement of tibia due to the muscle spasm of a tuberculous knee-joint, with final bony ankylosis. (Lexer.)]

_Muscle spasm_ is one of the most significant features of these cases as well as almost the earliest. It is of the greatest diagnostic value, and, if genuine, should never be neglected. It subsides under the use of an anesthetic, hence it is not advisable to employ anesthetics for diagnostic purposes. It produces at first fixation, without particular deformity, but may lead later to this or to pronounced subluxation. It is most helpful in the early stages when it does not particularly interfere with a medium range of motion, and seems to lock the joint before the extreme of motility is reached. Muscle spasm is pronounced even after muscle atrophy is well advanced, and serves more and more to fix joints until they are held by adhesions formed within. _Muscle atrophy_ is also significant and begins about the time when diagnosis becomes fairly possible, _i. e._, in the early stage of the disease. With the advance of disease it becomes more pronounced and a joint which is fixed by intra-articular lesions will stand out prominently because of the notable wasting of the muscles by which ordinarily it would be moved. It is this which gives the elbow and knee especially their spindle shape. (See Plate XXXIV.)

_Pain_ is also a characteristic feature, especially that which is produced by motion and allayed by rest and that which is accompanied by involuntary muscle spasm, and occurs during sleep, _i. e._, the so-called _osteocopic or starting pains of tuberculous panarthritis_. These occur most distinctively in children, but may be complained of at any period of life. Children thus affected will cry out sharply during their sleep and appear for a few seconds very much distressed, and yet do not awaken sufficiently to recall or describe their sensations. The explanation of this phenomenon is a sudden reflex spasm of the muscles by which tender joint surfaces have been suddenly pressed tightly together and pain thereby provoked. Something of this kind may occur in syphilitic bone disease, but, taken in connection with the other signs and symptoms above mentioned, such pains are practically pathognomonic.

The various measures to which orthopedists and surgeons resort for employment of traction, by splints or weights, are directed against overcoming muscle spasm by tiring out the muscles. It must not be thought that by any reasonable degree of traction joint surfaces are actually separated widely from each other. All that it is expected to accomplish is by a steady pull to exhaust the muscles, and prevent them from thus exercising deleterious pressure by pulling joint surfaces together.

The pain complained of is by no means necessarily limited to the joint involved; in fact, some of the most significant pains are those which are described as _referred_. These furnish illustrations of the fact, well known to physiologists, that _irritation in the course of a nerve is referred to its distribution_; thus in hip-joint disease most of the pain will be centred in the knee, and when the knee is involved the ankle will be the part to which the patient will refer much of his discomfort.

There also comes an overuse of the unaffected joints of a limb by which the diseased joint may be spared as far as possible. The flexors, as a group, being always stronger than the extensors, the former will overcome the latter in time, and these joint _contractures are a later expression of chronic muscle spasm_. This is true even when atrophy is well advanced.

Tuberculous joint disease usually has at first no particular constitutional complications. These come on later in proportion as the general health suffers from the confinement entailed by the disease. General health will suffer quicker when the lower limb is involved than when it is the upper. By the time joint lesions are well advanced careful observation will usually reveal a rise of evening temperature and progressive anemia. The symptoms included under the term _hectic_ are those belonging to the destructive stage and are due to a combination of causes in which auto-intoxication figures largely.

=Diagnosis.=--Tuberculous joint disease is usually easy of recognition, except perhaps in the earliest stages. (See the general subject of Orthopedic Surgery.) Differential diagnosis between this condition and syphilis, or between it and hysteria, has occasionally to be made, and may at first cause some difficulty. An hysterical hip or knee may so strongly simulate tuberculous disease as to lead one at first into serious doubt. Again, as between the tuberculous and non-tuberculous forms of hydrarthrosis, there may often be doubt, even after aspiration and examination of the fluid. In fact, that which began as one may terminate as the other. Fortunately in these last cases local treatment is about the same for each, and, while the question of diagnosis may never be absolutely satisfactorily decided, the patient may nevertheless recover in either event.

=Treatment.=--The treatment of tuberculous arthritis should be both local and general, one being about as important as the other. The general treatment for this as for every other tuberculous disease may be summed up as follows: The remedies for tuberculous disease are _oxygen_ and _hypernutrition_. The best place for the patient is the place where these means can be procured. As explained above, this will, to a considerable extent, depend upon the circumstances of the patient or the family. When it can be afforded a high altitude is almost as good for joint tuberculosis as for that of the lungs. The nearest approach that can be made to it will be the most desirable. Hypernutrition will in some cases consist almost in forced feeding. Here as elsewhere in tuberculous disease it is of at least theoretical as well as of practical advantage to saturate the system with some bactericidal remedy, if such there be, and for obvious reasons. Creosote or its congeners, in more or less palatable form, seem at present to best serve this purpose. In addition to this arsenic, iron, and the iodides, the latter especially if there be any suspicion of syphilitic complication, can be used to advantage. In proportion as patients become confined to the house their elimination is usually restricted. All measures then by which elimination may be improved will be indicated.

The use of _tuberculin_, or some of its modifications, has been occasionally followed by excellent results. It is an agent to be employed with great discretion, but is well worth a trial in those cases where its effects may be carefully watched.

_Locally_ the most important measure is the enforcement of _physiological rest_ of the affected parts. This may imply confinement to bed, especially when the spine, the pelvis, and the hip are affected, but should be reinforced by mechanical contrivances, by which traction or “_extension_” may be carried out. The purpose of traction, as mentioned above, is to overcome muscle spasm and thus ensure rest. It is effected by many of the orthopedic apparatuses. (See chapter XXXIII.[32]) It may be enforced by fixed dressings of plaster, etc.

[32] The fundamental idea expressed in all of the methods for
enforcing rest by traction is of American origin, and constitutes
one of the advances in surgery for which the world is indebted
to America. For a long time it was referred to in Germany as the
American method, and yet now the Germans claim so much for it that
one of their surgeons has written a book of 600 pages devoted to the
employment of traction for various surgical purposes, in which but
very little credit is given to the men who originated it.

Normal Knee-joint. (Child, seven years old.)

Tuberculosis of Knee, with Partial Dislocation.

(Child, seven years old.)]

With a better appreciation of the pathology of the condition numerous methods were devised by which the germs should be attacked _in loco_. Thus various antiseptics have been injected in varying strengths, either into joint cavities or around them. Lannelongue devised a “sclerotic method,” by which zinc chloride solutions were injected into the peri-articular tissues, to so condense and harden them as to imprison and destroy their contained germs. The method, however, is an extremely painful one and has not found general favor. For a long time iodoform was employed for the same purpose, in emulsions of 10 per cent. and 20 per cent. strength, in sterilized glycerin or olive oil. It affords a curious paradox that the iodoform itself must be sterilized before being thus used. This emulsion has been injected into the peri-articular tissues or into joint cavities, which, when containing appreciable amounts of fluid, should be first emptied and washed out; all of which can be done through the same small trocar used for introduction of the iodoform. The verdict of surgeons today is rather against the employment of iodoform, since they have learned to not rely upon it because of disappointment so often following its use.

Bier, in 1891, advised the so-called _congestion treatment_ of tuberculous joints, basing it upon the fact that tuberculosis does not develop in lungs which are the seat of venous stasis from valvular heart disease. He proposed to produce an artificial stasis, in the joint structures and about them, by which living germs should be destroyed and their disease products encapsulated, claiming that as the result of the hyperemia thus produced the alexins are thus brought into more complete contact with the bacilli. The method is applicable to the limbs below the shoulder and hip. It consists in the application of an Esmarch bandage above the affected joint, applied with sufficient firmness to obstruct the returning blood, but not to interfere with the arterial supply. If there be room the limb is also bandaged below the joint with an ordinary cotton roller. This congestion is kept up at daily intervals for increasing periods, beginning with perhaps half an hour and continuing until it is in operation at least half of the time. Meantime other methods of treatment are not interdicted. In the earlier stages of tuberculous joint disease this method has given very encouraging and pleasing results. (See Fig. 208.)

_Tuberculous hydrops_ may be treated by aspiration and elastic compression. Should fluid distend the joint it should be opened and thoroughly cleaned, then closed and perhaps drained.

The treatment of _pyarthrosis_ and of _peri-articular cold abscess_ has long been a mooted subject. The orthopedic surgeons still adhere to mildly or absolutely non-operative measures, whereas the general surgeon prefers to adopt more radical methods. Each case should be judged on its own merits, and these should include a careful estimation of the general condition of the patient. Should evidences of septic intoxication be present or the ordinary general signs of the presence of pus, then these collections should be opened and cleaned out. If hectic can be excluded, then other considerations will indicate what is best. At all events there will be seen many cases where a delay in operation will be advisable, in order to permit of improvement of the general condition by measures above described. To merely open up a tuberculous focus and leave at least two fresh raw surfaces exposed to contamination is rather to invite the spread of the disease than to correctly meet the indication. Every old focus will be lined or surrounded with a more or less dense membrane formerly called _pyogenic_, but now more correct knowledge shows it to be _pyophylactic_. (See p. 113.) To leave this _in situ_ is to leave germ-laden walls, while to dissect it thoroughly is to make a larger, fresh raw surface and to open up innumerable absorbent vessels. Thus, whether it be removed in whole or in part, or allowed to remain, some sufficiently strong caustic material should be promptly employed, by which both destruction of living residual germs and closure of the mouths of the absorbents shall be effected. This has been set forth more fully when dealing with cold abscesses in general, but is of so much importance that it may be reiterated here. Whether the actual cautery, pure carbolic acid, strong zinc chloride solution, or some other agent be used should depend upon circumstances, but every portion of the surface which it is proposed to leave more or less exposed to the possibility of infection should be thus protected. In proportion to the intensity of the caustic action there will be separation of more or less cauterized and sloughing material, for whose escape provision should be made; but it will be separated by the granulation process, aided by an active phagocytosis, and when removed will leave a granulating surface which is but slightly absorbent. These facts pertain to small incisions for drainage as well as to extensive arthrectomies.

_The operative treatment_, then, of tuberculous arthritis varies from tapping, with or without drainage, to complete arthrectomy or amputation. When the joints of the foot or ankle are extensively diseased, and the patient, as usually happens, is in poor condition, it may appear that amputation will afford the most complete relief, and that a stump with an artificial member will be of much more use to the individual than a mutilated, tender, and disabled foot.

Calcified mass in old “cold abscess” about hip-joint. (Buffalo Clinic. Skiagram by Dr. Plummer.)]

To incision with or without drainage is given the name _arthrotomy_. When the joint is widely opened and portions removed with the sharp spoon or otherwise, it is known as _arthrectomy_. When bone is removed irregularly the measure is called _atypical resection_. When entire bone ends are removed the operation becomes an _exsection_ or _resection_. The ordinary arthrectomy is not sufficient when foci are present in the epiphyses. Here at least atypical resection is called for. Arthrectomy may properly include a wide exposure of articular surfaces and the removal of the thickened and diseased synovia, with its fringes, or with the cartilages, by which cancellous structure is more or less widely exposed. When arthrectomy is undertaken it should be thoroughly made and by a large incision, since the more completely the joint cavity can be inspected and attacked the better are the interests of the patient subserved. All fresh or cold abscess cavities which connect with the joint or lie in contact with it should also be attacked at the same time, and those which do not communicate with it should be separately drained. While drainage by tube or other means will usually suffice, there are cases where the disease is so extensive that it will pay to pack the cavity with balsam gauze for a few days, placing secondary sutures by which the incision can be closed after its removal. In the shoulder and hip, for instance, such a method will give satisfactory results.

The advantage of avoidance of resection is the non-interference with the epiphyses and their junctions, thus permitting the growth of the bone to continue. _Therefore complete and typical excisions should be practised as seldom as possible, especially in growing children._ They may be practised to advantage even in advanced age, and the writer has seen satisfactory results after complete excision of tuberculous joints in senile cases. When operating upon a tuberculous tarsal joint the surgeon is likely to find one or more of the tarsal bones so much involved in the tuberculous disease that he is compelled to scrape it out and thus leave a cavity almost the size of the bone itself. Should he have to do this to a series of the bones it would be better to make a formal resection of the tarsus or possibly an amputation. The cavity should be left open with a sufficiently large incision so that it may be easily packed. A cavity of this kind left unpacked will fill up with clot, which will disintegrate and the result will be much less satisfactory. In the former case there is an open cavity which fills with granulations, but this can be kept accessible under observation and with more effect and comfort. This is equally true of those cavities where both arthrectomy and bone curettage have been practised.

MOVABLE BODIES IN THE JOINTS.

Several different terms have been applied to loose and movable bodies, even in the various joints, depending on their size, arrangement, and appearance. Thus we have the _rice-grain_ or _melon-seed bodies (corpora oryzoidea)_, which have already been described and are now supposed to indicate a form of tuberculous synovitis which has undergone a partial if not complete subsidence. Again we have larger masses occurring singly or in very small number, especially in the knee, to which the Germans have given the significant name of _joint mice_. Also in the knee, owing to its peculiar construction, another form of movable body is met with, _i. e._, a displaced and more or less _motile semilunar cartilage_. This condition was first described by Hey, and especially studied by Allingham, who made it a prominent feature of what he described as “internal derangement of the knee.” Lastly, in those joints in which _synovial fringes_ occur, the knee especially, it is held that portions may become detached by having been infiltrated and cast off or broken loose, and thus form a fourth variety of floating body. The joints most often affected are the knee and the elbow. In many instances there is a history of injury, especially when the mass is of considerable size. The theory of an “osteochondritis dissecans” has also been invoked to account for the resemblance between some of these bodies and the articular cartilages. Some pathologists have held that they may result from the organization of clots, which are subsequently rounded off and shaped by attrition (Fig. 209). These bodies then may consist of condensed fibrinous material, of cartilage, of true bone, or of hyperplastic and fatty synovial tassels. To these may be added rare instances of mucoid connective tissue.

Floating bodies--“joint mice”--from knee-joint. (Lexer.)]

=Symptoms.=--_Rice-grain bodies_ may be suspected in cases of chronic tuberculosis and often in arthritis deformans, while in many instances they may be felt gliding beneath or between the joint structures. A perfectly loose _floating body_ will produce symptoms which are quite distinctive. They consist of sudden and intense pain, with such muscle spasm as to fix the joint and prevent its use, thus “locking it.” Occurring at the knee the individual is instantly disabled, but usually learns by some peculiar manipulation, with or without assistance, to “unlock” the joint, and after a few moments to resume its use. Such a complaint as this should always suggest the condition. Patients who have had it for a long time learn how to avoid it as well as how to relieve it, and will often discover and be able to indicate to the surgeon the existence of a movable body, and even to describe its usual resting place.

Partial or complete _dislocation of a semilunar cartilage_ in the knee is usually the result of traumatism, a distinct history of which can generally be obtained. It may not have been discovered at the time, owing to swelling or tenderness, but will produce its peculiar symptoms later, _i. e._, after use of the joint is resumed. Here, again, so long as it remain in proper position, it interferes but little; with a misstep or sudden movement, however, the patient is seized with sudden and painful disability. Here the movable cartilage may be felt projecting near its proper location. In such cases as these it is movable only to a certain extent and makes no free excursion about the joint. When not detected it may be suspected from the description which the patient gives of his seizures.

=Diagnosis.=--So far as diagnosis is concerned, when a movable body can be felt all doubt is set at rest. When it cannot be discovered its existence may be inferred with an accuracy proportionate to the patient’s description of his difficulties.

=Treatment.=--The treatment of rice-grain bodies is essentially that of the chronic hydrarthrosis and probably tuberculous condition which have led to their formation. It will consist usually in arthrotomy, with thorough irrigation; often in some form of arthrectomy. With the larger floating bodies, the “joint mice,” the most radical measures are the best. In most of these instances there will be some degree at least of hydrarthrosis. The joint cavity being distended and relaxed, the indication for arthrotomy is the more urgent, since it will permit also of irrigation or of dry sponging, with the same benefit with which analogous intraperitoneal conditions are treated by the same measures. The joint may be opened by a sufficiently ample incision, through which the foreign body or bodies may be removed. The operator should not be satisfied with mere removal of one, but should make a thorough search for others which may have escaped previous detection.

Perhaps no operative measure in surgery better illustrates the advantages of asepsis. This operation, which now can be done with impunity, was in the pre-antiseptic era one which had a discouraging fatality, death resulting from septic infection in about 40 per cent. of cases.

FOREIGN BODIES IN THE KNEE-JOINT.

“Joint mice” are of sufficient frequency and significance to justify brief separate consideration. According to Connell these may be grouped as follows:

Those composed of foreign material, fatty tissue, fibrous tissue,
etc.;

Those composed of bone, cartilage, or of a mixture of the two.

Among the many explanations offered are the following:

Dry arthritis, with overgrowth of the margins of the cartilages;

Bony growths, separation from their attachments;

Infarct of the articular cartilage, with final separation;

Plate of bone formed outside of the joint and then invaginated;

Calcification or chondrification of enlarged synovial fringes;

Irritation and growth of embryonal cartilage or bone cells in the
synovial fringes;

Concretions whose nuclei are clots, torn fringes, or some foreign
body;

Some portion of the articular cartilages broken off by injury, or
damage and subsequent separation.

Injury figures largely in the opinion of most of the authorities, it being well established that an injured portion of articular surface may become subsequently detached by a fatty necrosis, spoken of by König as osteochondritis dissecans, or by Paget as “quiet necrosis.” Others imagine that these floating bodies are rarely of traumatic origin.

Symptoms are usually marked and significant. There is sudden sharp and shooting pain, sometimes so severe as to cause faintness. Along with this there is “locking” _i. e._, fixation of the joint, usually in the flexed position, probably due to the entanglement of the floating body between the articular surfaces or between the bone and the capsule.

Ankylosis of hip with contracture of knee, following post-scarlatinal arthritis.]

It is the smaller rather than the larger bodies which give the most acute symptoms. This “locking” may last for only a few moments or for a number of hours and may or may not be followed by acute effusion. When with the above symptoms the presence in the joint of a movable mass can be made out diagnosis is complete. Some patients discover the movable body in their own joints before they go to the surgeon.

When the diagnosis is established the removal of the offending material is imperative. In the pre-antiseptic era this was an extremely hazardous operation. It is now one involving only theoretical risks. These bodies are sometimes extremely movable and slip about within the joint in a manner to almost defy removal even after the joint cavity is open. If such a body can be felt and fixed by digital pressure, or by the method of “stockading” suggested by Andrews some years ago, _i. e._, fixation by forcing sterilized pins into the tissues around it so that it cannot escape, it is then an easy matter to cut down upon it and remove it. Otherwise incision may require to be sufficiently ample to permit insertion of a finger and the general exploration of the joint before it is encountered. These bodies sometimes exist in small numbers, and it may be possible to remove several through a single opening. If the joint be opened and explored it should be done thoroughly in order that nothing may escape. After removal the capsule is closed with buried sutures, the balance of the wound closed as usual, and the limb then dressed upon a splint with absolute fixation for several days, in order to ensure physiological rest (Fig. 209).

ANKYLOSIS.

The term _ankylosis_ implies _angular deformity_, but is used to designate partial or complete fixation of joints, such fixation being usually accompanied by more or less deformity or displacement. It is a name for a condition and not for a disease, but is always produced by the latter or by injury. The term itself implies nothing as to the nature, extent, or appearance of the exciting cause. The actual cause may have been disease of the joint, of the tissues around it, or may have been the result of injury rather than of infectious or other active disease.

For convenience we speak of _fibrous_, _false_, or _pseudo-ankylosis_, and of that which is _bony_ or _actual_. A more accurate use of terms would lead us to refer to the former as contracture rather than true ankylosis.

_Contractures_ are the result of acute, usually septic intra-articular and peri-articular processes, where muscle spasm is a pronounced factor and where the intensity of the process has more or less weakened the joint structures. The profession is hardly in the mood to accept acute rheumatism as an infectious process. If true or not the acute rheumatic affections are frequently followed by fibrous ankylosis with contractures. Disfigurements of this kind are often produced as the result of the surface lesions of severe burns or ulcerations, followed by cicatricial contraction and the formation of dense bands and scar tissue. This is a condition which can always be foreseen and which should be guarded against with very great care. (See Treatment of Burns.) Contractures also occur as the result of certain diseases of the spinal cord, either as the result of active contraction of one set of muscles, or of paralysis, by which the opposing muscles are deprived of resistance and thus draw the limb out of shape.

_True ankylosis_ is sometimes fibrous, sometimes osseous, and occasionally both combined. The older the case the more probable is actual osseous union of joint surfaces. Bony ankylosis implies a sharply destructive type of arthritis, which may have been originally of pyogenic, gonorrheal, or tuberculous character, or else indicates a series of very slow ossific and calcific changes, such as are connected with the osteo-arthritis already described. Many of these cases are to be referred to lesions of the cord, and many of them are of polyarticular character. Fig. 195, illustrating one of the cases of so-called “ossified men” under the writer’s observation, will portray a series of lesions of this kind, most of the vertebral as well as the other joints being involved in an absolute osseous union.

Bony ankylosis of hip. (Ransohoff.)]

Bony ankylosis of knee. (Ransohoff.)]

Bony ankylosis of hip with deformity. (Ransohoff.)]

When a joint is stiff bony ankylosis may be inferred. So long as there is any motion possible it is essentially of the fibrous type. The condition is one easy of recognition, and is seen in all degrees of completeness. In many instances joint fixation is accompanied by adhesions of tendons and tendon sheaths, while as time passes all the structures around a joint thus fixed become less movable and more stiffened. Even the patella may become firmly attached to the bony surface upon which it normally rests, and thus interfere with motion of the knee almost as much as though the femur and the tibia were alone involved. Occasionally one of the acute exanthems is followed by contractures of a joint, with or without actual joint lesions, by which when neglected distressing deformities are produced; such, for instance, as partial flexion and fixation of the knees, or such stiffening of the hips as to prevent the thighs from being separated. While in such cases stiffening cannot always be prevented, deformity at least can be if suitable measures instituted sufficiently early.

Figs. 211 and 212, from Ransohoff, illustrate osseous union in the hip and the knee, while Fig. 213 illustrates the deformity which may be produced by contractures and ankylosis at the hip.

The following tabular presentation of the types of ankylosis will perhaps convey the greatest amount of information in small space:

{ {Capsular
{Peri-articular { { Tendinous
Ankylosis, { {Extracapsular { Tendovaginal
true and false { { { Muscular
{ {Synovial
{Articular {Cartilaginous
{ {Osseous

Murphy has prepared the following table of the types of arthritis which lead to some of these varieties, and which may be classed as follows:

{(_a_) Primary hematogenous fibrous arthritis
{(_b_) Dry fibrous arthritis. Non-traumatic
{ {With fracture
{(_c_) Traumatic fibrous arthritis {into joint
{ {Without fracture
{ {(contusion)
{ { {Cryptogenetic
{ { { {Typhoid
{ {Hematogenous {Metastatic {Scarlatina
Arthritis { { { {Pyemia
{ { { {Gonorrhea
{(_d_) Suppurative { {Traumatic
{ { { {Tuberculous
{ { {Osteitis {Osteomyelitic
{ {Extension { {(infective)
{ { {Peri-arthritis (phlegmon)
{ { {Panarthritis
{(_e_) Ossifying arthritis (primary)
{(_f_) Static adhesive

=Treatment.=--The best method of treatment should be determined by the original character of the exciting cause, the duration of the condition, the amount of deformity present, and the degree of joint fixation. That which will be possible if done early will be useless if not resorted to until the case is old and chronic. In every acute or subacute condition which may threaten ankylosis every possible precaution should be taken to prevent it. If ankylosis be inevitable it should occur with the limb in the most suitable position. At the elbow, for example, this will be the right-angle position; at the knee, one with the leg almost completely extended. In the lower extremity traction with weight and pulley will serve a useful purpose in many instances, either to overcome a threatening condition or to improve one actually existant. Mechanical measures (_i. e._, use of various splints or forms of orthopedic apparatus) will sometimes be of great use. These may be arranged for the purpose of providing absolute rest, with fixation in a desirable position rather than in one which is undesirable, or they may be made with such devices as shall permit of frequent change of position.

The mildest operative measure which can be practised in these cases is manipulation, either gentle and frequent, combined with massage, or more violent and painful, such as requires anesthesia for its performance. The question of when to resort to these manipulations is one calling for the soundest judgment, as on one side the surgeon faces the possibility of setting up a renewed and more or less acute disturbance, and on the other of seeing a joint gradually stiffen, perhaps in a bad position. There is also a third difficulty, _i. e._, the necessity for continuing motion in order to prevent the re-formation of adhesions, and this in spite of the fact that it may be intensely painful to the patient. Fortunately, however, the use of nitrous oxide anesthesia usually permits this to be done as often as may be necessary with a minimum of discomfort.

Firm, fibrous ankylosis will be attacked with great hesitation by the experienced surgeon. Even though he may succeed in restoring the limb to a better position, he may feel quite positive that the patient cannot undergo the pain of the subsequent frequent handling. With bony ankyloses he may feel that nothing short of radical measures will suffice. Here it is rarely a question of restoring motility but rather of overcoming deformity. At the knee a wedge-shaped portion of the joint may be removed, its angle corresponding to the angle of deformity, and thus a crooked leg may be restored to the straight position; in fact, with a raised heel under such a limb it may be made almost as useful as ever. At the hip one may do a subcutaneous osteotomy, dividing the femoral neck either with chisel or with a small and protected saw, and then bringing the limb down into the normal position of extension, allowing the bone to repair itself, and effecting improvement only in position, or, by constantly moving it, securing a false joint; or a more formal exsection may be made and by removing the head of the femur and clearing out the acetabulum a degree of motion may be established at this point. At the wrist, elbow, and shoulder-joint resections will usually give good results if the operation be performed before the muscles have almost disappeared by atrophic processes.

Danger attaches to the performance of the so-called bloodless operations, in that there is a possibility of laceration of nerve trunks or of large vessels which may have become fixed in the condensed tissues and be torn with them. There is more danger of this perhaps at the knee than in other joints, and ruptures of the popliteal vessels and nerves have been repeatedly reported. The first attempt in breaking up such a joint should be to increase the degree of flexion. If by efforts in this direction the tissues can be first released, then there is less danger of their yielding when extension is made. Another danger which threatens in all resistant cases, and especially in elderly people, is fracture of bones. The writer has seen the upper end of the tibia as well as the neck of the humerus yield under these circumstances. In the latter event one should endeavor to prevent bony union, and thus to gain a false joint in place of the original.

In regard to the nature of the operative attacks upon the above types, the following is copied from Murphy:[33]

A. Extracapsular {1. Tendon elongation (tendoplasty).
disease {2. Tendovaginitis (exsection of sheath).
{3. Cicatrices (removal).

B. Intracapsular {1. Adhesive synovitis (exsection of capsule).
{2. Replacement by aponeurosis or muscle.

{1. Disconnect bones.
{2. Remove neighboring bony processes or
{ prominences.
C. Osseous {3. Liberate soft parts.
{4. Prevent subsequent bony contact.
{5. Interpose tissue to form hygroma or fibrous
{ surface.

{1. Mandibular.
D. Joints suitable {2. Hip.
for operation. {3. Shoulder.
{4. Elbow.
{5. Knee.

{1. Flap formation (skin flap with fascia, or
{ muscular).
{2. Exposure of ankylosed area.
{3. Osseous separation.
E. Technique {4. Transplantation and fixation of interposition
{ flap.
{5. Replacement of bone.
{6. Fixation of parts.
{7. Drainage.

{1. Passive motion
F. Subsequent {2. Active motion.
treatment {3. Forced traction.

[33] Journal American Medical Association, May 20, 1905, p. 1573.

To the various expedients which may be adopted for making stiffened joints more useful may be given, in a general way, the term _arthroplasty_. A variety of mechanical contrivances have been resorted to in the past, operators hoping to be able to secure, for instance, a movable knee instead of one which is stiff. Artificial joints, made of celluloid, ivory, etc., have been used for experimental purposes, but while occasionally they have given good results in animals, they have rarely been satisfactory in man. For the prevention of re-adhesion, plates of celluloid, thin metal, gutta-percha, rubber, etc., have been used. These are either wrapped around a bone end or are used for lining a bone cavity, and rapidly accumulating experience is showing that this may be done with great benefit.

Thoroughness of operative work is one of the important contributing agents to the securement of wide range of motion, especially in complete removal of synovial membrane, capsule, and ligaments. Soft parts should be liberated thoroughly. Of the materials which can be interposed between bone ends in order to prevent reunion, muscular aponeurosis, with a certain amount of fatty tissue, makes the best material for interposition. When aponeurosis cannot be secured, then muscle should be tried, with some fat, as the former flattens out and undergoes structural changes, with conversion into fibrous tissue.

It should be represented to the patient as a legitimate scientific experiment, and in such a way that no matter what may happen no blame can be attached to the operator. In general it may always be stated that the older the lesion the less satisfactory will be any measure of treatment except possibly resection and arthroplasty.

ARTHRODESIS.

This term applies to the intentional production of ankylosis in a joint previously healthy or nearly so, with the intention of stiffening a useless limb and thus enhancing its usefulness. The measure applies mainly to those cases of infantile paralysis, with loss of control of the knee or ankle, or both, when by stiffening the limb it can be made to serve the purpose of a crutch. It is the last resort in this direction when there is no possibility for tendon grafting. Long confinement of a limb in a fixed dressing will lead to considerable stiffening of the joint, yet a joint so immobilized lacks that firmness of support called for in cases above mentioned. Therefore when it is desired to perform arthrodesis the joint is usually opened and more or less of its articular surface removed, the intent being to produce the effect in the shortest time and in the best way. It can be better attained by a removal of articular surfaces with the saw and the apposition of fresh bone surfaces to each other, their retention being ensured either by sutures (tendon or wire) or accurate fixation in plaster of Paris. Under these circumstances drainage should not be necessary, and limbs can be completely enclosed in a fixed dressing.

MAJOR OPERATIONS ON JOINTS.

Aside from arthrotomy and partial or complete arthrectomy, as above mentioned, the latter, including removal of synovia or cartilage, and perhaps curetting of bone foci, the formal _resections_ or _excisions of joints_ remain to be considered. The latter is the preferable term, as it is meant to include removal of the component parts that enter into the construction of joints, while the term resection implies rather the removal merely of portions of bone.

_Joint excisions_ are practised especially for the following purposes: (_a_) To atone for the result of old unreduced dislocations; (_b_) in certain compound dislocations, with or without fracture; (_c_) in certain comminuted fractures where there is no prospect of recovery with useful joints; (_d_) in the destructive forms of acute arthritis where the entire joint is disorganized and the bone ends carious; (_e_) in tuberculous arthritis or panarthritis, with or without suppurative complications; (_f_) in occasional instances of disabling osteo-arthritis; (_g_) for relief of ankylosis, either for improvement of position (knee) or restoration of motion; (_h_) occasionally after gunshot injuries. _Excisions required by the exigencies of traumatisms should be promptly done._ If the case be complicated with septic infection the prognosis is much less favorable. For convenience of description excisions may be classified as _primary_, _intermediary_, and _secondary_. According to the joint involved, as at the knee, the purpose underlying the operation is to effect an absolutely rigid bony ankylosis.

The development and perfection of the general method of joint excisions is a matter of but little more than a century. Previous to that time amputation was almost the only resort when destruction had occurred. The most prominent surgeons in the early development of the measure were Park, of Liverpool, and Moreau, of France. During the latter part of the past century Ollier, of Lyons, greatly improved the technique by demonstrating the importance of the periosteum and by introducing the so-called _subperiosteal methods_. This is of great value in _uninfected_ cases. It is a mistake, however, to endeavor to save periosteum which has become involved in the tuberculous process; in fact, in the presence of tuberculous disease we cannot be too radical in the removal of all affected tissue.

In the so-called subperiosteal method the operator endeavors, so far as possible, to preserve the periosteum of the parts exposed to attack, and, if possible, the capsular ligament as well. Thus at the elbow the capsule, _if not diseased_ or obliterated, should be preserved, the osseous tissue being shelled out from within, so far as possible. The less, then, the connections between the capsule and the periosteum are disturbed the better. The French apply to this method the term “subcapsular periosteal.” When the bone covering can be preserved new bone is easily formed to replace that which has been lost, especially during adolescence, while the preservation of the capsule, with its ligamentous connections, affords a better joint cavity than will the substitute which results from natural processes. Furthermore the surrounding tendons are less disturbed and the condition remains more like the original. Nevertheless one does not exsect healthy joints, and the method is not always easy nor even possible of performance. It will suffice to say that it should be adhered to only as far as circumstances may justify or permit.